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The Ljlkckt, July 5,1919.
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NINETY - SEVENTH YEAR.
SAMUEL SQUIEE SPRIGGE, M.A.,'M.D. Cantab.,
EDITOR.
LONDON
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'6342
THE LANCET, January 4, 1919
f.\
% Jfnr%r Investigation / >''
INTO
INFLUENZO-PNEUMOCOCCAL AND
INFLUENZO-STREPTOCOCCAL
SEPTICAEMIA:
EPIDEMIC INFLUENZAL PNEUMONIA ” OF HIGHLY
FATAL TYPE AND ITS RELATION TO
" PURULENT BRONCHITIS.”
By ADOLPHE ABRAHAMS, M.D. CANTAB.,
M.R.C.P. Lond..
MAJOP A.M.C. ; O.I/C., MRDICAL DIVISION, THE COHN AUGHT HOSPITAL,
ALDERSHOT;
NORMAN HALLOWS, M.D. Oxon., D.P.H.,
CAPTAIN, R.A.M.C. ; PATHOLOGIST TO THR CONNAUGHT HOSPITAL,
ALDERSHOT ;
AND
HERBERT FRENCH, M.D. OxoN., F.R.C.P. Lond.,
LIEUTENANT-COLONRL, R.A.M.O. { CONSULTING PHYSICIAN TO THR ALDER¬
SHOT COMMAND; PHYSICIAN TO GUT'S HOSPITAL.
(With Coloured Plate.)
Introduction.
When we published a paper upon “Purulent Bronchitis,
its Influenzal and Pneumococcal Bacteriology,” in conjunc¬
tion with Dr. John Eyre, in Thh Lancet of Sept. 8th,
1917, we were particularly desirous of drawing attention to
the anomalous character of many of the cases of “ pneu¬
monia” that we had encountered in the Aldershot Command
during the years 1915, 1916, and 1917, and because we felt
that “pneumonia,” in the sense of true croupous lobar
pneumonia, was a misnomer in connexion with many of them.
The “purulent bronchitis ” type of certain of these anomalous
esses that had up to that time been returned generally as
“ pneumonia ” is now familiar to most Army physicians, but
at the time of our own investigations, and those of Hammond,
Holland, and Shore, 1 the bacteriological nature of this severe
purulent bronchitis, with its remarkable heliotrope cyanosis,
abundant spatum, and high mortality, was not, we think,
recognised generally.
Though it was occurring in the form of multiple small
epidemics in France and in England, there was then no
generalised epidemic to lead to the suspicion that it had an
influenzal basis ; and it was as the result of extended bac¬
teriological research, intra vitam and post mortem, and not
from the observation of clinical phenomena, that its causation
was found to be primarily influenzal, with symbiotic or
secondary invasion of the respiratory tract and circulating
blood by either pneumococci or streptococci, the virulence of
which, it seemed, had been so exalted by the coexistence
of influenza bacilli that they caused death in a high percentage
of cases by reason of a veritable pneumococcal or strepto¬
coccal septicaemia.
The condition, though labelled “purulent bronchitis”on
account of the dominating characteristics—viz., the severity
of the chest symptoms, and particularly the appearance and
quantity of the sputum—seemed to us, even at that time,
to be an inflnenzo-pneumococcal ” or an “ influenzo-
streptococcal ’ septicaemia with a prominence of lung sym¬
ptoms rather than a purely pulmonary disease. The question
of the relationship of the streptococcal to the pneumococcal
cases is elaborated later in this paper, but it may at once be
stated that there is now much evidence in favour of the
view that the streptococcal organisms described in certain
epidemics may be really pneumococci growing temporarily
in streptococcal form.
8ince 1916, when the “ purulent.bronchitis ” oases were
differentiated more or less clearly from amongst the big
group of anomalous “ pneumonia ” oases, we have had ample
opportunities, more especially during the recent epidemics,
for broadening and extending our views. We believe now
that the “ purulent bronchitis ” type is merely one of many ;
that “ inflnenzo-pneumococcal septicaemia ” is responsible for
much, if not all, of the fat al “ influenzal pneumonia ” which
i Thr Layout, July 14th, 1917, p. 41.
is at the present moment (October, 1918) causing sickness
and death, not only amongst troops in camps, but also, and
to an almost greater extent, amongst the civil population,
affecting Africa, America, and Asia as well as Europe,
leaving few towns untonched in any country in which it has
obtained a start, and spreading virulently amongst those
who are aggregated closely together—for instance, when it
breaks ont on board ships on the high seas.
It is for others to deal with its epidemiology ; we would
confine our remarks to the clinical, bacteriological, and post¬
mortem aspects of the disease as we have seen it amongst
troops at Aldershot and elsewhere. But once again, and
even at the risk of becoming monotonously insistent, we
wonld emphasise oar view that in essentials the influenzo-
pneumococcal “purulent bronchitis” that we and others
described in 1916 and 1917 is fundamentally the same con¬
dition as the “influenzal pneumonia” of this present
pandemic, and that it is only a matter of degree whether
there is “purulent bronchitis,” “capillary bronchitis.”
“ broncho-pneumonia ”—disseminated in some cases, lobar
in distribution in others, multiple abscesses in the lungs, or
even gangrene of the lungs. Few, if any, of the cases are
true lobar pneumonia, and death seems due to an extreme
toxaemia or septicaemia rather than to the extent of the lung
lesion. In other words, the extent of pulmonary involve¬
ment is of comparatively little importance and bears no
relation to the virulence of the essential septicsemlc
conditions.
Statistics : Incidence.— Owing to the extreme pressure of work, the
overtaxed state of the medical staff, the variability of nomenclature In
official returns, and other similar causes, it has been impossible to keep
detailed records of all the cases encountered. In the aggregate we have
seen several thousands, of which well over two thousand have been
“pneumonic”; and have examined over four hundred autopsies. 8o
variable, however, is the severity of the influenza itself In different
units or hospttals at the same time, and so greatly does the mortality
vary in troops from different countries that we make no attempt to
give statistical details, beyond Indicating that our experience is based
on thousands of cases and not merely on hundreds.
Pneumonic incidence in the influenza cases. —Of the total
number of cases seen in Aldershot and elsewhere during the
last few weeks, the majority have been straightforward
influenza. Roughly speaking, we may say that ont of 1000
cases of “ influenza ” upwards of 800 have taken an ordinary
simple uncomplicated course with fairly speedy recovery and
without sequelae. The remaining 200 have become more or
less pulmonary—of these perhaps 80 being of moderate
severity, the remaining 120 have been desperately ill; and
of this last-named category somewhere between 60 and 80
have died.
These figures do not hold good throughout, for the lung complica¬
tions and mortality have struck us as being very much higher amongst
soldiers who have recently joined up than among-t those of longer
service. They have been higher still amongst certain troops from over¬
seas—South Africans, United States troops, and New Zealanders, par
excellence— than amongst others.
The “ pneumonic *’ cases and the mortality amongst them have also
seemed to form a much higher percentage of the total “ influenza ” cases
In a unit in which the epidemic has just started than after the epidemic
has prevailed in the unit for a week or two. It is when the epidemic
is in its earlier days that It is apt to spread like wild-lire and cause
the greatest damage and the highest death-rate; although, so far as a
whole Command Is ooncerned, the daily sick and the dally mortality
may continue at a high level for a longer time than it does in a single
unit owing to the fact that the epidemic, whilst subsiding In one unit,
tends to spread and break out in fresh units one after another.
The Symptoms.
(a) In the Straightforward Influenza Cases .
The symptoms in the straightforward influenza cases are
precisely similar to those of ordinary influenza as it occurs
in other places and at other times.
The onset has generally been sudden and acute. There have, of course,
been many quite mild cases, but again and again a perfectly healthy man
may be taken ill In the street or on duty with a sense of general
malaise; he feels chilly, suffers from achei in his back, limbs, and
bead, and rapidly develops such a sense of prostration that wherever
he is he has to lie down. He may rally sufficiently to be able to get
himself back to his quarters with some difficulty, or he may be so
bad that he has to be carried.
He gets to bed and is only too glad to stay there. He is nauseated
at the sight of food and “ feels rotten.” Though drowsy, often he
cannot sleep. His temperature is raised, generally as high as 104° F. or
more. The pulse Is full and Arm, Its rate Is aa rule not raised propor¬
tionately to his temperature, and his respiration-rate is between 18
and 30. Many oases have red injected palate and anterior fauces and
eomplain of sore throat, but many have no such complaint, and on
examination of the chest physical signs are absent. The tongue is
almost invariably coated with a thick fur, superficially yellowish-brown
at the back and on the dorsum, pale yellowish-white beneath the darker
surface, and often with no fur on the margins and tip.
. Epistaxis, sometimes of almost alarm!'ig degree, has been an un¬
usually common phenomenon In this epidemic, sometimes at the
A
No. 4975
2 The Lancet,] DBS. ABRAHAMS, HALLOWS, AND FRENCH : INFLUENZAL SEPTICAEMIA. [Jan. 4, 1919
beginning, more often after the patient haa already gone to bed, and in
quite a number of cases the hearing has become muoh impaired, a few
eases having become temporarily stone deaf. Quinine prophylaxis may
be a factor in this, but that there is middle-ear catarrh in at least some
of the cases has been shown by subsequent ear discharge, and in one or
two cases by considerable bleeding from each ear.
Vomiting has not been usual, but it has occurred often enough to
attract attention. Diarrhea to the extent of six or seven loose motions
on the first day or two has been rather less uncommon.
Abdominal pain has not been a pronounced feature although occasion¬
ally it has existed of sufficiently severe character to lead to a provisional
diagnosis of appendicitis, and even to some solicitude as to differentiation
from an acute abdominal condition urgently needing operation.
In the earlier part of the recent epidemic laryngeal symptoms
were not common to the same extent as in a curious outbreak of
supposed •*influenza” last year (not the “ June, 1918,” epidemic), but
latterly quite a number of the men have been huslcy-voiced or even
unable to phonate at all. These cases have not necessarily passed on
to the “ pneumonic ” type.
The temperature has remained raised a variable number of
days. (See Charts.)
Sometimes it fell suddenly as early as the second day, sometimes
ending almost by crisis on the third, fourth, or fifth days, sometimes
coming down more gradually to reach normal by lysis between the
third and the fourteenth day of the attack. Speaking generally, the
duration of the pyrexia has been far longer in the recent pandemic
than in the cases encountered in June, and the subsequent prostration
appears to be proportionately greater.
As long as the temperature has been up to anything like 101° the
patient has continued to feel “ rotten.” With the fall of temperature
rapid improvement sets in; the tongue cleans, the patient feels alto¬
gether better, begins to take his food with avidity, and convalesces in
tne ordinary way. Delayed convalescence has occurred cither in those
who have deferred taking to bed at the beginning, or, more usually,
in those who. for duty’s sake, have felt obliged to get up and work again
before the acute stage of the disease has fully passed.
(h) Symptoms in the “ Pneumonic ” Cases.
The “ pneumonic ” or “ bronchitic ” complications, so much
dreaded just now, come on at no fixed or definite period of
the influenzal attack.
Frequently there is no distinct Influenzal period at all, the case being
then very similar to one of ordinary lobar pneumonia In the first day or
two. Numbers of such cases have been diagnosed as true lobar pneu¬
monia by those who are unfamiliar with the post-mortem findings, and
It Is remarksble how difficult it is to persuade those who have not seen
such esses before that they are not dealing with ordinary pneumonia.
More often the patient has been ill for a day or two with simple
influenza, often apparently not at all severe and indistinguishable from
the general run of simple Influenza cases, before acute or even fulminat¬
ing pulmonary complications set in, and they may die so rapidly and
with so little actual consolidation that it is clearly not the “ pneu¬
monia” but something more generalised, a veritable septicaemia, which
kills them.
In a third type of case the “influenza” has nearly run Its oourse,
and the temperature may have returned to normal or nearly so for a
day, or even several days, before it rises again with the onset of
•• pneumonic ” complications.
All three types have been met with in abundance; the
commonest is that in which the case has seemed to be one of
simple “influenza,” for one, two, or three days before it
passes on into the much more serious phase of long and
general systemic complication.
There may or may not be a definite rigor; the temperature,
already high, may or may not rise further. {See Charts.)
The patient complains in some way of his chest; he coughs with short
dry hacking to begin with the question of his sputum is discussed
below. He often complains of pain in one or other side of his chest or
In both sides, either in the region of the anterior axillary line abont
the level of the sixth and seventh ribs, or posteriorly at one or other
base, or all over, or down the front oi the manubrium aternl “ as though
he is all raw inside there.”
Sometimes the skin Is hot, dry, and pungent as In lobar pneumonia,
occasionally a scarlatinlform raah of transient duration may be noted,
but, on the other hand, it may be covered with profuse clammy sweat,
the latter often loading to widespread sweat vesicles (sudamina and
miliaria).
The breathing becomes rapid (often 30 per minute or thereabouts,
but not seldom 40, 50, or even 60 per minute). The pulse-rate rises, but
it is nearly always no faster than corresponds with the pyrexia, and
often it is relatively Infrequent except at the very end. There Is no
orthopnosa, and although there is rapid breathing there is no
dye- pnoea.
The facies is at first flushed and red, but in bad cases it speedily
becomes less and leas of a purely red tint and assumes more and more
of a lavender, heliotrope, or violaceous hue mingled in the varying
degrees of redness (pallor with heliotrope hue, redness with heliotrope
hue. plethora with heliotrope hue, and all intervening degrees), this
peculiar oolouration being highly reminiscent of that of acutely gassed
cases and an evii sign, for few cases recover when once this character¬
istic hue has become established.
The physioal signs in the lungs .—Certain of the main
symptoms will be discussed presently, bat first we would
refer to the physical signs in the lungs. These are extremely
variable, and when a large number of cases have been seen
one realises that neither the diagnosis nor the prognosis can
be gauged by physical examination. Even at the risk of
becoming wearisome we wish to emphasise this. A man with
only a few rhoncM to be heard in either lung may die as
certainly as another who has dullness, bronchial breathing,
bronchophony, pectoriloquy, and crackling r&les over the
whole of both lower lobes. The extent of consolidation is no
measure of the severity of the infection; and a man may die
of this disease with practically no lung symptoms during life
and no evidence of consolidation post mortem.
In a considerable number of cases the’ clinical condition may be illus¬
trated by saying that the patient when first seen looks so exactly like
an example of lobar pneumonia that when one examines the chest and
finds absolutely no abnormal signs at all one is inclined to say, “lam
sure he is pneumonia all the same and I expect we shall find the signs
of consolidation and probably rusty sputum by to-morrow.” One
examines the next day, and may again find no abnormal signs, or
perhaps only a few scattered rhonchi in front, with subcrepitant r&les
at the bases behind without dulness or bronchial breathing. One may
still expeot consolidation signs the next day, and so on ; and the case
mav run its entire course—to recovery after a week, ten days or a
fortnight, or to death in one, two, three, four, five, six, seven, or even
more days—without any further signs than the rhonchi in front and
the non-consonating r&les posteriorly.
On the other hand, the case may start as above, and in a day or two
one may find markedly impaired percussion note at one or both bases,
with bronchial breathing and sharp crackling riles, bronchophony
and pectoriloquy, either of patchy distribution, or frankly all
over a whole lower lobe or over a whole lung, or over both
lower lobes. In such cases the unwary diagnose croupous lobar
pneumonia simply because they arc familiar with these signs in lobar
pneumonia and forget that they may be also due to any other cause
of extensive consolidation, or even to congestion only. In these cases
the autopsy findings show this consolidation in the present cases to be
due not to croupous pneumonia but to confluent bronoho-pneumonia
with varying admixtures of haemorrhage, peribronchial infiltration
even to the extent of abscess formation, oedema, turgid congestion,
infarction, and pleurisy.
In other cases, again, the physical signs of some kind of consolida¬
tion may be pronounced almost from the start; and although these
are to be found a hundred times in the lower lobes, especially behind,
or in the middle lobe, for once they are found first in the upper lobes
in front, there are occasional cases in whioh the dullness, bronchial
breathing, and crepitant rales develop in one or other upper lobes and
not in the lower lobes at all.
In another type of case there is no bronchial breathing any where, but
both lungs— front and back alike—are full of crepitant or subcrepitant
rftles from apex to base, recalling the signs met with in some cases of
generalised pulmonary tuberculosis.
In yet another type, whatever signs there may be elsewhere in the
ehest, one base becomes completely dull with silence as to breath and
voice sounds ; the dullness being of variable extent but generally
extending a hand’s breadth or more upwards from the base. Needling
generally discovers turbid fluid in the chest in such cases, and small
amounts of pleuritic effusion are common if the patient does not
succumb too soon, although large pleural effusions are relatively rare.
Another phenomenon adds complexity to the picture.
This is the disappearance of bronchial breathing, which may have
been pronounced and unmistakable a few hours previously, ordinary
vesicular murmur now being heard instead. The bronchial breathing
may re-develop perhaps a few hours later, or next day. either
where it had been heard before, or in another lobe, and again it may
disappear and be replaced by harsh vesicular murmur. The explana¬
tion of this seems to be the varying degrees of collapse that result from
accumulation of thick muco-pus in the tubes. When a fair area of lung
tissue becomes temporarilv airless from this cause, bronchial breathing
may be heard over it; within an hour the muco-pus in the tube coming
to this part may have been displaced, and the alveoli have re-expandea
with air, so that vesicular murmur is heard where a short time pre¬
viously bronchial breathing was marked.
Apart from consolidation, the formation of fluid in the chest has been
infrequent, remarkably so for oases in this Command, in whioh empyema
is so common as to be almost the rule in all pneumococcal and strepto¬
coccal infections of the lungs. The coexistence of pleural effusions
will be dealt with in the consideration of prognosis, suffice it to say
here that its relative infrequency seems to Indicate a high degree of
virulence of the infecting organism and the incapacity of the tissues
to react thereto. Towards the termination of the epidemic effusions
became far more frequent in the pneumonic type of case with a high
percentage of recoveries.
The sputum .—The cases of fatal “ purulent bronchitis ” of
former years were characterised by the expectoration of
immense amounts of sputum—often from 10 to 15 ounces In
the 24 hours, this sputum being in the main pure pus, with
little froth, with some blood, bright red in some cases, rusty
in others, in a minority of the patients. Precisely similar
sputum, necessitating the emptying of full sputum pots twice
or more in the 24 hours has occurred in one group of oases
we have seen in the present epidemic—the earlier and very
fatal cases amongst United States troops ; bat in every other
group we have been much struck by the relative paucity and
even the entire absence of sputum.
This paucity has not been confined to cases with any particular
variety of predominant physical signs. Cases have been encountered
with signs mainly of bronchitis with only a little frothy sputum ; other
cases with only bronchitic signs, and yet an expectoration of 15 ouneea
of pus a day ; other cases in which the signs were those of extensive or
confluent broncho-pneumonia with hardly any sputum ; others, again,
with physical signs of broncho-pneumonia of confluent type and lobar
distribution with copious purulent expeotoratlon equal to that which
is familiar in “ purulent bronchitis ” cases.
There is no rule as to the amount of sputum, and those cases that
have little sputum are, in other respects, especially as regards prognosis,
very similar to those that produce half a pint In 24 hours. What has
struck us a good deal In this connexion is that the oases that occur In any
particular district tend to conform to one type In regard to the amount
Tm Lanobt,] DRS. ABRAHAMS, HALLOWS, AND FRENCH : INFLUENZAL SEPTICEMIA [Jan. 4, 1919 3
Charts of 5 Cases of Recovery. Charts of 5 Fatal Cases.
\
■The temperature charts in the cases of influenza and influenzal “ pneumonia ” have been so extremely variable in type that
a hundred or more would have to be reproduced if every species were to be depicted. The above serve to represent
certain of the commoner types, however. The five on the left-hand side are from cases that recovered ; the five on the
right-hand side from cases that died. The authors think that the charts and their variability speak for themselves, so
they have not commented on them in detail.
4 The Lancet.] DRS. ABRAHAMS, HALLOWS, AND FRENCH: INFLUENZAL SEPTICAEMIA. [Jan. 4, 1919
of sputum. Probably this is not a universal ru!e. but It has been a
striking phenomenon In the present epidemic in which we have seen
large collections of cases in widely-separated districts.
The sputum, when it is abundant, has generally consisted mainly of
S os with or without blood ; it is then not strikingly frothy. When
is not abundant it still contains pus, but it is often frothy and
mpcold in addition. In neither case has it any strikingly offensive
smell.
It is often free from blood, but occasionally it has a definitely rusty
colour, simulating that of croupous pneumonia to some extent;
though even when it is definitely rusty it is seldom of the glairy
tenacious consistence that is so characteristic of true pneumonic
sputum.
Hemoptysis. —Apart from more or less altered blood in
the sputum itself, actual haemoptysis has been a very common
phenomenon.
In the slighter cases with this condition the sputum pot exhibits frothy
muco-purulent material in which occur streaks and splashes of bright red
blood in varying quantity. Thie blood is spat up as a rule independently
of the actual sputum, even if sychronously with it. In quite a con¬
siderable number of cases this haemoptysis has attained a degree com¬
parable to that of phthisis. The bed-clothes, wall, and floor have
become blood-spattered during a coughing paroxysm, and as much as
10 ounces of bright red blood may be coughed up in a few minutes.
The conclusion has sometimes arisen that an old phthisical cavity
must have beoome lit into activity by the new acute pulmonary infection,
but post-mortem examination in suoh cases has not confirmed this
suspicion, and there is little doubt that the haemoptysis is due in many
oases to the opening of small pulmonary arterioles by the acute infective
process, in others it may be due to the infarcts in the lungs which are
seen frequently at autopsy.
In cases of only slignt haemoptysis streaks and wisps of blood may
oome from the Intensely engorged mucosa of the lower trachea and
main bronchi, and in these the prognosis is not absolutely bad; when
considerable haemoptysis occurs it seems probable that it is due to
localised lung destruction, with the opening of arterioles before they
have time to thrombose, and the prognosis is grave.
We have only once seen a haemoptysis so abundant immediately
before death that the haemorrhage itself could be regarded as actually
the cause of death. On the other hand, we have seen cases with acute
and considerable hemoptysis recover, so that though a very grave
sign it is not a hopeless one; when the hemoptysis has been only
In the form of wisps and streaks we do not think the prognosis any
worse than it is in the cases generally.
A final reference as to hemoptysis must be made to a few cases in
which, after recovery has occurred and the patient has been apyrexial
for several days, he has begun to expectorate quantities of compara¬
tively fresh blood although no alteration in the symptoms occurs. In
all these cases—we have seen perhaps eight in all—nothing untoward
has developed.
Hemorrhage #.—Haemoptysis has been common, as just
described, but epistaxis has been £ar commoner.
This symptom is not confined to the “ pneumonic” cases, but has
been met with in a high percentage of the uncomplicated cases. We
do not think that the occurrence of epistaxls indicates any special
liability of the Influenza to develop into the dreaded “ pneumonic ” or
virulent type. In quite a number of cases the epistaxls has been really
severe and difficult to control; more often, however, it has been merely
a temporary nuisance liable to recur several times but invariably
oeaslng without treatment.
The blood from the nose has generally been bright red, suoh as would
come from a small arteriole if it were ulcerated ; and the prevalence of
this epistaxls acquires additional significance when one realises how
often the sphenoidal and ethmoidal sinuses contain pus at autopsy
(see Morbid Anatomy, below), this pus being found to be teeming
with pneumooooci, sometimes associated with Pfeiffer’s bacillus. The
epistaxls occurs early; it s character suggests erosion by an Inflammatory
process and encourages the suspicion that the pneumocoocl gain access
not primarily from the lungs, but from tne nose, naso-pharynx, and
accessory nasal sinuses, and we would consequently advocate the
wisdom of using simple antiseptic gargling and nasal douching as a
therapeutic measure in all influenza cases in the first stages, and also
emphatically as a prophylactic precaution in healthy individuals
exposed to the infection.
Hcematemesis has not been common, but we have met with
it in approximately a dozen cases.
In some of these there has been the possibility of epistaxls occurring
during sleep, the blood from the nosn having passed down Into the
stomach until enough has accumulated there to make the patient vomit
and bring up an alarming amount of blood not really derived from the
stomach at all. In a few cases, on the other hand, the vomiting of
swallowed blood could be excluded, and true haematemesis must have
ooeurred.
In one such case, for Instance, the patient was awake all the time ;
he vomited at 2 p.m , bringing up only mucus and partly digested milk;
at 4 p.m., without any nose bleed or hemoptysis in the interval or
afterwards, he vomited again and brought up over a pint of pure blood,
darker than fresh arterial. He had no particular abdominal pain, but
in this case, and in several others, we felt sure that there was some
bleeding breach of surface In the gastric mucosa, possibly of haemor¬
rhagic erosion type. Suoh haematemesis is not confined to the fatal
cases.
Melaena has also been observed .- but whether this has resulted from
swallowed blood in every case we cannot say. We have, however, met
with many cases in which a quantity of bright blood has been passed
per rectum; this has particularly occurred shortly before death.
H:nnattirin has attracted notice very seldom. In a small number of
cases the urine has been blood tinged or even red or blackish : but in
all of these that we have seen the hsematuria has been part of a
definite acute nephritis; the latter has been very common, and blood
cells may be found in the urine microscopically in a high percentage of
the “ pneumonic ” cases. Hsematuria apart from nephritis we have not
met with.
Purpura or other form of haemorrhage Into the skin has been very
uncommon indeed. In a malady associated with such severe toxaemia
we should have expected purpura to be common. We have met with
no case of generalised purpura. One oase had extensive purpura of the
extremities; another exhibited severe purpura of the legs between
knee and ankle, associated with a haemorrhagic bullous eruption of the
same parts. Both recovered.
Several cases have occurred of acute sudden painful oedema of one or
both feet associated with diffuse dull red deep seated purpuric tender
spots beneath the skin of the dorsum of the swollen foot, similar to
those described by Osier in cases of Infective endocarditis; possibly
both the swelling, the pain, and the tender purpuric spots on t he feet
in such patients are the result of local changes in the smaller vessels of
the parts—thrombotic or embolic.
Htrmorrhagc Jrom the ears has been seen by us In one oase only ; the
blood-staining of the pillow that resulted was extensive, but the total
blood lost was not great. It was the result, we think, not of any
special haemorrhagic tendency, but of blood-discharge from very acute
bilateral otitis media.
Other forms of haemorrhage have not attracted notice; we have seen
approximately 50 of the “ pneumonic ” cases in the female sex (mainly
in the Nursing Staff), but in none has there been any special tendency
to undue uterine bleeding.
A further indication of the haemorrhagic tendency is afforded by those
cases which have developed a pleural effusion. In the majority of
these cases the prognosis is relatively good, the fluid has been sterile
and the preponderating cell has been thelymphocyte. In a few cases the
fluid, wnlob has still been markedly haemorrhagio, has contained
pneumococci. In three cases a. sterile haemorrhagic fluid in con¬
siderable amount was obtained from one side of the chest and thick
streptococcal pus from the other.
The colour of the patient: heliotrope cyanosis. —Of all the
features of the “pneumonic” cases we would lay most
stress on the colour of the patient. He may not have much
colour at all, he may be hashed, he may be sunburnt, or he
may be plethoric; but whatever the degree of his facial
colour we have always been thankful when this colour has
remained red. It may be a sallow face with redness of the
lips and ears only, or the patient may be of a rubicund type
with general redness of his whole face, or he may be flushed
with the unnatural redness of fever ; but so long as his lip
and ear colour, whatever its degree, is red there is ample
room for hope of recovery, no matter what the lung signs,
the temperature, the pulse rate, or the respiration rate.
When, on the other hand, to reproduce the colour of the
patient’s facies, especially the lips and ears, one would need
to mix some heliotrope, or lavender, or mauvy-blue with red
paint to produce the right tint, the prospect is grave indeed,
even if at the moment the patient seems comfortable, has no
signs of consolidation in either lung, is sleeping fairly well
and taking nourishment, has no more than an ordinary
degree of pyrexia, a good pulse rate, not unduly fast, and a
respiration rate that may not strike one as being, unusual
in the circumstances.
This colour may be confined to the lips and can, or it may affect the
rest of the face as well; in either case it is the surest basis on which to
pick out those cases in a ward that are likely to be dead in a day or
two from those who, unless they themselves develop the same hue
later on, will most probably recover. It is not impossible for a “ helio¬
trope cyanosis” patient to recover, but that he should do so has been
the rare exception in this epidemic. The tint is precisely the same as
that whloh struck us so muoh in the cases of fatal “ purulent
bronchitis ” in 1916 and 1917; and it has been commented on by many
other observers.
The actual colour of the patients differ greatly, because some have
much, others little, blood in their superficial capillaries, and there is
every intermediate degree; but common to them all is the mauve or
heliotrope element that would have to be mixed with the red to repro¬
duce the hue in a painting. We do not pretend that all the serious
types are like the seoond of the ooloured illustrations which we
reproduce, but m«ny of them are exactly like it, and we have taken an
, unmistakable case to Illustrate with emphasis what we mean. We
would also lay muoh stress upon the fact that the dreaded tint gene¬
rally develops before the patient himself seems otherwise any more ill
than those around him who are going to recover. Once the hue is
there, however, treatment, as we have elaborated below, seems totally
unavailing.
The change of colour may come on In a few hours. In the morning
the man may be simply flushed but of good red colour, as in Plate I.
By the evening or the next morning, not necessarily feeling much
worse in himself and still quite cheerful and clear-headed though ill,
he may have developed some degree of the colour of Plate II.; and
then it is generally a matter only of hours, or at most a day or two
before he becomes of ghastly appearance like Plate III.
At one time we thought the colour might be due to methaemo-
globlmcmia. but the spectroscope shows no abnormal pigment in the
blood in these cases, nor is there any defect in the oxygen-carrying
capacity of the blood (see below); the condition is one apparently of
what Professor Haldane terms “anoxaemia,” precisely similar to what
is seen in gassed oases at the Front and possibly due to analogoua
causes, to judge from the histological changes seen in the lungs.
The breathing . —One of the most striking features about
the breathing in the “pneumonic” cases is the absence
of orthopnea even in patients who are breathing very
rapidly.
Amongst female oases the desire to be propped up by pillows Is not
so uncommon, but in regard to men one can go round a hospital and
see upwards of 500 esses In all stages of the disease, and it will be
exceptional to find even one who is desirous of being so supported. The
great majority lie at full length, and although It la probably goodi
Thb Lancet,] DRS. ABRAHAMS, HALLOWS, AND FRENCH : INFLUENZAL SEPTICAEMIA. [Jan. 4, 1919 5
practice to vaiy the patient’s position, so that he is not too long con¬
tinuously on his back, the patient himself prefers to lie flat.
This absence of orthopnoea applies as much to those with confluent
consolidation as to those who have signs of bronchitis only. It is not
dne to the patients being too ill to care, for the mild, the medium, and
the severe are alike in this respect. The probable explanation is that
the pulse remains good until quite at the very end, and there is little
dilatation or failure of the right ventricle. Failure of the right heart
fe the commonest cause of orthopmca in cases of dyspnoea without
obstruction to the bigger air-passages, and it is a striking feature of the
hearts of these cases at autopsy that its dimensions, right and left sides
sUke, remain practically normal. In a word, the cyanosis is not
cardiac.
The patients breathe with greater rapidity than normally, silently as
a rule, except in the terminal phase, and each respiration is short and
shallow. When left to themselves the patients may be breathing only
IS or 30 times a minute, but the slightest exertion, such as that
entailed by rolling to one side or trying to undo the buttons of the
shirt, increases this rapidity to 40, 50, or 60 per minute for the time
being, any liability to cyanosis being markedly increased at the same
time. There la clearly very little reserve power in the respiratory
system, but very few patients complain of difficulty in breathing unless
the respiratory movements are interfered with by the pain of acute
pleurisy. It is not a dys-pnoea, but rather a tacky -pnoea or poty-pneea.
Cough is troublesome in some cases, almost absent in
others.
It is apt to reour in paroxysms, and these may be very exhausting in
the cases in which there is little sputum. When the latter is abundant
It comes np fairly easily so long as the patient has a reserve of strength;
hi bad cases a time comes when the effort of coughing is too much, and
the patient, whose lungs are full of what would be better expelled,
neither coughs nor expectorates at all.
We have fonnd that a persistent cough is aii Indication for the
examination of the chest (undue examination is, of course, to be depre-
eated in these •• pneumonic ” cases) for evidence of fluid.
“ The pulse. —The heart does not fail as a rule, unless quite
as a terminal event.
It is remarkable how often, when the general appearance of a patient
shows he has only minutes to live, the pulse may still be quite regular,
of good volume, and not much faster, perhaps, than 120 per minute.
Barker, the pulse-rate is generally not faster than corresponds to the
degree of pyrexia; and oiten it Is less rapid than the ordinary
temperature-poise ratio would lead one to expect. There are, of coarse,
cases in which Irregularity develops, or the pulse races towards the
end; but, broadly speaking, the condition of the heart remains satis¬
factory throughout and the patients do not die from cardiac failure.
It Is noteworthy that in no single case did we meet with pericarditis
either clinically or post mortem. This, we think, will not prove the casea
in records from other districts, and we are surprised at not having seen
one case.
In one single case typical auricular flutter developed; this appeared
to be a direct result of the Influenza itself and not of the pneumonic
complications, for it was already present when the latter supervened
during convalescence from an ordinary influenzal attack. The man
irnriA no complaint about his heart though it was beating over 250 times
a minute and the pulse waves were too small to feel, and he was doing
well nntil he contracted pneumonic complications a few dayB after he
had seemed to have recovered. He had In fact been apyrexlal for two
days and had got up in the ward. Digitalis In large doses had an
excellent effect upon the pulse rate, which in just 96 hours from the
Institution of treatment fell to 90 beats to the minute.
Herpes facialis .—Herpes of the lips or chin or alas nasi
has occurred in a small number of cases, roughly speaking
5 per cent.
The eruption has seldom been extensive, though sometimes the
vesicles themselves and the inflamed area on which they stood have
become a haemorrhagic scab. In one case only has this haemorrhagic
tendency been extreme. In this patient the wide area of the eruption,
affecting both nostrils, the upper lip, the lower lip, both cheeks near
the mouth-margin, the chin and the neck for some distance below the
jaw, with the accompanying haemorrhage into the area of the eruption,
was like that of severe spirochetosis ictero-hsmorrhagica. But It was
not followed by a fatal result.
Herpes of the ears .—Sometimes with, but as often without,
herpes of the lips and face, herpes of both pinnae has
occurred.
The vesicles were generally disseminated over the outer aspects of
the pinna either'singly or In groups of two or three, and not as
coalescing patches. The eruption here was not associated with any
other special feature In the cases, but the soreness of the ears was a
trouble to the patient.
The eyes and eyelids .—Quite early in the disease the upper
eyelid tends to droop, as though the patient were half
asleep. This is illustrated typically in Plate I.
In the purely Influenzal cases, or In the "pneumonic” cases that
are not severely affected, this drooping of the upper eyelids Is Incon¬
stant, and the patient opens hls eyes fully when his interest Is aroused ;
but in the severer cases the droop persists even when the man is
spoken to; It is more than a mere state of being " heavy-eyed ” then,
and it is an unfavourable sign. The eyelids are those of a man who is
very toxic or half doped, and at the same time, in bad case s, the con¬
junctiva is dull and the eye looks dazed. The condition supports the
view that the symptoms are due less to the condition of the lungs
themselves than to the extremely toxic state of the blood and tissues
generally.
Delirium. —Mild degrees of delirium, especially in the
early hours of the morning, have occurred even in the
purely influenzal cases. In those with “pneumonic” com¬
plications there have been remarkable variations in the
degree of delirium presented by patients at different periods
of the epidemic and in different areas of the Aldershot
Command.
At one time hardly a single " pneumonic ” patient out of hundreds
presented any delirinm at all worth mentioning; then we meet with a
series of cases in which delirium lasting day and night, with hallucina¬
tions and a tendency to be physically and vocally violent, was pro¬
nounced. This delirium seemed unrelated to previous alcoholism, and
the cases in which it was most marked were not necessarily fatal. More
common than violent delirium with hallucinations was the low
muttering type, with the tendency to get shakily out of bed until nurse
came and put the patient quietly back again.
Upon the whole, however, delirium of either mild or \io1ent degree
was less marked a feature even of the severe and fatal cases than one
would have expected. On the contrary, it has been heart-rending to see
bcliotrope-cyanosed lusty great men breathing 50 to the minute, and
obviously bound to die within a brief hour or two, still clear-headed,
able to talk connectedly, not complaining and not obvioutly in physical
distress, yet fully conscious of what is about to happen to them by
reason of what they know has happened to their fellows from the same
regiment a day or two before.
On the other hand, there is a type of termination in which a restless
coma precedes death by many hours or even by a day or two. The
patient lies low in bed with his head thrown back, moving hls limbs or
his whole trunk restlessly from time to time, with partly opened mouth,
a ghastly yellow pallor of the hollow sunken cheeks, pallid lavender
hue of lips and ears, rapid sighing respiration, Incontinence of urine
and of faeces, a heavy closed-up-cellar sort of smell about the bed, but
complete oblivion and total absence of any suffering.
Siibsultus tendinum. —Apart from delirium, a high per¬
centage of the more serious cases, whether fatal or not,
has exhibited the following condition.
ThiB is not so much the " picking at the bedclothes ” tendency as
marked involuntary jerkings and twitchings, now of one leg, now of
the head and neck, now of a wrist or fingers, now of a whole arm, now
of one side of the abdomen or of the back—an extreme degree of sub-
sultus tendinum. So very twltchy and jerky have some cases been
that an overdose of strychnine has been the first suspicion, but the
condition has been common without Btrychnlne or any other drug
having been used at all. The symptom is further evidence that the
patients suffer from generalised toxaemia of severe degree, the badly
oxygenated state of the blood being perhaps an added factor In the
subsultus, the nervous system being starved of oxygen by reason of
the anoxhsemla.
Otitis media .—Deafness of some degree has been a fairly
common symptom, both in the purely influenza oases and in
those with 4 ‘ pneumonic ” complications.
Here and there a patient has become stone-deaf for the time being,
even when no quinine, aspirin, or salicylate has been administered. It
seems likely that the chief factor in the production of this deafness is
mlcroblc infection, perhaps pneumococcal, spreading from the nasal
mucous membrane to the Eustachian tube. In further confirmation of
this view is the fact that, though many of the cases have lost their
deafness spontaneously after a few days or a week, some have had
severe earache followed by otorrheea. The radical mastoid operation
has been required in two such cases already, and there may be others
still to be similarly dealt with. In one case the bilateral ear discharge
was so acute that it consisted of almost pure blood. Unfortunately we
have not ourselves been able to investigate any such ear case
bacterlologically.
Parotitis. —In about a dozen cases—one of the severe
“ pneumonic ” type which ended fatally, the others of
simple influenzal type—unilateral or bilateral swelling of the
parotid glands has developed when the patient was already
in hospital for his influenzal attack.
The chief difficulty in these cases has been to decide whether they
were examples of mumps developing during influenza or whether they
were infective parotitis other than mumps arising as a complication of
influenza, and this difficulty has been Increased by the knowledge
that an epldemlo of mumps has been simultaneously present In the
command. Orchitis did not occur, but even If it had done bo the
further difficulty of possible gonococcal orchitis would have presented
Itself - such orchitis is met with so often in men who fall ill witbr
something else. None of the parotid glands Involved in our oases
ended in suppuration. On the whole the swelling, whatever the
degree, was relatively painless, and ability to open the month fully waa
comparatively unimpaired.
Jaundice.— Jaundice has been quite uncommon in the
oases in the Aldershot Command.
No case has presented more than a slightly icteric tinge of the con¬
junctiva Through the courtesy of Captain Means, United States
Medical Service, however, we have seen 15 caseB of definite jaund ce in
"pneumonic’ influerzal cases in Unite* States troops; the condition
of all these men was grave at the time. Full details of these and other*
will, we hope, be published by the United States authorities.
The smell of the patients. —Just as many typhoid fever
patients have a peculiar smell which is difficult to describe,
but which is none the less almost characteristic, so do many
of the influenzo-“ pneumonic ” cases exhibit a peculiar faint
indefinite smell, best noticed, perhaps, when the bedclothes
are first turned back for purposes of chest examination.
It is not the sour smell of perspiration, nor is it merely feetorfrom
the coated tongue or the s«rdes that are apt to collect < n lips and gums
in tpite of the most careful nursing. It could nor be call* d pathogno¬
monic, bat it has seemed to us worth while to ca'l attention to it.
More than once it has been so pronounced that we have asked whether
6 Thh LANOBT,] DR8. ABRAHAM8, HALLOWS, AND FRENCH : INFLUENZAL SEPTICEMIA. [Jak. 4, 1919
the patient has had a small dose of paraldehyde or any aoch drug
eome time previously ; but the smell seems to have no relation to any
■drug that has been given.
Min several cases there has been quite a different smell—a real stench,
not of the mouth or of the sputum, nor the result of incontinence, but of
the patient's living body generally. It has no particular application to
those who have died of the disease, for In no case at autopsy has the
body presented any unusual odour, nor do the tissues decompose or
beoome evil-smelling with any undue rapidity, at any rate at the
temperature of the month of October.
Nephritu .—A high percentage of the “pneumonia” oases
suffer from acute nephritis, bat this fact would be missed if
reliance were placed upon clinical evidence alone.
There is no oedema of the legs, back, or eyelids. The amount of urine
passed dally is not lessened beyond what one would expect from the
pyrexia. In a series of cases daily measurements of the urine passed
varied between 45 and 70 ounces, with an average of 54 ounces.
It is very exceptional to find enough hsrmaturia for it to be recog¬
nised by the naked eye. In the course of routine urine examination,
however, albuminuria is found in some degree in nearly all the severer
cases; and in quite a large number the amount of albumin present is
from 1 to 5 parts per 1000. in association with renal epithelial cells, and
fragmentary tube casts, generally epithelial and often ill-formed owing
to the acuteness of the condition. Red blood corpuscles are seldom seen.
It Is most important that absence of all oedema in this type of very
acute nephritis should be realised to be the rule and not the exception,
and we would urge that the routine examination of urines should be
carried out with even greater zeal than usual during an epidemic of
this sort lest patients should be discharged as cured when really they
are still nephritic. It is from cases such as these that “ Rose Bradford
kidneys" arise later on—the small, white, granular kidney of
•* unknown ” origin.
Large, red, blood-oozing kidneys of the type seen in acute scarlatinal
uraemia have been almost constant at the autopsies of the fatal cases,
and the occurrence of this acute nephritis is further evidence of the
infecting agent, or at any rate its toxins, being widespread through¬
out the body, the “ pneumonic ’’ part of the disease being but a portion
of the w hole.
Localised abscesses .—The commonest form of localised
abscess in these oases is empyema.
Acute pleurisy is the rule rather than the exception. In many
cases this remains dry. but in many others it leads to the exudation
of a small amount of fluid, thin but turbid, often blood-stained, not
actual pus, though it contains numbers of polymorphonuclear leuco¬
cytes and organisms such as pneumococci. In fatal cases death
generally occurs before there is time for this to change to true pus,
and in cases that recover the fluid most often re absorbs spon¬
taneously, notwithstanding the presence of micro-organisms and pus
oells in it. Here and there, however, we have found cases in which
the fluid has gone on accumulating, and far from this proving a bad
omen, the majority of such cases have ultimately done well.
We do not think it wise to resort to surgical treatment of the
empyema with the same rapidity that one would adopt were the
Infection in the abdomen. It has seemed to us that when the infec¬
tion thus shows a strong attempt at localising itself to a definite pus-
focus the virulence of the general toxemia or septicemia has lessened,
as though from the formation of a “ fixation-abscess ’’ (vide infra). We
have come to regard it as a source for congratulation when one of these
patients, very gravely ill, develops a definite empyema; our view upon
the prognosis improves at once, and we have formed the impression
that, unless there are strong Individual reasons to the contrary, it is
wiser to wait a whole day, or even longer, before resecting a rib.
Another point that has Impressed us in this connexion is that simple
needling of the chest has been so often followed by Improvement in the
patient's general condition that we would advocate such needling
being done with less hesitation than is generally the case.
Subcutaneous abscesses of pyaemic nature have been seen
by us in two oases only.
Although recovery was slow both these cases, very gravely ill for a
long time, ultimately recovered. Painful, slightly swollen red areas,
generally of small size, developed now In one part, now In another—
perhaps a dozen altogether in the oourse of four or five days. One
or two of these broke down into pus, softened, and incision was
necessary, the rest resolved by themselves without forming abscesses.
Very grave though the outlook had appeared at one time in both
these cases, we are inclined to think the subcutaneous formation of
abscesses helped these patients to recover in some obscure way.
These cases may be analogous to that of the *' fixation abscess" pro¬
duced In the manner described below, and suggest a deflection of the
toxins to one focus, converting a septicaemia into a comparatively
benign focus of Infection.
Hemiplegia .—This occurred in one case only, and it was
preceded by auricular flutter for some days. We thought
the hemiplegia most likely due to a oerebral embolus from
an intra-auricular clot rather than to a cerebral haemorrhage
or to local thrombosis.
Phlebitis of one or other leg, with typical painful swelling
•of the whole limb, was met with in half a dozen cases.
In one or two the leg condition developed whilst the general disease
was at its height; in the others it was a phenomenon of early con¬
valescence. In none of the cases did the vein-clotting lead to any
«upporation locally, and the patients recovered gradually without
further complications.
Skin rashes .—We have referred above to one case of
purpura of the legs associated with haemorrhagic bullae
between knees and ankles, and to a number of oases exhibit¬
ing curious painful purple spots over the dorsum of the foot
accompanied by general oedema of one or both feet. We
have also referred to the absence of any generalised purpura
in our series of oases, though so many of them were so
extremely toxic or septic, and we have discussed herpes of
the lips and ears.
Other skin eruptions were infrequent.
In a small number there has been acute Inflammatory reddening of
the skin arcund the nose and nostrils, spreading for a variable distance
over the face, and presenting the characters of facial erysipelas; these
cases did not do badly.
In several there has been a widespread erythema of limbs, trunk,
neck and face, resembling the rash of scarlatina at first sight, but
exhibiting no characteristic puncta and differing from scarlatina in
that neck and face, as well as the trunk and limbs, might be involved
by the rash. This erythema could not be attributed to any drug, such
as aspirin, belladonna, or salicylate in some of the cases at any rate,
and it was not the result of serum Injections, though serum rashes did
occur in some of the cases treated with antitoxic serum.
In one case there was a generalised morbilliform rash without the
corjza or other phenomena of measles.
Meningitis .—Notwithstanding the extreme severity of the
general infection and the recovery of pneumococci or strepto¬
cocci from the blood and viscera post mortem and even
during life, meningitis has not been met with as a phenomenon
of influenzo*pneumonic cases.
Several patients suffering from acute meningitis have been admitted
as cases of Influenza, but these have all been found to be meningococcal.
A certain number of cerebro-spinal fever patients come in all the year
round, but the number has. on the whole, been appreciably smaller
during this Influenzal epidemic than it has been in general. It would
not be surprising if here and there amongst the thousands an instance
of rlmultaneous influenza and oerebro-splnal fever should occur, and
we believe that this has happened, but we do not regard the meningo¬
coccal meningitis we have thus seen as essentially related to the
Influenza. The existence of a widespread eptdemic of severe influenn,
however, does make the early recognition of oerebro-splnal fever more
difficult than ever.
In no case of “pneumonic" influenza seen by us post mortem has
there been any obvious meningitis.
Finally, a fairly extensive investigation of severe cases of Influenza
with special reference to the cerebro-spinal fluid, yielded in all cases an
absence of any evidence of Increasing intracranial pressure; the fluid
was always clear and contained no excess of albumin, very few oells,
and was always sterile.
Ruptured rectus abdominis muscles .—In upwards of 20 cases
we have seen spontaneous rupture of one or both rectus
abdominis muscles, generally in that portion of the muscle
which lies below the level of the umbilicus.
The effort of coughing is apparently the Immediate cause of this
rupture, but the muscle has beoome diseased before it breaks. Some¬
times one finds the rectus extensively affected post mortem without
actual rupture having oocurred. In most instances, even when there
has been no rupture, the affected portion of the muscle presents the
same sort of appearance as does the breast of a pheasant when one skins
the bird after It has been badly shot at close quarters; the muscle la
dark orimson, of bruised appearance, full of diffusely extravaaated dark
blood, friable, readily torn by the fmgers, and it may be squeezed Into a
pulpy mass without much force.
Why this muscle in particular should be affected in this way we do
not know, unless it is the result of vessels in it giving way in con¬
sequence of violent coughing efforts. Doubtless the lesion is related to
Zenker’s degeneration of the muscle such as occurs in other infective
maladies, enterlca for example; but in ordinary Zenker's degeneration
the muscle Is pallid and not haemorrhagic, whereas in the present cases
the lesion has gone on to a local haemorrhagic pulpy state even if the
muscle has not been actually ruptured during life. Both rectus
abdominis muscles are apt- to oe affected at the same time in cases In
which either is affected at all; that is to say, bilateral rupture has been
as common as unilateral.
Subcutaneous emphysema of the chest wall .—In about 15
cases altogether palpation has elicited the striking pheno¬
menon of widespread subcutaneous crackling of the deep
tissues of the chest and neck and back, the result of
subcutaneous emphysema.
This has always started on one or other side of the thorax itsel',
generally in front or towards the axilla rather than behind, spreading
rapidly over a variable extent of the whole thorax and even to the
neck, where it may form a complete collar of crackling swelling. It
is an event of very grave import, though one case at least recovered
after its development.
It is generally difficult to demonstrate post mortem how the air
reaches the subcutaneous tissues. One explanation is to assume its
origin from the lung root via the mediastinum; but in some cases at
least it results from a small acutely necrotic focus in one lung ulcerating
directly through both layers of pleura Into the extra pleural tissues.
Minute or small superficial abscesses In the lungs are met with in quite
a number of cases; these are surrounded by sticky pleuritic exudate
sufficient to prevent the development of pneumothorax when the
visceral pleura is ulcerated through at a pin-hole point. The parietal
pleura becomes Infected by direct extension, and it only needs a pin¬
hole perforation in it, too, to cause the subcutaneous emphysema of the
chest wall which has* been so striking In certain cases in this epidemic.
That acute ulcerative or focal necrotic changes in the lung tissue ate
in this way the cause of the emphysema 1 b further suggested by the
way the onset of the subcutaneous crackling has not infrequently
been simultaneous with acute haemoptysis, as though the focal lung
necrosis opened up an arteriole at the same time. Nearly all these
patients die.
ThbLanobt.] DBS. ABRAHAMS, HALLOWS, AND FRENCH : INFLUENZAL SEPTICAEMIA. [Jam. 4, 1919 7
Morbid Anatomy.
The Lungs.
Although we believe that the infection is widespread
and not confined to the lnngs, the patients exhibit a pre¬
ponderance of chest phenomena, so that naturally the lnogs
attract first attention at autopsy. We would emphasise,
however, the bacteriological findings in the heart blood and
spleen, and the prevalence of acute nephritis, as indicating
that the lung lesions are very far from being the whole
basis of the so-called “ pneumonic ” cases. We think that
the fatal disease is an influenzo-pneumococcal or influenzo-
streptococcal septicaemia with more or less marked local
lesions in the lungs, but we do not think it is in the main a
lung disease any more than we would regard enterica as
essentially a bowel malady, notwithstanding the ulcers in
the ileum being the chief lesions found post mortem in
typhoid fever cases. '
In the next place, although the physical signs during life
may often be precisely those with which one is familiar in
lobar pneumonia, it is absolutely exceptional to find the
straightforward typical hepatisation—red or grey—of true
croupous pneumonia.
Only in one single case have we found what appeared to be true
red hepatisation—and this was in two-thirds of one lobe only, the rest of
the lungs presenting broncho-pneumonia, hemorrhage, and bronchio¬
litis of the type described below. In one other case a small portion of
one lobe looked like grey hepatisation in contrast to the multiple and
diverse lesions elsewhere in the same lung.
True lobar pneumonia is not what is found post mortem in the vast
majority of the cases. Whole lobes may be consolidated and in an
anatomical sense the lesion is “lobar"; but the term “lobar pneu¬
monia ” has come by common consent to be a particular and well-
defined variety of lobsr consolidation, and one does not use the term
“lobar pneumonia" of every form of lung consolidation that happens
to have a lobar distribution.
In the next place, though some variety or degree of con¬
solidation has been the rule throughout the serious cases in
the present epidemic, we would lay much stress upon the
fact that here and there an autopsy reveals practically no
lung consolidation at all.
The lower lobes may he dark-red, almost black-red, heavy, (edematous,
congested, the upper lobes pale and distended; but no part of any
lobe actually sinks In water, or. at any rate, only tiny portions, care¬
fully searched for, found with difficulty, and cut out with fine scissors.
These oases without consolidation have run almost identically the same
clinical course as those with much, and It is one of the striking features
of the disease that the extent of the lung consolidation is no measure
whatever of the severity of the infection.
This is precisely what struck us when we wrote In 1917 about
“purulent bronchitis.” Fatal cases of the latter exhibited varying
degrees of broncho-pneumonia associated with bronchitis or bronchio¬
litis or without any broncho-pneumonia at all. And we believe that
the “purulent bronchitis " then described was only one type of a con¬
dition which has recently shown itself to be remarkably protean.
The next point to emphasise is the absence of thick
abundant bronchlolar pus in our own cases at the present
time.
In the “ purulent bronchitis ” cases one of the most marked pheno¬
mena poet mortem was the way In which thick yellow pus welled in
smaller or larger spots and dots from all the bronchioles when the lung
was cut. This peculiarity has been strikingly absent in the great
majority of the recent Aldershot influenza cases, only small quantities
of pus being expressible from the tubes, as a rule. And yet In pre¬
cisely similar “ influenzo-pneumonia " cases seen in another command
during the same epidemic the amount of pus expressed from the
bronchioles was similar in amount to that of the “ purulent bronchitis’’
cases. There Is nothing constant about the lung lesions, and what may
be true of a group of cases in one place may not hold good for another
group of oases elsewhere, although the disease in general is clearly the
same in both.
We will now try to indicate the kind of lesions met with,
as a rule. It is not easy to depict these because they are
so variable in the degrees and extent to which the following
various conditions may be mingled together, namely :—
Pleurisy.
Compression (by fluid).
Interstitial emphy-
semi.
Bronchitis and peri¬
bronchitis.*
Gangrene.
Bronebo-pneumooia. Multiple small areas
CBdema. of collapse.
Bxtreme congestion. Massive collapse.
Diffuse haemorrhage, Formation of absoessee,
not solid. generally small, but
Solid haemorrhage. often multiple and
Infarction. aggregated.
* Difficult to demonstrate macroscoptcally, but shown to be extensive
microscopically.
One case may exhibit extreme congestion and oedema, with dis¬
seminated non-confluent broncho-pneumonia, subpleural haemorrhages,
and angry-looking purulent pleuritic lymph.
The next may have complete consolidation of both lower lobes by
confluent broncho-pneumonia without any pleurisy at all.
The next mav have not lobar consolidation but irregular maesss which
are more easily felt than seen, of deep crimson consolidation due to
combined broncho-pneumonia, collapse, and hemorrhage, scattered
widely through all the lobes of both lungs, with or without acute
pleurisy.
The next may have one entire lung apparently healthy, the upper
lobe of the other pale and over-distended, and the remaining lower lobe
heavy, nearly but often not totally airless, of a consistence to suggest
spleen rather than liver, and of a dull, deep-slate colour externally,
still further suggesting a post-mortem spleen.
The next mav have broncho-pneumonia, more or less extensive in the-
lower lobes with firmer wedge-shaped areas amongst the latter strongly
suggestive of infarcts; whilst the upper lobes, free from broncho-
{ meumonia. may present from one to half-a-do/en or more typical
nfarcts. generally not large, of deep red colour, contrasting with the
paler hue of the rest of the upper lobes.
In another case these infarcts may not be uniformly deep red. but
pale, with crimson margins, due to the breaking down of the central
parts into one or more incipient small abccesses.
Again, there may be no definite infarct, and yet over a more or less
circumscribed region of one lobe, and often just below the pleura, as if
they were originally in an infarct, one may see 20 or 30 pale yellow,
slightly prominent areas, each of which turns out to be an incipient
abscess or even a definite necrotic focus from which the contents
can be washed out with a medium stream of water or readily ex¬
pressed with the finger. It is from such superficial abscesses as these
that perforation of both layers of pleura and consequent subcutaneous
emphysema may arise; and if thi9 is the sequence of events it is easy
to understand why the development of subcutaneous emphysema
generally prognosticates a fatal tennlnatioo.
What the pathology of the infarcts is we cannot say with
certainty.
Very possibly they are thrombotic and not embolic, in which case
they point to severe changes In the vessel walls and perhaps in the
blood itself. On the other hand, when one considers the frequency of
purulent infection of the sphenoidal air cells (see below) one feels that
thrombosis of venules in the neighbourhood of the bane of the skull,
where they are difficult to demonstrate either clinically or post
mortem, is not an improbable event, leading perhaps to small but
virulent septic emboli of the lungs with Infarction and the formation
of abscesses in the infarcts.
Perhaps both thrombotic and embolic infarcts occur; in either case
their occurrence, not by any means in all cases but none the less in
many, is a reminder that the vascular route of long infection must not
be forgotten. It seems highly probable that much of the lung mischief
is due to direct Invasion through the respiratory passages—from main
bronchus to bronchioles and from the latter to the alveoli, bronchitis
preceding broncho pneumonia. But an ither route may be via the
blood stream, thus accounting for the great severity of the infection
and its high mortality.
Apart from actual iofarcts, h.rmorrhage into the deep lung tissue
has been very common. Sometimes it is diffuse and difficult to
demonstrate, owing to the already very deep crimson colour of the
congested lung ; but even then one can see it in the form of very dark,
almost black, patches or ill-defined diffuse network, or a bigger
localised mass which can be felt and which sinks in water.
. The lower lobes have been affected very ranch more
than the upper, though apical consolidation with oonflnent
broncho-pneumonia is met with in a few instances.
With few exceptions the colour of the lower lobes has been deep
crimson from extreme congestion, and very marked <rd9ma of the lower
lobes has been the rule, frothy blood-rtained serous fluid pouring from
the cut lungs when they are geatly squeezed. This <rdema is respon¬
sible for much of the increased weight of the lower lobes, and it oooure
equally whether there is much broncho-pneumonia or little.
Although we have met with manv cases with multiple small areas of
necrosis or abscess formation, and many in which the lungs were
pulped with ease by the hand, much in the same way as a decomposing
spleen may be squeezed to pulp, we have met wltn no case so far of
actual gangrene of the lung, and there has been no odour suggesting
incipient gangrene. Perhaps this is due to the rapidity witn which
the disease progresses, so that patients have died before there has been
time for true gangrene to develop.
We have met with no case of pneumothorax.
Pleurisy has been very variable in its incidence.
Quite a number of consecutive caseo have exhibited acute pleurisy
of the “ lack-lustre" type with little or no fibrinous exudate and no
free fluid, the aoute pleurisy affecting one or both lower lobes, and
much less often an upper lobe. Another group of cases have demon¬
strated no naked-eye evidence of pleurisy, although tbelntra-pulmonary
lesions may be various and abundant. It has been exceptional to find
much free fluid in the pleural cavity; one or two ounces of turbid
bl »od-tinged fluid are present in a fair number or cases, but a large
effusion has been exceptional postmortem. This is partly due to the
recognition of fluid in the chest during life and its removal by aspira¬
tion, for fairly large pleuritic effusions have not been particularly
uncommon in the wards. It is also partly due to the recovery of the
whole of those cases In which the fooallslng effect of a copious effusion
has been the patient's salvation.
The thin turbid fluid is clearly of the nature of an empyema, but it is
not actual pus; it may become pus and need operation clinically, but
we have not seen more than one or two cases of actual empyema In this
disease post mortem. Wc think the empyema cases tend to do well
for the reason stated above.
Interstitial emphysema In the form of a fine melon-rlnd network
beneath the pleurir has occurred in several cases; the condition is
doubtless the result of inflamed alveolar walls giving way under the
•tress of coughing efforts.
Acute bronchiolitis is nearly always present.
The histological changes In the lung tissues must be postponed for a
subsequent communication. We would only say here that in many
sections there is an appearance in and around the bronchioles and
Inside the alveoli which at first makes one think that the paraffin has
been imperfectly removed from the tissue. We thought at first that
this was actually the cause of the appearance Been, but on further
testing it seems that the appearance Is due to a homogeneous structure-
lets non-cel I ular exudate which tills the bronchi -lea and the peri¬
bronchiolar tissues and forms as it were a plastering ronnd the Inside
of the alveoli. It is not florinous like the exudate of croupous pneu¬
monia. Presumably it is aa albuminous exudate, coagulated in the
process of fixation, and It is very similar to that which can be seen in
fatal eases of poisoning by chlorine gas.
$ Th* Lancet,] DRS. ABRAHAMS, HALLOWS, AND FRENCH : INFLUENZAL SEPTICAEMIA. [Jan. 4, 1919
This albuminous exudate throws much light on the nature
of the dreaded cyanosis. If the oxygen in the alveoli has
to traverse this albuminous layer in addition to the alveolar
wall before it can get to the haemoglobin of the blood, it is
evident why there is such marked anoxaemia.
Other Pott-mortem Findings.
The larynx, trachea, and bronchi .—Starting at a variable
distance down the trachea, often near the top of it and
sometimes in the larynx itself, there is reddening and con¬
gestion of the mucosa, the depth of crimson increasing
rapidly as one passes down the trachea, until in the main
bronchi the dark-red colour is extreme.
•That there is tracheitis and bronchitis in addition to whatever
<<hanges there may be in the lungs suggests strongly that, even if a
blood infection does occur as well in the way we suggest, invasion of
the 'respiratory tissues by extension from above downwards is pretty
constant. In addition to deep crimson congestion there is often a
granular appearance of the surface of the mucosa of the lower part of
She trachea and of the main bronchi, suggestive of a small amount of
exudate upon the surface. This may even reach the stage of giving
the appearance of a very fixed milky film over a crimson base, but we
have not seen the definite membranous exudate described by others.
When viewed in an oblique light the Inflamed mucosa often exhibits
multiple minute depre«ions. very shallow but well defined. These
look like extremely small surface ulcers not penetrating the whole
thickness of the epithelial covering, but they may, on the other hand,
he merely normal unevennesses exaggerated by the congested swollen
fltate. As yet we have not settled this point histologically.
The bronchial glands .—The lymphatic glands below the
bifurcation of the trachea have been found enlarged and
crimson from injection in praotically every case, and as a
rale they have been not merely large bat very large.
In one case only had actual suppuration occurred in a big gland
below the right bronehus; in this Instance it contained fully
•2 drachms of pus. It had not burst to produce mediastinal suppura¬
tion, though It seemed clear that this must have been the result if the
fNitient had survived a day or two longer.
The glandular infection is not confined to those about the main
bronchi; the glands in the root of each lung, in the superior and
fK>sterlor medlastina, and the deep glands up the neck even as high
«s the crieoid cartilage also are often enlarged and deeply crimson
from inflammatory congestion. We have not noticed similar involve¬
ment of glanis elsewhere —for example, in the abdomen.
The thyroid gland .—Considerable enlargement of the
thyroid gland has been the rale.
In one or two cases the swelling has not been less than that seen in
an average case of Graves’s disease, and the Isthmus was enlarged in
the came proportion as the lateral lobes. Presumably this enlargement
of the thyroid is the result of the general toxaemia, corresponding in
this respect to its enlargement in some other forms of toxic trouble; at
any rate. It has been quite pronouuoed and almost constant in our
•cases.
The heart .—The most remarkable feature about the heart
is the general absence of dilatation.
In quite a large proportion of cases tho-e has been no trace of dilata¬
tion ; in a fair number of others there has been some dilatation of the
right side, but this has se'dom been extreme, perhaps enough to cause
the apex of the heart to be formed about equally by right and left
ventricles. Most often the heart has appeared of normal dimensions
and the apex has been formed entirely by the left ventricle. This
absenoe of dilatation accounts for the clinical absence of orthopnoea.
Whether or no pericarditis ever occurs, we have not met with one
«aae of it yet; and the same applies to endocarditis.
We have also been struck by the absence of subpeticardial petechia;,
eaoh as are generally met with in very toxic conditions.
The spleen .—In many cases no enlargement of the spleen
has been evident; in many others it has been slightly
-enlarged—half as big again as normal, or, exceptionally,
twice its normal size. It has never been pronouncedly big—
never big enough, for example, to have been palpable below
the rib margin.
In most cases the splenic substance has looked normal. In a few
there have been multiple small areas of increased firmness and darkened
-colour, due apparently to quite small lufarcts. In two cases there have
teen massive and unmistakable infarcts, one of which was alreadf
aoftening into an abscess. Whether these were embolic or thrombotic
It is difficult to say, but in the absence of endocarditis their thrombotic
nature seems the more likely.
In one or two cases there have been multiple ill-defined small areas
paler than the rest just beneath the capsule, not firm like Infarcts, not
palpable at all, and yet on close inspection seeming to be very slightly
swollen above the general contour of the organ. None of these have
ahown any tendency to break down, bnt there have been granules and
4ag« of recent fibrin on their surface, so that they would appear to be
foci of localised infection in the spleen with focal acute capsulitis
aver them.
The liver .—The liver has been in nearly all cases of a paler
brownish-red colour than normal and moderately increased
In bulk, but otherwise not obviously affected. The naked-eye
changes are those common to any acute febrile illness of
short duration. There has been no undue congestion, still
less any nutmeg change.
The stomach , intestines, and vermiform appendix .—The
Alimentary canal has not exhibited any particular change.
We have had no case of pneumococcal or streptococcal peritonitis.
The stomach and intestines have been relatively empty, for the patlenta
have been too ill to take food. There has been no special tendency to
over-distension of either the stomach or the bowels with gae.
The vermiform appendix has not shown any notaole change. We
mention this because there has been a tendency elsewhere, we have
been told, for certain of these infiuenzo-pneumonio cases to develop
acute appendicitis.
The kidneys. —These, in the fatal cases, have presented
uniformly, the same, or approximately the same, appearances.
They are of slightly larger size than normal, the capsules peel
readily, the stellate veins upon the surface are not markedly obvious,
the colour Is dull purplish red but not strikingly abnormal, but on
cutting each kidney open in the ordlnsry wav and leaving It to lie for a
moment, tbe cut surface rapidly becomes obscured by dark red blood
which wells slowly but steadily from every part of the organ,
particularly from the glomerular region. On close inspection one oan
me the reddened swollen glomeruli fairly easily, and on pressing the
organ the blood oozing becomes still more pronounced.
There Is no evidence of cardiac passive congestion, the pyramids are
not particularly more cyanosed than is the cortex, the whole condition
Is reminiscent of acute soarlatlnal nephritis. After scarlet fever the
large red kidneys are described as “ blood-dripping ”; In the present
cases the kidneys are rather “blood-oozing"than “dripping,” though
If they are held up and gently pressed they drip blood slowly in fair
amount.
Histologically there is confirmatory evidence of acute nephritic
changes, particularly of the “ acute glomerular ” type. Details of this,
as of other histological appearances in these oases, must be kept for
another section; but that so many, if not all, of these fattl influenzo-
pneumonia cases have acute nephritis even though they have no
(edema is, it seems to us, a point of much importance.
The sphenoidal and other accessory nasal sinuses .—We have
examined the sphenoidal and ethmoidal air cells in 20 con¬
secutive cases.
In one only was there no naked-eye evidence of disease of one or
other or both, particularly of the sphenoidal which lends itself most
easily to clear examination. In most of the 19 there was definite pale
bright-yellow pus In the sphenoidal air cells: in several this pus
squirted out on to the chisel used for opening the bone. When there
was not thick yellow pus there was turbid serous fluid with angry red
congestion of the lining membrane and adjacent parte. Doubtless this
is one factor In the severe headache from which Borne of the patients
complain, when they are not too ill to complain at all.
We did not examine the frontal sinuses or the middle ear
as a routine. We are much impressed, however, by the
frequency with which the sphenoidal air sinuses are infected
or full of pus, and we must add in passing that we think this
serves to emphasise the importance of the uppermost air
passages, especially the naso-pharynx, in connexion with the
disease. It is very unlikely that the sphenoidal air cells
became infected secondarily to the lungs. In some cases
the total length of illness had been so short that, for so
much purulent fluid to have been present in the sphenoidal
air cells, infection in that region must have been present
from the start. When the frequency and severity of
epistaxis is remembered, as well as the tendency to otitis
media already commented on, the importance of the naso¬
pharynx as a likely site from which the whole trouble starts
can hardly be exaggerated. The practical issue of this
surmise should be insistence on tbe simple antiseptic toilet
of the nose and throat—by nasal douche and gargle —once a
day or oftener both by healthy individuals exposed to the
danger of infection, and by the influenzal cases themselves
at the earliest possible moment before they are too ill to
gargle or to douche.
The bacteriology of the sinus infection is dealt with lower
down.
Treatment.
Treatment of influenzal cases naturally divides itself into
two categories—that directed to the general run of simple
uncomplicated cases, and that which has been tried for the
virnlent septic®mic group.
Uncomplicated Cases.
The first group is readily dismissed. Although a large
number of different remedies have been recommended and
vaunted as 11 specific ” for the early treatment of influenza,
consideration of their application with controls upon a very
large scale has encouraged us to doubt whether the course of
the disease is modified or abated in the slightest degree by
any one of them. And in this connexion we would like to
add our gradually increasing conviction that although
common sense naturally dictates the greatest reasonable
precaution possible even for the mildest case, yet the
virulent type appears to originate ab initio and to develop
in spite of early treatment. We have been struck so
frequently by the change in character of the mild into the
virulent type in spite of every care in the early stage that
the conclusion appears to ns irresistible that development of
the virulent type was unavoidable.
The Lancet,] DRS. ABRAHAMS, HALLU*V3, AND FRENCH : INFLUENZAL SEPTICAEMIA.
[Jan 4, 1919
Fig. 1.—This illustrates an early case in
which the facial colour is frankly red,
and the patient might not appear ill
were it not for the drooping of the upper
eye lids, giving a half-closed appearance
to the eyes.
Fig. 2. — This illustrates a pronounced
degree of the “ heliotrope cya¬
nosis.” The patient is not in
physical distress, but the prognosis
is almost hopeless.
Fig.3.- Thisillustratesanother
type of the cyanosis, in which
the colour of the lips and ears
arrests attention in contrast
to the relative pallor of the
face. The patient may yet live
for twelve hours or more.
THK “HELIOTROPE CYANOSIS” OF 1NFLUENZO-PNEUMONIC SEPTICAEMIA.
Tra Lanott,] DR8. ABRAHAMS, HALLOWS, AND FRRNOH : INFLUENZAL SEPTICEMIA. [Jan. 4, 1919 9
As a routine procedure every case was given calomel gr. iv.
and mag. aulph. 5 *»• on (he following morning. Aa * specific ”
remedies we employed ol. cinnamon, aspirin, quinine, and
sod. salicylate, and our ultimate ooncluaion has been that
althoagh drugs at this stage are of value aa symptomatic
remedies no value attaches to their application either in
cutting short the duration of a mild attack or in preventing
its development into the more serious type.
Qainine merits a word of special reference, since its
advantage as a prophylactic has been loudly acclaimed.
Whilst it is impossible to declare that no defence whatever
is produced by this drug, we nan at least publish the experi¬
ence of seeiug eight cases in men who bad for a month
previous to their admission to hospital with influenza been
taking 10 grains of quinine regularly everyday for malaria.
Finally, we would aid a warning that the attempt to
belittle the condition and allow the patient to return to his
ordinary duties after a short febrile period has been poor
economy. In very many cases — we are speaking of the
present epidemic, as distinguished from the cases in June,
which took a much milder course—a recurrence has occurred
on the third day after the patient has been allowed to rise ;
and we consider it highly necessary to insist on at least three
afebrile days before the patient gets up at all, and then three
clear days up and dressed with relative inactivity before he
is permitted to return to his unit even for light duties.
Treatment of the Virulent Type of Cane.
In the earlier cases reliance was placed upon (1) the
employment of oxygen in the orthodox fashion ; (2) the
administration of cardiac stimulants ; and (3) venesection.
It is convenient to consider venesection first. Notwith¬
standing the absence of right-sided cardiac dilatation, the
blue appearance of the patient seemed analogous to that of
a typical pneumonic case in which venesection was indi¬
cated. and suggested this form of treatment. In no case
has venesection produced the slightest improvement, not
merely in the patient’s general condition, but even in the
degree of cyanosis. Apart from other considerations, the
act of venesection itself is unsatisfactory. The blood flows
with great difficulty, and only with prolonged perseverance
has it b-en possible to extract the quantity likely to be of
any benefit; in fact, the absolute failure to ameliorate the
condition induced the conclusion that mere venosity of the
blood alone was not the cause of the colour, but that some
change had taken place in the blood itself which prevented
its taking up oxygen, as, for example, the formation of
methsemoglobin or even of some other pigment which had
destroyed its capacity for carryiog oxygen. Such a con¬
clusion has, however, been completely disproved by the
absence of any characteristic bands in the spectrum, and
also by our experiments upon the oxygen-carrying capacity
of the blood, which showed in all cases a condition fully
equal to the normal, and in a few cases, presumably owing
to pdycythaemia, actually surpassed normal controls.
Similarly, the employment of oxygen in the routine fashion
10-15 minates at a time failed to produce even temporary
relief. Reference will be made later to the continuous
administration of oxygen.
With the failure of venesection, sal ne infusions were next
adopted as a routine procedure in all “ blue” cases. Sub¬
cutaneous, or rather Intramammary, introduction was found,
with one curious exception (vide infra), to produce no
improvement. On the principle that a more immediate
effect might be produced by intravenous medication, this
route was substituted for the subcutaneous method, but wirh
no greater success. And, again, no more favourable report
is possible in the case of the simultaneous processes of vene¬
section and intravenous injections, which other observers
have claimed to employ with satisfactory results.
With the failure of saline infusions, addition of various
substances to the saline solution was instituted on more or
less empirical lines. On the principle that “acidosis”
was playing a part in the production of ovano«is sodium
bicarbonate in various quantities was used, and later glucose
in 1, 2. and even 4} per cent, strengths of solution.
The specific treatment by Mul ford’s anti pneumococcal
serum, administered intravenously, was tried in a few cases
only owing to the comparative difficulty of obtaining large
quantities, but no results accrued to encourage its employ¬
ment on a large scale.
And. indeed, h wever lamentable such an admission must
be, we must place on record the conclusion that not one
single line of treatment can be credited with the capacity of
saving one of the virulent cases. Certainly desperate oases
recovered though few in number, and in not one of these
cases was any special line of treatment adopted.
A striking instance was afforded by one particular case
whose condition was so extremely grave as to appear hope¬
less, so much so that it was felt to be unfair to adopt any of
the special methods of treatment which were on trial, for
failme in this case could hardly be a reflection upon the
adequacy of the treatment. And yet this case was one of the
very few extreme cases which recovered.
Other forms of 'treatment.
It has been mentioned that one curious exception occurred
in the treatment by subcutaneous saline injection. In this
instance suppuration occurred at the site of inoculation with
sloughing of the tissues and the formation of an abscess, in
the pus of which were identified Staphylococcus aureus and
a streptococcus morphologically resembling the organism
recovered from the heart’s blood in some of the fatal cases.
The patient made a complete recovery, although a week
previously his condition had appeared hopeless. On the
principle of forming other “ fixation abscesses ” of this kind,
intramammarv saline infusions were then resumed in another
series of cases, the idea being that injury to the tissues by
distension with the fluid might lead to the same happy result
as in the case referred to. Not a single case, however,
responded in similar fashion, nor was any improvement
otherwise obtained. In a more heroic attempt to encourage
abscess formation alive culture of streptococci obtained from
the heart’s blood of a fatal case were injected in a dozen cases,
the dose administered being estimated at 15 millions. In not
a single case did any suggestion of suppuration appear at the
site of inoculation, and of the 12 cases upon whom this
treatment was tried 8 died. It only remains to be added
that the fo ir who recovered were severe but not desperate
cases, and it cannot be -supposed that the culture contributed
in any way to their recovery, as dozens of similar cases
recovered without such treatment. Injections of turpentine
were aho employed, but without any advantage.
On the presumption that want of oxygen was the cause of
the cyanosis and presumably of death, the continuous adminis¬
tration of oxygen by the Haldane apparatus, similar to that
employed in “gassed ” cases, was then undertaken. It must
be added that only a certain percentage of cases are suitable
for this treatment which, as recommended by Professor
Haldane, must be practically continuous for many hours. The
patient mu-t be sufficiently intelligent and compos mentis to
understand the persuasion that it is necessary for him to
tolerate any slight discomfort for the sake of the ultimate
gain, and the application is impossible in the case of patients
with pulmonary secretions which soon foul the apparatus.
We cannot state that any real advantage arose from this
method of treatment. A few patients admitted a certain
temporary gain in comfort at the end of several hours,
although ultimately death ensued; the majority resented
its application altogether.
The stimulant employed as a routine procedure was
brandy, 4 oz. in 24 hours being administered. Strychnine
was found to be unsuitable. It appeared to excite the
patients unnecessarily and increased delirium ; and whilst
of no value to the sufferer was the cause of much annoy¬
ance and distress to other patients by the noise produced.
8edatives were also employed, principally bromide,
hromide and chloral, tlnct. opii and morphine hypodermic¬
ally, but the last named alone appeared to have any value
in producing sleep or quietening delirium. Paraldehyde
has been more recently tried, but at the time of writing no
definite conclusion in its favour can he stated.
Emetics were administered in a few cases in which, from
the chest signs, expulsion of purulent material might have
been expected. La ge doses of vinum ipecac, and vinum
antimoniale proved useless ; emesis was induced by apo-
morphine hypodermically, but no relief could be noted.
We may perhaps anticipate one criticism of our attempts
to treat the virulent cases under consideration. It may be
argued that the value or otherwise of no line of treatment
can be estimated by its application to moribund or desperate
cases. This, of course, is perfectly true, but, as we have
found reason elsewhere to mention, it is impossible to esti¬
mate the severity or the probable development of severity
of a case; and to apply any line of treatment indis¬
criminately to all cases on the principle that some might be
10 The LANOHT,] DRS. ABRAHAMS, HALLOWS, AND FRENCH : INFLUENZAL SEPTICAEMIA. [Jan. 4, 1919
prevented from developing into the virulent type would be a
useless method of estimating the value of the treatment,
since the large majority of cases which spontaneously
recover would have to be credited to the particular treat*
ment under consideration. It cannot be argued that any
time was lost once the suspicion arose that a desperate case
was to be anticipated, and since it is obviously impossible to
quote actual statistics under this head, we can only express a
conviction that so far as our observation extended nothing
prevents the development of the serious case from one
apparently trivial, and nothing can claim to avert the course
of its virulence once it has developed.
Prognosis.
This leads us to say a few words on the question of
prognosis. The great majority of cases of influenza, of
course, recover. What particular percentage comes into
this category it is not possible to decide, since the 3800
or so cases admitted to the Connaught Hospital during the
recent epidemic afford no indication as to the total number
of cases in the Command, and the difficulty of obtaining
figures sufficiently reliable to be of value has been insuper¬
able. The comparatively mild cases are treated in large
numbers at their own units, only those who are clearly from
the outset of comparative severity or those in whom pyrexia
has persisted for 48 hours are sent into hospital. We would
once again indulge in the consolatory reflection that we are
convinced that no untoward results must be attributed to
the deprivation of early hospital treatment in all cases;
neglect of any case is of course to be condemned, but again
we would add that the virulent case appears to be something
sni generii.
As regards the prognosis of the admittedly serious case, we
must confess to having found difficulties in the establishment
of criteria, even after an experience of many hundred cases.
Early in the epidemic we were persuaded that the cyanosed
cases invariably succumbed. Later we were fortunately able
to record that a certain, even if a small, number of "these
recovered ; and yet the latter have been quite indistinguish¬
able from the majority of the cyanosed cases who died.
No criteria as to temperature, pulse-rate, or respiration-rate,
and not even of general condition, can be absolutely deter¬
mined. It is true that a rapid fall in temperature without
any amelioration of symptoms was in a “blue” case almost
always a precursor of death within 24 hours, and that the
case with blue colour, when accompanied by a cold, clammy
skin, might be considered to be beyond hope of recovery.
And yet cases whom earlier in the epidemic we considered
to be beyond redemption certainly recovered, encouraging
the determination not to abandon hope entirely until the
patient was unmistakably moribund.
An even more painful indication of one’s prognostic
deficiency was afforded by cases who, not only at their
admission but even for several days of treatment in hospital
appeared to run a comparatively trivial course and to give
rise to no legitimate anxiety, suddenly took a turn for the
worse, rapidly developed cyanosis, and died within a few
hours of being only trivially ill.
Prophylaxis.
A few final words may be added on the question of prophy¬
laxis. We cannot refer to the greater question of dealing
with the prevention of the epidemic or of limiting its spread
once it has appeared, for these are matters for the considera¬
tion of sanitary officers, both relating to troops and the
general public. The precautions taken in the hospital itself
were the ordering of a gargle as a routine procedure twice
daily for all in attendance upon the patients and for those
patients who had exhibited the disease to a comparatively
mild degree. The solutions utilised were either pot. per¬
manganate 1:4000 or tinct. iodine 1 drachm to the pint.
In addition all medical officers, nurses, and orderlies were
instructed to use a gauze mask around the nose and mouth
whenever they were in attendance upon patients.
It may be added that not a single case developed in five
special wards of the hospital devoted to tuberculous and
neurasthenic cases, although these patients were from force
of circumstances being visited by medical officers who were
in attendance elsewhere upon influenza patients, and that in
the large venereal division of the hospital only two or three
sporadic cases appeared—these had apparently entered the
hospital with the disease—who were immediately segregated,
and no instance of infection of other patients occurred. In
the Detention Barracks at Aldershot, in which every patient
occupies a separate cell in which he takes his meals, only
coming into contact with his fellow inmates when he parades
in the open air, not a single case developed. Incidentally,
to complete the story, it must be added that the medical
officer who visits these barracks daily is attached to the
Connaught Hospital, and in addition to other duties has
been in charge of influenzal patients.
Pathology.
This investigation was carried out with a view to establish¬
ing, if possible, the identity of the causal organism or
organisms and their distribution in the body in cases of
influenza. Furthermore, the work appeared profitable if it
were only to establish or disprove the connexion between the
present epidemic and what had previously been described
under the term “purulent bronchitis.”
The most striking feature of the results obtained is the
frequency with which streptococci were isolated, while the
Baoillns influenza could not be demonstrated with equal con¬
stancy. These streptococci fell into two groups : (1) a long-
chained streptococcus; (2) a small short-chained strepto¬
coccus exhibiting a preponderance of diplococcal forces. This
latter organism appeared to have some claim to individuality
and will be referred to as a “ diplostreptococcus.”
Before describing the organisms in detail the pathological
and bacteriological findings will be considered.
Throat swabs .—The material was taken from the naso¬
pharynx with a West swab and inoculated on to blood-agar.
-
Mild cases.
Severe cases.
1 2
1 3
4 5
6 7 ' 8
l luini.
9 , 10 1
Pneumococcus ...
4 i "
— 4 1
+ 1-1 3
M. cakv'rh. group
+ ! -
4-
4- +
I + + 1 - i
+ ! - 7
Strept. Ion pus ...
1 - I +
+
—
+ 4- 4-
+ : + 7
Diplostreptococcus
4- 1 4
4- +
- | 4- 1 7
B. ini!urnz;r
I - ^ +
4-
4- -
1 + - ! 4- j
+ ! + ! 5
Profuse expectoration in these cases was uncommon, so
that it was not possible to draw any conclusion from the
small number of sputa examined.
Blood culture#. — Blood cultures were made in glucose broth
in 10 cases shortly before death, but although several dilu¬
tions were tried only 1 case gave a positive result; the
organism in this instance was the Streptococcus longus.
Urines .—Examinations gave the following results:—
Cases.
'Albumin %
Deposit. [ Culture.
1. Moribund..,
. ! 0 02
Granular and cellular casta. No growth.
2.
. [ 01
No casta. Transitional
1
epithelial cells.
3. Severe
. j 0-5
Transitional epithelial cells.
4.
. | 0 1
Cellular casts and leucocytes.
5.
. 1 0-4
No casts. Transitional ,,
1
epithelial cells.
It is remarkable that although in some cases casts were
abundant, red blood-cells were not identified in the urinary
deposit. Examination of the kidneys from these cases
furnished no evidence of old-standing renal disease.
Leucocyte counts .—The following are the total leucocytes
per c.mm. and the differential counts (P., polymorpho-
nuclears; L., lymphocytes; L.M., large monocytes;
E., eosinophiles):—
Case.
Total.
P.
L.
L.M.
E.
1. Severe.
6200
54* n
39%
6%
1%
2. Moribund „.
• 5840
68° 0
26°/ n
5%
1 O
3. Slight cyanosis.
4650
44*, o
47 %
7%
2 C ■„
4. Mild .
4960
66°/ 0
30%
3%
1°. n
5. Moribund.
4960
70°. o
26%
2%
2° r
6. Bronchitis. Slight cyanosis.
6820
86%
ll°/o
2°/o
1° O
In the last case bronchitis with purulent expectoration
was present, which may account for the higher polymorpho¬
nuclear value, as compared with the other cases.
Cerebrospinal fluid .—In two severe cases the fluid was
clear, pressure normal; albumin (1) 0 006 per cent.,
(2) 0 0009 per cent. ; cells normal; organisms negative;
culture, no growth. In the absence of signs of meningitis
or meningism this examination was not pursued to any
ZBBUVOBT,] DR8. ABRAHAMS, HALLOWS, AND FRENCH: INFLUENZAL SEPTICEMIA. [Jan. 4, 1919 H
length, and the above results are tjpioal of the total
somber investigated.
Oxygen capacity of blood .—This was in control case and
four severe cases as follows (oxygen per 100 c.cm. of
blood)
Control. 12 3 4
18*5c.cm. ... 17’0c.cra. ... 20*5c.cm. ... 18 5 c.cm. ... 18 0 c.cm.
Haemoglobin = 105 per cent.
These results were obtained by nsing Haldane’s potassium
ferricyanide method. It was not possible in the circum¬
stances to estimate the blood carbon dioxide or alkali
reserve. The absorption bands of metliaemoglobih were not
detected in the samples of blood examined.
Apparently the cyanosis in these cases may be attributed
to the inadequate functioning of the pulmonary epithelium.
Bacteriological findings in post-mortem material. —The
following organisms were found :—
Description of the Organisms Isolated.
The characteristics of the organisms isolated are given
below.
The long-chained streptococcus grew well on all ordinary media, and
on agar formed discrete pin-point colonies. On blood agar hrcmolysls
•centred In all oases. Nocloc was formed in milk during three days'
incubation, but acid was produced in lactose and glucose media.
The “ diplofetreptococcus ” also grew well on all ordinary media. On
agar the colonies were larger than those of the long-chained strepto¬
coccus and showed flattening of the surface and a spreading margin,
which did not appear raised. Confluence of the colonies was seen in
some cases. Haemolysis occurs to a slight extent.
Ancillary action of the Staphylococcus jtyogenes aureus was very
marked, resulting In increased size of the diplostreptococcal colonies.
A turbidity was usually formed in broth daring the first 24 hours of
incubation, but within three days floccuil settled to the bottom of the
tube, leaving the supernatant fluid clear. The organism is Gram-
positive, but in a few Instances some members of a chain have failed to
retain the Gram stain. Involution forms appeared In old cultures. A
capsule was not demonstrated by Muir's staining method.
Tbe pleomorphisra exhibited by this organism Is a striking feature ;
In 24 hours* pure culture on agar many dlplococcal forms appear,
together with short chains of coccoid individuals. After repeated sub¬
culture the streptococcal forma preponderate. The formation of chains
does not appear to occur more readily in broth or other fluid media
than on agar.
This organism has been found in pleural exudates during life and
showed dlplococcal and streptococcal forms, while pure cultures
obtained from these fluids again gave evidence of pleomorphism.
The action on carbohydrate media has been uniform : acid is pro¬
duced in glucose and a dense clot is formed in milk; there is no action
on lactose, mannite, saccharose, or inulin, nor has gas been formed in
any of the media used. The organism Is not bile soluble. Agglutination
reactions with anti pneumococcus sera Types I., II., and Ill. were
negative.
roar cultures from heart blood and two from the lung were inoculated
subcutaneously into mice, but in no instance did death occur, nor was
a local suppurative lesion produced.
In one case following subcutaneous Baline injection abscess formation
occurred, and It is interesting to record that the organisms is >lated
were the “ diplostreptococcus ” and the Staphylococcus pyoycncs aureus .
The “diplostreptococcus”appears to resemble the Strepto¬
coccus frrevis, although the latter is not usually regarded as
pathogenic to man. Perhaps it would be best to use the name
Streptococcus brevis generically; the “diplostreptococcus”
could then be regarded as a species if its consistency of
action and conformity of type could be established. In some
respects the diplostreptococcus resembles the Streptococcus
ririda/ts, but the characteristic greenish hue of the colonies
was not observed.
Gruber and Schiidel, and also Bernhardt and Meyer, have recently
described a diplostreptoooccus which oocurred In the Internal organs of
cases examined post mortem. They regard this organism of decisive
importance In tbe cansatiun of acute pulmonary conditions and fatal
complications of Influenza.
Histology.
The histological findings in the lungs, kidneys, and liver
are now briefly described.
The lungs. -In tbe majority of cases congestion and redema were the
most marked changes recognised in the post-mortem room, while a
definite broncho-pneumonia was of less frequent occurrence.
In the former type of lung the alveoli contained a scanty fibrinous
exudate with erythrocytes and polymorphonuclear leucocytes. The
bronchial epithelium tbiokenei and proliferating, and leucocytic
Infiltration of the peribronchial tissue was present. Dilatation and
engorgement of the peribronchial blood-vessels was a marked feature.
These appearances correspond with those seen at an early stage of
broncho-pneumonia.
Sections examined from lungs at a later stage showed a confluent
broncho-pneumonia. The alveoli were completely filled with sero¬
fibrinous material, in which numerous polymorphonuclear leucocytes
and pigmented catarrhal cells were seen. The smaller bronchi contained
marses of leucocytes and epithelial cells embedded in a tero-fibrinous
matrix. In the more congested areas the alveolar septa in many places
had given way and the exudate had become confluent.
The kidneys. -Cloudy swelling • -f the tubular epithelium was seen
in some areas. The glomeruli were engorged with blood, and Bowman’s
capsule w*s thickened in most of the specimens examined. In a few
instances a clear exudate was seen within the Malpighian bodies. There
was no evidence of interstitial changes or endarteritis.
The liver.— The liver cells in the portal areas showed cloudy swelling
and fatty degeneration. No cellular infiltration was evident in the
tissues surrounding the portal vein. Amyloid change was not ^een in
the arterial zones.
Summary.
1. The recent pandemic of influenza has included a large
number of cases of septicaemia or toxaemia with a high
degree of mortality.
2. These severe cases appear definitely related to the
cases of “purulent bronchitis ” which have been described as
occurring in various parts of the country and in France.
The essential feature is an infection by the Bacillus i» ft uencce
with a secondary infection by some other organism. The
existence of copious purulent expectoration is only an
incident which may or may not be present and which has
been singularly absent in the recent pandemic.
3. The secondary organism in question is the pneumo¬
coccus, Streptococcus pyogenes longus , or a “ diplostrepto¬
coccus,” the virulence of which appears to be exalted by the
initial influenzal infection.
4. The characteristic features of the septicaemic type of
case are variable lung symptoms, ranging from slight
bronchitis to lobar pneumonia, very characteristic heliotrope
lividity, dyspnoea, or rather polypnoea, and very rarely
orthopnoea. These, with other so-called complications of
influenza, such as pleurisy, nephritis, and others of lesser
import, are evidence of the septicaemia or toxaemia referred to.
5. The relative frequency of the septicaemic type of case
cannot be estimated with any degree of accuracy. The
mortality of the septicaemic cases would appear to be as
high as 90 per cent, at the beginning of an epidemic, falling
to 50 per cent, at its termination.
6. Infection takes place in the upper respiratory passages,
and involves the accessory nasal sinuses, where a septic
sinusitis develops. From this and possibly other foci as
yet undetermined, the toxaemia or septicaemia originates.
7. In view of the large number of instances in which the
diplostreptococcus has been isolated in pure culture from the
heart’s blood and internal organs immediately after death, it
is concluded that this organism plays an important role in
the fatal cases.
8. The very large majority of cases of influenza run an
uncomplicated course, terminating in from 3 to 14 days.
No treatment has been found to be of any value in aborting
an attack, or in preventing its development into the virulent
type.
9. The large majority of cases of septicaemic type die in
spite of any form of treatment. Cases have recovered who
have been given no specific treatment of any kind.
We desire most gratefully to express our obligation to
Major-General E. G. Browne, C.B., C.M.G., A.M.S.,
D.D.M.S., Aldershot Command, who has not only encour¬
aged the undertaking of this investigation, but has often at
great personal inconvenience assisted in the arrangements
in various parts of his Command, arrangements which have
placed at our disposal an enormous amount of material
which would otherwise never have been seen.
Our thanks are also due to Lieutenant-Colonel W. Turner,
C.M.G., H.A.M.C., O,C. Connaught Hospital, Aldershot,
where the greater part of the investigation, clinical and
pathological, has been performed. We are also greatly
indebted to Colonel Robertson, C. A. M.C., O C. Bramshott
Military Hospital; Lieutenant-Colonel Cole, C.A.M.C.,
O.i/C., Medical Division, Bramshott Hospital; Lieutenant-
Colonel J. Tidbury, O C. Woking Military Hospital ; and
Captain Means, of the United States Medical Service, all of
whom have generously placed at our disposal the patients
under their command and care.
To the medical officers attached to the hospitals where
investigations have been performed we offer a general
expression of gratitude for their invaluable cooperation.
12 Thb Lancbt,] DR. G. R. MURRAY : THE OOMPARATIVR PATHOLOGY OF INFLUENZA. |\Un. 4, 1919
NOTE ON THE COMPARATIVE PATHOLOGY
OF INFLUENZA.
By GEORGE R. MURRAY, M.D , D.O.L., F.R.O.P.,
TEMPORARY COLONEL, A.M.8. ; PROFESSOR OF SYSTEMATIC MEDICINE IE
THE VICTORIA UNIVERSITY OF MANCHESTER; CONSULTING PHYSICIAN
TO THE ITALIAN EXPEDITIONARY FORCE.
The comparative pathology of an infective disease is
always interesting, and it has in many cases thrown light on
the modes of infection in man. Daring the present pandemic
of influenza I have not met with any reference to the
occurrence of a similar malady in either domestic or wild
animals. It is possible that some animals have been affected,
and it wonld be of interest to ascertain if any localised
epidemics of influenza in animals have been observed. The
pulmonary complications, as seen this year in man, alike in
England, France, and Italy, due to mixed infections of the
respiratory organs, so closely resembled those observed in an
epidemic in horses which came under my notice more than
20 years ago that a brief account of it may be of interest at
the present time. I write entirely from memory, but the
main features of the epidemic were as follows:—
A certain railway company had a number of valuable
horses whioh were kept in large stables. Two long rows of
stalls were arranged in each of the buildings, which were
well ventilated and kept in excellent condition. Many of
these horses were rapidly attacked by an acute illness with
symptoms of nasal oatarrh whioh was accompanied by a
clear watery discharge from the nostrils. The majority of
the horses made a good recovery, but some of them developed
symptoms of acute pulmonary disease and died. Post¬
mortem examination by the veterinary surgeons in attend¬
ance Bhowed that death was due to acute lobular pneumonia,
complicated by pulmonary abscesses which developed in the
areas of consolidated lung. A puzzling feature of the
epidemic was the irregular distribution of the cases. The
malady did not spread in sequence from stall to stall, but
oases occurred at irregular distances from eaoh other in the
same stable.
As several valuable horses had died and the disease con¬
tinued to spread, I was asked to investigate the cause of the
epidemic and to give advioe as to the most suitable means to
be adopted in order to stop the further spread of the infec¬
tion. On making a bacteriological examination i obtained
from the nostrils of horses suffering from the acute nasal
catarrh cultures of a small bacillus closely resembling, if
not identical with, Pfeiffer’s bacillus. The same bacillus
was recovered from the patches of broncho-pneumonia in
the lungs of a fatal case. In this case there were several
abscesses which had formed in the consolidated areas of the
long. Cultures prepared from the pus in these abscesses
yielded growths of Staphylococcus albus.
It therefore was evident that the disease was primarily an
aonte catarrhal infection of the respiratory passages closely
resembling influenza in man. In some cases the same
bacillus invaded the lung and broncho-pneumonia super¬
vened. This was complicated by a secondary staphylococcic
infection which caused a rapid breaking down of the con¬
solidated luog and the formation of localised abscesses.
In human influenza the usual mode of spread appears to be
by aerial convection of the infection to those in the immediate
neighbourhood of the patient, as was so clearly shown by
Major Michael Foster and Major Anstey Cookson in the case
of a limited outbreak in a surgical ward. 1 In the epidemic in
horses the irregular spread of the disease was apparently due
totbenseof dry moss litter as bedding, fine particles of which
could be seen floating in the air when illuminated by a ray
of sunlight. The nasal discharge from an infected horse
dripped on to this bedding, where it dried and was carried to
all parts of the stable by light currents of air.
The company was advised to remove all the moss-litter,
and after thorough cleansing to wash out each stable with a
disinfectant and to use sanitas sawdust as bedding. This
was done in each stable while the horses were out at work,
with the result that the epidemio ceased at once and no more
horses were lost.
The chief points of interest in this epidemic were the
resemblance of the disease to human influenza, the rapidly
fatal results of the acute pulmonary complications caused by
a double infection of the lung, and the part played by dust
in increasing the range of aerial convection from one animal
to another. The range of aerial convection in human
influenza is usually short, but in the management of patieuts
it is advisable to keep the air of the sick room as clean and as
free from dust as possible, and to dUinfeot all handkerchiefs
and spittoons just as in oases of open pulmonary tuberculosis.
i The Lancet, 1918,11., t>88.
B. MULTIFERMENTANS TEN ALBUS.
By JAMES L. STODDARD, M.D. Mass.,
CAPTAIN, M.O., U.8.A.
(From U.S.A. Bom Hospital No. 5.)
The bacillus described here was isolated from a case of
gas gangrene of the arm which recovered promptly upon
excision of infected muscle. An account of the charac¬
teristics of the bacillus has been undertaken because—
1. The bacillus appears to differ from the anaerobes
described in the literature. (The references available
include the report on anaerobes of the Briti»h Medical
Research Committee, by Dr. James McIntosh, and the mono*
graphs of Captain H. G. M. Henry and of Weinberg and
Seguin.)
2. At a certain stage the bacillus produces swollen and
irregularly staining forms olosely resembling the so-called
‘‘citrons” usually believed to be characteristic of B. vibrion
septique.
3. Certain fac f s suggest that the bacillus may be of
importance in symbiosis with B. sporagones in producing
local muscle infectious. This is merely a possibility, how*
ever, and it seems on the whole most probable that the
pathogenic importance is slight and of rare occurrence.
The author is greatly indebted to Dr. McIntosh for the
serological reactions as well as for his confirmation of the
impression that the baoillus differs from those described in
his report.
Cask.— Pte. X. Patient reoeived a perforating explosive wound of
left forearm, with frao'ure of ulna. Excision of muscle for gas
infection at. C.O.8. Entered base Hospital next day with localised gaa
Infection of forearm. Immediate operation with exoiaton of portions
of flexor and extensor tendons, whioh were found gangrenous. No
fuither evidenee of gas infection.
Cultures —A swab was taken at operation from the
gangrenous muscle in the depths of the wound and planted
in chopped meat medium.
Technique of isolation.—After growth for three days the culture was
streaked on slants of dtftitt«’s egg medium made wir.h trypstnlsed
broth, and incub-tted In McIntosh and Pildes jars. This method has
been found to give excellent and rapid growth of all anaerobes tried,
including B oedem itiens.
Two sorts oi colonies were immediately evident: (1) those t;pleat of
B. sporogenes ; (2) very elevated, sharply defined, olrcular yellow
colonies, turning white on the second or third day. Several of each of
these two kinds of colonies were fished where widely separated,
emulsified (by shaking with sand In sterile sale solution), and replated
a°pa r atel v. After apparently nura cultures were obtained, this imme¬
diate replatlug of Isolated colonies was repeated several times. (The
first attempt gave two colonies free from B. spnrogenes.M tested by
growing in chopped meat, tbu* indicating the article, cy of the plating
method.) No other organisms than B. sporogenes and the bacillus were
obtdned. it Is extremely improbable that B w Ichii, at least, was
overlooked, because the experiment was tried of plaining B. welchii
and this bacillus t >*etber in chopped meat and streaking on egg, and
invari-bl B. welchii gave many times the number of colonies, which
were easily distinguishable.
The cultural characters were as follows:—
Anaerobiosis. -There is no growth aerobically on slants. There is
an extremely slight sediment in cultures planted In gluoose bouillon
which has been fre«hly shaken with air. The bacillus proves to be a
fairly st rict anaerobe.
Motility. - The bacillus is very actively motile in the condensation
water of **gg slant. In chopped mea'-its motility is le»s marked. It
is actively mobile in plain bouillon, but n m-motlle in gluoose bouillon.
Proteolytic action .—There is nc demonstrable proteolysis from
pr >tuse culture* grown on egg for long periods. Chopped meat shows
no evidence of digestion. In ml'k the ourd underg >es softening, but a
diminution iu volume is questionable. There is no blackening of meat
or egg.
Snccharolyiic action.— Glucose, lactose, saccharose, maltose, glycerin,
inu'in. raifiimse. and saliciu are fermented vigorously. There is no
ao ion in riulctte or mannite.
J»d >l production .—No indol Is produced.
Odour. - Paint, and not characteristic. No special odour of butyrio
act* in milk cultures.
Hxmotysis .—Surface colonies on blood agar produce a definite ring of
hsemul^sitt iu 24 hour*.
The gross appearance of cultures is described below.
Chopped meat. Wi'h'n 24 hours gas is produced. There is no
blackening or •'tge»ti><n <d the meat evtn after long i no u bat ion, and no
definite change in co’our.
Glue -sc bouillon. — In 24 hours there is a heavv flocculent precipitate.
The me limn is slightly cloudy from small fl oating flecks. The
fl->cculent pr cpftate is easilv broken up by shski g but quickly settles
out again. Ot8 is produced and appears throughout the culture witen
it I- shaken (as in ch onpagne).
Plain bouillon.— The medium is diffusely cloudy with a slight
sediment, somewhat 11 cculont.
Milk. -Tne u-u»l reaction in 24 hours Is a thickening of the con¬
sistency. apparently from the precipitation of th« oa«ein, with the
evolution of gas. which produces a coas-ly bubbly foam, i in. to & lu.
deep, over the surface. With further incubation the casern precipitates
; more completely, settles to the bottom, and leaves a cloudy fluid abjve.
The Lancet,]
DR J L. STODDARD: B. MULTIF ERMENTANS TEN A LB US.
[Jan. 4, 1919 13
With a heavy inoculation or under excep* tonally good conditions a more
vigorous re*ciIon takes place, and in 24 or 48 hours the culture closely
rrsemble* the reaction with B. welchii. There may he a floating clot
fil ed aith bubbles. The clot is softer than with B. welcMi and is easily
broken up.
The nature of colonies is as follows :—
On glucose ngar surface colonics in 24 hours appear greyish. 2-3 mm.
Indi'tne'er, raised, wii h sharp edges and -omewhat Irregular outline.
A hand-lens shows a clear transl-cent stratum in which float white
flecks. The flecks are not definitely distinguishable by the n^ked eye.
They form triangular or ither straight-bided geometrical figures, and
thus present a crystalline appearance.
Intworin s the colony apre<rs whiter. The hand-lens shows more
numerous flecks, which have increased in size. Ins me colonies the
whole centre is opaque and white, Bbadtng gradually off to a clear
trans ucent border.
In three days nearly the whole colony is a dense, opique clear white
with a narrow translucent rim, which may still show the crystal-Ilke
fleck*, often arranged radially. The consistency is sticky, stringing out
when picked, but not adhering to the agar.
As tlra** g**09 on the Colony grows, reaching a size of 5 mm. It heaps
□p so that it becomes quite thick, with rather steep sides. The edge is
dear and sharp The colour io opaque pure white.
Deep colonies on glucose agar are small, white, opaque, and irregular
In shape. They are often leuticu'ar, win * a horn-itke project! n from
one side, or reel form, with a projection from the '‘hilu-*.” They are
li mm. in size. In two days th**y enlarge a little, there Is a tendency
to form large gits bubbles, which tear uu the agar, giving a confluent
jrrnwth ab »ut their periphery. Often the growth extends an a white
film over the under surface of the agar.
On blood agar i he surface colonies are smaller and more opaque at
the "tart and do not ahow clearly t he crystalline flecks. They tend to
he flatter, not to increase in size, and to become level with the agar
They have a definite haemolytic zone.
Daep on'onies on blood agar re-emMe in shape those on glucose agar,
but gradually become a Vandyke brown, thus standing out sharply
tro'r the pale vellowsh red agar.
Colonies on egg medium (whole egg and tryptic broth inspissated in
slants).—In one day the colonies are 1-2J ram., rsised, yellow, with
sharp, regular edge. They are very coherent and elastic, and adhere
closely to the medium. A pla'inum loop may he rubbed with moderate
pressure over a colony without affecting it visibly. If part Is loosened
and pulled away it atretenes out. and finally Bn*ps after it t he rest of
the colony In a mass. The second or t hird day the colony Is larger, and
la tirey or white, with a narrow colourless or light yellow border. It is
now sticky, but not so adherent or elastic.
Tbe colony Increases to a size ot 4-6 mm. and to a thickness of
2-3 mm., and become* a pure opaque white. There is never blackening
or digestion of the egg.
The colonies on this medium are easily distinguishable from those of
B. welchii fallax vibrion seplique, cedematiens, aero fetidus , or any of
the proteolytic group.
The morphology of the organism is next described.
The bacillus Is more slender than B. welchii. and varies in length
according to the conditions of the culture. iFig. 1 ) Tbe short forms
Fio. 1 —Shows the bacilli, and the most typlca 1 forms occurring in the
evo uMon of the spores. From a 24-hour co'ony of B muUifcrmentans
lemlbu* on a tryp-egg slant. At a is drawn in lor comparison a
B. welchii from a similarly grown culture. Scale in microns.
tend t-o b« slightly curved; the long forms usuallv show sinuous dis¬
tortions. The end < are verv rounded a< d occasionally almost conical-
The bacillus resembles B vib ion seplique In shsp*. hot. under the name
Conditions of culture has a larger p oportlou of short and swollen
forms. It is Gram-positive in very young cultures, but quickly
becomes Gram-negative in places or feebly Gram-posi'ive throughout,
and fi .ally within 2-3 r«a*s. is usual y Gram-negative. A one-day
cut'ur-e ahuws al> vari «iions from th-> Gram positive to Gram-negative
firms. The bacilli usually have a granu'ar appearance and are 'eebiy
refrtet ve. T my do not anpear as clear Cut as B. welchii or B. vibrion
seplique. There is no capsule.
Occasionally bacilli occur end to end, but long chains are n >t found.
Lon* thread- are produced on agar. There is no e-p“clal grouping on
s ».far*. ex« epr. in the case of the early sporulating forms, which tend
Btrongly to slick together in dense masses
The mast striking feature is the rapid production of large
numbers of swollen forms and spores. (Fig. 2.)
These are produced in greatest profusion in cultures on egg medium
but occur in bouillon, in milk, nr on agar
Usually in t >rming the spore the bacillus swells centrally, with a
gr-uiual i apering off to the ends. At this stsge it becomes Gram-
negative and faint-staining, the process starting at the end which is to
r i ri r I I l Ld
A-SK-
Fio. 2. —Shows various swollen and irregularly staining forms, a long
rod, and numerous Gram-negative btcllll. From a 3$ day colony of
B. multi/ermentans tcnalbus on a tryp-egg slant. Scale in microns.
produce the spore. A deep-staining Gram-positive spherical mass
appears at the opposite end. Soon alter a large oval retractile sub-
terminal sp ire a pears, the remainder of the ba-illus gradually fading
out and disappearing. A 24-hour culture in milk usually shows prac¬
tically no oi her forms but tbe swollen or sporulating b dill. Numerous
min >r vari tions from this process occur. The bacillus may become
pear-shaped or barrel-shaped, or mav elongate. The spherical chromatic
dots often appear at e*ch end. The decolonisation ofia-n proceeds
irregularly, leaving Gran-positive dots or bands. Tnese forms resemble
closely the orresp ndlng stages of B. vibrion septique. Toe swollen
for ns and sp ires, however, are produced In much greater profusion
than In the case of the vibrion, and are also produce 1 earlier. A one-
day culture on egg medium closely resembles a two- orthree-davculture
of B. vibrion seplique on the same medium. Occaaiona ly subermlnal
or central spores develop quickly in a bacillus before it has swollen or
become Gram-negative.
Serological reactions.— One bacillus is agglutinated neither
by the *erum of B. vibrion septique nor B ohauvai. For
these findings I am under obligations to Dr. McIntosh, of the
British Medical Research Committee.
Identity. —Since the bacillus appears to differ from those
described in the literature it has been named, provisionally
at least, B. multiformentans tenalbus. The first name
suggests the wide fermentative properties ; the second an
artificial condensed word compounded of the terms tenax
and albus. the chief characteri-tics of the colonies.
Definite differences in colony characters, morphology,
serological reactions, and pathogenicity distinguish it from
B. vibrion septuple.
The bacillus differs from B. II. of GhoD and Sachs (1909)
by complete absence of tendency to grow in loDg chains in
liquid cultures, as well as in its fermentation reactions.
From B. chauveci it is distinguished by its serological and
fermentative reactions.
B. emphysematis maligni of Wicklein was a proteolytic
organism.
From B. welchii , erdematiens, fallax , Hibler IX., butyncus ,
and the proteolytic group the differences are obvious.
It appears to be closely related to, if not included in, the
somewhat ill-defined group of motile fermenting anaerobes
called by Grassberger “ saccharolyticus mobilis."
Pathogenicity. — Experiments were carried out to determine
the pathogenicity of the organism.
Technique —The sites of injection were shaved and treated succes¬
sively wi h alcohol, e'her, and iodine. Unless otherwise stated, the
cultures were grown 24 horns In 1 per cent, glucose bouil on and
in.j ctei intramuscularly In the thigh. The culture of B. sporogenes
was inula'ed from the ease described above.
Protocols.—R ibbit I. : 2 c.cm. of B. multifcrmenlans. No evident
effects.
R i “b>‘t II. : ljc cm. of B sporogenes. No effects.
Rabbit III : 1 c.cm. of B sporogenes and 1 c.cm. of B. muVi-
Jermentau". Death in 20 hours. Autopsy.—Local muscle infection,
contioed to muscle gr>up injected. Cultures of both organisms
recovered from the muscle. H. -f. Blood cultures negative.
14 ThbLahor,]
DR. F. 8. ROOD: SPINAL ANAESTHESIA.
[Jan. 4, 1919
Hobbit IV.: 9 minims of a 2-day chopped meat culture of
B. mrUlifennentans. No effects.
Rabbit V.: 1 c.cm. or a 9-day meat culture of B. mtUtifermentans.
No effects.
Rabbit VI.: 1J c.cm. of B. sporogenes + 1 c.cm. of B. muUi/er-
mentans. Within 18 hours rabbit appeared sick, with marked local
swelling and tenderness. Rapid recovery.
Rabbit VII : l£ c.cm. of a 36-hour culture planted with B. sporogenes
and B. multifennentans together. No delinlte effects.
Guinea-pig I. : 1 c.cm. B. sporogenes + 1 c.cm. B. multifermentans.
In 18 hours marked local swelling. Did not appear sick. Killed In
36 hours. Swelling still present. Autopsg.— Slight muscle infection
of group injected.
Guinea-pig II.: 1 c.cm. of a culture planted simultaneously with
B. sporogenes and B. multiiermenlans. In 20 hours moderate local
swelling, 8till evident after 36 hours.
Rat 3 minims 9-day meat culture B. mullifermcntans. No effects.
Summary of animal experiments. —There appeared to be
a production of lesions with B . sporogenes and B. multi -
fermentans in combination which were not produced with
larger doses of either alone. In one case death was pro*
duced in 24 hours. The lesions, as a rule, appeared to be
local, consisting in swelling and tenderness for a short
period and in a muscle infection for one to three days.
B. mutt fermentans alone in moderate doses seems to be
non-pathogenic ; with B. sporogenes both become able to
cross the threshold of the animal’s resistance, but do not
give extensive lesions.
These experiments were made a considerable time after
both organisms had been isolated. Therefore they may not
represent the true pathogenicity of the bacilli.
SPINAL ANAESTHESIA. 1
By FELIX S. ROOD, M.B., B.S. Durh., M.R.C.S.,
L.R.C.P.,
ASSISTANT ANAESTHETIST, UNIVERSITY COLLEGE HOSPITAL, LONDON.
Spinal anaesthesia has now been used in this country
with increasing frequency for the last 10 or 12 years. It has,
in spite of considerable opposition, attained a position as one
of the recognised agents for producing anaesthesia. A large
number of cases have been collected by various observers,
and I think we may hope that the time has now been
reached when a comparison of experiences may be of con¬
siderable use to us all in deciding the exact type of case in
which this form of anaesthesia is most valuable.
It is not my intention in opening this discussion to enter
into the technique of spinal anaesthesia, which is now very
well known, but rather to speak of my own experiences of
its use in a considerable number of cases.
I have always used stovaine except in about 250 cases in
which novocaine was employed. After this trial I gave it up,
because although novocaine produced perfect anaesthesia it
does not produce a muscular relaxation equal to that produced
by stovaine.
Effect of Density of Solution and Posture on Diffusion.
A 5 per cent, solution of stovaine, the density of which
was increased by the addition of 5 per cent, of dextrose, was
used in most cases. As this solution is heavier than the
cerebro-spinal fluid the position and extent of the anaesthesia
obtained with it can be regulated by the position of the
patient during the injection. There is no doubt that although
the stovaine-dextrose solution is diffusible its movements
are controlled by gravity for a few minutes after injection.
For instance, if a patient is placed upon his right side, with
his pelvis slightly raised, so that there is a good steep slope
from the third lumbar vertebra down to the mid-dorsal
region, and the injection is made between the second and
third lumbar vertebras, this fluid will sink downwards in the
spinal canal to the mid-dorsal region, producing an anaes¬
thesia of the right half of the body before producing any
effect upon the left side, and, moreover, if the patient is
kept in this position for some few minutes before being
turned on to his back the anaesthesia will be more complete
on the right side—that is to say, it will extend higher on the
right side than on the left and it will last longer on the
right side. Muscular power will return first on the left side,
and the patient will be able to move his left leg before he
moves his right leg.
If immediately the stovaine has flowed to the mid-dorsal
level the patient is turned upon his back it will flow across
o/lfe^kSne r0 * d betore the 8ection of Aesthetics °t the Royal Society
the mid-line, and there will be practically no difference
between its effects upon both sides of the body. Or, again,
if the injection is given with the patient in the sitting
posture the stovaine-dextrose solution will Bink downwards
in the theca and produce an anaesthesia which is more or
less limited to the sacral plexus.
For young children I found that a dextrin-stovaine solu¬
tion is less diffusible, and consequently the upper limit of
the anaesthesia and muscular paralysis was more sharply
defined, which is naturally a great advantage, as in the
short spinal cords of young children the vital centres are
not far removed from those parts of the cord in which it is
necessary to produce anaesthesia.
In a few hundred cases a solution of stovaine in saline was
employed. It was found that, irrespective of the position of
the patient, the stovaine diffused about 10 in. upwards from
the point of injection and equally on both sides of the body.
It was with this solution impossible to limit its action or to
increase it beyond this point except by increasing the dose,
and then only very slightly. The anesthesia produced by
the saline-stovaine solution was found to be more transient
than in those cases in which the denser solution was used
and it was generally found necessary to employ almost
double the dose of stovaine to produce equally long
anaesthesia.
Position of Patient After Injection.
It might at this point be appropriate to say a few words in
regard to the position of the patient after the introduction of
the stovaine. I have already remarked that the dextrose
and dextrin-stovaine solutions are mobile in the cerebro¬
spinal fluid for a few minutes after injection, but only for a
few minutes, and we have never found it possible after about
five minutes to increase the height of the anaesthesia even by
very considerable elevation of the pelvis—that is to say, I
think that the stovaine becomes fixed in from three to five
minutes. It follows from this that the patient’s head and
the cervical region of the cord must be kept raised during
injection and for the first few minutes afterwards.
In the early days of the use of spinal anaesthesia we were
very careful to keep the head and shoulders of the patient
raised not only during the injection but throughout the
operation, and even in bed afterwards. This posture
increased that tendency to syncope which is not at all
uncommon. Latterly, after a few minutes, the patients have
been allowed to lie quite flat, and we have found that this
fall of blood pressure has been much less common and there
have been no cases in which the stovaine has risen to a
dangerous level.
Similarly, in regard to the use of the Trendelenburg
position, it does not appear to be material whether the light
or heavy solution is used. Generally I have employed the
heavy solution, as I found that the analgesia lasted longer
with a smaller dose of stovaine.
Combination with Other Methods of Anesthesia.
When spinal anaesthesia was first employed the great merit
claimed for it was that it did away with the necessity for
general anaesthesia. But I think as time has passed and
experience been gained that opinion has been very much
modified, so much so that I think that all who have had any
experience with this form of anaesthesia are agreed that the
one great disadvantage of stovaine—the conscious patient,
the patient present at his own operation—outweighed many
of the advantages of spinal anaesthesia, and nowadays it is
rarely employed without either some modification of
“twilight sleep” or a little general anaesthetic. There is
no doub^ that a loDg operation in the Trendelenburg position
or an operation on the rectum, such as a combined abdominal
perineal or a Kraske’s excision, are ordeals which few patients
can face, even if it were to their advantage to do so.
Speaking generally, for severe operations the method
which has been employed has been to produce anaesthesia
with ether, then to inject the stovaine, discontinue the ether
for a time, and then just to give a whiff to keep the patient
unconscious.
For operations of a less severe type, such as hernia or
appendicectomy, scopolamine and morphine are administered
in the ward approximately an hour before the operation.
The spinal injection is then given in the anaesthetic room
before the patient reaches the operating table.
In this connexion I should like to mention a method for
increasing the effect of scopolamine and morphine which was
ThxLakobt,]
DR. F. S. ROOD: SPINAL AN^STHE8IA.
[Jan. 4,1919 15
shown to me recently by Mr. P. P. Oole, and which I have
used since with very great success. After the administration
of the scopolamine and morphine the patient’s ears are
plugged with cotton-wool and the eyes covered with a
bandage so as more or less to shut ont the stimuli of light
and sound. The increased effect of the scopolamine and
morphine is most surprising, and many patients who have
been treated in this way, although they have been lifted
from the bed and carried upstairs, given an injection of
stovaine and then been operated upon, have never known
that they have left their room.
The (Question of Safety.
It is important to gain some idea of the safety of spinal
as compared with other methods of producing anaesthesia,
as many of the indications for its use are relative and not
absolute. Speaking from my own personal experience of
about 8000 cases I have had two deaths.
One was a case of obstruction of the small Intestine. The patient
was very collapsed, there was profuse vomiting, and after the Injection
a flood of stercoraceous material from the mouth. The patient was
apparently asphyxiated. The respiratory passages were found to be
full of vomited matter at the post-mortem.
IlTtae second case was a child of 4 years, more or less moribund, suffer¬
ing from a gangrenous intussusception. Death occurred during the
operation from circulatory failure and not apparently from any Inter¬
ference with the respiration, woich continued for a short time after any
sign of cardiac activity could be observed. Apparently the fall of blood
pressure caused by the stovaine, added to tne shock already present,
was sufficient to cause death.
I think thab in the light of further experiences these were
both instances of a mistaken choice of anaesthetic.
The above records include patients of all ages, from a few
hours up to 80 years. The results obtained with young
children were very satisfactory. Once the injection was
given they generally passed into a somnolent condition and
appeared to be in no way disturbed by the subsequent
proceedings. The youngest infants were new-born babies
suffering from imperforate anus and hernia into the umbilical
cord. It is interesting to note that a relatively larger dose
of stovaine is required to produce satisfactory anaesthesia in
infants than in adults. A dose of 2 5 eg. of stovaine is
required for the smallest babies and more for children of one
or two years. Advanced age does not appear to be a contra¬
indication, and many of the patients included in this series
were between 70 and 80 years. Klderly people are perhaps a
little more liable to syncope if the anaesthesia reaohes a high
level.
Complications.
The complications met with daring the coarse of the
anaesthesia have been : (1) Interference with the respiration,
owing to the stovaine reaching too high a level; (2) com¬
plications dne to fall of general blood pressure, syncope, &c.;
(3) vomitiDg.
Difficulties due to the stovaine reaching too high a level
have been very rare, generally occurring in children where
the margin of safety is so much less,, or the patients have
been fixed in some form of splint, or were in such pain that
it was difficult to get a proper position of the spine before
injection. Usually this complication was quickly relieved
by a little oxygen. Two oases did definitely and progressively
stop breathing as the stovaine ascended. One most instruc¬
tive incident occurred.
The patient wan a poor frail little boy who looked as if all tils vitality
had been sapped by the long strain or a suppurating tubercular hip.
in spite of his condition amputation through the hip-joint was decided
upon. Great difficulty was experienced in getting the child Into a
proper position for the injection. The stovaine undoubtedly reached
too high a lavel. The immediate relief of pain following the injection
was most striking.
Shortly after the commencement of the operation the Intercostal
muscles became paralysed. Then very shortly afterwards the diaphragm
also—the child became intensely pale, lost consciousness and ceassd to
breathe. Very gentle artificial respiration by pressure with the hand
on the front of the chest was performed, oxygen administered, and the
•rperation hurriedly completed. These effort-* at resuscitation had been
continued for about five minutes when suddenly there was a slight
movement of some of the muscles attached to the lower jaw, followed
immediately by efforts at respiration, first by the diaphragm, next
hy the intercostala. Then, with startling rapidity, the child com¬
pletely recovered. Before the last stitch had been put in the little
patient volunteered the statement that he had been to sleep. No
shock followed the operation and the child made an uninterrupted
recovery.
The majority of difficulties met with were due to a fall of
blood pressure, which varied from a slight pallor to a severe
syncopal attack, with loss of consoionsness and disappear¬
ance of the radial pulse. This complication was much more
common in the earlier cases, before we realised that it was
not necessary to keep the head and shoulders raised con¬
tinuously. Only three cases stopped breathing from syncope.
The sequence of events was the same in each case—sudden
pallor, loss of consciousness, a few gasping breaths, then
cessation of. respiration. These cases also occurred in the
earlier days, when the patients were propped up. As we
did not like to lower the head in order to treat this condition
we raised the legs and pressed upon the abdomen. Recovery
in each case was as sudden as the onset—one patient again
remarking that he bad been to sleep. A certain amount of
pallor and fall of the general blood pressure occurred in
about 30 per cent, of the earlier cases, but since the adoption
of the recumbent position it has been much less frequent.
Vomiting occurring during the operation seems to be more
or less dependent upon the height of the anaesthesia ; if the
anaesthesia involved the dorsal cord it was not uncommon,
but very rare if the stovaine affected the lnmbar and sacral
plexuses only.
Without entering into the vexed question of the cause of
the vomiting, whether it is subsequent to a fall of blood
pressure and more or less mechanical in origin, or is due to
direct absorption of the drug, I think experience has shown
that measures directed towards raising the general blood
pressure, such as slight Trendelenburg position, elevation of
the legs, and pressure upon the abdomen, much relieve this
symptom.
Sequela.
Another question of perhaps hardly less importance than
that of immediate safety is whether spinal amesthesia is
more prone to be followed by serious and unpleasant
sequelae than other forms. This, of coarse, could only be
answered by time. I think that the length of our experi¬
ence now justifies the expression of certain impressions and
some definite statements being made upon this point.
Headache, vomiting, and pnlmonary complications have
occasionally followed the administration of stovaine. Head¬
ache was not very common and then slight, but sometimes
undoubtedly it was severe. My impression is that the
headache was more commoo when the patients were
conscious during the operation—that is, before a general
anaesthetic or scopolamine and morphia were used in com¬
bination with the stovaine. It also seems that if the patients
were handled very gently after the operation, and not jolted
or shaken on the way back to bed, and kept quiet afterwards
and not allowed to talk, they were less liable to this
symptom. One or two cases of severe headache were almost
instantly relieved by lumbar puncture and the withdrawal of
about 20 c.cm. of cerebro-spinal fluid, although this fluid did
not appear to be under any abnormal tension. Post-
ansestbetic vomiting following stovaine was very rare and
not prolonged in the few cases which did occur.
I think that there is evidence to show that spinal is much
less frequently followed by pulmonary complications than
any other method of anaesthesia. I have seen bronchitis and
pneumonia both follow its use, as I have also seen these two
complications follow after the use of local anaesthesia, and
we must not forget that these are occasional complications in
case of accidents, such as fractures, where no anaesthetic at
all has ever been administered. It seems to me that respira¬
tory complications under stovaine depended more upon the
pathological conditions present, the condition of the patient,
and the type of operation performed.
Acute septic conditions, as appendicitis and osteomyelitis,
were generally present in those cases in which pneumonia
followed the use of stovaine. Occasionally there were
pulmonary complications after operations upon the upper
abdomen which, I presume, were due to a reflex rigidity of
the chest and insufficient expansion of the lungs, consequent
upon the position of the abdominal incision.
Statistics Shearing Absence of Permanent After-effects.
One of the difficulties which the pioneers of stovaine
amesthesia had to contend with was the suggestion that
permanent muscular paralysis might follow its use, and from
time to time cases in which there was some form of muscular
paresis, loss of sphincter control, permanent ansesthesia, and
even complete paraplegia have been reported.
I have been able to collect in all abont 10,000 cases, of
which I have actual personal knowledge. These include 400
cases which were done by the late Mr. A. E. Barker, which
have not been published, but the records of which he gave
to me, about 1500 or 1600 cases done at hospitals by the
16 ThbLanobt,]
DR. F. 8. ROOD: SPINAL ANAESTHESIA.
[Jan. 4,1919
resident officers, and about 8000 done by myself. In not
one of these cases has there been any permanent paralysis
of muscles or abolition of sensation, or any trophic lesions,
with the exception of three cases of paralysis of the external
rectos muscle of the eyeball, producing diplopia, which
lasted about three weeks. Many of these cases were done
by people with no special skill, but the same technique was
more or less followed in all cases, so that I cannot help
feeling that those cases of permanent after-effects which
are reported occasionally may be due to some error of
technique.
As far as I can gather, these permanent palsies have been
more frequent when the puncture has been made very low
down—viz., between the third and fourth lumbar vertebras.
Personalty, I have generally made the injection between the
eleventh and twelfth dorsal. It is generally easier, and if.
directly the needle has passed through the supraspinous and
interspinous ligaments the stylet is removed and it is pushed
gently, it is difficult to see how the cord can be damaged,
as directly the meninges are entered cerebro-spinal fluid
appears, and, moreover, the peculiar sensation imparted to
the Hagers as the meninges are punctured is quite charac¬
teristic, much resembling the puncture of tense tissue paper.
Indications for Spinal Aruathcna.
It appears to me that the value of spinal anaesthesia is
not, as I have previously remarked, that it abolishes the
general anaasthetio. There are a few cases in which spinal
anaesthesia presents great advantages over any form of
general anaesthetic, such as in amputation tor diabetic
gangrene and for operations of emergency which cannot be
done under local anaesthesia in patients suffering from acute
respiratory diseases.
I have found spinal anaesthesia of special value for patients
suffering from acute or chronic septic condi* ions with con¬
siderable toxaemia, such as acute appendicitis or osteo¬
myelitis. Operations upon these cases are notoriously liable
to be followed by disturbances of metabolism leading
to a general acid intoxication and also to pulmonary
complications.
I think that the general opinion of those who have used
spinal anaesthesia to any extent is that the results are on
the whole, better if general anaesthesia is not employed.
Of course, as acidosis is already present in many of these
patients before operation, and as the symptoms of acid
intoxication following chloroform or ether (only very rarely
after the latter) are much the same as those produced by
septic absorption, it is only possible to express a general
impression of the value of stovaine in these conditions after
the experience of a considerable series. I think this is one
of the points upon which we should much appreciate the
opinion of our surgical friends.
But, undoubtedly, the great value of spinal anmsthesia
is that it either abolishes or very much reduces the amount
of shock associated with long surgical operations. This
method of ansssthesia has been used nowadays extensively
for many operations which are notoriously associated with
shock, such as Wertheim’s operation and various procedures
for the removal of the rectum, and I think there is a general
consensus of opinion that the results in these cases have
been much improved.
Similarly, I think that the more severe operations in
young children, such as excisions and amputations, espe¬
cially at the hip-joint, are much less formidable under spinal
anesthesia.
Lastly, stovaine produces absolute muscular relaxation.
This, of course, much facilitates the performance of many
operations and renders long-continued and forcible retrac¬
tion unnecessary. I do not think that it is overstating the
case to say that there are some operations, such as the
radical care of a large and irreducible hernia in a fat and
muscular subject, which would be hardly p *ssible without
its use. The slightest muscular rigidity makes the operation of
prostatectomy very diffi mlt. The complete muscular relaxa¬
tion of spinal anaesthesia renders such great assistance that
this operation is not often undertaken nowadays without its
aid. Farther, the amount of general anaesthetic necessary
to produce muscular relaxation is very different to the
amount necessary to produce loss of consciousness, so that
by means of stovaine it is possible with a minimum of
general anaesthetic to produce narcosis and complete
muscular relaxation.
Contra-indications.
Perhaps almost more important than the indications for
the use of spinal anastheida are the contra-indications
against its use. I think these may be very shortly summed
up if we say That spinal ansestheria should never he adminis¬
tered to patients who are hkrly, from their condition, to
be seriously affected by the fall of blood pressure, which is
so often associated with the use of stovaine.
I believe that the experience of most operators in the
military hospitals in France has been in accord with our
experience in the civil hospitals at home, that spinal anaes¬
thesia is absolutely dangerous for patients suffering from
profound i-hock, and I believe that in most cases after a
short trial it was given up. Of course, in the base hospitals
there has been more scope for its use, as the conditions
more or less approximaTe those of civil hospitals, and severe
operations are undertaken upon patients who are in com¬
paratively good condition at the time. Therefore, it seems
to me that it shonld be clearly emphasised that spinal
ansesthesia protect* patients from the onset of shock due to
severe and prolonged surgical procedures, but should never
be administered to patients who are suffering from shock
at the time.
I think that the impression that spinal ansesthesia is a
substitute, when the patient is supposed to be too bad to
stand a general anesthetic, has been responsible for many of
the reported fatalities. ' Ir. is difficult to generalise as to the
position of spinal aneesthesia in heart disease; in mitral
disease with much pulmonary congestion it is sometimes
very useful, but certainly never in aortic disease, nor in any
other cardiac or vasoular condition in which the patients are
prone to syncope.
A problem which has often to be decided is whether the
dangers associated with an immediate fall of blood pressure
outweigh the benefit, to be obtained from stovaine. This is
especially the case in acute abdominal surgery. Here the
advantages of stovaine are well known—the muscular
relaxation, the ease with which the whole abdomen can be
explored and the consequent shortening of the operation,
and the diminution of t he shock,' which is so often associated
with manipulation of the intestines. But if the patient is
much shocked and almost in extremis from long-conii« ued
obstruction, stovaine should be used only with the greatest
caution. Bach case of intestinal obstruction must be judged
upon its own merits; some <»f the most brilliant results of
spinal ansesthesia have been obtained in this field of surgery,
but l think t hat a routine practice of using this method for
all cases of intestinal obstruction, irrespective of the con¬
dition of the patient, is only courting disaster.
Conclusion,
Finally, I should like to say a word in regard to the use of
stovaine in hospitals as one of the routine methods of pro¬
ducing anaesthesia—I mean in those cases in which no
definite indication for its use exists, but where anaesthesia
merely is required for such operations as appendectomy,
hernia, varicose veins, and so on. It is obviously an
advan'age to gain experience of this method so that when
those cusps do occur, in which the special indications for its
use are apparent, it is not in the nature of an experiment.
It has been urged against this view that spinal anaesthesia is
not so safe as general anaesthesia, but I do not think that,
given the ordinary care and skill, the facts warrant this
conclusion I have never seen a death from spinal ansesthesia
administered for any simple operation, and I believe that
many lives have been saved by its use, when occasion
requires, and if it is one of the methods in dailv use it is
more likely to be selected and skilfully administered.
So that, I think, we mav say that spinal anaesthesia Is now
long past the experimental stage. It is one of the recognised
means of producing anaesthesia. It is not a universal
anaesthetic to be applied to all cases. It has its special
dangers. It has its special merits, but used in its proper
sphere it is a very valuable method of producing surgical
anses’hesia.
Clarence Gate Garden*, N.W.
Royal Free Hospital Fair.— The League of
Nations Fair, held on Dec. 3rd and 4th at 16, Carlton House-
terrace by permission of Lady Cowdray, resulted in a sum
of £2500 for the Royal Free Hospital.
Th* Lanopt.]
PROFESSOR A. HARDEN AND OTHER8: INFANTILE SCURVY
[JAN. 4, 1919 17
INFANTILE SCURVY:
THE ANTISCORBUTIC FACTOR OF LEMON JUICE IN
TREATMENT.
By A. HARDEN. F.R.S.,
HEAD Or THE BIOCHEMICAL DEPARTMENT. LISTER INSTITUTE;
SYLVESTER S. ZILVA, Ph.D., M.Sc.,
ASSISTANT, LISrRR INSTITUTE;
AND
G. F. STILL, M.D., F.R.O.P.,
PHYSICIAN TO THE HOSPITAL F *R SICK CHILDREN, GREAT
ORMOND* STREET.
Lemon juice has long been recognised as a powerful anti- |
sco’ha tic. It han recently been demoo"trated by Harden
and Zilva (1918; 1 that, after removal of the free citric and
other acids from lemon juice, the residue retains anti¬
scorbutic activity. As far as can be detected by the methods
now aval able for the quantitative estimation ot antiscorbutic
potency, the main, if not the entire, antiscorbutic potency of
the jnioe is retained by this residue, which is "lightly acid to
litmus, but can be made neu ral if desired withjur. vitiating
its potency, and contains about 15 mg. of solids per c.cm.
The method of preparation has been described elsewhere. 1
Experiment on animal" has sho that with precautions as
to the emp^rature used thi- preparation can be concentrated |
in bulk to any desired volume, or even evaporated down almost
to dryness without losing its potency as an antiscorbutic.
Application of Experiment*/1 Binding» in Treatment.
The application of these experimental findings to the treat¬
ment of human beings is of more than academic importance.
The treatment of infantile scurvy, thanks to the clinical
and pvhnlngicHl observations of Mir Thomas B«rlow and the
la»e Dr. W B Cbeadle, has long been highly satisfactory in |
its results, albeit empirical in its origin, but the rapidity of
relief and cure has depended upon the quantity of certain
foods of recognised antiscorbutic value which could be
administered, and this quantity has necessarily been deter¬
mined chiefly by the toleration of the patient. In the case
of infants this imposes considerable limitation, for the
articles chiefly used are orange juice, grape juice, and
powdered potato beaten up with milk. Duewtive disturb¬
ance, particularly diarrhoea, is apt to occur unless these are
used with caution. The antfec »routic potency of suoh foods
cannot, therefore be utilised to itn full extent.
U was hoped that this difficulty might be overcome by the
above mentioned preparation, on the assumption that the
almost complete elimination of the acids from the fruit juioe
would remove or diminish its irritant property, and that the
concentration of bnlk would make it possible to give much
larger quantities of the antiscorbutic faotor than has hitherto
been practicable. This preparation was therefore used in
the treatment of the following four cases of infantile
•curvy.
Note* of Case*.
In the first case to be recorded, a severe one, rapid
recovery ensued.
Case 1.—Ma>e Infant axed 7 months. Had been fed on sterilised
4, humsn'8*n ” milk from birth until the pmsent time; the juice of one
orange was given once a week until 'he child was 5 months old. but not
subsequently. At 4 months he cut. r wo teeth and at 5 months two more,
when the gum" wers first noticed to he swollen; a fortnight later the
gnnns hied easily. At raontns he began to scream as if In pain when
moved ; the pain seemed to be In t he I* g*.
On adm1«si<>n to hospital 'he upoe- g»ms were greatly swollen, dark
pn~ple. and funsatlng, projecting almost between the lips. The edge
of the eetitr-1 incisors could just, be seen almost hurled in the swollen,
projecting gum-. The legs were motionless, except for movement of
ankles and to-s; som* thickening of low*- third of rlg'«t feinur and
over enrrea ondlng part of I-ft f ront B »th legs see ned very painful
tot-nirh There was some recant haemorrhage into vaccina ion scars;
urine contained red blo>*d cells.
The Infant was put. »pon a diet of undiluted boiled milk, which
clinic*) experience has shown to have no curstlve effect on scurvy.
One ounce of the concentrated preparation equivalent to double the
bulk of o Igln&i I mon juice was given three t*mes a day l.e , the
equivalent of about 4 lemons daily. A'ter 3 doses, about 18 hours
after ireatment was egun, there “some improvement; not. so
ctstresaod wh n bed is approached an • Is moving 'e*» a little." After
4 doe*-*. 25 hou>s ifrer treatment, was begun, “obviou-lv better, moving
bo*h legs, especially the lef , which Is less swo'bui.the fu gating upper
gums project 'ess and the teeth are less **urlel than yesterday."
The d.«e was then increased to l£ ot. or this concentrated
preparation for 2 doses and ihen to j of a much more concen¬
trated preparation = 7 times the bulk of l*-mon juice, so that the child
bat the equivalent of 6A lemons dally. After two doses of the former
and one of the latter*, 48 hours after tr-atment was begun, the protru¬
sion of the gums was less, t e legs were moved much more freely, and
the tenderness was *• much diminished ’’ ; the child’s colour was also
improved.
Tne solution was continued davs altogether; the child took in the
first 24 hours the equivalent of 7£ lemons, in the next 24 hours the
equivalent of 6£ 'emmis, in the next = nearly 9 lemons, next = 12
leinooB. and next = 8 lemons.
The recovery was very rap! I; 72 hours after treatment began all
swelling had gone from the thighs, the >egs were moved normally, and
there w ah no pain. The gums were much lw-a swollen and the blood
had disappeared from the urine. After 54 days the solution was
stopped, the child be‘ng well except for slight swelling of the gums
(which 2 days lster became normal in colour and showed very little
swelling).
The ehi'd had taken In 5 days the equivalent of the juice of
42? lemons without the slightest disturbance of dlgestloa.
on stopping the solu ion, 2 renapoonfuls of grape juice were given
three times dariy. and the s'ooIh atonoe became too frequent 5 a day.
In contrast to the normal 1-3 per diem whilst taking the much more
potent ant isc v butte preparation.
Ca^e 2 was one of mild scurvy, with much less severe
symptoms than in the preceding case, but the rapidity of the
cure was none the less striking.
Case 2.—Male infant aged 10 month*. Was breast-fed two weeks,
then on glaxo fo r one month, and B'nce then fe 1 only on a raal'ed food,
apparently a oreparaion of dried milk with malted cereal. For
two week" before a Imi-sion began to erv as If with pain whenever the
leg" were touched On admission he lay with legs flexed at hips and
abduced ; did not m »ve them md ae-mei tender over lower ei ds of
ti ire. where perhaps 8'<gbt thickening, but very vague. One tooth
jn-t showing, but gums norma'. •
The child was put u on a diet of undiluted boiled milk. One and a
half ounces of the concentrated preparation, equivalent, to twice the
bulk of lemon juice, were given three times dally. The first dose was
siren at 7 p.m., the second at 2 a.m on toe following day, the third at
10 a.m. Shortly after this the tenderness was found to have dis¬
appeared and there was more m«»^ment of the legs Two and a half
hours after th* fourth dose—1 e. 26£ hours after treatment was b*gun—
there was no tenderness and the ohild was moving the leg" well, though
not vigorously Tt<e next day. a'ter six doses, it was noticed that the
Ohild * lo ks much better ” The legs were moved well. There was no
looseness of the bowels, though the equivalent of 12 lemons was taken
in 38 hours.
The a ilutlon was continued regularly in doses of 14 oz. of the double
strength until the Infant h«d taken the equivalent of 18 lemons In
72 hours, after whtnh only a few do-*es ai Irregular Intervals were
given, ah hough really unnecessary, as the child was already well.
In the next case also there was rapid recovery.
Case 3.—Male Infant aged 83 months. Ped on Savory and Moore's
foot pr*pared in the usual way with milk and water since 3 weeks
o'd. F r the la*t th ee weeks has cried when lifted, as if hi" legs hurt
him. When first seen be did not move eith-r leg. and was evidently
| afraid of b-1ng touched. No definite periosteri thickening could be
detected There were three teeth, hut the gums were normal.
This case was seen in private consultation. No accurate reoord of
the i*ro*res8 was obtainable, but on J£ oz. doses of the concentrated
pr*'para'ion, = twice the bulk of lemon juioe, there was a very rapid
recovery.
Case 4 was one of severe soarvy, with maoh more
subperiosteal haemorrhage than was present in any of the
three previous oases.
Cask 4. Female Infant aged 114 months. After the age of about
34 months was fe i on Savory and Moore’s food for nearly 5 months,
and then oo Allen and H-nmirys No. 3 f *od prepared with pasteurised
m<lk 3 pa'ts, barley WAter 1 part. At abou'. 10 months old some
swelling of lower ends of tibis and then just above wrists was notloed ;
the child seemed In much pain. At 11 months there was some blood In
stools; more recently a large bruise-like mark had appeared over right
buttock.
Wh**n the child was first seen there was over both femora and tibiae,
especially the left, marked i hlckenlntf with acute tendernes". There waa
no movement of either leg or thigh, except very slight flexion and
extension of ankles. The gums were swollen and purple.
The child was put upon a diet of undiluted boiled milk. The oon-
oemrated preparation - twice the bulk of lemon juice w«s iven, and
afrer 2 rio-es the Infant seemed “much brighter and happier." It
was o mtlnued in doses of 14 «*z. three rimes dally, and 48 hours later,
after 6 do-es. the child was s®en ag in. The chili’s colour was
noticrabh better; she had also laughed and made baby sounds for the
first time t.h«t day for many nays. There was more movement of
ankles and toes, the gums were less swollen and less purple. The
thickening over left femur eras declledly less, but that over left tibia
was rat her increased.
Th" child was next seen 5 days later, when the right leg was actually
being kicked ah >u freely; the left l**g showed some mot!.>n, but only
very litfe. The thickening over the left tibia and femur was still
prese t, but much less; thi gum* were now only “purplish."
B*gh' days later the lef'. leg could he moved and 4 days after this
the Infant, wa- atil* to enjov its bath, moving both legs almost normally,
though the swelling in t.he left did n t finally disappear until about
26 days after treatment beg«n.
This last case was one in which there was evident! a
large amount of subperiosteal hemorrhage, and, according
to the history, this was probably of some weeks' duration so
that recovery of movement and disappearance of swelling
was necessarily a slower process than in the other cases
where the thickening, and therefore presumably the sub¬
periosteal hsemorrhage, was much less in degree; the
1 Harden and Zliva (1918), Biochemical J„ all., 260
18 The Lanobt,]
DR. W. R. REYNELL: HYSTERICAL VOMITING IN SOLDIERS.
[Jan. 4,1919
improvement, however, as compared with other cases of similar
severity treated by the ordinary methods, was undoubtedly
unusually rapid.
Value of the Treatment.
The outstanding feature of this treatment was the use for
the first time clinically of the antiscorbutic factor separated
from the greater part of the inactive components of the
foodstuff in which it occurs. Moreover, this antiscorbutic
factor was given in concentration at least double—in one
case seven times—as strong as that in which it occurs
naturally in the foodstuff (lemon) from which it was obtained.
The treatment was thus, so to speak, 4 * intensive.”
As was hoped, the result was found to be extremely rapid
amelioration of the symptoms. It is very difficult to give any
accurate comparison between the results obtained and those
which come from the ordinary treatment hitherto adopted,
whether with ‘‘potato cream” (i.e., powdered cooked potato
beaten up with milk) or orange juice or grape juice. No two
cases of scurvy can be guaranteed to be of exactly the same
severity; moreover, the effectiveness of the ordinary treat¬
ment has often been diminished by insufficiency of dose, and
unless the maximum quantity which could be tolerated has
been given it would be unfair to assume that the maximum
effectiveness of such antiscorbutics has been demonstrated.
Owing, however, to their tendency to cause looseness of the
bowels these foods cannot be increased beyond certain
limits, which vary with the particular infant. Even within
these limits the results of their administration are so striking
and rapid that it might have been thought hardly possible
to improve on them; one of us (G. F. S ) has elsewhere
mentioned that * 4 under efficient antiscorbutic diet the
tenderness and pain on movement is usually appreciably
less in 48 hours.” With the use of the concentrated pre¬
paration of the antiscorbutic factor the improvement is even
more rapid.
Consideration of Results.
In Oase 1, which was severe, there was noticeable im¬
provement—viz., diminution of distress and increased
movement of legs about 18 hours after treatment was
begun. In Case 2, a slight case, there was definite improve¬
ment in these respects in about 16 hours, and very marked
improvement in 26£ hours. In Case 3, a very severe case,
there was 44 a great change”—viz., diminution of distress
within 22 hours.
This increased rapidity of improvement is not due to
anything new in the essential element of the treatment,
which is the so-called 44 antiscorbutic factor” ; this was the
curative principle in the ordinary antiscorbutic diet just as
muoh as in the preparation we have used. The difference
is that in the experimental preparation the unessential and
irritant part of the foodstuff has been eliminated and the
antiscorbutic faotor left in an aqueous medium, associated
with little extraneous matter, and this even when consider¬
ably concentrated seems to have no irritating effect upon
the stomach or bowels. In this way it is possible to give
quantities of the 4 4 antiscorbutic factor”—eg., the equivalent
of the juice of 6-12 lemons daily—which, if given in the
ordinary form of potato or fruit juice, would set up very severe
gastro-intestinal disturbance. In ultimate completeness
of cure this mode of treatment offers no advantage over the
ordinary antiscorbutic foods which only more slowly secure
an equally satisfactory result, but it is no small matter if we
can hasten even by a few hours the relief of the very acute
distress caused by infantile scurvy.
The above results bring out another point of theoretical
interest—namely, that they confirm the results obtained
experimentally in animals. This antiscorbutic preparation
was first tested by Harden and Zilva (1918) in the prevention
of the disease in guinea-pigs and curatively in a monkey
suffering from scurvy. The clinical course of the recovery
in the infants described above was almost identical with that
observed in the monkey, and there can now be little doubt
as to the bearing results obtained in experimental scurvy
with monkeys and guinea-pigs have on human scurvy.
Medical Appointments in Ireland during
Demobilisation. —The Local Government Board have in¬
timated to the Omagh guardians that they will not sanction
a permanent appointment of a doctor to a dispensary district
until after demobilisation. As a result the proposal to fill
up the Gortin Dispensary has bad to be abandoned and the
guardians decided to make a temporary selection.
HYSTERICAL VOMITING IN SOLDIERS.
By W. R. REVNaLL, M.A., M.D. Oxon., M.R.C.P.,
CAPTAIN, R.A.M C.
(From the Seale Hayne Military Hospital , Nercton Abbot.)
Hysterical vomiting is comparatively common among
soldiers. It is surprising how scanty are the references to
this symptom in the very large literature on war neuroses.
Besides being a most distressing condition in itself, it may
lead to a severe degree of neurasthenia, with progressive
emaciation and increasing mental distress, the loss of
appetite with which it is associated finally leading in severe
cases to a condition of anorexia nervosa. In many cases it
is the only symptom, but the slighter forms of hysterical
vomiting are common among patients suffering from all
kinds of war neuroses. In a large nnmber of cases which
have come under our care the hysterical nature of the dis¬
order has apparently not been recognised, and the patient
has been diagnosed and treated as a sufferer from gastritis.
From the only paper I have seen dealing with hysterical
vomiting in soldiers, it would appear that the condition is
usually very resistant to treatment and that a complete care
can rarely be expected in less than several weeks or months.
Such has not been our experience at Seale Hayne Military
Hospital. Out of some 600 cases of war neuroses admitted
between June and October, 1918, 18 have suffered from
hysterical vomiting of from four to twelve months' duration.
All of these patients have been cured within three weeks of
admission, most of them within ten days, and a few after a
single treatment.
Etiology and Pathogenesis.
Hysterical vomiting is the perpetuation by suggestion of a
symptom due in the first place to a pathological condition,
such as that caused by gassing, dysentery, phthisis, or
appendicitis. In a certain nnmber of cases the exciting
cause is purely emotional.
1. Gassing -Gassing is the most frequent exciting cause
of hysterical vomiting in soldiers. When a man is gassed,
saliva is secreted abundantly as a result of a protective reflex,
and when swallowed it carries in solution enough of the
irritant to set up acute gastritis with frequent vomiting.
The existence of acute gastritis in such cases has been proved
by post-mortem examination of fatal cases. In the large
majority of oases the inflammation of the gastric mucosa and
the vomiting subside pari passu within a few days and at
most within two or three weeks. In the predisposed neuro¬
path or in a soldier, whose suggestibility has become
exaggerated as a result of war strain, the vomiting may
persist as an hysterical symptom after the organic disturbance
which gave rise to it has disappeared, in the same way as
aphonia and blepharospasm, which are the other common
hysterical sequels of gassing.
2. Infections and intoxications .—In a number of cases the
onset of the vomiting dates from an attack of dysentery,
trench fever, and other infections. Post-mortem examina¬
tions have demonstrated the existence of a definite gastritis
in bacillary dysentery, and perpetuation of the vomiting
occurs in a certain proportion of patients in the same way as
in gassing.
Hysterical vomiting following dysentery.— Pte. Da aged 29, a baker’s
assistant in civil life, had always been delicate and inclined to be
nervous and excitable. He enlisted In September. 1914. After being
in India for over two years he was tran«ferred to Palestine In April,
1917. He was beginning to feel very run down as a result of malaria
and a “touch of the sun,” when in June, 1917, he contracted dysentery.
Vomiting occurred from the onset of the dysentery, and persisted to a
slight extent after he left hospital. A few weeks later it became worse
ana he had to be readmitted. On admission to Seale Hayne Hospital
in August, 1918, the patient Btated that he had vomited alter food for
the past 14 months with the exception of short periods when the
sickness had not been sufficient to Incapacitate him and he had
rejoined bis unit. For the last three and a half months he had vomited
three or four times a day. His weight was 8 st. 9 lb. 3£ st,. less than on
enlistment. Treatment was begun the day after admission to hospital;
the vomiting at once became less frequent, and within ten days It had
ceased entirely. There has been no relapse in the six weeks which have
since elapsed.
Hysterical vomiting following trench Jever— Pte. P., aged 29,
accountant, always suffered from “nerves and headache.” He had
a nervous breakdown in lbl2. He enlisted in July, 1916, and went to
France in December, 1917. He w-is admitted into hospital in January
with a severe attack of trench fever, for which he was kept in bed for
four months. After he had been ill some weeks he began to suffer from
sickness after food; he coaid retain nothing but small quantities of
The Lancet,]
DR. W. R. REYNELL: HYSTERICAL VOMITING IN SOLDIERS.
[Jan. 4, 1919 19
peptoniaed milk. For several weeks be was treated by rectal feeding,
but even then he was siok three or four times a day. On admission to
Seale Hayne Hospital In July, 1918, he was in an extremely emaciated
and depressed condition.
Treatment was begun at once, and a stomach-tube was passed once
a day for a week. After the fifth day the patient vomited once a day,
and at the end of a fortnight the sickness had ceased completely.
There was no relapse, and when the patient was discharged from the
Army three months later he was able to go back to his civilian work
immediately.
Captain J. W. Moore has recently bad under his care a
case of hysterical vomiting following an anaesthetic, and he
has kindly furnished me with the following notes of the
case.
Hysterical vomiting following surgical amesthesia.— Pte. B., aged 34,
manager of a dairy In civil life, has never been robust or able to do
bard work. His brother suffers from neurasthenia and has never
been able to work. He was called up in Maroh, 1917, and was sent to
France the same month. He was classified B 2 on account of his
genertl weakness, and only did orderly work. A week after his arrival
In France a shell burst ne«r his hut and a piece of metal entered his
buttock. He was operated on two days later and a piece of shell was
removed. After the operation he vomited constantly for several days,
and since then he had been unable to take any solid food without
vomiting.
On admission in July, 1918. he was emaciated and weak, and it was
with great difficulty that he was persuaded to eat solid food. Repeated
explanations of his condition and constant encouragement were
auocessful In stopping the vomiting 10 days after admission. There
was no relapse and he was discharged seven weeks later completely
cured.
3. Be flex vomiting .—Among the causes of reflex vomiting,
which may be perpetuated and exaggerated as hysterical
vomiting, phthisis and appendicitis are comparatively
common.
Hysterical vomiting in phthisis.— Pte. B., aged 40, was admitted for
“gastritis” on May 1st, 1918. He had vomited after every meal for
more than 12 mouths. He was emaciated and looked very ill. Exami¬
nation of his chest showed extensive tuberculous changes, but the con¬
dition was now one of smouldering activity with an evening pyrexia of
99® to 99‘6° F. The patient was kept in bed until his temperature was
normal. His vomiting was treated as if it were hysterical, and within
ten day* it had ceased completely and no relapse occurred. He rapidly
gained in weight and was discharged from the Army in a satisfactory
oondition, not having vomited for two months.
4. Emotional vomiting .—In the genesis of all neuroses
emotion is a factor of prime importance, and in a number of
cates of hysterical vomiting this was the exciting cause.
Thus a soldier was detailed to bury some decomposed German
corpses. The work was of such a revolting nature that he
was sick, and the vomiting continued for several months until,
when the origin and nature of his illness were explained to
him, he was able to control the habit.
Symptoms.
In moat cases the patient vomits after every meal,
but sometimes vomiting only takes place once or twice
a day. In slighter cases several days may pass without
sickness, and in sucb patients the vomiting can often be
traced to slight emotional upsets, such as fits of temper, a
disturbed night with nightmares, bad news, orauddeD excite¬
ments. One of my patients, who had not vomited for three
weeks, was sick twice after being moved from one ward to
another, but after this there waB no relapse. Sudden active
movements, such as running, lifting, or even stooping to
lace up boots, may be enough to cause sickness.
The vomiting is often preceded by epigastric pain, which
is always relieved when the patient has been sick. Some
patients are sick almost immediately after food. Others are
only sick after an interval of half an hour or more. One
patient of mine never vomited during the day. but was sick
every night two or three hours after going to bed, four or
five hours after his last meal. Water-brash is a common
precursor of the actual vomiting; patients complain of a
rifting up,” “repeating," and a feeling that their stomach
contents are being “ churned up."
A characteristic feature of hysterical vomiting is its inde¬
pendence of diet. Sometimes,* however, a patient can take
liquids but not solids. In others some particular article of
diet, such as meat or potatoes, will always cause vomiting.
But in Bevere cases sickness occurs when anything solid or
liquid is swallowed, and I have had several patients who have
been fed exclusively by the rectum for weeks without cessa¬
tion of the vomiting. If the vomit be examined it will be
found to consist of undigested or partly digested food, but the
quantity is less than the amount of the meal last taken. It
is often watery in character and may contain but little solid
matter.
Examination of the patient reveals no sign of organic
disease; some epigastric tenderness may be present, but this
is unusual.
If the vomiting is of long standing, wasting may be con¬
siderable, and many of my patients had lost several stones
in weight, but the loss of weight is rarely such as would be
compatible with organic disease of the same duration. If a
barium meal be given and an X ray examination made, the
size, shape, and movements of the stomach are found to be
normal, and it is emptied at the normal rate, if vomiting
does not take place.
Diagnosis.
The diagnosis is not usually difficult. It depends upon
the absence of signs of organic disease, often with a
characteristic history of the onset following gassing or
emotional stress. Independence of diet is typical of hys¬
terical vomiting, and as a rule the variety of diets that
have been tried is in marked contrast with the monotonous
regularity of the vomiting. The watery character of the
vomit and the absence of pain both point to a functional
disorder. In doubtful cases a barium and X-ray examination
may be made, but this is rarely necessary.
The following case is instructive, and illustrates how
important it is to be on the look-out for a slight organic focus
of irritation in cases which do not recover completely under
treatment.
Hysterical vomiting associated n-ith reflex vomiting, due to dysenteric
appendicitis — Pte. M. t aged 30, contracted dysentery in Egypt in
November, 1917. During his illness he vomited ten or twelve times a
day. He was transferred to England in March, 1918, still vomiting
three or four times a day. On May 13th he was admitted to Seale
Hayne in an emaciated condition. He said that he had never vomited
less than three times adty during the last eight months. He was very
weak and depressed, and had lost 3 st. in weight.
Examination revealed no sign of organic disease, and the condition
was diagnosed as hysterical. Treatment was successful In reducing
the vomiting to once a day, with occasional days in which the patient
was not sick at all. but a complete cure could not be obtained.
Some weeks after admission the patient complained of a slight pain
in the right iliac fossa. Examination showed definite though slight
tenderness in this region and Bastedo’s inflation test was positive.
Appendicitis was diagnosed and the patient was transferred for opera¬
tion. He was not sick after the anaesthetic and lias been completely
free from vomiting since, a period of six weeks.
It is quite evident that this patient suffered from ohronic
appendicitis, which, though insufficient to cause definite
symptoms until it became aente, was enough to give rise to
a habit of vomiting which was very largely hysterical in
nature, as it was very greatly improved by psycho-therapy.
Prognosis.
A certain number of cases of hysterioal vomiting recover
spontaneously without treatment, but in a large pro¬
portion the symptom persists indefinitely unless suitable
treatment is given. Elaborate dieting, drug-therapy, and
especially rectal feeding, do more harm than good by confirm¬
ing the patient in his belief that there is something serious
the matter with his stomach. I know of one case in which
a gastro-enterostomy had been done as the patient was
supposed to have a duodenal nicer as a result of gassing, but
the natural consequence of performing each an operation on
a normal stomach was to aggravate the vomiting and make
it less amenable to psycho-therapy.
Treatment.
The method of treatment I have used for nearly all
my patients with hysterical vomiting has oonsisted of
psycho-therapy, reinforced by the suggestive effect of
the passage of a stomach-tube. The patient is interviewed
in a private room the day following his admission to
hospital. A fall history of the illness is taken and a
thorough physical examination is made. In some of the
earlier cases an X ray examination was carried out. The
patient must be made to feel that his oase has been
thoroughly investigated and is thoroughly understood.
The origin of the hysterical symptoms is now fully
explained to him. He is told that his illness began with a
definite inflammation of the stomach, but that the inflam¬
mation subsided within a few weeks; at the end of that time
the complex act of vomiting, which would be almost
impossible to carry out by a normal person, had become
very easy for him, so that what he is now suffering from is
a habit.* His stomach has acquired the bad habit of con¬
tracting soon after it has been distended with food, and all
that is necessary is to break this habit. It is explained that
a stomach-tube will be passed before his meals, and that this
will cause retching and a contraction of the stomach, so that
the organ will be given the exercise that it has grown used
to about meal-times, but that having contracted before
meals it will not have the same tendency to do so after
meals. The explanation is, of course, not to be regarded as
a scientific one. but simply as one which will appeal to the
patient’s mind. I tell him that it is a method of treat¬
ment that I have never known fail, and that it will
depend on him how often the tube need be passed,
as in many previous oases a single treatment has
stopped the vomiting completely. I impress upon
the patient particularly the importance of breaking
the habit immediately, as mnoh trouble will be saved
thereby. In order to make his effort successful at once I
20 The Lancet,]
CLINICAL NOTES.
[Jan. 4, 1919
order that his first meal shall be dry, no fluid of any kind
being taken for two hours after meals, which should consist
at first of toast and butter and an egg. As soon as the
patient can retain dry light meals the diet is gradually
increased until a full diet can be taken. After that fluids
are allowed with meals, beginning with small quantities.
The vomiting becomes less frequent at once and usually
ceases at the end of a week or ten days; in favourable cases
it should stop after the first treatment.
In patients of superior intelligence it has often been
possible to effect a rapid cure by pure psycho therapy
without the aid of suggestion. The patient is made to
understand his condition exactly, and is told that in men of
more than average intelligence success usually follows such
an explanation, but that, failing that, a method of treatment
is available which never fails, though it is somewhat
unpleasant, and will therefore not be used unless it is
absolutely necessary.
Note on Hysterical Vomiting of Civil Practice.
There is no doubt that many cases of chronic vomiting
met with in civil practice are hysterical in nature, although
this is not us tally recognised. It is probable, though further
research will be necessary to establish the fact, that most,
if not all, cases of so called pernicious vomiting of pregnancy
are purely hysterical, the acc »mpanying acidosis being the
result and not the cause of the vomiting. The following
case is one of several seen by Lieut -Colonel A. F. Hurst.
Hysterical {so-called pernicious) vomiting of pregnancy cured by
psycho-therapy.— A patient. 21 yea s old, In her first pregnancy buffered
during the first few weeks irom the vomiting which is so common hs
to bo regarded as physiological. Instead of ceasing, b< wever, at the
usual time, it continued In an aggravated form, so that by the third
month she was quite unable to retain any solid food. When first seen
by Lieut.-Colouel Hurst, at the end of 'he fifth month, she had become
extremely emaciated and weak. She vomited fluids ss well as solids,
and during tne la t three weeks she had been ted by rectum, but the
vomiting returned directly anything was taken hy ip.-uth as well as
independently of this. Her urine contained diacetic acid and acetone,
and a trace of albumin; her breath smelled of ace one. As all drug
treatment bad tailed, the gynaecologist who saw her at the same
consultation urged immediate emptying of the uterus. Li**ut.-Colonel
Hurst asked for 24 hours’ do'ay. He explained to the patient how her
symptoms had arisen as a h*bit. maintained after the normal vomiting
during the first weeks of pregnancy had ceased, and how afier its long
rest her stomach c >uld now de»l with ordinary diet in spite of its failure
with slops and fluids, which were not the normal food of an adult. She
was thoroughly convinced, took a good luncheon, tea, and dinner the
same day, and never vomited again. The signs of intoxication, which
were simply the result of starvation rapidly disappeared, and she was
delivered of a healthy boy at full term. 6he had gained so much in
strength that she was able to nurse him, and had lived a normal life
during the last three months of pregnancy.
It seems probable that many cases of persistent vomitiDg
after operations are purely hysterical, and the well-known
efficacy of gastric lavage in such cases may be more the
action of suggestion than due to the removal of mucus or
other irritant from the stomach. On several occasions
patients, who have suffered so severely from vomiting after
previous anaesthetics that they have only been persuaded
with difficulty to undergo a further operation, have not
vomited at all when told convincingly that the anaesthetist,
who was going to give them ether on this occaMon. had a
special method which was certain to prevent vomiting,
although it was quite indifferent what special modification
he used.
In the same way the vomiting associated with gastritis,
gastric ulcer, chlorotic anmmia, and appendicitis may in
suggestible individuals continue or recur as the result of
auto-suggestion after the original cause has disappeared, as
Lieut.-Colonel Hurst has pointed out. In all such cases it
can be rapidly cured by pure psycho-therapy.
Dr. Vermylen, a Belgian physician who has been
for the past three years house surgeon at the North Devon
Infirmary, Barnstaple, was recently presented with a cheque
to defray his expenses of returning to Belgium by the com¬
mittee of the institution. The gift was accompanied with a
resolution expressing appreciation of his services. The
medical staff presented Dr. Vermylen with a case of surgical
instruments.
The late Dr. J. Michell Clarke. —As a memorial
to the late Dr. Michell Clarke it has been decided to enlarge
and continually to add to the medical library controlled by
the Bristol University and the Bristol Medico Chirurgical
Society. The cost of the scheme is estimated at about
£2000. The subscription list will shortly be closed. Mr.
Rafter, registrar of Bristol University, is acting as honorary
treasurer, and donations should be forwarded to him.
CInutal Stotts:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
-♦-
FRACTURE-DISLOCATION OF ASTRAGALUS,
WITH POSTERIOR DISPLACEMENT
OF SUPERIOR FRAGMENT.
By H. C. Orrin, F.R.C.S.Edin.
The following case appears of sufficient interest and rarity
to merit record.
Patient, private, aged 46, came under my care in hospital
within seven days of his injury in France, and was said to be
suffering from a “ swollen aud contused right ankle.” During
a bomb raid he was rendered unconscious, but thinks he was
struck on the ankle by a flying missile. So severe, however,
was the injury sustained that doubts have arisen as to
whether he was hit diiect on the ankle or, the foot being
fixed, his body was laterally forced away from his foot by
the bursting of the bomb. Personally I incline to the latter
view.
On examination upon arrival here, there was marked
swelling and ecchymosis of the right calf, inner side of foot,
ankle, and tarsal region. No movement whatever could be
elicited at the tibio-astragaloid articulation. Through the
Fracture dislocation of astragalus.
oedematous tissue on the inner side of ankle could be felt a
bony mass, situated laterally between posterior aspect of in¬
ternal malleolus and tendo Achillis. At a later date, when the
swelling had subsided, this mass could be defined as hemi¬
spherical in shape. Stereoscopic X ray plates were taken,
aud the injury was found to be one of fracture of the
astragalus, with posterior dislocation and displacement of
upper half on to superior surface of os calcis.
Operative measures were not undertaken until all swelling
and ecchymosis had subsided. I then investigated the con¬
dition by making an incision on inner side of ankle, between
internal malleolus and tendo Achillis, and through which I
removed the fractured and dislocated half of the astragalus.
When the bone was fully exposed, its position was still more
remarkable, for not only had a fracture-dislocation occurred,
but in its displacement backwards the upper half was found
rotated on itself, so that its superior articular surface was
looking inwards. No tendons or important structures were
divided in the operation, and the wound was closed without
drainage. Healing was by first intention.
Passive movements and massage were commenced early,
and when ten weeks later the patient walked out of hospital
his range of movement at the ankle-joint was most
remarkable.
The Lancet,]
CLINICAL NOTES.—MEDICAL 800IETIE8.
[Jan. 4, 1919 21
A PERMANENT CRITERION FOR THE
STANDARD AGGLUTINATION TEST.
By A. D. Gardner, D.M. Oxon., F.R.C.S.
{From the Department of Pathology , University of Oxford ,
Standards Laboratory.)
One of the difficulties in obtaining absolutely uniform
results with the macroscopic agglutination test (Dreytr’s
technique) lies in the fact that different observers may adopt
different degrees of agglutination as “standard agglutina¬
tion.” In the directions sent out with standard agglutinable
cultures this is defined as “ marked agglutination, without
sedimentation.” Bat a considerable range of size of flocouli
is covered by this definition, and it is desirable, if possible, to
introduce greater uniformity in this section of the technique.
Even a single experienced worker cannot always keep in his
mind’s eye precisely the degree of flocculation that be is
accustomed to take as “standard,” though his error from
this cause will be small. The divergence of the standards
of any two observers, however, may give rise to discrepancies
in the calculation of standard agglutinin units amounting
to 20 per cent, or more.
A satisfactory way of overcoming this difficulty would be
found in the issue from the central laboratory of permanent
tubes showing the precise degree of flocculation that is best
adopted as standard agglutination for the various types of
bacilli.
The writer has found a way of preparing such tubes in the
following manner: —
Tube *.—Special agglutination tubes are made donble the
length of the small agglutination tubes used in Dreyer’a
method, but of the same calibre.
Gelatin Solution .—A 20 per cent, solution of gelatin in
normal salt solution. This is used for diluting the serum.
It must be made as clear as water.
Culture .—Standard agglutinable culture of the bacillus to
be agglutinated.
A suitable dilution of the specific serum is made with
the melted gelatin solution. One c.cm. of Oxford standard
serum mixed with 9 c.cm. of gelatin solution answers well.
Ten drops of this are thoroughly mixed with 15 drops of
standard culture in each tube, and the tubes are incubated
until the desired degree of agglutination appears. Then
the tubes are immediately stood in cold water and one
small drop of commercial formalin is added to each. Such
tubes as show, on further minute inspection, the precise
degree of agglutination desired are sealed off in the blow pipe
flame. The formalin fixes the gelatin, which will not again
melt even at boiling temperature.
Thus we have a tube presenting all the appearances of an
ordinary agglutination tube with the agglutinated fluid
contents, but actually containing a solid and permanent
block of fixed gelatin. 1 have observed no alteration in the
appearance of these tubes over a period of six months or
more. If desired, a series of such tubes may be made
showing every degree of agglutination from total to the
finest trace. A series of this kind may be very useful for
reference in fine experimental work.
Different emulsions of the same organism mfty present
variations in the quality of agglutination they show. And
particularly in the c - se of B paratyphosns A and B many
emulsions are found to agglutinate somewhat imperfectly.
Standard agglutination tubes ought, theoretically, to be
prepared for each species of bacillus, but for practical
purposes it is quite sufficient to use one species of a group
as type for the whole group—e.g., B typhosus for the
“enteric ’’group of bacilli and B. dysenteric (dbiga) for the
dysentery group. “ Standard ” agglutination of the latter
group is finer than that of the former.
Oxford.
A CASE OF TRAUMATIC ANEURYSM OF THE
EXTERNAL CAROTID.
By S. C. Dyke, M.B., B.Ch. Oxon.,
CAPTAIN, R A.M.G. (T.O.).
The following case seems to show several points of surgical
interest:—
Private-, age 34, was wounded by a bullet on August 8th.
Bullet entered on left side of noee, just below the root, passed
through upper part of nasal cavity, across right side of face,
and made its exit through the right external auditory meatus.
On August 13th he was admitted to a hospital in England.
He then bad little pain. Entrance and exit wounds were
both clean; there was considerable swelling of right side of
face, over parotid region, and apparently limited by the
parotid fascia. This swelling showed no signs of inflamma¬
tion, and was ascribed to extravasated blood. X rays showed
some fragments of bullet casing in right parotid region
and a fracture of the right ascending ramus of inferior
maxilla. There was some paresis over distribution of upper
branch of right facial nerve. This had disappeared by
August 21st.
On August 22nd patient complained of much pain in right
side of face, and on examination it was found that the
parotid swelling was now- pulsatile. A diagnosis of
traumatic aneurysm was made, though whether of internal
or external carotid it was impossible to say.
The patient was seen by Major Cecil Be vers, R. A.M.C. (T.F.),
who aeoided, in view of the impossibility of learning by
other means, to expose the carotid and determine by occlu¬
sion of the vessels whether the external or internal carotid
was involved. Further, in view of the manifest difficulties
in the way of performing distal ligature on a vessel lying in
the midst of a large extravasation of blood deep in the
f >arotid gland, it was decided to try the effect of proximal
igature of the affected vessel.
Operation was performed the following day. The carotid
was exposed through usual inoision. The operation was
rendered difficult by the shortness of patient’s neck, the
bifurcation of the carotid being right up under the angle of
the jaw. It was found that pulsation of the swelling was
completely stopped by occlusion of external carotid; this
vessel was accordingly ligated immediately above bifur¬
cation. The establishment of a collateral circulation through
the branches of the external carotid of the other side, as
feared, did not occur. The swelling decreased in size imme¬
diately after operation, and 10 days later, except for the
fracture of jaw, condition of patient was normal.
The case is of interest as showing the successful result of
early proximal ligature in traumatic aneurysm, even of a
vessel forming such free anastomoses as the external carotid.
The successful result was probably due to the rapid develop¬
ment of the aneurysm, which outran the widening of the
anastomosing vessels and gave no time for the formation of
a collateral circulation. In an aneurysm of slower growth
the result would probably have been different.
XUbual Sflritltts.
SOCIETE DE BIOLOGIE, PARIS.
The following is a summary of some of the papers read at
the meetings of the society held on Dec. 16th and 21st:—
P. Carnot. —The Question of Antiseptics.
1°. Ant.isep»ie des milieux exterieurs: Is dose et la specificity dee
anfcUeptlques. la production des formes de resistances du microbe:
8p<>rulati<>n. etc. - sort des nations importin'ea k acquerir. Une
mftme espdee microbienne peut se comporter dlffert-mment vis k via
d’un mftme antisepiique suivant la dose. Lors du pas<age dans
f economic, il pent y avoir augment «tion de resistance aux anli-
sept.iques et acc<*utumance A cefc antlseptlque. Avec une dose d'anti-
septlque infeiieure A la dose moit»lle, on peut obtenir une action
antigenetique seulement. (Test faction attenuante d'antiseptique.
Bn dlmlnuant les doses I’antlseptique deviant accelerant. A dose
minuscule faction *e poursuit. La question des relations de* proprtetea
physicociiimiques et des propriety antiseptiques eat complexe: lea
phinomdoes de dissociation, d’lonlsMtlon, de solubilisation ont un rfile
complex® & jouer. L’actIon do milieu exterieur, electrolyte, proteine,
cellules vb antes du mtlieu, est Import ante et modifieconstderat ment
I’mfluence des antiseptiques. 2°. Au debut de la guerre, I’asepsie
cbinirgicale dominant. Puis fantisepsie a domine. Beaucoup de
chirurgtens la coriBlderalent. com me nocive, la discussion reste ouverte.
La sterilisation des plates semble ne leuestr que d’une fa^on precoce et
dans de bonnes condl*ions: method® Carrel. Sur les suppurations
anciennes aucune substance ne semble avoir faction. L'action curative
se fera o’autant plus sentir que le contact, avee le germe sera plus pro-
longe et plus Intime. Action sur laplaie: (1°) Antiseptique k action
antibiotique generate sur microbe et cellules. (2°) Action anticellu-
lalre peu intense. (3°) Action antiseptique de plus en plus r eglig* able
mais ay ant nn rdle empGahant indirect sur f organisms: action exsuda-
tive, l> mphorie, Ac. i 9 . Antisepsie interne. Antisept-ie des canaux et
des cavites: on chercbe k porter dtrectement fantiseptique faible au
contact du germe & combattre Dans les Infections generates, on
emplote des substances k action antiseptique indirecte.
A series of papers followed on the action of particular
antisep' ics:—
Pbilardeau.— Sodium Fluoride.
A. Latarjet and Mile. Promsy. —Antiseptic Action of
Ionisation.
E. Fournbau and E. Donard —Chlorides of Iodine.
W. Mestrbzat and Th. Cabalib. —Monoohloride of Iodine.
22 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Jan. 4, 1919
W. ME3TREZAT.— Chlor-alum.
Cl. Reoaud. —Artificial Serum under Pressure.
Maurice Cazin and Mme. S. Krongold-Vinaver.—
Electivity of Antiseptics for Particular Organisms.
Louis Bazy and Faure-Frbmiet. —Wound Zones
Accessible to Antiseptics.
Plulb and Faure-Fremiet— Paraffined Dressings.
Gate and Decho3al. —Vaccination against Influenzal
Complications.
Rcsultats fournls par 105 recherches portant sur 82 cas de grippe,
dont 37 sev&res et compliqu^s. 1°. Le B. de Pfeiffer s’est montre une
•eule fois dans les crachats. 2°. Le pneumocoque frequent dans les
crachats aetc trouve 5 fois seulementdansdes pus pleurauxau debut.de
Tepidemie. jamais dans le rang. 3°. Le Streptocoque tu'innlytiqiie a ete
vu 18 fois dans les crachats, 12 fois dans des pus pleuraux, 4 fois dans les
h^mocultures. Tiej virulent pour 1‘homme (6 dec^s sur 12 pleurisies,
3 sur 4 septiccmies). Ce streptocoque a montre peu de virulence pour
le lapln. 4°. Des essais pen nombreux de raccinotiu'rapic curat ire anli-
streptocorcique ont paru donner des resultats assez nets, quand il a'est
agi de grippes compllquees de Btreptococclet.
Mery and Girard.— Action of Antiseptics on Virulent
Germs in the Naso-pharynx.
Che/, trois entente porteurs de pneumocoqnes. vlrulents pour la
eouris, dans le rhino-pharynx, le collargol au 1/100 et 1’hulle gomenolge
au 1/10, verses par les narines largement dans le cavum pendant
ploalenrs jours de suite, n'ont reussi qu it dimlnuer le nombre des
colonies microbiennes ensemencees avec le mucus sur boitesde Petri,
sans attenuer la virulence des germes, notamment du pneumocoque,
qnl demeure virulent pour la sourls.
Pommay-Michaux, B. Michaux and Moutier.- A Diplo-
ooccus Occurring in the Hasmocultures of Influenzal Cases.
Dans vingt quatre. lee hemocultures de grippes ont dicele un diplo-
coque prenant le Oram, poussant lentement en milieux ordinalres,
trfcs blen en milieux A Tasclte, qui rappel le les caract&ree norpho-
ioglques du pneumocoque, mais ii n’est pas pathogdne pour les
animaux usuels de laboratolre (sourls, oobaye, et lapln).
Bruntz and Spillmann.— Trench Feet a Vitamine
Deficiency.
Le manque de vltamlnes entrains dee troubles scorbutlquee ou nivri-
tlquee. Ces aoctdente sufflsent pour expli<|uer le mal des tranchees, qui
de oe fait peut-£tre considere comma une avitamlnose.
North of England Obstetrical and Gynaeco¬
logical Society. —A meeting of this sooiety was held in
Liverpool on Dec. 13th, Mr. Miles Philips, of Sheffield, the
President, being in the chair.—Mr. W. W. King showed Two
Cystic Tumours of the Vulva of somewhat doubtful patho¬
logy. The first was probably a cystic adenoma of Bartholin’s
gland, and the other a cystic endothelioma.—Dr. Blair Bell
showed an Abscess in a Fibromyoma undergoing Red
Degeneration, and Encephaloid Canoer of Abdominal Wall
secondary to paracentesis abdominalis for ascites due to
intra-abdominal carcinoma.—Dr. J. H. Willett showed a case
of Ectopic Gestation in which the mole, about the size of a
hen’s egg, was lying in the pouch of Douglas, and toth
Fallopian tubes apparently normal, except that on the right
side a salpingotomy had been done some years previously,
and this was found to be closed. He also showed a speci¬
men of a Uterus with a large number of fibroids, in which
there was an early pregnancy, in which hysterectomy had
been necessary on account of severe pain.—Dr. Leith Murray
showed a specimen of Sessile Red Fibroid weighing one pound
on the anterior wall of the uterus, causing acute symptoms
during pregnancy and enuoleated at the twenty-first week
without interruption of gestation.—Dr. Fletcher Shaw read
the notes of a case of Extra-uterine Pregnancy which had
progressed to the fifth month, and for which he had had
to do an abdominal section on account of severe pain.—Dr.
Briggs read a short note on the Radical Cure of Complete Pro-
oidentia, illustrating his paper with diagrams and photo¬
graphs and reading the notes of several illustrative cases.
National Food Reform Association— “Dietaries
Suitable for Secondary Schools, Colleges, Hostels, Clubs, etc.,
with Reoipes, Notes, Quantities, and Weekly Expenditure,
Approximately, 8 s. per head,” 1*. 3d. net, is about to be
published by the National Food Reform Association, Danes
Inn House, 265, Strand, W.C. 2.
Livingstone College, Leyton.— This college,
which normally exists for the training of men who are, or
intend to be, foreign missionaries in an elementary knowledge
of medicine and surgery, has been used since August, 1915,
as a hospital for wounded soldiers. In a little over three
years more than 2000 patients have been received from the
Bethnal Green Military Hospital to which Livingstone
College is an auxiliary. It has now been decided, temporarily,
to close the institution, and it is hoped that the ordinary
work of the college will be resumed next October. In the
meantime the Hospital Council are appealing for funds in
order that they may be able to hand over their accounts to
the college with no deficit. About £300 is repaired.
$Ubiefoi wto IMfos of
A Text-book of Pharmacology and Therapeutics. By A. R.
Cushny, M.A., M.D., LL D., F.R.S. Seventh edition,
thoroughly revised. London : J. and A. Churchill. 1918.
Pp. 712. 184. net.
In revising his text-book for its seventh edition Professor
Cushny has not found it necessary to introduce modifications
so extensive as those which distinguished the sixth edition
from its predecessors. The classification of drugs—adopted
in the sixth edition—on the basis of the organs most charac¬
teristically affected by them has justified itself, and is
retained. Only closer study of the new edition reveals how
much has been done, by deft re-statement here and addition
there, to ensure that the book keeps pace with the progress
of knowledge and continues to justify its reputation as a
storehouse of practically all that is of proven significance in
pharmacology.
The immediate need for this new edition was created by
the issue of the Ninth Revision of the United States
Pharmacopoeia. The inclusion in this of biological standards
for certain remedies necessitated a short chapter on methods
of biological assay. This chapter goes hardly at all beyond
description of the methods thus rendered official in America ;
and such a restriction was probably almost inevitable, for
the sake of the American student, to whom a discussion of
unauthorised methods might have proved confusing. More
than one opinion is possible, however, concerning the
validity of some of the methods adopted by the U.S.P., and
the optimist may look forward to the possibility that before
another new edition of the text-book is required a more
progressive spirit among those responsible for such matters
in this country will have widened the scope of this chapter.
Only those who have tried for themselves to cope with it
can form any estimate of the vast crop of pharmacological
and therapeutic observation to be gathered in the world’s
medical and scientific literature, or of the extent to which it
is scattered through journals devoted to the neighbouring
sciences of physiology, chemistry, pathology, and practical
medicine. The attempt at gleaning over these immense
fields, to say nothing of the threshing and winnowing, means
bewilderment for most of us. Professor Cushny’s power
of surveying a wide range of the literature, not only of
avowed pharmacology but of the kindred sciences as well,
of seizing instinctively what is new and significant among so
much which is neither, and of presenting it in the light of <
his ripe experience as teacher and investigator, has given to
his book the position of unique authority which it has long
held among text-books of pharmacology in the English
language.
Pharmacology, as an independent science, is a compara¬
tive novelty in the medical curricula of this country. The
gradual displacement of the medley of materia medica,
pharmacy, aud clinical empiricism, with odds and ends of
toxicology, which at one time took its name and its rightful
place; the growing recognition of experimental pharma¬
cology as the necessary basis of the scientific therapeutics
which all desire—no changes have had more importance
than these in the recent developments of medical education
and practice. No influence has been stronger in promoting
this change, and its logical outcome in the transference of
exact methods to the clinical study of therapeutic effects,
than that exercised by this text-book and by its distinguished
author. It is to be hoped that more and more students
will make it their teacher and guide. They may gain from
it not merely equipment for examination tests, but a habit
of mind which will be a lasting possession, an insight into
methods which will enable them in turn to use their oppor¬
tunities of practice for the advancement of medical science,
as well as for the immediate benefit of their patients.
The Practice of Medicine. By Sir Frederick Taylor,
Bart., President of the Royal College of Physicians.
Eleventh edition. London : J. and A. Churchill. 1918.
Pp. 1091. 24#.
It is a high and arduous task to supply the needs of the
average medical student for a systematic text-book of internal
medicine during a period of 28 years, but Sir Frederick
Taylor has done it. The first edition of the “Practice of
Th> Lancet,]
REVIEWS AND NOTICES OF BOOKS,
[Jan. 4, 1919 23
Medicine ” appeared in 1890; the eleventh edition is now
before os. During this period most one-man text-books have
become systems with a number of contributors, and it is
now recognised to be impossible for any one man to cover
adequately and equally the whole ground of internal medicine.
It may be that no other will attempt it. But in ‘that case
the fortunate student of the future will still have one cause
of regret, for a one-volume one-author text-book gives a bird’s-
eye view of a subject which is obtainable in no other way.
8ir Frederick Taylor has added to the present edition short
paragraphs on the new diseases, or new aspects of diseases,
arising during the war. A certain number of new charts and
illustrations also appear ; but their selection is arbitrary, and
it is doubtful whether 85 blocks are of any real value in
illustrating so enormous a field. The lecture diagram, the
ward, and the clinical laboratory are the proper illustrations
to a book on the practice of medicine.
A few verbal errors have, as is natural, crept into the
text, but on the whole the book is a marvel of accuracy.
Ortkopadio Treatment of Gunshot Injuries. By Leo Mayer,
A.M., M.D., instructor in Orthopaedic Surgery, New
York Post-Graduate Medical School and Hospital. Illus¬
trated. London and Philadelphia: W. B. Saunders
Company. 1918. Pp. 250. $2.50.
This book is largely the outcome of Dr. Mayer’s experience
as orthopaedic surgeon to the Urban Red Cross Hospital and
to the Oscar Helene Home for Crippled Child'en. But
although he follows the methods of German orthopaedic
surgeons to a considerable extent, he pays a tribute to the
work of Sir Robert Jones, and in various parts of the book
shows evidence of a wide acquaintance with the work of
British surgeons. While illustrations of Professor Sauer-
bruch’s operative technique for utilising the muscles of the
stump are given, no mention is made of the further develop¬
ments in this direction made by Signor Putti.
The book deals with the treatment of war injuries before
and after admission to the base hospital. Before admission
the essential requirement is the proper fixation of the injured
part; in the base hospital the problem is to determine the
proper time to discontinue fixation and restore motion. In the
first part Dr. Mayer discusses the best methods of fixation of
limbs with fractures of the bones or injuries to joints, the
diagnosis and immediate treatment of injuries to nerves, and
the orthopaedic treatment of injuries to muscles, tendons,
and cutaneous tissues ; in the second part he deals with the
subsequent treatment in the base hospital. Dr. Mayer
emphasises the fact that gunshot injuries to bones do not
heal so rapidly as fractures due to indirect violence; after
removal of the immobilising splint he advocates the use of
an apparatus to protect the injured bone and to restrain the
movement of adjacent joints. Macewen’s view that the
periosteum acts only as a limiting membrane is not upheld
by the author; his experiments support the conclusions of
Ollier—viz., that the most important of the osteogenetic
cells are those lying between the outer fibrous layer of the
periosteum and the surface of the bone, the so-called
cambium layer of the periosteum. In bone-grafting Dr.
Mayer insists on the importance of postponing the operation
till all signs of infection have been absent for four months.
He refers to his investigations on the anatomy and physio¬
logy of tendons and points out the importance of the
ll paratenon,” a name given to the loose areolar tissue
containing an unusually large number of elastic fibres,
which separates the tendon from the fascia outside the
tendon sheath and extends downward into the sheath in the
form of a tongue-like fold, the plica. On contraction of the
muscle, the plica allows the tendon to glide freely and at
the same time maintains the sheath wall intact. The
author does not find that electrical tests assist in deciding
as to the necessity of an operation on an injured nerve ; he
places reliance on alterations in sensory symptoms or in the
extent of paralysis and the probability of the nerve being
directly injured its anatomical course and the direction of
the bullet being taken into consideration. Dr. Mayer
insists on the value of workshop therapy and lays especial
emphasis on the necessity of the Military Orthopsedic
Hospital including a workshop for the manufacture of
artificial limbs and appliances. This shop allows the
hospital to make its own splints ; it affords opportunities for
workshop therapy ; it enables every patient to learn how to
mend bis own artificial limb or appliance; it teaches some
of the men a well-paid trade.
Although the choice of words and phrases is not always
happy, the subject-matter is excellent. The book is
extraordinarily well illustrated ; the text below the figures
affords complete explanations.
Medical Ophthalmology. By Arnold Knapp, M.D. Inter¬
national System of Ophthalmic Practice , edited by
Walter L. Pyle, A.M., M.D. London: Heinemann.
1918. Pp. 509. 21*.
The aim of this book is to give the essentials of what is
known of the relations of ophthalmology with every other
branch of medicine and surgery. The must prominent place
is naturally taken by diseases of the nervous system, since
in them the presence or absence of optic neuritis may be
essential to the diagnosis. Of almost equal importance is
an efficient ophthalmoscopic examination in late syphilis,
albuminuria, and diabetes, and in many other conditions,
especially circulatory. On all these subjects and on others,
including ocular tuberculosis, poisons affecting the sight,
and the relations of heredity to eye diseasts, the volume
before us, although from the nature of the subject it contains
but comparatively few pronouncements which can be con¬
sidered final, will be found useful both by the general
practitioner and by the ophthalmic surgeon.
The author’s endeavour is to give an impartial expression
to varying views rather than to press his own conclusions on
the reader. It must be confessed that such a book is lacking
in the interest which belongs to one in which first-hand
observation predominates, such, for instance, as Gowers’s
“ Medical Ophthalmoscopy.” On the other hand, it is mote
comprehensive and necessarily t more up to date, though in
this latter respect it will doubtless need revision if it is
to become a permanently valuable text-book. The section,
for instance, on ocular symptoms of bead injuries is
principally based on pre-war writings in the Graefe-Saemisch
text-book, and ignores many important observations which
have already been published by English and French surgeons
within the last four years. We may suggest, too, that the
addition of illustrations and ophthalmoscopic pictures to the
text would greatly add to the quick comprehension of the
book. The illustrations already there are entirely confined
to the preliminary chapter on the anatomy and physiology of
the visual paths and ocular nerves. The subject of treatment
is entirely outside the scope of the volume.
Medical and Surgical Reports of the Episcopal Hospital.
Vol. IV. Philadelphia: W. J. Dorman. Pp. 326.
Ten short articles in this volume refer to ophthalmic
subjects. The most valuable of them is a description of a
case of implantation cyst of the anterior chamber by Dr.
Goldberg, illustrated by two good drawings. Dr. F. Krauss
contributes an article on bilateral choked disc following
thyroidectomy of some speculative interest, and another on
a method for the ligation o£the ophthalmic vein for exoph¬
thalmos, with the report of a case. The clinical report of a
case of mirror writing, by Dr. S. H. Brown, is also of interest
as showing what can be effected by a painstaking teacher in
counteracting this rare abnormality.
The Ship Captain's Medical Guide. Edited by CHARLES
Burland. MD.Brux.,F.R.G. 8., Senior Medical Inspector
to the Board of Trade. London and Edinburgh: His
Majesty’s Stationery Office; Dublin: E. Ponsonby, Ltd.
Pp. 172. 2s. net.
The ideal in which no ship would put to sea without
having a competent surgeon on board can never be
realised, and the need of such a manual as this will always
be necessary. The various accidents and diseases that are
likely to occur on board ship are explained as completely as
possible, having regard to the fact that the practitioner will
be a layman ; if the instructions are intelligently carried
out, much avoidable sickness and suffering among the crews
will be obviated. Scales of medicine and lists of the
medicinal stores issued by the Board of Trade are given, as
well as invalid diets, while stress is laid on the importance
of watchfulness in preventing disease. We note with satis¬
faction that careful attention has been peid to those diseases
which, owing to the exigencies of war, may prove more than
ordinarily troublesome—infectious diseases, plague, malarial
24 The Lancet,]
ANALYTICAL RECORDS.
[Jan. 4, 1919
fevers, and venereal disease. Regarding this la»t matter
attention is called to the importance of instructing the crew
in the dangers of infection and the value of prophylaxis.
Together with a knowledge of fi^t-aid (which all candidates
for master’s and mate’s certificates mus r . now possess), the
book should prove useful to travellers in places where skibed
medical advice is unobtainable. The last edition of the book
was published in 1912, a new edition having been called for
in consequence of a large number of copies having been
destroyed with the ships that contained them.
Transactions of the Sixth Internitional Dental Congress.
Published by the Committee of Organisation, 19, Hanover-
square, London, W. Pp. 753.
.The Sixth International Dental Congress was held
in London in August, 1914, but owi> g to the outbreak
of war the work of the Congress was considerably
curtailed. The transactions of the various meetings
have been issued recently and form a useful contributi n
to the science of dentistry. Although the majority
of the papers deal with purely technical subjects there
are a few communications of interest to those not engaged
in the practice of dentistry. The paper on the Teeth of the
Australian and Tasmanian Aboriginals, by B. Nicholls,
should be of great value to anthropologists, and the paper
on the Evolution of the Human Dentition, by J. Humphreys,
is a useful r6sum6 of our present knowledge of this subject.
In the section on oral surgery there are several papers well
worthy of careful perusal ; of these, the most interesting
are those on Cysts of the Dental System, by L. Widman,
of Stockholm; Regeneration of the Mandible after Caries
and Necrosis, by H. M. Cryer (America) ; aod Dental Sepsis
as a Predisposing Cause of Cancer, by F. St. J. Steadman.
Reports anfc Jnalgtkal ^etorbs
PROM
THE LANCET LABORATORY.
ITALIAN ICHTHIOL—8YN. AMMONIUM SULPHO-
ICHTHYOLATE.
(Societa Industrie GhiMiohr, Naples. Agency: Paul Bkhrends,
4, Adbia-road, Didsbury, Manchester.)
The discovery of iohthyolitio shales in the mountainous
regions of Giffoni Yallepiana, S demo, has opened up a
supply of Italian iohthyol which, according to our examina¬
tion, is not in any degree inferior to that produced in the
Tyrol (Seefeld). The'therapeutic impor anoe of icbthyol
probably depends upon the presence of “ sulphidic ” sulphur
associated with an organio group Sulphuretted hydrogen
itself has marked bactericidal properties. The sulphur in
this Italian iohthyol, according to our analysis, is distributed
as follows: As sulphonate, 1*9 per cent. ; as sulphate, 2*0
per cent.; and as sulphidic sulphur, 4*5 per cent.; giving a
total amount of 8*4 per cent, of tne element. It is easily
soluble in water, yielding a dark brown, practically clear
fluid without deposit. The sulphur compound is possibly
present in the colloidal form, which adds to its activity as
a therapeutic agent, to quote some cases of its application
in gynecological, urological, and dermatological practice.
The ammonia set free by magnesia amounted to 4*60 per
oent.. and the lo-s on prolonged heating at 100° C. was
56*60 per cent.; this includes a small proportion of volatile
matter, the bulk of this loss being due to moisture. The
manufacture of ich hyol consists in the distillation of the
shale and the subsequent sulphonation of the resulting oil.
INFLUENZA VACCINE (MIXED).
(Burroughs. Wellcome, and Co., Snow Hill Buildings, B.C.)
• his mixed vaccine is based ou the directions which
resulted from the Conference on Preventive Vaccination for
Influenza held at the War OflSoe on O :t. 14th, 1918 1 E «ch
cubic centimetre contains 60 millions ti influenza, 200
n*il lions pneumococci, and 80 millions streptococci, and
includes, it is stated, more than 20 strains i oh ted from
oases occurring during the present epidemic. The “first,
dose” is represented in 0 5c.cm. and the “second dose” in j
i The Lancet, Oot. 26th, 1918, p. 56a.
1 c.cm., as laid down by the Conference. The vaccine is con*
tained in I c.cm. phials and 25 c.cm. rubber-capped bottles*
ETHYL CHLORIDE FILMS.
(Hrdlzy and Co. (Lbyton8thnb). Lt**., 120, Harrow-road,
* Leytonstonb, London, B. li.)
The ready solability of »o many useful medicaments in the
easily volatile ethyl chloride has suggested an interesting
method of employing these drugs for local application. The
fallowing are examples of ethyl chloride solutions which we
have examined, but th« list is an extensive one : Iodine
(3 per cent.) menthol, stlioylic acid, resorcin, phenebol et
safroi, and iod -form. The liquid sprayed on the skin rapidly
evaporates and leaves a perfectly uniform film of the active
constituent which, unlike a loose powder, adheres firmly.
The useful applications of this method will readily occur, but
mention may be made of such examples as the employment
of antiseptics, vesicants, or soothing agents to the skin,
local analg-sios (menthol), parasiticides, and plastic pro-
teclives. Tbe merits of this ingenions and effective method
may well claim attention.
GENASPRIN.
(Genatosan, Ltd., 12, Che *iks street. London, W.C. 1.)
The purity of acetyl-salicylic acid is of importance if its
dissolution is required to be deferred until the drug reaches
the alkaline intestinal juice. We found neither free salicylic
nor acetic acid in this preparation. The tablet disintegrates
satisfactorily in water, and gives absolutely no violet
colouration with ferric ohloride. On adding 0 2 per oent.
hydrochloric acid, representing the acidity of the gastric
juice, there is still no response to the iron test, slight
hydrolysis only taking place after several hoars. The claim
is substantiated that this preparation is a particularly pure
specimen of acetyl-sal icy lie acid.
“COFECTANT” LOZENGES.
(Howard Cook and Co., Ltd., Bow, London, B.)
The germicidal efficiency of “onfeotant” a non-toxic
ooal-tar derived phenoloid, was definitely established in our
inquiry on disinfectants some years ago. It is well adapted
to form the antiseptic basis of a lozenve coupled with
some eucalyptus and peppermint.. The lozenges are well
designed and are free from any harsh effect in the mouth,
where, in fact, they are agreeably demulcent. Apart from
their value in keeping the mouth clean in a real aseptic
sense, and relieving irritable conditions of the throat, they
serve also as nn anti fermentative, and they therefore prove
useful in certain dyspeptic conditions.
(1) FEROXAL; AND (2) VERONIDIA.
(Modern Pharmaoals, 48, Mohtimer-strbkt, Cavendish-square,
London, W. 1.)
(I) We are not aware that protoxalate of iron has been
prescribed in this country to any extent, though Mr. W.
M«rtindale mentions it as being included in Sparish and
Hungarian pharmacopoeias and as having been given in
anaemia and as a nerve tonic. Combined with the alkaline
phosphate of sodium under the name of “feroxal” it is
reported, chiefly in French clinics and recently, to be of
peculiar value in the anaemia and chlorosis of pregnancy and
in debilitated conditions generally. We found the composition
of “ feroxal " re be as stated. The dose is small, as other¬
wise the toxicitv of the oxalic group might give rise to
apprehension, although the acid is present in many foods,
notably cocoa, tea. spinach, and rhubarb. (2) Veronidia
provides an agreeable way of administering a well-known
hypnotic, under, of course, tbe direction of the physician.
It is a syrupy preparation containing aromatics, glycerine
and spirit as solvents, preservatives, and flavouring agents.
Brighton Hospital Sunday Fund. —The alloca¬
tion of tbe sum collected in tbe churches and chapels of
Brighton, Hove, and Preston, on Hospital Sunday (Ocr.. 27th)
has just been made. The total sum collected was £1220 12s. Id.,
and the highest grants made have been as follows:—Royal
Busnex Cou**ty Hospital, £528; Koyal Alexandra Hospital for
8ick Children, £135; Brighton, Hove, and Preston Dis¬
pensary, £132; Queen’s Nurses, £102 10s.; Hospital for
Women, £98 Two circumstances told against the previous
year’s total of £1527 15s. 3d. being reached—the wet Sunday,
and the fact that tbe day before was one of many “ flag ” days.
The Lancet,]
A NEW YEARS WISH.
[Jan. 4, 1919 25
THE LANCET.
LONDON: SATURDAY, JANUARY 4, 1919.
A New Year’s Wish.
The New Year opens with so much immediately
ahead of the medical profession that no one can say
what matters call most urgently for attention, or
what particular developments will be the first to
receive the public interest without which progress
can be but hardly made. We have a new world and
a new sort of Parliament to direct our energies for
national and for international good, and in this
challenging environment medicine takes a stand,
ready to alter in the cause of truth, while strong to
maintain the proven essentials of science. And this
much is certain, the public will expect from medicine
an amount of prevision and guidance which has
never before been sought from us. That the
good health of the people is the people’s
greatest asset is now universally admitted, from
which it follows that legislation with such an objec¬
tive will be warmly welcomed, and from which it
should follow that medical advice ^ill be sought
and acted upon by Parliament to an increasing
degree. Our professional voice in the new
Parliament cannot be a loud one—this will be
apparent from the result of the polls in which
medical men were concerned, and which we
publish elsewhere; but if what the medical
Members say within the Senate is found to reflect
a solid consensus of scientific opinion without,
benefit to the nation of supreme value should
follow. May the New Year bring, out of the many
schemes to the same end, a real union of medical
men, in which our national services may be properly
recognised and fully utilised.
- 1 -
Lessons of a Great Epidemic: the
Pathology of Influenza.
The second wave of a great and—let us be frank
about it—unexpected epidemic has passed over our
heads and left us breathless, indeed, but seized of a
firm resolution to get even with the greatest plague
of modern times. On the clinical aspect of influenza
fresh light is thrown by the important work done at
Aldershot which we print at the front of this issue
of The Lancet. On this, as well as on the epidemio¬
logical aspect of influenza, we reserve comment
until next week. For while the morbid chain may
be broken at any of its links—epidemiological,
etiological, pathological, or clinical—it is, at the
moment, to pathology that the thoughts of many
have turned with the greatest prospect of result.
To the October number of the Medical Supplement
there was contributed an admirable review of
the etiology and pathology of influenza. We
can recall no more masterly review in our
language of this or, indeed, any other “ war
disease ” during the last four years, so that dis¬
cussing the more recent developments it is fitting
to take it as a basis. As a result of his study of
the literature, European and American, the author
(Dr. Rajkmann) concludes: “ The cold logic of the
post-mortem room in the dispassionate home
surroundings does not leave, however, any doubt
that B. Pfeiffer when present did not play any more
important part than the ubiquitous diplo-strepto¬
coccus. The real virus, classified faute de mieux
as ‘ invisible,’ or a ‘ filter-passer,’ so as to cloak our
ignorance of its nature, remains to be discovered.”
How far are these conclusions borne out by the
later studies ? As indicated by more than one of
the articles which appear in this and last week’s
issues of The Lancet, the diplo-streptococcus is still
with us. But two, at first sight directly contradic¬
tory, series of observations deserve note. On the
one hand, whereas the earlier literature of this
epidemic laid stress upon the infrequency, or at
least inconstancy, of the discovery of the influenza
bacillus in the sputum, its rare recovery from the
lungs in cases of influenzal pneumonia, its still
rarer recovery from the blood, and this on the part
of trained bacteriologists of the first class, to-day
with a striking unanimity those who have succeeded
in preparing sterile trypsinised blood media along
the lines laid down by Matthews, 1 or who, follow¬
ing Levinthal, 2 have employed heated blood
media, announce that Pfeiffer’s bacillus is obtain¬
able in abundance from the sputum of practically
every case of the disease. On the other hand, we
have the series of observations which from various
sources, confirming one another, appear to establish
a “ filter-passer ” as the primary agent and essential
cause. This series was begun by Selter, s who
sprayed his own throat and that of his assistant
with a saline filtrate of throat swabbings and
throat washings of several patients. Each
developed a typical though mild attack of influenza.
Next, Nicolle and Lebailly, 4 in Algeria, making a
similar saline filtrate through a Chamberland
(porcelain) L. bougie, conveyed the disease to
monkeys by intranasal and conjunctival intro¬
duction of the filtrate, intravenous injection pro¬
ducing no results. Subcutaneous injection of the
filtrate into two volunteer subjects induced the
typical disease. At the meeting of the Acad&mie
des Sciences a week later, Dujarric de la Riviere '
reported that the filtered mixed defibrinated blood
of four patients inoculated subcutaneously induced
in himself a well-marked attack of the disease.
More recently Gibson, Bowman, and Connor, 1 '
working under the Adviser in Pathology of the
British Forces in France, Colonel Cummins, A.M.S.,
at an Army laboratory in France, with the aid of the
Medical Research Committee, confirmed the observa¬
tions of Nicolle and Lebailly as regards the effects
of intranasal and conjunctival injections upon
monkeys, and call special attention to the develop¬
ment of pulmonary haemorrhages and haemorrhagic
i Thb Lancet, 1918,11., 104.
3 Zfcscbr. f. Hygiene, 1918, Ixxxvl., 1; and Berl. klin. Wochenschr.,
1918, lv., 712.
3 Deutsche med. Wcbnschr., 1918, xliv., 932. It deserves note that in
1917 Major G. B. Foster, junior, of the U.S. Army, had brought forward
evidence that a •• filter-passer ” la the active agent in the production
and spread of common “ colds ” (Jl. of Infectious Diseases. 1917, xxi., 461).
4 Cftea. Rend. Acad, des Sciences, Oct. 14th, 1918, 617, and Presse
Mid., Oct. 17th, 1918.
3 Ibid., Oot. 21st, 1918. « Brit. Med. Jour., 1918,11., 645.
26 Thb LanobtJ
A FELLOWSHIP OF MEDICINE.
[Jan. 4, 1919
exudates into the alveoli of the inoculated animals.
The affected animals afforded no cultures of the
influenza bacillus.
How are these apparently opposing sets of facts
to be harmonised? To this all pathologists who
have studied the lesions of fatal cases are agreed—
namely, that, in Dr. Rajkmann’s words, “The
essence of the whole pathological picture consists
. in the abundance of hesmorrhages seen
in the mucous and serous membranes . and in
the lungs. The whole process seems to be primarily
a bacteriasmia localised in particular in the pul¬
monary blood-vessels. Haemorrhages in the lungs
pave the way for secondary infections.” Now
characteristically the influenza bacillus is absent
from the blood in the early stages of the disease.
It cannot, therefore, be the cause of the outstanding
vascular lesions. Accepting the influenza bacillus
as constantly associated with the disease—at least
in this later phase of the epidemic—we are met
thus with the alternative, either that we deal with
one organism which presents itself in two phases,
a minute filterable form which becomes hemal and
a bacillary form mainly developed in the air-
passages, or we deal with a symbiosis, and are to
regard the filterable form as gaining entrance
through the air passages, and by its presence
favouring the coincident growth of Pfeiffer’s
bacillus, and this in such a way that the two
viruses are conveyed together from individual to
individual. Such symbiotic growth of the filter¬
able virus and the diplo-streptococcus was first
suggested by Selter, and, remembering the so
frequently recorded presence of a “ diplo-
streptococcus ” there presents itself a third possi¬
bility—namely, that minute forms of this small
organism constitute the filter-passer, and that we
deal pre-eminently with a symbiosis of a two-
phased streptococcus and the influenza bacillus.
In favour of this view is the fact that streptococci
as a group are hmmal organisms, with a tendency
to multiply and form bacterial emboli in capillaries,
and that Little, employing the diplo-streptococcus
isolated by him from a large proportion of fatal
cases 7 (a form identical with or closely allied to the
Diplococcu8 epidemicus , which Bernhardt 8 regards
as the essential cause of the disease), has been able
to set up in rabbits a fatal condition in which early
pulmonary haemorrhagic lesions are the charac¬
teristic feature.
It is along these lines, it would seem, that the
problem is to be solved. Will the “ filter-passer ”
remain invisible, or, when grown under suitable
conditions, will it develop into a visible streptococcal
or a bacillary form ? If it will not, then the symbiotic
theory will have to be accepted, or the closely allied
view, which has gained much support from French
workers, of composite and successive infection.
Here one organism, the filter-passer, preparing
the ground for smother, the influenza bacillus, which
for a time flourishes and has the upper hand, and
in its turn prepares the way for, and is replaced by.
a member of the streptococcus group, or by the
7 See Little. Garofalo, and Williams, The Lahokt, 19)8, li. t 34; and
Little, 1918,11.. 707.
8 Med, Klin., 1918, xiv., 683.
pneumococcus, just as in the maturation of a dung-
heap we find a succession of forms replacing each
other until the cellulose of the straw and the
proteids of the excreta are broken down stage by
stage into their elementary constituents. Of these
two views the symbiosis hypothesis, with coincident
conveyance from throat to throat of two or more
species of micro-organisms, appeals to us, we
confess, as meeting more closely the observed
facts of the epidemic.
-»-■ ■ -■ —
A Fellowship of Medicine.
At the beginning of last month Sir Arbuthnot
Lane presided over a meeting held at the house
of the Royal Society of Medicine to consider the
desirability of forming an association for coopera¬
tion in medicine among the English-speaking
countries. It was understood that the national
limitations thus indicated would not be insisted
upon, though for the time being the promotion of
mutual understanding between the medical pro¬
fession in the United States and the British Empire
was the main objective of the movement. The
meeting at the Royal Society of Medicine grew out
of an earlier and informal gathering held at the
invitation of Lord Eustace Percy, at which it
was urged that the opportunity presented by the
coming together of medical men from America
and all parts of the British Dominions should
be utilised to organise some permanent form of
organisation. At that meeting the obvious argu¬
ments for the advancement of some plan mutually
beneficial to the medical profession of both nations
were ably stated by the host and convener, and
by others present, and as a result Sir StClair
Thomson and Mr. J. Y. W. MacAlister were
asked to act as honorary secretaries and requested
to formulate a scheme. These two well-chosen
representatives of science and organisation having
consented to do their best, at the meeting at the
house of the Royal Society of Medicine a short
report was submitted by them on Dec. 4th, and
from this report it appears that the Royal Society
of Medicine has generously agreed to let the new
organisation have office room in the house of the
Society, so that 1, Wimpole-street, may now be
regarded as the official headquarters of the
movement.
The Royal Society of Medicine has now issued
a cordial invitation to the medical men of the
Dominions and America, as well as to the medical'
men of all the Allies, to use the buildings of the
Society as the home of a Fellowship of Medicine,
which henceforth has a local habitation with a
tentative name—“The Inter-Allied Fellowship of
Medicine.” Further support of the movement
has been reported on the part of the Director-
General of the Army Medical Service, Surgeon-
General Goodwin, who has arranged that in all the
commands the medical officers from overseas
should be cordially invited to attend clinics,
lectures, and demonstrations, and be given every
facility for imparting as well as obtaining informa¬
tion. As regards London, the principal hospitals
have been invited to extend the teaching of their
institutions to overseas medical officers, and &
general invitation has been accordingly given to our
medical colleagues to come to the hospitals afc
stated hours and to attend lectures or operations.
We wish we could add that the London hospitals-
The Lancet,]
A SURVEY OF CRIPPLES
were with one accord ready to welcome American
medical men, medical men from the Dominions,
and representatives of our science from among all
our Allies to a properly arranged course of post¬
graduate instruction. As yet no such organisation
exists, and the pity of this is now terribly apparent.
Here, in London, we have unexampled opportunities.
Our pathological material is unrivalled. The local
centre of the medicine of six millions of people,
London is the metropolis of an empire beneath
whose sway—no statement to be proud of—every
disease in nosological nomenclature occurs daily,
and the meeting place of the doctors of civilisation,
and of the tropical disorders of the world. No
centre offers such clinical opportunities to the
post-graduate student, and no city has taken less
trouble to display its wealth for the benefit of
those, who, by obtaining a share of it, might
disseminate what they thus obtained to the incal¬
culable advantage of the world. The Fellowship
of Medicine was founded because the congregation,
in circumstances of war, of medical men from all
parts of the United States and of our Dominions
called for some practical outcome of the reunion.
The most practical issue conceivable would be that
those who joined the Fellowship would find them¬
selves post-graduate students of the Metropolitan
Medical Schools, and we trust that this is what
may occur. This is said with no ignorance of the
severe task of organisation that lies before those
who would put any scheme of the sort into being.
There is a great deal of spade work to be done
before the London hospitals can provide some sym¬
metrical yet flexible post-graduate scheme from
which we and our Allies could derive real profit.
But before the war Berlin and Vienna could give
solid reasons why post-graduate students from
other countries should resort to their clinics.
Berlin and Vienna will issue no invitations in the
immediate future, and if they did the invitations
would be declined. The opportunity of New York
and Liondon is unparalleled: speaking only for
London, why should it not be taken ? Dr. Hale
White, on another page, asks the same question in
pertinent manner.
To return to the doings of the Fellowship, the
report, presented by Mr. MacAlister, was supported
by Sir StClair Thomson, who, in recommending
its adoption, urged the desirability of establishing
individual cooperation. He said that if volunteers
would offer to take personally conducted parties
to visit institutions a permanent entente would be
created. This is true, but a series of disconnected
and desultory visits to London hospitals will count
for nothing that is permanent in pathology, how¬
ever deep the memory of the casual hospitality
may be. At the end of the meeting at the Royal
Society of Medicine a general committee was
nominated, Sir Arbuthnot Lane being appointed
honorary treasurer and Sir StClair Thomson, Mr.
Douglas Harmbr, and Mr. J. Y. W. MacAlister
honorary secretaries. To the officers of the new
movement we would point out earnestly that one
objective of the Fellowship is clear. It is the insti¬
tution of a real post-graduate medical school in
London, but the preparatory labour will not be
light. Moreover, it will have to be undertaken
with full knowledge of existing designs in the
same direction. It will be necessary that the
Fellowship should come into rapport with Sir
William Osler and others, so that previous
thought and accomplishment may not be wasted,
and overlapping may be avoided.
[Jan. 4, 1919 27
Annotations.
"He quid nimis.”
A SURVEY OF CRIPPLES . 1
Before the participation of the United States of
America in the war a survey of all the cripples of
Cleveland, Ohio, was made (1915-16) under the
auspices of the Welfare Federation of Cleveland.
The cripples were located by house-to-house can¬
vassing ; to make the objects of the survey known,
and to ensure a satisfactory reception of the
canvassers the public were informed of the move¬
ment through the medium of the daily papers. A
section of the public were too helpful; many of the
poorer families went to great trouble to produce
somebody who would pass for a cripple. The can¬
vasser was followed very closely by the investigator
who filled up the carefully drawn-up schedules. The
whole of the expenses in connexion with the survey
amounted to approximately £2400. Ab the result
4186 cripples were enumerated, a ratio of 6 per 1000
inhabitants. Of this number 2638 were males and
1548 were females, the preponderance of males being
caused by accidents, especially occupational acci¬
dents. Seven per cent, of the disabilities were due
to congenital causes, 43 per cent, to accidents—one
quarter of which, at least, occurred during occupa¬
tion—and 47 per cent, to disease, 3 per cent, being
unclassified. As regards age distribution 22 per
cent, were children under 15 years of age, 61 per
cent, of working age (15-60 years), and 17 per cent,
over working age. Each of these groups present
different problems.
Of the children of school age, 246 out of the
total 771 were not at school, although special
classes for cripples were available. The combined
needs of these children for education and care can
only be met, the writers consider, by a hospital
school. The solitary life of the crippled child at
home does not afford the opportunity for the healthy
competition upon a footing of equality which tho
cripple must have to gain the self-assurance and
the self-reliance required to care for himself and
manage his own affairs. The Massachusetts Hos¬
pital School is held up as a model. At this institu¬
tion over 300 temporarily and permanently crippled
children are cared for; the authorities pride them¬
selves on the number of children restored to
the ordinary public elementary school with
their education as advanced as the sound children
of their own age. An outstanding feature of
the institution is vocational training by the
apprenticeship system. In addition to the routine
training by vocational instructors who devote the
whole of their time to teaching, children who
manifest an interest in a particular trade or
occupation are attached to the institution as.
apprentices. One of the most gratifying results of
the survey was its disclosure of the large propor¬
tion of cripples who were at work in some gainful
occupation. No less than 1743 (59 per cent.) were
earning a living; more than half of these were
supporting a family or relations. A discount, how¬
ever, should be made for those cripples not seriously
handicapped for normal occupation.
Of the cripples of working age, an estimate of
working capacity was made by the directors of
the survey ; they considered that 29 per cent, were
1 Education and Occupation of Cripple* t A survey, repon ed by Lucy
Wright and Ami Hamburger, in Cleveland, Ohio. Publication of the
Bed Cross Institute for Crippled and Disabled Men, Series II., Number 3.
28 The Lancet.]
THE HOUSING PROBLEM.
[Jan. 4, 1919
not seriously handicapped for normal occupation,
45 per cent, were capable of working at selected
trades and processes, while 26 per cent, were too
disabled to be able to work alongside normal
persons. An analysis of the physical disability in
relation to employment showed three groups with
a large proportion of unemployed; these were com¬
bined defects of arm and leg, combined defects of
limb and body, and defects of both feet or legs;
many of these cripples used crutches or wheel¬
chairs, which hindered their finding employment.
The unemployed included a small group—either
invalids or aged—eager for occupation who could
carry on home industries and make some contribu¬
tion to their own support il they could be taught in
their homes. An attempt was made to analyse the
reasons for unemployment in the case of 859 cripples.
Of these, 22 per cent, were in need of placement at
selected trades or processes, 15 per cent, in need of
special training or special conditions of work, and
5 per cent, in need of home employment. These are
minimal estimates; further information would
place in one of these three groups some of the
58 per cent, which, for various reasons, could not
be classified; this number includes those who were
not helpable, and the inevitable accumulation of
those whom it was too late to help with any sub¬
stantial hope of economic success. In addition to
those unemployed, a number were found who
were only partially employed or fit for better
employment.
The directors of the survey recommend the
establishment of a central bureau in Cleveland to
represent all the forces touching the lives of
cripples most closely—medical, educational, and in¬
dustrial—and to promote the welfare of all cripples
by devising means for providing the latest methods
of surgical treatment, industrial training, and
placement. Such a bureau would assist any
effort in the way of research, educational cam¬
paigns, or legislation to prevent crippling.
The report serves as a timely reminder that peace
produces cripples no less than war. During recon¬
struction it is to be hoped that the efforts that were
being made, notably by Belgium, to provide for the
crippleB of industry, but which were interrupted
by the war, will be renewed with greater force, and
that the lessons we have learnt from the treatment
of the injured in war may be applied in their
entirety to those injured in the battle of life.
THE HOUSING PROBLEM.
Members of the new House of Commons, when
they take their seats, will have fresh in their
memories numerous and pointed questions asked
by their constituents as to their intention to
support and press forward legislation for the better
housing of the working classes, and the election will
have made it clear to them that the working classes
themselves are very keenly alive to the importance
of this branch of social reform. In the metropolis
the problems presented are perhaps more difficult
of solution than elsewhere owing to the largeness
of the areas covered by insanitary dwellings, but
there exists everywhere the difficulty of providing
homes for the inhabitants of such dwellings during
the period of demolition and reconstruction, and
apparently the policy likely to be adopted by some of
the London boroughs is one of building outside their
own areas for the benefit of their poorer inhabit¬
ants. This will, of course, necessitate increased
provision of rail and tramway accommodation.
A recent inquest held by Dr. F. J. Waldo in the
borough of Southwark illustrated the shortcomings
of the existing system under which it is possible
for slum areas to drag out their existence as such
long after their shortcomings have been officially
recognised and condemned. A chimney-sweep,
52 years of age, was proved to have died from
natural causes, chronic bronchitis accelerated by
self-neglect, in a single room, 9 feet by 6 feet in
size, which he inhabited in a house in Tabard-
street. Another chimney-sweep who had lived in
the house for 53 years had allowed the deceased to
occupy his room rent free, being himself the
tenant of the county council at 8s. 6 d, a week. The
house had long ago been condemned, but apparently
had been patched up pending its rebuilding, and
these persons had been allowed to continue to
inhabit it. The coroner, in addressing the jury,
referred to the Tabard-street area as one to
which he had frequently called attention—in
this we can certainly bear him out—as having
been for many years a source of danger to
the public, and the jury in returning a verdict
in accordance with the medical evidence, ex¬
pressed their surprise at the continued use of
houses after their condemnation as unfit to be
inhabited. The war has no doubt put a stop during
the past four years to building operations, but
the conditions obtaining in Tabard-street were
recognised and acknowledged by the local autho¬
rities responsible many years before August, 1914,
and it certainly seems difficult to say what may be
the importance of “ condemnation ” if it leads to
no substantial improvement of the conditions
which call for it. The houses of Tabard-street,
however, do not stand alone in their unfitness to
be the homes of working men and women in a
great and wealthy city, and the delay in re¬
constructing them is not unprecedented or without
parallel. The difficulty of dealing with the whole
matter of re-housing is now complicated by the
cessation of building operations due to the war,
but the hopeful feature of the situation is to be
found in the apparently general recognition of it
to which we have referred. There should be no
unemployment in the building trade or in those
trades which provide building materials for many
years to come. _
MIGRATION OF A ROUND WORM INTO THE EAR.
The entrance of a round worm into the ear from
the alimentary canal is a recognised phenomenon,
but so rare that the details of any case are of con¬
siderable interest. In the Revue de Laryngologies
(V Otologic et de Rhinologie Dr. H. Coussieu has
reported the following case. A girl, aged 4 years,
was brought to him for pain in the right ear which
began suddenly eight hours previously. In spite
of popular topical remedies she never ceased
to cry, and the pain seemed to be paroxysmal. Dr.
Coussieu suspected otitis media, but was surprised
by the results of the local examination. The tym¬
panic membrane was certainly red and bulging, but
the latter condition was limited to the posterior
half, and there was no pain in the position of the
mastoid and no fever. Examination of the nose
and pharynx was negative. Instillations of hot
carbolised glycerine and hot compresses were pre¬
scribed, with instructions to bring the child on the
following day if these means did not give relief.
Twenty-four hours later the child was brought
again. She had suffered much since the previous
day. The membrane was redder and more bulging.
The Lancet,]
MOTORING—PRE8ENT AND FUTURE.
[Jan. 4, 1919 29
Under local anaesthesia paracentesis was perforn^d,
and Dr. Coussieu was surprised not to obtain pus.
Hoping the pain would subside after the paracentesis,
he left the child in charge of a colleague who was
summoned on the following day. The pains became
worse and worse, and during the night an attack
of syncope, crises of nystagmus, and general con¬
vulsions occurred. The meatus was blocked by a
vermicular body, like that produced by pressure on
a tube of pomade. The practitioner seized the body
with a forceps and brought away a living male
ascaris, 15 cm. long. Tl\e child went to sleep and
slept for the greater part of the day. The tympanic
incision quickly healed, and recovery was complete.
No history could be obtained of the passing of
worms. Dr. Coussieu thinks that the pain began
when the worm entered the Eustachian tube. On
the first examination, eight hours later, it had
entered the tympanum and produced bulging of the
membrane. It finally escaped by the incision.
MOTORING-PRESENT AND FUTURE.
The release of petrol, which is to take place on
Jan. 10th. should ensure to the medical motorist
that sufficiency4o carry on his arduous duties which
has been denied to him for some months past. Many
have had to give up their cars altogether, and most
of the remainder have been harassed by the tiny
quantity doled out to them. Add to the deficiency
of the supply its execrable quality, and the medical
motorist may well look forward to better times in
more directions than one. Not the least pressing
consideration at the moment is the problem as to
what cars are likely to be on the market in the
near future, and how far and how soon they
will offer advantages over pre-war designs.
Post-war cars will consist, first, of those produced
directly the makers are able to supply anything to
the public, and of these there is little to say. But
cars produced later as the result of experience
gained with motor-car and aero engines during the
war will embody many new features and possibly
startling novelties; but—only in the future. The
first cars to be placed upon the market will not
differ very much in appearance or design from
their predecessors—except, perhaps, in price. War
conditions will have taught the manufacturers
to improve the springing and strength of the
axles. The present low quality of petrol, which
tends to engine fouling and difficult starting,
suggests that combustion heads will be detachable
and machined, so as to permit of more easy clean¬
ing and less likelihood of carbon deposit. Some
device, too, will be fitted to assist the vaporisation of
the heavier fractions of the imperfect fuels. Ignition
on the cheaper cars may be by coil and accumu¬
lators charged by a generator, but the satisfactory
high-tension magneto will continue on most cars.
Lubrication will probably be automatic, and
mechanical starters and electric lighting will form
part of the standard equipment. Makers may have
embodied many new features in prepared designs,
but they have mostly been engaged on munition
work and cannot have given such designs practical
tests. Before doing bo they are not likely to make
use of them for the public, at the possible risk of
damaging the reputation of their products.
Three points are just now exercising the minds
of many motoring doctors—viz., whether to con¬
tinue with their present Cars, having them over¬
hauled if needful, or to dispose of them and try to
buy a second-hand War Office car, or to order a
new car. The condition of the present car should
certainly influence the decision. The pre-war car
must by now have revealed its good and bad points,
and often the ills we know of are better than those
we know not of! Many of the 1913 and 1914 cars
are excellent, and, if desired, can be brought up to
date. Shock absorbers or spring gaiters will ensure
smooth running, even on our present rough roads.
An extra air-inlet on the intake pipe will permit
the use of benzol, while a compromise for a
mechanical starter may be found by priming
the engine with a mixture of equal parts of petrol
and ether, which will help to do away with the
morning starting exercise. As to the second-hand
war cars, it is said that the Government have some
100,000 to dispose of. It has been suggested that
it would be a good idea if the respective makers
repaired them prior to their disposal, or even took
them over and sold them on behalf of the authorities
after putting them into thorough running order. If
this be done it will not be so great a lottery, though
even then some blanks may be drawn. Paint and
varnish may camouflage a badly worn engine.
A certain number of makers have already a 1919
programme, but few can give actual dates of
delivery. Some, though they are willing to put
names on the waiting list, cannot yet state the price.
For six months after peace is declared war wages
will have to be paid, and materials are at present
rationed and high in price. The car-buyer must
expect to pay this increase in cost of production.
In the meanwhile improvements will be experi¬
mented with, and ultimately, when materials and
wages reach the normal, though it may never be
a pre-war level, then with standardisation a fairly
cheap and reliable automobile will be obtainable.
It is doubtful, however, whether this position will
be reached before 1920. After production really
starts there should be a tendency with each month
for prices to drop.
“ROYAL” ARMY VETERINARY CORPS.
His Majesty’s approval of the prefix “ Royal ” to
the title of the Army Veterinary Corps marks a
distinct advance in the status of the military side
of the veterinary profession; and, inasmuch as by
far the greater bulk of the A.V.C. is at present com¬
posed of civilian practitioners with temporary com¬
missions, it is an acknowledgment of the present
position of British veterinary science in general.
All professions have been afforded an opportunity
by the war to prove their worth, and the
veterinary profession has responded manfully.
Quite recently Major-General Sir Frederick Smith
made public some of the work which has
been done by the British A.V.C., and it is
gratifying to learn from other sources that
the French and American Veterinary Corps
have acquired much from British methods. The
organisation of the corps has been perfected under
war conditions, and hospitals have been erected
and equipped at the various fronts in a manner that
has called forth unstinted praise. It is announced
that in regard to the animals treated at the
various surgical and special hospitals and at the
convalescent depdts on the Western front, recent
figures show that 72 per cent, have been evacuated
to the Remount Department for re-issue to the
front. The percentage of discharged animals has
been higher than this, but after four years of war the
age of the animals has had its effect on the number
of patients judged fit for further active service.
Aft in all previous campaigns, contagious diseases
have accounted for a large proportion of admissions
30 The Lancet,]
ACIDOSIS AND ITS SIGNIFICANCE.
[Jan. 4, 1919
to hospital; these, however, have been so success¬
fully dealt with that contagious diseases of all
kinds were responsible for less loss at the time of
signing of the armistice than at any other period
of the war.
ACIDOSIS AND ITS SIGNIFICANCE.
The seventh report of the “ Special Investigation
Committee on Surgical Shock and Allied Condi¬
tions,” which was appointed by the Medical Research
Committee in August, 1917, deals with the con¬
troversial question of “ acidosis.” The name itself
is a somewhat unfortunate one for the state which
it is used to designate—namely, that in which the
normal reserve of potential alkali, practically sodium
bicarbonate, in the blood has become reduced below
about 70 per cent, of its proper value. It suggests
that the reaction of the blood has been changed
towards the acid side. This is very rarely the case.-
We have but to remember that, putting the matter
Somewhat crudely, blood is made alkaline by the
sodium bicarbonate, acid by the dissolved carbon
dioxide; so that, if the former goes down, it
is only necessary to reduce the latter in pro¬
portion in order to maintain the hydrogen-ion con¬
centration at its normal value. The removal of
carbon dioxide is effected, as is well known, by
increased activity of the respiratory centre. Since
it is actual increase of hydrogen-ion concentration
that is responsible for the physiological effects of
acidity, as shown in Section VI. of the report, it is
difficult to see how, apart from this, a reduction in
the concentration of sodium bicarbonate should
have such serious results as are attributed to the
state of acidosis. But it has been found that not
only in wound-shbck, but after anmsthesia and in
diabetes, the alkaline reserve is reduced, and
certain observers have held the state of wound-
shock to be essentially due to thU factor. It is
obvious that an important question of treatment is
involved. If the decrease in bicarbonate is the
actual cause of the state, no further treatment
should be required than the administration of
alkali. It was therefore necessary to subject the
question to a thorough experimental and critical
examination. The results of this are given in the
Report before us. The original report must be
consulted for the methods used and details of the
experiments. We must be content here with a
summary of the conclusions arrived at.
The first point tested was whether the reduction
of the alkaline reserve in normal animals has any
serious consequences. Although this was reduced
by the injection of acid to a lower level than that
of the most severe cases of diabetic coma reported,
the cats and rabbits used showed no abnormal
symptoms, except some slight dyspnoea on exertion.
This conclusion is the more convincing because
some members of the committee had at one time
obtained shock-like symptoms by the injection
of acid, but they were ultimately completely
convinced that their results were not due
to acidosis. The next question discussed is,
“ Does acidosis favour the production of
shock by other agencies, such as hemorrhage,
histamine, peptone, adrenalin, vaso-motor para¬
lysis?” No evidence was found that there is any
such effect, except perhaps that acid may exaggerate
the depressant action of some anesthetics. If, then,
we are led to the conclusion that acidosis does not
produce shock, either directly or indirectly, it is
necessary to account for the fall of bicarbonate
reserve observed in shock. Evidence is giv&n in
the report that this is the result of defective supply
bf oxygen to the tissues, brought about by the
slowed circulation. Details are given of experi¬
ments in which a low blood pressure was
produced in different ways, with the result
of acidosis of varying degrees of severity. The
experiments of Wright and Colebrook, pub¬
lished in these pages, 1 confirm this conclusion.
The next section is a valuable account of the
factors controlling the reaction of the blood, show¬
ing the distinction that is to be made between a
reduction of bicarbonate reserve and a real increase
in acidity ; while the final section describes briefly
the methods in use for the actual determination of
either of these properties. From the practical
point of view emphasis is laid on the cardinal
importance of maintaining an adequate oxygen
supply to the tissues. Since an increase in the
acidity of the blood stimulates the respiratory
centre to increased ventilation of the lungs, the
production of acid in the tissues tends to correct
itself in this way, so that the introduction of alkali
may even be injurious. But a significant conclusion
drawn from experimental evidence is that “ oxidation
in the tissues is far more easily rendered inadequate
by defective circulation through tjie capillaries than
by a reduction either of the oxygen-carrying power
of the blood or of oxygen-tension in the inspired
air.” As much as 75 per cent, of the total blood
volume can be removed from the circulation with¬
out harm, provided that it is replaced by gum-
saline solution. The value of measurements of the
bicarbonate reserve is that they indicate deficient
circulation and the need for increasing the volume
of the blood. A good supply of oxygen by the blood
to the tissues is obviously of importance in
restricting the spread of infection by anaerobic
organisms. The question of gas gangrene is
discussed in a special section, and experiments are
given which show that the failure of the circulation
cannot be attributed to the production of acid.
MR. HENRY SANDFORD.
On Christmas Eve, at his house, Bladen, Bromley,
Mr. Henry Sandford, the solicitor to this journal,
died in the 86th year of his age. Nearly ninety
years ago Thomas Wakley, the Founder of
The Lancet, in one of the worst of his many
legal embroilments, turned to the firm, of which
Mr. Henry Sandford was the senior representative
at his death, for help and advice. The firm then
included one of Wakley’s cousins, and from that
time the same firm, now under the style of Potter,
Sandford, and Kilvington, has advised the pro¬
prietors and editor of The Lancet to our great
benefit. -
ALOIS EPSTEIN.
Professor A. Epstein, whose recent death in his
seventieth year has escaped general notice, was not
only director of the principal children's clinic in
Bohemia but had at his disposal the whole of the
Prague Foundling Institute for teaching purposes.
This combination accounts for the fact that his
clinical teaching was so fruitful in result at home
and so widely accepted over the world. Epstein's
life was, in fact, devoted to the physiology and
pathology of the new-born child, and the immediate
result of his medical direction of the foundling
institution was a drop in mortality from almost
incredible figures to 5 per cent., where it bas since
i The LaxouT, 1918, L, 783.
The Lancet,]
DR. W. HALE WHITE: ON THE TEACHING OF MEDICINE.
[Jan. 4, 1919 31
remained. Excellency Czerny, who writes of the
great loss to German pediatrics from Epstein’sdeath,
fears that his clinic at Prague will be lost asaGerman
teaching institution. That may well be, but the work
which he initiated in Bohemia is, nevertheless, likely
to outlive him. Epstein was himself a Bohemian,
born at Neuhaus, and graduating M.D. of Prague
University. Later he became a corresponding
s \
\_ r
1. Bohn’s palatine nodules. 2. Rertnar s pterygoid ulcers.
3. Epstein’s pseudo-diphtheria.
member of medical academies in many lands. The
pseudo-diphtheria of the new-born specially asso¬
ciated with his name he showed to be the end-stage
of the palatine nodules described by Heinrich Bohn
and the pterygoid ulcers of Alois Bednar, and all
of them due to the mechanical cleansing of the mouth
practised by the ignorant midwife or mother. The
comparative series of three illustrations of this in¬
teresting infection is taken from Dr. A. R. von Reuss’s
“Diseases of the New-born.” Stomach lavage in
the suckling and sepsis occurring within the first
few days of life were other subjects which Epstein
made peculiarly his own. In a single year among
702 children at the Prague Foundling Institute he
had 61 cases of septic gastric haemorrhage. He
was also an authority on the manifestations of
tuberculosis at an early age.
Dr. I. D. Chepmell, who died on Christmas Eve
at his house in Worthing at the advanced age of 90,
practised for many years in London and in Paris.
He ascribed his long maintenance of robust health
to the practice of fencing, of which he was a keen
exponent. One of his most distinguished and ever
grateful patients was Robert Louis Stevenson. While
he was in Paris he acted as Paris correspondent to
The Lancet.
A first instalment of the usual New Year
Honours contains the names of three medical men
upon whom knighthoods have been conferred.
These are Dr. William Leslie Mackenzie, medical
officer to the Scottish Local Government Board ;
Dr. George Dancer Thane, professor of anatomy at
University College, London, and principal inspector
to the Home Office under the Cruelty to Animals
Act, and Lieutenant-Colonel John Hewart, Member
of the House of Assembly of the Union of
South Africa and Assistant Director of Medical
Services of the Union. Sir George Anderson
Critchetfc has been promoted to knighthood in the
Victorian Order, and the services of Dr. Robert
Bruce Low, late assistant medical officer to the
Local Government Board, are recognised by a
Companionship of the Bath. To these and others
whose names are recorded elsewhere in this issue
we offer in the name of the medical profession
hearty congratulation.
ON THE TEACHING OF MEDICINE.
By W. Hale White, M.D. Lond. & Dub.,
COLONEL, K.A.M.O. (T.); CONSULTING PHYSICIAN TO GUY’S HOSPITAL.
Reconstruction is in the air and it is much to be hoped
that ere long the teaching of medicine will be reconstructed
and improved. No one should take part in rebuilding the
means by which those who study medicine are taught unless he
has studied “Some Notes on Medical Education in England ”
by Sir George Newman, K.C.B Every reader will feel,
when he has finished this admirable pamphlet, that medicine
demands such wide knowledge, such high trainir g in clear
thinking, such experience in the art of observation, such
fostering of research, such judgment in separating the
true from the false, and is withal of such importance, not
only to individual sufferers but to the well-being of the com¬
munity, that no trouble or expense is too great to get it
taught as well as we know how. Most of us who have had
experience of teaching medicine will surely agree with
nearly all Sir George Newman’s suggested improvements,
radical as they are, and would like to see them carried into
practice forthwith. The following comment is put forward
partly in the hope of keeping alive interest in the matter
and partly because the writer has for many years devoted
much energy to the teaching of clinical medicine.
Post-graduate Teoohiug.
Towards the end of the “Notes” 8ir George Newman
tells us of four main things lacking, and the fourth is post¬
graduate teaching It is in this that we are most deficit nt.
Up till now the ordinary medical student has been taught,
often by do means as well as he should be, teachers have
been found, but frequently they have been atrociously paid,
research has been carried on, but under difficulties lhat
should never have hampered it, but the post-graduate in
this country has been left without guidai ce and without
any but the poorest encouragement except in the Services.
We all trust that one result of the war will be a friendship
between those speaking the French, Italian, and English
languages, which will make some of us wish to go to our
friends’countries and some of them to come*to us to study
medicine. The wealth of clinical material in London is so
great that it is to this city they should be attracted, but unless
we make things very different from what they were before
the war there is little to tempt them here.
The first improvement in medical education should
be to put post-graduate teaching in London on a proper
footimr, not only for the sake of our visitors and our
own doctors who want to come back for a few months to
bring themselves up to date, but for the sake of our own
prestige. But if it is to be efficient it must be s» pa rated
from the teaching of ordinary students ; at least, that is my
experience. Two courses are open, either to have a large
hospital and medical school, complete in all clinical depart¬
ments, devoted to post-graduate teaching only, aDd this is
probably the best, or to have post-graduate teaching at
ordinary medical schools, but during the months that the
clinical teachers are engaged in post-graduate work they
must be absolved from teaching the ordinary student either
at the bedside or by lectures. He is best taught in most
cases by the clinician who is not past 45 or 50 ; on the other
hand, a post-g»aduate clinical teacher is probably at his best
from 45 to 55, for then he has a wealth of experience, and
let us hope has not become unprogressive and discursive. It
might be a good thing if there were a separate p- st-graduate
teaching institution, to promote a teacher who had been
successful in interesting ordinary medical students in any
British school to a clinical post in the post-gr«duate school,
for we should thus be able to secure for it teachers who had
already proved their capability to teach.
To put post-graduate instruction in London on an entirely
new and a thoroughly efficient basis will require much money
and much hard work, but most emphatically it ought, to be done
and on a large scale, for if first-rate teachers are provided a
post-graduate school will attract large numbers of students.
Should it be decided to have such a school separate from
the ordinary medical school, the difficulty will be to find a
large hospital, and it must be large, to provide sufficient
clinical and post-mortem material. It mnst. contain all the
special departments of a modern hospital, including, if
possible, buildings for infectious cases, mental cases, and
a lying-in charity. Professors in the clinical subjects
32 Thh Lancet,]
DR. W. HALE WHITE: ON THE TEACHING OF MEDICINE.
[Jan. 4,1919
most be appointed, and in addition, there must be
professors of clinical chemistry, pathology, and bacteriology,
each with well-equipped laboratories. All the professors
must be so well paid that they will be able to devote
their whole time and energy to teaching and research
in the school. Teachers in clinical subjects other than the
professors might be allowed private consulting practice.
Wherever the post-graduate school is situated there should be
close to it a large hostel, with a library, common rooms, and
sleeping accommodation for the students who come to it.
The Medical School .
In a medical school teaching ordinary medical students
there certainly should be properly paid professors of
anatomy, physiology, pathology, bacteriology, clinical
chemistry, and pharmacology, and if the preliminary
subjects of chemistry, biology, and physics are taught at
the school professors of these also. All should be experts in
their science, capable of teaching, skilled in investigation,
and able to help students to investigate and to think for
themselves. It may be said that, judging by our experience,
it will be difficult to find enough suitable teachers. The
answer is that these posts have up till now in most cases
been miserably paid. Let each of these professors have
proper sratus and pay and plenty of men will be found.
Supply follows demand. Hitherto many who would
have enjoyed a life devoted to these subjects have been
forced to the clinical side of their profession in order to gain
a livelihood. It seems often to have been thought that all
that is necessary to make an efficient school is to build
laboratories. The man matters far more than the buildings
in which he is housed. Sir George Newman would ensure
proper payment by State aid, others prefer the addition to
students’ fees to be by endowment by private benefaction,
but, be that as it may, the fundamental fact is that you
cannot expect able men to take these posts unless you give
them the position and income to which their ability entitles
them. If it is objected, with regard to London, that with
so many medical schools as there are there, it would be
impossible to pay, as they should be paid, the large number
of professors required, the answer is that there ought to be
in some cases amalgamation between certain of the present
schools; it is well known that something has already been
done in this direction with regard to the earlier subjects.
Outline of Scheme .
Turning now to the purely clinical subjects, and taking
medicine as an example, some such plan as the following
would be, it is suggested, the best way to deal with it, and
might, with necessary modifications, be applied to other
clinical branches. To teach to the best advantage it is
necessary to have plenty of material, and for a large medical
school there ought to be. say, 220 medical beds. There
should be a professor of clinical medicine who should be
physician to 80 of these beds, and two other physicians
with 50 beds each. There should be four assistant physicians,
each seeing out-patients once a week, two corresponding to
the professor, each with 10 beds, so that these assistant
physicians should have beds into which they could send, from
out-patients, patients whom they wished specially to watch.
Of the other two assistant physicians one should correspond
with each of the other physicians, and should in addition
have 10 beds of his own, for the purpose just mentioned.
When the professor is away on a holiday or from illness, his
work in the wards should be shared by his two assistant
physicians, and when either of the other two physicians is
away his corresponding assistant physician should take
charge of his beds.
In addition to bis ward work, the professor should see out¬
patients one day a week, so that on five days a week medical
out-patients will be seen ; he and the four assistant physicians
should do out-patient teaching on the days on which they see
out-patients. Students will be appointed as out patient clerks,
who will make notes of the cases, and generally assist, and learn
at out-patients from the professor or the assistant physician,
as the case may be. The two physicians other than the
professor should each do bedside teaching three days a week,
and the professor should do bedside teaching five days a
week. Every ordinary student will work in the medical
wards as medical ward clerk for six months, for three of
these with the professor and for three with one of the other
physicians, half of the students being with each of these
physicians ; but as every student will work in the wards under
the professor, he, having double the number assigned to each
of the physicians, will divide his clerks into two sets. Some
of the abler students will have longer than six months io the
medical wards, for they will hold the post of olinioal
assistant, and if qualified that of house physician. Both
physicians and the professor will give clinical lectures, one
being delivered each week.
The professor will devote his whole time to the duties of
his office, he must have what laboratory accommodation he
needs, he should be of such a temperament that he can
teach clinical medicine and undertake research, and he must
do everything he can to encourage and help all who wish to
do research under him. It is to be hoped that the assistant
physicians will pursue investigations with his sympathy.
Consideration of Some Details.
In details this scheme is a little different from Sir George
Newman’s. In the first place, the professor is not to engage
in private practice. This, I feel, is the right line to adopt.
If a man has an aptitude for private practice it is almost
impossible for him to say he will only do a little. Quite
apart from the fact that if it becomes part of his source of
income he can hardly be blamed if he pursues it honourably,
there are many cases, and often* the most trying, which if
he is asked to see he must see; he cannot refuse to go. The
professor ought to be so well paid that he can always say he
does not engage in private practice. He will then be freed
from all its thousand and one worries, and he will have time
to think out the problems of medicine that need investiga¬
tion ; he will not be liable to be called off from his laboratory
work, and he will have leisure to direct research amongst those
working under him.
In the second place, there are other physicians and
assistant physicians than the professor. The advantages
of this are many. It is desirable that the student
should learn medicine from more than one teacher, for it
is an art as well as a science, and it will be of distinct
benefit to the learner to hear different opinions, to see
different methods of treatment and diagnosis, and to observe
different lines of thought. Every student on the plan sug¬
gested will get part of his training from the professor, a
physician, and an assistant physician ; this must widen his
horizon and help to give him that breadth of outlook which
is such a desirable part of real education. Further, no single
professor could possibly treat and look after the numerous
medical in-patients that a large school ought to possess.
The student cannot have too much actual contact with
patients, and each should have enough cases assigned to
him for note-taking to keep him busy in the wards. He will
pay special attention to his own cases, and will at the
same time observe and learn under the direction of his
teacher from the cases of his fellow-clerks. Also no
single teacher can properly teach more than about ten
clinical clerks at the same time, for he ought to get
to know the minds of each of his clerks so as to help each
individual one over his particular difficulties. Other students
may come round with the professor and physicians, the more
the better, for a large audience brings out the best in a teacher,
but his particular attention must be his own clerks.
Lastly, it is much better for the professor himself to
have others in the same school teaching medicine; both he
and the others mutually stimulate each other. If there is
more than one teacher of medicine, each is prompted to try
his hardest, so that his teaching may be as valuable as, if not
more valuable than, that of his colleagues.
Conditions of Appointment of Staff.
The assistant physicians should be well paid for their teach¬
ing, but they should be allowed private practice. In medicine
this does not come in great amount to the young, so that the
assistant physicians being properly paid would be able to
throw nearly all their energy into teaching and investigation.
The two physicians, other than the professors, should receive
good payment for their bedside teaching and clinical lectures,
but this need not be on the scale of the professor’s pay,
for they should be allowed private practice, and in order
that they should be saved from the temptation in
later years of neglecting their teaching for private prac¬
tice they should retire from the hospital at an age
certainly not later than 55, the precise age depending on
how their private work interfered with that in the hospital
and upon the quality of their teaching. The professor
should retire at the age of 60. If something of the plan
here sketched for medicine were applied to surgery perhaps
other ages for retirement would be more suitable.
ThbLanost,]
DR. W. HALE WHITE: ON THE TEACHING OF MEDICINE.
[Jan. 4, 1919 33
An advantage of this early retirement would be that the
promotion of the assistant physicians would be quicker than it
is now. Of the four assistant physicians, two might look
forward, if they had proved their value to the school, to a
foil physician’s post, one to a professor’s post at his own or
some other school, and perhaps one out of the four would
ultimately teach at a post-graduate school or practise some
special branch of medicine, and, bearing in mind such trans¬
ference, possible losses from early death or ill-health, and
the failure of some to be good teachers, four is often not
more than enough to replace three. When an assistant
physician is appointed the appointment should at first be
for three years only, so that if it were discovered that he
had not the art of teaching he need not be reappointed
unless it were desirable for other reasons— such as brilliant
research—that he should. Those on such a hospital staff
who are allowed private practice should confine themselves
to purely consulting practice. My object is only to give a
general outline of the teaching of clinical medicine, as no
mention has been made of how far assistants or demon¬
strators shall be employed for rudimentary teaching; the
practice would vary in different schools.
Special Departments.
In a properly equipped medical school the special depart¬
ments of medicine should present little difficulty. There
should be a physician for children’s diseases, who would see
out-patients and have charge of a good-sized children’s
ward, and a physician for mental diseases, also*with charge
of out-patients and suitable wards for the treatment of early
cases. The physician for skin diseases should also see out¬
patients and have some beds. Many of the commoner
nervous diseases, such as cerebral haemorrhage and chorea
and tabes, are best taken into ordinary medical wards, so
that the students can learn from them in the course of their
ordinary medical work, for such cases will come before them
very frequently in general practice, but probably it would be
well to have a separate out-patient department for nervous
diseases. It would be a great advantage to a medical
school to have a fever hospital near to it. The
students attending their course of fevers would not waste
time going long distances, and those in charge of the general
hospital and those in charge of the fever hospital would be
able to meet frequently to interchange ideas, and the advice
of the professors of medicine, pathology, and clinical
chemistry, and the use of the corresponding laboratories
would be of help to the physicians in charge of the fever
hospitals for any investigations they might want to under¬
take. I am aware that in this sketch more beds have been
assigned to medicine than is possible in some hospitals, but
I have put forward the numbers here mentioned as the ideal
number when the students are numerous.
Pharmacology and Therapeutics.
The complete medical school must have a properly paid
professor of pharmacology with a well-equipped laboratory.
The great want is a closer connexion between the professor
and clinical work. It would not be wise to give the pharmaco¬
logist charge of beds, for he has usually done little clinical
work, and before the drugs can be given to a patient the
physician in charge must find out what is the matter
with him ; this is the duty of a clinician, who can usually do
it better than a pharmacologist, whose training lies in
devising experiments to discover the mode of action of
drugs. But there should be close friendly cooperation
between the clinician and the pharmacologist, who should
be encouraged to go to his clinical colleagues and say, “ I
want to observe the effects of such and such drugs on such
and such diseases; let me know when you have suitable cases,
and I will come and make the observations I desire,” The
clinician would, by seeing the results of the observations, be
adding to his own knowledge. Often, too, he would be able
to suggest to the pharmacologist fruitful lines of research ;
it would be a great gain to the progress of medicine if
researches at the bedside were made hand-in band between
the pharmacologist and clinician and published under their
joint names.
Sir George Newman has been unfortunate in the impression
he has formed about the teaching of therapeutics. He says,
“ The case is diagnosed and its treatment prescribed, but such
treatment is but rarely closely observed or assessed by the
student,” and again, 14 Is he a doer of the word, or only a
hearer 7 ” Every good clinical teacher, after he has explained
to the students how the diagnosis is reached, goes on to talk 1
1 over with them the details of the treatment, not only by
drugs but by many other methods ; he discusses what kind
of life the patient should lead, what be should eat and drink,
where he should live, and what occupation he should follow ;
what therapeutic means other than drugs should be employed,
such as massage, remedial exercises, electricity, X rays, and
so forth ; and while the patient is under observation in the
hospital he from time to time points out the success or the
failure of the therapeutic means that have been adopted.
Every single patient that comes into the hospital ought to be
the subject of a therapeutic discourse.
A first-rate medical school will have attached to it the
necessary therapeutic departments—e g., massage, remedial
exercises, electrical and others, in which the student can see
the carrying out of all these special treatments, but it will
be a bad thing to have a special teacher of therapeutics-
bad for the professor of medicine and the other phy¬
sicians attached to the hospital, for they will cease to be
first-rate physicians if they do not fully know how to treat
their patients, and if they do know, why should they not
impart their knowledge direct to the students, instead of its
filtering through a professor of therapeutics ? Should this
subject be taken away from clinicians it will have an evil
effect upon the students, for they will be encouraged to
believe that the treatment of the patient is a thing apart.
There has been too much of that in the past. The duty of
the physician is to find out what is the matter with the
patient, and to treat when possible the condition found. He
should frequent the departments where special treatments
are carried out, and he must keep himself abreast of all new
therapeutic suggestions. He should have an open mind and
be able to assess each mode of treatment at its right value.
Sir George Newman quotes with approval a lecture
course and the accompanying therapeutic clinic thus:
“(3) to discuss the pathology of the case and the precise
purpose of treatment; (4) to review the relative value of the
means of accomplishing the object.” This is exactly what
the clinical instructor should do as part of his bedside
and lecture teaching. If he does not do it he ought, and I
hope that it is rare for the student to be “ actually unaware
of the medicinal treatment to which the patient is subject.”
If his clinical teacher has not made him aware of it great
blame attaches to the teacher, and the cure lies cot in
appointing a professor of therapeutics, but in getting a
better man to do the clinical teaching. However, there is
little difference of opinion between Sir George Newman and
myself, for although his report covers the whole of medical
education, this is the only principal point in which I differ
from him.
Pathology and Bacteriology .
Just as the clinical teacher will discuss with his hearers
the diagnosis, prognosis, and treatment, so he should indicate
to them the pathology of the disease from which the patient
is suffering, for this will be necessary to explain the sym¬
ptoms scientifically. Although the key to many symptoms
is to be found in the pathological laboratory rather than the
dead-house, yet there aie few diseases without some morbid
anatomy, and the bedside teacher will, out of hearing of the
patient, indicate to his class what might be expected to be
found on post-mortem examination, and if the patient dies
he should ^ake the students to the post-mortem room and
point out how far the conditions found there can be correlated
with those observed during life. The most essential thing in
teaching medicine is to train the students to visualise what
is wrong inside the patient. I frequently take my students
away from the bedside to say to them, 44 Supposing we this
very afternoon killed this patient, tell me what you would
see on post-mortem examination, for unless you can do that
you have not really conceived what is the matter with him.”
The professor of pathology will not be the least busy of
the professors ; pathological research is so fascinating that
he will have plenty of enthusiasts working under him whose
work he will direct. In addition, he will have his own
original work and lectures, so that while, of course, he will
have complete control of the dead-house, and, if he likes,
make some post-mortem examinations, a great many should
be made by the assistant physicians, for, other things being
equal, the man who has made most post-mortem examinations
is the best physician and the best teacher of medicine. The
greatest corrective to any slovenly habits of diagnosis is the
knowledge that if the patient dies it may be open to all to see if
the diagnosis is correct; therefore students must be taken into
the post-mortem room as much as possible, and particnlarly
34 The Lancet,]
THE STANDARD ILLUMINATION OF SNELLEN’S TYPES.
[Jan. 4,1919
when a post-mortem examination is made on any of the
oases they have seen daring life. The advantage of this in
training them to proper diagnoses cannot be overestimated.
The precise relationship of the professor of bacteriology to
the professor of pathology will, no doubt, vary in different
schools, bat ample provision must be made for bacteriology,
and the head of the department should be well enough paid
to render private practice unnecessary. Indeed, in a large
school he should not have time for it as there will be
laboratories to be controlled, numerous investigations from
in- and out-patients, classes for students, his own research,
and many doing research under him who will need advice.
Modern advancements have made a clinical chemistry
department absolutely necessary. Good laboratories are
essential, and the professor should be on the same footing
as those already mentioned. Experience has shown that
a large hospital and school will keep him fully employed
in routine work from the wards, in teaching, in his own
researches, and in those of others.
Examination*.
Before we can get the medical students properly taught
the prevailing system of examinations mnst be altered.
There is no donbt that, as at present conducted, they impair
teaching, especially the best, and frequently fail to separate
the g >ats from the sheep. I have conducted many exa¬
minations, and am fully aware of their shortcomings. It is
difficult to frame questions that cannot be as well answered
by a student with a retentive memory for what he has read
or been taught by a coach, as by one who has gained his
knowledge by bedside observation. It is even more difficult
to devise a clinical examination that shall fairly test the
candidate who, when left quietly to himself, is quite good at
his clinical work, yet “ goes to pieces” when he feels that
everything depends upon his hearing particular murmurs in
a limited time. A teacher’s opinion as to the fitness of a
particular candidate to pass ought to be at least as good as
that of the examiner who only knows his man for as many
minutes as the teacher knows him for months. Somehow or
other, a plan must be devised in which the bedside and
laboratory work done by the candidate during his training
counts in the examination. This will stimulate the teaoher
and stimulate the student.
“ University Eduoation.”
There is no need here to try to explain what is meant by
the phrase “ university eduoation,” for it is fully and
admirably expounded by Sir George Newman in Section 3
of his “Notes ” and is there illustrated by noble quotations,
of which perhaos the finest is that from John Henry
Newman’s Lectures. But this is certain, that in medicine of
all professions the teaching should endeavour to reach the
high ideals denoted by the phrase “ university education,”
for he who practises medicine has to deal with a science as
well as an art, his mind must be accustomed to the hard
facts of the dissecting room and the laboratory, to the
process of reasoning required to reach a diagnosis, to the
skill necessary to conduct correct treatment, and to the
judgment of the proper way of dealing with human beings.
His education must not only have taught him facts but must
have trained his mind how to think, how to appreciate the
relative value of fac s, and how always to be receptive of
new discoveries and new aspects of old questions. Indeed,
it is donb’.ful whether any profession requires that width of
training implied by “ university education ” more than that
of medicine.
The teachers themselves should remember, too, that all
through their lives they must educate themselves. It has
been too much the habit of some to remain in their wards,
others in their laboratories. They should frequently meet;
half an hour’s conversation between a physician and a
physiologist or chemist does immense good to both. In a
medical school aspiring to reach a university standard there
should be a common room in which all the teachers can
meet and exchange views, and each should know the others
well. Frequent meetings will have this further great
advantage, it will encourage “team-work.” In order to
solve almost any medical problem it must be regarded from
several standpoints. It is to be hoped, therefore, that in the
future we shall see much more “team-work” than we have
in the past. Speaking generally, “ team-work ” papers are
more complete than 'hose of individuals and contain fewer
mistakes, for before publication each author has been able
to be a friendly critic to the others.
THE STANDARD ILLUMINATION OF
SNELLEN’S TYPES . 1
The Council of British Ophthalmologists have been well
inspired in investigating the circumstances under which
Snellen’s types are used in testing the vision of c«ndidates
for the public services. It has long been realised that in
the absence of any standard method of illumination great
injustice might be done to candidates. The conditions, for
example, on a November day on a ground floor are hardly
comparable to those of a well-lighted upper room in summer.
The Council of British Ophthalmologists, which consists of the
Presidents, past and present, of the Ophthalmological Society
of the United Kingdom and of the Section of Ophthalmology
of the Royal Society of Medicine as permanent members, is
reinforced by elected members both from the society and
from the section, and for the purpose of carrying out the
investigation the following were appointed as a committee :—
Sir George Berry (chairman). Sir Richard Glazebrook, C B.,
F.R.S. (Director of the National Physical Laboratory), Mr.
C. 0. Paterson, O.B.E. (National Physical Laboratory), Mr.
Leon Gaster (secretary of the Sooiety of Illuminating
Engineers), Mr. J. Herbert Fisher, Colonel J. Herbert
Parsons, Mr. A. B. Grid land, and Mr. W. H. MacMullen,
O.B.E. (secretary).
The report runs as follows:—
The effect upon visual acuity of variations In the illumination of test
objects has been the subject of a series of careful investigations since
the time of Tobias Mayer (17f4). Two chief facts emerge from these
researches: (l) That thee is a rapid rise in acuity as the illumination
is increased from zero up to about 2 foot candles; * (2) that above
2 or 3 foot candles there is scarcely any appreciable rise in acuity.
The results obtained by different observers are not entirely concordant,
the discrepancies being attributable to variations in the te-t object,
eontraat, size of pupil, Ac. So far as the testing of visual acuity for
clinical purposes is concerned, it appears to be sufficiently accurate to
regard the results obtained with an illumination of 3 foot candles or
more as valid and comparable under the ordinary conditions of clinioal
testing.
There is, however, no doubt that this minimum is by no means
always ensured under the actual conditions in which the testing of
candidates for military or other public services occurs. Apart from the
fact, which should be borne in mind, that the tear, types often do not
conform to Snellen’s criteria, they are frequently dirty, thu * diminish¬
ing contrast, are varnished, thus giving rise to disturbing direct
reflection of light and are viewed under very great variations of day¬
light in rooms which are often ill-suited for the purpose.
It is possible to lav down precise and simple rules for the efficient
illumination of test types, and we see n» reason why these rules should
not be generally adopted. For the public services It is. in our opinion,
unfair to the candidates and detrimental to the services themselves
that the examinations should take place under unsatisfactory, and often
hurriedly Improvised, conditions. The tenting of visual capacity is now
an essential part of tbe physical examlnttlon of candidates for a large
number of the public services, such as tbe Navy, the Army, the Mer¬
cantile Marine, tbe Indian Civil Service, and so on. We are of opinion
that these tests should be conducted under approved condition*, and
that thin object would be best attained if the examinations were held at
properly equipped centres.
We fully recognise that variations of visual acuity arise from many
causes other than the actual illumination of the test types, such as the
condition of retinal adaptation, contrast between the test ohjeot and
its background, the size of the puotl, lateral ilu.mlnttlon. and so on.
We think, however, that these effects can be minimised sufficiently
for practical clinical purposes if tbe testing takes place In a moderately
weli-iliumlnated room, with the test tvpes efficiently lighted, and with
the careful elimination «*f any glaring lights, or bright objects from the
candidate’s field of vi ion.
We consider that the requirements are sufficiently well satisfied by the
following meanB : Two ordinary 2u watt tungsten lamps (see diagram,
L 1 , L 2 ) with straight filxments are fixed vetically 15 inchestn front of the
pi a e of tbe test card (A, B/, one on each side, at a horizontal distance of
12 Inches from the vertical plate normal to and blsect'ng the card. One
lamp is placed higher than tbe «thrr, one being opposite 1 be junction
of the upper arid middle thirds of the card, the other opposite the
junction of tbe middle and lower thirds. Opaque non-reflecting screens
(3, S> are fltteo, so as to prevent direct light irom the lamps reaching
the candidate’s eyes.
Tms method ensures:
(1) Sufficient illumination. With new lamps the illumination on
the test types will be of the order of 10 foot candles. Tne ordinary
variations of current, deterioration of lamps, and the darkening of the
test card with age will not reduce the b ightness of the test csrd so
Illuminated to a value has than that, of a perfectly white surface
receiving an Illuml? atlon of 3 loot candles.
(2) Sufficient unif. rmlty of Illumination. Whilst we are aware that
the same result can be achieved by tbe employment of properly
designed and carefully placed reflectors we have bad to recognise In
making these proposals lhat the testing of vis «al acultv must often
be carried out In clrcua stances which do not admit of the use of
1 Report on Standard Illumination of Snellen’s Types use »in Testing
the Vision of Candidates for Public Services. Pub'ished for the ' ouncil
of British Ophthalmologists by (J. Pulman and dons. Ltd., 24, Toayer-
Btreet London. W 1. Price 6a
* One foot candle is the illumination received from a source of one
candle power falling perpendicularly on a surface at a distance of 1 foot
from the source.
Thi Lancet,]
MEDICAL CANDIDATURE FOR PARLIAMENT.
[Jan. 4, 1919 35
■pedal lighting arrangements, requiring technical skill in their
installation or upkeep We have, therefore, endeavoured to prescribe
a method of ensuring the necessary illumination which Is simple to
erect, is not liable to become deranged by subsequent treatment, and
wb>ch et ablea ordinary lamps on the market to be employed.
Where electric light is not available a similar arrangement can be
Installed, using other llluminan's.
Daylight illumination.— There is no theoretical objection to the use
of diffuse daylight so long as the Illumination on the test types is
adequa'e—l.e., noes not fall below 3 foot candles. In cases of doubt it
would be nei*es8ary to apply tests requiring the skilled use of some
form of photometer. We are, therefore of opinion that in order to
secure uniformity and comparable results artificial illumination should
in general be used, and Invariably in testing for the public services.
PLAN FRONT VfEW
Diagram to illustrate the arrangement recommended to illuminate
the test-card.
We therefore make the following recommendations.
I. The test types.— The test types shall be of the dimensions laid down
by Soellen ana printed on a matt white surface.
II. Illumination.—(a) The minimum illumination on the teet-oard
shall be such that its brightness shall be equivalent to that of a new
csrd Illuminated to at least 3 foot candies. ( b ) The illumination o' the
test types shall be as uniform as possible, (c) Artificial illumination
shall be u*ed in preference to daylight. Id) The testing-room shall
be moderately illuminated, and care shall be taken that there are no
glaring lights or bright objects In the candidate’s field of vision,
(e) Bxtreme contrast between the Illuminated teat-card and the back¬
ground shad be avoided.
III. Method of lighting—{a) The method of lighting described In
this report shall be in general adopted, (b; This method shall be made
compuisory for sight testing in all public services.
As an appendix there is a note on the illnminatioh of test
types by gas or oil lamps.
Qasligh'ing.— Two “medium” Inverted incandescent burners, con¬
suming 24-22 cub. ft. of gas per hour, are fixed 24 ft. in front of the
test card, one on each side, at a horizontal distance or 12 inohes from the
vertical plane, normal to and bisecting the card. One burner should be
higher than the other, one being opposite the junction of the upper
surf middle thirds of the o*rd, toe oth*r opposite the junction of the
middle and lowvr thirds. Burners Bhould be equipped w«tb clear glass
globes, and care should be taken to ensure, by regular maintenance,
that mantles and burners are kept in good order andln dean condition.
Opsque non-reflecting screens are fitted so as to prevent direct light
from the burner reaching the • andidate’s e> es.
Oil lighting. —Two standard “Duplex” oil lamps, each having a
double straigni wick, 1 inch In width, and a chimney 104 Inches in
length, are fixed 2 fi. in front of the t~st card, one on each side, at a
horizontal distance of 12 inches from the vertical plane, normal to and _
bisecting the card. One lamp should be higher than the other; one I
being opposite the junction of the upp^r and middle thirds of the card,
the other opp< site the junction of the middle and lower thirds. The wick
sbou'd be turned up as high as is possible without smoking, and the
lace of the wick Bhould be turned towards the card. The dUtance from
top of wick to level of oil in reservoir should not exceed 5 inches. The
bmp should be lighted 20 minutes before the test, so as to ensure
stesdy conditions of burning. Opaque, non-refleci ing screens are fitted,
•o as to prevent direct light from the Lamps reaching the candidate’s
eyes.
The Council of British Ophthalmologists was founded in
May. 1918, at a general meeting of all ophthalmic surgeons
of the United Kingdom held at the Royal Society of Medi¬
cine. It was empowered to act in all matters of ophthalmo-
logical interest arising in connexion with public affairs and
to be ready to provide when called upon a body of expert
opinion to advise on any ophthalmic subject. The council,
whose constitution has been given above, was founded
on a basis which should ensure its authoritative character.
The first report of the council, given above, will be seen to
deal with an important subject—types used in testing the
vision of candidates for pnblic services. The regulations at
present in existence with regard to the standard illumination
of test types say that these tests shall take place in “ordinary
daylight ” (Army Regulations) or “ in a good light, but not
in direct sunlight ” (Board of Trade Regulations for Mer¬
cantile Marine). In practice (as has been said above) this
may mean anything, and a more definite standard was
obviously required iu the interests of the public and the
candidates alike. The council was fortunate in securing
valuable scientific cooperation in the preparation of its
report. The suggestions are straightforward, and the object
aimed at should be secured at very small cost.
MEDICAL CANDIDATURE FOR j
PARLIAMENT.
SUCCESSFUL AND UNSUCCESSFUL.
Members of the medical profession were candidates for
Parliamentary suffrage in at leant 32 constituencies in the
British Isles daring the recent General Election. From
the results made public last Saturday, Dec. 28th, it will be
seen that in more than a third of these contested elections
they were successful. We append a complete list, so far as
we know it, of the constituencies in which a medical man
took part in the contest, giving in each case his position in
the poll (in black figures), the total number of voters (in
square brackets), and the number of votes secured by the
medical man and his competitors, along with the political
labels by which they were known. An asterisk is placed
against the name of any medical man who sat in the last
Parliament. Whether successful or not, the experience
gained should be of use to others.
Universities .
Belfast (Queen's). 8ir William Whitla (1).
1. (U.) 1487. 2. (S.F.) 118.
Dublin (2 seats). Sir Robert Woods (2)>
1. (U.)1273. 2. (Iod.) 793. 1 3. (U.) 631. 4. (N.) 257.
London [10,1331. Sir Wilmot Herringham (4).
1. (Co.U.) 2810. 2. (Lab.) 2141. 3. (Teachers) 885.
4. (Ind.) 715. 5. (Ind.) 210.
Scotland (3 seats) [27,322] . *Sir Watson Cheyne (1). Dr.
Peter Macdonald (4). Professor W. K. Smith (5).
I. (Co.U.) 3719. 2. (Co.L.) 3499. 3. (Co.U.) 3286. 4. (Lab.) 1581.
5. (Ind.) 850.
London District.
Battersea (South) [43,036]. •Mr. Arthur A. Lynch (2).
1. (Co.U.) 15,670. 2. (Lab.) 3333. 3. (L.) 2273. 4. (N.F.D.S.S.)
1657.
Bermondsey (West) [23,100]. Dr. Alfred Salter ^3)-
1. (L.) 4260. 2. (Co.L.) 2998. 3. (Lab.) 1956. 4. (N.F.D.S.S.
1294.
Shoreditch [45,686]. *Dr. Christopher Addison (1).
1. (Co.L.) 9532. 2. (Ind.) 3414. 3. (Lab.) 2072. 4. (L.) 1524.
5. (N.P.) 504.
Southwark ( Central ) [27,699]. Dr. L. Haden Guest (2).
1. (Co.L.) 8060. 1 (Lab.) 3126.
Stepney (Whitechapel) [23,666]. Dr. Robert Ambrose (2).
1. (L.) 3025. 2. (Lab.) 2522. 3. (Co.U.) 2489. 4. (Costers) 614.
Willesden ( West) [36,449]. Dr. J. S. Crone (3).
1. (Co.U.) 10,503. 2. (Lab.) 7217. 3. (L.) 1697.
County Boroughs.
Birmingham ( Moseley ) [41,546]. Dr. R. Dunstan (2)-
1. (Co.U.) 16,161. 2. (Lab.) 3789. 3 (L.) 3422.
Cheltenham [23,217]. Dr. Richard Davies v2)-
1. (Co.U.) 9602. 2. (Ind.) 6317.
Leeds (North) [37,904]. Dr. A. C. Farquharson (1).
1. (Co.L.) 13,863. 2. (Lab.) 3423. 3. (N.P.) 1282.
Liverpool ( Wavertree) [31,262]. Dr. Nathan Raw (1).
1. (Co.U.) 11,326. 2. (Lab.) 5103. 3. (L ) 2484.
Morpeth [39,773]. Mr. G. D. Newton (4)» Dr. T. M.
Allison 5).
1. (Lab.) 7677. 2. (Co.L.) 7143. 3. (U.) 4320. 4. (N.F.D.S.S.)
2729. 5. (N.D.P.) 511.
WaUasey [42,1741. Dr. B. F. P. McDonald (1).
1. ^U.) 14,633. 2. (Lab.) 4384. 3. (L.) 4055. 4. (N.F.D.8.8.)
Wolverhampton (Bilston) [28,504]. Mr. J. X. Kynaston (2)-
1. (Co.U.) 10,343. 2. (Lab.) 6744.
Counties: Great Britain.
Carmarthen: Llanelly [44,657]. Dr. J. H. Williams (2).
1. (Co.L.) 16,344. 2. (Lab.) 14,409.
Derby : High Peak [33,075]. Dr. CLIFFORD BROOKES (2).
1. (Co.U.) 12,118. 2. (L.) 8504
Durham: Bishop Auckland [32,689]. Dr.V.H. Rutherford (3)*
1. (Lab.) 10,060. 2. (Co.L.) 7417. 3. (L.) 2411.
Glamorgan: Llandaff and Barry [34,041]. Mr. C. F. G.
SlXSMITH (3).
1. (Co.U.) 13 307. 2. (Lab.) 6607. 3. (Ind.) 1539.
Hants: Basingstoke [31,687]. *SlR AUCKLAND GEDDES (1).
1. (Co.U.) lf,2L8. 1. (Lab.) 6277.
Inverness: Western Isles [18,237]. Dr. Donald Murray (1).
1. (L.) 3765. 2. (Co.L.) 3375. 3. (Highland Land League) 809.
Lanark: Lanark [27,431]. Dr. W. E. Elliot (I).
1. (Co.U) 12,976. 2. (Lab.) 5821.
1 Increased by P.R. at the second count to 1094.
36 Tb* Lanott,]
MEDICINE AND THE LAW.
[Jan. 4. 1919
Lancs : Famworth [34,160!. Sir Thos. Flitcroft (3)-
1. (U.) 10,237. 2. (Lab.) 9740. 3. (L.) 3893.
Lindsey : Gainsborough [27.5031. Dr. J. E. Molson (1).
1. (Co.U.) 8634. 2. (L.) 6556.
Notts : Mansfield [39,0411. Mr. N. M. Tarachand (4).
1. (Lab.) 8957. 2. (Co.N.D.P.) 6678. 3. (L.) 4000.
4. (Ind.) 878.
Stirling: Clackmannan and Eastern [31,910j. *Dr. W. A.
Chapple (3).
1. (Co.U.) 6771. 2. (Co-op.) 5753. 3. (L.) 5040.
Counties: Ireland.
Mayo : North 120,2121. Mr. JOHN CROWLEY (1).
1. (S.F.) 7429. 2. (N.) 1861.
Meath : North [14,7161. Mr. P. J. Cusack (2).
1. (S.F.) 6982. 2. (N.) 3758.
Wexford: South [23,1681. Dr. James Ryan (1).
1. (S.F.) 8729. 2. (N.) 8211.
The names of the medical men entitled to sit for the
first time in the House of Commons on Jan. 21st next are
therefore :—
Mr. John Crowley,
Dr. W. E. Elliot,
Dr. A. C. Farquharson,
Dr. B. F. P. McDonald,
Dr. J. E. Molson,
Dr. Donald Murray,
Dr. Nathan Raw,
Dr. James Ryan,
Sir William Whitla,
Sir Robert Woods,
along with three others who have already established their
position there:—
Dr. Christopher Addison, Sir Watson Cheyne,
8ir Auckland Geddes.
On behalf of several of these successful candidates we have
been asked to express gratitude to their professional
colleagues for help freely rendered.
MEDICINE AND THE LAW.
Illicit Traffic in Drugs.
The inquest, which has not yet been concluded, upon the
body of a young actress named Stewart and known upon the
stage as “Billie Carleton” has already produced as one of
its results the prosecution and conviction of two persons—
Len Ping You, a Chinaman, and his wife Ada, a British
subject by birth. They were mentioned in the early stages
of the inquest upon Miss Stewart, with allegations as to the
wife having assisted the deceased and others in the smoking
of opium, and owing to the facts thus disclosed they were
recently charged simultaneously at two different police-
courts. The Chinese husband was arrested at Limehouse
Causeway, where he lived, and brought before Mr. Rooth at
the Thames police-court, who sentenced him to pay a fine of
£10 for having opium in his possession without authority,
and also for having an opium pipe and other utensils
connected with this use of the drug, the offence, to which
he pleaded guilty, being one against a regulation made
under the Defence of the Realm Act. The wife, Ada, was
brought before Mr. Mead, at Marlborough-street, and charged
with supplying opium prepared for smoking to Miss Stewart,
and also with being in possession of prepared opium at
16, Dover-street, where rooms were occupied by a man
named De Veulle and his wife. To the latter charge she
pleaded guilty, having denied supplying the opium at the
time of her arrest and afterwards. The facts narrated by
the solicitor for the prosecution as to the use which the
prisoner made of a drug, which possibly, if she told the
truth, she found already provided on the premises, were of a
character to earn for her a sentence of five months’ imprison¬
ment with hard labour. Acting as a “ priestess of unholy rites, ”
to adopt the phrase of Mr. Mead, the magistrate, she filled
and lit the opium pipe which passed from mouth to mouth
in an opium-smoking debauch lasting from 10 o’clock one
Saturday evening until 3 o’clock on the following afternoon.
The party to whom she thus ministered consisted of five or
six young men and women, for whom cushions were spread
upon the floor, and who before taking part removed their
clothes and put on pyjamas and night-dresses respectively.
Miss Stewart, who arrived late after a performance at
the theatre where she was engaged, was one of these.
The observations made by the magistrate upon what
he characterised as a disgraceful orgy, and the sen¬
tence which he passed upon the woman who took so
leading a part in promoting it, can hardly be criticised
as too* severe. It is to be noted also that he described
indulgence in opium as a prevalent form of vice, and
expressed the hope that the imprisonment which he was
ordering the prisoner to undergo would act as a warning
to others. The frequency of prosecutions for this kind of
offence recently to be observed in police reports may to some
extent be due to there being more space than formerly for
the publication of such items of news, but whether this is
so or not it is evident that the use of opium, cocaine, and
other drugs in late years has attained substantial proportions,
in spite of the efforts made by the authorities under the
Defence of the Realm Act to hinder the illicit traffic. It
is to be hoped that whenever that statute may become
obsolete permanent provision will be made to protect the
willing victims of drug-taking from themselves and from
the temptations placed in their way by others. The use of
oooaine by soldiers, to prevent which a special effort has
been made through the regulations under “D.O.R.A.,” is
said to be due to an alleged effect of the drug in producing
a reckless indifference to environment and disregard of
danger. The circumstances of war service have ceased, but
the desire for temporary relief from anxiety or discomfort
will contribute even now to render men and women anxious
to obtain drugs, the surreptitious importation and sale of
which it is very difficult to prevent. Among typical recent
cases we note one of a Chinese cook caught with two pounds
of opium, which he might have sold for anything up to £60,
under his shirt. He was fined £22 at Tower Bridge police-
court, and another Chinaman was charged on the same day
at the Thames police-court for keeping an opium den at
Limehouse and fined £10. Cocaine is even more easily carried
and concealed than opium, and perhaps on this account
and for the reasons above suggested commends itself to
many drug-takers, who, however, do not appear at once to
adopt a particular form of intoxication, but prefer to experi¬
ment for a time with whatever opportunity may throw in
their way. This, at least, is the impression conveyed by the
reports of the inquest upon Miss Stewart and the other cases
which have arisen out of it. In connexion with the use of
cocaine we call attention to the conviction at Liverpool of a
woman for stealing a bottle of cocaine from the consulting
room of a dentist who was treating her. This should be a
warning to medical men who dispense their own medicines
of the great importance of keeping all dangerous drugs
beyond the reach of their patients.
An Ingenious Impersonator.
At the Bromley (Kent) police-court recently a man named
James Allan was ordered to pay a fine of £20 and £10 costs
after being proved to have used medical titles and prac¬
tised as a medical man in somewhat unusual circumstances.
The name of a Mr. James Allan, who had duly qualified at
Edinburgh University, appeared with the usual particulars of
his qualifications in the Medical Register from 1892 to 1898,
when he died. In 1901 there were published in the
“Medical Directory” the same name and qualifications,
“James Allan, M.B., C.M. Edinburgh,” and they con¬
tinued so to appear until the conferring of the order
of Officer of the British Empire upon a gentleman so
described attracted the attention of the Registrar of the
General Medical Council, who was unable to find a corre¬
sponding entry in the Medical Register. At or about the
same time one of the usual forms issued for the purpose of
corrections or additions by the publishers of the Medical
Directory was sent to Mr. James Allan at his address at
Chislehurst, and was returned by him with the addition of
the letters O.B.E. After inquiries had been made by the
Registrar of the General Medical Council, the matter was
laid before the Director of Public Prosecutions with the
above result. The defendant was stated by counsel to be
the son of a farmer in Ireland, who had been at one time a
shop assistant and had afterwards studied medicine. He had
not qualified as a medical practitioner, but had acted as an
unqualified assistant to medical men, and since 1902 had
practised at Chislehurst as James Allan, M.B., C.M. Edin.,
and in that capacity had signed death certificates. A charge
made in respect of these was not proceeded with by the
prosecution. A detail which was mentioned in the case
should be noted by the personal representatives of medical
men. After the death of the real James Allan, referred to
above, his sister was asked by someone who wrote from Glasgow
and was stated to be an acquaintance of the defendant,
whether she would sell her brother’s medical diplomas, the
The Lancet,]
THE BELGIAN DOCTORS’ AND PHARMACISTS’ RELIEF FUND.
[Jan. 4,1919 37
writer stating that he had a hobby for collecting such docu¬
ments. The object of the offer, in so far as it proceeded
from the defendant, is obvious, and as the diplomas of
deceased medical men cannot, except perhaps in the case of a
few distinguished personages, be of any interest except to
their children or other relatives, willingness to pay for them
on the part of a stranger should at once excite suspicion
on the part of the possessor. James Allan, of Chislehurst,
cannot complain that the punishment inflicted upon him
was in excess of his deserts, in spite of the fact that
witnesses, including the rector of Chislehurst, expressed
themselves satisfied with the skill with which he treated his
patients. This was a bad case of impersonation, and if the
prosecution had laid stress upon the points involved the
proceedings could hardly have stopped where they did.
We feel sure that those responsible for so carefully edited
a work as the Medical Directory must keenly regret the
inaccuracy which in some way was admitted to its pages.
Fro it v. King Ed/va/rd VII. National Memorial Association
for the Prevention , Treatment , and Abolition of
Tuberculosis.
In this action, in which Mr. Justice Eve granted in last
May an injunction to restrain the defendants from using
Cardigan House, at Newport, Monmouthshire, as a hospital
for surgical tuberculosis, a settlement has been arrived at.
This was announced by counsel when the case was called in
the Court of Appeal, the terms being stated to be that the
house should continue to be used as before until the expira¬
tion of six months after peace, and then should become a
residence for one of the physicians of the association and a
central dispensary for their work in Newport and Monmouth¬
shire. Conditions were added such as should make the
settlement a binding one and prevent any further litigation
in the future, and it was provided that the defendants should
pay the taxed costs of tfye plaintiff.
THE BELGIAN DOCTORS’ AND
PHARMACISTS’ RELIEF FUND.
A meeting of the Committee was held at The Lancet
Offices on Dec. 23rd, 1918, when Dr. Squire Sprigge
reported that he had received through Lord Hardinge the
necessary forms to secure a passport for a representative of
the Fund to go to Belgium, the only preliminary formality
being the favourable recommendation of the Belgian Control
Office. Dr. Sprigge also reported a visit from Dr. Th6o
Huyberechts, who had come as a member of the Belgian
Doctors' and Pharmacists’ Committee sitting in Brussels, to
express the gratitude of that Committee to the Fund,
testifying that the help of the Fund had been “beyond
words valuable.”
Sir Rickman Godlee called the attention of the Com¬
mittee to the fact that there remained at their disposal
many instruments still housed at the Apothecaries’ Hall.
One selection, he said, had been packed and sent, under the
superintendence of Mr. Samuel Osborn, to a Belgian
hospital at Bruges, but many more, and some of very
good workmanship, remained. Mostly they were old-
fashioned but of excellent steel and make. He instanced
some knives by famous makers, and thought that metal
might be substituted for the wooden handles, when they
would be serviceable instruments to-day.
An article published in Le Beige Independant was
received by the Committee describing the establishment of
the dispensary in Aldwych for the Belgian refugees at the
opening of the war and the foundation of La Society Beige
de Medecine en Angleterre. Dr. Clement Philippe, with
the assistance of Dr. J. H. Philpot and Dr. H. A. Philpot,
organised the former movement, and for some time the
Philpot and Dr. Des Vceux, with the assistance of
certain refugee Belgian doctors, carried on very useful
work. It may be remembered that this work was afterwards
transferred to the Metropolitan Asylums Board, and now
that the Belgian doctors are returning to their homes the
Board will continue its supervision over the remaining
patients. The article also described the preliminary circum¬
stances which led to the establishment of the Belgian
Doctors’ and Pharmacists’ Relief Fund. This Fund oame
mto being upon representations made, by Dr. Charles Jaoobs I
mainly, to the Editors of The Lancet and the British •
Medical Journal, and the article in Le Beige Independant
bears witness to the generosity of the members of the British
professions, by whom some £25.000 has been subscribed,
the bulk of which has been expended on Belgian sufferers
in Belgium.
As just sufficient money remained in hand it was decided
to send to Belgium the full mensuality of £800 for next
month.
The following subscriptions have been received
£ d.
Dr. Alfred Cox (monthly). 110
Lt.-Col. Fremantle, R A.M.0. 10 0 0
American Red Cross Commission for Belgium (monthly) ... 200 0 0
Dr. D. Douglas-Crawford . 5 5 0
PARIS.
(From our own Correspondents.)
Diet Kitchens for Military Hospitals,
An interesting experiment in the organisation of diet
kitchens has been made during the last two years in French
military hospitals. Begun in a tentative way to meet an
obvious need in one of those hastily improvises establish¬
ments dotted about the provinces in the early days of the
war, the experiment has now crystallised into a definite
work of undoubted importance in the caring for the sick
and wounded, and will possibly form the basis of a radical
change in the dietary treatment of hospital patients through¬
out France.
Even before the war the food giveD to the patients in
French civilian hospitals was bad enough to justify the
writer of a Paris guide-book in stating that * * the catering is
the worst possible patients being fed almost exclusively on
a beef diet with vegetables, mostly of the dried order, beef
being given three times a day in the form of soup once and
boiled beef twice.” The war naturally aggravated these
conditions, and in many of the hurriedly organised military
hospitals the cooking was entrusted to unskilled people
whose knowledge of catering for large numbers of wounded
was sadly deficient.
The initial difficulties of this new phase of hospital
administration were hard to overcome, but a reform movement
was supported by General Rouget, the Director-General of
the Service de Sant6, Dr. Mourier, the under-secretary, Mr.
Joseph Reinach, and many highly-placed persons, and the
scheme from a small beginning is now assuming a definite
importance. One difficulty lay in the fact that the cooks in
military hospitals are nearly always soldiers ; and in France
a soldier is theoretically supposed to be master of all
trades, and credited with a superhuman versatility, while his
military duties come before all others. A woodcutter or a
bricklayer may be detailed to do the cooking for several
hundred men, and when he gained a working knowledge of
the job he may be moved to the other side of France for
purely military reasons to attend the stoking of furnaces in
a depot. It was realised that while the food supply was quite
adequate, everything was spoiled by this use of unskilled
labour, and that the only remedy lay in the appointment of
specially trained cooks working under a surveillante.
Early in January, 1917, Miss M. Oliver, daughter of
the late Dr. George Oliver, received permission from
the French Service de Sant6 to open the first diet kitchen
of the “Service des Regimes” at Hospital No. 75 at
Vichy. Two ladies took charge of the cookiDg with some
voluntary help in the distribution. The hospital was the
medical centre of the 13th Region, and offered a good deal
of variety in the clinical work, so the workers gained much
experience in satisfying the individual needs of each case.
The work was carried on till the following July, when the
hospital was taken over by the Americans. By May the
Government authorisation had been gained for starting a
diet kitchen at the Villemin Hospital in the rue des
RGcollets, Paris. At that time there were there about 500
beds. The majority of the cases were tuberculous, and
the diet kitchen was opened for these and for two wards of
abdominal cases.
Two mouths later a diet kitchen was started by two
lady workers in the Val-de-Grnce Hospital, the oldest and
biggest military hospital in Fiance, principally to provide
additional purges and soups for Dr. Mores tin’s famous
surgical division of wounded in head, jaw, and throat. As
38 The Lancet,]
CANADA.
[Jan. 4. 1010
these men can only be fed through tubes, it is particularly
necessary that attention should be paid to the assimilative
qualities and to the nutritive value of the food. The success
of this experidient was so marked that in November the work
was enlarged so as to include the whole hospital: a large
refectory was turned over to the Service des Regimes, as the
diet kitchens are called, and fitted up by the hospital authori¬
ties with a range, two gas stoves, and every up-to-date con¬
trivance for a model kitchen. The whole of the 14 divisions
of this great hospital, as well as the annexe containing
another large division of head, jaw, and throat cases, is now
provided with special diet, when necessary, by the diet
kitchen.
The next expeiiment was made at Epernay, where a diet
kitchen was opened on Jan. 1st, 1918, in the principal bone
fracture hospital in France. Unluckily, the German offensive
in June put a stop to the excellent results obtained by the
extra nourishment given through the diet kitchen, for the
entire ho-pital had to be evacuated to a field ambulance far
behind the lines—the kitchen was trampled down and the
ouifit scattered. The hospital will, however, soon go back
to its old quarters when the diet kitchen will be re¬
established. A fifth diet kitchen was opened in the Le
V6sioet Hospital, near Paris, on July 1st, 1918, where the
work done in providing gassed patients with suitable nourish¬
ment has saved many lives. Diet kitchens have also been
well started in St. Jacques Hospital, at Besan$on, and in
the military hospitals at Troyes and Rtdms. The working of
the diet kitchens in each case is practically identical. The
directress of the work goes round the wards and notes the
diet cards filled in by the doctor, and measures out the
quantity of food required by each case. The cooking is
done by paid workers under the supervision of the directress.
The regular hospital fire is provided by the authorities, but
the expense of the special diet is covered by Miss Oliver’s
“ Service des Regimes,” which also pays the salaries of the
workers.
The excellent results shown since the establishment of
these kitchens have evoked unrestricted appreciation from
the doctors in charge of the hospitals, as well as of the
heads of the French Service de Sant 6 . The success is so
notable that Miss Oliver is now hoping to develop her work
so as to provide every hospital in France with a Service des
Regimes. The only difficulty is the lack of funds. Once
this is overoome, and each hospital has its special diet
kitchen. Miss Oliver wante to cooperate with the “ Service
de 8ant6” in the formation of a “Service de Cuisine,”
where women cooks and women inspectors might be trained
to specialise in hospital cookery.
French authorities, with a fine defiance of Voltaire, have
welcomed this practical aid, and the endowment of every
military hospital with a properly organised “Service de
Ouisine ” will form one more link in the friendship between
England and France.
Medical Demobilisation in France.
Dr. Mourier, Under Secretary of State for the Service de
Sant6. has already made some progress with demobilising
his own department. Red Cross hospitals have been dealt
with first, and in Paris alone eight closed their do ^rs last
week. A knotty pdnt is the allocation of the enormous
accumulation of surgical material. As regards beds and
furniture, the proposal is to devote them to help rehabilitate
the devastated communes in the north of France. Medical
officers themselves belonging to the earliest classes will be
demobilised at once and replaced by more recent classes,
who will as far as possible be detailed to their own districts,
where they can get in touch with their practices. On
demobilisation pay will be continued for some little time.
Those who desire to remain will be retained in the services,
as well as a certain number of indispensables. In Paris the
larger proportion of consultants attached to military hos¬
pitals have asked to continue their work.
Influenza in Franoe.
Influenza, which seemed to be dying out, has had a new
lease of life the last three weeks with the prolongation of
the warm moist weather. The number of severe and fatal
cases has, however, been much smaller than two months ago.
Disinfection leaves much to be desired on account of short¬
ness of sanitary staff. A wealth of new suggestions for
treatment have been made to the Academy of Medicine and
other learned societies. M. Armand Gautier has advised the
injection of quinine and arrti6ual dissolved in normal saline.
M. Albert Robin has obtained excellent results with this
remedy. M. Sen de Rouville and M. Netter have used
inoculations of oxide of tin in colloidal suspension. They
have had success in certain desperate cases, observing that
the inoculations have produced the maturing of fixation
abscesses, provoked by turpentine injection after the method
of Fochier, in cases in which such injections had evoked no
reaction—a condition tantamount to a fatal prognosis.
Finally, MM. Grigant and Moutier have employed injections
of blood serum from patients convalescent of influenza,
obtaining remarkable results when the injections were given
practically from the onset of the fever.
Maternal and Infantile Protection in Paris during the War.
A central office was set up in Paris at the outset of the
war to assure protection for necessitous mothers and
infants in Paris and its neighbourhood in intimate rela¬
tion with all the maternities and with every local authority.
M. Pinard recently reported to the Academy on the work
done by this central office. More than 100,000 mothers and
babies have received a-sistance during the last four years.
In the last year of all 31.262 mothers claimed help before,
during, or after their confinement, a large proportion of the
34,125 births registered in Paris. Australia’s contribution
to the work has been invaluable. From Dec. 18th, 1915, to
June 22nd, 1918, the Franco-Australian League at Sydney
remitted to Mme. Michel, honorary president of the work, a
sum of more than 150.000 fr., and the same League at
Melbourne a total of 550 000 fr., for which M. Pinard in his
report tenders the warmest thanks. Mortality in Paris
during the first year of post-natal life has Bensibly
diminished in the last 12 months; from 155 per 1000
births in 1914 the figure has fallen to 140, or less than
what it was before the war. Deaths due to enteritis fell
from 1363 in 1914 to 762 in 1918, a result attributed to
the increase of breast-feeding and to the special cow’s milk
reserved by the Government for hand-fed infants. Con¬
genital debility has, alas, increased as a cause of early
death in the last two years. This mortality stands in close
relation to the exhaustion of the mothers by arduous work,
a condition which did not exist in the first year of the war.
French Doctors and the Excess Profits Tax.
A considerable levy has been made on war profits in all
professions. The Association of Medical Societies of France
has recently held a reunion at which the unanimous demand
was made for the exemption of the medical corps from the
tax. Except in the rarest cases the medical profession has,
it is alleged, during the war only made paltry profits, since
the overwhelming proportion has been mobilised and of the
remainder most have given much of their time gratuitously
to Red Gross work. The question has been submitted to the
highest financial authority, but should its decision be
unfavourable to the doctors the Association has decided to
memorialise the Council of State, asking that the basis of
fiscal control should be the medical man’s ledger, the pro¬
duction of which is now contrary to the law of professional
secrecy.
Dec. 28th, 1918. __
CANADA.
(From OUR OWN 0ORRR8PONDSNT.)
The Influenza Scourge.
Commencing in late September, Canada has passed
through a terrible epidemic of influenza. It is yet-
impossible to give any figures for the whole country, but the
deaths in Toronto reached as high as 150 on one day. In.
Canada the disease has not been made reportable or notifiable,
and no quarantine has been practised, but isolation has beeia
put into force to some extent by private practitioners and in.
hospitals. Toronto grappled with the epidemic by rapidly
preparing two emergency hospitals, one of which has not
been used. Toronto's health officer claims that that city
reached the crest of the epidemic much earlier than other
Canadian and American cities. Some physicians u«ed n
prophylactic vaccine and speak well of it, and the Ontario
B su'd of Health participated in the making of such vaccine.
That board discussed reporting, isolation, and quarantine
in regard to influenza before the epidemic invaded the
TrbLangbt,]
URBAN VITAL STATISTICS.
[Jan. 4. 1919 39
province, but concluded that these measures were imprac¬
ticable. There was much disruption of business and educa¬
tional life, but, speaking generally, each municipality was
left to its own resources in fighting the disease. Evidence is
strong that the mass of the people still cling to alcohol in the
treatment of influenza. In Prince Edward Island clergymen
were empowered to write prescriptions for alcoholic liquors,
and temperance laws were in general more plastic than at
other times. In Toronto there are two licensed vendors of
liquors under the Ontario Temperance Act, and the long
lines of waiting citizens testified to the number of prescrip¬
tions written by physicians. The Montreal Board of Health
had prepared a circular advising the public to take to bed
and send for the physician at the first sign of the disease.
In regard to vaccines, the public was informed that the
treatment was still in an experimental stage, and that no
body of medical opinion was prepared to endorse their use
as a prophylactic measure. The opinion has been widely
expressed that the epidemic of influenza “ has taken a
terrible fall out of” preventive medicine. It is scarcely
understandable how medical officers simply waited for the
inevitable.
Some Mental Statistics in Canada.
6031 patients were in the hospitals for insane in Ontario in
one recent year, which would make in proportion 20,000 for all
of Canada. Represented in money this would be an economic
loss to Canada annually of more than $16,300,000. While
the exact numbers of the feeble-minded in Canada have not at
any time been determined, in oertain centres they have been,
for in Toronto, with a population of more than 500,000, 2500
cases have been discovered; and figuring on this basis,
approximately there are 36,000 mental defectives in the
Dominion. The late Dr. Gilmour, parole officer for
Ontario, estimated that 33 per cent, of prisoners in
Ontario institutions were mentally abnormal. The Toronto
General Hospital psychiatric clinic, in three years,
had 1300 mental defectives referred a to it by the juvenile
court of that city. Thus, about 40 per cent, of the total
number of children found guilty of repeated offences
against the law are defective delinquents. Take prostitu¬
tion at the venereal clinic in the same institution—between
50 and 75 per cent, of all the loose women are mentally
defective. In one institution of the city that cares for girls
of weak moral nature 90 per cent, of one hundred odd cases
examined were of the feeble-minded order. Of 10,000
school children examined by Dr. Hincks, psychiatrist of the
Board of Health, 2 per cent, were feeble-minded, and 100
of these were guilty of evil sexual practices.
Canadian Association for the Prevention of Tuberculosis:
The Eighteenth Annual Report.
The secretary of this association (Dr. George D. Porter,
Toronto) reports that nine years ago there were just six
institutions in Canada for the care and treatment of the
tuberculous. There was only one institution of this character
west of Hamilton, Ontario, to the Pacific coast—in British
Columbiar—with 16 beds. Now there are ten institutions
west of Hamilton, and a proportionate growth east of that
city to Halifax and Prince Edward Island. The total
accommodation throughout Canada nine years ago was
about 350 beds ; to-day it is about 3500. The association
has abundantly justified its existence. The money spent in
maintenance was about $150,000 per annum ; to-day it totals
over $900,000 per annum. Some $3 000,000 have been spent
in plants. The National Sanatorium Association was the
pioneer organisation, and some interesting figures are given
of it below. It has the largest number of patients. The first
provincial sanatorium was established in Nova Scotia; and
at Hamilton, Ontario, was erected the first local or
county institution in all Canada.
The National Sanatorium Association.
The following institutions are controlled by this associa¬
tion : Muskoka Free Hospital for Consumptives, Muskoka
Cottage Sanatorium (both near Gravenhurst, Ontario), 1
Toronto Free Hospital for Consumptives. King Edward
Sanatorium for Consumptives, Queen Mary Hospital for
Consumptive Children, Free Dispensary-Gage Institute,
Toronto, the Sanatorium Club, the Weston Sanatorium Club.
It has been a serious problem to manage all these institutions
during the war period, owing to the advanced prices of foods
1 Thk Lancet, mo, 11 ., 1041.
and the shortage of trained nurses. Four years ago, at the
beginning of the war, the daily average number of patients
in residence was 485, now it is 688. The annual expenditure
advanced in that time from $275,000 to $510,000 ; a con¬
servative estimate for the present year’s requirements is
$585,000. The per capita cost of maintenance in the
Muskoka and Weston institutions advanced from $10.50 to
$14.52 per week. For the present year $55,000 has been
received from appeals to the public, and for the past hos¬
pital year the expenditure for maintenance exceeded the
income by $52,000. The doors of these institutions are open
to residents of the province of Ontario, and during the past
hospital year they have cared for 1707 patients, making
a total of 11,679 cared for in all the hospitals since
establishment.
Tuberculosis Toll in Canada.
Almost as many people died in Canada of tuberculosis
during the four years and three months of war as there were
Canadian soldiers killed in battle in the same period. It is
also claimed that as many civilians at home were stricken
with the disease as the number of soldiers who went overseas.
Dr. Harding, the secretary of the Royal Edward Institute,
Montreal, has made this statement. During the past hospital
year of that institution 11,000 patients had consulted the
dispensary, and there had been 1063 new patients, of whom
391 were found on examination to be tuberculous. Two hundred
and forty soldiers had been treated in the military annexe,
preparatory to being sent to Ste. Agathe Sanatorium. Some
of these were advanced and hopeless cases, and 21 of them
had died of the disease.
New Military College.
The National Cash Register Building in Toronto, whioh
was purchased by the Canadian Government a short time
ago for an orthopaedic hospital, will probably be opened early in
1919. It is to be the centre for orthopaedic work in Canada
and will also be used for teaching clinical orthopaedics. It
is to accommodate from 1500 to 2000 and is equipped with
all modern apparatus. The hospital will have an assembly
hall to accommodate 850.
Toronto. Deo. 20th, 1918.
URBAN VITAL STATISTICS.
VITAL STATISTICS OF LONDON DURING NOVEMBER, 1918.
In the accompanying table will be found summarised statistics
relating to sickness and mortality In the City of London and in
each or the metropolitan boroughs. With regard to the notified
casea of Infectious disease it appears that the number of persons
reported to be suffering from one or other of the ten diseases
specified in the table was equal to an annual rate of 4*0 per
1000 of the population, estimated at 4,026,901 persons; in the
three preceding months the rates had been 3'2, 4*7, and 5*9 per
1000. Among the metropolitan boroughs the lowest rates from
these notified diseases were recorded In St. Marylebone, Hamp¬
stead, the City of London, and Greenwich ; and the highest
rates in Bethnal Green, Poplar, and Southwark. The prevalence
of scarlet fever was 29 per cent, lower than in the p-seeding
month; this disease was proportionately most prevalent In Bethnal
Green, Poplar, 8outhwark, Bermondsey, and Lambeth. The Metro¬
politan Asylums Hospitals contained 1107 scarlet fever pstientB at
the end of the month, against 690, 931, and 1184 at the end of the three
preceding months; the weekly admissions averaged 146, against 101.
164. and 178 in the three preceding months. The prevalence of
diDhtheria was 32 per cent, lower than in October; the greatest
prevalence of this disease was recorded in Stoke Newington,
Hackney, Stepney, Poplar, and Southwark. The number of
diphtheria patients under treatment in the Metropolitan Asylums
Hospitals, which had been 886, 1051. and 1155 at the end of the three
preceding months, had declined to 1000 at the end of November; the
weekly admissions averaged 129, against 107,166, and 169 in the three
preceding months. The prevalence of enteric fever declined 60 per
cent, compared with the previous month; of the 16 cases notified
4 belonged to the City of Westminster, 3 to Fulham, and 2 each to
Greenwich and Woolwich. There were 33 cases of enteric fever under
treatment in the Metropolitan Asylums Hospitals at the end of the
month, against 32, 43, and 56 at the end of the three preceding months;
the weekly admissions averaged 3, against 6, 6, and 9 in the three
receding months. Erysipelas was proportionately most prevalent in
t. Pancras, Shoreditch, Bethnal Green, Poplar, and Bermondsey. Of
the 5 eases of puerperal fever notified duiing the month 2 belonged to
Lambeth: 4 cases of cerebro-spinal meningitis were notified from
Islington; and 1 of poliomyelitis from Poplar.
The mortality statistics in the table relate to the deaths of civilians
belonging to the several boroughs, the deaths occurring in institu¬
tions having bean distributed among the boroughs in whioh the
deceased had previously resided. During the four weeks ended
Nov. 30th the deaths of 13.061 London residents were registered,
eqnal to an annual rate of 42'3 per 1000; in the three preceding
months the rates had been 10*1,11*4, and 27*3 per 1000. The death-
rates ranged from 27*7 in Hampstead, 28*5 in Lewisham, 28*9 in Stoke
Newington, and 30*8 in Woolwich to 50 0 in Poplar, 51*7 In Southwark,
53*4 In Bermondsey, 56*5 in Finsbury, and 62*0 in Holborn. The 13,061
deaths from all causes lnoluded 211 which were referred to the
40 The Lancet,]
URBAN VITAL STATISTICS.
[Jan. 4. 1919
principal infectious diseases, and comprised 70 from infantile diarrhoea,
66 from diphtheria, 38 from measles, 17 from whooping-cough. 15
from scarlet fever, and 5 from enteric fever. No death from
any of these diseases wab recorded in Hampstead and only one
in Paddington, in the City of Westminster, and in the City of London ;
the highest rates were recorded in Hammersmith, St. Marylebone,
St. Pancras, Holborn, and Bethnal Green. The 38 deaths from measles
were 43 below the average number in the corresponding period of the five
P receding years, and included 8 each in Hammersmith and St. Pancras,
each in St. Marylebone and Camberwell, and 3 in Kensington.
The 15 fatal cases of scarlet fever were 6 below the average, and in¬
cluded 3 each in Southwark and Lambeth, and 2 in Hackney. The 66
deaths attributed to diphtheria were 6 above the average, and included
8 in Lambeth, 7 in Hackney. 6 in Poplar, and 5 in Southwark. The
deaths from whooping-cough numbered 17, and were 16 be'ow the
average; of these. 2 each belonged to Islington, Hackney, Stepney,
Bermondsey, and Lambeth. The 5 fatal cases of enteric fever were 4
below* the average, and included 2 in Hammersmith. The 70 deaths
from infantile diarrhoea were 67 below the average, and included 11
in Islington, 7 each in Stepney and St. Marylebone, and 5 in Woolwich.
In conclusion, it may be stated that the aggregate mortality from these
principal infectious diseases in London during November was 38 per
cent, below the average.
(Week ended Dec. 14th, 1918.)
Scotch Towns —In the 16 largest Scotch towns, with an aggregate
population estimated at nearly 2,500.000 persons, the annual rate of
mortality was 16*4, against 23 7 and 19*8 per 1000 in the two pre¬
ceding weeks. Of the 756 deaths from all causes, 18 were classified
to influenza, which was also stated as a seconda»y cause in 103 deiths
classified to other diseases; in the previous week these numbers were
24 and 165 respectively. The 322 deaths in Glasgow corresponded to an
annual rate of 15*1 per 1000, and Included 6 from infantile diarrhoea,
4 from whooping-cough, and 2 from diphtheria. The 103 deaths in
Edinburgh were equal to a rate of 161 per 1000, and included
2 from diphtheria and 1 from whooping-cough.
(Week ended Dec. 21st, 1918.)
English and Welsh Towns.— In the 96 English and Welsh towns,
with an aggregate civil population estimated at 16,500,000 persons, the
annual rate of mortality was 16*8 per 1C00, against rates declining from
36 5 to 20*2 per 1000 in the three preceding weeks. In London, with a
population slightly exceeding 4,000,000 persons, the death-rate wsb
16*0, or 2 2 per 1000 below that recorded in the previous week ; among
the remaining towrns the rates ranged from 4 0 in Swindon, 5*1 in
Hornsey, and 7 2 in Ipswich, to 27*9 in Dewsbury, 32 8 in West
Hartlepool, 41 *2 in Sunderland, and 48*9 in Barnsley. The principal
epidemic diseases caused 154 deaths, which corresponded to an
annual rate of 0*5 per 1000, and included 52 from infantile
diarrhoea, 47 from diphtheria, 21 from whooping-cough, 17 from
measles, 13 from scarlet fever, and 4 from enteric fever. Diph¬
theria caused a death-rate of 1*1 in Liverpool and 2*9 in Oxford.
The deaths from influenza, which had declined from 7557 to 1885 in
the six preceding weeks, further fell to 1014, and included 186 in
London, 68 in Birmingham, 55 in Manchester, 43 in Liverpool, 32 in
Bristol, and 31 in Sunderland. There were 2 cases of small-pox, 1030
of scarlet fever, and 1056 of diphtheria under treatment in the
Metropolitan Asylums Hospitals and the London Fever Hospital ; the
two latter were 59 below and 39 above the respective numbers remain
ing at the end of the previous week. The causes of 41 deaths in the
96 towns were uncertified, of which 8 were registered in Birmingham,
6 in Liverpool, and 3 in Gateshead.
Scotch Towns—In the 16 largest Scotch townB, with an aggregate popu¬
lation estimated at nearly 2.500,000 persons, the annual rate of mortality
was 14*8. against rates declining from 243 to 16*4 per 1000 in the four
preceding weeks. Of the 683 desths from all causes. 7 were classified
to Influenza, which was also stated as a secondary cause in 74 deaths
classified to other diseases ; In the previous week these numbers were
18 and 108 respective! v. The 299 deaths in Glasgow were equal to a
rate of 14 0 per 1000, and included 4 each from diphtheria and
infantile diarrhoea, and 1 from whooping-cough, The 81 deaths in
Edinburgh were equal to a rate of 12*7 per lOOO, and included 3 each
from scarlet fever and whooping-cough, and 1 from diphtheria.
Irish Towns. —The 145 deaths in Dublin corresponded to an annual
rate of 18*9, or 3*1 per 1000 below that recorded in the previous
week, and Included 14 from influenza, 2 from infantile diarrhoea, and 1
from measles. The 145 deaths in Belfast were equal to a rate of 19*2
per 1000, and included 2 from infantile diarrhoea and 1 from diphtheria,
(Week ended Dec. 28th, 1918.)
English and Welsh Towns- In the 96 English and Welsh towns, with
an aggregate civil population estimated at 16,500,000 persons, the
annual rate of mortality, which had declined from 36 5 to 16'8 in the
four preceding weeks, further fell to 14*8 per 1000. In London, with
a population slight ly exceeding 4,000,000 persons, the death-rate was
13*8 or 2 2 per 1000 below that recorded in the previous week ; among
the remaining towns the rates ranged from 6 0 in Darlington, 7*3 in
Enfield, and 7*6 in Ilford, to 26*1 in Sunderland, 27*3 in Bootle, 28 2 in
Bury, and 45*7 in Barnsley. The principal epldemio diseases caused
137 ' deaths—the lowest number recorded in any week of the
year; this number corresponded to an annual rate of 0*4 per
1CO0, and Included 45 from Infantile diarrhoea, 35 from diphtheria.
22 from measles, 18 from whooping-cough, 13 from scarlet fever, and
4 from enteric fever. The deaths from influ nza, which had steadily
declined fr.un 7557 to 1014 in the seven preceding weeks, further fell to
581, and included 95 in London, 44 in Liverpool, 39 in Manchester.
25 in Birmingham, and 24 in Barnsley. There were 2 cases of small pox,
1101 of scarlet fever, and 1105 of diphtheria under treatment in
Metropolitan Asylums Hospitals and the London Fever Hospital;
the two latter were 71 and 49 above the respective numbers remaining
at the end of the previous week. The causes of 38 deaths in the
93 towns were uncertified, of which 10 were registered in Liverpool, f>
in Birmingham, and 3 in Gateshead.
Scotch Towns— In the 16 largest Scotch towns, with an aggregate
population estimated at nearly 2.500,000 persons, the annual rate ot
mortality was 16*1, against rates declining from 24 3 to 14*8 per 1G00 in
the five preceding weeks. Of the 744 deaths from all causes, 6 were
classified to influenza, which was also stated as a secondary cause m
(Continued at foot oj next column.)
42 The Lancet,]
THE WAR AND AFTER —OBITUARY.
[Jan. 4,1919
Lt.-Col. (acting Col.) P. G. FitzGerald. D.S.O.; Capt. W. Foot, M.C.;
Maj. (acting Lt.-Col.) W. H. Forsyth ; Ma.j. J. K. Foster ; Temp. Maj.
T. M. Frood.
Temp. Capt. D. S. Graham ; Temp. Maj. (acting Lt.-Col.) G. D.
Gray ;Temp. Capt. H. A. Grierson ; Capt. J. H. Gurley.
Temp. Hon. Capt. F. Hall; Maj. (temp. Lt.-Col.) P. J. Hanafin,
D.S.O.; Temp. Capt. C. G. Harmer; Capt. (acting Maj.) W. C.
Hartgill, M.C.; Maj. (temp. Lt.-Col.) T. E. Harty, D.S.O.; Temp.
Capt. (acting Maj.) J. H. Hebb; Capt. (acting Lt.-Col.) C. Helm, M.C.;
Temp. Capt. W. J. Henry; Temp. Capt. S. P. Hodkinson; Temp. Hon.
Maj. T. Houston ; Capt. (acting Lt.-Col.) I. R. Hudleston ; Temp. Capt.
J. B. Hunter, M.C.
Temp. Capt. (acting Maj ) R. C. Irvine.
Temp. Capt. T. B. Johnstone.
•Temp. Capt. (acting Maj.) N. McD. Keith ; Maj. (temp. Lt.-Col.)
H. B. Kelly, D.S.O.; Temp. Capt. M. J. Kelly; Temp. Capt. L.
Kilroe; Temp. Capt. G. B. King; Temp. Capt. (acting Maj.) A. E.
Knight. M.C.
Temp. Capt. G. D. Laing; Temp. Capt. R. D. Laurie; Temp. Capt.
L. R. Lemprieie; Temp. Capt. P. R. Lowe ; Temp. Maj. S. G. Luker ;
Temp. Capt. J. Lumb.
Temp. Capt. (acting Maj.) R. B. Macfie ; Capt. K. P. Mackenzie;
Temp. Capt. (acting Lt.-Col.) K. W. Mackenzie, D.8.O.. M.C.; Temp.
Capt. Malloch ; Temp. Maj. (acting Lt.-Col.) E. H. Marshall, D.S.O. ;
Temp. Capt. A. E. S. Martin ; Temp. Capt. (acting Maj ) A. Massey;
Temp. Capt. (acting Maj.) R. Massie; Maj. (temp. Lt.-Col.) F. A.
McCarnmon, M.C.; Temp. Capt. J. McDonnell, M.C. ; Temp. Capt.
J. P. McGreehin ; Temp. Capt. J- B. P. McLaren; Temp. Capt. J. W.
McLeod; Temp. Capt. K. C. Middlemiss; Temp. Capt. E. T. C.
Milligan; Temp. Capt. W. Moodie; Temp. Capt. (acting Lt.-Col.) H.
Moore, D.S.O., M.C. (died of wounds); Temp. Capt. J. Morris ; Temp.
Capt. (acting Maj.) W. G. Muraford; Maj. (acting Lt.-Col.) C. D.
Myles, O.B.E.
Temp. Capt. G. E. E. Nicholls.
Maj. (acting Lt.-Col.) E. M. O’Neill, D.S.O.
Temp. Capt. (acting Maj.) M. P. Paton, M.C.; Maj. (temp. Lt.-Col.)
H. 8. Peeke; Temp. Capt. E. I. P. Pellew; Capt. H. M. J. Perry;
Temp. Capt. H. J. Pickering; Temp. Capt. A. B. Pinniger ; Capt.
(acting Lt.-Col.) L. T. Poole, D.S.O., M.C.; Temp. Capt. A. V. Poyter;
Capt. (acting Lt.-Col.) R B. Price, D.S.O.
Temp. Capt. A. C. Reid; Temp. Capt. (acting Maj.) A. Richmond,
M. C.; Maj. M. B. H. Ritchie, D.S.O.; Temp. Capt. (acting Maj.) T. C.
Ritchie ; Temp. Capt. (acting Maj.) J. E. H. Roberta; Maj. (acting Lt.-
Col.) T. T. H. Robinson; T*»mp. Capt. (acting Maj.) R. B. Roe; Temp.
Capt. H. A. Ronn ; Temp. Capt. (acting Maj.) S. J. Rowntree.
Temp. Capt. S. H. Scott; Capt. (acting Lt -Col.) T. H. Scott, D.S.O.,
M.C.; Temp. Capt. (acting Maj.) E. J. Selby ; Temp. Capt. W. F.
Shanks; Lt. (temp. Capt.) F. R. S. Shaw, M.C.; Temp. Capt. (acting
Lt.-Col.) L. D. Shaw, D.S.O.; Temp. Capt. F. N. Stewart, D.S O.,
M.C.; Temp. Capt. J. L. Stewart, D.S.O., M.C.; Capt. (acting Lt.-Col.)
C. H. Stringer, D.S.O. ; Temp. Capt. C. E. Sundell; Temp. Capt.
(acting Lt.-Col.) R. Svensson, M.C.
Maj. (acting Lt-Col.) R. G. H. Tate; Capt. E. S. Taylor; Capt.
(acting Lt.-Col.' G. P. Taylor, D.S.O., M.C.; Temp. Capt. E. M.
Townsend ; Temp Lt.-Col. C. J. Trimble, C.B., C.M.G...V.D.
Maj. (acting Lt -Col.) T. B. Unwin.
Temp. Capt. (acting Maj.) R. J. Vernon.
Capt. and Bt. Maj. A. Walker, D.S.O.; Temp. Capt. K. M. Walker ;
Temp. Capt. H. H. Whaite; Maj. 0. F. White; Temp. Capt. R. W.
Willcocks; Temp. Capt. R. L. Williams, D.S.O., M.C.; Temp. Capt.
(acting Maj.) II. G. Willis, D.S.O., M.C.; Temp. Capt. (acting Mai.)
H. B. Wilson; Temp. Hon. Capt. W. Wilson ; Temp. Capt. (acting
Maj.) F.B.Winfield; Temp. Capt. R. S. Woods; Temp. Hon. Lt. H. W.
Woodward ; Capt. (acting Lt.-Col.) F. Worthington, D.S.O.
ROYAL ARMY MEDICAL CORPS (S.R.).
Capt. (acting Maj.) R. P. Ballard. M.C.; Capt. (acting Maj.) W.
Barclay, M.C.; Capt. (acting Maj.) J. H. Bayley, M.C.; Maj. W. H. G. H.
Beat; Capt. A. D. Child; Capt. W. Darling, M.C.; Capt. (acting Maj.)
D. Dougal, M.C. ; Capt. C. Gamble; Capt. (acting Maj.) C. B. H.
Gater; Capt. (acting Maj.) B. Goldsraitn; Capt. (acting Lt.-Col.)
C. J. A. Griffin ; Capt. G. G. Jack; Capt. A. R. Laurie ; Capt. (acting
Maj.) G. Marshall; Maj. (actingLt.-Col.) S. G. McAUum ; Capt. (acting
Lt.-Col.) W. McK. H. McCullagh, D.S.O., M.C.; Capt. (aoting Maj.)
W. C. B. Meyer; Capt. (acting Lt.-Col.) K. D. Murchison, D.S O.;
Capt. (acting Lt.-Col.) C. M. Page; Capt. (acting Lt.-Col.) A. T Pitts,
D. S.O.; Capt. (acting Maj.) H. D. Rollinson; Capt. B. S. Rowbotham ;
Capt. (acting Maj.) A. L. Shearwood ; Capt. (acting Maj.) J. C. Spence,
M.C. ; Capt. (acting Maj.) L. W. O. Taylor; Capt. (acting Lt.-Col.) W.
Tyrrell, D.S.O.,M.C.; Capt. (acting Maj.) W. W. Wagstaffe ; Capt. (acting
Lt.-Col.) J. H. Ward, D.S O., M.C. ; Capt. (acting Maj.) C. J. B. Way,
M.C.; Capt. C. O. J. Young, M.C.
ROYAL ARMY MEDICAL CORPS (T.F.).
Capt. (temp. Maj.) H. C. Adams; Capt. (acting Lt.-Col.) E. Alderson,
D.S.O.
Capt. (temp. Lt.-Col.) J. Barkley: Capt. (acting Maj.) C. B. Baxter;
Capt. (acting Lt.-Col.) W. Blackwood, D.S.O.; M*j. H. D’A. Blumherg,
T.D.; Capt. (acting Maj.) W. Briggs; Capt. A. 8. Bruzaud; Capt.
(acting Lt.-Col.) R. Burgess, M.C.; Capt. (acting Maj.) H. Burrows;
Capt. J. W. Burton.
Maj. (acting Lt.-Col.) A. Callam ; Capt. J. Chalmers ; Lt.-Col. W. K.
Clayton, T.D.; Capt. (acting Maj.) H. D. Clementi Smith ; Capt.
(acting Lt.-Col.) L. D. B. Cogan; Capt. (acting Lt.-Col.) J. M. A.
Costello, M.C.; Maj. (acting Lt.-Col.) E. H. Cox ; Capt. (temp. Lt.-
Col.) H. H. B. Cunningham.
Capt. (acting Maj.) J. Dale; Capt. (acting Lt.-Col.) H. K. Dawson,
D.S.O.; Capt. (acting Lt.-Col.) F. G. Dobson; Capt. (acting Maj.) H.
Drummond.
Capt. (temp. Lt -Col.) C. W. Barnes.
Capt. (acting M*j.) R. V. Favell; Capt. (acting Maj.) N. M. Fergusson ;
Capt. (acting Maj.) D. E. Finlay; Capt. N. S. Finzi ; Capt. (temp.
Maj.) M G. Foster ; Capt. (acting Lt.-Col.) J. H. P. FraBer, M.C. ; Capt.
(acting Maj.) W. D. Frew.
Maj. W. H. G lloway; Capt. N. Gebbie: Capt. (acting Maj.) J.
Graham ; Capt. (acting Lt.-Col.) F. L. A. Greaves.
Capt. (acting Major) T. W. Hancock; Capt. (acting Maj.) F.
Hauxwell; Maj. (temp. Lt.-Col.) A. R. Henchley, D.S.O.; Lt.-Col.
F. W. Higgs; Lt.-Col. (temp. Col.) C. H. Howkins, D.S.O.
Capt. J. Jackson; Capt. R. Jacobs (killed in action); Capt. A. E.
Jury.
Capt. (acting Maj.) N. W. Kidston.
Capt. (acting Lt.-Col.) C. L. Lauder, M.C.; Capt. H. Lightstone,
D.S.O., M.C. ; Capt. (acting Maj.) H. B. Low, M.C.
Capt. (temp. Lt.-Col.) J. MacMillan, M.C.; Capt. S. A. S. Malkin;
Capt. (acting Maj.) T. B. McKee ; Temp. Capt. (acting Maj.) A.
Meams ; Capt. (acting Maj.) W. H. Morrison ; Maj. A. R. Murray.
Capt. J. C. Newman.
Capt. H. D. Pickles, M.C.; Capt. (acting Maj.) H. B. Pope; Maj.
(temp. Lt.-Col.) T. P. Puddieombe, D.S.O.
Capt. J. Ramsay ; Capt. S. E. Rigg ; Maj. (temp. Lt.-Col.) H. B.
Roderick.
Capt. F. W. Schofield; Capt. (acting Lt.-Col.) D. J. Scott, M.C.;
Capt. (acting Lt.-Col.) H. Seddon ; Maj. (acting Lt.-Col.) J. H. Stephen ;
Maj. (temp. Lt.-Col.) W. G. Sutcliffe.
Capt. A. White; Maj. (acting Lt,.-Col.) G. F. Whyte; Maj. (acting
Lt.-Col.) P. G. Williamson, M.C.; Capt. (acting Lt.-Col.) T. B.
Wolstenholme.
Capt. (acting Lt.-Col.) J. Young.
CANADIAN ARMY MEDICAL CORPS.
Maj. (acting Lt.-Col.) W. A. G. Bauld ; Lt.-Col. R. A. Bowie; Lt.-
Col. E. R. Brown; Capt. M. G. Brown; Lt.-Col. P. G. Brown; Maj.
J. F. Burgess; Lt.-Col. S. Campbell: Capt. G. F. Den yes ; Lt.-Col,
A. S. Donaldson, D S.O. ; Hon. Capt. J. A. Dougan; Capt. (acting
Maj.) G. J. Gillam ; Capt. J. Graham; Capt. S. E. Holmes; Lt.-Col.
J. F. Kidd; Capt. W. J. MacKenzie ; Capt. T. A. Malloch; Lt. C. B.
Maxwell; Maj. R. J. McEwen; Maj. I). W. McKechnie, D.S.O.;
Lt.-Col. H. E. Munroe : Lt.-Col. T. J. F. Murphy, D.S.O.; Maj. H.
Orr; Maj S. G. Ross. D.S.O.. M.C.; Lt.-Col. E. Seaborn; Capt. A. H.
Veitch; Lt.-Col. C. W. Vipond; Capt. R. E. A. Weston; Capt. T.
Whitmore (died of wounds); Maj. (acting Lt.-Col.) J. H. Wood.
AUSTRALIAN ARMY MEDICAL CORPS.
Maj. A. W. H. a’Court; Maj. H. I. Carlile; Lt.-Col. R. W. Chambers ;
Maj. A. J. Collins, D.S.O., M.C.; Lt.-Col. W. E. L U. Crowther; Col-
J. A. Dick ; Lt.-Col. (temp. Col.) T. P. Dunhill; Maj. C. N. Finn ; Lt.-
Col. H. K. Fry, D.S.O.; Lt.-Col. A. H. Gibson ; Capt. A. J. de S.
Howard ; Lt.-Col. A. F. Jolley; Maj. F. D. H. B. Lawton ; Maj. (temp.
Lt.-Col.) F. N. Le Messurier, D.S.O. ; Maj. G. B. Lowe; Lt.-Col. G. W.
MacArtney; Maj. (temp. Lt.-Col.) A. F. Mac Lure; Lt.-Col. C. J.
Martin, F.R.S. ; Maj. A. McKillop; Maj. J. B. Metcalfe. D.S.O., M.C.
(died of wounds); Maj. C. Moriet; Maj. W. A. Morton ; Maj. J. D.
Norris ; Capt. S. V. O’Regan. M.C. ; Maj. V. W. Savage : Maj. W r . C.
Sawers; Maj. (temp. Lt.-Col.) V. O. Stacy; Maj. D. MacD. Steele, M.C. ;
Maj. R. St. C. Steuart; Maj L. G. Tassie, D.S.O.; Lt.-Col. W. G. D.
Upjohn ; Maj. F. L. Wall, M.C.; Lt.-Col. A. M. Wilson, D.S.O.
NEW ZEALAND MEDICAL CORPS.
Maj. F. T. Bowerbank; Lt.-Col. G. Craig; Maj, E. L. Marchant;
Col. D. J. McGavin, D.S.O. ; Lt.-Col. H. J. McLean ; Lt.-Col. D. N. W.
Murray, D.S.O.; Capt. Simcox.
SOUTH AFRICAN MEDICAL CORPS.
Capt. (acting Major) H. R. Mullins; Maj. M. S. Power, D.S.O.
AMERICAN MEDICAL CO KPS.
Lt.-Col. R. H. Harte, Harvard Unit; Maj. R. I. Lee. Harvard Unit.
OBITUARY OF THE WAR.
DENIS COTTERILL, M.B., Ch.B. Edin., F.R.C.S. Edik. ,
CAPTAIN, ROYAL ARMY MEDICAL CORPS.
Captain D. Cotterill, who died of pneumonia following
influenza on Dec. 2nd, at the age of 37 years, was eldest son
of Lieutenant-Colonel J. M. Cotterill, C.M.G., consulting
surgeon to Edinburgh Royal Infirmary. Educated at the
Edinburgh Academy, he went on to Christ’s College, Cam¬
bridge, where he spent two years in medical study. He
completed his curriculum
in Edinburgh, gaining
distinction in pathology
and surgery, and gradu¬
ated in 1906. In 1910
he was elected a Fellow
of the Royal College of
Surgeons, Edinburgh,
and took bis seat a3 a
Fellow during his father’s
occupancy of the pre¬
sidential chair. He was
house surgeon under the
late Professor Annan-
dale, and on the Con¬
tinent and in London
and Liverpool studied
surgery, especially in its
orthopedic aspects, in
which he intended to
specialise. On his return
to Edinburgh Captain Cotterill began practice as a surgeon,
acted as tutor in clinical surgery, and in 1913 was appointed
an assistant surgeon to the Royal Infirmary.
In November, 1914, he went to France and was attached
to No. 11 Stationary Hospital at Rouen, where he worked
for some time, maintaining a high standard of surgical
work. Later he resigned his appointment at Rouen, joined
The Lancet,]
OBITUARY.
[Jan. 4, 1919 43
the R.A.M.O., and was appointed to No. 50 Casualty Clearing
Station, where, during the early days of the great advance
and subsequent fighting, his unit was often working day
and night without cessation. Captain Cotterill married in
1908 Miss Emily Roberts, and leaves a widow and two sons.
HERBERT GEORGE FLAXMAN SPURRELL, M.A.,
M.B., B Ch. Oxf.,
CAPTAIN, ROYAL ARMY MEDICAL CORPS.
Captain H. G. F. Spurrell, who died of pneumonia at the
19th General Hospital, Alexandria, on Nov. 8th, at the age
of 41 years, was only son of the late Herbert Spurrell, of
Eastbourne. Educated at Merton College, Oxford, where he
gained the Welsh Memorial Prize in 1901 and took the M.A.
degree, he qualified in 1907 from the London Hospital,
taking the Diploma of the London School of Tropical Medicine
in 1912. He was then Assistant Professor of Physiology at
the University of New Orleans for a year, and held medical
appointments in West Africa and South America, where he
indulged a passion for
scientific research and
discovered several new
zoological species. One
of these was a new
species of West African
rodent, A nomaluru*
imperator , a type of
which he presented,
together with a number
of other rare and in¬
teresting West African
mammals, to the British
Museum. Whilst in
Colombia he continued
his zoological research,
and during the first
few months of his
stay in the Choco
brought together a
series of batrachians
and reptiles which
he presented also to the British Museum. A further
important series of these animals was collected and
presented by him in 1914, and in 1915 he discovered
and presented a new limbless reptile (Amphisbaena spurrelli)
and a new snake (Herpetodryas vioinus). In recog¬
nition of his work he was awarded the silver medal of
the Zoological 8ociety. On his return from Colombia in
1915 he was sent abroad by the Government on a secret
mission, and in 1916-17 acted as Temporary Medical Officer
at Obussi, S. Ashanti. In 1917 he took a commission in the
R.A.M.C. and was employed on the R.A.F. Medical Board
until his death. Besides his scientific monographs Captain
Spnrrell wrote a book on social evolution, entitled “ Modem
Man and His Forerunners,” and a popular work on
physiology. _
Major D. D. Jamieson, M . C., A.A.M.C., who met his
death as the result of an aeroplane accident which occurred
on July 18th, at the age of 39 years, was born at Kew,
Melbourne. Educated at Hawthorn Grammar School, he
paduated in medicine and surgery at Melbourne University
in 1905, and practised at Perth, Fremantle, and Laverton
Hospitals, and at Katoomba, N.S.W., and Stawell Hospital,
Victoria. He joined the A.I.F. in July, 1915, and served
for a short time in England before proceeding to Egypt. On
his arrival in 1916 he joined the 2nd Light Horse Field
Ambulance, and was awarded the Military Cross for gallantry
and devotion to duty in the field at the Bir-el-Abd battle in
September, and was mentioned in despatches. He acted
as adjutant and was with his Brigade during all its
operations in Sinai. In 1917 Major Jamieson was trans¬
ferred to the 8th Light Horse as R.M.O., and remained with
them until he proceeded to Port Said to await transport duty
to Australia, where he met with the accident which resulted
in his death. He was promoted to the rank of Major in
November. 1916. He was associated with the 2nd Brigade
und the 8th Light Horse Regiment in all the main engage¬
ments the Light Horse had undertaken since crossing the
Suez Canal.
NOTTIDGE CHARLES MACNAMARA, F.R.C.S. Eng.,
F.R.C.S. Irel.,
CONSULTING SURGEON TO THE WESTMINSTER HOSPITAL.
Mr. N. C. Macnamara, who died on Nov. 21st, after a
brief illness, at the advanced age of 86, retained to the end
his keen and penetrating interest in life He was a student
at King’s College, London, qualified with the Membership
of the Royal College of Surgeons of England in 1854, and
became almost immediately an assistant surgeon in the East
India Company’s service. On arrival in India he took charge
of the First Bengal Fusiliers and before he had been many
weeks at Dinapur was called upon to grapple with an
appalling outbreak of cholera with only a few coolies to help
him. Cholera remained for long a chief interest with him,
and his “History of Asiatic Cholera” went through several
editions and was translated into various languages. In the
following two years Macnamara served in the Sonthal
rebellion, and during the Indian Mutiny was officer of the
Tirhut Volunteers until he was placed by the Viceroy in
charge of the captive King of Oude. Later he became civil
surgeon of Mirzapur and professor of ophthalmic surgery in
the Calcutta Medical College. His ophthalmic work gained
him widespread recognition, and the natives on whom he
operated regarded him with veneration, while he was able
to carry out in the face of great difficulties the desire
of his heart to establish an ophthalmic hospital for
the native poor of Calcutta. In 1866 he published a
volume of lectures on Diseases of the Eye, of which a fifth
edition appeared in 1891, while the year in which he became
surgeon-major, 1873, was marked by the publication of
“Lectures on Diseases of Bones and Joints,” a third
edition of which appeared in 1887. For three years he was
editor of the Indian Medical Gazette.
In 1875 Macnamara obtained the F.R.C.S. Eng., and
retiring from the service in the following year was appointed
surgeon and lecturer on clinical surgery to the Westminster
Hospital and surgeon to the Royal Westminster Ophthalmic
Hospital, becoming consulting surgeon to both hospitals
on his retirement from active work in 1897. He was elected
a Fellow of the Royal College of Surgeons, Ireland, in 1887,
and from 1885 to 1901 he was a member of the Council of
the Royal College of Surgeons of England and Vice-President
in 1893 and 1896. He was the Bradshaw lecturer, 1895, on
Osteitis, and Hunterian orator in 1901, taking for his subject
the Human Skull in Relation to Brain Growth. As a
member of the British Medical Association he did much
useful work, being a member of Council, chairman of several
committees, Vice-President of the Section of Surgery at the
annual meetiDgs in 1881 and 1895, President of the Section
of Ophthalmology in 1891, and treasurer of the Association
from 1885 to 1887. He also took a keen interest in the work
of the Royal Medical and Chirurgical Society and played a
generous and active part in securing the house in Hanover-
square, which it occupied for several years.
In addition to his contributions to medical literature,
Mr. Macnamara wrote the articles on Cholera and Tetanus
for the first edition of Quain’s “ Dictionary of Medicine,”
and those on Cholera and Leprosy in Davidson’s “ Hygiene
and Diseases of Warm Climates,’’ while two volumes of the
• ‘ International Scientific Series, ” on the evolution of purposive
living matter, are from his pen. His latest published book,
“Instinct and Intelligence,” which we reviewed in these
columns at the beginning of 1916, was a plea for an altera¬
tion in our present system of education in which he sustained
the thesis that “The animal side of man’s nature results
from a specific arrangement of elements entering into the
formation of his central nervous system which he has
inherited from his progenitors and cannot, therefore, get rid
of or permanently alter.”
Macnamara was one to whom work was a delight, and his
numerous appointments did not prevent a considerable
literary activity. Both were an expression of an overflowing
physical energy. He revelled in outdoor exercise—hunting,
shooting, and later golf. With a great dislike for formal
entertaining he kept open house to all his friends. On
reaching his seventieth year he retired into the country at
Chorley Wood, ever continuing busy with the writing of
books. Mr. Macnamara married Mia, daughter of the
44 T«i La^obt.1
OBITUARY.
•Hon. Henry Vincent Bayley, and had two sons and six
daughters. His eldest son, Lieutenant-Colonel Carroll
3Iacnamara, was killed at the Battle of the Somme.
LEONARD GEORGE GUTHRIE, M.D., B.Ch.Oxon.,
F.R.C.P. Lond.,
PHYSICIAN, HOSPITAL FOR EPILEPSY AND PARALYSIS, M A IDA VALE, ETC.
The death of Dr. Leonard Guthrie, which occurred on the
morning of Dec. 24th last as the result of an accident the
previous evening, is an event which will bring deep sorrow
to many hearts. He was a man of an exceedingly fine
sensitive nature, with many friends and no enemies, and he
will be mourned alike by gentle and simple. He had reached
his sixty-first year, but he had no appearance of such age,
and his interest in his work and his recreations was
undimmed, and, indeed, had become keener as he advanced
in years. He was unmarried, but he lived with a brother to
whom he was devoted, and to whom all who know him will
. offer their keenest sympathy.
Leonard Guthrie was educated at King’s College School
and then proceeded to Magdalen College, Oxford, where he
-subsequently took his M.A and M.D. degrees. His medical
education he completed at St. Bartholomew’s Hospital. His
time there was not very congenial. The energetic and perhaps
somewhat boisterous medical student life was not suited
to his gentle and retiring nature, and it was only a few
years later that he really found his metier in clinical work,
which he could pursue in his own fashion. He became
connected with the Paddington Green Children’s Hospital,
first as house physician and then as physician, and at the time
of his death he was senior physician to that institution. His
work there was a constant pleasure to him, and no one will
ever know the innumerable acts of unostentatious kindness
which he showed to patients and staff alike. He was
for several years physician to the North-West London
Hospital, but he severed his connexion with that hospital
when it became amalgamated with the Hampstead Hospital.
He was also on the staff of the Hospital for Epilepsy
and Paralysis when it was in Regent’s Park, and he
remained connected with it when it moved to Maida Vale,
and had much to do with its reconstruction there. He
became senior physician there on the recent death of his
•colleague Dr. George Ogilvie, whose career is also made the
subject of notice this week. He also acted as consultant to
several other institutions, and during the war he was on
the staff of Lord Knulsford’s Hospitals for Neurasthenic
Officers. He had filled the office of President of the
Harveian Society and of the Section for the Study
of Disease in Children of the Royal Society of Medicine.
He had recently been assisting the Registrar of the
Royal College of Physicians of London—a duty which gave
him the keenest pleasure. His historical knowledge and
interests were such as to make such work as he was called
upon to do in this capacity extremely congenial, and there
is no doubt that the recognition of his ability and capacity
which the invitation to such labours implied was a great
gratification to one who, like Guthrie, was too modest and
too ready to undervalue his own abilities. He had only just
been appointed examiner in medicine to the University of
Oxford and was keenly anticipating a renewal of his
connexion with the University.
Dr. Guthrie's medical interests, as will be evident from
his appointments, were chiefly in children’s diseases and
nervous disorders. His main literary work, “ The Functional
Nervous Disorders of Childhood,” indicated this duality of
interests. It is a work of great ability inspired by sympathy
and keen observation, and written with a graceful literary
charm not too common in medical writings. He also con¬
tributed several articles to Garrod and Batten’s “Diseases
of Children ” and to Allbutt’s “ System of Medicine.” His
article on “Night Terrors” in that System is one of the
best known, and one of the most readable medical articles
that has ever been written. His FitzPatrick lectures at the
Royal College of Physicians of London on the History of
Medicine form a marvellous storehouse of medical history,
and it is to be regretted that they were never published in book
form. Like many others, he was deeply interested in the
medical history of Napoleon Bonaparte, and his article con¬
tributed to the International Medical Congress of 1913,
“Did Napoleon Bonaparte Suffer from Hypo-pituitarism
[Jan. 4, 1919
Towards the Close of His Life l ” is a careful examination of
the question, arriving, we feel, at convincing conclusions.
A good many years ago several series of “Hospital
Sketches” were published in the Pall Mall Gazette, and
subsequently appeared as a small volume. It is now known i
that Leonard Guthrie was the author of these, and all t
who have read them agree that no such true and accurate, i
and at the same time humorous, descriptions of out-patient
experience at a children’s hospital have ever been written.
It may well be said that all that Guthrie wrote was charac¬
terised by accurate and graphic observation, and was
pervaded by scholarliness and human interest. The man
was behind all that he wrote, but the man was much more
than anything he wrote. His was one of the most delightful
and lovable natures, full of sympathy which overflowed in
every direction. And yet he was so modest and unassuming
that he was almost ashamed to be discovered in any good
action. To his friends who all loved him, his loss is
irreparable; to those who were nearest and dearest to him
his death is no less than a calamity.
GEORGE OGILVIE, M B., C.M., B.Sc. Edin.,
F.R.C.P. Lond.,
SENIOR PHYSICIAN TO THE FRENCH HOSPITAL AND TO THE HOSPITAL
FOR EPILEPSY AND PARALYSIS. MAIDA VALE ; PHYSICIAN,
SPANISH EMBASSY.
Dr. George Ogilvie, who died on Saturday, Dec. 14th,
1918, after an illness of some weeks’ duration following an
accident, was born in 1852. He was educated at Hamilton
and at Edinburgh University, where he graduated B.Sc. in
Mathematical Sciences in 1875 and M.B., C.M. in the
following year. He was also “ Neill-Arnott ” prizeman.
After completing his medical education by taking courses at
Paris, Wurzburg, Vienna, and Florence, he started practice
as a physician in London. In 1881 he was appointed phy¬
sician to the Hospital for Epilepsy and Paralysis, Maida
Vale, and in 1889 to the French Hospital. He was senior
physician to both these institutions at the time of his death,
and it was in recognition of his services to the French
Hospital that he received the Order of Chevalier de la Legion
d’Honneur. For similar services he was created Knight, Order
de Isabel la Catolica, and Knight, Order of Nossa Senhora de
Villa ViQOsa by the Spanish and Portuguese Governments
respectively. In 1889 he became a Member of the Royal
College of Physicians, and in 1908 he was elected to the
Fellowship.
As a physician and neurologist he was sound, acute in
observation, and essentially practical in treatment. Perhaps
the most important of his contributions to medical literature
was a paper on the Exceptions to Colies’s Law (Med. Chir.
The Lanoet,]
THE PRACTICE OP THE ABSENTEE.
[Jan. 4, 1919 45
Trans., vol. lxxix.). Although the discovery of the Spiro-
ohata pallida and of the Wassermann reaction renders
Oolles’s law a matter of rather academic interest now, the
paper aroused considerable attention and discussion at the
time. Other papers of his on the Inheritance of Disease,
Los Descendants des Tuberculeux, Her^do-predisposition,
the Transmission of Syphilis to the Third Generation, show
the trend of his studies and investigations, and all are
characterised by the same clearness of thought, logical
sequence of ideas and conclusions, and, moreover, by
punctilious attention to literary style and composition.
He was a very well-read man, an ardent student of
Shakespeare, poetry, and general literature. An accurate
knowledge of the history of individuals and of countries
was thus acquired, while he had a curious topographical
sense, beiDg able to point out at once on the map the name
of any town or locality in the world, however obscure and
insignificant it might be. An accomplished linguist, he spoke
German fluently and French like a Frenchman, and he had
also a sound acquaintance with Spanish and Italian. His
reputation as a raconteur was early established, and in
pre-war days the entertainment at medical banquets
and functions never seemed complete without “some
of Ogilvie’s stories,” which, in his deep grave voice,
he told so effectively and humorously. A thoroughly
kind-hearted man, he never said an ill-natured word and
was ever ready to give help to any struggling or youthful
professional brethren. We have sketched a “citizen of the
world,” and such, with his bonhomie and unaffected
geniality, strong views, and fairness in argument, was
Ogilvie. His imposing presence seemed sometimes to
embarrass him, for he often made jocose remarks concern¬
ing it, but he was not unduly sensitive on the point, and he
thoroughly enjoyed a not altogether flattering presentment
of him in the pages of Punch.
Death has removed a familiar peraonage in medical circles,
one who was liked by all who knew him. and loved by many
friends. He married in 1893 Helen, daughter of the late
Surgeon-General John Houston, who survives him, and to
whom and other members of his family we tender our
sympathy and regret. _
C. S. HAWES, M.R.C.S. Eng.
Colin Sadler Hawes, M.R.O.S.Eug., who died after a
long illness on Dec. 15th, in bis forty-third year, was
educated at Haileybury and St. Bartholomew’s Hospital,
where he was proxime accestit for the Brackenbury scholar¬
ship and house surgeon. Qualifying in 1900, he went out
two years later to South Africa to take up an appoint¬
ment at the hospital at Grahamstown. It was here that
pulmonary tuberculosis became manifest, and the rest of
his life was spent in a brave and patient struggle against
his disability. For a time he acted as assistant at the
sanatorium at Nordrach-upon-Mendip, and after the out¬
break of war successively held appointments at St. Andrew’s
Hospital, Dolli8 Hill, and at the South African Hospital in
Richmond Park. A man with a genius for making friends,
and who, given health and strength, would have made a
mark in his profession, he has left an example of a struggle
against heavy odds borne with fortitude.
Sir William Bartlett Dalby, consulting aural
Burgeon to St. George’s Hospital, died on Deo. 29th last,
at Montagu-place, London, where he had resided since his
retirement.
Sir Ernest Tritton, the well-known financier, who
died on Dec. 28th last, after a short illness, was vice-
chairman of the Metropolitan Hospital Sunday Fund.
Home fob Men Disabled by the W t ar.—T he
Committee of the Royal Portsmouth Hospital have become
responsible for the management of a large house at
Purbrook Park, which under a scheme of the War Pensions
Committee is to be fitted up as a home for paraplegics and
convalescent discharged sailors and soldiers, it is hoped
that accommodation will be available before the end of the
present winter for 20 paraplegic cases and from 10 to 15 con¬
valescent cases. The number of Portsmouth men needing
treatment increases considerably. There are now no fewer
than 4365 disabled men upon the local register.
Cffrrespnhnre.
" And! alteram partem."
THE PRACTICE OF THE ABSENTEE.
To the Editor of The Lancet.
Sir, —The letter appearing under the above heading in
your issue of Dec. 28tb, 1918, shows that notwithstanding
the fairly wide distribution of information and the letter
written by Sir A. Pearce Gould after Sir Watson Cheyne’s
suggestion appeared, the objects and the existence of the
“War Emergency Fund” do not seem to be sufficiently
known. I beg leave, as treasurer of this Fund, to say that it
exists to provide as a free gift assistance to members of our
profession who have suffered financially owing to war service.
There is no question of loan. There is an impression among
some that the fact of having received help would become
known in their neighbourhood. Let me say that the means
taken to prevent this render such an occurrence prac¬
tically impossible. The facts are known to a small
committee in the first instance—often only the president,
secretary, and treasurer. Thenceforward the applicant is
represented by a number. Any information can be obtained
from the honorary secretary, 11, Chandos-street. Cavendish-
square, W. 1. We are prepared to consider applications at any
time, and hope no one will look upon this effort on the part
of their brethren as a charity. It is a recognition of the
sacrifices they have made in many ways, and we hope will
be accepted in this spirit and in no sense as a charity.
I am, Sir, yours faithfully,
Charters J. Symonds,
Deo. 31«t, 1918. Treasurer, War Emergency Fund.
To the Editor of The Lancet.
Sir,—F or some time past you have been publishing, at
intervals, letters written in a similar strain to that of “ Major,
R.A.M.O. (T.O.),” appearing in The Lancet of Dec. 28th,
1918. Here are a few choice extracts from his letter: “Sir
Watson Cheyne’s proposal to lend money to medical men
whose practices have been filched from them owing to their
absence at the front”; “These men have been as muob
injured by their professional brethren as their Belgian
colleagues have been by the Hun ” ; and “ It is now suggested
by Sir Watson Cheyne that some of the ill-gotten gains of the
medical pilferers should be advanced on loan at interest to-
their victims. ”
This is nice sort of language to use of the medical men
who have stayed at home and have overworked themselves
in looking after the patients of absentee doctors as well as
their own. I honestly believe that in the town to which 1
belong the medical men who have stayed at home have
loyally done their best to play the game and keep together
the practices of their absentee colleagues. It has, of course,
been impossible to keep the incomes from the absentees'
practices up to their former level, for no patient will send as
readily for a stranger as he would for his own doctor, and
therefore he has probably “ carried on ” on several occasions
when, had his own doctor been at home, he would have sent
for him. I am sorry to think it is true that many have
suffered as “Major” appears to have done, but that is no
justification for alluding to the home profession generally as
“medical pilferers.” It would be more fair to the men at
home if “Major,” or any other correspondent wishing to
write in the same strain, would sign his letter with his own
name, or give the town to which he belongs, or both. Then
perhaps something might be done. Many, besides myself,
resent extremely the tone of such letters as “Major’s,” and
would have expressed their resentment before, but that they
have had something else to do than write letters.
I am, Sir, yours faithfully,
Bolton, Dec. 2Sth, 1918. F. R. MALLETT.
PRIMITIVE AGENTS* IN TREATMENT.
To the Editor of The Lanobt.
Sir, —I was much interested in the leading article which
appeared under the above title in your issue of Deo. 21st.
I wish heartily to endorse the opinions expressed, since
from careful observation and personal direction of these
primitive agents I know that they are infinitely more
46 Thb Lancet,]
THE MEDICAL EXAMINATION OF AVIATION CANDIDATES.
[Jan. 4,1919
effective and less costly than other and more generally
accepted methods for the remedy of certain disabilities,
when intelligently applied. It is in the hope that serions
consideration will be given by the State to the adoption of
these means not merely for sailors and soldiers disabled in
this war bat for those engaged in other public or national
services of the future that I write this note. At a very
large command depot, of which I was appointed to the
medical charge, I found, on taking over, a great amount
of indoor treatment being done with not very satis¬
factory results, but on sweeping out much apparatus
and substituting outdoor physical training a striking
improvement followed. The system of open-air physical
training was therefore developed to its fullest extent, sup¬
plemented by hydro-therapy and massage for a small per¬
centage of cases. Dr. Frank Radcliffe, who contributed a
letter to The Lancet on the Value of Physical Treatment, 1
ably assisted me in this work and had charge of those men
requiring special or individual attention. The vast majority
of the men were dealt with in larger squads or classes under
special instructors who had been trained at the Army
Physical Training Schools at Winchester or Aldershot.
Graduated exercise has done an immense deal for tuber¬
culosis (the question of auto-inoculation apart), and I am
confident that, properly supervised, outdoor physical exercise
will refit a large number of men who, treated under other
conditions, would drift into a state of pauperism.
I am, Sir, yours faithfully,
J. H. P. Graham,
Manchester, Dec. 23rd, 1918. Lieutenant-Colonel, R.A.M.C. (S.B.).
THE MEDICAL EXAMINATION OF AVIATION
CANDIDATES.
To the Editor of The Lancet.
Sib,—I n your issue of Dec. 14th Dr. G. A. Sutherland
rightly says that a proper selection of men fit to fly cannot
be made unless the examiner is also fit to make a proper
selection. He then goes on to show how the examiner
should be trained in this work, laying down principles which
should act as a guide. With these excellent principles all
will agree ; the practical application of them, however,
on the part of the examiner is by no means easy.
It takes time to make an experienced assessor, able
to weigh one set of functions against another. The
beginner is apt to be over-cautious in estimating the
character of the pulse and in imagining cardio-vascular
debility. In certain men with large muscles it is difficult
to feel the radial pulse when the arm is raised, and it is
necessary to press deeply with the fingers. When raising
the arm to estimate the character of the pulse the elbow
must be bent to prevent the muscles becoming tense. These
are some of the practical points liable to be overlooked by
beginners.
Standards of aerial fitness must be adapted to the varying
conditions. At the beginning of the war it tfas thought
wonderful for an aeroplane to travel 60 miles an hour and to
rise to a height of 10,000 feet in half an hour. Now it is usual
for airmen to travel at three times that speed and to ascend
in one-sixth the time, and the end is not yet. Now, when
we subject the human body to such sudden changes in
oxygen pressure and temperature it is reasonable to devise
some test to decide whether a rapid ascent to a high altitude
can be tolerated. This is a question where physiology can
be usefully combined with clinical medicine. If a simple
test can be devised it should certainly be used. Amongst
the borderland cases we want evidence which will throw
light on the functional efficiency of the cardio-vascular and
nervous systems. Dr. Sutherland suggests that to stand the
candidate on one leg with his eyes shut for 15 seconds, to
observe whether his outstretched fingers are tremulous and
whether his knee-jerks are normal is sufficient evidence for
the examiner to go upon. These are all important points,
no doubt, but why not test also the cardio-respiratory centres
in the medulla ? This can be done thus :—
The candidate Is directed to expire so as to empty the chest and then
to take a deep Inspiration and blow through a tube so as to raise a
column of mercury to the height of 40 mm. and keep it there for 40 or
SO seoonds. Tne experiment may produce considerable embarrassment,
with marked flushing of the race, and when asked to describe his
sensations the candidate will often say that he felt a •* bursting In the
head ” or that ** he felt giddy." This may be termed an abnormal answer.
i The Lancet, 1918,11., 880.
On the other hand, a youth who has good nervous control and a good
cardio-vascular system will hold his breath against 40 mm. Bg pressure,
with little or no discomfort for the same period, and his answer wlH be
that be “ wanted to breathe” or he “ wanted more air a normal answer.
During the holding of the breath the pulse-rate In the two cases varies:
In the normal boy the rate will increase from 20-30 beats per minute
and stay there until the end of the experiment, whilst in the abnormal
case the rate will increase by 60 or more beats per minute, and before
the end of the experiment it will drop to a rate lower than at the com¬
mencement. I have watched the manometer te«t in a great variety of
cases, and I feel sure that It has Its value and should form part of our
examination, because It affords evidence of the stability of nerve
centres which cannot be elicited in any other way; but, of ooum, It
should never take the place of a thorough physical examination.
The Medical Research Committee have published some
statistics on this subject which show that successful pilots
who are fit can pass this test, whilst those who are “ stale ”
or who have suffered from crashes cannot. More work is, no
doubt, required before the test can be generally accepted,
but at this early stage in the problems of flight we must try
to keep our minds open with regard to the tests for flying
men.
A number of chamber experiments have been carried out
on men who have suffered from faintness or other flying
disabilities at certain heights. The conditions prevailing at
these varying heights, such as pressure and lack of oxygen,
have been reproduced, and it is remarkable how the same
symptoms appear again at approximately the same heights.
These results seen to me to be too suggestive to be passed
over in silence.—I am, Sir, yours faithfully,
H. Ronald Carter,
Temp. Oapt. K.A.F.; late Member, Aviation Candidates
Dec. 17th, 1918. Medical Board.
ADVANCES IN THE TREATMENT OF
FRACTURES.
To the Editor of The Lancet.
Sir, —In their letters in The Lancet of Dec. 14th and
21st Dr. R. Soot Skirving and Sir W. Arbuthnot Lane
have brought to notice again the great importance of Major
M. Sinclair’s work on the treatment of fractures. The
military surgeon has found the methods he has advocated
of the greatest value, and a large sum of money in pensions
has been saved by their adoption. No other method of
splinting can compare with Major Sinclair’s for immobilising
the parts, extending fractures, and at the same time
allowing of easy access for dressing the wound. On his net
frame cases that would be otherwise a perfect nightmare to
sisters become quite easy to dress and nurse, and the
patient ceases to live in constant dread of the next dressing,
or drawing of his sheet. By fitting the patient’s boot on to
a Thomas’s splint a cheap and easily obtained ambulatory
splint is produced which allows the limb to be used and
greatly improves its nutrition. One can scarcely enter any
ward without seeing some patients being treated by one or
other of Major Sinclair’s original methods of extension.
We are. Sir, yours faithfully,
James Taylor, Major, R.A.M.C.,
District Consulting Surgeon, Aldershot Command ;
W. S. Edmond, Major, R.A.M.C.,
Dec. 23rd, 1918. Surgeon 1 c Division, Cambridge Hospital.
THE CAUSES AND INCIDENCE OF DENTAL
CARIES.
To the Editor of The Lancet.
Sir, —For upwards of 20 years I have on several occasions
insisted that the appalling prevalence of dental caries and
“adenoids” in this country is due to remedial dietetic
causes. It was therefore with great interest that I read
Major W. E. Niokolls Dunn’s letter in your issue of Dec. 21st,
calling attention to this matter. I have again aud again
referred to the prosaic fact that there are among the
inhabitants of this country some 200 million carious teeth,
as many alveolar abscesses (pyorrhoea alveolaris), and some
30 million root abscesses—for the most part preventable by
the simplest possible means. Well may Major Dunn exclaim
that it (< i8 impossible to exaggerate the state of the teeth
in this country.” It constitutes, indeed, a national disgrace.
Dr. Sim Wallace has time after time debated this matter
with me, and we have long felt that the remedy can only
come through the medioal profession.
Three great problems confront the Ministry of Health—
the problems of food, housing, and venereal diseases—all,
I believe, capable of solution by the application of common
48 The Lanobt.]
MEDICAL NEWS.
[Jan. 4,1919
THE LANCET, VOL. II., 1918: THE INDEX.
The Index and Title-page to the volume of
The Lancet which was completed with the issue
of Dec. 28tb, 1918, is in preparation. Owing to the
continued shortage in the paper-supply, the Index
will not be issued with all copies of The Lancet,
as was the custom prior to the War. Subscribers
who bind up their numbers are requested to send
a post-card (which is more convenient for filing
purposes than a letter) to the Manager, The Lancet
Office, 423, Strand, London, W.C. 2, when a copy of the
Index and Title-page will be supplied free of charge.
HUfaital JJMm.
Society of Apothecaries of London.—A t
examinations held recently the following candidates passed
in the subjects indicated:—
Surgery.— T. A. Jordan (Sects. I. and II.), Manchester; J. E. Nicole
(Sects. I. and II.), Westminster Hoep.; S. H. Robinson (Sect. I.),
Guy's Hosp.; G. E. Spero (Scot. II.), London Hosp.; and 0. de B.
Thomson (Sect. I.), Middlesex Hosp.
Medicine.— T. A. Jordan (Sect. II.), Manchester; F. W. Kemp
(Sect. II.), Charing Cross Hosp.; and J. B. Nicole (Scot. II.),
Westminster Hosp.
Forensic Medicine.—Vi. S. Hughes, Charing Cross Hosp.'; J.
Kershaw, Manchester; and S. Robinson, St. Thomas's Hosp.
Midwifery. —J. Kershaw, Manchester.
The Diploma of the Society was granted to the following candidates,
•entitling them to practise medicine, surgery, and midwifery: T. A.
Jordan, J. B. Nicole, and S. Robinson.
University of Dublin, Trinity College, School
of Physic.—A t examinations held recently the following
candidates were successfnl :—
Final Medical Examination.
Part /., Materia Medica and Therapeutics, Jurisprudence and
Hygiene, Pathology.— Leonard Abrahamson. Robert Dormer,
Salmon Louis Feldman, William Bernard Joseph Pemberton.
Maurice Nuroclr, Johannes Marthtnus Benjamin de Wet, Wonter
De Vos Scholtz, Johannes Phllllppus de Villiers, Doris Louisa
Graham, Joseph Ballantyne Maguire, and Elsie Anna Burns.
Materia Medica and Therapeutics , Jurisprudence and Hygiene only.—
Percival Israel Levitt.
Pathology ( in completion).— Gerald FltzMaurice Keatinge and Samuel
Reginald Hill.
Part II. % Medicine (If./?.).—William Phllp Biford, Thomas*Mulock-
Bentiey, Robert Bevan Nangle Smartt, Herbert Stratford Collios,
William Alfred Shannon, Becher FitzJames Haytbornthwaite,
Cecil Joseph Quinlan, James Bdward Jameson, Frederick John
Dymoke, Bthel Marjorie Luce, and Johannes Tobias Mynhardt.
Surgery (B.Ch.).— John Henry Coolican, William Phtlp El ford,
William Sweetraan, Louis John Patrick Murphy, William Alfred
Shannon, Alewyn Johannes Vorster, Eric Reginald Tivy, Kenneth
MacGregor Grew, Bthel Marjorie Luoe, and Eric James Lyndon.
Midvnfery (B. A.O.).— Victor Millington Synge, Henry Blundell Van
der Merwe, Gertrude Rice, John Charles Joseph Callanan,
Alfred Leopold Wilson, Johannes Tobias Mynhardt, Albert Hugh
Thompson, Louis John Patrick Murphy, William Joseph Hogan,
Richard William Shaw, William Andrew Byrn, James Sinclair Quin,
•Gerald Fit/.Maurloe Keatinge, Samuel John Laverty, Thomas
James Russell Warren, and Cecil Joseph Quinlan.
Diploma in Public Health.
Part Bacteriology, Pathology , Chemistry , Physics , and Meteorology.
—John Spearee, Alexander Hugh Blaxell Pearce, Joseph Warwick
Bigger, and Harold Sauuderson Sugars.
Partll ., Sanitary Engineering , Vital Statistics and Public Health ,
Hygiene , and Epidemiology. — Joseph Warwick Bigger, Edgar
Ormond Bowie, James Beckett, Alexander Kirkpatrick Oosgrave,
and Alexander Hugh Blaxell Pearce.
At the meeting of the Society for the Study of
Inebriety, to be held in the rooms of the Medical Society
of London, II, Cbandos-street, Cavendish-square, W., on
Tuesday, Jan. 14th, at 4 p.m., Lord d’Abernon will deliver an
address on the Scientific Basis of Drink Control.
New Regulations for ’the Supply of Cream.—
With a view to relieving in some measure the present
shortage of milk, the Food Controller has issued a new
Order, the Cream Order, 1918, which places further restric¬
tions on the supply of cream. The Order will come into
force on Monday next, Jan. 6th, and will farther restrict the
sale of cream. Cream for children under 5 will be limited
to a maximum of half a pint per week. To obtain cream for
such children applications should be made to the local
Food Committee for a permit, which should be lodged with
the retailer. In the case of invalids, permits for cream may
be granted as an alternative to butter and margarine. These
will be granted by the Food Committee on a medical certifi¬
cate in the case of invalids suffering from certain specified
diseases. Applications in respect of invalids suffering from
other diseases must be submitted by the Food Committee
for special authorisation from the Medical Section of the
Ministry of Food. Snch applications must be accompanied
by a medical certificate giving specific reasons why oream is
recommended. Directions as to oases in whioh applications
for cream may be entertained by the Food Committees are
being furnished to medical practitioners for their gnidanoe.
Applications in respeot of inmates of institutions must be
made by the head of the institution on their behalf, and all
existing authorities for cream in the hands of consumers
and retailers will cease to be valid and fresh applications
will have to be made.
Sir Robert Armstrong-Jones will deliver the
Gresham lectures on Physio at Gresham College on Tuesday,
Wednesday, Thursday, and Friday, Jan. 14th to 17tb, each
day at 6 o'clock. On the first day (Tuesday) the subject of
the lecture will be “ Heredity,“ with special application to
mental and nervous diseases ; Wednesday, “ Alcohol: its Use
and Abuse"; Thursday, “Venereal Diseases: their Conse¬
quences and their Control"; Friday, “Influenza and its
Results, especially in regard to the measures taken to
combat its spread.
Metropolitan Asylums Board : Diploma in
Public Health.— A course of lectures and demonstrations
in hospital administration, extending over three months,
will be given at the Western Hospital, Seagrave-road,
Fulham, London, S.W., by Dr. R. M. Bruce, medical super¬
intendent, on Tuesdays and Fridays, at 5 p.m., beginning
Tuesday, Jan. 7th. The fee for the course is £33#., payable
to the Clerk to the Metropolitan Asylums Board, Embank¬
ment, London, E.C. 4.
The Royal Institute of Public Health.—I n
connexion with the work of the Venereal Diseases Depart¬
ment of the above institute a special conference will be held
on Wednesday next, Jan. 8th, at 4 p.m.. when Professor
J. G. Adami, M.D., F.R.8., Colonel, C.A.M.C., will open a
discussion on the Prevention and Arrest of Venereal Disease
in the Army. The chair will be taken by Lord Sydenham,
and amongst those who will take part in the discussion are :
Dr. Mary Scharlieb, Colonel M. A. De Laney, Liaison
Officer, U.8. Army; Colonel William F. 8now, M.C.,
U.S.A.; Lieutenant-Colonel George Walker, M.C., (J.3.A.;
Colonel Hugh H. Young, Chief of the Division of Urology,
American Expeditionary Force; Lieutenant-Colonel L. W.
Harrison, D.S.O., medical officer in charge, Rochester Row
Military Hospital.
Central Midwives Board.—A special meeting of
the Central Midwives Board was hela at Queen Anne’s
Gate Buildings, Westminster, on Dec. 19th, with Sir Francis
H. Champneys in the chair. A midwife was struok off the
Roll, the following charges amongst others having been
brought forward
Neglecting to wash the patient, ax required by Rule B.8, at any
time after the day of the confinement; neglecting to take and record
the pulse and temperature of the patient at each visit, as required by
Buie E. 14 ; entering on her records false statements of the pulse and
temperature of the patent; neglecting to wash the patient on the
termination of the labour, as required by Rule E. 8f; neglecting to
remove the soiled linen, Ac., used at the confinement from the
neighbourhood of the patient, as required by Rule B. 11; and
endeavouring to persuade the patient to give to the officers of the
local supervising authority false Information regarding the number
of her visits and her compliance with Rule B. 14. That when attend¬
ing her patients the midwife did not on each occasion wear a clean
dress of washable material, as required by Rule B. 2, and ahe
neglected to afford to the Inspector of midwives of the local
supervising authority reasonable facilities for an Inspection of her
methods of practice, and more particularly she was guilty of obstruct¬
ing the inspector in carrying out such inspection.
At a meeting held on Dec. 19th a letter was considered
from the chairman of the Standing Committee of the
County Nursing Associations of the Queen Victoria’s Jubilee
Institute for Nurses asking the Board to hold more frequent
examinations in London. The Board decided that the reply
be that the Board is unable to see its way to comply with
the request of the Standing Committee of the County
Nursing Associations of the Queen Victoria’s Jubilee
Institute for Nurses.—A letter was considered from Dr.
Herbert Williamson, physician-accoucheur, St. Bartholo¬
mew’s Hospital, with reference to the admission to the
Board’s examination of a nurse of Danish nationality. The
Board directed that Dr. Williamson be informed that, having
regard to the Board’s resolution on the subject, the Board
regrets its inability to make an exception in any particular
case.—The Board having considered draft rules requiring a
midwife to notify the local supervising authority when she
has advised artificial feeding, decided that the rales as
amended be approved, subjeot to the approval of the Privy
Council.—The Board having considered draft rules regu¬
lating the payment of expenses incurred by members in
respect of their attendance at meetings of the Board, decided
that the rules as amended be approved, subject to approval
by the Privy Council.—The Board having considered draft
rules deciding the conditions under which midwives may be
suspended from practice in penal oases by (a) the Board,
(b) the local supervising authority, decided that the rules be
approved, subject to approval by the Privy Council.
The Lancet.]
APPOINTMENTS.—VA0ANCIK8 -BIRTHS, ETC.—MEDICAL DIARY. [Jan. 4, 1919 4^
Low, V. WiBRp, C.B , has been appointed a Member of the Court of
Examiners of the Royal College of Surgeon* of Bngland.
Maks mo, Thomas Davra, M.B., B.S. Lond., L.B.O.P. Lond., M.R.C.S.,
Medical Officer for the Weymouth District.
The following have been appointed Surgeons under the Factory and
Workshop Acts: Wade, N. N., M.D. Edin. (Rises District of
Monmouth) ; Hull, G. B. t L.A.H.Dub. (Rogeratone District of
Monmouth); Robertson. J. M.. M.B.. C.M. Gla*g. (Biggar District
of Lanark); Rees, M. W., L.R.C.P. & S. Bdin. (Llanfair Caereinion
District of Montgomery.
Itaitries.
For further information refer to the advertisement columns.
Aberystwyth Infirmary Cardiganshire General Ho*pital. —H.S. £200.
Aylesbury. Hacks County Asylum.— Asst. M.O. £360.
Bedford County Hospital. — H.S.
Birmingham General Dispensary.—Res. M.O. £360.
Bolingbroke Hospital, Wandsworth Common, S. U r .— Res. M.O. £200.
Bradford Royal Infirmary. - H.S.
Bristol General Hospital.— Sen. H.S. £3C0.
Chichester , Royal West Sussex Hospital.—H.S. £160.
Edinburgh, Venereal Disease* Scheme.— Female Asst. M.O. £400.
Elizabeth Garrett Anderson Hospital, Eus.on-road. X. IP.—Female
Obst. Asst. £50.
Exeter City Mental Hospital, Digbys, near Exeter.—Asst. M.O. £300.
Glamorgan County Asylum, Bridgend.— Temp. Asst. M.O. £66 s. per wk.
Greenock Corporation .—Female Med. Prac. £350.
Gnildjord, Royal Surrey County Hospital— H.S. £250.
HeUingly, Sussex, East Sussex County Asylum.— Temp. Asst. M.O.
7 gs. per week.
Hospital for Sick Children, Great Ormond-slrrel, London.— H.S. £100.
Huddersfield County Borough Education Authority,— Asst. School
M.O. £350.
London Homoeopathic Hospital, G reat Ormond street and Queen-sauare,
W.C. —U.M.O. £80.
Manehe-ter, Ancoats Hospital , Mill-street.— Hon. P.
Manchester Royal Infirmary and Dispensary.— Hon. Asst. Gyn. S.
Margate, Royal Sea Bathing Hospital for Surgical Tuberculosis. -S.
Xational Hospital for Disemes of the Heart.— Non-Res. M.O.
National Orthopedic Hospital.— Res. H.S. £100.
Xoncich. Xorfnlk and Xorwich Hospital.— H.P. £250.
Hymouth, South Devon and East Cornwall Hospital.— H.S. £250.
Putney Hospital, Lower Common, S. IF.—Res. M.O. £160.
Rochdale Infirmary and Dispensary.— Jun. H.S. £100.
Rijtherham Hospital.— Sen. H.S. £250,
Royal Free Hospital, Grays Inn-road. \V.< '.—Sen. Res. M.O. £200.
■ v f. Mark's Hospital for Cancer, Fistula, and Other Diseases of the
Rectum, Ciiy-roaa, London, E.C.— H.S. £250.
Shrewsbury County Asylum.— Two Locum Tenentes. 7 ga. per week.
ScutAampton Free Eye Hospital.— Asst. Oph. Surg. £100.
Westmorland Sanatorium, Meathop, Grange-over-Sands.— Asst. M.O.
£300.
Wjatehaven and West Cumberland Infirmary.—Res. H.S. £150 to £180.
Wolverhampton and Staffordshire General Hospital .—Senior Student
as Assistant. Also Res. M.O. £200. Also H.S. £200.
The Chief Inspector of Factories, Home Office, S.W., gives notice of
vacancies for Certifying Surgeons under the Factory and Workshop
Acta at Rochdale, Lancs; and at Shrewsbury, Shropshire.
The Home Secretary gives notice of a vacancy for a Medical Referee
under the Workmen's Compensation Act, 1906, for the Alfreton,
Buxton. Cbapel-en-le Frith and New Mills, and Chesterfield
County Courts in Circuit No. 19. Applications should be addressed
to the Private Secretary, Home Office, London, 8.W., not later than
Jan. 15th, 1919.
Sirius, gtarriagfs, rob geatjjs.
BIRTHS
Haece.—O n Deo. 23rd, 1918, at Bombay, India, Catherine (u# Leonard),
the wife of Major J. Bennett Hance, I.M.S., of a daughter.
MARRIAGES.
Gibboh—Fletcher.— On Dec. 28th, 1918, at the Parish Church.
Standish. Lancashire, Major Richard B. Gibson, O.B.B., R.A.M.C.,
to Daphne Margaret, youngest daughter of the late Ven. R. O.
Fletcher, Archdeacon of Blackburn, Rector of Choriey.
DEATHS.
Bennett. —On Dec. 28tb, 1918, at Paignton, suddenly, Lawrence H.
Bennett, M.B. Oxon.
Guthrie.— On Dec. 24th, 1918, from Injuries received in an accident,
Leonard George Guthrie. M.A.. D.M.Oxon., F.R.C.P., Upper
Berkelcy-street, Portman-squarc, W., in his 61st year.
Shelmerdinb.— On Dec. 29th, 1918. at Torleigh, St Mary Church,
Herbert Shelmerdlne, M.B., In his 59th year.
To beer. —On Deo. 24th, 1918, instantaneously, the result of a lift
accident, Douglas Hamilton, younger son of Captain William
Turner, R.A.M.C.T., M.S., F.R.C.S., of 92, Harley street, W.l,
aged 8 yean 10 months.
M.S.—A fee of 5 b. is charged for the insertion of Notices of Births ,
Marriages, and Deaths.
JRtbical $kr2 fur % trailing 8&ttL
SOCIETIES.
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-atreet, W.l.
MEETINGS OF SECTIONS .
Thursday, Jan. 9th.
NEUROLOGY (Hon. Secretaries—C. M. Hinds Howell, B. G. Fearn-
sides): at 8.30 p.m.
Papers :
Captain T. A. Ross: Interrelations of Peace and War Neuroses.
Lieut -Colonel A. F. Hurst and Major Symns: Hysterical Element
in Organio Nervous Injuries and Diseases (with cinematographic
demonstration).
Friday, Jan. 10th.
EPIDBMIOLOGY AND STATE MBDICINB (Hon. Secretaries-
Willlam Butler, M. Greenwood): at 5.30 p.m.
Paper:
Lieut.-Colonel Martin Flack, B.A.F.: Some Simple Tests for
Physical Efficiency.
Those Members of the Section who desire to dine after the
Meeting are requested to send in their names to Captain Green¬
wood, 7, Northumberland-street, W.C. 2, not later than Jan. 8tb.
The Royal Society of Medicine keeps open house for
B.A.M.C. men and M.O.’s of the Dominions and Allies. The
principal hospitals in the metropolis admit medical officers
to their operations lectures. Ac. Particulars on application,
to the Secretary at 1, Wimpole-atreet, London, W.l.
RONTGBN SOCIETY, at the Royal Society of Arts, 18, John street.
Strand, W.C.
Tuesday, Jan. 7th.—8.15 p.m., General Meeting. Paper: Dr. H. S.
Allen: Electrical Cbanges produced by Light.
LECTURES, ADDRESSES, DEMONSTRATIONS, Ac.
POST-GRADUATB COLLEGE, West London Hospital, Hammersmith-
road, W.
Clinics each week-day at 2 p.m., Wednesday, Friday and Saturday
also at 10 a.m.
(Details of Post-Graduate Course were given In issue of Nov. 30th, 1918.>
Communications, Letters, Ac., to the Editor have
been received from—
A. —Dr. D. E. Anderson, Lond.;
Sir R. Armstrong-Jones, Lond.;
Messrs. Abdulla and Co., Lond.;
Col. J. G. Adami, A.D.M.S.;
Mr. J. H. Allan, Liverpool; Major
T. M. Allison, R.A.M.C.(T)
B. —Dr. F. J. H. Bateman, Lond.;
Dr. J. Brownlee, Lond.; Prof.
W. M. Bayliss, Lond.; Dr. J. W.
Bigger, Sheffield; Mr. W. H.
Bowen, Cambridge; Dr. A. G.
Bateman, Lond.
C. — Lt.-Col. J. M. Ootterill, C.M.G.,
R.A.M.O.; Capt. A. B. Chisholm,
R.A.M.Cl; Chicago 8chool of
Sanitary Instruction; Canadian
War Records, Lond., Offlcer-ln-
Charge.
D. -Lt.-Col. J. F. Donegan, O.B.,
R.A.M.C.; Dr. Y. Dickinson,
Lond.; Capt. F. Dillon, R.A.M.O.
B.—Mr. W. H. Bvans, Lond.; Capt.
Bagleton.
F. —Factories, Chief Inspector of,
Lond.; Dr. J. J. L. Ferris,
Bsguley; Capt. W. Fletcher,
R.A.M.C.; Capt. A. Fleming,
R.A.M.C.; Col. N. Faichnle,
AMS
G. —Capt. J. Geqghegan, B.A.M.C.;
Lieut. J. H. P. Graham,
B.A.M.C.(S.R.); Mr. W. Glenis-
ter, Aylesbury.
H. —Dr. J. Hodsdon, Edinburgh;
Capt. C. W. Hutt, R.A.M.C.;
Capt. J. A. Had held, R.A.M.C.;
Prof. P. Hobday; Mr. P. B.
Hoeber, New York; Mrs. B.
Hancock, Lond.; Mr. D. Harmer,
Lond.; Capt. A. Harwood.
I —Dr. S. T. Irwin. Belfast.
K. —Dr. T. N. Kelynack, Lond.;
Mias G. Keith, Lond.; Dr. A. M.
Kennedy, Glasgow.
L. —Local Government Board,
Lond.; Mr. B. M. Little. Lond.;
Mr. B. Lee, Blackrock; Dr. O. B.
Lea, Frimley.
M. —Mr. J. B. Macalpine, Man¬
chester; Mr. D. O. McMurtrle,
New York; Ministry of Food.
Lond.; Metropolitan Asylums
Board, Lond., Clerk to the; Lt.-
Ool. C. S. Myers, R.A.M.C.; Dr.
| F. R. Mallett, Bolton; Miss D.
Macnamara, Rickmans worth ;
I Dr. R. MacLelland, Matlock;
j Medical Officers of Schools Also
| elation, Lond., Hon. Sec. of.
N. — Newspaper Proprietors Asso¬
ciation, Lond.; National Pood-
Reform Association, Lond.
O. —Rev. B. G. O'Donoghue, Lond.;.
Mr. H. O. Orrin, Lond.; Dr. S. A.
Owen, Bpsom; Dr. W. J.
O’Donovan, Lond.; Dr. H. B.
Overy, Lond.
P. —The Pastel Society, Lond.;
Major M. G. Pearson, S.A.M.C.;
Capt. H. Platt, B.A.M.C.(T.);
Mr. L. Paton, Lond.; Mr. C. B.
Price, Orpington; Mr. D’Arcy
Power, Lond.; Dr. H. R. Pren¬
tice, Lond.
R.—Mrs. M. F. Rogers, Mussel¬
burgh ; Royal Institution of
Great Britain, Lond.: Dr. J.
Reid, Lond.; Dr. C. 8. Redmond,
Manchester; Rontgen Society,
Lond.; Lt.-Col. J. W. F. Rait,
I. M.S.; Red Cross News Bureau,.
Lond.; Mr. P. B. Roth, Lond.
8.—Dr. A. G. Shera, Netley; Col.
A. B. Soltau, C.M.G., A.M.S.;
Dr. H. Sutherland. Tain; Society
for the 8tudy of Inebriety. Lond.;
Society de Biologle, Paris; Mrs.
A. H. Smith ; Dr. B. I. Spriggs,
Banff; Mr. H. M. Savery, Bud-
leigh Salterton; Mrs. H. R.
Spurred, Lond.; Society of
Apothecaries of London; Dr.
J. H. Sequeira, Lond.; Mr. J. F.
Stuart, Bournemouth; Mr. C.
Smith, Sheffield.
T.-Major J. Taylor, R.A.M.C.;
Dr. J. Taylor, Lond.
V. -Dr. F. Villy, Keighley.
W. —Dr. W. Watson, Glasgow;
Major W. J. Wils >n, R.AJ1.C.;
Sir William Whltla, Belfast; Dr.
F. G. Wallace, Lond.; Dr. F. J.
Waldo, Lond.; West London
Hospital Post-Graduate College,
Lond.; Mr. B. H. Worth, Lond.;
Mr. A. Watson, Banff; War
Emergency Fund, Lond., Trea¬
surer of.
Y.-Mr. B. Yeates.
Communications relating to editorial business should be
addressed exclusively to The Editor of The Lancet,
423* Strand, London, W.C. 2
50 ThbLanobt,] NOTK8, 8HOET OOMMBNTS, AND ANSWERS TO CORRESPONDENTS.
[Jan. 4.1919
Jjtofrs, j5ftorf Cffmmmts, anfe g,itskrs
to (Jffmsponhnts.
HOSPITALS AND DISPENSARIES IN INDIA, 1917-18.
In the United Provinces there was a severe visitation of
plague, which in the epidemic year reckoned from July 1st,
1917, to June 30th, 1918, caused 173,881 deaths, nearly double
the mortality of the preceding year, and greater than in any
year since 1910-11; it reached its maximum in March
{41,759 deaths), and then rapidly decreased, the June deaths
numbering only 566. Rat destruction gave very satisfactory
results, and evacuation of infected villages is increasing
in popularity with the inhabitants. Colonel C. Mactaggart,
C.I.E., I.M.S., refers to the good work done by the Lucknow
Anti-tuberculosis League by means of magic lantern
lectures, pictorial posters, and distribution of pamphlets
on the subject.among the clerical establishments in various
offices.
In the report on hospitals and dispensaries in Burma
Colonel P. C. H. Strickland, I.M.8., refers to the difference
in small-pox mortality among vaccinated and unvaccinated
persons; 3 out of 126 vaccinated cases were fatal, while out
of 71 unvaccinated cases 16 were fatal, the respective per¬
centages being 2*38 and 22*5. Ten dispensaries had to be
closed on account of the war.
In the North-West Frontier Province a total of 12,650
patients were treated in hospital, showing a decrease of
235 on the preceding year, four dispensaries and two hospitals
having been closed, though, on the other band, three new
hospitals have been opened. It is remarked by Lieutenant-
Colonel T. W. Irvine, I.M.8., the chief medical officer of the
rovince, that “the total number of in-patients is always
isappointing, and has been remarked on repeatedly.”
Accommodation is provided for 901 patients, but the average
daily number under treatment was only 435. Lieutenant-
Colonel Irvine considers that this shows that “ the public
not only doubt the skill of the medical staff, but have other
and good reasons for not availing themselves to a much
greater degree of this accommodation.” Such a statement
appears to require explanation.
THE TREATMENT OF SCURVY.
To the Editor of The Lancet.
Sib,—I n your issue of Dec. 21st last Dr. Muir Evans
quotes a prescription, published in 1676, for making
medicated beer, which includes horse radish and scurvy-
grass. The same use of horse-radish was recommended still
earlier by Dr. John Woodall in “The Surgeon’s Mate”
{published in 1617), where he Bays that “Horse-radish
sauce alone, or mixed with beer, is exceeding good.” Dr.
Woodall suggests also using herbs, including Bcurvy-grass
and sorrel, in new milk or whey. There is an early tribute
to the usefulness of scurvy-grass in the account by Gerrit de
Veer of the voyages of Wiilem Barentz (1594-97).
“ There to our great good we went on land, for In that Island we
found great store of leple leaves (Icpelbladeren, spoon wort or scurvy-
grass, Cochlearia officinalis) which served us exceeding well; and it
seemed that God had purposely sent us thither, for as then we had
many sicke men, and most of us were so troubled with a scouring in our
bodies ( schorbok , scurvy) and were thereby become so weak that we
could hardly row, but by means of those leaves we were healed thereof:
for that as soone as we had eaten them we were presently eased and
healed, whereat we could not choose but wonder, and therefore we gave
God great thanks for that and for other his mercies showed to us, by
his great and unexpected ayd lent us In that our dangerous voyage.
Ana so, as I aayd before, we eate them by w'hole handfuls together,
beoause in Holland we had beard much spoken of their great force;
and as then found it to be much more than we expected.' 1
But later Arctic explorers have, I believe, expressed the
opinion that sorrel (Rumex acetosella ) is more effective than
scurvy-grass. I am, Sir, yours faithfully,
Dec. 23rd, 1918. A. HENDERSON SMITH.
A NASAL DOUCHE.
We have received from Messrs. Hewlett and Son, Charlotte-
street, London, E.C., a neat and convenient form of nasal
douche. Its appearance is that of a small bulb-shaped
pipette, and it consists of a glass tube about 4 inches long,
closed at one end and having at the other end a pear-shaped
bulb with an orifice to allow the medicament to escape.
The central part of the tube is a bulb into which the
medicament is poured through an orifice which also serves
as a vent-hole. The closing or unclosing of this hole by the
finger controls the flow of the fluid. As the douche is made
of toughened glass it can be sterilised by boiling without
fear of breakage.
COLONIAL HEALTH REPORTS.
British Guiana.—Mr. G. B. Greene, Assistant Government
Secretary, in his report on the Blue-book for 1917, states that
the estimated population of the colony on Dec. 31st was
313,999—163,405 males and 150,594 females. The birth- and
death-rates per 1000 of the population of the several races
representing the community were as follows
Race. Birth- Death- Race. Birth- Death
rate. rate. rate. rate.
9 * 137 CW ““ . ** *»
PortuguMe 25-9 31-2 BlKks . 27-9 29-9
E*st Indians. 27*6 33‘1 Mixed races. 32*0 21*5
The number of deaths of children under 1 year of age
was 1781, or 199 per 1000 births. The mean rate for the
previous five years was 183 per 1000. The six principal
causes of death throughout the colony during the past
five years are given by the Registrar-General as follows:
Bowel complaints (including dysentery, diarrhoea, and
enteritis, &c.), 13*4 per oent. of the general mortality;
fever (malarial and other), 14*3 per cent.; pneumonia and
bronchitis, 12*2 per cent.; kidney diseases, 9*6 per cent.;
diseases of early infancy (including premature birth,
infantile debility, &c.), 8*9 per cent.; and phthisis and other
forms of tuberculosis, 6*3 per cent. Enteric fever is a
notifiable disease; during 1917 723 cases were notified, with
123 deaths. Antimalaria and antimosquito measures are
being generally and gradually enforced, with visible signs of
success. Ankylostomiasis, which has engaged the attention
of the mbdical department for several years, has consider¬
ably decreased on the sugar estates; this is attributed to
improved sanitary measures and the erection of latrines.
The hospitals and asylums of the colony were maintained
during the year in their usual efficient condition. There are
five public hospitals in the principal centres of population
and the outlying districts are served by dispensary hospitals
and dispensaries. The immigration law also requires the
maintenance of hospitals on every plantation on which
there are indentured East Indian labourers, and those
institutions are available for the treatment of emergency
and pauper cases from the general community. There were
439 patients in the public hospitals at the beginning of the
year, and 13,271 were admitted during the year; there were
1413 deaths. In addition to those admitted to hospital out¬
door treatment was given to 55,388 persons. At the Leper
Asylum there were 297 patients when the year began—
205 males and 9£ females. During the year 71 were admitted.
Enquirer .—It has been explained in our columns, but we
will make an opportunity for repeating the information.
The price of the book entitled “ Married Love," reviewed
in The Lancet of Dec. 28th, 1918, is now 6s.
Burberrys’ annual sale takes place as usual in the months
of January and February at their Haymarket, London,
house, ana affords the opportunity to obtain from their
surplus stock, at about half the ordinary cost, any of their
weatherproof topcoats, suits, and gowns.
At the last meeting of the Taunton town council it was
decided to appoint Dr. H. J. Alford consulting medical
offloer of health and school medical officer at a salary of
£350 per annum.
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THE LANGET, January ll r 1919.
% Jfinal tfrairiintioB
CO
THE STUDY OF SHELL SHOCK. 1
BEING A CONSIDERATION OF UNSETTLED POINTS
NEEDING INVESTIGATION.
D* CHARLES S. MYERS, M.D., Sc.D. f F.R.S.,
X1KUTRV4WT-COLONEL, B.X-M.C- (T.C.).
No medical officers tore loll the strain cl war more
^severely than those engaged in the treatment of functional
ntrveus disorders. Both in this country and overseas their
time and energies have been so fully occupied that any
systematic research in their special sphere of work has been
generally out of the question. But now, perhaps, this
tension may be relieved; and inasmuch as, even at this
jbte hour, it is still possible to investigate various problems
which have arisen during the past four years, I have
-endeavoured in this paper to draw attention to those which
eeem to me of the greatest importance. If, perchance,
there be any who have relevant data which are too scanty to
to published separately and would otherwise lie hidden
•away ia note-books, I shall be happy to receive them, and
will, ef course, be careful to acknowledge their source in
Any compilation which can be usefully made from them.
Etiology.
Them is a general agreement that the war neuroses are to
he regarded as the result ef functional dissociation arising
irom the less of the highest controlling mental functions.
Yet considerable controversy exists as to how those con¬
trolling functions are lost, and precisely what occurs when
they are lost. Some, for example, consider that functional
nervous disorders are dependent on increased suggestibility
.arising from fear, horror, or other emotional or fatiguing
conditions; while others maintain that, quite apart from
uuggestion, emotional conflict or excitement is capable of
producing functional disorders. Some have distinguished
a se-called ecu motional from an emotional syndrome ;
others have insisted that whether a man has been buried in
a trenoh or has seen his best friend's brains scattered before
trim the functional symptoms are identical. All now-agree
that mere concussion or the polsonons action of carbon
monoxide or other noxious gases does not necessarily give
vise to functional nervous disturbance.
Many neurologists hold that the effects of suggestion and
-of functional disturbance are limited to phenomena which
•can be imitated voluntarily by the patient; they accordingly
dhnit functional disturbances to those which can as well be
produced by malingering. Hence local or general sweating,
•vaso-motor disturbances, changes in the reflexes or in
muscular tone, and any disorders of movement which do not
disappear during sleep or under an anaesthetic cannot,
•according to this view, be due to suggestion and cannot be
classed as functional disorders.
But oases of contracture occur which clearly cannot be
imitated voluntarily 9 ; so do, more seldom, oases of
spasmodic movement and of inoodrdination. The persist¬
ence of contractor^ or of spasmodic movement is likewise
inimitable by volition. Moreover, every physician of experi-
eaoe must have met with patients suffering from functional
deafness, whose sleep has not been in the least disturbed by
the loudest noises, and they must have seen contractures and
spasmodic movements persisting during sleep and during at
least the first stages of chloroform anaesthesia: We may
Teeall the ease of persistent contracture described by
Ballet, 9 which was oarefully tested during sleep by means
-of stamp-paper gummed to the affected region.
It has, however, been objected that in such exceptional
-cases of contracture the possibility of joint adhesions has
wot been coneidered, or that the contractures are due to
peripheral causes and are therefore to be placed in a special
group of “ reflex contractures.” In this country, at least,
I think it difficult to exaggerate the harm that has arisen
* Four previous communications on this subject Appeared in
StffiSS'WhS&SK. 1 * 316,1 *“• “■ (p - «•
• 0#. Boussy: Bev. Neurol., 1918, xxv., p, 204.
No. 4976 ‘Md., 1915, xxt!., p. 767.
from an uncritical acceptance of Babinski’s hypothesis of
V reflex ” paralysis or contracture. I have met with expert
neurologists who, on diagnosing a ease as belonging to the
“ reflex ” group, have at once regarded it as 14 organic ” and
have refused it admission to one of the special hospitals for
functional disorders. For my part, I have never seen such
a case in which the paralysis or contracture has not been
cured by psycho-therapeutic measures (aided, sometimes, by
manipulation under an anaesthetic), and the other so-called
reflex symptoms (loss of muscular tone, coldness, sweating,
fco.) have not disappeared pari pass* with the regain of
normal voluntary movement.
Chief Topics for Investigation,
There are, then, three main topics for investigation : (1) the
existence of distinct commotional and emotional syndromes;
(2) the justification for limiting the effects of suggestion to
volitionally imitabie phenomena; (3) the sufficiency of
suggestion m an explanation of all functional dissociation.
Of these the first merely requires the collection of observa¬
tions. My own experience is that in patients who have been
exposed to physical violence (i.e., having been buried,
knocked over, or lifted in the air), stnpor, hyper®sthesia,
and spasmodic movements are commoner than in those
whose disorder has a purely mental origin. If these differ¬
ences are confirmed by others their explanation would not be
difficult, but at the present moment would be out of place.
So, too, it would be inopportune here to consider whether a -
special kind of commotion—e.g., a fine “molecular ” com¬
motion, such as might be produced by moderately short
waves of the disturbed air—may ever be directly responsible
for functional disorder, producing dissociation through its
exhaustive effect on the higher “ intellectual ” regions or
through its excessively stimulant effect on the lower
11 emotional” regions. In passing, we may note that
emotion alone can give rise to inorease of pressure and of
albumin content, and even, according to soine, to leuoo-
cytosis in .the oerebro- spinal fluid. But fuller observations
are needed on this matter.
The second topic suggests a variety of investigations. Can
suggestion produce local pallor or blushing ? Most experts
in hypnosis maintain that local disturbances in blood-supply
can be induced by hypnotic suggestion. Some claim even to
have produced blisters, but further work under the careful
conditions adopted by Captain J. A. Hadfield, R A.M.O.
(then a naval surgeon <) is uigently needed. Similarly in
regard to local sweating. Ac.
The third topic involves the consideration of the other
causes, besides suggestion, which have been advanced as
responsible for functional dissociation. Some have thought
that an excessive emotional experience may suffice to bring
it about. Others have laid stress on the repression of an
emotion or instinctive action arising from its conflict with
other antagonistic processes, especially with the higher -
motives of conscience, social sanction, See. Particular
stress h&6 been laid on the conflict of 44 wishes,” on mal-
adaptation to environment, on the fear of death, and oh
defence mechanisms before cm intolerable situation; the
object being to bring all the war neuroses under two
heads—the 44 conversion hysterias” and the “anxiety
neuroses.”
Classification of Main Types of War Neuroses.
With a view to determining the sufficiency of suggesti¬
bility as a cause of functional nervous disorders, let us
endeavour to classify the main types of the war neuroses,
beginning with obviously hysterical, “ suggested,” cases
and passing to those which show more and more clearly
the need for other explanations.
1. A highly “nervous” soldier is hit on the forearm by
a piece of shell. His arm drops to his Bide, and the
thought at once occurs to him that he has lost the use of
it. The entire limb becomes functionally paralysed. Here
we have a clear case of suggestion noting under the
influence of fear.
2. After an accident in civil ljfe a man had long ago
suffered pain or impaired mobility. A slight bruise in the
same region on the battle-field produces functional hyper-
sesthesia or paralysis. The by pence thesia gives place to
an®sthesia, or with recovery of movement a condition of
extreme incoordination ensues. The influence of suggestion
* The Lancet, Nov. 3rd, 1917, p. 678.
B
52 Thh Lancet,]
DR. C. 8. M£ERS: THE STUDY OF SHELL SHOCK.
[Jan. 11,1919*
Is here fairly obvious. The soldier may even admit that the
braise revived the memory of his former accident. Bat is
it necessarily and always tree that hyperesthesia has been
converted into anaesthesia by suggestion or that the in-
coordination can be imitated volitionally ?
3. In childhood certain spasmodic movements were
temporarily induced by a severe fright. Of this the soldier
has lost all memory. Sudden fear in the trenches revives
this disordered movement, which persists for many weeks.
The influence of suggestion is here less sure. But even
if suggestion can explain the origin it cannot account for
the long persistence of the movement, which may even con¬
tinue daring sleep. But if (as is usual) it ceases during
sleep can it be supposed that each morning on waking the
patient receives a fresh suggestion ? Do we not gain a
clearer insight into the condition by regarding the move¬
ment as a dissociated emotional expression inherent in the
waking personality of the patient, especially when this view
leads us to cure the disorder' by reviving in the patient the
memory of the original trouble, and thus helping to restore
his normal personality ?
4. A soldier in previous good health is buried owing to a
shell explosion. After a period of stupor or contusion
(perhaps preceding, accompanying, or following excitement,
depression, or fugue), he “ comes round ” mute and amnesic,
but he has clearly not quite returned to his normal self.
Here there is no evidence of suggestion, but it is possible
that suggestion may have influenced the patient when the
state of confusion or stupor was passing away. By means
of hypnosis memories of a patient’s thoughts or environment
duriDg confusion or stupor may often be recovered. Hypnotic
investigation may therefore serve to clear up this point. Yet
even if loss of speech had been suggested during recovery
from confusion or stupor, suggestion is impotent to explain
such a patient’s loss of memory. The soldier may confess
to having felt some previous fear, but what man has not
at some time had that experience in the trenches ? There is
often no evidence of any mental conflict before or after
burial. Bat he may have been unconsciously repressing
some tendency to action. Here hypnosis may again prove of
use in revealing the presence of such past conflict or inhibi¬
tion. It cannot be said that mutism and amnesia are obvious
. measures of escape from the firing line; and amnesia can
only be called a defence mechanism in the sense that, like
stupor, it safeguards the patient from suffering further
emotion. In such cases, may we not suppose that the shock
of an excessive emotion (or ? commotion) is adequate to
produce an abnormal, stuporose, or confused personality,
on emergence from which the memories of events relating
thereto are necessarily lost, mutism persisting as a piece of
dissociated behaviour expressive of the mental disturbance?
5. A soldier suffers pain in one or more limbs consequent
on burial or a wound; or the application of a splint to his
wounded limb results in prolonged immobility. He
gradually develops a functional condition of muscular con¬
tracture or paralysis. There is no evidence of suggestion
here. The patient is usually quite unable to account for the
onset of his condition, but more careful mental exploration 5
in the waking or hypnotic state is likely to throw light on
the matter. Without this exploration all such facile
explanations a§ the wish to escape from an unpleasant
situation, the habitual persistence of immobility, the desire
for a pension or for discharge from the Army, are scienti¬
fically worthless.
6. A soldier has for several months been suffering from
self-reproach, owing to some act he has committed; subse¬
quently he develops a functional disorder. For instance,
he has shot at the uplifted arm of a surrendering enemy,
whose arm drops helpless as he falls to the ground ; later
the patient’s arm is slightly‘injured, and it becomes com¬
pletely paralysed. Or he has long worried over past sexual
abuse ; and on breaking down from the strain of warfare he
develops washing-like movements of the hands, symbolic of
ridding himself of his impurity. Or he has reproached
himself with causing the death of a comrade ; and on break¬
ing down he begins to suffer from visual hallucinations of
seeing an avenging finger pointing at him, or from audi¬
tory hallucinations of hearing an accusing voice, or from
the conviction that he has sinned unpardonably, Ac. Sugges-
5 i prefer the term “ exploration M to “ annljsls,” alike because it is
more exact, and because It does not imply adhesion to any special
“ school."
tion is powerless to account for these various examples or
loss of control over bodily or mental processes. They ar*
clearly the result of imperfectly solved conflicts, the more
or less repressed, dissociated oomplex finding expression in
motor, sensory, or ideational disorder. For with the explore
tion of their origin, their explanation to the patient, and his-
increasingly successful efforts to face and to solve the
conflict his troubles come to an end.
But even if we admit that suggestion may act on the*
involuntary nervous system, that suggestion plays but a
small part in the causation of the war neuroses, and that
extreme emotion and conflicting complexes are by far their
most important determinants, there still remains for con¬
sideration to what neural level functional dissociation may-
ex tend.
Limits of Dissociation.
Cases frequently occur in which the sudden recovery of'
lost memory is accompanied not merely by the restoration of
speech, not merely by the cessation of spasmodic move¬
ments, but also by a marked change in the entire facies of'
the patient. He not only (as he states) feels, but he also-
looks, another person. His pupils, pulse-rate, and skin
colour regain their normal condition. We may consider
their previous abnormal state as due to the persistence of
emotional expression, either uncontrolled by, because dis¬
sociated from, the ncarnal personality, or belonging to an
“ultra-emotional" personality which held sway owing to*
dissociation of the normal personality.
In the third of these contributions I suggested the general
resemblance of certain cases of functional hyperesthesia to-
the features of disordered sensibility described in cases of
thalamic over-action, where the optic thalamus has been cut¬
off from the normal control exercised by the cerebral cortex.
Can the effects of loss of higher control in the war neuroses
be similarly manifested in disorder of the sympathetic and*
reflex systems?
As a rule, the nystagmus, clonus, and rombergism observed*
in functional disorders are clearly distinguishable from those*
occurring in organic cases. The nystagmus is rather of the
nature of an unsteadiness, the clonus is only obtained at a-
particular angle of flexion or degree of tension, the
rombergism disappears when the patient’s attention is-
distracted from the fear of falling. But everyone with
sufficient experience must have occasionally seen cases-
where these disturbances in a clearly functional case are
indistinguishable from truly organic disorders, just as a bo-
called hysterical convulsion may occasionally be indis¬
tinguishable from one due to so-oalled idiopathic epilepsy.
It is a question of what neural levels may be involved as
the result of functional dissociation and loss of control.
In his zeal to limit the manifestations of “pithiatism" to*
the sphere of volitional activity Babinski refuses to believe
that the patellar reflex can ever be exaggerated in the
functional neuroses ; and neurologists holding such view*
delude themselves by using the epithet “brisk" in place
of “exaggerated." But will any dispassionate observer
deny that iu the war neuroses the knee-jerk can be as
exaggerated as in disseminated sclerosis, at the outset of
which, by the way, we may recall the appearance of various
“ functional" disturbances ?
The Plantar Reflex*
Let us consider in similar fashion the plantar reflex.
In maoy cases of war neurosis no response is obtainable,,
or an extension of the toes may result from plantar stimula¬
tion, especially when there is well-marked hypertonus of
the extensor muscles. Often this extensor response is-
clearly of a voluntary character, and is associated with strong
flexion at the ankle ; but in some cases, especially, of course,
where the disturbance of consciousness has been severe after
burial, a temporary extensor response may be obtained which
is indistinguishable from one resulting from organic inter¬
ference with the pyramidal tract.
The appearance of the extensor response at the close of
an epileptic convulsion can only be due to a temporary loss
of higher control arising from exhaustion of the inhibiting
paths. May not such loss of control sometimes as well arise
through functional dissociation ? A case has been recently
reported to me where the emotional excitement consequent
on the revival, during hypnosis, of terrifying repressed
incidents of trench warfare, produced a temporary extensor
plantar response.
TH Laugh,]
DR. C. 8. MYERS: THE STUDY OF SHELL SHOCK.
[Jan. 11, 1919 53
Clearly, farther investigation of the plantar response under
these and other conditions is urgently needed. In many cases
of asymmetric plantar reflex I have found that on the side on
which the flexor response is weaker or absent, the knee-jerk
and the abdominal reflex are also weaker than on the opposite
side, and the cutaneous sensibility is also diminished/’ Some¬
times this association is reversed. These were all purely
“ functional ” cases. Here, again, we need further
observations.
flypotkesis of “ Reflex ” Origin 0 / Certain Disorder*.
Ik is easy to hold to the clear diagrammatic view that all
functional neuroses are confined to disturbances of volitional
activity, and that where disorders of the reflexes or of the
vaso-motor system occur, or where sweating, muscular hypo-
tonus, hyperexcitability, &o., arise, they stamp the case to be
one of Babinski’s “ reflex ” cases. $uch a simple view, like
the old conception of aphasia, overlooks many difficulties.
For instance, the so-called reflex phenomena are usually
limited to the hands or feet, whatever the site of the wound;
they may occur in patients who have not received any wound
at all; they are very rare in wounded patients who show no
signs of paralysis or contracture ; the contracture or para¬
lysis is always amenable to psycho-therapeutic methods.
That the vaso-motor and other disturbances do not dis¬
appear as rapidly as the paralysis 01 contraction is no proof
that they are produced by reflex causes.
Babinski and Froment have observed 7 that the abolition
of the plantar reflex, the muscular and nervous hyper-
excitability, and the slowness of contraction, characteristic
of their “ reflex ” cases, are closely associated with hypo¬
thermia. Warming the affected limb abolishes these
abnormal conditions. But this is po proof that they are
of “reflex ” origin. It will be recalled that after the division
of afferent nerve fibres in his arm, Head found that a cold
day woald throw its state back several weeks ; the just-
reacquired epicritic system was depressed, leaving the more
primitive protopathic system alone in activity. That is to
say, higher and more recently acquired systems of sensibility
and reaction are prone to be inhibited or dissociated by cold
and to be redintegrated by warmth. ,
Babinski and Froment have also observed* that in their
“reflex" cases of paralysis and contracture chloroform
anaesthesia often causes at a certain stage an exaggeration
of the tendon reflexes and a well-marked clonus on the
affected side, while in healthy people they fail to get any
similar appreciable effect. But these observations on the
effect of chloroform anaesthesia, as well as those on the effect
of warmth on the reflexes, need to be carried out on purely
functional cases where there can be no question of “ reflex ”
causes.
Theory of Lose of Some Higher Control or Endoorinio
Disturbance.
If we discard the hypothesis of the “reflex" origin of
these disorders what explanation can we offer in its stead ?
On the one hand, we may regard them as consequent on the
low of some higher control, due to emotional disturbance, in
which case their limitation to a single region is due to the
same cause as the limitation of the voluntary muscular
paralysis or contracture. Or, on the other, we may regard
them as immediately due to some disorder of the internal
secretions, in which case their localised manifestation may
be attributed to a local nervous predisposition, either con¬
genital or acquired. Thus, Babinski and Froment n have
described certain cases of “reflex" disorder in which a
smaller pulse was observed on the affected side. But
d’Oelsnitz and Boisseau 10 find that the pulse is small in
such cases on the unaffected side also, and they regard the
inequality as merely the accentuation of a constitutional or
acquired disposition. Boisseau 11 observes that after cure the
previously smaller pultie (on the affected side) may become
larger than that on the opposite side, as the limb becomes
warmer and less cyanosed. Clearly further investigations
are needed on this subject.
But in either event, whether the so-called “reflex"
phenomena are due to loss of higher control or to endo-
crinfc disturbance, emotional disorders are fundamentally
responsible for the condition. It only remains to determine
6 Cf. Dejerlne: Rev. Neur., 1916, xxii., No. 19.
Hysteria or PithUtiara (Bog. trana.). 1918, pp. 137,148, 243, 264 IT.
9 Op. dt.. pp. 97.152, 263. » Op. ott, pp 126, 261 If.
10 Rev. Neur., 1918, xxv., pp. 292 ff. 11 Ibid., 1917, xxiv.. 289.
by investigation whether these nenral disturbances are pro¬
duced directly by the emotion or indirectly through the
action of the “ emotional centres ’’ on the endocrine glands.
The one reliable method of determining whether there is
any disorder in internal secretion would seem to consist in
ascertaining if the patient is unduly susceptible or in¬
sensitive to doses of the various glandular extracts, the
normal effects of which have been observed by control
experiments on healthy persons.
I recall two cases of “ shell shock " lying side by side in
a clearing statioa in Flanders. I drew a cross with my
finger on the abdomen of each, and obtained in the first a
vivid tache cSrSbrale , bright red in colour, while the second
yielded an equally vivid image of a cross in white—a
phenomenon now recognised to he due to arterial hypo¬
tension, such as may arise from adrenal insufficiency. Here,
then, conceivably we have two patients respectively suffer¬
ing from an increased and a diminished tone of the sym¬
pathetic system, associated with hyper-and hypo-adrenalism.
In a series of cases examined by me within a few hoars
after^he onset of “shell shock," I conld find no sphygmo-
manometric evidence of increased blood pressure, nor by
Fehling’s fluid could I detect (save in one case) the slightest
trace of sugar even in the first urine passed by these patients
since they left the trenches. But sympathetic (or vagal)
neuroses may be associated with glandular exhaustion, as
well as with glandular over-action.
We need a careful record of the effects of glandular
extracts on the emotional condition of cases of war neuroses,
and of their effect on the psycho-galvanic reactions and on
the reaction times of such patients in association tests.
We are as yet uncertain of the range of action of the
sympathetic system, and h^hce of the extent of its influence
in the war neuroses. 13 That it can control the tone of
voluntary muscles and affect the steadiness of their contrac¬
tion there is little doubt. Can it also produce the osteo¬
porosis and muscular atrophy which is observed in cany
so-called “reflex" cases? Every experienced physician
must have occasionally met with a surprising degree of
atrophy, alike in cases where there has been some local
wound or central concussion and in cases where there has
not. This atrophy is often very slow to disappear and in the
experience of some is intensified by the returning use of the
affected muscles. In certain cases it may arise from vaso¬
motor disturbances in the cord, induced by the sympathetic
system. In addition to the collection of data bearing on this
obscure subject we need a series of investigations by modern
methods on the electrical reactions of functionally disordered
muscles.
In this country, at least, we have been paying so much«
attention to the mental aspect of the war neuroses that a
detailed examination of the accompanying bodily symptoms
has been generally neglected. We have yet to ascertain
what symptoms usually occur in combination. My own
experience, for example, leads me to think that a feeble or
absent plantar response is usually associated with a sluggish
reaction of the pupils to light and with a tendency to clonns
and catatonia, while an unusually brisk flexor plantar
response is associated with an extra-active pupil reaction.
Rigidity of the limbs oiten seems to go with hypermsthesia,
weakness with anesthesia. But much more information is
needed on this subject.
A more careful study is also needed of the mental and
physical changes occurring during recovery. A most
promising subject of investigation would he the changes that
terrifying dreams undergo as the patient improves—victory,
perhaps, replacing defeat in his dream battles, and civil
elements gradually intruding into the dreams .of warfare. 13
Treatment.
Those who have had most experience in war neuroses are
generally agreed that different physicians attain different
degrees of success according to their particular mode of use
of the same treatment, and that there is hardly any form of
treatment recommended that has not its value in appropriate
In agreement with Pighfnl (Riv. sperim. di Freniat.. 1917, xlii.,
298), Orr and Rows have pointed out (Brain, 1918. xli., 19) how intimately
the sensorl-motor and psychic areas of the cerebral cortex are associated
with the sjmpathetic system, and hence how disordered functional
activity of the former may spread through the lai ter to lower centres
In the mid-brain, bu>b, and cord, causing dilatation of the pupils and
cardio-vascular and other disturbances.
11 Of. D. B. Core: The Lancet, August 10th, 1918, p. 169.
B 2
54 The Lancet,] MR. H. A. BAYLIS: ENT A MCE BA HISTOLYTICA , BTC., IN NAVAL ENTRANTS. [Jan. 11. 1919
cases. Nearly all of as have learned to ban the routine use
of hypnotic drags; yet in some cases they are unquestionably
valuable. An unbiased record is needed of such successes
and failures. So, too, we have learned that it is usually
disastrous to send a patient to employment or amusement in
the hope tbat he may forget all his worries and solve his
conflicts by neglecting them. Yet in some cases this treat¬
ment is successful. Again, therefore, we require a careful
record of the special determinants which should guide our
adoption of the policy of sending mentally uncured neur¬
asthenic cases out of hospital for work or golf.
Experience has also shown that a certain class of patient
on recovery of the use of a functionally disabled limb regains
his normal mentality and is able to throw off all his
psychic disturbance. We need, a record of the particular
class of case in which this treatment is successful. We
need to follow up the cases where the psychic disturbances
have been thus neglected or where they have been indirectly
treated, and to record, not only the speed, but also the
permanence of the cure. When the psychic disturbance is
allowed to persist behind the scenes, a showy lightning
removal of some bodily functional disability is no True
cure at all; the same (or some other) disability will later
develop on the slightest provocation. In this connexion I
would point out how prone the enthusiastic devotees to one
special mode of treatment are to self-deception. I have
repeatedly had soule method demonstrated to me by its
advocate, who has said to me: ‘ ‘ See what a marked
improvement (say) in stammering has been effected by my
treatment,” whereas to a dispassionate observer the benefit
is almost, if not quite, imperceptible.
In my early experience of shell shock I came to lay great
stress on disturbances of persorihiity, and I regarded the
amnesia and the bodily disorder, mutism, tremor, incoordina¬
tion, or spasmodic movement, so commonly observed in cases
seen soon after their onset, as the expression of this change
of personality, due, like it, to some functional dissociation.
Accordingly, I adopted the therapeutic principal of restoring
the amnesia with or without the aid of hypnosis ; and with
the restoration of the amnesia came a restoration of the
speech and a resumed control of the bodily movement.
Brown, 14 who pursued the same method, came to the con¬
clusion that its efficacy was due not so much to the redin¬
tegration of the normal personality as to the working off
(abreaction) of the repressed emotion. On the other hand, 1
appeared to produce as good results by discouraging the
patient from giving rein to his emotions during treatment.
But clearly a series of carefully controlled investigations is
required, in which equal numbers of patients are exhorted
to restrain and to express their emotions, and the resulting
effects compared. Later I began to treat the bodily dis¬
abilities first and the mental disturbances after. We have
yet to discover which order of treatment should be adopted
in different cases.
Electrotherapy and Hypnosis.
Lastly, there remain for consideration and unbiased
investigation the debated values of electrotherapy and
hypnosis. Bach, if improperly used, has its dangers. I
have seen vast numbers of stammerers whose condition, I
am convinced, has been produced by the alarm they expe¬
rienced during the electrical treatment of their previous
mutism. I have observed similar results from the application
of faradism to other functional motor disorders. Yet I
should err in recommending that electrotherapy should
never be employed What we need is an inquiry into the
special conditions in which it is beneficial and the particular
methods which free it most completely from dauger.
Perhaps against no method of treatment has there been
greater prejudice than against hypnosis. Early in the war I
remember the commandant of one military hospital telling
me that he would not in any circumstances countenance its
employment because the reputation of his unit would suffer
thereby. I have read pages of vituperation against hypnosis
written during the war by medical men who had had no per¬
sonal experience of its use. Imagine what would be our
attitude towards a physician who wrote in condemnation of a
particular drug which he had never tried. There is, however,
an instinctive aversion from the practice of hypnosis which
seems to justify almost any attack against it. I recognised
it for a long time in myself. Hypnotism savours of the
14 The Lancet, August 17th, 1918, pp. 198,199.
; uncanny, mysterious, and unknown. One’s first attempts at
hypnotism demand even more self-mastery than one’s first
sight of an operation.
In these circumstances what an urgent need there is for a
dispassionate investigation of its merits and defects, of its
uses and abuses 1 It has been claimed that hypnosis makes
the patient for ever dependent on the hypnotiser. We may
ask, Must it do so, any more than exploration of the mind
in the waking state need make him dependent on the
explorer ? We need to inquire into the different results in
this respect arising according to the different modes of
hypnotic treatment adopted. It has been urged that
hypnotism gives the patient a temporary relief, like a
hypnotic drug or a brandy-and-soda. That, again, must
depend on the method of its use.
Here, too, we need careful inquiry into the comparative
values of hypnosis as a method of mental redintegration
(unearthing repressed complexes) and as a method of somatic
redintegration (restoring bodily disabilities by direct sugges¬
tion). And, above ail, we need an inquiry into the sub¬
sequent permanence of cure of those patients who have been
treated by either of these two methods with and without
hypnotism.
* Is it too late to hope that systematic inquiry may yet be
begun, at least along some of the lines which I have indi¬
cated in this paper ? Up to now the field has been almost
wholly neglected. Far from being barren, it is rich with the
possibilities of valuable results.
INCIDENCE OF ENTAMCEBA HISTOLYTICA
AND OTHER * INTESTINAL PROTOZOA AMONG 400
HEALTHY NEW ENTRIES TO THE ROYAL NAVY.
By H. A. BAYLIS, M.A.,
ASSISTANT, DEPARTMENT OF ZOOLOGY, BRITISH MUSEUM (NATURAL
HISTORY); PROTOZOOLOGI8T (TEMPORARY), ROYAL
NAVAL HOSPITAL, HA8LAR.
The large amount of work that has been done in con¬
nexion with amoebic dysentery during the last three years
has opened up a number of questions, not the least interest¬
ing of which is to what extent carriers of Entammb*
histolytica exist among the civil population in countries with
a temperate climate. Some inquiries on this point have
already been made in this country, more particularly by the
energetic group of workers at the Liverpool School of
Tropical Medicine, who have been engaged primarily in the
protozoological investigation of the stools of soldiers
invalided from the various fronts.
A summary of the results originally published in their
earlier papers, 1234 together with more recent data, was
presented by Professor Warrington Yorke r> before the
Society of Tropical Medicine and Hygiene in June, 1918.
An instructive table is there given, in which the results of
the examination of various classes of civilians and young
recruits are compared with those obtained in the course
of routine examinations of convalescent soldiers, both
dysenteric and non-dysenterio. Among 450 civilian patients
in the Liverpool Royal Infirmary it was found that 1*5 per
cent, were carriers of E. histolytica , while the examination
of 246 children under 12 years old in the Liverpool Children’s
Infirmary revealed 0*8 per cent. “ positive.”
The incidence among recruits, 18 to 19 years of age, who
had been iu a training camp for various periods not exceed¬
ing three months, was considerably higher (5*2 per cent.).
This may be partly accounted for by the fact tbat there were
also in the camp some men who had returned from the
Mediterranean area, and from whom the recruits'might
have aoquired their infectious. This hypothesis, however,
as the author states, would not altogether account for the
facts, since it was proved that many of the recruits hod
almost certainly been infected before going into the camp.
From these results it appears therefore that in some
sections of the civil community in England there may be
carriers of amoebic dysentery to the extent of from 1 to 5 per
cent, of the apparently healthy population. If this is the
case, questions naturally arise as to the wisdom or necessity
of spending much time and trouble in discovering and
attempting to cure such carriers, as has been done to a great
extent among the naval and military forces during the war.
On the publication of the statistics above referred to, it
was suggested to the Admiralty by Surgeon Oaptain P. W.*
Bassett*Smith, C.B., R.N., that the protozoologist at Haslar
TBlLAMOMS,] MB. H. a. BAYLI8: BNTAMWBA HISTOLYTICA , BTC., IN NAVAL ENTRANTS. [JAN. 11, 1919 56
should undertake an inquiry on similar lines, making use of
new entries to the Navy at Portsmouth as a sample of the
material from which the Navy is recruited. Accordingly,
instructions were given by the Admiralty, and arrangements
ba^rg been made through Surgeon Lieutenant* Commander
P. Fildes, R.N.Y K., in charge of the laboratory at Hislar,
with the medical officers of the Royal Naval Barracks, Ports¬
mouth, and one or two other establishments in the neigh¬
bourhood, for supplies of material to be sent to the
laboratory, the work was begun in July;
the terms Entavurba histolytica and Entamoeba coli refer to the
encysted forms. Table I. shows the incidence of Entamoeba
histolytica and other intestinal protozoa among new entries to
the Royal Navy and Marines at Portsmouth. Total number of
cases examined = 400. These men came from all parts of the
British Isles, and were in no way representative of this
district in particular.
(a) Total number of ea*e* found to be Infected. (5) Ool. (a) as per¬
centage of the cases, (e) Pure infections, (d) Mixed infections.
Table I .—400 New Entrie*. Table II .—888 Patients.
# I. Material.
Altogether specimens of the stools of 400 men who had
just entered the service were examined.
With the exception of a few from the Royal Marine
Barracks, Eastney, and a still smaller number from the
Royal Marine Barracks, Forton, all these came from the
Royal Naval Barracks, Portsmouth.
The new entries at the barracks were attending in daily
batches at the sick hay for throat-swabbing, in accordance
with the routine for the detection of carriers of the meningo¬
coccus. It was found convenient, therefore, to arrange that
five of these men daily Bhould be selected at random and
specimens of their stools collected and sent to Haslar. The
men came from all parts of the country, and this system of
random selection was calculated to ensure that the cases
examined would not be representative of any one particular
district or section of the oivil community, but would be a
fair sample of the whole.
Owing to the pressure of work on the medical staff at the
barracks, and other considerations, it was not found possible
to obtain the histories of all caseB sent for examination, but
it was thought sufficient to make special inquiry as to the
history of eaoh case found to be a carrier of Entamaba
histolytica. A scheme of questions was drawn up, as to
whether the man had ever been abroad, his occupation,
residence, Ac., during civil life, and whether he had ever
had symptoms of intestinal disease. These questions were
put to eaoh man as occasion arose, and the answers provided
the “ histories ' to be given later.
II. Technique.
As it was desirable to examine a fairly large number of
cases, and considerations of time and convenience of arrange¬
ment with the barraoks had to be taken into account, it
was decided to allow only one examination in eaoh case.
It was therefore necessary to define, as a standard, exactly
wbat constituted “ one examination.” In practice, in the
routine examination of patients in the hospital, it bad been
found that the exhaustive inspection of two cover-glass
preparations of thin emulsions of eaoh stool was generally
sufficient for one examination (i.e., if cysts or amoebae of
E. histolytica were present in any given specimen, they
would generally be detected by this method, unless the
infection was a very slight one). In fact, records were to
hand showing that two preparations had been the average
number devoted to eaoh first routine examination of new
oases for many months at Baslar.
This standard was therefore adopted in dealing with the
whole of the 400 new entries; it had the advantage of render¬
ing the results more nearly comparable with those obtained
far convalescent dysenteries and other patients examined in
the hospital, and these will be given for the sake of com¬
parison, being now published for the first time in full." It
also happens to be identical with the standard adopted for
"one examination” by the Liverpool workers, (*, p. 412)
and therefore makes the results strictly comparable with
theirs, except in so far as the personal element has to be
considered.
From each specimen, then, two small drops of emulsion
were placed side by side on a slide, and each covered with a
cover-glass. As a rule, one emulsion was made in normal
saline, the other in Weigert’s iodine solution, and the
" loopfuls ” of fseces were usually taken from different parts
of the specimen, to allow for the possibly unequal distribu¬
tion of the protozoa. The two-preparations were then gone
over completely under the microscope with the aid of a
mechanical stage, using a A inch objective and a No. 3 (x 8)
ocular. If no protozoa were found, the case was reoordea
aa negative. If any cysts of doubtful nature were found,
it was sometimes necessary to make further preparations,
but this, of course, does not alter the standard of *' one
examination.”
III. Results .
The results of the investigation may be most conveniently
stated in the form of a table. It may be mentioned here
that in no case were any active amoebae found. In all cases
* JL note on the proto zoological findings in the first 394
at Haslar be* been published in the Medical Research Com¬
mittee's Report on Dysentery Cases received from the Eastern
MedHerraneui (Special Report Series, No. 6, HI.. 1917, p. 24.)
Organism.
(<*>
0)
(C)
(d)
(a)
(ft)
(O
(d)
Protozoa of any kind ...
120
; 3oo
no
10
202t
22*7
179
23
Entamoeba histolytica ...
10
i 2-5
9
1
52
5*9
35
17
Entarrueba coli .
94
23 5
86
8
118
13*3
104
14
Entamoeba nana .
3*
j 0*75"
1*
2*
_ .
—
-
(iiardia [ Lamblia ] intes (
jf tinalis... ... 1
22
5*5
14
8
47
5*3
41
6
ChiUrmastix [Tetramitus] {
metnili . S
1
| 0*25
-
1
2
-
1
Trichomonas hominis ...
—
! _
i
—
2
—
-
2
» The figures for Entamcr.ba nana cannot be regarded as trustworthy,
as no »pedal effort was made to search for it, ana when present in small
numbers it mav bave been frequently overlooked.
t Including 3 cases of Entanvrba nana (which was only recognised
during tbe latter part of the period covered, and even then probably
often overlooked) and 1 case of an amoeba of the Umax type.
Before discussing the significance of these results it will
be well to compare them with those derived from the exa¬
mination of cases in the Royal Naval Hospital, Haslar,
between March, 1916, and July, 1918, most of whom were
convalescent dysenteries, or were suffering from intestinal
disorders of various kinds, and had been serving abroad,
many of them in the Mediterranean area. Table II. shows
the incidence of the various protozoa among 888 such
cases. Account is taken only of first examinations , in order
to make the results more comparable with those already
given. When further examinations are included, the per¬
centages of “ positives,” of course, increase with evety addi¬
tional examination.
It has not been possible to classify the cases included in
Table II. into men who have and men who have not
suffered from dysentery, as the laboratory records do not
supply sufficient information as to their history. It should
be borne in mind, however, that some of the cases included
in the table were at the time of examination actually in an
acute phase of amoebic dysentery, or, at all events, were
passing active amoebse. At the first examination free
amoetae were found, either alone or together with the cysts,
in nine cases. Subtracting these from the 52 in column (a)
in the table, we have only 43 E. histolytica carriers, as
distinct from Actual oases. This brings the percentage 5 9
in column ( b ) down to 4*8.
Comparing tbe two tables (I, and II ), therefore, we find
that the incidence of the “harmless” protozoa severally—
Entamoeba coli, Lamblia intestinalis , and Tetramitus mesnili f
—and that of protozoa taken as a whole is actually higher
among the “ new entries ” (more or less representative of the
civil population of the British Isles) than among the men
who have been in regions where they would presumably be
more likely to be exposed to infection; while the presence of
Entamaba histolytica , though of considerably lower frequency
than among the latter, is still about half as frequent. It
must be remembered that all the figures probably err on the
side of being too low, owing to the small number of examina¬
tions of each case, and that they give a totally inadequate
idea of the actual incidence of infection. In Section V. an
attempt will be made to estimate the probable amount of
error in the case of E. histolytica , and it may be assumed
that at least au equal amount of correction would be
necessary in the case of the other protozoa.
IV. Histories of the "New Entry ” Cases Po&tive for
Entamoeba histolytica.
A summary may now be given of the histories, as far as
they are known, of the ten cases found to be carriers of
E. histolytica.
Case 5.—Age 18; farm labourer; uaual place of residence, Petlar,
Shetland* (In a village with 100 inhabitant*). 8tata* he has always
lived at home until entering the Service, working on a small farm.
Ha* never been abroad. Ha* never had symptoms of Intestinal disease.
t Trichomonas wa* not found at all among the new entrie*.
56 The Lancet,] ‘ MR. H. A BAYLIS: ENTAMCEBA HISTOLYTICA , BTC., IN NAVAL ENTRANTS. [Jan. 11,1919
Case 27.—Age 32 years 9 months; plumber; residence, Reading.
Had resided at Baroda, India, for three years (February, 1915, to May.
1918), and had had a slight attack of dysentery there in 1917.
Cask 40. —Age 33; schoolmaster; residence. Preston. States he
lived in the country in Lancashire until 12 years of age. Has never
been abroad. Has had recurrent attacks of diarrhoea at Intervals of
nine months, lasting three or four days; last attack four months
previous to examination.
Case 44.—Age 21 i; fitter and tailor; residence. West Bromwich.
Birmingham. Has never been abroad. Has never had symptoms of
intestinal disease.
Case 84.—Age 18; outside porter; residence. East Qdnstead, Sussex.
Never abroad. Never had symptoms of intestinal disease.
Case 161.—Age 18; bootmaker; residence, Kettering, Northants.
Never abroad. Never had symptoms of intestinal disease.
Case 211.—Age 18: bricklayer's labourer; residence, Wolverhampton.
Never abroad. (This case was admitted at Haslar with “catarrh,"
developed pneumonia, and died before further information could be
obtained. At the post-mortem examination made by Surgeon-
Lieutenant S. L. Baker, R.N., nothing abnormal was found in the
intestines.)
Case 374.—Age 38; fireman in Merchant Service; residence, when in<
England, Rotherhithe. Had been in the service of the Orient Line
since 20 years of age. Never had symptoms of Intestinal disease.
Cask 389.—Age 19; fisherman ; residence, Portstewart, Coleraine,
Oo. Derry, Ireland. Never abroad. Never had symptoms of intestinal
disease.
Case 393.—Age 27; ticket collector ; residence, Queenstown, Co. Cork,
Ireland. Never abroad'. Never had symptoms of intestinal disease.
The following points of interest may be extracted from the
preceding histories. Out of 10 carriers—
(а) Big ht had never been out of the British Isles. One had resided
abroad (in India) (Case 27). One had travelled extensively in the East
(Case 374).
(б) Seven at least had never had symptoms of intestinal disease. (In
regard to Case 211 information is lacking.) One had had dysentery
(Case 27). One had had recurrent diarrbtea (Case 40).
(c) Plve bad lived exclusively In England. One had lived exclusively
in Scotland. Two had lived exclusively in Ireland.
Out of the eight carriers who had never been abroad only
one (so far as is known— vide Case 211) had ever had
symptoms which might be attributable to his infection
with E. histolytica.
Age and occupation appear to have no bearing whatever
on the incidence of infection.
As far as the small number of cases justifies such a con¬
clusion, infection appears to be pretty evenly distributed
within the British Isles.
It is to be observed that two of the oases oannot
strictly be considered representative of the population of
these islands (Cases 27 and 374). The subtraction of
these from the total gives 2, instead of 2*5, as the per¬
centage of incidence (see column ( b ), Table I). There is
reason to believe, however, that the real incidence is much
greater, and certainly not less, than 2 5 per cent., as will be
seen from the arguments in the following section.
V. Estimation of the Probable Incidence of B. histolytica
had all Cases received numerous Examinations.
It is well known that infection cannot he detected at every
examination, even in cases who occasionally pass very large
numbers of cysts. The limitation of examinations to one
for each case gives results which are only a fraction of the
actual number of carriers probably existing in any given
series of cases. Various attempts have been made to calculate
the minimum number of examinations necessary in practice,
and also to work out the margin of error where the number
of examinations is too small.
Dobell. 6 after much study of the matter, has expressed
the opinion [p. 43] that more than three negative examina¬
tions must be made on an untreated case before it can
reasonably he said to be free from E. histolytica , but that it
is probable that in three examinations not more than half to
two-thirds of the infected cases will be detected. Six exa¬
minations are suggested as a minimum in practice.
The Liverpool workers 1 - have also studied this question at
some length, and their final conclusion is that three examina¬
tions will only discover 50 to 57 per cent, of ail aotnally
positive cases.
Owing to the regulations regarding 4 ‘negative examina¬
tions ” of convalescent dysenteries in the Service, the number
of examinations in the Haslar series has always been too
small from this point of view. The following figures show
the increase in the percentage of positives for E. histolytica
at each examination as far as the third. The number of
oases examined more than three times was so small that it
has not been thought worth considering in this connexion.
Out of 888 cases examined at least once, 52 (or 6*9 per cent.) were
found positive at the first examination.
Out of 335 cases examined at least twice, and negative at the first
examination, 12 (or 3*6 per cent.) were found positive at the
second examination.
Out of 164 cases examined at least three times, and negative at the
first and second examinations, 3 (or 1*8 per cent.) were found positive
at the third examination.
It is calculated, therefore, that if the Whole of the 888
cases in the series had been examined twice the percentage
of positives found would have increased from 5 9 to 9*5, and
if all had been examined three times a still further increase
to 11 3 would have taken place.
These figures, as far as they go, are so closely similar to
those given for a series of 1713 cases by the Liverpool
workers [-, Table XI.] that it is assumed that had more
examinations been made of the whole Haslar series the
percentage of positives would have continued to increase at
the same rate for subsequent examinations as in the Liver¬
pool series, and that conclusions based on that series may
therefore be applied to the present inquiry.
In the Liverpool series referred to it was calculated that
33*4 per cent, of all cases that would have been found
positive in six examinations were discovered at the first
examination; and six examinations were calculated to be
enough to detect the great majority of infections. It appears,
therefore, that if the percentage of positives discovered at
the first examination of any series he multiplied by 3 we •
shall have a moderate estimate of the percentage of positives
actually existing in that series.
Applying this rule to the present series of 400 44 new
entries,” where 2 per cent, were actually found positive at
the first examination, we find that the real incidence would,
in all probability, be not less than 6 per cent. Furthermore,
since these men were not selected cases in any way, and
were fairly representative, it is believed, of the general adult
male population of the British Isles, we have the rather
startling conclusion forced upon us that something like
6 per cent, of such a population are carriers of E. histolytica ,
and this figure might be found to be still too low, if a large
series of cases were taken and the number of examinations
of each were indefinitely increased.
VI. The Pathogenicity of the Cysts.
Granted that some such percentage of carriers as that
indicated in the foregoing section exists among the popu¬
lation, it is desirable to find out to what extent they are a
danger to themselves or to others with whom they are asso¬
ciated. The data on this subject are unfortunately at present
quite inadequate.
It is now recognised that the cat is a suitable animal for
laboratory experiments with E. histolytica , but it is not always
easily infected, and young kittens have been found to be
more susceptible than older animals.
It was thought desirable to test the cysts from the new'
entries from the point of view of pathogenicity, since it .was
not certain that the strains of the parasite found, though
morphologically identical with those from dysenteric patients,
possessed the same pathogenic properties. Accordingly two
kittens were obtained and kept in readiness, soon after the
first few “positives” were recorded. Unfortunately some
time elapsed before another positive case was available, and
by that time the kittens were almost half-grown, which
possibly accounts for the failure of the experiments. The
faeces of the two animals were examined from time to time
before the infection experiments took place, and no parasites
except those normal to oats were detected.
Experiment 1.— On Oet. 29th at 6.30 p.m., each kitten was given
10 c.cm. of an emulsion in normal saline of faeces from Case 374. (Tbe
history of this case was not known at the time.) Tbe emulsion was
made in the morning of the same day, strained through muslin to
remove gross particles, and left standing at room temperature till thS
evening. It was examined before use to make sure that it contained a
fair number of healthy cysts. The injection was given by Dr. Fildee
with a 10 c.cm. syringe attached to a No. 8 soft rubber catheter, which
was lubricated with glycerine and passed down the oesophagus. The
two kittens were kept under observation and their faeces examined
daily (with few omissions) until Nov. 15th (17 days from tbe beginning
of the experiment). On one or two occasions there was some dUrrhcea;
with mucus in the stoolB, but no amoebae were ever found and none of
the signs of scute dysentery were observed.
Experiment 2.— Ou Nov. 15th, at 6.30 p.m., with the same technique
as before, the kittens received injections (given by Dr. Fildee) of two
separate emulsions, as follows: Kitten 1 received 10 c.cm. of emulsion
from Case 389 containing numerous healthy cyBts, the average
diameter of which was 8 M (a very small strain). Kitten 2 received
10 c.cm. of emulsion from Case 393. in which there were mans healthy
cysts of typloal average diameter (13 A 1 ). As In the former experiment,
the faeces of both kittens were examined almost daily, until Nov. 29th
Tot Lancct,]
DR. F. DILLON : THE ANALYSIS OF A COMPOSITE NEUROSIS. [Jan. 11, 1919 57
in the case of No. 1, and until Nov. 30th in the case of No 2, and
though there were again occasional diarrhoeic stools, with mucus, no
serious signs arose and no amoebae were found.
Kitten 1 was killed (by coal gas) on Nov. 29th and a post-mortem
examination failed to reveal any lesions of the mucous membrane of the
intestine, or any amoebae in the coutenta or in scrapings from the
•nrfsce. Kitten 2 was similarly killed and examined on Dec. 2nd.
No amcehie were found in t he intest inal contents or in scrapings from
the mucous membrane. The rectum showed prominent lymphatic
noouies, but sections of these revealed nothing of a pathological
nature.
It is worth recording that both the kittens were fonnd to be fairly
heavily infected with Ijamblia (apparently the human species). The
cysts were first found in the feoes of No. 1 on Nov. 2nd (tour days after
the first infecti<>n experiment) and in the fa*ces of No. 2 on Nov. 20th
(five days after the second iufectlon experiment). Cysts of Lamblia had
not been observed in any of the human stools used in the experiments,
but Lamblia is not known to be a normal parasite of the cat, and it is
probable that the infection was artificially produced. The cysts were
found repeatedly daring the examinations of the feces of the kittens,
sod numerous active forms of Lamblia were found post mortem in the
lower part of the small intestine of each.
The negative result of the experiments as regards
E. histolytica is probably of little significance. A positive
result would have been valuable, but other workers have
found that experiments in the infection of cats with cysts
per os are often failures, especially when the cats are too
old. Dale and Dobell 7 succeeded in infecting one kitten
oat of eight in this way, and the Liverpool workers 4 one
oat of four. The present experiment, therefore, though
negative, must not be taken as an indication that strains of
amaab® from carriers in the British isles are non-pathogenio.
Further evidence on this point is necessary before any
statement of this kind can be made.
VII. Summary and Conclusion.
Among 400 healthy new entries to the Royal Navy, freshly
joined from places all over the British Isles and examined
once each, 10 were found to be carriers of Entamoeba
kistolytioa. Of these, 8 had never been out of the British
Isles, and 7 at least had never had dysentery. Taking
the 8 home cases only, the percentage of infections found
at a single examination is 2. This, however, is a minimum
figure, and it can be calculated that the real percentage of
carriers among the adult male population mast be nearer
to 6 . If this is the case, it may be doubted whether the
rigorous treatment of carriers in the Services, who have
not themselves suffered from dysentery, is justified or
necessary. The percentage of carriers is naturally higher
among men who have served in countries where the disease,
in its acute form, is endemic, and especially under the
conditions of war. Bat in all probability, given good
sanitary conditions, the ordinary carrier is not a serious
source of danger to others. The view that he is a source
of danger to himself, in that he may at any time develop
dysentery or hepatic abscess, remains in any case to be
considered, and upon this point the present inquiry offers
no evidence.
Experiments on kittens were tried with a view to obtaining
evidence of the pathogenicity of the strains of oysts from the
“new entries. 1 ’ The fact that the kittens failed to beoome
infected is not, however, regarded as evidence for the non-
pathogenicity of such strains.
The writer’s thanks are due to Mr. C. 0. Dobell, F R.S.,
for his kind suggestions as to the general lines of the
work, and for some hints on the method to he employed in
the infection experiments on kittens; and to Dr. P. Fildes,
Surgeon Lieutenant-Commander, R N.V.R., for the actual per¬
formance of those experiments, and for his kind assistance
and criticism throughout the work.
References.— 1. Carter, H. F.. Macklnnon, D. L., Matthews, J. R.,and
Hallos Smith, A.: The Protozoal Findings lu 910 Oases of Dysentery
Bxamin+d at the Liverpool School of Tropical Medicine from May to
September, 1916 (First Report), Ann. Trop. Med and Parasltol., x.,
No. 4, February, 1917. 2. Carter, H. F , Macklnnon, D. L. t Matthews;
J. R., Malins Smith, A., and Stephens, J. W. W.: Protozoologies
Investigation of Cases of Dysentery conducted at the Llverpo 1 School
of Tropical Medicine (Second Report), Ann. Trop. Med. and Parasltol.,
xt. No. 1, June, 1917. 3. Malins Smith, A., and Matthews,
J. R.: Tne Intestinal Protoz* of Non-dysenteric Cases. Ann.
Trop. Med. and Parasltol , x., No. 4, February, 1917. 4. Yorke,
W.. Carter, H. P., Macklnnon, D. L., Matthews, J. R., and
Nalina Smith, A.: Persons who have never been out of Qreat
Britain as Carriers of Entamoeba histolytica, Ann. Trop. Med. and
Parasltol.. xi.. No. 1, June, 19l7. 6. Yorke. Warrington : The Presence
of Entamoeba histolytica and E. coli cysts In People who have not been
oat of Ragland. Trans. Soc. Tmp. Med. and Hyg., 1918. July, xl.. No. 8,
p.291. 6. Dobell. C.: Amoebic Dysentery and the Protozoologioal
Investigation of Cases and Carriers. Medical Research Committee
Beport, 1917 (Special Report Series, No. 4,1.). 7. Dale, H. H . and
Dobell, C., Experiments on the Therapeutics of Amoebic Dysentery,
Joum. Pharmacol, and Bxp. Therap., x.. No. 6, December, 1917.
THE ANALYSIS OP A COMPOSITE
NEUROSIS.
By F. DILLON, M.B., Ch.B.Emn.,
TEMPORARY CAPTAIN, R.I.M.C.; LATE NEUROLOGIST TO 3RD ARMY, ll.E.f
As for that wandering ship of the drunken pilot , the mutinous
crew and the angry captain , called Human Nature, "fantastical ”
fits it no loss completely than a continental baby s skull cap the
stormy infant.— Meredith, “TheTragic Comedian.”
From time to time in the study of the neuroses of war
cases are met with which disclose the combination of a war
neurosis with another of different order: composite con¬
ditions in which the development of a neurasthenia or allied
disorder resulting from war strain has taken place in con¬
junction with a pre-existing neurosis or the rudiment of one.
War neuroses, in common with others we were familiar
with before the war, we know to be entities of considerable
complexity. These composite neuroses, however, attain a
double complexity from the synthesis of two pathologically
distinct conditions. From the consequent adjustment of
the treatment which this implies it is of the utmost import¬
ance, therefore, for the condition to he recognised.
The case about to be described forms an example of such
a condition. It was treated at an advanced centre in
France, and consequently under difficult and unfavourable
conditions. It presents, however, a number of points of
considerable interest, not only in the fact of the improve¬
ment which resulted from an analysis left by force of circum¬
stances incomplete, but in the illustration it provides of
several of the present-day problems ef psycho-analysis.
However much the significance of the sexual factor as
taught by the Freudian school may he disputed, the value of
the psycho-analytic method is becoming more and more
widely recognised. In the stimulating nature of the dis¬
coveries made by its means and the widening scope for
investigation it has suggested, it has inspired the spirit of a
sort of renaissance for psychology and psychiatry. One
of the chief errors, in my view, of psycho-analyst schools
hitherto has been in the mode of presentment of their
subject. The results of their very important investigations
have been described along lines entirely uncorrelated with
the principles of normal psychology. Mechanisms and
principles of mental activity have been described with no
reference to what was already known on the subject. In
consequence it seems that two psychologies have developed
—two parallel systems, the psychology of psycho-analysis,
and the academic system of the schools.
This may have been inevitable in the beginning. Jung
observes that psychology had little to offer to the psychiatrist
until Freud’s discoveries . 1 But since the publication of
“ Selected Papers on Hysteria” in 1895, psychology has
made very considerable advances, and a correlation between
the two is not only to a large extent possible, hut urgently
desirable.
The process, however, has by certain authorities unfor¬
tunately been carried further. A remarkable esoteric
phraseology has been evolved which has had the effect not
only of obscuring the issues of the subject, but by its semi-
mystical colouring has laid it open to the accusation of
oneiromancy and superstition.
There is, so far as I am aware, no reason why scientific
knowledge should not be expressed in clear and simple lan¬
guage. New mechanisms, new facts as they are brought to
light, undoubtedly require new names to label them, but in this
case it has been carried beyond the limits of merely technical
necessity. Freud remarks: ** A clear and unequivocal manner
of writing shows us that here the author is in harmony with
himself, but where we find a forced and involved expression
aiming at more than one target, as appropriately expressed,
we can thereby recognise the participation of an unfinished
and complicated thought .” 2 In this regard the elaborate
and obscure terminology developed by some of the psycho¬
analyst pioneers raises a suspicion—however wrong it may
he—that the obscurity of expression may indicate a corre¬
sponding obscurity of conception.
Account of Case.
The present case is similar in many respects to others
described in psycho-analytic literature except that it gaihs
a special interest and ^importance from the fact of the
58 Thb Lanobt,] DR. F. DILLON : THE ANALYSIS OF A COMPOSITE NEUROSIS.
[Jan. 11, 1919
oonflict which was disclosed being combined with the
syndrome of a war nenrosis.
Pte. C. N., an intelligent young man of 23, of flood
social position, was admitted into hospital on July 21st, 1917.
He was in a mildly depressed state, complained that he was
confused in mind and that bis nerve had given way in the line.
When asked to describe ip greater detail his mental confusion
he said that when coming down in the motor ambulance to
hospital he felt as if he were losing himself and didn’t know
where he was. He had to sit up and look around to assure
himself of his surroundings. His head felt larger than its
normal size and he had a heavy feeling in it as if he had had
a “night out.” There was “a lack of power of thinking
properly” as if there were a brake on his thoughts: a
definite feeling of effort was required to think. The content
or scope of consciousness Beemed to be restricted and smaller
than normal except when he was dropping off to sleep,
when, he said, his thoughts “ wandered all over the place."
He joined the Army in October, 1915, and came to France in
March, 1916. He remained perfectly well, acting as stretcher-
bearer, until April 10th, 1917. On that day he was one of a
stretcher squaa carrying a patient to adressingstation; a shell
burnt in the middle of them, killing three. Patient was left
unwounded and a short amnesia exists for the events imme¬
diately succeeding this. He found himself some time later
lying against the wall of a house, very shaky, nervy, and
jumpy. He walked down to the dressing station of a field
ambulance, and after two or three days was sent down to the
base. He remained there for a fortnight and then rejoined
his unit. It waB at that time behind the line, and patient
stated that he felt well, and as they were out of the shelling
area his “ nerves” did not trouble him. Three or four weeks
before admission to hospital he was sent into the line again
to F-. Then he noticed his nerve beginning to give way;
Bhelling made him nervous, he was jumpy, shaky, and easily
scared, which he had never been before. Abouta fortnight later
hemoved to a dug-out with a signboard opposite—a signboard
destined to play a significant part in his neurosis. His
nerves gradually-grew worse, he began to have terrifying
dreams, and to feel confused and “ silly "—as if he could not
answer questions sensibly. The following morning he bad
an attack of siokness and vomiting, brought on, he thought,
by eating sardines from a tin previously opened, and he was
sent to hospital.
There was no history of any nervous or mental abnormality
in hiB past life and, apart from the faot that his Bister had
been a sleep-walker for some years, his family history was
negative. On examination of the patient there was no sign
of any organic derangement.
The facts described of his history and condition were
elicited without difficulty. From his manner, however, it
was evident that there was something more to be told, and
after some hesitation he admitted, with a certain humorous
shamefaced ness, that a particular image was constantly
recurring in his consciousness. It kept continually obtruding
Itself, no matter what he attempted to do. He felt it was so
ridiculous that he did not care to mention it in the first
instance. He could describe it in no other way than by
saying it was just like a “ spotted pudding.”
We have here an obsessive “ overweighting of a particular
element in consciousness ” and consequent loss of the homo¬
geneity of mind which is recognised invariably to denote the
presence of a mental oonflict.’ The significance of this
symptom was sufficient to show that we had to deal with a
disorder more complex and severe than the common forms of
war neuroses.
The first step in the treatment was to undertake an
investigation of the obsession which offered itself for analysis.
Treatment was begun on August 1st, 1917, and it will be
interesting to record the material of association exactly as it
was produced by the patient. The spotted puddiDg brought
into his mind the image of the “ trunk of a tree; one in a
jig-saw puzzle in the ward—a white spot above it—a white
rabbit—pink eyes—ferns with red flowers—Isle of Wight—
Italy and Sicily- 1 -an Italian woman with a basket—wearing
a navy-blue shawl—with a white edge.”
At this point he stopped, and when asked to tell what was
passing in his mind he became somewhat agitated and
indignant, and said he repudiated the suggestion—an
immoral one—that had been put into his mind regarding
the Italian woman. A few further details were obtained
at this interview, but from the patient’s somewhat disturbed
state it was considered advisable to go no further in the
investigation that day.
The next morning he brought to me the following dream
that had occurred to him during the night:—
I came out of a sohool (dirty old brick affair with court¬
yard), rushed past L., who was standing in the yard (dressed
in dark blue), and was carried some distance (against my
will) into some side streets of an unknown town.
I felt that she was hurt with me and was half afraid to
meet her, yet had a deep longing to meet her. She
apparently followed me (in a very dignified mood).
She came down a narrow street to where I was standing
and the last I saw was a man in khaki trying to force his
attention on her while she was still resisting. (Ucnew that his
attempt to force his company on her would be unsuccessful.)
This, it is evident, is a dream in which the meaning is very
little disguised. The manifest is little different from the
latent content, and the elements of oonflict are readily
discernible.
Analysis brought to light the fact that some time before
the war he had fallen in love with, and become privately
engaged to, a girl much beneath him in social position. His
people were aware of the attachment and bitterly opposed to
it. He was not in a position himself to earn a livelihood but
was living with his people at home who, he knew, would out
him off if he married without their consent. All his prospect^
were bound up with his people’s goodwill towards him.
Relations were consequently very strained at home: an
uncomfortable restraint grew up between him and the rest of
his family and every meeting with his Jianoie had to be
arranged by subterfuge.
A further factor which intensified the conflict was the
strong love he had for his mother. Since his love difficulty he
had had to repress his feelings for his mother—he must give
it all, he said, to one or the other. And he had realised lately
how much he owed his mother, how much she had sacrificed
for her family. His duty towards her he conceived to be respect
and love, but he felt that under the existing circumstances
this was impossible. He was not sure, he said, if he was
justified in continuing this attitude of suppression towards
his mother; he felt that he was not doing what he ought to
be doing. It implied that he would have to make a decision
sooner or later unless he could lead a double life. This, in
brief outline, was the substance of the conflict.
It is interesting to observe how the elements of oonflict are
expressed in the dream itself. L., of course, is his fiamoie,
manifested directly without symbolic concealment. The
phrases, “Rushed past L.,” “Was carried some distance
(against my will),”-“I felt that she was hurt with me
and was half afraid to meet her, yet had a deep longing to
meet her,” very clearly indicate the conflicting impulses of
his state of mind. The school he recognised to be one he
used to pass every day when at home ; the dream, the story
or reproduction of his mental conflict, is given, in other
words, in the first place its natural or realistic setting. The
unknown town he realised at once to be Arras; he could see,
he said, the wreckage and ruin about him. Arras had made
a great impression on him. He was in the Arras sector
when he broke down and had to be sent to hospital. It
formed, in fact, a symbolical indication of the mental wreck
he found himself as the result of the conflict. “She came
down a narrow street to where I was standing.” This led him
through a series of associations to a street—a narrow street
—in his home town and a block of flats there, the sort of flat,
he said, he would choose as a home if he could afford it—
an interpretation whose significance is sufficiently apparent.
The analysis of the “man in khaki” brought out further
factors of the conflict. He proved to be the girl’s present
employer, who, patient said he had reason to believe, was
forcing his attention on her ; he had read between the lines
of her letters.
The investigation of this single dream supplied, it is
evident, an illuminating insight into the patient’s state of
mind, and it furnished, further, the key to the solution of
the “spotted pudding” obsession, the analysis of which
had been left incomplete. The Italian woman, patient
admitted, was his fianoie , L., and when the significance of
the attribute Italian was investigated he stated that the
foot-shaped contour of Italy brought him back to the pre¬
paratory school in which this had been first impressed on
him. He remembered that at this school he had been
punished by the teacher for something he was not guilty of,
and the strong feelings of resentment and injustice he bad
felt had made an impression, he said, which remained to the
present day. The Italian attribute expressed symbolically
the feelings of resentment and injustice associated with the
idea of L. against his people in their treatment of her.
As the nature of the condition was rendered clear it
became evident that the symptoms expressive of war strain—
the shakiness, loss of nerve under fire, &c.—were of minor
importance in comparison with the mental conflict seen to be
dependent on causes wholly antecedent to the war conditions.
Thb Lanobt,]
DR. F. DILLON : THE ANALYSIS OF A COMPOSITE NEUROSIS. [Jan. 11, 1919 59
The shock received from the explosion of the shell, by pro¬
ducing a common type of war neurosis based upon a different
emotional pathology, had impaired the mental synthesis or
“ equilibration.” It had thus created a condition of affairs
predisposing to the development of the second neurosis, which
till then had existed only in embryo. The former were,
consequently, ignored in the further analysis of the condition
as being capable of alleviation or cure only in conjunction
with a removal of the deeper conflict.
The following day—the second after treatment had begun
—he reported that the “spotted pudding” obsession had
disappeared. It went gradually, he said. After he dis¬
covered the Italian woman she took the place for a time of
the “ spotted pudding,” and now the Italian woman had
also ceased to trouble him. Another obsession had taken
their place and was constantly obtruding itself in the same
way. It was the image of the sign-board that had been
opposite the dug out he occupied at F-.
This obsession was accordingly analysed and the associa¬
tions as they came up were as follows :—
“ The colouring of the signboard impressed him (it was
an advertisement for Michelin tyres)—yellow with a bright
blue edging—the French flag—colouring appeared round the
word 4 F—r- '—it changed from green to blue—became dark,
almost black—the word ‘ F-’ resolved itself into a golden
line—two vertioal lines appeared at the edges of it—they
widened to the extent of the board—it appeared like a
hansom cab seen from behind—the ooacbman with tall hat
and oockade—it is a wedding—through the window at the
back he sees a man and a woman kissing-” . After some
hesitation he admitted that it expressed his own wedding.
At the next interview, two days later, he reported that he
felt considerably improved ; his headaches were better and
the obsessions had ceased to trouble him. From that time,
as the analysis of the condition proceeded and one by one
the various and complex factors of the conflict were brought
to light, although from time to time he showed transient
fluctuations, he made steady progress towards improvement.
On August 20th, 1917, that is after three weeks' treatment,
he reported that the chief symptoms that remained were
feelings of weakness and of effort in the attempt to do
anything. The obsessive ideas had disappeared, he was free
from the feeling of conflict and worry he used to have, and
the parsesthesias about the head had gone.
The condition as it unfolded itself became complex to a
considerable degree. It would be impossible, therefore,
within the scope of a short article to describe all the
elements as they revealed themselves and brought to light
the various aspects of the many-sided conflict. £wo further
dreams, however, are of some considerable interest. The
first is as follows:—
I dreamt that an I lay in bed I suddenly realised the
presence of a cat (dark colour) on my right shoulder. I
stroked it and it commenced purring, whereupon I disposed
of it (how I don't remember). Then another oat (also of
dark colour) appeared in the same position, but it was not
uite as tame as the former. Whether it disappeared or not
cannot say, as a small dark-brown, smooth-haired dog
made its presence felt on myself. It had hypnotising
bluish-green eyes (with large pupils) protruding from its
head, and upon my attempt to soothe it (with the ultimate
intention of throwing it out of the window or otherwise
disposing of it) it bit into the palm of my left hand , and the
pain caused me to wake up.
The patient had at this stage gained a certain proficiency
in the art of analysing his own dreams, and he voluntarily
produced the following interpretation. The oat, he said,
seemed to typify his present condition, and the dis¬
posal of the cat seemed to mean that he had thrown off and
got the better part of his mental trouble. The other cat
typified a more diifichlt mental trouble yet to be got rid of.
The dark colour signified his mental condition. The fact
that the second cat was not so tame meant that this remain¬
ing difficulty was not so easy to get rid of as the former one.
Here his analysis ended ; as regards the dog he could find
no interpretation for it. Further investigation, however,
brought to light its meaning. It was shown beyond doubt
to be the symbolic representation of his fiamoSe. and “bit
into the palm of my left hand ” he interpreted as “ some¬
thing I want to get rid of pressing on my brain—something
that binds me, holds me captive that I can’t get rid of it.”
The condensation mechanism in regard to this symbol is
shown in an instructive way in the fact of its being associated
or 44 constellated ” with two complexes of fear, one of whioh
was the memory of an actual experience of being bitten \>y a
rat on one of the fingers of the left hand at the age of 5 or 6.
The significance of this symbol in conjunction with the
parenthetical phrase in the dream 44 with the ultimate
intention of throwing it out of the window, or otherwise
disposing of it,” gives the first indication of the direction in
which a solution of the conflict was shaping itself in his
mind—an inference confirmed subsequently on the patient’s
own admission.
The remaining dream is not without its humorous aspect.
Someone (connected with the staff of this hospital) appeared
and told me that Captain Dillon had committed suicide (as
far as I can remember by means of a tazor). I know that
the scene where the dream took me was unfamiliar, but
cannot recall details.
The “someone” on analysis proved to be my clerk, and
the patient’s immediate further association was that the clerk
prepared all the base lists. He was wondering if he were going
to be sent down to the base. Captain Dillon was the person who
was at the time keeping him back. The unfamiliar scene he
associated as 44 the roadway through the gate of the hospital
—outside—freedom—Blighty. ” The dream, in short, ex¬
pressed his desire to get to England. He had, in fact, a
doubt as to whether he was being treated in order ultimately
to be sent back to the line again. Captain Dillon formed
the obstacle to his desire, and it is arranged that he
conveniently puts himself out of the way. *
The mechanism is well illustrated here of exaggeration or
over-estimation of dream impulses by which difficulties or
obstructing influences are removed not merely sufficiently for
the purpose in view, but in an unnecessarily complete and
extravagant way. This is well shown, too, in the dream of
a patient who came to me in a very distressed state of mind
because he dreamt that he had murdered his father. His
father, it transpired, was a chronic invalid and a severe
burden on the patient, who had a difficult struggle to keep
his wife and children in decency. In the dream the un¬
conscious took a thorough and effective method of disposing
of the handicap, although consciously the patient had never
entertained more than a passing and involuntary regret over
the state of affairs.
Conclusion.
The treatment extended over a period of six weeks. Two
days before being evacuated to the base the patient reported
that the sense of fatigue had diminished, the feeling of
restriction to consciousness had gone, and his power of
concentration was returning.
The case illustrates in a striking way the great value of
early treatment in disorders of this class, and shows that
much may be done even under the conditions of an advanoed
centre in France. It forms a certain endorsement of the
mechanisms of dream formation and of the principles in
general of psycho-analysis. But, probably as important, it
brings forward certain problems in the subject which are
still awaiting settlement.
It will be noted, for instance, that all of the dreams in
the case were not found to contain on analysis a sexual
interpretation, as taught by Freud. |fy limited experience
in this respect coincides with that of the schools of Jung and
Adler in opposing the exclusively sexual interpretation; As
regards, too, the question of a fixed symbolic meaning I am
led to agree with Jung, who teaches that there are no fixed
symbolic meanings to the images in dreams. 44 The various
dream pictures have each their own peculiar value.” *
Another feature of the subject illustrated is the fact that
while in some dreams the whole manifest content is
4 4 phantastic ” in form, every element being disguised in
symbolic figures, in others this is only partially the case,
certain of the elements being used 44 realistically ” in their
everyday significance or value. To what extent the
components of a dream are to be interpreted symbolically
depends on the ultimate analysis of the dream as a whole.
In his conception of the 44 manysidedness ” of dreams Jung
has laid emphasis upon another aspect of dream formation of
very great importance. 44 In view of the comprehensive
manysidednessof the dream material,” he writes, 44 one must
beware above* all of one-sided formulations. The many-
sidedness of the meaning of a dream, not its singleness of
meaning, is of the utmost value, especially at the beginning
of the psycho-analytic treatment.” 5 This is well shown in
the first dream described above.
Finally, there is the problem raised by the nature of the
conflict revealed in the analysis. We have had to deal here
with a neurosis, the expression of a mental conflict dependent
60 ThbLanokt,] DR P. J. OAMMIDGE: PREVENTION AND TREATMENT OF DIABETIC COMA. [Jan. 11, 1919
inherently, not on early or infantile “fixations,” but on a
present and pressing difficulty urgently requiring removal.
In a chapter in “Analytic Psychology ” Jung discusses with
Dr. Loy whether there are not certain moral problems
in their nature incapable of solution. In the present case,
analysis brought to light a conflict which was in large part
unconscious, in which the opposing factors were unrecognised
by or unknown to the patient. By this means the import and
significance of the disrupting influences affecting his mind
were made conscious and clear to him, the different elements
as they appeared laid before him, as far as possible, in their
true proportions. A new mental orientation was thus made
possible for him, a new capacity given him to deal with the
situation. Jung says : “Because (men) will not and cannot
think out to its logical conclusion what it is they really desire,
their erotic conflict is largely unconscious. ” B
The case, I am aware, affords opportunity for an exponent
of the extremer school to maintain that if the analysis had
been carried far enough the inevitable early sexual “fixa¬
tion ” would have been unearthed—perhaps in this instance
in regard to the relation of the patient to his mother. It
is not, of oonrse, impossible, but as it can be neither verified
nor disproved it has little practical bearing on the subject.
On the other hand, the disappearance of the obsessions and
the improvement which resulted in the remaining symptoms
are sufficient practical indication of the accurate direction
of the treatment. An interesting epilogue is formed by a
letter reoeived from the patient a month after evacuation
from the hospital, in which, after expressing his thanks
for the treatment, he says: “ I had very little faith in it
until I realised that you had (1) analysed and thereby
dispelled the obsessions I was troubled with; and (2) proved
to me the mistaken attitude I had adopted towards certain
matters.”
Since the article was first written I have learned that the
patient is now back at his former occupation.
References.—V. Analytic Psychology, p. 355. 2. Psycho-pathology
of Rvary-day Life, p. 114. 3. Hart: Psychology of Insanity, p. 163.
4. Jung: Loc. dt., p. 308. 5. Jung: Loc. olt., p.217. 6. Jung: Loc.
dt., p. 372. ^
THE PREVENTION AND TREATMENT OF
DIABETIC COMA.
By P. J. CAMMIDGE, M.D. Lond.
Of all the complications of diabetes mellitus the
commonest and most fatal is coma. In 60 to 60 per cent,
of cases it is the immediate cause of death, and when
once developed is usually fatal within a day or two, and
sometimes within a few hours, of the onset of the charac¬
teristic symptoms.
Symptom*.
Cana may occur early or late in the course of the disease,
although it is particularly prone to develop during the
first year of treatment, and is more common under
than over 40 years of age. The most striking symptom,
exaggerated respiration without cyanosis or evidence of
physical cause, often appears with dramatic suddenness.
The respiratory movements change their character and
gradually involve all the accessory muscles of respira¬
tion, inspiration is prolonged like the breath preceding
a yawn, while expiration seems forced and more com¬
plete than normal, the so-called air-hunger of Kussmaul. 1
In the earlier stages the respiratory rate is not much accele¬
rated, 16 to 20 a minute, but as the coma deepens it becomes
more rapid and may reach 40 a minute, and there is then no
evident pause between inspiration and expiration. A
ohazacteristic sweet, fruity odour of the breath, which may
pervade the whole room, is noticed occasionally and will
suggest to an experienced observer the cause of the coma.
The face has an anxious expression and is sometimes flushed,
although it is often pale and drawn, with a yellowish tint.
The eyes are generally half closed, the pupils react to light
until deep coma occurs and are usually dilated, less often
contracted. Softening of the eyeball, due to a fall in the
intraocular pressure, is an early and important sign of
diabetic coma. The pulse is soft and accelerated, but rarely
exceeds 120 a minute. The blood pressure is always low and
1 Dent. Arcb. f. klin. Med., 1874, xiv.
falls further as the coma develops. The usually subnormal
temperature of a diabetic rises with the onset of coma and
may reach 100° F. or thereabout, but as death approaches it
sinks again and may fall as low as 90°. The extremities
are cold and in some instances there is slight oedema of the
feet.
Although coma may develop suddenly, particularly in the
course of some intercurrent infectious disease, it is usually pre¬
ceded by several days of suggestive symptoms, which point to
the imminence of its occurrence. The appetite becomes capri¬
cious, digestive disturbances and slight nausea are complained
of, weight is lost more rapidly than would be expected merely
from defective nutrition, and cramp in the legs and abdomen
occurs, particularly at night and the early morning. The
patient beoomes restless and irritable, and complains of
headache, which is frequently attributable to the obstinate
constipation which usually exists. Marked lassitude super¬
venes, and this is followed by drowsiness, which gradually
deepens into profound coma from which the patient cannot
be roused.
Coma of the type described is met with in many cases,
but in some typical air-hunger is slight or absent and
cardiac weakness dominates the picture. The patient may
die suddenly with few warning symptoms, consciousness
being retained to the end, or there may be a complaint
of nausea or weakness, the pulse is found to be soft
and rapid, 140 to 160 to the minute, the heart sounds
are barely audible, and loss of consciousness is rapidly
followed by death. In a few cases the onset of coma is
ushered in by acute excitement and convulsions.
Indication* of Commencing Addon*.
Although the clinical symptoms of diabetic coma usually
develop with startling suddenness, and the premonitory signs
are often so slight or indefinite as to be easily overlooked,
regular examinations of the urine, blood, and alveolar air
furnish indications of the probable onset of the complication,
so that if they are frequently carried out it should come
as no unforeseen event. Ever since Stadelmann, in 1883,
discovered oxybutyric acid in the urine in severe diabetes
and compared diabetic coma with the condition produced
in animals by poisoning with mineral acids, it has been
recognised that diabetic coma is usually associated with a
high degree of acidosis which, unlike the acidosis occurring
in conditions where there is no disturbance of carbohydrate
metabolism, is accompanied by the presence of acetone
bodies in the urine.
• The appearance of these bodies is usually the first sign
of commencing acidosis. As the alkaline reserves of
the body are lowered, through their being used for the
neutralisation of the excessive formation of acids, the
tolerance for sodium bicarbonate increases so that instead
of 5 g. (77 gr. or 1} dr.) given by the mouth, being
lowed by the excretion of part in the urine, with a conse¬
quent change in the reaction to litmus from acid to alkaline
as in normal persons, 75 to 100 g. (24 to 34 oz.) or more
may be required in individuals on the borderland of coma.
At the same time there is an increase in the ammonia output
in the urine from the normal of 0 6 to l*0g. per day, up to as
much as 10 or even 12 g. in cases of deep coma. As a rule
an excretion of 4 g. a day rarely exists for more than a few
days without coma developing. Normally the ammonia
nitrogen constitutes 4 to 5 per cent, of the total nitrogen of
the urine, but as coma becomes imminent 40 to 50 per oent.
of the nitrogen may be excreted as ammonia.
A useful indication of serious acidosis is a diminution in the
available carbonates circulating in the blood which may be
determined indirectly, from a lowering of thecarbon dioxide of
the alveolar air, or directly from the blood itself. The carbon
dioxide of the alveolar air can now be estimated at the bed¬
side very easily and quickly by the simple and ingenious
method devised by Marriott,- but for the analysis of the
carbon dioxide content of the blood the more elaborate
laboratory methods of Van Slyke 3 are required. A diminu¬
tion in the titratable alkalinity of the blood indicating an
acidosis of clinical significance can be readily detected by
the method described by Sellards, 4 which depends upon the
change in reaction to phenolphthalein from alkaline to
3 Journ. Araer. Med. Association, 1916, lxvi., p. 1694.
* Proc. Soc. Hxpt. Biol, and Med., 1915, xii., 184 ; Journ. Biol.
Chem., 1917. xxx., 305. Ac.
* Principles of Acidosis, Harvard T’niv. Press, 1917, p. 103.
Thb Lancet,] DB. P. J. OAMMIDGB: PREVENTION AMD TREATMENT OP DIABETIC COMA. [Jan. u, 1919
61
neutral ol the protein-free filtrate of the serum when the
alkali reserve of the body is definitely subnormal.
Criticism of Alkali Therapy.
Clinical experience and many laboratory experiments have
suggested that diabetic coma is the culminating point of an
increasing acidosis, and one might therefore expect that
therapeutic measures to counteract and control the acidosis
would prevent the onset of coma and cure it should it have
developed. The obvious treatment would be to make good
the al&aline reserves of the body and ensure their being main¬
tained at the normal level by the administration of alkalies
by the mouth or, if need be, by intravenous injection. It is
true that a certain degree of success has apparently attended
tins method of treatment, and there are even a few cases of
diabetic coma on record where large doses of sodium
bicarbonate have saved the patient, at any rate temporarily,
but on the whole the results of alkali therapy have been
disappointing, and it can hardly be claimed that the death-
rate has been materially improved by it. After all, it is only
symptomatic treatment which does not touch the source of
the trouble, the excessive formation of organic acids. More¬
over, the attempt to control an acidosis with alkalies is not
always free from danger and discomfort. Large doses of
alkali, such as are often necessary, are apt to cause irritation
of the gastro-intestinal tract and give rise to nausea and
vomiting, especially if not administered in very dilute solu¬
tion, and then the large amount of fluid may overburden
toe stomach and throw excessive work on the kidneys.
When taken over long periods alkalies interfere with diges-
tion, tend to deplete the body of necessary salts, particu-
lany chlorides, and have a depressing effect on the heart if
sodium salts are chiefly used. Finally, as Joslin has pointed
out, it is possible that the administration of alkalies over
long periods may set free acid bodies existing combined,
quiescent, and harmless in the tissues, and so do harm,
for the constant use of alkalies appears to promote the
ocmstant excretion of acid bodies. It is doubtful, therefore,
whether the attempt to treat acidosis and prevent coma in
diabetes with alkalies is sound practice, more especially as
Allen s experiments 3 have shown that in diabetic dogs no
apparent prolongation of life results from keeping the
alkaline reserve of the body normal with alkalies given
intravenously or by the mouth.
Control of Fat Intake.
A more satisfactory way of attacking the problem would be
to prevent the formation of unoxidised acid products by
limiting the material from which they are derived, and this
is quite a feasible proposition, for the work of Rosenfeld,
Hirschfeld, Magnus Levy, and others have shown that fat
is the chief source of the acetone bodies and that it is from
the fat of the food they are mainly derived. Recent work
has proved that careful oontrol of the fat intake in the diet
is one of the most certain practical methods at present at
our disposal for preventing acid intoxication and subsequent
coma. By this means Joslin, 8 who was a pioneer in that
aspect of the treatment of diabetes, has been able to reduce
hw death-rate through coma from an average of 64 per cent,
to 44 per cent. . r
AU Th f r f to . he two reasons why systematic control of
fat intake m diabetes has been hitherto neglected •
(1) the very prevalent idea that diabetes is merely a defect
of carbohydrate metabolism; and (2) the generally held
doctrine that loss of weight by diabetics must be prevented
at all cost. Experiments with diabetic animals and clinical
observation have alike shown that both these ideas are
erroneous. Diabetes is not a mere inability to assimilate
giucose; from the first it is a defect in the metabolism of
carbohydrate, protein, fat, and probably mineral sub-
stances as well, so that treatment directed to the control
of the glycosuria alone deals with one aspect of
the disease and overlooks what may be more serious but
tor a time, less evident defects in the chemistry of the
body. I he treatment from the commencement must be based
on the hypothesis that we have to deal with a general failure
of metabolism, and that while restriction of a single food
principle, such as carbohydrate, may suppress the symptoms
temporarily the progress of the diabetic process only be
prevented and complications, including coma, avoided by
dealing with the rendition ap a whole. ^
« __. 5 Amw. Joor. Med. Sol., 1917, M&roh.
Treatment of Diabetes MeUltus, Lea and Feblger, 1917, p. 342.
Fat being the principal source of the unoxidised acid
end-products giving rise to acidosis, control of the fat
in the diet of a diabetic is obviously a matter for serious
consideration from that point of view alone, but it
is also important from another aspect. It would seem
that the weakened metabolic functions of the diabetic
are capable of dealing with only a definitely limited
load, and that when this load is exceeded failure of the
metabolic processes occurs. Consequently, although a
reduction of the carbohydrate in the diet may stop the
glycosuria, it will not prevent the disease progressing if the
total intake of food is maintained by adding fat or protein.
The metabolic functions will then still be over-taxed, and in
spite of an apparent improvement the glycosuria will
eventually return with increasing acidosis, See. For a time
the progress of the disease may again be stayed by
lowering the carbohydrate intake, but so long as the total
load of food is not reduced the downward progress of the
disease will continue. In other words, the case will have
the characters of a progressive diabetes with a steady fall in
carbohydrate tolerance, a type one so frequently meets,
especially in young people where an attempt is being made
to keep up the weight by over-feeding with fat and protein.
If, on the other hand, such patients are allowed to lose
weight until the body mass is reduced to a level that can be
maintained by a total load of food below what be
efficiently dealt with by their defective metabolic powers
the apparently inevitable progress of the disease is checked,
return of the glycosuria is prevented, and acidosis is avoided,
or at least kept within narrow limits. It is true that
patients treated in this way become thin, but it does not
follow that they are less efficient muscularly, for, as
Williams’s experiments have shown, 7 and my own clinical
experience confirms his results, muscular efficiency and
weight are not synonymous. A thin patient feeding within
his metabolic limits can do more, and is less'easily tired,
than one who is over-taxing his metabolic powers in an
attempt to maintain a hypothetical weight for an individual
of his size or who is over weight.
Causation of the Coma.
Regulation of the fat intake in diabetes undoubtedly
places in our hands a most useful weapon for combating
acidosis, and it appears probable that the death-rate from
coma may be materially reduced thereby, especially when
control is exercised from the earlier stages of the disease,
but it does not necessarily follow that no other methods
are available to reduoe still further a mortality which is
appallingly high.
It has been for so long the custom to acoept acidosis
and coma as cause and effect in diabetes that the pos¬
sibility of the acidosis being an associated, and perhaps
an incidental, phenomenon has not received the attention
it deserves. The failure of alkali therapy to achieve the
results expected of it has been one of the main stumbling
blocks in the way of a general acceptance of the acid
intoxication theory, and it has therefore been suggested by
some that the ketonic acids and their salts induce coma,
not in virtue of their acid properties, as that theory
assumes, but in consequence of some specific toxic action
they possess. But experiment has proved that these sub¬
stances are not poisonous to normal animals in doses likely to
be met with in practice. To meet this difficulty it has been
claimed H that aceto-acetic acid and its salts are toxic if the
animal is first rendered diabetic by extirpation of the pancreas.
I am not prepared to deny that a diabetic and a normal
animal may react differently to these substances, and that
they may be more poisonous to the former than to the latter,
but the fact that a condition which is known to alter funda¬
mentally the metabolism of the body, and of itself leads to
coma, has to be instituted before reasonable doses produce a
toxic effect rather tends to weaken the force of the argument.
There can be no doubt that coma is the consequence of an
auto-intoxication, but consideration of the evidenoe available
suggests that it is a toxaemia resulting rather from the
general failure of metabolism occurring in diabetes th**
from a specific toxin originating in a break in the chemistry
of the body in one particular direction. It seems moat
likely that coma may be produced by several toxins of
different origin acting together. In some instances, however,
7 Arch. Int. Med., September, 1917, p. 399.
8 Poulton: The Lancet, June 29th, 1918, p. 897.
62 ThbLanott,] DR. P. J. CAHMIDGB: PREVENTION AND TREATMENT OF DIABETIC COMA. [Jan. 11,1919
the metabolic defect may be more complete or rapid in one
direction than another, and occasionally there may be
associated defects in excretion, such as we know to occur in
interstitial nephritis, which will cause one type of poison to
have a preponderating effect. In this way we can account
for the variations in the symptoms met with in different cases
and for the occasional beneficial effects of the alkaline
treatment.
Possible sources of toxins, other than fat, are carbo¬
hydrate and protein, while the modifying influence of
inorganic salts on metabolism must also be taken into account.
It is unlikely that carbohydrates give rise to poisonous
materials that tend to produce coma directly, for experience
has shown that increase in the carbohydrate content of the
diet when coma threatens often brings about a temporary
improvement, especially when the patient has been treated
previously on the historic lines of a “carbohydrate-free”
diet, consisting chiefly of protein and fat. Indirectly an
excess of carbohydrate in the diet, no doubt, has an influence
in causing this complication, first through its effect in
accentuating the metabolic deficiencies which underlie the
diabetic condition, and secondly through the dehydration of
the tissues consequent on the presence of an excess of sugar
in the circulation. Water is needed to maintain the volume
of the blood required for the mechanical efficiency of the
circulatory apparatus, to carry nourishment to the cells, to
remove the waste products of metabolism in solution, and
to maintain the osmotic conditions essential for cell life.
When it is abstracted from the body, and the loss is not
made good owing to conditions of the gastro-intestinal
tract which prevent retention and absorption, acidosis,
sudden large inflammatory exudates, and other reasons,
serious and rapid loss of weight occurs, the respira¬
tions and pulse increase in frequency, the systolic
blood pressure falls, the tension of the eyeball is
markedly diminished, the tongue becomes dry and parched,
there is oliguria with constipation, the patient becomes
restless and irritable, then apathetic, and, finally, comatose.
The similarity of these symptoms to many of those met with
during the onset of diabetic coma suggests that some of the
latter, at least, may be a consequence of the dehydration of
the tissues produced by a high concentration of sugar in the
blood. It also helps to explain the frequency with which
coma is precipitated by gastro-intestinal disturbances,
particularly when there is vomiting or diarrhoea, and by
conditions where large inflammatory exudates take place.
Disturbances of Protein Metabolism.
In 1913 Pribram and Loewy 9 suggested that abnormal
products of protein cleavage might be responsible for part.of
the symptomatology of diabetic coma. Other authors have
since claimed that death in some cases may be entirely due
to the effect of toxins resulting from the imperfect meta¬
bolism of proteins, and quoted cases of fatal coma where no
evidenoe of acidosis existed. 10 The occurrence of suoh cases,
the absence of typical air-hunger in many instances, and
the failure of alkali therapy to control the coma in most
oases favour the argument that the condition does not
always, or entirely, depend upon the acid products of
defective fat metabolism and lend support to the view that
other toxins are involved.
It has been shown experimentally that some of the
products of protein disintegration are toxic, producing
among other symptoms lowering of the blood pressure,
depression, and narcosis, but no attempt appears to have
been made to isolate such substances in diabetes. Sjme
experiments I commenced four or five years ago with that
end in view had to be abandoned temporarily, but so far as
they went, and taken in conjunction with the results of the
routine analysis of the urine in a large number of cases, they
showed that protein metabolism in diabetes tends to become
less and less complete as the disease advances, and that this
is associated with a progressive failure in the functions of
the liver similar to what is met with in acute yellow atrophy,
some of the toxaemias of pregnancy, Ac. One of the most
striking features of the urine in all severe cases of diabetes
is the constant presence of amino-acids, which increase
in amount as the disease advances, so that the amino-
aoid nitrogen often constitutes 50 per cent, or more
of the total “ammonia nitrogen” as estimated by
• Zeft. f. klin. Mad., 1913, Ixxvil., 384.
» Sea Pauly and Boulud, Lyon M&Ueal, March, 1917. p. 118.
the Malfutti formalin process. In one instance, for
example, I found 6'3 g. of amino-acid nitrogen out of
a total of 7*8 g. of “total ammonia nitrogen ” in a 24 hours'
specimen of urine passed six days before death from coma
took place. In three cases where an analysis of the collected
24 hours' urine was made shortly after the premonitory
symptoms of coma had appeared the amino-acid nitrogen
was found to have dropped suddenly and in one had entirely
disappeared, although 4*3 g. had been present the previous
week. The nature of the amino-acids was investigated in
II cases, three of which eventually died of coma. Tyrosin,
histidin, phenyl-alanin, and glycocoll were found in all,
while tryptophan, alanin, leucin, and arginin were only met
with in the more advanced. In two cases, both of which
died shortly after of coma, an amine resembling in some
respects a toxic base described by Dale and Laidlaw 11 was
isolated. Very often a marked increase in the uric acid out¬
put, which may reach 8 or 9 g. a day, is seen at, or about,
the same time as the rise in the amino-acid nitrogen occurs
and without any change in the diet being made. As a rule,
the curves of excretion of uric acid and creatinin tend to run
in opposite directions in diabetes and the rise in the uric
acid preceding the onset of the symptoms of coma is no
exception, a corresponding fall in the creatinin output
usually being seen. Simultaneously the excretion of urobilin
in the urine increases. These observations point to the onset
of coma being associated with a failure in the functional
activity of the liver, and it seems likely that the resulting
imperfections in protein metabolism may be a contributory
factor at least in bringing about the condition.
Effect of Withdrawal of Bases from the Tissues.
In a previous paper 13 1 considered the effect of the with¬
drawal of bases from the tissues resulting from acidosis, and
particularly of calcium and magnesium. I there pointed out
that a balance between the two appears to be necessary for
the smooth and efficient working of the nervous system and
that an excessive loss of magnesium is associated with
nervous instability. A striking increase in the magnesium
and calcium loss in the urine is a constant feature of all
severe cases of diabetes, and it is not unlikely that this loss
renders the nervous system more susceptible to the action of
toxins formed in the liver and elsewhere. The experiments
of Osborne, Mendel, and Ferry lend support to this view, for
they found that rats fed on a diet poor in inorganic salts, but
otherwise satisfactory, eventually developed coma, and that
they could be resuscitated by the administration of a mixture
containing calcium and potassium phosphate, sodium
chloride, and citrates of sodium, iron, calcium, and
magnesium. 1 ’
Preventive Treatment.
If, as the foregoing considerations suggest, diabetic coma
is not due to one cause, but is a complication arising from
the cumulative effects of several, which result from the
general metabolic failure of the diabetic organism, it is clear
that treatment directed to one cause is not likely to control
the symptoms, at any rate, more than temporarily, and that
the only “cure” is to prevent all possible causes by so
arranging the diet that (1) the patient's tolerance for carbo¬
hydrate, protein, and fat is not exceeded ; (2) the total load
of food is within his metabolic capacity; (3) the diet is
correotly balanced; and (4) a sufficient allowance of
inorganic salts is provided. Obviously the earlier in the
course of the disease such treatment is commenced the
better are the results likely to be and the less difficult will it
prove to arrange a diet fulfilling the neoessary conditions, but
even with advanced cases a surprising improvement can
be effected by careful dieting along these lines.
When a diabetic patient is first seen no change should be
made in the character of his food. If possible he should be kept
for a few days on an ordinary mixed diet of known composi¬
tion and the opportunity taken to investigate his metabolism
by analyses of the urine, blood, Ac. The effect of excluding
fat from the diet should then be tried. After a day or two
on a fat-free diet the protein may be reduced by half.
Subsequently the carbohydrate allowance may also be
halved, then the remainder of the protein excluded, and
the carbohydrate further reduced until a diet of green vege¬
tables of low carbohydrate value only is being taken. If
11 Journ. PbyaioL, 1910, xll., 318.
u American Medicine, June, 1916, p. 370.
13 Carnegie Institute of Washington, 1911,166, il., 80.
Thb Lakobt,] DR. P. J. OAMMIDGE : PREVENTION AND TREATMENT OF DIABETIC OOMA. [Jan. 11, 1919 63
sugar is still being excreted in the urine or the blood Bngar
is high and serious acidosis or evidence of abnormal tissue
waste persist, two or three days’ “ starvation ” may be pre¬
scribed, bat longer continaoas fasts are best avoided.
Abstinence from food usually has a remarkable effect,
improving carbohydrate tolerance, correcting errors in
protein metabolism, and reducing acidosis, so that patients
apparently in a grave condition may often be rescued and
put on a metabolic basis that permits of a satisfactory diet
being subsequently constructed.
The building up of the diet must be gradual and be carried
out in the reverse order to that outlined above—that is to say,
green vegetables alone, with a gradually increasing carbo¬
hydrate content, should be allowed first, then a very limited
amount of fat-free protein, such as boiled white fish or chicken,
is added, more carbohydrate is next given, and later the pro¬
tein is increased until the patient is in nitrogenous equilibrium.
When this point is reached fat may be allowed, at first in
small quantities and later in larger amounts, but the effect
on protein metabolism and the utilisation of carbohydrate
must be carefully watched by regular examinations of the
urine and blood. It is necessary that part of the carbo¬
hydrate should continue to be taken in the form of green
vegetables, the exact proportion varying according to the
patient’s tolerance for starchy foods. It is also an advantage
if at least one serving of raw vegetable (e.g., as salad) is
eaten each day. These precautions not only help to over¬
come the constipation from which most diabetics suffer, but
also ensure a sufficient supply of the inorganic bases that
are essential for proper metabolism and render the medicinal
use of alkalies unnecessary.
No attempt should be made to work the diet up to a theoretical
caloric content based upon the size of the individual. If
this can be done without risk so much the better, but the
future progress of the case should not be sacrificed for a
merely temporary benefit. The diet must be arranged
to suit the patient’s present metabolic capacity, not his
appetite; in other words, he must be taught “ to eat in
order to live, not live to eat.” The cardinal and very
common mistake of an unbalanced diet should be carefully
avoided. The effect of an excess of carbohydrate soon
shows itself in the urine and is easy to recognise, but the
equally deleterious results of too much protein or fat are not
at once so evident. The best guide to the protein limit is
the nitrogen balance, and the protein allowance should be so
arranged that its nitrogen content does not exceed the daily
total nitrogen output in the urine by more than 1 or 2 g. So
long as this ratio'exists further trouble from disturbances of
protein metabolism need not be feared. Fat, unbalanced by
other foods, is an insidious poison for the diabetic, and every
endeavour should therefore be made to keep the fat allow¬
ance at a level corresponding to the patient’s capacity for
dealing efficiently with other foods. For practical purposes
it may be taken that the allowance of fat, at least in the
earlier stages of treatment, should not exceed the allowance
of carbohydrate, or at most not be more than half as much
again. A higher proportion-is likely to lead to subsequent
difficulties, and these are certain to occur if the proportion
of fat to carbohydrate is more than 4 to 1. Determina¬
tion of the fat content of the blood is undoubtedly
the best guide for ascertaining the optimum allowance of
fat in the diet, but regular estimations of the percentage of
sugar in the blood also give useful indications, for a steady
increase, especially if not associated with glycosuria,
suggests that too much fat is being taken.
I have recently had under my care a patient, sent to me by
Sir John Tweedy owing to an eye trouble associated with
diabetes, who illustrated this point very well. When I first
saw him his blood sugar stood at 0-20 per cent, and he was
passing 15 g. of sugar a day in his urine. After a week of
treatment the glycosuria had disappeared and his blood sugar
had dropped to 0 *08 per cent. A week later on a diet containing
50g. of carbohydrate and 70 g. of protein, but practically no fat,
the blood sugar had risen to 0*11 per cent. He was then given
fat in gradually increasing amounts up to 60 g., when it was
found that the blood sugar had risen to 0*18 per cent.,
although there was no sugar in the urine. On dropping the
fat to 10 g. but not otherwise altering the diet, the blood
sugar came down to O il per cent, again. A return
to the previous allowance of fat was followed by a rise
in the blood sugar to 0*18 per cent., but still without
glycosuria.
Treatment of Cases with Coma .
So long as the exact cause of diabetic coma remains
obscure preventive treatment based upon a system of dieting
calculated to stay the progress of the disease as a whole is
the most certain means for eliminating this, and other, com¬
plications. It sometimes happens, however, that a patient
is not seen until coma has developed or its onset is imminent.
Under these circumstances he should be put to bed and be
kept warm with suitable clothing, hot bottles, ice. All dis¬
turbing influences should be avoided and absolute rest and
quiet be insisted on. The bowels should be thoroughly
cleared by one or two large enemata. If there is a history of
constipation a small pill containing bile-salts, calomel, and
pil. rhei co., or colocynth and hyoscyamus, may be given
and repeated if necessary, but excessive purgation with the
risk of subsequent diarrhoea must be avoided. Gastric lavage,
if practicable, may help to eliminate toxins. Whatever diet
has been taken previously it should be stopped and replaced
by 2 oz. of lemon juice, and either 7 to 8 oz. of potato or
2£ to 3 oz. of oatmeal, taken in the form of thin pur6e
or gruel in small quantities at 3 or 4 hourly intervals
over the 24 hours. If possible the starch should be
dextrinised by steaming the potato for 3 to 4 hours
and gently boiling the oatmeal for 5 to 6 hours. After
24 to 48 hours even this small amount of carbohydrate may
be omitted for a day or two. From the first the patient
should be encouraged to drink as much liquid as possible,
preferably in the form of hot water, weak tea or coffee,
thin broth, &c., a minimum total of 5 to 6 pints, distri¬
buted evenly over the 24 hours, being aimed at. Should so
much fluid be refused, nr if there is a tendency to vomiting,
the balance should be administered as normal saline per
rectum, or, if need be, intravenously. Intravenous injec¬
tion should not be too long delayed, as there is much more
hope of its being beneficial during the premonitory stage
than when coma has actually developed.
It has been the custom to give large doses of alkali in coma
and threatened coma, but lately Joslin has claimed that better
results can be obtained if alkalies are avoided altogether
and simple salt solution, or even tap water, is used for
injections.' According to him, if alkalies have been given
previously they should be omitted at the rate of 10 g. a day.
There are some cases which are undoubtedly benefited by
alkali therapy, however, particularly those where there
is a uraemic element in the condition, and I therefore
think that if speedy improvement does not follow the
measures outlined above alkaline injeotions should be
tried. Small uncontrolled doses are useless, the only
method likely to be of much avail is to employ
massive doses and regulate their administration by
repeated examinations of the blood by Sellards’s method or
by estimations of the carbon dioxide content of the alveolar
air. The injections should be continued until it is dear
that any acidosis, whether due to the diabetic condition or to
uremia, has been neutralised by a return to normal of the
titratable alkalinity of the blood or of the carbon dioxide
content of the alveolar air. The copious diuresis that
follows large intravenous injections will tend to eliminate
other toxins, and bleeding from the opened vein to the extent
of 10 or 20 ounces will also help in that direction.
Bioarbonate of soda is the alkali usually employed for intra¬
venous injection, although some have advocated the use of
the normal carbonate, on the ground that it has a greater
neutralising power; but this advantage is more theoretical
than real, for while it is true that weight for weight the
carbonate can neutralise more than one and a half times
as much acid as the bicarbonate, the latter can be used
with safety in so much stronger solution that the difference
is more than counterbalanced. Observation has shown
that an average adult possesses not much more than 200 g.
of sodium bicarbonate, or its equivalent, in a form available
for the function of respiration, and that with a deficit of
150 g. or more air-hunger and coma develop. We may
therefore assume that in most cases of coma a dose of
bicarbonate of soda approaching 150 to 200 g. (5 to 7 oz.)
will most likely be required. It would obviously be dangerous
to introduce this amount into the circulation at one dose,
and the maximum that should be attempted is 50 to 60 g., in
the form of a litre of a 5 to 6 per cent, rotation, or 1$ oz. of
sodium bicarbonate in 30 oz. of water. The solution should
be sterilised if possible, but precautions should be taken
to prevent the formation of the caustic normal carbonate,
64 The Lancet,]
CLINICAL NOTES.
[Jan. 11,1919
whioh readily occurs on boiling. If the bicarbonate
solution is filled into strong narrow-necked bottles,
with tightly-fitting stoppers tied in place so as to
reduce the air-space to a minimum, this danger is very
largely avoided, and to make sure a stream of carbon
dioxide gas may be bubbled through the solution after it
has cooled. In an emergency unsterilised tap-water may be
used without serious risk. The solution should be injected
by the gravity method very slowly, half to one hour being
allowed for a litre, and it should be kept at or about the
temperature of the body. It is usually necessary to repeat
the injection in about six hours, and if need be it may be
repeated again after 12 and 18 hours.
Cardiac stimulants are advisable at an early stage in all
cases of coma or threatened coma. Digitalis, subcutaneously
or by the mouth, is probably the best, but strychnine,
caffeine, alcohol, ether, camphor, ammonia, and pituitary
extraot may also be useful. There is a natural disposition to
administer oxygen to relieve the distressing symptoms of
air-hunger, but it is a useless procedure, excepting for the
mental effect on those who are watching, for the difficulty in
respiration has been proved not to be due to lack of oxygen.
Climral Stotts:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
♦ . -
A NOTE ON THE FORMATION OF OTHER
AGGLUTININS IN CASES OF MALTA FEVER.
By L. T. Burra, M.D. Oxon.,
la.tr temporary captain, r.a.m.c.
This note was written with a view to its publication in
June, 1916, when the work was cut short by my transfer
from Malta to Egypt, but owing to circumstances which
arose at that time permission to publish it was withheld. I
am indebted to Colonel A. C. O'Sullivan, A.M.S., for his
permission to publish it, which was granted at a later date,
and of whioh I now avail myself.
In the course of routine examinations of patients’ sera
in the laboratory of the Military Hospital, Imtarfa, Malta, I
noticed that in cases of Malta fever agglutinins for the
Vibrio cholera appeared, although, according to their
histories, the patients had not been inoculated against
cholera and had no symptoms of cholera. I have not been
able to collect sufficient cases to state that in cases of Malta
fever there is always the power to agglutinate a cholera
emulsion, but the occurrence of this phenomenon in six
cases is perhaps sufficient justification for drawing attention
to it in this note.
The routine examinations of sera for agglutinins were
made on slides by the rapid macroscopic method, using
dilutions of serum from 1 in 10 upwards and emulsions in
normal saline of dead and washed bacteria. In three oases
the sera were put up in a series of dilutions in Wassermann
tubes in the usual way, and were examined after 24 hours at
the laboratory temperature.
The results of my observations were that in all six cases
both M. melitensis and V. cholera were agglutinated. In one
case the serum when first examined agglutinated the former
only ; two weeks later there was feeble cholera agglutina¬
tion as well, while six weeks after the first examination this
serum agglutinated M mclitensU up to 1 in 1600 and
V. cholera up to 1 in 200. In those cases in which I had
enough serum I added to a 1 in 5 dilution of the serum
an equal quantity of the emulsions of M. melitenrit and
V. cholera in separate tubes, examining the serum for
agglntinins after 24 hours at laboratory temperature. In
every case saturation with if. melitenei* emulsion removed
the power of agglutinating cholera ; and in the four
cases in which the serum was saturated with cholera
emulsion it retained its power of agglutinating if. melitensis.
I am indebted to Professor Zammit for the sera of three
goats which were known to be infected with M meliterms .
which I examined on the same lines as the human sera. All
of these sera agglntinated V. cholera as well as if. mditensti,
and after saturation with M. melitenris emulsion this power of
agglutinating V. cholera was removed.
In no case was the serum heated, and in none of the
patients was the if. meliteiuie grown from the blood, so that
the evidence of if. melitetisis infection may be considered
insufficient. The point, however, may be of interest to those
who have the material for further investigation, and for this
reason I draw attention to it. In conclusion, I wish to
express my thanks to Professor Zammit and to Surgeon
Lynch, R.N., who kindly provided me with some of my
material; and to Captain W. B. Alcock and Captain N.
Campbell, R.A.M.C., for their advice and suggestions as to
the tests which I have made.
Ajlesbury. _
A CASE OF ASPIRIN POISONING.
By F. W. Lewis, M.R.C.S., L.R.C.P.,
ACTING MAJOR, R.A.M.C. (T.).
In view of the promiscuous way in which aspirin, often
self prescribed, is taken by the general public, the following
case is of considerable interest to the profession.
Patient, sergeant, U.S.A., aged 24, was admitted to the
Thetford Military Hospital on Oct. 25th, 1918, with the
history of having been taken ill two days previously with
influenza. He was a powerfully built man and gave no
history of previous gastric or intestinal trouble. He stated
that he had beea taking aspirin capsules of his own in
addition to 18 5-gr. tablets given to him by the medical
orderly. Instead of keeping to the prescribed dose, he had
taken‘them all, together with a number of capsules in the
course of six hours. He did this in order to get fit quickly,
as he was under instructions for France.
On admission patient was markedly anaemic, temperature
101 a 4 c F., pulse 120. During the day he vomited undigested
milk, with no trace of blood. On Oct. 26th the amemia was
more profound. Pulse 150—weak and irregular. An enema
was administered with little result. The vomiting continued
at intervals. On the following morning, at 5 a.m., a large
quantity of blood was passed by the bowel and he rapidly
became unconscious. No thought of an exploratory laparo¬
tomy oould be entertained. He died a few hours later.
Post-mortem .—There was no peritonitis, and no free fluid
in the abdominal cavity. The last 5 feet of the ileum was
acutely congested, and the caecum and colon were loaded
with blood clots. The line of demarcation between healthy
and congested bowel was very definite. On opening the
small intestine it was found to be uniformly inflamed. The
mucous coat had apparently disappeared, leaving the sub¬
mucous coat and blood-vessels exposed and eroded. Bleeding
from this large area had evidently been the cause of death.
The other organs were in a healthy condition.
Remarks.— Aceto-salicylic acid is known to pass unchanged
through the stomach and upper portion of the small intestine,
and is then converted into free salicylic acid. It is probable
that this man took nearly 200 gr. of the drug into an empty
alimentary canal, and that the salicylic acid formed was
responsible for the removal of the whole lining membrane of
the bowel in the area described. The mucous membrane of
the osecum and colon appeared to be unaffected. An inquest
was held and a verdict of ‘ ‘ Death by misadventure through
an overdose of aspirin ” was returned. It would be interest¬
ing to know if this possible action of large quantities of
salicylic acid on the bowel is recognised, or if this case may
have been due to some impurity in the aspirin.
A CASE OF STRANGULATED FEMORAL
HERNIA.
By Stephen M. Lawrence, M.D., B.S.Lond.,
M.R.C.S., L.R.C.P.,
ASSISTANT SURGEON, GRAVE8END GENERAL HOSPITAL; 8URGEON, YACHT
CLUB, V.A.D. HOSPITAL.
The following case of strangulated femoral hernia seems
worth recording, partly because it is unusual for such a
condition to come under treatment so late and partly because
several mistakes were made in the treatment, and by these
mistakes it is hoped that something may be learnt.
The patient, aged 47, is the mother of nine children. She
sent for her doctor on Nov. 27fcb, 1917, who diagnosed a
strangulated femoral hernia which bad existed for four days.
She had been in great pain all this time, had vomited con¬
tinually, and had passed no flatus, but she had not kept in
bed.
First operation (Nov. 27th, 1917).—On opening the sac it
was found full of offensive pus and a knuckle of gangrenous
bowel, about 2 inches long, whioh was giving way at the
Tu Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Jan. 11, 1919 65
neck of the sac. The same incision was extended upwards
and outwards, the deep epigastric vessels ligatured, Poupart's
ligament divided, and the peritoneum opened, thus exposing
well the whole damaged bowel without pulling on or in any
way disturbing the parts. 1 The strangulation was about
5 feet above the caecum. About 5 inches of the gut were
removed. An attempt was then made to get the cut
ends delivered out of the wound for an anastomosis. But
the mesentery was so oedematous, congested, and friable,
that any further handling caused tearing and bleeding, and,
what was worse, stripping of bowel from mesentery. After
wasting much time in this attempt and arresting haemor¬
rhage, another three or four inches had to be resected where
it had stripped from the mesentery, and, finally (what should
have been done in the first instance) a Paul’s tube was tied
into the proximal gut. This was anchored to the lower end
of the incision (i.e., the femoral ring) and the distal gut
anchored to the very top of the incision. The patient stood
the operation better than I expected. The Paul’s tube held
for three days. The superficial part of the wound
suppurated and prevented further operation for seven weeks.
In the meantime the patient lost much flesh although she
took food well, and in spite of opium and bismuth, which
were exhibited to delay peristalsis.
Second operation (Jan. 16th, 1918).—A vertical incision was
made just to the right of the middle line. Towels were
clamped to the edge of the wound by Van Houzel and
Backhaus forceps. On opening the peritoneum it was
difficult to identify the parts because of adhesions, which
considerably delayed the operation. The distal portion of
the bowel, which had shrunk to very small dimensions, was
then divided at (a), about 3 inches from where it was
anchored to the skin (6), and both ends closed. A lateral
anastomosis was then made to the proximal gut at (e), about
8 inches from where the latter was anchored to the femoral
ring ( d ). The distal gut was so small and the proximal so
large that, fearing symptoms of obstruction, the division of
the latter at (c) was left for the subsequent operation. I
thought that by plugging the orifice at (d) the faeces could
be induced to go entirely along their new channel, and that
possibly a third operation might not be necessary. This was
undoubtedly a mistake.
The patient suffered no shock from the operation, but had
severe ether bronchitis with a marked rise of temperature.
After 14 days, by the aid of enemata, about half the faeces
appeared in the stools. After that the amount in the stools
steadily declined. Plugging the orifice was useless. The
plug was forcibly ejected after much pain. Saline aperients,
which the pharmacologists tell us act chiefly on the lower
bowol, were tried, but only increased the amount on the
dressings. The patient’s skin got very bad. She became
emaoiated, listless, and depressed.
Third operation (Feb. 18tn, 1918).—The abdomen was opened
through the scar of the last operation, much care being
taken to shut off the skin, whioh was very swollen ana
eczematous from being in oonstant contact with f races. This
operation proved the most difficult of the three on account
or the massive adhesions. It was impossible to identify the
piece of bowel for severing except by pushing a long instru¬
ment into it through the opening at (d) and feeling for the
end inside the abdomen. It was divided about 5 inches from
its opening on the surface. The end of the bowel was then
dosed—silk for the mucous membrane and catgut Lembert
sutures for the peritoneal surface. I used catgut because
1 feared a possible stitch sinus. But the catgut must have
slipped and f races in abundance appeared in the wound on
the third day. The mesentery of the detached piece of
bowel ( c-d) was next ligatured and divided. This piece of
gut was then forcibly dragged out of the wound, leaving a
large hole at the site of the femoral ring, admirable for
draining. The central wound was then closed and a drainage
tube placed in the old femoral ring. The patient was so
well after the operation that on the third day I risked
ordering an enema. This was most disastrous. Faeces
again appeared in the wound and I thought I had lost my
patient. However, this was the only time we saw them.
From that time on she never looked back again. Liquid
paraffin was the aperient used on all occasions.
The little portion of bowel ( a-h ) has never been detached,
and when she left the hospital it formed a small sinus 3 inches
long, occasionally discharging a little mucus. Subsequently
this has quite dried up. No special measures were taken
to repair her femoral ring and yet there is no hernia now.
Considerable praise is due to the sister in charge of the case
for not infecting the central incision after the second
operation. The patient cooperated well, too, telling the
nurse directly she was soiled.
She is now at her work again and feels no abdominal
discomfort, and has even discontinued her liquid paraffin,
which was such a stand-by earlier. She consulted me about
two months ago because she thought she was pregnant.
$Ubitfos anb Notices af Jtaoks.
The Operative Treatment of Chronic Intestinal Stasis. By
Sir W. Arbuthnot Lane, Bart., O.B., Consulting
Surgeon to Guy’s Hospital and to the Hospital for Sick
Children, Great Ormond-street. Fourth edition, revised
and enlarged. London : Henry Frowde and Hodder and
Stoughton. 1918. Pp. 328. 20#. net.
Everyone who has devoted any attention to the matter
must recognise that to Sir Arbuthnot Lane we owe in great
part the increased attention now given to the dangers
attendant on the too prolonged retention of fracal matter in
the bowel. He it was who first drew attention to the risks
of absorption from the intestine of the products of the
activity of colon bacilli and of other micro-organisms ; and it
was he who first laid stress on the importance of kinks in
the bowel produced by adhesions as the causes of intestinal
stasis. And so clearly has he put forth his facts and his
inferences, so carefully has he marshalled the data on whioh
he founded his theories, that now those who accept his con¬
clusions are continually increasing in number, and yearly
more and more surgeons base their practice on his teachings.
We do not say that Sir Arbuthnot Lane may not have pushed
his theories too far ; he may have thought that their applica¬
tion was wider than it really is, but even allowing for the
over-enthusiasm of the discoverer there can be no dbubt that
he has brought to our notice facts that were almost unknown
or ignored before, that he has pointed out a potent cause of
much chronic ill-health, and that he has indicated the
direction which treatment must take if these evils are to be
overcome.
This book is not the unaided work of Sir Arbuthnot Lane,
for he has many coadjutors. Dr. Alfred Jordan has contri¬
buted a most important chapter on the investigation of
chronic intestinal stasis by means of the X rays ; he shows
the immense value of the additional information that may be
obtained by the use of this method, so that the surgeon shall
be in a position to act with the best effect when the abdomen
is opened. Dr. Nathan Mutch has supplied a short but
valuable chapter on the bacterio-chemistry of the small
intestine and a much longer chapter on chronic streptococcal
infection. Professor Arthur Keith has written on the great
bowel from the anatomist’s point of view, and Professor J. G.
Adami has furnished a chapter on intestinal stasis and intoxi¬
cation. The relation of intestinal toxaemia to loss of
accommodative power has been explained by Mr. Ernest
Olarke, and Dr. Leonard Williams insists on its im¬
portance from the medical standpoint. Major White
Robertson has described the blood picture of this condition,
and Mr. Harold Chappie has written on the gynaecological
aspect of the stasis. The connexion of pyorrhoea with
stasis in the bowel haw been pointed out by Mr. Harry
Forsyth. It will thus be seen that Sir Arbuthnot Lane and
his collaborators have traversed the whole field of intestinal
stasis; they have collected together a vast oorpus of infor¬
mation all bearing on the subject, and the reader cannot fail
66 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Jan. 11,1919
to acknowledge that there is a large amount of troth In the
claim that intestinal stasis is a potent factor in disease, and
that the prevention and removal of the stasis is of vital
importance. The veriest sceptic, if indeed there be any
such, cannot rise from the pernsal of this volume without
recognising that the matter deserves the closest study. To
all medical men we commend this book, for it gives a full
and faitaful presentation of this important subject.
A System of Clinical Medicine. By Thomas Dixon Savill,
M D. Lond. Fifth edition, thoroughly revised. London:
Edward Arnold. 1918. Pp. 948. 28#. net.
The issue of a fifth edition of Savill’s System gf Medicine
is surely an evidence of its increasing popularity. The fourth
edition was issued in 1914, and reprinted in 1916. The
present edition has been thoroughly revised, notably the
chapter on diseases of the nervous system by Dr. Harry
Campbell, and some of the sections, such as those dealing with
diabetes mellitus and syphilis, have been entirely rewritten.
There are many additions, amongst which may be mentioned
splroohsetosis ictero-hemorrhagica, purulent bronchitis, and
trench fever. So much for a short account of the more
important changes in the new edition which may be of
interest to those who are already acquainted with the work.
To the les9 fortunate we may give a short description of
Dr. Savill’s method of dealing with the study of disease, or
rather with the study of disease as manifested by any one
particular patient, for this textbook is essentially clinical
in its outlook. The author does not describe each disease
separately, as is usually done in text-books, but the order of
sequence is, as he says, that which 4 4 should be adopted in
the examination of the patient," the principle throughout
being to trace 44 from effect (symptoms) to cause (the morbid
cause in operation).” To quote the author again: 44 Each
chapter is divided into three parts. Part A treats of
the symptoms which may indicate disease of the organ or
region under discussion, the fallacies incidental to their
detection, and gives a brief differential account of the various
causes which may give rise to those symptoms. Part B
treats of the physioal signs of disease in that organ and the
various methods used to elicit them. Part C, which consti¬
tutes the major portion of each chapter, is prefaced with a
clinical olassifoation of the various maladies affecting that
region and a summary of the routine procedure to be
adopted; this is followed by a series of sections dealing
with the several diseases arranged according to their clinical
relationships. For example, in Chapter III., on the heart.
Part A describes and differentiates the various causes of
breathlessness, dropsy, palpitation, prae cordial pain, and
Ahe other symptoms which may be indicative of heart
disease; Part B describes percussion, auscultation, and
.other methods of examining the heart; and Part C deals
seriatim with the various cardiac disorders, classified and
arranged on a clinical basis. ” To the busy practitioner the
•utility of such a work is obvious; in a difficult case he has
but to turn to the chapter dealing with the affected region,
and he finds at once a simple method of differential diagnosis.
But the work is especially helpful to the student newly
arrived at that stage in his curriculum when he is faced with
the problem of a particular patient and is obliged to carry
•out his examination and make his diagnosis on its result.
This text-book will help him on from stage to stage, and if
in the end the diagnosis is still in doubt he will have learned
how to observe accurately, how to reason clearly and
correctly, and by balancing the evidence will at least be
able to understand the possible diagnoses which his teacher
will discuss in due course.
The Australian Army Medical Corps in Egypt in 1914-15.
By Sir J. W. Barrett, K.B.E., M.D., F.R O.S., Temp.
Llentenant-Oolonel, R.A.M 0., and Lieutenant P. E.
Deane, A.A.M.C. Illustrated. London: H. K. Lewis
and Co., Ltd. 1918. Pp. 259. 12 s. 6 d. net.
THIS book is very much of the nature of an expanded
report on the working of No. 1 Australian General Hospital
at Cairo and the Australian Branch of the British Red Cross
Society. Sir James Barrett combined the duties of consult¬
ing oculist and aurist and registrar of the hospital, and
executive offiser of the Australian Branch of the Red
Cross Society; Lieutenant Deane was quartermaster to
the hospital. The presenoe of this Australian Hospital
in Egypt was especially fortunate on account of the
sudden influx of wounded from the Dardanelles, whioh
necessitated the expansion of the hospital from one of
520 beds to a group of hospitals providing accommo¬
dation for 10,500 patients. The story of the expansion
is interestingly told, although perhaps the experience is
not so unique as the authors imagine ; very much the same
difficult course of events occurred at Alexandria where the
problem was tackled by the R A.M.C. The book brings up
all the various problems which have beset our armies else¬
where—the recruitment of the unfit, the drink problem, the
venereal diseases problem. We are in debt to the authors
for their frank account of events; their extensive experience
of the methods tried to prevent venereal disease lends
weight to their criticism of the new constitution of the
Australian Red Cross Society, which does not allow of the
spending of money for the maintenance of social clubs for
soldiers :—“Why not supply for the benefit of the men places
of entertainment, with music, refreshments, and the like,
similar to, and better than, those which the prostitutes
supplied, but minus the prostitute ? ” The whole-hearted
cooperation of the Australian medical forces with our own
and the French is incidentally revealed; Australia in the
early days in Egypt provided motor transport for the whole
of the wounded and gave away 75 per cent, of their Red
Cross stores to hospitals for British or French troops. Over
100 pages of the book are given up to a detailed account of
the work and criticism of the functions of the Australian
Branch of the Red Cross Society in Egypt. The numerous
photographs illustrating the book are exceptionally good;
the three maps included are useful. The book is apparently
intended for the Australian lay public ; although it is not a
contribution to the study of Egyptian medicine it will be
read with much interest by every medical man who has
served in Egypt.
JOURNALS.
Revista Espahola de Medicine, y Cirugid . Proven za 273.
Barcelona. Pp. 50. 2 ptaB.—We have received the November
issue of this review, being the fifth monthly number sinoe
its first publication in 1918 at Barcelona under the editor¬
ship of Dr. Francisco Tons Biaggi. It seems to ua a
practical and up-to-date addition to medical literature,
such aB is wanted not only in Spayi but in other
countries. This number oontains an article on Technique
in Miorosoope Work by Dr. Pujiula, in whioh he explains
his methods of staining sections of nervous tissue by
nitrate of silver and Kopsoh’s bichromic formol ana
the use of bichromated gum arable in mounting. Dr.
Esquerdo contributes a paper on the Treatment of
Placental Remains in the Uterus. From the editorial pen
there is a lucid summary of our present knowledge of she
etiology, symptoms, and treatment of the so-called Spanish
inflaenza, of whioh our Iberian colleagues had an early
and abundant experience; their practical acquaintance
with this epidemic is further shown in another series of
short articles dealing with the disease from various points
of view, by various well-known scientists, such as Dr.
Farreras, Dr. Freixas, and Dr. Moragas, chief of the bacterio¬
logical laboratory of the Santa Cruz Hospital. The opinion
of the latter observer is worth quoting, being to the effect
that in the present epidemic there was something more than
Pfeiffer’s bacillus, the pneumococci, the diplo-strepto-
cocci and accessory bacteria whioh he isolated fronu his
cases, as the initial cause of the infection; that it
seemed as if the influenzal infection, benign in itself, as
seen in the earlier cases of the epidemio, prepared
the soil for the colonisation of the accessory baoteria
which, by transmission from one patient to another,
acquired an unusual virulence and gave rise to com¬
plications of extreme gravity. These views are of interest
to compare with those expressed in our leading articles on
the same subject in last week’s issue of The Lancet and in
the present number. It would seem that in many countries
work is proceediug on similar lines and that the results
obtained point to similar conclusions. Another section of
the publication is devoted to abstracts from other journals,
both Spanish and foreign, the latter part being very copious,
and embracing all the chief medical periodicals of the
world, over 20 pages arranged under various headings being
given up for this purpose. Another portion is dedicated to
reviews of books and a list of recent publications. One
interesting feature of the Revista Espahola , which should not
be allowed to pass without attention being drawn to it, is
that each original article is accompanied by a r6sum6 in
French, a delicate and thoughtful concession for the
benefit of those of its readers who may not be conversant
with Spanish. We heartily congratulate the editorial Btaff
on the excellence of their new medical periodical and wish
it every suooess.
Thb Lancet,)
FRENCH SUPPLEMENT TO THE LANCET.
[Jan. 11, 1919 67
FRENCH SUPPLEMENT TO THE LANCET
Under the Editorial Direction of
Professor CHARLES ACHARD, and Dr. CHARLES FLANDIN, D.S.O.,
2‘ROFKSSOR OK PATHOLOGY AND THERAPEUTICS IN THE M KDKCIX-MAJOR DE 2MB CLA8SE; CHEN DK CLINIQUE
UNIVERSITY OK PARIS. _t A J.A FAOULTK DE PARIS.
GUNSHOT CONCUSSION OF THE SPINAL CORD. 1
By HENRI CLAUDE,
PROFESSOR IN THR PARIS FACULTY OF MEDICINE; PHYSICIAN To l HE
PARIS HOSPITALS;
AND
JEAN LHERMITTE,
FORMERLY DIRECTOR OF THE CLINIC IK THE PARIS FACULTY
OF MEDICINE.
Concussion of the spinal cord had already been an object
of study before the present war era, bat authors were only
able to devote themselves to a description of the anatomical
and clinical manifestations following on direct blows to the
vertebral column or on falls from a height. Experimentally
it was also possible to observe the lesions produced by
successive blows on the vertebras. We may recall the
studies which had already established the existence from
the clinical and anatomical point of view of concussion
of the nervous centres, notably of the cord, because we
wish to limit this account to the description of functional
disorders and alterations in the cord which occur in those
who have been subjected to gunshot injury, but in whom the
cord has not been direotly damaged by the missile. We
are speaking here of traumatisms due to the bursting of
shells near the patient, or of wounds produced by projectiles
which have not struck the cord itself.
I.
Concussion of the oord may be divided into two categories:
{#) Indirect concussion, respiting from the bursting olose to
the patient of large shells, and in which the symptoms are
caused by sudden variation of pressure, (b) Direct con¬
cussion, produced by the impact on the vertebral column or
at a certain distance from it, of varions projectiles (bullets,
shell splinters, &c.), but in whiohthe oord and its membianes
have not been damaged by the missile. Such is the distinc¬
tion which we have endeavoured to make in our previous
work on this question. In both cases the spinal lesions are
associated with the agitation of the nervons centres which
have not been directly injured by the missile.
- (a) Indirect concussion. —Indirect concnssion includes those
oases in which spinal paralysis occurs as a result of the
explosion of projectiles of large calibre, and in which it is
impossible to find any external wound as the explanation.
From the beginning of the war these facts arrested the
attention of medioal officers; they have been attributed to
the action from a distance on the central nervous system of
the “ wind from the bullet,” bub it is necessary to subject
these observations to a critical and careful study in older to
discriminate between disorders of organic origin and those of
a psycho-neuropathic nature.
In France the imsea of Sencert, of Ravaut, 3 of Guillain,''
of Heitz, 1 of Babinski,* of P. Marie and Chatelain 8 have
pnt beyond a doubt the existence of motor and sensory dis¬
turbances due to organic lesions of the cord in patients
showing no evidence of any wound, bat who were within the
range of an exploding shell. A. L6ri 7 has collected most of
these facts in a critical study.
Functional disorder may supervene immediately after the
explosion. The patient is unable to use his limbs, he has
the impression that they have been carried away, whilst at
the same time he often complains of severe pain in the
hack. Sometimes disorders at first little noticed become
accentuated some hours later. On the other hand, in some
cases paralyses, which before had been.general, are seen to
lessen and to become limited to certain limbs (Lhermitte h ).
A. L$ri 9 has insisted lately on the presence of “ delayed ”
ooncussion, in whioh several days and sometimes even weeks
after the explosion the first important gross symptoms of
organic lesion have made their appearance.
The spinal syndrome following conpussion due to explosion
generally assumes the aspect of a quadriplegia or a
paraplegia caused by transverse myelitis. The paralysis
ie accompanied by changes in the tendon reflexes, by
disturbances of sensation, weakness of the sphincters r
and trophic phenomena (bed-sores), such as are found
in organic spinal lesions. But it should be borne in mind
that there may be partial paralysis, anaesthesia of abnormal
distribution, and retained reflexes which make the diagnosis
doubtful, at least at first, because the hypothesis of
simple functional disease is not easy to eliminate. The
organic signs then only develop slowly. Such are certain
muscular atrophies indicating an alteration in the grey
matter of the cord, and giving, on electrical examination,
the reaction of degeneration. These amyotrophies, moreover,
tend to improve.
The evolution of these paraplegias or partial paralyses
occurring after concussion varies according to the extent
and gravity of the lesions. Relaxation of symptoms or their
transformation into others is fairly common. For example,
paralysis, flaccid at first, tends to become spasmodic.
Nevertheless, the prognosis often continues quite favour¬
able. A fatal termination, however, may ocour either
daring the early hours or days as the result of shook, or
later from pulmonary complications or various infections.
It is difficult to follow completely the history of indirect
spinal concussion caused by explosion, because the morbid
anatomy, and, above all, the histology of the lesion has
not yet been investigated. Lumbar puncture, it is true,
has shown in some cases the presence of haemorrhage into
the cerebro-spinal fluid or the remains of haemorrhage (albn-
minose, xanthochromia), which has induced certain authors
to deduce that spinal lesions are probably haemorrhagic in
type. There is no doubt that haemorrhagic foci are
present in many cases, but at the same time we cannot
exclude the view of Roussy and Lhermitte, 10 who hold that in
a certain number of cases the nervouB agitation caused
by the deflagration has produced a direct traumatism of
the vertebral column, and that the spinal ooncussion will
therefore be of the same nature as the second category
of spinal lesions, to whioh we have given the name of direct
concussion.
The following has been urged in support of the hypo¬
thesis. The concussed man is often thrown to the ground,
blown up, bruised, or buried, so that the rflle of agitation ie
not easy to distinguish from that of direct injury. More¬
over, even when a single explosion can be shown to be the
cause it occurs in the most typical cases behind the patient,
who gathers the impression of having received a blow on hie
back or loins (L6ri). There would thus be produced a sort
of blow on the vertebral column, and we know as a fact »
that in these patients ecchymoses do occur in the limbs
and certain other parte of the body exposed to the de¬
flagration, which, aoting like a blow, causes haemoptysis,
hematuria, and the like. It is possible that the same may
hold good in concussion, or that the blow caused by the
explosion is superadded to the phenomena which accompany
atmospheric compression or decompression—factors often
brought in to elucidate the pathogeny of concnssion from
explosion. Roussy and Lhermitte, 11 from a study whioh
they have made of these symptoms, have formulated a theory
which brings the symptoms of indirect concussion into
close association with those of direct concnssion. The impact
—violent and limited by the edges of the cone of compressed
gas to the spine or paravertebral region—would be comparable
to the impact of a projectile. In each oase, the authors
say, the impact is transmitted to the nervous or spinal
elements by the cerebro-spinal fluid, the sole difference being
that in direct concussion the immediate traumatic agent
penetrates and bruises, whereas in oononssion caused by
pure explosion there is commotion and agitation only.
It appears, then, that the study of direct concussion ought
especially to give us interesting information, seeing that it
appears to resume in a more general way the story of spinal
ooncussion. U.
(b) Direct concussion ,—In our first study of direct spinal
ooncussion (Ostober, 1916) we demonstrated that the passage
of war projectiles through the vertebral canal or its imme-
68 Th» Lancet,]
FBKNOH SUPPLEMENT TO THE LANCET.
[Jan. 11,1819
diafce neighDourhood (fracture of the spinous processes, for
instance), even when the dura mater is not injured, leads,
by the violence of the impact, to a series of phenomena
suggesting a lesion of the spinal cord. Further, direct con¬
cussion of the cord may result from the passage of a projectile
into the spinal muscles or from the impact of neighbouring
bony surfaces (ribs, spinous processes, scapula) on each other.
This is direct concussion as a result of impact at a distance
from the spine. The clinical phenomena are the same
whether they result from indirect concussion (at a distance
from the spine) or from direct (by traversing the spine).
Spinal lesions always attain their maximum intensity at the
layei where the violence is applied, and, of course, the
disturbances observed depend on localisation of these lesions
at different levels of the spinal cord.
We shall now study these disorders according to the part
injured.
Ceroioal region. —M. Pierre Marie and Madame A. Benisty 13
have described the transient quadriplegia which follows
injury to the cervical region ; they have also pointed out the
frequency of spinal hemiplegia of the concussional type
which usually changes to brachial monoplegia. We have
seen many cases of permanent quadripUgia produced by
concussion in the upper cervical region. On a stage of
flaccid paralysis of the four limbs there follows a more
and more marked tendency to spasm and the paralysis
becomes complicated by sensory disturbances, both sub¬
jective as well as objective, of spinal or radicular origin.
In three cases a Claude Bernard syndrome of cervical type
wad present, and in one case the Claude Bernard-Horner
unilateral syndrome made its appearance.
We have also seen & primary brachial monoplegia occurring
both as a flaccid and secondarily spasmodic type; this mono¬
plegia is usually associated with subjective and objective
sensory disturbance, of radicular distribution, sometimes
very obstinate.
Brachial diplegia is one of the most curious of the clinical
types of cervical concussion. It occurs early as a sequel to
certain injuries of the nape of the neck (transverse retro-
vertebral bullet-tracks). The upper limbs are from the first
completely paralysed, even while the lower limbs remain
unaffected, and it is not without astonishment that some
days after the injury the wounded man is to be seen standing
and walking about, whilst his upper limbs, still completely
paralysed, hang inert at his sides. Among the most charac¬
teristic symptoms of this clinical type we may notice shooting
pains of radicular type and disturbances of sensation,
especially concerning deep sensibility and tactile sense, with
greatly increased interval at which compass pricks can be
separately discerned, and even after the patient has recovered
adequate movement of the hands the astereognosis persists.
Finally we must add, to complete a very special clinical
picture, frequent want of coordination of the movements of
the lower limbs noticeable in the ereot attitude and becoming
mapifest in the upper limb when movement reappears
(asynergy, dysmetry), all manifestations of cerebellar nature.
This concussional brachial diplegia appears to us always
to terminate favourably ; movement returns little by little in
the paralysed limbs, but their functional use is disturbed
for, a long time by asynergy or dysmetry of cerebellar type as
much as by the ataxia associated with alterations of deep
sensation. These last phenomena persist long into the
remote phase, when the recovery of motor power is nearly
complete. In two cases which we studied these cerebellar
disturbances existed without paralysis or any important
disturbance of sensation. Such a patient presents the
staggering, tipsy gait of cerebellar lesion, whilst his move¬
ments are sudden and spasmodic, and examination confirms
the presence of spasticity. This cerebellar spasmodic form
of spinal concussion of the cervical region appears to us
to be of favourable prognosis, for the incoordination, though
well marked, passes off rapidly.
Besides these well characterised types we must include a
series of abortive forms which vary according to the pre¬
dominance of one or another symptom.
Dorsal region .—Concussion of the dorsal region gives rise
to a symptomatology of which the gravity is variable from a
paresis of the lower limbs lasting but a short time to a
complete paralysis such as occurs after complete section of
the cord, along with all intermediate types. Generally the
symptoms come on with striking rapidity; motor and sensory
functions apparently much involved are re-established, at
least to some extent, after some weeks. Flaooid paralysis
from the beginning becomes transformed in these as in the
cervical forms without much delay into spasmodic para¬
plegia without gross sensory changes. The bladder and
rectum are generally involved.
Lumbar regi»n.—\\e have seen only very few cases of
direct concussion of the lumbar region. Their symptomat¬
ology depends upon the height of the lesion and the addition
of radicular lesions to the spinal. There is no need to insist
on a common clinical picture, which is that of compression
or division of the cord, capable of easy analysis.
III.
Morbid anatomy .—Cerebral and spinal concussion are
regarded by most authors as based upon an anatomical sub¬
stratum, of which haemorrhage, associated or not with
softening, is tha usual lesion. We have been at pains since
1915, by histological examination of numerous cases, to
combat this opinion, founded more on imagination than on
exact anatomical examination. Haemorrhagic foci are aeun,
but less frequently even than meningeal haemorrhages, and
they are not the essential and characteristic lesion of con¬
cussion. Direct concussional agitation of the nervous system
leads to changes of two kinds, diffuse and local , both of
the necrotic type.
Local changes.—These we have described under the term
insular necrosis. They consist in more or less extensive
foci, generally situated exactly at the level of the point of
application of the injury, whether this be actually vertebral
or in the vicinity of the vertebral column. In these foci
the, nervous elements—axis cylinders, myelin sheaths, and
nerve cells—are in process of destruction or already com¬
pletely transformed, whilst the neuroglial elements are in
process of proliferation and new blood-vessels are being
formed. The whole appears to be a process of pure necrosis
without either thrombosis or haemorrhage. Later on pro¬
liferation of the fibrillary neuroglia proceeds and disposes of
the last remains of the granular bodies. In some very severe
cases the interstitial elements themselves die and the fotus
is absolutely necrotic. The tissues of the foous are absorbed
and a cavity is formed, surrounded by a neuroglial network.
This observation is not devoid of interest; the appearance
of the cavities in syringomyelia exhibits the most marked
analogy with the loss of substance occurring in concussion.
Diffuse changes .—The diffuse changes which we have de¬
scribed under the term of acute primary degeneration of the
spinal tracts are apt to elude observation, and can only be
studied properly by the silver method and in longitudinal
sections. The axis cylinders are then easy to see broken up in
larger or smaller fragments, pea-shaped or moniliform. Hie
nerve fibres have for the most part lost their parallelism, they
are retracted, curled on themselves, and cross one another.
Around the broken fibres are grouped the granular bodies of
neuroglial origin, oontaining in their protoplasm the debris of
axis cylinders and amoeboid cells with protoplasmic processes
dissociating the myelin fibres which snrronnd them.
The structure of the grey matter is not easy to make out.
The ganglion cells are loaded with lipochromes, and, above
all, the protoplasm appears full of chromophile grannies
fused in large irregular lumps. This change appears to us
characteristic of spinal concussion.
We may add that the central canal is often dilated
between constrictions, and there is often desquamation or
proliferation of its epithelium ; curiously enough, the fibres
of the roots take part in the process of acute primary
degeneration noted higher up in the fibres of the cord.
We consider, then, that the anatomical lesions, of which we
have here given a general picture, and which we have described
elsewhere at length, are of a type so distinct that they merit
a place apart in the record of the morbid anatomy of spinal
lesions. The results of these inquiries are of great interest
because they show that spinal concussion is not, as is generally
supposed, dependent upon so simple a change as haemato-
myelia, but can only be regarded as a complication of changes
occurring in the spinal cord and originally quite distinct.
We conclude further that concussion of the spinal oord,
and especially direct concussion resulting from impact on
the vertebral column or in its neighbourhood, should, from
its etiology, its clinical course, and its morbid anatomy, be
assigned a place apart in war neurology. Its history is still
incomplete, but we thopght it would be of interest to surgeons
and physicians to- have pointed out to them at this stsge the
principal features, for the condition deserves to be better
known and not to be confused with the other common
Thb Lancet,]
FRENCH SUPPLEMENT TO THB LANCET.
[Jan. 11,1919 69
traumatic changes in the cord on the one hand, or with
functional nervous disorders on the other hand, in view of
the very different prognosis and treatment needed by these
diverse spinal syndromes.
References.— 1. H. Claude et J. Lhermitte: Etude Clinique et
Anatoino-pathologique de la Com motion Mtklullaire par Projectiles de
Guerre, Annalea ae Medecine, No. 5, Octobre, 1915. Troubles Medul-
latres dans les Commotions Directes. m*U h Distance, de la Colonue
Vertebrale, Paris M6dloal, Julllet, 1917. Etude Anafcomo-ollnlq us de la
Commotion de la Moelle Cervicale, Revue de Medeoine, Decembre,
1917. H. Claude et H. Meuriot : Le Syndrome d’Hypertenslon
Cephalo-rachidlenne cons^cutlf aux Contusions de la Region
Cervicale, Progrds Medical, 5 Decembre, 1916. 2. Ravaut : Les
measures Indirectes du Systdme Nerveux deter ml nees par le
“vent de I'explcwif,” Presse Med., Avrll, 1915. et Aout, 1915.
3. Guillala et Barre: Troubles Pyramidaux et Organlques oon-
secutlfs a 1'licUtement d'un Projectile sans Plate Rxterieure,
Bulletin de 1* Soc. Med. des Hoi), de Paris, 26 Mai, 1916. 4. Heitz:
Cinq Cas de Paraplegle OrgAnique consecutive a des Eclatements
(TObus sans Ble<>sure de la Moelle, Paris Metical, 22 Mai, 1915.
5, Baolnski: Lealou Spinale par Eclatement d'Obus >\ Proximite,
Revue Neurologique, Juillet, 1915. 6. P. Marie et Chatelaln:
Un Cas d’Hematomyelle par Kclatement d’Obus u Distance,-
Bull. 8 kj. Med. des Hdp. de Paris, 29 Suillet, 1915. 7. A. Mr i:
Lee Commotions des Centres Nerveux par Bclatement d’Obus,
Revue Generate de Pathol, de Guerre, p. 52, Vigot ellt.. Pans.
8. J. Lhermitte: Les L6slons Fines de la Commotion Directe de la
Moelle fioim&re, Aunties de Medecine. Juln-Julllet, 1917. 9. A. Leri: Les
Commotions •• Retard&s” par Explosion d’Obus, Presse M&ilcale, 5 Aout,
1918. p. 403. 10. Roussy et Lhermitte: Les Blessurea de la Moelie, 1 vol.
Collection Horizon, Masson edit.. Parts, 1918. 11. Loc. olt. 12. P. Marie
et Mme. A. B^uisty: HemlpKgte Spinale Droite par Contusion de la
Coloone Vertebrale par Babe, Revue Neurologique, Juin, 1915.
CONTRIBUTION TO THE STUDY OF THE
MANIFESTATIONS OF EMOTIONAL SHOCK
ON THE BATTLEFIELD.
By Cl. VINCENT,
PHYSICIAN TO THE PABI8 HOSPITALS; FORMERLY MEDICAL OFFICER TO
THE 46th aid 98th r.i. and to the 44th b.c.p.
Many observations have been published dealing with
mental disorders or nervous troubles following on the
emotions experienced on the battlefield. In nearly all these
cases the connexion between the mental and nervous troubles
observed and the emotional shock which has produced them
has been established on the evidence of the patient. But
experience has shown us that in most oases the man has given
no account of the first manifestations of his emotion. We are
also aware how rapidly in the light of reflection—either spon¬
taneous or produced by systematic questioning—the ideas
which the man has about what has occurred to him become
changed. If we add that in many cases the man declares
that he lost consciousness it will be readily understood how
difficult it is to establish the origin of mental and nervous
troubles following on emotion, especially emotional shock.
The observations which recount the phenomena presented
by soldiers from the moment at which the emotion occurred
until their return to the normal state have, in my opinion,
an entirely different value. These observations show, in the
first place, that many of the disorders attributed to con¬
cussion are really manifestations of emotion ; and, on the other
hand, they establish the relationship between phenomena
observed in certain soldiers behind the lines and at army
depots, and the quasi-instantaneous manifestations of
emotional shock to which men on the battlefield have been
subjected. Consequently they help, to some extent, in
unravelling the nervous and mental troubles seen during the
days which follow the emotion, and which are difficult of
interpretation when their origin is unknown. The same
observations also explain, in a measure, the differing values
placed by neurologists on phenomena of the same origin, to
be explained by the fact that they have seen their patient on
the battlefield only and have not followed the development
of the first phenomena shown ; or else their observations have
been made behind the lines or at depots where they have
only seen secondary and late phenomena and not the initial
stage. These neurologists are talking of two consecutive and
differing aspects of phenomena having the same origin.
Aooaunt of Cate.
In the account which follows it has been possible to watch
the man from the moment of Infliction of the emotional
shook to the instant at which the phenomena following the
the emotion disappeared. The physical and mental disturb-
janoe lasted about a fortnight. All phases have been noted. 1
i In Franco various regimental, medical officers f Vol venal: Progrds
M6)lcal, 1918; Oberthiiret Duroselle: Revue Neurologique, 1916; Dlde;
ButotJuns, Alcan tfcUteur. 1918) have published observations made
.•et**Uy on tlve field of battle.
A-, 11th Comp., 98tn R.I., aged 23 yean. On active service for two
yean. Not alcoholic. Had not been overworked. The regiment had
just had a long rest. Had never suffered from concussion.
On August 20th, 1917, at 4.35 a.m , while his company was advancing
to take A-Wood, a shell of medium calibre fell on the enge of the
trench whence they were .starting. It slightly wounded some of them
and affected another without touching him, without even throwing him
to the ground, but la sucu a way that he was unable to follow his
comrades to the assault. I was a few dozen metres away, and being
warned at once ran to him, less than 5 mlautes elapsing from the fall
of the projectile to the moment at which I reached the man. He was
sitting at the bottom of the treach, some yards from where the shell
had fallen. He was trembling all over. It was implies ble to get a
word from him except, “ Oh, my ears! ” I tried to help him, but he
paid no attention I trie! to make him stand up, but he remained inert.
But it was “ the hour H-.’ The men were attacking. Some had
alresdy fallen and I could not remain with A-. I said to him, “Go
to the aid-post of the battalioa as quickly as you can.”
When I returned to the aid-post at about 10.45 a.m. my man
was there. Tbe orderly said to me, “He came in 5 hours ago." But
from the trench where he hsd been affected to my regimental aid-
post in the ravine of C-was at least 1200 metres. Beddes, he had to
pass the battalion aid-post. It had not, therefore, taken him long to
come.
Examination on August i0th at 11 o'clock— that is to say, 6£ hours
after the shock. I pu' a certain number of questions to him; he
answered slowly after reflection, but precisely. He gave the fol owing
information: “ ft was 4.30 a.m when the shell fell. 1 believe It was a
*105.’ It tell half a metre from me on the edge of the trench. Twoofmy
comrades were wounded. One was wounde i in the face. They are gone;
I do not know what has become of them. I lost consciousness, but not
for long. I do not know exact y for how long. When I came to mvself
1 was trembling. Some men were passing who accompanied me to tbe
aid-post of the battalion. I did not know where I was. I followed the
streicber-bearers in order to get here—l.e., the regimental aid-post.
Condition at the moment of observ ition.— Appearance dull and tearful.
Pulse 110, respiration 36, although he hsd been lying down tor some
time. There was a tine tremor of the hands, but sufficiently coarse to
be seen at a distance. His body did not tremble. He complained of
a deep pain in his ears. He was conscious of whistling and buzzing.
Auditory acuity diminished; he oouid hear the speaking volee at half a
metre. Tendon, cutaneou*, and pupil reflexes normal. Sensation
normal. No contraction of the visual field.
I escorted him to the regimental aid-post, where he lay on a hanging
stretcher covered by a blanket. The rest of the day of August 20th, the
night of the 20lh-21st, the day of the 2lstj be did n<*t stir either to eat or
drink (refusing what was offered to him) or to urinate.
August 21st: Still trembling; still dull. He only answers slowly,
as if with great effort, the questions put to him. Pulse 120, respira¬
tion 42. Blood-pressure i Sysco le 135, diastolic 90. Same state of
auricular apparatus. As be had not passed water since the morning of
the 20ch the hypogastric region was percussed out. A suprapubic
dullness was present. He was asked to pass water. Micturition took
some time. He succeeded in passing some grammes of urine, which
examination showed to be normal. Lun\bar puncture; cerebro spinal
fluid normal. (The lumbar puncture was carried out after retention
of urine was discovered.)
August 24th: Has completely emptied his bladder this morning—
about 1000 g. of urine. Trembling much less. Pulse 110; respiration 42.
Bars in the same condition. Appearance less dull. It was easier to
make him answer, although it still took a long time to gee anything
out of him.
In order to estimate his intellectual activity, we asked whether he
had written home. He said that he had not, because. In the first place,
he was trembling too much, and also it was not long since he had
written. Usually he wrote every three days, and he hsd written before
going into the line. When we said to him: “ But that is five days ago,
you should have written,’’ he answered: “ I did not think that we had
been so long In the line.”
He bad lost count of time. He thought that it was July, whereas we
were in the month of August. We gave him ’ he jAper to read. He read
with difficulty, without fluency, and very differently from the way in
which he read afterwards. After reading a few lines we asked him what
he had read, but he was unab e to say. We made him count up to 20,
which he did slowly and with difficulty. We made him count from 100
to 120, which he did still more slowly. Sometimes two or three
seconds elapsed between two consecutive figures. We gave him some
sums to do, addition, subtraction, and multiplication, which la r er he
did correctly, or nearly so. These he no m took a loog time to do and
all were Incorrect,'even addition and subtraction. In these the results
of the first two columns of addition and subtraction were correct, but
those of the other columns were wrong. The results were wrong when
he attempted addition and subtraction of more complicated figures.
Also they were wrong because each time he had forgotten to carry. He
wa* unable to fix his attention.
August 26th: Reading more freely than on the 24th. Counts without
stopping between the numbers. Knows which month it is. Cannot
remember the meaning and the words of a sentence which he has been
made to copy. We again made him do the same sums he had done
before. He did them very slowly. All were wrong.
August 30th: -Respiration 25. Still trembled slightly, especla’Iy In
the right hand. Was, however, able to write home on August 28th.
The condition of tbe ears was Improved, even though the whistling
and buzzing persisted, especially in the right ear. He Is fully aware
that It Is the month of August and th*t the attack was carried out on
August 20th. He counts up to 20 in 7 seconds. It takes him 15 minutes
to do the sums. They are still wrong, but the mistakes are fewer.
Sept. 4th: Respiration 26. Blood-pressure: Systolic 106, diastolic 70.
The trembling has disappeared even in the right hand. The ear con¬
dition is still better. He suffers no longer; he Is still a little annoyed at
times by the buzztng, and auditory acuity is not normal. He has re¬
covered his appearance. He no longer has the dull air which he bad. He
writes home every day and occupies himself in one way or another.
When he was told to oome In to be examined he was looking for wood
to make a door to the aid-post. He did the sums in 5 minutes 2£> seconds*
The addition was right. There was one mistake In the subtraction and
one in the multiplication. Returned to duty.
Uct. 16th, 1917 : Has been on duty slnoe the day he joined hia
company. Intellectual activity normal. Did the sums as described
-above In 6£ minutes. The addition was correct; there was one mistake
70 ThbLanott,]
FRENCH SUPPLEMENT TO THE LANCET.
[JAN. 11, 1019
in subtraction and two In multiplication. Tbe ear condition was not
jet quite normal. He complained of buzzing in the ears, especially in
the evening. He oould not hear tbe witch ticking at more than
20 cm. from the right ear. Pulse 72. Respiration 24. The trembling
had disappeared.
Discussion of Causation.
Before going further, the following question at once
arises. To what cause are we to attribute the troubles which
developed in A—- immediately after the explosion of the
projectile which fell on the edge of the trench where he was
awaiting the assault ?
There can be no doubt that A-was the victim of a
labyrinthine concussion. It is to this that we must attribute
the disturbances of hearing, the deep and diffuse auricular
pain. But are we to regard the other phenomena as evidence
of cerebral concussion or of emotion 7
In my opinion this man is suffering from emotion and not
from cerebral concussion. He did not lose consciousness or,
at least, entire consciousness for a moment after the shock
due to the explosion, and was far removed from the state of
consciousness of a man struck down by apoplexy or by
cerebral concussion. 2 3 * 5 I saw him a few minutes after the
explosion of the shell. He was sitting, not lying, in the
trench, trembling, and his expression was at the same time
dull and lacrymose. He was groaning: “ Oh, my ear! ” On,
the other hand, questioned six hours after the shock, he
showed that he remembered the circumstances of the occur¬
rence. He said to me: “ It was a * 105/ which fell on the
edge of the trench and slightly wounded two of my
comrades/' And what is more, be had understood the order
which I gave him: “ Go to the aid-post at 0-/’ and half
an hour afterwards he was there. It was 1200 metres from
the trench to this aid-post, and the ground was incredibly
cut up by the shells. A man suffering from concussion, who
has lost consciousness, who is “ knocked out/’ who is in
transient- or prolonged coma, does not behave like this.
Here, on the other hand, are some details of the observation
of a man suffering from slight concussion whom I had the
opportunity of seeing about 20 minutes after the shock. He
was struck on August 19th in a trench at W-, about 200
yards from my aid-post. He arrived escorted by two comrades.
His face was black with smoke. In giving an account of
himself he said to me: “ I came out of the dug-out and sat
down on a windlass. Then, without knowing why or where¬
fore, I found myself on the ground. There I had to remain
for a while. When I began to come to myself I was sur¬
rounded by smoke. I thought it was gas .” 3
Now, although this man had lost consciousness for a very
short time, be was totally unable to give an account of what
had happened to him. Loss of consciousness in the man
suffering from concussion was totally different from the loss
of consciousness which occurred in the case we are discussing
immediately after the explosion of the shell. Therefore it
is not admissible,to say that A- is suffering from con¬
cussion, whilst at the same time he exhibits phenomena
which, taken as a whole, are characteristic of emotional
shook—viz., trembling, tachycardia, and tachypncea.
Nevertheless, two objections can be made to this point
of view: (1) our man showed evidenoe of labyrinthine con¬
cussion ; (2) he himself described the state in which he was
immediately after the shock as loss of consciousness.
Let us now discuss these two objections.
(1) The fact that a man suffers from labyrinthine con¬
cussion by no means implies that he is suffering from cerebral
2 Some esses of cerebral oonoutsion without loss of consciousness
have been published (Gulll&in), but they are the exception. As a rule
tbe concussed man loses consciousness under the shook which has
struck him down.
5 This m&a also showed the presence of aurioular concussion. Blood
was running from bis left ear, and with this ear he oould only hear
sounds with difficulty. Voltaic vertigo (right unilateral inclination)
was affected. When be arrived his pulse was 110 and his respiration 28.
He was not trembling. An hour and a half later the pulse was 68 and
respirations 20. This man spoke to me quietly, but at times he could not
Ana certain words, so said one word instead of another. This slight
aphasia decided me to do a lumbar puncture. This proved easv, and the
eerebro-spinal fluid was found to contain a little blood. There appeared
to be no head wound. Shortly after the examination my attention was
drawn to tbe patient's helmet. The left half of the helmet was
indented over a circular area about 2 cm. across. A projectile had struck
it here. When the helmet was replaced on the man’s head the
depression was found to correspond with a small region which, on
parting the hair, showed bruising and was painful on pressure. This
area was adjacent to the point which surgeons regard as corresponding
to the Inferior extremity of tbe Assure of Rolando. In short, tbe
cranium via the helmet had transmitted to Broca’s area a shock which
at once explained alike the slight aphasia and the meningeal haemor¬
rhage. Tois man was evacuated and recovered without sequel of his
cerebral concussion. He had a left otitis media, and bad to undergo a
mastoid operation.
concussion. Cerebral ooncuseion is one thing, labyrinthine
concussion another. One or other may exist alone. Cases of
labyrinthine concussion without cerebral concussion occur
frequently. Here is one which I saw from the very moment at
which it was produced. A sentry and my assistant medical
officer F-were looking through a loop-hole at an advanced
post, their heads close together. The sentry saw a boche at
a loop-hole opposite about 30 metres away. He brought his
rifle to his shoulder, pointed it in the direction of the
enemy and fired. F- turned away quickly, putting his
hand to his left ear. At the report he felt a severe pain
in his left ear, after which he heard nothing more in this
ear. A moment afterwards he perceived a very sharp
whistling. All that day and the next the whistling remained,
and the deafness persisted. It was nearly a week before
the trouble disappeared. There was in this case auricular
concussion without cerebral concussion. I may add, also,
without emotion.
(2) As to the statement of the patient that he had lost
consciousness, it is not enough to justify the doctor
in concluding that the man lost consciousness in the
same sense as a patient suffering from cerebral concussion.
I saw the man at the time he declared that he had lost con¬
sciousness, I enquired in what bis loss of consciousness
consisted, and I can only repeat that this man did not
lose consciousness in the same sense as ai man suffering from
cerebral concussion. Without doubt he had passed through
a violent mental disturbance; later I shall endeavour to
analyse this mental disturbance, but there was no loss of
consciousness. A-is above all suffering from emotion,
he is not suffering from cerebral concussion. The disturb¬
ances exhibited by him must be attributed to emotion, and
not to concussion.
Sequence of Phenomena following the Emotional Shook.
I do not insist on the manifestations which determined
the emotional shock in this man. I only wish to draw
attention to the manner in which they unfolded themselves.
In the case of A- in the space of a moment a violent
emotion has disturbed his physical and mental equilibrium;
nearly instantaneously he was overcome by an intense
trembling; his heart beats and his respiration became
extremely rapid. His mental state was changed ; his face
took on a lacrymose and mournful expression; it was impos¬
sible to obtain from him an answer or gesture to show that
he understood what was said to him. The reaction to
emotional shock was therefore immediate.
Six hours after the shock some of the phenomena still
persisted—tachycardia and tachypnoea. Others had become
less and been modified. The trembling had diminished but
not disappeared. His appearance was still stupid, but one
could get into communication with him. He answered
questions slowly as if it was an effort to do so, but he
answered correctly, and he gave details spontaneously. Thus
after six hours, and although he was under cover, the dis¬
turbance produced in my patient’s organism by the emotional
shock had not yet calmed down. Certain of the physical
phenomena by which emotion shows itself persisted un¬
changed ; others were present but in less degree. The
mental state appeared to approach the normal.
But this improvement of mental state was but a truce.
Indeed, on the third and fourth days after the shock the
state of A- was as follows: tachycardia and tachypnoea
persisted; trembling had become less and was localised to
the right hand. But the mental state was more disturbed
than it was six hours after the shock. A condition of
stupor and pronounced mental confusion existed, which
amounted to refusal of food and retention of urine. Thus, in
the case of A-the primary period of psychic inhibition had
been followed by a period in which a certain psychic activity
was apparent; then this period of relative improvement gave
place to a period of mental confusion with stupor.
At tbe end of about a week all the phenomena had begun
to get less, and 14 days after the onset A-had recovered.
In A —-s case, then, emotional shook produced an imme¬
diate perturbation of the organism, the effects of which were
felt for two weeks in the form of tachycardia, trembling,
mental troubles in different keys and aspects, hence lasting
long after the cause which had produced the shock was
removed. So in certain cases the disorders following emotion
on the battlefield which have been observed behind the lines
or at the depdts are only the primary or secondary phenomena
by which emotional shock manifests itself, and which last after
the cause whioh has disturbed tbe organism no longer exists.
The Lancet,]
THE NEUROSES OF THE WAR.
[Jan. 11,1919 71
THE LANCET.
LONDON: SATURDAY, JANUARY 11, 1919.
The Neuroses of the War.
The war, now happily, and finally we trust, come
to a victorious end, will not be characterised in
the histories of the future by any such limiting
territorial epithets as have been assigned to all
previous wars. Unique in its designation as the
Great War, or even simply The War, it has also been
unique, militarily speaking, in its air and sea,
under-sea, land and even under-land aspects.
From the point of view of medical science, further,
it has certainly provided the stimulus for more
sustained, more concentrated, more widespread
and more fertile medical research than any previous
event in the world’s history. At its close we may
now perhaps take the opportunity of passing in
review the stages in the development of our
knowledge of the neuroses of war, a subject which
has been productive of clinical investigation to a
quite unusual degree. Before the war the cate¬
gories covered by the clinically descriptive terms
of neurasthenia, psychasthenia, and hysteria were
well recognised and more or less ^ell differentiated
and accepted, in this country at least. Into this
time-honoured scheme came with upsetting
suddenness and momentum the new conception
of “shell shock” as a clinical entity; old
terms were given up, and “shell shock” repre¬
sented the latest and all-embracing idea in the
neuroses or psychoneuroses. Men came home with
“ shell shock ” on their labels, and soon both the
medical and the lay mind were permeated with it;
it was the cause of every functional disturbance,
mental or nervous, and special hospitals were
rapidly organised for the reception of the “ shell¬
shocked.” Ere long, however, calmer consideration
and more painstaking research showed that under
the term was included a multiplicity of clinical
conditions, most, if not all, of which seemed familiar
enough. Somehow there was at first a disinclina¬
tion to think of the soldier—the “ old contemptible,”
the volunteer, the patriot—as a possible subject of
ordinary traumatic hysteria; but that war hysterics,
and malingerers, too, were appearing at base hos¬
pitals and in military hospitals at home could not
be gainsaid. Gradually it came to be felt that
“ shell shook ” was confusing by reason of its
indefiniteness, and traumatic hysteria, traumatic
neurasthenia, psychasthenia, and the rest seemed
to come into their own again. If we mistake not,
there is now appearing a tendency to group the
war neuroses after the Freudian fashion, and to
force them into the pigeon-holes labelled “con¬
version hysteria,” “ anxiety hysteria,” and “ anxiety
neurosis.”
But poor indeed would be the advance in our
knowledge of the neuroses as the result of war
experience were “ shell shock ” as a psychogenic or
neurogenic factor to be minimised, or a sexual
element in their genesis to be necessarily implied,
by the adoption of a Freudian nomenclature. In
our English fashion we have essayed a compromise
between the old and the new, and many have come
to regard the war neuroses as essentially identical
with those of civil life, except in so far as the
events of the battlefield are novel excitant factors
and the instinct of self-preservation more potent
than the instinct for the propagation of the species.
The French, perhaps less apt than we to be influ¬
enced by precedent, less conservative, less bound by
preconceived ideas, have divided the neuroses of
war origin into “commotional” and “emotional”
syndromes. 1 With that facility for new word-
formations to which their language lends itself,
they speak of the “ commotionne,” the “emotionn6 ”
and the “ contusionne ”; we have in the translation
of our French Supplement followed tradition in
rendering “commotionne” as “concussed,” but
have done so with regret. The contusionne , the
patient with signs of local or general cerebral
irritation and probably a somewhat blood-stained
cerebro-spinal fluid, is, of course, clearly enough
defined. The commotionne is the man who,
after loss of consciousness from a shell explosion
in his immediate vicinity, remains in a state
of subcoma or obnubilation, with a variable
degree of physical and mental inertia and of
cerebral inhibition; his pupils are usually dilated,
his pulse slow, and his reflexes diminished. The
emotionne , on the other hand, does not as a rule
lose consciousness in the strict sense (as Dr. C.
Vincent shows in his interesting paper published!
in our French Supplement); he has a quick pulse,
moderate reflexes, and a pale, haggard or frightened
visage; he trembles, and sweats; concentrated on
his own ango%88e y he is indifferent and inattentive
to what goes on around except as it bears on his
own safety and security. Such descriptions refer
to the patients’ states on their arrival at a C.C.S.;
in the base hospitals the clinical appearances have
changed to some extent. The emotionne has
become a case of “ emotion-neurosis ”—like the
anxiety-neurosis more or less; he is a pantophobe,
with familiar psychical and physical symptoms.
Or he may develop into an “ emotion-neurasthenic ”
with physical and psychical overstrain, asthenia, and
fatigability as the most prominent features. Or
again, he may, ere he reaches the base, for that matter,
have developed one or more of the pleomorphic
manifestations of hysteria. Emotion-hysteria is
common enough, but it should be clearly understood
that hysterical phenomena do not form a constant
and integral part of the emotion-syndrome, and may
arise independently of emotional stimuli. It is
comparatively rarely that the commotionne shows
subsequent signs of hysteria; he remains, as a rule,
an “ inhibe,” it may be, for months.
A schematisation of this sort may be perhaps
rather cut-and-dry, and naturally cases presenting
* See In particular A. L6rl, Commotions et Emotions de Guerre
(Paris, Masson et Cle, 1918).
72 The Lancet,]
LESSONS OF THB INFLUENZA EPIDEMIC.
[Jan. 11,1919
combinations of symptoms are met with; but it has
mnch to commend it, and for practical purposes has
proved, and is proving, useful and illuminating.
And yet it leaves many problems unexplained, or
at least only superficially elucidated—how much
so can be gathered by a perusal of Dr. G. S. Myers’s
interesting contribution in another column. Dr.
Myers indicates for us certain topics on which
further investigation is desirable, and states that
the mechanism of production of "functional dis¬
sociation ” is still imperfectly understood. Emotion,
suggestion, conflict (in a non-physical sense),
maladaptation to environment, and so on, are
factors whose evaluation remains to be determined.
At this psychical end of the war neuroses there is,
then, not a little for further research, in spite of
the fact that in this country, as Dr. Myers
remarks and as we have always maintained, the
mental aspect of the war neuroses has been elabo¬
rated at the expense of neglect of an equally
detailed study of the accompanying somatic
symptoms. Many have noted involvement of sym¬
pathetic, glandular, and reflex systems in emotion-
neurosis and in emotion-neurasthenia, but only
the fringe of the subject has been touched. Dr.
Myers pertinently asks whether functional dis¬
sociation may extend to these systems, and to what
degree or “ level.” Similarly, in hysteria resulting
from the war we should like to see more detailed
investigation of the somatic and visceral accom¬
paniments; so far from regarding such investiga¬
tion as reactionary in view of the psychical nature
of the affection, we feel that by it we should gain
further insight into the extent of hysterical dis¬
sociation in somatic systems and learn useful
criteria for diagnosis. It is not enough, in our
view, to explore the recesses of the concep¬
tual World by psycho-analysis or autognosis
when the objective neural disturbances of
the patient are analogous to what is found
in certain endocrine affections or in certain
organic conditions of the neuraxis. Dr. Myers,
albeit in an admittedly sketchy fashion, gives us
enough clinical data for a realisation of the signifi¬
cance of investigation along such lines, and his con¬
tentions carry the more weight as coming from a pro¬
fessed psychologist. The varying orientation of our
ideas on war neuroses during four years, apart from
its intrinsic interest in the history of medicine, is of
extrinsic importance for future diagnosis and treat¬
ment. Numerous, indeed, are the “ unwounded
wounded ” at home or still abroad, and for a long
time yet we shall have to deal with them thera¬
peutically. To place them in their appropriate
medical category is a matter of justice and equity;
to separate the malingerer from the hysteric, the
commotionne from the emotionne , the exaggerator
from the inhibit is a labour calling for knowledge
and acumen. Treatment itself, as Dr. Myers shows,
has not been made a subject of systematic inquiry;
successful workers, it is true, have published results
in profusion, but there has been too little following
up of cases for re-examination after an adequate
interval. The war is over, but the physician’s task
is far from an end.
Lessons of the Influenza Epidemic.
• Epidemiology and Clinical Aspects.
From our review of the etiology and pathology
of influenza in last week’s leading article the
complexity of the problems involved is apparent,
and it is obvious that further investigation is neces¬
sary for their solution. This is especially true of
the epidemiological aspects of the disease which
have not figured prominently in the various
papers which we have published; nor is this
surprising, since the materials necessary for the
foundation of a considered judgment have yet to be
assembled. _ . _
Epidemiology.
In the highly valuable discussion at the Royal
Society of Medicine on Nov. 23rd last Dr. Major
Greenwood provided data from the records
of the Ministry of Munitions and the Royal Air
Force which suggested that the incidence curve of
the summer outbreak was closely similar to that of
the first pandemic in 1889-90 and that the secondary
wave partook of the characters observable in 1891-92.
These data were, however, incomplete. For instance,
an epidemiological explanation of the relatively
greater mortality at younger ages in the present
outbreak remains to be found. The official
mortality figures of the Registrar-General's 96
great towns display the asymmetrical character
of the autumn epidemic very clearly. The
maximum number of deaths—7557—occurred in
the week ending Nov. 9th, having risen to this
height from 1887 in the week ending Oct. 19th. The
decline again to this level has been more gradual,
almost the same number of deaths, 1885, being
recorded in the week ending Dec. 14th. An examina¬
tion of individual towns suggests that the maxima
occurred earlier in the seaports, but it is impossible
yet to correlate either the severities or the rates
of temporal extension in the outbreaks with geo¬
graphical and economic factors. A perusal of the
clinical and bacteriological papers in our own
columns alone suggests the desirability of investi¬
gators not delimiting the field of inquiry too
narrowly. Dr. Harold Whittingham and Dr.
Carrie Sims, for instance, in our issue of Deo. 28th,'
1918, drew attention to the clinical differences
of the summer and autumn outbreaks, and
inferred that the causal organisms must have
differed. The observation is, of course, a very
familiar one in the history of epidemic diseases,
and has been made with especial frequency
relatively to scarlet fever; it would appear to be
consonant with our experience of scarlet fever to
infer that the variation is not so much of the causal
organism as of secondary invaders responsible
for sequelae of the primary disease. Dr.
Whittingham and Dr. Sims also refer to the
"distinct tendency when an epidemic disease is
raging to assign all maladies to the one common
origin,” and we suspect that they deprecate this
tendency; yet it may be the more or less conscious
expression of an important epidemiological truth.
The clinical convergence of disparate types of
disease in a given year or cycle of years and the
clinical divergences of the same disease at different
epochs are the foundations of that doctrine of
epidemic constitutions which held so prominent a
place in the teaching of our first epidemiologist,
Sydenham, and depended upon wide experience
and accurate observation. The total discredit into
which the old theory has fallen is, of oourse, due to
the fact that the biological prophylaxis of clinically
THU LANCET,]
LESSONS OF THE INFLUENZA EPIDEMIC.
[Jan. 11, 1919 73
convergent types, such, for instance, as typhoid and
paratyphoid infections, is distinct. Bnt a hetero¬
geneity from this point of view does not invalidate
the claim that from another point of view such
a group of diseases is homogeneous; just as a
sample of men may be heterogeneous in political
opinions but homogeneous as regards their incomes
or occupations. The point we are making is of
much importance, and unless it be kept clearly in
mind epidemiology becomes logomachy. We have
to inquire in the first place whether in the
late epidemics any general morbid process has
developed, and, if so, whether it can be identified
with any recorded before and whether its course
has been significantly different from that of any
previous epidemic.
‘ * There are in truth varied constitutions of the years, not
dependent upon heat or cold, dryness or moisture, but rather
upon some hidden and inexplicable change in the very bowels
of the earth, whence the air is contaminated by such effiuvise
which predispose and determine towards this or that disease
the bodies of mankind, so long as the dominion of the
'particular constitution endures, which constitution, its term
having run, yields and gives place to another. Each of these
general constitutions is characterised by a special fever
peculiar to itself and not otherwise seen ; such fevers we
term stationary fevers. ” l
Unlike Sydenham, we should regard the hidden
change as being within the field of possible
epidemiological research and not rest content
with a vague metaphor, but the idea at the back of
the passage cited appears to us still fruitful, and
attention should not be diverted from it by too
sedulous pursuit of bacteriological details, important
as these latter are from other points of view.
Clinical Aspects .
In its clinical aspects epidemic influenza has
been characterised in past outbreaks by very varied
manifestations, and attempts have been made to
separate out different types of the disease with in¬
different success. The epidemic at present so widely
distributed is no exception to this rule; indeed, so
protean have been its manifestations and so un¬
equal its virulence, that some doubts have been
expressed, chiefly in the lay press, as to the disease
being influenzal in origin. Various fantastic theories
have obtained a wide currency with little or no basis
of support. One fact that seems to emerge clearly,
through intensive study of the epidemic from the
clinical and pathological points of view, is that
the epidemic is influenza complicated by certain
secondary organisms or infections. The complexity
in the causation, which is suggested by bacterio¬
logical observations, may be, and probably is, an
important factor in the variability of the clinical
manifestations of the disease; with further correla¬
tion of the bacteriological and clinical observations
the diversity of clinical types may find accurate
explanation, and different forms of the disease
may be associated with different secondary infec¬
tions. The clinical features of influenza become
somewhat more easy of explanation in the light
of the pathological conditions observed in fatal
cases, and these are admirably described in the
paper by Dr, Adolphe Abrahams, Dr. Norman
Hallows, and Dr. Herbert French, which
we published on p. 1 of last week's issue of
The Lancet. They point out that even in the
so-called pneumonic cases the lung lesions are
only a part of the morbid changes usually found.
They regard the fatal forms of the disease as a
septicemia of influenzo-pneumococcal or influenzo-
streptococcal origin with more or less marked local
1 Sydenham: Obeervatlonam Medicarum, lib. 1., oap. 2, par. 5.
changes in the lungs. The lung conditions found
post mortem are even more varied than the
clinical features of the disease, and comprise
bronchitis, bronchiolitis, broncho-pneumonia,
hemorrhage, infarct, collapse, oedema, multiple
abscesses, gangrene, interstitial emphysema;
indeed, practically all possible morbid lesions
except that lobar pneumonic consolidation is
exceptional—a somewhat surprising fact in view
of the physical signs, which frequently appear
typical of this condition. The pleural n^anifesta-
tions are also variable, and range from localised
dry pleurisy to large effusions of thin sero-purulent
fluid. Without attempting enumeration of the
lesions found, it is important to emphasise the
frequency of renal changes, amounting to actual
nephritis in a very considerable percentage of the
fatal cases—a fact liable to escape observation
clinically unless a routine examination of the
urine is carried out, for oedema is absent. This
is of especial importance in cases where con¬
valescence is delayed. The pathological changes
found allow little room for doubt that the fatal
cases are of toxeemic or septicaemic character, and
the discovery of organisms in the blood during life
and in the internal organs immediately after death
affords confirmation of this view.
A critical account of the symptoms of the disease
will be found in the paper by Dr. French and his
collaborators; but it may be worth while to point out
that the character of the symptoms seems to differ
in different parts of the country, and even in cases
in the same place at different times. For example,
some cases with pulmonary complications have been
associated with an almost incessant cough, others
with copious expectoration, while in some other
cases with marked pulmonary involvement very
little expectoration has occurred. Laryngeal, pul¬
monary, and lethargic varieties have been described.
The types of case observed in the last few months
have varied from mild febrile attacks associated
with malaise, general pains in the back, limbs,
and head, feelings of great prostration, thickly
coated tongue, and almost complete loss of appetite,
to fulminating cases fatal within 24 or 48 hours,
j A special feature, even of mild cases, in some parts
of the country has been epistaxis, often frequent
and copious. Other haemorrhagic phenomena have
been present in the septicsemic or pneumonic cases,
including haemoptysis and haematemesis. On the
other hand, purpura seems to have been uncommon,
although such might have been expected in the
septicaemic cases. The colour of the patients with
severe pulmonary complications is one of the
features which has attracted almost universal
attention, a peculiar dusky pallor, described as
heliotrope cyanosis, being of most sinister prog¬
nosis, even though it may be present with ohly
moderate pyrexia, a deceptively good pulse-rate,
and not very extensive physical signs. The point
is emphasised by the three observers just men¬
tioned, who call attention also to the absence
of orthopncea and the comparatively slight
degree of carffi&C~ dilatation . which may be
present even in cases dying rapidly with marked
cyanosis. These are points which strongly support
the view of the septiciemic nature of the cases as
opposed to the pulmonary origin of the symptoms.
The frequency with which suppuration in the sphen¬
oidal sinuses has been found in fatal cases, as
well as the occurrence of severe epistaxis even in
mild cases, and the existence of pharyngeal or
laryngeal inflammations in some forms of the
disease all serve to suggest that the channel of
74 The Lancet,]
RABIE8 AND 118 TREATMENT IN THIS COUNTRY. ,
[JAK. 11, 1919
inf ection is usually by the upper air-passages. The
use of antiseptic gargles and nasal douches as a
preventive appears, therefore, to be well founded,
and the use of a gauze mask over the mouth and
nose by nurses and medical men in attendance on
cases in institutions seems a reasonable precaution.
The physical signs in the pulmonary type of case
are as variable as the other features of the disease.
There may be general or local catarrhal signs,
scattered patchy consolidation or signs strongly
suggestive of lobar involvement, though they are
in reality due to aggregations of broncho-pneu¬
monic areas. Neither diagnosis nor prognosis can be
gauged by physical signs too closely. In other cases
signs of fluid may develop rapidly, but diagnosis of
the lung or pleural conditions is often rendered
difficult by variations in the physical signs from
day to day. An interesting condition which has been
observed in a few cases is subcutaneous emphysema
—sometimes localised, occasionally widespread.
Treatment .
In regard to treatment no satisfactory routine
measures can be said to have been discovered as
yet. The various “ specifics ’’ suggested seem hardly
to justify the claims made by their partisans. In
all cases some such scheme of expectant and
symptomatic treatment as that outlined by Sir
Thomas Horder in The Lancet of Nov. 23rd last
should be adopted, and this with efficient nursing
may be all that is required; but in the severe
pneumonic, toxremic, or septicemic cases the thera¬
peutic resources of the practitioner may be taxed to
the utmost and yet fail, for some of the cases,
notably those with the peculiar “ heliotrope”
cyanosis, seem all but hopeless. The question of
treatment by vaccines and serums is still an open
one. Evidence seems to be accumulating as
to the value of prophylactic inoculation with
mixed vaccines of the Pfeiffer bacillus, the
pneumococcus and the streptococcus. We may
hope that statistics on this question will -be
forthcoming eventually, and that the value of the
procedure will be authoritatively appraised. Anti¬
streptococcus serum has been used by many
observers in the toxic cases, but the results
recorded seem to offer but moderate encourage¬
ment, though its use is rational in cases in
which the presence of the streptococcus has been
established. The use of vaccines in the treat¬
ment of the disease itself has been deprecated on
the supposition that the induction of a negative
phase might affect the course of the disease
unfavourably. In a paper published in The Lancet
of Dec. 28th by Dr. W. H. Wynn this objection is
denounced as theoretical, and the value of vaccines
in acute influenza is strongly affirmed. This ques¬
tion, like many others, must be regarded as still
sub judice , but we may hope that when the expe¬
rience afforded by this epidemic has been collated
some practical knowledge may result which, while
not preventing further epidemics, at least will
render them less serious in their effects.
-»■ ■ —
Rabies and its Treatment in this
Country.
Our insular position and the spirited action of
the Board of Agriculture under Mr. Walter Long
resulted in the complete immunity of Britain from
rabies for more than a decade. The faint academic
interest felt for an infection occurring only on the
continent has been violently stimulated by the
recent outbreak of rabies in Devon and Cornwall*
The airship and the dislocation caused by war
conditions have made the rabies blockade in¬
effective, at all events for the moment, although
no one will have any sympathy for the blockade-
runner whose thoughtless selfishness may result in
such terrible consequences to his countrymen.
Hitherto anti-rabic treatment has not been avail¬
able nearer than Paris, but Dr. Emil Roux, before
relinquishing the office of director of the Pasteur
Institute in Paris, with which he has been so long
and honourably associated, rendered a very valuable
service to this country by enabling anti-rabic treat¬
ment to be given with material sent over at
frequent intervals from the institute to the Local
Government Board. It is practicable, in the expe¬
rience of the institute, to rely upon glycerine and
cold to preserve the virus in a proper degree of
potency for several weeks, and by these means
to supply for use in this country spinal cords
representing fixed virus of different ages, from
which emulsions can be prepared and treatment
can be given on lines parallel to those used*
at the parent institute. The Local Government
Board have now announced to the local authorities
of Devon and Cornwall that in place of the
elaborate arrangements which had recently been
l made to facilitate the journey to Paris of persons
known to have been bitten by rabid animals, anti-
rabic treatment can in future be given at Plymouth,
where the arrangements have been placed under
the charge of Dr. W. L. Pethybridge, pathologist
of the South Devon and East Cornwall Hospital.
District councils afb authorised in this connexion
to pay reasonable sums for the maintenance in
Plymouth of persons requiring treatment who
cannot stay there at their own expense for the two
or three weeks necessary for the completion of the
course.
This provision of anti-rabic treatment is obviously
necessary while cases of rabies in dogs and other
animals continue to occur in these two counties.
The disease has not disappeared, though there is
reason to believe that the various restrictions on
the movements and keeping of dogs, and the com¬
pulsory muzzling requirements of the. Board of
Agriculture, have already greatly reduced the oppor¬
tunities of its spread, and apparently no cases are
occurring outside the two counties named. It is
understood that about 30 persons have actually
been bitten by dogs definitely ascertained to be
rabid since the outbreak was discovered. Nearly
all of them have received anti-rabic treatment at
Paris or at Plymouth, and it is satisfactory that no
human case of hydrophobia has so far occurred.
In their last Memorandum to the local health autho¬
rities, dated Dec. 31st, 1918, the Local Government
Board state that the Board of Agriculture take steps
to secure that the names of all persons known to
their officers or to the police to have been bitten
by dogs known or suspected to be rabid are at once
communicated to the medical officer of health of the
district. That officer communicates direct with the
medical department of the Local Government Board,
through which he learns of the facts regarding the
dogs which have been ascertained at the laboratories
of the veterinary officers of the Board of Agriculture,
and obtains any further information available to
guide him in deciding whether anti-rabic treatment
should be advised. Where this advice is necessary
the arrangements for treatment are to be made by
the medical officer of health by direct communica¬
tion with the pathologist at Plymouth, in order
that the course of treatment may be started as
speedily as possible.
The Lancet,]
TUB ETIOLOGY OF LINGUAL GANGER.
[Jan. II, 1919 75
"He quid nlmia.”
THE ETIOLOGY OF LINGUAL CANCER.
In his Bradshaw lecture on Cancer of the
Tongue Mr. D'Arcy Power referred to the fact that
it is almost entirely a human disease ; it is always
of one type; it is unknown in children; it is
common in men, rare in women, and is not
associated with any inherited predisposition to
caroinoma. He gave an interesting description of
the disease from the historical standpoint, pointing
out that it did not become important surgically
until the seventeenth century, the Greek, Latin,
and Arabian writers on surgery hardly mentioning
it, and so far as can be ascertained at present it is
unknown to the Anglo-Saxons.
“The first definite notice of cancer of the tongue is the
case of Ralph Freeman who died on March 16th, 1634, whilst
serving the office of Lord Mayor of London. He suffered
from secondary haemorrhage and it was the opinion of the
physicians and surgeons who were in attendance upon him
that a mercurial course might have been of use at an earlier
period of the disease. The second recorded case occurred
m Germany, and was looked upon as a miraculous punish¬
ment for cursing the clergy. The story runs that 4 lately a
oertain baron spoke abusively to all and sundry, but kept
his most venomous shafts for the clergy and for those who
devoted themselves to God’s service. One day a holy brother
of good repute whom he bad just lashed said, “ Your foul
tongue has overlong deserved that punishment from an
offended God which it will shortly receive.” The baron rode
off undismayed, but a few days later a small swelling began
to grow at the side of his tongue. Little by little it increased
in size until it became an inoperable cancer, and the baron,
penitent and confessed, died miserably afflicted.’ From
the middle of the seventeenth century onwards cancer,
of the tongue became so frequent that it was no
longer necessary to invoke a miracle for its production.
At the present time cancer of the tongue is known to have
occurred in one horse, three cats, and one dog. All these
animals were aged, and in each the cancer was of the
squamous-celled variety. It appears fair to assume, there¬
fore, that lingual carcinoma has always ocourred in men
and domesticated animals; that originally in man it was no
more frequent than it is now in animals ; but that from the
seventeenth century onwards it has increased out of all
proportion in man, whilst the incidence has remained
stationary in animals.”
The returns of the : Registrar-General were
quoted in order to show the rate at which cancer
of the tongue has increased in man. Dr. T. H. C.
Stevenson, Superintendent of Statistics at Somerset
House, writing in 1909, said that “ the recorded mor¬
tality has increased amongst males by no less than
228 per cent, in 41 years. The increase, moreover,
is entirely confined to the male sex.” Mr. D’Arcy
Power then considered the possible factors causing
this increase, among which irritation had long
been looked upon as important, and it has been sug¬
gested that pyorrhcsa and dental caries have become
more common. He thought that the virulence, but
not the amount, of pyorrhoea seemed to have
increased lately, whilst caries did not appear to be
more frequent now than it was in some parts of
England during the prehistoric period. Roman
skulls found in England, he said, had nearly as
many carious teeth as there arp in the skulls of
Londoners who died within the last 200 years, and
if cancer of the tongue were the direct result of
carious teeth the disease should have been
as well known to the surgeons at Rome as it
now is to us. But neither in Celsus nor in the
Latin satirical poets is there any allusion to it.
With regard to the question of syphilis being a pre¬
disposing cause, the lecturer gave, in discussing
this point, an account of 169 persons who were
admitted to St. Bartholomew’s Hospital with cancer
of the tongue during the years 1909-1916.
Nine of the patients were women, the rest were men, or a
proportion of 18 to 1; the true proportion, as shown by the
returns of the Registrar-General, being 1 woman to 8 men.
Of the women seven were married, one was unmarried,
and the social state of the other is not mentioned. Of
the seven married women, one gave a history of syphilis,
two showed signs of syphilis, and one was a widow who had
only one child alive out of five; the note adds, 44 She looks
as if she drank.” One woman bad leucoplakia of the tongne
at the age of 17, and stated that her father had suffered from
an “abscess of the brain” which was cured by medicine.
This was probably a gummatous meningitis. There was no
history of syphilis, either acquired or inherited, in the other
two married women. The unmarried woman—a nurse—
said that her father died of aneurysm, and that she herself
had suffered from an abducent paralysis which came on
suddenly and was oured by medicine. None of the women
smoked, but all bad bad teeth.
In the case of the men 93 out of the 160 were syphilitic.
62 gave a history of syphilis, and the remaining 31 showed
signs of the disease, the syphilis being invariably of long
standing. Twenty-six patients stated definitely that they
bad never had syphilis, bat one of these had suffered from
gonorrhoea, and the blood of two gave a positive Wassermann
reaction. Many of the patients had drunk to excess, but
did uot, as a rule, acknowledge that they had taken spirits
freely.
A Wassermann teBt had only been performed 26 times; it
was negative in 12 and positive in 6 cases; in 5 it was donbt-
fnlly negative and in $ doubtfully positive. These results
were compared with those obtained by Captain Arnold
Renshaw, R.A.M.C., of the Manchester University Medical
School, and Captain Archibald Leitch, R.A.M.C. (T.), of the
Cancer Hospital, Brompton, and it was thought that the evi¬
dence brought forward pointed to a close association between
syphilis and cancer of the tongue. The syphilis might be
active, but it was more often quiescent or even extinct,
the conclusion arrived at being that, as in some cases of
tuberculosis, 44 syphilis made the bed upon which cancer is
born.’’ It appeared, further, that an increase in the number
of deaths from lingual carcinoma had occurred after periods
when mercury had temporarily fallen into disuse in the
treatment of syphilis. Such insufficient treatment was the
rule in the later years of Queen’s Elizabeth’s reign, when
guaiacnm, sarsaparilla, and the 44 vegetable ” cures displaced
the original mercurial methods; as also during the Regency
period, when some of the Army medical officers nearly
succeeded in abolishing the use of mercury; and, again in
the early Victorian era, when the value of potassium iodide
was unduly exploited. Many of the patients whose cases
were recorded at St. Bartholomew’s Hospital stated
voluntarily that they had only been treated with mercury
for a fortnight or three weeks, after which they considered
themselves cared.
Syphilis, Mr. Power concluded, could not be con¬
sidered as more than a predisposing cause of cancer
of the tongue, because lingual carcinoma occurred
in animals. An exciting cause, therefore, must be
looked for, and that cause ought to have become
more prevalent during the last 50 years if the
increase in cancer of the tongue was to be attri¬
buted to it. The cause must also be one which
acts in men more than in women. He thought that
the increased consumption of tobacco seemed to
fulfil these conditions. Cancer of the tongne, he
said, vlid not become frequent until some years
after the introduction of smoking in the last quarter
of the sixteenth century. The habit spread slowly
during the seventeenth, eighteenth, and nineteenth
centuries. Cigarettes were introduced about 1877,
and from that time onwards the smoking of tobacco
has steadily increased until it is now an almost
universal habit with both sexes from adolescence
onwards. Smoking acts in two ways as an irri¬
tant to the tongue, partly through the nicotin
and partly by the increased heat in the month,
which is measurable by the thermometer. In the
latter respect it may bear the same relation to
cancer that heat does in kangri cancer, where the
thermal irritation appears to be a definite factor in
the production of epithelioma. Although the pre¬
disposing and the exciting causes of cancer may be
76 Thb Lancjst,]
MOTOR MECHANICS FOR CRIPPLES.
[Jan. 11,1919
known, the actual cause has yet to be discovered,
but if two factors are recoguised it ought not to be
impossible to discover the third. It is theoretically
possible to reduce cancer of the tongue to the sub¬
ordinate position it occupied before the seventeenth
century and which it still holds in the domestic
animal, and this could be effected by a thorough
treatment of syphilis in its initial stages. Persons
who were being treated for syphilis should be told
never to smoke, not to drink to excess, and to pay
regular visits to the dentist. Such advice should
be given whilst the patient is still under treatment,
and should not be deferred until the tongue has
become sore. Failure to follow this advice and a
continuance of the treatment of syphilis on in¬
effective lines will be followed in ail probability by
a very large increase in the number of patients
with cancer of the tongue. This increase should
begin about 1950, and should affect women as well
as men, for syphilis is now more widely spread
amongst the younger generation than it has been
for many years past, and both sexes smoke much
larger quantities of tobacco than ever before.
MOTOR MECHANICS FOR CRIPPLES.
Motor mechanics is proving in the Dominions,
as here, a popular subject of instruction for crippled
soldiers on their way to become self-supporting
workers. Mr. Douglas C. McMurtrie, director of the
Red Cross Institute for Crippled and Disabled Men
in New York City, writes that the trade is almost
too popular in the Canadian schools. Practically
every Canadian soldier, when asked to choose from
among the various trades in which classes are held,
selects automobile mechanics. Most of the men
now have to be dissuaded from their intention or
the supply of mechanics would soon far exceed the
demand. Canada, England, Germany, and India
amongst the belligerents are * offering training
courses in motor mechanics to disabled men of
their own forces, and America is falling into line.
At the large reconstruction hospital at Fort
McHenry, for instance, automobile mechanism is
taught, and one-armed or one-legged mechanics
will be no new thing oncO the general public has
accepted the principles of re-education. In British
Columbia gasoline engine classes were organised
soon after the wounded began returning from
overseas. Vancouver, Victoria, Esquimalt and
Westhaven provide instruction in motor mechanics.
In Victoria the Military Hospitals Commission
and the Board of Education together operate a
fully-equipped motor repair-shop in which men
who wish to become chauffeurs are taught. Men
trained in this course conduct a well-patronised
taxi-stand in the town. Those who wish a thosough
course in motor mechanism are sent to Vancouver,
and later to the new workshops at Esquimalt and
Westhaven. The Commission has arranged for
war cripples at Vancouver to be taught driving in
the evening classes of an excellent automobile
school. At this school any disabled soldier may
attend the day classes free of charge. Men from
other parts of British Columbia are kept in
Vancouver on a maintenance allowance while
receiving training. Courses are also given at the
University of Saskatchewan, and at the Provincial
Institute of Technology and Art in Calgary. In
this country, as is well known, the workshop at
Roehampton is fitted up as a model garage in
charge of disabled men who, besides being skilled
instructors, understand the special problems of the
war cripple. At Dusseldorf the course in auto¬
mobile mechanics was established at the request of
the motor repair-shop owners, who needed work¬
men and could not obtain able-bodied men. Within
a very few months of its inception the pupils had
successfully repaired 14 different types of motors.
In India Queen Mary’s Technical School in Bombay
gives opportunity for the study of automobile
mechanics by the crippled natives, whose imagina¬
tion has been roused by this method of equalising
their physical handicap.
THE NOTIFICATION OF ENCEPHALITIS AND
POLIOMYELITIS.
To those who have made a study of epidemic
disease the decision of the Local Government
Board to make acute encephalitis lethargies notifi¬
able is a source of very real pleasure. It is all to
the good that the hands of tlfe public health
authorities should be strengthened in respect of
this disease, and there is much significance in the
fact that although it has been discovered so
recently it is already included in the list of diseases
dealt with under the Public Health Acts. The
advantages of notification as the fundamental step
in the elucidation of the problems of infectious
disease in general appear now to have been fully
recognised, and the arduous labour which attended
the struggle to get acute poliomyelitis on the list is
bearing fruit in another direction. Judging by past
experience there is the possibility of a recurrence of
encephalitis lethargica in the spring, and the
medical profession will not be caught unprepared
for the visitation. The general characters of the
disease, at any rate in its more striking forms, have
been brought prominently before the profession in
our columns and elsewhere. With information of
the occurrence of cases at their disposal the
authorities will be able to coordinate research, and
the discovery of the cause of the disease, which is
the first step towards rational treatment, will be
advanced. _
SPANISH-AMERICAN MEDICAL FELLOWSHIP.
The spirit of friendly cooperation has invaded
medical circles on both sides of the Atlantio, and
one of its latest developments is the proposed issue
of a Spanish edition of the very ably edited Journal
of the American Medical Association. The purpose
of the issue is to promote the study of scientific
medicine, and in so doing to further a closer inter¬
national relationship between the great federation
of English-speaking states in the North and the
looser union of Spanish-speaking republics in the
South. Last March President George E. Vincent, of
the Rockefeller Foundation, approached the editor
of the Journal of the American Medical Association
with a suggestion on the subject, and at a sub¬
sequent meeting of the board of trustees of the
journal the publication of a Spanish edition was
authorised. The first number is arranged to appear
early in the present month, and the issue will be
continued, for the .time being, twice a mouth. All
that is of more general interest and permanent
value in the weekly Chicago edition will appear in
the Spanish issue. Some 2000 medical practitioners
in Central and South America have been asked for
their opinion as to the reception such a journal
would meet with, and all the replies as yet received
have been favourable. Up to the present Mexioo
and South America have been wont to turn to
1 France and Germany for undergraduate and post-
Thk Lancet,]
PARALY8I8 AGITANS AND THE CORPUS STRIATUM
[Jan. 11, 1919 77
graduate teaching, and to take from them their
inspiration towards progress. This new venture
may lead the scientific men generally of the
American Continent to realise their identity of
interest and to open up opportunities for inter¬
change of knowledge and of the results of research
in various fields. We do not construe it in the
sense of a rigid application of the Monroe doctrine.
Certain standard English text-books of medicine
have already been translated into Spanish, and we
should like to see this peaceful form of penetration
continue and develop. _
PARALYSIS AGITANS AND THE CORPUS STRIATUM.
It appears that we are within a measurable
distance of an understanding of the pathology of
this chronic nervous syndrome. In an interesting
paper by Dr. J. Ramsay Hunt in the Archives of
Internal Medicine (November, 1918) this writer
records in full detail the morbid findings in two
cases of paralysis agitans; in both the sole lesion
was found to be a primary atrophy of the pallidal
system of the corpus striatum. The corpus
striatum in man is divided by the passage of the
internal capsule into two structures, the caudate
nucleus and the lenticular nucleus. The latter is
subdivided into an external segment, the putamen,
and an internal, the globus pallidus. The globus
palliduB is older phylogenetically than the caudate
nucleus and putamen (neostriatum). It is also dis¬
tinguished from these structures histologically.
The neostriatum contains two types of cells, a small
type of ganglion cell of pyramidal form, and a
large type of ganglion cell, the homologues in the
corpus striatum of the Betz cells in the motor
cortex; the globus pallidus contains only these latter
large cell types. By the course of .the fibres related to
these two cell systems their functional significance
can be inferred. The small-cell fibres end in the
globus pallidus; they constitute a short association
and inhibitory system for the oorpus striatum, and
atrophy of this system is the essential cause of
Huntington's chorea (Hunt). The large-cell fibres,
on the other hand, have a wider distribution; they
extend to the optic thalamus, constituting the
efferent pallidal system, and exert, through the
red nuoleus and substantia nigra, a regulating
influence upon the extra-pyramidal motor system
of the spinal cord. Lesion of this pallidal system
results in paralysis agitans. The corpus striatum
and the strio-spinal system are to be regarded as
constituting a mechanism for the control and regu¬
lation of automatic and associated movements,
paralysis of which results in the syndrome of
paralysis agitans; in this sense it is to be dis¬
tinguished from the other type of central palsy
characterised by spastic paralysis, a paralysis here
of isolated and discriminatory movements, and
referable to damage of the pyramidal system.
The two cases recorded confirm these views as to
the pathology of paralysis agitans. In the first,
that of a man aged 56, who died of an intercurrent
infection, there were found atrophic changes in the
large motor cells of the neostriatum, with slight
reduction of the medullary network of the globus
pallidus and thinning of the strio-hypothalamic
radiation. The second case showed atrophic
changes in the large motor cells of the corpus
striatum and other changes in the globus pallidus
similar to those met with in the first case. There
were no other evidences of central nervous involve¬
ment in either case. Dr. Hunt discusses the causa¬
tion of the symptomatology. The rigidity and tremor
are referred to a loss of striatal inhibition, the
corpus striatum controlling muscle tonus as does
the cerebral cortex. When this inhibitory function
is abolished hypertonicity results. The striated
muscle has a double innervation—the anisotropic
disc system controlled by the motor nerves, and the
sarcoplasmic substance controlled by the .sympa¬
thetic system. The former subserves the function
of quick contraction; the latter, plastic function con¬
cerned in posture. It is suggested that there exist
two distinct centres for the control of muscle tonus
—one for contractile tonus, which regulates the
anisotropic disc system, the other for the plastic
tonus. Both centres are under the control of the
pallidal system, and loss of this control may be indi¬
cated by tremor or rigidity according to the system
involved. _
THE FUTURE OF THE V.A.D.
Now that hostilities have ended and the women
of the Voluntary Aid Detachments are being
demobilised, the question arises as to how we
can assist them in qualifying for some useful
career. Many of them are women of the educated
classes who have given up the work which
they had already entered upon in order to help
the country in its great need: others were
living a life of leisure and amusement when
the call came. All have answered nobly; in the
one case careers have been cut short, in the other
the women have become imbued with the ideal
of a life of activity and of usefulness to their
fellows such as would not have dawned for them
had there been no •“ Great War." It is with
the endeavour of helping these women that Lady
Ampthill, chairman of the Joint Women’s V.A.D.
Committee, has initiated a scholarship scheme,
and the Joint Committee of the British Red Cross
is contributing a sum of money u as a tribute to
the magnificent work so generously done by V.A.D.
members during the war.” Various spheres of
work are suggested, for which scholarships will
be given which are likely to prove attractive to
different types of mind. The list, which makes
no pretence to be complete, includes: medicine;
nursing (military, naval, and civil); district
nursing; village nursing; midwifery; school
nursing (elementary schools); nursery nursing;
school matrons; physical culture; instructors of
mental defectives; pharmacy; X ray assistants;
dentistry; domestic science; institutional cookery;
sanitary inspectors; health visitors; welfare super¬
visors ; hospital almoners; and infant welfare
workers. Many V.A.D.’s have given yeoman service
in domestic capacities and have proved their worth
as cooks. Those who have given their time
to nursing and other work of a medical character
may wish to continue along the same lines.
For many years the conditions and prospects of a
nurse’s life have not in general been such as to
attract the best class of woman. The hours are
long, the work is arduous and exacting, the pay is
poor, and the. prospects are uninviting. Anyone
can be, or call herself, “a nurse,” there is no
definite qualifying standard, and consequently the
position, when attained, is to some extent spoiled
of the honour which is its due. There has never
before been such a harvest of well-bred, well-
educated women for the hospitals to garner if they
can. But infant welfare work, domestic science,
teaching, and many other attractive occupations are
competing. Is it too much to suggest that the nursing
profession should take this occasion to put its house
78 thb lanottj the death-rate of mental defectives in institutions.
[Jan. 11, 1919
in order? The Great Northern Hospital has just
given a lead by raising the scale of remuneration to
ward and theatre sisters. Another London hospital
is planning its nursing on three shifts instead of two.
But much more remains to be done before nursing
becomes a career to which we shall gladly commend
our daughters, instead of a self-sacrificing adventure
which they themselves choose, and one fit only for
altruists. _
THE DEATH-RATE OF MENTAL DEFECTIVES IN
INSTITUTIONS.
In noticing the annual report of the Royal
Earlswood Institution for Mental Defectives in a
recent issue (The Lancet, 1918, ii., 656) we com¬
mented upon the excessively high death-rate
recorded at the institution during the year 1917.
Calculated on the average number of residents,
this rate amounted to 81*5 per 1000. The medical
superintendent of the institution, Dr. Charles
Csddecott, informs us that the high death-rate is
the product of several causes. In the first place, a
large number of patients were elected many years
ago to be maintained in the institution for life,
and although on any average expectation of life these
patients would have died off some years ago, there
are, in fact, 20 to 30 of them still alive, and the death-
rate is therefore each year unduly loaded by these
survivals. During 1917, 16 of the recorded deaths
occurred amongst such “ life ” cases. In the second
place, asylum populations have not escaped the
epidemics of the last two years. During 1916 a
severe epidemic of scarlet fever occurred with
about 70 cases; in 1917 an epidemic of measles
with a total figure of 150 cases. These two epi¬
demics, in Dr. Caldecott’s opinion, left the conva¬
lescents more liable to general diseases, especially
tuberculosis, and the latter was, in fact, the cause
of about one-half the deaths. Added to this the
stringent regulations respecting the lighting in force
during the latter part of the war necessitated the
closing of windows and ventilators or the close
curtaining of windows, with resulting lack of fresh
air and its invigorating qualities. The rationing
of staple articles of diet doubtless had an
undue effect on the conservative taste of insti¬
tution patients and tended further to under¬
mine their constitution^. Accepting this analysis
as true in measure of the high death-rate of mental
defectives, it will be seen that part of it is apparent,
part irremediable, and part—possibly a considerable
part—due to removable causes, some of which have
already been removed. As with statistics in general,
careful sifting is required to bring out any useful
lesson.
MEDICAL INFLUENZA VICTIMS IN SOUTH AFRICA.
In South Africa, as elsewhere, doctors and
nurses have been endeavouring to stem the
tide of the influenza epidemic, and many have
succumbed to the disease, their death in some
cases having been caused or hastened by overwork.
Dr. Charles Howard Spaulding, of Johannesburg,
who had been working at high pressure for several
weeks, refusing to relinquish his professional
duties although advised to do so, died in October
at the age of 51 years. He was an M.D. of Chicago,
who went out to South Africa in 1892. James
Alexander Thwaits, a surgeon, who died on
Oct. 11th, was the son of a Cape Govern¬
ment surveyor, and was born at Beaufort West
in 1870. He was educated at the South African
College, Cape Town, qualified at Edinburgh, and
served as senior medical officer with Kitchener’s
Horse for two years during the Boer war.
Dr. William Mortimer died of influenza at
Potchefstroom on Oct. 24th. He was born at Port
Elizabeth in 1864 and was educated at St. Andrew’s
College, Grahamstown, and Diocesan (Bishop’s)
College, Rondebosch. He entered the London
Hospital Medical College in 1883, securing the
Conjoint Diploma in 1887. He took a deep interest
in public affairs, was town councillor in Potchef¬
stroom from 1905-06, and again from 1907-09, and
was elected Member of the Legislative Assembly
for Potchefstroom in 1907. Lieutenant-Colonel
H. S. van Zyl, who, at the time of his death, was
in command of No. 2 General Hospital, Maitland,
Capetown, was, as his name implies, of Dutch
descent. He was .medical officer to General Botha
during the Boer War of 1899-1902, and had been
on active service since the Boer rebellion of 1914'.
Dr. A. S. Kuny died of pneumonia at the New
Somerset Hospital, Capetown, where he was one
of the resident medical officers, on Oct. 17th. He
was the son of Dr. Kuny, of Volksrust, Trans¬
vaal, and was 26 years of age. He qualified at
Edinburgh in 1915, and had served in the R.A.M.C.
in Flanders for two years before returning to the
Cape last August. The medical men who remain
have been terribly overpressed, and some who had
retired have returned for the nonce to active prac¬
tice. The Hon. Sir Thomas Smartt, a Member of
the Legislative Assembly since the retirement of
the late Sir Starr Jameson, and Leader of the
Opposition in the Union South African Parliament,
who qualified in 1878, has during the epidemic been
carrying out inoculations at Stellenbosch. It is
not alone the human population which has suffered
in South Africa; baboons and monkeys also appear
to have fallen victims. Farmers in the Hekpoort
district state that hundreds of baboons have been
found lying dead in the kloofs and along the road¬
side, whilst monkeys are reported to have succumbed
in the Cape Province. Witch doctors are reported
to have been kept busy, with what success does
not appear. Some of the Orange Free State natives
are refusing medicine and pinning their faith to
their ancient methods. This is natural, as medical
science has not in this field shown anything very
striking to compete with necromancy and sorcery.
Sir John Goodwin’s tribute to the temporary
officers of the Royal Army Medical Corps will be
found on p. 84. _
Six Hunterian lectures will be delivered at the
Royal College of Surgeons of England on Phases in
the Life and Work of John Hunter, by Professor
Arthur Keith, Conservator of the Museum, at 5 P.M.
on Mondays, Wednesdays, and Fridays, commencing
Jan. 20th. The dates will be announced in our
Medical Diary from week to week.
In a further list of New Year Honours, announced
as we go to press, are the names ot three medical
men upon whom a well-deserved Knighthood of the
British Empire has been conferred—namely, Dr.
Edward Napier Burnett, chairman of the Economic
Committee of the Army Medical Department; Dr.
G. ArchdalL Reid, F.R.S.E.; and Dr. William Hale
White, chairman and consultant to Queen Mary’s
Royal Naval Hospital at Southend. Other appoint¬
ments to the Order appear under the heading “ The
War and After ” or will be given next week.
The Lancet,]
“ HBTSB^EBTHEBIA.”
[Jan. 11, 1919 79
Cemspnlime.
•* Audi alteram partem."
“ HETER.ESTHESIA.”
To the Editor of The Lanobt.
Sib, -In connexion with Major D. W. G&rmalt Jones's
paper, “Sensory Changes in the Diagnosis of Trench Fever,”
which appeared in The Lancet of Oct. 5th, we think that
onr own observations on a somewhat similar phenomenon
may be of interest. We originally found that in a case of
Brown-S6quard paralysis the phenomenon of allocheiria
occurred at segmental boundaries when one electrode of the
faradic battery was drawn across the skin upon the side of
the body which exhibited sensory changes. -In this manner
we were able to map the segmental areas upon the whole of
the left side of the body from the level of the second
thoracic segment downwards, but were unable to find any
corresponding phenomenon upon the right side of the body.
This latter fact and the precautions which we took negatived
the possibility of “ suggestion.” Having found this pheno¬
menon accidentally, we proceeded to look for similar
phenomena in other conditions. We found that when the
unipolar faradic electrode is drawn over the skin (a pin
may be used with less satisfactory results) in certain
neurological* conditions the patient responds either by a
movement or by speech when cutaneous lines (which seem
to be segmental or radicular) are passed across. His response
indicates that the apparent sensory value of the stimulus
{which varies in locus but not in strength) changes as the
electrode passes across the line. The change may be in
either direction—increase or decrease. The conditions in
which we discovered this phenomenon are: concussion of
the brain with fracture of the base of the skull; concussion
of the spinal cord from the graze of a live shell; true shell
concussion. In these states the phenomenon is transient—
disappearing in a few days or weeks.
In many individuals it is extremely easy to obtain the
phenomenon by “suggestion ” even when it is thought that
suitable precautions are being taken to prevent this. The
drawing of a line upon the skin with a blue pencil in itself
suggests to the patient where the next change should be felt,
and we have found in our practice that it is advisable to
mark points of change with dots, and to pass haphazard
from one part of the body to another, finally joining the dots
with lines for permanent record by photography. Where a
line of change is being investigated it is essential to start the
electrode at different distances from the expected line and
to move it at an even rate over the skin. After using every
precaution we are certain that the phenomenon as it occurs
in such cases is a true one, and not due to “ suggestion.”
We would like to propose the term ‘ ‘ hetenusthesia ” for
the phenomenon. As the lines of change do not, in our
experience, mark a‘ constant variation in sensibility (for at
one time the line of change may be one at which the sensa¬
tion is apparently intensified, while at another time, the
eleetrode being drawn in the same direction across it, the
change may be one of diminution) it has occurred to us that
the phenomenon may be due to the disturbance of a higher
mechanism which normally tends to adjust the excitabilities
of the spinal segments, and, when disturbed, may allow
those excitabilities to have greater than normal variation
amongst themselves.
We have had the advantage of controlling onr results in a
large number of cases, many of whom have had malaria, and
•can say definitely that it is not necessarily present in men
who have had malaria without concussion. But we have not
examined cases of malaria during the fever or immediately
after it. We have to a certain extent relied on this
phenomenon of “ hetenesthesia ” in the diagnosis of shell
•concussion.
It would be interesting to know what Major Carmalt
Jones's experience is with regard to the relation of the
phenomenon to the period of fever and with regard to the
duration of the phenomenon after the fever has ceased. We
hope that a short paper which we wrote la*t year on this
phenomenon as it occurs in neurological cases will shortly
appear in another journal.
We are, Sir, yours faithfully,
Neuvotofttaal Department, B.S.F.,
Nov. lat, 1918.
T. Graham Brown.
R. M. Stewart.
ANTIMONY IN BILHARZIOSIS.
To the Editor of The Lancet.
Sir,—I have read Mr. J. E. R. McDonagh's note in
The Lancet of Sept. 14th. Nothing is new in medicine,
and I dare say that tartar emetic (antimony tartrate) has
been used many times for bilharzia, especially in days gone
by before tartar emetic fell into disrepute. I have not seen
Mr. McDonaeh’s book.
In May, 1917, after making a trial of antimony tartrate by
intravenous injection for leishmaniasis (kala-azar, espundia,
tropical sore, all of which are found in the Sudan), and
finding it, as other workers had found before, a specific, I
began to try it for the Schistosomum hannatobium (Bilharz),
and found it equally successful, and we have since used it as
routine treatment and have still the treatment under trial at
the Khartoum Civil Hospital. I hold the same opinion about
it as I did at first—that it is a specific cure for bilbarziosis.
My work was original, and has been, independent of anyone
else’s work and quite spontaneous, and I had never read of,
or heard of, or dreamt of any other worker having before
tried antimony for bilharzia.
Although I had written my paper considerably before I
despatched it to The Lancet on June 2nd, it was published
on Sept. 7th, 1918. I have now had one and a half years’
experience of cases under the treatment, and think it will
prove a great benefit to the people of Egypt. If they can get
rid of the scourge of bilharziosis the Egyptians will become
a clear-complexioned, rosy-faced race. One of the most
striking features of the treatment is the change from the
muddy, sallow face to a healthy, pink, clear complexion. I
intend to publish more observations on the treatment shortly,
but there is no hurry.
I may say that antimony tartrate for bilharziosis is under
trial at the Egyptian'Army Military Hospital, Khartoum, and
I hope that Major Innus, R A.M.C. (T.), who is interested in
the treatment, and who is carrying it out with the caution
an<] patience and with all the splendid critical qualities of
the Scottish race which have made its scientific work so
valuable, will have something favourable to put on paper
soon. I am, Sir, yours faithfully,
J. B Christopiibrson, M.D.,
Director, Khartoum and Omdurman Civil Hospitals.
Khartonm, Sudan, Nov. 20th, 1918.
EPIDEMIC ENCEPHALOMYELITIS AND
INFLUENZA.
To the Editor of The Lancet.
8ir, —It seems worth while, at the risk of being wearisome,
to draw attention to the increasing volume of testimony
that points to the essential unity of epidemic encephalo¬
myelitis (in the epidemiological sense at least) with epidemic
influenza. In this connexion the reoent paper by Dr. Smith
Jeliffe, 1 and the remarks of Dr. Beates, 2 as well as the
observations of Sir Thomas Horder 3 concerning the present
prevalence of poliomyelitis, are of very great importance.
Professor Chartier 4 has discussed, with delicate irony, the
Claims of “ encephalitis lethargica ” to be considered an
autonomous affection, and hints, not obscurely, that it is
really “ une varicte symptomatv/ue d'vne infection gbrfralc
telle q»e V influenza .” In a paper read by me a week or two
ago before the Section (of the Royal Society of Medicine) for
the Study of the History of Medicine, I gave many historical
records of epidemics of encephalitis, encephalo-myelitis, and
poliomyelitis, definitely associated with epidemics o' ii fluenza.
But though Brorstrom, in 1910, first showed the relation
between poliomyelitis and influenza it is Dr. Hamer who,
above all others, has insisted on the importance of recog¬
nising the epidemiological association between these various
epidemic prevalences generally.
As Lombard, of Geneva, 5 wrote many years ago : —
La grippe eat souvent precede par une constitution emlnement
nerveuse, dont leu caraetdres princtpee aont de porter la trouble dans
lea fonctlons du cerveau et dea nerfs enc^phallques.
In 1837, too, the “apoplectic” forms of encephalitis oh
which Dr. Farquhar Buzzard has justly laid so much stress werfe
observed by Recamier and others, while Gintrac, of Bordeaux,
described in the clearest manner “epidemic stupor” in
1 New York Medical Journal, 1918, it., 757. 807. * Ibid., 922.
s Thu Laxcet, 1918,11., 87*.
* La Preene Medicate. Deo. 23rd, 1918, 660.661.
■' Gar.. Med., 1833, 729, and 1837. 214.
80 The Lanobt, ] RESIDENTIAL TREATMENT FOR PREGNANT WOMEN WITH VENEREAL DISBA8B. [Jan. 11,1919
children; all this occurring, in Maloorps’ words, amongst
the “ prodromes nerveux ” of the epidemio influenza of that
year.
Sorely then, as Ohartier says, if “ encephalitis lethargica ”
is to take place as an autonomous affection, “il serait
important de fixer nettement les limites et les caract^res
differentials de cette maladie.”
I am, Sir, yours faithfully,
Harley-street, W., Jan. 3rd, 1919. F. G. CROOK8HANK.
RESIDENTIAL TREATMENT FOR PREGNANT
WOMEN SUFFERING FROM VENEREAL
DISEASES.
To the Editor ofTaa Lanobt.
Sir,—I n an annotation on the Prevention of Syphilis
among Infants in your issue of Dec. 28th last reference was
made to work done by the London Hospital, Whitechapel,
and the Thavies Inn Venereal Centre for Pregnant Women,
and it was stated that the London Hospital Venereal Depart¬
ment and the Thavies Inn Venereal Centre provided the only
residential treatment in the metropolis for pregnant women
suffering from venereal disease.
We have been desired by the board of management of the
London Lock Hospital to write saying that this is incorrect,
as since May, 1918, the London Lock Hospital has had a
large maternity department open and working at the Harrow-
road institution. Daring the period from May to December,
1918, 68 married and unmarried pregnant women have been
admitted and treated and 42 women delivered, of whom 20
were suffering from syphilis and 22 from gonorrhoea, and
43 babies have been born.
We are informed by Mr. Charles Gibbs, F.R.O.S., and Mr.
Arthur Shillitoe, F.R.O.S., honorary surgeons at Harrow-
road, that all our pregnant syphilitic patients have a full
course of “606 ” before their confinements. The results are
most gratifying, as a large proportion of these women give a
negative bloo ■ lest before confinement and are delivered of
child ran with a negative reaction. |
In conclusion we wish to state that intravenous injections |
of “606 " h ive been given to expectant mothers and babies
admitted to the Lock Hospital since February, 1916, and it
most be noted that the figures given above only refer to the
period May to December of last year.
We are, Sir, yours faithfully,
Kinnaird,
Chairman of the Board,
J. F. W. Deacon,
Deputy Chairman of the Board.
J. Ernest Lane,
Chairman of the Medical Committee.
London Lock HoepiUU and Reacue Home, Harrow-road,
London, W., Jan. 3rd, 1919.
%* We are glad to hear of 42 other women offered
effirient treatment in their desperate extremity. But the
need must be tenfold greater than the accommodation, and
this was the main lesson we wished to draw.— Ed. L.
ADVANCES IN THE TREATMENT OF
FRACTURES.
To the Editor of The Lancet.
Sir,—S everal letters have appeared in the columns of
The Lancet under the above heading emphasising the
great work carried out by Major M. Sinclair in his method
of extension and immobilisation of fractures of the long
bones. It may appear to be ungracious to offer auy criticism
when the results obtained are so good as far as the length
and the alignment of the fractured bone are concerned, but
in many cases treated by prolonged immobilisation by Major
Sinclair’s method there remains a considerable degree of
limitation of movement in the joint below the fracture. In
the case of the fractured femur this has been overcome by
the method devised by Major Besley and subsequently
modified by Major W. Pearson, by which the extension is
made directly to the lower end of the femur by means of
pointed callipers, whilst movement is made frequently in
the knee-joint without any interference with the fracture.
Major Sinclair’s net-frame is of great advantage when, in
addition to the fractured femur, there are wounds in the
buttock, or when abduction is required, but the arrange¬
ment of the more recent fracture bed devised by Major
Pearson allows of an equally simple dressing, &c., without
the disadvantages of a special and somewhat cumbersome
apparatus.
However, the greatest credit must still be given to Major
Sinclair as the originator of methods, even if certain modi¬
fications of these methods have been found more efficacious
in some forms of fracture.
I am, Sir, yours faithfully,
R. H. Jocelyn Swan,
Major, R.A.M.C.; Consulting Surgeon, Woolwich District.
Jan. 6th, 1919.
THE CAUSES AND INCIDENCE OF DENTAL
CARIES.
To the Editor of The Lancet.
Sir, —lu his letter on this subject published in The Lancet
of Jan. 4th Dr. Harry Campbell states : “I have again and
again referred to the prosaic fact that there are among the
inhabitants of this country some 200 million carious teeth,
as many alveolar abscesses (pyorrhoea alveolaris), and some
30 million root abscesses.” I presume that Dr. Campbell
will not object to furnishing some evidence of this “ prosaic
fact ” (?) for the benefit of your readers, many of whom are
(like myself) deeply interested in the subject.
I am, Sir, yours faithfully,
R Denison Phdlhy.
Railway Approach, London Bridge, S.B., Jan. 6th, 1919.
THE PRACTICE OF THE ABSENTEE.
To the Editor of The Lanobt.
Sir,—I cannot understand Dr. F. R. Mallett’s indignation
with the letter of Dec. 28th, 1918. signed “Major,
R.A.M.C. (T O.)." I am a doctor in general practice who
has been to the front and returned to practice. I find on
my return that several of my former patients are being
treated by professional brethren who remained at home ;
these patients are not asked if they wish to return to me.
There being very little opposition, the doctors who remained
at home charged high fees, frequently demanding the
money before they left their houses. My midwifery cases
who had “ booked ” the other doctors are not returned to me.
New panel patients, who in the ordinary course would have
come on my list, have been put on the lists of the doctors
who remained, and every difficulty is put in the way of their
coming to me.
The doctors who remained at home opened during my
absence a surgery within half a mile of my house. It is
still open. These tactics will not pay in the long run, but
it is a little irritating to those who have undergone the hard¬
ships of active service and who have been under shell fire to
bear so much about ‘ ‘ the overwork ” of those who stayed safely
at home and who probably earned twice their usual incomes.
I would suggest that these overworked gentlemen should
join the R.A M.C. for the demobilisation and so allow their
brethren who have been to the front to come back at once
and start their practices with less opposition.
I am, Sir, yours faithfully,
Jan. 6th. 1919. _ TEMP. R.A.M.C.
To the Editor of The LANCET.
Sir, —With reference to the correspondence in The Lancet
on the above subject, may I state my own case as I have
jnst been demobilised after 20 months’ service ? I arranged
with a neighbour to carry on in my absence, the receipts to
be divided between us. There was very little panel (only
100), the rest beiDg private work. The practice is an old-
established one, and has never done less than £1000 per
year. At the time of handing over there was a visiting list
of 20 per day; when I returned I was given a list of six
patients only y not six per day. Daring the whole of this
time I have received exactly £42 from the private part of
the practice and about an equal amount from the panel,
which has, of course, steadily got less. My rent and rates
are £76 per year, so that had the war continued a little longer
I should have been compelled to either give up the house or
file my petition.
However, I am so pleased to be back comparatively sound
that I do not complain, and if I can only manage to get
through this year without getting very much into debt I
shall indeed be a happy man. I don’t blame anyone, least
of all the practitioner who has carried on for me, as
The Lancet,]
A MONTHLY RECORD OF ATMOSPHERIC POLLUTION.
[Jan. 11, 1919 81
patients naturally go to whom they fancy, and, so long as
human nature is as it is, will not always say that they are
someone else’s patients. Mine may be an extreme case, as
upon one occasion I was officially reported killed in action
and upon another died after being wounded.
I am, Sir, yours faithfully,
Jan. 6th, 1919. DemOBILISKD.
PURULENT BRONCHO PNEUMONIA ASSO¬
CIATED WITH THE MENINGOCOCCUS.
To the Editor of The Lancet.
L SIR,—In your issue of Dec. 28th, 1918, Captain J. A.
Glover publishes a note describing six cases of broncho¬
pneumonia. His article bears a title which is wholly mis¬
leading. Looking at the heading, and knowing that Captain
Glover bad charge of the C.-S. Fever Laboratory for the
London District, one would expect to find on reading the
article that he would bring forward proof of the meningo¬
coccus causing broncho-pneumonia. But he does not do so.
He simply describes broncho-pneumonia occurring in six
patients, three of whom undoubtedly “carried” the meningo¬
coccus in their naso-pharynx. Captain Glover quotes notes
from Dr. T. H. Jamieson describing the six cases and stating
that •* examination of the sputum showed pneumococci/'
Post-mortem examinations were done on two cases, yet
nothing is stated concerning the bacteriology of the broncho¬
pneumonia found. Captain Glover then states that in his
opinion the broncho-pneumonia was probably due to a
mixed infection of pneumococci or Pfeiffer’s bacillus and
meningococci.
Captain Glover is entitled to have his opinion, but before
it can be accepted by others he must bring forward proof.
Although three out of six cases of broncho-pneumonia were
found to be “carriers” of the meningococcus in their naso¬
pharynx, this is no proof that the broncho-pneumonia was due
to this organism. The pneumococcus was found in the
sputum in all the cases, and efforts to isolate the meningo¬
coccus from one case failed. Even had Captain Glover
isolated the meningococcus from the sputum this would not
exclude the naso-pharynx as the source. Further, Captain
Glover gives no bacteriological proof whatsoever for bringing
Pfeiffer’s bacillus into the cases. We still await definite
bacteriological proof that the meningococcus can cause
pneumonia. Captain Glover has not supplied it, and we
cannot therefore accept his opinion.
I am, Sir, yours faithfully,
Jan. 4th, 1919. BACTERIOLOGIST.
A MONTHLY RECORD OF ATMOSPHERIC POLLUTION.
Meteorological Office: Advisory Committee on Atmospheric Pollution: Summary of Reports for the Months
ending
Feb. 28tK 1918. March Slit , 1918.
Metric tons of deposit per square kilometre.
| Metric tons of deposit per square kilometre.
Place.
f!
11
11
I
Insoluble matter.
Soluble
matter.
Inoluded
in soluble
matter.
Place.
iff
*3 ©
Insoluble matter.
Soluble
matter.
i
inoluded
in soluble
matter.
Tar.
Carbon-
| aceous
other
jtban tar
I
I Ash.
I
§s
n
i
1
S-
II
*3 m
ao 9
\L
130
-a'-
P
Ammonia
|b
p!
Tar.
Carbon¬
aceous
other
than tar
Ash.
g B
o o
it
3
1
i
3-
jSo
O.X
is
Chlorine
(Cl).
3 .
§3
8g
<4
HxeLAXD.
1
Bxolakd.
|
Leicester.
38
0*33
4*92
! 6*89
2*37
11*26
25*74
7*00
0*34
0*10
Leicester.
10
0*04
1*08
1*75
0*85
1*52
5*24
0*83
>0 22
0*06
London—
London—
Meteorological
Oil
1*83
M 31 e o r o logical
3*43
Office ..
21
3*89
1*26
2*52
9*61
0*90
0*41
0*03
Office.
24
0*13
2*20
1*24
3-56
10*56
1*03
0*54
@133
Embankment
Bm bankment
1
Gardens .
m
0*14
3*65
6*48
5*37
10*85
26*49 5*93
1*70
0*19
Gardens .
26
0*24
3*61
8*53
0*14
9*36
21*892*77
1*23
0 20
Finsbury Park ...
37
0*15
1-50
6*01
3*49
6 62
17*684*40
0*65
0C6
Finsbury Park ...
10
0*04
0*20
1*07
1*13
2*58
5*01|1 62
0*27
0*04
Ravenscourt Park
23
0-09
1-27
3*42
1*36
2*73
8*85|l*69
0*28
0*08
Ravenscourt Park
4
0*01
0*18
0*32
0*44
0*77
1*720*15
0*13
3 06
Southwark Park
31
Tr.
1-36
4*96
3*57
6*23
15*12:3*57
0*70
0 08
Bouthwatk Park...
9
0*06
0 68
2*22
1*43
2*39
6*77
1*33
0*45
G*08
Victoria Park ...
16
005
1-27
2*99
151
3*45
9*28|l 1-6
0*22
0*08
Victoria Park* ...
—
—
—
—
—
—
—
—
—
Wandsworth Com.
17
Nil.
Nil.
0*03
0*86
1*28
2*16:0*78
0 26
0*02
Wandsworth Com.
22
0-07
1*96
8*86
079
2*40
14*08
118
0-33
0*06
Golden Lane
23
016
226
2*68
1-71
2*79
9*501*22
0*84
084
Golden Lane
27
0*11
2*58
3*31
.1*38
3 20
10*60
1*32
0*97
0*16
Malvern .
£8
Tr.
007
0*28
0*33
0*99
1*67 0*43
0’1C
0*01
Malvern..
33
f.t.
0*07
0*25
0*28
0*93
1*54
0*41
0*07
0*01
Manchester—
Manchester—
Queen's Park ...
School of Techno-
52
—
—
—
—
5*70
—
_
—
Queen’s Park ...
School of Techno-
49
—
—
—
—
6;01
—
—
—
logy .
42
—
—
—
—
10*60
—
—
logy .
40
—
—
—
—
—
12*50
—
—
—
Newcastle - on-Tyne
28
0-03
2-80
4-25
1*45
2*67
11*19
1*07
0*63
0*12
Newcastle-on-Tyne
26
0*31
3*70
7*43
1*77
2*91
.16*11
1*46
0*50
0-10
Rochdale.
—
—
—
—
—
—
33*96
—
—
—
Rochdale .
—
—
—
—
—
—
33*95
_
—
—
St. Helens .
80
060
6*74
853
2*39
6*85
25*11
3 28
1*51
0*24
St. Helens .
48
0*27
3*19
5*76
2*52
7*67
19*31
3*71
1*49
0*38
Sootiakd.
0-10
Scotlahd.
Coatbridge .
68
2*14
6*31
2*88
6*31
17*74
276
0*38
0*26
Coatbridge .
32
0*09
1*68
3*95
2*37
560
13*69
272
0*18
0*19
Glasgow—
79
0-38
177
4*26
Glasgow—
Alexandra Park...
1-27
3*88
11*56
2-42
0*52
0*18
Alexandra Psrkt
—
—
—
—
—
—
—
—
—
—
Bellahouston Park
105
017
1*39
4*18
2*22
4*90
12*86
3*47
1*00
0 07
Bvllahouston Park
37
0*25
1*73
2*98
2*34
263
9*94
1*82
3*20
006
Blytbswood-sq. ...
118
0 40
2*09
3*59
1*25
7*49
14*823*83
0*74
0*25
Bl\thswood sq....
36
0*12
1*89
3*63
1*53
4*07
11*24
2*08
3-27
Olo
Botanic Gardens
117
0*27
074
6*92
1*20
6*04
15 1715*24
0*89
0*17
Botanic Gaidens
40
0*13
1*40
6 36
2*12
3*34
13 34 2*01
3*16
0*19
Richmond Park ...
1L7
0*26
1*70
5*00
2*16
4*16
13*28 2*92
0*36
0*22
Richmond Park...
35
0 07
1*62
5*16
116
4*14
12*152*32
1-13
0*12
Rucbill Park ...
119
0 38
1*25
3*33
2*25
4*91 12*12 3*42
0*75
017
Ruchlll Park ...
24
0 24
2*36
8*58
417
5*69
21*04 2*28
0*10
0*04
South Side Park.
ne
0*33
116
4*35
1*95
5*18|l2*97|3*42
0 66
0*16
South bide Park..
33
0*13
3*80
6*25
2*76
2*59
15*53|l 95
0*14
0*08
Tollcrose Park ...
102
0-37
1*56
5*65
2*27
4*10 |l3*86|3*33
0*60
018
Tollcross Park ...
29
0*28
1*56
3*42 |
8*26
2*65
10*171*76
0*15
0*0?
Victoria Park ...
114
0*48
1*87
5*13
2*07
7*66117-11-4-07
0 73
0 19
Victoria Park ...
37
0*16
1*36
5*19 1
2 07
310
11 *8812 19|0*19|
O'10
Tr. = trace. * No returns. t Sample lost.
“Tar” Includes all matter Insoluble in water but soluble in CS*. “Carbonaceous” Includes all combustible matter insoluble in water and
In CS*. “Insoluble ash” includes all earthy matter, fuel,ash, Ac. One metric ton per aq. kilometre is equivalent to: (a) Approx. 9lb. per
acre: (5) 2 56 Bngllsb tons per sq. mile; (e) 1 g. per sq. metre; (<f) 1/1000 mm. of rainfall.
The personnel of public health authorities concerned in the supervision of these examinations and of the analytical work Involved remains the
woe as published in previous tables. The analyses of the rain and dsposit caught in the gauge at the Meteorological Office are made in
The La* cf.t Laboratory.
The Royal Institute of Public Health.—A
further course of lectures and discussions on “ Public Health
Problems under War and After-war Conditions” is being
held in the lecture-hall of this Institute (37, Rnssell-rquare,
London, W.C. 1) on successive Wednesdays in January,
February, and March at 4 p.m. The subjects include
industrial hygiene, the influenza epidemic, clean milk,
women and the Ministry of Health, the tuberculosis
problem, and after-war reconstruction, and amoDg the
lecturers are Dr. T. Carnwatb, Captain, R.A.M.C. (T.F.),
Profeseor I. Walker Hall, Professor E. W. Hope, Dr. W. J.
O’Donovan, Mr. P. C. Yarrier-Jones, Bir A. Newsholme, Sir
ThomaB Oliver, and Viscountess Rhondda. The next lecture,
on Coal and National Health, will be given by Professor
W. A. Bone on Jan. 15th, and the others will be duly
announced in the Medical Diary from week to week.—
An exhibit of organic arsenical preparations used in the
treatment of venereal disease, as well as a striking collection
of propagunda pamphlets and posters dealing with the anti-
venereal campaign, is on view at the Institute. The latter
has been presented to the Institute by Colonel Bnow, of the
Surgeon-General’s Offioe, U.8. Army.
82 Thi Lancet,]
OBITUARY.
[Jan. 11, 1919
THOMAS BUZZARD, M.D. Lond., F.R C.P. Lond.,
CONSULTING PHYSICIAN TO THE NATIONAL HOSPITAL FOR PARALTSIS
AND EPILEPSY.
The death occurred last week, at an advanced age, of
Dr. Thomas Buzzard, the eminent neurologist. For some
time Dr. Buzzard had retired from the practice of his pro¬
fession owing to ill-health, but until nearly 80 he advised
patients to their great benefit, and only two years ago
came before the public with an admirable book of personal
experiences in the Crimean War.
Thomas Buzzard was born in London in 1831, the son of a
solicitor, and was educated at King’s College School and the
University of London. He left the school young and became
apprenticed to a doctor in accordance with the then pre¬
vailing methods of entering the medical profession. After
apprenticeship he proceeded to King’s College Hospital,
where his career as a student was successful, and he became
house surgeon to Sir William Fergusson. Then came two
remarkable opportunities for gaining terrible experience. First
he worked in 1854 with John Snow and French in fighting
the cholera epidemic in Soho ; and in 1855 he went to the
Thomas Buzzard, M.D. Lond.
Crimean War, being appointed to the British medical staff of
the Ottoman Army, attached to the headquarters of H.H. Omer
Pasha. He was present at the siege of Sebastopol, at the
second expedition to Kertch, and at the battle of Tchemaia,
and after the fall of Sebastopol he accompanied the second
Turkish Army to the Caucasus and took part in the establish¬
ment and conduct of base hospitals at Trebizonde and Sinope.
For these services he received the Crimean medal with clasp
for Sebastopol, the Order of the Medjidie and the Turkish
War medal. The story is graphically and modestly set out
in his book “With the Turkish Army in the Crimea and Asia
Minor : a Personal Narrative,” which was published by John
Murray in 1916, with illustrations by the author.
On his return from the Crimea he resumed his studies
and with such success that he became university medical
scholar and later gold medallist in surgery. He graduated
M. B. in 1857, and though his displayed and personal bent at
the time was strongly towards surgical work he went into
general practice as doctor to the St. Luke’s district of
St. James’s parish. Here he remained for some six
years, adding to an already great experience consider¬
ing his age, that first-hand knowledge of life, men, and
manners which made him a practical psychologist as well
as a learned clinician. At this time he developed a
gift which proved very valuable to him in his after-career.
He employed his intimate acquaintance with certain sides of
large affairs, as well as of the working life of the lower
strata of society, in journalism, turning to writing for the
press as a congenial task and an obvious method of adding
to resources until private patients came. In 1863 he cut
loose from his official work as a parish doctor and started in
consultant practice in Green-street, Park-lane. For some
time he was regularly on. the staff of the Daily New#,
for which paper he had acted as correspondent during
the Crimean War, and he also joined the staff of
The Lancet. A feature of this paper at the time
was a department entitled the “ Mirror of Hospital
Practice,” the articles which appeared under this title
being notes written on the spot by a representative
of the paper who was present at the various operating
theatres of London. At this time operations were infrequent
and were performed at the various hospitals only on certain
days of the week and on certain hours of those days.
Buzzard’s work as a contributor to the “ Mirror of Hospital
Practice ”—this, it may be said, is his own statement—first
brought him into touch with the National Hospital at
Queen-square, and provoked his interest in neurology and
started also his lifelong and intimate friendship with
Hughlings Jackson. He was shortly elected to the staff of
the hospital, and here, while his main interest in neurology
was essentially clinical, he never neglected the pathological
side and, indeed, was one of the first to recognise the
relationship of bacteriology to neurological problems.
Perhaps his chief contributions to our medical knowledge
had reference to the discrimination between organic and
functional disorders especially in reference to disseminated
sclerosis. This line of work was prompted by frequent con¬
sultation upon his gynaecological patients with William
Playfair, to whom a great many women had recourse who.
rightly or wrongly, were supposed to be the subjects of
hysteria. Buzzard's book, entitled the ‘ ‘ Simulation of Hysteria
by Organic Disease,” was the outcome of the investigation of
such cases, and it was along these lines of medicine that he
deservedly made his European reputation. Although he
was only attached to one hospital, and that a neuro¬
logical institution, his knowledge of general medicine
saved him from taking narrow or loose views of his
patients. He was able to devote a large part of his time
to bedside study because he served one hospital only,
while he made the most of the wonderful opportunities
afforded him at Queen-square. So far was he from being
merely a specialist that, in a way, the range of his
interests and their large clinical nature probably obscured
his scientific position, and to no other reason can we
attribute the fact that a man, much of whose work was
so original as well as so fruitful of work in others, should
never have been invited to become a Fellow of the Royal
Society. He was at different times President of the Clinical,
Harveian, and Neurological Society, and Foreign Corre¬
sponding Member of the Societe de Neurologie de Paris.
Although Buzzard wrote with ease and distinction he was
not a voluminous author. He contributed the articles on
hysteria, sciatica, and tic to ‘ ‘ Quain’s Dictionary of Medicine,”
and wrote in the journal of the Ophthalmological Society,
to these columns, and to the columns of the British Medical
Journal upon various neurological subjects. His record of
his Crimean experiences, to which we have alluded, shows
that had the idea appealed to him he could have easily gained
a large public as a writer. He was a good public speaker
and had also considerable artistic gifts, was an accomplished
painter in water colours, etched with some success, and
exhibited on several occasions. He was devoted to travel,
and in his later life made many sea voyages, garnering
impressions and sketching.
Dr. Buzzard married in 1869 Isabel, daughter of the late
Joseph Wass. by whom he had two daughters and four sons,
one of whom is Dr. E. Farquhar Buzzard. Ou the occasion of
his marriage he removed from Green-street to 56, Grosvenor-
st.reet, where he remained over 20 years, finally moving to
74. Grosvenor-street, where he died. His domestic life was
ideally happy, and the loss of his wife, who died in 1901,
was a blow which he felt during the remainder of his days.
He died very peacefully after a short and mild attack of
influenza.
OBITUARY.—URBAN VITAL STATISTICS.
fJ an. 11,1919 63
TBS LANC1T,]
Sib WILLIAM BARTLETT DALBY, M.A. Cantab.,
F.R.O.S Enq.,
CONSULTING AURAL SURG30N, ST. GEORGE'S HOSPITAL.
We announced last week the death, at an advanced age, of
Sir William Bartlett Dalby, who was a well-known aural
surgeon in London a generation ago, as well as a regular
contributor to the literature of these subjects in the
cooperative medical treatises of the day.
Sir William Dalby was born at Ashby-de la-Zouohe in
1840 and was educated as Sidney Sassex College, Cambridge,
and the medical school of St. George’s Hospital. He
graduated in Arts at Cambridge in 1863, proceeding to the
M.B. degree in 1866, and for a time went into general
practice at Chester. He soon, however, returned to London,
became a Fellow of the Royal College of Surgeons of
England in 1870, and decided to specialise in diseases of
the ear. He was fortunate in becoming assistant to that
singular and famous man James Hinton, who was then
practising as an aural surgeon in Savile-row. Hinton died
in 1874, but during his last illness Dalby took entire charge
of his practice, and on the death of his chief acquired the
house and connexion from Hinton's executors. Such a sale
of consultant practices was in those days not unusual,
though soon afterwards the proceeding was regarded askance,
and, as a matter of fact, Hinton himself had purchased the
practice and premises in Savile-row from the eminent aural
suigeon Toynbee. With such an apprenticeship and such a
start Dalby’s success was assured, but he soon made a real
and original departure, with which his name is not now
associated as closely as it should be, for at the time he was a
pioneer. No doubt he acquired much both of his theories
and his information from Germany, but to Dalby’s credit it
should be remembered that his advocacy of the instruction of
the born-deaf child by lip-reading has transformed a large
number of persons indicted with a grave disability into
perfectly capable, competent, and happy citizens. It was
for work in this connexion that Dalby received his knighthood
in 1886.
Daring the 20 years between 1875 and 1895 Dalby had a
very large practice, and his opinion was sought from all parts
of the kingdom. He published a series of lectures on diseases
and injuries of the ear, and wrote articles on the same
subject in Holmes’s “System of Surgery’’ and Quain’s
“Dictionary of Medicine,” while his “Short Contributions
to Aural Surgery ” ran through three editions, and deserved
its popularity by its wide practical information and its
pleasant writing. Dalby was not in any sense a good
operating surgeon, and though he may have neglected steps
to keep abreast with the surgical operative procedure of his
day, it must be remembered that cranial surgery, when
he was at the head of his specialty, was in its infancy.
As aural surgeon to St. George’s Hospital his out¬
patient clinics were well attended by the students
who learned such science and technique as were then
generally accepted, and who were often profoundly amused
by Dalby’8 shrewd, humorous, caustic, but kindly attitude
towards his patients. Many of the leaders of medicine and
surgery of Dalby’s day found themselves in an unstable
position by the enormous development in operative surgery
following on the discovery of Listerian doctrines and the
perfection of methods of administering anaesthesia; and
undoubtedly Dalby was embarrassed as a man of science by
the date of his active work. But he was the main link
between the periods of non-operative and operative aural
surgery, and the developments in aural surgery following
upon the work notably, among others, of Sir William Macewen
and Sir Charles Ballanoe, he wisely determined not to
attempt to follow praotically. He never performed any
complete mastoid operation, leaving such procedures to a
younger generation.
Dalby was essentially a man of the world. His elaborately
groomed appearance was more that of a leisured country
gentleman than that of a leader in a highly technical surgical
specialism. His wise if cynical attitude towards life was
well displayed in the “Letters of Dr. Chesterfield,” which
he contributed towards the end of his professional career to
the Comhxll Magazine , and from a worldly point of view most
of what he said wittily in those letters cannot be contro¬
verted. He had a host of friends, was a member of the
Athenaeum, Carlton, and Garrick Clubs, was especially
popular among artistic and literary people, was a well-read
Shakespearian scholar, and a keen and constant attendants
at the theatres. He rode, shot, fished, and yachted at-
various periods of his life, out of which he derived far more
amusement than most medical men contrive to obtain.
Sir William Dalby married Hyacinthe, the daughter of
Major Edward Wellesly, by whom he had two sons and
three daughters. His elder son was drowned in a boating
accident at Sandhurst; his second son, a soldier, survives
him and was wounded in the present war. He leaves alsc-
a widow and three married daughters.
REGINALD PERCY COCKIN, M.D Cantab.,
AB8I8TAHT MEDICAL ENTOMOLOGIST, LONDON SCHOOL 07 TROPICAL
MEDICINE, ETC.
We regret to record the death of Dr. R. P. Oockin on*
Dec. 9th, 1918, at Kensington. Dr. Cockin was born at
Hull in 1879 and studied at Cambridge, taking his M.A.
degree in 1906 and his M.D. in 1913. His medical studies-
in London were carried out at the London Hospital. After
graduating in medicine he acted as casualty house surgeon
of Hull Royal Infirmary. Entering the West African
Medical Service, he was appointed district surgeon of Okigwi
in Southern Nigeria, and later on medical officer of the Niger
Cross River Expedition in 1908-1909. In 1910 he was trans¬
ferred to Cyprus, acting there as a district medical officer and
examiner under the Pharmacy Act. In 1913 he was posted.to-
Grenada, West Indies, where he was resident surgeon to
the Colony and Yaws Hospitals, and also did bacteriological
work. After this he joined the staff of the London Schoo>
of Tropical Medicine. In 1915 he was appointed a temporary
lieutenant in the Royal Army Medical Corps, and went to
Egypt with Colonel R. T. Leiper and Captain J. G. Thomson,
where he helped in the investigation of bilharziasis.
Owing to ill health he had to resign his commission as
captain, and resumed his duties at the London Sohool of
Tropical Medicine. When the special venereal clinics were
formed in London by the Local Government Board, Dr.
Cockin started the one at the Albert D >ck Hospital, acting
as its director.
Dr. Cockin’s death in early middip age is a loss to the
medical profession, for he was a man of wide experience and
high scientific attainments.
URBAN VITAL STATISTICS.
(Week ended Jan. 4th, 1919.)
English and Welsh Towns.— In the 96 Bugli-h a»»d Welsh towns, with
an aggregate civil population estimated at 16.500 000 • persons, the
annual rate of mortality, which h*d declln d from 36 5 to 1V8 in the
five preceding weeks, rose to 161 per 1 00. In London, with a
population slightly exceeding 4,000,000 penton*, the death-rate was
16*6, or 2'8 per 1000 above that recorded in the previous week ; among
the remaining towns the rates ranged from 7 3 in Bntield, 8*8 la-
Oiford, and 9 0 in Ilford, to 23*2 in Gateshead. 25‘4 in Sund«-rland, and
27*0 in Liverpool. The principal epideroi dls.-Mses caused 147 deaths,
which corresponded to an annual rate of 0 5 pef F00, and included
51 from Infantile diarrhoea. 49 from diphtheria, 17 from whooping-
cough, 14 from measles, 11 from scarlet <ever, and 5 from enteric
fever. The deaths from influ nza, which had steadily declined;
from 7557 to 581 in the eight preceding w^eks, further fell to
441, and included 66 in Liverpool. 65 in London. 19 each in Bristol
and Birmingham, and 14 each in Manchetder a d Leeds. There were-
3 cases of small-pox, 1062 of scarlet fever, a> d 1116 of diphtheria,
under treatment in the Metropolitan A«\ luim Hospitals and the
London Fever Hospital; the two latter sen 39 below and 11 above
the respective numbers remaining at the end ..i the previous week.
The causes of 61 deaths in the 96 towns w* re uncertified, of which
12 were registered in Liverpool, 8 in Birmlntthaot. 6 In Manchester,,
and 3 each in Nottingham, Blackpool, South Shields, and Gateshead.
Scotch Towns .—In the 16 largest Scotch t**w»s with an aggregate-
population estimated at 2.500,000 person*, the annual rate of mortality
was 16-7, against 14‘8and 16*1 per 1C00 in Ih^* tw- preceding weeks. The-
324 deaths in Glasgow corresponded to an annua* rate of 15 1 per 1000,
and included 6 from whooping-cough. 6 each from diphtheria and*
infantile diarrhoea, and 1 from meas’es. The 115 deaths in Edinburgh
were equal to a rate of 17'8 per 1000, and ind.ideo 3 from whooping-
cough. 2 from diphtheria, and 1 from scarlet f# ver.
Irish Towns .—The 182 deaths in Dublin corresponded to an annua!
rate of 23*4, or 3-0 per 1000 above that recorded in the previous week,
and included 2 from whooping cough and 1 from infantile diarrhoea.
The 133 deaths in Belfast were equal to a rare of 17*3 per 1000, and
included 2 from infantile diarrhoea and 1 fiom me tales.
Prizes of the Paris Academie des Sciences
have been awarded as follows: Prix Montyon (physiology)
to M. Stephen Chanvet, for a work on Pituitary Infantilism ;
Prix Lallemand to MM. Henry Cardot and Henry Langier,
for work on the electrical stimulation of nerves; Prix L. Laa
Caze to Professor Raphael Dubois, of Lyon, for contributions
to physiology.
$4 The Lancet,]
THJC WAR AND AFTER.
[Jan. 11,1919
i>\t $®ar anb Jfter.
Medical Demobilisation. I
Sir John Goodwin, the Director-General, Army Medical
^Service, states that owing' to the very urgent requests of the
Statfonal Service Ministry, the Civil Hospitals, and the
insurance Commissioners, it has been found necessary to
•demobilise immediately a large number of R.A.M.C. officers
<to meet the pressing needs of the civil population. The
Oirec tor- General greatly regrets that, owing to the short-
mess of the notice, he has not found it possible to see or
write personally to all officers on demobilisation, but he
■would like to assure them of his sincere gratitude for their
■valuable services and of his warm recognition of the very
•heavy personal sacrifices made by many of them in their
desire to serve their country and to render assistance to the
!*ick and wounded of the Army.
"The Scheme of the Central Medical War Committee
for Demobilisation.
A meeting of the Central Medical War Committee was
'held on Jan. 8th, at which the scheme for demobilisation of
•medical men was discussed. A circular letter having been
-esnt by the National ’Insurance Commissioners to the
Insurance Committees in England and in Wales, as well
ms to individual doctors. Sir Robert Morant addressed the
eneeting to point out that he disclaimed any desire to act in
•opposition to the Central Medical War Committee. His
•department, however, he said, must consider first the needs
•of the civilian population, and he added that, of the 12,000
•medical men on the panel before the war, at least one-third
■wen absent, either with the colours or owing to the inevitable
wastage of four and a half years; figures which meant that
the pre-war standard of medical practice could not be
maintained.
The Ministry of National Service having sent out a
-questionnaire to be completed by medical officers bolding
•commissions in any of the Services, Sir James Galloway
-explained to the Central Medical War Committee the present
.position. He indicated that the figure of 1400 had been
mentioned as representing the number of practitioners whose
return from the Services was urgently required, and that this
number was now within sight. The War Office, he said, had
found less difficulty than had been anticipated in releasing
men, large military hospitals were to be immediately demobi¬
lised, and no less than 18,000 V.A.D. beds had already been
-dtanantled.
General Principles of the Scheme.
The scheme for priority of release drawn up by the Central
Jiedical War Committee is intended to apply to thedemobilisa-
tlon on personal and professional grounds of all medical
•officers serving temporarily with the Forces. It has received
the approval of the Ministry of National Service ; but as it
feas not yet been adopted by the Scottish Medical Emergency
Committee, it applies at present to practitioners from
England and Wales only. The following notes will serve
•to indicate the principles upon which the scheme is based.
The main object has been to devise a plan which is at
•once simple, capable of amendment at any time, and easily
explained to those concerned. As soon as provision is made
for areas in which the medical service has been dangerously
depleted it is proposed that the demobilisation of medical
officers shall proceed along lines which take into account
.(a) length of service; (b) age ; (o) special personal hardships
in connexion with their practices; and (d) family re¬
sponsibilities. For this purpose the names of those over
<he age of 30 on Nov. 11th, 1918, will be classified in
4he following groups : (1) Those who were mobilised at the
•outbreak of war ; (2) those who have served over three years;
those who have served between two and three years ;
•<4) those who have served between one and two years;
<6) those who have served leas than one year. Each group
will be divided into four subgroups arranged according to
■age.
The data for this primary grouping are readily obtainable,
•definite in character, and easily tabulated ; but other factors^
lees easily tabulated, affecting some officers, must also be
■taken into account. Information which will be at the dis¬
posal of the Central Medical War Committee will enable it to
4&ke these special factors into consideration, and then, if
necessary, to shift the position of an officer into a different
group from that in which the primary classification bad
placed him. In this prooess the following points will be
taken into account: (I) Whether he is married or single, and
the size of his family, if any; (2) if ail the members of a
partnership are away, or if the practice is single-handed;
(3) bis paid appointments (panel or otherwise). If any;
whether such appointments are whole-time; and whether
they have been kept open for him.
Special claims on financial or other grounds, which are not
taken into account in the above method of classification,
may be submitted to the Committee for special assessment.
The soheme is as follows:—
PART I .—Men over 30 Years of Age at Date of Armi*tice—i^.,
Aten Bom on or before Nov . Xlth , 1888.
(i.) The following points will be awarded on the grounds
of length of service and age :—
Men mobflUcd at the outbreak of
toar(R.NV.R..RN R.,
R.A.M.C.{T.),<ScBA.M.a ( 3.R.)):
Points.
Over 45. 30
40-45 29
35-40 *8
30-35 27
Men xoith over 3 years' service:
Points.
Over 45. 28
40-45 25
35-40 24
30-35 . 23
Men with over yean’
service :
Points.
Over 45. 28
40-45 ... 21
35-40 . 20
30-35 . 19
Men xoith 1 year's I
service:
Points.
Over 45. 18
40-45 17
35-40 16
30-35 16
Men with less than
l year's service :
Points,
Over 45. 14
40-46 13
35-40 12
30-35 11
Part II.-
(ii.) The following points will be added or subtracted in
respect of the following modifying conditions;—
(1) If In whole-time salaried post, subtract.. . « points.
(2) If with no paid appointment or N.H.I. work, add . 3 „
i3) If in single-handed practice, add . ... «- ... 3 „
(4) If all members of partnership are on service, and no
member of the partnership Is otherwise entitled to
more than points, add, in case of one partner ... — 4 ,,
(6) If married, add. ... ••• ••• — — *•• 4 »»
(6) If dependents, children or otherwise, 1 point for each
dependent np to a maximum of . 4 „
(iii.) Additional points may be awarded in reBpeot of
financial or other circumstances of an exceptional character
which justify a claim to a higher order of priority than that
determined by the foregoing provisions. The award of any
such additional points would oe the subject of special assess¬
ment by the Committee, and any man who deems that he
has suffered special hardship on such grounds should apply
to the Committee for a special consideration of his case on
the facts^ , .
(iv.) The order of priority of men of 30 and over shall be
according to the net number of points accruing to each man
under this part of the soheme, men with a greater nu m be r
of points ranking before men with a less number of points.
Part II.— Men under 30 Yean of Age at Date of Armistice—
i.e, Men Bom after Nov. 11th , 1888.
(v ) The order of priority determined under Part II. shall
be in continuation of the order of priority determined under
^ hri.f The order of priority of men under 30 years at the
date of the armistice shall be according to their age, the
older before the younger, no priority being, however,
accorded as between men born in any one calendar year :
Provided that, in the event of the Central Medical war
Committee deciding, upon a special application, that
financial or other circumstances exist of an exceptional
character which justify a claim by the applicant to a higher
order of priority than that accorded under the foregoing
provisions, the Committee may award that the apphcaut
should be classed either on a level of priority (under Part II.)
with men born in a specified earlier calendar year, or on a
level of priority with men entitled to a specified number of
points (under Part I.). ___
The Casualty List.
The names of the following medical officers appear among
the casualties announced since our last issue :
Died.
Cspt. J. 8. Martin, R.A.M.C., \ros educated at Bdinbowh
and at St. Thomas’s Hospital, London, and qualified in
1895. He held appointments at the Rotherham Hospital
mid at the Royal Infirmary, Edinburgh, and prior to
joining up was in practice at Leigh, Lancs., where he
was honorary surgeon to the local infirmary.
Sorg. J. M. Pickthall, R.N., qualified in Edinburgh m 1885.
He practised in Cornwall and m the Clmnnel Islands,
and was latterly surgeon on the Hospital Ship
Oxfordshire, and the eable ship Britannia.
I*ANOBT,]
THE WAR AND AFTER.
[Jan. 11, 1019 9 §
OipiF. I. Mackinnon, R.A.M.C., qualified at Edinburgh in
1883, and was in Damascus when be joined up for war
service. He died at Alexandria from pneumonia.
Capt. W. F. Luton, Canadian A.M.C,
Wounded.
Lieut. A. J.Abreu. I.M.8.
Capt. G. A. Khan, l.M.8. -
• The Honours List.
The following awards to and promotions of medical
officers for services at home in connexion with the war or for
valuable services in the indicated spheres of operations are
announced
Serrioes at Home.
K.C.B.— Maj,-Gen. G. J. H. Bvatt, C.B.; Lt.-Geu. T. H. J. 0. Goodwin,
C.B.. O M.G., D.S.O., K.H.S . A.M.S.
K.C.M.Q.— M*j.-Gen. W. W. Pike, C.M.G., D.S.O., A.M.S.; Temp.
0*1. J. Atkins. C.M.G.. A.M.S.
C.M.G.— Col. H. A. Chisholm, Canadian A.M.C.; Temp. Col. (Hon.
Sukg.'Gen.) 0. S. Rvan. Australian A M.C. ; Lt.-Cnl. F. Marshall,
Anstralian A.M.O.; Col. B. J. O'Neill, D.S.O., N.Z M.C.
K.C. B.E.— Temp. Hon. Col. J. L. Thomas, O.B., C.M.G.; Col. H. B. B.
figure-Porter, C.M.G.. A.M.*. (T.F.).
C.B.E. —Lt.*Ool. C. W. Cathcart. R. A.M.O.(T.F.); Col. T. H. M. Clarke,
C. lf.G., D.S O., A.M.S ; Col. G. Daosey-Browning. A.M.S.: Lt.-Ool.
Sir J. Payrer, Bart.. R.A.M.C. (T.F.); Ool. R. Jennings, K.H.S., late
AM S.; Maj. H. J. Neihon, late R.A.M.C.; Temp. Hon. Maj. H. S.
Houttar. R.A.M.C.
O.B.E. —Col. W. H. Bull, V.D., A.M.S. (T.F Res.); Maj. J. J. Cot,
BA.M.C.(T.P.Hea.) ; Capt,. R. Johnson. R.A.M.C. (T.F ); Lt. Ool. J. R.
Mallln*, late R.A.M.C.; Dr. Adeline Roberts, Q.M.A.A.G., Recruiting
Medical Controller; Bt. Col. C. J. W. Tat ham, ret. pay, late R.A.M.C.;
Capt. J. 8. White, R.A.M.C. (S.R.).
M.B E.-Temp. Capt. J. N. Martin. R.A.M.C.
C.B.E.— Col. G. D. Fanner, Canadian A.M.C. ; Col. J. Stewart.
Canadian A.M.C.
Q.B.E.— Capt. (acting Maj.) J. R. Goodall, Canadian A:M.C.; Lt.-Col.
ft. Raftes, Canadian A.M.C.; Lt.-Col. A. A. Smith, Canadian Army
Dental Corps; Maj. (acting Lt.*Col.) A. W. Wlnnott, Canadian Army
Dental Corps.
C.B.E.— Lt.-Col. (temp. Col.) M. McWhae, C.M.G., Aust. A.M.C. ;
CoL H. C. Maudsley, C.M.G., Aust. AM.C.
O.B.E. — Maj. P. T. Beamish. Anst. A.M.C.; Maj. J. B. Down,
Auak Army Dental Corps; Lt.-Col. B. M. Sutherland, Anst. A.M.C.;
Mai. G. C. Willcocks, M.C., Aust. A.M.C. ; - Lt.-Col. C. Yeatman,
Aust. A.M.C.
C.JI.JB.—Maj. (temp. Lt.-Col.) W. M. Macdonald, N.Z.M.C.; Lt.-Col.
H. J. McLean. N.Z.M.C.
O.B.E.— Maj. A. j. Brewis, N.Z.M.C.; Maj. W. Bruof, N.Z.M.C.
C.B.E.-Temp. Lt.-Col. B. N. Thornton, O.B.B., S.A.M.O.
O.B.E.— Temp. Maj. M. G. Pearson, 8.A.M.C.
To be Brevet Colonel.—Lt.-Col. P. S. O’Reilly, C.M.G., R.A.M.C.;
KA.-Col. Sir J. G. Rogers, K.C.M.G., D.S.O., ret. pay (late A.M.S.).
To be Honorary Colonel.— Lt.-Col. W. H. W. Elliot, D S.O., ret.. I.M S.
To be Brevet Lieutenant Colonel—Temp. Maj. F. S. Brereton, ret.
<)at* R.A.M.C.;; Temp. Maj. G. P. Humpbery. R.A.M.C.
To be Brevet Major.—Temp. Capt. R. Bruce-Low, R.A.M.C.: Capt.
<actlng Maj.) A. A. Jubb, R.A.M.C. (T.F.); Capt. (acting Maj.) A. T. J.
MoOreery, M.C.. R.A.M.C.; Temp. Capt. W. J. Tulloch, R.A.M.O.
Operations in Egypt.
C.B.— Temp. Lt.-Col. H. L. Bason, C.M.G., R.A.M.O.
C.M.G. —Lt.-Col. (temp. Col.) B. P. Sewell, D.S.O., B.A.M.C.
C.B.E.— Temp. Col. 0. C. Choyee, R.A.M.C.-; IA.-O 0 L (temp. Ool.)
D. Garner, late R.A.M.C.
O.B.E.— Capt. R. Brlercliffe. R.A.M.G.(T.F.); Temp.Capt. F H. Higgle,
B.A.M.C.; Maj. W. Dvson, R.A.M.C. «T.F.); Maj. (acting Lt.-Colj
W. F. Bills, R.A.M.C.; Temp. Cspt. W. W. Forbes, R.A.M.C.; Temp.
Chpt. N. 8. Gilchrist. R.A.M.C.; Maj. F. Grade, R.A.M.C. (T.F.);
Cap*. D. L. Graham. I.M.S.; Capt. J. Inglis, R.A.M.C. (T.*.); Capt.
T. F. Kennedy, R.A.M.C.; Maj. (acting Lt.-Col.) J. W. Mackenzie,
R.A.M.C. (T.F.'; Capt. (acting Maj )L. M. V. Mitchell, R.A.M.C. iT.F.);
Temp. Capt. C. W. Smith, R.A.M.C.; Lt.-Col. G. R. F. Stammers,
R.A.M.C.; Maj. G. C. Taylor, R.A.M.C. (T.F.); Maj. F. B. Treves,
RA.M.O. (T.F.); Capt. (temp. Lt. Col.) P. S, Vlckarroan, R.A.M.C.
<S.R.); Capt. (acting Maj.) A. P. Watson, R.A.M.C. (T.F.); Temp. Lt.
X. R. Madan. I.M.8.
M.B.E.- Capt. J. Green, R.A.M.C. (T.F.).
C.B.E.— Lleut.-O 1. (temp. Ool.) G, P. Dixon, Aust. A.M.C.
O.B.E.— Lt.-Col. O. B. B ackbura, Aust. A.M.C. ; Maj. N. tt. Fairley.
Anst. A.M.C.; Lt.-Col. (temp. Ool.) R. Fowler, Aust. A.M.C.; Lt.-Col.
<temp. Col.) J. C. 8torey, Aust. A.M.O.
M.B.E.— B1 Yusbashi Halim Bffendi Sulman Shoucalr, Egyptian
Army M.C.
To be Brevet Colonel.— Lt -Col. B. B. Powell, D.S.O.. R.A.M.C.
To be Brevet Lieutenant-Colonel.— Maj. (acting Lt.-Col.)'A. W. Gibson,
K.A.M.C.
TO he Brevet Major.—Temp. Cant. P. H. Babr, D.S.O.; 1LA.M.G.
Distinguished Service Order.— Maj. B. B. Austen, attd. R.A.M.C.;
Maj. L. A. Avery, R.A.M C. (T.F.); Maj. (acting Lt.-Col.) J. Bvans,
B.A M.C. (T F.>.
Militant Cross.^-Qupl. (acting Maj.) J. H. Beverland, R.A.M.C. (S.R.);
Temp. Capt. G. J.C. Ferrler, R.A.M.C.; Capt. (temp. Mai.)I. P.Harria,
R.A.M.O. (T.F.); Capt. W. F. T. Haul tain, R.A.M.C. (S.R.); Teinp. Lt,
B. H. Kamakaka, I.M.S.; Capt. (acting Maj.) L. Milton, R.A.M.C. ;
Temp. Capt. H. J. Rae. R.A.M.C.; Temp. Capt. F. 0. Robbs, K.A.M.C. ;
Capt. (acting Maj.) A. B. P. Smith, B.A.M.C.; Capt. C. Anderson, Aust.
^ Operations in Italy.
C.M.O.— Lt.-Col. (temp. Col.) 8. A. Archer, R.A.M.C. ; Lt.-Col. (acting
CoU H. A- L. Howell, R.A.M.C.; Lt.-Col. J. W. West, R.A.M.C.; Lt,-CoL
C. H. Fnmtvall, R.A.M.C.
O.B.E. —Capt. (acting Maj.) T. D. Inch, M.C., R.A.M.C.; Ofcpt. A.
Plcken, B.A.M.C. V S R.); Capt. (acting Maj.) J. D. Well*, R.A.M.C. (T.F.)
TO be Brevet Co2oad.-Lt.-Col. H. Chopping, C.M.G., R.A.M.CL
To be Brevet Lieutenant-Colonel.— Maj. (temp. Lt.-Col.) J. G. Bell,
D.S.O., R.A.M.C.
To be Brevet Major.— Capt. (acting Col.) W. G. Wright, D.&Ow,
R.A.M.C.
Distinguished Service Order. —0«pt. (acting Lt -Cel) R. A Broderick,
M.C.. R.A.M.C. (T.F.); Temp. Capt. W. Mackenzie. R.A.M.C.
Military Cross.- Temp. Capt. A. H. Maokiia R.A.M.O.
Operations in Salonika.
C.B.—Temp. Col. A. G. Phear; Capt. and Bt. lfaj. (temp. Col.) R. B.
K6llv. R.A.M.C. (T.F.).
C.M.G -U.- Ool. 0. B Martin. S.A M.C.
O.B E.— Temp. Capt. (acting Maj.) D. I. Anderson. R.A.M.C.; Temp*
Capt. J. 0. M. Bsllev. R.A.M.C.: TemD. C*pt. (acting Ma.i.) G. V.
E akawell. R.A.M C.; Capt. (acting Maj ) T. Y. Barkley, R.A.M.C. (S.H.V;
t.-Col. M. Boyle, R. A.M.G.: Temp. Capt. A. H. Coleman, R.A.M C.;
Temp. Capt. J. A. Delmege, R.A.M.C ; Cemp. Capt. R II. Blworihr*
R.A.M.C.; Capt. (acting Maj.) W. B. Foley. B A.M.C. (S.R.); Msj. W.B.
Galwey, M.C., R.A.M.C ; Msj. (temp Lt-Col.) J. Gray, R.A.M.C.
(T F.) ; Lt. Ool. J. B. Hodgson R.A.M.C : Capt. H. K. McColl, R.4JMLC.
(S.R.); Lt.-Col. P. Mitchell. R.A.M.C. (T.F.); Capt. (acting Maj ) J.
Taylor. R.A.M.C. (T.F.); Lt.-Col. F. B. A. Webb. R A.M.C. (T.Fi).
M B.E.—Lt. (temp. Capt.. acting M*j.) K. A. Mansell, K.A.M.C.;
Temp. Lt. J. Ram*b->ttom. R.A.M.C.
To be Brevet Lieutenant - Colonel. — Maj. (temp. Lt.-OoJ.) J* A.
Anderson, R.A.M C.
To be Brevet M jar.— Capt. (temp. Msj.) R. B. Barnsley, M G.,
R.A.M.C.; Cap*, (acting Maj.) W. F. Christie, R.A.M.C.; Capt, (temp.
Maj.) M J. Williamson, M C , R.A.M.C.
Military Cross.— C*pt. R. D. Cameron, R.A.M C. (S.R.); Cspt. M. C.
Cooper. R.A.M.C. (S R.); Capt. G. B. Ege*um. R.A.M.C. (S.R.); TeoNff.
Capt. (acting Maj.) G. B. Hdroyde, R A.M.C. ; Capt. L. J. Shell,
R.A.M C. (S.R.); Capt. H. W. Torrance, B A.M.C. (S B.); Capt. L. H.
Wootton, R.A.M.C. (T.F.). _
The following is the continuation of the liafc the first part
of which was given in Thb Lancet of Jan. 4bh f p. 41:—
CI.E. -Lt.-Col. J. T. Calvert, I.M.S.; Maj. J. H. Murray, I.M.S.;
Lt.-Col. F. R. Swlnton. I.M.S. ; Lt.-Col. J. 0. Lamout, I.M.S (ret.).
C.B.E. ( Military Division).—Sura. Capt. G, T. Broach. R.N. ; Surg.
Capt. V. G. Thorpe, R.N.; Maj. (Hon. Lt.-Col.) M. W. Flack; Acting
Lt.-Col. F. F. Muecke.
O.B.E. ( Military Division).— Surg. Cdr. R. F. Bate. R.N.; Surg. Odr.
R. Hardle, R.N.; Surg.Lt. A. R. lies, R.N.; Surg. L'.-C<1r. L. M. Morris,
R.N.; Surg. C*r. (acting Surg. Capt.) H. L. Penny, R.N.; Surg. Cdr.
B. A. Shaw, R.N.; Lt.-Col. B. O. B. Carbery; Maj. B. R. OBetlly,
Canadian Forces; .Maj. F. H. Stephens, A.M.S.; Capt. (temp. Maj.) H.-U.
Adams, R A.M.C. (T.F.); Lt.-Col. W. J. P. Adye Curran, R.A.M.C.;
Temp. Capt. (acting M«j.) J. A. Arkle, R.A.M.C.; Lt.-Col. (temp. Cel.)
H. P. W. Barrow. C.M.G., D.S.O.. R.A.M.C. ; Capt. (acting M*j.) C. B.
Baxter, R.A.M.C. (T.F.); Temp. Lt.. (acting Lt.-Col.) J. L. Blrley,
R.A.M.C.; Maj. H. d’A. Blumberg, T.D., R.A.M.C. (T.F.); Capt. (acting
Maj.) H. Burrows. R.A.M.C.(T.F.); Temp.Capt. (acting Maj.) R. Charles,
R.A.M.C.; Capt. A. D. Child. R.A.M.C.(S R.); Capt. (acting Maj.) S. J.
Clegg. R.A.M.C.(T.F.); Temp. Capt. N. A. Coward, R.A.M.C. ; Capt.
(acting Maj.) W. H. Davison. H. A.M.C. (T.F.); Temp. Maj. W. S. Dickie,
R.A.M.C.; Temp. Maj. T. M. Frood, R.A.M.C.; Temp. Maj. (acting
Lt.-Col.) G. D. Gray. R.A.M.C.; Capt. (acting Lt.-Col.) F. L. A.
Greaves, R.A.M.C. (T.F ); Temp. Capt. A. H. Greg. R.A.M.C.; Capt,
(aotiug Maj.) T. W. Hancock, R.A.M.C. (T.F.): Temp. Capt. (acting
Maj.) J. H. Hebb, R.A.M.C.; Temp. Hon. Maj. T. Houston, R.A.M.C.;
Capt. A. B. Jury, R.A.M.C. (T.F.); Temp. Capt. R. D. Laurie^
R.A.M.C. ; Temp. Capt. L. R. Leinprlere, R A.M.C.; Maj. (temp. Lt.-
Col.) F. A. M(/Caramon, M.C., R.A.M.C.; Temp. Capt. J. W. McLeod,
R.A.M.C. ; Temp. <
Col.) F. A. Mo Cara 1
R.A.MC.; Temp. Capt. (acting Maj.) W. G. Mum ford, R.A.M.O.;
Capt. J. C. Newman, R.A.M.C. (T.F.) ; Capt. B. A. Odium*
R.A.M.C.; Temp. Capt. H. I. P. Pel lew, R.A.M.C.; Capt. J.
Ramsay, R.A.M.C. (T.F.); Temp. Capt. (acting Maj.) T. 0.
Ritchie, R.A.M.C.; Lt. Col. (temp. Col.) A. B. Soltau. C.M.G..
R A M.C. (T.F); Maj. (temp. Lt.-Oo!.)W. G. Sutcliffe, R.A.M.C. (T.F.);
Maj. (actingLt.-Col.) T. B. Unwin,R.A.M.C.; CaDt. (acting Maj.) W. W.
Wagstaffe. R.A.M.C. (3.R.); Temp. Capt. K. M. Walker, R.A.M.C.;
Temp. Capt. (acting Maj.) H. B. Wilson, K. A.M.C.; Capt. (acting
Lt.-Col.) T. B. Wdstenholme, R.A.M.C (T F.); Capt. footing Lt.-Cotl)
F. Worthington, D.8.O., R.A.M.C.: Lt.-CM. P. G. Brown, ' anadtan
A.M.C.; Maj. J. P. Burgess. Canadian A.M.C. : Maj. R J. MoBwan,
Canadian A.M.C.; Lt.-Col. H. B. Mtinrce, Canadian A.M.C.; Maj. H.
Orr. Canadian A.M.C.; Maj. D. M. Bmbelton, Australian A.M.C. ; Maj.
C. N. Finn, Anstraltan A.M.C.; Maj. (temp. Lt.-Col.) A. F. Maolnre,
Australian A.M.C.; Lt. C’ »l. W. D. G. Upjohn. Anstralian A.M.C.
lobe Major General.— Col.(temp. Maj.-Gen )J. Thomson,C.B., A.M.S*
To be Brevet Colonel.—LK-Co\. (temp. Col.) R. 8. H. Puhr.’n.M.G.,
D. 6.O., R A.M.C. ; Lt.-Col. (temp. Col.) A. G. Thompson, C.M.G.,
D.S.O., R.A.M C.
To be Brevet Lieutenant-Colonel.— Maj. (temp. Lt.-Col.) R. A. Bryden,
D.S.O., R.A.M.C.; Maj. (temp. Lt.-Col.) P. J. Haaafin. D.S.O.,
R.A.M C.; Maj. (temp. Lt.-Col.) H. 8. Paeke, R. of O , late R.A.MX. ;
Maj. (temp. Col.) D. Rorie, D.S.O., R.A.M.C. (T.P.); Maj. G. F.
Sheehan. D.S O., R.A.M.C.
To be Brevet Major.— Temp. Capt. 8. P. Hodklnson, R.A.M.C.; Capt.
(acting Maj.) W. L. Webster, R.A.M.C.
D.S.O.— Surg. Lt.-Cdr. H. D. Drennan, R.N.; Capt. (tamp. Lt.-Col,)
J. Barkley, R.A.M.C,(T.F.); Capt. (acting Lt.-Col.) R. Burgess, M.C.,
R.A.M.C. (T.F.); Maj. (acting Lt.-Col.) A. Cal lam, R.A.M.C. (T.F.);
Capt. (actingLt.-Col.) L. D. B. Cogan, R.A.M.C. (T.F.); Maj. (actingLt.-
Col.) B. H. Cox, R.A.M.C. (T.F.); Capt. (acting Lt.-Col.) F. G. Dobson*
R.A.M.C. (T.F.); Capt. (acting Maj.) T. I. Dun, M.C., R.A.M.C. ; Capt.
(temp. Lt.-Col.) O.W. Barnes. R.A.M.C. (T. F.); Maj. (acting Lt.Col.) C. T.
Edmunds, R A.M.C.; Maj. (acting Lt.-Col.) W. H. Forsyth, R.A.M.C.;
Capt. (acting Lt.-Col.) C. J. A. Griffin. R.A.M.C. (S.R.); Capt. (acting
Lt.-Col.) C. Helm. M.C., R.A.M.C. ; Temp. Capt. (acting Maj.) A. B.
Knight, M.C., R.A.M.C.; Capt. (acting Lt.-Col.) 0. LI. Lander, M.C.,
R.A.M.C.(T.H.); Maj. (acting Lt. Ool.) S. G. McAUum, R.A.M.C.(S.R.);
Lt.-Col. (temp. Col.) F. McLennan, R.A.M.C.; Capt. (acting Lt.-Col.)
J. MacMillan, M.C., R.A.M.C.; Capt. (acting Lt.-Col.) O. M. Page.
R.A.M.C. (S.R.); Temp. Capt. (acting Mai.) M. P. Patou. M.0. t
R.A.M.C.; M*j. (acting Lt.-Col.) T. T. H. Roblnaon, R.A.M.C..
Maj. (acting Lt.-CoM J. H. Stephen, R.A.M.C. (T.F .); Temp. Oapt.
Maj. (acting Lt.
H. Stephen, R.A.M.C. (T.F.); Temp. Oapt,
$6 The Lancet,]
THE SERVICES.
[Jan. 11, 1919
(Acting Lt -Col.) R. Svanason, M.C..R A.M.C.: Cspt. (moling Lt.-Col.)
J. Young. R.A.M.C. <T P.): Temp. Lt.-Col. C. W. Vipond. Cun Milan
A.M.C.: Maj. (acting Lt.-Col.) J. H. Wood, Canadian A.M.C. : Lt.-Col.
H. W. Chambers, Australian A.M.C.; Lt.-Col. W. B. L. H. Crowther,
Australian A.M.C.: Maj. (temp. Lt.-Col.) B. F. Lind. Australian
A.M.C.; Lt.-Col. G. W. Macartney, Australian A.M.C.; Maj. A.
McKillop, Australian A.M O.; Maj. C. tforlet, Australian A.M.C.;
Maj. W. A. Morton, Australian A.M.C.; Maj. V. W. Savage. Australian
A.M.C.; Maj. W. C. Savers, Australian A.M.C.; Lt.-Col. G. Craig.
N Z M C
Second Bar to the Military Cross.—Capt. H. K. Ward, M.C., R. A.M.C.
<3.B ).
Bar to the Military Cross.— Temp. Capt. (acting Maj.) J. Biggam,
M.O . R.A.M.C.; Capt. B. J. Brallev, M C., R.A M.C. (S.R ).
Military Cross. —Temp. Capt. li. J Aheme, R.A.M.C.; Capt. (aetlng
Maj.) W.K. Blore, If.A.M.C.(S.R.); Temp. Capt. A. Buchanan, R.A.M.C.;
Capt. (acting Maj.) W. B. Uathcan, R A. M.C. iS R. • ; Capt. (acting Maj.)
G. O. Chambers, R.A.M.C.; Temp. Capt. C. F. Drew, R.A.M.C.;
Capt. B. McM. Dunlop, R A.M.C. (T.F.); Temp. Capt. (acting Maj.)
J. Gibson, R.A.M.C. ; Capt. F. H. Guupy, R.A.M.C. (S.R.);
Temp Capt. (acting Mai*) B. L. M. H*cke‘tt. R.A.M.C.; Capt.
G. L. Matthews, R A M.C. ; Cspt. (acting Maj.) C. Nicholson,
R.A.M.C. (S.R.); Capt. (acting Maj.) A. P. O'Connor, R.A.M.C.;
Temp. Capt. J. F. Powell, R.A.M.C.; Temp. Capt. C. R. Reckitb,
R.A.M.C.; Capt. (acting Maj.) H. B. 8. Richards, R.A.M.C. (T.P.);
Capt. (actiDg M*j.) F. B. W. Rogers, R.A.M.C. (T.F.); Temp. Capt.S. P.
Stoker, R.A.M.C.; Capt. (acting Lt.-Col.) D. H. Weir, R A.M.C. (T.F.);
Temp. Capt. (acting Maj.) B. Whitehead. R.A.M.C.; Temp. Capt. J.
Wylie, R.A.M.C.; Capt. N. J. MacKay. Australian A.M.C.; Capt. N. H.
Dempster. N Z.M.C.; Capt. A. D. S. Whyte, N.Z. M.C.
Kaisari-HLnd Medal, let Class. —Mr. J. D. Price, Civil Surgeon,
Nowgong, Assam. _
Mentioned in Despatches.
In a lengthy and mo»t interesting despatch dealing with
the brilliant victories of the British Army on the Western
front which led np to the signing of the armistice on I
Nov* 11th last, Sir Douglas Haig pays the following tribute to
the medical services:—
During the period under review the medical services, under the
direction of Lteut.-General C. H. Burtchaell, deserve special com¬
mendation for the initiative, energy, and success which have charac¬
terised all branches of their work. The rapid advance of the troops and
the extended front on which operations were carried out during the
final stages of the offensive created problems in connexion with the
collection, evacuation, and treatment of wounded which bad not been
met with in the earlier phases of the war. These difficulties were met
with the most admirable promptness and efficiency.
My thanks are due to the consulting surgeons and physicians for the
invaluable assistance given by them in the application of new methods
to the treatment of wounds and disease; to the R.A M.C. officers and
permanent staffs of the convalescent de;>6ts for work which enabled
many thousands of men to be restored to the fighting ranks; to the
untiring and devoted work of the British Red Cross Society, the Order
of 6t. John, and all members of the uursing service, whose unremitting
kindness and constancy have done much to alleviate the sufferings of the
sick and wounded ; and, finally, for the very valuable services rendered
by the base hospital units and by Individual officers of the Medical
Corps of the United States of America attached to the British Army.
The following medical officers of the Royal Air Force are
mentioned in despatches for distinguished service in war
areas:—
Surg. W. A. S. Duck, R.N. (Adriatlo); Temp. Surg. A. L. Dykes,
R.N. (Adriatic); Temp. 8urg. R. 8. Overton. liN. (Mediterranean);
Fleet Surg. C. E. C. Stanford, D S.O., R.N. (Adriatic).
Also the following for distinguished and gallant services
and devotion to duty in connexion with the operations of the
British Force in Italy : —
Army Medical Service: Staff.
Lt.-Col. (temp. Col.) S. A. Archer; Lt.-Col. A. Chopping, C.M.G.;
Capt. (acting Maj.) M. Coplans. D.S.O., R.A.M.C. (T.F.i; Col. J. V.
Forrest, C.M.G.; Capt. (acting Maj.) T. D. Inch, M.C ; Temp. Oap r -.
(acting Maj.) B. H. Lucas, M.C.; Maj.-Gen. K. R. Newland, OB.,
C. M.G.; Lt.-Col. (temp. Col.) R. Pickard, C.M.G., T.D., R.A.M.C.
(T.F.); Temp. Col. H. H. Tooth. C.1L, C.M.G. (Lt.-Col, R.A.M.C.
(T.F.)); Capt (temp. Maj.) S. J. A. H. Walshe, D.S.O., R.A.M.C. (S.K.);
Temp. Col. 0. G. Wat*on, C.M.G.; Capt. (acting Maj.) J. D. Wells,
R.A.M.C. (T.F.); Col. T. Du B. Whaite, C.M.G.
/loyal Army Medical Corps.
Temp. Capt. C. J. Armstrong-D&sh; Mij. (temp Lt.-Col.) J. G. Bell;
D. S.O.; Maj. (acting Lt.-Col.) C. Bramhall; Temp. Capt. D. Fisher,
Lt.-Col. C. H. Fumivall; Temp. Capt. H. B. T. Gamlen ; Temp. Capt.
D. G. Gardiner; Temp. Capt. (acting Maj.) J. ureene, M.C.; Temp.
Capt. (acting Maj.) J. S. Hall; Lt.-Col. (acting Col.) H. A. L. Howell;
Temp. Capt. W. Mackenzie; Temp. Caj.t. S. Marie; Temp. Capt. J. B.
Matthew*; Temp. Capt. (acting Maj.) A. A. Miller; C<»pt. (acting Maj.)
J. A. Rensbaw ; Temp. C*pt. (acting Maj.) R. H. Rolllnson-Whitaker;
Temp. Capt. H. S. Thomas; Capt. (aetlng Lt.-Col ) B. W. Vaughan,
M.O.; Lt.-Col. J. W. West; Capt (acting Col.) W. G. Wright, D.S.O.
Royal Army Medical Corps ( S.B .).
Capt. J. E. Allan: Capt. (acting Maj.) T. O. Graham; Capt. A.
Picken.
Royal Army Medical Corps (T.F.),
Capt. K. S. Beken; Capt. (acting Lt.-Col.) R. A. Broderick. M.C.;
Capt. (acting Maj.) J. A. Davies; Capt. (acting Maj.) W. C. Hodges;
Capt. G. Moore, M.C.; Capt. P. Moxey.
The following should be added to the list of those
mentioned in despatches given in The Lancet of Jan. 4th,
page 41:-
. Canadian Army Medical Staff.—Ceil. C. A. Peters, DS.O.; Brig.-Gen.
A. B. Ross, CB , C.M.G.; Col. R. M. Simpson, D.S.O.; Col. R. P.
Wright, D.S.O.
THE SERVICES.
ROYAL RATAL MXDICAL 8BRVTCR
Thk following appo'ntmeats are notified .—Sun;. Com. W. H. Daw to
Donegal; Surg. Lieut.-Com. B. C. Hoi tom to Bristol; Surg. Lieut.
I. 8. Gabe to Royal Marine Division, Chatham.
ROTAL XAYAL VOLUNTEER RESERVE.
Temp. 8urg. Lieut. H. G. Davies. It.N.V.R.. who hae been Invalided
on account of ill-health contracted In the Servloe, to re Ain hla rank.
ROYAL ARMY MEDICAL C0RP3.
Lleutenant-Oolonels to be acting Colonels while employed as Assist-
I ant Directors of Medical Services of a Division; A. Is. Hamerton,
H. C. R. Hime, (Brevet Col.) G. J. A. Ormsby.
The undermentioned relinquish the acting rank of Lleutenant-Oolonel
on re-posting : Major W. J. Weston; Capt. W. Tyrrell.
To be acting Lieutenant-Colonels whilst in oom mand of a Medical
Unit: Capt. G. F. Rudkin. Capt. (acting Major) M White. Capt. H. H.
Leeson, Capt. (acting Major) M. J. Williamson, Major W. B. C. Lunn,
Capt. (acting Major) J. B. A. Wigmore, Capt. (acting Major) G. D*R.
Carr, M.O.
Lieut.-Col. F. 8. Le Quesne, V.C.. Is placed on retrod pay.
Temporary Colonels relinquishing their temporary commissions on
re-posting: R. B. Kelly (Captain. R.A.M.C., T.F.), H. A. Ballance
(Major, temp. Lieut. Col., R.A.M.C., T F.).
Lieut.-Col. J. B. Brogden is placed temporarily on the Half pay List.
To be aetlng Majors: Cant*. B. VArvlll. K. P. Mackenzie, W. B.
Tyndall; Temp. Capts. A. W. P. Todd, W. K. A. Richards, D. J. Stokes,
J. H. Hood. J. Rodger, D. S. Gtaham.D. R. Williams. O. N. Goad. A. L.
Ssunders, R. Felton, G. S. Brown, and D. M. Boss, and W. H. Stott
while commanding troops «>n a Hospital Ship.
Temp. Capts. relinquishing the acting rank of Major on re-posting :
R. V. Doloey, W. D. Cruicksaauk, W. G. Johnston, W. K. A. Richards,
R. Wilson. .
J. E. Briscoe to be Captain.
Temp. Hon. Capt. H. O. Stans field to beading Major whilst apscia'ly
employed.
Temporary Lieutenants to be temporary Captains: F W. Daniels
S. B. Turner, D. Holroide.
Temp. Hon. Lieut. A C. Delacroix to be temporary honorary Capt tin.
Officers relinquishing their commissions-.—Temp. Mijors: A. H.
Rlnrtloss. J. B. Howell, Temp. Hon. Major W. C. G. Aahdowne. Temp.
Capts.: G. Denholm, A. G. H. Lovell, G. N. L rimer, T. Clap-
t’erton, B. A. Miller, K. J. Me Fee ter*, C. J. A. N. Mercier G. M
Young, M. J. Ryan, W. G. B. Gunn, (Acting Major) B. H. Barton,
P. J. Child, E. C. Bourdaa, A. B. Altken, C. B. Lakln, C. 8.
Kingston, J. A. Gray (Home Hospital Reserve), A. Wester man,
A. K. Jordan, A. C. Halloes, J. B. McMorland. J. B English,
II. Dyer, A.. Dingwall, T. K. Ferguson, S. Vosper, R. J. Helsby. (Acting
Major) K. L. M. Hacketr. W. Holland, W. W. LLingtoi. J. A Davidson
H. M. Raven, B. C. Roberts, H. P. Newsholme A. D. Hunt. (Acting
Major) W. Anderson. G. Ilardwicke, R J. Lidd rdale J. L Cochrane,
J. R. Tibbies, G. D. B.Tallis, J. B. Ferguson, (Acting Major) R. Warren,
A. Currie, W. A. Young, M. J. Horgan, E E M. Price, W. R. Bayne.
H. S. Gabh. R F. Moore, A. F. W. Denning. H. L. Tidv, J. H Porter
(Acting Major) C. H. S. Webb, K. W. D. MacRac N. Morris, II. S. A
Hogg. N.' A Coward, O. W. Jones, R. D. Smedley. F P. Fisher, G.
Allison, G. B Wilkinson. R. M. Liddell, (Acting Major) W. Rankin,
(Acting Major) R. H. Paramore, T. L. Wormald, E. H. Walker.
(Acting Major) J. L. Gordon, S. Carter, A. J.V. Me Don m II, C. R. Wills,
A. Gillespie,W. H. Pallelt. K.M. Soames, J.O. Skevington.T. 8. Sharpies
To retain tne rank of Captain : B. B. Strutbers. On a count oi i*l
health contracted on active service and to retain the rank of Captain •.
A. C. B. Biggs, A. H. Sinclair, D. W. Jones, (Acting Major) W. \
Rogerson. On account of lll-bealth contracted on ac lvo service
C. Dundee, D. C. Alexander, F. L. Brewer, H. L. Mariyn. On account
of ill-health and to retain the rank of Captain : A. W. F. Edmond*,.
J. McCartney. On account of ili-heilth: Temp. Hcu. Capt. R. M.
Blske (on oea»ing to serve with the British Red Cross Society hr
France). J. M. Smith on account of ill-hea th and Is granted the rank
of Lieutenant. Temp. Lleuts. : C. J. E. Edmond*. F. P. R. James
A. Linn, G. S. Ward, D. G. Geliatly, F. G. F. Browns. D. Divl**,
D. Holmyde. H. Calrd, W. J. N. Todd, R. Hamer, A. L. Black, W. L.
Hogan. F. W. Hobbs; Temp. Hon. Lieut. J. P. Griffin (on ceasing to
serve with the British Red Cross Ho*pit*l, Neeley).
Canadian Army Medical Corps.
Temporary L'eutenants to bs temporary Cap a’ns: J W. Harper,
G. Leith, A. E. Kenn-dv, D. MacDougall, P. H. M Nulty. G A
Minorgan, W. B. Munro. J. E. Pritchard, E. Wer»hof, A. S McOann.
Canadian Army Denta’. Corps.
Temp. Lieut. 0. W. Smith, from Canadian Machine Gun Corps, to
be temporary Lieutenant.
SPECIAL RBSBBVS OF OFFICERS.
Capts. F. G. Foster and S. J. V. Furlong to be acting Majors.
Lieut. J. F. Cunningham relinquishes his commission on acoount of
ill-health.
Second Lieut. E. P. Whiteman to be Lieutenant.
• TERRITORIAL FORCE.
General list.—Capt. (Brevet Major) (acting Lieut.-Col.) R. 0. Dun
relinquishes his acting rank on ceasing to be specially employed.
Oapts. (acting Majors) J. Walker, K. W. 0. Brown, and F. H. Lacey
relinquish their acting rank on ceasing to be specially employed.
Major (acting Lieut.-Col.) D. G. Campbell relinquishes his acting rank
on ceasing to be specially employed.
Captains to be acting Majors whilst specially employed.: J. W
Thomson. J. W. Craven, J. 0. Newman, R. M. Wilaon.
Capt. J. W. Keay to be Major. , 4 „
1st Eastern General Hospital: Major (acting Lieut.-Col.) H. A
Ballance relinquishes his acting rank and is restored to the establish
ment.
1st London Sanitary Company : Lieut. S. W. Wingfield to be
Captain.
1st London General Hospital: Capt. P. Himill is restored to the
establishment.
The Lancet,]
MEDICAL NEWS.
[Jan. 11,1919
TERRITORIAL FORCE RESERVE.
Lieufe.-Col. W. E. Foggie, from 3rd Highland Field Ambulance, to be
lieutenant -Colonel.
Majors F. N. Grinling, W. T. Rowe, D G. Campbell, A. C. Turner,
B. R. Dyer. J. R. Garrood. B. G. Ewing, G. F. R. Smith, A. A. Gunn,
(rum Attached to Units other than Medical Units, to be Majors.
Major (acting Lleut.-Col.) P. G. Williamson, from Attached to Units
other 1 han Medical Units, to be Major.
A. A. W. Merrick, from 3rd West Lancs. Field Ambulance to be
Major.
Capts. J. R. Chalmers and C. W. Greene from 1st Home Counties
field Ambulance, to be Captains.
Capt. (acting Major) A. R. Muir, from Lowland Mounted Brigade
Field Ambulance, to he Captain.
Capt. N. T. K. Jordan, from South Wales Mounted Brigade Field
Ambulance, to be Captain.
C*pt. (sctlng Major) J. G. Cooke, from Attached to Units other than
Medical Units, to be Captain.
Capt. (acting Major) H. F. W. Boeddlcker, from 1st South Midland
field Ambulance, to be Captain.
C*pt. F. H. Lacey, from Welsh Border Mounted Brigade Field Ambu¬
lance, to be Captain.
Capt. L A. Mackenzie, from 1st West Riding Field Ambulance, to be
Captain.
Capt. A. A. Pratt, from 4th Northern General Hospital, to be Captain.
Capt. H. Stonehouse, from the 2nd Northern Field Ambulance, to be
Captain.
Capt. W. J. Wilkinson, from 2nd Bast Anglian Field Ambulance, to
be Captain.
Capt. W. Batley-Thomson, from Notts and Derby Mounted Brigade
Fl«*ld Ambulance, to be Captain.
Capt. G. H. Kirby, from South Midland Casualty Clearing Station, to
be Captain.
Capt. J. H. Paul, from Yorks Mounted Brigade Field Ambulanee. to
be Captain.
Capt. W. L. HIbbert, from Home Counties Casualty Clearing Station,
to be Captain.
Capt. D. Macnair, from 2nd Wessex Field Ambulance, to be Captain
Capt. H. N. Crowe, from 2nd South Midland Field Ambulance, to be
Captain.
Capt. (acting Major) H. C. Adams, from 2nd Wessex Field Ambulance,
to be Captain. -
ROYAL AIR FORCE.
Medical Branch .—Major J. L. Brie? to be acting Lieutenant-Colonel
while employed aa Lieutenant-Colonel. The following are grauted
temporary eommUsion* : As Lieutenant-Colonel: Surg.-Cnmmanner
O. B. C. Stanfo d. As Majors: Acting Majors, K.A.M 0.. W. W
Shorten, T. J. Kelly, H. H. Robinson ; Stnff-Surgs. R.N., P. H. Stephens,
A. V. J. Richarcson. As Cap'&ina (acting Majors while specially
employed): Acting Majors, K.A.M.C., M. N. Perrin. J. H. Porter.
As Captains: Surg. Lieuts., R.N., W. A. S. Duck. 1). S. Stevenson.
P. B. Giihespy, D. Ross, R. W. Meller, A. L. Dykes, L. S. Go*a. R. B.
Adams. J. H. M. Sandeson, B. McLean; Surg. Lieuts., R.N.V.R.,
C. F. A. Hereford, T. B. Dixon. D. A. Macnherson; Capts
R A.M.C., D-Arcy Power, J. H. Owen, A. Sutcliffe, J. M. Wyatt,
F. A Hampton. N. C. Graham, A. G. H. Smart. L. W. Shelley,
C. P. Sells, E. W. Craig, W. J. McKeand A. G. H. Moore,
W. 8. T. Connell, J. Freeman, G. Cranetoun, W. Waugh, C F Graves,
1). H Fras- r, W. H. Cam, J. W. Keay, A. D. Kennedy, J. B. Lascelles,
C. H. Thompson, J. E. Dunbar, V. T. Ell wood, J. H. Coke, P. H.
Young, J. Cnambre, T. N. Wilthew, A. Leltoh, 0. K. Attlee, C. W. W.
James, W. B. Dove.
G. D. M. Beaton (temporary Lientenant, R.A.M.C.) is granted a
traspmary commission as Lieutenant.
Denial Branch.—A* Captains: J. Barrett, G. Dawson, L. S.
Woodiwls.
THE LANCET, VOL. II., 1918: THE INDEX.
The Index find Title-page to the volume o£
The Lancet which was completed with the issue
of Dec. 28tb, 1918, is in preparation. Owing to the
continued shortage in the paper-supply, the Index
will not be issued with all copies of The Lancet,
as was the custom prior to the War. Subscribers
who bind up their numbers are requested to send
a poet-card (which is more convenient for filing
purposes than a letter) to the Manager, The Lancet
Office, 423, Strand, London, W.C. 2, when a copy of the
Index and Title-page wil^be supplied free of charge.
Shbital $etos.
University of Aberdeen. —The following degrees
were conferred recently
il.B. and Ch.B .—Patrick 8fcephen Gerrard Cameron. Marjory
Johnston Dutton, Anne Simpson, and John Geddes Smith (second-
class honours).
Royal Society of Medicine. —The Section for
the Study of Disease in Children will hold a discussion upon
the Etiology, Prevention, and Non-operative Treatment of
“ Adenoids ” at 1, Wimpole-street, on Friday, Jan. 24th, at
5 p.m. The discussion will be opened by Dr. Harry Campbell
and Dr. Edmund Cautley.
West London Medico-Chirurgical Society.—
An ordinary meeting of this society will be held to-day
(Friday, Jan. 10th) in the society’s rooms, West London
Hospital, at 8.30 p.m., when a paper will be read by Major
W. McAdam Eccles, entitled *'Stumps and their After-
treatment.”
Medical Magistrate.— Dr. G. W. Eustace, ex-
Mayor of Arundel, has been placed on the commission of the
peaoe for Sussex. He was awarded the Military Cross for
gallantry at Ypres in September, 1917, being then attached
to the Queen Victoria Rides. Dr. Eustace also served in the
South African War, receiving the medal and three clasps.
King Edward’s Hospital Fund for London.—
A meeting of the General Council of King Edward’s Hospital
Fund for London was held on Jan. 6th at the offices
of the Fund, 7, Walbrook, E.C., the Right Hon. James W.
Lowtber, M.P. (Speaker of the House of Commons), in the
chair, when the order of appointment to the council, com¬
mittees, and executive was read, and the resolutions pro¬
viding for the work of the Fund for 1919, approved by the
governors on Deo. 17th last, were formally adopted.
BOOKS, BTC., RECBIVED.
Allen, George, and Unwin, Ltd., London.
A °* Nations with Large Powers. By F. N. Keen. LL.B.
Wltn Preface by the Rt. Hon. oir W. H. Dickinson, K.B.K., M.P. Is.
Church.ll, J. and A., London.
Year Book of Pharmacy. Edited by J. O. Br&ithwaite and Others.
Sanitation in War. By Lieutenaut-Golone) P. S. Lelean. K.A.M C
3rd ed. 7*. 6 d. *
Uoddxr and Stoughton, London.
One Man’s View. By L. Merrick. With an Introduction by Granville
Barker. 6 a.
How to Reduce Your Income Tax by Liberty Currency. By A. B
Sitwell, la. 3 d.
Jack, T. C. and B. C., London.
An Introduction to the Study of Biological Chemistry. By S. B
Schryvcr, D.Se. 6*.
Limurt Press, London.
Physiology of Industrial Organisation and the Re-em ployment of the
Disabled. By Professor J. Amar. Translated by A. F. Stanley
Kent, D.8c. 3C*.
Masson kt Cie., Rditeurs, Paris.
Lepons do Chirurgle de Guerie. Publlees, sous la direction de
Cl. Regaud, de llnstitut Pasteur de Paris. 9 fr. ( + 10 per cent.)
Uhivebsitt Press, Cambridge.
Calendar for 1918-1919. 10«. 6 d.
University of London Press. London.
Regulations for External Studeuts of t he University of London. 1*. (
Calendar of the University of London, 1918-1919. 1*. 6 d.
Year Book Publishers, Chicago.
Practical Me-iicino Series. Vo I V., Gynecology. Edited bv B
0b#tefcrlcs - Edited by J. B. de Lee, M.D. Ser
j Wlo. 91 . 60 .
The position of Freqch medical students still
on active service is being considered by an Inter-Ministerial
^^deaf 1011 ° Ver wbich M * Dam * n y» med. de l.classe,
King George’s Fund for Sailors.— At a
meeting of the general council of this fund, which was held
at Trinity House on Dec. 20th last, it was announced that
£50,000 had been allocated to the Marine Benevolent Institu¬
tions. The fund has for its object the amelioration of distress
among seamen and their dependents, and letters were read*
at the meeting from the King and other members of the
Royal Family expressing their gratification at the success
of the fund and their appreciation of the generous
response on the part of the public, both in this country
and in the dominions and colonies. His Majesty expressed
the wish that next year the donations might reach a total
of £1,000,000. ;
University of Edinburgh. — The following
medical items from the annual report for 1917-18 are of
interest
During the academic year 1917-18 the total nomber of matriculated
students was 2091, of wnnm 1339 were men and 752 were women. Of
these there were enrolled in the Facultv of Medicine 1147 (823 men
and 324 women—an increase of 84 up n the number of women for the
previous session). Of ihe students of medicine, 588, or over 51 per,
cent., belonged to Scotland ; 199. or over 17 per cent., were from
England and Wales; 36 from Ireland; 299, or 26 per cent., from
British Dominlous, Colonies, and Dependencies of whom 76 came from
India and 25 from foreign countries Toe following medical degrees
were conferred,: Biche'or ot Medicine and Bachelor of Surgery 106,
Doctor of Medicine 15. The total annual value of the University
fellowships, scholarships, bursaries, and prizes now amounts to about
£21,485, of which £5610 belongs to the Faculty of Medicine. The'
coming of peace has already brought bask many former students, and
others have entered the commencement of whose course had been
delayed by mtiltary service. W*>en the spring term opens there will*
be a further large augmentation of numbersinall departments of study.
The University authorities »re addressing themselves to ihe various
problems which lie ahead, and It is hoped that, alike by some reasonable
relaxatlr n of preliminary requirements and bv the provision of courses
of instruction adapted to the special needs of'the time, the case of thw
returning student will be adequately and even generouily dealt
88 ftn Laxoit]
MEDICAL DIART FOR THE ENSUING WEEK.
[Jan. 11, 191f
with. The University of .Edinburgh, in common with the other
universities of Greet Britain, hes drawn up e statement of
Its most pressing financial needs, and It Is anticipated that the
Gwernment will supplement their existing grants to some extent.
Two vacancies have occurred during the year In the ranks of the pro¬
fessoriate, one by resignation, the other owing to death. Sir Thomas
Fraser resigned, as from the end of September, the chair of materia
medloa, which be had held for 41 years, adding lustre to the University
daring this long period, not less by the importance of his scientific
Investigations than by his success as a teacher. He has been succeeded
by Mr. A. R. Ousbny, who was formerly professor of materia medica
and pharmacology in the University of London. The deaths ot two
University lecturers are receded—viz . Dr. W. G. Smith, who was
appointed to the George Combe Lectureship in Psychology on its institu-
turn In 1906, and who, in spite of indifferent health, discharged the
duties devolving upon him with excepional competence and devotion ;
and Mr. Denis Cotterill, one of the lecturers In clinic *1 surgery, who for
several years rendered services of the highest value In connexion w th
No. 11 Hospital, Ruuen. Sir Willian^pVatson Cbeyne, Bart., K.C.M.G.,
has been elected as one of the three Parliamentary representatives for
the universities of Scotland. Among the benefactions is a bequest
by the late Dr. Grace R. Cadell, to the University, jointly with the
Edinburgh Hospitd for Women and Children and Hoipice. of the
residue of her estate; the moiety failing to the University being
to help in the medical education of women in that University." •
Lord Ashton, of Ryelands, Lancaster, has sent
to the Preston Royal Infirmary a cheque for £2000 to free
the institution from debt.
The subscriptions to the French War Medical
Assistance Fund have reached a total of more than a million
francs. This fund also makes grants to the families of
medical men. Its address is 5 rue de Surene, Paris.
University op London.— Dr. John W. H. Eyre
(Guy’s Hospital Medical School) has been appointed pro¬
fessor of bacteriology, and Dr. Arthur E. Boycott, F.K.8.,
has been reappointed director, and Dr. C. Bolton, F R.S.,
acting director, of the Graham Legacy Laboratory, during
Dr. Boycott’s absence on military duty.—In cooperation
with the London County Council the University has arranged
a series of five lectures for teachers on “ Surgery, Ancient
and Modern, with special reference to Lister and Pasteur,”
which will be delivered by Sir Rickman J. Godlee at Univer¬
sity College on Wednesdays, at 5.30 P.M., beginning on
Jan. 22nd. Sir Cooper Perry will preside at the opening
tooture.
Communications, Letters, Ac., to the Editor have
been received from—
A— Snrg.-Lieut. A.L. Abel, B.N.;
Messrs. Abdulla and Co. Lond.;
Major G. L. Arnold, R.A.M.O.;
Army Medical Service, Lond.,
Director-General of.
B. —Dr. B. F. Buzzard, Lond;
Dr. C. Burland, Blundellsands;
Messrs. Butterwjrth and Oo.
(India), Ltd., Calcutta; Lt.-Col.
H. W. Bayly, B.A.M.C.(T.>; Mr.
J. L. Balderston, Load.; Dr.
A. G. Bateman, Lond.; Capt.
T. G. Brown, Lond.; Birming¬
ham, Medical Officer of Health of:
Snrg.-Capt. P. W. Bawetfc-Smith,
O.B., C.M.G., B.N.; Mr. B. A.
Barton, Lond.; Dr. C. Bose,
Calcutta.
C. —Dr. P. G. Crook shank, Lond.;
Canadian War Records. Officer in
Charge of, Lond.; Mrs. B. M.
Cnrbett, Beaconsfield; Mr. F.
Coca, Madrid ; Mrs. M. Comber,
Lympetone; Dr. A. J. Chalmers,
Khartoum; Mr. J. Cabbura,
Lond.
D. —Domestic Engineering Co.,
Lond.; Decimal Association,
Land.; Dr. J. N. Dyson, flest-
bourne; Dr. I. David. Colombo;
Dr. W. F. De&rden, Manchester.
B.-Mr. L. Emery, Leysln; Dr.
ETllston, Porthleven.
P.-Dr. J. D. Fergusm, Scar¬
borough ; Factories, Chief In¬
spector of, Lond.
G. —Oapt. J. Geogbegan, R.A.M.C.;
Dr. n. B. Grove, 8t. Ives, Dr.
H. L. Gordon, Lond.; General
Meilcal Council, Lond., Regis¬
trar of.
H. — dr. T. G. Hill, Lond.; Fleet-
8urg. W. B. Home, R.N.
J. —Mr. F. Jenner, Boecombs; Mr.
R. R. James, Lond.; Lt.-Col.
A. L. Johnson, C.A.M.C.
K. —Dr. W Kidd, Lond.; Bt. Hon.
Lord Kinnaird, Lond.; King
Bdward’s Hospital Fund for
London, Hon. Secs, of; Dr. A. M.
Kennedy, Glasgow; Mr. O. H.
Kahn, Boston.
L — Dr. R. B. Lord, Colwyn Bay;
Major G. C. Low, Lond.; Local
Government Board, Lond.
M. —Ministry of National Service,
Lond., Sec. of; Dr. I. Moore,
Lond.; Dr. J. C. Me Walter,
Lond.; Mrs. J. T. McBntlre,
Dublin; Lt.-Col. C. S. Myers,
B.A.M.C.; Mr. G Mayall, Bolton;
Medical Research Committee,
Lond.; Mr. J. Y W. MacAlister,
Lond. Dr. R. Morton. Lond.
N. -Capt H. L.0. Noel. R.A.MO.
P.—Mr. F. H. Porry costs, Poiperro;
Mr. R D. Pedley, Lond.; Dr. A.
Powell, Bombay.
R. — Royal Mcroecoplcal Society.
Lond ; Royal Institution of Great
Britain, Lond.; Mr. S Rowutree,
York; Royal Institute of Public
Health, Lond., R. S.; Dr. H.
Rah met Bey, Cairo : Mr. P. B.
R>th. Lond.; Mr. H. M. Rains-
ford. Lond ; Dr. Reynolds. Lond.;
Dr. N. Raw, Lond.; Royal Society
of Arts, Lond.
8.—Mrs. J. Simpson, Lond.; Sir
G. H. Savage, Lor,"'.. Dr. W. O.
Swayne, Clifton; Sir Stewart
Stockman, M.K.C.V.S., Lend.;
Mr B. Slopoe. Loud.
T. — Mr. D. R. Thom. Aberdeen.
U. —University of Edinburgh, Sec.
of
W.— Capt. A. H. Watson; Mr.
O. B. West, Load.; Capt. A
Wylie, R.A.M.C.; Majo/ C. F.
White, R.A.M.O.; Dr. F. P.
Weber, Lond Mr. W. C. Whit¬
worth, Searrier; We<t London
Medico-Cbirurgical Society; Mr.
A. Watkins, Hereford; Wallace
Automatic Disinfecting and De¬
odorising Co., Lond.; West
London Hospital Post-Graduate
College, Dean of.
Y.—Dr. R. A. Young, Lond.; Capt.
F. W. B. Young, K.A.M.C.(T.)
Communications relating to editorial business should be
add rased exclusively to The Editor of The Lancet,
423, Stnrad, London, W.C. 2
JUebfoal for % tm ing ®eek.
SOCIETIES.
ROYAL 80CIBTY OF MEDICINE, L Wimpola-rtreet, W.L
Tuesday, Jan. 14th.
GBNBRAL MEBTING OF FALLOWS, at 5 p.m.
Discussion:
Ou *• Conditions under which Pensioners of the Army, Navy, and
Royal Air Force are Admltte t into and Treated in Civil Hos¬
pitals," to be opened by Mr. H. J. Waring. Any Fellow wishing
to take part in the Discussion should send his n a me to the
Secretary as soon as possible.
MEETINGS OF SECTIONS.
Tuesday, Jan. 14th.
PSYCHIATRY (Hon. Secrotartes-Bemard Hart, G. F. Barham):
at 3.30 p.m.
Clinical Mkitdio at the Swell War Hospital by courtesy of Lt.-Ool.
M. A. Collius, R.A.M.O., D.D.M.3. Eastern Command, and of the
Committee, L.G.O.
Train leaves Waterloo at 2.37 p.m., arriving Swell 3.10 and
Bpsom 3.15. Return train leave* Ewell at 5.59 p.m. for Waterloo.
Wednesday, Jan. 15th.
HISTORY OF MBDICINB (Hon. Secretaries-Charles Singer, Arnold
Chaplin) i at 5 p.m.
Papers :
Sir William Osier: A Bodley MS. of Lectures of Andrea Owalplnos,
1590. .
Dr. Gumston: A Contribution to the History of the 8nrgloal Treat¬
ment of Aneurysm, from notes of Dr. Charles Mauneir of
Geneva, made in 1802.
Thursday, J&tl 16th.
DERMATOLOGY (Hon. Secretary—S. B. Dore) ; at 4.30 p.m.
Cases will be shown.
Friday, Jan. 17th.
OTOLOGY (Hon. Secretaries—J. F. O’Malley, H. Buckland Jones) =
at 5 p.m.
B^r^Hugh B. Jones (President of the Section): Deafness associated
with the Stigmata of Degeneration.
BLBOTBO-THBRAPBUTICS (Hon. Secretaries— Robert Knox, Walter
J. Turrell): at 8 JO p.m.
Adjourned Discussions on the following Papers : —
A Note ou the Construction of the Diathermy Machine (with
demonstration): by O. M. Dowse, B.So., and 0. B. Iredell, M.D.
Diathermy in Gynaecological Oases: by G. Bellingham Smith,
F.R.O.S..C. B. Iredell. M.D., and A. B. Marsden. Surgeon. R.N.
Pars »nal Experiences o» Burning due to Secondary Radiation; by
James Metcalfe, M.D.
Diathermy and Figuration in Malignant Disease: by Philip
Turner. F.R.O.S., Lt-Col., R.AM.0., and 0. B. IredeU, M.D.
^’iflatherray in Diseases of the Bye: by O. Msadowa-Ryley, Surgeon,
R.N. and C. B. Iredell. M.D.
The Diathermy of the Abdomen: by O. B. Iredell, M.D., with a
Note by W. H. Barber, M.D., Captain, R.AM.O.
Dr. S. Gilbert Scott will show lantern slides of interesting cases.
CLINICAL
OBSTETRICS AND GYNECOLOGY
SURGBRY: Members of these Sections are specially Invited to attend
the Meeting of the Section of Electro-Thera jeutlcs.
The Royal Society of Medicine keeps open house for
R.AM.C. men &od M O.’8 of the Dominions and Allies The
principal hospitals in tae metropolis admit medical offloera
to their operations, lectures Ac. Particulars on application
to the Secretary at 1, Wimpole- street, London, W. 1.
SOCIETY OF TROPICAL MBDICINB AND HYGIBNB, 11, Ohandos-
street. Cavendish-square. W.
Friday. Jan. 17th.— 5.33 p.m.. Paper:—Lt.-Col. 8. P. James, I.M.&.
(retd.): Malaria in England.
LECTURES, ADDRESSES, DEMONSTRATIONS, Ac.
POST-GR ADU ATB COLLBGB, West London Hospital, Hammersmith-
road, W.
Clinics each week-day at 2 p.m., Wednesday, Friday and S stne Gs y
also at 10 a.m. ' v
(Details of Post- Graduate Course were giv min issue of Nov. 30tJh, 1918.)
ST. JOHN’S HOSPITAL FOB DISBASES OF THB SKIN, 49, Letoestar-
square, W.C.
Tuesday. Jan. 14th.—5 p.m.. Dr. W. X. Sibley: Ionisation.
Wednesday. -5 p.m.. Dr. W. Griffith: Skin Diseases In the Army.
ROYAL INSTITUTE OF PUBLIC HBALTH. In the Lecture Han off
the Institute, 37. Russell-square, W.O.
Course of Lectures and Discussions on PubMc Health Problems under
War and After war Conditions :—
Wednesday. Jan. 15th.—4 p.m., Prof. W. A. Bone: Coal and
National Health.
The King has conferred the Order of Mercy on
Lieutenant-Colonel R. R. Sleman, R.A.M.O.
Classes in the various faculties were resumed
in the University of Lille on Jan. 3rd. The Facnlty of
Medicine in Brussels reopens its doors in the course of the
month.
Thb Lancet.] APPOINTMENTS-VACANHKS -BIRTHS, BTO.— SHORT COMMENTS.
hTO. [Jan. 11, 1919
Sppointmwtfs.
KM
■"KSJS-.JSS" 1 * *•• *'»•• °* B - Coont, Mfldlc.l OfBwr of
^ U fho A v’ w’ M vP‘ BdIn -* Coroini8*!ofrer of Meitfca*! Servk»B for
ss asaa* Ee * ioQ - wwoh , “* ud ««»•«-?«*ssShS
fatswies.
jy* farther information refer to the advertisement column*.
Asat M.O. £330.
C7^d> Hospital.— M.O. £150.
5°*A Roya> United Hospital.—R. P. *,.a h s
te*Jor& County HospUaL-Rt*. Cllr>. A a* 6. '$2 2 *. ~
C0M " <M - **■ J K&. «*
£rf«foi General Hospital.—Sen. H.S. £30 n .
CHckt sler, Royal West Sussex Hospital.— H 8. £1«T
Corset County Asylum.—8 rand A»t. M.fh £303
":°i& <rab -
^ 0°“^.
®££»SS*. Venereal Diseases Scheme. —Female Aaat M.O £400
^reof Northern Central HospSeU^HoUoweou-ivad N — u k £6 *iiJ? er wlc ’
gHgVord .^ .Surrey C^ HoZi^U^' ^0 HS ' £I60 ‘
BeUinaly % Kost Suw€x County A sviuwi* —Ton tv. Ai^t m n 7 ,,__ ,
BuU&v education ammlttee.-hZL P*&, sThioffi o Wk
Co ™* m P t(/m and Dieeatee of Me Chcet, Smmpto
JfaneAe ter, Anooats Hospital, Mill-street.—U<m. P
SlBtUtB(ahin ff Hospital for ttorgiecU Tuberculosis.-8.
Mw^hshire Cnunty Council.-Vem*\e Asst. M.O. £ 400 .
Riding Asylum .-Locum Tenena M.O. 7 «p. dop
C’ottwty 5ofow^A —Temp. Tuberc. Offleer. £4oi
AfoncfcA .torfi** «*<* Norwich Hospital.- H. P. £250 p
PWn«, Lowr Common, S.W.-Hm. *.a«68 '
^Men * Hospital for Children. Hackvey-road. E. —Temo Am» p »»
XayifomtM for Me EaibBnd. SrW«<Sz5l a
fading. Royal Berkshire HospiUiL-Roa. P M O ‘
Il i* rr H ar y. and M*Pensary.— Jun. H.S. £100
■ fiocAea ter, 8t Bartholomew’s Hospital.—Clin. Asst.
Rotherham Hospital.- 8en. H.S. *250 ^
b *a.i n %m?* tal - Srav '° In ”- road - r.c.- h.p. *so. c «u»ny
*ly n V Education Committee.—8ehoo\ Dentist. £300.
Hospital.— Bea. Senior Student, pifip
Swindon Borough.—host. M.O.H. £500
rtefc. fa Rnejgxal for Children. TUe-etreet. CheUea. & Hr.-H.P. „4
WnjMOrtwd SmatoHmn, Mealhop, Orange-mer-Sandt.-Amb. H.O.
and r«f Cumberland Infirmary.-**,. H .8. HUD to £188.
SsSSSBaaSSfeSSS
iotes, ^jjorl Comments, aitb Jnstocrs
to Corresponirtnts.
COLONIAL HEALTH REPORT8.
»PPears from the Blue-book for 1917 that the
raSoO 0 "™.^.^ ° f ‘ hat y«“ w*a esiims£d at
tbo* J2*V, Tbl9 .®t»owed a net increase of nearly 85 000 over
FSSaSSS
?!l^P® rso Sf. f he European population who left for war
service. The following are details of the population :—
KatioimUty. No. ^ottota^
Sinhalese ... 2.961,100 *!?? U 63‘7 >D '
Jwnila ... 1.838.100 ... 2"*9
Jdoon . 276 *50 ... fr9
Bmgheaa ... 28.760 ... 6*6
Kntfannltty.
Malaya
Percentage
of t**tai
.. ___ pepulaMon.
14,000 ... 03
N<r.
Others.,
7,200
ie,t )00
0*2
0*4
£150.
JNl*, SwriJires, nr* Jtstjjs,
births.
!^***^ 5 ' th *
the
marriages.
^ ghter °'
Eobin Hall MB BPK u* Holland mad, W.
•on of Dr. ’and Sira* Robert HaM C n# P ^Jlu’ *}* *»««. elder’
only daughter of Mr. and Mra Gerald ^ t0 . G *T ft,dlne Bhio,
Kenalogton, W. ’ Gera ^ d Edmund Routledge, of
Ji 2*l.ton. tool. Bruce
_ deaths.
L'ic P. 1 "' ^ toodo “' W *“»“ At<»» B1H., M.H.C.8..
Herrio^'ltB*,' LH.c’s. Ma’^rndgo!" * Nur * ln ® Ho “e,
L“JS3u^D, D M.a! Ul 6 M 18 ’ M B l cT <t felf’ ^P n « u ">«>l». frnnh
AA.M.O. C»ml»nip).^ e d« M B C 8 ' W DemMOo.). C^rtAtc,
MJh-dM Retlee.ojmr^
^r^h 00 ^*'® 8 ^“i 16 P°PPla«on there are 89 female
19^ M which*^fa8 d the g *t^best r6 Tbe’mroportiOT**?
iSS ttl ?h b ^ th ® '! a ® 104 ^ 10 °- The <S^rate wSi M*7 e J?
1£XX), the lowest recorded during the last 10 years r ^h*
wans: e&,“ sns ‘Az’ AtiS ’rZ
the year 28*2 per cent, were those of1^5
of age, corresponding to a mortality-rate of 174 ner 1000
births registered. This rate is 20 Der 1000 haiTTw 1000
?Qic fche n^ reCedin ** decedDium » anflO per 1000 below ttaauS
1916. The proportion of deaths in the p*nAwai «™L-! at -? r
from certain principal causes to a million D ^?
population was a. “oll^ 8 ,”,^ "‘“^oes “^T
diarrhoea, 2217; pneumonia, 1090 • Dhthiate »9i .
W m T 8 - 575; ^S«iS4f3r*S
*mature birth and congenital defects 34Q* ” j
malarial cachexia, 278 ? brow WttTtb ;cm^ 92‘ Sd •
?^ ter iK. ,eV fl er ’. 9 V- P,a .8 Qe - which broke ““ i n c’e^
for the first time in 1914 is ofiii • ey, f? 1
scourge, having claimed as ’its victims in the* vea?
under review 211 persons, aczainst 286 in iqia a « •,
wS
£,SSfiTl S -S &r “^ a ®“”Xi«3
18 ID ft«?“ e<4 8 ^ eat l y rise in the case mortalitv which
S 8 7 92 l P 1f i r‘J n ^ 92 8 *“ W15, 9 ““u mt and ^in
^^ma| r e g s leingTttacked
ffl^-a^srsahsy'ssiarasai
^S‘S»”£l“vrl#S
tion of coutaots, evacuation and closnre S tAffS-f*®
tenements in infected localities pending the "S3
structural improvements by the owners, d esterk,in* of
and adjacent houses, sulphur fumigation of^rwk
tunnels, capture and poisoning of rats Th<» nn ; rt _
against ankylostomfasisrwhich g is extromely prevtten“lS
£» e T y p i rt0f island, ?d»igS
7 JZ by offl , ce !f 8 ^ fehe International Health Gom-
wit^ th«^^T«Ti°d k 8 J?® 0 ? a EP re ciated, in conjunction
hotels 2 d ^ partntGnfc V are 84 GovirnmcS
hos^teJs and 441 Government outdoor dispensaries The
gM P “S.^ SS »“ ? "“ ’~ ttf B
miles from Colombo, contame^zg^Srats'at^the end
A , ss& i ssas^
The general rebuilding scheme in c^te^JS!
Daprove ^. en ^ Medical College was deferred
owing to the war. The fnli course of traiXg*“ S
90 The Lancet,] NOTES, SHOHT COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Jan. 11, 1919
students is five years. A diploma in medicine, surgery, and
midwifery (which can be registered in the United Kingdom), is
granted to successful medical students. A two years' course
of training is provided for apothecaries, who. on becoming
ualifled. are employed by Government. The attendances
uring 1916 and 1917 totalled—medical, 620; apothecary, 253:
the passes were—medical, 30; apothecary, 30. In Colombo
there are a bacteriological institute, a general hospital, an
ophthalmic hospital, a lying-in home, a hospital for women
and children, and one for infectious diseases. There is an
establishment for the manufacture of calf lymph, and at
Kandy and Galle there are special dispensaries for the treat¬
ment of eye diseases. An anti tuberculosis institute in
Colombo was opened during the year, fitted with an up-to-
date X ray apparatus. A start was also made in connexion
with the provision of a Pasteur Institute in Colombo. ___
ELECTROLYTIC DISINFECTANT IN INFLUENZA?"
IN view of the Memorandum on Epidemic Influenza
which has been issued by the Royal College of Physicians
of London (The Lancet, Nov. 16th, 1918), in which, as
a preventive, is recommended gargling the throat with
20 drops of solution of chlorinated soda in a tumbler of
warm water and sniffing up the nose a solution of common
salt, Mr. F. W. Alexander, medical officer of health of Poplar,
sends us an aocount of the method adopted in that borough
for dealing with the outbreak. The drawbacks to using
chlorinated soda on a large scale are that it is difficult to
make and has to be freshly prepared. The electrolytic fluid
as made in Poplar contains common salt and hypochlorite
of magnesium (a solution of chlorinated magnesium), it is
alkaline and stable, and if it is necessary to give it a tint
permanganate of potash may be used for the purpose,
as it retains its colour when added to the solution.
During the first three weeks of November 5370 gallons
were distributed free in the borough, the cost, including
that of electricity and materials, being Ad. per gallon
(or about £12 per 5370 gallons). This fluid has been avail¬
able free in Poplar for the last 12 years, and as soon as
influenza broke out in the borough handbills were dis¬
tributed and the district posted with bills instructing the
inhabitants to rinse the mouth, gargle the throat, and
douche the inside of the nose with the council's electrolytic
* disinfectant, which could be procured free at one of "the
council's seven distributing depots. Mr. Alexander points
out the advantages of installing plants for making the fluid,
especially on ships and at seaside towns, where the electro¬
lyte is always at hand and always ready. It could be used
immediately in outbreaks of diphtheria and cerebro-spinal
fever.
OIL OF CHENOPODIUM FOR ANKYLOSTOMIASIS.
In the Colonial Health Report from Ceylon, which we
notice on page 89, the extreme prevalence of ankylosto¬
miasis in that island is noted. A note in the current
number of the Colonial Journal quotes a report from
the Fiji Islands stating that the employment of the
oil of chenopodium, or American wormseed oil, is con¬
stantly increasing there. The reasons given for the use of
this drug are that it is less toxic, more efficient, less costly,
and has a greater effect upon the ascarides associated with
hookworms than thymol. Failure to obtain good results
with the oil of chenopodium is claimed to be due to small
dosage, the correct amount being as follows : Over 60 years
of age, 20 m or 40 drops; 21 to 60 years, 30 m or 60 drops; 11
to 20 years, 20 m or 40 drops ; under 10 years, 3 drops for each
year of age; pregnant women, 18 drops. The doses are
divided into two equal parts, one to be given at 7 a.m.
and the other at 9 a.m., these being preceded by a
dose of well-diluted magnesium sulphate on the after¬
noon of the day before treatment with the oil is begun.
Two hours after the last dose of oil a second dose
of the salts solution is given. A report based on the first
1000 cures occurring in Fiji states that of those receiving
two treatments 70 per cent, or more are cured. In a few
selected parts where the people were obedient to advice in
regard to diet the cures after two treatments reached 85 per
cent. Of the 1000 cures obtained in the first three months
of active work, 801 occurred after two treatments, 184 after
four treatments, and the remaining 15 cures after five treat¬
ments. No untoward results have been reported from the I
use of the drug.
HEALTH TEACHING.
The importance of right training in hygiene, especially at
school age when the future citizen is under control for
training, was admirably discussed in his flrst Milroy lecture
last year by Professor H. R. Kenwood and reported in
The Lancet of May 11th. In this connexion the health
and temperance syllabus drawn up for the Natal Education
Department by its medical offloer, Dr. A. B. Mac Arthur
Thomson, for the instruction of hygiene in elementary
schools, is of interest, for it is a genuine attempt to introduce
practical instruction in place of a pseudo scientific method
of teaching. The syllabus is graded to suit the various
Standards 1. to VI., and includes, in addition to the usual
subjects of food, air, and cleanliness, instruction in first-aid.
In Standard V. reproduction is discussed by means of vege¬
table physiolrgv, the study and development of the chicA
taking its place "in Standard VI. The great feature of the
syllabus is the application of the lessons where possible by
meanB of inspections, drills, and parades, the senior standard
stndying the seasonal prevalence of disease in environments
and making visits to mnseums to view appropriate models.
Senior health monitors are also appointed to report on the
sanitation of the school grounds. Precept and practice thua
go hand-in-hand. Another commendable feature of the
scheme is the telling of stories dealing in a general way
with the triumphs of hygiene, such, for instance, as the
construction of the Panama Canal.
THE METROPOLITAN WATER-SUPPLY DURING
JULY, AUGUST, AND SEPTEMBER, 1918.
Although the mean rainfall during* the month of July at
12 stations which have been selected as giving equal repre¬
sentation for all parts of the Thames Basin was 2*06 inohea
above the average mean rainfall for that month during the
previous 35 years, the raw river waters showed an improve¬
ment in quality judged by chemical examination, but all three
raw waters (Thames, Lee, and New River) contained more
bacteria than their respective averages for the year 1917. The
filtered waters likewise improved in chemical respects, while
bacteriological examination yielded, generally speaking,
not unsatisfactory results. There were no typical B. colt
found in 75*3, 43*5, and 74*8 per cent, of the filtered water
samples derived from the Thames, Lee, and New Kiver
< water respectively, even when 100 c.cm. were examined. In-
I August, on the other hand, the rainfall was 1*47 inch.,
being 1*17 of an inch below the average mean rainfall
for that month during the previous 35 years. Though in
some particulars not maintaining the chemical quality of
the previous month, all three raw river waters yielded
results better than their respective averages in 1917, and the
same condition is recorded as regards the filtered watere,
except that the colour showed Jess satisfaction' results,
in the case of the New River and Lambeth "supplies.
There were more bacteria present in the raw water
from the Thames and Lee than in 1917, but the baoterio-
logioal results of the filtered waters were satisfactory.
September was a relatively wet month, the rainfall
being 5*86 inches, which is 3*91 inches above the mean
average rainfall for that month during the previous 35 yeara.
All three raw waters showed, generally speaking, a deteriora¬
tion in quality according to chemical examination, but the
filtered waters maintained their quality on the whole. The
Lee and New River raw waters contained more bacteria
than their respective averages for the year 1917, but raw
Thames water contained fewer compared with the same
period. All filtered waters as they reach the consumer gave>
satisfactory bacteriological results.
THE “ARELLANO” INFLUENZA MASK.
Particulars are given in our advertisement columns this
week of the " Arellano ” influenza mask, named after ita
designer and made by Messrs. John Bell, Hills, and Lucas,
Ltd., who were so successful as manufacturers of the poison-
gas respirators used in the field by H.M. forces. The>
Arellano mask has been approved by medical men for ita
purpose, aud will be placed immediately, in large quantities
and at a low price, on the market. Our readers know that
the use of masks has been suggested as a precaution in more
than one quarter during the recent epidemic of influenza.
KHAKI MONOTONY.
“A wearer of khaki,” a medical man, who “craves for.a
little colour ” and who believe* that” bright colours cheer
us on our way through life,” calls our attention to the
monotony and sombre hue of khaki, and thinks that after
more than four years of war the prevalence of this dim Uni
has a malign influence. There can be no doubt as to the
influence of colour on the mind of the savage and of the
sophisticated, though the psychological effects may differ in
depth aud quality, but whether it would really dispel anj
existing depression caused by the war if, when public ana
State ceremonials call for military escorts and processions,
the soldier appeared in full dress uniform we are not so sore
as our correspondent. Probably there are plenty of uniforms
stored away which oould become available at short notioe,
so that the authorities could comply with the suggestion
without much public expense, but we are not convinced of
the utility of doing so. With regard to military displays,
and it is to these that our correspondent specially refers, it
should be remembered that for the men taking part in them
full dress uniform is not the most comfortable in which to
remain often for long hours and perhaps with inadequate
opportunities for food.
THE LANCET, January 18 , 1919 .
®j}t femination
or THE
VERMIFORM APPENDIX BY X RAYS.
By E. I. SPRIGGS, M.D. Lond., F.R.C.P. Lond.,
SENIOR PHYSICIAN, DUFF HOUSE.
With Photographs and Drawings h
O. A. MARXER,
RADIOGRAPHER, DUFF HOUSE.
I.—Introduction and History.
In examinations of the human alimentary tract by means
of a meal opaque to the X rays, the appearance of. the
vermiform appendix on the fluorescent screen or photo¬
graphic plate has been until lately infrequent and uncertain.
Although there is already a large literature of the radiology
of the alimentary tract, references to the appendix are, as
would be expected, scanty.
B6cl£re, in 1909, showed a radiogram of the appendix,
which had been taken at the end of 1906, with a five minutes’
exposure. In 1910 Liertz, and in 1911 H. D. Reid, reported a
similar observation. In 1911 GrigoriefT communicated to a
congress of physicians in Moscow that he had seen the
appendix fill with opaque material, move, and empty itself;
ana stated that with suitable methods it would fill in all
oases in which its lumen was in free communication with the
caecum. M. Cohn, who reported observations of his own in
1913, and from whose paper we quote the Moscow communi-
tion, thought that Grigorieff’s powers of vision were uncanny;
bnt the description given was accurate enough, and can now
be<conflrmed daily. In the same year (1911) A. C. Jordan had
observed that a little bismuth entered the appendix in a good
many cases.
In^ 1913 the work of J. T. Case called the attention of
A. W. George and I. Gerber to the appendix. These workers,
using an opaque meal of barium sulphate suspended in
buttermilk, claimed that the appendix could be seen in
70 per cent, of the patients examined, and published photo¬
graphs. In 1914 A. F. Hurst expressed the opinion that the
appendix was visible on the screen, more or less, in half the
cases examined, recording two cases of diseased appendices
which had been recognised with the X rays, and Rieder
advocated a more thorough examination of the appendix.
Case (1914) saw the appendix in one-third of a series of 763
cases and published good photographs, but at that time it was
thought probable that the appendix was or had been diseased
if the contents of the csecnm were seen within it. In 1915,
Imboden published 17 photographs of which 7 were probably
normal, and expressed the opinion that the demonstration
of the appendix was no evidence of disease; and in the
same year George, writing this time with Leonard, published
good photographs of diseased appendices. Quimby (1913)
and Eisen (1915) have also published instructive papers with
photographs. Carman and Miller, of the Mayo Clinic, show
a few photographs of appendices in their recent excellent
work. They speak doubtfully, however, of the value of
direct X ray examination of the appendix.
-George and Leonard, claimed that with a meal of 90 g.
of bismuth, or equivalent of barium sulphate, and one pint
of buttermilk the appendix, whether healthy or diseased,
unless its lumen be obliterated, can be demonstrated in
every instance. Such a claim cannot, of coarse, be made
good, as, short of operation, there is no control means of
knowing whether the lumen is obliterated or not. Oar
observations in the last two and a half ysars nevertheless
enable us to support the view that the opaque meal they use,
of barium sulphate and buttermilk, is of great value in the
X ray examination of the appendix. With a meal of bread
and milk, or porridge, and bismuth oxychloride or barium
sulphate, the appendix was often looked for bat seldom seen.
With buttermilk and barium we now see it in the majority
of cases.
II.— Method.
We use a rather smaller meal than George and Leonard.
In all oases we have given the same quantity of bufcfcer-
mtlk, 3/4 of a pint (425 c.cm.). The amount of barium is
vairied according to the build of the subject. With a thick
body 150 g. is stirred in ; with thinner folk less is used. The
meal is not so viscid as a standard meal of bread and milk,
and bolds the barium in suspension better than milk alone.
George and Leonard state that cereal mixtures do not readily
enter the appendix. Perhaps the absence of milk fat in
tfielr meal is also an advantage, or the acidity. The taste of
the buttermilk is unpleasant to some, but now that it is
No. 4577
clear that the appendix can be demonstrated more palatable
mixtures will be sought, and probably found. As regards
the examination of the rest of the alimentary oanal, we have
not found any disadvantage in the use of the buttermilk
mixture, but the reverse. For oesophageal lesions a more
solid meal would naturally be given. The normal rate of
passage of the buttermilk meal through the body is about
12 to 24 hours less than that of a meal of porridge and
barium.
An opaque enema has not proved, either in the experience
of others or ourselves, to fill the appendix so often as an
opaque meal.
We found over three years ago that the appendix is more
frequently seen when the bowel has been emptied by castor'
oil given 36 hours before the opaque meal.
The manner of examination is, of coarse, of great import¬
ance, as well as the kind of meal and the previous emptying
of the bowel, for a careful search and suitable manipulation
will often reveal the appendix when it would otherwise have
been missed. We would lay stress on the following points ;—
1., Careful screening with manipulation is needed to
And the appendix, also to observe its mobility and the
presence or absence of active movements or of tenderness,
that is, pain on direct pressure.
2. Photographs must be taken in all cases: we take fre¬
quently half a dozen or more of the same appendix. The
chief features which help a decision as to whether the
appendix is healthy or diseased can only be observed
adequately on the photographic plates. These features are
—the Ailing and emptying of the appendix, its position and
its outline.
3. The best views are obtained as a rule when the patient
is lying down, usually supine ; occasionally the semi-lateral
position is required, rarely the prone.
4. The gloved hand is used at first in ascertaining the lie
of the parts; for the final movements, the wooden spoon
is used because it is not opaque to the rays and a plate can
be exposed so soon as the appendix is brought into the field.
5. The ileum and ceeoum are drawn aside carefully in
different positions so as to get a view of the whole
appendix whenever possible. A better contrast is obtained
if the appendix can be moved over a part of the bowel
which contains air before the photograph is taken.
6. When the cmcum lies in the pelvis the appendix can
often be shown, but, generally speaking, its mobility
cannot be tested. It is possible, however, in most oases
to move the crecum into the iliac fossa by the following
procedure. The patient lies on the right side and takes
half a dozen deep breaths, then turns semi-prone on the
right, still breathing fully; he then moves on to his
book and the abdomen is stroked deeply from the sym¬
physis pubis to the right iliac crest. Another means of
moving the csecum out of the pelvis is to distend the
rectum with air, the patient lying on the right side; we
have used this method, but have generally found it
unnecessary.
7. If the appendix lie behind the csscum it can often be
shown by taking an oblique view or by moving the csecum
to on3 side.
8. It is an advantage if the end of' the ileum and the
appendix can be Bhown filled at the same time. Should
there be opaque material in the ileum, but not in the
terminal part, it will often be moved on into the terminal
part if a drink of hot water be given, provided there is no
obstruction to prevent the hot water leaving the pylorus.
The patient should turn on to the right side.
9. When there is pain, tenderness, or inflammation
movements and manipulations must not be made, or
only made with great care.
10. A 2 l mm. aluminium screen is interposed for both
screening and plate exposures, using a Coolidge tube.
11. In doubtful cases where the appendix fills in part
only, or empties before it has completely filled, a suc¬
cession of buttermilk meals at breakfast, lunch, and tea-
time may fill it. The usual amount of barinm is divided
between the three meals.
The value of (i.) the special meal and (ii.) practice Is
illustrated by the following experience. The first 100 cases
in which we observed the passage of an opaque meal
through the alimentary canal are left out of account, as the
ileo-cssoal region was not examined with such care as is now
given it. In the next 200 cases we saw the appendix
clearly in a few. Many of these were prepared with castor
oil. We then began to use the barium and buttermilk meal
after preparation by castor oil. In the next 100 cases the
appendix was seen 24 times, in the following 100 cases
25 times, then 54 times, then 72 times, and in the last, and
eighth, 100 cases 86 times.
Observations .—Wo have now photographs ot about 300
appendices, seen in the whole or a part of their length. In
c
92 »The Lancet,] DR. K. I. SPRIGGS : EXAMINATION OF VERMIFORM APPENDIX BY X BAYS. [Jan. 18, 1919
many no evidence of disease was found in the appendix or
in its neighbourhood; it was in such that the observations
described in Section III. below were made. Others were
diseased or in close relationship to diseased organs; these
are described in Section IV.
III.—The Normal Appendix.
* Previous observers, especially George and Gerber, George
and Leonard, and Case, have noted that in health the
shadow may vary in width from £ inch down to a thread
(Figs. 1, 6, 9, II, and 12) or a row of dots (Fig. 3); that
the lumen may be seen to fill and empty several times, espe¬
cially in young people; and that it empties finally at the
same time as the caecum. George and Leonard state that
it is best seen in the plates taken at 6 hours and at 24 hours
after the ingestion of the meal.
As the appendix is often diseased, care is needed before it
can be concluded that the appearances seen are not patho¬
logical. Clear evidence must be obtained of natural posi¬
tion, mobility, and outline of the appendix and surrounding
parts ; of a natural rate of filling and emptying of the ileum
and caecum ; of the absence of tenderness to direct pressure;
and of pain or any symptom suggestive of appendical disease.
The mobility of the appendix, so far as it is not limited
by its short mesentery, and the absence of tenderness on
pressure, cannot usually be determined when the caecum lies
in the pelvis, unless it is, as above mentioned, manoeuvred
into the iliac fossa. The distal part of the appendix should
be movable within the limits of its attachments, and the
whole should move freely with the caecum. The outline of the
healthy appendix should show no constant irregularities.
According to our observations the appendix begins to fill
soon after material has entered the caecum—that is. about
3 to 4 hours after the meal has been taken. It may fill in a
few minutes from end to end. Frequently, however, the
filling is quite Blow and is not observed in process; also it
may not take place for some hours after the caecum and
asoending colon are filled. In some oaseB, with rapid filling,
the material entering appears of the same breadth through¬
out (Figs. 10,11, and 12), as if it were foroed in by higher
pressure in the cmcum, and occasionally material may be
seen to pass along the lumen when the caecum is pressed
gently. In others temporary constrictions can be seen.
(Figs. 2, 5, and 8.) We have not actually seen a wave of con¬
striction passing isolated pieces of opaque material from the
base towards the apex of the normal appendix, but we have
seen material lying loosely in the middle occupy the tip
three seconds later, its tail showing a tapered appearance,
apparently as a result of a contraction of the appendix, the
basal part near the caecum remaining tightly constricted.
In some pathological oases, with over-aotivity, a definite
wave can he seen to propel material from base to apex of
the appendix. In Buch we have observed a block of material
moving towards the apex, showing a round head towards
the tip and tailed off towards the base where the wave of
constriction was grasping it.
Sometimes the appendix can be seen to fill and empty
repeatedly during a single screening within a few seconds.
This has been most definite in young people; for example,
inr two subjeots aged 16 and 9 respectively (Fig. 6 was taken
from one of them). Or it may fill and empty at a slower
rate several times in the course of a few hours.
The width of the lumen varies considerably in different
appendices and in the same individual; it is usually fully
relaxed after fresh material has entered, and becomes con¬
stricted later. (See Figs. 31 and 32 taken at an interval of
20 seconds). It bears no proportion to the size of the csecum
and ascending colon. It is usually narrowest at the base
—i.e., near the csecum. (Figs. 6 and 8.)
The time at which the best view is obtained is usually
about 12 to 14 hours after the opaque meal, but there is muon
variation in this respect.
The appendix oommonly remains filled until the ccecum
is dear, when its contents are discharged. The density of
the appendical shadow lessens as the ccecum empties
(Fig. 10). In some cases in which there is no evidence of
disease the contents remain longer—e.g., until the ascending
colon is clear. If there is further delay we regard the
appendix as Bluggish. The appendix empties itself by waves
or oontraotion which we have seen pass from .the tip to the
base, propelling material into the caecum. It may empty
while the ceBCum is still filled.
In some cases the tip can be seen to wave about actively
with a serpent-like motion (Figs. 7 and 8), presumably from
contractions of its wall, or from the passing in of material
from the caecum. Such movement of the middle part has
also been observed repeatedly at the same time as food was
passing from the ileum into the caecum.
It has been stated that the appendix tends to become
gradually obliterated with age. This is not, however, a
necessary accompaniment of advancing years, for in one of
our subjects, aged 74 years, in whom the alimentary canal
appeared to be healthy in all respeots, the diameter of the
shadow was greater than that in many young people.
(Fig. 10.)
In one patient, in whom the appendix was found healthy,
on re-examination 18 months afterwards two pellets of shot
were seen within it and could be moved about (Figs. 11 and 12J
They gave rise to no symptoms, but the appendix emptied
itself more slowly than before, containing some barium
24 hours longer than the crocum. The abdomen was
screened weekly and three weeks later the pellets had gone.
A similar occurrence was recorded by G* H. Orton in 1907,
but the appearances were not so distinct, the nature of the
foreign bodies casting the shadow being discovered at an ■
operation. The appendix appeared healthy.
IV.— The Diseased Appendix.
In most cases of acute appendicitis the patient is not fit
to be X rayed ; neither is such a method of diagnosis needed.
In the diagnosis of chronic appendicitis we have found
direct X ray examination of the appendix of great value,
not only in cases in which suspicion had been cast upon
that organ, bat especially in the subjects of vague abdo¬
minal symptoms of unknown cause ; in many such it has
been possible either to demonstrate a normal appendix or to
show that it was or had been the seat of disease.
The direct observation of the appendix is only a smalt
part of the complete examination of the alimentary traot,
and in many cases in which a suspected appendix has been
found normal an explanation of the symptoms is furnished
by lesions or disorders discovered elsewhere in the course of
the examination. Every part of the stomach and bowel
must, of course, be observed carefully. Further, it must be
emphasised that all such methods of investigation are
supplementary to a thorough olioical inquiry. Indispensable ■
as the laboratory is for the medicine of to-day, it can never
replace accurate and exhaustive examination at the bedside.
We have not been situated especially favourably for the
observation of cases of chronic appendicitis, as Duff House
is for medical cases, and no patient is sent there who is
known to be the subject of that complaint. Our cases are
therefore of two classes: (1) those in whom the symptoms
of chronic appendicitis have not been definite; and (2) patients
sent by doctors in the neighbourhood. The latter class
is small in numbers, but has the advantage that one of us
has frequently been able to be present at the subsequent
operation.
In 36 cases we have details of operative findings, and upon
these this section is mainly founded. A summary of each
is given. Our opinions and conclusions are founded also
upon the examination of otheroases. We have in all, as
stated in Section II., photographs of 300 appendioes with a
clinical history of each patient.
It is sometimes possible to make a diagnosis of chronic
appendicitis from X ray findings in the ileo-caeca! region
other than direct observations of the appendix. Such
findings as adhesions of parts, ileal stasis, insufficiency of
the ileo-caecal valve, and spasticity of the colon have been
put forward as affording contributory, evidence of appendi¬
citis. Adhesions about the appendical region are, of course,
suggestive of former inflammation. Ileal stasis is an
uncertain guide.* It was present in 21 out of 35 oases
operated upon ; also in cases in which the appendix had been
removed. Eisen states that ileal stasis and regurgitation are
as frequent in normal cases as in those of appendicitis. To
insufficiency of the ileo-csecal valve and spasticity of the
colon we do not attach importance in this connexion.
Examination of the appendix itself with the buttermilk
meal gives more valuable information in most cases than
can be derived from observations on surrounding parts made
with those opaque meals which enter the appendix less
often.
In the direct examination of the appendix the points to
which attention must be paid are : (1) the filling or empty¬
ing of the appendix—delay or stasis ; (2) shape—cons trie-
* Ileal stasis has been slid to be present If the terminal Ileum is not
empty nine hours after the opaque meal. Such a definition can only
apply If the stomach is empty in a normal time, for the ileum oannot
discharge Its oontents promptly unless It receives them promptly from
the stomach. This fact has sometimes been overlooked and ileal stasis
has even been depicted in the literature by a photograph in which
opaque material can still be seen In the stomach. As a working .
definition we speak of ileal stasis or delay if the terminal ileum
contains opaque material more than four nours after the stomach.,
Is empty. f*'
TBS Lanobt,] DB. B. I. SPRIGGS: EXAMINATION OF VRRM1FORM APPENDIX BY X RAYS. [Jan. 18, 1919 93
tion aad dilatation ; (3) faecal concretions—vacuoles;
(4) mobility ; (5) hyperactivity—spasm ; (6) tenderness ;
(7) position. These features are placed in the order of their
value in a series of cases. In individuals any one feature
may be of chief importance.
1. The Filling and Emptying: Delay or Stasis.
The appendix may not admit any barium, or not enough to
cast a shadow, either because it already contains inopaque
material or because it is obstructed or obliterated. The first
is but seldom the case when the bowel has been purged with
castor oil. Constriction near the base or obliteration will, of
course, account for some of the cases in which the appendix
is not seen. (Cases 29 and 30.) The fact that with increasing
practice more and more appendices are visible shows that
an impervious lumen is much less common than was thought.
But we do not think it justifiable in the present state of our
knowledge to conclude that an appendix is abnormal because
it does not fill; though we should naturally regard it with
suspicion, as it is unusual to fail to demonstrate the appendix
in a person thought to be normal, especially if a second
examination be made with three small buttermilk and barium
meals, as described above.
Most frequently in chronic appendicitis the appendix fills
in part (Figs. 13, 16, and 18), the passage of barium into the
distal part being blocked, sometimes by obliteration (Fig. 20
and coloured drawing, Case 8), or constriction or kinking
(Fig. 17). but generally by stagnant inopaque material
(Figs. 13, 16, and 18) which the appendix has been unable to
expel owing to limitation of movement by inflammation or
its results. Sometimes the barium mixes with this material,
forming a fainter shadow.
Such interference with the muscular activity of the
appendix wall also prevents the punctual discharge of the
barium which has entered, so that instead of the appendix
emptying at about the same time as the caecum it retains its
contents 12, 24, or more hours longer. We have seen barium
remaining for 26 days, and it has been known to remain for
several weeks. Sometimes a blob of material also remains
in the adjoining part of the cteoum. whioh forms a sort of
antechamber to the appendix.
In cases of moderate appendical stasis without any other
abnormal feature such as irregularity of outline, uneven filling,
immobility or tenderness, we have not recommended excision;
though an appendix showing prolonged stasis is one in which
faecal concretions would be likely to form. If the shadow
is very fine and the appendix rigid there is probably a fibrous
atrophy.
2. Shape ; Constrictions and Dilatations.
Irregularity in the outline of the shadow, is, next to
uneven filling, the commonest sign of diseased appendix.
Care must be taken, by repeating the photographs, to see
that the irregularities are persistent and are not due to
normal waves of contraction. Many forms of dilatation and
constriction are illustrated in Figs. 13, 17, 19, 21, and 22,
and in the coloured illustrations.
3. Fatal Concretions; Vacuoles.
Concretions of long-standing become infiltrated with lime
salts and cast a shadow which may be seen independently
of an opaque meal (Fig. 14). Such a shadow may be con¬
founded with calculi in the urinary tract. It is usually a
symmetrical oval which may help to distinguish it from the
shadows of calcareous glands and phleboliths. The lumen
proximal to an. old concretion is often bent into a sharp
hook ; indeed, a hook-shaped end to the appendical shadow,
as in Figs. 14, 18, and 22, should suggest the possibility of
a concretion.
More recent concretions, which cast no shadows of their
own, may block entirely the passage of barium, in which
case they cannot be recognised, though they may be suspected
in appendices of irregular outline which fill in part only and
show a hook. In Figs. 16 and 18, for example, such con¬
cretions lay in the distal part of the appendix which did not
show in the photographs. In many cases the barium passes
round a soft concretion, which then gives the appearance of
a vacuole (Figs. 13, 17, and 18). There may be more than
one of these abrupt or gradual widenings of the lumen, which
are constant in different photographs, alternating with narrow
places. In other cases the barium extends around the
proximal part only of the ooncretion, giving a V* or cup¬
shaped shadow as in Fig. 13.
4. Mobility.
If the appendix cannot be moved about within the limits
of its attachments adhesions are suspected, but if the csecum
and appendix lie in the pelvis this sign cannot, as a rule, be
established unless they can be brought into the iliac fossa.
Adhesion of th§ appendix to other parts of the digestive
tube can often be shown by manipulation, the adherent parts
moving together. Thus the appendix shown in Fig. 23
(Case 12) oould not be moved away from the cmcum. It is
most often adherent to the iliac fossa, the ileum, the
caBCum, or in the pelvis. In Case 2 (Fig. 14) the ragged
outline of the ascending colon where the appendix appeared
fixed confirmed the suspicion. The appendix may fill with
barium, even when it is bound down for the whole of its
length, as in Case 17 (Fig. 26), where inflammatory mem¬
branes covered the appendix and caecum and constricted
the ileum.
Sharp kinks must be noted carefully, but it is important to
take several photographs, for what appears to be a kink in
one may prove to be a rounded curve when viewed from
another aspect. (See Case 15, Figs. 27 and 28.)
5. Hyperactivity: Spasm.
The normal filling and emptying movements of the
appendix, which in the young are, like the mass move¬
ments of the colon, often vigorous and rapid, may be
aggravated in older people by acute and subacute inflam¬
mation in those parts of the appendix in which gross changes
have not taken place. In chronically inflamed appendices
containing a fixed faecal mass offering resistance to free
progress we have observed vigorous waves travelling from the
caecum towards the tip (Fig. 30), but not in the reverse
direction, even when barium lay distal to the obstruction.
Such hyperactivity was observed in Cases 1 and 14. Figs. 16
and 30 are photographs of appendices during contractions.
The drawing here
shown was made from
an inflamed appendix
which showed vigorous
contractions apex-
wards proximal to an
obstruction.
Such pathological
hyperactivity differs
from the normal acti¬
vity in that it is often
continuous for hours
during the filling
period ; we have even
seen it still going on
at 24 and 36 hours.
Whereas the normal
movements are only seen, through the good luck, so to
speak, of happening to observe the appendix at the right
moment. The block of material in the normal appendix
also shows as a rule a symmetrical tapering each end,
which can be seen in Figs. 2 and 5.
Another characteristic appearance of the inflamed appendix
is that of spasm. A particular part remains constricted for
a considerable time, the blocks of opaque material being cut
off abruptly (Figs. 15, 25, and 33), whereas when they are
being moved on by waves of contraction they have tailed or
rounded ends (Figs. 16 and 30). Slight or varying dilatation
of the lumen is nearly always present also. When oon-
cretions are present there is generally no spasm. A veiy
small lesion may cause spasm and impair the rate of
emptying. In one case there was spasm at a place where a
spray of purple spots in a mucous crevice was afterwards
found, f
6. Tenderness.
Tenderness or pain on direct pressure over the appendix
shadow may be a valuable and unequivocal sign of inflamma¬
tion. * An enlarged part of an appendix is frequently, though
by no means always, painful on direct pressure. But, taken
alone, tenderness is of less uniform significance than might be
expected. It is not safe to make a diagnosis of appendicitis
from tenderness in the absence of the more important
signs above mentioned. If direct though gentle pressure is
made upon the base of the appendix pain is often felt,
t In order to avoid confusion between It llammation and tranma the
surgeon should take the mesenteric tissue Into the for cepe duping
removal, and not the appendix itself.
C, (tecum, o. Obstruction, p. Trail of
preceding wave of oonstrlction. wave.
Abrupt and complete obliteration of
the lumen by wave of constriction
starting at the vestibule propelling block
of material before It.
94 Thb Lancet,] DR. E. I. SPRIGGS : EXAMINATION OF VERMIFORM APPENDIX BT X RAYS. [Jan. 18, 1919
Details of 36 Cases in which the Radiographic and Operative Findings have been Compared.;
and Index to Figures of Diseased Appendices.
Clinical summary.
X ray.
Operation.
1 Male, aged 20; bad suffered for years
(554) | from Intermittent pyrexia, constipa¬
tion, diarrhoea, and abdominal pain.
Pyrexia had been ascribed to phthisis,
evidence of which years before;
appendix had not been suspected.
2 I Male, 36. Flatulence, heartburn,
(686) wasting, weakness. 6 years’ history;
worse last 2£ years. Had been
X rayed repeatedly; treated for
dilated stomach; advised to have
large Intestine removed. Appendix
not suspected.
Fig. IS.— 9 hours after opaque meal. Appendix lies horizon¬
tally, across irregular shadows from Ileum, tip near umbi¬
licus. Proximal part filled and showed vigorous contrac¬
tions. Shadow beyond formed dilatation with irregular
cupped or V appearance, due to barium reaching round
sides of a faecal mass * This part and base were tender. An :
hour later proximal part was contracted. At 24 hours all
material except a coating had passed from bowel, but not |
from appendix. At 48 hours still barium in appendix and |
in adjoining part of ctecum. (See also Fig. 13 a.)
Two inflamed enlargements of ap¬
pendix. (See coloured drawing I.)
Barium bad reached to firBt one;
acute bend beyond and large bulbous
end not shown on plate. First
enlargement contained soft solid
matter, terminal one hard faecal mass.
No appearances of tuberculosis In
appendix or surrounding peritoneum.
3
( 616 )
4
( 668 )
6
‘( 604 )
Female, 32. Pain In umbilical region
on much exertion; easily tired:
bowels irregular. X ray evidenoe of
former phthisis. Appendix had not
been suspected. .
Female, 31. Fl&tulenoe. headaches,
bad taste ; several years’ history
Female, 13. Repeated attacks of
severe pain in right lilac fossa.
Pia. JL .—8 hours after opaque meal. Caecum lies In
pelvis. 8hadow of material in caecum and ascending
colon is Interrupted at brim of pelvis. Appendix lay
upwards, partly behind ascending colon. Proximal part
appears natural. Distal part was large till near end,
where narrow curved constriction can be seen, ending at
oval concretion ; this could not be moved from ascending
oolon, which had here ragged outline, ascribed to
adhesions. (See explanatory diagram.)
Pig. 15 .—13 hoars after opaque meal. Appendix lay
upwards behind csecum; It appeared large and somewhat
Irregular, and showed spasm at all stages. Tip did not
fill.
Fig. 16.— 10 hours after opaque meal. Shadow shown
spreading out into dilatation of appendix. Opaque
material not seen beyond Inflamed area. At 24 hours
caecum lay in the pelvis. Appendix is still Irregularly
filled. It lay upwards; tip bent and could not be moved
about; except that the proximal part could be moved as a
whole with caecum, lo same position at 10, 24, and 36
hours; was tender. No ileal stasis.
Position as shown In photograph.
Complete narrow mesentery, loop
seen being due to shortening at one
part. Appendix somewhat dilated
beyond bend,; after dilatation there was
fibrous constriction and large ooncre*
i tlon beyond. Wall enclosing ooncre*
' tlon adherent to ascending colon. (See
I coloured drawing 11. Drawing is less
than natural size.)
Middle of appendix enlarged, blue and
inflamed, tip fibrous. (See ooloured
drawing III.)
Appendix narrowed near base and
bent and anchored by short mesentery.
Beyond this dilated and congested.
(See coloured drawing IV.)
Male, 44. Indigestion on and off over
25 yewrs. 24 years ago short attack
abdominal pain and pyrexia; may have
been appendical. On active service
In Fraioe 3 years. Ineluding retreat.
Forse last few months. Hyperacidity.
Male, 45. Symptoms of hyperacid
Indigestion for years.
9
< 713 )
10
11
<« 6 )
12
<788)
13
*4
15
/ 64. Ten years’history of hyper-
acid type of indigestion, flatulence,
and distension In right lilac fossa
three boars after food.
Male, 38. Occasional attacks of indi¬
gestion for over 20 yean. Hyper¬
acidity.
Female. 16. Pain after food; much
worse at periods.
Female, 25. Attack of abdominal pain,
tiredness, and anorexia six weeks
before, succeeded as it passed off by
pricking pain in right iliac fossa.
Female, 36. Occasional attacks of
epigastric discomfort, with vomiting,
for yean. Three days before admission i
more severe gnawing ache, pyrexia, -
rapid pulse, and furred tongue, j
Tenderness to right of umbilicus.
Male, 25. Pain and tenderness in
right illao fossa. Had vomited twice.
Fig 17.— 38 hours after opaque meal. Appendix filled lm*
perfectly; kinked, irregular In outline, bulbous tip, tender.
Middle part gave faint diffuse shadow such as Is seen when
opaque material mixes with inopaque. Cecum filled
Irregularly j Mo definite notches at any stage; ileal
terminal was not seen evenly filled. No Ileal stasis. (See
| explanatory diagram.)
| Fig. /A—>36 hours after opaque meal, Cecum lay In
i usual position of hepatic flexure. '’Ascending” colon
J descended from it in front; then turned to left to become
transverse oolon. Appendix did not fill well; seen above
osecum curled upwards and to right, Bulbous; had hook
appearance often seen proximal to concretion. Much
delay, material still In appendix at 140 hours. Rest of
bowel clear at 72 hours. Kinking of lletrft* with stasis.
Pig. 19. - 8 hours after opaque meal. Outline of appendix
irregular. X ray evidence of duodenal lesion. No Ileal
stasis. (8ee also Fig. 19 x.)
Fig. *>.—24 hours after opaque meal. Appendix tffln
filled Imperfectly at all stages} emptying much delayed.
Terminal ileum anchored to lilac fossa; great delay iff
ileum.
Proximal part of appendix much dilated, A little diffuse
barium seen te enter distal part 4 hours earlier does not
now show; it appeared packed with stationary faecal matter.
Material delayed fadilated proximal part of appendix and
adjoining part of e%cum after rest of bowel was empty.
Also X ray evidence of lesion of duodenal cap.
Pig. 31.—10 hours after opaque met), I regular btftboua
appendix; delayed emptying; no tenueruess; Heal
A pericecal &6flibfth6. Appfihdtk
( enlarged, kinked, inflamed; ooncre-
i Mans at end, one solid, (See eoloored
, drawing V.)
14. Two mild attacks of
appendicitis. Headaches.
Female, 37. Had had dysentery,
Sought adrloe for loss of flesh and
appetite. Mild Indigestion.
Fig. 22.— 2A hours after Opaque meal. Appendix
has irregular outline, proximal pant much the
larger at all stages. Hooked appearance associated with
concretion shown. No tenderness. Ileal stasis.
•
Fig. 2:(.-6 hours after opaque meal. Appendix filled
unevenly ; Irregular outline, constriction. FroxVmal part
not mobile: tender. Appearance constant. Terminal
ileum on right of picture; ileal stasis. Pig. j/„—At 36
hours. Stenosis at junction of middle and proximal
third. Distal part now filled better; Irregular outline;
spasm near end. Dropped transverse colon lies to right
of picture.
Fig. 25.— 14 hours after opaque meal. Appendix showed
Irregular outline, spasm, and tenderness-. No ileal stasis.
Fig. 20.-10 hours after opaque meal. Appendix showed
Irregular outline, contracted vigorously; was tender.
End of appendical shadow seen spreading. Heal ter¬
minal appeared Incapable of normal dilatation at all
stages; much stasis.
Fig. 27.-8 hours after opaque meal. Appendix* showed
oonstrlctlon. constant, near base. Terminal part seen to
oontaln Inopaque material. Some Heal steals. Fttj. 3&\—
At 81 hours. Shadow* of appendix shows that what
appeared kink In Fig. 27 is rounded curve. Sharp bend
in asoendlng colon, which is fastened to transverse colon;
Irregular segmentation in both. Calcareous glands seen:
Cwcum and (Ufifihdlng oolon (tftf MSh
a mesentery. Crttoom lay high in loin,
ascending colon depending from It In
front. Appendix long, congested,
bulbons. and contained con cr etions,
(See ooloured drawing VI.)
Appendix bulbous, adherent, con¬
tained concretions. (See ooloured
drawing VII.) Ulceration or doatrlsa-
tion of duodenum.
Tip of appendix fibroua* (8ee coloured
drawing vIII.) Lane’s kink in Ileum.
I Appendix bound down; constriction
i near middle. Also a hard scar in first
part pf duodenum.
AnffeAVfrt Signs of recent inflam-
mSK-e % thickened mucous lining
andinJfehteS* ibperltoneal vessels.
Whole appendh *
eoncretloAfe:
thickened; three
Operation 7 fc ter * Appendix
partlallv bound Bo* V hlS
and kraked; btilbocm ^2'
appearance of gilbsMtog. Inflammation.
Very long appehdlx. TWfrpw c
inflammation of m deoils memfct. *****
Appendix had been lbflemed,
atricted by band; wfcfc narrowed L „
base, dilated at middle part. Hu
bound down.
Appendix showed constriction: Large
bowel bent and adherent as* described*
Calcareous glands were removed:
* The appearance was not altered by gentle pressure, as Is sometimes possible when blockage Is due to soft matter or bubble.
The Lancet,] DR. E. I. SPRIGGS : EXAMINATION OF VERMIFORM APPENDIX BY X RAYS. [Jan. 18,1919 95
Details op 36 Cases in which the Radiographic and Operative Findings have been Compared;
and Index to Figures of Diseased Appendices—( Continued ).
Case.
Clinical summary.
X ray.
Operation.
16
<276)
Male, 45. Patient X-rayed 18 months
before. Meal of porridge, milk, and
barium. Appendix not seen.
Long curled appendix seen lying external to cecum.
Ileal stasis.
Operation a year later; appendix
found as described. Calcareous gland
in its mesentery dose to appendix
wall, causing bend in proximal part;
vessels In this region somewhat, in¬
jected.
17
Male, 30. Acute appendicitis 12 years
ago; appendioeetomyrefused. Milder
attacks followed ; increasing constipa¬
tion ; frequent distension after food.
Condition becoming grave.
Fig. 26.— 10 hours after opaque meal. Appendix retro
cecal and fixed, but position could be made out and Is
shown in explanatory diagram. Whole region tender.
Terminal ileum constricted; enormous dilatation of
Ileum behind constriction; marked stasis.
Terminal ileum, caecum, and appendix
were wrapped tightly in Inflammatory
tlaane thought to have arisen from
disease of appendix. Ileostomy was
done aa temporary measure, but issue
was fatal.
18
<686)
Mala, 50. Patient sought admission
for severe pain. Hyperacidity; Xray
evidence of lesion about pyloric
region.
Appendix showed two constant narrowings and hooked
appearanoe ; material remained In It at 72 hours, c«cum
having discharged its contents. Ileal stasis.
Pylorus adherent to gall-bladder and
liver. Appendix contained two hard¬
ened masses of faeces, one fixed and
one movable.
19
<619)
Discomfort after food 4 months.
Hvperacidlty. Symptoms improved
with treatment. 8ix weeks later pain
and tenderness in right iliac fossa for
24 hours with pyrexia.
Appendix kinked at middle where outline was Irregular;
It appeared fixed, though moving freely with caecum.
Tip did not empty Its contents for over 12 hours after
caecum. No Heal stasis.
Appendix inflamed.
20
Male. 60. 15 years' history of exces¬
sive flatnlence after food.
Proximal part of appendix was kinked and irregular In
outline. Much Ileal stasis.
At operation appendix adherent to
ileum and kinked. Jackson's mem¬
brane and Lane’s kink.
21
Female, 12. Periodic billons attaoks.
Appendix showed persistent bulbous appearance; con¬
striction beyond. No tenderness. No Heal stasis.
Showed dilatation and oonstriction.
22
Female. 22. Nutrition poor; occasional
bilious attacks; vomiting; no pain.
Base only of appendix seen. Ileal stasis.
All appendix except first Inch bound
down. A Lane’s band.
23
Male, 38. Symptoms suggested
duodenal uloeratlon.
|
Appendix appears fixed along Inner border of caecum.
X ray evidence of duodenal ulcer.
Duodenal ulcer. Appendix adherent
as described, and extended about half¬
way up ascending colon. Otherwise it
appeared healthy inside and out.
24
Male, 12. Recurrent attacks of
vomiting; a little pain.
Caecum lay nnder ribs. Appendix appeared kinked. It
oontalned chiefly air, could not be displaced; was tender.
No ileal stasis. •
Appendix lay as described. It was
kinked by band of adhesions and had
been inflamed.
25
Male. 65. Long-standing pain in*right
side of abdomen and oonstipatlon.
Appendix retrocsecal and fixed; otherwise appeared
normal. Ileal stasis.
Appendix adherent behind caecum.
Jackson's membrane.
26
Female, 27. Indigestion, oonstipatlon,
and anaemia. Had been treated as
case of gastric ulcer.
Appendix lay behind caecum. Ileal terminal filled Irregu¬
larly ; much delay therein.
Retrocecal appendix adherent to ter¬
minal ileum. Stomach normal.
27
FCmale, 42. Symptoms of duodenal
uloeratlon.
Appendix filled In part only; not tender. X ray evldenoe
of duodenal lesion. No Heal stasis.
Duodenal uloey. Appendix had been
Inflamed and was kinked.
28
Female, 28. Pain in right side of
abdomen near ribs, going round to back.
Very little opaque material passed into appendix. Some
Ileal stasis.
There were adhesions between appen¬
dix and terminal ileum.
29
Male, 10. Not thriving; occasional
billons attacks; vomiting. No pain.
Appendix not seen. Ileal stasis.
Appendix kinked and not patent.
30
Male, 50. Symptoms of duodenal
uloeratlon.
No barium seen in appendix. No ileal stasis.
Duodenal ulcer. Appendix was repre¬
sented by fibrous cord.
31
Female, 18. Intermittent pain In
right side radiating to back, never
acute; constipation and poor appe¬
tite. Tender spot on palpation.
Appendix showed Irregular bulbous outline; was tender.
Ileal stasis.
[ *
Appendix dilated in places; had been
inflamed.
32
Male, 42. Pain to right of umbilicus
relieved by emptying bowel. Con¬
stipation. Had had appendicitis 17
yean before. Dilated ascending colon.
Only first part of appendix filled; this was tender on .
pressure.
Old and recent adhesions about
appendix which was patent for
about an inch. Distal part oblite¬
rated.
33
Female, 16. Recurring abdominal
discomfort with Indigestion. Six
weeks ago pain in right iliac fossa
and rise of temperature.
Proximal part of appendix Irregular; spasm seen beyond.
Distal part kinked. Material remained in appendix for
20 days.
Appendix loosely anohored to brim of
pelvis. Distal part kinked; oontalned
concretions.
34
Male, 19. Indigestion several yean;
periodic attacks of pain in abdomen,
especially to right. Bouts of diarrhoea
and constipation.
Appendix lay behind caeonm, filled Irregularly, and
appeared rigid.
Appendix lay behind caecum and
showed irregular narrowings.
35
<823)
Female, 37. Ten yean’ history of
epigastric pain two houn after food,
flatulence, and constipation. Reoentty
nausea, salivation, and retching after
exertion. Gastric juice hyperacid.
Proximal part of appendix dilated, with narrowing
beyond; narrow portion appeared fixed and kinked.
Tip reached to middle of spine. Crater of gastric ulcer
mmu on lesser curvature, and arrest of peristalsis.
Appendix long, kinked, and contained
large concretion at distal end. Gastric
nicer on lesser curvature ofastomaoh.
36
Female, 26. Periods of diarrhoea since
childhood. In last five years flatu¬
lence, heartburn, general discomfort,
irritability, and depression. Mucus
in stools at times.
Appendix mnoh dilated; spasm at one point, with small
projection beyond. Distal part did not fill. Material
remained at 72 hoars when rest of bowel wss olear.
Appendix hypertrophied and wall
oedematous. Several concretions.
Figwret from Cates Not Operated Upon.
Fig. 90, No. 587. —Male, aged 70. 12 boon after opaque meal. The
appendix had an Irregular outline and showed great over-activity,
waves of contraction passing material continually from the base
towards the tip. The waves ceased where the appendix became
bulbous. Heal stasis. Tbe patient had periodic indigestion with
vomiting, but had recently had the prostate excised. No further
procedure was advised at present.
Fig. 31, No. 79?.—Male, aged 48. 7 hours after opaque meal. Early
stages of filling with wide lumen.
Fig. 89.— The same. 20 seoonds later. A narrow curved tip can be
seen. Theresas a UUle ileal stasia.
Fig. 88, No. U80. —Male, aged 49. 9 hours after opaqne meal. The
appendix shows a dilated proximal part with hook appearance, and
is abruptly bent. 8pasm. It is tender. The patient is subject to
cramping pains on the right side of the abdomen. There were reasons
against operation, but he was advised that he must not go far away
from the possibility of surgical help. There was a little ileal stasis.
. 3U, No. 699.— Male, aged 50. 48 hours after opaque meal. Rctro-
appenoix with irregular outline. Stasis; the cacum is partly
empty. At 96 hours when the rest of the bowel was dear there was still
a residue In the tip of the appendix. No ileal stasis.
Fig. 85. —Female, aged 14. 120 hours after opaque meal.- Stasis.
26 days later the opaque material was still to be seen in the append!*.
96 Tot Lancet,] DR. K. 1. SPRIGGS: EXAMINATION OF VERMIFORM APPENDIX BV X RAYS. [Jan. 18, 1919
[Jan. 18. 1919.
The Lancet,] I)R. E. I. SPRIGGS: EXAMINATION OF THE VERMIFORM APPENDIX BY X RAYS.
MR. S. T. IRWIN: ACUTE APPENDICITIS AND ACUTE
APPENDICULAR OBSTRUCTION.
The Lancet.] DR. E. I. SPRIGGS: EXAMINATION OF THE VERMIFORM APPENDIX BY X RAYS. (Jan. IK. 1919.
RADIOGRAMS OF NORMAL APPENDICES
RADIOGRAMS OF DISEASED APPENDICES
OR. E. 1. SPRIGGS: EXAMINATION OF THE VERMIFORM APPENDIX BY X RAYS
RADIOGRAMS OF DISEASED APPENDICES
# '^V
V A * *
|P* ' ^
[ m r
5k v
V
1
p 7.
SL
o|l a ^VIK9
teg _ V |
29
Xhb Lancet.] DR. B. I. SPRIGGS : EXAMINATION OF VERMIFORM APPENDIX BY X RAYS. [Jan. 18, 1919 97
We may summarise the above by
spying that the signs of present
inflammation are, in addition to
pain and other clinical symptoms,
a tender point and varying dilata¬
tion of the lumen from hyperactivity
and spasm, whilst evidence of
former disease, reoent or remote,
is given by concretions, abnormal
outline. delay in filling or emptying,
adhesions, severe kinks, and, in
certain cases at least, by the absence
of a shadow.
-l_--i
Pfcetograph of concretion from
OhLss'S. bee Pig. 14, also
coloured drawing.
Figures traced from Additional Photographs in Cases 1 and 7.
13a
19a
Case 1 .— After 10 hours. C, Cwcum. c, Con¬
traction of proximal part at compared with
Fig. 13. la, Inoptqne material in first bulb.
It, Coating In ileal terminal.
Case 7.—Alter 8 boon. C, Oaseum. It, Ileal
terminal, h, Beginning book appearance.
14
Explanatory Diagrams to Figs. 14.17. and HO (Diseased Appendices).
17
26
Case 2. — C, Caecum. Ca.
Ascending colon. It, Ileal
terminal, bl, Bulb contain¬
ing oouoretion. cn. Con¬
striction. f. Fixed portion of
loop, r. Bagged outline.
Cask 5.—Ab, Appendix base. Abt, Its bulbous
tip. Ap, It* proximal portion, b. Diffuse
appearance of barium traversing the first bulb,
k. Site of kinking. C, Cwcum.
f c J i !
v ! \Ab J X to
v \ !
t ltd .'nN ’
\ &' \ I
\ _)
Case17.— A, Appendix. Ab, Its base. 0,Cascum.
in, Inopaque material. I. Ileum. ltd,
Dilated ileal terminal. Ito, Obstructed ileal
terminal, k, Bite of kinking if erect posture
is assumed, r. Ragged outline of terminal;
Bite of adhesion to cwcum.
Of the last 100 cases examined, in 40 the appendix
appeared to be normal, though one of these showed
tenderness. This was the case above mentioned, in which
the patient was ill owing to a growth of the stomach. In
19 cases the appendix was reported diseased ; 11 of these
have already been operated upon and the diagnosis con¬
firmed. In 27 slighter abnormalities were found, such as
appendical stasis (18 cases), kinking, fixation, partial
obliteration or diminution of lumen. In the remaining 14
the appendix was not seen. One of these has been operated
upon and a constriction found at the base of the appendix.
We wish to express our thanks to the surgeons who have
kindly informed us of the condition of the appendices
excised by them, especially to Dr. Manson Fergusson, of
Banff (17 cases), Dr. J. C. Galloway, of Banff (5 cases), and
Professor J. Marnoch, of Aberdeen University (7 cases). We
are also indebted to Mr. Gilbert Barling, Sir Arbuthnot
Lane, Mr. Hugh Lett, Sir Berkeley Moynihan, Mr. H. S.
Pendlebury, Mr. J. H. Pringle, Sir Harold Stiles, and Professor
Alexis Thomson.
Summary.
1. It is possible to observe the appendix with the X rays,
in the large majority of cases, by the use of an opaque meal
of buttermilk and barium sulphate after preparation with
castor oil. An account is given of the methods and manipu¬
lations which have been found useful in the examination of
900 appendices.
2. The normal appendix fills and empties about the same
time as the caecum. It may, especially in young people, fill
and empty repeatedly, while the caecum remains full. The
best view is usually obtained about 12 to 14 hours after the
opaque meal. Twelve photographs of normal appendices are
shown.
3. Direct X ray examination of the appendix is of much
help in the diagnosis of chronic appendicitis. With adequate
observation it is found that the proportion of cases in which
no barium sulphate enters the appendix is small.
4. In determining whether the appendix is or has been
diseased attention roust be paid to filling and emptying,
shape, mobility, position, and the presence of ooncretlons,
hyperactivity, spasm, or tenderness. Continued contractions
and spasm are associated with active inflammation. The
existence of a tender point is a valuable sign, but requires
care in its interpretation.
5. Details are given of 36 eases in whioh the X ray reports
are compared with the operative findings. In all of these
the diagnosis was verified at the operation. Twenty-three
photographs of diseased appendices are shown and eight
coloured drawings of appendices after removal.
Iir.f'rencc8— (The list includes some papers which are not referred to
by name in the text.) 1. B^clOre: Bull, de Soc. de Radiol., 1909, i., 192.
2. Carman and Miller : The Roentgen Diagnosis of Diseases of the
Alimentary Canal, Phi lad. and Lond., 1917. 3. Case, J. T. -. New York
Med. Journ., 1914, c., 161. 4. Cohn, M.: Deutech. med. Wochenschr.,
(Continued at foot of next page.)
C 2
98 Thb Lancet,] MR. S. T. IRWIN: ACUTE APPENDICITIS AND APPENDICULAR OBSTRUCTION. [Jan. 18,1919
ACUTE APPENDICITIS AND ACUTE APPEN¬
DICULAR OBSTRUCTION.
By S. T. IRWIN, M.Ch.Bblf., F.R.C.S. Edin.,
ASSISTANT TO PROFESSOR OF SURGERY, QUEEN'S UNIVERSITY’, B <LFAST •
TEMPORARY ASSISTANT SURGEON, RoYAL VICTORIA HOSPITAL,
BELFAST; 8UHGKON, ULSTER HOSPITAL. AND MILITARY ORTHO¬
PEDIC HOSPITAL, BELFAST; TEMP. CAPTAIN, R.A.M.C.
( With Coloured Illustrations .)
Introduction.
It is the aim of this paper to analyse the results following
upon 131 consecutive argent operations for acute disease of
the appendix ; to discuss and, if possible, to elucidate some
of the apparent incongruities between physical signs and
pathological findings; to offer some observations upon the
variations in the anamnesis; and, last of all, to direct
special attention to a large and homogeneous class of case
in which the origin of the disease aod its morbid anatomy
are primarily and directly due to obstruction.
This list of cases includes operations performed in the
most unpromising surgical surroundings, both in respect of
the operation itself and of the snbseqnent nursing, though
there seems to be often more risk in the removal of a patient
in certain types of the disease than in operating where few
facilities are at hand and many things must be impro¬
vised. It is not the actual operation which is severely
handicapped, bat rather the subsequent nursing of the case
—if, for example, it be found necessary, as indeed it often
is in sach oases, to drain the abdominal cavity. Removal
of a patient may entail serions risks in that (1) it delays the
operation; (2) it may provoke rupture of a thin-walled
gangrenous appendix ; (3) it may cause a localised abscess
to burst and thus infect the general peritoneal fluid ; or (4)
it may cause direct extension of infective material into the
subphrenic region. Where removal mast be faced this shonld
be carried out in the Fowler position (Crawford Renton).
Let me call attention here to the frequency with which
pas is met with in cases demanding surgical interference.
Out of the 131 cases, no less than 84 had already gone on to
suppuration. It was Finney who said :—
"The presence of pus in an appendicitis operation Is prima facie
evidence of a mistake on the pArt of somebody, the patient, the
physician, or the surgeon."
In my own series all excepting one, and that one already
perforated, were operated on as soon as seen. In my
opinion pas is due not so mnoh to a failure to recognise
that the appendix is at fault as to a failure to recognise
by its symptoms and signs the grave type of the disease in
its early stage. And this suggests the question of diagnosis
—often easy, bat not seldom difficult, and at times well-
nigh impossible. It is not enough to arrive at the conclusion
in any case that the appendix is at fault, though this is, of
course, the first step, bat we should also aim at deciding
whether it be a case of (1) acute appendicitis or (2) acute
appendicular obstruction. If the latter, what is the con¬
dition of the appendix wall ? Is it gangrenous, with perfora¬
tion imminent ? or has perforation already occurred and is
there pas present, and, if so, is the pas encapsuled or is
there infection of the general peritoneal contents 1
If the appendix be gangrenous, and if perforation
be close at hand, then only the gravest disadvantages will
justify delay in operating. Mr. Robert Campbell, in first
directing attention to acute aopcndicular obstruction, showed
what a dangerous form of the disease it was—that it has a
definite coarse, extending usually for a period of not less
than 36 hoars before perforation, and after perforation it has
a very grave issue, for the contents of the distended appendix
(Continued from preceding page.)
1913, 608. 5. George, A. W., and Gerber, I.: Surg., Gynec.. and
Obstet.,Chicago. 19H, xvil.,418. 6. George. A. W.,ftnd Leonard. R. D. :
The Roentgen Diagnosis of Surgical Lesion* of the Gastro intestinal
Tract, B wton. 1915. 7 Grlgorieff: 1911; see Cohn. 8. Groedel, F. M. :
Miinch. med. Wochenschr, 1913 I.. 744. 9. Hurst. A. F. . Arch. Roent.
Ray. 1915, xix . 249. 10. Imboden, H. M. : Amer. Jour. It >ent., 1915,
li.. 591. 11. J >rdan, A. C. : Proc. Roy. So*. M-d., 1911, v.. El Sect., 9. 12.
Llertz. K. : Deutch med. Wochenschr., 1910. li.. 1269. 13. Orton, G. H.:
Proo. Roy. Soc. Med.. 1907-8. i., Bl. Sect.. 29. 14. Qulmby, A. J. : New
York Med. Joura.. 1913, xcvlll.. 697. 15. Rleder, H.: Munch, med.
Wochenschr., 1914. li., 1492. 16. Vilvandre, G.: Arch. Radiol, and
Klectrother.. 1916, xxi., 49. 17. Walsham, H., and Overend, W. -. Arch.
Radiol, and Blectrother., 1916. xx., 260.
are under considerable pressure, and when rupture occurs
the pus is often sprayed far and wide throughout the general
peritoneal cavity. It was to this type of the disease, doubt¬
less, that Sir Berkeley Moynihan referred in his vivid picture
of the effect of the homely dose of castor-oil which usually
anticipates by some hours the arrival of the surgeon, pre¬
cipitating a calamity which it is his aim to avert, and
transforming an aseptic operation field into a veritable
quagmire.
The series under review has been divided up as follows : —
1. True acute appendicitis -34 cases.
2. In cdnite-10 cases, which from insufficiency of evidence I was
unable to classify either as inflammatory or obstructive.
3. Acute appendicular obstruction—87 cases, which have been
subdivided fuither into—
Stage I Oostructed only (10 cases);
Stage II. Obstructed a.id gangrenous (18 oases); and
Stage III. Oostructed, gangrenous, and perforated (59cases).
Each group of cases has been arranged in sequence
according to the interval of time between the appearance
of symptoms and time of operation.*
True Acute Appendicitis.
The following case is an example of aonte appendicitis
Case 30.— Patient, man aged 24. otherwise healthy, was seen with
Dr. G. F. Campbell on July 17th, 1913. He had taken 111 about eight
days before, with feeling of sickness, especially after meals. No
actual vomiting; nausea persts r ent and distressing. The nowels
became sluggish. He had a varying amount of pain, worse in evening
and at night., and sometimes had to be relieved by poulticing. He had
suffered from indigestion for some years. Pulse was 100, temperature
99° F. There was a tender point just internal to anterior superior spine
on the right side ; small phlegmon present. Operation through right
rectus incision ; appendix inflamed with thickened walls, lying external
to csecum and buried in piastic lymph. No pus; abdomen closed In
layers without dialnage.
I would especially direct attention to the indefinite onset,
to the absence of any great pain as initial symptom, and
to the absence of troublesome constipation. Many of these
cases, however, go on to suppuration. These are cases of
aente appendicitis in which, from the onset, the temperature
and the pulse are elevated, and in which pain, though
present, is not of such a severe type as in the cases due to
obstruction, and even from its first beginnings is definitely
localised to the right iliac fossa. In these cases, too, vomit¬
ing and constipation are not troublesome, and if pus be
present it is small in amount and well walled off by the
surrounding organs, which are adherent to the appendix and
the caecum. The walls of the appendix are thick and fleshy
and there is no distension of its cavity.
In this, the commonest type of acute appendicitis, if per¬
foration occurs it is of less importance than in the obstructive
cases for two reasons : (1) There is but little material within
the appendix, no distension of its lumen, and therefore no
increase of tension ; and (2) the appendix is well surrounded
by adhesions. Mention must be made, however, of those
inflammatory cases in which perforation, if not the first, is
an early symptom of disease. In such cases, no doubt,
obstruction plays a prominent part, but the group about to
be described under the term acute appendicular obstruction
is so definite, so large, and so important from the point of
view of prognosis that we do not include those cases in it.
In one case (No. 2) perforation occurred so early that it can
only be explained by antecedent ulceration, which bad so
thinned the wall that the slightest increase in tension
produced rupture.
Indefinite cases .— To this group I do not wish specifically
to refer, except to say that so far as they could be examined
the more serious cases showed considerable evidence of being
primarily obstructive in origin.
Acute Appendicular Obstruction.
I have come across 89 cases of acute appendicular obstruc¬
tion, of which 10 showed obstruction only, 18 showed
obstruction with a varying amount of gangrene of the wall,
and in 59 rapture of the appendix had followed the gangrene.
A typical case from the third stage of this group is as
follows :—
Case 99. — Youth, aged 19'; taken suddenly ill on Dec. 28th, 1915. with
very severe pain in stomach; he vomited three times that evening.
His bowels till then regular, became constipated. He was seen next
morning by Dr. Robert Boyd. Patient complained of pain in left, hypo¬
chondriac region. Pulse and temperature normal. Slight rigidity
over right reef us below. Breath was foul, and tongue thickly coated;
otherwise he looked well. The next day he was again seized with a
* From pressure on space, the schedule of cases could not be printed.
The Lancet,] MR. S. T IRWIN : ACUTE APPENDICITIS AND APPENDICULAR OBSTRUCTION. [Jan. 18, 1919 99
sudden severe pain, now localised to right lower abdomen. Tempera-
tore 99°, pulse 100. I was asked by Dr. Boyd to see him, and
diagnosing a perforated gangrenous appendix, bad him removed to
the Royal Victoria Hospital, where, through the kindness of Mr. A. B.
Mitchell, 1 was allowed to operate upon him. Operation under open
ether; right rectus incision. Appendix found gangrenous for about
2 inches from tip; large perforation, size of a sixpence, lying in
abeeese cavity containing about an ounce of pus. Appendix removed,
cavity drained; good recovery.
The foregoing is a type representative of a very large
percentage of the critical cases which a surgeon is called
upon to see. They are, so far as my experience goes, the
most serious of all the common emergencies in abdominal
surgery, and consider for a moment what the pathology of
this case was. I make no apology for quoting briefly from
the recent experimental work of Mr. D. P. D. Wilkie, who
demonstrated the pathological changes which take place in
an isolated loop of small intestine into which some caecal
content has been introduced, the loop being t completely
obstructed and there being no interference with its blood
supply: —
“When the loop Is filled moderately full with csecal content, the
animal having been fed on a carbohydrate diet (porridge), distension
occurs with foetid fseonlo-purulent fluid, and either an empyema of the
loop results or a gangrenous pitch develops with perforation.With
the loop filled with csecal ooment in an animal previously fed on a rloh
protein diet (lights) the changes are much more striking, and as a rule
the animal is dead within 20 hours. On openiog the abdomen post
mortem the loop is seen to be green and gangrenous."
These are the changes which occur in an occluded piece
of animal’s intestine, and similar changes occur when the
human appendix becomes obstructed at or near its base.
The lumen beyond the obstruction becomes rapidly distended
with fseculo-purulent material and localised patches, or the
whole organ may become gangrenous, to be followed later by
rupture.
A consideration of Wilkie’s experiments, oar own expe¬
rience of the morbid anatomy of cases seen in the earlier j
stages, and the appearances found at the operation, agree in
indicating that in the above case the symptoms arose from
an obstruction near the base of the appendix ; that there was
present within the appendix a certain amount of faeculent
matter; that this obstruction led to gangrene of the
appendix ; and that, following the gangrene, perforation had
supervened. If, then, this be the pathology, and if the
appalling mortality in acnte diseases of the appendix be due
to this type of case, then obviously the remedy lies in
diagnosing the condition before perforation occurs ; in other
words, had one been able to foresee that, in spite of the
normal temperature and normal pulse, there lay interned
within his abdominal cavity a sloughing appendix, then no
excuse would have justified us in allowing perforation to
take place.
That this is no unusual type of case, and that symptoms
and signs are often unalarming on the second day, numerous
arguments and examples go to prove. Here is another :—
Cask 100.—On Dec. 8th, 1914, at the Royal Victoria Hospital. I was
asked by Mr. A. Fullerton to operate upon a boy, sged 10, just
admitted to hospital. He had taken 111 on Dec. 6th. He had been seen
on the second day by his own doctor, who was present at the operation,'
and who told me that the boy suffered considerable pain on Dec 6th
but on the 7th he was so much better that he thought that he might
lie able to do without operation. On the night, of Dec. 7th he was
again attacked by acute pain, and when the doctor saw him next
morning he sent him straight into hospital. On admission tempera-
ture 98\ pulse 122. Large area of dullness present on right lower
abdomen. Operated on by gridiron Incision, pus released, and tube
placed in abscess cavity.
The boy’s condition precluded the removal of the appendix, but
there can be no reasonable doubt that this case was identical with the
one already quoted.
Causation of Obstruction of Appendix.
In these obstructive cases it is our contention that the
primary cause of the disease is obstruction of the lumen of
the appendix. On examination of the appendices removed
at operation it is fonnd that obstruction may be due to one
of five causes (1) Concretions ; (2) strictures ; (3) kinks;
(4) bands ; (5) worms, fruit-seed % and other foreign bodies.
Concretions are by far the commonest form of obstruction,
especially in those cases which go on to the production of
gangrene : in my series they were present in about 50 out of
87 obstructed cases. In cases of completely gangrenous
appendix coproliths will be found dividing the healthy from
the diseased portion, and in the early stages where gan¬
grene is not evident outside it will be found on opening
the appendix that the mucous membrane of the distal
portion is sloughing. It is no uncommon thing to find,
besides the obstructing concretions, several others lying
within the cavity of the appendix. After perforation one or
more concretions may escape into the abscess sac, and in
one case (No. 119) the abdominal wound healed completely
over such a foreigo body, which was only found at the sub¬
sequent operation for the removal of the appendix.
The exact relationship of these concretions to the disease has
not hitherto been definitely established. In our opinion they
are the definite causa causans of the particular form of the
disease now under discussion. They act by suddenly block¬
ing the lumen of the appendix and, by preventing the return
of the contents of the appendix into the caecum, give rise to
the acute symptoms of pain in the upper abdomen and
vomiting already referred to. If the obstruction be not
relieved, and more especially, as haB been shown by Wilkie,
if the patieut has been fed chiefly on proteid food, the vitality
of the appendix rapidly falls, and m from 30 to 40 hours
sloughing supervenes.
Strictures .—The second form of obstruction to which I
would direct attention is stricture, of which at least six
examples were met with. I first observed this in Case 54.
I find that strictures of the appendix have been well recog¬
nised and described for many years, notably by Abb£, of
New York, and others. These have been attributed by
Runyon, as quoted by Kelly and Hurdon, to previous attaoks
of appendicitis with ulceration, in which the mucous lining
of the appendix has been destroyed. In Case 54 the boy had
never previously suffered from any form of disease, and it
may therefore be an example of what Lenzmann and Ewald
have described as appendicitis larvata. It adds a farther
argument to the hypothesis of obstruction by proving that
inflammatory changes, even to the extent of uloeration, may
take place without arousing the suspicion of disease in the
mind of the patient.
I saw another case in which stricture and concretions were
combined. This was Case 69, in which an ordinary third-
day perforated gangrenous appendix was fonnd. I showed
this to Professor J. Symington, and on his advice it was first
hardened in formalin, then cut with a razor till we found
the exact position of the stricture. This strictured area we
then prepared in the ordinary way for microscopical exami¬
nation. It showed a mass of newly formed granulative
tissue filling up the lumen of the appendix. It was con¬
tinuous with the submucous coat ana no trace of mnoons
membrane could be found. Since then Dr. W. W. D.
Thomson has kindly investigated the appendix from
Case 82.
This was a typical case In which soon after the administration of a
dose of castor oil on the second day the patient, a bov of 164 years, was
suddenly seized with pain in the right iliac region. Next day, at opera¬
tion, we found an appendix obstructed by two complete strictures.
Between the strictures the appendix was completely gangrenous
and at one point a perforation big enough to admit a slate pencil
was found.
Fig. 1.—Outline drawing of an appendix showing position of two
complete strictures at 1 and 2.
A line drawing of this appendix is shown in Fig. 1, and
Dr. Thomson has gone fully into its pathology and reports
as follows:—
J\ 'uked-cyr appearance.— The cavity of the appendix Is divided by two
strictures inr.o three compartments. Tne proximal compartment is
continuous with the cavltv of the caecum. Its mucous lining and
submucous tissue are alike normal. The middle compartment-Is com¬
pletely gangrenous and perforated. The distal compartment is full
of pus.
Microscopic appearances .—Serial sections were prepared : —
1. The strictures are both complete. Each is formed of a dense mass
of granulation tissue which c unpietely replaces the lumen, epithelial
lining, and mucous coat of the appendix. It is continuous with the
submucous la\er. A photomicrograph of this section is shown In Fig. 2.
2. A section through the middle compartment shows necrosis of all
the layers of the appendix, with a ragged perforation at one point.
3. The terminal compartment is »woll»n, tense, and filled with
purulent material swarming with Bacilli coli.
Kinks.—The third form of obstruction is that due to a kink
which is produced by the cod traction of an adhesion between
two adjacent parts of the appendix. In this way a sharp
angularity is formed. Both ends of the adhesion take their
attachment from the appendix.
Bands .— A similar angularity may be caused by a band
one end of which is adherent either to the parietal peri-
tonenm or other part of the alimentary canal and the other
to a proximal part of the appendix Contraction of this
100 ThbLanobt,] MR 8. T IRWIN : ACUTE APPENDICITIS AND APPENDICULAR OBSTRUCTION. [Jan. 18,1919
hand causes the appendix to be drawn out to a sharp angle
which interferes with the free passage of the appendicular
contents.
In obstruction due to bands and kinks the progress of
morbid change is generally slower than in the case of con¬
cretions, and so, by giving time for the production of pro¬
tective adhesions, lessens somewhat the gravity of peri¬
tonitis, if and when it appears.
Fig. 2.—Section through stricture at 2. Photo- micrograph.
foreign bodie *, such as intestinal worms, fruit-seeds, Ac.,
are rare forms of obstruction.
Stages of Acute Appendicular Obstruction , with Illustrations.
The late Mr. Edmund Owen, in his book “ Appendicitis,”
makes the deliberate statement that no surgeon of experi¬
ence pays much attention to history. Rarely can such a
statement be justified, least of all in acute disease of the
appendix in which there is a well-defined sequence of events
and a very definite symptom-complex. It is this symptom-
complex which I wish to consider now, and by comparing it
with appendices removed at the different stages of the
diseases to correlate symptoms and signs with pathological
findings. There may still be some doubt as to whether in
any particular case obstruction did or did not exist in the
case of bands or kinks ; no such doubt can arise with a
concretion which blocks like a ball-valve the appendicular
canal. All the examples which I show depend on this
cause for the obstruction. Fig. 3 shows a typically
obstructed appendix. It is a section of the appendix from
Case 58, distended with gelatin and cut longitudinally.
It is difficult from a consideration of preserved specimens
to get even the faintest idea of the course and stages of the
disease owing to the rapidity with which the characteristic
colours disappear and to the fact that no known method of
mounting will preserve these delicate colourings. Again
I am indebted to Professor Symington for suggesting that
these specimens should be drawn to scale and coloured
immediately after removal from the abdomen. This course
I have followed, and 1 think the illustrations show in con¬
clusive fashion the morbid changes through which the
obstructed appendix passes, and by comparing these with the
history and clinical signs we are able to arrive at an accurate
estimate of the intra-abdominal condition in any given case.
Stage I .—Coloured Illustration I. is from a coloured
drawing of an appendix removed 21 hours after the onset
of symptoms (Case 46). (See Coloured Illustrations inset.)
Cash 46.—A man, aged 45, a patient of Dr. W. McWilllam of
Banbrldge. took 111 at 3 a.m. on Oct. 2nd, 1915. and was operated on
about midnight. The attack begun with very severe pain in the upper
abdomen referred to region of umbilicus. Vomiting took place at short
intervals throughout day. Pulse and temperature normal. Con¬
siderable rigidity in right rectus muscle and tenderness localised to
small area immediately below McBurnev's point. When I Baw him
temperature was 98'6°, pulse 84, tongue clean, and breath not foul. The
pain was of a colicky character, and between the attacks he was quite
comfortable. Small area of tenderness as above stated; otherwise
abdomen normal. The diagnosis of obstructed appendix was made and
appendioectomy performed. On opening abdomen no sign of in¬
flammation ; appendix tense and rigid; concretion felt close to
proximal end. Appendix removed. Uninterrupted and rapid recovery.
This is a typical example of the first stage of obstruction
of the appendix. There are no signs either local or general
of inflammation. There are 10 such cases in the series and
results of treatment by operation leave nothing to be desired.
The period of disability is short and the risks of complica¬
tions and sequela? almost nil. And yet if left to nature or
if treated on medical lines a certain proportion of them will
proceed in the direction of gangrene and perforation as
exemplified in the succeeding stages.
Stage II .—In the following case operation was performed
24 hours after first symptom.
Cask 55. —Patient, a young woman aged 21, was seen by Dr. W. Martin
of Whitehead, on the night of July 10tn ; history of having been ill with
pains in Btomach and vomiting for Bix hours. Temperature and pulse
normal; no sign of any tr mole in abdomen. He aaw her again next
day; temperature 100° and pulse 100; he sent her straight Into hos
pital. At operation an appendix obstructed by a concretion at its base
was found ; very small area of gangrene on one side of organ. (Fig. 4.)
Recovery in this case was retarded, as It frequently is in cases of
gangrenous appendix, by infection of the layers of the abdominal wall,
but the patient ultimately made a satisfactory recovery.
Here we have an appendix exactly similar to the first, but
somewhat later in the course of the disease, and it seems
reasonable to conclude that this is the second stage of the
disease which follows obstruction.
The next case is that of a patient operated on 30 hours
after the onset of symptoms. (Coloured Illustration II.)
Casf. 58.—A woman aged 35, a patient of Mr.W.Bovd.of Banbridge. took
ill ai9.30 p.m. on April 2nd, 1915, with pain in epigastric r**g«onand vomit¬
ing ; symptoms lasted continuously for 12 hours. When Mr. Boyd s*w
her temperature and pulse were normal; no pain, tenderness, or rigidity
in any part of abdomen. Four hours later pain had returned, not now
in epigastric region, but in right iliac fossa. Temperature now 101-2°
and pulse 104. When I saw- her about 12 hours later (that is 30 hours
after onset) temperature was 101°, pulse 108; there was extreme
tenderness not only over appendix, but over whole lower abdomen.
Fig. 3 and Coloured Illustration II. are from drawings of the appendix
which was removed. On opening the abdomen a huge, tense, obstructed
appendix was found. During manipulations a concretion was felt to
escape into the caecum, and when the appendix was afterwards distended
with gelatin a cavity corresponding to this became evident. The
appendix contained a number of small concretions aud a large quantity
of foul pus mixed with bocal matter. There were two considerable areas
of gangrene. Recovery uneventful; patient left hospital in four weeks.
Here let me direct attention first of all to the absence of
symptoms and signs when first seen by Mr. Boyd, and.
secondly, to the moderate rise of temperature and pulse with
the appearance of gangrene. This is the further stage in a
disease caused by an obstruction.
The next case was operated on 31 hours after the onset of
symptoms.
Cask 59.— Man. aged 35, a patient of Dr. G. F. Campbell, of Bangor,
took ill on Dec. 2lst, 1915. with severe pain over "lower end of breast
bone," and vomiting. Similar attack two years before. After 12 hours
the pain began to settle in right side about 1 inch above McBurnev’s
point. Thirty-one hours af er onset tongue was clean, temperature 100 4 r
pulse 80; abdomen showed a single tender spot; right rectus muscle
somewhat rigli, but not markedly so. Operation Immediately by
gridiron incision. There were some adhesions, but without, difficulty the
appendix, completely gangrenous, was removed. (Fig. 5.) Stump of
appendix could not be invaginated, but was simply ligatured in
abdomen.
The appendix was a typically obstructed one in which the
whole organ was obstructed, distended, and gangrenous.
This man before being operated on declared that he was
getting over the attack just as he had got over the previous
one, and one could not from clinical signs have denied the
possibility of this, and yet we find this foul gangrenous
appendix with perforation imminent. It is difficult to decide
why in the previously mentioned cases one or two areas of
gangrene occur, whilst in this case the whole organ was
affected.
Coloured Illustration II. is an example of an unperforated
gangrenous appendix, of which there were 18 in the series.
They all recovered, though they are somewhat less satis¬
factory than the foregoing, and mainly for two reasons : (1) a
few of them required drainage owing to the suspicion of infec¬
tion of the peritoneal fluid, and therefore ran the risk of
hernia; (2) even in the absence of peritoneal infection there
is considerable liability to infection of the abdominal wall,
a fact previously pointed out by Mitchell and others. On the
whole, prognosis is rarely grave in this series.
Stage III. —Coloured Illustration III. shows the condition
of the appendix at a later period.
Cask 90. —Patient a woman aged 47, seen with Dr. R. Boyd, of Strand
town on Oct. 12th. 1915, had already been ill three days. Examination
showed a w* 11-defined mass in the right, iliac fossa and on right side of
pelvis. Temperature 10T5 ; pulse 108. She wss at once sent to hospital
and operated upon. There was an abscess of considerable size situated in
right iliac fossa and extending down into right side of pelvis. Appendix
gangrenous and perforated ; and about 11 Inches from base obstructed by
large concretion ; also concretion in abscess cavity.
This is unfortunately the usual type which one meets with
at operation, but the previous history shows that it began
with the same early symptoms of vomiting and pain in the
upper abdomen : after 24 hours pain in the iliac fossa as
The Lancet,] MR. S. T. IRWIN : ACUTE APPENDICITIS AND APPENDICULAR OBSTRUCTION. [Jan. 18,1919 1Q1
secondary inflammatory changes reach the peritoneal coat
of the appendix ; after 36 hours perforation ushers in sup¬
purative peritonitis, and soon a large abscess extending into
the pelvis has developed.
This is a type of the 59 obstructed, gangrenous, and
perforated appendices occurring in Stage III. A considera¬
tion of their histories shows that most of them were seen
during the second stage, and not a few of them even in the
first stage. As a profession, therefore, we cannot absolve
ourselves from responsibility for failing to recognise, or at
all events to prevent, the dangerous course of the disease.
First, and most important, look at the death-rate -
8 deaths out of 59 cases, 13 5 per cent. It may be urged
by some that such a high mortality was due to immediate
operation. In only one case can I think, on looking back,
that I might have been justified in postponing operation
(No. 102, a child aged 2£ years), though, on the other hand,
there would certainly have been also the opposite possibility
that the child would in 12 hours have been moribund. Of the
other deaths two, Nos. 40 and 114, were due to rupture of a
localised abscess into the general peritoneal cavity—a most
fatal complication and one directly due to delay in operating.
prominent feature, and recurs from time to time as the
patient tries to relieve his thirst. Constipation is usually
a prominent feature. These are the symptoms of the first
stage—as for signs, the temperature rarely exceeds 99 ,
the pulse may show a slight increase in frequency, though
it is often normal, and between the attacks of pain the
patient is comfortable. On examination of the abdomen
some tenderness will be found when pressure is made over
the distended appendix, but the rectus shows but little
rigidity. Operation at this stage reveals an appendix tense,
rigid, and distended, as exemplified by Coloured Illustration 1.
Twenty-fours later, if the obstruction persists, we shall
find diminution of pain, with disappearance of vomiting.
The temperature and pulse are now slightly elevated, the
temperature being, say, 99 to 100 and the pulse 110. An
examination of the abdomen shows not only an area of
extreme tenderness near McBurney’s point, but also a wide
area of rigidity. Operation reveals an appendix partially or
wholly gangrenous, surrounded by a varying amount of
plastic lymph gluing it to the neighbouring organs. Some¬
times the omentum will be found wrapped round the
diseased organ and closing off the general peritoneal cavity,
which contains an excess of fluid. If such were the circum¬
stances surrounding every perforation the outlook would
I not be so gloomy, but often we find no omental sefitry on
Fig. 3.—Longitudinal section of appendix
obstructed by concretion and containing
concretions.
Fig. 4.—Obstructed and gangrenous appendix.
| Fi G . 5.—Obstructed and coirpletely
gangrenous appcnilx.
Two died of pneumonia, which could not have been foreseen.
One death was due to acute intestinal obstruction (No. 95),
which had gone on well for a fortnight, the temperature and
pulse having been normal for ten days. Three cases, Nos. 87,
97, and 106, all children, were moribund on admission to
hospital —they had their abscesses opened under local ames-
thesia, though they were past all but the remotest chance of
recovery. What evidence is there here for further delay when
at least five of the cases had already been delayed too long,
viz., the three last mentioned and the two cases of ruptured
abscess ?
So much for the death-rate. Let us now look at the
complications—secondary abscess, fiecal fistula, hernia,
pneumonia, Sec. ; of such the earlier cases are free. Then
one must consider prolonged convalescence, the semi¬
invalidism, and the incapacity for work which follow
these.
Typical Case of Obstruction of the Appendix.
Keeping in mind these stages, let us now endeavour to
reconstruct a typical case of acute appendicular obstruction,
from the onset of symptoms until perforative peritonitis
occurs.
The disease begins with severe pain usually referred to
the epigastric or umbilical region ; it is colicky in
character and is very severe, it is soon succeeded by
vomiting which, though occasionally absent, is usually a
patrol, and when rupture occurs the line is broken and
extensive invasion of the peritoneum takes place. Figs. 4
and 5 and Coloured Illustration II. are examples of this stage.
When rupture of the gangrenous appendix and infection
of the peritoneal fluid have occurred we shall find a further
attack of pain, this time referred to the right iliac fossa,
continuous in character and often more severe even than
the pain in the original obstruction. Vomiting is not a
marked feature of this stage, though a feeling of sickness or
slight vomiting may occur. Constipation is still present.
At the moment of perforation the temperature may fall to
sub normal, but soon begins to rise again, except in very
grave cases, and the pulse is greatly accelerated, running up
to perhaps 120, or even more. Examination of the abdomen
reveals a board-like rigidity of the muscles over the whole
of the right side of the abdomen; the point of maximum
tenderness will depend upon the situation of the ruptured
appendix. Operation will show either a localised collection
of pus or a general peritonitis dependent on whether the
material from the appendix has been limited or not. Coloured
Illustration III. is an example of an appendix from such
a case.
These outlines may be regarded as the ordinary signs and
symptoms of a case of obstructed appendix, but certain
exceptions must not be lost sight of.
For example, in the case of an appendix which is lying in
the pelvis it is not unusual to find both signs and symptoms
referred even from the first to the pelvic region, or even to
find a gangrenous appendix in the pelvis without definite
102 ThbLancbt,] MR.S.T. IRWIN i ACUTE APPENDICITIS AND APPENDICULAR OBSTRUCTION. [Jan. 18,1919
symptoms suggestive of an appendix disease at all. In such
cases we have to depend on the history of an acute onset,
painful micturition, and localised tenderness and swelling
on vaginal or rectal examination.
A retroccecal appendix becoming obstructed produces at
first the typical symptoms of pain and vomiting referred to
the upper abdomen, t>ut afterwards the pain and tenderness
are referred to the dank, or even to the site of renal pain
beneath the last rib.
Where the appendix is adherent to the anterior abdominal
wall tenderness and rigidity are more marked than when the
anterior parietal peritoneum is unaffected.
Is pain ever absent in these cases ? Probably it is never
absent throughout the attack, but pain and discomfort
frequently disappear when gangrene is developing and when
rupture is becoming imminent. Comparable to this pheno¬
menon is the disappearances of pain in a strangulated hernia
when the gut is becoming gangrenous. Vomiting is a charac¬
teristic feature cf the early stage of obstruction of the
appendix. It is not so severe as in intestinal obstruction,
is never faecal, and after the stomach has been emptied is
only provoked by the taking of something to relieve thirst.
In the late stages of peritonitis, however, the vomiting may
be continuous and not infrequently gives place to hiccough.
It will thus be seen that perforation of the appendix in the
great majority of cases is preceded by well-defined signs and
symptoms, extending usually to a period of not less than
36 hours, and of so definite a character that there should be
no excuse for allowing a case to proceed to perforation if it
be seen during this preliminary period. There may be some
doubt as to the right oourse to pursue in cases which have
already reached Stage III., but in regard to the earlier stages
there can be no question that such cases should be operated
on without delay, and where the history and the signs lead
one to suppose that perforation is near at hand then no
delay or disturbance of the patient should be permitted
until after the appendix has been removed. In this type of
case the presence of pus, far from justifying operation, must
be taken as incriminating some one responsible for the care
of the patient.
Prognosis.
Under modern methods, therefore, whilst the mortality in
clean cases is practically negligible, and whilst the results in
suppurative cases will vary with the dexterity, technique,
and sometimes the rapidity of the operator, as weli as the
subsequent care bestowed on the nursing of the patient,
widespread and general improvement can only be attained
by intelligent recognition on the part of the practitioner of
those cases which are likely to go on to pus formation.
If, then, pus be the cause of death, the cause of pus is
perforation of the appendix. In the present series perforation
was present in 50 per cent, of the cases. Perforation cannot,
I fear, be anticipated in every case. In two cases of the
series. Nos. 2-3, it was the perforation which directly caused
the symptoms for which the medical man was consulted,
and speaking generally we shall meet from time to time
cases in whom inflammatory changes have been going on
without the knowledge of the patient. Such perforations,
though of small size, are most sudden in onset. They compel
attention and demand immediate surgical interference, and
hence their death-rate is low. Not so the perforation of
acute appendicular obstruction, which, after causing con¬
siderable pain at first, enters upon a semi-quiescent stage
only to perforate later. The perforation is extensive and
ragged, the material extravasated is foul, virulently infective,
and considerable in amount.
Investigation of the cases shows that no less than 28 of
them required, or were thought by the practitioner to require,
operation on the third day. These appeared to be progressing
favourably until about 36 hours after the onset, when they
seemed to get suddenly worse. There can be no doubt that
this was due to perforation. The problem, therefore, is. How
shall we best anticipate this grave complication? Not by
blindly waiting and trusting to the fact that many cases
recover without operation, but by teaching our students and
practitioners the morbid anatomy of the obstructed gan¬
grenous appendix, that it may be recognised by its history
and its physical signs and symptoms, that it is never “a
mild attack of appendicitis,” but a grave and potentially
fatal disease, demanding promptitude and careful handling
if the patient’s life is not to be placed in jeopardy.
Within recent years discussion has been rife on the
mortality following acute disease of the appendix, and
without doubt the figures are showing improvement. Lett
compares two series of a thousand cases each from the
London Hospital: in 1900-1904 and in 1912, with death-
rates of 17-2 and 3*2 per cent, respectively—a reduction of
14 per cent. These results take no cognisance of (1) cases
moribund on admission and (2) cases too ill to be moved to
hospital—a not inconsiderable number, especially in children.
In 1910 Mutch analysed the results of the treatment not
necessarily operative, of 545 cases at Guy’s Hospital. These
gave a mortality of 13 per cent. But here again if we wish
to get at the general mortality rate we must allow for those
cases which died before removal to hospital was thought of
or at all events effected. More recent results will be better,
but still it must be admitted that appendicitis (using the
term in its generally accepted meaning) is a very lethal
disease.
How can this appalling death-roll be reduced ? This leads
me to ask the further question—What is the direct cause of
death in this disease ? To this the answer is suppuration.
The truth of this has been proved repeatedly. A. B. Mitchell
in 1910 analysed the results of 500 consecutive operations
for appendicitis at the Royal Victoria Hospital, Belfast;
although the total mortality ran up to 15 per cent, yet no
single death occurred in a non-suppurative case. In 1910
Anderson reported the results of 973 operations at the
Nottingham General Hospital; out of 89 deaths, only 1
occurred in the absence of pus. Burgess out of 500 con¬
secutive operations at the Manchester Royal Infirmary in
1912 found but one death where the inflammation was
limited to the appendix. In the series here under review no
death followed operation in a clean case. Amongst cases
already suppurating I find the following figures (in some
cases approximate):—
Operator.
t Beatson
Btlllngton
Burgess
Sup.*
cases.
Deaths.
Operator.
Sup."
cases.
Deaths.
73 ...
9<12'3%)
Paterson
. 66 ...
5 (8-9%)
360 ...
48 (13'3 /)
Richardson ..
. 350 ...
48(13-7%)
366 ...
39(10-6%)
Irwin .
. 84 ...
10 (H-9%)
* Suppurative.
r Assumes deaths to have been amongst suppurative case?.
References.
Crawford Renton: Mortality after Operations for Appendicitis, Brit.
Med. Jour., 1912, i.
Kelly and Hurdon : The Vermiform Appendix, 1906.
R. Campbell: Transactions of Ulster Med’csl Society, 1912-13.
Mnvnlhan : Acute Emergencies of Abdominal Disease, Brit. Med. Jour.,
1911,1.
Wilkie: Acute Appendicitis and Acute Appendicular Obstruction,
Brit. Med. Jour., 1914,11.
Owen : Appendicitis—A Plea for Immediate Operation, 1914.
H. Lett: The Present Position of Acute Appendicitis and its Com¬
plications, The Lancet. 1914, i., 296,
Mutcb : Guy's Ilospit&l Reports, 1910.
A. B. Mitchell: Transactions of Ulster Medical Society, 1910.
Anderson : The Mortality of Appendicitis, Brit. Med. Jour., 1910, ii.
Burgess : Analysis of 500 Consecutive Operations for Acute Appendicitis,
Brit. Med. Jour., 1912, i.
Beataon: The Treatment of Acute Appendicitis—When and How to
Operate, The Lancet, 1912,1., 1253.
Billington : The Influence of Age and Type of Patient upon the Course
and Treatment of Appendicitis, Brit. Med. Jour., 1912,1.
Paterson : Acute Appendicitis—A Plea for Barly Operation, Brit. Med.
Jour.. 1912, ii.
Richardson : The Results of Operations upon 619 Cases of Appendicitis.
. Brit. Med. Jour., 1912,11.
Gift to the Northampton General Hospital.—
Mr. G. T. Hawkins, of Northampton, has given £3000
towards the building and equipment of a pathological
laboratory for Northampton General Hospital. It is hoped
that the work of construction will commence almost
immediately.
Royal Sanitary Institute. —Courses of lectures
and demonstrations for the spring term, 1919, at the Royal
Sanitary Institute, 90, Buckingham Palace-road, London,
S.W., commence next month. A course for sanitary officers
will be given on Mondays. Wednesdays, and Fridays, from
Feb. 17th to May 2nd, the fee for the first part, which will
deal with sanitation generally, being £2 12*. 6 d.. and for
the second part, which will deal with food inspection, £1 Is.
The complete course is £3. On Mondays, Wednesdays.
Fridays, and Saturdays (not consecutive) from Feb. 21st to
May 2nd there will be a course of lectures for women health
visitors, tuberculosis visitors, school nurses, and school
teachers, a supplementary course for child-welfare workers
beginning on Feb. 24th. The fee is £111s. 6 d. in both caBes,
but the two courses may be taken together at an inolnsive
fee of £2 12s. 6d., 10s. 6 d. of this being carried towards the
examination fee. The lecture hour in each case is 6 p.m.
Thr Lancet,J
DB J. R. LEE : PELVIC-FEMUR SPLINT AND ARM SPLINT.
[Jan. 18, 1919 103
THE CONTROL OF THE CPPER FRAGMENT
IN HIGH FRACTURES OF FEMUR AND HUMERUS BY
A NEW FORM OF PELVIC-FEMUR SPLINT AND
ARM SPLINT. 1
By JOHN ROBERT LEE, M.D., B.S. Melh.,
F.R.C.S. Edin.,
MAJOR, R.A.M.C. ; OFFICER IN CHARGE, SURGICAL DIVISION, FULHAM
MILITARY HOSPITAL, HAMMERSMITH, LONDON, VV.
AT Falham Military Hospital, London, we have had many
opportunities of treating fractured femurs and also of
seeing the results of treatment in other hospitals, as shown
by cases which have been transferred to us The number of
cases which come to amputation from sepsis or which join
up in bad position with stiff joints is very great. For
instance, during last June we had 20 fractured femurs sent
over to us from France, where they had been in special
hospitals from one to five months; of these, some were in
fairly good position and not very septic, several of them
were more or less united in bad position, and most of them had
sequestra due to trauma and inefficient drainage. It is the
fractures of the femur in its middle third that I wish
especially to deal with. Ten of the 20 femur cases
admitted in June were those of fractures in the upper
Fig. B.— Arm splint.
third ; of these, 3 were in good position and only slightly
septic, 2 were in fairly good position but septic, 5 were
in bad position, and of these 3 were very septic. There¬
fore, 50 per cent, were in bad position and 50 per cent,
were very septic. These results should be capable of
improvement.
Fractures of upper third of femur .—The position or dis¬
placement of the fragments in fractures of the upper third of
the femur, as a rule, is as follows : (1) The upper fragment is
abducted and flexed by the glutei and ilio-psoas muscles ;
(2) the lower fragment is displaced backwards, upwards,
i Being part of n paper read at the Section of Surgery of the Koyal
Society of Medicine on Dec. 4th, 1918.
aud inwards by the hamstrings, quadriceps and adductor
muscles. The powerful adductor raaguus being an exceed¬
ingly important factor, there is also some rotation. This
deformity is typical ; the main causes producing it are the
direction of the fracturing force and the action of the muscle
groups.
The essentials of correct treatment rest on an adequate
consideration of the anatomical factors and the principles of
Fig. C.— Radiogmma of fracture (compound) of right femur at upper
third, with abduction of upper fragment. After application of
pelvic-femur splint adduction and fixation of upper fragment with
good alignment are seen to result.
surgery, the latter including arrest of haemorrhage, establish¬
ment of efficient drainage, provision for antisepsis, general
care of the patient, massage, &c.; I want, however, to draw
special attention to the anatomical factors. The fragments
should be brought into correct alignment, the muscle groups
placed in a condition of physiological rest, and the limb
securely fixed in order that there may be no movement of the
fragments or spasm of muscles ; at the same time any inter¬
ference with the circulation of the limb should be avoided.
Hitherto it has been taught that in fractures of the upper
third “the upper fragment, being short, cannot be con¬
trolled.” Therefore attempts have been made to procure
alignment by abducting the lower fragment. This method
is icrong in principle. I have taken measurements of a great
many men and find that the distance between the symphysis
pubis and the adductor tubercle is on an average two inches
greater in the abducted position than when the knees are
side by side. Hence in the abducted position of the fractured
limb the adductor group of muscles have a greatly increased
pull and are in a condition of spasm instead of physiological
rest. Therefore, although the two fragments are brought
parallel to one another, an X ray examination in m'iny cases
reveals the fact that the upper end of the lower fragment
has now moved upwards a distance of about two inches and
takes up a position near the lesser trochanter. An amount
of extension that can be applied with safety fails to correct
the shortening. Unless the two ends of the bone were
impacted what has been accomplished is increased over¬
lapping of the fragments and not an elongation of the
adductor muscles. It occurred to me that if the upper
fragment could be controlled and the abduction overcome
the fragments could be brought into proper alignment with
the limb and the muscles in a nearly normal position.
Pelvic femur splint. With the above principles in view I
designed a new appliance which I have called a pelvic-femur
splint.
It consists of a grip with two pads (Fig. A, 1) which fit the
pelvis ; modified Thomas’ frames for both lower extremities
are hinged on to the pelvic grip (2). The pelvic grip can be
adjusted to fit any pelvis comfortably aud securely. The
elvis and upper part of the femur on each side are grasped
y the pelvic pails. The abducted upper fragment can be
controlled and adducted to its normal position quite easily.
(See radiograms, Fig. C.) The amount of pressure required
is regulated aud the fragment kept in position by a fly nut
104 The Lancet,] DR. W. FLETCHER: MENINGOCOCCUS BRONCHO-PNEUMONIA IN INFLUENZA. [Jan. 18,1919
workiDg on a screw (Fig. A, 3). Both limbs can be put up
in the iron frames in the ordinary way. The upper fragment
having been brought into proper position, the lower one can
be placed in correct alignment by abducting or adducting,
raising or lowering as required while on the splint, the latter
working on hinges or joints (near 2, Fig. A). Any backward
displacement can be corrected by manipulating the small
wooden splint by means of screws (Fig. A, 4). Adequate
extension can be applied. If much extension is found to be
necessary an adjustable piece similar to that used in the
arm splint (Fig. B) can be fitted from the pelvic pad to the
axilla on each side ; hence the upward thrust of the extending
force will be partly taken by the axillae and trunk and the
pelvic calliper grip not displaced.
All these manipulations should be done on an X ray couch
(if necessary under an anaesthetic) so as to see that the ends
of the bone are in actual alignment, not merely supposed to
be so. Having completed all manipulations necessary the
binding screws are firmly adjusted. The pelvis and lower
limbs can be suspended by means of pulleys on a frame—
the patient’s body raised as needed for convenience of
nursing, the prevention of bedsores, Ac. Many patients
complain that splints fitted with a ring around the thigh as
in a Thomas’ splint, cause much discomfort. With this
splint there are no bands encircling the limb; hence, no
interference with the circulation occurs, which is a very
important factor, especially in septic cases.
The splint can be easily applied with a minimum of move¬
ment. When it is applied the fragments of the bone are
securely held in proper anatomical position; the muscles
are at rest. All necessary dressings, nursing, Ac., can be
carried out, and if any movement of the patient is necessary
he is moved as a whole and not in parts.
Fig. D.—G.S.W. of rljfbt arm, compound fracture, displacement, upper
fragment abducted. After application of arm splint the fragments
are shown in good alignment.
The iron leg portion of the splint can be raised at right
angles to the operating table, and thus out of the way should
any operative procedure be necessary, the upper fragment
being perfectly controlled by the grip pad, the lower steadied
by an assistant.
The splint is made double to ensure steadiness and to
enable the patient to be moved easily. The final result is
that the patient lies with the fractured thigh in its proper
position comfortably beside the healthy limb. In all cases
skiagrams are necessary—both antero posterior and lateral-
in order to show whether the fragments are actually in
correct position.
The splint is useful in all fractures below the great
trochanter where there is abduction of the upper fragment,
but its use is not limited to compound fractures of the femur.
It would be of great value in treating fractured pelvis, intra-
capsular fractures, and anterior poliomyelitis to give rest to
paralysed muscles.
Arm splint .—An efficient splint for the upper extremity
should be firmly fixed to the patient’s body so as to carry
the limb and keep the fracture in proper position and at
rest. Usually the splint hangs on the limb instead of
supporting it.
The splint for the upper extremity which has been designed
by me consists of two parts (Fig.'B). One fits firmly on to
the trunk (1); the other carries the limb (2). The upright
trunk part is fitted to the hip with an adjustable piece which
allows its upper forked end to be securely fitted into the
axilla (3). This part is fastened round the body by two
straps. To the upper end of the fork the part which carries
the limb is attached by joints (4), which allows the arm to
be abducted to any desired angle and retained there. The
centre of movement passes through the head of the
humerus. By releasing a set screw (5) on the tubular piece
the hip portion can be turned round ; the limb attachment
is then turned completely over; hence the splint can be
used for right or left limb equally effectively. The splint
can be adjusted so as to support the shoulder in any desired
position. The forearm can be placed in either the semi-
prone or supine position. Provision is made for any
necessary extension. When properly fitted the patient
carries the upper extremity with the whole weight supported
by the body ; hence the limb is kept quite steady and at rest.
Dressing of wounds, massage, Ac., can be carried out without
interfering with the splint. (See radiograms, Fig. D.)
After much careful observation of many cases I have
designed these two splints, one for each extremity, and have
proved that both appliances are efficient, easy to apply, and
give great comfort to the patient. I hope that their use in
treatment of such cases may help to produce better results
in the future. In conclusion, I desire to express my warmest
thanks to my colleagues, especially to Lieutenant-Colonel
C. T. Parsons, for valuable help and encouragement; to Dr.
Florence Stoney for her great assistance with the X rays ; to
the staff of the Kensington War Hospital Supply Depot; and
to Messrs. Arnold and Sons, who made the splints for me.
MENINGOCOCCUS BRONCHO-PNEUMONIA
IN INFLUENZA.
By WILLIAM FLETCHER, M.D. Cantab.,
CAPTAIN, H.A.M.C.
(From the Laboratory of the University War Hospital,
Southampton.)
“The epidemic of influenza which has visited'this country
during the later months of the year 1918 has been charac¬
terised by an unexampled severity due to pulmonary compli¬
cations. In the cases of broncho-pneumonia, which have been
responsible for most of the deaths in this epidemic, the lungs
are invaded not by Pfeiffer’s bacillus alone, but by that
bacillus aided and abetted by one or other of the many
organisms which inhabit the respiratory tract, such as
pneumococci, streptococci, diphtheria bacilli, and, in the
cases which I am about to describe, meningococci.
Sometimes these secondary organisms are, by themselves,
of low virulence; the pneumococci are very often of the
fourth group, and the streptococci frequently belong to the
viridans type, but when they join forces with the influenza
bacillus and follow its lead in a descent upon the lungs they
can play a deadly part.
Bacteriological Findings.
Between Sept. 25th and Nov. 23rd, 1918, cultures were
made, after death, from the lungs and from the heart’s blood
of 36 American soldiers who had died from broncho¬
pneumonia. These men, for the most part, had been taken
ill with symptoms of influenza a week or 10 days before
admission to this hospital, while they were on board
transports crossing the Atlantic.
In films prepared from the lungs of some of them the only
organisms to be seen were Gram-negative diplococci in
enormous numbers, the majority of them lying within poly¬
nuclear cells. In one or two instances they were so
numerous that there was hardly a cell that did not contain
some. Plate cultures were made post mortem from the
lungs of all the cases ; numerous colonies of Gram-negative
cocci were obtained in 11 of the 36, and in three instances
Tam Lanott,]
MB. G. E. FRIEND; APPARENT
they were grown from the heart’s blood as vyell. Sab-
cultures of these cocci from seven of the cases were examined
at the Central C.-S. Fever Laboratory, with the result
that six were found to be Type II. meningococci, while the
seventh conformed to Type 1. The other four strains were,
unfortunately, not kept for farther examination, but as, with
one exception, they were derived from cases of influenza
which occurred on the same transport as the other seven, and
as the appearance of the Aims prepared from the lungs was
the same, it is probable that they, too, were meningococci.
In all these 11 eases I*feiffer's haeillvs was present in asso¬
ciation with the meningococcus; it was not always found in
the Aims, but it always grew on plate cultures made from
the longs. In two instances pneumococci were also present;
in one case streptococci and in another both pneumococci
and streptococci were found.
Clinical Features : Condition of Lungs Post Mortem.
The duration of illness from the beginning of the influenza
to the end in death was from 11 to 16 days, except in one
instance, where the patient lived for 24 days from the date
of onset. The men did not reach this hospital until they
had been ill for some time, and there are no available
clinical records of the course of the disease in its early part.
All of them, except one who came from a hospital in France,
had been attacked by influenza while on board the transport,
and when they were admitted here about a week later they
were very ill indeed. Four of them died within 48 hours of
admission, 4 within a week, and 3 within a fortnight.
There were no special features by which these meningo¬
coccus broncho-pneumonias could be distinguished clinically
from the other cases in this ship epidemic which were due to
a combined infection with Pfeiffer’s bacillus and pneumococci
or streptococci, except that in the meningococcus infection
there was possibly a greater tendency to haemoptysis. In
one or two of the cases which were seen in the earlier stages
the sputum was rusty and tenacious, but for the most part
it was nummular, airless pus mixed with dark blood.
In several of the cases an even high temperature was
gradually coming down by lysis during the first few days
after admission, when it suddenly rose again as though some
fresh bacterial invasion had occurred, and instead of remain¬
ing steady there were wide oscillations between 99° F. in the
morning and 104° or 105° at night. The pulse-rate in these
fatal cases increased to 120 or more, and the respirations to
about 60. It is noteworthy that in the case of one man,
from whose heart and lungs meningococci of Type II. were
isolated, the skin was a bright yellow colour for several days
before he died. None of the patients showed any signs of
meningitis before death took place, nor was any evidence of
it seen afterwards.
In every case confluent broncho-pneumonia was found
post mortem, producing large areas of consolidation, and both
lungs were affected, though generally the process was more
advanced on one side than on the other. In two instances
red haemorrhagic patches beneath the pleura were a striking
feature, in four the pleura was covered with recent lymph,
and in two there was turbid fluid in the pleural cavity.
In some cases the broncho-pneumonic patches coalesced
to such an extent that whole lobes were solid and airless,
while in others the patches of consolidation remained
separate, so that the affected lung felt like a bag of plums.
In every case when pressure was applied by squeezing the
lung, thick yellow pus oozed from the blocked bronchioles.
In one instance there was an abscess with ragged walls at.
the base of the right lung, which contained a thick, dark,
red fltfid full of Gram-negative cocoi.
Other Observations.
Shortly after the death of these men a British soldier
suffering from bronchitis was admitted from France, where
he had been under treatment in an American hospital. He'
had been taken ill suddenly with giddiness and pains in the
back 15 days before. His temperature was of the same
type as that of the American soldiers who died from
meningococcus broncho-pneumonia, swinging -from 98° or
99° in the morning to 103° at night, but his pulse was not
above 100 and his respirations were never more than 40
to the minute. Films prepared from his sputum, which was
frothy and purulent, contained large numbers of Gram¬
negative cocci, and a plate inoculated with it gave a
profuse growth of meningococci of Type IV. and a few
staphylococci. This patient’s temperature came down by
lysis and was normal on the twenty-fifth day.
IMMUNITY FROM INFLUENZA. [Jan. 18, 1919 105
Lieutenant* Colonel M. H. Gordon, to whom I am greatly
indebted for carrying out the agglutination tests on these
meningococci, has very kindly drawn my attention to a
paper by Jacobitz, 1 who investigated an outbreak of disease
which occurred in a Jiiger battalion at Colmar during
February, 1906. He found two men suffering from typical
cerebro-spinal meningitis without complications, three cases
of meningitis associated with meningococcus pneumonia,
and one case in which there was meningococcus pneumonia
without symptoms of meningitis ; this last case ended by
crisis and recovery. In addition, he observed four 'cases of
bronchial catarrh (with meningococci in the sputum)
without any symptoms of meningitis, all of whom recovered.
He does not appear to have found Pfeiffer’s bacillus in any
of his patients.
Summary.
1. In the post-mortem examination of 36 men who had
died from broncho*pneumonia following influenza, Gram-
negative cocci were the predominant organisms found in
the lungs of 11 cases.
2. All the men, with one exception, had been taken ill on
board the same transport.
3. In six cases these Gram-negative cocci were Tvpe II.
meningococci and in one case they belonged to Type I.
In four instances the cocci were not tested by agglutination.
4. In each of the 11 cases Pfeiffer’s bacillus was found in
symbiosis with the Gram-negative cocci.
5. The meningococcus, like other "respiratory’’organisms,
may, when it occurs in conjunction with Pfeiffer’s bacillus,
produce a fatal broncho-pneumonia.
APPARENT IMMUNITY FROM INFLUENZA
AT A PUBLIC SCHOOL.
By G. E. FRIEND, M.K.C.S., L.R.C.P*,
MEDICAL OFFICER, CHRIST’S HOSPITAL SCHOOL, WEST HORSHAM.
In view of the fact that certain statements have appeared
in the public press in reference to the absence of cases of
influenza among the 800 odd boys at Christ’s Hospital
School, West Horsham—which statements were not entirely
accurate—it is possible that some authentic account of the
local conditions may be of interest.
Incidence tn Summer and Winter Terms.
The summer term, which had shown a good health return,
ended on July 25th. On Saturday, July 20th, the school
cricket XI. went to Brighton to play a match. As a sequel
to this visit five of the team became infected with influenza
and were admitted to the school infirmary on Sunday
morning with 3 other boys who were not in the team but
came from the same houses as those who were, and had
obviously been infected from them. Only 2 cases were
admitted on July 22nd, and 7 on Tuesday, 23rd, 18 on
Wednesday, 24th, and 4 cases on the morning of the 25th.
There were thus 39 cases occurring as a result of this
exposure. Nearly all these boys were from the same houses
as the first five. There were during the previous ten days
21 cases of mild influenza occurring in various houses of the
16 that comprise the school, but they were sporadic and
milder in type than the 39 later cases. None of these
60 cases were severe, and there was no case with ; any
complication in the school.
Several cases (probhbly about 30) occurred after the boys
arrived home among those who must have been ill on the
morning of leaving but who did not report. Every term all
the boys are inspected by me on the afternoon of the day
before going home, but as they start at 6 a.m. in the
morning it is impossible to inspect them nearer the time of
departure.
During the holidays the infirmary was washed down and
the mattresses and.wards used for influenza cases were dis¬
infected. I did not, however, think it necessary to carry
out disinfection on a larger scale.
The winter term began on Sept. 13th and ended on
Dec. 18th. During the whole term the medical Illness was
less than it had been in any term since 1898. The total
number of medical cases admitted was 115 for 13 weeks.
Of these, 36 were " chills i.e., cases of illness with raised
i Der Dlptocoocm Meningitidis Gerebrosplnalis els Brregsr von
grknmkungen der Lunge und Bronchlen, Jaeobltz, Zelt. f. Hyg.,
106 Thb LANOTT,] MR. G. E. FRIEND: APPARENT IMMUNITY FROM INFLUENZA.
[Jan. 18, 1919
temperatures of 24 hours or more without definite physical
signs. The cases occurred sporadically amosg the 16 houses,
and there was nothing in their distribution or incidence to
suggest that they were anything more than the ordinary
so-called “ohill.”
Preventive Keasures.
After the experience of the summer term cue was naturally
anxious, and at the beginning of the winter term I
advised the Headmaster to stop all leave of absence and
to keep the boys strictly in bounds. The school is self-
contained and lies in a ring fence. Walks outside were
allowed, but the town, 2£ miles away, and all the houses
off the school estate were put out of bounds. It was
not found possible to keep visitors away, and swarms
of these arrived every Wednesday and Saturday throughout
the term, many usually staying over the week-end, nor was
it possible to stop all leave of absence. There was a further
exposure to infection via non-resident masters and servants,
the latter especially being possible carriers. These are
supposed to report to me in the event of any illness occurring
in their homes, and when possible I suspend them coming
into contact with the school, but I do not think this is a
very certain check. As an attempt to adjust actual
conditions to the reduced diet values which have recently
pertained we had previously increased the amount of
sleep by one hour and decreased the amount of work and
play, and these measures were continued in force. I also
introduced the nasal drill as described by Dr. Isabel
Ormhton in Thr Lancet of August 24th, 1918. The method
used is substantially as described by her, and the boys do
the drill twice daily—on rising in the morning and before
going to bed at night.* The-nose-blowing is performed six
times to the word of command, which is given by the
monitors, who act as pupil instructors of physical training,
and form the first exercise at every P.T. drill, which at
present is done in the dormitories after washing in the
morning. (I am aware that this is not the most suitable
time, but at present it has not been found possible to give
another time for P.T., and it is not done on an empty
stomach, as the boys are given two wheaten biscuits each on
rising.)
Dr. E. L. Hunt, bacteriologist to St. George's Hospital, sug¬
gested to me the possibility of vaccine prophylaxis—and after
talking it over with him we decided to give a single small
dose of polyvalent influenza vaccine. We were averse to
using a mixed vaccine, because we regard cases of pneu¬
monia and streptococcal infections as “ complications ”
occurring, in the majority of cases, after the onset of an
influenzal infection. In some cases, it is true, pneumonia is
present when one first sees the case, but that is, we think,
to be expected in a certain percentage of cases. Also, as
the inoculation of a large school might, if not successful,
have occasioned considerable comment, I preferred what
seemed to me the lesser risk of an unmixed vaccine. We
decided to give a 70 million dose to all boys over 14 and
30 million to those under 14. A post-card was sent to
every boy’s parent or guardian informing them that their boy
would be inoculated as a preventive measure unless they
wrote to me that they objected.
Account of the Prophylactic Vaccination.
I inoculated the boys on Oct. 30th (approximately at half
term).
306 boys received 70 million. | 327 boys reoeived 30 million.
Total: 633 boys inoculated.
39 boys’ parents objected to inoculation.
128 boys I considered unsuitable for inoculation.
19 boys were absent ill.
Total: 186 boys not inoculated.
Approximately 77 per cent, of the school were inoculated.
In addition 34 of the staff received 70 million.
The proceeding was, of oourse, voluntary as regards the
staff and their families, but the response to the invitation
was poor, as approximately 13 per cent, only of the staff and
families were inoculated. Every precaution was taken.
Temperatures were taken morning and evening the day
before, the day of, and three days following, the inoculation.
All games and O.T.O. parades were stopped for the same
period, and only very moderate exercise allowed until the
sixth day after.
All the boys were inooulated the same day by me, with the
assistance of two nurses, one charting particulars, the other
preparing the skin. The injection was made with a 5 c.cm.
Record syringe, holding 10 I c.cm. doses, and given in the
left forearm on the extensor surface just below the elbow.
The first 100 were swabbed with ether, but after that, owing
to the fumes, tinct. iodi was used.
The boy8 marched to the infirmary by houses, according to
a time table previously circulated, stripped coats in my out¬
patient room, and then came through an inner room where
the injection was given. Then returned to the first room and
waited until the whole 50 boys in the house had been inocu¬
lated or rejected. In this way any bleeding, faintness, Ac.,
was known of and seen to.
The needle used was dipped into boiling water between
each puncture, and the syringe refilled every 10 punctures.
The vaccine was made for me by Dr. Hunt from a series of
cultures of Pfeiffer’s bacillus obtained at St. George's
Hospital in the year’s epidemics, and was put up in bottles
of 100 doses, the dose in each case being £ c cm. of vaccine,
the labels for the bottles containing the 70 and 30 million
doses being different. In this way I was able to get through
the whole 633 inoculations and see also the 167 rejected.
Every boy was seen and questioned by me as to fitness before
inoculation. Each house of 50 boys came up in charge of the
head boy, who brought a list showing the temperature of the
boys for that morning and the previous evening.
The temperatures were taken in each house by the house
matrons, assisted by the masters or senior boys, and this
work was supervised during the day by a nurse who was
specially employed for this purpose and who afterwards
charted the complete records. Possibly as a result of these
precautions there were no cases of severe reaction.
The boys were all seen again three days after the inocula¬
tion (when they attended for the mid-term weighing) and
were questioned by the nurse in my presence as to reaction
with the following result
Dose
in
milliona
Local.
Focal.
General.
Inocu¬
lated.
Markedj Slight.
So»e
throat.
Cold.
Malaise
Diarrhoea.
70
0 i 4
10
1
19
0
308 *80
30
0 I 6
9
4
29
1
3271®"
Total...
0 j 10
19
5
48
1 (G. total. 83)
In no case was a rise in temperature recorded. Of the 83
only one boy was sufficiently incommoded to report at the
infirmary, and he was one who had light brawny swelling
round the site of puncture, which subsided after the appli¬
cation of a couple of cold-water compresses. Of the 48 cases
of malaise probably half can be discounted, if not more, as
no one had reported, and the majority of the histories were
given in response to leading questions by the nurse. If all
are included the number of reactions equal 13 per cent.
The Immunity from Disease in the Winter Term.
There were during the term no cases of definite influenza
among the boys except one—a boy who had been inoculated
with a 30-million dose on Oct. 30th. He went home to
attend his mother’s funeral on Nov. 20bh, she having died
from influenza. On his return on Nov. 24th he leported to
me according to the school rule, and I kept him isolated.
The same evening he had,a slight rise of temperature, with
headache and pain in the back; the next day coryza and
cough—no other signs—and the temperature became normal
in three days. Probably this was mild influenza. In regard
to the rest, there were during the term 36 cases of “ chill,”
as already mentioned. These were cases of raised tempera¬
ture, malaise, slight sore-throat. Ac., without definite physical
signs admitting of an exact diagnosis. They all recovered
with a day or two in bed on a light diet.
Influenza was from September on very prevalent in
Horsham and in all the surrounding villages, and from
Oct. 14th onwards there were cases among the staff living in
the school precincts. Oa Oct. 14th a maid from the Prepara¬
tion School House went down with influenza, and on the
15th and 18th a second and third went down. Two of these
developed pneumonia the second day of disease. A fourth
maid from the same house went home on the 19th quite well
and went down with influenza at home that afternoon. She
afterwards developed pneumonia. On the 23rd and 26th
two maids in another house developed mild influenza. All
these cases were immediately isolated in the infirmary, and
there was no further spread in the school. On Oct. 24th a
The Lancet,]
CLINICAL NOTES.
[Jan. 18, 1919 107
master's wife and on Nov. 4th a second master’s wife, living
at the opposite end of the avenue, developed definite
influenza. They were both isolated, and no further spread
occurred. About 10 other cases occurred in various houses
on the estate, but not so immediately in contact with the
school proper. All these cases recovered, and except the
3 pneumonias there were no complications. None of these
were inoculated, and of these cases 6 only occurred after
the school had been inoculated.
As already stated, the total number of medical cases
treated in the school during the term was considerably lower
than the number for any other term, winter or summer,
since 1898, before which date the records have not been
tabulated. The majority of these were definite cases of
bronchitis, pleurisy, gastritis, &c., but 36 were perforce
classified as “chill.” It may be argued that these were
cases of modified influenza. Unfortunately, bacteriological
examination was not practicable.
Against the diagnosis of influenza are the absence of
definite symptoms, the short duration of illness in the
majority of cases (the average time in hospital of the 36 is
just under three days), and the complete absence of after¬
effects. In favour of the diagnosis is the known contact
with many potential carriers and close proximity to several
definite cases. Twelve of the 36 occurred before Oct. 30th,
and 24 occurred after Oct 30th. Of the 24 occurring after
Oct. 30th, 7 were among the uninoculated = 42 per cent.,
and 17 were among the inoculated = 26 per cent. (2 with
70, 15 with 30 million).
The view has been put forward that the administration of
any vaccine produces an increase of resistance to any
organisms in the individual. 77 2 per cent, of the school
were inoculated on Oct. 30th. Sixty-four medical cases of
all kinds were admitted to the infirmary after that date ; of
these, 41 had been inoculated = 6 per cent. ; 23 were
uninocnlated = 13 per cent.
The statement was made in the Press that I had instituted
a routine nasal douche of potassium permanganate. This is
incorrect. It would have been impossible to arrange to
douche 800 noses by trained help, and I should regard such a
proceeding, if left to the unaided resources of the boys, as a
most unsafe method. I think the fact that inoculation was
performed acted as a great mental factor. It is possible
that the cases labelled chills were in fact cases of modified
influenza, though, in my opinion, the clinical evidence is
against this.
The chief factors in what is an extraordinary immunity
appear to be — (a) the physical training, which though it has
been seriously undertaken for six months only, has already
produced a marked improvement in physique. (&) The nasal
drill, which perhaps is the most important of all. (c) The
fact that for the past three months the caloric value of the
school diet has reached practically the pre-war value of
3000 calories per boy per diem—for the first time since 1916.
(d) The effect of inoculation, therapeutic and moral.
It will be interesting to know when the school reassembles
how many boys have contracted influenza, or have been
definitely exposed to it during the holidays.
Note by Dr. E. L. Hunt.
The following note as to particulars of the preparation of
the vaccine has been kindly added by Dr. Hunt.
The vaccine used was a polyvalent one, containing only
the influenza bacillus, obtained from different sources.
The organisms used were as follows :—
(a) Bac. influenza obtained from nose, October, 1918.
(bj ,, „ sputum, June, ,,
(c) ,, ,, nose, October, ,,
(«) „ 11 sputum, July, ,,
( e ) ,, ,, ,, September, 1918.
These organisms from when first isolated had been kept
going on blood-agar medium at 37° C.
The medium used for the vaccine tubes was rabbit’s blood
agar, made by adding some 5 drops of the blood, freshly
obtained under aseptic conditions, to 4 c.cm. of melted
lemco-peptone-salt-agar at about 60° C., the tubes being
mixed, slanted, and allowed to cool.
Ten tubes were inoculated (Oct. 26th, 1918) from each of
the 5 organisms, respectively (50 tubes) and grown for
48 hours at 37° C.
The vaccine was heated in a water-bath at 55° C. for
30 minutes. Sufficient vaccine was thus obtained to yield—
5 x 50 o.cm. bottles, i c.cm. = 70 million.
5 x 50 c.cm. ,, A c.cm. 30 „
Clnural Stales:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
NOTE ON A CASE OF PERICARDIOTOMY.
By T. P. Noble, M.D. Edin,,
CAPTAIN, R.A.M.C. ;
AND
A. B. Vine. M.R.C.S., L.R.C.P. Lond.,
CAPTAIN, R.A.M.C.
In the following case pericardiotomy was performed on the
twelfth day after passage of a rifle bullet through the chest,
with recovery of the patient.
The patient, a lieutenant in the Lancashire Fusiliers, was
wounded on April 11th, 1918, by a rifle bullet which entered
in the third interspace \ in. internal to the nipple line on
the left side, and had its exit 1A in. to the left of the
mid-line behind, on a level with the seventh dorsal spine.
His first sensation when he was hit was a burning pain
behind ; then he fell, and all power seemed to leave him. A
few minutes later he was able to run 50 yards with the aid
of a man supporting him on either side*. He did not lose
consciousness, but had considerable dyspnoea. Admitted to
No. — C.C.8. (April 11th). The noteson his field medical card
show the follow
ing: “ Entrance
and exit wound
left cheBt, swell
ing in the left
pectoral region,
and signs of a
small h so m o
thorax.”
Admitted to
No. — Stationary
Hospi tal on
April 14th. Con¬
siderable diffi¬
culty in breath¬
ing, and had to
sit almost up¬
right. P. 90, R.
30, T. 100-6F.
E. and E. wound
as noted. (See
Figure.) The entrance wound was merely a puncture
with a rather larger exit one. Cardiac dullness : Right side,
1 in. to right of sternum; left side, to the nipple line and
upwards to the lower edge of the second rib. Pericardial
friction heard to the right of the sternum and near the apex.
Posteriorly there was dullness up to the level of the exit
wound, breath sounds heard all over, but weak. April 16th :
T. varies from 100 to 102°. Friction more marked and
audible all over the prtecordia. Dyspnoea continues and
cough troublesome. April 20th: Cardiac dullness slightly
increased, friction persists, dyspnoea more marked, cough
very distressing. P. 92, T. 102-6°. Seen by Major-General
Sir John Rose Bradford, who advised exploration of the
chest and, if necessary, pericardiotomy. April 21st: Con¬
dition worse, cough, dyspncea and pulse-rate all increasing.
An X ray photograph which was taken showed the peri¬
cardium distended with fluid.
Operation .—General anaesthesia with chloroform and
ether, with preliminary morphia and atropine hypodermi¬
cally. Twelve ounces of clear fluid were withdrawn from the
left pleural sac, which was proved to be sterile. An incision
was now made along the fifth rib and cartilage from the mid¬
line to the nipple-line, the fifth costal cartilage was resected,
the fibres of the triangularis sterni muscle were separated,
and the internal mammary artery drawn inwards. The
Plate from Johnson Symington’s “ Atlas of Topo¬
graphical Anatomy,” Indicating the probable
path of the bullet, which appears to have punc¬
tured the pericardium and grooved the muscular
wall of the heart.
108 ThbLancot,)
CLINICAL NOTES.
[Jan. 18, 1919
pericardium was now picked up and a vertical incision was
made in it. Very little fluid at first escaped, but when tbe
finger was insinuated between tbe right auricle and tbe
pericardium and between the left ventricle and tbe peri¬
cardium cloudy fluid escaped in quantity, which on bacterio¬
logical examination was found to contain a short strepto¬
coccus. Glove drains were inserted to the right and left
inside the pericardium and the wound was closed.
April 23rd: Breathing and cough much easier; drains
removed. Pulse and temperature now gradually fell and
the wound healed by first intention. Four weeks later he
was evacuated to England. The cough and dyspnoea had
disappeared, the cardiac dullness was much less, and there
was no friction.
Subsequent inquiry two months later showed that his
improvement was maintained.
THE MOLYBDENO-TUNGSTEN ARC IN THE
TREATMENT OF VARIOUS SUPPURATIVE
LESIONS.
(As v-sed at a Divisional Rost Station and a Stationary
Hospital, Italian E.F .)
By B. Michell Young, M.R.C.S., L.R.C.P., D.P.H.,
CAPTAIN, R.A.M.C. (T.)
Thb very numerous cases of old wounds, ulcers of
various parts of the body, carbuncles, inflammations of
the cutaneous tissues, and such like, have presented many
difficulties to obtain rapid healing. Many methods have
been employed with more or less success to lessen the
period during which the man is incapacitated from duty. In
March, 1917. I first used the molybdeno-tungsten arc on skin
lesions, and suggested that it should be employed for the
treatment of this class of case. The lamp was erected first
at the divisional rest station, the necessary current being
obtained from a repair-motor lorry’s engine situated some
400 yards away. This was satisfactory. Afterwards it was
connected to the town-supply at the stationary hospital.
The cases selected for treatment were chiefly those which
were of considerable duration and which showed little or no
improvement obtained by previous methods of treatment.
The exposure given was generally three minutes at a distance
of 50 cm. from the arc. The dressings used were practically
in all cases of gauze damped with sterile water; in a few
normal saline was used. This was adopted as it was
desirable to eliminate any cause of improvement, or the
reverse, other than the effects of the ultra-violet rays pro¬
duced by this arc. I am basing my remarks tin my own
experiences and on a series of cases treated by Lieutenant-
Oolonel Wells, to whom I am indebted for kindly forwarding
to me his notes and observations. In considering the various
effects and non-effects produced, the cases tend to group
themselves into acute lesions, stationary or inactive lesions,
and chronic. In the acute lesions, frost-bite, carbuncles,
large areas of inflamed and ulcerated skin responded readily.
A series of frost-bites especially, with loss of tissue, afforded
effective comparison, as only one limb was exposed to the
light, while the other was treated with the usual methods.
In every case the light caused prompt healing in about eight
days, while the other remained unhealed. In 38 cases of
generalised sores many were healed more speedily by this
method of treatment.
Ulcers of heels and toes require relatively more exposures
according to the length of time they have acquired their
indolent condition. But once the effect is produced they
steadily progress ip the process of repair. Occasionally
a case is met which refuses to respond. For this I can
advance no reason ; one such occurred in this series—possibly
specific.
Taking the whole series, the exposure of three minutes is
sufficient in the first group and good results were obtained,
but this should be increased even to causing erythema of
the surrounding tissues, until evidence of activity in the
sores is produced in those obstinate cases, and possibly more
rapidity of healing would be obtained. Cases of bubo which
had been incised were treated from the outset with daily
exposures of three minutes, and each healed in eight days,
leaving a narrow healthy linear scar, comparing favourably
with cases treated in the usual way; and my experience
shows that, speaking generally, there is an absence of
thickening and puckering in cases sp treated.
Some patients develop an erythema in the surrounding
skin (especially those of the fair type) in response to the
light, but increase of distance or interposition of the quartz
globe neutralises this effect. The skin soon becomes tolerant,
when full exposures may be given.
The lamp now employed is known as the “meridian”
automatic feed arc fitted with the new molybdeno-tungsten
electrodes. It is connected in the usual manner with the
ordinary house supply, and is a suitable contrivance for all
voltages above 100 volts, both direct and alternating current.
The observations which these cases afford lead one to the
opinion that this method of treatment is useful for shorten^
ing the incapacity for duty.
A PLASTIC VOCAL CORD.
By Ferris N. Smith, B.A., M.D. Michigan,
HON. CAPTAIN, R.A.M.C.
Thb following case is reported because of the unusual
possibilities which it suggests at this time, when many cases
of traumatic aphonia are added to the usual list of such cases
resulting from disease. The technique was quite original;
no similar procedure has been found or suggested in the
literature. The patient is the secretary-manager of a large
home for aged Dutch people, and was in excellent health
when last heard from in June, 1918.
J. C. H., aged 62, came for examination in January, 1917,
on account of rapid loss of voice, some referred pain radiating
to the right ear, and slight loss of weight. He gave a
history of removal of a small mass from the right vocal oord
and cauterisation three years previously. Inspection revealed
a nodular, rough mass about the size of a split pea at the
mid-portion of the free margin of the right true cord ; this
prevented apposition of the cords, causing the loss of voice.
A small specimen for examination was removed through the
laryngoscope. The pathologist reported “ squamous-cel led
carcinoma.”
In view of the previous history and findings a radical
operation—hemilaryngeotomy—was indicated, but on account
of the man’s occupation, which necessitated the retention of
some speaking voice, I was loath to follow this procedure.
The posterior end of the cord with its arytenoid attachment
was apparently free from infiltration, and offered a founda¬
tion for the procedure which was carried out. There was a
great deal to gain and very little to lose in the effort to
reconstruct this vocal cord before resorting to the radical
rocedure. Further, any healthy mass of tissue which could
e put in the cadaveric position of a vocal cord would
furnish an abutment for the" functioning cord and' ensure
spoken voice. The functioning arytenoid offered hope of
some motion.
With the above considerations the following operation was
conceived and executed in two stages at the Blodgett
Memorial Hospital, Grand Rapids, Michigan, in February,
1917 :—
Stage 1 consisted in the dissection and paoking of neck
structure about the larynx to produce an inflammatory
barrier against infection of the deep planes of the neck after
opening the airway and preparing the distal end of a flap to
imitate the form of a vocal cord. This was done by maxing
two short incisions to outline the lateral borders, dissecting
the skin free from underlying tissues, planting a small piece
of cartilage, and suturing a tuck or fold in the skin to include
this cartilage. The crest of this fold was three-eighths of
an inch above the normal skin level. The balance of the
flap was not dissected until the second stage of the operation.
At the second stage a laryngotomy was performed, and the
anterior three-fourths of the cord, with all soft parts in a
wide area extending down to the thyroid cartilage, was
removed. The skin flap, with a broad base in the supra¬
scapular region of the right neck and its prepared distal end
just above the right nipple, was dissected. The distal end
was trimmed to fit in the denuded area of the larynx in
such a manner that the fold containing cartilage assumed
the level of the former cord. It was sutured to the cord
stump on the arytenoid and border soft parts with horse¬
hair. A tracheotomy-tube was inserted through the upper
two tracheal rings and the larynx packed with bismuth
aste gauze. The larynx was held slightly open with a
ansen mastoid retractor. The skin opening of the neck
and chest was closed by undermining ana sliding the skin.
The patient was plaoed in a bed which was considerably
elevated at the foot. He was fed with a gastric tube. The
skin flap was covered with warm, constantly changed, boric
compresses, and the larynx was dressed twice daily.
On the eighth day the mid-portion of the pedicle of the
flap showed signs of withering. This was resected on the
ninth day, part of tbe base being returned to the neck. A
small part of the inferior border of the larynx implant
Thb Lancet,]
ROYAL INSTITUTE OF PUBLIC HEALTH
[Jan. 18, 1919 109
sloughed, but this was not in a position to vitiate the result.
The tracheal tube was withdrawn at this time and the
larynx and neck closed, excepting tbe tube tract, which was
lightly packed. Subsequent recovery, except for a mild
bronchitis, waB uneventful.
The patient had a hoarse, whispering voice immediately
upon closure of the larynx. The voice quality constantly
improved with the disappearance of the local reaction until
it was functionally excellent, only a slight huskiness
remaining.
Several improvements in technique have occurred to me
since seeing the plastic work of Major H. D. Gillies at Queen’s
Hospital, Frognal, Sidcup. His method of tubing a long
pedicle by suturing its raw edges would undoubtedly prevent
the gangrene which occurred in my flap, and leave a clean,
healed neck to deal with at the time of the major procedure.
The distal end of the flap should be completely outlined by
skin incision and resutured in place to increase its blood -
supply, and the cord accurately reproduced, even to a thin
edge, by shaping a piece of costal cartilage instead of using
the thin septal cartilage. This should be done in the first
stage.
The method is applicable to cases of hemilaryngectomy,
either surgical or traumatic, if three stages are employed,
the second stage to consist in removal of the diseased or
scarred portion of the larynx and lining the deficiency with
skin, leaving for the third stage a shaped cartilage implant
to give stability to the larynx box and an abutment for the
functioning cord._
Utriwral Sflrietb.
ROYAL INSTITUTE OF PUBLIC HEALTH.
Discussion on the Prevention and A rrest of Venereal Disease
in the Army.
A special conference was held on Jan. 8th.
Lord Sydenham, chairman of the National Council for
Combating Venereal Diseases, who presided, said that
medical science in all its branches had been powerfully
stimulated by the war, and victory had been gained
over many of those diseases which used to cripple
armies in the past. We understood now better than
ever before that medical science and sound administration
must always go hand-in-hand, and together could produce
an immense improvement in public health. Public health
and the happiness of the people went together. In so far as
venereal disease could be arrested in the army it must be
an immense gain and protection to the civilian population.
During the war there had been an increase of infection
among that population which would increase the risks to
demobilised men.
The Policy of Silence.
Professor J. G. Adami, Colonel, C.A.M.C., read a paper
opening a discussion on the Prevention and Arrest of
Venereal Disease in the Army. He said that the perform¬
ance of a physiological function which the individual in his
heart of hearts knew to be in itself natural and desirable had
to be regarded and taught as contrary to good morals. We
found ourselves torn asunder between Peter and Paul ; the
Peter that is within us teaching us that what God has given us
is clean and is to be enjoyed ; the Paul, that woman is a snare
and that even a bishop should have but one wife—and scarcely
that. And as youth was largely irresponsible and the sense
of social duty a plant of slow growth, which in some
throughout life was choked by the weeds of personal
predilection, it had followed that the whole matter
of sexual conduct had for generations been surrounded
with an atmosphere of insincerity, not to say hypocrisy.
The “dead hand” of training began in early childhood,
whereby we were taught to regard the open discussion of
sexual matters as taboo ; and there was the “ dead hand of
schoolboy “form,” according to which public acknowledg¬
ment of one’s standing in relationship to moral matters,
save on the part of those who had donned the cloth and
become professional moralists, branded one as either a
prig or a humbug. Happily, we were passing out of this
phase.
What this policy of silence had cost the country and the
Army during the last four years was awful to contemplate.
Before the war the annual reports of the Director-General
had warned the Government as to the prevalence of
venereal disease in the Army; a quarter of all admissions
to hospital were due to this cause, but, with the war, no steps
had been taken to render the regulations against harlotry
more rigid. Our men had been in the venereal hospitals not
by companies but by battalions. Each case had meant two
months and more on the sick list, and weeks and months
before the individual could be restored to full vigour at
the front, if, indeed, there was nob left a legacy of
rheumatism, eye disease, and enfeebled general health*
The Position during the War.
When in the autumn of 1914 the first Canadian contingent
arrived upon Salisbury Plain it was found that the Common
Law of England and the Military Law were equally impotent
to cope with the condition of affairs revealed. Harlotry in
England seemed to be a protected but not a controlled pro¬
fession. This, however, was also largely true of Canada, but
the Canadian authorities did expect that in England in war
time they would get willing help from local and London
authorities in protecting the soldier. Of help there was
little. Each week-end there poured into Salisbury Plain
from London from 80 to 100 loose women, and it was not
until under the Defence of the Realm Act in 1916 that the
naval and military authorities in one area, where there had
been a large outbreak of venereal disease, were empowered
to transport out of that area those directly or indirectly
concerned in the profession of prostitution.
He was convinced that the policy of frank dealing and
open speaking on the subject was the only one that would
improve conditions. Even at this late hour he begged the
National Council for Combating Venereal Disease to in¬
fluence the Government to publish a statement regarding
the venereal situation in the Army in successive years of the
war, in the different regions—at home, France, Mesopotamia,
and the like—so that the country might know the extent of
the trouble as it affected the Army, and, simultaneously, to
obtain powers to make an investigation in selected areas or
classes of the population into the frequency of either syphilis
or venereal diseases in general in those areas or classes.
Let the situation be known and faced. Had the medical
profession, the National Council, and the Government spoken
out at the beginning of the war the well-being and
happiness of the country and the conditions of our
troops would to-day have been very different from What
it is. In 1912, before the war, the Surgeon-General at
Washington had published outspoken regulations directing
all soldiers returning to camp to state whether they
had exposed themselves to the possibility of venereal
infection and detailing the early preventive treatment to be
given to those who had been exposed. This he (Colonel
Adami) had reported upon to the War Office, but the “ dead
hand ” had prevented its adoption for close on two years.
Preventive Measures and their IlesvZts.
With regard to the methods in vogue in the overseas military
forces of Canada it had been found in practice that there
was no one procedure which was effective in arresting
venereal disease in the army ; it was necessary to employ a
combination. The Director-General had put into force all
the methods save one (court martial)—education, warning,
recreation, diversion, protection, isolation, prophylaxis, and
penalties.
With regard to early treatment every Canadian orderly
medical room in England was an early treatment
centre, open day and night, with trained N.O.O.’s to
supervise and see that the soldier earned out fully the
instructions given. For those on leave in London
there were open day and night two early treatment centres,
at Southampton-street and at Victoria, and another treat¬
ment was given on their return to their units. The Dominions
worked together, and if no Canadian centre was open the
men could go to an Australian or New Zealand centre. The
Canadian authorities in their talks to the men on parade
made a point of emphasising that neither prophylactic nor
early treatment assured absolute immunity to venereal
infection. Experience had shown that even under expert
supervision no procedure was free from occasional failure.
The Canadian authorities firmly believed that if the Army
and the populace in general were advised that absolute
deterrents existed when this was not the case, there
110 The Lancet,]
ROYAL ACADEMY OF MEDICINE IN IRELAND.
[Jan. 18, 1919
was a possible danger of their employment leading, not
to diminution, but positive increase in the spread of
venereal disease. This had actually happened in Germany.
One set of statistics alone, he thought, would eloquently
show the effects of the campaign undertaken by the Director-
General through Lieutenant-Colonel Amyot and his staff.
During the month of September, 1916, from nearly 42.000
Canadian troops in Great Britain there were admitted to
hospital suffering from venereal diseases 960 cases, practi¬
cally a battalion. During the month of September, 1918,
from amoDg 110,000 Canadians in Great Britain there were
750 similar admissions. In two years the venereal incidence
had been reduced more than 66 per cent. ; it stood now at
less than a third of what it did two years ago. Had they
continued at the same rate the admissions during the month
of September, 1918, would have been, not 750, but over
2500—that is, two battalions and a half out of action.
The Dangers Ahead .
Throughout the war the soldier had been well cared
for with regard to venereal disease, but it was the civil
population that today constituted the grave danger,
and nothing had been done to meet the emergency.
When our soldiers returned and were feasted, made
drunk, solicited, and fell, there would be no medical
orderly-room to go to after demobilisation, no pro¬
vision for early treatment, no N.C.O. to see that the
elaborate toilet was duly performed. The soldier would
receive and not give, and, admitting that the provision
of prophylactic treatment to an uninstructed public might
well result in the spread rather than in the production of the
disease, he was strongly of opinion that the soldier before
demobilisation should be provided with the means of pro¬
phylactic treatment, should be advised where and how to
obtain “ tubes” without difficulty, and, moreover, be given
precise detailed instructions as to the method of employ¬
ment. For the good of the country he saw no other possible
course. To those who, in the supposed interests of morality,
would still maintain the policy of silence he could only
repeat what he had sa d in Westminster in July to the
National Conference upon Maternal and Infant Welfare :
“ Which is the more immoral act, to advise a man how to
prevent infection if he has transgressed the moral code, or
calmly and coldly to look on without moving a finger while,
through ignorance on his part, t.he innocent wife and children
are diseased, and they and the community suffer through
generations? ” Unless something were done and that imme¬
diately the next few months would see a spread of venereal
disease in this country that for generations would cause the
Empire to suffer. Now, if ever, it was well to repeat His
Majesty’s famous exhortation, “ Wake up, England.”
Discussion.
In the discussion which followed Professor Hugh H.
Young, Colonel, U.S.M C., strongly advocated the use
of prophylactic treatment which had been enforced in the
United States Army in 1912. In the following five years
venereal disease was reduced nearly 50 per cent. During
the war as far as possible large centres like Liverpool and
London were avoided in sending troops through England,
and in France brothels were placed out of bounds with very
gratifying results. Some of the brothels in that country
were terrible places, accommodating as many as 1000
or 1500 men in the course of an afternoon or evening.
Even granting that the women there appeared to be
healthy on medical examination, when men followed each
other in such rapid succession the women became carriers of
the disease. In one case a boy doorkeeper who had
frequent connexion with these women was found to be
actively syphilitic. The women acted as temporary hosts
for the disease and sources of danger regardless of the most
o&reful medical examination. This was a point which he
thought was new. The situation in London and other big
cities was a disgrace, and it was a crime that the police
should not be able to arrest the women W'om they knew to
be prostitutes. The soldiers would come back to a civil
population presenting far more dangers than the soldiers
themselves. Prostitutes were greater criminals than thieves,
for what was the loss of a little money compared with the
health of the country's manhood ? The calomel packet with a
leaflet giving full instructions for use on one side and moral
instruction on the other, if thought necessary, should be on
sale in slot machines at Id. throughout the country.
Professor William F. 8now, Lieutenant-Colonel, U.S.M.O.,
who is in charge of the Repression of Venereal Diseases
Department of the Surgeon-General’s Office, United
States, said, starting on the basis that continence was
the best remedy, the American Government had pro¬
vided all kinds of entertainment as a counter-attraction
for sexual excitement. The public were notified as to
what was being done and told that the Army would be
affected by the way the public authorities looked after its
manhood. The public had never opposed any of the Army’s
proposals. There was no conflict between morals and public
health. He did not fully agree with Colonel Young as to
the use of slot machines, because the packet gave the man
the opportunity of making his own diagnosis and treating
himself, which might not be done properly. If all dispen¬
saries opened their doors to the man who said “ I have just
exposed myself” he did not see any moral danger in it.
Major-General Sir Francis Lloyd, who had commanded
the London district for the past five years, said the question
ought to be dealt with from every point of view.
Sir James W. Barrett, Lieutenant-Colonel, R.A.M.C.,
late Australian A.M.C., in giving his experiences with
Australian troops, said that moral forces had been brought
to bear, but it was only after the use of prophylactic
methods that any general good had resulted. In regard to
the general question, the root cause of the whole trouble was
the marriage age. While that age remained ou an average
30 for men and 27 for women, there was nothing that would
prevent the sexual relationship of many people.
Surgeon Captain P. W. Bassett-Smith, R.N., detailed the
voluntary prophylactic methods in use in the Navy.
Sir Arthur Neavsholme considered that the Canadian
and American methods of meeting the venereal peril were
the most complete that had yet been devised, but he was
imbued with a sense of despondency at the relative ill-
success of the results. If under military discipline the
results were disappointing, what prospect of very rapid or
immediate success was there under the free conditions of
civilian life? When a public health measure came in conflict
with morals the first would suffer, and if a public health
measure were to be carried and applied with success moral
sentiment must go with it.
Professor J. A. Amyot, Lieutenant-Colonel, C.A.M.C.,
; said that the men were given every possible means of treat¬
ment, and the results had been satisfactory.
Dr. Helen Chambers was of opinion that the reason for
the ineffective way of dealing with the matter in the past was
the fact that the woman’s point of view had been ignored.
The time had come when women should receive instruction
from the medical women of the country. The scandalous
state of the streets should be dealt with by women polioe.
She pleaded for institutions where patients suffering from
venereal disease could be sent as infectious patients and
retained till cured, and where the nature of the disease would
not be made public.
ROYAL ACADEMY OF MEDICINE IN
IRELAND.
Section of Obstetrics.
Exhibition of Cases and Specimens. — Abderhalden't
Pregnancy Reaction.
A meeting of this section was held on Nov. 22nd, 1918, Sir
J. W. Moorb. the President of the Academy, being in the chair.
Dr. R. D. Pcrefoy showed a specimen of Tubal
Pregnancy, which was discussed by Sir William Smyly and
Dr. Bethel Solomons.
Dr. Solomons showed a specimen of Sarcoma of the
Cervix which he had removed from a woman aged 50. She
had been married 26 years and had 11 children, the youngest
of whom was 11. She complained of a feeling of “ womb
falling ” after the birth of her last child, but the symptoms
vanished until 14 days before she consulted him. On exa¬
mination it was found that a large mass, about the size of a
large grape fruit, filled the vagina and was connected with
the posterior 1 lip of the cervix, with which it was incor¬
porated. The tumour was removed, and as the cervix was
hypertrophied it was amputated. A pathological examination
by Dr. J. T. Wigham revealed the growth to be a spindle-
celled sarcoma, with a large amount of hyaline degeneration
of the capillaries, forming a kind of cylindroma. Following
Th« Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Jan. 18, 1919 m
this report. Dr. Solomons performed Wertheim’s hysterec¬
tomy, and convalescence was without incident. The uterus
on examination proved to be normal. He commented on the
silent growth of the tumour, with absence of symptoms,
which was typical of these rare cases of primary sarcoma.
He thought that a radical hysterectomy should always be
done in this class of case.
Dr. J. T. Wigham thought that the sarcoma, although
malignant, was, if one might call it so, a benign form of
sarcoma.
Dr. Pcrefoy said that sarcoma limited to the cervix uteri
was rare. In very young subjects myxosarcoma was some¬
times seen springing from the cervix in the form of numerous
small cysts, but its removal was generally followed by
recurrence. Notwithstanding the pathologist’s opinion, he
was inclined to regard Dr. Solomous’s case as one of uterine
fibroid showing sarcomatous degeneration.
Sir William Smyly showed Two Tumours of the
Mesentery removed from a patient in the Adelaide Hos¬
pital. The patient had a large cystocele which protruded
through the vulva and caused much difficulty in emptying
the bladder. On examination a tumour was discovered in
Douglas’s pouch which was supposed to be ovarian. After per¬
forming an anterior colporrhaphy the abdomen was opened
and the tumour, which was exceedingly friable, was drawn
out and found to be^ intimately connected with the intestine.
A second tumour was discovered higher up in the mesentery.
The tumours, which were thought to be malignant, were
removed, together with about two feet of the ileum and a
large piece of mesentery, and the severed gut restored by a
side-to-side anastomosis. The patient made an uneventful
recovery.
Captain J. Speares, who examined the specimen, said
that the edges of the tumour were tubercular, but the
central portion was so necrotic that it was impossible to
diagnose the condition.
Dr. W. M. Chofton read a paper on Abderhalden’s
Pregnancy Reaction and Beard’s Theory of the Alternation
of Generations in Vertebrates. After describing the nature
of tissue digestion of normal foodstuffs and abnormal sub¬
stances given parenterally, he showed that the substrate—viz.,
the placenta—with the possible exception of the syncytial
layer, could not possibly be considered foreign or dis¬
harmonious, and that, therefore, no specific ferment would
be found for it in the maternal system. On the other hand,
if Beard’s theory was correct, the cells of the chorionic villi,
Ac., belonging to the phorozoon or asexual generation were
foreign or disharmonious, and therefore a specific ferment
would be formed to their protein which could be recognised
by a complement fixation test. He criticised Abderhalden’s
method of detecting the presence of his protective ferments.
Lectures on Infant Care.— On Mondays, from
Jan. 27th to April 14th, at 6.30 to 6.30 p.m., a course of
12 advanced lectures on infant care, for nurses, health visitors,
teachers, infant-welfare workers, and others, will be held at
1, Wimpole-street, London, W., under the auspices of the
National Association for the Prevention of Infant Mortality.
The coarse is in preparation for the advanced certificate of
the Association. The fee for the course is 5s. and for a single
lecture Is. On Thursdays, at 7 to 8 P.M., from Jan. 23rd to
April 10th, a similar course of elementary lectures, in pre¬
paration for the creche nurses’ certificate, arranged by the
Association, together with the National Society of Day Nur¬
series, will be held at the Midwives’ Institute, 12, Buckingham-
street, Strand, London, W.C. To secure this certificate
students must take 12 months’ training and gain a certificate
for proficiency at an approved day nursery, attending
two courses of 12 lectures, of which this is the first.
The fees are 10a for the course or Is. for a single lecture.
Tickets from Miss Halford, secretary, National Association
for the Prevention of Infant Mortality, 4, Tavistock* square,
London, W.0.1, or from Miss Maddock. secretary of the
National Society of Day Nurseries, 13, Victoria-street,
London, S.W. 1. A further special course of 12 lectures
on infant care for health visitors, midwives, school
teachers, voluntary health workers, and committees of
nursing associations, will be held at the University
Museum, Oxford. Some local authorities now have the
power under the Maternity and Child Welfare Act of
August, 1918, to defray the expenses of their workers in
attending lectures snob as these. I
$Ubutos nb flatlets of Jaoks.
War Story of the Canadian Army Medical Corps. Vol. 1.
By J* George Adami, M.D., F.R.S., Temporary Colonel,
C.A.M.O. Published for the Canadian War Records Offioe
by Colour, Ltd., and the Rolls House Publishing Co. f
Ltd. 1918. Pp. 286.
Sir Robert Borden, in opening an admirable collection of
Canadian war pictures at the Royal Academy, London, on
Jan. 4th, spoke of the inspiration he found in witnessing the
triumph of spirit in Canadian hospitals over dull pain and
monotony of long weary months, and that the inspiration
was not lacking on the side of those who devoted their
services to the care of sick and wounded is abundantly
evident from the pictures themselves as well as in the story
of the work of the Canadian Army Medical Corps told by
Colonel Adami in a book to which Sir Robert Borden con¬
tributes an introduction. The record is intended, first of
all, for the actual men of the corps, to whom, and to whose
children’s childreo, the wealth of personal detail will be of
surpassing interest. But to the non-Canadian reader the
story has the freshness of an adventure. The first volume,
which is in oar hands, deals with the medical service of the
first contingent of Canadian troops up to the autumn of the
year 1916 Canada beiDg in the happy position of having
seen little active warfare since 1812, the C.A.M.O. had to
woik out its arrangements largely as it went along. The
Riel rebellion in 1885 necessitated the appointment of
medical officers to the field force, and it was in this little
campaign that a surgeon-general was first appointed at
Ottawa. The wounded were few and sickness was slight in
a campaign on conspicuously healthy terrain. It was as
recently as 1896 that a definite medical subdepartment was
created to the militia, when the late Sir Frederick Borden,
himself a medical man, became Minister of Militia.
The story of the organisation of the corps during the
following 20 years is of more than ephemeral interest.
Appreciation of the value placed upon research is one of
the strong traditions of the corps, with the result that
research was carried on in the field, and . No. 5 Canadian
Mobile Laboratory has formed the background of a number
of articles of permanent value which we have published in
our own columns dealing with such practical matters as
chlorination of water, mosquito prevention, and sundry
aspects of trench fever. The use of poison gas as a weapon
of offence was a terrible experience in which the C.A.M.C.
was the first to participate. The diary of Thursday,
April 22nd, 1915, cannot now be read without breathless
interest, and the enterprise of Lieutenant-Colonel Nasmith
in reporting almost at once on the nature of the attack and
the means desirable for facing it may count as one of the
achievements of the corps. Alongside the Turcos staggering
back through the lines, dazed and weaponless, ran numbers
of Belgian hares escaping from the gas and already so
affected by it as to be knocked over without effort by the
canteen cooks. Incidentally, poison gas had one thing to
recommend it: Colonel Adami records that it materially
reduced the live stock in the dug-outs and had an excellent
potency in destroying the parasites of “ that most irritating
and most humiliating skin disease ”—namely, scabies.
The C.AM.O. is happy in its biographer, and the con¬
cluding volume or volumes will be awaited with keen
anticipation.
The Organs of Internal Secretion , their Diseases and Thera¬
peutic Application: A Book for General Practitioners.
By Ivo Geikie Cobb, M.D., M.R.C.S Second edition.
London: Bailliere. Tindall, and Cox. 1918. Pp. 274. Is. 6d.
When the physiology of the internal secretory organs has
been so far elucidated, and the effect upon them of disease
and their therapeutic application have been so fully studied
of late years, some such work as this was needed in order
to give the busy practitioner a simple lucid acoount of the
role of the ductless glands, together with a practical guide
to thi<« means of treatment. The first edition was published
in 1916. The second edition has been revised and brought
up to date, and a chapter dealing with the relation of the
internal secretions to functional nervous disease has been
added, and will be found a useful addition at the present
time.
112 Thb Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Jan. 18, 1919
Clinical Case-taking. By Robbrt D. Keith, M.A.,
M.D. Aberd. London : H. K. Lewis and Co., Ltd.
1918. Pp. 104. 3#. 6d. net.
This is an excellent little book for the junior hospital
student, being simple, clear, and concise. It was originally
written for the students of the King Edward VII. Medical
School. Singapore, so that the question of common tropical
diseases is more than usually prominent. The introductory
chapter gives a useful r6sume of the scheme of case-taking,
which is described and expanded in the following chapters,
and the student cannot do better than have it at hand when
examining a patient, and follow it out in every detail.
Perhaps here at home, where, generally speaking, there is no
language difficulty and time is available in which to deal
fully with each case, we should be inclined to bestow more
oare and trouble in investigating the previous and family
history than is here suggested, but that is a minor defect in
an otherwise valuable little manual.
Differential Diagnosis. Vol. II. Presented Through an
Analysis of 317 Cases. By Richard C. Cabot, M.D.
Second edition, revised and illustrated. London and
Philadelphia: W. B. Saunders Company. 1918. Pp. 709.
25s.
The essence of the manner in which the subject of differ¬
ential diagnosis is treated in these volumes is contained in
the subsidiary title. The method is new and very instructive.
This volume treats of the differential diagnosis of 19 pro¬
minent symptoms, and includes chapters on abdominal and
other tumours, vertigo, diarrhoea, dyspepsia, haemoptysis,
hoarseness, pallor, &c. The cause of each symptom is first
given and the relative frequency of its occurrence in various
diseases is shown in tabular form, after which the oases are
described and discussed and the outcome recorded, whether
recovery or otherwise, or the findings either at operation or
post mortem. The reading of such a book as this is the
next best thing to a course of post-graduate clinical study.
Materia Medica and Therapeutics; An Introduction to the
Rational Treatment of Disease. By J. Mitchell Bruce,
M.A., LL.D. (Hon.) Aberd., F.R.C.P.; and Walter J.
Dilling, M.B., Ch.B. Aberd. Eleventh edition, revised
to correspond with the War Amendments of July, 1917,
and March, 1918. London : Cassell and Oo., Ltd. 1918.
Pp. 675. 9s.
This edition was being prepared when the changes were
being made in the British Pharmacopoeia consequent on the
scarcity and increasing cost of many of the drugs in general
use. The original formuhe appear as before, but the reader
is referred in each case to a War Emergency Formulary at
the end of the book, where the temporary substitutes are
described. Many new remedies are noted, and such measures
as electrical treatment, massage, and exercises are described
more fully than before.
Aids to Medical Diagnosis. By Arthur. Whiting, M.D.
Second edition. London : Bailliere, Tindall, and Cox.
1918. Pp. 167. 3*.
“Aids” of any kind are to be deprecated unless used in
the manner for which they were intended. Students of the
less ambitious sort are tempted to rely on manuals of this
size in the wrong way, and to regard them as “cram”
books instead or setting themselves to the study of medicine
* in its fuller and larger aspects. Nevertheless, such a book
is useful, provided it be looked at from the proper stand¬
point. These little “ Aids ” are of snch a size that they can
b* carried about in the pocket, and are valuable for reference
during, for instance, the examination of a patient. There
are a few slips which should be corrected in a sub¬
sequent edition. On p. 45 it is stated that the characteristic
feature of diseases of the blood is pallor ; this is, of course,
not so in all blood diseases. With regard to “scurvy-
rickets,” it was shown by Cheadle in 1878 that this
name was a misnomer. The disease is usually known
either as “ Barlow’s disease” or “ infantile scurvy,” the
rachitic features being by no means always present and
being entirely distinct, etiologically, from scurvy. Sporadic
cretinism would benefit by a fuller description than that
given. Perhaps the meagreness of the description is .due to
the fact that infantilism is not dealt with in any fonn, and
this, we think, is a disappointing omission, as many forms
of infantilism are by no means uncommon, and the main
diagnostic features would take up little space. Dry pleurisy
should surely not be included under “ Diseases with Dullness
on Percussion,” a dull percussion note being said to be one
of the diagnostic signs. Books of this kind have their nses,
but students should be warned against placing too much
dependence on them to the neglect of fuller reading.
JOURNALS.
Reconstruction. A Monthly Bulletin published by the
Department of Soldiers Civil Re-establishment, Canada.
October, 1918.—An Order in Council has been passed to
protect discharged soldiers with amputations from the com¬
petitive attention of representatives of private manufacturers
of artificial limbs. Sir James Lougheed, the Minister
responsible, points out that no man with an amputation
can ever feel he is bodily complete, however long he has
been wearing the most perfect artificial limb possible.
Although no trouble or expense has been spared by the
Government to provide the best limb available, a number
of manufacturers and vendors of artificial limbs have
endeavoured to convince returned soldiers that the Govern¬
ment issues are olnmsy and of little value. All artificial
limbs and appliances manufactured by the Government are
stamped; the Order in Council enacts that no person to
w'hom an artificial limb or appliance is issued shall transfer,
exchange, or otherwise relinquish such limb except with the
written consent of the Minister, nor must such limbs or appli¬
ances be altered without similar consent. Any person dis¬
paraging goods manufactured Or issued by the Department
is liable to a fine. A blinded officer who after training at
St. Dunstan’s has been carrying on his former profession,
that of electrical engineer, has been appointed to the
vocational staff to represent the Government in dealing
with blinded soldiers. These men will be persuaded, if
ossible, to accept the Government offer of training at
t. Dunstan’s before leaving England. 1347 men have
already graduated from industrial re-edneation courses;
1877 are at present under instruction. Since, the work
began only 339 men have refused to take up a oourse;
558 have discontinued for various reasons. This number,
however, includes 111 men whose course has been suspended
for a short time to enable them to take part in agricultural
production.
The Military Surgeon .—In the issue of this journal for
October, 1918, Colonel Victor C. Vaughan and Captain
G. Palmer complete their aocount of the infectious
respiratory diseases in the C.S. Army last winter. These
diseases were specially frequent among men from country
districts and particularly from the Southern States. This is
in great measure due to want of acquired immunity, but
even more to want of education in sanitation, and the
correlated personal carelessness. In the camps most
attacked were men who had grown up in bad sanitary
surroundings and who did not know how to look after
themselves. Consequently they had, many of them, before
entry, become infected with hookworm and malaria and
venereal disease, and classes had to be held to teach them
the use of water-closets and toilet paper. They were un¬
accustomed to the better food of the Army; they did not
wash their hands before meals; they expectorated every¬
where and could not see any harm in that; thev required
more bedding and clothing than others and they were j
easily fatigued. As very few were immune they rapidly
developed these infections. The better the hospital accom- I
modation in the camps, the more quickly cases 41 going sick ”
were sent there, the fewer the deaths from pneumonia. Over¬
crowding is considered a cause of infectious disease pre¬
valence, but little weight is given to that, and ventilation j
is hardly mentioned. Still, it is noted that officers, who are '
less crowded, more often escape these diseases. It is I
observed that officers, too, are generally less fatigued. In I
one camp the men who did guards suffered most; the
quartermaster’s staff, the cooks, and the officers escaped.
Faulty quarantine also did great barm. It is hoped that in
future recruits will be sent to observation camps to begin
with, there to be quarantined, vaccinated, and taught
hygiene and a little physical drill before they are transferred
to the large camps to undergo military training.
A Tribute to Sir Leonard Rogers, LM.S.—The
Calcutta School of Tropical Medicine, which alread
possesses a portrait of Sir Charles Pardey Lukis, has now
memorial to the work of Sir Leonard Rogers, the prof esse
of pathological medicine in Calcutta Medical College,
bust of Sir Leonard Rogers has been unveiled by Loi
Ronaldshay.
The Lancet,]
INDUSTRIAL EFFICIENCY AND PREVENTIVE MEDICINE.
[Jan. 18, 1919 113
THE LANCET.
LONDON: SATURDAY, JANUARY IK, 1919.
Industrial Efficiency and Preventive
Medicine.
The physical inefficiency of our industrial classes
is one of the spots in our social organisation which,
hitherto dark, the searchlight of war has all too
brilliantly illuminated. Our national unreadiness
for war was most marked not in the fighting forces
but in the industrial organisation behind these
forces. Our Army may, as regards size, have been
“contemptible,” but it was constructed on a model
which withstood the test of tenfold multiplication.
The call of the Army for men, on the other hand,
laid bare an appallingly low standard of physique
among men of fighting age; and when this call had,
so far as was possible, been met, our industries,
particularly the munitions industry which supplied
the fighting forces with their life-blood, had to rely
mainly upon the fit in our population, who were over
military age, and much admirable female labour.
Then the discovery was made that owing to the
conditions of industrial life during the past
half-century there were but few skilled craftsmen
over the age of 50 who had not already “ gone
West.” Now the war is over, and attention is being
given to reconstruction and reorganisation; and
nowhere is fresh effort and new work more called
for than in trying to ensure for the future genera¬
tion a higher standard of health among the indus¬
trially employed. Two questions call for prompt
reply: Who is to be entrusted with the effort
which is needed ? and How is the effort to be
carried out ?
The questions are really one, for the methods
adopted will to great extent depend upon the agency
selected. In the past what has been done to im¬
prove the lot of the worker has been carried out by
the Home Office administration of the Factory Acts,
Shops Hours and Mines Regulations Acts, and the
Coal Mines (Minimum 'Wage) Act, and a decision
must now be arrived at as to whether action con¬
cerning health and industry in relation to labour is
in the future to be administered by an * office
destined, according to the Haldane Committee 1 to
become a Ministry of Justice. If the decision is
against the Home Office continuing in charge of the
work, should the administration be entrusted as a
health question to a new Health Ministry, or as an
employment ‘matter to the Ministry of Labour ?
There is much counsel, and as usual the old adage
“ In the multitude of counsellors there is wisdom ”
falsifies itself, because each counsellor counsels
differently, and the adage does not indicate how the
» Report of the Machinery of Government Committee (Od. 9230).
H.M. Stationery Office, 1918. Price 6<i. net.
wisdom is to be jsifted out from the multitude. For
once, however, on an admittedly difficult question,
we have before us advice flowing from two separate
sources which is in close agreement. First, the
Haldane Committee are definite and explicit:
” We are satisfied that the inspection and regulation of
conditions affecting the health and Bafety of industrial
workers are matters for which the Minister of Employment,
and not the Minister of Health, must be responsible to
Parliament. The ordinary methods of consultation
(between two departments) will probably require to be
supplemented from time to time by the appointment of
special committees, on the principles which have proved
conspicuously successful in the case of the Health of Muni¬
tion Workers Committee, to advise the Minister of Employ¬
ment upon problems of industrial health which are new m
kind or have assumed a peculiar importance or urgency."
Secondly, the Association of Certifying Factory
Surgeons a has recently prepared a report upon
this subject and state:
•' We think, however, that early arrangements should be
made for transferring the whole of the Factory Department
from the Home Office to the Ministry of Labour. It appears
to us that the Ministry which has the economic problems of
labour under its care and direction is the proper body to
take charge of occupational health and safety problems, but
we are particularly influenced in our view by the conviction
that Labour Exchanges could be made into such useful
adjuncts to medical examination by securing for young
people employment suited to their physical condition. We
are also of opinion that the health and welfare measures
established by the Ministry of Munitions cdnld be more
suitably carried on by the Ministry of Labour than by the
Home Office.”
Clearly, then, the balance of opinion would favour
that the Ministry of Labour (or, as the Haldane
Committee prefer it to be called, the Ministry of
Employment) should be entrusted with the duty of
organising industrial health supervision. There
remains for consideration—How is the end in view to
be attained? An answer to this question is hardly to
be sought from the Haldane Committee, lor it was
not within their terms of reference, but the
report of the certifying factory surgeons contains
many valuable suggestions as to the way in which
the work could be done by linking up the Employ¬
ment Exchanges with the Medical Factory Service,
especially in relation to juvenile employment. We
would here express a word of regret that adults are
not more fully considered by the Association of
Certifying Factory Surgeons, feeling, as we do, that
only by close and intimate association between the
Employment Exchanges and the places of employ¬
ment can any coordinated attack be made upon
what is to-day the most serious economic loss in
industry—that due to the turnover of labour, and the
resulting wastage of workers. Our readers should
in this connexion be familiar with the admirable
report issued from the Medical Research Committee
on the wastage of female labour in munitions
factories. 8 Apart, indeed, from the serious loss
thus indicated, social economy is not served by
sending A1 men to work which could be carried
out by C 3 men, while to send C 3 men to attempt
A 1 work is homicidal.
We desire to see every employer of labour with
the whole- or part-time services of a doctor at his
disposal to advise him on welfare and health
* Report on Reconstruction of Factory Medical Service. Manchester
Cooperative Printing Society, Ltd., 118, Corporation-Street, 1918.
3 Medical Research Committee: A Report on the Causes of Wastage
of Labour In Munitions Factories Employing Women. H.M. Stationery
Office, 1918. Price Is. 6 d. net.
114 Th* Lancet,]
ACCURATE DIAGNOSIS IN APPENDICITIS.
[Jan. 18, 1919
matters; to examine new workers; to watch over
the health of his whole staff; to supervise the
hygiene of his establishment as regards ventilation,
light, temperature, cleanliness, and first-aid appli¬
ances; to advise and help the Welfare Department;
to be, in fact, an industrial medical officer of health.
Such officers should also be retained to advise the
local employment exchanges as to the type of
worker to be drafted to this or that trade or pro¬
cess. They should also be employed to conduct the
periodical examinations of juveniles industrially
employed as will be required under the provisions
of the Education Act, 1918, and so to coordinate
the school and factory medical supervision. Such
local officers would require to be directed and
assisted by a medical organisation controlled from
headquarters—a nervous system of which the
local service would be the peripheral end-organs.
The value of such a medical organisation, asso¬
ciated with the Government Department concerned
with employment, would be incalculable not only
to carry out investigations and assist research into
the effect of industrial conditions and hours of
labour, but also to influence the adoption of health
reform based on sure knowledge so obtained.
Probably in the whole field of preventive medicine
nothing more urgently calls for action than the
establishment of organised medical supervision of
employment on sound lines; probably no field
promises in return for cultivation a finer harvest
of results. In the past unfavourable conditions of
employment, overwork and fatigue have caused
irritability and labour unrest, impaired physique
and disease.
“ The subject of industrial efficiency in relation to health
and fatigue is in a large degree one of preventive medioine, a
question of physiology and psychology, of sociology and
industrial hygiene. Without health there is no energy,
without energy there is no output. More important than
output is the vigour, strength, and vitality of the nation.” 4
Thus the final report of the Health of Munition
Workers Committee in the sentences we quote
summarises the whole great truth. In the imme¬
diate future the nation, as never before, must
obtain industrial efficiency through preventive
medicine.
Accurate Diagnosis in Appendicitis.
During the last 30 years the role of the
appendix vermiformis in health and disease has
been a frequent topic both in medical and lay
circles. Before that time little of ill had been
laid to its charge; if a criminal, its crimes
remained undetected. But at the present time it
has become the pathological scapegoat, every pain
and ache below the diaphragm casting suspicion
upon the appendix; so that the hand of every
surgeon is against it. In spite of the attention
that it has received the fact remains that the
normal appendix has not been sufficiently studied,
not only in its anatomy but also and especially in
its physiology, and there are questions as to the
activities of the appendix which have not, hitherto,
* Health of Munition Workers Committee, Final Report, Industrial
Health and Efficiency. H.M. Stationery Office (Cd. 9065), 1918. Price
2s. net.
received any very definite answers. The means
to accurate diagnosis are not yet at our disposal.
In the present issue of The Lancet is an im¬
portant paper by Dr. E. I. Spriggs on the normal
anatomy and physiology of the appendix as revealed
by the aid of X rays, and the paper is illustrated by
accurate coloured drawings and a large number
of admirable skiagrams taken by Mr. O. A. Marker.
The X rays have already been employed to a certain
extent in the investigation of the appendix but
the observations in this paper are more complete
and more thorough than anything that has preceded
them.
The first thing to be settled by Dr. Spriggs and
his collaborator was the best material for the
opaque meal when it is required to demonstrate
the appendix, and it was found that buttermilk
and barium sulphate formed the most suitable
opaque meal. Moreover, the best results were
obtained when the bowel had been previously
thoroughly emptied by castor oil. With these
preliminaries adjusted, much physiology was
made clear by the ensuing observations. In
the first place, it became certain that even in
health some of the contents of the caecum enter
and leave the appendix, that it fills when the
caecum fills, and that when the contents of the
caecum pass on their way the appendix discharges
what it has contained, though sometimes the
emptying of the appendix may be a little delayed.
In the young, indeed, the appendix may fill and
empty several times while the caecum is still full.
It is also certain that in the young the appendix
is much more lively than in those who are old.
The appendix was seen by Dr. Spriggs to move
actively; some times the movement occurs as
the organ fills, and sometimes without any
reference to the passage of material into or
out of it. So that we have learned much from
these researches as to the conditions of the appendix
when it is normal, something of its physiological
movements, but, alas! we have learned nothing to
enable us to answer the important question whether
the appendix has a function or not. That it may
be removed without any obvious impairment of
health is no proof that it is valueless, for the
spleen can be, and has many times been, removed
without the least harm resulting, and yet no one
would deny that the spleen is of functional import¬
ance. The persistence of the appendix, and its
active movements, certainly do suggest that it may
have some function in the economy of the human
body; small though that function may be.
These investigations further afford us much
insight into the pathology of the appendix,,
although such technique can be employed only in
cases of chronic appendicitis, for in the acute form
the time needed to prepare for and to take the
skiagrams jnust not be spared. But in cases where
the diagnosis of chronic appendicitis has not been
definitely made, and when there are obscure pains
in the abdomen of long duration and uncertain
cause, it is all to the good if a diagnosis can be
made whether there is or is not definite disease
of the vermiform appendix. When sufficient skill
The Lancet,]
THE HARVARD MEDICAL UNIT.
[Jan. 18, 1919 115
has been acquired and when adequate care is
taken it is found that very great reliance can be
placed on the appearances presented by the
skiagrams, and Dr. Spriggs and Mr. Marxer
are to be heartily congratulated on their work.
They found that it is often necessary, as in the case
of the X ray diagnosis of disease in other parts of
the alimentary canal, that repeated observations
should be made to determine whether the con¬
ditions indicated are temporary or permanent. By
these means they have found it possible to say
whether there are constrictions or kinks in the
appendix, whether concretions are present or not,
whether the appendix is dilated, and whether
adhesions exist. If the appendix always occupies
the same position, if manipulation with the hand
cannot induce it to move, then we may be sure
that adhesions exist which chain it down to
one place. In one case brought forward by the
authors the appendix gave all the indications
of being healthy and empty, yet at a subsequent
examination two small shot were seen in it; but
they gave rise to no symptoms, though the appendix
emptied itself more slowly than before, for it was
found to contain some barium sulphate 24 hours
after the caecum had discharged its contents. The
appendix was examined every week, and three
weeks later the shot had gone. This interesting
observation shows us that foreign bodies may
not only enter but may also leave the appendix.
That the diagnosis made by the X rays may be
considered trustworthy we learn from Dr. Spriggs,
for in all the cases in which a subsequent opera¬
tion was performed the condition found was that
which had been recognised on the skiagram. Thus
there can be no doubt that we have in the use of
the X rays a valuable aid in the diagnosis of chronic
appendicitis, just as there can be no doubt that the
information needs highly skilful record. The work
of Dr. Spriggs and Mr. Marxer has been very
thorough, and must have entailed great expenditure
of time and pains well directed. The illustrations
showing the actual skiagraphic appearances are
sufficient guarantees of the practical worth of the
research, for by the methods adopted information
can be obtained that is otherwise unavailable—
information which may either render operative
measures unnecessary or much reduce their
duration.
In this issue of The Lancet, also, Mr. S. T.
Irwin, of Belfast, gives a careful classification
of the forms of acute appendicitis, supported by
some effective coloured drawings, and he claims that
it is possible to discriminate definitely between the
several varieties before the abdomen is opened,
though many surgeons will hesitate to concur. He
points out that in the obstructive form the attack
always begins with the sudden onset of pain, and
he beUeves that this suddenness is characteristic
of the obstructive form, certainly the most
dangerous of all the varieties. He shows that it
is the obstructive form which on rupture gives
rise to widespread peritonitis, for the pus which
the appendix contains is at high tension, and only
rarely is it that adhesions exist to confine the
infection. In these obstructive cases the essential
in the treatment is early operation, for the rate
of mortality rapidly increases with delay, and few
of the cases in which the appendix has given way
end in recovery. Mr. Irwin rightly insists that the
remedy for the high mortality in cases belonging
to this category lies in the earlier operation, and
the possibility of this depends mainly on the doctor
who is first called to see the patient. In only too
many cases is the surgeon told that the doctor has
not urged the need for an operation, that he has
tried soothing remedies which sometimes succeed
in masking the serious nature of the attack—even
the cessation of pain, which not. rarely occurs on
the onset of gangrene, has been mistaken for real
amelioration. With the medical profession lies the
onus of impressing on the patient and his friends
the necessity for an early operation if the patient’s
life is to be saved in these cases. Correct diagnoses
should be made in cases where the symptoms are
well marked and the history is clear. The illus¬
trations accompanying Mr. Irwin’s paper show
appendices in varying conditions immediately after
removal, and illustrate appearances which are, of
course, completely lost in preserved specimens.
- ■ —
The Harvard Medical Unit.
After three years of friendly cooperation with
the British Army Medical Corps in France, the
Harvard Medical Unit is passing through London
on its way back to the United States. In 1915
Colonel Hugh Cabot gave up his assistant pro¬
fessorship of genito-urinary surgery at Boston, with
Dr. G. C. Shattuck and a group of colleagues,
determined to offer us any help they could during
the war and to see the business through to
the bitter end. The Harvard Unit consisted
of American medical officers and nurses with
English personnel, at first under the command
of Sir Allan Perry, and from October, 1915, on
with Colonel Cahot as chief. A most excellent
friendly feeling has prevailed throughout amongst
the members of the unit and between them and
their British helpers, and has been no mean factor
in that close professional relationship which has
been springing up between American and British
officers. The position of the unit has enabled it to
form independent views on the important topics of
war-time surgery. Their experience, Colonel Cabot
tells us, gives no support to the belief that any of
the hew antiseptics and ingenious methods of apply¬
ing antiseptics will have any permanent place in
surgery. No antiseptic has yet been produced
which may not do as much damage to the human
tissues as it does to the micro-organisms. Anti¬
septic, in distinction to aseptic, surgery has not,
in the opinion of the unit, gained strength by the
experiences of the war. Direct blood transfusion,
on the other hand, Colonel Cabot thinks, would gain
by more frequent use, the simple method practised
in America being preferred. The permanent record
of the Harvard Medical Unit is still to come, but
whatever the value of the scientific work it con¬
tains, the contribution made by the unit to a
friendly feeling and a sympathetic understanding
between the two Armies will be no less permanent.
The war has done much to draw the two English-
speaking peoples together, and we warmly endorse
Colonel Cabot’s expressed .desire to make this
rapprochement more intimate by the interchange
of students, both before and after graduation, pro¬
viding for the purpose a large scholarship fund
available for promising students on either Bide of
the water.
1
116 The Lancet,] WAK CURES. [Jan. 18. 1919
Jnnniatians.
" Ne quid nlmls."
WAR CURES.
Much stress has been put, and rightly, on war
diseases. That way progress has lain. But there
have also been war cures, and of these we have
heard less. The disappearance of functional nervous
disease among the civil population during the last
four years is, however, a matter of general com¬
ment. In Berlin we understand that migraine
disappeared completely from the month of August,
1914, and, without doubt, the work of general
practitioners in this country has been mitigated
by the fact that they have seen fewer minor ail¬
ments. Many of these, while real enough, are
such as the patient communicates only to his or
her (generally her) family doctor, and the particular
family doctor has generally been away. Minor
ailments cannot be assessed in actual figures, but
there is a certain amount of evidence accumulat¬
ing in regard to definite morbid conditions
which have become numerically less frequent
during the war. Dr. Herbert Elias and Dr.
Richard Singer laid before the Vienna Medical
Society on Oct. 18th last a therapeutic study 1
of the influence of war diet upon diabetes. Their
conclusion is based upon figures, and it is
a remarkable one. All degrees of diabetes as it
occurred in Vienna were favourably influenced
by the altered circumstances of war, in males
almost without exception, in females frequently
but by no means universally. The chart which we
191
14
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1915,16
| 1916,17
1917/18
HalVlc
2
Halft«
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Halfle
Halfte
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t.
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i
Halfte
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Halfte
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reproduce here shows the decreasing number of
diabetics dying in the Vienna General Hospital
during the last five years, the thick line indicating
total deaths, the interrupted line the deaths occur¬
ring in coma. The authors express regret that they
cannot give the result in percentages, inasmuch as
the total diabetic admissions to hospital could not
be ascertained, but of the general lesson to be
drawn from the chart there appears to be no doubt.
The better war prognosis in males as distinguished
from that in females is a fact claimed by these
observers as a new observation, coinciding with
their pre-war experience, for which they venture to
advance no explanation. In the case of patients with
slight glycosuria the difference between war and pre¬
war experience was very striking. Whereas not one
of 29 slight diabetics before the war could be regarded
as cured, 33 out of 39 became sugar-free under war
conditions. The experience of Bouchardat during
the siege of Paris in 1870-71 is quoted as having
been similar. G. Klemperer, P. F. Richter, and
others have noted the increased carbohydrate
1 Wiener klin. Wochenscbr., Nov. 21st, 1918.
tolerance, and have made similar observations in
enemy countries during the present war. The
cure of diabetes is perhaps of greater interest
than the disappearance of obesity, of gout, and of
chronic constipation noted during the same period
and the increasing rarity of eclampsia in pregnant
women. The balance is not equalised by the alleged
increase in the frequency of peptic ulcer. Any
observations of a similar character made in this
country would be of interest and might throw
useful light on the relation between habit and
metabolic disorder.
BRONCHO-SPIROCH/ETOSIS.
Thanks to the work of G. A. Lurie, 1 Galli-Valerio,'
and H. Violle, 1 the subject of broncho-spirochietosis
has received considerable light. The condition
until recently was only of interest to the tropical
practitioner, but lately it has become a serious
matter to medical men in Europe, cases of the
malady having been reported from Serbia and the
Balkanic zone, Switzerland, and France. The
condition and its etiological agent were first
described in Ceylon in 1905 by Castellani, who
later named the causal agent Spirochcctabronchialis.
His researches were confirmed by S. Branch in
1907 in the West Indies, by Jackson in the same
year in the Philippine Islands, and by several
other observers, whilst H. G. Waters in 1909
recorded numerous cases from India. The con¬
dition was later found in practically every
part of the tropics, of special importance
being the work of Chalmers and O’Farrell, who
succeeded in reproducing the disease in monkeys,
and the thorough investigation of Fantham on the
morphology of the organism. Spirochccta bronchi-
alis , according to the description given by all these
authors, is so markedly polymorphic that the
suggestion arises whether the term does not cover
more than one species or variety of spirochffite.
The classical investigation of Fantham 4 seems to
prove, however, that the various forms found
belong, in reality, to only one species, differing
from the spirochaetes occurring commonly in the
mouth. Fantham discovered the coccoid stage of
the parasite, which he believes to be of fundamental
significance in the dissemination of the malady.
Clinically, three types of the condition are to be
distinguished—the acute, the subacute, and the
chronic. The acute type develops abruptly ;
the patient complains of headache and rheu¬
matoid pains all over the body; he feels chilly
and coughs much, though there is but very scanty
mucoid or mucopurulent expectoration. The
fever generally lasts from 3-6 days. This influenza¬
like type of broncho-spirochetosis has given rise to
a suggestion 5 that true influenza may be a form
of spirochaetosis. The subacute and chronic types
of broncho-spirochaetosis are of practical relevance,
as they may closely simulate pulmonary tuber¬
culosis. In these types the patient often spits up
blood, and this, together with wasting, an evening
rise of temperature, and, on examination, the pre¬
sence of patches of dullness and crepitations, may
suggest a diagnosis of phthisis. In a certain
number of cases, however, the general condition
remains good. The first patient seen by Castellani
in Ceylon in 1905 was still alive in 1915, and Violle
quotes a number of cases in which the general
1 Journal of Tropical Medicine, Dec. 1st, 1915.
* CorrespomlenzMatt fur Schweizer-Aerzte, February. 1917.
3 Presse Medlcale, July 11th, 1918 ; The Lancet, 191& 11., 775.
4 Annals of Parasitology, July. 1915.
De Verhizier: Bull. Academic dc Medeclne, Stance 8 Octobre, 1918,
The Lancet,]
LUNACY IN EGYPT.
[Jan. 18, 1919 \\7
condition remained good throughout the course of
the malady. The prognosis of bronoho-spirochetosis
is, therefore, in most cases, good as far as life is
concerned, but relapses seem to be extremely
common, and cases of a malignant type, terminating
fatally, have been placed on record.
As regards treatment most authors rely on arsenic,
whilst others employ change of air, rest, and
plenty of nourishing food. Galli-Valerio has used
salvarsan with apparently good results. The whole
subject deserves further investigation, especially
in regard to the geographical distribution of the
condition in the temperate zone, and the mode of
infection. The practitioner should also be on his
gnard, as it is quite possible that a certain number
of cases which, in the past, have been regarded as
pulmonary tuberculosis, even though tubercle
bacilli were constantly absent in the sputum, may
have been cases of broncho-spirochcetosis.
LUNACY IN EGYPT.
We learn from the Report on Lunacy in Egypt
for the year 1917 that the total number of admis¬
sions to asylums in that year was 1062, the largest
on record. There are still only the two asylums in
Egypt, one at Cairo, chiefly for the city dwellers,
male and female, and the other at Khanka, where
patients from the scattered districts are chiefly sent.
The two groups of cases differ materially, general
paralysis being common at Cairo but very rare at
Khanka. Three different social classes are treated in
the asylums, the paupers, those who contribute
something towards their support, and the private
paying patients. Voluntary boarders are still
received. The patients we regret still to And in the
parent institution are the criminal lunatics. The
increase in the number of admissions is due chiefly
to the fact that more patients are sent direct to the
asylum 8 and not detained in the local general
hospitals; among them are a very large number of
pellagrous insane. At both the asylums accom¬
modation is inadequate, with the result that
many partially cured patients are prematurely dis¬
charged to make room for the more acute cases,
and frequently these patients break down again or
add to the sum of criminal lunatics. The death-
rate is very high in the two asylums, the total
number of deaths during the year being 369,
or 17*4 per cent, of the number resident. It
should be noted, however, that many deaths
occurred in patients who had only recently been
admitted, due to the fact that they had been kept
too long at home. A special hospital for military
patients has been constructed out of the former
assistant medical officer’s house, to which during the
year 126 cases were admitted, nearly every form
of mental disorder being represented. The resi¬
dence of these soldiers in the hospital was very
short, and no accidents or deaths occurred. The
admissions included a large number of adolescent
cases, four general paralytics, and only two
alcoholics; delusional cases were common, and
melancholia occurred more frequently than mania.
As to the apparent (or rather attributed) causes of
insanity, congenital mental defect and general
physical strain due to shell shock or to dysentery,
or other debilitating causes, were recorded as
common, and there were many relapses, but in the
greater number the cause was mixed or doubtful.
Turning to the medical superintendence of the
asylums we call attention again to the work of Dr.
John War nock, C.M.G., and during his absence
on active service of Dr. H. W. Dudgeon. Their
administration has been of the highest order, and
praiseworthy effort is continually made to carry
on scientific investigation; the State laboratory
has assisted in the examination of the blood of 100
consecutive admissions, a positive Wassermann
reaction being found in many other forms of
mental disease than general paralysis of the insane.
Blood and fsBces were also examined in cases of
bilharzia. In each report a table is given showing
the number of criminal lunatics admitted, the nature
of their crimes, and the form of their insanity.
Eighty persons were thus received, namely 72 men
and 8 women, and of these pellagrous insanity
provided 12, hashish only 1, and G.P.I. 2. Next to
pellagra, dementia is given as the most common
form of insanity met with. In all there were 400
male criminal lunatics and 37 females. Attempts
at murder were common, but theft was the most
usual offence, the same applying to the pellagrous
insane, while every form of antisocial crime was
represented.
TETANUS WITHOUT TRISMUS.
The enormous medical experience of the war has
modified our knowledge of many diseases. Perhaps
the most striking example is tetanus. It used to
be taught that trismus was a characteristic early
sign on which the diagnosis turned in cases of
doubt. But the extensive prophylactic use of anti¬
toxin in the wounds of war has produced new
types of the disease in which old and well-estab¬
lished rules fail. We now know that the disease
may be so mitigated that the spasms may be con¬
fined to the neighbourhood of the wound (local
tetanus) and trismus or other spasm be completely
absent. This form was known previously in experi¬
mental tetanus in animals. But the view of the
pathology of tetanus brought forward by Professor
H. H. Meyer and Dr. Fred BanBom (The Lancet,
Dec. 22nd, 1917, p. 929) that the increased irrita¬
bility of the nerve centres is due to the passage of
toxin up the motor nerves to the spinal cord, in
which process the nerves of the infected area are
at an advantage, would suggest that tetanus should
always be local in onset, and, indeed it has been
asserted that if cases are carefully watched from
the beginning spasms of the muscles in the
neighbourhood of the wound will always be
observed. Not only is trismus absent in local
tetanus, but, more remarkable, French observers
have Bhown that it may be absent in general
tetanus when modified by the prophylactic use of
antitoxin. In the December number of the Medical
Review is given the following case, recorded in the
Lyon Medical by M. Roubier.
An Arab soldier waB wounded in the left hand by a
grenade on April 22nd, 1917. On the following day 20 c.om.
of tetanus antitoxin were injected, and eight days later
10 c.cm. On May 8th, when the wounds were healed and he
was considered cured, the temperature rose to 102*6° F., and
next morning to 105°. He sweated profusely and complained
of pain in the neck and a little difficulty in swallowing.
There was no trismus, and Kernig’s sign was absent.
Though the spleen was not enlarged malaria was suggested
and quinine given. The temperature fell but rose again,
and there were intense headache, slight dysphagia, and some
stiffness of the neck. Kernig’s sign and slight hyper-
aesthesia of the lower limbs were found. Blood examination
was negative. On May 14th these symptoms persisted, and
in certain regions a prick or even grazing of the skin pro¬
duced local muscular contractions which were not painful.
Lumbar puncture yielded normal fluid not under increased
pressure. The contractions, which consisted of rapid
twitches, not durable contractures, became more intense.
On the 23rd the contractions were /or the first time painful
and there was oontracture of the anterior muscles of the
right thigh. It was increased on the slightest touch and
paroxysms occurred spontaneously whioh were grafted on to
the permanent hypertonia. Spontaneous twitches of the
118 Thb Lanobt.J
HYSTERICAL VOMITING IN SOLDIERS.
[Jan. 18,1919
sub-umbilical region occurred at variable intervals. Im¬
provement began on June 7th and recovery followed. The
treatment consisted in the administration of antitoxin and
Baccelli’s fluid. The absence of trismus rendered the
diagnosis difficult. Malaria, septicaemia, and, on the
appearance of the cervical rigidity, meningitis were in turn
suggested.
Several French papers on tetanus without trismus
have recently been published. Montais has shown
that the classical form of tetanus which occurred
at the beginning of the war became rarer as pre¬
ventive serotherapy was more methodically applied.
Lumiere among 54 cases of tetanus after pre¬
ventive injection found trismus absent in 15 and
attenuated or late in appearing in 13. The
explanation of the absence of trismus is not
clear. A considerable immunity conferred by anti¬
toxin would explain very well local tetanus or the
late appearance of trismus as an initial symptom.
But why should what are normally the most
sensitive centres to the toxin become insensitive
while other centres retain their sensitiveness *?
v HYSTERICAL VOMITING IN SOLDIERS.
The war has given a great impetus to the study
of functional nerve disease, and the literature of
this subject promises to become a large and
important one. The emotional stress and physical
strain produced by the conditions of warfare are
such as to provoke various neuroses, particularly
in those predisposed to them. When these func¬
tional derangements are referred to the viscera
their nature is likely to be overlooked. We
published in The Lanobt of Jan. 4th an interesting
paper on hysterical vomiting in soldiers by Captain
W. R. Reynell. He points out that the hysterical
nature of vomiting occurring in soldiers is liable
to be overlooked and the condition thus often
recorded and treated as if it resulted from some
organic disturbance, such as gastritis. Captain
Reynell gives a valuable definition of hysterical
vomiting as “ the perpetuation by suggestion of a
symptom, due in the first place to a pathological
condition such as that caused by gassing, dysentery,
phthisis, or appendicitis.” He states that gassing
is the most frequent exciting cause of hysterical
vomiting in soldiers, but he has observed that in a
number of cases the vomiting is referred to an
attack of dysentery, trench fever, or other infection.
In either case the vomiting persists as an hysterical
symptom long after the original exciting causes
have ceased to be operative. In some cases the
origin appears to be purely emotional. The vomiting
may occur after every meal or only once or twice a
day, while in mild cases there may be intervals of
several days and the attacks of vomiting may be
traced to emotional upset or to sudden excitement.
The vomiting may be preceded by epigastric pain,
which is relieved when the vomiting has occurred.
It seems to be independent of diet in the majority
of cases. There is an absence of any sign of organic
disease, though wasting to the extent of the loss of
several stones in weight may occur. The examina¬
tion by X ray8 after a barium meal shows nothing
abnormal and the stomach empties at the normal
rate unlesB vomiting occurs. Captain Reynell states
that the diagnosis is not usually difficult and
depends upon the persistence of the vomiting in
the absence of signs of organic disease, especially
where there is a history of gassing or emotional
stress. He points out the importance of recog¬
nising the hysterical nature of the condition
owing to the fact that in a considerable proportion
of cases the vomiting persists indefinitely in spite
of dieting and treatment by medicines or by rectal
feeding, which tend rather to prolong than to cure
it. The treatment recommended by Captain Reynell
is to impress upon the patient the fact that his case
has been thoroughly investigated, and then to
explain the origin of the symptom and to indicate
that it has now become converted into a habit.
If necessary, a stomach-tube is passed before meals
for its suggestive effect upon the patient. He is told
that it is a method which does not fail, and that it
will depend upon him how often the tube need
be passed. Captain Reynell found that the vomit¬
ing usually ceased after a week or ten days, a&d
that in patients of superior intelligence it is
frequently possible for a cure to be effected
by psycho-therapy without the passage of a tube.
He adds a note to his paper expressing the opinion
that hysterical vomiting is frequently overlooked in
civil practice, and that many cases of chronic
vomiting are hysterical in nature. He goes so far
as to maintain that it is probable that most, if not
all, cases of the pernicious vomiting of pregnancy
are purely hysterical. While we should not be pre¬
pared to subscribe to this view without further
evidence, Captain Reynell’s paper is interesting and
suggestive, and should lead to a more careful
examination of cases of persistent vomiting of
obscure causation in civil practice, in order to
eliminate the possibility he suggests of hysterical
persistence of vomiting, originally of organic causa¬
tion, when the primary cause has ceased to be
operative. _
THE LESSONS OF THE LOUSE.
In a primitive society feeble folk survive the
dangers which beset them either by means of a
shyness which withdraws them from taking risks
or by a parasitism which claims the protection of
something stronger. Like the coney, the louse is a
feeble folk which, unlike it, has established its
survival by an extreme intimacy with man, and in
so doing has come to have a bearing on public
health which is only now becoming generally appre¬
ciated. Mr. LI. Lloyd, Lieutenant. R.A.M.C. (T.),
whose experience as chief entomologist in Northern
Rhodesia entitles him to speak with authority on
zoological subjects,deals with this feeble parasite and
its menace to mankind in a book, 1 intended avowedly
for the general reader rather than for the specialist,
the great merit of which is the statement of ascer¬
tained facts in a form bringing out the practical
hygienic lessons to be drawn from them. Slow,
short-lived, and defenceless, the louse has neverthe
less been man’s close companion from prehistoric
times, for Mr. Lloyd considers the body-louse and
the head-louse to be slightly divergent forms of
a parent species infesting primitive man in his
naked and hirsute state. At what stage in its
history the louse became the intermediary of
pathogenic spirochaetes and other organisms is
not dealt with by Mr. Lloyd, but would form a very
interesting chapter in the history of parasitism.
We do not even know whether the Ioubo itself is
only the innocent medium of these noxious wares
or whether as middleman it derives any personal
benefit from the traffic. The first great hygienic
lesson which emerges from a study of the facts is
that the parasite must be regarded with respect.
For untold ages the louse has been the object of
shame and jest, but not of serious study, and this
unfortunate symbiosis of ideas has been singularly
successful in keeping up the still more unfor-
1 Lice sad their ICensoe to Man. By. LI. Lloyd, R.A.MJQ. (T.) With
s chapter on Trench fever by Major W. Byam. B.A.It.O. Oxford
Medical Publication*. 1919. Fp.136. Price ?s. 6ci.
Thb Lahcbt,]
A CONFERENCE ON THE TUBERCULOSIS SERVICE.
[Jan. 18, 1919 119
tunate physical symbiosis essential to its life.
Even Mr. Lloyd has a special repugnance for the
crab-louse which he describes as an “ abominable”
insect. Bacteriologists do not brand even the
Pfeiffer bacillus. But surely applied knowledge
cannot fail to deal with a feeble creature which
lives for but 40 to 50 days, has little or no means
of finding a new host, and soon dies of starvation
when removed from the human skin on which its
normal habit is to dine at least four or five times a
day. The second lesson is that of thoroughness.
Although so easy to kill, dying at a mere touch, on
being dried or slightly warmed the failure of even
drastic methods applied without system to extirpate
it has resulted in a deeply-rooted notion that the
louse arises spontaneously from the ground. Our
soldiers in the South African War shared this belief
with the Egyptians of Pharoah’s time, before whose
eyes the dust became lice. But disinfestation—
as the phrase now runs—is only a question of
thoroughness. In the Army at first only the man’s
shirt was disinfested, leaving his other garments
as a safe refuge for the parasite. Then the whole
clothing was treated, overlooking the hair, in which
lice or nits still lurked. And, finally, the failure to
deal simultaneously with the whole body of troops
resulted in the ready re-infestation of the dis¬
infested section by adjacent and still infested
men. It was on the Eastern front that
this lesson was most strikingly illustrated by
Colonel W. Hunter’s great achievement with the
Stammers method, in which men’s kits by the
ten-thousand were sterilised by live steam in a
special railway van. 2 The problem, Mr. Lloyd tells
us, is a difficult one to solve under civilian con¬
ditions, but it is through the diffusion of the know¬
ledge acquired under war conditions that the
solution will come. The clear and concise know¬
ledge imparted in this book should greatly help the
civilian campaign against the louse. An illustrated
poster just issued by the British Museum of Natural
History at South Kensington at one half-penny,
entitled “The Louse Danger,” will help in the same
direction. _
A CONFERENCE ON THE TUBERCULOSIS SERVICE.
The larger aspects of the tuberculosis question
were just beginning to be seriously faced when the
European upheaval put an end to all constructive
labours. The position has been rendered vastly
more urgent by the war, and public opinion has
become less tolerant of delay. On the Tubercu¬
losis Service of the country will rest a very
heavy responsibility in the years ahead of us.
The Tuberculosis Society foresees the need of
strengthening the hands of those on whom the
responsibility will fall and has arranged for a
conference to be held at the house of the Royal
Society of Medicine, 1, Wimpole-street, London, W.,
at 7 p.m. on Saturday, Jan. 25th, to discuss the
status of the Tuberculosis Service under forth¬
coming legislation. Matters coming specially within
the limits of the discussion are the scope of the
tuberculosis officer’s work, his relation to the
present Public Health Service, his remuneration,
security of tenure and superannuation; and it is
hoped that the discussion may lead to a com¬
prehensive and united policy for the control and
eradication of tuberculosis, and he attended not
only by tuberculosis officers, in the strict sense,
but also by medical officers of sanatoriums,
open-air schools, farm colonies, and tuber-
2 The Lahcet, Sept. 14th and 21st, 1918.
culosis hospitals. Resolutions to be submitted
to the conference will be based upon the
memorial passed by the Tuberculosis Society in
1914 and submitted at the time to members of the
Government. The claims then made were that
tuberculosis officers should be regarded as an
independent service so far as. their clinical duties
are concerned, and be responsible for the manage¬
ment of institutions to which they are attached;
that a satisfactory status and security of tenure
should be secured for them; that the Tuberculosis
Service should not count as a subsidiary branch of
the Public Health Service; and that security of
tenure and superannuation should be ensured too
its members comparable to those ruling in the
Lunacy and Prison Services. We trust that the
conference will herald the development of the
united policy which its promoters foreshadow.
PROPHYLACTIC MEASURES AGAINST INFLUENZA
AT A PUBLIC SCHOOL.
The responsibilities of those in charge of institu¬
tions, particularly public schools, at the present
time are heavy, and any statistical results of
prophylaotic measures adopted must be welcome*
We publish in our present issue an interesting note
by Mr. G. E. Friend, medical officer of Christ’s
Hospital School, West Horsham, to which we may
draw our readers’ attention. After a small out¬
break in the summer term, to which we will refer
later, measures were taken to minimise the risks of
infection as far as possible. The school being self-
contained and enclosed by a ring fence, Mr. Friend
advised the headmaster at the beginning of the
winter term to stop all leave and keep the boys
strictly within bounds—walks outside being allowed,
but the town, 2k miles away, and all houses off
the school estate were put out of bounds.
Segregation was, however, only possible to a limited
extent, since visitors could nofc be kept away, and
large numbers came twice a week, some of them
staying over the week-end; nor could all leave of
absence be stopped. Non-resident masters and
servants were also possible sources of infection
which could not be prevented. The time allowed
for sleep had previously been increased by one hour
and the amount of work and play reduced. The nasal
drill described in The Lancet of August 24th,
1918, by Dr. Isabel Ormiston was carried out
twice daily. A polyvalent influenza vaccine, unmixed
with other organisms, prepared by Dr. ET. L. Hunt, was
given to about 77 per cent, of the boys in a single
dose—boys over 14 years of age receiving 70 million,
those under this age 30 million. In all, 633 boys
were inoculated, 306 receiving the larger dose, apd
327 the smaller. Only 39 boys’ parents objected to
inoculation, but 128 boys were considered unsuit¬
able, and 19 boys were absent, ill, so that 186 boys
were not inoculated. Only one definite case of
influenza occurred during the term, and the cases
of medical illness were less than in any term since
1898. The one case was that of a boy—inoculated
with 30 million of vaccine—who went home to
attend the funeral of his mother who had died from
influenza. He developed coryza and cough and slight
fever, and apparently suffered from mild influenza.
In addition there were 36 cases of “ chill ”
of very mild character which clinically could
not be regarded as influenza, and they were
not examined bacteriologically. Inoculation was
only carried out on Oct. 30th—i.e., at about
half term—and 12 of the caseB of “ chill ” occurred
before this date. Of the 24 cases occurring after
120 TheLanobt,]
MEDICINE AND THE LAW.
[Jan. 18.1919
inoculation 7 were among the uninoculated—i.e.,
4*2 per cent., and 17 among the inoculated—i.e.,2’6 per
cent. From September onwards influenza was very
prevalent in Horsham and in all the surrounding
villages. About 18 cases, 3 of them complicated by
pneumonia, occurred among the staff, and these
were at once isolated. Mr. Friend attributes the
gratifying freedom from influenza among the boys
to physical training, nasal drill, an increase of the
caloric value of the diet, and to the inoculation. To
this we may add that prompt isolation of the
cases occurring among the staff was also no doubt
a valuable precaution. It is somewhat difficult to
appraise the actual value of the inoculations owing
to the absence of any outbreak of the disease
among the boys from the success of the general
measures adopted.
A small outbreak in the summer term mentioned
by Mr. Friend is worth a briqf reference. In
the ten days previous to July 20th 21 cases
of mild influenza occurred in various houses
of the school. On the date just mentioned the
cricket eleven went to Brighton to play a match.
Next day five of the team were admitted to the
infirmary, together with three other boys who.
were not in the team, but came from the same
houses. Within the next four days 31 other cases
were admitted, nearly all from the houses which
had supplied the cricket team. Mr. Friend attri¬
butes this outbreak of 39 cases to the Brighton visit
of the cricket team rather than to the 21 mild cases
previously present. We do not feel quite convinced of
the correctness of this explanation, since it involves
a very short incubation period even for the five
members of the cricket eleven, and an even shorter
one for the three boys who were admitted to the
infirmary on the same day, who must on this
supposition have been infected by the five players
during the early part of their incubation period.
We may recall the interesting observations pub¬
lished by Major Michael G. Foster and Major H.
Anstey Cookson in The Lancet of Nov. 2nd, 1918,
in which the incubation period of influenza seemed
to be about 48 hours. _
Sir David Bruce has been elected a Correspondent
of the Academie des Sciences.
Sir Anthony Bowlby will deliver the Hunterian
Oration at the Royal College of Surgeons of England
on Friday, Feb. 14th, at 4 p.m.
After having completed 20 years' service on the
full staff of St. George’s Hospital, according to the
regulations, Sir Humphry Rolleston has ceased to
be physician to the institution. But instead of
automatically becoming consulting physician, which
up to the present time has been the unbroken rule
of the hospital, the house committee, on the recom¬
mendation of his colleagues, has appointed him
emeritus physician for his lifetime, with the privi¬
lege of using the clinical material in the wards for
teaching. _
THE L4NCET, VOL. II., 1918: THE INDEX.
The Index and Title-page to the volume of
The Lancet which was completed with the issue
of Dec. 28th, 1918, is now ready. Subscribers
who bind up their numbers are requested to send
a post card (which is more convenient for filing
purposes than a letter) to the Manager, The Lancet
Office, 423, Strand, London, W.C. 2, when a copy of the
Index and Title-page will be supplied free of charge.
MEDICINE AND THE LAW.
The Irregular Sale of Poisons.
At a recent inquest upon a police superintendent at
Hemel Hempstead the evidence showed that the deceased,
who had had to give up bis position owing to his period of
service having come to an end, had taken his life with
prussic acid, and that he had been able to purchase the
drug without complying with the regulations imposed by
the Pharmacy Act. He had told the druggist who sold it to
him that he wanted it in order to kill a dog, and the
druggist, according to his own version of the transaction in
the witness-box, had “presumed he would be all right
in serving the police.” The witness in question will no
doubt have received a lesson which he will never
forget, and in future will carry out to the letter
any legal enactments which may affect his business.
Probably he disregarded it in this instance because he
thought that the local police superintendent was one who,
of all others, would not be likely to make an improper nse
of his purchase, but he might have remembered that he was
also the last person who should have tempted him into an
irregularity such as be committed. The sale of dangerous
drugs in contravention of the law which seeks to restrict and
to supervise such transactions, no doubt, takes place not
infrequently, and recent cases have Bhown that in relation
to some drugs, after they have left the hands of the
legitimate retailer, a substantial profit* may be made by
surreptitiously disposing of them. At another inquest,
held at Isle worth, it was shown that the deceased,
an elderly woman, experienced no difficulty in obtaining
morphia from a firm of druggiots in London by send¬
ing a succession of written orders, and that she
received it in quantities of about 45 grains, one consignment
lasting her for not more than three days. A prescription
was mentioned as having been used by her, but particulars
of it were not given. Her way of taking the drug was to
moisten a finger with saliva, draw it across the packet of
powder, and suck it. The medical officer of the infirmary in
which the woman died ascribed death to valvular disease of
the heart and congestion of the lungs, expressing at the
same time an opinion that it had been accelerated by chronic
morphia poisoning. The coroner observed that the druggist
had been “ very slack—to put it no higher.”
Medical Practitioners and the Detection of Crime.
It is to be hoped that the publicity given by the news¬
papers to the case of William Henry Gordon, described as
an analytical chemist, with an address in Pall Mall, will
be a useful lesson to druggists and others that the treatment
of venereal diseases has been directly entrusted to the
medical profession by the Venereal Diseases Act, 1917, and
that in areas where that Act is in force there are heavy
penalties provided for unqualified persons who attempt to
administer such treatment. Gordon, it will be remembered,
was recently sentenced by Mr. Denman at Marlborough-
street police-court to pay a fine of £100 and £21 costs, or, in
default, to undergo imprisonment for three months for having
prescribed treatment and given advice to a member of the
police force who was in good health and who had been sent to
him for the purpose of detecting and convicting him. The
sentence was well deserved, and Mr. Denman intimated that a
more severe one would have been parsed if another case
mentioned had been proved before him, in which a person
who had visited Gordon as a bona-fide patient was stated to
have been treated by him as if for venereal disease, although,
in fact, he was as free from it as was the police detective.
The case upon which the conviction took place was. in
short, a well-laid trap which will have had a desirable effect
if it has procured the punishment of an offender, and if at
the same time it serves as a warning to others. It has been,
moreover, the result of action on the part of the National
Council for Combating Venereal Diseases, whose late
honorary medical secretary. Dr. Oto May, arranged the intro¬
duction of the police detective to Gordon, giving him a letter
which he presented on his first visit to the defendant’s office.
In congratulating the National Council for Combating
Venereal Diseases on its success we venture, however, to
express a doubt as to the desirability of a member of the
medical profession intervening directly in the detection of
' offenders in this or in other classes of criminal acts. We do
THELANOET,]
IRELAND.
[JAN. 18,1919 121
sot question that Dr. Otto May, actuated by a sense of
public duty, brought about with certainty a conviction
which it was desirable to secure without failure through the
omission of any detail. We are, nevertheless, of the opinion
that medical men on such occasions are entirely within
their proper sphere in giving necessary scientific evidence
after qualifying themselves to do so by observation of the
facts relevant for that purpose, and that by going further
than this they travel out of that sphere without the
justification that their action is necessary and indis¬
pensable. In other words, there are functions, such as
acting when suitable the part of the agent provocateur y
which rightly are performed by the police as everyday
official duties and which are best left to them. If we
were to hold as a matter of principle that a medical man
should be willing, at the request of the police, to introduce
a supposed patient to someone who in the name of medicine
was likely to attempt a crime, one more step would take us
to the point where such action would be looked upon as
obligatory. The nature of the criminal offence is immaterial,
but a parallel may be drawn between the treatment of
venereal diseases and the more serious case of abortion.
We can well imagine an occasion when a man suspected
of procuring miscarriage in pregnant females might
usefully be brought to justice by means of a sham
subject employed by the police. Such a man might
be a member of the medical profession, a regrettable
black sheep whom many of bis colleagues would gladly
see brought to book. We should not, however, regard it as
desirable that the actual bringing of the supposed pregnant
woman into touch with the suspected person should be the
work of a medical colleague. And yet the fact of the
suspect being a medical man would not affect the question
of his being a person whose detection was desirable, and in
conceivable circumstances such an introduction of the
supposed patient as we have suggested might be extremely
effective in bring about that end. We prefer, nevertheless,
to distinguish in such matters between the duties of those
professionally entrusted with administering and enforcing
the law, and duties which devolve upon medical men as
citizens invited to assist in a limited degree in deference to
their special qualifications for so doing.
IRELAND.
(From our own Correspondents.)
Irish Medical Committee.
A meeting of the Irish Medical Committee was held early
in the month to discuss various matters affecting medical
interests in Ireland. Mr. R. J. Johnstone, of Belfast, and Dr.
Joseph Power, of Co. Tipperary, were re-elected chairman and
vice-chairman respectively. Several grievances arising out of
the working of the National Health Insurance Act were dis¬
cussed, and the attention of the Commission was directed to be
drawn again to the continued impropriety of permitting the
Approved Societies to appoint the medical referees who are
paid out of public funds. The Commission in 1915 pledged
itBelf that it would retain all such appointments in its own
hands. The opinion was expressed by the Committee that
the remuneration for certification was, under present con¬
ditions, quite inadequate. The Committee considered the
failure of many Poor-law unions to adopt graded scales of
salaries for their medical officers, and decided to press the
Local Government Board to use their powers to fix adequate
salaries in the case of such unions. The probability of the
Irish Government proceeding to introduce a Health Reform
Bill for Ireland was also discussed by the Committee, and a
watching committee was appointed to report any information
that might be gained as to the intentions of the Government.
The Ministries of Health Bill.
All those who have the true interests of Ireland at heart
were surprised to learn, on the introduction of the
44 Ministries of Health ” Bill last session, that it did not
apply to Ireland, and in a speech delivered in Belfast on
Nov. 15th, 1918, Sir Edward Carson, M.P., said that as soon
as he learned from Dr. Addison, M.P., that Ireland was to be
excluded he put down immediately a resolution to move
that the House of Commons refuse to go on with the Bill
until Ireland was included. Ireland may have been excluded
either on political or non-political grounds. In a medical
journal I do not enter into controversial matters like politics,
further than to say that surely—even in a divided country
like Ireland—people might agree on a question affecting
their health, no matter what religious or political opinions
they held. Tet what non-political reasons could be assigned
for keeping Ireland out of a health measure, except
that, owing to the backward state of public health in
that country, it could not be treated simultaneously in the
same way as England and Scotland ? And so Ireland must
have a measure for herself alone. For many reasons, in
both Scotland and England, public health is half a century
in advance of what it is in Ireland, where there are
full-time officers of health only in the few county boroughs,
while in the whole country there is not a county medical
officer of health. There are no primary school boards, with
the result that medical inspection of schools does not exist,
and in the Insurance Act medical benefits in Ireland are
conspicuous by their absence ; while a Central Midwives
Board was established in England in 1902 and in Scotland
in 1915, the Irish Board came into existence only towards
the end of 1918 and is not yet in full practical activity. If
ever there was a country which needs a thorough reorganisa¬
tion on modem lines of its public health conditions it is
Ireland, and it is, therefore, to be hoped that when the new
measure so much talked of at present—to coordinate health
departments—is introduced, it will either include Ireland
or give us a separate measure dealing with our country.
The Salaries of Dispensary Doctors.
The dispute between the dispensary medical officers and
boards of guardians in reference to increase of salaries is
rapidly approaching a crisis in the north of Ireland. At
Derry the matter is still unsettled, and at Ballymena no
action was taken on Jan. 4th, although a week later
the guardians yielded to a threat of resignation. At
Coleraine on Jan. 4th a letter from Dr. H. S. Morrison,
secretary to the County Medical Committee, to the effect
that he was instructed to say that the proposed scale of
increase passed by the guardians was inadequate, making
the initial salary £125 instead of £100, rising to £175
instead of £150, with special scale for the Coleraine
Dispensary of £150 of initial salary, rising to £200, was
marked read, and no satisfactory arrangement has keen
made. At Omagh the Local Government Board have
sanctioned the increase of salaries of each of the medical
officers of the union from £100 to £140 and the granting of
three quinquennial increments of £10 each till a maximum
of £170 is reached. The Belfast guardians are to consider
the question of the request of their medical officers for an
increase in their salaries at a special meeting.
* Health of Belfast.
At the January meeting of the Belfast City Council,
in seconding a resolution to the effect that the Infectious
Disease Notification Act, 1889, shall apply in Belfast
to the disease known as septic pneumonia (i.e., influenza),
Mr. J. H Stirling, a leading councillor, blamed the health
authorities for taking no action until Dec. 7th last, and
pointed out the admitted want of knowledge of the medical
profession as to the nature of the epidemic or as to its
real causation. It appears that the deaths for the four weeks
ended Dec. 14th, 1918,. were 863 from all causes, and of
these 250 were attributed to chest affections. In reply, the
chairman of the public health committee took the line that it
was no part of the duty of the Belfast public health com¬
mittee to set up a department of research to find out the oause
of influenza, which, he declared, was entirely outside their
jurisdiction. Their duty was to administer the law, and
it was for the Universities or the Government to under¬
take research work. In other words, notwithstanding the
fact that the Belfast City Council have a medical officer of
health, a pathologist, a tuberculosis health officer, and
numerous doctors (all paid) engaged at centres for child
welfare, and with the rates of the city for public health
work steadily rising, the whole business they are to do is,
according to the chairman of the public health committee of
the city of Belfast, to administer the law. Is it any wonder
that in Belfast for 1918 we have a high general mortality
rate and high rates for tuberculosis and infantile mortality ?
“ To administer the law,” says the chairman of the public
health committee of the great city of Belfast, is all the duty
that the health authority has to do. Let others bother
themselves about the research work necessary to find out the
cause and, as a natural corollary, the means of preventing
and treating disease.
122 The Lancet,]
THE WAR AND AFTER.
. [Jan. 18, 1919
%\t Mar anb Jfter.
The Casualty List.
For the first time for very many weeks past we have not to
make any announcements of casualties amongst the members
of the medical profession engaged in the war.
We are glad to learn from Dr. J. S. Martin, late Captain,
R.A.M.C., of Leigh, Lancs, that he is not the Capt. J. S.
Martin, R.A.M.C., who was ollicially reported to have died
in the casualty list issued from the War Ofjjce on Friday,
Jan. 3rd, and published in The Lancet of Jan. 11th.
OBITUARY OF THE WAR.
JAMES THOMAS McENTIRE, M.B., Ch.B., D.P.H. Dub.,
mons star ; l£gton d’honneur ;
LIKUTKNAMT-COLONKL, ROYAL ARMY MEDICAL CORPS.
Lieutenant-Colonel J. T. McEntire, who died of pneu¬
monia following influenza at Salonika on Oct. 29th, was
eldest son of the late Alexander Knox McEntire, J.P.,
B.L., official assignee in
Ireland. Educated at
St. Andrew’s College,
Dublin, he graduated
at Trinity College and
took the B.A. and M.B.
degrees in 1902 and the
D.P.H. in 1911. He
joined the R.A.M.C. in
1903, and served in
South Africa for five
years and on the West
Coast of Africa for two
years. He went to
France from Ireland in
1914 with the original
expeditionary force and
received the Mons Star.
In recognition of his
work in the early fight¬
ing, in which he was
often in positions of great danger, the French Government
conferred on him the Legion of Honour after the first battle
of Le Cateau. He was further mentioned in despatches
on three occasions In 1917, after a short rest at home, he
was sent to Salonika in charge of the surgical division of a
general hospital, and early this year was given command of
a stationary hospital, with the acting rank of Lieut.-Colonel.
Colonel McEntire married Mary, daughter of the late
James Little, of Dumfries, N.B., and leaves one daughter.
HENRY PARKS WHITWORTH, M.R.C.S. Eng.,
CAPTAIN, ROYAL ARMY MEDICAL CORPS.
Captain H. P. Whitworth, who died on Oct. 29th from
wounds received 12 days previously, was second son of the
late Wm. Whitworth,
M.R.C.S. Eng., of St.
Agnes, Cornwall. Edu¬
cated at Epsom College
and Guy’s Hospital,
where he played in the
Rugby team during the
seasons of 1912-13 and
1913-14, he qualified in
1914, taking the dip¬
lomas of the Conjoint
Board, and then held
several house appoint¬
ments at his hospital.
He joined the R.A.M.C.
the same year and was
posted to the 26th Field
Ambulance. After being
severely wounded during
the first battle of the
Somme in 1916 he
again went to France in 1918 and was attached to the
6th K.O.S B. Whilst attending to his patients during the
advance through Belgium he was wounded in the head and
died in a casualty clearing station near Ypres.
GEORGE ELPHINSTONE KEITH, M.B., C.M.Edin.,
CAPTAIN, ROYAL ARMY MKDICAL CORPS.
Captain G. E. Keith, who died in Italy of pneumonia
following influenza on Dec. 6th last, at the age of 54 years,
was youngest son of the late Dr. Thomas Keith of Edinburgh.
Never robust, he spent a year on a ranch in Texas before
graduating at Edinburgh in 1887. He-held appointments in
Edinburgh under the late Professor Annandale, and in the
following year went to New York, where, after taking the
M.D. degree at the
Long Island College,
Brooklyn, he became
house surgeon at the
W o m a n’s Hospital,
and there came in
close contact with the
leading gynecologists
of America. Before
settling down in
Manchester -square,
London, where he
devoted himself more
especially to mid¬
wifery, he accom¬
panied Lord Randolph
Churchill when he
went round the world
in his vain search for
health. He was part
author of a text-book
on abdominal surgery,
and for 10 or 12 years had devoted a large part of his time
to the treatment of cancer by injection, the early account of
the work being contained in “Cancer ; Relief of Pain and
Possible Cure.” He joined the R.A.M.C. in July, 1915, and
was promoted captain in 1916. Although over age, he served
with the Expeditionary Force in France and Italy, and was
one of the medical officers on the Britannic when she was
torpedoed in the /Egean Sea. Captain Keith was unmarried.
Casualties among the Sons of Medical Men.
The following additional casualty among the sons of
medical men is reported:—
Lieut.-Col. G. Buckston Browne, D.8.O., R.F.A., died of
pneumonia, son of Mr. G. Buckston Browne, of Wimpole-
street, London, W. _
The Honours List.
The following appointments of medical men to the Most
Excellent Order of the British Empire for services in
connexion with the war are announced :—
K.C.B.E.— B. N. Burnett. J.P.. Chairman of the Economic Com
raittee of the Army Medical Department, War Office; G. A. O'B. Reid;
Col. W. H White, R.A.M.C., Chairman and Consultant, Queen Mary b
R oval Naval Hospital, Southend.
C.B.E.— H. H. Dale. F.R.S. ; A. Elchholz, Senior Assistant Medical
Officer, Board of Education ; S. Lyle, Commissioner of Medical Services,
Ministry of National Service; Col. W. G. Beyts, A.M.S., Assistant
Director of Medical Service, Bombay Brigade; Lt.-Col. E. L. Ward,
I.M.S., Inspector-General of Prisons, Punjab. «... „ ,
O.B. E. —A. M. Billot, Headquarters Medical Examiner, British Red
Cross Society; A. C. Ferguson, Commandant and Medical Officer.
Thirsk Auxiliary Hospital, Yorkshire; J. T. Grey, Donor and Medical
officer, S'anmore House Auxiliary Hospital, Lenhara; R. W. Johnstone.
Commissioner of Medical Services. Ministry of National Service; J. R
Lunn, Commandant, ‘ The Cecils ” Auxil ary Hospital, Cbapp 11 Croft,
Sussex; H. A. Macewen Me Heal Inspector, Local Government Board:
Capt. L. E. C. Norbury. Surgeon. British Red Cross Hospital, Netley;
Maj D V. Rees. T.D., Operating Surgeon, Brecon and BuUth Auxiliary
Hospitals ; C. Reid, Deputy County Director, Staffordshire Branch,
British Rod Cross Society; E. C Roberts, J.P., Senior Medical Officer,
Grovelands Auxiliary Hospital, Southgate Middlesex; Maj. C. S.
de Segundo, V.D., Deputy C »mmissloner of Medical Services, Ministry
of National Serv ice; P. G. Selby, Medical Officer. Auxiliary Hospital.
Slttlng'iourne, Kent; G. R. F. Stilwell. Medical Officer. Balgowan
Auxiliary Hospital, Beckenham, Kent; G. M Winter. J.P.. Chairman,
Torquay Food Control Committee; Lt.-Col. F. S. C. Thompson, LM.S.,
Superintendent. Presidency Jail, Bengal; F. C. Madden, Senior
Surgeon. Kasr-el-Ainy Hospital. Kgyp*\
M.E E.—J. Adams; W. S. Ariett, Medical Officer, Knighton Auxiliary
Hospital, Leicestershire; W. Baigent. Officer in Charge. Northallerton
Auxiliary Hospital. Yorkshire; G S. Brock. British Red Cross Hos¬
pital, Italy; J. Culross, Medical Officer in Charge, Newton Abbot
Auxiliary Hospital, Devonshire; G. Hovle, Commandant, The Plains
and Brooksbank Auxiliary Hospital, Elland ; H. F. Powell, late Trans¬
port Officer, Cheltenham Group of Hospitals; J. Slmcock, Assistant
County Director for Heston Chapel Division, Lancashire Branch,
British Red Cross Society; J. C. Smyth, Commandant and Medical
Officer. Fairfield Auxiliary Hoepital. Malvern; J. Wallace, Com
mandant, Ashcombe House Auxiliary Hospital, Weston-super-Mare .
I C. H. Lincoln, Acting Consul, Mohammerah. Persian Gulf.
Thb Lanobt,]
ETIOLOGY OF LING CJAL CANCER.
[Jan. 18,1919 123
C0msiJ0nbme.
" Audi alteram partem.”
ETIOLOGY OF LINGUAL CANCER.
To the Editor of Thb Lancbt.
Sir,—Y our annotation on the above subject appearing in
The Lancet of Jan. 11th, in connexion with Mr. D’Arcy
Power’s Bradshaw lecture, is of the highest interest to the
medical and general public, since it contains a grave warning,
and prophesies a great increase in the disease unless measures
are taken to deal adequately with the predisposing and
exciting causes. Mr. Power concludes that syphilis cannot
be considered more than the predisposing cause, and he
suggests that the increased smoking prevalent in both sexes
is the exciting cause.
As to Mr. Power’s first conclusion, we know that even ex¬
tremely severe types of gummatous tongue of long duration may
not always develop into carcinoma ; and as to tobacco being
the exciting cause, as is pointed out, there most be at least
another factor, at present unknown. Otherwise, why are not
all excessive smokers (or at least a far larger proportion than
is the case) also victims of the disease ?
In discussing the etiology of lingual cancer it might be
well to remember that with but few exceptions, notably that
of new growths, affections of the tongue have hitherto been
rightly regarded as merely symptomatic of general, or local,
disease originating elsewhere, and that there is an intimate,
though still obscure, relationship, anatomical and physio¬
logical, between the tongue and the stomach, or gastro¬
intestinal system, the state of the tongue—e.g., the presence
of fur, dryness, moisture, swelling, &c.—being a useful index
to the presence of various febrile or gastrointestinal dis¬
turbances.
Further investigation may show that we have been mis¬
taken in excluding from this list of diseases, arising from
disturbances elsewhere, new growths of the tongue, which,
after all, may prove to be due to some cause primarily
affecting the stomach. Has the state of the gastric juice
in lingual cancer been recorded ? In investigating the
etiology of lingual cancer, therefore, I urge a closer scrutiny
of, and comparison with, the etiology of peptic ulcers,
of which condition clinically I have had considerable
experience.
We know from Dr. Charles Bolton’s experiments that
gastric ulcers can be produced by certain toxins, but do we
know exactly how, in ‘‘atonic dyspepsia,” the apparently
analogous condition in the tongue, peptic ulceration, arises 7
Clinically, in my experience, this condition is especially
associated with “starchy dyspepsia,” an inability to digest
certain starches (especially of potato, peas and beans, corn¬
floor, &c.), and with mental and emotional strains, overwork,
and anxiety. Closely allied to this is the question of the
“sore tongue ” known to smokers, and hitherto generally
attributed by them to the tobacco itself.
A prolonged consideration of the etiology of peptic ulcers
of the tongue inclines me to think that though the acrid and
very strong tobacco used by the poorest classes can and does
produce ulceration of the tongue, the ordinary and milder
tobaccos smoked by the majority in pipe and cigarette are
probably far less frequently the cause of the sore tongue
occasionally experienced, and attributed to it, than is some
other associated but less obvious condition—namely some
slight gastric disturbance. Let me illustrate this by quoting
an experience which must be familiar to most smokers
dwelling in towns.
The late Marcus Beck, professor of surgery in University
College, London, often used to remark that he suffered from
a sore tongue if he smoked much in London, whereas, using
the same tobacco, he could smoke all day, unaffected in this
way, when holidaying and out on the moors all day. Here
is a case where the same quality of tobacco produces
different effects according to the smoker’s general condition,
which when poor more often than not manifests itself by a
more faulty digestion than otherwise. With the relief of
mental and physical strain the gastric metabolism is better
and no sore tongue occurs.
Is it not reasonable, therefore, to consider that the sore
tongue of smokers is essentially, or ecologically, to be hence¬
forth regarded as a peptic ulcer due to overlooked or unsus¬
pected, because perhaps mild, gastric disturbance occurring
in jaded town-dwellers? If so, perhaps in the sore tongue
of smokers we may have a clue which may lead us to the
discovery of the real cause of lingual oancer.
In conclusion, I suggest (1) that the trophic nerves governing
gastro-intestinal metabolism, when exhausted by mental or
emotional strain, give rise to the secretion of abnormal gastro¬
intestinal juices, which are unable to digest certain starchy
foods, particularly potatoes, peas, and beans, and the absorp¬
tion of the toxins arising from subsequent fermentation results
in peptic ulcers of the tongue ; (2) that the sore tongue of
smokers (with the exception named previously) is due to
associated mild gastric disturbance of the same kind \ and
(3) that these considerations as to the etiology of peptic
ulcers may provide an important clue to the etiology of
lingual cancer.
Even if my conclusions are shown to be unfounded, a dis¬
cussion, focussing the experience of medical observers
everywhere, cannot but be of the greatest assistance to
future investigators.—lam. Sir, yours faithfully,
Harley-street, W.. Jan. 12th, 1919. HENRY CURTIS, F.K C.S.
CAUSES AND INCIDENCE OF DENTAL CARIES.
To the Editor of The Lancet.
Sir, —Mr. R. Denison Pedley asks me to furnish some
evidence of my statement “that there are among the
inhabitants of this country more than 200 million carious
teeth, as many alveolar abscesses (pyorrhoea alveolaris), and
some 30 million root abscesses. ” Taking the population of
the United Kingdom as 45 millions, this, according to my
estimate, implies for each individual 4£ carious teeth,
4£ alveolar abscesses, and 2 root abscesses for every three
persons. Does this estimate strike Mr. Pedley as excessive?
I have before me Dr. James Wheatley’s 1914 report to the
Education Committee of the Salop County Council, and an
excellent report it is. Referring to his investigation into the
prevalence of dental caries among elementary sohool
children, he writes:—
“The figures have been in such close agreement each year
that it appears certain that they may be taken as an
accurate description of the amount of dental caries amongst
the elementary school children of the county. The striking
points are: (1) That only 3 per cent, of the children at age 12
and 5 per cent, at age 5 were free from caries; (2) that the
average number of decayed teeth at the age of 5 was 6 8 and
at the age of 12 was 4-8; (3) that out of 3794 ohildren
examined at the age of 5 no less than 1017 had ten or more
decayed teeth, and out of 3580 children at 12,876, had seven
or more decayed teeth.”
When we come to examine adults we find that a consider¬
able proportion of carious teeth have been extracted owing
to the trouble they have caused, so that the number of
carious teeth in a given mouth does not represent the number
of permanent teeth which have become carious within it.
Similarly, in regard to pyorrhoeic alveoli, the number present
does not take account of those which have closed up in con¬
sequence of extraction or spontaneous shedding of the teeth.
The number of teeth spontaneously shed as the result of
pyorrhoea is enormous, embracing as it probably does all
those which are shed as the supposed result of senile decay.
In other words, the edentulism of the aged is essentially
pyorrhoeic in origin.
In order to provide Mr. Pedley with figures I have hastily
examined the teeth of 17 men, mostly discharged soldiers,
occupying one of the wards of the West End Hospital for
Diseases of the Nervous System. Their ages range from
21-43 years, and they come from various parts of England.
I found the pyorrhoea average to be 9 (i.e., double my
estimate), and the CAries average to be 3 (i.e., one-third
below my estimate).
Since pyorrhoea alveolaris is practically limited to adults,
the average number of purulent alveoli in adults would need
be considerably higher than 4£ (as it actually is in the serieB
examined), in order to bring the average of the total popula¬
tion up to this figure. The caries average in my series
would have been much higher but for the large number of
extractions—i.e., 9 per individual. Had no carious teeth
been removed the average would have been 12 (i.e., more
than double my estimate).
1 have no statistics to give regarding root abscesses. I
shall be surprised, however, if the estimate of two such
abscesses for every three persons is regarded as excessive by
dental surgeons. I am. Sir, yours faithfully,
Cavendish-square, W., Jan. 11th, 1919. HARRY CAMPBELL.
124 The Lanobt,]
CAUSES AND INCIDENCE OF DENTAL CARIES.
[Jan. 18, 1919
CAUSES AND INCIDENCE OF DENTAL CARIES.
To the Editor of Thb Lanobt.
Sir, —I am glad your columns are being used to emphasise
the connexion between soft, sugary, or starchy food and
decay of the teeth. School clinics are doing much to cure
and prevent caries at school age, but why should it be
allowed to occur at all? Nature shows that the young
animal should pass from its mother’s milk to hard food,
which keeps the teeth clean and exercises the jaws, and that
with such diet animals rarely get caries. Museums show
that caries is exceptional in uncivilised man. Yet our
mothers are still, with medical approbation, encouraged to
feed their babies as the teeth emerge on soft, sweet food,
with its inevitable consequences of contracted jaws and
decaying teeth.
Dr. Sim Wallace has shown that caries may be largely
prevented without altogether imitating Nature if every meal
is completed with a detergent food. If it is not practicable to
revert to a diet which will produce a larger jaw and better
developed teeth we may at least follow Dr. Wallace’s
teaching sufficiently to greatly diminish the occurrence of
caries with all the suffering and ill-health which go along
with it. The matter is largely in the hands of the medical
practitioner. I am, Sir, yours faithfully,
Woolwich, Jan. 8th, 1919. SIDNEY DAVIES.
AUTOTHERAPY OR BLEEDING.
To the Editor of Thb Lanobt.
Sir,— A new line of treatment is suggested in the annota¬
tion in The Lancet of Dec. 28th, 1918, p. 889, on Dr. Luigi
Meille’s method of treating influenza by subcutaneous
injection of the patient’s serum, presumably containing
antitoxins. Having tried this practice without beneficial
results in another disease, I beg leave to record a negative
observation. Two years ago, assuming that opsonins are
free in serum, I withdrew 50 c.cm. of blood from a tuber¬
culous patient showing severe intermittent pyrexia. Blood
was run direct from the median basilic vein into a sterile
flask and left to coagulate for 24 hours. Most of the serum
was recovered and injected into the patient’s groin. This
was done twice with an interval of ten days. After with¬
drawing the blood there was a transient fall in temperature
and in pulse-rate, but as the actual injection of serum had no
influence on the disease, and as blood-letting is generally
contra-indicated in pulmonary tuberculosis, the practice was
abandoned.
May I also suggest that Dr. Meille’s results were possibly
due to the bleeding and not to the serum, and that the practice
of bleeding, so universal in the past, may have some advan¬
tages over our indirect modern methods of reducing engorge¬
ment of arteries or veins. Until the middle of last century
even healthy adults were regularly bled, and, according to
Sir James Paget, “ not one of these persons suffered harm.”
Again, Sir Thomas Watson considered venesection to be 44 a
potent and life-preserving remedy ” in many diseases.
Acoording to Quain, blood-letting in the early stages of
pneumonia “ relieves pain, abates fever, and, if it does not
arrest the disease, it certainly appears to lessen its duration.”
Curiously enough, this author states that physicians first
learnt that blood-letting was not a universal panacea during
the influenza epidemic of 1830.
I am, Sir, yours faithfully,
London, Deo. 29th, 1918. HALLIDAY SUTHERLAND.
PURULENT BRONCHO PNEUMONIA ASSO¬
CIATED WITH THE MENINGOCOCCUS.
To the Editor of Thb Lanobt.
Sir, —In your issue of Jan. 11th “Bacteriologist” deals
somewhat harshly with a short description I gave in
The Lancet of Dec. 28th, 1918, of “Six Cases of Purulent
Broncho-pneumonia Associated with the Meningococcus.”
He states that this title is “ wholly misleading,” although I
purposely used the words “associated with.” Apparently
he considers them synonymous with “caused by” or “doe
to.” When, after summarising the facts, I gave what
appeared to me the probabilities, I was most careful to
commence by saying it was only my opinion. I make no
pretence to “bacteriological proof,” nor is this to be
wondered at, seeing that three of the six patients were dead
and the other three entirely convalescent at least a fortnight
before I heard of them.
I published the notes because the series of cases, and their
sequel in the occurrence of a case of oerebro-spinal fever,
appeared to me so suggestive in the light of other reports,
not yet published, as to be quite worth recording. That the
meningococcus does cause pneumonia in certain cases is
believed by many, 1 but this little series of cases which I
have been able so imperfectly to investigate becomes
especially interesting if viewed in the light of information '
derived from such an outbreak as that at Colmar in January,
1906, which is fully described by Jacobitz.- The outbreak
occurred in one company of a Jtiger Battalion. Twelve
patients (other than carriers) were proved to be infected by
the meningococcus, and Jacobitz divides his 12 cases into
five groups, thus :—
1. Two cases showing typical cerebro spinal meningitis without
complications.
2. Three cases showing meningococcus pneumonia in association with
meningitis.
3. One case of pneumonia without meningitis. The symptoms
included pyrexia ending by crisis.* rusty sputum, and signs of con¬
solidation. Microscopic examination of the sputum showed only
Gram-negative intracellular cocci, which were cultivated and Identified
as meningococci by agglutination. Meningooocci were also present in
the naso-pharynx, but pneumocooci were never observed in the sputum
In this case.
4. Four cases of bronchial catarrh without meningitis. These
patients were only moderately ill, but the apntum showed numerous
meningococci, which were cultivated and proved by agglutination.
All had meningooocci also in the naso-pharynx.
5. Two case* of lung infection in which the meningococcus was
found mixed with other bacteria.
Referring to my own series, may I add that none of the
three convalescents have proved chronic carriers, although
when first examined they all showed almost pure and very
abundant cultures. This disposes of the explanation that
coincidence had brought together three chronio carriers of
Type I. One of “Bacteriologist’s” criticisms is just, I
should not have mentioned Pfeiffer’s bacillus.
I am, Sir, yours faithfully,
J. A. Glover,
Jan. 13th, 1919. Captain. R.A.M.C.
%* Dr. Glover will be interested to read a short paper by
Dr. William Fletcher, published in this issue.—Ed. L.
CROOKES’S LENSES.
To the Editor oj Thb Lanobt.
Sir,—M ay I ask any of your readers to be so kind as to
explain what are the special benefits which accrue to the use
of Crookes’s tinted lenses ? Djes their light-yellow tint merely
cut off from the eye a small portion of the red and violet rays
which go to make up white light ? and, if so, would not any
glasses of the same tint have the same effect ? Or have they
by their composition other properties than these, and, if so,
what are they, and what is the construction of the glass
which gives them these properties?
I am, Sir, yours faithfully,
Jan. 11th, 1919. ENQUIRER.
%* In consequence of the prevalence of cataract amongst
glass bottle makers researches were undertaken by Sir
WillUm Crookes some years ago into the possibility of
obtaining glass opaque to the noxious ultra-violet and ultra-
red rays and still transparent to light. In the course of his
experiments a large number of metals were used, salts of
which were incorporated in the experimental glasses, over
300 varieties being prepared. While none of them fulfilled
the above conditions with perfection, some of them did very
nearly, and the “No. 1 ” Crookes glass which is now sup¬
plied by opticians, while being practically completely trans¬
parent to light, does effectually cat off a very high percentage
of both heat and actinic rays, and in this respect is superior
to ordinary amber or smoked glass for cases in which it is
desirable to protect the eyes from these rays without inter¬
fering with vision. Opticians also supply a “ No. 2 ” Crookes
glass which is partially opaque to light, suitable to be
employed only in those cases where the amount of visible
light is excessive. Sir William Crookes’s own report on his
experiments will be found in the Philosophical Transactions
of the Royal Society for 1913.— Ed. L.
1 Of. Sophian, Bpidemlc O.S.M., p. 65.
- Zeltschriffcfnr Hygiene, Bd. lvi.. 1907.
Tbs Lanobt,]
OBITUARY.—THE SERVICES.
[Jan. 18,1919 125
THE LATE HENRY SANDFORD.
To the Editor of Thb Lancet.
Sir,—I have read with great regret your announcement of
Mr. Henry Sandford's death. He wap, I believe, the last
survivor of those connected with Thk Lancet, in any
capacity, when I joined the staff 47 years ago. Mr. Potter,
his senior partner, was then in the full vigour of bodily and
mental health, but whenever he was unable to attend at
Thb Lancet Office “ young Sandford,” as he was then
called, used to take his place.
By a melancholy coincidence Dr. Thomas Buzzard died a
few days later than Mr. Sandford. With him passed away
the last of the literary and editorial staff existing when I
joined. At that time there were, in addition to Dr. James
Wakley, Tilbury Fox (who acted as editor during Dr. James
Wakley’s illness), J. P. Steele, Brudenell Carter, James Grey
Glover, Christopher Heath, Anstie, Henry Power, Jeffrey
Mareton, Harry Leach, Stallard, John Netten Radcliffe, Vivian
Poore, and others whom at the moment I cannot recall.
Thomas Henry Wakley, F.R C.S., eldest son of the Founder
of the paper, was at that time in charge of the business side
of the journal. All these and a few others were, I remember,
at the Jubilee Dinner of The Lancet in 1873.
It is witb pleasure I notice the continued vitality and
prosperity of The Lancet.
Wishing you a happy and prosperous new year,
I am, Sir, yours faithfully,
Harley-atreet, W., Jan. 6th, 1919. JOHN TWEEDY.
WILLIAM ASHTON ELLIS, M.R.C.S. Eng.
Mr. W. A. Ellis, who died on Jan. 2nd, aged 66 years,
was son of the late Robert Ellis, M.R.C.S., of London.
Educated at Westminster (1866-1870). where he won a
Queen’s scholarship in 1867, be entered St. George’s Hospital
in 1871, took the M.R.C.S. in 1876, and the L.R.C.P. in
1878. He is chiefly to be remembered as a Wagnerian
scholar; for some years he edited The Mtister (quarterly
journal of the Wagnerian Society), and he was the author of
“ Richard Wagner’s Prose Works,” in eight volumes, and of a
life of Wagner in six volumes. Soon after qualification he
had acted as resident medical officer to the Western Dis¬
pensary, and during the war he bad resumed his old post
there. Mr. Ellis was formerly honorary secretary of the
Association of Members of the Royal College of Surgeons of
England, and during the latter years of the last century he
was a prolific writer on the subject of reform of that body.
LAWRENCE HENRY BENNETT, M.A., M.B. Oxon.,
M.R.C.S. Eng.
Mr. L. H. Bennett, who died suddenly on Dec. 28th at
Paignton, was third son of Henry Bennett, of Bedminster, Glos.
Educated at Clifton (1877-80), he matriculated at Trinity
College, Oxford, in 1880, at the age of 18. He took bis
B.A. degree in 1884, and entered at St. George’s Hospital
the same year, obtaining the qualification of the Conjoint
Board in 1889 and taking the M.A., M.B., B.Ch. Oxon. in
1890. After serving as ophthalmic assistant and orthopeedic
assistant at St. George’s Hospital he settled in practice at
East Ilsley, near Newbury, Berks, and later moved to
Paignton, where he had an extensive practice.
THE BELGIAN DOCTORS’ AND
PHARMACISTS’ RELIEF FUND.
THE SERVICES.
ROYAL ARMY MEDICAL CORPS.
Major (acting Lleut.-Ool.) H. A. Davidson to be acting Colonel whilst
employed as an Asa! tant Director of Medical Services of a Division.
Major C. W. O'Brien relinquishes the acting rank of Lieutenant-
Colonel on re-posting.
Major (acting Lleut.-Col.) H. F. Shea to be acting Colonel whilst
specially employed.
Tmp. Major C. H. G. Ramsbottom to be acting Lieutenant-Colonel
whilst specially employed.
Capt. (acting Majoi) J. W. Bennett to be acting Lieutenant-Colonel
whilst specialty employed.
Temp. Capt. (acting Major) W. Kennedy-Taylor to be aotlng
Lieutenant-Colonel whilst in charge of Guildford War Hospital.
Major C. P. Thcmson is placed on the halt-pay list.
To be acting Majors: Capts. B. A. Austin, D. W. Beamish, C.
McQueen; Temp. Capts. R. Bruce Low, A. S. Wakeh, A. G. M.
Middleton. O. K. L. Wilson, J. R. Anderson, J. G. Moseley, H. J. de
Brent. T. B. Amyot, J. McDonnell A. R. Ester, W. L. Cassells.
Temporary Cm ptal* s to be acting Maj rs whilst specially employed:
S. B. Martin, J. C. Muir. F. R. Barwell.
Temp. Capts. J. Anderson, L. F. Hemmans, F. G. Bell relinquish the
acting rank of Major on re-posting.
Temp. Lieuts. T. ▲. Matthews and N. J. Newbonld to be temporary
Captains.
D. C Parmenter to be temporary Honorary Lieutenant whilst serving
with No. 22 General Hospital (Harvard Unil).
Canadian Army Medical Corps.
Temp. Capt. (acting Major) M. H. Allen to retain the acting rank of
Major while employed in D.G.M.8. Office.
Hon. Capt. (acting Hon. Major) A. B. Clifton, D.C.M., to retain the
acting rank of Honorary Major while employed as Inspector of Technical
Equipment in D.G.H S. Office.
Temp. H< n. Capt. J. W. White relinqnlshes the acting honorary rank
of Major on oeaslug to command a Depot.
SPECIAL RESERVE OF OFFICERS.
Capt. P. Walsh relinquishes the acting rank of Major on re-posting.
Captain* to be acting Majors: S. K. Young, W. O. Tobias. Whilst
specially employed; A. J. Brown, W. C. Mackie.
W. Oats to be Lieutenant.
TERRITORIAL FORCE.
Major (acting L1eut.-Col)J B. Yeoman relinquishes acting rank on
oeasing to be specially employed.
Major W. R. E. Williams relinquishes his commission on account of
ill-health.
Captains to be acting Majors while specially employed: B. B. Pitta.
J. W. Wood, W. L. Cockroit, A. C. Tibbits.
Capt. (acting Major) G. 8. Williamson relinquishes his acting rank
on ceasing to be specially employ ed.
Capt. L. E. H. R. Barker relinquishes his commission on acoonnt of
ill-health contracted on active service.
Major A. M. H. Gray, Capts. A. B. Webb-Johnson. W. J. Wilson
(Bt. Major), G. A. Williamson, Lieut. F. J. Clemlnson (temp. Capt.)
(retains his temporary rank) are transferred from the List of Officers
Supernumerary tor servioe with the Officers Training Corps.
Officers seconded for service witn the R.A.F. : Maji.r J. W Keay,
Capts. J E. Dunbar, V. T. tf 11 wood, A. D. Kennedy, J. E. Lascelles.
1st Sou hern General Hospital.—Major W. Kirkpatrick to be acting
Lieutenant-Colonel whil»t specially employed, nnd to be seconded.
5tb Northern General Hospital.—Capt. J. W. Patrick Is restored to
the establishment.
2nd London Sanitary Company.—Capt. (aotlng Major) F. S. Carson
relinquishes his acting rank on ceasing to be specially employed.
1st Northern General Hospital.—Major (acting Lieut.-Col.) G. Hall.
C.M.G., relinquishes his acting rank on ceasing to be specially
employed.
1st Eastern General Hospital.- Capt. (acting Major) R. V. Slattery
relinquishes his acting rank on ceasing to be specially employed, and
remains seconded.
3rd Southern General Hospital.—Capt. W. B. Seeretan Is seoonded
for duty with the Heading War Hospital.
4th London General Hospital.—Lieut.-Col. Sir N. I. C. Tirard is
retired on attaining the age limit, and retains the rank of Lieutenant-
Colonel.
Major (Brevet Lleut.-Ool.) Smart, from 1st Scottish General Hoepltal,
to be Lieutenant-Colonel on the permanent personnel.
TERRITORIAL FORCE RESERVE.
Capt. B. 8. Stork, D.S.O., from Attached to Units other than
Medical Units, to be Captain.
Capt. P. C. Mitchell re tnqulshes his commission on ceasing to be
employed, and retains the rank of Captain.
Lieuts. G. T. Nlobols and O. W. Stewart relinquish their com¬
missions on ceasing to be employed, and retain the rank of Lieutenant.
Subscriptions to the Second Appeal.
The following subscriptions have been received op to
Monday, Jan. 13th
£ s.d. £ s. d.
Mr. B. Bpenoer Bvans Mr. J. F. Cownie . 110
(monthly) . 0 10 0 Ur. C. Buttar. 3 3 0
American Bed Cross Dr. Vincent S. Hodaon 110
Commission for I Dr. B. S. Green . 110
Belgium (monthly) ... 200 0 0 I
Subscriptions to the Fund should he sent to the treasurer
of the Fund, Dr. H. A. Des Vceux, at 14, Buckingham Gate,
London, S. W. 1, and should be made payable to the Belgian
Doctors* and Pharmacists’ Relief Fund, crossed Lloyds
Bank, Limited.
BOYAL AIR FOBCB.
C. G. Galpin (temp. Capt., ret. pay) is granted a temporary honorary
commission as Major.
Capt. G. Fehrsen relinquishes his commission on eeasing to be
employed, and retains his rank. __
DEATHS IN THB SERVICES.
Surgeon-General Sir James Howard Thornton, on Jan. 6th, aged 85.
He entered the I.M.S., in which his father was a major. In 1856, aud
the two served throughout the Indian Mutiny. The sun then went to
China, and was later wounded in action m the Kh&sta aud Jynkia Hills
campaign. He was chief medical officer in the Suakin and Hargara
expeditions. He was live times mentioned in aespatebes, received
four medals with seven clasps, the Khedive's Star, the C.B , and was
dually cieated K.C.B. in 1904. He retired m 1891 to »ettie at Hove,
where he became a magistrate and a valued member of the town council.
126 T&aLANOiT,] MEDICAL DIART FOR THE ENSUING WEEK.—MEDICAL NEWS.
[Jan. 18,1919
gtdtical $krg for % tnsnmg Meek.
SOCIETIES.
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W. 1.
Monday. Jan. 20th.
GENERAL MEETING OF FELLOWS : at 5 p.m.
Ledturi:
Lieut.-Colonel Sir James Barrett, R.A.M.C.: The Management of
Venereal Diseases in Egypt during the War (with illustrations).
Tuesday, Jan. 21st.
GENERAL MEETING OF FELLOWS: at 5 P.M.
Ballot for Election to the Fellowship. (Names already circulated.)
Thursday. Jan. 23rd.
OBNBBAL MEETING OF FELLOWS, at 5 p.m.
BU&UMiOHt
On' “ Shock," opened by Professor Bayllss, F.B.S., and Dr. Dale, F.R.S.
MEETINGS OF SECTIONS.
Wednesday. Jan. 22nd.
SURGERY (Hon. Secretaries—V. Warren Low, Cyril A R. Nitoh):
at 5.30 p.m.
Poser .*
Major C. W. Waldron, O.A.R.O., and Captain E. F. Bisdon, O. A.M.O.:
Mandibular Bone Grafts.
To be followed try a Disoussion on “ Bone Grafting.” Speakers
Captain W. B. Gallle. O.A.kf.G., Major Naughton Dunn, R.A.M.C.,
Majer Alwyn Smith, D.S.O., RA.M.C., Major Robert Milne,
B.AM.C.
Cases will be shown at 5 p.m.
Friday, Jam. fifth.
STUDY OF DISEASE IN CHILDREN (Hon. Seoretariee—G. & C.
Pritchard, H. O. Cameron, C. P. Lapage): at 5 p.m.
Cases ;
Dr. F. J. Poynton: (1) Myoclonia Multiplex In a Girl aged 24 years;
(2) Pseudo-hypertropnio Muscular Paralysis.
Discussion :
The /Etiology, Prevention, and Non-operative Treatment of
“Adenoids,” opened by Dr. Harry Campbell and Dr. Edmund
‘ Cautley.
Those wishing to take part in the Discussion are requested to
forward their names to the Senior Hon. Secretary.
The Royal Society of Medicine keeps open home for
RA.M.C. men and M.O.'s of the Dominions and Aides. The
principal hospitals in the metropolis admit medical officers
to their operations, lectures, Ac. Particulars on application
to the Secretary at 1, Wimpole-street, London, W. 1.
and gynaecological subjects.—The secretary reported that
one dissertation on 44 Injuries and Diseases of the Pancreas
and their Treatment,” the Jacksonian prize-subject for 1918,
had been received.—It was resolved that in pursuance of
the action taken by the Council in 1915 the President be
requested to represent to His Majesty’s Government that
in any legislation relating to the promotion of the public
befflth provision sbonld be made for ensuring an adequate
supply of material for the anatomical and surgical instruc¬
tion of students and practitioners of medicine.
URBAN VITAL STATISTICS.
(Week ended Jan. Uth, 1919.)
English and Welsh Towns .—In the 96 English and Welsh towns, with
an aggregate civil population estimated at 16,500.006 persons, the
annual rate of mortality was 16*0, against 14'8 and 16*1 per 1C00 In the
two preceding weeks. In London, with a population slightly ev oa yHn g
4,000,000 persons, the annual death-rate was 15’8, or 0‘8 per 1000 below
that recorded in the previous week ; among the remaining towns the
rates ranged from 7 9 in Walthamstow, 8*2 in Hornsey, and In
.Ilford, to 22*7 in West Hartlepool, 23*7 In Hastings, ajnd 27*3 In
‘Liverpool. The principal epidemic diseases caused lw deaths, which
corresponded* to an annual rate of 0*5 per 1000, and included 64
from diphtheria, 46 from infantile diarrhoea, 17 each from measles and
whooplngrcough, 15 from scarlet fqver, and 5 from enteric fever.
The deaths fjrom influ *nza, which had steadily declined from
7559 to 441 in the nine preceding weeks, farther fell to 3B0, and
included 68 in London, 56 in Liverpool, 19 in Bfrmlnghsai, 10 in
Manchester, and 14 each in Bristol and Leeds. Thefe were 5 cas es
of small-pox, 1058 of scarlet fever, and 1139 of diphtheria under
treatment in the Metropolitan Asylums Hospital* and the London
Fever Hospital; against 3, 1062, and 1116 respectively at the end of
the previous week. The causes of 52 deaths In the 96 towns were
uncertified, of which 10 were registered in Liverpool, 8 In Birmingham,
5 in London, and 3 each in Manchester, Gateshead, and Tynemouth.
Scotch Towns.— In the 16 largest 8ootch towns, with an aggregate popu¬
lation estimated at nearly 2.500,000 persons, the annual rate of mortality,
which had increased from 14*8 to 16*7 per 1000 in the tjirec preceding
weeks, further rose to 18*6 per 1000. The 399 deaths in Glasgow corre¬
sponded to an annual rate of 18*6 per 1000, and included 9 from
whooping-cough, 5 from Infantile diarrhoea, 3 from diphtheria, 2 from
scarlet fever, and 1 from enteric fever. The 122 deaths in Edinburgh
were equal to a rate of 18 9 per 1000, and included 11 from whooping-
cough and 2 from diphtheria.
Irish Towns .—The 165 deaths in Dublin corresponded to an annual
rate of 21*2, or 2*2 per 1000 below that recorded in the previous week,
and included 2 from infantile diarrhoea. The 167 deaths in Belfast
were equal to a rate of 20*4 per 1000, and included 2 from infantile
diarrhoea and 1 from measles.
LECTURES, ADDRESSES, DEMONSTRATIONS, Ac.
ROYAL COLLEGE OF SURGEONS OF ENGLAND, Llnooln’s Inn
Fields, W.O.
Six Hunterian Lectures on Phases in the Life and Work of John
Hunter. The Lectures will be illustrated by Hunterian
Preparations, Drawings, and Records:—
Monday, Jan. 20th.— 5 p.m., Lecture I.:—Prof. A. Keith: The
Cradle of the Hunterian School.
Wepnksday —5 p.m.. Lecture II Prof. A. Keith : The Rise and
Decline of the Hunterian School In London.
Friday.—5 p.m., Lecture III.: -Prof. A. Keith: The Time, Place,
and Glrcumstanoe of John Hunter’s Oareer in London.
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith-
road, W.
Clinics each week-day at 2 p.m., Wednesday, Friday and Saturday
also at 10 a.m.
(Details of Post-Graduate Course were given In issue of Nov. 30th, 1918.)
ROYAL INSTITUTE OF PUBLIC HEALTH, in the Lecture Hall of
Gie Institute, 37, Russell-square, W.O.
Course of Lectures and Discussions on Public Health Problems under
War and After war Conditions
Wednesday, Jan. 22nd.-4 p.m., Prof. I. W. Hall: Industrial Hygiene
in Relation to War Strain and Technical Development.
Stekkal Stilus.
University of Liverpool,—T he following have
passed the Janaary examination for the Diploma m Public
Health : Shaikh Ghulam Mohamed, M B.. Ch.B., and Peter
Paul Wright, M.B., B.Ch., B.A.O.
A scheme for establishing a chair of Mental
Diseases at Edinburgh University has been approved by the
University Court. The board of the Royal Edinburgh
Asylum for the Insane has made the foundation possible by
offering an endowment of £10,000.
Royal College of Surgeons of England.—
A quarterly meeting of the Council was held on Jan. 9th,
Sir George Makins, the President, being in the chair.—It
was resolved to accord a vote of congratulation to Sir John
Lynn Thomas on being made a Knight of the British
Empire.—In accordance with the recommendation of the
Museum Committee, it was resolved that the skeleton of the
Greenland whale be taken down and placed in a room in the
basement.—The best thanks of the Council were given to
Mr. Alban Doran for presenting to the library five volumes
of bis literary contributions, together with five other
volumes of pamphlets and articles mainly on anatomical
Communications, Letters, Ac., to the Editor have
been received from—
A. —Col. J. G. Adami, A.D.M.S.
B. —Dr. H. Brown, Lond.; Messrs.
John Bell, Hills, and Lucas,
Lond.; Dr. F. J. C. Blackmore,
Lond.
C. —Dr. H. Campbell, Lond.; Col.
S. L. Cummins, A.M.8.: Capt J.
Campbell, B. A.M.O.(S.R ); Mr.
H. G. H. Clarkson, Bir»twith;
Dr. 0. Coombs, Clifton; Dr. A.
Cox, Lond.; Dr. S. Obeiliah.
Colombo; Chicago School of
Sanitary Instruction : Dr. J. A.
Oalantar, Lond.; Dr. C. M. Craig,
Abergele; Dr. B. L. Oollis,
Lond.; Dr. R. Craig, Lond.; Dr.
b. E. Core, Lond.; Mr. H.
Curtis, Lond.; Mr. J. Cabburn,
Lond.
D. -Dr. W. F. Dearden. Man¬
chester; Dr. S. Davies, Lond.;
Mrs. Duffy, Jesmond; Dr. J. N.
Dyson, Eastbourne.
B.—The Misses Erwin, Lond.
F. —Capt. J. Fr.ver, R.A.M.O.; Mr.
H. Faulds, Hanley; Capt. W.
Fletcher, H.A.M.C., Major B. B.
Fothe gill, It.A.M C.; Surg. G.
Findlay, R.N.; Lt.-Ool. H.
French, K.A.M.O.; Factories,
Chief Inspector of, Lond.; Capt.
J. N. FeiguBson, R.A.M.C.; Dr.
A. W. Falconer, A!>erdeen.
G. —Capt. J. A. Glover, R.A.M.O.;
Dr. H. 1. Goldstein, Camden,
Hew Jersey; Lt.-Col. J. H. P.
Graham, R.A.M.CJS.R.)
H. —Dr. C. W. Hutt, Brighton;
Mr. B. H. Hunt, Secunderabad
(Deccan); Lt.-Col. A. F. Hurst,
R.A.M.C.; Lieut. J. A B. Hicks,
R.A.M.C.
I. —Illuminating Engineering So¬
ciety, Lond.
K. —Prof. A. M. Kennedy, Glas¬
gow.
L. —London Units of the Scottish
Women’s Hospitals ; Major J. R.
Lee, R.A.M.G.; Local Govern¬
ment Board, Lond.; Mr. M.
Little, Lond.
M. —Dr. R. Morton, Lond.; Dr. I.
Moore, Lond.; Ministry of Muni¬
tions of War, Lond.; Capt. H. C.
Martin, R.A M.C.; Mr. A P.
Melville, Edinburgh; Mr. P.
McBride, Edinburgh.
N. —Xurging Times, Lond., Editor
of ; National League tor Health,
Maternity, and Child Welfare,
Lond.; National Food Reform
Association, Lond.
O. —Oliver-Pell Electric and Manu¬
facturing Co., Lond.; Official
Press Bureau, Lond., Director
of; Mr. J. Offord, Lond.
P. —Dr. J. Pearse, Lond.; Major
J. Parkinson, R.A.M.C.; Dr.
H. R. Prentice. Lond.
R.— Mr. B. S. Rowntree, York;
Royal College of Surgeons of
England, President ana Council
of; Royal Institution of Great
Britain, Lond.; Mr. P. B. Koth,
Lond.; Dr. J. D. Rolleston, Lond.;
Royal Sanitary Institute, Lond.;
Capt. H. Robinson, R.A.M.C.;
Mr. R. F. Ratnakar, Manchester;
Capt. J. Ryle, R.A.M.C. (S B.)
8.—Sir George Savage, Lord.; St.
George’s Hospital Medical School,
Lond., Dean of; Mr. J. Singh.
Nalia; Dr. P. L. Sutherland,
Wakefield; Mr. A. B. Searle,
Sheffield; Mrs. H. R. Spurred,
Lond.; Selborne Society, Lond..
Gen. Sec. of; Mr. J. E. Sykes.
Huddersfield ; Dr. R. V. Solly,
Exeter; Capt, J. L. Stoddard,
M.C.. U.S.A.
T. - Dr. J. Tattaam, Ox ted ; Lt.-Col.
E. N. Tboruton, S.A.M.C.; Sir
John Tweedy, Lond.
U. - University of Liverpool.
W.— Dr. S. A. K. Wilson, Lond.;
West London Hospital Post-
Graduate College: Western
Chemical Co., Hutchinson,
Minn.; Dr. F. J. Waldo, Lond.
Communications relating to editorial business should be
addressed exclusively to The Editor of The Lancet,
423, Strand, London, W.C. 2
The Lancet.] APPOINTMENTS.—VAOANCIK8-—BIRTHS, BTC.—SHORT COMMENTS, ETC. [Jan. 18,1919 ] 27
Jpintmeirts.
Alls*. V. F., L.R.C.P. A 8. Edln., L.F.P.S. Glasg., has been ap¬
pointed Certifying Surgeon under the Factory and Workshop Acts
for the 8 waff ham Distrust of Norfolk.
Curne, 8. J., M.D. Manoh., Deputy Medical Offloer of Health for
Newcastle.
Hacxett, J. A. W., M.B., Cb.B. Edln.. reappointed Medical Offloer for
the Gainsborough Urban District.
Hall. Robert, L.B.C.P. Ed., L.S.C.S. A L.M. Ed., Examiner in
Clinical Medicine in Belfast University, and Consulting Physician
to the Ulster Volunteer Force Hospital for Discharged Sailors and
Soldiers, Belfast {under Ministry of Pensions).
Hakdcastlx, W., M.B. Lond., and Stephshsov, G. B., Captain,
B.A.M.G., Police Surgeons for Newcastle.
n D. M„ M.B.».Ch.B. Bdin., Physician Superintendent, James
array’s Boyal Asylum, Perth.
Sharplky, J. B., M.K C.S., L.B.C.P. Lond., reappointed District
Medichl Officer of the Blyborough District, Gaimborough Union.
Uacmtms.
For further information refer to the advertisement columns.
Birkenhead Borough Hospital —Jun. H.S. £170.
Birmingham General Dispensary— Tuber. Officer. £600.
Birmingham General Hospital. —Vacancies on Res. 8taff.
Bradford Royal Eye and Ear Hospital—Ophth. S.
Chichester, Royal west Sussex Hospital.—H.S. £160.
Croydon County Borough ( Ante-Noted Clinic).— Female Med. Prac.
£1 Is. per session.
Dorchester , Dorset County Asylum.— Second Asst. M.O. £300.
Dorset County Council.— Temp. Asst. M.O.H. £400.
East London Hospital for Children and Dispensary Jor Women, Shad-
well. E.—hsat. Res. M.O. £125. Also Casualty Offloer. £120.
Eeclcs and Patricrofl Hospital , near Manchester. —Res. H.S. £250.
Edinburgh, Venereal Diseases Scheme.— Female Asst. M.O. £400.
Elizabeth Garrett Awlcrson Hospital, Euston-road, N. IK.—Female
Temp. Asst. S.
Exeter City Mental Jlosoital, Dighys, near Exeter—hast. M.O. £300.
HeUtnply, East Sussex County Asylum.—Temp. Asst. M.O. 7 gs. per wk.
Hull City Education Committee. — Asst. Female School M.O. £400.
Manehetfer, Ancoals Hospital. Mill-street.— Hon. P.
Monmouthshire County Council.— Female Asst. M.O. £400.
liorth Riding Asyfuro.—Locum Tenens M.O. 7 gs. per week.
Northampton County Borough.— Temp. Tubero. Officer. £400.
Putney Hospital. Lower Common, S. IF.—Res. M.O. £150.
Rochester, St. Bartholomew's Hospital.— Clin. Asst. £150.
Royal Free Hospital, Gray’s Inn-road, W.C.— H.P. £60. Casualty
H.S. £100.
Swindon Borough.—hast. M.O.H. £500.
Taunton, Taunton and Somerset Hospital.—Sen. R.S. £250.
University of London.— Examiners. .
Victoria Hospital for Children, Tite-street, Chelsea, S. IF.—H.P. and
H.S. £200.
Wtstem Ophthalmic Hospital, Marylebone-road, iV. W.— Vacancies on
Medical Staff.
Westmorland Sanatorium , Meathop. Grange-over-Sands.—Ben. Asst.
M.O. and Asst. Tubero. Offloer. £350.
Whitehaven and West Cumberland Infirmary.— Res. H.S. £150 to £180.
Tu Chief Inspector of Factories, Home Offloe, 8.W., gives notloe of
vacancies for Certifying Surgeons under the Factory and Workshop
Act* at Alford, Aberdeen; Heokington. Lincoln; and 11 minster,
Somerset.
Jgtarrisges, mb gtidb§.
BIRTHS.
Altouwtae.— On Jan. 6th, at Hamp*tead, the wife of Oaptain B. H. R.
Atyounyan, R.A.M.O., of a daughter.
OoxriKLD.— On Jan. 12th. at Pembroke-road, Clifton, Bristol, the wife
of Oaptain Charles Corfield, R.A.M.O. (T.F.), of a daughter.
Pairbaiea- On Jan. 8th, at Blackpool, the wife of Major J. Fair balm,
M.B., R.A.M.C., of a daughter.
Williams. —On Jan. 9th, at Gre.vstones, Canford Cliffs, Bournemouth,
the wife of Dr. C. Campbell Williams, of a son.
MARRIAGES.
Bliss—Cooper.— On Jan. 8th. at the Parish Church, Henley-on-Thames,
Captain |M. F. Bliss, M.C., R.A.M.O., to Vlolette Mary, only
daughter of the late John .Manning-Cooper, Mel rose-avenue,
Orleklewood.
Mackessack—Rirtor Gor^.— On Jan. 9th, at the Church of 8t. James
the Less, Plymouth, Captain R. J. Mackessack, R.A.M.C., to Ada
Mary Frances, eldest daughter of Colonel and Mrs. Ribton Gore,
Thornfields, Lisnagry, Co. Limerick.
STouTfc— Pike.— On Jan. 9th, at Sutton, Surrey, Douglas Garnet
Stoute. Major, R.A.M.O., of Georgetown, Demerara, to Margerle
Anne (Nancy) Pike, of Sutton.
DEATHS.
Berjtaid.—O n Jan. 7th, at New Silk worth, Sunderland, Gerald
Bernard, M.D.
Butcher.— On Jan. 10th, at Holyrood, Cleveland-road, Baling, William
Deane Butcher, M.R.C.8., aged 71.
THOwrroH.—On Jan, 6th, on the eve of his 85th birthday, 8nrgeon-
General Sir James H. Thornton.
VJB.—A fu of 6s. is charged Jor the insertion of Notices of Births,
Marriages, and Deaths.
Jtoits, Comments, mtb Juste
to Correspondents.
HEALTH, MEDICINE, AND SANITATION IN INDIA.
I.
There has recently been presented to Parliament a state¬
ment exhibiting the moral and material progress and
condition of India during the year 1916-17. The following
are amongst the references to nealth, medical, and sanitary
matters contained in it
Medical Administration in War-time.
The year was marked by an unprecedented and almost unlimited
growth In military medical administration. There is not space to record
in detail the list of new hospitals, instituted or taken over by Govern¬
ment, the great expansion of many existing hospitals, the large number
of fresh medical units established for service overseas or in India Itself,
the immense additions made to personnel and equipment, and the
special preventive measures organised against infectious and epidemic
diseases, flies, heat, glare, and other discomforts incidental to cam¬
paigning in the Bast. We can mention here only two matters of
particular interest.
The first is a new departure in the foundation of orthopaedic Institutes
for the treatment of wounded and disabled soldiers. A large and very
fdlly equipped institute of this kind is being established at Debra Dan,
and the King Edward Hospital at Cawnpore has also been taken over
for conversion into a special orthopaedic hospital for Indian soldiers.
Another such Institute has been founded In Bombay.
Toe second matter is the Increasingly difficult problem of providing
trained medical officers. The civil side of the Indian Medical Service
Is not only the Government channel of medical administration and
Instruction for the whole of India, but it forms also the reserve of
medical offioers for the Indian Army on mobilisation. AH Indian
Medical Servloe officers liable to surrender from civil employ were
returned to the Army in the very early stages of the war, and many
others not technically liable were returned with or soon after them.
Only the barest minimum of officers was retained to occupy the most
Important of the administrative and executive charges ana to
maintain at full working pressure the medical schools and
oolleges on which practically the whole supply of medical prac¬
titioners, official and n m-offlolal, in this country depends. Even
so, the numerloal strength of the service proved far below military
demands, and has bad to be supplemented by the grant of temporary
commissions to numbers of civil assistant surgeons and private practi¬
tioners. Still greater difficulties beset the provision of subordinate
medical offioers for the Army. Exceptionally favourable terms have
been offered to induce civil sub-assistant surgeons to enter military
employ, but the number of candidates Is still far short of require¬
ments. Ou the other hand, there is a point beyond which the medical
needs of the vast population of India cannot bo sacrificed, and we have
every reason to believe that the response already made to military
demands has reduced the available medical personnel in most provinces
to that point. Government has in this matter a responsibility to the
civil population of India which it must discharge, and were a wide¬
spread increase of plague or other epidemic to find it unprepared and
inadequately equipped the consequences would be disastrous.
Public Health and Medicine in Madras.
In the days before the war it was a common charge against tbe
organisation of medical relief in India that the staff was quite in¬
sufficient to supply the needs of both tne military and civil branches in
the contingency of a great war. That there was some measure of reason
for this apprehension oan be seen from the fact that the Madras
Presidency has had to surrender to the military department all Its
Indian Medical Service officers, except 16, Jn addition to 27 assistant
surgeons and 76 sub-assistant surgeons. During the past year, in spite
of shortage of staff, aud notwithstanding financial difficulties, it was
possible to increase both the number of institutions and the number of
patients relieved, while at the same time there was a pronounced fall
in the hospital death-rate. This state of afflairs could not have been
maintained had it not been for the efficiency of the remaining officers
of the superior service, who have each been doing several men’s duties,
and of the assistant surgeons who have been called on to take charge of
important hospitals.
During tbe year 1916-17 more than seven million patients were treated
In the public hospitals and dispensaries maintained or aided by the
State and by local bodies. There was a very large and satisfactory
increase in the number of medical students, due pari ly to the opening
of a new medical school at Osllcnt. Tbe Pasteur Institute treated a
record number of patients, and efforts are being made to collect reliable
statistics a* to the efficacy of the treatment.
In Madras City a careful malaria survey has been made and pre¬
ventive measures hsve been taken on a fairly large scale against this
disease. By means of itinerating dispensaries something la also being
attempted in the Mufassal, but the huge area over whlcn malaria
prevails precludes any possibility of concentrations of effort such ms have
been successful in the cities of Europe and America. Great differences
of opinion exist as to the effloacy of the measures taken in the Madras
Presidency for the prevention of the spread of plague, but tbe fact
remains that the larger part of the Presidency has enjoyed a com¬
parative Immunity from tne disease, which may or may not to ascribed
to the working of the plague passport und notification systems. As
regards cholera there has for some time been a tendency for epidemics
to be less serious and more local. It is hoped that the Improvement of
water-supply and the spread of education In hygiene will, in a very few
yean, reduce the mortality from cholera to much smaller dimensions.
Bombay.
The year was far from being as healthy as its predeoesaor, and the
number of in-door and out-door patients treated in hospitals and dispen¬
saries showed a further Increase. Among in-door patients this occurred
chiefly among cholera, small-pox, and malaria cases, while malarik was
the chief disease amongst out-door patients. Bight sub-assistant
surgeons were placed on special duty in the most malarious parts.
128 The Lancet,] NOTES, SHORT COMMENTS, AND ANSWER8 TO CORRESPONDENTS.
[Jan. 18, 1919
The Beoond half of the year wai marked by a rise In plague mortality,
which reached Ita maximum In Deoember. The Deccan districts, the
Southern Mabratta country and Bombay City were most seriously
affected, but deaths were reported from all except three districts.
Special inoculators were sent to the badly-infected districts, and
Inoculations were performed on a larger scale tban in 1915-16. As
usual, these resulted In a much lower incidence of attacks of, and
mortality from, the disease amongst Inoculated persons, and confidence
In Inoculation Is steadily increasing. Work and investigations in con*
nexlon with rat destruction were continued, and hydrocyanic acid gas
was tried as a suitable poison for rats and fleas In houses and grain
stores.
From cholera the heavy mortality of almost 20,000 deaths was
recorded. East Khandesh and other districts, to which the disease
spread from it, were the chief sufferers. In sanitary matters arrange¬
ments ha*e been made for the examination of drinking-water, the
supplies of various important towns have been Improved, and a com¬
mittee investigated the problem of the sanitation of pilgrim centres,
which are a fruitful source of epidemic diseases. Small-pox cases were
more numerous than in the previous year, but less than the deoennlal
average. Vaccination is voluntary except in the large towns, and is
being popularised by the use of glycerinated calf vaccine. District
sanitary associations have been formed and have done useful work,
while a\anlt*ry demonstration held at Belgaum was largely attended.
A new civil hospital was opened and another completed during the
year. Six taluks dispensaries were also opened and many additions
and improvements made st civil hospitals. To spread q knowledge of
the danger of tuberculosis instruction to school teachers and children
was given and lectures and demonstrations were held. Owing to the
war the medical services have been depleted to the utmost extent, and
the loss of staff and curtailment of expenditure make present progress
difficult. No fewer than 43 officers in the medical service out of the
sanctioned staff .of 58, the entire staff of military assistant surgeons
employed on civil duties, almost one-third of the civil assistant
surgeons, a large numher of civil sub-assistant surgeons, and many of
the nurses and the trained servants of civil hospitals were surrendered
to meet military requirements. In spite of this depletion a large
military hospital in Bombay was worked by a civil medical staff, and
various civil hospitals have undertaken the treatment of military oases.
{To be concluded.)
THE BISMUTH ORDER.
The Minister of Monitions has modified the Bismuth
Order made by him and dated Maroh 12th, 1918. On
and after the 10th day of January, 1919, Clause 2 is to
be omitted and a fresh Clause 2 (b) substituted. This sets
out that no return is required from any person whose total
stock in hand is not intended to be used in connexion with
the manufacture of metallic alloys and who has not,
during the period for which a return was necessary,
exceeded a supply of 56 lb. of bismuth metal or any alloy
thereof.
•LEMON JUICE OR LIME JUICE?
To the Editor of The Lancet.
Sib,—M ro. Alice.Henderson Smith, in her most interesting
paper (The Lancet, Nov. 30th, 1918), for which we must all
be grateful, says that “about 17 years later ” than the return
of Sir John Ross, therefore about 1860, the Admiralty began
to use true lime juice, which is not antiscorbutic.
Could she certainly say if it was lime or lemon juice used
in the Crimean War and in the Baltic (1854) ? I write far
from books of reference, but I remember that in the Baltic
a French Bbip suffered severely from scurvy, met an English
frigate (? Meander) t and got from her “ lime juice,” which
speedily cured the scurvy. This was, I now suppose,
probably lemon juice; could Mrs. A. H. Smith perhaps
tell us ?
For the papers of Miss H. Chick and others on vitamines
we must all be greatly obliged to them.
I am, Sir, yours faithfully,
W. E. Home,
Dee. 13th, 1918. Fleet Surgeon.
NEW RECORDS CONCERNING IMHOTEP
(ASCLEPIOS).
Some 13 years ago considerable interest in connexion with
the history of ancient medicine was aroused in the career of
Imhotep, the oelebrated physician of a very early age
in Egypt, whom the Greeks subsequently associated to
Asclepios. This sage’s story was elaborated with consider¬
able skill from the fragmentary evidence of papyri and
inscriptions by Professor Sethe and others, and ably utilised
by Dr. Richard Caton for the Harveian Oration of 1904. 1
Some years later an important Greek papyruB concerning
Asclepios-Imhotep was published by the Egypt Explora¬
tion Fund, and summarised in our pages.* Since then,
excepting a few references in Egyptological journals, the
matter has not received any further elucidation.
In last year’s “ Bulletin de l’Ecole Fran^aise d’Arch£-
ologie Orientale ” of Cairo, M. Henri Gauthier has edited
“ Un Nouveau Monument du Dieu Imhotep.” This is an
inscribed base, or plinth, for a statue of a personage named
Pedubastit (which also gives the name of bis wife and three
daughters). He was a prophet, or priestly scribe, of Imhotep,
who is therefore in the record recognised as a deity and
he is styled son of Ptah in the texts. Pedubastit’s religious
duties, among other matters, consisted in seeing that the
various ancient ffites or holy days of Imhotep were properly
* Tn Laxckt, 1904,1., 1709. * The Laxcet. 1915, it., 1204.
observed, and in the panegyric of his career he sets fort
these days fully in a list giving six dates, but not in the:
correct chronological order. In another text upon the sam
stone, however, Pedubastit, or his survivors for him, moi
completely describe the events in Imhotep’s life whic
caused each day selected to have been reserved for a festive
in his honour.
This information is new and of great interest. The firs
occasion for commemoration was Imhotep’s birthday
16th of the month Epiphi. His mother is stated to hav
been a lady named Khardit Ankh. The second f£te was th
anniversary of Imhotep’s presentation to his divine fatbe
Ptah and to Sekmet, a goddess, paredra of Ptah. Th
third day was kept in honour of” the time when Sekzne
destroyed the vile Asiatics in a naval battle upon the re
lake.” The fourth day, 17th of month Mesore, was, accord
ing to M. Gauthier’s reading of the new-found records, tha
of Imhotep’s death, and the 23rd of the same month that c
his burial.
Other Egyptologists who have read the inscription disput<
this rendering, thinking the fourth fete was that of the onse
of the physician’s fatal illness and the fifth that of his decease
Only a few remarks are possible here. Firstly, as contrary
to M. Gauthier. During his career as a physician Imhotei
must have become famed for his medical skill, and con
sequently revered. But it was probably not until long aftei
his earthly career had ended that he was canonised and
finally alleged to have been of semi divine origin and so a
deity. This was a common assertion as to procreation of the
deified Pharaoh. It is obvious that the f£te day of Sekmet'!;
viotory was foisted into the catalogue of the medical hero’e
memorials. However, Imhotep at some remote date was
deified. Now an interval of but six days between death and
burial was insufficient to perform the funerary rites and
proper mummification of even the poorest personages, but
it is just possible that Imhotep died in a.year when the
Egyptians inserted an additional month to rectify their
calendar—if so it would give 35 days. On the other hand,
verily a festival in honour of the illness of a god of healing
would have been curiously contradictory. Moreover, there is
great weight in an argument used by M. Gauthier—i.e., that
never does an Egyptian text refer to the illness of a deity,
neither does the writer ever reoollect even a reference to in¬
dividual illness exoept in medical papyri or in some book of
a Job-like type in which the author laments senile decay.
The thousands of obituary notices merely state a person was
born in a certain year, died in a subsequent one, and some¬
times enumerate the length of his life. However, the monu¬
ment tells us that on the fourth day of the month Paoni
Imhotep’s spirit departed for Paradise. It adds that he was
interred in the great Dehan whioh is believed to have been a
vast cave, or excavation, in the desert near Memphis. In
later time its surrounding land had become an immense
Campo Santo. It probably bore some title indicative of
being sacred to Imhotep, whioh word the Greeks rendered
as “ Asclepeion.”
Also we nave many inscriptions omitting all reference to
his godship, while Imhotep’s titles, too, are human enough,
bo also are his parents and wife. It is evident that, in time,
there were two] traditions of him. One, the oldest, makes
him a marvellous physioian, and great in other sciences
and friend of royalty. The second speaks of him as a deity.
The new papyrus of Imhotep Asclepios referred to throws
no light upon the subject. It is a literary effusion of a Greek
author who, after Imhotep had been identified with Asclepios.
in order to exalt him, alleged that Menkaura, the builder of
the Great Pyramid, had granted certain bounties to Asclepios,
son of Hephaestus, and to two other people named Horus
and Caleobi8, who, he says, were sons of Hermes and Apollo.
Horus was not, however, son of Hermes-Thot, but Apollo
himself, whilst Caleobis is unknown. Imhotep was not an
uncommon name in Egypt and Horus was still more
frequent. There may have been sepulchral texts near the
pyramid of people with these names, or the statement may
be pure invention. The other new-found reoord discussed
here is of value as confirming the fact by an inscription of'
one of his temple hierophants that Imhotep was deined and
had numerous worshippers.
THE USE OF CREOSOTE IN INFLUENZA.
To the Editor of The Lancet.
Sib,—T he use of creosote during the recent epidemic
appears to have been fairly general, but what has impressed
one more particularly has been the manner in which it has
been possible to abort pneumonia. I had been sceptical of
this until several cases occurred, and I am personally con¬
vinced that this has been due to the creosote and potassium
iodide. I doubt if this has reoeived sufficient attention, the
early exhibition of this drug is of such capital importance;
in some cases one has found that the patient has been
unable to aooept creosote in mixture, then resort has been
made to capsules or some preparation of goaiacol in cachet.
* 1 am, Sir, yours faithfully,
Jan. Uth, 1919. I.M.8. j
THE LANCET, January 25, 1919.
% personal Jletrasped
GENBRAL^PEACTICE.
By JAMES PEARSE, M.D. Edin.
Some Limitations op General Practice.
It is a frequent statement that the accumulated experience
of the general practitioner finds inadequate, expression, and
adds too little to the store of scientific knowledge of disease.
Too much may readily be demanded from this source. The
nature of the general practitioner's work leaves him as a rule
little opportunity for the reasoned and detailed consideration
of the items of his experience, and he perforce has in general
to be content with the immediate alleviation of disease and
to leave considerably to others the direct advancement of
science.
Allowance, however, being given to this consideration, a
personal retrospect cannot bat leave a sense of disappoint¬
ment that, though there may have been some gain of one’s
individual knowledge, there has been complete failure to add
even an iota to the store of general knowledge. “ Produce,”
says Carlyle, “ produce: were it but the infinitesimalest frac¬
tion of a product, produce.” Alas for the failure to respond
to that call from Sartor, the Bible of early days of struggle !
Bat why the failure, and wherein is it of general application ?
Partly temperamental; and it would be unreasonable to
expect advanced scientific work from every general practi¬
tioner. It is not every mind that has the scientific bias ;
not every medical student is a budding Pasteur. The faculty
of practical application of knowledge, which is the essential
r61e of the practitioner, is often divorced from the faculty
of coordination of experience and inductive reasoning there¬
from. Partly educational; and looking back upon one’s
training one realises that there was too little evocation of
individual powers of reasoning, presentation of items of
aoqnired knowledge with insufficient stress on the un¬
explained factors the elucidation of which is necessary
for a fuller understanding of the problems of disease.
In short, the student is apt to blossom forth into
the practitioner, feeling that his knowledge is gained
and that his function henceforth is only to utilise it.
The bias thus given to the mind has been retained, and
the mens medim has grown as a crystal grows, by accretion,
and not as an organism by absorption, metabolism, and
development. Herein is the essential need, the need of vital
reaction. The danger is that we all tend to be creatures of
habit, slaves of routine, to work as a machine in an
accustomed groove, to do to-day what we have done yester¬
day, to wear blinkers whereby our vision is limited. It is
difficult to resist this tendency, and only the favoured few
can fully do so and retain a mind impressionable, alert,
imaginative, vital. Hence the failure to see in any presenta¬
tion of disease more than has been seen before or the text¬
books have revealed ; hence an unwillingness to test autho¬
rity by experience ; hence the submergence of the individual
mind, and the bondage of tradition. This tendency is to a
certain extent inevitable. It is a counsel of perfection to
expect the busy practitioner after long days and disturbed
nights to keep his mind ev*er alert; moreover, the individual
patient asks to be relieved and not to be studied. Neither
is the tendency altogether to be deplored ; the human
material dealt with is too precious, the interests at stake too
vital, to allow with safety the unbalanced play of minds
“complexionally propense to innovation.” The middle
coarse is to be desired. And such consummation is the more
likely to be attained if the young graduate should leave the
portals of his school, not only with a mind stored with
ascertained facts, but should carry with him and retain some
vision of the unexplored domain, an awakened sense of the
* responsibility and power of individual thought, heightened
by a knowledge of the work of tLose who have broken ground
before them untilled.
Ungh artei: Seas.
Medicine, it has been said, is an inexact science. Its
practice is sometimes an object of scornful criticism by
those who have no inner knovledge of its difficulties and
may be accustomed to deal with subjects more demon-
stnble and less elusive. Again, many of the public appear
No. 4978
to regard the practitioner of medicine as one whose brain is
compactly pigeon-holed into compartments, each labelled
with the name of a disease and carefully docketed with the
appropriate remedy. Alas, the matter is not so simple that
there is never room for hesitancy ; but one soon, finds that
to express hesitation is to be lost, and to be in doubt is
interpreted as weakness. And the young practitioner himself
is apt to start out with a perhaps undue consciousness of
the fullness of his knowledge and of the resources of his
scientific equipment, soon, however, to find himself in
uncharted seas.
Two considerations lend themselves to this misconception.
In the first place, disease as seen in practice is often not
according to schedule. Disease as pourtrayed in the text¬
books is an entity, a finished picture, a completed building,
an orderly procession ; illness, as frequently seen in the
consulting-room, is not a definite entity, is ill-defined,
incomplete, refuses to be labelled, presents a disarray of
vague symptoms. It is with this sphere of vague illness, of
initial stages, of the symptomatic manifestation of ill-defined
disease, of functional disorder, that the work of the general
practitioner is largely concerned. Such illness does not lend
itself readily to clinical teaching, or exact portraiture ; its
origin and course are frequently obscure and its treatment
outside the range of ordinary routine. Thus it has not come
readily within the scope of early systematic training, and
the practitioner must gain his knowledge from his own expe¬
rience and the exercise of his own judgment, strengthened, if
possible, by contact with his seniors in assistance or partner¬
ship. The second consideration, which is associated with the
first, and which goes far to explain the inexactitude of
medicine, is that the practitioner early discovers that
he is not so much called upon to treat disease as to
treat persons who are ill ; in other words, that he has
to deal not with a mechanism, but with a delicate
organism inhabited by an individual. It is not only the
gross effects of disease which have to be countered, but the
reaction of an individual to such disease. There is always
the personal equation. It would almost seem as if there *
were a physiological or a pathological character. The
author of Hydriotaphia finds individual divergence even in
decay when he states, “bodies in the same ground do not
uniformly dissolve, nor bones equally moulder.” Sven in
the more definitely objective types of disease no two cases
are exactly similar ; no two cases of enteric are identical in
course and manifestation, one case of pneumonia differs
from another, carcinoma may develop aberrant processes.
But the personal equation is much more than this. There
is the individual characteristic ; his general attitude to life,
the courage with which he meets the strokes of fate, his
kicking against the pricks, his equanimity cr irritability, his
self-concentration or self-forgetfulness. And other factors
enter in: the wisdom or unwisdom of relatives, business
anxieties, family anxieties, all the social factors which are
involved when illness lays a heavy hand on a household, or
extinction threatens a life on which affection is centred.
Here, then, is an uncharted sea in that the family practi¬
tioner has to face more than the mere problem of disease.
Said Bacon :'
"Physicians are some of them so pleasing, and conformable to the
humour of the patient, as they press© not the true Cure of the Disease :
and some other are so regular In proceeding according to Art. for the
Disease, as they respect not sufficiently the Condition of the Patient.
Take ope of a Middle Temper."
There is an art as well as a science of medicine. The
practitioner is incomplete who has the art without the
science, or the science without the art; but incomplete also
if the science and the art are limited to medicine alone, for
the field is wider far. Hence the necessity for a width
of outlook in medical education, for a knowledge of the
humanities, for a social interest: herein the factor which
precludes the supersession of the general practitioner by the
specialist: herein the necessity of visualising the human
factor in disease.
Some Difficulties of General Practice.
For those men who do not succeed to established practices
there is a varying period of waiting for patients, followed
by a period of moderate success, and then, if fortune and
merit favour, a period of unremitting activity. Sir Andrew
Olark is said to have stated that he strove 10 years for
bread, 10 years for bread and butter, 20 years for cake and
ale. The early years are not pleasant to live through, but
n
130 The Lancet,] DR. J. PEARSE: PERSONAL RETROSPECT OF GENERAL PRACTICE
[Jan. 26,1919
they bring a pleasure In the retrospect of difficulties sur¬
mounted. They have their special dangers—financial
anxiety, the ennui of idleness, the temptation to use specious
methods of advancement; they have their advantage in a
continued opportunity for study, and in the fact that work
when it does come may be done without rush in thorough¬
ness, and thus a good foundation laid.
Bat the difficulties of the general practitioner arise more
especially in the busy years, when there may be not too few
but too many patients to be seen, when the day may bring
no interval for leisure and the night be often robbed of rest.
There are men, who are to be envied, who can compass a
large amount of work without evidence of ha9te and who,
however busy they may be, leave a patient with the
impression that he only is the chief concern. But others
of ns in busy times are conscious of a constant sense of
strain, of thiaking in one house of the next, of a feverish
anxiety as to how the round of the day is to be completed.
It is in this atmosphere of haste that some of the main
difficulties of general practice are to be found. It has often
been said that mistakes are made not from lack of know¬
ledge but from lack of examination. Full examination is
neglected not so much from carelessness as from absence of
sufficient time for thorough review. Thus the work is left to
the next visit or consultation, or to the one after that, and
may be still postponed, until complications may develop or
the patient go elsewhere, to the detriment of reputation.
There arises from this another danger, that of the mere
symptomatic treatment of disease. It is a commonplace
statement that such symptomatic treatment is sometimes all
that can be compassed, as the ultimate cause may be
obscure and undeveloped. Also the patient demands relief
from urgent symptoms, and relief can often be given. But
the tendency grows all too readily to be content with the
alleviation of the obvious, to fail to probe to ultimate
causes, to forget the guiding rule causa, sublata , tollitnr
effective. Hence the relief of pain by analgesics, of insomnia
by hypnotics, of debility by tonics, of dyspepsia by drugs
aldne, while the essential cause remains untouched. An
associated tendency is that of routine. It is so much ea ier
to do what one is accustomed to do than to follow on and
develop new ideas. And this is an inevitable result of an
experience which sees so many new ideas and suggestions
fail to stand the test of time and yield their place again to
old-established method. In the youth of practice one tries
with enthusiasm every new proposition : in later years one
waits to see if the new is to be permanent. But though
there is reason for such attitude it is difficult to escape an
undue conservatism, a blind adherenoe to established
routine, and to avoid “the great tendency of the human
mind to fall into a groove and pursue its work on lines that
give no occasion for mental strain.*’ 1
A further danger is that which, for want of a better term,
may be designated “ staleness. ” Its occurrence calls to
mind the teaching regarding summation of stimuli, that
under the frequently recurring influence of electrical stimula¬
tion a muscle gradually reduces its response and finally fails
to react further. It produces the failure of the most obvious
diagnosis, and the feeling under which every difficulty is
magnified, and “ the grasshopper becomes a burden.” It is
not that knowledge is lacking, but that the tired mind
fails to absorb the transmitted impression. Probably most
practitioners in times of stress have realised this; well for
them if, recognising the danger-signal, they can find relief in
a well-earned rest.
A farther danger associated with the fullness of the prac¬
titioner’s life is that which may always follow excessive
concentration on one subject—namely, a failure of interest
i n other spheres of life. It is illustrated by the fact that
few general practitioners retire from practice : the majority
die in harness. The reason, to a large extent, is that not
many are able to lay aside the means to provide for later
years; but a further reason is that work has been so
absorbing that there has been too little opportunity for the
cultivation of hobbies or outside interests, and thus without
the interest of work life would be lacking in zes*--.
These seem to be the especial dangers of which a per¬
sonal experience of general practice has-brought cognisance.
They are not all peculiar to the calling of the practitioner,
but there are special features of his life which give them
i Mackenzie: “ Interpretation of Symptoms.”
prominence. Herbert 8pencer, in a criticism that education
deals inadequately with the conduct of life, says that the
question “Is it worth while?” is not asked with sufficient
frequency, and emphasises that work exists for life rather than,
what is the more currently expressed view, that life exists for
work. To this question the practitioner of medicine cannot
reply only from his own point of view : others may, perhaps,
be in a better position to answer for him. But it may be
well sometimes to ask the question and consider whether too
heavy a price is not being paid, especially if the price may
possibly involve the risk of deterioration in value.
Some Requirements of the General Practitioner.
Every practitioner who has carried on practice for any
considerable time mnst recognise that he is faced with
special difficulties unknown to his predecessors. For them
the years brought but slow advance in knowledge, and they
were perforce in the main dependent upon their own develop¬
ing experience. All this is altered ; changes have been ao
revolutionary that no man, even of the widest experienoe,
can feel that this alone is a sufficient equipment. Who
amongst us who graduated even 20 years ago can pretend to
an accurate knowledge of late developments ? It is sufficient
to stabe a few of these—the intricacies of cardiac diagnosis ;
the theories of immunity and vaccine therapy ; the action of
the internal secretions; the extended use of X rays; the
diagnosis and treatment of syphilis; the various blood
changes. It is impossible for the general practitioner with
little leisure to be thoroughly conversant with all new work.
Yet that he should have a working knowledge of it is
essential. Many men. to their oredit, strain every nerve to
extend their knowledge and adaptability and to maintain
themselves abreast of tbe times. Others give up the effort
and two tragedies may occur : the tragedy of lives hazarded
by imperfect diagnosis or treatment, the tragedy of practices
lost to yoanger men with fresher knowledge.
It will thus be seen how essential it is that medical
practice should be combined with continued study. The
desirability of this will be generally admitted bat its attain¬
ment is not easy. When once a mao has developed a busy
practice the demands on his time are so continuous, periods
of leisure are so scanty, that opportunity for study is but
limited. However laudable intentions may be, attainment
of neoessity lags behind.
There are three directions in which it would appear that
this requirement might to a certain extent be met.
1. Post-graduate Study.
Facilities for snch exist, but only a li nited number of
practitioners are able to avail themselves of these. Holidays
from general practice are rare and refreshing, and no small
degree of enthusiasm is needed to forgo snch for the sake of
study. And to leave a practice for any lengthened period is
both costly and hazardous.
Some modifications of the present system seem worthy of
consideration. The number of centres where post-gradoate
training has been developed is limited. The development of
snoh work at other centres would be an advantage, especially
if the work were so arranged as to be available to practi¬
tioners in the adjacent area withont undue absence from
practice. Many practitioners who would find it impossible
to attend a prolonged session would make an effort to
attend a short course—for example, a series of lectures on six
or eight afternoons or evenings once a week ; and in a
specially adapted course much might be learnt in that limited
time.
A farther modification might be advisable as applicable
for more rural areas where even the limited attendance above
indicated would involve too long absence from home. There
might be developed extension lectures in medicine, and a
lecturer attend occasionally at a given centre in the country
for the enlightenment and encouragement of the rural
practitioner. True, such lectures could not be attended by
a large number, and would not be directly remunerative
to the-lecturer, but their valte might be very great.
Further, the hospitals miiht render very material assist¬
ance to the general practitioner by developing courses of
clinical lectures at times adapted to his convenience. And
especially would this be the case if use were made of
hospitals not only in the recognised teaching centres, but
also of those situated elsewhere.
Developments such as theke would have far more than
their direct teaching value. Medical men, who too seldom
Thb Lancet,] dr. J. pmR8E: .PERSONAL RETROSPECT OF GENERAL PRACTICE. [JAN. 25, 1919 131
meet in fellowship, would be brought together in the pursuit
of knowledge. They would form Contact with a larger sphere
than that in which their daily!work is often cast; their
horizon would be extended and ithey would return to their
work with a heightened interest and zest. With all its
variety, even medical work is afjt to become monotonous;
there are times when the interest of the most zealous will
pall, and his mind become staid: whatever will counteract
such tendency is of value not oflly to the practitioner, but
also to the community. 1
2. Specialist Facilities.
No practitioner can now have at his immediate disposal
the whole equipment necessary for the adequate diagnosis and
treatment of disease in accordance with modern requirements.
Neither can any practitioner have the requisite knowledge to
use such equipment in every variety. Where resources other
than his own are required he must send the patient else¬
where, and often to a considerable distance. The advantage
or disadvantage to the patient is not now under considera¬
tion, but the result to the practitioner is that with much more
frequency than was formerly the case he must lose touch
with his patient, even in the matter of diagnosis. The danger
is lest he become a mere sieve for the sifting out of cases,
and that those requiring refinement of diagnosis or technique
pass beyond his ken. With such an issue his mental power
must inevitably decline and his usefulness to the community
diminish. Thus an extension of specialist facilities, so that
there might be more ready access for the average general
practitioner, would be a great boon. Especially is this true as
regards the practitioner in the country or the small country
town. The city practitioner has facilities at hand, and may
have access to them when he will and if he will. His more
isolated colleague is by his isolation handicapped ; he may
send a patient to be X rayed and have to be content with a
photograph, which perhaps he does not understand ; he may
receive a detailed diagnosis of an obscure heart case, but
know nothing of the technique involved ; he may send a
scraping of a chancre to a pathologist, but the spirocheete
may be only a name. Experto crede.
The continuous development of the general practitioner,
which is so essential, is impossible without an extension of
facilities. But here, again, the middle course is the safest.
To spoonfeed the practitioner, to encourage him to depend
too exclusively on the resources of others, would be disaster.
Isolation or semi-isolation is not without its advantages ; it
develops a resourcefulness and self-reliance which in many an
instance are of more avail than the most up-to-date knowledge.
Many a country doctor will perform, as part of his recognised
routine, surgical operations which a London West End prac¬
titioner, in receipt probably of a much larger income, would
consider as beyond his province.
3. Medical Literature.
Post-graduate studies have their place, specialist facilities
have their place, but the main resource of all practitioners
must be in medical literature. Research herein is again beset
with difficulty. In the early years of practice there may be
abundant, even too abundant, time for reading, but this
suffers from not being brought to the bar of sufficient expe¬
rience ; in later years stress of work and scanty leisure allow
little opportunity for study. Hence a tendency to depend
upon the knowledge gained from accumulated individual
experience without refreshment from other minds. More¬
over, as years increase, there tends to be a less open mind,
less adaptability to new impressions. Bacon has said :
“For It is true that late learners cannot so well take the pile:
« lt be in some Mlndes that have not suffered themselves to
it have kept themselves open and prepared to receive con-
tlnuall Amendment, which is exceeding Bare.'
This lessened pliability of mind reinforces the difficulty
induced by diminished opportunity for study, and the
tendency grows to be content with an occasional dip into a
medical journal, and to leave aside deliberate and purposeful
study.
It is not, however, from this point of view that the
subject is mainly considered. Tkese are the difficulties of
the practitioner in approaching medical literature, but they
are too often enhanced by the nethods of presentation of
such literature. The assistance which the practitioner seeks
from books is mainly in two directions—clinical instruction
which will help him in his daily round, and instruction
in new developments. As regards the former there has
been much improvement in recent years. Time was when
there were only ponderous tomes, weighted with unrequired
details, which had to be laboriously sifted in order to obtain
the essential knowledge. The practitioner does not require
the elaborate text-book, but the graphic presentation of the
essentials of diagnosis, prognosis, and treatment—the
clinical portrait. It is on the clinical lecture of his Btudent
days, impressed by the personality of his teacher, that his
knowledge of practical medicine is really based, and it is
the continuance of such vivid type of teaching that he still
desires. That such literature is more in evidence is of good
omen, but there is still a tendency to dwell unduly on the
rare.
More difficulty is experienced in following writers in the
later fields of research. Perhaps it is because much of
the new work is done in the laboratory, but certain it
is that the language in which it is expressed is often
far from easy of comprehension. It must be difficult
for those working in these fields, to whom new ideas
and new terminology are current knowledge, to realise
that many practitioners have yet the alphabet to learn
of their science, and that what is to themselves
a simple statement may be to others a maze of
intricacy. But it would be well if writers were more
adequately to visualise their audience, and Btudy their
expression and terminology, not from the point of view of
those who write, but of those whom the writers address.
No grown man expects to be fed on pap food, end it is
alwayft well to have some mental pabulum on which to bite
hard; otherwise the thinking faculties may atrophy. But
the more difficult a subject the more necessary that its
exposition should be divorced from needless obscurity.
Vis Medicatrix Nature.
One lesson, of principle rather than of detail, emerge*
from experience of general practice—namely, a recognition
of what is involved in the vis medicatrix natwrce. As young
practitioners we are apt to commence with a consciousness
of knowledge, with a sense of our primary importance as
agents; experience brings the recognition of a secondary
place in waiting on and assisting the efforts of Nature.
“ Knowledge is proud because he knows so much, Wisdom
is humble that he knows no more.”
The objective manifestations of disease are often to be
regarded, not necessarily as morbid processes, but as the
efforts of Nature to be rid of a foreign element, to limit its
activities, or to minimise its ill-effects. Pain is a warning ;
the rigidity of muscles is a protective effort; the effusion of
serum is a separation of inflamed surfaces; the formation of
pus is directed to the removal of a noxious agent; the
swelling of glands is evidence of a defensive organisation ;
elevation of temperature is not necessarily an evil. Nature
is always on the alert and resents disease in man. The
recognition of that fact leads one to watch her efforts and to
take a second place. It awakens the consciousness of an
agency other than one’s own, brings a realisation of power
and law in cooperation with which lies one’s sphere. It
brings reliance on the common-place, on rest, on dieting, on
fresh air, on sleep, on exercise, on the simple life. It
emphasises the removal of hindrances to health as preferable
to active interference when health has become unbalanced.
Recognised by the medical attendant, the carrying out of
this principle is often obstructed by patients or the friends
of patients who exemplify the spirit of Naaman, who, wroth
at the simple instruction to go and wash in the Jordan,
demanded drama and that the Prophet should surely come
to him and call on the name of the Lord and strike his
hand over the place. Herein is an advantage that surgery
has over medicine, that its action is so much more frequently
immediate, direct, and impressive. And it is recognised, of
course, that there are conditions, especially surgical emer¬
gencies, which constitute a violent disruption of Nature and
call for prompt and primary interference.
All this does not mean that the policy of the practitioner
is to be one of drift or wholly of masterly inactivity. That
the healing of a fractured limb is Nature’s work does not
preclude the necessity of careful setting ; that pneumonia
runs a recognised course does not preclude the duty of
relieving a struggling heart, or aerating the lungs, or
watching for complications; that labour is a natural
process does not preclude a timely assistance or direct
| intervention when Nature is obstructed. In no way are the
132 The Lancet.] DR. J. PEAR8E: PER80NAL RETROSPECT OF GENERAL PRACTICE.
[Jan. 26,1919
duties of the practitioner lessened ; bat his attitude and
activities are modified when his position as Nature’s servant
is recognised. Indeed, rightly considered, this tenet con¬
duces not to a policy of laitsez-faire but of increased
resourcefulness. The recognition that disease is not
inherent stimulates to search the cause of any deviation
from the normal: should a. case of illness not run the
recognised course it postulates the presence of an un¬
explained factor and probes for such; it produces dis¬
satisfaction with issue other than recovery.
And this creed brings with it another tenet—that of a
reasoned optimism. Realising that Nature has many assets
which postpone bankruptcy, one learns in certain cases to
hope almost against hope. So many patients have been seen
who recover from desperate straits that experience justifies a
caution in expressing pessimism. This optimism must not
be unreasoned: there are indications which cannot be gain¬
said, there are conditions in which experience tells that the
final ending is inevitable, but short of such the attitude of
hopefulness and patience is often justified. In both the
aspects considered—of waiting on the powers of Nature and
of hopefulness—it is refreshing to bear in mind some words
of Ambroise ParA If any man, judged by our knowledge,
had grounds for pessimism, surely he. But through his own
records there run like a refrain the words, testifying the
humility of greatness, ‘‘1 dressed his wounds and God
healed him and in reference to one case he states: “ I
told him that there was still some hope because he was
young, and God and Nature sometimes do things which seem
to physicians and surgeons impossible. ”
And there is a wider optimism which argues that if disease
is resented in the individual so is it resented in the com¬
munity, that its general incidence is not inevitable, and that
the reaction of the larger organism is directed to its removal.
The past 50 years have witnessed a revolution in the attitude
to disease, wrought more especially by the work of Pasteur
and Lister. They countered the doctrine, and the hopeless¬
ness engendered of the doctrine, of an inherent tendency to
disease, of a oontagium sui generis, manifested by such views
as that there was a * 1 morbid spontaneity of the organism, ”
that typhoid fever “is engendered by ourselves within
ourselves/' that there was “a spontaneous tuberculous
degeieration of the organism," that the pysamic infection
was “tenacious and ineradicable,"and that its source was to
be found in “ hospitalism." Pasteur wrote to Bastian :
•• Do you know why I desire so much to fight and conquer you ? It
is because you are one of the principal adepts of a medical doctrine
whloh I believe to bs fatal to progress in the art of healing—the doctrine
of the spontaneity of all disease.
This fatal doctrine has now gone, and a hopefulness has
succeeded hopelessness. The counter doctrine is extending
to fields wider than those of the infections, and the nature
of causative factors is more generally recognised. But
disease has been ever present, and familiarity therewith
has bred the view of its inevitable occurrence. Inevit¬
able it will be for a yet indefinite time. But the
general practitioner who moves amongst various sections
of the community, practising amongst the wealthy and the
poor, amongst those well-fed and those under-nourished,
amongst the well-housed and the ill-housed, amongst the
over-worked and those capable of leisure, be they rich or
poor, knows that the incidence of sickness and of types of
disease varies according to the surroundings and circum¬
stances of his clientele. And experience justifies a reasoned
optimism that with wider knowledge, a saner life, and a
healthier environment the community will utimately escape
from many ills which now seem inevitable.
On Professional Relations.
The peace and happiness of a medical man’s life is largely
influenced by his attitude to his fellow practitioners or their
attitude to him. The writer’s lot was cast, so far as pro¬
fessional relationships were concerned, amidst pleasant
circumstances. He remembers no single incident of rancour
or misunderstanding, and' for this he thanks the example of
older practitioners. There is no doubt that such an expe¬
rience is not universal, and that professional relationship
often leaves much to be desired. Osier, in one of his
addresses, says “ No sin will so easily beset you as uncharit¬
ableness towards your brother practitioner.” Why should
this be so ?
The work of a general practitioner differs from most other
oallings in the personal relationship it establishes with
patients; it is not a mere exchange of goods, a business
transaction, not a mere giving of advice or a transient calling
at a house, but a contact between individuals, an intimate
reaction. Hence the severance of relation between doctor
and patient cuts deeper than a similar severance in other
spheres, and it is only reasonable to anticipate that it should
create some heartburning. But it is unwise that it should
be allowed to create bitterness. Just because the work so
nearly touches human natare, and because human nature is
so varied, is there the more scope for divergence. And it is
unwisdom that secession should create animosity to the
succeeding practitioner, but this is frequently the result.
He is not of necessity a supplanter, and has not necessarily
taken his place by devious and unprofessional ways. It is
easy to blame the patient for whims and ingratitude, to
blame the colleague for insidious advertisement, but a wiser
rule is to consider in such case whether there has not been
some error in one’s own conduct or knowledge, and if this
cannot be established to endeavour to cultivate a philosophic
calm. After all, a patient has as much right to change his
doctor as to change his grocer, and it would be well if this
were more generally recognised. There are some words of
Sir Benjamin Brodie in this respect which are worth
remembering :—
*' Taking all things Into consideration ft appears to me to be a
question whether there Is not, on the whole, more cause for wonder In
the patience of the many than in the Impatience of the few, and
whether the gratitude of those who over-estimate our services does not
even more than compensate for the neglect of those who withhold from
us the credit which we really deserve.
Much depends upon the primary attitude to medical prac¬
tice and its financial issue. Much sentiment has been
uttered and written on the nobility and self-sacrifice of a
doctor’s work, sentiment which, to the credit of the pro¬
fession, has often been justified. But a doctor has his
obligations to meet as other men; he cannot educate his
children on a reputation for philanthropy, nor live in old
age on the memory of good deeds; he would not be
human if he did not derive gratification from financial
success. In any case, for the general practitioner
such success is seldom proportionate to the strain
involved, and it frequently arrives late, after years
of penury and straggle. But there is all the difference
in the world between a legitimate satisfaction in well-earned
reward and a primary regard for the shekels. As an ultimate
issue it is the difference between the love of work and the
love of money ; between the attitude which regards a patient
as a person who is ill and the attitude which regards him as
au individual who pays fees ; between medicine viewed as a
profession and medicine viewed as a commercial career.
And if the fee aspect is unduly predominant there is an
added likelihood of bitterness in the event of a patient
severing relations. Competition is defined as “common
strife for the same object"; if the object is the fee return it
is obvious that what one gains another loses ; if the object is
the cure of the patient it really does not matter if the patient
is cured by someone else so long as he is cured. Such
detachment is not easy to attain, is probably only attainable
by the few, but the pursuit of its attainment is a wise ideal.
And after all, if patients never left us much needed
stimulus would be lacking ; a shock to equanimity and self-
satisfaction is not without its value.
There is no work so Individoalistlo as that of the general
practitioner. Day by day he has to exercise his own
judgment in vital matters; he is an autocrat whose word
is law ; he moves as it were in his own preserve, seldom
challenged, responsible in his private practice to his patient
and to himself alone. This individual and personal responsi¬
bility is one of the attractions of the practice of medicine.
Bat it brings with it a tendency to come too little in contact
with fellow-practitioners or to know them only as others
engaged in their own special preserve. Anything which
breaks down this tendenay and brings medical men together,
not as competitors but As participators in other spheres of
life, is a great advantage; it brings the knowledge that the
other man is not so bad a fellow after all, that he has human
as well as professional ftiterests and other objects in life
than the purloining of patients.
Some Compensations.
I call to mind a Soottisqc
try to dissuade from the
the warning, “You are
body,” indeed, he was
side. Years afterwards,
ountry practitioner, who used to
Ife of a general practitioner with
jtet a' body’s body." “ A' body’s
ever a wide stretch of oountry-
uBeting in a railway carriage far
THBLANOST,] sib william
IMYLY: ACCIDENTAL HEMORRHAGE AND EOLAMPSISM. [Jak. 25, 1919 ] 33
from the neighbourhood a fellow traveller from the same
district, to the question, “Do jpn know Dr.-?” there
came the reply, ‘ ‘ Ken Dr.- 1 1 Why, he brooht me intil
the world, and he’s the finest pujr mon’s doctor that ever
breathed.” I see him now, age^, retired, with shattered
health, and indifferent means, ah ending to his days far
other than he has merited, but withal content, and, I
think, not regretful that he hasi been “a’ body’s body.”
Another comes to memory whq worked from youth to
advanced years with almost unremitting toil, a man against
whom no breath of evil whisper ever stirred, of whom I have
baud it said, “ If I had committed a murder I would go
and tell Dr.-.” Such ap attitude is the result of the
human relationship, the penetration >to the depths of human
life, the intercourse with its sanctities and woes, which is
inherent in the work of the practitioner and which is the
compensation for the difficulties of his life. The life-work
of most other callings is less intimate, controlled more by
the “tyranny of mere things.” I recollect an incident
related by a colleague of his entry to a sick room, and of
how the patient, putting down a book which he had in his
hand, and which happened to be the Bible, made the
comment, “ It’s only the doctor.” The observation on the
incident was that clergymen see men at their best, lawyers
lee men at their worst, while doctors see men as they are.
It is this touch of nature, this human intimacy, which leads
many patients to regard their doctor, not as professional
adviser only, but as guide, philosopher, and friend, and to
seek his advice on matters outside his immediate sphere.
The general practitioner has, indeed, abundant opportunity
for the observation of human nature. He presides at birt.h
and is sought in death, he knows of the skeleton which is
hidden in most cupboards, he knows the tragedies which
blast a life, and the minor discords which embitter it, he
sees human virtue and human frailty, joy and sorrow, life
in its seaminess and life in its excellence. Well for him
if he can preserve a genial toleration for the frailties of
mankind and the spirit of charity. The contrary might be
expected: as it is put by the Shepherd in Noctes
Ambrosian® :
“ Physicians, ane might think, seein’ folk deeing nlobt and day In
s' manner o' agonies, and bein’ accustomed to pocket fees by the
death*bed-side, would become in the oore o’ their hearts, as callous as
eustoeks.”
As a matter of fact, though doctors spend most of their
time battling with the ills of life, there are surely few in
whom this engenders any spirit of resentment against
Fate: and this from no lack of sympathy. In the first
place they view these ills not from the point of view of
philosophic abstraction but as men who are engaged in
the concrete work of overcoming them, and who derive
satisfaction therefrom. A further reason is that if they see
much of the ills of life they see also much of the good, if
they see many shadows they see also much radiance. They
witness the pangs of labour, but also the joy that a man-
child is born into the world; they company death, but know
that he seldom comes as the King of Terrors, but often as
“ the poor man’s kindest friend ” ; they see a child stricken
low, but also the heroism of the nursing mother ; they see
unch&rity and selfishness and vice, but also charity and
self-forgetfulness and virtue. Doctors could reveal better
than most men the degradation and sorrow of which human
nature is capable, but also its elevation and joy. It is well.
to be impressed by the latter while not forgetting the
former. If practitioners might enrich medical literature by
a more frequent detailing of their clinical experiences they
might also rebuke pessimism by a record of their human
experience. One incident among many comes to mind. I
reoollect a visit to the cottage of a rural labourer. I see now,
strapped to a chair in the garden, a repulsive form with
enormous head and stunted limbs, speechless, helpless as a
new-born babe, a youth of 14 years, idiot from birth : I hear
now the mother’s anxious query, “ Have you come to take
him away ? ” and her quick addition, with hand uplifted in
emphasis, “Sir, I would not part with that child, though
you gave me all between earth and sky.”
But apsurt from this general human touch it is questionable
if there is any sphere of work which can bring the same
sense of direct pleasure in its fruition. The French have a
saying, “Une cure c’est une patarnitA” And to tend a
patient through a severe illness, to see him smitten down in
the midst of robust health, to watch the descent into the
valley of the shadow of death, to mils* all that is involved
to those in anxious waiting, to watch again the gradual
emergence to life and strength, and the final restoration ; all
this brings a sense of satisfaction which surely can be seldom
rivalled by success in other callings.
It is not meant to imply that considerations such as these
are the dominant factors in the practitioner's life. Perchance
they only emerge when there is time and opportunity for
reflection. It is a frailty of human nature to realise while
engaged in a given occupation all the difficulties thereof, and
to realise the advantages only when these are no longer at
hand. And the difficulties of the general practitioner’s life
are obvious enough : stress of work, little opportunity for
rest and recreation, frequent financial hardship, contact
with folly and ingratitude, all indeed that is involved in
being “a’ body’s body.”
This intimacy of relationship has its concomitant danger
in that it may tend to the submergence of the strictly
professional aspect, and there is an element of truth in the
warning, “Never have your friends among your patients.”
But, and more especially in country districts, this is a counsel
of perfection. It may*be difficult, but is not impossible, to
be the doctor as well as the friend, and the harmonious
merging of the two is one of the chief compensations of
general practice. It was said of Lister:—
“ In early life Lister belonged to a Society the members of which
called all men Mends, and now in torn because of his inestimable
beneficence and service to mankind, all men the world over call him
Friend.”
Such an epitaph may not without fitness be applied to
many members of the profession in less exalted spheres,
who, if they have passed henoe unsung, have not passed
unhonoured or unwept.
January, 1919.
ACCIDENTAL HAEMORRHAGE IN
CONNEXION WITH ECLAMPSISM.
By Sir WILLIAM SMYLY, M.D. T.O.D., F.R.C.P. Irbl.,
GTHvEOOLOCI 1ST, ADELA1DX HOSPITAL, DOBLDt.
In my opinion Schmorl was right when he stated that
puerperal eclampsia is a definite disease peculiar to pregnant
women and their infants, and characterised by peouliar
pathological changes, consisting chiefly in thrombosis of
blood-vessels, necrosis of the cellular elements of tissues,
and haemorrhages. Such conditions are, of course, met with
in other diseases, but never so widely distributed, or involving
so many important organs, as in eclampsia. They were
found by Schmorl in all the necropsies on women who had
died from eclampsia, and were considered by him to be
essential to, and characteristic of, the disease ; therefore,
when they were present the case was one of eclampsia,
when they were absent it was not. Subsequently he
found the same pathological conditions in cases which
had died in coma, but without any convulsions; therefore
they also were oases of eclampsia, though they had no
convulsions.
There can, I think, be no doubt that the so-called pre-
eclampsic toxmmia is also essentially the same disease
whether it culminates in fits or not; and since all these
conditions are, therefore, examples of one and the same
disease it is desirable that they should be grouped under one
name. Eclampsia and toxaemia are not definite enough for
the purpose, because the former is commonly applied to
convulsions of all kinds and is hardly applicable to those
cases in which there are none. Toxaemia, also, is unsatis¬
factory, because there are toxaemias which are not, as far
as we know, in any way connected with eclampsia. Dr.
Bar has suggested, and I think it an excellent suggestion,
that whilst retaining the term eclampsia for the cases in
which there are convulsions, we might employ the word
“ eclampsism ” for those in which there are none.
Aooidental Hamorrhage.
One of the essential features of the disease, as I have
already stated, is haemorrhage; most frequently small
petechial haemorrhages, but occasionally very extensive,
serious, and even fatal in amount. Anyone who has much
experience of eclampsia must have met with such cases
where the bleeding occurred into the brain, the eye, under
the skin, or into the peritoneal cavity. But it is only
recently that our attention has been called to the fact that
134 Thh Lanobt,] SIR WILLIAM SMYLY: ACCIDENTAL HAEMORRHAGE AND EOLAMPSISM. [Jan. 26, 1919
they occur into the uterus also; and the association of
accidental haemorrhage with eclampsia, or rather with
eclampsism, has attracted notice. It would be impossible,
in the present state of our knowledge, to say in what pro*
portion of cases it occurs, but from personal experience I
am inclined to believe that most of the cases of severe,
and especially of concealed internal haemorrhage are due to
this disease.
Since Rigby taught us to distinguish accidental from
unavoidable haemorrhage our knowledge of its nature and
treatment has developed slowly. We discovered in course of
time that such haemorrhages are frequently associated with
albuminuria, and that those in which the effused blood is
wholly, or almost altogether, retained are much more serious
than those in which it escapes freely from the vagina. In
attempting to explain these facts, however, it was assumed
that the albuminuria resulted from a nephritis which, by
causing endometritis, produced a diseased and loosely
attached placenta. AH that I believe to be erroneous, the
condition of the kidneys is more neciptic than inflammatory
and in the cases examined by Whitridge Williams there was
no endometritis.
The treatment of concealed haemorrhage by abdominal
section originated with Dr. William Bagot, now of Denver,
Colorado, when my assistant in the Rotunda Hospital, and
was successfully carried out by him upon a patient in the
extern maternity. But it was several years after that any
other operator ventured to follow his example, and when in
1910 Dr. Amend Routh published a report upon 1280 cases
of Cesarean section, collected from obstetricians living in
Great Britain and Ireland, it contained only three which had
been done on account of accidental hemorrhage. Since
then, however, abdominal section has been resorted to more
frequently, and is now, I believe, regarded as generally
advisable in those cases, at least, in which the patient is not
in labour, and the haemorrhage is more or less concealed.
Pathological Conditions.
Since the introduction of this treatment which, in my
opinion, marks a distinct epoch in obstetric history, we have
learned that the actual conditions are very different from
what we had imagined them to be. We knew, of course,
that the placenta was detached from the placental site, and
that the uterus was distended with blood ; and we assumed,
from the fact that the effused blood was not expelled, that
there must have been a weakening or paralysis of its walls,
but we had no idea, or a wrong one, as to its cause. Now
we know that the blood is poured not into the uterine cavity
alone but also into its muscular wall, which is suffused with
blood, separating and no doubt injuring its muscle cells;
sufficiently explaining not only the yielding of the uterus
to the pressure of the blood, but also the extreme difficulty
which has sometimes been experienced in controlling post¬
partum hemorrhage. In many of the reported cases there
was haemorrhage also into the pelvic cellular tissue, especially
between the folds of the broad ligaments, and in some into
the peritoneal cavity.
In two cases reported by Whitridge Williams, in which
the uterus had to be removed, the microscopic examination
showed that the haemorrhages had spread apart the indi¬
vidual muscular fibres and bands, and in places was asso¬
ciated with considerable oedema; apparently it was not
connected with the larger vessels. Section through the
placental site showed similar changes in the muscular wall,
but the deciduae were normal except for small haemorrhagic
areas. In this region many of the larger veins were almost
completely filled with large thrombi, and many of the smaller
veins were almost occluded with thrombi. The large arteries
were normal, but many of the small ones presented changes
in the intima, suggesting a mucoid change, and it projected
into the lumen and in many places defects were observable
in it.
The principal pathological conditions present, therefore,
were thrombosis of veins, necroses of the intima of the small
arteries, and haemorrhages into and oedema of the uterine
walls. This remarkable condition of the uterus has during
the last few years been frequently noted by other observers
in connexion with accidental haemorrhage, and at a meeting
of the Obstetrical Section of the Royal Society of Medicine
in November, 1916, no fewer than eight cases were reported.
In all of them in which the urine was examined it contained
albumin ; five had large haematomata in the broad ligaments
and two free blood in the peritoneal cavity. In all of them
not only was the placenta more or less detached and the
uterine cavity filled with blood, but blood was also
extravasated into the uterine wall, most markedly in the
superficial layers, and especially under the peritoneal coat.
Causation.
Couvelaire described this condition as utero -placental
apoplexy, and although he believed it to be a constant
feature in accidental haemorrhage, yet he regarded it as a
result of over-distension of the uterus, and nqt as the cause.
If he were correct in this assumption, and the haemorrhages
were merely the result of over-distension, then their
connexion with eclampsia is not so obvious as I suppose
it to be. But if, on the other hand, it can be proved that
this condition is not caused by over-distension, that it only
occurs in patients with other symptoms of toxaemia, and that
the anatomical conditions associated with it closely resemble
those which cause haemorrhages in other parts of the body
in eclampsia, then it would seem to me a justifiable con¬
clusion that it is due to the same cause.
As regards the theory that the remarkable condition of the
uterus is merely due to its over-distension I would refer to
experiments carried out by Dr. Arthur N. Morse in Yale
University Medical School. 1 His first endeavour was to
discover whether sudden over-distension could produce such
phenomena. With that object he exposed, by abdominal
section, the uterus of a pregnant bitch, inserted a cannula
into it, and injected saline solution until it was distended
almost to bursting. No ill-effects excepting abortion
followed, and when the abdomen was again opened, after
48 hours, the previously distended horn was found to be
entirely normal, without any sign of injury. That experi¬
ment proved that even extreme and acute increase in intra¬
uterine pressure did not cause an extravasation of blood into
the myometrium.
A further series of experiments was carried out with a
view to ascertain what would be the results of venous
obstruction in a pregnant uterus. He discovered that in
pregnant rabbits, when all the veins returning blood from a
pregnant horn had been ligated, it became deeply cyanosed
and distended, at first fluctuant but ultimately firm, tense,
and resistant to pressure. After about two to four hours it
was enlarged to about twice its former size and was
quiescent, muscular action having ceased. The uterine
cavity was filled with blood, which surrounded the
unruptured foetal sacs; the placentae were partially or
completely separated from their attachment, and minute
extravasations of blood were visible in the myometrium.
The microscope showed haemorrhagic extravasations in the
decidua, and at various points in the uterine wall, as well as
dissociation of the muscle fibres; in fact, in every particular
an exact reproduction of the conditions found in cases of
accidental haemorrhage.
. Illustrative Cases.
The following oases, which came under my notloe during
the past four years, support the contention that there
is a close connexion between eclampsism and accidental
haemorrhage.
Case 1.—Patient, admitted to the Rotunda Hospital in Maroh, 1915,
nnder Dr. B. H. Tweedy’s care, was pregnant about seven months. Her
face, legs, and thighs were (edematous. She complained of Intense
headache, dimness of vision, and vomiting; secreted very little urine,
'which contained numerous tube casts and became almost solid when
boiled. The blood pressure was 200 mm. Hg; In fact, a typical example
of the pre-eclamptic state. The usual treatment was adopted, under
which she appeared to improve. But at the end of a week she
suddenly complained of violent abdominal pain, and a bloody discharge,
which was slight at first hut gradually Increased to a considerable
haemorrhage, escaped from the vulva. The vagina was plugged, bat
though it controlled the external haemorrhage her general condition
grew steadily worse. The abdomen appeared to become more distended
and tender to pressure, and .from her general symptoms It was evident
that serious Internal haemorrhage was continuing.
On opening the abdomen a considerable quantity of free blood was
found in its cavity, the so woe of which was discovered in the right
broad ligament, and a ltgaiure thrown around the ovarian vessels on
that side prevented further loss. The uterus contained a large
Quantity of blood and a dftad foetus, which were removed by the
- * ' ^-Operation, ’ the uterus being left. Them
and she left the hospital in good
ordinary classical Caesarean
was no poet-partum h«mor
health.
Cask 2.-Patient, aged 30,
Sept. 1st, 1917, at 8.40 a.m.
minated normally at full te
nothing unusual until the p
as admitted to the Rotunda Hospital on
Her two previous pregnancies had ter-
i, and on this occasion she had noticed
__ lous evening, when she was seized with
abdominal pain, and a feelinghf distension, and she notloed an Increase
in the size of her abdomen. Vhen admitted to the hospital she was in
a oollapsed condition, blancbid, and cold; temperature 96*4° V.; pulse
i Surgery, Qyneoologd and Obstetrics, February, 1918.
The Lancet,] DR. G. M. FIN
DfLA
lard ai
alible
Y: DIAGNOSIS OF AM(EBIO AND BACILLARY DYSENTERY. [Jan. 26,1919 135
hardly to be felt. The uterus very hatd and tender on palpation; no
total parts could be made out, no viltble hemorrhage, urine soanty,
loaded with albumin, casts in large dumber, some pus and red blood
cells. ,
It was decided to operate as soon is possible. When the abdomen
was opened the uterus presented a reniarkable appearance, dark, almost
blue, in colour, with blood extravasation in patches over its surface,
the peritoneal covering being in placet raised in large blebs filled with
blood, one of which upon the posterior surface had burst, the rent being
about an inch in length; and there was free blood in the peritoneal
cavity. When cut through the uterinewall showed blood extravasation
throughout. The cavity was filled with blood and the placenta com¬
pletely detached; the child, of course, Iras dead. After the uterus had
been emptied and the wound closed in the usual manner It contracted
well after adoee of pituitrln had beei^ administered hypodermically.
There was no post-partum haemorrhage and she made a good recovery,
the urine being free from albumin before she left the hospital.
Case 3. —Patient, aged 39, 9-para, 36 weeks pregnant, was sent to the
Rotunda Hospital by Dr. T. W. Rice, of Portarlington, and admitted on
Deo. 7tb, 1917. Twelve years previously her first pregnancy terminated
prematurely at the eighth month owing to eclampsia, preceded by
headaches and disordered vision, and since then the sight in her left
eye had been impaired. She had convulsions and was unconscious for
a week; the child was stillborn. The four succeeding pregnancies
were normal and the children lived. But after the birth of the last
child she did not make a satisfactory recovery, and had subsequently
three abortions.
On admission the patient said that she bad been ill for about three
weeks, suffering from headaches and Impaired vision. There was a
large eoohymosls on the leit buttock. Her urine was scanty and of a
bright-red colour, and contained a large quantity of blood and tube-
easts. The child could be easily palpated, its head presenting in the
first position. The diagnosis was pre-eclamptic toxteraia, and she was
treated in the manner formulated by Dr. Tweedy, and which has been
adopted as a routine in the Rotunda Hospital for some yean; nothing
was given by the mouth but water and bicarbonate of soda. She got
little sleep in spite of a hypodermic of morphia, and the total quantity
of urine passed in the first 24 hours was 20 oz. and the blood pressure
was 260 mm.
The following day there was no improvement, and some twitching in
the muscles of her arms, for which she was given 1 gr. morphia. During
the following days there was little change in her condition until the
sixth day, when she seemed to be rather better and had passed 31 oz.
of mine during the previous 24 hours, but in quality it was the same,
and the blood pressure was still 260 mm. Considering that she had been
restricted to soda and water for five days since her admission to hos¬
pital and that she said that she had eaten nothing for two days before,
I thought It advisable to give her some nourishment, so at 12.30 p.m.
she took 4 oz. of milk with an equal quantity of barley-water. At
1.10 p.m. abe complained of a violent pain in her abdomen and said that
she could aee nothing. She looked pale and collapsed. Her skin felt
oold and clammy and was bathed In perspiration. The temperature was
below normal and a little reddish discharge flowed from the vulva. Her
abdomen was evidently larger, the nterus swollen, hard, and tender,
and the foetus no longer palpable. Her condition appeared to be almost
hopeleae, but being persuaded that her life could be saved In no other
way, I determined to operate Immediately.
The abdomen having been opened, the uterus presented the same
remarkable appearance which I have already described, being much
distended, of a dark bluish-purple colour, with numerous patches of
eochymosis on its surface. The wall when out through showed blood
extravasated throughout Its substance. The placenta was completely
detached, the cavity full of blood and olota, and the foetus was dead.
To save time, which appeared to be of vital importance, I closed the
uterine wound with a running suture of chromicised gut; otherwise
the operation was carried out in the usual manner. Towards Its close
the patient appeared to be dead, but with the aid of pituitrln and other
restoratives she gradually came round and was removed to bed.
The patient made a good recovery, although in consequence of her
toxsemlc condition we thought it advisable for three days more to give
her nothing but soda and water. After delivery the urine rapidly
improved both in quantity and quality, so that on the fourth day It
waa normal in colour and free from albumin.
i Commentt on Cases.
I have not reported these cases as exceptional, bat, on the
contrary, as being such as are generally met with in cases of
severe accidental haemorrhage. I believe that the detach¬
ment of the placenta and the haemorrhage in such cases are
caused by thrombosis of the veins of the plaoental site,
probably due to toxaemia, and that the disease is the same as
that which causes puerperal convulsions.
Those are the chief points that I wish to emphasise, bat
there are two others to which I shall allude. One is that in
none of the oases was it necessary to remove the uterus—
indeed, had I done so in the third I am certain she could
not have recovered ; and the other as regards dietary. It is
generally believed that a milk diet is necessary in these
oases, and there is no doubt that it is better than any other
kind of food. But Dr. Tweedy maintains—and I agree with
him—that water only is much better even than milk, and
the fact, which I have not^ed in tbe third case, that serious
aggravation of the patient’s condition has followed the inges¬
tion of even a small quantity of milk has been observed by
us on several occasions. In answer to the question as to how
long a patient can be restricted to water alone I would call
attention to the fact that this woman had nothing, with the
exoeption of 8 ounces of barley-water and milk, but soda and
water for eight and possibly tn ten days, and yet she
recovered.
Dublin.
THE
DIFFERENTIAL DIAGNOSIS OF AMCEBIC
AND BACILLARY DYSENTERY
FROM THE BLOOD.
%
BY G. MARSHALL FINDLAY, M.B., Ch.B.Edin.,
TEMPORARY SURGEON, B.X.
The early, and at the same time correct, differentiation of
amoebic and bacillary dysentery is a matter of very con¬
siderable importance from the point of view of treatment;
for whereas in amoebic dysentery it may be possible to with¬
hold emetine for a few days without any dire result, in
bacillary dysentery it is certainly inadmissible to delay
the administration of serum. Unfortunately, the present
diagnostic methods of dysentery are by no means simple;
they take up a considerable time, require a certain amount
of skill, and presuppose the existence of a well-equipped
laboratory. On active service these conditions are not always
obtainable.
In the present paper an attempt has been made to arrive
at a simple method of differential diagnosis from an examina¬
tion of the blood alone. It must in the first place be
remembered that the underlying pathology of amoebic and
bacillary dysentery is absolutely dissimilar. The former
condition is produced by the action of a protozoon which by
meanB of a proteolytic enzyme sets up a colliquative
necrosis of the tissues in its immediate vicinity, the latter
condition is of the nature of a well-marked bacillary
toxaemia. Description of Tests.
In the differentiation of amoebic and bacillary types of
dysentery the two following reactions have been used:
(1) the iodine reaction in the polymorphonuclear leucocytes ;
(2) the production of nuclear pseudopodia in the polymorpho¬
nuclear leucocytes.
1. It has long been known that in certain pathological
conditions the polymorphs, when treated with dilute iodine
in dry blood films, give a glycogen reaction, but it is only re¬
cently that Bond 1 and others have shown that even in health
a large proportion of the white blood corpuscles normally
give under certain conditions a reaction with iodine which
is closely related to the glycogen reaction met with in
certain diseases. When normal white blood cells are incu¬
bated for a quarter of an hour at 37° C. and are subsequently
treated with a 1 per cent, solution of iodine in water ana
potassium iodide a certain number of the white cells show
the presence of one or more mauve-coloured droplets.
These droplets gradually coalesce to form one large drop,
which eventually breaks the lining membrane of the cell
and escapes into the surrounding medium. The particular
cells whioh show the presence of this iodophile substance
are oertain of the polymorph leucocytes. The actual
technique for the demonstration of tbe iodine reaction is aft
follows
A drop of blood from the finger is placed in a Ponder's
plasticine cell 3 and incubated for one hour at 37° C. During
incubation the white blood corpuscles pass out from the
clot and adhere to the cover-glass above and the slide
beneath. The cover-glass and cell are then removed and
the clot is washed away with normal saline. Two films of
leucocytes are thus obtained, which are mounted in the
1 per cent, solution of iodine in potassium iodide. All the
cells in oontact with the iodine take on a yellowish tint,
but, as before mentioned, oertain of them show tbe presence
of mauve globules in the protoplasm. In the normal indi¬
vidual the number of cells giving the reaction is roughly
59-60 per cent. Bond, however, has pointed out that in
conditions associated with the presence of bacillary toxins
in the blood the amount of iodophile substance is increased,
as there is a large increase not only in the number of cells
actually giving the reaction, but also in the amount of iodo¬
phile substance present in th6 individual cells. This increased
iodine reaction persists in the blood for a fortnight or
three weeks after the disappearance of the active symptoms
of the disease. Applying the above reaotion to tbe case of
bacillary dysentenr, it is found that the number of white
cells giving the iodine reaction is 69-80 per cent., while the
increase in the amount of iodophile substance is also well
brought out. By this means, therefore, we have a method,
with oertain reservations, of determining whether the
dysenteric infection is due to a bacillus or not. It is
necessary, however, to exclude any recent septic infeotion,
such as a sore-throat or whitlow, sinoe such a condition
produces a similar iodophile condition in the blood.
In one of the earliest oases examined—an amoeblfl
infection—the blood gave a well-marked iodine reaotion, a
130 THa liANOTT,]
DR. D. GUTHRIE : NASAL OBSTRUCTION IN AVIAT0R8.
[Jan. 25,1919
phenomenon only explained when it was found that the
patient bad a suppurating venereal bubo in the groin.
In addition, in long-standing amoebio infections where
there is secondary bacillary infection the blood may also
give a well-marked iodine reaction.
2. The formation of nuclear pseudopodia. An examina¬
tion of a large number of polymorph leucocytes derived
from healthy individuals reveals the fact that in a very
small percentage of cells the nuclei are furnished with
flnger-like processes, or pseudopodia. These processes are
usually classified into three types : (1) pyriform ; (2) blunt
or sessile; (3) spioulated. The cause of the formation of
these pseudopodia is at present unknown, except in so far
as they appear to be due to active nitrogenous metabolism.
Gruner,* who has studied their production, has found that
they are produced by a purin-containing diet, while they are
also numerous in carcinoma, except in those oases where
the tumour is so circumscribed that the cancerous excreta
oannot enter the blood stream. An examination of the
blood films from cases of amoebio dysentery reveals the fact
that in this condition also there is a large increase in the
production of nuclear pseudopodia. This increase is notice¬
able on the second or third day of the disease. Thus in
amoebic dysentery the percentage of polymorphs with
pseudopodia was found to vary from 12-5 per cent, to 52 per
cent., the average being 18 per cent., while in bacillary
dysentery the percentage obtained varied from 0 to 11. Out
of 50 cases of oacillary dysentery examined the percentage
of polymorphs with nuclear pseudopodia was in no instance
above 12. It is interesting to note that in two cases of
liver absoeas without any dysenteric symptoms the number
of cells with nuolear pseudopodia was 25 per cent, and 27 per
oent. respectively.
Avery large number of blood films from various patho¬
logical conditions have been examined for the production of
nuclear pseudopodia, with the result that the only other
condition in which the change could be found was chronic
tuberculosis of the lungs. Provided, therefore, that the
patient is living on a purin-free diet and that it is possible to
exclude cancer and pulmonary tuberculosis, the formation
of nuclear pBeudopoaia in a case of dysentery is highly
suggestive of an amoebio infection.
Conclusion.
Taken in conjunction, the two tests above described
enable an accurate diagnosis of the type of dysentery to be
given at an early stage of the disease in at least 90 per cent,
of cases. The occurrence of a well-marked iodine reaction
without the formation of nuclear pseudopodia is suggestive
of a bacillary infeotion, while the absence of the iodine
reaction and the presence of nuclear pseudopodia naturally
point to an amoebio origin. Should a well-marked iodine
reaction occur in conjunction with the formation of nuclear
pseudopodia the possibility of a mixed infection should not
be overlooked.
References.— 1. Bond: The Influence of Antiseptloa on the Activities
of Leucocytes and on the Healing of Wounds, Part III., Brit. Med.
Jour., Feb. 3rd, 1917. 2. Ponder: The Lancet, Dec. 12th, 1908.
3. Gruner: The Leucooytes in Malignant Disease, British Journal of
Surgery, vol. ill., No. 2.
NASAL OBSTRUCTION IN AVIATORS.
By DOUGLAS GUTHRIE, M.D.Edin., F.R.O.S. Edin.,
CAPTAIN, ROTAL AIR FORCE; INTERIM 817 EG EOS TO THE EAR
AID THROAT DEPARTMENT, ROYAL HOSPITAL FOR
SICK CHILDREN, EDINBURGH.
The science of aeronautical medicine is still in its infancy.*
Researches pursued in various directions have proved that
the successful pilot must possess a sound heart and sound
lungs, a stable nervous system and a healthy “mentality.”
Scarcely less important fs the possession of good binocular
vision and of normal ears. The ear-mechanism obviously
becomes a more essential factor in flying when we remember
to regard the ear not only as the organ of hearing but as
an accessory organ of equilibration. Although the aviator
depends mainly on his sense of vision it is, perhaps, a
matter of regret that the sense of equilibration, a sense so
highly developed in birds, and so readily accurately esti¬
mated in man by the B4r4ny tests, has received so little
attention from those who have, in this country, studied the
medical aspects of aviation. Into the rationale of those
tests and their relationship to aviation I do not propose to
enter in this short paper, but would merely refer to one
aspect of the subject which is well worthy of notioe—i.e.,
the question of nasal obstruction.
To the flying man free nasal respiration is an important
asset. The statement will meet with general acceptance,
though the reasoning on which it is based may not be so
widely understood. During the past few months I have had
occasion to examine and operate upon a considerable number
of officers and cadets suffering from nasal obstruction, and
although I have followed the subsequent flying history in only
a few instances oertain interesting facts have come to light.
Results of Nasal Obstruction.
The main conclusions regarding the baneful effects of nasal
obstruction on the aviator maybe summarised as follows:—
1. Effect on the lungs. —The mouth-breather cannot satis¬
factorily expand his chest, and his lungs are never sufficiently
aerated. Mendel has demonstrated experimentally the in¬
feriority of respiration by the mouth and has shown that the
amount of air which the mouth-breather iD hales with each
breath is less by one-fifth than the amount inhaled in normal
nasal respiration. It follows, then, that if the subject be an
aviator he will readily suffer from symptoms of “ oxygen-
want.” This aspect of 44 oxygen-want ” probably deserves
further investigation.
2. Effect of equilibration. —The Eustachian tubes, the
function of yrhich is to adjust the pressure of air within the
middle ear to the changes produced by sound-waves, atmo¬
spheric pressure, &c., and which come into use so largely
during flying, are impaired in their function if auy nasal
obstruction is present. During a rapid descent the tympanic
membranes are driven inwards by atmospheric pressure,
causing deafness and earache. Normally those symptoms
disappear if the ears are ‘ 4 inflated” by swallowing or by
movement of the jaw. But if the nasal passages be blocked
so that air does not freely reach the Eustachian tubes the
alteration of pressure within the middle ear cannot be com¬
pensated and the symptoms persist, perhaps with the
addition of giddiness caused by altered labyrinthine tension,
communicated from middle to inner ear through the round
and oval windows. Under such oiroumstances the risk of a
crash is, naturally, considerable.
3. “Reflex” effects. —A third possible result of nasal
obstruction is headache coming on in the air or after landing.
This is in many cases due to the pressure of a deflected nasal
septum against the middle turbinal, the so-called reflex nasal
headache. Headache of this type is, of course, not peculiar
to aviators, but is aggravated by flying for reasons to be
presently described.
Causes of Nasal Obstruction .
The commoner causes of nasal obstruction are adenoids,
hypertrophic rhinitis, and septal deviations.
Polypi were encountered on only one oooasion in the
present series. Adenoids were present in many cases, accom¬
panied, as a rule, by enlarged and septic tonsils, but in few
cases were the post nasal growths so large as to cause much
nasal obstruction. They were, however, liable to attacks of
inflammation, and then the Eustachian tube became blocked,
not by adenoid tissue, but by the mucus and pus which that
tissue secreted.
Hypertrophic rhinitis, affecting the anterior or posterior
ends of the lower turbinal, was fairly common and was
readily cured by partial turbinectomy. '■
Deformities of the nasal septum were the cause of the
obstruction in the majority of cases. As a rule the patient
gave a history of former injury at boxing or football. Some
of those definitely traumatic cases had almost complete
obstruction of both nostrils. In others the symptoms were
nil, and the patient was unaware of any nasal trouble until
he came before the examining board.
Aggravated cases of septal deformity naturally call for
treatment before the subject can be passed as fit for flying,
but the wisdom of operating on minor degrees of septa)
deviation in cadets is questionable. Absolute symmetry of
the septum nasi is a rarity among civilised races, and an
examination of over 2000 skulls has revealed deformity of
the bony septum in 75 per cent. (Morell Mackenzie). At the
same time it is to be noted that a degree of nasal obstruction
which would cause little trouble on the ground may be
very troublesome in the ait. At heights over 7000 to 10.000
feet the mucous membiane of the nose becomes swollen
and engorged, and any existing obstruction is thus greatly
aggravated. I
This is borne out by the following typical reply to an
inquiry addressed to one df the patients: 44 Before the opera¬
tion,” he writes, 44 1 wm |ompelled, when flying, to breathe
through my mouth ; this was difficult to do and was irritating
to the throat, especially raien I flew a fast scout at heights
i over 8000 feet and in cold freather. The operation has cured
The'Lancet,]
H. WILSON : POST-INFLUENZAL HAEMOPTYSIS.
Jan. 25, 1919 137
this trouble, and I have since floi
with no difficulty whatever.*’
at 12,000 feet and over
Treatment.
The treatment of the cases in question is a matter of some
importance. The main object, from a military point of view,
is to render the patient fir as rapidly as possible. To this
end it is advisable to employ local anaesthesia for septum
cases. A method which answers well is to pack both nasil
cavities half an hour before operation with 10 per cent,
cocaine, and at the same time give a hypodermic of
morphine and atropine. The patient complains of little
discomfort during the submucous resection, even if one
has to gouge away part of the maxillary crest.
After-treatment consists in packing both sides with ribbon
gauze wrung out of liquid paraffin, a dressing which adapts
itself to the tissues and is easily removed on the following
day. Treated in this way septum cases need remain in
hospital for only a few d&ys.
In conclusion, it may be remarked that while commercial
aviation will naturally impose much less strain upon the
pilot than 11 war” flying, nevertheless the medical problems
of aeronautics should be studied more and more in the
future, and it is only by attention to such minor details as
those indicated above that knowledge can be advanced and
tests standardised. Aviation can only be developed on a
sound footing by the mutual researches of the designer,
the mechanic, the pilot, and the doctor.
POST-INFLUENZAL HEMOPTYSIS.
By HORACE WILSON, M.D., B.S. Lond., D.P.H.,
TUBERCULOSIS MEDICAL OFFICER A ED A88I8TAWT M.O.H., BOROUGH OF
SOUTHWARK; DEMONSTRATOR OF BACT*•BIOLOGY, PUBLIC HEALTH
LABORATORY, KING'S COLLEGE.
Attention has been drawn to the occurrence of eplstazis
and other haemorrhages in the recent epidemic of influenza,
and there has also been a large group of oases in which
hamoptysis occurs which may readily be mistaken for
pulmonary tuberculosis. These oases are often puzzling
and may lead to erroneous diagnosis, and have to be care¬
fully differentiated from those cases which drift almost
insensibly from influenza into acute pulmonary tuberculosis.
As a rule the haemoptysis in influenzal cases commences
towards the end of the illness, when there is slight cough,
an increasing weight, and no great tendency to wasting.
The sputum shows a bright red staining, and not the typical
rusty tint of acute pneumonia. Pneumococci are the pre¬
dominant organisms and tubercle bacilli are absent.
The characteristic physical signs are generally marked by
their bilateral posterior distribution in the suprascapular
areas, where breath sounds are faint and moist granular
adventitious sounds are abundant, with no bronchial breath¬
ing and some bilateral impairment of the percussion note.
The corresponding areas in front show little or no change,
excepting some lack of resonance on percussion. The mid-
area of the lungs posteriorly is fairly clear, but the bases
show congestive crepitation on both sides.
The temperature for a time is irregular and fluctuating,
and the pulse-rate not so rapid as would be the case in
a tubercular bacillary toxaemia corresponding to similar
physical signs.
Careful observation of these cases for a few weeks will show
subsidence of physical signs and temperature, with increas¬
ing weight and improved general condition. If, therefore,
with slight haemoptysis the physical signs are bilateral and
chiefly marked posteriorly it is well not to be too precipitate
in diagnosing pulmonary tuberculosis, but to make frequent
examinations of the chest and sputum while taking the
general progress of the case into consideration. Many of
these cases have proved to be pneumococcal and transient,
and a hasty diagnosis of tuberculosis on the ground of
haemorrhage may cause considerable distress.
As regards the physical signs the converse also holds
good, and monolateral anterior sigss with haemoptysis give
rise to much more suspicion of earl? pulmonary tuberculosis,
particularly with no regain of Height on convalescence,
rapid pulse, and night sweats.
So many cases of each type lure come under the writer’s
notice during the last 12 months ttat he hopes these notes
taken from bis cases may be sone guide to others when
diagnosis is doubtful.
NOTE ON
STAPHYLOCOCCUS AUREUS SEPTICAEMIA
AS A COMPLICATION OF INFLUENZA IN AN EPIDEMIC
IN MALTA.
By ADAM PATRICK, M.D.Glasg.,
TEMPORARY CAPTAIN, R.A.M.O.
With a Note by Colonel Sir A. Garrod, K.C.M.G., A.M.S.
In the bacteriological examination of a number of cases
of influenza and bronoho-pneumonia which have oome under
treatment in military hospitals in Malta it has become
increasingly apparent that in this epidemic a secondary
infection with Staphylocoocus aureus is a not infrequent and
a very serious complication. Attention was first directed to
this point by the post-mortem findings in the case of a soldier
who died on July 5th.
After this condition was recognised it was seen that the
cases in which Staphylococcus aureus was found were fre¬
quently those of a severe type of bronoho-pneumonia, with
characteristic symptoms. I am greatly indebted to Colonel
Sir A. Garrod for the following note descriptive of cases of
this type:—
Note on Symptomatology by Colonel Sir A. Garrod.
( ‘ In the present epidemic of influenza in Malta the cases
have been, for the most part, of a mild character, but
amongst them, as always, cases of broncho-pneumonia have
oocurred and a small proportion of deaths. In a number of
cases there have been pulmonary trembles of a peculiar kind,
such as I have not seen in previous epidemics. Such cases
occurred chiefly in groups of men coming from special
centres.
These patients present a well-defined clinical picture, unlike
that of ordinary influenzal pneumonia. After the subsidence
of a short primary fever the temperature rises again, and
the condition of the sufferer suddenly becomes grave. He
acquires a cyanotic tint, his breathing becomes shallow and
very rapid, from 40 to 60 respirations per minute. He is
anxious about his state at first and begs to be put out into
the open air, but later he becomes apathetic, drowsy, land
appears not to hear what is said to him. He may lapse into
coma, with picking at the bedclothes, or may even develop a
condition of coma-vigil. Delirium of a mattering kind, or
even of more active form, usually preceded the onset of coma.
On the other hand, some patients remain conscious and
anxious thronghont, convinced that they are going to die.
The pnise is rapid and the temperature high, reaching
104° F. in some cases, 105° in a few. The tongue is dry
and covered with a thick brown fur, and its clearing is one
of the earliest signs of improvement. The spntnm is almost
invariably rusty or pink daring the attack, and in some oasee
there is definite hemoptysis. The spleen is sometimes
enlarged, but I fancy that this is an outcome of local condi¬
tions. The nrine usually contains albumin, a trace to a
dense clond. The physioal signs are soanty considering the
conspicuous embarrassment of breathing. Large areas of
impaired resonance or dullness, chiefly over the lower lobes
behind, and scattered crepitations, and sometimes pleural
friction are the usual signs. Bronchial breathing is not
usually heard. The temperature may maintain an even high
level or may fall suddenly with symptoms of collapse, only
to rise again in a few hours. Death may occur during an
attack of collapse, but more often is ushered in by steadily
increasing dyspnoea with increasing cyanosis.
The whole clinical picture is that of gradual suffocation.
The pulse seldom fails seriously before the approach of death
unless there be an attack of collapse. The cases recall
those rare examples of acute oedema of the lungs in
children, and, as Professor Zammit first pointed oat to ns,
general oedema of the lungs is found post mortem. In cases
ending in recovery the temperature falls by somewhat rapid
lysis commencing on the eighth or ninth day of the
secondary fever. The rate of respiration falls gradually,
the colour improves. In some cases the sputum remains
rusty for some days after the temperature falls. ”
Bacteriological Examination of Sputum.
The spntnm of 50 patients with inflnenzal broncho¬
pneumonia has been examined bacteriologioally (Table I.)
Nine of these 50 patients died, and Staphyloooeous aureus
had been found in the sputum of seven of them. The nine
others who had shown staphyloooocus recovered, though
138 TraLANCVr,] DB. A. PATRtOK: STAPHYLOCOCCUS AUREUS SEPTICEMIA III INFLUENZA. [Jan. 25,1919
Table I.-
OrganUm.
Pneumococcus.
Micrococcus catarrhalis
Streptoooccus.
Staphylococcus aureus ...
Gram negative bacillus
several had a severe attack.
.. 21
.. 18
.. 16
.. 13
Organisms found in the Sputum of 50 Patients
with Broncho-pneumonia .
Times |
found
45
Gram-positive coed {other
than above)...
Yeast...
B. influentae
B. septus ...
The amount of this organism
grown from the spntnm of the fatal cases varied, being
sometimes a small growth mixed with other organisms, and
onoe an abundant pure culture.
Post-mortem, Findings .
The bodies of six of the nine patients who died, and also
the bodies of five others in whose case the sputum bad not
been investigated, were examined post mortem. Of these
11, nine gave evidence of staphylococcus septicemia. In the
two other cases staphylococcus was obviously not the cause
of death. The post-mortem findings may be summarised.
The lungs of the nine staphylococcus cases showed broncho-pneu¬
monia, not always extensive, but there was widespread congestion and
noticeable oedema. No considerable area of lung tissue was found pink
and spongy. The cedema tended to affect not only the pneumonic
portions he lungs but also those parts which remained uncon¬
solidate*. i section of the lungs a watery, frothy, slightly blood-
tinged fluid exuded on slight pressure. In one case the amount of
this fluid was excessive, and the lungs weighed 50 oz. and 42£ oz.
respectively.
The bronoho-pneumonic areas were not densely consolidated, but the
prooess had a speolal tendency to go on towards abscess formation, and
four stages could be distinguished :—
1. Broncho-pneumonia present, but consolidation not very firm ; luhg
dark brownish-red on section; out surface smooth: exudation of
slightly blood-stained watery fluid on pressure.
2. Surface of cut lobule coarsely granular, and slightly raised from
surrounding area of lung, but not quite so dark in colour as in stage 1;
exudation of cedematous fluid on pressure, but in addition appearance
of beads of pus in the ent bronchioles.
3. Out surface very distinctly raised and coarsely granular, with
numerous miliary abscesses visible in the substance.
4. Lung tissue largely destroyed and lobule converted into aoollection
of abscesses separated by fibrous septa.
The distribution of these stages was lobular and a sharp line of
demarcation could be made out between stages 1, 2, and 3 on
the cut surface. The broncho-pneumonio prooess tended to involve
•speolally the greater portion of the lower lobes, and the inner half
of the upper lobes. The lower anterior edge of the lower lobe was
nearly always spongy. In most of the cases the prooess had not pr o¬
gressed as far as the formatlou of visible abscesses. In six out of the
nine there was no obvious evidence of pus, but abscesses were present
in sdme part of the lungs in the th ee others.
Three oases showed empyemats from all of which Staphylococcus
aureus was obtained in pure oulture. In a case with double empyema
smears of the pus showed pneumococci on one side and pneumococci
and streptocooci on the other, but the only growth on culture was of
staphylococcus.
The spleen was generailv enlarged, in one cate weighing 14 oz. and in
two others 13 oz. The substance, as a rule, was of normal consistence
and appearance. In the case of a patient with well-developed abaoesses
In the left upper lobe it was small (2£ oz.), pale, and soft Considerable
oedema was sometimes observed In the liver. The condition of the
other organs called for no remark.
Two other cases remain to be mentioned.
In one of these there was considerable abscess formation and oedema
In both lungs and their general appearance resembled that of the
staphylococcus cases, except that the consolidated areas wera denser
than In any of them. Very numerous pneumococci had been found in
the sputum during life and after death extensive acute pleurisy was
found, with unmixed pneumooooel In the fibrin us exudate. Pneumo¬
coccus, sometimes mixed with a Gram-negative bacillus, was grown
from most of the organs. It was isolated in pure culture from the
spleen. ▲ few colonies of Staphylococcus aureus were grown from the
right lung, but the pus formation and the septicaemia could not be
attributed to It. This patient was already ill when he arrived on the
Island, and It was not certain, though probable, that be was suffering
from influenza. Clinically he had been regarded as different from the
staphylocoocus cases.
In the other fatal case in which staphylococcus was not found the
appearance of the lungs was quite different. There were about 2 oz.
of pus in the left pleural cavity, and the lower lobe of each lung was
deeply congested and in a state of splenlsatlon. The distribution of the
consolidation was lobular. The right upper and middle lobes and the
left upper lobe were light pink In colour and showed no congestion or
cedema. Streptoooccus in pure culture was grown from the left lower
lobe and streptococcus mixed with a few sarclnse from the right lower
lobe and the empyema.
Table II. shows the result of cultures from organs in the
11 cases, and also whether Staphylococcus aureus had been
found in the sputum during life.
In four cases in which it was estimated the leucocyte oount was
rather low—4009 (staphylocoocus case), 7800, 6800 (stapbyttcoocus case),
and 6800 per c.mm. Blood cultures were taken from five patients and
no growth resulted In any. One of these was made two days before
death in a case in which staphylococcus was afterwards found in the
heart blood.
Staphyloooeous aureus is rather a rare organism in the
respiratory tract, and in ordinary circumstances the tisanes
seem to have adequate powers of resisting it. It is not so
Table II.— Cultures from Organs in 11 Fatal Cases of
Broncho-pneumonia .
Organ.
Case.
1 } 2
3
; 4
5
6
7
8
9
10
11
Heart blood.
s. Is.
S.
_
S.»
_
8.
Pn.
Bight lung .
8.1S.
s.
S.
_
S.
8.
Str. 4
S.
Pn.,8
S.3
Left lung .
... j ..
• a.
s.
s.»
s.
8.
Str.
8.
Pn.*
8.3
Right pleural cavity
Left pleural cavity
... I-..
...
s!
8.
Str.
Sar.
8.
Bac.
...
Spleen .
Liver .
S. jS.
s.
s.
s.
S .*
—
—
Pn.
—
s.
s.
8.
8.
8.3
—
—
Bac.
8.3
Gall-bladder... ...
- Is.
3
—
—
—
—
—
—
—
Right kidney
3.
s.
—
S.
s.
—
—
Pn.»
a:
Left kidney.
8putum (during
i
...
s.
—
—
—
85
Pn.*
No 8.
life) .
S.
S.5
8 - s
8.5
No S.
...
Organisms found in pure culture except where otherwise stated.
S. = Staphylococcus aureus. Str. = Streptococcus. Pn. = Pueutno-
coccub. Sar. = Sarcina. Bac. = Gram-negative bacillus. — = No
growth.
1 Almost pure oulture. * Mixed with pneumococcus. * With a Gram-
negative bacillus In small numbers. 4 With a few saroinc. • With
other organisms.
with some of these cases of influenza, in which the sequence
of events emphasises the fact that when conditions are
favourable to its dissemination throughout the body Staphy¬
lococcus aureus is an organism of great malignancy. The
examination of the sputum in most cases of broncho-pneu¬
monia gives little information, bat the results of this short
series show that, in influenzal broncho-pnenmonia it may be
of some value in estimating the prognosis.
ON SOME SIMPLY PREPARED CULTURE
MEDIA FOR B. INFLTJENZJE
WITH A NOTE REGARDING THE AGGLUTINATION REACTION
OF SERA FROM PATIENTS SUFFERING FROM INFLUENZA
TO THI8 BACILLUS.
By ALEXANDER FLEMING, F.R.C.S. Eng.,
TEMPORARY CAPTAIN, R.A.M.C. ; HUNTERIAN PROFESSOR, ROYAL
COLLEGE OF SURGEONS.
(From the Research Laboratory attached to a Base Hospital
in Franoe.)
The traditional text-book method for the growth of
B. influenza was agar to which a certain amount of fresh
blood or blood corpuscles had been added. On such a
medium B. influenza showed very tiny pin-point colonies
sometimes very difficult to see with the naked eye. More
recent investigations have shown that much more copious
growths can be obtained when the added blood has been
altered in various ways.
Fitzgerald and Cohen {Centralblati fUr Bacteriologies 1911) obtained
greatly enhanoed growths by heating the blood to 80° C. for three
minutes.
Matthews (The Lancet. July 27th, 1918) showed that very profuse
growths occur when the blood has been digested with an exoeas of
trypsin for five days at 37° C.
Levinthal (quoted in the October number of the “ Medical Supple¬
ment to the Dally Review of the Foreign Press") obtained profuse
cultures by adding blood to agar in the proportion of 1 to 20, then
boiling and filtering the medium.
The object of the present communication is to emphasise
the advantages of blood altered in various ways on the
growth of B. influenza and to indicate certain very simply
prepared media on which enormous growths can be obtained.
The author has had the opportunity of seeing and making
many cultures of B. influenza on agar with blood digested
with trypsin, as for some years at St. Mary's Hospital all our
B. influenza vaccine was made from cultures on this medium,
and there is no doubt as to the wonderfully profuse growths
which can be obtained from its use. The preparation of the
medium is, however, cumbersome, as it takes four or five
day8 for the trypsin to produce the necessary charge in the
blood. It is thns impracticable to use such a medium if it
is desired to make cultuites of B influenza without previous
warning unless a stock oflthe medium is kepton hand. It also
requires sterile blood and feterile trypsin, which are not always
to hand. It would be oflconsiderable advantage, therefore,
if the same profuse grounh could be obtained on a medium
which could be prepared on the spur of the moment and
which did not necessitate the nse of materials not readily
obtainable. The followiig observations show that this can
be done.
The Lancet,] MR. A. FLEMING 1 SIMPLY PREPARED CULTURE MEDIA FOR B. INFLUENZAE. [Jan. 25,1919 139
Blood boiled in agar .—If blood i added to a tube of agar sterilises the blood, even if it is very badly contaminated,
and boiled for one minute the] whole of the colouring This is brought out in the following experiment.
matter of the blood and the coagulable proteid is pre¬
cipitated in masses. The tube tan then oe sloped, and
before the agar cools sufficiently to become solid the
whole of this precipitate will havfe settled to the bottom,
leaving the upper part of the medium clear. If B. influenza
is planted on this an enormous growth results. The same
result is obtained if blood oorpusol^B only are used.
The amount of blood which ifeiis necessary to add is
indicated in Table I.
Table I.—Blood added to 5 c.cm. agar, boiled, oooled, and
planted with B. influenza.
Rwultut growth.
Copious confluent growth.
„ „ „ (not quite so heavy).
11 *» It *• II
„ (colonies like streptooooous).
Colonies small and growth scanty.
No visible growth.
Blood boiled with water and the resultant fluid added to agar.
—If I c.cm. of blood is boiled with 9 c.cm. water the whole
of the colouring matter of the blood and the coagulable
protein is precipitated in masses which rapidly separate,
leaving a clear, colourless, watery fluid.
It may be necessary to add a small amount of aeetlo acid to get
annotate precipitation, but the amount of acid added should not be
enough to neutralise the alkalinity of the blood. It is not material to
Amount of blood added.
0 25 c.cm.
012
0116 „
003 ,.
o-oi „
0006
1 c.cm. of blood was added to 5 c.cm. of tap water and the mixture
was then heavily contaminated with faces. 1 c.cm. of normal
sulphuric acid was. then added, and the tube, after being shaken, was
left at room temperature for half an hour, when 1 c.cm. of normal
caustic soda was added. Of the resultant fluid 1 c.em. was added to
liquid agar, sloped, planted with B. influenzas and incubated at 37° O.
An extremely oopious growth of B. influenzas resulted, the medium
being otherwise sterile.
It has been found that on media prepared from blood altered
in these ways other organisms, such as staphylococci, do not
exercise any symbiotic action on the growth of B. influenza.
It would appear, therefore, that the change produced in the
blood by boiling or by strong acids is of a similar nature to
that effected by these organisms whioh exercise suoh a
powerful symbiotio effect on B. influenza when unaltered
blood is used.
Agglutination of B. influenzas by strum of men suffering
from influenza,.— From the media described above very good
emulsions of the bacillus can be obtained for agglutination
purposes.
The sera of 21 patients suffering from influenza were
examined for agglutinins to B. influenza. Wright capillary
tube method was used, and the tubes were Incubated at
50° C. for two hours before readings were made. The results
were as follows1 serum agglutinated the baoillus up to a
dilution of 1 in 1000 ; 2 sera up to 1 in 128; 3 sera up to 1 in
64; 10 sera up to 1 in 32; 4 sera up to 1 in 16; and 1 serum up
to 1 in 8.
The duration of the disease in these men had been from
tbe growth of B. influenzae whether the liquor obtained is dear or
whether It contains debris of altered blood. Olear fluid has, however,
the advantage that it gives a transparent medium Indistinguishable In
appearance from ordinary nutrient agar.
This fluid is added to liquid nutrient agar and sloped. On
planting with B. influenza a very profuse growth takes place.
The following experiment (Table II.) shows the quantity of
this fluid whioh it is neoessary to add to 5 c.cm. of agar.
- Table II.
three days to three weeks, but most of them were convales¬
cents about seven to ten days after the onset. It will be
seen that all the patients' sera agglutinated B. influenza to
some extent, whereas none of the control sera tested showed
any agglutination even in a 1 in 4 dilution. It follows from
this that B. influenza is either the cause of the disease, or it
is an extremely common secondary infection, and if it is a
secondary infeotion then it follows the primary infeotlon
very rapidly, as agglutinins had developed in one oase only
three days after the onset. 1
. Corresponding to
Itald added. original blood Resultant growth,
volume of —,
1 c.cm. 0*1 c.cm. Copious confluent growth.
0*5 „ 005 „
0 25 ,, 0*025 „ Copious colonies (small).
012 ,, 0*012 „ No growth.
A differential medium for isolating B. influenzas.—It has
long been known that certain dyes, among them brilliant
green, had the power of Inhibiting the growth of Gram-
positive bacteria to a very much greater extent than Gram¬
negative bacteria. It was thought that possibly, now we
have a medium whioh grows B. influenza luxuriantly, the
addition of a small amount of brilliant green to the medium
The whole of the coloured fraction of the haemoglobin is
precipitated from the blood by boiling and only a colourless
watery fluid is added to the agar. It is olear, therefore, that
whatever is the nature of the substance which favours the
growth of B. influenza , it is not, as was generally supposed,
the coloured element of haemoglobin.
Blood broken down by acids .—If to blood is added an equal
volume of a normal solution of one of tbe strong mineral
acids, such as sulphuric acid, tbe red colour is immediately
changed to brown by the breaking down of the haemoglobin.
If now an equivalent volume of normal causticsoda is added,
a brown precipitate is formed and a brownish fluid separates.
It la important-to test the reaction of the fluid after the addition of
tbe cauatto soda to see that tbe reaction la only faintly alkaline to
Utimui as a am a 1 error in the quantities of acid or alkali of this
ttren*' h makes an enormous difference to the reaction of the medium,
sod consequ *nily to the growth of the bacillus.
If this fluid is added to liquid agar it furnishes a medium
on which the most profuse cultures of B. influenza can be
obtained. It would appear, therefore, that so far as the
growth of B. influenza is concerned sulphuric acid will effect
the same change in blood in less than one minute that it
takes trypsin four or flve days to produce.
The q'uantities of fluid neoessary to add to 5 o.om. of agar
are shown in Table III.
Table III.
* Corresponding to
original blood
volume of—
0*1 c.cm.
0*06 „
0*085
0*01 „
The best proportions in whioh to mix the fluids seem to be
as follows: Blood, 1 part; water, 5 parts; normal sulphurio
acid, I part. This mixture can be boiled and stored at room
temperature for some weeks without ieterioration.
This medium, whioh certainly give* as oopious growths of
B influenza as any other, is very eas, f to prepare, and it has
the additional advantage that it does not require sterile blood.
The sulphuric acid is a very powerfu antiseptic and rapidly
Resultant growth.
Copious confluent growth.
« it n
(sot quite so heavy!)
Copioss growth of small colonies.
Quantity of
fluid added.
1 e.cm.
0*5 „
0*25
might allow the growth of this bacillus while inhibiting the
growth of the cocci which commonly exist in the sputum.
Agar was made up containing some of the clear fluid
obtained by boiling blood and water, and to this was added
brilliant green in a strength of 1 in 500,000. On this was
planted B. influenza ,staphylococci, streptococci, and pneumo¬
cocci. After inoubation a profuse culture of B. influenza
was obtained, whereas all the cocci were completely inhibited.
I suggest, therefore, that suoh a medium might prove
extremely valuable in isolating B. influenza from a sputum
where it occurs, as it commonly does, mixed with strepto¬
cocci or pneumococci.
A medium for preserving the vitality of B. Influenzae.—In
certain quarters there has been difficulty in preserving alive
cultures of B. influenzas.
If this bacillus is planted into minoed meat medium suoh
as is commonly used for growing anaerobes to whioh a little
blood has been added, it will preserve its vitality for a con¬
siderable period. Subcultures from this medium after six
weeks gave growths as copious as after two days.
Summary .—Very profuse growths of B. influenza can be
obtained (1) from blood boiled in agar; (2) from agar to
which has been added some of the clear colourless fluid
resulting from boiling blood in water; (3) from agar to
whioh has been added blood which has been broken down by
a strong mineral aoid. If a strong mineral acid is used to
break down the blood sterile blood is not required. The
substance which stimulates the growth of B. influenza is not
the coloured fraction of hsamoglobin.
By the addition of brilliant green to tbe medium pneumo¬
cocci, streptococci, and staphylocooci are inhibited to a
muoh greater extent than is B. influenza.
Cultures of B. influenza oan be kept alive for a considerable
period on a blood meat medium.
All the patients tested who were suffering from influenza
agglutinated B. influenza.
J Further work In this direction has shown that different strains of
B. influenza differ markedly in their agglutination reactions, Soma
■trains were readily agglutinated by patients’ sera, while others were
unaffected. The serum of a rabbit inoculated with one strain agglutin¬
ated only this strain and one other out of 20 different oultnres t e sted .
140 ThhLanobt,]
CLINICAL NOTES.—MEDICAL SOCIETIES.
[Jan. 26,1919
Climtal Slates:
MEDICAL, SURGICAL, OBSTETRICAL, AND
therapeutical;
A CASH OF
CANCER OF THE CAECUM WITH PELVIC
ABSCESS AND GANGRENE OF RECTUM.
By J. K. Haworth, M.D., B.S. Durh.,
CAPTAIN, R.A.M.O.(S.R.); SURGICAL BPKCIALIST, 8th (LUCKNOW) DIVISION.
The following case may be of interest.
Private D., age 46, was admitted from tbe medical ward,
Station Hospital, Lncknow, with a large sinus discharging
fffioes and pus about & inch to right of anus and communi¬
cating with the anus. Patient bad been ailing with hectic
temperature and general debility and loss of weight for some
weeks before reporting sick. Abdomen flaccid and nothing
palpable. The only physical signs were the sinus and the
marked debility.
An operation was performed on July 26th. The sinus was
,explored and found to lead to a large abscess cavity in the
pelvis in which the lower end of the rectum was almost free,
triable, and gangrenous. A large tube was inserted. The
patient died some hours later. At the post-mortem exami¬
nation a large soft, fungating oanoer was found in the
osscum. In the pelvis was a large abscess cavity with rectum
sloughing and gangrenous in it. The growth was causing no
obstruction.
The explanation appears to be that the glands in front of
the sacrum had suppurated and the pus tracked down the
rectum, opening into it and involving it, and finally finding
exit near the anus wall.
A CASE OF ECTOPIC GESTATION WITH AN
APPARENTLY IMPERFORATE HYMEN.
By S. G. Papadopoulos, M.B., B.S. Lond.,
M.R.O.S., L.R.C.P. Lond.,
RESIDENT SURGICAL OFFICER IN CHARGE OF SURGICAL OUT-PATIENT
DEPARTMENT, THE MILLER GENERAL HOSPITAL FOR SOUTH-EAST
LONDON, GREKNW1CH-ROAD, 8.E.
An ectopic gestation is a fairly uncommon condition, and
a hymen which at the time of the operation is imperforate is
also rare. A combination of the two makes the case so out
of the common that I consider it worth publishing.
The patient, a voang woman of 28, married 6 months, was admitted
on August 19th, 1918, with a history that on the 5th of that month she
was taken suddenly 111 with a severe attack of abdominal pain, that she
soon became faint, and very pale. Her usual medical attendant was
called in who ordered her to bed for a week. On August 11th she first
lost blood and as she was getting worse she was »ent to this hospital.
Bhe also stated that she never had any discharge per vagina, hut that
she used to menstruate once every & days. During the last two
months she had not done so.
On examination she was very pale, pulse 98, temperature 99° F. There
was a Urge swelling at the left lilac region ; the abdomen wa« rigid and
tender on palpation. The vulva appeared normal. The hymen was
anrnptured and very resistant, and at that time one could find with
difficulty a tiny aperture permitting the entrance of a fine probe, from
whlc’i a dark, tar-like fluid was esc ping. The vagina was patent, for
on pushing the hymen with the finger one could lnvaglnate It and the
lower end of tbe vagina up «ard like an Invertedglove.
I performed laparotomy shortly afterwards. There was free blood In
tbe peritoneal oavity aud large pieces of blood-olot were surrounding an
enlarged uterus, rhe size of a two months pregnancy. These clots
were swabbed out, and the Fallopian tube (left), which was very
enlarged, was found imbedded In the organised clot. The whole mass
was adherent on tbe rectum and anteriorly In the utero-vesical pouch,
whl»h was carefully separated. From the nxture of the adhesions it
seems that gestation continued after the Fallopian tube was ruDtured
and the foetal sac ruptured later. Tbe left ovaiy was also imbedded in
the mass and the whole Fallopian tube, sac, olot, and ovary, were
removed, and the stump firmly tied In the usual way. The patient
made an uninterrupted recovery.
On 9ept. 13th a p'sstlc operation was performed on the valve. On
examination of the bvmen, under anaesthetic, It was found that it
formed a oomp'ete sentum, completely oloslng the vagina without any
signs of aoerture or even sear I I therefore pinched It at Its middle
with toothed forospa and cut a small opening into It. A little tar-like
fluid escaped, and with the finger It was found that the vagina was
normal, and therefore the considerably thickened membrane was
removed with solss rs and the raw edge stitched by a continuous catgut
suture leaving a normal-sized canal. The patient Is now completely
well and back to her domestic duties.
There is no doubt that the menstrual flow was delayed iu
the vagina eaoh time until the pressure prodnoed tem¬
porarily a little puncture through which fluid ooald escape,
and that conception took place at one of these periods.
From tbe condition of the hymen it is obvious that no proper
sexual intercourse could have taken plaoe, but in spite of
that abnormal pregnanoy occurred.
SJfMoI Sandies.
ROYAL SOCIETY OF MEDICINE.
The Management of Venereal Diseases in Egypt during the War.
A GENERAL meeting of Fellows was held on Jan. 20th,
when an illustrated lecture was delivered by Sir James W.
Barrett, Lieut.-Colonel, RA M C., on his own experience
in the management of venereal diseases in Egypt during the
recent war. Sir James Galloway occupied the chair.
Commencing with a brief reference to the history of
venereal diseases in Australia prior to the war. Sir Jambs
Barrett stated that efforts to combat these diseases began in
1896 and culminated in 1910 with an investigation made by
the Government at Melbourne. The results of this were so
impressive that clinics were established, an educational
campaign instituted, and. probably for the first time, news¬
papers opened their columns to communications on the
subject, couched in technical terms. Little result followed
this early effort, and a committee was then formed to work out
the details of prophylaxis, while pressure was brought on the
leading chemists of the city to place calomel ointment on sale
for this purpose. Ministers of State and ministers of religion
were approached for their support, but many of the latter
did not approve of the steps proposed. It was, however,
arranged for a committee of clergy to be taken to the
asylums to see cases of general paralysis and locomotor
ataxia, to visit hospitals and clinics, and further work in this
direction was contemplated when war broke out and the
lecturer left for Egypt. On his way thither Sir James
Barrett gave lectures to the men on the value of continence,
pointing out that if determined to expose themselves to
infection they must take precautionary steps. Iu January,
1915, venereal diseases were very prevalent in Egypt, and
the military authorities were keenly anxious about the
health of the troops. The troops were then occupying the
Delta, and here it was that the diseases were contracted.
Afterwards when the Army reached Gaza, and in 1917 when
the Turkish lines were broken through, a new problem arose
with the appearance of considerable numbers of new
infections. The lecturer held that trouble might
have been expected in the case of troops coming
from a dominion where discipline was not pronounced
and thrown into an Eastern country like Egypt and
surrounded by every inducement to sexual intercourse,
natural and unnatural. When the break-through occurred
in Palestine venereal diseases were more easily kept under
control, the lines of communication being then 600 or 700
miles long. Here the lecturer interpolated the remark that the
military campaign was iu essence a fight against malaria, an
enemy which bad previously arrested Mark Antony, hindered
Trajan, destroyed the Crusaders, and impeded Napoleon.
The Measures Adopted and their Resvtts.
Sir James Barrett on his arrival in Egypt was invited
by General Bird wood to do anything he oould for the
Australian troops, who were being infected at the rate
of 800 or 1000 men a day, social and moral measures
alone being permitted. He visited every ship arriving
in port, the men being forbidden to leave until he came
on board. A leaflet of advice was handed to each
man warning against the perils of native alcohol and of
exposing themselves to venereal infection, and the position
was fully explained to the officers without going into the ques¬
tion of prophylaxis. In the hospitals, on the other hand,
besides enlightening literature, the men were provided
with prophylactic outfits consisting of calomel ointment.
On the value of prophylaxis being challenged, an examina¬
tion of those Australian troops who had been supplied
with outfits established the fact that out of a group of
200 men exposed to infection only one contracted disease,
and he had not taken precautions. In the lecturer’s
experience primary prophylaxis had been practically certain
in its results. But, at, the same time, Sir James Barrett
emphasised his view that no educational opportunity should
be neglected. He showed pictures illustrating the huts and
converted buildings usedjas social and athletic clubs for the
troops in order to provide counter attractions. All this had
been done in association With the Y.M O.A., which had per¬
formed invaluable work s following the men high up to the
front line and erecting pots there for their comfort and
The Lancet,]
LONDON ASSOCIATION OF MEDICAL WOMEN.
[Jan. 25,1919 141
diversion, and organising clubs. Social advantages were
thus kept close to the men during the whole of their
advance. During the latter half of 1915 Sir James Barrett
was invalided for a time to England, and there was a period
when the work was not pushed, bjit the result was that an
intense moral and restrictive campaign, together with con¬
structive work in the establishment of magnificent soldiers'
dubs, produced a moderate amelioration and tolerable
decency.. But where prophylaxis 1 was properly taught and
applied venereal diseases were practically non-existent. At
the end of 1915 the men returned from Gallipoli and moved
to France, when infections became more numerous. The
Australian troops returning from the Dardanelles in the
first five months of 1916 included 10;000 with venereal infec¬
tions, and at one time the average infection rate was
25 per cent, per annum. After the adoption of measures
which included penal measures against unnatural offences,
public indecency and pimping, the control of advertisements,
the restriction of the sale of alcohol, the strict medical
examination of prostitutes, the provision of ablution rooms,
and the supply of prophylactics, the infection rate became
reduced to very modest proportions. On the march into
Palestine the moral and prophylactic campaigns were com¬
bined, and in the latter half of 1918 the disease was
checked. Whilst these events were taking place throughout
Egypt, at Port Said martial law was proclaimed by Lieu¬
tenant-Colonel Elgood, and prostitutes were excluded from
European quarters. The women who would not leave Port
8aid were confined to the Arab quarter, under the Egyptian
Public Health Department. An end was put to the white
slave traffic discovered by the censor, and the women were
examined. But soldiers still became infected from women who
were reported free of disease.
Whatever the measures taken, the disease could not be
stopped altogether, and so long as intercourse took place
without precautions venereal diseases would necessarily
result. But the value of prophylaxis emerged. In one
camp through which 9282 troops passed 4500 men reported
exposure to infection, and as a consequence of early pre¬
ventive treatment only 13 infections resulted. The lesson
taught by experience in Egypt was that all social methods
combined resulted only in a limited reduction in the
incidence of venereal diseases, and that unless some form of
prophylaxis was adopted many infections were certain to
result. From the establishment of venereal centres in this
country Sir James Barrett anticipated nothing but good.
The ethical side of the problem, so far as it concerned medical
men, was the wholesale infection of the innocent, and Sir
James Barrett could see no immorality in the prevention of
venereal diseases by prophylaxis, or any value in a morality
dependent upon the fear of consequences. If normal desire
was to be satisfied marriage must not be postponed until the
summer of life, or irregular unions would be formed. The
matter, the lecturer concluded, lay largely in the hands of
women; if they revised their standards of value and did not
observe the existing and artificial social assessments, much
of the existing sexual problem would speedily be solved.
Discussion.
Dr. Otto Mat, who was in general agreement with the
remarks of the lecturer, pointed out that at the present
time we were concerned less with the actual restriction of
the disease in the Army than with the evil among the
civilian population. The danger of demobilisation was now
generally recognised, and the Local Government Board was
planning the establishment of a large cumber of treatment
centres. He hoped that each county oouncil and each
county borough council would establish a full-time venereal
clinic open day and night and every day, and that provision
for early preventive treatment would be established at these
clinics. In theory this solution of the problem was admir¬
able, provided people could be induced to attend there for
early treatment. In practice, however, it was a failure, for
it would take almost a year before the clinics could be in
working order. There was also the difficulty of pro¬
viding an adequate staff. But even if every town
had a clinic we should be a long way from solving
the problem, because people would not go immediately
after connexion for early treatment. The only reasonable
alternative was to authorise the distribution of prophylactic
outfits. The sale of drugs for thfe purpose was now illegal,*
• sate under the advice of a medical man, and Dr. May
aoggested that the Local Govemnent Board or its successor,
the Ministry of Health, should make this question its own
particular subject. The disease would not be wiped out
altogether by the use of prophylactics, but that was no excuse
for passivity, and there could be little doubt that a great
diminution would follow if these steps were taken promptly.
Professor J. G. Adami paid a tribute to the work of
Sir James Barrett, which had, he said, exerted a profound
influence in America and Canada.
Sir James Galloway laid stress on the present difficulty
of getting a complete staff for venereal clinics; there were
not sufficient trained pathologists and bacteriologists avail¬
able. The question of proper remuneration also demanded
consideration.
Professor Adami suggested that non-commissioned officers
of the R.A.M.O. might be employed to give instruction at
the centres under the supervision of a medical man.
In replying, Sir James Barrett said that a forceful and
intelligent presentation of the case to the public was neces¬
sary before it could be induced to, spend money on the
prevention of disease.
LONDON ASSOCIATION OF MEDICAL
WOMEN.
The Future of the Medical Profession.
A meeting of this association was held on Jan. 14th at 11,
Ohandos-street, Lady Barrett, the President, in the chair.
Dr. Jane Walker opened the discussion with a paper on
“ A State Medical Service," in which she referred to the
need for a Ministry of Health, with the medical profession
organised into a whole-time salaried service on the lines of
the higher branches of the Civil Service, but admitted that
there would be a transition stage with some part-time and
some whole-time workers. Dr. Walker then drew attention
to some of the well-known disadvantages of general practice
as it is now conducted—the uncertain hours, the difficulty
of making a sufficient number of visits in many cases of
illness, the powerlessness of the profession in dealing with
such evils as bad housing and the inroads made lately
upon general practice, as in the treatment of tuber¬
culosis and venereal diseases, and in maternity and child
welfare. In a State Medical Service provision would
be made for full hospital opportunity for all patients, for
study leave every five to seven years, and for each medical
officer to rise according to his merits and in the direction in
which his talents lay. The medical profession was now too
great to acquiesce in the plan whereby eaoh man and woman
competed with his neighbour; it should organise itself so as
to ensure the greatest public welfare.
Dr. Chribtine Murrell spoke on* the position of the
general practitioner in domiciliary treatment as a link
between consultants, and to the advantageous position which
he sometimes has over the medical officer of health in dealing
with such evils as slum property. She referred to the conduct
of American clinics on a collective system, in which treat¬
ment was open to all, with payments according to means,
and assessed by almoners.
Dr. Jessie Campbell spoke on methods by which the
standard of work in general practice might be raised. She
advocated part-time appointments for such work as infant
welfare, school treatment centres, and the treatment of
tuberculosis and venereal disease. This would keep the
general practitioner more up-to-date than attending post¬
graduate courses.
Dr. Dorothy Hare said that the standard of work in
general practice dropped because practitioners worked alone,
and so lost mental stimulus, and that they found it difficult
to try new treatment owing to want of moral support such as
they would have in a hospital.
An interesting discussion ensued in which the following
took part: Dr. Ruth Bensusan-Butt, Dr. Dickenson
Berry, Dr. M. Cockerell, Dr. 0. Lbwin, Dr. Meakin
Herford, Dr. L. Fairfield, and Lady. Barrett.
At the last meeting of the Edinburgh University
Court, Dr. Dawson Turner was appointed additional
examiner in medical physios.
Literary Intelligence. —P. Blakiston’s Son and
Co., Philadelphia, announce a second and revised edition
of the American Red Cross Text-book on First Aid, by
Colonel Charles Lynch, U.S.M.C.
142 Th a Lancet,]
REVIEWS AND NOTICES OF BOOKS.—NEW INVENTIONS.
[Jan. 25, 1919
Jlelmfos attb Jtfltices of $ooks.
The Soldier's Heart and the Effort Syndrome . By Thomas
Lewis, M.D. Lond. London : Shaw and Sons. 1918.
Pp. 144. Is. 6 d.
Into this small book Dr. Lewis has packed much informa¬
tion. As is his wont, he writes only of those things he has
himself found to be true, and he sets these down in a well-
knit form easy to apprehend. His experience of cardiac
disabilities in soldiers is probably unrivalled, and this book
is therefore one which no one handling these problems can
afford to do without. It is written especially to help
members of invaliding and pensions boards, and this purpose
is admirably fulfilled.
Dr. Lewis’s main thesis is that the “soldier’s heart”
syndrome is made up of the same subjective and objective
components as follow strenuous exercise in healthy men.
In the exhausted soldier, however, the point of cardiac
distress is much more easily reached. For its causation this
exhaustion depends on several factors, some inherent, some
acquired. It is to be detected mainly by testing the man
with physical exercises. These, if graduated, constitute a
means of prognosis as well as of treatment. They are also
applicable to the recruiting problem. These arguments, with
tabulated results of the treatment based thereon, and much
sound advice as to the discernment of organic heart disease,
constitute the bulk of the book. It appears at an opportune
moment, for one of the great tasks which the Pensions
Medical Service (if and when we have one) must tackle is
that of assessing fairly the claims of the man with a cardiac
disorder or lesion. The book is clearly printed, and can be
read in two or three evenings.
what is really being thought will value the little book and feel
thankful and friendly towards its author. In a somewhat
different vein to most of the book is an “ essay in little, ” called
“ The War and Kensington Gardens,” which Mr. Street says
should have been really a sonnet or sonnet sequence. It
would be pleasant if the author would try his hand in that
mode ; he has not only the deftness and delicacy but also
the power which make up the true sonneteer.
A Health Reader for Qirls. By Agnes L. Stbnhouse
and E. Stenhouse, B Sc. Lond. London : Macmillan and
Co., Limited. 1918. Pp. 190. 3*.—This is an excellent little
book in which the subject of health is dealt with in the
simplest language. The body is first described, after
which an account is given of food, digestion, care
of the teeth and cleanliness, clothing, breathing, ventila¬
tion, the blood, the nervous system, and special senses.
The only chapter to which we take exception is that on the
Food of Babies. Milk is not necessarily sterile after being
stood in a pan of boiling water for a quarter of an hour.
The information given on preparing the baby’s food, on the
amounts which should be given, and on the times of feeding is
long out of date. No special dilution and no definite amount
of food is now given to a baby of a certain age, and, though
these instructions may be useful in helping to prevent
disasters, it is a mistake to put a hard-and-fast rule on record
in a book which may be referred to in the home, or to give a
mother the idea that her baby can be fed by any rule-of-
thumb method. Babies’ digestions, like babies themselves,
are not all made on one pattern.
JJUfo fnbenthras.
A 14 DROPPED-FOOT ” APPLIANCE.
LIBRARY TABLE.
Kala-azar, Us Diagnosis and Treatment. By Ernest Muir,
M.D. Edin., F.R.C.S. Edin. London and Calcutta : Butter-
worth and Co. 1918. Pp. 38. Rs. 2.—This little book is intro¬
duced by Sir Leonard Rogers, and is written with the object
of supplying to the medical practitioners in small towns and
villages in India a guide to the diagnosis and treatment of
this very prevalent disease. Until lately kala-azar was
almost always fatal, but Dr. Muir considers that if the con¬
dition be treated by the intravenous injection of soluble
antimony salts, as advocated by Sir Leonard Rogers,
“ recovery may be expected in almost all cases where
the treatment is begun in time and carried out
efficiently.” Having considered the question of diagnosis,
the author describes*- his method of treatment, which
he divides into four divisions : (1) the production of
leucocytosis by the intramuscular injection of turpentine,
camphor, creosote, and olive oil ; (2) the destruction of
parasites by antimony salts ; (3) the treatment of complica¬
tions ; and (4) general tonic treatment. The work should
be useful to those who are actively engaged in dealing with
kala-azar, as the technique of various operations, such as
spleen puncture and the intravenous injection of antimony,
are described in detail.
At Home in the War. By G. S. Street. London:
Heinemann. 3#. 6 d .—The normal psychological attitude
displayed towards the war, as it went on, by middle-aged
men averagely endowed for comprehension and sympathy is
probably a fair definition of the thing which Mr. Street was
trying to express in this little book. He has been misled by
his modesty if he thinks that his description of such an attitude
represents the average man’s ability. Such remarks as this :
“It is a universal foible of humanity to exaggerate the
work of what you know and another man does not know ;
the vanity of special knowledge is seen everywhere ”; or the
analysis of the anti-national spirit in the paper entitled
“ Our Intellectuals,” are in their neat and terse manner
expressions of what mo9t of us would be proud to say half
as well. The “Revanche” for middle age, in the paper called
“ The War and Age,” is a specimen of the author’s pleasant
humour. On page after page one finds set out with lightness
and charm some thoughts of which most middle-aged men at
home have been conscious without being able to define them.
Mr. Street holds up to many of us a mirror from which the
haze obscuring our real thoughts has been skilfully wiped
away. Many quite conscious of an imperfect realisation of
We have received from Mr. Frank Jenner, surgical boot¬
maker, Christchurch-road, Boscombe, au appliance intended
to enable the sufferer from “dropped foot” to walk with
ease and comfort. It consists of an iron framework formed
of two sickle-shaped arms joined together at the straight
ends by a short transverse bar passing under the sole of the
boot and close to the heel, to which it is affixed by a flat
broad hook. The straight parts of the sickle-shaped
sides pass upwards towards the ankles, the bend in
the sickle allowing
for the protrusion
of the malleoli.
The framework
is kept rigid
and in place by
a strap passing
round the back of
the boot. The free
ends of the frame¬
work are joined to
the front part of
the boot by spiral
springs at points
at either side of
and at a level with
the bottom of the
laced opening. These springs can be adjusted so as to
correct any tendency to inversion of the foot or the opposite,
and the whole apparatus can be adapted to any sized boot.
The appliance, which costs 15s.. is ingenious and may
proYe useful in practice—we are informed that it has been
used with satisfaction at the Boscombe Military Hospital—
but it seems to us that the upper portion of the lever is too
short, consisting as it doei only of the part corresponding to
the last inch of the tibia and that the pressure of the strap
over the tendo Achillis cal hardly fail to be excessive if the
device is to keep the toe fipm dropping. The hooks, too, by
which the springs are connected with the boot do not seem
very well adapted for haid wear. These criticisms, if in
practice they are found to be just, can be readily met.
TB> Lanobt,]
THE PSYCHOPATHIC CRIMINAL.
[Jan. 25,1919 H3
THE LANCET.
LONDON: SATURDAY , JANUARY 25, 1919
The Psychopathic Criminal.
Amongst the problems to*'which the war has
given a new aspect and an added urgency the
treatment of the mentally defective and unstable
criminal is one of considerable importance.
Large numbers of men will be returning to this
country or will be coming out of the military
hospitals while still suffering in some degree from
mental and nervous disabilities brought about by
the unexampled stresses of modern warfare. It
may be anticipated with a fair measure of assurance
that in many cases the mental enfeeblement of these
invalids will be manifested by disorders of conduct
of more or less gravity, bringing them into
conflict with the law; and several instances of
this kind have, in fact, come before the criminal
oourts within the last few weeks. Public opinion
will not tolerate the treatment of these war victims
by the indiscriminate methods which have been
applied to the general mass of law-breakers. The
demand will certainly be made that in every
such case full consideration should be given to
the mental condition of the offender, and that he
shall be dealt with on curative lines adapted to his
individual needs, and not merely by the stereo¬
typed punitive and repressive measures which up to
the present have been the sole resource of the
law. To satisfy this demand, which can obviously
be urged with no less force in regard to other
categories of psychopathic delinquents, it will be
necessary to introduce an entirely new spirit into
the system of procedure in criminal cases and to
recognise to a far greater extent than in the past
the importance of the help which the expert in
morbid psychology can give in the administration
of justice.
A proof of public opinion in this direction is
supplied by the proposals in a report which was
submitted to a meeting of the justices of the City
of Birmingham on Jan. 2nd of this year by their
General Purposes Committee. This report, pre¬
sented by Mr. Gbrald Beesly, deputy chairman of
the justices, voices the dissatisfaction which has
been felt by the Birmingham magistrates—a dis¬
satisfaction which has doubtless been shared by
magistrates in other parts of the country as well—
st being compelled to deal with criminal cases
Without having any regular facilities for obtaining
expert advice touching the mental condition of
the offenders, and without adequate means of
giving effect to such advice even if it were
obtainable. In the opinion of the com¬
mittee, this deficiency in the legal machinery
had been an important factor in the relative failure
of the existing penal system as a reforming agency
snd as a preventive of recidivism. With a view to
organising a more satisfactory method of treatment
the committee have put forward a number of
valuable suggestions, which they divide into two
categories—those which are immediately practic¬
able, and those which can only be carried out by
special legislation. Of the proposals under the
former heading the most important is the recom¬
mendation that a physician with expert knowledge
of psychiatry should be attached to the court, with
whom the justices can confer and take counsel in
any particular case. It is interesting to note, as
bearing on this suggestion, that a similar system
was introduced in 1914 at the instance of Chief
Justice Harry Olson, in connexion with the
Municipal Court of Chicago. Here a psycho¬
pathic laboratory was instituted under the
direction of Dr. W. J. Hickson, for the examina¬
tion of accused persons presenting indications
suggestive of mental abnormality; and according
to the recent reports of the Court (Tenth and
Eleventh Annual Reports of the Municipal Court of
Chicago) the results obtained have been such as to
convince the judicial authorities of the practical
utility of psychiatric assistance, not only in
deciding as to the treatment of offenders. but
also, in many cases, in assessing the reliability of
witnesses. It is difficult to think of Chicago as a
field for the propagation of academic theories and
doctrinaire views ; and the fact that the authorities
of this typically business centre have been moved
by scientific psychology to consider the proper
treatment of the criminal justifies the attach¬
ment of considerable weight to such testimony
to the value of psychiatry in the administration
of the law. The example of Chicago should
encourage the citizens of Birmingham to carry
out the interesting experiment which they have
projected. They will, of course, be impeded in
this enterprise by the fact that, in the present
state of the law, only very limited means exist
for applying differential treatment to the various
categories of mentally defective and unstable
offenders; but the accumulation of definite data
regarding the relation of mental abnormality to
crime, which this scheme should provide within a
short time, will in itself be of considerable value
in educating public opinion, and will do much
to further the adoption of the legislative reforms
which they advocate.
These reforms are set out in Mr. Beesly’ s report
as follows:—
1. The provision of “ places of detention ” for observation
of oases of mental instability, instead of prison on remand.
2. The provision of farm colonies and the like for oases
whioh cannot be dealt with under the Lunacy or Mental
Deficiency Aots, instead of prison.
3. The establishment of a consultative olinic, associated
with the administration of justice, with expert medical
practitioner and lady superintendent in oharge, for voluntary
treatment of cases where some form of mental weakness
is exhibited, and to which the friends or relations of the
person affected might appeal for help and guidanoe.
4. The clinic might also: (a) Assist in determining how
far more or less recidivist criminals submitted for examina¬
tion by the police are fit to be at large; (b) examine persons
suffering from * 4 borderland insanity,” whether submitted
by publio authorities or by their relatives, prescribing [or
certifying) appropriate treatment where mental instability
is established; (c) deal with feeble-minded women and girls
who have borne illegitimate ohildren, or have beoome
infected with venereal disease.
5. Amendment of the Mental Deficiency Act, 1913, espe¬
cially by extending its operation to cases of mental debility
other than those existing “ from birth or from an early age.”
These proposals should find general acceptance as
indicating the principles to be kept in view in
reforming our present methods of dealing with
mental weakness which leads to anti-social conduct.
Such modification as they may need in detail will
144 Thh Lanobt,]
THE ROLE OF THE CATALYST.
[Jaw. 26, 1919
be more clearly perceived when the immediate
action contemplated by the Birmingham magis¬
trates has given a more accurate and more compre¬
hensive view than we have yet obtained of the
nature and dimensions of the problem. It will
then be possible to decide, for instance, whether
such a psychopathic clinic as suggested in
the Birmingham scheme should be primarily
associated with the administration of the criminal
law, or whether it might not be preferable to
institute it in connexion with a general hospital,
or with an out-patient department attached to an
asylum for the insane. On this and on other
points the decision ultimately arrived at will, no
doubt, be determined very largely by the extent
and character of the reforms in lunacy administra¬
tion which will inevitably form part of the coming
reconstruction of the health services of the nation,
and which are urgently needed to bring psychiatry
into closer touch with other branches of medicine.
Meanwhile we may cordially congratulate Mr.
Beesly and his coadjutors on their initiation of
an experiment which, in addition to its imme¬
diate practical results, should do much to stimulate
the public demand for a wider application of
scientific methods in dealing with the problem of
criminality.
— ■ - ■ — ♦ ■■ ■
The Role of the Catalyst.
The catalyst is assuming an importance no less
in medicine than in industries. Chemists long ago
found out the peculiar action of a third party
in promoting chemical interaction. The classic
example is that of the preparation of oxygen gas
from chlorate of potassium. The fused mass of the
salt, with heat still applied to it, yields its oxygen
reluctantly, but at that point it is dangerous to intro¬
duce a trace of manganese dioxide since at once
the evolution of oxygen becomes explosive though
the manganese remains unchanged. An earlier
example of catalysis was the Dftbereiner lamp, in
which spongy platinum was the catalyst effecting
the union of a mixture of hydrogen and oxygen at
such a speed that ignition was the result. The most
remarkable catalyst of all is water, without which,
it has been shown, combustion or oxidation is impos¬
sible. Similarly the louse is a catalyst in respect of
man and trench fever. Catalysts, briefly, are pro¬
moters of chemical action for reasons not yet fully
explained. They may function equally in the
relatively cold or under conditions of high tem¬
perature. The remarkable behaviour of catalysts
in the human body at its normal temperature illus¬
trates the importance of their action in promoting
healthy nutrition, which after all means the complete
chemical assimilation of food substances.
We have much yet to learn as to the nature of
the action of the accessory factors in food—for
convenience called vitamines—which serve as anti-
neuritic and antiscorbutic agents. It is conceivable
that in the chemical sense they act as catalysts—
that is, as a third party, rendering the potentialities
of food available for che maintenance and growth
of the organism. It is known, at all events, that
they occur in quite minute proportions, in spite of
which they prove to be essential to growth. When
we consider the very remarkable results pro¬
duced in great industrial processes by the agency
of the merest trace of a third party, the catalyst,
out views are strengthened as to the importance
of a certain factor present in however minute
quantity* There is good reason for suggesting that
the vitamines are catalyst! just as are the enzymes,
whose action in many respects resembles that of
inorganic catalysts, particularly in the colloidal
state. Dr. G. G. Henderson, in a recent valuable
treatise on Catalysis in Industrial Chemistry, 1 says
that the term “ catalysis ” is now generally used to
designate those chemical changes of which the
progress is modified by the presence of a foreign
substance, and he further points but that it has
for long been known that the velocity of many
chemical reactions which take place very slowly
if the reacting substances alone are present
in the system is greatly increased by the addition
of certain substances, which have the same
composition after the change has been completed
as at the beginning, and which therefore appear
to influence the course of the reaction without
taking any definite stoicheiometric part. This
definition would appear to include all accessory
food factors as catalysts, having no direct nutritive
value themselves, but serving as promoters of a
nutrient consummation.
The application of catalysts in industrial opera¬
tions is growing very rapidly in importance, and the
behaviour in many respects of the catalysts
employed shows a curious parallel to well-
known physiological phenomena. Traces , of
arsenic, mercury, sulphur, hydrocyanic acid,
“ poison ” in so many cases the catalysts’ activities,
and there are also negative catalysts which inhibit
the action of positive catalysts not by “ poisoning ”'
them but by neutralising their potentialities. as
acid does an alkali. Sir Edward Thorpe, writing
in his introduction to the excellent “ Monographs
on Industrial Chemistry ” now being issued,
says an obscure phenomenon like catalysis is
found to be capable of widespread application
in manufacturing operations of the most diverse
character. The phenomenon may be obscure,
but its applications are suggesting great possi¬
bilities in arts and industries which are bound
to have an important bearing on the commercial
prosperity of this country. The catalyst, in short,
promises to open a way to important economic
productions, as witness the hardening of liquid
fats for food purposes, the production of fertilisers
from the air, and the output of many valuable
commercial products. The advances made and the
vista opened up by the study of catalytic action,
though confined largely to industrial processes,,
should persuade biologists, as well as biological
chemists—we see no dividing line between these
two schools of workers—to accept a cue which,
followed, may lead to results in the study of life
processes of immeasurable importance. The part,
played by conceivably a catalyst in human nutri¬
tion may, when thoroughly investigated, enable us
to adopt a regimen which will seoure for certain
patients a dietary in which the supply of accessory
factors is well represented. It is a matter of
history that industrial developments have been,
shown to give a helping hand to medicine—the.
coal-gas industry with its output of antiseptics,
synthetics, and colours, the brewing and wine
industries which formed the basis of Pasteur's suc¬
cessful researches are esses in point. The prominent
place which the catalyst is rapidly taking in indus¬
trial advances will shed a light on the chemistry of
the human mechanism, Its liabilities, and the factors
which count in its healthy maintenance.
1 Catalysis in Industrial Ctyemltry, by G. G. Henderson, X.A., D.Sc.,
LL.D., F.S.S. Longmans, Grain, and Co., London, 1919, pp. 202,
price 9». |
] 46 m Lakott,] SPECIAL CLINICAL MEETING OF THE BRITISH MEDICAL A88<»CIATION. [Jan. 25, 1919
typhoid vaccine only, and in 3 over 12 months had passed
since inoculation.
Of the 12 para. B inoculated twice, 2 were inoculated
with the simple vaccine only.
1917-1918 (Triple Typhoid Vaooine.)
No. of men.
Inoculated onoe.
Inoculated twioe.
20,910 ...
... 1486
19,424
Total oases of enterios, 96, comprising 79 typhoid, 6 para.
, and 11 para. B:
Typhoid. Paratyphoid A. Paratyphoid B.
Inoculated once .
6 .
— . 2
Inoculated twice.
.. 12 .
2 . 2
Not inoculated .
.. 61 .
Deaths,
4 . 7
Inoonlated twice.
1 .
— _
Not inoonlated .
5 .
1 . —
. Of the 12 typhoid cases who had been inoculated
twice, in 9 of them over two years had elapsed
since being last inoculated, but in one the period
was only 10 months, and this case was fatal. Of
the two para. A, one had been inoculated six
months before and one a little over a year, showing
comparatively slight protection from this form of
the disease. Of the two para. B, in both the
cases the inoculations had been given over two
years previously. The results show that the pro¬
tection for typhoid and para. B is good, but at
least two inoculations are required, and that
reinoculations should be made not later than
18 months. _
THE SPECIAL CLINICAL MEETING OF THE
BRITISH MEDICAL ASSOCIATION.
The customary annual meeting of the British
Medical Association has not been held during the
last four years. That meeting was formerly
arranged with domestic and general subdivisions \
the domestic consisting of the meetings of the
Council and of the Representatives, and dealing with
the internal work of the Association, the general
consisting of the sections prepared to discuss the
clinical and scientific work of thg year. During
the war the sectional debates on the various
branches of professional learning have not been
held, as so many prominent exponents of medicine
were engaged on the medical work of the Navy,
Army, or Air Force, when the annual meeting
resolved itself into meetings of the Council and of
Representatives. At the annual general meet¬
ing at Aberdeen just prior to the war it was
arranged that an annual general meeting, pre¬
sumably of the usual type and scope, should take
place in the following summer in Cambridge under
the presidency of Sir Clifford Allbutt, but as that
date approached it became clear that no adequate
meeting could be held. The University had become
practically a large training camp for staff officers
as well as cadets, and was so denuded of all
accommodation that the hospitality of its walls
could no longer be proffered. Moreover, by this
time all men began to see that the end of the war
was far away. The question of the next annual
general meeting of the Association has been held
under consideration ever since, only the domestic
gatherings being held. And, now that hostilities
are suspended, the position of strain in the medical
profession has been so little relieved that it has
been thought wise to attempt no regular annual
general meeting until 1920, in which year, however,
Sir Clifford Allbutt has announced that the Univer¬
sity is looking forward to entertaining the Associa¬
tion. In the circumstances it has been decided that
a special meeting should be held this year for the
discussion of clinical and scientific subjects, but on
a smaller scale as to sections than "has marked
previous annual meetings. This special general meet¬
ing will take place early iu April, and last for two, or
perhaps three, days. A general committee has been
appointed for its promotion, together with two sub¬
committees, one taking over the organisation and
the other dealing in detail with the programme of
scientific work. The decision is an expression on
the part of the Association that the time has come
to relay old tracks and to make plans for recon¬
struction, even though no attempts at a compre¬
hensive scheme can yet be entered upon. The
meeting will be held in London and its main
object will be to bring'together British workers and
visitors from the Dominions and the United States.
There will be no large disengagement from their
duties before April either of our Colonial or our
American colleagues, so that an exceptionally
strong medical voice ought to be obtained on many
subjects from a series of officers who have studied
war medicine and war surgery on many spots and
from many points of view. Colonel A. M.
Whaley, speaking as United States liaison medical
officer with the War Offioe, has given a warm
welcome to the proposal, which has also received
the support of Colonel J. G. Adami, Professor of
Pathology at the McGill University, Montreal, and
Colonel R. D. Rudolf, speaking for Canada, and of
Colonel C. T. M. De Crespigny and Colonel Bernard
Myers, speaking respectively for the Australian
and New Zealand Army Medical Services. Hearty
acceptance of the proposal has also been received
from Sir William Norman, Medical Director-
General of the Navy, Sir John Goodwin, Direqtor-
General of the Army Medical Service, and Colonel
T.D. Barry, representing the medical administration
of the Royal Air Force. If the scheme of the
meeting is well drawn up, and precautions are
taken only to admit authoritative communications,
the net result for good ought to be .very great. But
those who draft the programme of scientific work
will have to be tactful and firm, for the time at the
disposal of the meeting will not allow for much
duplication of opinion, or any desultory discussion
of the admitted and the obvious. First-hand and
new experiences will have to be given all possible
opportunity for expression.
PUBLIC HEALTH WORK IN EGYPT.
We were permitted to publish in The Lancet
some weeks ago the substance of the report of a
Commission appointed in the summer of 1917 by the
High Commissioner to advise as regards the future
organisation and work of the Egyptian Department
of Public Health. The Commission was composed
of Lieutenant-Colonel Andrew Balfour, Lieutenant-
Colonel G. E. F. Stammers, Mr. E. S. Crispin,
director of the Medical Department for the Sudan
Government, and Dr. Charles Todd, director of
the laboratories in the Department of Publio
Health, Mr. H. Sheridan acting as secretary.
It was referred to the Commission to consider
the present organisation and duties of the Public
Health Department and its relations with other
Government Departments, and to make proposals
for increasing the efltyciency of the Public Health
Department. In these circumstances the Com¬
mission was authorised to call for all necessary
evidence, and was givtn access to pertinent docu¬
ments and records. 1 (The report is now published
by the Cairo Government Press, and we trust that
its highly valuable and practical recommendations
will shortly be acted u|on. __
i See Tax Laaoff, Nov. 23rd, 1918, p. 715.
Thb Langst,]
j THE STORY OF LETHARGIC ENCEPHALITIS.
[Jan. 26, 1919 147
THE STORY OF LETHARGIC ENCEPHALITIS.
The report od Encephalitis Lethargies, issued
under the title of an Enquiry into an Obscure
Disease, by the Local Government Board (New
Series, No. 121), may justly tie claimed as a brilliant
vindication of the application of team-work in the
elucidation of a medical problem. Attention was
drawn to the appearance of the new syndrome by.
Dr. Wilfred Harris in the columns of The Lancet
on April 20th, 1918. The similarity between some
of the symptoms and those which characterise
infection caused by food contaminated with the
Bacillus botulinu8 created a general anxiety which
was natural in the circumstances of the time. A
preliminary 'inquiry was started at once to deter¬
mine whether food contamination could be held
responsible for the outbreak. The result of this
inquiry was entirely negative ; no direct or indirect
evidence of an association of the illness with infection
from food was obtained. On the other hand, certain
features, particularly the pathological examinations,
raised the suspicion that the outbreak might be
one of epidemic anterior poliomyelitis, or Heine-
Medin disease. With a view to determining the
correctness or otherwise of this suggestion the
present inquiry was instituted on a comprehensive
scale. The results of the well-coordinated inves¬
tigation—clinical, epidemiological, pathological,
and bacteriological—are contained in this report,
and the conclusion arrived at is briefly that the
disease is identical with that described by Yon
Economo in Austria and Professor Netter in
France, that it is sui generis and distinct, both
anatomically and clinically, from analogous
affections—e.g., acute poliomyelitis. It belongs
to the class of polio-encephalitic diseases which
are inflammatory in nature, but the inquiry has
not yielded any conclusive evidence as to the
character of the causal agent. When it is con¬
sidered that the organism which causes the
analogous disease poliomyelitis is still a matter for
debate, although thousands of cases have been
investigated from the bacteriological point of
view, it is not surprising that the problem of the
causal agent of encephalitis lethargica is as yet
unsolved. Sir Arthur Newsholme in his introductory
review says:—
“ Although a negative finding is unsatisfactory, and affords
little basis for preventative action, the speedy cessation of
the outbreak makes it necessary, for the present, to leave
the problem at this point. Possibly a larger number of
oases hereafter may supply material for farther epidemio¬
logical and bacteriological researoh and animal experiment.”
Dr. A. S. McNalty, who carried out the clinical part
of the work, makes the arresting suggestion that tjie
relation between acute poHomyelitis and lethargic
encephalitis may be comparable to that between
typhoid and paratyphoid. He also lays stress on
the influence which diminution of resistance in
individuals may have on the “ evolution M of a
disease. The virus may well have been fairly
generally present in the human organism and the
strain of the years of war may have so altered the
resisting powers of certain individuals that an
ordinarily saprophytic organism had become
pathogenic for them. Such a suggestion is made
more probable when the widespread sporadic
distribution of the cases in the recent epidemic
is considered, and this point is very clearly
brought out by Colonel S. P. James in his
epidemiological survey of ihe outbreak. 1 Patho-
i Turn Lancet, 198, li M 837. ~’~~
logical investigations were carried out by
Professor Marinesco, whose services were most
fortunately secured through the Medical Research
Committee, and by Dr. James McIntosh. Both
emphasise the similarity between the lesions
found and those of poliomyelitis—namely, cellular
infiltration around the smaller veins in the basal
ganglia, the upper part of the pons, particularly in
the grey matter of the floor of the fourth ventricle,
and to a much less degree in the medulla. Both
failed to find satisfactory evidence of the presence
of a specific micro-organism, and the intracerebral
inoculation of monkeys with emulsion of diseased
tissues carried out by Dr. McIntosh was void of
result. The only striking pathological difference
was one of localisation. Yet here combined work
supplied the corrective. The masterly analysis of
the clinical differences set forth by Dr. McNalty,
supported as it is by the epidemiological evidence,
leaves no reasonable doubt that the two diseases
are separate entities. Sir Arthur Newsholme and
his coadjutors are to be congratulated upon this
report as an instance of what can be achieved by
orderly scientific investigation.
NATIONAL REGISTER OF POPULATION.
At a meeting on Jan. 6th of the Commission for
the Reconstruction of the National Birth-rate an
urgent appeal was made on behalf of the Registrar-
General by Dr. T. H. C. Stevenson for the establish¬
ment of a national register of population, which
should supersede the many partial registers in
present use. The list already includes, in addition
to the national and electoral registers, the school
attendance and food registers, and those relating
to sickness, unemployment, insurance, and some
others. Sir Bernard Mallet, in full accord
with his predecessors, lay as well as medical,
at the General Register Office, once again
revives the official demand for a complete
registration system on the ground that the
Census, which is the only complete register, is
revised not more frequently than once in ten
years. It therefore rapidly becomes out of date,
and is of little value except for statistical
purposes. Practically all the registers now in
vogue are independently compiled and maintained,
the information contained in each one being
seldom available for the purposes of the others.
The Registrar-General accordingly proposes that a
single master register should be inaugurated which
should include every man, woman, and child in the
country, giving particulars of name, address, sex,
age, occupation, and date of birth, together with
information as to marriage and family. But inas¬
much as no single register could possibly contain
all needful information, it is proposed to link up
each unit with the general register as part of a
coordinated system, providing for the communi¬
cation to each of the special registers of the
information of common interest collected by
the general register, and leaving each of them
to amplify this according to individual. require¬
ments. For this purpose the general register might
record, in code form; the necessary particulars,
and information respecting removals could be com¬
municated to the local branches as required. As
this register would deal with many millions of
names it would have to be arranged in local
sections throughout the country. Nevertheless, it
would be necessary to maintain at headquarters
an index to the local registers everywhere. To this
148 Th* Lancet,]
THB EUROPEAN FOOD SITUATION.
[Jan. 26,1919
central index all births, deaths, and removals would
of course be referred, but it is essential that all
local registers should be controlled and coordinated
by the central organisation.
With the object of allaying the fears already
expressed that th& present proposal would result in
the exaction of family secrets to which objection
might be taken. Dr. Stevenson was able to assure
his hearers that the new proposals did not increase
in any way the statutory information hitherto
demanded from the public. It only altered the
form in which it would be required. The Com¬
mission resolved—
“ That in the view of the National Birth-rate Commission
there is immediate need for the improvement of the vital
statistics npon which all its conclusions must be based by
the formation of a joint register on the lines advocated by
the Registrar-General."
The meeting was presided over by the Bishop of
Birmingham on behalf of the National Council of
Public Morals. The apparently imminent establish¬
ment of a Ministry of Health, and the appoint¬
ment of Dr. Addison and Sir Auckland Geddes
as heads of the departments concerned, would
indicate the present moment as judiciously chosen
for the presentation of the Registrar-General’s
request. This seems to us reasonable and necessary
for the discharge of the additional responsibilities
which the establishment of a Health Ministry would
entail on his department, and for the fulfilment of
which a complete system of registration would be
indispensable. _
THE EUROPEAN FOOD SITUATION.
We have received from the Provisional Com¬
mittee on the European Food Situation (77, Avenue
Chambers, London, W.C. 1) a letter signed by Lord
Parmoor intended to bring the facts of the European
famine, due to the continuance of the food blockage,
before the medical profession and to obtain their
opinion upon its probable results. The facts are
substantiated as regards Vienna by a translation of
an article published on Dec. 27th in the Arbeiter
Zeitung by the vice-burgomaster of the city, and of
the statistical material laid before the Inter-Allied
Commission by the burgomaster of Vienna. The
percentage of deaths attributed with certainty to
malnutrition is given as 7 per cent, or over for each
month since last July, and there is a presumption
that the actual proportion is more than double that
figure. _
During the fourth quarter of 1918 98,998 deaths
from influenza were registered in England and
Wales; this number, though given officially, is
provisional. _
’At a general. meeting of Fellows of the Royal
Society of Medicine, held on Jan. 14th, the condi¬
tions were discussed under which pensioners should
be admissible to treatment in civil hospitals. We
have been obliged to hold over a detailed report of
this important discussion until our next issue.—
The Council of the Society has decided to have a
social-scientific evening once a week for the recep¬
tion of officers attached to the R.A.M.C. and Red
Cross, and officers of the Medical Services of the
Dominions, the United States, and other Allied
Powers. The reception will be held every Wednes¬
day evening at 8.30, when a short informal discourse
will be given, after which it will be free to any
present to raise and discuss any question in which
they are interested. The first discourse will be
given on Wednesday, Feb. 3th, at 8.30 P.M., when Sir
John Bland-Sutton will discourse on Gizzards and
Counterfeit Gizzards, illustrated by specimens.
- f —
Sir Arthur Newsholmefs impending retirement
from the medical officersjhip of the Local Govern¬
ment Board is announced. The good wishes of the
Public Health Service, which he has served so well,
go with him. 1
A course of four lectures on Malaria will be
delivered at noon on Jan. 31st, and Feb. 7th, 14th,* and
21st, in the Lecture Theatre of the Medical School,
King’s College Hospital, by Colonel Sir Ronald Ross.
Officers and men of the R.A.M.C. are invited to
attend. Microscope specimens and lantern slides
will be shown at the two last lectures.
The Council of the National Medical Union
decided in December last to invite a mass meeting
of the medical profession to consider the establish¬
ment of a medical advisory body in connexion with
the proposed Ministry of Health. This meeting,
which will be open to panel as well as to non-panel
practitioners, will be held at the Wigmore Hall,
London, W., on Sunday, Feb. 2nd, at 4 p.m.
A special meeting of the Faculty of Insurance will
be held on Tuesday next, Jan. 28th, at 7 p.m., at the
Central Hall, Westminster, when an address will be
delivered by Mr. E. B. Turner (chairman of the
Medical Committee for Combating with Venereal
Disease) on Venereal Disease considered as an
Urgent Health Problem. Mr. P. Rockliff (President
of the Faculty) will initiate a discussion on
Prophylactic Treatment.
AT the meeting of the Medical Society of London
to be held on Monday next, Jan. 27th, at 8.30 p.m.,
a discussion will take place on “ The Modem
Treatment of Gonorrhoea of the Genito-Urinary
Organs.” The debate will be introduced by Colonel
L. W. Harrison, R.A.M.C., who will be followed by Dr.
D. Thomson, Dr. R. A. Bolam, Dr. A. Cambell, Dr. D.
Lees, Dr. David Watson, and Mr. Campbell Williams,
among others. Medical officers of the Colonial and
Allied Armies will be welcome at the meeting.
THE LANCET, AUGUST 24th, 1918.
The Manager of The Lancet would like to
re-purchase or tb receive copies of the issue. of
August 24th for which readers may have no further
usfe, to enable him to replace copies for libraries
and institutions in India and the East which were
lost at sea owing to enemy action. Such copies
should please be addressed to him at 423, Strand,
London, W.C. 2. _
THE LANCET, VOL. II., 1918: THE INDEX.
The Index and Title-page to the volume of
The Lancet which was completed with the issue
of Dec. 28tb, 1918, is i now ready, and copies have
been supplied gratis to those subscribers who
have, up to Jan. 22n$ intimated to us their wish
to receive them. Otheb subscribers will be similarly
supplied, so long as thi stock remains unexhausted,
on application to the Manager, The Lancet Office,
423, Strand, London, Iw.C. 2. Such applications
should be sent in at onke.
ThiLamcbt,]
PROSTHESIS OF THE LOWER LIMB.
[Jan. 25,1919 149
PROSTHESIS OF THE}
LOWER LIMB.
Bkporb the war amputations of! the limb were becoming
rare; now the number of British sailors and soldiers requir¬
ing an artificial leg is about 40,000, a number sufficiently
large to give rise almost automatically to inquiries as to the
construction of artificial limbs. . Although the problems
presented by artificial limbs have nbt been completely solved
in the case of the lower limb, a considerable measure of
agreement as to the modes of their solution exists ; for this
reason the following article is limited to the consideration of
ibis part of the subject. t
Condition of the Stump.
Before an artificial limb can be fitted the stump must be
in a suitable condition for wearing a limb. Owing to the
unfavourable conditions under which many of the primary
amputations have been performed subsequent trimming
operations (or rarely re-amputations) are necessary in the
majority of cases. At the beginning of the war 90 to 95 per
cent, of amputation stumps seen at a German limb-fitting
hospital required a second operation to render the stump
painless and capable of wearing a prosthesis, but this
proportion during the second year of the war diminished to
75 per oent.
The stump must be covered with sound movable soft parts
which, however, must not be excessive in amount, especially
if any part of the weight of the body is to be borne on the
end of the stump. Excessive mobility of the soft parts of a
stump is detrimental. The mobility is brought about by the
surgeon, instead of fixing the muscular aponeuroses to the
end of the bone, suturing the flexor and extensor masses to
each other across the end of the bone and healing taking
place without adhesion between the aponeuroses and the
bone. When the patient attempts to move the stump the
first effect is the movement of the scar to and fro over the
end of the bone. When a limb is fitted and the patient tries
to walk much power is lost by this movement; friction
between the skin and the limb is liable to produce abrasions.
The scar should be thin, movable, and neither eczematous
nor ulcerated. Ulceration of the scar often results when a
guillotine amputation (usually performed as a temporary
measure) is not followed by a re-amputation ; the fibrous scar
resulting often gives rise to. trouble. On flexion of the
artificial limb the soft parts of the stump are dragged up,
thus interfering with the nutrition of the scar.
When the skin flaps are voluminous a troublesome eczema
of the skin is sometimes seen. The skin is usually adherent
to the bone; the condition is usually the result of a
secondary operation performed while the tissues were in
too septic a condition to allow of primary union.
Scars over the end of the bone do not always prevent the
use of an end-beaiing pad.
A posterior scar is to be preferred in all amputations of
the thigh and leg where considerable pressure has to be
borne by the front of the lower end of the stump when the
artificial limb is lifted or swung forward.
Although the best end-bearing stumps are those in which
the section has been made through cancellous bone, end¬
bearing is possible when the section has been made through
the compact bone and medullary cavity of the shaft. In the
lower part of the leg the area of bone is too small to permit
of end-bearing; in view of the fac^ that a stump of 7 to
9 inches in length affords sufficient leverage re-amputations
are often permissible in this region.
Outgrowths of new bone-forming spurs rarely give rise to
trouble; they are seldom large exoept in the thigh, when
they are usually found at the inner side of the end of the
bone, a situation not exposed to much pressure.
Other conditions obviously requiring treatment before the
fitting of a limb include painful nerves and the presenoe of
sinuses. If necessary surgical measures must be taken to
render the movement of the joint above the site of amputa¬
tion as free as possible ; daily passive extension of the hip-
joint as soon as the condition of the wound allows does much
to prevent a deformity commonly found.
Provisional Appliances.
Universal opinion in Germary, Austria, France, and
Belgium is in favour of the use of a provisional limb as
early as possible; the use of crutches is not allowed any more
than is inevitable. The disadvantages of crutches include
the danger of crutch palsy, the alterations of balance caused
by the long use of only one leg, and the loss of power in
the muscles of the stump. Besides preventing these dis¬
advantages the use of a provisional limb also prevents pain
and stiffness of joints; the circulation in the stump is
improved, healing and shrinking are expedited, *and end¬
bearing promoted.
In the case of the lower limb the provisional appliances
often takes the form of a Thomas’s knee splint attached to
the body by a suspender passing over the shoulder on the
sound side. Flexion of the hip is assisted by the use of a
strap attached in front to each side of the splint. The
stump is encased in a plaster socket in which the sides of
the splint are incorporated. Professor Mommsen uses a
plaster socket and fastens to it the finished artificial limb.
Provisional appliances can be used five or six weeks after
the amputation.
Construction of the Buoket: Materials Used.
The first point to consider in regard to the artificial lower
limb is the construction of the bucket. No definite conclusion
has yet been reached as to which is the best material. Although
at present in practically every instance the bucket is made of
wood or of leather, strengthened with steel supports, both
these materials have disadvantages which prevent their being
ideal. Leather has a tendency to 11 give ” ; the shrinking of
stumps after fitting prevents a cavity carved out of the
interior of a wooden block to fit a stump in its earlier
condition from being satisfactory at a later stage.
Experiments are being made as to the suitability of other
materials. The value of such different materials as ply
wood and glue, combined with muslin bandages, is being
tested. A specially prepared liquid glue is well worked into
the muslin bandage while it is being wound round a plaster-
of-Paris cast. When dry the surface is rubbed with sand¬
paper and varnished. The material, it is claimed, is equal
to celluloid or acetone, but is very considerably cheaper;
it is light, strong, non-flammable and, when varnished,
practically impervious to moisture. At La Panne Dr. Martin
is experimenting with wood shavings and glue. With a.
plaster model of the stump as a foundation, he glues-
together several layers of beech wood shavings, each layer
being arranged in a different direction. The glue is
especially prepared with the object of rendering it impervious
to moisture.
The great advantage afforded by the use of wood is the
independence of the external form of the limb of the shape
of the socket; this feature is not presented by any other
material used in the construction of limbs. Of the various
woods used for the purpose, willow is the most popular in
England and America. It combines the maximum of
strength with the minimum of weight ; in addition to being
pliable it has the advantage of not undergoing any change of
form under the influence of changes in the humidity of the
atmosphere. Seasoned wood is best, but unfortunately
owing to the greatly increased demand kiln-dried wood must -
now be largely used ; this method of drying increases the:
liability of the wood to crack.
Methods of Pitting the Buoket .
At Roehampton House the process of making artificial
limbs can be seen from start to finish. The trunks of willow
are sawn into appropriate lengths for thigh and leg pieces,
the bark trimmed off, and the block roughly hewn to its
future shape. If intended for a thigh bucket the central
portion of the block is “pulled ” (drilled out) by a machine.
The shapes of the top and bottom of the bucket are roughly
outlined on the ends of the block and superfluous portions-
removed by a band saw.
Various methods are used to ascertain the dimensions of
the stump. Plaster casts are still held in favour by some
fitters; the stump is bandaged with plaster-of-Paris bandages
and allowed to set; with this as a mould a cast is made.
Certain precautions are necessary : To reproduce the form of
the stump, when wearing a bucket, as accurately as possible
the stump is bandaged with the patient inathe erect position.
To reproduce the alteration of form caused by pressure on the
end and sides of the stump by the end-bearing and bucket, a
sock is worn over the stump and pulled up tight before the
bandage is applied. Care is taken to mould the plaster well on
to those points on which pressure is borne; in the case of the
thigh the fist brings pressure to beaf just below the ischial
150 Thb Lancet,]
[Jan. 25,1919
PR08THE818 OF THE LOWER LIMB.
tuberosity. When the interior of the socket is being “palled”
trial is made from time toatime of the progress by inserting
the plaster cast.
Other fitters work “in profile*’—measurements are taken,
including the length of the stump and its circumference at
different levels; a diagram is sometimes made by carrying a
pencil along the inner and outer sides of the limb and stump
when the patient is resting with his limb in the horizontal
position over a piece of paper. The size and shape of the
section of the stump at different levels are reproduced in a
set of “charts” made of flat pieces of leather or metal, the
outline of each chart being a reproduction of the form of the
stump at the corresponding level; with these to help him to
determine the desired shape the maker “pulls” the interior
of the rough backet.
Adaptation of Buckets for Various Amputations.
Certain amputation stumps, including those resulting from
a Stephen Smith and Syme’s amputation, are practically
always covered with a leather socket. In these cases plaster
casts are made, or limb and stump are reconstructed in wood
from measurements ; on these casts or lasts the leather is
moulded. Workers “ in profile” claim that they succeed in
producing a bucket which grips the stump more closely than
when the size of the socket is determined by the insertion of
a plaster cast. In the case of a below-knee stump the lateral
diameter of the limb is greater opposite the head of the
fibula than at the higher level through the knee-joint; if
made by cast the diameter of the top of the bucket must be
equal to the greatest diameter of the interior, so as to permit
the introduction of the cast; in these cases a gap is left
between the stump and the inner surface of the socket
above the level of the head of the fibula.
In the case of a thigh stump a considerable alteration in
the form of the inner surface takes place when the limb is
used for walking; contraction of the adductor muscles,
especially the adductor longus and adductor magnus, then
occurs.
In a recent amputation of the leg of a well-developed man
the head of the fibula and the anterior tuberosity of the
tibia are not prominent, but soon become so as the stump
shrinks. If allowance is not made for these projections they
give rise to troublesome bursae. The plaster mould then
gives an impression of the stump in its present form ; by
altering the “ charts” or “ lasts” slightly to correspond with
the size and shape that experience has shown will within a
comparatively short time be assumed by the stump a better
permanent fit, it is claimed, is produced.
The shape of the top of the thigh bucket is determined by
the ischial tuberosity and the anterior part of the perineum.
The ischial tuberosity is the only bony point on which
pressure can be borne; to ensure that the tuberosity rests
on its upper border the backet is so constructed that the
diameter at this point is less than the diameter of the limb.
The anterior part of the perineum is unable to bear
pressure ; the bucket must be out down to clear this part.
In a limb for a thigh amputation the roughly made thigh
bucket is “ keyed ” on to the knee-piece, to which is attached
tile leg-pieoe and foot with the boot on ; the patient is fitted
at least twice while the limb is in the rough state.
Other Points in Regard to the Bucket.
The tendency of all wooden buckets to crack is in the
case of the American limbs prevented, or at least the
cracking is localised, by the use of a thin covering of raw
hide. This membranous covering is thoroughly wetted and
spread evenly over the whole of the outer surface of the
bucket, exposed to the action of heat, and then varnished ;
the result is a transparent oovering, the presence of which
can only with difficulty be detected.
The Hanger bucket is farther strengthened by the insertion
of screw wires tangentially to the inner surface at levels
where experience has shown strengthening is required; in
the case of the thigh these wires are inserted at a distance
of 1 inch or 1£ inches from the edge of the socket.
A ventilation hole is always provided below the end of the
stump; above this hole comes the end-bearing pad, usually
made in the form of a net of intercrossing leather laces
fastened through small holes to the side of the bucket.
The average life of an artificial lower limb is about three
years. In the case of the first limb worn this depends to a
considerable extent upon the rate of shrinking of the
stump. Every patient wears at least one stump sock; these !
are of uniform thickness and obtained through the limb- |
makers. If shrinking of the stump causes the socket to become
too large another sock is addea The limit is usually reached
when the man is wearing five or six socks ; the bucket is
then lined with leather, and if this does not suffice must be
renewed. As a rule the stump ceases to shrink by the end
of two years after amputation, but in a few rare instances
shrinking may continue as loqg as seven years.
The Knee-joint.
Other parts of the prosthesis will now be described.
In the construction of the knee-joint it is essential that
the bolt should be placed behind the centre of gravity of the
anatomical joint. If the axis of the artificial joint corre¬
sponds in position with the anatomical centre a slight
degree of flexion of the knee brings the line of action of the
body-weight behind the axis of the joint, when further
flexion must occur. If the axis of the joint has been displaced
posteriorly the weight of the body falls in front of the axis
and tends, instead of producing further flexion, to look the
knee.
The distance the axis is set behind the centre of gravity of
the joint depends upon the particular leg-maker. Perhaps
the usual distance the axis is set back is between £ and
£ inch; this amount, while allowing a sufficient margin of
safety, does not interfere with the naturalness of the gait.
If the axis is set farther back the patient, when bringing
from the flexed to the extended position, swings his foot in a
slightly longer arc, causing the action to appear unnatural.
Daring weight-bearing the rigidity of the knee-joint is
secured by the simple means of mounting the foot in a
position of equinus. When the artificial limb is swung
forward to take a step the heel comes in contact with the
ground first; then, as the leg becomes vertical, the entire
sole lies flat on the ground; with the foot in equinus this
position is to all intents and purposes only possible when the
knee is hyper-extended. When, therefore, the sole of the foot
slopes obliquely downwards and forwards and the weight is
taken on the toe the weight of the body acting vertically
downwards tends to force the lower end of the thigh-pleoe
into the hyper-extended leg-piece and prevent any move¬
ment of the two parts on one another.
As the thigh-piece is attached to the leg-piece by means of
a spindle which passes through a metal eyelet hole projecting
upwards from each side of the leg-piece, the action takes
place between the spindle and .the sides of the holes rather
than between the surfaces of the thigh and leg pieces.
An arrangement must be provided to extend the leg-pieoe
on the thigh at the appropriate phase of the step. The
patient on raising the foot of the artificial limb to take a
step raises and moves the limb forward by active flexion of
the hip-joint; the weight of the leg-piece causes it to assume
a vertical position, and thus bends the knee-joint. But
during the weight-bearing phase the leg-piece must be in a
vertical line with the thigh-piece. The change of the leg-
piece into this position is effected by the action of gravity ;
when the patient is supporting himself on his sound limb the
weight of the artificial limb causes it to swing forward like a
pendulum. This movement is, however, both slow and
incomplete. Some patients learn to supplement this
pendulum movement by flexing the thigh slightly as soon
as the foot touches the ground, but although this may suffioe
when the stump is long and the leverage in consequence
powerful, in most cases some mechanism is required if the
patient is not to walk with short steps and a mechanical gait.
Control of the knee (s effected by cords pulling on the
front end of a short lever which has the knee-bolt as a
fulcrum, the posterior part of the lever being attached to the
back of the leg-pieoe or the foot. Two cords are provided;
these run over a roller and are hooked on to the front and
back ends of a double suspender passing over both shoulders.
When the patient raises his leg from the ground the weight
of the appliance makes the cords tense; the pull on the front
of the lever extends the leg-piece. By bracing up his
shoulders as he throws his limb forward the patient oan
assist in the extension of the leg. The object of the roller
is to do away with to-and-lro movements of the suspenders
across the.shoulders, substituting the movements of the oords
round the roller inside the knee-piece.
The “ knee control” used in the Hanger leg allows of an
alteration of the rapidity with which the leg is extended. By
tightening the suspender, the distance of the end of the lever
from the fulcrum can be altered ; a hinge-joint in the lever
enables this alteration in length to be effected.
TmfLANOBT,]
PROSTHESIS OF THE LOWER LIMB.
[Jan. 25,1919 151
i
A knee-locking device most bej provided for patients who
by reason of shortness of the tpigh stamp are unable to
oontrol the movements of the kn4e-joint, or whose daily life '
entails much going downstairs or walking downhill. In
its simplest form the knee-lock consists of a piece of stoat
wire running along a canal in the outer side of the backet;
this wire can be pushed down between the knee-piece and
the inner surface of the leg-piece, which is guarded at this
part by a metal plate; the thick wire serves as a wedge
between the two parts and prevents movement.
An automatic knee-lock has bien devised by Mr. F. H.
Oritchley, of Liverpool. The joint consists of a very narrow
barrel attached by side-irons to the thigh-piece; ciroum-
ferenti&lly to this is placed a cylinder of metal attached to
the central tube of the leg-piece. The circumference of the
barrel is gripped by a band-brake tightened by the pull of a
rod attached to the heel. When the weight of the body is
thrown on the toe-piece the foot rotates at the ankle-joint,
depressing the heel, thus pulling on tbe rod and locking the
knee-joint. This action takes place no matter the position
of flexion of the knee when the weight of the body is placed
on the artificial limb. When the pressure is no longer exerted
on the foot, the knee-joint automatically becomes loo-e and
the leg-piece free to swing. The band normally tends to open
by its own resilience, but a compression spring is usually
added to ensure the opening taking place. The range of
movement of the knee-joint is limited by an external stop.
The Ankle joint.
A movable ankle-joint is now almost universally used, but
tbe movements are commonly limited to those of flexion and
extension. With the boot on, the part of the foot represent¬
ing the articular surface of the ankle-joint is horizontal. The
surface of the leg-piece forming the front of the joint is
inolined at an angle of 15° with the ground, the back part
at an angle of 30°. The wider posterior angle renders
possible the degree of flexion of the foot required when the
patient walks downhill.
The following describes an arrangement in common use.
On the upper surface of the foot two cavities are hollowed,
one in front of, the other behind, the bolt of the ankle-joint;
in each of these cavities is placed a- cylinder of rubber, the
posterior about twice as high as the anterior. On these
cylinders rests the leg-piece, ending in front in a short
instep lying within the cavity hollowed out in the foot. Tbe
foot is attached to the leg-piece by a bolt made in the form of
an inverted T; the base formed by a steel tube which fits
into two corresponding grooves in the leg and foot is attached
to the leg by the vertical part, a rod which is secured by a
nut at the bottom of the hollow of the leg-piece. Upon the
steel tube moves a steel U-shaped staple, the two ends of
which pass through the foot and are fastened in position by
two nuts secured by a locking-nut.
The ankle-joint must be kept tight enough to prevent any side
motion, but not too tight to interfere with the movements of
flexion and extension. The freedom of movement of the joint
can be altered by tightening the nuts and compressing the
rubbers, or vice vend, or by altering the size of the rubber
buffers. If the locking-nut is not kept in position the foot
work* off and break.. ^
The foot is now usually made of wood. To allow of its
bending when the patient comes forward on the front part of
the foot for the next step the foot is divided transversely at a
level corresponding to the middle of tbe metatarsal bones.
The front part is attached by a dorsal and plantar piece of
leather or rubber reinforced by wire ; between the two parts
are two rubber cylinders whioh, when the limb is at rest,
keep the toe-piece extended at an angle of about 15°, but
allow of extension to 45° when the foot is pressed on the
ground.
As mentioned above, the foot is mounted in the equinus
position; the heel is 2 or 3 om. off the ground, the usual
height of the heel of a boot. The foot should point slightly
outwards, as in the normal standing position, the usual angle
being 18*6°.
Amputation* Through Hip-Joint and Upper Thigh .
Special considerations for each amputation remain to be
dealt with. For amputations through the hip-joint the
11 tilting table,” perfected during the war. Is the most satis¬
factory appliance. It consists of a leather socket moulded
round one half of tbe pelvis, reaching upwards as high as
the iliac crest and attached to the trunk by a pelvic band.
The pelvic band is a steel girdle which rests on the iliac
aim and extends a short way in front of each anterior
superior iliac spine ; it is covered with leather and buckled
together in the front. The metal is moulded to the patient's
body while in a soft state, and is then tempered. To the
socket an artificial limb is attached by steel supports.
To enable the patient to bend the limb at the level of the
hip-joint when he sits down a hinge-joint with a spring
lock is placed in the outer steel support; this joint auto¬
matically locks when the patient rises, enabling him to walk
with a rigid leg. On the inner side the steel piece runs
around on a quadrant fastened to the under surface of the
leather socket.
The “ tilting table ” has also proved to be the most suitable
appliance for high amputations of the thigh, leaving a stump
of less than 7 inches in length. These stumps are often
incurably flexed and abducted ; also the patient with so
short a stump is unable to control an artificial limb. When
wearing this appliance the patient sits on his flexed stump,
the end of which protrudes slightly through a hole in the
front of the moulded socket.
If a patient with an amputation of the thigh has difficulty
in controlling the artificial limb, a pelvic band should be
fitted. A properly fitted pelvic band not only ensure* firm
fixation of the limb, but also prevents eversion of the foot
and rotation of the bucket.
Amputation* About the Knee.
A complete end-bearing is often possible in the case of
amputations through the condyles of the femur, disarticula¬
tions of the knee, and very short stumps below the knee.
If a wooden bucket is to be worn, owing to the bone at
the lower end of the stump being larger than at a higher
level a modification of the bucket is necessary to ensure its-
gripping the stump firmly. The front of the lower half of
the backet is cut away and the wood replaced by leather,
which laces in the middle. It is perhaps more usual of late,
instead of using a wooden bucket, to encase these stumps in
a tightly fitting case of sole leather.
When a transcondylar operation has been performed
before the plaster mould is made it is as well to pad the
edges of the cut femur. The length of the stump does dbt
leave sufficient room for the use of a knee-bolt; movement
of the knee-joint is permitted by two hinged side-steels
identical with those used for below-knee amputations ; these
steels lock dead tight when the knee is in the position of
extension.
Amputation* Through the Leg .
A wooden socket can be fitted to amputations through the
leg if the stump is at least 6 cm. long, if tbe knee-joint
moves freely and can be folly extended by the patient, and
if no adherent scars are present round the tuberosities of
the tibia. The wooden bucket is fitted accurately to the head
of the tibia and to the lower portion of the patella ; it must
grasp tbe tuberosity of the tibia firmly. The patellar tendon
is capable of weight-bearing. Care must be taken lest the
bucket press on the head of the fibula; a deep conoavity
must be present at this point.
The shape of the top of the bucket is important. To
avoid nipping the flesh between the upper edge of the
bucket and the lower end of the thigh corset, both these
edges must be concave; a concavity of a finger’s breadth
below the axis of the joint suffices. The baok of the socket
is flattened; if hollowed out too much at this point the
8*ump is tilted forward and the flesh at the back of the knee
pinched.
The leg is usually attached to the thigh by a leather corset;
side steels, hinged at the knee, connect the corset and socket.
The shorter the stump below the knee the larger the
bearing surface, and therefore the better the end bearing; bat
on the end of any round stump, provided an adherent scar is
not present, a part of the weight of the body can be borne.
Occasionally, however, it is found necessary to fit a leather
thigh bucket reaching up as far as the ischial tuberosity,
which bears part of the weight.
The wearing of braces increases the stability of the limb
and allows of looser lacing of the thigh corset, with the con¬
sequent advantage of freer movement of the thigh muscles.
The braces pass over the shoulder of the sound side and are
attached either to the thigh corset or the leg-piece. If the
stump is short it is an advantage to attach the brace to a
strap from which two branches pass down in tbe form of an
inverted V and are fixed to tbe front of the leg-piece.
152 The Lancet,}
THE INTER-ALLIED FELLOWSHIP OF MEDICINE.
[Jan. 25, 1919
In the case of short stumps a leg socket should be fitted
whenever possible; with the kneeling leg the gait of a
patient is much less natural than when a socket is worn.
When the patient has to walk on the bent knee a moulded
leather bucket is provided, similar to that used for trans¬
condylar amputations ; a posterior band passing over the end
of the flexed stump helps to keep the artificial limb in position.
Syme't and Chopart's Amputations.
In a Byrne's amputation the end of the stump should be
able to bear the weight of the body. The stump is usually
fitted with a leather bucket strengthened with steels, usually
four—an external, an internal, and two anterior ; it rests on
a cushion within the buoket. An elastic strap is attached to
the top of the instep and above to each side of the front of
the socket.
If the end of the stump remains sensitive the patient must
wear a leg bucket, embracing the head of the tibia. In rare
instances a thigh corset, with side steels jointed at the knee,
must be worn.
In a true Syme's a sufficient vertical depth exists below
the end of the stump for the joint to be placed at the level
of the normal ankle. If the malleoli have been left the
joint must be placed in the lateral steels outside the boot.
Ohopart's amputations are often unsatisfactory; in about
half the cases the action of the tendo Aohillis and the
tibialis posticus causes the foot to assume a position of
equino-varus when the patient walks on the anterior end of
the os caloU and astragalus. If the position of the foot is
satisfactory a leather casing is moulded accurately to the
foot and ankle and attached to the instep of the anterior
half of the foot. Side steels are usually neoessary ; these
should be jointed opposite the ankle-joint to permit of free
flexion of this joint.
Standardisation.
Finally comes the question of standardisation. The
large number of artificial limbs required has caused atten¬
tion to be directed towards the possibilities in regard to
this. The ohief advantage to be gained from standardisa¬
tion is the ease with which a damaged part can be replaced;
a qertain saving of money will also be effected, but only
slignt, because the cost of a limb is due not so much to the
expense of the material as to the cost of labour. Another
advantage would be the possibility of ensuring the same
quality of material in each limb.
It is obvious from what has been written above that
standardisation of the bucket is impossible, but standardisa¬
tion of the component parts of the limb is possible in many
cases.
The Army, before and in the earlier stages of the war, was
composed of men of more or less similar physique ; certain
standards as regards height and chest measurement were
maintained, with the result that the physique of the average
soldier ranged within cimainscribed limits. Even later in
the war when these standards were more or less abandoned,
by a process of more or less conscious selection, the men in
the fighting line were in most cases similar in physique to
those of the earlier Armies.
On analysis of the measurements of men with amputations
it was found that, excluding about 15 per cent, for the
purpose of fitting artificial limbs, the sizes of the various
parts required could.be grouped into four—four sizes of feet,
four sizes of leg-pieces, and four sizes of knee-pieces. With
these three parts 64 combinations can of course be made.
The four sizes of feet correspond with Nos. 7, 8, 9, 10 sizes
in boots. The leg-pieces are of such a form as to be suitable
for the tall thin man, the man of average height and pro¬
portions, the short stout man, and the bantam—i.e., the
small, well-proportioned man. It is the exception for a
tall man to possess a big calf. A fat man over 6 feet in
height probably suffers from some physical disability which
would prevent his being accepted as a soldier; the tall very
muscular man with a well-developed calf would be included
in the 15 per cent, of exceptions. The four sizes of knee-
joint correspond with the different sizes of leg-pieces and feet.
One size and form of ankle-joint suffice for all sizes of the
other parts. The knee-bolt, with side plates fastening on to
the leg-pieces, are made in four sizes, corresponding with the
different sizes of knee-piece.
Another part which it is possible to standardise is used for
below-knee amputations: this is the side steels for whioh
one size only suffices.
THE INTER-ALLIE0 FELLOWSHIP OF
MEDICINE.
A WELCOME TO THE HARVARD MEDICAL UNIT.
The Executive Committee of the Inter-Allied Fellowship
of Medicine gave a dinner at the Connaught Rooms, Great
Queen-street, on Jan. 15th to the members of the Harvard
Medical Unit at present paying a short visit to London, and
on their way home from France, having served with the
British Army since the second year of the war. Sir William
Osler, the chairman of the Executive Committee, presided
over a distinguished gathering of medical men who acted as
hosts to the Harvard Unit. A letter of regret having been
read from the American Ambassador for his inability to be
present, the toast of 4 4 Health and Prosperity to the Harvard
Unit ” was given by Dr. Norman Moore, President of the
Royal College of Physicians of London.
Dr. Norman Moore said:—
This afternoon I was examining a portrait of the first Fellow
of the B"val College of Physicians, Dr. John Chambre. He was
elected a Fellow of Merton College, Oxford, In the year In which
America was discovered. The portrait was a most beautiful copy by
Isaac Oliver of a work of Holbein, and as I examined its wonderful
execution I was interrupted by a message asking me to propose the
health of the Harvard Unit at this dinner, so I had at ono* to turn my
thoughts to America, which I had never visited, and to Harvard, the
fame of which we all know. I remembered that In the ancient church
of St. Bartholomew, whioh stands over the way near the hospital with
which I have been connected all ray pro r esslonal life, there is the
richly adorned tomb of Sir Walter Mlldmay, Chancellor of the
Exchequer to Queen Elizabeth. He was a Puritan, and there
are no figures upon his tomb, not even his own efflgv, and, in
addition to his epitaph, only the very serious inscription,
“ Mors nobis lucrum. ’ He was the founder of Emmanuel College,
Cambridge, where Harvard was educated. It is a college not
unconnected with medicine; Indeed it comes into the history of
Sydenham, one of the most illustrious or English physicians slnoe he
wrote one of his medical epistles to Dr. Henry Pa man. who became a
member of Emmanuel in 1643. and was a life-long friend of his. As I
looked into my memory I regretted more and more that 1 had never
been to America. What can that famo is land be like? Our old
writers said El Dorado was there. In our day, when the >>lace nf some
famous picture is vacant on a wall and we ask where it Is, the answer is.
that it has gone to America. When a library of rare books has empty
shelves and the visitor asks where the book* are, the answer Is the
same-America! Wonderful land, well knowing how to put the rt has
of El Dorado to good purpose. I am glad that its inhabi ants hould
enjoy pictures and books which are worth seeking In our old world, and
that they are worthy to enjoy them. But your country has a finer
product than gold, a greater store at home, a nobler export to improve
other nations. It produces the greatest of all the pro 1 ucts of the
world—men. The Harvard Unit is a collection of observant., ingenious,
laborious, and thoughtful men, who brought their energies to he p
England’s need, and I offer them affectionate saluta* ion, regard, and
gratitude.
Lieutenant-Colonel Hugh Cabot, C.M.G., R A M C.,
Commanding (Harvard Unit) 22 General Hospital, respond¬
ing to the toast, said :—
Now that the “ Harvard Unit" has ended its mission and, like the
many things referred to by Dr. Moore a few moments ago, is about
*‘to go to America,” It la perhaps possible to estimate in some degree
what has beeu Its effect and wbat it has reallv accomolithed. It was
the outcome of a great spirit of restlessness which exi»t**d all over the
United States as the attempt to •• keep the coun ry out oi war.” It
is perhaps n<>t unnatural that this spirit should have been particularly
evident at Harvard and tnat she should have desired to assist the
country from which she sprung iu the defenoe of democracy. Many of
the plans with which we started, and i*artlcularly our s rgic&l equip¬
ment, had to be revised as not suited to the existing conditl n, of which
we were naturally ignorant. Only the other day in winding up the
affairs of No. 2Z General Hospitil, B.E.F., which this Unit, has
carried on since July, 1915, I found that we had in hand a very
large number of surgloal instruments which had not be-n out f their
original cases, and which, though not well suited to the su-gery of war,
will, I believe, be found well adapted to the usages of peace They
have been presented to St. Bartholomew's Hospital as a token of our
appreciation of many kindnesses and much assistance given by Major-
General Sir Anthony Bowl by.
The original conception of the Unit was that it should provide the
staff of a British base h-tspltal for a period of three moaths. and that
it should then be succeeded elt her by Oolurnbtanr John* Hopkins. This
plan, however, fell through, and it devolved up m Harvard to continue
the work alone if it was to be done at all. It, was not, however, until
Deoember, 1916, that the Importance of service for the duration of 'be
war was realised, and at that time the Go poration of the Untver try
voted to continue the Unit for duration, and the offlents were «ivea
commissions in the B A.M.O. Then, for the first time, it was possible
to make plans for the future, and develop the Unit into an efficient and
hard-bitting organisation. We cannot, I think. cLlm to have con¬
tributed much that t« new or strange to the surgery *f wa>*, and
perhaps if we had done so we might have laid our-elves open to the
charge of being aggressively American. We have, however, tried to
turn out a large amount of satisfactory work, and no matter how great
the pressure for help might be we lave always been able t» find some.
We have, to some extent, acted as k clearing house for Am -rtoa'i ideas,
and have done something to extend the use of direct blood trausfuaion
In the treatment of haemorrhage ank shock.
Looking book now I believe that 4ur most important work has been
in bringing together the pcofeeskn on both aides of the Atlantia
The Lancet,]
E tNTBB-ALLIED FELLOWSHIP OF MEDICINE.
[Jan. 25, 1919 153
We have sent many officers to work with clearing stations In
forward areas, and In this waj h*ve brought them in oontact
with the British brethren. It is only since I have been Intimately
Msoriated with Englishmen, Scotchmen, Irishmen, Canadians, and
Australians that 1 nave o me to realise that we were, In fact, the
nme blood—that the differences weje wholly superficial, though
at times very apparent. These differences are largely matte*s of
manners and mode of expression. The American, for instance, almost
always overstates bis case, and his use of superlatives is exceedingly
common. The Englishman, on the other hand, generally understates
his, and often appears to be trying to conceal the fact that he has a
esse at all. His very modesty may malm him appear to his American
brother as a dull fellow without much to say for himself. The American
always nuts his best foot foremost and selects with care that which is
best polished, whereas the Englishman is likely to put forward the one
that la least presentable for fear someone might think that he was
trying to attract attention. Though these habits and manners
nowhere touch the essentials of. the man they make a brave show,
and to the superficial appear to be important, and do, in fact, delay
progress in the close association which we must have In the future.
On the other hand, I have been deeply impressed by the fact
that in a close working association Englishmen and Americans
soon come together, and each sees and admires the qualities of the other.
Therefore, I say to you that we must not be satisfied with a superficial
relation, but must work for that close working union which alone can
cement tbe bond. The onlv League of Nations which seems to me
Immediately possible is s working union of all the branches of the Anglo-
Saxon race, and this is within our grasp. Anglo-Saxon unity must
precede sny League.
It is to this bringing together of the British and Americans that we
have most effectively addressed ourselves. We have been part and
parcel of tbe British Service and have given it the best that we had to
give. At the same time we have *• with a decent respect for the
opinions of others." maintained our own manners and customs, and
hsve perhaps lived wit b. somewhat greater freedom and worked and
played & little harder than sound Biitlsh custom would sanction. We
have been a gathering place for all sorts and conditions of men, and we
desire to acknowledge tbe debt we owe to Sir William Osier in helping
forward this mixing of professional men and women from both sides of
tbe Atlan> ic.
Sir StClair Thomson, joint honorary secretary with Mr.
Douglas Harraer and Mr. J. Y. W. MacAlister of the Inter-
Allied Fellowship of Medicine, then proposed tbe health of
the Fellowship, describing it as “ a very young person ; in
fact, a true war baby.’* The origin of the Fellowship, he
said, was a visit to the United States last summer by Sir
Arbuthnot Lane, Sir James Mackenzie, and Colonel H. A.
Bruce, who on return brought the message that American
medicine was looking to, London to replace Berlin and
Vienna as the Mecca for *the English-speaking doctor. He
continued :—
The objects of the Fellowship of Medicine might be grouped under
four principal headings.
1. The coordination of all tbe reaourcea of medical interest throughout
this country, ao as to make them readily available for demonstration
and Invea* igatlon.
2. Initiation of schemes of scientific entertainment. These would
embrace the arranging of facilities for visits to, or courses of study In,
the vat it,us clinics, laboratories, museums, and other medical Institu¬
tions ; l he regular attendance on any one particular service, or course
of lecture, or demonstration, and, in addition, the preparation of
specially arranged addresses, demonstrations, or scientific visits.
3. Later on the Fellowship would be actively helpful in collecting
and distributing Information and in facilitating visits to overseas
medical schools, meetings, and congresses; in being a centre through
which the temporary occupation of professional chairs or exchange of
professorships might be arranged.
4. Toe promotion of personal friendly intercourse between the
members of the profession in this country and their brethren from
overseas.
To promote these objects a centre had already been granted through
the kindness of the Koyal Society of Medicine at No. 1, Wimpole-
street. There arrangements would be made to collect, file, and circulate
Information on all matters of medical interest. Rooms would be
available for conferences, discussions, demonstrations, or exhibitions.
In fact, the Fellowship of Medicine would act as a sort of oentral Cook's
tourist office for travellers in the medical world.
The primary object of this association Is not to arrange post-graduate
study. This is the care of a separate association, which » also under
the aegis of Sir William Osier and with which there would be tbe
moat friendly cooperation. Bat post-graduates were particularly
desirous of continuous and intensive training in one or more
circumscribed departments of medicine. Now the Fellowship
oaters for all visitors, not only those seeking post-graduate
classes, but also those wishing to study our medical history,
Our Institutions and organisations, our hospitals, infirmaries, diB-
POntarles, asylums, fever hospitals, lying-in institutions, nursing homes
and sanatoria, or our 8'ate and municipal hygienic arrangements.
We propose to help them to bear and join in the scientific medical life
of this country and provide them with entertainments of medical
Interest. We will help them to see any one particular man operate or
hear any special clinical demonstration; to work in any laboratory or
study or in any library; to visit any asylum or investigate any
system of drainage. We. ourselves, are so apt to work in water-tight
compartments that we forget all about the wealth of this country in
other matters of professional interest which lie outside our own
practice or study.
Sir StClair Thomson went on to show that the organisation
of a complete course of post-graduate teaching must require
time, but that they had already been able through the help
of 8tate departments and the courtesy of the deans of the
London medical schools to arrange opportunities for
giving scientific hospitality to Dominion and American j
surgeons. The Director-General of the Army Medics^ 1
Service, Sir John Goodwin, had already cooperated
by arranging with the Deputy Directors of Medical
Service in command in the United Kingdom to
institute facilities for mutual collaboration. The future
coordination and arrangements for instituting a great post¬
graduate centre would require detailed, exacting, and con¬
tinuous work, and Mr. Douglas Harmer was now associated
with Mr. MacAlister, the first motive force of the movement,
in perfecting their programme. Sir StClair Thomson con¬
cluded by referring to the fact that Lieu tenant-Colonel Hngh
Cabot was the direct descendant of the pilot, Sebastian
Cabot, who used to sail out of Bristol city, and was the real
discoverer of the Western Hemisphere.
Sir Arbuthnot Lane congratulated the Fellowship
Society in its good fortune in being able to .fix its
paternity on Sir William Osier, who would make an ideal
ohairman.
“ He is fortunate,” he said, “ in possessing all the progressive
capacity of our trans-Atlantic brethren combined with the tenacity of
the Briton. While, as occasionally happens, doubts may arise as to
the paternity of the offspring, none can exist as to the maternity.
This we owe, as we do so much else, to tbe originality, tact, indomit¬
able energy and wisdom of our very old and beloved friend Mr.
MacAlister. Wherever trouble arises Mr. MacAlister Is the man who,
in the most Inconspicuous manaer possible, has the capacity and
ability to develop new ideas or to put things straight.” Sir Arbuthnot
Lane was certain that the young Fellowship would grow rapidly and
would require no artificial food to hasten Its growth. There was enough
material in London and the provinces to produce a field of study that
would compare very favourably with that in any part of the world. He
would like to take this opportunity of expressing to the medical
departments of our Dominions also the deep debt the profession
wholly In the mother country owed them. He looked to them for
invaluable help in making the new Fellowship the greatest possible
success.
Sir John Goodwin, the Director-General of the Army
Medical Service, said :—
. I may perhaps claim a longer acquaintance and friendship with the
Harvard Unit than most of those who are present to-night. I first
had the pleasure of meeting this Unit when in France in 1915. I had
the good fortune of knowing many of the officers intimately and saw
much of their work, which was of an extremely high standard, and that
standard has been consistently maintained throughout the war. I think
1 am correct in stating that more than 150 000 British soldiers have been
treated and cared for by the Harvard Unit during its stay in Prance. May
I ask you to think what that means in tbe way of actual assistance to our
medical service, and may I suggest that, splendid as this record Is,
there is also something more, something not quite so tangible but
equally valued by us, and that Is the sentiment of brotherhood and
affectionate feeling which was brought home to all of us when the
Harvard Unit came over to France In 1915 to work with our armies and
to succour our wonnded. The members of the Harvard Unit endeared
themselves to all of us, and we eagerly welcomed the many hundreds
of medical officers and nurses who, immediately the United States
entered the war, and many even before that date, volunteered for
service with the British Armies and were of untold assistance to us,
both in this country and In the theatre of war overseas.
I am sorry to say that there have been many casualties, many
dexths; in view of a medical officer’s duties in modern warfare this was
inevitable, and the American officers were always eager for front line
work; their honoured memories will remain with us for all time. One
often hears discussion as to the international sentiment between
America and ourselves during the past and in tbe present. With,
regard to this an old Arab proverb has very often occurred to me. I
first came across it when studying Arabic In the Bast many years ago.
The literal translation runs as follows
“I and my brother may differ, I and my brother might possibly
quarrel, but—it is my brother and I together against the whole world.
The Harvard Unit Is now returning to the United States, leaving
behind It a splendid record of work performed and carrying with it the
respect and affection of everyone who has ever met any of its members
or Been Its work. We wish them Godspeed and all possible happiness
and prosperity in the future. In saying this I am conveying the
thoughts and wishes of my whole service.
General G. L. Foster (Canada) said :—
It is with peculiar pleasure that I join with other speakers to-night
in wishing the members of the Harvard Medical Unit God-speed on their
homeward journey after three years of war labour. How well I reeal
their arrival in France during the summer of 1915; an event which
meant to those of ns from America—Canada being in America—that
tbe United States would eventually join the Allies In the great
struggle to uphold, the right and liberties of mankind and to avenge
the outraged women and children of Belgium and France. For the
sending of such men as Harvard and other Universities of the United
8tatea sent to us in those early mouths was bound to have a far-
reaching effect throughout the whole country, and awaken men and
women In all walks of life to the justice of our cause. And now that
the war is at an end, right having prevailed, we all shall 'sooner or later
have returned to our several homes with tne warmest feelings of
friendship for those who suffered side by side with us these weary
years. That friendship will ripen into a true fellowship of two of
the world’s greatest people to safeguard the world against future wars.
The enemy and tbeir leaders will receive a just judgment. We may
hope that they will retnm to their senses, and cease from following
t hat false xnltur which is even now sinking In the afternoon of history
and will in time be swallowed up In the thick night of oblivion.
.Sir W. Watson Cheyne, M.P., then proposed the health
of Sir William Osier. He said:—
Sir William Osier is well known to the medical profession all over the
world for his writings and speeches and his general learning, but he
occupies a peculiarly important position in connexion with the project
of an International Fellowship of Medicine, especially a Fellowship of
151 Thb Lanobt,]
THE REPORT ON DUBLIN HOUSING.
[Jak. 25,1919
the English-speaking races, because he has held professorships In three !
groat countries amt universities. Beginning as Professor of Medicine
m Canada, in the University of Montreal, he was invited to hold
a similar position In the Johns Hopkins Univer tty in the United
States of America, and in the fullness of time he was invited to bring
his no w ripe and varied experience to the Old Country and to take up a
similar position in the venerable University of Oxford.
As you have heard to-night. Sir William Osier is the chairman of
the committee which is working out one part of the scheme of this
Fellowship—viz., that of rendering the wealth of clinical material
which exists in this country available for post-graduate study as well
as our great stores of p thology in various museums, of which the great
type is the Royal College of Surgeons of Bngland. But, as SlrS&ialr
Thomson has p doted out to night, the Fellowship to be successful
should also have another side—viz., that which promotes friendly inter¬
course between the medical men of the various nations, of which the
first attempt—and 1 think a highly successful attempt—Is our meeting
here t>night.
This is the age of young men, and we have it on very high authority
that we croes the watershed of life about 40, and thereafter gradually
go down the hill. I therefore ventured to suggest the other night that
we might divide the work of this Fellowship according to the ages, the
men up to 40 being engaged in imparting knowledge in tbe post¬
graduate work, while the men at a la er period of life do more on the
social and entertainment side. Of course, we could not draw a very
hard-and-fast line, for nine might think that the experience of the
older men might be of help in the post-graduate work, while the
vivacity and energy of the younger men might add lo the joy and
pleasure of the social side. So perhaps my suggestion was not quite
seriously meant and may not be taken up. I ask you, ladles and
gentlemen, to drink to the health of our most popular chairman.
Dir William Osier.
Sir William Osler responded as follows:
After thanking the company for their kind response to the toast, the
chairman r<ald that among the advantages of ndvanclng years was the
knowledge one might have of three generations, and this was his
position with regard to the profession of B jston, which may be called
the cortex cerebri of the United States. Oliver Wendell Holmes's
Brahmin class existed in a larger proportion in the profession of New
England than in any part of the English speaking world. It was a
peculiar pleasure to him to welcome the Harvard Unit, which contained
grandsons of men whom he had known well In the seventies. Opposite
to him sat- Major George Oheever Shattuck, whose father, Frederick
Oheever (a friend of student days in Germany and Professor of Medicine
at Harvard) was the son of the distinguished George Oheyne, also a Pro¬
fessor of Medicine, the son of George Oheyne (primus), called after the
famous English physician of that name, and son of Benjamin Shattuck—
all of whom had practised medicine in Maa*achusetts— caute, caste et
probe. Five generations of Warrens had served Harvard and the Massa¬
chusetts General Hospital—John, at present In the anatomical depart¬
ment. son of J. Collins, still alive and well and an honorary F.R.O.S.,
whose anceetorv, Jonathan Mason. John Oolltns, and John Warren (the
founder of the Harvard Medical School) were great figutes in Boston.
And there were many other medical families—as the Bowditches,
Jacksons, Bigelows—which had given an hereditary distinction, as rare
as it is valuable In the profession of any city.
The New Bngland spirit—the keen sense of right and wrong, and the
desire to help, inspired Harvard to send this Unit long before America
could enter i he war as a united nation. And they were fortnnate In
the ohoice of the man who has had charge. Dr. J. William White, of
Philadelphia, at the outbreak of war, and until his untimely death,
fotight the battle for the Allies against Germany in a way I hope we
shall here never forget. And our chief guest and his brother, Dr. Richard
Oabot, early entered the propaganda, but they did not confine their
work to the Eastern States where sympathy was largely with the
Allies, but they went West to the stronghold* of German influence and
held public meetings, sometimes In the faoe of stormy and even dis¬
orderly opposition. A rude little rhyme about the Oabots indicates
their position in popular opinion
Here’s to good old Boston,
The home of the bean and the ood.
Where the Cabots talk only with Lowells,
And the Lowells walk only with God.
The Unit returns with the grateful thanks of all classes of this
country for the good work it has done in the relief of the British
wounded; and it is a happy angury for the future of our Fellowship
that Its first official act has heen to greet our brethren from overseas
and to wish them a happy and a safe return.
It was allowed on all sides that the dinner should prove
an admirable introduction to a great movement.
THE REPORT ON DUBLIN HOUSING.
This report, by Mr. P. 0. Cowan, D.Sc., M.Inst.O.E., is of
far more than local interest, since Dublin’s housing problem
fundamentally resembles that of many other towns, though
perhaps few have so much leeway to make up before a
tolerable standard of housing is reached. For in Dublin
more than 40 per cent, of the population “urgently required
improved housing at the end of 1913,” and conditions are
mnch worse now. Mr. Cowan has faced the whole situation
In the bold and thorough way which those who know him
would have expected.
The immediate task is to build 16,600 houses with the
least possible delay, and Mr. Cowan suggests replies to the
many vital questions involved in their erection. Who is to
build aud manage them ? Where shall they be built ? How
many shall be built per acre ? What Bize and type of house
shall be built, and of what materials? His recommendations
on these matters are worthy it careful study, for they are
based on the long experience and close thought of a man
who combines a practical kiowledge of building with a
sympathetic insight into the human needs of the people to
be housed. He realises that; in all our schemes we must
remember that we are buildidg not only for the present but
for the future. Wages are rising, and with them the standard
of comfort. Hons esjust good enough to-day will not be good
enough to-morrow.
“ It would be a most grievous and irretrievable error,” says
Mr. Cowan, “ to base the standard for new houses on the
E resent homes, habits, and incomes of the poorer classes in
lublin. In many oases they only reqaire the opportunity
to respond to better environment, and it should be remem¬
bered that tbe standard of housing has risen steadily for
many years, and that the houses erected now may have to
serve at least two generations.”
This is advice which all those who bnild under the present
Government scheme will do well to remember. Mr. Cowan’s
recommendation that only 10 houses should be built per acre
is quite in accord with up-to-date practice ; but, as land near
the centre of Dublin is very dear, he recognises that if such
a limitation is observed the provision of adequate transit
facilities would be a necessary corollary. The absence of each
facilities, and the practice—soon, all must hope, to pass
away—of starting work at 6 A.M., compel too many
employees to live close to their work. Hence the anomaly
to which Mr. Cowan draws attention—that “ poor people, as
a rule, live on dear land, and rich people on cheap land.”
In connexion with transit, Mr. Cowan makes the interest¬
ing suggestion that it may eventually be provided free, just
as roads and footpaths are. This is by no means as
impracticable a policy as it may appear at first sight. The
late Alderman William Thompson, in his “ Housing Hand¬
book Up to Date,” states that:—
“ The cost of equipping suburban land with trams may be
taken at £25,000 per mile for initial capital outlav, or includ¬
ing working expenses and loan charges £5000 per mile per
annnm. This is on the assumption that there is in each
direction a five-minute service for 12 hoars each day, and a
ten-minute service for another six, hours, or a total of 131,400
oar mile per annum, and that the inclusive cost is 9id. per
mile—an outside estimate.
“ It is difficult to Bay how much land oould be served by a
mile of track, but reckoning 15 minutes’ walk as the maxi¬
mum distance on either side of the trams, we get an area
of, say, 1760 by 2500 square yards, or 1000 acres, so the
annual cost of free tramway equipment may be put at
£5 per acre per annum, and this sum capitalised at 30 years
means £150 per acre as the initial capital outlay per acre ;
that ought to be sufficient to convert comparatively inacces¬
sible land into accessible building sites, with free trams
running to and fro for 18 hours each day. Now assuming an
average of only fonr houses to the aore, this means less
than 6<Z. per honBe per week rent, to include free travel.”
This is considerably less than would be saved in rent by
living away from the town, not to speak of the advantage of
having a house surrounded by a garden instead of being
wedged into a sordid street.
Almost the whole of Mr. Oowan’s report is full of excellent
suggestions and wise counsel. But in considering the
number of bedrooms which should be provided per house he
adopts a point of view which is curiously at variance with hif
general attitude. On the strength of some very uncon¬
vincing statistics he recommends that no less than 60 per
cent, of the houses built should only have two bedrooms.
Here be runs counter to all modern ideas; unquestionably
it would be a catastrophe if his advice were followed. We
positively must get away from the two-bedroomed house,
which, when occupied by a family is quite inadequate,
whether to meet the requirements of health or deoency.
One of the serious difficulties that we have to face to-day is
that more than half the houses in the British Isles have only
two bedrooms or less, whereas, judging from the Census
returns, considerably over a million of these should have
three bedrooms or more in order to meet the minimum
housing requirements of their occupants. Surely, not a
shadow of a case can be made out for adding to the number
of two-bedroomed houses, save in the rarest cases.
But this is only a momentary “lapse from grace,” and
Mr. Cowan’s report is a fitie piece of work, and should be
widely read. The plans ai the end, illustrating the houses
which have been erected py various Irish municipalities,
should, however, be studied with discretion, since obviously
only some of them are meant to be examples, while the others
are warnings against what ft avoid.
Thb Lanobt,]
THE ifOTURE OF THE AMERICAN RED CROSS IN PARIS.
[Jan. 25.1919 165
&0ms$0itbenu.
'* Audi alteram pfrtem.”
THE FUTURE OF THE AMOEBIC AN.RED CROSS
IN PARIS.
To the Editor of T^b Lanobt.
Sir,— A permanent Chapter of the American Red Cross
has been formed in Paris, known as the Paris District
Chapter, and of said Chapter I am the chairman. It is
proposed that this Chapter shall be the permanent organisa¬
tion of the American National Red Cross in France, and its
functions will be to carry on to a conclusion the work
inaugurated by the American Red Cross after the Com¬
mission to France which during the war has been in charge
of said work has ceased to exist. After the completion of
this work it is proposed that the Chapter shall continue to
perform all functions ordinarily performed by a Chapter of
the American National Red Cross. It is impossible at this
time to foresee just what the character of this work will be,
bat among other things it may involve the care of the graves
of American soldiers and sailors buried in France, and also
to have an organisation constituted and capable of carrying
on any work that it is proper that the Red Cross should do.
I am, Sir, yours faithfully,
Gurnby E. Nbwlin,
Major, A.B.O., Chairman, Faria Dlatrlot Chapter.
4, Place de la Conc orde, Parla, Jan. 17th, 1919.
CAUSES AND INCIDENCE OF DENTAL CARIES.
To the Editor of Thb Lancbt.
Sib, —Dr. Harry Campbell's courteous reply to my inquiry
is somewhat confusing. In your issue of Jan. 4th he
states—
“ I have again and again referred to the prosaic fact that there are
among the inhabitants of this country 200 million cartons teeth, as
many alveolar abscesses (pyorrhoea alveolarls), and some 30 million root
abscesses.”
I ventured to ask for evidence of this “ prosaic fact,” and
Dr. Campbell replies by stating that—
“ Taking the population of the United Kingdom as 45 millions, this,
according to my estimate, implies for each Individual 44 carious teeth,
4A alveolar abscesses, and 2 root abscesses for every three persons. Does
this estimate strike Mr. Pedley as excessive ? ”
To Dr. Campbell's question I answer frankly: very
excessive! Not in accordance with my experience; but
that it only my opinion. Surely calculations based upon
such estimates are not facts. Faett are truth*, and can only
be regarded as such when supported by irrefutable evidence.
Here is an illustration. Dr. Campbell quotes extracts from
Dr. James Wheatley's report of 1914 to the education com¬
mittee of the Salop County Council as to the prevalence of
dental caries among elementary school children, and if it is
remembered that the percentages include temporary teeth as
well as permanent teeth I entirely agree, because it accords
with the evidenoe of the Schools Committee of the British
Dental Association, and it has been amply proved by 1000
school medical officers during the past ten years, as recorded
in the annual reports of the Chief Medical Officer to the Board
of Education. One brief quotation will suffice. On p. 29
of the 1915 report it is stated—
“The proportion of defective teeth including all degrees of defect Is
higher than in any other malady, and often exoeeds 70 or 80 per cent."
Curiously enough, Dr. Campbell seems to refute part of his
estimate, for he writes:—
When we come to examine adults we find that a considerable pro¬
portion of carious teeth have been extracted owing to the trouble tnev
have caused, so that the number of carious teeth in a given mouth
does not represent the number of permanent teeth which nave become
carious within It.”
Either the 45 million inhabitants have the 4J carious teeth
or they have not.
With regard to the 4J alveolar abscesses (pyorrhoea
alveolaris), these diseases are not identical. Alveolar
abscesses are in the majority of oases root abscesses.
Pyorrhoea alveolaris is suppuration at the necks of the teeth
with slow destruction of the alveolus. The dental surgeon
differentiates them, as the physician does pneumonia from
pleurisy. Therefore the 4± aheolar abscesses, and the
two root absoessas for every thiee persons, may be added
together. 1 do not understand Dr. Campbell’s estimate of
pyorrhoea alveolaris. His endeavour to find figures for me
in 17 men “ hastily examined ” reminds me that, like many
of my colleagues, I have examined during the past four and a
half years quite a large number of soldiers* and sailors’ mouths.
I believe it is possible to identify, clinically, four or five
different forms of suppurative inflammation of the gums
which at first might be described as pyorrhoea alveolaris, but
which heal up under appropriate treatment without the loss
of any teeth.
In conclusion, I deplore the extent of dental caries and its
effects, but I think much harm may be done by loose state¬
ments and exaggerated ideas. Experience has taught me
that there is no royal road to the prevention of dental
diseases. To believe that our nation will alter its diet to save
its teeth is chimerical. The chief safeguards are habitual
cleanliness, systematic inspection, and early treatment. Much
has been done during the past 20 years to help the children
in our residential Poor-law schools, and an excellent beginning
has been made during the past 10 years by the establishment
of 300 school dental treatment centres for the children of
the elementary schools. Only when skilled assistance is
available for every child in the country can we hope to have
a nation with clean and healthy mouths.
I am, Sir, yours faithfully,
R. Denison Pedley.
Railway Approach, London Bridge, S.B., Jan. 20th, 1919.
THE DREAMS OF THE TERROR-NEUROSIS.
To the Editor of Thb Lanobt.
Sir,—D r. C. S. Myers (Lieutenant-Colonel, R.A.M.C.
(T.O.)), in his article published in your issue of Jan. 11th,
draws attention to the dreams of the terror-neurosis
encountered in warfare. He raises certain points of interest,
in particular as to how such dreams subside as the neurosis
improves; whether there is any gradual intrusion into the
incidents of warfare characteristic of the terror-dream by
those of civil life.
In my experience there is rarely any such history.
Patients who have suffered severely from terror-dreams
during the earlier phases of their disability associate their
improvement with the subsidence, not of the terrifying
incidents only, but of dreaming altogether. In the majority
of cases of the terror-neurosis patients in the period of
cure cease to dream at all, and this is of interest in that it
agrees with what the same patients so often say in reply to
the questions as to the nature of their dreams before they
broke down, before they were invalided, that is to say. For
the most part they are oonsistent in saying that they did
not dream at all, and certainly bad had no frightening
dreams.
There would appear, therefore, to be no period before
the dysthymic somatic symptoms become obtrusive in which
there are terrifying dreams; the somatic bodily symptoms
precede the dream. At first sight this may seem to be
curious ; it might have been thought that when the conscious
intelligence was in abeyanoe during sleep any emotional tone
that was experienced in the waking state and was not
allowed free play would make itself felt. The fact that this
is not so in many cases may be associated perhaps with the
intensity of the 4 * blocking” to which it was subjected
during the waking hours, the intensity being so great that
it 44 overflows ” into the sleeping state with a similar result,
and is, of course, responsible for the terminal somatic
symptoms of the neurosis. Once the somatic symptoms
have made their appearance and the patient is in a position
in which there is no further need for the emotion to be
blocked, then fear does appear, and, in severe cases, not
only in the dream but in the periods of wakefulness as
well. Then we do see the effect of intelligent control,
for as the case improves the fear leaves the patient
during the day but persists during sleep when such
control is in abeyanoe. In the course of time the
control exerted during wakefulness overflows into the
period of sleep and lessens the intensity of the dream.
Possibly the powerful efforts made by 'the patient to
control himself consciously operates in excess and stops
dreaming altogether for a time.
We might almost go so far as to say that the patient who
did experience fear in his dreams before the onset of somatic
symptoms would not suffer severely when the neurosis was
formed; the essential blocking of the emotion of fear in his
oase not being of any great intensity, not sufficiently intense
156 The Lancet,]
ENCEPHALITIS LBTHABOICA AND TYPHUS.
[Jan. 25,1919
to overflow into his sleep and prevent the terror-dream, and
therefore not sufficiently intense to bring about the neurosis
in any degree of severity.—I am, Sir, yours faithfully,
Manchester, Jan. 14th, 1919. DONALD E. CORE.
ENCEPHALITIS LETHARGICA AND TYPHUS.
To the Editor of The Lancet.
Sir, — I have been struck by the close clinical resemblance
which encephalitis lethargica as described in your columns
by Dr. A. S. McNalty and Lieutenant-Colonel A. J. Hall bears
to typhus fever, a disease little familiar to the medical
profession in England except in the pages of such a book as
Vincent and Muratet in the “ Military Medical Manual”
Series. The onset, the rash, constipation, the nervous sym¬
ptoms of both organic and hysterical nature, the stupor, the
inability to protrude the tongue (Remlinger’s sign in typhus,
hypoglossal palsy mentioned by Dr. F. G. Crookshank), and
tremors are some of the striking points these diseases have in
common. Epistaxis, however, has not, so far as I know,
been mentioned as occurring in lethargic encephalitis ; the
experience of most medical officers serving with the E.E.F.
is that epistaxis is also rare in typhus, contrary to the usual
teaching. I inquired recently about this point from an
Egyptian medical officer who had seen over 1000 oases of
typhus while serving with the Turkish Army; in no instance
did he observe epistaxis.
On the pathological side the cause of both diseases is
unknown, but an increase of the oellular content of the
oerebro-spinal fluid has been found by Major C. ft. Box in
lethargic encephalitis, and by Devaux in typhus in Roumania,
although it is to be noted that an excess of lymphocytes was
described by the former, and or polynuclear leucocytes by
the latter. Finally, the low mortality of lethargic encepha¬
litis does not contradict this thesis, for typhus mortality is
based on epidemics associated with starvation, bad hygienic
surroundings, and lack of proper hospital accommodation;
further, a mild form of typhus {Typhus lemssimus ) has been
recognised abroad for some time.
I am, Sir, yours faithfully,
H. L. C. Noel,
-Egyptian Hospital, E.E.F. Captain, B.A.M.O.
INVALIDISM FOR 15 YEARS THROUGH NASAL
BLOCKAGE.
To the Editor of The Lancet.
Sir, —In hisartiole in The Lancet of Dec. 14th, 1918, Dr.
G. A. Sutherland writes that men with cardio-vascular debility
“stand cold weather badly.” Last winter I saw a B 3 man
who told me he dreaded the cold weather. He always kept
several pairs of boots going and wore very thick socks, and in
them he placed felt soles. Damp boots and socks were a
horror to him. He said he was an invalid and had a bad
circulation. By chance my attention was drawn to his nose,
and I found his septum was deflected to the left side. He
refused an operation. I noticed his alae nasi did not move,
so I suggested he should practise nasal respiration. In a
week the action had become automatic, and he told me with
rapture he had passed from invalidism to strength. He
found that he could wear the same pair of boots every day,
and even do without socks. This latter was a great advant¬
age, as it saved him darning socks ! He told me he noticed
that on a cold day the air passing into his now opened-up
nostrils would send his blood shooting to the tips of bis toes
and Angers and acted like champagne on his mind.
He said the cold weather he used to dread now acted as a
tonic, and he revelled in it. The only alteration in his
manner of life that brought this change about was nasal
respiration, whioh kept his nasal passage on left side patent.
I am, Sir, yours faithfully,
Deo. 20th, 1918. Chas. J. Hill Aitken, M.D. Edin.
PHTHISIS IN FACTORY AND WORKSHOP.
To the Editor of The Lancet.
Sir,—M ay I write a few words in answer to Sir G.
Archdall Reid (The Lancet, Dec. 28th, 1918) ?
1. I consider tuberculosis a contagious disease produced
by the Baoillut tuberculosis.
2. Even though practically everybody is exposed to the
infeotion, only a relatively smell number of human beings
die from it—only predisposed people. Naegeli (500 cases of
post-mortem examination) found that 97 per cent, of the
patients dying in hospital (most of them living in towns)
showed evidence that tubercular infeotion had at one time
taken place. I
3. Predisposition is either hereditary cr acquired.
4. Amongst the most powerful causes of predisposition,
hereditary or acquired, is alcoholism.
5. We snow very well that civilisaticfti brings alcohol in
its train, and that many primitive races have disappeared
because they have taken to drinking “fire water.”
6. But we must add also that civilisation has brought
new diseases to those populations—measles, tuberculosis,
syphilis.
7. Dr. Ed. Bertholet has made the following observation.
Up to 25 years of age practically all his oase# of death from
tuberculosis occurred amongst abstainers or very moderate
drinkers ; over 25 years practically all the cases were chronic
alcoholics. I do not know whether his researches have been
confirmed elsewhere.
8. In my letter of Dec. 6th (The Lancet, Dec. 14th,
1918) I was trying to suggest a possible explanation of the
great difference in mortality from tuberculosis between men
and women under practically similar living conditions, the
only difference between them being what Dr. W. O. Sullivan
has called “ industrial alcoholism ” in the men.
I should be very glad to know if Sir G. Archdall Reid and
Prolessor Benjamin Moore have other explanations or hypo¬
theses to offer regarding these facts, my opinion being that
women are certainly living, in their homes, under conditions
more favourable to contracting tuberculosis, and to death ,
from it, than their husbands.
I am, 8ir, yours faithfully,
M. F. Boolenger.
Darenth Industrial Colony, Dartford, Kent, Jan. lOtb, 1919.
THE LEUCOCYTE COUNT IN INFLUENZA.
To the Editor of The Lancet.
Sib,—I have seen a few references to the blood in influenza
in papers published on the recent epidemic, and they all con¬
firmed past experience. So far as they go my results do the |
same, but I made no total counts. Obviously this omission
could not introduce abnormal cells into my films or take away
from them normal forms which they did not contain. And in
these respects alone has my experience been exceptional.
Excluding moribund and mild cases, it is based on the i
examination of three moderately severe uncomplicated cases |
which made good recoveries, and on three oases with severe '
bronchitic or pneumonic complications which died after 6-10 j
days of illness.
Briefly, in seven examinations of the fatal cases I saw no i
eosinopnile, and in the other cases these cells disappeared
during the height of the disease. Again, in every one
of the six cases plasma cells were seen on the fourth day or
later. Usually 1 or 2 per cent, were present, but in one of 1
the fatal cases there were 5 per cent, on the sixth day—four '
days before death. I have never seen enything approaching
this in the adult, and it is no exaggeration to call it a
phlogocytosis.
In pneumonia and typhoid the eosinopenia is well known.
In whooping-cough I have seen 3 per cent, of plasma cells
in children. But in a woman of 46. previously healthy,
5 per cent, in influenza seems worthy of record.
I am, Sir, yours faithfully,
Baling, W. ( Jan. 19th, 1919. R. ORAIK, M. D. Glasg.
METRORRHAGIA IN INFLUENZA.
To the Editor of The Lancet.
Sir,—T he very complete and excellent aooount of the
last influenza epidemic by Dr. Adolphe Abrahams, Dr. N.
Hallows, and Dr. H. French in The Lancet of Jan. 4th,
seems to me to require one slight emendation from the
clinical side, in which only I am able to criticise. It is said j
that in the haemorrhages nothing abnormal was found from
the uterus. If the authois will make a few further inquiries
they will find that while * pis taxis was common in males, it
was rare in females, but these latter in a large proportion
had menses coming on luring the fever and before the
proper time. It was at least so in this neighbourhood, and not
alone in my experience. In two instances definite miscarriages i
The Lancet,]
THE SERVICES.
[Jan. 25,1919 157
occurred. One pregnancy terminated three weeks before
time on the second day of illness and the influenza ran an
ordinary gourse afterwards of about a week, the mother
nursing her baby all the time. One patient aborted at
seven months about 12 hours after lung symptoms with
cyanosis had appeared ; the child was stillborn and the
mother was dead about 16 hours afterwards, the third death
from the septicsemia in that houie and family. It seemed
that epistaxis or metrorrhagia always denoted a bad or
prolonged attack.
Another point was that a high temperature did not mean
a severe attack ; three oases hpd an ascertained temperature
about the second or third day of 106° F. and they all came to
normal in an average time and afterwards recovered quickly.
They were all in girls and in families who kept clinical
thermometers ; probably there were others, for I am glad to
say only a minority of my patients indulge in the luxury of
thermometers. I am, Sir, yours faithfully,
St. Ives, Huntingdon, Jan. 6th, 1919. W. R. GROVE.
to practise till the Franco-German War. While in Paris,
where he became physician to the Galignani Hospital, he
had many distinguished Frenchmen as patients and was
Foreign Correspondent to The Lancet for many years.
Settling in London in 1871, he practised there until his
sight failed as the result of glaucoma. Here also he con¬
tinued to advise many distinguished foreigners. The Empress
Eugenie was his patient and friend. A skilful practitioner
and a gracious personage, he had many warm attachments.
Ohepmell was a keen and expert swordsman, and several
of his London colleagues were induced by his example to
take up fencing. Of his two sons one became a member of
the medical profession, the other entered the Army, and
three of his grandsons have fallen during the war.
I am. Sir, yours faithfully,
Devonshlre-place, W., Jan. 20th, 1919. GEORGE H. SAVAGE.
AMCEBIC DYSENTERY CARRIERS : A
CORRECTION.
WAR DEAFNESS.
To the Editor of The Lancet.
Sir,—I n the contribution of Dr. 0. S. Myers to the study
of shell shock in your issue of Jan. 11th thdre occurs the
following statement;—
“ Moreover, every physician of experience must have met with
patients suffering from functional deafness whose sleep has not been in
the least disturbed by the loudest noises/’
May I venture to ask Dr. Myers whether he or any observer
in whom he has confidence has recorded any number of such
-cases ? So far as I am aware, many of us believe that func¬
tional deafness is extremely rare, and that it can only be
diagnosed with certainty after recovery has taken place. For
my part, were the question addressed to me, 1 should have
to answer it with a decided negative.
I am, Sir, yours faithfully,
Jan. 17th, 1919. P. McBRIDE.
THE “ SPECTRUM ” OF EPILEPSY.
To the Editor of The Lancet.
Sib,—T he weirdness of some of the fits of some of the
men discharged from the Army as epileptic makes prominent
in one’s mind the ever-present question : Whether there is a
boundary line between epilepsy and hysteria ? To be always
able to tell hysteria from epilepsy suggests inexperience ;
it is easier to the medical student than to the epilepto-
logist. The student can quote a text-book. The fact may
be that there is no dividing line. As we know nothing
About epilepsy—though much about epileptics—and the
physiology of the nervous system is still an infant, fanciful
explanations are still permissible. We may fancy that there
are three diseases: malingering, which is an affair of the
eonscionsness, hysteria (rampant egoism of the subliminal
self), which is an affair of the subconsciousness, and
epilepsy, which is an affair of the unconsciousness. If that
be so, there are no dividing lines between the three
diseases. Epilepsy shades into hysteria and hysteria into
shamming, as the colours shade into one another in the
spectrum. It might tend to promote scientific treatment
of convulsive diseases if the physician would make a
spectrum-like chart of malingering, hysteria, and epilepsy,
and attempt to plot on it the individual fits of his particular
patient. I am, Sir, yours faithfully,
Alan MoDougall,
Director of the David Lewis Epileptic Colony.
Sandla Bridge, Cheshire, Jan. 19th, 1919. y
ISAAC DOBRfiE CHEPMELL.
To the Editor of The Lancet.
Sir,—T he death of Dr. I. D. Chepmell was briefly noted
in The Lancet of Jan. 4th. He was one of the oldest
members of the profession, but having left London many
years since his life is familiar only to a few. Bom in
Guernsey in 1828, the second son of Captain Charles
Chepmell, he was at first educsted at Elizabeth College,
Guernsey, and later at King’s Co lege, London. In 1850 he
took the L.S.A. and then travelled in France and Italy with
Lord Holland. He became master of French and Italian,
thus laying the foundation of his future professional success!
In 1859 he married and .settled ii Paris, where bb continued
To the Editor of THE LANCET.
Sir,— In my recent article on amoebic dysentery carriers
among new entries to the Royal Navy (The Lancet,
Jan. 11th) I made the statement that Laviblia “ is not known
to be a normal parasite of the cat.” This appears to have
been erroneous. Neumann, in " Parasites et Maladies
Parasitaires du Chien et du Chat ” (Paris, 1914), mentions
the cat among the list of hosts from which this parasite has
been recorded. I am, Sir, yours faithfully,
Jan. 20th. 1919. _ H. A. BATLI3.
PLACE AUX EMBUSQUES?
To the Editor of The Lancet.
Sib,—A n open appointment as medical officer to the
Corporation of Birmingham Pensioners’ Hospital was
advertised, preference being given to “ senior men having
recent hospital experience.” A Lieutenant-Colonel, a
Major, and three Captains, Royal Army Medical Corps, all
with war service, were candidates. The appointment was
given to a young recently qualified man who has never
served his country. The undersigned gave up a good
position in 1914 to do his bit. He has served con¬
tinuously in four hospitals in Egypt and France since then,
and was foolish enough to hope that such war experience
would be taken into consideration in making the
appointment.
Demobilisation of temporary Royal Army Medical Corps
officers is imminent, and it is a great source of anxiety to
many men whose practices are now dereliot, how are they
to provide for the future of those dependent upon them.
I am, Sir, yours faithfully,
A. W. Comber, R.A.M.O.
THE SERVICES.
ROYAL ARMY MEDICAL CORPS.
Major R. G. Archibald, D.S.O., la placed on the half-pay list
under the provisions of Article 307 (7), R.W. for Fay and Promotion.
Temporary Captains relinquishing the acting rank of Major on
re-posting : J. H. Hood, A. M.Crawford, J. Greene, A. Manuel, W. H. D.
Smith, R. C. Alexander.
Temp. Capt. G. G. Buchanan to be acting Major whilst specially
employed.
Temporary Lieutenants to be temporary Captains: H. M. Berry, J. L.
Schilling, T. A. Fall, A. Robin, R. H. Vercoe, H. M. Birkett, 0. A. A.
Lever, S. Johnson, L. W. Huelin, H. Gibson, C. Clyne, T. J. Cobbe, P.
Savill, G. R. Jeffrey, W. B. Valle, B. Gandy, E. O. Hughes, A. P. Hall,
J. F. O'Mahony, G. B. Proctor, J. Mathewson, W. J. B. Lavery. C. H.
Blliston, E. G. Bunbury, J. C. Duncanson, C. I. McLaren. C. Dean,
B. M. Grace, G. O. M. Davis. B. K. Griffiths, G. A. Thompson, D. 0.
McCormick, C. G. Burton. R. N. Poner, B. A. T. Peters, F. J. Cairns,
J. B. Taylor, I. L. Maolnnes, V. J. A. Wilton, C. E. F. Salt, F. King,
S. S. Rosebery. G. Young, W. H. A. BUiott, H. S. Dixon.
Temp. Hon. Lieut. H. A. Haskell to be temporary Honorary Captain.
Officers relinquishing their commissions: Temp. Col. O. Richards.
C. M.G., D.S.O., AM. 8., and retains the rank of Colonel. Temp.
Lieut.-Col. Sir J. W. Barrett. C.B., C.M.G., and retains the
rank of Lieutenant-Colonel. Temp. Hon. Lleut.-Cols. H. A. Powell
and G. Dreyer. Temp. Majors W. M. Robson and A. J. Cleveland
and retain the rank ol Major. The following retain the rank of Major:
Temp. Capta. (aoting Major*) F. B. Young. A. Richmond, H. H. Warren,
W.S. Dickie, H. R.Grelletfc,W. M. Badenoch. R. S. Renton, J. L. Menzles,
Temp. Capta. J. S. Bellas, J. B. McCabe. J. M. Glasse, A. R. Jackson,
J. fif. Hebb. To retain the rank of Captain: Temp. Capta. G. W.
Ancrum, H. B. Brown, R. N. Porter, H. G. Rloe, G. H. Rodolph, G. B.
Moflfatt, 0. Y. Fiewitt, J. F orest, A. G. J. Thompson, H. W. B. Ruxton,
A. D. Hamilton, H. Smurthwaits, S. H. Ryan, D. 0. MoArdle, A.
158 The Lancet,]
THE WAR AND AFTER.
[Jan. 25,1919
t
Dingwall, J. L. Johnston, J. T. Gunn, A. B. Laldlaw, W. W.
Wood, J. A. H. White, A. Dixon. J. Ferguson, R. H. S. Tornev,
D. J. McAfee, W. B. Watson. T. A. Matthews, G. E. Oatta,
J. L. McCann, D. J. Foley, C. Watson, L. J. Weatherbe, W.
Warburton, J. H. Morris-Jones, J. Fletcher, T. E. Flitcroft. S
McNair, F. W. Perry, A. H. Murch, W. H. Beat, G. R. Phillips,*
J. A. V. Matthews, J. Reid, M. Golding, J. C. Wootton, R. W. Greatorex
A. 8. Wilson, f. 8. Adame, D. T. H. Croly, F. Barnes, T. Henderson.
B. H. Worth, S. C. H. Bent, M. W. Baker, H. Walker, A. H. B. Hartford,
T. N. Bride, G. Dnsworth, D. Mann, H. P. Wright, R. B. Whitting.
J. Morris, G T. Bogle, A. F. Waterhouse, P. W. L. Camps.
J. Steward, G. P. Young, M. S. Baler, V. Lloyd-Rvans, A.
Simpson, P. B. MacNaught, R. F. Bminson, A. G. Wilson, O. J.
Nicholson, H. Tren, G. Graham, J. Clark, F. M. H. 8anderson, T. B
McKendrick, G. H. 0. Lum-den, A. Manuel (acting Major). E. Wight
G. W. Thompson, J, CameroD, H. D. Haworth, W. B. Hendry, E. A. B
Poole, H. F. Warner. T. B. Johnston, K. Fraser. R. Appleton, D. J*.
McLeish, O. Smith, P. de S. Smith, R. C. Ilarkness (acting Major),
J. C. Mead, R. O. Smyth, B. L. Hutchence, A. S. Bradley, W. H
Blakemore. J. T. Carson, ,*S. S. Brook. W. P. Lowe, R. B. Johnston!
G. H. Davy, W. C. Fowler, T. F. Murphy, H E. Middlebrooke. J.
Holland, C. Barnard, W. V. Naish, G. Stoddart, L. Bromley, H. Upcott,
G. P. Humphry, G. W. Curtis, A. J. Hutton, A. J. McConnell, H
Widdas, A. Mason, E. J. Moiton. R. Edridge, H. M. Joseph, F W
Ritson, A. G. Henderson, D. A. Dewar, R. B. Walker, A. Ferguson!
A. Bryans, A. H. Mountcastle, J. H. Trench. R. J. Bonis, D. A. Powell
E. F. R. Alford, J. V. Cope, G. C. Cossar, D. W. Daniels, G. B. Moffatt.
H. S. Millar. H. R. Ramsbotham, C. A. R. Gatley, E.W. Milne, J. Wright,
J. Proctor. Temp. Hon. Capts. R. A. Holmes and C. E. 8. Jackson retain
the hon. rank of Captain. Temporary Lieutenants retaining the rank
of Lieutenant: W. Q. Wood, D. Robertson, J. Craig, R. Price, F. J.
Power, C. E. Elliston, B. Hutcheson. Temporary Lieutenants : A. A.
Hall, Temp. Hon. Lieut. H. A. Lownds. The undermentioned on
transfer to R.A F.: Temp. Major (acting Lieut.-Col.) J. L. Birley;
Temp. Capt. (acting Major) J. H. Porter; Temp. Capts. J. H. Cooke.
P. H. Young, W. S T. Connell. L. W. Shelley, W. J. McKeand, C. W. W.
James, A. G U. Moore. F. A Hampton, C. H. Thompson, C. K. Attlee,
C. F. Graves. J. Cbambre, W. Waugh, T. N. Wilthew, W. B. Dove,
A. G. H. Smart, N. G. Graham, E. W. Craig, D. H. Fraser, G. Cranstoun,
J. Freeman, W. H. Cam; Temp. Lieut. G. D. M. Beaton.
SPECIAL RESERVE OF OFFICERS.
Lieut. G. N. Groves to be Captain.
TERRITORIAL FORCE.
Major (acting Lieut.-Col.) J. Evans relinquishes his acting rank on
ceasing to command a Field Ambulance.
Capt. (acting Major; H. Drummond relinquishes his commission on
account of ill-health contracted on active service, and is granted the
rank of Major.
Capt. A. E, Ralne relinquishes his commission on account of ill-
health contracted on active service, and retains the rank of Captain.
2nd Western General Hospital: Capt. C. P. Lapage reverts to the
list of officers available on mobilisation and is restored to the
establishment.
1st Eastern General Hospital: Major A. Cooke Is restored to the
establishment.
TERRITORIAL FORCE RESERVE.
To be Majors: Major (acting Lieut.-Col.) A. E. Hodder, from 3rd
North Midland Field Ambulance; Major W. M. Mackay, from Attached
to Units other than Medical Units; Major W. U. Milbanke, from
Attached to Units other than Medical Units ; Major A. B. Murray, from
Attached to Units other than Medical Units; Major (acting Lieut.-
Col ) A. Cal lam, from 2nd Bast Lanca* Field Ambulance ; Major H. E.
Corbin, from the General List.
To be Captains: Capts. R. D. Cran, F. Harvey, A. N. Crawford,
John Livingston. G. Eustace, J. D. Lickley, N. G. H. Salmon,
M. Wilks, O. Teichmann, from Attached to Units other than Medical
Units; Capt. (acting Major, T. H. Peyton, from 1st Home Counties
Field Ambulance; Capt. H. C. H. Bracey, from General List; Capt.
A. J. Campbell, from South Wales Mounted Brlgtde Field Ambulance;
Capt. J. Carroll, from 3rd Welsh Field Ambulance: Capt. C. R. Crowther,
from 2nd Wessex Field Ambulance ; Capt. A. C. C. Lawrence, from
2nd Northern Field AmbuUnce; Capt. (acting Major) G. Potts, from
Attached to Units other than Medical Units; Capt. (acting Major)
A. C. Watkin, from 2nd Home Counties Field Ambulance ; Capt. (acting
Major) S. McCaualand, from 1st West Lancs Field Ambulance ; Capt.
J. Fenton, from Wessex Casualty Clearing Station; Capt. W. S. Forbes,
from 1st Loudon Casualty Clearing Station; Capt. W. W. J. Lawson.
3rd West Riding Field Ambulance; Capt. C. H. Lilley, from 2nd London
Sanitary Company; Capt. A. V. M*vbury, from 3rd Wessex Field
Ambulance; Capt. C. G. Meade, from Yorkshire Mounted Brigade Field
Ambulance; Capt. R. W. Nevln. fr -m 1st Northampton Field Ambu¬
lance ; Capt. (acting Major) W. Sneddon, from 3rd West Riding Field
Ambulance; Capt. (acting Major) J. L. M. 8ymns, from 1st Bast
Anglian Field Ambulance; Capt. (acting Major) R. M. Vick, from
3rd London Field Ambulance.
ROYAL AIR FORCE.
Medical Branch— Major A. V. J. Richardson to be acting Lieutenant-
Colonel whilst employed as Lieutenant-Colonel. L S. Gross (durgeon-
Lieutenant, R.N.) is granted a temper try commission as Captain.
Capt. J. A. Watson, Capt. H. Greenwood, Capt. E. J. Boyd (Surge >n,
R.N.), Major-Gen. R C. Munday, C.B. (retains the rank of Major-
General), Capt. H. J. Shanley (Captain. R.A.M.O., T.F.), and Capt.
J. A. Wilson relinquish their commissions on ceasing to be employed.
Capt. A. E. McCulloch and Lieut.-Col. H. J. Hadden (Fleet Surgeon,
R.N.) relinquish their commissions at their own request.
The Swiney prize of the Royal Society of Arts
has been awarded for the second time to Dr. Charles A.
Mercier fora thesis on jurisprudence.
Dr. W. H. R. Rivers has been appointed Praelector
in Natural Sciences at St. John’s College, Cambridge, where
he already holds a Fellowship.
Cjif Mar an!) %iks.
The Casualty List.
The names of the following medical officers appear among
the casualties announced since our last issue :—
Died.
Surg.-Lieut.-Com. M. H. Langford, D.S.O., R.N., was a
student at Middlesex Hospital and qualified in 1909.
He joined the Royal Navy shortly afterwards.
Surg.-Lieut. M. Meehan, R.N., qualified in Ireland in 1912
and shortly afterwards joined the Royal Navy.
Casualties among the Sons of Medical Men.
The following additional casualty among the sous of
medical men is reported:—
Lieut. J. Clarke-Morri8, West Riding Regiment and K.A.F.,
accidentally killed whilst flying in France, youngest son
of the late Dr. K. Clarke-Morris, of Blackheath, Kent.
The Honours List.
The following awards to medical officers in recognition
of their gallantry and devotion to duty in the field are
announced *
Bar to Distinguished Service Order.
Lieut.-Col. ANSON SCOTT DONALDSON, D.S.O., 3rd Fd. Arab.
Can. A.M.C.—For conspicuous gallantry and devotion to duty. This
officer was in charge of the evacuation of the forward area, and showed
great initiative In establishing dressing stations and collecting posts
directly In rear of the advancing infantry. He kept in touch with the
battalion and succeeded in evacuating the casualties almost as soon as
they occurred, in spite of heavy machine-gun and shell fire.
Lieut.-Col. THOMAS JOSEPH FRANCIS MURPHY’, D.S.O.,
6th Fd. Amb., Cau. A.M.C. — During an attack there were several
wounded cases whose evacuation was being held up by the intense
enemy barrage. This officer then brought up two motor ambulances,
which he left some distance in rear, and came up with bis runner to the
village and searched for the regimental aid-post, which he found after
much difficulty, all the time exposed to heavy fire himself, as he passed
several times through the enemy barrage and machine-gun fire. It wai
through his utter disregard of personal danger that the wounded were
Bafely cleared and many lives saved.
Distinguished Service Order.
Major JOHN CHARLES CAMPBELL, 7th Fd. Amb., Austr. A.M.C.
—For conspicuous gallantry and devotion to duty. This officer was in
charge of stretcher-bearers, evacuating all wounded from the right
sector of the advance throughout five days' fighting. He kept close
behind the Infantry and kepi in touch with the various medical offioers
under constant heavy fire. One night a direct hit completely
demolished his aid-post, but he got his men to a place of safety and
continued the evacuation of the wounded. He superintended the work
for five days continuously with groat oourage and persistence, setting
a fine example to all under him.
Capt. (acting Lieut.-Col.) THOMAS HBNRY SCOTT. M.C., 14th Fd.
Amb.—For conspicuous gallantry and devotion to duty. When the
vicinity of his advanced dressing station was being heavily shelled, it
was due to his coolness and able management that a number of
stretcher and walking cases were evacuated quickly and smoothly.
His foresight and organisation were mainly responsible for the very
large numbers of officers and men successfully evacuated during this
period under most difficult conditions.
Capt. (temp. Major) WILLIAM DUNCAN STURROCK.—For con¬
spicuous gallantry and devotion to duty, when the main surgical ward
and operating tent of a field ambulance were wrecked by shell fire, one
officer and two other ranks being wounded. He very quickly put
matters right, and. owing to the excellent arrangements made by him
throughout the operations, the wounded, in spite of difficult country
and lack of roadB, were very rapidly collected and evacuated.
Major (acting Lieut.-Col.) GBORGB GRANT TABUTEAU, No. 1 Fd.
Amb.—For conspicuous gallantry and devotion to duty in supervising
the evacuation of casualties during three days’ operations under heavy
shell fire. He maintained a chain of medical posts in close touch
with the battalions of his brigade, and the rapid removal of the
wounded was due to his coolness and untiring energy, which Inspired
his officers and men with confidence.
Second Bar to Military Cross.
Temp Capt. (acting Major) JOHN SAMUEL LEVIS. M.C., 51st Fd.
Arab.—For conspicuous gallantry and devotion to duty. During an
attack, when the regimental Std-posta were under direct enemy obser¬
vation, this officer, approaching them over ground swept by m«chtne-
gun fire, made arrangements for the wounded to be evacuated by a
safer route. He was IndefatlgaUe in the day in keeping touch with the
aid-posts as they moved forwaid, and during the night took stretcher-
bearers up to tbe front line to starch for wounded.
Capt. (acting Major) CAMPB8LL McNEIL McCORMACK, M.C.,
15th Fd. Amb.—For conspicuous gallantry and devotion to duty.
During various attacks this officer supervised the collecting of wounded
over a large part of the dlviional front. He closely followed the
advancing troops with his strefcher-bearers, evacuating the wounded
skilfully and speedily. On one Occasion during a retirement he person¬
ally, under heavy fire, reconnoitied the ground where the wounded lay,
and by his dlsp witlons of the stretcher-bearers undoubtedly saved their
lives and the lives of many of thj wounded.
Th» Lancet,]
THE WAR AND AFTER.
[Jan. 26,1919 159
Ttomp. Capt. CHARLES GORDON TIMMS. M.C., attd. 7<h Bn.,
B. Fus.—For conspicuous gallantry and devdtion to duty. During a
counter-attack this officer went forward'faun battalion headquarters
and effected several rescues of seriously Wounded men, conducting
them persona*ly to the lines. Throughout the week's fighting he
worked night and day, and the manner In which he disposed of
stretcher cases under heavy fire was admirable.
Bar to Military Crost.
MCapt. WILLIAM JAMBS DOWLING, M.O.v attd. 3rd Bn., M.G-
Corps, T. attd. 142nd Fd. Amb.—Be was in charge of stretcher-bearers
during very heavy fighting lasting for two days, and repeatedly went
forward to satisfy himself that the R.A.P. were bring kept clear. On
many occasions he himself led forward stretcher »quads under very
heavy fire. He invariably displayed great gallantry, and afforded a
magnificent example to all ranks working under him.
Capt. (acting Major) JOHN CBUIL ALEXANDER DOWSB, M.C.,
attd. H.Q.. 63rd Div.—For oonspiouous gallantry and devotion to duty.
This offloer controlled the evacuation of wounded from the whole of t he
divisional front under artillery, machine-gun, and rifle fire, and their
rapid and efficient evacuation was due to his untiring zeal and energy
in maintaining constant communications between battalions and field
ambulances. He set a splendid example to all ranks.
Capt. HUGH HAKT.M.O., No. 5 Fd. Arab., Can. A.M.C.—During an
aetlon this officer was in charge of the field ambulance stretcher-
bearers. His work under very heavy machine-gun and shell fire was
characterised by thoroughness and a clear and concise idea of the
situation at all times which was due to his keeping In dose touch with
the rapidly advancing Infantry. On this and other occasions he cleared
all casualties with exceptional rapidity. Bis courage and tireless
persistence w®re a source of Inspiration to all under him.
Lieut. WILLIAM PBAT HOGG. M.C., I.M.S.-Por conspicuous
gsllantry and devotion to duty. When his aid-post was heavily
shelled he collected all his casualties with great coolness and
nromptltude, and conducted them to a new post. He has previously
done similar fine work In action.
Oapt. JOSBPH RBGIS ALBBRIO MARIN, M.C.. Can. A.M.C., attd.
22nd Bt., ran. Inf., Quebec B.—During three days' hard fighting he
was Indefatigable In his attention to the wounded, working often under
heavy fire. He saved many lives by his skill and devotion to duty.
When all the officers had become ca-ualtles, and he himself was
wounded, he remained at duty and continued bis good work. Later on
be was severely gassed and had to be evacuated. The examp'e of his
self-sacrificing and gallant conduct had a great effect on the whole
battalion.
Temp. Surg. FRANK PBARCB POCOCK, D.S.O., M.C., R.N., attd.
Drake Bn., R.N.V.R.—He attended to the wounded under very heavy
fire and most adverse circumstances during operations lasting several
days. His courage and self-sacrificing devotion to duty were a splendid
example to his stretcher-bearers, and his skill was Instrumental In
saving the lives of many wounded men.
Temp. Oapt. (acting Major) MAURIOB AIUY8IUS POWBR, M 0.,
attd. 148th Fd. Amb.—For conspicuous gallantry and devotion to duty.
Whilst in charge of stretcher bearers he attended to and collected
wounded under heavy machine-gun fire. He worked unceasingly
directing stretcher-bearers, and evacuated several hundred wounded
from the B.A.P.’s in his sector. Although wounded (for the third
time) he remained on duty and showed great endurance, as on previous
occasions.
Capt. (acting Major) OUTHBBRT SC ALBS, M.C., attd. 150th Fd.
Amb.—For conspicuous gallantry and devotion to duty when in
charge of stretcher-bearers. -He exposed himself oontlnuiuly, moving
from place to place to collect the wounded under heavy machine-gun
and rifle fire. Thanks to the close touch he kept with the battalions,
several hundred wounded were quickly collected and evacuated.
Capt. (acting Major) HERBERT WILLIAM WADGE. M.C.. No. 10
Fd. Amb., Can. A.M.C.—This officer was In charge of the stretcher-
bearers of the ambulance during five days' fighting. He worked con¬
tinuously, directing the evacuation of the wounded In the forward
area. Under his leadership the bearers worked strenuously, and the
•wounded were evacuated with great rapidity. Although considerably
abakan by the explosion of a shell, he oontinned his work. .
Capt. THOMA8 WALKER, M.C., attd. 2/3rd Lond. Fd. Amb.—For
conspicuous gallantry and devotion to duty. He took a motor
ambulance ear to an advanced regimental aid-post under very heavy
shell fire and evacuated the wounded. Throughout the whole action
-he displayed great skill and disregard of danger in handling his
bearers, and was night and day in the line, keeping touch with the
regiments, under heavv shell fire.
Temp. Oapt. PHILIP HBWBR WBLLS, M.C., attd. 2nd Bn.,
C. (ids.—When moving up to an aid-post with the battalion head¬
quarters a shell fell on the party, causing many casualties, includ¬
ing the only other officer. Oapt. Wells, showing complete disregard
for personal safety, organised tne party and attended to the wounded.
Throughout the day he ceaselessly carried on his duties, and under
most trying conditions, being exposed to heavy shell-fire the whole
time. In aplte of tbe number of wounded he managed to attend to
all and arrange for their evacuation.
The Military Cron .
Capt. SIDNEY GEORGB BALDWIN. No. 9 Fd. Amb., Can. A.M.C.
—For oonspiouous gallantry and devotion to dnty. Under his
direction the wounded were dr e s s ed and removed from the battle¬
field without any delay. He often led his bearers through machine-
gun fire to reach wounded men, whom he successfully evacuated.
All through tbe fighting he displayed great disregard of danger.
Lieut. BAWA HARKI8HAN SINGH, I.M.8. — For conspicuous
gallantry and devotion to duty and coolness under fbe when in charge of
the dressing station of the ambulance. The dressing station came under
heavy fire at night and the situation was critical for a time. Be,
however, collected tbe wounded and brought them in. He alro showed
great coolness and Initiative when the ambulance was bombed by
aeroplanes during and after the attaok.
Temp. Surg. DAVID LBISBMAN BAXTER. R.N., attd. 1st Bn.,
B. Marines.—For oonsplcnous gallantry and devotion to duty during
an attaok. He early established an ail-poet well forward, and con-
tinned to move forward with the advance, showing utter disregard of
personal danger when search!og for wounded and having them
dr es sed under heavy fire. He caused all wounded to be rapidly
evacuated, and throughout set a very fine example to his staff.
Cspt. NEIL DOUGLAS BLACK, Can. A.M.C., attd. 25th Bn , Can.
Inf., Nova Scotia R.—For oonspiouous gallantry and devotion to duty.
With at’solute Indifference to the heavy shell fire this officer advanced
with the leading companies and attended to tbe wounded. The second
afternoon of the attack he advanced beyond the line under Intense
enemy machine-gun fire and dressed the wounded of other battalions.
His coolness and example were a source of .Inspiration to officers and
men.
Capt. TILLMAN ALFRBD BRIGGS, Can. A.M.C., attd 116th Bn,
Can. Infy., 2nd C. Ont. R. — During an attack he rendered Invaluable
assistance to the wounded of this and other battalions. He attended to
a number of casualties In the jumping-off position in spite of heavy
machine-gun and artillery barrage. Most of his dressers became
casualties, but he oontlnued to dress the wounded. As soon as he bad
attended to those he pushed forward across the open aud assisted
those who bad fallen, fils services were most valuable, and his work
of a very high order. He displayed remarkable coolness and energy
under fire.
Capt. HERMAN MACLEAN CAMERON, No. 3 Fd. Amb., Can A.M.C.
—For conspicuous gallantry and devotion to duty. This officer per¬
formed valuable work in establishing a new A.D.8. to conform with the
advancing line, under heavy machine-gun fire and artillery barrage,
working continuously for 24 hours without rest.
Temp. Capt. FREDERICK ORLANDO CLARKE, attd. 149tb Fd.
Amb.—For oonspiouous gallantry and devotion to duty in attending to
and evacuating tbe wounded from the forward area under heavy rifle
and machine-gun fire. He worked on until every case had been evacu¬
ated, and set a splendid example of zeal and endurance to all ranks
under him.
Temp Capt. ANDREW LESLIE EDMUND FILMBR COLEMAN,
attd. 2nd Bn., S. Gds.—For conspicuous gallantry, tirHess energy and
devotion in tending t he wounded during operations. For two da} s and
nights be never left his post, though ubjeoted to continuous machine-
gun fire and frequent bombardments of high explosives and gas.
During this period a oontiuuous stream of wounded poured in, both
from his own and other units, and by bis prompt attention and
ceaseless hard work be undoubtedly sated the lives of many severely
wounded cases.
Oapt. (acting Major) FRANK COLEMAN, 6th Lond. Fd. Amb.—He
displayed coT-spicuoua gallantry and devotion to duty at an advanced
dressing station wbioh Was frequently under heavy shell fire and night
bombing. He attended to and arranged for the evacuation of a very
large number of wounded, and his skill and able organisation were the
means of saving several lives.
Temp. Capt. PURSER DAVIES, att. 6th (London) Fd. Amb.-He
worked with little or no rest for 60 hours in the open under heavy fire,
dressing and evacuating tbe wounded. His oonspiouous exnmpte of
gallantry and self-sacrificing devotion to duty were an inspiration to
the stretcher-bearers, whose services be organised with great ability.
He saved many lives by his skill.
Temp. Capt. TREVOR G. FBATHBRSTONBAUGH.—For con¬
spicuous gallantry and devotion to duty In attending to the wounded
and withdrawing them to cover. In doing so be bad constantly to
move across ground exposed to fire. It was due to his ability and
ooolneas that casualties were evacuated so expeditiously, thus pre¬
venting any hampering of the critical operation in progress at the
time.
Temp. Capt. JOHN FINNEGAN, attd. 7th Bn., Lincolnshire B.—
For conspicuous gallantry and devotion to duty. At one time, when
the battalion was held up lining a bank, be oontlnued to move up and
down what was actually tbe front line, under enfilade fire, attending
to and evacuating wounded of his own battalion and also of other
dtvislona. By his disregard of danger for himself he saved numerous
lives of others.
Capt. DAVID DAWSON FREEZE, Can. A.M.C., attd. R. Can. B.—
In an attack he displayed great courage In dressing wounded under
heavy shell and machine-gun fire. He followed close up with the
battalion In the attack and. In the most exposed position, he continued
to dress tbe wounded and organise carrying parties, so that all the
Iwttallon casualties were evacuated in very short time. After the
objective had been reached be proceeded in advance under heavy
machine-gun fire, and dressed the wounds of a large number of tbe
enemy and evacuated them. Learning that a number of men of
another division were lying in front of our line, having been wounded
two days previously, be proceeded under heavy fire, dressed their
wounds and supervised their evacuation. His devotion to duty
throughout was admirable.
Temp. Capt. DOUGLAS HUGH AIBD GALBRAITH—For con¬
spicuous gallantry and devotion to duty. He was wounded In the
head whilst attending to a wonnded officer, and, though iu great pain,
oontlnued to carry out his duties for the remainder of the day with zeal
and determination.
Capt. ARTHUR HINES, Can. A.M.C.,attd. 26th Bn., N. Brunswick R.
—For conspicuous gallantry and devotion to duty during an attaok.
He went forward with tbe a> tacking waves, and on numerous occasions,
in tbe open and in face of the heaviest shell and machine-gun fire,
dressed the wounded. His utter disregard of danger was a constant
source of Inspiration to all ranks.
Temp. Capt. EDWIN LANCELOT HOPKINS.—For conspicuous
gallantry and devotion to duty in dressing wounded under fire during
a reconnaissance. He haa on all occasions displayed great coolness and
resource in carrying out his work.
Oapt. JAMBS STEWART HUDSON, Can. A.M.C., attd. 1st Bn.,
Can. Mtd. Rif.—F<>r conspicuous gallantry and devotion to duty during
operations. He attended to tbe wounded nnder exceptionally heavy
Shetland machine-gun fire. He personally superintended the collection of
wounded, and organised stretcher parties. His coolness and courageous
conduct set a high example to all.
Capt. ROY BERTRAM JENKINS, Can. A.M.C., attd. 24th Bn..
Can. Infy., Quebec R.—For conspicuous gallantry and devotion to
duty. D'urlng two days’fighting this officer accompanied tbe troops,
and was tireless In attending to the wounded under heavy shell, gas,
and machine-gun fire. As soon as the battalion had made good Its line
he established a rear aid-post close up, where be received and evacuated
wounded. Being exposed to fire himself, he arranged what cover was
possible for the wounded and continued at work until he was sure that
all had been cleared. He worked unceasingly, never thinking of
himself.
160 The Lancet,]
THE WAR AND AFTER.
[Jan. &5, 1919
Oapt. ALEXANDER JOHNSTONE.—Por oonspicuous gallantry and
devotion to duty. He display »-d the utranet energy and coolness in
collecting, dressing, and evacuating the wounded under heavy fire.
Through his untiring efforts 200 cases were disposed of in a very short
time.
Temp. Capt. JAMES GAY MER JONES.—For conspicuous gallantry
and devotion to du*y. Although exposed to heavy and continuous
shell fire throughout the dav, he continued to dress the wounded in
the gun line, thereby alleviating much suffering and saving many lives.
His courage on all occasions has been most marked.
Temp. Lieut. RATBNSHAW NARIMAN KAPADIA, I.M.S.—For
conspicuous gallantry and devotion to duty. Exposed to heavy fire,
he continued throughout the action to collect and dress the wounded,
who were much scattered, thereby saving many lives.
Temp. Surg. CHARLES EDWARD LEAKK, R.N.. attd. Hawke Bn.,
B.N.D., R.N.V.R -He was with the battalion during six days’ in¬
cessant fighting, and displayed untiring demotion to duty, dressing the
wounded under constant fire. His gallantry and coolness were a
splendid example, and Inspired the stretcher-bearers under his com¬
mand to great efforts to evacuate all the wounded, which was
accomplished with admirable care.
Temp. L»eut. DOUGLAS BURROWES LEITCH, attd. 13th Bn.,
Welsh R.—For conspicuous gallantry and devotion to duty. When
his battalion came under heavy shell and machine-gun fire be went
forward and rendered first aid to men lying In the open and removed
them to cover, being shot at by snipers and machine guns while
doing so. His zeal and disregard of danger throughout the operations
were splendid. Finally he was severely wounded.
Temp. Capt. JOSEPH PATRICK McOREEHIN, attd. 4th Bn.,
R. Fus.—Wh»le proceeding to assembly positions he^was knocked over
by a large piece of shell and badly shaken. Nevertheless be pushed
on and established his O.P. behind a bank. Unfortunately, unknown
to him, it was In the vicinity of a water point, and was very accurately
•helled all day and finally hit. In spite < f this, be worked on with
the greatest courage, dressing with care all the wounded, and in one
case amputating a foot
Oapt. ROBERT DEWAR MACKENZIE, Can. A.M.C., attd. 15th Bn.,
Oan. Infy., 1st O., Ontario R.—For conspicuous gallantry and devotion
to duty He dressed wounded under continuous shell fire, and kept
moving his dressing station forward, so as to be able to attend to the
more serious oases. He cleared the eases with the utmost dispatch,
and many times during the day went up, under shell and machine-
un fire, to rtre*s stretcher oases. His conduct throughout was
eserving of high praise.
Capt. DONALD CAMPBELL MALCOLM,8th Fd. Amb.,Can. A.M.C.
—He was in charge of the bearer division in the left sector during the
fighting. He showed great initiative and judgment at all times,
keeping in close touch with the advancing troops and clearing the
wounded. He worked continuously for 48 hours searching for and
attending the wounded in the open. On one occasion when the
advance was delayed near a wood he led his stretcher squads across the
open ground which was being swept by machine-gun fire and brought
many wounded back to safety. He displayed the greatest coolness
under fire and a perfect disregard for personal safety during the entire
action.
Capt. JOSEPH REGIS ALB ERIC MARIN. Oan. A.M.C., attd.
22nd Bn., Quebec R.—For conspicuous gallantry and devotion to duty
during an attack. He, through his prompt dressing of wounds under
heavy shell and machine-gun fire, alleviated the sufferings of many
wounded and saved the lives of some of the more seriously wounded.
His fearless example had the best possible effect on the m wal of the
men. He worked with determination and cheerfulness for two days
under very trying and dangerous eondltlons.
Temp. Capt. WILLIAM MILLERICK. attd. 10th Bn„ A. A S.
Hlghrs.—For conspicuous gallantry and devotion to duty. Hearing
that there were a number of severely w< unded cases in a village, which
oould not be moved until properly dressed, this officer at onoe went
forward and carried out his duties under heavy fire of every descrip¬
tion. He continued his work untiringly throughout the day, and by
hla skilful organisation of dressing and carrying parties was undoubtedly
responsible for saving many lives.
Temp. Capt. FREDERICK HAROLD MORAN, attd. 15th Bde.,
R.F.A.—For conspicuous gallantry and devotion to duty during an
advance. Throughout the operations he maintained his aid-post
practically at the battery positions, and dressed wounded of many
units under heavy Bhell fire. He more than once passed through heavy
barrage to get at and attend to wounded. His zeal and disregard of
personal safety were splendid.
Temp. Capt. (acting Major) DUNCAN METCALFE MORISON,
38th Fd. Amb.—When the infantry were ordered to attack at short
notice he went forward through a heavy barrage and completed the
neoeasary arrangements with the medical officer of the battalion for the
evacuation of the wounded. His gallantry and devotion to duty
ensured the wounded being rapidly cleared and many lives were saved
thereby.
Capt. DUNCAN ARNOLD MORRISON. 1st Fd. Arab., Can. A.M.C —
For conspicuous gallantry and devotion to duty, fie accompanied the
advanc ng Infantry to the final objective, and though wounded himself
remained on duty, continuing to do excellent work during two days’
operations, establishing an A D.S. as soon as the infantry passed
through. He behaved splendidly.
Capt. ROBERT DAVIES MOYLE, 2nd Fd Amb., Can. A.M.C.-For
conspicuous courage and devotion to duty. He followed the infantry
Into the open white it was still under machine-gun fire. Owing to the
condition of the ground it was impossible to get transport up, but he
organised bearer parties, collected all wounded Into a place of safety,
and suoceeded in securing dressings, food, and water for them, Baving
many lives. He set an example to all rai<ks under him.
Lieut, (temp. Capt.) WILLIAM DOUGLAS NEWLAND, 92nd Fd.
Amb.-Under conditions of open warfare he collected a number of
wounded for evacuation. The place came under verv heavy shell fire,
due to a number of Tanks passing close to his post. With great courage
and devothm he remained with the wounded until he was able to clear
them all, although the fire was so heavy that all troops had to leave the
immediate neighbourhood.
Capt. FREDERICK McGRBGOR PETRIE, Oan. A.M.C., attd.
31st Bn., Alberta B.—This offioer displayed great courage, coolness, and
devotion to duty under heavv fire and in most trying conditions. He
showed great executive ability in the evacuation of wounded, and,
although the casualties were very heavy, at no time was there any con¬
gestion at the R A.P. By his skill ul organisation and untiring energy
many wounded were evacuated during the operation.
Temp. Li*ut. GEORGE FITZPATRICK RIGDEN, attd. 16th Bn.
Iaq. Fus.—He established a first-aid post well forward, and in spite of
heavy machine-gun fire oarrled on his duties with admirable self-
possession, several times going forward in face of Intense fire to dress
wounded lying in exposed positions. It was largely due to hi*
unselfish devotion that some of the most serious cases received prompt
attention. His courage throughout was most marked. Finally he was
wounded.
Capt. LEWIS WILSON SHELLY, attd. No. 1 Aeroplane Bnpp.
Depdt, R N.—For conspicuous gallantry and devotion to duty. When
this depot- was heavi y bombed in a night raid he organised a dressing
station at the Repair Park, attending the wounded in the open. Several
b«*mhe fell close to him, woundli»g those around him, but he stuck to
his work and saved the lives of many by his coolness and courage.
C»pt. CHARLES GORDON STRACHAN.—For conspicuous gallantry
and devotion to duty in charge of stretcher-bearers. He worked for
24 consecutive hours across open ground which was constantly shelled.
He rallied his bearers when somewhat exhausted and disorganised by
heavy fire, and set them a very fine example of cheerfulness and com¬
plete disregard of personal danger. The successful evacuation of all
wounded was largely due to his uersonal conduct.
Capt. ROY HINDLEY THOMAS, 1st Fd. Amb., Can A.M.C.—For
superintending the evacuation of wounded when he went over the
entire area, still under heavy fire, locating the wounded, and after dark
succeeding in safely removing them all. His untiring devotion to duty,
initiative in establishing collect Ing-poate, and organisation of carrying
parties undoubtedly saved many lives.
Brought to Notice.
The names of the following medical officers, all of the
R.A.M.C., have been brought to the notice of the Secretary
of State for War for devotion to dnty and valuable services
rendered by them when prisoners of war, daring epidemics
of cholera and typhus fever, at the Prisoners of War Camp
at Wittenberg, Germany
Oapt. S. Field (since deceased); Maj. W. B. Fry (since deceased); Lt.
(temp. Capt., acting Major) J. La P. Lauder, D.S.O., M 0.; Maj. H. B.
Priestley, C. M.G.; Capt. A. A. Sutcliffe (since deceased); Maj. A. C.
Vidal, D.S.O.
Also the following for valuable and distinguished services
rendered in connexion with the operations in North
Russia:—
Lt. F. Evans, R.A.M.C. (T.F.); Lt -Col. T. McDermott, R.A.M.C.
Foreign Decorations.
French.
Croix dc Guerre.— Col. G. W. Barber, O.M.G., D.S.O., Austr. A.M.C.;
Maj. H. d’A. Blnmherg, R.A.M C. (T.F.); Bt.-Maj. L. G Bourdlllon,
D.S.O., M.O., R.A.MC.; Capt. E. J. Dickinson, M.O., Can. A.M.C.;
T mp. Oapt. (acting Maj.) D. McKelvey, M.C., R.A.M.C.; Capt. G. W.
Rogers, M.C.. R.A.M.C. (T.F.): Temp. Capt. (acting Maj.) H. B. G.
Russell, R.A.M.C.; Capt. (acting L'-.-Col.) G. P. Taylor, D.S.O., M.C.,
R.A.M.C ; Capt. (acting Maj.) A. P. Thomson, M.C., R.A.M.O. (T.F.);
Maj. F. L. Wall, M.C., Austr. A.M.C.
Croix de Guerre , avec Palme.— Col. R. J. Blackham, C.M.G., C.I.B.,
D.S.O., A.M.8. _
Sir Nestor Tirard has returned to 74, Harley*
Btreet, W.l, on his retirement from the command of the
Fonrth London General Hospital, Denmark-hill.
The Irish Dispensary Doctors’ Agitation.—T he
fight between the boards of guardians and their dispensary
medioal officers has taken an entire ohange owing to a reeo¬
lation, passed unanimously by the Cookstown (Co. Tyrone)
board of guardians on Jan. llth, condemning the present
dispensary system as being unsatisfactory both to the rate¬
payers and to the poor, and stating that the time had
arrived when the poor man should have oboioe of a
doctor for himself and his family. The idea underlying
this motion (a copy of which it was decided to send
to the Tyrone M.P.’s, to the Irish Chief Secretary, and
to each Poor-law board m Ireland) is that the dispensary
“lines” should be made available to any medical practi¬
tioner who was willing to accept them, and who would be
paid at each quarter for the number of the “ lines ” that had
been presented to him. It will be interesting to note what
other boards of guardians will do in the matter. At the
Coleraine board of guardians on Jan. 18th letters were read
from all the dispensary doctors in that union, returning the
increase of salary for the quarter, on the ground that the
scale fixed by the guardians was wholly inadequate to
meet the requirements of the doctors. It was moved
and seconded by two of the guardians to take no farther
action in the matter, but saner advice was followed, and an
amendment was carried (14 to 8) to consider the question at
a special meeting, the proposer of the amendment saying
that the Beale that they had adopted was inadequate, and
that the doctors shonla t>e paid a decent salary. So the
question rests for the present.
The Lancet,]
URBAN VITAL STATISTICS.
[Jan. 25, 1919 161
URBAN VITAL STATISTICS. *
(Week ended Jan. 18th, 1919.)
English and Welsh Tovms.— In the 96 English and Welsh towns, with
an aggregate civil population estimated at 16,500.000 persona, the
annual rate of mortality was 15 5, against 161 and 16 0 per 1C00 In the
two preceding weeks. In London, with a population slightly exoeeding
4.000,000 persons, the annual death-rate was 14*8, or 1*0 per 1000 below
that recorded in the previous week ; among the remaining towns the
rates ranged from 3 3 in Gl ucrstcr, 4 5 in Smethwick, and 5*9 in
Gillingham, to 23*5 in West Hartlepool, 26 0 in Liverpool, and 26 5 in
Bootle. The principal epidemic diseases caused 161 <lea*hs, which
corresponded to an annual rate of 05 per 1CO0, and included 60
from diphtheria, 49 from infantile diarrhoea, 24 from w’hooping-cough,
15 from scarlet fever. 8 from measles, and 5 from enteric fever.
The deaths from influ nza, which had steadily declined from
7559 to 380 in the ten preceding weeks, further fell to 274, and
included 43 in London. 33 in Liverpool, 18 in Manchester, and 12
in Sheffield. There were 5 cases of small pox, 1092 of scarlet fever,
and 1145 of diphtheria under treatment In the Metropolitan Asylums
Board Hospitals and the London Fever Hospital, against 5, 1058,
and 1139 respectively at the end of the previous week. The causes
of 54 deaths in the 96 towns were uncertified, of which 10 were
registered in Birmingham, 9 in Liverpool, 5 in Gateshead, and 4 in
Manchester.
Scotch Towns .—In the 16 largest Scotch towns, with an aggregate popu¬
lation estimated at nearly 2.500,000 persons, the annual rate of mortality
w*s 17*0, against rates increasing from 14 8 to 18 6 per 1000 in the
four preceding weeks. The 319 ocaths in Glasgow corresponded to an
annual rate of 14*9 per 1000, and included 6 from whooping-cough,
4 from diphtheria. 2 from infantile diarrhoea, and 1 from scarlet
fever. The 136 deaths in Kolnburgh were equal to a rate of 21*1 per
1000, and Included 8 from whooping-cough and 4 from diphtheria.
Irish Toxcns.— The 172 deaths in Dublin corresponded to an annual
rate of 22*1, or 0*9 per 1000 above that recorded in the previous week,
and Included 3 from infantile diarrhoea and 1 from measles. The 121
deaths in Belfast were equal to an annual rate of 15 7 per 1000, and
(□eluded 5 from infantile diarrhoea and 1 from measles.
VITAL STATISTICS OF LONDON DURING DECEMBER, 1918.
Ix the accompanying table will be found summarised statistics
relating to sickness and mortality in the City of London and in
each of the metropolitan boroughs. With regard to the notified
cases of infectious disease it appears that the number of persons
reported to be suffering from one or the other of the ten diseases
specified in the table was equal to an annual rate of 4-2 per
IdOO of the population, estimated at 4,026,901 persons; in the
three preceding months the rates had been 4 7. 5-9, and 4*0 per
1CO0. Among the metropolitan boroughs the lowest rates from
these notified diseases were recorded in Chelsea, the City of
Westminster, St. Marylebone, Hampstead, Finsbury, and the City of |
London; and the highest in Fulham, Ilacknev. Bethnal Green, Stepney. 1
Southwark, and Bermondsey. One case of small pox was notified during
the month ; this case belonged to Holborn. Tne prevalence of scarlet
fever was slightly less than in the preceding month: this disease waa
proportionately most prevalent In Fulham, Beihn&l Green, Stepney,
Poplar, Southwark. and Lambeth. The Metropolitan Asylums Bos
! piials contained 1087 scarlet fever patients at the end of the month,
against 931, 1184, and 1107 at the end of the three preceding months;
the weekly' admissions averaged 136. against 164. 178, and 146 in the
three preceding months. The prevalence of diphtheria was about
i 10 per cent, higher than in November; the greatest prevalence
of this disease was recorded In St. Paneras, Hackney, Bethnal
Green, Southwark. Bcrmo idsey, and Camberwell. The number of
rlipnthcria patients under treatment in the Metropolitan Asylums
Hospitals, which had been 1051, 1165, and ICGOat the end of the three
preceding months, numbered 1089 at the end of December; the
weekly admissions averaged 146, against 166, 169, and 129 in the
three preceding months. The prevalence of enteric fever was
about equal to that in the previous month; of the 15 cases notified
3 belonged to Kensingt> n, 2 to Hampstead, and 2 to Lambeth. There
were 23 cases of enteric fever under treatment in the Metropolitan
Asylums Hospitals at the end of the month, against 43, 56. and 33 at
the end of the three preceding months; the weekly admissions
averaged 1, against 6, 9, and 3 in the three preceding months.
Erysipelas was proportionately most prevalent in Chelsea, 8t. Paneras,
Stepney, Southwark, Camberwell, and Deptford. One case of
puerperal fever was notified during the month from each of the
boroughs of St. Paneras, Islington, Shoreditch, Bat tersea, and Wands
worth. Of the 7 cases of cerebro spinal meningitis 2 belonged to
Hammersmith, and 1 each to Paddington. Lambeth, Battersea, Dept
ford and Greenwich; while 1 case of of poliomyelitis belonged to
Holborn and 1 to Poplar.
The mortality statistics In the table relate to the deaths of civilians
belonging to the several boroughs, the deaths occurring in institu¬
tions having been distributed among the boroughs in which the
deceased had previously resided. During the four weeks ended
Dec. 28th the deaths of 5717 London residents were registered,
equal to an annual rate of 18*5 per 1000; In the three preceding
months the rates had been 11*4, 27*3, and 42*3 per 1000. The death-
rates ranged from 10*0 in Lewisham, 11*7 in Woolwich. 13*6 in
Hampstead, 15 0 in Finsbury, 15*2 in Wandsworth, 16 2 In Hackney,
and 16*3 in Greenwich, to 22*0 in Kensington, 22*1 in St. Mary-
lcbone, 23*3 in Holborn. 23*8 in the City of Westminster. 25*8 in
Southwark, and 26*7 la the City* of London. The 6717 deaths from all
causes included 124 which were referred to the principal infectious
diseases ; of these. 13 resulted from measles, 9 from scarlet fever. 36
from diphtheria. 7 from whooping-cough. 6 from enteric fever, and
54 from diarrhoea and enteritis among children under 2 years of age.
No death from any of these diseases was recorded during the month
in Finsbury, and in the City of London. Among the metropolitan
boroughs the lowest death rates from these diseases were recorded in
Hammersmith the City of Westminster, Shoreditch, Greenwich, and
Woolwich ; and the highest death-rates in Paddington, Holborn, and
Southwark. The 13 deaths from measles were 85 below the average
number in the corresponding period of the five preceding years, and
Included 2 in Islington and 2 in Woolwich. The 9 fatal cases of scarlet
fever showed a decline of 9 from the average number; 2 of these
belonged to Hampstead. The 36 deaths attributed to dinhtheria
were 25 below the average, and included 6 In 8outhwark and 3 each
in Paddington, St. Paneras, Islington, Hackney, and Bermondsey.
ANALYSIS OF SICKNESS AND MORTALITY STATISTICS IN LONDON DURING DECEMBER, 1918.
(Specially compiled for The Lixckt.)
Notified Cases of Infectious Disease. Deaths from Principal Infectious Diseases. |
Cities and
Bobouohs.
Estimated civi
population, 191'
Small-pox.
Scarlet fever.
Diphtheria.*
Typhus fever.
Enteric fever.
Other con¬
tinued fevers.
Puerperal
fever.
J
&
*5
b
w
|«
c *
n£
25
ll
i
*3
3
e
a
o
"o
Ch
i
H
Annual rate
per 1000
persons living.
K
1
00
s
1
a
i
£
O
1
JS
-
a
5
I.
li¬
ft
I s
Enteric fever.
Diarrhoea and
enteritis (undei
2 years).
1
1
'S c
*§I
ly
a Q-C
* &
If
58
1
1!
P
LONDON.
4,026,901
I 1
559
558
_
15
1 _
5
150
7
2
1297
42
13
9
36
7
5
54
124
0'4
5717
185
West Districts :
Paddington .
122.507
, _
1 N
13
2
1
30
3*2
_
_
_
3
_
' 3
6
06
186
19*8
Kensington .
161,535
I —
15
15
_
3
_
_
2
1 _
35
30
—
1
—
1
1
—
1
4
i*3
256
22*0
Hammersmith
114.952
—
13
13
_
1
_
_
3
2
_
32
3*6
—
1
—
—
—
1
2
02
146
16*6
Fulham .
145.186
—
34
20
_
1
_
_
3
_
_
58
5*2
1
—
1
—
—
3
5
0*4
196
17 6
Chekea .
57,368
—
4
i 2
_
_
_
_
3
_
_
9
20
—
1
—
—
—
1
2
0*5
86
19*5
City of Westminster
122.046
—
6
! 7
_
1
_
_
2
_
_
16
1*7
—
—
—
1
—
—
1
2
0*2
223
23*8
Xorth Districts :
St. Marylebone ...
92,796
_
1
13
1
15
2*1 ,
_
_
_
_
_
2
2
0*3
157
22*1
Hampstead .
75.649
—
1
4
_
2
_
_
3
_
_
10
1*7
—
—
2
—
1
—
3
0*5
79
13 6
St. Paneras .
186.600
—
17
38
_
1
_
1
13
_
70
4*9
_ ,
_
—
3
—
—
2
5
0*3
304
21*2
Islington.
297,102
—
25
27
_
1
8
_
_
61
27
-
2
—
3
—
—
4
9
04
396
17-4
Stoke Newington...
47.426
-r
2
6
_
_
_
1
_
9
2*5
_
_
1
—
1
—
2
0*5
62
17*0
Hackney.
Central Districts :
196,598
34
42
—
—
—
—
8
—
84
56
—
3
1
—
2
6
0*4
244
16*2
H< Ibom .
35.303
1
—
6
_
_
_
1
_
1
9
3*3
_
_
—
2
—
2
07
63
23*3
Fiusbury.
City of London ...
68,011
—
4
1
_
_
_
3
8
1*5
_
_
—
—
—
—
—
—
—
78
15 0
16,128
—
2
1
_
_
_
_
3
2*4
_
_
—
—
—
—
—
—
—
33
26 7
Cast Districts:
Shoreditch .
89,675
12
5
_
_
_
1
2
_
20
2*9
_
_
—
1
1
0*1
135
196
Bethnal Green
107,362
—
27
31
_ |
1
_
5 !
_
64
7-8
_
_
—
1
—
—
2
3
0*4
155
188
Stepney .
232,010
—
56
39
_
1
_
_
21
_
117
6 6
_
1
—
— 1
—
1
0
8
04
350
19-7
Poplar .
143,443
—
28
10
_
_
7
1
46
4*2
_ 1
_
1
—
—
—
3
4
0*4
234
21*3
'■ruth Districts :
Southwark .
167,936
55
35 !
_
_ 1
10 1
ICO
7*8
_
1
_
6
1
1
2
11
09
332
258
Bermondsey .1
107,635
—
12
35 ;
_
_
_
4 1
_
51
6-2
_
1
3 i
—
—
—
4
0*5
178
21 6
Limbeth.
272,038
—
52
39
_
2
_
6
1
100
4*8
_
_ ]
1
2
_ '
—
6
9
0*4
404
19 4
Battersea.
150,023
- J
12
16
_
_
1
6
1
36
31
_
\
1
1 1
_ !
—
3
6
0*5 I
215
18*7
Wandsworth.
300,787
—
38
45
_
_
_
1
7
_ 1
91
3*9 |
_ 1
1
— 1
5
6
0*3 ,
350
15*2
Camberwell .
239,461
_
22
44
_
_
_
12
_
78
4*2
_
1
1
2
1
—
4
9
0*5 :
352
19*2
Deptford.
103,527
17
13
_
_ I
_
6
1 i
37
47
1
2 1
_
— 1
1
4
0*5 |
148
18*6
Greenwich .
90,440
12
12
_
1
2
1
28 •
4*0
_ |
1
_
_
—
1
0*1 ;
113
16*3
Lewisham .
161,405
—
20
15
_
_
6
_ 1
41
3*3
_
- !
1 f
2
1
-
2
6
0*5 1
124
10*0
Woolwich.;
131,942
—
22
11
—
—
—
_
3
_
36
36
_
2 |
—
—
—
2
0*2
118
11*7
Port of London ...
~ l
-1
2
- j
- ,
1 J
-1
-
- |
-1
“I
3
“ 1
- 1
- 1
” ,
"I
-
— j
—
—
“ 1
—
—
* Including membranous cronp.
] 62 Lancet,]
MEDICAL DIART.—APPOINTMENTS.—VACANCIES. ETC. [Jan. 25. 1919
The deaths from whooping-cough numbered 7, and were 45 lielow
the average; of these. 2 belonged to Holborn. The 5 fatal cases
of enteric fever were 3 below the average. The 54 deaths from diarrhoea
and enteritis among children under 2 years of age were 38 below the
average, and included 6 in Stepney, 6 in Lambeth, 5 in Wandsworth,
4 in Islington, and 4 in Camberwell. In conclusion, it may be stated
that the aggregate mortality from these principal Infectious diseases
in London during December was 62 per cent, below the average.
Hhtiorl for fte miring $Stek.
SOCIETIES.
ROYAL SOCIETY, Burlington House, London, W.
Thursday, Jan. 30th.—Papers:—Prof. J. C. McLennan and Mr.
B. J. Lang: An Investigstion of Extreme Ultra-violet Spectra
with a Vacuum Oiating Spectograph.—Prof. J. C. McLennan
and Mr. J. F. T. Young: On the Absorption Spectra and the
Ionisation Potentials of Calcium, Strontium and Barium.—Prof.
J. 0. McLennan, Mr. D. S. Ainslie, and Mr. D. S. Fuller:
Vacuum Arc Spectra of various Elements in the Extreme Ultra¬
violet.—Mr. R. C. Dearie: Emission and Absorption in the
Infra-red Spectra of Mercury, Zinc, and Cadmium (communi¬
cated by Prof. J. C. McLennan).—Mr. B. Wilson : The Measure¬
ment of Magnetic Susceptibilities of Low Order (communicated
by Prof. J. W. Nicholson'. —Dr. F. Horton and Ann 0. Davies:
An Experimental Determination of the Ionisation Potential for
Electrons in Helium (communicated by Mr. 0. T. R. Wilson).
ROYAL SOCIETY OF MEDICINE. 1, Wimpole-street, W.l.
MEETINGS OF SECTIONS.
Monday, Jan. 27th.
ODONTOLOGY (Hon. Secretaries— F. N. Doubleday, G. Paton Pollitt,
J. Howard Mummery): at 7.30 p.m.
Paper:
Captain William Blllington, M.S., D.R.C.S., B.A.M.C., Mr. Arthur
H. Parrott, M D.S., L.D.S., and Mr. Harold Round, M.D.S.,
L.D.S.: Bone Grafting in Gunshot Fractures of the Jaw.
Tuesday, Jan. 28th.
MEDICINE (Hon. Secretaries—Charles R. Box, W. Cecil Bosanquet):
at 5.30 p.m.
Papert:
Dr. Gordon Ward i Apvrexi&l Symptoms in Malaria.
Dr. David Thomson: The Complement Deviation Test in Malaria.
Thursday, Jan. 30 th.
BALNEOLOGY AND CLIMATOLOGY (Hon. Secretaries-Ohas. W.
Buckley, J. Campbell McClure): at 5.30 p.m.
Paper :
Dr. C. F. Sonntag* Temperature Environment and Thermal
Debility,a Study of the Beneflcialand Injurious Effects of Heat.
The Royal < Society of Medicine keeps open chouse for
R.A.M.C. men and M.O.’s of the Dominions and Allies. The
principal hospitals in the metropolis admit medical officers
to their operations, lectures, &c. Particulars on application
to the Secretary at 1, Wimpole-street, London, W. l.
Finzi. N. S., M.B., has been appointed Medioal Officer In charge of tLc-
. X Ray Department, St. Bartholomew’s Hoiplta 1 .
fteanries.
For further information refer to the advertisement columns.
Alnwick Infirmary.—R.3. £150
Bath U tyal United Hospital.— H.P. and H.S. £150.
Bedford County Hospital.— Res. M.O. £150.
Birkenhead Borough Hospital —Jun. H.S. £170.
Birmingham General Hospital.— Vacancies on Res. Staff.
Bradford Royal Eg* and Ear Hospital.— Opbth. S.
Card id City. — Female Asst. M.O. £350.
Dcvonpod Royal Albert Hospital.—Ren. H.S. £300.
Dorset County Council -Temp. A*-st.. M.o.H. £403.
Elizabeth Garrelt Anders ni Hospital, Easton-road, .V. II'.—Female
Temp Asst. S.
Goran District Asylum. Cardonald, Glasgow,—Sen. Asst. M.O. AY->
Jun. Asst.
Hospital for Consumption and Diseases of the Chest, Brompton.—H.?.
30 guineas.
It a'inn Hospital.— H.S. £150.
Leeds General Infirmary.—R ob. S.O. £160. Res. Aural O. £1.0.
Oph. H.S. £50. Also Two H.S. and two H.P.
Manchester Royal Eye Hospital — Junior H.S. £120.
Norwich. Norfolk and Norwich Hospital.— Fourth Res. Surg. O. £2’.'C
Putney Hospital. Lower Common, S. II’. — Ite«. M.O. £150.
Uneeri'sHospital for Children,Hackney-road, E.—Rea. M.O. £200. AY
H.P. and H.S. £100.
Reading, Royal Berkshire Hospital. — H.P. and Sec. H.S. £250.
Royal Hospital for Diseases of dir Chest, :.!l, City-road, E.C. —Clin. Asst v
Royal National Orthnpwdlc Hospital.- Rob. H.S. £100.
South Lon dm Hospital for Women .—Female Asst. Path. £150.
Taunton, Taunton and Somerset Hospital.—Sen. H.S. £250.
Tewkesbury Union.— M.O. £55.
University of London — Examiners.
Western Ophthalmic Hospital, Marylelnne-road, N. II'.—Vacancies on
Medical Staff.
Westmorland Smatortum, Meathop. Grange-over-Saids.— Sen. Asst
M.O. and Asst. Tuberc. Officer. £350. Abo Jun. Amt. M.O. £250.
Softs, IRarriages, art feafts.
BIRTHS.
Pl vtt. —On Jan. 16th, at Daisy Bank-road, Victoria Park, Manchester,
the wife of Harry Piatt, M.S., F.R.C.3., Captain, R.A.M.C. (TA, of
a son.
Rankin.— On Jan. 11th, at Cairo. Kathleen, the wife of Captain
Thomas Thomson Rankin, R.A.M.O., of a son.
Tannfr.— On Jan. 12th, 1910, at Nursing Home, Worthing, the wife oi
Captain W. E. Tanner, R.A.M.C., of a son.
MEDICAL 8O0IBTY OF LONDON, 11. Cbandos-st., Cavendish-sq.,W.
Mohdat, Jan. 27th.—8.30 p.m.. Discussion on the Modern Treat¬
ment of Gonorrhoea of the Genito-Urinary Organs, introduced
bv Col. L. W. Harrison, K.A.M.O. Followed by Capt. D.
Thomson, Lieut.-Col. R. Bolam, Major A. Cambell, Capt. D.
Lees, D.S.O., Capt. D. Watson, Mr. C. Williams, and others.
M< 'ileal officers of the Colonial and Allied Armies will be
welcomed at the meeting.
TUBERCULOSIS SOCIETY, at the Royal Society of Medicine,
1, Wimpole-street, W.
Monday. Jan. 27th.— 8.30 p.m.. AddressDr. J. D. Grant :
Practical Remarks on Tuberculosis in Relation to the Upper
Air- and Food-passages.
ROYAL 80CIBTY OF ARTS, Jobn-street, Adelphi, W.C.
Wednesday,. Jan. 29th.—4.30 p.m., Paper:—Dr. F. Keeble, C.B.E.:
Food Production by Intensive Cultivation.
LEOT CJEES, ADDRESSES, DEMONSTRATIONS, &c.
ROYAL COLLEGE OF SURGEONS OF ENGLAND, Lincoln’s Inn
Fields, W.C.
Six Hunterian Lectures on Phases in the Life and Work of John
Hunter. The Lectures will be illustrated by Hunterian
Preparations, Drawings, and Records : —
Monday, Jan. 27ih.— 5 p.m , Lecture IV. : — Prof. A. Keith: John
Hunter as a Physiological Anatomist.
Wednesday —5 p m , Lecture V :—Prof. A. Keith : John Hunter as
an Experimental Physiologist.
Friday.— 5 p.m.. Lecture VI.:-Prof. A. Keith: John Hunter as
an Anthropologist.
KING'S COLLEGE HOSPITAL MEDICAL SCHOOL (University of
London), at the Lecture Theatre of the Medical School, King’s College
Hospital. Denmark Hill. S.E.
Course of Four Lectures on Malaria. Microscopic specimens and
lantern slides will be shown at the two last lectures.
Friday, Jan. 31st.—12 noon. Lecture I.:—Col. Sir Ronald Ross,
K.C.B., K.O.M.G.. F.R.S. Officers and Men of the Royal Army
Medical Corps are Invited to attend.
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith-
road, W.
Clinics each week-day at 2 p.m., Wednesday, Friday and Saturday
also at 10 a.m.
(Details of Post-Graduate Course were given in issue of Nov. 30tb, 1918.)
ROYAL INSTITUTE OF PUBLIC HEALTH, in the Lecture Hall of
the Institute, 37, Russell-square, W.O.
Coarse of Lectures and Discussions on Public Health Problems under
War and After-war Conditions
Wednesday, Jan. 29th.-4 p.m., Capt. T Carnwath, D.S.O.: Lessons
of65 • 1 nfluents Epidemic.
MARRIAGES.
Hallixax—Crosbie. —On Jan. 18th. a*- St Mary's Church, ClaphXm.
Major William Edward Hallinau, M.C.. K.A.M.C., to Lilian Annie
Crosbie. daughter of Colonel Crosbie, C.B. /
DEATHS.
Mould.— On Jan. 14th, at his resident, Colwyn Bty, George William
Mould, M.R.C.8., in his 84th year.
N.B.—A fee of 5*. m charged jor the insertion of Nnice* of Bird ■>.
Marriages, and Deaths.
BOOKS. ETC., RECEIVED.
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A Preliminary Course of Surgery. By R. L. Spittel, F.R.C.S. Bs fi 6
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Surface Tension and Surface Energy, and their Influence on
Chemictl Phenomena. By R. S. Willows, D.Sc., and E. Hatachek.
2nd ed. 4$. 6 d.
Catalytic Hydrogenation and Reduction. By B. B. Maxted, F.C.S.
As. 6i.
Transaction* of tbeOphthalmnlogieal Society of the United Kingdom.
Vol XXXVIII. 1918. 12s. Gd,
Constable and Co., London.
Italian Sea Power. By A. Hurd. 2 s.
Fifield, A. C.. London.
Wise Parenthood. By Marie Carmichael Scopes, D.Sc. With
introduction by Arnold Bennett. 2*. Gd.
Frowde, Henry, and Hoddf.r and Stoughton, London.
Tae Karly Treatment of War Wounds. By Colonel II. M. Gr.n.
F.H C S jo.v,
Manual of Bacteriology. By R. Mnir, M.D., and J. Ritchie, M.D
7th ed. 16*.
Manual of Elementary Zoology. By L. A. Borradatle, M. A. 2nd ed. Uv
Hoddkr and Stoughton, London.
The Disease and Remedy of Sin. By the Rev. W. Mackintosh Macksv.
B.D. Is. 6 d.
Longmans, Grf.ex. and Cu m London and India.
Recent Advances in Organic Chemistry. By A. W. Stewart. D.ai'.
With Introduction by J. X Collie, LL.O. 3rd ed. 14*.
System of Physical Chemintry. Bv W. C. McC Lewis, D.Sc. Edited
by 8lr Wm Ramsay. 2o4 c.i. VoN. I. and II. 15*. each.
Intravenous Injection in Wound Shock (Oiiver-Sharpey Lecture*.
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Simpkin, Marshall, London. Littleburt, Bros., Liverpool.
Hvpnotlc Suggestion and fcNvcho-Therapeutics. By A. B. Tap!in.
i L.R.C.e. and L.M. Kiln. 10..fid.
ThbLanokt,] NOTES, SHORT COMMENTS, AND ANSWERB TO CORRESPONDENTS. [Jan. 25, 1919 163
Jolts, Sjprci Ciranmnls, aid) Jnsfoers
Is d^omsponbeirls.
HEALTH, MEDICINE, AND SANITATION IN INDIA.
II.
Punjab.
The year 1917 was a healthy one tor the Punjab, exoept for a pre¬
valence of malaria In the last three months. The birth rate, 45'3 per
1GC0. was 0‘1 below the quinquennial average, but the death-rate, 37'9
( the same as in the United Provinces) was 6' ‘ above the average, and was
only exceeded by that for the Bo mb Ay Presidency (40* 76; in the year
uuder review ; the high rate was due entirely to “ levers,” whi-di caused
510,812 deaths, equalling 26*42 per 1000. the highest mortality since
1H08. Cholera was somewhat prevalent in Slalkot district, where
there were 232 deaths from this disease; in Sialkot itself there were
ill. and in Multan 118 deaths. Plague caused only 0 5 deaths per 1000,
but as 4084 ^nearly half) of these occurred during the last two months
uf the >ear, a bad epidemic was anticipated in 19l8. At Simla there
were 25 cases of enteric fever, 22 of which were among Bur pea ns ; in
10 of these cases the disease was considered to have been contracted
locally—no definite or common origin crnld be traced. Colonel H.
Hendley, who presents the report, held the appointment of
Sanitary Commissioner throughout the year, in addition to that of
Inspeotor-General of Civil Hospitals.
Xorth-Wesi Frontier Province.
In the North-West Frontier Province the blith-rate in 1917 (32*1 per
i000)was 2*2 below the quinquennial average, and was lower than in
any other province in India, except Assam ; the decline is attributed to
the severe outbreak of malaria in 1916. The death-rate was 29 9 per
1COO, being higher than the quinquennial average <25*5); nearly ail the
deaths (viz., 24 8 per 1000) were returned as " fevers.” No other disease
esased as much as 1*0 per 1000 mortality. Lieutenant-Colonel T. W.
Irvine. I.M.S., considers that the general population are too lethargic
and lazy to .take quinine until the attack actually comes on, and is
doubtful whether its unsupervised issue is of any use. He recommends
the cheaper quinodine as of value in treating mild infections.
Bihar and Orissa,
The growing appreciation of Wes ern medicine is noticeable every¬
where in the statistics of attendance both of indoor and outdoor
patients at the oharttable dispensaries. Most district boards have now
set before themselves a definite programme for Increasing the number
»f their dispensaries, and at the same time private practitioners are
becoming more numerous and enterprising, and Government service
1* by no raeanB the only career open to successful medio tl
students. The province has now established a board of medleal
examiners and has adopted a Medical Act to control the regula¬
tion of qualified practitioners and penalise fraudulent practitioners,
in this province the birth-rate for 1917 was 40*4 per 1000, a consider¬
able increase over the ratio for 1916 (36 6), probably due to stricter
registration, but lower than the average for 19ll-15, which was
42*8. A table is given showing the great variation in birth-rates in
tbe different provinces of India. Assam stands lowest (In 1917) with
313, and the Central Provinces highest with 48*1 per 1000. For the
quinquennium, 1911-15, Madras was lowest (31*6), and the Central
Provinces highest(49*2). Tbe death-rate in Bihar and Orissa was 35*2,
also higher than the ratio (32*8) for 1916, and that for 1911-15(31*1).
This increase is considered by Major W. C. Boss, I.M.S., the Sanitary
Commissioner, to be a real increase, due to the general uubealtbiness
caused by prolonged and excessive rains The mortality from
cholera (3 1) was high. On account of the expense and difficulty
in obtaining potassium permanganate for well disinfection, quick¬
lime was used, also cblorjgen. The mortality from fevers (22 5)
was also high, the deoennlal ratio for 1907-16 having been
20'6 per 1000. Anti-malarial measures on the usual comprehen¬
sive lines are being carried out. but the people appear to take
small interest in the work, and the difficulty of getting them to take
quinine as a preventive continues, though matters appear to be now
improving. Plague caused a mortality of 1*3 per 1000, higher than In
the preceding year (0 7). due partly to copious and prolonged rains.
Inoculation was carried out. but it is stated that it *• has never been
pooular, and as it is not a general preventive measure of any real value,
ths maintenance of a specie staff for inoculation has been discon¬
tinued ” Hat-killing by public agencies is also considered to be
“ essentially a failure because It does not accomplish the destruction
of any appreciable number of rats.” Evacuation appears to bs the only
preventive of practical value, bscause it is accepted by the people and
is carried out promptly. Major Rojs advocate* *‘a s'ow but definite
programme of legislation, involving a gradual advance in the standard
of sanitation required in cimmunities, with a view to enforcing the
idea of citizenship and responsibility in sanitary matters.**
Assam.
From the vital statistics for 1916 it does not appear that the health of
the province was seriously affected b» the disastrous floods of October.
There were cholera epidemics of some severity in Qoalpnrn, Darrang]
Nowgong, and North Lakhlropur. but on the whole the mortality from
this disease was below the average. There was no change In the
Reneral death-rate from small-pox, but the increased efficiency with
which the provisions of the Vaccination Act are administered produced
a substantial reduction In the prevalence of this disease In urban areas.
Fever was rather more severe than usual ia all dlstr<cts. The mortality
from ka'a azar va*led little from that of the preceding two veirs, but
the tendency which this disease is showing to spread in the upper
districts of the Assam Valley, which have hitherto been free from it, is a
source of considerable anxiety. In jails the dea’h-rate per 1C00, which
reduced from 43 53 in 1914 to 21*40 in 1915, again fell to 18*51
jn 1916, the last figure being the lowast ever recorded for the province.
The number of hospitals and dispensaries in the provinces rose during
Jhe year from 205 to 215, of which 124 were supported by local bodies.
18 ty private persons, and 73 by the Btste.
Owing to the transfer of medical offi ’cr* to military service and the
diffleulty of securing qualified substitutes the total number of Institu¬
tions at work Is still less by ten than It was at the commencement of
1914. A Pasteur Institute and School of Research was opened at
Shillong lu January, 1917, and has made a most promising start. The
Assam Medical Bill, the object of which is to protect the medical
profession and the public from imperfectly trained and irregularly
qualified practitioners, has been passed Into law.
The birth-rate in Assam for 1917 was 31*35 per 1000, slightly higher
than in 1916 (30*52), but lower than the quinquennial average (1911-15)
of 32*75, and lower than in any other provinca for 1917. The Sanitary
Commissioner, Major T. C McCombie Young, I.M.S., calls attention to
the defective character of the registration and of the population
returns. The death-rate was 27*09, compared with 28*59 for 1916 and
26 37 for 1911-15. An outbreak of typhoid occurred at Shillong; the
civil surgeon. Dr. Gordon Roberts, and Captain R. Knowles, the
director of the Pasteur Institute, carried out inoculation of 1760
natives, this being the first Instance of an Indian population volun¬
tarily submitting to typhoid vaccine inoculation on a large scale. An
outbreak of diphtheria occurred in a hoarding school at Shillong,
apparently Imported from Calcutta; stringent measures of isolation
were adopted, suspected cases and contacts were swabbed, and
the very large European child population of this crowded hill station
saved from an epidemic by the prompt action of the medical
authorities. Much work has'been done in the way of malaria prophy¬
laxis, especially at Lumdlng, an important junction on the Assam-
Bengal railway. A Urge distribution of quinine tablets was made,
and substantial improvements effected in details of drainage, applica¬
tion of iarvioldes, Ac. Kala-azar, as has been indicated, increased
during the year and extended to areas previously uninfected. The
disease is "tending to extinction” in Sylhet, but Nowgong, with
591 deaths from this cause, shows a considerable increase over any
previous year, and the disosse is now endemic in this distriot.
The United Provinces of Agra and Oudh.
The year was an unhealthy one. There was a heavy death-roll from
cholera, plague, and malaria, owing to the long continuation of wet.
The death-rate was 39*95 per 1000. The birth-rate In 1917 was 46*08
per 1000, tbe quinquennial average (1912-16) having been 44*91.
Shahjshanpur district had the excessively high, death-rate of 79 22.
due to cholera and fevers. The excessive mortality throughout
the provlnoes it put down to cholera and fevers, including under
the fatter head relapsing fever. Infantile mortality was excessive
(215*7), tetanus being unusually prevalent. Pamphlets and Instructions
to pothers and midwives in the vernacular have been distributed, mid¬
wives have been trained, and at Benares, Lucknow, and Allahabad
municipal dairies have been established. Cholera is still somewhat
prevalent (0*46 deaths per 1000) In spite of disinfection of wells and
general sanitary improvements, but Is much less fatal than had latterly
been the case (1*24 deaths per 1000 ia 1907-16). Plague caused 129,034
deaths (2*76 per 1000), a large increase over the quinquennial average
of 1*85. Thij is considered to be disquieting, but the weather condi¬
tions favoured spread of the disease. Tbe fever death-rate (27*05) w as
also unsatisfactory, being considerably higher than tbe quinquennial
average of 21*74; in Shahjahanpur district the ratio was 68*69 per 1000.
Owing to the scarcity of qualified officers, malarial investigations had
unfortunately to be discontinued, but anti-malarial works were carried
out, especially at the important station at Meerut Owing to the high •
price of quinine tbe “ qulnlnisation ” of school children was ordered by
tbe Government to be dropped. Colonel C. Maotagg&rt, O.I.E., the
Sanitary Commissioner, considers the high mortality from plague and
•' fevers ” to have been chiefly due to excessive rainfall.
Baluchistan.
The province has enjoyed immunity from every kind of epidemic
disease except cholera, which appeared in Zhob in June, 1916, when 35
villages were infected, causing 328 cases and 174 deaths. Thanks to
the timely and energetic efforts of tbe local medical and civil officers
the disease was prevented from spreading still further. A party of
Powlndahs who passed through the district on itheir way from the
Punjab to Afghanistan was responsible for Introducing the disease into
Zhob. Antlmalarlal measures were Adopted in several places with
good results During the year under report the number of malarial
eases treated In the dispensaries of the province fell by 3*77 per cent,
as compared w ith the number treated in the previous year. The vaccine
operations among the Zarkun and Mari tribes show that the moat
ignorant and backward people of Baluchistan are now beginning to
appreciate the advantages of vaccination.
Conrg.
An index in the well-b'ing of the labourer is to be found in the state
of the public health, which was considerably be ter than has been
noted for several ye*rs. The number of blithe was 9*68 percent, above, and
the number of deaths 24 52 per ce *t. below the average for the previous
five years. Quinine prophylaxis against malaria continued to he
administered in the secondary schools with satisfactory results. 50,500
quinine powders were sold to the public through tli9 agency of the
post offices. DelM
Sanitary conditions, especially within the city and civil station,
continued to show the improvement which has resulted from the
attention paid in recent years to this side of administrative
activity. The municipal report shows that the Banltary establishment
was increased, a new slaughter-house constructed, and drains extended.
The Important and costly antlmalarlal measures in the Bela were
pushed on and one section completed win the e vil station a brick
channel was constructed to the Najafgarh drain cut. Considerable
additions were made to the city western extensi »n. which should in
the time draw off a large number of mental occupations from the city.
The heavy monsoon rains rendered the year leas healthy than its pre¬
decessor, but. the death-rate (32 92 per 1030) nevertheless compared
very favourablv with the years preceding 1914. The exce s of births
over deaths, though lower than in 1915-16, also reflected a far more
satisfactory state of things than in 1914.
The Andaman and Xicoltar Isl i nds.
The record of the health or the year shows improvement as compared
with that of 1915-16, but the incidence of sickness and mortality has
still been high. The main cause of sickness was, as usual, malaria,
and of death pneumonia, now recognised to be a direct result of
malarial infection In the settlement Malaria not only affecta the
convict population, but persistently saps the vigour of tbe entire official
staff* leaving after-effects In its wake which are often permanent.
164 Thb lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Jan. 25, 1919
Hyderabad.
The difficulties to which the people were exposed on account of
unseasonable rain and high prices were still further aggravated by an
extremely severe epidemic of plague. In Hyderabad cltv alone no
lees than 14 053 peraonB died of this disease between the months of
October and April. In the districts the epidemic was no less revere,
and in out-of-the-way villages the suffering was very great, as it was
impossible to render these people any material assistance. The results
of this visitation were fa'-reaching and extended to almost every
-department of the State. Progress on the more important works was
seriously delayed and schools and courts were closed for several month*.
Numerous temporary hospitals to de^l with plague wore opened at the
«apital and in tne districts.
Crnlral India.
All the Ageucles. except Baghelkhand and Bundelkb&nd, were visited
toy plague, the only respite being in the hot weather. The incidence
was severest in Indore, where there were 1777 deaths out of 2396 in the
province. Fortunately, people now evacuate their houses as soon as
rats begin to die, and the increasing popularity of inooulat.inn is shown
toy over 90 r 0 persons having been inoculated in Indore. Cholera, in all
parts of Central India, accounted for 5474 deaths. Small pox was
prevalent, but reliable figures cannot be given. The birth-rate shows a
further fall from 11*81 to 11*15 per 1000, but the statistics are
unreliable. The death-rate Increased from 9 55 to 10*60 per 10C0.
LEMON JUICE OR LIME JUICE ?
To the Editor of The Lancet.
Sir, —YeB, the “ lime juice ” used by the British Navy in
1854 was lemon juice, as Fleet Surgeon W. E. Home
uuimoses. In my historical inquiry (The Lancet, Nov. 30th,
1918) I gave the approximate date of the change from lemons
to limes as “ about 17 years" after, not the return of Sir
-John Ross in 1843, but the return of Sir James Clarke
Ross from his search for Franklin in 1849. Records may
be found of the supply of lemon juice from Malta up to
the year 1862; this supply was for the whole Navy, except¬
ing only ships on service in the Went Indies which, from
1846, were famished with juice from Bermuda. The
Admiralty medical and victualling records later than 1862
-are not kept in the Public Record Office, and, since I bad
enough information for my immediate purpose, I did not
S ursue further in the records the question of the exact
ate at which the change was made to West Indian limes.
By 1875 the nse of West Indian lime juice had been estab¬
lished in the Navy, and the belief in its superiority is
further shown by the fact that It was used in the Meroh&nt
Service also as far as it was available; about one-third of
the merchant ships were supplied with it, the other two-
thirds having to be content with lemon iuice.
Between these dates—1862, when Malta lemons were still
tised in the Navy, and 1875, when limes had superseded
them—the Merchant Shipping Amendment Act was passed
in 1867. Before that, what w&b supplied to merchant ships
«6 lemon or lime juice was often grossly adulterated, but the
mere fact of having so-called “ lime juice ” on board (com¬
pulsory since 1844) wtaken by carelesaowners and captains
*s relieving them of any further responsibility for the care
of the health of their crews. This Amendment Act of 1867
•enacted that the lime or lemon juice issued must be such as
had been approved, fortified, and sealed in the presence of
az) officer of Customs. And juice was received for examina¬
tion and sealing only from manufacturers who held licences
from the Board of Trade. I suppose that it would be on the
introduction of these new regulations that the growing West
Indian industry would have an opportunity of securing its
position, but I have never exactly verified this supposition,
And am at present remote from records. In any case, it was
■certainly about that time.
A fuller account of some facts in the history of “lime
Juice ” is to be published soon in the Journal of the Royal
Army Medical Corps. —I am, Sir, yours faithfully,*
Ju. 21st, 1919. Alice Henderson Smith.
HEALTH AND RADIANT HEAT.
In his lecture on Coal and National Health, delivered at
the Roval Institute of Public Health on Jan. 15th, Professor
W. A. Done admitted that in the past a great deal of coal had
been wasted in domestic grates through our ignorance of the
first principles of combustion. The science of clothing as
well as that of indoor heating and ventilation largely resolved
itself, he said, into a question of aiding the skin in main¬
taining the normal bodily temperature under varying con¬
ditions of work and plajt without symptoms of discomfort
and distress. Dr. Leonard Hill had laid dow*n the conditions
of comfort and health to be those prevailing in the open on
a balmy summer day, with the ground warm to the feet, the
surface* of the body exposed on the one side to the radiant
heat of the sun and on the other to the cooling bree/.e which
played around the bead. No monotony, but a continual
change of thermal conditions. The cooling and drying
breeze round the head meant that more arterial blood
had to pass through the vessels supplying these parts
in order to maintain the body temperature, and that far
more lymph had to pass through the respiratory membranes
to maintain the evaporation required to saturate the dry air.
Contrast these conditions with the tropical and monotonous
state of the warm, humid air of crowded rooms, heated by
steam coils, and it became evident both what we ought to aim
at and what we ought to avoid in our domestic heating and
ventilation. The British climate being what it is, we should
aim at warm floors and avoid monotony in our physical
environment by the use of the open fireplace. Much waste
of fuel and personal discomfort were, he said, unneces¬
sarily caused by the prevailing practice of flooding living
rooms in the early winter mornings with cold, damp air.
Living apartments should at all times be sufficiently venti¬
lated and aired whenever the external atmospheric con¬
ditions admitted, bnt in winter time “ airing ” should be
confined to the middle part of the day. In the early
mornings or on cold raw days it was better to keep windows
closed and to allow chimneys to draw in the outside air.
The immediate line of practical reform lay in the direction
of constructing all fireplaces on scientific principles and in
substituting for the raw coal a low-temperature “ semi-
ooke ” as soon as this could be produced commercially on a
large scale at a reasonable price. For gas fires silent com¬
bustion and adequate ventilating efteot should be insisted
upon. The choice between these two types of heating was,
he said, determined not so much upon hygienic gronndsas
on personal predilection and local conditions.
A WARNING.
To the Editor of The Lancet.
Sir,—T hefts from motor-cars are on the increase. I have
just had a nitrous oxide oxygen outfit stolen from my car,
which bad been left for 25 minutes outside a shop in New
Cavendish-street, and I gather from the police that other
thefts occurred on the same day, Jan. 15th. As my box
weighed about 601b., and only contained stuff of value to an
anaesthetist, I imagine that the thief is somewhat dis¬
appointed. I send this notice in the hope that others in this
neighbourhood may be on their guard.
I am, 8ir, yours faithfully.
Up, cr Wimpole-atreet, W., Jan. 18oh, 1919. H. EDMUND G. BOYLE.
D. R. R — No English translation of Nagelschmidt’s book
on Diathermy has appeared, but we are informed that •
work on the subject from the pen of Dr. E. P. Cnmberbatch.
medical officer in charge of the electrical department of
St. Bartholomew's Hospital, will shortly be published by
Heinemann.
Communications, Letters, &c„ to the Editor hare
been received from—.
A-Major G. J. Arnold. K.A.M.G.;
Mr. J. E. Adams. Lond.; Mr.
J. L. Austin, Sheffield.
B. — Surg.-'apt. P. W. Bassett-
Smith, R.N.; Mr. H. Blakeway,
Lond.; Dr. H. Br< wn, Lond.;
Capt. H. b. G. Boyle, R.A.M 0.,
Lond.. Boot’s Pare Drug Co.,
Nottingham; Mr. G. Bethel 1,
Lond.. Battersea General Hos¬
pital, Lon<i.. Sec. of; Mr. H. A.
Baylls, Lond.; Mr. J. L. Brown, ' , „
Bombay; Dr. M. B. Barnes, 0.-Oliver-Pell Electric andJlano
Chlengroai, Slam ; Prof. W. M. 1 lecturing Co.. Lond.; Capt. S.A.
Bav lias, Lond. ; 0*en, KA.M.C.
C. —Col. 8. L. Cummins, A.M.S.; P.-Mrs. A. Pratt, Lond.; Fu»d
vince; Medical Research Com¬
mittee, Lond.; Lt.-Col. S. Mort,
R.A.MC.; Medic *-Psychologies!
Association of Great Britain and
Ireland; Dr. A. MoDougall,
Alderley Edge; Mr A. P &el
vllle, Edinburgh ; Capt. 1). M.
Mae line, S.A.M.C.
. - North London Medloo-Ohir-
urgical Society, Hon. See. of;
Major G. E. Newlin, A.R.C.;
t Va f iotial Medical Journal, r
Dr. R. Craik. Lond.; Countess
of Dufferin's Fund, Delhi, Joint
Seo. of; Dr. fi. P. Oholraeley,
Forest Row; Mr. B. Clarke,
Lond.
D. —Mr. H. Eicklnson, Lond.: Mrs.
K. Dutfv. Jesmond; Dowslug
Radiant Heat Co., Lond.
E. —Dr. A. Erdos, Nagyvarad,
Hungary; Mr. A. Evans,
Swansea.
F —Mr. C. Fitch, Lond ; Dr. A. W.
Falconer, Aberdeen ; Major B. R.
Fothergill RA.M.C.; Dr. H. L.
F»int, Mansfield.
G. —Capt. P Gully, R.A.M.C.; Mr.
W. Glenlstcr. High Wycombe;
Mr. H. E. Gird!e*tone, Peters-
field ; Capt. D. Guthrie, K.A.F.
H. — Major F. Hobday, A.V.C.;
Lt.-Col. A. F. Hurst, R.A.M.C. ;
Mr. J. T. Henderson, Pieter¬
maritzburg . Mr. M. Hill.
I. —Insurance Committee for the
County of Londou; Mr. S. T.
Irwin, Belfast.
L. —Mr. K. A Lees, Lond.; Mr.
H. J. Langford, Plymouth; Dr.
B. Lowry, Loud.; Liverpool
Medical Institution, Sec. of.
M. —Dr. H. E. C. K. Murray,
Burley; Metropolitan Asylums
Board. Lond.; Mr. J. Y. W.
MacAllster, Lond.; Dr. t P.
Committee for the County of
London; Mr. R. D. Feriley, Load.:
Dr. B. Pritchard, Lond.; Or.
F. J. Poynton, Lond.; Kt. Hon.
Lord Parmoor, Lond.
R. -Dr. C. Riviere. Lond.;
Statistical Society, Lond.; Hr.
C. B. Richards, Bridge-if-Allan;
Royal Institution of (hast
Britain, Load.; Royal Medics!
Benevolent Fund, Lond., Seo.of;
Dr W. B. Russell, Colwyn Bay;
Mr. S. C. Ranncr, Lond.; Royal
Society, Lond.; Royal Society of
Arts, Lond.
S. -Prof. J. W. W. Stephens, Liver
pool; Dr. L. Stamm, D>od.;
Capt. A. G. Shera. B.A.M.C.;
Dr. B. 8olomons, Dublin; Col.
A. W. Sheen, A.M.S.; S coUM
Poor-law Medical Officers’ Asso¬
ciation, Lond.; Dr. G.B. Shuttle-
worth, Lond.
T. — C*pt A. J. Turner, IfA H-C-;
Sir John Tweedy, Lond.; Capt*
I) Thomson, R.A.M C.; Dr-j
Tatham, Ox ted; Dr. A. »•
Thompson. Lond.; C*pt~ A- J-
Turner, R.A.M.C.; Dr. D. Turner.
Edinburgh.
W.— Wallace Automatic Disinfect
ing and Deodorising Co., Lond.;
Sir Kingsley Wood, M.P., L.C.C.,
Lond.. Sir William Bale White.
Lond.; Mr. J. Wallace, Bombay.
Dr D. P. D. Wilkie, Edinburgh;
Dr. A. Wylie, Lond.
McBride, Edinburgh: Dr. J.
Maberly, Woodstock, Cape Tro- _ _
Communications relating 1 to editorial business should be
addressed ’ exclusively to The Editor of The Lancet,
423, Strand, London, W.C. 2
THE LANCET, February 1, 1919
-*V*kT*
% flea
FOR
MEDICAL UNANIMITY AND
PUBLIC SPIRIT:
THE STATE AND THE DOCTOR.
By Sib HENRY MORRIS, Bart., M.A.,
PART PRESIDENT OF THB ROYAL COLLEGE OF SURGEONS OK ENGLAND
AND OF THE ROYAL SOCIETY OF MEDICINE OF LONDON.
My object in publishing the following remarks is to try to
induce those who do me the honour to read them to
endeavour to promote unanimity between the several
flections of the profession ^ith the view to secure (1) satis¬
factory State and municipal conditions in the National
and Municipal Health Service ; (2) fuller recognition by
the public and the Government of the importance of medical
opinion and advice; (3) unition of the voices of the
profession when legislation is in prospect on questions
which gravely concern the mental, physical, and social
welfare of the people; and (4) a larger representation
of the profession in Parliament and an organised medical
party in the House of Commons as a step towards the
attainment of these ends.
The systematic fight against disease and the combining of
preventive medicine with clinical and curative medicine is
becoming yearly more and more a Government function.
The medical profession, however, has got to recognise that
sanitary matters are among the most important matters of
State policy, and that it cannot any longer turn its back
on ‘ 4 politics,” as hitherto it has always somewhat con¬
temptuously done, but that, on the contrary, so far as medical
“ politics ” go, the profession ought to take quite the leading
rdle.
Legislation Affecting the Medical Profession.
‘Within the last 45 years Parliament has imposed a large
number of statutory demands upon the time and service of
the medical profession. Under the powers conferred by
numerous Acts of Parliament passed since 1871 the general
practitioner is liable to be called upon to undertake a great
variety of duties concerning and ranging over the whole
period of the life of a man, from his cradle to his grave, and
extending even beyond to the removal and disposal of his
body after death.
The doctors’ liabilities under these Acts concern the state
of mind and body of men, women, and children, the con¬
dition of their property, houses, and tenements, their
environment and fitness daring school life, their protection
against the infinitely small and the abominably loathsome
pests which attack their bodies and assault their health, the
nuisances about their dwellings, the dangers of their trades
and occupations, the workmen’s compensation for injuries
and their superannuation and pension claims, and a score of
other matters, besides the National Insurance Act of 1911,
under which 14 millions of persons are eligible for medical
care.
And all these Acts of Parliament exacting service from the
medical practitioner have been passed by non-medical legis¬
lators, some few of the prime movers in which were no
doubt prompted and instructed by medical men, but the
bulk of whom neither knew nor took the trouble to ascertain
the opinion of the general practitioners who are the agents
by whom the Acts are mainly made effective.
Inadequate Representation of Medicine in
Parliament.
Yet during the whole period of this exploitation of
the profession by Parliament the profession has been
docile and servile, has done nothing, beyond the British
Medical Association, towards becoming an important factor
influencing legislation, and remains to this day without any
recognised political standing in the State.
Ab a result of the recent General Election the profession is
slightly better in the number of representatives in Parliament
than it was before. Out of 37 medical candidates for
Parliamentary seats, 16 were successful ; but as 5 of the
elected are Sinn Feiners, there will, in all probability, be only
11 who will take their seats in the House of Commons, as
No. 4979
against 9 in the last Parliament. Compare these figures
with the 92 members of the legal profession (solicitors and
barristers) who were elected—67 for England and Wales,
11 for Scotland, 11 lor Ireland, 2 for English universities,
and one for Trinity College, Dublin. Add to these election
results the numerous important well-paid public and political
offices which lawyers occupy, and the fact that there are at
the present time five ex-Lord Chancellors (one of whom, it
is true, is an M.D. of Edinburgh, but he very early in life
forsook medicine for law), each in receipt of £5000 a year
pension, and a six'h just appointed at the age of 46, with a
prospect of long years of a pension after ceasing to receive
while in office as Lord Chancellor £10,000 a year—and we
get some idea of the comparative advantages and public
recognition of the two professions.
Medicine and the State.
This lack of proper State recognition, and of an adequate
Parliamentary representation of medicine, is largely due to
its self-imposed seclusion from affairs of State, to the
reluctance of the profession to take its part in any great
national scheme, and its persistent resolve to continue mb
long as possible as an individualistic class.
This disposition is a legacy from the traditions and
prejudices of the priest-physicians of antiquity, and the
monastic influences of the Middle Ages; for, notwith¬
standing the medical treatment of patients in the “ Asclepia”
—the ancient Greek equivalent of our modern hospitals—
and the efforts of Hippocrates to dissociate medioine from
priestcraft and its many superstitious devices, and to-
break the long-standing and confused connexion between
philosophy and medicine, professional individualism has
been perpetuated by the devout inculcation throughout the
ages of the Hippocratic “ Oath ” and “Law.”
It is to-day, however, becoming apparent to many of the
profession, as well as to the public, that the old individual¬
istic character of medical practice is incompatible with
modern requirements and must be supplemented by a much
wider view of the place which medicine is called upon to
occupy in the State ; and that in the interest of the com*
munity this aloofness of the profession from every movement
of a political character can no longer be maintained.
There are two principal reasons for this change of view,
one special to the‘profession, the other a produot of the
socialistic tendency of democratic administration.
Scientific Development of Medicine.
The first is based upon the constant developments of
modern science and the progressive adaptation of scientific
discoveries to the practice of medicine and * surgery in
relation both to diagnosis and treatment.
Whilst this adaptability of many sciences to medioal
diagnosis and treatment renders necessary a more extended
and varied application of medical resources to the Public
Health Service it also necessitates the coordination of expert
experiences and the cooperation of specialists and general
medical piactitioners for the efficient up-to-date treatment of
private patients.
In the life of a nation, as Karl Marx forcibly pointed
out in connexion with the growth of revolutions, the
material forces of production at ceitain stages of develop¬
ment come more and more into conflict with the existing
relations of production, or in other words with the relations
of private property. In the same way the development of
medical and scientific knowledge brings into use improved
material means of investigating and treating disease whioh
are incompatible with the old exclusively personal relations
between doctor and patient.
As the material forces of industrial production were
improved the spinning-wheel, the weaver’s handloom, and
the private workshop were superseded by the spinning-jenny,
the weaver's mechanical loom, and the factory. So in the
progress of science the individualism of cflnsulting-room
and bedside practice has had to yield to research work in
bacteriological and biochemical laboratories, to radiography
and other light and electrical processes, and other expert
specialties.
As a consequence, the individual services of the family
doctor have to a large extent given place to the associated
services of a number of medical scientists, and the curative
results of treatment in a large proportion of cases are the
product of this cooperation—just as the yarn and the fabrios
which come from the factories are the outcome of the labour
i
106 The Lancet, J SIR HBNRY M0RKI8; MEDICAL UNANIMITY AND PUBLIC SPIRIT.
[Fkb. 1,1919
of many workmen, and not, like the commodities of former
times, the single-handed products of individual artisans.
The Medioai Profenion and the Community.
The seoond of the reasons for the change of view referred
to is the natural democratic doctrine that the community
does not exist for the benefit of professions or vocations;
that neither do the professions exist for the benefit of indi¬
viduals only, but that the proper function of each profession
is to render such services as are special to it for the benefit
of every section of the community and not for those persons
only who can afford to obtain them by payment.
The object of professional organisations in a democratic or
socialistic State, it is held, ought, in fact, to be to promote
the greatest good of the greatest number. This is the spirit
of the National Insurance Act, and when wrongly interpreted
it is the spirit which exploits the profession for the benefit of
the mass of the people without any regard for the dignity
and prestige of an ancient, honourable, and learned calling.
Reconstruction: National Health Services.
It follows from the progress of medical science and this
conception of the communal services of the professions that
there are in prospect, and within the purview of post-war
reconstruction, changes, expansions, and, it is to be hoped,
improvements in the National Insurance Act, whereby
arrangements will be made for bringing modern and highly
specialised remedies and means of diagnosis within the reach
of the poorer classes, so that the patients of all general
practitioners and panel doctors may have the same advantage
from improvements in the medical sciences as the rich and
well-to-do classes have.
It is to be desired that this will be brought about without
interfering with the patient’s free choice of doctor, or
debarring medical men from attendance on their own
patients, or depriving independent general practitioners and
consultants of their freedom to render professional services
to any persons who desire them, whether those persons are
under the National Insurance Act or otherwise.
But it must be realised that a considerable increase in the
number of whole- and part-time salaried doctors will be
required to cope with the increasing volume of public health
work, and that, in view of such increase, steps ought
to be taken to make it possible for the ordinary general
practitioners to bring their distinctive opinions to bear on
the authorities concerning any schemes affecting the National
Health Services, as well as to make known their views about
the State Clinical Service.
The Teaching of Preventive Medicine.
An outcry is being raised in a certain quarter against the
‘‘strange neglect” of teaching preventive medicine and
public health in the medical schools of this country, about
the necessity of every medical student being as well equipped
in all the problems of hygiene as in clinical medicine, and
in favour of every medical practitioner being trained to form
an integral part of any scheme of preventive medicine in the
district in which he practises. To this end a most formidable
array of subjects and details of subjects is set forth as
necessarily to be included in the ordinary course of
instruction given to every medical student.
I am entirely opposed to the views of those theorists and
idealists who would still further weigh down the already
greatly overtaxed medical student by insisting on his studying
during his five years curriculum all that is known by experts
concerning personal and public health ; who would introduce
a mass of “field work” as well as courses of lectures into
the ordinary medical student’s career ; and who deplore the
fact that these students before they leave the schools to
enter into practice are without a knowledge of such items as
the local arrangements of Poor-law treatment, the practical
operation of the Midwives Act, every detail of factory
hygiene, of the sanitary machinery for dealing with tuber¬
culosis in the*district in which they are going to live, and of
the numerous instruments and agencies provided by the
State for the alleviation of an artisan’s family in the event
of sickness.
This exorbitant demand on student study reminds one of
Francis Bacon, three centuries ago, aiming at the acquisition
of a knowledge of all that was known or knowable in his
day; or of Rabelais’ fable of Gargantua urging his giant
son Pantagruel to defend, successfully against all comers, in
the crossways of the city, no less than 9764 theses, and then
to return home to receive blessing before his giant father
died.
I know of no criticism more misleading for the layman,
more unfair to medical teachers, and so unappreciative of
their ever-increasing, self-sacrificing, unaided, and well-nigh
hopeless efforts to keep medical education level with the
knowledge of the day, as that on page 12 of Sir George
Newman’s Memorandum on Medical Education in England,
addressed to the President of the Board of Education.
His remarks on the disparity between the growth of medical
education and the growth of medicine would, I feel sure, have
been tempered by some extenuating reasons had the author
reflected for a moment that there is a limit to the mental
receptivity within a given period of even the most brilliant
students, and that it is impossible to compress the contents
of a big and overcrowded store-room into the dimensions,
say, of a table drawer of ordinary capacity.
But in spite of the inevitable limitations of the five years
curriculum and of the shortcomings in the medical student’s
education on which so much stress is laid, the young
practitioner, with such scanty knowledge as he has picked
up at his medical school, soon learns by experience in the
working of a practice what is expected and actually required
of him ; and, with the exception of those who have under¬
gone special training to fit them for holding public health
appointments, he knows a great deal better than consultants,
and members of college councils, and university faculties,
how to carry out the practical details of preventive medicine.
Representation of Views of General Practitioners.
But, be this as it may, it is essential for the smooth •
and efficient administration of any State Medical Service
that the voice of the great body of general practitioners
should be heard and more readily listened to in future
than has been the case in the past. It is but reasonable
that they should have ample opportunity to make their
views known about the terms and conditions under
which their own services in future are to be rendered. It
is as much, or more, in the interest of the State as in that of
the medical profession itself that these terms and conditions
should be based upon a sound, satisfactory, and honourable
footing. It is also very desirable for the successful working
of any national scheme relating to the medical care of the
poor, to health insurance, preventive medicine, and local
sanitary measures, as well as for the satisfactory enactment
of medico-political reforms, that there should be a clear
understanding and well-directed cooperation between the
general practitioners all over the country and the Members
of Parliament and other laymen who take a genuine interest
in the national struggle against disease. This is, however,
not likely to be the case unless the views of the mass of the
profession can, somehow, be brought into continuous and
uncensored touch with Parliament, with the Health Minister,
and, if desired, with the heads of other departments of
Government.
The practice which has hitherto prevailed, in so far as the
Government has sought the advice or guidance of any
medical men at all other than those in the central govern¬
ment employ, has been to consult the Presidents or Councils
of the Royal Colleges, the General Medical Council, and the
so-called heads of the profession. This plan, however, has
not given general satisfaction in the profession ; and on this
point I should like to make a few remarks. It is unreason¬
able, indeed senseless, to pour out vials of wrath and columns
of contemptuous abuse on those institutions, as the manner
of some is to do. The Royal College of Surgeons of England,
for example, has been frequently condemned because it will
not dissipate a part of its income in a costly annual ballot by
post of its many thousands of members, and will not comply
with the demands of an infinitely little band of agitators
who clamour for votes and seats in the Council so that they
may have the use of the College funds to improve their
status and pursue their claims to what they choose to call
their professional rights. Such agitations if successful
would destroy the usefulness of the College, and as it is they
stir up, or \end to stir up, ill feeling in the profession
against that great and honourable corporation.
The General Medical Council is from time to time
reproached, reproved, and belittled because it will not
infringe the Acts of Parliament and its standing orders by
putting upon the Medical Register some skilful and popular but
non-qualified “ surgical manipulator,” or by restoring to the
TheLancet,] SIR HENRY MORRIS: MEDICAL UNANIMITY AND PUBLIC SPIRIT. [Feb. 1, 1919 167
Register the names of doctors who continue to associate
themselves in the treatment of patients with persons other
than legally qualified medical men.
Thb Royal Colleges and General Medical Council.
The Colleges and the General Medical Council have very
important public and professional duties to discharge. The
Royal Colleges, for generations before the Universities took
any part in the education of the general practitioners, or
the passing of the Medical Acts which established
the Medical Council as the authority in medical educa¬
tion and registration for the United Kingdom, were the
pioneer directors of medical education and examination
of the great bulk of the medical practitioners of the
country and its public services. They took an early, and
have ever since taken an active and important part in
providing for research work. They have valuable libraries
and museums and lectureships to guard and maintain,
which are accessible to any member of the profession and
available for the use of general visitors on application.
The Museum of the Royal College of Surgeons of England
is unequalled in the world for the importance, the variety,
and the extent of its collections. Upon these and upon the
buildings which contain them £163,000 have been spent,
of which the British Government has provided £57,000 and
the College of Surgeons £106,000. But this large sum gives
a very inadequate idea of what the College has expended
in adding to and in the preservation of the contents
of the museum. The superintendence of the museum is
confided by the Council to a committee of its own members,
who are responsible to it and to a body of trustees, some of
whom are appointed by the Government and others by the
College.
The General Medical Council, besides controlling the disci¬
pline of the profession and the medical education and regis¬
tration of the United Kingdom, coordinates the education and
examinations in the dominions, colonies, and elsewhere, where
reciprocity of registration is desired ; and from time to time
toges upon the Privy Council the need for legislation
concerning medical and dental practice. Then there are
the Royal Society of Medicine, the Medical Society of
London, and other similar societies in London and the great
cities of the United Kingdom whose function is the reading
and discussion of papers and the interchange of opinions on
medical and surgical subjects and the collateral sciences.
But while recognising the very important functions of the
General Medical Council, of the Royal Colleges, and of the
learned medical societies, and while not in the least degree
disparaging or depreciating the admirable manner in which
those bodies discharge their functions, and without
attempting to dispute the wisdom of their own methods of
administration or control, there is no denying that the Royal
Colleges and the medical societies are not the best qualified
bodies to give advice on most subjects of national and local
medical administration. They lack that intimate acquaint¬
ance with the conditions of life amongst the great masses of
the people, either in urban or agricultural districts, which
the general practitioners possess. Nor do these institutions
act wisely and in the best interests of the nation by refusing
to cooperate in honest, disinterested efforts to found an
independent consultative and advisory board to keep watch
ever all matters concerning medical legislation.
Suggested Scheme.
What is wanted now, and will be none the less needed
alter the setting up of a Ministry of Health, with its
advisory oommittee composed of salaried and State-appointed
members, is a oommittee oomposed of unpaid and unofficial
delegates representing all the various sections and corpora¬
tions of the profession. These delegates might be elected
either at a general meeting open to the whole profession, or
by ballot conducted through the poBt, or, if local or branch
committees are established throughout the oountry, by the
election by these local committees of their own delegate or
delegates. These representatives would bring together the
knowledge and experience of their several sections and
institutions. The function of this committee would be to
coordinate, cooperate, criticise, and confer, but would have
no executive power. The committee should be privileged,
however, to present reports containing their considered
opinions and conclusions to the Health Minister, to the Prime
Minister, or to Parliament direct.
At present no snob body exists. The British Medioal
A s soc iation is the nearest approach to it. But it was not
founded to exercise, and does not profess that it exercises
exclusively, or as its principal object, any such funotion ;
nor does it embrace more than one-half of the profession ;
and, whether rightly or wrongly, it is very generally con¬
sidered to be engaged in directing its efforts at least as
much, if not more, in advancing the personal and collective
professional interests of its members as in safeguarding and
promoting national objects.
The Medical Parliamentary Committee.
It was partly with the view of ultimately setting on foot
such a oommittee as I have just outlined that a large meet¬
ing, open to the whole medical profession, was held in
Steinway Hall on Oct. 1st, 1918. It was hoped that the
profession would become alive to the fact that it is the duty
of every medical man to further any medical policy for the
benefit of the community, and to join in any scheme for
employing the full powers of medical and sanitary science
to add to the general efficiency of the State.
It was foreseen that for this purpose the unanimous
cooperation of the profession is essential. It was urged that
in order that the matured views of responsible medical men
might be adequately brought to the notice of the public
there ought to be a larger number of medical men in the
House of Commons. With these ends in view a committee
was there and then elected, with power to add to
its numbers. This committee is now known as the
"Medical Parliamentary Committee.” Its composition
makes it representative of consultants, general practitioners,
and many medical organisations. But the Royal Colleges,
and the Royal Society of Medicine, and the Medical Society
of London, eo far, stand aloof. It is to be hoped that in
time all these bodies will come into line, and that the
"Medical Parliamentary Committee" will represent every
section and every organisation of the profession, with branch
committees keeping in touch with provincial and county
counoils, and local sanitary authorities throughout the
Kingdom.
Summary.
The points I have endeavoured to bring out in this article
are the following
1. That there is not, and never has been in this country,
what is very badly wanted—namely, a Medical Federation
such as the recently constituted Medical Parliamentary Com¬
mittee aims at becoming, the primary or exclusive objects
of which should be to bring to the notice of Parliament and
the nation the importance of medical knowledge and
medical service in advancing the good of the State, the
proper sanitation of its villages, towns, and cities, the
virility of its manhood, and the general health of its
people ; to instruct the legislature and the public as
to how this knowledge is to be applied and thiB service
rendered with the utmost efficiency ; to criticise pro¬
posals, to offer advice, and to give practical assistance
in regard to measures having relation to the particular
functions of the profession, when under consideration
with a legislative or administrative object; and to offer
suggestions and advice as to reforms which from time to
time may be needed to keep the standard of public service
on a level with progressive medical science. The Medioal
Federation, in fact, should be an unattached advisory board
to the Minister of Health and his official advisory com¬
mittee, without any independent executive power, but having
a recognised moral, if not a statutory right to be consulted
on all measures or changes affecting the medical and
sanitary services of the State, and with the privilege of
making uncensored reports, when necessary,, direct to
Parliament or to the Prime Minister.
2. That before such Medical Federation can be set up the
existing tendency to professional segregation, or self-imposed
isolation, and individualism, and the deeply rooted pro¬
fessional prejudice against taking part in any public move¬
ment whatever of a political character must be greatly
modified if not abandoned.
3. That the progress of science, the development and
extension of medical knowledge, and the socialistic demands
of modern democracy make such a change in the outlook
and relations of the medical profession necessary—and,
indeed, essential as being conducive to the commonweal.
4. That the Medical Federation here suggested need not,
I and, indeed, cannot, and ought not to attempt to interfere
j with or to be in any way mixed up with the ordinary and
| special functions of existing corporate bodies and institutions;
168 Thb LANOBT,] DR. I. HARRIS: INVERTED “T” IN FIRST LEAD OF OAl DIOORAM.
[Fbb. 1. 1919
though it deserves to have the encouragement, good will,
cooperation, and material assistance of all of them.
5. That the Medical Federation, or Medical Parliamentary
Committee, ought not to concern itself with functions such
as those exercised by the British Medical Association. It
should have nothing of the nature of a trade union. It
should not be looking after and promoting, by Parliamentary
and other committees, the interests of its members, or insur¬
ing their lives, or laying down and enforcing the terms of
medical appointments, or attempting to direct the ethics of
the profession. And though its membership would be
medical and scientific it should not be what is commonly
understood by the term “a scientific society.” It therefore
should not, like the Royal Society of Medicine and other
kindred societies, direct its energies to the advancement and
development of the science and art of medicine, or to
discussing unsettled questions relating to new discoveries
or methods. It should, in factf, be a political association with
its sphere of “ politics M strictly confined to the promotion,
improvement, and authoritative criticism of, and to expressing
its matured responsible judgments and its deliberate unified
conclusions upon, those matters as to which it ought to be
both the duty and the privilege of the profession to give
counsel and render service for the benefit of the community
at large. It should substitute for the sporadically and occa¬
sionally sought opinion of college councils and the so-called
heads or leaders of the profession the opinion of the main
body of the profession, as being the regular recognised
source of instruction and guidance for Ministers, Parliament,
and the public.
6. The Medical Federation should be thoroughly represen¬
tative of the Royal Oolleges, the medical societies, the
British Medical Association (whose cooperation, detached
from its other functions and spheres of usefulness would be
of the utmost help and importance), and very especially of
the general practitioners throughout the kingdom, whose
delegates should be nominated exclusively by themselves.
7. For its success, unity in the profession, and on the
part of the federation itself, moderation and restraint of
differences in its consultative procedures, and suppression
of discordant voices and actions in its public utterances and
activities are requisite ; and when successfully established
the Federation, or Medical Parliamentary Committee,
should encourage the formation of branches, or local
advisory committees of a precisely similar character, and
exercising a similar guiding, suggesting, and persuasive
influence over the county and borough councils in their
respective neighbourhoods, as the parent association should
aim at exercising over the nation and the legislature.
SIGNIFICANCE OF AN INVERTED “T” IN
THE FIRST LEAD OF THE CARDIOGRAM.
Bt I. HARRIS, M.D., L.R.O.P.,
FROM THE OARDIO-THERAPRUTIC DEPARTMENT, DAVID LEWIS
NORTHERN HOSPITAL, LIVERPOOL.
The inversion of T in electrograms in the third lead has no
particular significance; in the second it is a sign of a grave
myocardial condition. The information obtainable in electro¬
cardiographic literature in regard to the meaning of inverted
T in lead I. is very meagre. The table below is made up from
records of out-patients attending a general medical depart¬
ment. An electro-cardiogram was taken from those cases
who complained of dyspnoea on exertion, fainting fits,
oedema, without showing any obvious causes accounting for
the symptoms. However, a number of cases of valvular
disease are contained in the table.
T in I. lead inverted in all these cases. An inversion of
T in the I. lead is often found in oases who are under the
influence of digitalis. 1 Cases who were complaining of
dyspnoea, &c., did not always show an inversion of T. On
the other hand, all those cases who showed an inversion
of T in the first lead have invariably shown one or more
symptoms usually associated with defective heart action.
The conclusion is that an inverted T in the first lead is a
reliable sign of a damaged heart muscle.
I am indebted to the Medical Board, Northern Hospital,
for permission to use material in connexion with this note.
* The Lancet 1918,1., 464.
Table of 40 Medical Out-patients in whom an Electrogram wa»
taken. The last ooliumn records the inversion or not of
the first lead.
u
<
Previous
history.
Symptoms.
Heart sounds.
Murmurs.
: T.
1
M
Scarlet fever
D.b.e.
M.I.and Il.acc.
M. Presys.
Inv.
Pneumonia.
Rheum, le.er
II. Pulm.aoc.
l
17
No history.
I
!
M.I. rough.
II. Pulm. ace.
M. Systolic.
Nor.
3
B
113
(Edema of
No alteration.
8ystollc
i
feet.
murmur.
4
W
125
Pain in
All sounds
None.
„
cardiac
region. F.f.
slightly aoc.
5
B
29 Rheum, fever.
D.b.e.
Heart sounds
• l
•1
(Edema.
rather soft.
6
C
••
D.b.e.
Sounds pecu¬
liarly loud.
• f
Inv.
7
W 25
D.b.
M.II. dupli¬
M. Systolic.
Nor.
cated.
II. Pulm.aoc.
Presys.
8
W
23
"
D.b.e.
II. Pulm. acc.
ft
„
9
B
17
Scarlet fever.
D.b.e. Dizzi¬
Normal.
None.
Inv.
Appendicitis.
ness.
10
F
13
Some kind of
F.f.
A. sounds sec.
M
ft
fever.
11
S
16
Chorea.
D.b.
Short and
M. Presys.
Nor.
snappy.
12
s
20
T.B. in
sputum.
• I
Normal.
None.
-
13
c
17
No history.
Pain in car¬
diac region.
Inv.
14
M
14
Rheumatic
fever. Scarlet
P.f.
”
••
Nor.
fever.
15
A
17
Scarlet fever.
Rheumatism.
D.b.e.
"
Inv.
16
D
63
No history.
All sounds soft.
tf
#|
17
E
55
Spec! ho.
F.f.
I. A. aoo.
II. A. see.
If
18
B
37
D.b.,Ao.
A. I. A II. aoc.
Pulm. 11. aoo.
A. systolic
and presys.
..
M. I. acc.
19
D
27
No history.
Irritable
heart. F.f.
A. II. acc.
None.
Nor.
20
B
26
D.b. Pain in
cardiac region
Unable to do
mueb work.
Normal.
Inv.
21
0
ll
#|
D.b.e.
A. II. aoc.
„
Nor.
22
r
29
Pain in
M. II. aoc.
it
Inv.
cardiac
region. F.f.
A. II. acc.
23
M
19
F.f.
M. I. aoo.
A. II. aoo.
*1
Nor.
24
W
57
ft
D.b.e.
Alteration in
tt
I.M.
25
R
33
Fainting.
A. II. aoo.
II. pulm. aoo.
if. systolic.
Inv.
26
w
32
D.b.e. Fits.
Normal.
None.
Nor.
Pain in
cardiac region
27
P
45
After lifting
F.f.
M. I. dupli¬
,,
,,
la heavy parcel
cated. II. Pulm.
felt faint.
aoo. All sounds
loud-pitohed.
28
W
19
No history.
D.b.e.
Normal.
If
•1
29
R 'll
Congenital
D.b.
II. Pulm. aoo.
if. systolic.
syph.
30
S 29
Rheumatic
*1
(Edema.
M. 11. soft.
,,
fever.
31 C
27
No history.
T.B. pulm.
D.b.e.
II. Palm.
None.
n
32
M
19
F.f.
slightly aoc.
II. M. aoo.
Inv.
33
K
36
D.b.e.
All sounds
,,
Nor.
altered.
34
N
56
No history.
Rheumatic
D.b.e.; F.f.
Normal.
Presys.
Systolle.
„
35
Ji
i5
D.b.
II. Pulm. acc.
,,
fever.
I. and II. M.
altered. I. M.
36
S 44
Nephritis.
_■'
prolonged.
U. I. rough.
Systolic M.
Inv.
19
II. duplicated.
II. Pulm. aoc,
37, W
Rheumatic
D.b.e.
II. Pulm. acc.
Nor.
fever.
II. M. dupli¬
cated.
38
S
47
No history.
D.b.
Normal.
None. |
Inv.
39
C
47
X ray report
showed
mediastinal
»•
f f
"
growth.
40 IK
20
Chronic
Dizziness.
9 f
Nor.
,
bronchitis.
!
D.b., Difficulty in breathing. D.b.e., Ditto on exertion.
F.f., Fainting fits. Inv., Inverted. Nor., Normal.
The Lamcet,] 81R J. H08B BRADFORD AND OTHERS : A FILTER-PASSING VIRUS. [Feb. 1, 1919 169
PBBUMINABY BBPOBT ON
THE PRESENCE OF A FILTER-PASSING
VIRUS IN CERTAIN DISEASES,
WITH ESPECIAL REFERENCE TO TRENCH FEVER,
INFLUENZA AND NEPHRITIS.
By Major-Gbneral Sir JOHN ROSB BRADFORD, AMS.;
Captain E. F. BASHFORD,* R.A.M.C. ;
AND
Captain J. A. WILSON, R.A.M.C.
(--i Report presented to the Director- General Medical Services,
British Armies in France .)
During the autumn of 1917, and the spring and summer
of 1918, observations were carried out by us on the pathology
of acute infective polyneuritis. These resulted in the
detection, isolation, and culture by the Noguchi method, of
an organism that reproduced the malady when inoculated
into animals, and further, this organism was recovered by
culture from such experimental animals. The details of this
work will be published in the forthcoming number of the
Quarterly Journal of Medicine and therefore need not be
considered here. The causative organism of polyneuritis
belongs to the group known as “ filter-passers,” in that the
virus will pass through certain filters, although it is not a
filter-passer in the sense that some other organisms are, as it
does not pass through certain filters with very fine pores.
The satisfactory results obtained in the study of poly¬
neuritis led naturally to the same method that had proved
so successful with this disease being applied to other
diseases where there was either evidence or suspicion that
the causative agent was a filter-passer. A considerable
number of such diseases have been investigated on these
lines duriDg the last six months in the laboratories attached
to certain hospitals in the Staples area.
Captain J. A. Wilson conducted the whole of the bacterio¬
logical portion of these inquiries in the laboratory of No. 20
General Hospital. Further, the observations on trench fever
mentioned below were all made in this hospital, and Major
Frank Clayton, R.A.M.C., had charge of the clinical
observations on the volunteers inoculated with the virus of
trench fever.
Captain Peacock controlled the whole of the entomological
part of the inquiry, and more especially the provision of
clean lice to control observations on infected lice.
The experimental work on animals and the histological
work on the lesions so produced has been carried ont by
Captain Bashford in the special laboratory attached to the
Observation Hut at No. 26 General Hospital. The present
report is merely a preliminary statement as to certain results
achieved, the full details, olinical, experimental, and histo¬
logical, will be published later.
Trench fever was one of the first diseases examined at the
suggestion of Captain Wilson. Other observers have adduced
evidence showing that the virus of this disease belonged to
the group of filter-passers.
Trench fever .—The virus isolated in trench fever consists
of minute coccus-like bodies, grouped in pairs, with the
opposing surfaces flattened, and varying in size from 0 3 ju to
0-5 /a. It is Gram-positive and stains readily if the film
preparations are washed in ether before the stain is applied.
It passes through Berkefeld N. and V. filters, and also
through Massen porcelain filters, and can be cultivated from
such filtrates. It resists heating to a temperature of 56° 0.
for 30 minutes, and it is an anaerobe.
This organism has been recovered by culture from the
blood in II out of 15 cases of trench fever examined during
the pyretic stage, and in 3 out of 8 cases examined when
apjretic. It was not found in over 40 control cases where
blood culture with the same technique was carried out.
A similar organism was recovered from four separate
supplies of infected louse excreta kindly supplied to us by
Sir David Bruce.
It was not found in 31 specimens of excreta from batches
of clean lice.
The culture obtained either from the blood of or
from louse excreta, when inoculated by scarification into
» Captain Bashford took no part in the portion of this work dealing j
with trench fever. |
man, produces a mild illness, and the organism can be
recovered from the blood by culture during such illness, and
also from clean lice fed on the patient during the illness.
Influenza .—The virus isolated in cases of influenza consists
of very minute rounded coccus-like bodies, varying from
0*15/4 to 0-5/t. It is Gram-positive, and passes through
Berkefeld N. and V. filters and Massen porcelain filter. It
is an anaerobe, and resists beating to 56° C. for 30 minutes.
It has been isolated by culture from the blood in 6 out of 9
cases examined, from the sputum in 6 out of 6 examined,
from pleural fluid in 4 out of 4 examined, and from the
cerebro-spinal fluid in the only case so examined. It has
also been isolated from the lymphatic glands post mortem in
the only two cases examined. This organism can not only
be grown from the blood, and from exudates, but it can also
be seen in stained films prepared from exudates—e.g.,
sputum, pleural fluid, cerebro-spinal fluid.
The culture (second generation) when inoculated into
animals subdurally, or intravenously, produces illness in
guinea-pigs and monkeys, and on post-mortem examination
the following lesions have been found: extensive lobnlar
pneumonia with hemorrhages, some nephritis, myocardial
and hepatic lesions, such as extreme congestion, interstitial
haemorrhages of small size, and fatty degeneration. Passage
experiments done from such animals when slightly ill, by
injecting their blood, bile, &c., into healthy animals, causes
in these more severe and even fatal illness, and post mortem
the same lesions are found. The organism has been recovered
by culture from the tissues of such experimental animals.
Nephritis .—Up to the present time (January, 1919) only
one variety of nephritis has been investigated—i.e., that
characterised by the presence of pyrexia and hematuria at
the onset.
The virus isolated in such cases of nephritis consists of a
round coccus-like body varying from 0*3/4 to 0 6 p in size, and
in culture often occurring in the form of short chains of four
individuals. The same organism may be seen in urinary
sediments either singly or in pairs. It is Gram-positive and
passes through Berkefeld N. and V. filters, and also through
the Massen porcelain filter. It is an anaerobe and resists
heating to 56° for 30 minutes.
It has been isolated from the blood in 6 out of 9 oases
examined and from the urine in 7 cases. The culture
(second generation) when inoculated into animals produces
nephritis iu monkeys and guinea-pigs. In monkeys this
can be determined not only by post-mortem examination,
but also clinically, since the urine contains blood, albumin,
and casts. In both guinea-pigs and monkeys extensive
lesions, glomerular and tnbular, are foond on microscopic
examination. In severe cases pulmonary lesions are also
present.
The organism has been recovered by culture from the
tissues of the animals experimentally inoculated.
These three diseases are those that have been most studied
as yet, but organisms of the same group, although differing
from one another, have been recovered by culture in a
number of other diseases of obscure etiology. In most of
these no adequate experimental work has been possible up
to the present, and in others it is incomplete owing to
insufficient time having elapsed to establish results with
certainty. Amongst the more important diseases where true
“ filter-passing ” organisms have been isolated by culture
from the blood and seen in suitably stained films mumps,
measles, rose measles, and typhus, may be mentioned. In
mumps four cases have been examined, and all gave the same
positive result. Two cases of typhus have been examined, but
as yet it has only been possible to get material from one
each of measles and rose measles.
An organism allied apparently to that of polyneuritis has
been isolated from brain tissue in cases of encephalitis
lethargica, both from material obtained from England and
also from cases observed in the Army in France. A con¬
siderable amount of histological work has been done on the
lesions present in animals (monkeys) successfully inoculated
with these cultures. These results will be published later.
If the organisms found in polyneuritis and encephalitis
are excluded, all the others have many points in common
and possibly belong to one group. Although exceedingly
small, they present individual differences in their morphology,
and in their mode of growth in culture. These details must
be reserved for fuller and later publication.
Staples, Jan. 21st. 1919.
170 Tra Lancet,] DR. W. H. JOHNSTON: SUSPENSION TREATMENT OF FRACTURES OF THIGH. [Fbb. 1,1«I9
A STUDY OF THE
SUSPENSION TREATMENT OF FRACTURES
OF THE THIGH.
By WILLIAM H. JOHNSTON, B.A. (N.Z.), M.D.,
Ch.B. Edin.,
CAPTAIN, B.A.M.C. (T.CJ.) ; LATE ASSISTANT SURGICAL REGISTRAR, SPECIAL
MILITARY SURGICAL SECTION, READING WAR HOSPITAL.
At the moment of writing several thousand oases of gun¬
shot fracture of the thigh are under treatment in onr
hospitals. Some have been recently wounded, most have
passed the critical septic stage, all have still to regain in a
greater or less degree the proper functional use of their
limbs.
Our ideals have been to eliminate sepsis by early radical
operative procedures, to aim at rapid aud complete repair of
bone, and to secure unrestricted movement of all joints with
the best possible nutrition of the limb. The ultimate
functional efficiency of the limb will depend largely upon
the severity of the lesion, the type and the degree of the
infection, aud the coefficient of recuperative power, especially
with regard to bone. Those cases where, as a result of
these factors, union is long delayed will naturally present
the most difficulty, for the limb must, in such cases, be
subjected for the longest periods to fixation and extension
with detrimental results. The muscles of the thigh may
become indurated with inflammatory products, bound up in
callus or adherent to scar
surround or surmount it. The simplest type may be found
in the wire cradle splint of Hey Groves, aud the most
complex in the Gassette frame with travelling overhead gear,
multiple uprights aud crossbars, aud a multiplicity of cords,
pulleys, and weights. The commonest type is, perhaps, a
modification of the well-known Hodgen splint.
This system, unlike the former, is not ushered in as a rule
with complete reduction under anaesthesia. Keduction is
provided by a weight exerting what is believed to be a
constant pull acting over a pulley, and counter-reduction is
gained by elevating the bed and by throwing in the body
weight. It is claimed for this method that it allows
greater freedom of movements in bed and better access
for dressing.
With regard to these two systems, the following points are
to be made :—
1. The principle of the Thomas splint is the only tenable
one in so far as complete reduction should always be obtained
as the first step in any method of treatment, and it can be
done only under deep anaesthesia with or without operative
interference.
2. There is no doubt that by securing this, uncomplicated
cases properly treated on the Thomas splint so speedily
acquire union that movements of the knee-joint are little
impaired.
3. By the failure to secure complete reduction ab initio the
suspension system, often handicapped from the outset in
overcoming resisting muscles, has perforce to resort to a
reducing force acting over a longer period than would other¬
wise be necessary.
tissue. The tissues in and
around the knee-joint may
undergo definite pathological
changes resulting in impair¬
ment of function, the restora¬
tion of which superimposes
upon the treatment of the
fracture, a tedious and diffi¬
cult process.
Hostilities have ceased, but
our task is but half accom¬
plished. It must be admitted
that at least oue of the ques¬
tions we have to face is the
problem of delayed union. The
percentage of such cases is un¬
avoidably high, and the treat¬
ment must be a protracted
one. Bone-grafting opens up
a new field here, but our real
difficulty will lie in conserving
nutrition aud movements, in maintaining equality of length 4. A failure to secure and maintain complete reduction in
and natural alignment during the intervening months. This either method undoubtedly prolongs the fixation of the limb,
being the case, the writer may be pardoned for treading upon and in many cases the immobilisation of the knee-joint.
5. In the early stage of treatment movements at the knee
can be secured in both these methods only by releasing for
the time the reducing forces, a procedure which by virtue of
the mechanism of the appliances involved wonld immediately
lose control of the broken ends of the bone, destroy immobilisa¬
tion of the fracture area, aud produce pain.
Direct Bone Flotation Methods ( Calipers , Screw-clamps.
Transfusion Pins,
associated with the methods of suspension and the employ- This method of applying the reducing force directly to
meet of weights and pulleys, is that of gradual reduction, the femoral oondyles is now widely used. It implies the use
Both employ axial traction on the limb. Both aim at com- of a superstructure aud the suspension of the limb. Splinting
plete muscle fatigue. of some sort is applied to the thigh, but the leg is left free
In the former muscle fatigue is obtained by a concentrated to move from a position of full extension through 90° of
process by which the muscular resistance is overwhelmed, flexion on the thigh. Many ingenious devices are in use by
the displaced bones reduced to position, and the results which these movements are procured, and some surgeons go
gained rigidly maintained from the beginning. This process so far as to say that every fracture of the femur, irrespective
is ushered iu by deep general anaesthesia or by spinal j of site, should be treated by the use of calipers,
anaesthesia, ensuring absolute flaccidity of the muscles The method is theoretically the simplest and most
involved, which are never permitted to resume their deform- economical of all methods of reduction. The reducing
ing action on the fragments. Reducing and counter- force is directly applied to the femur itself, and, irrespective
reducing forces are concentrated upon the limb by the of the movements of tbe pelvis or the leg, must act always
ingenious mechanism of tbe Thomas splint. Muscular con- along its axis.
traction, while it lasts, acts against two rigidly fixed points In any other method whenever the leg leaves the position
—namely, the tuber ischii and the distal end of the splint. of full extension the reducing force acts indirectly via the
In the second method a superstructure is necessary, which knee-joint, and therefore at a mechanical disadvantage,
is solid, which may lie upon the bed, be built up from it, Wherever this method is usbd movements of the leg should
ground which, after four years of war, may rightly be regarded
as well explored.
A RSsum-S of Principles and Methods.
• In our treatment to-day of fractured femurs there are
broadly two principles involved, associated with two
divergent methods. The first, associated with Thomas and
the Thomas splint, is that of complete reduction, ab initio,
and immediate and continuous fixation. The second,
Thb Lanobt,] DR W. H. JOHNSTON : SUSPENSION TREATMENT OF FRACTURE8 OF THIGH. [Feb. l f 1919 1 / I
always be provided for by the mechanism adopted, and the
limb should never be rigidly fixed from hip to ankle in a
splint of any kind.
On Adhesive Plaster , Glue , ,SV.
Perhaps the commonest method of affixing the reducing
force to the limb is the old method of glning or sticking
bilateral bands of suitable material along the skin of the
limb. If the limb be treated in the fully extended position
throughout the adhesive plaster can be carried up to, or
above, the site of the fracture, and the force will act directly
along the axis of the femur—i.e., most economically. There
is a further economy in the available skin.
If, however, the limb be flexed at the knee the adhesive
should be carried to a point below the knee, and the force
then acts indirectly along the femoral axis and at a
mechanical disadvantage—i.e., uneconomically. There is
also a loss of available skin. The trouble due to the use of
adhesive plaster has been great. Notwithstanding the
greatest care'in its application and supervision, this trouble
is still present. It is certain that such a method of affixing
a reducing force to a limb will not permit of haphazard
methods with pulleys and weights. It is a crude method at
best.
It is suggested that much of the trouble could be avoided
by the strictest economy in the application of force. Thus:
1. Weights are often applied by guess* work at angles
mathematically uneconomical.
2. A resolution of forces employed in a given case would
give a resultant upon the femur not at all in proportion to
the total weights used.
3. Heavy weights are often left acting upon the adhesive
and skin long after the complete reduction of the femur has
r~ ——:- 7
L#- — — —
1
fb . 3. ,
^1
pdL,
\
/•v*
Method 1, Case B. * and y t less thi
z = zin Fig.
in x and y In Pig. 2.
been accomplished, when very muoh lighter weights are all
that is necessary to maintain the results gained. This may
be due to lack of observation, failure to measure the limb
regularly and to make repeated radiographic examinations.
4. A change of position in bed may throw the system out
df gear, cause variation in the reducing force, and allow of
relaxation and fresh displacement at the fracture site. To
overcome this heavier weights are again resorted to, with
additional strain upon the skin.
If attention be paid to these details a great deal of the
above trouble may be avoided. The question to be asked
is—What is the minimum weight that can be used to produce
in the shortest time the result aimed at ? What is the correct
way of applying it? The answer is to be found in the study
of the mechanics of suspension.
Experimental Study of Certain Methods and Fallacies oj
Suspension .
The efficiency of the Hodgen splint lies in the fact that the
forces acting upon the rigid framework from above are divided
into two sets : ( a ) those acting along the limb from hip to
heel (direction) ; (b) those acting from below upwards. The
former are transmitted by the bands of adhesive fixed to the
distal end of the splint and applied to the skin of the leg—
a tension effect. The latter are transmitted to the limb by
the supporting crossbands of the splint—a pressure effect.
There is thus a distribution of the reducing force into a
tension and a pressure , each distributed more or less equably
along the limb.
Consider here three of the commonest suspension methods
in which the Hodgen splint, or modifications of it, are used.
The apparatus (Fig. 1), constructed of wood, was used as a
means of checking the geometrical results shown below. The
broken femur is represented by two wooden blocks, connected
on each side by small spring balances, each capable of regis¬
tering 201b. tension. By its use the theoretical findings
were in every case substantiated.
Method 1 .
Case A .—The first system investigated was the method
originally described in the text-books as the Hodgen splint.
This is shown diagrammatioally in Fig. 2. The limb is sus¬
pended by one cord passing over a single pulley, B; the latter
is rigidly fixed to the overhead bar or upright. A large
spring balance was let into the fixing cord. The mechanism
of this case may be briefly solved as follows
ABC is a continuous cord running over the pulley. There¬
fore, tension in A B equalB tension in B C. The resultant
tension must bisect the angle ABC , and must therefore
act along B D. Gravity produces a turning moment upon
the pelvis. Let this force be 2 , acting through D. The
forces x and £ must have a resultant, acting parallel with the
axis of the femur. Draw Dy through D parallel with the
femur, and taking Dx any convenient length, complete the
parallelogram Dxyz.
If x in direction and magnitude represents the tension in
the fixed cord, then according to the parallelogram of forces,
y must represent in direction and magnitude the reducing
force upon the femur. Therefore y lbs. are exerted upon the
balances at the fracture site by a tension of x lbs. in the fixed
cord (see the large balance). Note, further, that y is not
acting directly along the axis of the femur but parallel with
it, and that y is a little more than half of x.
Case B— Now let the patient move towards the foot of the
bed, say 6 inches, all other fixtures being unaltered. What
happens is demonstrated in Fig. 3, which is drawn exactly
to scale with Fig. 1. It will be observed that the only force
which does not alter in both direction and magnitude is the
force of gravity, The new resultant, y , is greatly reduced,
certainly by more than half, and the angle of the femur to
the bed is, of course, altered. The deduction from the above
is that by a movement of 6 inches, downward towards the
foot of the bed, there is loss of 60 per cent, tension produced
upon the femur. In practice, the patient soon finds this out.
Considerable elevation of the bed often fails to check this.
The practice of elevating the foot of the bed considerably is
172 Thi Lancet,! DR. W. H. JOHNSTON : SUSPENSION TREATMENT OF FRACTURES OF THIGH. [Feb. 1, 1919
to be condemned. It is quite unnecessary and can be
obviated by varying the angle between the femoral axis and
the horizontal. The nearer tne femur approaches the
vertical position the greater becomes the counter-reducing
force of body weight. This was recognised by Scudder.
Method 2.
Case A (patient stationary).—Next oonsider the system
where (see Fig. 2) instead of the cord being fixed to the
upright, a second pulley is supplied and a weight of x lbs.
is suspended to the end of the cord—i.e., the same weight
as the tension shown upon the balance in the case of the
fixed cord. It is unnecessary to say that, in this case, every¬
thing remains as in Case A, Method 1, provided the patient
remains stationary in bed.
Case B (patient moves).—Now again, let the patient move
towards the foot of the bed, say 6 inches: Fig. 4, drawn to
same scale as former figures, demonstrates the change of
forces, both in the direction and magnitude, which occurs.
The direction and magnitude of all forces save that of
gravity, r, change, y?, the resultant force, is greater than in
Method 1, Case B (Fig. 3), and less than in Method 2, Case A
(Fig. 2); in other words the second pulley with weight is an
improvement and saves a certain amount of loss of tension
on the femur due to movement of the pelvis. If the patient
moves towards the foot of the bed extra weight must be
added to the cord, therefore, to maidtain uniform tension.
Method 3.
Case A .—One frequently sees a limb suspended in a
Thomas splint, bent at the knee in varying angles with the
adhesive strapping secured to the distal end of the splint.
The ring of the splint is usually in loose apposition to the
gluteal fold and tuber iscbii and the main reducing force is
applied by weight and pulley from a superstructure to the
distal end of the splint.
A similar method is also frequently seen with the Hodgen
splint. It is not suspended as in Figs. 2, 3, and 4, but by two
or more upright or oblique cords applied at either end of the
splint and one about the middle. The main reducing force
is then applied by weight and pulley from a superstructure
to the distal end of the splint. These oases are analogous.
The Thomas splint is here used merely as a supporting
framework for the limb. Diagrams are unnecessary, as they
are well-known types.
f lbs. (Fig. 5) acts directly along the axis of the leg. Let it
be required to produce / lbs. pull along the axis of the
femur. Let a represent /lbs. pull in magnitude and in the
required direction. With a as a radius, describe arc
Complete the parallelogram orse.
To get a resultant equal to /. lbs. a second additional
weight, it will be seen, must be added, represented in
direction and magnitude by o r and represented diagram¬
maticallly by x lbs. over a second pulley. Vary the angle of
the splint at the knee (and from experience this is a very
variable angle) and both the magnitude and direction of the
force o r must vary. The weight y represents any number of
tensions suspending the limb, applied along the splint and
counteracted by gravity *—i.e., the limb is suspended in
equipoise.
The importance of this upon the two types of cases just
cited is that: 1. The weight f acting over the pulley produces
only a little more than half its weight as a direct tension
along the axis of the thigh. 2. In all such cases as the above,
a second weight varying in direction and magnitude with
the leg-thigh angle is necessary to secure a resultant pull
along the axis of the femur equal to the pull applied at the
end of the splint. 3. This is irrespective of the weight
already in use to secure oquipoise on the limb. Therefore,
whatever angle is selected at the knee in this type of rigid
splint, the additional force and its angle of application
should always be carefully calculated before use.
Case B (patient moves).—Fig. 6 shows the position when
patient moves towards the foot of the bed. The drawing is
to scale with Fig. 5. It will be seen that the direction and
magnitude of the force y alters. Part of this force formerly
used to secure equipoise nowaots along the leg in opposition
to f, and to this extent gravity 2 is unopposed. Hence the
distal end of the splint tends to drop. The force x alters
very little in magnitude but its direction is changed, and
hence the new resultant a alters appreciably in magnitude.
The inference here is that even with the additional weight x
a change of position in bed produces a falling off in the
resultant force, and at the same time a tendency for the'
limb to rotate downwards upon the pelvis.
To sum up : The Hodgen splint, as used in Figs. 3 and 4,
and the Hodgen and Thomas splint used as in Fig. 6, fail to
give a constancy of the reducing force upon the site of the
fracture. Movement of the patient up or down in the bed also
produces variations in the accessory forces which may be
applied. (See Fig. 6.) In all, flexion of the thigh is possible,
but causes a variation in the force of reduction acting upon
the fracture site. In all, movements at the knee-joint are
impossible without throwing the apparatus out of gear.
A Mechanical Device for Securing Free Movement at the Knee
without necessarily using Calipers , Clamps , Transfixion
Pins , <Vo.
In the methods discussed and in other modifications, the
forces employed are often multiple and they are not applied
directly along the axis of the femur. Eventually they are
all resolved, some in roundabout ways, so that part at least
of each force acts in this way. By acting at a mechanical
disadvantage greater weights are thus often used to produce
a given resultant than there is any necessity to use. The
legitimate inference is that in all indirect methods of apply¬
ing the reducing force there must be :—
1. A mathematically accurate method of arranging the
forces so that the maximum resultant is obtained along the
femur with the minimum components.
~ 2. An angle of flexion of the leg upon the thigh, which is
the most economical angle—i.e., one at which the leg shall
bear the strain longer and easier and with less tension and
pressure effects than at any other angle.
3. That variation of this angle will produce a variable but
proportionate distribution of the forces acting upon the
knee and leg and consequently a conservation of skin.
This can be proved as follows:—
Let A B (Fig. 7) intersect CD at right angles. With centre E
and radius EF describe the circle FG UK. Take any point
L between K and B on A B. Join L F and L //, make E M
equal to EL, and join FM and H if. The figure FLHM is
a parallelogram. Let L B represent a foroe divided into
two equal forces LF and LU. The resultant force is LSI
(in direction and magnitude). Now let the line C D assume
any other angle with A B— e.g., C' D'— at an angle of 45°. Let
the points where C D' intersects the circle be F and H'.
Join L F and L H\ and F' M and H’M. The figure L F MU'
can be proved to be a parallelogram.
Observe again that it LB represent a force dividing into
two components L F and L H’ respectively, the new
resultant is still L M in direction and magnitude.
And so it can be proved that whatever angle C D makes
with A B, the resultant force must always lie along the line
A B and be represented in direction and magnitude by LM f
whioh is the constant diagonal of a varying parallelogram.
Apply the above, then, to the treatment of a fractured
femur. Let A E represent the thigh, E the knee-joint, and
The Lancet,] DR. W. H. JOHNSTON : SUSPENSION TRE4TMBNT OF FR4CTURES OF THIGH. [Feb. 1, 1919 173
Arched
distance b&.r.
E D tbe leg, and let it be
imagined that these lines
represent tbe iron framework
of a Bnlint. Suppose tbe rigid
bar EIJ be prolonged in tbe
direction of E C to F, so that
E F equals E H. Let F L H
be a cord passing over a
pulley at L, and let L B repre¬
sent tbe main cord passing
over a fixed pulley overhead.
Let there be a moveable
hinge-joint at E.
Case /.—Let the leg E D be
flexed at 90° to the thigh. A
force L B, acting equally
along the two cords to tbe
points F and H , equidistant
from E , produces obviously
a resultant L M acting per¬
pendicularly to the axis of
the leg.
Case 2 —Let the leg E D
take the position E Z)'—i.e.,
at an angle of 135° to the
thigh. The iron framework
of the leg assumes the line
<!' E D\ and the forces L F*
and L IV along these cords
are now unequal. But the
resultant L Af ( vide parallelo¬
gram of forces L E* M IT) is
the same in direction and
magnitude. Note, however,
that the resultant LM now
acts at an angle of 45 c with E D\ and we can resolve it into
two sets of forces, one acting along E D' from E to D', and the
other perpendicularly from below against E D’. It is obvious
that these two sets of forces must at this angle be equal.
As the angle DE D’ increases the tension force acting along
ED’ proportionately increases, and the pressure force acting
Fig. 8.
£u3per\aory
A A Co '' d * to equipoise
**£>U6pci\Sory cord
to extension
weight.
Open Wire TVame
Co surround foot
when nccecaeery.
Ml Iron.
Le^rra.me
fa Pd. 1
Oblique
di&Cnnce
ArcK
t
Strap Co Owe
coupling force
2. These movements must be so controlled that whilst
they are being carried out the reducing force noting upon
tbe femur shall not vary.
3. The reduoing force must be the most economical one
possible—i.e., it must be applied along the axis of the femur.
4. Movements of the pelvis shall not throw the system out
of gear and alter forces in direction and magnitude—i.e.,
the angle of the thigh to the horizontal should be capable of
variation without affecting the main reducing force applied
to the femur.
5. The thigh must be sufficiently elevated above the
horizontal to secure adequate counter-reduction from body-
weight without raising the foot of the bed.
6. Anterior arching of the fractured segments shall be
provided for.
Fig. 9.
perpendicularly to ED' proportionately decreases. At
length, when ED' comes to lie upon EB— i.e., when the leg
is in full extension—the whole reducing force upon the femur
is now applied directly along the axis of the leg and thigh.
All this suggests an apparatus iu which the following
points can be satisfied :—
1. The leg must have complete freedom of movement
from full extension to flexion at 90° to the thigh.
The following is the apparatns in question:—
' Method of Applying the Splint.
The splint (Fig. 8) is applied by first straightening it out
so that the femur frame is iu line with tbe leg-frame. The
i transverse axis of the knee-ioint is next marked upon
the limb, and the splint is laid in position, flat on the oed
and enclosing the limb. The knee hinge is placed exactly
opposite the spot marked. The adhesive plaster which has
been applied beforehand to a point just below the knee iB
now secured by any convenient method to the distal end of
the splint (see Fig. 9). Supporting bands of calico or other
suitable material about 4 inches wide and carrying 1 inoh
depth of superimposed wool or Gamgee tissue are next fixed
to the side bars, passing beneath the leg. The lower third of
the leg should be completely ensheathed in wool and firmly
secured between the bars of the leg-frame either by a buckled
strap passing over the crest of tibia or by a firm bandage. This
constitutes a couple in the turning movements about the
knee-joint, and ensures that the leg and leg-frame move as
one. The cords A and B are next fixed as in the diagram
and passed over fixed pulleys and attached to their respec¬
tive weights. With an assistant supporting the thigh, the
limb is now elevated and slung in delicate equipoise. This
is easily effected by accurately estimating, by a spring
balance held in the hand, tbe exact weight upon each corfi
necessary to produce a stable and at the same time a
delicate equilibrium. The cords A and B should subsequently
be made to act vertically by using a plumb-line before fixing
the respective pulleys overhead. This is a matter of great
importance, because upon the fineness of these adjustments
depends the stability of the leg in any position of flexion
selected. Pnileys should be well oiled and at least 1$ to
2 in. in diameter, and so constructed that the cord cannot
jam. Lastly, the cord C, with wire foot-frame and pulley,
is fixed to the leg-frame, as indicated in Fig 8, and the main
reducing weight is applied to this cord passing over a fixed
pulley, the latter being placed most conveniently at a point
almost vertical to the foot of the bed. The thigh is secured
io tbe femur frame after the manner shown in Figs. 10, 11,
and 12, superimposed dressings being used for this purpose
(see Fig. 9), but other methods of securing anterior bowing
oan be used according to the site of the fracture.
Fig. 10 shows the apparatus applied and the manner in
which the leg-frame rotates about the knee-binge at o. A and
B weights support the limb in equipoise. The apparatus after
rotation remains in the new position without any fixing, as
shown by .ii B\ and Ai Bi. In the position Aq Ik— i.e., fall
extension—the foot passes into tbe wire foot-frame, whioh is
designed to permit of this. The reducing force C remains
unaltered, as also does the angle at the hip, by this rotation.
Distributed pressure along thq calf (E) and pull upon the
adhesive (F) vary with the angle at the knee. At the angle
174 The Lancet,] DR. W. H. JOHNSTON : SUSPENSION TREATMENT OF FRACTURES OF THIGH. [Fbb. 1,1919
Author's Method. Flexion of knee-joint. Rotation of splint about hinge
at o. A and B supporting weight of leg and splint In equipoise, the
apparatus after rotation remains in new position as A, B, and A%, B%.
Pallet <7and angle at hip remain unaltered by this rotation. Pressure
at E and pull on adhesive at V vary (see force diagrams). Explanatory
letters denote same points as in other diagrams.
of 135° they are equal (pee midposition). The parallelograms at
the side indicate how these forces vary in the three selected
positions—i.e., C is resolved into e and t/, <»i, yu and eiy 2 .
Fig. 11 is a diagrammatical representation of mobility in
bed and flexion of the hip. The pelvis may move from
to £ 2 , i.e., 30 inches to scale—a large range of movement.
The angle 0 X changes to 6 and then to # 2 * The leg-frame
changes from position A\B\ to A B, and then to A% # 2 - The
reducing forces Ci, C , and C a always act along axis of femur.
E E E denotes the pressure effect distributed along the calf,
and F denotes the conple effect produced by the bandage or
strap around lower third of leg. Y denotes the tension acting
along the axis of the leg due to the mechanism of the
adhesive plaster fixed to the distal end of the splint.
From this it is evident that, once the position is selected
from which it is impossible for the patient to withdraw
towards the head of tne bed, an adjustment of the overhead
fixed pulley transmitting the main reducing foroe may
produce an angle “ 0 ” of the femur with the horizontal, to
increase whioh is for the patient both irksome and difficult.
This position then is tne position in whioh the reducing
force is counteracted by the greatest available body-weight,
and its effect is similar to that produoed by extreme eleva¬
tion of bed. When the height from mattress line to super¬
structure level is 4 ft. 6 in. or over, roving pulleys are quite
unnecessary. The fixed pulleys then make such small angles
to A\ Aq and B\ B% that the effect iB negligible.
In the apparatus described above (Fig. 12) no new
principle is involved. It is a simple adaptation of the
Hodgen splint and its efficiency is largely due to the
mechanical device at the knee end of the leg-frame whereby
a couple effect is produced.
It will be observed that the movements of the knee so
distribute the forces acting upon the leg that when one set
exerts too much strain or pressure this may immediately be
relieved by alterations of the leg-thigh angle. The other set
Author’s Method. Mobility in bed and flexion at hip. Change of angle 0
at hip. X1-X3 = 30 Inches, a targe range, f.p., fixed pulley, r.p.,
roving pulleys.
then takes up the difference. Thus by varying the angle at
the knee a corresponding variation is produced between the
forces acting along the axis of the leg and those acting
perpendicularly to it.
Accessory Methods.
The apparatus lends itself to the employment of most of
the well-known methods of affixing the reducing force to the
limb, thus :—
1. The crest of the tibia may be transfixed by a suitable pin
long enough to rest upon the lateral bars of the leg-frame, to
which it can be firmly secured. Two such pins may be used,
one 3 inches below the tubercle and a second 3 or 4 inches above
the ankle-joint. The effect of
FIG. 12.
Author'* Method. B pperstus sa used in ward*, a? pulley carries the weight to hesd of bed.
this will be to do away with any
pressure upon the calf posteriorly
and to eliminate the necessity of
adhesive plaster or glue should
the use of suoh be inadmissible
or regarded unfavourably.
2. Two small cups at each upper
extremity of the thigh supports
are provided for the use of a Stein-
mann’s pin should transfixion of
the oonayles be preferred.
3. Chutro’s or Finochietto’s
stirrup may be used in prefer¬
ence to the adhesive plaster, and
the attachment can be made to
the end of the leg-frame.
4. Calipers can be applied in the
usual way, in whioh case the biurs
of the leg-frame should be set
below the horizontal teeth of the
calipers. The cord <7, with its
wire foot-frame, will be fixed
directly to the calipers and not to
the leg-frame. The rest of the
apparatus remains the same.
It must be recognised that it is
not always convenient or even
possible to use calipers or any of
the methods of fixing the re¬
ducing force directly to bone,
and that in any case there are
always a number of surgeons
who do not approve of them.
That being the case, the above
apparatus, it is hoped, may be of
use in utilising the older methods
to the best advantage.
The Lancet,]
DR. B. T. ROSE AND MR. E. H. SHAW : ECTOPIC GESTATION.
[Feb. I, 1919 175
AN INTERESTING CASE OF ECTOPIC
GESTATION.
By B. T. ROSE, B.Sc., M.B. Birm., F.R.C.S. Edin.,
LATE RESIDENT MEDICAL OFFICER OF THE GREAT NORTHERN CENTRAL
HOSPITAL.
With Pathological Description by
ERNEST H. SHAW, M.R.C.P. Lond.,
PATHOLOGIST TO THE GREAT NORTHERN CENTRAL HOSPITAL.
Macroscopic .—The specimen consists of the whole length of the
Fallopian tube and the lateral angle of the uterus. (Fig. 1.) The outer
half of the tube is rather swollen and red, and the isthmus gradually
becomes thinner as it approaches the uterus, where it ends in a large
ovoid swelling projecting from the uterus. This swelling is about
1 inch in vertical diameter and about i of an inch in its other dimen¬
sions. It is covered with peritoneum except at the apex, where
abinallpiece of blood-clot protrudes from a small perforation. Blood
shows through the peritoneum for some distance round the clot.
On section the tumour is seen to be red and solid, and blood is effused
into the loose tissues below. Although fairly well-defined, the mass
of blood-stained tissue is not limited by a capsule, nor is there any
sac or membrane suggesting amnion or chorion. No foetus can be
made out.
Cases of ectopic gestation are not very rare events in the
emergency operation list of a large general hospital. There
have been on an average five a year in this hospital during
the last ten years. The case, however, which it is desired
to note has certain peculiarities which render it of more than
usual interest. It is an example of a very early rupture-
six weeks’ pregnancy only—of the rarest of all types of
ectopic pregnancy—viz., that in the interstitial part of the
tube; while the difficulty of diagnosis is also worthy of
note.
Account of Case.
THE ERADICATION OF LATENT SEPSIS
PREPARATORY TO BONE TRANSPLANTATION IN NON¬
UNION OF GUNSHOT FRACTURES OF THE LIMBS.
The patient was 30 years of age, and previously had been
quite healthy. She had had no children, but 18 months
before she had had an incomplete abortion, which rendered
evacuation of the uterus under an anaesthetic necessary.
She had suffered occasional attacks of acute pain in the
right iliac fossa, which her doctor diagnosed as appendicitis.
On admission, at 11 p.m. on August 16th, the patient stated
that she had been quite well until 2 a.m. on the morning of
that day. when she was seized with acute pain in the right
lower abdomen. The pain was severe while it lasted, but
ceased after a short time, to recur again at intervals. There
was no sickness and no irregularity of the functions of the
bowel or bladder. Menstruation had been quite regular
until six weeks ago, so that the period was only 14 days
overdue. No haemorrhage or discharge had occurred from
the vagina.
On examination the patient’s general condition appeared
good. The pulse was fairly rapid—about 98 beats to
the minute—while the temperature was 100 2 F. and there
Fig. 2.—A section of the uterine portion of the Falloplau tube showing
chorionic villi in situ, x 90.
Microscopic (Fig. 2).—A section made through the tumour at the site
of the perforation shows blood and remains of muscular tissue at
the periphery and a tuft of chorionic villi within and also projecting
through the hole In the wall. The villi are well formed and are
embedded in blood. No decidual tissue is seen in this section.
I have to thank Mr. Mower White, senior surgeon to this
hospital, under whom the case was admitted, for his
kindness in allowing me to publish the case, and also for
the opportunity of operating upon it. I also wish. to
acknowledge the kindness of Dr. Shaw for his description
of the specimen and his help in preserving it.
Fig. 1 .—The specimen in the fresh state. Note the emerging ectopic
pregnancy, x 2/3.
was no marked pallor. The tongue was furred, the breath
foul,and sordes were present round the teeth. The abdomen
moved well with respiration, there was no rigidity anywhere,
but acute tenderness was found localised to the right iliac
fossa, with its maximum well below McBurney’s point. No
tumour could be felt in the abdomen and nothing abnormal
by the vagina.
A diagnosis of an inflamed refcro-csecal appendix was made,
though it was thought possible that some tubal trouble
might be present. Laparotomy was decided upon. On
opening the abdomen nothing abnormal was seen until the
C elvis was explored with the hand, when a large amount of
lood welled up into the wound. This rendering the
diagnosis of an ectopic pregnancy probable, the patient was
placed in the Trendelenburg position and the pelvic
viscera explored. Both tubes seemed quite normal; the
uterus, however, was somewhat enlarged, and at the right
cornu there was seen what looked like a small mass of blood-
clot about the size of a filbert adhering to the uterus. The
abdominal incision was enlarged and a partial hysterectomy
with right-sided salpingo-oophorectomy performed. The
abdomen was closed, a considerable quantity of warm saline
being left in the peritoneal sac.
The following description of the specimen removed was
kindly written by Dr. Shaw.
By HARRY PLATT, M.S. Lond., F.R.C.S. Eng.,
HONORARY SURGEON AND SURGEON IN CHARGE, ORTHOP.EDIC DEPART¬
MENT, ANCOATS HOSPITAL. MANCHESTER; CAPTAIN, R.A.M.C. (T.) ;
ORTHOP.EDIC SURGEON IN CHARGE, SPECIAL MILITARY SURGICAL
SECTION. 2ND WESTERN GENERAL HOSPITAL.
The two outstanding causes of the immediate failure of
many bone graft operations for ununited gunshot fractures
are the occurrence of infection derived from pre-existing
latent foci and the breaking down of ill-nourished skin
cicatrices. Experience of such failures has brought about
the almost universal practice of postponing a reconstructive
bone operation until a considerable period has elapsed from
the time of the complete healing of the wounds, and of
excising adherent skin scars at a preliminary operation. Six
months has been adopted by more or less common consent
as an adequate waiting period, but only if during this time
physio-therapeutic treatment of the limb has caused no such
inflammatory reaction as would indicate the presence of
latent sepsis.
The Empirical Basis of the Present Methods.
The probationary period, the exsection of skin scars, and
the provocative manoeuvres of the massage and electrical
departments form a triad of precautionary measures which
176 ThbLangkt,]
MR. HARRY PLATT: THE ERADICATION OF LATENT SEPSIS.
[Feb. 1, 1919
in a great many cases—probauly the majority—ensures a t
successful result for the subsequent bone transplantation.
Such a standard of safety is, however, founded on an
empirical basis; each one of the three factors may prove
untrustworthy.
In the first place a six months period is an arbitrary one,
as in a given case the tissues may be sterile at the end of
two months or may be still capable of infective reaction as
late as nine, or even 12, months after healing. A knowledge
of the anatomical situation of latent septic foci in these
ununited fractures throws considerable doubt on the ability
of physio-therapeutic treatment to produce with certainty a
“flare up ” when it is remembered that the encysted foci
are found in the avascular fibrous tissue between and around
the bone ends and in the bone ends themselves, For the
same considerations no vaccine or serum test can be expected
to afford evidence of any positive value. Finally, there can
be no doubt as to the necessity of exsecting adherent skin
scars in the region of the non-union, but in my experience
this operation does not go far enough.
Provided the necessary preliminary mobilisation of joints,
tendons, and muscles, and the stretching of contractures
have been obtained, it is desirable to be able to carry out with
safety a bone transplantation where indicated, at the earliest
possible date. This is especially desirable in complicated
injuries such as combined bone and nerve lesions where
operative interference is necessary for the repair of the
latter. Furthermore, from the standpoint of the patient
the prolonged delaying of an operation is to be avoided, if
possible, but this economic factor must not be allowed to
exert undue influence in the plea for early operation.
We are confronted with the fact that there is no certain
test or combination of tests by means of which one can
determine when a limb has reached the stage of safety. It
is therefore reasonable to regard every limb with an
ununited fracture as capable of an infective reaction at any
stage, however remote the time of healing may be. An
attempt to effect a radical excision of the area containing
the suspected foci in every case before performing the bone
graft would seem to be a logical procedure.
A Two-Stage Procedure.
Working on this basis, during the past 18 months I have
used a two-stage procedure in bone graft operations in the
majority of my cases and have now adopted it as a routine
in every case.
Stage 1 .—When the wounds have been soundly healed for
eight weeks, during which period regular physio therapeutic
treatment has been carried out, the following operation
is performed. After an excision of the adherent skin
scars the site of the non-union is exposed. The fibrous
tissue filling up the gap is exsected, together with a
slice of the bone ends sufficient to expose vascular tissue,
The block of tissue is removed as far as possible en masse ,
and all isolated bone fragments and attached bone “ spikes ”
are included. The clean section of the bone ends and the
removal of the fragments is an essential step. The excised
tissues are placed in a sterile test-tube or jar and sent to the
pathological laboratory. The bed for the subsequent graft is
now swabbed out thoroughly with Harrington’s solution. The
bone ends and the region of the gap—now increased iu size-
are covered in by a restoration of the fascial and muscular
coverings and the skin wound is sutured after undercutting
the flaps to allow easy approximation.
This operation is at once an attempt at wound sterilisa¬
tion, a provocative measure, and a reconstruction of the
bed for the future graft. In two to three weeks’ time the
limb is usually ready for the resumption of physio-thera¬
peutic treatment.
Stage 2 .—The bone transplantation is performed in from
six to eight weeks’ time after the uncomplicated healing
of the first stage operation. During this period the usual
physical treatment is continued. Ionisation of the wound
area is always prescribed in order to obtain the maximum
softening of the superficial and deep scars. The details of
the technique of the bone graft operation are outside the
scope of this article, but my experience of more than 80
bone transplantations for various disabilities has emphasised
the superiority of the inlav graft over all other methods. A
graft must be long enough to reach several inches above
and below the actual gap and should need no additional
fixation when accurately wedged into the gutter.
The bacteriological examination of the tissues removed in
the first stage is of the greatest importance, whether the
findings be negative or positive. If the tissues prove to be
sterile, and an uncomplicated healing of the operation wound
occurs, the future bone graft can be awaited with confidence.
The cultivation of organisms (other than skin germs, e.g.,
( Staphylococcus albus, the appearance of which should cause a
scrutiny of the operative technique) associated with primary
healing of the operation wound affords strong indication
that sterilisation of the area of non-union baB been achieved.
Two cases in my series illustrate this point. In one, aD
ununited fracture of the femur of 12 months’ duration, with
wound scars which had been healed for six months, B.proteus
was cultivated from the fibrous plug found in the medullary
cavity of the lower fragment. Infection of the wound
followed. In the second case, non-union of the radius, the
same type of organism was isolated, but primary healing
occurred and the patient resumed physio-tnerapeutic treat¬
ment in two weeks without any subsequent reaction. In this
type of case the second stage' should be postponed a little
longer than usual, though the waiting period need not exceed
three months.
In my opinion the two-stage procedure for bone-graft
operations, carried out as described above, has conclusively
proved its value, and I regard any procedure less radical than
that advocated in the first stage as an inefficient index of the
subsequent sterility of the limb and an inadequate prepara¬
tion for the introduction of the transplant.
SOME ADVANCES IN POLYGRAPHIC
TECHNIQUE.
By H. L. FLINT, M.D. Leeds,
CAPTAIN, F.A.M.C. ; ASSISTANT CARDIOl OG1ST IN THE NORTHERN
COMMAND; ASSISTANT SURGEON TO THE MANSFIELD HOSPITAL.
The clinical polygraph has only gradually been making its
way into everyday use since its introduction by Sir James
Mackenzie many years ago. This instrument in the hands of
a few pioneers has given us such valuable information of the
mechanism of the heart beat, and has so far unravelled the
tangled skein of cardiac irregularities, that it might appear
surprising that the clinical polygraph is not now in daily use
by all practitioners.
There are, I think, several reasons why this instrument is
not as widely used by the profession as the importance of
the information it yields would warrant. The chief obstacle
may be a difficulty in procuring an instrument, ; but that is
not the only cause, for one occasionally meets a medical
man who possesses an ink polygraph but has given up using
it. The great objection to the instrument in the past
has been the length of time taken not only in assembling
the instrument, taking the tracing, and then packing it up
again, but in measuring out the tracing and arriving at a
correct interpretation. The busy practitioner, much as he
would like to use the polygraph, finds he cannot spare the
time which is at present necessary if he would acquire the
information it will yield.
It is obvious, therefore, that before the polygraph can
come into general use the technique must be simplified, I
Fig. 1 .— The polygraph In position of use, and the wrist splint.
claim that the following three procedures, which I have
adopted, very materially reduce the time, not only in
taking the tracing, but in measuring it and arriving at an
interpretation : (1) the adoption of a box in which the
instrument can be carried about fixed ready for use ; (2) the
use of a wrist splint; (3) the introduction of a modified
slide rule for measuring out the tracing.
Description of Improved Methods.
With the aid of diagrams only a short description of each
improvement is necessary.
1. The new polygraph box.— Fig. 1 shows the polygraph in
the box. The top and front of the box open on hinges;
when shut they are fastened by lock and key. All the parts
of the instrument, including even the pens, are kept in
The Lancet,]
DR. H. L. FLINT: SOME ADVANCES IN POLYORAPHIC TECHNIQUE. [Feb. 1, 1919 1 77
178 The Lancet,]
CLINICAL NOTES
[Fkb. 1, 1919
Clinical Sates:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
A CASE OF SPRUE ASSOCIATED WITH
TETANY.
By P. W. Bassett-Smith, C.B., C.M.G., F.R.C.P.,
F.R.C.S., D.T.M.&H.,
SURGEON CAPTAIN, R.N.
The onset of tetany in association with diseases of the
digestive system has been not infrequently noted, bat it has
not before beep recorded in a case of sprue.
The patient, a male, aged 45, contracted the disease on the
China Station in 1911-13, probably at Shanghai. He had
suffered from many relapses of diarrhoea and sore tongue,
but more frequently during the past two years. In July,
1918, he was admitted to the Royal Naval Hospital, Plymouth,
for ohronic colitis, and the disease was then diagnosed as
sprue, the stools being pale, bulky, and fermenting. He was
extremely emaciated and debilitated, and weighed 84 lb. On
Sept. 19tn, 1918, he oame under my charge at the Dread¬
nought Hospital, Greenwich. The condition then was that
of a typical case of sprue in its last stage. The tempera¬
ture was subnormal, pulse 74, respirations 24, and bis
mental condition was clouded, but he was generally very
cheerful. There was intense emaoiation, dry skin with
increased pigmentation around nipples, scrotum, face, and
axillae. The conjunctive were pearly white, tongue was dry
and glazed but no uloeration was present; the abdomen was
distended, peristalsis very active and easily stimulated. The
stools were semi-solid, pale yellow, abundant, offensive, but
not fermenting. The urine showed a trace of albumin. No
oedema, petechim, or sores. The systolic blood pressure was
95 mm., and the pulse of low tension. Examination of the
blood showed red oells, 1,480,000, and white oells 3200;
polymorphs, 61; lymphocytes, 34; mononuclears, 3; and
transitionals, 2 per cent. The blood picture was that of
a severe secondary anaemia without nucleated red cells.
Under treatment the patient showed signs of improve¬
ment, but on Sept. 23rd he complained of slight cramps in
right hand and wrist. These were relieved by warmth. On
the morning of the 24th he felt well but for the cramps, and
passed a large fermenting stool; at mid-day definite tetany
set in, chronio spasm of right hand fingers, wrist, and fore¬
arm. The deep reflexes were lost, but the muscles reacted.
The condition rapidly became worse, with collapse, intense
pain, and sweats, the spasm spreading up the arm and across
the ohest, with a marked trismus, typical risus sardonicus,
and the right leg was slightly affected. The bowels aoted
involuntarily. Oxygen was administered, an ether injection
iven subcutaneously, and also a turpentine enema. At
.30 p.m. the trismus had passed off and he felt muoh better,
but the hand was still clenched. At 3 p.m. he was taking
food and felt more comfortable, but was very weak. Calomel
was given with Dover’s powder, and he was ordered a course
of thyroid extract.
There was no return of the tetany, but the general con¬
dition did not improve, and on Oot. 3rd slight pyrexia with
pulmonary symptoms oame on. He died on the 7tb quite
quietly in the night from heart failure, apparently free from
pain.
Post-mortem showed a complete absence of fat in the tissues. The
heart (5 oz.) was very small and superficial white patches were present.
The Intestines contained much soft faecal material; no ulceration was
found anywhere, but the walls were very thin, especially those of the
lower part of the jejunum and ileum. The mesenteric glands were
enlarged. The spleen was small and free from adhesions and weighed
1£ oz. The liver appeared normal, weighing 3 lb. The kidneys were
both large, pale, and weighed 4-5oz. Toe pancreas appeared normal,
and the thyroid was atrophied. The left pleura was adherent
throughout and both lungs showed intense oedema, most marked at
the bases.
A microscopical examination of the organs was made. The liver
showed a slight amount of interlobular cirrhosis. In the kidneys there
was some evidence of chronic tubular nephritis, but no infarcts or
hemorrhages. The lungs showed hemorrhagic and catarrhal infiltra¬
tion of localised areas. The pancreas appeared to be normal. Sections
of the small intestines showed atrophy of the villi with a small-celled
infiltration in the submucosa, and in this layer were a number of stout,
oval, and slightly curved, rather large Gram-poBitive bacilli, but no
evidence of ycast-like cells could be found.
The chief interest in the case lies in the severe attack of
tetany which came on late in the disease from no apparent
cause other than some intestinal irritation ; its unilateral
character as far as the limbs were concerned, and the severe
bilateral trismus; the extreme emaciation of the patient,
making the contracted muscles stand out more prominently
even than usual. The rapid action of the subcutaneous
injection of ether in relieving the spasm is noteworthy.
PERITONSILLAR ABSCESS
FOLLOWED BY OSTEOMYELITIS, NECROSING
ENCEPHALITIS, AND MENINGITIS.
By Andrew Wylie, M.D. Glasg.,
SURGEON, CENTRAL LONDON EAR AND THROAT HOSPITAL.
With Report on Pathology hy Wyatt WlNGRAVB, M.D. Durb.
From the comparatively trivial degree of its early
symptoms, the regrettable delay in evacuating pus, and
the extensive lesions revealed by necropsy, this case is of
the deepest interest. It is instructive to note the extensive
destruction of bone, and that the patient should have
suffered so little pain or even discomfort. She continued
her work until eight days before death. The thrombosis of
the jugular bulb evidently prevented pulmonary sepsis. An
early diagnosis of the peritonsillar abscess 16 days before the
patient attended hospital, with a free incision and evacua¬
tion, would have obviated the serious and fatal complication.
The notes of the case are as follows.
Mrs. A. B., age 48. was In good health until April 29th, when she had
an attack of tonsillitis and a peritonsillar abscess on the right side; no
treatment except a gargle. On May 4th swelling of the left eyeball,
slight pain in the throat and back of head; bat she did not consult
anyone, and continued her daily work. On May 15th the swelling of
the left eyeball became worse, and she went to the Western Ophthalmic
Hospital. Mr. George Thompson sent her to my clinic, and she was
admitted as an in-patient at once.
On admission the patient had pain in the back of the head, neok, and
in the oervical region; her speech was not clear. There was a
prominence of the left eyeball with ptosis, slight Injection in the outer
canthus, a dry tongue, and temperature 102° F. No pain over the frontal
sinus. Fluctuation was found in the faucial arch due to a peritonsillar
abscess of 16 days’ duration, which had not been opened or spon¬
taneously evacuated. This abscess was at once freely incised, a large
amount of foul pus evacuated, and 25 c.cm. antlstreptococoal scrum
was given.
On May 17th pus was still escaping from the incision. Patient some¬
what drowsy, both eyeballs prominent, the movement of the right one
limited. Temperature 104°. Pulse 110. 25 c.cm. antistreptoooeoal
serum lnjeoted; an Intravenous Injection of 1 in 1000 solution of per-
chlorlde of mercury given a few hours later. On May 18th patient
drowsy, restless, sleepless. Both eyeballs swollen and prominent. Two
doses of antlstreptococoal aerum Injected. Temperature 104°. Pulse
116. Slight rigor. Abscess explored to ensure thorough drainage. On
May 19th patient unconscious. Thick foetid pus still escaping from the
abscess cavity. Temperature 102°. Pulse 100. On May 20th patient
unconscious, both eyes prominent and fixed. No reaction to light.
The house surgeon. Dr. George Lean, reported that ophthalmoscopic
examination revealed “ choked disc ” in the right eye with thrombosis of
veins and small haemorrhages. Temperature 102°. Pulse 120. Severe
rigor. On May 21st condition much the same. Temperature 102°.
Pulse 126. Patient died on May 23rd.
Report of Necropsy by Dr. Wvatt Wingrave.
On removing the tongue, larynx, and pharynx a sloughing space
was found laterally about the level of the soft palate, which travelled
backwards In the deep oervical fascia to the p re vertebral area. Follow¬
ing the track upward a large packet of green pus was evacuated and
traced In the prevertebral muscles to the basi-occlpital and bast*
sphenoidal bones. Only a thin shell of these remained, their cancellous
elements being reduced to a soft green foetid mass extending Into
ethmoid and orbit.
On removing the skull and dura diffuse purulent meningitis was
found involving the whole brain. Over the right temporo sphenoidal
area was an extensive patch of necrosing cortical enoephalitls which
extended to a depth of 3 cm. All the ventricles were distended by a
foetid green pus. Seen from the intracranial aspect the bast-sphenoidal
and basi-occlpital bones showed complete necrosis. Only their outer
walls remained. The pituitary body was reduced to a semi-fluid mass
and the adjacent osseous sinuses were full of pus. The jugular bnlb,
sigmoid, and lateral sinuses were firmly thrombosed.
Films of the pus from all the regions showed the same character—
viz., streptococci, staphylococci, mycelia, and coarse forms of Spiro -
chxta firtida with some bacilli of xerosis type (diphtheroid).
The thoracic and abdominal visoera were normal. The right orbit
contained green pus which entered by a perforation in the ethmoid,
the roof was intact, and the left orbit not involved.
A specimen of green pus, removed on opening the peri¬
tonsillar abscess, showed no evidence of recent suppuration.
The .bacteria were the same as those found at the necropsy.
This material was evidently an old pocket of pus from
which infection burrowed into the deep cervical fascia in an
upward direction causing acute osteomyelitis of the basi-
occipital and sphenoidal bones followed by a meningeal infec¬
tion and necrosing encephalitis. Such conditions strikingly
illustrate the powerful tryptolytic action of unevacuated pus
even upon living structures bard or soft, an action second
only in importance to that of the infecting organisms. The
streptococcus was the active pyogen, the spirochaetes being
doubtless merely symbiotic saprophytes, yet adding to the
destructive powers of the locked-up pus.
ThbLanohy,]
ROYAL SOCIETY OF MEDICINE.
[Feb. 1,1919 179
ROYAL SOCIETY OF MEDICINE.
Admission of Pensioners to Civil Hospitals.
A general meeting of Fellows was held on Tuesday,
Jan. 14th, Sir Humphry Rolleston, the President, being
in the chair, when Mr. H. J. Waring opened a dis¬
cussion upon the Conditions under which Pensioners of the
Army, Navy, and Royal Air Force are Admitted into, and
Treated in, Civil Hospitals.
Mr. Waring said that the question of the admission of
pensioners into general hospitals for treatment was con¬
sidered by the council of the Section of Surgery, when it
was thought that some agreement should be come to among
the hospitals as to the lines of admission and remuneration.
With the assistance of Mr. Warren Low and Mr. J. Y. W.
MacAlister, circulars were sent round to all the London
hospitals with medical schools and a certain number *of
others. The communication ran :—
1. Does your hospital receive payment from the Ministry of Pensions
at the rate of Is. per head for in-patients and 2s. per head for out-patients ?
2. Are the naval, military, and Royal Air Force pensioners admitted
aa in-patients placed in special wards, in special beds allocated for the
purpose or along with ordinary hospital in-patients ?
3. Are they placed nnder members of the hospital medical staff
specially appointed for the purpose or are they treated in the ordinary
routine practice of the hospital *
4. Are similar pensioners treated as out-patients seen at special clinics
for the purpose or are they seen along with the ordinary hospital out¬
patients?
5. As regards the funds reoeived from the Ministry of Pensions, are
thqy entirely allocated to the general funds of the hospital or are they
in part used for payment of the members of the hospital staff who treat
the pensioners, and, if so, how are the staff paid ?
The replies received could be divided into four classes.
The first class, comprising a comparatively small number, receive
these patients and decline to accept any remuneration, because
they do not pay any members of the staff for attending to them.
Two large London hospitals adopt that principle. There are also two
without schools which do so, and one outside London.
The second class comprise those hospitals who receive payment—
that is to say, Is. per day per patient for in-patients, 2s. per attendance
for out-patients, and do not pay the staff who attend them. Four large
London hospitals take these patients in in that way, and one of them
proposes, at the end of the year, to discuss the question of what shall
be done with the money so received. One very large provincial bos-
S tal, which takes 5s. per day for in-patients and Is. 6 d. per attendance
r out-patients, does not pay anything to the staff.
The third class take these pensioners at the prices mentioned, and
pay 10 per cent, oi the total receipts to the members of the hospital
staff who attend them. Two London hospitals with schools are on
that basis and four provincial hospitals.
In the fourth group the staffs are paid, but in different ways. One
receives these patients at 7s. per head and 2s. per attendance respec¬
tively, and 20 per cent, is allocated to the medical staff. That,
apparently, 1« the largest payment tostaffs of any of the hospitals in this
connexion. The hospital is a large one, but without a medical school.
Another hospital pays the staff one guinea per attendance per day,
giving about four guineas per week to the staff who attend
these men as out-patlenta. (No details as to in-patients.) At one
hospital the medical staff are paid £50 per annum for the work,
bat, apparently, that particular hospital does not reoeive a large
number of these patients. Another hospital which has received the
7s. and 2s. rate does not propose to renew the agreement with the
Ministry of Pensions on the present terms.
•Arrangementsfor Treatment and Remuneration.
Considering first the best method of dealing with
pensioners in hospitals, Mr. Waring said that the most satis¬
factory way to him was to allocate a special ward or wards,
and to place them undei definite members of the medical
staff; and as regards out-patients, many of whom were able
to do a certain amount of work, to have special clinics in the
latter part of the day, so that employed men could attend
without interfering with their work. Itwasdifficultto estimate
the numbers of these men. Originally it was said that there
would probably be 100,000, but the War Office authorities
now suggested that that number would not be reached. In
the case of a small hospital the matter would be met by
allocating special beds in certain wards under the care of
particular members of the staff, the out-patient arrange¬
ments remaining the same. The value of pensioners for
teaching purposes in hospitals with attached medical schools
should be borne in mind. Such hospitals should consider
how far cases applying for admission were suitable for the
education of the medical student. Certain cases were
undoubtedly of value for this purpose—e.g., nerve injuries,
some bone injuries, but others, such as chronic suppurating
bone sinuses, were unsuitable.
In regard to payment, the State had admitted its duty to
look after pensioners. They were sent to the hospitals by
the Local Pensions Committee on the recommendation,
usually of their medical referee, that they required speoial
treatment. The question therefore arose, Ought the members
of the honorary medical staffs to be paid as well as the hos¬
pitals ? As the State admitted its liability for payment for
the treatment, be thought that the staffs ought to be suit¬
ably paid. The payment in the majority of cases was
apparently 10 per cent. If in a hospital there were 20 beds
that would give an income from the pensions authorities of
£2000 in the year, of which the medical men who looked
after the cases would receive £200. If the allotted beds
were not constantly full the income would be correspondingly
diminished. If several members of the medical staff looked
after these patients the individual emoluments would be
very small.
Turning to out-patients, with remuneration at the rate of
2s. per attendance, 10 per cent, of that was less than 2 \d.
Hospitals which paid this 10 per cent, seemed to think it
was right for members of their honorary Btaff to attend these
patients on what to him appeared an extremely minute
payment. He did not think any member on the staff
ought to he asked to attend under such conditions. There
was the further question of whether the hospitals were making
anything themselves. In 1917 -the last year for which the
returns of the King’s Fund were available—in one hospital,
charging respectively Is. and 2s., the average cost of each
in-patient per week was £3 5s. That hospital was therefore
paying its staff for doing something for the State. For out¬
patients the average cost being Is. 2d. on a 10 per cent,
basis the hospital was making l\d. out of each attendance.
The difference between in-patients and out-patients was
therefore striking. At two hospitals £3 5s. was the
approximate coBt, and one of them had refused to go on on the
Is. rate. In regard to the hospitals with schools the average
worked out at £123 4 s. per bed per year, which, of course,
was considerably more than the State was paying. Taken
altogether, the State was not paying sufficient for the
treatment of these patients.
Mr. Waring asked if any of the Fellows had proposals
to make as to what the State ought to pay if pensioners
were to continue to be treated in civil hospitals. The first
thing to be done in his view was for hospitals to be paid at
least the staffs’ out-of-pocket expenses and adequate pay¬
ment to the medical staff. It would he a fair proportional
remuneration to look upon the hospitals as receiving
two-thirds of the payment and the staff one-third. The
10 per cent, basis was evidently far too small. Some
might prefer the proportions $ to If his suggestions met
with approval he proposed to move a resolution that
pensioners should be in special wards, or special beds,
under particular members of the staff, that the out-patients
should he seen at special clinics, and that, as regards pay¬
ment, the hospitals should receive two-thirds and the staff
one-third of the total amount received from the Pensions
Committee.
Criticism of Various Points.
Sir Nkstor Tirard said that he spoke as a free-lance,
being no longer connected with the Army, except in an
honorary oapaoity. One difficulty in treating pensioners
in a general hospital arose from the different point of view
observed in dealing with pensioners and Army men and
with the ordinary type of cases admitted to hospitals. The
people likely to he sent to the hospitals by Local Pensions
Committees would still carry on some of the sort pf Army
tradition in regard to qualification for admission to a
military hospital. They would in no sense, as a bulk, be
suitable for teaching purposes. In dealing with the patients
nothing whatever was to be gained except the satisfaction
of doing one’s duty for men who bad been injured in the
war. He did not want to minimise that satisfaction, but the
profession had to consider if it was prepared to undertake
whole-time work in connexion with the Ministry of Pensions,
in the same way as they had undertaken such work during the
war. There was another difference. In ordinary hospital work
patients were visited on definite days settled on by the
administration, twice or three times a week, and at other hours
when the necessities of patients demanded it. In a military
hospital, on the other hand, the principle had been daily
attendance during the morniDg hours. Members of the
hospitals had been invited to offer for whole-time work in
connexion with the Ministry of Pensions, and by whole-time
work was meant daily attendance, whether, in the doctor’s
opinion, the condition of the patient demanded it or not.
180 The Lancet,]
ROYAL SOCIETY OF MEDICINE.
[Fbb. 1,1919
It was the practice in a civil hospital for the resident
medical officer to have interim charge of wards. Whether
the wards contained pensioners or not this was the only con¬
venient way of working them; and for the members of the
staff who have charge of the wards to act as consultants and
attend at regular times on definite days. In regard to
payment, it would not be necessary to demand daily attend¬
ance from the ordinary consulting physicians and surgeons
of the London hospitals ; their time would be wasted in the
majority of cases. For instance, in the medical group it was
not necessary for the expert in neurology, shell-shock,
dysentery, malaria to attend daily. The work was done by
the resident medical officers, who should therefore take a
reasonable proportion of the remuneration. If anything
came of this proposal for payment, he hoped that the
payment would be primarily devoted to the younger men in
the profession, those who were living in the hospital and
doing the work.
Views of a Hospital Secretary.
Mr. G. Q Roberts (Secretary, St. Thomas’s Hospital) said
that in the early discussions held between the representatives
of the managing committees and of the staffs of four or five
of the largest hospitals in London, the decision was reached
that everything possible must be done for the men who had
suffered in the war. But, at the same time, there must be a
recognition, by a payment, of the services rendered by the
staff in doing work for which the Government had accepted
full responsibility. Personally, he had thoroughly disagreed
with the idea of payment by such a ridiculous proportion as
the 10 per cent, indicated. Taking the out-patients alone,
that represented about 2d. per attendance. A new case was
not examined under about 20 minutes. Four fresh cases per
hour were about all which could be got through, and 8 d. an
hour was hardly adequate for the most junior man on the
staff. But if, as should be, a man sees also the returned
cases, the average per hour goes up. When the 2s. per
attendance was mentioned it was never thought that vgould
adequately pay any members of the staff who did the work.
With regard to the arrangements made for seeing pensioners
there were two important points. Cases likely to be useful
for teaching purposes, on which the opinion of an expert was
required, should be assessed by the member of the staff seeing
the cases, who decided whether he should see the case again
for continued treatment. For the remainder, and they were
many, in large part functional, a regular evening clinic
should suffice. They had been completely snowed under by
attempting to treat war pensioners at the ordinary afternoon
clinic. The number of new cases usually sent round to out¬
patient physicians and surgeons was strictly limited. The
number of war pensioners referred to hospital who did need
the opinion of an experienced man was so great that it unduly
handicapped the resident assistant physician or surgeon
in selecting ca*es to send round for the opinion of the staff
from among the civilians. Hence the evening clinic under
the charge of comparatively young men of experience. Mr.
Roberts said that he interpreted the agreement in regard to
war patients not that cases sent by the Medical Referee were
necessarily received, but they were examined on the opinion
of a member of the staff in the same way as civilians were.
The members of the staff had been unanimous in saying that
as pensioners were occupying beds which, in the ordinary
way* would have been occupied by civilians, they would not
aooept payment for those cases. The governors had there¬
fore felt'justified in accepting from the Ministry a payment
of Is. per day, which was the average cost of each in-patient
per day at the time the rate was fixed. This year the cost
would be found to be considerably higher. Pensioners were
hearty eaters, and they cost more to feed than the average
civilian patients. The vast majority of the cases attending
required massage or electrical treatment, and for these four
sessions per week were provided, in addition to the ordinary
four sessions taken by the physician and the surgeon. Those
cases did just about pay for themselves.
With regard to payment, the money was being kept
entirely separate on a twelve months' trial, and an agreed
sum was being allotted to the individuals doing the work,
including masseurs, those doing medical electric-d treatment
in the evenings, as well as clerks to keep a complete register.
If at the end of the year a balance should remain, its dispersal
Would only be made after full consultation with the staff.
As a hospital manager be Would not set adide special wards
forthe treatment of war pensioners. These men had been
much spoiled and petted, had been granted little licences
and freedom, and were difficult to control afterwards. In
ordinary civilian wards they soon fell into the routine discipline
of the ward. On an average they had had only 17 in-patients
during the year; they could not set aside a special ward for that
number. Most of the wards contained 28 patients apieoe ;
the medical cases had to be separated from the surgical,
the specially septic cases from tbe cleaner ones, so that a
number of wards would be required if pensioner cases were
allocated to separate wards. If special wards were to be
provided the Ministry of Pensions would have to make other
arrangements. On tbe present plan the pensioners had the
personal direction and decision of members of the staff, who
attended to them in precisely the same way as the civilian
cases.
Further Discussion .
Sir Kenneth Goadbt said that the first broad question to
face was the actual number of wounded in tbe hospitals at
the present time, and the number of * those who were
potential patients. In his own observation of 10.000
wounded cases, exactly 10 per cent, had re-presented them¬
selves for various treatment. For cases requiring continuous
treatment the military hospital was the best that could be
devised. The only way to enforce discipline was by knocking
off a proportion of the man’s pension, a difficult thing to do
in a civil hospital. Many of these men would want treat¬
ment during the rest of their lives ; they were going to be
in and out of hospital out-patient departments, with
occasional stays as in-patients. He agreed with Sir Nestor
Tirard that a large proportion of these would be of no value
for teaching purposes. He submitted the advisability of
continuing the fixed disability pensions of these men. A
man was more likely to work if his pension was continued.
He wanted to know how far hospitals would place themselves
under the control of the Ministry of Pensions by accepting
payment for the treatment of pensioners.
Dr. Sydney Phillips said that the question whether
hospitals were prepared to take pensioners at all still
appeared to be an open question. Sir Nestor Tirard appeared
to think that men who came in as pensioners should be
required to come under tbe same regulations as soldiers.
But the men had already left the Army, and the inquiry
came to the hospitals from the Pensions Committee who had
not laid down rules Buch as obtain in military hospitals.
He had not heard that the staffs of London hospitals were
being asked to do whole-time work. So far as he had seen,
there was no intention on the part of the Pensions Com¬
mittee to interfere with the treatment of the cases; they
left the hospitals to supervise the treatment for which
the staffs of those hospitals were responsible. Medical
officers in hospitals would as before go as often as
they thought right. He saw. no reason for not receiv¬
ing the proposition of the Pensions Committee with
favour. It had already been received by St. Thomas’s,
St. Mary's, and others throughout the year, and, he thought,
without very much difficulty. Pensioners would be civilian
patients and not even ex-soldiers. The Army in this war
consisted to the extent of 99 per cent, of civilian BQldiers.
They were the same people whom hospital staffs had been
attending all along, and they were coming into hospitals
every day with the same complaints as they had before.
Having been in the Army three or four years, some of them
less, did not prevent them having the ordinary diseases and
ailments. Of two patients suffering from melaena, one
came through the Pensions Committee, the other was seen
because it was an emergency. It was impossible for the
large hospitals in London to refuse to take pensioners,
because a great part of the male population between
25 and 35 years of age who had served in the
Army would be in the next ten years patients at
ordinary civilian hospitals. It was only a matter of terms.
In regard to the objection raised that pensioners were not
cases for admission into hospital, he said that the Pensions
Committee only asked for cases to be sent in on which the
medical staff of the hospital acquiesced as suitable. If there
were additions it was to the interest of the hospitals to appeal
to the public to improve the hospitals for the requirements of
men who had served in the Army. If the hospitals refused to
accept these men they would lose the interest of the student for
new cases, such as tropical disease, many of which would
come in from war areas, and there would be lost an un¬
paralleled field for medical study. The question of payment
Thb Lancet,]
ROYAL SOCIETY OF MEDICINE.
[Frb. 1, 1919 181
was more one for the administration to debate. The
Pensions Committee had never made any secret of the
fact that they would pay the medical officers. They had
said they would pay so much per man to hospitals in which
there were resident medical officers, and so much less if
there were not resident medical officers, clearly showing they
would pay the doctors for the services they rendered and
that there were two classes of hospitals, which would not be
reckoned as of the same value. They had now said how
much they would pay, and it rested with hospitals to allocate
it between the staff and the management. Before any
hospital could say what they would take they surely must
know how much the medical staff was prepared to ask.
In fpture resident medical officers would not be obtained
without payment. There would either be unqualified medical
officers or paid medical officers resident in hospital.
Discussion of Resolution.
Hr. Waring then read the resolution which he proposed :
That If naval, military, and Royal Air Foroe pensioners are to con*
tinue to be admitted to oivil hospitals these conditions should obtain
1. In-patients should be admitted to special wards or special beds under
special members of hospital staff. 2. Out-patients should be seen at
special clinics. 3. As regards payment, hospital authorities and
medical staff should receive remuneration on the basis of two-thirds
to the hospital, one-third to the staff.
He added that after this discussion had been planned it
was publicly announced that in future naval and military
pensioners would be treated in military hospitals, and he
understood that in the main that was being done.
Mr. Roberts explained that the instruction was per¬
missive, not compulsory. As far as St. Thomas's was con¬
cerned, the pensioners were preferring otherwise, and there
had been no diminution in their attendance.
Sir Nestor Tirard seconded the resolution, adding that
he had seen copies of the circular sent to two of the medical
schools, asking, on behalf of the Ministry of Pensions,
whether members of the staff were prepared to undertake
whole-time duty with them.
The Question of Hospital Accommodation in General.
Dr. Lauriston Shaw said that to him the question was a
larger one than that of dealing with pensioners. If we were
not getting the most satisfactory arrangements for those who
had been hurt as combatants the reason probably was that
we were not having satisfactory arrangements with regard to
people who had been crippled in industry. And he hoped
the experience now being gained would enable us to see
where our difficulties are. ~ Some of the confusion which
arose in early negotiations was because we did not clearly
make a distinction between the hospitals which had schools
and hospitals which had not them. The conditions were
utterly different. A strong stand should be taken against
cumbering beds with cases which could better be treated in
hospitals with less elaborate arrangements and equipment
than the large hospitals with medical schools attached. It
was clear that an enormous increase of hospital accommoda¬
tion was wanted in this country. This need not be accom¬
panied by corresponding increase in hospital staffs, for a
large proportion of hospital patients came in on the recom¬
mendation of practitioners, who should continue to treat
them in hospital. Patients frequently came solely because
their home conditions were not suitable. Hospital accom¬
modation should be classified into that required for serious
oases needing special investigation and expert treatment, and
cases to be dealt with by a kind of cottage hospital.
Secondly, it was necessary to hold the State to the prin¬
ciple that if it undertook the responsibility for the treatment
of the patient it must pay the medical profession for that
treatment. It was impossible to say to the Government,
• 1 We, as philanthropists, will treat your patients for nothing.”
We would do so if the philanthropic public would come
along and pay for the patients sent into hospital. Any other
oourse would lead to the impoverishment of the profession.
Further Adverse Criticism.
Sir John Bland-Sutton said he was hoping to hear of
some alternative scheme to that of foisting disabled soldiers
on the general hospitals. In London that plan had been
already tried for a year. At the commencement of the war,
surgeons, he said, saw that their services at a military
hospital would not end with the hostilities, but that many
of the men would require treatment for months and years.
The proper way seemed to be to convert the hospitals for
their reception practically into Poor-law infirmaries, places
for incurable and chronic oases. Then a surgical and
medical staff could be organised to meet the new condi¬
tions who need not be London consultants at all. There
must be many men with surgical and medical experience in
the Army during the war who would be well able to look
after these cases in such institutions. If the practice
became general of receiving these cases into the general
hospitals, they would soon be filled with chronic and
incurable cases. The question of payment was one for the
lay bodies of the hospitals, and they could not agree upon it.
He suggested putting a motion urging the Pensions Minister
to establish his own institutions and rid the hospitals of the
incubus. There must be something like 300,000 sick and
disabled soldiers to deal with.
Mr. Coles said that at one provincial hospital they
had allocated 25 per cent, of the money received from the
Pensions Ministry for these cases for the payment of the
honorary medical and surgical staff. He thought the time
would oome when these patients would have to be dealt with
in the evening, and the cost would then necessarily be in¬
creased. At the present time the rates of Is. and 2s. did not
leave much to be handed over to the staffs.
Major J. Adams suggested that the management and
teaching staffs of hospitals were rather at variance in their
points of view as regards the clinical material of the hospital.
The Ministry of Pensions was taking advantage of the bad
financial condition of hospitals in offering a subsidy which
the management in present circumstances felt tempted to
accept. The hospital staffs did not want their beds filled
with unprofitable clinical material. A member of the
teaching staff of a hospital was at present a servant
of that hospital, and if it was right for a hospital to
accept payment for patients received, it was between the
hospital and the particular member of the staff to agree as
to what remuneration he should receive. At St. Thomas’s
Hospital he had treated a certain number of pensioner
patients, but only as if they were ordinary civil cases. Ho
did not go to the hospital more frequently for seeing them,,
and had not spent extra time in operating upon them. He-
should, therefore, not like to make a claim for special pay*
ment. The proposition that there should be separate wards
and separate payment for those wards, he thought, was too
difficult for most hospitals to arrange. He agreed that the
pecuniary reward to medical officers should in teaching
hospitals go to the younger men.
Reply to Points Raised in Discussion .
Mr. Waring, in reply, said he agreed with Sir Nestor
Tirard that the medical officers who did the greater part
of the work for the patients should receive the emoluments.
His main contention was that the medical profession
should be paid for the work it did. At St. Bartholomew’s
there was a special ward with 20 beds and a certain number
of patients had to be taken into the general wards in addition.
By separate wards he implied that these patients should
be definitely placed under certain members of the staff.
That would be easier for administration and also easier for
the Ministry of Pensions. With regard to discipline, his
experience was that if these men were in a general ward
they fell in with the usual routine. Evening clinics were, he
thought, of great importance in saving of time for pensioner
patients. Dr. Shaw’s suggestion that more hospital accom¬
modation was required was apparent to all. Modern surgical
and medical treatment could not be given under bad
surroundings; in the matter of institutional treatment for
the non-hospital classes we were one of the most backward
countries. As to using the present military hospitals, many
of the temporary buildings were constructed only for a few
years’ u«e, and some were already beginning to fall down.
The President then put the resolution, clause by olause.
Part 1 was lost; Part 2 was carried ; Part 3 was carried with
the deletion of the word “adequate.” On the proposition
of Dr. Shaw, seconded by Mr. Warren Low, it was decided
to send a copy of the resolution to the British Hospitals
Association. -
SECTION OF SURGERY.
Bontb Grafting.
The ordinary meeting of the section was held on
Jan. 22nd, Sir John Bland-Sutton being in the chair.
A paper entitled “Mandibular Bone Grafts,” by Major
O. W Waldron, O.A.M.O., and Captain E. F. Risdon,
C.A.M.C., illustrated by oases and numerous slides, was read
182 The Lancet,]
ROYAL SOCIETY OF MEDICINE.
[Feb. 1,1919
by Captain Risdon, and formed the introduction to a general
discussion. The authors state that although bone trans¬
plantation is a surgical procedure of long standing, the
unexampled opportunity afforded by war injuries has enabled
a careful study to be made of its limits and possibilities,
especially in cases in which the mandible has been seriously
broken up. Within a few days of being wounded most of the
cases have arrived at a special centre for treatment, and the
large number of cases which had achieved good union testify to
the fine results of those who specialise in this work. They
consider that the close and continuous cooperation of surgeon
and dental surgeon is of prime importance in these cases.
In early stages the mouth must be kept as clean as possible,
special care being taken in regard to septic pockets and
cavities, and in this stage dental splints should be used, the
hindering sequestra being from time to time removed, for the
prevention of displacement and to ensure due control
of the edentulous posterior fragments. Dental splints
are usually required for at least two months. In oases
where non-union is obvious there should be early attempts at
movements of the jaw for the purpose of avoiding atrophy
and articular ankylosis. Careful periodic examination of
the teeth and the extraction of such as need it is regarded
as important. Teeth which are of service in the immobilisa¬
tion of the parts should be preserved, and there should not
be any great pressure on the teeth. Drainage must persist
so long as there are any unhealed sinuses. At least six
months should elapse since the disappearance of sepsis
and inflammation before bone-grafting operations are
attempted; and when the ununited fragments are strong
and easily controlled, so that the patient is able to
masticate with the aid of splints, this period before
operation can be extended. The authors believe that quite a
number of failures have been attributable to operation having
been done too early. Grafts should include both the peri¬
osteal and the endosteal surfaces; in fact, all the elements
should be comprised—the graft will then most nearly
approach the physiological. When open cancellous bone,
such as that of the rib, is used replacement is rapid; it is
lesB rapid in grafts cut from face or tibia. The relative
osteogenetic activity of transplanted bone varies with the
individual case. The authors’ work has been done with
autogenous bone-grafts. In most instances it is preferable
to fix the fragments in good position by means of
strong dental splints - and carry out the operative
procedure accordingly. The splints should be cemented
to the teeth at least a week before the opera¬
tion to allow the buccal mucous membrane to become
habituated to their presence. In 19 of the cases dealt
with the amesthetic employed was rectal oil ether, and
the authors think highly of it. Every effort must be made
to avoid perforation into the mouth cavity. The edge of
the fragments should be trimmed back 2 cm., and inter¬
vening cicatricial tissue excised and discarded. Simple
instruments have been preferred; it seemed dangerous to
use such an implement as an electrically-driven saw in such
a confined space. After a good deal of experience they
believe bone from the iliac crest gives the best results. The
patient should be kept in bed a few days to prevent the
formation of a haematoma, which might become infective.
If a case requires closure of the mouth for months it should
be opened at intervals for inspection.
Discussion.
Captain W. E. Gallie, C.A.M.C., said that some of the
old beliefs on this subject had been rudely shaken as a result
of experience with war injuries. In the clinic to which he
is attached many experiments on dogs had been carried out.
When a piece of living bone has been separated from its
circulation and implanted elsewhere in the body of the same
patient the immediate result is seen to be a coagulation of
nerves and vessels, to which the surrounding lymph cannot
percolate. This means the death of all the cells in the
Iacunre and of most of those in the Haversian canals. The
absorption of these structures occupies three to four weeks. On
the open mouths of the canals are osteoblasts, which are able to
absorb lymph. Ten days after implantation the proliferation
of the osteoblasts is well established on both the endosteal
and periosteal surfaces, and in a few days new bone forma¬
tion can be seen on these surfaces. These proliferating
osteoblasts attack the dead bone of the graft and quickly
cause excavations. Meantime, a re-establishment of, the
circulation has been taking place as a result of the ingrowth
of new blood-vessels into the motiths of the Haversian
canals. This occurs in about two weeks. Ultimately the
whole graft is seen to be permeated by vessels and osteo¬
blasts. The union of the graft takes place by the laying
down of new bone on the surface. If from the graft
endosteal and periosteal surfaces are removed very
little osteogenesis takes place from the graft itself.
The rapidity with which the changes occur depends on three
factors : the size of graft, its density, and the abundance of
the osteoblasts on the surface which survive. In some cases
months must elapse before replacement can occur. When
boiled bone is used for grafts the changes take place at a
definitely slower rate. Where there is a gap to be bridged
only autogenous grafts promise success ; if boiled bone be
used here the living elements will slowly disappear. The
great point to aim at in grafting, as it is only on the surface
that living osteoblasts survive, is to have the largest osteo¬
blast-bearing surface possible ; hence the width of the graft
should be greater than its thickness. Except in cases where
a strong graft is essential tibial bone should not be
employed ; that of the rib is better, as it is not only more
porous but is better supplied with lymph. It is wise to
split the graft longitudinally into a number of portions ; in
that way a large number of osteoblasts will be given the
chance of survival. Boiled bone-graft plates have been
largely used at this clinic instead of Arbuthnot Lane’s
metallic plate and have given much satisfaction. Not only
is there no likelihood of these getting loose, but at the end
of 10 months (as shown in slides) the only evidence of irre¬
gularity is a slight fusiform swelling, and even this dis¬
appears after a still further interval.
Major Maonaughton Dunn, R.A.M.C., also gave his
experiences on the subject in considerable detail, supported
by a carefully selected series of sequential slides. He alluded
to errors of technique and their results.
Major S. Alwyn Smith, D.S.O., R.A.M.C., spoke mainly in
connexion with operative fixation of carious vertebrae, and
stated the kind of cases which should be chosen for it and
the technique to be followed.
SECTION OF OTOLOGY.
Deafness Associated with the Stigmata of Degeneration.
A meeting of this section was held on Jan. 17th, Mr.
Hugh E. Jones, the President, being in the chair.
The President read a paper entitled " Deafness Asso¬
ciated with the Stigmata of Degeneration.” The object of
the communication was to show that there is an association
between deafness and defects of auricles, the latter being
regarded as indices of degenerations or deficiencies of various
important neurons. He was not dealing with those
gross stigmata of the face and middle ear which result in
direct interference with the conduction of sound, but rather
with the more subtle signs of defects and even of degeneracy
the recognition of the significance of which affected, for
good or ill, the reputation of the specialty. Of 210 out-patients
in an ear clinic, 64 per cent, showed auricular defects, suoh
as were regarded as associated with degeneracy. Of cases of
chronic tympanic catarrh and oto-sclerosis, there was a
proportion of 49 defective auricles to 9 good ones, whereas
among cases of nerve affection the numbers were 23 to 3.
Among accidental affections the proportion was 35 imperfect
auricles to 41 good ones. The small numbers which Mr.
Jones had been able to deal with definitely showed that
there was a preponderance of more or less degenerate
auricles in patients who were the subjects of ear disease
and deafness. Specially was this true of oto-sclerosis,
and that type known as psychical. Of the general
public, he was satisfied that defective auricles did
not occur in a greater proportion than 1 in 5. On
a particular Sunday he noticed that all the ohoir-boys
(who might be deemed to have sound and sensitive ears)
had well-formed auricles, as also had the organist and the
clergymen, whereas of the 200 worshippers, 1 in 5 had
defective auricles. Of 114 eye patients, 90 had good lobules,
12 doubtful ones, and only 11 were actually defective. None
of the eye cases complained of deafness. Patients in the ear
department disclosed a high proportion with defective
external ears.
He quoted the following case in support of his thesis, as it
was very rare to find this ear condition uncomplicated with
other diseases of the organ. He believed degeneration to be
the underlying condition and the predisposing cause of
many diseases of the internal and middle ear:
Tub Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Feb. 1, 1919 183
The case was that of a boy, aged 17, who wished to enter
the merohant service,Irat feared that deafness and imperfect
eyesight might interfere with hiB career. He had already
consulted five aural surgeons, and had been under varied
treatment for a number of years. On the advice of one of
the surgeons the lad was taken to a medical electrician, who
charged him £150 for treatment which produced no benefit.
His father died at the age of 45, his grandfather at 43, but no
family history of deafness was obtained. The boy had
narrow attached lobules. There was no enlargement of
tonsils and no adenoids. The boy was neurotic but
intelligent. His ear symptoms might be regarded as
caused by pre-senility. His defect was nearly equal in the
two ears. There was distinct loss of bone conduction.
The boy appeared to be giving the examiner proper
attention, but fatigue reaction was not noticed. Ophthal¬
moscopic examination showed pigmentary degeneration of
the peripheral zone of each retina, not, however, of the type
of retinitis pigmentosa, as there were no spider-like patches
of pigment.
There appeared to be, therefore, in this case correlative
degeneration of the auricles, one or more auditory neurons,
and the pigment layer of the retina, all of which are epi-
blastic tissues. Mr. Jones considered that this type is far
commoner than it is generally thought to be, and that the
factor of degeneration Should be taken into account in cases
of ear disease which occur in persons exhibiting any of the
stigmata of degeneration, however slight. The “type case”
quoted presented to the speaker problems which were phylo¬
genetic, ontogenetic, and sociological in character. Treatment
must be preventive. F. W. Mott had stated, in one of his
lectures, that the neuron, like other cells, nourished itself and
depended for its development, life, and functional activity
upon a suitable environment, and that it must possess
inherent vital energy. In the neuropathic individual, how¬
ever, in some portions of the nervous system, especially the
brain, there might exist communities, systems, or groups of
neurons with an inherited low power of storage, hence the
energy would rapidly become exhausted and depression of
function would be liable to ensue. Mr. Jones did not agree
that many who showed defects of the pinna had a criminal
tendency or showed defective brain power, but rather, he
thought, such defects were associated with localised potential,
or actual, degenerations of the auditory nerve tract.
Mr. Jones then proceeded to discuss the subject from the
embryological standpoint, and passed on from that to the
sociological, declaring that attempts should be made from
birth to counteract the tendency; the degenerative factor
could only be dealt with on general lines, and nutrition always
played a very important part.
A discussion followed, and the President briefly replied.
Liverpool Medical Institution.—A t the annual
meeting held on Jan. 16th the following list of officers and
members of council was adopted
President: W. Thelwall Thomas. Vfce-Presldents: K. W. Mon-
L. Morgan, Hubert Armstrong, and A. Oraigmile. Treasurers
B. Thurstan Holland. General Secretary: W. Hurray Calms. Sec¬
retary of Ordinary Meetings: T. 0. Litler-Jones. Secretary of Patho¬
logical Meetings t EL Leith Murray. Librarian and Editor of the
Journal : R. W. Mackenna, Council: J. H. Abram, F. 8. Heaney,
£* Macalister, Courtenay Yorke. G. C. E. Simpson,
P. W. Bailey, J. Martin Beattie, Owen Bowen, Frances Ivens, F. C.
Du-kin, and R. G. Sheldon. Auditors: Reginald T. Bailey and F. S.
Heaney.
The annual report of the council for the year 1918 was
presented and adopted, whioh showed that a programme of
meetings similar to that of 1917 was successfully carried
through, and that many medical members of the Overseas
Forces and of the American Medical Corps had availed
themselves of the hospitality of the institution. The fact
is noted that two members of the institution, Dr. Bonverie
McDonald and Dr. Nathan Raw, have been elected Members
of Parliament in the recent Election. The report notes a
certain shortage of members owing to the wastage through
death and resignation during the war period, but speaks
with certainty of the large influx of new members on the
retnrn of normal conditions.
Exeter City Asylum.—A t the last meeting of
the Exeter City Council it was decided, on the recommenda¬
tion of the asylum committee, to increase the salary of Dr.
G. Norton Bartlett by £125, with an additional £100 per
annum next year. The committee alluded to Dr. Bartlett’s
excellent services and to his devotion in carrying on for
three years without an assistant medical officer. The
council decided to advertise for an assistant medical officer
at a salary of £300 a year, with maintenance and lodging.
mb Jtolias of Jtooki.
Physical and Occupational Re-education of the Maimed . By
Dr. Jean Camus and Others. Authorised translation by
Snrgeon W. F. Castle, R.N. Illustrated. London:
Bailliere, Tindall, and Cox. 1918. Pp. 195. 6 *.
Most of the chapters of this book have been contributed
by various Frenchmen and Belgians who, by reason of their
special experience, are qualified to write on the subject of
their chapters ; for the sake of completeness four chapters
on the work being done in England are included. The result
is a very readable book, although it presents some of the
faults liable to occur in a symposium : the length of the
chapter does not always correspond with the importance
of the subject, and no attempt can be made to reconcile
apparently conflicting views of the separate writers.
Several of the chapters are very slight, especially
those giving an outline of the features of various institu¬
tions. Among the most valuable parts of the book are those
dealing with agricultural re-education and the work for the
blinded. In France it is of the highest importance that
agricultural labourers, who have composed 70 percent, of the
Army, should return to the land, where there was a dearth
of labour before the war. The writers point out that agri¬
culture has a large number of branches, each of which calls
for its specialists. It is cheaper to live in the country, where,
too, people are more willing to help one another.
The simplicity of the movements required in agricultural
work makes this occupation suitable for men with arti¬
ficial arms. A patient whose stump is sufficiently long
to include the bony insertion of the deltoid muscle has
complete control over any prosthesis, and can be made into
a useful agricultural worker ; even if the stump is useless,
M. Boureau holds, there is always work on every large farm
for a one-armed man. M. Lindemans, of Port Yillez, points
out that even the most mutilated soldier can earn a good
income from poultry and rabbit breeding and beekeeping.
MM. Nov 6 -Josserand and Bourget provide a temporary arm
and tool-holder for men to use while being taught farming
at the limb-titting centre ; for permanent working hands
they suggest that the men, in addition to the routine ring
and hook hand, should also be provided with Boureau’s
swivel ring, Jullien’s tool-holder and straps, the use of all of
which can be learnt in a few days at the centre. M. Boureau
describes a different set of working hands, and deals with the
alterations necessary to adapt agricultural and harvest imple¬
ments and the handles of ploughs and motor tractors for
use by farms hands with an artificial arm. The use of
motor and electric power to work the land will make up for
the shortage of workers due to the war. Dr. Bourrillon is
training agricultural mechanics at St. Maurice ; after a six
months’ course the men are able to repair and drive motor
tractors. He finds that for this occupation men require
their full complement of limbs ; slight paralysis is no bar ;
ankylosis of joints and shortening of limbs resulting from
badly united fractures are among the commonest lesions of
men who have undertaken this work successfully. Dr.
Bourrillon includes agricultural work in the limited number
of manual trades be considers can be carried on satis¬
factorily by a man with an artificial arm. He holds
that only work which does not vary much or call for a
constant change of tools can be carried on with the help of
an artificial limb with a reasonable prospect of success; he
considers that the contrivances which the men themselves
devise to help in their work are often more useful than
artificial limbs, and that it is the duty of medical men to
make all such contrivances widely known. At Port Yillez
Dr. Nyns tells us that of 83 men with amputations of
the arm 25 were working in the literary section to qualify
for some minor administrative post, and 58 in the work¬
shops. The most intelligent of the men are advised to
take up clerical work ; of the others, those skilful in the
use of their remaining hand are taught printing, photo¬
graphy, drawing, and painting. Men from the country side
take up farming and dairy work, while those who are not
very intelligent are instructed in French polishing.
In France one half of the blinded soldiers return to farm
work and make themselves useful in doing various jobs, such
as cleaning out the yard, milking the cows, digging up the
beets and potatoes and putting them Into heaps, tossing the
184 Thb Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[Feb. 1,1919
hay, &o.; in wet weather and in their spare time they work
at brush*making. Sir Arthur Pearson reminds us that the
typewriter was originally invented to enable persons blind
from infancy to write; practically all the men at St. Dunstan’s
learn typewriting in order to communicate with others by
writing ; he finds that the handwriting of a blind man
inevitably deteriorates. Some of the men having learnt
ordinary typewriting and shorthand-writing, a special type¬
writer with Braille writing being used, have been placed in
situations as shorthand typists, where they are giving entire
satisfaction. The employment of the blind teacher, who is
not encouraged at ordinary workshops for the blind, has
resulted in blinded men learning occupations in a quarter of
the time usually supposed to be necessary. Dr. Ferrien calls
attention to the work of the Association Valentin Hatty in
providing books in Braille ; he calls for volunteers to under¬
take the printing of books for the blind, and advises the use
of a small Braille printing press invented by M. Vaughan.
The translator has carried out a useful piece of work well;
in one or two places only, by attempting to make too literal
a translation, has he rendered the text slightly difficult to
follow.
Hygiene of the Eye. By Wm. Campbell Posey, A.B., M.D.
London and Philadelphia : J. B. Lippincott Company.
1918. Pp. 344. 18s.
There is room for a book on ocular hygiene, and this one
fulfils the need satisfactorily, though we think it a pity that
it should include several chapters on diseases of the eye
which are hardly adapted to a book addressed to the lay
public and insufficient as a guide to the general practi¬
tioner. Useful information on the prevention of eye
diseases and on the proper care of the eyes will be
fonnd, however, in a chapter which deals with the pro¬
tection of the eyes of the new-born ; and the same may be
said of chapters dealing with the importance of an efficient
treatment of squint in young children (more stress might
perhaps be laid on tl\is), with refractive errors as corrected
by glasses and the proper adjustment of spectacles, with the
school curriculum suitable for high myopes and children
with serious defects of sight (taken from Bishop Harman’s
paper on the subject), with the lighting and seating of
schools, th6 protection of the eyes against industrial
accidents, and the dangers to sight resulting from an
excessive use of tobacco and alcohol. There is also a
chapter on the education and employment of the blind, and
the problem of preventing the spread of trachoma is touched
upon. The illustrations are good.
Surgical Treatment: A Practical Treatise on the Therapy of
Surgical Diseases for the Use of Practitioners and Students
of Surgery. By James Peter Warbassb, M. D., formerly
Attending Surgeon to the Methodist Episcopal Hospital,
Brooklyn, New York. London and Philadelphia: W. B.
Saunders Company. In three volumes, with 2400 illustra¬
tions. 130.00. Vol. I. 1918. Pp. 947 ; 699 figures.
This is the first volume of an ambitious work, whose
object, as stated in a discursive preface, is 44 to place in the
hands of the surgeon the means for rendering help in every
surgical condition under all circumstances.” The author
hopes, he says, “ for the day when all surgeons who are
entrusted with the lives of human beings shall be so
equipped that they can apply the ideal treatment in all
cases which come to their hands.” We venture to doubt
if such a Master of Surgery will ever exist. Those who have
watched the progress of surgery during the last few years,
and the increasing difficulty of anything like a complete
grasp by any one mind of all that is commonly accepted
as 44 general surgery,” know that the years to come will
make less and less possible the realisation of the author’s
dream ; and however undesirable the increased tendency
to specialisation may be, specialism will remain, and the
ambition of a general surgeon, to give an example from the
volume before us, to include in his accomplishments a com¬
plete acquaintance with diseases of the skin, is for ever
doomed to disappointment. Indeed, this chapter of 30 pages
on the diseases of the skin is an example of one of the chief
defects of a book with such an encyclopaedic aim as this:
the anxiety lest anything should be omitted produces the
result that much that is included is dealt with in a super¬
ficial manner.
This first volume deals with general principles of
treatment, including asepsis and antisepsis, surgical
materials, and anaesthesia; with wounds and operations,
inflammations, and surgical infective diseases in general;
with tumours; with diseases of the vascular system, diseases
and injuries of bones and joints; with muscles, the skin, and
nerves. Much of the information given is very up to date,
but it is surprising to note, in the sections on wounds, on
the blood-vessels, and on nerves, how little has been included
of the vast experience gained by surgeons in four and a half
years of war. The book is admirably got up and profusely
illustrated, but a large proportion of the illustrations, par¬
ticularly those of operations, are of a somewhat unpractical
character.
We cannot avoid the conclusion, drawn from the first
completed volume, that this 44 practical treatise ” woald have
been far more practically useful if it had been less inclusive,
nor can we admit that the subject of treatment ought to be
so divorced from reference to pathology and symptomatology
as has been thought advisable here. The discussion of
indications or contra-indications and of prognosis in par¬
ticular methods of treatment ought to form an important
part of a work with such a declared aim—a much more
important part than has here been accorded to it.
Gun-Shot Fracture* of the Extremities. By Joseph A.
Blake, Lieutenant-Colonel, U.S.M.C. With 40 illus¬
trations. Paris : Masson et Cie. 1918. Pp. 136 + xi. 4 fr.
Colonel Blake has written a very concise and useful
little book embodying the latest practice in the treatment
of gunshot fractures and wounds of joints of the extremities.
Although we may hope that the supply of these injuries has
now ceased and that there will be no renewal of it, the book
should prove useful for some years to come to those who
have occasion to treat such wounds. In his preface Dr.
Blake tells us that the work is the outcome of a request from
the late Dr. Lewis A. Stimson to write a chapter in a book
which he was compiling for the Council of National Defence
in America, but Dr. Stimson’s sudden death prevented its
publication. All the most up-to-date and successful methods,
such as those practised by Major Sinclair and those largely
involving the use of Thomas’s splints and the necessary
cutting operations, are well and clearly described.
The section on the treatment of wounds of joints lays
down the principles which have generally been found sound
in recent British and French experience, and may be taken
as a trustworthy guide. We must, however, differ with the
author as regards the operative treatment of extensive
injuries of the tarsus. If his advice 44 to resect the entire
tarsus, removing the astragalus, but always leaving the os
calcis ” (the italics are ours) be followed, a stump will be left
to which it is extremely difficult to fit an artificial foot, and
which will be much less useful than that resulting from a
Syme’s amputation performed well above the malleoli with no
redundancy of flap. Experience in limb-fitting hospitals
during the last four years has well established this fact.
This little book is very well and clearly illustrated and
the print and paper are alike good, and its small size will
make it convenient for use.
Roentgen Technic ( Diagnostic ). By Norman 0. Prince,
M.D. Omaha, Nebraska. London: Henry Kimpton. 1918.
Pp. 142.
A Manual of X Ray Technic. By Arthur C. Christie,
Major, U.S M.O.R.C. London and Philadelphia: J. B.
Lippincott Company. 1918. Pp. 152. 12*. 6 d.
These two manuals by American authors dealing with the
same subject may be considered together. They both aim at
the practice of a more or less uniform system of procedure
in the examination of the various parts of the body.
Major Christie’s book is perhaps the more useful one for
a beginner, inasmuch as it deals with the elementary
principles more fully and has a chapter on X ray thera¬
peutics. Dr. Prince’s book is confined to the diagnostic side
of the subject and is adapted to the use of those who are
more advanced. The various dispositions of the patient and
apparatus are shown in an excellent series of reproductions
from photographs, full technical details accompanying each.
It is not intended to make any comparison in these
| comments, as any choice between the two would be deter-
I mined by personal taste and requirements.
This Lancet, J
MEDICINE AND THE STATE.
[Feb. 1, 1919 185
THE LANCET.
LONDON: SATURDAY, FEBRUARY 1, 1919.
Medicine and the State.
We publish this week a paper by Sir Henry
Morris, who pleads powerfully and practically for
medical unanimity on professional questions and
for the display of public spirit among medical men.
bo that the relations between the State and the
doctor can be placed upon a logical basis. Sir
Henry Morris’s plea is, in essence, for the forma¬
tion of a medical federation which should be an
unattached advisory board at the disposal of the
Government on all medical questions, and he urges
that this board should be created now, and that it
should be thoroughly representative of the medical
corporations, the medical societies, and of all
ranks of medical praotice. He marshals the
arguments for the creation of such a body
with the force and skill to be expected from
him. It would certainly be quite possible, as
all readers of The Lanoet will perceive, to
dissent frpm his criticism of those who have
criticised the Royal Colleges, while there are
passages in this able advancement of profes¬
sional unanimity to which many interested in
public medical service might fairly take exception;
but all that is only to say that Sir Henry Morris
has been honest in his advocacy and has not
hidden his personal views, even while arguing in
a wholly impersonal manner. He shows that
the medical profession and the public alike have
nothing but good to expect from medical unanimity.
This is very different from the spirit exhibited
by some medical reformers who seem to see
in medical unanimity a step towards the
formation of a medical trust, and to antici¬
pate with gusto the day when such a trust will
be powerful enough to exact terms from the
State. Such would-be reformers are dreamers.
This position will never be attained and it is a
thoroughly anti-social instinct which desires it.
A letter from a well-known physician, who prefers
to appear as F.R.C.P.', takes a fine and lofty stand
in respect of professional ideals and duties, but
simultaneously he conceives that those duties should
be rendered to the State out of high conviction
and not in accordance with a material responsibility
towards the State. F.R.C.P. points out correctly
that the original efforts of The Lancet were
towards unification of the profession, and expresses
his fears that the profession is “ in danger of fatally
dissolving an organic whole into its component
parts” under the stress of increased knowledge
and ill-directed specialism. He desirss unifica¬
tion, but his view of the relation of the
State to medicine is the pessimistic one that
the intrusion of the State into medical affairs tends
to destroy the individuality and independence of
the practitioner and to impair regard for the
patient as an individual. What form of unification
is that in which the State is to play no part?
The whole population of Great Britain is concerned
in the quality of the national medical service and
in the legislative and social conditions under
which that service is rendered. The medical
profession, which ministers to the public
in an important, intimate, and ungrudging
fashion, has a right to expect that by the
legislation now impending the calling of medi¬
cine will be placed upon a more secure and
dignified basis. Laws cannot, and should not, be
made in response to any sentimental claim, but the
new Ministry of Health is a recognition, once and
for all, of this truth—so well known to those who
can think and see—that the health of a nation is its
greatest national asset. But when the State enters
into relations with medicine for the national good
it cannot be regarded as an intruder even in our
individualistic calling.
To secure proper relations between medicine and
the State the Medical Parliamentary Committee
was founded. At the last meeting of this
Committee it was announced that Sir Watson
Cheyne had accepted the chairmanship of the
Committee rendered vacant by the resignation of
Sir Henry Morris, and at the same time the
objects of the Committee were definitely set out.
These will be found on p. 190 of this week’s issue
of The Lancet, and it will be seen that they
largely meet the position considered by Sir Henry
Morris as necessary when advocating the creation
of a medical federation to act as an advisory com¬
mittee to express “ its matured responsible judg¬
ments and its deliberate unified conclusions upon
those matters as to which it ought to be both the
duty and the privilege of the profession to give
counsel and render service for the benefit of the
community at large.” The Medical Parliamentary
Committee, however, possesses objects which
require for their justification a completely repre¬
sentative constitution. Such a constitution is as yet
wanting, for the Royal Colleges are unrepresented,
and the British Medical Association holds aloof.
But with its foundations truly laid, its chairman a
powerful voice in the opinions of the country, and
its executive working steadily and unselfishly
towards large ends, the promise of a representa¬
tive character is a very fair one. If the Medical
Parliamentary Committee, having an obvious desire
to labour in amity with all men and movements
that work for national health, does not succeed in
federating medical interests in accord with its
proposed scope, there would seem little chance of
any similar movement being more fortunate. Else¬
where there is announced the holding of a meeting
in London on Sunday next with the view of start¬
ing a new professional league in behalf of medi¬
cine. At the meeting a resolution will be proposed
stating that for divers reasons “the time has
arrived when a body representative of the whole
profession should be established to watch its
interests and be prepared to act in an advisory
capacity as occasion demands.” Surely such
doubling of energies can be avoided and coopera¬
tion substituted.
186 Thh Lancet,]
WAR PENSIONERS IN CIVIL H0SPITAL8.
[Feb. 1, 1919
War Pensioners in Civil Hospitals.
Every period of transition is apt to present new
problems, and the truth of this generalisation haB
recently been prominently brought to notice in
connexion with the treatment of war pensioners. The
discussion at a general meeting of the Royal Society
of Medicine, of which we publish a report, has done
good service in clearly setting forth the present con¬
ditions under which war pensioners are admitted
into and treated in civil hospitals, thus affording a
satisfactory basis for suggestions and recommenda¬
tions. The answers to a series of inquiries widely
circulated showed that no uniform system was
adopted by various hospitals. While the Ministry
of Pensions had tentatively offered certain terms,
the offer had been received by different insti¬
tutions in a way that might tend to confuse both
the oharitable public and the Minister of Pensions.
An initial informal discussion had already disclosed
the need of fuller investigation, but the divergences
were only clearly realised when the replies to
the inquiry were carefully tabulated. It was then
seen that the present system is chaotic. The
institutions concerned are still wavering about the
need of any special arrangements for war pensioners.
Some are so happily situated that they do not
desire any remuneration; others hesitate over the
allocation of the payments, and have not yet
realised whether the amount suggested is intended
to provide for the necessary outlay for working
expenses independently of any payment to the
medical staff, or whether such remuneration had
been contemplated in the original proposal.
The evolution of the present system has been
fairly simple, the national obligation for the treat¬
ment of those incapacitated through the war being
recognised from the outset. This provision was
primarily supplied by the military hospitals, with
medical, surgical, and nursing staff provided from
national funds through the War Office. In these
hospitals, and in their attached auxiliary hospitals,
treatment was continued until it was obvious that
nothing further could be done to ensure a return
to military service of any description, when the
man would appear before a medical board and be
discharged from the army. This conversion of a
soldier into a pensioner did not necessarily
imply that a “ cure ” had been effected. Occasion¬
ally the pensioner might be fit to resume some
form of civil occupation on leaving the hospital,
but frequently he required farther treatment,
in the wards, in the out-patient department,
or in some special section attached to the
hospital. The question by whom such treatment
should be supplied soon presented itself, and
for a long time it remained uncertain whether
pensioners should be provided for by the military
authorities, by the Pensions Board, or by the civil
hospitals as part of the charitable objects for which
they primarily exist. In early days military hospitals
were utilised for this purpose of further treatment,
the necessary official authority being obtained,
while this authority was only granted when the need
for treatment was distinctly the outcome of the
original war disability for which the pensioner had
left the service. The advantage of this system was
that the State had already made provision of equip¬
ment and personnel; the disadvantage was that the
beds, which were urgently needed for sick and
wounded coming from the front, soon became
blocked with pensioners. On taking over responsi¬
bility for their treatment, the alternatives for the
Ministry of Pensions to consider were to create
fresh institutions, which would involve delay and
great expenditure, or to negotiate with the civil
hospitals for the reception of pensioners in lieu of
soldiers. The present position formed the subject
of discussion, and many interesting facts and
opinions were elicited from representatives of
hospital committees and of hospital staffs. Many
considered that ward treatment would rarely be
necessary, that the numbers requiring admission
would not justify the provision of special wards,
and that discipline might be easier if these men
were treated in general wards. Others urged that
from the chronic nature of their troubles these
patients would not be suitable for teaching or
demonstration purposes like others in adjoining
beds, and that the fact of payment being made for
them might constitute a cause of trouble in a
general ward. It will be noted that this question
was left open at the end of the discussion while
agreement was reached as to the conditions for
out-patient treatment and for payment of those
concerned therein. Mr. H. J. Waring, who opened
the discussion and moved the resolutions, and Sir
Nestor Tirabd, who seconded them, were equally
emphatic about the need of special out-patient
clinics for pensioners, who cannot be expected
to attend at the ordinary hours, and they
both urged that some reasonable payment should
be made to those who had charge of these clinics.
The payment of the staff of a hospital is one of
those subjects which ever affords room for differ¬
ences of opinion. The old arguments made their
appearance in due course, and the position was
again affirmed that medical men do not pose as
philanthropists who scorn payment in their desire
to benefit the hospital patient, but consider that
the experience and the opportunity of teaching at
the hospitals afford adequate compensation. Now,
while this is true for the general work of a
hospital, it undoubtedly has no bearing on a clinic
for pensioners, and if the terms suggested for
pensioners as in-patients were correctly stated it
would seem to have been contemplated that the
medical staff should receive an honorarium. The
terms are far higher than those hitherto paid by
the military authorities for the maintenance and
treatment of sick and wounded soldiers from the
front.
It is not so clear that the conditions for admission
have been fully agreed upon by the Local Pensions
Committees and by the hospital authorities. If
special wards or special beds are set aside for the
reception of pensioners it may be feared that the
recommendation for in-patient treatment may be re¬
garded as equivalent to an order for admission. Ever
since hospitals have been established the system of
subscribers’ letters has been a source of annoyance
both to the hospital and to the subscriber. The
ThhLanoit,]
GREAT BRITAIN AND DENMARK.
[Feb. 1,1919 187
hospital naturally desires to sift the cases and to
admit only those likely to derive greater benefit
; than could be afforded by out-patient treatment.
The subscriber considers that the recommendation
has been wasted if his nominee is not admitted
" to the wards. To some extent this comparison
; between pensioners and civil patients may not
apply if the Local Pensions Committee act solely
on the advice of a medical referee; but even then,
as the discussion at the Royal Society of Medicine
showed, it was contemplated that all such cases
should be sifted in an out-patient or admis¬
sion room, and the suitability for ward treat¬
ment determined in the same way as for ordinary
civilians. Under such a system it is highly
~ probable that the number of pensioners found
suitable for admission will be extremely small
^ when there is great pressure on space; while
it may rise in large institutions with greater
elasticity of accommodation, or with greater need
of the financial assistance afforded by the Ministry
of Pensions.. With regard to out-patient clinics
there was no doubt that the resolutions of the
meeting accurately indicated the feeling of the
meeting that separate clinics should be held, and
' that those conducting them should receive adequate
remuneration. Arguments in favour of this course
were adduced by nearly every one who took
‘ part in the discussion, though Dr. Sydney Phillips
spoke rather vaguely of there being no essential
difference between pensioners and civilians. The
' qualification for admission to the pensioners’ clinic
'• should necessarily be that the need arises directly
' from some condition resulting from active service,
and this condition, in the majority of cases, has
already found expression in the recommendation
of the invaliding medical board. The Local
u Pensions Committees doubtless will be guided by
these recommendations, and will not send to the
hospitals men who, although pensioners, have fresh
; diseases or ailments which have no relation to
~ their military service. While it hardly seems
P necessary to advocate that the Pensions Minister
- should establish his own institutions and thus rid
the hospitals of the incubus of treating pensioners,
: we believe that many of the problems involved can
only be adequately dealt with by free discussion,
> guided by actual experience. For the present it
- may suffice to say that a public service has been
; rendered by definite pronouncement in favour of
x the separation of the pensioner class from the
ordinary run of out-patients, and by the realisation
: that in this work of national importance, for which
: the nation is prepared to pay, reasonable remunera-
tion should be given to those to whom it is entrusted.
The Poor-Law Dietary.—I n view of the intima-
^ tion by the Ministry of Food that it is no longer desired to
enforce even in institutions the restrictions on most un¬
rationed articles, Poor-Law authorities may now revert to
the use of the dietary tables in force before the introduction
; of rationing. It is still obligatory to keep within the scale
in the case of rationed articles—butcher’s meat, sugar, fats,
and jam—and the present allowances of milk and cheese are
' only to be increased with the oonourrence of the Local Food
'■ Control Committee.
^Knolxtioiis.
" He quid nlmls.”
GREAT BRITAIN AND DENMARK.
Officers of the R.A.M.C. recently with the
British Military Mission in Denmark speak with
enthusiasm of the welcome they received in that
country. The Royal Family, officials, and private
persons alike went out of their way to show
hospitality, not only to the prisoners of war return¬
ing from Germany, but also to the staff sent out from
England to arrange for their repatriation. For
more than four years Denmark has necessarily
avoided expressing her traditional admiration and
affection for our country, but since the armistice
she has felt free to show the warmth of her
sympathy. As a consequence our soldiers return¬
ing through Denmark have enjoyed almost
embarrassing demonstrations of friendship, and
“ Rule Britannia ” is received with enthusiasm in
all the restaurants and places of amusement of
Copenhagen. Early in January the staff of the
Fredericksburg Hospital gave a dinner in honour
of the medical members of the British Mission, and
this convivial meeting was much enjoyed both by
guests and hosts. During the evening Dr. Carl
JOrgensen toasted the visitors in a graceful speech.
He told how the youths of Denmark from their
earliest days were taught to venerate the country of
Shakespeare and Byron, of Dickens and Kipling, and
how Danish medical men looked with affection to the
home of Jenner, Lister, Moynihan, and Mackenzie.
He continued: “ Five years ago we admired you as
the most free people of Europe because you
refrained from conscription. Later we had to
admire still more because England submitted to
the raising of that glorious Army now returning
victorious from the most terrible war in history.”
The English officers made fitting replies to this very
flattering address, showing that their relations with
Danish colleagues in the prisoners’ camps and on
social occasions throughout the period of repatria¬
tion duty were most cordial. Most medical men in
Denmark have a fair knowledge of English, and in
conversation many of them expressed the wish that
more opportunities for post-graduate work should
be offered them in England. It is good to know
that through the activity of the Inter-Allied Fellow¬
ship of Medicine London can now offer them a good
deal of what they seek in this direction. They also
mentioned a desire that English medical books and
periodicals should be made more easily available
for the profession in Denmark. It is to be hoped
that something may be done to reciprocate the
desire for closer relations with their English
confreres which was thus so unmistakably demon¬
strated by Danish medical men.
THE UTILISATION OF RED CROSS AMBULANCES.
The disposal of the many'thousands of Red Cross
ambulance wagons and lorries which will fall into
desuetude when peace is signed is a public question
of some importance. The scheme put forward by
the joint committee of the British Red Cross Society
and the Order of St. John of Jerusalem to return
the cars to the districts from which they were
presented is practical. The plan adopted will,
no doubt, be that the more populous districts
will have the first claim ; but it must be remem¬
bered that these are usually in some measure
]88 The Lancet,]
THE SYNDROME OF THE FORAMEN LAOERUM POSTERIUS.
[Feb. 1,1919
provided with ambulance wagons, although no
doubt imperfectly. On the other hand, the more
sparsely populated districts are for the most
part ill provided with, and, in fact, in most cases
not provided at all with, any means of conveying
the injured and sick. There are many parts
of the country where no ambulance wagons are
available within a radius of a score or more of
miles, and it is especially to such districts that
help in the direction intended should be given.
It should be seen to that every country district
should have a means of transport within 20 miles
at least of any given point; that would be the area
of operation of any one wagon and would extend to
a diameter of 40 miles of country. The storage of
the wagon and the expenses in connexion with main¬
tenance should be provided by the district, either
by a small charge on the rates or by public sub¬
scriptions. The driver for these wagons would only
occasionally be called upon, and the permanent
employment of a driver would not be a public
charge, for volunteers would be found in plenty
for such work; these volunteers could be organised
for spells of duty alternately, a number of names
being kept in reserve, so that a driver would be
always available. For those that can pay a charge
should be made for the use of the ambulance wagon
to cover expenses to some extent, while the poor
should have the benefit of the transport. The
wagons would be most useful to convey persons
who have to travel to a large town for a surgical
operation, and who have in the meantime to travel
by train—a most unsuitable mode of transport
in many cases. For cases of infection that have
to be conveyed to an infectious diseases hospital
many parts of the country are well provided,
but, on the other hand, many are not so equipped,
and it should be a primary consideration of those
dealing with this scheme to see to it that this
defect is remedied. The infectious diseases wagon
would not, of course, be available for general use,
but kept for the special use of conveying cases of
infectious ailments. If only one wagon can be
had it might be necessary to decide whether
the one for infectious diseases should have the
primary consideration. The work in connexion
with the scheme would be met by the members of
the Humanitarian Corps in course of formation,
whose purpose is to provide “ first aid to those in
need,” be the nature of that “ need ” what it may.
THE SYNDROME OF THE FORAMEN LACERUM
POSTERIUS.
The ninth, tenth, and eleventh cranial nerves
pierce the dura mater close together and pass
through the middle division of the jugular foramen
in- arithmetical order antero-posteriorly. Imme¬
diately in front of the ninth is the inferior petrosal
sinus; immediately behind the eleventh is the
jugular vein at its commencement. A membranous
sheath, sometimes a minute osseous spicule, is all
that separates the vessels from the nerves. It
should also be noted that the three nerve trunks
are in oblique alignment, so that the spinal accessory
nerve is external to the vagus and the vagus to
the glosso-pharyngeal. Further, the internal carotid
artery is but a few millimetres anterior to the
jugular foramen. Below the exit from the cranial
cavity the three nerves begin to separate almost at
once, the eleventh inclining backward over or behind
the internal jugular vein and the ninth inclining
forwards over the internal carotid, while the vagus
proceeds vertically downwards. Unlikely or even
incredible as it might well have appeared before
the experiences of the war, a number of cases
have now been put on record where a bullet
has severed or injured these three cranial
nerves at their point of emergence without
touching either of the important vessels in their
immediate proximity. In such cases the course of
the projectile must be approximately from a point
behind the mastoid obliquely across the base of the
skull to an exit towards the inferior edge of the
orbit on the opposite side, or inversely. To Dr.
Maurice Vernet, 1 of the Centre d’Oto-rhino-laryngo-
logie at Marseilles, is due the credit of having
drawn attention to this syndrome and of having
contributed materially to our knowledge both of its
clinical entity and of certain interesting points
connected with the distribution of the individual
nerves concerned. To take the former first; Dr.
Vernet has shown that the main features of the
syndrome consist subjectively of the following func¬
tional triad: (1) nasal regurgitation of liquids (soft
palate paralysis); (2) difficulty in deglutition of
solids (pharyngeal paralysis); (3) hoarseness (laryn¬
geal paralysis). This does not, of course, exhaust
the syndrome, while, objectively, much more can
be determined. Taking the nerves individu¬
ally, Dr. Vernet adduces evidence to show that
the motor distribution of the glosso-pharyngeal
includes, inter alia , the superior constrictor of the
pharynx, which lies behind the pharyngeal mucosa
visible on the posterior wall of the pharynx when
the mouth is open. Accordingly, the result of
unilateral paralysis of the superior constrictor
is actually visible in a curtain movement of the
pharyngeal wall to the unparalysed side at the
commencement of deglutition. Functionally the
dysphagia consists in difficulty with solids through
failure in reduction of the calibre of the passage
sufficient to grip the bolus of food. On the afferent
side taste disorders of the posterior part of the
tongue always coexist with the motor paralysis
when the nerve is severely injured, but may be
absent in case of superficial injury or slight com¬
pression ; hence the diagnostic value of the curtain
movement of the upper pharynx. As far as the vagus
nerve is concerned, the chief part of Dr. Vemet’s
work on this subject has been directed to
showing that it ought to, be considered (1) as a
nerve irrelevant to all palato-pharyngo-laryngeal
motor innervation, the motor fibres of the nerve
really deriving from the internal branch of the
spinal accessory; (2) as an entirely sensory nerve,
even the cardio-inhibitory branches being relegated
to the internal branch of the eleventh. There are,
in our view, several difficulties in the way of sub¬
scribing to the whole of Dr. Vernet’s contentions in
respect of the vagus, but we may note the clinical
features of impairment of the sensory vagus and
their part in the complete syndrome of the jugular
foramen. They are constituted by: (1) defect of
ordinary sensibility in the area of the soft palate,
pharynx, larynx, and of the auricular branch—viz.,
a small area round the external auditory meatus
(when the nerve is irritated there is hyper-
cesthesia or actual neuralgia in the same regions);
(2) disorders of salivation, consisting of dryness of
the mouth or, if the nerve is irritated, hyper¬
secretion of saliva; (3) coughing fits, not unlike
pertussis, in irritation cases; (4) respiratory dis¬
turbance in the form chiefly of exertion-dyspnoea
or, in inhibition cases, dyspnoea of a pseudo*
* Paris Medical, December, 1916; Janaary and March, 1917.
The Lancet,]
LOCAL GOVERNMENT BOARD FOOD INSPECTION.
[Feb. 1, 1919 189
asthmatic type; (5) pulmonary disorders in the
form of recurring congestions. As already noticed,
Dr. Veraet attributes to the spinal accessory, via
its internal branch, the innervation of, inter alia ,
the middle and inieiror constrictors of the pharynx,
the muscles of the palate and vocal cords. What¬
ever be the final decision on the interesting ques¬
tions raised by Dr. Vernet his painstaking work
serves to throw into relief the lacunae in our exact
knowledge of the supply and function of these
important cranial nerves, and may well be utilised
as an appropriate basis for further research.
LOCAL GOVERNMENT BOARD FOOD INSPECTION.
In an extract, published separately, from the
Annual Report of the Medical Officer of the Local
Government Board for 1917-18 Dr. A. W. J.
MacFadden gives a brief statement as to the
work of inspectors of foods during that period. This
important branch of the Medical Department has
continued the work of supervising the preparation of
food materials for the Army which was commenced
on behalf of the War Department at the out¬
break of the war. During the year the work was
considerably increased owing to the decision of
the Army Council to provide home-killed meat for
the troops in this country, and arrangements were
made by the branch for providing the necessary
abattoirs, equipment, and staff of meat inspectors
for this purpose. The work of the year included
the investigation of several outbreaks of bacterial
poisoning. In one of these occurring at Brighton
Dr. W. G. Savage isolated an organism of a type
which has not hitherto been met with in
cases of this kind. A full account of this
outbreak is to appear in a forthcoming number
of the Journal of Hygiene, A paragraph on the
importation of liquid eggs from China is of
interest. Prior to the war it appears that small
quantities of this commodity were imported into
this country, the bulk of it going to Germany.
After the outbreak of war, however, large consign¬
ments arrived at certain ports in this country
as cargoes in prize ships, and since then large
quantities have been imported in the ordinary
course of trade. These products occasionally arrive
in the form of whole egg mixed, but usually the
yelk and albumin are sent separately. The City
of London analyst found them to contain boric acid
in amounts varying from 1*35 to 2*08 per cent.
These results were confirmed by the Government
chemist. As is pointed out, when used for the
manufacture of cakes and biscuits the amount of
boric acid in the finished food as eaten is reduced
to about 5 grains per pound. When, however, the
eggs became available to the general public for use
in milk puddings, pancakes, and so forth, the
amount of boric acid consumed by the individual
would be considerable. There is also reason for
believing that large quantities of these eggs have
been used for some time in restaurants. Dr.
MacFadden says that—
“ the employment of these boricised products for domestic
and restaurant use is open to very serious objection,”
and concludes that—
“As the importation of egg-produots from abroad will
necessarily increase in the future, it would be very
advantageous, both from the point of view of health of the
consumer and of the economy in shipping space, if arrange¬
ments could be made for the product to be snipped as dried
eggs instead of in liquid form.”
Such a product on the market is, of course, well
known, and we have had occasion to report in our
analytical columns that the eggs were so satis¬
factorily dried as to leave the yelk and albumin
uncoagulated. The material, in fact, makes a good
omelette, which is about as severe a test as can be
tried. _
FELLOWSHIP OF MEDICINE: EMERGENCY POST¬
GRADUATE FACILITIES.
The Fellowship of Medicine has arranged with
different medical schools in London for an emer¬
gency post-graduate course of three months for
qualified medical men from the R.N., R.A.M.C., and
R.A.F., from the Dominions, the United States, and
Allies. This course will admit to the general
practice of the institutions, clinical instruction in
the wards and out-patient departments, lectures
and demonstrations, post-mortem demonstrations,
laboratory work, &c. Tickets for the whole course,
or for one or two months, can now be issued at the
rate of £3 10s. for each month. These can be
obtained from the Secretary to the Fellowship at
I, Wimpole-street, W. 1, the house of the Royal
Society of Medicine, to which the Fellowship is
kindly given access._
“THE BIRTHPLACE OF GYNECOLOGY.”
The Woman’s Hospital of the State of New York
was founded in 1855, and in a volume of collected
papers 1 by members of the surgical board Dr.
J. R. Goffe claims for the hospital the distinction
of being the first of its kind in the world—namely,
founded by women for the exclusive use of women.
The hospital owes its origin to the indefatigable
labours of the women of New York, to whom Dr.
Marion Sims, the father of gynaecology, appealed on
behalf of women suffering from gynaecological dis¬
orders. But it is nevertheless somewhat of a blow
to find no women upon its imposing active staff,
with the exception of a junior attending surgeon
and the superintendent house officer. From Dr.
Goffe’s historical sketch we learn that Dr. Sims,
after many failures, had devised a means of over¬
coming the deplorable results of vesico-vaginal
fistula which so often followed on long and difficult
labours. Forceps were then not f n general use to
hasten delivery at this stage. Dr. Sims’s investi¬
gations were carried out at Montgomery, Alabama,
where he lived, but, seeking a change of climate on
account of his health, he took up his abode in New
York, and it was here that the Woman’s Hospital
was opened in May, 1855, with accommodation for
44 beds. In the following year the executive com¬
mittee were able to report that 60 patients had
been received, 21 of whom had been discharged
perfectly cured, and that all except one of the
patients still remaining in the hospital were pro¬
nounced by the resident surgeon curable. Twelve
years later another building was erected with
accommodation for 75 patients and staff, and a
further enlargement took place in 1877. The
present building was ready for occupation in 1906,
and its maternity department counts as a model of
what such a department should be. During the
year 1917 600 confinement cases were under care.
Several features are characteristic of the enlightened
spirit of this great institution. Interchange of
thought among the medical and teaching staff is
provided for by a society the object of which is to
cultivate social intimacy, maintain interest in the
1 A Report on the Scientific Work of the Surgical 8taff of the
Woman's Hospital in the State of New York. Edited by Herman
Grad.M.D. New York, 1918.
190 The Lancet,]
MEDICAL PARLIAMENTARY COMMITTEE.
[Feb. 1 , 1919
institution, bring out matters of scientific value
in the special line of the hospital’s work, and
advance the science of gynecology. Its active
membership numbers 60. The Social Service
Department assists the work of the staff by
instructing patients in their own homes.
Draft regulations for nursery schools, dated
Dec. 31st, 1918, have just been issued (H.M.Stationery
Office, G. 10, price l<i.) by the Board of Education
laying down very carefully the standards of
physical care required to meet modern hygienic
demands. _
The death is announced in Birmingham of Sir
James Sawyer, ex-professor of medicine at Queen’s
College and consulting physician to Queen's
Hospital, Birmingham. He waB in his seventy-
fifth year. _
Hunterian lectures are to be delivered at the Royal
College of Surgeons of England (Feb. 3rd) by Professor
A. J. Walton on the Surgery of the Spinal Cord in
Peace and War; (Feb. 5th) by Professor David Ligat
on the Significance and Surgical Value of Certain
Abdominal Reflexes; and (Feb. 7th) by Professor
G. Taylor on Abdominal Injuries of Warfare. The
time in each case is 5 p.m.
The annual dinner of the Hunterian Society will
be held at Cannon-street Hotel on Wednesday next,
Feb. 5th, at 7 p.m., Dr. Langdon Brown, the Presi¬
dent, in the chair. The annual oration will be
delivered by Mr. Hugh Lett on Wednesday,
Feb. 12th, at 9 p.m., at the house of the Royal
Society of Medicine. The subject will be “John
Hunter and His Influence on Urinary Surgery.”
All members of the profession are invited to be
present. __
THE LANCET, AUGUST 24th, 1918.
The Manager of The Lancet would like to
re-purchase or to receive copies of the issue of
August 24th for which readers may have no further
use, to enable him to replace copies for libraries
and institutions in India and the East which were
lost at sea owing to enemy action. Such copies
should please be addressed to him at 423, Strand,
London, W.C. 2. _
THE LANCET, VOL. II., 1918: THE INDEX.
The Index and Title-page to the volume of
The Lancet which was completed with the issue
of Dec. 28th, 1918, is now ready, and copies have
been supplied gratis to those subscribers who
have, up to Jan. 30th, intimated to us their wish
to receive them. Other subscribers will be similarly
supplied, so long as the stock remains unexhausted,
on application to the Manager, The Lancet Office,
423, Strand, London, W.C. 2. Such applications
should be sent in at once.
The late Dr. R. A. Buntine, M.L.A.—A memorial
service was arranged to be held in the City Hall, Pieter¬
maritzburg, Natal, on Sunday, Oct. 13th, in memory of six
victims of the torpedoing of the Galway Castle on Sept. 10th,
among whom were Dr. 11. A. Buntine and his elder
daughter. The ceremony was, however, postponed until
Dec. 15th owing to the influenza epidemic. As a medical
man Dr. Buntine had endeared himself to the town and
district by his skill and the kindly cheeriness of his tempera¬
ment. To the poor be gave of his best without stint or nope
of reward. His political influence was growing, and he had
begun to make bis mark in the Union Parliament.
MEDICAL PARLIAMENTARY COMMITTEE.
A meeting of the Executive Subcommittee of the Medical
Parliamentary Committee was held at the College of
Ambulance on Jan. 24th, when the resignation of Sir Henry
Morris from the chairmanship was announced and the
election to the post of Sir W. Watson Cheynb was unani¬
mously welcomed. Sir Henry Morris’s letter of resignation
explained the private grounds upon which he was acting,
and expressed his full sympathy with the work and objects
of the Committee, whose formation owes so much to his
preliminary energies and fostering care. The feeling of the
Executive Subcommittee, recorded in a unanimous vote, was
that the debt of the Medical Parliamentary Committee to
Sir Henry Morris was extremely great.
Sir Watson Cbeyne, on taking the chair, pointed out how
necessary it was that the objects of the Committee should
be well defined, as well as its constitution representative,
and he indicated very clearly to the meeting the main
functions of such a consultative body as he believed would
be most valuable. He would regard, he said, the Medical
Parliamentary Committee, though one of its objects might
be to promote the election of medical men to Parliament, as
primarily a body to which the medical men in the House of
Commons might turn for detailed information uprm medical
points as they arose in the coarse of Parliamentary work,
whether in the discussion of Bills in the House or in Com¬
mittee work. An interesting debate took place, at which it
was decided that the following should be adopted as definitely
the programme of the Medical Parliamentary Committee:—
Origin and Objects of the Medical Parliamentary Committee.
A large meeting open to the whole medical profession was held at
Steinway Hall on Oct. 1st, 1918. The objeot of those who called this
meeting wna to give the profession the opportunity of emphasising the
fact that it is the duty of medical men to make every endeavour, in
the interests of the community, to assist the State in all matters whieb
promote the health of the nation.
It was agreed that for this purpose unity of the profession is essential,
and that in order that the considered views of responsible medical men
and medloal organisations may be adequately placed before the public
it is necessary that a greater number of medical men should sit in the
House of Commons. Consequently it was decided to take all steps to
effect this increase.
With these ends in view a committee was appointed with power to
add to its numbers. This Committee is now known as the Medical
Parliamentary Committee. Its present composition makes it repre¬
sentative of all types of medical practitioner, and it is hoped that in
time the Committee will represent every organisation in the profession.
Thus the main object of the Medical Farliamenta»y Commit ee la to
endeavour to assist in placing the knowledge and experience of the
medical profession at the disposal of the Government and of medical
Members of Parliament tor the purpose of guiding legislation on
preventive and curative medicine In such a way that the health of
the community may be saleguarded and plaoed in the position to which
modern science entitles it.
While reserving the right to express opinions on matters affecting the
national health, the Committee hss no politics, and recognises that
Individuals must be left quite free to hold and pursue their personal
convictions on general political questions.
In order to achieve the objects set out above the Committee pro¬
poses: ( n) To keep in touch with the Government for the purpose of
urging the need for medical representation. (6) To keep in touch with
the Party Whips with a view to Introducing the mimes of suitable
medical candidates, (c) To keep in touch with the various medical
bodies which are pursuing medico-political activities, (d) To keep in
touch with medical Members of Parliament. { e ) To keep In touch with
possible medical candidates. (/) To bring together members of the pro¬
fusion interested in national health legislation aud the medical
Members of the House of Commons for the exchange of views.
Dr. C. Buttar, honorary secretary, pointed ont that a
meeting of the medical profession had been announced for
Sunday next, Feb. 2nd, at Wigmore Hall, having as its
object “ the constitution of a body representative of the
whole profession, to watch its interests, and to be prepared
to act in an advisory capacity as occasion demands.” It was
felt that the creation of such a new body would imply a
repetition of work done by the Medical Parliamentary Com¬
mittee, now developing into a truly democratic institution.
It was decided that, as a means of bringing the profession
into closer touch with the new medical Members of
Parliament, the Members should be invited to dine, together
with the members of the Health Ministry Conference which
has been constituted from the Royal Colleges, the Royal
Society of Medicine, and the British Medical Association.
Accordingly it has been arranged that a dinner will be held
at the Cate Royal, Regent-street, on Wednesday, Feb. 12tb,
at 7 30 p.m.
The Right Hon. Christopher Addison, M.P.. will be the
principal guest, and the dinner will be presided over by the
chairman, Sir William Watson Cheyne, M.P.
Thb Lahobt,]
MATERNITY AND CHILD WELFARE.
[Fbb. 1,1919 191
MATERNITY AND CHILD WELFARE.
Mother*' Pensions in the United 8tates of America.
American public opinion was considerably influenced by the
publication in 1909 of the Report of the Royal Commission
on the Poor-law in England, with its recommendations as
regards outdoor relief to widows, and attention has gradually
turned to the question of carrying out the scheme as a public
measure. Opinions differ as to the need there is for such
help. It was asserted that a large number of children were
being put into institutions who, it the means were available,
might be better and more economically brought up in their
own homes ; but as a result of an inquiry made in New York
city by Dr. E. T, Devine, and published in 1913, it appeared
that only about 4 per cent, of the children placed in institu¬
tions in the year of inquiry might have been kept at home
with some assistance. It was considered that if a scheme of
mothers'pensions were introduced the number of cases of
juvenile delinquency would be reduced, and on this subject
the statistics compiled by the Chicago School of Civics of
cases dealt with at the Juvenile Court in Cook County
for the 10 years 1899 to 1909 are instructive. It
was found that 34 per cent, of the children came
from families lacking the care of one or both parents.
Tne figures quoted in the report of the Bureau of Muni¬
cipal Research are as follows : Father dead, 14*5 per cent.;
mother dead, 9 6 per cent.; both parents dead, 3*7 per cent.;
parents separated or divorced, 1*9 per cent.; family deserted
by father, 2 0 per cent.; family deserted by mother, 0 8 per
cent.; family deserted by both parents, 10 per cent. ; one
or both parents in prison, 0*2 per cent.; one or both parents
insane or in institutions, 0*3 per cent. The relatively large
number of cases of juvenile delinquency in families in which
the father was dead appeared to be due to the fact that the
mother frequently tried to be the wage-earner as well as look
after the home, with unsatisfactory results to the children.
The object of all the laws for the grant of mothers' pensions
is to provide means for preserving ordinary home conditions for
dependent children when, on account of death or disability,
the usual means of support are wanting; and to secure that
the children shall be cared for by their own mothers instead
of beiDg placed in institutions or under the care of foster-
parents. With the exception of a few States, the laws apply
only to mothers, and in a few cases the pensions are expressly
limited to widows. Divorced and deserted wives are occasion¬
ally included, and in Massachusetts it is left to administra¬
tive discretion to deal with these cases. In Michigan alone
are unmarried mothers specially included in the law. Need
is, without exception, the basis of assistance in all the
laws, but in some laws definitions are added, dealing with
cases in which the woman owns property, <fcc. Practically all
the laws require the mother to be a fit person, morally and
physically, to have care of her children. In seven States it
is made a condition that the children live with the mother
and that she does not work regularly away from home. In
other cases she may obtain, and is encouraged to obtain,
part-time employment. The lowest age-limit at which the
pension ceases to be allowed on behalf of the child Is 14
years. More than half of the laws provide for administra¬
tion by the Juvenile or County Court. In one case only,
Massachusetts, was it made a function of the existing Poor-
law officers, under the control of the State Board of Charities.
In a few States the payment of mothers’ pensions is carried
out by the education authorities. Under some laws a new
organisation is set up. Periodical supervision is required in
all cases, either monthly, quarterly, or half-yearly visits, or
general supervision. In the majority of cases the funds for
the pension are derived from the county treasury, but in some
States they are provided partly out of county funds and partly
by mean8 of a State grant.
The methods of fixing the amount of the grant fall in
practice into three groups: (l)To allow the mother a monthly
sum equal to the difference between her average normal
income and the average standard of expenditure, provided
that the limits of the law are not exceeded ; (2) to allow the
mother the flat rate for each child fixed by the law ; (3) to
allow an amount for each child according to a scale in which
the amount is less for each additional child after the first.
The last of these methods is the one which prevails in most
States. As to administrative working, in Massachusetts it
appears to have been considered that if a new group of
workers were appointed to carry out the administration of
mothers’ pensions the accumulated experience of the already
existing Poor-law officers would not be utilised, as, it is
stated, cooperation between the two groups was not
anticipated. The administration of the new law was
therefore, as we have seen, made a function of the existing
Poor-law officers under the control of the State Board of
Charities. The law specially provides that the pensions are
to be non-pauper assistance. This is the only State in which
the Poor-law officers are entrusted with the work. Elsewhere
the general tendency has been to reduce their activities and
to put the administration of mothers' pensions under some
other authority. Thus in New York State in 1915 the
administration of funds and investigation of cases were to
be performed by a specially created body, the Board of Child
Welfare, the members of which are generally appointed by
the county judges, and in New York City by the mayor.
The report of the Bureau of Municipal Research says that
“ the chief defect is lack of strong central control, such as
the Massachusetts law provides for. Apart from this the
New York law offers another illustration of American
legislative tendency to create new organs of government
without adjusting them to earlier and older organs, so that
duplicate machinery is created and responsibility thus
diffused. Under the New York law widows’ relief is not
vested solely in the boards of child welfare; the Poor-law
officers—the overseers—may likewise grant such relief, and,
indeed, they compete in some instauces with the newer
Child Welfare Board. Finally, the New York Boards of Child
Welfare are irresponsible agencies divorced through their
method of appointment and retirement from control either
of the executive or of the electorate. ” The need for adequate
supervision is emphasised in many reports on the working of
the laws.
In the report of the Bureau of Municipal Research it is
suggested that a reasonable solution of the problem of
employment for mothers is that in most cases the mothers
should be expected to supplement the pension allowance by
earnings. Exceptions should be made where there is a large
family of young children and where the woman is not strong.
Certain kinds of occupation should be prohibited. One of
the most practical forms of work appears to be office clean¬
ing, as the hours can generally be arranged to meet house¬
hold needs. The wages, however, are very low and the work
often arduous.
In the instructions to the Poor-law officers (overseers of
the poor) issued by the State Board of Charity of Massa¬
chusetts in November, 1913, it is said that “there are
undoubtedly relatives or other reliable persons living with
many of these families who can give the dependant children
proper attention during the mother’s absence. To insist
that the mother shall not work regardless of home conditions
would tend to discourage that desire for thrift and inde¬
pendence which is an essential element in society. The
policy should be stimulative and constructive rather than
destructive.” The general practice of the State is to limit
the work to three days a week.
Effects of the mothers' pension system .—The danger that
mothers' pensions may lead to the weakening of family
obligation and the lessening of family responsibility is
fully recognised. Another danger referred to in the Report
of the Bureau of Municipal Research and elsewhere is that
by the extension of the system of public subsidies employers
of labour may be led to underpay their workers, relying on
social legislation to make up the deficiency. The direct
results of the pensions, inadequate though they are in many
cases, on the economic position of the families concerned,
is generally considered to be satisfactory. The chief pro¬
bation officer in Cook County says that “ for the children of
mothers with right motives and willingness to accept and
follow friendly and intelligent advice the system has been of
great benefit.” He points out that this form of assistance is
not successful with mothers who, although they meet the
requirements of the law, are not capable of using the
money to the best advantage, or who are unwilling to
accept advice on the subject.
With regard to the principle upon which mothers’ pensions
are based, the two chief theories held are (1) that the
pensions are compensation for services rendered to the
State, and (2) that they are a new form of public relief.
The report of the Massachusetts State Commission says that
1 9*2 Tux L inset,]
MATERNITY AND CHILD WELFARE.—IRELAND.
[Feb. 1, 1919
the terms “ pensions,’' 41 indemnity,” and “ compensation ”
are irrelevant, bnt the term “ subsidy ” implies that a
condition exists which, aided, will result in positive good to
the State. “ Subsidy makes it possible that children should
stay with their worthy mothers in the most normal condition
still possible when a father has been removed by death. The
present system of aid is primarily for the worthy poor.
What a good mother can do for her own children no other
mother can do, and in her task she deserves all honourable
aid.” Alternative measures suggested include a scheme of
social insurance, which would embrace the whole com¬
munity ; measures for preventing industrial accidents and
reducing preventive disease ; and general social improve¬
ments. About 45 per oent. of the fathers of families
receiving pensions in New York City had died of tuberculosis.
In Massachusetts in the year endiog Nov. 30th, 1916, 31
per cent, of the fathers had died of tuberculosis, 21 per
cent, of pneumonia, and 14 per cent, of the deaths were
due to industrial accidents; in many cases tuberculosis
appeared to have been contracted in the course of the man's
employment.
International Congress and Baby W eeks.
The outstanding feature of the 1919 Baby Week celebra¬
tions, which are again planned for the first week in
July, is to be a series of national conferences on infant
welfare, at which the chief points for discussion will be
(1) ante-natal and neo-natal casualties, their prevalence,
causes, and prevention ; and (2) the best non-medical means
of combating infant mortality and morbidity. The National
Association for the Prevention of Ihfant Mortality and the
National Baby Week Council are cooperating in the prepara¬
tions for these conferences, and arrangements are being
made for the holding of similar conferences and Baby Week
celebrations in every Allied and neutral country throughout
the world next year, at which the same subjects will be
discussed. Following on this an International Congress will
take place in London, at which the findings of the various
national conferences will be considered, leading, it is hoped,
to much light being thrown on these important subjects.
Saving Child Life in U.8.A.
According to authorities in the United States, the death-
rate of babies under one year is dependent upon a number of
individual and social causes, some of which are: congenital
and hereditary defects of debility ; hereditary tendencies
connected with syphilis, drunkenness, degradation, or
degeneration of parents; inexperience and negligence of
parents, voluntary or enforced by industrial conditions,
including improper feeding of infants ; employment of
women in factories during pregnancy and soon after child¬
birth ; poverty as a whole, with all that it implies, including
improper housing, congestion of working men’s quarters,
especially overcrowding of their living-rooms; a too high
birth-rate.
An infant mortality survey by the New York Milk Com¬
mittee has been made public, which shows that the efforts of
the various agencies engaged in infant welfare work, as well
as the work of the New York Milk Committee, have been
effective in reducing the infant death-rate in that city. The
survey covers the calendar year of 1917, for which the
death-rate was 88*8 per 1000 living births. In 1907 the rate
was 144.
The report of the. committee also contains figures from
163 of the largest cities, showing with one exception
decreases in the death-rate, among the most frequent causes
of babies' deaths being gastro-intestinal or diarrhoaal
troubles. In New York City the infant death-rate from
diarrhoeal diseases has steadily decreased from 44 4 in 1907
per 1000 children born to 19 1 in 1917. Not only have
thousands of infants’ lives been saved, but the health of
children of all ages has been greatly improved of late. This
is to a large extent ascribed to the creation in 1908 by the
New York Health Department of the Bureau of Child
Hygiene, the first of its kind to be established in the world,
which was soon imitated by other American cities. This
bureau supervises and educates the midwives; provides
instruction to mothers and expectant mothers through a large
number of “ baby health stations teaches young girls their
future maternal duties ; takes care of the nurseries and
kindergartens with their children of pre-school age; looks
after the health conditions of the school children by means
of the medical inspection of the schools and the help of the
nurses, who examine the children in the schools and in their
homes; and, finally, ensures with increasing success that
only adolescents who are physically fit are allowed to work
when they attain the legal working age.
The health committee of the Mayor of New York’s Com¬
mittee on National Defence is making a physical examina¬
tion of all children under 5 years of age in Greater New
York. Dr. S. Josephine Baker is directing the work, and
she has established clinics in all boroughs. More than 1000
nurses, welfare and social workers, have volunteered their
services, together with 300 physicians, who are working at
least two days a week free of charge. There are more than
100 clinics for this purpose in Manhattan alone, the principal
borough of New York. During the week beginning July 15th
some 3000 babies were examined. There is a total of over
600,000 children to be examined. And as the best time
to combat and to prevent tuberculosis is in childhood,
open-air classes for certain selected pupils have been
provided and have been a great help in the case of children
who are ill, anaemic, or predisposed to disease. The first
open-air school was started at Coney Island, near New York,
in 1904, and there are now 102 schools. The following
types of children are admitted to these open-air classes:
(1) children exposed to tuberculosis at home, or in whose
family there has been a recent death from this disease;
(2) children who have had tuberculosis, which is now
arrested or cured ; (3) children suffering from mal-
nultrition ; (4) children who. become tired easily or
show languor or fatigue before the end of the day, and
on this account are unable to carry on their class-work;
(5) children suffering from nervous disease except chorea;
(6) children who are frequently absent because of colds,
bronchitis, See. ; (7) children suffering from cardiac disease
who are recommended by their private physician as being
proper cases for these classes. This classification provides
for the tubercular, pre-tubercular, and physically subnormal
children who may be benefited by this open-air life. Dr.
L. Marcus, the supervising inspector of the classes, says that
the following results of open-air class-work have so far been
observed :—Physically subnormal children improve in their
mental and physical condition and their nutrition and weight
improve, the gain being in most instances permanent;
arrested cases of tuberculosis have no relapses ; the nervous
system is restored to a normal condition ; cardiac cases kept
under proper medical supervision improve markedly;
capacity for work is increased and brought to at least a
normal average ; absence from school on account of illness
is greatly reduced; proper diet is followed and food
properly prepared ; good habits are established; hygienic
rules are observed ; and children learn how to do the right
things at the right time.
This is an outline of the vast work done in the United
States to reduce infant mortality and to ameliorate the
conditions of child life. New York may be said to have led
the way in its excellent and efficient scheme for the starting,
supervision, and general conduct of day nurseries.
IRELAND.
(From our own Correspondents.)
The Milk-supply of Dublin.
A few months ago the Earl of Granard, chairman of the
Food Control Committee for Ireland, appointed a committee
to inquire into the present milk-supply in the city of Dublin,
and to report on the best methods of obtaining additional
supplies from the country, and placing the'supply of milk
generally on a more satisfactory basis. The committee
had as chairman the Lord Mayor of Dublin, and it
contained two representatives of the public health
committee of the city, two members of the Local
Government Board, a number of persons interested in
the milk trade, and certain others with special knowledge.
A unanimous report has now been presented, certain reserva¬
tions on minor points being noted by a few members of the
committee. It was found im possible to discriminate accurately
between the city and the immediate suburbs, and the report in
reality deals with the conditions affecting an urban population
of about 400,000. About two-thirds of the total supply comes
from producers within or on the confines of the city, while
Thb Lancet,]
THE WAR AND AFTER.
[Fkb. 1,1919 193
only one-third comes from country districts. Apart from
the small quantity of milk of cows privately owned, the rnilk-
supply of Dublin during the period of investigation would
afford about 2 40 pints per head per week. The committee
point out that the supply is inequitably distributed and
that some of the milk arrives sour from the country. The milk
vendors, in fact, were able to inform the committee that they
would have required about 1000 gallons additional per day
to meet the needs of their regular customers. There was,
therefore, a definite shortage—most acutely felt, as might
be expected, in the poorer quarters. The actual shortage
the committee calculate at 2000 gallons a day. This
additional supply could be obtained from the country were
it not that there is also a definite shortage of railway milk
churns. In regard to this matter the committee make a
grave charge against the Ministry of Food. A written
request for a priority certificate for the supply of 2000 churns
had been forwarded to the Ministry on Nov. 16th, but up to
Dec. 12th no contracts had been placed, and there was no
prospect of any chums being available before the end of
January, if then. The actual shortage of milk-cans seems
to be due in large measure to the slovenly methods of the
carrying companies, who make no charge, and take no
responsibility for “ empties.”
The committee discussed the relative advantages and dis¬
advantages of the system of city cowkeeping, under which
two-thirds of the milk-supply of Dublin is provided. The
system is, of course, closely bound up with the large
brewing and distilling industries of the city, which provide
cheap feeding-stuffs. Apart from this, its chief advantages
are that it permits two daily deliveries of fresh milk and the
dairies and cowhouses are subject to inspection by the city
health officials. The quality of the milk distributed in
Dublin has been a subject of much public discussion during
the past few years, and in view of the seriousness of the
allegations to producers as well as the public, the com¬
mittee consider that the matter should be investigated by a
competent authority, as they are not in a position to say
whether the statements are founded on fact.
Among other suggestions, the committee recommend the
temporary retention of the existing control of the export of
milch cows; retaining fixed prices for the raw materials
of production ; the enlistment of the services of voluntary
agencies so as to reduce the ultimate price of milk in the
poorer-class districts by the reduction of existing charges
for distribution ; and, finally, the establishment of milk¬
drying* factories at suitable centres of production.
The Strike in Belfa.it.
When the men at the shipyards struck and ordered out the
workers at the city tramways, gas, and electric stations, in
order to paralyse all parts of the city of Belfast, they showed
a disregard for human suffering which it is hard for
medical men to pardon. The hospitals suffered terribly by
loss of power, heat, and cooking, especially from the
interference with the gas, and the fate of many patients may
have been adversely determined.
The Belfast Hospital for Skin Diseases.
At the annual meeting of the supporters of the Belfast
Hospital for Skin Diseases, held on Jan. 24th, it was
reported that in the three months following on Oct. 1st, 1918,
there were admitted 270 patients, bringing the total since
the hospital was established up to 51,059. Financially, there
was a sum close on £250 on the credit side, which enabled
the committee to invest £188 18s. 6d. in purchasing £200
War Loan stock.
A mass meeting of the medical profession will be
held at the Wigmore Hall, Wigmore-street, W., on Sunday,
Feb. 2nd, at 4 p.m., under the chairmanship of Professor
William Russell, formerly President of the Royal College of
Physicians of Edinburgh. The following resolutions will be
proposed
1. In view of prospective legislation and the proposed establishment
of a Ministry of Health, and having regard to the experience of the
medical profession at the time of the passing of the National Insurance
Acts, the time has arrived when a body representative of the whole
profession should be established, to watch its interests and be prepared
to act in an advisory capacity as occasion demands.
2. That a provisional committee be now formed with the object of
securing the election of such a body.
All medical practitioners are invited. Admission on pre¬
sentation of visiting card.
anlr Jfter.
Medical Mobilisation and Demobilisation : The
Work of the Central Medical War Committee.
It is now recorded that the Central Medical War Com¬
mittee owed its formal inception in 1915 to the instruction of
the Annual Representative Meeting of the British Medical
Association held in that year, while each successive Military
Service Act as it reached the Statute Book gave the Com¬
mittee an increasing orbit of activities with correspondingly
increased states. The third Act, passed in April, 1918,
appointed the Committee, in fact, the medical tribunal for
England and Wales. As in the months that followed the
demand of the Army authorities for medical men became
hotter and hotter, the Committee’s work became highly
arduous and difficult in reconciling the demands of
the military authorities with the needs of the civilian
population and the rightful claims of the medical men them¬
selves. The fastigium was reached on Nov. 11th, when,
with the signing of the armistice, the statutory duties of the
Central Medical War Committee as a medical tribunal came
to a sudden cessation along with those of all other recruiting
tribunals. The Ministry of National Service was then
nominated by the Government as the department to
demobilise civilian doctors included in any branch of the
Services, and an Inter-Departmental Committee was
appointed under the chairmanship rf Sir James Galloway,
including two invited representatives of the Central
Medical War Committee. Bat the Committee’s share in
medical lysis has been a much greater one than this relation
suggests, for with commendable prevision the problems of
demobilisation had been carefully considered and a complete
scheme of priority drawn up in order to ensure the return of
medical officers to civilian life upon an orderly and equitable
basis. This scheme, which we published in Thb Lancet of
Jan. 11th (p. 84), it was, in fact, which the Ministry of
National Service adopted, although the final word in a
particular case rests with the Minister and not with the
Committee, the status of which in the matter is purely
advisory and consultative. Daring the whole period of
mobilisation and demobilisation the Central Medical War
Committee has played an honourable part, and its help was
specially valuable in the very acute stages before and after
the cessation of hostilities.
Casualties among thb Sons op Mhdioal Mhn.
The following additional casualties among the sous of
medical men are reported:—
Lieut. A. Haydon, Royal Engineers, died in London of
pneumonia, youngest son of the late Dr. E. Haydon.
Capt. R. M. R. Davison, North Staffordshire Regt., attaohed
Leicestershire Regt., died of wounds after repatriation
from Germany, youngest son of Dr. R. T. Davison, of
New Malden, Surrey. _
Foreign Decorations.
The King of the Belgians has conferred the Cross of
Chevalier of the Order of the Crown upon the following
medical men in recognition of their services to the Belgian
civil population in the Yser district, notably on the occasion
of an epidemic of typhoid fever in 1914-15, while working
with the Friends Ambulanoe Unit
Mr. G. R. Fox; Dr. S. A. Henry; Dr. W. Sraerdon; Dr. T. T.
Thomson ; Mr. J. B. Rees; Mr. H. C. Manning.
French.
Qrois de Guerre.— Surg.-Lt. N. H. Smith, B.N.
Japanese.
Order of the Sacred Treasure. Mrst Class.— Surg.-Vice-Adml. Sir
W. H. Norman, K.C.B. _
The Royal Sanitary Institute has arranged a
Conference on * ‘ Post War Developments relating to Public
Health ” to he held on March 13th, 14th, and 15th, at which
the following subjects will be brought forward for discussion :
City Hygiene in Relation to Employment; Housing for City
Clerks and Similar Workers; Public Health Aspect of
Tuberculosis; Public Health Work and Propaganda;
Welfare Work in Factories ; Child Welfare Work.
194 The Lancet,]
OBITUARY OF THE WAR.
[Feb. 1, 1919
OBITUARY OF THE WAR.
HARRY GEORGE MELVILLE, M.D., F.R.C.S. Edin.,
C.I.E.,
COLONEL, INDIAN MEDICAL SERVICE ; PROFESSOR OF MATERIA
MED1CA, LAHORE COLLEGE.
Colonel H. G. Melville, who died suddenly at Bagdad on
Dec. 7th, at the age of 49 years, was second son of the late
Francis Suther Melville, D.C S.. of Edinburgh. Educated
at the Edinburgh Collegiate School and the University of
Edinburgh, where he had a distinguished career, he acted
as demonstrator in anatomy under the late Professor Sir
William Turner, was the first president of the Edinburgh
University Union, and one of the three presidents of his
year of the Students’ Representative Council. He gradu¬
ated M.B., C.M. at Edinburgh in 1890, and after resident
positions at the Edin¬
burgh Royal Infirmary,
joined the Indian Medi¬
cal Service in 1892 and
became medical officer
of the 5th Punjab
Cavalry (now the 25th
Cavalry) in 1896. He
served in the Waziristan
Expedition of 1894-95
and received a medal
and clasp ; in the
Mohmand Campaign of
1897 and received a
medal and two clasps ;
and in Tirah in 1897 98.
In 1901 he was ap¬
pointed a professor in
Lahore Medical College.
He held several chairs
there, at the time of his
death being professor
of materia medica and becoming one of the most sought
physicians of Northern India. A recent principal of the
College at Lahore writes of the trust and affection in which
he was held by the Indian students who passed through his
hands. In 1911 he was appointed by the Punjab University to
represent it at the Quincentenary Celebration of St. Andrews
University.
In 1916 he was appointed consulting physician to the
Indian Expeditionary Fort 3 in Mesopotamia, and later to
the Mesopotamian Expeditionary Force, where he worked
with much success to reduce the toll of disease among the
forces there. Based at Basra, he paid periodical visits to
depots on the Tigris and Euphrates. After a brief respite
from his labours he returned to Basra in September, 1918.
and a month or so later was appointed to Bagdad, where
he died suddenly from arterio-sclerosis. He was mentioned
in despatches in April, 1918, and later was awarded a C.I.E.
Already master of several native languages, it was charac¬
teristic of him that after his appointment to Mesopotamia
he set himself diligently to study Arabic.
Colonel Melville married in 1903 Isobel, youngest daughter
of the late Alexander Lawson, of Bumturk, Fife, and leaves
a widow and one daughter.
Captain William Franklin Luton, C.A.M.C., who died
of pneumonia at the 2nd Southern General Hospital, Bristol,
on Oct. 20th, being admitted there from the vessel on which
he had been transport officer, was 29 years of age. Not
having been a member of the Canadian Expeditionary Force
in England, his official documents are not in the possession
of the Canadian authorities in London. It is known, however,
that he joined the active Militia in Canada in 1915 at
Victoria, British Columbia.
We announced in The Lancet of Jan. 4th the death of
Captain A. J. Milne, M.B., S.A.M C. Mr. James W. Milne
writes to inform us that he has definite information to the
effect that Captain Arthur James Milne, S.A.M C., died at
Fort Johnstone, Rhodesia, on Dec. 7th. He has received
South African letters, dated Dec. 8th and 15th, from the
family of Captain Arthur John Milne, S.A.M.C., who is his
bro her, and who, he concludes, is living. We regret the
error, which was also made, Mr. Milne tells us, by the
South African Records Office at Pretoria.
JOSEPH VINCENT DUFFY, L.R.C.P. Edin.,
CAPTAIN, ROYAL ARMY MEDICAL CORPS.
Captain J. V. Duffy, who died in East Africa of influenza
on Dec. 7th last, aged 27 years, was second son of Francis
Duffy, of Jesmond,
Newcastle - on - Tyne.
Educated at St. Joseph’s
College, Dumfries,
where he was a scholar
aDd prizeman, and
Glasgow University, he
obtained in 1914 the
triple diploma of the
Royal Colleges of Phy¬
sicians and Surgeons,
Edinburgh, and the
Royal Faculty of Phy¬
sicians and Surgeons
of Glasgow. After
qualifying he first went
into practice with Mr.
A. M. G. Walker, at
Hepburn-on-Tyne, sur¬
rendering this work in
order to join the Royal
Army Medical Corps.
He had served in all the principal theatres of war—France,
Gallipoli, India, and East Africa—before succumbing to the
common enemy of mankind.
WILLIAM ROBERT O’KEEFFE, L.&L.M. R.C.P. AS. Irkl.,
CAPTAIN, ROYAL ARMY MEDICAL CORPS.
Captain W. R. O’Keeffe, who died suddenly of septicaemia
at Beirut, Palestine, on Nov. 21st, was son of Mr. C. H.
O’Keeffe, manager of the Provincial Bank, Waterford, and of
Mrs. O’Keeffe, of Balls-
bridge, Dublin, grand¬
son of Dr. W. M.
O'Keeffe, of Mallow,
and nephew of Major-
General Sir M. W.
O’Keeffe, K. C. M. G.,
M.D., M.Ch. Educated
at Clonmel Grammar
School, Kilkenny Col¬
lege, and University
College, Cork, he
qualified in 1912,
and was afterwards
assistant to Dr. J. S.
Mather, of Bristol, and
Dr. White, of Stretford-
le - Hope, eventually
going into practice in
Sheffield. He was an
all-round athlete, being
a member of the first
fifteen at University College, Cork, when that team won
the Rugby Football Dudley Cup ; he was also a fine swimmer.
He leaves a widow and two children.
HENRY RUTHVEN LAWRENCE, M.D., F.R.C.S. Edin.,
MILITARY CROSS,
CAPTAIN, SOUTH AFRICAN MEDICAL CORPS.
Captain H. R. Lawrence, who recently died in a casualty
clearing station in France from pneumonia following influenza,
was son of the late Dr. T. Lawrence, of George, Cape Colony.
Educated at St. Andrew’s College, Grahamstown, South
Africa, he graduated at Edinburgh University and took his
F.R.C.S. Edin. in 1912. He then proceeded to Cape Town
and started practice at Newlands. He received a commission
in the Union Defence Force and was called up for service
within a day or two after the outbreak of war. He served
in German South-West Africa until this campaign was
successfully closed, and immediately volunteered for service
overseas, and came to England with the first draft of the
South African Expeditionary Force In September, 1915. He
served for a time in England and in France with No. 1 South
African General Hospital, and was then transferred to No. 1
South African Field Ambulance. Shortly afterwards he was
appointed regimental medical officer to the 4th South
African Infantry and with this regiment he went through
The Lancet,]
THE SERVICES.
[Feb. 1,1919 195
many of the fiercest battles in 1917-18. He was awarded
the Military Cross for bravery in action daring the last
month of hostilities.
Captain Lawrence was widely known in South Africa,
both as a skilful and successful practitioner and as an
athlete. He was a sportsman and yachtsman, and rowed for
his University as a student.
Captain C. R. Lister, M.C., A.A.M.C., who died from
influenza on Nov. 21st, was educated at Hawthorn College,
Melbourne, where he was a member of the cricket and foot¬
ball teams, and proceeded to the Melbourne University in
1909. During his first year he attended Trinity College,
though not in residence there, and graduated with honours
in March, 1914. He obtained his “University Blue” by
becoming a member of the University tennis team during
his third year, and was a member of the Victorian team in
the inter-State matches of 1912. After graduation in 1914
he was resident medical officer at the Melbourne Hospital
from March, 1914, to 1915, and was out-patient surgeon at
the Melbourne Hospital from 1915 until 1918. He was
also appointed demonstrator in anatomy at the Melbourne
University in 1915, and was subsequently appointed Stewart
lecturer in anatomy, holding this appointment for three years,
up to the time of his embarkation for active service in
1918. In 1915 he was appointed resident tutor in surgery
at Trinity College, and at the end of that year volunteered
for active service, but owing to the difficulty at that time
of securing a suitable successor as demonstrator in the
anatomy school the University authorities were unable to
release him. During the long vacation of 1915-16 he
served as a medical officer on a troopship between Australia
and Egypt. In 1917 he obtained the degree of Master of
Surgery of the University of Melbourne. At the end of that
year when the University authorities were able to release
him, he enlisted in December, and arrived in England in
July, 1918. After two months’ duty in England be pro¬
ceeded overseas to France, and died at No. 14 General
Hospital at Wimereux from influenza on Nov. 21st. He
married Miss Meryl Waxman, the daughter of C. R. Waxman,
of Melbourne, who is well known in tennis circles, and
leaves his widow with one child.
Mentioned in Despatches.
In a despatch received from the Commander-in-chief,
British Salonika Force, dated Dec. 1st, 1918, the following
reference to the Medical Services is included
In this unhealthy climate the efficient administration of the Medical
Services is naturally of extreme Importance, aud in this respect a very
high standard of efficiency has been attained. In an army saturated
with malaria, and passing through a severe outbreak of Influenza,
heavy calls were constantly made on the strength and devolion to duty
of the Royal Army Medical Co ps, of whose work 1 cannot speak too
highly. I am much Indebted to Major-General M. P. Holt, K.O M.G.,
C. B., D.S.O., and his subordinates for the admirable manner in which
their duties have been performed.
The names of the following medical officers have been
received from the Commander-in-Chief of the Egyptian
Expeditionary Force as worthy of mention for their services
during the period from March 16th to Sept. 18th, 1918
Staff.—Temp. Maj. (acting Lt.-Col.) J. J. Abraham, D.8.O., B.A.M.C.;
Temp. Capt. (acting Lt.-Col.) W. Angus, R A.M.C.; Capt. J. Chalmers,
R.A.M.C. (T.F.); Col. E. J. H. Bvatt. D.S.O., R.A.M.C. (T.F.); Lt.-Col.
(acting Col.) C. Garner, C.B.B.; Capt. and Bt. Maj. (temp. Maj.)
A. S. M. MacGregor, R.A.M.C. (T.F.); Capt. (temp. Maj.) P. A. Opie,
B. A.M.C.; Lt.-Col. (temp. Col.) B.P. Sewell.C.M.G., D.8.O., R.A.M C.
Army Medical Service and Royal Army Medical Corps.— Temp. Capt.
R. H. Astbury; Temp. Capt C. H. Butgess; Lieut, (temp. Capt.)
W. M. Cameron; Temp. Maj. J. P. l ampbell; Temp Capt. H. Cardin ;
Temp. Capt. J. Ohambre ; Temp. Col. C. C. Choyce. C.B.E.; Temp.
Capt. F. H. Dlggle, O.B.K.; Maj. (aoting Lt.-Col.) W. F. Ellis, O.B.E.;
Temp. Capt. W. W. Forbes, O.B.E.; Temp. Capt. N. 8. Gilchrist, O.B.B.;
Temp. Lieut. E.‘Gofton; Temp. Capt. E. G. Goldie; Temp. Caot.
W. F. Hawkins; Capt. T. F. Kennedy, O.B.E.; Maj. (acting Lt.-Col.)
W. E. C. Lunn, M.C.; Capt. (acting Maj.) W. Mathlescn ; Capt. J. T.
Simson; Temp. Capt. 0 W. Smith, O.B.E.; Temp. Oapt. (acting Maj.)
E. B. Smith; Temp. Capt. (acting Maj.) W. H. D. Smith; Capt.
B. H. H. Spence; Lt.-Col. G. E. F. Stammers, O.B.E.; Temp. Capt.
J. A. H. Telfer.
Royal Army Medical Corps (S.R.).— Capt. H. W. Evans, M.C.; Oapt.
D. Fraser, M.M.; Capt. (temp. Lt.-Col.) P. S. Vickerman, O.B.E.; Capt.
O. Williams.
Royal Army Medical Corps'(T.F.).— Maj. L. A. Avery, D.S.O.; Oapt.
B. Briercllffe, O B.E.; Capt. C. Douglas; Maj. W. Dyson,O.B.E.; Maj.
(acting Lt.-Col.) J. Evans, D.S.O.; Maj. F. Gracie, O.B.M.; Capt. J.
Inglls, O.B.E, ; Lt. H. Jessop; Capt. G. J. Llnklater; Capt. (temp.
Maj.) W. C. Macaulay; Mat. (acting Lt.-Col.) J. W. Mackenzie. O.B.E.;
Capt. J. M. Mttcheil, M.C.; Capt. (acting Maj.) L. M. V. Mitchell.
O.B.E.; Capt. (temp. Maj.) R. Phillips; Oapt. (acting Maj.) G. B.
Pritchard; Maj. G. C. Taylor, O.B.B.; Maj. A. Thomas; Maj. F. B.
Treves, O.B.B.; Oapt. (acting Maj.) A. P. Watson, O.B.B. I
Indian Medical Service— Lt.-Col. (temp. Col.) W. H. Ogilvie,
C.M.G.; Capt. (temp. Lt.-Col.) A. G. Couliie; Capt. D. L. Graham,
O.B E. ; Maj. (temp. Lt. Col.) E. C. Hodgson, D.8.0.; Lt.-Col. P. S.
Lelean. C.B.; temp. Lt. K. R. Mad an, n B.E.
Indian Subordinate Medical Department.— Asst. Surg., 4th Class,
F. M. Grah-.m; A»st. Surg., 2nd class, R. H. Hughes; Asst. Surg.,
3rd Class, J. A. Pinto.
Australian Army Medical Corps.— Capt. A. M. Asplnall; Lt.-Col.,
C. B. Blackburn, O.B.E.; Lt.-Col. (temp. Col.) G. P Dixon, C.B.E.;
Col. R. M. DowntB, C.M.G.; Maj. N. H. Parley, O.B B ; Lt.-Col.
(temp. Col.) R. Fowler, O B.E ; Capt. W. H. Kliner; Lt.-Col. W. L.
Kirkwood; Capt. A. T. Robertson; Capt. R. J. Sltverton ; Lt.-Col. J. C.
Storey, O.B.B. _
THE SERVICES.
ROYAL NAVAL MEDICAL SBRV10B.
Temp. Surg, Lieuts. J. H. B. Hogg and R. W. Payne, who have been
invalided on acoount of ill-health contracted in toe service, to retain
their rank. -
ARMY MEDICAL SERVICE.
Temp. Major-Gen. Outhbert S. Wallace relinquishes his commission
and retains the rank of Major-General.
Temp. Col. H. A. Bruoe (Colonel, Canadian Army Medical Corps)
relinquishes his temporary commission and retains the rank of Colonel.
ROYAL ARMY MEDICAL CORPS.
Mkjor (temp. Lleut.-Col.) Kewinald V. Cowey relinquishes the
temporary rank of Lieutenant-Colonel on re-posiing. «
Majors to be acting Lieutenant-Colonels; Whilst In command of a
Medical Unit: T. S. Blackwell. Q. R. Painton, T. H. Gibbon, W. J.
Watson. Whilst employed as Assistant Directors of Medical Servioes
of a Division: J. H. Brunsklll, W. B. Sparkes.
Captains relinquishing the acting rank of Lieutenant-Colonel and
reverting to the acting rank of Major, with pay and allowances of their
substantive rank : S. 4. Higgins, J. F. Grant.
Temporary Captains relinquishing the acting rank of Major on
re-posting: W. G. Waugh, C. F. White, Alan R. Green, J. D. Duncan,
C. G. H. Morse, A. H. M. Rotertson. J. Lam .nt.
To be acting Majors : Capts. R. D. Davy, J. P. Little, B. P. A. Smith,
F. A. Robinson ; Temp. Capts. W. C. dorton, G. L Keynes, G. D.
McLean, J. C. Sale, W. Morris, V. L. Connolly, D. H. Ru-sell, G. H.
Davy, W. P. Cooney, C. G. Mackay, J. A. G. Burton, A. R. Elliott,
S. S. Dunn (while in command of troops on a Hospital Ship). Whilst
specially employed: Temp. Capts. M. McLeod, C. U. Lord; Capt. D. B.
McGrigor.
Temp. Major S. H. McCoy, C.A.M.C., to be temporary Lieutenant-
Colonel.
Capt. J. J H. Beckton to be acting Lieutenant-Colonel whilst in
command of a Medical Unit.
Temp. Major B. O. Hort relinquishes his temporary commission and
Is granted the temporary honorary rank of Lieutenant-Colonel whilst
specially employed with the Red Cross Society.
Temporary Captains to be acting Major*: G. B. Elliott. Whilst
specially employed : ▲. G. Caldwell. T E. R. Branch.
Temp. Capt. P. D. 8aylor, C.A.M.C., to bs acting Major while
employed as Director of Sales.
Temp. Capt. H. Gibson to be acting Major while In charge of Qlen-
lomond War Hospital.
Temp. Capt. H. A. Snetslnger, C.A.M.C., to be temporary Major.
Temporary Lieuteuants to be temporary Captains: J. H. P. Vivian,
J. M. McCormack, B. F. Lawson, J. J. Delaney, O. H. Woodcock,
J. Good, H. S Roberts, A. E. Erie, A. G. Wright.
Temporary Honorary Lieutenants to be temporary Honorary Captains:
H. W. Woodward, A. Gregg, D. C. Parmenter (from No. 22 General Hos¬
pital, Harvard Uniti, W. S. Rutherford.
0. M. Halsall to be temporary Lieutenant.
Officers relinquishing their commissionsTemp. Majors retaining
the rank of Major: R. T. Herron, J. C. MacNeillie, H. Hemsted
(Major, S.A. Med. Corps), C. C. Heywood, H. Dodgson. Temp. Capts.
(acting Majors) C. A. Boyd, J. Lamont, T. I. Bennett, and retain the
rank of Major. Temp. Major W. U. Mackenzie. Temp. Capts. R.
Briffault, D. P. Williams, H. fi. Mlnshull, W. E. R. Dlmonri, F. Gravely,
J. Boyd. And retain the rank of Captain: A. B. Le Mesurler, A. H.
Hall, J. P. O Connor, G. B. Brown, D. M. Barry, C. H. Brookes, C. A.
Moseley, J. Bain, J. C. Macaulay, W. H. Johnston, J. P. O’Flynn,
A. Malseed, G. Lawrence, G. Thom, L. H. Brysou, H. W. Wlnrtsor-
Aubrey, J- P. Febily, W. Daunt, T. A. Adams, S. J. Simpson, V. B.
Kyle, M. Henry, V. E. Rldewood, J. T. O Boyle. W. Macdonald. D. L.
Tate, H. M. Reeve, R. G. Gillies. A. F. Wilson-Gunn, it. C. Cummins,
E. C. Abraham, A S. Dawson, C. F- Knight (acting Major , R. D.
Lemon, J. L. Rentoul, J. A. Black, W. Parker, L. 8. O’Gradv,
F. Garrett, R. C. Lowe, J. McA. Hill, 8. Rowland, 0. S. Vartan, H. T.
Llpptatt, W. B. Rutherford. Temp. Lieuts. P. N. Twomey, G. B.
Oates, N. S. Williams, A. A. Angells, and retain the rank of Lieu¬
tenant. Temp. Capt. (acting Major) Maurice N. Perrin relinquishes
his commission on transfer to the K. A.F.
TERRITORIAL FORCE.
Major F. Gracie and Capt. H. F. Humphreys to be acting Lientenaut-
Colonels whilst specially employed.
Captains to be acting Majors whilst specially employed: W. H.
Milligan, C. M. Gozney, J. M. Pringle, 0. M. Nicol, F. Arvor, W. N. P.
Wiliams, J. H. Donnell, L. N. Reece.
Capts. (acting Majors) L. M. V. Mitchell, G. B. J. A. Robinson,
W. C. Hodges, H. F. W. Boeddicker, F. Wigglesworth, C. E. H. Milner,
A. Mowat, and H. W. Wler relinquish tueir acting rank on ceasing to
be special!} employed.
Capt. E. W. Richards relinquishes his commission on acoount of
ill-health ami retains the rank of Captain.
C«pt. H. G. Mai lam relinquishes his commission on account of ill-
-health contracted on active Bervice and retains the rank of Captain.
Major (acting Lieut.-Col.) P. G. Williamson relinquishes his acting
rank on oe&aing to be specially employed.
Capt. A. W. NuthaU to be Major.
196 ThbLanobt,]
‘ TRIVIAL OASES AT VOLUNTARY HOSPITALS.
[Feb. 1, 1919
2nd London General Hnepital: Gapt. (Brevet Major, acting Lieut. -
Gol.) E. H. Fenwick relinquishes bis acting rank on ceasing to be
specially employed, and Is restored to the establishment.
3rd Northern General Hospital : Gapt. (acting Major) J. H. Cobb
relinquishes his acting rank on ceasing to be specially employed, and
is restored to the establishment.
2nd Northern General Hospital: Gapt. A. Richardson is restored to
the establishment.
1st Western General Hospital: Capt. R. W. MaoKenna is restored to
the establishment.
2nd Western General Hospital: Gapts. H. Buck and R. Molr are
restored to the establishment.
5th Northern General Hospital: Gapt. W. I. Oumberlldge is restored
to the establishment.
1st London Sanitary Company: Lieut. F. N. McRae to be Captain.
2nd London Sanitary Company: Capt. N. Gobble to be a Deputy
Assistant Director of Medical Services, and to be acting Major whilst
so employed. Lieut. H. Jessop to be Captain.
The undermentioned Lieutenants to be Captains and to remain
seconded: T. H. Savory, G. N. F. Reddan, J. Dali, A. 8ykes, D. Smith.
TERRITORIAL FORCE RESERVE.
Lieut.-Col. E. J. Cross, from Eastern Mounted Brigade Field Ambu-
lanoe, to be Lieutenant-Colonel.
Lleut.-Col. A. Ogston, from the High. Casualty Clearing Station, to
be Lieutenant-Colonel.
Major B. B. Waggett, from 3rd London Field Ambulance, to be Major.
Majors P. G. Williamson and R. Stirling, from Attached to Units
other than Medical Units, to be Majors.
Major J. McD. Niooll, from 2nd Northern Field Ambulance, to be
Major.
Major J. E. Motion, from Attached to Units other than Medical
Units, to be Major.
Capt. J. M. O’Meara, from Eastern Mounted Brigade Field Ambu¬
lance, to be Captain.
Capt. H. J. Sbanley, from 2nd Northern Field Ambulance, to be
Captain.
Capt. C. Corfleld, from the 3rd South Midland Field Ambulance,
to be Captain.
Capt. (acting Major) D. Lamb, from 4th Scottish General Hospital, to
be be Captain.
To be Captains: Capts. W. M. Wilson, from 2nd Northern Field Ambu¬
lance ; T. P. Caverhill (acting Major), D. R. Harris, H. L. Munro,
W. J. Lacey-Hickey, J. W. M. Jamieson, from Attached to Units
other than Medical Units; W. C. Hodges, from 1st South Western
Mounted Bde, Field Ambulance; H. F. W. Boeddickcr, from 1st Sooth
Midland Field Ambulance; A. E. Barnes (acting Major), from 3rd
Northern General Hospital; W. D. C&rruthers, from 1st London
San if ary Co.; A. Greene from Wessex Oasnalty Clearing Station;
F. Wigglesworth, from 1st West Riding Field Ambulance.
8. Robertson relinquishes bis commission on ceasing to be employed,
and Is granted the rank of Captain.
Lieut. H. B. Pearson relinquishes his commission on ceasing to be
employed, and retains the rank of Lieutenant.
ROYAL AIR FORCE.
Medical Branch.— Lieut.-Cols, to be Lieut.-C61s. (Grade A): B. O. B.
Carbery, H. Cooper, B. O. Crldland, H. J. Hadden, N. H. Harris, R. H.
Moraement, J. St. J. Murphy, T. Philip, W. H. Pope, N. J. Roche,
H. B. South, H. V. Wells.
Majors (acting Lleut.-Cols.) retaining the acting rank of Lleut.-Col.
whilst employed as Lieut.-Ools. (Grade A): G. N. Biggs, H. C. T.
Lingden. T. F. Muecke.
L. B. Stringer (temp. Surg. Lieut., B.N.) Is granted a temporary
commission as Captain.
VITAL STATISTICS OF ENGLAND AND
WALES FOR 1918.
The following statement shows the birth- and death-rates
and the rates of infant mortality in England and Wales, and
in certain parts of the country, during the year 1918,the figures
being provisional
~ i
1
Birth-rate
per 1000
total
popula¬
tion.
1
Civilian
death-rate
per 1000
civilian
population 1
(crude rate).
Deaths
under
lyear
per 1000
births.
England and Wales*.
| 177
p
~97
96 great town*. Including London )
(population* exceeding 50,000 at -
the Census of 1911). )
1
1 17-6
l
181
i 106
148 smaller towns (populations from )
20,000 to 50,000 at the Census of >
1911) .}
1
! 18*0
1 161
94
London .
15-8
18-7
107
* The civilian death-rate for England and Wales cannot be stated at
present, the number of non-civilian deaths in the fourth quarter of
1918 not being available.
Major Sir Samuel Scott, Bart., M.P. for St. Maryle-
bone, London, is to introduce the Nurse’s Registration Bill
drafted by the Central Committee for the State Registration
of Nurses.
Cjmspirtimt.
" Audi alteram partem/’
“TRIVIAL ’CASES AT VOLUNTARY HOSPITALS.
To the Editor of The Lanobt.
Sir, —May I traverse one statement that has appeared
regarding the future of voluntary hospitals ? It is that these
hospitals should be relieved from “ trivial ” cases. I think
that there are but few “ trivial ” cases. Any real departure
from health is to be regarded as serious. Early diagnosis
and, following that, early treatment are wanted. The
beginnings of disease are difficult to diagnose. The recurrent
catarrh may be phthisis; the “piles” which the chemist
treats, may be rectal cancer; indigestion may be early
stomach cancer or what not 1 ; sciatica may mean hip
disease. How insidionsly many grave nervous diseases begin!
Some affections of vision indicating serious disease have
slight beginnings ; neglected pyorrhoea may lead to many
things ; either headache or cough may be the beginning of a
serious malady ; constipation has multitudinous possibilities.
What of the recurrent disabling trivialities with their con¬
comitant periods of economic uselessness, such as nasal
catarrh, lumbago, “neuralgia,” dysmenorrhoea, “rheu¬
matism,” some skin diseases, mal-nutrition ? The poten¬
tialities of gonorrhoea or of “running ears” are enormous.
Then what of the medical student ? Is he no longer to see
“ trivial ” cases at his medical school ?
I have taken examples of disease just as they occur to me,
hut they might be multiplied indefinitely. In all of them
anyone can recognise the necessity for elaborate and careful
diagnosis and treatment. If the voluntary hospital—or
whatever the health institution of the future be aalled—
eliminates “trivial” oases from its activities, assuredly
there will result grave medical disadvantage to the public.
I am, Sir, yours faithfullly,
A. W. Sheen,
Colonel, A.M.S. (T.F.), Consulting Surgeon,
India, Dec. 3rd, 1918. War Hospitals.
THE HYPOTHERMIC, OR DEPRESSION, STAGE
OF INFLUENZA.
To the Editor of The Lanobt.
Sir,—T he depression which follows influenza is so constant
that it ought to be regarded as part of the disease. During
this period of depression the temperature is subnormal. This
stage of subnormal temperature is not generally recognised,
but it is of great importance, for it is during this period that
the risks of complications are so great, and convalescence is
not established until the temperature has reached its normal
level again. The condition deserves a name, and I propose
to call it hypothermia, and to speak of the stage as the
stage of hypothermia, or the hypothermic stage. There is
a hypothermic stage after every fever, to which it bears a
general relation, being short where the initial fever has been
short, and prolonged where, as in typhoid fever, it has been
prolonged.
In no fever is the hypothermic stage more pronounced and
prolonged than in influenza, and that often in oases where
the initial attack has been slight, or where, as in the
so-called afebrile cases, the temperature is not known to
have been raised at all. Daring the prevalence of influenza
cases are not at all uncommon in which the patients feel
cold and miserable and cannot get warm even before a
blazing fire or in bed, and the temperature is all the while
subnormal. These are, I believe, instances of hypothermia
following an unrecognised attack of influenza, for they are
not often met with except when influenza is prevalent.
1 drew attention to this condition in my account of the
epidemic of 1890 and have referred to it frequently since,
yet it has not gained general recognition and in the recent
clinical descriptions of influenza it is not even referred to.
Perhaps if it receives a name it will get the attention it
deserves. Anyway, the recognition of this stage is of
practical importance, for it is at this period that complica¬
tions are so likely to occur which might have been avoided.
The difficulties often lie with the patients, for as soon as the
fever has gone they are so apt to think themselves well and
to disregard the doctor’s warnings. If they are made to
The Lancet,]
ACCURATE DIAGNOSIS IN APPENDIOITIS.
[Fbb. 1,1919 197
understand that the hypothermic stage is part of the attack
and that they cannot be considered convalescent until the
temperature has ceased to be subnormal, and it has risen
again to the normal level, the appeal to the thermometer
may make them more amenable.
I am, Sir, yours faithfully,
Wimpole-street, W., Jan. 23rd, 1919. • SAMUEL WEST.
ACCURATE DIAGNOSIS IN APPENDICITIS.
To the Editor of Thh Lancet.
Sir, — I venture to think that in the various papers written
upon the subject of appendicitis hardly sufficient attention
—in fact no attention—has been given to certain experiments
conducted by Dr. Alexander Paine and myself, published in
Thb Lancet of August 17th, 1912, and elaborated in our
volume on 4 * Researches on Rheumatism.” These experi¬
ments were of some historic interest, for they demonstrated
for the first time that it was possible to isolate from human
appendicitis a micro-organism which on intravenous inocula¬
tion reproduced the disease in rabbits. The specimens were
presented to the Museum of the Royal College of Surgeons
of England.
Their importance lies in the demonstration that the
infection is a blood infection not attacking from the lumen
of the appendix, but from the peritoneal surface by the blood
stream. Every step in the process was demonstrated and
the pathology is fully illustrated in our book. As a result of
the infection “ballooning” of the appendix may occur
without any concretion, and whether or not the 44 balloon”
bursts clearly depends on the extent of necrosis of the wall
infected. The result of the inflammation is catarrh in the
tube, which, when the process is chronic, causes the formation
of a faecal stone, and this in turn adds the factor of
traumatism. The strictures are the result of local chronic
inflammation from the blood infection and a 44 mitral
stenosis” of the lumen of the duct, if I may coin a term to
save space. The stricture complicates the history of
appendicular disease, as all are aware. The technical
difficulties of the bacteriological investigations are described,
and a method for overcoming them detailed, in our book.
I believe it to be of importance that it should be realised
that appendicitis is in origin a blood infection and not a
local infection, for the difficulties of early detection and
obscurities in the history are made much more obvious when
the pathology is turned outside-in and not inside-out, as is so
often the case. I am, Sir, yours faithfully,
Devonshire-place, W., Jan. 26th, 1919. F. JOHN POTNTON.
ACUTE APPENDICITIS AND ACUTE
APPENDICULAR OBSTRUCTION.
To the Editor of The Lancet.
Sir, —The paper on this subject by Mr. S. T. Irwin in
your issue of Jan. 18th is of great interest to me, bringing
forward as it does the most valuable corroborative evidence
of the thesis which I put forward at the meeting of the
British Medical Association in July, 1914—namely, that
there are two acute diseases of the appendix—acute inflam¬
mation and acute obstruction. I maintained that the one
disease differed from the other not only in its symptoms and
pathology, but also in its danger to life and in the urgency
of the treatment required.
In my original paper 1 I brought forward clinical and
experimental evidence which appeared to me to be conclusive
in this connection. Later experience has confirmed me in
my views, and I have now no hesitation in saying that our
teaching of the symptomatology and pathology of acute
appendicular disease should be based on those clear and
distinctive lines. Unless this is done the description of the
symptoms of so-called appendicitis must be qualified in so
many points that it ceases to be distinctive. With two well-
defined clinical pictures based on sound pathology the
student and practitioner are in a position to detect the
different forms of acute appendicular disease in their early
stages, and by recognising the great urgency for immediate
operation in the cases of obstruction to reduce to a minimum
the needless loss of life which still obtains in this disease.
I am, Sir, yours faithfully,
Edinburgh, Jan. 20th, 1919. D. P. D. WlLKIE.
1 Brit. Med. Journ., Dec. 5th, 1914.
A PERSONAL RETROSPECT OF GENERAL
PRACTICE.
To the Editor of The Lancet.
Sir,—I have read with interest, sympathy, and the
appreciation of experience, the thoughtful paper by Dr.
Jasaes Pearse, * which appears under the above title in
The Lancet of Jan. 25th. Its excellence justifies' the
prominence you have given it. The advocacy of the interests
of the general practitioner by The Lancet, from its
inception under its Founder—Thomas Wakley the first—until
the present day, gives you an authoritative position in dis¬
cussing his status and prospects.
Times change and we with them are altered, and one
would like to think that the position of the general practi¬
tioner in the present day and his prospects had altered
for the better. He would, however, be a bold man who
would maintain this thesis. My own retrospect of practice,
first as a general practitioner and later as a consultant, now
reaches rather more than 40 years, a period nearly equally
distributed in the two spheres of work. I may therefore
claim to be in a position to appreciate Dr. Pearse’s
account of the difficulties and the advantages and dis¬
advantages of the environment of the general practitioner
and his relation to other branches of the profession. Time
was when, in England especially, a considerable gulf
yawned between the practitioner and the consultant, and the
infringement of the commercial interests of either was
resented by both. Even now there is an echo of this in the
occasionally insistent angry query, “ What is a consultant ? ”
In the humblest days of the visiting apothecary the action
of the College of Physicians of London in supplying good
drugs to the poor was resented by the former, aided by
interested friends among the physicians, as related in Garth’s
Dispensary, at a time when medicine languished and men
14 studied lucre more and science less.”
It was the calculated design, on the other hand, of the
consultant to keep the chasm wide between the two classes,
when The Lancet was founded, which brought its doughty
first editor and proprietor into the field as a medical informer
and reformer, and Thomas Wakley’s work should never be
forgotten by that section of the body which he left with at
least some title to be considered a liberal profession rather
than a debased trade. Whether the action of more recent
medical politicians is likely to have an equally beneficial
effect may be gravely doubted. Wakley’s efforts were towards
a unification of the profession. Present-day tendencies
appear to be towards its undue division. He, by his
educative work, promoted evolution from the general to
the particular; now, by a hopeless gaze upon the increase
of knowledge and an unwise specialism, we are in danger of
fatally dissolving an organic whole into its component parts.
As Dr. Pearse points out, this danger is less in country
districts than in larger centres of population, where the
general practitioner, robbed of responsibility, has too easy
opportunity of delegating work, and tends to become a mere
“ sifter ” of cases, to use Dr. Pearse’s term.
Research and practice cannot be divorced in any sphere of
cultivated medicine without detriment to the quality and
utility of both. Research cannot be fruitfully pursued
without touch with practice. Positions of more particular
research may arise in general investigation, but there is a
danger in the creation of special research posts to be filled
by men without active touch with general experience. Even
the shortness of life and the length of art do not justify the
creation of such.
With all that Dr. Pearse says of the influence of individual
temperament and the education of the man preparing for
practice one must be in full agreement. The value Of the
inspiring teacher cannot be overestimated. It needs, how¬
ever, an inspired teacher to inspire others, and, unfortu¬
nately, he cannot be produced even under the fostering
influence of that twentieth-century recipe for genius, a
large salary l The student, once inspired, remains a student
all his life, and the uninspired student had very much better
adopt some other calling than medicine, which is a rough
road not often leading to a gold mine. Duly educated, how¬
ever, and once in the profession, the secret of progress for
the general practitioner, promotive alike of his own growth
and benefit and of the public good, is contained in a single
vr or&—collaboration.
198 ThbLanobt,]
VENEREAL DISEASES IN EGYPT.
[Fbb. 1,1919
The writer can recall a group of men who, in a then com¬
paratively detached part of this metropolis, by collaboration
in research in general practice (they were also the first so-called
“team workers” among practitioners) produced, in its own
degree, work comparable with any other work in interest
and utility, and begot a camaraderie and punctilio in
ethics which rendered it a joy to be a general prac¬
titioner, notwithstanding days and nights laborious in more
senses than one. Many of those collaborators have passed
away, including one—the Atlas who bore that little world—
and all largely unsung, some poor, but none, as Dr. Pearse
says, unhonoured or unwept. That under any State system, in
being or contemplated, the same spirit will be evoked to the
benefit of the individual, the profession, and the community
is more than doubtful. The intrusion of the State into
medicine tends, and in the opinion of many will ever tend,
to destroy the individuality and independence of the prac¬
titioner, and, what may appeal to the State more, to impair
also regard for the patient as an individual and his freedom
as a citizen, and, with this, sufficient medical interest in
him. 1 am, Sir, yours faithfully,
Jan. 27th, 1919. F.R.C.P.
VENEREAL DISEASES IN EGYPT.
To the Editor of The Lancet.
Sir, —In the report of my lecture on the above subject
which you were good enough to print in your issue of
Jan. 25th, it is implied that during the first five months of
1916 10,000 Australian troops were infected.
Will you permit me to correct the statement ? The total
known infections of all troops in Egypt were 10,000. I did
not attempt to discriminate between the various sub¬
divisions of the army.—I am, Sir, yours faithfully,
Jan. 87th, 1919. JAMES W. BARRETT.
WAR DEAFNESS.
To the Editor of The Lancet.
Sir,—D r. P. McBride, commenting in your issue of
Jan. 25th on the contribution of Dr. C. S. Myers to the
study of shell shock (The Lancet, Jan. 11th), gives it as
his opinion that functional deafness is extremely rare and
that the statement—
“ Every physician of experience must have met with patients suffer¬
ing from functional deafness whose sleep has not been in the least
disturbed by the loudest noises
would have to be answered by him with a decided
negative.
I have had two cases of absolute functional deafness as
the only symptom following shell explosion, and in both
sleep was not in the least disturbed by noise.
One case is of special interest in that the patient was
tested from this point of view by Mr. Arthur Cheatle, who
failed to wake the sleeper with the loudest noises right over
his ear. The duration of the symptom in this case was
three months and I could not satisfy myself that he even
gave a flicker with the dropped-bucket test. Mr. Cheatle
gave it as his opinion that the case was functional, and
normal hearing was restored after five days’ treatment by
suggestion.
An additional interest is attached to this case in that
though at first he showed genuine delight at the recovery of
his hearing he later developed anxiety neurosis. It shows the
disposition to equivalent symptoms in hysteria and also that
suggestion, though a valuable therapeutic agent for the
removal of symptoms, is insufficient as a method of cure.
I am, Sir, yours faithfully,
E. Pridbaux,
Ewell War Hospital, Jsn. 26th, 1919.
Temporary Captain, R.A.M.C.
CAUSES AND INCIDENCE OF DENTAL CARIES.
To the Editor of The Lancet.
Sir,—I regret that Mr. Denison Pedley should have found
my letter confusing. How far the fault here rests with
him or with me I leave others to decide. Mr. Pedley seems
much concerned to prove that I have exaggerated the amount
of dental disease in this country. I am content to know
that so high an authority as Dr. Sim Wallace does not share
his opinion. Mr. Pedley’s outlook and my own regarding
the practical handling of the dental question are entirely
different. He pins his faith largely on the establishment
of “ school dental treatment centres for the children of the
elementary schools.” This is mere patehwork. Our primary
aim should be prevention. It has been shown conclusively
that dental disease in children can be reduced almost to the
vanishing point by the adoption of quite simple precautions,
and it is the plain duty of our profession to bring this
pregnant truth home to the people of this country and to do
its best to remove a national disgrace.
I understand from a highly educated native doctor that it
is a general custom with the Hindus to rinse the month out
after every meal from the time of weaning onwards. Even
a beggar will ask for water for this purpose. The care of
the teeth is with them almost a religion, and not to have
good teeth a disgrace which is felt keenly.
I am. Sir, yours faithfully.
Cavendish-square, W., Jan. 28th. 1919. HARRY CAMPBELL.
MEDICAL PRACTITIONERS AND THE
DETECTION OF CRIME.
To the Editor of The Lancet.
Sir,—T he National Council for Combating Venereal
Diseases are anxious in the public interest to secure the
enforcement of the Venereal Diseases Act, 1917.
With reference to the note under this title in your issue of
Jan. 18th we wish to draw your attention to the fact that
Dr. Otto May undertook, on behalf of the Council, to assist
in obtaining the conviction of a quack in active practice.
Though in many ways repugnant to him, he considered
the interest of the community and of the individual
sufferers as paramount, and therefore sacrificed his personal
feelings and undertook this disagreeable duty.
Dr. May was acting throughout as a representative
member of the public and not in his capacity as a medical
man. Therefore the analogy drawn in the article between
his action and that of a medical man dealing with a case of
abortion is not a true parallel. '
I am, Sir, yours faithfully,
S. Gotto,
General Secretary, National Council for Combating
Jan. 28th, 1919. Venereal Diseases.
%* We are certain that Dr. May sacrificed his personal
feelings to undertake a disagreeable public duty, and we
respect him for it. We said expressly that we did not
question that he was actuated by a sense of public duty.
But a medical man could obviously be actuated by the
same sense in dealing similarly with a oase of abortion.
The analogy which we drew was a true one.—E d. L.
PLACE AUX EMBUSQUES?
To the Editor of The Lancet.
Sir,—I n your issue of Jan. 25th Mr. A. W. Comber does
well to draw, under this title, the attention of the medical
world fin general to the action of the Birmingham Health
Committee with regard to the Birmingham Pensioners’
Hospital. This and other happenings—for example, the
scheme for priority of demobilisation, which gives the same
number of points to the man who has never been out of his
own home and to the man who has been on active service
all the time—are serious portents of what is going to occur
in the near future.
It was surely too obvious that an R.A.M.C. officer who had
been on active service, and who accordingly must know onr
soldier and his ailments at first hand, would be better qualified
to look after him than a doctor who has not had active
service experience. That, quite apart from the invitation of
the advertisement—“senior officer preferred.” Presumably
the gentleman who has been appointed will (under the
Central Medical War Committee’s scheme) shortly be called
np to replace iD the Army one of the unsuccessful applicants
for the post. May I bring this point of view to the notice of
the Central Medical War Committee?
I am, Sir, yours faithfully,
Jan. 28th, 1919. ‘ ‘ RESERVE. ”
Centenarians.— Mr. Edward P. Smart, of Spark-
ford, Somerset, celebrated the 100th anniversary of his birth¬
day on Dec. 23rd, 1918.—Mrs. Arthur Mozley, of Malvern
View, Cheltenham, celebrated the 104th anniversary of her
birthday on Jan. 22nd.
ThnLancbt,]
MEDICAL NEWS.
[Feb. 1, 1919 199
UJefcical Beta*.
Royal College of Physicians of Edinburgh,
Royal College of Surgeons of Edinburgh, and Royal
Faculty of Physicians and Surgeons of Glasgow.—
The following are the resalts of the Triple Qualification
Examinations
Third Examination.
Douglas Chiene Scotland, James Foster Cook, Lachman Singh
Ahluwalia, Arthur Henry Jacobs, Ronald MacKinnon, and Bernard
McLaughlin.
Pathology. —Sayed Chaleband Stanley Sewell Nicholson.
Materia Medica.— Perclval Charles Holden Homer.
Finat. Examination.
» Lazarus Samuels, William Francis Gawne. Lachman Singh Ahluwalia,
Arthur Kinsey Towers, Victor Albert Rankin, John Vaughan
Griffith, George Alexander Graudsoult, t^uintin Stewart. William
Brownlee Watson, Ben Cheifitz. ami Klelmrd Irving iniggle.
Medicine. —Driniel Adrian Stegmnn. Thomas Eerguson Mint'ord,
James Miller Speirs, Reginald Leslie Wright, and John Archibald
8teel Campbell.
Surge* y. —William Gibb, and John Archibald Steel Campbell.
Midndjcry .—Hassan Amin Mail war, Thomas Ferguson Minford,
Gilbert Llewellyn Stanley, James Miller Speirs, Reginald Leslie
Wright, and Sidney Hill Waddy.
Medical Jurisprudence.—Daniel Adrian Stegman, Walter Oarew,
Veeravagu Katheravel Paramanayagam, Donald Mackay, Gordon
Beveridge, and Leo Hugo Peries.
Central Midwives Board.—A special meeting of
the Central Midwives Board was held at Queen Anne’s Gate
Buildings, Westminster, on Jan. 23rd, with Sir Francis H.
Champneys in the chair. Two midwives were struck off the
Roll, the following charges, amongst others, having been
brought forward :—
Neglecting to wash the patient’s external parts with soap and water
and to swab them with an efficient antiseptic solution after the term¬
ination of the labour and during the lying-in period, as required by
Rule E.8; neglecting to remove the soiled and stained linen from the
neighbourhood of the patient as soon as possible alter the labour ami
before leaving the house, as required by Rule E. 11; neglecting to give
all necessary directions for securing the comfort and proper dieting of
the mother %nd child during the lying-in period, as required by
Rule B. 12 ; not being scrupulously clean in every way, as required by
KuleB.2; not taking and recording the pulse and temperature of patients
at each visit, as required by Rule B. 14 ; not entering records of pulse and
temperature in a note book or on a chart carefully preserved, as
required by rule E. 14, and not keeping a register of cases as required
by Rule E. 24. A child suffering from inflammation of or discharge
from the eyes, the midwife did not explain that, the case was one in
which the attendance of a registered medical practitioner was required,
as provided by Rule B. 21 ( 5 ), and when called to a confinement she did
not take with her the appliances and antiseptics required by Rule E. 3.
A meeting was held on Jan. 23rd, when a letter was
considered from the Local Government Board asking the
Central Midwives;Board to reconsider the form of the draft
rules approved at the Board meeting of Dec. 19th, 1918,
requiring a midwife to notify the Local Supervising Authority
when she has advised artificial feeding. The Board decided
that Draft Rule E. 12 a be amended to read as follows
“A midwife must forthwith notify the Local Supervising Authority
of each case In which it is proposed to substitute artificial feeding for
breast feeding.”
—The Board, having considered the appointment, for a
limited period, of an assistant secretary to the Board,
decided (a) that it is desirable to appoint an assistant
secretary with a view to his appDintment as secretary,
should the Board so determine, on the retirement of the
present secretary on Sept. 6th next; and (b) that the chair¬
man, Miss Paget, and Dr. West be appointed a sub¬
committee to consider applications and to bring before the
Board the namea of three candidates for appointment of one
of them by the Board.—The secretary reported that copies
of the draft rules regulating the payment of expenses
incurred by members in respect of their attendance at
meetings of the Board had, on Dec. 20tb, 1918, been
forwarded to the Scottish and Irish Midwives Boards for
their information, and that no comment thereon had been
received from either Board. The Board decided that the
secretary be directed to forward to the Privy Council copies
of the draft rules framed by the Board under Section 4
of the MidwiveB Act, 1918, and to request the Privy Council
to approve them.—The secretary reported that copies of the
draftrules deciding theconditions under which midwives may
be suspended from practice in penal cases had on Dec. 20th,
1918, been forwarded to the Scottish and Irish Boards for their
information and that no comment thereon had been received
from either board. The Board decided that the secretary be
directed to forward to the Privy Council copies of the draft
rules framed by the Board under Section 6 of the Midwives
Act, 1918, and to request the Privy Council to approve
them.—The Board having considered the form of certificate
to be granted to women certified by the Board by reason of
holding an equivalent certificate obtained in any other part
of His Majesty’s Dominions directed that the draft forms of
certificates as submitted by the secretary be adopted and
that they be forwarded to the Privy Council for approval.
Imperial Studies Lectures. —A course of six
ublic lectures, arranged in connexion with the Imperial
todies Committee of London University, will be given at
King’s College, Strand, W.C., on Wednesdays at 5.30 p.m.
The first lecture is by Professor W. D. Halliburton on
Physiology and the Food Problem, with Sir Alfred Keogh in
the chair. The other lectures will be announced from week
to week in the Medical Diary. Cards of admission (free) on
application to the lecture secretary.
Medical Inspection of School Children.— At
Exeter last week a parent summoned a school medical
officer and the school nurse for assaulting his daughter,
aged 11 years, by conducting a medical inspection of the
child’s eyes without his consent. The summons was dis¬
missed. Another summons was then proceeded with, when
the parent was charged with neglecting to have the child’s
eyes attended to. The defendant suggested that he should
be allowed to take the girl to an ophthalmic surgeon and to
provide spectacles if necessary. The bench of magistrates
agreed to this proposal and adjourned the case for a week.
Royal Institution.— On Tuesday next, Feb. 4th,
at 3 o’clock, Professor J. T. Macgregor-Morriswill deliver the
first of a course of two lectures at the Royal Institution on the
Study of Electric Arcs and their Applications. On Thursday,
Feb. 6th, Dr. W. Wilson will give the first of two lectures on
the Movements of the Sun, Earth, and Moon, illustrated by
a new astronomical model. The Friday evening discourse
on Feb. 7th, at 5.30, will be delivered by Professor J. G.
Adami on Medical Research in its Relationship to the War ;
on Feb. 14th by Professor Cargill G. Knott on Earthquake
Waves and the Interior of the Earth.
The late Mr. W. A. E. Hay, M.R.C.S., L.S.A., J.P.
—William Alfred Edward Hay died at his residence, West
Allington, Bridport, on Jan. 18th, in his 66th year. The
deceased, who belonged to an old Dorsetshire family, had
been in practice for many years in Bridport. He held
several appointments and was medical officer of health for
the Bridport rural district. He was formerly surgeon-major
in the 1st Y. B. Dorset Regiment and was a justice of the
peace for the borough of Bridport.
Royal Medical Benevolent Fund.— At a
meeting of the committee, held on Jan. 14th, 17 oases
were considered and £175 voted to 14 of the applicants. The
following is a summary of some of the cases relieved:—
Daughter, aged 50, of M.B. Loud, who practised in Staffordshire and
died in 1885. Loss of income through bad investments. Bad health
will not allow applicant to work. Only income 1C>\ a week from a
nephew and help from the Guild. Relieved four times, £40. Voted
£12 in 12 instalments.- Widow, *gfd 70, of L.lt.C.P. A S. Irel. who
practised In Essex and died in 1846 . Applicant left without means
and lives with a married Ron who has a large family and is unable to
help his mother. Pays 3x. per week rent. Only income an Epsom
Pension of £30. Relieved seven times, £84. Elected to an annuity of
£20.—L.lt.C.P. A S. Kdin., widower, aged 61, who practised at Old
Kirkpatrick. Applicant suffers from spastic paralysis. Has one son
who allows £50 a year ; other income £20 from anothercharity. Kent
*£26 10*. Relieved 14 times. £ 168 . Voted £12 in 12 Instalments.—
Daughter, aged 65. of M.l). Kdin. who practiced at Ealing and died in
1873. Applicant, along with two sisters, endeavour* to make a living
by taking in paying guests, but finds U difficult to me-t expenses
Other Income: dividends, £46; from relatives, £30; rent£40. Wants
help to provide coal. Relieved three times, £35. Voted £10.—Widow,
aged 50, of L.S.A. Load, who practised in London and died in 1911.
Was left with two young boys, now aged 14 and 16 yean. Precarious
health prevents applicant from doing any permanent work. Sister-in-
law allows 30v. per week. Kent £18 a year, and £18 paid for insurance
for children. High cost of living makes it impossible for applicant to
manage. Relieved three times, £25. Voted £10.—Wife, aged 52, of
L.R.C.P. Irel., separated from her husband since 19(5. Had to bring up
three children, now aged 18 to 23. the youngest, a son, in the Army.
Other children help when possible. Has a pension of £21 from the
R.U.K.B.A. Has done some work at a V.A.I). hospital, hut this haa
now finished. Is suffering from an eye trouble. Relieved five times,
£50. Voted £12 in 12 instalments.—Widow, aged 53, of M.R.C.S. Eng.
who practised at Bex hill and died in 1912 Has two children, the eldest
24, w'ho is a clerk, not living at home, and the youngest daughter, aged
14 years, at St. Anne’s School, and has to be kept during the holidays
and provided with clothes. Applicant has post as companion, at £z0
r annum. Relieved four times, £40 Voted £10 in two instalments.—
idow. aged 38, of M.R C.S. Eng. who practised at Swansea and died
in 1914. Applicant lives with her mother, who is unable to keep her.
Only child, aged 10. at St. Anne’s School, but 1ms to bo kept during the
holidays and clothed. Applicant’s health is bad, ami she is unable to
work. Helped by the Guild. Relieved four times, £48. Voted £12 in
12 instalments.—Daughter, aged 66, of M.R.C S. Eng. who practised at
Watford and died in 1879. Owing to ill-health unable to work. Income
from property £26 ; R.U.K.B.A , £26 ; and occasional help from friends.
Rent 3s. per week. Relieved 12 times. £135. Elected to an annuity of
£10. —Daughter, aged 68. of L.R.C.S. Kdin. who practised at Liverpool
and died In 1893. Applicant endeavours to earn a living by letting
rooms, but owing to the high cost of living finds it impossible to meet
expenses. Health has been bad recently. Rent £25 per annum. Has
received about 16s. per week by letting rooms. Relieved twice, £17.
Voted £12 in 12 instalments.
Subscriptions may be sent to the acting honorary treasurer,
Dr. Samuel West, at 11, Chandos-street, Cavendish-square,
London, W. 1.
200 The Lancet,] APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS.
[Feb. 1,4-919
Jan. 26th was observed in Bristol as Hospital
Sunday.
In the Governors’ Hall at St. Thomas’s Hospital,
to-day (Friday, Jan. 31st), at 4.30 p.m., Major-General Cnthbert
Wallace, G.B., G.M.G., will deliver a lecture on the Surgical
Work of a Casualty Clearing Station.
The King of the Belgians has conferred the
Chevalier de l’Ordre de Leopold upon Dr. A. George
Bateman, of London, for services rendered to Belgium
during the war.
South Devon and East Cornwall Hospital,
Plymouth.— As a result of the Hospital Sunday collections
on Oct. 27tb, 1918, the sum of £623 was raised for the funds
of this hospital.
Advisory Committee on Anthrax.— The Home
Secretary has appointed an advisory committee to deal with
the establishment of atrial disinfecting station as recom¬
mended by the Departmental Committee on Anthrax, and
with other measures of protection against accidental infec¬
tion. The secretary of this as of the previous committee
is Mr. G. E. Duckering, one of H.M. Inspectors of Factories.
Address : 72, Bridge-street, Manchester.
The late Dr. B. W. Cherrett, op Nairobi.— Mr.
Bertram Walter Cherrett, M.B , B.S. Lond., died at Nairobi,
British East Africa, of influenza, on Nov. 4th. Trained at
St. Bartholomew’s Hospital, London, he qualified in 1906,
and for eight years past had been medical officer of health
to the Protectorate. Known all his life as a cheery worker,
the Nairobi Leader speaks of him as the type of British
official imbued with the “ true spirit of public service.”
The Swiney prize of the Royal Society of Arts
for 1919 has been awarded, as was announced in The Lancet
last week, to Dr. C. A. Mercier for his book, “Crime and
Criminals,” published in December, 1918. The prize iB a
silver-gilt cup designed by Maclise, and of the value of £100,
and money to the same amount. It is awarded every fifth
year to the writer of the best work on jurisprudence
published since the last award, being given alternately for
general jurisprudence and for medical jurisprudence. The
prize was founded in 1844, and in the 75 years of its existence
has been awarded sometimes to very* distinguished men.
Dr. Mercier won the 8winey prize in 1909, and this is the
first occasion on which it has been awarded to the same
candidate for the second time.
Death of Mr. G. V. Langworthy, M.R.C.S.,
L.M. Eng., L.8. A.—George Vincent Langworthy died recently
at bis residence, Modbury, Devon, in his 83rd year. He was
the third son of the late Mr. W. F. Langworthy, surgeon, of
Modbury. Mr. Langworthy, who qualified in 1864, practised,
for many years in Modbury with his brother, Mr. W. F.
Langworthy, but had retired from active work for more
than 20 years. He had an extensive practice, and was highly
esteemed in the district.
Scottish Poor-law Medical Officers’ Associa- * 1
■non.— In their report for the year 1918 the committee state
that practically no correspondence had taken place with
regard to the grievances noted in their annual report for
1917, and that up to the present time the offer of the
secretary of the Association to accompany a deputation of
the Highland members to bring their grievances before the
Highlands and Islands Service Board had not been accepted.
The gri^ances referred to were ,the unsatisfactory condi¬
tions as regards income, area, and facilities attaching to the
work of the medical officers in the crofting counties. During
the year a circular had been sent to parish councils asking
for an increase in salaries, and although the total number of
increases granted was not known, the secretary reports that
he has knowledge of increases of a rise of *25 to 50 per
cent, reported in more than 50 cases.
Special Examinations for the Primary F.R.C.S.
Eng.—T he Council of the Royal College of Surgeons of
England has decided to bold a special primary examination
in anatomy and physiology for the Fellowship for surgeons
who hold or have held commissions during the war and have
done commendable surgical work during their service. The
examination will be partly written and partly viva voce;
the questions asked will have a direct bearing on practical
surgery and will not include morphology, embryology,
histological or chemioal methods, or practical examination
in the use of the apparatus of the physiological laboratory.
The first of these special examinations is to be held early in
May and the second in November of the current year. A
third examination is planned for some time in 1920.
Entrance will be permitted only to one such examination.
Candidates must be Members of the College or graduates in
medicine of a university recognised by the College. Further
particulars may be obtained from Mi*. F. G. Hallett, at the
Examination Hall, Queen-square, London, W.C. 1.
^ratals.
Brash, Edward John Yei.verton, B.A., U.B., B.C. Cantab., L.R.C.P..
M.B.C.S., has been appolntei Public Vaccinator for Bxeter, and
Medical Officer for tbe No. 1 District.
Coates. Vincent Middleton, L.K.O.P., M.K.C.S., Pathologist at the
Salonica Military Hospital.
Hodder, A. E., M.B., B.C., Certifying Surgeon under the Factory and
Workshop Acts for the Stafford No. 2 District of the County of
Stafford.
McMurray, A., F.R.C.S., acting Assistant Medical Officer of Health,
Johannesburg.
Reynolds, Francis Mortimer, M.B., C.M. Bdin., Medical Officer of
Health for 8eaton (Devon).
Riggall, Robert M., M.R.C.S. Bng., L.R.C.P.Lond. A Bdin., Burgeon
Lieut.-Commander R.N., Medical Officer to the Clinlo of Functional.
Nerve Disorders under the Ministry of Pensions.
Uacanrws.
For further information refer to the advertisement columns.
A In wick 1 nfi rmary .— H. 8. £150.
Bedford County Hospital .— Res. M.O. £150.
Birkenhead Btrough Hospital — Jun. H.S. £170.
Birmingham Corporation Pre-Maternity and Infant Welfare Work.—
Female Doctor. £350.
Birmingham General Hospital.— Vacancies on Rea. Staff.
Bir mingham, Queens Hospital .— Hon. S.
Bueuos Aires. British Hospital.—Senior B.M.O. and Asst. B.M.O.
£500 and £450.
Cardiff City. — Female Asst. M.O. £350.
Chester Royal Infirmary.— H.S. £200.
Dcronport Royal Albert Hospital .— Res. H.S. £200.
Edmnntnn Infirmary .—Asst. M.O. £1 per day.
Folkestone. R u/al Victoria Hospital —H.S. £150.
Glamorgan County Council .— Inspection of Children in Public Ele¬
mentary Schools.— Three M.O.’s. £400.
Govan District Asylum, Cardonald, Glasgow.— Sen. Asst. M.O. Also
Jun. Asst.
Harrogate Infirmary.— H.S.
Jsleworth Infirmary.— Asst. M.O.’s. £300 and £250.
Italian Hospital.— H.S. £160.
Johannesburg, South African School of Mines and Technology.—Pro-
feasors of Anat. and Pnysio. £1000 in each case.
Kingston-upon-Thames Borough Education Authority.— School M.O.
£300.
Leeds General Infirmary.—"Res. S.O. £150. Res. Aural O. £100.
Oph. H.S. £50. Rea. M.O. £60. Also Two H.S. and Two H.P.
London Homeopathic Hospital, Great Ormond-street and Queen-square,
Bloomsbury, W.C .—Clin. Path, and Bart. £200.
Norwich. Norfolk and Norwich Hospital.— Fourth Res. Surg. O. £200.
Portsmouth Corporation Mental Hospital.— Jun. Asst. M.O. £250.
Portsmouth Workhouse Infirmary , Workhouse, and Children’s Home.—
First Asst, M.O. £*00.
Queen’s Hospital for Children. Hackney road, Bethnal Green, E. —Asst. P.
Royal National drthopwlic Hospital.— Res. H.S. £100.
St.' Bartholomew's Hospital.— Kefiaci ion Arats. One guinea per session.
St. Mark's Hospital for Cancer, Fistula, and Other Diseases of the
Rectum. City-road, Imndon. E.C. —H.S. £250.
Smethwick County Borough. — M.O. EL £800.
South London Hospital Jo? Women .— Female Asst. Path. £160.
Southport General Infirmary.— Jun. H.S. £5 5s. per week.
Tewkesbury Union.— M.O. £55.
University of London. —Examiners.
Warwickshire County Council. —Asst. M.O.H. £400.
Western Ophthalmic Hospital, Marylebone-road, N. IF.—Vacancies on
Medical Staff.
BVtff Ham Union Sick Home, Forest-lane, Stratford, E.— Temp. Bes.
Asst, M.O. £6 &«. per week.
Westmorland County Council.—Verna}* Asst. M.O. £400.
Windsor, King Edward VII. Hospital.—Anat.. Hon. 8.
The Chief Inspector of Factories, Home Office, S.W., gives notloe of
a vacancy for a Certifying Surgeon under the Factory and Workshop
Acts at Hitch! n.
$tri|;s, Carriages, art geatjjs.
BIRTHS.
Bate. —On Jan. 28tb, at Hove, the wife of Captain A. G. Bate,
R.A.M.C. (T.F.), of a daughter.
Collyns.— On Jan. ICtb, at Kampala, Uganda, the wife of John
Moore Collyns, M.B., Colonial Service, of a Bon.
McMillan.— On Jan. 19th, 1919, at Dublin, Patricia (n€e Smyth), the
wife of Temporary Surgeon Kenneth H. McMillan, R.N., of a son.
MARRIAGES.
Butcher—Sinclair —On Jan. 18th, at the Church or St. Oswin, South
Shields, Walter Herbert Butcher, Temporary Surgeon-Lieutenant,
R.N., to Cecilia St. John, youngest daughter of D. Sinclair,
Brlnkburn-terrace, South Shields.
DEATHS.
Coghill.— On Jan. 24th, at Guildford, Harold Sinclair Cogblll, M.B.,
Ch.B. Edln., D.T.M. Loud. (W.A.M.S.), aged 38.
Le QussNe.— On Jan. 24th, at " Melbury, Havre des Pas, Jersey,
Edwin Joseph Le Quesne, M.R.C.S., L.R.C.P., in his 68th year.
Sawver.-O n Jan. 27th, at his residence, Haseley Hail, Hatton,
Warwick, Sir James Sawyer, M.D.Lond., F.K.C.P. Lond., in his
75th year.
N'£,—A fee of 5s. is charged Jor the insertion of Notices of Births,
Marriages , and Deaths.
The Lancet,]
MEDICAL DIARY FOR THE ENSUING WEEK.
[Feb. 1, 1919 201
SU&icitl fliarg far % tossing Meek.
SOCIETIES.
ROYAL SOCIETY, Burlington House, London, W.
Thursday. Feb. 6th.—Papers: —Mr. A. Matlock: Note on the
Blaaticlty of Metals as affected by Temperature.—Mr. W. L.
Cowley ani Mr. H. Levy : Vibration and Strength of Struts
and i ontinu'Mis Beams under End Thrusts (communicated by
Sir Bichard GUz-brook)—Mr. A. Dey: A New Method for the
Ahpolu'e Det r mi nation of Frequency (with a prefatory note by
Mr. O. V. Hainan) (communicated by Dr. G. T. Walker).
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-ptreet, W.L
Wednesday. Feb. 5th.
SOCIAL KVBNING: at 8 .30 p.M.
Sir John Blani-Sutton will discourse on “ Gizzards and Counter¬
feit Gizzards,” iWustmte i by Specimens. The Library will be open
and visitors are invited to raise and discuss any question in which
they are interested. (Tea. coffee, and smoking )
Medical Officers of the Navy, R.A.M.C., the Dominions, United
States, and the Allies are cordially invited
MEETINGS OF SECTIONS.
Tuesday, Feb. 4th.
PATHOLOGY (Hon. Secretaries—Gordon W. Goodhart, J. A. Murray):
at 8.30 p.m.
Papers:
JJr. J. A Murray: A Staining Method for Bacteria in Tissues.
Dr. Murray will also give a Demonstration of Acariasis of the
Lungs in the Macacus Rhesus.
Mr. O. A. R Nitch and Professor S. G. Shattock: Diffuse
Emphysema of the Intestine.
Wednesday, Feb. 6th.
OPHTHALMOLOGY (Hon. Secretaries—Leslie Paton, Malcolm
Hepburn): at 8.30 p.m.
Papers:
Dr. James Taylor: Changes in the Sella Turcica in Association
with Leber's Atrophy.
Dr. W Wallace j Fundus Changes resulting from War Injuries.
Mr. R. Foster Moore: A Case of Sympathetic Ophthalmitis with
• Fundus Changes.
Cases:
Mr. A. 0. Hudson: Retinal Degeneration following Intraocular
Foreign Body.
Thursday, Feb. 6th.
OBSTETRICS ANO GYNAECOLOGY (Hon. Secretaries-Comyns
Berkeley. J. 8. Falrbairn): at 8 p.m.
Discussio n :
On Reconstruction in the Teaching Of Obstetrics and Gynsecology to
Me leal Students. Speakers:—
Dr. Walter Griffitn: A General Survey or the Subjects to be Taught
and of the Methods of Teaching them.
Dr. J. S. Falrbairn : The Training of the Student from the Stand¬
point of Preventive Medicine.
Dr. Lovell Drage : The Teaching of the Student from the Point of
View of a General Practitioner.
Dr. Russell Andrews, Dr. Blaclier, and Dr. Amand Routh will also
speak.
Dr. Lap borne Smith will show “The Obstetric Helper.”
Those wishing to take part in the Discussion are requested to
aem in their names to the Senior Hon. Secretary of the Section
(Mr. Comyns Berkeley, 53, Wimpole-street, W. 1).
Copies of the Opening Papara will be available for distribution to
Intending speakers a week before the meeting on application to the
Secretary of the Society.
Friday, Feb. 7th.
LARYNGOLOGY (Hon. Secretaries—Frank A Rose, Irwin Moore):
at 4.30 p.m. ,
Cases will be shown at 3.45 p.m. by :—
Dr. Andrew Wylie, Mr. Stuart-Low, Mr. G. Seccombe Hett, Dr.
Irwin Moore, Dr. W. S. Syme, and Dr. Macleod.
RuNTGBN SOCIETY, at the Royal Society of Arts, 18, John-street,
Strand, W.C.
Tuesday. Feb. 4th.—8.15 p.m., General Meeting. Paper: Dr. F-
Hernaman-Johnson, Hon. Capt., R.A.M.O.: Protection in
Diagnostic Work: A Consideration o( the Effects of Scattered
Rays and Secondary Rays.—Lieut. W. Makower will describe
and exhibit a Langmuir Exhaust Pump.
HUNTKRIAN SOCIETY.
Wednesday. Feb. 5th.— 7 p.m.. Annual Dinner at Cannon Street
Hotel, the President, Dr. Langdon Brown, in the chair.
LECTURES, ADDRESSES, DEMONSTRATIONS, Ac.
ROYAL COLLEGE OF SURGEONS OF ENGLAND, in the Theatre'
of the College, Lincoln's Inn Fields, W.C.
Monday. Feb. 3rd.—5 p.m., Hunterian LectureProf. A. J.
Walton : The Surgery of the Spinal Cord In Peace and War.
Wm>NhSDAY — 5 p.m, Hunterian Lecture:—Prof. U. Li gat: The
Significance and Surgical Value of Certain Abdominal Reflexes.
Friday.— 5 p m.. Hunterian Lecture:-Prof. G. Taylor: Abdominal
Injuries of Warfare.
POST-GhaDUaTK COLLEGE, West London Hospital, Hammersmith-
road, W. V
MofrDAV, Feb. 3rd.—2 p.m., Medical am^Surgloal Cllnloa. X Raya.
Mr. D. Armour: Operations. Mr. B. Harman: Diseases of the Bye.
Dr. Simson : Diseases of Women.
ImcsDAY.—2 p.m.. Medical and Surgical Clinics. X Rays. Mr.
Baldwin: Operations. Dr. Banks Davis: Diseases of the
Throat, Nose, and Bar. Dr. Pernet: Diseases of the Skin.
Wbus bsda y. -10 a . m. , Dr. Arthu r Saunders: Diseases of Children. Dr.
Banks Davis: Operations of the Throat, Nose, and Bar. 2 p.m.,
Medical and Surgical Clinics. X Raya. Mr. Pardoe: Operations.
Tbursday.— 2 p.m., Medical and 8nrgloal Clinics. X Rays. Mr. D.
Armour: Operations. Mr. B. Harman: Diseases of the Bye.
Friday.—10 a.m., Dr. Simson: Gynasoologloal Operations. 2 p.m.,
Medical and Surgical Clinics. X Rays. Mr. Baldwin : Opera¬
tions. Dr. Banks Davis: Diseases of the Throat, Nose, and Bar.
Dr. Pernet: Diseases of the Skin.
Saturday.— 10 a.m., Dr. Arthur Saunders: Diseases of Children. Dr.
Banks Davis: Operations of the Throat, Nose, and Bar. Mr. B
Harman: Bye Operations. 2 p.m., Medical and Surgical Clinics.
X Rays. Mr. Pardoe: Operations.
UNIVERSITY OF LONDON, KING’S COLLEGE, AND KING’S
COLLEGE FOR WOMEN.
Course of Six Public Lectures arranged in conjunction with the
Imperial Studies Committee of the University on Physiology and
National Needs:—
Wednesday. Feb. 5th.—5.30 p.m.. Lecture I.:— Prof. W. D. Halli¬
burton : Physiology and the Food Problem.
KING’S COLLEGE HO 3PIT AL MEDICAL SCHOOL (University or
London;, at the Lecture Theatre of the Medical School, King’s College
Hospital, Denmark Hill, S.E.
Course of Four Lectures on Malaria. Microscopic specimens and
lantern slides will he shown at the two last lectures.
Friday, Feb 7th.—12 noon. Lecture II.:—Col. Sir Ronald Ross,
K.C.B., K.C.M.G.. F.R.S. Officers and Men of the Royal Army
Medical Corps are Invited to attend.
ROYAL INSTITUTE OF PUBLIC HEALTH, in the Lecture Hall of
the Institute. 37. Russell-square, W.C.
Course of Lectures and Discussions on Pnblie Health Problems under
War and After-war Conditions :—
Wednesday, Feb. 5th.—4 p.m., Mr. W. Buckley: Practical Steps
that should be taken to ensure a National Clean Milk Supply.
BOYAL INSTITUTION OF GREAT BRITAIN, Albemarle-street
Piccadilly, W.
Friday, Feb. 7th.— 6.30 p.m.. Prof. J. G. Adaml: Medical Research
in its Relationship to the War.
BOOKS, ETC., RECEIVED.
Lea and Frbioer. Philadelphia and New York.
A Text-Book of Biology. By W. M. Smallwood, Ph.D. 3rd ed. 10s. 6 d.
Livingstone, E. and S.. Edinburgh.
Hughes’ Nerves of the Human Body. By C. R. Whittaker,
F.R.C.S. Bdin. 2nd ed. 3*. 6d. *
Masson et Cie., Paris.
L’Expertlse Mentale MUltalre. Par A. Porot et A. Hespard. 4 fr.
Traite de Physiologic. Tome V. et dernier : Fonctlon de relation et
fonction de repr'Miuctlon Par J. P. Moral, profesaeur & 1’University
de Lyon, et M. Doyon, prof esse ur adjoint & la Facnlie de M&iecine
de Lyon. 25 fr.
Milford, Humphrey. London.
Destroyers and Other Verses. By Henry Head, M.D. 4s. 6d.
Murray, John, London.
Handbook of Physiology. By W. D. Halliburton, M.D. 14th ed. 16s.
National Food Reform Association, London.
Dietaries Suitable for Secondary 8chool*. Ac. By Dorothy 0. Moore,
L.C.A., and C. E. Hecht, M.C.A. Is. 3a.
Panini Office, Allahabid.
Diabetes and its Dietetic Treatment. By B. D. Basu, Major, I.M.S.,
retired. Its 1.8.
University Press, Cambridge.
Technical Handbook of Oils, Fats, and Waxes. By P. J. Freyer,
F.I C..and F. E. Weston, B.Sc. Vol. II.
University Press, Manchester. Longmans, Green, and Co., London.
Dreams and Primitive Culture. By W. H. R. Rivers, M.D. Is.
Communications, Letters, &c„ to the Editor have
been received from—
A.— Dr. F. S. Arnold, Berkham-
K. —Oapt. M. A. Kfrton, R.A.M.C.
L. —Messrs. Lawson and Co.,
sted; Dr. J. B. Adams, Lond.;
Prof. Ch. Achard, Paris ; Messrs.
Allen and Han bury s, Lond.
B. —Lieut.-Col. A, Balfour, C.M.G.,
R.A.M.C.; Major-Gen. Sir J.
Rose Bradford, A.M.S.; Major-
Gen. Sir Anthony Bowlby,
K C.M.G., K.C.V.O.,C.B.,A.M.S.;
Surg.-Gen. R. Blue, Washing¬
ton ; Board of Agriculture and
Fisheries, Lond.; Sii*J. Bland-
Sutton, Lond.
C. —Mr. A. L. Clarke, Lond.; Dr.
J. B. Christopherson, Khartoum ;
College of Nursing. Lond., Sec.
of; Dr. J. Campbell, R.A.M.C.;
Sir James Cantlio, Lond.; Con¬
joint Board of Scientific Societies,
Lond.
D. —Dr. F. W. Dobbin, Balllneen;
Mr. H. Dickinson, Lond."
B.—Dr. A Eichbolz, Lond.
P.-Dr. H. L. Flint, Mansaeld;
Factories. Chief Inspector of;
Mrs. Bedford Fenwick, Lond.
G. —General Medical Council,
Lond., Acting Registrar of.
H. —Mr. C. R. Hewitt, Lond.;
Prof. W. D. Halliburton, Lond.;
Dr. C. W. Hutt, Brighton; Dr.
J. F. Horne, Barnsley.
J,—Brevet-Major J. L. Joyce,
R.A.M.C (T.)
Lond.
M. —Mr. J. M. Martin, Gloucester;
Dr. C. A. Mercier, Parkstone;
Mr. J. W. Milne. Lond.; Rev. S.
Matthews, Dublin; Capt. W.
Mac Adam. R.A.M.C.
N. — National Medical Union, Asst.
Sec. of; Dr. J. T. Neech, Hali¬
fax ; National Council for Com¬
bating Venereal Diseases, Lond.
O. —Dr. J. Oliver, Lond.
P. —Dr M. Pettinati. Lond.
R. —Royal College of Surgeons of
England, Lond.; Dr. J. W. Rob,
Wey bridge; Capt. O. H. L.
Rixon, R.A.M.C.; Mr. D. D.
Robertson, Lond.; Dr. W. C.
Rivers, Worsboro’ Dale; Royal
Sanitary Institute, Lond.
S. —Mrs A H. Smith, Lond.; Mr.
S. T. Shovelton, Lond.; Dr.
B. W. Scripture, Lond.; Mr. W.
Scott, Bridgwater; Lieut. L.
Stamm, R.A.F.; Mr. B. G.
Slesinger, Lond.; Dr. T. H. C.
Stevenson, Lond.
T. -Mr. G. F. Tidbury, Lond.;
Sir N. Tirard, Lond.
W.— Dr. 8. West, Lond.; Mrs. K.
Warren, Lond.
Y.—Miss M. Yates, Lond.
Communications relating to editorial business should be
addressed exclusively to The Editor of The Lancet,
423, Strand, London, W.C. 2
202 Tn LANOBT,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Ebb. 1,1919
Jtotess, Comments, anfe Jnsfoers
to Correspondents.
INDUSTRIAL UNREST AND THE NEW PUBLIC
HEALTH.
At a meeting of the Royal Institute of Public Health on
Jan. 22nd, at which Lord Moulton presided, Dr. I. Walker
Hall, professor of pathology.in the University of Bristol,
delivered a lecture on Industrial Hygiene in Relation to
War Strain and Technical Development. He started from
the assumption that the eveuts of the last four years had
profoundly altered the enduring capacity of the people of
this country, and it was more than possible that some of
the present industrial unrest was due to this cause. The war
had been responsible for various degenerations of the cardiac
and vascular systems, for alterations in the pulmonary
tissues, both directly as a result of chest wounds and inhala¬
tion of poison gas, and as a sequel to widespread epidemics.
Trench fever and war nephritis had, in their turn, impaired
the renal tissues. There would consequently be a consider¬
able percentage of people unable to bear climatic change
and fatigue. Mental strain, malaria, and venereal diseases
were further factors to be taken into account, as well as the
crippled condition of many whose wounds had healed. In
view of these things we were, he said, faced by the need for
a more rigorous application of hygiene in industrial life.
Revision of the existing regulations might well be necessary,
and as a beginning a routine* attempt should be made
at estimating the man’s liability to fatigue and generally
at defining the limits of physical endurance of working
units. Medical officers of works would in future have
to pay more attention to this side of their work than to
therapeutic problems. Research would be necessary in
regard to new industries which might bring in their
train new industrial dangers and diseases. America had
reported 32 new poisons in the preparation of munitions
of war, and in tne coming days of peace workers ought
not to be subjected to the risks of such poisons until
the conditions of their harmful action were definitely
known. Proposals for increased production or lessened cost
must always be considered alongside an estimate of the
possible dangers to the health of the worker resulting from
the change. New processes before being tried on a com¬
mercial scale should all be investigated in the laboratory,
both in regard to possible ill effects on animal tissues and
with a view to prevention of these ill effects. But when all
this had been done the human factor still remained. It was
here that legal provisions might fail and the only remedy
might prove to be the conscientious discharge of his duties
by the medical officer of the factory, who would in the
coming years devote more of his time to the workers than
to the works. On the data obtained from the experimental
laboratory the doctor would be in a position to observe
closely the danger stages in all industrial processes and to
assess the precise value of precautionary measures.
Professor Hall concluded by reminding his hearers that
the habits of the working man, as of all of us, were formed
in childhood, and while these habits might be modified or
consolidated in school life, no education, however skilfully
devised, could replace the teaching of the primary habits of
body which should be taught in the home. The hygienic
status of the worker was cradled iu the training of the
child. He looked to a great crusade directed towards
raising the standards of home-life.
Lord Moulton agreed with the lecturer in tracing the
ultimate value of an industrial population to early training
in childhood, but he had found the chief hygienic difficulty
of the last four years to lie in the technical character of the
work rather than in the quality of the workmen. It was
especially difficult to make working men appreciate the
importance of hygienic rules to be observed by themselves
or recognise that neglect of cleanliness might led to illness
and possible death. The colossal demand made on the
worker by the chemical side of munitions work had not led,
in his opinion, to any undue strain. To find evidence
of overstrain it was rather to the mechanical side of
munitions manufacture that atteutiou should be turned.
While competition was ever becoming keener the working
classes themselves were likely to take care that the condi¬
tions of work did not become more trying. To those who
were not content with their existing level and prospects an
increasing temptation arose to over exert themselves. The
danger in the future was far greater to this exceptional
class than to the ordinary worker, whose future was
clouded rather by the danger of carelessness in health and
manner of life.—Miss Anderson welcomed the lecturer’s
recognition that men and women were highly endowed
agents rather than mere instruments in industry. The
service rendered by warfare work to industrial organisa¬
tion had already been proved.—Dr. T. M. Legge concurred
with the lecturer in the desirability of investigating
processes technically in the laboratory before they were
introduced into the works.—Dr. E. L. Collie remarked
| on the incompleteness of our medical knowledge of
! industrial life at the beginning of the war. In the past
medical practice had dealt mainly with agricultural pur¬
suits, the doctor living among his patients and knovnng
accurately their conditions of work and consequently the
{ >roper methods of treatment. Whatever medical know-
edge a practitioner possessed-he could not give the same
useful advice to his industrial patients that his grandfather
gave to his agricultural patients if he was totally un¬
acquainted with their conditions of daily work. Here was
an entirely new field of preventive medicine opening before
them.
THE HYGIENIC REPAIR OF THE ROADS.
It has been freely stated that something like a sum of
£40,000,000 will be required to restore to qur roads, badly
broken by heavy military traffic, a uniform surface.
Our road authorities are, uo doubt, seriously exercising
their minds as to the best way this work of repair can be
done. For the ordinary traffic of the country the dress¬
ing of the surface of roads with tar and grit seemed
temporarily at least to suppress the dust nuisance created by
fast motor vehicles. Such a dressing appeared to be a cheap
and ready form of asphalting the surface, and the way tar
and grit subsequently set and hardened on the top suggested
that a definite and unexpected combination took place. In a
communication we have received from Dr. J. A. Calantar
he points out also that the basic fault of roads treated in
this way (except wood-paved ones) is that they are grouted
with a very large proportion of whinstone sand, gravel,
granite chips, and other earthy, gritty substances which,
in time get pulverised by traffic and give rise to dust
and mud, and by this circumstance quickly wear away. His
prosposal is that all these earthy substances should be
completely excluded from road surfaces, and itf their place
some fibrous substances, such as sawdust, should be used in
combination with hot bitumen or pitch and creosote or
other non-drying oil well amalgamated and laid on the
roads, as ordinary asphalte is done. He points out that saw¬
dust cannot be pulverised ; it absorbs the hot bitumen or pitch
and oil into its innermost fibres, which get matted together
and when cold present a very hard, tough mass, which can
neither be broken nor made into powder. Such a surface,
he maintains, will be water-tight, not liable to decay, free
from dust and mud, still be resilient, not cold to the feet,
noiseless, and more durable than asphalted roads. The
effects of traffic ou such a surface are anticipated to make it,
if possible, more dense, because the particles, being adhesive,
will cohere together still more strongly under the pressure,
instead of getting pulverised as the road surfaces are now.
Such claims sound attractive, and if based on actual practical
trials should receive the careful atteutiou of our road
authorities. Objection as to the contamination of rivers,
streams, and lakes is urged, and a good deal turns on the
question as to whether sawdust is available in anything like
the quantities or the low prices that prevail lor granite
chippings.
COLONIAL HEALTH REPORTS.
Malt a .—Accord i n g to the Blue-book for the year 1917-18,
the civil population on April 1st last was estimated at
224,'323, an increase on the previous year of 582. The birth¬
rate for the year aras 29 81 per 1000, and the death-rate
26 22 per 1000. The death rate among children under 12
months was 293 51 per 1000 births, as against 253*80 in the
previous year; that of children under 5 years was 128*35
per 1000 of the population at that age, as compared with
105-80 in the previous year. 'There were 1496 marriages, as
compared with 1274 iu the previous 12 months. Small out¬
breaks of enteric and measles occurred during the year, and
a considerable epidemic of whooping-cough. Tnere was
also an increase in the number of cases of pulmonary tuber¬
culosis. Apart from these circumstances, the general state
of health of the two islands may be regarded as satisfactory.
The number of goats and sheep found infected with
undulant fever and destroyed was 287 out of a total of
5044 that were examined. 4011 persons were successfully
vaccinated. The mean temperature for the year was 64 8, as
compared with 66-3 in 1916-17. The total rainfall was
17 71 inches -1*98 more than in the previous year. The
number of patients admitted into the hospitals of Malta and
Go/.o was 3610, and 148,116 persons were attended by the
district medical officers at the Government dispensaries or
at their own residences. The number of inmates id the
leper hospital on March 31st, 1918, was 98, as against 114 at the
end of the previous year. Since the last annual report, it
has been found possible to dispense with many of the
hospitals which had been opened to meet military require¬
ments during the earlier stages of the war.
Cioix de Guerre wonld be glad to know of a print or
photograph of Saint Luke suitable for the centre light of a
stained glass window to be erected in memory of a medical
man.
THE LANCET, February 8, 1919
% Jctturc
ON
GIZZARDS AND COUNTERFEIT GIZZARDS
Delivered at the Royal Society of Medici no on
Feb. 5th , 1019,
By Sir JOHN BLAND-SUTTON, F.R.C.S. Eng.,
SURGEON TO THE MIDDLESEX HOSPITAL.
It is a simple lesson in anatomy to watch a cook gut a
fowl, open the gizzard, wash out the stones, and after turning
it inside out she skewers the gizzard under one wing and the
liver under the other. The bird is then ready for the front
of a fire or the inside of an oven. Boys who have watched
the trussing of fowls learn from this simple lesson that cocks
and hens are not always gathering grain when they diligently
peck about the barn-yard. They pick up also small stones.
An inquisitive boy asks: Why do birds swallow stones ? and
in this way learns the relationship between the absence of
teeth in birds and the need of a gastric-mill for grinding the
hard seeds they swallow.
Structure and Function of the Gizzard.
The stomach of most birds consists of a proventriculus,
which is glandular, and the gizzard, or grinding portion,
which has thick muscles and a hard lining. The muscularity
of the gizzard and the thickness of its lining depend entirely
on the nature of the food, in the same way that the skin
covering the palm of the hand varies with occupation.
John Hunter experimented to find out the nature and use
of the gizzard. The gull, a fish and flesh eater, has a thin-
walled gizzard, but when fed on grain the walls thicken and
the gizzard resembles that of a grain-eating bird. Hunter
also noticed that when the gizzard is working the noise of
the grinding can be heard if the ear be placed on the side of
the fowl—a simple and curious lesson in auscultation. With
metal sometimes stick through the walls. Birds that live on
fish often have the gizzard pierced with fith-bones. The
bustard is a grand bird, and at one time common inEngland»
The museum at Salisbury contains two stuffed bustards,
reputed to be the last .two examples shot on Salisbury Plain.
When the gizzards were opened they contained, among other
stones, some flint arrow-heads.
The gizzard of the ostrich is big and powerful; this bird
shows little sense in selecting objects for swallowing, espe¬
cially when confined in a menagerie—stones, glass, and
glittering objects, especially coins, which it will snatch from
the hands of children. William Hunter’s collection at
Glasgow contains the gizzard of an ostrich with a wooden
peg 3 inches long sticking through a hole in its wall. This
gizzard also contained pieces of a silver buckle. I found,
among other odd things, 49 bronze coins and a fourpenny-bit
in the gizzard of an ostrich that had long been in the
Zoological Gardens, Regent’s Park. The coins were Smoothed
and some were thinned and edged like knives. An ostrich
in the menagerie at Clifton swallowed a Book of Common
Prayer and died soon afterwards. Dr. Harrison examined
the bird and found the remnants of the book. Nearly the
whole of this Prayer Book had been destroyed, but the
Thirty-nine Articles were intact; even an ostrich found them
indigestible—too many and too much.
One of the most remarkable gizzards among birds is found
in the snake-bird or darter ; it has a third compartment,,
known as the pyloric bulb, that leads into the duodenum.
(Fig. 4.) The bulb is beset with a thick fringe of hairs
serving as an excellent strainer to hinder fish-bones entering
the narrow intestine. Snake birds are voracious fish-eaters.
Hairs are sometimes found on the walls of the cuckoo’s
gizzard, but they have a different origin.
Hair balls.
The nature and direction of the movement of the stomach
have occupied the attention of many physiologists. It is a
matter of common observation that hairy animals lick their
skins and swallow the hair, which is felted by the motion of
the stomach and forms a ball. When such a ball is divided
Fig. 1.—The gizzard of a turkey, showing the central tendon and
its relation to the muscular bundles.
patience and care cocks and hens soon submit quietly to the
examination. Under the X rays the movements of the small
stones are easily seen, and without distress to the bird.
The grinding power of the gizzard in some birds is great,
for the stones they swallow are polished like pebbles. Birds
swallow hard bodies promiscuously. It is not uncommon to
find in gizzards pieces of glass and crockery, pins, needles,
hoiks-and eyes, and occasionally coins. Pointed pieces of
No. 4980
Fig. 2.—Gizzard of a turkey in section, showing the thick
muscular walls.
the hairs will be found to lie in the same direction. Hunter
noted that this effect could only be produced by a regular
motion of the stomach. He studied the arrangement of the
fine hairs that are occasionally found in the gizzard of the
cuckoo. In certain seasons this bird lives on the hairy
caterpillars of the tiger moth known as woolly bears, and
the hairs stick on the walls of the gizzard and acquire a
regular spiral arrangement due to its rotatory motion.
F
204 Thh Lancet,] SIR J. BLAND-SUTTON : GIZZARDS AND COUNTERFEIT GIZZARDS.
[Feb. 8, 1919
i
Fig. 3.—Gizzard of a fowl, with stones in *ifu.
Oat-hair Concretions.
J The Hunterian collection contains a number of con¬
cretions, irregular in form and of various sizes, found in the
great intestine of men and women who lived for the most
part in Scotland and the northern counties of England.
These concretions, large examples of which may be as big
as the fist, are dirty white or brown, smooth externally,
and exceedingly light. On section they displayed concentric
layers of a fibrous substance, felted, velvety to the touch,
and with a foreign body, such as a piece of bone, or metal,
or a fruit stone, for the nucleus (Fig. 5). Alexander Munro,
sen., had in his collection 42 examples of such concretions,
varying in size from a pea to masses 6 inches in circum¬
ference.
Oat-hair concretions puzzled many until their composition
was detected by Wollaston. He found that they consisted
for the most part of velvety vegetable fibres pointed at both
ends, and this led him to suspect that the concretions arose
from some kind of food peculiar to Scotland. Clift, the con¬
servator of Hunter’s museum, suggested to Wollaston that
the fibres might come from oats, and
on examining oats, the vegetable
material of the concretions was found
to be identical with the fine hair-like
bodies within the husks. Portions of
oat-husks and other vegetable fibres
are found in the concretions, and it
was definitely established that they
chiefly occur in persons who live upon
undressed oatmeal. A century ago
oat-hair concretions were common in
Scotland, but they are uncommon
now, and this is probably due to improvements in dressing
oatmeal and the decreased use of it as a food.
Oat-hair concretions occur in horses, usually in the caecum
and colon. The farrier calls them “ dung-balls.”
Counterfeit Gizzards. $
Outside of the bird tribe there are animals with stomachs
so modified as to resemble gizzards. The most remarkable
are the gizzard trout, the grey mullet, the crocodile, and
the ox.
The Gizzard Trout and Grey Mullet.
Hunter made a special study of the stomach of the gizzard
trout and, as lawyers would say, he stated a case which is
well worth consideration.
In the gillaroo trout, known in Ireland as the gizzard
trout, a portion of the siphonal stomach is thick and
muscular for crushing the shells of the freshwater molluscs
on which it feeds. The stomach of this trout is more
globular than that of most fishes, and endued with sufficient
strength to break the shells of small molluscs, but it can
scarcely possess any power of grinding as the whole cavity
is lined with a fine villous coat.
The grey mullet ( Mvgil ) has a stomach that approaches in
structure and function very closely the gizzard of a grain¬
eating bird. This fish has feeble teeth and lives on minute
organisms mixed with sand. The second portion of the
stomach is globular and thick; the muscular tissue is
arranged circularly and equal in thickness throughout, and
the stomach has a thick liniDg.
Hunter came to the conclusion that neither the stomach
of the gillaroo trout nor that of the grey mullet can be
justly ranked as gizzards ; they want “ a power and motion
fitting for grinding and a horny cuticle.” His opinion
reminds me of a considered legal judgment on a contentious
case. The judge discusses the facts, but does not settle the
matter.
It is not easy to frame a definition of a gizzard, and in
order to show the difficulty it will be worth while to consider
the counterfeit gizzards of crocodiles and oxen.
The Crocodile'* Stomach.
In the beginning of winter 1764 Hunter got a crocodile
5 feet long that had been in a show several years before it
Fio. 4.—Gizzard of a snake-bird. ojen ar.d shoeing the hairy strainer
In the pyloric bulb. (Muieum, Royal College of Surgeons.)
died. At that time crocodiles were rare in London. After
making a careful examination of its viscera, he writes : “The
crocodile comes nearest to the fowl in the structure of its
internal parts of any animal I know. The stomach is of the
gizzard kind and has a middle tendon on each side about the
breadth of a shilling and all the fleshy fibres pass to it.”
The stomach of one he had from Jamaica contained the
feathers of a bird and a few bones. There were stones in
the stomach, some bigger than the end of a man’s thumb,
and seeds. The Hunterian Museum contains the skeleton of
a crocodile shot in the Nile near Silsilis in 1877. The
brute, which had been a terror to the natives of a long
stretch of the valley, was 16 feet long and reputed to be
80 years old. The stomach contained three hoofs of a
sheep or goat, a donkey’s hoof, a donkey’s bridle, and an
ear-ring.
Kermit Roosevelt shot a large crocodile in British East
Africa ; in its stomach there were sticks, stones, the claw
of a cheetah, the hoofs of an impalla, big bones of an eland,
and the shell plates of a large river turtle.
A crocodile caught in fishing nets near Khartum lived for
seven months in the Zoological Gardens, Cairo. The
stomach contained two litres of quartz pebbles, fragments
of the hoofs of an ungulate, and piece of water-worn bottle
glass. (Shann.) Stones are invariably found in the
stomachs of mummified crocodiles. The presence of stones
in a stomach does not make it a gizzard , for pebbles are often
present in large quantities in the stomachs of seals and
sea-lions.
The Lancet,]
SIR J. BLAND-SUTTON: GIZZARDS AND COUNTERFEIT GIZZARDS.
[Feb. 8,1919 205
The Omasum of Ruminant x.
If the capacity to grind is the first qualification
of a gizzard, the nearest approach to one in
mammals is that compartment of the complex
stomach of ruminants known as the omasum.
The stomach of an ox consists of four compart¬
ments. The first is a large receptacle called the
rumen ; the second is a recess of the rumen and
named, from its likeness to honeycomb, the
reticulum ; this when cleaned is the choicest kind
of tripe. The third compartment, the omasum, is a
dilatation of the passage between the reticulum and
the fourth compartment, the abomasum, or rennet.
The omasum is curious and complex ; it is in a
full-grown ox of the same shape and as big as a
bladder of lard ; the walls are thick and muscular,
and the mucous membrane is arranged in folds or
leaves (Fig. 6); nearly a hundred leaves hang
from its dome, stretching from the oesophageal
opening to the entrance of the abomasum. These
folds vary in width and produce an appearance like
that of the flies of a theatre seen from the stage.
The folds earned for the omasum the name of
manyplies, and psalterium from its likeness to a
book. Butchers call it the bible.
The omasum, like the gizzard, is a triturating
organ and the details of its structure were
described by Ellenberger (1881). The leaves
near the entrance are beset with long papilla;
resembling the teeth of a harrow, and hinder the reflux of
food to the reticulum. Towards the abomasum the papillre
are shorter, closer set, and flattened, like the low elevations
Fro. 7.—The dory, 7eus fabcr, and the 15-spined iticklebaek.
Fig. 6.—Omasum of an ox In transverse feet ion, showing the oesopliageal
opening and the disposition of the folds. ^
on a rasp or a file. The covering of the leaves is hard,
almost horny, and resistant to dilute solutions of acids,
alkalis, and peptic juices. The walls of the omasum
contract powerfully ; grass and sodden hay from
the rumen pass between the leaves and are
thoroughly rasped by the papillie before enter¬
ing the abomasum, the true digestive com¬
partment. The larger part of the ruminant’s
stomach is like a pocket, non-digestive.
The leaves of the omasum are occasionally
transfixed by needles and pins. Hunter observed
that this was common in cows feeding in the
grass of bleaching fields, but he did not realise
the gizzard-like action of the omasum.
In culinary art few things are meaner than a
gizzard. It is only fit for a dog to eat, but to
Hunter it furnished food for thought and
became the subject of experiment. It has often
happened that observations made on appa¬
rently common things in nature have led men
to investigate some of the most profound
problems of physics, of which life is the most
complex manifestation.
Post-mortem Digestion of the Stomach.
Why does the stomach not digest itself ?
Many have asked this question. John Hunter
about 1772 discovered that the stomach some¬
times digests itself after death. His first
observation was made on a man who had been
killed by one blow of a poker, after taking a
hearty supper of cold meat, bread, cheese, and
ale. The stomach was dissolved at the cardiac
end and a considerable part of its contents lay
loose in the general cavity of the belly. The
second case occurred in a man who died after
receiving a blow on the head which broke his
skull. Hunter subsequently found another
example in a man who had been hanged.
These observations led him to procure the
stomachs of vast quantities of fishes whose
deaths are always violent, and they are at the
time in perfect health and usually with their
stomachs full. In some instances a fish will
swallow another fish and a part of it will be in
the stomach and a part in the gullet. The part
of the fish in the stomach will be dissolved,
while the piece in the gullet remains sound. In
many of the instances the digesting part of the
stomach was itself reduced to the same dis¬
solved state as the digested food. Then it
struck him that the stomach, being dead, was
no longer capable of resisting digestion.
206 The Lancet,]
DR. L. E. STAMM: MEDICAL ASPECTS OP AVIATION.
[Feb. 8,1919
Self-digest! cm of the stomach has been studied by patho¬
logists. Modem experiments prove that gastric juice is only
poured into the stomach when the material to be acted upon
makes its appearance therein. When a person dies with the
stomach empty it may be found several days after death
unaltered. If there be food in the stomach and the digestion
process in operation when the person dies, then on examining
the organ a few hours after death its coats may be found
destroyed, allowing the contents of the stomaoh to escape
into the belly.
Animals which Swallow their Prey Alive.
Hunter's observations on post-mortem digestion of the
stomach led him to experiment on digestion, and the
“pursuit led him into an unbounded field.” He discusses
the probability of live animals being digested, and at once
states, “no fresh proofs are necessary, as we eat oysters
every day.” This is no proof that they are digested alive.
Snakes sometimes swallow their prey alive. A girl whom
I knew kept tame snakes as pets. One day she took a grass-
snake and two tree-frogs in a basket to amuse her friends.
On opening the basket she could only find one frog and the
snake ; but a bulge on the snake indicated its position, so
she promptly cut off the snake’s head and released the frog
by a post-mortem coeliotomy. The frog survived delivery.
Here is another instance. Two boas, companions in the sajpe
cage in the Reptile House at the Zoological Gardens, London,
seized the same rat at 6 P. m. These snakes were nearly of
the same size. At 6 o’clock the following morning only one
boa was visible, but the officer in charge saw the tail of a
snake sticking out of the mouth of the boa. A keeper
seized the tail of one snake ; another keeper dragged on the
tail of the snake that had been swallowed and gradually
released it. An hour after extraction this boa took a rat
on its own account and in good style. What would have
happened to the incarcerated snake if it had not been
delivered is not a matter for surmise: it would have been
digested, as the following incident proves :—
Some 20 years ago a Madagascar boa swallowed a boa, its
companion boa of nearly the same size, retained, and
digested it. Two weeks later I made a search among the
pebbles at the bottom of the cage in which the survivor
lived and collected some of the vertebra belonging to the
victim. All the soft parts had been thoroughly cleaned in
the process of digestion.
1 have often thought that live animals, such as fishes,
frogs, lizards, and chameleons, when swallowed by storks,
bustards, shoebills, or secretary birds, must have an un¬
comfortable time in stomachs of their captors, and have
pictured to myself the agony of being digested alive or slowly
ground to death in a gizzard mill. At sunrise I watched
some birds fishing in a swamp of the White Nile near
Tewfikia. One of the men shot a marabou, and in its
stomach I found seven cat-fishes each the size of a sprat.
They were dead. The back of eaoh had been broken by the
powerful bill of the bird. It is a fair inference that many
fishes swallowed by birds are either killed or paralysed
before they reach the gizzard.
Fishes do not always kill the prey they swallow. A dory
living in an aquarium with a 15-spined stickleback was bold
enough, after some consideration, to swallow its spiny
companion, and for a few seconds tried hard to bear the
tickling; it was beyond his power and he vomited the
stickleback, which seemed none the worse for the adventure.
In recording this event, Hornell states that when the dory
stalks a fish the coloured bands on his sides intensify and
darken. The dorsal fin goes up and with a swift dash—the
great telescopic mouth is thrown out—and the prey is gulped.
(Fig. 7.)
The black mark on the side of the dory is, by fishermen of
Roman Catholic countries, regarded as the mark of Peter’s
thumb when he seized the fish and “ opened his mouth ” to
find the shekel wherewith to pay the tribute. (Matt. xvii. 27.)
Those who believe this tale forget that the Sea of Galilee is a
freshwater lake and the dory a salt-water fish.
Royal Institution.—A general monthly meeting
of the members of the Royal Institution was held on
Feb. 3rd, Sir James Criobton-Browne, M.D., LL.D.,
F.R.S., treasurer and vice-president, in the chair. The
chairman reported a bequest of £300 from the late Dr.
T. Lambert Hears, who was a member of the institution for
53 years.
MEDICAL ASPECTS OF AVIATION . 1
By L. E. STAMMS B.A., B.So., M.D.Lond., R.A.F.
[After taking a brief survey of the necessary physical
qualities to meet the special conditions of stress and strain*
in the air, Dr. 3tamm dealt with the mental qualities in
more detail.]
Conscious Control of the Muscles.
We must first refer to the nerve mechanisms which sub¬
serve the mental functions. We have, in the first place, th*
sense organs of sight, hearing, and touch, also the
muscular sense and sense of equilibrium. It is most
essential that each one of these senses should function in
a normal manner, and they are all tested in the course of
medical examination.
In regard to the motor mechanism, it is important that
the muscles show good tone and a power of nice control and
adjustment. Deficiency in this respect is usually charac¬
terised by the pilot instructor as “ heavy on controls.” Such
natural inherent clumsiness is a bad quality in a pilot, and
means have been devised to test for this on the ground ; but
there is another deficiency which has not received much
attention, but which I think is of some importance, and that
is “conscious control of the muscles.” A Mr. Matthias
Alexander has developed the subject, and is disposed to*
ascribe all the ills of humanity to this lack of “ conscious
control.” It is a fact, although it would be a surprise to*
most to learn it, that very few people have full conscious
control of their muscles, and it can be demonstrated in this
way : If a person is told to move a limb in any direction he
will do so, but if he be told to relax the muscles of any limb
so that you can move it in any direction he will probably not
be able to do so, and the more you ask him to try to relax
them the more rigid will the muscles become, while assuring-
you all the time that they are relaxed.
This inability to relax or inhibit muscular contraction
shows a lack of conscious control of the motor mechanism,
and is a factor of some importance for the pilot. It shows a
lack of complete rapport between the muscles and the brain
nerve centres that should control them. There is a great
difference between individuals in this conscious control or
lack of it. It is quite simple to test. The person is-
instructed to lie down on the floor and relax all the muscles
of his limbs. One of the limbs is gently raised and then let
go. If the limb is really relaxed it will, of course, drop at
once, as if lifeless. If, however, as is often the case, the
muscles are not relaxed, the limb remains in the air in the
position to which it was raised. Some are so convinced that
the muscles are relaxed that the limb remains in the air
without its possessor realising the absurdity of the situation.
Apart from the importance of the general principle of perfect
rapport between brain and muscles, this unconscious rigidity
may be responsible for a serious condition of things in the=
air in the course of training, as when a pupil loses his head
and hangs on like grim death to the joy-stick, making it
difficult or even impossible for the instructor to take proper
control.
In my medical inspections of pupils at the aerodrome I
used to test for this ability to relax and give directions
for practice to obtain a proper control of the muscles and ta
be able to relax at will. I would suggest that some such
instruction should be embodied in the ordinary physical
training.
Mental Qualities. ,
In ordinary flying a pilot of any experience controls his
machine automatically—that is to say, his sensations of
sight, hearing, and touch giving him the necessary informa¬
tion about his machine are transmitted to the nerve centres,
and the consequent muscular movements are carried out
without any interference or control from the higher centres.
But in the air circumstances are continually occurring calling
for the exercise of the higher centres connected with
decision, discrimination, judgment, in the most rapid and
definite manner. At certan times rapid action following
quick and right judgment decides his fate. Above all things,
one requires for a good pilot a mental constitution that has
the capacity to take in all the circumstances of a situation
i A paper read before the Royal Aeronautical Society at the Royal
Society of Arts on Jan. 15th, 1919.
TH B LANCET,]
DR. L. B. STAMM: MEDICAL ASPECTS OF AVIATION.
[Feb. 8, 1919 207
qnickly and correctly and make a rapid and correct decision, j
When the engine conks the experienced pilot automatically
puts the nose of the machine down and looks to his pressure
gauge, and with his conscious mind looks around and takes
in the conditions before him for a forced landing, and decides
upon his course of action. For the inexperienced pilot some
of the necessary actions, such as observation of pressure
gauge, may not be automatic, so that there is still more to
occupy the conscious mind.
For all this one requires not only a' quick and accurate
coordination between the senses and the muscles, but also
between these and the higher mental functions.
A quick coordination between the senses and the muscles
can be tested by taking the “ simple reaction time,” that is
the interval of time that elapses between a person receiving
a signal, either visual, auditory, or tactile, and his response
to the signal, in the form of some movement, such as pressing
an electric key. In my opinion, testing for this “ simple
reaction time ” is of little or no practical value for the Air
Service, because in healthy young men with normal senses
and muscles the coordination between these and, therefore,
the “ reaction time” is sufficiently quick and accurate for all
practical purposes, and in actual experience I have obtained
some comparatively slow reactions from very capable
individuals and very quick responses from some of poor
mentality. In candidates for the Air Service I do not think
these simple reaction time tests would eliminate 1 per cent,
of undesirables.
What one requires to test is the ability of the candidate to
respond quickly and accurately under conditions in which
the higher conscious mental functions of discrimination,
decision, and judgment are involved. For this purpose one
has a number of different signals, requiring different
responses, the candidate not knowing which signal to expect.
This necessitates the intervention of the conscious mind
between the perception of the signal and the motor response,
and consequently the reaction time is lengthened. The
mental ability is tested by the rapidity and accuracy of
response in proportion to the complexity of the problem
presented to the candidate.
Many forms of apparatus have been devised, but as the
interval of time is only a fraction of a second and variations
are measured in l/ 100 ths of a second some difficulty
has been found in obtaining accurate and reliable
apparatus that is also sufficiently simple for practical
purposes. With the help of Major Burgess, engineer, R. A.F.,
I have devised an apparatus which is comparatively simple
and which in practice has proved of value in testing
candidates for the Air Service. A diagram of the apparatus
is shown.
Reaction lime Apparatus.
It consists of a ohronoscope, A, which registers to
l/ 100 tb second, and is worked electrically by a hammer, If,
from a coil, C, and accumulators, D. There are four signals,
two differently coloured lights, E and F, an electric horn, G,
and an electric bell, H. The operator has a switchboard, S,
by which any one of the signals is put in the current, and the
signal is given by touching the key, K. The candidate sits
opposite the operator and places his right-hand first finger
on the brass plate, P , which is equidistant from the three
keys, Ai, K % A». The end keys, Ki and1 As, are for the
corresponding lights, and the middle key, A 9 , is for the horn
or the bell. It was not considered desirable to complicate
things to the extent of four keys. . . . .
When the operator presses his key, A, one of the signals is
given, and at the same time the ohronoscope starts. The
candidate responds by touching the appropriate key, At,
A 2 , or As, which stops the ohronoscope, and the reaction
time is read off in 1 /lGOth seconds.
The method of examination is as follows. After a short
preliminary rehearsal to acquaint the candidate with the
method of working the apparatus, the candidate is tested for
the simple “ automatic reaction time” by one signal, which
he knows beforehand. He is tested in this wav by a series
of each of the four signals. As already stated, I set no
value on these tests, but they enable the candidate to get
used to the apparatus. After testing for the simple reaction
time with each separate signal the candidate is now told
that he may get either one of the two lights, and he is to
respond by touching the appropriate keys, Ai or A». Having
done a series of ten with the two light signals, he is now
given a series with three possible signals, the two lights and
the horn, and finally a series of all four signals—two lights,
horn and bell—but for the bell for which he has previously
used the middle key, A 2 , he is now told to keep his finger on
the brass plate. This involves mental inhibition. .Each
series shows an increase in the reaction time, owing to the
increased complexity of the problem before the candidate.
Recently I have used a further series of four signals, in
which the keys previously used for the lights, each corre¬
sponding to the light on the same side, are now reversed.
This further complicates the problem and causes a farther
increase in the reaction time.
Diagrammatic Representation of the Reaction Time Apparatus.
( 2 )
27
25
32*4
34 5
40-4
46
The following are (1) the averages of 150 cases, including
pupils and instructors (good pilots) and (2) of 20 instructors
[experienced pilots), for the different tests in l/100th seconds.
The latter yield, as would be expected, appreciably*lower
figures ^
(1) Simple visual reaction (one signal) . 28
(2) „ auditory „ „ .. •••
(3) Two signal test (two lights) ... ... . 35
(4) Three (two lights and horn) ... ... ... 38
( 5) Pour ,, (two lights and twb sound signals) 44
(6) „ „ (with keys to lights crossed) ... 48
Taking the last two tests as the crucial tests of the men¬
tality of the pupil, I have found a remarkable correspondence
between the results and their capacities as flying pupils.
Having tested a certain batch of pupils, I send the names to
their instructors and ask for their opinion as to their flying
capacities and possibilities of making good pilots. Arranging
them in the order of the results from the machine, as a
general rule the top names have “very good” or “good
against them, the middle ones “ fair ” or “ average,” and the
bottom ones “ poor ” and probably “ turned down ” or sent
to “ heavier machines.”
Appended is a list of pupils examined, with the results
of the test' and the criticisms of their instructors,
from which the value of the test can in some measure be
estimated.
I should point out that with my apparatus there is a mus¬
cular adjustment involved in the movement of the fingers to
the different keys. In my opinion this is a valuable factor
as a further test to the nerve mechanism, but it necessarily
prolongs the reaction time, so that even the simple reaction
time with my apparatus is longer than the usual without
such muscular adjustment. It is quite easy to dispense with
this for simple reaction to one signal by placing the finger
ready on the key.
The Value of the Tests.
The value of the tests lies in the fact that they involve
considerable adjustment and coordination between the
senses and the muscles and at the same time call for a rapid
and accurate working of the higher mental functions of
conscious discrimination and decision, a complexity of
conditions similar to that involved in piloting an aeroplane.
Moreover, it calls for a prolonged effort of attention, and the
ability to sustain the effort is shpwn by the way in which the
candidate succeeds in keeping up his rate of response to the
end of the tests or shows evidence of mental fatigue by
sudden lengthening of the time intervals or by mistakes in
the keys.
208 Tn LANCET,]
DR. L. B. 8TAMM: MBDIOAL ASPECTS OF AVIATION.
[Feb. 8, 1919
1
2
3
4
6
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
28
27
28
29
30
31
34
36
36
37
38
39
40
41
42
31 Haphazard, W.7.
35 Very int^llfgent and quick.
35*5 *\ 120. Nervy, guts mentally.
36 Sturdy, sports, W.3.
38 Sturdy Canadian,horse-riding
39*5
39 5 All there—guts.
39*5 Says upiet by 3 Instructors.
40 No nerve physique.
41 —
42 —
42 Capable, good type.
42
42 Alert, good type.
42 —
43 Intelligent.
43 5 Sports, average intelligence.
44 —
44*5 Uptake slow.
44*5 Lethargic.
46 Dumpy.
46 ttuslcal. nervy.
46 Slow uptake, no sports, clerk.
47 slow uptake, no sports, clerk.
47 %lert—sports.
47 Nervy.
47*5 Very anxious, W. 4.
48 —
49 Windy, paralysed by horn
signal, bad type.
50 —
50*5 Bank olerk, not robust.
60*5 Bright; guts.
60*5 -
52 Slow bnt good type.
52 -
52 Sturdy—rough and ready.
52*5 slow and dull.
53 Nervy, sick on stunting.
55 Haavy—dull.
55 5 Dull and windy.
57
75*5 Mentality very poor.
Good, lacks judgment.
Very good - now instructor.
Fair—nervy, drinks too muoh.
Good but Blow.
Good, quick, guts.
Average.
Good—plenty of guts.
Poor, tio guts, gets sick.
Average.
Very good; steady.
Go«»d.
Extra good.
Average.
Very good—now instructor.
Average, just started flying.
Good.
Pair—guts.
Average.
Good out silly.
81ow but solid.
Average, slow.
Pair.
Average.
Average, slow learning.
Good.
Poor—windy.
Average, persevering.
Poor, sent to heavier machines
Poor—windy.
Average, large flying
experience.
Average.
Good—lots of gut8.
Poor. ? Windy. To be turned
down.
Slow, but will make good.
Pair.
Pair—solid —heavy-handed.
Average to poor.
Poor.
Poor, sent to heavier machines
Poor, sent to heavier machines
Poor.
Hopeless.
Plight Group No. II.
Good: previous flying expe¬
rience.
Good.
Very good.
Good—guts -keen.
Very good.
Good.
Good.
Good but objectionable.
Average.
Average, perseveres.
Very good—now instructor.
Good.
Good, slow learning.
Very good and keen.
Heavy handed; to be turned
down
Poor and slow.
Very good, steady and keen.
Go«>d but windy.
Average, rather slow.
Gooi but Blow learning.
Good but slow lea ning.
Keen, lacks judgment, windy.
Average, keen, guts.
Average, keen, guts.'
Average but slow.
Good.
Good.
Good and very keen.
Average to poor.
Average.
Average.
Good guts—slow learning.
Average—windy.
Slow—improving.
Poor—windy.
Poor but guts.
Very slow ; to be sent to
heavier machines.
Average.
Hopeless, turned down.
Poor - very slow.
Average.
Very poor—turned down.
Poor—neavy handed.
Average—guts.
Average—gats.
Poor.
Poor—* low.
Plight Group No. III.
No.
4-slgual
test in
1/100 sec.
Remarks of M.O.
Instructor's remarks.
90
34
Alert—bright.
Very good.
91
35
Average
Average, not keen.
92
58
Canadian, good type, sports.
Very good.
93
38
Good type.
Very g od.
94
38
—
Average.
95
39
M.A. Good type.
M.A. Rather slow in uptake.
Very good—now instructor.
96
40
Very good.
97
40
—
Poor—Inattention.
98
40
M.A. Alert.
Good.
99
42
Good type—sports.
Very good.
100
42
Windy.
Intelligent, bat no guts.
101
42 ,
Artistic. M.A.
Good,
102
43
—
Good.
103
43
—
Good.
104
43
—
Good.
105
43
—
Fair, lades confidence.
106
45
Good type—bright.
Good.
107
45
No physique—windy.
Poor, windy and sick.
108
45
—
Average to good.
109
45
Alert and bright, good phy¬
sique.
Average to good.
110
46
Rough type.
Average to good.
111
46
—
Good.
112
46
Canadian, rather stoHd—guts.
Good.
113
47
Canadian, sports, M.A.
Good, bnt very slow.
114
47
stolid, but gu s.
Good—guts.
115
47 .
Russian, Intelligent.
Average.
116
48
—
Average.
117
48
—
Average.
118
48
Alert—guts.
M.B. Slow in uptake.
Average.
119
1 50
Average.
120
60
—
Average.
121
50
Slow-stolid.
G>od, guts.
122
Ml
—
Poor.
123
52
Too talkative and plausible,
windy.
Average—windy.
124
52
Bright and intelligent.
Average.
125
52
—
Average.
126
52
—
Average.
127
62
Good type Canadian, sports.
Average.
128
53
—
Average.
129
54
—
Poor.
130
54
M.C.
Average to poor.
131
54
M.C., heavy.
Poor.
132
65
—
Poor.
133
56
Haphazard, M.C.
Average.
134
56
Rather heavy but good type.
Average stow but solid.
135
56
Feeble mentally A physically.
Average to poor.
13S
63
Poor type.
Average to poor.
137
63
—
Average.
138
66
Slow but sturdy, horse-riding
Average to poor, very slow.
Poor - very slow.
139
68
Charterhouse School, bnt
slow, heavy.
W. = mistakes in keys. M. = mentality. A, good. B, average.
C, poor. Where not stated mentality is average.
Over and above everything else there is the “ will ” factor
to be taken into account. This may act in at least two
different ways. It may be negative. Then the results of
the tests will not represent the best that the candidate can
do. Or it may be very positive. It may be exercised to.
sach an extent that the candidate exceeds for a time his
normal power of reaction. In this case the excess of his
efforts usually shows itself by mental fatigue setting in
before the tests are finished, and he is unable to keep up the
pace he has set for himself. All these variations are very
useful to observe in forming an estimate of the candidate’s
mental constitution and capacity.
I would, in fact, claim for the apparatus that it not only
gives figures of some value for estimating the mental capacity
of a candidate for aviation, but that it affords a means of
employing a candidate in a way which gives considerable
opportunity of making mental notes in regard to his
intelligence and personality, by the manner in which he
tackles the machine. Some tumble to the game at once and
show a remarkably quick adaptability, whereas others are
equally slow in picking up the idea, but may warm up as one
proceeds and give quite a good account of themselves in the
final tests. Some are light in touch and accurate ; others
heavy and clumsy, so that they often miss the keys and
almost break them when they tooch them. I have myself
been surprised in dealing with pilots personally known to me
to observe how the machine seems to bring out and record
their personality, and especially their flying personality.
There appear to be two good but different types of mentality
which react differently to the apparatus. In the one the
reaction times are very quick, but in cutting down the time
allowed for discrimination to the utmost io the final tests
several mistakes may be made. In the other good type the
Tbs Lancet,]
DB. L. S. STAMM: MEDICAL ASPECTS OF AVIATION.
[Feb. 8,1919 209
reaction times are appreciably longer, perhaps even above the
average, bat the signals are responded to with absolute
aocaracy. The flashy, crack scout pilot shows the first type
oi reaction, while the steady careful pilot is characterised by
the Becond type of reaction.
Any flying man may say, “ These tests may be very good,
bat even if a man has ever such quick discrimination and
judgment he is no use as a pilot unless he has guts. ” This
brings us to the second important mental factor—the
emotional.
Emotional Stability.
We can distinguish two extreme types—one in which dis¬
turbance of these centres, by some emotion, whether that of
fear, anger, sorrow, or joy, causes a most profound effect
upon the rest of the nervous system, resulting in rapid heart
action and other disturbances of the circulatory system,
rapid respiration or temporary stoppage of same, tremors of
the muscles, and an upset of the digestive system; and all
this bodily disturbance may be accompanied by an inhibitory
effect upon the higher nerve centres, so that the processes of
thought, judgment, discrimination, and action are paralysed.
In such a type it does not matter a straw whether under
normal conditions the individual can think, decide, and act
quickly or slowly, because when he is emotionally disturbed
by, say, impending danger his mental processes are para¬
lysed and his bodily functions are so disorganised that his
machinery is out of control. In the other type the emotional
oentres are so stable that no such disturbances to the rest of
the machinery take place, even under the most trying con¬
ditions. There may be, and almost certainly is, some
activity of these emotional centres set up, but this results in
a stimulation of the rest of the mechanism, so that his
powers of thought and action are actually increased.
One has here a striking analogy between the effect of the
emotional centres upon the rest of the nervous system and
that of drugs ; all drugs such as alcohol, opium, and the
anaesthetics that have the power of affecting specially the
nervous system first stimulate it to greater activity and then
paralyse it. If the dose is small the effect is chiefly that of
stimulation, and the period of stimulation may be of some
duration, but if it be large the period of stimulation is very
short or non-existent, and the chief effect is that of paralysis.
The difference in emotional effect is again exemplified in
artistic performers. In some the emotional disturbance of
fear is so great that they are unable to perform in public.
In others the emotion serves as a stimulus to help them to
do their best.
It is obvious that the individual who is liable to such
serious emotional disturbances or, in the language ^of the
Service, liable to get the “wind up,” is constitutionally
unfitted for work in the air. And here I would point out that
such a person is not necessarily a coward in the ordinary
acceptation of the term. The condition is constitutional.
He may have the mental “guts,” the will-power to force
himself to incur any risks. He may have proved himself an
excellent infantry officer and go into the Air Service with
all the desire and determination to win laurels by bringing
down Huns in the air, but when he finds himself in the
position of danger that he has voluntarily incurred he is
handicapped by these emotional disturbances and is not
likely to do the best for himself.
Testa for the Emotional Factor.
There are, of course, many intermediary conditions
between the extreme types I have depicted, with a certain
average, but it is most important that we should be able to
eliminate at least individuals in whom the tendency to
severe emotional disturbance is likely to manifest itself.
Various tests have been devised, the principle of which
consists in trying to arouse the emotion of fear by some
sudden and alarming noise, such as a pistol shot, and
testing the bodily reactions, such as increased heart action,
muscular tremors, Ac. The artificiality of the conditions
somewhat vitiates the results.
I have found that the - pulse-rate under ordinary medical
examination is a very fair guide to detect the “windy”
type. People who manifest their uneasiness at coming
before a doctor for examination by a rapid pulse, which does
aot settle down in spite of every effort to put them at their
®**e, prove by that fact that there is a lack of control of the
aerve mechanism of the vital centres, that there is an
Instability and liability to serious disturbances by the emotion
of fear, and they belong to the “windy” type. This
instability does not appear to be in the vital centres them¬
selves, but in the higher nerve centres controlling them,
because such individuals respond to the ordinary physical
test in a normal manner. The manometer test, the exercise
test, show a perfectly normal acting mechanism ; it is the
rapid pulse of emotional disturbance.
Then there is a typical facial expression which one gets
well acquainted with in carrying on this work. It consists
in a furtive, apprehensive look, as if always expecting some¬
thing unpleasant to happen, with a certain look of indecision
and uncertainty, in marked contrast to the straight, direct,
decided expression of the crack fighting pilot. One cannot
say that an amount of “ windiness ” above the normal may
not be present without this obvious expression, but when it
Is well marked I should have no hesitation in throwing its
possessor out as undesirable for the Air Service.
It has been found that the bodily expression of an
emotion owing to the disturbances in the circulatory system
causes a deflection of a sensitive galvanometer proportional
to the disturbance, so that this would appear to offer a
means of comparing the extent of emotional instability in
different persons. The chief difficulty lies in artificially
producing the conditions necessary for calling forth the
emotion. To some extent my apparatus is a test of an
emotionally nervous instability, because in a highly nervous
person the ideal of being examined in this way tends to set
a condition of stage fright, and I have had cases in which
the startling noise of the horn has shown a paralysing effect
by causing a pronounced lengthening of the reaction time to
this signal as compared with the other signals. But the
apparatus is by no means a satisfactory test for the
emotional factor, for in actual practice this emotional
factor has been the chief disturbing influence in the results
of these tests ; pupils giving good results with the apparatus
may be marked “poor ” by the instructor because they are
“windy,”and others showing long reaction times may be
marked “good” by their instructor because they have
“guts”l Very frequently, however, 1 have also detected
these qualities by the tests I have referred to and made notes
to the same effect.
Essential Menial Qualities for Aviation.
We have, then, these two chief mental qualities—quick,
accurate judgment and an emotional stability or “guts,”or,
to use the term in a general sense, “confidence.” Now,
although instructors lav so much stress upon the “ guts ” of
a pupil, disregarding to some extent the intelligent factor
and judgment, in my opinion one requires a nice balance
between the two. Crashes occur from two chief causes:
(1) “ wind up ” or “ losing one’s head,” due to loss of control
from emotional disturbance of fear in the manner already
j described ; (2) over*confidence in an intelligence or judgment
which is below the average and which therefore does not
justify the confidence.
The one condition is quite as responsible for disasters as
the other. I have cases on record that have given poor
results with my apparatus, and of whom I have formed an
adverse opinion on account of lack of intelligence on general
grounds, education, Ac., but who have been marked “good ” by
the instructor because they have “lots of guts.” The verdict-
of my apparatus has been in the end justified, because the
inevitable crash has come. Above all things it is necessary
that a man shoilld know his own limitations as well as those
of his machine.
It must be admitted that when we have picked out these
two important factors of “judgment” and “confidence”
and applied our tests for them we have not exhausted the
whole subject of mentality. There still remains the general
temperament and mental constitution, though these are
largely made up of varying degrees of these two functions.
We have in any case no further tests, physical or otherwise,
that we can apply to discriminate between the various
types.
This power of judgment and quick decision does not
appear to involve the highest intellectual functions of the
mind ; it is rather on a par with what we call “tact” in
ordinary life. It is the power quickly to take in all the
circumstances of a given position and react to it in the best
manner—to do the right thing instead of the wrong with
quick decision. There is a certain type of highly intellectual
person who would by no means take first prize at the tests
with my apparatus, but also he would not make a good pilot.
i
210 Thb Lanobt,] DR. H. FLACK : SOME SIMPLE TESTS OF PHYSICAL EFFICIENCY.
[Feb. 8,1919
While one may in this way pick oat special mental
characteristics essential for the sacoessfal aviator and exclude
anyone specially deficient in any one of them from air
service, one mast at the same time recognise that there is an
infinite variety in the temperaments and mental constitutions
of men, and that therefore no hard-and-fast line can be
drawn. Just as there are many types of aeroplanes, each more
or less useful for a particular purpose and in each of which
the designer has had to compromise between the lift and the
drift or the speed and the climb, so the pilot of cool
judgment, though somewhat slow and deliberate in action, is
suited for one service, while the quick, high-spirited, though
somewhat emotional, erratic type may be chosen for another,
such as the fighting scout. In both cases they may be a
compromise in comparison with the ideal pilot.
Aviation requires, above all things, a strong, tough nervous
system that can withstand all the stresses and strains, both
mental and physical, in the air, that controls well the vital
organs, reacts to external conditions quickly and accurately,
and is not affected detrimentally by emotional disturbances.
Just as one uses the term “physique” to the general develop¬
ment of the body and one speaks of good or bad “physique,”
so I would suggest the expression “nerve physique” to
describe the general tone of the nervous system. There is
a general consensus of opinion that a good “nerve physique”
is focn 1 in young men who have led an outdoor life. Out¬
door pursuits not only tend to develop such a nerve physique,
but also offer in many ways the best training for aviation by
developing their power of observation and quick response, as
in the case of riding, shooting, hunting, and, though perhaps
in a less degree, almost any sport.
The Fighting Spirit.
It has been suggested that the best type of fighting scout
must possess the fighting spirit and be capable of developing
the emotion of anger with his foe—in other words, must be
able “to see red.” With this I disagree. In conformity with
what I have already said in regard to the emotions, it is my
firm conviction that a pilot requires to be as free as possible
from any emotional disturbance, whether of fear or anger, and
that if he “sees red” his judgment is liable to be clouded
and faulty. I must admit that this is to some extent an
armchair opinion, but I have sat in a machine taking part in
a scrap many times, and I think I have sufficient imagina¬
tion to fill in the rest of the picture; and as it appears to
me, the fighting scout requires the hunting instinct, with all
the judgment, cunning, and zest to down his prey, rather
than the fighting spirit of “seeing red.” It is the man who
goes forth in this spirit, aggressive but cool, that is most
likely to carry through those nice turns and twists in the
right direction and at the right moment that seal the fate of
his adversary and render him the victory.
Alcohol and Tobacco
Then there is the much-vexed question of alcohol and
tobacco. Froin what I have already said it will be obvious
that it is not only necessary for the pilot to possess a good
nerve physique, but to keep it up to pitch, and any excess
reacts deleteriously upon the nervous system more than on any
other part of the body, more especially excesses in drugs
such as alcohol and tobacco. Nothing will better contribute
to the restriction of these than t.he ample provision of
facilities for out-of-door sports. More especially I would
plead for the provision of horse-riding, both for pilots and
pupils under instruction. Horse-riding is one of the best
physical exercises, and probably comes nearer to controlling
an aeroplane than any other ground occupation. 1 would
suggest that every aerodrome should have its stables as well
as its hangars, and what better place than an aerodrome for
polo? Furthermore, there is a much greater inclination to
indulgence as a means of combating conditions of stress or
“staleness” from long service. In my opinion no one
should be engaged in continual flying, whether as instructor,
ferry pilot, or on active service, for more than three months
without a complete rest of at least a couple of weeks.
Water-supply of Karachi. —The President of
the Karachi municipality states that ample supplies of
water are now available and that the new wells provide a
reserve of supply up to twice the consumption even of the
period immediately preceding the monsoon.
SOME SIMPLE TESTS OF PHYSICAL
EFFICIENCY. 1
By MARTIN FLACK, C.B.E , M.B., B.Ch.Oxon.,
LIEUTENANT-COLONEL, B.A.F.M.8.
I wish to bring to notice some quite simple tests which
I believe will be of use in determining the physical efficiency
of an individual. I am approaching this problem from the
point of view of a physiologist, and the tests have been
devised to show the physical condition, not particularly
of any one system, but rather of the individual as a whole.
The procedure has been to select for examination, as far
as possible, healthy controls. In this connexion officers of
the R.A.F., who have made good and who have been chosen
by their commanding officers for their efficiency in flying and
in fighting, have been examined and standards have been
set, provisionally of course, and may have to be altered. On
the other hand, a number of officers who have broken down
for some reason or other have also been examined, and the
results obtained compared with these healthy controls.
I would like to emphasise that these tests are not designed
to supplant the work of the clinician in any way, and when
a man is reported as physically unfit on these tests it does
not mean that the work of the physician is finished, but that
it is beginning. If the subject does not come up to the
standards on being overhauled by the applied physio¬
logist, then the psychologist, neurologist, cardiologist, or
general physician will find something is wrong with him.
These tests give indications for such overhaul.
The chief point in connexion with these tests is the
technique. This is important because, if adopted, it is
essential that all the tests be carried out in the same way
on all occasions, so that various medical officers may apply
them to the same individualat different times. It has been
suggested in regard to the care of officers in the R.A.F.
that preventive treatment is best;. If officers were periodic¬
ally subjected to these tests by medical officers at different
stations they would carry with them a certain definite
amount of information as to their physical condition at the
time of the various examinations.
Description of Tests.
The first test is the response of the pu l se to exercise.
It is of importance the way this is done. I would point
out that there is no limit to the number of times a man may
be asked to stand upon a chair, but the technique here
suggested is suitable to the examination of a large number
of subjects. The test is that a man shall lift his body
weight through a definite height five times in 15 seconds.
The rate of increase in the pulse as a result of the exercise is
noted and the rate of return to the normal, the pulse having
been taken standing immediately before the exercise. In
this way uniformity of observation is obtained. Hitherto,
if ten medical officers were examining candidates, some
might order the candidates to touch their toes four times:
the enthusiastic man would do so in 5 seconds, the
lethargic man in 20 seconds. The test as devised is an effort
to set a level basis for all candidates. Preferably the sitting
rate of the pulse is first taken. The pulse-rate is then taken
standing. If the rate is unsteady it should be counted
in periods of 5 seconds until a steady rate is obtained.
The candidate is then put through a regulated exeroise,
which should be carried out as follows: Standing before a
chair, he places one foot upon the seat of the chair and
steadily raises his whole body to the height of the seat five
times in 15 seconds, one foot being retained on the chair
throughout. The examiner should regulate the speed and
rhythm in the following way: Standing beside the candi¬
date, holding the wrist, with his fingers on the pulse, the
examiner swings the arm forward and backward to indicate
the time of raising and lowering the body.
The subject still standing, the examiner then counts the
pulse in 5-second intervals, and notes the acceleration and
the time taken to return to the previous rate. In a good
subject the increase of rate is about 20 and the time of
return to normal 15-25 seconds. If the time of return
exceeds 30 seconds it is suggestive of cardio-vascular
inefficiency.
The breath-holding test. —Test No. 2 is quite simple, and
consists in getting the subject to hold his breath without
any preliminary deep breaths.
1 A synopsis of a paper read before the Epidemiology and 8tate
Medicioe Section of the Royal Society of Medicine on Jan. 10th. 1919.
The Lancet,]
DR. tf. FLACK: BOMB SIMPLE TESTS OF PHYSICAL EFFICIENCY. [Feb.8,1919 211
I would insist upon the aotnal lines on which the test is
laid down being followed: A deep expiration followed by the
filling of the lungs, clipping the nose, holding the breath as
long as possible. The significance of the test should not be
mentioned to the subject. He should just be told to breathe
out and breathe in as far as possible and then to hold the
breath. At the end of the test the question should be asked
as to what are the sensations experienced by the subject
during the holding of the breath.
The test was originally designed to show whether there
was oxygen want, and I still believe the test does show^the
subject who would suffer from oxygen want. From'my
experience I found that people who were likely to suffer
from “oxygen want” would give upafter a very short time in
holding the breath and would almost invariably return an
abnormal answer. A normal answer would be that the
subject “ had to give up,” “felt he would burst,” an abnormal
answer that the “ blooa ruBhed to the head,” “ things became
blurred,” &o. The test, however, has other significance.
The man without resolution, for example, will give up
early.
As originally shown by Dr. Leonard Hill and myself, if a
man who had held his breath in this manner then takes a
lungful of oxygen instead of a lungful of air, the time of
bolding the breath will be increased from 14 to 24 times as
long. Therefore what one breaks down from is, in the first
case, oxygen want, because when one breaks down in
holding the breath on oxygen the symptoms are quite
different, and are those due to COa excess—headache,
sweating, &c.
Another interesting point in this connexion is this: It is
known that the power to hold the breath is greatly
diminished at altitudes. Therefore a mau who can hold
.his breath a long time at ground level without discomfort
has greater room for diminution in bis power to hold his
breath than a man who can hold his breath a short time
at ground level before discomfort occurs. An efficient man
at altitudes is a deep breather, whereas the man who is
inefficient is a pan ter. Figures in regard to holding the
breath were worked out in the first instance on 40
successful pilots, all picked out by squadron commanders,
or by the Admiralty, or the R.F.C. as being quite able.
The time the breath is held averages about 69 seconds
and the sensations experienced normal. The vital capacity
averages at 3800 c.cm., with a minimum of 3400 c.cm. in
efficient fliers. .In a number who were sent up for medical
boarding the breath was held for not more than 45 seconds,
usually much under, and in most cases the answers recorded
were not normal.
The deduction, then, is that the breath-holding test on an
individual would be an idea as to whether he was likely to
do well in the air. As the results appeared to show that
poor breath-holders could not last in the air, the breath-
bolding test was adopted at the R.A.F. Commissions
Board. In my opinion it is preventing people going into
the Air Force who would not do well. The question of
4 ‘oxygen want” is a matter for serious future research,
and in peace-time one will be able to do such research on
a more scientific basis.
The third test is a combination of the first two tests.
Having got the pulse response to exercise and the time of
the breath holding test, then the time the breath can be held
after exercise can be taken. In the unfit the breath-holding
power comes right down, probably by 30 seconds. The fit
man may possibly hold bis breath almost as long as before,
but will not have a fall of more than 20 seconds. The man
out of condition gives a big fall in time after exercise.
The standard for admission for the ordinary breath¬
holding teBt was set at 45 seconds. Under 45 seconds should
cause the subject to be looked upon with suspicion, and
probably graded in regard to the height to which he
should go.
The vital capacity of pilots —The minimum in the table
of successful flying officers is 3400 c.cm.
I suggest that the use of a modified gas-meter is the best
way of measuring vital capacity, and preferably one made
by an English firm ; this has the great advantage over the
German model, from which it was copied, that its capacity
cannot easily be overshot. Among officers who had broken
down a great number of those tested were under the
minimum of 3400 c.cm., but it was subsequently found that
this was due to flying stress, some having a vital capacity of
only 2800 c.cm.
Captain H. C. Bazett, M.C., R.A.F.M.S., has shown that in
addition to these tests, if the respiration-rate is multiplied
by the ventilation per minute and divided by the vital
capacity, it is a very good indication of the power of a pilot
to fly. A figure below 30 is good, a figure above 30 poor. A
test like this will be of value for the selection of the high
flier.
If tube tests .—The apparatus for the next teat I wish to
describe is a U tube manometer filled with mercury, with
the scale moveable.
The test is a measure of the tone of the abdominal wall.
The subject is asked to blow up steadily the mercury column
as high as possible. The number of mm. Hg blown is
recorded. If for any reason it is suspected that the subject
is not trying, he is asked to try again with the scale of the
manometer turned away. There should be but little differ¬
ence from the previous reading, and in suoh a case
encouragement may cause the subject easily to surpass his
previous effort. He is then asked to try again while looking
at the column. If he is not trying he will surpass his first
effort, which he saw.
The sixth test is another test with the U tube manometer.
This test is performed as follows : —
The subject is asked to empty the lungs, fill up, blow the
mercury to the height of 40 mm. and hold it there, without
breathing, for as long as possible. The nose should be
clipped. A valuable adjunct to this test is the behaviour of
the pulse during the time the mercury is being sustained. It
is counted during each period of 5 seconds that the mercury
is sustained. Starting at the 5th second in the normal indi¬
vidual there is generally a slow, steady rise in the rate of the
pulse or a fairly marked rise which is sustained most of the
time. For example, the pulse-rate may rise gradually from
72 to 96 or 108, according to the time the breath is held, or it
may rise at once from 72 to 96 or 108 and be sustained there.
A large rise in rate—e.g., from 72 to 132 or 144—is unsatis¬
factory. In cases of flying stress a characteristic response is
for the pulse to jump up to a quick rate during the 5th to
the 10th or 15th second and then to fall away in rate to
normal or even below. Such a response is fts follows :—
Normal at start, 84; 5th-10th second, 144 (sometimes
almost impalpable); falling away (say 20-25 seconds) to 72
or even 60. Such cardiomotor instability is frequently asso¬
ciated with flying stress and is indicative of a need of rest.
In any case the subject is generally not in a condition to be
allowed to continue to fly. Other points in the examination
should, however, be taken into consideration.
The averages obtained for these tests from some selected
’flying officers were :—
Expiratory Force . 112 mm. Hg.
Mercury held . 52 sec.
Xt ii suggested that they should all conform to the minimum
standard, and preferably to the average standard.
Remits of Tests %n Suooestfal Pilots.
Table I. gives a synopsis of results obtained from: various
sources.
Table I.
Subjects.
Number
examined.
Breath
held.
if
ii
11
co 2
8
Expira¬
tory
force.
tf
]a
&9
Fit instructors.
22
sec.
67*
c.cm.
4062
c.cm.
1620
mm. Hg.
112
sec.
52
Ditto.
—
46t
3300
1000
80
43
Home Defence pilots .
24
72
3940
1496
119
50
British candidates.
23
69
3823
1590
106
52
U.S. candidates .
7
66
3814
1386
116-4
53-5
Delivery and test pilots ...
10
57
3620
1050
108
40
Pilots returned for rest
17
57
3897
1423
95
40
Pilots training for scouts ...
15
62
3820
1433
96
49
Pilots taken off flying1
through stress . S
27
49
3480
1134
7«
25
* Average. ' 1 Minimum.
One or two Buffering from stress are Included among the Home
Defence and test pilots.
Practically all the cases examined in hospital fell below
the standard. There was one very interesting case, who
came with a letter to the hospital and was examined. I
told him he seemed very fit, and on reading the letter after¬
wards fonnd he was still doing very good service in France
and had not really come for treatment to the hospital, but
for especial examination on account of his fitness and
meritorious flying service. Another was a one-eyed man,
whose only disability was that he was nearly blind in one
eye. I could find nothing wrong by these tests. Many
other instances could be given.
Remits of Tests in Rejected Men.
Having found standards from the examination of
successful pilots, I went to the Commissions Board and
examined a number of rejects as the result of the routine
examination there. The results are appended in Table II.
It will be seen that exoept one man, who was unfit on
the vital oapaoity test, every man was rejected by the fatigu'
312 THBLAKOTT.] 8IK A. BMP te DR. P. H. BOYDKS: TREATMENT OF VBRBRBAL D1SKASK. [Fm>. 8,1919
Table II.
6
S3
Age.
Breath held, i
Vital i
capacity.
2%
11
"8
Expira¬
tory
force.
ax
| a
s a
5s
Remarks.
1
1711
sec.
55
c om.
4200
mra. Hg.
80
sec.
42
Rejected.
2
17H
84
60
25
„
3
18
53
55
32
,,
4
18
66
30
5
rm
53
60
25
,,
6
18
48
3600
70
27
7
17U
44
120
35
,,
8
18
85
2750
•900
100
28
,,
9
17H
71
2400
50
Unfit by V.C. standard.
10
19
60
3100
1000
60
20
Rejected.
11
19
63
—
—
60
40
»•
12
19
42
3800
—
40
33
,,
13
23
42
4200
-
60
25
"
14
18A
64
_
_
60
33
M.O. aays fit, but does not
like him. Referred by
assessor.
Assessor did not like the
15
22
61
100
301
16
23A
63
4300
1800
351
look of them.
17
21*
55
4100
1 ml
371
History of migraine; re¬
ferred by assessor.
18
18*
48
3800
1700
100
351
Average
58
3650
_
1450
77
32
—
tost. Some of these were people whom the medical officer
was in donbt about and had sent them for examination,
saying he had to pass them fit, bat did not like the look of
them, thoagh he coaid see nothing wrong with them.
Importance of Using Tests in Combination.
I do not saggest that any one test should be taken in examin¬
ing a candidate, bat that they should be used in combina¬
tion, and the instructions are that they should be used by
the assessor for his guidance.
The results obtained by Lieutenant-Colonel J. L. Birley
from pilots who had been fighting for several months and
were being sent home for a rest support the results obtained
by tne U tube test. These pilots were fairly up to the
average standard. On the other hand, cases who had been
■ concussed were below average. One has here, therefore, a
valuable test for the effect of crashes.
Lieutenant-Colonel Birley obtained from these found
permanently unfit for flying the following results:—
Average expiratory force . 76 mm. Hg.
Sustaining 40 mm. Hg. 28 sea
As I have stated, it is the combination of the tests,
however, that is important. The average standards are
given in the following table :—
Average standard. Minimum standard.
Breath holding . 69 sec. . 45 sec.
Vital capacity ... M . 3900 acm. 3400 c.cm.
Bxpihitory f >roe. 110 min. Hg. 80 mm. Hg.
Fatigue test (U tube) . 52 sec. . 40 sec.
Pulse response to exercise-
increase per min. - . 12-21 beats . 36 beats
Return to normal . 10-20 sec. 30 sec.
Practical Value of the Tests.
I believe that every pilot oould be overhauled by the
breath-holding, expiratory force, and U tube tests and a
station graded according to its efficiency. As a matter of
foot, this has been done. At a certain fighting station the
medical officer found that the average for all the pilots by
these tests were—
Breath-holding . 65 sec.
Expiratory force. 103 mm. Hg.
Sustaining 40 mth. mercury. 67 sec.
He picked out one officer as being badly off colour, a pilot
with 250 hours 1 experience. The pilot soon after went for a
flight, there was nothing wrong with the machine, but the
pilot lost contr 1, crashed, and was killed. His results for
the three tests just previously were—
Breath-holding . 33 sec.
Expiratory force. 95 mm. Hg.
Sustaining 40 mm. Hg. 22 sec.
The medical officer had suggested that this officer should
not be allowed to fly. This unfortunate incident so im¬
pressed the commanding officer that the medical officer was
asked every week to grade the pilots. It soon became
evident that the officers who were picked out by the com¬
manding officer or senior flight officer for special duty were
practically always those graded by the tests as extra fit. It
would seem from this that the selection of pilots for special
work by these tests if adopted would be of great value. The
commanding officer eventually made a rule that if an officer
did not come up to the standard of the tests he must not be
placed in charge of a machine. The medical officer then
gave him instructions for making himself fit, and he was
told if he was still unfit by the tests in a fortnight he
would go up for a board, and possibly be found unfit for
flying. This was actually done in one or two cases. By
this means the efficiency of the station was greatly
increased.
I suggest that these tests would also be of value for
measuring trench fatigue, industrial fatigue, and fatigue in
women workers ; also for the grading of people for positions
of trust, such as special motor drivers and members of mine-
rescue teams. With special standards set according to age,
they would possibly also be of value to educational autho¬
rities in assessing how children are maintaining their physical
efficiency. _
THE
TREATMENT OF VENEREAL DISEASE.
By Sir AROHDALL REID, M.B.Edin.;
AND
P. HAMILTON BOYDEN, M.D. Edin.,
9URGRON COMMANDER, H.N.
Every great war has been followed by an increase in
venereal disease, so marked that on occasions it has
amounted to a pestilence. Unless timely sanitary pre¬
cautions are taken the greatest of all wars is unlikely to
furnish an exception to the rule. We think it desirable,
therefore, to give an account of an essay in preventive
medicine which, as may be judged from the following,
achieved considerable success.
One of us (A. R.) has been in medical charge of a rapidly
changing body of men generally numbering about 2000.
Up to the end of 1916 venereal disease was common among
them in spite of numerous moral lectures and in spite of
adequate provision of what is known as “ early treatment”
—that is, disinfection after the “ contact” has returned to
quarters. At the beginning of 1917 a new system was
instituted. The men were instructed to disinfect themselves
immediately after danger had been incurred—just as a
surgeon would disinfect his hands. This procedure is what
is known as prophylaxis. It differs from early treatment
merely in that the man carries the disinfectant and uses it
immediately. Each man who applied was given an ounce
of solution of potassium permanganate (at first in a
strength of 1 in 2000, later in a strength of 1 in 1000),
a small swab of cotton-wool, and careful directions.
Potassium permanganate was chosen merely because it
happened to be the most accessible disinfectant. The
rationale of the procedure was fully explained, so that on
an emergency the man could purchase the materials from
any chemist. Daring 1917 and 1918 about 20,000 men
passed through the station, and among them precisely
seven cases of venereal disease occurred, six of gonorrhoea
and one of syphilis. Of the six cases of gonorrhoea, two
only were contracted by men on leave, in each case from
the man’s own wife. Two of the others were drunk and
took no precautions. The fifth man was infected the
night he arrived, and he also, being unaware of the system,
took no precautions. The sixth man practised early treat¬
ment an hour after intercourse. The man who acquired
syphilis also carried no disinfectant, and used it (per¬
manganate and calomel) two hours after intercourse. He
had a long prepuce, and therefore a sensitive gland, and
probably did not—probably could not—rub in the calomel
vigorously.
The other of us (P. H B.) commenced prophylaxis against
venereal disease in the Royal Navy in 1907. Some 18 months
ago he took over medical charge of an establishment numbering
The Lancet,] DR. 0. RIVIERE: HILU8 TUBERCULOSIS IN THE ADULT. [Feb. 8, 1919 213
over2000officers and men. The amount of venereal disease, and
especially gonorrhoea, was considerable, and it* was recognised
that of the men who stated they had used the so-c-illed ‘ 1 dread¬
noughts ” some 40 per cent, contracted the disease. It thus
became evident that nargol jelly as a preventive was
practically inert. For the past nine months the method of
immediate prophylaxis by means of the apolication of a
solution of potassium permanganate (1 in 1000) has been
employed with results as striking as those mentioned above
in the case of the soldiers. Not a single case of gonorrhoea
occurred amongst those employing this method, and only
one of syphilis. This latter made the application about six
houre after exposure to infection, and may therefore be
counted out. Unfortunately, the Navy is a very conservative
body, and many men still persist in sticking to the “ dread¬
noughts. ” But in lectures given on the subject of prophylaxis
man are gradually being convinced of the simplicity and
efficacy of immediate prophylaxis.
The calomel cream is still reserved for those who have
omitted to carry the permanganate solution on their persons,
as it seems likely that the former affords some protection,
even if an hour or two has elapsed since the risk of infection
has been run.
It will be seen that no man who followed instructions
and disinfected himself immediately acquired disease. Evi¬
dently the time element is of extreme importance. Probably
there is no special virtue in potassium permanganate. Any
other active antiseptic would be equally effective. But
permanganate is the cheapest disinfectant and the best
known to the public, the least poisonous, and least irritating.
HILUS TUBERCULOSIS IN THE ADULT.
By OLIVE RIVIERE. M.D.Lond., F.R.O.P. Lond.,
PHTBIOIAK TO CITY OF LOITDOV HOSPITAL FOB DIBBASE8 OF THE
CHEST, AHD TO BAST LOffDOV HOSPITAL FOB CHILDREN.
The following case, one of many possible examples, illus¬
trates a condition which must be very familiar to all with a
wide or prolonged experience of chest disease.
patient, aged 24 years. History of six months’ ooagh and wasting,
night sweats, dyspnoea on exertion, and poor appetite. The patient is
very thin and sallow; there is no olubblng. Pulse 128. Temperature
102° P.
Chat —Reflex bands of impairment are present over the baoks. (See
Kg. 1.) Movement is equal on the two sides. Percussion finds no
impairment, but there is double paravertebral dullness, and the apical
resonance (Krbnig’s isthmus) Is narrowed to 2 cm. on both sides (normal
4Jh5 cm ). There are no crepitations nor r&les, the breath sounds are
normal, and the air entry fairly good.
A radiopram shows “ disseminated tubercle of fluffy character
{alveolar), to quote the radiologist’s report, through both lung*. On
the left side almost the whole field Is filled, and there Is cavitation just
outside the root; on the right disease involves, in the main, the upper
half of the lung. The root shadows are very heavy, and suggest
glandular involvement.
Six weeks later the signs are similar, bnt a few crepitations have
appeared at the left base behind.
Her© we have a “central lung” or “hilus” tuberculosis
of broncho-pueumonic type, the counterpart in the adult of
a condition which is quite familiar to the pediatrist. Because,
on account of its striking symptoms and fatal issue, such a
case cannot well be overlooked nor the presence of disease
denied, it serves very well to illustrate at the outset the con¬
dition which forms the subject of the present paper. If the
existence of hilus tuberculosis in the adnlt had to be proved
entirely on grounds of the far more common ohronic cases,
it might be more difficult to bring convincing evidence of its
undoubted occurrence. When, however, a patient obviously
“consumptive,” presents a chest wall entirely innocent of
those crepitations which are considered by-many the main
sign of tubercle, and yet a radiogram shows advanced and
active disease, it seems difficult to deny that we are dealing
with a process which has developed in the deep parts of the
lung and has not yet involved the surface. If, in addition,
before death, crepitations appear rapidly over one or both
lungs, as commonly happens, then the evidence for outward-
spreading disease is still more convincing.
Now, just as acute apical phthisis is rare, so also is aoute
hilus tuberculosis compared with the quiet and ohronic
forms which constitute, to those whose eyes are open to their
existence, the main bulk of our tuberculous material. It is
particularly to this latter class of case that the writer is
anxious to draw attention in the present communication.
But before going any further it must be made dear that
the term hilus tuberculosis of adults is not here used to
include those evidences of obsolete tuberde which are to be
found in every X ray plate and are apt to bulk large in
the radiological report on a suspicious chest. Such scars
of old battle are accompanied by no symptoms, and give rise
to no clinical signs at the surface. True, at the time of their
development in childhood physical signs were probably dis¬
coverable in some proportion at least of the more marked
cases if looked for, but such signs vanished with the passage
of years, and it is only when disease is reawakened and a
fresh spread occurs that the chest changes to be presently
described appear, and the case merits the designation of
“hilus tuberculosis in the adult.” This awakening of
obsolete disease appears to add very little that is distinctive
to the radiogram so long as disease is of a quiet and
chronic type, and thus it happens that the clinician is in
reality better equipped for the diagnosis of hilus tuberculosis
of this type than is the radiologist. The former can point to
signs indicative of recent disease as confirmation of the
symptomatic evidence, the latter must rely Bolely on the
symptoms, unfortunately seldom distinctive, as proof of
present activity. This is, however, to anticipate what may
be more appropriately discussed later on.
It must be understood, then, that the term hilns tuber¬
culosis in the adult refers to a fresh and active process,
involving the deep areas of the lungs where remain the old
foci of childhood infection, and thence spreading outwards
towards the surface. It thus stands in close relationship to
the common form of tuberculosis of childhood, though with
less tendency to glandular involvement; and also in decided
contrast to apical phthisis of adults, a localised infiltration
involving the apex of the lung.
Hilas tuberculosis is commonly a peribronchial disease of
chronic and intermittent coarse—onr first knowledge of it
we owe to the radiologist, whose “peribronchial phthisis”
and “peribronchitis tuberculosa” have referred, as a rule,
to this condition. From the clinician it has suffered a scan¬
dalous neglect, and it is in the form of a somewhat belated
atonement that the writer offers the present communication.
Only two contributions to the subject on the olinioal side
have, np to now, come nnder the writer's notice, both some¬
what inadequate from the point of view of the recognition
and diagnosis of the disease. Philippi, of Davos, in 1911,
gave an interesting description of “ iutrathoracio glandular
and lung-hilus tuberculosis of adults” (to paraphrase his
German heading), and in all but the means for its diagnosis
the account is clear sighted and fairly complete. Stranb
and Otten. in 1912 issued from v. Romberg’s laboratory in
Tubingen a paper which showed that they recognised the
hilus origin of certain clinically “unilateral” oases of
advanced pulmonary tuberculosis; they do not deal with
the early stages of the disease nor with its diagnosis, and
many of their cases occurred in children rather than in
adults.
Clinical Characteristics of Hilus Tub&roulosis.
Before going into the symptoms and physical signs of
hilus tuberculosis in the adult, or its differential diagnosis,
it will be well to lay down in the rough the main charac¬
teristic points which distinguish it from apical phthisis.
1. Its bilateral nature.— Wherever the signs may appear on
the surface in these oases the central lung disease is practi¬
cally always bilateral, though stress may fall for a time
more heavily ou oue or other lung. Its bilateral character
is generally very evident to radiological examination; it
reveals itself clinically in two directions: firstly, move¬
ment of the two sides is very commonly equal or nearly
so; and, secondly, there is marked retraction of both apioes
(Kronig’s area) to topographical percussion. (See Figs. 3
and 4.) In both these particulars it stands in marked con¬
trast to apical phthisis, and the latter point, the double
apical retraction, provides the means by whioh it is distin¬
guishable from phthisis ou the one hand, and from the ohest
of health, or of chronio bronchitis, on the other, these being
the three conditions under which error most commonly
arises.
And now if we look back to the oase cited at the opening
of this paper, what were the characteristic points to
observe? (I) The equality of the two sides in movement
and in “ contrast percussion.” (2) The double narrowing of
the apices—only 2 cm. instead of the normal 4J-5 om. Both
these points are evidence of bilateral disease. (3) The
absence of crepitations at the surface, evidence of the deep-
lying looation of the disease. And this last point brings ns
214 The Lancet,]
DR. G. RIVIERE: IIILUS TUBERCULOSIS IN THE ADULT.
[Feb. 8, 1919
to the second main characteristic of hilus tuberculosis—
namely, the atypical distribution of the sigDS when they do
reach the surface, a point in the diagnosis of cases already
advanced.
2. The atypical location of surface signs.— Just as in
pulmonary tuberculosis of the young child—always a hilus
tuberculosis save where a miliary dissemination has occurred
—the stethoscopic signs may appear at any point on the chest
wall, and no spot is truly characteristic, so in hilus tuber¬
culosis of the adult. When the disease which has been
smouldering for so long, too often unheeded, deep in the
lung, at long last reaches the surface, it does so at some
spot other than the apex of the lung. Very commonly
crepitations appear over the front of the chest on one side,
often in the axilla, not infrequently at the base behind.
Since disease spreads out from the root fanwise along the
lung framework towards all points of the surface, it is
obvious that it may first reach the stethoscope of the
physician at any point. Similarly it must be expected that
when disease has reached the surface at one point it will not
be far from the surface at other points also. And this
brings us to the third characteristic point about hilus
tuberculosis.
3. The characteristic spread of stethoscopic signs over the lung
surface. —Having once reached the surface at one point, the
signs, crepitations and the like, tend quickly to spread,
unless disease becomes arrested, over the greater part of
that side, front and back, often within a comparatively few
weeks. On this account it is not uncommon to meet with
cases of clinically “unilateral” tuberculosis involving the
whole or greater part of one lung and apparently sparing
the lung on the opposite side. This umlaterality is,
however, apparent only, and a radiogram will reveal disease
of little less extent, though often of lower activity, through¬
out the other lung also. If disease is progressive in this
second lung, and it soon becomes so when “ tolerance” to
autotuberculin fails and fever shows itself, signs will soon
appear at this surface also and spread rapidly in area just as
on the first side involved. Even before crepitations appear
the patient may be dyspnoeic and cyanosed from the abund¬
ance of deep disease.
Here, then, before discussing its physical signs and
diagnosis, we have an outline of the three main character¬
istics which tend to mark down the hilus origin of a case of
pulmonary tuberculosis. No further notice will be taken of
cases so far advanced as to give stethoscopic signs at the
surface, and, indeed, the majority of cases never reach this
stage. The rest of our space will be directed to the sym¬
ptoms. clinical signs, and differential diagnosis of hilus
tuberculosis in its early and curable stages and in its chronic
forms.
Symptoms.
Such symptoms as are of toxic origin are identical for
hilus tuberculosis and apical phthisis. In addition,
certain symptoms occur which may be considered more
characteristic of hilus tuberculosis than of apical phthisis.
Particularly, shortness of breath on exertion is a symptom
which is often prominent, and due in some cases to wide¬
spread peribronchial disease and in some to the emphysema
and bronchitis which are occasional complications. Chest
pain is also fairly common, often in the central regions of
the chest, occasionally in the side in association with the
marginal pleurisies which are such frequent accompaniments
of this disease.
Physical Signs.
A patient comes to his physician with symptoms sugges¬
tive of tuberculous chest disease, but on examination no
signs are present pointing to the unilateral apical infiltration
characteristic of apical phthisis—how is “ central lung” or
“hilus” tuberculosis to be detected? If this disease is
present we shall find the following signs : —
Insrection and Palpation.
On inspection and palpation it will be established that
chest movement is equal in the two sides, at least in early
stages. In certain cases, however, the stress of disease may
fall more decidedly on one lung, particularly the right, or
decided pleuritic involvement may occur. Then of necessity
a unilateral limitation of expansion is present, as in phthisis,
and the characteristic balance of movement is lost.
Percussion.
Through percussion are achieved the main elements of
diagnosis.
1. The reflex hands of impairment over the backs described by
the writer in a former communication 1 as evidence of active
Iiarenchymatous disease will be present (see Fig. 1).
1 The Laxcet, 1915,11., 387.
2. There may be a slight difference of note between the
two sides of the chest to “ contrast percussion ” ; and this is
commonly against the right side.
3. Often there is present a wide and well-marked area of
paravertebral dullness on the right side (Fig. 2), a point on
which Philippi very rightly laid stress in the diagnosis of
these cases. This 'area is familiar to pediatrists and is
acknowledged evidence of intrathoracic glandular enlarge¬
ment, mainly, the writer has reason to believe, enlargement
of bifurcation glands causing pressure on the right pulmonary
artery, and thereby reducing the function and volume of the
right lung. This'dull area may overstep the normal “oval
interspinous dullness ” (see Fig. 2) between the first and fifth
dorsal spines, so as to stretch out some 6 or 7 cm. on one
or both sides and extend down to the sixth or seventh dorsal
spine.
Parasternal dullness is sometimes present, though less
often than paravertebral, and it generally points to enlarge¬
ment of lateral tracheal and tracheo-bronchial glands.
Normally there exists some 2$ cm. (1 inch) of impairment
on each side of the sternal border, and this may be increased
in these cases to 5 or 6 cm. on one or both sides.
Fig. 1.-Reflex bands of impairment Fig. 2.— Paravertebral dullness.
Figs. 3 and 4.—“ Krbnig’s itthmua” of apical resonance, normal
and reduced.
4. Most important of all as evidence of deep disease we
find a bilateral narrowing of “ Krtinig's isthmus ” of apical
resonance at the top of the shoulder. (See Figs. 3 and 4.)
In the normal chest this “isthmus” measures 4 4 to 5 cm.
on each side, though in women and undersized men of
sedentary occupation it may fall as low as 4 cm. Incases
of hilus tuberculosis we find it considerably reduced on both
sides, very commonly to 2J cm. This bilateral narrowing
gives us valuable evidence in two directions. Firstly,
it is no healthy chest we are examining—though nothing
else can be found at the surface we can be quite sure that
some central disease, whether of present or recent activity,
is present. Secondly, a bilateral narrowing is not charac¬
teristic of apical phthisis, save in its later and bilateral
stages when abundant other surface signs will be present.
In phthisis, as a rule, the retraction of the isthmus is less
marked—often only to 3* cm.—and in early stages is
unilateral. .
A comparison of the width of the apical resonance in a
number of cases taken at random will serve to bring out
clearly the importance of this sign in the differential
diagnosis of hilus tuberculosis.
Hilus tuberculosis.
Apical phthisis.
Chronic bronchitis.
Right,
Left.
Right.
Left.
Right.
Left.
24 cm.
24 cm.
3£ cm.
6 cm.
44 cm.
44 cm.
24 „
2k
24 ,i
54 „
41
4j ..
3 „
34 „
5 „
3
54 ..
54
2 „
2 „
2i „
4 „
34 ..
34 %.%
24 „
2 ••
6 „
3 „
|. 4 -
4
5. In hilus tuberculosis of adults tidal movement at one or
both bases may be diminished or may entirely fail. In the
absence of extensive lung disease loss of tidal movement
usually indicates adherent pleura, and this is especially so
where the loss is on one surface only. Pleurisy is a very
frequent complication of hilus tuberculosis, but pleural
adhesions are by no means a necessary accompaniment.
The Lancet,]
DR. 0. RIVIBRE: HILUS TUBERCULOSIS IN THE ADULT.
Feb. 8, 1919 215
Auscultation,
Of auscultation in all bnt the last stages of hiius tubercu¬
losis there is little or nothing to be said. As already indi¬
cated, the surface will be entirely free of stethoscopic signs,
even though extensive disease occupies the deeper parts of
the lung. Still more is this the case in those earlier or more
chronic cases for whose recognition and detection the writer
here offers a plea.
But though no crepitations are to be expected at the
surface in such cases, other signs may be incidentally met
with in certain cases. Thus, fleeting marginal pleurisies
are common, and fine friction, with or without pain, may
be discovered at one or other base or axillary region. Fine
inspiratory sounds of indeterminate or mixed nature are
also often heard at the bases in cases of hiius tuberculosis
in the adult, as in ohildren. These may be atelectatic, or
may stand for oedema or lymph stasis, or may be mere tissue
sounds developed under pressure of the stethoscope—their
nature generally remains undecided! If the breath sounds
are blowing ” at the right apex, as sometimes happens,
this may be due to glandular enlargement, and is not
necessarily evidence of pulmonary consolidation.
Radiographic Appearances.
Something must be said of the radiographic appearances,
and these may be conveniently divided into three types
according to the activity of the process.
Chronic and quiet disease with little or no evidence of
activity .—This represents perhaps the commonest type of
case, the evidences of activity being entirely dependent on
other factors than the X ray picture. The main point
about the radiogram is the abnormal visibility of the whole
lung reticulum, which appears thick and strongly shadowed
in all its “ twigs’* right out to the periphery. The main
branches appear thickened, often wide and tape-like, or may
appear as rings or flgures-of-eight, with or without some
dilatation of their lumen. The whole picture has a general
“fibrous appearance,” nodules maybe absent and yet the
case tuberculous, or there may be a nodular appearance
throughout. In many of these chronic cases the radiogram
may present so “fibrous” a picture that it is hard to
believe any activity can be present. Yet the patient may
present symptoms and develop a fresh pleurisy as evidence
that the process is not obsolete.
In hiius tuberculosis, of whatever form, it often appears
that the diseased area is, roughly, equal on the two sides and
often reaches nearly to the periphery; it may present a
sharply-marked outer margin, giving a butterfly appearance
and strongly suggesting a simultaneous spread out to this
point rather than a slow creeping outwards. Indeed,
judging from the X ray and post-mortem experience, the
writer is convinced that a simultaneous “sowing ” of disease
over a wide area occurs not infrequently, though the gradual
outward spread presumed in the general description of the
disease can also be proved to occur, and is perhaps the
rule.
More active disease .—This may show itself in a more woolly
and less sharp-cut appearance of disease which yet remains,
to X ray examination, purely “ peribronchial.” The thicken¬
ing of the bronchi is more marked both round the root and
farther out in the lung, and a nodular or even “budding”
appearance may be noticeable. The finer network of the
lung is thickened irregularly or nodular shadows of various
size and not very sharp outline may be linked up in it.
Active and acute disease .—This is sufficiently illustrated by
the X ray plate of the case described at the opening of this
paper. The strands of the lung network vanish and the
pulmonary fields beoome filled with woolly broncho-
pneumonic shadows of smaller or larger size, with eventual
coalescence and cavity formation.
Differential Diagnosis.
And now, having indicated something of the symptoms
and physical signs, and of the general characteristics of
hiius tuberculosis in the adult, it still remains to emphasise
the main points in its differential diagnosis. And first of
all it is necessary, in the early cases, to indicate the points
which separate the healthy ohest from that containing a
oentral lung lesion. For those who are careless over their
physical signs the healthy chest is merely one that presents
equal movement on the two sides, no obvious areas of dull¬
ness, and no stethoscopic signs. But the chest of early
hiius tuberculosis shares with the normal chest all these
negative points; hence these are useless in its diagnosis.
Only after Kronig’s isthmus has been carefully mapped and
measured, paravertebral and parasternal dullness searched
for, and, less important, tidal movement at the bases
explored, can early hiius tuberoulosis be excluded. In
particular, it cannot be too strongly insisted that Kronig’s
apical resonance represents one of the essentials of chest
examination, since it supplies practically the only key to
the condition of the central area of the lung. True, the
X rays will also reveal these central areas, but the infor¬
mation they give is largely clouded by the constant presence
of the shadows of obsolete tubercle remaining from the
common childhood infection ; the question of recency and
activity cannot be decided with the X rays save for acute
forms of the disease, with which we are not here concerned.
The points on which a differential diagnosis must be based
may be shortly indicated as follows:—
—
| Normal ohest.
Early hiius tuberculosis.
Befiex band* (Pig. 1).
Absent.
Present.
Krbnig'* Isthmus
(Figs. 3 and 4).
Of normal
size.
Contracted on both sides.
Parsven* Nral dullness
(Pig. 2).
Absent.
Often present on right
side.
Parasternal dullness.
91 1
Present in some cases.
Tidal movement.
Of normal
amount. {
Often absent or reduoed on
one or both aides.
Having discovered through the evidences of these signs
that the chest under consideration is outside the normal,
what proof have we that the malady is of tuberculous causa¬
tion ? Often, it must be confessed, very little in the indi¬
vidual case. For hiius tuberculosis may smoulder for years
without any very characteristic symptoms, and tubercle
bacilli may be absent from the sputum almost throughout its
course. Where there are definite evidences of glandular
enlargement, as shown in paravertebral and parasternal
dullness, the case presents striking similarity to tuberculosis
of childhood, and there exists strong probability of its tuber¬
culous nature.* Where, however, the only definite sign is a
double narrowing of Kronig’s area (and again it must be
insisted that a healed childhood infection does not leave this
sign behind), we have evidence of a oentral lung lesion but
none of its activity, and still less of its tuberculous causa¬
tion. We must look elsewhere—to symptoms mainly—for
{ evidence that disease is not arrested or healed, and in doing
! so we sometimes find tubercle bacilli present and our whole
difficulty solved.
Failing this fortunate chance, only an appeal to experience
can supply us with means of reaching conclusions at least of
high probability. For, apart from the well-recognised pre¬
dilection of tubercle for the lung root, its almost constant
presence as the result of a childhood infection, and its known
tendenoy in this situation to persistent quiet activity And
intermittent spread, we shall have clear recollection of
patients with identical physical signs who later passed over
into the region of proved tuberculosis. (The writer is here
presuming that his own experiences are, or may become,
common to others.) Our position is little worse than in the
diagnosis of apical phthisis in the absence of bacillary
sputum, again a matter of probability of a high degree.
“ Given apical changes," remarked Turban, ** without previous
S neumonia, and when inhalation of duet oan be exeltided, then the
iagnosis is almost certain.”
And the same might be claimed, perhaps, for central or
hiius lung disease. A patient with narrowed apices and sugges¬
tive symptoms, but with no history pointing to dust inhalation,
may be regarded as probably suffering with active peri¬
bronchial tuberculosis ; a patient with narrowed apices and
no symptoms is probably the victim of arrested disease of
similar causation. For, failing this explanation, there must
exist a disease, presumably a peribronchitis of chronic
course, of whose causation and pathology we are at present
entirely unenlightened—a rather improbable proposition in the
writer’s opinion. Only occasionally, indeed, in these cases
do other points fail to give additional support to their
presumed tuberoular origin—paravertebral dullness in a large
proportion of the cases, and not infrequently the occurrence
of a “ marginal ” pleurisy at one or other base.
The differentiation of hiius tuberculosis from apical
phthisis is, as a rule, simple and straightforward, particularly
in its early stages. With the advance of disease the two
conditions may become difficult or even impossible to
separate. Indeed, it must be admitted that between the
two characteristic types intermediate pictures of disease may
be observed not clearly conforming to either, or possibly a
blending of both. But in spite of this occasional failure of
type the differential diagnosis can generally be made, 11 f
216 The Lancet,]
DR. J. H. FRYER: AIR FOR OXYGEN IN ANESTHESIA.
[Feb. 8,1919
it is always worth an attempt on acoount of the differing
course and prognosis in the two conditions. For hilus
tuberculosis is nearly always of peribronchial type and
extreme chronicity; tending to spread over wide areas, often
with greater mechanical than constitutional disturbance;
becoming arrested for long periods; showing occasional
activity, often of a pleuritic nature, and then again dying
down. Smouldering always, and always difficult to quench,
but only at long last, and in exceptional cases, breaking into
a conflagration of such intensity as to threaten life, and then
usually at so advanced a stage that the outlook is obviously
hopeless. The broncho-pneumonic case quoted at the
beginning of this paper presents only a rare exception to
the usual course.
In all particulars of its spread it stands in some contrast
to apical phthisis, of which the immediate prognosis is
always more serious and uncertain, and which moves forward
more rapidly, accompanied by fever and constitutional dis¬
turbance, albeit with periods of arrest, towards its ultimate
ending in death or cure.
Already, under the heading of the characteristics of hilus
tuberculosis, some of the main points of distinction from
apical phthisis have been insisted on—its bilateral character
from the beginning, its appearance at other points than the
apex of the lung, and its spread over a wide area of the chest
wall once the surfaoe is reached. In practice the differential
points may shortly be tabulated as follows.
Hilaa taberculoala.
Phthisis.
Iaspeo- Nothing oh&racterisblo, but any change,
tion. such as flat chest or emphysema, will
be bilateral.
Per¬
cussion.
Palpa¬
tion.
Auscul¬
tation.
Perhaps slight “contrast” impairment
on one side, generally the right.
Parasternal or paravertebral impair¬
ment, or both.
Bilateral narrowing of KrOnig's isth¬
mus. (Pig. 4 )
Movement equal or nearly so on the
two sides.
No stetboscoplc signs at earlier stages,
at most fleeting pleurisies or transient
basal crepitations; then granular
breath sounds over a wide area,
changing to crepitations. Wide areas
Involved, often tbe middle or base of
thelung. Often the whole of one lung
involves before signs appear on
opposite side.
Flattening or hollow¬
ing and lagging of
one apex In ad¬
vanced disease.
Decided impairment
at <>ne apex.
Neither.
Unilateral narrowing
of less extent.
Unilateral deficien¬
cies of movement.
Fairly early stetho-
scoplc signs at one
apex, sooo crepita¬
tions here, later at
oppjeite apex.
So much for the differential diagnosis between these two
forms of pulmonary tuberculosis, or rather between fairly
typical ca#§in of each. That many borderland cases occur
whose classification is doubtful the writer has already indi¬
cated, but the classical case of hilus tuberculosis at a
characteristic stage clearly belongs to a type by itself.
Where an element of doubt in their differentiation must
sometimes exist is in the eventual progress of certain early
examples of disease—whether these must necessarily be
regarded as on the way to become hilus tuberculosis as we
eventually see it, or whether their future advance might be
on the lines of an apical phthisis. This is a matter on which
there can exist no great certainty at present. For these
earliest examples might possibly represent, in some cases at
least, a “sub-tuberculous” stage from which both phthisis
and hilus tuberculosis may later emerge, and the writer has
not shut his eyes to this possibility. But for one of these
early cases, with double narrowing of apices, to progress
towards apical phthisis it would be necessary for this apical
contraction to open out. This the writer has never known
to occur uoder observation, unless perhaps partially in a
single case. As a rule, the apices tend to become narrower
with time, whether with a spread of disease in a progressive
case, or with flbrotio changes where repair is taking place.
More tempting is it to assume a true etiological distinction
between the two types of disease, hilus tuberculosis being
regarded, as the writer has frankly presumed it at an earlier
stage of this paper, as a reawakening of the arrested lesions
of childhood, and phthisis as a reinfection from without. If
this were a true picture of the case, then there could of
necessity be no early stage common to both diseases.
Variation* in Type of Cate.
And now, at the close of this paper, ft is necessary to
mention the existence of certain variations from the common
typd of hilus tuberculosis outlined above.
1. Hilus tuberculosis associated with bronchitis. —In many
cases of hilus tuberculosis of chronic “ peribronchial ” type
there is a tendency to attacks of bronchial catarrh, and the
recurring cough and sputum are often, in all probability, of
this origin. Certain cases may, indeed, present all the
symptoms and many of the signs of chronic bronchitis with-
emphysema, and often with asthmatic attacks.
As a rule, there are certain points which direct attention
in such cases to the underlying tuberculous disease. The
history is likely to be of short duration, and wasting will
generally be a prominent symptom. Often one or more
brothers and sisters of the patient are pronouncedly tuber¬
culous. The pulmonary signs may be in most respecte-
typical of chronic bronchitis, though often with a bias of
signs against one side of the chest. But it is to a narrowing
of Kronig’s isthmus that we must look for more definite
evidence of central disease. In chronic bronchitis it might
well be expected that Kronig’s isthmus would oommonly,
owing to the presence of emphysema, show a more or less
striking enlargement. In some cases, truly, tbe apex may
be as wide as 5} cm. or even 6 cm., or it may maintain the
normal 5 cm.; but much more frequently tbe raising of tne
shoulder girdle, and possibly also the development of some
amount of peribronchial fibrosis, tend to reduce the isthmus
to a figure rather below the normal, often to 4J cm. or 4 cm.
In some cases where the isthmus is diminished to 34 cm.
doubt will be felt whether the condition belongs to the
category of simple bronchitis or not. Where the reduction
is to 3 cm. or 2} cm. there iB decided evidence of central lung
disease, and in the absence of a history of exposure to
dust diseases this will probably be hiluB tuberculosis. The-
possibility of tubercle masking under the guise of asthma
or chronic bronchitis must always be borne in mind.
2. Hilus tuberculosis , with tuberculosis of manifest gland *.—
These are cases in which gross enlargement of the cervical
and axillary glands occurs, and sometimes of other groups*
The lung condition is usually a secondary incident, and the
ohest picture is that of enlarged chest glands. The writer
has had five such cases under his care, and in two of these
there was associated enlargement of the thyroid gland. It
is to this class of oase thas Philippi called particular atten¬
tion, insisting above all on the characteristic parasternal
and paravertebral dullness. .
3. Hilus tuberculosis of broncho-pneumonic type.— This has
already received illustration at the outset oi this paper.
Suffice it to remark once again that this represents but a
rare variety of the disease. Hilus tuberculosis in its charac¬
teristic type runs a chronic and intermittent course, and
when the proper means are employed for its recognition it
will be found to be of widespread distribution, and even to
oonstitute the most prevalent form of pulmonary tuber¬
culosis in the adult as well as in the child.
Qu9en Anne-street, W._
THE SUBSTITUTION OF
AIR FOR OXYGEN IN ANESTHESIA
WITH HEWITT’S GAS AND OXYGEN APPARATUS.
By J. H. FRYER, M.B., B.O.Oamb.,
ca.pt4.ix, b.a.m.0. (t.c.), 63rd GKNERAX HOSPITAL, B.K.F.
Some months ago, during a temporary failure in the
supply of oxygen for anasthetio purposes, it ooourred to me
to try ordinary* air in place of oxygen with the Hewitt’s
apparatus in general use here. This proved so satisfactory
that the use of gas and oxygen has been entirely discon¬
tinued at this hospital, and some hundreds of administrations
of duration varying from a few minutes to a fall hoar have
been given by the air method.
The air is supplied by a foot-bellows such as that made by
Messrs. Fletcher, Russell and Go., of Warrington, which is
attached to the oxygen tube of the apparatus, and the two
bags are easily kept full by the same foot.
The Hewitt apparatus is provided with a series of ten holes
for the graduated introduction of oxygen to the inhaler, and
by means of a coarse adjustment representing 10 and
20 holes the number used can be varied from 1 to 30. In
working with air it is, of course, necessary to use a freer
entry than is the case with oxygen. The method employed
is as follows:— ., . , . .
A perforated metal “ootton-reel” gag is placed between
the teeth, and a square of Gamgee tissue with a central
cruciform hole intervenes between the face and the mask.
The gas is set slowly leaking from the cylinder into its bag,
so as to keep it just fully distended, while the air-bag is kept
in the same condition by the foot bellows. About seven
“holes” are opened for air entry at the beginning of the
administration, and this number is rapidly increased by
means of the coarse adjustment to nearly the full 30 as soon
as the breathing becomes deep. This is in some eases
Thb Lanoet, J MB. K. PRIDEAUX: STAMMERING IN THE WAB PSYCHO-NEUROSES. [Feb. 8, 1919 217
sufficient to avoid all cyanosis, stertor, or jactitation, during
the induction period, but many patients also require an
occasional breath of pure air at this stage. The pupil
dilates somewhat towards the end of the induction period,
but soon returns to a mid position and remains so through¬
out the administration. The colour is, on the average,
slightly mors dusky than when oxygen is used, but the
difference is small. The induction takes distinctly longer
thn-n with oxygen, and the surgeon generally wishes to begin
too soon.
Breathing soon becomes regular and moderately deep, and
the air entry can then be reduced. There is much variation
between different individuals in the amount of air required
to maintain complete quiet anaesthesia. The average
amount is 15 to 20 “ holes.” Some do best with fewer than
ten, while others require nearly the full 30 “ holes,” and
others, again, an occasional breath of pure air in addition.
Towards the end of a long administration more air and
ess gas is needed, especially with greatly debilitated
subjects
No Ill-effects have been noticed during or after administra¬
tion, and I have not come across any instance of post¬
anaesthetic vomiting. The limitations of this method are
much the same as those of gas and oxygen, though it is
undoubtedly easier to produce and maintain a satisfactory
degree of muscular relaxation when using air. It is very
easy to administer in cases where vitality has been redaced
by shock, haemorrhage, or sepsis, while strong, fall-blooded
men are difficult subjects.
I have not so far used the method for intra-abdominal
operations, and for intra-thoracic I prefer oxygen bubbled
through chloroform and warmed by the Shipway apparatus ;
but for amputations and most general surgical procedures it
is well adapted unless postural requirements contra-indicate
by rendering it difficult to maintain the face-piece in position.
This method has advantages over gas and oxygen from the
points of view of economy and portability of apparatus.
STAMMERING IN THE WAR PSYCHO¬
NEUROSES.
By E. PRIDEAUX, M.B.C.3., L.R.O.P. Lond.,
TEMP. CAPTAIN, B A.M.C., EWELL WAB HOSPITAL.
Stammering is a common symptom of the war psycho-
neuroses, and appears to be one of the most difficult
symptoms to treat. The original theories on stammering
pointed to some physical cause as the basis of the condition
and regarded as responsible factors some weakness of the
organs of articulation, or tongue, or incorrect respiration
with spasms of the diaphragm, &c., perhaps connected in
some way with the blood-supply of the brain. Most of the
treatment at the present day has been based on these old
theories and consists of various forms of complicated speech-
drill and regular breathing exercises. The partially successful
results, obtained by these methods, have convinced both the
instructors themselves, and others, of the apparent truth
of these theories, and there seems some danger that we
should lose sight of the real nature of the affection and the
process underlying the mechanism of its cure.
The Pari Played by Suggestion.
The history of the treatment of stammering, which
includes the use of drugs, both internally and externally,
surgical operations such as that of Dieffenbach by cutting
the root of the tongue, or of Braid, by removing the tonsils
and uvula, various forms of electricity and hypnosis, ail of
which have been successful in their day, must make one
snspect that the present various methods of speech-drill
and breathing exercises, owe their efflcaoy to the same
mechanism—namely, ( ‘ suggestion. ”
My own experience in the treatment of war stammerers
has convinced me that this is the oase. I have removed
stammers by direct verbal suggestion, both in the waking
and hypnotic states, and by indirect suggestion by insinua¬
tion, with the help of electricity, or different forms of
exercises and speech-drill, the effects of which have pro¬
duced physical reactions directly opposed to each other. I
have also used Lays’ old method of so-called “transfer,”
with the help of a hypnotised subject. Some of the
patients treated by these methods had been attending
stammering classes for five months, and gave up their
stammer in ag many minutes.
Just as a stammer can be made to disappear by suggestion
so it can be reproduced by suggestion in certain subjects. A
few of my cases give a history of beginning to stammer only
when being brought into contact with other stammerers.
This is the process named by Freud “ identification.” They
stammer because they have had the same experience as the
others, and do so by auto-suggestion. I have never known a
patient who is undergoing treatment and understands his
condition get a stammer in this way.
Stammering as a Symptom of Hysteria .
Stammering, then, must be considered ms a symptom only
of hysteria, for it even conforms to Babin ski’s limited
definition 1 that “ hysteria is a pathological state manifested
by disorders, which it is possible to reproduce exactly by
suggestion in certain subjects, and can be made to disappear
by the influence of persuasion (counter-suggestion) alone.”
It is also a very good example of Janet's 12 “disposition
to equivalences ” in hysteria, the tendency of one appa¬
rently quite different symptom taking the place of another.
Yealland’s 3 case of an officer with monoplegia of the lower
limb who returned two days after his leg had been cured,
with a stammer, is an instance of this disposition. An
interesting case of mine showed this very markedly. The
patient had been a stammerer since childhood, and at the
age of 21 developed a monoplegia of the right arm after an
accident. Two months elapsed before he came to me for
treatment, and during this time and on admission he had no
trace of stammer. After recovering the use of his arm the
stammer returned, and was removed by further mental
analysis.
Stammering following removal of mutism and aphonia is
also an example of the disposition to equivalences, and does
not occur after modern psycho-therapeutic methods. In the
same way other symptoms may appear as the result of
removing a stammer, when the underlying psychical cause
has not been discovered and explained to the patient.
The psychical nature of the condition is also shown by the
following facts. In my experience stammerers who have
developed their stammer after having once learnt to talk
normally in childhood, do not stammer in their sleep, or
when standing on their heads; they can sing and whisper
without stammering, and stammer less, or not at all, when
talking to inferiors, or reading aloud to themselves. On the
other hand, they stammer more when in a state of emotion,
and stammer particularly over words and incidences which
are associated with some past emotional experience of a
painful nature.
These facts have led me to believe that the physical
theories as to the origin of stammering, such as hyperemia
of the brain, 4 muscle spasms, and weakness of the organs of
articulation, are quite untenable, and' that the present treat¬
ment, by physical methods founded on these theories, is
wrong in principle, and often does harm, even when it is
used by those who recognise the psychical nature of the
condition. Treatment.
In the war psycho-neuroses we meet with two distinct
classes of stammer:—
1. That in which the stammer is more or less constant,
when the patient does not really concern himself about his
stammer; it resembles in this respect mutism, aphonia,
monoplegia, &c., and is the true hysterical type, belonging
to Freud'8 “ conversion hysteria ” class.
2. That in which the patient is intensely anxious about
his stammer, and in which the dread of stammering is suffi¬
cient to keep up the condition. It may only occur in a
state of emotion, and it is more marked in relation to words
and incidents associated with past emotion&l experiences.
This is the “ psychasthenic ” type, and belongs to Freud’s
“ anxiety hysteria ” class.
The treatment of these two classes is fundamentally the
same—viz., finding out the underlying psychical cause for
the origin of the stammer, which will be found to be
connected with some past emotional experience of a painful
nature, giving rise to mental conflict and undergoing
repression.
In the true hysterical type I think it is better to remove
the stammer first by some form of persuasion or suggestion,
using the simplest method possible, so that the patient realises
that he himself is responsible for the cure, as emphasised
recently by Dr. T. A. Ross. 5 Physical exercises for this
type may be used as a means of suggestion and do no harm,
218 THE Lancet,] DR. P. L. SUTHERLAND : STAINING THE DIPHTHERIA BACILLUS.
[Feb. 8 , 1919
provided that the process is carried through in one sitting,
bat they are not necessary. After this a short mental
analysis and explanation are required to complete the care.
I used to rely on some form of suggestion only, bat I soon
found that permanent cure was uncertain. The analysis
mast discover the moment when the stammer or its equivalent
symptom first appeared and the circumstances which led up
to it; all the unpleasant experiences must be folly brought
back to memory, so as to produce complete abreaction, and the
patient must be encouraged to talk freely about them, for
“an emotion, which is judged, and which has become an
integral part of acquired consciousness, is by this very fact
no longer an emotion.” 6
The treatment of the psychasthenic stammer is more
difficult, and more prolonged mental analysis is generally
necessary. In this class I think that physical exercises
definitely do harm. They attract the patient’s attention still
more to his speech, make him painfully conscious of his
stammer, and increase his dread, thereby increasing the
repression of his past experiences. I find that it is better to
make no attempt to treat the psychasthenic stammer as such.
I explain to the patient why he stammers, and reassure him
as to its removal. I tell him that the stammer is only an
expression of the condition of his mind, just as weeping is,
but that in the former he is unconscious of the cause, and
that when we have discovered the cause the stammer will
disappear. When this has been done, and the patient is
able to talk about his experiences without emotion the
stammer gradually disappears.
My experience of war stammers has convinced me that
stammering in civil life must be due to similar causes, that
habit does not play such an important part as is supposed,
and that the best method of treatment is by mental
analysis.
References.— 1. Hysteria, Bablnskl and Froment. 2. Major 8ymptoms
of Hysteria, Janet. 3. Hysterical Disorders of Warfare. 4. Journal of
Royal Army Medical Corps. August, 1917. C. Mac Mahon. 5. The Ljjtcet,
1918, U., 516. 6. Psychotherapy, Dejerine and Gtouckler.
A SIMPLE METHOD OF
STAINING THE DIPHTHERIA BACILLUS
BY A TOLUIDINE BLUE ACETIC ACID MIXTURE.
By P. L. SUTHERLAND, M.B., Ch.B., D.Sc.Glasg.,
BACTERIOLOGIST, WEST RIDIKG COUWTY COUKGIL.
Numerous methods of staining have been devised to
differentiate the Bacillus diphtheria from allied organisms
occurring in cultures from throat swabs. Of these methods
that of Neisser is probably the most extensively employed,
as experience has shown it to be reliable, and it clearly
brings out the characteristic polar bodies of the bacillus.
Neisser’s procedure has, however, the disadvantage that
the counter-staining, washing, and drying of the films
occupies a considerable amount of time, a matter which
is of importance in public health laboratories where
large numbers of cultures are examined daily, ifor routine
examinations the use of methylene blue applied in the
manner recommended by Cobbett and Phillips (1897) has the
advantage in this respect. In this method the smear is made
on a cover-glass and is allowed to dry; a drop of dilute
Loffler’s methylene blue (1 in 5) is then placed on a slide
and over this the cover-class is placed film side down. The
excess of stain is removed by pressing the preparation cover-
glass downwards on a layer of filter paper and the specimen
is ready for examination. The staining is inferior to that
obtained by Neisser’s method, as the Bacillus diphtheria has
very frequently a segmented appearance and the polar bodies
are not clearly shown, with the result that it is often difficult
to distinguish it from the longer forms of Hofmann’s bacillus.
Later, Oobbett (1901) showed that by running a few drops of
dilute acetic acid (5 per cent.) under the cover-glass the
bodies of the bacilli become decolourised, and the polar
granules tend to become more clearly defined.
After a considerable experience of the use of Cobbett’s
method it was thought that it might be possible to prepare a
stain which, applied in a similar manner, would give results
more closely resembling those obtained by Neisser’s stain.
Numerous stains and combinations of stains were tried, and
it was found that toluidine blue, owing to its polychromatic
properties, gave the most satisfactory results. The use of
toluidine blue for the Btaining of Bacillus diphtheria has
already been recommended by Pugh (1905) and by Ponder
(1912). Pugh’s formula was tried, but was found to contain
too much acetic acid.
The stain, the composition of which is given below, was
finally adopted in the Public Health Laboratory, Wakefield,
in 1910, and the formula was published in a short note in
the bacteriological section of the annual report of the county
medical officer for the West Riding of Yorkshire for that
year. The method has now been in use for a period of eight
years, daring which time the annual average number of
specimens examined has been 7000; it may, therefore, be of
interest to those engaged in similar work to describe the
method.
The staining solution, which keeps well, has the following
composition : toluidine blue, 0T g. ; glacial acetic acid,
0-5 c.cm. ; distilled water, 100 o.cm.
The smears are made on slides and are fixed with heat in
the usual way. When large numbers of cultures have to be
examined it is most convenient to make the smears in a
series of 10 or 12 at one time. A drop of the stain is placed
on each film and a cover-glass is then placed over the pre¬
paration. The excess of stain is removed by blotting each
slide between two layers of blotting-paper immediately
before being examined. The first slide is ready for exa¬
mination about one minute after the stain is applied, and
the others are taken in rotation. The best results are
obtained by using strong artificial light.
When stained in this way the polar, granules of the
Bacillus diphtheria are of a deep reddish-purple, while the
bodies of the bacilli appear faintly blue. Most of the
organisms found in diphtheria swabs, including Hofmann's
bacillus, are more faintly stained, so that the Bacillus
diphtheria is readily detected when present only in small
numbers.
The stain may also be used in a similar manner for demon¬
strating the bacillus in smears made direct from the swabs, in
which case the film should be allowed to stand in the stain
for from two to three minutes before removing the excess.
References .—Cobbett and Phillips (1897): The Pseudo-diphtheria
Bacillus, Journal of Pathology and Bacteriology, vol. iv., p. 193. Cobbett
(1901): A Note on Neisser’a Test for Diphtheria Bacilli, The Laxckt,
1901, vol. li., p. 1403. Pugh (1905): A Note on tbe Examination of
Cultures and Smears from the Th oat and the Nose, The Lancet, 1906,
vol. 11., p. 80. Sutherland (1910): Annual Report of County Medical
Officer, West Riding of Yorkshire, 1910, p. 21. Ponder (1912): Tbe
Examination of Diphtheria Specimens, A New Technique in Staining
with Toluidine Blue, The Lakcft, 1912, vol. il., p. 22.
Corrigendum .—At the head of the last column of the table
illustrating Dr. I. Harris’s note on the Inverted “T”in the
First Lead of the Cardiogram (The Lancet, Feb. 1st, p. 168)
? T. should read ? P. T was inverted in all the cases. We
regret the error, which was not the author's.
Literary Intelligence. — The University of
London Press announce the issue of five further volumes in
their Military Medical Manual Series as follows : Disabilities
of the Locomotor Apparatus, by Aug. Broca, edited by Sir
Robert Jones; Electro-Diagnosis of .War, by A. Zimmern
and P. Perol, edited by Dr. E. P. C amber batch ; Wounds of
the Pleura and Lung, by R. Grcigoire, edited by Lieutenant-
Colonel C. H. Fagge; Mental Disorders of War, by Jean
Lupine, edited by Dr. Charles Mercier; Commotions and
Emotions of War, by A. Leri, edited by Sir John Collie.
A Doctor’s Welcome in Uganda.—M edicine
earns its due meed of recognition in Uganda, where, at
Kampala, Dr. Albert Ruskin Cook, superintendent of the
hospital, had a great reception from the European, native,
and Indian communities on his recent return from England,
where he had received a decoration of the Order of the
British Empire. At tbe official residence of tbe Kabaka
there was a large gathering of guests assembled to present
an address of welcome, including the Bishop of Uganda,
Mr. Pellew-Wright, the Deputy Commissioner, and 8ir
Apolo Kagwa, ex-Regent and present Prime Minister. The
address was read by the Lukiko’s secretary, Musa Musoke.
The Indian community erected a handsome arch on the
S ublic road bearing the inscription, “Welcome to Dr. and
[rs. Cook.” A necklace of flowers was presented by Mr.
M. M. Khandwala> president of the Indian Association, who
also read an address of welcome. The day ended with the
cutting the brides’ cakes by Dr. Cook and his wife for the
double wedding in Namirembe Church, when the twin
daughters of Sir Apolo Kagwa were married to the sons of
important chiefs.
Thu Lancet,]
MEDICAL SOCIETY OF LONDON.
[Feb. 8, 1919 219
JJtrirwal Sfftwiws.
MEDICAL SOCIETY OF LONDON.
Gonorrhoea of the Qenito-urinary Passages.
A meeting of this society was held on Jan. 27th, Dr.
A. F. Voelcker (Major, R A.M.O. T.). the President, being
in the chair, when Brevet Colonel L. W. Harrison opened a
discussion on Gonorrhoea of the Genito-nrinary Passages.
Colonel Harrison said: I confess that since I accepted
the honour of yonr invitation to open a discussion on gonor¬
rhoea I have looked forward to the event with considerable
misgiving. For I have no hope of being myself able to say
anything which is new and instructive to the members of this
learned society, and can only trust that I may induce others
to discuss certain details connected with the treatment of
acute gonorrhtca which may be interesting and profitable to
us all. The points which I propose to raise are connected
with the abortive treatment of gonorrhoea, some details of the
technique of irrigation, and the attack on the gonococcus
through the blood stream.
Abortive Treatment of Gonorrhoea.
In other places I have frequently said that if the general
public only realised how easy it is to abort gonorrhoea when
treatment commences on the very first day, and yet how
very difficult it is to cure it when it has been given a start of
even two days, they would apply for advice on the first
appearance of any abnormality, and gonorrhoea would cease
to be the scourge it is. As you know, the gonococcus is an
extremely easy germ to kill with antiseptics, provided that
those antiseptics can only reach it, and had it not been for
its faculty of penetrating to the deeper layers of the mucosa
and into the follicles and crypts opening on to the mucosa,
the gonococcus would long ago have ceased to exist.
We can reckon with a fair amount of certainty on all the
gonococci within an urethra being accessible to antiseptics
only on the first day of the diseate , so that promptitude of
action is of the very first importance. Unfortunately, In
the very great majority of cases the patient will go on
hoping for the best until the discharge has become frankly
purulent, and by that time the gonococcus is well out of
reach. Our colleagues of the Overseas Medical Services have
been pioneers in a widespread endeavour to break down this
fatuous optimism of patients by diligent propaganda and
have met with a considerable amount of success. I would
quote in this connexion Lieutenant-Colonel Raffan, of the
A.A.M.C., who has informed me that in a period of six
months the 18 abortive treatment centres which the Australian
authorities established in this country were successful in
aborting over 2600 cases of gonorrhoea. He agrees with
Ballenger in expecting 90 per cent, of successes when the
treatment commences on the very first day, success meaning
complete cure in a week or ten days.
Encouraged by the success of the Colonial medical
authorities, 1 obtained consent in the latter end of last
year to the establishment of an abortive treatment centre
for Imperial troops in the London district. We have
not met with such a high percentage of success as have the
Australians, mainly, I think, because practically all the
cases on which we have attempted the abortive treatment
have been in the second or even third dav of the disease.
From August last to the end of 1918, out of 738 cases of gonor¬
rhoea which reported at the centre, 129 were considered
worth the attempt at abortion. In 69 the*attempt failed,
and the patients had to be admitted to hospital ; in 10
cases the patient failed for one reason or another to complete
the period of observation after completion of the treatment,
so that it is uncertain whether the attempt was successful
or not, and in 60 cases the disease was aborted in a week or
ten day8. I may mention that in all cases the diagnosis
was verified by microscopical examination of the urethral
secretion and the cure by examination of the patient a
week after cessation of all treatment. As I mentioned,
I think that our success would have been considerably
greater if our cases could only have started treatment a day
earlier, and I have seen sufficient of the abortive treatment of
gonorrhcBa to urge on you the importance of spreading a
knowledge of its possibilities amongst the general public.
Technique.
We have tried many of the plans which have been recom¬
mended for the abortion of gonorrhoea, including iodoform
bougies, large irrigations with permanganate of potassium,
and Ballenger’s sealed-in treatment, in which about 20 minims
of 6 per cent, argyrol are sealed into the urethra for six
hours. The Ballenger method proved fairly successful, but
our cases were mostly too far advanced for its application,
and our present method is as follows :—
1. The parts are thoroughly disinfected with 1/2000 per-
chloride of mercury solution.
2. The urethra is irrigated with 1/4000 permanganate of
potassium solution, using a two-way nozzle and about two
pints of solution.
3. Ten per cent, argyrol or 5 per cent, protosil solution is
injected into the urethra and retained for 20 minutes.
This is repeated twice daily for 3-4 days and then the
silver compound is omitted, the permanganate irrigation
being continued for another 4-6 days. Films of the urethral
secretion are examined every other day for gonococci to
judge the prospects of success. When the discharge has
completely ceased or has become extremely scanty and no
gonococci can be found in it after an honest search, the
treatment is omitted for a day,-and if by the tenth day the
urethra seems to be perfectly quiet all treatment is stopped
and the patient told to report again in a week for confirma¬
tion of the cure. Sometimes he comes back in a few days
with a return of the discharge and is then admitted to
hospital as a failure. The after progress of patients who
have been so admitted has been quite as good as, if not
better than, that of patients who were admitted at once,
so that the method of abortive treatment which we have
adopted does not, like some of the drastic measures which
have been advocated, prejudice the cure when it fails in its
immediate object. Perhaps a longer period of probation
would be a better index of success, but this would involve
considerable administrative difficulties, and after all it is
unlikely that live gonococci would remain a week in a fresh
urethra without setting up acute inflammation.
Some Details of Technique of Local Treatment.
After the disease has passed the stage when abortive treat¬
ment is practicable there is some difference of opinion as to
whether it would not be better to rely only on general
measures rather than to supplement general measures by
treatment applied to the urethra. I am bound to say that it
would be a great advantage if we could dispense with local
treatment, but I have treated parallel series of cases with and
without local treatment, and there is no question that those
on local treatment cleared up very much quicker. I
would also refer you to a paper by Donald and Davidson,
who treated two series of 200 cases each, one by local and
general treatment and the other by general treatment only.
Their experience agrees with my own and -that of most
genito-urinary surgeons, that in the present state of our
knowledge we cannot profitably dispense with local treatment.
There are a few details connected with the local treatment
which may be worth discussion, and I should like to deal
first with
The Prevention of Secondary Infection.
If one takes the trouble to examine the secretion frequently
throughout an attack of gonorrhoea, or, more certainly, if
one takes cultures, it is depressing to find how quickly
secondary organisms make their appearance, particularly
staphylococci and diphtheroids, which are normal inhabitants
of the preputial sao. No doubt these organisms are largely
saprophytic, but I do not think they are as harmless in an
inflamed urethra as they may be in the preputial sac. I have
seen cumbers of cases of chronic urethritis where diph¬
theroids and staphylococci seemed to be the only organisms
present, and there were good grounds for believing that one
or both were responsible for keeping up the irritation.
Occasionally, too, one comes across a case where a
prostatic abscess has formed years after an attack of
gonorrhoea and the pus is packed with staphylococoi, and
we have good evidence that diphtheroids can set up a
particularly intractable form of ulceration of the penis and
inguinal region.
In dealing with large numbers of patients, as we have to
do in the Army, I have found it particularly difficult to
exclude this secondary infection. Circumstances work
rather strongly against one’s efforts. Those responsible
220 The Lanobt,]
MEDICAL SOCIETY OF LONDON,
[Feb. 8,1919
for the constructional details of irrigation rooms have
tended to act on the principle that the arrangements for
snch a sloppy process as irrigation could most suitably be
housed in a wash-house type of place, and once an irrigation
room has been built it is pretty difficult to get it altered.
Such surroundings must act on the patient's mind and tend
to increase his normal carelessness over such details as dis¬
infection of the glans prior to irrigation. Most patients are
content to allow a little of the irrigating fluid to flow over
the glans prior to insertion of the nozzle, but I have never
been able to see the value of a preliminary sluicing with
weak permanganate of potassium solution and have tried
to institute a more effective system of preliminary dis-
infection. In the beginning of the war I provided spirit
lotion with which to swab the glans thoroughly. Later
perchloride or biniodide of mercury lotion was provided,
but I am afraid that even in my own hospital there
is a great amount of carelessness over this preliminary rite,
and unless one, so to speak, makes a drill of it, it is apt not
to be carried out. I have brought up the point because the
great majority of gonorrhoea patients will have to be treated
in public institutions where they will have to irrigate them¬
selves, and unless they are drilled into a habit of preliminary
disinfection secondary infectioo of the urethra is sure to be
common. Also it is fairly certain that subsidiary irrigation
centres will be established, and it would be well to insist
on their internal arrangements approaching the operating
theatre rather than the washhouse standard.
Nature and Strength of the Irrigating Solution.
The nature of the irrigating solution and its strength are
matters over which there is much divergence of opinion.
Before the war I myself experimented with many different
compounds, and I have since had the privilege of seeing very
many more tried by different medical officers, never having
interfered with anyone who wished to try a new remedy,
provided that he did not propose something which was
obviously dangerous and that he undertook to proceed care¬
fully at first. Amongst others I have seen filtered sea-water,
hypertonic saline, eusol, chloramine, and almost the whole
range of silver salts, but, almost without exception, medical
officers have settled on either one of the flavine compounds
or permanganate of potassium, with a weak solution of a
silver compound for a variant. At Rochester Row we have
tried acri- pro- and homo-flavine in different strengths
varying from 1/500 to 1/5000 and have supplemented it with
an ointment kindly provided by Dr. Browning with a view to
keeping up the antiseptic effect. The stronger solutions
seem to have been too irritating and most medical officers
whoare using it now employ a strength of 1/5000, though Davis
claims the best results from injection of 1/1000 acriflavine.
Our results with the flavine compounds have been very similar
to those we have obtained with permanganate of potassium,
but we are inclined to think that the permanganate are
rather better. Permanganate of potassium solution may be
said to be almost the routine irrigating fluid in Army hos¬
pitals, not because there is any order about it, but because
medical officers have themselves found it to be the most
reliable application we have for average cases. The strength
of the permanganate of potassium is a matter over which
there are differences of opinion. Some prefer to commence
with about 1/4000 and increase to as Btrong a concentration
as 1/1000. while others commence with 1/8000 and do not
exceed 1/4000 in the later stages.
Advocacy of Weak Solution*.
Personally, I believe in the weaker solutions at first,
though I know that the stronger solutions may stop the
purulent discharge quicker by their astringent effect. After
all, the purulent discharge represents the effort of Nature to
cast the gonococcus out of the deeper tissues and from the
follicles and crypts which open on the mucosa, and in the
acute stages of gonorrhoea one should do nothing which
will interfere with drainage. My view is that stronger
solutions of permanganate and all definitely astringent
solutions when used in the acute stages of gonorrhoea do
interfere with drainage, and by doing so promote the forma¬
tion of peri-urethral infiltrates.
Some time ago, on the strength of Captain Thomson’s dis¬
covery that gonooocci are very soluble in alkali, I suggested
a trial of alkaline irrigating fluids. I thought that they
might prove more soothing to the mucosa, more destructive
of gonococoi, and, by their solvent effect, assist drainage.
At first a sufficient amount of sodium carbonate was added
to the permanganate solution, immediately before use, to
make a 0*75 per cent, solution of the alkali, but this was
found to be too strong, and we reverted to a £ per cent.
Dr. Stoker, at the Rochester Row Hospital, has adopted the
alkaline irrigation as a routine. He finds that it is more
soothing, and there is some evidence that it promotes
drainage better in the comparative absence of peri-urethral
infiltrates.
Anterior versus Anterior and Po*terior Irrigation in Anterior
Urethritis.
Genito-urinary surgeons are divided in opinion a9 to
whether in purely anterior urethritis one should confine one’s
irrigation to the anterior urethra or, after washing the
anterior urethra, allow the solution to enter and be ejected
from the bladder. It is urged against irrigation into the
bladder that the posterior urethra may become infected
unnecessarily, and that such complications as epididymitis
are much more likely to occur. I should like to advance
some arguments in favour of irrigation into the bladder in
all cases, whether purely anterior or not. First, it is well
known that in a high proportion of cases the posterior
urethra becomes infected without any local interference
whatever, and posterior infection is not unknown under
purely anterior treatment.
Also it is impossible to detect the moment when the infec¬
tion is implanted on the posterior urethra. Yet it is granted
by all that the surest method of preventing infection of the
urethra is to wash away the infection as soon after its
implantation as possible. I think that on these grounds
alone, with the chance of the infection passing to the
posterior urethra always present, one should keep it well
washed from the first. Then it will be admitted that our
object in irrigation is to wash away the irritating discharges
and promote drainage from the deeper tissues, follicles and
crypts opening on the urethra. I should like for a
moment to consider which method is the more likely
to effect this purpose. With anterior irrigation the urethra
is distended as far as the compressor urethrse, and, when the
nozzle is removed, the irrigating fluid is forced out of the
urethra merely by the collapsing walls of the urethra. It
slops out, in fact, and its effect in removing secretion which
may be blocking the mouths of crypts and follicles must
be very slight. Then consider the effect when the sphincter
is persuaded to open and the fluid allowed to enter the
bladder. After some ounces have collected in the bladder
the nozzle is removed and the patient forcibly ejects the
fluid. I think it must be granted that the cleansing effect
must be greater; the mere rush of fluid past the mouths of
the follicles in this direction must tend mechanically to
remove the plugs from them and assist their drainage.
Regarding the risk of epididymitis, there are so many
causes of epididymitis that it would be difficult to prove
that posterior irrigation was a prominent one. The general
incidence of epididymitis in gonorrhrea has been estimated
by various authors at anything from 10 to 25 per cent. The
experience of military hospitals is that the highest percentage
occurs before admission to hospital—i.e., for the most part
before any local treatment has been applied. For instance,
out of 9797 cases admitted to one hospital which received
patients direct from the front 11 *7 per cent, arrived with
epididymitis, while out of 1000 admissions to my own hospital
14 4 per cent, were suffering from epididymitis on admission.
After admission to hospital the rate varies with different
hospital and I strongly suspect it has more to do with the
amount of work the patients have to do than any other
factor In the hospital which I have just mentioned, where
fatigues at one time were very heavy and have since become
moderate, the rate after admission of those cases which
arrived with no epididymitis has been 6 per cent. ; in another
hospital where there is a football ground the rate is 8 per
cent.; while at Rochester Row, where the patients lead a
very quiet life from the point of view of physical exercise an
analysis of 268 consecutive cases admitted last year without
epididymitis showed that 4, or 1*4 per cent., developed
epididymitis while under treatment, and the rate for 1000
cases of 1917 and 1918 has been 2*1 per cent. I admit that
irrigation can cause epididymitis, but it is wrongly conducted
irrigation, especially irrigation at too high a pressure, but in
most cases one can usually find another cause in too hard
work, too early prostatic massage, or too early instru¬
mentation.
Tot Lanobt,]
MEDICAL SOCIETY OF LONDON.
[Fbb. 8,1919 221
1 believe, then, that the best instrument with which to
irrigate the urethra is the bladder, provided that certain
conditions are fulfilled. Thus, the anterior urethra should
be washed first as well as it is possible to do so with an
anterior irrigation and then the sphincter must be perwadrd
to open by a combination of trickery and pressure of
irrigating fluid. But the less pressure the better, and with
ordinary irrigating tubing and Janet nozzle I prefer the
vessel to be 4 rather than 5 feet above the penis. j
_ The Attack on the Gonococcus Through the Blood Stream .
I think that most surgeons who have treated gonorrhoea to
any extent must have felt keenly the limitations of local
treatment. Until the gonococcus has been cast out of the
deeper tissues by natural agencies we have no means of
attacking it by local applications. Too often Nature fails to
complete her task and we are left with residua of infection
which require careful individual treatment to eradicate.
Many remedies have been devised to penetrate the mucosa
and destroy the gonococcus, but none have yet succeeded,
and everyone will admit that if a remedy could be found
which, circulating in the blood stream, would directly or
indirectly bring about the destruction of the gono-
ooocus gonorrhoea would be a much more satisfactory
disease to treat than It is at present. My colleagues and I
have experimented with a large variety of compounds,
but have so far not found any chemical agent which is a
specific for gonorrhoea in the sense of bringing ab*wt destruction
of gonococci. At one time a very large number of patients
under my control were treated with intramuscular injections
of mercurial compounds, especially succinimide of mercury,
and at first it seemed as if a solution of the difficulty might
be found in a mercurial compound. Very frequently the
first injection of the merourial compound was followed by an
almost miraculous disappearance of the discharge, and very
many cases seemed to clear up very rapidly indeed. On the
other hand, relapses were much more frequent than under
ordinary treatment and cases which did not clear up quickly
seemed to drag on with a chronic gleet much longer
than those treated by ordinary methods. Altogether, when
the account of about 7000 cases was made up I found
we had gained nothing. I should not have pursued
this will-o’-the-wisp so long had it not been for the
fact that of all the mercurial compounds which I tried
the succinimide and camphorimide had the greatest effect
and some makes of suocinimide of mercury worked better
than others, all of which led me to think that by patient
research we might arrive at the right combination eventually.
I am inclined now to think that the mercurial compounds
reduced the discharge by interfering with the reactive power
of the tissues, bludgeoning them so to speak. This would
account for the slowness of recovery of those cases which
failed to clear up at once, though I admit that it does not
account for those cases whioh undoubtedly did clear up in
marvellously quick time.
Vaccine Treatment.
Failing a drug or a chemical compound we are left with a
more natural method of ousting the gonococcus—viz., in¬
creasing the anti-gonococcal power of the patient's tissues
by vaccines. Treatment of gonorrhoea by vaccines has
appealed to me since in the early days of my closer acquaint¬
anceship with gonocoocal infections I witnessed the almost
miraculous effect of vaccines I had prepared on oases of
gonococcal arthritis. I admit that, in metastatic complica¬
tions of gonorrhoea, one can obtain excellent results from
the injection of a variety of foreign substances into the
body, as I shall mention in a moment, but I am convinced
that these earlier results of vaccine treatment were not of
the same type, and I can attribute them only to the specific
effect of the vaccine in increasing the antibody content of
the patient's blood. My experience of the vaccine treatment
of gonococcal infections has been mixed. For the most part
it has been an experience of long periods when odo could
legitimately doubt whether they did any good at all unless
one compared parallel series of cases, vaccine and non-
vaccine treated, with one another. These periods were,
however, broken by brighter interludes which were repeti¬
tions of my earlier experiences when the injection of vaccine
was undoubtedly producing excellent effects.
Summing up the whole matter, I concluded that the
ordinary gonococcal vaccine is a poor antigen, but that
oooasionally one hits off a method or happens to use a strain
which results in a vaccine of good antigenic power. The
conclusion is not original, since many workers, amongst
whom I would mention Eyre, Nicolle and Blaizot, and
McDonagh and Klein, have studied to improve the antigenic
power of gonococcal vaccines, either by selection of strain
or by method of preparation. The difficulty until recently
has been to estimate the antigenic power of different
vaccines by serological methods. McDonagh and Klein
suggested that strains which were good antigens in the
complement-fixation test should be selected for use as
vaccines, and I think that in the complement-fixation test
we have the best means of testing the antigenic power of a
vaccine, though not quite in the manner suggested by
McDonagh and Klein.
Inquiry in Regard to Gonocoooal Vaccine.
When Captain Thomson joined as pathologist at Rochester
Row in 1916 I suggested to him that gonococcal vaccine was
a subject well worth study. Captain Thomson 1 began by
devising a culture-medium on which gonococci grow pro¬
fusely, and was thus able to command a large supply of
gonococcal emulsion for experiment. A further step was
made when the method of performing the complement-
fixation test by preliminary fixation for many hours in the
ice-chest proved to be a great improvememt in regard
to its delicacy. This improvement was suggested by the
work of Mr. F. Griffith and Dr. W. M. Soott, of the Local
Government Board Laboratory, who have extensively investi¬
gated preliminary cold fixation in the Wassermann test
for syphilis. Then Captain Thomson found that the gono¬
coccus is very soluble in alkali, and this has led to
improvements in the method of preparing gonocoooal
vaccines which I hope that Captain Thomson and Captain
Lees will have an opportunity of explaining to you.
I will not trespass on their territory more than to
sum up the matter thus. One may divide a gonococcus
into two constituents, stroma and toxin. The toxin has very
slight antigenic power in the quantities of it which can be
administered with safety, while the stroma freed from its
toxin can be administered in such large amounts that a
far quicker antibody response is produced than by injection
of the ordinary emulsion. Captain Thomson’s vaccine is,
therefore, gonococcus stroma minus gonotoxin, and is a far
better vaccine than any I have yet seen administered.
Fortunately for Captain Thomson’s investigations he has
had the advantage of collaborating with Captain Lees,
whose careful observations of the clinical effects of the
vaccine have proved of the greatest value.
Nature of Antigenic Effect.
It has been urged in some quarters that the good effects
which have been noted in the complications of gonorrhoea
as following on the injection of vaccines are not due to a
specific antigenic effect but to that non-specific effect whioh
has been termed protein shock, or, as Add has termed it,
pyrogenic therapy by the injection of foreign Bubstanoes
into the blood stream. There is no doubt that pyrogenic
therapy is a most valuable aid to the treatment of metastatic
gonococcal infections, especially arthritis, and we have a
fairly large series of cases now in which the intravenous
injection of 120 millions of ordinary antityphoid vaooine
has produced most striking improvement. The dose is
repeated, or increased to 150 millions, in about five
days, and the improvement is proportional to the reaction
produoed. Very much the same effect is produced by
the injection of intramine, but, on the whole, 1 think
that the antityphoid vaccine produoes the quicker results.
At one time we bad half an acute ward on the anti¬
typhoid injections and the other half on intramine. They
ran one another very closely, and the effect was always pro¬
portional to the general reaction. I have not yet tried horse
serum, but believe that a similar effect would be produced.
I do not think that the good effects we have experienced
from vaccines depend on the same principle as protein shook
because the new gonococcal vaccine produces little or no
general reaction and we have had no good results from
intramine or antityphoid vaccine unless a general reaction
was produoed.
Discussion.
Captain D. Thomson said that although about 90 per omit,
of 200 clinicians who had written on vaccine-therapy in
i The Lakcet, 1918, il., 42.
222 The Lancet,]
ROYAL SOCIETY OF MEDICINE.
[Feb. 8,1919
gonorrhoea were in its favour very little experimental work
hud been done to explain the cause of their success. Using
the amount of complement-deviating substances as an index,
he had been able to show that antibodies could be evoked in
the human by the use of gonococcal vaccine ; the serological
results obtained were illustrated diagrammatically. He had
succeeded in detoxicating the vaccine, thus permitting the
use of much larger dosage than had formerly been possible—
e.g., 10,000 millions of cocci could be injected without pro¬
ducing more than a slight reaction. The detoxicated vaccines
were very successful in inducing the formation of anti-
substances. If the complement deviation could be raised to
10 or 12 positive, no cocci were obtainable from the infected
source.
Clinioal Evidence of Value of Detoxicated Vaccine.
Captain D. Lees, speaking from the clinical point of view,
said that he .had compared the therapeutic results in five
ierjes of cases, each series being specially treated. Those
which cleared up first and spent the shortest time in hospital
were treated by vaccines. The remaining series in order of
therapeutic success were oases treated by mercury for three
day? and tfyen by vaccines, cases treated by medicine and
irrigation* pases treated by mercury alone, and, lastly, cases
treated only by rest in bed, without local or general measures.
The, cases treated by vaccine were characterised by a
.greater moderation ip symptoms, absence of complications,
improvement in general condition and mental outlook,
leas time spent in hospital, and freedom from relapses.
. Certain groups of cases had been treated by detoxicated
vaccines. One such consisted of 12 cases complicated
by epididymitis in all of which cocci were found.
2500 million organisms were injected, the dose being sub-
. sequently worked up to 10,000 million. The acute cases
cleared up very quickly, 1 in 6 days, 1 in 7, and 1 in 15 ; all
have reported regularly since, and with one exception have
kept free from infection. Another group was composed of
3 oases complicated by prostatic abscess. On an average
the cocci disappeared in 45 days, the discharge in 59, the
prostatic enlargement in 62, and the period in hospital was
69 days. Two cases with multiple arthritis and active
gonorrhoea were similarly treated ; the gonococci disappeared
in 4 days, the discharge in 16-5 days, and the joints were
normal in 56 days. The prostatic cases stood the treatment
less well, than the epididymitis cases and showed more
focal reaction; in the joint cases there was no focal
reaction and the general reaction was slight. A series
of acute cases of five to seven days’ duration was then
treated, and the.results were very striking. . Comparative
results of cases treated by no vaccine, by ordinary vacoine,
and by detoxicated vaccine emphasised the value of the last
as.gauged by the complement deviation, the length of period
preceding disappearance of organisms and discharge, and
the duration of stay in hospital. With this treatment
•local reaction was practically absent, focal reaction slight
for one day, and general reaction also slight except in one
case. Disappearance of symptoms, cocci, and discharge
was rapid. No complications developed except slight
•folliculitis in one case. The clinical results therefore tallied
with the serological. He was convinced that the treatment
•is a valuable adjunct to that usually employed.
Viens of Other Speakers.
, Lieutenant-Oolonel R. Bolan had oritioally scrutinised
the effect of the treatment by vaccines in a hospital of
which he was in charge, and expressed himself as satisfied
that the method was the best yet employed.
■ Captain D. Watson was in almost complete agreement
with Colonel Harrison. With him he favoured uretbro-
uesical lavage. He had given up all attempts of doing good
by internal methods. His experience with vaccines had
•been varying, and he had seen cases where harm had been
caused by their use. In 307 cases of acute gonorrhoea, the
average stay in hospital had been 26 8 days. In 222
treated by acriflavine the period was reduced to 21 days.
Twenty-six of these were accompanied by complications; in
the remaining 196 the average stay was 19 8 days. Six per
cent, relapsed. Complications arising in the 222 cases
were epididymitis in 2 cases, subacute prostatitis in 2 cases,
oystic abscess in 3 cases. The treatment must be continued
for 10 or 12 days, although the discharge ceased after 3 or 4.
The strength employed had been 1-4000 acriflavine with
normal saline.
Captain Edwin Davis, U.S.A., who had worked experi¬
mentally with acriflavine, considered that it is worthy of a
more thorough trial, for it inhibits growth of gonococci in
1-300,000 dilution, does not lose its power in urine, shows a
great tendency to penetrate tissues, and, moreover, is non¬
toxic and non-irritating.
Mr. Campbell Williams spoke critically of many of the
procedures adopted in the treatment of gonorrhoea, notably
the giving of injections with the patient lying on his back,
the use of mechanical apparatus for elevatiag the containing
vessel, and the application of a band around the penis. He
cited an instance where the disease had been prevented after
infection. Relapse was frequently due to reinfection from
small glands in the neighbourhood of the frenum, and
treatment directed towards them would often avoid it.
Colonel Harrison briefly replied.
ROYAL SOCIETY OF MEDICINE.
SECTION OF MEDICINE.
Apyrexial Symptoms of Malaria. .
A meeting of this section was held on Jan. 28th, Dr. A. F.
Voelcker (Major, R.A.M.O. T.) being in the chair. .
Captain Gordon Ward read a paper entitled “ Apyrexial
Symptoms of Malaria.” The object of the paper was to
provide guidance as far as might be for those who might be
called upon to report (1) as to whether a man showed signs
of haviDg recently had an attack of malaria ; and (2) as to
how far a man was disabled owing to chronic malaria, the
existence of which in the case was not denied. It was
anticipated that such questions would arise after the war in
industrial spheres and before pensions boards. The class
of case met with would be quite different from anything
hitherto widely known in Great Britain and, to a large
extent, very different from the class of case met with amongst
inhabitants of a malarial country. The paper was based on
observations made on over 1000 cases of soldiers under treat¬
ment in hospital. These had contracted the disease in various
parts of the world, but were seen only after their return to
France or England. Owing to the needs of military service
the patients were takingquinineduring the period of observa¬
tion. It was believed that the picture of malaria seen in
these circumstances was that which would be met with in
civil.life for some years to come.
Symptoms.
The following list of symptoms did not profeBs to be
exhaustive, but comprised those most likely to be of value.
1. Apyrexial rigor. A typical malarial rigor with shaking
and hot and sweating stages might occur with no rise of
temperature. This would not be often met with, but a
knowledge that it did occur might prevent mistakes.
2. Herpes labialis was common the day after an aoute
attack.
3. Headache. This was frontal as a rule, sometimes occi¬
pital, almost never vertical. Temporal and frontal headache
together were often seen. The patient’B statement might
often be verified by detecting hyperalgesia at the margins of
the area in which pain was felt. ..
4. Eye signs. Conjunctivitis, photophobia, and nystagmoid
jerking were frequent in acute attacks. In chronic cases
photophobia, pain behind the eyes, and rarely strabismus,
were seen.
5. Pharyngitis and laryngitis both occurred in* association
with acute attacks, just as they did in influenza and many
other fevers. , a „
6. Jaundice. Some people seemed especially prone to
jaundice after attacks of malaria. A slightly yellow colour
was suspicious in chronic cases.
7. Perisplenitis. A friction rub (lasting three to five days)
might be heard over the spleen in a few cases.
8? Pain in the side. This might be due to pleural adhesions.
If so, it was felt most on deep inspiration, and a course of
deep-breathing exercises would often dispel it. It might be
due to splenic adhesions when more complaint was made
when the patients stood for long or took much exercise. These
two occurred in chronic cases, and both were often due to
malaria, the former, of course, indirectly. Pain in the side
might also depend on hyperalgesia of the skin or muscles.
It was then at times bilateral. This was frequent in acute
^l. 6 Tremor. A fine tremor of the tongue and hands, rarely
of the lips, was common. It might persist in chronio oases,
and was then often associated with chronio headache and
depression.
The Lancet,]
TUBERCULOSIS SOCIETY.—SOOlfiTft DE BIOLOGIE, PARIS.
[Feb. 8,1919 223
10. Pigmentation. At times pigmentation was seen to
increase with attacks and diminish between them; this was
a good but rare sign.
11. Tachycardia was common when the patient first got
ont of bed, and might persist or only be elicited on exertion.
12. Hyperidrosis. This was not infrequent, although
not often complained of. Occasionally it was so severe as to
constitute a serious disability.
13. Splenomegaly. This was an uncertain sign in oases
such as those under consideration. It occurred in indis¬
putable form in severe attacks and when jaundice also was
present.
14. Transient oedema. Local swellings of the nature of
giant urticaria were sometimes seen on hands or legs; they
lasted a few days only.
15. Raynaud’s symptoms. “Dead fingers” and feet were
Often seen.
16. Weakness was often complained of, but was hard to
assess.' With the patient under observation it could be done
by various tests, but must, as a rule, be a matter rather of
opinion than demonstration.
' 17: Blood changes. The presence of the parasite was
deflhite evidence. The presence of an increased number of
mononuclears ” was of no value. A fall in htemoglobin
always needed explanation, but was not nqpessarily due to
mpl^ria. An increase of eosinophils was suggestive of
malaria, as also was the presence of endothelial cells. The
tO&l number of white cells was of no particular value in
di&fgnosis. The presence of abnormalities of the red cells,
tfuch as polychromasia, anisocytosis, and megalocytosis, was
important and strongly suggestive of malaria.
In addition to the above, transient hemiplegia had been
seen. Leg pains similar to those of trench fever were to be
expected in a certain proportion of oases. Purpura was rare
in the class of case dealt with. Urticaria and mastitis and
a specific rash had been noted by some writers. Sudamina
were hot rare. Albuminuria would be of importance, bat
there was no opportunity of inquiring into the point.
Discussion.
Colonel Andrew Balfour spoke of the relapses as
probably indicating sporulation in internal organs. He
agreed as to the occurrence of apyretic rigors, which usually
merged later into more definite pyrexial relapses. It was
questionable as to whether the rectal temperature would also
have been found to be normal. If the thick film method of
examination had been used the chances of finding parasites
would have been increased. He raised the question of
hepatic tenderness after malaria, a sequel which he thought
not uncommon. It was difficult to state definitely that all
the symptoms were malarial in origin.
Dr. F. S. Lang mead deprecated the common fault of
ascribing all symptoms occurring in people coming from a
malarial country, or even in malarial subjects, to the malaria
itself. A more patient examination would sometimes show
that a patient who was regarded as suffering from an
unusual form of malaria was really the subject of an
independent *or secondary infection. Despite this warning,
he agreed that malaria was almost as protean in its
manife?>tations as Captain Ward had declared. He
had had facilities for observing about 10,000 cases
of malaria, and agreed as to the occasional occurrence
of rigors without fever. Such rigors were frequently accom¬
panied by malaise, headache, sweatfbg, rapid pulse, mental
depression, and even by vomiting. Cases had been seen
of all degrees, ranging from those with rigors without altera¬
tion of temperature, through those with rigors where the
temperature only attained the normal line, and those where
the rigor was associated with a very slight pyrexia, up to
those with characteristic pyrexial attacks. Pigmentation
might be so severe as to resemble that of Addison’s disease,
and with this he associated also cases with temporary or
persistent low blood pressure and small pulse, possibly
ascribable to suprarenal defect. Defective action of this
gland and also of the thyroid was suggested by the tachy¬
cardia, tremor, and exophthalmos which had been referred
to and which certainly occurred. He had come to regard
tachycardia in malaria as occurring in three clinical forms :
(1) a transient form abating with or soon after an attack ;
(2) a more persistent form which subsided after several days
or weeks ; (3) a chronic and protracted form which possibly
Wctald remain permanent. It was difficult to say when the
last two forms were indications that the malaria was merely
in abeyance. Statistics as to the efficacy of various forms
of treatment in preventing relapses were unreliable, as what
constituted a relapse was often decided by rule of thumb
and apyrexial uttaoks were not considered.
Dr. J. A. Arkwright spoke of the presence of urobilin
in the urine as a valuable help in diagnosing malaria in the
absence of a paroxysm.
Captain Ward briefly replied.
TUBERCULOSIS SOCIETY.
Practical Remarks on Tuberculosis in Relation to the Tipper
Air and Food Passages.
A meeting of the Tuberculosis Society was held at the
Royal Society of Medicine on Jan. 27th, under the presidency
of Dr. Halltday Sutherland.
Dr. Dundas Grant in a lecture on the above subject
touched upon most of the conditions which tax the
resources of the tuberculosis officer and the medical
officers of sanatoria and hospitals. Many of the forms
of treatment of tuberculosis of the larynx are only
suitable for the specialist, but Dr. Dundas Grant gave an
optimistic review of the results obtained by the simpler
methods. Attention was called to rest to the larynx by
silence and the voiceless whisper, much improvement occur¬
ring in the voice and condition of the vocal cords in a few
weeks. Although a ‘ ; useful ” cough was to be permitted,
many coughs by patients were useless and injurious. Much of
this injury might be avoided by the voiceless cough practised
without closure of the vocal cords. Continuous inhalation,
advocated by Dr. Burney Yeo and Dr. David Lees, was
referred to, but Dr. Dundas Grant considered its value
chiefly due to relief of cough and not to any bactericidal
effect. He recommended the following inhalant:—
Creasot. 3111.
Ol. pint sylvest., spir. ohlorof. ... aa3iss.
01 . cinnamon., ol. citronell. aa mv.
With menthol gr. v., gradually increased unless found irritating.
Nasal obstruction and nasal catarrh had a markedly detri¬
mental effect upon laryngeal disease, and he said that these
conditions should receive full attention. The use of a
simple alkaline and antiseptic nasal lotion, employed with
the aid of Grant’s inspiratory nasal douche, of the following
formula was often followed by very good results :—
Sod. biborat. gr. xcri.
Sod. chlorid., sod. salicylat. ...aagr. xlviil.
Glyc. pur. Ut lxxii.
Aq. menthol. ad 5 vi.
A teaspoonful to the ounce of warm water.
In local conditions with great pain removal of portions of
the epiglottis or the aryepiglottic fold had frequently to be
performed, but in a great measure these procedures were
obviated by the use of the galvano-cautery, the results in
disease of the larynx, tongue, and nose being most gratify¬
ing. In this connexion inhalation of orthoform and anses-
thesin by means of Leduc’s powder inhaler, whioh the patient
could learn to use by himself, was advocated and described.
Dr. Dundas Grant said that the injection of alcohol into the
superior laryngeal nerve to produce complete anaesthesia
might with a little practice be accomplished with fair
precision, affording great benefit. In concluding he
mentioned the treatment of enlarged tonsils and adenoids,
the remote effects of which were of such importance in the
chest disease of the child.
SOCIETE DE BIOLOGIE, PARIS.
The following is a summary of some of the papers read at
the meeting of the society held on Jan. 25th:—
P. Portier. —Development of Larvae on Sterile Food.
L’auteur a observ6 le d^veloppement complet dea larvos de‘ TinObrio
molilor obfcenues au moyen d'une nourriture stlrillsAe A haute
temperature (130°). Lea animaux dans ces conditions aont approvi-
slonn^s de symbiotes par un m6can1sme special (cryptogames ou micro-
organismes Indus dans leurs tissue) qul s y developpent et echappent A
la oarence.
Michel Biedlecki (Cracow).—Remarks on the Terrifying
Attitude in Animals.
A propos de ce qu’on appelle "la position terrifiante” des animaux,
1° La position de bataille et celle qu’on appelle terrifiante ne sont pas
les mdmes. 2° Trds sou vent la position terrifiante n’a pas de valour
pour la defense de l’anlmal. 3° Le position terrifiante peut fitre pro-
▼oqu4e non seulement par la presence de I'enneml au voisinage de
l’anlmal, mats aussi par different® autres agents, aoit la fatigue, soit en
g^n£ral une Irritation de tout l’organlsme.
224 The Lancet,]
REVIEWS AMD NOTICES OF BOOKS.
[Feb. 8.1919
Dr. Bonnefon.—R- tgeneration and Revivescence.
" RAeAnAration ” rFAg^le P»» “ revivlacenoe.” Lea AI Amenta cellu-
laires mnrts sont rcmplaoes par dea celules Abnmg&res au ifr«*ffon. II y
a done »-©*£'lArauon eb non revivlacence. Quant A la trame connective
du jpreffon qui aert de canevasA cebbe regeneration, elle n’apaa A mourlr,
nl pas consequent A survivre ou revlvre paiaque e’eat un “co^gulum
inerte.” Bile ne peut qa’ c re aaslmiiAe. To us cea f&i a ont eb etu lea
et InterprAtAs au coura dee recherche* d'avaut guerre aur la greffe
de la cornAe.
L. La UNO y — Antagonistic Action of Blood Seram against
Bacterial Proteases.
II rAsnlte de cea recherchea que pour dea actions protAolytlqaes quail-
tatlvement egaiea, Faction nu serum aanguln eat beaucoup plua talble
sur lea probei8«a mtcrobiennes que aur la trypaine. D'oii 1' auteur
conclut que FinterprAtatlon qui fait du pouvolr anbibryptique du sA'um
un phAnomAne banal, eat incompatible avee lea faita. D'autre part,
l’anteur a obtenue p«r l'lnjectlon au lapin de protAases microblennea
l’apparltion dans le serum de proprtAbe j inhibitrioea trAi Auergiquee.
Oe* proprlA'A* lnblbitricea aonfc ape dfiquee p >ur la protAwe InjeotAe.
A. Grigaut, A Ranque, et Mrae. Pommay-Michaux.—
Measurement of Bacterial Proteolysis.
Lea different* microbes de la plale de guerre, enaemencAa aur le
milieu k Toeuf, determinant une protAolyae plua ou molna abondante
dont la raarohe peut 6tre auivie oommodAment au moyen du procAdA
de neaalAriattlon dAcrit par lee auteur*. Le doe age de laso e non
protAlque notamment permet d’apprecier le taux de la protAolyae dana
un mideu de oulture dAterminA et de mesurer I'activii protcolytiquc
compares des d ffirentes csplcct ou associations microbiennes.
F. Chbvrel, A. Ranque, Gh. Senez, et E. Gruat.—
Vaccine Therapy in Influenza.
Le* injection* Intraveineuaee de vacetn pnenmo-atreptocoocique iodA
parfaibement tolA A* ont amenA dea defervescences bruaques aveo
K Art son dan* de nombrenx c%s k corapiioationa pulmonairea grave*.
m l«a aeptlcAmiee k atreptoooquea le vaccln n'a pa« donnA de rAaultaba
apprAciables ; par oontre dana lea aepblcAmles k pnenmocoquee, la
vmocinobhAraple a donnA dee rAsultata exoellenta.
JUtriefo* snh Jolicts of ^aoks.
Training and Rewards of the Physician . By Richard C.
. Cabot. M.D. London and Philadelphia: J. B. Lippincott
Companj. 1918. Pp. 153. 6s. net.
The title of. Dr. Richard Cabot's work is somewhat of a
misnomer in that the book says not much about the studies
and carricolam of a medical school. One admirable point
in the work is the insistence with which Dr. Cabot urges the
necessity for the physician being trained to understand his
fellow men, seeing that patients are not merely “cases,”but
human beings with their own very real troubles and limita¬
tions. We mast take exception to Dr. Cabot’s statement on
p. 45 that the physician,
•• during hla experience as a hospital Interne tend*.to dlacard
whatever he had anoirnof human feeling*, fear*, delicacies, aspiration*,
and especially to Ignore tne difference* of individuals and their need of
individual treatment .... the young doctor at the end of his Interne-
ship ia often more newly dehumanised than at any period in his life-
before or after hla hospital year."
We cannot think that this is strictly true ; in oar
experience a year’s work as a house surgeon or house
physician in a big hospital will teach a man more about his
fellow men and their needs than he would learn in the same
time in almost any other work.
Dr. Cabot lays stress upon an important point which the
ordinary public is in danger of forgetting and which many
medical men do not realise, and that point is that nowadays
the main work of the medical profession is devoted to doing
away with illness—i.e., its own professional source of sub¬
sistence. While writing on this subject he quotes from a
letter written by a patient suffering from tuberculosis who
mentions that in June, 1903, he consulted a
"physician regarded aa eminent in his profession and a man of long
experience. 1 had then lost about ten pounds in weight. He examined
me carefully, examined my sputa, found tubercle bacilli.”
The patient continued to lose weight—namely, 81b. more
in three weeks—and continued under the care of the
physician until August, during which time “nothing was
said to me in regard to outdoor living.” He then read an
article on open-air treatment in a popular magazine and,
after consulting another phvsician, tried it together with
rest, and recovered. Dr. Cabot quotes this incident as
an example of the good which may be done by articles on
medicine in the lay press. Such articles may, as in the
above instance, do good, bat they often do harm, and we must
express surprise at a physician “ regarded as eminent in his
rofession and a man of long experience,” who, moreover,
new abont tubercle bacilli, being either ignorant of, or
inorednlons as to the benefits of, open-air treatment so
recently as the year 1903. Pablic experience had made
the value of open air pablic knowledge years before—
in this connexion we may note that one of the earliest
references in the lay press to the benefits of open-air
treatment appeared in Lytton’s “Strange Story,” first pub¬
lished in 1862, while Reade used the same incident in
“Foul Play” a few years later. A fine chapter in Dr.
Cabot’s boos deals with the rewards of the physician. What
these are we mast leave to readers of the work to find out ;
we will merely quote Dr. Cabot’s last sentence. Of the
practice of medicine he says: “Its rewards, as I see them,
are beyond those of any other profession.”
United States X-Ray Manual. Authorised by the Surgeon-
General of the Army and Prepared under the Direction of
the Division of Roentgenology. New York: Paul B.
Hoeber. 1918. Pp. 506. $4.00.
This volume supersedes the small manual hurriedly pre¬
pared at the beginning of the war and is to serve as a guide
to radiologists taking up military work, as well as a text¬
book for those without previous X ray experience. It is in
consequence a very complete and concise treatise on the
whole subject of X ray diagnosis, prepared with mnoh care,
containing numerous illustrations and diagrams which
remove all ambiguity with an absence of superfluous
verbiage. While, naturally, military practice predominates
the line of demarcation between this and civil practice is
really a very narrow one and the fundamental principles are
the same. It is thus not too mnoh to say that as a text¬
book for those who aim at proficiency in X ray diagnostic
methods this would be hard to beat.
Every branch of the subjeot is treated as folly as the
occasion demands, neither too much nor too little, and it is
unnecessary to pick out any section for special comment.
Great praise is due to those responsible for its production,
not omitting the publisher, whose work is exactly suited to
a book of this kind.
The Chemistry of Synthetic Drugs. By Percy May. D.Bc.
Lond., F.I.C. Second edition, revised and enlarged.
London: Longmans, Green, and Go. 1918. Pp. 250.
10 *. 6 d.
The progress that has been made in this country since the
war in the production of synthetic drugs, formerly confined to
Germany, adds considerably to the interest of this volume,
now brought to a second, revised and enlarged edition. It is
good to learn from an authority like Dr. May that though
the manufacture of synthetic organic chemicals on a large
scale presents many difficult problems, yet most of these
have been successfnlly overcome by British chemists in so
short a time; but he rightly points ont that these successful
efforts some day will oome up against the vast and highly
organised German organic chemical industry. That will
present a problem which it will be the duty of our fiscal
authorities to solve, but there is another point to
be remembered. There can be little donbt that it
would be an advantage if many of the synthetics
were ruled out so far as regards therapeutics. As
this book shows, it is not difficult to modify the
structure of many compounds and to build up by the
substitution of groups an extensive series of products
which have a commercial impulse behind them rather than
a pharmacological interest. Mainly addressed to the chemist
who may not happen to know the exact chemical nature of
these preparations, the book nevertheless affords attractive
reading to medical men, who may thns trace the relationship
of constitution (groupings) to therapeutic action.
SUricheiometry. By Sydney Young, D. Sc., F.R.8. Second
edition. With 90 figures in the text. London: Longmans,
Green, and Oo. 1918. Pp. 362. 12*. 6d.
The not very elegant word “ stoioheiometry,” the title of
this book, implies a study of the laws governing chemical com¬
bination and their application to ohemical calculation. This
study involves a consideration of atomic values, according to
latest determinations, of the functions related to these
values, the properties of the different forms of matter
as we know it, the solid, liquid, and gaseous states, the
properties of all three states, their behaviour to one
another, as in the solubility of gases and solids in liquids.
The Lancet,]
REVIEWS AND NOTIOEB OF BOOK8.
(Feb. 8,1919 225
absorption, adsorption, and so forth. These subjects form
the conspectus of the ground traversed by Professor Young,
who has devoted himself to theoretical questions with the
thoroughness and detail which have characterised his studies
since the early diys of his professional career. The prac¬
tical importance of his work is revealed throughout the pages
of the book, wherein the painstaking labour of investigators
is revealed in sequence since the classic work of Stas
(1831-1891), who, in spite of relatively simple facilities,
obtained values so accurate that to this day they are retained
as representing the truth as near as we can reach it by
modern knowledge. It is of interest also to remember that
Stas laid the foundations of the methods employed to the
present day in the separation and identification of alkaloids.
Professor Young has made a very important addition to a
valuable series of text-books of physical chemistry, first
issued under the editorship of the late Sir William Ramsay.
Introduction to Inorganic Chemistry. By Alexander Smith.
Third edition, rewritten. London : G. Bell and Sons,
Ltd. 1918. Pp. 985. 8 s. 6 d. net.
Professor Smith’s teaching experience at Columbia Univer¬
sity, where he is a professor of chemistry and administrative
head of the department, has led him to try how best
to open his subject to beginners, whether at university,
college, or school. He makes the study of chemistry of
interest from the start by coupling with the reading of this
book a systematically arranged course of laboratory work in
general chemistry, and the early chapters contain a discussion
of a few typical experiments which bring before the student’s
consideration the manifold and broad questions with which
chemistry deals, and the real purpose of its study. The
theoretical portions are clearly written and well sustained by
practical illustrations. This third edition is brought up
to date, as evidenced in the chapters on dissociation,
ionisation, and the modern methods of writing formulae
expressing reversible reactions.
There have been issued also two further books by the
same author and publishers. One, .1 Laboratory Outline of
College Chemistry (pp. 206, 3s. net), and the other, Experi¬
mental Inorganic Chemistry (pp. 170, 3s. 6d. net), which both
form excellent guides to practical work in which particular
attention is given to those details which, when instructions
are followed, carry experiments to a successful issue and
ensure accurate training.
Veterinary Post-mortem Technic. By Walter Crocker,
B.S.A., V.M.D., Professor of Veterinary Pathology,
University of Pennsylvania. With 142 illustrations.
London and Philadelphia: J. B. Lippincott Company.
Pp. 233. 16#. net.
As stated by the author in his preface, “ the scientific
study of pathology without proper post-mortem technic is
impossible,” and it is with a view to describing to the
student the proper way to make a post-mortem examination
that books of this kind are written. Veterinary literature
has not been enriched by many books upon this subject, and
Dr. Crocker’s work should certainly be welcomed by many
readers. It describes in full detail all the particulars
necessary for exposing the important organs to be examined
in cases of death from any special (or, indeed, any ordinary)
disease, and the illustrative plates are excellently made, so
that with these and the text no student can possibly go
wrong.
The descriptions are a little American in style, and occa¬
sionally the expressions strike an Englishman as not being
quite those he has been used to in student days, but they
are very clearly put, and autopsies of all kinds of animals
and birds are fully ^detailed. It is a book particularly useful
in these days where even the ordinary practitioner is called
upon to find certain hidden glands in order to obtain micro¬
scopic preparations from them and otherwise examine them.
The clinical practitioner is apt to forget their exact locality,
and as some are quite small he has difficulty in finding them.
Fromsuch a book as this for reference he can obtain all the help
and guidance he needs, and a most useful chapter is given
on the average measurements and weights of organs. The
'book should be bought; if it goes too fully into small details
the fault is on the right side. The author deserves every
praise for a work which will be of real use to the veterinary
profession.
JOURNALS.
British Journal of Children's Diseases. Vol. XV., October-
December.1918. Edited by J. D. Rolleston, M.D.—In their
article on Ruptured Aortic Aneurysms in Childhood Dr. E.
Bronson and Dr. G. A. Sutherland record a case of death due
to the rupture of a fusiform aneurysm of the ascending arch
of the thoracic aorta in a boy aged 5 years and 10 months.
The aneurysm apparently followed a partial stenosis of the
aorta between the insertion of the ductus arteriosus and the
left Bubclavian artery. That this structure was a congenital
anomaly was supported by the presence of a diaphragmatic
hernia, subluxation of the joints, and defective cranial
development. The writers classify aneurysms in childhood
into (1) arterio-sclerotic; (2) traumatic; (3) embolic or septic;
(4) false due to erosion from without; (5) due to congenital
anomalies. The present case was an example of the last
group. Two other instances on record of aneurysmal
dilatation due to partial stenosis of the aorta are
summarised, as well as five cases of aneurysms apparently
due to congenital anomalies in the structure of the ductus
arteriosus. In two of the latter rupture caused death.
The writers have found in the literature seven reports of
death following rupture of thoracic aortic aneurysms in
children, one oase oi rupture of the aorta without aneurysm,
and two cases of aneurysms of the abdominal aorta. A
complete bibliography is appended.—In an article on the
“Food Deficiency” or“Vitamine” Theory in its Applica¬
tion to Infantile Beri-beri, Major F. M. R. Walshe
summarises the present state of our knowledge of beri¬
beri as follows. Beri-beri is dietary in origin in that it is
associated with a physiologically inadequate diet. Yet the
purely negative vitamine-starvation explanation of its patho¬
genesis, apart from the inadmissible nature of its contained
assumption that a disease which clinico-pathologically is
clearly an intoxication could be solely and directly caused by
the mere absence of anything from the food, is inadequate in
that it does not recognise the existence of the two factors
essential to the production of the disease. These two
factors are: (1) the absence of an unknown accessory factor
or vitamine; and (2) the consumption of carbohydrates.—
In a note on Abnormal Naughtiness in Normal Children,
Dr. John Thomson points out that cases of this kind are
essentially of the same nature as those of “ moral imbecility”
in children who are to some degree mentally defective. The
proper treatment is as follows: (1) all severe corporal punish¬
ment must be stopped—it never does any good; (2) nobody
must ever appear shocked, amused, or even surprised at
anything the child does; (3) his misdeeds are never to be
alluded to in his presence; and, lastly, he should be noticed
and encouraged in every way when he is good, and
altogether ignored when he is naughty.—Dr. Reginald C.
Jewsbury records a oase of Muscular Spasm in a Child,
which Dr. F. Parkes Weber, in his remarks on the
case, shows is the first example published in England
of “Dystonia Musculorum Deformans” (Oppenheim) or
“ Progressive torsion spasm of childhood.” The present oase
is exceptional in that hitherto the disease has been described
only in Russian, Polish, and Galician Hebrew families.
It runs a chronic progressive course with intermissions and
even with periods of improvement, and may then come to a
standstill, other portions of the nervous system remaining
unaffected. It is characterised by a peculiar mixture of
hypertonus and bypotonus of the affected muscles. The face
and muscles of articulation are usually not affected except
in late stages, when there is involvement of the muscles of
the neck. Among the earliest symptoms is partial or total
loss of function of one or more extremities due to faulty
tonus innervation. Talipes tends to persist. The move¬
ments of the affected parts are spasmodic, but not truly
athetotic. Psychical symptoms may occur, but the mental
condition is generally normal.—The abstracts from current
literature deal with diseases of the alimentary canal,
surgery, orthopaedics, and ophthalmology.—The very full
index contained in this issue should be an invaluable guide
to current paediatric literature.
Journal of the East African and Uganda Natural History
Society. No. 13, November, 1918. London: Longmans,
Green, and Co. Price, to non members, 5s. 4d.—Among the
contents of this issue is an article by Mr. A. Blayney Percival
on Game and Disease, in which the author develops his
view that Nature has her own methods of preventing the
spread of disease among wild animals, while at the same time
she utilises disease as one method of ensuring the survival of
the fit. Ngar narua he identifies with anthrax, and states that
the Masai recognise the disease as one which man may con¬
tract. The Masai’s treatment of the human patient is to
promote perspiration by wrapping him in the freshly stripped
warm hide of an animal, at the same time depriving him of
all milk, giving him to drink only a decoction of a native
root. In British East Africa, according to the author, both
game and cattle have developed to some extent immunity
against rinderpest, while the wart-hog has failed to do so.—
In his notes on East African snakes Mr. A. Loveridge shows
226 The Lancet,]
NEW INVENTIONS.
[Feb. 8, 1919
that there is no easy criterion for distinguishing between
poisonous and harmless species, variations in colour and
shape of head being inconclusive.
La Medicina Ibera (Madrid, weekly) has now entered on
its second year of publication, and may be congratulated on
having won for itself a distinctive place among Spanish
medical journals. Its abstracts of articles in Spanish,
British, French, and American periodicals are a prominent
feature and are excellently done. In the number before us
that for Dec. 28th last—Dr. Encinas abstracts the Spanish
and Dr. Zapata the foreign journals. It is not easy to
make abstracts interesting, but both writers have succeeded
in doing so, thanks to an easy and lucid style and a
sure judgment for salient points. Original articles are con¬
tributed by Dr. Villaverde and Dr. Alvarez. The former
writes on “ Spasm of the Orbicularis Palpebrarum and
the Cervical Muscles,” and discusses an interesting case
in which bilateral orbicularis spasm, leading to almost com¬
plete closure of the eyelids, and causing the patient to throw
his head back in order to see through the narrowed palpebral
aperture, was followed,after a time, by a tonic contracture of
the cervical muscles, fixing the head in the position at first
adopted voluntarily. The case i3 of special interest in that the
electrical reactions of the facial nerve were perfectly normal
and that, of the muscles supplied by the facial nerve, none
but the two orbicularis muscles were affected in the slightest
degree.—Dr. Alvarez writes on Milk as a Vehicle for Iodine.
His article is a somewhat enthusiastic plea for a wider use of
free iodine in therapeutics as against the mineral iodides,
and for milk as the vehicle par excellence for its adminis¬
tration. _
JUfo Indentions.
NITROUS-OXIDE-OXYGEN-ETHEU OUTFIT.
The accompanying illustration depicts one of the patterns
of the above machine. The main points are : (1) each
cylinder is provided with a fine adjustment reducing valve
200 gallons, 2 of 500 gallons, and 1 of 40 ft. capacity for
oxygen. (&) The next size—the one depicted here—is meant
for work in hospitals at home, and carries 4 cylinders of
nitrous oxide of 200 gallons each, and a 20 ft. cylinder of
oxygen. Types (a) and (6) are on wheels, and can easily be
moved about. ( c ) The size for private practice takes
4 cylinders of 100 gallons, 2 of nitrous oxide, and 2 of
oxygen. Cylinders of 25 or 50 gallons capacity can be used
with this pattern. This type is so devised that the stand
carrying the ‘‘sight feed” bottle and the ether bottle can
easily be dismounted and securely stowed away between the
cylinders. There is a covering lid and carrying handle.
These machines are economical in consumption of gas.
80 gallons of nitrous oxide and 20 gallons of oxygen are
usually enough for one hour’s continuous anaesthesia. I
have now completed over 2000 personal administrations with
this method, and am able to record over 1600 administrations
by Captain Trewby and the residents at the 1st London
General Hospital, making a total of over 3600 cases without
any fatality. I desire to thank Captain Geoffrey Marshall,
R.A.M.C., for many and valuable suggestions with regard to-
what was, or was not, required for use with this machine in
Fiance. H. Edmund G. Boyle,
Captain, R.A.M.C. (T.); Anaesthetist to St. Bartholomew's Hospital.
A MODIFIED BUCHNER’S ANAEROBIC TUBE.
The advantages claimed for this method are : (1) Sim¬
plicity. No special apparatus is required. (2) Tubes are
shorter and less cumbersome than ordinary Buchner s tubes.
(3) Economy of materials, which are readily obtained and
are portable and compact. (4) Good anaerobiosis is
secured. (5) Any medium can be used for cultivation.
The requirements are :— *
1. A strong glass toat-fcube 6 inches long with an
internal diameter of 7/3 inch and a well-fitting rubber
cork of 1 inch diameter. . ...
2 The medium tube, containing liquid or sloped solid
media of any kind, of a length of 5 inches, with an
internal diameter of 7/16 inch. I /— N 1
3. Four leaves of ordinary thick blotting-paper cut to f M
a size of 4 x 3 Inches. Ll U
4. Pyrogalllo acid powder 1 g. . , .. \‘ ■
5. Caustic potash solution 16 c.cm. (Stock solution > ■
109 g. caustic potash dissolved in 145 c.cm. water. V-L /B
Diluted 1 in 4.) I
The conditions requisite for good absorption B
of oxygen in a vessel by alkaline pyrogallic 4B
acid solutions are: (1) large surface area of f|
pyrogallic acid solution : (2) small air space / B
containing the oxygen to be absorbed. These f B
conditions are obtained in the manner shown / B
in the accompanying diagram. / I
! Method oj use.- The dry pyrogallic *jld powder (1 g ) / |
is placed in the bottom of the outer tube. The / I
lavers oi blotting-paper, between the layers of whlcha / ■
little pyrogallic acid powder is placed, are wrapped / B
roundthe medium tube, the long axis of the paper in HI H
the'long axis of the tube. Medium tube and layers of LV^/J
DaD er are then slipped into the outer tube. (Outer L „ j
tubes can be kept ready for use containing the blotting- VLM
nanpr layers and pyrogallic acid powder.) The caustic
notash (16c cm.) poured into the outer tube, and the medium tube is
SSdly slipped into the centre of the paper cylinder As the medium
tube is pushed In, the alkaline pyrogallic acid solution mountas* a
thin "aver between the outer tube and the medium tube to within
. Lw^dlstancc of the top of the latter and drives out the air
from tlmouter tube, thusrcducing the amount of "dead space
from which oxygen must be absorbed. The rubber cork ^ pushed
Hffhtlv Into the mouth of the outer tube, the rim of which I. sealed
w?th oaraffin wax. The layers of blotting-paper absorb a portion of the
a iS the absorbed pyrogalJic acid solution a large surface
are<^f o?the absorptioiTnf° oxygen. The medium tube is suspended in
the pyrogallic acid solution. . , , ,
That good anaerobiosis is obtained is indicated by the
fact that a tube containing 5 c.cm. of ordinary 1 per cent,
glucose broth containing a solution of methylene blue or
litmus is rendered quite colourless in 24-48 hours. Litmus
milk tubes are also decolourised. The tube should, however,
be left 2-3 hours to allow oxygen absorption to take place
before incubation. Good surface growths of anaerobes with
discrete colonies have been readily obtained on human
. -rum glucose agar medium by thU nman.^ ^ ^
! CapUin. R.A.M.C. (T.F.).
> _ —-- ~*
i WFST London Medico-Chirurgical Society.—
i A clinical meeting will be held to-day (Friday, Feb. 7fcb), m
. the society’s rooms, West London Hospital, when cases will
f shown at 8 P.M.
The Lanobt,]
THE MEDICAL ASPECTS OF FLYING.
[Feb. 8 , 1919 227
THE LANCET.
LONDON: SATURDAY, FEBRUARY S, 1919.
The Medical Aspects of Flying.
Elsewhere in our columns we publish two
papers which, although dealing primarily with the
aeronautical side of medicine, are capable, in our
opinion, of wider application. Dr. Louis Stamm
describes a new form of reaction time apparatus
which in his hands has proved of great value in
assessing the mental qualities of flying pupils. It
is true that with the coming of peace its applica¬
tion for the selection of officers appears to be
somewhat curtailed, since the necessity for
differentiating temperamentally the various types
of pilots is no longer a matter of urgency. Indeed,
for commercial purposes the good, steady, bombing
pilot, or the unperturbed artillery observation
officer, will possibly be looked upon with greater
favour than the “ star ” of great stunting and
fighting propensities. Nevertheless, in times of
peace such an apparatus could undoubtedly be
profitably used in the selection of airmen, and will
probably prove of value in elucidating nervous
conditions associated with “ flying strain.” Dr.
Stamm attaches great importance to the more
elaborate tests, and believes that these are of con¬
siderably greater value than the simple reflex times
which can also be recorded. In view of the work
done by Professor Nepper and others on these
simple refjexes, and the considerable importance
attached by the French authorities to such
tests, it will be interesting to see if the
work of others confirms this opinion. It
appears too soon to discard such Bimple tests
altogether, and the matter must be investigated
more fully. Apart from the examination of airmen
or would-be candidates for aviation, it appears that
the tests of Dr. Stamm are likely to be of con¬
siderable value in the examination of cases of shell
shock, neurasthenia, hysteria, and other allied
nervous conditions, and might profitably be worked
in conjunction with “emotive” observations on
the psycho-galvanic reflex.
The second paper, by Lieutenant-Colonel Martin
Flack, is in some ways of more immediate im¬
portance. With the coming of commercial aviation
it will be a matter of supreme importance that
only fit pilots are allowed to take passengers into
the air. It will be particularly desirable that no
pilot shall be liable to any breakdown which may
endanger the lives of those entrusted to his care.
Since all the tests described in the paper have had
the normal standards set by observations upon
successful flying officers, it appears to us that tests
Buoh as these should be employed in the examina¬
tion of peace-time pilots. If properly carried out,
the results of such simple tests will convey a
rand of useful information to a medical officer
OftUed upon to examine airmen, and by a comparison {
with results previously obtained an opinion
will be formed as to the manner in which the
subject is standing the strain of his occupation.
The treatment of “ flying stress ” is essentially a
preventive treatment, and careful examination
along the lines suggested should be especially
fruitful in preventing the onset of undue fatigue.
It will give early indications of the need for rest
on the part of the subject and prevent the bold
and intrepid airman taking the air when, as not
infrequently happens, he is not altogether in a fit
condition to do 60 . Besides being of value from
the point of view of the selection of the flying
officer, we understand that the tests have proved of
considerable value in assessing the effects upon
the individual of what may be termed “ minor
crashes.”
Apart, however, from their value in relation to
flying, it appears to us that the tests will ulti¬
mately be found to be of wide application. With
suitable modifications and appropriate standards
they may be introduced into the various medical
examinations in which the aim is to obtain an idea
of the physical efficiency of the subject. In the
past the physician has frequently concentrated his
attention on the study of the abnormal, and has
not assessed the normal at its true value. In a
similar way the physiologist, while studying the
more abstruse problems of the healthy body, has
tended to overlook the value of such simple tests
in estimating its efficiency. We believe that the
simplicity of these tests will appeal to many
and will serve to strengthen the bond of service
which should exist, but too frequently does
not, between physiology and medicine. Thus
far in science there has been too much work in
watertight compartments and insufficient liaison
between the various branches. It is to be hoped
that the time has now come when a close relation¬
ship will be maintained among the various scien¬
tific allies whose duty it is to make for the building
up and preservation of the efficient state.
The Teaching of Medicine.
There are manifestations just now of a greater
interest in medical education than has been known
for a generation, and of a widespread conviction
that reform is imperative. It is satisfactory to find
that the monograph of Sir Georoe Newman, whose
views must be of great practical value at this
juncture, has stimulated thought and discussion on
a complex and difficult question. In Scotland, as well
as in England, the same interest is being evinced:
the Edinburgh Pathological Club, for instance, has
recently debated two papers by Mr. J. W. Crerar
and Dr. D. E. Dickson on the Training of Medical
Students for General Practice, 1 wherein the existing
curriculums are closely scrutinised. The arguments
in these two papers are not always directly applic¬
able to English schools, but the defects of medical
education in Edinburgh, as expounded at the
Pathological Club meeting, are generally similar to
those perceived by English educational authorities
to be present south of the border. In some
respects, however, changes advocated by English
authorities have been inspired by a desire to bring
English methods of teaching to a nearer approxi¬
mation to Scottish practice.
Sir William Hale White is a consultant physician
of unrivalled authority and experience as a teacher of
1 Edinburgh Medical Journal, December, 1918, p. 360, et tej.
228 The Lancet,]
BELGIAN DOCTORS’ AND PHARMACISTS’ RELIEF FUND.
[Feb. 8,1919
clinical medicine. His summary of the problem of
post-graduate medical education in our columns on
Jan. 4th includes principles which command uni¬
versal assent, but when he comes to his own province
of “primary” education in clinical medicine he
becomes at once more detailed and more definite.
He goes right to the heart of one of the diffi¬
culties of the medical reformer in London: the
fact that the material rewards of moderately
successful consulting practice are enormously
greater than such emoluments as even the best and
most hard-working of medical teachers can expect.
This is a difficulty which is more acutely felt in
London than elsewhere, in marked contrast to
Edinburgh, which suffers less than many other
schools from this disturbing factor. Sir William
Hale White would forbid the chief of a medical
clinic to engage in private practice, whether as phy¬
sician, surgeon, or obstetrician; and if the salary
of such a professor, as he would be called if any
semblance of a chair were found for him, were
large enough, and if such imponderabilict as
professional status and public recognition were
certain enough, there is a great deal of force in
the arguments by which abstention from actual
practice could be justified. But in present circum¬
stances it is possible neither to offer sufficient
salary nor to fulfil the other conditions named
above, as far as London teachers are concerned,
and, we should say, as far as the teachers are con¬
cerned in any part of England. Unless this state
of affairs is fully faced any comprehensive scheme
for reforming medical education is academic rather
than practical. State aid is necessary; and with
this the long-proposed principle of amalgamations
among London medical schools can be combined.
Sir William Hale White’s plan would ensure the
student receiving his teaching in clinical medicine
from at least three teachers instead of from one
only: a plan which, he believes, is good not for
the student alone but for the teachers also. That
must be rather a matter of surmise. The actual
contact with the patient in the wards has always
been the great point of London medical education,
a contact which the inexhaustible clinical material
of London has rendered peculiarly easy, and one
which all our provincial schools try to provide for
their students.
The equipment of the medical student for general
medical praotice presents at every centre of medical
education one great problem—how best to correlate
clinical teaching with laboratory work. Mr.
Crebar advocates that the general practitioner
should be trained to do bacteriological work for
himself; he dislikes the mere laboratory diagnosis
of diphtheria^ The tendency of the day is rather in
the opposite direction of specialisation in clinical
pathology, a tendency easily to be explained by
the ever-increasing multiplicity and complexity of
the work done in the laboratory. But it is abso¬
lutely necessary that the clinician should be
associated with the pathologist and the bac¬
teriologist in treatment. They study the patient
from different angles of vision, and perspec¬
tive is best attained when they exchange their
points of view, while their intercourse should be
free and frequent. It is in assessing the value
of recent developments of laboratory diagnosis that
general practitioners are often at sea; and many
of them feel that of late years they have not had
altogether the happiest of guidance in such questions
from those leading teachers and consultants from
whom they have the most right to expect it. Too
often methods of diagnosis and treatment have
received the blessing of well-known teachers and
clinicians, only to prove, after longer or shorter
experience, to be fallacious. Many a practitioner has
had to face this experience of feeling hi mself 44 let
down ” by those in authority, whose vigilance has
been, to say the least, insufficient. And such failures
not merely discourage the practitioner genuinely
anxious to keep abreast with modern research;
they directly encourage quackery amongst the less
scrupulous, and rule-of-thumb methods amongst
the lazy. Proper relations at all educationsd
centres between the laboratory and the ward on the
one hand, and proper relations between the clinical
and the pathological aspect of disease in the prac¬
titioner’s mind on the other hand, should alter
all this, and it should not be impossible to secure
these things.
■ ■
Belgian Doctors’ and Pharmacists’
Relief Fund.
At the last meeting of the Executive Committee
of this Fund a letter, a translation of which is
reproduced in full on p. 235, was received by the
Committee from Dr. V. Pechere, the President of
the Comite National de Secours et d’ Alimentation
(Aide et Protection aux Medecins et Pharmaciens
Beiges Sini6tres). The Comite National is the
body sitting in Brussels to whom the dispensation
of the contributions of the Funds in behalf of the
suffering Belgian doctors and pharmacists in
Belgium has been entrusted. The Belgian Doctors'
and Pharmacists’ Relief Fund has raised upwards
of £25.000 during its life of a little over four years.
The greater part of this money has been received
directly from British doctors and pharmacists at
home, in the Colonies, and in India, though during
the closing stages of the war substantial grants
have come from the American Red Cross, to the
enormous benefit of the charges of the Fund.
After the immediate wants of Belgian doctors and
pharmacists and their families, arriving in this
country as refugees, had been met by the Fund,
the bulk of the money was duly distributed in
monthly donations varying from £800 to £400
among Belgian doctors and pharmacists remaining
in Belgium, the organisation of which Dr. Pech&re
is the head undertaking the difficult and delicate
task of distribution. Dr. Pech£re’s committee has
wisely husbanded the contributions sent to them,
so that a certain amount of money should remain
in hand for the succour and rehabilitation of
Belgian doctors and pharmacists after the war; and
it goes without saying that the extraordinarily
generous suggestion of Dr. Pechere, which will be
found in his eloquent letter of gratitude—that
this money should be returned to the Fund—has
been disregarded by the Committee of the Fund.
It was definitely stated in the original programme
of those who organised the Fund that it would be
impossible for British doctors and pharmacists
to give too much money, because, when the
immediate needs had been met, those of rehabili¬
tation must remain and be very heavy. Many
doctors and pharmacists in Belgium were materi¬
ally ruin&d and would not be able to return to
work without pecuniary grants. All readers of
the medical and pharmaceutical journals who
have kept the objects of the Fund in recollection
will approve of the decision of the Committee
of the Fund.
The Lancet,]
THE CONTROL OF TUBERCULOSIS IN FRANCE.
[Feb. 8 , 1919 229
The Belgian Doctors’ and Pharmacists’ Relief
Fund is closed as from Monday next, Feb. 10th,
the small sum remaining in the hands of the
honorary treasurer being probably sufficient to meet
any remaining calls from Belgian refugees in this
country. The Fund has disbursed the whole of
the sum collected—over £25,000—save £90; and
the cost of collection and distribution has been
under £200, including the printing and postage
of circulars and reports at war rates. The
secretarial work and that of the treasurer
have been done gratuitously, both by the officers
named and by their assistants; a large pro¬
portion of the postage has been defrayed by
The Lancet ; the auditors made their inspections
of and reports on the books of the Fund for a
nominal fee; and the Bank treated the Fund
with special courtesy. These are the things that
account for the economical administration of the
Fund’s resources.
Jnnfftatians.
11 He quid nlmis.”
THE CONTROL OF TUBERCULOSIS IN FRANCE.
France, ahead of this country in so many
departments of preventive medicine, has yet been
tardy to take any concerted action in controlling
the ravages of the tubercle bacillus; and with the
history of the opposition to such measures in this
country still vividly before the mind our Paris
Correspondent’8 graphic story of the conflicting
currents of medical opinion in Paris makes excel¬
lent reading. The great majority of doctors in France
are, he says, hostile to the compulsory notification
of tuberculosis. So they were in this country;
but the notification has been confidential, has not
broken that deep-seated instinct of professional
secrecy which Paris holds as dear as London,
the Frenchman as dear as the Briton, and noti¬
fication has now, in consequence, no consider¬
able body of opponents. Our Correspondent
pictures the unhappy position of the notified
patient when the agent of the local authority
arrives with imposing apparatus to disinfect
him and his dwelling, thus spreading terror
among the indignant neighbourhood. Doubtless
where tenement houses are the rule rather than
the exception, the necessary measures of control
and hygiene may attract undue attention, but in
this country the tact of the tuberculosis nurse and
sanitary inspector have already won the day. It is
only exaggerated language that has ever described
the tuberculous patient as a social pariah in
this country or in France, and the tendency is but
slightly marked in the stratum of society which
provides the largest number as well as the highest
percentage of tuberculous patients. The segrega¬
tion of the advanced case of tuberculosis is of all
measures the most practicable and the most urgent,
and it should be possible to concentrate upon this
without interfering unduly with the legitimate
liberty of the subject. The Paris discussion is not
without bearing on our own circumstances, where
the return of the ex-Service and repatriated man
constitutes a problem in tuberculosis control as
urgent as any other problem facing us; and, unless
properly handled, this problem is likely to cast a
shadow on a generation or more.
SUGGESTED LUNACY REFORM8.
The spirit of reconstruction, so much in the air,
has recently been conspicuous in regard to our
arrangements for those suffering from mental dis¬
order. The results of the treatment of shell
shock and other neuro psychoses, brought into
evidence by war conditions, on lines differing
from conventional asylum treatment have of late
attracted much public attention, and in January,
1918, the Medico-Psychological Association of Great
Britain and Ireland appointed a special com¬
mittee to consider the amendment of the existing
lunacy laws. This committee, after lengthened
consideration, reported last November in favour of
certain radical changes as regards methods of
dealing with cases of unconfirmed mental disease.
Its recommendations included the establishment
of “clinics” by local authorities for the treat¬
ment of nervous and mental diseases in their
early stages, quite distinct as regards location
and management from recognised institutions for
the insane, and, where practicable, in the form of
an annexe to a general hospital so as to be available
for clinical teaching. The extension of the system
of voluntary boarders to all classes of institutions
for the insane was also recommended, as were
facilities for the reception without certification of
patients suffering from mental disease in its early
stages into homes approved by the Board of Control,
whether private or charitably founded, as well as
into asylums, registered hospitals, and licensed
houses, the only formality being an intimation to
the Board of the fact of the patient’s reception or
removal. The committee, while not advocating,
for the present, any complete revision of the
Lunacy Acts, conclude their report by suggesting
certain modifications of nomenclature as regards
mental patients and the institutions for their treat¬
ment which would tend to eliminate the stigma
attaching to such terms as “ lunatic ” and
“ asylum.” It may be well to add that the report
purports to deal exclusively with English lunacy
legislation. The Board of Control in their fourth
annual report, issued in August, 1918, express sym¬
pathetic views as regards the recognition and
treatment in their earlier stages of indications
of mental disorder. They proceed to recom¬
mend that the existing law should be amended
so as to enable incipient or recent cases “to
receive treatment in general or special hospitals,
mental institutions, nursing homes, or elsewhere
for limited periods, say, six months, without the
necessity for certification under the Lunacy Acts,
provided it has the supervision of the Board.”
They also approve of the establishment of
“ sections ” (for both in- and out-patients) at
general hospitals for the early diagnosis and
treatment of incipient cases, including facilities
for organised study and research where the hospital
is attached to a medical school.
Having stated these expert professional views,
we proceed to consider those forwarded to us of a
“Conference of the Visiting Committees of the
Asylums of England and Wales,” which met at
the Guildhall (City of London) on Oct* 29th
last, having been convened by Mr. Thomas Field,
chairman of the visiting committee of the Bucks
County Asylum. This may be taken as mainly
representative of the lay element in the adminis¬
tration of public asylums outside the county
of London, with the addition of a small medical
element, its committee including also five
230 The Lancet,]
THE MOBILISATION OF VENEREAL DI8EA8ES.
fFas. 8, 1919
delegates of the Medico-Paybiological Association.
The conference is reassembling at the Guildhall
this week, and it may therefore suffice to say
here that amongst the recommendations are
that the words ‘ pauper,” “ lunatic,” “ lunacy,”
and “ asylum ” should be deleted from the
lunacy laws; that special mental hospitals for
both in-patients and out-patients suffering from
incipient or actual mental disease be established
by local authorities, and that in such hospitals
(not to be under the supervision of the Board
of Control) certification should not be required
until it may become necessary, in the opinion of
the medical director of such hospital, to transfer
the patient to an institution now known as
an asylum. “ Psychiatric clinics,” it is suggested,
should be established in connexion with every
medical school, and proper facilities be provided
therein for research and for teaching and training;
and that medical officers appointed to institutions
for the mentally afflicted should, within two years
of their appointment, be required to hold a
recognised diploma in psychiatry.
Reviewing these several sets of opinions, it
would seem that there is a general consensus
of feeling that the time is ripe for the relaxa¬
tion of the legal fetters which have impeded
the medical treatment of mental illness, especially
in its incipient stage. In times past actual, as
well as alleged, abuses have given rise to panic-
begotten legislation, the restrictions imposed by
which have tended to curtail the efforts of the con¬
scientious practitioner for his patient’s recovery.
The restoration of greater freedom in dealing with
those suffering from minor mental ailments is
desirable alike in the interests of the patient and
his doctor, and a reasonable discretion as to the
most suitable surroundings for an incipient or
harmless case of mental aberration ought not to be
withheld. At the same time due precautions are
necessary to guarantee the fitness and integrity of
those undertaking the personal charge of mental
cases, and some form of official approval—not to say
supervision—seems indispensable for this purpose.
The determination of the best form may appro¬
priately be delegated to the prospective Ministry of
Health. Though psychiatry must necessarily remain
a specialty of the profession, its practitioners need
to keep closely in touch with the advances of
medical science, and it is to be hoped that the
establishment of local clinics will tend to bring
together in greater degree the family doctor and
the specialist, at the same time affording oppor¬
tunities to the general practitioner for a better
insight into expert methods of mental treatment.
It has been alleged that some medical officers
of asylums, by reason of remoteness of their
establishments from centres of ordinary medical
activity, tend to comparative isolation from
their confreres, and better opportunities of inter¬
course such as would result from the institution of
psychiatric clinics would be beneficial to both
classes of practitioners. We are glad to see that
one of the proposals before the Guildhall Con¬
ference is to relieve medical superintendents of
mental hospitals, as much as possible, of their
administrative, clerical, and routine duties, so as to
leave them more time for medical and scientific
work. It must be remembered, however, that in
comparison with similar establishments in America
and on the continent the medical staff is pro¬
portionately low in British asylums, and much
remains to be done in the equipment of laboratories
for purposes of adequate scientific research.
THE MOBILISATION OF VENEREAL DISEASES.
The appointment of an Inter-Departmental
Committee last week by Dr. Addison to in¬
vestigate the dangers of communicable diseases
incident on demobilisation, and to devise concerted
measures to meet these dangers may be taken as a
recognition on the part of the Government of the
extreme urgency of the situation in regard to
venereal diseases. But while the need is bo urgent
responsible opinions are still sharply divergent in
regard to the methods to be employed, and espe¬
cially whether it is in the best interests of the
community at large to popularise precautionary
measures to be taken before infection has been
incurred. Two important communications which
we print this week should be read with close
attention. At the Medical Society of London
Colonel L. W. Harrison brought forward striking
evidence of the value of the abortive treat¬
ment of gonorrhoea. We can reckon, he states
from his abundant authority, with a fair amount
of certainty on all the gonococci within the
urethra being accessible to antiseptics on the first
day of the developed disease. Promptitude of
action is here of the first importance, and diligent
propaganda are necessary to promote it. Sir Archd&ll
Reid and Surgeon Commander P. H. Boyden, R.N.,
take the disinfection back to the very earliest post¬
contact stage. A swab of cotton-wool, a small quantity
of a 1 per mille solution of potassium permanganate,
used with sober care, have been effective in pro¬
tecting 20,000 men—and an untold number of
innocent women and children—against infection
with the gonococcus. These are results which must
be carefully weighed by any committee appointed
to consider prevention of venereal diseases.
THE AMERICAN PUBLIC HEALTH ASSOCIATION
AND INFLUENZA.
The annual meeting of the American Public
Health Association was held in Chicago under the
presidency of Dr. Charles Hastings, medical officer of
health for Toronto, from Dec. 9th to 12th, 1918, after
having been postponed from October on account of
the severity of the influenza epidemic. Many of
the papers contributed dealt, as was to be
expected, with influenza in its various phases,
and an editorial committee was appointed to
prepare and publish a bulletin formulating the
facts and opinions brought out at the meeting.
The main points in this influenza bulletin may be
briefly stated thus. Influenza is believed to be
caused by an organism of an infective nature, not
yet exactly determined, which lowers the resistance
of the body as a whole and of the respiratory organs
in particular. This diminution of vital force leaves
the system open to the invasion of other patho¬
genic organisms, of which the most important
are the Pfeiffer bacillus and various strains of
pneumococcus and streptococcus. Certain of these
organisms are regarded by careful observers as the
primary cause of the disease; but while one or more
of them may be isolated from a particular case, the
dominant variety of organism has been found to
vary in different parts of the American Continent.
As regards the use of prophylactic vaccine, if it is
assumed that the cause of the epidemic is an
unknown virus it seems impracticable to prevent
the primary disease by vaccination with known
organisms, whatever theoretical basis there may be
for the use of vaccines direoted against secondary
infections, especially if the vaccine used includes
The Lancet,]
KUPTURE OF THE CARDIAC VALVES DUE TO AN EXPLOSION. [Feb. 8,1919 231
the organisms responsible for the particular
complications ruling in the locality. Vaccines
adjusted to meet local conditions have been used,
but any evaluation of the reports is premature.
Stock vaccines have appeared to mitigate some of
the outbreaks and the severity of the complicating
infections, but in cases where control observations
have been made no appreciable effect has been
noted. The fact that the vaccine is usually
employed after the epidemic has broken out
and is perhaps declining, and that an unknown
number of people have been exposed, make it
difficult to draw conclusions as to its efficacy.
The committee recommends that until such time
as the efficacy or otherwise of prophylactic vaccina¬
tion against influenza has been established vaccines,
if used at all, should be employed with control
observations, permitting a fair comparison to be
made of the number of deaths among the vacci¬
nated and unvaccinated groups. Particular atten¬
tion should be directed to securing data as to the
period in the epidemic at which vaccinated and
unvaccinated persons developed the disease. The
committee are of the opinion that the indis¬
criminate use of stock vaccines against influenza
alone, or against influenza plus pneumonia, is not
to be recommended. On the basis of the most
trustworthy data then available a sub*committee of
the association appointed to consider the history
and statistics of the epidemio estimated that
there were not less than 400,000 deaths from the
disease in the United States during the months
of September, October, and November last, the
greater number occurring in the age-group 20-40.
An unusually high pneumonia rate for several
years to come was held to be a probable after¬
effect of the epidemic. The report emphasises
the comparative uselessness of terminal disinfec¬
tion, the fact that the taking of alcohol serves no
preventive purpose, and the futility of sprays and
gargles. Instead of protecting the nose and throat
from infection their employment is held to tend to
remove the protective mucus, to spread infection,
and to increase the chance of infecting organisms
gaining an entrance. Assuming that influenza is
spread solely by means of discharges from the nose
and throat of infected persons, the most effective
method of prevention lies in sputum control and
in the supervision of food and drink. Isolation of
infected persons will achieve this end and should
be enforced as far as possible. The desirability
of wearing masks during an epidemic was discussed
at considerable length, and it was pointed out in
an editorial in the Journal of the American Medical
Association for Dec. 21st, 1918, that u evidence
leads to the opinion that, properly used, the face-
mask has value in the x>rophylaxis of influenza.”
Whether it is practicable on a wide scale the
editorial committee holds to be quite a different
matter. _
RUPTURE OF THE CARDIAC VALVES DUE TO
AN EXPLOSION.
Traumatic rupture of the cardiac valves is a
rare accident; only about 80 cases have been
recorded. In the war French writers have reported
cases of lesions produced by explosions, often at
some distance, due to the concussion of the aerial
waves (the “wind” of the explosion). Rupture of
both lungs and lesions of the nervous system have
been described. But not till 1918, after three years
of war, was a cardiac lesion recorded. Cramer
then described a case of aortic insufficiency due to
an explosion, and later Brossard and Heitz two
eases. The question has been raised whether such
lesions may not have been due to the projection of
the patient against the ground. In the Paris
Medical MM. M. Perrin and G. Richard have
recently reported two cases which are important,
because the only explanation of the lesion appears
to be the force of the explosion.
In one the patient was a strong but obese soldier, aged
36 years, who bad been carefully examined on several
occasions, and special attention paid to bis heart, because of
slight dyspnoea on exertion. In the battle of Cappy on
Sept. 26th, 1914, he received a bullet wound in the thigh.
While being removed with other wounded in a cart a shell
burst near it, smashing one of the wheels. The wounded
were much shaken, and the patient was rendered uncon¬
scious for a few seconds. On recovery he complained of
oppression and pain in the chest. He was evacuated to a
town in the interior, and suffered from attacks of suffocation
ever since the explosion. When he came under observation
again in 1917 he had resumed bis occupation of commercial
traveller. He had regained bis weight, but was sallow, and
suffered from dyspnoea and palpitation on going upstairs.
The heart was hypertrophied, the apex beat being in the
sixth interspace two finger breadths outside the nipple line,
and there was aortic regurgitation.
In the second case a woman, aged 46 years, was in good
health until a bomb dropped within 3 metres of her during
an air raid on Nancy on Oct. 6th, 1917. The violence of the
explosion was such that she felt lifted from the ground and
would have fallen if she had not taken hold of railings. She
felt an acute retrosternal pain, but was able to get home, a
distance of 400 metres. On the way she bled severely from
the nose. During the following days the pain disappeared,
but there was dyspnoea on the slightest effort. When
examined a fortnight after the accident the pulse was 88,
small and irregular, and there was an apical systolic
murmur which was propagated in all directions, but princi¬
pally towards tbe axilla. In January, 1918, these conditions
persisted. Probably the chordse tendinese of the mitral valve
were ruptured.
In none of the necropsies in cases of tranmatic
rupture of the mitral valve was the valve itself
found torn; the lesion involved the chordaB tendinese
and the musculi papillares, and the former twice au
often as the latter. Numerous cases have been
published of rupture of cardiac valves due to violent
effort. Rupture of the aortic valve is more frequent
than rupture of the mitral, and this than rupture of
the tricuspid. Only a single case of rupture of the
pulmonary valves appears to have been recorded.
SAFE ANESTHESIA.
A year ago, in discussing the use of gas and
oxygen as an ansBSthetic mixture, we suggested
that ansBsthetistB might congratulate themselves
on being able to bring the comforts of a non-toxic
anaBsthesia within the reach of a large proportion
of patients undergoing operation. Since then the
method has had a further extended trial with the
armies in France, and it can hardly be doubted that
many lives have, been saved thereby. It has been
observed at more than one casualty clearing station
that multiple amputations carried out under gas
and oxygen anaesthesia recovered, while men who
submitted to similar operation under other anaes¬
thetics died. Gas and oxygen has been found to be
the only anaesthetic tolerated in the case of wounded
men suffering from serious collapse. At home, in the
wards of the 1st London General Hospital and of
Queen Alexandra’s Hospital for Officers at Highgate,
many profoundly septic cases have taken this anaes¬
thetic with happy results; five cases of amputation
at the hip-joint in men who were already profoundly
toxeemic all recovered. We therefore call attention
with pleasure to the outfit described by Mr. H. E. G.
Boyle, Captain, R.A.M.C. (T.), on p. 226 of our
present issue. Mr. Boyle there records 3600
administrations by himself and others without
232 Thb Lancet,]
FAMILIARITY WITH THB OPHTHALMOSCOPE.—CANADA.
[Feb. 8,1919
fatality. In a number of abdominal operations a
little ether or chloroform-ether mix tare was used
to supplement the nitrous oxide and oxygen. This
addition is stated not to prejudice the well-known
condition of well-being that follows the administra¬
tion of this anesthetic. Patients regain conscious¬
ness almost at once when the administration stops;
little, if any, taste of ether or chloroform remains
and vomiting is exceptional. Certain objections
there are to this method of anaesthesia, and
for the most part of an obvious nature. Steel
cylinders to contain compressed gases are at present
heavy and expensive, and gas is liable to be wasted
by accidental escape at high pressure with damage
to tubes and alarm to the patient. The expense,
while inevitable, is one which the private patient
is likely to face gladly enough. The substitution
of air for oxygen suggested, on the basis of his own
experience, by Dr. J. H. Fryer, Captain, R.A.M.C. (T.),
on p. 216, would tend towards economy. Mr. Boyle
states that with his apparatus the cost of materials
works out at about 10s. an hour. The difficulty in
regard to weight has been to some extent surmounted,
as Type (c), for private practice, weighs only some
60 lb., allowing for 2} hours’ administration. Waste
of gas has been practically abolished by the use
of reducing valves on the cylinders. Other more
elaborate safeguards have been tried. At one casualty
clearing station in France an ingenious arrange¬
ment for equalising pressure has been worked out
by the Rev. J. A. Gray, M.C., who has administered
several hundred anesthetics with it for Dr. J. Basil
Cook and Dr. A. W. H. Donaldson, Majors, R.A.M.C. (T.).
Oil drums, adapted to rise and fall on the principle
of the large gasometer, were inserted between the
cylinders and the inhalation-bag. The two medical
officers substantiate Father Gray’s claims for his
appliance, which are as follow:—
1. The drams automatically stop the flow of gases from
the cylinders when the containers rise to a certain height,
thus avoiding any danger of wasting gas, straining, or
bursting the bag or rubber tabes. The breathing bag can
never be more than nicely fall, as the pressure in the gaso¬
meters is only sufficient for this.
2. They ensure a reserve of gas sufficient for the require¬
ments of the patient, when a cylinder runs empty, and
afford the anaesthetist convenient time to replaoe the empty
with a full cylinder.
3. The gases enter the mixing chamber at an unvarying
pressure throughout the time that the patient is under.
Once complete anaesthesia is reached the patient continues
to breathe steadily for a long time, almost without attention
from the anaesthetist, whose only duty usually is slightly to
increase the flow of oxygen from time to time if the opera¬
tion iB a long one, and to note the gauges on the cylinders to
see that they do not run empty.
The mechanical difficulties of this safe and
comfortable form of anaesthesia are thus being
surmounted, and we doubt not that administrators
will readily acquire skill in the new technique.
FAMILIARITY WITH THE OPHTHALMOSCOPE.
In a symposium on the teaching of eye diseases
in the medical curriculum, published in a recent
issue of the Edinburgh Medical Journal , Dr. W. G.
Sym, recognising the fact that the average practi¬
tioner almost never uses an ophthalmoscope, deems
it hopeless to expect to alter this state of things,
whereas Dr. Freeland Fergus would not let a man
enter the medical profession unless he can use an
ophthalmoscope almost with the same facility with
which he uses a clinical thermometer. In view of
its importance in the diagnosis of syphilis, diabetes,
arterio-sclerosis, nephritis, pernicious anemia,
tabes, and especially in cerebral tumour, it would
seem that Dr. Fergus is right. At the same time,
if the student is only taught its use in connexion
with a special course on eye diseases we believe
in the majority of cases the ultimate effect will be
but slight. The remedy is for the student, having
early in his course got over the technical difficulties
of mastering the instrument, to be required to
employ it during his medical training on every
case when it might throw light on diagnosis. In
this way the student would realise its importance
in connexion with general disease and come to look
upon it as a necessary part of his equipment.
THE LANCET, AUGUST 24th, 1918.
The Manager of The Lancet would like to
re-purchase or to receive copies of the issue of
August 24th for which readers may have no further
use, to enable him to replace copies for libraries
and institutions in India and the East which were
lost at sea owing to enemy action. Such copies
should please be addressed to him at 423, Strand,
London, W.C. 2.
CANADA.
(From our own Correspondent. )
Lepers in Canada .
While leprosy is still endemic in Louisiana, and 400 or
more cases have been recorded this century in this and other
North American States, Canada is fortunate in having at
present a total of only 13 lepers in the lazaretto at Traoadie,
N.B., and 5 in the Darcy Island lazaretto, British Columbia.
These are the only cases in the Dominion of Canada so far
as is known.
Pensions to Canadian Soldiers.
The Board of Pension Commissioners in Canada has
authorised the following information with regard to the
granting of pensions to the Canadian soldiery:—
1. Soldiers are not pensionable for service only. #
2. Pensions are awarded only to cases of disab ement due to a wound
or disease occurring on, resulting from, or aggravated on servioe.
3. Disablement is estimated only by the effect it may have upon the
soldier's capacity for ordinary work. That he cannot return to his
former occupation does not entitle him to a higher pension than the
extent of his disability warrants.
4. If a soldier is so disabled that he is oompletely Incapacitated for
ordinary work he receives a “ total disability " pension, which has been
fixed at $50.00 a month.
5. If by his disablement a soldier’s capacity for ordinary work is
lessened he receives a percentage of the “ total disability r ’ pension
equal to his handicap.
6 . This percentage has been most carefully and thoroughly worked
out for every disability, and it is as accurate and fair as it is possible to
make it.
7. The earnings a man may be capable of making or the amount of
his pre-war earning* will not in any way affect tha amount of pension
awarded. The extent of his disability Is alone considered.
8 Widows of soldiers or sailors who have died are entitled to pensions
for so long as they do not marry.
9. Children of sailors or soldiers are entitled to pension np to the
age of 16 If boys, or 17 if girls.
10. Pension is only granted to the parents of a sailor or soldier when
he was their main support previous to death.
Health Department: Province of Alberta.
A recent Order in Council of the Government of the
Province of Alberta has transferred the whole health work
of that province to the Department of the new Minister of
Municipalities, the Hon. A. G. Mackay, who sounds a note
of warning with regard to the proposed municipal hospitals
in that province. He thinks that the hospital areas may be
too small for safe financing. It would be unfortunate if
small districts were saddled with heavy assessments and not
have sufficient funds to carry on hospital work successfully ;
and the Minister states he will not establish a district unless
he is absolutely satisfied that the financial position is suffi¬
ciently strong. The matter of boundaries most receive
carefnl consideration, as small territories might be left
stranded between districts.
Improving the Health of Canada .
Revelations as to the average standard of physical fitness
of single men, as shown by the military records in Western
Canada, have resulted in the inauguration of a movement
THB L ANGST,]
PARIS.
[Feb. 8,1919 238
led by the city councils of certain cities in Western Canada,
particularly Saskatoon, Sask., to improve the health of
Canada as a whole. Representations are to be made to all
Provincial Governments and to the Federal Government as
well, advising them to take advantage of the records so
compiled by the military authorities. The matter has been
considered in Counoil by the Dominion Government, and the
Minister of Militia has been authorised to prepare a report
on the subject and submit it to Council.
The Cate of Military Medical Officers and Civilian Practice.
An order has recently been issued : “No medical officer
who is engaged in civil practice will be permitted to draw
full-time pay and allowances except when sent for temporary
duty away from his home station.”
PARIS.
(From our own Correspondent.)
A Bill to Provide Treatment for Tuberculous Patients.
M. Louis Mourier, Under Secretary of State for the Service
de Sant k at the Ministry of War, has laid upon the table of
the Chamber of Deputies a Bill, supported by the Govern¬
ment, the objects of which include the compulsory notifica¬
tion of tuberculosis, the gratuitous treatment in hospital of
necessitous consumptives, and the allocation of grants to
their families. According to the draft of the Bill every case
of pulmonary tuberculosis must be notified within eight days
following the establishment of the diagnosis, the notifica¬
tion to be made by the medical man treating the case
to a specially instituted sanitary service. The doctor
will be required to state in his certificate whether
medical care and preventive measures are assured.
Should this guarantee, which the sanitary service will
have the right of checking, not be produced, the
service will invite the patient to attend at a dispensary,
where hospital treatment will be prescribed if his physical
condition and the absence of available care render it
indispensable. When desirable resort will be had to dis¬
infection. Communes, Departments, and the State itself
are called upon to provide for the treatment, in or out of
hospital, of necessitous persons attacked by tuberculosis,
and to give grants to the families in which the supporting
member has been sent away to hospital. Penalties are pro¬
vided for lack of observance of these instructions.
In the preamble to the Bill M. Mourier explains his intention
to extend to the whole of the population the benefits of the
organisation which has been set up during the war for
tuberculous soldiers. He indicates that 55,000 soldiers
attacked by tuberculosis have been treated in hospitals and
sanitary stations, and that France at the moment has to deal
with something like half a million cases of tuberculosis. The
amount budgeted for is 84 million francs for setting up the
service and 100 million francs for annual expenses.
The Compuhory Notification of Tuberculosis.
The announcement that this Bill has been laid upon the table
of the House has provoked lively interest in medical circles. It
is not the first time that this question has been raised by the
Government of the day. Since the year 1890 the Academy
of Medicine has five times been asked to give favourable
•consideration to the placing of tuberculosis on the list of
diseases to be compulsorily notified. Four times the
Academy refused; the fifth time 46 voted for notification,
45 against, and 1 abstained. It appears that the great
majority of doctors is, in fact, hostile to the measure. All
the professional corporations have pronounced themselves
unanimously against it. The Medical Association of the
Seine at its meeting on Oct. 8th last passed a vote in
anticipation that it would not submit to the new Bill if it
became law.
Medical men see in it a gross attack on professional
secrecy, which must expose the practitioner who violates
this secrecy to the mistrust and loss of his clientele.
In cases where the doctor has thought it his duty
to notify to the authority the existence of tuberculosis
the next item on the programme has been the arrival
of a disinfecting engine, which has spread terror among
the neighbours, after which the unfortunate tenant has
been expelled from the house by the landlord, with no
chanoe of finding other lodging. Notification is received
well enough by the public in the case of acute infectious
disorders of rapid progress, such as oblige the sick man to
keep his bed, when humane feeling forbids the overbearing
neighbour to demand his expulsion. It is not the same with
the apparently lusty patient who goes about and whom his
neighbour desires to see living elsewhere. After a prolonged
period of complete indifference to the danger of contagion in
tuberculosis the public, under the spell of the vigorous cam¬
paign undertaken to spread the fear of contagion and the
necessity of serious prophylaxis, is now the prey of a verit¬
able tuberculophobia. The working man recognised as
tuberculous is dismissed from his factory ; the clerk from
his office; the domestic from the house where she serves.
All are thus deprived of their means of livelihood and the
family which they support is plunged into misery.
Other Arguments against the Bill.
Such are the arguments used by the opponents of the Bill.
Professor Albert Robin, who may be regarded as their ring¬
leader, adds several other interesting points. He regards
disinfection as an illusory measure if not carried out in all
the places traversed by the consumptive, or unless he is
interned like a plague-stricken subject. Systematic measures
of internment or of in-patient treatment would, however,
entail, including grants to families deprived of support,
an initial expense of 250 million francs and an annual
administration cost of 210 million francs. Society, M. Robin
thinks, can protect itself at less cost and with weapons
of greater efficiency by combating alcoholism, unhealthy
housing conditions, and by observance of greater public
and private hygiene, and all this can be done without any
vexation or economic damage to patients and their families.
Efforts already made in this sense have not been in vain, since
during the last 20 years tuberculosis has diminished in Paris by
one-quarter. And since in practice the State cannot succeed in
caring for all the known consumptives, when compulsory
notification has made known their exact total, the law will
remain a dead letter.
M. Robin proposes, in agreement with the medical
corporations, to ask the doctor to notify tuberculosis to
the head of the family, who shall turn to the State if
he does not possess the power to observe the necessary
care and preventive measures. In any case the doctor must
not be made the denunciator. For the rest, disinfection of
lodgings should be made compulsory after each change of
occupant in the absence of a medical certificate to affirm the
non-necessity.
A dvocacy of the Compulsory Notification.
These are the views of the opponents. Compulsory
notification, however, has its advocates in the medical
faculty. Professor Letulle and Professor Bezan$on argue
that the war has produced a new situation by spreading
over the country thousands of consumptives, some of them
ex-service men with disease aggravated by the war, others
repatriated from Germany where insufficient food and bad
treatment had resulted in the development of the disease.
The question is not merely one of caring for the men them¬
selves, but of preventing the infection of the civil population
in which they move. They would like to see a number
of special sanitary centres set up, directed by competent
and well-paid specialists, occupied with this service alone, to
whom notifications should be sent by the family doctor, who
would continue to safeguard his professional secrecy. These
officers would decide if it was desirable for the State to
intervene with the measures already enumerated. All agree
that the country must be prepared to make every sacrifice to
protect itself from a disease which has made great strides
during the war and which, at the present rate of progress,
threatens in several years to annihilate the greater part of
the population, already none too numerous.
The Academy of Medicine has decided, on the proposition
of Professor Hayem, in the presence of this new situation,
to reconsider the question of notification and has charged
a special commission to present a careful report.
Vital Statistics of Calcutta— In the third
December week, the last for which the statistics are avail¬
able, the total number of deaths registered was 976. Of
these 44 deaths were due to cholera (against 41 and 56 in the
two preceding weeks), the number being higher than the
average of the past quinquennium by 20. There was no
death from plague ; 3 deaths from small-pox. Deaths from
influenza were returned as 277, against 332 in the previous
week. Excluding imported cases the death-rate of the week
was 523.
234 The Lancet,]
THE WORD-ASSOCIATION TEST IN PSYCHIATRY,
[Feb. a, 1919
THE WORD-ASSOCIATION TEST IN
PSYCHIATRY.
Studies in, Word-Association. By C. G. JUNG, M.D.,
LL.D. Authorised translation by Dr. M. D. Eder.
London : William Heinemann. 1918. Pp. 375. 25 1 .
Papers on Psy oho-analysis. By Ernest Jones, M.D.,
M.R.O.P. Second edition. London: Baillifcre, Tindall,
and Oox. 1918. 25 s. (See Chap. XXII.)
The Theory of Psycho-analysis. By 0. G. JUNG, M.D.,
LL.D. New York: Nervous and Mental Disease Pub¬
lishing Company. 1915.
The Psy ehopathoiogy of Everyday Life. By Professor Dr.
Sigmund Freud. LL.D. Authorised English edition by
Dr. A. A. Brill. London : T. Fisher Unwin. 1914.
It was in 1904 that Dr. C. G. Jung and his colleagues began
their researches on word-association, and in a series of some
13 papers they have so elaborated and elucidated the method
as definitely to establish its trustworthiness for the investi¬
gation of the conscious and the unconscious mind. Yet it
has been productive of surprisingly little original study in
this country, has aroused comparatively little attention, and
has not, apparently, taken any regular place in the routine
examination of nervous and mental cases, whereas in
America word-association tests have been freely used both
in experimental psychology and in practical psychiatry. We
may hope for augmentation of interest in the subject in
England now that the sources of information are accessible
to the English student in Dr. Eder’s excellent translation
and edition of the original papers of Jung. Riklin, Bins-
wanger, Bleuler, and the others, some of which work, it is
curious to remember, was first published in the pages of
Brain (1907), though at the time little seems to have been
made of it.
For a generation writers of psychological text-books have
embodied chapters or sections on “association of ideas,”
and have formulated “laws” and devised experimental
illustrations of its action, but they have been singularly
lacking in any fertility of application to clinical problems
of these psychological laws—an instance of the remoteness
of scholastic psychology from the actualities of psychiatry.
Word-association as a part of association of ideas is not a
novelty ; it was alluded to by Galton in his “ Inquiries into
Human Faculty ” as long ago as 1883. To Jung, however,
must be assigned the credit of developing word-association
into an art, and of raising it to a science. And let it not be
supposed that the process is of mere theoretic interest as
furnishing suitable exercise for the budding psychologist;
apart from its use in the investigation of the normal mind,
it constitutes in conjunction with the method of psycho¬
analysis a diagnostic instrument of the greatest utility, and
Without its aid psycho-pathology would not have made su
strides in recent years. As Dr. Eder remarks, every serious
student of psychology, every educationist, everyone who
wishes to engage in the study or treatment of morbid mental
processes, will find in Jung’s “Studies ” a storehouse of facts
which will serve not only as a solid basis for his own studies
but also as a starting-point for further research.
Obviously the first step was to determine the nature of
association-reactions in normal individuals, and to be
satisfied of their value as an index to the working of the
mind, before proceeding to deal with the abnormal. It is a
truism that association is a fundamental phenomenon in
psychical activity, precisely as is linked neuronic function¬
ing for the physiological activity of reflex arcs; and as
differing sensory stimuli may simultaneously compete for
and one gain possession of the final common path to
motor action, so may psychical associations, con¬
currently aroused by some stimulus, undergo modifica¬
tion by inhibition, distraction of attention, variability
of mood, interest, fatigue, and other psychical factors,
whereby development follows, if at all. in one direction
only. To simplify the pleomorphic complexity of reaction
to a stimulus, to facilitate investigation and to prevent
loss of precision owing to the awakening of numbers
of more or less distinct presentations in succession, the
word-association method requires one response only to the
stimulus-word, to be given as quickly as possible, ‘ ‘ without
thinking” so to say—i e., without allowing the action of
direoted or conscious thought to begin at once to modify the
train of association aroused. Only thus can any real insight
be gained into the processes not merely of the conscious but
especially of the unconscious mind. We wish the response
to the stimulus to be as inevitable, as immediate, as uncon¬
trolled by higher psychical considerations, as is the orbicularis
response so the particle irritating the cornea uncontrolled by
conscious interference. Difficult as this may be of realisa¬
tion in all cases, the fact remains that the method of
immediate reaction to a stimulus-word by the utterance of
the first word, and no other, thereby presented to the
subject’s mind has proved of extreme practical value in
tracing unconscious mechanisms, not seldom to the surprise
of the subject of the experiment.
For ordinary purposes a list of some 100 words is taken
(various lists are given in various books; any worker may
evolve a separate set for himself) and the subject is directed
to give, in answer to each of them in succession, the first
word that comes into his mind, while the reaction-time is
noted by the observer in fifths of a second. Jung and Riklin
worked oat no less than 12,400 associations in normal
subjects in order to determine “types” of reaction and to
ascertain the effects of attention on the association process.
Their classification is based on the examination of educated
and less educated individuals of both sexes, and may be
(incompletely) summarised as follows :—
I. Inner association (associations of affinity or similarity).
1. Coordination: e.g., cherry— apple; pain—pleasure.
2. Predicate relationship (the response refers to the stimulus-word
as subject or object, noun-ad jeotive responses, Ac.) : eg., glass—
brittle; brave—soldier; to polish—brass.
3. Causal dependence: e.g., pain—tears.
II. Outer association (associations of practice or oontiguity).
1. Coexistence: e.g., Sunday—church; pipe—tobacco.
2. Identity : e.g., quarrel—dispute; take care—look out.
3. Verbal-motor forms (“mechanical” responses through constant
association in speech): e.g., bitter-sweet; white—black;
hammer—tongs. Also word-complements: e.g., tooth—ache;
fish—monger.
III. Clang-reactions (depending on sound).
1. Word-completions: e.g.. wonder—ful; modest —y.
2. Clang: e.g., green—greed ; window - winter.
3. Rhyme: e.g., make—shake; Moses—noses.
IV. Residual group, including indirect and meaningless reactions,
faults, perseveration, repetition, verbal Unking, and egocentric
reactions.
Perseveration 1 is of much significance. It consists in
an association conditioning or influencing one or more of
the following reactions. A fault is the omission of a
reaction, usually under the influence of emotion, while
the repetition of the stimulus-word is also an emotional
phenomenon.
Passing now to some of Jung and Riklin’s generalisa¬
tions, we may cite them without any critical digressions.
Where clang-reactions occur they are indicative of dis¬
turbance of attention, a fact of much diagnostic value. The
educated show a distinctly shallower or more superficial type
of reaction than the less well educated, a phenomenon
mainly of attention. The chief reasons for this somewhat
unexpected result seem to be that for the uneducated subject
the experiment is taken more seriously; be is less at ease;
influenced by habit, he instinctively apprehends the single
stimulus-word as a question or a command, with the intensity
of attention necessary for a proper answer. In men indirect
associations [e g., remorse — (mourning) — black ; ear —
(sound)—ground; mast—(master)—servant; milk—(-maid)
—rosy; severe—(father—mother)—dead ; &o.] are distinctly
more frequent than in women. Indirect reactions may also
be taken to indicate distraction of attention.
More important, perhaps, is the differentiation of two
general typeB of response: (1) that of the individual who
shows an objective, impersonal habit of mind; (2) that
where subjective experiences are made use of, often
emotionally charged. In the former tbe reaction is
usually connected by objective meaning with the
stimulus-word ; in the latter “constellations” oocur. Asso¬
ciations which are only explicable by personal events of
reoent date or of ihe present moment usually charged with
an affective tone, are known as constellations. Further, a
complex—i.e., a system of ideas revolving round some central
focus constituted by tome particular previous experience
commonly associated with emotional disturbance, often
stands out so prominently and acts so intensively, as Jung
1 Persistence is a better expression than perseveration, whleh has
quire other significance in connexion with ceirtain organic cerebral
symptoms.
The Lancet,]
THE BELGIAN DOCTORS’ AND PHARMACISTS’ RELIEF FUND.
[Fkb. 8, 1919 235
gays, as to form a whole number of constellations, faults, and
reactions with long reaction-time. Such complex-ci nstella-
tiona, in the second type, may be expressed undisguisedly,
or, and here at length we reach the essence of the method
as applied to the neuroses and psychoses, may occur in a
disgui- ed form in consequence of a repression which is not
always conscious. One of the conspicuous services rendered
to psychopathology by Jung and Riklin has been their detec¬
tion of the « fleets of unconscious constellation and uncon¬
scious repression as revealed in responses to association tests.
The departures in such cases from the normal and usual
types of reaction are called by them “ complex-indicators,"
and may be enumerated as follows :—
1. Prolongation of the reaction-lime.
2. An unusual and suspicious set ting of the reaction, frequently in
sentence form, not explained by the reaction-word itself.
3. Intrusion of the phenomena of attention. When a complex
emerges it draws a certain amount of attention to Itself, hence the
reaction to a given word becomes unexpectedly superficial, and If the
•ame phenomenon Is repeated at a similar stimulus-word the occur¬
rence of some Inward dlstraetloc is confirmed.
4. Fault8. The emerging complex absorbs all the attention.
6. Perseveration. The critical reaction may not have been noticed,
hot the succeeding reaction is under the influence of the persisting
emotional element and is Been to be abnormal.
6. Assimilation of the stimulus-word, wntuh is taken in a peculiar
sense or misunderstood in a peculiar way, in accordance with the
affective idea filling up consciousness.
7. Finally, in some subjects rrpe< itlons of certain words In their
answers are often found to be more or less closely associated with the
complex, or to represent it Indirectly.
It would be easy to give from experience concrete illustra¬
tions of the actual occurrence of these complex-indicators ;
suffice it to say that Jung’s contention that minute observa¬
tion of the subject and his responses enables the worker to
detect traces of affective processes linked with concealed or
half-concealed complexes is absolutely borne out by experi¬
ence of the association test. In his own words, “the
reactions are an extremely refined reagent for affective pro¬
cesses in particular,’’ which, as we know, play a prominent
part in the evolution of the psychoneuroses. No one
ignorant of the method can form any true idea of its
extraordinary delicacy, and may well be inclined to
disbelieve that in such simple means a key to unlock
the unconscious mind lies at hand. But that this
is so needs no further proof than the experiences of
those who use the method. Its relation to psycho¬
analysis is that of an adjunct; both are technical
methods for the exploration of unconscious mental processes.
By means of the association test a number of defective
reactions—complex-indicators—are obtained, and for their
amplification and interpretation psycho-analysis can be used.
Freud says that “the dream is the via regia to the uncon-
scions,” but in word-association tests we have an easy and
simple method of Teaching unconscious or partly conscious
constellations, and not infrequently, in actual practice, one
due thus obtained has sufficed to render possible the un¬
ravelling of the whole pathogenic complex. Clinically, it is
often enough ascertained that repression is not so complete
as is supposed, and, therapeutically, good results often
sucoeed the following np of association clnes without resort
to intricate and long-continued psycho-analysis.
There is no inherent difference between the word-
reactions, as such, of the normal and of the pathological
individual. All of us have our complexes and our con¬
stellations, and our affective trends too. In the case
of the neuroses, however, affective processes play a
prominent r61e; in certain conditions, notably hysteria,
they are perhaps all-important. Hence studies in word-
association in the various neuroses and psychoneuroses may
serve to show predominance of certain types of reaction
over others, and this is precisely what has been demonstrated
by Jang’s colleagues. The associations of imbeciles and
idiots, of epileptics and hysterics, of sufferers from dementia
prascox, have all been patiently worked at, and are par¬
ticularly instructive from the viewpoint of diagnosis. There
is, however, still a vast amount of ground to be covered.
Dr. 0. S. Myers, in his latest contribution to the study of
shell shock and allied conditions, begs for investigation of
association tests in such patients and of the possible effects
of glandular extracts on their reaction-times. Dr. Eder
hopes that the application of the method to education will
result in the establishment of standard tests for normal and
abnormal children, complementary to the intellectual tests
standardised by Binet. The method is obviously capable of
the widest application. S. A. K. W.
THE BELGIAN DOCTORS’ AND
PHARMACISTS’ RELIEF FUND.
Meeting of Executive Committee : Closing of the
Fund.
A meeting of the Executive Committee of this Fund was
held on Jan. 30th at the offices of The Lancet, Sir
Rickman Godleb being in the chair.
A letter was read from Dr. V. Pechdre, the President of
the Oomit6 National de Secours et d’Alimentation (Aide et
Protection aux M6decins et Pharmaciens Beiges Sinistrgs).
Having been warned by the Chairman of the Belgian
Doctors’ and Pharmacists’ Relief Fund that the reserves of
the Fund, which bad been able to continue its work steadily
until the end of 1918, were now coming to a close, the
following reply, brought by hand by Madame Pech&re, was
received:—
_ „ Bruxelles, Dec. 15th, 1918.
Dear Sir Rickmajt Godleb, —I have received your kind letter of
Nov. 24th and sincerely thank you for It. In writing to you as
President of the “Belgian Doctors* and Pharmacists' Belief Fund," I
wish to let you know as soon as possiole our infinite gratitude for the
InesMmsble kindness that my foreign colleagues, and particularly my
English ones, have rendered to the members of the Medical and
Pharmaceutical Professions during the war. It goes without Baling that
our Committee wishes to include all, whoever they may be.’in their
expression of gratitude, who, either from far or near, have helped to
succour tbeir suffering Belgian colleagues.
The praise that you express of all your helpers, especially Dr.
DesVoeux, Madame Des Vueux, and their admirable secretary In their
generous efforts in favour of the doctors and chemists who took refuge
In England, and in the special assistance of Dr. Eprigge(of The Lancet),
so highly appreciated, also of certain i ad lee attached to your committee;
all this is very pleasant to hear.
We wish particularly to thank those who have taken a preponderant
part In the joint profess! nal responsibility until we can do so person¬
ally, of which 1 do not despair In the near future. While awaiting the
moment we feel our words are insufficient to express our feelings, but,
believe me, they are profoundly sincere and addressed to each and all.
As to the American contribution sent by the Ued Cross, and by the
doctors and chemists of the United States, we know they showed great
generosity on our behalf. We wrote to Mr. Poland when he was staying
in Brussels to express our gratitude. I personally saw Hr. H over aa
he parsed through Belgium two years ago, and asked him to express
our thanks to those to whom they were due. I am writing to the
representative of the American Bed Cross in the same terms of gratitude
as those expressed in this letter.
We have often written letters to you and to our benefactors, but we
are convinced they never reached you. Now that communication Is
possible, we wish everyone to know that the gifts we have received
have helped to better the sad lot of our poor charges (prot£g<5s), which
was deplorable. Your help will never be forgotten, but the brotherly
enthusiasm whloh stirred up and kept going your inestimable contri¬
butions has touched us more than the material help represented.
You tell me in your letter, In reference to a cheque for £400 and
another for £800, that our English colleagues have themselves felt the
effect of the war and that their generosity has probably reached Its
limit. That Is a thing we can well understand; th- re comes a time
always In giving when, with the best intention In the world, one Is
obliged to come to a full stop.
H e are now feeling scruples, as we have In our possession funds
which might be useful to our poorer English colleagues. My Com¬
mittee unanimously agree that we should return par* of the fnnda.
The existence of a considerable sum perhaps needs some explanation.
Our grants at the beginning of the war w»re from 300 fr. to 600fr. a
quarter to each necessitous person. These allocations were raised later
to 700 fr. and sometimes 800 fr. tn particular cases of an urgent sort.
These grants were only given after repeated inquires, carried out with
the closest attention to the financial state of the receivers, as we were
most anxious to discharge your Instructions “only to give to the
most needy cases.’* These funds often had to feed, clothe, and
warm families consisting of numerous persons whote source of living
no longer existed. If you realise the price of food In Belgium
during the war—1 kilo of meat cost 30 fr., lib. of butter 20 fr.,
one ordinary suit of clothes 350 fr.. a pair of shoes 2C0 fr. I think
you will consider we acted with parsimony. Nevertheless, those we
helped were contented never complained, showed great courage and
endurance. Many gave up the subsidies we alluwed them and follow¬
ing the suggestions of the English committee we have often reduced
the amount given, allowing only for their necessary w»nts. (Aux plus
basses 11 ml ten compatible avec lea legitimes besolns de nos proteges.)
Moreover we had to look to the future, presuming that in the rationed
and fighting are-ts, with whicb the Germans would n -t allow us to
corresp *nd, there were confreres who might suffer the greatest misery
on the retreat of the enemy, and would be obliged to have recourse to
us for help, therefore we thought it wise to keep funds In reserve,
especially as this applied to all Flanders and part of Halnault (nearly
the third of our country. We had also to foresee that we not only had
to feed aud clothe our friends but might have to provide them*with
domiciles. Lastly, we thought our help could not. end with the cessa¬
tion of hostilities and must continue for some time, and this did really
happen. Notwithstanding the armistloe, the price of food is still as
high as during the ar.
We hear by inquiries and the justifiable demands which are sent by
most of our proteges, and bv some new ones that help Is badly
needed. Thus the Bums which we have received have not been fully
spent, but we shall find the proper employment for them. The
resources of our professional societies are very much reduced, the
funds from abroad must diminish, or cease. Frankly, our committee,
faced by new demands, are glad they have taken such precautions and
hope to meet with the approval of yonr oommlttee. We shall be glad
236 Thh Lahokt,]
ROYAL OOLLRGB OF PHYSICIANS OF LONDON.
[Fbb. 8, iai»
to hoar your views on this matter. In the future, aa In the paat, we
wlah to proceed entirely in agreement with you, aa the beat way in
which to prove our gratitude is to act in perfect accord with your
intentions.
I aball send very shortly the procis-vcrbaxix of our meetings and a
resume of our work and you ean judge therefrom of our position.
Veuillez agreer, cher Sir Hickman Godlee, pour voua et vos collogues
1 'assurance de mea sentiments trfia devours.
Blen k vous,
Dr. V. Pbch&re.
It was decided immediatelj to hand to Mme. Pech6re the
reply of the Executive Committee that there could be no
question whatever of the return to the Fund of any dona¬
tions. It was decided to point out that the Comit6 National
de Seoours et d'Alimentation had acted not only with care
and foresight hut actually in accord with the declared inten¬
tions of the originators of the Fund—viz., to reserve as much
money as possible to meet the position of “mldecins et
pharmaciens sinistr6s ” after the war.
Sir Riokman Godlee called attention to the faot that
there remained still at the Hall of the Society of Apothecaries
a large assortment of instruments presented by British prac¬
titioners. He mentioned that he had received a communica¬
tion from Mr. Samuel Osborn enclosing letters of thanks for
certain instruments already distributed in Belgium. It was
decided to send immediately to Brussels those instruments
whioh had already been set in order by an instrument-maker
and to remove the rest to the offices of The Lancet, whence
they could be distributed as occasion arose.
Dr. Des V<eux informed the Committee that early in
January Mr. David Wallace wrote from Edinburgh offering
a complete hospital equipment to go to Belgium. The
Comit6 National in Brussels were informed immediately,
but, no answer having been received from Belgium, Dr.
Des Vobux wrote accepting Mr. Wallace's offer, which will
be brought to the notice of the Comit6 through Mme.
Pecb&re.
The treasurer’s statement showed that a balance remains
in hand of £91 16s. 6d. after the January mensuality of
£800 had been despatched. The Fund continues to relieve
now and again by small grants certain Belgian doctors and
pharmacists or their wives remaining in England, but it was
felt that the existing balance at the disposal of the Fund
should now meet all such calls in the future. It was conse¬
quently decided definitely to close the Fund on Feb. 10 r h,
and to notify those who have generously given monthly
subscriptions that these should now cease. Among these
subscribers the Committee alluded with gratitude to the
particular generosity of Sir Alfred Pearce G’ould.
Subscriptions to the Second Appeal.
The following subscriptions have been received up to
Monday, Jan. 27th:—
£ 8. d.
Hampshire Pharmacists' Association, per Mr. 0. H Baker
(making £56 5s.) . 6 5 0
Dr. Charlotte B. Warner. 10 0
Dr. Alfred Cox (monthly) . 110
Subscriptions to the Fund should be sent to the treasurer
of the Fund. Dr. H. A. Des Vobux, at 14, Buckingham Gate,
London, S.W. 1, and should be made payable to the Belgian
Doctors' and Pharmacists’ Relief Fund, crossed Lloyds
Bank, Limited.
ROYAL COLLEGE OF PHYSICIANS OF
LONDON.
An ordinary Comitia was held on Jan. 30th, Dr. Norman
Moore, the President, being in the chair.
The following candidates, having passed the necessary
examination, were admitted as Members of the College:
Dr. C. T. Champion de Crespigny, Dr. W. H. Grace, Dr.
N. F. Hallows, Dr. G. R Pirie, Dr. W. G. Porter, Dr. A. F.
Rook, and Dr. T. W. Wadsworth.
Licenses to practise physic were granted to 64 oandidates,
who, having conformed to the by-laws and regulations, had
passed the required examinations. Seven Diplomas in
Pablic Health were also granted.
The following were elected councillors on the nomination
of the CouncilDr. H. Davy, Dr. H. Head, Dr. J. W.
Carr, Dr. G. F. Still, and Dr. M. Craig.
On the nomination of the Council, Sir Francis Champneys
was elected a representative oh the Central Midwives Board.
Dr. Sidney Martin waa elected a representative on the8enate
of the University of London, vioe Sir Frederick Taylor,
resigned.
An address was received from the Royal College of Phy¬
sicians of Ireland on the occasion of the quater-centenary of
the College. A gold Browne medal was received from Dr. R.
Crawfurd.
The President announced that he had appointed Dr.
Crawfurd to be Harveian Orator and Dr. A. P. Bed dart to
be Bradshaw lecturer in 1919, and that the Council had
appointed Dr. Aldo Castellani to be Milroy lecturer in 1920.
A report was received from the representative of the College
upon the proceedings of the General Medical Council in the
session held in November last.
The following report was received from the Committee of
Management :—
The Committee recommend that the course* of instruction in
pathology, practical pathology, and bacteriology, at the University of
Cape Town be accepted as fulfilling the requirements of the Regula¬
tions, Section II., par. XXI. id) and ( h ) 4, 6, o. and 8.
The Committee of Management have received an apDllcatlon from
the National Hospital for Epilepsy and Paralysis, Q teen-square,
and also one from the Hospital for Sick Children, Great Ormond*
street, for recognition as teaching institutions for students in
clinical medicine, and for part or the medical olerkshlp and
surgical dresserahlp. Both these hospitals are already reoognlsed as
teaching institutiins bv the Universities of Oxford, Cambridge,
London, and Durham. The Committee of Management feel that it
would be highly undesirable for any considerable amount of time spent
on clinical instruction and in holding appointments in special hos¬
pitals to take the place of the period required in a general hospital, but
they offer no objection to a period, not exceeding two months in all,
for clerking and dressing being spent at these two hospitals or other
special hospitals which may be hereafter reoognlsed by the Committee
of Management. With regard to an application whioh has been made
by the Dean of University College Hospital Medical School to utilise
this concession, the Committee of Management assume that the .
National Hospital and the Hospital for Sick Children will allow
students from other medical schools than University College to go
there in exactly the same way should the deans of their schools desire
to send them.
The Committee have also received an application from the London
Scho >1 of Medicine for Women that students may be allowed to oom-
plete their gynaecological clerkships at the Elizabeth Garrett Anderson
Hospital in which 50 per cent, of the surgical oases are gynaecological.
The Committee recommend that this application be granted.
After some formal business had been transacted the
President dissolved the Comitia.
MEDICINE AND THE LAW.
The Inquest on “ Billie Carleton. 1 ' -
The inquest held by Mr. S. Ingleby Oddie at the Coroner's
Court, Westminster, upon the body of a young woman
called Stewart, better known by her stage name as Miss
Billie Carleton, was concluded <>n Jan. 23rd, the death
inquired into having taken place on Nov. 27th. The
unavoidable length of the proceedings was due not to any
doubt that Miss Stewart died as the result of taking cooaine
but on account of the desirability of determining by what
means and through whom she had obtained the drug. In
order to elicit all the facts bearing upon this point
a large number of witnesses had to be called, and
as many of these were naturally anxious to screen
themselves or others their evidence had to be care¬
fully sifted and examined. Those who had some know¬
ledge of the matter were numerous, this being accounted
for by the fact that the deceased was one of a group
of people on terms of intimacy with one another, whose
common interest consisted in their addiction to drugs,
and whose common pursuit, in the case at least of Borne of
them, consisted in scheming to obtain drags for their own
or for one another’s consumption. An explanation given by
a witness named Reginald de Veulle of his own anxiety to
have cocaine for use on the night of the “ Victory Ball,” the
night on which Miss Stewart took the dose or doses which
proved fatal, may be noted. He said, in reply to a question
by the coroner, 4 ‘ It was because I knew perfectly well that
I could not get a single drink there.” To this he added that
he wished to get it for his own consumption only. It was
upon this witness that the coroner’s jury eventually laid the
responsibility for supplying the drug to the deceased, in the
following verdict:—
“We find that Miss Carleton died from an overdose of
cocaine, self administered, by misadventure, and that she
had no intention of committing suicide. We are of the
opinion that the cocaine was supplied to her by De Veulle in
a culpably negligent manner.”
The Lancer,]
URBAN VITAL STATISTICS.—CROOKES’S LENSES.
[Fbb. 8 , 1918 23 T
As this amounted to a verdict of manslaughter, the ooroner
issued a warrant for the arrest of De Veulle, who has since
been brought before a magistrate, and comment npon the
bets as affecting him must be withheld. The coroner’s
summing-up, however, of the law with regard to the supply¬
ing of cocaine in general contained passages which may be
quoted, with a view to their comparison with any future
enunciation of the principles to be observed in such cases.
Mr. Oddie said—
“ Somebody supplied her, that is certain, and it is an 1
unlawful act for anyone to supply anyone else with cocaine.
If one person supplies another he is doing an unlawful act.
If the cocaine causes death he is guilty of manslaughter.
If charged, it is a settled principle of law in this country
that if a person does an unlawful act and by that act causes
death, even if death was never intended or contemplated, he
is guilty of constructive manslaughter.’ 7
The illegality of the act of supplying cocaine in the case
before him. would arise, he explained, under regulations
made under the Defence of the Realm Act, and in case the
jury might feel disinclined to press hardly against a person
infringing a law made more or less to meet the emergency of
war, he proceeded to the following further definition of
what might constitute manslaughter, saying :—
“If a person does a, lawful act which is dangerous to life,
and if he does it negligently, and if the jury think that that
negligence is gross and culpable negligence, that it shows
recklessness and indifference to consequences, and is so
grossly negligent, that it shows the person doing it has a
wicked mind, and if that lawful, though dangerous, act
causes death, then the person doing it is guilty of man¬
slaughter. That is settled law. The Common Law of
England provides that people who do dangerous things
must use reasonable care, and if the jury decide that such
an act as supplying cooaine—which is a dangerous drug if
supplied recklessly—negligently, grossly negligently—then
you can return a verdict of manslaughter.”
In the course of his summing-up the coroner referred to
the relations between the deceased and a medical practi¬
tioner who had given evidence, and he expressed himself
satisfied that this gentleman, as to whose conduct he
admitted that he had felt suspicious, had, in fact, tried to
persuade Miss Stewart to give up drugs. One of his letters
to her, found among her papers, contained the passages:
“ I'll do anything to save you from the bottomless pit of
darkness, despair, and depression.Get over these lapses.
Get over the influence and existence of the damned stuff.
Leave it to do its useful work as a local anaesthetic and
kill pain, not people.”
The concluding phrase quoted by Mr. Oddie is a
singularly apt one.
URBAN VITAL STATISTICS.
(Week ended Jan. 25th, 1919.)
English and Welsh Towns .—In the 96 English and Welsh towns, with
• an aggregate civil population estimated at 16,500.000 persons, the
annual rate of mortality was 15 0, against 16 0 and 15 5 per 1C00 in the
^^P£®o®ding weeks. In London, with a population slightly exceeding
4,000,000 persons, the annual death-rate was 14*1, or 0*7 per 1000 below
that recorded in the previous week ; among the remaining towns the
rates ranged from 6 0 in Bury, 6 8 in Warrington, and 8*2 in
Hornsey, to 23 2 in Wigan, 24*6 in Liverpool, and 28 0 in Hastings.
The principal epidemic diseases caused 162 deaths, which corre¬
sponded to an annual rate of 0 5 per 1000, and inoluded 58
from diphtheria, 48 from infantile diarrhoea, 24 from whooping-cough,
13 from measles, 11 from scarlet fever, and 8 from enteric fever.
The deaths from influenza, which had steadily declined from
7569 to 274 in the 11 preceding weeks, further fell to 222, and
included 40 In Liverpool, 33 in London, 15 in Leeds, and 10 in
Bristol. There were 6 cases of small-pox, 1057 of scarlet fever, and
1174 of diphtheria under treatment in the Metropolitan Asylums
Board Hospitals and the London Fever Hospital, against 5, 1092,
and 1145 respectively at the end of the previous week. The causes
of 36 deaths In the 96 towns were uncertified, of which 9 were
egutered in Liverpool, 8 in Birmingham, and 4 In Darlington.
ScofcA Towns. —In the 16 largest Scotch towns, with an aggregate popu¬
lation estimated at nearly 2,500,000 persons, the annual rate of mortality
**■ against 18 6 and 17 0 per 1G00 in the two preceding weeks.
* deaths in Glasgow corresponded to an annual rate of 16 4 per
iUUO, and Inoluded 13 from whooping-cough, 3 each from measles and
diphtheria, and 2 from infantile diarrheea. The 138 deaths in Edin¬
burgh were equal to a rate of 21 4 per 1000, and included 12 from
Sph§ieria C0U *h’ 3 fr0m mea8le8 ' 2 from scarlet fever, and 1 from
IrfsA Towns. —The 179 deaths in Dublin corresponded to an annual
rote of 23*0, or 0*9 per 1000 above that recorded in the previous week,
•ua Included 3 from Infantile diarrhoea and 1 each from scarlet fever
and diphtheria. The 145 deaths In Belfast were equal to a rate of 18*9
P® 1 1000, and Included 2 from infantile diarrhoea and 1 from diphtheria, i
Cffmspnfcmt.
" And! alteram partem.'*
CROOKES’S LENSES.
To the Editor of The Lancet.
Sir,—“E nquirer" and others may find useful a little
farther information on Crookes's lenses beyond that givers
in your editorial note (The Lancet, Jan. 18th, p. 124).
Although these lenses have now been for some years on the
market, there appears to exist still a good deal of ignorance
in the medical profession both as to their composition and
their use.
Crookes’s A or No. 1 is the glass most used in this climate,,
and its composition is: Fused soda flux, 83 per oent. and
cerium nitrate 17 per cent. It is difficult commercially to-
got the cerium salt pure, there is present a small amount of
didymium which gives the glass a brownish purple tint when
viewed edgeways, and gives the whole glass a slightly greyish
tint, but this tint is so slight that when worn in spectacles
it is indistinguishable from ordinary glass. The value-
of this glass is that it cuts off the ultra-violet rays of
transmitted light without any loss of luminosity. Any
ordinary tinted glass, of whatever kind, cutting off the same
amount of those deleterious rays is not only extremely un¬
sightly, but also lowers the luminosity to a very marked
degree. In photaugiaphobia, or fear of the glare of light (differ¬
ing from photophobia, which is the fear of light), Crookes’s
No. 1 is invaluable, and myopes who have worn their cor¬
rection made up with it appreciate it most highly. In work
with incandescent gas and electric light it has a most soften¬
ing and soothing effect. Another important charaoteristia
of this glass is that it does not make the retina more sensitive
to light when discontinued, which is not the case with
ordinary tinted glasses.
Crookes's R, or No. 2, is only required when great glare is
encountered, as in tropioal climates or snow regions, or in.
diseases of the eye which call for smoked glasses. Its
composition is slightly different from Crookes’s A, having
nickel and cobalt sulphate and uranoso-uranic oxide added in
small quantities, and it is only transparent to 45 per cent,
of incident light.
It is difficult to over-estimate the enormous benefit that
these lenses give in correcting errors of refraction, and it is
another cause of gratitude we owe to that “ grand old man*”'
of science. Sir William Crookes.
I am, Sir, yours faithfully,
Feb. 1st, 1919 . Ernbst Clarke, M.D., F.R.C.S.
MUCOID FORMS OF PARATYPHOID.
To the Editor of The Lancet.
Sir,—B eing on active service I have only just observed
the article by Captain W. Fletcher, R.A.M.C., on Oapsulate
Mucoid Forms of Paratyphoid in The Lancet of July 27th,
1918. I was particularly interested to read* it, as I made a
similar observation some time ago and recorded it in my
annual report of the Enteric Convalescent Depdb, Naini Tal,
which was published in the Army Sanitary Reports, India,
1916. Like Captain Fletcher’s cases, mine was also a
carrier of B. paratyphusus B, and I satisfied myself that
the organism was the genuine article. In my report I
remarked that I was not aware of a similar observation
having been made before.
Daring 1918 I made an observation on another carrier. I
was making daily examinations of an officer who was a
chronic carrier of B. para. B, and one day through press
of work put off the examination of the plate, which had
been incubated for 24 hours, till the next day, and mean¬
while the plate lay on my table for another 24 hours. By
this time I noticed that several colonies showed a secondary
(mucoid) growth round their edges, giving the appear¬
ance of tiny thickly tyred wheels. Mindful of my former
experience, I tested these colonies and proved them to be
B. para. B. In this particular case the cultural peculiarity
of the organism proved a great saving of labour, as it was
only necessary to leave the incubated plate for another
24 hours at room temperature for the organism to demon¬
strate itself by its secondary growth. I never found, though
I controlled the observation many times, that in this
238 The Lancet,]
THB WAR AND AFTER.
[Feb. 8, 1919
particular case did any other organism show the same
peculiarity. I should have mentioned that, like Captain
Fletcher, the medium I used was Endo’s.
The term “ mucoid ” would appear to be a better one than
the one I used—viz., “ gelatinoid,” a9 it more accurately
describes the appearance of the colonies, but it is just a
question whether “ zoogloeic ” would not more accurately
describe this form of growth and I would suggest that it is
an indication of attenuation. I am sorry I am unable at
present to refer to my notes for more accurate details.
I am, Sir, yours faithfully,
J. C. Kennedy.
Lieutenant*C« lonel, R.A.M.C.
Meeopotaraian Expeditionary Force, Dec. 28th, 1918.
CAUSES AND INCIDENCE OF DENTAL CARIES.
To the Editor of The Lancet.
Sir, —As Dr. James Wheatley’s figures with regard to
the prevalence of dental caries among children have been
cited and admittedly confirmed, it may be well to take note
of his figures with regard to dental caries in adults. In a
recent lecture he said : “ Among 83 women, mostly between
25 and 30 years of age, examined by me for nursing scholar¬
ships, the average number of teeth decayed or lost was
17 6.” Now, unless these figures are regarded as quite
unreliable, it would appear that Dr. Harry Campbell’s esti¬
mate is not “ very excessive,” but quite the contrary, and I
trust we may not be debarred from further inquiry such as
Major Nickolls Dunn urges, by anyone attempting to belittle
the seriousness of the state of the teeth, or in any way
seeking to hinder research for the truth. When those in
authoritative positions know and teach the truth, the diet in
the nursery at least will soon be changed ; but, to quote
from a recent editorial article in a dental journal, “until
teachers of physiology in our medical schools recant the
erroneous doctrines of diet and nutrition that have been the
source of so much misplaced confidence during the last half-
century on the part of the anxious-to-learn public, little can
be done.” I am, Sir, yours faithfully,
Harley-street, W., Feb 1st, 1919. J. SlM WALLACE.
WAR DEAFNESS.
To the Editor of The Lancet.
Sir,—D r. P. McBride seems determined to deprive men
suffering from war deafness of the chance of being cured by
psychotherapy, as his letter to you of Jan. 25th is, I believe,
the third communication to the medical journals attempting
to prove that hysterical deafness rarely, if ever, occurs,
whereas all who are familiar with the war neuroses know
that the vast majority of cases of so-called shell-shock
deafness are hysterical and therefore curable, even if com¬
plicated by some slight organic lesion, such as a perforated
drum. I therefore welcome Captain E. Prideaux’s letter of
Feb. 1st, confirming what Lieutenant-Colonel C. S. Myers
wrote on the subject on Jan. 18th. In the majority of our
cases we have not investigated whether the hysterical
deafness persisted in sleep, but this was proved quite clearly
in two cases which I published with Captain E. A. Peters in
The Lancet on Oct. 6th, 1917. It cannot be too widely
known that the old tests which were supposed to distinguish
organic from hysterical deafness have proved most fallacious,
and that every man suffering from “shell-shock deafness”
ought to be given a chance of recovering under psycho¬
therapy.
I was surprised to read Captain Prideaux’s statement that
there was a disposition for other symptoms to develop after
recovery from hysterical conditions. This must clearly
depend upon the method of treatment employed. If the
simple method of psychotherapy, by means of explanation,
persuasion, and re-education, which we have adopted in
preference to all methods of gross suggestion, is used, such
substituted symptoms hardly ever occur. Among several
hundred cases which have been treated in this hospital new
symptoms have not followed recovery in more than three or
four instances, and in every case the secondary symptom
was rapidly cured. On the other hand, it is a daily occur¬
rence for the removal of one hysterical symptom to be imme¬
diately followed by the disappearance of other nervous
symptoms, whether hysterical or not. For example, the cure of
hysterical tremor or stammer, which may have lasted for many
months or even for a year or two, at a single sitting is often
followed by the immediate disappearance of insomnia, war
dreams, and headache, with which they have been associated
during the whole period. In the same way the cure of I
hysterical paralysis of a leg will often be accompanied by i
recovery of power in the arm in hemiplegia without any j
treatment being directed to the latter. In the case of a man
who had been totally blind for four and a half years after
being blown up constant headache and extreme depression,
as well as almost complete bilateral deafness, which had
previously been regarded as organic, completely disappeared i
in 24 hours without any direct treatment, as a result of the
cure of his blindness by explanation, persuasion, and j
re-education. I am, Sir, yours faithfully,
Arthur F. Hurst,
Lieutenant-Colonel, R.A.M.C.
Seale Hayne Military Hospital, Newton Abbot,
Feb. lBt, 1919.
Cjje SStar m \\i Jftcr.
Auxiliary Royal Army Medical Corps Funds.
The usual quarterly meeting of the committee was held
on Jan. 31st at 11, Chandos-street, W. Colonel Ewen
Maclean was in the chair. Grants were made to the
widows and orphans of four officers and to the widows and
orphans of seven men of the rank and file. Widows or
orphans of officers or men of the Auxiliary Royal Army
Medical Corps requiring help should apply to the Honorary
Secretary of the Funds at 11, Chandos-street, Cavendish-
square, W. 1. _
It is now officially announced that Colonel
A. Webb, A.M.S., at present Assistant Director of Medical
Services at the War Office, has been appointed Director-
General of the Medical Branch of the Ministry of Pensions.
OBITUARY OF THE WAR.
SAMUEL WAUCHOPE MATTHEWS, M.B.. B.Ch. N.U.I.,
CAPTAIN, ROYAL ARMY MEDICAL CORPS.
Captain S. W. Matthews, who died at Lindi, East Africa,
on Nov. 15th, 1918, at the age of 31 years, was fourth son of
the Rev. S. Matthews, of Belgrave-square, Dublin. Educated
at the Wicklow Academy, where he was awarded several
first places and composi¬
tion prizes by the Irish
Intermediate Education
Board, he went on to
University College,
Galway. He held junior
scholarships as an
undergraduate and a
senior scholarship in
his final year, was
chairman of the College
Debating Society,
captain of the cricket
and hockey teams, and
in 1910 was awarded
the President’s Medal
for oratory. In 1913
he graduated in medi¬
cine at the National
University of Ireland
and was appointed
resident at the Children’s Hospital, Temple-street, Dublin.
He volunteered for service with the R.A.M.C. on the outbreak
of war and was sent to German East Africa, where fellow v
officers testify to his efficient work. Weakened by several
attacks of malaria and jaundice he fell a victim to an attack
of enteric fever. Captain Matthews was unmarried.
Captain Robert Percy Young, A.A.M.C., who was ^
killed on Sept. 18th, was educated at Caulfield Grammar
School, where he played in the cricket and tennis teams,
and at Ormond College, Melbourne University, where he ^
was a medical student from 1909 to 1913, and graduated
M.B., B.S. in March, 1914. After a short period as resident
Th> Langv,]
OBITUARY.—MEDICAL NEWS.
[Feb. 8,1919 239
medical officer of a public hospital, he joined the A.A.M.C.
in 1916, and was sent to Egypt, where he was attached to
the 4th Divisional Ammunition Column at Serapuem. He
was in England for a time in the early part of 1917 with the
A.I.F., and at the end of June was sent to the 1st Australian
General Hospital in France. From there he went to the
front and was attached successively to the 1st Battalion, 1st
Field Ambulance, 3rd Field Ambulance, and 10th Battalion.
With this last unit he went into action at Jeancourt, and
was killed while attending to the wounded on the first day
of the last operations carried out by the 1st Australian
Division.
Sir JAMES SAWYER, M.D., F.R.C.P. Lond.,
F.R S. Edtn.,
CONSULTING PHYSICIAN TO THE QUEEN'S HOSPITAL, BIRMINGHAM.
Sir James Sawyer, who died at his residence at Hatton,
Warwick, on Jan. 27th, aged 75, was the eldest son of the
late James Sawyer of Carlisle, and was educated at Queen’s
College, Birmingham. He qualified as a member of the
-Royal College of Surgeons of England in 1866, and in the
following year graduated in the University of London as
H.B. with first class honours. He was then appointed
resident physician and medical tutor at the Queen’s Hospital,
Birmingham, a post which he held for several years. In
1875, having proceeded to the M.D. London, he was
appointed professor of pathology at Queen’s College,
‘Birmingham, where three years later he became professor
of materia medica, holding the chair for seven years, when
he became professor of medicine. In 1879 he was elected
physician at Queen’s Hospital, and became F.R.C P. Lond.
ift 1883, and after 22 years’ service he became consulting
physician to the hospital. He was knighted in 1885. In
1908 he delivered the Lumleian lectures at the Royal College
of Physicians of London on “ Points of Practice in Maladies
of the Heart.”
He was a man of many activities, being ex-president of
the Midland Medical Society, the Birmingham branch of the
British Medical Association, the Birmingham Medical
Benevolent Society, and the Birmingham Clinical Board.
He was also founder and first editor of the Birmingham
Medical Review, vice-president of the Therapeutics Section,
International Medical Congress of London, 1913, president
of the Warwickshire Chamber of Agriculture in 1902, and
Justice of the Peace for Warwickshire and Birmingham.
He was author of numerous contributions to practical
medicine. He also took a strong part in Birmingham politics.
He was president of the Birmingham Conservative Associa¬
tion in 1885, and in those forceful days he never became
reconciled to the Conservative alliance with the Liberal
Unionist Party.
8ir James Sawyer married a daughter of the late Rev. J.
Harwood Hill, and leaves a widow and two sons, of whom
the rider, Lieutenant-Colonel J. E. H. Sawyer, Administrator
of the 1st Southern General Hospital, is assistant physician
of the General Hospital, Birmingham.
Death op Dr. William George Kemp.—D r. W. G.
Eemp, of Oakhurst, Hastings, died with tragic sudden¬
ness while in a tramcar on Jan. 24th. Dr. Kemp was
born at Alnwick in 1846, and educated at King’s School,
Canterbury, and St. Bartholomew’s Hospital. After quali¬
fying M.R.C.S. and L.R.C.P. Lond., he was house surgeon
at Nelson Hospital, N.Z., and in 1870 began practice in
Wellington, N.Z., holding the appointment of surgeon to
the Wellington Hospital, and having a wide consulting
general practice. He was the first surgeon to perform
ovariotomy in New Zealand, where he was highly esteemed
for his skill and sterling character. He returned to England
*n 1892 and took the M.D. Durham, but retired from all
practice shortly afterwards. Dr. Kemp married Charlotte,
daughter of Dr. J. D. Greenwood, and leaves a widow, four
sons, and three daughters. One daughter, a King’s College
-Hospital sister, was killed by a German bomb while working
at aRed Crofes hospital in Belgium. One son is Major in the
N.z. Medical Corps, one Captain, R.A.M.C., and a third son
Vs in medical practice in New Zealand.
Plague and cholera are reported in the Indian
Sola-fields and are causing anxiety to the authorities.
Examining Board in England by the Royal
Colleges of Physicians of London and Surgeons of
England.— At the Final Examination, held from Jan. 14th
to 28th, the following candidates were approved in the under¬
mentioned subjects, but are not eligible for diplomas:—
Medicine.—J . H. Allan, Liverpool; G. A. K. Barnes and B. F.
Beliman, Univ. Coll.; T. G. D. Bonsr, Guy’s; Sarah Atleen
Florence Boyd-Mackay, Royal Free; H. M. Brown, Guy’s; B, B.
Carter, St. Thomas's; C. K. Cullen, London; Sylvia Victoria
Elman, St. Mary's; V. N. Fenton, Cambridge and London; H. H.
Goodman, Leeds; C. Griffith-Jones, St. Bart.’s; K. A. Hardy,
Charing Cross; W. B. Hargreaves, Manchester; M. S. Hashish,
St. Bart.’s; H. C. Hopkinson, Cambridge and Manchester; R.
Jenner-Clarke, London; S. Kelly, Manchester; Muriel Mercer
Kenworthy. Royal Free and Liverpool; M. A. Keshvalu, Hyderabad
and Univ. Coll.; B. D. Macmillan, St. Bart.’s; A. A. K. S. Man sour.
Charing Crons; J. S. Moore, St. Thomas’s; Eva Morton, Royal
Free; J. L. Niebet, St. Bart.'s; A. A. Osman, Guy's; Sigrld Letitla
Sharpe Pearson, Royal Free; G. A. Pennant, Bristol; Norah
Dorothy Pinkerton, Royal Free; Bnid Margaret Maiy Quaife,
St.. Mary's; W. A. Richards, Charing Crons; H. S. Robinson,
London ; A. K. Sawdsy, Guy’s ; A. II. Why te, Durham; S. C. de S.
Wijeyeratne. Univ. Coll. ; Ethel Dorothy Will's, Manchester; M.
Wong, St. Thomas’s ; and G. R. Woodhead, London.
Surgery.— R. J. Allison, Manchester; W. B. Bracey, Birmingham ;
T. Fernandez, Cambridge and Guy's; Margaret Hammond, Royal
, Free; B. C. Hardlman, Queen’s Univ.; H. Kamal, King’s Coll.;
V. G. Mobile, Grant Medical College; C. F. Newman, Birmingham;
J. 8. Rogers, King's Coll.; M. L. Schroeter. Zurich Univ.; B. N.
Showell-Rogers, Cambridge and St. Thomas’s; and B. R. Webb,
Guy’s.
Midwifery.— W. S. Adams, Birmingham ; W. J. McB. Allan, Guy's ;
H. B. Archer, St. Bart.'s ; B. A. Asttey-Weston, Bristol; P. 0.
Brett, St. Thomas's; B. F. Brown, Birmingham; J. D. M.
Cardell, St. Thomas’s; I. J. Cruchley, London; G. L. Cults,
Guy’s; Sarah Helen Davies. Royal Free; A. M. El-Mlshad, King’s
Coll.; A. H. El Rakshi. Univ. Coll.; C. W. Emrcy, London ;
Kathleen Field and J. O’F. Fletcher, St. Mary’s; W. T. Flooks,
Guy's; L. P. Garrod, Camhtldge and St. Bart.’s; St. G. B. D.
Gray, Guy’s; Dorot hy Margaret Greig, Royal Free; Mary Isabel
Alleyne Grimmer, Charing Cross; T. L. Uillier. Cambridge and
St. Thomas’s; F. G. Hobson, Oxford and St. Thomas's; Mabel
Marian Ingram, Royal Free; S. W. Jeger, London; S. Kelly,
Manchester; R. C. B. Ledlle, Guy’s; J. N. Leitch, St. Bart.’s;
T. I. Makar, Middlesex ; C. Nlcory, St. Thomas’s ; J. L. Nisbet,
St. Bart.’s; J. L. C. O’Plyn, St. George’s; F. R. Oliver,
Cambridge and St. Bart.’s; G. Packham, Cairo and Guy’s;
W. W. Payne, Guy’s; F. F. Petersen, London; G. S. B.
Philip, Charing Cross; J. Prr ujanBky, London ; R. R. B. Roberts,
Liverpool; H. T. Roper-Hall. Birmingham ; R. B. R. Sanderson,
St. Bart.'s ; B. R. Sarra, Cambridge and London ; H N. Schapiro,
Guy’s; F. P. Schofield, St. Bart.’s; F. G. Spear, Cambridge and
St. Thomas’s; Doris Elsie Florence Stanton, Birmingham ; J. G.
Strachan, Toronto; A. Sudkt, Birmingham ; C.SufTern, Cambridge
and Sfc. Thomas’s; S. R. Tattersall, St. Thomas's; R. Thurez,
King’s Coll.; W. A. Turner, Guy’s; N. S. B. Vinter. St. Bart.’s; W.
Walsbam, St. Mary's; C. J. L. Wells and J. 8. White. St. Bart.’s;
A. H. Whyte, Durham ; Octavia Margaret Wilberforoe, Royal Free
and St. Mary’s; May Grant Williams, Royal Free; C. B. Wilson,
Cambridge and Univ. Coll.; and A. B. Young, Bristol.
-Royal College of Physicians of London.—T he
following candidates having conformed to the by-laws and
regulations and passed the required examinations have been
granted licences to practise physic
Iskander Mikhail Abd-el-Said, Univ. Coll.; Wilfred Mark Anthony,
St. Thomas’s; Douglas Albert Raoul Aufranc, Middlesex; Percy
Banbury, St. Thomas’s; Hezeki&h Barbash, Cambridge and St.
Bart.'s; John Myles Blckerton, Cambridge and King’s Coll.;
"Ursula Poussett Blackwell, Royal Free; Edward Phililmore
Brockman. Cambridge and St. Thomas’s; Jacob Brodetsky, London ;
Jean Bbo sy, Lausanne; Charles Henry Bubb, Guy's; Michel
Henri Burnler, Lausanne; "Alix Jeanne Churchill, Royal Free and
St. George's; Roger Heine Clarke, Cambridge and St. Bart.’s;
Cecil Gerald 8edgeley Corner, Madras and Univ. Coll.; Ahmad
Rahlmtula Ilhalak Dina, Bombay and Guy’s; Geoffrey Barrow
Dowling and Arthur Alan Forty, Guy’s; Reginald Stafford
Foes, St. Thomas’s; Lionel Brule Frazer, Cambridge and St.
Thomas’s ; Joseph Pinkus Freillch, Univ: Coll. ; Bdward
James Gaffney, Guy’s ; John Francis Gaha, Dublin and
Univ. Coll.; Christopher Frank Good and Boris Abramovltz
Morshovitz Gordon, London ; Frank Gray, Cambridge and
St. Bart.'s; Hubert Oliver Gunewardene, King’s Coll.; Arthur
Clare Halliwell and Aithur Thomas Hawley, Cambridge and
St. Thomas's; Christopher Thomas Helsham, Durham and Guv’a;
Charles Harold Sterne Ilorwitz, Guy's; Gilbert Rashleigh Hull,
St. Thomas's; Graydon Oscar Hume, Guy’s; Tom Aubrey Jones,
Cambridge; Henry David Keif, St. Bart.'s; Francis Widiarn Kemp,
Charing Cross; Gdal Lelzer Levin, Univ. Coll.; Philip Clermont
Livingston, Cambridge and London; Pierce Lloyd-Wllliams and
Ernest Kenneth Macdonald, St. Thomas’s; John Alexander
Mackenzie, Manitoba; ChArles Fergus McLean, Cambridge and
St. Thomas’s ; "Malatl Madgavkar. Birmingham ; Charles Dundas
Maitland, St. Thomas’s; Hugh Bethune Maitland, Toronto;
Humphrey Ingllby MarViner. St. Thomas's ; Samuel Raynor Meaker,
Harvard; Anakara Vadakath Radbakrlshna Menon, Madras and
Univ. Coll.; David Richard Owen, Liverpool; Aerath Narayanan
Nauoo Panlkkf r, Edinburgh ; "Dorothy Priestley Priestley, Leeds;
Rowan William Revell, Univ. Col.; Rupert Idris Rhys, St. Bart.'s;
Francis Henry Smith, Cambridge and St. George’s ; Francis Rupert
Snell, St. Thomas's and Durham; Robert James Staley, Birming¬
ham ; Howard William Copland Vines, Cambridge and St. Bart.'s;
240 Thb Lancet,] APPOINTMENTS.—VACANCIES —BIRTHS, MARRUGES, AND DEATHS. [Feb. 8, 1919
Arthur Elston Ward and Hveljn Cecil Whitehall-Cooke. St.
Thomas's; Roger Lester Williams, Cambridge and St. Bart. ’a;
Sik To Wong, Guy’s; Raymond Benedict Hervey Wyatt, Oxford
and St. George's; Harold Blacow Yates, Cambridge and St. George’s;
and Frank Young, Guy's.
* Under the Medical Act, 1876.
Diplomas in Public Health were granted conjointly with the
Royal College of Surgeons of England to the following
candidates
George Alexander Bimle, John Alexander Drake, Thomas Hill
Jamieson, Arcot Doralaawmy Loganadao, Keith Myrle Benoit
Simon, Philip Smith, and John Wotherspoon.
The Medical Meeting at Wigmore Hall.—A t
the meeting of the medical profession which took place at
the Wigmore Hall, Wigmore-street, London,on Sunday last,
under the chairmanship of Mr. Fielding-Ould, a singular
position was reached. The following resolution was pro¬
posed, seconded, and carried by 182 votes to 93.
In view of prospective legislation and the proposed establishment
of a Ministry of Health, and having regard to the experience of the
medical profession at the time of the passing of the National Insurance
Acts, the time has arrived when a body representative of the whole
profession should be established, to watch its interests and be prepared
to act in an advisory capacity as occasion demands.
The opposition to this resolution came from the repre¬
sentatives of the British Medical Association, who protested
against the formation of any such body on the grounds that
the medical profession had in the Association a body capable
of acting in the proposed manner. The meeting being now
definitely committed to the formation of a new body, the
following resolution was proposed and seconded
That a provisional committee be now formed with the object of
securing the election of such a body.
To this resolution the following amendment was proposed
and seconded
" That this meeting of the medical profession, In view of the urgency
arising from contemplated legislation, approves the recognition of the
Parliamentary Medical Committee as the provisional committee to be
entrusted with the task of drawing up the constitution of a body to
develop along the lines indicated by the first resolution.”
The amendment on going to division was negatived by 105
to 87 in a dwindling meeting. A second amendment to the
resolution was then proposed in the following terms
“That in the opinion of this meeting no committee or organisation
is capable of effectively representing the Interests of the profession
unless it is a registered medical trade union/'
This amendment, being seconded, went to division and was
announced by the Chairman to have been lost by 73 votes
to 71, those being the figures of the count. The supporters
of the amendment demanded a recount, which the chairman
ruled to be impossible aB members of the meeting who had
voted had already left the building. The meeting refused
to accept the chairman’s ruling, who thereupon left the
platform.
The result of the meeting, therefore, was to decide that a
new body should be formed in accordance with the first
resolution, while the second resolution, under which the
actual formation of such a body should have taken place,
was never reached, and the two amendments to it failed.to
secure the necessary support. No action, it would seem,
arises from the meeting.
The Child-Study Society of London. — A
course of five lectures on alternate Thursdays at 6 p.m.
begins on Feb. 13th at the Royal Sanitary Institute
(90, Buckingham Palace-road, London, S.W. 1), when Mr
C. W. Kimmins, M.A., D.Sc., deals with the Significance of
Children’s Dreams. Dr. Eric Pritchard gives the conclud¬
ing lecture on Home versus Institutional Training of Young
Children. The lectures will be announced in the Medical
Diary.
Lepers in India. — An Indian auxiliary to the
Mission to Lepers, which has been working for 44 years, has
inst been formed in 8imla by Lady Chelmsford, wife of the
Viceroy. The work of the Mission is to be the subject of a
series of lantern lectures in important oentreB by the
secretary of the Mission. The modern treatment for leprosy
is to be promoted under a committee presided over by the
Director-General of the Indian Medical Service. Sir
Leonard Rogers and the secretary are drawing up a scheme
for the trial of new remedies in the 60 leper asylums con¬
ducted by the Mission.
Medical Society of London.— The programme
for the second half of the 1918-19 season includes a paper by
Sir StClair Thomson on the Operation by Laryngo-nssure
(Feb. 10th) and by Mr. R. A. Ramsay on Congenital Hyoer-
(Feb * 24th i* ° D Mar0h 10fch » 17th,
and 24th Dr. W. H. Willcox, Colonel, A.M.8., will deliver the
Liettsomian lectures on a subject to be announced later. The
annual oration will be delivered by Sir John Tweedy on
May 12th, following the general meeting. The ordinary
meetings will be held at 8.30 p.m., the general meeting at
8 p.m., and the Lettsorfiian lectures at 9 p.m.
Spektafs.
Rowland, Stephvn, M.B. Edln., D.P.H. O&mb, has been appointed
temporary Tuberculosis Officer tor Northampton.
Hamms.
For further information refer to the advertisement columns.
Ashford, Kent. Qrosvenor Sanatorium , Kennington.—Re*. Amt. M.O.
Birkenhead Byrough Hospital — Jun. H.S. £170.
Birmingham Corporation Pre-Maternity and Infant Welfare Work.—
Female Doctor. £350.
Bradford Union —Asst. M.O. £400.
Buenos Aires. British Hospital.— Senior R.M.O. and Asst. B.M.O.
£500 and £450.
Folkestone , R 'yal Victoria Hospital.— H.8. £150.
Glamorgan County Council—Inspection of Children in Publie Ele¬
mentary Schools. —Three M.O.’s. £400.
Huddersfield Royal Infirmary .— Jun. H.8. £100.
Johannesburg, South A frican School of Mines and Technology. — Pro¬
fessors or Anat. and Physio. £1000 in each case.
King George Hospital, Stamford-street, S.E.—Re*. fl.8. £1 per diem.
Jjecas Hospital for Women and Children.— Hon. Asst. S.
Liverpool Eye and Ear Infirmary.— Hon. Asst. Surgeons.
Manchester, St. Mary’s Hospitals.—R on. Asst. S. for Women.
National Hospital for Diseases of the Heart , Wcstmorcland-street, W.—
Res. M.O. £100.
Newcastle-upon-Tyne Poor-law Infirmary.—Ferns,]* Asst. Res. M.O.
£250.
Northampton General Hospital.— Juu. H.8. £150.
Nottingham City Asylum.— Junior Asst. M.O. £300.
Portsmouth Corporation Mental Hospital.— Jun. Amt. M.O. £250.
Royal Free Hospital, Gray’s Inn-road , W.C.— Clin. Asst.
Royal National Orthopxdic Hospital.— Res. H.8. £100.
St. Thomas’s Hospital, S.E.— Asst. Bacteriologist. £400. Also Asst*
Pathologist and Demonstrator of Morbid Anatomy.- £250.
Sheffield Royal Hospital.—Css. O. £131. Also Amt. H.P. £120.
Smethwick County Borough.— M.O.H. £800.
Stoke-on-Trent County Borough.— Temp. Tuberc. O. £550.
Sunderland Royal Infirmary, Children’s Hospital.—Re*. M.O. £200.
University of London. —Examiners.
Walsall General Hospital.— H.S- and Anaesthetist. £175.
Warwickshire County Council.— Asst. M.O.H. £400.
Western Ophthalmic Hospital , Marylebone-road, N. IF.—Vacancies on
Medical Staff.
West Ham Union Sick Home , Forest-lane, Stratford , E.— Temp. Res.
Asst. M.O. £6 6s. per week.
Westmorland County Council.— Female Asst. M.O. £400.
Windsor, King Edward VII. Hospital.—Amt. Hon. 8.
The Chief Inspector of Factories, Home Office, S.W., gives notice of
a vacancy for a Certifying Surgeon under the Factory and Workshop
Acts at Wolston (Warwick).
Strifes* JHarriagts, art Jeatfei.
BIRTHS.
Abel.— On Jan. 25th, at Badsleigh-street, W.C., the wife of A. Lawrenoe
Abel, M.B., B.S. Lond., temporary Surgeon-Lieutenant, R.N., or
a son.
Bate. —On Jan. 28tb, at Hove, the wife of Captain A G. Bate,.
R.A.M.C. (T.F.), of a daughter.
Bell.— On Jan. 28th, at Raven&croft, Luton, Bedfordshire, the wife of
Dr. R. D. Bell, M.O., of a daughter.
Cordner.— On Jan. 31st, at Glad holm, Andover-road, Cheltenham, the
wife of Major B. R. Cordner, A.A.M.C., of a son.
Cowkic.— On Feb. 2nd, at Claremont-avenue, Blackpool, the wife of
Captain (acting Major) B. G. H. Cowen, R.A.M.C., of a son.
David. —On Jan. 2lst, at “ Delmar,” Babbacombe, Torquay, the wife of
Captain W. E. David, M.C., R.A.M.C., of a daughter.
Harrison.— On Jan. 23rct, the wife of Captain W. L. A. Harrison,
M.C., R.A.M.C., of a daughter (stillborn).
Hedley.— On Feb. 1st, at Harley-street, the wife of Captain John
Presoott Hedley, R.A.M.C. (T.), of a son.
Lonostaff.— On Jan. 21st, at Thornhill, St- Mary’s-road, Ditton-hiD,
Surbiton, the wife of Captain E. R. Longstaff, R.A.M.C. (S.R.), of
a daughter.
Tatlor. —On Jan. 28th, at Church Circle, Farabo rough, the wife of
Major James Taylor, R.A.M.O., of a son.
MARRIAGES/
Blair—Steeoe.— On Dec. 27th, 1918, at 8t. Matthias Church, Rich¬
mond, Surrey, Charles James Lmgworth Blair, Surgeon*. R.N., to
Lilian, daughter of Mr. and Mrs. F. W. Steege. of Richmond.
Booth—Allkn.—O n Jan. 20th, at St. George's, Hanover square. Major
Ernest Brabazon Booth, D.S.O., R.A.M.C., to Marguerite Agnes*
widow of Captain Leslie J. S. Allen, The Hampshire Regiment.
DEATHS.
Fisher.— On Feb. 3rd, at Walmer, Kent, James William Fisher, M.D.,
Inspector-General, R.N., aged 72.
Logie. —On Feb. 1st, at the 1st Northern General Hospital, Neweastle-
on-Tyne, of pneumonia, Captain A. G. S. Logie, R.A.M.O. (T.F.)*
aged 53.
Turner.— On Feb. 3rd, at Lulttngton-road, Anerley, Robert Turner*
M.R.C.S., A.M.S. (retired), in his 86th year.
N.B.—A fee of 5s . is charged for the insertion of Notices of Birth*,
Marriages, and Deaths.
The Lancet,]
MEDICAL DIARY FOR THE ENSUING WEEK.
[Feb. 8 , 1919 241
Skkital far % ensuing SKeek.
SOCIETIES.
ROYAL SOCIETY OF MEDICINE, L. Wlmpole-street, W. I.
Wednesday. Feb. 12th.
SOCIAL EVENING: at8.30 p.m.
Sir Arbuthnot Lane will discourse on some aspects of " Stasia.
The Library will be open and visitors are Invited to raise and disouss
any question in which they are interested. (Tea, coffee, and
smoking)
Medical Officers of the Navy, R.A.M.O., the Dominions, United
States, and the Allies are oordlally invited.
MEETINGS OF SECTIONS.
Thursday, Feb. 13th.
NEUROLOGY (Hon. Secretaries—C. M. Hinds Howell, B. G. Fearn
sides): at 8 p.m.
Cates will be shown by the following
Dr. Frank Eve, Dr. Farquhar Buzzard, Captain Rlddoch, and Mr.
Rocyn-Jones.
Friday, Feb. 14th.
EPIDEMIOLOGY AND STATE MED (CINE (Hon. Secretaries—
William Butler, M. Greenwood): at 5.30 p.m.
Paper:
Dr. John Brownlee (Director of Statistics, Me ileal Research Com¬
mittee) : An Investigation into the Periodicity of Epidemics of
Measles in the Large Towns of dreat Britain and Ireland.
Members intending to dine are requested to send their names to
Captain Greenwood, 7, Northumberland-street, W.O. 2, not later
Feb. 12tb.
The Royal Society of Medicine keep* open house for
RJLM.C.men and M.0.’s of the Dominions and Allies. The
principal hospitals In the metropolis admit medic &l officers
to their operations, lectures. &c. Particulars on application
to the Secretary at 1, Wlmpole-street, London, W. 1.
MEDICAL SOCIETY OFLONDON, 11, Chandos-st., Cavend1sh-aq.,W.
Monday, Feb. 10th.—8.30 p.m.. Paper:—Sir StCUlr Thomson:
Intrinsic Cancer of the Larynx. Operation by Laryngo-fissure
and Its Results (sequel to a paper read before the Society on
Feb. 12th, 1912).
MBDICO-LBGAL SOCIETY, at the Rooms of the Medical Society of
London, 11, Cbandos-street, Cavendish-square, W.
Tuesday, Feb. 11th.— 8 p.m.. Council Meeting. 8 30 p.m., Papers :—
Dr. Spilsbury: Criminal Abortion.—Dr. H. U. Ross (introduced
by Mr. R. H. Wellington): A New Combined Teat for the
Presence of Albumin and Sugar in Urine.
HUNTERIAN SOCIETY, at the Rooms ot the Royal Society of Medicine,
1, Wlmpole-street, W.
Wednesday, Feb. 12th.— 9 p.m.. Annual Oration:—Mr. H. Lett:
John Hunter and hfs Influence on Urinary Surgery.
ROYAL SOCIETY OF ARTS, John-street, Adelphi, W.O.
Wednesday, Feb. 12tb.—4.30 p.m.. Paper:—Sir Frank Heath,
K.C.B,: Tbe Government and the Organisation of Scientlflo
Research.
CHILD-STUDY SOCIETY LONDON, at the Royal Sanitary Institute.
90, Buckingham Palace-road, 8.W.
Thursday. Feb. 13th.—6 p.m.. Lecture:—Dr. O. W. Kimmins: The
Significance of Children's Dreams.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
ROYAL COLLEGE OF SURGEONS OF ENGLAND, in the Theatre
of the College, Lincoln's Inn Fields, W.C.
Wednesday, Feb. 12th—5 p.m., Hunterian Lecture:—Prof. A.
Fleming: The Action of Ghemioal and Physiological Anti¬
septics in Septic Wounds.
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith-
road, W.
Clinics each week-day at 2 p.m., Wednesday, Friday and Saturday
also at 10 a.m. . *
(Details of Post-Graduate Course were given In issue of Feb 1st.)
■ORTH BAST LONDON POST-GRADUATE COLLEGE, Prince of
Wales’s General Hospital, Tottenham, N.
Out-patients each day at 2.30 p.m.
NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC,
Qneen-squ&re, Bloomsbury, W.C.
Emergency Post-Graduate Course In Neurology:—
Monday, Feb. 10th.-2 pm. Medical Out-p&tlenta: Dr. Collier.
3 30p.m., Lecture:—Dr. H. Howell: Anatomy and Physiology
of Nervous System.
Tuesday.— 2 p.m.. Medical Out-patients: Dr. G. Stewart. 3.30 p.m.,
Ward Caaes: Dr. R. Russell.
Wednesday.— 2 p.m., Lecture:—Mr. Sargent: Surgery of Nervous
System. 3.30 p.m., Lecture >—Dr. G. Holmes: Methods of
_ Examination of Cases.
Thursday —2 p.m.. Medical Out-patients: Dr. F. Buzzard.
3.30p.m., Lecture:—Dr. H. Howell: Anatomy and Physiology
of Nervous System.
Friday.— 2 p.m.. Medical Out-patients : Dr. G. Holmes. 3.30 p.m ,
Ward Oases: Dr. Tooth.
ST.JOHN’S HOSPITAL FOR DISEASES OF THE SKIN, 49, Leloester-
sqnare, W.C.
Tuesday. Feb. lith.-4 p.m., Dr. J. L. Bunch: Some Common
8kin Diseases. 5 p.m., Dr. W. K. Sibley: Syphilis and ita
Treatment.
Wednesday.- 5 p.m., Dr. W. Griffith: Skin Diseases In the Army.
UNIVERSITY OF LONDON, KING.S COLLEGE, AND KING’3
COLLEGE FOR WOMEN.
Course of Six Public Lectures arranged in conjunction with the
Imperial Studies Committee of the University on Physiology and
National Needs: —
Wednesday, Feb. 12th.— 5 30 p.m.. Lecture II.:-Dr. M. S. Pembrey :
Physical Training of the Open-Air Life.
KING’S COLLEGE H03PITAL MEDICAL SCHOOL (University op
London;, at the Lecture Theatre of the Medical School, King’s College
Hospital, Denmark Hill, S.E.
Course of Four Lectures on Malaria. Microscopic specimens and
lantern slides will be shown at the two last lectures.
Friday, Feb. 14th.— 12 noon, Lecture III.:—Col. Sir Ronald Ross.
K.C.B , K.C.M.G., F.K.S. Officers and Men of the Royal Army
Medical Corps are Invited to attend.
ROYAL IN3TITUTS OF PUBLIC HEALTH, In the Leotnre Hall of
the Institute, 37, Russell-square, W.C.
Course of Lectures and Discussions on Public Health Problems under
War and After-war Conditions :—
Wednesday, Feb. 12. h. -4 p.m.. Right Hon. the Viscountess
Rhondda: Women's Place in the Ministry of Health.
BOOKS, ETC., RECEIVED.
Bailli&re, Tindall, and Cox, London.
Intensive Treatment of Syphilis and Locomotor Ataxia by Aachen
Methods. By R. Hayes, M.R.C.S. 3rd ed. 4*. 6d.
Bale, John, 8ons, and Danikls9on, London.
Science and Art of Deep Breathing a< a Prophylactic and Thera¬
peutic Agent In Consumption. By Shoziburfi Otabe, M.D. 5s.
Lenzmann'a Manual of Emergencies—Medical, Surgical, Obstetric:
Their Pathology, Diagnosis, and Treatment. By J. Snowman,
M.D. 15*.
Cassell and Go.. London.
The Doctor in War. By Woods Hutchinson, M.D. 7*. 6 d.
Frowdk, Henry, and Hodder A Stoughton, London.
Trench Fever. Report of Oonmission, Medical Research Com¬
mittee, American Red Cross. 2i*.
Orthopaedic Effect* of Gunshot Wounds snd their Treatment. By
S. W. Daw, Captain. It.A.M.O. (T.F.). With Foreword by Majo^
General Sir R. Jones anl Appendix on Functional Disabilities by
Dr. W. Cuthbert Morton. 7 8. 6 d. J
Kimpton, Henry, London.
Physiology and Biochemistry in Modern Medicine. By J. J. Macleod.
M.B., and Others. 37s. 6 d.
Roentgen Diagnosis of D'seases of the Head. By Dr. Arthur
Schiider. Translated by F. F. Stocking, M.D. 21*.
Essentials of Medical Electricity. By E. P. Cumberbatch, B.M.
4th ed., revised. 7 8. 6ci.
Qenito Urinary Diseases of Syphilis. By H. H. Morton. M D
4th ed., revised.
Lewis, H. K., and Co., Ltd., London.
The Epidemics of Mauritius. With a Descriptive and Historical
Account of the Island. By Daniel B. Anderson, M.D. Lond. and
Paris. 16*. net.
Longmans, Green, and Co., London.
Experimental Education. By K. Rusk, M.A. 7*. 6d.
University of London Prfss, London.
Crime and Criminals. By Charles Mercier, M.D. 10*. 6 d.
Wright, John, and Sons, Ltd , Bristol. 8impkin, Marshall, London
Py 2 es Surgical Handicraft. Edited by W. H. Ciayton-G.eene, F.R.O.s!
Communications, Letters, Ac., to tiie Editor have
been received from—
A. — Arts Gazette. Lond.;.Major O.
Armstrong, R.A.M.C.
B —Dr. A. G. Bateman, Lond.;
Dr. R. A. Bennett, Torquay;
Surg.-Lieut. R. A. Barlow, K.N.:
Mr. R. Basu,„ Calcutta; Prof.
W. M. Bayliss, Lond.; Mr. T. W.
Bassett, Cork; Mr. C. Burroughs.
Atascadero, California: Board of
Agriculture and Fisheries, Lond.;
Dr. H. Brown, Load.; Dr. O.
Burland. Liverpool; Dr. W. H.
Bowen, Cam brio ge.
C.—Chicago School of Sanitary
Instruction; Mr. H. Curtis,
Lond.; Dr. B. L. Collis, Lond.;
Mr. C. H. Cutting, Lond.; Mr.
F. P. do Caux, Lond.; Dr. G. 6
Candy, Great Book ham; Child
Study Society, Lond.; Capt.
O. M. Craig, R.A.M.C.; Col.
S. L. Cummins, O.M.G., A.M.S.
B. —Dr. H. A. Ellis, Middlesbrough;
Dr. J. Byre, Lond.
F.-Capt. 4. G. Forbes, R.A.M.C.;
Mr. 0. Fitch, Lond.; Capt. 8. D.
Fatrweather, R.A.M.C.; Sgt.
H. A. French, R A.M.C.; Dr.
B. R. Fotherglll. Hove.
O.—Dr. A. K. Gordon. Lond.;
General Medical Council, Lond.,
Acting Registrar of.
H.—Mr. T. G. Hill, Lond.; Bt.-Col.
L. W. Harrison, D.S.O.; Dr.
C. M. H. Howell, Lond.; Dr. I.
Harris, Liverpool.
J*—Mr. B. Jebb, Crow borough;
Journal of Immunology, Balti-
mi re.
K>—P*>f. H. Kenwood, Lond.; Dr.
W. Kidd, Cheltenham ; Dr. W. H.
Kesteven, Kingston Hill.
L. —Prof D. Ligat, Lond.; Mr. J.
Lewenstein, Hull; Dr. C. Lil¬
li ngston.
M. —Dr. H. J. May, Southampton;
Capt. D. M. MacRae, S.A.M.O.;
Medical Society of London; Capt.
J. Miller, R. A M.C.(T.)
0.—Dr. J. Oliver, Lond.; Mr. J.
Offord, Lond.
R. —Hon. N. C. Rothschild, Lond.-
Mr. T. G. Retd, Blackgang;
Monsieur G. Roussy, Paris; Dr.
J. W. Rob, Wey bridge; Capt.
H. H. Read, R.A.M.C.; Royal
Institution, Lond.
S. —Dr. C. F. Sontag, Lond.; Dr.
G. B. Shuttleworth.Lond.; Lady
Henry Somerset, Lond.; Dr. G.
oe Swtetcchowski, Lond.; Mr. J
W. D. Span ton, Hastings.
T. —Dr. A. H. Thompson, Lond.
W.—Prof. A. J. Walton, Lond:;
« r ’- Whitley, Colchester;
Major B. A. Willcocks, A.I.F.
Y.—Miss M. Yates, Lond.
Communications relating to editorial business should be
addressed exclusively to The Editor of The Lancet
423, Strand, London, W.C. 2.
242 The Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Feb. 8,1919
Stoles, Sjpnrl (tamtnto, aito Jnsfoers
to Cflmspmtomts.
LESSONS OF THE INFLUENZA EPIDEMIC.
On Jan. 29th, at the Royal Institute of Public Health, a
lecture on Lessons of the Influenza Epidemic was delivered
by Captain T. Carnwath, D.S.O., medical inspector to the
Local Government Board. He said that Dr. Bruce Low had
pointed out that the epidemic had probably originated in the
East, and not in Spain as was at first thought. Influenza in
epidemic form was prevalent in France and in our own
armies as early as April, 1918, the gradual diffusion of the
epidemic from populous centres to outlying rural districts
being explained by the short incubation period, the sudden
onset, the high infectivity of the patients during the first days
of illness, ana the fact that no one seemed to enjoy immunity,
at any rate when the epidemic had attained its pandemic
stride.
A short account was then given of the clinical features
ol the epidemic in the summer outbreak, and Captain
Carnwath then discussed the various preventive means at
our disposal. Quarantine had been suggested as a means of
controlling the disease, but was not very practicable. Some
system of notification was required, together with oppor¬
tunities for research. The importance of isolation as a
measure of prophylaxis could not be too strongly urged, the
isolation of severe cases being insisted upon ; it would almost
certainly result in a considerable diminution of the severity of
the disease. The UBe of face-masks required more indisput¬
able evidence as to their efficacy. The mouth and nose should
be disinfected, especially after attendance at a crowded
meeting or where a number of people were congregated
together. On the other hand, it had been suggested that the
natural resistance of the tissues to invasion by microbes
might be lowered by lavage. It was impossible for any
permanent health staff to cope unaided with a large epi¬
demic of this kind, and in matters of public health it was
necessary to obtain the cooperation of the public. For this
there should be a greater diffusion of knowledge. The
newspapers for a long time had had a city page dealing with
financial matters, and he did not see why they should not
publish a health page under competent medical editorship,
where carefully considered accounts could be given of recent
advances in preventive medicine. Research work, too, was
greatly needed; we had been indifferent about it for too long
in this country.
Sir Arthur Newsholme, who presided, said that the non¬
proven tabi I ity of influenza had been cast as a reflection on
preventive medicine, but that was answered by pointing to
its triumphs over such diseases as typhoid fever, malaria,
typhus, small-pox, &c. In the cane of influenza we were
waiting for further research to enable us in some way or
another to secure immunity from attack, but possibly we
should have to work for many decades on a much larger
scale before catarrhal infections could be prevented.
Influenza spread with lightning rapidity, and before it
was recognised many thousand cases might occur; the
disease got ahead long before communal means could over¬
take it. It was here that educational measures were neces¬
sary, measures which would also raise the standard of
conduct of the ordinary man or woman whom one met in
the tram or tube or in other places, especially with regard to
Bneezing and other insanitary habits. Until everyone adopted
the most rigid precautions we could not hope for greater
success. In the future he had no doubt that face-masks of a
modified kind would be used more generally during epidemics.
Every doctor and sick nurse ought to take that precaution.
The palpebral, as well as the nasal, mucous membranes
should be protected. If any further epidemic occurred it
would be necessary to organise teams of doctors and nurses
to go from one area to another. This had been done to some
extent during the present epidemic, but such measures
would no doubt in future have to be carried on on a larger
scale.
Dr. W. A. Bond Baid that bis experiences in dealing
with the epidemio confirmed the doubt as to the causal
nature of Pfeiffer's bacillus ; it was desirable that as much
research work as possible should be undertaken.—Dr. R. J.
Ewart said that endemic and epidemic influenza were as
distinct from each other as measles was from whooping-
cough.—Captain Baily spoke of his experiences in
Mesopotamia, and said that he believed the severity of the
disease was lessened by treating the cases in tents in the
open air. With the exception of one case of bronchitis and
one of slight heart affection, the symptoms had passed off
normally within three to four days.
In his reply to a question by Dr. T. N. Kelynack, the
lecturer said that the evidence from open-air sanatoriums
was rather conflicting, some institutions appearing to have
•soaped, whilst others had been less fortunate.
COLONIAL HEALTH REPORTS.
Northern Territories of the Gold Coast.— The Census, oom-
S leted in 1911, gave an estimated population of 361,806 to the
orthern Territories—an average of 11*6 persons to the
square mile. The returns for the Southern and North-
Western Provinces were considered to be fairly accurate,
but those of the North-EaBtern Province fell far short of
being correct, and it is estimated that not more than two-
thirds of the inhabitants were enumerated. Systematic
work is being oarried out to render the next Census returns
reliable in every respect. In spite of the heavy infant mor¬
tality, it is considered that the population at the present day
is greatly in excess of that shown in the last Census returns.
An outbreak of small-pox occurred in the North-Western
Province in December, 1916, and continued into 1917. Some
men of the Northern Territories Constabulary, with their
families, were allowed to go to Tamale from the infected area,
with the result that 10 cases of small-pox, with 3 deaths,
occurred. The disease also spread from Wa to Bole, but
in each case the outbreak was quickly suppressed. Small¬
pox again broke out in the North-Western Province in
November, and it is thought that the natives spread the
disease by vaccinating themselves from infected cases. In
spite of repeated warnings a number of fatal cases of anthrax
occur annually among the natives, due to their ineradicable
propensity to eat the meat of cattle that have died from
that disease. Leprosy is not on the increase, and while
uncommon in the Southern and North-Western Provinces is
of more frequent occurrence in the North-Eastern Province.
The natives look upon it as “ a visitation of Allah,” but say
that it shows no signs of spreading, and are generally averse
to compulsory isolation. There are Government native
hospitals established at Tamale, Salaga, and Bole in
the Southern Province; at Wa, Tumu, and Lorha in the
Northwestern; and at Gambago, Zouaragu, and Bawkn
in the North-Eastern Provinces. The first two hospitals
mentioned are permanent buildings constructed by the
Public Works Department; the others are built of “swish,”
or sun-baked bricks and are thatch-roofed, but little, if any,
advantage is taken of them by the natives where medical
officers are not in residence. The total of in-patients treated
during the year was 178 and of out patients 5045; there were
10 deaths and 22 operations under anaesthetic.
St. Helena .—The estimated civil population on Dec. 31st,
1917, was 3634, as compared with 3604 on the corresponding
date in 1916. The birth-rate in 1917 was 26*41 per 1000, and the
death-rate 13*7 per 1000. Of the deaths registered 14 were of
persons over 70,8 over 80, and 1 over 90 years of age. Early in
the year there were epidemics of dysentery and influenza, both
of a mild type and causing no deaths. Later in the year these
maladies reappeared in a more serious form and airectly or
indirectly accounted for several deaths. A mild outbreak of
chicken-pox occurred in December, necessitating the closing
and disinfecting of all schools. There were no cases of diph¬
theria or enteric fever. Frequent shortage of food supplies
threatened seriously to undermine the health and stamina
of the people, especially those dwelling in and around
Jamestown. The entire want of any qualified dental atten¬
tion in the island, beyond the extraction of teeth by the
colonial surgeon, tends to affect the general health in an
increasing degree. The enervating climate, the nature of
the water, ana the high consumption of sugar by the inhabi¬
tants all tend to make dental caries very rapid, and to this
want of dental attention the general low stamina of the
inhabitants is mainly due. The keeping of pigs in James¬
town for the purpose of augmenting the food-supply was
recommended by a majority of the members of the Board of
Health, but was disallowed for medical and sanitary reasons,
records showing that, in years gone by, diseases were trace¬
able to the keeping of pigs in the proximity of dwelling-
houses in the tropical climate and confined limits of James¬
town Valley. There were 139 admissions to the hospital
during the year, 85 being males and 54 females; there were
11 deaths. The lady superintendent returned from leave
early in the year. Of the three nurses, two completed their
three years m the colony in March and November respec¬
tively, but nurses could not be obtained to relieve them.
The former of these remained at duty until August, when
she was obliged through ill-health to return to England; the
latter was still on duty at the end of the year in spite of bad
health. Dr. O. J. Murphy arrived from England m January
as acting colonial Burgeon.
A H08P1TAL FOR BOGNOR.
Bognor is to have a cottage hospital as a war memorial,
Springfield House, Chichester-road, being the venue. This
property is to be purchased for £3000, and £1000 are to be
spent on its equipment. Mr. James Fleming is generously
providing half of this total sum—viz., £2000, provided the
remaining £2000 are raised locally, and, furthermore, Mr.
Fleming has given £5000 for an endowment fund. At a
meeting under the auspices of the urban district council,
which is giving every support to the scheme, nearly £700
were raised towards the £2000.
THE LANCET, February 15, 1919.
jmttman. ferture
on
THE SURGERY OF THE SPINAL CORD IN
PEACE AND WAR.
Delivered before the Royal College of Surgeons of England on
Feb. Srd , 1919 ,
By A. J. WALTON, M.S., F.R.C.S., B.Sc.,
ASSISTANT SU BO CO If AHD DKMON8TRATOB OP A If ATOMY, LOUDON
HOSPITAL; 8URGEON, POPLAB HOSPITAL, 2ND LONDON GENERAL
• HOSPITAL, ETC.
Mr. President and Gentlemen,— I must first express to
you my appreciation of the honour I have received in being
asked to give this lecture. It is with some trepidation that
I have undertaken the task, for on several previous occasions
the subject of spinal cord surgery, in one or other of its
many aspects, has been chosen for the Hunterian lecture.
It is only because the present war has so altered our views
on many points that I have felt encouraged to continue. On
the one hand, our knowledge of the symptoms of spinal
injury has been enormously increased and the indications for
operation much more clearly defined. On the other hand, the
prognosis after operation, and especially after the purely
exploratory operation so often advised, when really contra¬
indicated, has been so relatively poor that its value in civilian
lesions is tending to be unjustly depreciated. For these
reasons I feel hopeful that a brief r6sum6 of our present
knowledge of those conditions showing partial or complete
lesions of the spinal cord, to which time will alone permit
me to give attention, will not be without value.
Pathological Changes in Neoplasms and other
Lesions.
The pathological changes that occur in the cord are very
variable. In the case of extra- and intra dural tumours they
consist at first, as Gowers 16 pointed ont, of a simple com¬
pression, followed by inflammatory changes at a later date.
As evidence of compression the cord may be flattened,
narrowed, and indented, but shows little or no change in
appearance or consistence. Cases that recover after removal
of the pressure show no other alteration to the naked eye,
and it is probable that on microscopic examination no other
change would be discernible. Our knowledge of such cases
is, however, slight, for such will recover if treated correctly,
or, if left to progress to a fatal termination, will have passed
on to a later stage.
In more advanced cases the consistence of the cord alters.
It is at first softened, but later its consistency may be
increased. The affected part will be grey in colour and on
microscopic section will show a general increase of inter¬
stitial tissue, degeneration of the nerve elements, and
abundant masses of myelin. In extreme cases all the fibres
may be destroyed, but there is never actual division of the
cord itself. These changes may extend for one or two inches
on either side of the lesion, and beyond them again the
changes of ascending and descending degeneration can be
discerned.
Although described as inflammatory in nature, it must be
remembered that such changes are in reality only those due
to the reaction around destroyed tissues. They are, in fact,
reparative and only a means of replacing by scar the already
destroyed tissues. They thus do cot tend to spread, and
may indeed be found in cases of compression where the dura
has not been perforated.
The onset of these destructive changes is cot due to the
site of the lesion, but to the rapidity of its progress. Thus
it is that in cases of malignant disease of the vertebrae the
so-called inflammatory change is always more marked than
the compression, whereas with Blowly growing tumours and
with tuberculosis of the spine the compression is the more
marked factor. This is also clearly shown clinically, and it
is well recognised that the more rapid the onset of paraplegic
symptoms the less likely is recovery to follow the removal of
the compressing agent. Even in inflammatory and malignant
neoplastic formations the destruction of the oord is due to
the rate of growth and the rapidity of the increase of
pre ssur e rattier than to the nature of the lesion, for in
NO. 4981
neither of these two conditions is the oord ever actually
destroyed by an extension of the disease.
The same law still holds good, even if the pathological
process is situated in the substance of the cord itself.
Provided that the change is slow in onset it may exist for a
considerable time and yet not lead to destruction of the
cord, so that complete recovery may follow its removal.
Elsberg* 10 13 has evolved a technique for the removal of
such intramedullary tumours, and has recorded several cases
where complete recovery followed the removal. A similar
condition may even be seen in centrally situated inflammatory
lesions, as in one of my cases where there was a centrally
situated tubercular abscess which gave rise to a partied
paraplegia. (Case 1.) A case which I believe to be unique
in being the only one on record where such an abscess has
been opened and a complete cure followed, although Elsberg 13
has reported a somewhat similar one where great relief
followed operation.
Pathological Changes in Traumatic Lesions.
If, then, the general principle be true that the amount of
destruction of the cord, and therefore the prognosis, is
dependent neither upon the site nor upon the nature of the
lesion bub upon the rapidity of its progress, very marked
changes would be expected from a traumatic lesion where
the whole course of the disease is almost instantaneous.
Such, indeed, is seen to be the case.
The present war has given us unrivalled opportunities for
observing large numbers of traumatic lesions, the patho¬
logical changes of which have been carefully investigated by
Holmes. 20 He finds that where the cord has been direotly
injured by the missile or by displaced fragments of bone, a
portion of the cord may be disintegrated, so that on incision
of the pia a semifluid custard-like material may escape.
Around this there are marked oedema and multiple minute
haemorrhages chiefly into the grey matter. The oedema may
extend to several segments, and bears no definite relation to
the severity of the wound. There are also distant lesions
consisting of swelling of the axis-cylinders which may
degenerate and disintegrate for a distance of four or five
segments beyond the site of the lesion, and irregular patches
of focal necrosis with the formation of curious cylindrical
cavities, the contents of which consist of degenerating fibres
and neuroglia.
Of even more interest than the above are the changes
found in those cases where the cord has not been directly
injured and the dura is unopened, where, in fact, the
changes can only be attributed to concussion or commotion.
Even in these cases Holmes 20 found that microscopically
there were punctiform haemorrhages with oedematous swelling
and diffuse or focal necrosis, or there might even be complete
destruction of all the functional elements of the cord.
Collier 5 believes that the injury in these cases is due to a
sudden rise of pressure, and states that the changes are
always more marked in the lower part of the cord, as it is
more closed below. He also describes two other patho¬
logical changes that may occur—namely, organisation of
clot around the roots of the cauda equina and total necrosis
of the distal portion of the cord, changes which in my
experience have been extremely rare.
Olande and Lhermitte 23 have described in detail the
changes which they have found to be present in cases of
gunshot concussion where there was no visible injury of the
cord or meninges. Locally they found, quite apart from
haemorrhage, patches of necrosis which they describe as
insular necrosis. These patches are usually situated at the
level of the injury, and in them the nervous elements, axis-
cylinders, myelin sheaths, and nerve cells are in process of
destruction or already completely transformed, whilst the
neuroglial elements are proliferating and new blood¬
vessels are being formed. In some cases the interstitial
elements themselves die and the focus is absolutely necrotic.
In addition to the above there are diffuse changes which
they have called “ acute primary degeneration of the spinal
tracts.” Here the axis-cylinders are seen broken up in
larger or smaller fragments and the nerve fibres have for the
most part lost their parallelism ; they are retracted, curled
on themselves, and cross one another. Around the broken
fibres are grouped the granular bodies of neuroglial origin.
In the grey matter the ganglion cells are loaded with lipo-
chromes and above all the protoplasm appears full of chromo-
phile granules fused in large irregular olumps.
o
244 The Lanoet,] MR. A. J. WALTON : SURGERY OF SPINAL CORD IN PEACE AND WAR. [Feb. 15,191R
Clinical Manifestations in Spinal Tumours.
The symptoms of benign or malignant neoplasms of the
spine or of tubercular lesions will be relatively slow in on«et,
and therefore will tend to be focal in nature. There is
thus to a certain extent a distinction according to the situa-
tion of the lesion, and the difficulties with which the surgeon
or physician will be confronted are rather those of diagnosing
the nature and site of the lesion than of determining whether
or no a portion of the cord is destroyed. If the pressure can
be removed there is every probability that the cord will
recover.
In those cases where the disease commences in the
vertebrae specific symptoms of such a lesion will not un¬
commonly be present, and will generally antedate those of
interference with the function of the cord or its roots. In
tuberculosis, for instance, the characteristic symptoms of
pain, rigidity, and deformity will generally have been in
existence for a long period before the onset of paraplegia.
Similar symptoms may occur with secondary carcinoma, but
here the local pain is the more marked. In my own series of
cases of this nature severe aching pain, increased by exercise,
was very constant, its onset in the majority occurring from
three to six months before that of the other symptoms. In
one case the period of existence of this pain was difficult to
determine, for the patient's condition had been complicated
by the presence of a renal calculus, which, added to the fact
that he had an old kyphosis datiDg from birth, greatly
increased the difficulties of diagnosis—so much so, in fact,
that he was sent to hospital as a case of functional paraplegia.
This localised pain will in the later stages generally be
replaced by the characteristic root pain, but the history of its
presence iu the early stages of the disease will be a valuable
indication of the nature of the underlying lesion. For this
reason every case showing an onset with such localised pain
should be examined for the presence of a primary focus. As
Elsberg 12 and Armour 1 have pointed out, this focus is most
commonly in the breast, and the spinal lesion may even
occur five to eight years after the breast has been removed.
These cases are thus more common in women, and most
frequently the spinal deposit is found in the dorsal region,
and may here, as in one of my cases (Case 2) infiltrate several
of the vertebral bodies.
M tot Pains.
Of the actual cord symptoms root pains are usually the
first to appear. Their presence has generally been taken as
an indication that the tumour was extramedullary, but
although it is true that severe pain of this nature is more
common with such lesions, its value as a means of
differential diagnosis is not constant. Elsberg 11 has shown
that in his series root pain was not uncommon with intra¬
medullary tumours, and in one of my own cases of this
nature a laparotomy had even been performed for this
symptom before the patient came under my care. Hunt and
Woolsey 24 have found that if such pains are present in
intramedullary lesions they are more likely to be unilateral,
but in some cases, as in one of my own (Case 3) an extra¬
medullary tumour may be associated with unilateral root
pain. It will probably be found, however, that in the latter
case the motor loss is confined to one leg, whilst the central
tumour is more prone to cause bilateral paralysis.
In a similar way the presence of such pain is not a true
indication that the tumour is situated posteriorly or laterally.
Although the commonest intradural tumour is the subpial
endothelioma, which is generally situated to one or other
side and thus is likely to interfere with the posterior roots of
one side only, yet even in these cases the pain may be
bilateral, and in the rarer cases of osteoma or chondroma
arising from the bodies of the vertebrae, of which I have had
two cases, the lesion, although situated anteriorly, may give
rise to root pain.
It must be remembered also that the position of this pain
may, unless care be taken, even give rise to errors in the
diagnosis of the level of the lesion. The level of the initial
root pain is of the first importance in determining the site
of the lesion, but the later symptoms may, as Elsberg “ has
pointed out, suggest a much higher level owing to stasis of
the cerebro-spinal fluid. It is thus essential that a careful
history be taken of the early symptoms. On the other hand,
Hunt and Woolsey 31 have described cases of extramedullary
tumours in the cervical region where there was a distinct
girdle sensation or constriction situated at the umbilical
level which in all cases disappeared after removal of the-
growth. Reynolds 10 has pointed out what may be the
explanation of this—namely, that pain may be due to
pressure on the sensory fibres in the cord, in which case it
is referred to an, area considerably below what one would
expect from the situation of the cord lesion. In comparison
with these vagaries of the root pains it must be kept in mind
that in cases of chronic spinal meningitis, as described by
Sir Victor Horsley, 31 there may be a band of hyperesthesia
extending over a relatively wide area. In one of my
patients, for instance, there was a bilateral hyperesthetic
area corresponding to the sixth to the tenth dorsal segments
inclusive.
Motor Symptoms.
The motor symptoms will to a certain extent depend upon
the site of the lesion. It is well known for instance that in
cases of tuberculosis of the body of the vertebrae the earliest
symptoms are generally those of spasticity followed by loss
of power. These cases are, however, rather exceptional in
that when the disease is extradural the pressure, probably
owing to the interposition of the cerebro-spinal fluid, is
usually more diffuse, and for the same reason the motor
symptoms below are frequently bilateral. On the other
hand, they are generally unilateral when the lesion is
situated within the dura. In the common type of subpial
endothelioma, for example, the Brown-S6quard syndrome is
often found in the early stages. In both my cases of osteoma
of the vertebra the paralysis below the lesion was unilateral,
for in these cases the tumour grew forward, so that it pro¬
jected within the dura and was only covered by a thin layer
of stretched-out tissue, and thus, although pathologically
extradural, was clinically within this membrane. It may be
said, therefore, that the presence of a local or unilateral
paralysis is more in favour of an intradural lesion, and this
is also true in those cases of bilateral symptoms where one
leg was clearly affected previously to the other.
As a general rule the paralysis below the lesion is of the
spastic type. Later, and especially with more rapidly
increasing pressure, the limbs may become flaccid with
loss of tone. It is on such cases that the older views of
the association of a complete lesion with fiaccidity and loss
of tone were based. In view of the more recent knowledge
gained by our experience of war surgery it is probable that
these views will have to be modified. It is possible that
this condition of fiaccidity may be found when cases are
more carefully examined to pass off and be followed by a
condition of extensor spasm ; if the disease be not, as is so
often the case, associated with sepsis of the urinary tract.
At the level of the lesion itself there will be a segmental
paralysis of the lower neuron type with wasting and com¬
plete fiaccidity. This symptom is of great value in locating
the level of the lesion in the cord, and may not uncommonly,
indeed, be of more value than the level of the sensory
changes. The local paralysis may, if located to the erector
spinas muscles, give rise to a scoliosis, to which treatment
may in the earlier stages be alone directed, as in a case
recorded by Harris and Bankart. 17
Sensory Chanjes. •
The presence of sensory changes below the level of the
lesion is extremely common. Hecht 1- even goes so far as
to say that “ Some disturbance of sensation, most commonly
of the tactile variety, will be present in all tumour cases. I
should even say must be present." He states that a positive
diagnosis of a spinal tumour has never been made in the
complete absence of objective disturbance.
The amount of sensory loss will vary with the site and
rate of growth of the tumour. As in the case of the motor
symptoms extradural lesions will usually give rise to a more
diffuse pressure on the cord and hence all types of sensation
are likely to be affected. Although in the more slowly
increasing tubercular lesions there is no loss of sensation
except in the late stages, in cases of secondary carcinoma
the reverse is true, and the most common change is a
rapidly increasing loss to all forms of sensation, until in a
short space of time all are absent. Such, in my experience,
has been the invariable condition with this lesion.
With intradural lesions it is usually believed that the
extramedullary give complete loss of sensation, while the
intramedullary show marked dissociation. This does not,
however, appear to be true. It would rather seem that the
dissociation is only found, as would, indeed, be expected.
The Lancet,] MR. A. J. WALTON: SURGERY OF SPINAL CORD IN PEACE AND WAR. [Feb. 15, 1919 245
with slowly growing tumours. Thus in my two cases of
osteomata there was marked dissociation in the legs. In a
similar manner it may be found that a slowly growing
snbpial endothelioma presents a marked dissociation, as in
Case 4, where a tnmonr of 1 cm. diameter had developed in
seven months, whereas in a second case of a similar tnmonr
which in seven months had grown to a diameter of 3 cm.,
there was complete loss of all sensation. Rapidly growing
extramedullary sarcomata, in my experience, have invariably
shown complete loss of all forms of sensation below the level
of the lesion.
With intramedullary lesions it is more common to find in
the early stages a loss to pain, heat, and cold, with an absence
of vibration sensation over an extensive area, whereas in
extramedullary lesions this loss is generally over a much
smaller area than that in which the other forms of sensation
are absent. This, however, is by no means constant, and
Elsberg 11 has reported cases among his series of intra¬
medullary tumours where there was no dissociation and root
pains were present. It is in the more rapidly increasing
lesions, as, for instance, a haemorrhage, that the widely
spread loss is found, whereas with a slowly increasing
syringomyelia the dissociation is most marked.
Just as the level of the root pains may be deceptive as a
means of diagnosis of the position of the lesion so also may
the sensory loss be other than would be expected. As a
general rule the upper limit of the loss is apparently too low.
Reynolds *° has pointed out that this is especially so on the
back, and he quotes a case where a lesion at the level of the
sixth dorsal segment gave rise to anaesthesia on the front of
the body up to the level of the seventh dorsal segment, but
on the back of the body only up to the level of the eleventh
dorsal segment. It has already been noted that an increased
collection of cerebro-spinal fluid above the lesion may give
rise to a diagnosis of pressure at a level higher than the
situation of the tumour.
Reflexes.
Until investigations had been carried out on the large
amount of material supplied by this war the condition of the
reflexes in lesions of the cord was regarded as settled. In
spite of the work of Sherrington on animals and the clinical
findings of Brarawell and Gowers the changes were regarded
as simple and constant. In all incomplete lesions the
reflexes in the part below were regarded as being exagger¬
ated, the plantar reflex was up, ankle and knee clonus were
often obtainable, and all the tendon reflexes were increased.
In the segments corresponding to the actual lesion the
reflexes, both superficial and deep, were abolished. There
is no doubt that this is the characteristic condition with
incomplete lesions resulting from tumours of slow growth but
rapid changes—e.g., haemorrhage into the growth may produce
at first a picture of flaccid paralysis similar to that of the 1
first stage of a complete division, but during the second
stage of reflex activity the picture alters.
It is as regards the changes in the reflexes with complete
lesions that our views have undergone the greatest chaDge.
In the later stages of a tumour there usually occurs, as
described by Bastian, a stage with complete paralysis and
absolute loss of all reflexes and loss of tone. Such had come
to be regarded as the characteristic change with a complete
lesion and any return of reflex activity was regarded as
evidence either that the lesion had been incomplete or that
recovery was occurring. It must be remembered here that
since with a tumour there is never complete destruction of
the cord it is therefore more difficult to prove that its
functions are permanently destroyed. Moreover, these
cases are but rarely the healthy subjects such as are
seen with complete division from military wounds and
being therefore more liable to suffer with septic complica¬
tions but rarely pass from the stage of complete loss of
reflexes. With the increase of our knowledge there is no
doubt that these symptoms in advanced cases of spinal
tumour will have in the future to be examined from a
different aspect.
It is evident, therefore, that neoplastic formations inter¬
fering with the functions of the cord will give rise to focal
symptoms which may remain localised for a very prolonged
period. The destruction of the cord will vary with the rate
of growth of the neoplasm, and in slowly growing tumours
may be relatively slight, while in the more rapidly growing
ones, although of relatively small size, much permanent
damage may be caused. Owing to the comparatively slow
progress of the disease treatment will probably be sought
long before there are symptoms of a complete transverse
lesion. In attempting to determine the site of such a tumour
careful consideration will have to be given to each group of
symptoms, for any one alone may give rise to a fallacious
diagnosis. The apparent limitation of the lesion to one or
more tracts is not a certain indication of the site of the
neoplasm, although it is well to remember that intra¬
medullary lesions will tend to spread up and down the cord,
whereas with the growth of an extramedullary tumour the
symptoms will increase in width—i.e., to involve more and
more tracts.
Clinical Manifestations in Traumatic Lesions.
With a traumatic lesion of the cord the problem is very
,different. Owing to the acuteness of the lesion, the whole
process of which is almost instantaneous, there will at first
be a complete loss of function of the portion of the cord
below the injury giving rise to a flaccid paralysis, and this is
true even in those cases where there has been only partial or
even no anatomical destruction of the cord. It is only later
when the lower segment has recovered from the condition of
shock that it will be possible to determine whether the whole
of the cord has been destroyed, or whether there is a
local injury which may recover with or without the help of
operation.
A consideration of the pathological changes has shown
that where there is even partial destruction of the cord by
the passage of the missile the lesions are widespread and
that recovery is therefore unlikely to occur. Hence, if the
paraplegia remains complete the prognosis will generally be
poor. X ray examination will always be of great value, not
only in determining whether the missile or displaced bone
has actually destroyed a portion of the cord, but it may
often enable the surgeon to ascertain the path of the
bullet and thus diagnose with fair accuracy whether or no
the cord has been in part or wholly divided. The greatest
disappointment is, however, caused by those cases in which
perhaps the dura has not even been perforated and yet a
permanent paraplegia has been caused.
The majority of traumatic lesions are followed by the
onset of paraplegia, but there are many exceptions to this
rule. In civilian cases cervical injuries not uncommonly are
free from spinal symptoms ; according to Armour, 1 this is
true of one-third of the cases. Campbell 3 has also reported
six cases of fracture of the bodies of the lumbar vertebra
where there wt*re no symptoms referable to the cord or cauda
equina. In others, again, the symptoms may be only partial,
but even here they may be progressive, and this from various
causes. Holmes, 20 for instance, describes cases where the
symptoms increase after two to three days, probably owing
to the onset of secondary haemorrhage or progressive soften¬
ing. Mixter and Osgood 2 * have also described late symptoms
due to the gradual onset of myelitis by the irritation of long-
continued abnormal position or callus formation. Neuhof 39
reports the onset of paraplegia after many months of apparent
cure owing to a rarefying osteitis of the bodies of the
vertebra, so that with the onset of spinal symptoms a
kyphosis is caused—the so-called Kuemmell’s disease.
In all of such cases the extent and site of the lesion are
clearly defined, but where the paraplegia is at first apparently
complete it is possible that only a portion or indeed none of
the symptoms may be due to irrevocable injury of the cord.
This is specially so in lesions of the cervical region, Marie
and Benisty 3C describing a series of six cases due to wounds
where the paralysis did not remain complete for more than a
few weeks. Claude and Lhermitte have likewise seen
cases of this transient quadriplegia produced by concussion
in the upper cervical region. In addition they describe
cases of primary brachial monoplegia occurring both as a
flaccid and secondary spasmodic type. It is usually
associated with subjective or objective sensory disturbance of
radical distribution which is often very obstinate. In other
cases there is a brachial diplegia following injuries of the nape
of the neck, so that the curious condition may be seen of a man
standing and walking about with the completely paralysed
upper limbs hanging inert by his side. Here also there are
sensory changes, the deep sensibility and tactile sense being
chiefly affected. There is frequent want of coordination
of the movements of the lower limbs noticeable in the
erect attitude, and becoming manifest in the upper limb as
246 Thb Lancm,] MB. A. J. WALTON: SURGERY OF SPINAL CORD IN PEACE AND WAR. [Feb. 15,1914
movement reappears, all manifestations of cerebellar nature.
A similar condition of temporary paraplegia may follow lesions
of the dorsal region, the motor and sensory functions,
apparently mnch involved, being re-established to some extent
after a few weeks.
Since the whole question of operative interference will
depend upon the diagnosis of an incomplete lesion it
beoomes a matter of considerable practical importance to
determine upon what symptoms such a diagnosis can be
made. It is becoming more and more clear that in the early
stages there are no distinctive symptoms. In either case
there may be within a day or two of the wound a complete
flaccid paralysis to the level of the lesion, sensory loss to a
similar level, the absence of all reflexes, and retention
of urine. In those cases where there is return of some form
of sensation and of motor power it is evident that the lesion
is incomplete. It is in the less well defined cases where
there is alteration in the reflexes alone that the greatest
errors have arisen, and many such cases have been operated
upon because it was believed that the lesion was incomplete,
whereas there was in fact a complete division of the cord.
On the other hand, the change in the nature of the reflexes
is often the first indication that the injury is only partial
and that an operation should be undertaken. It is the
failure to recognise these points of distinction between com¬
plete and incomplete lesions, and the tendency to operate on
those cases where the cord is destroyed for one or more
segments and where therefore the prognosis is hopeless, that
has brought discredit upon this branch of surgery.
Re Hexes.
The changes in the reflexes have been fully described in a
most able paper by G. Riddoch, 31 which should be consulted
by every surgeon and physician interested in this type of
injury. He shows that in cases of acute trauma there are
three stages in the clinical picture.
Firstly, there is the period of flacoidity, during which no
distinction can be made between a complete and an incom¬
plete division. There is a flaccid paralysis df all the muscles
below the level of the lesion with loss of muscular tone,
complete loss of all forms of sensation to a similar level,
and the abolition of all spinal reflexes, the only exception to
this latter being tonic contraction of the sphincters of the
bladder and rectum (probably the internal sphincters
supplied by the sympathetic fibres).
Secondly, there is the stage of reflex action during which
the differential diagnosis can be made. If the lesion is
complete there is a gradual reappearance after one to three
weeks of the flexor reflexes. At first only induced by
nocuous stimulation of the skin or deep tissues, they are later
brought out by the slightest touch or even by jarring of the
bed. At the same time the reflexogenous area rapidly
increases, so that in a short time stimulation of any portion of
the skin almost up to the level of the lesion may induce dorsi-
flexion of the toes and flexion of the ankle, knee, and hip.
The mass reaction may even spread to the abdominal muscles
and bladder, and generally is associated with a similar flexion
reflex of the other leg. This flexion reflex is not followed by
contraction of the extensors, as it is in cats and dogs.
Should the knee-jerk, ankle-jerk, and ankle clonus be
present they always appear later than the flexion reflex, and
the knee-jerk shows a quick falling away of the contraction
of the extensors. With the complete establishment of the
flexor reflexes there are involuntary flexor spasms of the legs,
retnrn of some muscular tone, and automatic action of the
bladder and rectum. Case 5, which has been reported in
full by Riddoch, 31 shows clearly the nature of these reflexes.
It is the appearance of such a picture as described above
which has not only often led to the belief that the lesion was
incomplete, but has given rise to the hope that recovery has
commenced after some operative measures have been under¬
taken. When the physiological division is incomplete the
reflexes are very different, and this is even so in those cases
where there is still loss of voluntary power and sensation.
The postural or static reflexes recover at the same time as
the flexors, so that the flexion movements are much more
gentle and controlled owing to contraction of the extensors,
and may be accompanied by extension of the knee and
plantar extension of the toes of the other leg. After a
short period the stimulated leg extends and the opposite leg
flexes, giving a diphasic or stepping movement. The reflex
Is not so widespread—i.s., looal signature is present, so that
the abdominal muscles are not involved, and the limbs lie
in the bed extended at the hip and knee. In fact, as a
rule the flexion reflexogenous area is limited to the periphery,
and above this nociceptive stimuli give extension of the
limbs. The knee-jerks are present and well sustained,
and there is a definite extensor thrust on dorsiflexing the
ankle. Case 6 is a good example of such a lesion and shows
clearly the differences in the character of the reflexes from
those in Case 5.
The third stage is that of the presence of septic complica¬
tions, and its onset may be delayed for a prolonged period.
In the presence of septic broncho-pneumonia, pyelitis, or
bed-sores the reflex activity may be diminished and the
limbs pass again into a stage of flacoidity, to be replaced by
the onset of reflexes as the sepsis passes off.
Progress of Cases.
* A certain number of cases may pass through the stage of
flaccidity, and, having been clearly identified in the stage of
reflex activity as incomplete lesions, may, without operative
interference, make steady progress towards recovery. At a
later stage, usually from one to two years after the infliction
of the wound, progress may be interrupted or a recession
occur and at operation the characteristic appearances of
meningitis serosa be divalged. The presence of such a
complication can generally be determined by the nature of
the symptoms. The area involved in the root pains will
increase, so that instead of being limited to one or two
segments, five or six may be involved. There will be a steady
increase of the spasticity, either flexor or extensor, and a
corresponding decrease of voluntary control. The sphincters,
however, will be but rarely affected, so that if the sphincter
control be regained it will not be again lost. In some cases,
however, if the lower sensory roots are affected true rectal
incontinence may be simulated by loss of anal sensation.
Indications for Operation.
Before any operation upon the cord is undertaken the
surgeon must have clearly in view what benefit is likely to
accrue to the patient by such intervention. It would appear
to be self-evident that it is useless to remove an aseptic
bullet when the cord has been completely divided, or a
tumour when the functions are irrevocably destroyed. A
review, however, of published cases shows that these points
are not kept clearly in mind, and many cases are subjected
to operation when there is no possibility of improving the
conditions.
Neoplasms and Other Lesions.
A consideration of the pathological and clinical factors
makes it clear that the problem presented by the slowly
progressive neoplastic cases is very different from that with
the traumatic lesions. In the former the damage is almost
wholly due to pressure, so that the removal of such pressure
is likely to be followed by a complete cure. This may be
true even when the symptoms of paraplegia are complete,
provided that they have only been present for a short time
and there are no septic complications such as cystitis or bed¬
sores. It is only in the later stages that the destruction
becomes complete and return of function impossible. The
slower the progress of the disease the less likely is it that
inflammatory or degenerative changes have taken place in the
cord. This is true even for intramedullary lesions of slow
growth. It is now clear that many such lesions may be
operated upon with a very good chance of removal and a
complete or nearly complete recovery of the functions of the
cord. The problem here, then, is relatively easy of solution.
The rule will be to operate and remove the pressure and to
operate at as early a stage as possible before any permanent
damage has been done to the cord. One has rather to
consider what are the exceptions to the. rule. It must be
remembered here that a well-conducted laminectomy carried
out with careful technique where there is no septic wound
is a proceeding almost devoid of all risk.
The first group of cases in which laminectomy should be
postponed or not undertaken is that in which the lesion
commences in the bone. Of the two main varieties tuber¬
culosis is almost certain to be cured by rest and adequate
orthopsedic measures. It is only when such measures have,
been carefully undertaken and have failed that operation for
the relief of paraplegia should be considered. Neoplasms,
on the other hand, if capable of being diagaosed as situated
within the bone, are almost certain to be malignant and
The Lancet,] MR. A. J. WALTON : SURGERY OF SPINAL OORD IN PEACE AND WAR. [Feb. 15,1019 247
generally secondary to carcinoma elsewhere. Operation will
therefore never be undertaken in the hope of effecting a care,
and only very rarely as a palliative measure—e.g., for the
relief of severe root pains.
Before operation is undertaken, the possibility of the sym¬
ptoms being due to acute myelitis or a softening of infectious
origin should always be considered, for in such cases the
progress will probably only be accelerated by operation. At
the present time cases of disseminated sclerosis should
always be eliminated as there is no evidence that such a
condition can be relieved by these measures. The elimina¬
tion is not always simple. In one of my own cases there
were well-defined focal symptoms of a lesion at the level
of the fifth lumb&a segment, the only symptoms pointing
to disseminated sclerosis being the presence of a well-
marked lateral nystagmus. Syringomyelia as a general
rule is too diffuse to be relieved and the operation should
therefore only be undertaken after careful consideration if
there are definite level signs. All other cases, whether the
symptoms point to an intra- or extra-medullary lesion, should
be operated upon without delay.
Traumatie Lesions.
’ When the damage is due to injury the problem is very
different, and even before our knowledge had been increased
by the experience gained in this war many surgeons were
becoming doubtful as to the value of operative measures. We
were passing through an intermediate stage in which the
views of surgeons, as expressed in their writings, were very
diverse. Thus, on the one haDd, Sir V. Horsley, 23 Schachner, 32
and Armour 1 advocated early operation, stating that in all
cases of doubt an exploration should be carried out. At the
other extreme Neuhof 29 took a very conservative view, and
after discussing the contra-indications only advised inter¬
ference where there was evidence of progressive intradural
haemorrhage, as shown by repeated lumbar puncture or
unquestionable proof by the X rays that a fragment of bone
was encroaching upon the spinal oord at the level suggested
by the symptoms.
The majority of surgeons such as Hughes 23 and Elsberg 9
adopt, however, a somewhat intermediate attitude, and
whilst decrying operative intervention in the early stages,
suggest that it is indicated when there are signs of recovery,
pointing to the fact that the cord has not been wholly
divided. In regard to the evidence of an incomplete lesion,
a statement of the latter surgeon is of considerable interest
when compared with the work of Riddoch. 31 He pointed out
that an npgoing movement of the toes replacing a down¬
going movement when the sole is scratched, is of very great
significance as evidence of the transmission of some nerve
impulses through the cord. This had been generally
accepted until Riddoch pointed out its fallacy. This latter
observer has made clear that this change is simply the first
stage in the appearance of the flexion reflex. The various
stages in any lesion, whether complete or incomplete, when
the cord is passing out of the influence of shock, are probably
as follows. On scratching the sole of the foot the earliest
response is a downgoing adduction movement of the toes;
later with this the hamstrings can be felt to contract. Later
still the toes move up and abduct, the foot is flexed at the
ankle, and the hamstrings and the flexors of the hip contract.
A study of the pathological changes shows that in these
traumatic cases, in the early stages, at least, the damage is
practically never due to pressure. In both the civilian and
military lesions what damage there is is done at the time of
the injury, and is due to the momentum of the body. Any
increase in the destruction of the cord, if it appear within a
short time, will be due to inflammatory changes secondary
to the infection of the wound, or if due to Tong-continued
irritation of a foreign body, either metal or bone, will only
appear after a prolonged interval. It will therefore be seen
that there is no indication for immediate operation for the
purpose of removing depressed bone or metal. These
structures have already done all the damage they will do,
add their mere removal will do nothing to restore the portion
of cord already destroyed. On the other hand, the operation
may do much to depress farther the already lowered vitality
of the patient. If, however, the damage is merely due to
concussion and the cord is not completely divided, a foreign
body may, after a prolonged period, give rise to secondary
changes which may cause permanent damage to the cord,
and hence its removal becomes imperative. In other words,
operation should not be undertaken until there is evidence
that the lesion is incomplete, but when such evidence is
present interference should Dot be delayed.
It is therefore of considerable importance that the points
of distinction between a complete and an incomplete lesion,
as enumerated by Riddoch, 31 should be clearly understood.
In my earlier series of war lesions it was my custom to
operate upon the majority of cases presenting evidence of a
lesion of the cord, and nothing has been more disappointing
than those cases where there was a bullet, a piece of metal,
or a piece of bone lying outside but compressing the un¬
injured dura, with the cord apparently intact. In not a
single case showing no previous sign of recovery was there
any progress after removal, but if operation had only been
undertaken when there was some such evidence that the
cord was not completely divided, then a marked progress,
even if not complete recovery, followed the operative
measures.
Selection of Cases for Operation.
Hence it may be stated that in the early stages no opera¬
tion should be undertaken unless there is some sign of
recovery or the lesion is incomplete, in which case the earlier
the operation is performed the better. There may be an
apparent exception to this rule. It is possible that in
certain cases presenting an irregular septic wound operative
steps in line with these carried out for other wounds and
aiming at the excision of the wound and septic focus would
be of considerable use in the prevention of meningitis.
They would be instituted solely for the prevention of infec¬
tion and not for the removal of pressure, but the full
technique of such a method would, of course, include the
removal of any missile or displaced portion of bone. If any
such series of early operations have been performed their
resalts have yet to be published.
In later cases the problem is much more simple. Should
symptoms develop at a later date they will be due either to
the collection of inflammatory exudates, to the contraction
of scar tissue, or to the excessive formation of callus. In
each case they are directly due to pressure for the relief of
which an operation should be performed without delay. It
may occasionally happen that even where there is evidence
of complete division of the cord the presence of severe root
pains may make the patient’s life unendurable, and since
such cases may otherwise live in comparative comfort for
three or more years an operation devised solely for the relief
of this pain will be quite justifiable.
A word must be said here about operations undertaken for
the purpose of repairing an injured cord either by suture or
by grafting in other, usually heterogeneous, cord tissue. Such
methods have been advocated 27 but, unfortunately, the details
given of the cases were so meagre as to be of but little value,
and although great stress was laid upon the condition of the
reflexes they would appear to be only those which would be
expected to be present in a cord which was recovering from
shock after partial division. All available evidence must be
taken as absolutely negative to the possibility of any such
recovery—a recovery which could, indeed, not be expected—
occurring after suture or cord-grafting. It should never,
therefore, be advocated, for not only is it a distinct risk to
the life of the patient, a source of disappointment to himself
and his friends, but it is also likely to bring the operation
of laminectomy, performed for whatever cause, into consider¬
able disrepute.
Operative Technique.
In an operation of this nature the technique will vary
considerably in the hands of individual surgeons, and as
each man perfects his own methods so will it be found that
equally good results will follow. There are certain details,
however, which the extensive experience provided by the
present war has shown to be important.
The first essential is a wide exposure of the lesion. The
incision should be at least six to eight inches long, but
whether made as a straight incision or as a lateral flap
will depend upon the circumstances of the case. The flrsx
method will give less haemorrhage as fewer subcutaneous
vessels will be divided, but with a mid-line wound is more
likely to pass through the infected focus and does not give
so firm a scar if any mild infection be present. It may
therefore be said generally that the vertical mid-line incision
should be the one of preference, but should be replaced by a
lateral flap if there be an old mid-line wound. If the wound
be recent and an operation be considered necessary the
incision will be in the line of the wound, the treatment
248 Tn LABOR,] MB. A. J. WALTON : SURGERY OF SPINAL OORD IN PEAOB AND WAR, {Feb. IS, 1919
being directed rather towards the sterilisation of the wonnd
than to the exploration of the spinal cord.
The erector spins muscles having been separated from
the spines and lamins, for which purpose a wide-bladed
sharp chisel will be found most useful, the spines should be
removed with powerful cutting forceps, leaving the surface
of the laminae as smooth as possible. Here again a wide
exposure is essential. In every case at least four spines
should be removed, and not uncommonly it will be prefer¬
able to take away five or six. The risk is not increased
thereby, and nearly all the difficulties that may be experi¬
enced are due to the fact that insufficient spines have been
removed. In the preceding stages there is often a consider¬
able amount of haemorrhage, which is mainly venous and
can readily be controlled by packing the wound with gauze.
Occasionally a few points may have to be tied.
Many different methods have been advocated for opening
the canal. The safest and most rapid will be to trephine a
healthy lamina, preferably not directly at the site of the
lesion, so that opposite the trephine opening the dura will
be free from the bone. The circle of bone having been
removed the dura is freed from the under surface of the
lamina above and below with a Horsley’s elevator and the
bone divided with sharp, narrow-bladed bone forceps. At
least three laminae should be removed, so that adequate
exposure is obtained. The opening in the canal is now
widened on either side with guillotine forceps in its entire
length, and all fat and blood-clot carefully removed from the
underlying dura. The extradural space can now be freely
examined for any loose fragments of metal or bone, or for
any other abnormality and the character of the dura,
whether thickened or adherent, whether pulsating or not,
noted.
The question will cow arise as to whether or no the dura
should be opened. If it appear abnormal—that is to say, if
it be thickened or show no pulsation this step should
unquestionably be undertaken. It is in those cases in which
a lesion is clearly situated extradurally and the dura and
cotfd appear normal that difficulty will arise. The natural
tendency is to feel that with the removal of the extradural
lesion everything has been accomplished and nothing further
should be done. Provided, however, that there is no septic
extradural focus it will always be better to examine the
cord. The lesions of this war have shown especially that
even with an uninjured dura there may be gross change in
the underlying cord, and although in such cases but little
could be done of a curative nature, yet even in them there
will be no increased risk, and much help may be obtained
In giving an accurate prognosis. If there be a definite
septic focus outside and no visible lesion of the cord or dura
it will be better not to open this latter structure.
Before the dura is incised all bleeding should be controlled
and all blood-clot removed. A mid-line incision is then
made with a sharp tenotomy knife, care being taken that
the arachnoid is left untouched. If healthy, this latter
structure will bulge through the dural incision as a clear
transparent bladder filled with cerebro spinal fluid, and any
increase in the amount of fluid or abnormal adhesions will
be clearly discernible. Having been examined it can be
divided and the cerebro spinal fluid allowed to escape. If
the fluid had been under pressure pulsation, previously
absent, may now return.
The cord is examined and any extra- or intra-medullary
change noted. Extramedullary tumours will be clearly
defined and may be removed, every care being taken that the
cord is manipulated as little as possible. Xi it be necessary
to displace it, it should be lifted by one of the slips of the
dentate ligament. Should the presence of an intramedullary
tumour be shown by a localised swelling of the cord, a small
vertical posterior incision should be made and the tumour
allowed slowly to extrude, so that, as described by Elsberg, 10
it may be removed by a second operation after seven to ten
days’ interval. Even if the tumour be irremovable by such
methods the case recorded by Clarke and Lansdown 8 would
hold out hopes that improvement might be looked for by the
application of radium at this stage.
In cases of injury examination should be made for the
presence of foreign bodies or portions of bone in the sub¬
stance of the cord, for, provided that the symptoms were
those of an incomplete lesion, the removal of such a foreign
body maybe followed by very marked improvement, as in one
of my own cases where a piece of bone was embedded in the
posterior columns, giving a Brown-Sequard paralysis, which
largely oleared up after removal of the fragment, and in a
remarkable case reported by Schachner, 32 where the removal
of a *22 bullet from the posterior columns was followed by a
marked recovery.
The presence of an intramedullary haemorrhage may be
indicated by a swelling of the cord, in which case improve¬
ment may follow a small posterior incision and evacuation <
of the blood (Allen’s method). It will often be found, how¬
ever, that such an incision will be followed by the escape of
a oustard-like material, showing that the cord is disintegrated
and recovery impossible.
If the operation has been performed for the relief of root
pains care should be taken that a sufficient number of roots
are divided. This is more especially so if the underlying
lesion is a meningitis circumscripta, in which case it may
be necessary to divide as many as five or six in order to give
relief. At the completion of the operative steps upon the
cord the dura should be sutured with a few fine catgut
sutures, except in the case of serous meningitis, when it
should be left open for the fluid to drain into the muscles.
In all cases, and especially in this latter condition, the
muscles must be carefully closed in layers to prevent any
subcutaneous collection of cerebrospinal fluid, which
not uncommonly has a very irritating effect upon this
tissue and may cause the wound to break down. Unless
there is deep sepsis it will never be necessary to drain the
wound.
Appendix : Illustrative Cases.
Tubercular Abscess in Substance of Cord.
In this case of tubercular abscess in the substance of the
cord operation was followed by complete recovery.
Cask 1.—A male child, aged 5, was admitted to hospital on
June 26bh, 1916. One year before admission he developed pneumonia,
which was followed by a left-sided empyema. After operation he
remain© t well until six weeks before admission, when he fell down
whilst playing with a hoop, and has been unable to walk since. The diffl-
culty in using the legs bad increased, and for three weeks he had had
incontinence of urine.
He was well developed mentally and physically, and there were no
signs of active trouble In the left lung. He was unable to walk alone
and on being supported stood with a wide base. On attempting to
walk the legs were moved with a high-steppage gait, the feet were
plantar flexed, and he was unable to get his h**els to the ground. All
movements of the legs were spastic, very Irregular, and ataxic, so that
he could move them but little. The reflexes were all increased In the
leg*, the plantar* being definitely up. and ankle and knee clonus being
easily elicited. The lower abdominals were greatly Increased, but the
upper were normal. The arms were normal In all respects.
Sensation appeared to be affected but. little, but the results of
examination were doubtful In so email a child. There was Incontinence
of urine and faeces. The spinal column showed no change In shape or
rigidity and an X ray photograph gave no evidence of spinal disease,
but there was a cavity in the head of the left sixth rib suggestive of
tubercular osteitis.
Operation was performed on Jane 28th.
The spines or D. 3-10 were removed and a small cavity, quite localised
and apparently tubercular, opened In the head of the sixth rib. On
removing the lamina of D. 5 the cord was seen to be swollen opposite Its
lower border. Free exposure Bhowed that this swelling extended to the
upper bor ier of D. 7. Above this swelling the cord pulsated, but below
there was n<> pulsation. The meninges were opened above, and here a
normal cord was seen, but below at the site of the swelling It was
firmly fused with the meninges. The swelling was carefully opened by
a vert ical mid-line Incision on its dorsal aspect, and about half a drachm
of pus removed from the centre of the cord. The wall of the abscess
was formed of thinned and flattened cord tissue. There was no lesion
of the bone and the dura was freely movable ever tne surface of the
verte’TH*. There was no visible communication between the cavity
in the head of the sixth rib and the spinal canal. The edges of the
opening In the cord were sutured with fine catgut and the wound
clos-d
Healing took place without complication and the pathological report
on the p*iH (Or. G.T. Western) showed the presence of tubercle bacilli on
August 13th. Tne patient was sent to a convalescent home, being ableto
walk wit h assistance, but all movements being Jtill very spastic. On
return from convalescent, home on Oct. 10th he was walking perfectly
and able t * run. There was complete control of the sphincters, but all
reflexes were g>eaMy increased.
• m Jan. 16th, 1918, he was normal In every respect, but the knee-
jerks were, perhaps, a little more brisk than normal. All movements
of the legs, walking, and running were quite unaffected.
Secondary Carcinoma of Vertebra.
The next case is one of secondary cnboidal-celled
carcinoma of the vertebrae.
Case 2.—Patient, aged 58, first notloed the onset of severe pain In
her back in February. 1917, following an attack of tonsillitis. It was
treated as lumbago. This improved with rear, but in the early part of
Julv Bhe not.1< bd severe pain of a somewhat different nature. It was
un ier the shoulder blades and passed right round the thorax and
abdomen, feeling like a bind about two Inches wide. In the middle
of July she noticed •• pins and needles ” in both feet, but chiefly in the
left, and at the same time the left leg became weak, to be followed
short.lv Hf erwarda by weakness of the right leg. This weakness had
t-een increasing steadily and she had been losing all feeling in the body
below the waist.. Two weeks ago she first had difficulty in passing
urine and a the time of admission to hospital on August 8th, 1917, had
to have a catheter passed twice a day.
The l. gs Uy ext, n-ied flit in the bed and there was no voluntary
power of anv* movement in them, but when they were touched there
were mv..| untar , movements of oontraction ol the hip flexors and ham-
8r,-ings, the leg* being usually drawn up. The reflexes were all
increase i, rhe pian'ars were up, ankle clonus » resent and . the knee-
jerks greatly increased. The abdominals were all absent. There was
complete lo*s to ^11 torms of sensation, including vibration, up to the
levt-l of t he ninth dorsal segment. Above this area of loss w.as a wen-
defined band of hyperesthesia about two inehes wide (Fig. 1). Tfyerewere
i
THE Lakoet,] MR. A. J. WALTON : SURGERY OP SPINAL CORD IN PEACE AND WAR. [Feb. 15,1919 249
retention of faeces and oonstlpation. The X ray of the spine showed
no abnormality and no primary growth could be found in the breasts,
thyroid, or abdomen.
Operation, August 11'h, 1917. A flap Incision wss made, exposing
the spines of D 4-12. and r hese spines removed. The laminae of D. 7, 8,
and 9 wore excised and a mass of soft gelatinous growth seen spreading
from the bod tea of the vertebrae ar<m-.d the dura. The upper and lower
borders of the growth were not delimited, but a portion was removed
for microscopic examination and the wound closed. The ptthological
report showed a secondary small spheroidal-belled carcinoma. Progress
was steadily downhill, death occurring in the middle of September.
Ossifying Chondroma.
Id this case the lesion was ossifying chondroma of the
body of the vertebra.
Casa 3.—A man, aged 44, was admitted to hospital on Feb. 29th.
1916. Four months before he had noticed the ons*»t of pain in the bad
and passing round the left side of the chest. Two weeks later nnrab-
«@ss started in the right foot and soon passed up the whole leg. Two
months before admission the left leg commenced to be weak in
walking, and two weeks ago numbness began in the left font and had
continued since, bat had not spread up the leg. There had been no
trouble with mlcturl'lon.
On «dm salon he was found to walk with great difficulty. keeping his
eyes nuon the ground. The right leg was a> axlo and tbe left was boi h
ataxic and spas' ic. When the eves were dosed he was unable to keep
upright. All the movements of the left leg were performed very clowly
on account of the rigidl y, but he could flex and extend his toes, and
the individual movements, although very spastic, were strong. All the
mnvemonte of the right leg were strongly and quickly performed and
were not incoordinate when the e> es were open, but when he closed
bis eyes they were extremely ataxic.
He complained of numbness in the right leg up to the hip and some
numbness in the left foot. There was no loss anywhere to cotton-w*x»l,
but complete loss to prick, heat, and cold over the right leg up to the
Cask 4.—Patient, aged 36, was quite well until September, 1916,
when be had an attaek of influenza. This was associated with pain In
the back and the left side of tbe abdomen at the level of the umbilicus.
After the attaok be started work for a few days, bat noticed that on
crossing tbe road he always kicked the curb with hia left foot and was
unable to lift his toes up. At the same time be commenced to expe¬
rience difficulty with micturition, chiefly in starting tbe flow. There
was no reten> ion and no lnoontlneiioe. In December, 1916, he had a
second attack of influenza, after which his left leg waa weaker, to that
he had to swing it on walking, but he conld still manage to walk about
four miles. The trouble with rhe urine increased, and In March, 1917,
he noticed that tbe right leg felt numb below the knee. He was
admitted tc hospital on May 6th.
It was found tnat in his left leg the quadriceps and hamstrings were
much weaker than on the right side and tbe anterior tlbial group of
muscles conld not be contracted at all. There was no weakness in the
arms or right leg. On i he right side tbe knee-jerk was greater than on
the left, and on this side ankle clonus was just obtained. On scratching
tbe left sole the toe went up and there was a contraction of tbe left
quadrioepa and hamstrings. On tbe right s»de the toes were up, but
the reflex was limited to the foot. The abdominal reflexes were not
obtained.
On the sensory side there was no loss anywhere to cotton wool. Sen¬
sation to pin-prick, to beat and to cold, were completely lost over tbe
wholeof the right leg and trunk up to the level of the third dorsal
segment. On the left s«de there was loss to the same forms of sensation
on the lower leg. (Vide Fig. 3.)
Operation was performed on May 16th.
The spines of D 1-8 were exposed in tbe usual manner and removed
The lamina of DQ was trephined and those of D 5,4.3, and 2 removed
with forceps. The dura was a little distended and the*e was oulv slight
oulsation. On opening the dura no lesion could be seen, but pulsation
did not return. The laminae of D1 and C 7 were therefore removed.
As soon as tbe latter was out pulsation returned, and at this spot the
cord appeared widened. It was gently lifted with a slip of the dentate
Pic. L—Qasb 2. Shaded area, loss to pain,
best, and oold. Light touch lost, but upper
level of loss 2 in. lower down. Vibration loss
up to ninth dorsal segment. Dotted atea,
band of hyperesthesia.
Fig. 2.—Case 3. Dotted area, loss to
vibration ; shaded area, lost to prick,
heat, and cold.
Fie. 3.-Oi8K 4. Shaded area, loea to
prick, heat, and cold.
hip (vide Fig. 2). There was total loss to vibration In both legs nearly up
to tbe level of tbe loss of prick. It was completely lost even in t he left
leg. where sensation to cotton-wool was still present. In the lett lower
extremity and tbe right toes and ankle there was complete loss to the
power of reoognistng passive position. There was a baud of definite
hyperesthesia on tne left side corresponding to the eighth dorsal
segment.
Toe reflexes in the left lower limb were increased, the ankle- and
knee-jerks being gretier than on the right, and on this side the plantar
reflex was up. When he sat. up there was a slight curve st the i«vei of
the eighth dorsal spine, evidently due to relaxation of the muscles,
especially on the left side.
Operation was performed on March 25th, 1918.
A large rectangular flap was turned over to the left, exposing the
spines uf D 4-12 an i toe spines and laminae removed in tbe usual way.
Tbeoord was seen to be Blightly displaced and a tumour was felt
ante*ior to it at tbe level of the eighth dorsal vertebra. The dura
oouid not, however, be preled off the tumour. It was therefore opened
and tbe ooni gently pubed over to tbe right by means of a slip of tbe
dentate ligament. At this level tbe cord was seen to be compressed by
a small hard white tumour which was firmly atta-hed to the posts'lor
•urfsoe of the b<siy of the vertebra rather to the lett of the middle Hue.
With a small chisel tbe tumour was removed from the surface of tbe
bone alter *he dura around its base had been divided with a tenotomy
■nile. The dura was sutured over tbe bare area of the bone and the
cord ivplaced. 1 he posterior opening in t be dura was now completely
owsei and ihe wound sutured without drainage.
He made favourable progress and two months later, when transferred
Diek t * the medical side, was able to walk alone. Tbe movements of
legs were much less spastic on the left ode and much less ataxic on
bote skies. The pathologies* repot showed a calcified, centrally
necrosed chondroma of tbe body ot the vertebra.
Suibpial Endothelioma .
Th e fourth case is one of snb-pial endothelioma of the
oord.
ligament, and a translucent mass waa then seen apparently projecting
from the lateral oolumna on the left aide. On carefully incising the
pia over the tumour it was seen to be extramedn lary and by gentle
dissection could be entirely freed. It lay between the left roots of 0 7
and D 1. being embraced by these roots in its upper and lower extremi¬
ties. The dura was closed entirely and the wound sutured without
drainage.
Two days later the power of flexion of the left toes and ankle bad
returned. On May 22nd the wound was healing well. He had now
the p jwer of voluntary contraction o' the extensors of the left foot and
toes. The plantar reflexes were both down, tin the 26th the wound
was healed and all movements of the legs and feet were perfect. On
June 14th he was walking perfectly antvonly felt slight weakness In
tbe left ankle There was slight dulling to pin-prick In the right leg
but he could feel it all over. There waa no hypere«tbesla and no urinary
symptoms. Allowed home.
Complete Division of the Spinal Cord.
The next case is one*of gunshot wound with complete
division of the spinal cord.
Case 5.*—Patient, aged 26, while passing through the German
barrage on August 6th, 1916, was hit in the baok by a shrapnel bullet.
He fell at once wit h no pain, but with the feeling that tbe body below
the middle of the cheat had gone. There was no dtffloulty in breathing.
He whs carried ba-k by singes to the C.C.S. In the first part of
the journey he was semi conscious but later bad a good deal of pain
<n tbe back. From tbe O.G.S. he was t<ken to Ca* nes where be was
X rayed. The bullet was seen in the mid-line at the level of the sixth
dorsal vertebra. His bladder had to be emptied nlgbt and morning
with a cat heter, and whilst hare his lower limbs were flaodd and power¬
less. On A igust 16th he was admitted to tbe Empire Hospital.
On an mission there was a small clean wound of entry to the right of
the spine of tbe second dorsal vertebra It was nearly healed. There
was a large deep bedsore over the upper part of the sacrum. All
* This case was reported In fall by Captain Riddooh, from wbeae
notes my own were hi large part abstracted.
G 2
250 Tn Lmoif,] MB. A, J. WALTON: SURGERY OF SPINAL OORD IN PEACES AND WAR. [Fbb. 16,1M9
noacIfB of the trunk balow the sixth rib and of th« legs showed t**tal
flaccid paralynie but there was no wasting. There were no Involuntary
movements of the legs. At the level of the fourth Inte'-spxoe there was
a narrow band of bypersesthesla. Vibration was lost up to the level of
the ninth rib and all other forms of sensation up to the level of the
sixth rib.
On August 28th, for the first time, on scratching the soles of
the feet, upward movement of the toes was noticed and at the same
time tightening of the ham«trlng tendons could be felt with coavaa-
tlon of the anterior tibtal group of musoles. The receptive field was
limited to the soIqs of the feet. On the 31st there were periodic In¬
voluntary upgoing toe movements, with tlgh<enlng of the tibialis
antlcus and hamstring tendons. On briskly tapping the right
patellar tendon there w*a contraction of the qnadrloeps, which was,
however. Insufficient to move the leg. On scratching the sole there
were fairly brisk upgoing toe movements, with contraction of the
flexors of the knee and hip and of the adductors of the thigh. The
reflexogenons area extended from the sole to rather above the middle
of the calf.
On Sept. 6th the involuntary contractions were sufficient to cause
slight flexion at hip and knee, dorslflexlon at the ankle, and upward
movement of the toes. The receptive area for the flexion reflex
had extended from the centre of tne calf to the groin, and was at
tildes associated with contraction of the Ipsl lateral rectus abdominis.
There was periodic contraction and emptying of the bladder.
Operation was performed on Sept. 8tb.
The spines of D 4, 6, and 6 were removed with foroepe and the
corresponding laminae th n exolsed. Opposite the bodies of the fourth
and fifth dorsal vertebrae the c >rd was found completely divided, the
ends being separated, by about an inch. The shrapn**l bullet was
emoedded in the body of the sixth dorsal vertebra and was easily
removed. The wound was closed in the usual way.
On 8ept. 20th the wound had healed well. There were strong
involuntary flexor spa»mi of both lower limbs recurring at frequent
intervals. The limbs were both flexed at the same time, and the
extension which followed the spasms was purely passive and due to
gravity. There was distinct tone of the physiological flexors, but the
extensors were undoubtedly flabby. On tapping tne patellar ligament
there was contraction of the extensors, but no movement of the knee.
▲ stimulus applied to the sole was followed by flexion of all the joints of
the ipsliateral leg. There was no return of sensa' ion.
On Oct. 26th the flexor spasms had become very frequent, and the
abdominal recti were more involved. The knee-jerks were increased
and equal with good extension of the leg at the knee. The plantar
reflexes were “extensor as before, and were always associated with
gene* al flexion reflex of the lower limb. The limbs never flexed
together.
On Nov. 4th the reflex spasms were more frequent, and the involuntary
movement consisted of flexion stthe hip, adduction of the thigh, flexion
of the knee, dorslflexlon at the ankle and upgoing toes, with fanning of
the four outer toes. Usually there was an aooompanying contract**n
of the quadriceps cruris and oalf musoles of the opposite leg. The
ipeilateral rectus abdominis pvt lot pa ted more often in the flexor
spasm. The flexion reflexes were easily obtained. The knee jerk* and
ankle-jerks were brisk and equal, and definite ankle clonus was
obtained on both sides.
After this date the condition persisted without much change,
excepting that daring and after an attack of pyelitis all the reflexes
were decreased, the flexion reflex was obtained with difficulty, and the
reflexogenoua area was greatly decreased. As the effect of the infection
passed off the reflexes were obtained more readily and the involuntary
spasm increased.
Partial Divition of Spinal Cord.
The last ease is one of gunshot wound, with partial division
of the spinal cord.
Cass 6.—Patient, aged 21, was with a working party behind the
support lines on June 8th, 1918. He was picking up some sticks when
he suddenly fell down with a tingling feeling in his legs, hut be felt no
bio# or wound. On attempting to rise he found that he nad lo*t all
power in his legs. He did not lose consciousness. He was taken back
to the dressing station and then to the stationary hospital. There he
was found to have a wound In the upper dorsal region, with complete
paralysis and loss of sensation below. He had to be oalbeterised. On
Jane 12tb a laminectomy was performed and a portion of the lamina
of the third dorsal vertebra found depressed on the cord. It was
removed. The dura was uninjured.
Ou Jane 18th he arrived at the 2nd London General Hospital with
the wound healing well. There was then complete motor paralysis
with fUccldity below the fourth dorsal segmeot and complete loss of a*l
forms of sensati m to the same level. There were no ankle-jerks, but
the knee-jerks were just obtainable. When the sole was scratched there
was dorslfl *xion of the foot, flexion of the knee, and flexion of the hip
on the abdomen.
On July 25th he lay in bed with the legs extended. There were a few
slow contractions of the legs, and if the bedclothes were moved they
were both flexed at the hip and knee and adducted. Tney could,
however, be easily drawn down. The bladder had commenced to
oontract automatically, b«it there was still complete loss of voluntary
C rwer In the legs and complete loss to all forms of sensation up to the
vel of the nipple. If the legs were touched they were flexed at the
hip and knee, bat the flexion was slow and gradual, with no sharp and
painful contraction. There was now a well-ma ked knee-jerk, with a
sustained contraction of the extensors on both sides. Ankle clonus
oonld be obtained and on dorslflexlng the foot there was a definite
extensor thrust. On scratching the Inner side of either sole the toes
were shvply dor-lflexed. with flexion cf the hip and knee and drfinlta,
but slight, extension of the oppo-ite leg. Tne flexion reflex of the
stimulated leg was imme -lately followed by a movement of extension
at the knee. Tne receptive field was llmlte i to tbe sole and ankle «-n
either side and at no time was the reflex accompanied by any contrac¬
tion of the abd »mlnal musoles.
On August 22nd there was return of voluntary movement of flexion
and extension of tbe toea ou both sides, but no movement of the ankle,
knee, or hip. With it there was some return of sensation, prick being
S rrsent above PoupArt a ligament and on the soles, but not on the legs,
otton-wool was absent below the umbilicus. The plantar reflex was
as before, but there was now more marked ankle olonus, and the knee*
jerks were greatly increased.
Sept. 13th : The general condition was good.
The motor spasms were less, the contractions being slower and more
regular. Voluntary contraction was still limited to the toes of both
feet. Sensation remained as before. On ecra*ohlng the soles of i he feet
there w»b dorslflexlon of the toea with flexion of the Ipsilateial
knee. Both quadriceps and hamstrings contracted shvply, but
there waa no movement at tbe hip. The other leg aid not
contract. Tbe rrflexogenous area was limited to the so e and
donum of tbe foot. Ankle donas was readily obtained and the
knee-jerks were gr-atly Increased. The uoper abdominals were just
obtained. There was still urgency and he was unable to hold his urine
or fscoes when he felt the desire.
On Jan. 27th, 1919, the general condition was very good
and there was no pyrexia.
He was able to get about In a ohair with the legs hanging down. He
lay tn bed with the legs extended. Toere were very few spasms and
the legs could be bandied without inducing them, but occasionally a
marked flexor spasm was caused by a pin prick to the sole. There was
then dorslflexlon of the toes, flexion of the knees and hips on both
sides, but no contraction of t> e abdominal muscles. The tone of all
muscles was good. There was voluntary contraction of tne flexors and
extensors or the toes and ankles. He could flex the knees snd hips,
but this Induced some spasm so that he could not extend them again.
They could, however, be easily extended by steady pressure. On
scratching tbe Inner side of tne soles there was dorslflexlon of the
toes, slight flexion of the knee and hip, and a powerful and visible
contraction of the quadriceps and cslf muscles. There was no con¬
traction of the contra-lateral leg and no oontraotlon of tbe abdominal
muscles. Tbe reflexogenoua area waa limited to the sole and outer
side of the ankle.
Knee-jerks were much increased and ankle olonus was present on
both sides. There was loss tn prick, heat and cold over the left leg
tn m the umMlfons dosmwards to the ankle, hut It w«s present over
the whole of the right leg and the left, foot; Sensation to ootton-wool
was still absent to the level of the ambitions.
References.—I. D. J. Armour: The 8 argeryof the Spinal Oord and
its Membranes, Thk Labi err, March 7th, 14th, and 2lst, 1908.
2. W. 0. Campbell Fracture of the Lumbar Spine without Compression
of the Cord, Medical Review, March. 1916, p. 104. 3. J. M. Clarke and
R. G. Lansdown: Intramedullary Tumour of the Spinal Cord, An.,
Brit. Med. Jour., May 9th, 1914, p. 1009. 4: S. Cobb: Hamanglama of
the Spinal Cord. Annals of Surgery. December, 1915, p Ml.
5. J. Collier: Gunshot Wounds and Injuries of the Spinal 0>*d,
Thk Lancet, April 1st, 1916, p. 711. 6. R. Derby: Gnnshot
Injuries of the Spinal Oord, Annals of Surge y, Jnly, 1916,
p 643. 7. C. A. Biting: Intramedullary Gllosarooma o* tbe
Cervical Cord, Ac., Ibid.. Jane, 1911, p 648. 8 . O. A. Blsberg:
Experiences In 8 plnal Surgery, Surg., Gyner.., and Obsteta., February,
1913, p. 117. 9. O. A. Blsberg: 8 ome Surgical Features of Injuries of
the Spine, with *pecUl Reference to Spinal Fracture. Annals of
Surgery, September, 1913. p. 296. 10. C. A. Blsberg: 8 urgloal Treat¬
ment of Intramedullary Affections of the Spinal Cord, Surg., Gvneo.,
and Obsteta., February. 1914. p. 170. 11. 0. A. Blsberg : Laminectomy
for Spinal Tumour, Annals of Surgery, Oct«*ber, 1914, p. 464. 12. O. A.
B'sberg: Diseases of the Spinal Cord and ite Membranes, 1916.
13. C. A. E’sherg : Annals of 8 urgery, February, 1917, p. 269. 14. O. A.
El-berg: Fractures of tbe Spine with Cord and Root Symptoms, IbM.,
January, 1918. p. 104. 15. <3. H. Frasier : Certain Problems and Pro¬
cedures tn tbe Surgerv of tbe 8 pinal Column, 8 urg., Gvnec.. and
Obsrets.. May, 1913, p. 552. 16. W. R. Gowers : Diseases of the Herron
8 ystem. vol/i., Churchill. 1892. 17. W. Harris and A. 8 .U. Bank-rt: A
Owe of 8 plnal Tumour with 600 II 0 Is. Thk Lancet. June 2ts», 1913,
p. 1730. 18. D’Orsay Hecht: The 8 nrgery of Spinal Cord rumours from
a Neurologic Viewpoint, 8 urg., Gynec.,and Obsteta., if ay 1913, n. 475.
19. C M. Hinds Howell: The Diagnosis and Treatment of Com pre s s i o n
Paraplegia, Brit. Med. Jour.. Nov. 23rd. 1912, p. 1444. 20. Go-don
Holmes : 8 olnal Injuries of Warfare. Gou»*tonian Lectures, Ibid.,
Nov. 27th, 1915, p. 764. 21. Sir V. Horsley: Chronic Spinal Meningitis,
Ibid.. Feb. 27th, 1909, p. 613. 22. Ir V. Horriey: The Diagnosis and
Treatment of Compression Paraplegia, Ibid., p. 1443. 23 D. M. Hughes:
Laminect-omy for Gnnshot Wound, Ibid., March 9th, 1918. p. 290.
24. R. J. Hunt and G. Wooisey: A Contribution to the Sym¬
ptomatology and Surgical Treatment of 8 ptnal Corl Tumours,
Annals of 8 urg., Sept., 1919, p. 289 25. J. Lherrattte and H. Claude:
Btude Clinique et Anatomo-pa*ho'ogique de la O mmotion M&lullalre
par Projectiles de Guerre, Annalee de H&ieolne, No. 5, October, 1916.
26. P*erre M. Marie and A. Benlstv: Thk Lancet, August 21st. 1916,
& 403. 27. A. W. Mayo Robson: The Treatment of Paraplegia from
unsbot or Other Injuries of the Sptnml Cord, Brit. Med. Jour..
Deoe* her, 1917 p. 853. 28. 8. J. Mlxter and R. B. Osgood : Traumatic
Lesions of the Atlas and Axis, Annals of Surgery, February. 1910, p. 193.
29. H. Neuhof: Some Observations In Spinal Oord Surgery. Ibid.. April,
1917. p. 410. 30 E 8. Reynolds : Tbe Diagnosis and Treatment of Com¬
pression Paraplegia, Brit.. Med. Jour.. Nov. 23rd. 1912, p. 1440. 31. G.
Riddoch: The R flex Functions of the Completely Divided Spinal Ooid
in Man Compared with those Associated with Lets Se* ere Lesions,
Brain, xl.. Parts 2, 3, p. 264; Thk Lancet Dec. 2lst 1918, p 839. 32. A-
Schschner: Injuries of the 8plnal Cord, Surg., Gvnec., snd Obsteta.,
June, 1916 p. 706. 33. J. W. T. Walker : The Bladder In Gunahot snd
Other Injuries o( the Spinal Oord, The Lancet, Feb. 3rd, 1917, p. 173.
Literary Intelligence.— Messrs. Cassell and
Co., Ltd., announce the publication of “Elements of Surgical
Diagnosis,” by Sir Alfred Pearce Gould and Mr. Eric Pearoe
Gould. This is the fifth edition, revised, of a work which
has for some time been out of print. It has now been
brought up to date, and embodies tbe advanoes that have
been made in the diagnosis of surgical affections in con¬
nexion with war surgery. Muoh new matter has been added.
—Messrs. Sampson Low, Mars ton and Go., Ltd., are pub¬
lishing a work on child life by Dr. Courtenay Dunn, entitled
“ The Natural History of the Child."
teg Lahore,) MR. A. H. TUBBY * OTHERS: THE TREATMENT OF GUNSHOT WOUND8. [Fbb. 15 1919 251
THE TREATMENT OF GUNSHOT WOUNDS.
REPORT ON ACRIFLAV1NE USED AS A PASTE
AND IN SOLUTION.
By A. H. TUBBY, C.B , C.M.G.,
COLONEL (TEMP.), A.M.S. ; CONSULTING SURGEON, EGYPTIAN
EX P EDITION ARY FORCE;
GEORGE R. LIVINGSTON, M D., F.R.C.S. Edin*.,
MAJOR, R.A.M C. (T.F.);
AND
J. W. MACKIE,
CAPTAIN, R.A.M.C. (T.) J BACTERIOLOGIST. MILITARY PATHOLOGICAL
LABORATORY, E.E.P.
(FVom, the Ward* of a General Hospital , Alexandria .)
I.—Agriflavine Used in the Form of a Paste.
In the course of our inquiries into the value of a solution
of aoriflavine in the treatment of septio gunshot wounds it
oocurred to one of us thut if it were used in the form of a
paste, on the analogy of the well-tried "bipp” paste intro¬
duced by Rutherford Morison, its effect might be as satis¬
factory, or even more so. A paste was made up of pulv.
bismutbi subnit., 50 per cent.; paraffin, about 50 per cent.;
aori flavine, 0 5 per cent. Three oases having shown signs of
bismuth poisoning, we adopted the carbonate instead, when
we could obtain it. We are now modifying the composition,
thus: bismuth carbonate, 25 per oent.; paraffin, 75 per cent.;
acriflavine, 0-5 per oent.
On the introduction of any new detail in wound treatment
a word of caution is necessary. The principles of surgery—
vis., never to allow discharge to accumulate and to maintain
free drainage in all septio conditions—stand fast as ever. At
the risk of being thooght somewhat behind the times, we
urge that it is not so much the particular method of wound
treatment or the individual antiseptic used as the laborious
and oonsoientious attention to detail which brings success.
We would insist upon the regular bacteriological counts and
cultures of organisms during the treatment of wounds, just
as we insist upon the routine examination of all fractures
by X rays.
Method of Using Flavine Paste.
We have found very great advantage from its use in 18
oases, especially in gunshot fractures, and in suppurating
polyarthritis, as in the foot. Having established free drain¬
age and removed any parts actually necrosed, we have
umgated the wound by an automatio flushing method with
enaol for 48 hours to 5 days. Then, under an aneestbetic,
any remaining neorosed tissues are carefully out or scraped
from the wound and it is then very thoroughly washed out
with methylated spirit, or absolute alcohol, and packed with
the Ravine paste. In our oases relief from pain was usually
very noticeable, and as a rule it is not necessary to dress
them more then onoe a week.
Wounds treated in this way show a marked local improve¬
ment and in a comparatively short time take on all the
appearances of a healthy aseptio wound. In some cases
after three or four weekly dressings under an anaesthetic
with rigorous aseptic precautions, the wound and the dis¬
charge have become sterile, even in severe septio bone and
joint cases, and it is then allowed to heal up or is secondarily
sutured. The general oondition as a rule shows rapid
improvement.
Illustrative Cases.
Space allows only of a brief summary of some of the
eases treated with (a) eusol and acriflavine solution and
acriflavine paste in succession ; (b) with eusol and acriflavine
parte; and (<?) with acriflavine paste only.
Busol and Acriflavine Solution, and A criflnvine Paste in Succession.
Case A—Admitted N»v. 6th, 1917. 0.8.W. thigh, knee, and shin;
very extensive, reaching from 8 Inohts above knee to upper and middle
thirds of tibia. Knee-joint bad been laid open and pttella turned over
to Inne* side; sinuses In popliteal space and oalf. Com In non* Irriga¬
tion with etuol. On Deo. 18th necrosed patella was removed. B tcteno-
lngieal count Dec. 90th, Staph, and Streptocoecip . aur. 36 In field: 22nd,
27; 28th, scanty. Gram - bacilli 12. Ou Dec. 23rd aorifUrine solution
used as dressing, after 24 hours Irrigation with normal saline. On
Dec. 29ih thorough cleansing under CHGIf and free application to
Wounds, knee-joint, and sinuses of acriflavine solution ou gauze. On
Jan. 7th, 1918, wounds cleansed, spirit applied, and paste used.
Baeterlologlcal count Jan. 11th, 15. The paste was used as a dres-ing
until he was transferred to Bn gland. On and after its introduction the
improvement r, f the wound was very marked at fi'st «nd then s eadlly
continuous, especially as regards extensive anterior lesion, although
sinuses c mtinued to discharge. Sixteen bac’etiologies! c mnts made
between Jan 11th and March 1st gave an average of 8 per field.
This case was noteworthy on account of the sever tv of tHe lesion,
the fact that the Umb was ultimately saved, particularly by timely
surgery end by the freedom from pain after dressing when the paste
was need.
Gunshot Wounds Treated with Eusol Irrigation and Ac iflavinc Paste*
Case 5.—Shrapnel wound lower extremity right ulna on Nov 6tb,
1917. Admitted Nov. 13th. No F.B. Bubo! irrigation till Dec. 13*b,
when acriflavine paste u»e *. BA 0 te> lologloal count steadily diminished
from 15 on Deo. 13* h to 1 in two fields on Jan. 8th; average of 14
oounts, 4 per field. With the exception of extrusion of minute sequestra,
the wound, dressed w<th the paste at Intervals, did very well, and wss
healed on Apr!* 14ih, 1918.
Cask 6.— G.W.S. right foot. Was admitted to General Hospital on
Nov 19th, 1917. Gho art’s amputation performed p eviously to admis¬
sion; wound was freely suppurating; nerrotds of astr gains and
os oalds. Busol was ua*d; organisms In field remained uncountable
for a month. The wound was then thoroughly scraped under an anes¬
thetic and treated with ab-olu'e alcohol and acrlflivlne paste. The
organisms tell to 2 in three fields and were finally nil. Improvement
was very marked; pit-lent was discharged to England in three months
with wound healed all but superficially.
Case 8.— G.8.W. Involving knee-joint. Admitted Dec. 20th. 1917.
Joint laid freely open by turning down patelUr flip. Was flushed with
eusol until organisms in field were 2 In number; then a weekly dress¬
ing with acriflavine paste substituted until Mar oh 3rd. 1918. when signs
of stomatitis appeared, due to bismuth absorption. Weekly examiner
tio’sof discharge from wound showed small numbers, varying from
2 10, • f Staph, and Streptococcus aureus. The paste was stopped on
March 3rd and b»ric acid substituted. The wounds ultimately healed.
Case 12.— G 8.W. leg; admitted April 9th, 1918. Wound had been
excised on east side of 8uez Ganal, “hipped," and stitched. When
admitted suppurating freely. All stltohes removed; mas* of “bipp”
and pus evacuated. Dressed by intermittent Inigatlon with eusol. On
April 20th packed with fUvlne paste. On May 2nd symptoms of
bismuth pois >nlng supervened; paste discontinued, and ensol sub¬
stituted. While flavine paste wss In use the wound made rapid
progress, and was “clinically sterile” on discharge of patient to
England.
Case 13.—Patient was blown np when ship was torpedoed, and piece
of metal driven into thigh. On admission wound was septic; it was
repeatedly opened up: sinuses drained and counter openings made.
Hip-joint became Involved; bead of bone was excised. Organisms
6 in field, Acriflavine paste was used ; in 8 days bacteriologist reported
sterile.
Gass 14.—G.8.W. and fracture of bones of foot. Admitted April 9th,
1918. 8oft tisanes around wound bad been freely excised at O.U.8. and
“hipped" on April 1st, 1918. Wounds were opened up, enlarged,
“bipp" was removed, and Staphylococcus aureus f.»und in pus. The
foot improved steadily bat slowly, un May 5th wound was cleaned,
and aorlfUvlne paste applied. From “organisms uncountable" to
“wound clinically sterile'* occupied 28 days. Patient discharged to
England on June 20th, with merely surface dre-sing. All sinuses
closing rapidly and no bare bone felt; good prospects of patient having
a useful foot.
Case 16.—Extensive G.S.W. thigh and leg, Nov. 7th. 1917. Admitted
Nov. 10th; also suffered from malaria. Treated with eusol Irrigation.
F.B. removed and better drainage provided. Biclllaty count 1, scanty*
3. 2, 2, 3, 3 Staph, p. aureus pure. On Jan. 29th tibia scraped and
wound packed with aorifl ivine paste. Average couut 2 per field In
16 counts. Acriflavine paste dressing continued. Healed by May 15th,
1918.
Case 18— G.S.W. right thigh on Nov. 25th, 1917. Admitted
D«c. 3rd. Large discharging wound at Inner aspect of lower third of
thigh and cnmmlnut Ion of femur. Discharge continued. On Feb. 13th,
1918, bacterial count was 27 Staph, p. aureus (pure) per field. On
Feb. 14th amputation was discussed; but packing with acrifltrine
paste was don**, after removal of necrosed bone. Subsequent counts,
Feb. 22nd 2; March 8th. 5; 13th, %; 27th, 3 per field. Pain bad been
a distressing feature In dressing, but none «aa felt after use of paste.
The wound oontinued to do well, and it was erideut that loss of limb
had been averted. He was Invalided to England almost healed.
Value of the Treatment.
Although the oases treated are only 18 in number and too
few on whioh to dogmatise, yet we feel that the use of a
paste of aoriflavine is worthy of more extended trial. In
itself we do not think that 0 5 per 'oent. of acriflavine had
any toxio effect; and any symptoms of poisoning observed
were undoubtedly produced by bismuth subnitrate —perhaps
impure. Similar calamities were observed when, following
the initiative of Beok, of Chicago, the bismuth treatment of
| tuberculous sinuses was practised, and doubtless poisoning
occurs from time to time when the bismuth and iodoform
| paste is used.
[ Various surmises have been made as to the method by
which pastes act. It is quite clear that a rigid technique
| must be adhered to and the wound thoroughly cleansed
and rendered practically sterile clinically before they are
employed. If these precautions are not taken the paste aots
as a foreign body and has to be removed, as in two of our
oases which were “ hipped ” at anot her hospital.
It is difficult without more experience to assert that
acriflavine paste is superior to ‘-bipp,” but that it is
efficient when properly employed we have reason to hope.
And we would insist again upon this fact that the element
of suooess is thorough cleansing of the wound, washing
every nook and oranny with absolute alcohol, and then
applying the paste. The facts that painful dressings are
not required, that dressings need only be done occasionally,
and that there is little or no pain after pasting as compared
with packing sinuses with gauze soaked in other antiseptios
are very significant. We have observed that under the
Th* Lanott,] DRS. J. E. SWEET k H. i). WILMER: TREATMENT FOR TRENCH FEVER. [Feb. 15, 1919 253
of the cases reaching the base by no means the 90 per cent,
reported by the British Trench Fever Committee. We have
learned of no method of distinguishing between a case which
will spontaneously recover, and one which will spend the
next six months in hospital.
It will be noted that a pronounced reaction follows the
intravenous injection of 10 c.cm. of a 1 per cent, solution of
x
collargol, made in sterile distilled water, and it is of interest
that the patients often compare this reaction to their initial
attack. We are not disposed to consider this reaction as a
harmful effect. The only untoward symptom will develop if
the injection does not enter the vein but passes into the
cellular tissue. If this occurs a decided inflammatory
reaction may follow, even leading to abscess formation.
We are under lasting obligation to the American Red Cross
for a small supply of the collargol of recent manufacture.
Nos. 6 and 7 is to be explained by coincidence, then the
effect of the second injection, when the fever and pain had
returned after a six-day interval, makes the theory of coin¬
cidence appear like an excellent treatment. Nos. 6 and 7
were followed for three weeks after the second injection—
x
a week more than is charted—with no return of symptoms of
any kind.
No. 1.— T’aptaln A, l.S M.C. Attack began Feb. 6th 1918; course
marked by fever, recurring every seventh dsy, prec. ded by chills and
accompanied by backache, headache, and shin pain. Lost ►bout 20 lb.
in weight. June 21st, 10 c.cm. cnllarttol. Has had no return of
symptoms since, and has regained the lost weight. Has been under
observation for 15 weeks since the collargol. H
x
Illustrative Cases.
We have chosen the accompanying 7 of our 35 charts to
illustrate certain points. The time of the injection of the
collargol is indicated by an x. It will be noted that we
have not always carried out the injection at two- or three-
day intervals. In some we have done this, and the reaction
seem* generally to be much less marked when the second
injection follows the first after a short interval (No. 5). We
_.Yo. 2.— Private S. Entered hospital bringing chart for Angu't 12th to
19th. August 26th, colUrgol. Temperature fell to subnormal the next
day. rose to normal August 28th, and remained normal until discharge.
Sept. llih.
No. 3.— Private H. Admitted August 5th, 1918. Patient says he has
had chills and sweats, pain in head, back, and sh ns, for five week , and
had the same sort fit attack 14 months ago. Collargol August 9th.
Observed until 22nd with no return of fever or typical pain. His
X X
X X
purposely did not carry out the two- or three-day injections
in many cases, for it seemed a way to control the question of
whether we were dealing in coincidence. Nos. 1 and 2 are
somewhat difficult to explain on the theory of coincidence ;
Nos. 3 and 4 may possibly be so explained, as well as,
peihaps, No. 5. But if the effect of the first injection in
charged complaining of weakness and stiffness and pain in knee and
wrist-joints.
No. 4.—Private H. Admitted to C C.8. August 13th, 1918, com¬
plaining of headache, backache, pain in shins, and chill* and Cover.
Admitted to hospMal on 22nd. 24th c>*llarg*>l. 28th out of bed, no
discomfort. Ob*>erved to 8ept. 4th ; no complaints except feeling weak.
No. 5.—Private 3. Attack began August 4th. Fever, chills, pain in
head, back, and shins, perspired easily. Fever eviaently of the six-day
Tbm Lanott,]
DB. N. MACLEOD; WHOOPING-COUGH.—CLINICAL NOTES.
[Fb». 16.1MB
made, bat overlooked until a oase with severe paroxysms
seen last year in consultation recalled both notes and
suspicion. The latter—viz., that the drug resorcin had
probably little, if anything, to do with the success of the
mode of treatment, was farther strengthened recently by
reference to Whitla’s “ Dictionary of Treatment,” where
resorcin and some seventy odd drags and modes of their use
are said to be employed in the treatment of whooping-oongh.
From this it may safely be inferred that no one of them is
generally regarded as pre-eminently successful.
Without the sedative and antixep'io effects claimed for
resorain, how could success be accounted for ? Though the
following oonsideration8 presented themselves while treat¬
ment was going on, until they were arrayed together lately
their force did not appear manifest. The throat-brushing
procedure is accompanied by physical and physiological
results independent of the drug. Are they in themselves
sufficient to aooount for success ? They are:
1. Physical. It was very early noted that after most
applications examination of the brush disclosed more or
less mucus. When it is realised that the brush is used
hourly during the waking period, and also that the cough
frequency and violence are in all probability not so much due
to the quantity of mucu«, usually not large, but to its par¬
ticularly tough and sticky character, it is manifest that its
removal by brush lessens the need for removal by cough.
2. Physiological. The frequency and violence of the cough
paroxysms and laryngeal spasm indicate increased irritability
of the reflex nervous mechanism concerned. There is also
inadequate inhibitory control manifested by the difficulty
in getting patients to restrain or repress the congh. In
the course of the disease the reflex is exercised more than
the inhinitory mechanism. Inhibitory power is materially
reinforced by hourly obedience to the order to open the mouth
widely and stick out the tongue during forced respiratory
effort, and continuing all three efforts while a brush is
being even only once turned round in the pharynx, and, as
not infrequently happens, in the larynx itself. Pharyngeal
and laryngeal tolerance of the brush demonstrates lessened
irritability of the sensory and motor halves of reflex cough
and spasm mechanisms in the presence of a foreign body,
and contributes to better exercise of inhibitory aotion in
such circumstances.
Psychological effects accruing from the discipline are also
involved in the hourly performance, and. even on the part of
the youngest patients, satisfaction and pride in successful
codperative effort.
Description of Method.
The writer is greatly mistaken indeed if those handling
whooping-cough cases may not be confidently assured of
attainment of the results here set forth when the procedure
recommended is carried out thoroughly—viz., such ameliora¬
tion within a week or ten days of starting brushing in cases
where paroxysms and spasms are violent and frequent that
the disease ceases to cause distress to the patient and anxiety
to the parent, and, when applied early in suspicious cases,
prevention of development of distressing cough and spasm.
Material —For each case a wire-handled throat brush,bent
at first suitably for pharyngeal use; when tolerance there is
established it should be further bent to form almost a right
angle about It inches from its point, proximal and distal
parte being straight, for laryngeal brushing—quite prac¬
ticable without artificial light and mirrors; a 2 per cent,
solution of resorcin in glycerine and water, I and 12 parts
respectively.
It may be noted that whan tracheal injections came into vogue for
tubercular lung trouble the writer so*«n discarded the use of artificial light
and mirrors on finding that be could introduce the syringe point into
the larvnx and inject the menthol solution whilst the i*me pre¬
cautions were carried out by tbe pa* lent as when the brush was used.
This new mode of procedure was preferred, success and failure in
entering tbe larynx being also distinguished, by the patient.
Procedure .—Immediately before each early application of
the brush it is well to put the patient through a preliminary
drill in breathing deeply with the mouth wide open and tbe
tongue well protruded, to be persisted in while the brush is
introduced into and passed quiokly once round the walls of
the pharynx. Mucus should be washed off on withdrawal
and the brush kept in a tablespoouful of the resorcin solu¬
tion—renewed daily—to be ready for tbe next performance
an hour later, the procedure being repeated regularly during
the waking period. In cases shy of tbe brushiDgitis helpful
at the first performance or two to be satisfied with brush
introduction Bbort of the pharynx, so that tbe tongue, <fco.,
contact becomes tolerated sufficiently, end the sweet taste of
the solution experienced, repeated say three or four times
on each oooasion. Gradually introduced further the brush
soon reaches the pharynx, where a single turn round its
walls will suffice. The attempt to enter the larynx should
not be made until brush toleration is set up in the pharynx.
An exhibition of successful performance by another patient
—younger if possible—is a good preliminary to beginning
operations with new ones.
Perhaps someone already using this method of treatment,
or adopting it, will be good enough to test and report whether
resorcin is essential to its success.
Shanghai. _
Clinical Stoles:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
- - ♦ ■ ■ ■■
▲ CASH OF
ACUTE ERYTHEMA RESEMBLING MEASLES.
By F. H. Kelly, M.B., B.S. Lond.
Cases of acute erythema simulating scarlet fever have
been described not infrequently, and a certain diagnosis
may be wellnigh impossible. Oases in which measles is the
disease simulated are less common, and diagnosis usually
comparatively simple. The case to be described is of
interest both on account of the intensity of the eruption, and
also because in the early stages the resemblance to measles
was more than usually close.
The patleut was a healthy boy of 13 at a large publlo
school. He had had four attaoks of urticaria for whfoh no
oause had been found, and also measles There was no
infectious disease except influenza du ing the term in
question. In tbe middle of term be w s found to have a
rash. He had felt perfectly well previously and did not feel,
ill. Temperature 100° F. The rash consisted of large
discrete papules with a well defined edge about I inch in
diameter, confined to upper part of front of chest. One
small gland in posterior of neok; occipital glands not
palpable. Marked, though not intense, conjunctivitis of
both eyes, about as intense as seen at commencement of
measles. Thin layer of whitish fur on tongue; papillae not
enlarged; slight inflammation of fauces. No Koplife spots.
Next day the rash bad spread rapidly and coalesced,
covering whole body, except scalp, palms of bands, or soles
of feet; ciroumoral region completely covered. The rash,
brick-red on the trunk owing to underlying pigmentation,
was a vivid soarlet on the face and limbs, ana was especially
bright on the legs. Considerable oedema of skio generally;
no haemorrhages in skin. A large bulla had formed on the
neck, discharging watery fluid. Eyelids stuck together by
exudate in morning. Lips cracked and sore. Tne tongue
was as on previous day, except for an elongated blister h inch
long. There was now intense inflammation of the mucous
membrane of tbe mouth and pharynx, most marked in five
or six places on inside of cheeks; on these places small
vesicles, up to i inch across, bad formed. But for the
larger vesicles the smaller might easily have been mistaken
for Koplik spots. The inflammation of the throat was fairly
uniform. Temperature 102°.
On tbe third day the intensity of the rash was still greater;
oedema of skin so marked as to cause great stiffness o
limbs; joints and muscles unaffected. Tbe face was qnite
unrecognisable, being very similar to a severe case of
dermatitis venenata. Around the neck and on the limbs
numerous bullsB had appeared, not at all tense, and in most
discharging contents freely. A few small subcutaneous
haemorrhages on tbe trunk. The lips were crooked, and bled
profusely on the slightest touch. The resides in the mouth
had spread, and in some cases burst.
No marked change for some days. The bullas increased in
size, one over right patella 5 in. long. Any part subject to
friction or pressure became sore owing to bullsB which burst,
but the sacral region, where the rash was not so intense,
did not become sore. The formation of bulls passed imper¬
ceptibly into desquamation, and also in places where bullas
had not formed, such as anterior surface of trunk; tbe.
epidermis when it separated revealed a dry surface under¬
neath. In places it was hard to say whether the desquama¬
tion had been preceded by bullous formation or not. Approxi¬
mately desquamation may be said to have commenced at
least as early as the fourteenth day, occurring while
the rash was still well out, although oedema of skin
had lessened a good deal. The whole surfaoe desquamated.
256 * Thb Lancet,]
ROYAL SOCIETY OF MEDICINE.
[FBB. 15,1019
including scalp, palms of hands, and soles of feet,
mostly in large sheets, some several inches in diameter.
The skin of the palmar surfaces of the hands and
plantar surfaces of the feet separated in practically
entire sheets at about end of third week. There was con*
siderable pigmentation of the skin after desquamation was
oomplete and the colour had faded, especially marked on
lower abdomen. The skin of the limbs, and especially of the
legs, remained rather a mottled purple colour. Desquama¬
tion was complete in five weeks.
The great trouble was the intense discomfort caused by
the condition of the lips and interior of the mouth. The
temperature, never above 102°, fell to normal on the eleventh
day. Throughout the patient never appeared particularly
ill. He had no vomiting or diarrhoea and at no time any
cough or nasal catarrh. No special treatment was adopted
except local remedies to keep the various lesions clean.
No cause was found for the eruption. The patient did
not seem to have eaten anything unusual or anything which
he had not eaten many times before. He could not remember
if he had eaten anything which he had also eaten preceding
one of his attacks of urticaria.
Hurstpierpoint, Sussex.
REPORT OB THB USB OF
FORMALIN SPRAY IN CHECKING INFLUENZA
AT THE GERMAN PRISONERS OF WAR CAMP, ISLEWORTH.
By Angus Wylie, M.B., B.C.Camb., M.R.C.S.,L.R.C.P.,
CAPTAIN, R.A.M.C.; M.O. I/C TBOOPB.
. In the reoent epidemic of influenza among the troops at
No. 1 centre. The College, Isleworth, and among the
Q.M.A.A.C. of the Hounslow, Osterley, and Isleworth area,
I found that the spraying of all billets, mess rooms, and
canteens by a fatigue party of eight men under the charge of
a non-commissioned officer appeared to be followed by an
immediate check in the spread of the epidemic.
At a later date, Nov. 4th, a severe outbreak of the epidemic
occurred among the prisoners of war billeted in the rooms
of a house at Isleworth, in which I had an opportunity of
testing this simple method of combating the disease. The
sprays, three in number, which were used twice daily from
the second day of the epidemic, were Heppel’s hand fly
sprays with a capacity of 1$ pints of fluid in each. Each
spray was charged with 6 drachms of 40 per cent, formalde¬
hyde to If pints of water, making approximately a; solution
and vapour of 1 per cent, formalin.
The table shows the daily strength of the prisoners, the
daily number of cases of pyrexia, fresh cases, and their
disposal. After the removal of the first batch of 15 cases
to hospital on the second day of the epidemic no further
oases were removed to hospital until the fifth day, owing to
shortage of hospital accommodation. Some of these oases
in the billet were severe, but all recovered.
Table of Cases.
Date.
Day of
epidemic.
Strength.
No. of
cases of
pyrexia.
Fresh
oases.
Disposal.
Nov. 4
First.
56
3
Nil.
Kept in billet.
„ 5
Second.
56
15
12
15 eases removed
to hospital.
„ 6
Third.
41
20
20
Kept in billet.
.. 7
Fourth.
41
6
Nil.
ft •«
8
Fifth.
41
3
1
3 ca*es removed
to hospital.
„ 9
Sixth.
38
1
1
Kept In billet.
„ 10
Seventh.
38
2
1
..
11
Eighth.
38
1
Nil.
»* ft
„ 12
Ninth.
38
1 .
Nil.
Nil.
—
Of the 56 prisoners 18 had a normal temperature through¬
out. Two days after the spraying was commenced, on
Nov. 5th, the fresh infections dropped from 20 to nil and the
epidemic appeared to be suddenly deprived of its strongly
infectious character, although single fresh cases occurred
until the eighth day of the epidemic. These results con¬
firmed my impression that the method had been effective in
dealing with the previous outbreak at the College and among
the Q M.A.A.G., and are interesting enough to justify me in
specially bringing them to notice.
Httital Satieties.
ROYAL SOCIETY OF MEDICINE.
Dismission on Shook .
At a general meeting of Fellows of this society, held on
Jan. 23rd, a discussion on Shock was opened by Professor
W. M Bayliss and Dr. H. H. Dale.
Professor Bayliss said: The condition known as *• trau¬
matic,” “surgical,” or “wound” shock, although well
recognised, is difficult to define. It may be said to be a
state of general collapse, associated with low blood presaore,
and the various phenomena dependent on this low pressure,
such as coldness, pallor, sweating, and so on. Perhaps the
most serious consequences of the deficient circulation are
those due to the deprival of the necessary supply of oxygen.
The remarks that follow refer to what is usually known as
“secondary shock,” since it is this that demands practical
interference. The sudden “primary” shock that occurs on
the receipt of an injury is analogous to feinting and is
doubtless of nervous origin. It has its interest and import¬
ance and will probably receive attention in the course of the
discussion. While, indeed, nervous factors are not dealt
with in my short account, their possible cooperation in the
production of the vascular phenomena forming the basis of
secondary shock has to be kept in mind. It will suffice to
mention those causes which have been found, on investiga¬
tion, not to be the agents responsible for the state : arterial
or venous dilatation, heart failure, acidosis, vasomotor
paralysis, suprarenal exhaustion. The low blood pressure
is, in practice, the most important feature of the condition,
since it gives a direct indication for treatment. Indeed, one
may say in general that, both experimentally and clinically,
if the blood pressure is restored the other symptoms dis¬
appear, some with rapidity, others more slowly.
Causation of Deficiency of Volume of Blood in Circulation.
In the course of investigation it has gradually oome to be
realised that the chief, if not the only really important,
factor is a deficiency in the volume of blood in circulation.
This applies not only to that form of shock brought about by
actual loss of blood out of the blood-vessels, but also to cases
where there is no reason to suppose that there h*s been any
great loss of blood. Apart from the fact that the general
symptoms of haemorrhage and shock are very similar, estima¬
tions by the “ vital red ” method of the volume of blood in
circulation have shown that it is decreased in both cases.
The name “ examia" has been proposed by Lieutenant-
Colonel Cannon for the general condition. It is clear that
blood must be accumulated or held up somewhere or other
in dilated regions of the vascular system. Observations made
in the course of abdominal operations give no support to the
view that there is any significant degree of dilatation of the
arteries or veins of the splanchnic area. The region in
question must therefore be that of the capillaries. Observa¬
tions by Colonel Cannon had already suggested that there is
stasis here in wound shock.
But what is it that brings about such a dilatation of the
capillaries ? At an early date in the discussion of the
problem it was pointed out by Major-General Cuthbert
Wallace that operations involving injury of large masses of
muscular tissue were especially liable to produce shock.
Experiments by Colonel Cannon and myself in the beginning
of last year showed that crushing the thigh muscles of cats
was followed by a progressive fell of blood pressure and
other signs of shock. We found that section of the spinal
cord above the origin of the limb nerves did not prevent the
result, whereas clamping of the artery and vein did do so.
Some chemical product of the tissue injury must then be
the responsible agent. This view was confirmed more espe¬
cially by Major McNee’s observations on wounded men in a
state of shock, where it was found that excision of the
injured parts, or even preventing by a tourniquet blood
passing through it from entering the general circulation, was
followed by marked improvement. We thought at first
that the toxic agent might be lactic acid, but experi¬
ment showed injection of this or .other acid to be
innocuous. In fact, “acidosis” turned out to be a negli¬
gible factor in the carnation of shook- It U Ike result.
Thb Lancet,]
ROYAL SOOTBTY OF MEDICINE.
[Fra. 15,1919 557
not the cause, of the lew blood pressure. The real agent
is a much more toxic one. Dale and Laidlaw have
described the action of a base, histamine , which has the
remarkable effect of powerfully dilating the capillaries, but
not the arterioles, and which in larger doses produces a con¬
dition of profound shock. There is reason for believing that
substances of this kind are produced in injured and dis¬
integrating tissues. It was found further that massage of
the injured muscles in the experiments on cats resulted in
accelerated fall of blood pressure, so that we have an
experimental justification for keeping injured parts as
immobile as possible, as is done by the Thomas's splint in
the case of fractured femur. These injury effects are, of
course, intensified by causes tending to depress the
circulation, such as cold, anxiety, fatigue, thirst, hemor¬
rhage, and so on.
Treatment.
The indications for treatment seem obvious. The volume
of the blood in circulation must be increased. While trans¬
fusion of blood itself is the natural means, it is clear that
if a satisfactory substitute, in the form of an artificial solu¬
tion, could be made, it would frequently be of value. No
simple saline solution, whether iso- or hyper-tonic, or con¬
taining sodium bicarbonate or calcium salt, has any per¬
manent effect. The liquid introduced does not remain in
the blood-vessels for more than half an hour or so. To
ensure that it shall not leave the circulation, the addition of
a colloid is necessary. The function of this is to attract water
by its osmq^ic pressure and so to counteract the filtration
produced by the blood pressure. Of those colloids admissible
gum arabic is, on the whole, the most satisfactory. To
correspond with the proteins of the blood plasma a 6 or 7 per
cent, solution in 0 9 per cent, sodium chloride is correct.
8och a solution has been found in practice to serve as well
as one containing bicarhonate or excess of calcium. The
use of vaso-constrictor drugs is to be deprecated. It has
been found that the reserve of haemoglobin is sufficiently
great for recovery to take place even when it is reduced to a
quarter of its normal value. Hence, it would seem that
gum-saline should be effective in the majority of cases. A
reduction of haemoglobin to the extent mentioned implies a
loss of blood of nearly 4 litres in man. It has not yet been
possible to state definitely what are the clinical signs show¬
ing the necessity for blood transfusion, apart from actual
determinations of the blood volume and haemoglobin per¬
centage. Some surgeons state that no case failing to react
tO'gnm is amenable to blood. If, however, the delay between
injury and treatment has been great, no measures avail. The
tissues, especially those of the nerve centres, as shown by
Colonel F. W. Mott, become so far damaged by the low blood
pressure and want of oxygen that recovery is impossible.
In actual practice the following general procedure may
be recommended :—If the patient is cold and fatigued by a
lofig journey, try first the ordinary measures of resuscitation,
such as warmth, water to drink, and rest. If little or no
improvement in half an hour or so, 750 c.cm. of warmed
gum-saline slowly into a vein. This may probably be in¬
sufficient in amount. Therefore, if some benefit in half an
hour, more gum-saline. If no result at all from the first
injection, transfusion of blood if available. But the evidence
on the whole suggests that if gum-saline is ineffective blood
will be also useless, except in the rare cases where the loss
of blood has been more than 75 per cent, of the total volume.
Investigation by the Shook Committee {Medical Research
Committee ).
. Dr. Dale traced the historical connexion of the point
of view arrived at by the Shock Committee (Medical
Research Committee) with work done before the war. The
reflex inhibition of heart and varcular tone, demonstrated
in the classical experiment of Goltz, probably accounted for
the condition of immediate collap»e which surgeons in the
war had called “primary shock.” The more slowly
developed “ secondary shock ” had formed the subject of
the Committee's investigations. When these began, Crile’s
conception of this condition as due to exhaustion of the
v a8omotor centre, leading to arterial dilatation and collec¬
tion of blood in the great veins, was widely held. Oom-
munications from surgeons in France, however,, showed
that the condition of shock as seen in the clearing stations
corresponded rather with a conception which had grown
out of the work of Malcolm, Henderson, Mann, and others,
according to which the essential feature was a deficient
volume of blood in effective currency—an “oligemia,”
This loss of volume was due partly to loss of plasma
from the vessels, as Sherrington and Copeman first
pointed out, but the defect of return to the heart was
not wholly explained by such loss. Lack of tone in
the arteries would not account for such a condition, and
according to the clinical evidence the arteries were con¬
tracted rather than dilated and there was no sign of
accumulation of blood in the great veins.
The Committee had failed to identify any nervous
mechanism by which such a complex qould be produced,
though tbeir failure did not prove that nervous factors could
be excluded. They had considered and rejected the claims
put forward for “acidosis” as a cause. A clue to a factor of
probable importance was given by work carried out by Dr.
Laidlaw, Professor Richards, and the speaker on the action
of the base “ histamine,” the effect of which could be taken
as a type of the effects of a large olass of protein cleavage-
products, formed by autolysis, bacterial action, Ac. Histamine
and substances having this type of action, when injected into
an»8thetised animals, produced the anomalous association of
arterial constriction, with fall of arterial blood pressure and
concentration of the blood by loss of plasma. The output of
the heart failed became the return of blood to it was
inadequate. Analysis of the action of histamine had led to
the conclusion that it caused general dilatation of the
oapillary blood-vessels, and later a morbid permeability of
the endothelium ; the blood tended to accumulate at the
periphery, to become concentrated by loss of its plasma, and
to stagnate in the capillaries, so that the heart and larger
vessels became depleted and a large part of the blood ceased
to circulate effectively. The condition thus described
obviously represented a rapid generalisation throughout the
system of a process which, if occurring locally, would be
recognised as inflammation. The analogy between the
condition of the blood-vessels in shock and that seen in
inflammation was pointed out by Malcolm in 1893.
The Toxeemio Factor in Shook.
The next step was to show that shook could be produced
by absorption from injured tissues of substances having this
type of action. This had been demonstrated by the experi¬
ments of Professor Bayliss and Colonel Cannon, who had
shown that massive trauma of the muscles of a limb caused
shock, even when the nervous connexion with the rest of the
body had been interrupted, but that occlusion of the vessels
to the injured part prevented its occurrence. These experi¬
ments, with their therapeutic implications, had been fully dealt
with by Professor Bayliss. Major-General Oubhbert Wallace
had early pointed out the association between shock and
extensive injury of the muscles. This had been further
accentuated by the clinical observations of Colonel Cannon,
Major McNee, and others. The French surgeons. Qu6qu
and Del bet, had independently reached similar conclusions
as to the importance of a toxsemic element in shock, it
should be pointed out that, though injury to muscles had
figured prominently in war wounds, toxic substances having
this type of aotion were especially abundant in the stomach
and small intestine, and their presence might be significant
in connexion with the familiar association of shook with
injury to, or rough handling of, those viscera.
The Committee were not putting forward this conception
of “traumatic toxaemia ” as a complete explanation of all
kinds of shock. They believed it had been an important
factor in shock as seen during the war. The definition of
shock was by symptoms, not by causation. Probably In
many cases unrecognised haemorrhage and infection played
a great part. In others, causes as yet unknown might be at
work. The Committee believed that they had identified a
factor of which the importance had not yet received adequate
appreciation. The important points for discussion were,
bow far the conclusions drawn from the study of shook as
seen in the war were applicable to the conditions of civilian
practice, and how far the therapeutic measures which bad
proved of value in war were likely to be of similar value In
peace.
Discussion.
Lieutenant-Colonel F. W. Mott, F.R.8., said the invest!*
gafcion of the brain in various conditions of shook was
difficult, and the results of his observations and experiments
regarding the bio-physical and bio-chemical changes seen
2£8 Thb LANCET,] ROYAL SOCIETY OF MEDICINE: OBSTETRICS AND GYNAECOLOGY. [Fra. 15,1019
required confirming by further investigation. He showed,
by means of tbe epidiascope, slides illustrating the vascular
chaoges in (1) shell shock ; (2j shell shock with burial and
probably gas poisoning; (3) extensive burn shock; (4) wound
shook ; and (5) shell shock with cardiac contusion. All the
oases < f shell shock had a great fall of blood pressure before
a fatal termination. The burn shock and wound shock
cases died pult-eless in spite of the injection of gum solu¬
tion. Shell shock brains werecharac erised by haemorrhages
into the sheaths of the vessels and minute scattered haemor¬
rhages ; they were dae to a rupture <>f very small vessels and
the escape of blood into the peri-adventitial sheaths or into
tbe brain substance. In wound shock, shell shock, and
burn shock there was evidence of engorged veins in the
meninges, and in the substance of the brain there was
venous and capillary stasis, with associated marked anaemia.
Mr. J. D. Malcolm referred to his work on the subjeot
in 1893 and 1905 He considered that the conception of
shock as arising primarily from a reflex vascular contraction,
extending from the periphery to tbe centre, fully explained
every change known to take place in the condition. When
tbe vessels became generally contracted the cubic capacity
of tbe vascular syst* m most necessarily be reduced, and so
the quantity of blood in the vessels must be diminished.
One of the constant features of severe shock was profuse
sweating; much fluid escaped from tbe vessels and from
the body generally. He agreed as to the great importance,
in the face of severe hssmorrhage, of giving ample fluid to
compensate for the loss, most usefully when the state of
shook was developing.
Remit* of Clinical Experience*.
Captain Kenneth Walker's remarks were based on his
experience of primary shock, that supervening before the
man's arrival at tbe casualty clearing station, but he devoted
special attention to the points which might have a useful
bearing on civil praotice in the future. The careful and
exaot w»rk during the war on blood volumes carried out by
Robertson and K*rith at the base was mobt valuable in this
connexion; they showed that the volume of blood after
hmmorrhage sometimes fell to 50 per cent, or 60 per cent,
of its original figure; hence the importance of maintaining
-the body’s fluid reserves. The speaker had found that
critical cases made a dramatic recovery from their shock
when transfused with bicarbonate after blood. He did not
think either blood or bicarbonate alone could have produced
the same effect. After the use of these fluids the general
results showed a steady improvement. In judging as to the
value of gum injections, the amount of transport, the degree
of oold, and other difficulties the men had to suffer must be
taken into account. He did not favour the use of the
tourniquet for the purpose of trying to prevent the toxins
from macerated mu*>ole entering the general circulation, as
it caused tbe man so muoh pain that it introduced the
element of nerve shock to complicate the case.
Oolonel 0. J. Bond (Leicester) spoke of the varying quality of
blood sera in different people, with the resultant uncertainty
as to the degree of its action on the red cells and the leuco¬
cytes. He also criticised, on the basis of records of experi¬
ments on animals, the placing of- patients with shook in
the full supine position, owing to its action in impeding the
heart. This was conflrmei by the fact that patients dis-
• tressed with heart disease -naturally assumed the posture of
leaning forward. With regard to the injection of gum in
cases of shook, that had not maintained its reputation
among the officers with the Macedonian Army, but the
difficulties of transport there were certainly very teal.
Dr. 0. H. 8. Frank act quoted figures to show the
unfavourable effeot of cold on these cases, the wounded
eases on whioh tbe observation was made numbering 14.000.
Major-General Cuthbbrt Wallace summarised his
olinical experiences of the cases he had seen during the
war, 8ir Ahbuthnot Lane referred to the importanoe in
•hook of acute intestinal anto-intnxication, and the debate
was continued by Mr. P. Lockhart-Mummery and Captain
H. O. Bazett, who referred to effects of various ansostbetios
and to the necessity for a more general use of oxygen in oases
of shook.
Rcpl* to Point* ranted in the Di*cu**ion.
• Professor Batliss in his closing remarks said : It seems
to ms thtt something more than arterial constriction, as
suggested by Mr. Maloolm, is required to explain tbe
phenomena of secondary shook. It is difficult to realise
how the loss of fluid, caused presumably by the high blood
pressure, is sufficient to account for the large decrease in
effective blood volume, espedallv in view of tbe fact referred
to by Major-General Onthbert Wallace that the tissues are
not particularly moist. Evidence has also been presented
that the arterioles are still constricted even when the blood
pressure has fallen very low.
As regards the absence of marked cyanosis in shook, we
must remember that a very small dilatation of the capillaries,
if widely distributed, may soak up a large volume of blood,
and there is always the possibility that the pale cases may
have lost blood by external bsemorihage. I understand from
Major-General Guthbert Wallace that the majority of cases j
of wound shock seen by him had lost blood and were pale. -
The blue cases were exceptional, but may have lost blood.
Two particular cases, which were blue, had not lost '
blood. I
Captain Walker’s experience with a combination of blood j
and saline is important. It seems to show that the essential
thing is to keep up a good volume of fluid in the circulation. a
I am somewhat surprised that he did not find gum to serve c
this purpose. The advantag* of intravenous injection of gum
over forced fluid by the alimentary canal is tbe rapidity of
its effect—sometimes a matter of importance. When the -
state of shock is due to capillary stasis it has.always seemed
to me that the advantage of gum over saline is that it keeps
up a good circulation until the capillary blood has been . J
restored to the main body of the circulating fluid. Saline *
leaves the vessels too quickly to ensure this; otherwise there
is no obvious reason why it should not serve the purpose
when no blood has been lost by hemorrhage. With reference a
to the bad effects of deficient oxygen-supply in anesthesia,
the question as Ur why they are so lasting is an interestsg
one. It was also the case in the experimental shock ^
investigated by Cannon and myself.
There seems to be no doubt that the cases in Macedonia, ’■*
referred to by Colonel Bond, were not treated sufficiently - J
early. They were all desperate cases. The transfusion of 51
blood was not performed. It has frequently happened that the ^
first dose of gum is insufficient in amount and that a repeti- 1 p
tion effects the desired object. It is remarkable how large ^
a quantity can be given without harm. It is also to be kept <T
in mind that some samples of gum are ineffective, for some *-
unknown reason. I have not found this to be the case is
with that sold as “ Turkey elect,” whioh was used for the
supply in France. The cross-circulation experiment suggested ‘i
by Mr. Lockhart-Mummery would be valuable. But the ' ?
fact that shock is produced by muscle injury in oats when ^
the nervous supply of the limb is cut off shows that there is ^
something in addition to nervous reflexes.
t|
L, 2*
SECTION OF OBSTETRICS AND GYNECOLOGY. ^
fit]
Ditcuteicn on Reoonxtructinn in the Teaching of Obetetrie* mnd ^
Gynaecology to Medioal Student*. * ?
A meeting of this section was held oh Feb. 6th, Mr. J. D. k*
Maloolm, the President, being in the chair. ^
Dr. W. R. A. Griffith opened a discussion on Reconstruo- ^
tion in the Teaching of Obstetrics and Gynaecology to Medical i
Students. He gave a general survey of the subjects to be >
taught and of the methods of teaching them, accentuating *
the importanoe of a thorough training in obstetrics for ^
students of medicine. Gynaecology, he said, was so
intimately bound up with obstetrics that any attempt to
teach them as separate subjects was futile, though there ^
was much in each subject to be taught independently. He .
discussed the subject under the following heads: 1
(I.) subjects necessary to be taught; (II.) methods of *
teaching. ^
(I.) Subject* to be Taught.
The obetetrie anatom# of the peUn* must be taught by the
obstetrician ; the anatomy of the pelvic organ*, not necessarily ^
in minute detail, but with tbe greatest aocoracy. ^
The phytiology of the generative organ*, including menstrua- ^
tion, puberty, and the climacteric, must be taught by the
obstetrician whose experience would enable him to give the C
student a view of its far-reaching importance in health and ^
disease, mental and physical. ^ .
Pregnancy.— (1) Tbe general structural changes In all ^
parts of tbe body affected by pregnancy as weU as the ^
Tn Lanqbt,] ROYAL SOCIETY OV MEDICINE: 0B8TKTRI0B AND GYNJCOOLOGY. [Fib. 16,1919 259
special organa and their functions, by which the symptoms
and physical signs are recognisable in diagnosis. (2) The
general development of the ovum into the mature foetus,
placenta, and other parts. (Minute details of development
are unnecessary in this course.) (3) Morning sickness.
(4) Duration of pregnancy and the prediction of the probable
day of confinement. (5) The various positions of the foetus
and the means for recognising them.
Lab<ntr.—(Y) The general process and phenomena.
(2) The doctors' and nurses' duties in preparation for and
during labour. (3) Anaesthetics and substitutes. (4) Drugs
—ergot and pituitrin.
The Puorycrium .— The process in general, and phenomena.
Lactation; breast-feeding; care of the breasts; doctors*
and nnrses' duties ; doctors’ and nurses' fees.
Pathology.— (1) The pathology of pregnancy, intra- and
ertra-uterine, with the diagnosis and treatment. (2) The
pathology of labour; the treatment of many obstetrical
complications should be taught, not only by methods
applicable when skilled assistance, trained nurses, and the
most approved instruments are available, but in the circum¬
stances when the attendant has to rely on himself and
simpler resources. (3) The pathology of the puerperium.
(4) The pathology of the young infant. (5) Artificial
feeding of the infant.
(II.) Methods of Teaeking.
The means at our disposal comprised demonstration-
lectures, laboratory, museum and post-mortem work, clinical
work, and teaching in wards and out-patient departments.
AU subjects which involved diagnosis and treatment should
be taught during the time that the student was engaged in
his clinical work in obstetrics and gynaecology; instruction
in obstetric anatomy, menstruation, normal pregnancy and
labour should immediately precede this course ; the student
should have completed his course in medicine and surgery,
including pathology with bacteriology, before taking the
special course. He disapproved of the long, wearisome
courses of lectures which were customary in the medical
schools, but considered that good lectures, well illustrated
by personal experience, were of great value to advanced
students. Demonstration-leotures were very valoable, espe¬
cially if well illustrated and with plenty of viva vooe
questioning. The subjects which could be taught well in
this way were the obstetric anatomy of the pelvis and its
contents; menstruation; the anatomy of pregnancy, of
labour, and of the puerperium; and the mechanism of
labour, which should be taught with a foetus, not with the
festal skull only. The whole of the remaining subjects should
be taught by demonstration-leotures accompanying clinical
work in the wards and out-patient rooms.
With regard to gynecology, the large out-patient depart¬
ments of the hospitals, if properly organised for teaching,
afforded valuable means of instruction, the students
attending for three months and having charge of the
oases allotted to them, preparing the notes and examining
the patients individually with the physician. If the
case-taking was done systematically the students would
gradually acquire the power of forming correct opinions
about the nature of the ailment from the history alone: a
very valuable asset to the young practitioner, especially in
gynaecological cases, where the patient might hesitate to
allow him to make a proper examination. This personal
responsibility for forming correct opinions for diagnosis,
prognosis, and treatment could not be inculcated too soon ;
it was an unpleasant experience to have to begin to acquire
it in practice.
Teaching of Obstetrics in Out-patient Departments .
Out-patient obstetric work comprised two distinct depart¬
ments : (1) The attendance by students on patients in their
own homes; (2) the attendance of pregnant women in the
out-patient department of the hospital.
The value of the former to the student was very great.
The responsibility he met with compelled him to find out his
deficiencies on the one hand, and gave him oonfidenoe and
self-reliance on the other. The training in the out-patient
department was also valuable. He learned to diagnose
pregnancy when advanced ; to diagnose the position of the
foetus and the presentation by abdominal and vaginal exami¬
nation ; to measure the pelvis; to recognise and deal with
abnormal presentations and various other complications; to
examine the breasts, and what could be done to relieve con¬
ditions which might interfere with lactation; to examine
the urine, and in doubtful oases to obtain a catheter
specimen; to examine the vulvo-vagina for evidence of
infection, and to take the necessary steps for thorough dis¬
infection and treatment. Above all, he would learn the
value of the systematic examination of all women advanced
in pregnancy and the advantage of being sure that all
important details were normal before confinement, and of
being forewarned of difficulties and complications.
Qytuxcolotjy .—Owing to the abundance of surgical material
at the present time the student learned too little of the
minor gynaecology which would come to him in general
practice, and was induced to take little interest in cases not
needing operative treatment. He learned little of the treat¬
ment of the ordinary common cases of dysmenorrhoea or of
the methods for the relief of cases of inoperable carcinoma,
which he would have to attend to the end.
Organisation of Maternity Wards or Hospitals.
With regard to olintoal means for teaohing obstetrics, Dr.
Griffith said that no branch of medicine and surgery oould
be properly taught in an out-patient department only, espe¬
cially when the department was scattered over an area of,
say, a square mile, with no real and effective super¬
vision and without the aid of competent nursing. Hos¬
pital authorities had provided a few beds for special
oases, but though these were of immense value they were
but a pittance. He thought that the value of a hos¬
pital for teaching purposes was not necessarily in proportion
to the number of its beds; this depended on the number
being adequate and on the ability of those in charge of it
to make the best use of them. At Queen Charlotte's there
was the great advantage of teaching at the bedside and in
the labour wards mixed classes of students, both under¬
graduate and post-graduate, together with midwives and
monthly nurses, and it would be difficult to determine who
gained most from the mixed classes—the students, who soon
disoovered how little they knew of the nurses' duties, or the
nurses, who gradually began to realise their own ignorance
and the difference between their superficial training and
that of the doctors. This oombined training, if general,
would, in his opinion, also do much to place the relations of
doctor and midwife on the friendly footing of mutual confi¬
dence and help that should exist for the benefit of the
poorer women and their infants. The organisation of the
maternity wards pr hospitals in our great teaching centres
should be improved and made comparable to those devoted
to medicine and surgery. A three months’ combined course
in obstetrics and gynaecology, the whole time being given up
to the subjects, would probably prove to be sufficient.
Mr. John S. Fairbairn discussed
The Teaching of Obstetrics and Gynaecologyfrom the Sta nd point
of Preventive Medicine.
He said that he had chosen this aspect of the recon¬
struction of our teaohing methods, because the most
definite movement in medicine was dearly that towards its
preventive side. The proposed Ministry of Health and the
talk of a State Medical Service were indications of how this
movement dominated the situation. The case for reform in
this direction had been greatly strengthened by the publica¬
tion of the Memorandum on Medical Education In
England by the chief medical officer to the Board of
Education, Sir George Newman. He quoted Sir George
Newman’s chief criticism on the teaohing of obstetrics and
gynaecology:
“Above all, the student Is not being taught midwifery from the
standpoint of preventive medicine. It Is not sufficient to require mefce
attendance on 20 cases of childbirth, to be got through somehow.
There are direct and serious responsibilities resting on medical practloe
during the ante-natal stage, at the confinement, and post-natal. The
maternal accidents of confinement, the gynaecological condition^
following unskilful obstetrics, and the Infant mortality incidental to
childbirth must be prevented. The need is insistent and widely
recognised/'
In speaking of the teaching of preventive medicine, Sir
George Newman said:
“ But much more Important win be the revitalisation of the whole
subject of medicine by the experimental, the scientific, and the preven¬
tive spirit. For preventive medicine Is not a subject which oan be
taught ad hoc or in a watertight oompartment. Its pu-pose and Its
spirit should pervade the entire ourriculum and system of medicine—
the practice of phfslc, surgery, obstetrics, psychiatry, pediatrics, and
the other specialities, for they all need the inspiration of the true pre¬
ventive method, yielding a deeper and a wider consideration of each
patient."
Teachers of midwifery and gynaecology had special oppor¬
tunities and, therefore, special responsibilities in this regard.
Midwifery and the diseases of women must be considered
260 ThiLavobt,] ROYAL SOClKTt OF MBDICINE: OBSTETRICS AttD GYNECOLOGY. [Fra. 16,1019
as two branches of one subject and studied clinically
at the same time and under the same teachers. Sir George
Newman made a point of the teaching of the two subjects of
obstetrics and gynaecology being taken together. In this way
the study of the normal and abnormal processes of repro-
duction would go hand-in-hand with the diseases of the organs
concerned in reproduction, so that cause and effect would be
considered together— labour and abortion in the production
of pelvic disease, and pelvic disease in the production of
abortion and sterility. This simultaneous soaking-in of the
two divisions of the one subject was essential if the pre¬
ventive aspect was to be emphasised. In the one the student
was taught how to avoid the injuries and infections of child¬
bed, and in the other was shown their consequences, immediate
and remote.
Hospital Provision for Tracking.
The medical school must provide for the adequate training
of its students. (1) The maternity centre would require
both out- and in-patient accommodation for the pregnant
woman, the woman in labour, aod the mother and nursling.
In maoy hospitals this would involve an increased provision
of beds for maternity work, say five or six beds for
pregnant women, a maternity ward sufficient to allow
each student five or six cases indoors before attending cases
in the outdoor district, and three or four observation beds
and cots for mothers and infants. As this provision for
teaching was absolutely necessary, it was useless to accept
a non possumus attitude from medical colleagues or hospital
committees. The accommodation must be provided if the
medical school was to train the practitioners of the future.
Arrangements might be made with lying-in hospitals. Poor-
law infirmaries, maternity centres, and infant welfare clinics
in the neighbourhood, and the work of the student carefully
organised so that he obtained a proper perspective of the
scheme as a whole. (2) The department for diseases of
women was part of the establishment of every hospital with
a medioal school. Provision should be made for the
reoeption of cases of puerperal infection in all stages, and
for cases of gonorrhoea in the earlier stages, as they were
often withdrawn from the student’s range of vision by being
relegated to a special venereal disease clinic, thus spoiling
the completeness of the preventive view. (3) A full staff of
Workers would consist of (<x) medical officers and the
students; (6) nurses and mid wives for indoor and outdoor
patients ; and (o) almoners and health visitors.
Outline of Requirements .
He then described the atmosphere in which the student
•h'tuld be trained during three months in the practice of
midwifery and diseases of women. He laid special stress on
the student being taught in the clinic for pregnant women
to look for the beginnings of disease and to consider the
individual character, mode of life, and home conditions of
each patient as factors in her case. In the maternity ward
all preventable conditions which occurred were discussed as
to why they were not foreseen and what could have been
done—eclampsia, macerated foetus, or some unexpected
difficulty in labour. All failures as well as successes in
ante-natal management should be emphasised, especially
failures to breast-feed, retracted and sore nipples, and such
points which were not likely to attract the student’s attention
unless specially drawn to them. His interest was easily
stimulated in breast-feeding as an important part of the
prevention of infant mortality, and this was one of the
matters on which pupil midwives, nurses and medical
students could all be taught together.
On the district the student had to adapt methods acquired
under ideal conditions with every convenience to his hand to
conditions quite the reverse—in itself a great education. The
student should be associated in the work of the social side—
obtain reports from it as to his patients, and be encouraged to
make a report to it on ceasing attendance If instructed on
the proper points to observe he might give much valuable
information as to the hygiene of the home, the woman’s
capacity as a mother, whether she followed her instructions
as to the feeding and care of the baby, and possibly be able
to offer suggestions as to special watching of the patient
afterwards A greater effort must be made to interest the
student in the study of the baby, and to keep up the study
long after the infant has passed from the care of the
obstetric department.
This led up to the very important question as to
where the dividing line between obstetrics and pediatrics
was to be drawn. There was something to be said for mother
and nursling remaining under the obstetric departmenbaod
the weanling and older children going to the children's
department The mothers who were patients of the obstetric
side during pregnancy, labour, and lying-in were known and
understood and more readily influenced by its officers;
difficulties in breast-feeding and the overcoming of them
were frequent problems in the maternity ward, and naturally
a continuance of the same interest and supervision was
advantageous. The plan in contemplation at St. Thomas’s
Hospital was that of the appointment of a special officer
for the child-welfare clinics, who would begin by taking
part in the teaching on «the infant in the maternity
ward, where he would become known to the mothers
and learn to know them, and thus preserve continuity
from the maternity clinics to the baby clinics.
The beds for mothers and nurslings need be but few—three
or four should suffice unless the department was very large—
and into them should be admitted cases of difficult breast¬
feeding and such like; they were as necessary for the
student’s education as for the mother’s. The student should
follow the mother and child through the clinics so as not to
lose the practical object lesson in prevention which a com¬
plete survey of the scheme would give him. The student's
time was now so far occupied with work that had a distinct
examination value that he could not spare the time for work
that had only a practice value, and therefore little more
than casual attendance at the welfare clinics could be
expected, except perhaps by a few of the more far-seeing or
specially interested students. Every student should have
a six months’ training in obstetrics, gynaecology, and
paediatrics. The first half of this term would be as sketched
and would be followed by three months in the various
children's clinics.
Creation of Atmosphere of Preventive Medicine.
He drew attention to the "psychological aspect of
preventive medicine, hitherto greatly neglected." We
had become so absorbed in operative work and hospital
accommodation had been so monopolised by operation cases
that our teaching material was in no way representative of
the future practice of our students. The resulting tendency
had been to overlook the most common of all factors in the
production of disability, overstrain and mental stress. In
women with pelvic symptoms such causes as domestic
worries, family anxieties, and marital and sexual troubles
played a very important part. As Sir George Newman said,
"preventive medicine to be effective must deal with the man,
the whole man, as an individual as well as member
of the community.” In short, we must acknowledge
the special responsibility on us to create an atmo¬
sphere of preventive medicine round our teaching, and
for this purpose every medical school must be pro¬
vided with a complete maternity and child-welfare
centre. By cooperation with the paediatric side instruction
covering a period of six months should be continued from
midwifery into child welfare, so that the student, while
acquiring the practice of obstetrics, gynaecology, and
paediatrics, was made to feel that he was playing at any
rate a minor part in a scheme of preventive medicine, the
complete working of which he could visualise.. As the study
of obstetrics and gynaecology brought to the student "new
applications of his clinical experiences, new social relation¬
ships," it was incumbent on us not only to teach the actual
practice of these subjects but to give the student a wider
outlook and to teach him to apply his professional know¬
ledge towards increasing the resistance of the normal
to disease and arresting the progress of incipient disease,
and so raising the whole standard of the health and physique
of the nation’s mothers and children. This involved a fuller
consideration of the social factor, the psychological factor
and other factors affecting the life and well-being of the
individual patient and of the community as a whole.
Dr. Lovbll Drags spoke on
The Teaching of Obstetrics and Gy rue oology from the Point of
View of a General Practitioner.
He drew attention to the increasing demand made upon
the time of the student by the teachers of special depart¬
ments. The time of the student could be saved by
the exclusion of the preliminary subjects of study;
chemistry, physics, morphology, and physiology should
be undertaken previously to registration as a student;
and, until a sufficient test had been applied, registration
TheLancet,] ROYAL SOCIETY OF MEDICINE: OBSTETRICS AND GYNECOLOGY. [Feb. 15,1919 261
should be denied. A very large part of gynaecology
was purely suigical and should be treated as part of the
course in surgery. The subjects to which the teachers of
diseases of women and. midwifery should devote them¬
selves should be just those which were theirs before
surgery arrived at its present state of perfection. The
special importance of a knowledge of the various infective
agents should never be out of the mind of the student,
and would never be if the course in general pathology
bad been sufficiently appreciated. If practitioners would
but consider it a disgrace when they had a case
of infection after delivery there might be a chance of the
practical banishment of puerperal fevers caused by infection.
Knowledge of the infections of the genital tract of women
was of more importance to the general practitioner than a
knowledge of anything else in the whole of the subject of
obstetrics and the diseases of women. Much depended
upon the teachers of the subject and much less on schemes
of teaching. The subjects of obstetrics and gynaecology
were not large in themselves, and three months would he
sufficient time for students to expend on them before
examination at the final Board.
The question now arose—especially in view of the prospects
held out by the promotion of a Ministry of Public Health—
whether all students should be compelled to undertake the
subject before registration as practitioners. Many men did
not intend to practise obstetrics or dabble in gynaecology;
and there did not appear to be any reason why the time
and energy of such should be wasted in cramming up
sufficient knowledge to pass an examination. The
basis for the demand to the medical profession that it
should take up the work of supervision over maternity centres
appeared to be that it was impossible to manage an A1 empire
with a C 3 population. One reason for the statement that
we were a C 3 population was that the medical profession for
pnany years past had successfully prevented the destruction
of the class which in Dame Nature’s scheme was classed as
unfit. In addition, the birth-rate had steadily declined. In
his sanitary district in 1886 there were 220 births ; for the
five years before the war the average was 190, with an
increase of population o£ nearly 2000. The proportion of the
fit to the unfit who are born into the world was probably
about the same as it had always been, but we had by our
attention to the unfit increased the numbers of the unfit who
reaohed maturity. Nature provided, if left alone, a large
excess of increase in our species in order to provide for the
loss of the unfit. The medical profession prevented to a
considerable extent the loss among the unfit, and other
factors had diminished the excess in production. It did not
appear that there was any reason to suppose that the super¬
vision of pregnant mothers would produce any other result
than that of raising up to maturity more unfit adults. The
production of a healthy stock depended upon the healthy
condition of the parents, and resistance to disease de¬
pended upon factors which at present were little understood.
The practical question remained as to whether a large
expenditure of public money was justified in the absence of
any reason for supposing that a larger stock of healthy
children, who had strong resistance to disease, would result.
The Importance of Better Obstetrical Teaching.
Dr. Amand Routh thought that Dr. Drage’s proposal
that general surgeons should perform the operations which
were' now performed by gynecologists would be a retrograde
step. In a lying-in hospital the ante-natal clinic should be
obviously an important part of the training of the students
and mid wives, and should be attended by those actually
engaged in their practical midwifery. Amongst the subjects,
there taught were the recognition of venereal disease and
the recently proved safety of dealing with syphilis by
salvarsan during pregnancy and after birth; the recogni¬
tion of tests for early toxaemia, especially now that
accidental haemorrhage with its 75 per cent, of
fatal mortality was believed to be often toxsemic in
origin, and might be preventable; pelvic contractions,
both the major and minor varieties ; the significance of the
previous maternity history of the mother and her children ;
such complications as heart or bronchial disorders, old kidney
disease, diabetes, Graves’s disease, and pregnancy pyelitis.
Labour, whether natural, prematurely induced, manipula¬
tive. or operative, should be taught in the maternity wards,
and knowledge should be imparted regarding lactation, and
hand-feeding where lactation failed. Students should be
taught to assist in laboratory research of all kinds, such as
special urinary tests for toxaemia, examination of all expelled
products of conception for detection of spirochsetes and
other causes of death, attempts to unravel the mysteries of
toxaemia, and of the functions of the syncytial ferments,
examination of milk, &c. Opportunities should be found
for giving students information on the causes of sterility by
malformations, gonorrhoea, or as the result of operaiions,
plumbism, X rays, &c. ; on the causation of the low birth¬
rate, such as sterility, criminal abortion, and methodical,
chemical or mechanical restrictions of child-bearing. The
responsibilities of doctors in cases of criminal abortion were
useful subjects to learn before private practice began.
In urging the necessity for better obstetrical teachingit was
important to contemplate the fact that out of 1000 conceptions
probably 250 infants died during gestation and before their
first birthday, and that this proportion of deaths was doubled
in illegitimate cases. Dr. Drage’s statement that “medieal
supervision would do no more than raise up to maturity more
unfit adults ” was extraordinary. There seemed every reason
to believe that if the methods advised in the two addresses
were carried out, at least half the ante-natal and early
post-natal infantile deaths would be avo ded, for doctors
would be thoroughly equipped in the knowledge of the
preventive hygiene of pregnancy, parturition, and the
puerperium.
Advocacy of a Radical Change.
Dr. G. F. Blacker said that he had listened to the
remarks of the openers of the debate with much interest,
but he did not think that any one of them had really
reached the root of the matter. He thought that they
should seek an answer to two questions 1. Why was
the standard of teaching in midwifery not of so high a level
as that of medicine and surgery ? 2. Why was the reputa¬
tion of the London School of Obstetrics for research so
relatively poor ? He imagined that this debate was being
held because it was recognised that the teaching in obstetrics
was unsatisfactory, and therefore it was important to
endeavour to find an answer to these two questions.
He thought the answer to the first question was to be found
in the fact that most of the practical teaching was done by
junior men, registrars and bouse surgeons who often bad
become qualified only recently. From the very nature of
the work it was generally impracticable for one of
the honorary staff to be present when patients required
operative interference in their confinements, and a
student mijfht well pass through the whole of bis
midwifery training and never see one of the senior staff
conducting an ordinary confinement or performing any
one of the common obstetric operations. It was impossible
to arrange for practical teaching in midwifery at the bedside
or in the theatre at set hours, and therefore a great deal of
this part of the teaching had to be done by junior men with
but little experience. It was quite easy for senior members
of the surgical and medical staff to carry out teaching at the
bedside, but it was very difficult for the senior obstetricians
to do so. In his opinion, then, it was necessary not to
consider what the student should be taught but how he
should be taught and what changes were possible to over¬
come the present unsatisfactory state of affairs.
It seemed to him that there was only one way out of the
difficulty—namely, the provision of four or more large lying-in
institutions in different parts of London in which, under the
same roof, the student could receive his practical teaching in
midwifery. gyDrecology, and maternity and child welfare.
These institutions should be large enough to provide for all
the medical students in London, and must be officered, if the
Btudents were to be taught properly, by resident whole¬
time properly paid senior teachers. They should be
either whole-time or full-time. By the first he meant
debarred from private practice altogether; by the second,
compelled to devote so many hours a day to their
work and not allowed during these hours to undertake
any other work. They should further have the services
of whole-time paid assistants and all the laboratory
facilities necessary for the proper carrying out of the patho¬
logical work concerned in the treatment of their patients,
and for research work. The present lying-in hospitals
had not, in his opinion, justified their existence so far as
teaching was concerned, they should be closed or amalgamated
with these larger institutions.
262 "*H■ Lancet,] ROYAL SOCIETY OF MEDICINE : OBSTETRICS AND GYNECOLOGY.
[FRb. 16,T9li
The student should be required to spend four months In the
praotical study of midwifery and gynsoology, of which two
should be devoted to gynaecology and two to midwifery.
During his term of duty in midwifery he would be resident in
the institution while on duty in the wards, and he would
spend the second month of his attendance doing duty in
the extern maternity department. In these circumstances
students would receive their teaching from teachers
of equal standing and experience to those engaged in
the teaching of practical medicine and surgery, they
would have ample opportunities of seeing large numbers
of gynaecological and obstetrical cases and at the same time
would be able to attend in the maternity and child welfare
department. It would further be possible to carry out the
students* practical training in the best possible surround¬
ings. The present small number of lying-in beds in most of
the general hospitals were of very little value and were
wasted in most cases, as it was impossible for the students
to live near or in the hospitals, and they were therefore not
available when wanted to attend at emergency operations.
Arrangements of this kind would enable any man who
desired to do so to carry out research work with credit to
himself and to the school to which he belonged, and suoh
a development would be in keeping wiih the schemes which
were on foot at the present time for the appointment of
whole-time paid teachers in medicine and surgery. He did
not think that anything short of this very radical change
would ever succeed in improving the present unsatisfactory
methods of teaching practical midwifery in London.
Further Discussion.
Dr. T. W. Eden placed the responsibility for the poorness
of teaching at the present time on the system of multiple
hospitals. This arose from the over-staffing of the hospitals,
so that each member of the staff of one hospital found it
necessary to seek additional clinical material in another.
Moreover, the clinical material in the hospitals was not
representative of the future work of the students.
- Dr. Bardlet Holland attributed the neglect of the student
to (1) the claims of the midwife, who had absorbed most of
the lying-in beds; (2) the apathy of modern gynaecologists
towards ordinary work ; (3) the idea that it was .unnecessary
to train the student to a high standard if this could not be
maintained in after life. That obstetrics and gynaecology
should be treated as separate subjects was the opinion of a
few, who thought that by this means the obstetrician could
devote more time to the baby; but he would like to see the
infant taken over entirely from its birth by the^psediatriciao,
Who should also be responsible for the corresponding teach¬
ing and research. He disagreed with Dr. Drage with regard
to antenatal supervision. It permitted a diagnosis of the
presentation, and of the presence of syphilis, albuminuria,
tnmours, Ac. Moreover, the mothers suffered from neglect
of supervision as well as the babies.
Sir Walter Fletcher accentuated the importance
iff the teaching of the normal physiology of reproduc¬
tion, including lactation, which at present were imperfectly
understood by the student, even at the time of his quali¬
fication.
- Dr. F. J. McCann advocated State-subsidised maternity
hospitals in London and throughout the country, and the
adoption of the Continental system of whole-time resident
assistants, paid a salary of, say, £500 a year. The appoint¬
ment should be for five years, and the holders should travel
for at least one month annually in order to bring back
reports of the work in other schools. Means must be found
to retain the poor man who had ability. The need had
been accentuated now that the training of midwives and
nurses had to be undertaken. Till suoh hospitals were
established London would not take its plaoe as a leading
teaohing centre.
Dr. E. L. Collis pointed out that now that women were
being employed industrially to such a great extent, the
student should be given definite instruction as to the amount
and kind of work, Ac., which a pregnant woman should be
allowed to do, and should be put in a position to be able to
answer questions which might arise in the course of his work
. as medical officer to a factory.
Other Criticisms and Suggestions.
Mr. Victor Bonnet said that teaching must be judged by
its results. The maternal death-rate due to pregnancy and
labour had remained constant for the past 70 years in spite
of great progress in knowledge. Deaths still occurred from
toxaemia and sepsis. Pregnancy was the growth qf a
neoplasm; labour was the occurrence of self-inflicted
wounds; the puerperium was the healing of those wounds.
A great proportion of deaths cotlld be prevented by the
application of surgical principles. He hoped to see the day
when midwifery would be regarded as a subsection of surgery
and taught as such.
Dr. H. Williamson preferred the clinloal system to that
in vogue on the Continent. Obstetrics and gynaecology
should be studied simultaneously. Each student should be
compelled to train for one month in a lying-in hospital
before doing extern work, and should personally deliver four
or five women under competent supervision. This instruction
was now largely left to mid wives. Every general hospital
should have a lying-in ward, officered by a good teacher who
knew his work. He did not agree that a large institution
was necessary, for it would introduce the German system of
lectures and demonstrations. Students should be examined
by their own teachers, in the presence of an assessor if
thought desirable. The three failures were haphazard
training, fallacious examination, and the absence of ah
atmosphere of research.
Dr. A. Lapthorn Smith emphasised the necessity of
impressing upon the student the importance of examining
the urine to forestall eclampsia, and of wearing rubber gloves
in order to prevent sepsis. He thought that there should be
a great Rotunda Hospital for London with several branch
ones, where thousands of poor women could be delivered by
skilled obstetricians under aseptic conditions, who would
otherwise be confined at home in most unfavourable
surroundings. In time private rooms should be available for
the rich, and the revenue from this source, as well as from
the middle class, and even a little from the poor, would go a
long way towards making these institutions self-supporting.
The deficit could be made up in various ways, such as
bequests and donations. The master would perform the
deliveries in the daytime and the assistant would be in
attendance at night, but every delivery should take plaoe in
the theatre under anaesthesia, and every student in a few
months should have been present at a hundred cases instead of
half a dozen, and have observed the methods of the very ablest
exponents of the art. Each medical school might in turn be
responsible for the service, under the supervision of the
master, who would be elected by all the schools for three or
five years. His reward would be a large consulting practtoe.
Lady Barrett thought that at least six months should be
devoted by the student to the study of the two subjects, of
which at least one month should be spent at a lying-in
hospital, before doing outside maternity work. A month
should also be spent in the combined study of the pathology
and physiology of obstetrics and gynaecology, the student at
the same time keeping in touch with the clinical aspeot of
the work by attending the physician in the wards and
exhibiting the specimens from the cases.
Dr. R. W. Johnstone described the methods of teaohing
in vogue in Scotland. Teaohing, including that of minor
cases, should be done by the senior teachers. He did not
agree with the appointment of a whole-time teacher; the
emoluments would not be such as would attract the best type,
and the teacher, being out of touch with the oondltions of
general practice, would become unable to impart to the
students what they would be likely to require.
Dr. T. G. Wilson compared the teaching of this subject
in London with that of other large centres. With their
valuable olinioal material he attributed their failure to
attract overseas students to a faulty system of teaching.
In such hospitals as the Johns Hopkins there were working
under the head of the department as many as five or rix
assistants, who were only permitted to teach the students after
having acted as assistant for three or four years, and having
done at least one year’s pathological work in the department.
The subject could be taught as well in a small as in a
large institution.
Dr. H. Russell Andrews agreed with the general propo¬
sition that obstetrics and gyn©oology must be taught
together, that old-fashioned formal lectures were not of
great value, and that students should not be sent out to
attend patients in the district until they had had a thorough
midwifery training in the wards. He agreed with Dr.
Lovell Drage that "the medical profession prevents to a
considerable extent the loss among the unfit,” but felt
much more deeply that the medical profession does not
prevent a large unnecessary loss among the fit The only
TmLnran,]
MEDICAL SOCIETY OF LONDON.
[Fbb. 15,1919 263
way to prevent this was by improving the teaching of mid¬
wifery. He disagreed emphatically with Dr. Lovell Drage’s
opinion that supervision of pregnunt women would produce
no other result than that of raising up to maturity more
unfit adults. He pointed out that in cases of syphilis and
in mmor degrees of contraction of the pelvis, to take only
two examples, supervision of pregnant women resulted in
the production of AI citizens. He considered that a depart¬
ment for medical supervision of pregnant women formed an
integral part of a modern teaching hospital.
Dr. Griffith replied. _
SECTION OF PATHOLOGY.
Diffuse Emphysema of the Wail of the Small Intestine.
A westing of this section was held on Feb. 4th, Dr.
W. Bulloch, the President, being in the chair.
Mr. O. A. R. Nitch and Professor S. G. Shattock
described a remarkable example of the above rare coiidition,
which was unexpectedly found daring an operation carried
out for a simple stricture of the duodenum immediately
beyond the pylorus, associated, presumably, with the presence
of an ulcer. The patient bad suffered for many years from
pyloric obstruction, the stomach being so dilated as to reach
the crest of the ilium. He bad been in the habit of washing
out the organ with a soft rubber tube. A gastro enterostomy
was successfully performed, the symptoms completely dis¬
appearing afterwards. A small V-shaped piece of the
affected intestine was removed for the purpose of investiga- j
tion, the parts being immediately sutured without untoward
result. In this the gas oysts were found to lie beneath
the mucosa, the other tissues being here uninvolved. When
exposed at the operation, the whole of the small intestine,
with the exception of the duodenum and the first foot of
the jejunum, was covered with blebs of gas.
The condition itself fell into a group * o which the name
44 pneumatoses ” had been applied 1 —a group which included
the various lesions due to the presence of air or of
gas in the different structures or cavities of the body. Into
ft fell, besides common emphysemas (bacterial and
mechanical), the aspiration of air into the vagina or rectum,
oesophagus, and stomach ; into the peritoneum during lapa¬
rotomy ; the passage of gas from the intestine into the
peritoneal cavity, apart from discovered perforation, in cases
of chronic obstruction, Ac. The entry of air occurring in
operations carried out in the Trendelenburg position upon the
bladder or vagina was due, of course, to the negative
pressure caused by the gravitation of the abdominal viscera ;
in cesophagoscopy, the inflation of the canal arose from the
negative pressure within the thorax. After punctured
valvular injuries of the abdominal parietes a local emphy¬
sema was at times observed (M. Romanis), doe to the
Inspiratory movements, which was liable to be misdiagnosed
as indicative of perforation of the intestine. In birds
Hunter bad pointed out that fraoture of the bones
containing air might be followed by a local emphysema.
The only homologue of suoh a result in the human subject
was furnished by the escape of air that sometimes took
place from the frontal sinus after fracture. .
In discussing the etiology of the condition recorded, a bac¬
terial factor was excluded by the study of sections made from
the piece excised. Nor during life did the tissues exhibit any
traces of inflammation. The oysts or spaces were lined with
a single layer of endothelium, a moltinnoleated cell being
here and there intercalated. After excluding a secretion or
liberation of gas from the tissue plasma as an explanation,
the etiology became reduced to a mechanical one. The
condition oould not be ascribed to distension of the gut
itself, sinoe there was no obstruction on the distal side, but
air or gas must have been driven from the dictended
stomach through the base of an ulcer immediately beyond
tile pylorus, into the Intestinal walls, the peristalsis of the
gut facilitating the onward movement of the gas. Brouardel
(»• Death and 8udden Death ”) had described a case of sub¬
mucous emphysema of the stomach about a recently perforated
ulcer, but proof was wanting that the condition had occurred
daring life. And the same doubt existed in regard to the
case recorded by Haller, in which a tympanitic distension of
the intestine was accompanied with the formation of gas
blebs beneath the peritoneum.
; i J. P. Frank . 44 De Morbia HomJmirn CursndU,” 1821.
MEDICAL SOCIETY OF LONDON.
Intrinsic Cancer of the Larynx.
A meeting of this society was held on Feb. 10th, Major
A. F. Voelcker. R.A.M.C. (T.), the President, in the chair.
Sir StClaik Thomson read a paper on Intrinsic Cancer of
the Larynx, which furnished a sequel to that read before
the same society on Feb. 12th. 1912. Laryngeal cancer, he
said, was not a common disease, but, fortunately, the
intrinsic form was more common than the extrinsic. Of
212 -cases Semon found the disease intrinsic in 136.
Chevalier Jackson's figures showed that the intrinsic form
was more frequent in the proportion of 96 to 43, and
Sohmiegelow, in 66 oases of intraiaryngeal cancer, found the
disease limited to a vocal cord in 36. Only a restricted
proportion of cases came to operation beoause of delay in
diagnosis and sometimes beoause the patitnt did not present
himself sufficiently soon. Hence the amount of clinical
material was always small. In 18 years he bad only
encountered four hospital cases which justified a 1 aryngo-
fissure, while he had performed it 34 times in the smaller field
of private practice. Of these 38 cases of intrinsic laryngeal
cancer which had been operated upon, 22 were alive and
well without recurrence at periods varying from 6 months
to 10 years since the operation. Seven oases survived the
operation but died from other causes at periods varying
from 10 months to 10 years later. Local recurreooe
took place in only 6. Two cases died from recurrence
in the glands, but without recurrence in the larynx.
In one this occurred 7± years after laryngo-fissure; In
the other within 7 months. Two oases are alive, but
recurred. In one the disease recurred in the glands of the
neck 1£ years after laryngo-fissure, the glandB were operated
upon, and he is now well. In the other recurrence was
suspected in the subglottic area and on the opposite side
3£ years after operation.
In these cases, comprising 4 females and 34 males and
varying in age from 40 years to 75, no patient bad died from
a cause attributable directly to the operation. These figures,
taken in conjunction with those of Semon, Ghiari, and
Sohmiegelow, confirmed the view that the results are
exceedingly good and compared favourably with those
obtained by surgical treatment of cancer in other internal
organs, and that the advance was striking. The figures also
showed that the first year after operation was the anxious
one as regards recurrence. He felt considerably diminished
anxiety if the third month passed without a suspicion of
re-growth. When an epithelioma was limited to a vocal oord
and recurred within 12 months, he would regard it as an
incomplete removal. Recurrence was more apt to take plaoe
and after a longer interval when the anterior commissure, or
subglottic area was involved. In none of the 38 oases had
a laryngo-fissure been performed for canoer, and the disease
found to be of another oharaoter, but in several cases the
diagnosis had to be deferred for a time, varying from a few
months to a year.
The Operation,
In. addition to the usual preparations, the mouth and
teeth are rendered as clean as possible and tobaooo and
: alcohol are reduced to a minimum or cut off for thrfee
days before. A dose of bromide (15 to 20 gr.) is given
on the previous evening, but neither morphia nor atropine.
Half an hour before the operation the line of the incision
is infiltrated with eudrenine (a solution of euoaine and
adrenalin). The skin of the neck is purified with soap and
water and a carbolic dressing, and not damaged by painting
with iodine. A general anesthetic, preferably ohloroform, is
given in the usual method. One long incision is made from the
thyroid notoh to the sternum. 10-15 drops of a 2| per cent,
solution of oocaine, to which a few drops of adrenalin
are added, is injected intratraoheally, and a similar injeo-
tion made through the crico-thyroid membrane. Medium
tracheotomy after dividing the thyroid isthmus, if it oannot
be hooked upwards and downwards, can then be carried out
without spasm or cough. A large^sized Durham tracheotomy
tube is then introduced and the thyroid cartilage divided
exaotly in the middle line with saw, knife, soissors, or shears.
A Killian’s median rhinosoopy speculum 1 b then used to
dilate and inspect the endo-larvnx. After applioatiob of
5 per cent, cocaine and the insertion of a gauie plug through
294 Th* Lahcbt,]
BOTAL ACADEMY OF MEDICINE IN IRELAND.
[Fib. IS, 1919
the thyroid opening over the top of the tracheotomy cannula,
the larynx is semi-dislocated sideways to bring the affected
oord more en fane. This is then raised, with all the soft
tissues, by a subperichondrial dissection. The outer peri¬
chondrium of the thyroid cartilage is peeled off and the
greater portion of the ala clipped away, and the growth sub-
seqnently removed, with a good margin around it, with
ourved scissors. Bleeding is arrested by pressure, the tracheal
ping removed, and the thyroid opening closed by drawing
the soft tisanes together over it. Deep (car-gut) and super¬
ficial (silkworm and horse-hair) sutures close the whole
external wound, except opposite the tracheal opening. The
tracheotomy tube having been removed and a dry .gauze
dressing applied, the patient is returned to bed in a sitting
posture. „ ., .
He spoke emphatically of the value of open chloroform
administration in these oases, at first through the mouth and
later through the tracheotomy cannula. Most of the patients
were able to swallow within a few hours and many of them
sat out of bed and read their newspaper the same evening.
It was the exception for the patient not to be sitting up in a
chair next day and eating semi-solid food. . The preliminary
infiltration of the skin incision with eudrenine and the intra¬
tracheal injection of a 2& per cent, solution of cocaine
greatly attributed to this satisfactory result. He preferred
one long incision to the two which had been proposed—-i.e ,
one over the larynx and one for the tracheotomy—consider¬
ing the slight cosmetic gain in the latter procedure more
than counterbalanced by the greater facility and safety of
. one long incision. He could see no gain in abandoning the
safeguard of tracheotomy. There was no need to plug off
the pharynx through the split larynx. In 25 cases
tracheotomy tube had been withdrawn as soon as
the operation was completed, but in two it had to
be replaced for sharp hsemorrhage. He was glad that
in both there had been a preventive tracheotomy, and that
the skin in the neck had not been stitched up over it. He
saw no great objection to retaining the tube for the first day,
particularly when there was a tendency to bleeding at the
time of the operation, or the patient was congested or with
r a history of alcohol and tobacco, or when the growth was
xery extensive or largely subglottic, or should no experienced
surgeon be at hand. Excision of the thyroid ala left no
drawbacks and facilitated removal of the growth and control
of bleeding.
A fter-treatment.
His patients were placed in bed with a bed-rest, almost
sitting upright. The same evening many could sit out
of bed and were able to drink sterilised water. The
appearance of a large granulation in the wound during
healing sometimes caused much anxiety. In 11 cases
it was detected at times varying from 15 days to
2 months after laryngo-fissure. It appeared on the
cicatrising cord or in the anterior commissure. In 4
• oases it was left alone and took from 3 to 12 months
to disappear. Of the other 7 cases he removed it through
toe mouth and under cocaine by McKenzie’s duck-bill
forceps in 5. In one of the remainder it was subglottic in
position and so large that stenosis was threatened, and
tracheotomy had to be done. The tube was worn for six
weeks, after which time the granuloma had disappeared In
tiie other a large granulation, the size of a cranberry,
appeared in the anterior commissure two months after
operation and proved to be an exostosis. It caused little
trouble and was still present two years after the operation.
The patient was 72 years old. Most patients were sitting
out of bed and eating solid food on the day following the
operation. They suffered no shock and recovered rapidly.
, The windows were left freely open day and night. The old
paraphernalia of screens round the bed, closed windows and
“ even temperature,” steam kettles, and such like bad long
, been abolished. It had been his custom to keep the
. patients silent for the first three weeks. They then
started whispering, and as soon as a good cicatricial
oord had replaced the one removed they were not only
enoonraged to speak, but in cases of bad speakers farther
improvement was secured by sending them to a voice
trainer. The voice was always sufficient for the ordinary
purposes of life; schoolmasters had been able to continue
.their, profession and others could make pnblio speeches. But
a ll the. patients had not been kept silent for these first three
weeks, and he thought that by earlier resumption of vocal
use there had been better compensatory results and not that
tendency to contraction which had been observed in two of
the most silent cases. He now thought a week’s silence
was sufficient. If patients applied early with epithelioma
limited to a vocal cord the death-rate should be nil, the
restoration of voice satisfactory, and the cure lasting.
Discussion.
Surgeon-General Birkhtt, C.A.M.C., agreed that fixa¬
tion of the cord was no invariable sign. All most have seen
cases when it was absent.
Mr. Wilfred Trotter said that his practical experience
was confined to conditions extra-laryngeal. He had been
removing the ala of the thyroid cartilage for ten years for
another reason—namely, to obtain access to the upper part
of the larynx—and consequently had removed the ala more
completely, including both cornua. He had probably
removed the whole ala 50 times, and there was no evidence
that it interfered with the recovery of the patient’s voioe.
It was a harmless and very useful procedure. He had never
ligatured or clamped the thyroid isthmus, and no evil
results had followed. Au important reason for dividing the
isthmus was that if the tracheotomy tube had to be removed
the isthmus could not descend over the opening and hinder
its replacement. He had known lives sacrificed in this way
by leaving the isthmus intact.
Dr. W. Hill mentioned a case in which fatal haemorrhage
had occurred as evidence of the value of retention of the
tracheotomy'tube and plugging temporarily, for by this
means death might have been avoided.
Mr. Herbert Tilley had operated upon 22 of such cases.
He thought that this kind of cancer might form a basis
from which some clear ideas might be evolved on the infeo-
tivity of the disease. In this respect cases in which growth
recurred 10. 12. or more years after operation were interest¬
ing. He doubted whether “recurrence” was the proper
term, and queried whether an immunisation took place and
that the so-called “recurrence” followed when that
immunisation wve off. , ^ _
Mr. Irwin Moore advised that the tracheotomy tube
should be left in situ for a few hours if neither the surgeon
nor a dependable substitute were within immediate call.
There was particular risk in leaving a patient with no tube
after low tracheotomy. The results of operation were so
gnod chiefly because the operation was done early and the
diagnosis was established. He hoped for more cooperation
with the general physician in cases of persistent hoarseness.
Mr. C. McMahon offered the following practical suggestions
for re-edncation of the voice in these cases: 1. Develop the
8terno-thyroid and sterno-hyoid muscles, and keep the
larynx low. Use a tongue depressor to help to accomplish
the descent of the larynx. 2. Make the patient speak as
little as possible until a deep pitch of voice is established.
3 Let the breathing movement be inferior lateral costal,
with a small but definite expansion, and let the motive power
of the voice be the powerful contraction of the abdominal
muscles. 4. When the larynx is established in its low
position instruct the patient that voice gets its chief
resonance in the head and chest, and that the throat is a
conduit pipe between them, and must be entirely uncon¬
stricted ; and also that free lip movement increases oral
resonance. If further vocal treatment is necessary the
resonator positions of vowel sounds and clearness of articula¬
tion generally should be taught. It was safe to say that a
really useful voioe could be anticipated in pract i cal l y all cases.
ROYAL ACADEMY OF MEDICINE IN
IRELAND.
Section of Obstetrics.
Endothelioma of the Ovary .— Exhibition of Specimen.
A meeting of this section was held on Jan. 10th, Dr. H.
Jellett being in the chair. .
Dr. J. S. Ashe read a paper on Endothelioma of the
Ovary. He had removed the ovary and had previously
shown the sppcimen to the Academy. Three months after
the ovary had been removed by him and Dr. Purefoy the
patient had become pregnant and was delivered of a full-
term baby, the confinement being uneventful. At the time of
the operation it was seen that the other ovary was small and
atrophic, and he was surprised when she became pregnant.
Dr. R. D. Purefoy said that the affected ovary was
so little enlarged and so little troublesome that it slight very
[Feb. 15,1919 265
Thb Lancet,] REVIEWS AND NOTICES OF BOOKS.
easily have been overlooked. The healthy ovary was so
small and shrunken that its functional activity seemed some¬
what problematical. The return of menstruation and con¬
ception shortly after the removal of the diseased ovary
suggested that some inhibitory action was exercised by the
dise&oed organ.
Dr. H. Jellett said that he did not approve of leaving the
second ovary if the first was known to have undergone
malignant change of any kind, as the danger of a simul¬
taneous malignant condition in both ovaries was too great.—
Sir W. Smyly and Dr. B. Solomons also spoke.
Dr. Jellett showed a pyosalpinx and ovarian abscess
removed from a patient aged 23. who had a double uterus.
The left side alone was affect-d, the right horn of the uterus
and corresponding ovary and tube being quite healthy. The
uterine cornu on the infected side was also removed. The
pus from the abscess contained streptooocci and colon bacilli.
The patient was making a good recovery.—Dr. R. J. Rowlbtte
also spoke.
500 Gmseoutive Operation* at Mercer's Hospital.
Dr. Bethel Solomons read a paper on 500 Consecutive
Operations Performed at Mercer's Hospital. The main con¬
cisions arrived at were that: 1. Skin disinfection was best
accomplished by some reagent which hardened the skin. Ether
followed by iodine was an excellent method. 2. There was less
chance of pulmonary embolism if the patients were encouraged
to move about freely in bed after operation. A lengthy stay
in bed was inadvisable. To prevent pneumonia and pneu¬
monitis care shopld be taken that the patients were warmly
clad going to or coming from the theatre. 3. Curettage,
when carefully performed, was a beneficial operation. 4. Of
the many operations described for the cure of backward
displacement, the modification of Tod Gilliam’s technique,
which he described in the paper, had been found to be the
best. Ventral suspension and Alexander-Adams’s operation
had their indications, and ventral fixation was satisfactory
after the menopause. 5. When it was necessary to treat
sterility by operation it was justifiable to open the abdomen
to examine the state of the adnexa, even though there were
no marked signs of disease. Tubes of normal size with
closed ostia, hydrosalpinges, and very small cysts of the
ovary were often discovered. 6. This paper on imme-
mediate results of operation for gynaecological ailments
was presented as a preliminary to the presentation at a later
date of the remote effects, which were more important. The
percentage mortality was small, the morbidity was practically
nil. and the after-results were excellent. In a large number
of operations for the cure of sterility there were no deaths. By
comparing these results with those obtained by the workers
in radium and X rays knowledge could be gained as to
which was the better.
Sir William Smyly said he believed in the modified
Gilliam operation for backward displacement. Despite the
unfortunate results which had been reported following
ventral suspension, he still did the operation with satis¬
factory result. He did not approve of Alexander-Adams’s
operation, as he liked to see the inside of the abdomen. He
agreed with the main principles of Dr. Solomons' paper.
Dr. Ella Webb asked if the cases of pneumonia were
recent and if pure ether was the anaesthetic employed. She
agreed that great care must be taken to keep the patients
warm in going to and coming from the theatre.
Dr. R. J. Rowlbtte said that a definite diagnosis as to
malignancy in large ovarian tumours was sometimes impos¬
sible. He thought that most papillomatous tumours were
malignant. He suggested that chloroform might be re¬
introduced as an anesthetic when the doctors came hack
from France, and he did not welcome the idea.
Dr. Ashe said that he agreed with the author of the paper
that it was important to exclude the male as the cause of
sterility before operating on the female.
Dr. Jellett considered Alexander-Adams's operation to be
the ideal one for all cases of undoubtedly uncomplicated back¬
ward displacement, but thought that it was contra-indicated
in cases associated with sterility or any possible pelvic
complication.
Dr. Solomons, in reply, said that he had had no recent
cases of pneumonia. Ether, or gas and ether, was the
anesthetic employed in his cases, and he would never permit
the use of chloroform. He thought that many women would
be saved unnecessary operations for sterility if the male
semen were examined.
Jltlrotos snb Jtoiicw of §ooks.
The Physiology of Industrial Organisation. By Professor
J cjles Amar, Director of the Laboratory of Physiological
Research in thn Conservatoire des Arts et Metiers, Paris.
Translated by Bernard Miall. Edited by Professor
A. F. Stanley Kbnt, M.A., D.Sc. With 135 illustra¬
tions. London : The Library Press, Ltd. Pp. 371. 30s.
So excellent a book as this must inevitably be translated
sooner or later. Toe French edition has already been
reviewed in The Lancet 1 ; the translation has been
admirably carried out by Mr. Bernard Miall, who while
retaining the French turn of thought has not failed to write
excellent English. The book has been edited by Professor
Kent, who in addition to writing an introduction has
supplied some useful notes. The shorter hours of work, of
which there are now more than indications, render all the
more important the organisation of industrial work. This
book gives ns a timely exposition and criticism of F. W.
Taylor’s methods of increasing output in factories. Taylor
apparently judged the optimum rate of work by means
of an instinctive knowledge of the appearances of fatigue
acquired as the result of experience; Dr. Amar points
out that observations as to the decree of fatigne pro¬
duced made at a glance cannot replace objective tests
and measurements. In the case of work performed by war
cripples the physiological limitation of great numbers of
persons of this class, the necessity of using them in good
earnest, and the social problem created by their employment
io industry demand a completer system of scientific control
capable of analysing all the factors of human energy.
In addition to describing the methods (derived from
the physiological laboratory) by which he investigates
fatigue he gives practical directions on such matters
as the optimum weight of tools and the best attitudes
of the body for particular kinds of work. The book
includes the result of bis investigations of the scientific
principles involved in the construction of artificial limbs. By
means of his dyoamographic gangway he is able to register
all the phases of support and propulsion, the locomotive
efforts, and the duration of the elements of activity of the
two legs, the normal and the artificial. With the respiration
gauge he measures r.he expenditure involved by walking a
given distance with the model under examination, and by
these two means is enabled to appraise the relative value of
the various makes of artificial legs. The well-known Oanet
mechanic*! arm was constructed as the result of investiga¬
tions carried out under the direction of Dr. Amar. Descrip¬
tions are giveo of several forms of registering apparatus
used for the physical re-education of men with arm stumps.
JOURNALS.
The American Review of Tuberculosis. Baltimore: National
Association for the Study and Prevention of Tuberculosis.
October, 1918. 35 cents.—Of the five original articles in this
number two are devoted to psych io aspects of tuberculosis,
three to treatment by artificialpneuraothorax. The paper
by Dr. Charles L. Minor on. “ The Psychological Handling
of the Tuberculous Patient" is a well written essay on
tact and optimism, tempered by judgment, in the treatment
of the oonsumptive. The author illuminates observations
perilously akin to platitudes by his facile and sympathetic
style. In a paper by Dr. Tohru Ishigami on “ The Influence
of Psychic Acts on the Progress of Pulmonary Tuberculosis "
the opsonic index is used as a guide, and its fall, as aaequel
to psychic factors, is taken as evidence of their ill effects.
More convincing is the author’s observation that psychic
acts often cause transient glycosuria. He has found that
both sugar and adrenalin inhibit opsonio reaotion. His con¬
clusion, based on valuable and evidently laborious research
work, that mental overstrain in youth contributes largely to
the mortality from tuberculosis will be endorsed by many*
The three papers on artificial pneumothorax, by Dr. IS.
Morris, Dr. 8. A. Slater, and Dr. H. F. Gammons, are
typical of the mature and deliberate verdict which most
American specialists in tuberculosis give in favour of this
treatment. The first of these papers deals with as many as
202case8. The second records a case iu which this treat¬
ment proved beneficial during pregnancy and labour. The
third is a plea for artificial pneumothorax in acute tuber¬
culous pneumonia, a oase being recorded in fall to point the
author's argument.
1 Tax Lasost, 1917,615.
NSW INVENTIONS
Jttfar Jnbntibns.
A BED FOR FRACTURES AND GENERAL HOSPITAL
PURP08ES.
Thb bedstead shown in the accompanying illustrations,
devised originally for the treatment of gtmshot wonnds of the
femur, has now been modified so as to ad»pt it for general
hospital purposes. In an earlier improvised form it was used in
the Sonth African and other hospitals in France during 1917
and 1918 ; when officially adopted by the War Office for the
speoial femur hospitals in England it was thought that it
would be both more economical and more satisfactory to have
it manufactured de novo for the purpose and at the same time
to extend its utility. In its new form it greatly eases the
nursing of all fractures, spinal injuries, paralytic oases,
wounds of the back—in fact, of all cases, medical and
surgical, where lifting or rolling the patient is difficult.
buttook, so that the wound o*n be irrigated wit hunt lifting the patient
or wetting the bedding. Other nursing processes are equally faciltta*ed,
and for ra dogra hie purposes one h«a the great adv*nt4ge of b-lng
able to place the X ray tube below the limb and the screen above with
no wire mattress Interrupting the view.
Further to rase matters for the nurse, the can vis sling under the
wound has a quick -release device shown in Fig 5. which does away
with the need lor undoing buckles each time it is used. The movable
section with its quick re ease can, of course, be placed at any part off
i he bed according to the nature of the wound.
Each bed has with it a supply of tubular fittings and
damps of Maddox type, fastening on to the foot and head of
the bed, and adaptable to almost any form of extension or
suspension of the limbs, in wide abduction if required, and
with or without pulleys. The derriok at the head of the
bed and the cranked extension posts at the foot are inter¬
changeable ; all are hexagonal at their bases and fit into
hexagonal cups.
The feet at the top of the bed have large wooden
castors; those at the other end are not wheeled but are
telescopic, so that the foot of the bed can be raised
anything up to 12 inches without the aid of blooka—a*, for
instance where body-weight counter extension is required.
Bedstead stripped, arranged aa lor wide
abduction of right leg.
The sameaa Fig 3, hot with overhead suspension
equivalent to Balkan beam, and with lower end
off bed elevated by means of theteleaoopic legs.
Showing bed arranged as foe fracture of
right leg and right arm.
high, but after many trials of both higher and lower,
experience has shown that this is none too high. Many
have been in use daring the last year, and the unanimous
opinion of nnrses, even short nurses, is that the present
height of 36 inches is the one that suits them best, and
that it Baves them a great deal of fatigue in dressing and
washing the patient. t l L
The essential feature, however, is not the height but the
■eotional nature of the whole top of the bed.
The usual spring mattress is replaced by seven transverse slings
fastened to one side-bar by flat iron hooks, and to the other by straps
and buckles, by which they can always be kept tight. These canvas
slings are 11 Inches wide, meet frige to ed*e, and are kept free from
wrinkles and quite flat by a strip of instil sewn into each end.
The mattresses ehloh rest on top of them are also sectional, hut it is
not neeesaary to have so many; for all ordinary oases we use only one
small Motionil mattress 11 inches wide, the rest of the bed being oovered
by two Army “ biscuit ” mattresses.
For instanoe, in a femur ease the small mattress is put exactly on top
of the canvas sling which lies under the Uriah, immediately distal
to the ring of the Thomas’s splint. When dressings are to be done
the small mattress and its corresponding canvas are released and
dropped, giving free a«*d unimpeded aooesa to tbs back of the thigh ur
Advantages of the bedstead.— To summarise, the chief
advantages claimed are :—
1. Nursing and dressing processes made much quioker and
easier for the nnree and much less painful for the patient.
2. The patient, bed, and suspension apparatus all together
form one self-contained unit, freely movable into the open
air if desired as in fire emergencies.
3. No attachments to floor or ceiling, no structural altera¬
tions in buildings in order to get overhead suspension.
4. Adaptability to general snrgioal and medioal purposes.
5. The greatest advantage by far is undoubtedly the fast
that the patient need never be lifted or moved at all, even
for buttock or rectal wounds.
Because of its height the bed is not suitable for convalescent
patients who get in and out of bed with difficulty.
I am much indebted to a War Office committee for helpful
suggestions regarding the overhead suspension apparatus.
The bedstead here described is a War Office issue and is
made by Messrs. Whitfields, Ltd., Birmingham.
Maurigb G. Pbarsov, M.B., B.So.Lond.,
F.R.O.S. Eng.,
Major, 8 A.M.C.. 0«o«r l/o Fsmur Wards,
Bdmouton Special Military Surgical UuspSaL
T HB Li NOW, 3
MEDICINE, PARLIAMENT, AND PUBLIC.
[Feb. 15, 1919 267
THE LANCET.
LONDON: SATURDAY\ FEBRUARY 15, 1919.
Medicine, Parliament, and Public.
The King’s Speech to Parliament was a dignified
yet buoyant recognition that a new era has dawned
for the world, while it contained splendid assurances
that the aspirations in this country for a better
social order will be encouraged by prompt and
comprehensive action. Among these assurances
the following are second to none in importance:—
“We must stop,” he said, “at no sacrifice of
interest .or prejudice to stamp out unmerited
poverty, to diminish unemployment and mitigate
its sufferings, to provide decent homes, to improve
the nation’s health, and to raise the standard of
well-being throughout the community. You
will be asked to approve a Bill for the creation of a
new Ministry to deal with public health, with a
view to the establishment throughout the land of
a scientific and enlightened health organisation to
combat disease and to conserve the vigour of the
race.”
In direct reply to the speech from the Throne,
Dr. Christopher Addison, President of the Local
Government Board, intimated that at an early
date he would introduce Bills (1) to establish a
Ministry of Health and a Board of Health in
England and Wales and in Scotland respectively,
to exercise functions connected with health and
local government; and (2) to amend the law
relating to the housing of the working classes.
That one of the principal measures lying imme¬
diately ahead of legislation is the institution of *a
Ministry of Health medical men, in common
with the rest of the country, know, but it is not
so certain that the country appreciates that the
administrative work in connexion with the new
bureau will have to be done by doctors, while no
general opinion among doctors obtains, or apparently
can be obtained, as to what is the right way for the
State to avail itself of medical assistance and
advice. There is no consensus of view as to how
the medical service of the country can be best
utilised, and there is no evidence that the country
(loudly as it may acclaim the utterance by
politicians of such aphorisms as “ You cannot
have an A1 country with a C 3 population ” or
"The nation’s soundest asset is sound national
health”) is prepared to set a high value on the
medical work which can turn such aphorisms into
practical aspirations. And this fact may embarrass
the progress of the Ministry of Health Bill, whose
first reading is announced for this week.
A letter which will be found on p. 279 of this
issue of The Lancet goes over old ground, but is
of considerable interest because of the unhackneyed
way in which a big question is dealt with: and it
is a big question, for the author is asking to have
a value set upon the worth to the community
of its medical service, as a preliminary to urging
that proper payment for that service should be
made. And he asks the question at a most opportune
time. Dr. Spence Candy sums up fairly the unfor¬
tunate side of panel practice, and in doing so he
shows that the evils displayed are perfectly
remediable. The inequalities of earning, the pro¬
crastination in payment, and other haphazard
features to which he alludes, should all be capable
of prompt reform, and it will be the duty of those
who lay the foundations of the Ministry of Health
to ensure that such defects no longer occur. But
their duty will go further than this. They will
have to arrange that the whole medical profession
of the country, in consolidated and also in detailed
manner, is rallied to the task of making the work
of the Ministry of Health a national blessing. And
they will have to see that, while interpreting the
desire of the nation to be made healthy under a
Ministry of Health, there is allotted to medical men
a responsible share in the work under conditions
that are consonant with the position of a learned
profession, as well as with the material needs of men
who have lain down under much exploitation and
who seem everlastingly unable to arrive at common
conclusions. How can we obtain an opinion from
the medical profession which shall receive such
support that the Government, in the planning of
the new work, may be sure of our professional
cooperation ? We know from the public pronounce¬
ment made by Dr. Addison, then Minister of Recon¬
struction and now President of the Local Govern¬
ment Boaird, at a public meeting of the medical
profession held in October lastt that the Ministry of
Health Bill has no lineage derived directly from the
medical profession. It is intended to be an assort¬
ment of different departmental responsibilities in
health matters. What we want to know further is
the assortment of responsibilities, opportunities, and
returns which haB been designed to fit the medical
profession as a whole. We need not recapitulate the
circumstances which have called for a coordinate
arrangement of the duties discharged by six or
seven State Departments. All this is familiar
to our readers; what we want to know is, how
the medical profession—the .general practitioner,
the consultant, the specialist,"and the pathologist,
the consulting-room, the laboratory, and the institu¬
tion—can be fitted into the picture. Assuming
that a complete regimented State Service is
not and cannot be intended, at any rate for
the present, there remain several schemes before
the profession which have many points in common.
Two of these, as well as the scheme emanating
from the British Medical Association, have been
published at length, one by Major J. F. Gordon
Dill, senior physician to the Sussex County
Hospital, and one by Major-General Sir Bertrand
Dawson. Major Dill’s scheme is for the establish¬
ment of a State Service of Medicine alongside of
which there would run all opportunities for
private practice with some openings for personal
initiative and for success in accordance with
special characteristics or with the display of
individual talents. Under his scheme the detailed
268 The Lanokt,]
THE DEVELOPMENT OF POST-GRADUATE FACILITIES.
[F*». is, an*
work of any new medical bureau would be dis¬
charged by medical men where medical details
touched the life of the people. In other direc¬
tions Sir Bertrand Dawson’s scheme is full of
valuable promise, for it would give scope for
centralising, around county hospitals as a focus,
the clinical and scientific practice of all large
centres of population in the oountry. Thus imme¬
diately the general practitioner would be brought
into touch with the specialist and the pathologist,
while the officials of the new Ministry of Health
would enter upon a real union with their unofficial
professional brethren. We want now a common
expression of opinion upon these and analogous
schemes, so that progress may be made along
accepted lines.
But how difficult this is to arrive at we see
on every side. The Ministry of Health will
affirm the principle of a State Service of
Medicine by taking over the work of the National
Insurance Commission, which has for its charge
the care in sickness of some 14 million sub¬
scribers; and which provides work of the most
strenuous sort for a large proportion of the
effective medical profession upon terms that are not
satisfactory to many of those who have to do the
work. Some appear to be perfectly satisfied with
the existing conditions, some wish to have them
reformed in certain definite directions, and to some
panel practice is a deadly sin. Again, to nationalise
the hospitals is for some the beginning of reform,
and to others simply anathema. These are not easy
circumstances in which to arrive at a consensus
of opinion. For our part, we hold that professional
differences have been exaggerated. We do not
believe that there need be irreconcilables, but
we are certain that there will be unless the
general plan of the Ministry of Health is laid
down with anxious regard as to what is due to
the medical profession. For we must be the execu¬
tive of the Act, whatever Act emerges. We know
that in the existing Bill provision is made for the
institution of Consultative Councils, and if the
functions of these Councils are well defined—in
other words, if the personnels are carefully chosen
—and if the public is made immediately and
clearly aware of the reasons which determine State
action on medical grounds, these Councils will be a
power for good; but it is absolutely necessary that
the Councils should themselves be able to ascertain
the views of the medical profession as a whole, and
the reasons of general justice and particular wisdom
on which they are based. Dr. Addison, at a dinner
given by the Medical Parliamentary Committee to
the medical Members of Parliament on Wednesday
last, declared his intention of making these
Councils “ bond-fide bodies, real and hard working,”
and it is the aspiration of the Medical Parlia¬
mentary Committee to place the medical profession
in close touch alike with the work of the Con¬
sultative Councils and with the medical Members
t of Parliament. At the same dinner a statement of
the aims before the Medical Parliamentary Com¬
mittee was made, showing its wide constitution
and affirming its hope that from a scheme, which it
is preparing for submission to the medical pro¬
fession, a representative body may emerge, neither
committed to the support of, nor inimical to, any
professional sections, but rather striving to provide
a Bound Table at which these sections can thrash
out their differences.
" He quid nlmU."
THE DEVELOPMENT OF POST-GRADUATE
FACILITIES.
We announced recently that the Inter-Allied
Fellowship of Medicine had arranged with different
medical schools in London for emergency post¬
graduate courses to which men from the services,
the Dominions, United States, and our Allies would
be welcomed. We remind our readers that tickets
for the course, at the rate of £3 10s. for each month,
can now be obtained from the secretary of the
Fellowship at the House of the Royal Society of
Medicine, to which the Fellowship has been given
access.
Alongside of this development of post-graduate
activity the usual post-graduate courses in London
will soon commence, and the course in connexion
with the West London Hospital, Hammersmith, is
now announced. A special eight weeks’ course will
he held at this hospital, beginning on Monday next,
Feb. 17th. The fee for the course is 5 guineas, and in
return the subscribers can attend clinics during the
afternoons of five days of the week, including a
venereal diseases clinic, and can also be present at
operations and at demonstrations in the wards.
Classes in all the usual medical and surgioal
specialties will be arranged in accordance with the
entrances, and in return for special fees. Further
particulars of the course will be found in our
weekly diary.
Our Edinburgh Correspondent sends us the
following information with regard to post-graduate
teaching in Edinburgh, so that in the Scottish
capital a similar determination to develop the post¬
graduate side of instruction has been arrived at.
The Executive Committee of the Edinburgh Post-Graduate
Courses have resumed their activities, which have been
suspended since 1914 owing to a large proportion of the
teaobers having been engaged in war work. In reorganising
the courses the committee have kept in mind the need for
meeting the immediate requirements of graduates who
have for some years been out of touch with civilian praotioe,
particularly of those who proceeded to work in the services
as soon as they had obtained their degrees. Many of these
men, before entering upon the careers they had pro¬
posed to follow but for the war, will desire to revive
the knowledge of those branches of praotioe whioh
have been in abeyance while they have been engaged
with the Navy or the Army. To meet this demand the
committee have arranged to hold during each academic
term a course in clinical medioine and a course in olinioal
surgery, and during the months of August and September
a course in obstetrics, gynecology, and child-welfare. The
instruction will be largely practical, the members of the
courses taking part in the olinical work in the wards of the
Royal Infirmary, Royal Hospital for Siok Children, Royal
Maternity Hospital, and of other institutions. Arrangements
have also been made by which practical work will be con¬
ducted in the anatomical, physiological, pathological, and
bacteriological departments. A series of lecture-demonstra¬
tions will be held in each subject m addition. The olaBses
are open to women graduates. The courses are conducted
under the »gis of the University and the Royal Colleges.
Mr. Alexander Miles, F.R.C.S., is acting as interim honorary
secretary.
We learn also from our Paris Correspondent
that courses of study are being arranged by the
Faculty of Medicine in Paris specially designed for
doctors and students of Allied and neutral countries.
Professor F. de Lapersonne will conduct a course
of ten lessons on Orbito-ocular Surgery, limited to
30 students, in the Amphitheatre Dupuytren (Hdtel-
Dieu), on Tuesdays, Thursdays, and Saturdays, gl
4 P.M., beg inning March 11th. On May 6th will
commence a finishing course in Ophthalmology,
including clinical, operative, and pathological work,
LAhgev.]
NSW HUNTKRIANA.—THK PHYSIOS OF SHOOK.
[Feb. 15,1919 269
conducted by Professor Lapersonne, with the assist¬
ance of Professor Terrien and Dr. Velter, director
of the laboratory. The fee for the first course is
50 francs and for the second 10Q francs, and at the
conclusion of each a certificate is granted.
NEW HUNTERIANA.
Professor A. Keith, in his recent Hunterian
lectures on “ Phases in the Life and Work of
John Hunter,” has undoubtedly succeeded in
throwing a flood of light on the early life of the
great surgeon, whom he compares to Shakespeare,
Newton, and Aristotle. John Hunter was one of
the world’s outstanding geniuses, and research
such as Professor Keith’s continues to add to his
lustre. Yet despite all this, in many particulars
John Hunter’s personality remains dim to us, and
even when new facts come to light we are often
left wondering how he looked and acted among
contemporaries. Thus a new glimpse of Hunter
afforded in the second series of the William Hickey
Memoirs, recently published, leaves us with but a
Bbadowy impression. Mr. Hickey, that delightful
bon invent, got very tipsy, as was his wont, at the
house of his ultra-hospitable friend, Mr. Crane, of
Margate, in or about the year 1780. He played cards
with his friends, but went to doze off the fumes of
wine in front of a roaring fire. He awoke in
excruciating pain and was found to be suffering
from a burnt foot. The burn had gone clean
through a thick “wax leather" boot. The
Margate surgeon, who was at once sent for,
prophesied life-long lameness for poor Mr. Hickey
on the ground that some of the large vessels of
the foot appeared “materially hurt." Mr. Robin Adair
was then summoned in consultation from London,
but as he was out of town and Mr. John Hunter
had “undertaken to act" during his absence the
latter came down to Margate. “ After meeting the
Margate surgeon and inspecting my foot," says
Hickey, Hunter “ at once declared no ill-con-
sequences would arise, and that a few days’ quiet,
keeping my leg in a horizontal position, and fre¬
quently applying an embrocation which he ordered,
would completely cure the hurt, and so it proved."
It is a pity that the garrulous Hickey, who has
recorded such vivid impressions of nabobs and
others once famous, should have left us so much in
the dark as to details of John Hunter’s manner,
mode of address, Speech, and so forth.
We gain no clearer picture from Peter Pindar,
who in 1788 echoed the public’s dislike of scientific
discovery in some mordant lines descriptive of
various leaders of the Royal Society. The satire in
which the lines occur is the well-known “ Peter’s
Prophecy: or, the President and Poet." It takes the
form of a dialogue, with notes, between Sir Joseph
Banks and Peter Pindar (Dr. John Wolcot):—
Sir Joseph:
Hunter with fish intrigues our House regales—
Peter i
The tender history of cooing whales!
Sir Joseph:
Great in the noble art of gelding sows !—
Peter:
And giving to the boar a barren spouse!
Wbo proves, wbat many unbelievers shocks,
That age converts hen partridges to cocks 1
And why not, since it is deny’a by no man
That age hath made John Hunter an Old Woxak?
Believe me, full as well might Papists bring
Quills from a Seraph’s tail, or Cherub’s wing:
Or bones from Catacombs to form new saints.
To oure, like all quack medicines, all complaints !
ouch might the journals of the House reoord,
' As well as Hunter’s wondrous cock-hen bird /
Dr. Wolcot, the son and grandson of surgeons, and
himself for many years a practising physician at
Truro, previously to which period he had been
Physician-General to the forces in Jamaica, was
well acquainted with the movements of science.
Hence his rage against John Hunter must be
attributed to political bias and to his violent dis¬
like of authority, especially as embodied in the
Royal Society and Royal Academy, which latter
corporation in his capacity as art critic he
also skitted mercilessly. But we could wish
that Peter Pindar had left us a portrait of
Hunter as a man similar to his comic satiric
impressions of the personalities of George III. or
Banks. The King, according to Hazlitt, greatly
enjoyed Pindar’s terrible attentions and even
proposed to pension him! Hunter’s rugged sense
of humour should have appealed to Pindar
at all times, but Pindar refuses to describe him.
There is, indeed, in Hunter’s case the Bame careless
or unpremeditated conspiracy of silence of which
we complain in that of Shakespeare. Of John
Hunter, Matthew Arnold might have sung, as he
did of Shakespeare :—
•• Others abide our question. Thou art free.
We ask and ask—Thou smileat and art still,
Out-topping knowledge.”
We look in vain in Mrs. Chapone’s, Mrs. Montagu’s,
or Horace Walpole’s letters, or in Boswell’s pages,
for a pen-portrait of John Hunter or even for an
allusion to him, and, finding none, we are driven to
conclude that for the majority of the diarists and
chronographers of his day he stood “ on earth
unguess’d at.” _
THE PHYSICS OF SHOCK.
Physiologists are apt to complain that their
teaching takes a generation to percolate down to
actual medical practice, or, in other words, that little
or no use is made of experimental research until
the students to whom it is imparted become the
well-established medical practitioner. Some lag is
inevitable, but the complaint in its extreme form
is already out of date, for the physicist is already
having the chief say in one of the most frequent
and urgent circulatory disorders—namely, secondary
i shock. The discussion at 'the Royal Society of
Medicine, of which we give a full report on
another page, ieaves barely a doubt that the most
important factor in the shock which follows severe
injury or surgical operation is not exhaustion of
nerve centres, suprarenal deficiency, inefficient
cardiac contraction, or acidosis—is not even
loss of vascular tone, although any or all
of these things may play their part: it is
simply the small volume of fluid in effective
circulation. The vascular tree is underfilled and
oxygen no longer is distributed to the tissues
in proper quantity. Granted this postulate, the
corollary at once follows that some means is
required of bringing up the volume again to the
required level. Warm physiological saline solution
may be used, but in half an hour it has passed
through the capillary walls, and the condition is the
same as it was. Thus far the surgeon. The
physicist then whispered to him: “ I can tell you of
a fluid which, if you put it inside a vein, will
not come out again. Try a solution of some
colloid with molecules so big that the capillaries
will not let them through their walls." Gelatine
was first tried and given up on the purely acci¬
dental ground that, prepared as it commonly is from
calves’ feet, it was apt to contain tetanus spores.
The physicist then suggested gum, a substance
270 The Lancet,] SOCIAL EVENINGS AT THE ROTAL SOCIETY OF MEDICINE.
[Feb. 15,1919
easy to obtain and to sterilise, adding that in 6 per
cent, solution gum not only possessed the same
viscosity as blood but also the same osmotic
pressure, or, in other words, this gummy solution
introduced into a vein neither impedes the circula¬
tion nor has any tendency to leave the vessels.
Clinical evidence has now abundantly confirmed
the fact that three-quarters of a litre of a 6 per
cent, solution of pure gum arabic injected at body
temperature into a vein is far and away the most
potent agent in dealing with secondary shock.
Its use is not necessarily confined to surgical cases.
We have just received from Sir Leonard Rogers the
text of his presidential address delivered last month
before the Indian Science Congress at Bombay.
Since 1895 he has sought to overcome the collapse
stage in cholera by injecting various fluids. Begin¬
ning with normal saline subcutaneously and per
rectum, he went on to give the same fluid intra¬
venously, he then increased the percentage of salt,
and finally added permanganate and alkali to the
hypertonic salt solution. In so doing the proportion
of recovery rose at each stage, starting from 41 per
cent, and going on through 49, 67, and 74 to the
high figure of 81 per cent, in the period 1915 to
1917. We can hardly be wrong in expressing the
hope that here also a gummy solution may attain
even better results. The whole literature of the
subject may be found in Professor W. M. Bayliss’s
Oliver-Sharpey Lectures recently published 1 in
book form. _
WHISKY AND WATER.
Some years ago there was considerable dis¬
cussion as to what constituted the injurious
secondary products in potable spirits in general,
and in whisky in particular. The popular notion
used to be that fusel oil was a source of
headache from whisky drinking. Chemists im¬
proved the occasion by suggesting that amongst
the toxic products occurring in malt whisky were
aldehydes, certain oils, and bases more or less
eliminated by maturing. The order of the Liquor
Control Board to the effect that no whisky is allowed
to be sold at a greater strength than 30° under
proof seems to have suggested a new light on the
question. Whisky was formerly. supplied at a
strength of about 17° under proof (approximately
48 per cent, by volume of alcohol), whereas at 30°
under proof the alcoholic strength by volume is
about 40 per cent. Grain spirit stands this dilution
without turning appreciably opalescent, but malt
whiskies and blends get turbid, and so filtering has
to be resorted to before bottling the spirit. This
turbidity is due to certain oils and other
substances derived from the malt in distillation,
which are soluble in the old strength of spirit,
but insoluble in that now supplied. There are,
therefore, absent in whisky as it is now provided
certain bodies removed by dilution and filtration
whioh were present in the pre-war spirit. The
outcome is that the whisky of to-day keeps bright
in the glass on dilution with water, with results,
it is probable, that are all the better for the
consumer. The interesting question remains,
What is the nature of the constituents causing
the opalescence produced by dilution and removed
on filtration ? The present circumstances offer
opportunity for determining this point, for there
must be an accumulation of this material in
1 Intravenous Injootlon in Wound Shock. London: Longmans.
Green and Oo. 1918. Pp. 172. 9s.
the filters used by the whisky dealers. Those
who are interested in the chemistry of whisky
might well investigate the question with a view of
throwing a light on the nature of these materials
and of determining their physiological action. Such
an inquiry might settle old vexed questions as to
the toxic bodies in whisky, other than alcohol.
Diluted whisky, subsequently filtered from the
opalescence which forms, is thought to be more
wholesome (if that word can be applied to the
drinking of spirits at all); this belief may find
scientific explanation when the substances which
cause this opalescence have been investigated. Or
does the fact that less alcohol is being consumed
in the whisky of to-day account by itself for the
increased wholesomeness ?
SOCIAL EVENINGS AT THE ROYAL SOCIETY OF
MEDICINE.
In spite of the unfriendly meteorological condi¬
tions and the failure of transport facilities, the first
social evening held at the house of the Royal Society
of Medicine on Wednesday, Feb. 5th, was the un¬
qualified success of a function attended only by
those who wanted to be there. Sir John Bland-
Sutton gave the discourse on Gizzards which we
printed last week, and he afterwards demonstrated
specimens with much humorous detail. The
Library was open for informal discussions, and a
number of Dominion medical officers were present.
During the evening two noteworthy cinema films
were thrown on the screen, the first showing
the circulation as a going concern, the corpuscle?
traversing the capillary network in the frog's
lung being specially effective. The second film
depicted every stage in the inoculation of a rabbit
with the Spirochceta pallida and the cure with
salvarsan injection. The spirochetes were well
seen in movement on the screen under dark-ground
illumination.
An attractive series of discourses is announced
on successive Wednesdays at 8.30 p.m. at the Social
Evenings. Sir Arbuthnot Lane took Stasis as his
subject this week. Next week Dr. Norman Moore
will deal with English Morbid Anatomists. In the
weeks that follow Sir William Osier will discourse
on Sir Thomas Browne, Dr. Henry Head on Disease
and Diagnosis, Mr. W. G. Spencer on Larrey and
War Surgery. A cordial invitation to attend these
Social Evenings is extended to medical officers of
the various services, and especially to those from
the Dominions, the United States, and Allied
countries temporarily in this country.
WORD8 CAU8ING PHY8ICAL INJURY.
Judgment was delivered recently by Mr. Justice
Avory in the case of Janvier v. Sweeney and Barker.
The plaintiff, a Frenchwoman, claimed damages for
nervous shock and injury to her health caused by
certain statements made to her by the defendant
Barker,assistant to the defendant Sweeney, a private
inquiry agent. The plaintiff's case was that Barker,
in order to obtain through her intervention certain
letters written by a deceased officer to a lady living
where Miss Janvier resided, told the latter that he
was a police officer and that she had been corre¬
sponding with a German spy, and that the fright
and agitation resulting from this accusation had
made her ill. The jury, in answer to questions
put to them, found that Barker had used the words
imputed to him, that they were calculated to
ThkLancbt,}
LARYNGO-F IS8UBB AND CANCER OF THE LARYNX,
[Feb. 15,1919 271
erase physical injury to the plaintiff, that they
were made maliciously, and that the plaintiff
had been made ill by them. Damages of
£250 were awarded. Argument took place as to
whether as a matter of law words, even when
causing physical injury, could be actionable, except
in the case of defamation, and whether there was
evidence justifying the jury in finding that the
injury suffered by the plaintiff was the result of
the statements above referred to. Mr. Justice
Avory held with regard to the first point that false
statements, if they cause physical harm, afford
ground for an action at law in respect of such
harm, and gave judgment in her favour against
both defendants for the damages above mentioned.
In view of an appeal a stay of execution was granted.
LARYNGO-FISSURE AND CANCER OF THE LARYNX.
The history of the operation of laryngo-fissure is
interesting. Originally suggested by Desault in
1812, it was performed for the first time by Brauers,
of Louvain, in 1833, for a papillomatous growth.
This operation was carried out without an anes¬
thetic, without a preliminary tracheotomy, and
before the days of laryngoscopy—a bold and
brilliant performance. The first record of a
laryngo-fissure for a malignant growth, and with
the protection of a tracheotomy, is that of Gordon
Buck, of New York, in 1851. But for the eradica¬
tion of cancer it failed at first to succeed. In his
first 8 cases even a great surgeon like Billroth had
6 recurrences. Morell Mackenzie condemned it.
Paul Bruns recorded 19 cases, of which only 2
survived a year, and cod eluded, in 1878, that “ the
attempt at radical extirpation of cancer by means
of thyrotomy had proved itself completely unsatis¬
factory and worthless.” A curious and interesting
part of the history of this operation is that
three of the pioneers in establishing it were at
first very hopeless about it. In 1883 Bhtlin wrote
that “ the crease is far too deeply seated to admit
of removal by so slight an operation”; as late as
1886—only 33 years ago—Semon formed the opinion
that it should not be attempted; and Moure (of
Bordeaux) concluded that thyrotomy appeared a bad
operation in established laryngeal cancer. This
was in 1891, and yet, before the century finished,
laryngo-fissure had given results which rivalled
those for cancer in any other part of the body.
Professor Schmiegelow of Copenhagen (another
of the pioneers of this subject), stated in our
columns on August 1st, 1914, that “ the whole of our
present knowledge of the diagnosis and treatment
of this disease is founded on the work of Semon
and Butlin, who, towards the end of the last century,
entirely revolutionised our views with regard to
the malignancy of intralaryngeal cancer.”
How well this revolution has been consolidated
can be seen by reference to the paper on Intrinsic
Cancer of the Larynx read at the Medical Society of
London (see p. 263) by Sir StClair Thomson. He
produces evidence to confirm his conclusion that if
patients applied early with epithelioma limited to a
vocal cord and are operated on by laryngo-fissure,
then the death-rate should be nil, the restoration
of Voice satisfactory, and the cure lasting. This
remarkable change in 30 years has been achieved
by improved skill in early diagnosis, and increased
perfection in surgical technique, and both of these
are the result of such cases being handled by expert
laryngologists. Further, the study of Sir StClair
Thomson's account of his cases suggests that from
such work we obtain help in elucidating the wide
subject of the whole etiology of cancer. Recurrences
are dealt with. A cancer may appear in the same side
of the larynx 5 to 15 years after a laryngo-fissure.
Or that side of the larynx may remain healthy and
an epithelioma may start in the opposite cord 13
years later. Or it may show on the opposite side
of the tongue 3 years later. Or the larynx may
remain quite free from disease and yet the patient
may die from cancer of the stomach 8 years after
a laryngo-fissure, or from cancer of the rectum 18
years after a successful operation for the same
disease in the larynx. Can these be called 44 recur¬
rences ” ? Are these not entirely fresh new
growths ? What is their connexion, if any, with the
original vocal cord cancer ? What is this tendency
to cancer? These histories should stimulate our
scientific imagination to new researches. Anyhow,
the operation of laryngo-fissure for intrinsic cancer
of the larynx, which was condemned by some of its
own pioneers 33 years ago, has since achieved such
successes that, as Chevalier Jackson says, 44 nowhere
in the whole realm of the surgery of malignant
diseases have such results been obtained.”
THE COLLEGE OF AMBULANCE AND THE
FUTURE OF THE V.A.D.
Last year 1 we endorsed the appeal of Sir
Rickman Godlee and Sir James Cantlie, the
President and Principal respectively of the College
of Ambulance, Vere street, W., for funds in order
that the College might have an assured income
and be enabled to carry out in peace time the
immeasurably useful work which it has done
during the war. As .we then pointed out, there
are many ways in which the College can help to
preserve human life. One of these ways was
admirably demonstrated on Saturday last, when the
County Director, Lieutenant-Colonel J. F. Badeley,
paid an official visit of inspection to the College.
Sir James Cantlie gave a demonstration—in reality
a repetition on an enlarged scale of that which was
given in May last a -—illustrating the means by which
improvised methods of first-aid might be success¬
fully applied to accidents on the farm. The keynote
of the method was simplicity and the adaptation of
materials at hand for stretchers, splints, and dress¬
ings. Colonel Badeley said that up to Dec. 1st, 1918,
there were 1168 Red Cross hospitals and 245 hospitals
under the control of the Order of St. John. The
Voluntary Aid Detachments controlled by these two
organisations numbered 3138 and 985 respectively,
the total personnel being nearly 300,000. Although
the Red Cross Society had accomplished the work
for which it had been called into existence, it
would be impossible to revert to a pre-war footing.
In addition, the voluntary workers desired in some
way to continue their services to the country for
which they had been trained. For this purpose
he suggested that the charter of the British Red
Cross Society should be enlarged in such a way that
the organisation might undertake welfare wdrk.
This, he said, would demand a corps of trained
workers, together with a body of part-timers, who
would find employment under the various care
committees now in existence or about to be formed,
and in other ways. Some V.A.D. workers could be
trained for the higher technical posts of inspectors
of factories, health visitors, Ac.; there would be
welfare secretaries at headquarters and a secretary
1 The Lahokt, Deo 14th, 1910, p. 823.
* The Laxost, May 26th, 1918, p. 758.
-THE FUTURE OF WESTMINSTER HOSPITAL.
[Bn. 15,1919
L/2 TnLAMif,]
in each borough, who would attend to requisitions
from the local workers. The men’s Y.A.D. might
form a brigade to be available for epidemics,
accidents, and on ceremonial occasions. Colonel
Badeley concluded by stating that the ingenious
display which Sir James Cantlie had provided
should be seen by everyone throughout the country.
CLINICAL MEETING OF THE BRITISH MEDICAL
ASSOCIATION.
The special clinical meeting of the British Medical
Association has now been fixed for four days,
Tuesday, April 8th, to Friday, 11th, and a provisional
programme has been drawn up. The meeting will
divide into three sections: medicine, surgery, and
preventive medicine with pathology—the three to
run concurrently. In the section of medicine,
influenza, venereal disease, and prognosis in
cardio-vascular affections will be the principal
subjects discussed. In the section of surgery,
gunshot wounds of the chest, wound shock, and
reconstructive surgery take the premier position.
Influenza also figures in the section of pathology
along with the dysenteries and malaria. Demon¬
strations in all the three sections cover a wider
field and include a time-table of visits to general and
special hospitals. The war collection of pathological
specimens at the Royal College of Surgeons will be
on view daily during the meeting from 10 to 6.
THE FUTURE OF WE8TMINSTER HOSPITAL.
We understand that at a meeting of the Governors
of Westminster Hospital next week a resolution
will be considered recommending amalgamation
with King’s College Hospital, the reasonable
reservation being added that the name, identity,
and traditions of the Westminster Hospital shall be
fully and permanently preserved in the combined
institution. The resolution, it will be seen, puts in a
sentence the result of long negotiations. Eight years
ago the principle of removal was adopted at a meet¬
ing of the Governors of Westminster Hospital, when
under a provisional scheme a site at Clapham
came under consideration and was eventually
purchased, a proposal for amalgamation with
St. George’s Hospital having broken down. The
altered conditions of finance and labour brought
about by the war led, however, to a recon¬
sideration of the intention to migrate to Clapham,
with the result that on the one hand many
objections were raised to the rebuilding of the
institution upon the site at Clapham, while
strong arguments were found for amalgama¬
tion with King’s College Hospital. The main
objections to the Clapham scheme are: (1) that the
site is not completely ready, inasmuch as various
purchases of adjacent properties remain to be
made, and (2) that the cost of labour and materials,
already excessive, would make it imprudent to
expend the greater proportion of the available
capital in building a small hospital—for the Clapham
project had in view a hospital of only 300 beds.
There are, moreover, at Clapham voluntary institu¬
tions meeting the urgent needs of the immediate
neighbourhood. The arguments in favour of
amalgamation with King’s College Hospital meet
the objections to the Clapham scheme. An amal¬
gamation with King's College Hospital will result
in the transformation of two institutions, neither
of which is wealthy, into a single first-class
modern hospital, and it is agreed on all
hands that .no new hospital with an attached
medical school should be built in the metropolis,
having less than 500 beds. King's College Hospital
is already installed in part of its new buildings at
Denmark Hill and by amalgamation with West¬
minster Hospital these buildings can be completed
and extended to the full dimensions of a first-rate
teaching institution. And perhaps the strongest
argument of all in favour of a junction of forces
between Westminster Hospital and King’s College
Hospital is that in this manner a really strong
medical school would be secured. The prospects of
a medical school attached to Westminster Hospital
as an institution of 300 beds on Clapham Common
must be regarded as very unfavourable. By joining
forces with the medical school of King’s College
Hospital a large school should soon arise affiliated
to a first-class modern institution.
PERFORATION IN CANCER OF THE 8TOMACH.
While perforation is common in gastrio ulcer it
is very rare in gastric cancer. Writers give
statistics varying from about 2*5 to 6 per cent,
of the cases. In the American Journal of ike
Medical Sciences for January Dr. J. Friedenwald
and Dr. A. McGlennan have published an important
paper on the subject. In a series of 1000 cases of
cancer of the stomach there were only 23 cases with
signs of perforation, and in only three of these was
perforation demonstrated. The process of ulcera¬
tion is 8low>allowing time for the development of
adhesions which wall off the general peritoneal
cavity, so that perforation occurs into a protected
cavity and a chronic abscess is produced. The
following is an example:—
An emaciated negro, aged 53 years, was admitted into
hospital with a nodulated mass below the right costal
margin. He had suffered from nausea and vomiting for
three months. To the left of the middle line and above
the umbilious was the soar of an operation, at the lower end
of which was a gastrio fistula, through which milk was
discharged in a curdled state about an hour after ingestioQ.
Carcinoma with perforation of the stomaob was diagnosed.
After three days the patient died from exhaustion. At the
necropsy oaroinoma of the pylorus with metastases was
found. The fistula passed from the stomach through the
cancerous mass to the abdominal wall.
Acnte perforation may occur in gastrio oanoer.
The following is an example:—
On August 3rd, 1906, a woman, aged 62 years, sought advice
for indigeston of three months’ duration. There warn
nausea, occasional vomiting, and gastric pain not related
to the taking of food. A hard mass was felt at the oentre of
the epigastrium. Operation showed a oarotnomatous main
involving the pylorn9 and nearly half of the body of the
Btomach. On aooonnt of metastases in the mesenteric
glands and liver no attempt at excision was made. Gastro¬
enterostomy was performed. The patient was able to take
nourishment better for a time. On Deo. 10th she was
seized with intense abdominal pain, which was followed by
symptoms of shock—rapid pulse, clammy extremities, ana
cold perspiration She died within a few hours. The
necropsy showed a large perforation in the middle of the
cancerous mass at the pylorus. The gastro-enterostbtny
opening was patent. _
Sir Anthony Bowlby delivers the Hunterian
Oration on British Military Surgery in the Time of
Hunter and in the Great War at the Royal College
of Surgeons of England to-day (Friday), being the
anniversary of Hunter’s birth.
The Arris and Gale lectures are to be delivered at
the Royal College of Surgeons of England by Mr.
Edred M. Corner on Feb. 19th and Mr. E. M. Co well,
Lieutenant-Colonel, R.A.M.C., on Feb. 21st, at
' 5 p.m. Mr. Corner has ohosen as his subject the.
Nature of Scar Tissue and Painful Amputation
Stamps. Mr. Cowell will deal with, the Initiation
of Wound Shook and its Relation to Siwgiaal Shook.
tiW,)MR. T. O. HILL: BIOLOGY AMD
BIOLOGY AND THE MEDICAL
CURRICULUM.
By T. G. Hill,
m&DKK LB PLANT PHYSIOLOGY, UNIVERSITY OK LONDON,
UNIVERSITY COLLEGE.
.. All licensing bodies wisely require a medical student to
pass an elementary test in biology (or botany and zoology),
chemistry, and physics before permitting him to take his
examination in anatomy, physiology, and pharmacy. For
very many years botany has been taught to medical students
since, in the past, it has been of direot importance. Zoology
was introduced later in order to provide a knowledge of the
methods of anatomy and to form an introduction to the
detailed anatomical study of the human being.
The direct value of botany for the most part has dis¬
appeared at the present time, and, in view of the changes
proposed in the teaching of botany to elementary students,
the present is a convenient opportunity for raising certain
questions regarding the instruction of medical students in
biology.
Deficiencies in Organisation and Teaching.
It will be generally conceded that biology has a high
educative value and also is the obvious means of providing
a preliminary training in the methods and technique which.
form bo important a part in the student’s future work. At
the present time instruction in botany and zoology is given
in the Universities by the staffs of the two departments, so
that a medical student attends lectures and practical
classes in botany and zoology, the two subjects being, in
the majority of cases, uncoordinated. In the larger medical
schools, on the other hand, there is usually a lecturer
on biology who instructs in both branches of his science ;
the student at the medical school, therefore, has the
advantage, but not infrequently the teacher is under the dis¬
advantage of having fewer facilities for teaching. It is not
the present intention, however, to deal with medical schools
in particular; but, from wide personal experience as a
teacher under both systems, to point out some of the more
outstanding deficiencies which obtain in organisation and
teaching.
Since medical science is a branch of biology the import¬
ance of general biology—not botany and zoology as such, but
a general introduction to the knowledge and study of life
and an education in the methods of biological work—in the
preliminary medical sciences cannot be over-estimated. The
exact amount of actual knowledge gained by the student is
immaterial provided be thoroughly understands what he
knows and is able to apply the principles learned. In a
phrase, education rather than mere information. This is, of
ooonae, realised ; vividly by some, dimly by others, and
efforts have been made to bring the more ideal state of
affairs Into being. For example, in the first examination for
medical degrees in the University or London, which replaced
the older Preliminary Medical Examination, the syllabus has
been much cut down and, instead of separate examinations in
botany and zoology, papers are set in general biology. The
success of these experiments has not been oonspiouous, nor
will be until certain reforms are carried out.'
' Suggested Reforms .
The first reform is that the medical students must have a
special course of instruction, not a bowdlerised edition of
the instruction given to students in the Faculty of 8oienoe.
This course must be general biology treated as one subject;
it sbould not be resolved into its components botany and
zoology. Clearly this is not possible unless the instruction
be given by a professor or a lecturer, with an adequate staff,.
who must be held entirely responsible. In other words, he
must be independent of other departments of biology; be
should be of the Faculty of Medicine rather than 0 f the
Faculty of Science.
H may be argued that it will prove a very difficult matter
to find teachers of any standing to undertake the work and
that, nowadays, no biologist has the time to keep abreast of
the details of botanical and zoological research, and so on.
These are but minor difficulties. When it is understood that
there is a high and worthy object in view, the proper people
will be forthcoming, provided the terms of appointment are
attractive; it is, for example, an anomaly that the lecturer
THE MEDICAL CURRICULUM. [Feb. 16, 1919 273
on biology in a medical school should be paid a much lesser
salary than the leoturer in chemistry. Other difficulties would
speedily disappear if the right candidate were selected. •
The medical student must be taught the principles of
biology. Morphology, for example, must be thoroughly
understood; this does not necessitate a large selection of
types, the average syllabus contains quite as much material
as is requisite. Physiology is most imp »rtant, and every
advantage should be taken of plants simply because the
main vital functions can be more easily demonstrated with
plants than with animals. Further, it is all-important that
the study of function should go hand-in-hand with structure.
The medical man must in practice always associate function
and structure, and the sooner this habit of mind is formed
the better. As it is, the relegation of physiology to a week or
so at the end of the course is all but valueless in training.
With regard to practical work, it is to be remembered that
in addition to mental education, the education of the hand
and the eye is all-important. A high degree of skill in dis¬
section and in the preparation of objects for microscopic
examination should be insisted upon. A student should be
absolutely at home with the microscope and should be able
to use the microtome. All should be able to write a
description of a preparation or other object in clear and
simple language and illustrated by dear and accurate
sketches.
It does not always appear to be realised what parts of the
subject are of direct value to the student in his subsequent
studies. To take an example: much too little attention is
paid to fundamental facts of the anatomy of plants. Sections
of stems, roots, and leaves are all very well, but are of no
value without a knowledge of the actual tissue elements.
The study of macerated material, judging from examination
results, would appear to be dying out. 1 remember being
asked by a pathologist, a very highly qualified man, to
examine some milk films, as they showed curious bodies
which he had never before seen. These bodies weie nothing
more than lignified vegetable d6bris—oell walls, protoxylem
rings and spirals; in brief, the milk was contaminated from
an obvious source.
With respeot to physiology, there is reason to suspect
that ip many oases the apparatus Is put up and the experi¬
ments performed by a demonstrator. This is quite wrong,
students should themselves set up their experiments as far
as is possible and should invariably perform them. Further,
the reason for all negative or peculiar results should be
ascertained. A few carefully selected experiments actually
set up and observations made by the students themselves are
worth hundreds of demonstrations performed by the teaobsr.
In other words, the teacher should act in an advisory
capacity.
It is not infrequently stated that no reform can be made
owing to the examination system ; if this be so, the sooner
the system be reformed the better. Examiners are to ascer¬
tain what a candidate knows and wbat he can do. and
whether be has a sufficient equipment to proceed with his
studies. If examiners gave more credit for the practical
examinations and less for the theoretical a great improve¬
ment would very quickly result, especially in a subject like
general biology, where the number of possible questions for
the written papers, as judged by the published papers,
appears to be limited.
PARIS.
(Fbom our own Correspondent.)
Proposal for a Centred Health Department.
The Commission of Hygiene of the Chamber has adopted
a report drawn up by Dr. Navarre in favour of the forma¬
tion of a Ministry of Public Health, under the direction of
which would be placed all the health services, both civil
and military, of relief and public hygiene. The idea is
not a new one, having been advanod by a number of
deputies more or less suspect of coveting the post of
executive officer. Possible occupants of the post are,
indeed, numerous. The present medical staff is not
unfavourable to the idea in view of the fact that the varidus
services of hygiene are distributed among all the Ministries,
each occupying a subordinate position without right of
Initiative or liberty of action. At the Ministry of the
274 ThiLakor.]
PARIS.— IRELAND.
[Fra. 16.1019
Interior there now exists the important directorate of
hygiene and of publio relief, both these services
being nnder the same administration; and this is a funda¬
mental mistake, for many questions of relief are un¬
connected with hygiene and are more often closely
related to finance and especially, unfortunately, lo party
politics. The most serious fault of the present system is
that it entrusts the carrying out of hygienic measures to the
usual agents of the Ministry of the Interior, the mayors and
the prefects. The former dare not apply the penalties of the
law to infringements committed by their electors in order
not to displease them ; the prefects are prone to the same
indulgence, also for political reasons, while the deputy of
the department intervenes in favour of his own faithful
doctors. I have known the closing of an oyster bed, known
to be contaminated by a leaky sewer, deferred so as not to
influence the district unfavourably on the eve of an election.
So long as hygiene is left to the Ministry of the Interior
it will not be applied in the face of the formidable political
influence ruling there. The teaching of medicine and of
hygiene is in the hands of the Minister of Education, as also
are sohool hygiene and physical culture. Food hygiene and
the supervision of the control of qualities of foodstuffs
which are injurious to health belong to the Minister of
Oommerce. International sanitary conventions and the
organisation of the struggle against pandemics occurring in
different countries are in the domain of the Minister of
Foreign Affairs. The question of wines, alcohol, tobacco,
where hygiene is involved, the hygiene of the State manu¬
factures, appertains to the Minister of Finance, The hygiene
of the railways and the disinfection of carriages belong to
the Minister of Public Works. Accidents occurring in
industrial life are in the purview of the Minister of
Labour. Medical jurisprudence is under the Minister of
Justice. Finally, the Minister of War and the Minister of
Marine have each their special State service. Oovious
inconveniences result from this dispersiou of effort. Two of
the*e are : a personnel too numerous and often incompetent;
undue delay in the solution of problems which, as often
happens, concern many Ministers at the same time. It is this
administrative anarchy which it is proposed to end by the crea¬
tion of a single Ministry to centralise the scattered services, of
which the chief alone would retain the right of being consulted
when a question of hygiene arose which concerned him.
The Ministry of Public Health, when set up, would have the
power of carrying out its decisions by its own agents, all
recruited from among those who are both competent and
well-fitted for their particular mission. Recently a press
campaign has been conducted demanding the creation of
this new ministry, and suggesting handing over to it as a
nucleus the Under-Secretariat of Hygiene created since the
war at the Ministry of War. A first indication in this
direction lies in the fact that it is this particular Under
Secretary who has introduced to the new Chamber the Bill
aiming at official organisation of the anti-inhereulosis
campaign.
Hygiene and the Frenchman's House at Hit Castle.
The Council of State has just given an important decision
on a hygienic matter in which doubt arose in the interpreta¬
tion of the law declaring a private house to be inviolable
save only to the officers of justice. The Mayor of Toulouse
has informed the people under his administration that, for
the purpose of forming a sanitary house inventory, officers of
the Bureau of Hygiene would attend on all the premises to
draw np a survey. He added that all who refused admittance
would render themselves liable to summnry conviction.
Manv property owners saw in this demand an attack on the
inviolability of the private domicile, and addressed a resolu¬
tion on the subject to the Council of State. The Council
decided that the right of ordering the inspection of property
in a commune to determine whether its hygienic arrange¬
ments are satisfactory already belongs to the mayor by virtue
of the very liberal powers vested in him by the law of
Feb. 15th, 1902 (Protection of Public Health). The exercise
of such powers would be, however, in many cases rendered
nngatory without examination of premises. The establish¬
ment of a sanitary inventory does not, in the Council's view,
impose any special restraint on private property.
The Reerudeteenee of Rabies in Pa*is.
I have already called attention to the increase of rabies
among dogs in Paris. This iLcrease has now become
alarming, and M. Martel, chief veterinary surgeon to the
Prefecture of the Seine, has pointed out to the Academy
the grave danger which threatens. In the Paris area 411
cases of rabies were reported in 1918, and 61 during the
first 25 days of the month of January just past; compare
this with the 3 or 4 cases per annum with which we h*d to
reckon in 1913 and 1914. 350 bitten people have attended
the Pasteur Institute, and several deaths have ocourred,
three of which are recent. Stray dogs withoat leash or
muzzle are numerous in Paris. The disease is thought to
have been carried by dogs abandoned by tbeir masters la
the war zone, and by others which have escaped from the
camps established near Paris to test the effect of the new
asphyxiating gases. M. Martel demands the application of
strict police measures : all dogs should be numbered, regis¬
tered, and obliged to wear a collar with a medal attached
certifying that the tax has been paid by their owners; in
addition, they should all be muzzled. Stray dogs should be
ruthlessly collected by police agents and brought to the
special depot {La Fouriere) to be destroyed if not claimed
within a week.
Feb. 10th. _
IRELAND.
(From our own Correspondents.)
Medical Reform for Ireland .
The dilatoriness of the Government in putting forward
any scheme of health reform for Ireland parallel with the
Ministry of Health Bill for Great Britain is causing ener¬
getic protest on the part of the various medical corporations
and organisations in Ireland. The need for reform is
admitted on all sides, lay and medical, and, indeed is far
more urgent in Ireland than in Eagland, inasmuch as
Ireland has bad lir.tle or no part in the sanitary
progress of the last 50 years. Ireland still stands where
England was a generation ago. It is held here, not
only in medical circles, that the mere application of
the English Ministry of Health Bill to Ireland, or even
the establishment of a special Ministry of Health for
Ireland, would be of little avail. Conditions are so backward
that thoroughgoing medical reform must go hand-in-hand
with the establishment of a Ministry of Health. The
reform must include the unification of the Poor-law
Medical Services and the medical services given under
the National Health Insurance Acts, the establishment of
medical inspection of schools, the provision of medical .and
dental treatment of sch k>1 children, the reform of the entire
hospital system, the development of a thorough sanitary
system, and the endowment of medical research. Such a
scheme of reform should constitute an important part of the
work of national reconstruction. In this connexion it is
interesting to note that both the Irish Reconstruction
Association, under the presidency of Sir Horace Plunkett,
and the new Centre Party, have appointed special com¬
mittees to report on the problem of health reform, while
the latter organisation has adopted health and housing
reform as one of “the planks of its platform." Medical
opinion in the country is also taking steps to make itself
felt. The Riyat College of Physicians of Ireland has had the
matter under consideration, and at its last meeting decided
to invite the other medical corporations and the various
voluntary medical organisations in the country to unite in
a joint deputation to the Chief Secretary, if he should be
willing to receive it, in order to persuade him of the urgency
of the problem of health reform in its bearing on the
welfare and happiness of Ireland.
Sir William Wkitla , M.P.
Sir William Whitla has resigned his position as senior
physician to the Royal Victoria Hospital, Belfast, and, having
been thanked for his services, has been placed on the consult¬
ing ntaff. He is also about to give up the chair of materia
medica at the Belfast University, a professorship held by
him since the year 1890.
The Royal Victoria Hospital , Belfast.
At the nsual bi-monthly meeting of the Board of Manage¬
ment of the Royal Victoria Hospital, Belfast, held on
Feb. 5th. a communication was received to the effect that
Mr. Evelyn Cecil, Secretary-General of the Chapter of St.
John of Jerusalem, would present to the hospital the
273 Thb Lancet,]
THBWAB AND
[Fn. 15,1819
Major (acting Lieut.-Col) WILLIAM ALFRED GORDO79 BAULD,
dan. A.M.C.—For oonsplouou* gallantry and devotion to duty during
mounted operations from Oct. 8t h to lltb, 1918. He was in command
of the advanced cavalry field ambulances. On the nlght.of Oct. 9tb-10tb.
when ordered to search and dear the wounded from three villages,
which were being heavily shelled and the approaches badly damaged by
craters, he organised the evacuation of the wounded, making certain
that all were found and removed. He showed great coolness and
energy.
Major DONALD DUNBAB CRUFTS. Aust. A.M.C.—On Sept. 1st,
1918, during the a*tack at Mont St. Quentin, although the R.A.P. was
con latently shelled, he attended the wounde.l almost continuously for
58 hours, during five of which he was forced to wear his gas respirator,
displaying throughout the greatest courage and devotion to duty. On
the day prior to the attack a shell burst on a dug-out, wounding
several men and pressing one down, severely wounded, blocking the
entranoe. He immediately went forward, regardless of intense shell
fire, and succeeded in extricating the man and removing him, over
exposed ground, to the rear.
Maior GEORGE WILLIAM HALL, Can. A.M.C.—For conspicuous
gallantry and devotion to duty. During the action in front of Arras,
from 8ept. 2nd-6th be was in charge of the evacuation of wounded.
Time and time again he went t hrough heavy enemy shell and machine-
gun firs to direct the clearing of the wounded. On the afternoon of
Sept. 2nd he succeeded in clearing a number of wounded who were
being shelled with gas shell to a place of safety, and dressed many
wounded under heavy fire, flls work throughout the battle was
admirable.
Temp. Capt. (acting Major) HUGH ROSS MACINTYRE, M.C.—For
conspicuous gallantry ana devotion to duty during operations on the
PSave between Oct. 27th and 29rh, 1918, especially on the morning of
the 27 h when In charge of stretcher^ bearers. He crossed to the right
bank of the Plave immediately bebini the infantry under very heavy
fire, and supervised the collection and evacuation of the wound-d
under great difficulties, having to ford the river several times. He set
a very fine example to all under him by his untiring energy and total
disregard for his own safety.
Lieut.-Col. JAMBS HARDIB NBIL, N.Z.A.M.C.—For conspicuous
gallantry and devotion to duty during operations near Bapaume and
Banoourt from August 23rd to Sept. 3rd, 1918. He was in command of
the ambulance and constantly visited the forward R.A.P. under heavy'
■hell fire, and selected positions for the bearer relay poets. During toe
action round Banoourt he went forward with two light ambulance cars
to within a few hundred yards of the front line and supervised the
evacuation. It was owing to his gallantry and persona! supervision
that the evaenation of the wounded was so successfully carried out.
Gapt. PATRICK J03BPH FRANCIS O’SHBA. M.C., Aust. A.M.C.—
For conspicuous gallantry and devotion u> duty near Chuignes on
August 23rd, 1918. Keeping up with the advance, he was always in
the hottest part of the line dressing wounded and organising stretcher-
bearers. Realising that an R.A.P. could not cope with the casualties,
he dressed them where they lay and made prisoners carry them back.
In many castes he carried men book himself under heavy fire of all
descriptions and working in gas-drenched areas. He hid no rest for
three days and nights, and did another medical officer’s work as well as
his own.
Temp. Capt. (acting Major) PHILIP RANDAL WOODHOUSE, M.C.
—For conspicuous gallantry and devotion to duty in command of a
bearer division. On Sept. 27th, 1918, at Mai son Rouge, wh-n loading
wounded on an ambulance wagon It was damaged tnd an ammunition
dump close by set on fire by heavy shelling. He at once got the fire
ont and evacua ed the wounded to safety. On two other occasions he
did good work under heavy shell fire, clearing a road which* was
blocked by a tree blown across it find also in evacuating wounded when
his A.D.S. was hit by a shell.
Third Bar to Military Cross.
Temp. Capt. CHARLBS GORDON TIM US, M.C.—For oonspionons
gallantry and devotion to duty near Gambral on Oct. 1st, 1918. Daring
a severe enemy barrage, when his O.O. was wounded, heat once took np
a squad of stretober-bearers Into the barrage to tbe rescue, tending his
wounds and seeing that he was conveyed to a plaoe of safety.
Second Bar to Military Cross.
Temp. Capt. (acting Major) GEORGB BOYD MoTAVISH, M.C.—
For conspicuous gallantry and devution to duty west of Vlllera Gntslaln
from Sept. 19 h to 27th, 1918. He worked for eight days and nights,
refusing to be relieved, walking constantly through heavy barrages and
machine-gun fire, organising bearer squads on tbe whole divisional
front. Although gassed he still carried on, and siwed the life of an
officer who was knocked over by a shell when he was talking to him,
holding an artery until help eame, he himself having been knocked
over by the same shell.
Bar to Military Cross.
Capt. JOHN BRNBST AFFLECK, M.I., Can. A.M.C.—For con¬
spicuous gallantry and devotion to duty during the fighting east of
Arras, Aug. 26tb-28th, 1918. Hi* work was carried out under con¬
tinuous shell and machine-gun fire, and many times he led his bearers
olose up to ihe front line, collecting seriously wounded men. By hie
cool judgment and energy he was enabled to get all the wounded under
Temp. Capt. (acting Major) JOHN CRAWFORD, M.O.—In the area
north of Ypres occupied by Belgian troop* on dept. 23tb-30th, 1918. he
was conspicuous for his indefatigable efforts In evacuating the wounded
from six field batteries and ten T. 9. hatcerl s. During the advance he
was constantly we'l ahead, with complete disregard <or his own aaf-ty,
under heavy shell-fire, and by his initiative and organisation all the
wounded were evacuated smoothly and rapidly.
Capt. WILLIAM DON tLD, M.C.—For conspicuous gallantry and
devotion to dutv during npeiatl ns against 8ugar Loaf and Tbetassel on
Sept. 18th and 19th, 1918. He went fearlfssly forward umer the
heaviest fire to rescue wounded lying in front of • he enemy’s positions
By bis onurage he set the finest example to bis BTetcer-bearers, and
was frut umen>al In saving many Uvea. He worked unceasingly tor
tb^ee days, and refused to rest until all wounded had been brought in.
Capt. O dARLBS MARSH GOZNBY, M.C.—For conspicuous gallantry
and devotion to duty during th attacks on Happy Valley and MolsUlns
between August 24nn and Sept. 2nd, 1918. He showed great initiative
in moving his aid-poris forward and keeping in touch with the
advanced troops. His arrangements for the evanuat'on of the wounded
were splendid, and he undoubtedly was responsible for the saving oi
many lives.
Ttemp. Capt. FRANCIS HBNDERSON, M.C.—For conspicuous
gallantry and devotion to duty at Masnieres on Oct. 1st, 1918. He worked
under heavy fire throughout the day and cleared the battlefield all
through the night. Hearing that two officers of another division were
lving out severely wounded, he made his way to them under heavy
shell fl»e, dressed them, and brought them safely in. His work through¬
out was magnificent.
Capt. KENVBTB ARTHUR MoLEIN, M.C., Aust. A.M.C.-On
August 31st, 1918, near Clery. tbe battery was heavily shelled, two men
being killed and two badly Injured. He immediately went to the
battery and commenced dressing one man wbo cou'd not be moved. He
continued his work until one shell burst close to him, wounding htm
severely in tbe arm and mortally wounding the stretcher-bearer who
was assisting him. He showed marked courage and devotion to doty.
Temp. Capt. HENRY LBS LIB MESSENGER. M.C.—For conspicuous
gallantry and devotion to duty on Sept. 18th. 1918. near Doldejeli. He
led a party of stretcher-bearers some 400 yards across the open through
a heavy barrage, and succeeded in rescuing and bringing in a large
number of casualties to his advanced post. The next dav he established
touch forward with the attacking battalions under beany artillery and
machine gun fire. Throughout the action he showed the greatest
energy and disregard of personal danger.
Capt. DUNOAN ARNOLD MORRISON, M.C.. Can. A.M.O.-For
oonautcnnua gallantry and devotion to duty during the operations on
8ept. 2nd and 3rd, 1918, between Gagnicourt and Buiaav, when he kept
in touch with four infantry battalions, repeatedly going up and dovro
under heavy fire, hastening the evaouatlon of the wounded. He was
untiring in searching for any who might have been overlooked and
directing the bearers in their duties. His coolness and judgment
helped on the evaenation enormously.
Capt. (acting Major) WILLIAM BARRY POSTLBTHWAITB, M.C.
— v or conspicuous gal antry and devotion to duty on August 22nd,
1918. in clearing casualties at tbe crossing of the Anore river. On
August 25th. 19i8. he had great difficulties in the advance beyond
Pricourt, owing to heavy shelling, but by a daring reoonnalssanoe
found a comparatively safe track for evacuating the wounded. On
August 30th, north of Qomblee, after searching all night, he again
found a practicable evacuation route. His endurance and initiative
were beyond praise.
Oapt. (acting Major) JOHN GRAY RONALDSON, M.C.—For oon-
spionous gallantry and devotion to duty In the operations near Oambtai
from Sept. 18th to 30th 1918. He was in charge of the be ire-s olearing
the dlvislo al front, and during the whole period he was living under
heavy shell fire, including gas. Through casualties to M.O.s, he bed
only one officer left to help him, but by constantly visiting the front
posts he cleared all casualties and his cheerfulness kept up the spirits
of the bearers.
T*mp. 0«pt. (acting Major) WILLIAM RUSSELL. M.O.—For con¬
spicuous gallantry and devotiou to duty whilst in command of bearers
near Ballleul on Augnst 22nd and 24th and Sept. 3rd, 1918. He eon-
sta tly visited a 1 1 tbe R.A.P. by day and night, often under considerable
s’>ell and machine-gun fire and disposed his heare*s and ambnlaaoe
oars with suoh skill that all wounded were collected and placed in the
most favourable condition* for recovery with the utmost oeierity. Ister
he was gassed by a direct hit on his A.D.8., but continued to evaouste
wounded until his relief arrived.
Capt. CBORI1 MURRAY SAMSON, M.O., Aust. A.M.0 -On the
morning of August 22nd, 191«, north of Chlpllly, on the Bray-Corbie
Road, he took a car along to the R.A.P. in npite of heavy shelling and
gas. He superintended the line ot evacuation continually, taking freak
squads up to R.A.P. through heavy fire. Again, on August 31st, he
dressed a wound* d medical officer and his orderly in tbe open, being
wounded while doing so. During tbe period August 20ti-31st, 1918,
his fearless energy and devotion to duty were responsible for the rapid
evacuation of so many wounded.
Capt HUGH KINGSLEY WARD, M.C.—For conspicuous gallantry
and devotion to duty on July 10th, 1918, when, after an Intense bom¬
bardment of several hours, tbe enemy at aoked the battalion sector
eapt of Neuport Bains. During the bombardment he went no t»the
front line and remained in attendance «>n a badly wonnded officer until
he died. He wss subsequen ly wo mded while attending another
officer, but continued looking after many other wounded men until he
returned to the dressing station, when he worked for over tw > hours to
the open, and when the enemy approached he stood outside to prevent
them bombing the wounded.
•
The Military Cross.
Capt. HUGH WAN3RY BAYLY.—On Sept. 16tb, 1918. at Baude-
mont, when tbe village was heavily bombarded. In spite of the fact that
he himself was ill he remained at his post dressing and attending to
the wounded, and throughout a trying period he disp eyed admirable
composure and disregard of danger.
Temp. Capt. (acting Major) JAMES BIGG AM—For conspicuous
gahaotry and devotion to duty. On the night of Oct. 3rd-4th, 1918. he
carrie 1 important messages to alvancad c electing poets at Jonoourt,
the road being under neavy machine gun fire and bombing from air¬
craft. On the night of Oct. 9tb-l0th be carried out an exhaustive
reconnaissance of roads and villages under heavy shell fire. His
untiring energy was worthy of great praise.
Llent. GHORGB BDMONOSON BIRKBTT.—For conspicuous
gallantry and devotion to duty throughout 8ept. 15th and 16th, 1918.
during operations south of Mai«*emy. Working under heavy shell and
machine-gun fire he brought in several wound*d men. Tne enemy shot
down many stretcher-beatvrs and stretcher parties on the 16th. but
this officer worked indefatigably and continued to search for and
bring in wounded until he was wounded in the spine by a sniper ou
the 16ch. By bis personal oourage and energy he undoubtedly saved
many valuable lives.
ThbLanoet,]
THE WAB AND AFTER.
[Feb. 15, 1919 277
Temp. Gapt. DtNIHL HIOfliflL BiOHAN.—For conspicuous
gallantry and devotion to duty daring «he attack on the “ P ” Ridge on
dept 18* b 1918. Having established an aid poe r and dressed a very
laige number of caeualttee, he moved forward with stretehe^bearere
lofrnit. of the line and brought In wounded from the mont exposed
positions under trenoh-mortar an 1 machine-gun fire. He worked
continuously from dawn to dark, togardlett of pers >nal danger.
Outt. (now Major) JnHN ALPRBD BRIGGS. Can. A.M.O.— During
the fighting east of Arras, August 26-<£tb. 1918, this officer worked con-
ttooously. On many occasions he led his stretcher-bearers forward
close np to the front line under heavy shell and machine-gun fire to
diem and evacuate wounded. Althou«n blown np and bruised by a
shell he refused to leave, and remained on duty. He set a fine example
of gall «ntry and devotion to duty.
Oapt. (acting Mgjor) HBOTAR MAOKAY OALDBB, D.S O.-Por
conspicuous courage during operations between August 22nd and
Bspt. 8th. 1418. in the region of Happy Va'ley, north of Bray, and at
Mots lain*. He did most valuable work evacnatlng wounded under most
strrna<'us conditions, and during the many peri«<ls of heavy shelling his
aetlrtng zeal wan a p werfnl stimulus to all ranks.
Oapt. PKBDERICK THOMAS CAMPBELL. Gan. A.M.O -For con¬
spicuous gallantry and devotion to duty. During an advance on the
&nal du Nord on 8ept. 3»d, 19 1 8, the battalion suffered heavy oasualtle*
from shell fire and as It was Imprac^O'b e to evacuate the wounded he
went np and attended to them under heavy fire. Throughout four days
he w«s conspicuous for hit disregard of fatigue or danger, and un¬
doubtedly saved many lives by bis efforts.
temp. Oapt. GRAHAM WILSON 0HRI8TIB.—For conspicuous
gallantry and devotion to duty during operations on Oct.. 1st and 2nd,
I9U*, near Ghelnwe. He dressed the casualties of the advanced guard,
utter heavy shelling and machine-gun fire. During 36 hours he
evacuated over 200 wounded from different units, working continuously
without rest. His skill and qulukne-a undoubtedly saved lives.
Oapt. LEWIS PI BBS OtUTHOHIl L, Gan. A M.G.-During the
fighting east. of Arras, August 26th-28th, 1918, he was continuously on
dvty under heavy shell fire, and had absolutely no relief during the
whole period. He kept In touch with all his R.A.P. and was responsible
lor the rapid evacuation of hlo wounded from the forward line. His
zeal sad devotion to duty were admirable.
Temp. Capt. AILWYN HBBBifKT GLABKB.—For conspicuous
gallantry and devotion to dnty on Oct. 10th. 1918, abont two miles
oerth-west of Le Gateau. He several times pruoe-dwi und*r heavy
shelling to the sunken road south-east of Bamhourlleux Farm, to
attend to wounded. He succeeded In dressing all the wounded under
heavy fire, and got them carried away to safety.
Gapt. BBKBBKT AUGU8TU8 GOGH BANS, Gan. A.M.O.—On
Sept. 2nd, 1918, when the battalion attacked the Drooonrt-Qneant
line, although wounded two days previously, he remains i at duty and
established a dressing station well forward* before zero hour. Shortly
after the start of the attack he dressed several oases undvr heavy
barrage and continued forward, dressing many wounded in the open
under machine-gun fire. He worked all day, continually exposing
himself, and his gallant oonduot undoubtedly saved a great deal of
soffeiiig.
Capt. PBBOERICK BRBOKBN DAY. Gan. A.M.C.-On Sept. 2nd.
MI8, near Arras, for mat ked gallantry and devotion to duty. During
the course of the hatt'e he made many trips un <er heavy machine-gun
•Id-post, not only those of hts own battalion but also of at least five
other battalions and many wounded of the enemy. It was without
doubt due to bis exertions that the wounded were oleared so qulekly,
and many Uvea were saved thereby.
Temp. IJeut. CHRISTOPHER DEAN.—For conspicuous gallantry
and devotion to duty a<- Holnon f uring t he operations of Sept. 17th and
19th 1918. Although suffering from a sprained ankle, he was untiring
la hi* efforts to collect and attend wounded. He wm constant ly exp< sea
to shell fire, but took no notice for himself, though he mace nil
stretcher-bearer* take cover.
Temp. Oapt. FRB DERICK ROBERT DODGAN.—On August 26th,
1918, near Mametz, when thlt offloer wae clearing an Infantry brigade,
the Sussex Regiment was held up in a valley, the only exit from which
was in full view of the enemy. Throughout the day this offloer
lepestedly brought up squads of bearers and superintended the removal
of the wounded unoer continued heavy fire. Had It not been for his
personal courage the wounoed of the battalion could not have been
for many hours. On another oooas on he personally led a single
•Quart under heavy fire in order to bring In a wounded N.O.O. of his
«wn bearer division.
Temp. Capt. JOHN MVLYILLH ELLIOT.—For conspicuous gallantry
•od devotion to duty u der heavy fire when in chargeot stretcher-bearers
on 8ept. 18th-19th, 1918. He took squads backwards and forwards from
A.D.8. to R.A.P. near Sugar Loaf through heavy barrages. He also
assisted In dressing wounded for 48 hours unceasingly In a constantly
shelled camp. It was mainly due to his initiative and disregard of
pononal danger that touch was kept with B.M.U.’s under very trying
dreumstanoee.
Temp. Capt. ALEXANDER KHITH F >RBBS.—F >r conspicuous
gallantry and devotion to dnr.y east of the Canal du Nord on Sept. 27th,
1918. Soon after zero he established the R.A.P. In the Canal, having to
ttoss a t-tretcb of ground swept by machine-gun fire. From this well-
•bosen forward post be was able to dress all the wounded of his own
•pd other units, undoubtedly saving many lives. Be went out many
tames Into the shell swept area and brought in wounded.
Ospt. NORMAN McLB' -D HALKBTT. Can. A. M.C - For conspicuous
gallantry and devotion to duty curing operations against the Dmcourt-
Queant line near Durv between 8<-pt. lst-3rd, 1918. Near Vis-m-
Artols the area In which the regimental aid-pobt was located was per-
•mtoiitly searched by enemy artillery, causing many casualties. He
Later the regimental aid po-t was established in an open trench, and
he again carried on under severe shell fire with untiring ener gy and
utter disregard for bis own personal s f ty.
Oapt. JouN CLAUDE MOSELEY H VRPBR, Au«t. A.M.O.-During
th* operations on the Somme River and east ot Mom- 8». yuentm on
wi cooh.eas in attending t he wout>ded, although he was under heavy
and machine gun fire for the whole time. H'S untiring en»*rg> and
•oteo« id example and his personal supervision of the evacuation of the
W0un rtert yielded excellent results in spite of most trying conditions.
Temp. Lieut. BENJAMIN HUTOBH'tON.—During the operations
east of Arras on August 30t^« 1918, » e displayed conspicuous gallantry
and devotion to rtut.v, working in the open under heavy machine-gun
and artillery fire attending to the wounded with an unselfish disregard
of danger that was a splendid example to all.
Capt. FNBOBRIO B04ART JkMBS. Aust. A.M C.—During the
attack on Per-mne on 3ept. lst-3rd, 1918, this offloer was conspicuous
for his gallantry and devotion to duty, working unceasingly under
heavy fire and practically without s'eep during the whole period,
attending to a large number of wounded. His energy and untiring
self-sacrifice were worthy of the high* st praise.
Temp. Oapt. HBNRY MICHAEL JOSEPH.—During operations from
August 8 h-lOth, 1918, near M rlanoourt. thl* medical offloer displayed
great oourage and energy in dealing wit h the wounded f m August luth,
1918. be moved fo» want Immediately behl* d the fighting troops and
saved manv lives by timely aetl- n. When the objective was gained,
and b <ttle patrols went out. the enemy's m-tohlne-gun fire was especially
heavy; he nevertheless went forward and dealt with cases, carrying
one badly wounded man to a place of safety on his bade under
heavy fire.
(To be concluded.)
The following awards for servioes rendered in East Afrioa
are announced
<7.lf.G.-T*»mp. Lt.-Ool. H. B. G. Newham, B.A.M.O.; Maj. (acting
Lt.-Ool.) R. E. Humfrey, R.A.M G.
C.I.E. - Lt.-Col. (temp. Col.) W. W. Clemesha, I.M.8.
0 B.E —Gapt. G. P B. Wall. 8. Afr. M O.; Oapt. I. J. Block, 8 Aft.
MO ; Temp. Capt. A. G. Bid red, Nyasaland M 8.; Temp. Gapt. G. B.
Howard, R.A.M.G.; Temp. Oapt. Q. Madge. BA. M.O.; Temp. Gapt.
L. R. H. P. Marshall. R. A.M.O.; Temp. Oapt. 8. Mason, 8 Afr. M.O.:
Gapt. G. McG. Millar, I.M.3.; Temp. Maj. B. Semple, B.A.M.G.;
Temp. Maj R. Standish White B. a.M.O.
To be Brevet Major.—Capt, (aottng Lk.-0«U J. D. Kidd, M.O.,
R.A.M 0.; Capt (acting Lt.-Ool.) J. A. Manifold, D.8.O.. R.A.M.G.;
Gapt. B. A. Sutton, M.G., R.A.M.O.
Gapt. H. A. Sutton, M.C., R.A.M.O.
Military : row.—Capt. A. Robertson, B.A.M.G.
Mentioned in Despatches.
The names of the following medical offioers are mentioned
In despatches:—
British Salonika Faroe.
Staff.— Maj. (temp. Lt.-0o1.) J. A. Anderson. R.A.M.O.; Got. B. T. F.
Blrrell, O.B.. O.M G., A.M.8.; Ool. H. J. M. Bulst, 0. M.G., D.8.O.,
A.M.S.; Gapt. facting Maj.) W. F. Christie, R.A.M.G.; Lt.-O I. (acting
Col.) T. B. Fielding, D.S O., R.A.M.G.; Maj. W. R. Galwey, O.B.B.,
M. O., B.A M.O.; Lt.-Ool. J. B. Hodgson, O B B., R.A.M.G. (died);
Maj. and Bt. Lt.-Ool. (temp. Got.) O. W. Holden. D.8.0. R.A.M.G.;
JAaj.-Gen. M. P. G. Holt. K.O.M G., OB, D 8.O., AMS.; Oapt.
(acting Maj.) N. V. Lothian, M.C., R.A.M.G.; Lt.-Ool. 0. B. Martin.
O.M.G., R.4.M.C.; LL-Gol. and Bt. Gul. (temp. Gol.) W. H. 8.
Nickerson, V O., C.M.G., R.A.M.C.
Army Medical Service.—Temp. Ool. L. 8. Dudgeon. C.M.G.; Temp.
Gol. R. B. Kelly, C.B. (Capt. and Bt. M*j., R.A.M.G. (T.P.)); Temp.
Ool. A. G. Pheer C.B.
Royal Army Medical Corps.—Temp. Gapt (acting Maj.) A.G. Anderson;
Temp.Oapt. D I. Audemon. Temp. Oapt. J. 0. M. Bailey. O. B.E. ;
Temp. Capt. (acting M j.) G. V. Bakewell. O B.E.; Temp. Capt. V. J.
Bona via; Lt.-Ool. M. Boyle, O.B E.; Temp. Gapt. M. 8. Bryce, M.O.;
Qrtnr. and l.t. (temp. Maj.) W. H. Butler; Temp. Gapt. (aottng Maj.)
8. Campbell; Temp. Gapt. L. Oaaaldy; Temp. Gant. A. H. Coleman,
O.B.E.; Temp. Capt. J. A. Delmege O.B.E.; Temp. Oapt. B R.
Biwortby, O.B.B.; Temp. Oapt. O. Y. Flewltt; Temp. Oapt. G. O.
Hem peon; Temp. Oapt. (acting Maj.) J. V. Holmes; Temp. Gapt.
N. B. Kendall; Temp Capt. F. Newey; Temp. Oapt. J. L. H.
Paterson; Temp. Capt. (acting Maj ) W. H. Peaoook; Temo. Capt. W.
Thomas; Lt.-Ool. A. D. Waring; Temp Capt. J. Warnook; Temp.
Oapt. J. 8. Webster; Temp. Lt.-Ool. 0. M. Wenyon, C.M.G.; Temp.
Gapt. H. O. Went; Temp. Gapt. E. 0. White.
R.A.M.C. (8.R.).— Oapt. (acting *ej.) T. Y. Barkley, O B.E.; Oapt.
R. D. Cameron; Capt. (acting Maj ) W. B. Foley, O.B.B.; Gapt. A. Q,
Harsant; Capt. G. M. Hetherington; Capt. H. B. McOoIl, O.B.E.;
Gapt (aot-lng M«j.) B McKlnlay ; Capt. W. O. F. Sinclair.
R.A.M.C.(T.F.).- Cant.G.L. Findlav; Maj. (temp. Lt.-Col.) J.Gray.
O. B.B.; Gapt. T. S. Hele; ('apt. A. M. Jonea; Maj. (acting Lt -Ool.)
A. B. Kidd ; Oapt. (acting Maj.) J. O. Marklove; Lt. Ool. P. Mitchell,
O.B.B.; Oapt.. (acting Lt.-Ool.) K. P. Na»h; Oapt. (temp. Lt.-Ool.) J.
Pb'rlok; Capt. (acting Maj.) H. A Playfair-Robertson; Gapt. J. Steed-
man ; Gapt. (acting Maj.) W. D. Sturrock D.S.O.; 0^>t. (acting Mgj.)
J. Taylor; O.B.B.; Lt.-0ol. F. B. A. Webb, O.B.B.
East Afrioan Faroe.
Staff.- Ool. G. W. Tate, O.M.G., D.S.O., A.M.S.
R.A M.O. —Oapt. D. 0. Buchanan; Temp. Oapt. 0. B. Olay; Temp.
Gapt. H. M Fisher; Temp. Capt. T. J. H. Hnakln; Temp. 0apt..0. R.
Howard (died); Maj. (acting Lt.-Col) R. B. Humfrey; Temp. Capt. Q.
Madge; Temp Capt L. R H. P. Marshall; Temp. Lt.-C"l. H. B. G.
Newham; Temp. Maj R. Semple; Temp.Gapt. B. W.L.Sharp; Temp.
Maj. R. 8»a* dlsh-White.
South African Medica' Corps.— Capt. 0. P. Bllgh-Wall; Capt. I. J.
Block; Temp. Capt. 8. Golyer; Lt. T. J. Dwyer; Temp. Oapt T. A.
Fuller ; Capt. A. W. Goldsmith; Temp. Capt. 8. Mason; Temp. Capt.
W. McG. Montgomery; Maj. R. 0. Morley-floare; Oapt. (actlug Maj.)
W. H. R. Sntton. _ „ .
East African Medical Service.— Capt. W. A. Trumper; Maj. (acting
Lt. Ool I A. D. J. B. W llUmB.
Nyasaland Medical Service.— Temp. Oapt. H. B. Arbuokle; Temp..
Gapt. A. G. KM red.
Rhodesian Medical Corps.— Temp. Oapt. F. Innea; Temp. Oapt. B. R.
Murra\ ; Temp. Capt. W. J. 8heehan. _ ^ ^ ___
Indian Medical Service.— Oapt. W. D. Keywnrth; Oapt. G. MoG.
278 Thb Lancet,]
t£e services;
[Fbb 15,1919
THE SERVICES.
PAY IN THE INDIAN MEDICAL SERVICE.
The Secretary of 8tate for India received on Feb. 10th a
deputation from the British Medical Association regarding
the pay and prospects of the Indian Medical Service, when
he explained the steps which bad been taken and which it
was hoped to take in fntnre to improve the conditions of the
Indian Medical Service as regards pay, leave (including
study leave), and facilities for research. Regarding the pay
of the Service, be announced that he had sanctioned the
introduction, with effect from Dec. 1st, 1918, of improve¬
ments in the rates of pay for permanent officers of the
Indian Medical Service on both the military and the civil sides
approximating in the aggregate to an increase of 33& per
cent, on the present rates of military grade pay. These rates
are as follows:—
Rank. G "1S. P * y *
Lieutenant . 350
Oaptaln . 400
„ after 5 years' service . 450
„ after 7 years'service . 500
„ alter 10 years’service . 550
Major . 650
„ after 3 years’service as Major . 750
Llentenant-Oolonel . 900
„ „ specially selected for Increased pay 1000 I
The detailed rates of pay to give effect to this decision are !
being worked out in India and will be announced as soon as
possible.
The object of this measure being to attract to the Service
European candidates with the highest professional qualifica¬
tions, the question whether Indian candidates entering the
permanent Service after Dec 1st, 1918, shall be eligible for
increased rates of pay, and if so, to what extent and under
what conditions, has been reserved for future consideration.
All Indian officers already in the permanent Service on
Dec. 1st, 1918, will be eligible for the increased rates of pay.
As regards private practice Mr. Montagu explained that,
Bubiect to the reservation that it must be under the control
of Government, he was of opinion that it was to the public
interest that the Service should enjoy as fully as possible
opportunities of private practice, and he assured the deputa¬
tion that no further restriction of the facilities for private
praotice now enjoyed by the Service was contemplated.
ROYAL NAVAL MEDICAL SERVICE.
Surg.-Onmdr. J. Menary is placed on the Retired List with rank of
Surgeon-Captain.
To be temporary Surgeon-Lieutenant*: P. Banbury, A. C. Halil well.
E P. Brockman, A. T. Hawley, B. K. Maodonald, W. M. Anthony, P.
Lloyd-Williams, C. T. Helabam, O. F. McLean, A. B. Ward, B. C. W.
Cooke.
Temp. Surg.Lleul*. A. W. Cooking, J. G. Stevens, and H. C. C.
Veitch have been transferred to the Permanent List as Surgeon-
lieutenants. —
ABMY MEDICAL 8BRVICB.
Lieutenant-Colonels, from R.A.M.C.. to be Colonels: Temp. Col.
N. Fhlcbnie, O. B. Martin, Temp. Col. A. G. Thompson, C.M G..
D. S.O , J. B. Anderson, A. H. Waring, D.S.O., Temp. Col S. A. Archt-r,
J. McD McCarthy.
Temp. Col. G. 0. Chnyce relinquishes bis commission.
Temp. Col. H. A. BalUnoe (Major (temp. Lieut.-Col.), R.A.M.C..T.P.),
relinquishes his temporary oomralsdou on re-p eting.
The undermentioned temporary a >pointme«it as Staff Surgeon Is
made at the War Office: Capi. T. Sheedy, R.A.M.O., Spec. Rea.
ROYAL ARMY MBDICAL CORPS.
Majors to be Lieutenant-Colonels.-. Aoting Lleut.-Cols. R. F. Ellery,
H. A. Branshury, J. F. Whelan. C D. Myles, H. R. Bateman, 3. B.
Smith, M. W. Faikner; Temp. Lleut.-Cols. A. J. Hull, H. A. Davidson;
and J. H. Brunaktll, W. M. B. Sparkes, R. MeK. Skinner, R. L.
Popham.
Capt. (acting Major) B. G. Gauntlett. R.A.M.O. (T.F.), to be tem¬
porary Lieutenant-Colonel whilst specially employed.
Temp. Major G. W. Milne to be acting Lieutenant-Colonel whilst
commanding troop* on a hospital ship.
To be acting Lieu enant-Co oneis whilst In command of a Medtoal
Unit: Majors W. C. Nlmmo, R. P. M. Fawcett; Oapts. O W. McSheeby,
E. Catlord ; Acting Major J. J U. Roc’>e; Temp. C pt. T. H Martin.
Temp Capt. (acting Uej-.r) W. J. A. B. Wlahart relinquishes his com¬
mission and retains ibe rank of Major.
Relit*qutsuing the acting rank of Major on re-posting: Oapts. F. B.
Laing, 8. M. Hattersley; Temp. Capts. R. B. Maefle. B.O. Chlpp, G. C.
Price, J. L. Menzies.
Major A G. cummins is restored to the establishment.
To be acting Majois whilst specially eioplojeo: Capt.. A. B. B. Jones,
Temp. Oapts. B. Tawse, E. B. Barton, b. A Owen, H. V. A. Gatcbell.
To be acting Majors: Capts. B. A. Odium, B. A Straohan. R. W.
Vint, H. P. Hart, W. Foot, D. H. 0. Mac Arthur; Temp. Capts. T. H
Oliver, A. C. S. Courts, D. C. McCabe-Dal las, J. L. Wilson, C. K.
Gibson, G. P. Armstrong, J. F. McG. Sioan, J. W. Robertson, J.
Parkinson. A. U. Miliar, L. Crabb, J. M. Burnford, D. Fisher, J. N
Humphry y, J. L Jackson, G. Jackson, T. Stordy, W. H. Hardy; Lieut,
(temp. Capt.) F R. 8. 8haw.
Major W. Tibbiis is retained on the Active List and to be auner-
Major W. Tibbiis is retained on the Active List and to be super¬
numerary.
Capt. (acting Major) W. B. Allen, V.C., from R.A.M.O. (T.F.), to be
Captain and to retain his aoting rank.
L'entenanta (temporary Captains) to be Oaptalns: W. J. Robertson,
W. O'Brien (acting Major), F. R. S. Shaw, O. Russell (acting Major),
B. Stowers, W. J. Kn*gnt. K. A. Mansell (acting Major).
Capt. Claude M. Rigby is restored to the establishment.
Lieutenants to be temporary Captains» J. Brown, J. J. Donrdall,
G. W. R maldson.
Temporary Lieutenants to he Temporary Captains: A. B. Kosher,
H. S. Lister. G. Stanger, A. N. Fell, H. L. Taylor, F. Robinson,
A. Ashkenuy, A. H. Firth, A. G. L. Smith.
Temp. Hon. Lieut. B. B Fi'zgerald to be temporary Honorary
Captiin whilst se vi g wl»h No. 22 General Hnep tal (Harvard Unit).
Officers relinquishing their commissions: Temp. Li^ut.-Col. A. J. J.
Johnston, and retains the rank of Lieutenant-Colonel; Temp. Lieut.-
C«il. A. W. Falro er on re-postlng.
M'jor B. F Q. L’Bstran.eand 'apt. O. C. P. Cooke relinquish the
acting rtnk of iJeutenantrC<>lonel on re-posting.
Temp Hon. Lieut.-Col. H. Cabot, Temp. Hon. Majors G. G.Shattuck,
E. G. Crabtree, B. H. Alton, V. H K*za jlan. Temp. Hon. Cap s.
R. Harding F. Brigham. P. Gustafson. D. B. Ford. B 3 Welles, R. 3.
Fish. F. Packard, C. N. Lewis, W. H. Ramsey, L. M. Van Stone. R. M.
Dodson, D. J. Knowlton, F. L. Johnson, A. Gregg, B. B. Fitzgerald,
H. W. Woodward. Temp Hon. i.ieut. M. M. 3tevens reli quUh their
commissions on cessing to serve with No. 22 General Hospital (Harvard
Unit) and retain their honorary rank.
Temporary Majors retaining the rank of Major: B. K. Martin, J. F.
Cunningham, A. Neve.
Captains (to retain rank of Oaptaln): M. A. O'Oallagan, R. S.
Smith.
Temp. Capts. (acting Majors) (retaining the rank of Major) > J. W.
Bill tt, F. G. Collins, J. R. Craig. H. D. Smart, S. J. Rowntree. A. 0. T.
Woodward. B. Burstal. Temp. Capts. W. A. Young (and retain the
rank of Captains R. Davl 4 son, W. C. C. Kirkw *od, A. I. Shephard*
Wa)«yn, J 8ulllvan, H. Snape, H. A. Ly'b, D. Glen, H. O. imvler,
G. B. A. Mitchell, C. W. Windsor. W. 3. Campbell, H. Y. Mansfield,
H. J. Beldow, A. Cox, W G. Attenborough. C. K. lies. G. J. Meldon,
a. L. Walker, W. Mason (acting Major). W. J. Crow, D. M.
Calender, G. W. Stanley, D. Kennedy, D. MacKinnon, R. J. W.
McKane, B. P. Campbell, H. M. L. Orawf-ird. B. Bvana, I. Fiaca, J M.
Ahern, D. R. Acheson, W. A. Dewhirst, B. A. Price, F. A. Juler, W. S.
Garden. A. H. Laird, D. M. B ohan. H. B. Heapy, C. C. Austen,
A. V. Boyall. W. B. James. J. B. Mitchell. L. C. Newton, W. A.
Thompson, P. A Sutll an, F. D. dimnson, P. R. H. Patev, J. M.
Lazenby, J. D. Marshall, H. R.Cran, A. W. Ew ng, L L. Winierbotham,
A. B. Lenpingweli, L. B. C. Tmtter, J. P. Jarroll. N. Kenned v. J. F.
Weston, B.G. Bark. J. Ritchie, H.G. Rashlelgh, A. H. Morley.G. Garland,
P. Steele (acting Lieut.-Col.) (retains rank of Lieutenant Co one!),
C. D. Gondennugb. G. M. Davies. A. Morton, C. B Hutchison, A. H.
Burnett, A Umerson, H. D. Led ward. C D. Rankin. G. R. Dobrashian,
B. H. B. Oram, J. D. Barris, B. L. N. Rhodes, J. Gaff. S. C. W. Morris,
D. W. Roy (acting Major). C. L. Warke, J J. Smith. H. Maffin, W.
Craig, R. 1 1. Lee, C Duncan, J. M. Anderson, »). C. Adam. J. D. Mercer.
T R Evans, V. S Partridge, A S L. Malcolm, C. Mo.K. Craig, J. Young,
W. Fairclougb, P. Ulan. D. Boas, W. J. Ashley, J. A. Jones (acting
Major), E. J. Fisher, P. MacFadyen, J. R. Hewetson, R. S. Woods,
J. Bain, C. H. H&rbin-on, J. Sullivan, N. Bradley, V. H. Betook, J. L.
Ranklne (acting Major), J. McKie. A. J. M Wright (acting M«jor), A. L.
Saunders (acting Major), T. B. Williams, F. J. Morris, F. N. Stewart,
L J. Hood. O. Bruce.
Temporary Captains to retain the rank of Captain: H. R. L. Allot,
G. Leggtt. J. W. Bride. C. Banks, F. W. MacKtchan, G. 3. Deane,
B. R. D Maeonochie. S. T. Davi*-s, J. R. B. Do'S'm. M. D. MtcKeiidk
J. K. Muir, A. C. Brown, C. A. Blrts, H. bin son, P. Figdor, A. B. Vine.
A. B. Huckett. M. A. Swan, J. Plrie, J. M. Shaw, W. B. A. Worley.
R. 3. Stevenson, A. Bradshaw. I. J. Roche, A. Snelley. J. W. Trevao,
H. V. White, R Hughes, M. T. Morgan, F. G. Sergeant, A. B. ftsd,
H. ft yth, C. G. A. Chlslett, B. B. Hughes. H. 3. Knight. H. i brlstal,
J. G. Moselev (»cm ng Major), D. G. 4cRae. J. Robertson. A. B eiey,
J H. B. Davis. R. Steel. W. J. Stephe a. L. W Shad well, W. O.
McKane. T. Marr*n, G. Wight, P. 3. Clarke, D. C. Mac Lachlan,
F. W. W. Smith, W. C. J&rdine. A. G. W. Oaen. J. McN. Murray.
R. S. Kills, 3. H Robinson, T. B. Watson, H. Millar, H. E. Humphry*,
J. B. Binns. F R. L. Atkins.
Temp. Capts. P. T. Spencer-Phillips, A. Duncan, to relinquish their
oommis-ionn ; Temp. Hon Cap s. 3. A Henry and A. D. Brunwln (on
oea-ing to be employed with dt. Johu’s Amb. Brig. Hoap., and retain
tne honorary rank of Captain).
i Temp. Lieuts. (to retain the rank of Lieutenant): J. W. Steohen,
J. H. Boon. A. Ashkeuny, 0. 3. Maoask e, F. J. Gordon, M. If.
' Munden, W. Knapp. A S. L. Biggart, R. P. Parker. O. L. Dapper,
A. F. Calwell, Z. M. H. Ross, W. B. Jones, B. A. King, B. D. D. Davis.
Canadian Army Medical Corps.
Temporary Captains to be Temporary Majors: S. L. Walker, F. W.
Manning.
Temp irary Captain D. A Clark to be acting Major while employed
at No. 9 Canadian Stationary Hospital.
Temp. Capt. T. W Sutherland to he aoting Major while employed at
No. 8 Canadian Ste» ionary Hospital.
Temporary Captain A Collins to be acting Major while employed at
Canadian Convalescent Hospital, Bear Wood.
Canadian Army Dental Corps.
Temp. Lieut. A. Kennedy, from 2nd Central Ontario Regiment, to be
temporary Lieutenant. __
ROYAL AIR FORCB.
Medical Branch.—Captains to be graded for pay as Captains: A. A.
Atkins u, W. H. H. B nnett, R E. Bell. H 8. Baker, R D. Goldie.
J. J. C. Hamilton, F. O. Kemp-on, J. M Kirknees. A. MaoLenntn,
J. A. Parsons, F. Ro-ens, O. P O. Sargent, A. Soott-Turner, C. J. G.
Taylor. C. Webb, N. R. Williamson.
A. B. P. Parker (temporary Surgeon, B.N.) Is granted a temporary
commission as Captain.
Capt. H. C. Bazett (R.A.M.O., Spec. Res.) is transferred to
unemployed lint.
C. F. Hmlnson Is granted a temporary com mission as Lieutenant.
M<jor (acting Lieut -€ >1.) A. H. 0beetle relinquishes his eommtseloo
on ceasing to be employed, and is permitted to retain the rank of
Lieutenant- Colonel.
The Labor,]
THE MEDICAL EFFECTS OF THE TUBE STRIKE.
[Fbb. 15,1919 279
Cormpnfetntt.
“ Audi alteram partem.”
THE MEDICAL EFFECTS, OF THE TUBE
STRIKE.
To the Editor of Thb Lancet.
Sir,—T he medical profession has a special interest in the
effect of the recent Tube strike upon the poorer classes of
London and its suburbs. The absence of travelling facilities
inflicted more than mere hardship upon thousands of delicate
and elderly individuals of both sexes, workers all of them.
Only the medical man can know the thousands of injuries
received in the struggle to enter the overcrowded buses, and
the serious and fatal illnesses incurred by the long walks
through frost and sleet after the day’s labour, and the
insidious beginnings of chronic ill-health originated by the
suffering uncomplainingly borne by those who were obliged
to spend sleepless nights on the floors of offices and crowded
lodging-houses.
It has been suggested that medical men and women should
compile with care a list of these results which are known to
them personally. Revolution, with its bloody toll of human
lives belonging to the upper classes, may leave the imagina¬
tion of the worker cold. The illness and death of fellow
workers, brought about by his hasty action, would of a surety
bring home to him the cruelty he had unwittingly caused,
and lead him to realise that the action of the Government in
taking precautions to become independent of Labour had as
motive not the protection of the capitalist but the protection
of the workers themselves.
I am, Sir, yours faithfully,
Weymouth-street, W., Feb. 11th. 1919. AGNES SAVILL.
A NATIONAL MEDICAL SERVICE : WHAT IS
IT WORTH?
To the Editor of The Lancet.
Sir,—I n the programme of reconstruction figures largely
the Ministry of Health, which is generally expected to deal
with the question of supplying medical assistance to the
whole or a portion of society. This is a question which
must interest the public as well as the medical profession,
and this letter may help everyone to appreciate the position
of members of that profession.
The National Health Insurance Act has not been an un¬
qualified success, and any scheme grafted on this will not
meet with the undivided support of the medical profession.
The faults in the Insurance Act are many:—1. It treats
the rural practitioners similarly to the urban,* though the
conditions of practice are essentially different in the two
cases. 2. The costs of administration are too large for the
benefits given. Many men outside the medical profession
draw larger salaries than the practitioners who do the work.
This last objection would be removed if these posts were
filled by medical men incapacitated by the war from taking
a part in the wear-and-tear of general practice. 3. The
Insurance Committees have not protected the profession
from the mean people whose income is above the limit ,
although this could have been done by a reference to the
surveyor of taxes. 4. The question of inflation. My In¬
surance Committee admits that there are more patients on
the panel in this county than they receive subscriptions for,
and therefore do not pay the full capitation fee. This is
not the fault of the doctors, yet they are liable to provide
E rofessional attention to every person for whom the
osurance Committee has issued a card. 5. Delay m settle¬
ment of accounts. In November, 1918,1 received cheque in
settlement of 1917 account.
All these difficulties must be overcome if any use is to be
made of the machinery of the Insurance Act. Personally I
advocate the scrapping of the Poor-law Medical Services and
the Health Insurance Act, and that the whole service, under
whatever scheme is adopted, be organised by the existing
Public Health Service in the different counties and boroughs.
The idea which most appeals to me is that of Sir Bertrand
Dawson—i.e., “team-work.”
This scheme in the towns would go far towards achieving
the objects we all desire. It would save the time both of
doctors and patients, because under this scheme we should
arrive at a correct diagnosis with the least possible delay;
the doctors might even have some chance of an “ eight-hour
day,” and why not? Even in rural districts the organisation
of a “ team service ” of motor ambulances and laboratories
should be a possibility which could be realised for the
collection of patients and specimens to be taken to the base
or clinic with notes from the general practitioner.
This brings us to the question of remuneration as the
scheme to be successful must be generously endowed.
It has been suggested that any scheme the Government
may introduce must result in a loss of income to the pro¬
fession. I do not believe this to be the case, because we all
know under present conditions how many people get more
than their money is worth owing to the homan sympathy of
the great majority of the profession. In our dealings with
the State through the Ministry of Health no such considera¬
tion is demanded. The State has the money; after the
armistice was signed—but before the General Election—
wages were raised 5s. a week in consideration of the increased
cost of living.
What did the State do for the doctors during the war?
The fee for the notification of infectious diseases was
reduced from 2*'. 6 d. to 1*. The State has the money, and
if the popular principle of “ nothing for nothing ” were
adopted in the case of the medical profession the average
income would be increased rather than diminished. This
involves the State control of all charitable institutions.
The medical and surgical staffs of these institutions would
be paid either on a whole-time basis or by a definite fee for
each operation or consultation.
Mr. Lloyd George has said every man should have a fair
return for what he has to offer. In many cases the physician
or surgeon offers life. What is it worth ? In the case of the
specialist recognised as able to render valuable service to
the State is it not worth the £5000 a year of a Cabinet
Minister or a judge ? The position of the general practi¬
tioner is not so straightforward, but I state my view frankly
that every capable general practitioner by the time he is
40 years old should be able to earn an income of £1000 per
annum free of all expenses in the earning thereof.
There are objections to a whole-time district medical
officer:—
1. It interferes with the independence of the doctor and
the patient. 2. It tends to diminish the competitive element
and the personal equation. Many general practitioners owe
their success in practice not to academical attainments, but
to personal qualities not correctly estimated in the examina¬
tion room.
We have all had a good deal of registering to do lately, so
that it would not be an innovation or hardship if some such
method were adopted as the following :—
Every general practitioner recognised by the State to be
paid a retaining fee, say £300 per annum, as compensation
for the time and money expended on his education which
the State expects to utilise and has never endowed in any
way. Every person included in the scheme must register
with the doctor of bis choice. The doctor to be paid for
services rendered, on a fixed scale, from funds collected and
administered by one central body, and provided by a special
tax or by an addition to the income set aside for this purpose.
In this way the delay in meeting the doctors’ accounts
should be obviated. The question of mileage might be met
by the grant of free petrol on the basis of existing petrol
licences.
Finally, who is to be allowed to take advantage of this
scheme, and where is the line to be drawn ? I would suggest
that as the Government has failed in the past to protect the
profession from imposition by those above the wage-limit, it
will not be able to do so in the future ; the profession must
therefore insist on a remuneration which will cover every
class of society, and every member of society will be able to
avail themselves of the Government system if they think it
good enough.
The whole question of a successful National Medical
Service appears to me to depend on the answer to the ques¬
tion of “What is it worth ? ” Can Mr. Lloyd George answer
this question ?—I am, Sir, yours faithfully,
Great Bookh&m, Surrey, Feb. 11th, 1919. G. SPENCE CANDY.
X RAYS IN THE DIAGNOSIS OF APPENDICITIS.
To the Editor of The Lancet.
Sir,—T he exhaustive paper by Dr. E. I. Spriggs on this
subject in your issue of Jan. 18th should serve as an
encouragement to physicians and surgeons to seek the
assistance of the radiologist in obscure abdominal con¬
ditions, and as a stimulus to the radiologist himself to cast
more widely his diagnostic net. On the technical side there
280 Thb LANOBT,] THB PRESENCE OF a FILTER-PASSING VIRUS IN INFLUENZA. ETC. [Fbb. 15,1919
are points of detail in Dr. Spriggs’s paper the carrying out of
whioh would involve, at any rate in London, some amount of
inconvenience, if not actual difficulty. The first is the supply
of buttermilk for the special meal described. Fortunately, this
particular meal is not necessary to demonstrate the appendix,
although it is true that the ordinary mixture of bread and milk
and barium often fails. I have now for two years used the meal
introduced by Dr. James Metcalfe, and put up by Messrs.
Allen and Hanburys under the trade name of “ umbrose.” In
this the barium is very finely triturated and intermixed with
the other ingredients, and probably for this reason has no
difficulty in entering the appendix. A second point is that
Dr. Spriggs states that the best view of the appendix is
obtained 12-14 hours after the meal. Now, as a rule, one
wishes to examine the stomach with the same meal. I have
found personally that if the meal be given at 10 a.m., the
appendix will be satisfactorily seen between 4 and 6 o’clock
in the afternoon, or the next morning. In consulting-room
practice the 12-14 hour examination is impossible as a
routine, though it may be necessary to arrange for it in a few
special cases. Lastly, those whose outfits do not permit of
radiographing the appendix in less than one second should
not be discouraged from examining it, as, although failure
will occur in a few cases, in the majority reliable data will be
obtained. With regard to the “ numerous photographs ” said
to be necessary, a careful screen study is often of as much,
or more, value, two or three plates being taken as a record
at each examination. With the technique modified as above,
there seems no reason why the X ray examination of the
appendix should not be generally carried out.
As to the desirability of radiographic investigation of the
appendix, a striking feature of the cases quoted by Dr.
Spriggs is that few or none were suspected of having
appendix trouble. Their ill-health had been ascribed to
various causes other than this. Herein the present writer’s
experience coincides with that of Dr. Spriggs. I have
frequently had cases sent to me for examination of the lungs
or of the kidneys where the trouble ultimately proved to be
appendicular. If a man should say that in all cases of
chronic and unexplained ill-health the appendix should be
investigated by X rays, perhaps he might be suspected of
monomania ; and yet his madness would not be without
method. I am, Sir, yours faithfully,
Harley-atreet, W., Feb. 4tb, 1919. F. HERyAMAN-JOHNSON.
THE PRESENCE OF A FILTER-PASSING
VIRUS IN INFLUENZA, ETC.
To the Editor of Thb Lanobt.
Sir,—I have read with interest the preliminary report by
Major-General Sir John Rose Bradford, Captain E. F.
Bashford, and Captain J. A. Wilson, published in your
issue of Feb. 1st, on a filter-passing virus found in certain
diseases, the more so as it appears to lend support to the
claim originally advanced by Nicolle and Lebailly that
influenza, one of the diseases specifically mentioned in that
report, is due to a filterable virus. If this be further
substantiated by others, it follows that Pfeiffer’s bacillus,
as that is usually understood and described, can no longer
be looked upon in the light of a responsible etiological
factor. In a letter 1 expressing disbelief in the claims made
by the advooates of Pfeiffer's bacillus, I ventured to state
that we had to deal, not with a double infection, primary
and secondary, but with one infective agent only and that a
pleomorphous one of which I gave a brief description in a
letter to The Lancet of Nov 23rd, 1918.
fiinoe writing these letters my attention has been drawn
by a private correspondent to certain experimental work
oarried out by Rosenow 1 and others, working on acute
epidemic poliomyelitis in America. I was unaware of the
existence of this work at the time of writing but have since
been able to gain access to some of Rosenow’s articles. I
have been struck with the extraordinary resemblance
between his organism and the one which I have already
described and to which I have given the provisional name
of organism “ D.” Whether Rosenow’s organism is exactly
identical or not with organism “ D ” I am unable to say, as
all Rosenow’s data are not available at present to me. It is
well kndwn, however, that Flexner and Noguchi were able
to reproduce acute poliomyelitis by the inoculation of a
1 Brit. Med. Jour., Dec. 21st, 1918.
3 Journal of Infect. Diseases, Chicago, vol. xxil., No. 4, pp. 281 et seq.
filter-passing virns, consisting of small 4 * globoid” bodies.
Rosenow and his co-workers have sinoe been able to trans¬
form pure cultures of these globoid bodies, obtained from
Noguchi’s laboratory, into the pleomorphous organism which
they claim is the cause of acute poliomyelitis. Not only so,
but they have been able to grow their organism in the form
of the Flexner-Nogucht “globoid ” bodies.
In my letter of Dec. 21st, 1918, already referred to, I
stated that the claim which I there made did not necessarily
exclude the possibility of there being a filter-passer phase
of organism “ D.” It seems necessary to emphasise this, in
view of the accumulating evidence that influenza can be
produced by a filterable virus. When once it has been proved
that a given infective agent is a filter-passer it has been
the custom to argue that other organisms, of ordinary size,
which may previously have been regarded as the causative
agents, are merely contaminations or secondary invaders.
This argument is obviously fallacious unless and until it be
proved beyond any question of doubt that the filterable virus
can exist in no other form. It is just as fallacious as the
argument that pieomorphism is a synonym for impurity
of culture. It will be granted at once that in some cases
such has been proved to be the case, but that pleomorphism
does exist has been sufficiently well established by modern
bacteriological methods.
In connexion with Rosenow’s and my own claim it is of
interest to refer to a letter which appeared in Thb Lancet
on Jan. 11th from the pen of Dr. F. G. Crook shank, in which
the latter claims that, on epidemiological grounds, there is
reason for believing that acute poliomyelitis, encephalitis
lethargies, and influenza are so closely related as to consti¬
tute different group manifestations of a single infective
agent. 8uch a view has much to commend it, and is
at least quite as acceptable as that which, while the causes
of these diseases are still in doubt, claims that encephalitis
lethargies and poliomyelitis are to be regarded as two
distinct diseases.
May I be allowed to add, in conclusion, a few further
particulars for the benefit of those who may have been
stimulated by my previous letters to look for organism
“ D ” ? The latter grows well at room temperature, does
not liquefy gelatin, and produces acid without clot in milk.
It forms acid in dextrose, lactose, maltose, saccharose,
raffinose, and dextrin litmus peptone water. There is also
an indication that the organism has some connexion with
the Pasteurella group, but a definite statement on this point
cannot be made at present.
I am, Sir, yours faithfully.
Beading; Feb. 4tb, 1919. ROBERT DONALDSON.
PARASITIC MANGE IN HORSES
To the Editor of Thb Lanobt.
Sir, —In July of last year I was instructed by the Joint
Propaganda Committee—Board of Agriculture and Ministry
of Food—to draw your attention to the prevalence of para¬
sitic mange in horses and the likelihood of its spreading in
the coming months ; also to the issue by the Joint Committee
of a special leaflet (No. 8) in whioh particulars were given ‘
(a) as to the Orders in existence in regard to the disease;
(5) the penalties attached to breaches of the Orders;
(c) means whereby the disease can be prevented, discovered,
and treated.
Since the issue of this leaflet (No. 8) two additional leaflets
on the same subject have been published which have had a
very wide circulation.
We are informed that the local authorities view with
growing anxiety the increasing prevalence of mange in horses
reported in the returns furnished by them. Further, there
are grounds for believing that the disease exists in many
districts to a much greater extent than is revealed in the
returns furnished. The Committee would like to point out
the serious effect the disease has in decreasing the useful¬
ness of the horse. These facts are the justification for the
Joint Committee again asking you for the kind hospitality
of your columns to make the existence of our leaflets as
widely known as possible and to state that copies can be had
free and post free on application.
I am. Sir, your obedient servant,
J. Nugent Harris,
Seoretary, Joint Committee, Board of Agriculture
and Ministry of Food.
6a, De&n’s-yard, Westminster, S.W. 1, Feb. 8th, 1919.
Ths Lancet,]
THE MEDICAL PARLIAMENTARY COMMITTEE.
[Feb. 15, 1919 281
INFLUENZA AND CHRONIC LUNG DISEASE.
To the Editor of The Lancet.
Sib,—W hilst temporarily transferred for doty to Maitland
Military Hospital, Cape Town, where there were upwards of
600 cases of influenza of every variety, I noticed that
patients with a previous history of chronio catarrhal condi¬
tions of the lungs bore the disease well. On my return to
Tempe, where the epidemic was very severe, I found this
observation confirmed in the survival of all but 4 of 46
tuberculous patients, most of whom had contracted the
disease. Two of these, however, were in the last stages of
consumption before I left them, and I may add that many of
those who recovered from the influenza attack were almost as
bad. Of 27 natives suffering from glandular and pulmonary
tuberculosis 4 died, and these were also cases of a desperate
type. Farther, 6 white patients with asthma and chronic
bronchitis all contracted influenza and recovered without
any complications.
It seems, therefore, fair to conclude that chronic catarrhal
conditions of the lungs, even when associated with so
formidable a disease as tuberculosis, confer a certain degree
of protection against this disease. I shall be interested to
know whether others better qualified than myself to judge
have had a similar experience.
I am. Sir, yours faithfully,
Duncan Mackenzie MacRae, M.A., M.B., Ch.B.,
Captain, S.A.M.C.
Tempe, Bloemfontein, Dec. 13th, 1918.
THE MINISTRY OF HEALTH.
To the Editor of The Lancet.
Sib,—T he reports of meetings which have been held in
order to support the formation of a Ministry of Health
are proof that those who attend them know very little
of the work which has been performed under present
conditions. The Health Service in this country has given
the lead to every other country in the world, and as the
result, a large number of persons are attempting to pull
down the foundations upon which the work has been
carried ont. The desirability of decentralisation, and
not centralisation of power under politicians’ regime, is
the real problem. Now the political party dominant is
apparently that of the working class, and the question
arises, Has this party ever shown any desire to promote the
interests of medical science ? It was largely responsible for
tbb introduction of the conscientious objector into the
Vaccination Acts, and as a result vaccination against small¬
pox has become more and more a dead-letter. There is no
guarantee that when health matters become more centralised
and under political control the presence of politics will not
again interfere with important safeguards against disease.
The present position with regard to venereal diseases is
most unsatisfactory. These diseases are of the type of
virulent infective disease, and the obvious coarse to be
pursued is to make them notifiable under the Public Health
Act and to leave them under the authority of the local
councils. Politics most be considered, and therefore
palliative measures are to be adopted and not measures
sufficiently strong to stamp out the disease—a matter of no
great difficulty from the practical scientific point of view.
The work performed by the Local Government Board and
Home Office has, on the whole, been of a very high order,
and I do not suppose that either Office has ever
neglected to give sufficient support to medical officers
of health in the carrying out of their duties. After
more than 30 years of service as medical officer of
health, one notice to quit, and a triumphant re-election
owing to loyal support from the Local Government Board,
I have had sufficient experience to be quite satisfied with
the conditions under which I have worked. The troubles
which most perplex medical officers of health are often
caused by local politics, and I apprehend that worse will be
in store for them when politicians of the Labour party are in
power at the Ministry of Health.
One of the most difficult problems at the present time is
that of housing, and this trouble has been the direct result of
a popular land budget—passed by some politicians for the
advantage of their party machine.
I asn. Sir, yours faithfully,
Feb. 6th, 1919. LOVELL DBAGE.
THE MEDICAL PARLIAMENTARY
COMMITTEE:
A DINNER TO MEDICAL MEMBERS OF PARLIAMENT.
A dinner, presided overby Sir W. Watson Cheyne, M.P.,
was given by the Medical Parliamentary Committee at the
Cate Royal, Regent-street, on Wednesday evening, Feb. 12th,
to the medical Members of Parliament, when Dr. Addison,
President of the Local Government Board, replying to the
Toast of “The Guests,” made a very free and frank
statement with regard to the Bill erecting a Ministry of
Health for England, Wales, and Scotland. He compared
the differences of opinion manifested by various existing
medical bodies to teething troubles, and said that
he had no doubt that a way would be found to
some form of organisation. The Bill, he said, would be
immediately read for the first time, printed, and circulated,
and he declared that it was the intention of the Government
to consult the different representative organisations at the
present juncture, and to make of the Advisory or Con¬
sultative Councils, which will be an essential part of the
Bill, bmid fido bodies, real and hard-working.
Sir Bertrand Dawson, speaking to the toast of “The
Unity of the Medical Profession,” said that the Ministry of
Health was arriving, and would find the medical profession
imperfectly organised to meet the situation.
Mr. E. B. Turner, responding to this toast, said that
though he had much experience of public speaking, this was
the first time in which he had been asked to reply for a thing
which was non-existent, but he urged the medical pro*
fession to get their best energies to work, and to work
together like a good football team. Colonel Hurry
Fenwick, who also spoke to Sir Bertrand Dawson’s toast,
agreed with Mr. Turner in finding unanimity in the medical
profession remarkably absent.
Sir James Galloway proposed “The Medical Parliamentary
Committee” in a thoughtful address upon the existing state of
medical politics, and the Chairman replied in terms that
justified the activities now being displaced by the Committee.
Preliminary to the speeches Dr. Arthur Latham read a
brief statement setting out the objects before the Medioal
Parliamentary Committee. The statement showed that the
Medical Parliamentary Committee consists of specially
nominated representatives of a number of existing medical
organisations and of non-official members, a large proportion
of whom are engaged in different types of practice. The
Committee is a temporary body having as its primary object
the drawing up of a scheme under which there might come
into being some council or committee representative of every
section of medical thought.
Among others present at the dinner were Vice-Admiral
Sir W. Norman, Lieutenant-General Sir John Goodwin,
Major-General M. H. E. Fell, Sir Robert Morant, Dr. T. H. C.
Stevenson, Lady Barrett, Sir Robert Woods, M.P., Sir
William \Vhitla, M.P., Captain W. E. Elliot, M.P., Colonel
Nathan Raw, M.P., Dr. Bouverie McDonald, M.P., Dr. R.
Murray, M.P., Major J. E. Molson, M.P., Major Waldorf
Astor, M.P., Sir W. Hale White, Sir Thomas Oliver, Dr. Jane
Walker, Major J. F. Gordon Dill, Professor Kenwood, Dr.
G. E. Haslip, and Mr. J. Y. W. Mac A lister.
New Public Health Regulations for the
Control of Epidemic Disease.— The Secretary of the Local
Government Board has circulated to sanitary authorities and
medical practitioners a general order (P.H. 2A. 1919) con¬
taining the Public Health (Pneumonia, Malaria, Dysentery,
&g .) Regulations, 1919, and a circular (P.H. 2) explaining
these regulations. Their object is to secure better control
over oertain epidemic diseases prevalent or threatened at
the present time and to increase the facilities for their
treatment. The regulations impose the duty of notifica¬
tion by practitioners of any cases of pneumonia occurring
under their care, if primary or the result of influenza.
All cases of malaria, dysentery, and trench fever must
be notified unless the practitioner knows that this has
been done in the same district within six months. The
regulations in regard to the handling of food by carriers are
extended to the enteric fevers, and the duties in relation to
lioe borne disease to typhus and relapsing fever. Local
authorities may provide medical assistance for any of the
diseases named In the regulations, which are to come into
force on Maroh 1st.
282 Thr Lancet,]
MEDICAL NEWS -MEDICAL DIARY.
[Feb. 15,1919
gfcbital Jjfofos.
The late Lord Rhondda has, among other
bequests, left £20,000 to the Cardiff Infirmary.
Tuberculosis Society.—A conference of tuber¬
culosis officers in the United Kingdom will be held to-day,
Saturday, Feb. 15th, at 4 p.m., at the Royal Sooiety of
Medicine, 1, Wimpole-street, W., to consider a scheme for
the National Prevention and Treatment of Tuberculosis.
Major Thomas Reginald St. Johnston (District
Medical Officer and District Commissioner, Fiji) has been
appointed by the King to be Colonial Secretary of the
Falkland Islands.
Royal Faculty of Physicians and Surgeons
of Glasgow.— At the monthly meeting, held on Feb. 3rd,
Maior-General Sir William B. Leishman, K.C.M.G., C.B.,
F.R.S., was admitted an Honorary Fellow.—At the same
meeting the following were admitted .as ordinary Fellows :
Dr. Donald MacPhail (Coatbridge) and Dr. John Nairn
Marshall (Rothesay).
Astley Cooper Prize, Guy’s Hospital.— This
prize has not been awarded for 1916-1919 by the trustees,
the physicians and surgeons of Guy’s Hospital. The subject
set was “ Gunshot Wounds of the Lungs and Pleura,” and
the unsuccessful essays will remain at the museum of Guy’s
Hospital until claimed by the authors by letter to Mr.
C. H. Fagge, honorary secretary of the trustees.
Retirement of Professor J. B. Hellier.— Dr.
E. O. Croft has been appointed to succeed Professor J. B.
Hellier in the Chair of Obstetrics in the University of Leeds.
Dr. Hellier's long association with the Leeds Medical School,
both as teacher and adviser on questions of policy, has been
an important factor in its successful development. The
council lias passed a resolution expressing its high appre¬
ciation of the services he rendered to the University suc¬
cessively aB demonstrator, lecturer, professor, and dean of
the faculty of medicine.
Royal Institution.— On Tuesday next, Feb. 18fch,
at 3 o’clock, Captain G. P. Thomson will give the first of
two lectures at the Royal Institution on “ Aeroplanes in the
Great War.” On Thursday, Feb. 20th, Professor H. M.
Lefroy will give the first of two lectures on “ Insect Enemies
of our Food Supplies ” ; the second od Thursday, Feb. 27th,
jon” How Silk is Grown and Made.” The Friday evening
discourse on Feb. 21st, at 5.30 o’clock, will be delivered by Mr.
A. T. Hare on “ Clock Escapements”; on Feb. 28th by Pro¬
fessor J. A. McClelland on “ Nuclei and Ions." On Saturday,
Feb. 22nd, at 3 o’clock, the Hon. J. W. Fortescue will give
the first of two lectures on “ The Empire’s Share in
England’s Wars."
The late Professor George Carey Foster.—
The death is announced of Professor G. Carey Foster in his
84th year. He was appointed to the chair of physics at
University College, London, in 1865, from which he retired
in 1898. He began his professional career as a student of
chemistry, but found the borderland between that science and
physics of peculiar attraction, and his work in this direction
did much to show how interdependent chemical and physical
phenomena are. When we recollect the advances that have
been made in bio chemistry in recent years, we must realise
that the study of the physical side of chemistry, or the
chemical side of physics, has added considerably to the
Bum of knowledge on the working of the human machine.
Professor Carey Foster will be remembered by British
scientific men as one who worked bard to make the British
Association for the Advancement of Science a successful
organisation in its early days.
London Inter-Collegiate Scholarship Board :
Entrance Scholarships and Exhibitions.— Thirty-one
scholarships and exhibitions of an aggregate total value of
about £3075, open to both sexes, and tenable in the faculties of
arts, science, medical sciences, and engineering of Uni¬
versity College, King’s College, East London College, and
Bedford College, will be offered for competition on May 13th
next. Seventeen medical entrance scholarships and exhibi¬
tions of an aggregate total value of about £1550, tenable in
the faculty of medical sciences of University College and
King’s College and in the medical schools of Westminster
Hospital, King’s College Hospital, University College Hos-
{ )ital, the London (Royal Free Hospital) School of Medicine
or Women, and the London Hospital, will be offered for
competition on July 15th next. Full particulars on appli¬
cation to the secretary of the board, Mr. S. C. Ranner, M.A.,
Medical School, King’s College Hospital, Denmark Hill,
London, S.E. 5.
gtebital $iarg for % ensuing Meek.
SOCIETIES.
ROYAL 80CIBTY, Burlington House, London, W.
Thursday, Feb. 20th.—PapersM. Jean Dufrenpy: Note on the
Metabolism of the Glucostdes of the Arbutin Group (com¬
municated by Prof. A. K. Cmhny).—Dr. S. 8. Zilva and Mr.
E M. Wells; Dental Changes in the Teeth ol the Gutuea-pig
produced by a Scorbutic Diet (communicate 1 by Dr. A. Harden).
—Dr W. B Bullock and Dr. W. Cramer: On a New Factor in
the Mechanism of Bicterial Infection (communicated by Prof.
W. Bulloch).—Major W. J. Tulloch : The Distribution of the
Serological Types of B. tetani in Wounds of Men who received
Prophylactic Inoculation, and a Study of the Mechanism of
lafectlon in. and Immunity from, Tetanus (communicated by
Major-General Sir David Bruce).
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-street, W.l.
Tuesday, Feb. 18th.
SPECIAL GENERAL MERTING OF FELLOWS, at 5 p.m.
To consider and, if approved, to confirm the following Resolution
passed by the Council: —
41 That the necessary steps be taken to increase the Subscrip¬
tion of Fellows living or practising within one mile of the
Society's House from Three Guineas to Five Guineas."
Ballot for Election to the Fellowship. (Names already circulated.)
Wednesday, Feb. 19th.
SOCIAL EVENING: at 8.30 p.m.
Dr. Norman Moore (President, Royal College of Physicians) will
discourse on " English Morbid Anatomists.”
MEETINGS OF SECTIONS .
Wednesday, Feb. 19th.
HISTORY OF MBDIOINH (Hon. Secretaries—Charles Singer, Arnold
Chaplin): at 5 p.m.
Paper:
Mrs. Singer: A Survey of the Medical Manuscripts of the British
Isles.
Friday, Feb. 2lst
OTOLOGY (Hon. Secretaries—J. F. O’Malley. H. Buckland Jones):
at 5 p.m.
'sr J. S. Fraser: The ^Radical and Modified Radical Mastoid
Operation.
Mr. Hunter Tod: Accidental Injury of Lateral Sinus during the
Operation of M&stoidotomy.
Members are requested kindly to send cases typical of the opera¬
tions described, at 4 p.m.
BLIOTBO THERAPEUTICS (Hon. Secretaries—Robert Knox, Walter
J. Turrell): at 8.30 p.m.
Paper :
Mr. W. 8&mpson Handley: On the Mode of the Spread of Cancer
in Relation to X-Ray Treatment.
The Royal Society of Medicine keeps open house for
RJLM.C. men and M.O.’s of the Dominions and Allies. The
principal hospitals in the metropolis admit medical officers
to their operations, lectures, &c. Particulars on application
to the Secretary at 1, Wimpole-street, London, W. 1.
ROYAL STATISTICAL SOCIETY, 9. Ad ol phi-terrace, Strand, W.O. 2.
Tuesday. Feb. 18th.—5.15 p.m., Paper:—Oapt. M. Greenwood,
R.A.M.C.(T.): Problems of Industrial Organisation.
SOCIETY OF TROPICAL MEDICINE AND HYGIENE, 11. Chandoe-
street. Cavendish-square, W.
Friday, Feb. 21st.— 5.39 p.m.. PapersDr. J. A. Arkwright, Mr. A.
Bacot, and Mr. F. M. Duncan : The Minute Bodies (Rickettaia)
found in Association with Trench Fever. Typhus and Rocky
Mountain Spotted Fever.—Sir Stewart Stockman: Pathology
and Epi/.ootiology of Louplng-ill, with Special Reference to
Chromatin Bodies in the White Corpuscles.—Mr. C. Bonne
(Paramaribo) (read by Dr. Bagshawe): Has Emetine any Influence
on the Schistosomes ?
LECTURES, ADDRESSES, DEMONSTRATIONS, ftc.
BOYAL COLLEGE OF SURGEONS OF ENGLAND, In the Theatre
of the College, Lincoln’s Inn Fields, W.O.
Monday, Feb. 17th—5 p.m.. Prof. E. S. Schleainger The Treat¬
ment of Compound Fractures and other Severe Injuries of the
Upper Limb.
Wednesday.— 5 p.m.. Arris and Gale Lecture:—Mr. E. M. Corner:
The Nature of Scar Tissue and Painful Amputation Stumps.
Friday.— 5 p.m., Arris and Gale Lecture:-Lleut.-Col. B. M.
Cowell. D.S.O., R.A.M.C.(S.E }: The Initiation of Wound
8hock and its Relation to Surgical Shock.
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith-
road, W.
Special Eight Weeks’ Course of Post-Graduate Instruction (First
Week):—
Monday, Feb. 17th.—10 a.m.. Dr. S. Pinchin: Demonstration on
Medical Cases in the Wards. 2 p.m.. Operations. Mr. Baldwin:
Surgery. 3 p.m , Mr. B. Harman : Diseases of the Eye. 4.30 p.m.,
Mr. Addison : Surgery. 5.30 p.m.. Venereal Diseases Clinic.
Tuesday. — 2 p.m.. Operations. Mr. Pardoe: Genito-Urinary Dis¬
eases. 3 p.m. , Dr. Banks D&vIb: Diseases of the Throat, Nose,
and Ear. 4 30 p.m., Mr. T. Gray : Surgery. 5.30 p.m., Venereal
Diseases Clinic.
Wednesday.— 10 a.m., Operations on the Throat, Nose, and Bar.
2 p.m.. Operations. Ool. Armour: Surgery. 3 p.m., Dr. Slmson :
Diseases of Women. 4 30 p.m., Dr. Beddard: General Medicine.
5.30 p.m., Venereal Diseases Clinic.
Thb Lancet,] , NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Feb. 15, 1919 283
Thursday. —2 p.m.. Operations. Dr. Saunders: General Medicine.
3 p.m., Dr. S. Pinchln: General Medicine. 4 30 p.m.. Dr. G.
Stewait: Diseases of the Nervous System. 5 30 p.m., Venereal
Diseases Clinic.
Friday.— 2 p.m., Operations. Dr. Morton : Radiograph?. 3 p.m ,
Dr. Fernet: Diseases of the Skin. 4.30 p.m., Major Pritchard:
Clinical Pathology. 5.30 p m., Venereal Diseases Clinic.
DNIVBR8ITY OP LONDON, KING'S COLLEGE, AND KING’S
COLLEGE FOR WOMEN.
Course of Six Public Lectures arranged in conjunction with the
Imperial Studies Committee of the University on Physiology and
National Needs: —
Wednesday. Peb. 19th.—5.30 p.m.. Lecture III.:—Prof. F. G.
Hopkins: VI .amines. Unknown but Essential Accessory Factors
of Diet.
KING’S COLLEGE HOSPITAL MEDICAL SCHOOL (University of
London;. atthe Lecture Theatre of the Medical School, King’s College
Hospital, Denmark Hill, S.E.
Course of Pour Lectures on Malaria. Microscopic specimens and
lantern slides will be shoun at this lecture.
Friday. Peb. 2Ut.—12 noon, Lecture IV.:—Col. 8ir Eonald Boss,
K.C.B., K.C.M.G., F.H.8. Officers and Men of the Royal Army
Medical Corps are invited to Attend.
ROYAL INSTITUTE OF PUBLIC HEALTH, in the Lectnre Hall of
the Institute, 37, Russell-square, W.O.
Course of Lectures and Discussions on Public Health Problems under
War and After war Conditions :—
Wednesday, Feb. 19th.—4 p.m., Mr. P. C. Yarrier-Jones: The
Future of the Tuberculosis Problem.
facanats.
For further information refer to the advertisement columns.
Birkenhead Borough Hospital — Jun. H.S. £170.
Birkenhead and Jt’trraf Children’s Hospital, Woodchurch-road. — H.S.
Brighton, Royal Sussex County Hospital.— Jun. H.S. and Asat. H.S. £80.
Burton-upon-Trent County Borough -Asst. M.O £350.
Coventry and Warwickshire Hospital — Rea. H.P. £200.
Derbyshire County Council —Venereal Disease* Officer.
Dorchester. Dorset County Asylum.— Second Asst. M O. £300.
Dudley, Quest Hospital and Eye Infirmary.— Asst. H.S. £120.
Fulham, Metropolitan Borough. Female Asst. M.O. £506.
Glasgow Eye Infirmary.— Res. Med. Supt. and H 8. £300.
Gravesend Hospital, Rent.— Locum H.S. £1 Is. per day.
Herefordshire General Hospital.— Hon. P.’s and Hon. S.’s.
Huddersfield Royal Infirmary.—Jun. H.S. £100. .
Lancaster County Asylum. - Temp. Asst. M.O. 7 gs. per week.
Ijceds Hospital for Women and Children.— Hon. Asst. 8.
Leicester Rnyat Infirm ry.— Hon. S. Also H.S. £250.
Liverpool, Brovmlow Hill Poor Law Hospital.— Res. Asst. M.O. £300.
Liverpool Eye and Ear Infirmary — Hon. Asst. Surgeons.
London County Mental Hospitals, (a) Bexley, Kent , (6) Long Grove,
Epsom, Surrey.— Temp. Asst. M.O. 7 gs. a week.
Northampton General Hospital.— Jun. H.S. £15C.
Maidstone, Kent County Ophthalmic Hospital. — Ophth. S.
Manchester Hospital for Consumption and Diseases of the Throat and
Chest. —Bet*. M.O. £2-0.
Middleton-in- Wharfedale Sanatorium, nr. Ilkley.- Asst. Res. M.O. £32$.
Reading, Royal Berkshire Hospital.— H.P. £250.
Rousay and Egtlshay, Orkney. Parish of.—M.O. £300.
Royal London Ophthalmic hospital , City-road, E.C.—Ajut. S. Also
Sen H.S. £150.
Royal National Orthopaedic Hospital.— Rea. H.S. £100.
Serbia Hospital.— 8.
Shantung Christian Cnicersity Medical School ( Tsinanfu,N . China).—
Medical Missionaries.
Sheffield Royal Hospital. — Cas. O. £130. Also Asst. H.P. £120.
Smethwick County Borough.— M.O.H. £800.
Southend-on-Sea County Borough Education Committee.— School
Dentist. £370.
Stoke-on-Trent County Borough.— Temp. Tuberc. O. £550.
Sunderland Royal Infirmary. Children’s Hospital.— Rea. M.O. £200.
Taunton, Taunton and Somerset Hospital.— Sen. H.S. £250.
Tunbridge Wells General Hospital.— H.S. £160.
The Chief Inspector of Factories, Home Office, S.W., gives notice of
vacancies for Certifying Surgeons under the Factorv and Workshop
Acte at Wolston (Warwick), Clevedon, Sheffield, Ballyward, and at
Braemar.
JRarriagei, mi gftxtys.
MARRIAGES.
MacDonald—Speirs Alexander.—O n Feb. 1st, at St. Paul’s Church
Portrasn-square, W., Sydney Gray MacDonald, M.A., M.B., B.c!
Cantab., F.R.C.Si, to Mary Msrtlneau 8pcirs-Alexander (May),
widow of Captain A. R. SpeirsAlexander, I.M.S.
DEATHS.
Archer.— On Feb. lOtb, at his residence at Barnes, after a short illness
Thomas Archer, M.D., C.M. McGill, L.R.O.P. A S Bdln.
Bell.— On Feb. 3rd, at Hastings, James Vincent Bell, M.D., F.R.C.S.
of Bocbester, seed 80 years. ' **
Khory.— On the 5th Feb , at 249, Hackuey-road, E.2, Susan, the teloved
wife of Dr. K. N. Khory, af'er a long illness.
Kitson.— On Feb. 6th, at The Lodge, Beaminster, Dorset. Francis
Parsons Kitaon, M.R.C.S., L.B.C.P., aged 54.
Neshjlm. —On Feb. 5th, at Ellison-place, Newcastle-upon-Tyne. Robert
Anderson Nesham, F.R.C.S^ L.B.O.P. y ’ “ OUBri '
NJL—A fee of 8t. is charged jor the insertion of Notices of Births,
Marriages , and Deaths.
JJtoifs, Comments, mi Jtrsfoers
to ^orrespimients.
PHYSIOLOGY AND THE FOOD PROBLEM.
Last year at King's College a series of free lectures were
delivered by well-known professors from representative
Universities of the country on the important part which
zoology had played in the service of the Empire during the
war. The Beries is being continued this year with the object
of showing how the needs of the nation are being served by
physiology, and on Feb. 5th Professor W. D. Halliburton,
F.R.S., delivered the introductory address, taking for his
text Physiology and the Food Problem. Beginning with a
general >urvev of the relation of physiology to daily life.
Professor Halliburton said that hygiene and pathology were
the direct practical outcome of physiological knowledge.
Science had contributed to the other side of warfare, but tne
physiologist and the physiological chemist had stepped in
to alleviate distress; for example, the deadly chlorine gas
bad become in their hands the basis of new antiseptics.
During the war medical research had progressed rapidly,
and this progress ought not to be allowed to slacken during
the period of reconstruction. Instead of spending millions
a day on war, the Government must be prepared to expend
a few thousands a year in the endowment of research. For
the first time in the history of war biologists and physio¬
logists had been called upen to do national work, and the
present Cabinet, although it contained no .physiologist, had
anatomists at the head of two important departments—Dr.
Addison and Sir Auckland Gedaes—a good augury that
science at last was coming into its own. The Medioal
Research Committee had issued a medical supple¬
ment giving extracts from foreign medical publications
relating to the work done in other countries daring
the war, and he hoped that these supplements would
be continued, and wonld increase in usefulness during
the time of peace. But, be added, such publications re¬
quire State help. Other scientific committees had been
formed, not the least important of which was the Food War
Committee of the Royal Society. Principles had been laid
down upon which food legislation should proceed, and
numerous statistics had been collected which would be of
incalculable value to those who would in the future be
engaged in the administration of food. Much investigation
had been done, but much remained to be discovered, espe¬
cially as regards the effect of the various types of food in
producing energy for different kinds of work. As an inBtanoe
of the investigations which had been carried oat, Professor
Halliburton said that abont the middle of 1917 the fat
shortage became serions because so much was being used in
the manufacture of explosives. After the extraction of
glycerine from the fat the fatty acids remained, and the
question arose as to whether it would be possible to employ
these acids for the various purposes for wbich fats were pre¬
viously used. The Royal Society Subcommittee was asked
whether these substances could be employed as the com¬
ponent part of some butter substitute. The first experi¬
ments were made upon rats. These animals were
comparatively short-lived, and if they were fed on a
particular diet for a few weeks or months it was equivalent
to feeding a long-lived animal, such as a man, over a
longer period. On a diet of fatty acids the rats thrived
and multiplied, and it remained to try the effect of the
food upon man. Professor Noel Paton obtained voluntary
assistants for the test and the experiment proved a com¬
plete success. There was as yet no need for a diet of this
kind, but in case of emergency a source of a supply for fat
was here indicated. A curious fact came out in these
experiments. It was found that if an animal were fed upon
fatty acids they passed into the blood stream as fat, the
animal making its own glycerine, possibly from sugar.
Owing to British enterprise, the manufacture of mar¬
garine had now greatly increased, this success being, to a
large extent, due to the fact that British firms had been
able to give it an agreeable fiavour. The prejudice against its
use had practically died out, but it must be remembered
that the ^reat mass of margarine was made from vegetable
fats. Animal fats had the same energy value as butter, and
animal margarines, with few exceptions, contained vita-
mines, which were not present m the more palatable
vegetable margarines. If, therefore, the children of the poor
lived exclusively on vegetable margarine we should be
running a great risk of becoming a C3 nation. Although
vegetable oils did not contain vitamines, green vegetables
did, but they were not suitable as a food for infants, and if
there was a shortage of milk the babies muBt have the lion’s
share. A pore milk-supply was essential. This had been
secured in America and Australia, and it waB time that the
mother country protected the lives of her ohildren in the
same way. He hoped that under a Ministry of Health
284 Tn Lamott,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Fbb. 15,1019
THE LANCET, February 22, 1919
Jjtmteriait ttratian
ox
BRITISH MILITARY SURGERY IN THE TIME
OF HUNTER AND IN THE GREAT WAR.
Delivered before the Royal College of Swrgeons of Engl ind o>n
Feb. llfth, 1919, the Anniversary of Hunter's Birth ,
By Sm ANTHONY BOWLBY,K.C.M.G.,K.C.V.O.,C.B.,
TEMP. MAJOR GENERAL, A.M.3. ; CONSULTING SURGEON, BRITISH ARMIES
1H TRANCE; SURGEON IN ORDINARY TO H.M, THE KING;
SURGEON TO ST. BARTHOLOMEW S HOSPITAL.
From Pare to Hunter: Lack op Progress.
In the year 1792 John Hunter finished the last of his works
and dedicated it “ To the King.”
•• May It please your Majesty.
In the year 1761 1 had the honour of being appointed by your
Majesty a surgeon on the staff in the expedition against Belleiale.
In the year 1790 your Majesty honoured me with one of the most
Important appointments in the Medical Department of the Army, in
fulfilling the duties of which every exertion shall be called forth to
render me deserving of the trust reposed in me and not unworthy of
yonr Maj asty’s patronage.
The first of these appointments gave me extensive opportunities of
attending to gunshot wounds, of seeing the errors and defects in that
branch of military surgery, and of studying to remove them. It drew
my attention to inflammation in general, and enabled me to make
observations which have formed the basis of the present Treatise. That
office which I now hold has afforded me the means of extending my
pursuits and of laying this work before the public.”
This dedication is dated “Leicester Square, May 20th,
1792,” although Guthrie states that “the work was not
published until 1794 ”—i.e , the year after Hunter’s death ;
but in spite of the fact that more than 30 years had passed
since the period of Hunter's active service before he
published his treatise, yet his interest in what he had seen
at Belleisle remained so keen and his description of indi¬
vidual cases is so vivid that it might easily be supposed he
was describing events of very recent occurrence. The whole
“ Treatise ” is quite short, and occupies only 56 pages in the
octavo edition of 1828.
In the “Roll of Commissioned Officers in the Medical
Service of the British Army,” by the late Colonel William
Johnston, C.B., and published in 1917, Hunter’s record reads
as follows:—
"John Hunter, 8urgical Staff, Great Britain, 30th October, 1760.
Half pay, 1764. Full pay. Assist. Surgeon General, 4th January, 1786.
Surgeon-General and Inspector of Regimental Hospitals, 17th March,
1790. Died October, 1793. Belleisle, 1761. Portugal, 1762.”
An interesting fact which is not commonly known is
supplied in this brief statement, for it appears that Hunter
had acted as “Assistant Surgeon-General” for four years
before his appointment as Surgeon-General.
At the time when Hunter went to Belleisle just 200 years had passed
since Ambrolae Par£ had published his collected works, and it is not too
much to say that military surgery had not advanced materially since
his death in 1590. This lack of development was certainly not due to
lack of opportunity, for the 200 years had been years of war, and fire¬
arms had quite replaced the arrows and bolts which in Park's day were
still frequent causes of Injury, in spite of tne then recently Invented
calverlns and arquebuses.
A hundred years later than Pare, the great English surgeon,
Wiseman, had written the most Important treatise published since the
time of the French master, and in the aame year that saw the attack on
Belleisle, Ranby, who hid attended King George the Second In his
Flanders campaigns, published a little book on gunshot wounds.
In France the successor to Pare was Le Dran, who in 1740 produced a
considerable work on gunshot wounds based largely on ParA
It would appear that the authors I have here enumerated
were the only guides to whom Hunter could have turned for
help and counsel when he set out to the wars. It is,
however, noteworthy that he does not refer by name in his
treatise to any surgical author at all, and that on the other
hand be notes—
"Little has been written on the subject . and what has been
written ia so superficial that it deserves but little attention.”
It was, indeed, left for the following century to provide at
its very commencement the men whose work, expanding and
extending that ef Hunter, laid the foundations of the
military surgery of the nineteenth century, and the names of
Larrey in France and Guthrie in England will for ever be
associated in this connexion.
Hunter’s War Experiences.
It is of interest to glance for a moment at the wars of
John Hunter’s life-time.
No. 4982
Marlborough’s campaigns had ended in 1711, before Hunter’s birth,
after his successful, but fruitless, attack at Arletix on the French line of
trenches which lay across France from Nnmur to the sea at Montreull,
but Hunter was a youth of 17 years when, in the campaign of 1715, the
battle of Fontenoy was fought. From tnat time until shortly before
the attack on Belleisle there was a lull In the fighting and again, after
1763, there ensued a long period of peace, as far as England was con¬
cerned, except for the wars in America aud India. It thus happened
that the opportunity for further work in military surgery was lacking,
and Hunters careful notes of his eases made in 1761 remained without
the additions which further wars would no doubt have provided.
His experience of military surgery in the field was thus
limited to the Belleisle and Portuguese expeditions, and a
brief description of these little known naval and military
operations in which Hunter served will not, I think, be out
of place. To Mr. A. D. Cary, the librarian of the War Office,
I am much indebted for some of the following details.
Belleisle.
The first of these expeditionary forces consisted of about
10,000 troops under the command of General Hodgson, and
was escorted by a powerful squadron of eight ships of the
line and several frigates under Admiral Keppel. Its object
was the capture of the island.
Belleisle is off the coast of Brittany and is about 12 miles in its
greatest length and about 5 miles in Its greatest width. It Is sur¬
rounded by precipitous cliffs and forms a natural fortress. The chief
town was on the northern edge of the Island and was protected by a
citadel, garrisoned by about 4000 men under the command of the
Chevalier de Saint Croix.
According to the French historian, this garrison was very insuffi¬
cient, and "Saint. Croix, in order to deceive the British as to its
numbers, mounted 50 volunteers on farm horses of the island, his
efforts being admirably seconded by the female population. The
women asked permission to help in this deception, Rnd formed a
squadron clothed in red capes. Those who- had no horses mounted
cows.” (Waddington’s " La Guerre de Sept Ans.”)
The first attack took place on April 8th, and after an initial success,
resulted In the repulse of the British with the loss of about 450 killed,
wounded, and prisoners. Of these there were rescued 75 British
wounded, and there were also captured 51 wounded Frenchmen. All
these appear to have b ien taken for treatment to the ships. A second
attack on April 22nd was successful in occupying the island and driving
the defenders Into the citadel, where they withstood a siege for nearly
two months, and finally surrendered on June 7th.
The French estimate of their own losses was 200 killed and 450
wounded, while Fortescue states that " the losses of the British
throughout the wholo of the operations were about 700 killed and
wounded,” and he adds: "Thus was Belleisle secured as a place of
refreshment for the fleet.” It was restored to France on the conclusion
of peace in 1763.
j Portugal.
After the capture of Belleisle Hunter remained as one of
its garrison for nearly a year, for it was not until the summer
of 1762 that the opportunity came for some of the troops to
embark on an expedition to Portugal, and there is no doubt
that he accompanied this force.
The explanation of this event is thus described by Fortescue: —
"The Spaniards on the pretext of Portuguese friendship with
England, in April 1762, invaded Portugal, overran that country as far
as the Douro from the North, and threw another force against Almeida
from the East. The injured kingdom appealed to England for help,
and in May orders were sent to Belleisle for the departure of four
regiments of infantry together with, a detachment of the Sixteenth
Light Dragoons to Portugal. Two more regiments were added from
Ireland, bringing the total up to about 7000 men.” (Fortescue’s
" History of British Army,” vol. II., p. 516.)
The force stood on the defensive to cover Lisbon and the line of the
Tagus, but on August 27th Brigadier-General Burgoyne with 400 troops-
and the Grenadier company of the Buffs surprised and annihilated a
regiment of Spanish infantry and took Valentia with very few
casualties.
On Oot. 4th another attack again took the enemy by surprise and
resulted in the capture of six guns and other booty, with great loss to
the Spaniards, but at the cost of only one man killed and eight
wounded to the British. The results of this expedition are thus
summed up in the "Historical Kecords of the Third Foot” (The
Buffs): —
"This advantage being obtained at a critical moment was attended
with important consequences; the enemy was disheartened, the season
for military operations was far advanced, heavy rains fell, the roads
were destroyed, and the Spaniards fell hack to their own frontiers.
Thus Portugal was saved by British valour and British skill.”
Such, in brief, were the two expeditions in which Hunter
saw active service, and it would appear that in Portugal
there were very few casualties.
It Is probable that in the Belleisle expedition the wounded numbered
about 500, although by no means all of them could have been under
Hunter's care. It is. however, likely that some of the patients were
kept on the island until they had recovered, and so were under treat¬
ment for a long time.
It Is also evident that a certain number of the French wounded were
left to the care of the British surgeons, for it was provided by Article XI.
of the capitulation that " the officers and soldiers who are in hospital in
the town and citadel shall be treated in the same manner as the
garrison, and after their recovery shall be furnished with veuels to
carry them to France.”
Hunter's Position at Belleisle.
The actual position occupied by Hunter during his stay on
the island has hitherto been somewhat uncertain. 1 have,'
286 The Lancet,]
SIB ANTHONY BOWLBY: THE HUNTERIAN ORATION.
[Feb. 22,1919
however, been fortunate enough to be supplied by Professor
F. Wood-Jones with a letter which shows that Hunter was
not merely one of a surgical staff, bat was in charge of the
hospital, for in addition to his appointment as “staff
surgeon,” he is described as the “ Deputy Purveyor,” and in
that capacity he was supplied by the Government with
money to be spent on the hospitals by himself. The letter is
dated April 12th, 1762, and was written only a short time
before the forces at Bellelsle were embarked for Portugal.
It is as follows:—
“ Bellelsle, 12 April, 1762.
Sib,— The Hospital here being In want of moneyas appears by a letter
aent to me this day by Mr. John Hunter, the Deputy Purveyor thereof,
a copy of whloh is hereunto annexed, I have in compliance therewith
issued my warrant to you of the same date as this letter for the sum of
Two Hundred Pounds payable to the said Mr. John Hunter for the use
of the said Hospitals, without deduction, but upon account, and do
hereby direct and desire (as the Lords of the Treasury have not issued
any money to you for the contingencies of this garrison) that you will
pay the same out of the money which you have in your hands for the
subsistence of the Troops here.
I am. Sir,
Tour most humble servant,
To Charles Bembridge, Esq., H. A. Lambert.
Deputy Paymaster-General to Forces at Bellelsle.”
An examination I have made of the “Journals of the
House of Commons” has disclosed other payments as
follows:—
“ December27th, 1761, to John Hunter, Esq., for the use of the Hos¬
pital £300.0.0.”
" Mar.h 10th, 1762, to John Hunter, Esq, for the use of the Hospital
£ 100 . 0 . 0 .”
"April 12th, 1762, to John Hunter, Esq., for the use of the Hospital
£ 200 . 0 . 0 .”
It teems, therefore, that Hunter was both the staff
surgeon and also the Chief administrator of the British Hos¬
pital at Bellelsle. But, small though the number of
wounded was in those days when compared with the tens
of thousands of the present day, it is evident that at
Belleisle it was sufficiently large to provide Hunter with
food for much thought and study. He had no other duty
except to care for his soldier patients, no other problems to
solve save those of gunshot wounds, and we can picture him
on the sea-girt cliffs pondering over the questions which
presented themselves to his busy brain and shaping the
newly born thoughts of inflammation suggested by his first
experience of war.
It seems to me very possible that we owe more to that
period of contemplation on the remote island of Belleisle
than has ever yet been guessed, and as we find Hunter him¬
self saying of his experience of war 30 years later, “ it drew
my attention to inflammation in general,” we shall not be
far wrong if we conclude that the germs of much of his
most important later woik were brought to life in the
quietude which followed the siege and capture of the citadel.
The Military Medical Services in the Eighteenth
Century.
At the time of Hunter’s appointment as Surgeon-General
in 1790 the Army had but one Physician-General and one
Snrgeon-General, who were elected from the ranks of
eminent oivilian practitioners of the day, and it was the
duty of the first to supply physicians to the Army and of the
second to examine all candidates for appointments as sur¬
geons. The Surgeon-General also recommended surgeons
and “surgeons’ mates” for appointments “to hospitals and
regiments.
In times of peace these duties were not arduous, for the
standing Army was small, but when in 1793 we were obliged
to raise ever-increasing armies for the war in Flanders it
beoame impossible to provide the necessary surgical staffs.
Hunter must have had many anxious hours at a time when
his health was failing, for his own death occurred within
six months of the declaration of war. I will therefore ask
you to consider the condition of the Medical Services in the
eighteenth century and the difficulties which were inherent
in supplying the troops with efficient medical officers.
Inadequate Pay and Status.
The Army Medical Service both before and during Hunter’s
lifetime left very much to be desired, and the pay and status
were such that they offered no inducement to men of skill
or learning.
John Woodall, writing in 1639 in his book called “ The Surgeon’s
Mate,” says : •• And for tne surgeons in his Land service he (The King)
alloweth to the Surgeon-Major of the wholecampfiveshillingsaday. Also
his Majestie alloweth to each Surgeon two shillings and sixpence a day,
which is three pounds and fifteen shillings a month, and to each Mate
three pounds a month.And further His Highness hath referred to
the ancient Masters and Governors of our Society (i.e. the company of
Barber-Surgeons) the pressing of all Surgeons and Surgeon's Mate* or
servants to Surgeons and Barbers.” It is therefore evident that, aa the
pay was not a sufficient inducement, surgeons were "pressed” or
forced, as seamen were forced by press-gangs, to join the service when
war oalled for surgical help.
More than a hundred yean later, and consequently after Hunter’s
experience at Belleisle, the inducements to serve were still not ixn-
roved, for in 1787, only three years before Hunter’s appointment as
urgoon-General, Robert Hamilton wrote: "Each regiment Is allowed
a Surgeon, as he is termed, and a Surgeon’s Mate. Their business Is to
attend to the diseases of the men at all times whenever it is judged
necessary. For this service the surgeon is allowed four shillings a day;
the mate three and sixpence. But out of this are levied from them
considerable duties; from the surgeon a shilling, and from the mate
sixpence a day. This makes their subsistenoe equal, so that each is
limited to a guinea a week, and on this they must subsist as well as
they can.”
The pay of John Hunter as staff surgeon is uncertain, but
was probably ten shillings a day, and he also had another
ten shillings as “ Deputy-Parveyor.” He joined the Army
for the Belleisle Expedition chiefly in order to obtain a
change of duties and surroundings after illness and over¬
work in London ; when the war came to an end he returned
to his studious life, and started practice in Golden-square at
the age of 35.
It is evident that one of the ohief causes of inefficiency in
the medical service in the eighteenth century was the
custom of employing ignorant and often uneducated men as
* * surgeon’s mates. ”
The mate was the assistant of the surgeon and was usually
unqualified, except that he might have been a surgeon’s apprentice In
civil practice. Some few, it Is true, were well-educated men who had
attended loot urea on anatomy, surgery, and medicine, but all of them
were only " warrant officers ,r and did not hold commissions.
So long as there was no war to make demands for an increase of the
staff of surgeons the evil was not very great, but in 1793, on the out¬
break of war with France, "an increase of the hospital establishments
of the Army became necessary, and, the pay of ‘ hospital ’ mates being
higher, many ‘regimental mates’ transferred to the hospitals as
* hospital mates.’ An increase In the number of surgeons led to the
promotion of many regimental mates, and many also purchased
commissions.” (Colonel Johnstone.)
The result of this was, first, that many of the men who now held
commissions as surgeons were very ignorant fellows, and second, that
the places of the promoted mates were filled by men of low class, most
of whom had no surgical knowledge at all, but were yet in control of
the treatment of hundreds of men. For example, we read that on one
occasion “ five hundred invalids were embarked from Anaheim In
barges under the care of a single surgeon’s mate without sufficient pro¬
visions and without even straw to lie on.” (Fortescue: "British
Campaigns In Flanders.”)
Bad State of Medical Sertrioe in 1793-4 -
But, not only was the pay and status of the surgeons
bad, the administration of all the Army was on a thoroughly
unsound footing, for, after Marlborough’s time its efficiency,
or the reverse, depended on the Minister in power in England
for the time being.
Military history shows that in the campaigns of 1793 and 1794, just
when Hunter’s work was published, mismanagement and incapacity
in the Government had reduced the whole Army to a state of
inefficiency and chaos. Thus, Fortescue writes: "The men were
imperfectly disciplined, there were no efficient company officers to
look after them ; no efficient colonels to look after the company
officers; no generals to look after the colonels. ....... *No effort
was made to clothe recruits, who received a linen jacket and trousers,
and many were sent on active service In this dress, without waistcoat,
drawers, or stocklngB.” (Fortescue, p. 372.) So bad indeed was the
supply of army clothing that great-coats were supplied to some
regiments by public subscription. The medical service was such as
might be expected when ;the Army, as a whole, was in this condition,
and the state of affairs in July, 1794, is described as follows
" But the very worst department of all was that of the hospitals
wherein the abuses were so terrible that men hardly liked to speak of
them. Some kind of a medical staff was improvised out of drunken
apothecaries, broken-down practitioners, and raguea of [every descrip¬
tion. who were provided under some cheap contract; the charges of
respectable members of the profession being deemed exorbitant. ..
* The dreadful mismanagement of the hospitals is beyond description,
wrote General Craig.” (Fortescue.)
It will be noticed that this explanation of the rotten state
of the medical service was the unwillingness to spend the
money necessary for efficiency, and it requires but little
study to realise that gross maladministration and peculation
of public money were at the root of most of the troubles in
all departments of the Army.
Hunter had been appointed in 1790 to be “ Inspector-General of
Hospitals and Surgeon General In the Army,” but he had died on
Oot. 16th, 1793, before the breakdown I have mentioned above. As far
as I can ascertain, however, his authority did not in any case extend
overseas, and, even had it done so, it is quite certain that he would
have been powerless to check abuses which originated In maladminis¬
tration of Ministers In England, and which resulted ultimately In the
armies being so starved of supplies of food and clothing that by
November, 1794, there were 11,000 sick out of a total foroe of infantry of
21,000. It is not too much to say that the collapse and defeat of the
British forces in Flanders at that time were brought about more by the
want of ordinary care for our troops than by anything else. Even the
best 'medical service Is pow erless when no provision is made for the
ordinary necessaries of life, especially if the combatant officers are as
Ignorant and inefficient as were very many of them at that time.
Tb* Lance*,]
SIR ANTHONY BOWLBY: THE HUNTERIAN ORATION.
[Feb. 82,10W 287
) A Modern Contrast.
In the present wkr the splendid health of our armies has
mot been due solely to the work of the medical service daring
the war, good though that has been. It has also been dne to
the Inst ruction of the combatant officers before the war in
the value of good hygiene and of the proper care of the men
ms camps and billets. This, in its tarn, has been supported
by the abundance and excellence of the supplies of food and
clothing which have everywhere followed our troops through¬
out the campaign in a never-failing stream ; while the super¬
vision and supply of drinking-water, the precautions taken
to destroy flies and to burn refuse, to inspect and cleanse
billets, Ac., have all contributed to save life and to avoid
etokness.
The result is that the invaliding rate from preventable
disease in the fourth and fifth years of the present war has
been no more than the same rate in times of peace, and
while the war in Flanders at the end of Hunter’s life failed
largely because of the immense loss to the forces caused by
the sickness of the whole Army, it is not too much to say
that in the present war much of the efficiency and fighting
power of the British troops has resulted from the good
health and the consequent high spirits of all ranks. The
records of many sieges have proved that sick and half-
starved men may hold on to a defensive position and fight
well to the last, but it is only robust, vigorous, and thoroughly
healthy troops who are capable of enduring the immense
efcrain of pressing home for many weeks in rapidly succeeding
battles such a strenuous and victorious offensive as that
initiated by the British Army on the over-memorable day of
August 8th, 1918, and consummated in the armistice of
Nov. 11th.
Hunter's Writings on Gunshot Wounds.
It is very difficult properly to appreciate the value of
Hunter’s writings on gunshot wounds at the time of their
publication, but their interest for surgeons can be better
estimated if it is remembered that no one had previously
written much about these injuries for many years, and that
Hunter’s great reputation and his position as Surgeon-
General compelled the attention of everyone connected with
the medical service.
Superstition and ignorance had united to create the belief that there
was something about a gunshot wound which rendered it quite unlike
any other, and, to use Hunter’s own words, “ they have been considered
apart from other wounds and are now become almost a distinct branch
ofsurgery." He then proceeds to point out that they are essentially
“contused wounds,” although they have certain peculiarities due to
the passage of foreign bodies Into the tissues, and that they should be
treated on ordinary commonsense principles.
Hunter was the first to clearly appreciate and teach that In the
«U D *bot wounds of his time “a part of the solids surrounding a wound
is deadened. and is afterwards thrown off as a slough, which
prevents such wounds healing by the first intention." He pointed out
how the separation of a slough might open a part of a large artery or a
portion of intestine.
’HtTftttlised that “ the greater the velocity of the bullet the cleaner it
wounds the (soft) parts.’
He noticed that “when the velocity Is small the direction of the
wound produced by the ball will, in common, not be so straight, there¬
fore Its direction not so readily ascertained, arising from the easy turn
of the ball.”
He taught the much-needed lesson of not interfering with any
wound unless a definite object was to be gained. He wrote : “ We must
see plainly something to be done for the relief of the patient by this
opening (of the wound) which cannot be procured without it,” and
fae was able by his influence and reputation to alter the practice of the
routine opening up of every bullet wound, regardless of any indication
for so doing, which was a universal custom before he challenged It.
His descriptions of peritonitis following intestinal injury and of infec¬
tion of a haemothorax caused by a wound of the lung are masterpieces
of observation and perception, and his opinion that a hemothorax might
be advantageously treated by emptying the blood from the pleura
coincides with the practice of the present day.
Hunter’s Views on Primary and Secondary
Amputations.
Ib is evident that Hunter felt, as all surgeons have felt,
the difficulty of deciding the best time for toe removal of a
hopelessly smashed limb, and it seems also clear that his
experience of “primary” amputations, with the primitive
methods of that day, had been bad.
The consequence was that he advocated delay, more especially when
the lower extremity was concerned, but It is not clear what period of
delay he had In his mind, for he does not indicate at all how maoy days
he would wait. Here is his view : —
“ In general, surgeons have not endeavoured to delay it (amputation)
till the patient had been housed and put in the way of cure; and
therefore it has been a common practice to operate on the field of
battle; nothing can be more Improper than this practice, for the
following reasons. In such a situation it is almost Impossible for a
surgeon In many Instances to make himself sufficiently master of the
caae, so as to perform so capital an operation with propriety; and it
admits of dispute whether, at any time and at any place, amputation
should be performed before the first inflammation is over."
Again: “ The only thing that can be said in favour of ampnfaation on
the field of battle is that the patient may be moved with mote eeee
without a limb than with a shattered one.bat it may be obeenreB
that there will be little occasion to amputate an upper extremity in
the field, beeause there will be less danger In moving such a pate
than If the Injury had happened to the lower.”
There is no doubt that modern surgeons would not agree
I that obviously necessary amputations should be delayed for
several days, and would advocate their performance as soon
as the condition of the patient permitted it. But we must
remember that in the year 1760 methods of averting hemor¬
rhage were very primitive, and that severe loss of blood
from an operation which followed soon after the primary
hemorrhage due to the injury might well prove fatal, whoa
delay might have lessened the risk.
Guthrie’s Advocacy of Primary Amputation.
In 1815 Guthrie published his book on “ Gunshot Wounds
of the Extremities Requiring the Different Operations of
Amputation,” and in it he strongly defended primary ampu¬
tations and opposed with excellent reason the advioe given
by Hunter. In this he was certainly in the right, and largely
because his opinions were founded on a very extensive
experience.
Guthrie at the time I allude to was very young In years, for he wee
only aged sixteen when he joined the Army in 1801 as assistant surgeon.
But the time he had spent In the Peninsular War had been a time of
oonstant fighting, and his talents and skill had quickly earned for him
a most responsible position In which he had opportunity for muoh
operative surgery.
I therefore desire to direct your attention to the results whioh he
a uotes In support of his own views and In opposition to the advioe of
[unter. These relate to (A) primary operations on the field of battle
(Toulouse); (B) secondary operations in general hospitals (Toulouse).
(A) Primary (B) Secondary
amputations. amputations.
Total. Died. Cured. Total. Died. Cured.
Upper extremities...
7
... 1 ...
6 ...
... 15
... 3 ...
12
Lower extremities ...
40
... 8 ...
32 ...
... 36
... 18 ...
18
Total.
47
9(19°/ 0 )
38
51
21 (41°/ e )
30
To these figures Guthrie supplies the comment: “ The medical
duties both in the field cn the day of action and In the Hospitals
afterwards until the final evacuation of Toulouse were more Imme¬
diately under my observation and control ”; so that it is clear that the
figures given represent the final results.
But 1 do not quote these figures merely for the purpose of
showing that the practice of primary amputation was to be
preferred to that of secondary, but also to draw attention
to the fact that these results of primary amputation must be
considered very good, and to ask the question how it was
that these patients did so well.
No doubt one very Important reason was that at the end of the
Peninsular War surgeons had become very expert in the act of removing
a limb, for the amputation rate was exceedingly high, and In the
battle of Toulouse itself no less than 98 patients lost a limb out of a
total of 1407 wounded, or about 1 In every 15.
It must also bo remembered that In many patients Ihe injury which
justified amputation In those days was not necessarily so severe a* to
Induce a serious condition of shock, for many amputations were done
not so much because of the serious condition of the limb at the moment
as on account of the complications which could by experience be
foretold. Thus, It was well known that in few patients with fracture
of the femur could life or a useful limb be saved, and all wounds of the
knee-joint complicated by any fracture were also treated by amputa¬
tion, conditions for which in the present war we should very rarely
advise removal of the limb unless there were serious com pile ationa.
But although Hunter’s advice to wait for amputation until
“the first inflammation is over” was not accepted by his
successors, it must be noted that we do not ourselves
advocate operation “on the battlefield,” nor should we in
these days be satisfied as easily as Guthrie, who says :—
"The "military surgeon should never bo taught to expect any con¬
venience; his field-pannier for a seat for the patient, and a dry p'ece
of ground to spread his dressings and Instruments upon are all that are
required.’’
We should further note that Hunter himself advocates
removal of a limb at once ‘ ‘ if the parts are very muoh torn
so that the limb only hangs by a small connexion,” and
also that ‘ * it may be necessary to perform the operation to
get at blood-vessels which may be bleeding too freely.”
Primary Amputations at the Present Day.
Let me ask you to consider the treatment of gunshot
wounds by primary amputation at the present day.
Tn the first place, many surgeons besides myself have always advised
that a completely shattered limb should be removed as soon as the
patient can be brought into a field ambulance, unless his condition is
such as to prohibit any operative treatment at all. There Is no doubt
In the minds of careful observers that the keeping of such a limb, even,
for a short time, is most prejudicial to the patient, probably to some
extent because of the absorption of toxins from the smashed musoles (
and that as soon as he is rid of It his condition Improves.
In proportion as shock is severe and the limb is nearly severed, it Is
not, however, advisable to do at once a formal amputation above the
288 The Lancet,]
SIR ANTHONY BOWLBY: THE HUNTERIAN ORATION.
[Feb. 22,1919
•eat of Injury—especially If the lower extremity be the one concerned— j
and It is enough at the moment to sever the remaining tissues with
knife or scissors, to tie bleeding vessels, apply a dressing, and then to
leave the patient to Improve before more is done. This severance of
the remaining tissues of the limb requires no amesthetto save a small
doee of morphia and the tight application of a tourniquet, for the
latter causes so much numbness that no pain is felt from the procedure
I have advocated.
It is especially inadvisable to give chloroform or ether if the condi¬
tions require the early evacuation of the patient or if a formal opera¬
tion under an aneesthetlc is shortly to be performed. A second
administration of these anaesthetics after an Interval of only a few
hours has proved most harmful in such patients, and should certainly
be avoided.
In other cases where the limb Is not completely shattered but yet
requires removal, it is generally best to splTnt It carefully and to send
the patient to a casualty clearing station, where he can be put to rest
in a warm place and be carefully tended till he has recovered from the
effects of the journey and has taken plenty of fluid and has slept.
After that there is generally n* object in further delay, but in many
cases it is necessary, in order to get the patient into an "operable"
condition, to administer fluid of some kind either per rectum or by intra-
venoui injection. For the latter purpose we nave used with good
results a 6 per cent, solution of gum arable, or, if the loss of blood has
been excessive, a pint or more of blood has been transfused, and by
these means many lives have been saved.
I have already mentioned the inadvisability of two
administrations of ether or chloroform, bat where a patient
is goffering from severe shock or haemorrhage even a single
ansesthetisation by either of these is very definitely dangerous,
and may be quite enough to turn the scale in the wrong
direction and prevent recovery.
I believe that in such cases as we are considering it is safer to give
no anaesthetic than to give chloroform, and ether is not much better.
Far the best method of anaesthesia is the administration of gas and
oxygeti, and amputations may often be performed when the pitient is
under the influence of this anaesthetic which could not be done at all
without it.
I am indeed inclined to believe that the success in primary amputa¬
tions of Guthrie and his contemporaries would have been diminished
if chloroform could have been given, and I am quite convinced that it
should never be employed in such oases.
Daring the present war we have gradually but steadily so
improved our methods of treatment of men with severe
shook caused by smashed limbs that we are now able to save
patients by amputation of an extremity who would previously
have died without operation being possible. On the other
hand, we are also able to save very many limbs which would
four years ago have been lost. Whereas in our longest estab¬
lished general hospitals about one patient in every 100
wounded men lost a limb in 1914-15, in the same hospitals
during the past year amputations have been performed in
only about one patient out of every 200.
Gas Gangrene.
It is a curious fact that Hunter has practically nothing to
say of the complications of gunshot wounds, and it is evident
that those he saw left but little impression on him. In the
present war the frequency of “ gas gangrene” has greatly
impressed all surgeons, for in civil practice it was practically
unknown, and its frequency came as a rude shock to the
aseptically trained operator. But if it be asked, “ Did gas
gangrene occur as a common complication in Hunter’s time,
and has it been of frequent occurrence in other wars?’*
I believe that the reply should be in the negative. My own
belief is that in no previous wars has gas gangrene ever
played so predominant a part as it has in France and Belgium
in the early part of this war.
It must be admitted by all that acute gas gangrene is so striking and
terrible' a malady that it could not possibly have been overlooked if it
were at all frequent. Yet I find no description of It In Hunter’s work
or in those of any of the early writers on war surgery, and although
the latter wrote chapters on the subject of gangrene or" mortification,’’
It Is evident that they refer to that which Ts due to vascular lesions or
else to an extensive smashing of a limb followed by sepsis.
It lsoertatn that the so-oalled " hospital gangrene,” so fully deicrlbed
by Larrey as " pourriture des hOpltaux," was not gas gangrene, but a
spreading septic ulceration which characteristically did not ocour soon
alter injury, but rather in suppurating wounds, and was of the same
nature as the " sloughlng-phagedeena, whioh not so many years ago
was rife in wards for venereal diseases. And Larrey’s contemporary in
the French Army, Baron Percy, and Guthrie in the British Army, give
no description of a disease occurring in the Peninsular War resembling
the gas gangrene of the present day.
There is no mention of its occurrence, and still less of its prevalence,
in the Crimean War; while Professor W. W. Keen, who himself served
in the American War, writes to-day: “ Personally I never saw a single
case in the Civil War."
Various French writers described cases of gas gangrene in the Franco-
German War of 1870, but, although there is no doubt of its occurrence
at that time, there Is no evidence that it was generally prevalent.
Coming to still more reoent times, gas gangrene never occurred in
the South African campaign, and was of quite rare occurrence In the
Busso-Japanese War. Finally, I have personally inquired of many
surgeons who took part in the Balkan War of 1913, and there is no
doubt in their minds that it was very seldom seen.
In the present war gas gangrene has been practically unknown in
Mesopotamia, Egypt, or Palestine, and I am informed that it did not
oocur in the early days of fighting at Gallipoli, although it wa»
occasionally seen later on. At the Salonika front it has been of com¬
paratively rare occurrence, and it has not been nearly so prevalent on
the Italian front as in Flanders.
Incidence of Gat Gangrene.
It is well known that at the beginning of the war in
France and Belgium the medical services of all the com¬
batants were quite inadequate to deal thoroughly with the
immense number of wounded. Most of the latter at the
time of the retreat from Mons and in the fighting on the Aisne
had to be evacuated to base hospitals before any complete
surgical treatment could be carried out. There were prac¬
tically no “hospital trains” in those days, and the railway
services were so crowded with supplies for the armies that
traffic of all kinds was excessively slow. The result was
that the wounded, placed when opportunity offered in the
luggage-vans of empty returning supply-trains, were
frequently several days in reaching their destination after
being wounded, and great numbers of them were suffering
from extensive gas gangrene on arrival, or else had
succumbed to it en route.
Daring the ensuing “ First Battle of Ypres” and tha
succeeding winter it was still an exceedingly frequent com¬
plication, but diminished very much during the next
summer, when there was also much less fighting, until the
battle of Loos in September, and during this battle it wae
much increased. In 1916 it was less evident until the heavy
casualties of the battle of the Somme filled the hospital*
with wounded, many of whom developed gangrene; and
during the fighting at Arras and Vimy in the cold and
stormy spring of 1917 there were still very many cases, in
spite of good surgical work at the front. From that time r
now nearly two years ago. gas gangrene has rapidly
diminished, and during the year 1918 it has been compara¬
tively little in evidence, at any rate in its worst forms, as
will be gathered from the following samples of figures from
the base hospitals during heavy fighting.
A. Of 5270 cDusecutlve patients from the Mesilnes battle (In Jane,
1917) there were only 22 cases of gas gangrene.
B. Of 3690 conseeutlve wounded at the beginning of the Passchendaele
fight (in August, 1917) there were only 16 cases of gas gangrene.
G. Of 3200 at a later stage of the Bsme fight 7 cases.
D. Of 2900 patients In July, 1918, there were 11 cases of gas gangrene.
B. Of 10,000 wounded in August, 1918, there were 27 cases.
It will therefore be seen thit out of a total of about
25,000 patients at base hospitals, only 84 patients-
had serious, or “ massive,” gas gangrene; an incidence of
about 1 case in 300 wounded men, and many of these had
multiple wounds or badly smashed limbs.
Causes of Lessened Incidence of Gas Gangrene .
If the question is now asked as to what causes account for
the great diminution of this grave affection in 1917-18, it
must first of all be noted that:—
(a) The ascertained cause of gas gangrene is the presence of certain
well-recognised anaerobic organisms which are.’ present in highly
dunged and cultivated soil, and are absent from that of Che South
African veld or the sun-dried sand of Egypt and Palestine, while they
are present in small numbers and are apparently less virulent in
Eastern Europe.
( b ) The organisms conoemed have little power over healthy tissues,
but they are resistant to the strongest antiseptics and grow freely in
damaged muscle, especially if into the latter be thrust some foreign
body rich with the organisms, such as a piece of shell or muddy clothing.
Some of the very worst cases are those where the “ missile ” is composed
only of the mui itself which is driven with immense force by a shell or
bomb exploding in muddy ground, and frequently causes a great
number of small wounds, in some of which the mud may be driven
right through the deep fasoia or actually into the muscle sheath.
(c) Lowered vitality of the patient by exposure to wet and cold, and
exhaustion from want of food, and over exertion, are predisposing causes,
as is also to a very serious extent the deprivation of blood-supply,
owing to injury of a large vessel. It is also clear that wet and cold
weather and mud favour gas gangrene much more than heat and dust.
Such are the now well-recognised causes of gas gangrene
and the conditions in which it may be expected to occur,
and very much of the reduction now noticed is due to the
abandonment of strong antiseptics, and to the timely excision
and surgical cleansing of the wound and the removal
of all foreign bodies. It may also be claimed that the
thorough arrangements for the treatment of the chilled and
exhausted man by warmth, rest, and intravenous injections
have saved many lives through restoring the vitality and
resisting powers of the patients.
Influence of Changed Condition of Sail.
But, when all this is allowed for, it is evident that there
must have been other causes at work to account for so great
a diminution of this danger to the wounded man, and these
ThbLanomt,]
SIB ANTHONY BOWLBY: THE HUNTERIAN ORATION.
[Feb. 22,1919 289
most be sought in a lessened virulence of the infecting agent
itself which has occurred daring the past four years and has,
in its turn, resulted from altered conditions of the soil in
which the organisms are bred. That this is true is supported
by the following facts:—
In the Somme battle of 1916, In spite of many thousand operations
performed at the front, there were very numerous cases of bad gas
gangrene both In the casualty clearing stations and at the base hos¬
pitals, although they were much less frequent than in 1914. In the
Somme fighting over the very same ground, during the retreat in
March, 1918, when the cxsualty clearing stations had to be abandoned,
operations co ild not be done at the front. Patients had consequent ly
to be sent to the base In trains of all kinds as well as In ambulance trains,
and were often not thoroughly treated by surgical operation till after a
delay of one or two days. Yet there were far fewer cases of gas
gangrene in 1918 than In 1916, and in 20,000 patients at one base
between March 23rd and 29th the incidence was only 1 per cent.
But, whereas in the earlier years of the war much of the land was
covered with rich crops and had recently been very freely manured,
st the present time in the battle areas the face of the earth Is absolutely
changed A great stretch of country, comprising many hundreds of
square miles, has been practically destroyed, as far as its development
by mankind is concerned. What was once a prosperous country-able
with highly cultivated arable land is now little more than a desert,
pitted with shell holes, scarred by innumerable trenches and gunplts,
the chalk subsoil scattered over the surface of i he ground, the skeletons
of smashed and shredded trees alone marking the sites of destroyed
villages, and all appearance of cultivation wiped oat. The whole land
haa gone back to “ prairie conditions ” and looks like an extensive and
barren moor, although in summer time it Is partly redeemed by the
luxuriant growth of wild flowers.
In sueh a country which has been exposed to sun, wind, and rain, for
three or four years, uncultivated, unmanured, uncropped, deserted by
man and animals, it is probable that the anaerobic organisms have
diminished both In numbers and virulence.
But, be the causes what they may, it was an immense
relief to the surgeon in 1917-18 to find that this, the greatest
surgical epidemic of wound infection which has ever been
recorded, was neither so prevalent nor so dangerous as
formerly, and that the wounded man was no longer so
greatly exposed to grave risk of life or limb, even though his
wound itself were slight and involved no vital part.
Transport and Hospitals at the Front.
I now. turn to the arrangements for transporting and
treating wounded men.
Evolution of the Field Ambulance.
The history of the early hospitals in the British Army h$s
been carefully investigated by the late Colonel William
Johnston, and from his researches it appears that in
Hunter's day the patients at the front were treated in
“regimental hospitals” or else in “garrison hospitals.”
“Marching” hospitals or “ flying ” hospitals were estab¬
lished by William III., and first saw active service in his
campaign in Ireland. In addition to medical personnel they
had “ nurses, cars for the transport of the sick, drivers, and
men-servants. ” Unfortunately these precursors of our
present field ambulances came to an end with the completion
of Marlborough's campaigns in 1711, and were not revived
until the nineteenth century, so that they did not exist in
Hunter’s time.
Banby wrote in 1781 as follows: “ I would wish to be indulged in a
scheme which might, I think, be put into execution with all the
facility imaginable. It is this, when the army is forming for an
engagement let the surgeons with their respective mates of the three
o* four regiments that are posted next to each other collect themselves
into a body and take their station in the rear according to thee- mm&nd
of the general. Here let the wounded be put under their immediate
care and management. By this means they will be enabled mutually
to assist eaoh other and to perforin their duty both with care, exact¬
ness, and dispatch.”
It is thus evident both that the need of some arrangement
for mutual aid was felt and also that it did not exist in
Hunter's time.
In those days the wounded soldiers were taken to the base in country
wagons or in the regimental forage carts, and it was left to Larrey to
crcetein 1792 the first “ambulance cars,” which were reserved for the
•ole use of the sick and wounded and which were named by him
Ambulanoes Volanfces.” He figures and describes them as “ a kind of
carriage hung on springs, uniting great strength and solidity.” They
were of two kinds—the light with two wheels and the heavy *ith four
wheels. Bach ambulance “cadre” or “division” was provided with
12 light and four heavy cars and comprised a personnel of 340 officers
•na men. Larrey states that after the battle of Evlau In 1807 the
wounded were successfully transported by the ambulances tolantcs to
Chateaux “ at a distance of not lees than 55 leagues.”
This “division” may fairly be claimed as the first
efficient field ambulance in the history of war. 8ince this
period horsed ambulances of various types have been
employed as part of the transport of our own field
ambulances, but it was not until the present war that
‘‘ motor ambulances ” were added to the transport of the
field ambulances and that “ motor ambulance convoys ” were
provided to supplement the latter. I think it is hardly
realised how much in present warfare the whole system of
the treatment of the wounded is based upon and pivots on
the “ motor ambulances.”
Influence of Increased Range of Projectiles.
In Hunter's time the range of the musket was two or
three hundred yards and that of a cannon less than a mile ;
beyond this distance surgeons cohid work in safety. It was
consequently not at all difficult to carry the wounded man to
some place where a barn, or shed, or a stone wall offered
sufficient protection, for there were no shells.
At the present day there is no such thing as absolute
safety anywhere near a battle front.
Apart from bomba and guns of exceptional range, immense numbers
of shells are fired to a distance of from 6 to 8 miles. The con¬
sequence is that, while surgeons supply skilled help, at much risk,
at the regimental aid post or the advanced dressing station,
within a very short distance from the line, the patients have to be
removed quickly to considerable distances, and the casualty clearing
stations have to be placed some eight miles or more In the rear. The
consequence is that horsed vehicles could not posMbly make a sufficient
number of journeys to bring in the wounded from heavy fighting
within a reasonable time, and In addition the numbers of the wounded
are so great that there has been nothing in any previous war to compare
with the task of the ambulances of the present day.
It must, therefore, be understood that all wounded men
have now to be taken a considerable distance before reaching
a place where they can be both immediately treated by the
surgeons and also retained and cared for after operation. It
is during this long motor-car journey from the battle-front
that the patient runs risks of those further injuries which it
is the object of the surgeon to minimise as much as possible.
Care of Wounded during Removal.
One of these risks is exposure to cold.
This is a most serious danger to men suffering from shook or hsemor-
rhage. To avoid this hot-water bottles are freely used, stretchers are
covered with one folded blanket, and the patient is warmly wrapped in
others. The car Is also usually provided with a pipe heated by a supply
of hot air from the exhaust pipe of the engine.
The other most important risk is that of injury to the soft
tissues by the fragments of broken bones which are jolted by
the movements of the car.
The extent of this will largely depend on the roughness of the road
and Its pitting by shells, but to a still greater extent it will depend on
the care with which suitable splims are applied. It is the custom in
the British Army to splint all fractures as far forward as possible, and
In any ease at the field ambulance, with the result that, with the
apparatus now provided, fractures are so immobilised that the
minimum of risk is Incurred and the minimum of pain is caused by
the journey. It is not too much to say that very many patients who,
without a good splint, would arrive in a state of ooliapse and die, or else
would lose their limbs, now get down to the casualty clearing station
with discomfoi t rather than with suffering.
It has been remarked that the modern offensive methods which
characterise this war aie largely dependent on the invention and
development of the petrol engine, and that the tractors of great guns,
the war in the air, and the war under the se* are all dependent on this
device. It is at least some satisfaction to know that it is to the same
device that tens of thousands of wounded men owe. not only a more
comfortable transport than the soldiers of previous wars, but also the
saving of lives and limbs in numbers beyond measure.
The Casualty Clearing Station. ’
In Hunter’s day the only hospitals near the front seem to
have been those called “regimental,” and they were
apparently established in any buildings which seemed suit¬
able for the purpose. I have not found any records of their
equipment, the number of their personnel, or their accom¬
modation. It is probable that they were very primitive.
In our own Army at the present day the demand for
hospitals at the front has resulted in a new nnit which has
been created by the conditions peculiar to this war. I
allude to the casualty clearing stations, and these have
their counterparts in the armies of all the other European
combatants.
Great Development in Work of Casualty Clearing Station.
This unit had not been In action before the present war. At the
commencement of hostilities it consisted of a staff of six medical
officers with a commanding officer and quartermaster and 80 orderlies;
some of the latter were well-trained nurocs. It provided accommoda¬
tion for 200 patients on stretchers, but was not supplied with beds. Its
surgical equipment consisted merely of sufficient instruments and
appliances for the performance of a few urgent operations, and it was
provided with on« operating table and a few very primitive wooden
splints. Its function, as the name Implies, was “ to clear ” the field
ambulances and to pass on by train the sick and wounded for further
treatment at the base hospitals. Bach unit was Intended to be
attached to a division and was supplied w 1th horsed transport.
Since those days the long line of trenches and the comparative
Immobility of the armies until recent y have provided the opportunity
for very great developments, with the result that the casualty clearing
stations of the present day are very efficient and well-equipped
advanced hospitals, with theatres for six or more tables, and suitable
in every way for the performance of any operation. They have beau
expanded to provide, according to circumstances, for from 600 to 1200
patients, of whom 200 have beds and the remainder stretchers.
290 The Lancet,]
SIR ANTHONY BOWLBY: THE HUNTERIAN ORATION.
[Feb. 22,1919
A great deal might be said of the work of the casualty clearing
stations which would be out of place here, but it may be pointed out
that an advanced hospital of this type is an absolute neoeesity In the
warfare of the present day. Very little experience was required to
show that it was qnile impossible to carryout the pre-war Idea of doing
all the surgery (with few exceptions) at the general hospital** at t he
base. Men with suoh injuries as wounds of the chest and abdomen,
severe fractures, and wounds of large vessels, could not be safely con¬
veyed long distances by trains, while patients suffering from dangerous
•hock or the effects of profuse haemorrhage demanded immediate
treatment as near the front as possible. But, over and above all these,
the necessity which arose for early operation in order to prevent the
development and spread of gas gangrene or dangerous sepsis in even
slight wounds alone justified the expansion of the casualty clearing
stations.
The Surgery Carried out at Casualty Clearing Stations.
It will thus be seen that the object in view in their
development was to seonre efficient treatment as early as
possible. The ideal of surgical treatment would be the
supply of enough surgeons and enough hospitals close to
the front to allow of all operations being always performed
there with the least possible delay. This ideal has, indeed,
been often realised in the present war, when, during quiet
periods, the wounded were comparatively few, but it has
proved impossible to supply enough surgeons and enough
accommodation to realise the ideal when the casualties of a
great battle number many thousands a day, and when the
dnration of the battle is measured not by days but by weeks
or months. But, although it has not been always possible
to do that which is ideal, the custom of reinforcing busy
hospitals with " teams ” of extra surgeons, anesthetists, and
assistants has enabled an immense amount of work to be
done.
Apart from operations on the abdomen, the chest, and the
head, the vast bulk of this work is of a nature which appeals
to surgeons and to patients alike, for it is " conservative
surgery ” in the best sense of the term. In the first place it
consists largely in the thorough surgical cleansing of wounds
so as to save limbs and lives, and in the second place it
supplies the necessary foundation for the early closure of the
wounds by suture. In this way large flesh wounds are
prevented from suppurating, "compound” fractures are
made " simple” fractures, and the patient is saved from a
long illness and its debilitating effects. Such treatment
diminishes stay in hospital, frees hospital beds, lessens the
labour of nurses and surgeons, and, best of all from the
point of view of the Army, it enables many patients to
recover quickly and to return to their regiments.
I would claim that, apart altogether from considerations
of humanity, good front-line surgery very fully compensates
an army for the demands it necessarily makes on supply and
transport. It more than pays its way both by returning
sound combatants to the ranks, and also by saving the
country the expense of innumerable pensions on behalf of
men whose lives or limbs have been saved.
Value of Front-line Surgery to the Army .
Long before this war the combatant branches of the Army
fully realised the importance of the prevention and cure of
illness and their effects on the maintenance of armies in the
field, but it is only during the present war that the value of
good and prompt surgery has been fully appreciated and
that the necessary facilities have been supplied whenever
the military situation has permitted. Similar facilities will
henceforth be expected in all future wars.
It is well known to the medical profession that an
immense amount of this front-line surgery has been success¬
fully undertaken, and it is also well known to, and deeply
appreciated by, the combatants of all ranks, whose con¬
fidence and faith in the Army Medical Service is by far the
beet possible tribute that could be paid to it. I will not
attempt to supply any statistics, but some idea of the
magnitude of the surgical work at the front will be gathered
if I state that during the three and a half months of the
Third Battle of Ypres in 1917 61,500 operations were per¬
formed under anaesthetics in the casualty clearing stations
of two armies.
Organisation: Adaptation to War of Movement.
It will easily be realised that muoh forethought and pre¬
paration are required to produce these results, for they
require not only arduous work by day and night for, perhaps,
12 hours out of 24 —a tax on the strongest when continued
for weeks on end—but also the harmonious working from the
front to the rear of stretcher-bearers, regimental medical
officers, field ambulances, ambulance convoys, and ambulance
trains, any one of which is liable to interruption by accident
or by the acts of the enemy.
The staffing of the casualty clearing stations for the
Third Battle of -Ypres especially deserves to be recorded,
for on this occasion many of the most representative
surgeons from the United States, from Canada, Australia,
New Zealand, and South Africa were included in the
reinforcing surgical "teams,” or else were on the staffs
of the casualty clearing stations of the armies concerned.
Thus, for the first time in history, the surgical skill and
talent of ail the various sections of the Anglo-Saxon race
were brought together on a battlefield, and with the happiest
possible results to the wounded men. On this occasion,
because of the absence of heavy fighting in other armies,
more surgeons were available than at any other period, and
no olearing station had less than 24 surgeons and 24 nurses.
It was therefore possible to keep eight operating tables in
action in every unit, and there is no doubt that almost
every wounded man whose condition made it advisable was
passed through the operating theatre before being sent by
ambulance train to the base.
The war of movement which characterised the dosing
stages of the campaign called for the development of new
methods for meeting the situation thus created. Of the
details of these a great deal might be written which would
be too lengthy for the present occasion, but this much may
be said. The clearing stations were sufficiently reduced in
the bulk of their equipment to enable them to be rapidly
moved forward, and they were frequently able to take in
and treat many hundreds of men within 24 hours of their
arrival on a new site, while at no time during the whole
campaign was there more work done in resuscitating the
badly wounded and in the intravenous administration of
blood or of alternative fluids to men who had suffered from
severe haemorrhage.
Conclusion.
And now let me recall to your attention a phrase of
Hunter’s which I read to you at the beginning of this
address.
“If. (the appointment to the Beileisle Expedition) drew my attention
to Inflammation In general, and enabled me to make observations which
have formed the basis of the present treatise.”
The war was to him not merely a sphere for the exercise
of his surgical skill, but also an opportunity for observing
and studying conditions of which he had hitherto had no
experience. What has this war been to the surgeons of the
present day ? It may truly be said that very many of them,
and in all parts of the world, have entered into this work
imbued with the spirit of our great master. To them it has
not only afforded immense opportunities of helping their
fellow countrymen, but has also provided problems for study
and for solution.
The spirit has been one of progress and of development and
of unwillingness to rest content with conditions that might
be bettered or with methods which proved unsuitable. It
is not too much to claim that each year of war has seen
better surgical measures devised and consequently better
results obtained. The sufferings of the wounded have been
lessened, the dangers they run have been diminished, and
lives and useful limbs have been saved in constantly increas¬
ing numbers. Burgeons have not been content merely to
guess at possible answers to the never-ending questions
suggested by the complications of war. They have devised
new methods to meet new conditions and have put them to
the test of experience; and when they have failed they have
tried and tried again until they have compelled success.
In this great tragedy of war the Royal College of
Surgeons of England has played no unimrtortant part.
Hundreds of its Fellows and thousands of its Members have
willingly pressed forward for service. Some of them, like
our President, have occupied with credit and honour the
most prominent and important positions, and others of
them, often less prominent no doubt, have not only given
their services, but have also given their lives. The position
I have had the honour to hold in the Army Medical Service
has afforded me very abundant opportunities of appraising
the performances of others, and I am full of admiration both
for the skill and ability of our surgeons and for the splendid
work done by the Royal Army Medical Corps in rescuing the
wounded in conditions of unprecedented difficulty and
danger, and in organising the hospitals for the subsequent
treatment and restoration to health of the British soldier.
The Lancet,] MR. J. PHILLIPS: THE BURIED SEQUESTRUM: A POST-WAR PROBLEM. [Fbb. 22, 1919 291
THE BURIED SEQUESTRUM: A POST¬
WAR PROBLEM.
By JAMES PHILLIPS, F.R.C.S. Edin.,
MAJOR, R.A.M.O. ; OFFICER I C SURGICAL SKCTIOlf, BRADFORD
WAR HOSPITAL.
For long surgical skill will be required to remedy condi¬
tions resulting from gunshot wounds. The class of case
dealt with in this paper is certain to call for treatment in
hundreds of instances. I have followed the method of
treatment described below at the Bradford War Hospital
since the spring of 1917.
Causation and Treatment.
1. The condition is associated with the extraordinary
multiplicity of comminution which characterises war-wound
fractures. The bone is commonly splintered into many
fragments ; the periosteum is torn and separated from the
bone; the spaces between the various fragments and
between them and the periosteum become filled with new
bone, in the midst of which lie one or more sequestra. It is
these buried sequestra which are responsible for the persistent
suppuration.
2. In a majority of cases little aid is to be obtained from
X ray examination or from the condition or direction of the
sinuses, &c., towards diagnosing the character, size, and
position of these sequestra.
3. The only treatment likely to be successful consists in
baring the bone from overlying soft tissues and freely
chiselling through bone until the sequestrum is exposed.
This is a severe operation, and, as multiple sequestra are
not uncommon, more than one operation may be required.
4. The removal of the necrotic tissue makes it possible to
treat bone cases by the Carrel method ; the wound can be
made surgically clean, and secondary suture successfully
practised.
The r6le of the periosteum. —Fig. 1 shows a piece of femur
removed in re-amputation after a guillotine amputation in
France nine weeks previously. Evidently the periosteum
had been separated from the femur in the course of the
primary amputation and osteogenesis had resulted in the
formation of a large mushroom boss of new bone. Had the
1
Drawing of piece of femur removed in re-amputation of thigh.
a. Bone protruding, bare of periosteum, b, Epiosteal new
bone, surrounded by scar tissue and muscle, c, Normal bone.
case been left I have no doubt that the piece of bone (a) would
Dave become separated as a ring sequestrum. I am inclined
to think that in some similar pathology may be found the
explanation of myositis ossificans. This condition comes on
after an iniury, generally one affecting a muscle attachment
to bone. If we imagine that the injury has produced some
separation of periosteum from bone, it is not difficult to
picture the osteoblasts becoming free to invade the damaged
musole fibres and their subsequent conversion into bone
cells.
Fig. 2 shows a mass of new bone removed from a femur of
which there was a partial fracture. The missile has
penetrated the periosteum just externally to the small
trochanter. The man had been treated at another hospital
from May, 1917, to February, 1918, and was then sent to his
home in Bradford on furlough. The wound broke down,
and he was admitted to the Bradford War Hospital. A
lump was felt in the left femoral region which the X rays
showed to be a bony growth. An inch-long sequestrum was
removed from a granulation-lined cavity in the bone; the
cowl of new bone figured had been thrown out over the
sequestrum. The wound was treated by Carrel’s method
and secondary suture successfully performed.
Piece of bone chiselled from femur; It formed a cowl over a
sequestrum.
The same sort of rampant overgrowth of new bone takes
place around a badly comminuted (gunshot) fracture. A
femur may become two or three times its normal thick¬
ness ; nor does a radiogram usually show the full extent of
the enlargement, since many months are required before
the new bone is sufficiently calcified to be opaque to the
X rays. It may be that sequestra keeping up a constant
discharge are buried au inch or more deep in this mass of
new bone. The difficulties in the way of localisation are
very considerable.
The diagnosis of buried sequestra .—The persistence of one
or more sinuses is, of course, a constant feature where there
is chronic osteomyelitis. I have had all my cases X rayed,
but the number and size and site of sequestra more often
than not cannot thus be diagnosed with aiiy certainty. In
one plate (Fig. 3) the sharp end of what is obviously a
sequestrum is sticking out; in another (Fig. 4) a less dense
area in the shadow indicates a cavity which probably con¬
tains a sequestrum. But in a large proportion of cases the
findings are negative. (Fig. 5).
Method of Operation.
Whenever a case comes under my care in which either
rough bare bone is felt by the probe or a persistent sinus
leads to the seat of an old bone injury of the femur, and
especialiy if X-ray examination points to sequestrum forma-
lion, I operate in the following way.
An incision long enough to permit of the exposure of the
whole of the damaged area of bone is made and carried down
to and through the periosteum. All the soft parts, including
E eriosteum, are cleared from the bone with an elevator,
ony irregularities are chiselled away, Binuses in the bone
are followed up, and an attempt made to find and remove all
sequestra. How difficult this may be is illustrated by the
following case (the first treated in this manner).
Pfce. 8. admitted to Bradford War Hospital Sept. 8th, 1916. A month
earlier right lemur badly smashed by rifle bullet. He was treated on a
Thomas’s knee splint and firm union with good alignment obtained,
but pus kept collecting and bursting through sinuses in both front and
back of thigh. 1 opened up sinuses and used a sharp spoon on several
occasions, but suppuration persisted. I showed the case to Sir B. G. A.
Moynihan, and on his advice I undertook the method of treatment
now described.
On May 7th. 1917, a 10-inch incision was made in front of the thigh,
the femur cleared in the whole length of the Incision, and Irregular
new' bone freely chiselled away, two sequestra removed, and a fairly
smooth-walled shallow cavity left in the femur. The wound was
treated bv Carrel’s method; on May 29th reported sterile. On
June 1st it was dosed in the method described below ; stitches removed
on June 25th. On July 3rd “ wound dry and firm.” A day or two
later the apparently soundly healed posterior wound began to dis¬
charge. On July 20th it was opened up and further extensive
chiselling done; three large sequestra (the smallest nearly 2 lnohee
long) were found, which had been quite unsuspected.
The necessary chiselling of such a femur is an operation
which, if undertaken in a man who has been absorbing
toxins from a suppurating wound possibly for months, is
likely to be associated with a good deal of shock. More than
once I have thought it wise to complete this stage of the
operation at a later sitting. When every obvious crevice
and cranny in the bone has been smoothed away with the
chisel the soft parts are stitched oven by passing one or
more mattress sutures of thick ioained silk through the
muscles and then through the skin at some distance from
the edge of the wound.
The sterilising of the icound is done by Carrel’s method.
Dakin’s solution is instilled every two hours, and at least
once in 24 hours a thorough cleansing of the wound is
undertaken. The cavity is opened out to the bottom with
292 Tab LiNOBT,] MR. J. PHILLIPS: THE BURIED SEQUESTRUM: A POST-WAR PROBLEM. [Feb. 22, 1919
3
Sequestrum poking out of hole in a
femur (from Case 5).
4
Femur with cavity containing seques¬
trum. Four long sequestra were
removed from this femur.
5
Femur radiographed post mortem. A seques¬
trum 3 inches long could be seen through
a fenestrum in the bone, but the radiogram
gives no idea of its presence.
dresBiDg forceps and is tightly packed with gauze-aud-wool
swabs wrong out of Dakin’s solution, and these remain in it
while the cleansing of the skin is proceeded with (where
the cavity is deep it is most important that the swabs be
counted). Only by thus packing the wound have I found it
possible to prevent the sides of the cavity from growing
together. At first the packing is likely to cause pain and the
dressing may have to be done under an anaesthetic, but the
chief cause of the pain is sepsis and as the wound becomes
sterile pain and tenderness disappear. The discharge is
examined bacteriological Iy twice a week and when the “ film
chart ■’ shows 3 or less organisms per field for two successive
examinations the closure of the wound is proceeded with.
The closure of the wound .—The skin is prepared for opera- !
tion by the nurses as in any ordinary planned operation. On
the table a further cleaning up is done. The granulations
are thoroughly curetted, the soft parts are raised from the
absorbent dressing is applied and left in position for 14 days;
it is then renewed, but the sutures are left in situ for another
week. The result is generally a linear scar ; usually a little
discharge takes place from one or two stitch holes, but at
the end of a month there is, as a rule, a firmly healed
cicatrix.
Illustrative Cases.
Cask 1.—Gunner S., wounded by shrapnel March 21st, 1918. Admitted
Bradford War Hospital April 17r.b. Three vertical wounds, one behind
the other, about upper part of right thigh. X rav report: “ The
great trochanter lias been comminuted and some fragments of bone
driven i*ackwards into the gluteal muscles.” On May 6th the middle
wound was opened up and comminuted bone and surrounding granula
Mona chiselled away. Wound stitched open. By June 7th the “film
report ” was satisfactory and the wound was sutured and practically
primary union took place.
8 9
6 7
Case 8 three weeks after admission. After skin grafting.
bone until they can be brought together without much, if
any, tension. The akin is freely undercut and its edges
trimmed. The undercutting is essential if a non-adherent
linear scar is to result. The raw surface is swabbed first
with methylated spirit and then with bipp. A running cat¬
gut stitch brings the deep fascia edges together over the
muscles. Thick silk stitches are passed through all the soft
tissues from skin to periosteum so as to close the wound,
leaving no dead cavity. A continuous catgut stitch is used
to secure accurate apposition of the skin edges. An
Radiograms of CaBe 8 at periods corresponding to Figs. 6 and 7.
Cask 5.—Pte. P.. wounded July 9th, 1916. Lay In shell hole four
davs. bent straight to England, arriving atfiradiord War Hospital ou
July 15th. Badly comminuted fracture of lower third of right femur,
much sepsis, effusion into knee-joint. This was before the days of
blpp and Cirrel-Dakln treatment. Patient was extremely 111, abscesses
formed in various parts of tbe limb, and when union had taken place
and only one or two sinuses remained he was sent to country to
| convalesce. Readmitted on June 30th, 1917 A week later the wound
was opened up and several central sequestra, of which the largest
The Lancet,]
LIEUT.-COLONEL A. L. JOHNSON: “PROPELLER FRACTURE.
[Fkp. 22 , 1919 2 93
measured 2£ by 4 Inches, were removed. He was averse from further
operation. Wound, treated by Carrel's method, appeared to c ose from
the bottom slowly but satlf-faotorily. On Dec. 19f.h it was dry and he
was marked for Invaliding board. But on Dec. 27th pain, swelling, and
fever appealed and two days later an abscess burnt. On Jan. 14th, 1918,
the wound was laid open br a 10-Inch incision and some newly forme 1
bone chiselled away. On Feb. 18th the wound was clean amt it was
sutured. On March 14th the wound was dry; he was allowed up;
on March 23rd he proceeded home.
This case shows that secondary suture is require*! in addition to
removal of necrosis and cleansing of the wound. The wound was kept
clean and appeared to heal over, out a dead space remained, and in this
materials collected which became infected. When once more the
wound was clean and had been surgically closed healing took place at.
once, and lefs than five weeks after the closing operation the patient
was discharged with his wound soundly healed.
A fracture of the shaft of the humerus can often be most
successfully treated in the manner described, but of course
free incisions require to be carefully planned so as to avoid
the nerves.
Different treatment is required where the fractured bone
is subcutaneous or poorly covered with soft tissues—as, for
example, the condyles of the femur, the shin, the lower half
of the radius or ulna.
Case 8.—Driver B. H.E. shell wound of right leg on Oct. 4th, 1917.
F.B. smashed through upper end of right tibia and was removed from
calf. At C.C.S. Infected muscle and bits of comminuted bone removed.
Admitted to Bradford War Hospital on Oct. 15th with large wounds
bick and front of upper half of right leg, the latter showing badly
smtshed tibia and fibula. Carrel’s tubes inserted and leg placed on
Thomas's splint. The posterior wound healed up fairly quickly; on
Dec. 3rd firm union of the fibula and partial union of the tibia were
noted ; the extension apparatus was removed. On Jan. 4th, 1918, a
clean granulating surface 3£ by 1 in. over the front of the head of
the tibia was skin-grafted. No dressing of any kind was applied; the
leg was simply covered over by a cage. By Jan. 18th the graft wound
had healed and the man was getting about on crutches. What one lias
noticed in other cases was observed here—viz., that new bone
apparently continued to be formed beneath the healed grafts. At first
the scar was markedly concave, but after some weeks the cavity was
very definitely less deep.
There is a steady stream of men being sent to their homes
near Bradford, either as transfers or as pensioners, in whom
sinuses leading down to bare bone are present many months,
sometimes years, after the wound was inflicted. For such
cases radical methods such as the one I have described are
the only ones likely to lead to healing of what must other¬
wise remain in many instances permanently discharging
wounds. My sincere thanks are due to Miss Mitchell, the
radiographer, and to Mr. Bernal Riley, the honorary photo¬
grapher to the Bradford War Hospital, for the great trouble
they have taken with the illustrations.
PROPELLER”FRACTURE.
Lieutenant-Colonel A.
JOHNSON, C A.M.C.
At the word “contact ” from the mechanic the pilot throws
the switch into contact with the magneto, causing a spark,
which ignites the gas and starts the engine. If the “ team
SURGBOX SPECIALIST, MILITARY HOSPITAL, SHORNCLIKFE.
Fracture of both bones of the forearm by direct
violence, commonly caused by “back fire ” when cranking a
motor, was widely observed during the earlier years of the
automobile. It has become less common since the introduc¬
tion of s-df-starting appliances. That an analogous type of
fracture is common in aeroplane operation is suggested by
four cases of supracondylar fracture of the right humeius,
all caused by aeroplane propellers, which have been treated
294 The Lancet,] DRS. J. CAMPBELL&C. M. PENNEFATHER: THE BLOOD-SUPPLY OF MUSCLES. [Fkb. 22, 1919
2. A right-angled Thomas’s splint was next applied, with
the forearm in supination and with extension to the
lower end of the humerus. The fracture was reduced by
manipulation, but the appliance did not serve to retain
the fragments
in alignment
and apposi-
tion, there
being anterior
angul ation.
(See Fig. 2.)
3. The classi¬
cal text-book
treatment of
acute flexion
was next tried.
It had not been
possible pre¬
viously because
of the dressing
of the wound,
which would
have necessi¬
tated exten-
s i o n of the
forearm at
each dressing and consequent disturbance of the fracture.
In any case, good alignment was not obtained with the
elbow in acute flexion. (See Fig. 3.)
4. A Middledorf triangular splint (see Figs. 5 and 6) was
next applied, with anterior and posterior coaptation of
Gooch’s splinting. This appliance admitted of passive
movement daily of the forearm and gave a good anatomical
and functional result. (See Fig. 4, taken two months after
receipt of injury.)
Remarks .—The treatment of these four cases ran con¬
currently and the experience in all of them was uniform.
The following conclusions may be stated : 1. A straight
Thomas’s splint is useful during the first 10 days of treatment
to immobilise the arm and to facilitate treatment. 2. A
right-angled Thomas’s splint with extension is not suitable.
3. The classical treatment of putting the arm up in acute
Fig. 6.—Middledorf splint in position.
llexion is not suitable. 4. A Middledorf triangular splint
admits of correct alignment of the fractured humerus, a
satisfactory anatomical and functional result. It allows
passive movement of the elbow-joint during the period of
treatment without disturbance at the seat of fracture.
I am indebted for the accompanying photographs to
Colonel E. J. Williams, D.S.O., C.A.M.C., and for the radio¬
grams to Lt.-Col. George Musson, C.A.M.C. The clinical
notes were taken by Captain W. H Secord, M.C., C.A.M.C.,
and Captain C. S. Strong, C.A.M.C. The Middledorf
triangular splint may be had from the Kensington War
• Supply Depot, 13, Kensington-square, London, S.W.
AN INVESTIGATION INTO
THE BLOOD-SUPPLY OF MUSCLES,
WITH SPECIAL REFERENCE TO WAR SURGERY.
By J. CAMPBELL. M.D. Liyerp.,
CAPTAIIT, R.A.M.C. (S.R.);
AND
C M. PENNEFATHER, M B., B.S., M.R.C.S.,
L.R.C.P.,
CAPTAIN, R A.M.C. (T.C.).
It appeared to one of us (J. C.) that a knowledge of the
distribution and arrangement of the arterial supply in
individual muscles would be of use in the treatment of war
wounds: (1) with regard to the amount of tissue that should
be removed in primary excision of wounds ; and (2) with a
view to elucidating the cause, prevention, treatment, and
method of spread of gas gangrene. The information thus
gained is useful and important. Indeed, one of us has found
that it has been the means of saving quite a number of lives,
of avoiding a still larger number of amputations, and of
preventing recurrence of gas gangrene after operation.
Arterial Distribution in Mmole.
The scope of the present paper is limited chiefly to a
consideration of arterial distribution in muscle. Later com¬
munications will deal with the clinical aspect, &c., of gas
gangrene. For purposes of comparison the arterial dis¬
tribution in other organs was also investigated. Photographs
illustrating the vascular arrangement in muscle are seen in
the figures.* The radiological side of the investigation was
carried out entirely by Captain Pennefather.
If we compare the skiagrams of the muscles with
specimens and radiograms illustrating arterial distribution
in brain, heart, and small gut we see at once that the
arrangement of the arterial tree is identical in all cases.
We also see that in none of them are the vessels strictly
# Them* photographs were made by first of all Injecting che main
vessel of the region with a light bismuth salt and then radiographing
the excised muscles.
terminal—i.e., without any anastomotic communications.
In all cases anastomoses are present, but only as very fine
ones. (Fig. 3.) Large loops resembling those in the
mesentery or subcutaneous tissues are rare. Hence if we are
justified in calling the arteries in brain, heart, and small gut
“ end-arteries,” we are equally justified in applying the term
to those inside muscle.
If now we examine collectively the skiagrams of the
muscles, we readily see that we can divide the muscles into
three main classes : —
1. Those with a blood-supply derived from many different
sources and in which potential anastomoses between the
different sources are quite numerous. (Figs. 1 and 5.)
2. Those with a blood-supply derived from only two or
three different sources, but in which the potential
anastomoses between these sources are, relatively speaking,
few in number. (Figs. 2 and 3.)
3. Those with a blood-supply derived, for all practical
purposes, from only one source, and in which, granted that
this main source of Bupply is cut off, almost the entire
muscle becomes ischaemic, and therefore liable to almost
complete destruction, owing to the practically complete
absence of potential collateral channels. (Figs. 4 and 5.)
These classes are respectively illustrated by : —
I. The deltoid and pectoralis major. (Fig. 1.) To this
class also belong pectoralis minor, the scapular muscles,
biceps brachialis, brachialis anticus, triceps adductor
magnus, gluteus medius, gluteus minimus, f
II. Gluteus maximus (Fig. 2), rectus femoris, hamstring
muscles (semi-membranosus, semi-tendinosus (Fig. 3), biceps
cruris), sartorius.
III. Crareus (Fig. 5), gracilis (Fig. 4), inner head of the
gastrocnemius, outer head of the gastrocnemius.
Relative Liability to Gas Gangrene.
If now we look at these three groups of muscles we see
that they have a varying liability to gas gangrene (with the
exception of those mentioned in the foot-note as belongingto
Class 1). Thus Group I. is formed of muscles that are bat
t In this ciass we mint also place soleus, vastus interims, vastus
extemus (Fig. 5), the deep muscles of the calf, the anterior 1 m
muscles. These muscles are not included above for certain special
reasons that will be referred to later on in another communication.
The Lancet,1 DRS. J. CAMPBELL Sc C M. PENNEB'ATHER : THE BLOOD-SUPPLY OF MUSCLES. [Fer. 22, 1919*295
Pig. 1.—Arterial supply of pectoralis major (Group I.). a, Twigs from
humeral branch of thoracic axis artery; 6 6, Prom long thoracic
artery ; c C, Prom intercostal arteries; a d. Branches from internal
mammary ; t c % A number of branches from thoracic axis artery.
Fl ?.‘ Arterial supply of gluteus maximus (Group II.). , Superficial
division of gluteal artery; g. Sciatic artery; h h. Twigs from
external circumflex artery.
Pig. 3.—Arterial supply of semi-
t end I nos us (Group II.);
i, Twigs from sciatic artery;
L Branch from perforating
artery; l. Twig from anas to
motica raagna artery.
Pig. 4.—Arterial supply of
gracilis (Group III.);
m. Twigs from obturator;
w, Bra» ch from Internal cir¬
cumflex artery; o. Twig from
anastomotioa magna artery.
Fig. 5.— Arterial supply to crursus (C) and vastus externus (V E). The
vastus externus has been turned outwards, as on a hinge, on its
origin from the lines aspera. The two muscles are approximately
separated by the styiette. Crureus. Group III ; Vastus Externus,
Group I. d. Branch from external clroumflexartery ; qqqqq, Twigs
fp m the four perforating arteries; r r, Twigs from popliteal after
piercing biceps m.
296 Thi Lancet,]
DR. L. HIRSCHFELD: A NEW GERM OF PARATYPHOID.
[Feb. 22, 1919
rarely the subject of gas gangrene, though localised gas
infection is common. Group II. is formed of long, strap¬
like muscles (with the exception of the gluteus maximus)
that are particularly prone to gas gangrene. Group III. is
formed of muscles that are still more prone to gas gangrene
when the subject of any severe laceration.
From these observations, then, it would seem highly
probable that vascular distribution in muscle has a most
important bearing on the origin and spread of gas infection
in muscle. This subject is to be referred to fully in. a
further communication. In consequence of injury to the
arterial supply the mass of muscle to which the damaged
artery is distributed in Classes 2 and 3 either completely
dies or becomes devitalised to a marked extent owing to the
slow re-establishment of the circulation. When infecting
organisms, particularly the bacilli of gas gangrene, invade
muscle in this condition they find a nidus suitable for their
growth. This, we think, is what happens in many cases of
war wounds, with the result that gas gangrene makes its
appearance.
We can readily see, then, the importance in war surgery
of conserving the blood-supply to all muscles generally and
to certain muscles in particular (gracilis, crureus, and the
two heads of the gastrocnemius). The necessity for doing
so was well realised in pre-antiseptic days when operations
were specially planned along those routes which interfered
lea9t, if at all, with arterial supply. This is particularly
well illustrated by the classical posterior route for excising
the head of the femur. Here the incision is so placed as to '
divide the gluteus maximus muscle approximately along the
line of separation between the portions supplied by the
gluteal and sciatic arteries.
Conclusions.
1. The arteries in muscle are as much “ end-arteries” as
those in gut or brain ; but in none of these cases are they
strictly “ end-arteries.”
2. If the blood-supply to a muscle is cut off locally
(especially over large areas) death of masses of muscle may
take place owing to the difficulty in re-establishment of the
collateral blood-supply.
3. During operations the blood-supply to muscles and
inside muscles should be conserved in the most jealous
fashion.
4. When excising wounds of muscles, a knowledge of the
internal arrangement and distribution of the arterial supply
is essential to success. Take care to make the excision in
such a way that the main vessels and branches of supply are
not interfered with, otherwise much larger areas must be
excised.
5. Ischaemia of muscle due to damage of the arterial
supply is a most important factor in the production of gas
gangrene.
6. Should a large artery supplying a muscle be damaged and
the wound already the subject of “gas invasion,” cut away
the damaged muscle till definitely bleeding surfaces are
exposed. Should the case, however, be early and not yet
(clinically) “gas infected,” excise the wound locally and do
not sacrifice too much tissue. At the same time take care to
relieve all tension locally so as to allow of early re-establish¬
ment of the circulation. (This may explain the advantage
of “delayed primary suture” over “primary suture” in
gunshot wounds.)
7. In the ca9e of muscles possessing only a single vessel
of supply (e.g , crureus, gracilis), owing to the risk of cutting
the main artery of supply inside the muscle it is wiser not
to attempt excision of the track, but simply to clean out
the track very carefully with strips of gauze. Before being
satisfied with this course, however, make sure that the
blood-supply is intact by seeing whether or no free bleeding
occurs from a small incision made in the muscle at some
distance from the wound.
8. When dealing with muscles prone to “gas gangrene”
take every step after operation to raise and keep raised the
arterial tension.
9. Io “ resuscitation cases ” take care to slacken all tight
bandages so as to allow as much blood as possible to reach
any ischaemic masses of muscle by way of the fine collateral
channels that exist.
We wish to acknowledge our thanks to Colonel C. H. S.
Frankau, DS.O., A.M.S., consulting surgeon to the
5th Army, for the opportunity he most readily gave us for
carrying out this work.
A NEW GERM OF PARATYPHOID.'
By Dr. L. HIRSCHFELD,
DOZEXT OF THE UNIVERSITY OF ZURICH ; DIRECTOR OF THE CENTRAL
LABORATORY «>F THE SERBIAN ARMY.
In many of the specimens of blood sent to the laboratory
to be examined for typhoid or paratyphoid, germs have
been isolated by culture in bile which behaved, bacterio-
logically, like paratyphoid bacillus B, but were not in the
least agglutinable by the corresponding specific serum.
In August, 1916, I isolated such a strain from the
blood of patient No. 775. The reaction of Widal with
Eberth, paratyphoid A, and paratyphoid B was entirely
negative in this case, whilst the serum of the patient
agglutinated the germ in question, even in dilution
1 in 800. The serum of this patient has been employed
since, along with the sera anti-Eberth, anti-paratyphoid A,
and anti-paratyphoid B. for the serological differentiation of
strains isolated in haemoculture. With the help of this
serum I have discovered in haemoculture 11 more cases of the
same serological individuality in the latter half of 1916,
5 further cases in 1917, and 2 cases in 1918. The relative
scarcity in 1917 and 1918 is explained by the fact that the
polyvalent vaccine (of (Astellani), which I have prepared
since the beginning of 1917 for the Serbian Army, contains
this strain also.
The clinical picture, temperature, ice., of patients infected
by this germ is that of paratyphoid fever. The temperature
chart of the patient in question shows the classical febrile
course (Chart 1). Chart 2 shows the febrile course of another
patient suffering from tropical malaria and typical para¬
typhoid. I emphasise the fact that the two patients did not
react to Widal except with the germ in question, and therefore
it was not a case of an infection superimposed on typhoid or
paratyphoid, but solely an infection provoked by this germ.
We have also observed cases less severe and less typical.
Characteristics of the Organism.
From a bacteriological point of view there is no difference
between the germ in question and the bacillus paratyphoid B.
We have proved the absence of gas and of acidity in lactose,
the production of acid and gas in dextrose and mannite, the
acidity in dulcice with the production of gas retarded
acidity and production of gas in laevulose, and after the first
production of acid further typical alkalinity m litmus milk.
I A paper read before the Inter-Allied Medical Society In Salonika on
Dec. 10tn, 1918.
The Lancet,]
DR. L. HIRSCHFELD: A NEW GERM OF PARATYPHOID.
[Feb. 22, 1919 297
Broth with neutral red becomes fluorescent. It darkens the
medium with subacetate of lead. It does not produce indol.
The bacilli are endowed with typical movements and are {
Gram-negative. They are not agglutinated either by '
the agglutinating sera coming from the Pasteur Institute of
Paris, the Lister Institute of London, the Greek Laboratory
of Salonika, or by those which I brought with me from
Switzerland, although all these sera possess agglutinating
qualities in a high degree for paratyphoid B. On the other
hand, the sera of the patients possess considerable agglutinat¬
ing power towards this germ. The serum of a patient
agglutinated with a dilution of 1 in 3000, though it did not
in the least agglutinate the bacillus of Eberth, paratyphoid A,
or paratyphoid B. The serum of rabbits immunised by the
germ in question is absolutely specific for this strain. The*
serum that I employ in my laboratory agglutinates this strain
up to 1 in 2000, while it does not agglutinate Eberth, para¬
typhoid A or paratyphoid B at all.
We may therefore consider this germ a serological variety
of paratyphoid B provoking, clinically, paratyphoid fever.
This bacillus can be very virulent. Besides finding the
bacillus in patient 775, who died of the disease, I have
isolated the same germ post mortem from the heart of a
patient who succumbed to paratyphoid. This variety is more
frequent in the Serbian Army than paratyphoid B. I give
the monthly statistics from my laboratory :—
Our experiences partly confirm the observations of authors
on the mutability of the species paratyphoid B. We have
seen that a bacillus with the biochemical properties of the
paratyphoid bacillus B can change its serological specific
properties. It seems to us interesting that it is only some of
the serological characteristics of the paratyphoid bacillus B
which are capable of changing, while the agglutinability of
other germs, above all paratyphoid C, remains constant.
The Question of Preventive Vaccination.
It is two years ago since I first discovered this germ in the
blood of one of our Serbian patients. In August, 1916, I
communicated the fact to the French Service de bant6.
This atypical strain not having been notified by the labora¬
tories of the Allies, this question did not appear to
be of practical importance to any other Army than the
Serbian.
Lately, with a Bulgarian patient of the Hospital of
Petit Karabaroun I have been able to isolate the same germs
by haemoculture. The patient succumbed to the disease.
The culture from the faeces and urine of this patient gave a
pure and abundant growth of paratyphoid C. Lately we
have seen the Widal reaction positive up to 1 in 400 with
only paratyphoid C in the c*se of a Greek patient in the
town ; therefore this germ exists among the Bulgars, and
probably throughout the Balkans. In the last case Professor
1916.
1917.
1918.
1916.
1917. |1918.
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.
a.
©
D
-
O
I'l
Total.
y.
i
o
C-.
ii
Total.
No. of ha’moculture ...
77
no
99
73
60
8
23 12
8 23 8 27
16
4
1
26
13
16 -
-
-
3
7
-
2
7
12
s;
4
10
12 -
462
T-
142
-
65
No. of positives.
17
36
39
11
7
1
7
2
1
1 1
1
-
-
-
1
2
1 -
-
-
-
1
-
1
-
2
-
2
1 -
120
~
8
-
7
T. Eberth .
3
13
19
1
2
-
2
-
-
- -
-
-
-
-
1
-
-I-
-
-
-
-
-
-
-
i
-
-
1
40
345
1
12'5
2
Para. A .
11
18
14
5
2
1
2
2
-
-U
1
-
-
-
—
-
-
_
-
-
-
-
-
1
-1 -
55
43-0
1
125
1
Para. B ... .
1
5
3
-
-
-
-
-
-
- 1
-
-
-
-
-!
-
-
1
-
1
-
-
- -
9
77
1
12 5
2
Para. C.
1
-
1
5
2
-
3
-
1
1 -
-
-
-
-
2
1-
-
-
-
1
-
-
-
-
-
1 -
12
10-3
5
62-5
2
Not defined .
1
-
2
-
1
-
-
-
-
- j-
-
-
-!
-
-
-
-
-
_
-
-
-
-
-
4
4-0
-
-
—
Of i Vaccinated ...
?
?
?
5(4c) 2(lc)
1
-
-
- -
-
-
-
lc
- -
-
-
-
-
-
■
-
-
T
-
-
—
_
posit. ( Not vaccinated
_L_
p
6
5
\_
JL
2
1
1 1
1
JL
JL
l
1
i!-
-
jL
JL
1
JL
2
_L
_2
i -
-
-
-
-
I. * II. HI. IV.
I.—Inoculated with French vaccines (T„ para A and B). II., III., and IV.—Inoculated with Serbian vaccines (T., para. A, B, C, and cholera).
Further researches must decide whether in our case it is
a question of a bacillus with new serological qualities or
whether a comparison with atypical germs of paratyphoid B
isolated in the epidemics of alimentary intoxication, epi¬
demic jaundice, inagglutinable strains isolated during para¬
typhoids, &c., will show the identity of my bacillus with
strains isolated elsewhere. This variety, distinguished by
the same pathogenic properties as the paratyphoid bacilli,
and provoking clinically a paratyphoid fever, it would be
suitable to call the bacillus “paratyphoid C,”and to separate
it from the many serological varieties of the paratyphoid
bacillus B, which only provoke alimentary intoxication.
A point of great diagnostic importance in this atypical
bacillus of paratyphoid B is its serological constancy. For
two years I have studied this question in respect to the
germ, and having continually practised growing it I have
made the following conclusions :—
In the Serbian Army we have to deal with three different
serological varieties:—1. The pure paratyphoid bacillus C.
The quality of not agglutinating except with serum para¬
typhoid U remains constant. 2. The pure paratyphoid B
bacillus. The greater part of the bacilli of this category
retain their specific agglutinability. I have seen those, how¬
ever, which in addition to their agglutinability by anti¬
paratyphoid B serum acquire, at least fora time, the property
of reacting with anti-paratyphoid C serum. One strain
(No. 228) even lost its agglutinability with anti-paratyphoid B
serum, and would only agglutinate in the last two examina¬
tions with anti-paratyphoid C serum. 3. The bacilli which
were agglutinated from the beginning by the sera anti¬
paratyphoid B and anti-paratyphoid C, and which even after
being carefully isolated remained agglutinated by the two
sera, and in consequence possess these two agglutinable
qualities, can be called “bacillus paratyphoid B, C ”(5 cases).
These bacilli have lost in the course of the two years their
agglutinability with anti-paratyphoid B serum. It was not a
question in these cases of an absolute loss of agglutinability,
as these varieties preserved the property of reacting to serum
anti-paratyphoid C to the same degree.
j Vallardi, chief of the Italian Central Laboratory, discovered
by hiemoculture a paratyphoid C bacillus which agglutinated
with my anti-paratyphoid C serum which I gave him. I
gave a culture of paratyphoid C to Colonel L. S. Dudgeon,
R A.M.C., who told me he had confirmed the serological
peculiarities of my bacillus.
The question now arises whether the Allied armies
occupying Bulgaria and Turkey are vaccinated against this
species. I am not informed whether the vaccine employed
in the East contains the local atypical bacilli also. As far as
French vaccines are concerned I believe it is not so, for the
following reasons : (1) The agglutinating sera of the Pasteur
Institute, samples of which we received two months ago
through the Medical Reserve, do not agglutinate para¬
typhoid C ; (2) the Serbian Army was vaccinated in the
month of May, 1916, by vaccines of the Pasteur Insti¬
tute which contained Eberth, paratyphoid B, and para¬
typhoid A. In d.916 I saw eight cases of positive
hremoculture, although the patients had been vaccinated.
, Of these eight cases five were infected by paratyphoid C,
one fatally.
Thus we see that the greater part of positive haeraocultures
amongst vaccinated patients show paratyphoid C, in spite
of the fact that generally paratyphoid C was in the minority.
Since the end of 1916 the Serbian Army has been vaccinated
with the vaccine prepared by me, which contains para¬
typhoid C in addition to Eberth, paratyphoid A and para¬
typhoid B. As a result we can announce the disappearance
of this strain. All the positive haemocultures since this time
have been isolated from non-vaccinated subjects. Only one
case of a vaccinated person showed very slight paratyphoid
(fever lasting only three days). The efficiency of the vaccina¬
tions and the reactions, both local and general, has not been
modified by the presence of these other bacilli in the vaccine.
In view of the great practical importance of the question, I
considered it my duty to publish these facts. I can put
cultures of the paratyphoid C bacillus and its corresponding
agglutinating serum at the disposal of any laboratories
interested in the question.
298 The Lancet,]
CLINICAL NOTES.
[Feb. 22, 1919
Clinical Jtntes:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
A DINNER FORK IN THE STOMACH AND
DUODENUM.
By Kenneth A. Lees, F.R.C.S. Eng.,
SURGICAL REGISTRAR, ST. MART'S HOSPITAL, PADDINGTON.
In the following strange case of swallowing a fork the
patient, a domestic servant, aged 25, had only recently
arrived from the West of Ireland. It turned out to be a
small dinner fork of the plated variety (6£ inches long,
handle 4 inches).
The patient gave the following history. Having lost all
her upper teetb, and having had no plate fitted, she was
unable to masticate her food thoroughly. On Christmas
Day she swallowed a portion of a giblet which had some
difficulty in passing down the gullet. Later she vomited,
during which the undigested meat “stuck in her throat”
and caused difficulty in breathing. Thereupon she took
a small dinner fork from the kitchen table and passed
it down the throat, handle first. She dislodged the
foreign body and removed the fork. The piece of meat,
however, again stuck in the gullet lower down. On attempt¬
ing the same manoeuvre a second time she passed the
Radiogram of a fork in the stomach 48 hours after Ingestion. The slight
blurring at each end is due to active peristalsis.
handle of the fork “a long way down." To her dismay the
constrictor muscles gripped the fork, and she gradually lost
her hold upon the prongs and it disappeared.
The patient applied to the hospital for relief; her story
was not readily believed, but it was decided to take an X ray
pioture. Some little delay occurred owing to the Christmas
holiday, but on the 27th the photo was ready and showed a
dinner fork in the stomach with the handle towards the
pyloric end and the prongs towards the cardia. (See
radiogram.)
I was called to see her on the 27th at 6 o’clock. She was
complaining of pain in the epigastrium, which was much
worse when she ate anything, owing to peristalsis being
excited. Nothing could be felt abnormal in the epigastrium.
She was advised to have an operation for the removal of the
fork. At 10.30 p.m. I did a gastrotomy through a 2-inch
abdominal incision just to the right of the mid-line. There
was no difficulty in identifying the foreign body. The
shoulder of the fork was now lying against the pylorus, the
prongs being in the stomach and the handle in the
duodenum. It was removed prongs first through a 2-incb
incision in the anterior wall of the stomach. There were a
few black patches on it, possibly from the action of the
stomach acid. The subsequent suture of the organ was
carried out in the ordinary way, the whole operation taking
under 20 minutes. The patient made a successful recovery.
The accompanying radiogram was taken in the X ray
department, St. Mary’s Hospital. I am indebted to Mr.
J. Ernest Lane for permission to publish the case.
(?) CONGENITAL SYNOSTOSIS.
By Elizabeth Sloan Chesser, M.B., Ch.B. Glasg.
A child of two years was brought to me on account of hia
inability to supinate the right forearm. The movements of
pronation and semi-supination were accomplished without
difficulty. When the child was offered a coin he flexed the
elbow-joint and turned the hand backwards to receive the
coin in the palm of the hand. Dr. Tindal Atkinson X rayed
the case for me and the condition was found to be con¬
genital fusion of radius and ulna at the upper third. No
history of injury could be obtained.
Harley-Btreet, W.
A CASE OF AN UNUSUAL CONTRACTURE OF
THE PALMAR FASCIA.
By G. de Swietochowski, M.R.C.S., M.D.,
CIVIL SURGEON, 4TH LONDON GENERAL HOSPITAL, B.A.M.C. (T.)
I have failed to find any reference to a case similar to
the one described below in the largest libraries in London.
The interest of the case is further increased by the diversity
of opinions pronounced upon it.
The patient, 2nd Lieutenant, aged 21, was admitted to
hospital in August, 1917. Some time previously a shell had
burst close by and he was buried. A fragment hit his head
(small scar over right side of oociput); slight cutaneous
in j uries on right side. A fortnight afterwards the knuckles of
both hands swelled, and were slightly tender for 5-4 weeks;
and when this subsided he noticed his hands to be deflected ;
later occasional pain in hands on exertion.
It was found that when extended all fingers of both hands
deviated towards the ulnar side; there was loss of flexor
power. The ulnar deflection was very much less obvious
when the fists were clenched, the deviation increasing pari
passu with the extension. Extension was limited at the
metacarpo-phalangeal joints only; the inter-phalangeal
joints were hyperextended. There was no loss of tactile
sensation, and apparently no wasting of muscles of hands.
On the contrary, the tips of the fingers looked fleshy and
plump, and there were belly-like enlargements of soft
tissues around the lower part of the digits, especially in
middle and ring fingers. Some wasting of face, also loss of
flesh generally. The gait was normal; no deformity of toes.
No other joints affected. The radiograms of both hands
were normal. Family history negative.
On passive movement only it was not possible to extend
the fingers and also to undo the ulnar deviation. The
ulnar band of the palmar fascia to each finger was seen to
Btand out like a fine cord. This could be demonstrated by
The Lancet,]
ROYAL SOCIETY OF MEDICINE : SECTION OF OPHTHALMOLOGY. [Ff.b. 22, 1919 299
palling the fingers towards the radial side, all together or
separately. The condition was distinctly bilateral, being
more marked in the right hand. Complete correction was
not possible even under anaesthesia, daring which the
dragging on the palmar fascia was more marked.
In spite of the application of splints and vigorous treat¬
ment by massage ana electricity, no change, except perhaps
for the worse, was noticed for over three months.
The essential question was whether the case was organic
or functional.
In favour of functional origin were the circumstances
leading up to it; no history of a definite injury to the hands;
loss of memory by patient once, soon after admission.
Finally, the unusual and symmetrical deformity of hands
Fio 1.—Condition of hands on admission August. 1917. (Maximum
extension.) Note marked ulnar deflection.
had led several surgeons to support its functional nature.
On the other hand, there was a complete absence of the
usual concomitants of functional disorders, such as sensory
disturbances, wasting of muscles (except in the face), and it
was evident that the voluntary efforts were genuine. The
symmetrical disposition is known in cases of hallux valgus,
hammer-toe, and camptodactylia has been described
amongst organic disorders. Yet there was no hypothermia
nor acrocyanosis to indicate trophic disturbances.
The sole disorder known to be associated with the palmar
fascia resulting in a contracture of the fingers was first
described by Baron Dupuytren. This, however, results in a
more or less complete flexion of the digits, mostly of the
ring finger, without lateral deflection. Why the process of
shortening should have in our case chosen just the ulnar
fascicles and be symmetrical is difficult to answer. Perhaps
the slight arthritic affection determined the course to a
certain extent; for the appearance at the height of the
Fio. 2.—Condition of hands in July, 1918. (Maximum extension.) Note
absence of ulnar deflection. Two crucial scars in the left an<l three
In the right palm can be seen In relation to and above the lower
palmar crease.
contracture was not unlike the deformity met with in
advanced arthritis deformans. The interdigital folds (webs)
were very marked.
Whatever the origin, the deformity must have resulted
from a progressive fibrosis of the ulnar portions of the
palmar fascia. The finer anatomical studies of the fascia
reveal its intimate relations with the skin of the palm, with
which it is connected by perpendicular fibres of great
firmness.
Operation was resorted to in November, 1917.
Under general anaesthesia I put the affected portion of the
palmar fascia of the left hand on the stretch by reducing the
ulnar deflection. A fine scalpel was introduced, first
parallel to the fine prominent cord on the ulnar aspect and
then at right angles to the original incision, severing the
strings. At once the fingers could be easily straightened
out and the deflection undone. The bleeding was (compare
tively) not inconsiderable, despite care to avoid vessels and
nerves. Dressing was applied and a specially constructed
splint firmly tied on. Massage was resumed directly the
incisions were lightly united. The result was very good.
After a few months I attacked the right hand. Both hands
can now be used freely, without even a suggestion of ulnar
deflection. The splint is still worn at night on the right
hand. The grip is steadily improving and there is not the
slightest sign of relapse. It took exactly 12 months to cure
the case.
This case reminds one strongly of the type of reflex nervous
disorders described by Babinski and Froment, though I could
not find anything resembling it amongst their pictures. Also,
according to them such a contracture should be easily undone
in deep anesthesia. In conclusion, I wish to express my
thanks to Lieutenant-Colonel Sir Nestor Tirard, Commanding
Officer of the 4th London General Hospital, for his permission
to publish the case. I am also much indebted to Captain
E. B. Clayton for his untiring efforts in the massage depart¬
ment, and to Miss Berry for the execution of an ingenious
splint.
St. John’s Wood, X.W.
JSltbfral Surieties.
ROYAL SOCIETY OF MEDICINE.
SECTION OF OPHTHALMOLOGY.
A MEETING of this section was held on Feb. 5th, Mr.
W. T. Holmes Spicer, the President, being in the chair.
Retinal Degeneration.—Ioory Exostoti* of Orbit.
Mr. A. C. Hudson exhibited a case of Retinal Degenera¬
tion following Intraocular Foreign Body. The ophthalmo¬
scopic picture was that of folds in the internal limiting
membrane of the retina, probably resulting from contusion
of the eye. There were double contour reflex lines radiating
from the macular region and having certain peculiarities, one
of them being that they passed in front of certain of the
retinal vessels and another that they were faintly stippled.
He regarded the condition as pathological: there appeared
to have been oedema of the whole retina and optic disc.
Similar appearances have been seen by the exhibitor in a
case of retinitis pigmentosa, resulting, in that patient, from
traction on the retina. The lines were analogous to those
seen in some posterior capsules after cataract extraction.—
Mr. J. H. Fihher thought the history and appearance sug¬
gested that the lines were caused by some new formation,
probably in the fundus oculi.—Mr. A. W. Ormond considered
that the amount of swelling was much greater in the upper
than in the lower part of the disc and that it was patho¬
logical.
Mr. W. Lang and Colonel Donald Armour exhibited a
youth from whom an Ivory Exostosis of the Orbit had been
removed by Colonel Armour through the cranium. The patient
attended at the Royal London Ophthalmic Hospital, where the
members of the staff agreed it was a case for a general surgeon.
Colonel Armour did the operation of removal. His problem
was to remove the growth completely without doing damage
to the cranial or orbital contents, and to leave as little
facial disfigurement as possible. The skiagram led to his
decision to use an osteoplastic flap turned over the frontal
region, with its base at the supra-orbital margin, turning
down bone and scalp together. That displayed the cranial
portion of the tumour, which was found to be indenting the
under surface of the frontal lobe. By pushing the dura and
brain gently back over the summit of the tumour, he was
able to see the whole extent of its cranial portion. Removal
was effected in the main by means of hammer and chisel,
the small portion of the orbital roof being attacked with
cutting forceps. The recovery was practically uninterrupted
and complete ; there was very little external to indicate that
an operation had been carried out. The growth must, he said,
have originated in the frontal sinus, judging by the fact that
the lower portion of the tumour was covered with mucous
300 The Lancet,]
WB8T LONDON MEDICO-CHIRURGICAL SOCIETY.
[Feb. 22,1919
membrane. Colonel Armour had in mind during the opera¬
tion the possibility of the frontal sinus being involved,
bearing in view the question of subsequent sepsis and the
interference with respiratory movements, but at the operation
there were no signs of that. On the day following the
operation, however, and during the two or three succeeding
days, there was an escape of blood from the nostril, which
seemed to show some involvement of that sinus. It must,
however, have been aseptic, as there was no further trouble. —
Colonel Armour was congratulated on his success.
Exhibition of Other Cases and Drawings.
Mr. J. F. C CJNNINGHam showed a case of Cartilaginous
Tumour of the Hoof of the Orbit, and Colonel Armour
advised removal.
Mr. Elmore Brewerton exhibited a patient with Angioma
of the Retina. He regarded it as a form of cavernous
angioma. The blood-vessels did not appear to be diseased ;
the disease seemed to be in an oval swelling in the periphery.
The distension of the veins seemed to be purely mechanical.
The small branches arising from the main artery were
normal in size and general appearance. This was the
patient’s only eye. and there was reason to fear that the vein
would at some time begin to leak; it already showed slight
exudation at one point. There was evidently some con¬
genital fault below. His other eye had been removed at the
age of six years, as it was not only blind but painful.
Mr. Ormond described a similar case.
Dr. W. Wallace showed, by means of the epidiascope, a
series -of remarkable colour drawings showing Fundus
Changes resulting from Severe War Injuries. He offered
his collection to the profession.-He was warmly con¬
gratulated on them, and Colonel Herbert Parsons suggested
they should constitute the nucleus of an ophthalmic atlas,
which should be a permanent record of ophthalmological
work done during the war.
Leber's Atrophy : Changes in Sella Turcica.—Sympathetic
Ophthalmitis.
Dr. Jambs Tatlor read a short paper on Changes in the
Sella Turcica in Association with Leber’s Atrophy. The
speaker’s purpose was to support, by means of this case, the
contentions of Mr. Herbert Fisher, in his paper some months
ago, that the symptoms of Leber’s atrophy were associated
with definite changes, seen skiagraphically, in the sella
turcica. Skiagrams in this case showed departures from the
normal in that structure, especially in the posterior and
anterior parts of the glenoid fossa.—The President regarded
the contribution as a distinct advance. It would be a
comfort to know the origin of Leber’s atrophy ; it was
scarcely likely that changes in the sella turcica represented
the only abnormality. Ogilvie’s series of observations some
years ago on the deaths of large numbers of infants in
families afflicted with Leber’s disease seemed to point the
direction in which inquiry should be made.—Mr. Fisher
reminded the meeting of his paper in which he suggested
that Leber’s optic atrophy was due to implication of visual
pathways by the pituitary body when it was undergoing
excessive physiological changes in association with sexual
development or decline. He would welcome every confirma¬
tion of that view. He had not seen material alterations in
the bony outline of the sella turcica in every case of Leber’s
atrophy, but in one striking case, that of a woman aged 37
who reached the climacteric prematurely, a definite change
was perceptible there.
Mr. R Foster Moore read a paper on a case of Sym¬
pathetic Ophthalmitis with Fundus Changes. He said that
sympathetic ophthalmitis had been of rare occurrence duriDg
the war, therefore every such case was worth recording. In
the present instance the fundus changes developed during
the progress of the disease, and were visible throughout.
The Wassermann test was negative, but five doses of
neosalvarsan were given. It did not seem to have any
influence on the disease. These cases showed a tendency
to get well of themselves. The blood count was normal,
and that was usually so in this disease, according
to his experience.—Mr. Frank Juler, who made the
drawing of the case, confirmed the history and appearances
described. When the case was seen last October the
vitreous opacity was very marked indeed, so that the spots
of choroiditis could not be clearly defined. A few weeks
ago, when he next saw the case, the vitreous opacity had
almost entirely cleared up, and the keratitis punctata had
quite disappeared. He asked whether the neosalvarsan
injection seemed to play any part in the recovery from
relapses.—Mr. Moore replied that “ 606 ” did not seem to
have any influence upon the course of the disease. The
special Committee which the Ophthalmological Society
appointed to investigate this condition years ago stated at
the end of their report that mercurial inunctions had no
decidedly bad effect on the sympathetic ophthalmitis.
West London Medico-Chirorgical Society.—
A clinical meeting of this society was held at the West
London Hospital on Feb. 7th, Lieutenant-Colonel E. M.
Wilson, the President, being in the chair.—Dr. Reginald
Morton exhibited a series of radiograms illustrating a short
paper on the Most Common Site of Malignant Stricture of
the (Esophagus. The author stated that during the previous
nine years he bad examined in the West London Hospital
many cases where this condition was supposed to be present,
a proportion of which gave a negative result. Ignoring these,
there remained 66 cases of definite obstruction, practically
all of a malignant character—less than half a dozen where
the spasmodic element was the sole or predominating
feature. By X-ray methods he thought that the most
common site where malignant stricture of the oesophagus
occurs will soon be decided. To get at this radiologists
should agree on some uniform division of the (esophagus for
purposes of description, and these divisions must have
relation to familiar landmarks seen in this locality during
X-ray examination. The division that he had adopted was
chosen solely because he had found it convenient. The upper
part lies above the sterno-clavicular joint; the next cor¬
responds to the aortic arch, and extends from the sterno¬
clavicular joint to as far below the arch as the joint is above
it; the third portion includes that part of the tube where it
S ierces the diaphragm, and the last one is the region imme-
iatelv at and including the cardiac orifice. They might be
described as (a) the upper, (b) the aortic, (c) the diaphrag¬
matic, and (d) the cardiac portions. Applying this division
to the present series of 66 cases (eliminating one that was
purely spasmodic, as subsequent events proved) stricture
occurred with equal frequency in the first and third portions,
and also with practically equal frequency in the second ana
fourth portions. The disparity between the first pair and the
second pair—“ the odds and the evens’ 5 —is very striking,
the latter being nearly four times that of the former.
The actual figures were: {a) Upper (supra-sternal), 7;
(b) aortic, 25; (c) diaphragmatic, 7; and (d) cardiac, 26
(total, 65).—Mr. Asletfc Baldwin showed: 1. A case of
Plastic Operation on Face for Deep Scarring, caused by a
German hand grenade wound. Originally there was a
drawing down of the left angle of the mouth with
inability to open the jaws except to a slight extent. After
operation an excellent result was obtained. 2. A woman
from whom a large part of the tongue had been removed
for a huge papilloma of about one year’s growth which had
almost completely filled the mouth. Speech was fairly good
in spite of the large operation.—Mr. W. E. Fry showed a
specimen of Endothelioma of the Tonsil. The woman died
at the age of 64 after having had the growth for 18 years.
Enucleation had been advised but refused ten years
previously.—Dr. Arthur Saunders, Mr. Tyrrell Gray, and
Dr. F. S. Palmer also showed cases.
North London Medical and Chirurgical
Society. —A meeting of this society was held on Feb. 13th
at the Great Northern Central Hospital. Afteroflicial business
had been taken, Mr. Ernest Shaw read a paper on the
Relation of Pathology to Clinical Medicine. He shortly
sketched the history of pathology in recent times, empha¬
sising the epoch-marking work of Virchow and Koch in
establishing the relationship between bacteria and disease.
In describing the action and uses of sera, Mr. Shaw pointed
out that as there were many varieties of the same organism
an effective serum could only be made from those tissues
affected by a particular variety. Hence “ stock ” sera were of
little value. Although Jenner was responsible for the first
general use of a vaccine in this country, we owed our
modern knowledge of vaccine therapy primarily to Koch.
Mr. Shaw reviewed the diseases of special organs and tissues,
showing how much the medical man—whether surgeon,
physician, or general practitioner—owes to pathology, both in
diagnosis and treatment. Having briefly classified the
diseases of blood from the standpoint of the address, he gave
several cases in detail to demonstrate how the microscope
could often determine in a moment a disease which had
defied the most expert clinician. Speaking of the value of
blood-cultures, he insisted that the cerebro-spinal fluid also
should always receive attention when any condition is
present suggesting a lesion of the nervous system. Mr. Shaw
justified his classification of tumours, from the surgioal
point of view, into “ simple ” and “ malignant ” bjr stating
that the object of the physician or surgeon was simply to
302 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
(Feb. 22,1919
points are emphasised in heavy type; summaries are given
at the end of each case, where desirable, and then comes a
little series of questions and answers bearing on the diagnosis
of the case, and perhaps on its treatment, or on any matter
of interest it calls forth. The book sections are six in
number: nature and forms of neuro-syphilis ; systematic
diagnosis of forms of neuro-syphilis ; puzzles and errors in
the diagnosis of neuro-syphilis ; medico-legal and social
neuro-syphilis; the treatment of neuro-syphilis ; and neuro¬
syphilis and the war. Each section is illustrated by abundant
clinical material. Further, scattered at convenient intervals
through the book are 44 charts ” consisting of salient features
of neuro-syphilis tabulated as a sort of memoria Uohnica;
the headings, too, are often arranged in a fashion resembling
the insets on some front pages in the newspapers of the
day. Thus
"TABETIC NEUBOSYPHILI8 may produo* symptoms chiefly
If not entirely in the region supplied by
the CERVICAL PLEXUS (‘cervical tabes’)"
or—
“ The clinical symptoms of CHRONIC ALCOHOLISM
are sometimes largely identical with those of
PARETIC NEUROSYPHILIS (‘ general paresis V
These indications of originality of presentation may or may
not appeal to the conservative English reader; but they
are no mere catch-penny attempt at 44 neuro-syphilis made
easy,” for our perusal of the book has shown that it
oontains a mass of solid clinical, pathological, and thera¬
peutic information, thoroughly sifted, well arranged, and
eminently practical in all its bearings. We congratulate
the authors on the complete success of their experiment in
book-making.
Archive* of Neurology and Psychiatry. From the Patho¬
logical Laboratory of the London County Mental Hos¬
pitals. Edited by F. W. Mott, M.D., F.R.S., Ac.
(Lieutenant-Colonel, R.A.M.C. T.). Vol. VII. 1918.
London : P. S. King and Son. 10*. 6 d.
The latest volume of papers in neuro-pathology and
psycho-pathology issued under the segis of Dr. F. W. Mott
represents the work whioh he and his colleagues have been
prosecuting at the Maudsley Hospital, Denmark Hill. It
oontains some 12 communications, most, if not all, of whioh
have already been published elsewhere, mainly in the Trans¬
actions of the Royal Society of Medicine, during the last three
years. Here in convenient and oompact form are reprinted
Dr. Mott’s valuable researches on shell shock and kindred
subjects, including his Lettsomian lectures of 1916 on the
effects of high explosives upon the central nervous system.
In addition there are several useful papers on the inter¬
relation of the endocrine glands and the nervous system both
in its organic and functional aspect. The whole volume
bears witness to the indefatigable spirit of research animating
its editor and his collaborators, and worthily maintains the
high level of previous volumes in the series.
Advanced Suggestion (. Neuro-induction ). By Haydn Brown,
L.R.C.P. Edin., Ac. London : Bailliere, Tindall, and
Cox. 1918. Pp. 342. Is. 6d.
Hypnotic Suggestion and Psycho-therapeutics. By A. Betts
Taplin, L.R.O.P. Edin., late President of the Psycho-
Medical Society of Great Britain. London: Simpkin,
Marshall; Liverpool: Littlebury Brothers. 1918. Pp. 168.
10*. 6d.
Of making of books on psycho-therapy there seems to be
no end. In so far as this is significant of wider application
of psycho-therapeutic methods by the profession it is a
healthy sign, for the employment of essentially similar
methods under high-sounding names by unauthorised practi¬
tioners is certainly not decreasing, and there is always a
section of the public which prefers the obscure, mysterious,
and occult to straightforward, and therefore, presumably for¬
sooth, less impressive and less convincing procedures. The
main feature of suggestion-methods is their simplicity, too
simple for the 44 high-brow ” who seeks intellectual titilla-
tion in the garnishings of the faith-healer, the Christian
scientist, the clairvoyant healer, and all the rest of them,
whose very existence, as Mr. Haydn Brown says, con¬
stitutes a scathing criticism upon the shortcomings of the
profession in the study and application of treatment by
suggestion.
In the two books under review is contained, under some¬
what differing presentations, a body of sound teaching on
suggestion-therapy, illustrated by clinical examples of all
sorts. Some of these are less impressive than others, and
rather convey the idea of somewhat uncritical investigation
of the material. Many, however, cannot fail to demonstrate
to the sceptical the great practical value of treatment by
frank suggestion in suitable cases. If the suggestion-
therapist sometimes overstates his position by the exagge¬
rated nature of his claims, this should not blind the
physician to the genuineness of his achievements with
many cases which 44 have seen all the best men” and been
sent on 44 in desperation” to the psyoho-therapist. Neither
of the authors, who write of what they have seen and done,
speaks enthusiastically of pBycho-analysis as a therapeutic
method, though both have had experience of it. The
general contention seems to be that efficacious and enduring
results can be obtained by simpler technique, that many
neurotic cases have had no particular psychical traumata in
their history, and that cases already psycho-analysed
ineffectaally have come to them for further treatment.
As convenient text-books of unassuming pretensions they
may be recommended to the profession for sympathetic
consideration.
Neurological Clinics: Exercises in the Diagnosis of Diseases of
the Nervous System. Edited by JOSEPH COLLINS, M.D.
New York : Paul B. Hoeber. 1918. Pp. 271. $3.
Dr. Joseph Collins and his colleagues at the Neurological
Institute in New York have collected, from large material, a
series of clinical cases offering practical lessons in diagnosis,
since successful treatment obviously presupposes accurate
diagnosis. The cases range through all the aspects of
organic and functional neurology and include not a few
classifiable as psychiatric. The majority present features of
interest and show evidence of careful selection ; a few seem
to us to have been handled rather superficially, no doubt
merely from a praiseworthy effort on the part of the writer
at conciseness. There are some 41 cases in the book, whioh
will, we believe, form profitable reading both for the general
practitioner and the neurologist.
The Disease and Remedy of Sin. By the Rev. W. MACKINTOSH
Mackay, B.D. London, New York, Toronto: Hodder
and Stoughton. Pp. 308. 7*. 6 d.
In his preface Mr. Mackay defines the scope of this book
by describing it as an essay in the Psychology of Sin and
Salvation from a medicinal standpoint. Christianity is every¬
where regarded as the care and cure of spiritual disease.
The result is a book that is original and suggestive, it
abounds in medical terms and phrases, and shows the author
as well read in philosophy, medicine, and ancient and
modern Protestant theology. Sin, its causes, progress and
effects, are treated as a physician treats disease; it is traced
from its roots upwards in the first part of the book with
exhaustive accuracy, while in the second part we have the
remedy of sin under such headings as Conversion by
Crisis, Conversion by Lysis (by whioh latter the author
means the gradual turning of the life towards God),
spiritual surgery in cases of chronic sins, mortal sins, and
sins of compromise, the knife being absolute renunciation ;
any return to the sin so treated is likened to a cancer which
recurs after an operation. 44 The spiritual surgeon should
cut off all adhesions as well as the noxious growth.”
In his chapter on the Divine Surgery of Pain the author
reaohes his highest point; his whole treatment of pain is
illuminating, especially in his analysis of Hinton's Mystery
of Pain, in whioh he lays his finger unerringly on the weak
spot in that work—namely, Hinton’s ignorance of the fact
that the Incarnation was meant, amongst other things,
to teach us that God does suffer pain. The book is in
places brilliant, everywhere thoughtful, and yet, as from its
very nature perhaps it was bound to do, it leaves us cold; it
is a pitiless production.
On p. 15 Mr. Mackay refers to the confessional in the
Roman Church, and deplores the lack of such a system in
other communions. He appears to be ignorant of the pro¬
visions for voluntary confession which are laid down in the
Book of Common Prayer. The book, however, is one which
no earnest minister of religion can afford to miss, and It
will be found helpful to anyone who is called upon to be a
director of souls.
Thjl Lancet,]
A NEW EPIDEMIC DISEASES ORDER AND ITS EFFECT.
[Feb. 22,1919 303
THE LANCET.
LONDON: SATURDAY, FEBRUARY 'i, 1919.
A New Epidemic Diseases Order
and its Effect.
•
The Local Government Board have, under the
Public Health Acts, issued an Order 1 relating to
the prevention of certain epidemic diseases which
comes into operation on March 1st and requires to
be widely known by men in consulting and general
practice, as well as by the public health authorities
and medical officers of health to whom it has been
officially circulated. By one provision of this Order
the diseases termed “ acute primary pneumonia ”
and “ acute influenzal pneumonia” are made notifi¬
able to the medical officer of health of the district,
and every medical practitioner who becomes aware
that a person on whom he is in professional attend¬
ance is suffering from these forms of pneumonia is
required forthwith to notify the medical officer
of health of the district on the same form and
in the same manner as for scarlet fever or other
acute infectious diseases which are already noti¬
fiable. It should be noted that, as no alteration
has been made in the Notification of Infectious
Disease Regulations of 1918 or in the Emergenoy
Provisions Act of 1916, this duty is not accom¬
panied by any special remuneration, though
the general obligation of the local authority to
pay one shilling in respect of each notification
will apply to those reported under the new Order.
In using the special emergency powers of
Section 130 of the Public Health Act of 1875 to
require notification throughout England and Wales,
and to give the medical officer of health of the
district the duty of taking “such action as he
considers necessary and desirable ” in each notified
case “ to prevent the spread of infection and
remove conditions favourable to infection,” the
Order merely follows the practice by which in
recent years various other diseases, such as tuber¬
culosis and measles, have been made notifiable
under this Act, rather than by the use of the
Infectious Diseases (Notification) Acts. In the
case of acute and influenzal pneumonia nothing
further is required by the Order. The information
obtained by notification should have statistical
value when the next pandemic of influenza arrives,
as the course of its attendant pneumonia can then
be followed right through the various phases of
prevalence of influenza itself. Meanwhile it will,
no doubt, aid knowledge by promoting the study of
the circumstances in which pneumonia occurs, and
in certain districts at least it should be helpful to
local authorities as a guide to the selection of cases
in which to provide medical or nursing assistance.
This is at present the chief useful result obtained
from the notification of measles.
1 Local Government Board Order P.H. 2a, 1919: "The Public Health
(Pneumonia, Malaria, Dysentery, 4c.) Regulations, 1919." The accom¬
panying official circular is reproduced substantially on p. 309
The other infectious diseases made notifiable
under this Order are malaria, dysentery (both
bacillary and amoebic), and trench fever. These are
diseases hitherto of relatively rare occurrence in
this country, but which need to be specially pro¬
vided against in the circumstances attending
demobilisation and the resumption of normal
traffic with foreign countries after the war. In
regard to these diseases, as well as to enteric fever,
relapsing fever, and typhus, which are already
notifiable, the Order makes a number of
specific provisions, based on their known method
of spread, which are to be applied in all
notified cases. When a medical officer of
health becomes aware, by notification or other¬
wise, of a case of typhus, relapsing fever,
or trench fever, he is empowered to take special
measures for the destruction of lice, and he can
give a notice, addressed to the head of the family or
to any person in charge of or in attendance on the
patient, or to any other occupant of the building, or
to any person with whom the patient has been
recently in contact, requiring that person to take,
immediately and to the satisfaction of the medical
officer of health, specified measures to secure the
complete destruction of lice and their products.
Action for the same purpose can be required of
persons having the control or management of any
building, of the person who receives the rent in
the case of lodging-houses, and of the master of
a ship when a port sanitary district is concerned.
These notices must be complied with under risk of
substantial penalties. The segregation of contacts
until they and their clothing have been completely
freed from lice can be similarly enforced. Each case
itself must be treated in a suitable hospital unless
the medical officer of health is satisfied that treat¬
ment elsewhere will be carried out with all such
precautions as are necessary to prevent the spread
of the disease. The same provisions in regard to
hospital treatment are made in the case of dysentery,
and special clauses are added, applicable to enteric
fever as well as to dysentery, which deal with
risks of infection arising from the handling of food.
The notices which can be given in the case of
these diseases may require the person specified
within them to discontinue any occupation con¬
nected with the preparation or handling of food or
drink for human consumption, or to take suitable
measures in respect to cleansing, disinfection,
disposal of excreta, destruction of flies, and other
matters. A very welcome provision is that relating
to carriers of enteric fever or dysentery infection.
If there are grounds to suspect that a person
engaged in the milk trade or in the preparation of
other food is a carrier, facilities are to be given *
to the medical officer of health at his place of
occupation to obtain specimens for examination.
When a dangerous carrier is identified on evidence
that is considered sufficient the medical officer of
health may again proceed by notice, addressed both
to the suspected person and to the responsible
manager of the business, to prevent the former
from continuing in employment involving the
preparation and handling of food.
304 The Lancet,]
▲ TUBERCULOSES SERVICE.
[Feb. 22.1919
All cases of malaria are made notifiable (unless
they are known to have previously been notified in
the same district within six months), but the special
action required of the medical officer of health is
limited to those cases in which he considers that
steps should be taken to prevent the spread of infec¬
tion. The greater number of notified cases will
be in soldiers and others who have contracted
infection abroad and who then relapse in this
country: when this fact has been ascertained nothing
further will as a rule be required of the medical
officer of health. If, however, there is evidence of
the disease being contracted locally, he is required
to take all practicable steps to see that malarial
cases in his area are supplied with mosquito
netting, receive necessary quinine treatment, and
proper advice as to precautions. On the occurrence
of a focus of indigenous malaria (defined as
two or more cases contracted within the district)
the local authority may be required by the
Local Government Board to appoint and pay an'
approved medical practitioner for house-to-house
visits, collection of blood films, and supervision of
household precautions. Section 130 of the Public
Health Act of 1875, under which this Order is
made, was introduced into that Act with the special
object of taking emergency measures against
imported cholera, and it is interesting to see that
after this lapse of time it has proved possible to
utilise this section to provide a code of action
which is based on scientific knowledge of the
prevention of the diseases now in question. The
application of tbe regulations evidently calls for
close expert guidance from the centre if they are
to be most effectively used. Medical officers of
health will need the advice of those who have
specialised in the study of diseases such as malaria
and dysentery or have special knowledge of the
bacteriology of carriers. It is presumably with
this object that the Order requires each individual
case of trench fever, typhus, relapsing fever, or
malaria of indigenous origin to be reported at once
by the medical officer of health to the Local Govern¬
ment Board, as well as any outbreak of dysentery.
The effect of the Order in practice has yet to be
ascertained, but it is evident that its success will
largely depend on the opportunities afforded to the
epidemiologists of the Local Government Board
or of the future Ministry of Health to observe
and direct its working. But the spade-work, the
diagnosis, will have to be done by the general
practitioner, and for shilling fees, unless the public
conscience is aroused at the degrading discrepancy
between the size of the payment and the import¬
ance and responsibility of the judgment which sets
this official machinery in motion.
A Tuberculosis Service.
The meeting held at the Royal Society of
Medicine on Saturday last to consider a scheme for
the formation of a complete and self-contained
tuberculosis service was not a large one, but it
was widely representative of the various branches of
tuberculosis practice. The meeting was summoned
by the Tuberculosis Society, which had previously
circulated a draft scheme amongst its members,
and this draft, after some modification in detail, was
passed substantially in the form submitted by the
unanimous vote of those present. Accordingly, a
deputation was arranged to wait upon the Prime
Minister and the Minister in charge of the Ministry
of Health Bill. The scheme, which we print in
full on p. 310, asks for a special department of
the Ministry of Health to deal with the prevention
and treatment of tuberculosis. It asks that the
personnel of this department should include medical
commissioners, filled from the ranks of the tuber¬
culosis service, who, along with other commissioners
appointed by the Crown on account of their special
knowledge and experience, should advise a com¬
mittee representing medicine, the public health
services, local authorities, the Ministry of Pensions,
trade unions, Friendly Societies, and other organi¬
sations interested in social welfare. No doubt will
arise in regard to the need for cooperation among
all these agencies. The work of controlling tuber¬
culosis has been hampered in one district by lack
of funds, in another by deficient resident accom¬
modation, in a third by want of any organi¬
sation for after-care, in a fourth by apathy
on the part of the public health authority,
and in a fifth by failure to cooperate with the
general practitioner. All these defects must be
remedied if success is to be achieved.
But while admitting the necessity for cooperation
in all branches of tuberculosis work, the amateur
administrator might argue, with some show of
reason, that no far-reaching scheme of prevention
and treatment should be organised from top to
bottom, from patient to Government department,
for the sake of one pathogenic organism. Surely,
he would say, the Pfeiffer bacillus or the pneumo¬
coccus or the new filter-passer has a similar claim
to a special anti-service. But in practice, tuberculosis
is a special case. It is a life-long infecting agent of
relatively low infective power, raising problems of
prevention and treatment which exist side by side
and must be dealt with concurrently. Tuber¬
culosis seems, in fact, to provide at present the
most promising field for that combination of clinioal
and administrative service for the development of
which all eyes are turned towards the Ministry of
Health. The mechanism of such a tuberculosis
service may in the future be found applicable to
other than the white plague. If so, pneumonia and
influenza, standing as they do in such close relation
to the problems of tuberculosis, might then be asso¬
ciated with it. But that is no reason for hesitating
to make a beginning with the coordination of
measures against tuberculosis.
Granted that a special tuberculosis service has
its justification at the present time, it is no less
certain that its relation to the general public
health service mjist be an intimate one, closer
perhaps than Saturday’s meeting had in mind.
There may be, it is true, a certain number of
medical officers of health who are inclined to treat
the tuberculosis officer as a clinical tyro; there may
be also inexperienced tuberculosis officers with bees
in their bonnets, whose acquaintance with the ways
of local authorities and with the mechanism neoes-
Thi Lancet,]
THE RETURN OF INFLUENZA.
[Feb. 22,1919 305
8ary to deal with social conditions leaves something
to be desired. It is obviously expedient to make
the tuberculosis officer responsible for the adminis¬
tration of his own special work; but when all is
said and done it would be impossible for
him alone to provide those large measures
of reconstruction—clean streets, open spaces,
proper housing—which are destined to play such
a large part in raising the standard of public
health on which the prevention of all disease largely
depends. The tuberculosis problem will not be
solved by working in a water-tight compartment.
The spirit of the timeais against it. Any such pro¬
posal would be reactionary, not reconstructive. We
see little hope of lasting benefit from any scheme
which does not make the local authority (whether
county or county borough) the coordinating centre
of all hygienic and social measures in its own area.
There is a movement on foot to enlarge the Public
Health Service along the lines of the proposed
changes in the constitution of the Society of
Medical Officers of Health. This is more urgent
at the moment than scales of salaries and
commissionershipB.
Jnnotatiaits.
"He quid nimla.”
THE RETURN OF INFLUENZA.
To speak of the return of influenza is to imply
that this multiform, obstinate, and in many
directions mysterious epidemic, whose manifesta¬
tions among us at two epochs in 1918 were so
serious, had definitely gone, and this, we are certain,
should not be assumed. We have not enough know¬
ledge. Major As tor, Parliamentary Secretary to the
Local Government Board, stated in the House on
Tuesday last, in reply to a question, that influenza
may be combated by continuous research and intel¬
ligence work: until such endeavours have borne
fruit, it must be impossible to say for certain either
how long the infection of influenza may linger
in a community, or what are the circumstances
which conduce to its quick removal or to its long
persistence. Many of these circumstances are
assuredly common to the natural history of all
epidemic visitations, but it is proven, if only by the
differing views of expert pathologists, that in the
case of influenza we do not yet know the whole
story. What, for example, induces changes in age-
incidence ? And how far is immunity conferred by
previous attack or other pathological conditions?
The extent to which the disease is now prevalent
among us can be gauged from sporadic reports, as
well as from such definite figures as those furnished
in our summary of vital statistics (see p. 311), and
undoubtedly many communities are faced with a
return of the troubles which they were experienc¬
ing last autumn. While medical men are working
along useful lines for prevention and with thera¬
peutic methods which sore experience has per¬
fected, it is the duty of the public to avoid as far as
possible the spread of the mischief. The local
health authorities may take steps for lessening the
public opportunities of infection, but they will be
useless till the public is ready to institute for them¬
selves a system of domestic inspection by which
prompt medical attention is obtained. Where the
public is intelligent the medical service, public and
private, becomes doubly effioacious, while remark¬
able results have been and will be obtained from
intelligent nursing. How many serious cases have
been saved, and how many less serious cases have
been lost, by the respective presence or absence of
the competent nurse would be a bold piece of
guessing, but, without attempting any exact reply,
we are convinced, on the numerous reports which
we have received, that when influenza has got a
definite hold upon a patient it is the nurse, and
anxious domestic care, which turn the scale most
frequently in the patient's favour. Major Astor
stated the intention of the Local Government Board
and other bodies to assist in the provision of
medical nursing and domestic aid to those attacked,
and any activity displayed along this line will be
fully rewarded. Research work has been proceed¬
ing for a long time in the hands of many observers,
and the medical officers of the Local Government
Board are at the present moment in active coopera¬
tion with other experts outside the Department by
means of a committee which meets at short and
regular intervals. All this is most valuable for
the direction of preventive measures, both now and
in future epidemics; but, in the place where we stand
to-day, the two urgent things are the assistance
of the medical man by the intelligent cooperation
of the public, and the assistance of the patient by
the provision of adequate nursing. A memorandum
will be issued by the Local Government Board this
week recommending the steps which should be
taken by the local authorities and also by the
public. This memorandum, we understand, will be
of a practical nature. _
COORDINATION OF MEDICAL SERVICE: SIR
GEORGE NEWMAN’S APPOINTMENT.
Sir George Newman, Chief Medical Officer of the
Board of Education, has been appointed Principal
Medical Officer to the Local Government Board,
retaining his position at the Board of Education,
where he is also Medical Assessor to the Uni¬
versities Branch of the Board. The post of
Principal Medical Officer to the Local Govern¬
ment Board is a new one, and Sir George Newman
will have the position of a Secretary of the
Board with administrative duties and responsi¬
bilities in respect of the work of his depart¬
ment. It should be clearly understood that
this is not the post of “ Medical Officer ” which
was recently held by Sir Arthur Newsholme.
Nothing in the new appointment, we are glad to
say, prevents the existing medical staff of the
Local Government Board, who have been bearing
the burden within the department of the public
sanitary service, from being advanced to a post of
the same standing, if not with the same title, as
that recently vacated by Sir Arthur Newsholme.
The appointment of Sir George Newman aB prin¬
cipal medical officer of the Board is a direct
step towards that coordination of public medical
service, which has been stated to be the primary
object of the Ministry of Health. Sir George
Newman has had practical experience, both urban
and rural, in the work of the medical officer of
health, while he is a recognised authority in school
hygiene. Moreover, in all questions of medical and
educational administration he has shown himself
on the side of the general practitioner, recognising
that a medical department can only be run satis¬
factorily from the top if the real executive, the
306 Thk Langst,] ROYAL SOCIETY OF MEDICINE : SUMMER CONGRESS OF LARYNGOLOGY. [Feb. 22, 1919
private doctor, is given fair play. Dr. Addison and
Sir George Newman are in a previously unrealised
position—two doctors they are, in their respective
spheres, controlling a public medical department.
In the present position of the medical profession
their opportunities for good are literally huge.
THE ROYAL SOCIETY OF MEDICINE : A SUMMER
CONGRESS OF LARYNGOLOGY.
The Section of Laryngology of the Royal Society
of Medicine is showing increased energy with the
return of many of its members from the war. Its
meetings have had large attendances during the
war, being favoured by the presence of many
American and over-seas laryngologists. It has
therefore decided to convert its annual gathering
in May into something more than the usual clinical
meeting. On Friday, May 2nd, there will therefore
be a summer congress; papers will be read in the
morning, demonstrations of cases, operations,
specimens, instruments will take place in the
aitemoon; and it is proposed to arrange a patho¬
logical museum of specimens relating to the
subject. We understand that all over-sea laryngo¬
logists will be heartily welcomed. Those who
intend to read papers or join in the discussion are
requested to notify the honorary secretaries of
the Section not later than March 3rd.
THE QUALITY OF COMMERCIAL VACCINE LYMPH.
In our correspondence columns we print a letter
dealing with recent experience as to the inferior
quality of certain samples of commercial vaccine
lymph in comparison with that which is issued
gratuitously to public vaccinators from the Local
Government Board’s lymph establishment. This,
unfortunately, is by no means the first occasion on
which complaint as to the potency of commercial
lymph has originated with practitioners, who per¬
force have to rely on trade sources for their supply.
Our correspondent adds to the value of his letter
by offering suggestions for meeting the difficulties
of the case, urging either the institution of adequate
control by Government of trade lymph supplies,
or more drastic procedure involving suppression
of commercial lymph establishments and instituting
gratuitous distribution of Government lymph to all
medical practitioners, whether public vaccinators or
not. Dissatisfaction with the potency and quality
of commercial lymph supplies is, as we have said,
not of recent origin, as reference to our own
columns in previous years will testify. And from
time to time, since glycerinated lymph for use in
the public services was first issued by the Govern¬
ment, attempts have been made to bring pressure
to bear in Parliament with the object of obtaining
official action along the lines of one or both of the
schemes advocated by our correspondent. As a
matter of fact, the more important private vaccine
establishments in this country have, we believe,
been officially inspected on occasion; but as
regards the considerable supplies of vaccine lymph
imported into this country from abroad, it is
obviously impossible for the Government to exercise
control short of putting a stop to such importation
altogether. In the House of Commons, replies to
a suggestion that the Government should itself
provide all the lymph required for purposes
of vaccination have generally been to the effect
that it was undesirable to take steps to the
detriment of trade interests, especially in view of
possibility that in time of pressure the Government
might need to enlist the assistance of Anna
engaged commercially in the production of vaocine
lymph. On the other hand, there is much to be
said for the contention that in view of State enact¬
ments requiring performance of vaccination as a
preventive measure, every medical practitioner
ought to be in a position to obtain supplies
of Government lymph; or, alternatively, of
glycerinated lymph produced under conditions
of State control and supervision, such as to
ensure clinical activity and bacteriological purity
as they are shown in the lymph issued from
the laboratories of the Local Government Board.
During the present war lymph for the vaccination
of our military forces has been issued from these
laboratories to the extent of some millions of doses,
while a stock of at least 1£ million doses is reported
to be available in cold storage in case of emergency.
In these circumstances it would seem that in
the event of the Government deciding to make
themselves solely responsible for the production
and issue of vaccine lymph in this country, no
Berious difficulty as to shortage of supplies need be
anticipated. _
THE EUROPEAN FOOD SITUATION.
We understand that Lord Par moor’s letter dealing
with the facts of the European famine 1 was circu¬
lated widely among leading members of the medical
profession, along with a summary of these facts, and
that a large degree of unanimity was found in the
replies to the questions. The first question, directed
to the credibility of the reports of starvation, was
not answered inasmuch as the medical profession,
as such, makes no claim to special sources of
information or to any special power of sifting the
evidence obtained. But replies, where received,
were at one in affirming the permanent ill-
effects to be expected from chronic starvation
prevailing among the children and young people
of all the nations to the east of the Rhine.
The Fight the Famine Council has only to
establish the existence of this chronic starva¬
tion to have the whole of the medical pro¬
fession on their side in regard to its ill-effects on
the coming generation and the urgency of the need
to prevent tl}is crippling of a whole continent.
Obviously the most important single measure is
to ensure the supply of sufficient food to the babies
and young children, milk being the simplest form
in which this provision can be made, or, failing
this, the supply of vegetable fats in some con¬
venient form. From the statements which have
reached us we believe that an urgent need does
exist, and that the medical profession can usefully
educate public opinion in regard to this need.
The information section of the Fight the Famine
Council has its temporary office at 4, Barton-street,
London, S.W.l. _
MISS EVA LUCKES.
The medical world, and the nursing world in
particular, will extend the deepest sympathy to the
London Hospital in the loss sustained by the death
of Miss Eva Luckes, the matron of the hospital.
Miss Luckes was educated at Cheltenham Collegfe,
took her nurse’s training at Westminster Hospital,
and was appointed matron to the London Hospital
in the year 1880, when she was only 26 years old,
and had therefore 37 years of strenuous work in
i The Lancet, Jan. 25th, p. 148.
The Lancet,]
THE DISADVANTAGE OF BEING HEALTHY.
[Feb. 22, 1919 307
and for the institution until death claimed her at
the age qt 63. Few of us realise what the condi¬
tions of nursing were in her youth. There was
no definite scheme of training provided, the pay
was paltry, the food was poor and insufficient,
and what are now regarded as essentials of
civilised life, such as the privacy of a bedroom, or
at least of a cubicle, and adequate bathroom
accommodation, were then wholly wanting. Miss
Luckes on her appointment as matron at once set to
work to improve the home condition of the nurses
by the institution of cubicles and a proper dietary,
and shortly afterwards tackled the question of train¬
ing by introducing three courses of lectures on
general nursing and on the special nursing of
medical and surgical cases. Miss Luckes was thus
a great and good friend to her own generation, and
we cannot blame her for lacking prophetic vision
in regard to the future. This limitation led her to
set her face firmly against a recognised curriculum
of nursing training extending over a fixed number
of years, against any qualifying examination, or
the registration of such qualifications. Her friends
sometimes wondered that one who had done so
much for her profession should halt at the point
where measures might be taken to place that pro¬
fession in line with others, protecting the trained
nurse and the public from thesemi-trained and handy
woman. It is not our wish, however, to make her
death the text of a discussion on this subject—her
views are known, and so is their defence. Miss
Luckes’s work received official recognition during
her life-time. She was appointed Lady of Grace to
the Order of St.John of Jerusalem, she received the
First Glass of the Royal Red Cross, and quite
recently the C.B.E. Her “ Text-book of Nursing”
and her “ Lectures to Sisters ” are well known and
appreciated. The unbounded confidence in her and
the affection of her nurses were openly displayed.
THE DISADVANTAGE OF BEING HEALTHY.
Last week in our correspondence columns Dr.
D. M. MacRae, of Bloemfontein, recorded his
observation that in Cape Town, during the recent
epidemic of influenza, patients with a previous
history of chronic catarrhal conditions of the lungs
bore the disease well. This disadvantage of being
healthy has received a certain amount of support
from other scattered observations, similar to those
recorded in a letter this week by Dr. W. H.
Dickinson, tuberculosis medical officer at New¬
castle-upon-Tyne. In one London chest hospital
the first influenza wave left almost all the
occupants of beds unscathed, and although during
the autumnal wave a number of rapidly fatal
cases occurred they were mostly admitted with
pneumonia already developed. In a thesis on the
Clinical Significance of Opsonins circulated in 1907,
E. C. Morland noted that six tuberculous patients
with slight influenzal infection suffered no diminu¬
tion of opsonic power while their (healthy) medical
attendant had a severe attack which brought down
his index to the low value of 0*68.
The Boston Medical and Surgical Journal of
Jan. 16th contains a remarkable paper by Dr. D. B.
Armstrong dealing with the same point. He refers
Jo the fact, so vividly impressed upon us during the
last few months, that influenza attacks with special
yirulence and causes a high mortality among those
m the prime of life, in the best physical condition,
and most free from previous disease. This differ¬
ence between the strong and the weak, Dr.
Armstrong adds, appears to be due not to the fact
that the former are predisposed to influenza, but
that the latter are in some way protected against it.
In Framingham, Mass., the organisation of the
“ Community Health and Tuberculosis Demonstra¬
tion ” furnishes reliable statistics oo the point. In
the recent first epidemic of influenza about 16 per
cent, of the entire population were attacked, while
only 4 per cent, of the tuberculous portion
were. Moreover, most of the tuberculous
persons had the disease in an arrested form
and were going about and working, and there¬
fore were as much exposed to infection as
the remaining part of the population. Indeed,
in the arrested cases the incidence was only 2 per
cent. Figures from other communities presented
at Chicago bear out the Framingham experience.
The fatality rate showed the same contrast as the
incidence rate ; other observations are also in agree¬
ment. It is stated that in Washington and St. Louis,
where there are large negro populations, influenza,
fatal and otherwise, was relatively much less pre¬
valent among the negroes than the whites.^ -The
high rate of tuberculosis among negroes is well
known. American army medical officers have fre¬
quently said that in the camps the northern boy lived
while the southern boy died; the city boy lived while
the country boy died. Was this due to the fact that
the one was more frequently tuberculised than the
other ? It has been stated that fihis greater suscepti¬
bility of the healthy is true for all types of acute
infection. Thus in typhoid epidemics it has been
observed that the big, strong, healthy individual
falls the readiest victim to fatal disease. But may
not this be due to the fact that typhoid infection
lowers the % resistance to acute respiratory disease
and that it is to this complication, as in the
case of influenza, the healthy individual succumbs ?
Thus the suggestion is that a kind of vaccination
against acute respiratory disease results from
chronic respiratory disease. This form of immunity
may, as indicated above, have a relation to race.
Framingham statistics showed that the incidence
of tuberculosis for the whole population was 2*2 per
cent., but for the Italian part only 0*5, while for
those of Irish stock it was 4*9 per cent. In the
influenza epidemic, on the other hand, there was
four times as much influenza and pneumonia
among the Italians as among the rest of the com¬
munity, made up in large part of Irish and Irish-
American stock. Should subsequent investigation
prove that chronic respiratory disease, particularly
tuberculosis, regardless of the race factor, in a
measure protects against acute respiratory disease,
what is the practical bearing? The disadvantages
of chronic disease certainly outweigh any advan¬
tages conferred by protection against acute disease.
Dr. Armstrong s view is that the solution should
be found, as in the case of small-pox, in some form
of artificial immunisation. Anti-influenzal vaccina¬
tion thus has its supporters in many lands.
THE INDIGENOUS DRUGS OF INDIA.
In a leading article in The Lancet of Dec. 28th,
1918, we referred to a movement begun by the
Government of Bombay in the direction of estab¬
lishing a pharmacological laboratory and research
institute for the investigation of drugs, and more
particularly the indigenous drugs of India. We
have recently received a copy of a pamphlet
written by Mr. J. C. Ghosh, pharmaceutical chemist
in the Government Medical Stores, Madras, and
published by Messrs. Butterworth and Co. (India), of
Calcutta, which deals with the scientific cultivation
308 Tn LanchtJ
A MEDICAL SCHOOL IN THE FAB EAST.
[Fkb. 22,1919
and manufacture of indigenous drugs in India*
with suggestions for the development of new
industries. The resources of the country are
evident when the writer points out in a list of
drugs recognised by the British Pharmacopoeia that
50 per oent. of the drugs are indigenous to India
and Ceylon, and that nearly the whole of the rest
could be cultivated. Amongst these are such
valuable drugs as belladonna, digitalis, hyoscyamus,
ipecacuanha, jalap, and podophyllum, but there
is little doubt that the list could be extended to
other plants by a plan of cultivation on the con¬
genial soil presented by the great continent. Mr.
Ghosh has done a good service in showing in what
valuable directions developments could be made to
go. He suggests the employment officially of a body
of trained analysts and the adoption of a course of
practical training in not only analytical but in
manufacturing work. The latter, of course, includes
the details in connexion with the economic extrac¬
tion. of active principles—alkaloids, glucosides, and
so forth. With these arrangements set on foot he
sees a new opening for the educated Indian as well
as the growth of a valuable industry. India, like
other of our possessions, has largely relied upon
the supply of drugs from abroad, and that fact was
made acute when the war broke out. The Indian
Government may now well turn its serious atten¬
tion to the question of realising its own home
botanical assets, as brought to light in the pamphlet
referred to.
A MEDICAL 8CHOOL IN THE FAR EAST.
An important development of medical education
in Northern China is taking place at Tsfhanfu, the
capital of the province of Shantung. Here in 1904
was established the Shantung Christian University.
Two missions, the American Presbyterian and the
British Baptist, were concerned in the enterprise,
which was nothing less than the setting up of a
modern medical school, the medium of instruction
being the Chinese language. Difficulties were
encountered at the outset, but the promoters
refused discouragement, and in 1910 commodious
school premises were opened, to which four years
later a well-equipped hospital of 118 beds was
added. By arrangement with the China Medical
Board of the Rockefeller Foundation a large body
of medical students was transferred from the Union
Medical College in Peking to Tsinanfu in 1916, new
laboratories being added at the same time to the
original school building. The China Medical
Missionary Association urged upon all missionary
societies in the country the policy of concentrating
at the Tsinanfu school, and the British Advisory
Board of Medical Missions endorsed the proposal.
Last year a British joint board, representing four
cooperating societies—namely, the Baptist Mis¬
sionary Society, the London Missionary Society,
the Society for the Propagation of the Gospel, and
the Wesleyan Methodist Missionary Society—was
formed in London with the object of promoting the
efficiency of the medical school. The board
includes in its membership Sir Alfred Pearce
Gould, Professor Alexander Macalister, and Sir
William Osier.
The Tsinanfu Medical School affords opportunity
for service to any who desire to give themselves to
medical missionary work in China. The students
are drawn from all over the vast republic, and not
only are the missionary possibilities very great,
but the various professorships afford an attractive
field for research and the study of diseases but little
known in Europe or America. At the present
moment there are vacancies on the teaching staff,
which were enumerated last week in our advertise¬
ment columns, and the joint board are anxiouB to
find British candidates to fill them. The great
need for western medicine in China is made
apparent when consideration is given to the system
of native practice, which has prevailed in China for
many centuries. It has been possible for anyone
to set up as a physician, and the old-fashioned
Chinese practitioner has been subject to no legal
requirements. Although much good has no doubt
been done through a knowledge of herbs, anything
like a scientific basis for the investigation and
diagnosis of disease has been unknown. An old
Chinese chart shows the oesophagus passing through
the heart, thence to the liver, and from there to the
stomach. Imaginative anatomy leads to disastrous
surgery. One of the commonest methods of treat¬
ment in China has been that of acupuncture; again
and again important organs have been punctured
with dirty needles, owing to the superstitious notion
that the “Evil Spirit" might thus be let out.
Many sufferers have been blinded or maimed for
life through such a practice. It is scarcely
necessary to add anything further to emphasise
the need for the spread of western medical science
amongst the 400 millions of the Chinese Republic.
A report of the Medical School and Hospital, along
with any further information desired, may be
obtained from Dr. R. Fletcher Moorshead, honorary
secretary to the Joint Board, 19, Furaival-street,
London, E.C. 4.
RECURRENT MALARIA.
Statements have been made that during the
present war there has been an increase of cases of
malaria, a greater degree of recrudescence of the
infection, and a more tenacious resistance of it to
quinine. Dr. Giuseppe Vaccaro, who has had excep¬
tional opportunities of investigating the subject at
the chief military hospital at Leghorn, contributes
some interesting remarks on the question in a
recent issue . of II Morgagni (Archives, No. 12,
Dec. 31st, 19i8). One explanation that has been
put forward of the failure of quinine to prevent
these recurrences is that the disease was produced
by species of parasite prevalent in Albania and
Macedonia which differ from those commonly met
with in Europe. It was found, however, that in
more than 500 of such cases examined by
Dr. Vaccaro the parasite of the species vivax
predominated, while the number of cases of
malignant tertian and mixed infection seemed rather
higher than in patients from the Lower Isonzo.
Quinine given rationally and in sufficient doses in
these cases acted in such a manner as to exclude
not only all doubt as to its efficacy, but also the
possibility of new and different parasitic forms
being present. Dr. Vaccaro is of opinion that cases
of malaria are more numerous because, for military
reasons, many individuals stationed in malarial
areas have been exposed to infection; that recur¬
rences are more frequent and obstinate because
the causes and conditions which have a provocative
influence over the onset and recrudescence of the
infection act together with more insistence and fre¬
quency, such as change of climate, exposure to cold,
hardships, and wounds; that quinine has not given
the results that were expected of it because the
patients were not subjected, for easily understood
reasons, to a reasonably sufficient and prolonged
treatment, and, in addition, the infection has been
extensively diffused owing to the large number of
The Lancet,] NEW LOCAL GOVERNMENT BOARD REGULATIONS A EPIDEMIC DISEASES. [Fbb. 22,1919 309
gametiierous patients left at large. The fact, how¬
ever, that many patients have violent relapses,
even while under treatment by quinine, is an indi¬
cation that the problem of recurrent malaria is an
important one. The prevalent theory, that of
Bignami, is that relapses are connected with the
survival of asexual elements, which, either from
their degree of development or because quinine
resistant, take refuge in internal organs, where
they remain living but inert, until from some
provocative cause they develop and constitute a
fresh febrile crisis. This theory, which might
explain relapses which occur within a few days
after the cessation of fever with incomplete or
suspended quinine therapy, fails to account for
those which manifest themselves a long time after
the fever has ceased and after systematic quinine
treatment, much less for those which occur at long
intervals or before epidemics. The capacity of long
survived in asexual parasitic elements, whose
vitality is bound up with the precarious vitality of
the red blood cells, at whose expense they live,
Beems to Dr. Vaccaro to be untenable and not
consistent with the sudden and violent manner in
which the clinical febrile symptoms show them¬
selves. Even admitting the possibility of survival
of asexual elements as an explanation of relapses
after a short interval, the cessation of fever would
depend upon the small number of these elements
which survive the action of quinine or the
defensive reaction of the organism, and are no
longer capable of provoking a febrile reaction,
and would not depend upon the interruption of
reproductive development. This interpretation of
returns of activity of malarial infection justifies
the indication to persist in the administration
of quinine with the object of suppressing com¬
pletely the febrogenetic generation for a long
time after the febrile attacks themselves have
ceased.
In the present state of our knowledge we do not
know the final transformations which the sexual
elements have to undergo in order to bring the
parasite to develop a fresh generation, but it may
be that the gametocytes can remain inactive in the
hematopoietic viscera and under the influence of
some internal or external cause develop and give
rise to parasites of febrogenetic generation. This
theory, which attributes recurrences of malaria to
the survival of sexual rather than asexual elements
of the parasite, seems to Dr. Vaccaro to be the
more probable. It is, in his opinion, highly
improbable that any recrudescence of sur¬
vived asexual elements could resist the action
of quinine already in the system; and if quinine
resisting, once launched into the circulation
they would soon be extinct, whereas numerous
Parasitic elements can be found in the circulating
blood on the first attack of a relapse. It seems,
therefore, more reasonable to admit that the
gametes arising from the development of the
sexual elements are attacked by quinine less
effectively than the young merozoites arising
directly from the sporulation of the mature asexual
elements, and hence the relapse takes place even
while successive generations become quickly extinct
mid disappear under the influence of the specific
drug. _
The Ministry of Health Bill was read for
jtoe first time on Monday last, Feb. 17th, and will
be found, practically in full, in our Parliamentary
Intelligence.
THE NEW LOCAL GOVERNMENT BOARD
REGULATIONS FOR CONTROL AND
TREATMENT OF CERTAIN
EPIDEMIC DISEASES.
Circular P.H.2. 1919 deals with the Pablio Health
(Pneumonia. Malaria, Dysentery, &o.) Regulations, 1918,
issued by the Local Government Board to sanitary authorities.
The regulations have been made with the object of securing
better control over, and means for treatment of, certain
epidemic diseases which are prevalent or threatened at the
present time.
Notification of Acute Primary Pneumonia and Acute Influenzal
Pneumonia.
Pneumonia, irrespective of the pneumonia complicating
influenza, is one of the chief causes of death in this country,
and the possibilities of bringing it under control have been
frequently considered. Apart from the possibilities of
diminishing itB prevalence, the recent epidemic of influenza
has shown the grave need for additional assistance in the
care of cases of pneumonia. The present regulations are
intended primarily to meet this need; but it is hoped that
notification of caseB of pneumonia will be followed by
investigation of the conditions under which it occurs, ana
increased knowledge of its natural history. The regulations
impose the duty of notification by a medical practitioner of
each case of pneumonia occurring in his practice, when
the disease is primary, or when it ooonrs as the result of an
attack of influenza.
Malaria , Dysentery , and Trench Fever.
During 1917 and 1918 a few local outbreaks of baoillary
dysentery and also of malaria due to infection contracted
in the United Kingdom, have come under notice. Their
study by the Board’s expert officers, in association with the
expert officers of the Army Medical Department, has shown
that it is particularly important that public health authori¬
ties should become aware of the occurrence of any cases of
malaria or dysentery at the earliest moment, so that prompt
and effective action may be taken to ascertain whether m
the circumstances there are any risks of the disease being
Bpread and, where such risks arise, to apply the appropriate
precautionary measures. The disease trench fever, whioh
has caused serious epidemics in different war areas abroad,
has not, so far as is known, hitherto spread in England and
Wales. Trench fever, however, has been shown to be a
disease the infection of which is carried by lice, and it is
important that the ocourrenoe of any case of trench fever in
civil life should at once be made the occasion of speoial
measures to limit the infection and to secure that persons in
the patient’s household, and those recently in contact with
him, should be effectively freed from all parasites which nan
convey infection.
In view of these considerations and of the possibility that
the opportunities of introduction of the infeotion of these
diseases will be increased under the circumstances of
demobilisation and the greater traffic with foreign countries
which is now to be expected, the Board have in these
regulations enlarged the dnties and strengthened the
powers of sanitary authorities and their medical officers of
health in regard to each of these diseases, and are prepared
to aid the work, whenever necessary, by advice or assist¬
ance from their own medioal staff. The regulations require
all cases of malaria, dysentery, and trenoh fever to be notified
by medical practitioners unless to their knowledge they
have been previously notified in the same district within
six months.
Enteric , Typhus , and Relapsing Fevers .
Certain powers and dnties imposed in the o&se of dys¬
entery, particularly those to prevent infection being conveyed
by the handling of food by ‘•carriers,” are made applicable
also to enteric (typhoid and paratyphoid) fever. Similarly
the powers and dnties in relation to trench fever are
extended to two other diseases the infection of which is
conveyed by lice—viz., typhus and relapsing fever.
Special Information in Certain Cases.
The regulations require the medioal offloer of health
immediately to send to the Board the name and address of
any case which comes to his notice of typhus, relapsing
fever or trenoh fever, or of any case of malaria in which he
has reason to believe that the infection has been contracted
in the United Kingdom. He is also required to give the
Board immediate information of any outbreak of dysentery
in his district. Similar information, except in the oase of
county boroughs, should be sent to the medioal officer of
health of the administrative county. These provisions have
been made in order that the Board may beln a position at
once to make any necessary inquiries or give any neoessary
310 The Lancet,]
* TUBERCULOSIS.
[Feb. 22,1912
warnings outside the district from which the oaee is
reported, and also to enable expert investigation to be made
by the Board’s medical inspectors or pathologists shonld the
oase so require.
Provision of Medical Assistance.
The local authority is empowered to provide medical assist¬
ance, which inoludes nursing, for patients who are in need
of such assistance, and are suffering from pneumonia, or
any of the other diseases mentioned in the regulations.
General.
The regulations will take effect on March 1st next, and
notice of the provisions as to notification should be given
forthwith to all medical practitioners resident in or prac¬
tising in the district.
Copies of the Order and of this Circular may be obtained,
either directly or through any bookseller* from H.M.
Stationery Office at the following addresses : Imperial House,
Kingsway, London, W.C. 2; 28, Abingdon-street, London,
S.W. 1; 37, Peter-.treet, Manchester ; and 1, St. Andrew’s-
crescent, Cardiff.
TUBERCULOSIS.
The Tuberculous Ex-service Man.
The very urgent nature of the problem presented by the
50,000 invalided men already discharged from the Services
suffering from tuberculous disease formed the text of a strong
appeal for the appointment of a Select Committee made by
Dr. Nathan Raw in a maiden speech delivered in the House
of Commons on Feb. 14th (see Parliamentary Intelligence
in other column). The problem, especially the effect of the
discharge of these men upon the civilian population, will
form the basis of an address to be delivered at the Central
Hall, Westminster, on Thursday, Feb. 27th, by Mr. P. C.
Yarrier-Jones, principal of the Papworth Tuberculosis Colony,
entitled “The Consumptive Soldier and Civilian.” Mr. P.
Rockliff, chairman of the London Insurance Committee, will
preside, and a discussion on after-care and the economic
problems involved will follow, in which Professor Sims
Woodhead, Dr. Noel D. Bard swell, and Sir StClair Thomson,
among others, are expected to take part.
Suggested Scheme for a Tuberculosis Service.
A representative conference of tuberculosis officers
met at the Royal Sooiety of Medicine on Feb. 15th, by
arrangement of the Tuberculosis Society, to consider a
scheme for the formation of a complete tuberculosis service
under the control of a separate department to be established
in the coming Ministry of Health. A scheme, previously
printed and circulated, was presented as a basis for discussion,
and after considerable modification was unanimously
approved in the following form:—
1. That a special department of the Ministry of Health in each
oountry be created for the prevention and treatment of tuberculosis.
The personnel of these departments should Include three Oom-
missloners of Tuberculosis in England, one in Wales, two in Scotland,
and two in Ireland. These Commissioners should be appointed by
the Crown. They should have special knowledge and experience of
tuberculosis. A Medical Commlssionershlp, being the highest appoint¬
ment in the Tuberculosis Service hereinafter mentioned, should be filled
by promotion from the ranks of that service. The Commissioners of
Tuberculosis should advise a committee, representing medicine, the
Public Health Service, local authorities, Ministry of Pensions, trade
unions. Friendly Societies, and other organisations interested in social
welfare, in each of the respective countries. The Department of
Tuberculosis thus constituted In each Ministry of Health would under¬
take the following duties (o) To be reponsible for general administra¬
tive measures against tuberculosis throughout the countries concerned.
(b) To be responsible for statistics relating to the disease, and to furnish
an annual report as to the results of all forms of treatment, (c) To
soggest, advise, direct, and if necessary finance schemes of after-care
and employment of tuberculous pat ients. (<0 To direct, to supervise, and
to finanoe an educational programme by means of lectures, travelling
exhibitions, appropriate olnema films, and by any other means, (e) To
direct and to finance research work in relation to the disease. (/) To
study housing and conditions of work in relation to the incidence of
tuberculosis, and to promote legislation dealing with this matter.
2. That Deputy Commissioners of Tuberculosis be appointed by the
Crown. These Deputy Commissioners would work under the direction
of the Commissioners, and shonld be appointed from the ranks of
medical practitioners in the Tuberculosis Service. Deputy Commis¬
sioners of Tuberculosis would undertake the following duties: (a) To
be responsible for an administrative area and to report direct to the
Commissioners as to whether the recommendations made by the
Department of Tuberculosis are being carried out locally. ( b ) To
report to the Commissioners on the care of tuberculous patients
throughout the country, these reports being based on the results of
direct Inspection, (c) To ascertain whether adequate provision has
been made in every administrative area for all tuberculous patients,
(a) To visit every class of institution, to report on the efficienoy of
treatment, and to ascertain whether suitable cases are being dealt with
by appropriate institutions. («) To eonfer with the tuberculosis ofleer,
the medical officer of health, and the local sanitary authority in wk
area on all matters pertaining totuberoulosis.
3. That tuberculosis officers be appointed throughout the kingdom.
Prior to any such appointment the selected candidate should be
approved by the Commissioners of Tuberculosis. No medical practi¬
tioner should be appointed as tuberculosis officer without having had
(a) experience in general practice, and (6) experience as resident
physician or surgeon in a general hospital, followed by one year's
special experience in an institution for the treatment of tuberculosis.
Tuberculosis officers would undertake the following duties: (a) To act
as administrative and clinical officer as regards tuberculosis in each
area. ( b) To be the direct adviser of the local authority as regards ibe
prevention and treatment of tuberculosis in that area, (c) To furnish
such reports as may be required by the Commissioners of Tuberculosis
and by the local authority, (d) To report to the medical officer of health
as regards any insanitary conditions affecting the incidence of tubercu¬
losis. (c) To supervise the after care and employment of tuberculous
patients in bis district. (/) To select patients for treatment in institu¬
tions and in their own homes, (g) To act as consultant in conjunction
with practitioners who may desire bis services.
4. That to assist the tuberculosis officer in these duties an adequate
number of assistant tuberculosis officers, of nurses, and of trained
health visitors be appointed by the local authority.
5. That iu respect of the foregoing services adequate salaries should
he paid.
6. That reasonable seourity of tenure be assured to theae officers by
the Department of Tuberculosis.
7. That central arrangements be made for the superannuation of all
the foregoing officers on a contributory basis.
It was resolved to bring the scheme before the Prime
Minister and Dr. Addison at an early date by a deputation
composed of tuberculosis officers representative of all groups
and districts.
Government Contributions to Residential Treatment of
Tuberculosis.
The Local Government Board, in a circular dated
Dec. 28th, 1918, has drawn attention to the new financial
arrangements for the provision of residential treatment for
discharged tuberculous soldiers. These arrangements came
into operation on Jan. 1st last, and they provide, among other
things, for the whole cost of treatment being defrayed by the
Exchequer, so far as it is not met out of insurance funds.
Hull After-care Colony.
The first annual report of the Hull After-care Colony
for 1918 gives an account of an undertaking run largely on
the lines of the Springfield Colony at Edinburgh. It was
decided that, with a view to limiting the liability of indi¬
vidual members engaged in this undertaking, a company
should be established (not for profit) without the word
“ Limited ” in its title. The sanction of the Board of Trade
was obtained for this plan and a licence secured to hold
100 acres of land. As a result of negotiations the Hull
Corporation, Insurance Committees, and Local War Pensions
Committees agreed to contribute a weekly maintenance rate
in respect of each colonist. Only arrested or non-infectious
cases of tuberculosis are eligible for admission, and the rule
that anyone who develops active symptoms must be dis¬
charged has already been enforced in two cases. The
present accommodation is for 17 men and 8 women. Hitherto
local applicants fulfilling the necessary qualifications for
admission have been so few that accommodation has been
found also for applicants from distant parts of the country.
Each colonist is trained in rearing poultry, pigs, and cattle,
and in intensive horticulture. The colony is under the
supervision of the tuberculosis officer for the East Riding
County Council.
Bournemouth After-care Colony.
The annual report of the Tuberculosis Aid and After-care
Association for the County Borough of Bournemouth outlines
a scheme for establishing a small-holding at Kin son, Dorset,
in conjunction with the farm colony already established
there. It is suggested that the small-holding should not be
managed with a view to immediate profit or even self
support, but that it should be a training centre for tuber¬
culous patients. Arrangements are being made for the
Y.M.C.A. to provide sleeping and living accommodation
in the existing administrative block of buildings. It will
also be responsible for the maintenance and training of the
patients at an inclusive cost of 35*. per head.
Welsh National Memorial Association.
Dr. H. E. Watson, medical superintendent of the North
Wales Sanatorium, Denbigh, in the February number of
The Welsh Outlooh , has reviewed the development of the
Association’s scheme since 1912. In the latter part of that
year it controlled only about 31 sanatorium beds. Early in
1919 its two sanatoriums in North and South Wales alone
Thb Lanobt,]
NOTES FROM INDIA.—URBAN VITAL STATISTICS.
[Feb. 22, 1919 311
ooold accommodate almost 600 patients. Of the 515 patients I line of research which is likely to be fruitful, and that is the
treated in eanatorinms under the Association in 1913, 255,
or 40*5 per cent., were found to be well and at work on
March 31st, 1918. Of the 790 patients treated in 1914,
52*1 per cent, were well and at work in 1918.
Compulsory Notification of Tuberculosis in France.
In a recent interview M. Louis Mourier, Under Secretary
of State, has outlined his scheme for making tuberculosis a
notifiable disease. This scheme is to go hand-in-hand with
the development of sanatorium treatment on State lines.
He recognises that State control is essential and that
notification is inevitable. It would appear that he anticipates
a certain amount of opposition from the medical profession. 1
Decline of Tuberculosis in Trinidad.
The thirteenth annual report of the Trinidad Association
for the Prevention and Treatment of Tuberculosis is a striking
testimony to the efficiency of the crusade against tuberculosis
in this colony. At the time the association was founded
(1905) the death-rate from tuberculosis showed a decided
upward tendency, being 216 per 100,000 in 1902-3 and 258
in 1905-6. In 1917 this death-rate had fallen to 126. A
comparison with the death-rate 13 years ago in Trinidad and
Tobago shows that it has fallen 49*4 per cent. As the
medical officer of the Association, Dr. G. S. Masson, points
out, Trinidad has thus reduced its death-rate from tuber¬
culosis by 49*4 per cent, in nearly half the time that it took
England to reduce her tuberculosis death-rate by 30 9 per
cent. It is suggested that the results achieved in Trinidad
may eventually lead to a revision of the assumption that
native races are especially susceptible to tuberculosis, for in
the past it would appear that the “ susceptibility ” of the
natives in Trinidad has largely been due to mass infection
in association with overcrowding and other insanitary
conditions.
NOTES FROM INDIA.
(From our own Correspondents.)
Indian Systems of Medicine.
An interesting summary of the views of local governments
and administrations on the questions of placing indigenous
systems of medicine on a scientific basis was before the
last session of the Imperial Legislative Council. The
unanimous opinion was expressed that the proposition was
an impossible one. The systems in question, it affirmed,
were a survival of a state of medical knowledge which once
prevailed in Europe, but had been superseded by a series of
scientific discoveries extending over several centuries.
“ They ignore,” it was said, "the instruments of scientific
investigation which have made modern medicine and
surgery possible, and the theories on which they are based
are demonstrably unsound. Even at the present time
there are numerous practitioners who have superimposed
a knowledge of Western medicine on Ayurvedic instruction
or vice versa % but there is evidence that these men do not
possess the confidence of the people to the same degree as
practitioners who have been trained solely in accordance
with the strict tenets of the Ayuviya, and the latter are
strongly opposed to any form of Government interference.
If advance is to be made on these lines it is essential that
there should be a strong movement among indigenous prac¬
titioners supported by public opinion to reform and organise
themselves, and of such a movement there is at present little
or no evidence.” The summary went on to say that the
hold which ancient systems undoubtedly have on the masses
is attributable in part to a form of credulity analogous to the
belief in the magical efficacy of quack drugs and patent
medicines which is still found in Western countries, but the
popularity of these systems is chiefly due to the smallness of
the fees which their practitioners are willing to accept.
The attendance at Government hospitals and dispensaries
where the treatment is gratuitous proves that the value of
such treatment is appreciated, and in the opinion of local
governments it would be a grave misuse of public revenues
to divert the funds available for this purpose to the
encouragement of systems which they consider to be
unsound. There is, however, the statement proceeds, one
i The LiHCET, 1919,!., 233,229.
scientific investigation of the properties of indigenous drugs.
Several local governments have already considered measures
for conducting such investigations, but these measures have
bad to be postponed owing to the impossibility of obtaining
during the war the services of competent pharmacologists.
Medical Research in India.
A small informal committee of medical men met recently
at Delhi in order to consider the future of medical research
in India, the composition of the staff which will be requisite
and the terms of their employment, and the relation of the
Research Department to the public health organisation.
Sick Pay for Indian Nursing Sisters.
It has been decided, with the approval of the Secretary of
State for India, that lady nurses of the Queen Alexandra
Military Nursing Service for India invalided on account of
wounds or sickness due to field service will receive during
sick leave full pay for the first three months and thereafter
three-quarters pay for six months and two-thirds pay for
such additional sick leave as may be granted up to a total
period of two years. Under this decision, which will have
effect from Feb. 17th, 1917, sick leave cannot be combined
with privilege leave.
New Honorary Surgeon to the Viceroy.
Lieutenant-Colonel J. B. Smith has been appointed
honorary surgeon to the Viceroy, vice Colonel H. F. Cleveland.
His pupils in every quarter of the globe will be glad of this
appreciation of his distinguished services to ophthalmic
surgery.
Allegations of Cannibalism in Sind.
A great deal of interest has been roused in Sind by the
trial of two men at Karachi for alleged cannibalism. This is
the first case of the kind for many years.
Simla and Delhi Health Officers.
Captain E. 8. Phipson, I.M.S., has been appointed health
officer of Simla, vice Major J. M. Holmes, I.M.S., who has
returned to Delhi as health officer.
Major Cook, I.M.S., has been posted to the United
Provinces, appointed civil surgeon of Moradabad.
Jan. 25th. **■****^^^**^*«
URBAN VITAL STATISTICS.
(Week ended Feb. 15th, 1919.)
English and Welsh Towns.—In the 96 English and Welsh towns,
with an aggregate civil population estimated at 16,500,000 persons, the
annual rate of mortality, which had Increased from 15*0 to 21'0 per
1000 In the three preceding weeks, further rose to 27*8 per 1000. In
London, with a population slightly exceeding 4,000,000 persons, the
annual death-rate was 27 2, or 7 0 per 1000 above that recorded in the
previous week; among the remaining towns the rates ranged from
8*1 in Coventry, 12 8 In Eastbourne, and 13*9 In Tottenham, to 43 6 in
South Shields. 43*9 In Huddersfield, 61*6 in Wolverhampton, 61*0 In
Newcastie-on-Tvne, and 62-5 in Tynemouth. The principal epidemic
diseases caused*172 deaths, which corresponded to an annual rate of 0*5
per 1000, and included 48 from Infantile diarrhoea, 44 from diphtheria,
27 from measles, 25 from scarlet fever, 23 from whooping-cough, and 5
from enteric fever. The deaths from influenza, which had been 222,
272, and 604 in the three preceding weeks, further rose to 1363, and
included 273 In London, 148 in Liverpool, 119 in Newcastle-on-Tyne,
50 in Bradford, 44 In Manchester, and 32 in South Shields.
There were 2 eases of small-pox, 1094 of scarlet fever, and 1179 of
diphtheria under treatment in the Metropolitan Asylums Hospitals
and the London Fever Hospital, against 5,1080, and 1156 respectively
at the end of the previous week. The causes of 80 deaths in the
96 towns were uncertified, of which 15 were registered in Birmingham,
14 in Liverpool, 6 in London, and 4 in Sunderland.
Scotch Towns. —In the 16 largest Scotch towns, with an aggregate popu¬
lation estimated at nearly 2,500,000 persons, the annual rate of mortality,
which had increased from 17*0 to 23*8 per 1000 in the four preceding
weeks, further rose to 32*0 per 1000. The deaths from influenza
numbered 76, while In 298 deaths classified as due to other conditions
Influenza was a contributory cause; in the previous week these
numbers were 31 and 164 respectively. The 677 deaths in Glasgow
corresponded to an annual rate of 31*6 per 1000, and lnolnded 23
from whooping-cough, 9 from diphtheria, 5 from infantile diarrhoea,
and 2 from measles. The 333 deaths in Edinburgh were equal to a
rate of 51*6 per 1000. and included 10 from whooping-cough, 4 from
diphtheria, and 1 each from measles and scarlet fever.
Irish Towns.— The 259 deaths In Dublin corresponded to an annual
rate of 33*3, or 8*3 per 1000 above that recorded in the previous
week, and lnoluded 6 from Infantile diarrhoea, 2 from whooping-cough,
1 each from measles and scarlet fever, and 21 from Influenza. The 175
deaths Id Belfast were equal to a rate of 22*8 per 1000, add lnolnded
2 from diphtheria and 1 from Infantile diarrhoea.
Donations and Bequests. —The late Captain
Edward Geoffrey Watson Smyth, of the Coldstream Guards,
has bequeathed £2000 to St. Dunstan’s Hostel for the Blind.
312 The Lancet,]
BIOLOGY AND THE MEDICAL CURRICULUM.
[Feb. 22, 1,919
CtrrtsgankKt*.
'* Audi alteram partem.'*
BIOLOGY AND THE MEDICAL CURRICULUM.
To the Editor of The Lancet.
Sir,—I should like to support strongly Mr. T. G. Hill’s plea
for the more efficient instruction of the medical student in
biology. That medicine is a biological subject is one of
those truths so plain that we are all apt to forget it. The
botany and animal morphology which have become con¬
ventional since Huxley and Martin are pretty good, but
Mr. Hill’s idea of merging them into a sound biology is very
much better. In recent years there has been a progressive
degradation of the relative position of bi >logy in the medical
curriculum in London, and by a curious coincidence the
importance of the general ideas of biology to medicine has
become increasingly obvious. The central point of pathology
is adaptation, and on the whole I should say that no idea
seems to be more novel to the average medical student
in his third or fourth year. Yet it is pretty nearly the
central point of biology as well, though I daresay I have
some pathologioal prejudice as to this.
But let the student be taught biology, and not just the odds
and ends which his teacher imagines will be useful to him as
a medical man. There is nothing really very scandalous in
the pathologist who did not recognise a spiral vessel so
long as he knew who to worry for the solution of his
difficulties. Knowing where to look for a thing is very
nearly as good as knowing it off-hand. The principle of the
relations of plants to one another and to their environment
is the sort of general notion which will be of permanent
and insistent value in the business at which the student is to
spend his life. And if a more effective teaching of biology
is necessary, it is equally i npossible to cram anything more
into the curriculum. If biology is to have more room it
must be at the expense of some other subject. Chemistry is
the most obvious victim; it is not a particularly educative
subject, and as the key which we have been so often told is
to undo all our troubles it has seemed to work rather stiffly.
A good many people seem nowadays to be thinking that
bio lo gical problems are best tackled by biological methods.
I am, Sir, youi$ faithfully,
Badlett, Feb. 17th. 1919. A. E. BOYCOTT.
MEDICINE, PARLIAMENT, AND PUBLIC.
To the Editor qf The Lancet.
Sir,—I n view of Sir Henry Morris’s plea in your issue of
Feb. 1st, of the turbulent meeting in Wigmore Hall on
Feb. 9th, and of Dr. Addison’s meeting in which he
expounded some of his proposals for the Ministry of Health,
may an old advocate of such a Ministry and a political
candidate of 13 years’ standing make a few suggestions 7
The demands and rights of the profession cannot be
authoritatively expressed by any body which will be qualified
to contribute the special knowledge and experience of the
profession to the conduct of the public services. The latter
requires a specially selected body, such as the Medical
Parliamentary Committee, or else the medical corporations
and institutions themselves, to give expert advice. It
will be the duty of the Minister of Health, with the
help of his advisory councils, to attach relative weight to
such advice, according to its internal or external evidence of
importance. No democratically elected “ Medical Parlia¬
ment ” could take over this function, nor would such a body
be free from the necessity, where medical rights were at
stake, of unconsciously subordinating its other recommenda¬
tions to the defence of such rights. A medical trade union
may or may not be necessary for such defence, but its advice
to the State would be suspect. We must contribute advice
that is not suspect. The two objects must be treated
separately, and it is my own opinion that the existing
corporations and institutions are able to give the advice
required for the second and more general object. The
Medical Parliamentary Committee may help as a clear ing-
house, but its authority will be indirect, voluntary, partial,
and the work of such a body rests on a few men who have
many claims on their time and energies.
The main requirement is to watch closely the statutory
machinery to be set up in connexion with the proposed
Ministry, to help it, scientifically to criticise it, and to bring
weight to bear in Parliament to secure efficiency and prevent
mistakes. For this purpose efficient Parliamentary repre¬
sentatives, medical or lay, are essential ; and if the Medical
Parliamentary Committee succeeds in putting effective repre¬
sentatives into Parliament and on to local authorities it will
provide the only effective influence on behalf of medical
science in public business.
It is too often overlooked that a Member of Parliament
must primarily represent a constituency and not any pro¬
fession, science, or other particular interest. He represents
his constituents in all the proceedings, great or small, in
which they or any of them may be concerned within the
ambit of Parliament or of any Government department. And
throughout he holds a brief for the particular policy or
attitude of the political association that supported his
candidature. It is only subject to these considerations
that he can make use of his medical experience—and he will
not find it of much help towards his election.
It is for lack of these considerations that the medical pro¬
fession, as compared especially with the legal, is so weakly
represented in Parliament. Qaite apart from party, politics
is a subject of great complexity, and requires no smatter¬
ing, but a sound knowledge and a strenuous, practical
experience. Without this equipment few candidates will
be elected and none will exercise any considerable power
in the counsels of Parliament. There, as in private
practice, the most convincing facts, the soundest advice,
are useless unless conveyed to the proper person, at the
proper time, in the proper way, and in the proper place;
and then they must be driven home with the aid of every
direct or adventitious force that can be summoned to their
aid. If a few of our best men, at the outset of their qualified
career, instead of devoting their spare time to coaching and
other by-play, will devote all their energies to this subject,
as do many young lawyers, the medical profession may then
confidently expect to play some part in the Government of
the nation comparable with that which, despite all criticism,
has on the whole so worthily been played by the legal
profession and other sections of the community.
I am. Sir, yours faithfully,
F. E. Fremantle,
KAeutensnt-OolonSl, B.A.M.O., T.F.
Queensbeny-plsoe, 8.W* Feb. 19th, 1919.
STATE MEDICAL SERVICE :
A COMPARISON WITH THE MILITARY PATTERN.
To the Editor of The Lanobt.
Sir,—A good deal has been written for and against a
State Medical Service. The subject continues to be dis¬
cussed from diverse points of view, and in support of the
argument for such a service and of the lines on which it
should be framed the Army Medical Service has been much
quoted. Again, the proposed civil service has been discussed
in a manner which makes it evident that some regard its
adoption as necessarily involving the disappearance of
the general practitioner, and that the survival or sup¬
pression of general practice is the crux of the whole
business. The medical service of the Army does not
make provision for some needs that amongst the civil
population a medical service must provide for, and
though in general the military could serve as a
model for the civil service, they must necessarily
differ in some detail. While the Army Medical Service ;
organised with a view to removal of the sick and injured to
central hospitals, and treatment “ in quarters ” by visiting
medical officers is made the exception, among the oivil
population the reverse holds good, the majority of sick
persons being treated in their homes (•• in quarters ”) and but
comparatively few in hospital. It is not feasible, with
advantage, to alter the position materially in either case.
The medical officer to a regimental unit (e.g., a battalion of
infantry) may be taken as the equivalent of the general
practitioner of civil practice, but he does not retain under
his care any but those who are suffering from quite trivial
ailments which do not unfit them for some form of duty. In
times of peace regimental units do not ordinarily have a
medical officer attached to them. A system is adopted for
dealing with the sick or injured soldier which resolves itself
The Lancet,]
THE QUALITY OF COMMERCIAL VACCINE LYMPH.
[Feb. 22, 1919 313
into treatment being given in hospitals and at medical
inspection rooms, located conveniently in garrisons, accord¬
ing to the nature of the disability.
It will at once be obvious that this method of dealing with
the sick is the reverse of what obtains in civil life: the
patient comes or is brought to the doctor instead of
vice versa. It also results that the military medical officer
has at hand means ready for the diagnosis and treatment
of such injuries and diseases as he finds are beyond his
resources. Since inter-communication is established between
hospitals and officers in immediate medical charge of troops,
and as these officers have access to wards and laboratories,
If not actual duties to perform in hospital, it follows that
every opportunity is afforded them of watching or practising
methods of diagnosis and treatment which the conditions of
their service debar them, for the time being at least, from
actually carrying out themselves. Obviously this arrange¬
ment is highly beneficial to both “ doctor and patient,” since
the former has no difficulty when need arises for expert
assistance in diagnosis and treatment in obtaining it, and
for keeping well abreast of all advances in both matters,
while the patient need suffer no delay in obtaining (> further
advice” or special forms of treatment when such are
required.
Turning to the conditions of civil practice, there is no
organisation affording equally and to all the assistance they
may require beyond what can be given by the general practi¬
tioner. The Public Health Service has means for dealing
with certain diseases in a limited way, charitable institu¬
tions and the Poor-law provide for the least well-to-do, but
a large percentage of the population is unassisted by these
means, and as more costly methods are naturally not very
readily sought after the public health suffers accordingly.
The pressing need is to assist the general practitioner in
obtaining diagnosis and treatment of those cases beyond his
resources in a way that will neither injure his reputation
nor excuse him from availing himself of them.
If this principle is accepted and developments are shaped
along these lines there will be no suppression of general
practice, it would rather be reinforced, supervised, and made
more effective. In a tentative sort of way the Public Health
Service does this by treating certain diseases, and affording
means of diagnosis for all (e.g., tuberculosis), and it does
not require great imaginative power to see how these small
beginnings could be developed to cover a much wider field
so as to render assistance both to doctor and patient which
It is difficult for any but the very poor or rich to obtain. A
service of the kind indicated would be costly if it is to
include the whole field of medicine, surgery, and midwifery,
for to run it on decent and efficient lines would entail the
provision of buildings, equipment, and personnel of un¬
questionable quality. But it should cause at its inception
less disturbance to existing conditions than any scheme
involving the abolition at the outset of the general
practitioner. I am, Sir, yours faithfully,
vtb. 14th, 1919. J. H. P. Graham.
THE QUALITY OF COMMERCIAL VACCINE
LYMPH.
To the Editor of The Lancet.
Sib,—I am anxious to draw attention to the present
condition of some of the vaccine lymphs as sold to general
practitioners. Being attached to the Infant Department
of one of the leading hospitals, part of my duty is to
vaccinate infants there with lymph obtained from the
Government laboratories. At the same time I am vaccinat¬
ing children in my ordinary practice with lymph supplied
commercially ; for the Government lymph is not for sale and
quite unprocurable for use in private practice.
For six months past 1 have been suspicious as to the
efficacy of the lymph sold to us and I am now able to prove
the comparative worthlessness of some of these lymphs.
At the hospital, where I use Government lymph, failure to
obtain a perfect vesicle at the site of every inoculation is
rare. It is rarer to get all places to “ take ” when using a
commercial lymph in private practice. Far more commonly
one or perhaps two places take in a feeble and unsatis¬
factory manner. Sometimes no inoculation takes and this
even after vaccination has been repeated. Recently, for
instance, I vaccinated an infant in private practice with
lymph with a good n4me from a well-known chemist. I
inoculated ia three places—none took. After an interval I
inoculated again in three places with fresh vaccine—none
took. I succeeded in getting a tube of Government lymph
and, using this, obtained three perfect vesicles.
Now the public are not fond of having their infants
revaccinated due to failure of lymph, and when after a
second time a feeble result occurs in one place only, the
practitioner certifies the child as 41 successfully vaccinated,”
warning the parents that the infant is only partially protected
and should be revaccinated in a year, or he may even fail to
do this, when the child remains a standing danger to the
community. There is one lymph for the rich and one for the
poor, and in this case I plead for the rich.
The importance of this matter can hardly be exaggerated,
and if we must use a commercial lymph I would urge for an
adequate control by Government of such lymph. But I
would go further and press for the suppression of all com¬
mercial lymph establishments and the distribution for use of
lymph adequate in power and free of cost by the Govern¬
ment. The risk of life and the danger to others of these
partially protected, and soon unprotected, children is
becoming ever greater, and I trust that one of the first
duties of a Health Minister will be to deal adequately with
the question. I am, Sir, yours faithfully,
Kensington, Feb. 3rd, 1919. E. A. BARTON.
THE PRESENCE OF A FILTER-PASSING VIRUS
IN INFLUENZA, ETC.
To the Editor of The Lancet.
Sir, —Dr. Robert Donaldson’s several recent letters have
raised many interesting questions which, it is to be hoped,
will not escape attention. When discussing last year in your
columns (May 18th, 1918) those cases then thought to be
examples of botulism, and now referred to, in the Viennese
style, as encephalitis lethargica, I made some reference to
Rosenow’s pleomorpbous coccus, which had till then almost
escaped allusion in this country. The possible identity of
this organism with that found by von Wiesner in the Viennese
cases was discussed by me with my friend. Dr. L. Rajchman,
the author of the Memoir on Influenza, so justly eulogised in
your issue of Jan. 4th (p. 25). Shortly afterwards, in
the first case nf 44 encephalitis lethargica ” that he had the
opportunity of investigating, he found, as a denizen of the
naso-pharynx, a remarkable organism which, so far as could
be determined, was identical, on the one hand, with that
found by Rosenow in poliomyelitis, and, on the other, with
that found by von Wiesner in 44 encephalitis lethargica.”
He found the same organism in other cases of an
44 influenzal” nature, which at the time we regarded as
possibly 44 abortive ” cases of the nervous disease. Further,
by strict and peculiar methods of anaerobic cultivation Dr.
Rajchman (whose critical acumen and bacteriological skill
no one can doubt) produced from his pure cultures of
44 Rosenow” a free growth of minute bodies which to us
appeared not distinguishable from Flexuer's 44 globoid
bodies,” and which now may be said to resemble those
described by the investigators at Staples.
A little later, when engaged in writing the memoir allnded
to, Dr. Rajchman came to the conclusion that phases of
Rosenow’s coccus, or at any rate of a closely Allied organism,
had been described by many observers in different countries
in relation to the vernal epidemic of influenza. Dr.
Rajchman was fully alive to the possibility of relation
between the filter-passers and the non-filter-passers, and
pointed out to me the interesting bearing of these newer
bacteriological developments on the epidemiological con¬
clusions that, following Dr. Hamer’s line of thought, I had
formulated and was about to express in the Chadwick
Lectures. Dr. Rajchman left England some months ago ; his
work was unfinished, and his cultures, I fear, have died out.
Dr. Donaldson knows, I am sure, that these lines are
written, not to detract for one moment from the originality
and value of his own work, but. on the contrary, to show in
what measure his ideas and results are supported by those of
others. Truly, there is no a priori reason to assume that
filter-passing organisms have no other stage or form of exist¬
ence. The work of Rosenow and others goes some way to
prove that the contrary assumption is sometimes true, and
that pleomorphism sometimes occurs to a quite unorthodox
extent. We allow even a tapeworm the luxury of 41 alternate
314 The Lancet,]
THE TREATMENT OF VENEREAL DISEASE.
[Feb. 22,1919
generations ” ; sorely the allegation of pleomorphism, even
when carried to extravagance, in the eyes of the old school,
need not wholly discredit a coccus, before, at least, the
allegation is disproved. Impartial investigation is called for,
and it is such investigation that Dr. Donaldson fairly claims
for organism “ D.”
Exclusive reliance on positivist forms of thought and
analytical methods of examination will not carry us much
further ; it is time that more play be given to the synthetic |
and imaginative faculties, without which, as Darwin said,
there is no useful observation.
I am. Sir, yours, faithfully,
Harley-street, W., Feb. 15th, 1919. F. G. CROOKSHANK.
THE TREATMENT OF VENEREAL DISEASE.
To the Editor of Thh Lancet.
Sir,— With respect to the article with this title which
appeared in your issue of Feb. 8th under the names of Sir
Archdall Reid and myself I desire to make it clear that the
prevalence of gonorrhoea amongst those who used nargol
jelly as a preventive applied to the period prior to April 1st,
1918. Shortly after this date the issue of nargol jelly was
discontinued in the Royal Navy, calomel cream Remaining
the sole official prophylactic against both syphilis and
gonorrhoea.—I am, Sir, yours faithfully,
P. Hamilton Boydbn,
Portsmouth, Feb. 17th, 1919. Surgeon Commander, B.N.
INFLUENZA AND CHRONIC LUNG DISEASE.
To the Editor of The Lancet.
Sir, —Captain D. M. MacRae’s letter of Dec. 13th, 1918,
which appears in your is-uie of Feb. 15th, raises a point of great
interest. While a greater number of acute cases of recent
origin are coming to notice, suggesting that an attack of
influenza with complications kindles a latent tuberculous
lesion into activity, still, in my experience also, subjects of
“ open ” phthisis have come through the recent epidemics
remarkably well. Thus out of an average of 520 “open”
cases on the Newcastle-upon-Tyne Dispensary register, only
2 are known to have died from the immediate effects of
influenza during the year 1918. So noticeable has this been,
and at the same time so unexpected, that I have been led to
conjecture that the 4 ‘ mixed infection” of “open” phthisis
has resulted in considerable immunity against the strepto-
and pneumococci which are responsible for the serious com¬
plications which have proved so fatal. It would be inter¬
esting to know the experiences of those having large
numbers of phthisical individuals under supervision in other
areas. I am, Sir, yours faithfully,
W. H. Dickinson,
Tuberculosis Medical Officer, Newcastle-upon-Tyne.
Feb. 18th, 1919. _
‘ MASS MEETINGS” AND THEIR REPRESENTA¬
TIVE CHARACTER.
To the Editor of The Lancet.
Sir,— In what sense are so-called “ mass meetings of the
medical profession” really representative of the medical
profession ? True, we all have the opportunity of reading a
general invitation to “The Wigmore Hall” or “ No. 1,
Wimpole-street.” Whatever our views, whateverour inclina¬
tions, the majority of us do not get the opportunity of
attending. London is a far journey for a host of us. Many
cannot in these days afford a week-end in London. Large
numbers cannot leave their appointments and practices.
The result is that a few hundred medical men meet
together and apparently arrogate to themselves the right to
speak for the multitudes that cannot attend. There is a
tendency for well-meaning coteries to run such meetings.
This is true of most medical societies. Surely there are
better means of ascertaining the views of the whole pro¬
fession and I trust that such means will be adopted in future
and save us from mob oratory and mob law and so conduce
to medical unity.
I am, Sir, yours faithfully,
Brmmcote Sanatorium, Feb. 11th, 1919. PETER W. EDWARDS.
ANDREW MELVILLE PATER80N, M.D. Edik.,
F.R.C.S. Eng.,
PROFESSOR OF ANATOMY Ilf THE UNIVERSITY OF LIVERPOOL AND
FORMERLY PRESIDENT OF THE ANATOMICAL SOCIETY
OF GREAT BRITAIN.
We regret to announce the death of Professor Andrew
Melville Paterson, professor of anatomy in the University of
Liverpool and assistant inspector of military orthopaedics,
which occurred at his Liverpool home on Feb. 13th, at the
age of 56.
Professor Paterson was the son of the late Rev. J. C.
Paterson, a well-known Presbyterian minister in Manchester,
and was educated in the Grammar School of that city and
later at Owens College. He proceeded to the University
of Edinburgh and graduated in 1883 with first-class honours
as M B. and C.M., taking three years later the M.D.
degree as a gold medalist with a graduation thesis on the
“Spinal Nervous System of the Mammalia.” He early
declared the special bent which his pursuits would take,
and was appointed in rapid succession demonstrator of
anatomy in the University of Edinburgh, then to the
same post in Owens College, to be elected in 1888 first
professor of anatomy in University College, Dundee.
Here he gained repute alike as teacher and writer, his
numerous articles on anatomical subjects showing how much
he was in the van of his science, while his 44 Anatomists’
Notebook,” his articles in Cunningham’s * 4 Text-book of
Anatomy,” and his 4 4 Manual of Embryology” displayed
him as an all round master. After nearly seven years’ work
at Dundee he was appointed professor of anatomy in the
newly constituted University of Liverpool, and in the
following year, 1895, was appointed Dean of the Medical
Faculty of the University, a post which he held for nine
years, to the great benefit of his adopted alma mater . As
might have been expected his services were widely requisi¬
tioned as an examiner, and at different times he examined
in anatomy at the University of Oxford, Cambridge, Durham,
and London, at the English Conjoint Board, and at the
qualifying examination for the Indian Medical Service. In
1903 be was one of the Hunterian professors of the Royal
College of Surgeons of E> gland, when he took as his subject
for his lectures the morphology of the sternum. These
lectures were later published in book form.
We have received from Professor William Wright, Dean of
the London Hospital Medical College an estimate of Professor
Paterson’s work and character, written, as he says, by “ one
who bad the privilege and pleasure of intimate friendship.”
In its fullness and discrimination it leaves little to be added.
Professor William Wright says
“ The outstanding feature to my raind of Paterson’s
personality was his tireless energy, an energy altogether too
kinetic for the somewhat frail body which it animated. He
was seldom, if ever, at rest. He thought rapidly, he formed
his judgments rapidly, he wrote rapidly whether in rhyme
or prose, he sketched rapidly and moved rapidly. These
characterisfcics had their advantages and their disadvantages.
He was pre-eminently one who accomplished things, and he
has left in the anatomical department of the University of
Liverpool a department which is, in my opinion, second to
none in equipment, arrangement, and endowment. On the
other hand, his haste sometimes made him appear intolerant,
but those who were granted the favour of knowing him more
intimately appreciated the fact that there was never any¬
thing personal in his criticisms or strictures; it was merely
that he was consumed with a desire to get things done. No
one I have ever known was less willing to compromise, no one
was ever less under the sway of what many of us believe to
be the really sound Greek maxim —wbtv dyav.
As an anatomist he was most regular in his attendances at
the meetings of the Anatomical Society and one of the most
frequent contributors to its proceedings. He did not,
perhaps, quite fulfil the brilliant promise of his early days,
a fact which he was not Blow to acknowledge, and which
he regretfully explained as due to his having allowed him¬
self to become engrossed in administrative duties and in
academic and polemical discussions. Still he has a luge
number of original, thoughtful, and highly important papers
on anatomy to his credit, his contributions to our know¬
ledge of the sternum, the sacrum, aud the limb-plexuses
being of special value. As an anatomist he formed, too, an
interesting link with the past, having served as a demon-
The Lancet,]
OBITUARY. -THE WAR AND AFTER.
[Feb. 22, 1919 315
strator to the late Professor Morrison Watson, of Man¬
chester, the earliest occupant, I believe, in the provinces of
a chair of human anatomy.”
Of Professor Paterson’s work in Liverpool, outside the
University, it is difficult to speak too highly. At the out¬
break of war he was called to the assistance of the War
Office; he held a temporary commiMsion in the R.A.M.C.
and worked at the orthopaedic centre at Alder Hay. His
military duties as Assistant Inspector of Military Ortho¬
paedics under Sir Robert Jones soon became of first-class
importance, and were discharged with his wonted thorough¬
ness. He was promoted to a lieutenant-colonelcy and
was largely responsible for the organisation of the special
orthopaedic centres. Indeed, there can be no doubt that
the whole-hearted way in which he threw himself into
the additional labours entailed upon him by the war,
while discharging to a considerable extent the duties of
the chair of anatomy in Liverpool, wore out a frame never
very robust. Moreover, like too many members of the medical
profession, the war exacted from him the most grievous
sacrifice of all, for his son was lost in the battle of Jutland.
Professor Paterson’s death will be felt by a large circle of
sincere friends owing to the generosity which he showed in
any cause where his sympathy and interest had been enlisted.
He was a man who inspired warm affection which will be
lasting. _
Professor BLANCHARD.
Dr. Raphael Blanchard, who succumbed very rapidly to a
sudden heart attack on Feb. 8th, was 61 years of age. He
had occupied for long the chair of parasitology at the
Faculty of Medicine in Paris, and his great reputation in
France and abroad
was due to his works
on medical zoology,
and particularly to
his researches on the
animal carriers of
pathogenic germs and
their role in the
propagation of epi¬
demics. The“Traite
de Zoologie MCdi-
cale,”intwo volumes,
first appeared in
1886 - 90. At the
time of his death he
was engaged on the
great task of a history
of medicine and had
made some progress in
the publication of a corpu* inscriptionum devoted to medicine
and biology. His diligence was incredible. He was secretary
to the Academy of Medicine, he founded the French Society
for the History of Medicine, the Colonial Institute of Medicine,
and the French Congress of Zoology. For 20 years he acted as
general secretary to the Zoological Society of France. Owing
to the part which he took at several of the International Con¬
gresses of Medicine he became a well-known figure abroad.
Death of Henry John Strong, M.D., M.R.C.S.—
Dr. H. J. Strong, who died at his house at Worthing on
Jan. 29th last, had reached the ripe age of 86. He entered
at St. George’s Hospital in October, 1850, and after taking
the ordinarv double qualifications of his day—M.R.C.S. Eng.,
L.S.A.Lond.—in 1854, he served as house surgeon at the
hospital. In 1862 he proceeded to the M.D. degree at St.
Andrews University, and began private practice at Stogursey,
Somerset. Shortly afterwards he moved to Croydon, where
he joined an already existent firm, and where he practised
for 30 years, being surgeon to the Croydon Hospital and
consulting physician to the Freemasons’ Institute, Croydon.
In about 1893 he moved to Worthing. He was a J.P. both
for Surrey and Sussex.
Mr. T. B. Johnston will begin on March 3rd, at
University College, London, a course in Anatomy for the
Primary Fellowship Examination, specially suited for
R.A.M.C. officers who are entering for the examination in
May, 1919, under the special terms arranged by the Royal
College of Surgeons. Full particulars of the course can be
obtained from the secretary of University College.
Cfee IStar anfc Jfter.
War Emergency Fund of the Royal Medical
Benevolent Fund.
The total sum raised for this Fund to date amounts to
about £21,000, and it is believed that a further amount of
£9000 will be required. At a meeting of the executive
committee of the Fund held on Feb. 4th, Lieutenant Colonel
Sir Alfred Pearce Gould in the chair, several applications
for assistance were received, and grants amounting to £450
were made. Applications (marked Confidential) should be
addressed to the honorary secretary of the Fund at
11, Chandos-street, London, W. 1.
The Casualty List.
The names of the following medical officers appear among
the casualties announced since our last issue :—
Died.
Col. C. M. Begg, C.B., C.M.G., New Zealand M.C., was a
student at University College, London, and qualified in
1903. He was a well-known practitioner in Wellington.
New Zealand, and at the time of his death was Deputy
Director of Medical Services of the New Zealand Oversea
Forces.
Major H. G. Gibson, R.A.M.C., was a student at Guy’s Hos¬
pital and qualified in 1907. He died in France from
pneumonia following influenza.
Lieut. F. P. M. Luett, Austr. A.M.C.
OBITUARY OF THE WAR.
MYRDDIN KMKYS JONES, M.R.C.S. Esc.,
SURGEON-LIEUTENANT, ROYAL NAVY.
Surgeon-Lieutenant M. E. Jones, who died on service of
pneumonia at Granton Naval Hospital, Edinburgh, on
Dec 4th, at the age
of 23 years, was second
son of Alderman R. E.
Jones, of Boderwydd,
Llanberis, and brother
of Captain E. H. Jones,
R.A.M.C., who was
repatriated from
Germany on Dec. 13th.
Educated at Llanberis
County School, where
he passed the London
Matriculation Examina¬
tion, and at St Thomas’s
Hospital, he took the
Conjoint Diploma in
January, 1918, and
obtained a commission
as temporary surgeon
in the Navy. After
serving as house sur¬
geon at St. Thomas’s
Hospital he was appointed to H.M.S. Indomitable .
*
Casualties among the Sons of Medical Men.
The following additional casualties among the sons of
medical men are reported:—
Lieut. W. M. McGeagb, South Lancs. Regt., died from
pneumonia following influenza, youngest son of Dr.
K. T. McGeagb, of Liverpool.
Lieut. A. W. Hooley, M.C., A.S.C., attached Queen’s, Royal
West Surrey Regiment, accidentally killed, only son of
Dr. A. Hooley, of Cobham, Surrey.
The Honours List.
The following is the continuation of the list the first part
of which was given in The Lanckt of Feb. 15th :—
The Military Cross .
Temp. Capt. CHARLES HUMPHREY LLOYD.—For great, courage
In guiding squads with wounded through Masnleres and the ground
south-east of Humllly on the night of Oct. 1-t 2ud, 1918. He dressed a
wounded officer In the open during a hea«ry burst of Are and got him
a wav to safety. On'Oct. 3rd ho searched for wounded officers under
tire, dressed their wounds, and brought them in.
316 The Lancet,]
THE WAR AMD AFTER.
[Feb. 22,1919
Temp. Oapt. GEORGE BkRTON MoCAUL.—For conspicuous
gallantry and devotion to duty. His battalion took up an advanced
position of readiness In Jackson's Rsvine early on Sept. 19th 1918, and
was for several hours exposed to concentrated shell fire. During this
K rlod he moved freely about attending to wounded, both of his own
tt-alion and another unit, and showing total disregard for his personal
safety. During the entire day his conduct was most exemplary,
and he undoubtedly saved many lives.
Gapt. ALEXANDER EDWARD MacDONALD, Can. A.M.C.—During
the attack on Upton Wood on August 3 th/31st, 1918, he wo-ked in the
open, under heavy fire, attending to and dressing the wounded, remain¬
ing at his duty until all the wounded were cleared, in spite of the
heavy shelling. On one oocadon a shell fell close to him, killing two
men and severely shaking him. but he at once pulled himself together
and went on with his work. His gallantry and composure were most
marked.
Oapt. HERBERT BRUCE MacEWBN, Can. A.M.C.-For con¬
spicuous gailaatrv and devotion to duty near Monohyfrom August 26th
to 28th, 1918. He kept lo close touch with the battalion in the
advance, attending to the wounded in the open under heavy shell fire.
He worked continuously, mostly in the open, for 36 hours, and was
largely responsible for the small percentage of killed in the unit.
Temp. Oapt. JAMES TAYLOR ROGERS MaoGILL.— For gallantry
and devotion to duty on Sept. 19th, 1918. He carried in wounded and
dressed them, under Intense machine-gun and artillery barrage.
Later, on Sugar Loaf, for four hours he helped to carry in wounded
after his stretcher-bearers were wounded. His oourage and energy
were the means of saving many lives.
Temp. Lieut. ROB ROY MacGR EGOR.—For conspicuous gallantry
and devotion to duty throughout the fighting of 8ept. 29th, 1918, south
of Villers Gulslaln. He worked untiringly under heavy shell fire, and,
though suffering from gas, attended over 200 cases. He had to carry
out his work in the open, there being no available shelters.
Oapt. JOHN DAYIS MARKS. N.Z. A.M.C.-For conspicuous
gallantry during operations near Ruvauloourt on Sept. 4th/5th, 1918.
While his R.AP. was twice heavily shelled and several casualties
occurred he continued at duty, binding men up and shifting them to
shelter in spite of the heavy bombardment. Again on Sept. 7th, when
the R.A.P. had been established on the edge of Havrlnoourt Wood, near
Quotient Avenue, the enemy bombarded the plaoe heavily. Under
this fire, which had Inflicted a number of casualties, he continued with
his work. On both occasions his devotion to duty was admirable.
Capt. CHRISTOPHER NORMAN MATHS SON, Aust. A.MC.-In
the a'tack on Mont St. Quentin on Sept. 2nd, 1918, he pushed forward
behind the first waves, nttendlng the wonnded under neavy artillery
and machine- gun fire. Later he established a forward post, and through
his gallantly and his untiring exertion he saved many lives by getting
their wounds expeditiously dressed and evacuating them quickly.
Oapt. ARCHIBALD LANG MoLBAN, Aust. A.M.C .—For oon-
S dcuous gallantry and devotion to duty. During the attack on
ugust 8th, 1918, east of Villers Bretonneux, near Amiens, he followed
the attacking troops with his section, tending and dressing wounded
under fire on the way. Almost immediately after the objective had
been taken be established his R.A.P. in the village of Warfusee, where
he worked continuously under great difficulties. Later, during the
advance on the following day, he established his R.A. P. almost on the
jumping off line, where be tended and cared for wounded under heavy
artillery fire. His energy and zeal saved many lives.
Capt. ALEXANDER PATER40N MURPHY. Aust. A.M.O.-For
conspicuous gallantry and devotion to duty near Peronne from
August 23rd to 26th, 1918, as R.M.O. of a battalion. He placed his
aid-post In a railway cutting, where he dressed the wounded of his own
and other units under machine-gun and shell fire. When all our
wounded had been cleared he went out and attended to the enemy in
the open; while doing so a shell burst in their midst, killing his
orderly, a stretcher-bearer and several wounded, and wounding nlra.
He continued at work for another 24 hours before reporting for relief.
Capt. EDGAR LLEWELLYN FOOT NASH.—For conspicuous
devotion to duty and contempt of dancer in oaring for w unded
under heavy shell fire at Achiet-le-Grand on August 23rd, 1918. He
moved about in the o. en under heavy shelling, dressing men’s wounds
and preparing them for immediate evacuation with the greatest
coolness, setting a very fine example to his staff and to the bearers. It
was due to his untiring efforts that the wounded were so successfully
and quickly evacuated.
Capt. REGINALD EDWARD ROWLAND, Aust. A.M.C.-For con¬
spicuous gallantry and devotion fo duty on Sept. 27th, 1918, near Ypres,
with the leading battery, which came Under heavy shell fire and
suffered many casualties. Ignoring all danger, he established an aid-
post on the roadside and attended to the wounded. Later In the day,
when the batteries moved further forward, he visited all the gun
positions and attended to the wounded.
Capt. LAUREL COLE PALMER, Can. A.U5D.—During operations
from Sept. 2nd/4th. 1918, near Arras, while in charge of squads evacu¬
ating wounded, he kept close up to the advancing Infantry, directing
the collecting and dressing of casualties. The enemy shelling ana
machine-gun fire was Intense, but time after time he went through the
barrage with a total disregard of personal safety. On the night of
Sept. 2nd t he relay post was heavily shelled with gas, but be kept at
his work, protected bis wounded, and got them to a place of safety. He
showed great courage and devotion to duty.
Temp. Oapt. (acting Major) DONOVAN BLAISE PASCALL.—For
conspicuous gallantry and devotion to duty during the operations
astride the Arraa-Oambrai road on 8ept. 2nd, 1918. He was In charge
of the evacuation of casualties from the front, and repeatedly made
i iourneys over the shell-swept area around Dury and Eterlplgny,
ocatlng and maintaining touch with R.A. P.'s and bearer poets.
Through his disregard of danger the casualties were speedily
evacuated. ^
Capt. (now Major) WILLIAM JAMBS ELLERY PHILLIPS. Aust.
A.M.C.—For conspicuous gall ntry and devotion to duty on Sept. 6th
and 7th, 1918, during an advance on Rolsel. He worked continuously
for 48 hours in charge of tbe evacuation of the wounded from the
forward aid-posts. Although tbe area was heavily shelled he got his
ambulance cars right up and cleared the woun ted with great rapidity.
His energy and perseverance set a splendid example to those working
with him.
Temp. Capt. HARROLD JOHN PICKBBING.-For conspicuous
S ll&ntry and devotion to duty from Sept. 25th to 30th, 1918, near
.mbr&l, especially one night, when, heartog that there was a conges¬
tion or wounded at a R.A.P., he went orward through heavy shell fire
and remclned all night, collecting bearers from every available source
and supervising the clearing of the post. Throughout the whole
period he only had one other officer to assist him ia the forward area.
He Inspired his men with his own cheerfulness, energy, and
endurance.
Capt. DAVID TURNBULL RICHARDSON.—For conspicuous
gallantry, initiative, and resource, on Oct. 22nd, 1918, when in
command of an advanced dressing station, in evaluating casualties
under heavy rifle fire. He has shown similar qualities on several
previous occasions.
Temp. Oapt. (acting Major) GEORGE WILLIAM RIDDEL.—Far
conspicuous gallantry and devotion to duty during the attack on
Gouzeacourt, Sept. 18th, 1918. He went up to the most forward aid-
post to organise the collection and evacuation of the wounded. Though
dazed early in the action by the explosion of a shell near him, he
carried on his duties untiringly through the day and night, often under
heavy shell fire. His coolness and disregard of danger inspired con¬
fidence in the bearers, and it was largely owing to him that tbe
wounded were cleared so expeditiously.
Capt. WESLEY McOONNBLL ROBB, C.A.M.O.—For conspicuous
gallantry and devotloa to duty on the Sosrpe front from August 26th
to 29th, 1918. Shortly after zero his advanced dressing station was
blown In by shell fire. Though dazed and partly burled, he imme¬
diately dug his orderly out. He then followed the battalion in the
attack, organising stretcher squads from prisoners, and evacuating
serious esses with the least possible delay. He several times attended
serious oases in the firing line.
Temp. Capt. HENRY ALBERT RONN.—For conspicuous gallantry
and devotion to duty In attending to wounded under heavy shell fire
on Oct. 3rd, 1918, near Montbrehaln, and on Oot. 9th at Honoeohy. On
both these occasions he set a fine example under moot trying
conditions.
Capt. JOHN ROWLAND.—For gallantry and devotion to duty
during operations against the Tassel on the night Sept. 17th-18th,
1918. He, although dangerously gassed, remained at duty, and for
three whole days worked Incessantly rescuing our wonnded, often in
close proximity to the enemy’s positions and under au Intense fixe.
Despite much suffering from tbe effeets of the gas he persisted In his
efforts, and by his fine example and personal exertions was the means
of saving scores of lives.
Cape. JOSEPH GREGOR SHAW, Can. A.M.C.—Daring the opera¬
tions near Dury, Sept. 2od-6th, 1918, he was la charge of stretcher-
bearers. During the whole period he was constantly on duty. On
several occasions he reconnoitred areas which were under heavy shall
and machine-gun fire, dressing wounded and arranging for their
evacuation In the open. In the vicinity of the windmill he came under
heavy fire while attending to his duties. His work throughout was
admirable, and his coolness in danger was an excellent example to his
stretcher squads.
Lieut. JOHN ALEXANDER STEWART.—During the operations
astride the Arrma-Cambral road on Sept. 2nd and 3rd, 1918, he displayed
conspicuous gallantly and unselfish devotion to duty, attending to the
wounded under heavy fire with a disregard of danger that was a
splendid example to all.
Temp. Capt. WILLIAM JOSEPH EDWARD 8TUTTAFORD.—Hear
Malssemy, Sept. 23rd and 24th, 1918, he organised and superintended
the evacuation of wounded under heavy shell fire. His courage
inspired confidence among his men, and his initiative and resource
saved many lives.
Temp. Oapt. ARTHUR MACGREGOR WARWIOK.-For conspicuous
gallantry and devotion to duty. After an attack on St. Servin b Fans
on August 30th, 1918. when he had cleared his aid-post of all casualties,
he organised stretcher-bearers and got In without delay a large number
of wounded who were lying out la front exposed to heavy shelling.
He carried out similar good work the following dsy.
Oapt. (acting Major) FRANK WIGGLESWORTH.—For conspicuous
gallantry and devotion to duty on the night of Sept. llth-12th, 1918,
prior to the attack on Havrlnoourt. Under heavy shell fire he recon¬
noitred t he routes of evacuation and set out his bearer-posts. The next
morning, during the attack, he supervised the whole of the evacuation
of the wounded, and for the next two days he kept well forward,
advancing bis cars and posts as circumstances allowed, thus evacuating
the wounded with the least possible delay. His disregard of danger set
a fine example all round.
Oapt. BRIC MBLVYN WYLLIE, N.Z.A.M.C.-Por ooniplcuous
gallantry and devotion to duty south of Oambrai from Oct. 3rd to 8th,
1918. During five days’ operations, constantly exposed to enemy fire,
he reconnoitred the country for the establishment of bearer relay posts
and car-posts. Oo Oct. 4th, after establishing a car post at Masnieres
he went forward under heavy fire aud established a bearer relay post
on the bank of the canal, afterwards going forward and supervising the
evacuation of wounded from R. A. posts.
Capt. HARVBY GORDON YOUNG, D.S.O., Can. A.M C.—For con¬
spicuous gallantry and devotion to duty during the operations east of
Arras from August 26tb to 29th, 1918. He was M.O. to the battalion,
and throughout tbe whole operation followed up the attacking troops.
Under heavy machine-gun and shell fire he attended to wounded, and
organised stretcher squads of prisoners. He worked unoeaslngly, and
it was entirely due to his personal energy and disregard of personal
danger that all the wounded were evacuated before relief.
Distinguished, Service Cross .
Surg.-Ueut. WALTER GRIMSHAW BIGGER, R.N.—For services
with the Royal Mariue Artillery Siege Gun Detachment in Flanders.
On May 29th, 1918, while he was attending to the wounded In
Cannae ” gun position a second shell burst in embrasure. Surg.-Ueut.
Bigger continued his work with noteworthy oalmaess and devotloa to
duty. The coolness under fire displayed by this officer ou other
occasions has gained for him the confidence of the officers and men
under his medical charge. _
The following appointments of medical men to the Most
Excellent Order of the British Empire , for valuable services
rendered in or in connexion with military hospitals, terri-
The Lancet,]
THE SERVICES,
[Feb. 22,1919 317
tori&l hospitals, war hospitals, auxiliary and civil hospitals,
command depdts, convalescent camps, or on other duties of
a similar nature in the United Kingdom in connexion with
the Army during the war, are announced:—
C.R.E.— Mr. R. Alooek; Mr. A. R. Anderson ; Mr. H. G. Frankltng;
Hr. W. H. C. Ortene; Mr. B. G. Hogarth; Mr. R. J. H oward; Dr.
W. J. Howarth ; Prof. B. May; Dr. W. C. Morton; Dr. P. Nicholson ;
Dr A. J. Bice-Oxley; Dr. T. Y. Simpson. _ _ „
O.B.E —Mr. R. Y: Altken; Dr. G. E Genge-Andrews; Mr. G. J. M.
Atkinson; Dr. I. Banka; Dr. R. H. Barter; Mr. W. 0. Bentall; Mr.
B. J. Blackett; Dr. J. Blomfield ; Mr. F. L. H. Brown ; Lt.-Col. W. H.
Cadge, I M.S.; Mr J. Caahln ; Mr. J J. Day ; Dr. J. Elliott; Dr. H. B.
Blton; Dr. D. Ewart; Dr. F. H. Fairweather; Mr. H. D. Parnell; Dr.
B. T. Ftoon ; Dr. J. F. Fleming; Dr. J V. Fox; Dr. J. D. Giles; Mr.
H. J. Godwin; Mr. J. E. Gordon; Dr. B. J. Gulllemard; Dr.
J. A. Harrison; Mr. J. H. Harvey; Mr. E. D. H. Hawke;
Mr. A. W. Hunfcon; Dr. Mary E. Jeremy; Mr. J. R. Keele; Mr. 0. G. B.
Kemne; Dr. M. A. Key; Dr. Mary F. Liston; Dr. C. J. R. MacFadden;
Dr. J. Macintosh; Dr. A. M. Mitchell; Mr. H. C. Orrtn; Dr. R. C.
Peacocke; Dr. G. H. Perelval; Mr. C. J. Pinching ; Mr. A. Y. Pringle;
Dr. F. Badelitfo; Dr. B. B«*e; Dr. K. Rogers; Dr. Winifred M. Ross;
Mr. 8. H Bouquette; Dr. L. B. Shore; Dr E. W. Simmons: Dr. C. D.
Somers; Dr. FI reoce A. Stoney; Dr. J. W. Taylor; Dr. B. B. T. Thorne s
Mr. J. W. T. Walker; Dr. A. D. Webster; Mr. C. G. B. Wood; Mr. B. A.
Worthington. _
Foreign Decobatiohs.
French.
Ugion (THonneur.—Croix de Chevalier: Temp. Capt. (acting
LL-Cfl.) J. R. O. Greenlees, D.8.O., R.A.M.C. „ „ , v „
MtdaiUe dee Epidemic* (en Vermeil).- M*j (acting U.-Col.) R.B.
Ainsworth, D.S.O., B.A.M.O.; Maj. (temp. Lt.-Ool) J F. Crombie,
D.8.O., R.A.M.C ; Capt. F. H. Guppv. R.A.M.C.; Maj. (actlngLt.-Ool.)
I. M. O'Neill, D.S.O., R.A M.O.; Temp. Capt. R. McC. Paterson,
BA.M 0.; Capt. (acting Maj.) F. H. 0. Watson, R.A.M.C.; Capt.
W.T. Wood, R.A.M.C. _
Mtdaille d'8 Epidemics (en Argent).- Maj. A. W. H. A Court, Auat.
A. M.C.; Capt. (acting L*.-Col.) H. N. Burronghes, B.A.M.C.; Maj.
C. L. Chapman, D.8.O., Aust. A.M.C.; C*pt. (acting Maj.) 8. J. Clegg.
B. A.M.C.; Temp. Capt. K. M. Hand field-Jones, M.C., R.A.M.C ;
Capt. A. G. Hebbleth waite, D.9.O., B.A.M.C.; Capt. W. H. Hill.
RA.M.C.; Capt. t act1ng Maj.) A. M. Hughes, R.A.M.C.; Temp. Capt.
L. B. Lemprlere, R.A.M.C.; Capt. J. McL. Macfarlane, M.C.,
RJLM.C.; Temn. Capt. O. de B. Marsh, R.A.M.C.; Cspt. T. J.
Murra - ----- - - - — - - -
J
B.A
B.A.M.C.
Portuguese.
Military Order of Avis: Third Class. — Surg.-Lieut.-Comdr. B.
Taylor, B.N. __
iJLe.C.; Temn. Capt. O. de B. Marsh, k.a.u.u. ; vap*. i. j.
Hurray, R.A.M.C.: Maj. H. Orr. Can. A.MC.; Capt. (acting Maj.)
r. H. Pandered, M.O, B.A.M.C.; Temp. 0*pt. A. F. 8. 8Tadden,
S.A.8C 0.; Temp. Capt. A. B. Stevens, R.A.M.C.; Capt. B. S. Taylor,
THE SERVICES.
BOYAL ARMY MBDIOAL CORPS.
Tn King has approved of the appointment of Field-Marshal His
Koval Highness the Duke of Connaught and Strathearn as Colonel-in-
Obief of the Royal Army Medical Corps.
IJeut.-Col. and Bt. Col. M. H. G. Fell Is seconded for service with
the B.A.F.
I4eut.-Col. and Bt. Col. R. H. Moore to be acting Colonel whilst
specially employed.
Lieut.-Col. J. 0. Connor to be acting Colonel whilst specially
employed.
0. J. Bond to be temporary Honorary Colonel whilst specially
employed.
Temp. Major J. C. Davies relinquishes the acting rank of Lieutenant-
Colonel on re-posting.
Temp. Capt. H. K. Wallace relinquishes the acting rank of Lieutenant-
Colonel on re-poating.
To be acting Lieutenant-Colonels whilst in oommand of a Medical
Uniti Majors A. N. Fraser, W. J. Weston, O. levers; Capt. G. O
Chambers.
Temp. Capt. J. G. Murray relinquishes the acting rank of Major on
reposting.
To be acting Majors whilst specially employed : Capt. H. V. Stanley;
Temp. Capte. J. B. Lester, J. Vallance, J. H. Peek, J Greene.
Captains to be M-jors: Acting Lieut.-Cols. W. K. Beaman, M. P.
Leahy, D. F. Mackenzie. W. W. Boyce, J. du P. Langrishe, T. H.
Soott, G. F. Rudkin, A, C. Blliott, W. B. Purdon, F. Casement, B. M.
Middleton; Brevet-Major H. G. Gibson; Acting Majors A. D. Frazer,
I. L. Wood, O. B. MacBwen, M. O. Wilson, L. A. A. Andrews, H. W.
Atfebrother, C. Cassidy. A. Irvine-Fortescue, F. H. M. Chapman,
H. M. J. Perry, F. T. Turner, J. B. M. Boyd, J. H. Gurley, V. T
Carruthere.
Temp. Capt. D. M. Hunter and Capt. W. F. Christie relinquish the
•cting rank of Major on re-posting.
To be acting Majors: Capte. A. Hendry, H. G. Robertson, J. H. M.
Frobisher; Temp. Capte. H. H. Elliot, A. B. Halllnan, D. B. I.
Hallett, a. C. Palmer, A. V. Poyser, C. C. Chance, R. W. P. Jackson,
H. G. Pesel, C. O. Bodman, H. B. Shepherd, H. H. Hepburn J. P
Mathle, G. Muir, W. Wamock, H. H. Raw, E. L. Dobson, H. B. Evans
W. 8. Martin.
Temp. Capt. Spencer S. Dunn to be Acting Major whilst in command
of troops on a Hospital Ship.
Temporary Lieutenants to be temporary Captains: J. Cullen, G. V.
Allen.
Temp. Hon. Lieut. D. B. Carter to be temporary Honorary Captain.
O. K. Lang to be temporary Lieutenant.
Officers relinquishing their commissionsThe undermentioned on
<*Mlng to serve with No. 6 British Red Cross (Liverpool Merchants’
Mobile) Hoepital, and retain their honorary rank: Temp. Hon. Lieut.-
Col R. Raw; Temp. H«n. Major F. A. G. J**ms; Temp. Hon. Capts.
J. Hayward. S. Raw, H W. Jones, F. C. Wilkinson. Retaining the
rank of Major; Temp. Major E. L. Gowlland, A. Goodale ; Temp. Capts.
(acting Majors) <<. 8. Frew, C. A. H Gee, W. S. Danka, E. G. C. Price,
H. B. St.lee, B. F. Bartlett; Temp. Major W. B Edwards (on aopolnt-
ment under the Ministry of N atlonal Service and granted the rank of
Lieutenant-Colonel); Temp. Capt. (acting Major) G. V. T. Me Michael
(retains the rank of Major).
Temp. Hon Majors, on ceasing to be employed with No. 2 Red Cross
Hospital, retain the honorary rank of Major: L. J. Austin, B. Hudson.
Temp. Capt. A. S. Glynn on transfer to R.A.F.
Temp. Capts. (and retain the rank of Captain): C. J. Todd,
A. Looming, H. L. Clift. W. LNloo. F. B. O’Dowd, W. C. Frogoso,
P. 8tewart, F. G. Ralphs, L. B. C. Handson, W. C. Gore. T. Lovett,
G. O. Hutchinson, A. 0. Rowswell, A. Ball, R. W. L. Fernandes, I. G.
Cobb, R Dane, F. H. Dodd, W. R. Meredith, F. Thompson, T. Stans-
field, T. J. Little; Temp. Hon. Capt. R. A. Chisholm (on ceasing to be
employed with No. 8 British Red Cross (Baltic and Com Exchange)
Hospital, and retains the honorary rank of Captain); Temp. Lients. W.
Wright and D. A. Johnstone.
Canadian Army Medical Corps.
Temporary Majors to be acting Lieutenant-Colonels: G. Masson
S rhile employed as Chief of the Medical Service at a Canadian General
ospltal), G.H. B. Gtbeon, D.S.O. (while employed as O.C. a Ca n a d ia n
Convalescent Hospital).
Captains to be acting Majors while employed at No. 12 Canadian
General Hospital: K. A. M&cKenzle, F. B. McIntosh.
South African Medical Corps.
The undermentioned relinquish their commissions on oeaslng to be
employed with the Union Imperial 8ervioe: Temp. Lt.-Ool. G. K.
Moberley, and retains the rank of Lieutenant-Colonel; Temp. Major
G. D. Maynard, and retains the rank of Major.
And retain the rank of Captain: Temp. Capts. I. Haalam, W. D.
Akers, J. A. Martin, A. J. Milne, A. McWalt Green, J. J. Commerell,
B. L. Galgut.
To be temporary Captains: T. J. Howell, 0. C. Murray, T. G. Barnett,
A. J. Milne.
Dental Surgeons: H. B. Osier, M. de Villiers.
Temp. Lieut N. B. Thomson relinquishes his commission and retains
the rank of Lieutenant.
SPECIAL RESERVE OF OFFICERS.
Captains to be acting Majors: H. W. H. Holmes, P. Walsh, G. Young,
0. H. Brennan, B. B. G. Atkins, A. R. Dale, J. B. OroMns, H. R.
Fried lander, B. H. Bradley, H. H. Brown, W. 8. Haydook, H. T.
Chatfield, W. B. Wood, M. J. B. F. Burke-Kennedy.
Capt. (acting Lieut.-Col.) W. H. L. McCarthy relinqniahes his com¬
mission and retains the rank of Lieutenant-Colonel.
Capt. G. R. Bruce relinquishes the temporary rank of Major on
oeaslng to be specially employed.
Capts. C. J. Orde, B. Talbot, C. Johnson, W. 0. 0. Baston, and
B. Mountain relinquish their commissions and retain the rank of
Captain.
Capt. M. R. Taylor relinquishes the acting rank of Lieutenant-
Colonel and reverts to the acting rank of Major.
Captains relinquishing the acting rank or Major on re-posting:
A. R. Dale, D. Mackle, W. A. Miller, J. Wa'ker, J. Adams.
Lieut. J. R. Dtngley relinquishes his commission on account of ill-
health and retains bis rank.
Lieutenants to be Captains: W. A. Fraser, M. O. Simpson, J. F.
Twort. W M. Kerr, W. H. Wallace, A. H. Morris, D. F. Panton, T. G.
James. W. G. F. Owen-Morris.
Lieut. N. B. Thomas relinquishes his commission and retains his rank.
TERRITORIAL FORCE.
Lieut.-Col. F. W. Higgs to be an Assistant Director of Medical
Services, and to be acting Colonel whilst so employed.
Major A. J. Biddett to be acting Lieutenant-Colonel whilst specially
employed.
Major H. D'A. Blumberg relinquishes his commission and retains his
rank.
Capts. C. Nyhan and J. C. S. Dunn to be acting Majors whilst
specially emplojed.
Capts. (acting Majors) "A. A Hlngston and T. S. P. Parkinson
relinquish their acting rank on oeaslng to be specially employed.
Captains to be acting Majors whilst specially employed: B. J.
Booroe, R. J. Chapman, J. A. Bell, M.C.
Capt W. S. MoCune relinquishes his oommtssion and retains the rank
of Captain.
Capt. L. T. Whelan to be a Deputy Assistant Director of Medical
Services, and to be acting Major whilst so employed.
Capt. (acting Major) O. L. Appleton to be Maj *r.
Capt. A. B. Barnes, from 3rd Northern General Hoepital, to be
Captain.
1st Eastern General Hospital; Major (acting Lieut.-Col.) H. A.
Ballance relinquishes his acting rank and is restored to the establish¬
ment. Capt. (acting Major) W. B. Marshall relinquishes his acting
rank on ceasing to be specially employed.
3rd Scottish General Hospital: Capt. A. W. Harrington is restored to
the establishment.
5th 8' utbecn General Hospital: Capt. (acting Major) P. H. Green
relinquishes bis acting rank on ceasing to be specialty employed, and
remains seconded.
2nd Eastern General Hospital : Capt. W. B. Prowse relinquishes his
commission, and retains the rank of Captain.
2nd Western General Hospital: Major (acting Lieut.-Col.) B. N.
Cunllffe relinquishes his acting rank on ceasing to be specially
employed. M*jor A. Wilson to be acting Lieutenant-Colonel whilst
specially employed. Major A. H. Griffith relinquishes his oommission
and retains his rank. Capt. G. Wright is restored to the establishment.
1st Southern General Hospital: Capt. J. W. Stretton is seconded for
service overseas.
1st London Sanitary Company: Capt. W. N. W. Kennedy to be acting
Major whilst holding appolmment as Deputy Assistant Director of
Medical Services. Lieut. F. G. Caesar to be Captain.
• 2nd London Sanitary Company: Capt. W. K Pa* bury to be acting
Major while specially employed. Capt. (acting Major) J. H. Wood
318 ThxLakobt,]
MBDIOAL NEWS.
[Feb. 22,1919
relinquishes bis acting rank on vacating his appointment of Deputy
Assistant Director of Medical Services.
3rd Southern General Hospital: Major (temp. Lteut.-Col.) ▲. P.
Dodds-Parker relinquishes his temporary rank.
4th Northern General Hospital: Capt. H. B. W. Smith is restored to
the establifthment-
AUached to Units nther than Medical Unit*.— Surg.-Major H. Waite,
from the Northern Command Signal Company, to be Major.
TERRITORIAL FORCE RESERVE.
Major J. M. Gover, from 1st Northern Field Amb., to be Major.
Oapt. H. C Adams, from 2nd Wessex Field Amb., to be Captain.
Capt. C. S. Brebner, from 1st London Field Amb., to b* Captain.
Capt. W. R. Pierce, from 2nd West Lancs. Field Ambulance, to be
Captain.
Capt. J. H. Hunter, from 3rd Highland Field Amb., to be Captain.
Oapt. N. Gebbie, from 2nd London Sanitary Company, to be Captain.
Capt. W. A Robertson, from Attached to Units other than Medical
Units, to be Captain.
Capt. W. Sneodon, from 3rd West Riding Field Amb., to be Captain.
Lieut. T. W. Emerson relinquishes his commission on ceasing to be
employed, and retains the rank of Lieutenant.
Lieut. A. G. Jennings to be temporary Captain whilst Commandant,
Prisoner of War Camp. _
ROYAL AIR FORCB.
Medical Branch .—Major A. V. J. Richardson to be acting Lieutenant-
Colonel whilst employed as Lieutenant-Colonel.
A. S. Glynn (temporary Captain, R.A.M.O.) is granted a temporary
commission as Captain.
G. McK. Thomas is granted a temporary commission as Lieutenant.
Oapt. A. E. McCuilooh is transferred to Unemployed List.
Capt. L. G. Davies relinquishes his commission on acoonnt of ill-
health, and is permitted to retain his rank.
The undermentioned are granted temporary commissions as Lieu¬
tenants.—T. H. Roberts, R. D. Jones.
Medical (Administrative).— L. W. Jones Is granted a temporary
commission as Second Lieutenant, and to be acting Captain whilst
specially employed.
Dental Branch.— Lieut. H. Wardill to be Lieutenant, from (A.).
University of Bristol.— At examinations held
recently the following candidates were successful :—
Final Examination for the Degress of M.B., Ch.B.
Pari JL (completing examination).—Ainu Gabriel Bodman, Elizabeth
Caason, Evelyn Bessie Salter, Arthur Denis Symons, and Reginald
Frank White.
Part I. only.— Sukhasagar Datta, and Thomas Henry Algernon
Plnnlger.
Examination fob the Diploma in Public Health.
John Wesley Gilbert.
Royal College op Surgeons of England.—
Meeting of Council.—An ordinary meeting of the Counoil waa
held on Feb. 13fcb, Sir George Makins, the President, being in
the chair.—It was resolved (1) that Diplomas of Membership
should be granted to 62 successful candidates; (2) that, in con-
1 *unction with the Royal College of Physicians, Diplomas in
Public Health should be granted to seven successful candi¬
dates ; (3) that a donation of 50guineas should be made to the
War Emergency Fund of the Royal Medical Benevolent Fund.
—Dr. W. S. A. Griffith was re-appointed the representative of
the College on the Central Midwives Board for the period of
one year from March 31st, 1919, and he was thanked for his
services on the Board during the past year.—Mr. G.
Bellingham Smith was reappointed for four years the
representative of the College on the managing committee of
the British Hospital for Mothers and Babies, Woolwich.—
The President reported that Lieutenant-Colonel T. B. Layton,
who was to have given an Hunterian lecture on Feb. 10th,
had been unable to obtain leave of absence to proceed to
England from Alexandria, wbere be was stationed, and that
accordingly it had been necessary to postpone his lecture, for
which it was hoped a date might be arranged later in the year.
—The President reported (1) that in pursuance of the
provisions of the Bradshaw Bequest he had appointed Sir
Charles Bal lance as Bradshaw lecturer for the ensuing year;
(2) that, as requested by the Council at their last meeting, he
had addressed a letter to the Home Secretary urging that in
any legislation relating to the public health provision should
be made for ensuring an adequate supply of material for the
anatomical and surgical instruction of students and practi¬
tioners of medicine; (3) that the committee on the special
examination for the Fellowship had drawn up the regula¬
tions. These have already appeared in The Lancet, but
they were modified in that the examination will be open to
surgeons (men or women) who have done commendable
work in connexion with His Majesty’s Forces daring the
war, provided that the other conditions are fulfilled.—A
letter was read from the Council of the Medico-Psycho¬
logical Association of Great Britain and Ireland enclosing a
oopy of a report by the Association on Lunacy Legislation
and expressing the hope that it would receive the careful
consideration of the College. The matter was referred to a
committee.—The President reported that a meeting of the
Fellows would be held at the College on Thursday, July 3rd
next, for the election of two Fellows into the Council in the
vacancies occasioned by the retirement in rotation of Sir
Berkeley G. A. Moynihan and by the death of Mr. L. A.
Dunn, and the Secretary stated that March 17tb would be
the last day for the nomination of candidates and that a
voting paper would be sent on April 1st to every Fellow of
the College whose address is registered at the College.
Diplomas of M.R.C.S. were conferred upon 62 candidates
(4 women) who have passed the Final Examination in
Medicine, Surgery, and Midwifery of the Conjoint Examining
Board, and complied with the by-laws. The names and
schools of the successful candidates are included in the list
given in The Lancet of Feb. 8th (p. 239) of candidates
granted the licence to practise physic by the Royal College
of Physicians of London.—The Diploma of F.R.C.8. was
conferred upon Frank Beauchamp Martin, M.B., B.8. Melb.,
Melbourne University and St. Bartholomew’s Hospital, who
passed the necessary examinations in 1914,. and has now
complied with the by-laws of the College.
The Hunterian Oration was delivered at the College on
Friday last, Feb. 14th, by Major-General Sir Anthony
Bowlby (see p. 285), and in the evening of the same day the
Hunterian Festival Dinner was held, the President presiding.
Dr. J. Charlton Briscoe will deliver an Arris and
Gale lecture on the Mechanism of Post-operative Massive
Collapse of the Lnngs, at the Royal College of Surgeons of
England on Monday, Feb. 24th, at 5 p.m.
Maternity and Child Welfare in* Southwark.
—A conference will be held in the Town-ball, Walworth, on
Tuesday, Feb. 25tb, at 5.30 p.m., to oonsider closer coopera¬
tion between all who are interested in the maternity and
child welfare of the borough.
Hookworm Disease in Bengal.— The Governor
of Bengal, in a letter to the Sanitary Board, invitee attention
to the importance of adopting measures for the extermina¬
tion or lessening of hookworm disease in the province. He
estimates the percentage of the population infected by the
disease as 80 per cent., giving a total of some 36 million
carriers. The disease, which even in mild cases is responsible
for inertia and lowered vitality, can, the Governor states, be
cured cheaply and effectively, but can be prevented only by
ridding the infected soil of the virus of the disease. The
latter can only be achieved by wide diffusion of knowledge
regarding the nature and oanse of the condition, followed
by a revolutionary change in the hygienic habits of the
population.
A meric an Gifts.—A quantity of valuable hospital
stores and comforts supplied by the American Red Cross
for the use of Americans treated in the U.S. Base Hospital
at Portsmouth has been given to the Mayor of Portsmouth
on behalf of the town, for distribution amongst the looal
hospitals, in appreciation of the kind reception of the
Americans in Portsmouth. Mach constructional work was
undertaken by the Americans, involving the purchase of
building and other materials, to adapt the Portsmouth
Asylum for the purposes of a hospital. The whole of thie
has been handed over to the Asylum Committee as com¬
pensation for any dilapidations or alterations that will need
to be carried out to restore the building to its original use.
The Medico-Political Union.—I n view of “ the
crisis in the medical profession,” the Council of the Medioo-
Political Union is convening a mass meeting of the medical
profession at Wigmore Hall, Wigmore-street, London, W.,
on Sunday next, Feb. 23rd, at o.30 p.m. The President,
Mr. Frank Coke, will preside, and the following resolution
will be proposed
That in view of the far-reaching changes inevitable in the medical
services of this country consequent on the coming Ministry of Health,
it is essential that the profeaalo n should be solidly and democratically
organised on a trade union basis to enable it to negotiate effectively
with the Government In the interests of the community no less than
those of the profession.
St. Mark’s Hospital : The Lord Mayor’s
Challenge.— The Lord Mayor of London, presiding at the
annual general meeting of the governors of St. Mark’s
Hospital, City-road, on Feb. 13th, referring to the £800 still
required to acquire the vacant building site adjoining
the hospital, said he would be veiy glad to give £50 if
the balance could be raised by March 13th. The report
showed that beside the ordinary patients a number of
wounded soldiers had been treated during the past year
—many of them straight from France with injuries to
the abdomen which had necessitated their being kept under
treatment for very long periods—some for over eight months.
But all those patients, except one, had been discharged fit
for duty. The War Office was very pleased with the results.
The Ministry of Pensions was arranging to send other
patients. Daring the year 1918 the total number of new
out-patients was 1479. The number of in-patients admitted
daring the same period was 705.
Thi Lancet,]
PARLIAMENTARY INTELLIGENCE.
[Feb. 22,1919 J3ifr
THE MEDICAL WORK OF THE MINISTRY OF
NATIONAL SERVICE.
The medical side of the Ministry of National Service
will be transferred to the Ministry of Pensions, and
arrangements are now in progress to effect the transfer.
The medical and secretarial staffs affected are at the
headquarters of the Ministry of National Service and at
the offices of regions and areas of the Ministry, and
will continue to carry out their duties as at present under
that Service, but will receive due notice of the arrangements
for transfer. The only officers not affected by the transfer
are the Chief Commissioner of Medical Services and the
Branch (M 4) dealing with demobilisation of medical and
dental officers on service with the armed forces of the Crown.
These will remain as at present in the Ministry of National
8ervice.
|)arliamtntar2 Intelligent*.
NOTES ON CURRENT TOPICS.
The New Parliamentary Session.
Both Houses of Parliament have now voted the Address
in reply to the Speech from the Throne. The House of
Commons is in the ffrst place devoting itself to a revision of
the Rules of Procedure so as to expedite the course of
Parliamentary business. Some of the Government Bills
which are deemed urgent will not be long in being presented.
Ministry of Health Bill.
Dr. Addison (President of the Local Government Board)
on Monday, Feb. 17th, presented a Bill in the House of
Commons “ to establish a Ministry of Health and a Board of
Health to exercise in England and Wales and in Scotland
respectively powers with respect to health and local govern¬
ment and for purposes connected therewith.” It was read a
first time.
Text of Bill.
The Bill has been published and the following are its
principal olauses
Clause 1 (Establishment of Minister)
For the purpose of promoting the health of the people throughout
England and Wales, and for the purpose of the exercise of the powers
transferred or conferred by this Act, it shall bs lawful for Hia Majesty
to appoint a Minister of Health (hereinafter called ** the Minister ”),
Who shall hold office during Ills Majesty’s pleasure.
Clause 2 (General powers and duties of Minister in relation
to health)
It ahall be the duty of the Minister to take all such steps as may be
desirable to secure the effective carrying out and coordination of
measures conducive to the health of the people, including measures for
the prevention and cure of diseases, the treatment of physical and
mental defects, the collection and preparation of information and
statistics relating thereto, and the training of persons engaged in
health services.
Clause 3 (Transfer of powers)
(1) There shall be transferred to the Minister : fa) all the powers and
duties of the Local Government Board; ( b ) all the powers and duties
of the Insurance Commissioners and the Welsh Insurance Commis¬
sioners ; (c) all the powers of the Board of Education with respect to
attending to the health of expectant mothers and nursing mothers and
of children who have not attained the age of five years and are not In
attendance at schools recognised by the Board of Education ; (d) all
the powers of the Privy Council and of the Lord President of the
Council under the Midwives Acts, 1902 and 1918; (e) such
S jwers of supervising the administration of Part I. of the
hlldren Act, 19C8. (which relates to infant life protection),
as have heretofore been exercised by the Secretary of Slate:
Provided that (1.) the power conferred on the Insurance Commissioners
by the proviso to Subsection (2) of Section 16 of the National
Insurance Act, 1911, of retaining and applying for the purposes of
research such sums as are therein mentioned shall not be transferred to
the Minister, but the duties heretofore performed by the Medical
Research Committee shall after the date of the commencement or this
Act be carried on by or under the direction of a Committee of the Privy
Council appointed by His Majesty for that purpose, and any property
held for the purposes of the former Committee shall after that date be
transferred to and vested in such persons as the body by whom such
duties as aforesaid are carried on may appoint, and be held by them for
the purposes of that body; and (11.) in such matters of a judicial nature
under the National Insurance (Health) Acts, 1911 to 1918, as may be pre¬
scribed under those Acts, the powers and duties of the Insurance Com¬
missioners and the Welsh Insurance Commissioners by this Act trans¬
ferred to the Minister shall be exercised by the Minister through a special
body or special bodies of persons constituted in such manner as msy be
so prescribed.
(2) It shall be lawful for His Majesty from time to time by Order In
Council to transfer to the Minister—(a) all or any of the powers and duties
of the Board of Education with respect to the medical Inspection and
treatment of children and young persons; (b) all or any of the powers and
duties of the Minister of Pensions with respect to the health of dis¬
abled officers and men after they have left the service; (c) all or any of
the powers and duties of the Secretary of State under the Lnnaoy Acta,
1890 to 1911, and the Mental Deficiency Act, 1913; (d) any other
powers and duties in England and Wales of any Government depart¬
ment which appear to His Majesty to relate to matters affecting or
incidental to the health of the people.
(3) It shall be lawful for His Majesty from time to time by Order In
Council to transfer from the Minister to any other Government
department any of the powers and duties of the Minister relating to
the matters specified in the First Schedule to this Act, and any other
powers and duties of the Minister which appear to His Majesty not to
relate to matters affecting or incidental to the health of the people.
And it is hereby declared that it is the intention of this Act that, in the
event of provision being made by Act of Parliament passed in the-
present or in any future session for the revision of the law relating to
the relief of the poor and the distribution amongst other authorities of
the powers exercisable by boards of guardians, there shall be trans¬
ferred from the Minister to other Government departments such of the
powers and duties under the enactments relating to tho relief of the
poor then vested in the Minister (not being powers or duties relating or
incidental to the health of the people) as appear to His Majesty to be-
such as could be more conveniently exercised and performed by suoh
other departments.
(4) His Majesty may by Order in Council make such incidental, con¬
sequential, and supplemental provisions as may be necessary or
expedient for the purpose of giving full effect to any transfer of
powers or duties by or under this section, and may make such adapta¬
tions in the enactments relatiag to such powers or duties as may be
necessary to make exercisable by the Minister and his officers or by
such other Government department and their officers, as the case may
be, the powers and duties so transferred.
(5) In connection with tho transfer of powers and duties to or from
the Minister by or under this Act, the provisions set out in the Seoond
Schedule to this Aot shall have effect.
Clause 4 (Consultative Councils)
(1) It shall be lawful for His Majesty by Order in Council to establish
consultative councils for giving, in accordance with the provisions of
the Order, advice and assistance in connection with such matters
affecting or Incidental to the health of the people as may be referred to
In Buch Order. (2) Every such council ahall include persons of both
Bexes, and shall consist of persons having practical experience of the
matters referred to the council.
Clause 5 (Provisions as to Wales)
The Minister may establish an office in such town In Wales as he maw
determine, for the exercise and performance In Wales, through such
officers as the Minister may appoint for the purpose, of any of the powers
or duties transferred to the Minister by this Act from the Welsh Insur¬
ance Commissioners.
Clauses 6, 7, and 8 provide, respectively, for the staff and
remuneration of the Minister ana the officials of the depart¬
ment; for the official style of the Minister; and for the
regulations as to Orders in Council. The Minister will
receive £5000 per annum, and in the expenses of the Ministry
provision is made for the payment of Consultative Councils.
Clause 9 (Application to Sootland)
This Act shall apply to Scotland, subjeot to the following modifica¬
tions (1) Section 1 of this Act shall apply to Scotland as It applies to
Kngland and Wale*, with the substitution of a Scottish Board of Health
(heelnafier referred to as ** the Board ”) for the Minister; and accord¬
ingly references in this Act to Kngland and Wales shall be construed as
references to Scotland, and references to the Minister or the Ministry
shall, bo far as applicable, be construed as references to the Board.
(2) The Sec*eta*y for Scotland shall be substituted for tho Secretary of
State, and the Local Government Board for Scotland and the Scottish
Insurance Commissioners shall respectively be substituted for tho
Local Government Board and the Insurance Commissioners, and
in Subsection (2) of Section 3 the Scottish Education Department
shill be substituted for the Board of Education. (3) The Board
shall, as at first constituted, con list of the existing members
of the Local Government Board for Scotland and of such of
the Scottish Insurance Commissioners as the Secretary for
Scotland shall appoint, and shall at all times comprise, in addi¬
tion to the peraous who by virtue of their office are under the
existing law members of the Local Government Board for Scotland, a
member of the Faculty of Advocates of not less than seven years’
standing, and a registered medical practitioner who Is also registered
on the Medical Register as the holder of a diploma in sanitary science,
public health, or State medicine, under Section 21 of the Medical Act,
1886. The number of members (other than ex officio members) Bhall at
no time exceed six, and subject as aforesaid the power of appointing
Buch membera shall be exercisable by His Majesty on the recommenda¬
tion of the Secretary for Scotland. The Secretary for Scotland shall be
President of the Board, and such member thereof as the Secretary for
Scotland, with the approval of Ills Majesty, may designate shall be
Vice-President, and be Chairman of the Board in the absence of the
President. The Vice-President and other members of the Board (not
being members ex officio) shall receive such salary or remuneration as the
Treasury may Jrom time to time determine : Provided that persona
qualified to be in the first instance appointed members of the Board
shall, whether so appointed or not, have the like right of transfer as,
and upon Buch trausfer shall be deemed to be, persons transferred and
attached to the Board in pursuance of this Act. (4) The Mldwivee
(Scotland) Act, 1915, shall be substituted for the Mid wives Acts, 1902
and 1918, and the Edinburgh Gazette for the London Gazette. Refer¬
ences to the Welsh Insurance Commissioners shall not apply.
(5) Section 12 of the New Ministers and Secretaries Act, 1916, shall
not apply, but a Parliamentary Under Secretary may be appointed by
the Secretary for Scotland, and there shall be paid to any Under
Secretary so appointed such remuneration as may be fixed by the Treasury.
The office of an Under Secretary so appointed shall not render the
holder thereof Incapable of being elected to, or sitting or voting as a
Member of, the Commons House of Parliament.
Clause 10 deals with consequential modifications of the
Insurance Aot. The other clauses in the main deal with
details of machinery.
320 Th* Lancet,]
PARLIAMENTARY INTELLIGENCE.
[Fbb. 22, 1619
HOUSE OF COMMONS.
Medicine in the House of Commons.
Sir Watson Cheyne has been appointed chairman of the
newly formed House of Commons Medical Committee, whioh
consists of Members who possess a medical or surgical
degree, or who are interested in medical or scientific
matters. The committee will exchange views upon all
proposed legislation which has relationship to any medical
or allied question. The deliberations will be aimed to avoid
the expression of conflicting medical or soientifio opinions
in Parliamentary debate by arriving at a common view
-where possible. The Committee will also invite reports
from, and hold conferences with, medical and scientific
bodies. Maior A. C. Farquharson is secretary to the Com¬
mittee, and sir William Whitla, Lieutenant-Colonel N. Raw,
and Captain W. E. Elliott form the executive committee.
It was decided that the Committee should take an early
opportunity of meeting Dr. Addison on various matters of
medical interest.
Thursday, Feb. 13th.
Artificial Limbs.
Answering Mr. Pennefather, Sir J. Craig (Parliamentary
Secretary to the Ministry of Pensions) said: The Pensions
Minister is examining the problem of artificial limb supply
in all its bearings, and nas appointed a committee to
consider and report upon the following matters—namely,
<1) whether, and in what respects, the existing arrangements
with regard to supply, fitting, repair, and refitting should
be modified ; (2) whether it is desirable that the Ministry
should provide one or more institutions for the supply and
repair of limbs and should employ therein partially dis¬
abled or limbless men; and (3) whether the existing
arrangements for the supply of surgical instruments are
satisfactory and, if not, how they can be improved. The
members of this committee will be Mr. Herbert Guedalla,
-chairman, and the honourable and gallant Members for the
Reigate Division of Surrey (Brigadier-General G. H.
Gockerill) and for Nelson and Colne (Captain Albert Smith),
who have kindly consented to act together with Sir Charles
Kenderdine, K.B.E., and a Reading surgeon.
In reply to a further question by Mr. Pennefather, Sir
J. Craig said: The number of men whose stumps are
healed awaiting the fitting of artificial limbs on Feb. 1st
was 2832, and the number of men whose stumps are not
sufficiently healed for the fitting to take place is 5321.
Arrangements for the repair of artificial limbs are now
made by the local committees. From the returns available
the arrangements appear to be working well, and I do not
know of any arrears. There has not yet been any general
provision of spare limbs. The promise made by the late
Pensions Minister was that the provision of spare limbs
would be undertaken when the arrears in the supply of
first limbs had been worked off. In urgent cases, however,
such as those of men going abroad or men in special need
because of their particular occupations, spare limbs have
Already been provided. The whole question is being
carefully considered.
Colonel Yate : Are these limbs supplied to officers ?—Sir
J. Craig : Yes, Sir.
After-care of Tuberculous Ex-Service Men.
Mr. Pennefather asked the Parliamentary Secretary to
the Ministry of Pensions whether the Treasury had
sanctioned a yearly expenditure for the after-care of tuber¬
culous ex-service men, and would he state the date and the
Amount so sanctioned, and also how many appointments had
been made in connexion with this matter; and whether any
scheme had yet been formulated for this purpose.—Sir
J. Craig answered; Sanction for the yearly expenditure of
£20,000 was given in May last, and thereupon a scheme for
the domiciliary visiting of tuberoulous ex-service men was
drawn up and considered in consultation between the depart¬
ments concerned—namely, the Ministry of Pensions, the
Local Government Board, and „the National Health Insur-
Ance Commission. On Dec. 4th last, the Local Government
Board issued to the local authorities an explanatory circular.
I am unable to say how many appointments have been made
by the local authorities. Special appointments would not
be necessary in all areas, as the scheme is an extension of
the arrangements which in many districts were already in
existence.
Ministry oj Health.
Mr. G. Locker-Lampson asked the Leader of the House
when the Government proposed to appoint a Minister of
Health.—Mr. Bonar Law replied : It is the intention of the
Government to proceed with a Bill setting up a Ministry of
Health at the earliest possible date.
Mr. G. Lockf.r-Lampson : Pending the appointment of a
Minister of Health, who will advise the Government in
regard to the health side of housing?—Mr. Bonar Law:
That will be done in the meantime by the Local Government
Board, I presume.
Missing Officers and Men.
Mr. Churchill (Secretary for War), in the oourse of a
reply to Mr. Joynson-Hicks, stated that there were still
about 64,800 officers and men reported “missing*’ whose
fate remained to be determined. As a preliminary step to
recover from Germany all who might still be detained there
on account of illness or any other cause after the great
majority of the British prisoners of war had been repatri¬
ated, medical units fully staffed and equipped were sent into
each army corpB district in the country with orders to
search every camp, prison, mine, asylum, hospital, or any¬
where else, with a view to gathering in all that might be
found, both sick and well. The former were concentrated in
central hospitals in each army corps district and moved from
there by hospital train. Other Allied powers undertook the
same service and each collected all of every Allied nationality.
The German authorities called for a complete roll of all Allied
prisoners still in the country on Jan. 25th, and issued a
proclamation threatening heavy penalties against any who
aid not bring those of whom they knew to notice. A list of
those who were known to have been prisoners of war and
have not yet been repatriated, or whose death had not been
officially reported, was in course of preparation. It would
be presented to the German Government with the demand
that they should account for every one of them. A central
inquiry office under British supervision would shortly be
established at Frankfort, from which inquiries regarding
any who might still be in Germany would be prosecuted.
Friday, Feb. I4th.
Tuberculous Ex-Service Men.
Mr. Hogge, in moving an amendment to the address on
the subject of pensions administration, mentioned that there
were no fewer than 50,000 discharged men who were
suffering from tuberculosis and only a small proportion of
them were receiving the attention to which tney were
entitled.
Lieutenant-Colonel Raw said that a very large number of
the men in question had contracted tuberculosis owing to
the rigours of active service. Tuberculosis if dealt with in
its early stages was curable. A few months in a sana¬
torium was not sufficient to cure tuberculosis, and some more
adequate scheme was required to treat the disease with
success. A long and expensive treatment was necessary, and
he appealed to the Government earnestly to appoint a
Select Committee, which would deal with tuberculosis alone
as it affected men discharged from the services. He urged
also that arrangements should be made for an immediate
and adequate form of treatment. While there was delay the
men were dying. The arrangements, whiGh ought to include
established colonies and open-air treatment, should be under
the direct control of the Government. The men were now
being passed on to the local authorities. He hoped that
the Government would fully recognise its responsibility
for men who had contracted and developed tuberculosis
while in the service of the country.
Sir H. Kingsley Wood complained of the delay in
London in admitting to sanatoriums discharged men
suffering from tuberculosis. To obtain benefit a patient
must be under treatment for 12 months, yet during the past
few months no fewer than 339 men discharged themselves
from sanatoriums in London after one month’s treatment,
467 after two months, 258 within three months, and 105 after
four months. In fact, only 20 discharged soldiers in London
last year stayed in a sanatorium of their own free will for
more than six months. He had oome to the conclusion that
there was need of more humane and sympathetic treatment
in the sanatoriums.
Sir J. Craig (Parliamentary Secretary to the Ministry of
Pensions), in the course of his reply, said that steps had
been taken to improve the treatment of cases of tuberculosis.
The man was given priority over any other case of tuber¬
culosis requiring treatment. Most of the cost of treatment
was paid and the accommodation in the institutions was
increased. Improvements had been made in the after¬
care and home treatment. Extended treatment had been
given in early cases and graduated employment found in
agriculture or other suitable industries. He went on to
mention that Colonel Webb had been appointed Director-
General of Medical Service at the Ministry of Pensions, and
he would earn* on the treatment required bv disabled soldiers
and sailors after [they had left hospital. The Ministry had
taken over the National Service Medical Board and had set
up a strong committee to increase the Bupply, fitting, and
repair of artificial limbs and surgicaljapplinnces.
Monday, Feb. 17th.
Irish Housing.
Answering Mr. Lynn, Mr. Bonar Law (Leader of the House
stated that housing proposals on similar lines to those
contained in the English Bill were at the present moment
under the consideration of the Government for Ireland.
22 The Lancet,]
MEDICAL DIARY FOR THE ENSUING WEEK.
[Feb. 22,1919
Manchester Children’s Hospital, Pendleburu , Out-patients' Department,
Oartside-strect, Manchester.—Asst. M.O. £200.
Manchester Northern Hospital for Women and Children, Park-place,
Cheetham Hill-road -H.S. £150.
Merthyr Tydfil Venereal Diseases Clinic.—M.O.
Metropolitan Ear, Nose, and Throat Hospital, Fitsroy-square, W. —Clin.
Aasts. and Anarsths.
Middlesex Education Committee.—Asst. 8ch. M.O. £400.
Middleton-in- Wharfedale Sanatorium, nr. IlkUy.- -Asst. lies. M.O. £325.
Mile End Infant Welfare — M.O.
Mount Vernon Hospital for Consumption and Diseases of the Chest ,
Northwnod, Middlesex .—Asst U«. M.O. £260.
Newcastle-upon-Tyne, Royal Victoria Infirmary.—Vies. M.O. £350.
Also Anaesthetist. BiQO. Also Asst. Rea. M.O. £250. And other
Resident Appointments.
Nottingham Children’s Hospital.— Female Res. H S. and Rea. H.P. and
Anse?th. £250 and £200 respectively.
Queen’s Hospital for Children, Hackney-rood, Bethnal Qreen, E.— Rea.
M.O. £200.
Reading, Royal Berkshire Hospital.—H.P. £250.
Rousay and Egilshny, Orkney, Parish of.-— M.O. £300.
Royal London Ophthalmic Hospital. City-road, E. C. —Sen. H.8. £150.
Royal National Orthopxdic Hospital.—Bes. H.8. £200. Also Hon.
Anicsth. One guinea per attendance.
St. Thomas's Hospital, S.E.— Asst. Bact. £400. Also Asst. Pathologist
and Demonstrator of Morbid Anatomy. £250.
Sheffield City Education Committee.— Sch. Dent. 8. £350.
Sheffield Royal Hospital .—Two Hon. Asst. P.’s.
Stannington , Northumberland, Children’s Sanatorium .—Female Res.
Doctor.
Stockport Infirmary. —Jun. Rea. H.S. £200.
Tunbridge Wells Gcneraf Hospital.— H.S. £160.
Wolverhampton and Midland Counties Eye Infirmary.— H.S. £200.
Thk Chief Inspector of Factories, Home Offloe, S.W., gives notice of
vacancies for Certifying Surgeons undpr the Factory and Workshop
Acts at Caatlederg, Wakefield, Wrotham, Gortin, and Broughton
Astley. _
JSirtfcs, JJtarrisges, sub Jestfes.
BIRTHS.
Bdmond.—O n Feb. 15th, at Cruck Meole H'uise, Han wood, Shropshire,
the wife of Major W. S. Edmond, F.R.C.S., R.A.M.C., of a daughter.
Longhurst.— On Feb. 9th, at Lsdbroke-gardens, W., the wife of Lieut.-
Colonel B. W. Longhurat, R A.M.C., of a son.
Wigmork. —On Feb. 13th, at Bernorsmede, Blackheath Park, the wile
of Capt. (acting Lleut.-Oolonel) J. B. A. Wlgmore, R.A.M.C., of a
daughter. _
MARRIAGES.
Dew—J ojinbton. —On Feb. 13tb, at St. Barnabas, Clapham Common,
Major J. Wescott Dew, M.C., R.A.M.C., to Marlon Harvey,
daughter of the late Mr. and Mrs. Alexander Johnson, of Belfast,
Ireland.
Gilmour—Turner.— On Feb. Nth, at Westerfield Church, Ipswich,
Major John Gilmour, M.C., R.A.M.C., to Marjorie Joyce, only
daughter of Mr, and Mrs. Leonard Turner, Spursholt, Ipswich.
Milne—Macdonald.— On Feb. 12th, at the Parish Church of Glen-
Urquh&rt, by the Rev. Roderick Mackenzie, Major John Morrison
Milne, M.C., R. A.M.C. (T.F.), to Annie Dallas, daughter of the late
D. D. Macdonald and Mrs. Macdonald, Div&ch, Drumnadrochit,
Inverness-6hlre.
Moulson—Rynd. —On Feb. 3rd, at Bombay, Captain Geoffrey Moulson,
R.&.M.C., to Eileen Helen, daughter of Fleetwood Rynd, late of
Mount Armstrong, co. Kildare.
O’Brien— Dobbin.— On Feb. 12th, at 8t. Aloyalus Church, Garnethlll,
Glasgow, Captain Patrick Aloysios O’Brien, R. A M.C., to KAthleen,
daughter of A. H. Dobbin, J.P., Chestnut Hill, Cambuslang.
DEATHS.
Axford.—O n Feb. Nth, at Bournemouth, William Henry Axford, M.B.,
in his 80th year.
Benson.— On Feb. 16th, at Lower Baggot-street, Dublin, of pneumonia,
Charles Molyneix Benson, M.D., F.R.C.8.I., aged 41.
Blareway.— On Feb. 15th, at 8t. Bartholomew’s Hospital, from
pneumonia, Harry Blakeway, F.R.O.S., M.S., B.8c., of Weymouth-
street, W., aged 3$
Beam well.— At 10, Heriot Row, Edinburgh, on Feb. 12th, Martha,
beloved wife of Byrom Bramwell, M.D., F.R C.P.B., LL.D.
MORRIS.— On Feb. 14th, at Halesworth. Suffolk, Prjoe Jones Langford
Morris, M.R.C.S., L.R.C.P., aged 78 years.
Beal.— Of pneumonia following influenza,on Jan. lOtb, at 2, Catherine
Villas, Darjeeling. Charles Edward Baldwin Seal, M.K.C.S.,
L.R.C.P., aged 54, son of the late Charles William and Sarah
Morford Snell Seal, of Basingstoke.
Temple.— On Feb. 13th, at Tunbridge Wells, Lieutenant-Colonel
William Temple, V.O., M.B , late Army Medloal Staff, aged 85.
N.B.—A fee of to. is charged Jor the insertion of Notioes of Births ,
Marriages , and Deaths.
Bt an Order of the Food Controller dated
Feb. 14th lard may again be nsed in the manufacture of
ointment. 9
The Wellcome Research Laboratories, London.
—Mr. F. L. Pyman, D.Sc., having been appointed professor
of technological chemistry in the Manchester Municipal
College of Technology, Mr. T. A. Henry, D.Sc. f late super¬
intendent of the laboratories at the Imperial Institute,
London, has taken his place as director of the Wellcome
Chemical Research Laboratories.
HfcM far % ensuing Meek.
SOCIETIES.
ROYAL SOCIETY, Burlington House, London, W.
Thursday, Feb. 27th.— PapersHon. R. J. Strutt: Scstterliug of
Light by Solid Substances.—Sir James Dobble and Dr. J. J.
Fox : Toe Constitution of Sulphur Vapour.—Dr. W. G. Duffleld-
Mr. T H. Burnham, and Mr. A. H Davis: The Pressure upon
the Poles of the Electric Arc (communicated by Prof. O. W.
Richardson). _
ROYAL SOCIETY OF MEDICINE, 1, Wlmpole-street, W.L
Tuesday, Feb. 25th.
GENERAL MEETING OF FELLOWS: at 5.30 P.M.
Occasional Lecture:
Sir Almroth Wright: On Lemons of the War in the Field of
Immunisation.
Wednesday, Feb. 26th.
SOCIAL EVENING: at 8.30 p.m.
Professor Sir William Os'er will discourse on “ Sir Thomas Browne
and his 1 Religio Medici ’—a Bio blbllographloal Demonstration.”
MEETINGS OF SECTIONS.
Monday, Feb. 24th.
ODONTOLOGY (Hon. Secretaries—F. N. Doubleday, G. Patou Pollitfc*
J. Howard Mummery): at 7.30 p.m.
Paper:
Mr. J. F. Colyer: Irregularities of the Teeth in Monkeys.)
Tuesday. Feb. 25th.
MBDICINB (Hon. Secretaries —Charles R. Box, W. Cecil Boeanquet):
at 5.30 p.m.
Paper:
Dr. Otto Leyton: Transfusion iu Diseases of the Blood.
Friday, Feb. 28th.
STUDY OF DISBASB IN CHILDREN (Hon. Secretaries—G. R. 0.
Pritchard. H. G. Cameron, C. P. Lepage): at 4.30 p.m.
Continued Discussion :
The Etiology, Prevention, and Non-operative Treatment of
Adenoids.
Those wishing to take put in the discussion are requested to
forward their names to the Senior Hon. Secretary.
The Royal Society of Medicine keeps open house for
R.A.M.C. men and M.O.’s of the Dominions and Allies. The
principal hospitals in the metropolis admit medical officers
to their operations, lectures, &c. Particulars on application
to the Secretary at 1, Wimpole-Btreet, London, W.l.
MEDICAL SOCIETY OF LONDON, 11, Chandoe-st.,Oavendiah-eq.,W.
Monday, Feb. 24th.—8.30 p.m.. Paper:—Mr. B. A. Ramsay : Treat¬
ment of Congenital Hypertrophy of the Pylorus.
TUBERCULOSIS SOCIETY, at the Royal Society of Medicine,
1, Wimpole-street, W.
Monday, Feb. 24th.—8.30 p.m.. Discussion on the Treatment of
Tuberculous Glaads (opened by Dr. H. de Carle Woodoook).
CHILD-STUDY SOCIETY LONDON, at the Royal Sanitary Institute,
90, Buckingham Palace-road, S.W.
Thursday, Feb. 27th.—6 p.m.. Lecture:—Dr. P. B. Ballard: The
Claim of the Individual Child.
LECTURES, ADDRESSES, DEMONSTRATIONS, Ac,
ROYAL COLLEGE OF SURGEONS OF BNGLAND, in the Theatre
of the Oollege, Lincoln's Inn Fields, W.O.
Monday, Feb. 24th —5 p.m., Arris an! Gale Lecture:—Dr. J. C.
Briscoe: The Mechanism of Post Operative Massive Collapse of
the Lungs.
POST-GRADUATE OOLLHGB. West London Hospital, Hammersmith-
r °Speclal Bight Weeks’ Course of Post-Graduate Instruction. (Details
of the Course were given in our issue of Feb. 15th).
LONDON HOSPITAL MBDIOAL COLLEGE, in the Clinical Theatre
of the Hospital.
A Course of Lectures and Demonstrations on Surgical Dyspepsia.
Monday Feb. 24th.—Lecture 1.:—Mr. A. J. Walton.
UNIVERSITY OF LONDON, KING’S COLLEGE, AND KING’S
COLLEGE FOR WOMEN. _^
Course of Six Public Lectures arranged in conjunction with the
Imperial Stu lies Committee of the University on Physiology and
National Neods. _ .
Wednesday, Feb. 26th.—5.30 p.m., Lecture IV.:—Prof. A. Harden ;
Scurvy, a Dlseass due to the Absence of Vitamlnea.
UNIVERSITY COLLEGE. LONDON, Gower-street, W.C.
Friday, Fob. 28th.-5 p.m., Public Lecture-.—Dr. J. Murphy:
Italian Methods of Surgical Amputation (illustrated by cine¬
matograph films).
ROYAL INSTITUTE OF PUBLIC HEALTH, In the Lecture Hall of
the Institute. 37, Russell-Bquare, W.O.
Course of Lectures and Discussions on Public Health Problems under
War and After-war Conditions :—__ __
Wednesday, Feb. 26th.—4 p.m., Prof. B. W. Hope, O.B.B.: The Bfile
of the Ports in the Protection of the Health of the Nation.
OHADWIOK PUBLIC LECTURES, at the Rooms of the Medical
Society of London, 11, Chandoa-street, Cavendish-square. W.
Wednesday, Feb. 26th.—5.15 p.m., Mr. A. Searle: The Use of
Colloids in Health and Disease (illustrated by lantern slides).
ROYAL INSTITUTION OF GRHAT BRITAIN, Albemarle-streei,
Piccadilly, W.
Friday, Feb. 28th.—5.30 p.m.. Sir Oliver Lolge: Ether and Matter.
Owing to indisposition Prof. J. A. McClelland will be unable to
deliver his dlsoourse on “ Nuclei and Ions ” as announced.
The Lancet,] NOTES, SHORT COMMENTS, AND ANSWER8 TO CORRESPONDENTS. [Feb. 22, 1919 323
Jtotes, Start Comments, aito JJnstoers
ta Correspondents.
THE LAWS OF LIFE.
The seoond of a series of lectures on Physiology and
National Needs was delivered on Feb. 12th at King’s College
by Dr. M. S. Pembrey, who took for his subject Physical
Training of the Open-air Life. Civilisation, he said, was a
constant struggle against some of the fundamental physio¬
logical laws; life in factories ran counter to these laws, and
human happiness and contentment would not be brought
about until the physiologist was allowed to deal with the
question. That physiology would lead to better results would
be shown by a study of man in his primitive state, when
physical education was not governed hy any departmental
care, but was a part of life itself. Under modern conditions
we had fallen away from that instinotive training and followed
■certain regulations not based on physiological truth. We
need not however take a pessimistic view of the matter.
The idea that man was so badly constructed that he could
be improved by the surgeon or the physiologist was not
tirue. The exercises suggested by the Inter-departmental
Committee on Model Courses for Physical Exercise were
futile, degrading, dull, and without any physiological
basis. Young people bad the capacity for developing
physical fitness if they were given the opportunity; the
child developed control over its muscles and used them
as a result of learning to crawl and walk, and in the same
way learned to play and to coordinate its various physical
-systems. By progressive work the heart was trained and
respiratory exercises carried out—none of them by word of
command. He disapproved of the system of training by
word of command, as was done in schools; the children
covered each other with a spray of saliva droplets, and the
authorities became alarmed on account of the spread of
infectious disease in the school. The child should be allowed
to enjoy itself with ordinary games in the open air. The
capacity for development and exercise was present in the
erm from the time of conception. We coula never abolish
isease because disease was a part of life itself. Resistance
to disease could only be increased by subjecting children to
the presence of tbe organisms which were common in their
country. If this were not done disease would fall upon
virgin soil, and an infection which was not so serious in
one part of the country would sweep the country like a
plague. The child, therefore, should be subjected at an early
age to the diseases which they would find present in their
environment, and great immunity would probably result, as
evidenced during the war, and by the recent epidemic of
influenza.
A certain amount of training, Dr. Pembrey went on
to say, must take place if man \vas to remain in perfect
health. The oldest key industry was agriculture, and
It was noticeable that the agricultural labourer never
revolted even when he had good reasons for so doing.
Hie was badly paid and his hours were long, but he rarely
worked against the machine. It was the machine that
killed the man because it set the pace. The agricultural
labourer set the pace himself or it was set by the animals
which he employed; all kinds of movements took place
which were controlled by conditions of weather, soil, and
crops. The conditions of these men were not ideal in every
respect, but the men were “ good lives ” and had supplied
some of the best soldiers. Coal-miners furnished excellent
** lives ” ; they did a large amount of muscular work; they
set the pace themselves, but their conditions of life were not
physiological. In contrasting the coal-miner with the
agricultural labourer it was found that the former com¬
pensated himself for adverse conditions—and rightly so—by
demanding shorter hours. He was fond of sports and games
and insisted upon higher wages, for he had to work against
adverse conditions and must be well fed. Hard work
never killed ja man, but the machine did. Directly the
machine became so complicated that the man had
only to feed it the result was a dull monotony in
which beneficial physical exercise was not needed.
Muscular work was a physiological necessity; and many
men did more work in foot pounds in games and sports
than would be done in manual labour. In the muscular
exercise of manual labour the same factors were involved
as in sports and games, and it was only by taking guid¬
ance on these points that we oould acquire the necessary
conditions of physical fitness. Directly soldiers went out
on manoeuvres their sick-rate fell; when they returned to
barracks the sick-rate immediately went up; exposure in
the open air actually increased their resistance to disease.
Factory conditions and open-air- work acted in a similar
manner.
The best condemnation of the set exercise Dr. Pembrey
found in its use in school as a punishment. In nearly all
games there was an unconscious education of the nervous
system. The digestive system could be developed by mus¬
cular work, and combustion and utilisation of food material
could be in this way increased, but under modern conditions
of work it was easily upset, ill-temper being the result. The
cutaneous system was constantly neglected. Physiological
and not conventional cleanliness was the thing most
needed for body and mind, but this could only be obtained
when the components of the skin were working in the
proper way, such as occurred if exercise were pushed to
sweating. That babies had lo9t their natural instincts for
remaining physically fit was not true, but there was a
constant struggle with the child to make him conform to
civilised life. Sterilised milk was supposed to enable him to
ward off disease, but after sucking from the bottle he was
generally put on the floor; he then wetted his fingers in his
mouth, brushed up the germs from the floor and afterwards
swallowed them. Resistance to disease was the thing to aim
at. Tooth-brush drill in the schools not only produced
retraction of the gums but transferred germs from one child
to another.
Professor E. H. Starling, who presided, said that there
could be no doubt as to the advantages of open-air exercise
over the artificial method. The greater longevity of the
typical Englishman as compared with almost any other race
was due to the fact that he loved sports. Open-air exercise
for the child would mean that he must have more food.
Lack of development was not altogether due to bad
conditions, for it must be remembered that we kept our
weaklings alive.
THE TREATMENT OF ADENOIDS.
To the Editor of The Lancet.
Sir,— In reply to the inquiry of “ M.D.” as to the treat¬
ment of adenoids, the methods advocated by Dr. Ormiston
are being carried out at the Roll of Honour Hospital at
688, Harrow-road on Tuesdays and Thursdays, 9.30-11.30 a.m.
Demonstrations are also held at 60, Greek-street, Soho, on
Fridays, 4-6 p.m., in connexion with work done by the
Westminster Health Society.
I am, Sir, yours faithfully,
Octavia Lewin, M.B., B.S.
Wim pole- street, W., Feb. 18th, 1919.
MANCHESTER AND DISTRICT RADIUM INSTITUTE.
The report of the work of this institution for the year 1918
is an interesting and useful document, for it not only gives
an account of the valuable results accomplished during the
year, but also the uses to which radium has been put during
four years’ employment at the Institute, together with
an indication of the types and classes of diseases in which it
has been found useful as a curative or palliative agent. This
last section of the report is illustrated with pictures, showing
the effect of radium in cases of rodent ulcer, periostefld
sarcoma, spring catarrh as affecting the eyeball, carcinoma
of the breast, and epithelioma of the lip. Between the
first day of January and the last day of December,
1918, 648 patients presented themselves for treatment, an
increase of 60 patients over the previous year. Forty-eight
cases of malignant disease, exclusive of rodent ulcer, were
rendered free from symptoms and signs. This represents
11*75 per cent, of the cancerous cases treated, an improve¬
ment of over 2 per cent, over the year 1917. The best results
were obtained in carcinoma of the cervix of the uterus.
Apparently, also, 18 cases of rodent ulcer were cured,
representing nearly half of the total treated. In addition
26 non-malignant conditions were cured. No cures of
exophthalmic goitre are reported, but a large number of the
patients treated were so much improved that they were able
to resume their normal occupations. In this connexion it is
interesting to notice that a careful record was kept during
the year as to the effects of exophthalmic goitre on the
menstrual functions. It was found that 14 per cent, of the
patients suffered from excessive haemorrhage, 35 pet cent,
were quite normal, and 51 per cent, suffered from periods of
amenorrhoea. The number of emanation plates used was
365, and of emanation tubes 968, making a total of 1333. The
number of patients demanding treatment steadily increases,
and the need for better accommodation is pointed out.
At present the Institute is located at the Manchester Royal
Infirmary, in underground rooms and under very inefficient
conditions. Considering the character of many of the
growths treated hygienic conditions ought to be of the best,
in the interests both of worker and patient. As the report
says :—
“ With the steady increase in the work of the Radinm Institute and
the tendency to change its aspect from purely experimental effort into
an essential part of the medical organisation of Manchester, it now
seems to be a suitable time to raise the question of the nature of the
premises occupied by the Institute, and the necessity for providing
special beds for the treatment of its oases.”
All users of radium as a curative agent will find the report
of much utility.
324 Tn LANOBT,] NOTES, SHOBT COMMENTS, AND ANSWERS TO CORRESPONDENTS.
[Feb. 22,1919
INFANT’S TENACITY OF LIFE.
The following account is given by the mother of the
infant, a girl aged 16 years, and is one of two doonments
supplied by the sub-inspector of police in the district in
which the occurrence tooh place
Translation of Statement mi.de by Mummmat Oocht , Wife of Ramloo
Vhangar, aged 1€ years.
I had left my husband’s house and returned to my parents for my
confinement. I begin to have great pain, and for seven days suffered
agony. Fever was very bad in the village, and most people had left It,
so there was no dayee [nurse] or anyone to he’p me.
After I had suffered for seven days and nights I could stand the pain
of existence no more, so without disturb'ng anyone I got up and went
to a small well at the end of the compound and, holding the wall at
the edge of the w'ell, let myself down, and then let go. I fell straight
Into the water and sank deep; then slowly rose to the surface and sank
again. As I was sinking the second time my child was born, and 1
snatched it to my body and rose to the surface again. The walls were
all within reach and I manager! to catch hold of a projecting stone, and
held mj*self up with the child pressed against me with my other hand.
I did not call for help, but very shortly after this my father came and
looked into the well and called, and I answered. Then he let down a
basket and I put the child In and he pulled it up. Then he let the
basket down again and 1 got in and he pulled me up. This all occurred
at about 3 a.m.
The report from the sub-inspector to the Deputy-General
of Police bears out the statement of the mother. It is said
that the woman and child died about a week or ten days
later, probably from influenza. In this case labour seems to
have been hastened by the shock of falling into the well and
commencing asphyxiation. The incident is probably unique
and is of some medico legal importance.
BOOKS OF REFERENCE.
Both the Ncic Hazell Annual and Almanack (London:
Henry Frowdeand Hodder A Stoughton. Pp. 997. Price 6s.)
and Whitaker's Almanack (London: Whitaker. Pp. 1005.
Price 6s.) appear late this year owing to the many difficulties
of publishing due to the war conditions. Delay has also been
oaused by the desire of the compilers to include in their
respective editions a complete result ’of the Parliamentary
elections. The contents of these two reference books for the
office, the library, and the public generally are so well known
that it is unnecessary to describe them at the present date,
bat it may be mentioned that in Hazell will be found a
short medical review of the year 1918, including the progress
towards a Ministry of Health and the history of the
influenza epidemic and the efforts made to combat it.
Whitaker as well as Hazell devote considerable space to the
war and matters connected therewith, and while neces¬
sarily there is some overlapping, the publications supple¬
ment each other both in this and other subjects. The delay
in publication has enabled the editors to bring information
up to date.
COLONIAL HEALTH REPORTS.
Zanzibar.— Mr. R. H. Crofton, acting Chief Secretary to
the Government, in his report for 1917, states that at the
last Census the population of the island of Zanzibar was
113,624 (42,991 adult males, 49,210 adult females, and 21,423
childreu), and that of Pemba 83,109 (28,463 adult males,
31,894 females, and 22,752 children), tbe density of population
being 175 per square mile in Zanzibar and 219 in Pemba.
The population of the town of Zanzibar was 31,822. The
birth-rate (births registered) for the year was 21-0, as against
19-08 per 1000 in 1916. (The death-rate, presumably by inad¬
vertence, is not specified in the report.) Measures are being
token to ensure more accurate registration of births, and it
is considered probable, when the registration of all births
is seonred, that it will be found that tbe births equal,
or even exceed, the deaths, contrary to opinions based
on the figures now available. The islands were free from
any severe epidemic of disease during the year, and the
general health of the community was fair. Twenty-three
cases of cerebro spinal meningitis were notified during the
year. , Of these, 15 occurred among the King’s African Rifles
recruits from the mainland. All the cases reported died
with the exception of 2 remaining under treatment at the
infectious diseases hospital on Dec. 31st. Eleven deaths
were certified as due to dysentery; 5 of these gave a history
of having recently arrived from German East Africa. There
were 31 deaths from malaria, 4 from blackwater fever, and
41 from tuberculosis. 8even cases of small-pox occurred
(all imported from Bombay), of which two died. There was
no case of plague. The systematic collection of rats in the
town was carried on as in past years ; 13,647 were examined
microscopically with negative results. During the year 504
cases, principally sick and wounded officers and men of
His Maiesty’s naval and military forces, were treated
at the European hospital. Iq the native hospital 1038
in-patients and 7475 out-patients were treated. Thirty-five
in-patients and 2406 out-patients were dealt with in
the dispensary at Mkokotoni. In the infections diseases
hospital at Gulioni, 126 patients and 85 contacts were
admitted daring the year and there were 17 deaths. There
is one Government hospital in Pemba, at Chake Chake, and
dispensaries at Mkoani and Weti ; 378 in-patients and 7260
out-patients in all were treated in these establishments.
The number of lepers in the two islands amounts probably
to abont 450, of whom 107 are segregated in one settlement
in Zanzibar (which is subsidised by the Government and
administered by the Roman Catholic Mission under the
supervision of the medical officer of health) and 177 in three
settlements in Pemba, while the remainder are at large.
There is a poor-house in Zanzibar which is practically a
home for the incurable. The number of patients at she
beginning of 1917 was 55, the number admitted during tbe
year 99, the number of discharged 28, and the number who
died 64. The large roll of deaths is accounted for by tbe fact
that the institution takes in many cases in the lastfstoges of
disease.
H. IV. C.— The X ray tubes in question were of German
make and are now unobtainable. Messrs. CoBsor and Andrews
make tubes for therapeutic purposes. A 6 in. Macalister-
Wiggin tube, seasoned by frequent running for fairly long
periods with as large a current as it will bear without
becoming too hot to hold in the hand at any part, takes at
first a current as small as 0*4 to 0 5 ma., but sooner or later
it becomes more tolerant, and when it will easily carry 1 ma.
for 15 minutes it will have a resistance equal to about a 4} in.
spark-gap in air. Such a tube, in spite of the increased distonoe
necessitated by its size, will frequently turn a Sabourand
pastille in eight minutes. As the tube gets older this time
may be shortened by uBing an increased current, but this is
not advisable except in cases where a single dose isreqnired;
in a ringworm case the tube would probably become over¬
heated before the usual five doses had been given. The
preparation or “seasoning” is troublesome, but once
secured the tube is well adapted for therapeutic work, and
if nsed with care and discretion has a surprisingly long and
useful life. In a busy clinio two or more are necessary so as
not to put any one of them to the strain of continuous
service.
BOOKS, ETC., RECEIVED.
Blackwell, Mr., Broad-street, Oxford. Longmans, Green and 0o. t
New York.
Wheels, 1918. Third Cycle. Edited by Edith Sitwell.
Chapman and Hall, London, and J. Wilet, New York.
Pharmacy, Theoretical and Practical, Including Arithmetic of
Pharmacy. By E. A. Rudd!man, M.D. 8e. 6d.
Examination of Milk for Public Health Purposes. By J. Baoe, F.l.G.
8s. 6 d.
Forster, Groom and Co., London.
The Whole Duty of tho Regimental Medical Officer. By Captain
P. Wood, K A.M.C. 2s. 6 d.
Lippincott (J. B.) Company, London and Philadelphia.
A Text-book of Chemistry. By S. P. Sadtler, Ph.D.,‘and Others.
5th ed. 21s.
C ommuni cations, Letters, 4c., to the Editor have
been received from—
A. —Dr. H. G. Adamson, Lond.
B. —Dr. W. L. Brown, Lond.; Miss
L. Brown, Wigan; Mr. B. J.
Bean, Lond.; Mr. E. J. Burdon,
Lond.; Dr. G. S. Buchanan,
C. B., Lond.; Dr. H. Barber,
Derby; Dr. P. Bousfield, Lond.;
Surg.-Com. P. H. Boyden, R.N.;
Dr. A. E. Boycott, ltadlett.
C. —Messrs. Chamberlain, Donner,
and Co.. Manchester; Mr. H.
Cooper, Lond.; Christian Science
Committee on Publication.Lond.;
Chicago School of Sinltary In¬
struction ; Chadwick Trust,
Lond., Sec. of; Central Council
for District Nursing in London;
Mr. F. V. Conolly, Lond.
D. —Dr. W. H. Dickinson, New¬
castle-upon-Tyne.
F. -Dr. S. B. Figgis, Brighton;
Factories, Chief Inspector of,
Lond.; Major E. R. Fothergill,
R. A.M.C.
G. —Dr. W. Gordon, Exeter; Dr.
H. J. Gauvain, Alton; Major
S. B. Gray, M.C., U.S.A.; Dr.
A. K. Gordon, Lond.
H. — Mr, C. J. Heath. Lond.; Prof.
W. Hall, Lond ; Dr. L. Hirsch-
feld ; Bt.-Col. L. W. Harrison,
D. S.O., R.A.M.C.; Mrs. B. Hand-
cock, Lond ; Dr. F. Hemaman-
Jolinson, Lond.
J. —Mr. Q F. Jenner, Boscombe;
Mrs. G. E. Jukes, Lond.; Lt.-Col.
A. L. Johnson, C.A M.C.
K. — Dr. H. C. Kidd, Bromsgrove.
L. —Dr. 0. B. Lakin, Lond.; Miss
E. Lowry, M.B., Lond.; London
Dermatological Society; Mr. D.
Communications relating to
addressed exclusively to Tl
423, Strand, L
Llgat, Lond.; Mr. K. A. Lees.
Load.; Mr. J. B. Lamb, Lond.;
Local Government Board, Lond.;
Major J. H. Lloyd,«R.A.M.C.(T.) ;
Miss O. Lewin, M.B ; Dr. C.
Lundie, Glasgow; Prof. H.
Littlejohn, Lond.
M. — Dr. R. Morton, Lond.; Mr.
A. P. Melville, Eilnburgh; Mr.
J. B. Macalpine, Aberdovey;
Medical Research Committee,
Lond.; Dr. H. J. May, South¬
ampton ; Dr. N. Moore, Lond.
N. —National Provident Institu¬
tion, Lond., Actuary and Secre¬
tary of; National Food Reform
Association, Lond.
O. —Mr. H. Oppenheimer, Lend.;
Mrs. K. O'Conor, Ware.
R.—Capt. J. Ryle. R.A.M.CfS.R.);
Royal Statistical Society, Lond.;
Royal Society, Lond; Royal
Institution of Great Britain,
Lond.; Capt. C. H. L. Rlxon,
R.A.M.C.; Royal Society of Arts,
Lond.
8.—Mr. S. Sanyal, Calcutta; Mr.
F. C. Stringer, Fazeley; Dr.
E. F. Skinner, Sheffield; South¬
wark, Mayor and Mayoress of.
T.—Mr. H. M. Traquair, Edin¬
burgh ; Mr. P. N. Turner, Lond.;
Dr. L. Tbateher, Edinburgh.
V, —Mr. R. M. Vick, Lond.; Dr.
P. O. Varner-Jones, Cambridge.
W. —Dr. C. Watson, Edinburgh;
Dr. J. A. Wilson, Warrington;
Prof. W. Wright, Lond.; Capt.
R. f. Williamson, R.A.M.C (T.);
Dr. W. H. Wynn, Birmingham;
Mr. H. T. Warner, Lond.
editorial business should be
e Editor of The Lancet,
radon, W.C. 2.
THE LANCET, March 1, 1919.
Jn Jnalnsis
OF
CASES OF TETANUS
OCCURRING IN THE BRITISH ARMIES IN FRANCE
BETWEEN NOV. 1st, 1916, AND DEC. 31st, 1917.
By S. L. CUMMINS, C.M.G., M.D., LL.D. N.U.I.,
COLONEL, A.M.S. ;
AND
H. GRAEME GIBSON, M.R.C.S., L.R.C.P. Lond.,
MAJOR, R.A.M.C.
The present analysis is a continuation of that published
by Colonel Sir William Leishman and Major A. B. Smallman. 1
All the information at our disposal has been collected under
the direction and supervision of Sir William Leishman
himself and would have been dealt with by him in due course
but for his transfer to the War Office. In arranging the
material handed to us by him we propose to adhere closely
to his methods of tabulation and to allow the tables and
charts, as far as possible, to speak for themselves. Such an
analysis would, however, lose much of its interest and value
if it were to consist merely in the setting forth of the informa¬
tion in tabular form without any attempt, on the part of the
authors, to formulate the impressions which they have gained
in their examination of the material available. We shall
therefore venture to draw such conclusions as we consider to
be justified ; at the same time expressing our regret that
circumstances have made it impossible for Sir William
Leishman himself to deal with the facts collected under
his direction and in the arrangement of which his great
experience and knowledge wouldhave been invaluable.
Table I.— Case Mortality of Present Series Compared with that
of Former Series in the B.Fj.F.
No. of
1 cases.
Died.
Recovered.
Case-
mortality.
July. 1915... .. ... ... 179
140
39
78*2%
July-October, 1916 . | 160
118
42
| 737%
Present series. 1 376
252
124
670%
Table I.a. —Distribution of Cases of Tetanus , together v?ith
the Case Moriality in Each Group.
(a) British battle casualties 291 191 100 65*6%
I (b) “Trench feet”. 24 21 3 87*5%
i (C) Accidental. 48 26 22 54*1 %
(d) German prisoners. 13 9 4 69*2%
Table I.b. —Case Mortality of Present Series of Cases when
Grouped in Chronological Order.
1st group... . 63 47 16 745%
2nd . 63 48 15 761%
3rd . 63 45 ! 18 714%
4th . 63 40 I 23 634%
5th . 63 36 I 27 57 1%
6th . 61 36 25 59*0%
among men suffering from “ trench feet,” 24 ; (o ) cases due
to accidents and other causes, 48 ; ( d) cases among German
prisoners of war, 13. Each of these groups has its own rate
of case mortality, as shown in Table I. A.
In the previous analysis the case mortality for the period
July-October, 1916, was 73 7 per cent. If the whole of the
376 cases, taken in chronological order, are divided into six
groups—five groups of 63 and the sixth group of 61—and
the case mortality of each group is examined separately, a
fairly steady fall will be noted. (Table I.B.)
Case Incidence.
The records at our disposal
cover the period from Nov. 1st,
1916, to Dec. 31st, 1917, and
deal with a total of 376 cases.
Daring this period complete
figures for tetanus cases among
the British battle casualties
are available and the case-
incidence per 1000 shows a
moderately steady decrease.
The * ‘ total wounded ’ ’ on which
Chart I. is founded does not
include “wounded (gas).” The
rainfall, though following to a
certain extent the minor fluc¬
tuations, does not appear to
bear any definite relation to
the case-incidence, which is
actually lower during the
wettest months of the period
under observation. Tempera¬
ture, however, may perhaps
have some effect, as the ground
Chart I.— Ratio of Case-incidence to Battle Casualties over Period Nov., 1916 ,
to Dec., 1917.
The bottom curve indicates average daily rainfall per month in decimals of an inch.
The upper curves show the average maximum and minimum temperature.
tends to dry up more rapidly in the summer and early
autumn. On the whole, Chart I. shows a satisfactory fall
in the case-incidence of tetanus during the summer and
autumn of 1917.
Case Mortality.
Of the 376 cases dealt with, 252 died and 124 recovered,
a case mortality of 67 0 per cent. Of the total deaths, 13
were from causes other than tetanus. As, however, it is
impossible to evaluate successfully the relative importance of
the factors leading to death in cases that have just passed
through an attack of tetanus, we have thought it better to
include these deaths in the total mortality.
Table I. gives the case mortality of the present series and
of the two previous analyses of tetanus cases in the British
Expeditionary Force. It is satisfactory to be able to record
a continued improvement in this respect.
The 376 cases of the present series fall into four groups :
fa) Cases among British battle casualties, 291 ; ( b ) cases
1 The Lancet, Jan. 27th, 1917; Journal of Koyal Army Medical
Corps, March, 1917.
No. 4983
Position of Wounds with Reference to Case
Mortality.
The following figures show the relative frequency of body
and limb wounds in cases of tetanus in this series of cases
and in the series July-October, 1916. Where wounds of the
body and limbs oceur in the same case it has been counted
as a case of body wound only. The increase in the
Table II.— Ratio between the Number of Cases suffering from
Wounds of the Limbs anil Body.
Series.
Body.
Limbs.
July-October, 1916: 157 cases...
79. 50-3 °/ 0
78. 49*7 °/ 0
Present series : 371 ,, *...
144. 38-8 %
! 227. 61*1 %
Table II.a.— The Position of the Wounds ii
Case Mortality.
t Reference to
Fatal cases : 251. |
102. 40-6 °/o
149. 59-3%
Recoveries : 120. j
42. 35*0%
78. 65-0 %
* Definite Information was obtainable on these points in 371 cases.
I
326 Tbe Lancet,] COL. S. L. CUMMINS & MAJ. H. G. GIBSON: ANALYSIS OF CASES OF TETANU8. [March 1, 1919
percentage of wounds of the limb is exaggerated, to a certain
degree, by the inclusion of more cases of tetanus from
“ trench feet ” in this series.
Table II. A shows the relative incidence of body to limb
wounds in the fatal cases and those which recovered. Very
little can be deduced from these figures, a slightly lower
percentage of body wounds, however, being recorded
amongst the recovered cases than in the previous analysis.
The relative frequency of sepsis, gas gangrene, the extent
and the multiplicity of wounds amongst the tetanus cases
under consideration is shown in Tables III. and JII.a. A
comparison has also been worked out between the frequency
of these conditions in cases in the present series and
Chai
among cases in the last analysis. The two series corre¬
spond in a striking degree with the exception that gas
gangrene has dropped to 19 9 per cent, in the later series.
With regard to the effect of these factors on the case
mortality, we consider that it would be dangerous to draw
conclusions. Each of the headings necessarily includes
many cases common to the others, and the relative influence
of each factor is obscure. The extent and severity of the
original wound naturally plays a predominant part.
Incubation Period.
Records of the incubation period are available in 343 out
of the 376 cases. The time between wounding and the onset
T II.
Table III .—Condition of Wound# a# regards Sepsis , Gas
Gangrene , dc.
Severe
| sepsis.
j 1
Gas
1 gangrene. 1
Extensive or
severe wound.
Multiple
wounds.
July-October, 1916: t
155 cases .*
112.
124.
80.
72*2%
42 5%
80*0° o
o
Co
Present series : 371 /
278.
74.
293.
190.
cases. \
1 74- %
1 199%
-j
OO
o
o
51*2%
Table III. a. — Condition of Wounds in Reference
Mortality.
to Case
Fatal cases, 251 . !
194.
77*2 °/ 0
56.
22 3 0 o
205.
81*6 %
131.
52-1 %
Recoveries, 120 .
84.
70*0 %
18.
15-0% '
1
88.
73 3 o/ 0
59.
49-1 %
of tetanic symptoms varied from 18 hours—a case of a gun¬
shot wound of the right thigh with fracture of the femur in
which no history of any previous injury could be elicited—
to 180 days. This latter case has been eliminated for the
purpose of working out the average incubation period,
which, for 342 cases, was 13 2 days, a little over one day
longer than in the previous analysis. Of the fatal cases,
230 in number, the average period was 12 5 days compared
with 10 7 in the July-October analysis, and of the 112
recoveries 14 9 as compared with 14 0 days. The difference
in the incubation period of fatal cases and recoveries is 2*5
as compared with a fraction over 3 days in the last analysis
and 2*75 days in the analysis of July, 1915.
A curve of the incubation periods by days is attached
(Chart II.). The peak of the curve is a day earlier than in
The Lancet.] COL. S. L. CUMMINS & MAJ.H. G. ^IBSON: ANALYSIS OF CASES OF TETANUS. [March 1,1919 327
the previous analysis, being reached on the seventh day
instead of on the eighth.
A combined curve of the present and previous series is
also appended (Chart III.).
Table IV. shows the case mortality for varying incubation
periods from 10 days and under to 22 days and over. Of
Table IV.— Incubation Period per Cent, of Cases.
Analysis.
! 10 days
and under
11-21
days.
j 22 days
and over.
July-October, 1316.
' 59-8° 0
CaJ
OO
o
c .
8-2°, a
Present series ... .
441® u
43'3° o
I 12*2°/ 0
Combined.
i 49*2° ,,
39-8°/o j
11 o%
Home eases, Deo. 1916, to March, 1917
io-o° o
21*0®, o*i
, 69 0® Q t
* = 11 to 22 days. t «■ Over 22 days.
the present series of cases 44*1 per cent, had an incubation
period of 10 days or less, 43 -3 per cent, of between 11 and
21 days, and 12*2 per cent, of 22 days and over. When
divided in this way the present figures show a lengthening
of the iacubation period as compared to those of July-
October, 1916.
The close connexion between the length of the incubation
period and the case mortality is shown graphically in
Chart IV. This connexion should not be lost sight of in
Chart IV.— The Relation between Incubation Period and
Case Mortality
comparing the results of treatment in cases occurring in
England with those in France.
Influence of Operation Before Onset of Tetanus.
Tetanus occurred after amputation affecting the upper or
lower limbs in 59 cases, or in 15 oer cent, of all the cases in
the series. Of these 59 cases, 38 died as a result of tetanu*
and 15 recovered, while 6 died from sepsis and other causes
after the tetanic symptoms had subsided. Among the 59
oases 42, or 71*1 per cent, occurred after amputation of the
lower limb, and 16, or 27*1 per cent., after amputation of
the upper limbs, while in one case both an upper and a lower
limb had been amputated. Among the cases of amputation
of the lower limbs in which tetanus subsequently developed
the case mortality was 76 3 per cent. ; in the case of the
upper limbs 60*0 per cent. The one patient in whom both
an upper and lower limb were amputated recovered from his
tetanic symptoms, but died from bronchial pneumonia 30
days later.
Influence of Operation After Onset of Tetanus.
Operative interference was resorted to after the appear¬
ance of tetanic symptoms in 27 cases or 7*1 per cent of the
total number of cases. Of these 22 died and 5 recovered,
giving a case mortality of 81*48 per cent. This is an even
higher case mortality than in the last analysis, where 7 died
out of a total of 9 cases, a case mortality of 77*7 per cent.
Table IV.A gives the nature of the operations performed,
the perio 1 between the onset of tetanic symptoms and the
operation, and the result.
The Prophylactic Use of Tetanus Antitoxin.
It is a matter of great interest that nearly one-fifth of the
total number of cases arising in the period under review
occurred amongst persons to whom n > inoculation had been
given. These were chiefly patients suffering from trench
Table IV.a.— Operative Interference After Appearance of
Tetanus.
Series
No.
1 Date of
I onset.
|
Date of p nun it-
operation! “ esult -
Nature of operation.
N. 2
Nov.
3,1916.
Nov.
3.
D.
Amp. middle of left calf.
N. 18
,,
15,
15.
D.
Opening up wound.
N. 23
' ,,
20, ,.
..
21.
D.
Excision of wound, drainage.
N. 32
,,
16, ,.
„
17.
R.
Amputation left forearm.
D. 1
{Dec.
5, ..
Dec.
5.
D.
Sloughing area excised.
D. 12
1
j
20, „
„
20.
I).
Amputation finger.
1). 21
25. „
.,
25.
1 D *
Sloughing area excised.
14
Jan.
8,1917.
Jan.
11.
R.
Neck drained, F.B. removed.
13
|Feb.
10, „
Feb.
10.
D.
Amputation thigh.
23
Mar.
3, „
Mar.
3.
D.
Free exposure of wound.
47
,,
20, ..
20.
R.
Abscess opened.
49
1
30, „
..
31.
| D.
Nail removed.
63
April 16, ,,
April 17.
1 D.
Wound incised and drained.
128
May
12, .,
12.
H.
Excision of wound.
86
3,
May
5.
! D.
F.B. removed.
88
I „
7, ,.
..
9.
! D.
Wounds opened.
110
20. „
20.
D.
F.B. removed.
112
19. .,
19.
D.
Abscess opened.
156
' ’*
18, „
’*
19.
D.
G.S.W. shoulder. Arm
moved under anaesthetic.
204
July
16, ..
July 24.
Fragment of tibia removed.
Wound sutnred.
206
Aug. 24, ,,
Aug. 28.
D.
Extensive incisions.
226
;Oct.
5,
Oct.
6
D ‘
Wound excised.
239
i
17.
20.
n.
For seciniary haemorrhage.
241
,,
22. ..
24.
D. !
„ „
251
i
24, ..
oh hrs.
later.
D.
Amputation right leg.
277
Aug.
7, ..
Few hrs
later.
D j
„ linger.
283
Nov.
29, „
Nov.
30.
D.
„ left leg.
* Tet&uic symptom* ceased 4/8/17.
foot or cases of accidental injury. In December, 1916, an
order was sent out from the office of the Director-General
Medical Services, that prophylactic inoculation was to be
given in all cases of trench foot, and this order became of
general application from the beginning of 1917 onwards.
It may be added that of the 14 cases arising amongst
uninoculated patients suffering from trench foot between
November, 1916, and Deo. 31*t, 1917, no less than 13
occurred before the issue of the order ab >ve referred to.
Influence <f Eirltf Administration of the Prophylactic Dose.
It is not possible to ascertain the proportion of all
wounded who received a prophylactic inoculation within
24 hours of wounding, nor the total number to whom the
Table X.—Influence of Early or Late Prophylactic Dose on
Case Mortality.
Prophylactic dose.
No. of
CA868.
Died.
Recovered.
Case
mortality.
Within 24 hours of wound {
More than 24 hours after (;
wounding . ) J
226
46 |
143
33 j
83
13
63*2%
71*7°/ 0
Table V.a.— Amount of Initial Dose and Ca*e Mortality.*
No prophylactic dose ...
70
; 48 ;
22 1
68*5°, 0
500 units .
...
161
1 109
52
63‘6°/ 0
750-1000 units .
...
52
I 27 ;
25
51*9°/ 0
1001-1500 units .
...
13
! 6 1
7
46*1° S
Table V.b —Case
Mortality in Cases Receiving only One
Prophylactic Dose.*
500 units .
...
| 119
90
29 !
75*7 o
750-1000 units.
...
27
12
US j
44*5 %
10:0-1500 units .
12
j ^
7
I
41*7® o
" In cases receiving this prophylactic dose within 24 hoars.
inoculation was given at a later period. The case incidence
in these two groups cannot, therefore, be estimated. From
the figures at our disposal we are able to compare the case
mortality in those receiving the early inoculation with those
I 2
328 The Lancet,] OOL. S. L. CUMMINS & MAJ. H. G. GIBSON: ANALYSIS OF OA8ES OF TETANUS. [Maboh 1,1919
in which this was not given until later than 24 hours and
the results are set forth in Table V. It will be seen that the
results, as far as they go, point to a decidedly lower case
mortality in those receiving the earlier dose.
Size of Prophylactic Dose.
During the whole of the period oovered by the previous
analysis and up to July, 1917, or the first eight months of
the period inoluded in the series now under examination,
the prophylactic dose had been, in practically all oases. 500
antitoxic units, and this dose undoubtedly gave very satis¬
factory results.
When the production of antitetanio serum had been placed
on such a footing as to ensure a constant and adequate
supply the question naturally arose as to whether a more
liberal dose might not be still more efflcaciouR in cases of gross
contamination of the wound. In July, 1917, an instruction
was circulated to all concerned from the Office of the
Director-General, Medical Services, recommending that a
dose of 1000 to 1500 units should be given “in all deep
wounds, in those which are contaminated by dirt, and in
those in which there is a fracture of bone.” This period
onward in the series marks not only the lowest ratio of tetanus
oases to battle casualties, but shows also a considerable fall
in the case mortality of this disease.
In view of the Director-General’s circular above referred to,
it may be assumed that a considerable number of cases have
reoeived the larger doses therein recommended, yet the number
of tetanus cases recorded as arising amongst persons to whom
the larger dose had been given is very small. This appears
to suggest that the increased dose is proving effective in
reducing case-incidence ; but, again, statistical information
is not available to render possible a reliable comparison
between the case-incidence in groups of wounded to whom
different prophylactic doses had been given.
Failing such statistical information, an indication was
once more sought in the mortality in groups of cases occur¬
ring after different doses, and the results are shown in
Table V.A. In this table only those cases in which the first
dose had been given within 24 hours are included, as the
varying interval between infection and the prophylactic doses
given at later periods bring in large possibilities of error.
It will be seen that the mortality was highest amongst
those in which no prophylactic dose had been given, and
that it fell steadily as the dose increased.
In order still further to diminish factors of error, it was
decided to exclude those cases which had reoeived a seoond
prophylactic dose before the onset of symptoms. Table V.b.
deals with those cases in which only a single prophylactic
dose had been given within 24 hours of wounding.
Although the figures, especially those referring to the
larger doses, are too small to justify final conclusions, the
information so far available tends to point towards a
favourable influence of the larger prophylactic dose on the
case mortality where tetanus subsequently develops.
The Therapeutic Use of Tetanus Antitoxin.
Of the 376 cases in the present series, all but four, each
of them fatal, were treated with antitoxin, so the tables
now to be discussed deal with 372 cases. We have arranged
our material in Tables VI. to XVI., which correspond to,
and should be compared with, Tables VI. to XVI. of the
previous analysis. As in the previous tables, we employ
the letter T to signify the intrathecal method; V the
intravenous ; S the subcutaneous ; and M the intramuscular.
In comparing Table VI. with the corresponding table of
the previous analysis it will be seen that there has been a
tendency to give larger doses, 195 (or 52 per cent.) receiving
upwards of 20.000 units, as compared with 41 (or 26 per
cent.) in the former series. It will be observed that the case
mortality of the whole series is 66 per cent., a figure which
compares favourably with 73*7 per cent, in the previous
analysis.
In Tables VII. to XI. we have followed the method of
tabulation adopted by Sir William Leishman and Major
Smallman, and for the purpose of facilitating comparison we
have reproduced their figures along with ours. Table VII
shows the total number of ca*es treated by serum (with or
without non-specific treatment), together with the number of
deaths and the case mortality per oent. The table also
shows the number of cases treated by any one of the four
available routes alohe or in combination wi«h one or more of
the three other routes. Tables VIII. to XI. show all cases
treated by the intrathecal, intravenous, subcutaneous, and
intramuscular routes, either alone or in combination with
one or more of the other routes.
It will be seen in Table VII. that the analysis of a larger
number of cases leads to results corresponding closely with
the previous figures. On the whole, however, the difference
between the results of treatment by the several routes tend
to be less marked. Extreme variations from the mean are
only seen in those groups where the total numbers are small.
For instance, the intravenous route still shows a mortality of
100 per cent., but this figure is based on a total of four cases
only.
In Tables VIII. to XI. a notioeable feature is the same
tendency to 1 ‘ levelling up ” observed in Table VII. It would
seem that the larger the number of cases available for com¬
parison the smaller tend to be the differences between the
combinations of the various methods of injection of anti-
tetanic serum. In Table VIII., for instance, the mortality
for the T S.M. combination, formerly 25 per cent., is 585
per cent, for the new series. It is to be noted that the total
mortality for all the administrations in which the intrathecal
route is inoluded falls from 75 per oent. to 68*2 per cent., a
figure not strikingly different from the 66-6 per oent.
mortality in the whole series of cases treated with serum.
The mortality in the oases treated by the intravenous route
and its combinations (Table IX.) falls in the new series to
78*9 per cent., a very small difference which perhaps merely
emphasises the resemblance to previous records. Tins
result is, however, based on such a small number of cases
that no very definite inference can be drawn. The deaths
following the administration of serum by the subcutaneous
route alone rise from 55 per cent, in the previous series to
78*2 per cent, in the cases now under consideration, while
the mortality following the intramuscular route alone moves
in the opposite direction, falling from 75 to 55 per cent.
It is p tssible that the rather high mortality still recorded
after the use of the intrathecal route alone is to be attributed
rather to the selection of this channel in desperate cases,
with a view to giving a last ohance to the patient, than to
any inefficiency connected with this route. It may prove,
however, that the high mortality associated with the intra¬
venous route is significant, although based on small figures,
and it should be mentioned that the only two fatal cases of
anaphylaxis in the series occurred where this route, among
others, was employed. If the figures of the previous series
be added to those of the present it will be seen (Table IX.)
Table VI .—Showing the Total Number of Case* Treated by Serum. ,
The cmm are grouped according to the total dosage, together with the case mortality. The groups are subdivided to show how many oases
fall into each one of the 15 possible combinations.
Dose (in units).
No. of
cases.
Died.
Case
mortality
T. | V.
3. 1 M.
TV.
T.S.
T.M
Method
•i V.8.
s of ad
V.M.
ministration.
S.M. ! T.V.S.
T.V.M.
T.S.M.
V.S.M.
T.V.S. M.
1,001- 5,000 ...
32
30
_ 93 7%,
10 1
10 6
1
3
! —
_
1
-
-
-
-
5,001- 10.000 ...
62
40
76*9°/ 0
5 | -
- 1 8
2
14
14
—
1
3
—
2
3
_
—
10,001- 20,000 ...
93
74
79 - 5 c 7o
6 1 1
5 | 17
3
8
23
1
2
7
4
4
12
—
—
20,0)1- 50,000 ...
113
67
59*2°/ 0
4 j 1 1
4 ; 18
3
11
31
4
—
11
1
6
16
3
60,001-100,000 ...
52
25
480° o
- ! i
4 6
1
2
16
. —
1
3
2
6
6
4
Above 100.000 ...
30
12
40*0%
__ i
— | 5
-
1
15
1 -
—
2
1
2
4
—
—
Totals .
372
2*8
66*6%,
25 | 4
23 | 60
37
102
1 6
4
l"_!
8
20
... L_
7
Four cases received no serum tieat jient; all died—100°/o case mortality.
ThbLayout, 3 COL. 8. L. CUMMINS fcMAJ. H. G. GIBSON : ANALYSIS OF CASES OF TETANUS. [March 1,1919 329
that of 112 cases treated by the intravenous group and its
combinations 89 died, representing a case mortality of 79 4
per cent. Although this high death-rate may be due in part
to the employment of the intravenous route in the severest
Table VII .—Cases Treated by Serum: Deaths and Case
Mortality.
No. of cases.
Methods of
adminis¬
tration.
. Leithman
Case mortality
per cent.*
Lelsbman
and
Present
series.
Lelsbman
and
Sraallman
88
84
100
100
78
55
55
75
78
78'
59
75
66
69
60
100
75
0
63
100
50
85
69
25
90
60
—
100
86
50
330 The Lancet.] COL. S. L. CUMMINS k MAJ. H. G. GIBSON : ANALYSI8 OF CASES OF TETANUS. TMabch 1.1£19
way as to show the fall details of every dose given in the 372
cases. The tables thas correspond to similar ones of the
previous series, with which they should be compared.
It is mt proposed to attempt to analyse these tables in
detail. The m >re the cases are subdivided under seclndary
headings the smaller the groaps become and the lessjustifi
cation do we iind for attempting bo draw conclusions. On
the other hand, taking the records as a whole, the dosage
tends to be decidedly larger in cases that recovered than in
the fatal cases.
This tendency is perhaps still more clearly seen in
Table XV(. where, as in the previous series, the results
obtained by each route individually are compared with those
obtained by the same route in combination with one or more
TABLE XVI .—Comparing and Contracting the Remits Obtained
by Each Route Individually with those Obtained by that
Route m Combination with One or More Others.
£
_ *o
Died.
Recovered.
"
Total caa
treated.
® S Q.
> O J
a
©
II
« o
Case
mortality.
Average
dosage.
_
fi
4 o
>»
ill
\£
a®
SI
4*
| 25
i Uni’s.
1
Units.
1
Units.
Intrathecal route
10.232
22
88
9,968
3
12
12,166
only .
224
Intrathecal embd.
with other routes.
11 742
! t.
148
66
10.219
T.
76
! 34
I 14,707
i T -
Intravenous route
only .
Intravenous embd.
with other routes.
4
31,625
4
i 10 ' 1
31,625
0
0
1
! “
53
16.709
V.
41
! ns ;
i 1
16 725
V.
12
226
j 16.116
V.
Snbc u taneous
23
27,206
18
i 78-2
21,222
5
21-7
■ 48,753
route only .
Suboutaneous
embd with other
routes .
125
12,578
S.
76
; 63-8
i
6.945
S.
49
392
21,316
S.
Intram uscular
60
33,896
33
| 55
28.972
27
45
39.914
route only.
I ntramuscular
embd. with other
routes.
201
29.019
M.
135
1 671 ;
! !
I
12.709
M.
66
l
i
32-8
1
47.228
M.
others. These apparently favourable results, however,
require oloser examination before they can be interpreted as
definite evidence in favour of the value of antitoxin
treatment in tetanus.
An obvious source of "fallacy, capable of vitiating con¬
clusions drawn from such records, is, that the early inter¬
vention of death leads to cessation of treatment and thus
diminishes the total amount of serum given, ia fatal as com¬
pared with favourable cases. In order to eliminate this
source of error as far as possible, an attempt has been made
to evaluate the effect of serum treatment with regard to
the quantity given during the first 43 hours after the appear¬
ance of tetanic symptoms. The results are recorded in a
total of 215 cases as to which the necessary information was
available in our records. These cases are divided into four
classes according to their relative severity, under the follow¬
ing headings: I. General Tetanus with Early Trismus.
II. General Tetanus with Late Trismus. III. General
Tetanus with no Trismus. IV. Local Tetanus. Tni*
differentiation, while perhaps rather slender as between
Glasses I. and II.. affords a general idea of the types of case
under consideration. It is to be noted that in 28 cases
no serum was given during the first 48 hours. The results
of this analysis are set forth in Table XVII.
It will be seen in this table that the actual quantity of
serum given within the first 48 hours was greater in the fatal
cases than in the recovering cases in Classes I. and II. ( the
opposite being the case in Classes III. and IV. The per¬
centage of recoveries was higher amongst the 28 cases
receiving no serum treatment within the first 48 hours than
amongst either of the o'her groups. It mast not be assumed
on this account that the exhibition of anti-tetanic serum
during the early stages of the attack is inadvisable. It is
much more probable that in some of the 28 cases under con¬
sideration the initial symptoms were so slight as to escape
recognition, and that these cases recovered because they
were of a milder type than the others. This apart,
Table XVII. shows clearly the danger of drawing conclusions
from a comparison of the dosage throughout the course of
fatal cases on the one hand and favourable cases on the
other.
A stronger argument in favour of the value of sero-therapy
in tetanus is to be found in Table VI., where a steady fall in
case mortality is seen to accompany a rise in the average
number of antitoxin units given. Bat here again other
factors may be at work, and the gradual improvement in the
early treatment of wounds which has developed with a
ripened experience in war surgery may well play an
important part in decreasing the general severity of tetanus
cases.
General Commentary.
Our analysis of the tetanus case-sheets at our disposal
cannot be said to give any very clear indication as to the
value of antitoxin treatment in tetanus. A steady fall in
case mortality has undoubtedly taken place. Where, how¬
ever, so many factors may have played a part, the greatest
caution should be exercised in attempting to draw definite
conclusions as to how this improvement has been brought
about. It must be admitted that the employment of anti¬
toxin has, up to the present, failed to produce such a striking
improvement as to be at once apparent in statistical records.
Oa the other hand, the dosage has been small.
The union of toxia and antitoxin may be assumed to take
place on quantitative lines. Since we are still ignorant of
the actual quantity of toxin requiring neutralisation in the
average casei we cannot accurately decide whether the
dosage of antitoxin hitherto given has or has not been on
an adequate scale. On theoretical grounds we are inclined
to the opinion that the dosage has not been large enough. It
is possible that more striking results would have been
obtained had larger doses been resorted to.
A point of more importance than any deduction from
docamentary records is the faci that the nse of tetanus anti¬
toxin is gaining ground amongst those charged with the care
of cases. This would appear to indicate that clinical experi¬
ence is leading to a favourable verdict, although statistical
analyses are still inconclusive. It is clear, at least, that no
ill-results follow this tendency to increase the dosage, as the
mortality has fallen synchronously with it. When serum
therapy is employed we are strongly of the opinion that the
antitoxin should be given at the earliest possible moment
and that it should be given in large doses.
Previous Analyses of Cases of Tetanus arising in the B.S.F.
1. Mem irandum on the Treatment of Injures In War published by .
the War Office in 1915. 2. An Analysis of Recent Oases of Tetanus in
the British Expeditionary Force, with Soeolal Kef-rence to their
Treatment bv Antitoxin, by Colonel Sir William B. Leishmm C.B..
F.B.S., and Major A. B. Small man, D S.O., The Lancet, Jan. 27 tb, 1917.
Analyses of Cases of Tetanus in England.
1. Analysis of OasAs Treated m Home Military Hospitals from Auvust.
1914. to August. 19L5, by Surgeon-General Sir David Bruce, O.B..
F.R.S., Brie. Med. Jour., Oct. 23rd, 1915. 2. Ad Analysis of Cases of
Table XVII. — Effect of Serum Treatment with Regard to the Size of the Dosage During First 48 Hours after the Appearance
of Tetanic Symptoms on Four Classes of the Disease . f
-
Class I.
Class II.
Class III. Ulass JsV.
No. of
cases.
Case
mortality.
No. of
ca^ea.
Case
mortality.
No. of
C'»es.
Case
mortality.
No. of : f Case
oases. 1 J mortality.
Fatal oa«es.
Recovered.
Owe. t«*ted with ..ram j
Cases receiving no serum i Fatal ...
daring first 48 hoars ...) Recovered
1°2
42
98
35
4
7
\ 70-8 % |
£ 73-82 {
\ 363Z |
53
22
46
18
7
4
\ 70-62 \
j- 71-82 j
^ 63-62 {
13
10
12
8
1
2
}■ 56-52 ^
^6002 {
[ 33-32 |
B9
\ 8-62
} 10-OX
J Sil.
Average number of units per case |
during first 48 hours.)
Died.
14,986
Recovered.
14,175
Died.
16,738
Recovered.
11,847
Died.
21,000
Recovered.
23,212
Died /
ll i i
Beenrered.
14,527
The Lanoit,] MAJ.-GEN. SIR DAVID BRUCE: ANALYSES OF CASES OF TETANUS. fMARCH 1, 1919 331
Tetanus Treated In Home Military Hospitals from August 1st, 1915, to
July 31st, 1916 bv Surgeon-General Sir David Bruce. C.B , F.K.S.,
The Lancet, Dec. 2nd, 1916. 3. An Analysis of Cases of Tetanus Treated
in Home Military Hospita's during August. September, and part of
October, 1916, bv Surgeon-General Sir David Bruce. C.B., F. R.S .,
The Lancet. June 30th, 1917. 4. An An dysis of Cases of Tetanus Treated
In Home Military Hospitals during part of October, November, and
part of December, 1916. by Surgeon-General Sir D*vld Bruce. C.B.,
F.R.S . The Lancet, Sep»\ 15th, 1917. 5 An Analysis of Cases of
Tetanus Treated In H«»me Military Hospitals during part of December.
1916, all January, February, and part of M*rch, 1917, by Surgeon
General Sir David Bruce, C.B., F.R.S.. The Lancet, Dec. 22nd, 1917.
SUMMARY OF SIXTH, SEVENTH, EIGHTH, AND
NINTH ANALYSES OF
CASES OF TETANUS TREATED IN HOME
MILITARY HOSPITALS
FROM MARCH, 1917, TO APRIL, 1918.
By Sir DAVID BRUCE, K.C.B., F.R S., F.R.C.P.,
MA.TOR-OKNh.RAL, ARMY MEDICAL SERVICE.
Five analyses of cases of tetanus treated in home hospitals
have been published in The Lancet. 1 The four further
analyses, each of 100 cases, here summarised cover periods
from March to June, 1917, June to September, 1917.
September to December, 1917, and December, 1917, to
April, 1918.
The Distribution of Cates of Tetanus from August , 1914, t°
April , 1918.
The number of cases of tetanus dealt with in the nine
analyses and the rate of mortality are given in Table I.
Table I.
Analyses.
No. of cases.
Recovered.
Died.
Mortality.
1914-15 .
231
98
133
i
1915-16 ..
195
99
96
49
Aug.-Oct., 1916 .
200
127
73
37
Oct.-Doc., ,, .
100
69
31
31
Dec.. 1916. to March, 1917
100
81
19
19
March-June, 1917.
100
71
29
29
June-Sept., „ .
100
85
15
15
Sept.-Dec., „ .
100
84
16
16
Dec.. 1917, to April, 1918
100
76
24
24
Total..
1226
790
436
35-5
Diagram 1 merely represents the number of cases of
tetanus which have been treated in home military hospitals
since the beginning of the war. They are taken from the
date of wound, cases from the date of the onset of the
• Diagram 1.
CASES or TETANUS by MONTHS DATC Of WOUND.
rr,,,', w
i 8i»
m ■ ■_
liil
sfSftj
fi
it! l 4~H~rh
r~| j t j-ffH
ry { | | I |
i
-44-M
ip
fp|§9
TrrnTnTrf
zjfFm
: .
^aXIi!
I
1
■sflen
JUPcj
=ntt |[|l
n.iiiiiiii
§
disease being shown in Diagram 2. The figures have no
relation to the number of wounded or the number of troops
engaged. The diagram shows periods of activity and
inactivity in the fighting line.
Diagram 2.
CASES OF TETANUS BY MONTHS FROM DATE OF ONSET Or DISEASE. 1 *' i
from date of wound, not from onset of disease. The abrupt
fall in the ratio in November, 1914. is due to the introduc¬
tion of prophylactic injections of antitoxin, which took
place about the middle of October.
Incubation Period.
Table II. shows the relation between percentage mortality
rates and incubation period in the various analyses.
Table II.
Incubation period.
I.
ii.
III
IV
V. 'VI '
VII.
VIII.
IX.
10 days and under.
| 66
82
42
83
40 35
27
46
11 to 24 days .
39
52
37
30
25 34
29
21
25 days and upwards ...
H
27
25 |
16
14 21
7
H
Table III. gives the average leDgth of incubation of cases
of tetanus treated in home military hospitals from August,
1914, to April, 1918.
Table IV. gives the number, in percentage of cases, with
short, medium, and long incnbation periods which have
occurred since the beginning of the war to April, 1918.
Table III. Table IV.
Analyses.
No. o»
cates.
Average
incubation
To 10 11 to 22
days. days.
More than
22 days.
1914-15 .
231
Dats.
13
P /o
47
°/o
46
0/ ^
1915-16 .
195
31
16
49
36
Aug.-Oct., 1916.
200
31
14
44
42
Oct.-Dec., ,, .
100
45
13
27
61
Dec., 1916, to March, 1917
100
67
10
21
69
March-June, 1917 .
100
44
20
34
46
June-Sept., „ .
100
56
15
24
61
Sept.-Dee., „ .
100
47
13
31
56
Dec., 1917, to April. 1918
100
47
26
29
45
Types of Tetanus: General and Looal.
The Ratio of the Number of Cases of Tetanus to the Number
of Wounded Soldiers.
Diagram 3 represents the ratio of cases of tetanus to the
number of wounded soldiers treated in home military hos¬
pitals from August. 1914, to April, 1918. They are reckoned
1 0) Thr Lanckt. Got. 23rd, 1915: (2) Dec. 2nd, 1916; (3) Juno 30th,
1917 ; (4) Sept. 15th, 1917; (5) Dec. 22nd, 1917.
In the first six analyses the proportion of local tetanus to
general tetanus was only given. In the seventh, eighth, and
ninth analyses a more detailed classification is attempted.
In the sixth analysis there were 80 cases of general and
20 cases of local tetanus with a rate of mortality in the
former of 36 2 per cent. There were no deaths among the
local cases. In the seventh, eighth, and ninth analyses there
were 223 cases of general and 77 cases of local tetanus. The
;*32 Thk Lancet,] MAJ.-GBN. SIK DAVID DRUCE: ANALYSES OF CASES OF TETANUS. [March 1, 1919
rate of mortality in the former was 25 per cent., in the latter
there were no deaths. (Table V.)
Table V.
—
Cases
J
; «
■g
5
5 S
(a) Trismus the earliest Bymptom—
1. With complete closure of jaws developing (
within 24 hours after onset of symptoms ... f
17
7 1
10
59
2. With complete closure of jawB developing [
alter 24 hours.j
19
14
•
5
! 26
3. With incomplete closure of jaws .
HI
85
26
23
(b) Trismus occurring after other symptoms of (
tetanus have shown themselves. \
57
46
11
19
(r) General tetanus without trismus.
19
16
3
16
(d) Local tetanus.
77
77
o 1
0
Position of Wounds icith Reference to Mortality.
Table VI. shows the position of wounds and the mortality
rates per cent, in the third to ninth analyses.
Table VI.
Position of wounds.
III.
| IV.
V.
VI.
VII.
VIII.
| IX.
Body .
32
37
20
18
18
D
Limbs .
68
27
17
36
13
H
The Effect of Fractures.
Table VII. shows the effect of fractures on the rate of
mortality in cases of tetanus in the last fouj* analyses.
Table VII.
Wounds.
1
No of cases.
' Recovered.
Died.
Mortality.
Fractures.
157
119
38
20-4%
No fractures ...
243
197
46
190%
Tetanus Occurring after Operative Treatment of the Wound.
In the fonr analyses there were 37 cases with 11 deaths, a
mortality of 30 per cent. In three cases the prophylactic
inoculation of antitetanic serum was reported to have been
given before the operation, and in one case the prophylactic
injection was only given on the day of the operation.
Prophylactic Treatment of Tetanus by Antitetanic Serum.
Table VIII. shows the rates of mortality per cent, np to
April, 1918, in those who received and those who did not
receive prophylactic injections.
Table VIII.
Prophylactic
injections.
1914 to 1915.
1915 to 1916. 1
o'
Oco
be—«
3
Oct -Dec.,
1916.
Dec., 1916,
to
March, 1917.
March-June, I
1917.
June-Sept.,
1917,
Bept -Dec.,
1917. j
Dec., 1917. to
April, 1918.
Received ...
51
43
27
16
1 18
27
11
16
22
Not recorded
41
52 1
45
41
15
45
33
60
None given .
63
56
L 55 .
65
29
20
1 57
14
50
Table IX.
No. of]
cases.;
Inoculated.
Recovered.
Died.
I Mor-
| tality.
264 i
On day of wound.
215
49
1 18%
62
1 day after wound.
48
14
! 22%
14
2 days after wound.
12
2
14%
5
3 ii «i
4
1
| 20%
7
4
5
2
30%
8
More than 4 days after wound.
8
0
1 °
1
Table IX gives all the available information in regard to the
question what influence, if any, has promptitude in giving
these prophylactic injections on the rate of mortality.
The figures relate to the sixth, seventh, eighth, and ninth
analyses.
On the result obtained from multiple jrrnphylaotic injec¬
tions. —The Tetanus Committee of the War Office have
advised that four prophylactic injections should be given to
every wounded soldier at intervals of seven days. Table X.
represents (for the last four analyses) the rate of mortality
of cases of tetanus which have received one to six
prophylactic injections.
Table X.
No. of inoc ulations.
No. of cases.
Recovered.
Died.
Mortality.
Received 1 ..
125
94
31
1
„ 2 ..
127
103
24
19
3 ..
52
43
9
19
4 ..
...
38
35
3
8
5 ..
14
13
1
7
6 ..
... |
2
2
_
0
Table XI. gives the results of none or more inoculations on
the period of incubation.
Table XI.
No. of
inocula¬
tions.
6th hundred.
7th hundred.
8th hundred.
9th hundred.
No. of
cases.
Average
incuba¬
tion
poriod.
No. of
cases.
Average
incuba
tlon
period.
1
No. of
cases.
Average
incuba¬
tion
period.
No. of
caseB
Average
incuba¬
tion
period.
0
_
days.
days.
7
davs.
83
2
1
38
45
36
47
25
28
27
22
2
31
49
31
66
33
30
31
23
3
10
39
15
62
13
62
14
56
4
2
127
5 !
60
: 16
70
15
111
5
2
97
2
79
3
94
6
134
6
1
63
1
122
I_
: —
—
—
—
Therapeutic or Curative Treatment.
All the 400 cases under review received therapeutic treat¬
ment with antitetanic serum. Of these 316 recovered.
84 died, giving a rate of mortality of 21 per cent.
Route of injection. —The Tetanus Committee in their
memorandum are of opinion “ that in acute general tetanus
the best method of treatment lies in the earliest possible
administration of large doses of antitoxin by the intrathecal
route. ”
Influence of dosage. —Table XII. shows the influence of
dosage on the curative action of antitetanic serum in the
400 cases.
Table XII.
(A) Total quantity of antitoxin given during the attack.
(B) Daily quantity of antitoxin given.
(A) (B)
L .
o g
Units received. | £ S
jfc s
Re¬
covered
Mor-
D,ed t*iit*.
1
o g
6 S
4 «-
I Re¬
covered
Died.
Mor¬
tality.
1,000
or
„ 1
under
i
l ;
0,
S
5
5
0
$
1,001
to
5,000 ,
10
10
o i
0
70
62
8
11
5,001
M
10,000 j
19
12
: 7 1
37
131 J
120
11
8
10,001
• «
15,000 |
23
! 20
13
74
14
19
15,001
It
20,000 |
10
‘ 9
1
10
46
1 34
12
26
20,001
M
30,000 !
43
26
17
39
46
21
25
54
30,001
»t
40,000
47.
! 37
io:
21
19
9
47
40,001
It
60,000
61
; 41
20
33
7
3
4
57
60.001
II
100,000
93
i 73
17
19
2
1
1
50
100,001
upwards
96
j 87
1 9 ,
9
1
Royal National Orthopedic Hospital.—
Arrangements are being made for the establishment of
a country branch for this hospital as well as for the enlarge
ment of the present buildings.
Thb Lancrt,]
SIR W. ARBOTHNOT LANK: OHRONIO INTESTINAL 8 TA 8 IS. [March 1,1919 333
CHRONIC INTESTINAL STASIS:
WHAT ABB THB INDICATIONS FOB OPBBATIVB
Xntbbfbbbnob?
Bt Sir W. ARBUTHNOT LANK, Bart., M.S., F.R.C.S.,
OOMSULTLSQhBITBQKOH. out's hospital, ktc.
* ‘‘S , -
In order to answer (his question correctly it is necessary
to have a thorough grasp of what intestinal stasis is and of
the relative importance of its causal factors and of its end-
results. These have been described so fulJy in previous
publications that no repetition is required at the present
time 1 gave a general sketch of the causal factors in my
discourse at the Social Evening of the Royal Society of
Medicine on Feb. 12th, indicating biiefly the origin of intes¬
tinal stasis in faulty training of the evacuating mechanism
in childhood, the progressive results of loading of the
alimentary canal from the lower end upwards, and the
relatively little harm produced until stasis reaches as high
as the ileo-rascal valve.
In the vast proportion of oas*s of intestinal stasis no
question of operation arises. The administration of paraffin
before meals, the use of a Ourtis belt, the assumption of
the recumbent posture at intervals, careful dieting, and the
employment of such drugs as relieve the symptoms of
hyperacidity, Ico., will usually afford the patient oomplete
relief.
Operation te Remove Obstruction Canted by Appendim or
Heal Kink.
The next group comprises those cases In which gastro¬
duodenal distension is clearly due to a damming back of the
ileal contents by the pressure exerted by a 44 controlling
appendix ” or by an 44 ileal kink.” Tlfe interference exerted
by these structures may be greater than can be met by the
simple treatment just described. Its degree can be deter¬
mined from the appearance presented by the patient, by the
history of the case, from the pain elicited on pressure on the
inflamed and hypertrophied end of the ileum, and from the
X ray findings.
The utility of a complete report on the passage of a
bismuth meal by a competent radiographer who is experi¬
enced in this work cannot be exaggerated. It is futile to
expect the surgeon to obtain much useful information from
a series of radiograms, however good, taken at intervals.
By far the most valuable portion of the information afforded
by the skilled radiographer is obtained by means of screen
work. Unless he is thoroughly familiar with the mechanical
conditions which exist in stasis, which he can only learn by
observing them frequently at the time of operation, the
services of a radiographer are of little value to the surgeon.
Simple treatment having failed in these cases recourse
must be had to operation. The removal of the anchored
appendix or the freeing of the ileal kink is usually sufficient
to liberate the duodeno-jejunal junction from the excessive
strain which is responsible for the partial or complete
occlusion of its lumen. It is well to remember that the
membrane which pr. duces the ileal kink when well
developed appears to contain lymphatics and that these
lymphatics drain what is always the most infected portion
of the ileum. Therefore, after the acquired band has been
dealt with by careful separation from the mesentery and by
accurate app sition of any torn peritoneal edges, a drainage-
tube should be left in for two or three days. This simple
precaution may t>e the means of saving the patient from
disaster. One must remember that the kiDk tends to re form
if the factors which produce it remain in action.
Should the symptoms or the X ray report suggest the
presence of any obstruction elsewhere, and especially at the
44 la8t kink,” it should be operated on at the same time.
Gastro-enterostomy.
The next question to consider is. What are the conditions
requiring gastro-enterostomy? When a peptic ulcer is
present in the stomach or duodenum, or in both, gastro¬
enterostomy should be performed, and in the case of gastric
ulcer it should be excised, if it seems advisable, or otherwise
dealt with to ensure its cure. When the stomach and
duodenum are dilated and the latter obstructed by such a
degree of kinking at the duodeno-jejunal junction that no
freeing of the stasis in the lower bowel is likely to be
sufficient to overcome this angulation, and as these con¬
stitute antecedent changes in a sequence which ends in
peptic ulceration and, Anally, in cancer, a gastro-enterostomy
should be performed.
Many are satisfied to regard peptic ulcers as primary con¬
ditions and to treat them by gastro-enterostomy with or
without excision, gastro-enterostomy not being performed
unless an nicer is present. Much thought has been given to
the best method of performing this operation, to the form
of suture to be used, and to the advisability of occluding the
pylorus temporarily or permanently. An ulcer of the
stomach or duodenum merely suggests to the mind of the
surgeon an operation on the stomach and nothing more. It
is obvious that while gastro-enterostomy at once relieves
the patient from the mechanical consequences of the
obstruction to the duodeno-jejunal junction and from muoh
of the pain and risk which they involve it has no effect
whatever on the causal factor—namely, the control of the
ileal effluent—while any pre-existing auto-intoxication
remains uninfluenced by the surgical procedure.
To limit the operation to establishing a communication
between the stomach and jejunum in peptic ulceration is,
therefore, obviously unscientific, since the patient derives
only partial benefit from it. The end of the ileum should
be carefully examined and any obstruction removed, the
44 last kink” should be dealt with if it is exerting any
abnormal control, as is usually the case in these conditions,
and any other locality where delay has been shown to exist
investigated and treated. To effect this a more extensive
incision than is usually made is necessary. A very popular
weakness of the surgeon is to do his work through a small
opening, and this is largely responsible for his frequent
failures to understand the conditions he is dealing with M
to benefit his patient. This is well illustrated by what might
be called the buttonhole operation for appendioectomy.
By carefully observing-the form and functioning of the
stomach and duodenum, both radiologically and at the
time of the operation, and by gauging the effect of traction
on the dnodeno-jejunal junction, the surgeon should be able
to decide as to whether a gastro-enterostomy is required or
whether he should cot floe himself to dealing with the con¬
ditions whioh are controlling the intestine lower in the tract.
How little the meohanical causation of peptic ulcers is
understood is illustrated by an operation called gastro-
duodenostomy, in whioh in cases of pyloric obstruction a
communication is established between the stomach and a
distended duodenum, which, as it is distended, must neces¬
sarily be obstructed at the duodeno-jejunal junction.
In the case of cholecystitis, with or without gall-stones, in
which an operation is required the primary cause of infection
in the intestinal canal should be as carefully investigated as
in any other end-result ot ehronio intestinal stasis.
Colectomy.
Finally comes the question. What are the conditions which
call for colectomy? In st^ch conditions as extreme con¬
stipation in which an evacuation can be obtained only at
intervals and with great difficulty and pain ; rapid and pro¬
gressive wasting ; mental depression which may be so great
at times as to make life intolerable both to the individual
and the relations, not infrequently driving the patient to
attempt suicide as the only escape from insufferable misery ;
total inability to lead an aotive life ; a distressing absence
of sexual desire leading to constant broils 1 ; progressive
degenerative changes in the breasts of those with marked
family history of cancer, toxic changes in the heart and
circulation, and all secondary conditions such as rheumatoid
arthritis, Raynaud’s disease. Still’s disease, many forms of
tubercle, Bright's disease, Addison’s disease: in these and
many other conditions colectomy offers the only hope of
oure.
By colectomy I mean the oomplete removal of the large
bowel with the exception of a sufficient length of the pelvic
colon to establish continuity. About twenty years ago I
satisfied myself that the removal of the caecum, ascending
and part of the transverse colon rarely served a useful
purpose, since the splenic flexure, last kink, and elongated
pelvic colon still continued to control the effluent
Should no complication arise such as the development of
adhesions which interfere with the normal functions of
1 A paper by McCarrlson “ The Pathogenesis of Deficiency Disease,”
an abstract of which is published in the British Medics' Journal,
Feb. 15th, 1919, has an interesting and important bearing on this subject.
334 Thb Lancet,]
MR. JAMBS B. MAC ALPINE: WHBELHOUSE’3 OPERATION.
[March 1,1919
tbe intestine, a condition which may follow any intra-
abdominal operation, the health of the patient improves at
once in a marvellous manner. Perhaps no alteration is
more marked than the change in the mental state of the
patient, showing how dependent the functioning • of the
brain is upon that of the intestine. The most miserable and
wretched woman becomes happy, gay, and lively. The other
symptoms .clear up with remarkable rapidity.
The delay in the small intestine as shown by X rays
affords a general indication as to the extent of the surgical
interference necessary, but it is well to remember that the
degrees of auto-intoxication and of the delay do not neces¬
sarily correspond, for the reason that a moderate amount of
stasis may be associated with a very virulent infection, while
the reverse may be the case. The surgeon must be guided
very largely by the severity of the symptoms manifested by
the patient. Much must be left to his experience and
instinct. A very long pelvic colon associated with much
sepsis always calls for colectomy, while a very large, pro¬
lapsed, and twisted caecum can practically be dealt with in
no other way. Tbe surgeon will find that he will frequently
wish that he had performed a coleotomy instead of some
lesser operation, but if he had performed a colectomy in the
first place he will rarely, if ever, regret that he had done so.
It is difficult, if not impossible, to answer the question
forming the title of this paper more definitely than has been
done here. The vast majority of colectomies are performed
for auto-intoxication and its results and not for the
mechanical effects of stasis. In many cases of colitis the
only effectual treatment consists in the removal of the large
intestine. It is well to remember that in ulcerative colitis
the process may extend for a distance up the ileum, and
that the ulcerated segment of small intestine Bhould be
removed. The pelvic colon is also ulcerated in many cases.
This necessitates the subsequent treatment of the residual
ulceration by means of vaccines, &c.
The operative treatment of diverticulitis and of canoer of
the large bowel calls for no special reference, beyond the
statement that in a certain proportion of cases, especially in
acute obstruction, it is safer and easier to remove the whole
of the large bowel above the pelvic brim than it is a portion
of it, while the health of the patient is benefited to a much
greater extent by the more extensive operation, and the risk
of recurrence is minimised.
Gavendikh-sqnare, W.
WHEELHOUSE’S OPERATION :
SOME POINTS WHICH ASSIST IN ITS PERFORMANCE.
By JAMES B. MACALPINE, M.B. Mangh., F.RC.S. Eng.,
HONOR%RY SURGEON, AND SURGRON Df CHARGE OF GENITO-VRINARY
DEPARTMENT, SALFORD ROYAL HOSPITAL; VISITING SURGEON,
MANCHESTER BOARD OF GUARDIANS, ETC.
Mr. Wheelhouse first described his operation in 1876. 1 It
was designed to deal with strictures through which a filiform
bougie could not be passed, yet without retention of urine.
Those through which a filiform bougie can be passed are
suitable for dilatation or internal urethrotomy. Those
associated with retention of urine are best treated by Cook’s
operation. But for the type under consideration Wheel-
house’s operation is generally chosen. Yet it is often a diffi¬
cult and tedious procedure, and not infrequently has to be
supplemented by other methods. In order to surmount this
difficulty I am putting forward certain methods which I have
adopted in my own practice, and which I believe will be of
service to others. The probability of success is increased
if Wbeelhouse’s instructions are closely followed as regards
the position at which the urethra should be opened in
reference to the stricture—namely, “in the groove of the
staff, not upon its point, so as certainly to secure a quarter
of an inch of healthy tube immediately in front of the
stricture. ” When the opening in the urethra is held open
there is a cone-shaped portion of urethra, leading to the
face of the stricture, at the apex of which the orifice of the
stricture should be seen. This, however, is the point at
which the operation frequently fails. The orifice can neither
be seen, nor discovered by means of a probe. It is interesting
to read Wneelhouse’s original account of the operation, and
to contrast it with the difficulties mentioned by subsequent
Authors.* 7
Causes of Difficulty.
The causes of difficulty wi\l now be considered.
1. Position. —The position in which the operation is per¬
formed is inconvenient. In operations on the perineum it
is customary to tilt the buttocks slightly, to bring them
nearer to the horizontal, but, broadly speaking, it may be
asserted that the wound occupies a vertical position, that
such instruments as retractors and pressure forceps occupy
the constant attention of an assistant, or will fall into incon¬
venient positions, whilst haemorrhage from the wound tends
to trickle vertically down the same. The position of the
operator is awkward and constrained.
2. The condition of the open inn .—In the practice of one
experienced in the technique of urethral instrumentation
only very tight strictures, will be submitted to this opera¬
tion, and many such strictures whose lumen could not be
found by the passing of bougies will prove to be undiscover-
able even when an attempt is made to pass a filiform or a
probe under the direction of the eye. The orifice of
numerous glands in the neighbourhood, or the openings of
false passages may mislead, whilst the true opening is not
infrequently concealed by oedematous granulations.
3. Hannorrhage.— This arises chiefly from the corpus
spongiosum, through which the incision passes. This body
consists of cavernous tissue. This accounts for the difficulty
often experienced in obtaining a dry field for operation, for
it is often impossible to ascertain the position of thearteiw
itself unless actually spouting, and to place clamps on the
cavernous tissue is obviously futile. Oozing tends to be
continuous and very disconcerting to tbe surgeon. More¬
over, it must be remembered that the slightest trickling of
blood is sufficient to obscure the opening of the stricture.
These, then, are the factors which, bo my mind, make
Wheelhouse’s operation in many cases a difficult and tedious
prdoeeding.
Procedure if Wheelhouse'% Method Fails.
In the event of the operation failing the following possi¬
bilities are presentedPfor choice: (I) Dissection of the
perineum, in order to find the urethra proximal to the
8triotnre; (2) suprapubic cystotomy and retrograde catheteri¬
sation ; (3) Co.ck’s operation.
Of these, Cock's operation may be summarily dismissed.
It was introduced by its author as a method of treatment
of cases in which retention is complete—in which, there¬
fore, to use Cock’s own words 2 —and these are of the essence
of the operation: “the urethra is distended and enlarged
between the prostate and tbe stricture.” It is almost
certain to fail where the urine can be passed, as in the
oases for which Wheel house’s operation is suitable, and io
which, therefore, there is no distension of the nrethra.
Dissection of the perineum behind the stricture .—The only
position in the urethra at which it is necessary to do
Wheelhouse’s operation is the bulb. Tne majority of
BtrictureB occur in this structure—Thompson gives 67%/*
Young 70%. 4 If strictures occur in front of this point,
Wheelhouse’s technique is unnecessary because the urethra
is easily found proximal and distal to tbe stricture.
Fig. 1 shows: 1. That there is a very abort length of
urethra between the site of the stricture and the triangular
to the ligament.
ligament. Sometimes, indeed, the stricture will oocur just
at the point where the urethra emerges from the triangular
ligament. 2. That the urethra makes a bend at this point,
so that the direction of that small portion of the urethra
which lies between tbe stricture and the triangular ligament
will be at right angles to the directipn of the penile urethra,
and therefore passing directly away from the surgeon.
These facts account for the trouble which is often experi¬
enced in finding the urethra proximal to the stricture, unless
Thh Lanott,]
MR. JAMES B. MACALPINE: WHEELHOUSES OPERATION.
[March 1, 1919 335
indeed one incises the triangular ligament and searches for
it behiDd that structure. To obviate the difficulty Young*
has recommended that a more posterior point be sought,
as being easier to find. He sets himself therefore,
deliberately, from the beginning of the operation to incise
the perineal muscles down to the membranous urethra, to
cut this and pass aguide from behind forwards to the stricture.
This is certainly a deliberate and purposeful operation, but
it involves injury to a very important muscle, the com¬
pressor urethrae, and a very deep dissection in the perineum.
The awkward position and hamiorrhage continue to annoy
the surgeon, and render the dissection difficult in this as in
previous stages of the operation.
Suprapubic cystotomy with retrograde catheterisation is an
admission of failure to find the proximal urethra, and will
only be undertaken if dissection of the perineum fails.
It will be seen that in the event of Wheelhouse’s operation
failing the advisable recourse is to a dissection of the
perineum, but that this may be a difficult procedure.
Suggestions to Rectify the above Difficulties.
To bring the perineum into the true horizontal position
and to fix it there steadily is the first necessity. To achieve
this I resolved to adopt the Trendelenburg attitude.
When this position is used in operations upon the pelvis
the tendency of the body to gravitate to the head end of the
1. The surgeon can stand to his work and the usual con¬
strained position gives place to one of comfort.
2. The light falls directly on to the surface of the wound, a
very important point.
3. As the operation area is in the horizontal position,
instruments can rest on the sides of the incision just as
they do around an abdominal wound. The advantages of
this are very obvious. Amongst others it frees the assistant's
hands for other work than supporting instruments and allows
the surgeon to proceed systematically with the operation.
4. The perineum occupies a position higher than that of
any other part of the trunk. I have found that the venous
sinuses of the pelvis and perineum, including the corpus
spongiosum, are thereby emptied, and that bleeding is much
less in quantity and easier to control. I should like to lay
emphasis on this important point. The field of operation is
much drier and easier to worn upon.
5. The patient is held very steadily, an item which surgeons
themselves will fully appreciate.
6. The assistant obtains a much more direct view of the
field of operation.
I have found these advantages to be very real and
increase the comfort and facility of the operation very
considerably.
The difficulty of finding the proximal urethra I have
endeavoured to get over by staining with methylene-blue.
Fig. 2.—Table, showing metal band and uprights in position.
table is counteracted in two ways : 1. By the shoulder rests
2. By bending the knees and fastening the legs over the foot
end of the table. It is obvious that the second method
cannot be used when the perineum is to be operated upon,
and further that the shoulders cannot be expected to bear
the full weight of the body. If they were called upon to do
so a brachial nerve tear would almost certainly result. Some
other support had, therefore, to be found, and I resolved to
utilise the iliac crests. For this purpose Messrs. Down Bros,
have made to my specification a pelvic rest (Fig. 2).
It consists of two curved metal uprights, which are
supported by a metal band and slide in slots to accommo¬
date themselves to the breadth of the patient. They are
fixed by thumb-screws. The band passes across the table
and is rigidly screwed to it. When in use the uprights are
adjusted so as to fit the iliac crests closely, a pad of cotton¬
wool alone intervening. The position on the table is so
arranged that the buttocks protrude slightly over the end.
When the feet have been fastened to the leg-rests the table
may be tilted, the patient being held rigidly in position by
the rests. It will be observed (Fig. 3) that tue feet are
attached to the outer side of the rests in order to render the
perineum more accessible.
The advantages which accrue from this position are
considerable and various.
Fig. 3 — Patient in position prior to spreading of towels, Ac.
I 11 practice it will be found convenient to work with the table
more tilted than is indicated.
This is done half an hour previous to the operation. An
ordinary urethral syringe is filled with methylene-blue, and
the total contents are emptied into the urethra. An average
anterior urethra holds about 10 to 12 c.cm.. which is the
capacity of an urethral syringe. The meatus is compressed
with finger and thumb, and the blue is milked back in order
to make certain that it has passed the .stricture and reached
the urethra proximal to the stricture. The patient com¬
presses the meatus for ten minutes to ensure that the
urethra is well stained. When he lets it go a certain amount
of stain will be expelled. It is well not to stain the passage
at too short an interval before operation, as the result would
be that when the urethra was opened free liquid methylene-
blue would escape into the wound and defeat its purpose.
The patient is not allowed to pass urine for one and a half
hours before going to the theatre.
By this means I have found that the urethra behind the
stricture is much more easily identified, and on several
occasions I have been able to trace the course of a sinuous
stricture through the surrounding scar. The assistance
given saves times and needless damage to the tissue of the
bulb by dissection.
I have nothing of interest to say concerning the stages of
the operation itself except that I believe I am enabled to do
it by more definite and deliberate steps than is usual.
386 Ths LlNORT.] DR. J. S. B. STOPFORD: GUNSHOT INJURIES OF CERVICAL NERVE ROOT8. f March 1/1919
Thus the original incision is deepened till the ejaonlator
nrinae is reached. The median raphe of this structure is
easily observed and the inoision now takes advantage of
that bloodless line to the extent of about two inches. Eaoh
portion of the musole should now be completely elevated
from the bulb, so that the extent of that structure is exposed
in the wound. By this means the opportunities of the
surgeon for successful orientation are materially increased.
If when the urethra is opened I am not successful in
quiokly finding the opening into the strioture mouth I do not
continue the search, but look for the stained urethra behind
the stricture. This is generally mor6 easily found and the
operation quickly completed in the usual manner.
The sphere of usefulness of the position which I have
represented is not limited to Wheel house’s operation, but
may be extended to many other procedures on the perineum,
anus, rectum, vesicles, prostate, Ac. I myself have so
employed it in a few instances. For two cases especially,
in which strictures were excised, I found it invaluable.
I am indebted to Mr. Ghosh, the resident surgical officer at
the Salford Royal Hospital, who has kindly prepared the
photographs for Figs. 2 and 3.
References.— 1. Wheelhouse: Brit. Med. Joan, June 24th, 1876.
2. Cook: Guy’s Hospital Reports, 1866, xil., 267. 3. Young; Johns
Hopkins Hoap. Reporta. 1906; The Treatment of Impermeable stric¬
ture of the Urethra. 4. Young: Ibid., The Tre«tment of Stricture of
the Urethra. 5. Sir Henry Thompson : The Pathology and Treatment
of Strioture of the Urethra and Urinary Fistula. 1885. 6. Jacobson and
Rowlands: The Operations of Surgery, fif < h edition , p . 694. 7. Cheyne
and Burg bard: Manual of Surgical Treatment, v., 387.
Manchester. _
GUNSHOT INJURIES OP THE CERVICAL
NERVE ROOTS.
Bt JOHN S. B. STOPFORD, M.D. Manoh.,
lecturer ui anatomy, university op Manchester.
(Report to the Medical Research Committee .)
Injuries of the oervical nerve roots form only a small
proportion of peripheral nerve lesions, but their recognition
is often difficult as they are liable to be confused with
injuries of the brachial plexus or spinal cord.
Although a vast amount of literature has been published
daring the last four years dealing with the various aspects of
gunshot injuries of the brachial plexus, oauda equina, and
peripheral nervous system in general, very scanty attention
has been directed to lesions of the cervical nerve roots.
From a careful study it appears that the pathological changes
are somewhat different from those seen in injuries of
peripheral nerves in other situations ; and it is dear, from
observations taken over long periods, that the prognosis is
wonderfully good and that surgical interference is not
required.
It is most convenient to subdivide the cases into two
groups, according as to whether or not there is an associated
lesion of the spinal cord.
1 . Injuries of the Cervical Roots Uncomplicated by any Cross
Lesion of the Spinal Cord.
Case 1.—Patient wu wounded March 9th, 1918, the bullet entering
immediately below the chin and passing out through the left aterao-
mastold muscles three inches below the mastoid process. There was
immediate loss of power In the left upper extremity, but the patient
was able to walk back some distance to reoeive medical attention.
Within a week he began to suffer from a burning pain In the tbnmb.
Voluntary power began to return gradually at the wrist and finger-
joints in about six weeks.
When examined In July the pain in the thumb was constant and
severe, especially when the hand got hot. but there was excellent
voluntary movement of the wrist and fingers. The sptnati were com¬
pletely paralysed, and there was only the feeblest voluntary •• flicker"
In the deltoid, bleeps, and brachlalis antlcus, whilst the triceps and
supinator lungns were both markedly paretic. No objective s* nsory
disturbance could be found. There was no loss of power or anaesthesia
In the lower extremities, and the reflexes were normal, except that the
knee-jerk on the left side was more active than on the right.
During the next month the deltoid, biceps, brachlalis antlcus, triceps,
and supinator longus Improved considerably, but no evidence of any
return of voluntary movement in the sptnati was noticed until the
latter end of September, by which time all the other muscles men¬
tioned, except the deltoid, bad regained practically full power. At
this time no difference in the reflexes on the two sides oould be found.
About this time the pain in the thumb abated considerably, and daring
the early part of October disappeared.
On examination early In November power was perfectly restored in
the biceps, brachlalis antlcus, and triceps, bnt the patient was only able
to abduct the arm to a right angle. The delto d and splnati are still
Improving, and in eight months the functional recovery has been
remarkably good.
It is clear that the fifth ami sixth roots had suffered chiefly
in this patient. The dissociation between the motor and
sensory symptoms is of considerable diagnostic value, since
implication of the upper trunk of the brachial plexus
might have caused a paralysis of similar distribution, but
there would almost inevitably have been more profound
sensory manifestation’s. The following report shows a more
marked dissociation.
Case 2.—Patient received a gunshot wound on August 25th, 1918;
the missile entered juat to the right aide of i.be aeventn cervical spins
and emerged tbrouith the anterior border of the lower half of the right
atemo-mastoid muacle. The fie'd medical card stated that the internal
jugular vein had been severely taoerated. but no reference was made to
any nerve or bone injury. He stated that at the moment he waa hit he
experienced pain in the right arm. which Immediately became “limp
and almost useless," but i here wasnoaffeorionof the lower extremities.
He was referred to me about three months after being wounded on
account of severe pain in the right arm, which had developed during
the last four or five weeks. He complained of a constant dull ache in
the thumb snd two outer fingers and a severe neuralgic pain <io»n ths
outer side of the arm and forearm on movement. The limb had fully
regained its power, as there was no perceptible weakness of any muacle
on comparison with th* other side, but the objective sensory manifesta¬
tions were marked. There was hyposesthesia and analgesia (to the
prick of a pin) of the thumb and two outer fingers and the outer naif of
the hand, forearm, and arm almost as high as the acr >mlon process. He
also complained of what he described as “electric shocks * down the
right leg on bending his head forward. The only objeci Ive disturbance
to be found In the legs was some Increase of the right knee-jerk.
In addition to the above symptoms there was also evidence of irrita¬
tion of the right cervical sympathetic and injury to the right recurrent
laryngeal nerve.
The next case differs from the former in two respects: in
the first place, the root lesion is bilateral and there is lees
dissociation between the motor and sensory symptoms; and,
secondly, the initial loss of power in the legs, which from
the rapid and perfect recovery must have been due to spinal
concussion.
Gase 3.—Patient received a gunshot wonnd of the neck on OoL 1st,
1917, the missile passing transversely and apparentlv between the
spines of the third and fourth cervical vertebra without injuring the
bones. There was immediate loss of power in all four limbs, bat the
leg" and ri*ht arm soon began to Improve, and the former had folly
regained their normal power In six weeks.
On examination at the end of November it was found that the right
arm had recovered except for paresis of the deltoid and slight hypo-
mthesla in the distribution of the circumflex nerve. On the left side
there was paralysis of the splnati, deltoid, biceps, and brachlalis
antlcus; marked paresis of the triceps, and moderate weakness of the
extensors of the wrist, thumb, and fingers, flexor longus pollids, flexors
of the index finger and the then«r muscles, together with anaastheda
and analgesia in the distribution of the fifth and sixth oervloal roots.
No disability or modification of reflexes was to be found In the legs.
During the next two months the forearm and band muscles rapidly
Improved, and by March had fully recovered their normal power,
whilst the upper arm muscles were all acting exoept the splnati,
although the deltoid remained very weak. About this time It waa
notioeable how the objective sensory disturbances ou the left side varied,
both in character and extent, from week to week. At times a gnawing
pain In the thumb was very troublesome. «
Within a year from the cUte of being wounded there was a complete
return of function, but some disturbance of the sensibility ef the
thumb persisted and at times the pain in this region recurred.
II. Injuries of the Cervioal Roots Complicated by Lesions or
the Spinal Cord.
In many of the former group, at the outset, paresis of the
legs and slight differences in the deep reflexes on the two
sides showed that there had probably been slight spinal
complications, but the rapid and perfect recovery demon¬
strated that concussion was likely to be the cause rather than
any gross pathological lesion.
It is not intended in this paper to refer to injuries ef
nerve roots accompanying severe lacerations of the coed,
but only those oases in whioh the radicular lesions are the
obtrusive feature and give rise to the ohief disability. In
this group I include all cases whioh give definite and per¬
sistent evidence of spinal complication by the presence of
objective sensory disturbances or modification of the reflexes.
In the first report the injury was localised chiefly to the
anterior and posterior roots of the eighth cervical nerve. The
difference in the deep reflexes of the legs on the two sides,
which persisted, indicated slight implication of the eard,
bnt it was insufficient to cause any serious subjective troubles.
OA8R 4.—Patient, wu wounded on April 24th, 1917, by a rifle bullet,
which entered the left stem -mastoid and came out in the region ol the
spinous process of the second dorsal vertebra. There was immediate
loss of power in the left arm, and some weakness in the left leg was
notloed for a few weeks. The left pupil was larger than the right. An
X ray report stated that there was •• an injury to the eighth (sic)
oervloal vertebra."
On examination In October. 1917, the leg had completely recovered,
the pupils were equal, and the left upper arm had regained fall power.
There was paralysis of the flexor profundus digitornm, intoromeL
lumbricalea, and hyoothenar muscles, with paresis of the flexor carpi
nlnaria. adductor polllels and the thenar muscles. In addition hvpo-
astheeia bnt no aaalgeaia of the little finger and ulnar hordes ef the
Thh Lancet,] DR. J. 8. B. STOPFORD: GUNSHOT INJURIES OF CERVICAL NERVE ROOTS. [March 1, 1919 337
hand was found. The left knee-jerk was exaggerated, but there was
no clonus or sensory loss In either leg, and the plantar response was
flexor in type on both aides.
During the next six months there was some Improvement in func¬
tion owing to better flexion of the fingers, the lumbricalea and flexor
profundus digitorum to the index recovering and the ptretlc muscles
gaining streogth. When discharged the hand was very serviceable,
but there was still paralysis of the lnterossei and hypothenar muscles.
The exaggeration of the left knee jerk also remained.
Daring the seven months he was under observation the
most striking feature was the almost daily variation in the
objective sensory disturbances in the left hand. The hypo-
assthesia was constant and persisted throughout, but from
time to time it was accompanied by analgesia or hypalgesia
to the prick of a pin, with occasionally thermal anesthesia
to water at 0° C. Heat was always well appreciated.
Oasb 5.—Patient received a gunshot wound on June 24th, 1915; the
bullet entered one inch above the inner end of the right clavicle and came
ont opposite the spine of the seventh oervlcal vertebra. An X ray
examination revealed an Injury to the transverse process of the seventh
cervical vertebra and the fragment was subsequently exolsed. Imme¬
diately on being injured there was complete loss of power in all four
limbs.
The left leg began to improve in two or three weeks and had
practically recovered In two months, whilst the left arm began to
recover in two months and steadily progressed, so that in about
seven or eight months it was merely a little weak, and " went numb ”
in cold weather.
The right arm did not show any improvement until May, 1916, but
after that time steady progress was maintained. Recovery In the right
leg was first noticed about three months after being wounded, and
continued for over a year.
I first saw the patient in December,* 1917, when he had been dis¬
charged from the Army for almost 12 months and had neglected treat¬
ment. All the fingers of the right hand were tightly contracted into
the palm, and there was paralysis and wasting of the flexor carpi ulnaris
and all the small muscles of the hand, together with anaesthesia and
analgesia in the greater part of the distribution of the eighth cervical
and first dorsal roots. He claimed to be able to walk about half a mile,
and could certainly get about easily without support, in spite of obvious
weakness of the right lower limb; the deep reflexes of the right leg
were exaggerated, and ankle clonus and an extensor plantar response
were found also on this side.
The left arm and leg bad recovered full power and range of move¬
ment. The left leg and left half of the trunk, as high as the level of
the fourth dorsal segment, showed complete analgesia and thermo-
anastheeia of spinal origin. No sensory disturbance of any form was
discovered on testing the right leg or left arm.
With treatment considerable Improvement has occurred in the right
arm, bat the motor and sensory condition doe to the spinal lesion have
remained stationary.
When seen last, in November, 1918, all the muscles of the right upper
extremity showed voluntary contraction, but considerable disablement
resulted from a seveie contracture of the flexor profundus digitorum,
which has resisted all forms of treatment. The sensory loss in this
limb was then confined to the two inner fingers and ulnar border of the
hand. No disability could be found In the left arm, but the patient
stated that the hand went weak and the inner border of the hand and
forearm numb in cold weather.
The clinical history in the above suggests an injury to the
lower cervical roots, complicated by a unilateral lesion
(possibly hsamatomyelia) in the right lateral column of the
cord.
A similar root injury has been seen recently accompanied
apparently by a haemorrhage into the posterior column of
one side, since the leg exhibiting marked alteration of the
reflexes also showed loss of the postural sense, but un¬
fortunately the patient was only seen once and it was not
possible to follow the progress.
Cask 6.—Patient was wounded on Sept. 20th, 1917, bya machine-gun
bullet, which entered just to the right side of the first dorsal spinous
process and emerged under the left lower border of the mandible.
In a report on the examination at the base two days later it is stated
that the muscles of the left arm were flaocid, except for the trapezius,
and there was considerable weakness of the right arm. On the left
side there was anaesthesia in the distribution of the fifth, sixth, seventh,
and eighth oervlcal roots, whilst on the right there was hypowsthesia
In the sixth and seventh cervical areas only. The left pupil was about
half the size of the right. The motor power, sensation, and reflexes in
both legs are recorded as normal.
. By Oct. 20th there was some return of power in the muscles of the
left upper arm and shoulder and the flexors and extensors of the wrist,
with considerable reduction in the sensory loss and less inequality in
size of the pupils.
During the early part of November he began to be troubled by
weakness of the legs, especially the left, although up to that time he
had been walking about freely without dlsoomfort and no difference in
the reflexes on the two sides had been found. Examination of the legs
at this time failed to reveal any obvious difference in power or tone on
the two sides, but the left knee-jerk was considerably exaggerated, and
there was an extensor plantar response on this side. Some analgesia of
the distal part of the right lower extremity was found, but sensation
was normal on the left side.
During the next month the leg condition remained stationary and
then began to Improve slowly, so that by January, 1918, he was able to
walk two or three miles although the altered reflexes remained. By
this time the right arm had shown great improvement, there remaining
merely some weakness of the hand-grasp; on the left all the muscles
were now acting voluntarily, but there was still marked paresis of the
shoulder and upper arm muscles and flexors of the fingers. The
objective sensory disturbance was now negligible.
During the next two months Improvement was maintained In both
the legs and arms, but the left leg was still apt to give way after walking
two or three mt’es. Toe difference in the knee-jerks on the two sides
was marked and an extensor plantar response was still elicited on the
left.
On discharge in May (eight months after the Injury) the right arm
had fu ly recovered, but the patient maintained that its power was apt
to vary, the left arm had regained full strength except for slight
paresis of the flexors of the fingers. No objective sentory disturbance
could be found, but the left leg still became weak on fatigue.
Pathology.
The most significant feature of the last case is the
development of a disability of the legs during the latter
part of the second .month of convalescence. A similar
complication was observed to develop at exactly the same
time (seventh week after injury) in another patient with
a lesion of the cervical nerve roots. The late appearance
of this manifestation suggests that it cannot be due to
any primary haemorrhage into the cord, but rather involve¬
ment from without—such as meningeal adhesions following
organisation of a haemorrhage around the cord.
The persistence of unilateral exaggeration of the deep
reflexes in Case 4 may be due to the same cause, but in
that case it is interesting to notice that the plantar reflex
was of the flexor type throughout.
The etiology of the leg disability in Case 5 is not likely
to be the same. In the latter paraplegia was present from
the first and only slowly improved, compared with the
rapid recovery in Oases 1, 2, and 3 (where the spinal trouble
was probably concussion), unilateral ankle clonns and an
extensor plantar response persisted, and there Was clinical
evidence of interference with the spinothalamio bundle, as
well as the pyramidal tract, shown by the loss of pain and
thermal sensibility in the contralateral leg. The pathological
lesion which seems most likely to cause such clinical signs is
a small haemorrhage into the cord, it being most improbable
that laceration by the missile could give rise to such well-
localised symptoms. It is qnite conceivable from recorded
observations that the divnlsive force of a bullet, as it passes
in the vicinity of the spinal canal, conld result in rapture of
the small vessels in the cord.
Therefore, it appears likely that the symptoms of spinal
cord complications in gunshot injuries of the nerve roots
may be dne to the following causes:—
1. Concussion in which recovery is rapid and complete.
2. Meningeal adhesions which will only give rise to clinical
symptoms daring oonvalesoenoe, and usually in the latter
part of the second month. Complications from this source
may arise in a patient who has recovered from oononssion
or who has not previously shown any evidence of spinal
complications.
3. H<ematomyelia characterised from the time of the injnry
by definite evidence of a lesion of the spinal cord, which does
not materially improve. From personal experience the
haemorrhage appears to be most frequently unilateral and
situated in either the posterior or lateral columns, but two
cases have been seen reoently in which the lesion appeared
to affect the posterior columns on both sides.
4. Laceration in which the cord lesion is so severe that the
radicular injury becomes of quite secondary importance.
It is not qnite so easy to decide upon the character of the
injury to the nerve roots. At first the loss of condnotion is
usually profound and affects several roots, but from the
rapid improvement it is clear that this most be due very
largely to concussion. From a study of the course of the
bullet it appears improbable, in most cases, that the missile
could possibly have lacerated any root fibres in its course.
In Case 3 the ballet passed transversely behind the vertebra,
and apparently between the third and fourth cervical spines,
without injuring bone. In those cases where the roots are
actually lacerated the concomitant injnry to the cord, is
muoh more serious, and a high proportion of these injuries
are probably fatal owing to laceration of the carotid or
jugular vessels.
The frequency of bilateral root lesions, without serious
injury -of the cord, further supports the contention that
serious laceration by the missile is rare in the patients under
discussion. Injury to the nerve roots by fragments of bone
can be responsible for only a small proportion, since X ray
examinations only revealed bone injuries in about 16 per
cent., and in a fair proportion of these the injury was so
situated that it could not possibly implicate the nerve roots.
Therefore it seems possible that the loss of conduction,
other than that due to concussion, in a large proportion is
due to haemorrhage around the nerve roots from the numerous
small vessels chiefly in the pia mater. This is supported by
the striking variation from day to day, which has been
^ referred to in several of the reports, in the objective sensory
338 The Lancet,]
CLINICAL NOTES.
[Marcs 1,1919
symptoms. This variation is characteristic of compression
and is only seen at a time when the haemorrhage will have
been replaced by fibrous tissue, which is liable to contract
upon the nerve roots.
The late development of spinal symptoms, which I suggest
are due to meningeal adhesions, is in agreement with this
contention. The haemorrhage from pial vessels is scarcely
likely to be sufficient, to cause compression of the cord, and it
is only after sufficient time has elapsed for it to become
organised that the symptoms make their appearance. The
marked recovery indicates that the compression is rarely
sufficiently severe to cause any serious destruction of fibres.
Diagnosis.
The segmental distribution of both sensory and motor
symptoms is most helpful in diagnosing a radicular from a
spinal injury. The absence of any alteration of reflexes or
sensory disturbance below the site of the injury is farther
evidence against any spinal injury, but in so many root
lesions there is some disturbance of conduction in the spinal
cord also. A localised haemorrhage into the grey matter
might cause a lower motor lesion of more or less segmental
distribution, but, instead of being accompanied by loss of
sensation in the corresponding sensory segment of the same
limb, would most probably be associated with altered reflexes
on the leg of the same side. According to the size and
position of the haemorrhage there might also be sensory
disturbances in the lower limbs, but these would show a
different arrangement and dissociation from those due to
lesions of peripheral nerves.
The differential diagnosis from brachial plexus lesions is
often difficult. Signs of concomitant loss of conduction in the
cord, even if only due to concussion, would be in favour of
a root injury. The segmental distribution of symptoms is
helpful in oistinguishing from an injury of the lower part of
the plexus, but of less service in differentiating from an
injury of the trunks, which would also give segmental
symptoms. In the latter difficulty, help may be obtained
often from the greater and more frequent dissociation
between sensory and motor symptoms in radicular lesions.
In some the decision is exceedingly difficult, and I have
seen one patient in whom the brachial plexus was exposed in
error right up to the intervertebral foramina with, of coarse,
negative results. The clinical condition at the time of opera¬
tion warranted the diagnosis of an incomplete division of
the upper trunk of the plexus, but an inquiry into the
history would have suggested the probability of the correct
anatomical localisation.
When suspicious of a root injury the presence of slight
increase of the reflexes of the lower limb on the same side is
of great diagnostic value. j
Treatment.
From a survey of these reports it is apparent that
the ultimate recovery is most striking 1 , considering the
great initial incapacity. It is necessary to consider the
treatment of the radicular and spinal lesions separately.
Radicular injury.
The affected limb
or limbs must be
supported at the
earliest possible
moment, so that
all paralysed or
paretic mucles are
relaxed. This is
particularly im- A
portant in lesions
of the fifth and
sixth cervical
roots, since failure
to support the
deltoid and spinati
in the early stages
causes irreparable
damage to the
muscles, which
will delay and
limit recovery and
render contrac¬
ture of antagonistic muscles probable. At the outset, when
the whole limb requires support, no appliance can compare
with an abduction splint fitted with suitable forearm attach¬
The objective sensory disturbance in Case 5.
a, Of peripheral origin, b. Of central origin.
ment, which can be modified slightly to meet the special
requirements of the patient, to support the muscles acting
on the wrist, fingers, and thumb.
Of almost equal importance is daily passive movement of
all joints to prevent mechanical limitation of mobility from
contraotures and arthritic adhesions. Persistent immobilisa¬
tion at this time frequently gives rise to disabilities which
last longer than those due to the nerve lesion directly, and
in themselves may cause permanent incapacitation (Case 5).
Beyond this little is required except daily massage of the
whole limb to maintain general nutrition of the muscles
as far as possible. With the earliest return of voluntary
movement careful muscle training may be commenced, but
care must be taken at first not to fatigue the recovering
muscles. If the muscles have been well supported from an
early date and daily mobilisation practised wonderfully
good results can be induced by the skilful and persistent
methods of muscle training.
The principles underlying the correct performance of this
form of treatment have recently been most elaborately
explained by Mackenzie. 1 The support of the muscles must
not be dispensed with too early, not until a fair range of
voluntary movement has returned, and even then it is
preferable that the splint should be worn at night for a
time.
In the later stages employment, suitable for further
development of the recovering muscles, may be undertaken.
Spinal lesion .—In the type of case to which this paper
refers the spinal lesion rarely causes any very serious
trouble. The little spasticity which may be experienced can
generally be relieved by massage and only infrequently
persists. If it provided serious disability at a late stage and
showed no signs of improvement, rhizotomy might have to
be considered. The weakness in the legs usually improves
with graduated exercises, and most patients have been able
to walk two to three miles without discomfort.
The treatment of the scar has also to be considered, since
it may restrict seriously the mobility of the neck. Ionisation
and manipulation will generally loosen it sufficiently to
prevent any serious limitation of movement, but in some the
extent and character of the cicatrix may necessitate its
excision. -
1 Mackenzie, C.: The Action of Muscles.
Clraital Sobs:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL..
-♦-
A CASE OF ERYTHR.EMIA.
By Margaret H. Fraser, M.B., B.S. Lond.,
PHYSICIAN, SOUTH LONDON HOSPITAL FOR WOMEN.
The following case was shown at a meeting held recently
of the London Association of Medical Women.
The patient, a married woman, aged 60, had for many
years noticed some blueness of the lace and hands daring
ooid weather and occasional epistaxis, but it waB only after
the death of her son 18 mouths ago that she observed
swelling of the abdomen and other symptoms—e.g., frontal
headache, a feeling of fullness in the bead, pain in the upper
abdomen, and some loss of flesh. When admitted to the
South London Hospital for Women in February, 1918, there
was congestion and cyanosis of the skin of the face, ears, and
neck, the mucous membrane of the mouth and tongue was
purplish in colour, and the conjunotivae were injected.
Discolouration of the forearms and hands was present and
some dilatation of the veins of the legs. The arteries were
thickened, the blood pressure measured 128 mm. Hg; the
heart was normal. A blood examination gave the following
result: Red blood cells, 9,510,000 per c.mm.; white blood
cells, 30,000; haemoglobin, 130 per cent.; colour index, 0*7.
A differential count gave per cent.: polymorphonuclear
cells, 86*8; lymphocytes, 8 6; hyaline cells, 14; eosinophil
oells, 15. No abnormal cells were seen. The liver was
enlarged, the edge being palpable 3 inches below the costal
margin in the mid-clavicular line. The spleen formed a
bard, somewhat nod liar mass in the left hypochondrium,
extending to the level of the umbilicas. The urine con¬
tained a trace of albumin; the specific gravity was 1013 to
Thb Lancet,]
royal SOCIETY OF MEDIOINE: SECTION OF OTOLOGY.
[March 1,1919 339
1018. The urea excretion was fairly good, and there was no
evidence of organic kidney disease.
The case was treated with calomel and saline aperients
and a somewhat restricted diet. X ray treatment was
applied to the spleen. Venesection was not done. The
subjective symptoms had now to a great extent disappeared.
The liver was smaller and the spleen, though not much
changed in size, felt less hard. The abdominal pain was
relieved by a belt, and the patient was now living an
ordinary life with little discomfort. The last blood count
showed 8,000,000 red blood oells and 13,000 white cells.
TWO CASES OF DISLOCATION OF TEETH.
By H.Mearns Savery, M.R.C.S. Eng.,L.R.C.P.Lond.,
LATE C.S.O., IPSWICH HOSPITAL.
The following cases may be of general interest, as I have
not been able to fiad any literature on the subject, nor have
I beard of similar treatment being adopted in the same
circumstances.
Gash 1.— A lad of about 13 years received an accidental blow In the
mouth from a stick. I found that hi* two upper centrals had been
completely dislocated, hanging loose In the mouth, and falling Into
my hand un being touche I. Considerable laceration ot the soft parts
and looe«n1ng of adjacent teeth. The teeth were not broken in any
wav, so having placed them in saline 1 cleansed the parts, removing all
blood cl.«ts from the cavities, and using flavine (1-1000). ihe two
teeth were then i eplaced, the lacerations of the gum necessitating a
few points of silk suture. The patient was furnished with a lint pad to
bite on and the jaw held up fairly tightly by a jaw bandage. Fluid
diet only was allowed. Pad and bandage were kept on for 48 hours,
ensuing treatment consisting In fluid diet aud thorough cleansing of
the t**eth and mouth twice daily with swabs soaked in flavine (L-1000).
In five or six days the solid diet was gradually given.
Six months later I found the condition quite satisfactory. For some
time the patient had been able to bite apples and tackle hard crusts
with no discomfort.
Case 2. —A youth, 18 fears, was kicked in the mouth while playing
football. The tir*t and second bicuspid and first molar teeth of the
right upper jaw were turned almost upside down, the crowns being
forced up and separating an appreciable portion of the alveolar
margin I did not take away the teeth, there being a consider¬
able attichment of guin. The parts were cleansed as in Case 1.
Here the restoration of the “bite” was more difficult owing to
the destruction in the continuity of the alveolar margin. After con¬
siderable manipulation. this w*a accomplished and after-treatment
instituted as in Case 1. i discharged this patient some time atterwards.
The only fault In an otherwise perfect result was that two of the teeth
were a fraction lower than previously, but this caused no incon-
veulence.
. Iam anxious to know if replacement of teeth is commonly
carried out. It seems a pity that permanent teeth should be
lost, as seems to happen so often in young people as the
result of accident, if there is any chance, and there appears
to be, that they might be saved.
Budlelgh Saiterton, S. Devon.
INTRAVENOUS INJECTION OF POTASSIUM
IODIDE IN TABES DORSALIS.
By F. J. Devota,
SBIIOR DRESSER, STATE HOSPITAL, KOTA BHARU, KELANTAW.
The following case is of special interest as regards the
beneficial effects of treatment by intravenous injection of
potassium iodide in tabes dorsalis :—
An Indian, a^ed 41, working as a railway guard in the
F.M.S. Ry. stationed at Pasir Mas, Kelantan section, was
admitted into the State hospital, Kota Bharn, Kelantan, for
treatmenton April 27th, 1918. For the past three waeks he had
been troubled with occasional shooting pains in the legs. He
gave a history of gonorrhoea at the age of 27 and of having
had a chancre when he was 37. On examination he was
found to be suffering from many symptoms pointing to
tabes dorsalis—e.g., pain in the limbs, loss of knee-jerks and
ankle-jerks, loss of pupil light reflex, shooting pains in the
lower extremities and also anaesthesia of the feet and lower
part of the legs; the patient could hardly walk.
On April 29th and May 6th and 13th the patient was given
a full dose of “914," bat no improvement was noticed, and
he complained of very severe shooting pains in the
legs and feet, especially at night-time; these pains were
partially controlled by morphia. After three intravenous
Injections of potassium iodide (gr. 30 dissolved in 4 oz. of
normal saline solution) improvement followed and the
patient was discharged from the hospital on May 31st.
This patient was last seen by me on July 5th, working on
the railway line, and I was informed by the patient himself
that the shooting pains in the legs and feet had entirely
-disappeared ever since he was discharged from the hospital.
Spiral Societies.
ROYAL SOCIETY OF MEDICINE.
SECTION OF OTOLOGY.
A meeting of this section was held on Feb. 21st, Mr.
Hugh B. Jones, the President, being in the chair.
Radical and Modified Radical Mastoid Operations.
Mr. J. S. Fraser and Mr. W. T. Garretson (Edinburgh)
contributed a paper on “Radical and Modified Radical
Mastoid Operations: their Indications, Technique, and
Results.” In the absence of the authors, the paper was
read by Dr. Dan McKenzie. The contribution was based
on the analysis of 306 cases of chronic middle-ear suppura¬
tion, composed as follows : 238 radical mastoid operation,
17 modified radical mastoid operation, 26 labjrinthitis,
25 intracranial complications. The average age of the
patients was 20 years. The most common causes appeared
to be scarlet fever and measles. Sometimes the aural dis¬
charge had been attributed to a blow on the ear. In only
66 cases did the patients or their relatives remember the
cause of the ear trouble. Among the precursory illnesses
were: measles in 26, scarlet fever in 25, pneumonia 3,
whooping-cough 1, mumps 1, small-pox 1, teething 2, cold 1,
injury 6. Middle-ear suppuration the authors found to be
much more common among the poor than among the better-
to-do. If the cases of severe suppurative otitis media were
properly treated when they arose there would be very little
chronic middle-ear suppuration, and consequently the radical
mastoid operation would seldom be called for. The public
authorities had, however, turned a deaf ear so far to the remon¬
strances of otologists in the matter. In 1913 the International
Medical Congress passed a resolution in these terms :—
“That it would be greatly to the advantage of the community If
experts in otology and laryngology were attached to the special
hospitals for the treatment of epidemic diseases.*’
The duration of the condition, according to the statements
of the patients, varied from 5 months to 20 or 30 years. In
only 48 cases was cholesteatoma diagnosed before operation,
though at the operation it was found in 104. There was
Eustachian obstruction in 34 ; in 70 cases t;he membrane
showed results of chronic suppurative otitis media. In
many of the cases there were more than one indication for
operation present. In 33 cases there was chronic sup¬
purative otitis media and failure of the conservative
treatment ; in 93 chronic suppurative otitis media
with polypi or granulations was present, and in 57
chronic suppurative otitis media with pain, mastoid
tenderness, and polypi. In 208 cases the mastoid
cortex was found to be normal. Particulars of the 238
cases in which the radical mastoid operation was performed
(the average stay of the patients in hospital was 22 days)
were briefly given as follows:—Mortality: all oases, 5*3
per cent. ; of uncomplicated cases, 0 7 per cent. Findings
at operation : mastoid process sclerotic. 174; sclerotic
diploe, 31 ; diploetic, 12 ; cellular, 8. Oholesteitoma
present in 104. Results: non-grafted (178 examined),
43 per cent, cured; grafted (70 examined), 70 per cent,
cured. Hearing after operation : non-grafted : improved,
39 per cent. ; unchanged, 39 per cent. ; worse, 23 per cent.
Grafted : improved, 29 per cent. ; • unchanged, 30 per cent. ;
worse, 38 per cent. Modified mastoid operation: 9 satis¬
factory, 3 had moist cavities, 10 had improved hearing,
2 had hearing unaltered, and 1 had worse hearing.
Discussion .
Mr. Arthur Oheatle regarded the paper as a masterpiece
in its way. He again urged the appointment of otologists to
fever hospitals. The Government were warned in 1902 of
the loss of man-power which had resulted from ear troubles,
and the experience of the war had brought home the truth
of what was then urged. Pensions would have to be paid
for many years owing to cases of ear disease which might
have been prevented. He recommended the appointment of
a Standing Committee of six to watch the Public Health Bill.
About 5 to 7 per cent, of candidates for the Royal Air Foroe had
to be turned down on account of chronic middle-ear suppura¬
tion. In 1902 he examined many school children and found
that 88 out of 1000 had chronic middle-ear suppuration. He
considered that the cases in which the modified or incomplete
340 The Lancet,]
ROYAL SOCIETY OF MEDICINE : SECTION OF OTOLOGY.
[Mabch 1,1019
mastoid operation was justifiable were very few and far
between, and for acnte and subacute inflammation of the
middle ear he regarded the incomplete operation as bad and
unscientific ; in some cases the Sohwartze operation had to
be performed after all.
Dr. J. Kerr Love said there appeared to be a tendency to
operate on ail cases of chronic middle-ear suppuration. He
had always under care about 600 school children with
chronic middle-ear suppuration, and he could count on
recovery .without operation in more than half the cases. He
curetted the naso-pharynx and removed enlarged tonsils,
and then subjected the external auditory canal and middle
ear to careful treatment over a considerable period. He did
the modified operation more readily in cases in which both
ears were involved, unless the evidence very strongly
favoured the radical operation. He believed operation had
been unnecessarily done in many of these cases.
What Operation should be Performed ?
Mr. Charles J. Heath said he assumed Dr. Love did
not perform the radical operation when both ears were
involved because the modified operation was likely to
secure retention of a more reasonable amount of hearing
than was the Sohwartze operation. On his, the speaker’s,
recommendation the Metropolitan Asylums Board had set up
a hospital in London where all the children under their
control who had ear discharge were sent. If, after a few
weeks’ treatment, the running did not cease they were
operated upon by the conservative method. The ear
dressing at the hospital was not a distressing procedure.
In reply to a question, he said he had not published a
summary of his results.
Dr. William Hill did not believe all the operations done
on the children under the Metropolitan Asylums Board were
necessary, nor that the best form of operation for their
trouble was selected. The meeting should let it be clearly
understood that the specialty did not regard the Schwartze
operation as obsolete, but considered it to be a good opera¬
tion for acute and subacute cases. By the so-called con¬
servative operation—that of Kiister, revived by Charles
Heath—he contended that the balance of the ear as a whole
was altered, and it was exposing the ear to vicissitudes of
climate, to draughts, and the entry of water. There was a
strong line of difference in this matter. Was Mr. Heath
right, or were the majority of otologists right 1 The matter
needed thrashing out.
Mr. W. Stuart-L ow pleaded for a better education of the
general practitioner on the dangers of the later results of
fugitive otitis media, which would lead to cases being
sent to the otologist early. Attention to tonsils and
adenoids would mostly prevent the onset of otitis. He
considered that the radical mastoid operation should never
be done on children. It was very sad to contemplate deaf¬
ness as a sequel to the operation. He discussed the tech¬
nique, and uttered a warning against tight bandaging.
Dr. J. Dundas Grant said that very seldom was a Schwartze
operation done for acute suppuration of the middle ear in
which the patient did not get perfectly well; therefore he
contended it was unnecessary to perform an operation which
left a chronic fistula. If a fistula were left after a Schwartze,
it would be called a very bad operation. He could not
help feeling that Mr. Heath’s teaching was responsible
for some of the ear work which had been done on soldiers.
He protested against the charge that the radical mastoid opera¬
tion (the Sohwartze) produced deafness, as it was an unfair
statement. When the anterior part of the tympanum was shut
off from the aditus and antrum, the modified operation, he
agreed, was very strongly indicated ; and he thought the
results in cases shown by Mr. Heath to-day were admirable.
Mr. Somerville Hastings said in many of his Schwartze
operations a sinus was left. He therefore tried the modified
operation, and in his hands the operation had given
admirable results in acute and subacute cases, healing
occurring quicker also, and the dressing was easier and more
satisfactory. He had now largely given up the Schwartze
operation, especially for children. For chronic cases he did
the Schwartze always.
When should a Bone Operation be Done ?
Sir Charles A. Ballanoe suggested that the essential
question in the discussion was, When should an operation on
the bone be done 1 There were fulminating cases of acute otitis
media In which the mastoid process was rapidly involved,
the cells becoming filled with pus after three or four days.
Those required operation ; wherever pus was present it must
be let out. He thought there was nothing better than the
Schwartze for those. If adequately and thoroughly per¬
formed in such cases it left perfect hearing, and healing
occurred in a short time. He was interested to return, after a
long absence, to find attempts still being made to improve the
older methods. He was against the idea of carrying out any
rigid operation as planned in the books; every operator
should be prepared to vary it in such a way as to deal
most effectively with what he found present. He insisted
on the importance of absolute and free drainage of the
tympanum. The tympanum should be interfered with as
little as possible.
Dr. McKenzie briefly replied for the authors.
Septic Infection of Lateral Sinus after Irywry at
Operation,
Mr. Hunter Tod read a paper entitled “ Septic Infection of
Lateral Sinus Accidentally Injured during the Operation of
Mastoidotomy. ” The author included only those cases in whioh
the mastoid operation was performed for chronic suppurative
disease of the middle-ear cleft and mastoid cells, and in which,
at the time of the operation, the sinus was apparently healthy.
Septic infection of the sinus after injury rarely took place.
These injuries were divisible into two groups: 1. A clean cut
through the wall of the sinus, with profuse hsemorrhage,
requiring obliteration of the lumen of the sinus. In these
cases he had never observed subsequent infection of the
sinus. 2. Grazing of the outer layer or puncturing of the
sinus wall with no bleeding or with only slight oozing of
blood for a moment or two, the injury being so slight as to
escape notice unless a careful examination be made at tne
time of the operation. He gave details of six cases, four in
his own practice, with one death. In the fatal case all
seemed to be going well until the eighth day, when the
patient had a rigor and the temperature rose to 103° F. Mr.
Tod operated again on the ninth day, performing ligation of
the internal jugular vein. Perforation of the sinus wall was
discovered and a septic clot was removed. The autopsy showed
septic thrombus and pus in the circular and both cavernous
sinuses, extending into both ophthalmic veins. Mr. Tod’s con¬
clusions were as follows. Whenever the lateral sinus was
exposed during the mastoid operation, careful examination
should be made to see if it had been injured, even slightly.
If so, it should be exposed freely on each side and its lumen
obliterated by packing with gauze well beyond the affected
area. There might be no evidence of infection of the sinus
until the ninth day or later ; a sudden rigor might be the
first symptom. This, with an increased pulse-rate, should be
regarded as a danger signal. If hsamorrhage occurred from
the mastoid wound a few days after operation, it was not
sufficient to arrest the haemorrhage by applying pressure to
the bleeding spot; the bone should be removed from the
sinus wall above and below the affected area, and a gauze
plug inserted between the bone and the outer wall of the
sinus. Haemorrhage associated with pyrexia or a rigor
always meant septic infection, and in the latter case the
internal jugular should always be ligated.
The paper was discussed by Dr. McKenzie, Mr. H. J.
Banks Davis, Mr. Stuart-Low, Mr. W. M. Molubon,
Mr. Heath, and the President, and Mr. Tod briefly
replied.
Literary Intelligence.—A third edition of
“ Diseases of the Skin,” by Dr. J. H. Sequeira, physician to the
skin department and lecturer on dermatology at the London
Hospital, is ready for publication in the hands of Messrs.
J. and A. Churchill. It is illustrated by 52 plates in oolour
and 257 text-figures.
Aberdeen Royal Infirmary: Staff Appoint¬
ments.— The vacancies on the staff of the Aberdeen Royal
Infirmary occasioned by the resignation of Dr. J. 8oott
Riddell and the death of Dr. A. H. Lister, the filling of
the latter post having been postponed daring the war,
have been filled by the appointment of Dr. Fred. K. Smith,
the senior assistant surgeon, to the office of surgeon, and
Dr. Thomas Fraser, the senior assistant physician, to the
post of physician. The vacancy occurring through the
resignation of Dr. W. Sinolair, the late superintendent, has
been filled by the appointment of Miss Edmondson, the
matron, who has performed the duties daring the last three
years, to the joint office of superintendent and matron.
ThbLanckt,)
FRENCH SUPPLEMENT TO THE LANOET.
[March 1,1919 341
FRENCH SUPPLEMENT TO THE LANCET
Under the Editorial Direction of
Professor CHARLES ACHARD, and Dr. CHARLES FLANDIN, D.S.O.,
PROFESSOR OT PATHOLOGY 1HD THERAPEUTICS IN THE mAdECDC-MAJOR DE 2MB 0LAB8E; CHRP DE CLINIQUE
UNIVERSITY OF PARIS. ____A LA FACULTY DR PARIS.
THE SURGICAL COMPLICATIONS FOLLOWING
EXANTHEMATIO TYPHUS.
By Dr. PAUL MOURE and Dr. ETIENNE SORREL,
PROOfeOTOHS TO THE FACULTY OF MEDICINE. PARIS; mAdBGINS AIDE-
MAJORS DE 1. CLA88E; SURGEONS TO THE FRENCH HOSPITAL
AT JASSY.
Thh surgical complications following typUus or relapsing
fever generally supervene at the end of the febrile period or
at the commencement of convalescence. The patients are at
the time in a state of feebleness, which predisposes them to
the development of secondary infections.
Micro-organisms, agents of these secondary infections, can
easily find a door of entry, in order to penetrate into an
organism already profoundly enfeebled. On the one hand,
bedsores over the sacrum, buttocks, or trochanters frequently
offer them fr* e access ; on the other hand, the bucco¬
pharyngeal mucosa, dry and ulcerated as it is at the height
of the fever, is a constant focus of infection.
These facts lead us to understand how nearly all the
surgical complications which we have had to treat among
convalescents from exanthematic typhus aod relapsing fever
have only been, so to say, the indirect result of these two
affections, their direct cause being the organisms of super¬
infection, ordinary micro-organisms such as staphylococci,
and especially streptococci. Never in the suppurative com¬
plications following relapsing fever have we recovered from
the pns the spirillum, the pathogenic agent so easily dis¬
covered in blood films. When the still unknown organism of
typhus is discovered it should, of course, be sought for in
the infected tissues and in the pus from abscesses, but we
can say in advance that most of the suppurative complica¬
tions observed by us during the epidemic of 1917 in
Roumania were due to the streptococcus. Danielopol, who
during this epidemic made numerous blood examinations,
was able by blood culture very frequently to find the strepto¬
coccus in the blood of typhus patients at the height of the
disease, or at the beginning of convalescence, proving thus
that many typhus convalescents are, in fact, suffering from
more or less latent streptococcal septicaemia.
On the other hand, blood oultuies carried ont in the
laboratory of Professor Oantacuzdne by Dr. Jonnesco, and
in the laboratory of Professor Slatineanu by Dr. Nasta, were
nearly always negative.
However this may be, the typhus patient who reaches the
end of the recurrent febrile period of his illness, lasting
from 12 to 16 days, is again exposed, and this in a consider¬
able proportion of cases, to the development of secondary
infections likely to end fatally.
These patients, who are, In fact, septicsemic, may present
all the localisations and all the forms of metastatic abscess.
Nevertheless, the serious localisations have been in our
experience rare, and we can classify as follows the surgical
complications following exanthematio typhus with which we
have had most frequently to deal: (1) Bucco-pharyngeal
complications'; (2) auricular and mastoid complications;
(3) parotid infections; (4) laryngeal complications ; (5) ocular
complications; (6) large subcutaneous abscesses; (7)gangrene;
(8) erysipelas.
I. Bucco-pharyngeal Complications.
Infeotion of the bucoo-pharyngeal cavity, for which the
way is opened by the dryness and ulceration of the muooea
existing at the height of the disease, may serve as a point
of departure for general infeotion without there being any
demonstrable local lesions, but the looal infection often
develops on its own acoonnt, determining a series of com¬
plications, such as gingivitis, osteitis, neorosis of the jaw,
and suppurative inflammation of the cervical glands.
Oingvoitis has been frequent because, in view of the
number of patients and the difficulties of hospital organisa¬
tion whioh only came into being at the moment of retreat,
sort of the patients oonld not receive the small attentions
necessary for severely febrile cases. Simple gingivitis was
the most frequent form, but it was not unusual to see
periostitis develop with loss of several teeth 'or neorosis of the
jaw. Looking at the gravity of the general symptoms and
the state of prostration, the localised giDgivitis naturally
turned one's thoughts to scurvy, but although some typhoid
cases were identified at this time in our patients who had a
suspicious gingivitis, we were nnable to show the presence
either of petechias, ecchymoses, or the characteristic muscular
induration.
In one case we observed total necrosis of the mandible in
a patient who was admitted moribund to one of our wards.
The mandible could, without anaesthesia, be removed in two
pieces after division in the middle. All the muscular
attachments and ligaments bad been destroyed by suppura¬
tion, and the bone was only held by a few fibres at the level
of the temporo-maxillary articalation. The specimen was
presented to the Medico-Chirurgioal Society of Jassy.
The gum infection, periosteal or osseous, which attacked
especially the mandible, spread sometimes to the cellular
spaces aud cervical glands ; we were able to observe all the
forms—fulminating, acute, subacute, and chronic (generally
the two latter)—of suppurative and non-suppurative cervical
adenitis.
One rather peculiar fact is the frequence with which we
have seen tuberculous adenitis develop. It seems as if
relapsing fever specially predisposes to inflammation of
the lympho-glandular apparatus. But, faced with the
simultaneous occurrence of exanthematio typhus and
relapsing fever, it was often difficult to apportion the part
played by each of these affections. Most of the cervical
adenitis, whether nni- or bilateral, involved the sub-
maxillary or oarotid glands, sometimes affecting simul¬
taneously all the -glandular chains of the neck and
mediastinum. Among these cases of adenitis, some, by
their slow development, their localisation, and the mobility
of the glands, justified surgical extirpation with ultimate
excellent results; others, by their rapidity, extent, and quick
diffusion, rendered all suigical intervention impracticable.
In certain cases we observed in the glands of the neck
mixed infections, a secondary infection with streptococci or
staphylococci becoming superimposed on (be tuberculous
lesion already healed. This gave rise to a subacute adenitis,
the glands suppurating and breaking down, leaving per¬
manent fistulas after incision or spontaneous discharge.
Moreover, it was not uncommon to see such subjects carried
off rapidly after some weeks by pulmonary or a terminal
miliary tuberculosis. In one oase we found chains of strepto¬
cocci in films made from pus contained in the glands excised
with the knife, while a guinea-pig became infected with
tuberculosis after inoculation with a fragment of these same
glands, the microscopic appearance of whioh left no donbt of
their tuberculous nature.
By the side of this cervical adenitis, which is the most
frequent, we have observed axillary and inguinal adenitis,
singly or in combination or alone, the prognosis of which la
generally more hopeful.
II. Auricular and Mastoid Complications.
The bucco-naso-pharyngitis, whioh occurs so frequently hr
typhus oonvalesoents, readily explains the large number of
cases of otitis media and mastoiditis which we have had to
treat.
Otitis media generally supervenes at the height of the
disease or at the beginning of convalescence. If its com¬
mencement is sometimes ushered in by pain of ah acute
character preceding by some days the ear discharge, little or
no pain is more often noted, the otorrhcea appearing as the
first symptom of the complication. The otitis media of usual
onset is sometimes unilateral, but more often bilateral; it is
generally accompanied by a slight rise of temperature, after
which the discharge appears. The pus, at first serous,
becomes purulent, and contains the streptococcus alone or
associated with other organisms. Treated by ojdiiuury
342 ?hh Ljlncbt,]
FRENCH SUPPLEMENT TO THE LANCET.
[March 1,1919
means, these middle-ear inflammations generally tend to
heal, bat some leave sequel®, becoming chronic or com¬
plicated by mastoid infection.
Mastoiditis following exanthematic typhus also shows
this peculiar characteristic of developing generally in a
sluggish form. This explains why patients generally
came to us at a late period of their lesion. The latency,
intelligible enough when the complication supervenes
in very prostrate subjects, appears more curious when the
convalescent’s general condition is less precarious or when
he even seems definitely cured. A certain number of our
patients have thus come first to consult us many days or
•even weeks after having left the typhus hospital. They then
complained either of ear discharge, which alarmed by
Its quantity or persistence, or of a swelling behind the ear
presenting the obvious features of a subcutaneous abscess of
mastoid origin. This latency of subjective symptoms was
in contrast with the frequent extent of the anatomical
lesion. Often the infection involved all the mastoid cells
from base to tip. Pus came to light under the skin behind
the ear or spread downwards towards the neck, along the
sheath of the sterno-mastoid or the posterior belly of the
digastric. One of our patients had a large deep abscess in
the temporal region following mastoiditis with caries of the
wall of the auditory meatus. The lesion led us to make a
large petro-mastoid resection through a pre-auricular incision,
the patient making a perfect recovery after radical cure.
In one patient suffering from otitis media with abundant
discharge a swelling appeared behind the angle of the jaw,
at the same time as the aural discharge diminished. This
swelling, the size of a nut, and inconvenient rather than
painful, caused limitation of the movement of rotation of
the head and slight trismus. The diagnosis lay between a
subacute adenitis and mastoiditis with cervical abscess.
The first hypothesis appeared the most reasonable, inasmuch
as pressure over the region of the antrpm produced no pain
at all. An exploratory incision showed a perforation of the
tip of the mastoid process, which was then cleaned out
completely, as it proved to be filled with granulations from
the tip to the base, and extending to the external wall of the
lateral sinus.
_ This sluggish behaviour sometimes masked lesions of con¬
siderable extent, and tending to complications involving the
brain. In one patient suffering from fungous mastoiditis
with 6eque8trums, an abscess of the temporal lobe of the
brain was discovered and emptied. The lesion, which
appeared at first to improve, caused death from encephalitis
with hernia of the brain two months after operation.
Most of these cases of mastoiditis with clinically slow and
snbacute onset were found to be fungating mastoiditis ;
examination of the granulations Revealing nearly always the
presence of the streptococcus with or without other organisms.
But the pus removed at the time of operation has never
shown more than a small number of micro-organisms,
generally one to three in a field.
In the treatment of these cases of mastoiditis we have
always employed the classic method, trephining the antrum
and scraping out the mastoid process, guided by the lesions
and under the control of the frontal mirror. After curetting
all the affected parts, the retro-auricular wound is closed with
horse-hair and a Carrel’s tube introduced into the antrum
The next few days the mastoid cavity thus closed is irrigated
with Dakin’s solution according to Carrel’s method, and a
regular count of micro-organisms made. In most cases (save
those complicated by brain lesions) a rapid disinfection of
the operation cavity resulted and complete cicatrisation
followed which, in 70 per cent, of the cases, did not occupy
more than 25 days. 1 The prognosis in these post-typhus
mastoiditis cases was generally good, provided that surgical
intervention was early enough to anticipate the more deadly
brain complications.
III. Parotid Infections .
Post-typhus parotitis has a similar origin to that occurring
in other prolonged febrile diseases, but this complication is,
in exanthematic typhqs, particularly frequent. It is favoured
ji arr ® st fc * ie P 41 * 0 ^ secretion during the febrile
period, leading to dryness of the mouth and rapid bacterial
multiplication. The onset occurs at the end of the acute
period, sometimes in advanced convalescence. We have
seen all forms of parotitis, from simple parotid inflammation
on one or both sides without suppuration to actual gangrene.
The most frequent forms were the suppurative and the
gangrenous.
As a rule patients evacuated from a distance reached us
with much delay and with suppuration fully developed ; we
rarely saw the beginning of the complication. Suppurative
parotitis showed its text-book characters. Generally spon¬
taneous liberation of the contents occurred, sometimes through
the skin, but more often into the auditory meatus. Otoscopic
examination demonstrated swelling on the anterior surface of
the canal, with a fistulous orifice situated at the junction of
the cartilaginous and bony portions. Pressure on the
gland caused pus to exude from this orifice. Examination of
the buccal cavity* showed a dry mouth, with sordes and
mucous excoriations, the orifice of S tenon’s canal showing
red.
The course of suppurative parotitis was generally long and
grave. After incision, if intervention had been early, the
swollen parotid wound allowed serous discharge to flow away
for some 48 hours, after which frank suppuration was
established and persisted for a long while whatever the
treatment adopted. For two, three, or five weeks the
operation wound could be seen suppurating, but slow
recovery generally took place.
The gangrenous forms were not exceptional, but their
gravity was considerable. It seems, moreover, that the form
of the actual parotitis stood in some relation to the general
condition of the patients ; those with the worst attacks pre¬
senting the grave forms of parotitis. In gangrenous
parotitis, most often bilateral, complete elimination of the
gland and neighbouring ce'lular tissue was noted in the form
of yellowish pulp and shreds. The skin, red and cedematous,
sloughed round the incision, which was sometimes the point
of origin of erysipelas. In one of our patients a trae
phlegmon of both parotid regions developed, with con¬
siderable oedema of the face and ulceration of the external
carotid which occurred during a dressing. Pressure forceps
were applied, and left in situ, and after large incisions on
both sides and drainage of the subparotid spaces complete
recovery fortunately occurred.
When the parotitis showed a tendency to heal after long
and profuse suppuration, the wound, which for long had
appeared atonic, resumed a healthy red colour and began to
granulate. The cavity, often enormous, opening up the
whole bed of the parotid, filled up. and complete cicatrisa¬
tion occurred. In the many cases we had to treat neither
facial paralysis nor salivary fistula was ever noted.
The treatment employed was always a curved incision
over the angle of the jaw under local anaesthesia or after a
few whiffs of eth?l chloride. The incision was followed by
opening up the gland with the curette, in order to remove at
once a large part of the dead tissue, the gradual elimination
of which was fouud to retard healing. Irrigation of the
operation cavity with Dakin’s solution rendered equally good
service.
The pus from these parotid inflammations contained
streptococci, sometimes alone, sometimes with other micro¬
organisms, but we were not able to identify the cocci and
bacilli seen in the films of pus. It is nevertheless
probable that the gangrenous forms of parotitis resulted
from the association of streptococci and anaerobes, a fact
recently demonstrated in the case of gunshot wounds.
IV. Laryngeal Complications.
In regard to the larynx, 2 two kinds *of corqplications were
noted—the one early and occurring at the height of the
disease, true larpngo-typhus; the other a late complication, a
sequel to lesions of the submucosa and oartilages, determining
stenosis of the larynx.
Laryu go-typhus occurs with the text-book characters,
analogous to that which supervenes in the course of typhoid
fever. We saw a typical case in which the laryngeal locali¬
sation was the first symptom of the malady, preceding the
characteristic rash the appearance of which some days later
allowed the diagnosis to be made. The patient died suddenly
one night from a crisis of suffocation, some days after the
appearance of the rash.
Laryngeal s*eno*is following exanthematic typhus is fairly
frequent. These cicatricial lesions of the larynx probably
follow localised secondary infections of the laryngeal
cartilages. •
iL hls • u 1 b Ject in the Knvue hebdomad&ire
laryngologie, otologic, rhinologte de Bordeaux, No. 20,1917.
2 See on thin subject “ La Pathologic de guerre du Urynx et de la
trachle.” By Moure, Llehault, Oanuyt. Paris: Felix Alcan
THELAllOKf,]
FRENCH SUPPLEMENT TO THE LANCET.
[March 1,1919 343
In the first instance a laryngeal chondritis is met with,
there is a general suppurative condition, with intra- and
extra-laryngeal abscesses, and consecutive fistulae. When
the patient has not been carried off either by the
general attack or by local complications, particularly
of respiratory type, a progressive cicatricial stenosis of
the larynx takes place. Generally the clinical phenomena
succeed each other in the following chronological order:
The typhus patient presents either at the beginning
or at the height of the disease signs of laryngitis,
which are but the exaggeration of the usual enanthem, which
generally accompanies the exanthem in a marked form ;
later the laryngeal phenomena increase in intensity, the
larynx becomes painful, and there is complete aphonia.
Laryngoscopic examination reveals oedema and a wide
infiltration of the laryngeal mucosa, the ventricular bands
covering and concealing the vocal cords. Soon respiratory
troubles appear which necessitate tracheotomy. The lesions
may be arrested at this stage, but generally the cartilages
are attacked by the infection, and chondritis and peri¬
chondritis lead on to suppuration; the laryngeal region
becomes painful, red, hot, and cedematous; abscesses form
which discharge spontaneously or are evacuated surgically.
Suppuration persists for a long time with elimination
of the cartilages, after which, little by little, the
inflammatory symptoms die down, the fistulas dry up after
many weeks, and when the cannula comes to be removed it
is found that the patient cannot breathe or breathes very
badly through the larynx. One is in the presence of a
"caoulard.” With our friend Dr. C istiniu, chief of the
special centre at Jassy, we saw a number of such cases. The
only rational treatment to apply to these canulards is
laryngostomy with dilatation of the larynx.
V. Ocular Complications.
The ocular complications of typhus have been recently
treated of by Dantrelle in an excellent thesis, the conclusions
of which we transcribe :—
Exanthematic typhus may produce complications of two
kinds. The first group includes complications at the height
of the disease, due to the malady itself, localised in the
visual apparatus. In this group are included: Lesions of
the iris and lens ; lesions of the choroid and retina ; lesions
of the optic nerve and central vessels ; ocular paralyses.
From their appearance these lesions are probably of
vascular origin, which is in accordance with the other mani¬
festations and with the morbid anatomy of the disease.
They are of g ave consequence to the vision, and treatment
is often powerless against them.
The second group, more important numerically, is con¬
stituted by complications which supervene duriog the first
days of convalescence. Following sometimes on simple
erysipelas, they are due to the streptococcus. In this group
are included palpebral abscess, phlegmon of the orbit v
corneal ulcers, and optic atrophy secondary to streptococcal
infection.
We have ourselves seen abscesses of the eyelids, especially
if the upper, and phlegmon of the orbit in patients who
had other lesions necessitating continued care in a general
surgical ward. We might mention, among others, the
case of a patient who presented simultaneously two large
Abscesses of the thigh and of the thoracic wall, a phlegmon of
the orbit of the right side, and an abscess of the left u^per
eyelid. The course was naturally fatal.
VI. Large Subcutaneous Abscesses ; Phlegmon of the Limbs.
Very frequently in patients recovering from typhus we
have seen large subcutaneous abscesses. Their occurrence
is generally late, progressive, and almost silent, and this
latency is extremely remarkable, the patient generally calling
no attention to their presence until an advanced stage. The
large subcutaneous abscesses are situated most usually on
the external surface of the thigh or the posterior surface of
the arm, but they are not unusual on the calf, the anterior
or posterior thoracic wall, and even in the abdominal
parietes.
The pathology of these abscesses is multifarious. Some¬
times they are the result of septic punctures, inasmuch as
the grave general state of these typhus patients demands
numerous injections of substances such as oil of camphor.
Bat although a lapse in asepsis may possioly sometimes
explain the formation of such abscesses it must not be
forgotten that the patients are suffering from streptococcal
septicaemia; and it is reasonable to assume-—Danielopol
insists on this point—that large doses of oil of camphor,
injected and absorbed, as they are, very slowly, play the
part of fixation abscess, the streptococcus being nearly
always recoverable from the pus of the abscess. Finally,
abscesses are often seen to develop at the sites of old
punctures.
The clinical course of these abscesses is slow, this being
one of their most typical characteristics. They come thus
to acquire enormous dimensions, forming large fluctuating
pockets under the skin, occupying, for instance, the whole
length of the thigh and separating two-thirds of the
integument. On their surface the skin, slightly raised it «
may be generally appears normal, without redness, without
heat, without pain, without oedema. Palpation gives a true
sensation of fluctuation, because the pus, being under little
or no pressure in the large sac which it does not distend, is
easily displaced. It is not unusual to see successive pockets
communicating, by narrow orifices, which permit fluid to be
pressed from one into the other.
When one of these large abscesses is opened a quantity,
often considerable, of thick, greenish-yellow pus flows away
under very slight pressure. It is then observed that the
walls of the cavity are formed on the surface by the skin, in
the depth by the aponeuresis, the surfaces of which are
hidden by sanious debris of cellular tissue. At an earlier
stage, a smaller quantity of pus may be found, but instead a
true areolar infiltration of subcutaneous tissue, forming an
infinite number of little purulent foci which later become
joined into one by destruction of the connecting fibres.
Examination of pus films reveals numerous polynuclears,
more or less destroyed according to the age of the lesion, a
large proportion of macrophages and, nearly always, chains -
of streptococci. Generally these large abscesses are sub¬
aponeurotic, and we have seen much more rarely total
phlegmon of a limb ; the latter is generally of fatal prognosis.
The large* superficial abscesses develop progressively, and,
if not treated, reach considerable proportions. Generally,
after surgical opening they recover perfectly.
Treatment is simple. Dehelly and Zislin have published on
this subject communications read before the Medical Society
of Jassy. It is necessary under local or general anaesthesia
to open completely the purulent sac. But it is not sufficient
to evacuate the pus and to drain as for an ordinary abscess.
Such a practice is followed by interminable suppuration. It
is necessary, after opening the sac, to evert the edges and
energetically to curette the walls, in order to clear from
them the granulation tissue and all the detritus of adherent
connective tissue. Then, according to circumstances, the
wound may. following the practice of Dehelly and Zislin,
be left widely open and irrigated with Dakin’s solution ; with
secondary closure after disinfection has been obtained, or
immediate partial closure may be performed, Carrel’s tubes
being left in to irrigate the partially closed cavity. These
two procedures have both given us excellent results. But
it is not exceptional to see, even after extensive and complete
operation, the infection spread upwards and downwards,
necessitating new incisions.
It must be added that these streptococoal abscesses are
particularly difficult to disinfect, and in a certain number of
cases we have had to leave them to cicatrise spontaneously
without any attempt at secondary suture.
VII. Gangrene.
Of all complications following exanthematic typhus
gangrene seems to be the only one which can rightly be
credited to the still unknown pathogenic agent of this infec¬
tion ; no absolute proof of this assumption can be furnished
so long as this infecting agent has not been recovered from
the wall of the obliterated arteries, or from the clot contained
in them.
Gangrene due to obliterative arteritis is relatively
frequent in the course of epidemics of typhus, and we have
seen it In a large number of cases; but here the variety of
adjuvant causes which we have found as the basis of other
complications must be taken into consideration. Of these
gangrenes three classes may be distinguished.
The first includes gangrene localised to the points of
pressure, which leads to confusion with bed-sores.
The second includes gangrene of the loner limbs, and
particularly of the fret, the pathology of which is still some¬
what in doubt, inasmuch as it is difficult to decide the effect
exerted on the arteries by the typhus infection, by secondary
infections and by a third adjuvant cause—the cold. We are
convinced that much of the gangrene of the feet sent to us
344 Thb Lancet,]
FRENCH SUPPLEMENT TO THE LANCET.
[March 1.1019
as a complication of typhus was nothing more than frost-bite,
supervening in convalescents who daring a rigorous winter
had to travel far, insufficiently clo'hed. in unheated trains
or on trucks, and along roads covered with snow.
A third class includes gangrene localised to one part of the
body , generally attacking the integument only, but affecting
also the muscles and deeper tissues. Oue particularly
frequent localisation is the scr ;tum ; gangrene may attack
it at one localised point, or may invade the entire scrotum,
threatening the testicles. On the thorax, the trunk, or the
arms, small patches of necrosis were seen, sharply localised
and coexisting with marbling, a very characteristic com*
bination. Granted the affinity of the still unknown germ
of typhus for the vascular system, these lesions might well
be thought to belong to the typha» infection. The course
was generally simple; the marbling disappeared steadily and
the small necrosed patches were cast off, leaving more or less
deep ulcers which cicatrised progressively. .
Bed-sores , which were extremely frequent, possessed no
special features. Their number, extent, and depth are an
indication of the more or less precarious state of the subject.
Gangrene of the limbs is seen nearly exclusively in the
lower extremities. We have received nearly all such
patients at an advanced period and in a state of dry
gangrene. Most often the gangrene involved the toes, fairly
often the ankle, and sometimes spread upwards to the
middle part of the leg. The general condition was always
very precarious, the lesion presented all the characters of
dry gangrene, the necrosed parts were black, hard, separated
from the healthy parts by a line of demarcation. The
patient, emaciated, shrivelled, often moribund in appearance,
sometimes complained of pain of a neuralgic character ; the
temperature was generally subnormal, oscillating around
36° 0. Throughout the time of our stay at Jassy we had to
treat a considerable number of oases of gangrene and came
to the conclusion that surgical measures Bhould be as con¬
servative and cautious as possible, avoidiog every routine and
text-book operative measure, particularly the cutting of flaps,
which generally led to disaster or to bad functional results.
On the one hand, the patients were in a state of equilibrium
so unstable that it was impossible for them to undergo a
serious operation, and, on the other, the tissues were so
deeply infected, even beyond the apparent lesions, that the
bistoury might always reveal infections of extreme gravity.
We therefore adopted the following technique. When patients
suffering from gangrene of the lower limbs arrived the
gangrenous part was covered for some days with antiseptic
wrappings of formol, alcohol, or Dakin’s solution, and, first
and foremost, we set ourselves to build up the general con¬
dition with good food, injections of serum, of sparteine, of
adrenalin, aud the like. Then often without the need of
an anaesthetic, the necrosed parts were cut off just below
the line of demarcation in such a way as not to result in
bleeding. Thus relieved of the focus of septic absorption the
cut edges of the amputations were irrigated for several days
by means of Carrel’s tubes. Generally the state of the patient
improved progressively; we were then able at a second opera¬
tion, under light narcosis or spinal anaesthesia, to set the stump
in order. But here again the greatest prudence was neces¬
sary. The actual operation often led to a lighting up of
grave miorobic infection, because these foci nearly always
still contained streptococci. For the toes, we contented
ourselves, after circular incision of the integument just at
the level of the lesion, with dividing the bone with the chisel
about a centimetre or so above the skin incision, which led
sometimes to the subjacent articulation. The result was
a series of small circular stumps which cicatrised slowly
after suppurating for some time, for it was necessary to
abstain from any form of suture. When the lesion involved
the ankle the technique was the same and just as con¬
servative. Excellent functional results were obtained by
practising simple transverse amputations of the foot without
troubling about lines of articulation, and, above all, without
cutting flaps, which are bound to suppurate, or often to
slough, and which involve much greater sacrifice of tissue.
On the other hand, daring long expectant treatment we
often saw lower limbs recover whioh presented total gangrene
of the ankle and islets of a superficial gangrene spreading
up the heel and even on to the leg, accompanied by redness,
lymphangitis, and oedema. A rapid operation, without
counting its gravity, necessitated a large and useless
excision, for having sacrificed only the actually necrosed
parts, the alarming symptoms were seen to pass off, the
integument took on a normal appearance, and the islets of
superficial gangrene progressively oicatrised. It was thus
possible to practise secondarily very conservative operations
on the ankle, when one might have been tempted to sacrifice
the leg by intervening too soon.
VIII. Erysipelas.
To the surgical complications just mentioned erysipelas
must be added. Its frequency, known since Marchison and
Trousseau as a complication of typhus, is easy to understand,
seeing the almost constant presence of the streptococcus in
typhus convalescents. Danielopol reported 9 oases among
200 typhus patients.
Its localisation was variable. In some oases it super¬
vened spontaneously, and was then situated on the face,
sometimes associated with lymphangitic abscesses. In others
—and this fact has struck us particularly—it supervened
after surgical intervention, such as incision of the parotid or
of phlegmons, but especially after operations designed to
adjust the stumps left after gangrene of the lower limbs.
As a result of the incision a veritable inoculation occurred
whatever antiseptic precautions were taken, and after an
incubation period of 3-5 days a typical erysipelas developed
which impaired the patient's outlook.
Ctutolusions.
Most of the surgical complications following exanthematic
typhus observed during the epidemic of 1917 in Roumania
were suppurative complications due to the micro-organisms of
secondary infections, and particularly to the streptococcus.
Streptococcal septicaemia—thp point of origin is the bed¬
sore or the bucco-pharyngeal ulcer—explains all the
suppurative localisations which we have had to treat. It
seems desirable to make an exception in the case of gangrene,
where the obliterative arteritis is possibly due to the still
unknown germs of the disease.
The clinical course of all these complications is generally
subacute or chronic.
The prognosis is very often grave; this is due lees to the
local complication than to the seriousness of the general
condition and to the exhaustion of the patient. Indeed,
most of our typhus convalescents, having reached the
extreme limit of physiological resistance and being
exhausted by successive illnesses, died from lack of the
power to resist a trifling infection.
The treatment must envisage the general condition and
the local complication. A first main point is to avoid
secondary infection by preventive treatment. For this it is
necessary during the acute period of the disease and during
convalescence to carry out oareful hygiene of the skin and if
the food and air passages.
The general treatment often surpasses local treatment. It
is necessary to struggle against the condition of physical
exhaustion and of extreme physiologioal want by means of
•good food, injections of serum, adrenalin, and the like.
The local treatment varies with the particular localisation,
it must be carried out in stages, regulated before all by the
condition of the patient. General anaesthesia must be
avoided as much as possible ; when it is necessary it must
be brief and cautious.
In the case of suppurative collections, after evacuation of
the pqs and curetting of the focus in order to eliminate the
necrosed tissues we have often employed discontinuous
irrigation with Dakin’s solution according to Carrel’s method,
and we have seen operation wounds thus become sterile; we
have even gone on to secondary suture, in spite of the
presence of the streptococcus. Possibly certain varieties of
streptococcus were less virulent, as the attenuation of the
general symptoms suggested ; perhaps the patients, who were
often septiesamio, had acquired a certain degree of immunity.
This immunity might, moreover, be accentuated by the
employment of antistreptococcic serum.
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30
The Lancet,] THE MEDICAL PROFESSION AND THE TRADE-UNION QUESTION. [Mabch 1, 1919 345
THE LANCET.
LONDON: SATURDAY\ MARCH 1, 1919.
The Medical Profession and the
Trade-Union Question.
A meeting, following An invitation extended to
the medical profession in the metropolitan area,
was held on Sunday last at the Wigmore Hall. The
meeting was convened by the Council of the Medico-
Political Union with the object of passing a resolu¬
tion for the organisation of the medical profession
on a trade-union basis, and such a resolution was
carried by a large majority at a gathering whose
sentiments on the subject were obvious, and
many of whom were committed already to
the programme. The time at the disposal of
the meeting was largely occupied by statements
made in behalf of the resolution, and, though
a hearing was given to certain dissentient
voices, the very brief period which the
chairman was able to allot to each speaker pre¬
vented the presentation in any adequate shape of
arguments directed against the manifest views of
the bulk of the audience: but even so, the majority
voters owed a proportion of their preponderating
strength to the argumentative, rattling, but reasoned
address of Dr. E. H. M. Stancomb, who came up
from Southampton to explain to a London audience
how his provincial experience ought to hold good
for his metropolitan brethren. We suggest, how¬
ever, with no idea of belittling the sound sense of
his words as a whole or of minimising the force of
his main arguments, that in a truly representative
audience he would not have escaped some funda¬
mental criticism.
Dr. Stancomb, speaking, we believe, for the
Council of the Medico-Political Union—and seldom
were any of his statements or deductions received
with dissent in the hall—developed his arguments
along familiar lines, and, indeed, referred to the
fact that he had made already scores of addresses
similar to the one he was delivering. Premising
that the medical profession in all attempts to
bargain with the State had got the worst of the
negotiations, he asserted that the lack of political
force among medical men was due to the fact that
the politician, necessarily a party man, was not
attacked at his only vulnerable spots—viz., party -
interest and self-interest. He pointed to the
success which had attended the methods of the
great trade-unions as a proof that Governments
would listen to the organised voice of trade,
but paid no attention to arguments or protests
presented in any other way. Admitting that
the last weapon of the trade-unions had been
the strike, he disavowed any intention on the
part of the Medico-Political Union to employ
such a weapon except in the long last, when, more¬
over, in no circumstances would it be used against
the sick, but only against Government regulations,
concerning which a fair heading had been refused
to accredited medical representatives. The first
step, therefore, must be to obtain for the medical
profession such accredited representation, when it
would follow, or ought to follow, that any bargain
entered into with Government by such an accredited
body must be adhered to in spirit and detail, unless
and until both parties to the bargain were agree¬
able to variation. The assumption, at this point
of the address, was that a medical trade-union
could be formed, and be generally accredited;
and while the particular audience at the Wigmore
Hall seemed to regard the assumption as a perfectly
safe one, they cannot in this particular have been
representative of the whole medical profession.
Dr. Stancomb dealt in an ingenious way with the
allegation that the medical profession would have
difficulty in forming an effective trade-union,
having regard to the fact that it could not have
either the numerical force or the mass influence of
the great trade-unions whose influence upon modern
legislation has been so marked. He denied that a
medical trade-union would be an impotent affair,
and, on the contrary, was apprehensive even of
the power that would thus be obtained, because
a medical trade-union would be, from the very
nature of the vocation concerned, protected
from the weakness caused by blacklegging. This,
of course, is true in the main, for, as a medical
man receives five years of intensive study at the
expense to himself of £1000 before he can acquire
the legal right to practise, substitutes for him
cannot possibly be found outside his own ranks.
But for this very reason does the trade combination
within his own ranks require to be held together
by a unanimity that can hardly be hoped for. If
all those holding the necessary medical qualifica¬
tions declined to carry out regulations which they
consider to be unfair until their arguments had
been properly attended to and their grievance^ if
proven, had been adjusted, there would be no
possibility of any other class taking their place either
temporarily or permanently. Thus an effective
strike would ensue. But those who follow the
profession of medicine have not always the simple
issues before them that confront the boiler-maker.
The inadequate pay of our calling is generally
felt, and there would be the general impulse
to combine and to cohere after combination,
but more than such an impulse would be
necessary to consolidate the working of a medical
trade-union.
A trade-union cannot succeed unless it represents
substantially a union of those employed in the
trade. We are perfectly aware that many trade-
unions have within their fold dissentient and sub¬
stantial minorities, but for practical purposes the
members have a common policy which can be easily
translated into political activity. The common
policy of the medical profession is to benefit the
human race, and how to translate this into political
activity is in theory and practice, principle and
detail, the eternal striving of all good citizens as
well as of all medical men. That policy is in
existence, is working daily with more force, and now
that a Ministry of Health is actually born is the
time for speeding its activities. It is, indeed, the
346 The Lancet,]
THE PREVENTION OF INFLUENZA.
[March 1, 1919
accepted time, because never was the public more
ready to back the medical profession than now, and
never was there a better chance of obtaining public
assistance for the persuasion or coercion of
politicians. Victory in the war has been obtained
primarily by the valour of our fighting forces, but
those forces were kept in being and efficiency by a
self-sacrificing, devoted, and able medical service.
In times of peace such a service will be as much
required as in times of war, and the public is fully
aware of this. The public will see in the formation
of a medical trade-union a perfectly legitimate
course in some directions of medical work, but
certainly not in other of the countless places where
the medicine of the future will be the mainspring
of legislation. Thus the formation of a medical
trade-union will be attended by two difficulties:
the movement will not receive enthusiastic adher¬
ence from all classes of the medical profession, and
it will not be supported in entirety by the public
for whose benefit it must be guaranteed to exist.
We agree entirely with Dr. Stancomb that an
accredited body representing medical opinion ought
to be placed in a position to negotiate with Govern¬
ments upon medical questions, but we do not think
that a medical trade-union, despite its obvious
advantages in certain important crises, would secure
for the medical profession that freedom to work
and to develop for the public good which is our
common policy. The questions here touched upon
should be, and perhaps will be, discussed by the
Joint Committee of the English Colleges whose
Memorandum on the formation of the Advisory
Medical Council under the Ministry of Health Bill
will be found in another column. They are also
questions which might well be closely debated
by such a body as the Medical Parliamentary
Committee aspires to become; but that body
mist be made representative of the various and
varying interests concerned before what issues
from it can have any political force. Will the
necessary cooperation be given to that Committee,
as a temporary measure, and in recognition of
the fact that no medical body, not even the Royal
Corporations or the powerful British Medical Asso¬
ciation, separately or in combination, can claim to
speak with the common voice of all ?
The Prevention of Influenza.
Wb are still on the rising side of the third wave
of the influenza pandemic and, it is to be hoped,
nearing the crest. From the clinical records as yet
available the type of disease does not appear to be
widely different from that of previous waves except
that severe cases, although lamentably frequent,
do not form so large a proportion of the total
attacks. There is also a wide impression that
older people have lost the relative immunity which
they at first enjoyed, an opinion, however, not
based upon exact figures and possibly having its
origin in the invasion of every hitherto safe nook
and cranny in the inhabited .world. Preventive
measures are still being much canvassed, although
the situation must soon be profoundly modified by
the exhaustion of all susceptible clinical material.
Few countries in the world have failed to issue
instructions to their sanitary authorities and
warnings to the public, and our own Local Govern¬
ment Board has taken the opportunity of resuming
the accumulated experience of the past six months
in a Memorandum which has just been widely
circulated. This Memorandum, which includes
the substance of the letter of advice issued
by the Royal College of Physicians of London, is
insistent upon the essential need of teaching the
individual citizen to realise his duty to the com¬
munity. The central pivot in the preventive pro¬
gramme is therefore a leaflet of advice to the
public which runs as follows:—
1. The golden rule is to keep fit, and avoid infection as
much as possible.
2. The way to keep fit is to cultivate healthy and regular
habits, to eat good food, and to avoid fatigue, ohill, and
alcoholism. Healthy living does not of itself ensure against
attack, but it makes the patient better able to withstand the
complications which kill.
3. The early symptoms of influenza are usually those of a
severe feverish cola. Though the actual cause of the disease
is unknown, we do know that it is rapid in onset, that it is
most infectious in its early stages, and that it is spread by
discharges from the mouth and nose, and that it kills mainly
by its complications. Every person suffering from the
disease, no matter how mild the form, is a danger to others.
4. It is not always possible to avoid infection, but the risks
can be lessened by¬
te) healthy living;
lb) working and sleeping in well-ventilated rooms ;
(c) avoiding crowded gatherings and close, ill-ventilated
rooms;
(d) wearing warm clothing;
(e) gargling the throat and washing out the nostrils; *
(f) wearing a mask j- and glasses when nursing or in
attendance on a person suffering from influenza.
5. Do not waste money on drugs in the false hope of
preventing infeotion.
6 . Those attacked should—
a) go home, go to bed, and keep warm;
b) call in a doctor;
(c) occupy, if possible, a separate bedroom or a bed
that is screened off from the rest of the room:
(d) when ooughing or sneezing hold a handkerchief in
front of the mouth ; the handkerchief should be boiled,
or burnt if of paper;
(e) use a gargle as described;
If) be careful during convalescence in order to avoid
relapse or complications;
( g ) avoid meetings and places of entertainment for at
least one week after the temperature has become normal.
Most of the measures, it will be seen, are based on
the now generally accepted dogmas that influenza
is to all intents carried exclusively by direct con¬
tagion and principally in the form of droplets of
infected secretion expelled in the act of speaking,
ooughing, sneezing, or hawking. The Memorandum
attributes a lesser danger to the finer infective
particles carried over longer distances by draughts
or air convection currents, the virus rapidly
becoming attenuated outside the body.
These dogmas suggest a number of rather obvious
general measures on which all are agreed, but
which, nevertheless, require for their complete
carrying out a degree of carefulness on the part of
the average citizen which is by no means yet at the
command of even the most enlightening local
authority. Two special measures merit further
discussion, inasmuch as they have been prominently
* The following may be used aa a gargle A eolation of common »lt
(one teaepoonfal to a pint of warm water) to which a few crystals of
potassium permanganate are added—enough to make the solution pink.
t The mask, which may be made of gauze (4 layers) or butter muslin
(3 layers) should cover the mouth and nose. To protect the eyes it Is
advisable to wear goggles.
This Lanobt.]
THE FRENCH SUPPLEMENT TO “THE LANCET.
[March 1,1919 347
brought before the public in the daily press and
are not nncontroverted in medical circles. Face
masks, the Memorandum suggests, should be used
as much as possible by those attending on the sick,
and certain authorities have gone further, especially
in America, and have enjoined their general use by
the public whilst travelling or exposed to infection in
ordinary social intercourse. We do not know on what
evidence the influenza mask has been held to be
an efficient preventive, but a careful investigation
by Dr. Lauterburg at the instance of Professor
H. Sahli, of Berne, has Bhown 1 that the usual
mask of commerce in Switzerland is completely
permeable for the fine droplets which Professor
Sahli considers to be the principal medium of
infection. Dr. Lauterburg carried out his experi¬
ments with a mask, adapted to a plaster-cast
of the face, through which air was aspirated
at a pressure carefully regulated to be less than
the inspiratory force. A nebulised watery sus¬
pension of B. prodigio8U8 passed freely through the
mask. In commenting upon this result Sahli does
not deny that the mask may yet serve some
purpose by holding back the coarser particles of
secretion expelled into the air during the act of
coughing. But he holds with the Fliigge school
that these visible pellets play an infective rdle sub¬
ordinate to that of the infected droplets which may
remain suspended for hours and be carried direct
into the alveoli of the lung. Analogy with the
cotton-wool plug of the oulture tube may, Sahli
thinks, have led observers astray, the conditions
being very different in the case of the plug, which
is of much denser construction and has no suction
on one side of it to draw bacteria through. The
kindred observations of his colleague, Professor
Kohlschutter, suggested that gas masks also
failed in their purpose by allowing small particles
of moisture charged with poison gas to pass readily
the material employed. Sahli does not discourage
the use of goggles and of a kerchief held before
the mouth and nose by physicians and nurses
for their own protection, stating that such
measures have a useful educational influence upon
the patient in contrast to the feeling of amazed
horror aroused by masked attendants. It would be
more reasonable for the patient to wear a mask,
but this is impracticable in view of further
impeding respiration, which already may be
difficult.
The second measure around which discussion
centres is the value of preventive inoculation.
8ince we are uncertain of the primary cause of
influenza, so the Memorandum runs, no form of
inooulation can be guaranteed to protect against
the disease itself. In this connexion Sahli' s
well-known distrust of hasty generalisations may
lend special weight to his views. The fact of
naturally acquired immunity in influenza he
holds to be proven beyond doubt, first by the
critical tall of temperature which points to the
sudden appearance of antitoxic forces in the
organism (using the term antitoxic in its widest
sense); then by the occurrence of relapses in the
strictly isolated patient, who must, in order to
relapse, have been harbouring the active virus
against which he was in a measure protected; and,
thirdly, by the partial immunisation of humanity
shown in the long periods between successive
pandemics. Young adults have been specially
affected by this epidemic both at home and
abroad, and Sahli in accepting this fact for
both the pandemics in his own experience
deduces from it that younger people were
first attacked owing to the residual immunity
retained by the older section of the community.
These facts have an important bearing on the
rationale of artificial immunisation, while they
greatly complicate accurate judgment upon < its
results. To the relative failure of immunisation
against influenza in animals Sahli does not attach
much weight except in deducing from it the
unlikelihood of obtaining a really potent antitoxic
serum. The vaccine he has employed himself
contains 80 million bacilli in the initial dose of
0*1 c.cm. To use a larger dose than this was to run
the danger of provoking the disease by inducing a
negative phase in subjects already exposed to
infection, but this limitation he finds unfortunate,
as it is only the large dose which confers a high
degree of immunity when the immediate risk of in¬
fection is not present. One interesting and apparently
forgotten observation by Dr. Julius Goldschmidt
may be recalled from the previous epidemic—
namely, that in the island of Madeira revaccination
against small-pox protected the population very
materially against a simultaneous epidemic of
influenza. It is quite evident that the inoculation
method requires and deserves all the attention which
can be given to it. Experience is accumulating
rapidly in many countries, and the results when
obtained and collated should be available for use
in the next pandemic if preventive medicine has
not by then forestalled the need for it.
The French Supplement to
“The Lancet.”
The article in the French Supplement in our
present issue on the Surgical Complications
following Exanthematous Typhus, raises once
more the interesting question of mixed infections.
Quite apart from the fact that the terms mixed
infection and latent infection are not clearly
defined bacteriologically, and are consequently used
in a vague sense, the question of symbiosis is likely
to become one of importance in the near future.
Dr. Paul Moure and Dr. Etienne Sorrel discuss
the problems as they may be associated with the
presence of tubercle bacilli and pyogenic cocci in an
infective disease of doubtful bacteriology; whilst
the prevailing influenza epidemic is now daily
raising similar etiological difficulties in yet
another direction. Bacteriologically there are
as yet very few facts to generalise upon.
Extensive observations are needed upon pleo-
morphism, pathogenicity and susceptibility, classi¬
fication and nomenclature. In the meantime
we must fain rest content with an interim view
that certain so-called zymotic diseases, and
amongst them typhus, measles, and whooping-
cough, diminish the resistance of the human
body to pathogenic organisms such as the tubercle
bacillus and the pyogenic cocci. Quite a number
of similar examples might be chosen at random
from the epidemiological history of the present
war. After all, it was but another aspect of this
same subject, the identity of infective disease,
which called forth Sir William Jenner's famous
remark that the voice of Nature could only
be heard 11 by patience and daily watching, by
keeping honest record of every sound she
uttered—by joining letter to letter, adding word
to word and line to line.’'
1 Oorre»pondenz-Hlfttt (Sr Schwelxer Aerzte, Feb. 16th, 1919.
348 TheLancet,] ACUTE INFECTIVE POLYNEURITIS —EPIDEMIC “FOOD POISONING.” [March 1.1919
"He quirt nimls.”
ACUTE INFECTIVE POLYNEURITIS.
How the discovery of a new technique may be
fruitful in many directions is exemplified in the
case of a research described under the above title
in the current numbers of the Quarterly Journal of
Medicine by Major-General Sir John Rose Bradford,
Captain E. F. Bashford, and Captain J. A. Wilson.
The successful cultivation by the Noguchi method
of the “ filter-passer ” globoid bodies, which are
regarded as the causative organism in acute polio¬
myelitis, led the authors to employ the same method
in the case of other diseases. As stated in their
communication to The Lancet of Feb. 1st, they
have been successful by this means in cultivating
organisms from cases of acute infective polyneuritis,
trench fever, influenza, nephritis, mumps, measles,
rose measles, typhus, and encephalitis lethargica,
which, in the case of the first four, they have shown
to produce these diseases when injected into
animals, and which are recoverable from those
animals while suffering from the maladies thus
caused. During the campaign in France and
Flanders a group of cases with generalised palsy of
a peculiar character has been recognised. In most
of the cases three stages in the disease can be
observed:—(1) An initial illness; (2) a period
of latency; (3) a paralytic stage. The initial illness
consists of moderate pyrexia, headache, vomiting,
and pain in the back: occasionally sore throat and
pains in the limbs. These symptoms disappear
in a few days. The period of latency seems to be
variable, in many instances lasting but a few days,
in some four to six weeks, while in others the
paralysis appears to be the first manifestation
of the disease. The paralytic stage may occur
suddenly, but is generally ingravescent and accom¬
panied by pareesthesim of the extremities. The main
peculiarities of the palsy are that the legs are
affected as a whole—i.e., there is no picking out
of individual muscles as in poliomyelitis, but the
proximal is usually more affected than the distal
part of the limbs; the arms and muscles of the
trunk are always affected, while palsy of the facial
muscles, which is bilateral and occurs later in the
disease, is most characteristic. Paralysis of the
third nerve was not observed at all, and palatal
palsy was very rare in the series of 30 cases studied.
The objective sensory changes are usually relative
in degree and have a glove-and-stocking distri¬
bution. The deep reflexes are abolished, while
sphincter control is not profoundly affected and
may remain normal up to the end even in fatal
cases. No cerebral or mental symptoms are recorded.
The blood shows a moderate leucocytosis and the
cerebro-spinal fluid exhibits no abnormality. The
mortality is high—8 out of 30 cases—half the deaths
occurring within a week of the onset of the paralysis
and being due to respiratory failure. Recovery is
slow but complete, the facial muscles often being the
first to show improvement. Macroscopic examina¬
tion post mortem is negative. Microscopically the
lesions found are: (1) acute neuritis in the nerves,
particularly the large trunks; (2) scattered minute
hemorrhages, diffuse round-celled infiltration, and
degeneration of nerve cells in all parts of the grey
matter of the cord, medulla, and brain. Captain
Bashford states that 11 consideration of the
whole pathological process would point to a
septicemia or systemic poisoning, which enters *
the central nervous system by way of the nerve
trunks, both motor and sensory, and is probably of
an infective nature.” The accuracy of this last
statement is proved by the results of subdural
inoculation of monkeys with emulsion of human
spinal cord preserved in glycerine. The animals
developed a disease identical with that observed in
man, and inoculation of further monkeys with
material from those affected was also successful.
All attempts to cultivate the organism by ordinary
methods failed, but success was attained by employ¬
ment of the technique of Flexner and Noguchi.
Captain Wilson states that “ the conditions of
growth, whether a primary culture or subculture
is in question, are of a strictly limited character,
and remains so.” The organism is similar to the
globoid bodies of poliomyelitis in its general
features, appearing as a rounded, oval, or kidney-
shaped body measuring 0’2 to 0 5m in diameter,
presenting a darkly stained, rounded spot, which is
surrounded by a narrow faintly stained area. But it
differs in several minor characters and crucially
in that “ the organism isolated from cases of
polyneuritis inoculated subdurally into monkeys
produces a disease which is clinically and patho¬
logically distinct from anterior poliomyelitis, a
disease which is identical with that from which it
was obtained.” Sir John Rose Bradford points out
that, “ in the presence of these facts, the con¬
clusion would seem to be justified that so-called
acute febrile polyneuritis is really a malady allied
to, but quite distinct from, poliomyelitis. The
conclusion would entail as a corollary that the
virus of poliomyelitis, instead of being an isolated
and peculiar virus, is really one member of a class
of organisms, and that the virus of polyneuritis
is another, but distinct, member of this class.”
In view of what has been already achieved by the
application of the new cultural methods, such
words appear to us to open up a vista of immense
possibilities in the not too distant future.
EPIDEMIC “FOOD POISONING.”
In the spring of 1918 an outbreak of “food
poisoning ” occurred in a military depdt in
France. The opportunity thus offered for a com¬
bined epidemiological, clinical, and bacteriological
research was not missed, and a report on the
investigations, which were carried out by Captain
H. M. Perry and Captain H. L. Tidy, has been
published by the Medical Research Committee, 1
and constitutes a valuable contribution to our
knowledge of the subject of “food poisoning” in
general. Outbreaks of “food poisoning” are not
of uncommon occurrence, and a number of such
epidemics have been investigated in detail in
different countries. In all of them the clinical
features have been similar, whilst the general charac¬
teristics have been the simultaneous development
of symptoms and their limitation to persons who
have partaken of some particular article of food.
The epidemic under consideration varies in that
while the infection was conveyed through the
consumption of food, after the initial outbreak
subsequent cases occurred extending over a
prolonged period.
Now bacteriological investigation of the food¬
stuffs and of the “ poisoned ” individuals in epi¬
demics occurring during the past 30 years has led
to the incrimination as causative agents of an
interesting group of bacteria, two members of
1 A Report on the Investigation of an Epidemic Caused by Bacillus
a r rlrucke % Medical Research Committee, Special Report Series, No. 84.
1919. 9d.net.
This .Lancet,] TWENTY YEARS OF PLAGUE IN INDIA.—OCCUPATIONAL FRACTURES. [March 1,1919 349
which, the Bac. enterittdis of Gaertner and the
Bac. aerbrycke of Durham and De Nobele, are most
usually at fault. The epidemic with which Captain
Perry and Captain Tidy had to deal was due to the
latter bacillus. There is still divergence of opinion
as to the relations of the organisms of this
“ salmonella ” group to each other and to those of
allied groups, and not the least interesting feature
of the report is that the authors are able to
produce evidence demonstrating not only the
possibility but the desirability of differentiating
between thefee bacteria. Of prime importance to
the medical reader is the establishment of the fact
that “ food poisoning ” may not only be caused by
the consumption of food in which active toxins are
present, but also by an actual bacterial infection
directly attributable to the ingestion of food con¬
taminated by a u chronic carrier.” The report is
worthy of careful perusal alike by the epidemio¬
logist, the clinician, and the bacteriologist. Not
only is it informative, but it contains much that is
suggestive, more especially as to the relationship
between *' food poisoning ” and other forms of
enteritis. Whilst drawing the attention of our
readers to the report, we venture to congratulate
Captain Perry and Captain Tidy on an accomplished
piece of work. __
TWENTY .YEARS OF PLAGUE IN INDIA.
India for some years has been by far the most
important reservoir of plague infection in the
world. Much of our knowledge of the disease has
been gained by investigations in that country, and
any report on the stibject that comes from India is
especially valuable, the more so if it is furnished by
an expert. A recent report of great interest has been
supplied by Major F. Norman White, C.I.E., Sani¬
tary Commissioner with the Government of India, 1
giving details of the annual epidemics of plague
in India during the past 20 years. As is known,
the disease was brought to Bombay in the autumn
of 1896, but it was not until 1898 that it became
more widely diffused outside that province. Like
other eminent Indian epidemiologists, Major White
adopts, not the calendar year, but “ the plague
year,” which begins in July and ends in June
of the following year. As July is the month
of the smallest incidence of plague in India, it
forms a suitable starting-point for tracing the
annual curve, which, rising in the latter months
of the year, attains its maximum in the follow¬
ing March and April, and falls rapidly in May and
June. From July 1st, 1898, to June 30th, 1918,
more than 10£ millions of people died from plague
in India. The four most serious epidemics were:
(1) in 1904-5 when 1,328,249 fatal cases were
recorded; (2) in 1906-7 when there were 1,286,513
deaths; (3) 1903-4 when 1,138,451 persons died; and
(4) 1917-18 when 820,292 deaths occurred. The two
mildest outbreaks were: (1) in 1898-99 when 119,045
fatal cases were reported; and (2) in 1908-9 when
126,442 deaths were registered. The three Indian
provinces which experienced the worst ravages of
plague were the Punjab, which during the 20 years
lost 2.992,166 of its population from the disease; the
United Provinces of Agra and Oudh, which lost
2,386,332; and the Bombay Presidency, which lost
2,295,221. Some parts of India have suffered but
little from the scourge, and it is stated that the
districts which have practically escaped have been
1 Twenty Yetrs of Plague in India, with 8pecial Reference to the
Outbreak or 1917-18. Published In the Indian Journal of Medical
Reseatcb, vol. v!.. No. 2.
mainly the rice-growing areas, the worst sufferers
being the wheat-growiDg districts. It is suggested
that in rice-growing districts comparatively little
grain is imported from other localities, and that the
facilities afforded by the movement of grain for the
transport of the infection (by infected rats and their
fleas) explains the difference to some extent.
Major White draws attention to varying intensity
of plague epidemics in different localities and in
different years. In this connexion he refers to the
investigations of the Plague Research Committee,
which showed that the severity and diffusibility of
plague outbreaks in certain areas appear to depend
upon conditions of atmospheric humidity, which in
turn depend on rainfall. Humidity in excess of the
normal at certain seasons of the year is beneficial
to the rat flea in all stages of its development; and
a flea population in excess of the normal appears
to be essential to plague epidemics of more than
average intensity. Major White thinks that there
is some evidence of a diminished virulence of
the plague infection in certain localities, and the
suggestion is made that this may be due to an
increasing immunity of the rat population. But
this immunity of the Indian rat cannot be
said to be by any means general, and it is
probable that a long time will elapse before
a marked decrease of plague in India from this
cause will become apparent. In the Times recently
an optimistic writer discussing this question stated,
“ there are now perceptible signs that the periodical
epidemics are permanently abating in virnlence.”
But the latest available figures, those above
mentioned for 1917-18, relating to India as a whole,
hardly support this too sanguine opinion, as that
outbreak, the worst that had occurred for 10 years,
caused the deaths of 820,292 persons. It is unlikely
that the plague-mortality in India will become
permanently reduced until public health administra¬
tion, especially in the rural districts, has been
placed upon a better footing. It is satisfactory,
however, to learn that steps in this direction have
already been taken, bat much more remains to be
done. _
OCCUPATIONAL FRACTURES.
We are accustomed to hear much about diseases
of the 6kin due to the occupation, and various
diseases, such as lead poisoning, are also classed
together as caused by the trade or business ; but it
has not been so well recognised that there are
certain fractures which are almost, if not entirely,
due to the work which the sufferer has been
doing. Last week we published a paper by Lieut.*
Colonel A. L. Johnson, C.A.M.C., which describes
a highly interesting form of fracture of the
humerus caused by a blow from the propeller of
an aeroplane. The author had seen four cases of
the condition and in each instance there was a
fracture of the right humerus a short distance
above the condyles. The fracture was compound,
and the wound and the fracture were both caused
by a blow from the blade of the propeller
from a premature starting of the engine before
the mechanic, who was “ swinging ” the propeller,
could get out of the way. It certainly deserves
to be classed with the occupational fractures.
Many motorists are painfully aware of the very
analogous fracture which arises from the back-fire
of a motor engine when starting, or sometimes it
may be caused from the handle striking the wrist.
This “chauffeur’s fracture” affects the radius near
its lower end, but the exact site varies, and now
350 The Lancet,] RESTORATION OF GLYCERINE AND OTHER MEDIA TO PHARMACOPOEIA. [March 1,1919
that self-starters are becoming common the lesion
is growing rarer. The war has led to the produc¬
tion of a new form of fracture of the humerus.
When hand-grenades were first introduced many
men endeavoured to throw them as if they were
cricket balls, forgetting that their weight was much
greater. The momentum caused by the weight of
the grenade was in many cases sufficient to cause a
curious spiral fracture of the bone. The same kind
of fracture has been met with but very rarely as a
result of the throwing of a cricket-ball, and it is
quoted in the text-books as an example of a fracture
caused by muscular action. The spiral fracture of
the fibula which is sometimes sustained by the
inexpert performer on skis also belongs to this
class. We may take it as certain that any new
industry or sport is likely to give rise to some new
form of disease or injury, and the latest of these is
the propeller fracture._
THE RESTORATION OF GLYCERINE AND OTHER
MEDIA TO THE PHARMACOPCEIA.
At its meeting on Feb. 24th, 1919, the Executive
Committee of the General Council of Medical
Education and Registration, having considered the
advisability of withdrawing the temporary altera¬
tions in the British Pharmacopoeia published during
the war, and arising out of the scarcity of sugar,
glycerine, and certain oils and fats, adopted the
following resolution:—
“ That the Executive Committee, on behalf of the Council,
order and direct that, on and after April 30th, 1919, the
British Pharmacopoeia, 1914, shall be altered and amended
by revoking and withdrawing the alterations and amend¬
ments made and published in the Gazettes of July 27th, 1917,
and March 29th, 1918; and that formal intimation of such
revocation and withdrawal be published according to law
in the Gazettes of London, Edinburgh, and Dublin, on
April 30th, 1919.”
This resolution will be welcomed and a word of
praise may well be accorded to those authorities who
issued instructions as to how glycerine and other
media could be replaced in official preparations.
As a temporary measure the inconvenience caused
by the restrictions was not so serious as some
anticipated. From time to time we have published
notes as to how glycerine and sugar could be spared
by the use of substitutes, which in the majority of
cases could be made to serve the same purpose.
While this information was useful there is little
doubt that a return to the classic excipients will be
appreciated. _
LOUPING ILL.
Several investigations have recently been carried
out on this disease in sheep, but little progress
made in its prevention. In the last number of the
Journal of Comparative Pathology and Therapeutics
Sir Stewart Stockman, of the Board of Agriculture
and Fisheries, discusses the rdle played by ticks
in the production of looping ill. Particulars are
given of 101' experiments conducted by the Board
with a view of throwing light upon the cause,
nature, and course of the disease. Sir S. Stockman
is not inclined to think that the complaint in Bheep
has any close relationship to poliomyelitis in human
beings. The disease is definitely tick-borne, and
the infecting agent is not a toxin. It is transmitted
by larval ticks (Ixodus ricinus) from females which
have heen feeding on the blood of infected sheep.
It was also produced by adult ticks which had been
fed as nymphs on infected animals and by inocula¬
tion of gland juice and blood from such animals.
Arrangements are being made to test the practical
value of protective inoculation in the case of adult
sheep brought on to farms for the purpose of
re-stocking, as well as in lambs born on the farms.
The eradication of the tick suggests itself as one
way of preventing the disease, and an intensive
study of the life-history of the parasite is obviously
a preliminary to the framing of an appropriate
campaign. _.
THE TOLL OF INFLUENZA.
The recrudescence of the influenza epidemic
is brought home to us this week by the fact that
we have to regret the death of Major H. Graeme
Gibson, R.A.M.G., whose paper, in cooperation with
Colonel S. L. Cummins, A.M.S., on Tetanus in the
British Army appears in this issue of The Lancet.
Again, only last week we published an interest¬
ing article on the blood-supply of muscles,
with reference to war surgery, by Captain J.
Campbell, R.A.M.C., and Captain C. M. Pennefather,
R.A.M.C., and we regret to say that while the
proofs were in his hands for correction Captain
Campbell died at a nursing home in LiverpooL
Mr. Harry Blakeway’s untimely death while acting
as resident assistant surgeon to St. Bartholomew’s
Hospital is a calamity to the hospital which he
served so well, and a sad loss to the review columns
of The Lancet, where his wide reading and clinical
experience made him a valued coadjdtor.
THE MARRIAGE-RATE OF SOUTH AUSTRALIA.
The Annual Report for 1917 of the Registrar-
General for South Australia, Mr. Adrian J. Korff,
has just been issued, and among the outstanding
features of the report the following maybe noted:—
“The number of marriageB showed a considerable falling
off, and was very much below the average of the last
10 years, and the marriage-rate also declined to a figure lower
than that of any year since 1906.
The fall in marriages was reflected in births, whioh also
stood at a low figure for the year, being nearly 1000 lees than
the average of the preceding five years.
The infantile mortality-rate for 1917 was very favourable,
the proportion of deaths of infants to 100 births registered was
the lowest ever recorded, and was very serviceable in
balancing the decline in the birth-rate.
The death record was much below the average, and the
death-rate was the lowest for the last six years.”
Owing, however, to the small number of births, the
natural increase lor the year 1917 was considerably
under the average, and the sex proportion of those
births presents some interesting features.
“ Of the total births registered, 5762 were male and 5564
female, the proportion of the former to 100 of the latter
being 103 56. The Commonwealth ratio in 1917 waB 106*26,
and m England, according to recent returns, the proportion
for the five years ended with 1916 was 104-0. In the last
anhual report I stated: ‘ The proportion in 1916 for South
Australia was unusually high, and at first sight might seem to
give support to statements which have been made that the
rate of male to female births is increased in time of war;
but it may be pointed out that 109 60 is not by any means
a record for this State—in two successive years, 1887 and
1888, the proportions were 109 70 and 109-82, while in 1903
the high total of 111-29 was reached. The average decennial
rates for the last 30 years were: 1887-1896, 104-78; 1897-1906,
105*62; 1907-1916, 105-43, the decade including the two war
years 1915 and 1916 takiDg only second place in the averages.”
As the proportion of male births for 1917 (103*56)
was very much lower than that of any of the four
preceding years, and was below the average of the
14 years 1904-1917, the female predominance in
South Australia is very marked.
Sir Nestor Tirard has been appointed Consulting
Physician to King's College Hospital, and has been
elected Emeritus Professor of Medicine by the
Council of King’s College, London.
The Lancet,]
THE MINISTRY OF HEALTH BILL.
[March 1,1919 351
THE MINISTRY OF HEALTH BILL.
The Action of the General Medical Council.
The Executive Committee of the General Medical
Council, at its meeting on Feb. 24th, considered a com¬
munication from the Lord President of the Privy Council
inviting its observations on the Ministry of Health Bill, 1919,
of which he forwarded copies.
The Committee, on behalf of the Council, authorised
the President to forward the following resolutions on the
subject to the Lord President, for communication to the
Government:—
1. That the Executive Committee observes with regret that
the Bill does not extend to the whole of the United Kingdom,
as was urged in the resolution of the General Medical
Council of Nov. 30th, 1918, and that the Executive Com¬
mittee presses on the Government the importance of intro¬
ducing legislation corresponding to that proposed for
England and Wales, and for Scotland, appropriate to the
special conditions obtaining in Ireland.
2. That the Memoranda No. 1 and No. 2, laid before the
Executive Committee by the Irish Branoh Council, be
transmitted to the Lord President for his information.
3. That in view of the very varied medical functions
devolving on the Ministry of Health in Scotland, including
measures for the prevention and cure of diseases, the treat¬
ment of physical and mental defects, the collection and
preparation of information and statistics relating thereto,
ana the training of persons engaged in health services, the
Executive Committee is of opinion that not less than one-
third of the members of the Scottish Board of Health should
be persons who are registered under the Medical Acts.
4. That the Executive Committee welcomes the introduc¬
tion into the Bill of Clause 3 (2) (d) f whereby the powers and
duties relating to public health, now exercised by Govern¬
ment departments other than those expressly mentioned,
may by Order in Council be transferred to the Ministry of
Health; and that it is desirable that the General Medical
Council should before they are issued have an opportunity
of considering the several draft Orders in Council so con¬
templated for the transfer of such medical powers and
duties.
It was decided that these resolutions should be communi¬
cated to the Lord President of the Council, with a request
that he would be pleased to transmit them to the Government.
Conjoint Action of the English Colleges.
Early in July last the Royal College of Physicians of
London and the Royal College of Surgeons of England
appointed a Joint Committee with power to coopt other
members, whose duty it should be to place before the
Government the conditions conceived to be essential in a
Ministry of Health Bill.
The members of the Joint Committee are: Dr. Norman
Mobre (President of the Royal College of Physicians), Sir
George Makins (President of the Royal College of Snrgeons),
*Lady Barrett. M.D., Sir John Broadbent, Sir Bertrand
Dawson, *Dr. Herbert French, *Dr. W. H. Hamer, Sir Robert
Jones, *Dr. H. R. Kenwood, Sir Berkeley Moynihan, Dr. J. A.
Ormerod, *Dr. John Robertson, Mr. Charles Ryall, and Mr.
H. J. Waring. Mr. F. G. Hallett is acting as secretary and the
coopted members names are marked with an asterisk. The
Home Secretary, now Viscount Cave of Richmond, with other
members of the Home Affairs Committee of the War Cabinet,
on July 29th received a deputation which submitted certain
proposals, including the appointment by the Minister of an
advisory body specially qualified to consider medical ques¬
tions, the right of such body to meet frequently and to have
direct access to the Minister, the equal representation on
that body of curative and preventive medicine, and with a
view to providing that the best opportunities for the pre¬
vention of disease and for the maintenance of health should
be available for every member of the community.
A Memorandum just issued by the Joint Committee runs
as follows :—
The Committee considered at many meetings the con¬
ditions it conceived to be essential to any scheme for setting
up a Ministry of Health, in so far as it concerned England
and Wales; it was considered that the profession in Scotland
and Ireland would more fittingly deal with those portions of
the United Kingdom.
While realising the difficulties there would be in gathering
together the health departments at present scattered through
various ministries under one head and effecting disentangle¬
ment from the Poor-law, the view was strongly held by the
Committee that if the Health Ministry is to take a wide out¬
look and be as little restrained as possible by established
tradition and habit, it should not be more associated with
any existing Government Department than is absolutely
necessary to secnre efficient organisation. In the opinion of
the Joint Committee the aim of any sound health policy
must be to render available the best opportnnities for the
prevention of disease and the maintenance of health for
every member of the community.
Considering that a large proportion of the work of the
Health Ministry, both as regards its policy and its execution,
will depend on the knowledge and cooperation of the
medical profession, the Joint Committee considered it
essential that there should be appointed by the Minister of
Health an Advisory Medical Council, drawn from every
section of the profession, such Council to have direct access
to the Minister, and the power to initiate advice.
Since there will probably be other advisory counoils
besides the Medical Advisory Counoil, the Joint Committee
are of opinion that there should be a connecting committee
in the Ministry for the correlating of the work of the Advisory
Councils in order to prevent overlapping and conflict of
advice.
The Medical Advisory Council, to be of real use to the
Minister, and through him to the nation, must be of
limited size—say, 21 members. It cannot, therefore, be
representative of the members of the medical profession in
the Parliamentary sense. Its members mast be not only
individually excellent, but suoh as will together constitute
a good council of advisers.
To this end the Joint Committee laid down the principle
that in selecting the members of this Council greater
regard most be had to special attainments and experience
than to interests and organisations as such.
Subject to this primary aim, an endeavour should be made
to represent the individual members and the corporate life
of tbe profession.
The Memorandum adds that the Joint Committee were
later received sympathetically by the then Minister of
Reconstruction, Dr. Addison, when explaining and urging
these views. Conferences between the representatives of
the Joint Committee of the Royal Colleges and the repre¬
sentatives of similar committee§ of the Royal Society of
Medicine and the British Medical Association have been
held for the consideration of these important questions
relating to the proposed Ministry of Health. At these con¬
ferences there has been substantial agreement, a fact of
great importance in view of the large body of medical
opinion these three bodies together represent. The Joint
Committee will continue their deliberations with a view to
helping in the formation of a sound national health policy.
PROPOSED EXTENSIONS OF THE
INSURANCE MEDICAL SERVICE.
Having practically completed the examination of the
present conditions of service, and possible modifications of
them, as regards the duties of insurance practitioners
(subject to the present limitations of tbe scope of services
provided) the Commissioners and the Conditions of Service
Subcommittee of the Insurance Acts Committee were pro¬
posing to proceed, in their Twelfth Conference on Feb. 6th,
1919, to the consideration of possible extension* of the scope
of service, including both those new services for which
grants were voted by Parliament in August, 1914, 1 and any
other extensions that might appear desirable.
It had been agreed, both by the Commissioners and the
Insurance Acts Committee, that a satisfactory examination
of this subject would not be possible Unless there were
present to take part in this portion of the discussions an
adequate number of physicians and surgeons and other
medical practitioners representing types of experience
specially involved in the subjects now to be discussed,
and not included in the membership of the Conditions of
Service Subcommittee.
With this object the Commissioners, with the concurrence
of the Insurance Acts Committee, invited on this occasion
1 (1.) Medical referees and consultants, with travelling expenses of
lnsnred persons presenting themselves for examina'Ion. (K) Provision
of specialist consultati"ns In connexion with the treatment of insured
persons, till.) Grants la aid of the equipment and maintenance of
clinics for the use of Insurance practitioners, (iv.) Grants towards the
provision of nur-ing for Insured persons, (v.) Grants towards the
provision of pathological laboratories.
The Lancet,]
[March 1, 1919 353
UNIVERSITY OF BRUS8ELS.—NEW YORK.
of Venereal Diseases, under which distribution of the
respective allotments of the million dollars to be expended
this year will be made to the States. The health autho¬
rities of these States have recognised venereal diseases
as communicable and dangerous to the public health and
have made them legally notifiable. It is anticipated that the
remaining States, with possibly one or two exceptions, will
do so in the near future. Thirty-two States have passed
laws rendering it illegal for druggists to dispense nostrums
and remedies for the treatment of venereal diseases.
The protection of the men in the military training camps
seems to have been adequately and effectively supervised oy
the Army medical authorities, and the same may be said with
regard to the personnel of the Navy. It is. however, obvious
that the main source of infection and spread is the civilian
population. The demobilisation of the soldiers will greatly
complicate the situation, for not only has there been a
decided increase of infection among the civilian population
during the time the United States was at war, but the
demobilised men will be likely easily to lay themselves open
to the risks of infection. They are all young or in the early
prime of lusty manhood ; after the hard and dangerous life they
have been leading, coupled with the fact that they are returning
home safe and sound after a long absence, they are likely to
be in that state of mind when caution is thrown to the
winds, and this feeling will be intensified by freedom from
discipline and all that it entails. In the Army they
were protected as far as possible from the risk of infec¬
tion, and, when infected, were treated promptly and
efficiently. “In this country,” writes one of our American
correspondents, “the most rigid precautions were taken
to prevent them contracting venereal disease. The obliga¬
tion to protect the health of the military forces in
civilian territory was placed upon the Public Health
Service by Executive order and Act of Congress, and this
duty has been performed excellently. The . campaign
inaugurated and being carried on under the auspices of the
Public Health Service and the American Red Cross will
undoubtedly have a good effect in protecting the demobilised
men and preventing the spread of venereal diseases
far and wide, but will hardly be successful in elimi¬
nating the menace. Many medical men here, as in
Great Britain, are in favour of prophylactic measures
similar to those enforced in the United States Army in
1912 and to those used among the Australian forces being
employed in civil life, provided that it is possible. The
seriousness of the problem is folly realised by both the public
and the medical profession, and this realisation alone is to a
great extent an augury of the success of the vigorous cam¬
paign that is being waged by the Government of this country
for the protection of the demobilised soldiers and civilian
population against venereal disease.”
UNIVERSITY OF BRUSSELS:
RESUMPTION OF MEDICAL COURSES.
The Free University of Brussels on Jan. 22nd resumed its
former coarses in the Faculty of Medicine for its own
students, while at the same time the M.D. degree has again
been thrown open after examination to registered medical
practitioners of other countries.
The Domestic Medical Curriculum.
The curriculum of study for Belgian students includes
a course of human anatomy and embryology, conducted
by M. Braohet and M. A. Lameere ; physiology and
histology is taken by M. Dustin and M. J. Demoor;
chemical biology and physiology by M. Slosflfe; surgical
pathology by M. Depage, who also conducts the surgical
clinic at St. Pierre ; general pathology by M. Spehl;
midwifery, including the obstetric clinic at the Maternit 6 . by
M. Cocq ; pharmacology and therapeutics by M Jacques;
bacteriology, parasito ogy, and epidemiology by M. Bordet;
special pathology and therapeutics of internal diseases, and
the medical clinic at St Jean, by M. Ren 6 Verhoogen;
morbid anatomy, by M. Sti 6 non; medical clinic at
St. Pierre, M. Vandervelde ; surgical clinic at St. Jean,
M. J. Verhoogen; psychiatry. M. Ley; ophthalmology and
clinical opht halmology at St. Jean, M. Gallemearts; theory
and practice of operative surgery, M. Laurent; medical
jurisprudence, M. Heger-Gilbert; hygiene, M. Gengou.
Complementary clinical courses are also arranged for
students and doctors of medicine who have registered with
the secretary of the university, and include coun-es at
St. Jean and St. Pierre on children’s diseases, mental affec¬
tions, skin diseases, syphilis, gynaecology, and diseases of
the ear, nose, and throat. Courses of instruction for the
diploma of public health have been arranged, as well as
free courses in (among othe. subjects) anthropology (M.
Houz6), practical urology (M. le Clerc-Dandoy), diseases of
children (M P6cbere), gynaecology (M. Rouffart), practical
radiology (M. Hauchamps).
The M. D. Brussels for Strangers.
The examination for the M D. degree is arranged in three
parts. No conditions of residence are needed ; the time
required for the three examinations seldom exceeds 10 or 12
days, and Candida*es who are unable to be so long away
from’home may take each part separately. The examina-
nations are conducted in Eaglish through the medium of an
interpreter (without additional charge). They take place on
the first Tuesday in November, December, March, and May,
and the second Tuesday in June. They are viva voce , but
candidates may have a written examination by paying an
additional fee of £1 for each test. This does not exempt
them from the viva voce examination. Part I. includes
general medicine; materia medica and pharmacology;
general surgery ; and the theory of midwifery. Part II.
includes general therapeutics; pathology and morbid
anatomy, and the use of the microscope ; special thera¬
peutics and medicine of internal diseases ; special surgery ;
and mental diseases. Part III. includes public and private
hygiene ; medical jurisprudence ; clinical medicine ; clinical
surgery; examination in operative surgery, consisting of
some of the usual operations on the dead subject—viz.,
amputation, ligature of artery, &c. ; ophthalmology; exa¬
mination in midwifery, consisting of obstetrical operation on
the mannequin (model of pelvis), examination in regional
anatomy with dissection ; and bacteriology.
Further information may be obtained from the secretary
of the University, rue des Sols. 14, Brussels.
NEW YORK.
(From our own Correspondent.)
Recrudescence of Influenza .
There has been an unpleasant, almost menacing,
ecurrence of influenza in New York City, and the
sontagion appears to be again spreading. As in the
ecent outbreak, the disease is accompanied, or rather
implicated, by pneumonia, to which most of the mor¬
ality is due. Medical men here, as elsewhere, are not
igreed as to the most effective means of treating influenza.
Many of the practitioners here, perhaps the majority, employ
me or other of the coal-tar products for the purpose of lower¬
ing the temperature. Some, however, hold that such treat¬
ment is frequently harmful owing to the depressant action
3 f these drugs, which may in the long run do more harm than
rood The administration of Warburg’s tincture has been
idvocated by some. The use of vaccines has been followed
with little or no success. The suppression of jnfluenza
undoubtedly depends on rational preventive methods rigidly
mforced, although it is plain that their enforcement is
attended with numerous difficulties.
A Nem Narcotic Drug Lam for New York State.
A new narcotic drug law has been created recently in New
VTork State which supersedes the existing law, and came
into force on Feb. 1st. According to the enactments of the
new law every physician, druggist, dentist, veterinarian,
hospital, sanatorium, or other institution, manufacturer or
wholesale distributer, prescribing, administering, dispensing,
selling, or manufacturing cocaine, opium or its derivatives,
had during the month of January, to file an application
and* receive from the department a certificate of authority
to deal in habit-forming drugs. No fee is teqxAred,
and the registration will stand for the remainder of the
State fiscal year; after that time, during the month of June
i nft h vaar those coming under the above designation
ihaU in with the New York State
Department of Narcotic Drug Control, and for this and each
354 Thb LanobT,]
THE SERVICES.—URBAN VITAL STATISTICS.
[March 1,1919
subsequent registration a fee of $1.00 shall be paid to the
Department.
Prohibition in the United States.
There is much strong feeling with regard to the question
of the prohibition law which will come into effect in all
States of the Union in January, 1920. On the one hand, it
is thought that the present time, when labour unrest is
rampant throughout the country, is peculiarly ill-fitted for
the passing of such a drastic law ; on the other hand, it is
recognised, both by the public and by the medical pro¬
fession, that the abuse of strong drink has been the cause of
much disease and an unspeakable amount of suffering and
misery. At the same time, it is considered by many that it
would have been wiser to proceed more slowly, to restrict
the facilities for procuring alcohol, to lessen the number of
public-houses in the large cities, and improve the quality
of the diminished number. Some of them have been
important factors in corrupt municipal politics and have
been centres of vice. An improvement in the housing
conditions would, in the opinion of many, proportionately
raise the standard of the public house. Among the various
evils whioh (it is prophesied) prohibition will bring in its
train is an increase of the drug habit. In Amerioan
Medicine , January, 1919, it is pointed out that the sale of
drugs increases pari passu with the decrease in the sale ot
alooholic stimulants. Moreover, liquor will be procured
secretly, and there will be a considerable'amount of illicit
manufacture of alcohol. It remains to be seen whether in
America, young and impatient of delay, it is possible to
make a nation sober by Act of Parliament.
Prohibition Begvlations for New York.
A Bill to enforce prohibition in New York State has been
drafted, in ratification of the Federal Amendment, for
introduction to the New York State Legislature. The
Bill contains very drastic provisions relating to the
sale of alcohol by medical men and druggists. The law
enacts that druggists may not sell alcohol except upon a
physician’s prescription, and an affidavit is required of all
persons desiring to buy alcohol for mechanical, chemical, or
sacramental purposes. A pharmacist’s licence to sell
alcohol may not be issued in any form except to druggists
who have never been convicted of an illegal sale of liquor,
and whose stock of alcohol in hand does not represent
more than 1 per cent, of the value of all goods in bis
place of business. Such druggists must be of temperate
habits and may not sell to any person known to be
accustomed to take alcoholic beverages. Moreover, the sale
Cf toilet, culinary, antiseptic, and flavouring extracts and
patent medicines, the manufacture of which involves the
payment of a United States liquor dealer’s tax, is prohibited.
No one but a druggist licensed to sell alcohol is permitted to
sell proprietary preparations or patent medicines except on
the prescription of a licensed medical man. Medical men
are required to keep a record of all prescriptions issued
by them for alcoholic compounds, and those allowed to issue
such prescriptions must first give a bond of $2000(£400) that
they will observe the provisions of the law and are licensed
by the Prohibition Commissioner.
Feb. 15th. __
THE SERVICES.
BOYAIi NAVAL ikBDIOAL 8BBVIOB.
Surg. Capt. W. G. Ax ford has been placed on the Retired List, with
the rank of Surgeon Rear-Admiral, In recognition of services rendered
daring the war.
Surgeon Commander to be Surgeon Captain: C. M. Beadnell.
Snrg. Lieut. Cdr. (Emergy.) G H. 8. Miller, R.N., granted rank of
Surgeon Commander (Emergency) for services rendered during the
war.
Temp. Snrg. Lieut. G. W. Pool, who has been invalided on account
of ill-health contracted in the Service, to retain his rank.
ROYAL ARMY MEDICAL CORPS.
Temp, and acting Major G. Tailor relinquishes his acting rank
on re-pos' ing.
Capt. W. H. 8. Burney to be aoting Major.
Temp. Col. S. M. Smith (Captain. R.A.M.C., T.F.) relinquishes his
temporary commissi'n on re-posting
Late temporary Cap ains granted the rank of Captain: J. S. 8.
Steele Perkins, J. C. King.
Temporary Lieutenants to be temporary Captains: B. Blacklock,
C. B. G. Q< stwyck, H.. P. Hutchinson.
C. H. Lloyd to be temporary Captain.
Temp. H^n. Lieut. L. M. Earle to be temDorary Honorary Captain
whilst serving wit h v the British Red Cross Hospital, Nelley.
Temp. Col. W. Thortmm, A.M.8. (Lieut Col, R.A M.C., T.F.) relin¬
quishes his temporary com ml™ ion on re-posting ; Oapt. St. J. Buxton
relinquishes the acting rank of Major.
Temp. Capt. (acting Major) T. D H. Holmes relinquishes his com¬
mission and retains the rank of Major.
Temporary C tptains granted the rank of Major: B. L. M. Hackett,
J. L. Gordon. B. H. Barton. S. J. Rowntree, O. A. H. Gee, R. S. Frew,
H. B. Atlee, J. R. Craig.
Temporary Captains retaining the rank of Captain: W. Anderson,
C. M. G Elliott, R. M. Walker, B W. Mosher. N. M. Keith, J. A.
Matson, B. F. Bailey. J. A. Jones. W. A. L. Marriott, B. C. Gimaou,
C. B. Droop, R. L. Blenkhom, A G. Brand
The undermentioned on ceasing to be employed with the St. John
Ambulance Brigade Hospital, and retain their honorary rankTemp.
Hon. Majors C. W. M. Hope, T. Houston; Temp. Hon. Capts. P. Coates,
W. P. Matthews, P. Hall, O. E. Butter worth, J. M. McOioy; Temp.
Hon. CaDt. S. E T. dhann, on oeaslng to be employed with Bo. 5
British Re 1 Cross Hospital, and retains the honorary rank of Captain;
Temp. Qon. Capt. A. C. Inman, and retains the honorary rank of
Captain,- Temp. Lieut. B. Cansfield.and retains the rank of Lieutenant.
Canadian Army Medical Corps.
Temp. Major F. B. Carron to be temporary Lieutenant-Colonel.
Temp. Major W. H. Merritt to be aoting Lieutenant-Colonel while
employed at a Canadian Special Hospital.
Temporary Captains to be acting Majors while employed at Canadian
Stationary Hospitals: V. N. Mackay, J. S. Hudson, H. C. Davis, M.C..
while employed with Canadian Field Ambulance.
SPECIAL RESERVE OF OFFICERS.
Capt. (acting Major) T. Y. Barkley to be acting Lieutenant-Colonel
whilst In command of a Medical Unit.
Captains relinquishing the acting rank of Major on re-posting:
W. 0. B. Meyer, A. A. Smalley.
Captains to be aoting Majors : W. Dunlop, G. G. Jaok, D. M. Lyon
Lieutenants to be Captains: C. F. J. Carruthers. J. W. O. Fair-
weather, B. Roger, A. Bulleld, C. F. Rainer, A. Blaokstock, L C.
Goument, W. E. Le G. Clark. A. W. Wells, T. Davies, B. B. Ash, G. W.
Ooombes. D. V. Halstead. J. R. Cox, M. W. Geffen.
A. 8t. G. J. McU. Buggett, R Gainsborough, W. H. Palmer, from
University of London Contingent, O.T.C., to be Lieutenants.
TERRITORIAL FORCE.
Major G. A. Troup to be Lieutenant-Colonel.
Major (acting Liout.-Col.) W. D. Watson relinquishes his acting rank
on oea-ing to be specially employed.
Capt. J. Angus relinquishes his commission on account of ill-health
contracted on active service and retains the rank of Captain.
Capt. M. B. H. Stratford relinquishes his commission on account of
ill-health contracted on active service and retains the rank of Captain.
Capt. J. F. W. Wyer relinquishes his commission on aooount of
ill-health and retains the rank uf Captain.
Capt. (acting Lteut.-Col.) A. C. H. McCullagh relinquishes his acting
rank on oeaslng to be specially employed.
Capt. T. G. Buchanan to be acting Major whilst specially employed.
Oapt. (acting Major) J. W Cairns relinquishes hts commission on
account of ill-health contracted on active service and retains the rank
of Major.
2nd Eastern General Hospital: Oapt. H. N. Fletcher is restored to
the establishment.
1st Western General Hospital: Capt. (acting L1eut.-0ol.) J. M. Hunt
relinquishes his acting rank on oeaslng to be specially employed.
ROYAL AIR FOROB.
Lieut.-Col. T. D. C. Bury is granted the acting rank of Colonel.
Majors granted the acting rank of Llentenant-Colonel: R. H.
McGiffln. G. D. Bateman, B. ft. Bickford.
Captains granted the acting rank of Major: W. Darling, J. M.
Klrkness, T. S. Rtpp n. B. A. Playne, P. H. Hadfield, R. H. Knowles,
P. L. Moore, A. A. Atkinson, J. J. C. Hamilton, F. 0. Jobtoo, M. R.
Dobson, J. MacGregor, F. N. B. Smartt, A. A. Bisset, H. S ted man,
L. C. M. Wedderburn, H. M. S. Turner, H. B. Whlttingham, A. Soott-
Turner, C. J. G. Taylor, O. H. Go tea, H. G. Anderson, H. A. Hewat,
W. Eoraght, D. Ranken.
Capt. (acting Major) C. E. Thwaites retains the acting rank of Major
whilst employed as Major, from (S.O.)
P. O. Moffat (temp. Oapt., R.A.M.C.) is granted a temporary eom-
miHsinn as Captain.
Lieutenants granted the aoting rank of Captain: O. H. Vernon,
G.W. Harhottle, L.C. Broughton-Head.
R. H. Turner Is gran' ed a temporary commission os Lieutenant.
Capt. D. Ross is transferred to unemployed list.
URBAN VITAL STATISTICS.
(Week ended Feb. 22nd, 1919.)
English and Welsh Towns.—In the 96 English and Welsh towns,
with an aggregate civil population estimated at 16,500.000 persons, the
annual rate of mortality, wbloh had increased from 15*0 to 27*8 In the
four preceding wr-eks, further rose to 35*7 per 1000. In London, with a
population slightly exceeding 4,000,000 persons, the annual death-rate
was 34 2, or 7 0 per 1000 above that recorded In the previous week;
among the remaining towns the rates ranged from 11*8 in Coventry.
16 6 in Walthamstow, and 19 1 In Enfield, <o 58*9 In Blackburn, 60*5 in
Bradford. 60*9 in bouthpnrt. 64*3 In Wakefield, 66*1 in Nowcastle-on-
Tyne, and 81*5 In West Hartlepool. The principal epidemic diseases
caused 196 deaths, which corresponded to an annual rate of 0*6 per
1000, and included 46 from diphtheria, 43 from mea-lee, 42 from
Infantile diarrhoea. 38 from whoop ng-cougb, 21 from scarlet fever, and
6 from enteric fever. Measles cauM-d a death-rate of 2 3 in Warrington
aud 4 4 In Middlesbrough, and whooping-cough of 1*2 tu Bristol. The
deaths attributed to influenza, which had Increased from 222 to 1363
in the four preceding weeks, further rose to 3044, and Included 663
in London, 188 in Liverpool, 163 iu Newcastle-on-Tyne, 142 In
Bradford, 130 in Manchester, 84 in Birmingham, and 82 in Leeds.
The Lanott,]
VITAL STATISTICS.
[March 1,1919 355
There were 1088 cases of scarlet fever and 1185 of diphtheria under treat¬
ment In the Metropolitan Asylums Hospitals and the London Fever
Hospital, again* t 1094 and 1179 respectively at the end of the previous
week. The causes of 89 deaths in the 96 towns were uncertified, of
which 17 were registered in Birmingham, 16 in Liverpool, and 5 each in
London, Manchester, and Gateshead.
Scotch Towns.—In the 16 largest Scotch towns, with an aggregate
population estimated at nearly 2,500.000 persons, the annual rate of
mortality, which hadflncreaaed from 17*0 to 32*0 in the five preceding
weeks, further rose to 38 4 per 10D0. The deaths from influ-nza
numbered 75, while in 503 deaths classified as due to other conditions
influenza whs a contributory cause; in the previous weeks these
numbers were 76 and 298 respectively. The 906 deaths in Glasgow
corresponded to an annual rate of 42 2 per 1000, and included 52
from whooping-cough, 6 from diphtheria, 4 from Infantile diarrhoea,
and 2 each from measles and scarlet fever. The 336 deaths in Bdin-
burgh were equal to a rate of 521 per 1000, and included 6 from
whooping-cough, 3 each from diphtheria and infantile diarrhoea, and
1 from scarlet fever.
Irish Towns.— The 351 deaths in Dublin corresponded to an annual
rate of 45*2, or 11 9 per 1000 above that recorded in the previous
week, and included 88 from Influenza, and 5 from infantile diarrhoea.
The 218 deaths in Belfast were equal to a rate of 28 3 per 1000, and
included a fatal case of Infantile diarrhoea.
VITAL STATISTICS OF LONDON DURING JANUARY, 1919.
In the accompanying table will be found summarised statistics
relating to sickness and mortality in the City of London and in
each of the metropolitan boroughs. With regard to the notified
cases of Infectious disease It appears that the number of persons
reported to he suffering from one or other of the ten diseases
specified in the table was equal to an annual rate of 4 5 per
1000 of the population, estimated at 4,026.901 persons; in the
three preceding months the rates had been 5*9, 4 0, and 4 2 per
1000. Among the metropolitan boroughs the lowest rates from
these notified diseases were recorded in Chelsea, the City of
Westminster, Hampstead, Holborn. Finsbury, and the City of London;
and the highest in Stoke Newington, Bethnal Green, Stepney.
Southwark, Bermondsey, and Deptford. Seven cases of small-pox were
notified during the month ; of these 4 belonged to St. Pancras and 3 to
Battersea. Tne prevalence ot scarlet fever was slightly less than that
ha the preceding month; this disease was proportionally most
prevalent in Fulham, Bethnal Green, Stepney, Southwark, Deptford,
and Greenwich. The Metropolitan Asylums Hospitals contained
1043 scarlet fever patients at the end of the month, against
1184, 1107, and 1087 at the end of the three preceding mouths;
the weekly admissions averaged 128, against 178, 146. and 136 in the
three preceding months. The prevalence of diphtheria was about
15 per cent, higher than in December; the greatest prevalence
of thlB disease was recorded in St. Marylebone, St. Pancras, Stoke
Newington, Hackney, Bethnal Green, Stepney, and Bermo dsey.
The number of dlkmtheri t patients under treatment in the Metro¬
politan Asylums Hospitals, which had been 1155, 1000, and 1089 at the
end of the three preceding months, numbered 1170 at the end of
January; the weekly admissions averaged 164, against 169, 129, and
146 in the three preceding months. Kntenc fever was slightly more
S revaient than in the preceding month; of the 25 cases notified in
anuary, 6 belonged to S epney, 4 to Battersea, 2 to the City of
Westminster, 2 to Islington, and 2 to Bethnal Gretn. There were
23 cases of enteric fever under treatment in the Metropolitan
asylums Hospitals at the end of the month, against 56. 33, and 23
at the end of the three preceding months; the weekly admissions
averaged 3, against 9, 3, and 1 In the three preceding months.
Krysipelas was proportionally most prevalent in Stoke Newington,
Shoreditch. Bethnal Green, Poplar. Southwark, and Camberwell.
Sixteen cases of puerperal fever were notified during the month;
of these 4 belonged to Fulham and 2 to Southwark. Of the 19 cases of
cerebro-splnal meningitis 3 belonged to Stepney, 2 to Fulham, 2 to
Islington, 2 to Bermondsey, and 2 to Battersea; while the 3 cases of
poliomyelitis belonged respectively to the City of Westminster, Poplar,
and Lambeth.
The mortality statistics in the table relate to the deaths of civilians
belonging to the several boroughs, the deaths occurring in institu¬
tions having been distributed among the boroughs in which the
deceased had previously resided. During the five weeks ended
Feb. 1st the deaths of 6036 London residents were registered,
equal to an annual rate of 15 6 per 1000; in the three preceding
months the rates had been 27 3, 42*3, and 18 5 per 1000. The death-
rates ranged from 12*6 in Wandsworth, 12 9 in Fulham, 13*2 in
Stoke Newington. 13'5 in Deptford. 13*9 in Batiers~a and 140 in
Lewisham, to 17*2 in Paddington, 17*3 in Chelsea. 17 3 in Finsbury, 17 6
In Shoreditch, 18*5 in St. Marylebone, and 20*7 lu Southwark. The
6036 deaths from all causes lucluded 217 which were referred to ihe
principal Infectious diseases; of these, 14 resulted from measles,
10 from scarlet fever, 82 from diphtheria, 11 from whooping-cough,
8 from enteric fever, and 92 from diarrhoea and enteritis among
children under 2 years or age. No death from any of these diseases
was recorded during the month in the City of Loudon and in
Greenwich. Among the metropolitan boroughs the lowest death-
rates from these diseases were recorded in bammersmilh the City
of Westminster, Holborn, Battersea, Wand worth, ai.d Lewisham;
and the highest death-rates in Fulham, Chebea, St. Marylebone,
Stoke Newington, Hackney, Shoreditch, and Bethnal Green.
Tne 14 deaths from measles were 126 below the average number
in the corresponding period of the five preceding years, and
Included 4 In Chelsea. 3 in Camberwell, and 2 in Kensington. The 10
fatal cas«8 of scarlet fever were half the average number; of these,
3 belonged to Lambeth and 3 to Deptford. The 82 oeaths from diph¬
theria were 7 above the average ; this disease »as proportionally most
fatal in Paddington, St. Marylebone. Stoke Newington, Hackney, and
Bermondsey. The deaths from whooping-cough numbered 11, and
were 93 below the average; of these, 3 belonged to Woolwich and
2 to Islington. The 8 fatal cases of enteric fever were 3 below the
average number. The 92 deaths from diarrhoea and enteritis among
children under 2 years or age agreed with the average; the greatest
proportional fatality from this disease occurred in Kensington, Fulham.
St. Marylebone, Shoreditch, Bethnal Green, and aoulhwark. In con¬
clusion, it may be stated that the aggregate mortality from these
principal infectious diseases in London during January was 51 per cent,
below the average.
ANALYSIS OF SICKNESS AND MORTALITY STATISTICS IN LONDON DURING JANUARY. 1919.
(Specially compiled for The Lancet.)
Notified Cases of Infectious Disease.
1
Deaths from Principal Infectious Diseases.
=
9
Cities and
Boroughs.
■&S5
■3 s
1!
■1
i
1
■
>1
I
s
I
*
i
5
JZ
C.
5
I
a
0.
£
w
G
>
g
o
1
&
si
o ®
S3
o S
Puerperal
fever.
a
I
*8
H
3
f
|
£
2
Annual rate
per 1000
persons living.
1
I
8
i
a
h
1
*
I
i
A
«a
A
a
5
Whooping-
cough.
i
£
O
■E
1
n
c
Ilf
If!
Q a
®
1
1
E-*
Annual rate
per 1000
persons living.
Deaths from a
causes.
ft
s
LONDON.
4,026,901
7
683
817
—
25
1
16
181
19
3
1755
45
14
H
□
8
92
217
0*6
6(36
15*6
West Districts :
0*7
Paddington .
122.507
—
14
23
—
1
—
—
2
—
—
40
3*4 1
_
—
—
El
—
3
8
202
17*2
Kensingi on .
151,635
—
24
25
—
—
—
—
4
1
—
54
3*7
_
2
—
—
—
7
9
• 6
239
16*4
Hammersmith ...
114.952
—
17
22
—
—
—
_
6
1
—
46
42
_
—
—
3
—
—
—
3
.03
163
14*8
Fulham .
145,186
—
42
20
—
1
—
4
4
2
—
73
5*2
_
1
—
2
—
1
10
14
1*0
180
129
Chelsea .
57,368
—
5
3
—
—
—
_
1
_
—
9
1*6
_
4
—
—
i
—
—
6
0*9
95
17*3
City of Westminster
North Districts :
122.046
7
12
—
2
—
1
3
1
27
2-3
—
—
—
2
—
1
3
0*3
168
14*4
St. Marylebone ...
92,796
9
29
—
—
—
1
3
1
—
43
48
_
1
—
4
—
4
9
10
165
185
Hampstead .
75.649
—
9
12
—
1
—
—
1
—
—
23
32
_
—
—
—
—
3
3
0*4
113
15*6
St. Pancras ...
186.600
4
21
57
—
1
—
1
12
1
—
97
5-4
_
—
4
—
—
7
11
06
285
15 9
Islington.
297.102
—
43
49
—
2
—
—
14
2
—
110
39
_
_
—
7
2
—
4
13
05
461
16*2
3toke Newington...
47.426
—
6
17
—
—
—
—
4
—
—
27
5*9
_
—
—
4
—
—
—
4
09
60
132
Hackney.
Central Districts :
196,598
—
31
63
—
1
1
8
—
—
104
5*5
—
i
14
—
—
3
18
1*0
323
171
Holborn .
55.303
—
—
10
—
—
1
_
_
_
_
11
3*2
_
_
_
1
—
—
—
1
0*3
52
15 4
Finsbury .
City of London ...
68,011
—
7
10
—
—
—
_
4
_
_
21
3*2
_
_
_
—
1
—
2
3
0*5
113
173
16,138
—
—
2
—
—
_
_
_
_
2
1*3
_
_
—
—
—
—
—
22
14 2
East Districts:
8horedltch .
89,675
—
11
17
_
_
8
_
_
36
4*2
_
1
_
2
—
1
4
8
0*9
151
176
Bethnal Green
107,362
—
33
38
—
2
—
1
10
_
_
84
8-2
_
i
1
—
1
6
9
0*9
156
15-2
8tepney ..
232.010
—
59
73
—
6
—
1
13
3
_
155
70
_
_
—
5
1
—
7
13
06
347
156
Poplar .
South Districts :
143,443
—
20
23
—
1
—
«
1
1
67
4*1
—
—
3
1
4
8
0*6
219
15*9
Southwark .
167,936
—
46
34
_
—
_
2
12
_
_
94
5*8
_
_
_
.4
8
12
0*7
334
20-7
Bermondsey.
107.635
—
21
40
—
1
—
1
2
_
65
6 3 ,
_
_
_
4
—
_
3
7
0*7
153
14 8
Limbeth.
272,038
—
46
37
—
1
—
_
10
1
1
96
3*7
_
_
3
2
—
1
7
13
0 5
419
16 1
Battersea.
150,023
3
23
18
_
4
_
_
5
2
65
3*8 '
_
1
1
—
1
1
4
03
200
13 9
Wandsworth.
300.787
—
43
43
_
_
—
1
11
_
98
3*4 1
_
7
—
3
E3
363
12*6
Camberwell .
239.461
—
32
50
—
—
—
17
1
_
ICO
4-4
_
3
1
4
1
_
3
12
0*6
362
15*8
Deptford ... ... ,.
103.527
—
54
28
_
_
_
_
5
_
87
8 8
3
1
_
1
_
5
0*6
134
13*5
Greenwich .
90,440
—
23
13
1
1
4
-
_
42
4-8
_
_
_
_
148
17*1
Lewi,ham
161.405
—
18
24
—
_
_
9
_
51
3*3
_
1
_
1
1
_
1
4
03
216
140
Woolwich.
131,942
—
19
25
—
—
—
1
3
—
—
48
38
_
1
2
3
1
1
8
Kill
193
15*3
Port of London ,..
—
—
- 1
—
—
— (
—
—
-
t
—
—
-
-
—
—
—
—
—
—
— 1
—
—
Including membran jus croup.
35& TOT Lancet,] ESSENTIAL PRINCIPLES 07 SUCCESSFUL MEDICAL ADMINISTRATION. [March 1,1919
Cffrrespnkiue.
" Audi alteram partem.”
THE ESSENTIAL PRINCIPLES OF SUCCESSFUL
MEDICAL ADMINISTRATION.
To the Editor of Thh Lancet.
Sir, —Carlyle has said that the most important fact about
a man is his religion. We may safely broaden this state¬
ment by saying that the most imp »rfcant facts about any
human policy are the principles which underlie it. In the
present crisis of the fortunes of medicine it will be
calamitous if we fail to realise this paramount importance
of princip’es.
The essential principles of successful medical administra¬
tion may be thus enunciated :—
* 1. The utmost possible freedom must be assured to the
practice of medicine in all its departments.
2. Adequate standards both of general education and
professional knowledge must be required on entry to the
profession.
3. The control of medicine must be by adequately educated
minds; medicine must have a sufficient voice in its own
control, together with sufficient authority in all matters
entrusted to it; and disciplinary powers over professional
practice must be primarily in medical hands.
4. Reasonable remuneration , holiday , and leisure must be
assured to all members of the profession.
Let me deal with these briefly. There is nothing new
about any of them. All have b ,*en before the profession for
years. The Lancet has. at one time or another, voiced
them all.
1 . freedom.
To insist upon the value of freedom, when so lately
millions have laid down their lives for it, might seem
unnecessary were it not that intelligent persons are advo¬
cating a wholesale surrender of the independence of the
entire British medical profession. For that is just what the
acceptance of universal whole-time medical State service
would mean. No art or science has long flourished after it
has been deprived of freedom, and Buckle has well put the
reason for this : “It is certain that men who begin by losing
their independence will end by losing their energy.” The
whole history of medicine illustrates this truth. Illustra¬
tions of it are even now under our eyes. There will be no
excuse of want of warning if, from defect of manhood'or
neglect of national duty, we allow our liberty to be taken
from us. How then, in a great scheme of medical adminis¬
tration, is this essential freedom to be preserved ? There are
certain sections of medical work which cannot be carried out
otherwise than as whole-time State service, and the question
naturally arises : “Will not that be injurious ? ” The answer
is: 11 No, so long as the mass of medicine is free to create the
atmosphere of medical liberty.” It is whole-time State
service of the mats which would be so pernicious in its effects
In the existing whole-time appointments of the Public
Health Service we have had an illustration of the protecting
influence of a free mass of medicine. But such sections will
need safeguards.
The first of such services is the Public Health Service.
None can deny that the work of this Service has already
been admirable. But few will dissent when it is asserted
that its medical officers should be made independent of
interested local influences. Its reorganisation as a whole¬
time State service under a Minister of Health will be in
reality a liberation from undesirable control. Its removal
from a subordinate position in an alien Ministry, such as the
Local Government Board, will be a further liberation. The
administrative officers of the military services must also form
whole-time services. But the experience of the war will leave
few in doubt of the necessity of liberating the Army Medical
Service from excessive military control and of bringing it
more fully into touch with the civil profession by making it
medically responsible to a civil Ministry of Health. Only
thus can the profession guard against the repetition of mis¬
fortunes which have flowed from two causes (the traditions
of an alien control), viz , attention to “forms” rather than
to patients and to “seniority” rather than to science.
For adequate freedom of the mass of medicine the other
three principles just enumerated are clearly essential, and
the following would seem to be necessary conditions:
1. Free choice of doctor by patient and patient by doctor
as the best means of maintaining the very peculiarly human
relationship of doctor and patient so vitally essential to
getting the best out of clinical work. 2. The existence of a
considerable proportion of medical men, as now, in * 1 private
practice,” outside the State services. 3. Wherever State
service is needed, and the choice is possible, the adoptipn of
part-time service instead of whole-time service. 4. Probably
payment by piecework or per patient in State clinical work
rather than any more inclusive system of State contract.
Whether or not institutions now admittedly working well
outside State service, like our voluntary hospitals, should be
touched by the State is a question needing the most serious
thought, but if their medical officers should come to be paid
by the State it would seem essential that their nervice should
be only part-time. Part-time State service would also meet
the case of the clinical teachers of medicine. ; Directed by
a Ministry of Health, part-time State service seems the only
practicable plan for the much-needed reform of the present
panel system. Part-time State service under a Health Ministry,
in fact, for the bulk of such departments of medicine as come
under the State, is probably the best solution of the problem
of State control.
2. Education.
The standard of preliminary general education required of
the doctor has now for some years been praotioally the same
as that for the veterinary surgeon or for the pharmaceutical
chemist; and the public, which has a nice discrimination in
matters of education, has rated us up, all three, as being on
practically the same level of culture. The technical educa¬
tion at the same time has grown so cumbersome as to
seriously need revision. This revision, both of technical and
general standards, together with the entablishment of their
uniformity throughout th-* United Kingdom, must be dealt
with by a State Medical Committee predominantly represent¬
ing the nation and the profession at large, and including not
merely medical men, but representatives of the chief general
educational authorities in the country. The faults of the
General Medical Council, however, it should be noted, reside,
not in the able and honourable men who compose it, but in
its peculiarly limited powers.
3. Educated Control.
Every department of State, be it Naval. Military, or
Medical, must be under the control of the community; there¬
fore the control of medicine must be as muoh in lay hands as
the control of the Navy or Army. But no more than the
control of the Navy or Army must the control of medicine
be in imperfectly educated hands. I yield to no one in my
admiration and regard for the average British fighting man,
whose superb qualities, alike in defeat and victory, this war
has once more illustrated. But it is neither for his good, nor
for the good of the nation, that, without special education,
he should be charged with the control of so complex and
vital a national organ as medicine. Outside Russia one does
not convene committees of able-seamen or private soldiers to
give directions to admirals and generals. His unfighting
fellows, who displayed at home such senseless selfishness at
critical periods of the war, gravely imperilling the victory of
the Allies, are manifestly unfit for such responsibility. The
administration of medicine, then, must be in the hands of
well-educated men, and, amongst these men, capable and
trustworthy representatives of the profession ramt form a
sufficient minority. The Minister himself should be a
medical man, because no other can properly voice to the
Cabinet, Parliament, and the public the medical require¬
ments of the country.
4. Reasonable Remuneration , Holidiy , and Leisure.
However self sacrificing an industry may be (and none has
been more self-sacrificing than ours), a limit exists below
which inadequate remuneration must spell a decline in
efficiency. That limit has been long passed for medicine.
What a man may reasonably claim as his minimum payment
for public service is a sufficiency to maintain himself and his
family in health and vigour (needing reasonable holiday and
leisure), to educate his children for work as responsible as
his own, to make provision for his old age, and to provide an
insurance for his dependents against his death or disable¬
ment. How many doctors get this? Yet they are all
entitled to it and, if they could only cultivate enough
mutual loyalty, they could obtain it.
I am, Sir, yours faithfully,
Bxeter, Peb. 17tb, 1919. WILLIAM GORDON.
The Lancet,] PREVENTIVE INOCULATION AGAINST INFLUENZA.—THIS WAR AND AFTER. [March 1,1919 357
PREVENTIVE INOCULATION AGAINST
INFLUENZA.
To the Editor of The Lancet.
Sir,—I think that the official Memorandum on Prevention
of Influenza just issued by the Medical Department of the
Local Government Board casts an unmerited slur on the
value of protective inoculation. I have had the opportunity
of carrying out inoculation on a large scale and the results
have been most satisfactory. Out of 1100 subjects about
800 were inoculated in November and December, and the
figures at the end of January were as follows :—
Incidence among inoculated . 0 5 per cent.
,, non-inoculated . v 10 0 per cent.
Death-rate of inoculated cases Nil.
„ non-inoculated. 19 per cent.
Since the above date I have heard of another death
among the non-inoculated.
In my opinion, inoculation can do no harm at the worst,
almost certainly has a protective influence against infection,
and certainly diminishes the risk of pulmonary complications.
I am, Sir, yours faithfully,
Birchin-lane, B.C., Feb. 24th, 1919. C. W. W IRC,MAN.
COMMERCIAL VACCINE LYMPHS.
To the Editor of The Lancet.
Sir, — My experience is very different from that of Mr. E. A.
Barton (The Lancet, Feb. 22nd, p. 313), I was public
vaccinator for 30 years and the payment depended upon
results— viz., four successful vesicles. I found that the
Local Government Board vaccine was not to be relied upon,
and I therefore always used Dr. Chaumiers lymph, with
such good results that I received four vaccination grants
during my period of office. In 1902 I vaccinated or re¬
vaccinated some 2000, every one successful. Of course, I
do not know the present virtue of the vaccine.
I am. Sir, yours faithfully,
Chelston, Devon, Feb. 22nd, 1919. A. T. Ro WORTH.
THE DISCUSSION ON SHOCK AT THE IlOYAL
SOCIETY OF MEDICINE.
To the Editor of The Lancet.
Sir,— In The Lancet report of the recent discussion on
shock at the Royal Society of Medicine, from the variety of
the opinions expressed, it is evident that there is, as yet, no
general agreement in regard to the problem of the “ missing
blood.” This problem is not solved by the assumptions of
the speaker who stated that : —
“ It is clear that blo >d must be accumulated or beM up somewhere or
other in dilated regions ' f the vascular wstcro. Observations made in
the course of abdominal operations give tie support, to the view that
there is any significant degr* o of oil upturn of t he art eries or veins of
♦he splanchnic area. The region in q-lesiion must therefore be that,
of the capillaries.”
It is unsafe to assume that the missing blood must still
be in some part of the vascular system, and it by no means
follows that, because this blood is not in the splanchnic
area, it must be in the capillaries. Very far from convincing
is the same speaker’s explanation of how blood can accu¬
mulate in capillaries without producing cyanosis.
“As regards the nbs?nco of marked evanosis in shriek, we must
remember that a very small dlUUtiun <>f the capillhries, if widely
distributed, may suck up a Inr^e v.-lumo ol bleed.”
Scepticism is justifiable in regard to the clinical existence
of an accumulation in the capillaries of blood sutlicient in
amount to be an important factor in shock and yet so widely
distributed as to fail to cause cyanosis. Clinically the
picture of shock is that drawn by Mr. John D. Malcolm—i.e.,
a contracted vascular system, a reduced capacity of the whole
vascular area, and a diminution of the volume of blood in
this area. The problem of the blood deficiency appears to be
a question not so much of missing blood as of missing blood
fluids, the total volume of the blood being diminished by the
escape of blood fluids from the vascular .system.
Might not laboratory workers, instead of looking for the
missing blood in some part of a vascular systom whose cubic
capacity is greatly diminished, with advantage turn their
attention to locating the missing blood fluids ?
I am, Sir, vonrs faithfully,
Plymouth, Feb. 19th. 1919. C. HAMILTON WlIITEFORD.
Mar anb Jfttr.
The Central Medical War Committee : The
Interests of Those who have been
on Service.
The steps which have been taken by the Central Medical
War Committee for the members of the medical profession
who have been on service have been made the subject of a
brief statement of the General Purposes Subcommittee. It
may be remembered that Local Medical War Committees
were instituted to protect the interests of medical men
serving, to cooperate in the choice of tho.«e who should serve,
and to provide for their medical work during their absence,
the organisation areas of the British Medical Association
j being employed for the purpose. The Local Committees
arranged a general agreement, under which half fees would
i be paid over by the practitioner remaining behind to the
• medical man on service, the patient to be handed back on
return from service. Further, it was generally agreed that
the substitute medical man should not attend the original
patients of a medical man, who had been on service, for one
year from the original doctor’s return.
In two other directions was an attempt made to safeguard
the position of those on service: regulations under the
Insurance Act were made abrogating during the war the
right of insured persons to change from the list of an absent
doctor ; all Government Departments consented to approve
the making of only temporary appointments during the war.
With regard to the position after demobilisation, a scheme
was laid down which provided for priority on personal
grounds, the primary consideration being length of service.
The statement continues as follows :—
In December last the Committee wrote to all the Govern¬
ment Departments which have medical work at their
disposal urging that preference should, wherever possible,
he given to doctors who have served. The Committee
emphasised the need for this work being available during
the first few months after the demobilised doctor’s return,
while he was building up his practice. The War Office,
the Ministry of Pensions, the Ministry of National Service,
and the Local Government Board all expressed their cordial
agreement with this principle, and promised their support.
At the same time the L.M.W.C.s were informed of this
step and were asked to help any man to secure such work
who, on his return, expressed his desire for it. It was
pointed out that vacancies should be made wherever neces¬
sary by the retirement of those who now hold the posts but
who have done no service.
Any doctor who now returns and who wishes for local
work of this kind should apply : (a) for military work to the
D.D.M.S. of the Command, stating his service, and asking
to be given any local work which may be available ; (M to -
the secretary of the L.M.W.C. (name and address will be
supplied on application) asking that the name of the
applicant be placed on the list of those available for Pensions
Boards or any similar work for which local practitioners are
being employed.
So far as whole-time appointments are concerned, with the
exception of an uncertain number which will be made by
the Ministry of Pensions, the Committee knows of none
except those connected with the local public health and
education authorities. The latter are advertised in the
medical journals, and the Central Government Departments
concerned are being asked to press on the local authorities
the necessity for stating that men who are on service may
apply, though they have not vet been demobilised. Applica¬
tion should be made to the Ministry of Pensions for
information about pensions medical appointrhents. Many
applicants seem to be under the impression that the
Ministry of National Service and the Ministry of Health
have, or may shortly have, numbers of appointments of an
administrative kind. There is no reason for this belief.
The Ministry of National Service is shortly coming to an
end, while the Ministry of Health is not yet in existence.
The experience of the Committee goes to show that
doctors who return to civil life should have little difficulty
in finding work, though it may be difficult for them to find
just the kind of work they would prefer. Before the war
the annual normal supply of doctors was hardly keeping
pace with the demand, so there is little doubt that for some
years to come there will be work for all. For five years the
normal supply of fresh blood for the profession has been
flowing into the services; consequently there are now many
openings in all kinds of practice, but particularly, of course,
in general practice. Moreover, during the years of the war
358 This Lancet,]
THE WAR AND AFTER —OBITUARY.
[March 1,1919
Tub Lancet,]
PARLIAMENTARY INTELLIGENCE.
[March 1,19X9 359
Ijarliamtirtaqj fnfclligeitct.
NOTES ON CURRENT TOPICS.
The Ministry of Health BUI.
The House of Commons on Wednesday, Feb. 26th, gave a
second reading to the Ministry of Health Bill. The debate
extended over the whole of the sitting, and, speaking
broadly, the reception given to the measure was most
favourable. Formal permission was given to the Committee
which will deal with the Bill to extend it to Ireland. A
separate Bill will now be introduced for Scotland.
The Evils oj Unqualified Dental Practice .
The Report of the Committee appointed by the Lord
President of the Council to inquire into “the extent and
gravity of the evils of dental practice by persons not
oualifled under the Dentists’ Act” has been presented to
Parliament during the week and is now publicly circulated.
It may be remembered that the Committee, which was
presided over by the Right Hon. F. D. Acland, and
included among its members Mr. C. S. Tomes, Sir Arthur
Newsholme, and Sir George Newman, had for its terms
of reference to inquire into: ( 1 ) the causes of the present
inadequate supply of qualified dentists; ( 2 ) the expediency
of legislation prohibiting unqualified practice; and (3) the
practicability of modifying the existing course of study,
diminishing the time and cost involved in training, without
impairing efficient practice. The Report claims for dentistry
the position of being one of the chief, if not the chief, means
for preventing ill-health, and marshals clearly the powerful
arguments for alike increasing the supply of qualified
dentists and minimising the evils arising from quackery.
HOUSE OF COMMONS.
Wednesday, Feb. 19th.
Ireland and the Ministry of Health.
Major Astor (Parliamentary Secretary to the Local
Government Board) informed Mr. Lynn that the Chief
8 eeretary for Ireland was proposing on the following day
to confer with honourable Members interested in regard
to the application of the Ministry of Health Bill to
Ireland.
Rabies in Devon and Cornwall.
Answering Mr. Carkw, Sir A. Griffith-Boscawen
(Parliamentary Secretary to the Board of Agriculture
eaid: At present the outbreak of rabies in Devon and
Cornwall cannot in any sense be said to be stamped
out. The disease may show itself at any time within
six months of its inception. The last case was
confirmed on Feb. llth, and, in addition, there is still
a number of suspected cases under investigation by
the Board’s Veterinary Department. The total number
of oaseB confirmed by the veterinary officers of the
Board to date is 118—Devon 94. Cornwall 24. The Board
tias reason to think that the responsible local authorities are
carrying out their duty as efficiently as their stafT permits.
I am informed that to date 18 civilians, 2 soldiers, and
1 sailor have been bitten and undergone the Pasteur treat¬
ment for hydrophobia.
Mr. Lambert : Can the honourable gentleman say whether
generally rabies in these two counties is decreasing or
increasing ?— 8 ir A. Griffith-Boscawen : On the whole, it
has been better recently, but it is by no means stamped out.
Medical Treatment of Discharged Soldiers.
Replying to Mr. Devlin, Sir J. Craig (Parliamentary
Secretary to the Ministry of Pensions) wrote: In Great
Britain all men, whether insured or not, who are invalided
from the forces or certified on demobilisation to be impaired
in health by reason of their service, are entitled to free
medical benefits under the National Insurance Acts—that is,
to the services of a general medical practitioner and the
supply of medicines, except in the case of uninsured men
whose total income exceeds £160 a year. There is no medical
benefit under the Insurance Acts in Ireland, but by speoial
arrangements with the Irish Insurance Commissioners,
which came into force in October, 1918, provision similar to
the above was extended to Ireland, so far as invalided men
are oonceraed, and the question of extending the arrange¬
ments to men in impaired health on demobilisation is at
present under consideration.
Accommodation for the Mentally Deficient.
Mr. Herbert asked the Home Secretary whether he was
aware of the inadequate accommodation for mentally
deficient persons throughout the country; and whether he
wonld direct the Board of Control to exercise their powers
under the Mental Deficiency Act, 1913, to provide suitable
homer for those mentally deficient persons whose n^ gi^ted
supervision was likely to be a daDger to the community.—
Mr. Shortt answered : The answer to the first part of the
question is in the affirmative. The provision of accommo¬
dation for mental defectives under the Act of 1913 rests with
the local authorities, and has necessarily been largely sus¬
pended during the war. The Board of Control is, however,
folly alive to the urgent need for further accommodation,
and a circular letter to local authorities on the subject will
be issued in a few days.
Thursday, Feb. 20th.
Supply of Spirits.
In reply to Colonel Ashley, who asked whether the
inhabitants of the districts round Preston were unable to
obtain spirits in cases of sickness, especially in the case of
influenza and pneumonia, when the same was prescribed by
the local medical men and a medical certificate given. Mr.
McCurdy (Parliamentary Secretary to the Ministry of Food)
said : In view of the limited supplies available, it was found
impracticable to carry out the arrangement contemplated
with reference to the supply of spirits to specific districts on
medical grounds. The whole question of the release of
spirits is now before the War Cabinet.
Assistant Medical Officers of Asylums.
Sir Watson Cheyne asked the Home Secretary whether
he was aware that assistant medical officers of asylums were
not allowed to marry, and if so, whether that rale would be
rescinded.—Mr. Shortt replied: Any rules governing the
conditions of service of medical officers of asylums are made
by the visiting committees who manage the asylums and
appoint the officers. I am informed that there is no general
rule preventing the marriage of assistant medical officers,
but the possibility of the marriage of assistant medical
officers is largely dependent on the nature of the residence
provided for them at the asylums, and in the large majority
of cases the accommodation is only suitable for an un¬
married officer. The Board of Control have used their
influence in the direction of securing the provision of such
accommodation as will enable the senior assistant medical
officer, and in large asylums the second assistant medical
officer, to marry. Separate houses have been provided with
this object in the grounds of some ten county asylums,
including four of those belonging to the London County
Council.
Influenza.
Mr. Ramsden asked the President of the Local Govern¬
ment Board whether his department was in possession of
information based on experience in other countries showing
any efficacious means of dealing with the persistence of
influenza; and whether any definite statement could be
made as to the value of inoculation.—Dr. Addison replied :
Reports and publications issued in other countries regarding
the prevention of influenza are specially collected and con¬
sidered in the Looai Government Board’s Medical Depart¬
ment. In answer to the second part of the question, I may
refer the honourable Member to the Memorandum I have
already promised to publish this week.
Mr. Neville Chamberlain asked whether the right
honourable gentleman was aware that one of the prinoipal
causes of the loss of life in the influenza epidemic had been
the lack of trained nurses ; whether his attention bad been
called to the fact that there were in France and Egypt a
large number of nurses who had little or nothing to do, bat
who.had not been demobilised because they had no fixed
employer who could apply for them ; and whether, in view
of the renewed epidemic of influenza, he wonld make
representations to the Secretary for War to have some of
these nurses released at once.—Dr. Addison answered: I
am aware that one of the prinoipal needs in the medical
treatment of influenza is competent nursing, and I am
referring the proposal made in my honourable friend’s
question to the authorities responsible for demobilintion.
The honourable Member is aware that local authorities and
nursing associations, and not the Local Government Board,
are responsible for the provision of nursing facilities.
&len Lomond Sanatorium.
Colonel Sir A. Sprot asked the Secretary for Scotland
whether, in view of the importance of the treatment of
tuberculosis, he would take the necessary steps to have the
sanatorium at Glen Lomond, which was established by the
counties of Fife, Kinross, and Clackmannan as a tuber¬
culosis sanatorium, but was now occupied by the War Offlres,
restored to the local authorities without further delay.—
Mr. Munro answered: Arrangements are being made in
oonsnltation with the War Office with a view to tbe early
restoration of this sanatorium to the local authorities.
Monday, Feb. 24th.
Demobilisation of Panel Practitioners.
Sir Kingsley Wood asked the Parliamentary Secretary to
the Local Government Board to state the number of medical
men on the panel lists on the date of the signing of the
360 The Lancet,]
PARLIAMENTARY INTELLIGENCE.
[March 1,1919
armistice and the number of doctors who had been
demobilised since that date; and what steps he was
taking to secure a more efficient medical service for insured
persons by obtaining an early demobilisation of medical
men.—Major Astor replied: The number of practitioners
working for the Insurance Committees in England on
Oct. 1st, 1918, was 8084, besides a certain number holding
commissions in the R.A.M.C. who were free to do some
part-time work for their Committee. Since Nov. 11th the
number of insurance practitioners on panels in England
who have been notified to the Commissioners by the War
Office up to Feb. 21st as definitely released from service is
647. In reply to the last paragraph of the question I must
remind the honourable Member that the responsibility for
arranging with the Military, Naval, and Air Force autho¬
rities for the demobilisation of doctors needed for the civil
population rests with the Ministry of National Service. My
Department makes periodical representations to that
Department for expediting the rate of release of doctors for
civil needs and for securing the release of particular doctors
required for specially urgent necessities in individual areas.
The Commissioners are in constant communication with
the various Insurance Committees as to the needs of their,
areas in this respect. I am sending the honourable Member
copies of circulars addressed to these Committees which will
explain the procedure adopted since the armistice.
Influenza.
Answering Sir Kingsley Wood, who asked a question
bearing on the measures taken to circumscribe the infection
of the present influenza epidemic, Major Astor said : It is, of
course, desirable to circumscribe infection as far as practic¬
able, and as to the various measures which may be adopted,
perhaps I may refer to the Memorandum on influenza
which has been prepared by the Medical Department to the
Local Government Board and issued last week. The Board’s
medical officers advise that notification of all cases through¬
out the country at the present time would not provide an
effective means of controlling the spread of the disease and
that any advantages which such notification would have
would be outweighed by the additional burden placed on
medical men and health officials. Influenzal pneumonia
has, however, been made notifiable as from March 1st, with
the special object of enabling assistance to be given in cases
of need of nursing or home assistance which local authorities
can provide or assist in providing. It is possible that
influenza may be spread by handling articles of food and
drink, but it does not seem practicable to remove this risk
by legislative action.
Discharged Tuberculous Soldiers.
Lieutenant-Colonel Haw asked the Leader of the House
whether he would arrange for a Select Committee to be
appointed to consider the best means of giving immediate
treatment to ex-service tuberculous soldiers and sailors.—
Mr. Bonar Law replied: The Government is already con¬
sidering the best means of carrying out what my honourable
and gallant friend haB in view.
Tuesday, Feb. 25th.
Demobilisation of Medical Men.
Viscount Wolmer asked the Secretary for War whether it
was a fact that among the.medical officers now serving with
the armies of occupation there were a number of obstetric
surgeons and recognised specialists in infant welfare ; and,
if so, whether he would give instructions that these officers
should be speedily demobilised so that their special know¬
ledge should find wider scope than waR likely in their present
employment.—Mr. Churchill replied: Individual medical
officers are demobilised at the request of the Ministry of
National Service, and the selection does not rest with the
military authorities. I may add, however, that the rate at
which doctors of all kinds are being demobilised is by no
means satisfactory, and I have given directions which I trust
will result in a substantial acceleration.
Medical Men and Income-tax.
Sir Watson Cheyne asked the Secretary of State for War
whether he bad given personal consideration to the claim
of medical men who, without holding commissions in the
Army, had been and were engaged under the War Office in
service in Army hospitals to the special service rate of
income-tax; whether that olaim was to be conceded ; and, if
not, on what specific ground was it refused.—Captain Guest
(who replied) said: So far as the War Office is concerned
this is a question of complying with the law and the action
taken has been based on legal advice.
Sir Watson Cheyne asked whether the War Office would
not bear the costs of a test case.—Captain Guest : That seems
rather to be a matter for the Treasury.
Spirits for Medical Use.
Colonel Ashley asked the Leader of the House why the
promise made by the Government in November and
December last that spirits should be released for use in
case of sicknesB when ordered by a medical man had not
been carried out.—Mr. Bonar Law replied: I am glad to say
that the Cabinet have decided that spirits shall now be
released up to 75 per cent, instead of 50 per cent, of the
quantities released in 1916 and that considerable additional
quantities will therefore be available.
Wednesday, Feb. 26th.
Ministrg oj Health BiU (Second Reading).
Dr. Addison (President of the Local Government Board),
in moving the second reading of the Ministry of Health Bill,
said that at present our practice was behind our knowledge,
and he wished to have them in accord. He spoke of the
negotiations relative to the measure in which he had taken
part, and said he found much agreement with its main
objects, but there were many “ buts,” and on investigation
these showed that there was always an axe to grind. Dr.
Addison described the main proposal of the Bill as being
designed to fix the responsibility with a central authority,
to unify control, and to have a common direction and policy.
All departments were to join in the effort to save the country
from the danger to which it was open during the period oi
demobilisation on account of the risk of the introduction of
tropical diseases hitherto not in existence here. The Bill
provided for setting up a central organisation which
would have transferred to it the duties of the Local
Government Board and its powers in regard to public
health, the duties of the Insurance Commissioners, and also
the powers of the Board of Education with regard to mothers
and nursiDg children, the powers of the Privy Council
under the Midwives Act, and the administration of Part I.
of the Children Act in respect of infant life pro¬
tection. These matters were regarded as sufficient to
tackle at the beginning of the Ministry, but later on it was
proposed to take powers in regard to mental defectives, the
functions of the Pensions Ministry in connexion with
disabled soldiers, and the duties of the Board of Education in
connexion with medical inspection. The reason why it was
proposed to transfer the Central Medical Research organisa¬
tion to the Privy Council was because it was a common
service of all departments. The reason why the Bill did
not apply in many respects to Ireland was because the
system there was different. He was prepared to make it
applicable to Ireland as far as he could in Committee.
There had been criticism of the setting up of the Advisory
Committees, but he thought they would keep the Minister
up to the mark.
Sir Donald Maclean welcomed the proposals coordinating
child welfare, but did not see why the medical Bide of the
factory work of the Home Office was not to come under the
Ministry.
Sir E. Carson protested against the faot that the Bill did
not apply to Ireland.
Mr. J. H. Thomas was glad a change was proposed in
regard to the Poor-law, which stank in the nostrils of
progressive people.
Mr. Devlin claimed that Ireland, equally with Scotland,
was entitled to a separate Bill.
Mr. Samuels (Attorney General for Ireland) repudiated
the suggestion that the Irish Government had been careless
in making inquiry in the matter. It was the intention of
the Irish Government to see that all ameliorative measures
for the health of the people in England and Wales would be
applied to Ireland, So far as the central machinery was
concerned the Irish position was ahead of the English.
Where they had broken down in Ireland was that the local
administration which had to deal with the practical matters
was permissive, and being permissive, the result had been
that the people who had the permissive power to put it into
operation or not had lamentably failed. There was a Bill
in preparation conferring on the Irish Local Government
Board powers similar to those of the Board of Education
regarding medical inspection and treatment of children. He
hoped there would soon be a measure which would deal with
the terrible state of public health in Ireland, to see that it
was enforced, and that those entrusted with the adminis¬
tration of it should carry out their powers.
Sir Watson Cheyne said this was a Bill which he believed,
when suitably amended, would form the basis of the erection
of a great health organisation. In regard to the machinery
of the Bill he laid down the axiom that the health of the
people was a matter of national concern rather than of
sectional and vested interests. His idea of a Ministry of
Health was that they Bhould have a central brain, thinking,
investigating, co-relating information from other sources,
and spreading information. That brain would have a great
deal to do. As a secondary thing to that there wonld be
executive branches which would carry out the information
which emanated from , the thinking body and apply it to the
various local conditions. Without the central brain the
organisation they would establish now would in a very few
years be ont of date because of the advances of medioal
science. He should like Dr. Addison to consider whether
4
Thb Lancet,]
MEDICAL NEWS.
[March 1, 1919 361
he should not have a board between the advisory bodies
and himself, a board which could co-relate the reports
that came from the advisory bodies and then the Minister
could digest them. He coufd not see a Ministry of Health
without a research ^department. He did not believe it
would come to anything. The medical profession was
in a state of great uneasiness and distress about the Bill, and
it would go far to relieve their minds and get more cordial
working if they could get an advisory body which was very
carefully selected and which could be trusted by the pro¬
fession and represent the best elements in it. He wished to
ask for an assurance that anything of far-reaching import¬
ance like, for instance, the taking over or interfer¬
ing with the great hospitals and teaching schools, would
be brought before Parliament, so that they might
have an opportunity of discussing it and, if necessary,
throwing it out. As" far as the medical men in the House
were concerned, and he thought as far as the greater part of
the profession was concerned, they were sincerely anxious
that the Bill should be a great success, and they would do
all they could to further it.
Mr. Thos. Griffiths appealed to Dr. Addison on behalf
of the Welsh people to give the same treatment to Wales as
was to be given to Scotland.
Mr. Leslie Scott urged that the subject of mental
deficiency should be taken over by the Ministry of Health
when created from the commencement.
Captain Loskby said the country was not satisfied with
tbe present method of licensing medical practitioners.
The public had a right to claim that those responsible for
tbe health of the nation should be competent to carryout
their task, not only at the time of their qualification, but
also during the whole period of practice. Something in the
nature of refresher courses might be organised.
Dr. McDonald heartily approved of the Bill, which was
designed to improve public health.
Major Farquharson also spoke in favour of tbe Bill.
Major Molson regretted that the Bill did not take under
its care the Medical Research Committee.
Colonel Raw approved of the Bill, but regretted it did not
take in the Medical Research Committee.
Major Astor (Parliamentary Secretary to the Local
Government Boardj, replying to the debate, said that the
Government meant the Bill to be a real one. They pould
dip into the public purse for it, and it would be money well
spent. He was sure that local authorities would get more
guidance from a single department than they had got in the
past. As to the position of tbe Medical Research Committee
under the Privy Council, he said that research over the widest
field should not be limited to a department which only
included England and Wales in its survey. But the Privy
Council covered, not only the United Kingdom, but would
be in touch with tbe whole British Empire. Far more
progress would be made in this way. Topical research, if
he might call it so, was carried on by tbe Local Govern¬
ment Board, and would remain there. But all depart¬
ments would more readily come to the Privy Council.
The Medical Research Committee had come to the
conclusion that it would be in the interests of
research that the course proposed in the Bill was the right
one. In conclusion, he paid a tribute to the efforts of the
late Lord Rhondda for his steady advocacy of the establish¬
ment of a Ministry of Health. Since the beginning of the
war the country had lost a quarter of a million infants
because of bad ante-natal and post-natal conditions. There
was a need for a Ministry of Health before the war. It was
doubly necessary now.
The Bill was read a second time.
On the motion of Captain Craig, an instruction was agreed
to giving tbe Committee on the Bill power to extend the
Ministry of Health Bill to Ireland.
Separate Bill for Scotland.
At question time Sir H. Dalziel asked the Secretary for
Scotland whether he had received an intimation to the
effect that Members representing Scotland were unanimous
in their demand that a separate Health Bill should be intro¬
duced applying to that country, and, with a view to saving
the time of the House, could he now state what the intentions
of the Government were in the matter.—Mr. Munro replied :
I have received an intimation of the general opinion held by
Scottish Members in this matter, and I have discussed it
with the Leader of the House. In view of the change of
rocedure which was adopted last week, the Government
ave decided to withdraw the Scottish Application Clause
from the Bill, to amend its title accordingly, and to introduce
a separate Bill dealing with Scotland only.
A conference on Influenza and its Prevention,”
arranged by the council of tbe Institute of Hygiene, meets
at the Institute, 33, Devonshire-street, London, W.l, at
3.30 p.m. this (Friday) afternoon. Sir Malcolm Morris will
occupy the ohair.
glrinral $etos.
Central Midwives Board.—A meeting of the
Central Midwives Board was held at Queen Anne’s Gate
Buildings, Westminster, on Feb. 20th, with Sir Francis H.
Champneys in the chair.—A letter was considered from the
county medical officer of health for Cheshire inquiring
whether nurse midwives in attending on, or expecting to be
called to, cases of confinement should be permitted to attend
cases of influenza, and if so under what conditions. The
Board decided that the county medical officer of health for
Cheshire be informed that in the view of the Board his
attitade with regard to cases of influenza attended by
midwives who also attend maternity cases, as detailed in
his letter of Dec. 27th, 1918, is correct and strictly in accord¬
ance with the rule of the Board E. 6.—A petition was pre¬
sented from the Midwives Institute praying the Board to
represent to the Privy Council under Section 1 (c) of tbe
Mid wives Act, 1918, that it is expedient to modify the con¬
stitution of the Board by conferring on tbe Institute power
to appoint a certified midwife as one of its representatives
on the Board. The Board decided that the secretary be
directed to acknowledge tbe petition.—Tbe Boafti having
considered the qnestion of printing the Midwives Roll for
1919 decided that having regard to the special circumstances
of the case, and particularly to the great expense involved in
printing the Midwives Roll at the present time, the Roll for
1919 be not printed, but that the Provisional Roll for 1919 be
printed as usual.
Royal Medical Benevolent Fund.—A t the last
meeting of the committee, held on Feb. 11th, 18 cases
were considered and £193 6s. voted to 15 of tbe applicants. The
following is a summary of some of the cases relieved:—
Widow, aged 69, of M.R.C.S. Eng. who was a surgeon in the Royal
Navy for 21 years and then practised in Cornwall and died In
November, 1918. Was left without means and has an invalid daughter,
aged 43. Rent and rates £18 a year. Had some temporary assistance
from friends. Husband’s Income ceased at his death. Voted £18 Id
12 instalments.—Widow of M.R.C.S. Eng. who practised in Manchester
and died in 1913. Was left with four children, ages now 11-23. Haa a
house, which lets at £25 a year, and small cottage, now unoccupied.
Applicant works as a sickness visitor and receives £84 10s. a year.
Receives from children £104. Rent £25. One daughter has been ill
for three months. Wants help for the education of the youngest child.
Voted £6 6s.—Widow, aged 44, of M.B. Lond. who practised in
Cheshire and died In 1907. Was left with two boys, now aged 12
and 14. Applicant acts as matron of a day and resident nursery and
receives £60 a year. Youngest boy lives with her at present,
but this privilege is not likely to he continued. Eldest
boy earns 9s. per week, but mo'ther has to supplement this
bv 11s. per week. Wants help for youngest boy's school fees.
Was helped bv the Fund in 1911 and 1912, £10 each time. Voted £10.—
L. K.C.P. A S~ Edin.,aged 72. married, who practised at Dovercourt.
Has one daughter, aged 32, who helps at home. Has lost an annuity
of £180 through the war. Barns £102 from practice, less £12 for drugs.
Has received £39 from the National Relief Fund, and an annuity of £8.
Rent £35 per annum. Voted £10.—Widow, aged 37, of L.K.C.P. Bdin.
who practised at Battersea and died in 1917. Applicant left with three
children, ages now 3-11, the two eldest going to school. She has been
living on the capital left by her husband, which is now nearly
exhausted. Weekly home expenses £3. Rent 11s. Voted £10.—
M. R.C.S. Eng., aged 73, widower, who practised In Devonshire and as a
ship’s surgeon. Income £30 from another charity and £19 from rela¬
tive. Was torpedoed in 1917, and as a result, of exposure suffers from
rheumatism and asthma. Relieved three times, £11. Voted £12 in 12
instalments.—Orphan, aged 13, of L.R.C.P. Edin. who practised in
Lancashire and died in 1917. Applicant was left with two elder
brothers penniless, and friends looked after her. She is now receiving
a good education and doing well, and help is asked for towards paying
school fees. A grant of £25 was made last year to help her
and her brother, who is now earning his living. Voted £15.—
Daughter, aged 60, of M.D. Lond. who practised in London and died
in 1868. Applicant left without means, and has earned a living by
acting as a nurse and housekeeper, but never been able to save. Health
now very indifferent and not able to work for any long period. Relieved
live times, £24. Voted £12 in 12 instalments.—Daughter, aged 56. of
M.R.C.S. Bng. who practised at Hadleigh and died in 1877. Applicant
is a chronic invalid, and her only income is from dividends. £18. and
R.U.K. B.A. pension, £21. Relieved three times, £26. Voted £12 In
12 instalments.—Daughter, aged 62. of M.R.C.S. Bng. who practised at
Box and died in 1894. Applicant is one of three sisters, and they are
all delicate. Earns £18 as a companion, and has £12 from another
charity. Another sister, who is unable to work, receives help from the
Fund and Guild. Relieved five times, £84. Voted £18 in 12 instal¬
ments.—Daughter, aged 56, of M.R.C.S. Bng. who practised in London
and died in 1880. Applicant is a chronic Invalid and unable to work,
and lives with a widowed sister. Her only income is a pension from
the R.U.K. B.A. of £25. Relieved eight times, £96. Voted £12 in
12 Instalments.
Subscriptions may be sent to the acting honorary treasurer,
Dr. Samuel West, at 11, Cbandos-street, Cavendish-square,
London, W. 1.
A presentation will be made to Dr. H. J. Cardale,
chairman of the London Panel Committee, at a luncheon to
be held at the Holborn Restaurant on March 4th, at 1.45 p.m.*
Sir James Galloway in tbe chair.
362 Thb Lancet,] APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS. [March 1, 1919
A meeting was held at the Wigmore Hall, London,
on Sunday last, Feb. 23rd, under the auspices of the Medioo-
Political Union and the chairmanship of the President of
the Union, Mr. Frank Coke, at which the following resolution
was proposed:—
That in view of the far-reaching changes Inevitable in the medical
services of this country consequent on the coming Ministry of Health,
It is essential that the profession should be solidly and democratically
organised on a trade-union basis to enable it to negotiate effectively
with the Government in the interest® of the community no less than
those of the profession.
The resolution was moved by Dr. J. A. Angus and eloquently
seconded by Dr. E. H. M. Stancomb. An amendment for the
insertion of words whereby a union shonld be formed on
trade-union principles and be affiliated to the Labour Party
and to the Trade Union Congress, having been unsuccessfully
brought forward, the original resolution was carried by a
majority of 207 to 30.
Medico-Psychological Association of Great
Britain and Ireland.— A quarterly meeting of the associa¬
tion was held in the rooms of the Medical Society of London
on Feb. 20th, Dr. John Keay presiding. A message of
greeting from the Medico-Psychological Society of Paris was
read, and a suitable letter drafted in response. The resigna¬
tion of Dr. R. H. Steen as general secretary was accepted
with regret, and Dr. R. Worth elected in his place. Dr.
£. P. Cathoart read a communication on Psychic Secretion.
At a public meeting of the subscribers and
supporters of the Aberdeen War Dressings Depdt, held in
the town ball on Feb. 22nd, it was decided that the surplus
funds of the society shonld be disposed of by giving £1200 to
endow a bed in the Royal Infirmary, to be used, if neces¬
sary, for the treatment of pensioners, and the remaining
£177 to the Sick Children’s Hospital, which gifts would con¬
stitute a permanent war memorial of the work of the War
Dressings Depdt. This society has had subscribed to it in
all £11,853, and has contributed 2,156,842 dressings and other
necessary articles, and in the early days of war did a great
deal towards the standardising of war dressings.
Medical Defence Union : The Notification
and Prevention of Specific Diseases.— The following
resolutions were passed unanimously, on Feb. 20th, at a
meeting of the Council of the .Medical Defence Union, Sir
John Tweedy presiding
“ That resistance to notification shonld be urged upon the medical
profession, as being wot only a breaoh of the confidence which exists
between patient and doctor, but also that notification would lead to
conceal meat of disease.”
‘“That the profession be encouraged to recommend to patients the
adoption of the very simple and easily carried out measures of pro¬
phylaxis, which have been proved to be effective in the Army and
Navy.”
Hospital Accommodation: Address by Sir E.
Napier Burnett. —On Feb. 20th there- was a large gather¬
ing of medical men and others in the library of the Royal
Victoria Infirmary, Newcastle-on-Tyne, to hear an address
by Sir E. Napier Burnett on Hospitals and their Relation to
the State. The chair was taken by Professor Rutherford
JMorison. After recounting his recent experience in military
hospital administration the lecturer dealt with the shortage
of accommodation in the civil hospitals of the country and
with the loss entailed by the necessity for waiting lists. A
resolution was unanimously carried urging the Government
to hold a comprehensive inquiry into the present hospital
accommodation. On the same evening Sir E. Napier Burnett
was entertained by the members of the North of England
GlMgow University Club at a complimentary dinner.
Govlbkn, C. B„ M.D. Oarmb., has been appointed Assistant Surgeon to
Royal London Ophthalmic Hospital (Moorfields Bye Hospital).
Siitpson, J. A., M.B. Aberd., Certifying Surgeon under the Factory
and Workshop Acts for the Alford District of the County of
Aberdeen.
For further information refer to the advertisement cs tmms .
Aberdeen Royal In firmary. —Asst. P. and Two Asst. 8.
Aylesbury, Royal Buckinghamshire Hospital.—R.3.
Birmingham General Dispensary.—Bern. M.O. £360.
Blackpool , Victoria Hospital.— H.S. £250.
BoUngbroke Hospital, Wandsworth Common, S. W.—»H.S. £160.
Bournemouth, Royal Victoria and West Hants Hospital , Boseombe
Branch.— H.S. £200.
■Bradford Childrc7is' Hospital.— H.S. £170.
Chartham, near Canterbury, Kent Couhty Lunatic Asylum*—Bind.
Superintendent. £800.
Chichester. Royal West Sussex Hospital.—H.S. £200.
Hartford, Darenth Industrial Colony.— Temp. Asst. M.O. £7 7 8. p.w.
Dudley. Guest Hospital and Eye Infirmary— Asst. H.8. £120.
East African Medical Appointments. — M.O.. £400-£20-£600.
Flintshire Education Committee.—hast. M.O. £400.
Hereford, Herefordshire Gen eral Hospital .—H.S. £200.
Hertfordshire County Council.— School Dentist. £350.
Holbom Schools, MUcham.-M O. £130
Hospital for Diseases of the Throat , Golden-square , IF.—Hon. Ansosth.
and Hon. Registrar.
Hospital for Sick Children, Great Ormond-street, W.C.—V.
Hull and Sculcoates Dispensary.— M.O.
Huntingdon County Hospital.—Res. M.O. £120.
Johannesburg, South African School of Mines and Technology ,— Prof, of
Anat. and Prof, of Phys. £1000.
Leeds Public Dispensary.—Three Hon. A*st. Dental Surg.
ljeicester Corporation Isolation Hospital and Sanatorium.— Two Res.
M.O. £350 and £300. Also Female M.O. £4G0.
Liverpool , Royal Southern Hospital.—Three Set. H.8., Two H.P.,
and One non-Rea. C.O. £100.
London Homoeopathic Hospital, Great Ormond-street, Bloomsbury, W.C.
—Clin. Path, and Bart. £200.
Manchester Children's Hospital. Pendlebury, Out-patients' Department,
Gartside-strect. Manchester.— Asst. M.O. £200.
Manchester Northern HosuiVal for Women and Children, Park-place,
Cheetham HiU-rond.-R.S. £150.
Manchester Royal Eye Hospital.—J un. H.S. £120.
Nottingham Children's Hospital.— Female Res. H.S. and Res. H.P. ^
Anteoth. £250 and £200 respectively.
Nottingham City Asylum.— Second Asst. M.O. £300.
Queen’s Hospital for Children, Hackney-road, Bethnal Green, E .— H.8.
and Cas. H.S. £100. Also Temp. Asst. P., and Asst, for Out¬
patient Cases.
Reading, Royal Berkshire Hospital.—Second H.S. £200.
Royal National Orthopaedic Hospital.—Res. H.S. £200.
Samaritan Fret Hospital for Women, Marylebone-road.— H.8. £150.
Scarborough Hospital and Dispensary.— Two H.S.
Shantung Christian University Medical School (Tsinanfu , N. China ).—
Medical Missionaries.
Sheffield Royal HosiHtal.—C**. Officer. £130.
Sheffield Royal Infirmary.- Oas. Officer. Also Opb. H.S. £160.
Staffordshire Education Committee.— Female Asst. M. Inspectors. £400.
Stockport Infirmary.— Jun. Res. H.S. £200.
Union of South Africa Mental Hospital Service.— Six Asst. Phva. £38 0
Warwickshire and Coventry Joint Committee for Tuberculosis.—Asst.
Tuberc. Officer. £400.
Western Ophthalmic Hospital, Marylebone-road, N. W. —Two Asst. S.
Whitehaven and West Cumberland Infirmary.—Res. H.S. £180-
Wolverhampton and Midland Counties Eye Infirmary .— H.S. £200.
The Chief Inspector of Factories, Home Office, S.W., gives notloe of
vacancies for Certifying Surgeons under the Factor? and Workshop
Acts stShefford, Woburn Sands, Beaminster, and Telgnmouth.
Xirtfes, Carriages, anil geatfcs.
BIRTHS.
Allchin.— On Feb. 21st, at Bury-road, Alvarstoke, Hants, the wife of
Temp. Surg.-Lleut. F. M. Allchin, M.B., B.S., Royal Navy, of a
daughter.
Dash wood-Howard.— On Feb. 19th, at The Mowle, Ludhara, Norfolk,
the wife of A. Dashwood-Howard, M.D., L.R.C.P., late Captain,
R.A.M.C., of a daughter.
Edmond.— On Feb. 15th. at Crunk Meole House, Hanwood. Shropshire,
. the wife of Major W. S. Edmond, F.R.C.S., R. A.M.C., of a daughter.
Farmer.— On Feb. 19th, at “ Stan well House,” Stanwall, near Staines,
the wife of Captain Herbert L. Farmer, R.A.M.C., of a daughter.
Tooth.— On Keb. 17th, at Clifton Nursing Home, Bristol, the wife of
Frederick Tooth, M.R.C.S., L.R.C.P., of a son.
Wbholey.— On Feb. 25th, at 8, Conynghmn-road, Victoria Park,
Manchester, the wife of Captain P. R. Wrlgley, R.A.M-C. (T.FJ, of
a daughter. _____
MARRIAGES.
Jones—Thatcher,— On Feb. 15th, at S. John of Jerusalem, South
Hackney, William Henry Jones, M.B., B.S. Lond., temporary
Lieutenant, R.A.M.C., to Gwendolen Frances Mildred, second
daughter of the Rev. and Mrs. W. Romaic Thatcher, of South
Hackney.
Nicholas-Hacking.—O n Feb. 18tb, at Holy Trinity. Sloane-street,
Captain C. F. Nicholas. R.A.M.O., to Ann Kathleen, fourth
daughter of the Venerable Archdeacon and Mrs. Hacking, Hill
House, Southwell, Notts. _____
DEATHS.
Andrews.— On Feb. 20th, at Gaiaglll, Blstree, Samuel Andrews.
M.R.C.8., L.R.G.P. Lond., aged 68.
Bower.— On Fsb. 18th, suddenly, at Barnsbuiy-road, N.,t£dward I.
Bower, L.R.C.P. Lond., M.R.C.S., L.S.A., aged 69.
Michael.— At Blmwood, Woodthorpe, Nottingham, of bronchitis
following influenza, Henry James Michael, Lieutsoact-OoloMi,
R.A.M.C. (retired), aged 62 years.
Nias.— On Feb. 20tb, at a nursing home, Joseph Baldwin Nias,
M.D. Oxon., of Rosary-gardens, S.W.
Stephenson.— On Feb. 24th, at Bonaccord-crescent, Aberdeen, William
Stephenson, M.D., LL.D., F.R.C.S.B., Bmerftns Profeasqr Of
Midwifery of the University of Aberdeen, in bis 82nd year.
WISE. —On Feb. 24th, at Dunstowe, Launceston, Cornwall, Oharim
Henry Wise, M.D., J.P. (late of Walthamstow). In his 65th year.
N.B.—A fee of 6s. in charged for the insertion of Notices cf Births,
Marriages, and Deaths .
ComnnmicatiQPS. tainting to editorial business should be
addressed exclusively to The Editor of Tta Langkt,
423, 8trand, London, W.C. 2.
Tm LaKctt.] H0TE8. 8H0BT COMMENTS. AND ANSWERS TO CORRESPONDENTS. [March 1,1919 36$
Jolts, Commenls, aifo Jnsfotrs
to Comsptjtante.
THE VITAL NEED.
Professor P. G. Hopkins, of the University of Cambridge,
the pioneer of the vitamine theory, delivered the third of the
series of lectures on Physiology and National Needs at King’s
College on Feb. 19th, his subject being Vitamines, Unknown
but Essential Accessory Factors of Diet. In the absence of
Lord d’Abernon, the chairman, and of the Principal of the
College, both of whom were suffering from the prevailing
epidemic, Professor W. D. Halliburton presided. Although
man had through the ages accumulated large experience
in questions relating to food, yet in the particular
matter of nutrition the results of scientific research
might forestall experience, which was always Blow and
expensive. In a community which could command a suffi¬
cient variety of fresh food, taste, appetite, and instinct
were sufficient to ensure that the individual was properly
nourished ; but in states of civilisation there was a tendency
to interfere with natural foods, and only a proportion of
their constituents was presented to the consumer. The
science of the nineteenth century had made it clear that it
was the quality and not the quantity of food which was all
important. The essential elements for human nutrition
were proteins, fats, carbohydrates, and a proper supply of
mineral salts, but it had been found that an addition to these
substances was needed, a something which waB produced by
plants in appreciable quantities, as well as a something
which was developed in small quantities, the nutritive import¬
ance of which was out of all proportion to the small amount
in which these substances occurred in natural foodstuffs.
Beri-beri.
In many rice eating communities the population suffered
from beri-beri, in which an extreme state of emaciation,
paralysis, and pronounced oedema occurred. For many years
efforts had been made, but without success, to find a microbic
cause for the disease. Damaged rice had been suspected,
but it was ultimately found that the trouble was due to the
way in which the rice waB prepared, an essential factor
necessary for food being removed in the course of prepara¬
tion. In 1897 the Dutch physician Eijkman brought
forward evidence to show the truth of this conception. In
37 prisons in the districts which he studied, the diet was
unpolished rice ; in 13 prisons polished and unpolished rice;
and in 51 prisons polished rice. Taking the prison popula¬
tion at nearly 306,000 and collecting the cases per 10,000,
there was 1 case among those living on unpolished rice, on
the mixed rice there were 416 cases, and on the polished
rice 3900.
Experiments showed that the missing element in the
rioe was to be found in the layer of tissue under the
husk which was known as the silver skin, in the embryo,
and in the bran. These were left in by the native
method of preparation, but removed by the modern
milling and polishing process. From these investigations
Eijkman concluded that the substance which was removed
neutralised another factor in the whole which was harmful;
the simple suggestion that something really necessary in
itself was removed did not oocur to him.
The Vitamines.
The lecturer described some feeding experiments on
animals, illustrated by charts thrown on the screen, which
showed that if the food consisted of pure proteins, fats,
carbohydrates, and mineral salts the animals not only
did npt thrive, but, after a longer or shorter interval,
died, whilst an extremely small amount of an addendum
to the diet converted it into a perfectly sufficient nutri¬
ment. In some early experiments which he had conducted
the addendum consisted of a small quantity of milk.
It was essential that these additions to the food should be
obtained from living tissue. We did not know what these
substances were which we called vitamines. Many patient
attempts bad been made, and were being made to isolate
•hem, but so far without success, though it was certain that
the factors were actual substances and not qualities. They
co&jd be extracted, precipitated, and redissolved, but they
^ld not be separated completely from other substances.
Their actual chemical nature and the exact amount neces-
»ry for the needs of the body were not known. There were
&t least three of these substances, each one distinguished
from the other two, and each one serving some particular
{unction in nutrition. As a proof that at least two existed,
had been shown that if an animal were fed on the pure
wet already referred to, and the fat were an animal fat,
growth was inhibited, but on adding watery extracts of
*knous foodstuffs, such as watery extracts of the wheat grain,
r\ e cortex or embryo, the animal grew and generally main-
excellent health. This did not occur if a vegetable
fat were used in the diet. Its valne to the body as fat was
probably just as good as animal fat, but there was something
in the animal fat which was not present in the vege¬
table. Of the two factors, therefore, one was soluble in
water and one was associated with fats, and an animal could
not survive unless both were present. Dr. Harden, as'the
result of some admirable work, had shown the distribution'
of these two factors. Wheat grain, with the exception of
the endosperm, contained both and was especially rich In
the water-soluble factor, as was also yeast. Butter was rich
i n both. God-liver oil contained a large amount of fat-soluble
substance.
Insufficiency Diseases.
The water-soluble substance was removed when rice
was polished, and it waB the absence of this which
caused beri-beri. It was therefore known as an antinenritic
substance. Birds were so sensitive [here the lecturer
Bhowed on the screen photographs of pigeons in which
neuritic disease had been produced by feeding them on
unpolished rice] that if suffering from this affection, by
administering to them as small a dose as half a grain of
the watery extraot the symptoms could be abated in the
course of an hour or two. Rickets in children, a disease of
great national importance, was associated with the fat
soluble vitamine. Dr. Edward Mellanby bad shown that it
was easy to find a food on which dogs would develop rickets,
and just as easy to prevent the condition by making sertain
additions to their diet, among which were certain fats rich
in vitamines. That cod-liver oil was a curative agent for
rickets had long been known empirically. The negro
population of the United States was particularly prone to
this disease, and in a community in which almost every
child was a victim striking results were obtained by
the administration of cod-liver oil. Mrs. Mellanby 1
had shown that grave errors of dentition occurred through
diet. Scurvy was another dietetic disease and would be
dealt with by Professor Harden on Feb. 26th, when it would
be shown that there was at least a third vitamine which was
less soluble than the other two, more easily destroyed by,
heat, and disappeared more readily when foods were kept.
Pellagra was another disease which was associated with
qualitative deficiency in the diet.
National Importance of the Dietetic Factor.
These facts were of practical and national importance.
Pure white bread did not contain either of the two vitamines
mentioned. This was of little consequence to those members
of the population who could obtain articles of food con¬
taining the vitamines, but the poor would suffer severely by
its use. Whereas brown bread and butter was a most
excellent combination, white bread and margarine was
a radically bad one. The whole vitamine question
was of the greatest importance in regard to the child
population. It mast not be forgotten that poliBhed
rice was used a great deal in this country and in poor
households the use of tinned foods was very common,
salads were seldom eaten, and in some parts of the country
very little fruit was used. Especially among children of
the poor we had real evidence that the question of vitamine
supply was of actual importance. In England, although we
might not have beri-beri or pellagra, and though scurvy
might be rare, we bad much ill-health which stopped short
of definite symptoms, minor departures from the normal
which occurred before the establishment of actual disease.
The absolute absence of vitamines meant disease, their
relative absence malnutrition. It was not sufficiently
recognised that the vitamines were not made in the animal
body but in the plant, and were accumulated in the tissues
of the herbivorous animal. From this it followed that if the
diet of the nursing mother was deficient in vitamines then
ultimately her milk would become so; there was evidence
that the milk of animals could be deficient in vitamines.
We probably required something to stimulate growth, and
the suggestion had been made that every living cell required
factors of the same sort. Research in this subjeot was
necessary, and the backing of the public was needed to
stimulate the administrator and the politician.
THE METROPOLITAN WATER-SUPPLY DURING
OCTOBER, NOVEMBER, AND DECEMBER, 1918.
All three months ending the year 1918 showed a
diminished rainfall. Thus the mean fall during the
month of October at 12 stations which have been selected
as giving equal representation for all parts of the Thames
basin was 1*77 inches, being 1*52 inches below the
average mean rainfall for that month during the
previous 36 years. A chemical examination showed that
the Thames raw waters deteriorated in quality, while
the raw waters of the Lee and New River generally
improved. The filtered waters also showed a falling off
in chemical quality, though giving satisfactory results
on bacteriological examination. While the raw waters of
the Thames and New River contained fewer bacteria than
i Vide Tik Lancet, Dec. 7th, 1918, p. 767.
364 The Lancet.]
SHORT COMMENTS. BTC—MEDICAL DIARY.
[March l t 1919
their respective averages for the year 1917, the raw water of
the Lee contained more bacteria than shown in its respec¬
tive average for 1917. In November the rainfall was
2*62 inches, being 0 08 of an inch below the average mean
rainfall for that month during the previous 35 years.
There was a chemical deterioration, again, in regard
to the raw river waters and some of the filtered
supplies, and there were more bacteria in the raw
waters of the Thames and Lee than in 1917, but
fewer in the New River water. The filtered waters, how¬
ever, were regarded as satisfactory. In December the |
rainfall was 2 80 inches, being 019 of an inch below the
average mean rainfall for that month during the previous
35 years. Chemical examination of the raw waters again
showed deterioration in some respects, while the filtered
waters showed improvement, though not up to the standard
of 1917. The raw Thames water contained more bacteria
than its respective average for the year 1917, while the raw
Lee and New River waters contained fewer. The filtered
waters were bacteriologically satisfactory. Sir A. C. Houston,
the Director of Water Examination, Metropolitan Water
Board, again points out that nearly the whole of the supply
is now stored antecedently to filtration and the improved
condition of the water after storage and before filtration
is best expressed by saying that on the average about one-
third of the pre-filtration samples contain no typical II. coli
in 10 c.qm. of water. The importance of storage is obvious.
BORN IN A WELL.
To the Editor of The Lancet.
Sir,— In your issue of Feb. 22nd (p. 324) you report a case
of a child born in a' well, and remark that the incident is
probably unique. In the British Medical Journal in 1891 I
reported a case of “ Childbirth in a Well*’ in the following
terms
Early in the morning (1 a.m ) of Sunday, December 21st, when the
thermometer was many degree* below freez’ng point, a woman, aged
39, wife of a bricklayer, while in labour with her eleventh child (only
one of whom is now alive;, left the* houso, where she waB alone in a
room with a couple of voung girls, and jumped down a well 20 feet
deep, with but 2 feet of water at the bottom. Instead of at once
calling the husband, who was In bed upstairs, these girls, who had
fallen asleep, and only awoke on heating the splash, ran off to the house
where one of them lived, about’a quarter of a mile distant, and
roused her mother. A man then came back and awoke the husband,
who at once got up and let himself down the well, where he fastened
the cha'n round ills wife and {she was drawn up, but, on reaching
nearly the top. the chain gave way and let her down again. Some t ime
was then lost in fetching a rope, and she was then drawn out, having
been, at the lowest calculation, forty minute.* in the well. She vras then
taken into the house, where she was supported on a ohsir till about.
3o’clock in her wet clothes, before geLt in/ women to come and undress
her. After sending her up the husband discovered a child floating in the
water. It was not till 10 a.m. (nine hours lifter she went down the
well) that I saw her. I found her on a mittress on the floor, very weak,
but wonderfully better than anyone could have expected, and with the
placenta, Ac., still in utcro, and this I had some diiHculty in removing,
having to insert my hand into the womb, when it contracted strongly
on my withdrawing it, and with very little lueinorrhago. She has
since made most satisfactory progress, and, in fact, has not had a bad
symptom, not, even after-pains, which is most unusual for a woman
who has been confined eleven times. She was probably saturated with
“liquor” at, the time, as the midwife who saw her in the morning
found her lying half on and half off the bed. smelling strongly <.f
brandy, and, again, in the afternoon found her sitting with a jug of ale
beside her, and in the evening, having lost her, after some search —
amoffgst other places, looking down the well, as it appeared she had
said somet hing about jumping down -.-he was found in a public-house.
Her system appears In this way to have been so hu;i -.tnetised as to
have prevents 1 much shock at the time, and si set after-pains. The only
marks after a jump of 20 feet, with only 2 feet, of water to break her
fall, being a small piece of skin off one leg and few scratches mi her
hands. A post-mortem examination on the child proved it to have
never breathed. 1 am, Sir, yours faithfully.
Fulbourn. Feb. 23rd. 1019. ‘ F. L. XlUHOLLS.
Jghbfcxl jfljiarg far % ensuing
SOCIETIES.
ROYAL SOCIETY OF MEDICINE, L Wlmpolft-street W.L ,
Wednesday, March 5th.
SOCIAL EVENING: at 8.30 p.m.
Dr. A. F. Hunt will discourse om “ War Neuroses” (illustrated by
cinematograph films and lantern slides).
MEETINGS OF SECTIONS.
Thursday, March 6th.
BALNEOLOGY AND CLIMATOLOGY (Hon. Secretartea-Ohas. W
Buckley, J. Campbell McClure): at 5.30 P.M.
Discussion:
On “ The Work of the Spa Physician in Relation to the Proposed
Ministry of Health.”
Opener: Dr. C. W. Buckley (Buxton).
Friday. March 7th.
LARYNGOLOGY (Hon. Secretaries—Frank A. Hose, Irwin Moore):
at 4.45 p.m.
Cases and Specimen* will be shown at 3.45 p.m. by-.—
Dr. A. L. Macleod, Mr. G. Secoorabe Hett, Mr. G. W. Dawson,
Dr. Douglas Guthrie, and others.
The Royal Society of Medicine keeps open house for
R.A.M.C. men and M.O.’s of the Dominions and Allies. The
principal hospitals in the metropolis admit medical officers
to their operations, lectures, Ac. Particulars on application
to the Secretary at 1, Wimpole-street, London. W-.l.
CHILD STUDY SOCIETY LONDON, at the Royal Sanitary Institute,
90, Buckingham Palace-road. S.W.
Thursday. March 6th.—6 p.m.. LectureMiss S. Walker: The
Training of Teachers from the Child-Study Standpoint.
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
POST-GRAD IT ATK COLLKGH, West London Hospital, Hammersmith-
road, W.
Special Eight Weeks’ Course of Post-Graduate Instruction. (Details
of the Course were given In our Is9uc of Feb. 15th).
LONDON HOSPITAL MEDICAL COLLEGE.
A Special Course of Instruction in the Surgical Dyspepsias will be
given at the Hospital by Mr. A J. Walton. Lectures, given in the
Clinical Theatre
Monday, March 3rd.—1 p.m.. Lecture III.:—Dr. Panton: Test
Meals. Technique for Aridity. Value of Results. Technique for
Motor Power. Examination of Fa'ces.
. Friday.—1 p.m.. Lecture IV.: Dr. G. Scott-. Radiological Examina¬
tion of Upper Abdominal Lesions. Value of Opaque Meals.
UNIVERSITY OF LONDON, KING’S COLLEGE, AND KING’S
COLLEGE FOR WOMEN.
Course of Six Public Lectures arranged in conjunction with the
Imperial Studies Committee of the University ou Physiology and
National Needs: —
Wi.dnkmjay, March titb.—5.30 p.m.. Lecture V.-.—Prof. D. N.Paton:
Pnysiology and the Study of Diseases.
ST. THOMAS’S HOSPITAL MEDICAL SCHOOL (University of
London), Governors’ Hall, St. Thomas’s Hospital, S.K.
A Series of Ten Lecturer on Diseases met with in the Sub tropical
War Areas illustrated with lantern slides, charts, diagrams and
microscopical preparations).
Widnknday, March oth, and Friday.—5 p.m., Lectures Land II.:—
Dr. L. S. Dudgeon : Malarial Fever.
ROYAL IN3TITUTH OF PUBLIC HEALTH, in the Lecture Hall of
the Institute. 37, Russel I-square, W.C.
Course of Lectures and Discussions on Public Health Problems under
War and After-war Conditions :—
Wednesday, March 5th. — 4 p.m.. Dr. W. J. O'Donovan: The War-
1 Tune Experience of Factory Medical Officers and the Position
of Factory Mofllcine under Peace Conditions.
CHADWICK PUBLIC LECTURES, at the Technical College Hall.
! Bradford.
! Thursday, March6th.—7.3d p.m.. Prof. L?pg9: Industrial Poisoning
1 and its Prevention—I . Anthrax and the Wool Industries
' * (illustrated by lantern slides).
Communications, Letters, &c., to tiie Editor have I r * Knf \ x * Lonci - ; Mr - w *
been received from- ! L.-^sifv)'w't;.w, c.b.. r,,n,i ;
A.— Dr. F. W. Alexander. Loud.; ; Santa Cru/., Calif.'rnia ; Hr. J. R. , Mr. E. C. Low.*, Lena s’.er ; l ocal
Annate of Medical History,Sew i Day. Lmd.; Dr. C. 11. Duncan, ! Governn.oid B <ard. L r rid., See. ol.
York, Editor of; American I New York. j M. —Medical Research CounniT.re*, |
.Journal nj Care for Cripples, E. Dr. C. C. Eastcrbrook, Dum- Loud.; Dr. J. Mahcrlv. Wood-
New York. fries. ; stock; Dr. P. R. Manning.
E. — I)r. N. Bardswr-U, M.V O., ■ F.- Miss M. H. Fraser, M.B., J Springfield, Mass.; Mr. C. Mac-
Loud.; Mr..7. C. Bhatt, Hyderabad; Loud.; Col. N. FaU'imic, A.M.S.; j mahon, Loud.; Dr. H. A. Mac-
Dr. M. Beuaroya, Loud.; Col. I)r. J. A. Fairer, Lci'-esi er ; Fac- i ewen. Loud.; Dr. J. P. McGowan,
W. P. S. Branson. A.M.S.; Dr. tories, Chief Imped or of. Loud.; Liverpool.
A. G. Bateman, Loud.; Dr. M. W. Dr. C. E. S. Flemming. Bradford- N.- -Nat ional Baby Week Council, i
Browdy. Manchester. un-Avon; Capt. J. G. Forbes, L >nd.; Dr. H. P. Newshohne,
C. —Messrs. Chamberlin, Don nor K.A.M.tJ, Trowbridge; National Food,
and Co., ldancnester; Miss J. G. —Dr. W. Gordon. Kxetor; Dr. ./<>* Loud.
Cowpcr, Loud.. Dr. K. Coopo. W. .1. Grant, Miliord; General 0.-<n-rsca.c, Loud., Asst. Editor
Liverpool; Conjoint Board of Medical Council. I ond.. Acting j of. i
Scientific Societies, Lond.; Miss Registrar of; Messrs. C. Griffin j P. — Mr. W. H. Plows, Lond.; Mr. j
H. ChesHliire, Lond.; Messrs. and Co.. Lond. i F. H. Perrycv-ste, Polperro : Mr. j
Cassell and Co., Loud.; Dr. F. G. H.--Humanitarian League. Lond., ' J. A. P. Perera, Sheitield ; Panel
Cawston. Durban; Mr. F. W. (r. Sec. of; Prof. W. D. Hadiburton, Committee for the County of j
Clinton, Lond.; Mr. T. Campbell, Lond.; Dr. R. A. P. liill, Wat- London. ' !
Wigan; Chadwick Trust, Lond ; ford. R. —Mr. A. T. Roworth, Lond.; Dr.
Lt.-Col. K. M. Cowell, D.S.O., I. — Incorporated Institute of Hy- G. M. Robertson, Edinburgh ;
H.A.M.C. gicne. Loud. Royal Society. Lond.; Dr. F. G.
D. —Capt. J. Driberg, R.A.M.C., J.—Major W. Johnscn, K.A.M.C. Rose, Georgetown, Demerara; j
Lond.; Col. T. A. H. Danes, (S.R.) j Dr. H. Renncy, Sunderland;!
Capt. J. A. Rale, K.A.M.C.;
Royal Society of Arts, Lond.;
Royal Institution, Loud.
S. —1>. A. G. Shera, Netley; Capt.
E. N. Snowden. R. A.M.C.fT.);
Prof. E. G. Sleslnger, Loud.;
Capt. C. F. Strange, R.A.M.C.;
Dr. C. Slater, Lond.: Sell’s
World s Press. Lond., Editor of.
T. — Capt. D. Thomson, K.A.M.C.;
Mr. W. S. Tiet jen, Lond.; Triplex
Safety Glass Co., I^ond.; Mr. P.
Turner, Lond.; Prof. B. H.
Tweedy, Dublin ; Mr. C. W. J.
Tennant. Lond.
U. — University of London Military
Education Committee, Lond.,
Sec. of.
V. -Mr. U. M. Vick, Lond.; Mr.
P. C. Varrier-Jones, Cambridge.
W. -Dr. F. J. Waldo. Loud.; Surg.-
Lieut. J. G. WHrdrop, R.N.; Mr.
C. II. Whiteford, Plymouth;
Wellcome Chemical Hesfearch
laboratories, Lond.; Dr. N.
Walker, Edinburgh; Mr. E.
Wortley, Roxeth; Mgr. M. E 1
Carton de Wiart, Lond.
THE LANCET, March 8, 1919
Jjmtlman Jftton
[IN ABRIDGED FORM]
OK
THE EARLY TREATMENT OF COMPOUND
FRACTURES AND OTHER SEVERE
INJURIES OF THE UPPER LIMB.
By E. G. SLESINGER, M.B., B.S., B.Sc. Lond.,
F.R.C.S. Eng.,
LATJB TKMPOKJLBY 8UBGKOK-UKUTKSUTT, B.K.
IN introductory remarks the lecturer said : I shall attempt
to deal with general principles rather than with detailed
technique. The subject is considered under (1) methods
suitable in the early hours of the injury and whose object
is the conversion of a compound into a simple fracture by
excision and suture, and (2) methods used if sepsis has set
in. The treatment of the first of these groups has usually been
undertaken at the casualty clearing stations, and that of the
second group at the base hospitals, so that in splinting early
cases a period of transport has to be considered. In the base
hospitals the most suitable splint can be used, regardless of
transport. The superiority of the worst natural arm over the
best artificial one should make the most conservative surgeon
more conservative still.
Primary Suture.
The primary excision and suture of wounds, which has
been so successful during the last two years, has improved
results enormously.
injuries without fractures.
In injuries without fracture the whole track can usually
be excised en bloo and the question of immediate or delayed
suture will depend upon whether the case can be retained
for at least 7 to 10 days, or must be evacuated forthwith.
When suture is performed an attempt should be made to
restore the functional anatomy of the limb, torn muscles
being united or grafted into others of the same group, inter¬
muscular compartments and tendon sheaths restored where
possible, and particular attention given to repair of the deep
fascia. Where careful previous examination is possible, it
will usually be evident which nerves are out of action, and
these should be traced and united wherever the injury
permits. Sven should the wound pursue a septic course
union of divided nerves will prevent retraction, greatly
facilitating later reparative operations.
In many injuries by either shell or bullet, entrance and
exit wounds are small in comparison with the extensive
muscular damage, calling for very careful and extensive
excision. Extensive muscular hsematomata, or even a diffuse
infiltration of the whole limb with blood may be found. All
such blood-clot should be carefully turned out, and if the
actual bleeding point cannot be tied, as, for example, occa
sionally in the upper forearm, the main vessel should be
ligatured above, sufficiently high to control the bleeding.
Both artery and vein should be tied, since, as Sir George
*Makins has pointed out, gangrene is more likely to follow
ligature of the artery alone than ligature of both vessels. In
such cases closure of the wound should be delayed for at least
48 hours, or until the danger of a sudden acute infection is
past, and the limb must be kept thoroughly warm, particu¬
larly if immobilised in a Thomas splint. If the wounds are
at all extensive the limb should be splinted as carefully as
if a fracture were present.
There is the vexed question as to whether any antiseptic
substance should or should not be left in the wound after
excision. In these early excisions there seems little doubt
that an almost similar percentage of successes can be
claimed by surgeons using different antiseptics or none at
all. Where primary suture is practised, heat, either in the
form of fomentations or as electric or hot-air baths, is of
value. The process of repair tends to be somewhat sluggish,
and sutures should be left in place at least 12 to 14 days, as
otherwise troublesome gaping is likely to occur on their
removal. Temperatures of 101°, or even 102° or 103° F., are
not at all uncommon after successful excisions, and the
pulse-rate and the local symptoms of the wound form the
only reliable guide to interference.
No. 4984
WOUNDS COMPLICATED BY FRACTURES.
If these cases can be operated on sufficiently early as
great a proportion of success can be hoped for from excision
and suture as in wounds of the soft parts alone. The same
general principles apply, though it is usually impossible in
cases of fracture to excise the whole wound en bloo.
In the upper limb a more radical removal of bone frag¬
ments is justifiable than in the case of the lower limb. The
French surgeons practise a most extensive removal of all
loose or even partially loose fragments in their “debride¬
ment ” operations, while the tendency of English surgery is
to leave any fragment which may possibly live in situ. In
most fractures of the upper limb a middle course is perhaps
best, but all completely loose fragments should usually be
removed, since not only are the chances of primary union
improved thereby, but the formation of an involucrum is
avoided, which in the forearm or hand is often very dis¬
abling. An exception should be made in the case of frag¬
ments bearing a portion of an articular surface, since the
disability attending their removal usually justifies the risk of
their retention except in certain places to be mentioned
later. The cleansing of the ends of the main fragments can
generally be satisfactorily performed with a sharp spoon,
though if there is no great loss of substance the removal of
a thin layer from each end is perhaps safer.
Fracture of the Humerus.
This bone is particularly favourable for treatment on
account of the comparative ease with which it can be
reached and dealt with and the wide muscular excisions
that can be performed, and partly on account of the rapidity
with which it throws out callus even after very extensive
loss of substance.
In fracture of the shaft, after excision has been performed,
the limb has usually been put up in extension in a straight
Thomas splint with swivel ring or in the suspension extension
splint described later. If the straight splint is used the limb
should be kept quiet in this for at least a fortnight, when gradual
movement may be begun. In the upper third of the humerus,
if excision has proved possible, position during transport has
usually been best maintained in a Thomas splint without a
swivel ring, and with the arm at right angles to the body.
Fractures of the lower end of the shaft are often very
difficult to deal with, and in the later infected stages a good
many cases are seen with very considerable disability from
malposition. The almost invariable trouble is the forward
tilting of the upper end of the lower fragment, which is
accentuated by the straight Thomas splint in which they are
often put up. Where excision and closure can be performed
the most satisfactory result in such cases seems to be
obtained by putting them up in extreme flexion, as for a
separated epiphysis, and steadying the line of the bone by
an acutely flexed internal or external angular splint with a
long upper limb.
In all compound fractures of this bone the musculo-spiral
group of muscles should be examined before operation if
possible, and if apparent paralysis is present the nerve should
be examined and repaired if necessary and feasible. Dorsi-
flexion of the wrist must be maintained in any after-fixation,
and if the nerve is found to be anatomically injured it is
sometimes a good plan to maintain such dorsi-flexion during
repair by excision of an elliptical portion of skin on the back
of the hand followed by linear suture, as described by Sir
Robert Jones in the treatment of infantile paralysis affecting
the elbow flexors.
Fractures of the Forearm.
Where only one bone of the forearm is fractured free
excision of the infected ends can usually be practised, and
especial care should be taken to reconstitute as far as possible
the contour of the bone to obviate troublesome adhesions of
tendons. The middle third of the radius presents special
difficulties, and unless the pronator radii teres can be made
to act as a splint the attainment of anything like perfect
position is often difficult or impossible.
In injuries to the upper end of the radius where the
fracture involves the articular surface, as it so frequently
does, it is often best to excise the head of the bone at the
primary operation. If movement is begun early very good
results can be obtained ; a more conservative practice is
often followed by considerable disability.
With fractures of both bones , particularly if loss of
substance is at all extensive, there are often considerable
K
366 ThhLahoet,] MR. E. G. SUBSIHQER {COMPOUND FRACTURES, BTC., OF TEE UPPER LIMB. [March 8 t 1019
difficulties. Ip the fij-st place, the numerous tendons prevent
a satisfactory excision of the soft parts, while, as regards the
bones, the maintenance of good position and the prevention
of cross anion, particularly where the fraoture includes the
radftis in itB middle third, is extremely difficult. Care
should be taken to reconstitute as far as possible the mesial
surfaces of the bones, and fragments projecting in this
plane should be removed if they cannot be readjusted.
In forearm fractures that have been excised and where
speedy transport is necessary a swivel-ring Thomas arm
splint has been used with extension obtained by a glove
glued to the hand, though where transport is not a necessity
better position and earlier movement can be obtained by
using the so-called suspension extension splint. Extreme
supination must be kept up, and with a Thomas splint
a convenient method is by a tennis ball placed in the palm
and secured to the bars of the splint in the required position
by threads sewn into its outer coat.
A tennis ball, or some form of wooden ball splint is also
best need in fractured metacarpal bones, provided the palmar
wound, if one exists, has proved capable of being closed.
Fractures of Phalanges.
The transverse and longitudinal arches of the hand—-the
former bony and ligamentous and the latter bony alone—
have received far less attention than their importance
deserves; in many cases of inefficient splinting of the
hand, either for injuries elsewhere in the limb, or more
particularly for fractured metacarpals, the condition of
“ flat hand ” which results is very crippling. In such a
hand not only is the opposing power diminished or absent
through the loss of tension in the transverse arch, but where
the metaoarpals have been improperly aligned the absent
longitudinal bony arch throws the metacarpo phalangeal
line of joints backwards and puts the interossei at a great
disadvantage in their action.
When phalanges are fractured even very extensive damage
can be dealt with without amputation by careful surgery of
the wound followed by adequate splinting, and Angers that
before the lessons of the war had been learnt would have
been lost, can be saved by careful conservative methods. It
must not be forgotten that perfect resumption of all normal
funetions is the essential object, and that it is not sufficient
to heal the wound or repair the bone unless the movements
can be restored. Extension is readily maintained in the
early stages by Sinclair’s ball splint, with extension by means
of a glued glove finger. In cases where this is impossible
Sinclair’s ingenious suggestion may be followed and traction
obtained bv boring a hole through the free end of the nail
and using the nail for the transmission of the necessary pull.
WOUND8 OF JOUSTS.
It is open to argument in many cases of compound fracture
whether primary suture following excision is the best treat¬
ment, considering the grave results which may follow an
imperfeob toilet of the wound ; but there can be little doubt
that where joints are involved the chanoes of a perfect result
which immediate cleansing and closure gives very greatly
outweigh the risks. In these cases the temperature chart is
often extremely misleading. A rise to 102° or 103° without
any greAt increase in the pulse is common, and can be dis¬
regarded if the other signs and symptoms are satisfactory.
Where the case is doing well the temperature will usually
settle to within normal limits in two, three, or four days.
Shoulder-joint.
Injuries of the shoulder-joint, if uncomplicated by fracture,
may usually be dealt with conservatively by washing out the
joint and closing the capsule. As to the injection of such
substances as ether, formalin, glycerine, &c. into the joint
cavity, no very definite evidence exists that they are of any
value provided the mechanical cleansing of the joint has
been complete.
Where a fracture of the head of the humerus coexists with
the joint injury sepsis is so liable to lurk behiud in the
cancellous tissue of the bone, and future painful adhesions
are so likely to follow such an injury of the large articular
surface of the head, that more radical treatment is often
advisable. In practically all other joints in both the upper
and the lower limb—except the radio-humeral joint—opinion
has been gradually hardening against the performance of
excision as a primary operation. In the case of the shoulder-
joint the results of excision, on the whole, are extremely
good. Where excision is performed a straight Thomas’s
splint without a swivel-ring, and with the arm abducted at
right angles to the body, is probably the best for transport,
while where the patient can be retained the system of slings
mentioned later is satisfactory and allows of early movement.
Elb aw joint.
Open injuries to this joint are not common without con¬
comitant fractures of the bones entering into ife formation ;
bat where they do occur they should be treated by thorough
cleansing of the joint followed by suture. It is often not
possible to reach the joint cavity satisfactorily through the
original traumatic opening, and if such is the case the
original track having been excised, the joint may be opened
by a longitudinal excision over the head of the radius with
the forearm prone, through which satisfactory lavage can be
carried out. This method exposes the radio-ulnar joint; or
can do, and damage to this important joint can be inspected
and dealt with. Unless the injury has destroyed th greatsr
pact of the articular surfaces of the elbow-joint, it would
seem best to limit interference as far as possible.
A set excision at this stage has practically nothing tc
recommend it. Every possible use should be made of the
tendinous expansion of the triceps to reconstitute* shattered
olecranon, and the continuity or otherwise of the ulnar nerve
must be verified and dealt with. Where the injury to the
articular surfaces renders it useless to hope for a movable
joint, great care must be taken in putting up these cases.
The forearm should always be eupinated, and the angle at
which the elbow is kept must depend largely on the patient’s
usual occupation. It is quite remarkable, however, how
grave an injury is compatible with a subsequently movable
joint, provided infection does not occur and the injury
allows of early active movement vigorously maintained. In
some cases where the olecranon is already separated and con¬
siderable artioular damage exists it is possible bo separate the
injured surfaces with a flap of fat and fascia, and so sacmre
a movable joint by means of a modified arthroplasty,
particularly with injuries in the region of the capiteUum.
It would seem best where the head of the radios is badly
damaged to exoise it completely, and in all these oases the
limb should be invariably kept in full supination and
movements of pronation and supination begun as early as
possible.
WrUtjoinL
Wounds of this joint are usually accompanied by injury
to the carpal bones, and the complexity of the synovial
cavities renders thorough cleansing extremely difficult.
Where the carpal injury is not too severe conserva¬
tive surgery is sometimes possible, and the intercom¬
munications of the synovial spaoes are very readily
shut oft under the influence of injury or infection, so
that if early vent is given to any remaining sepsis it is
usually fairiy easy to keep the process under control.
Limited excisions of the carpal bones in response to the
nature of the damage present give usually quite good results,
provided attention is given to the position of the wrist after¬
wards. Dorsi-flexion must be maintained and ulnar devia¬
tion prevented ; early and vigorous finger movement must be
insisted on.
Where a thorough exoision is not possible, and.particularly
when many of the tendons are divided, it is usually wiser nof
to aim at primary closure of the wound. In such oases a
careful anatomical reconstruction of the divided structures,
and as complete as possible a removal of dead tissue, followed
by the application of such a tissue solvent as Dakin’s fluid,
will usually allow of early secondary closure. If such a
case has to be left open, every effort should be made to avoid
leaving a tendon or tendons running utioovered through the
wound, as these will certainly die. When they cannot be
incorporated in the walls of the wound, it is usually bettor
to realise at once their inevitable death and to make as good
a provision as is possible for the resumption of the function
they subtend by such grafting or cross-unions as are
necessary.
Metamrpo-phalangeal and Phalangeal Joints.
Injuries to these joints should be treated as conservatively
as possible, and every attempt should be made to secure
primary union ; secondary sterilisation is a long and tedious
process. Sinclair’s ball splint is perhaps the best in the
after-treatment of these cases* and the good splinting attach¬
ment permits of graduated And increasing increments^
TBS EUNGBT,] MR. B. 0.8LBSINGER: COMPOUND FRACTURES, ETC., OP THE UPPER LIMB. [Masoh^ MM 367
Perhaps the modi difficult .problem for the eorgeon in the
early treatment of all these severe injuries is the decision as
to when excision and suture should not be performed. He
must-be guided partly by the length of time since the inflic¬
tion of the injury, partly by the anatomical possibilities of
the wound, and partly by the nature of the infection present,
if known.' Gas-bacillus infeotion is not greatly to be feared
where the main vessels are intact, since a wide excision of
aU dead or damaged tissues will prevent its development.
Further, its presence is readily recognised by the indications
present in the wound and by the character of the pulse and
the temperament of the patient. The most dangerous infec¬
tion possible in these oases is that caused by the haemolytic
streptococcus. Even with the most radical surgery the
ofcanoes of success are extremely slender.
The Treatment of Infected Wounds.
Having now briefly reviewed some of the principles which
underlie the early treatment of these severe injuries to the
upper limb, it remains to consider the methods to be adopted
when the case is seen too late for primary excision aud
suture or when this method has been tried but infection has
developed. This second line of treatment represents
mainly the work as performed in the base hospitals in
France. Consequently, where we attempt to apply the
lessons of the war to civil surgery it will usually be advisable
to adopt, in conjunction with “ first line” surgery, the
splinting of the “second line.”
Two sides of the subject have to be considered—namely,
(1) the treatment of the wound itself; (2) the treatment of
the part wounded ; but each is the necessary corollary of the
other. It is chiefly in the field of pure wound treatment
during this infected stage that the great controversy of
Opinion and practice has been waged during the war.
There can be little doubt that the treatment most likely
to provide practical success is that which most closely
imitates Nature’s own treatment or which exaggerates it to
meet the aggravated conditions present, and it is in the
interpretation of these processes that the experimental work
Of Sir Almroth Wright and his co-workers has been so
valuable. Approximately, it may be said that when dealing
with an infected wound the natural reaction of the body is
to limit as rapidly as possible the depredations of the
invading organisms by destroying the food on which they
live, and at the same time to guard against their further
invasion by setting up a strong zone of defence around the
wound. The first purpose is accomplished by the liberation
in^he wound, from dead pus cells, of trypsin, which splits
up the protein Of the dead tissues and deprives the organisms
of their necessary pabulum, since most organisms need, at
any rate, polypeptides for their growth. The second is
secured by the speedy construction of a band of leucocytic
infiltration and, as a guard against the activity of the body’s
own agents, by an increase in the normal antitryptlo activity
of the serum.
It is thus seen that both in the pre-infected and in the
inflected stage of a wound the same general principles
underlie its treatment—namely, the thorough removal of all
dead or dying tissues—and that the sole difference consists in
the fact that before bacterial spread has occurred the
process can be carried out quickly by means of the knife,
while at a later stage where the line between living and
dying tissues is no longer distinct, the slower process of
hydrolysis must be resorted to.
We have here, then, a natural line of wound treatment
along which success is to be expeoted. In the neutral
hypochlorite solution of Dakin and Daufresne we have a
substance of very great proteolytic value. Experiments on
the action of a 0 5 per cent, hypochlorite solution on
coagulated albumin, gelatin, albumin in solution, and dead
tissue showed that the solids were dissolved and the dissolved
peotein hydrolysed, the various stages of the formation of
alkali, albumin, proteoses, peptones, and lower products
being readily followed. The rapidity of the action is well
seen by two experiments.
In the first, if a solution containing 5 per oent. egg-white
and 0*5 per cent, hypochlorite is incubated for eight hours
at body temperature, no protein, proteose, or peptones oan
be detected although ail these substances are readily
demonstrated during the course of the experiment.
In the second an artificial wound was constructed by
placing a weighed piece of meat on a tray in a Petri dish
under sterile conditions, the whole being kept moist and at'
body temperature. In one case two-hourly irrigation with
two ounces of Dakin’s solution was carried out and in
another a similar procedure with normal saline. In each
case a piece of meat weighing 1* oz. was used, and the one
irrigated with Dakin’s solution was oofinpleteiy dissolved in
72 hours, while the one where saline was used was practically
unaffected.
This all-important action of the hypochlorite solution is,
of course, a purely chemical bulk action, and the J amount to
be used must be proportionate to the tissue to be dissolved,
a fact which accounts for tbe apparent failure of Dakin’s
solution in Sir Almroth Wright’s “ artificial slough ” experi¬
ment.
It would seem probable that along this line, the hydro¬
lysis of dead tissues and the consequent secondary sterilisation
of the wound, lies the most probable avenue for advance in
the treatment of all infections. A great deal of work remains
to be done, and whether further research shows ferment
action or some form of chemical or bacterial hydrolysis to
be the most successful, sufficient is already evident to estab¬
lish the principle that the speediest way of dealing with an
infection is to remove those substances in the medium which
are essential for bacterial growth.
In the treatment of infected wounds, therefore, as regards
the wound itself, Nature’s tryptic digestion has been replaced
by hypochlorite hydrolysis, the hypochlorite being intro¬
duced into the wound in the form of intermittent irrigation
with Carrel’s tubes. Dakin’s fluid so employed is used
solely for its hydrolytic power, and it is a coincidence, and
perhaps an unfortunate one, that in a test-tube this fluid
possessed a high so-called “ bactericidal power.”
The fact that a few seconds after its introduction into an
actual septic wound suffices to destroy the hypochlorite as
such, and the additional fact that organisms can be found
growing on any isolated portions of dead tissue remaining
in a wound which has been bathed in the solution, should be
sufficient to vindicate it from any charge of antiseptic action
in vivo , and prove, if proof is required, that its hydrolytic
power is responsible for its undoubted success.
Nature’s second method of dealing with an inflected
wound—namely, the establishment of a zone of leucocytic
defence round the wound—is best aided by the maintenance
of absolute rest and as perfect an alignment of parts as is
possible, and further by a minimum of operative interference
on the part of the surgeon while infection is active.
Treatment of the Part Wounded.
When splinting an injury of the upper limb at this stage,
the question of transport need no longer limit the choice.
The counterbalanced suspension method was used, and the
fracture wards were fitted with permanent superstructure
carrying adjustable cross-bars from which any splint can be
suspended in counterbalance by means of cord, pulleys, and
sand-bags. If the arm is extended by a running weight no.
movements of the patient can disturb the relative as opposed
to the absolute position of the limb in its splint.
In deciding on the position of the limb two factors must
be borne in mind : (1) the fractured bones must be brought
into and maintained in as perfect a position as possible,
and (2) the musculature of the limb must be held in the
position which will best favour resumption of functional
activity. Now the mechanics of the upper limb are rather
altered by the fact that the human body is usually active in
an upright position. With the body ereot certain groups of
muscles have, in addition to the act they are helping to
perform, to overcome tbe weight due to gravity. These
seems little doubt that this gravity effect is largely
responsible for the so-called preponderance of . certain
groups of muscles, and its results are well seen in cades
of infantile paralysis, where recovery is much more common
in the gravity*aided muscles. Consequently, when putting
the upper limb into its optimum repair position tbe gravity
opposing muscles shonld be as far as possible kept shortened.
The best position and a convenient one for wound treatment
is as follows. The shoulder is abducted and flexed at right
angles to the body, the arm is externally rotated, the fore¬
arm is flexed at right angles, and is kept in extreme
supination, while the wrist-joint is extended and the fingers
are held abduoted and extended. This position has been
used in most fractures of the humerus and bones of the
forearm, except where unfavourable to correct • bony
alignment.
368 Tab Lancet,] MR. B. G. 8LBSINGBR: COMPOUND FRACTURES, BTC., OF THE UPPER LIMB. [Maboh 8,1919
The Suspension Extension Splint .
The method employed is applied as follows. For example, in
fracture of the shaft of the humerus Sinclair’s glue is applied
to the front and back of thA forearm and gauze strips are fixed
to it; a glove is glued to the hand, leaving thumb and fingers
free. . Further, gauze strips are glued to as great a surface
of skin over the lower fragment as possible. A mackintosh
sling is applied over the dressings round the fracture and is
suspended by a cord which, runniDg over two pulleys, has
its other end attached to a hook. To this hook are fixed the
Suspension extension splint for treatment of upper-limb
Injuries in the optimum position for repair.
gauze strips from the forearm, also the strings from each
glove finger, permitting suspension by either or both.
The counterbalancing weight is fixed to the cord between
the pulleys, and the gauze from over the lower fragment is
fixed to a cord running over a pulley at the end of the bed, to
which extension weight is attached. Supination is obtained
by a torsion sling applied round the hand and running to
the top or bottom of the bed.
In upper-arm wounds where the extent of skin involved
proves too great for this method we have used an arm
Thomas’s splint, bent to a right angle, and with the angles
of attachment of the ring altered to fit over point of shoulder.
Extension is obtained by using the forearm as a lever. Gauze
glued to the lower third of the forearm and fixed to the
internal bar forms the fulcrum ; gauze glued to upper third
of forearm and pulled to the external bar forms the force,
and bo exerts traction in the line of the humerus. The
optimum repair position is maintained, except for the absence
of external rotation at the shoulder-joint.
Fractures of the forearm have usually been treated by the
suspension extension method described for the humerus,
with a sling from the seat of fracture to top of bed,
which counteracts any tendency of the fracture to sag. Very
extensive or very septic wounds have been treated for a time
on a form of suspension extension tray, consisting of a metal
tray with a drainage-pipe. A wooden upright, against which
the upper arm rests, serves m a counter-extension. The
wooden attachment runs forward under the tray and has at
its end a pulley over which runs a cord, taking extension
from lower forearm or fingers, according to situation of
wound. In fractures of both bones a wooden side-piece with
straps is added, so that the forearm can be treated in
supination. The whole apparatus is counterbalanced in
suspension. The drainage-tube is connected to a bottle at
the side of the bed, avoiding any wetting.
In wounds of the carpus and lower third of the forearm
this splint has also been used, usually with a wedge attach¬
ment to secure adequate dorsi-flexion of the wrist. Extension
is obtained by glove fingers glued to the skin and run by a
kind of wood gearing to one central pull, thus maintaining
good position of the fingers and an equal distribution of
strain.
Infected Wounds of Joints.
In dealing with infected wounds of joints, whether or not
complicated by fractures, a movable joint has been aimed at,
and it is surprising in what severe injuries a certain amount
of movement can be obtained. In the shoulder-joint, as
mentidbed before, excision is probably best if the head of
the humerus is gravely injured, and if this operation is
performed, the arm is put up abducted and flexed, ‘‘la
general, in infected joints in the upper limb, once drainage
has been established and hypochlorite introduced the
condition seems improved by movement. As a rule the
limb has been so arranged that if ankylosis should occur,
it should occur in the most desirable position, while
movement round this optimum position as a mean has
been encouraged.
In the shoulder-joint the arm and forearm have been
suspended in mackintosh slings, counterbalanced by weights
and pulleys, and if the balance is accurate, the patient is
able to move his arm with the minimum of muscular effort.
In the elbow-joint, where arthrotomy has had to be per¬
formed, the vertical incision over the head of the radius has
been used, which by a downward and inward extension will
also serve to expose the radio-ulnar joint. These cases
have been treated on a modification of the suspension
extension tray, the tray being so slung that its position of
rest is that in which ankylosis, if it should follow, is desired
to occur. If this splint is carefully counterbalanced, or if
the patient assists himself with his other hand, all the
movements of the elbow can be carried out, without in any
way interfering with the treatment of the wound.
In regard to the wrist-joint , oases of infection of this joint
have been treated in dorsi-flexion and have been kept strictly
immobilised, since the advantages of early movement do not
compensate for the risks of spread of infection along tendon
[ sheaths and communicating synovial spaces. In the mcta-
carpo-phalangeal regions the same methods have been used
as described in the early first line treatment. ~
Surgical Treatment.
As to the surgical treatment of these infected wounds the
essential condition is that all pockets and portions of the
wound must be made freely accessible to the irrigating fluid.
Tho scissors should be freely used to remove any exposed
tendinous expansion or intersections, as tendon tissue is
very slowly hydrolysed and is very apt to keep up a slow and
prolonged suppuration. In the early stages of acute sepsis
the least possible manipulation of the limb in search of hidden
or pocketed pus would seem best, as in the majority of cases,
where immobilisation is good, a barrier will be created
against any general spread of infection, and pus, if it is
formed, will be local in site, and readily dealt with when
the moment arrives.
Some form of bacteriological oontrol should be instituted
in these cases, and when what has been termed surgical
sterility is reached, secondary suture may be carried out,
with a large percentage of successful unions. All through
the treatment of these cases attention to the wound must be
paralleled by care that the restoration of function is
encouraged by every possible means, and of such means early
active movements are the most important. Fortunately
there is a satisfactory guide to the extent to which move¬
ment can be carried out, in the pain which follows any
excessive motion. If the limb has been arranged so that
movement does not disturb its correct alignment, active
movement can be safely encouraged in all cases within the
limits to which pain forms a safe and certain guide.
I would like to express my great indebtedness to my
colleagues Captain F. D. Saner and Captain O. G. Motgan
for the readiness with which they have allowed me to use
work which was jointly carried out.
Guy’s Hospital.
The War Emergency Fund has recently received
donations of 50 guineas eaoh from the Royal College of
Physioians, London, and the Royal College of Surgeons,
England.
The late Mr. G. B. McCaul. L.R.C.P.& S. Edin.—
The death is announced on Feb. 12th of Mr. G. B. MoCaul,
who for a considerable time was senior medical practitioner
and senior justice of the city of Londonderry. He was in
his eightieth year. A native of Newry, oo. Down, Mr.
McCaul went early in life to Londonderry. In 1869 he
became L.R.C.P.& S. Edin., and settled down in practice in
his adopted city, where he rapidly became one of the leading
medical practitioners. He also took a prominent part in the
civic life of Londonderry, entering the corporation in 1884,
and he was specially interested in guiding the public health.
He was most popular in every way and much esteemed as a
medioal doctor. One of his sons, Captain G. B. McCaul,
M.D., R.A.M.C., has been awarded reoently the Military
Cross.
Tam LAKcnrr,] DRS. HURST fc SYMN8: HYSTERICAL ELEMENT IN ORGANIC DISEASE, ETC. [Maboh 8,1919 >869
THE HYSTERICAL ELEMENT IN ORGANIC
DISEASE AND INJURY OF THE
CENTRAL NERVOUS SYSTEM.
BY ARTHUR F. HURST, M.A., M.D. Oxon., F.RC.P.,
LUStJTEN JUTT-COLO KIEL, R.A.M.O. ; PHYSICIAN A HD KKU ROLOGIST
TO GUY'S HOSPITAL;
AND
J. L. M. SYMNS, M.A., M.D. Cantab.,
MAJOR, R.A.M.O. (T.). »
(from the Seale Hayne Military Hospital , Newton Abbot.)
It has long been recognised that hysterical symptoms
may be grafted upon symptoms caused by organic disease.
Onr experience with soldiers daring the past foar years has
led ns to believe that this association is much more common
than has generally been supposed. We woald even go so far
as to say that there are few symptoms caused by organic
disease which are not liable to be aggravated and perpetuated
by Buggesti »n, so that it becomes necessary in almost every
case of impaired function to look for an hysterioal element
which can be removed by psychotherapy.
We have often found that hysteria may aoconnt for a large
proportion of the incapacity in a patient presenting such
definite signs of organic disease that it might very easily
have been presumed that the entire condition was organic.
We are consequently now in the habit of testing every case,
in which it is at all conceivable that an hysterical element is
present, by the only means which can yield the necessary
information—namely, by observing the effect of psycho¬
therapy. No other means are available, as, on the one
hand, organic physical signs do not exclude the possibility
of hysterical symptoms being present and, on the other
hand, our observations, as well as those of other investi¬
gators, have proved that the supposed stigmata of hysteria
are not present until they have developed as a result of the
unconscious suggestion of the observer, who may produce
them in suggestible individuals suffering from organic
disease just as easily as in those suffering from hysterical
disorders. 1
Disseminated Sclerosis.
It is not an uncommon occurrence to find an extensor
plantar reflex, ankle clonus, exaggerated knee-jerk, and
absent abdominal reflex in a patient who seeks advice for
some early symptom of disseminated sclerosis, such as
impaired vision or unsteadiness of the hands, in spite of the
fact that no symptom of paraplegia is yet present. These
physical signs are accepted as absolute proof that the disease
has involved the pyramidal tracts, and experience shows
that sooner or later the legs will become weak and that
severe spastic paraplegia will ultimately develop. The con¬
clusion to be drawn from these facts is that signs of organic
disease of the pyramidal tract may precede the onset of
symptoms.
Many patients, especially women, suffering from dissemi¬
nated sclerosis have a peculiar state of mind, often errone¬
ously called hysterical, one feature of which is an abnormal
degree of suggestibility. It is not surprising, therefore, that
hysterical symptoms—symptoms produced by suggestion and
curable by psychotherapy—may develop. When the lesion to
the pyramidal tracts in such a suggestible individual becomes
sufficiently marked to cause some stiffness and weakness in
the legs, the stiffness and weakness may give rise to the idea
of paralysis, and hysterical paraplegia may rapidly appear.
If the patient is Been at this stage it may be impossible to
make an accurate diagnosis, for we are face to face with a
case of hysterical paraplegia with all the physical signs of
organic paraplegia, although only a very small proportion of
the incapacity is a result of the organic lesion.
Such a patient may be given a rest cure, inunctions of
mercury, injections of salvarsan, or one of the numerous
other drugs which have from time to time been advocated
for disseminated sclerosis by individual physicians, only to
be rejected by others, who have employed them with less
faith and therefore with less effect. The treatment, what¬
ever its precise nature, is really a form of psychotherapy,
and the hysterical paraplegia disappears, leaving behind the
physical signs of organic paraplegia and the slight degree of
weakness and stiffness, which were present before the onset
of the hysterical symptoms
This we believe to be the chief explanation of the occur¬
rence of periods of more or less spontaneous improvement,
which is such a characteristic feature of disseminated
solerosis. It applies equally to the improvement of other
symptoms, such as amaurosis; the slight impairment of
vision, which results from the earliest changes in the optic
nerves, sometimes even before any change can be recognised
in the discs, suggests a grave loss of vision to suggestible
individuals, so that almost complete blindness may occur
long before definite optic atrophy is present. The vision
may greatly improve again either spontaneously or as the
apparent result of some form of treatment, but really as a
result of suggestion.
It is very common in disseminated sclerosis to obtain a
history of temporary weakness of the legs or temporary
blindness some months or even years before the true nature
of the disease is finally recognised. The temporary
symptoms have generally been regarded as hysterical,
but the physician who sees the patient now for the first
time is inclined to say that the old diagnosis was both
incorrect and unjust, as the symptoms must really have been
organic in origin and a part of the disease from which the
patient is obviously suffering at the present time. The
truth is that the early symptoms were probably to a great
extent hysterical, having been suggested by the very slight
incapacity caused by the organic disease. The hysterical
element disappeared, leaving the slight organic element
behind. The early diagnosis of hysteria, though only
partially correct and in one sense unjust, was distinctly
to the patient’s advantage if it led the physician to employ
psychotherapy, which would cause the rapid disappearance
of the hysterical sympb ms.
No satisfactory explanation has ever been offered which
would adequately explain the remittent character of the
symptoms of disseminated sclerosis if they were entirely
organic in origin. It is quite possible that a period of rapid
deterioration corresponds with the rapid development of new
areas of disease in the central nervous system, and that snob
a period may be followed by another of much slower develop¬
ment of the disease, during which changes may occur in the
rapidly formed areas of disease, which result in their con¬
traction, so that nervous tissue which was originally thrown
out of action by compression recovers its functions. This
probably explains the temporary paresis of cne or more of
the external muscles of the eye, and some of the slighter
variations in the degree of paralysis of the limbs and of the
impairment of vision, but it is hardly conceivable that suffi¬
cient change should occur in the central nervous system to
account for the conversion of complete paraplegia into very
slight stiffness and weakness of the legs, or of total blindness
into slightly indistinct vision. Our explanation also makes
it easy to understand why spontaneous improvement occurs
more often in females than in males, and in the neurotic
than in less suggestible individuals.
These ideas are represented diagram ? atioally in Diagram I.
The line AG 1 represents the gradual development of para¬
plegia in a case of disseminated solerosis. When the time
B is reached the degree of incapacity, BB 1 , is still so slight
that it remains unnoticed, but it is sufficient to produce
physical signs. When the time 0 is reached a certain
amount of stiffness and weakness is noticed, this being repre¬
sented as OC 1 . This may continue to develop with the
advancing disease until, at the point D, the incapacity is
370 The Lancet,] DBS. HURST &SYMN8: HYSTERICAL ELEMENT IN ORGANIC DISEA8E, STO. [March 8, 1919
DD 1 . It Is possible, however, that the slight impairment
of function represented by C 0 1 may suggest a farther degree
of incapacity, with the result that the patient becomes com¬
pletely paraplegic. The total incapacity, D D a , is then made
up of an organic element, DD 1 , together with an hysterical
element, D l D*. This condition of mixed organic and
hysterical paraplegia may last until the point of time E,
when, as a result of some counter-suggestion, the patient
begins to improve and the hysterical symptoms eventually
disappear, leaving him with the incapacity F F l , which is
somewhat greater than at the onset of the hysterical
symptoms (C C l ), but very much less than the total
incapacity. If the hysterical nature of the symptoms was
at once recognised, the total incapacity DD a could have
been reduced at a single sitting toDD 1 .
Tabes .
We have shown how disease of the lateral columns pro¬
duces physical signs before any symptoms have developed,
and how the earliest symptoms may be exaggerated as a
result of the development of hysterical paralysis on the top
of the organic incapacity. Exactly analogous phenomena
may occur in disease of the posterior columns. It is very
common to find lost ankle-jerks with feeble or lost knee-
jerks and some impairment in the vibration-sense over the
bones of the legs 3 in patients who have sought advice on
account of gastric or other crises, impaired vision,
impotence, or disturbances in micturition, whioh are due to
early tabes, but who have so far had no ataxy or other
symptom which would indicate that the posterior columns
are diseased. It is clear, therefore, that the physical signs
of disease of the posterior columns, as well as of the lateral
columns, precede the onset of symptoms.
Physical signs of organic disease of the central nervous
system are thus qualitative and not quantitative.
We have seen numerous cases, in which much of the
incapacity in a man obviously suffering from tabes was
proved to be hysterical by its rapid disappearance with
psychotherapy, the symptoms having been suggested to the
patient by the slight incapacity which resulted from the
actual organic disease. In addition to this auto-suggestion
hetero-suggestion often plays a part, symptoms being
unconsciously suggested by the medical officer in the
coarse of his examination. It is, for example, very easy to
suggest Romberg’s sign, and we have now seen a number of
oases in which a well-marked Romberg’s sign was obviously
hysterical. In some cases it was th-3 only hysterical symptom
present; in others, like the following reported by Lieutenant
3. H. Wilkinson, 3 it was accompanied by hysterical paralysis,
which had resulted from auto-suggestion.
Hysterical paraplegia and hysterical Romberg’s sign in a man with
tabes .—Driver B., aged 28, was blown up by a shill at Salonika on
Jan. 19th, 1917. On regaining consciousness he found he was unable
bo walk. In spite of treatment with electricity, hypnosis, and massage
at Malta he remained paraplegic. When admitted to Netley on
Jan. 8th, 1918, the paraplegia was found to be hysterical, and he
qntckly learnt to walk normally. By Peb. 13th he was feeling well in
ever? way and would hare been sent to duty had it not been for the
oond*tlon of his pupils. The right pupil was larger than the left; it
was oral In outline and reacted neither to light nor accommodation.
The outline of the left pupil was also slightly Irregular and gave a
typioal Argyll Robertson reaction. The knee-jerks and ankle jerks
were normal.
His medical officer, thinking that he might have tabes, asked him
whether he had ever felt dizzy or Ilk My to fall when closing bis eyes.
He answered in the affirmative, and on being tested for Romberg's
sign gave a well-marked reaction, which became more marked at sub¬
sequent examinations. This was subsequently recognised as being
anomalous, for the knee-jerks and ankle-jerks were normal, showing
that there could not be any great loss of muscle-sense In the legs. It
was concluded, therefore, that the Romberg’s sign had been uninten¬
tionally produced in the oourse of examination. This view was con¬
firmed when ever? trace of the sign disappeared two days later aa a
result of counter-suggestion.
The Wassermann reaction of the blood and cerehro-splnal fluid was
strongly positive, so that there can be little doub*. that the pupil
changes were due to early tabes, although the tendon reflexes were
normal.
The improvement in the gait of tabetic patients which
results from the methods devised by Frenkel does not, in onr
opinion, always act solely by educating the patient to use his
eyes to help his deficient muscle-sense, and to make the most
of such muscle-sense as he still has. The results obtained
are sometimes too rapid and too dramatic, aud can scarcely
be explained except as a result of suggestion, the incoordi¬
nation being largely hysterical and the nature of the in¬
capacity having been suggested by the slight degree of
unsteadiness actually caused by the organic disease.
One of us (4. F. H.) In 1913 saw a man with all the physical signs of
tabes who had been unable to walk for six years. He was brought In a
chair to the Guy’s Neurologioal Department at 9.30 ▲ m. Alter be had
been examined he was told that he would probably learn to walk again
it he carried out certain exercises which were shown to him. He con¬
tinued to practise these, and by 12 o’clock he had Improved to sueh aa
extent that he could walk the length of the room, and In a week he
was walking about normally.
This was regarded at the time as a triumph of re-education
of the deficient muscle-sense, bnt the re-education must
really have been re-education of the patient’s mind—in other
words, psychotherapy; as, if the total inability to walk had
been due entirely to organic changes in the oord, it is incon¬
ceivable that the little muscle-sense still present oould have
been re-educated to such an extent in a single morning after
lying dormant for six years.
Friedreich's Ataxy.
We have not had the opportunity of investigating many
cases of organic nervous disease daring the war, as, except
for those caused by syphilis, they are rare among soldiers.
The following case under the care of Captain W. R. Reynell
was a typical example of Friedreich’s ataxy, and until recently
we would have accepted all the symptoms as the result of
the organic changes in the central nervous system without
further discussion. We wonld have said that Friedreich's
ataxy is one of those nervous diseases in which very little
can be done, and that the patient could hope for no improve¬
ment, but would slowly and steadily get worse. We have no
doubt that this opinion would have been shared by the vast
majority of physicians.
So convinced have we become of the enormous importance
of looking for an hysterical element, even in the most
unlikely places, that Captain Reynell proceeded to treat the
patient as if his incapacity was hysterical, although there
was nothing in his mental or physical condition which gave
any grounds for such an idea. The treatment was fully
justified by the result, and instead of sending the patient
home as a helpless cripple, he has now been discharged from
the Army in a condition whioh will not prevent him from
earning a living in some light occupation for a time,
although, of course, the ultimate prognosis remains as
hopeless as ever.
Hysterical ataxic paraplegia associated with Friedreich's ataxy —
Pte. B. two years ago gradually became unable to walk in the dark,
but it was not until he was sent to France with a Labour Battalion In
October. 1917, six months after joining the Army, fchrt be had any
difficulty In the daylight. He was stooped several tlm-s by the
military police on suspicion of being drank, as h s gait w«a unsteady.
Alter an attack of Influenza In June, 1918, the ataxy was much
exaggerated, and from this date he only weno out in a ba« h-chtir. The
difficulty in walking then steadily Increased up to the time of his
admits! *n to Seale Hayne Hospital on Oot 12th. 1918.
Dr. W. H. Haupt informs u« that the patient's father was a very
heavy drinker and had infected his m »tber with syphilis, which had
led to the perforation of her palate. Ills brother is a complete cripple
and never leaves his home. Bight years ag i his hands became unsteady
and he had to give up his work. Dr. Haupt reports that he has
kyphosis and lateral curvature of the spine, pee cavns, absent knee-
jerks. extensor plantar reflexes, marked Romberg's sign, nvstogmus. a
peculiar hesitating, almost stuttering Bpeech. aod intention tremor.
He is very emot o< al and laughs and orles at the least provocation. He
is also very deaf. Dr. Haupt regards him as a typical case of
Friedreich’s ataxy.
Our patient’s speech is slightly affected, and there are sadden
changes of pitch, as in a voice that is breaking. On admission he
could soaroely do anything owing to extreme iuoobrdinatlon, and he
fell frequently when he tried to walk without assistance. He was very
unsteady on standing, and he fell tmmed'ately he closed bis eyes.
There was a slight but definite kyphosis, and the plantar arches were
abnormally high on both sides. The knee- and ankle-jerks are com¬
pletely absent on both sides. The plantar reflexes are dlffiouit to
obtain, but appear to be extensor. When asked to p mr water from a
jug into a tumbler definite incoordination in the arm movements was
well seen and much water was spilt. The Wassermann reaction was
negative in the blood and cerebrospinal fluid. A diagnosis of
Fredreich’s ataxy was made.
Treatment by persuasion and re-education was given, as It was sus¬
pected that the ataxlo gait might be partly functional. He learnt to
walk fairly well on the first day of treatment, and further improve¬
ment followed exercises practised for half an hour three times a day.
A week after treatment was begun the gait eras almost normal, and
unsteadiness oould only be detected when the patienn changed his
direction suddenly. The hands soon became so steady that he developed
into a competent potter.
Injuries and Acute Diseases of Brain and Spinal Cord.
Just as the physical signs of an organic lesion of the
pyramidal tract may precede the development of paralysis
due to the legion, and may be associated with hysterical
paralysis, persisting after the cure of the latter by psycho¬
therapy, so may these physical signs persist after recovery
from organic paralysis and be associated with hysterical
paralysis, whioh develops as the organic symptoms disappear.
ThbLavost,] DBS. HUR8Tfc8YMNS: HYSTERICAL ELEMENT IN ORGANIC DISEASE, ETC. [Mabch8, 1919 371
Injuries and acute diseases of the brain and spinal cord
may result in changes which are to a great extent evanescent.
The vaso-motor disturbances and microscopical changes in
the nerve cells, such as chromatolysis and eccentricity of
the nuclei, disappear entirely; inflammatory exudation and
oedema also disappear entirely or leave only a trivial amount
of permanent damage, and even haemorrhages are absorbed
to a great extent, the initial changes being thus very much
greater than the permanent results of the lesion. The
initial changes may, however, be sufficient to block the
transmission of nerve impulses and consequently to cause
complete loss of function in the parts which receive their
innervation from the affected portion of the nervous system.
But the permanent results of the lesion may be so slight that
no loss of function persists, although, corresponding with
the converse conditions in disseminated sclerosis, the damage
may be sufficient to give rise to the permanent presence of
organic physical signs. This is seen, for example, in the
hemiplegia and paraplegia following syphilitic endarteritis,
which have been treated early and thoroughly, and in the
spontaneous recovery in some cases of poliomyelitis.
In the majority of cases the gradual improvement in the
aotual lesion is accompanied by a corresponding functional
improvement. Occasionally, however, especially among
suggestible individuals, such as soldiers who are mentally
and physically exhausted as a result of the stress and strain
of active service, the patient may not realise that the lost
functions are returning. The initial incapacity gives rise to
the idea of permanent incapacity by auto-suggestion, often
aided by the unconscious hetero-suggestion of the physician,
and whilst a less suggestible man might recover the use of
his paralysed limbs in a few days, the paralysis is perpetuated
in the suggestible man by the development of an hysterical
element, which has been produced by suggestion and which
can be removed by psychotherapy. In such a case the
paralysis remains complete, and although at first it is entirely
organic in origin, the proportion of the organic to the
hysterical element in its make-up becomes steadily less, and
in some cases a stage is reached in which the incapacity is
almost entirely hysterical and independent of structural
change, although the latter may still be sufficient to give
rise to physical signs. A condition way thus ocour which is
primarily organic , hut is ultimately hysterical. Everything of
organic origin may disappear, or the residual le*ion may he
sufficient to produce organic physical signs without any less of
function, or both organic physical signs and some loss of
function.
These ideas can be represented diagrammatically in the
same way as in the case of disseminated solerosis. The
total incapacity resulting from the original wound or disease
steadily improves, and when the time 0 is reached recovery
may be complete (Diagram 2) or partial (Diagrams 3 and 4).
The partial recovery may leave no obvious physical incapacity,
but it may, as in Diagram 3, leave sufficient residue to result
in definite physical signs of organic disease, represented by
00 1 . In severer cases there may be some permanent
incapacity, as represented by 0 0 1 in Diagram 4.
In each case the steady improvement of the organic con¬
dition may be masked by a simultaneous development of
hysterical symptoms, so that at the moment B 'he incapacity
may be partly organic (B B 1 ) and partly hysterical (B 1 B a ).
If psychotherapy is employed at this moment the improve¬
ment represented by B l B a takes place, the organic residue
B B 1 remaining. If re-education is now constantly employed
steady improvement will occur. During the period B C the
symptoms and finally the physical signs disappear (Diagram 2),
the symptoms disappear but physical signs persist (Diagram 3),
Diagram 3.—Hysterical paralysis associated with organic paraljris,
which recovers but leaves organic phyetoal ngns.
or some symptoms as well as the physical signs persist
(Diagram 4).
If, however, no re-education is given the symptoms may
again be perpetuated by the development of an hysterical
element. In that case at the period represented by D, when
no further improvement can take place, the incapacity D D 3
in Diagram 2 and D 1 D 3 in Diagrams 3 and 4 is hysterical
and can be rapidly removed by psychotherapy. If the
partly hysterical nature of the condition is not recognised
at all until later, when no further improvement in the
organio residue is possible, as, for example, at the moment
marked E, psychotherapy will result in complete recovery
(Diagram 2), almost complete recovery although the physical
signs will still be present (EE 1 , Diagram 3), or incomplete
recovery (E E \ Diagram 4).
Diagnosis.
The numerous symptoms and physical signs which are
supposed to help in the diagnosis between organio and
hysterical paralysis fall into three groups. The first group
oonsists of the phenomena which afford visible and con¬
clusive evidence of structural changes in the nervous system,
such as optio atrophy and neuritis, and abnormal oells in the
cerebro-spinal fluid. Equally conclusive are the second
group of physical signs—those which are entirely beyond
voluntary control, such as the Argyll Robertson pupil,
the reaction of degeneration, and loss of knee- and ankle-
jerks. The third group of signs are those which oould
be imitated more or less accurately by anyone who bad
studied them, but which would not be likely to occur as a
result of auto-suggestion or be simulated by an ordinary
malingerer, as tbe individual would be unaware that such
sign 8 accompanied the disease he believed or pretended that
he bad.
The signs belonging to the last group lose much of their
value in distinguishing organio from hysterical paralysis,
when the latter has followed organio paralysis, as the
characteristics of the hysterical paralysis have been sug¬
gested by those of the organic paralysis. An ordinary
individual who develops hysterical hemiplegia shows no
paralysis of his platysma muscle (Babinski’s platysma sign),
because he is likely to be unfamiliar with the action of
the platysma, and being unaware of its existence would
372 Thb Lancet,] DR8. HURST fcSYMNS: HY8TBRI0AL ELEMENT IN ORGANIC DISEASE, ETC. [MabchS, 1919
continue to nse ft when the rest of the same side of the face
was paralysed, bat if the hysterical paralysis was a sequel of
an organic paralysis the characteristics of the latter, including
paralysis of the platysma, would be perpetuated.
Thus in hysterical hemiplegia and paraplegia following
organic hemiplegia and paraplegia respectively most of the
third group of physical signs, which are regarded as
characteristic of organic disease, may persist. Being caused
by suggestion, they are just as much a part of the hysterical
condition as the paralysis itself, and like the latter they are
completely removable by psychotherapy. Thus we have
seen cases of organic paralysis followed by hysterical
paralysis in which the platysma, pronation, and fan signs of
Babinski, combined flexion of the thigh and pelvis
(“ Babinski’s second sign”), ankle clonus quite indistinguish¬
able from that present in organic disease, Raimiste’s and
various other signs, were present; but the condition was none
the less hysterical, as the paralysis together with these
physical signs disappeared rapidly and completely under
psychotherapy.
The diagnosis of such oases may thus be extremely
difficult, as hysterical paralysis following organic paralysis
may not only be associated with permanent physical signs of
organic disease, such as the extensor plantar reflex, caused
by the residual organic disease, but also with the accessory
signs, which are supposed to indicate the presence of organic
disease, but which may themselves be really hysterical, being
produced by suggestion and removable by psychotherapy.
Treatment.
There is a widespread tendency to adopt a waiting
attitude in the treatment of acute organic nervous diseases
which is sound if confined to the early stages, but becomes
dangerous if it is continued for a longer period. The natural
tendency of most acute diseases is towards recovery, but the
functional capacity does not always tend to return pari passu
with structural recovery, unless the physician makes use of
psychotherapy in combination with re-education from the
earliest possible moment. In organic hemiplegia following
a head wound or an acute vascular lesion there is no reason
why passive movements should not be commenced on the
day of onset, and as soon as the patient’s general condition
permits he should be encouraged to attempt voluntary move¬
ments. When the hemiplegia is associated with aphasia
re-edacation of speech should be begun at the same time.
Treatment of this kind, in which psychotherapy is preventive
rather than curative, is extremely important and leads to a
maximum of recovery in a minimum of time. The same is
Me in such conditions as acute poliomyelitis, in which there
is often too great a tendency to rely upon meohanioal means,
such as massage and electricity, and to forget the psychical
side.
Illustrative Cases.
The following oases are some of the more striking
examples we have seen in soldiers of severe symptoms
resulting from organic injury or disease being perpetuated
as a result of the grafting of an hysterical element on the
original organic incapacity. The first case is perhaps the
most remarkable of all, as for two years he had been
regarded by everybody who had seen him as suffering from
incurable organic hemiplegia, but recovery with psycho¬
therapy was almost complete.
1. Combined hysterical and organic hemiplegia of two year*' duration
following nephritie; almoet complete recovery with psychotherapy.—
Pte. &., aged 29. reoorted sick on Sept. 29th, 1916 when he noticed
some oedema or bis legs. Nephritis was diagnosed and be was sent to a
hospital. On Oct. 1st be bad several fits and was unconscious for a few
hours. When he recovered consciousness he was suffering from severe
right hemiplegia, involving the face, arm, and leg. and he was also
aphasia. fie was transferred to England, and In July. 1917, as his
urine was now free from albumin, he was transferred to a neurological
hospital in London. The physician under whose care he remained for
more than a year reports that on admission " there was complete right
hemiplegia frith late rigidity and asphasia and also facial paralysis on
the same side. Wassermann reaction negative. Complete an»«tbesia
on the right side, tactile and thermal. No sphincter trouble. All deep
tendon reflexes much exaggerated, right greater than left, well-marked
ankle clonus right side; plantar reflex Indefinite; tongue deviation to
paralysed side. Later he developed spastic con nurture of the right
limbs." After a time he regained nis power of speech with reeducation.
In May, 19i8,a tenotomy was performed to overcome the flexion of his
right knee. As this was not successful, his leg was subsequently twice
moved forcibly under anesthesia. The physician and several colleagues
who saw him In consultation agreed that the hemiplegia was entirely
organic.
' In August, 1917, he was transferred to another neurological hospital
In London.as an attempt to gain him admission to the Star and Garter
Hospital bad failed. There was still no improvement when he came
under our care at Seale Havne Hospital in October, 1918. Th» right leg
and arm were totally paralysed and absolutely rigid, the elbow wrist,
and fingers being flexed ana the knee semi-flexed. The face, including
the platysma, was paralysed, but, as In ordinary organic hemiplegia,
the upper part was not Involved. The deep reflexes of the arm and leg
were much exaggerated on the right side and slightly exaggerated on
the left and well sustained; regular ankle clonus was present. The
abdominal reflex was absent on both sides. The plantar reflex oould not
be obtained owing to the extreme degree of spasticity.
The spas <c paralysis was treated by persuasion ana re-education and
in two and a half h'»urs the patient was able to extend his leg and arm
and move them slowly in all directions. At the end of ano>her hour
be was able to stand by himself and next day he was able to walk. This
result whs obtained witbout causing any pain to the patient in spite of
the extreme rigidity. The exaggerated deep reflexes and ankle clonus
remained unaltered, and an extensor plantar reflex was now obtained
on the right side.
An attempt was next made to overcome the facial paralysis, and in
10 minutes there was marked improvement. Alter 45 minutes’ treat¬
ment toe facial paralysis had disappeared and the platysma was con¬
tracting normally.
The patient is now (January, 1919) able to use his right
hand for all ordinary purposes—e.g., writing and needle¬
work—and he walks with only a slight limp.
2. Hysterical hemiplegia with persisting signs of organic disease
following concussion by shell explosion cured by psychotherapy after
persisting for eight months.— Pte. T., aged 22. w«s admitted to Seale
Hayne Hospital on June 20th, 1918, for hemiplegia of the left aide,
which developed as a result of being blown up by a shell eight months
be'ore. He could only stand with assistance and was quite unable to
walk. There were definite signs of an organic nervous lesion ; the left
plantar reflex was extensor, the abdominal reflex was absent, the
ankle-, knee-, wrist-, and elbow jerks were much exaggerated on the
left side, and well-sustained ankle clonus was present.
In spite of this it was decided that the condition was probably to a
large extent hysterical, and ’he patient was treated by vigorous
persuasion and re-education. Within an hour he was made to walk
and run, but it took five or six days to develop a normal walk and s
natural carriage of the left arm, which was at first held in front of his
left thigh. A fortnight later a distinguished neurologist who was
visiting the hospital witched him playing billiards, and was asked to
guess which had been the hemiplegic side, but the functional recovery
was so complete that he was unable to do so, although all the physics!
signs of organic nervous Injury were still present and had not altered
when the patient was discharged from the hospital, feeling perfeotiy.
well, two months later.
3. Combined hysterical and organic hemiplegia of 11 months’ duration*
following gunshot wou»d of the skult; great improvement with psycho¬
therapy.—L.fCp\. B., aged 23, was wounded In the right parietal region
in December, 1917, and was admitted to a general hospital In France
with left-sided hemiplegia. Anaesthesia was noted over the left l*g up
to the knee and over he left hand and arm to a point just above the
wrls'. The report states that be oould wriggle his toe and finger. On
Dec. 28th an operation was performed and a small crack In the skull
was found ; some b**ne was removed, but no Injury to the dura mater
was discovered, and pulsation was normal. The bone was replaced and
the wound sutured.
On April 3rd, 1918. when in hospital In England the following report
was made after a detailed investigation of nis cutaneous sensibility.
“ Loss of sensation over the whole of left leg up to the grnin, and ovar
the left aide of trunk behind a line drawn from the anterior superior
spine of the ilium to the middle of the armpit. Loss of sensation over
the upper limb up to the armpit and on the outer surface as far as the
acromion process. Sensation of beat corresponds with tactile sensation.
No st-nse of joint movement In upper or lower limbi."
On July 17th, 1918, he was transferred to Seale Hayne Hoepital.
The arm was rigidly extended at the elbow, the fingers were exte ded
at the metacarpo-pbalangeal joints, but flexed at the lnterphalangeal
joints. The leg was rigidly extended at the hip and knee and the
foot was fixed in a position of extreme dorsi-flexion. The deep
reflexes were increased on the left side and well-sustained and regular
ankle clonus was present. The big toe did not take part. In the plantar
reflex, but the fan sign was present on the le't side. Tbe degree of
rigidity was extreme and the strongest effort was required to bend any
joint.
The patient wu treated by persuasion and re-education ; movement
in all joints, except the shoulder, was obtaioed In one sitting of four
hours without much discomfort to tbe patient. His temperature rose
the next day, and he developed pleurisy with effusion, which
necessitated the postponement of further treatment for over two
months. Psvohotherapy was then continued and he quickly learnt to
walk well. He still has some spastloity, but Is slowly Improving.
At the present time (Mardfc 2nd, 1919) there are no si«ns of organic
disease, the ankle clonus and increased deep reflexes having dis¬
appeared.
Whilst in France limited anesthesia was found with
slight movement of the extremities; eight months of treat¬
ment with electricity and massage only had the effeofc of
making the paralysis absolute and increasing the area of
hysterical anesthesia; the aggravation of symptoms was
clearly due to suggestion unoonsciously applied bp hU
medical officers. If the patient had been encouraged to
move from the first progress would have been steady mad
recovery would quickly have taken place.
4. Syphilitic meningo-myelitis complicated by hysterical paraplegia.
— L./Cpl. M., aged 20, rep »rted sick on April 8th. 1916, with pain la
tbe legs. A fortnight later he noticed wearness and became unable to
walk. There was some loss of control over the bladder and rectum
during May. On admission Into hospital he was quite unable to walk,
but the loss ol power in the legs was Incomplete. Sensation was
normal. The knee- and ankle-jerks were exaggerated and ankle clonus
was well marked. The abdominal reflexes were absent. Plantar reflex
was examined on several ooc&aloni and was invariably flexor on both
Tam Lanost.] DR8. HURST k SYMNS: HYSTERICAL ELEMENT IN ORGANIC DI8EA8B, ETC, [Maboh8,1919 373
sides, but no doubt was felt by the consulting physician who saw him
in France that there was organic disease affecting the lateral columns.
On reaching England the Wassermann reaction o* the blood was
found to be positive, and there was some tenderness of the spine.
Iodides were given but no Improvement occurred, so that the original
diagnosis of syphilitic meningo-myelitls was discarded for disseminated
aderasls.
He came under our care for the first time in December, 1916. There
were now no physical signs of organic disease, and it was clear that the
paraplegia w,*? hysterical. With persuasion and re-education be rapidly
recovered. He was then given intendve anti-syphilitic treatment until
the Waseermann reaction was no longer positive.
The paraplegia was probably at first organic and due to
syphilitic meningo-myelitis. The iodide donbtless led to
recovery from the organic lesion, bat the paraplegia was
perpetuated as an hysterical condition, which only dis¬
appeared when treated by persuasion and re-education.
5 Hysterical paraplegia following organic paralysis due to con-
cussitm by shell explosion, cured by psychotherapy two months after the
onset.— Pte. M., aged 25. enlisted in September, 1914. and served for
six months in France and a year in Salonika. He was very fir. the
whole time, ani was never worried by the shell fire. On Nov. 22nd,
1916 he was Mown up bv a shell, and remained unconscious for four
days with signs and symptoms of complete organlo left bemiplegli
with pares!-« of the righr. leg, and incontinence of urine and fasces. He
began t * answer questions on Dec. 2nd, and complained of Bevere head¬
ache. His knee-jerks were then greatly exaggerated, especial I v the
left, and the olantar reflex ou both sides was extensor. The headache
soon disappeared and toe paralysis gradually improved, hut he was
still quite unable to walk when be reached Netlev «*n J*n 24t.h, 1917
He had no recollection of anything between the fight in which he
was blown up and the last few days in Malta. The righ knee-jerk
was 6, the left 7 (average normal 4); the left plantar reflex was st'll
extensor, but the right was now flexor, and the left aviominal refl»x
was absent. Toe Inability to walk was clearly hysterical, and it dis¬
appeared the day after admission as a result, of persuasion ; with
further re-education he soon learnt to walk without even a limp.
When next examined, on Feb. 2nd, the left plantar reflex had become
flexor, and the left abdominal reflex was as brisk as the right; but
Babtnaki’s second sign (combined flexion of thigh and pelvis) was still
▼e»y d-flnltely positive and the knee-jerks were as before. The
Waseermann reaction was negative.
He was discharged to duty In April, the superficial and deep reflexes
being normal and equal on the two sides, but Babinski’s second sign
was still present, though less marked.
A striking point in this case was the disappearance of the
extensor plantar reflex, which had persisted for 64 days,
within 9 days of the hysterical paraplegia being cured.
6. Hysterical paralysis associated with organic paralysis due to
hscmaUrmyelia , the result af spinal concussion following shell explosion.—
Pie. A. C., aged 24, ou Feb. 19th. 1917. was blown three feet Into the
air, falling heavily on his face, lie did not lose consciousness, and be
Is quite certain that his head was not doubled under him. He was
unable to m >ve for several hours, except that he managed to raise his
face out of the mud in order to breathe.
On being taken to hospital he remained quite helpless. His elbows
were kept acutely flexea, as in a lesion of the fifth cervical spinal
segment. His right arm and leg were completely paralysed, and only
very feeMe movements were possible on the left side. He had much
aching and tingling pain In his limbs and a spasmodic pain In the
calves. He bad some retention of urine during the first day and a
catheter was passed on one occasion, but after this his bladder and
tectum showed no abnormality. Though listless and suffering from
headache, bi* mind was not confused and his speech was normal.
Knee-jerks were very weak and no definite plantar reflex was obtainable.
By April 20th a slight degree of power had returned in the right
arm ; both arms were still painful. On May 12th it was noted that,
although there was no anaesthesia, sensation to light touch was
diminished up to the region of the clavicle. The headache had dis¬
appeared and the pain in the limbs was well marked. Slight improve¬
ment In power occurred as a result of massage, but the muscles
remained flabby and began to waste. By May 22nd the muscular tone
h*d improved. The knee-jerks were now increased, ankle clonus was
elicited on the right side. And the plantar reflex was extensor on the
right side but normal on the left; both abdominal rt-flexes were absent.
On admission toNetleyon May30rh be could move both arms and
both legs bur. they were very weak, the right side being worse than
the left. Slight pain was still present in the hands and arms, but the
pain in the legs had disappeared. There was marked wasting of the
moenles of the upper limbs, especially of the hands, the atrophy and
weakness of the right hand being severe. The right knee-jerk was 5
and the left 4j (normal 4); true ankle clonus was present on the right
side and also, though less well maintained, on tue left No abdominal
reflexes were obtained and the plantar reflex was definitely extensor on
both sides. The skin was much thickened over the palms of the hands
and soles of the feet.
It seems clear that a haemorrhage occurred into the cervical spinal
cord at the time of the explosion, probably as a result of aerial oon-
eossion rather than of the concussion caused by •falling after being
blown into the air, as the patient Is quite certain that the falt’rild not
hurt him particularly and that he could not put out his arms to save
himself when he wss in the air.
On June lltb the patient was still unable to sit up in bed and there
was no improvement In the condition of his arms and legs. It seemed
possible that some of the incapacity was hysterical In spite of the
definitely organic basis. He was thereto e treated by very vigorous
persuasion, and, although he would make no effort at first, at the end
of five minutes be was sitting npln a chair, and at the end of a quarter
of an hour he was able to stand and take a few steps with comparatively
little support.. During tbe next ten days he learnt to stand and walk
with an almost normal gait and without assistance.
Since then steady improvement has occurred both in tbo hands and
legs; his gait is almost normal, and he can use his hands for all ordinary
purposes, though there is still some atrophy and weakness of the smell
muscles. When discharged on Oot. 23rd the wrist-jerks were normal;
the right knee-jerk was 7, the left 6, and slight ankle-clonus was
obtained on the right side. Toe right plantar reflex was extensor, the
left flexor. The abdominal reflexes had not returned.
The condition must have been largely hysterical, and due
to auto-suggestion causing the perpetuation and exaggera¬
tion of symptoms which were originally entirely organic
and were still to some extent a result of organic changes in
the spinal cord.
7. Hysterical paraplegia following organic paraplegia , due to a
wound of the spine received 17 months previously.— L./Cpl. E., aged 43,
was wounded In the back by shrapnel on dept. 27th, 1916. He Imme¬
diately became paraplegic. A laminectomy of the sixth and seventh
dorsal vertebra was performed on Oct. 10th, and a piece of shrapnel was
removed, but no details about tbe operat'on are obtainable. He bad
incontinence of urine and constipation for several weeks. By the end
of February, 1917, he could get about on crutches with difficulty, lie
was transferred from hospital to hospital before he was finally trans¬
ferred to our care at Netlev on March 2 r 'th, 1918.
On admission he oould only stand with the aid of crutches. The
right knee-jerk was markedly exaggerated (9), with reponse to the
lower end of the tibia and slight spread to the opposite sld*; ankle
clonus was marked and sustained, but tbe plantar rt flex was flexor. The
left knee-jerk was 8 (average normal 4», ank'e clonus was present, but
not so well sustained, an 1 the piaatar reflex was flexor. With per¬
suasion and intensive re-education he was walking in leas than an
hour. In a month hit gait was normal, but rather heavy. Tbe signs
of organic disease remained unaltered. He was then discharged from
the service, but was quite fit to follow his civil occupation.
8. Spinal concussion involving posterior columns associated with
hysterical paraplegia.- Pte. W., aged 32, was burled by a collapsing
trench on July 3Jth, 1917; he was fit In every way before this
happened. When admitted to hospital in France he was unable to
speak or move his legs, and it was found that he had no knee-jerks.
His speech returned in a few days after stimulation with faradism, bnt
he continued to stammer.
On admission to Netley on August 28th he was still completely para¬
plegic and had a severe stammer; bo h knee- and ankle-jerks were
completely absent, and there was considerable rigidity of the legs.
The plantar reflexes were normal. As a result of vigorous suggestion
with the aid ot faradism he was Induced to walk on the day
of admission, and with re-education his speech aud gait slowly
Impr* ved. ....
At the beginning of January, 1918, the knee- and ankle-jerks were
still absent and a slight Romberg sign was present, but be walked
almost normally. Tbe Waseermann reaction of the blood and cerebro¬
spinal fluid was negative, and no abnormal oella were found in the
latter.
It seems probable that the loss of jerks and the
incoordination were due to the spinal concussion having
involved especially the posterior columns, as in a fatal case
described by Lieutenant-Colonel F. W. Mott. The response
to treatment by suggestion and persuasion shows that in
spite of this the paraplegia was hugely hysterical in origin,
the paralysis due to the concussion being perpetuated by
suggestion. The speech defect was, of course, entirely
hysterical.
It is generally taught that incontinence of urine is never
hysterical. But although the idea of inoontinenoe is very
unlikely to suggest itself to an individual spontaneously, it
is not uncommon for the incontinence which is normal in
babies to be perpetuated into childhood or even adult life as
an hysterical condition. Several cases of this sort in soldiers
have been described in the “Seale Hayne Neurological
Studies,” by Captain J. W. Moore, M.C., U.8.A., 4 to whom
we are also indebted for the description of the following
case of hysterical incontinence, occurring as a sequel of the
incontinence caused by the temporary organic changes
resulting from concussion of the spinal cord.
9 Hysterical incontinence of urine and hysterical paraplegia. foOewina
concussion of the spinal co d. with organic physical tigns. —Pte. If. P.
wss buried In a treoob in France in July, 1916. He was dog ou t and
admitted to hospital suffering from weakness of bis legs and lorn-
tlnence of urine. This condition continued until be was admitted to
8eale Bayne Hospital on August 2i d, 1918. On admission he oould
only walk with a shuffling and tremulous gait. He had generalised
tremors, especially of the head and neck, and was wearing a urinal day
and night on account of Incontinence The abdominal reflexes were
absent on loth sides, the knee-jerks were slightly increased (5 to 6),
and slight ankle elonus aod a definite extensor plantar reflex were
present on both sides.
The incontinence was treated by persuasion and re-education. In a
short time it was controlled during the day, but at first persisted at
night. He was then treated by hypnosis, and after three weeks was
completely cured. With the relief of ihe inoontinenoe the paraplegia
also disappeared, and he can now walk quite well, although the phj sloal
signs are unaltered.
In the following case blindness of a character generally
supposed to be typical of oiganic disease was perpetuated as
a hysterical symptom after the initial organic changes in the
brain had disappeared.
10. Partial hysterical blindness following organic blindness caused
by a wound in the occipital region and associated with hysterical
deafn ss.— Pte. W., aged 22 was wounded over the right occipital
region on June 7th, 1917. He was unconscious tor five days and was
tnen trephined. On admission to Netley on July 6th, 1917, he was
completely deaf in both ears, but as the vestibular reactions on rota¬
tion were normal the deafness was regarded as hysterical It was
noticed that he had difficulty in seeing and that he held anything he
374 The Lancet,]
DR. D. THOMSON : DETOXICATED VACCINES.
[March 8,1919
wished to read low down on the right side, although he volunteered no
complaint about this, and only spoke about his deafness. On further
examination it was found that he was totally blind except in the right
lower quadrant of the field of vision of both eyes, the blindness being
what might be expected to result from the wound over the lower part
of the right occipital lobe, near the middle line, which would be likely
to involve the left lobe also to a less extent.
▲n attempt was made at the end of August to cure the hysterical
deafness by a pseudo-operation, the patient being told that a cut
behind his ear would certainly restore his hearing. Nothing was said
to him about his blindness, which was regarded as organic. The
“operation” resulted in immediate Improvement In his hearing, as it
was now possible to carry on a conversation with him by shouting.
Quite unexpectedly It was found that his vision was now absolutely
normal, the blinaness having been cured by the suggestive effect of
the “ operation. ’
It must, therefore, have been due to perpetuation by auto¬
suggestion of the organic blindness, which was caused by
concussion rather than destruction of the occipital lobe.
11. Mental symptoms and hysterical paraplegia , aphasia , and
incontinence of five months duration following a w mnd of the brain
cured by re-education, persuasion , and suggestion.— Pte. P., aged 27,
was wounded in the left temporal region on Dec. 6th, 1917. The dura
mater was found to be torn and brain matter was escaping. A foreign
body lying half an Inch deep was removed and the wound was closed.
On Dec. 20th ihe patient had Blight paresis on the left side of face and
on Feb. 4th. 1918, be is reported to have had a fit. He was admitted to
Netley on March 20th, 19x8, after being in bed for 73 days in another
hospital in England.
He was drowsy and listless and was unable to articulate. He was
completely paraplegic and passed urine and faeces in the bed. There
were, however, no signs of organic disease. He was at once made to
get up in a chair and encouraged to take an Interest in bis surround¬
ings. In a few days he became clean in his habits and hia speech
returned.
A month after admission his mental condition was sufficiently olear
to make it possible to treat the paraplegia by persuasion. He improved
slowly and by May 24th was able to walk with a pseudo-spastic gait.
The next day he was treated by direct suggestion by means of faradism,
and in IS minutes was walking well and climbed two flights of stairs to
see a friend. He has now returned to his old trade as a carpenter, and
he is sound mentally as well ms physically.
References.— 1. A. F. Hurst and J. L. M. Symns: Review of Neuro¬
logy and Payohiatry, 1918, xvi., 1. Seale Hayne Neurological Studies,
1918.1., 1. 2. J. L. M. 8ymns: Quarterly Journal of Medicine, 1917,
xl., 33. 3. A. F. Hurst and 8. H. Wilkinson : Seale Havne Neuro¬
logical 8tudles, 1918, i., 24. 4. J. W. Moore: Seale Hayne Neurological
Studies, 1919,1., 141._
NOTH ON
DETOXICATED VACCINES.
By DAVID THOMSON, M.B., Gh.B Edin., D.P.H.Camb.,
TEMPORARY C APT AIK, R.A.M.O. J PATHOLOGIST, MILITARY
HOSPITAL, ROCHESTER-BOW, LOMDOH, S.W.
During the past year the author has conducted extensive
research as on the removal of the endotoxins from the gono¬
coccus and other organisms in order to produce non-toxic
vaccines which could be injected in sufficiently large doses
to develop a great amount of immunity.
Development of Immunity,
Reoent researches all point in the direction that it is very
difficult or almost impossible to develop antibodies to the
endotoxins of germs. The only successful antitoxins so far
produced are those against the exotoxins, such as are
developed by the diphtheria and tetanus bacilli. The toxins
of the majority of pathogenic organisms, however—e.g., the
gonococcus, meningococcal typhoid bacilli, Ac.—are endo¬
toxins, towards which little or no immunity is developed,
vide Wells (1918). 1
All observers are agreed, on the other' and, that agglutinins,
predpitins, complement-deviating sut. tanoes, and baoterio-
lysins, can be developed in a considerable degree against the
actual g^rm substance itself. If we take the'gonococcus for
an example, it is found that suboutaneous inoculations of the
germ into man or animals induces the formation of agglu¬
tinins, precipitins, complement-deviating substances, and
bacteriolysins in the blood. Thus immunity is developed
towards the gonooooous itcelf, whilst, on the other hand, no
suooes8ful antitoxin has so far been developed by inocula¬
tions towards the gonococcal endotoxin b. It seems most
reasonable to assume, therefore, that no advantage is to be
r ued by injecting the toxin and that it should be removed
possible so that larger doses of the actual germ substance
may be administered.
Torrey (1908) * found that inoculations of gonococci into
guinea-pigs produced no detectable immunity if the dose
administered was less than l/16th of the fatal dose.
1 Wells (1918): Cuemtoftl Phthoiony. W. B. Saunders Co.
* Turrets (19i8)t A Study of Natural and Acquired Immunity of
Qtrf n ea p lg sto ihe Gonooooeus. Jour. Med. Res., xvlli., 347.
Whereas, when inoculations amounting to l/8th to l/12th of
the fatal dose were given, marked immunity was produced
It would appear, therefore, that to get a large amount of
immunity large doses must be injected. Unfortunately
most pathogenic organisms are so toxic that such large doses
are impossible.
Reasoning in this manner,. it sewp'r* &pt&oio
removal of the endotoxin from germ
for vaccine purposes, since its presen conditions elongate
tages and no advantages. The pro n the taut m w.:
removal of the endotoxin without at ^ ?um ac.xne altering
the nature of the remaining non-toXic germ substance, so
that the latter would still be potent in stimulating the
production of agglutinins, precipitins, Ac.
Detoxicated Gonococcal Vaccine: Serological Testa,
The procedure which was adopted to attain this end will
be described in a detailed paper almost immediately. At any
rate, the toxicity of most germs was successfully reduced some
50 to 100 times. Thus, with ordinary gonooocoal vaccine it
was found necessary to begin in acute cases with doses not
exceeding 5 millions and gradually to increase to about a
maximum of 250 millions. On the other hand, the same
strains of gonocooci when detoxicated could be administrated
in acute cases in doses of 2500 millions and increased to
10.000 millions. These large doses caused even less toxic
symptoms than the small doses of the ordinary vaccine.
To test the therapeutic value of the new detoxicated
vaccine a large number of complement-fixation tests were
carried out on gonorrhoeal cases in three parallel eerie*,
treated at the same time by the same clinician.
Series A received no vaccine treatment.
Series B were treated with ordinary gonococcal vaooine.
Series C were treated with large doses of detoxicated
gonococcal vaccine.
The amount of complement deviated in the presenoe of
antigen and serum was estimated weekly in each case, as it
seemed reasonable to suppose that the amount of immunity
produced could be estimated by this method. Thus one
minimum hemolytic dose of complement fixed was taken to
represent 1 unit of immunity, two M.H. doses fixed repre¬
sented 2 units of immunity, and so on.
Series A showed on the average some 3 units of immunity
acquired naturally in the course of the disease.
Series B showed an average of about 4 to 5 units of
immunity indicating the value of ordinary vaccine.
Series G showed an average of about 8 to 12 units of
immunity showing a marked superiority of the new vaccine.
The therapeutic results obtained corresponded very
markedly with the serological tests. Thus it was found
that the oases whioh showed the highest degrees of immunity
as estimated by the complement-fixation test recovered
muoh more rapidly, and vice vena in those whioh showed s
low degree of oomplement-fixation the disease ran a pro¬
longed coarse.
Results obtained with Inoculation in Normal Individual*.
Ordinary gonooocoal vaooine was injected into several
normal persons who had never suffered from gonorrhoea,and
who gave a completely negative complement-fixation
reaction. In these cases it was found by repeated tests that
no complement-deviating substances were developed in the
serum after an injection of 100 millions of ordinary gono¬
coccal vaccine, followed by 200 millions six days laters.
On the other band, a dose of 5000 millions of detoxioated
gonooocoal vaooine induced the formation of sufficient anti-
Bubstances in the blood to give a doable positive reaction,
and a dose of 10,000 millions developed a triple positive
reaction in another normal person, whose blood was pre¬
viously negative.
Moreover, the dose of 200 millions of ordinary gonoooooa!
vaccine produced malaise and fever in the normal subject,
whereas the symptoms arising from a dose of 5000 millions
of the detoxicated vaooine were scarcely noticeable and no
fever was induced.
Further experiments have been carried out with detoxi¬
oated vaccines for the prevention and treatment of bronchial
and nasal catarrh and the results so far have been very pro¬
mising. Tne clinical evidence is increasingly convincing that
this detoxication process will revolutionise the whole subject
of vaccine treatment and preventive inoculation. I wish to
thank my commanding officer Bt.-Col. Harrison, 0.8.0.,
K.H.P., for the kind interest he has taken in this work.
Ths Lancet,] DR. A. C. COLES : SPIROCHETES IN THE BLOOD IN TRENCH FEVER. [March 8, 1919 375
SPIROCHiETES IN THE BLOOD IN
TRENCH FEVER.
c
i By ALFRED 0. COLES, M.D., D.Sc.Edin., M.H.C.P.Lond.,
F.R.S. Edin., *
~_--- NATIONAL SANATORIUM, BOURNEMOUTH.
— _ . > or three years I have examined a very
large nm~ n .' 1 films taken from cases of trench fever
in France anu i . local military hospitals. For the former
I desire to thank Captain Adrian Stokes, R.A.M.C., and
especially Captain A. T. Nankivell, R.A.M.C., for kindly
sending me films from France.
The Difficulties Met With.
* In common with so many other observers, my attention
was primarily directed to the search for spirochsetes, as the
disease has many characteristics of a epirochactosis. Nothing
but failure resulted from very prolonged efforts. Whatever
be the cause of trench fever, it exists either in very small
numbers or in the form of some minute, characterless, or
invisible organism, otherwise it would have been detected
before this.
It is quite conceivable that the causal organism is present
* in exceedingly small numbers in the blood. In syphilis, in
rat-bite fever, and in infectious jaundice spirochaates are
definitely known to be the cause, and in each case occur
a in the peripheral blood at one or other stage of the disease ;
yet how many observers h*ve succeeded in finding them in
human blood 1 My own experience in the case of infectious
jaundice illustrates this. Captain Adrian Stokes kindly sent
Y me eight blood films taken from a definite case of infectious
jaundice on the fourth day of the disease. A fortnight’s
examination entirely failed to find a single spirochsete.
Subsequently he sent me six films from a case on the second
day of the disease, and after numerous very prolonged
' examinations extending over several days I found two
spirochsetes.
f * Farther, it is probable that if spirochaates do occur in the
3 blood of trench fever they will be more likely to be found
during the first attack, and it is not always easy to say from
2 the first attack of fever what the condition may turn out to
be. Of the numerous films that I examined from cases in
our local hospitals none were earlier than the third or fourth
\* relapse.
Present Investigation .
In order to obtain blood films from the earliest stage of
t trench fever I applied to General Sir David Bruce, chairman
of the Commission on Trench Fever, and he asked Major
^ W. Byam, R.A.M.C., to send me films from successfully
inoculated or scarified men at the Hampstead Military Hos¬
pital, both just before and during an attack of the disease.
I take this opportunity of expressing my thanks to both of
these workers for their kindness.
t* In two out of six of these cases I have found a few
spirochsetes or spirochsetal-like bodies in one or two of the
# many blood films examined. Major Byam’s notes on these
f) cases were as follows :—
> Case 1.—Peripheral blood smears, 3.15 p.m., April 14tb, 1918. On
April 14tb. at 11 A.M., developed trench fever as result of inoculation
with infected bee excreta. Incubation eight dav*. Onset with frontal
headache and pain* in left hip, l*>ft side and down left arm. (Left arm
P was s?at of scarificstio i.) 3.15 p.m.: Slight shivering and increased
headache. T. 102° F.; P. 84. Pains in muscles of thigh snd in both hips
and loins. April 15th, 10 p.m. : Second day of disease. Blood films.
Case 2.—Blood films, 11.20 a.m.. Nov. 13th, 1918. First attack of
if fever. ,
The spirochaates or spirochaete-like structures vary con¬
siderably in their form, but thev have in common the fact
that they are all stained with Giemsa a delicate blue tint;
they are all faintly granular, and in no case are the ends
pointed. Figs. 1, 3, 4, and 6 could be found with the
1/12 oil immersion objective. Figs. 2, 5, 7, and 8 are very
faint indeed, and the photomicrographs show them even
better than they are seen under the microscope.
I have marked the position of each by a small ring on the
t film by a diamond-marker; the size* of the ring is such that
the whole is included in the field with a magnification of
i 240 diameters. Yet when such a ring is examined with a
1/12 objective it is most difficult to find the organism, espe-
daily that shown in Figs. 5, 7, and 8. It would therefore be
y almost impossible to find such a structure by direct examina-
if tion with an oil immersion lens. I found them by means of
dark-ground illumination, logged and marked their position
before mounting. This fact may vitiate against Figs. 5, 7,
and 8 being regarded as spirochaetes.
The photomicrographs give a better impression of the
appearance of the structures than any description.
mam wmmm
" r I
r\
Spirochaetes In blood filmB of trench fever. The original micro-
photographs have been slightly enlarged In reproduction, and
the magnification is now x 2000.
Fig. 1 ( Case 2).—Blood film A, taken at 10 p.m., April 15th, on secon
day of fever; open wavy spiral, ends round, length 12 6/* with two
turns, diameter 04/*, slightly denser stained areas are seen in Its
course.
Fig. 2 (Case 2).—Blood film B. taken at 3.15 p.m., April 14th, on first
day of fever; length 13'32* with five spirals, small and slightly
Irregular.
Fig. 3 (Case 2).—Blood film C, taken at 10 p.m. April, 15th, on second
day of fever; an irregular knotted form.
Fig. 4 iCase 2).—Blood film D, taken at 3.15 p.m , April 14th, on first
day of fever; a wavy filament with one or two turns, with very fine
granules, length about 11/*.
Fig. 6 (Case 2). —Blood film D, taken at 3.15 p.m., April 14th, on first
day of fever; similar wavy filament.
Figs. 5, 7, and 8 (Case S).— Blood film I, taken at 11.20 a.m.,
Nov. 13th, during first day of fever; faintly stained filaments, with
numerous irregular spirals.
Consideration of the Findings.
The questions whio naturally arise are these actual spiro-
chaetes, and, if so, what relation have they to trench fever?
In answer to. the former question, they have the general
appearance of soirochsetes, although those from the second
patient are very-elusive, of slight refractive power, and very
difficult to see. The staining reactions with Giemsa, a pale
blue colour, is not, however, Common in spirochaates in
general. They cannot be regarded as artefacts, and the
faint irregular structures in Figs. 5, 7, and 8 cannot be com¬
pared to “streamers,” which, in my experience, are never
met with in ordinary air-dried stained films.
Whether they have any actual causal relation to trench
fever is much more difficult to say. The fact that they were
detected only in the blood of definite cases of artificially
induced trench fever, and then only during the first attack
of fever, is at least suggestive. The generally accepted
statement “that at least in one stage of development the
virus of trench fever is filterable” does not exclude that
virus being a spirochsete. Some spirochsetes are known to
be filterable, and Nognchi states that the Spirochata iotero-
hcemorrhagice will pass the Berkefeld candle V.
376 The Lancet,] PROF. I. H. TWEEDY: LOWER UTERINE BBGMMNT AND UTERINE TENDONS. [March 6. 1918
THE LOWER UTERINE SEGMENT AND
UTERINE TENDONS. 1
Bt E. HASTINGS TWEEDY, F.R.C.P. IBEL ,
GYNECOLOGIST, DR. 8TEEVEN8’ HOSPITAL, DUBLIN; PROFESSOR OF
OBSTETRICS AND GYNAECOLOGY, ROYAL COLLEGE OF
SURGEONS, IRELAND.
Gynaecologists are, or should now be, agreed that the
uterus owes its stability to its connexion with the fibro-
muscular bauds which surround the cervix at the level of
the os internum and radiate in all directions to their attach¬
ments in the pelvis. These fibro-muscular bundles show an
unequal distribution, and where best developed they are
indicated by distinctive names—viz., sacro-uterine ligaments,
lateral ligaments of Mackenrodt, &c.
“Uterine Tendon*”
The anatomists’ description of this tissue is that it forms
an imperfect diaphragm, stretching across the pelvic cavity,
with an aperture towards its centre through which the neck
of the uterus fits. This conception cannot be correct, for
were it so destruction of the diaphragm would follow as a
result of the first parturition. When it is remembered to
how full an extent the foetal head occupies the oavity, it is
inoonoeivable that a membrane torn to such a degree could
ever renew its original continuity. Experience, however,
teaches that this diaphragm remains uninjured by normal
childbirth, and therefore the only inference which can
reasonably be deduced from the fact is, that these flbro-
muscniar bands are not interwoven one with anothei to
form a continuous membrane but pass separately into the
uterus and are centred in this organ. Thus the muscle
bundles at the internal os must exeroise a direct control
over this fibro-muscnlar tissue. The opening of the os
permits a slackening of the fibrous diaphragm and closure of
the os renews its tension.
In this respect the tissue behaves as tendons do in other
parts of the body, and surely “uterine tendons” is the
name that should be applied to them. From inductive
reasoning I surmise that this fibro-muscular tissue is derived
from the uterine muscle and not from pelvic fascia or
parametrium.
The recognition of the above mechanism has made clear
many obscurd phenomena in obstetrics and gynaecology. It
is evident that the uterus after childbirth owes its great
mobility to relaxation of the uterine tendons, and the same
condition permits the vaginal fornices to be pushed by
vaginal plugging so far up into the abdomen as to stop the
circulation in the uterine arteries. Daring the performance
of Caesarean section I have been able to demonstrate the
latter fact to a number of experts, so that the question is no
longer in doubt.
In a nulliparous woman the cervix is also closed by a
certain amount of fibrous and elastic tissue which is probably
derived from the pelvic fascia. This tissue is torn during
childbirth, and the tearing accounts for the different behaviour
of the multipara’s and primipara’s cervix during the process
of dilatation.
The Lower Uterine Segment.
The lower uterine segment is formed by a growth and is
not a mere stretching of pre-existing tissue. It is impossible
to account for its presence by any other explanation, and it
can be clearly shown that the cervix is the structure of all
others which most readily responds by growth to a continuous
pressure.
It is wrong to regard the cervix as consisting of tissue
prone to stretch. It possesses this property within very
narrow limits, and efforts at forcible dilatation, whether
during childbirth or in the unimpregnated, are prone to be
followed by extensive ruptures. On the other hand, it is
capable of phenomenal growth when exposed to a continuous
pressure strain. In procidentia uteri its supravaginal portion
becomes enormously hypertrophied. In spite of its greater
length its diameter does not diminish, which clearly shows
that the process is one of hypertrophy.
The following experience well illustrates this point.
Daring the performance of ovariotomy on an old woman
with prolapse of the uterus I amputated the uterus above
_ , _ _
‘ r A paper rea* at the Royal Academy of Medicine in Ireland (Section
Obstetrics), Feb. 14th, 1919.
the os externum and stitched the small stump to the
abdominal fascia in an effort to keep up the prolapse. In a
year the condition was worse than ever. The stump had
held to the abdomen, but the small cervix had hypertrophied
and again permitted the vagina to turn inside out. In this
instance the cervix mu&t have increased to twenty-fold its
original size, and there is no other structure of fcHip
wonderful metamorphosis.
The cervix does not under normal «
because of the protection it receives frbn uterine
tendons. These keep the uterus in eqoilibri - ~ud take up
all abdominal strain. The cervix lying beneath them is thus
freed from pressure.
When pregnancy occurs the internal os opens and the
ovum finds room for its increasing growth in the upper
region of the oervix immediately beneath the uterine
tendons. In response to this stimulus the upper part of
the cervix hypertrophies to form the lower uterine segment.
The fact that this segment is a growth comparable to that
which occurred in my case of uterine prolapse accounts for its
formation without any appreciable shortening of the cervix,
and satisfies the objections of those who doubt its cervical
origin because of the almost undiminished change in the
length of the cervix during pregnancy.
The last question to be considered is that of the true
boundary line which separates the cervix from the body of
the uterus. Attempts to define this boundary have been
made by microscopic and macroscopic efforts, but I am not
aware that anyone has before suggested that the taut
uterine tendons constitute the one and only division between
them. The cervix must then be defined as that portion of
the uterus which normally escapes pressure by lying beneath
a portion of the uterine tendons.
Dublin. _
ATTENUATION OF HUMAN, BOVINE, AND
AVIAN TUBERCLE BACILLI. 1
By NATHAN RAW, O.M.G., M.P., M.D.,
LIKUTKNAXT-OOLONRL, R.A MO.; O.C., AND SR«IOB PHYSICIAN,
LIVERPOOL HOSPITAL, B.K.F., FRANCE.
The object of this short paper is to demonstrate the
effect of long-continued and regular subculturing of pure
cultures of human, bovine, and avian tubercle bacilli on
artificial media containing glycerine. This process has been
continued without interruption for 12 years and the cultiva¬
tions are luxuriant and grow as readily as in the first year
of suboulturing. They retain all their characteristic and
selective appearances, and can be easily identified as distinct
types of tubercle bacilli.
Inoculation of rabbits and guinea-pigs by human and
bovine bacilli have been made at intervals daring the last
12 years (the full details of which will be published later),
with the result that there has been a gradual decrease in
virulence until at the present time they are almost non-
pathogenic to animals.
History of Cultures.
The original culture of human bacilli was given to me by
the late Professor Koch in 1906, and was prepared by him
from the sputum of a case of primary pulmonary tuberculosis.
The patient bad suffered from phthisis for four years, and
the culture was made in the last stages of the disease.
The original bovine culture was sent to me by Professor
Calmette, of Lille, and was from the mesenteric glands of a
cow which had been destroyed for advanced tuberculosis of
the udder. The avian culture was sent to me by Professor
Bang, of Copenhagen, and was from a chicken which died
from epidemio tuberculosis in fowls.
Careful photographs were taken of the original cultures
and at intervals up to the present time. All of these retain
in a remarkable degree the exact and typical appearances of
the original type, and can be easily and readily identified.
Avian bacilli being non-pathogenio to man need not be
considered in this paper.
The important fact to bear in mind in the study of tuber¬
culosis, and which has been amply demonstrated by a long-
continued study of the subject is, that (I) the human body is
1 A paper read b« fore a Medical Society In Franoe, at which cultiva¬
tions of the organisms were shown.
Tot Lancet,] DB. N. BAW: ATTENUATION OP TUBERCLE BACILLI.—CLINICAL NOTES. [March 8, 1918 8f7
attacked by two distinct types of bacilli—namely, human
and bovine; (2) those two types of bacilli cannot grow in
the body at the same time; (3) their method of infection is
different and selective; (4) human and bovine bacilli are
antagonistic to each other, and a mild infection of one type
in the human body will produce an immnnity to the other
type.
Selective Infection*.
The great bulk of tuberculosis is caused by human bacilli
directly infecting the lnngs and setting up primary pul¬
monary tuberculosis, pleurisy, tuberculous laryngitis, and
secondarily tuberculous enteritis. As a general rule, these
infections are limited to the respiratory organs and intestines,
and in progressive cases death results from exhaustion and
toxaemia.
Bovine bacilli are generally conveyed to the body in
tuberculous milk and food and infect the various organs
through the lymphatic channels. These infections are, as a
rule, limited to children and early adult life.
The lesions usually produced are: (1) Primary abdominal
tuberculosis (tabes mesenterica); (2) tuberculous glands;
(3) tuberculosis of bones and joints ; (4) meningitis and
lupus; (5) tonsils and adenoids (occasionally); (6) miliary
tuberculosis.
A person with primary pulmonary tuberculosis is not likely
to develop a tuberculous bone or joint, and a primary bovine
infection is not likely to develop a primary tuberculosis of
the lungs. The lungs are, however, not infrequently infected
in the course of a bovine infection of other organs.
Tubercle bacilli of bovine type would seem to be met with
in from 10 to 30 per cent, of samples of milk submitted to
bacteriological examination (Del6pine). If the milk is not
boiled or sterilised there is ample opportunity for the
infection of susceptible children.
The organisms (human and bovine) are not transmutable,
and cannot by any artificial growth be changed from one to
the other type.
Treatment of Tuberculosis.
The real object of this work was to find out if it was
possible to reduce the virulence of the bacilli to such a
degree that it might be possible to use them therapeutically
in the treatment of active tuberculosis. The longest period
before recorded of the attenuation of these bacilli was three
years, and that was not found to be enough.
Whilst a member of the International Committee on
Tuberculosis I undertook in the year 1905 to subculture
human and bovine bacilli for ten years. Unfortunately,
owing to the war, the clinical work was interrupted during
a four years’ residence in France, but the subculturing was
continued in my laboratory at home.
In 1914 several animals were inoculated with these bacilli
of nine years’ attenuation with practically negative results.
In no case was any progressive tuberculous process set up
in the animals, and post-mortem examinations showed no
active tuberculosis.
Eight cases of apparently hopeless tuberculosis of the
glands, bones, joints, and lupus, all with discharging
sinuses, were treated with injections of living bacilli at
intervals of one week. The injections were made sub¬
cutaneously in the triceps region, and beyond redness and
slight swelling no bad effects were observed, and the patients
noticed nothing unusual.
Later, four cases of acute and active pulmonary tuber¬
culosis with large numbers of bacilli in the sputum were
treated in the same way, and I have just seen and
examined a hospital sister who was treated five years ago
and is now on full duty and quite oured. So far as I know,
all these patients are still living, and a full report will be
published after an interval of five years from the date of
treatment.
The whole of the cases were treated by mixed bacilli, the
cultures being raised to a temperature of 220° F. for two
minutes before injection.
All doctors are agreed that the treatment of tuberculosis
is not satisfactory, and the results so far obtained are not
what we might expect. After a personal experience in the
treatment of over 4000 cases of tuberculosis in hospital and
private there is no doubt whatever that so-called surgical
cases (which, in my opinion, are chiefly of bovine origin), give
the best results. Tuberculin in a great many oases gives
excellent results, but the duration of the immunity produced
is too short and the tuberculin treatment has to be continued
for a long period.
Our whole object in attempting to cure tuberculosis is to
prevent the growth of the bacilli in the body, and I feel
sure this can only be done by some specific method as
described in this paper.
The cases treated are too few and the time which has
elapsed is too short to form any definite and final conclusions,
but I feel encouraged to think that the careful use of such
attenuated bacilli may have the effect of controlling and
probably preventing tuberculous infections in the human
body in much the same way as vaccination protects against
small-pox, and antityphoid vaccine against typhoid fever.
Barley-street, W. _•_
Clinical States:
MEDICAL, SURGICAL,'OBSTETRICAL, AND
THERAPEUTICAL.
■ — ♦
A CASE OF GONORRHCEA
COMPLICATED BY ACUTE GONORRHCEAL ARTHRITIS AND
KERAIOSIS, RESEMBLING A MIXED INFECTION OF
GONORRHCEA AND SYPHILIS.
By Norman P. Laing, M.B., Ch.B. Liverp.,
LATE CAPTAIN, R.A.M.C. (T.F.)
The case here recorded seems particularly interesting from
the following facts: 1. That the keratosis was generalised
and occurred on the trunk and limbs, and apparently in the
mouth and round the coronal sulcus of the penis and auud.
2. That the clinical appearance of the lesions made a
diagnosis of secondary syphilis combined with keratosis and
gonorrhoeal arthritis justifiable.
The patient was admitted with an uncomplicated anterior
urethritis. Incubation period six days. He reached
hospital three days after the discharge appeared. Gono¬
cocci found; piostate normal in size and consistency.
He was given anterior irrigations (at 8.30 a.m. and
5 p.m.) of 1/8000 pot. permang. increasing to 1/4000 after
four days. Demulcent drinks, ad lib .; patient rested
for first week. Progress was uneventful; two-glass urine
test showed a clear second glass till tenth day. The dis¬
charge was then mnoo-purnlent. On the eleventh day he
complained of slight dvsnria and frequency daring night.
The prostate was slightly swollen and tense; second glass of
urine was turbid and contained some blood. Temperature
100*6° F. He was put to bed at onoe, a morphia and atropine
suppository was given; hot reotal injections twice daily.
Irrigation was stopped.
The next day there wm Blight pain in the right knee bht
no swelling. Daring the following week both knees and
ankles became very painful and swollen, with definite
fluctuation. Temperature 99° to 102°. No drugs eased the
pain in the joints; temporary relief was obtained by repeated
hot soda packs.
On the seventeenth day after the joint pains began BOtne
small moist papules were notioed round the anus and
coronal salons of the penis, with very marked resemblance
to condylomata. Lesions on the mucous membrane of the
lips ancl cheeks, oval in outline and bluish-pink in colobr,
resembled mucous patches. No history or soar of a primary
sore: urethrosoopio examination showed no sere in urethra.
History of frequent exposure to infection for the past three
months. Major E. G. Ffrenoh (in charge of the syphilis
division) agreed that the case resembled secondary syphilis
but advised a dark-ground examination for spiroohsBtes from
the leBions. This proved negative.
The next day some small nodnlar bull© appeared on the
soles of the feet and on the legs. They were qnite isolated
and when a few days old formed a oorny mass, dark brown
in oolonr. These masses were most marked on the dorsal
aspect of the toes over the joints and on the plantar surface
over the metatarso-phaiaugeal joints, but also ooourred on
the shins and thighs and over the abdomen and oheat wall;
a few on the arms and hands. The diagnosis of keratosis
was obvious, but the lesions on the penis, anas, and in
the month were still thought to be syphilitic. Wassermann
blood test was t —. Following^ provocative dose of 0*6 g.
novarseno-benzol (Billon) the Wassermann showed a clear
negative. The diagnosis of syphilis was held in abeyanoe.
As nothing had seemed to influence the rheumatism I
gave 2i c.cm. intramine intramuscularly. There was a
good deal of pain at the site of injection but the joint pains
CLINICAL NOTES.
[March 6,1919
were relieved. Tne following day I examined the prostate
again ; tenderness not so acute. I gave a gentle massage.
Some pus was obtained and in the urine were many shreds of
S us. The intramine was repeated every four days for six
oses, posterior irrigation with 1/8000 pot. permang. started,
and every five days I massaged the prostate, which
improved rapidly. At the end of a month the patient
felt much better; the joints were almost normal; no
evening rise of temperature. He was allowed up and walked
on stioks for about half an hour daily. The prostatio
massage was proceeded with for another lb days. He could
then walk well without a stick; no pain or swelling in the
joints : lesions in the mouth, on penis, body, legs, and arms
bad disappeared; no urethral discharge. Irrigation was
stopped, and three suooessive examinations of the urine
for gonococci after prostatio massage proved negative.
Wassermann was again negative.
In another week he was transferred to a convalescent
depdt and three weeks later was found fit for general service.
A CASE OF PELVIC SARCOMA .
INVOLVING NERVES AND PRESENTING FEATURES
OBSCURING DIAGNOSIS.
By J. Hamilton Hart, M.R.C.S., L.R.C.P. Lond.
The following case, which showed some unusual charac¬
teristics obscuring diagnosis may be of interest.
The patient, a married woman, aged 49 years with no
children, who had always been healthy, first consulted me
in September, 1917. She then complained of pain in the
lumbar region and the back of the right thigh. She was
treated with salicylates and the pain improved. She again
consulted me on Feb. 17th, 1918, for pain, mostly located in
the front of the right thigh, of about two months’ duration,
and gradually getting worse, and accompanied by weakness
of that leg. I found the right thigh muscles wasted, the
thigh being one inoh smaller than the left; there was
distinct loss of power in flexing the thigh and great pain was
oaused by this movement in the region of the anterior
crural nerve, but no definite tenderness was made out.
Abdominally, a large tumour extending up from the pelvis a
couple of inches above the umbilicus, and presenting the
characteristics of a uterine fibroid, was found. No tender¬
ness or pain was noticed at this examination.
Dr. J. S. Fairbairn saw the case with me on July 20th and
confirmed my diagnosis of fibroids. Although the pain and
illness of the patient could not be fully explained by the
presence of the fibroid, he advised an operation, both with a
view to the removal of the tumours, making certain of their
nature, and to the complete exploration of the abdomen and
pelviB. The patient was moved to a nursing home on
July 24th, and it was then found that she had a temperature
varying from normal in the morning to about 100° F. at night.
Abdominal hysterectomy was performed on July 27th, the
uterus and appendages, with the fibroids, weighing 7* lb.
Search was made for any sign of other growth in the abdomen
and pelvis, but nothing was found. The abdomen was
dosed and healed by first intention; the patient stood the
.operation well.
After the operation the temperature rose to 100° in the
mornings, to 102° at night, and the pain in the right thigh
persisted:
On Sept. I5th slight swelling and tenderness over the right
femoral vein was detected, with oedema and puffiness of leg
and ankle. The patient, who had been improving in general
condition, now commenced to flag.
On Sept. 24th she was seen by Dr. J. E. Knox, on my behalf,
as I was away; he found her in a collapsed condition; tempera¬
ture 101°; pulse 130, weak. The right iliao region was found
to be occupied by a large fluctuating swelling, thought to be
an abscess. Vaginal examination showed that the right side
of the pelvis was filled by a soft swelling bulging inwards
from the lateral pelvio wall. A second operation was per¬
formed by Dr. Fairbairn. An incision was made down into
the swelling, which was found to be retroperitoneal arising
out of the pelvis, consisting for the most part of a large
hematoma in which were masses of soft jelly-like growth,
bled freely on handling, and apparently arose from the
lower and posterior part of the pelvis. The condition was
recognised as a vascular sarcoma, and as there was free
bleeding the cavity was plugged and closed. The patient
died on Sept. 26th.
A portion of the growth was sent for microscopical examination with
the following report: “This material is much altered by hemorrhage
and early necrosis, but we think it must be a soft, highly vascular
sarcoma. It is composed of very uniform round cells with deeply
staining nuclei in the scantiest of stromas. The blood-vessels are wide
and thin walled. There Is no evidence to show whence it originated.”
Remarks .—This was a case of sarcoma apparently arising
from the deep tissues of the pelvis and pressing on the nerve
roots, and after removal of the fibroids of very rapid growth.
The unusual features are: the pain in the back and leg of
some months’ duration, and which was the cause of the
patient seeking advice. Nerve pain and muscular wasting
being, as a role, a late symptom of malignant growths, it
was unusual that the growth in this case was not able to be
found at the time of the operation. In the examination the
mass of fibroids was disooverect, but being quite movable and
not impacted in the pelvis were not considered sufficient to
explain the nerve effect. The operation was done to exclude
the possibility of the fibroids being the cause, and to make
sure that the mass was not a malignant ovarian growth
adherent to the uterus, and to explore the abdomen and pelvis
for a possible cause.
The urinary condition was thought to be a possible
explanation of the fever and pain, an infective pyelitis
caused by pressure of an enlarged uterus, giving rise to
obstruction of ureter, as occurs sometimes in the pyelitis of
regnancy. The femoral thrombosis was evidently oaused
y the invasion of the veins by the growth and was rapidly
followed by the formation of a large hematoma, which arose
as the result of leakage from the vein or breaking down of
the growth, and whioh was at first thought might be an
abscess. •
The pyrexia, at first of slight degree and higher later on,
tended to bear out an infective process, either pyelitis or
cellulitis and pelvio abscess, although such pyrexia is some¬
times met with in sarcoma. The soft, jelly-like nature of
the growth and its probable origin in the deep structure of
the pelvis probably explains why it was not detected until
erosion of the vessel and formation of a hematoma.
In conclusion, I have to thank Dr. Fairbairn for his notes
on the second operation, at which I was unfortunately
unable to be present. The pathological reports are by the
Clinical Research Association.
Bast Molassy. _
TWO OASB8 OF
UNILATERAL HYDROTHORAX DUB TO
DISEASE BELOW THE DIAPHRAGM.
By W. Gifford Nash, F.R.C.S.Eng.,
SURQEOS, BEDFORD OOUMTT HOSPITAL.
The two oases related in this note most be very unusual,
as I cannot find any reference to a unilateral hydrothorax
being produced by subdiaphragifiatio disturbance. In the
first case cure was effected by removal of the cause, and in
the second recovery took place after numerous aspirations
although the cause persisted.
Case I.—In 1906 Mr. H. C. Strover, of Sandy, Beds, asked
me to see a woman, aged 45, who had a large ovarian cyst
and pleural effusion. The abdomen was filled by an
immense ovarian cyst. There was muoh dyspnoea doe to
the upward pressure of the cyst and effusion into the
left pleural cavity. The patient was admitted into a
nursing home, ana on Maroh 4th, 1906, 1 withdrew 85 os.
of clear fluid from the left pleura; 11th, 75 oz.; 18th, 66 os.;
26th, 55 oz. It was evident that the pleural effusion would
recur, so on Maroh 28th I operated and removed a very
large multiloonlar left ovarian oyst. The pleural effusion
did not recur and the patient was quite well when seen in
Jane, 1918.
Case 2.—A patient, aged 50, a chronio alooholic with an
enormously enlarged liver and ascites, was found in April,
1917, to be suffering from effusion into the right pleural
oavity. The following were the results of aspiration of
the pleural cavity: April 20th, 60 oz. : May 16th, 80 os.;
June 26th, 60 oz.; July 31st, 100 oz.; August 28th, 70 os.;
Oot. 22nd, 85 oz.; Deo. 11th, 80 oz. Improvement then
gradually set in, and it was not again necessary to aspirate
the plenra, although the alcoholism and liver condition
remained the same. There was never any left pleural
effusion. When last examined in Deoember, 1918, there
was no trace of any plenral effusion, and the right lung was
aoting perfectly. The liver was mnoh enlarged and nodular,
and there was a moderate amount of ascites. The amount of
whisky consumed was abont a bottle a day, besides other
alooholic drinks.
In neither case was there any cardiac or renal disease, and'
no suspicion of tuberculosis. The effusion was a gradual
one and free from any inflammatory symptoms. I can only
coDolude that pressure upwards of the diaphragm in some
way led to the plenral effusion.
Bedford.
The Lancet,]
R07AL SOCIETY OF MEDIOINS: SECTION OF MEDICINE. [March 8,1819 379
3®t&kal jfrroeiies.
ROYAL SOCIETY OF MEDICINE.
SECTION OF MEDICINE.
Transfusion in Disease* of the Blood .
A meeting of this section was held on Feb. 25th, Dr.
G. Newton Pitt being in the ohair.
Dr. O. Lb y ton read a paper on Transfusion in Diseases of
the Blood. Although he had transferred more than 60 litres
of blood from donors to recipients, he did not feel himself
to be in a position to make any dogmatic statements as to
the efficiency of transfusions in this regard. The main
object of the paper, based on 100 transfusions which he bad
undertaken, was to record the method adopted and the
results obtained.
His experience began seven years ago by the transference
of blood from an erythnemio patient to one suffering from
pernicious anaemia. A 20 c.cm. syringe was fitted with
a three-way tap, to which were attached suitable rubber
tubes and appropriate needles. The whole apparatus was
washed out with liquid paraffin and drained. Blood was
drawn from the erythraemio patient and directly injected
into the vein of the anaemic one. After 40 c.cm. had been
injected the latter complained of severe cramp in his limbs
and the transfusion was stopped. The symptoms subsided
after about a quarter of an hour, and it was found that the
red blood cells had increased from l£ to 2 millions
per amm. In the absence of a knowledge of Moss’s work
on iso-agglutinins the symptoms were ascribed to obstruc¬
tion of capillaries of the central nervous system by minute
quantities of liquid paraffin. The patient felt so much
better that he desired another transfusion. On this occasion
care was taken to expel all excess of paraffin and a glass
window was put in the tube close to needle to ensure that
no air was injected. 80c.cm. of transfused blood led to
the same symptoms as before together with nausea, vomiting,
and severe palpitation. The donor belonged to Group 2
whilst the patient was of either Group 4 or 3. No lasting
benefit followed.
The Multiple Syringe Method,
Being desirous in the case of a patient with recurrent
pernicious anramia of carrying out a series of transfusions,
he decided to use the multiple syringe method so as to
avoid cutting or obliteration of veins. The patient, whose
Mood was of Group 4, was in extremis. There was no
difficulty in transferring 200-300 c.cm. by this method, but
the blood in the needle in the donor’s vein then dotted
a fresh needle had to be inserted into a fresh vein. To
obtain 600 c.cm. the donor had to be pricked at least three
times, and sometimes, when fright hastened the dotting,
even four or five. Needles were therefore made with ;
if the blood in the cannula dotted, that was
withdrawn and a fresh one inserted. By this means an
unlimited quantity of blood could be obtained by pricking
the donor once. Needles and cannula of various gauges
were made. It was essential that the needle should be
sharpened every time before use and wise for the operator
to sharpen it himself. The cannula should project about
0*5 mm. beyond the point of the needle, and the end of the
cannula should be rounded to prevent damage to the wall of
the vein. The syringes were of 20 c.cm. capacity and had
attached about 10 cm. of rubber tubing of about 1 c.cm.
capacity. A nozzle attached the tubing to the mount of the
needle. The syringes were coated with vaseline and washed
out with liquid paraffin and the tubes were filled with a
solution of sodium dtrat^(5 per cent.) and sodium chloride
(0*45 per cent.) to prevent waste of blood and coagulation.
The rubber tubing permitted slight movement of the syringe
without damage being done to the vein. If the blood showed
a tendency to clot the citrate solution was caused to mix
with the blood by shaking the syringe slightly. The solution
should be made with water sterilised immediately after
distillation. Vessels containing sterile normal saline should
be near the recipient and donor in case the rates of drawing
and injecting blood failed to correspond, for the Interval
might be filled up by passing saline through the cannula,
thereby preventing clotting In the vein.
The introduction of the needle was facilitated by distend¬
ing the vein by applying a pneumatic armlet and compressing
the air in it to the diastolic blood pressure of the donor or
patient respectively. The arm should be kept warm until all
was ready, and the pressure should not be released until the
cannula had been passed through the needle.
, Selection of Donor .
It was essential that the donor belonged to the same group
as the recipient, as shown by related cases. He had heard
of a fatality following the transfusion of blood from a donor
taken at random, and even if donors of Group 4 only were
utilised there must be the risk that the serum of the blood
injected might haemolyse and damage the patient’s red cells.
Donors must be free from malaria, syphilis, and tuberculosis.
He preferred a donor unacquainted with the patient, because
frequent transfusions might be necessary, and the donor
might falsely assert that he was feeling quite well in order
to supply further blood to a relative or friend. If only one
transfusion was anticipated there was no reason to avoid a
relative as a donor.
The preparation of the donor consisted in reassuring him
that he would feel no ill-effects, and that the amount of
blood to be taken was less than half of that which he could
lose without discomfort. He usually gave him a cup of
coffee shortly before transfusion, and encouraged him to
smoke during the operation. If the donor became frightened
his blood clotted rapidly, and if. faint the blood ceased to
flow. A short interval, during which saline was injected, was
required before proceeding. There were no after-effects.
He favoured using the same donor frequently.
Preparation of the patient consisted of depriving him of
all but the lightest food for six hours before transfusion.
The occasional rigors and slight pyrexia were less frequent
and less intense if a small dose of morphine and hyoecine
was given half an hour before the operation.
Results and Conclusions .
One hundred transfusions were distributed very unevenly
among ten patients, one having more than 50, whilst two
had one each. The immediate effect was masked by the
morphine and hyoecine. Afterwards the patient felt much
less ill. When there had been haemorrhage from the bowel
or uterus it ceased. The vomiting and nausea, sometimes
accompanied by diarrhoea in extreme anaemia, were alle¬
viated. The blood picture improved, the red cells being
sometimes more than could be accounted for. Perhaps this
was explained by polyuria, which was very noticeable during
the first few hours after transfusion. The increased number
of red cells might be maintained or might disappear during
the next few days.
After relating oases, including some of pernicious anaemia,
a case of myeloid leukaemia, and two cases of aplastic
anaemia, wMoh were treated in this way he drew the
following conclusions: (1) In the majority of cases symptoms
are alleviated by the transfusions; (2) in some a series of
transfusions at short intervals leads to the blood becoming
normal for a time; (3) perhaps in a small percentage life
can be maintained indefinitely by supplying the blood at the
same rate as it is destroyed; (4) in many cases the disease
is progressive in spite of transfusions. The blood picture
becomes worse and worse, and death is only postponed for a
short time.
Discussion.
Mr. Alexander Fleming said that his experience was
confined to transfusion of surgical oases accompanied by
sepsis at the base in France. He had used the citrate method,
transfusing from 600 to 1000 c.cm. into the recipient. There
had been no untoward symptoms except In one case, when
considerable distress was experienced after the injection of
100 c.om. It was possibly explained by the transfusion
being [given too quickly, or by wrong classification of the
donor. The surgical teaching was that the blood of donors
of Group 4 could be given to anybody, since no sera
agglutinated their corpuscles. He had always used members
of this group. It was important to use a method where
cutting down was unnecessary because it avoided needless
discomfort to the donor and left no scar, which might
afterwards erroneously suggest that salvarsan had been
injected. The result of the transfusions had been to benefit
the patients immediately. Nearly all had had a secondary
haemorrhage. In them, after transfusion, the colour returned
and they felt better, an Improvement which persisted. An
1 Med. Klin., 1912, No. 42, p. 1702. Zeit. f. Chir., 1913, vol. xl„ No. 1, * Jo urn. Mner. Med. Amoo., 1914, Ixil., p. 2019. Sorg., 9 jd., end
p. 3. Obit., March, 1916, p. 251.
The Lancet,]
MEDICAL SOCIETY OF LONDON.
[March 8 , 1919 381
would require more time and involve measures for the
control of bleeding is unnecessary. On opening the peri¬
toneal cavity only the surface of the liver is exposed; by
means of a finger hooked under its margin this organ is
rotated upwards and the anterior wall of the stomaoh comes
into view. The advantage of this manipulation is seen at
the end of the operation, for when the pylorus is returned to
the abdomen the liver drops back into its normal position,
and so intervenes between the abdominal wound and the
intestines and omentum, their tendency to prolapse being
thus prevented much more effectually than by the use of
any intestine guard or other instrument. This incision is
well adapted to all the operations on the pylorus already
described, and is always used by Mr. Biirghard when
performing divulsion of the stricture.
The stomach having been exposed in the manner just
desoribed, its anterior wall is picked up with dissecting
forceps and drawn out of the wound. By means of gentle
traction ou this part of the gastrio wall the pylorus is
brought up to and out of the abdominal incision, the
rest of the stomach being returned to the peritoneal
cavity. The diagnosis having now been confirmed, the
pyloric swelling is held in the left hand and a
longitudinal incision is made upon its anterior aspect;
this incision should be placed midway between its upper
and lower borders where the pyloric and right gastro¬
epiploic arteries respectively lie; branches of these are seen
running transversely around the pylorus and between their
terminal twigs is a non-vascular area through which the
incision should pass. The incision is first made through
the thickest part of the muscle, and should be extended
towards the stomaoh where the transition to normal tissue
is gradual; on proceeding to a greater depth, the mucous
membrane is ultimately exposed at some part of the wound,
and at once bulges between the edges of the divided muscle ;
with this as a guide the incision is carried to the same depth
for the whole extent of the thickened band, the duodenal end
of the strioture being divided last and with great care, since
the sudden termination of the hypertrophy in this situation
increases the risk of wounding the mucous membrane. While
making the incision the fingers of the left hand draw the edges
apart as one proceeds, so that the deepest part is always clearly
seen and the mucous membrane easily identified as soon as
it is exposed. The complete incision is from three-quarters
of an inch to an inch in length, and its margins are separated
to the extent of nearly half an inch by the retraction of the
divided muscle fibres. Into the gap so formed a pouch of
mucous membrane prolapses, filling it up and thus relieving
the obstruction to the lumen of the pyloric canal. Little, if
any, hemorrhage occurs if the Site of the incision is chosen
as I have desoribed it, but should a small vessel ooze, a hot
sponge is usually sufficient for its control. The pylorus is
now returned to the abdomen, the liver allowed to rotate
into its normal position, and the wound in the abdominal wall
sutured. Prolapse of intestine, or more especially of omentum,
may delay this stage of the operation, but if the parietal
incision has been made aB already described and if the first
sutures are inserted at the lower end of the wound where
prolapse is most likely to occur, valuable time is saved, and
as speed'is such a great factor of success in these oases, I
consider this an important detail of the technique.
On return to bed the usual measures are taken to combat
shock, which although of a relatively slight degree is never¬
theless always to be feared, lest its increase leads to a fatal
result. Feeding is begun at once, with one drachm every
quarter of an hour, increasing the quantity and interval
rapidly till, at the end of 48 hours, 2 ounces every two hours
are being given. The stools show that the passage of food
from stomach to intestine occurs quickly, and therefore no
delay in feeding is necessary.
The final result depended upon the degree of wasting
present, and therefore the earlier the operation was done
the more hope was there of success of the subsequent
treatment by suitable feeding. Of Mr. Ramsay’s three
‘cases two had died, but in neither instance from
the post-operative shock hitherto so frequent and fatal.
All three recovered from the effects of the operation
and gave evidence of the patency of the pylorus, death
occurring in one case after six days from inability to assimi¬
late and in the ether after four and a half weeks from ileo¬
colitis. With a rapid method of surgical intervention such
as this, applied sufficiently early, he felt that the results of
treatment in cases of this nature could be greatly improved,
and he hoped that his paper would lead to a trial of
Rammstedt’s operation.
Disoussum.
Mr. D’Arcy Power agreed that pyloroplasty and Loreta's
operation were much too long and complicated, and he had
given them up in the case of young children. It was clear
that the earlier the operation was done the better for success.
Given the opportunity, he should try the operation just
described. It was important that some agreement should be
arrived at as to the optimum time for surgical treatment.
Mr. H. Tyrrell Gray said that it was difficult to decide
when to operate. He had performed Rammstedt’s operation in
from 15 to 20 cases, and agreed that it was the best surgical
procedure. All his first four cases recovered. After a phase
of disappointing results they were now much better again
and were improving. Loreta’s was essentially an operation
for early cases, but Rammstedt’s had the advantage of being
equally suitable later. Results would depend upon the time
of the operation and the after treatment. The time occupied
over the operation was not in itself sufficient to account for
its advantage.
Dr. E. C autley had suggested the operations and watched
them being performed by Mr. Ramsay, and agreed that the
results were good. The procedure was rapid, produced slight
disturbance, and procured a wide pyloric canal. Cases met
with in private practice were seen earlier and did much
better. This was partly due possibly to better conditions,
but the main advantage was that an operation could be done
earlier. He thought that it should be done as soon as a clear
diagnosis was made. He was not satisfied with a diagnosis
of hypertrophic stenosis of the pylorus unless a tumour could
be felt or the symptoms were very characteristic. Cases
of so-called recovery under medical treatment alone were
not generally, in his opinion, genuine cases. Many of them
were examples of mucous catarrh of the stomach. When
the hypertrophy was sufficient to cause obstruction he
was more than doubtful of recovery under medical
treatment. With Rammstedt’s operation he was inclined
to resort to surgical treatment even when the diagnosis
was less definite, as no serious harm resulted. The after-
treatment was in no sense special, but that suitable for an
ordinary infant of corresponding age and condition.
Dr. F. S. Langmbad took the view that recovery by
medical treatment alone was by no means uncommon, and
was all that was necessary in the less severe cases. He had
frequently seen undoubted cases in which a pyloric tumour
was distinctly palpable regain good health without operation.
In almost every case in which, with the usual history,
gastric peristalsis was characteristic and well defined, a
tumour could be felt sooner or later. He disagreed, however,
with those who deferred operation until too late or opposed
surgical treatment in these cases. If an infant of 2 to 3
months old when first seen weighed only 6-7 lb., it was a
case for operation without delay. If, on the other hand,
the baby’s condition was fairly good medical treatment
could be tried and might prove quite effective. If after one
to two weeks’ trial the weight was stationary or declining
operation should be no longer deferred. The need for
operation might also become indicated by the degree of
vomiting and the small amount of the stoolB. In breast-fed
infants he had found that restricting the feeding to 5 minutes
at hourly intervals sometimes led to prompt improvement.
The breast should be emptied after every third feed with a
breast-pump. Gastrio lavage once or twice a day according
to the amount of mucus and residne was the only medical
treatment beyond dietetic of any definite value. For artifi¬
cially fed infants he preferred small, frequent feeds of
peptonised milk.
The President had had under his care 33 cases of the
condition, and had analysed them carefully. The analyses
did not indicate what were the causes of death or what
determined the degree of wasting. The mortality had been
60 per cent., arid no cate had been treated surgically. He
had hesitated to advise operation, for he could never assure
himself that the obstruction at the pylorus was the cause of
the wasting. The prognosis depended very much on when
the patients came for treatment. Weight was an important
factor in prognosis. He had not found that one variety of
food suited better than others. Until he was confronted
with better figares for operative treatment than those
attained by medical measures he would not change his
opinion to one favouring the former.
A meeting of the West London Medico-Chirnrgical
Society will be held to-night (Friday), at 8.30 p.m., in the
society’s rooms. West Loudon Hospital, when a paper will
be read by Dr. F. G. Crookshank, entitled (< The Importance
of Symptoms.” . ,
382 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[MAEtOH 8,1919
Ipritfos mb Jtoiias of Jooks.
Orime and Criminal*: Bring the Jurisprudence of Crime—
Medical , Biological ’, and Psychological. By Ohablbs
Mbboirr, M.D., F.R C.P.,F.R.C.S. With an Introduction
by Sir Bryan Donkin, M.A., H.D. Oxon., F.R.O.P.,
Member of the Board of Directors of Convict Prisons;
late one of H.M.’s Commissioners of Prisons. London :
University of London Press, Ltd. 1918. Pp. 292. 10#. 6 d.
According to Austin, “the matter of the science of juris¬
prudence is law, strictly so-called,” a definition which need
not prevent a writer on jurisprudence from including in a
treatise upon crime and criminals the consideration of conduct
not punishable under the criminal law, but whioh he would
wish to see so punished. Dr. Mercier claims in an early
chapter more than a licence or qualification to instruct
the Legislature as to what acts and omissions ought to be
punished and what ought not, declaring that “a jurisprudent
would neglect his duty, a book on jurisprudence would lack
its most important factor, if this instruction were not im¬
parted,” for to him, not unreasonably, jurisprudence is
“the science of law whioh discusses not only what
the law is, but also what it ought to be.” He accord¬
ingly turns to first principles to discover the foundation
upon whioh the law rests, and to determine in what
directions it may be improved. It does not follow, how¬
ever, that the Legislature, or, indeed, the reader will be
brought to the same conclusions as Dr. Mercier, by
studying his chapters on the nature of orime, on kinds
of crime, on private and racial offences, and on criminals.
Every reader must find these chapters of interest, together
with those on the prevention, detection, and punishment of
orime, even though he may not accept all the views to which
the writer gives the weight of his approval, or of whioh he
claims to be the originator, but Dr. Mercier is a learned,
stimulating and amusing writer. One of the most con¬
vincing chapters is that in whioh a comparison is drawn
by Dr. Mercier between his own doctrine of the causation of
insanity as due in varying proportions to the two factors of
heredity and stress, and the proposition, equally his own,
that crime is due to “temptation or opportunity, the environ¬
mental factor or stress, acting upon the predisposition of the
offender, the inherent or constitutional factor.” “The more
potent the one factor the less of the other will be needed to
bring about the result,” he says, and he works out the thesis
in an eminently clear and readable manner.
If it be a legislator, however, or, shall we say, an average
Member of Parliament, whom we imagine as turning to Dr
Mercier’# work, with a view to bringing in a Bill for the
amendment of the criminal law, we picture him as a little
disappointed by the nature of the advice given, as the
result of psychological analysis of the criminal and his
orimes. Sir Bryan Donkin, in an appreciative preface,
prepares us for what we venture to regard as the principal
recommendation which Dr. Mercier desires to make, and one
of more importance than the suggestion to treat as larceny
the “stealing of the use of a thing.” “ Dr. Mercier,” writes
Sir Bryan Donkin, “ considers that breach of oontract and
felse imprisonment also should be crimes: and he seems to
have reason on his side.” On pages 172 and 175 will be
found the author’s statement of his opinions, or rather his
assertion that breach of contract * 1 undoubtedly ” ought to be a
criminal offenoe, and that' 1 the exclusion of false imprisonment
and breach of oontract from criminal offences is a blemish
in English jurisprudence.” This will be rather startling to
those who deprecate the tendency of modern legislation to
increase the number of acts in respect of which proceedings
in criminal courts may be taken. It may also strike them
from a merely practical point of view that the criminal
dooks of the country would not be able to contain the
persons charged with this new vast olass of offences, while
the Bar would be seriously depleted by the appointment
of the necessary number of stipendiary magistrates. Breach
of oontraot may satisfy every definition of crime. Dr. Mercier
says it does. It may also be injurious to society; but
even this does not prove, nor does he, that it is, in fact,
desirable to treat what has hitherto been regarded as a
matter concerning the two parties to the oontract. as an
offenoe against the State. Why, also, it may be asked,
should breaches of oontraot among civil causes of action
be rendered crimes, and not torts as well; or, rather,
why of all torts should false imprisonment alone be selected ?
This cannot be in order to diminish the number of trivial
prosecutions that would certainly follow if breaches of
oontract were made criminal, for in that case malicious
prosecution would have been included with false imprison¬
ment. However, we can express entire agreement with the
opinion, also to be found on p. 172, that the criminalising of
wrong acts now remediable only by civil proceedings is not
likely to be resumed, though whether this is due to a lack of
logical completeness and systematic order, inherent in English
law and the English character, is more doubtful.
Dr. Mercier is given to statements of a character which
challenges contradiction. He devotes many of his observations
to the expression of contemptuous dissent from the doctrines
of Lombroso and his school, but gives no references to the
works of Lombroso such as would prove that a particular
criticism is deserved. For example, at p. 38, he refers to the
prevalence of smuggling at one time among the inhabitants
of our coasts. These, he points out, became criminals under
the then existing laws, and he describes the physical charac¬
teristics which, “ if the doctrines of Lombroso, Qarofalo, and
the rest of the continental criminologists are true,” they
ought to have developed. “But did they?” be asks
triumphantly—a “ nnm ” question, as the Latin grammar
would hfive it. Well, first, the rejoinder might be made,
“ Did Lombroso and the others, in writing of criminals,
define them in such a way as inevitably to include the early
nineteenth century smugglers of our southern counties ? ”
And seoondly, the inference whioh he would have us draw is
not justified by the writings alluded to—at least, in our
opinion.
Dr. Mercier has written an able, useful, and original book,
which has deservedly earned for him, and for the second
time in succession, the Swiney Prise. His teaching gains by
his clearness and well-justified self-assurance, but its accept¬
ance is sometimes rendered unpalatable by his methods of
demonstration.
Report of the Work of the Invalided Soldier*' Commission ,
Canada. May, 1918.
The experiment of giving to the Army Medical Corps the
medical work in the hospitals and institutions of the Com¬
mission charged with the care of discharged soldiers was
found to be unworkable, and since the early part of 1918 these
men have been placed under the direction find control of the
Minister of Soldiers’ Civil Re-establishment. The Commission,
in addition to caring for all officers and soldiers suffering from
diseases either incurable or likely to be of long duration,
such as tuberculosis, epilepsy, paralysis, and mental dis¬
orders or relapses of their former complaint, retains the
control of vocational training in the hospitals before the men
are discharged and of subsequent re-education. The Com¬
mission will develop the vocational branch, establish a distinct
medical service of its own, and will arrange to secure closer
cooperation with the various Provincial Commissions ohargsd
with the duty of finding employment for returned men.
The total number of hospital beds retained by the Com¬
mission is 5575. A novel feature is the employment of
dietitians; three organising dietitians have been appointed
and dietitians have been placed at a number of the Com¬
mission’s hospitals; ladies who have taken University courses
and have specialised in this subject are employed. They
furnish detailed returns as to the consumption of the various
articles of food ; in this way a check is maintained on the
quantity of food consumed and the supply of the oorreot
amount of fat and other essentials to curative diet ensured.
At all the larger institutions a recreation building has been
provided ; the main hall is equipped with a stage and a
kinematograph, the lower floor being given over to class¬
rooms, workshops, and bowling alleys. One permanent home
with accommodation for 50 disabled men has been established
at Toronto.
A factory for the manufacture of artificial limbs is main¬
tained by the Commission. The artificial legs are made of
wood obtained from the brittle willow and golden osier; the
wood is cut into bolts about 22 inches long and bored through
the centre in order to season without 1 * checking. ” The bark
is removed and the ends painted; the bolts are then left to
season in the shade in the open air for two years. After
this they are kiln-dried and kept absolutely dry till made up
Thb Lanont,]
REVIEWS AND N0TI0E8 OF BOOKS.
[Maboh 8,1919 383
into an artificial limb. At present the Commission issues an
artificial arm with a working hook capable of holding
a knife, fork, or pen, and with which a man can pick up
articles and dress himself. The hook can be exchanged
for a gloved band with a movable thumb which enables the
man to hold an umbrella or valise or carry his coat on his arm.
Splints, braces, orthopaedic shoes, and other orthopaedic
apparatus are made at the factory. Several returned soldiers
are being taoght various branches of the making of artificial
limbs and orthopaBdio shoes. Men who have incurred dis¬
abilities on servioe which require appliances, such as ortho¬
pedic shoes, trusses, spectacles, rubber bandages and belts,
are granted an annual credit for renewals.
Reference is made to the difficulty of diagnosing epilepsy.
Convulsions, apparently typically epileptiform, are often
found to be due to other conditions than epilepsy, the
most frequent of these being hysteria. “ Those cases
developing seizures following exposure at the front, but
without a previous history of epilepsy, and in which,
on being invalided home, the seizures tend to diminish,
should be regarded with great suspicion.” A number
of feeble-minded were enlisted. Certain of the higher
grade defectives who had been able to carry on the
simpler forms of manual labour, including farm work,
proved totally incapable of carrying on in the Army. The
writer of the report points out that the war has resulted in
the medical examination and supervision of a large propor¬
tion of the male population, and has furnished information
concerning a considerable number of defectives. Use should
be made of this and definite after-care plans formulated for
at least two well-defined groups of ex-soldiers, epileptics and
feeble-minded.
Surgical Aspects of Typhoid and Paratyphoid Fevers. Founded
on the Hunterian Lecture for 1917, amplified and revised.
By A. E. WebbJohnson, F.R.O.S., D.8.O., Temporary
Colonel, A. M. 8. With Foreword by Lieutenant-General
T. H. Goodwin, O.B., O.M.G., D.S.O., Director-General,
A.M.S. London: Henry Frowde, Oxford University
Press ; Hodder and Stougbton. 1919. Pp. 190. 10*. 6 d.
This volume is an amplified account of the surgical aspects
of typhoid and paratyphoid, which formed the subject of a
Hunterian lecture published in our columns on Dec. 1st,
1917. Numerous illustrations, both black-and-white and
coloured, embellish the text, and the book can be confidently
recommended as a trustworthy guide to a new and interesting
subjeot.
Diseases of the Heart and Aorta. By Dr. A. D. Hirschfeldbr.
Third edition, revised. London: J. B. Lippincott Co.
1918. Pp.732. 30*.
In the preface to the first edition the author says that bis
aim has been “to present side by side the phenomena
observed at the bedside and the foots learned in the labora¬
tory in order to show how each supplements the other in
teaching us how to observe the patient and to direct the
treatment.” This principle has been elaborated throughout
the book, and in this third edition Dr. Hirschfelder has
faithfully correlated the fruits of recent research with the
clinical facts upon which they bear. The result is a volume
in which the reader in searoh of light on problems of the
pathological physiology of the circulation may be sure
of finding help. It is an industrious and exhaustive
compilation, and one which will be weloome to every¬
one interested in the study of cardiology. The student of
clinical medicine, however, will find that the facts are
presented more from the viewpoint of the laboratory than
from that of the bedside. Under such circumstances it is
not surprising that a large proportion of the writers quoted
are Teutonic. Dr. Hirschfelder has indeed done his best to
include the researches of America and Britain, but it is a
little disappointing to find no reference to the work of Thomas
Lewis and his colleagues in the chapters which discuss the
military heart.
A striking feature of the book is the wealth of diagram¬
matic illustrations. Many of these are of the utmost value,
and express in a lucid form that application of physiology to
medicine which is the dominant purpose of the author. Dr.
Hirschfelder is to be congratulated on the success of his
book. If in his next edition he were to secure the collabora¬
tion of a clinician, he might give us the beet aooount of
cardiac disease in the English language.
- 1 -
Pye's Surgical Handicraft. Edited and largely rewritten by
W. H. Clayton-Grbbnb, F.R.O.S. Eighth edition,
fully revised, with some additional matter and illustra¬
tions. Bristol: John Wright and Sons, Ltd. 1919.
Pp. 640. 21*. net.
A new and revised eighth edition of this useful manual
has just been published. The author has taken advantage
of the work of Sir Robert Jones in the section dealing with
orthopaedic cases. In this and other sections the letterpress
is full of information invaluable to the student, the house
surgeon, and the general praotitioner. The book is exceed¬
ingly well got up; the illustrations are dear and helpful.
A Medical Field Service Book. By 0. Max Page, M.S. Lond.,
F. R.C.8. Eng. With a Foreword by Sir Gborob Marins,
G. O.M.G., O.B. London; Henry Frowde, Hodder and
Stoughton. 1919. Pp. 160. 6*.
Thib is a very useful vade mecum for a medical officer in
the field, dealing as it does with cases of disease and wounds
prior to the entrance to the casualty clearing station. Similar
text-books have been peculiarly conspicuous by their
absence. The book emphasises the wide sphere of know¬
ledge required by a medical officer in a forward area,
and in giving samples of the information needed the author
has produced a usefal volume. He has quite rightly
dealt with minor ailments met with in the line and the
method of their treatment, and has not overburdened the
reader with the more elaborate methods of dealing with
wounds, the principles of treating which are much the same
in every zone of activity. The book is a valuable addition
to war literature.
A Treatise on Clinical Medicine. By William Hanna
Thomson, M.D. Seoond edition. London and Phil¬
adelphia: W. B. Saunders Company. 1918. Pp. 678.
24*. net.
In the second edition of this large work Dr. Thomson lays
particular stress on the application of different kinds of rays
in the diagnosis and treatment of carcinoma and sarooma.
Another special feature is the classification of diseases adopted
by the author. Under the heading, “ Infections Oommunio-
able by Intermediate Carriers,” are included (togetber with
typhoid and Asiatic cholera) pneumonia, tonsillitis, chorea,
cerebro-spinal meningitis, beri-beri, and meat poisoning.
This is the arrangement of a zealot or a prophet, and the
reader is driven to the former assumption on finding scurvy,
infantile scurvy, and cyanosis classed under Diseases of the
Blood, “hiccup” under Diseases of the Respiratory Appa¬
ratus, dysentery under Intestinal Disorders. Aad the
surprises could be indefinitely prolonged. The book
is designed with the object of “serving the physician
while he is actively engaged in the performance of Us pro¬
fessional duties,” but little space has been given to the
pathology of the various conditions, without a sound know¬
ledge of which the significance of the important symptoms,
upon which such stress is laid, cannot well be appreciated.
Some trained observation and some original ideas are to be
found in the book, but it is not one for the practising
physician to read without discrimination.
Diabetes and its Dietetic Treatment. By B. D. Basu, Major,
I.M.S. (retired). Ninth edition, revised and enlarged.
Allahabad: The Panini Office, Bhuvaneshvari Ashram.
1918. Pp. 104. Rs.1.8.
A nbw edition of this little book has lately appeared, the
ninth since 1909. In it the author develops Us view that
diabetes is, in a large proportion of cases, caused by
alimentary toxaemia produced by (1) errors in diet; (2) dis¬
ordered conditions of the digestive juices; and (3) toxins
discharged by the bacteria in the alimentary canal. He
regards the increase in the incidence of diabetes among the
people of India as due to factors such as the increased
export of wheat from India to the United Kingdom, and con¬
sequent dependence of the people of India on inferior food
grains for their bread; the importation into India of potatoes;
tea drinking; the nervous strain connected with modem
life, which is a well-known cause of disordered digestion.
With regard to the last-named he writes suggestively :—
“India is a country where, from time immemorial,
people were accustomed to take their principal meal in the
middle of the day, after which they used to spend an hour
884 Ths Lanobt,] ANALYTICAL RECORDS —BELGIAN DOCTORS’ RBLIEF FUND.
[KabohB, MK9
or two in siesta, which allowed for the proper digestion of
food. Under the altered conditions of tneir existence they
do not find time properly to chew and masticate their
food, which they are obliged to bolt down as soon As they
can, to attend to the studies or business in the middle of the
day.”
The Tribune (India) suggests in this connexion that “ it
might be worth while to make a change, at least experi¬
mentally, in the office hours, restoring the time-honoured
mid-day meals at leisure,” stomach disorders being practi¬
cally unknown among people not used to modern office
hours of business and harried meals. Among the various
forms of treatment which the author has found useful are
the exclusion of meat from the dietary ; starvation and
pirgatives; gastric lavage ; banana flour; unpolished rice,
from which the water has not been strained; green vege¬
tables. One outstanding idea running through all the
methods of treatment is the urgent need for foods rioh in
sitamines.
Reports aito Jnaljtical $etffrbs
FROM
THE LANCET LABORATORY.
ANIODOL.
(Tes Akglo-Frbwoh Drug Oo , Ltd., Gaxagb Buxldhtg,
Holborn, Lomdojt, JU.C. 1.)
ANIODOL is stated to consist of a stable combination of
tri-methanal with allyl sulphocyanide in a solution of
specially distilled glyoerine. Such a compound, we find,
is described in Thorpe’s “ Dictionary of Applied Chemistry ”
as the subject of a French patent in use as an anti¬
septic. According to our examination aniodol is a clear
colourless fluid miscible with water in all proportions,
which gives off a pungent gas on boiling. Tri-oxy-methylene
(tri-methanal), as is well known, is a polymer of formal¬
dehyde, and exhibits powerful germicidal properties.
Associated with aliyl sulphocyanide these properties are
increased in aniodol. The liquid is a strong reducing
•agent, and the presence of the sulphur group was proved in
our examination by the formation of black lead sulphide on
heating aniodol with lead acetate and caustic soda. Its
germicidal efficiency, according to particulars furnished,
is remarkable, varying with the organism tested, the
carbolic acid coefficient ranging from 25 as a maximum
•in the case of Bacillus typhosus to a minimum of
1 in the case of oholera vibrio. Aniodol may be used both
externally and internally, the dilation being non-toxic, while
•organic matter does not appear to impair its germicidal
efficiency. We have also examined aniodol powder, which
contains the same antiseptio combination, starch, according
to our findings, being used as an absorbent. It is practically
odourless and is suggested as an efficient substitute for
. iodoform and similar applications.
(1) DIGALEN; (2) OMNOPON; (3) SEDOBROL:
(4) THIOCOL.
{The Hoffmahh-La Roche Chemical Works, Ltd., Basle ;
AHD 7 AJTD 8, IDOLrLAKE, L/OMDON, B.O.3.)
These preparations are well known, and were noticed in
. these columns some years ago. Certain changes in form
.and advances have beep made, however, which may briefly
be recorded in view of our examination of specimens recently
submitted to us.
(1) Digalen was prepared from digitalis with the view of
scouring uniformity of pharmacological action of this most
. important drug. It thus represents the active principle of
digitalis with all inert matter oompletely removed. Digalen
is supplied in the form of a sterile, colourless standard
. solution of amorphous digitoxin upon which the therapeutic
. .action of digitalis depends. There are also available tablets
.and.ampoules containing standard amounts of thu active
, principle.
(2) Omnopon contains the soluble hydrochlorides of the
total alkaloids of opium in the proportion present in the
drag itself, the principal alkaloid, morphia, occurring in
each dose to the extent of about 50 per cent. Apart from
its ordinary administration as an opium derivative free from
unpleasant after-effects, its employment in combined anses-
theoia is well spoken of. Omnopon is also supplied with
scopolamine, & combination approved by some anaesthetists.
(3) Sedobrol is the outcome of a novel suggestion to
combine a sedative with a nutrient. It occurs in tablet
form containing sodium bromide, with chiefly soluble proteins
of vegetable origin and fat. It makes a palatable cup, with
saline taste, and may prove an acceptable means of
administering a sedative and nutrient to the patient under,
of course, the guidance of the physician. It is, in short, a
bromide bouillon ; it is said to be useful in insomnia, and
this action may be expected.
(4) Thiocol is a soluble gaaiaool derivative (potassium-
guaiacol sulphonate) which has been employed in pulmonary
affections and as an intestinal antiseptic. It is a non-toxic
germicide. The tablets submitted gave a characteristic
reaction with perohloride of iron, a deep violet colouration
resulting.
(1) SOLUTION POT. IODIDE (SOUFFRON);
(2) STROPHANTHUS AND STROPHANTHINE
(ORI8TALLIS&E).
(Mod ere Pharmacals, 48, Mortimer-street, Loir Dor, W. 1.)
(1) Importance is attached to the employment of chemically
pure iodides in medicine, and this preparation is simply a
distilled water solution of pure iodide of potassium, the salt
occurring, according to our analysis, to the extent of about
7 per cent. w/v. We found it to be entirely free from the
common imparities of the iodide, while it proved stable.
(2) The use of strophauthus as a cardiac tonic has been
discredited in some quarters, which, according to the French
chemist, M Oatillon, is due to the fact that the usual
tinctures have shown considerable variations in regard to the
amount of the active constituent, strophanthio, present. This
drawback has been overcome by the preparation of a
standardised extract of strophanthus in granule form, each
containing 1 mg. of the extract with the diuretic principle.
In addition, we have examined granules containing strophan-
thin in crystalline form (1/10 mg.), the diuretic principle in
this case being excluded. French authorities and clinical
records are quoted showing tbe reliability of these pre¬
parations. __
THE BELGIAN DOCTORS’ AND
PHARMACISTS’ RELIEF FUND.
This Fund was officially closed by the Executive Committee
at their meeting on Jan. 30th, the formal date of closure
being Feb. 10th Sinoe the date of the meeting the following
subscriptions have been received :—
£ s.d.
Hampshire Pharmacists’
Association (per Mr.
G. U. Baker, making
£56 6s.) . 6 5 0
Dr. Charlotte B. Warner 10 0
Dr. Alfred Cox (monthly) 110
Dr. P&plllon . 0 10 6
Dr. Leak ... «. ... ... 110
£ s.d.
South Australian Belgian
Belief Fund (per the
Agent-General for
8.A.) . ... 600 0 0
J. M. 0 10 0
Mr. D Arcy Power. 2 10 0
Mr. H. B. Morris . 0 6 0
The following monthly subscriptions were reoeired for
January and alio for February:—
Dr. B. C. Mortand .
£ «.
0 10
d.
6
Dr. T. L. Draper .
£ a. d,
0 10 0
Major B. B. Fothergill,
U.A.M.0.
0 10
0
Dr. F. W. Good body ...
Dr. A. Graham .
1 0
1 1
0
0
Dr. J. G Mu won .
0 10
0
Dr. W. Stewart .
0 10
0
Dr. G. G»ey Turner ...
L)r. A. W. Porrefct .
1 1
0
Dr. U. Whttehouse ...
0 10
0
1 0
0
Dr. Vincent Tigbe .
0 10
0
Sir Tbos. Barlow .
0 10
0
Dr. W. B. Good .
0 10
0
Dr. A. H. N&ish .
0 10
0
Dr. H. Oalger .
Dr. Hyla Grooves .
0 10
6
Dr. A. B. Stevens .
1 {>
0 t
0 10
0
Dr. Luffman . .
0 10
0 1
It will be seen that the Fund benefits by generous monthly
subsci iptions for January and February, and has also
reoeived from the South Australian Belgian Relief Fund,
through the Agent-General for South Australia, a munifi-’
cent donation of £500. In view of the terms of
the letter published on Feb. 8th from Dr. V. Peoh&re
the Fund was closed, but these handsome augmenta¬
tions are none the less extremely gratifying to the
Executive Committee who know full well in how many
directions the money can still be splendidly used. Dr.
Pechfcre, as President of the Comit6 National de Secours
et d’Alimentation (Aide et Protection aux M6decins et
Pharmaciens Beiges Sinistr6s), called our attention, when
deprecating the sending of farther subscriptions, to the fact
chat his society bad throughout practised tbe severest
economy in order to keep funds in reserve, inasmuch as grave
necessity would continue for some time. . The Fund will still
be able to do a little more to decrease the toll of misery.
ThsLanott,]
DENTAL PRAOTIOE, QUALIFIED AND UNQUALIFIED.
[March 8,1919 385
THE LANCET.
LONDON: SATURDAY, MARCH 8, 1919.
Dental Practice, Qualified and
Unqualified.
The Report of the Departmental Committee
appointed to inquire into the extent and gravity
of the evils of dental practice by persons not
qualified under the Dentists Act contains recom¬
mendations which directly concern members of the
medical and dental professions, and which no doubt
are being closely scrutinised and criticised by
them. Beyond this the report as a whole should
be of considerable interest to all intelligent members
of the general public; it is a pity that only a
small number of them, however, may be expected
to read a Departmental Report. The Com¬
mittee has to some extent gone outside the
terms of its reference. It has not confined itself
to consideration of the present inadequate supply
of qualified dentists and dental surgeons, of
the expediency of prohibiting the practice of
dentistry by the unqualified, and of the practic¬
ability of modifying the amount of study, time,
and money now expended in qualifying for a dental
career. The Committee has dealt with these
subjects more or less exhaustively, and they must
certainly have afforded it ample material for
reflection and deliberation. It has, however, also
included in its survey and in its report the question
of dental disease in relation to the health of the
people, having realised, as it tells us, that it would
be unable to report upon its reference until it had
taken evidence of the effect of dental disease upon
the general health, and of the incidence of such
disease at different periods of life. The considera¬
tion of these points the Committee deemed neces¬
sary in order to form an opinion upon the number
and kind of dentists likely to be required in
the future; and often as such proclamations have
been made of recent times, we weloome the public
insistence by the Committee on the fact that the
care of the teeth is an essential element in the
care of the health, whether of the public or of
the individual. Clearly the number of qualified
practitioners now devoting themselves to the
practice of dentistry is not sufficient to meet the
demand for their services which exists, and
which ought to exist in greater degree as the
public comes to regard the care of the teeth as
essential to the preservation of health. We
endorse warmly the Committee’s recommendation
that a thorough research investigation into the
causes and effect on health of dental caries is
needed, and pass to the measures advised for
improving dental treatment for the nation which
Beem likely to be dealt with by the legislature in
the near future.
These proposals are due to the conviction of the
Committee that quack dentistry offers a profitable
livelihood to any person who has the physical
capacity necessary to enable him to pull out a tooth,
and the commercial ability to manufacture and to
sell dentures of any sort, making known his trade by
specious advertisements and unscrupulous canvass-1
ing. It has been proved before them by evidence I
that unqualified dental practice is a source of
many and dangerous injuries to members of the
humbler classes of society—it is too often a
form of robbery to which they fall victims with
singular facility—while at the same time the
universal practice of dentistry by the unqualified
lowers the social status and public esteem of the
dental profession, and by rendering it unattractive
contributes to the shortage of qualified dentists.
The carefully considered epitome of the evidence
contained in the Report forms an explanation of
the two most immediately important proposals
of the Committee—namely, that unregistered
practitioners should be forbidden to practise
dentistry, and that in a new Register, in deference
to their vested interests, there should be included
unqualified persons who otherwise would be
deprived of their means of livelihood. The un¬
qualified have, of course, hitherto been able to
practise as long as they did not describe themselves
as dentists or use titles implying registration. As
distinguished from individuals, the Committee has
had to consider the case of dental companies with
which it finds gross abuses have been associated,
involving both malpraxis and fraud. As to these
the recommendation is that dental companies shall
not be prohibited from practising dentistry, but
shall be controlled, all the operating and managing
staff being required to be registered dentists,
and special provision is being made to meet the
case of existing companies, which will not be
allowed to carry on any other business. The
proposal to prohibit all practioe of dentistry
except by registered practitioners hardly requires
argument to enforce it, and a few of the facts
connected with unqualified practice noted in the
Committee’s Report should convince any but the
most fanatical and unreasonable denouncer of
so-called “monopolies.” The reason for creating
the monopoly in this case is the protection of
members of the public, their persons and their
pockets, and it may be mentioned that the
establishment of a Public Dental Service is not
the least interesting and important of the
suggestions of the Committee, which had before
it considerable evidence as to the uneven dis¬
tribution of dentists in the countries of the
United Kingdom and in different parts of each
country.
The forming of the new Register and its
enlargement by the admission to it of unquali¬
fied persons and by shortening and cheapening
the process of qualification are grave matters,
upon which there will be much to be said
and on which opinions will be strongly divided.
The Committee sums up the principle upon
which it wishes to see the admission of the un¬
qualified take place by advising that a reasonable
measure of precaution shall be adopted to ensure
that any person whose name is added to the
Register was in bond fide dental practice before the
date of this report, that this practice formed the
means of his livelihood, and that he can be trusted
safely to practise dentistry upon the public. It
is not likely to be easy to set up and maintain con¬
sistently throughout the country a standard of
bond fide dental practice, or to ascertain how far a
candidate for registration can be trusted safely to
practise. He will not be likely to have the capacity
and skill of a practitioner registered after due
training and examination, and the lowering of the
general standard of registered practice will follow
automatically. It is not proposed by the Committee
386 The Lancet,]
THE INFLUENZA PANDEMIC.
[Maboh 8,1919
that the unqualified candidate for registration
shall be examined, as it is of the opinion that there
would be considerable difficulty in conducting such
examinations; and it holds that any unregistered
practitioner or dental assistant, who has been
engaged continuously in the practice of dentistry
by performing dental operations within the mouth
for the period of five years immediately before the
date of the Report, should be entitled to registra¬
tion ; for those of less than five years’ standing an
examination within a period of two years is sug¬
gested. With regard to the admission of unregis¬
tered persons who have been working in the
manner defined above for five years the Com¬
mittee admits that “ possibly a number of not very
competent practitioners may obtain registration,”
but apart from the difficulty of examination, which it
foresees, it is of opinion that five years’ professional
work, combined with a satisfactory character, con¬
stitutes a vested interest which must be respected.
We would suggest with regard to this that the con¬
sideration of vested interests may be carried too
far in connexion with the unexamined, seeing
that every privilege extended to this class is detri¬
mental to the vested interests of the duly qualified
dental practitioner. If the admission without
examination, and more or less as a matter of course,
of those who have acquired a vested interest by
unqualified practice is to be combined with the
registration of future candidates qualified by train¬
ing less thorough than that of their predecessors, a
general lowering of the standard will be the
inevitable result; and here the advisability might
be considered of making some difference in title
between those who are on the Register by examina¬
tion, and those who are admitted there in recogni¬
tion of a good professional character of five years’
duration. The ideal proposed by the advanced and
scientific dental surgeons has always been that the
dentist should be a qualified medical man practising
dentistry as a specialty, just as the ophthal¬
mologist practises his specialty, and thiB ideal
has been advocated not in the interest of the
practitioner, but of the public. It may not be
one possible of attainment to-day, but it should
not be allowed to drop out of sight. It may be
beyond the reach of those now unregistered
practitioners who are recommended for admission
to the Register without any dental diploma what¬
ever, but every facility should be afforded to all
dentists for study after registration, and there
should be every inducement for them to undertake
such study. The proposal to establish a Dental
Service may enable such inducements to be offered,
if all posts in it are reserved for those whose
qualifications are of the higher order; and qualified
medical practitioners may be induced to specialise
in dentistry with the prospect of combining with
public service the building up of a private dental
practice. In any case the Dental Service should
bring within the reach of the working classes
treatment such as in many districts has been out
of their reach hitherto, except as a matter of
charity.
— ■■ — » ■ — .
The Influenza Pandemic.
Last week at a north country petty sessions it
was stated that of 140 persons attending a local
dance 122 shortly fell victims to influenza in
acute form and 12 died. The recrudescence
of influenza in many parts of the country raises
public health problems such as this, and continues
to be a matter of grave concern to sanitary
authorities and their officials. A great deal of work
is being done by medical officers of health with
the view of limiting, so far as possible, the spread
of the disease, but our imperfect knowledge of the
epidemiology of influenza makes it difficult to
reach satisfactory conclusions on the value of the
many preventive measures suggested. We may
well hope that the investigation of a filter¬
passing virus initiated by the late Major H.
Graeme Gibson may soon lead to more accurate
knowledge of the morbific agent. Short of this
the position is well set forth in the Memorandum
recently issued by the Local Government Board
to which reference was made in a leading article
in The Lancet of March 1st. Two well-marked
waves of influenza have swept over the country
in the past few months and we are now in the
midst of a third. Opportunity is thus afforded for
study of certain characteristics of the malady which
are still obscure. The most important of these is the
question of immunity. It is important to ascertain,
for example, whether one attack confers immunity
against subsequent attacks, and, if so, how long
this acquired immunity may be expected to last.
Many observers affirm that those persons who
suffered from influenza in June and July of last
year escaped during the subsequent autumn
epidemic, or, if they were attacked, it was only in a
modified and very mild form; this they attribute
to immunity acquired as a result of the summer
attack of influenza. If sufficient facts and figures
could be adduced in favour of this hypothesis, it
would be a distinct advance on our present some¬
what hazy ideas on the matter. Further, with
the view of arriving at a conclusion concern¬
ing the length of time that this acquired
immunity—if there is such a thing—lasts, it
would be interesting to know whether the persons
who were attacked last summer but escaped
in autumn are, or are not, victims during the
present recrudescence of the disease. Any observa¬
tion on the length of the inoubation period and the
stage of illness at which a patient is most liable to
infect others would also be useful. Most health
officers are at present far too busy in striving to
combat influenza prevalence to be able to give
their impressions on the relative value of the
different preventive measures adopted, but when
the results of the experience gained during the
present pandemic are recorded they should form a
valuable guide as to the form whioh future adminis¬
trative measures should take.
The preventive measures employed abroad appear
to be on similar lines to those adopted in this
country. In America school closure was not
adopted in Chicago or New York, as the public
school system is regarded in these cities as one of
the most important factors in the control of disease.
A large number of the New York school children
come from the poorest areas of the city in which
the housing conditions are very bad, and for this
reason they are probably less likely to contract
infection at school than at home. The better
ventilated theatres were used as education centres
at which the public were instructed, during the
epidemic, on matters relating to health. It is
difficult to ascertain whether the wearing of masks
by the general population is as efficient a safeguard
as was at first supposed. Experiments on this
matter have, we understand, been tried in a number
of American cities, but there appears to be lack of
unanimity of opinion as to the practical value of
The Lancet,]
THE EUROPEAN FOOD SITUATION.
[March 8, 1919 387
the measure, though, where masks were worn by
nurses and others attending on the sick, they seem
to have afforded at least some degree of protection.
Experimental work should help in a matter of this
kind, and Dr. H. Mason Leete’s observations at the
Edinburgh City Hospital, recorded in another part
of our present issue, should be read in this con¬
nexion. In view of the overcrowded condition of
the London omnibuses, tramcars, and underground
trains at certain hours of the day, which has
probably facilitated the spread of influenza in the
metropolis, it is interesting to learn, that in New
York such overcrowding was prevented on the sub¬
way trains by an ingenious plan “ to stagger the
hours of travel,” by which it was arranged that
different business establishments in the city
should open and close at different hours, thus
preventing congestion of public conveyances of all
kinds.
The value of proper ventilation both in the pre¬
vention of infection and in the treatment of the
disease comes out in much of the recent literature.
In last week’s British Medical Journal Dr. Leonard
Hill, F.R.S., develops his well-known views on the
important influence for good exerted by cool air
upon the respiratory membrane. 1 To combat the
influenza infection he urges the deep breathing of
cool air. An editorial article in the last number
of the iNew York Medical Journal tells of certain
naval recruits who were so confident of the
immunity to catarrh conferred by their open-air
life that they submitted to spraying of the throat
and nose with live cultures of influenza—without
ill result. A less dramatic story with the same moral
is told in a recent issue of the American Journal
of Public Health , where Surgeon-General William
A. Brooks, of the Massachusetts State Guard, gives
an account of an outbreak of influenza which
occurred among the men on the ships connected
with the recruiting service of the Shipping Board
of East Boston. In order to accommodate the
large number of patients a “tent hospital” was
established on Corey Hill. Cold and wet
weather prevailed during the firfct few days
and the patients had, on this account, to be
confined to their tents, but thereafter, when¬
ever the weather was good, every patient was
removed from his tent into the open air, a
sufficient degree of warmth being maintained by
the use of hot-water bottles or heated bricks
wrapped in newspapers. The results achieved by
this method of treatment were excellent. Nearly
every patient had a lower temperature at night
than in the morning and felt decidedly more
comfortable. The charts of these patients clearly
demonstrated the great value of fresh air and
sunshine for patients suffering from influenza and
pneumonia. The number of cases treated was 351
and there were 35 deaths. In view of the fact that
only the most serious cases were moved from the
ships to the hospital, such a rate of fatality among
the hospital patients may be considered small.
Very few of the attendants and nurses contracted
the disease. It should be added that they all wore
improvised masks made from gravy strainers with
five layers of gauze basted on to the wire frame,
while every nurse was instructed to wash and
disinfect her hands before taking food. Opportunity
was afforded during this outbreak to observe the
incubation period of influenza, which was generally
about 48 hours. Exact information of necessity
accumulates slowly, but we may hope surely.
Jnitofatnrns.
"He quid nlmlB.”
THE EUROPEAN FOOD SITUATION.
A clear conception of the physical results pro¬
duced by the food blockade of the (late) Central
Empires may be gained from the report of a special
sitting of the combined medical societies of Berlin,
held on Dec. 18th last, which has just come into our
hands. The meeting was called by the council of
the Berlin Medical Association to hear a series of
statements upon the medical aspect of the food
question by representative physiologists, hospital
physicians, and medical men engaged in food
administration. Scarcity had begun already in the
middle of the year 1916, but careful press censor¬
ship kept the seriousness of the situation hidden
not only from the people at large, but from the
medical profession itself. Speakers at the meeting
recalled with a certain grim bitterness, not untinged
with admiration, how when starvation was already
killing off thousands of elderly folk and maiming
countless young lives the official press was con¬
gratulating the country on the advantages of
diminished body-weight, the gratifying freedom
from gout and eclampsia, and the high standard
of intellectual life. Rubner, who, as director
of the Physiological Institute in Berlin, may
be considered Germany’s chief authority on
nutrition, set the example at the meeting
of throwing off the reticence of years, and
detailed the results of a general confidential
inquiry into health conditions in the Federated
States forced upon the Imperial Government by its
expert food advisers during 1917. This inquiry,
he said, showed, “ to the surprise of all,” how far-
reaching the effects of the food blockade had
already become, how rapidly the death-rate was
rising, how widespread was the oedema and other
disorders of nutrition, how ^reat the emaciation
and reduction of working capacity among the
middle classes especially, and how alarming the
increase in the death-rate from tuberculosis. From
one hospital the bulletin ran briefly: “Our inmates
are all dead.” Among the living, he added, all spirit
of enterprise, all buoyancy of thought, were lost in
the general unproductive depression. The actual
number of deaths due to lack of food he set down
as in the neighbourhood of 800,000. Hamel, medical
expert to the Ministry of the Interior, completed
Rubner’s picture by giving comparative figures
derived from official sources!. Among children
from 1-5 years old the mortality in 1917 was
50 per cent, greater than -the 1913 norm, in
older children, from 5-15, it had risen 75 per cent.
In towns of over 15,000 inhabitants deaths from
tuberculosis during the first half of 1918 out¬
numbered the total for the year 1913. Other
speakers gave harrowing details without adding to
the gravity of the picture shown by the actual
figures. The report, which appears in abstract in
the Muenchener medizinische Wochenschrift of
Jan. 3rd, is reproduced at length in a Berlin
medical paper which has been translated by the
Fight the Famine Council, 1 and is obtained on
application to the honorary secretary at 4, Barton-
street, London, S.W. 1. The meeting terminated
with the adoption of a formal resolution calling on
the German Government to do their utmost to
1 The Lancet, 1913,1., 1291.
The Lancet, Feb. 22nd, p 306.
388 Tbk Lancet, J THE RECENT INCIDENCE OF SMALL-POX.
allot equitably the available foodstuffs, and con-
eluding: “We make appeal to the conscience of
the men of enemy peoples in whose breast the
sense of responsibility before the tribunal of
history is not stifled.”
THE RECENT INCIDENCE OF SMALL-POX.
Small-pox has recently appeared in different
parts of Britain. We understand that there were a
few cases in Scotland towards the close of last year,
8 cases being notified in Aberdeen, and 1, which
was probably infected in Aberdeen, in Fochabers in
Elginshire. Since the beginning of the year 29
oases have been notified in England. The disease
ooourred in January in the following sanitary
districts:—Metropolitan borough of Battersea, 3
cases; metropolitan borough of St. Pancras, 4 cases;
urban district of Benfleldside, in the county of
Durham, 5 cases; Lower Bebington urban district,
Cheshire, 3 cases; county borough of Bootle, 7 cases;
Rowley Regis, Staffordshire, 1 case; Liverpool,
1 case. The following districts were affected in
February:—Urban district of Wisbech, Isle of Ely,
3 cases; Hartlepool, 2 cases; rural district of
Flaxton, N. Riding of Yorks, 1 case. There has
thus been a wide topographical distribution of the
disease, although nothing as yet like epidemic
prevalence. Since a large proportion, especially of
the younger section of the community, is now
unprotected by vaccination, the recurrence of
small-pox will demand vigilance on the part of
the health authorities of this oountry.
SPIROCHETES IN TRENCH FEVER. j
It is just three years since McNee, Brunt, and
Renshaw proved the infectivity of the blood in
oases of trench fever. One year later, Riemer
described scanty spirochcetes in direct blood films
from cases of Volhynian fever, which is undoubtedly
the same disease. Later, in 1917, Nankivell and
Sundell observed and recorded spirochetes in the
urine of trench fever cases. The American Com¬
mission, under Strong, proclaimed that the virus of
trench fever is filterable, and a very recent paper
by Sir John Bradford and his colleagues seems to
oonfirm this. Arkwright and Duncan demonstrated
the constant presence, after a suitable time, of
minute bodies (Rickettsia bodies) in the gut and
excreta of lice fed upon trench fever patients.
These bodies were not found in healthy lice fed
upon healthy men, and their presence was correlated
to the virulence of the febrile attack. In this issue
Dr. A. C. Coles describes scanty spirochetes found
in the blood of trcnrch fever patients purposely
infected at Hampstead. The characters of the spiro¬
chetes agree on the whole with those described
by Riemer in 1917 and also, but to a lesser extent,
with those of Nankivell. Perhaps the most striking
common feature is the looping and intertwining to
which Riemer refers very distinctly. 1 Nankivell
did not remark this feature, and, on the other
hand, described a tapering end to his spirochete,
whereas Dr. Coles finds that his spirochete never
tapers. The question as to whether these various
findings have any common ground appears partly
solved by the possibility of the Rickettsia bodies
being of filterable size, and also by the very pertinent
fact to which Coles alludes—namely, that Noguchi
found that the spirochaste of Weil’s disease will
pass through a Berkefeld V filter. The investiga-
* See Tas Luicrr, 1917,1., 347.
[Makcb 8,1919
tion of the filterable virus requires a very special
technique, of whioh McNee and his colleagues do
not seem to have taken full advantage, as Edward
Hort, whose pioneer work in this connexion is
unique, pointed out, and it is quite possible that
all these investigations may eventually be merged
into a single life-history. Until such a consumma¬
tion is attained we can but place on record such
findings as those of Dr. Coles without, for. the
moment, attempting to evaluate them.
THE RESTORATION OF 8ERBIAN LIBRARIES.
What Serbia has suffered in destruction of
human life and property during the last four years
can never be accurately stated, but in one direction
the loss is precisely known and very detrimental to
the resumption of normal intellectual life. Serbian
libraries and printing presses seem to have been a
special object of enemy attentions, their efforts
to destroy the monuments of Serbia's ancient
civilisation and the future means of culture and
education in that country being extremely thorough.
The library contained in the University of Belgrade
was destroyed, together with the University itself,
during the bombardment of that city; the library
of the monastery of Dechani was pillaged; and we
may add to the list the library of Nish, the scien¬
tific library of Alexinatz, the theological library
of Prizren, and those of Sloplje and Kragujevatz.
Serbia's heroism has defeated the military purposes
of her enemies, but she will be largely dependent
upon her Allies for help in the re-establishment of
her literary needs. In another column of this issue
Lord Crewe makes an appeal on Serbia's behalf for
books of every kind, old or new. Many people in
this country will respond generously to Lord
Crewe’s appeal from a pure desire to help an unfor¬
tunate ally, and it may not unfairly be pointed out
that their gifts will promote the study of our
language and literature in a oountry where it has
hitherto been little known. The secretary of the
organisation for the restoration of Serbian Libraries,
which is being promoted by the Royal Society of
Literature, is Miss Waring, 2, Bloomsbury-square,
London, W.C. __
RADIUM TREATMENT OF EPITHELIOMA OF THE
LOWER LIP.
Thebe is considerable diversity of opinion as to
the value of radium in the treatment of the
different forms of malignant tumour. Some
enthusiastic advocates of the therapeutic pro¬
perties of radium contend that it is of use in
almost any form of superficial malignant tumour
or at any stage of the disease. The more con¬
servative, however, hold that, while radium is of
decided value in the treatment of certain
cancerous growths, its scope of utility is limited,
and, on the whole, its main value lies in its employ¬
ment as an adjunct to surgery. Epithelioma of
the lower lip is a form of cancer winch, perhaps,
best lends itself to treatment by radium.
In the International Journal of Surgery for
December, 1918, Dr. George Elliott, of Toronto,
discusses at some length the radium treatment of
epithelioma of the lower lip and the origin of such
growths. That chronic irritation from pipe-smoking
is a frequent or even an exciting cause he is
inolined to doubt, and statistics from the Depart¬
ment of the Registrar-General of Ontario^ were
quoted in support of this view. Recently in one
year in the Province of Ontario the figures relating
Ths Linear,] SURGICAL TREATMENT IN HYPERTROPHIC STENOSIS OF THE PYLORUS. [March 8, 1919 389
to deaths from cancer in all situations were
thns tabulated: Cancer and other malignant
tumours* of the buccal cavity, 94; of the stomach
and liver, 631; of the peritoneum, intestines, and
rectum, 263; of the female genital organs, 177; of
the breast, 126; of the skin, 26; of other organs
and organs not specified, 489. Of a total of 1806
classified deaths cancer of the buccal cavity and
of the skin is the only form that can be con¬
nected with smoking. Dr. Elliott points ’ out
that when from this total of 120 are eliminated
those in other situations than the lower lip
it will be readily appreciated upon what meagre
grounds cancer of the lower lip is regarded
as being associated with pipe-smoking. He holds
that for this form of epithelioma radium is the
treatment par excellence . From the cosmetic
standpoint alone it possesses the obvious advan¬
tages that there is little or no scarring; it causes
scarcely any pain; it appeals to the patient, who is
usually terrified at the idea of operation; and the
result of treatment, so far as can be judged at
present, seems to be permanent. Statistics
obtained direct from the Deputy Registrar-General
of Ontario, Colonel J. W. S. McCullough, show that
there has been a marked increase in the number
of deaths ‘from cancer and other malignant
tumours in nearly aU situations, especially in
the skin, whereas deaths from cancer and other
malignant tumours of the buccal cavity have only
increased by three. Dr. Elliott attributes the
increase of mortality from malignant growths of
the skin to the fact that treatment is postponed
until the condition is so serious that nothing is of
any avail. Radium to be successful must be em¬
ployed early, and, for obvious reasons, the treat¬
ment must have a wider range than the clinical
distribution of the lesion. Early diagnosis is
essential and there is little doubt that in
some superficial cases of malignant growths,
and especially, perhaps, of epithelioma of the
lower lip, radium treatment is indicated. Dr.
Elliott, in his paper, mentions several Cases of
epithelioma treated successfully by radium. In his
opinion the most important detail of treatment is
the careful regulation of the dosage, the correct¬
ness of which must depend upon the judgment of
each individual administrator. He considers that
physiological chemistry may some day solve the
problem of cancer, and suggests, as has been done
before, that this disease may be due to an aberrant
metabolic process in the chemical constituents of
the cell.
8URGICAL TREATMENT IN HYPERTROPHIC
STENOSIS OF THE PYLORUS.
Although it is now many years since hyper¬
trophic stenosis of the pylorus was first described,
opinions have ever been at variance whether the
condition should be treated by medical or by
surgical means. Dogmatism has been rife, but
the question remains undecided. Whilst some
authorities express themselves as convinced that
no proved case ever gets well by medical measures
alone, others do not resort to surgical treatment at
all, believing that without it the mortality is less.
This divergence of view is, no doubt, largely due to
varying nomenclature, for the successes of treat¬
ment by medical means are regarded by the
extremists of the other school as examples of faulty
diagnosis, and of confusion between congenital
hypertrophic stenosis of the pylorus and mere pyloric
spasm. A view intermediate between these two
extremes has been gaining ground in recent years
and has found frequent expression in the literature.
It is to the effect that actual obstruction of the
pyloric orifice by the hypertrophied muscular band
is comparatively rare and that spasm is the deter¬
mining factor. If the hypertrophy is slight there
is a good chance of success by medical treatment
alone, but when it is considerable surgery offers the
only chance of success. If this view be accepted
it becomes a matter of great importance to deoide
when an operation is needed and the optimum
time at which it should be performed. One of the
reasons which have led the physician to hesitate
before resorting to surgery has been his unwilling¬
ness to subject so small and feeble an infant, and
one so lacking in resistance, to the shock insepar¬
able from a severe operation. Speed and a
minimum of exposure and manipulation are very
desirable if shock, hitherto the commonest cause
of surgical failure in this condition, is to be avoided
or reduced. These desiderata would appear to be
attained in the operation devised by Rammstedt,
one frequently employed in the United States, but
hitherto little known in this country. It con¬
sists in the simple division of the hypertrophic
muscular band by an incision in the long axis of the
pylorus transverse to the muscular fibres without
interfering with the mucous membrane and without
closing the gap so formed by sutures. The whole
operation, including the initial incision of the
abdominal wall and its subsequent closure, occupies
only from five to seven minutes, and very little
manipulation is required. Another advantage is
that the normal condition of the alimentary canal
is restored. At a recent meeting of the Medical
Society of London, a report of which is included
in this issue, Mr. R. A. Ramsay described in detail
this operation as he had performed it on three
i occasions. Although few in number they illustrate
the reasonableness of the procedure and serve to
bring the operation to the notice of physicians and
I surgeons on this side of the Atlantic. Mr. Tyrrell
Gray, whose experience had been greater, said that
| it was quite in accord with the general conclusions
arrived at, and the opinion of these two finds,
perhaps, its greatest support in the work of
W. A. Downes, of New York, who, by substituting
Rammstedt's operation for gastro - enterostomy
reduced the mortality fQr the surgical treatment of
this condition at his hands from 43 to 24 per cent.
SENSATION AND THE CEREBRAL CORTEX.
A recent number of Brain contains a further
contribution by Dr. Henry Head to the subject
which he has made peculiarly his own—that of
sensation in its different phases at each and all of
the various levels of the central nervous system. 1
He has taken the opportunity of restating and
succinctly summarising the results of previous
investigations on sensation as it manifests itself
in lesions of the peripheral nerves and spinal cord.
The war has provided numerous chances of minute
examination of cortical and subcortical cases where
the lesion is small and localised on the main
sensory pathways or centres, and Dr. Head is thus
able to provide a remarkably complete review of
the whole subject, which on both theoretical and
practical sides is deserving of close attention. In
the lower levels of the nervous system affection
of certain sensory tracts produces strictly limited
1 Ths Lakobt, 1918, tt., 657.
390 The Lancet,]
THE LOWER UTERINE SEGMENT.
[Maboh 8,1919
alterations in sensation. In the cord dissocia¬
tion of sensibility—touch, for instance, being
appreciated, while sensibility to pain and
temperature is lost—is a common occurrence,
and the neurologist justifiably localises the
conduction of certain forms of sensation in
certain paths. In the peripheral nerves the specific
characters of deep and cutaneous sensibility are
demonstrable with ease where lesions disturbing
the conduction of one or other take place. With
the cortex, however, the position is of a quite
different nature. If the sensory pathway, with all
its anatomical and physiological complexities, is
regarded as simply a chain, with a receiving organ
at the periphery, a transmitting tract, and a dis¬
criminating organ at the cortex, the sensory con¬
ditions are not identical throughout the whole
mechanism. At the periphery, as Dr. Head says,
we see how a measurable physical stimulus is
transformed into various physiological reactions;
at the cortex we observe the ultimate condition of
these impulses, in the act of subserving sensation,
after they have undergone integration and selec¬
tion. It should thus be manifest that in cortical
lesions we have changes which can be expressed
in psychical terms only. These changes are,
according to the results of the researches detailed
in this paper, definite loss of power to recognise
spatial relationships, graduated intensity, and
similarity or difference in objects in contact with
the body. Otherwise expressed, the cortex, speak¬
ing always from the sensory viewpoint, is much
less concerned with the direct appreciation of
crude sensory stimuli of whatever order than with
discrimination of the triple type just mentioned.
It is in the reactions of the optic thalamus, freed
from cortical control, that the non-discriminative
aspects of sensation find their expression.
In this ingenious way Dr. Head endeavours to
bring into line what on the sensory side corre¬
sponds to the more familiar facts of experimental
physiology $s evidenced on the motor side. We
owe more especially to the genius of Hughlings
Jackson and of Sherrington the hypothesis, and its
proof, of the existence of two motor mechanisms
in mammals, or, rather, of a primitive motor
mechanism subsequently controlled from higher,
cortical, areas, but nevertheless still existing and
oapable, in certain circumstances, of manifesting
its independence. Removal of cortical control
allows mesencephalo-spinal motor mechanisms
fuller play. With the details of these phenomena
we are not here concerned, but of the general
statement there can be no doubt. Analogously,
according to Dr. Head, removal of cortical sensory
control allows lower sensory mechanisms to
assert themselves, mechanisms which, apparently
abolished, nevertheless exist and are capable of
independent activity. This is, of course, but
a very incomplete statement of the facts, though
for the sake of emphasising the idea of cortical
sensory control, as opposed to mere appreciation, it
is well to strip, for the moment, the main con¬
ception of its accessories. At all physiological
levels of the nervous system sensory integration is
taking place. Stimuli of varying kinds compete
simultaneously for peripheral receptors. Many
impulses arising thus, by selection, in end-organs do
not, as a fact, traverse completely the sensory path¬
ways to the cortex, but are turned aside at lower
levels into reflex paths and never, ordinarily, reach
consciousness to become “ sensations.” Others,
however, reach the optic thalamus and the cortex;
in the case of the former, they excite conditions
underlying the affective aspects of sensation; in
the case of the latter, the discriminative aspects.
In a word, selection, rejection, and adaptation are
constantly taking place; only the sum is presented
to consciousness. Dr. Head holds that on the
higher physiological planes impulses precluded
from exciting sensation are not necessarily wiped
out; they may produce a profound and manifest
effect, although they cannot excite consciousness.
THE LOWER UTERINE SEGMENT.
The lower uterine segment has been a source of
contention among anatomists and obstetricians
for many years past and an immense amount of
literature bearing on the subject has been pub¬
lished. The question is by no means settled, and
from time to time papers are written by adherents
of the two main theories adding further testi¬
mony in favour of their particular view. The
real problem, put shortly, is, Doe? any part of the
cervix take a share in the formation of the lower part
of the body of the uterus during pregnancy or does
it not? Many of the earlier authorities believed
that towards the end of pregnancy the upper part
of the cervix became taken up and <Tontributed to
the formation of the uterine cavity, so that the
internal os was situated at a much higher level
relatively than in the non-pregnant uterus. Another
point which arises from this is the exact anatomical
situation of the so-called ring of Bandl or the
retraction ring. Does this represent the junction
of the upper and lower uterine segments, or is it
the upwardly displaced internal os ? At the present
time the great majority of anatomists and obstet¬
ricians, we believe, follow the teaching of Barbour,
and hold the former view rather than the
latter. At the same time the question is by no
means settled, for so recently as 1907 a drawing of
a new frozen section was published which appeared
to lend great support to the view that the
whole 'of the lower uterine segment is developed
from the cervix. In the present number of
The Lancet we publish a paper by Professor
Hastings Tweedy, in which he suggests that the
thickened fibro-muscular bands in the pelvio
diaphragm, which hitherto have been called tbfe
transverse ligament of the cervix, or Macken-
rodt’s ligament, should be termed the tendons of
the uterus. He cannot conceive of this tissue as
forming an imperfect diaphragm across the pelvic
floor, as he maintains if this were the case it must
inevitably be torn to such a degree in parturition
that it could never regain its original continuity.
It appears to us that the question of its ability
to stretch rather than to tear would depend upon
the relative amounts of muscle and fibrous tissue
present, and we see no insuperable difficulty in
believing that softened fibrous tissue could yield
sufficiently and not tear during labour. The lower
uterine segment, he holds, is formed by a growth,
and not by a mere stretching of pre-existing tissue,
and he adds that it is impossible to account for
its presence by any other explanation. With this
statement most authorities would agree, and there
would seem to be no difficulty in believing that
the lower part of the uterus grows, just as does
the upper part, during the progress of a pregnancy.
Whether the growth is due to the pressure of the
foBtus or to the stimulus to growth of the pelvic
tissues, which is one of the consequences of
pregnancy, does not appear to be very material.
The Lanoit,]
THE 8UPPLY OP MEDICAL 8TUDENT8.
[March 8,1919 391
Professor Tweedy further maintains that it is
wrong to regard the cervix as consisting of tissue
prone to stretch, and adduces as an argument in
favour of this assertion the hypertrophy of the
cervix which takes place in procidentia uteri. It is
easy, however, to demonstrate on any well-marked
case of procidentia uteri that the accompanying
elongation of the uterine cavity is due primarily to
stretching, and that the permanent elongation
which eventually occurs is a later phenomenon.
Professor Tweegy believes that when pregnancy
occurs the internal os opens and the ovum finds
room for its growth in the upper region of the
cervix, so that he is an upholder of the view that
the lower uterine segment is really derived from
the cervix. This view, of course, may turn out ulti¬
mately to be the correct one ; at present the matter
can only be regarded as non-proven. We do not,
however, think that the arguments put forward by
the author of this paper would be sufficient to
cause those obstetricians to change their opinions
who hold that the lower uterine segment develops
with the rest of the uterine cavity in the very
remarkable growth which occurs during pregnancy.
THE SUPPLY OF MEDICAL STUDENTS.
We have received from the General Medical
Council the following statement giving the number
of medical students in actual attendance on courses
of professional instruction in January of the present
year, for each period of the curriculum:—
First
Second
Third
Fourth
Final
Topical distribution.
year.
year.
year.
year.
year.
M.
W.
M. | W.
M. | W.
M.
W.
M.
W..
England and Wales
1069
350
700 326
4M j 291
354
141
428
108
8ooiland .
617
293
483 306
3X210
252
156
333
108
Ireland . .
446
112
336 125
40(! 92
339
64
176
10
Total .
2152
765
1579 767
U86j 593
946
361
936
226
M, men. W, women.
The totals for the several areas in the order given
are 4238, 3093, and 2159, with a grand total of
9490, of whom 6798 are men and 2692 women.
The figures should be compared with those for May
of last year which appeared in The Lancet of
July 27th, 1918 (p. 113). The gran.d total of medical
Btudents has received a quite astonishing addition
in the last six months, as will be seen from the
following summary:—
Total Medical Students in Attendance.
January, 1917 ... 6682 . May, 1918 . 7630
October, 1917 ... 7048 . January, 1919 ... 9490
Evidently nothing has occurred to make the pro¬
fession of medicine less attractive as a career in
the eyes of parents and their adolescent children.
The numbers of women entering on a medical
career are still increasing, but their ratio to men
students has diminished in consequence of the
very large influx of the latter in the last six months.
THE BRITISH PSYCHOLOGICAL SOCIETY.
The constitution of this society has received an
important emendation in the admission of persons
not actually engaged in psychological work. At a
special general meeting held in London on Feb. 19th
it was unanimously resolved to admit others
interested in the various branches of psychology,
and to institute three special sections, devoted
respectively to the educational, industrial, and
medical aspects. Further particulars of this
interesting development may be obtained from the
honorary secretary of the British Psychological
Society, the Psychological Laboratory, University
College, London, W.C. 1.
The Governors of the London Hospital decided
on Wednesday last to fill the vacancies on the
honorary medical staff, left by the retirement of
Dr. F. J. Smith and Dr. Henry Head, with whole¬
time paid officers, consisting in each case of
director, three clinical assistants, with laboratory
and clerical staff.
Dr. Addison, President of the Local Government
Board, has appointed Miss Janet Mary Campbell,
M.D., M.S., to be a medical officer of the Board in
special charge of the work of the Board in respect
of maternity and child welfare.
The following lectures will be delivered at the
Royal College of Physicians of London, Pall Mall
East, on Tuesdays and Thursdays in March and
April, at 5 o’clock:—Milroy Lectures: Dr. John C.
McVail (March 13th, 18th, 20th), “ Half a Century of
Small-pox and Vaccination ”; Goulstonian Lectures:
Dr. W. W. C. Topley (March 25th, 27th, April 1st),
“The Spread of Bacterial Infection"; Lumleian
Lectures : Sir Humphry Rolleston (April 3rd, 8th,
10th), “ Cerebro spinal Fever."
A conference on Post-war Developments relating
to Public Health has been arranged by the Royal
Sanitary Institute for March 13th-15th, to be held
at 90, Buckingham Palace-road, London, S.W. 1.
Among the subjects on the programme are: City
Hygiene in Relation to Employment, to be intro¬
duced by Dr. W. J. Howarth; the Public Health
Aspect of Tuberculosis, by Dr. Noel D. Bardswell;
Public Health Propaganda and Social Work, by
Professor H.R.Kenwood; Welfare Work in Factories,
by Dr. Edgar L. Collis; and Child-Welfare Work, by
Dr. Flora Shepherd.
URBAN VITAL STATISTICS.
(Week ended March 1st, 1919.)
English and Welsh Towns.—In the 96 English and Welsh towns,
with an aggregate civil population estimated at 16,500.000 persons, the
annual rate of mortality, which, hid increased from 15*0 to 35*7 in the
five preceding wreks, wav again 35*7 per 1000. In London, with a
population slightly exceeding 4,000.000 persons, the annual death-rate
was 32*4, or 1*8 per 1000 below that recorded in the previous week;
among the remaining towns the rates ranged from 13*0 In Coventry,
16 3 in Grimsby, and 16*6 in Gillingham, to 56*0 In Salford, 66 1 in
Tvnemouth, 62‘1 in Wakefield, 65*6 In St. Helens, and 66*7 in
Blackburn. The principal epidcmlo diseases caused 200 deaths,
which corresponded to an annual rate of 0*6 per 1000, and
included 51 from whooping-cough, 48 from measles, 47 from
Infantile diarrhoea, 38 from diphtheria, 12 from scarlet fever, and
4 from enteric fever. Measles caused a death-rate of 1*3 in Sheffield
and in Middlesbrough, 1*5 in Warrington, and 4*0 in Rotherham ; and
whooping-cough of 1*7 in Wolverhampton, 1*9 in Stoke-on-Trent. 2*0
in Rhondda, and 2*3 in Great Yarmouth. The deaths attributed to
influenza, which had increased from 224 to 3054 in the five preceding
weeks, further rose to 3889, and Included 808 in London, 196 In
Liverpool and in Mancbenter, 159 in Birmingham, 130 in Leeds. 129
in Bradford, 96 In 8&lford. 94 in Newcastle-nn-Tyne, and 90 in Leioester.
There were 1095 cases of scarlet fever and 1172 ot diphtheria under treat¬
ment In the Metrooolitan Aayluma Hospitals and the London Fever
Hospital, against 1088 and 1185 respectively at the end of the previous
week. The causes of 81 deaths in the 96 towns were uncertified, of
which 15 were registered in Birmingham, 12 in Liverpool, 7 in Man¬
chester, and 6 in Gateshead.
Scotch Towns. —In the 16 largest Scotch towns, with an aggregate
population estimated at nearly 2,500,000 persons, the annual rate of
mortality, which had Increased from 17*0 to 38*4 In the six preceding
weeks, further rose to 40 0 per 1000. The deaths from Influenza
numbered 78, while in 618 deaths classified as due to other conditions
influenza was a contributory cause; in the previous week these
numbers were 75 and 5o3 respectively. The 1037 deaths in Glasgow
corresponded to an annual rate ol 48*3 per 1000, and inoludea 37
from whooping-oougb, 9 irotn measles, 4 from diphtheria, 2 from
scarlet fever, and 1 irom infantile diarrntea. The £#S deaths in Edin¬
burgh were equal to a rate of 41*2 per 1000, and included 9 from
whooping-cough, and 2 each from soarlet fever and diphtheria.
392 Tub Lancet,] DR. H. MASON LEETE : SOME EXPERIMENTS ON MASKS.
[March a, 1919
SOME EXPERIMENTS ON MASKS.
By H. Mason Leete, M.B., B.S., B.Hy.Dubh.,
M.R.C.S., L.R.C.P. Lond., D.P.H.,
8KJTI0B MEDICAL iMIlTAR 1VD B ACTEBIOLOOIST, CITY
HOSPITAL, KDIHBCJBGH.
The third wave of the influenza epidemic finds os with no
settled ideas as to the use of masks as one of the preventive
measures in dealing with this disease. The lay press dis¬
cusses whether or no they should be worn, and there is little
wonder that opinion is diveigent when one finds opposite
views as to their efficiency given by medical authorities
themselves.
At the time of writing we have in this hospital three
pavilions set aside for inflaenza patients, and among the
staff attending these patients cases, some serious ones, are
constantly cropping np. Any hospital dealing with the
disease mast have to face a similar problem and mast be
anxioas to protect its staff in the best manner possible, and
the question of the use of masks arises. But if masks are to be
worn they mast be efficient ones, and the simple ex *eri-
ments described are attempts to test the efficacy of mask
protection and to form some opinion as to their value from
the bacteriological point of view.
Account of the Experiments.
Infection, whatever precise form it may be, comes from
the patient in the form of droplets of moisture from his
mouth and nose. In coughing and sneezing these droplets
are expelled with considerable velocity for some distance
from the patient, and in this manner those in close contact
with him are undoubtedly infected. In order to reproduce
this moisture distributidh method, and to give such droplets
a definite velocity, we prepare an emulsion of Staphylococcus
pyogenes aureus and project this in the form of a fine spray
from an ordinary De Villbiss Atomiser No. 16, fixed at a
given distance from a Petri dish upon which the inoculum
was received. In most of our experiments this distance was
9 inches, and as this particular atomiser will give a definite
visible spray for a distance of 3 feet it is obvious that at
9 inches distance the particles will possess a considerable
velocity.
The emulsion of staphylooocous used was standardised to
contain approximately 1000 million organisms per cubic
centimetre. The staphylococcus was chosen because it is
easily cultivated, easily emulsified, does not die out readily,
has distinctive definite colonies which show up early, and
being comparatively harmless its projection in the laboratory
in spray form has not the dangers which other organisms
might have. Here, again, it must be pointed out that we are
not dealing with inflaenzal infection from the standpoint of
the specific organism concerned, but are merely investigating
the carriage of living organisms contained in minute droplets
and the powers certain materials have of arresting the
progress of these infected droplets.
The material used in the first series of experiments was
ordinary non-medicated surgical gauze such as is commonly
used for dressings. This is a wide-meshed gauze which in
the rolls in which it is sold has already been folded on itself
three or four times. As this folding, however, is uneven aod
we require a standard thickness from which to work in all
our experiments, we opened out the gauze to its full extent
and the single layer of gauze so obtained is our standard—
this doubled is a two-layer gauze, and so on. Reckoning on
this plan the gauze as it comes in the package is a four-layer
gauze though, as stated, uneven. The gauze in various
layers was simply fastened across the open Petri dish and
was thus but a distance of 1*5 cm. from the medium which
it was protecting. The movable nozzle of the atomiser was
directed towards the centre of the dish, which was held
vertically, looking towards the atomiser at a distance of
9 inches. Two quick complete compressions of the bulb
were then given, and the plate which had thus been “ fired
at ” was immediately covered and incubated. Twelve
hours later the number of yellow staphylococcal oolonies
was counted and rec -rded.
In some cases where two plates incubated under the same
conditions showed any marked divergence in the number of
colonies we tested a series of plates and took the average
number of colonies as our number for that particular plate
and protection, though for convenience they are here
recorded as single plates. Where our two original plates
showed approximately the same number of oolonies that
number was accepted and a series and average not made.
Remits of Experiments .
Table I. shows the results in the first series, which are
rather surprising, inasmuoh as such a considerable number
of layers fail to prevent transmission. This is undoubtedly
due to the gauze being of a very open weave.
1. Surgical Gauze ; Dry. II.— Muslin ; Dry .
Plate
No.
Protection.
Colonies.*
Protection.
Colonies.*
1
Nil.
Confluent growth.
Counting Impossible.
2 layers.
4300
2
2 layers.
17.500
4 ,.
1400
3
4 „
4.200,
6 „
100
4
8 .,
2,000
8 „
40
5
12 "
700
10
Nil.
Working distances inches. * Approximate number of oolonise per plate.
In our second series of experiments (see Table II.) we
used ordinary butter-muslin as the protecting material, the
organisms, distance, and spraying method being exactly as
before. The muslin was a fairly fine one, having 24 threads
to the centimetre.
Our next modification consisted of using a muslin thick¬
ness of fairly permeable qualities as already ascertained, and
varying the distance of the spray. For this we chose a four-
layer muslin protection, and the average results are given in
Table UK. We then tried the effect of damping the muslin
III.— Muslin*; Dry. IV.—Muslin*; Damp. V.—Coarse spray .t
Plate
No.
Working
distanoe.
Colonies
per plate.
Working
distance.
Colonies
per plate.
Protec¬
tion.
Colonies
per plate.
1
12 in.
88
9 in.
2000
4 layers.
360
2
18 „
14
12
268
6 ..
230
3
24 „ !
7
18 „
127
8 ..
50
* Four layers, t Muslin; dry. Working distanoe 9 inohes.
by soaking the mask in water and then wringing it well out
(Table IV.). Finally, we modified the spray from the fine
atomiser effects used throughout. In this last series a much
coarser spray was used, this result being brought about by
closing the normal air-escape hole with which this particular
atomiser is provided. Taking a distance of 9 inohes and
using various layers of dry muslin our plates (Table V.)
showed that a fine spray has greater penetrative powers
than a coarse one, despite the greater momentum of the
heavier particles.
Conclusions.
When the conclusions deduced from this series of experi¬
ments come to be applied to the practical question of mask
wearing it is obvioas that certain modifying factors must be
taken into account. The force of our spray working at a
distance of 9 inches is undoubtedly much greater than that
produced by even vigorous sneezing or coughing by a patient.
Such a distance was chosen in order to get a series of
positive results and to provide a large margin of safety. On
the other hand the negative pressure produced by suction
during inspiration by the wearer of the mask and amounting
in practice to an increase of the projeotive force from the
patient has to be borne in mind. Then our orgauism
content of the spray is high, but here it must be urged that
the question is rather one of whether organisms oan pass
than as to how many actually pass.
Several points are being further inquired into and other
modifications devised, but basing our remarks on the experi¬
ments so far performed, it would seem that:—
1. Surgical gauze is an unsatisfactory material for making
masks.
2. Butter-muslin is a more satisfactory material and has
the advantage that it is easily obtained anywhere. Masks
made of it should consist of at least four layers.
3. Damping the mask has the effect of considerably
increasing the permeability and this fact should be borne
in mind when masks have to be worn for any length of time.
4. Sach a mask is not absolutely protective from droplet
i infection but materially reduces the risk and as such is of
i practical value.
The Lancet,]
MR. F. T. MARCHANT: PROPHYLAXIS IN INFLUENZA.
[March 8 ( 1919 393
5. A really protective mask would have to oonsist of six
or eight layers of muslin or similar material and would need
to be attached in an air-tight manner by means of an elastic
band gripping all round the head and fitted with air-tight
eye-pieces very much after the manner of the gas-mask in
use in the Army. As it is not likely that such a form would
ever become popular, the ordinary mask must be made as
large as possible, come up to just under the eyes above and
almost down on to the neck below, and be held in position
fairly tightly by elastic or tapes above the ears and round
the neck, thus decreasing as far as possible ‘ ‘ round the
corner ” infection.
6. It is only necessary to wear suoh masks in the immediate
vicinity of the patient.
7. Their application is suitable in any disease where the
infection appears to be conveyed by air-borne droplets ooming
from the patient.
I have to thank my colleague, Dr. R. J. M. Home, for
suggestions and assistance in carrying out the experiments.
PROPHYLAXIS IN INFLUENZA. 1
By F. T. March ant, M.RSan.I.,
▲S 810 TAXT DXXOBSTRATOR, PUBLIC HEALTH DEPARTMEHT, UjriTXBSITY
COLLEGE, LOHPOS.
As is well known, the foci of infection in this disease are
the upper respiratory passages. It is for this reason that
nasal and throat washes are recommended as a simple
expedient to keep the nose, naso-pharynx, and fauces clean.
Although probably efficacious if properly performed, their
use involves trouble and difficulty with some adults and
most children, and this tells against their employment.
Daring epidemic prevalence the odours which greet us
everywhere indicate the faith which the people have in some¬
thing which makes its presence distinctly evident. The
psychological effect is unquestionably valuable as a combative
measure ; but it is desirable to ascertain if there really is a
germicidal value in the emanations from these essential oils.
To test this the surface of the agar in several plates was
smeared with coli broth, then covers were applied and the j
plates inverted. A drop of the oil was next placed in what
is now the bottom of the plate, but which was previously the
lid, so that only the volatilised material came in contaot with
the inoculated agar above it. The plates were then incubated
for 24 hours at 37° 0. The results were as follows :—
OU of aniseed . Oil of oinnnmon
i, •« doves . and olovee .
,, „ eoonlyptua >M Alcoholic eolation
Menthol . A growth of aniseed, doves. No growth
Camphor . cinnamon, and for-
Aloonol alone .« ... malln .
Control... m. h. ... Formalin alone... • „. .
It will be seen from these results that oil of cinnamon
presumably destroys, or at least inhibits, the growth of the
organism. The same, of course, applies to the formalin. The
germicidal power of formio aldehyde is generally recognised.
Incidentally it has found a footing in the form of compressed
tablets whioh are in great demand for throat infections; but
owing to the irritation which they may produce their employ¬
ment is restricted. I find that cinnamon not only masks
the irritating effect of the formalin when the mixture is in
suitable proportion, but that a decidedly pleasant mixture
results whioh has a greater germicidal effect than the formic
aldehyde alone. The oil and the formalin mix readily in
alcohol or methylated spirit, making a very clear amber solu¬
tion. Various amounts of each were added to alcohol, and I
concluded that 120 drops of the oil and 60 drops of formalin to
the ounce of alcohol furnished the most satisfactory results.
If a few drops of this mixture be placed on a handkerchief
the alcohol quickly evaporates, leaving a very pleasant odour
with no appreciable irritation from the formalin. The
germicidal power of this mixture was determined as follows :
Five agar plates were prepared in the manner already
indicated. Two drops of the mixture were placed in four of
these, the fifth acting as a control. At the end of half-an-
hour the lid (now lower part) of one of the four plates was
replaced by a clean one, so that the organism was acted
upon by the volatile oil for 30 minutes only. In a similar
1 The Investigation was undertaken at the suggestion of Professor
H. B. Kenwood, M.O.H., Stoke Newington.
manner the organisms in the second and third plates were
acted upon for 1 hour and 14 hours respectively. The
following resultB were obtained after incubation for
24 hours:—
Organism exposed for half an hoar . No growth.
„ one hour. „
„ „ one and a half hoars ... „
Control. A growth.
Next, similar tests were performed to see if the formalin
usefully enhanced the proven power of the cinnamon and,
further, to ascertain what was the shortest time of effective
exposure. Two solutions were used, one containing to the
ounce of alcohol 120 minims of cinnamon, and the other
120 minims of cinnamon with 60 minims of formalin. The
results were:—
Cinnamon alone. Cinnamon and formalin.
6 minutes’ exposure ... A growth. A growth.
10 „ . .. . No growth.
15 ,, ,* ••• .i ......... ,,
In order to imitate the conditions under which the
mixture would actually be used four drops of the mixture
were applied to a square inoh of clean linen, which was
placed in the bottom of each plate. The last described
experiment was then repeated with the same results of
absence of growth after 10 minutes’ exposure. In order to
prove that the organism was destroyed and its growth not
merely inhibited sterile broth was poured on to the agar in
the plate, which was then incubated at 37° 0. for 24 hours.
The broth remained clear, proving that no coli organism was
living. Therefore, it seems safe to conclude that an
alcoholic solution of oil of cinnamon and formalin of the
strength indicated is capable by its emanations of destroying
the coli organism after an exposure of 10 minutes, and this
being so, we may infer that the influenza organisms wonld
also be destroyed. There can be little doubt that this
mixture applied liberally to handkerchiefs and so inhaled
would prove a useful prophylactic measure. I would like to
emphasise the fact that the emanations would permeate the
whole of the respiratory tract, thereby reaching parts that an
ordinary gargle, or even a throat lozenge, cannot possibly
reach. Moreover, the dissolved lozenge is swallowed, and
this sometimes leads to gastro-intestinal disturbances.
THE POST-GRADUATE ASSOCIATION:
SCHEME FOR POST-GRADUATE MEDICAL EDUCA¬
TION APPROVED BY THE LONDON MEDICAL
SCHOOLS.
A scheme of post-graduate medioal education, advanced
by representatives of post-graduate schools and special
hospitals in London, has now reaohed the stage of a final
draft. This draft is returning to the individual bodies for
their approval, after which a public meeting will be held,
probably some time in April, to place the whole organisation
on an early working basis.
The scheme begins by a general statement of objects. A
post-graduate scheme is obviously required to meet the needs
of these classes: Practitioners who wish to use any oppor¬
tunity, such as that afforded by a holiday, to bring their
knowledge up to date or to learn the details of some
specialism ; Officers of the Navy, Army, Air Force, Indian,
and Colonial Medical Services, often far removed from
scientific centres in their daily work ; Graduates from the
Colonies, from such Allied countries as France and Japan,
and perhaps especially from America, who have hitherto
taken out post-graduate courses in Germany and Austria
because no like facilities were offered in Great Britain.
This sort of assistance has been asked for by the Japanese
and it Is believed that it will be welcomed by the French.
The final draft scheme provides for the cooperation of
America and France through the recently organised
American Post-Graduate Union and the Committee of the
Soci6'6 M6dicale des Hdpitaux de Paris on •* Medical
Education in the Hospitals for Foreigners.”
Scheme for General and Special Pott-Graduate Courset.
The draft scheme provides for general and special post¬
graduate courses in the existent London medioal schools
where medioal ednoation for students is provided. It is
suggested that each sohool should provide two courses of
post-graduate teaching, each of a fortnight’s duration, or
394 The Lancet,]
MINISTRY OF HEALTH BILL.
[Mabgh 8,1919
one coarse of a month’s duration, the dates varying in
accordance with the convenience of the institutions and
conforming to a definite rota. The ordinary instruction of
the medical student will not be interfered with. The teachers
at each school will suggest what courses they are prepared
to institute, and will draw up a programme of details. At
each school also courses in some special subject will be
arranged, pasting usually for not less than three months,
where research work will be invited, and where those follow¬
ing the course may act as clinical assistants to the physician
or surgeon in charge of the particular subject. All the post¬
graduate students, moreover, will be afforded facilities to
attend the ordinary hospital practice.
Existing London post-graduate schools and special hos¬
pitals will continue the instruction they are already giving
in unison with the general scheme, but with such time limits
as they may choose; while the medical schools of the
United Kingdom—provincial, Scottish, and Irish—will be
invited to cooperate with the London Association in providing
periodical courses of instruction.
The Central Organisation.
The Council of the Post-Graduate Association will consist
of representatives of all participating teaching institutions,
as well as of representatives of the Board of Education,
National Insurance Commission, and analogous bodies in the
Overseas Dominions and the United States of America. The
constitution of the Association will be framed so as to enable
the holding of property and the receiving of grants from the
Board of Education. The Council will appoint an executive
committee and administrative committees, which bodies in
their turn will be responsible for the appointment of whole¬
time officers and secretarial staff. The home of the Associa¬
tion will be a building in central London, which it is hoped
will beoome the meeting place of the medical graduates of
the Empire and Allied Nations.
finance.
It is hoped that sufficient money will be forthcoming to
provide from private donations for the erection and equip¬
ment of the building and some endowment for its annual
maintenance. Every student will pay a registration fee in
addition to fees for instruction. The income of the Associa¬
tion will thus be derived from registration fees, fees for
courses, personal gifts, and Government grants. It is
proposed to apply to the Board of Education for a grant to
make the Association self-supporting. The participating
schools would be under no financial liabilities, while any
grants from the Board of Education will be paid to the
Association, the constituent schools being only responsible
to the Association for the instruction undertaken. The
Executive Committee will decide the fees in consultation
with the individual sohools, and eaoh participating school
will undertake to give no organised post-graduate courses,
save for ex a mi nat ion purposes, independently of the central
organisation.
MINISTRY OF HEALTH BILL;
VIEWS OF THE BOGIE IT OF MEDICAL OFFICERS
OF HEALTH.
The Society of Medical Officers of Health have had under
consideration the Ministry of Health BUI introduced into the
House of Commons on Nov. 7th. 1918, and have prepared
the following Memorandum, to which they are inviting the
attention of the local sanitary authorities. As the new Bill,
Introduced on Feb. 17th, is practically identical with the
earlier one referred to above, the Society of Medical
Officers of Health suggest that it would serve a useful
purpose if the councils of the authorities communicated the
result of their deliberations to the Member or Members of
Parliament for the borough or division at an early date.
Ministry of Health Bill, 1918.
Thfa Memorandum wae approved on behalf of the Societi
of Medical Officers of Health by the Council at a meetini
? eld u PP® r Montague-street, Russell-square, W.C., or
Jan* 17th.
The Society of Medical Officers of Health have urged fro
time to time the need for the establishment of a Ministry
Health. They note with satisfaction that a Bill has be<
t? tr ? d ,- ac ® d 10 e8tabllsb » Ministry of Health and a Board <
Health to exercise in England and Wales, and in 8cotlan
respectively, powers with respect to health and local gover
ment, and for purposes oonneoted therewith. They especially
approve of Clause 2 of the Bill, which makes it the duty of
the Minister of Health to take all such steps as mty be
desirable to secure the effective carrying out and coordina¬
tion of measures conducive to the health of the people,
including measures for the prevention and oure of diseases,
the treatment of physical and mental defects, the collection
and preparation of information and statistics relating
thereto, and the training of persons in health service.
The Society of Medical Officers of Health consider that
Clause 3 of the Bill dealing with the transfer of powers to
and from the Ministry of Health in unsatisfactory.
In the first place this clause encumbers the Minister at the
outset with matters outside the scope of national health,
notably those powers and duties of Insurance Commissioners
which are not strictly relative to health.
in the second place this olause does not transfer to the
Minister at once certain fundamental health matters each
as— (a) the powers and duties of the Board of Education with
respect to the medical inspection and treatment of children
ana young persons; (ft) the powers and duties of the Minister
of Pensions with respect to the health of disabled officers
and men after they have left the service; and (c) the powers
and duties of the Secretary of State udder the Lunacy Acts,
1890 to 1911, and the Mental Deficiency Act, 1913.
In the third place this clause transfers to another body,
the Privy Counoil, work for whioh the Minister of Health
should be responsible, namely, the duties heretofore
performed by the Medical Research Committee.
Lastly, this clause omits all reference—and there is no
reference in the Bill—to the transference to the Minister of
certain other fundamental health matters, for example, the
health functions of (1) the Home Office, including the
Banitary conditions of factories, the investigation and
prevention of industrial diseases, the work of certifying
factory surgeons, and the oare of patients under the
Inebriates Acts; (2) the Board of Trade as regards the
health of seamen and emigrants; (3) the Board of Agri¬
culture and Fisheries as regards certain dairy and farm
produce important as affecting national health; (4) the
Privy Council as regards the General Medical Council,
which oontrols the training and conduct of medical practi¬
tioners, and the Pharmaceutical 8ociety with similar powen
relative to chemists under the Pharmacy Acts.
The Society of Medical Officers of Health are of opinion
that the consultative councils to be set up under Clause 4 of
the Bill should report to the Minister through a health
council which should be established under the Bill, so that
the survey of national health maybe balanced, comprehen¬
sive, and continuous, and the coordination of the work of the
Ministry real and complete.
Generally the Society of Medical Officers of Health are of
opinion that any Bill for the establishment of a Ministry of
Health should be founded on the following basic principles:
that health is a matter of national ooncern rather than of
sectional or vested interests; that the functions of the
Ministry to be created must be to protect, maintain, and
improve the health of the nation as a whole and of every
unit of the nation in particular, regardless of age, sex,
occupation, the disease contracted, poverty, or insurance;
that to attain this end and secure and oomplete the central
organisation the Ministry of Health must from the outset
assume oontrol of all the health functions of existing central
departments; that a Ministry of Health will be in a large
measure ineffective unless there are established suitable
areas for local health administration with one local health
authority in each area responsible for all health matters.
In the opinion of the Society of Medical Officers of Health
a Bill not based on these principles, or based only on some
of these principles, is doomed in administration to failure,
complete or partial. The Memorandum is signed on behalf
of the Society of Medical Officers of Health, by order of the
Council, by Professor Henry R. Kenwood, President, and
Dr. Joseph Priestley and Mr. T. W. Naylor Barlow, the
honorary secretaries of the Society.
St. Andrew’s Hospital, Dollis Hill.— This
institution, which has just issued its sixth annual report,
was opened in 1913 at Dollis Hill for the reoeption of patients
who, while not suitable subjects for free treatment in
charitable institutions, are unable to meet the charges
necessary to secure adequate medical or surgical treatment
in private nursing homes. Daring the war it has been
used for the treatment of soldiers and sailors, but when the
beds are surrendered by the military authorities the hospital
will resume the work for which it was founded. The report
for 1918 shows a deficit of about £40 on the year’s working,
while the building debt amounts to £5524. Aiditional
expenses will be incurred in restoring the war<s to their
pre-war use, and an appeal is being made for contributions
to wipe out the debt and to provide a permanent endowment
for the hospital.
TH! UNO**,]
SOUTH AFRICA.— OBITUARY.
[March 8, 1919 395
SOUTH AFRICA.
(From our own Correspondent.)
The Influenza Mortality in South Africa.
In the Union House of Assembly at Cape Town on
Jan. 23rd the Minister for the Interior, Sir Thomas Watt,
stated that the deaths in the Union of South Africa from
influenza and its complications from August 1st to
Nov. 30th, 1918, were approximately Europeans, 11.726 ;
other than Europeans, 127,745. The returns showed :—
Cape : Europeans, 5855 ; others, 81,253. Transvaal :
Europeans, 3267: others, 25.397. Orange Free State:
Europeans, 2242 ; others, 7495. Natal : Europeans, 362;
others, 13 690. The Government and local authorities had
expended £308,000 in combating the epidemic ; a few minor
recrudescences of the disease still exist in South Africa.
Roughly one-fourth of the population are Europeans, yet
the mortality is over 10 natives to 1 European.
An interesting piece of news comes from Saul’s Poort,
50 miles from Rustenburg in the Transvaal, where there is a
native village of 1000 people. When the headman heard
about the influenza he issued orders that no one was to leave
the place and that no outsider was to be admitted. Every¬
one was dipped in a carbolic dip and took a dose of
medicine. Not a single case of illness occurred, although the
disease caused 16 deaths in two little native villages near
by. These villages were infected by a native wedding party
from * Rustenburg. These were guarded night and day to
prevent any access to the segregated clean village.
I may mention here that a somewhat heavy influenza
toll has been exacted in the British East African
Protectorate; Europeans, Asiatics, and natives all suffer¬
ing, the last named the most severely. As in South
Africa and other countries, several medical men have
died in the cause of duty. These medical men who have
8nccnmbed to the disease include Dr. B. W. Cherrett,
medical officer of health for Nairobi, the capital; Dr.
Barrett; Dr. I. M. O’Connell, medical officer, Kenia Province,
Fort Hall ; and Dr. W. H. Heard, of the Uasin Gishu plateau,
a Dutch district. Dr. Heard’s death occurred at sea while
en route for home, his wife also succumbing to the disease.
Dr. Heard had served through the Boer War, and tie Id the
Queen’s medal with two clasps. Mrs. Walker, another
victim to influenza, was the wife of the Government
veterinary pathologist.
Cape Medical Council.
The recent election of four members of the Cape Colonial
Medical Council resulted as follows : Dr. W. Darley Hartley,
172 votes ; Dr. J. Wood, 162; Dr. A. Jasper Anderson, 161 ;
Dr. A. Marius Wilson, 128 ; Dr. M. L. Hewat, 94. Another
candidate, Dr. L. A. W. Beck, is now deceased. The first
four gentlemen were elected, and will remain in office for
three years or until the coming into operation of the new
Union Medical Act Sir John Hewat, M.B., C.M. E4in., of
Woodstock, Cape Town, has received many congratulations
on his appointment as Knight Bachelor.
The Late Major H. W. Sykes , R A. M. C.
Major Harold Widdrington Sykes, R.A.M.C., died at
Beira, Portuguese East Africa, on Nov. 11th, aged 34, from
influenza. Major Sykes was the only son of the Rev. W.
Sykes, vicar of Meldon, Northumberland. He went out to
South Africa to take up a medical appointment at Grey’s
Hospital, Pietermaritzburg. He subsequently practised at
Greytown, Natal, and on the Rand. Answering the call for
military medical service. Major Sykes served as an Army
doctor in the Gallipoli Expedition, in Egypt, and in
East Africa.
Jan. 30th.
The Mental After-care Association.—T he
annual meeting of the supporters of this institution, which
seeks to care lor poor persons convalescent or recovered
from institutions for the insane, will be held on Wednesday
next, March 12th, at 3 p.m., at the Skinners’ Hall, Dowgate-
hill, London, E.C. The chair will be taken by Mr. Stanley
Keith, and among the speakers will be Dr. Norman Moore,
Mr. A. Hill Trevor (member of the Board of Control), the Hon.
John Mansfleld (Lord Chancellor’s Visitor in Lunacy), and
Sir Rowland Blades, M.P.
HOWARD GRAEME GIBSON, M.R.C.S. Eng.,
MAJOR, R.A.M.C.
An Appreciation by Colonel S. L. Cummins, C.M.G., A.M S.,
Adviser in Pathology, B E F.
Many both in the Army and outside it will have heard
with deep regret of the sad death from influenza, while on
active service in France, of Major Howard Graeme Gibson,
R.A.M.C. As his commanding officer at the time ot his
death and as a close personal friend, I feel constrained to
record, even briefly, an appreciation of one whose ability and
energy had already made valuable contributions to medical
knowledge and who seemed certain to be destined to a
brilliant career in the Corps.
Born in 1883, Gibson received his medical education at
Guy’s Hospital and entered the Royal Army Medical Corps
on Jan. 28th, 1907, being promoted Captain on July 20th,
1910.
My first personal contact with him was when, early in
the spring of 1914, he formed one of the “Specialist Class”
in bacteriology at the promotion course at the Royal
Army Medical College. Gibson entered into the work of
Major Howard Graeme Gibson.
the laboratory with enthusiasm. It was a pleasure to
have in the class a man with such keenness and
avidity for work. From the very beginning he stood out
as the possessor of exceptional ability, and the favourable
opinion which I had formed of him was justified, when, at
the end of the course, he made the highest marks in the
“ Specialist Examination,” and by his success in other
subjects as well as bacteriology succeeded in qualifying for
a year's acceleration of promotion. A few months later
the outbreak of war swept Gibson, like so many others,
away from scientific work to take an active part in the great
world drama. He joined the 12th Royal Lancers and
with them proceeded at once to the front. The duties of a
regimental medical officer with cavalry during the first
phases of a war are such as to put the highest strain on
initiative, endurance, and courage. This test Gibson met
with his usual cheery energy and zeal. Throughout the
retreat, throughout the advance, during the battles of the
Marne and of the Aisne, and later, when the British Expe¬
ditionary Force was rapidly and secretly moved north to
defend the Channel ports, he shared with the regiment its
trials, hardships, dangers, and glories. Then, just when open
warfare was changing to the war of trenches, and when the
cavalry was helping, dismounted, to eke out our numerically
OBITUARY,
[March 8,1919
weak infantry, Gibson was severely injured by a shell-burst
and was sent home, wounded, to England, where many
months of hospital treatment were necessary before he could
resume military duty. This injury and disability, so galling
at the time to one whose whole soul was with the Army,
proved a blessing in disguise, for it led to his resumption
of the bacteriological work for which he was so well
qualified.
Being quite unfit to resume active duty at the front,
Gibson was now posted to the Vaccine Department of the
Royal Army Medical College. Here, working under Lieu¬
tenant-Colonel D. Harvey, he had full scope for the applica¬
tion of his special knowledge. Although the claims of the
Vaccine Department made necessary long hours of routine
work, still, encouraged and aided by Harvey, he found time
to devote himself to research on protection against
bacillary dysentery. The result was a brilliant piece of
work communicated to the Jowrnal of the Royal Army
Medical Corps of June, 1917, and which culminated in the pro¬
duction of Gibson’s antidysenteric sero-vaccine. The severe
reactions following the inoculation of unaltered dysentery
bacilli had, for the most part, prevented the use of anti¬
dysenteric vaccines. Gibson, recognising the danger that
the sensitisation of bacilli by the homologous antiserum
might, while eliminating the severe reaction, eliminate also
the value of the emulsion as antigen, conceived the ingenious
idea of removing from the serum, by adsorption, all its
“ antibacterial ” “ immune bodies ” while retaining the anti-
endotoxic substances. Such a serum injected simultaneously
with the appropriate dose of killed dysentery bacilli might
be expected to prevent any severe local reaction, while still
leaving the bacteria uninjured and capable of evoking in the
body the production of agglutinins, opsonins, and other
immune substances. Experiments on animals proved this
conception to be correct, and the new principle was soon
applied in practioe, large supplies of the sero-vaccine being
manufactured and sent abroad for use. While it is still
too early to put forward final claims for the value of this
sero-vaccine, all the reports received have so far been favour¬
able, and there is every reason to hope that many lives will
be saved by this means in the future.
In November, 1917, Gibson, now greatly improved in
health, was passed “fit” for servioe in France, and joined
Sir William Leishman as assistant adviser in pathology at
headquarters. Here he threw himself with his usual ardour
into statistical work connected with the effects of the T.A.B.
inoculation and the use of antitetanic serum. His neat and
thorough records are before me as I write, and will constitute
a valuable source of reference in the future.
When in April, 1918, I succeeded Sir William Leishman
as adviser in pathology my task was rendered easy by the
fact that Gib-on, who remained on as my assistant, had at
his fingers' ends every fact connected with the office records
and every detail of the work in hand. Then came the
autumn epidemic of influenza, with its high death-rate and
its many unsolved problems. Research was a matter of
supreme necessity, and the number of men qualified to execute
such work, and at the same time actually available for
employment, was very small. I had decided that a research
team was needed at once. It seemed waste to keep such a
man as Gibson occupied with office records when knowledge,
enthusiasm, and technical skill were so badly wanted. He
welcomed my suggestion with the greatest delight, and I
was able to include him as the senior officer of the team.
His colleagues were Major F. B. Bowman, 0 A.M.O., and
Captain J. J. Connor, A.A.M.O., with whom was associated
for clinical work Major C. E. Rundell, R.A.M.C. Helped
generously by the provision of experimental animals through
the Medical Research Committee, these officers were
successful in transmitting the disease to monkeys and other
animals by the inoculation of filtrates of infected material,
thus confirming tbe work of C Nicolle and Lebailly. They
went further, and, employing the * 4 Noguchi” method,
were successful in obtaining cultures of a very minute filter¬
passing coccus which reproduces on inoculation into animals
the symptoms of the disease. This work, carried out
independently, has been completely confirmed by the publi¬
cation by Sir J. Rose Bradford of similar observations made
by Captain J. A. Wilson, R.A.M.O. At the very moment of
success, when the work of months had at last reached its
final stage. Major Gibson, who had been putting in long
hours with his cultures in the laboratory, himself developed
the disease in its severest form. Those who best knew him
will appreciate what the Army and the Corps have lost
through his untimely death. He was a man who seemed
destined to a career of distinguished success and utility.
Lives such as his add fresh laurels to the splendid traditions
of the Royal Army Medical Corps.
Additional Note by Major-General 8ir William Lkishmax,
K.C.M.G., C.B., F.R.S., K.H.P.
To the above appreciation of the late Major H. G. Gibson
by Colonel Cummins, to every word of which I subscribe, I
should like to add a few lines. Sudden death and the
cutting short of what promised to be a brilliant career has,
alas, been all too frequent during recent years, but the
poignancy of sorrow and regret, for relatives and friends,
remains as sharp as ever at each fresh loss. Of the many
friends and comrades whose lives have been given for their
country during the war there are none whom I shall miss
more acutely than Major Gibson. It was indeed an irony of
fate that he should have met his death at the very moment
when his devoted investigations into the aetiology of the
disease which killed him appeared likely to be crowned with
a success which would have brought him well-deserved
distinction.
No man had ever a better or more loyal colleague to work
with, and in the months in which we were associated in
France I not only formed the highest opinion of his work
and judgment but also of his upright and sterling character.
No one could have lived long in close association with him
without realising the rare qualities of his nature and con¬
ceiving for him a deep and genuine affection. In illustration
of this I may, perhaps, quote a sentence from a letter
received from one of the colleagues associated with him in
his last work. “ He was one of the finest characters I have
ever met, and never in the six months that I knew him did I
hear him say anything against anyone.”
One would like to think that it may perhaps be
some small consolation to his widow and family to know
that his brother officers will not readily forget their
lost friend, and that a large number of them realise
very clearly the great loss which the Corps has
suffered in the early passing of a man whose work
had already stamped him as destined to rise high in the line
to whioh he had devoted himself so whole-heartedly. >
War Office. Feb. 27th, 1919.
JOSEPH BALDWIN NIAS, M.D.Oxon., M.R.O.P. Lord.,
LATE RADCLIFFE TRAVELLING FELLOW AT OXFORD.
Dr. J. B. Nias, who died at a nursing home on Feb. 20th
at the age of 61, was a practitioner in whom erudition and
scholarship were blended with the love of the practioe of
medicine. He was born at Bath on Deo. 13th, 1857, and
was the son of Admiral Sir Joseph Nias. After five years
spent at Winchester, he entered Exeter College, Oxford, in
1875, where a year later he was eleoted to an open scholar¬
ship in science. In 1879 he was in the first class in the
final school of natural science, and subsequently entered at
St. Bartholomew’s Hospital, where he was afterwards house
physician to Sir William Church. In 1882 he was elected
Burdett-Coutts scholar and Radcliffe Travelling Fellow,
and in addition to the study whioh this appointment
entailed, set himself the task of becoming acquainted with
the life of his benefactor and embodying this knowledge in
a book, 11 Dr. John Radcliffe: a Sketch of His Life, with an
Account of His Fellows and Foundations,” 1 which was
published last year and reviewed in these columns at the
time. In 1883 he proceeded to the B.M. degree at Oxford,
and obtained the Membership of the Royal College of
Physicians of London, graduating M.D ten years later with
the thesis on Mastioation in Young Children. For many
years Dr. Nias practised in South Kensington, and among
the scholarly literary work which was so congenial to his
bent of mind was the compilation of a report on the Greek
Manuscripts contained in the Library of the Medical Society
of London. This was published in 1905. His clinical
writings covered such a wide field as the opsonic index in
phlyctenular conjunctivitis and the successful treatment of
streptococcal infection in the dog. All were characterised by
qualities of detachment and freedom from bias as weloome
as unusual. If only for this scientific detachment. Dr. Nias's
place will be bard to fill.
1 Txx Lahoet, Dee. 7th, 1918, p. 781.
ThbLanobt,]
THB MEDICAL PROFESSION AND THE TRADE-UN ION QUESTION. [March 8,1919 397
Camspicbme.
" Audi alteram partem.**
THB MEDICAL PROFESSION AND THE
TRADE-UNION QUESTION.
To the Editor of Thi Lakoit.
Sib, —It cannot be too widely known, as indicated in your
leading article of March 1st, that the meeting held in
Wigmore Hall on Feb. 23rd could not by any stretch of
imagination be regarded as representative of the great mass
of medical practitioners. The profession would be gravely
misled if the decision there reoorded went forth to the world
without some explanation as to the conditions under whioh
that vote was obtained.
The meeting was called by the Medico-Political Union—a
body for some years committed to trades-unionism, and four-
fifths of the audience were already whole-hearted supporters of
that policy. In the article above referred to you deal with the
aiguments put forward by the principal speakers, and mention
the fact that they were largely unanswered. This absence of
criticism did not mean acquiesence and was mainly due to
the fact that while the proposer and seconder of the resolu¬
tion expended one hour in recommending their invitation
to the whole profession to come under the trade union
umbrella, opponents, on the other hand, were only allowed
five minutes to argue their side of the question and were
then only accorded an impatient hearing with many inter¬
ruptions, mostly irrelevant. Any real discussion was there¬
fore impossible. It is clear, however, from the three mass
meetings recently held in London, that the medical pro¬
fession is at present politically in a ferment and has shown
itself to be divided into two main lines of thought.
One section still regards the practice of medicine as a voca¬
tion and not as a trade, and, in a materialistic age, aspires
to the twin virtues of service and sacrifice ; the other,
represented by the Medico-Political Union, argues all
questions of medical politics from the standpoint of profit
and loss, and takes up a firm trade-union position on a basis
of hard cash. To the practical medical politician, anxious
that his profession should pull its weight in the national
boat, it seems not imp>s8ible to correlate these divergent
views and so find some common ground from which to watch
the Interests of the profession and to promote the public
weal.
Would it not, then, be possible that from these two main
bodies of medical opinion two councils be formed, each
organised on its own lines to suit the special needs of its
constituents, and when grave matters of medical politics
are discussed they might meet in joint session and so bring
to bear on the responsible authorities the full weight of their
accumulated knowledge and experience. The Medical
Parliamentary Committee has already among its members
distinguished represent itives of the trade-union doctrine, and
I venture to suggest that this committee might well be made
a rallying ground for all shades of medical opinion and form
the nucleus of a general medical Parliament.
It Is clear that medical men in contract practice must
be treated by Government departments and Insurance Com¬
missioners differently from what they have been in the past,
their opinion must be sought, when medical questions are
under discussion, and their views not only heard but atten¬
tion must be paid to them. It is incontrovertible that panel
practitioners have been treated infamously on occasion. Dr.
E. H. M. Stanoomb and Dr. J. A. Angus proved this con¬
clusively at Wigmore Hall. Furthermore, members of the
profession who are practising as free men, unshackled by
Government contracts, must be enabled to make their weight
felt in the councils of the nation and wherever their expert
knowledge and experience may be of value.
In the future, and indeed in the pretent , no Minister of
Health oan afford to flout medical opinion, as have Govern¬
ment Departments in the past, and this must be made dear
in unmi takable terms. Fortunately, we have in the first
head of the new Ministry a medical man who is alive to the
value he is likely to gain by ready cooperation wUh his pro¬
fessional confreres. But the trade-union section must not
imitate their less educated brethren by exhibiting the canker
of unreasoning suspicion, but should take a broad and states¬
manlike survey of the situation and unite with the Medioal
Parliamentary Committee to form a really active and
properly representative body for the greatest good of the
greatest number.—I am. Sir, yours faithfully,
R. Fiblding-Ould, M.D., M.R.O.P., M.A.
William-street, 8.W., Mart* 4th, 1919.
CONTACT INFECTION OF CHICKEN-POX.
To the Editor of Thh Lancet.
Sir, —In an article published in Thb Lancet of Feb. 12th,
1916, on the aerial conveyance of infection of certain
fevers I added a note on the contact infection of chicken-
pox. F >r reasons stated the work on the aerial conveyance
of infection was stopped, but that on the contact infection
of chicken-pox continued, though necessarily slowly, until
the hospital was utilised as an American war hospital.
! In the note on chicken-pox contact infection 7 cases were
reported as having passed through the ward without causing
infection, the last case having been placed in the ward on
the eighth day of the eruption. Since that time 6 more
cases have passed through, and as the last marks a definite
infecting period there seems to me some reason for recording
them.
The ward chosen for the work was a scarlet fever one of
20 beds for small children, and no precautions were taken
to avoid infection from the chicken-pox cases introduced.
The ages of the unprotected children exposed to these five
cases were : 1 year, 7 ; 2 years, 6 ; 3 years, 9 ; 4 years, 13;
5 years, 10 ; 6 years, 6 ; and 7 years, 2. The five patients
introduced suffered from both chicken-pox and scarlet fever,
one being introduced on the eighth day of the chicken-pox
eruption, one on the seventh day, one on the sixth day, and
two on the fifth day. Only one case was introduced at a
time, and was kept in the ward until all the scabs had
separated or longer, while no patient was discharged from
the ward until more than 22 days had elapsed after the first
exposure, many being kept much longer.
No infection arose from the first four cases (Cases 8, 9,
10, and 11). but the fifth (Case 12) infected three children.
8th Case,— Eighth day of chicken-pox eruption; very
numerous scabs and numerous pustules. 19 other patients
in ward—11 protected, 8 unprotected. No infection.
9th Case.— Seventh day; numerous scabs and pustules.
19 other patients in ward—6 protected, 12 unprotected,
1 doubtful. No infection.
10th Case.—Sixth day; numerous scabs and vesioles; a few
pustules. 19 other patients in ward—8 protected, 10 unpro¬
tected, 1 doubtful. No infeotion.
11th Case.— Fifth day; moderate eruption, Bcabs and a few
pustules. 19 other patients in ward—8 protected, 11 unpro¬
tected. No infection.
12th Case— Fifth day; very abundant eruption, scabs and
some pustules. 19 other patient in wards—7 protected,
12 unprotected. Infected three children in wara. Of the
three infected children, one showed the eruption 14 days
after the introduction of the infector to the ward, and the
other two 16 days after. The infeotion was apparently by
indirect contact, for the infector and the three infected
were in bed for the first few days of exposure; the infeotor
for the first five days, two of the infected for the first four
days, and the other for the first three days. Further, the
infected were all in beds at some distance from the infeotor.
Altogether 12 cases have passed through this ward, and
though the number may seem small to some, it is to
be remembered that chicken-pox is a very infectious disease,
whioh seldom fails to cause infection in wards occupied by
small children. There is, therefore, some reason to think
that the contact infeotion of chicken-pox probably ceases
about the end of the first week of the eruption or the
beginning of the second. Further, that chicken-pox may ,
certainly be infectious by contact on or before the fifth day.
I am. Sir, yours faithfully,
Frederic Thomson.
North-Bastern Hospital. Tottenham, London, N.,
Feb. 27th, 1919.
“SHOCK” (SO-CALLED).
To the Editor of Thb Lancbt.
Sir, —A philosopher has written that 11 words shoot baok
upon the understanding of the wisest, and mightily entangle
and pervert the judgement,” and it would be hard to find
even in theological and metaphysical controversy an instance
of greater confusion than has arisen from the misuse of the
word “ shock.” According to the dictionaries it denotes
398 Tins Lancet/]
THE WAR AMD AFTER.
[March 8,1919
“a sudden and more of less' Violent physical or mental
impression: a startling agitation of the feelings.” By
some of the older writers, including, I think, Sir
William Savory, it was reserved to denote the event
which tended to produce a condition called collapse.
More recently, shock has been defined as “the reaction
of the central nervous system to abnormal or exaggerated
afferent impulses”—i.e., to an event or series of events,
which may or may not produce as an end-result a condition
clinically serious. This is, no doubt, strictly correct, but the
word is so generally applied to the condition of the organism
when its “protective” reaotion has failed, or has itself
proved noxious, that it seems hardly practicable thus to alter
the nomenclature.
Such being the case, I venture to suggest that at least by
‘ 1 surgical shock ” should be understood only that condition
which is a direct and immediate effect of some abnormal
impo ses from the periphery (as from a wound or in the
course of operation), and is essentially a disturbance of the
nervous system (Professor Bayliss’s “primary shock ”), with
instant disturbance of the vital functions it controls. As an
illustration I may mention that the most sudden and profound
shock I have seen occurred in a healthy woman undergoing
a minor operation on severance of a nerve which was
in a state like that of bulbous nerve-ends in stumps.
However (one may suppose because the clinical signs
are similar), a variety of conditions are also called, or
rather miscalled, “shock.” Such are those due more or less
indirectly to the “primary shock,” but in addition often
to other causes, chill, haemorrhage, want of nourishment,
&o., and now regarded as being essentially changes in the
quality and distribution of blood (“secondary shock”),
(“acapnia”); and even, strange to say, to the effects of an
overdose of morphine or chloroform, which so far from
causing true shock tend to prevent it! These conditions
should be termed “ collapse,” or at any rate, not “ shook ” ;
and it would certainly save much perplexity if every writer
and speaker about to make use of the word “ shook ” would
first try to define what he means by it.
I am, Sir, yours faithfully,
Palrfaazel Gardena, H.W., March 3rd, 1919. J. D. MORTIMBR.
HYPOTHERMIA IN INFLUENZA.
To the Editor of Thh Lakobt.
Sir,—I have always looked upon the hypothermia which
follows influenza as quite the most important and dangerous
symptom. Indeed, I have thought it to be almost patho¬
gnomonic, and was quite unprepared to learn from Dr. Samuel
West’s letter in The Lancet of Feb. 1st that it is not
widely recognised. I have never even heard it disputed, and
had taken for granted that it was familiar to practically
every member of the profession. The high temperature,
I have found, will usually go down of itself, but the low
temperature which follows is far more dangerous and difficult
to dleal with, and renders the patient specially liable to com¬
plications. This fact is, of course, a strong argument against
the use of any depressing remedies in the early stage. I
believe that the treatment by antipyrin, which was at one
time very prevalent, has been responsible for a great many
fatal cases. I am. Sir, yours faithfully,
Oakley-street, B.W., Feb. 7th, 1919. J. FOSTER PALMHR.
BOOKS FOR SERBIA.
To the Editor of The Lancet.
Sir,—M ay we appeal through your columns for books for
Serbia? The Austro-Hungarians and the Bulgarians were
at special pains to remove all means of education and culture
in Serbia, and they destroyed her libraries after taking from
them all that they themselves wanted. They also destroyed
every printing press in the country. It is impossible to
state in a phrase all that such losses must mean to a nation.
But those of us who have imagination will hardly refuse a
gift from our well-filled bookshelves. Books, old or new. of
practically every kind, and in any language, are needed,
and should be sent to Miss Waring, Hon. Organising
Secretary for the Reconstruction of Serbian Libraries, Royal
Society of Literature, 2, Blooimbury-pqaare, London, W.0.1.
The name and address of sender should be given on the out¬
side of the parcel.
Those who wish to help and who cannot give books are
asked to send donations towards expenses, and for the
providing of books that may be missing from among the gifts.
Cheques should be crossed “Messrs. Ooutts & Co., A/C War
Fund of the Entente Committee;”
I am, Sir, yours faithfully,
Crewe,
Hon. Director of Foreign Affairs of the
Feb. 27th, 1919. Royal Sobiety of Literature.
BUYING PRACTICES.
To the Editor of The Lancet.
Sir,—M ay I through your columns give a word of caution
to the large number of practitioners now returning to civil
life respecting the present value of practices. The position
is quite different now from pre-war conditions, and before any
practice is purchased very careful investigation is essential
in order to arrive at its value. Many practices to my
knowledge have been sold to unwary purchasers on the basis
of last year’s income, which is, in many cases, inflated by
munition workers or epidemic fees, to the extent of 50 per
cent, above the normal value. To be rushed into a purchase
such as this spells disaster. Far better, before making any
decision, to seek the advice of any of the old-established
agents, who have a reputation to maintain and who can be
relied on to advise after investigation as to the proper value
of any praotice. I am. Sir, yours faithfully,
126. Strand, W.C., Feb. 25th, 1919. PBRCIVAL TURNER.
anlr %ikx.
The Casualty List.
The names of the following medical officers appear among
the casualties announced since our last issue:—
Died.
Capt. A. M. Pryce, R.A.M.C., was a student at Middlesex
Hospital and qualified in 1903. He held appointments at
the Leeds Sanatorium for Consumption ana at the Leeds
City Fever Hospital, afterwards becoming assistant
M.O.H. for Leicester. At the time of joining the
R.A.M.C. he was demonstrator of bacteriology at the
University of Leeds. He died at Calais of broncho¬
pneumonia.
Capt. F- B. Chenoy, I.M.S., was a student at the London
Hospital and qualified in 1913. Shortly afterwards he
jqined the I.M.S.
Snrg. Sub-Lieut. F. W. Lemarohand, R.N.V.R.
Sorg.-Lieut. R. A. Hobbs, R.N., was a student at 8t. Mary’s
Hospital, London, and qualified in 1908. He held an
appointment at the Royal Surrey County Hospital,
Guildford, and, prior to joining the Royal Navy, was in
practice at High Wycombe, Bucks, where he was
honorary medical officer to the Memorial Cottage
Hospital. _
Casualties among the Sons of Medical Men.
The following additional casualty among the son a of
medical men is reported:—
Warrant Telegraphist T. A. Payne, R.N.R., died of pneu¬
monia, son of Dr. A. A. Payne, of Sheffield.
The Honours List.
The following awards to medical officers (all members of
the R. A.M.O. except where otherwise stated), iu recognition
of their gallantry and devotion to duty in the field, are
announced. The acts of gallantry for which the decorations
have been awarded will be given later:—
Bar to Distinguished Service Order.
Capt. (acting Lt.-Ool.) J. H. Fletcher, D.S.O., M.O.; Maj. (tamp.
Lt.-Col.) F. C. Samp«on. D.S.O.
Distinguished Service Order.
Capt. F. A. Ardagh. M.C., N Z.M.C.; Temp. Maj. C. F. Knight;
Maj. L. May, M.G.. Auat. A. VI C.; Lt.-Ool. S Paulin, Can. A.M.C.
Second Bar to Military Cross.
Temp. Capt. G. O. F Alley, M C.; Lt. (temp Uapt.) W. J. Knight,
M.C.; Tefcxp. Capt. (acting Maj.) M. a. Poorer, M.O.
Bar to Military Cross.
Capt. (acting Maj.) J. B. Owenagn, M.O.; Temo. Capt. F O. Clarke,
M.C.; Temp. Capt. C. N. Coal, M.C.; Capt. (ac*tng Maj.' *. F. Corktll,
M.O.; Temp. Capt. (acting Maj ) J. E. Davies. M C ; Cap*.. F. F. Dunham,
M.C.,Can AMO.; Capt. (*•• ’ i r Maj.) P. Qtmm, MO ; Oapt. (acting
Maj ) W. C. Hartgill. M.O.; Oa *t. (temp. Maj.) R. A. Hepple, M.O.;
Temp. Oapt. (acting Maj*) B. Knowles, M.O.; Temp. Capt. A C. ff.
Knox, M.C.; Temp. Capt. (acting Maj.) H. D. Lane, M.C.; Oapt. J. S.
Tn Labor,]
THE 8BEVICE8.
[March 8,1919 3 g 9
Maekay, M.C., Aust. A.M.C.; Temp. Gut J. D. MacKinnon, M.O.;
Gant, (acting Maj.) W. A. Miller, D.S.O., M.O.; Capt. L. C. Palmer,
M.C., Can. A.M.C.; Capt. J. G. Shaw. M.C.. Can. A.M.C.; Capt. (anting
Maj.) J. C. Spenoe, M.C.; Capt. D. G. K. Turnbull, M.C., Can. A.M.C.
The Military Cross.
.Temp. Capt. (acting Maj.) J. B. P. Allin; Capt. A. F. Argue*
Can. A.M.C.; Temp. Capt. (acting Maj.) B. W. Armstrong ; Capt. F. G-
Banting, Can. A.M.C.; Capt. J. H. Blair. Can. A.M.C.: Capt. B. J-
Bradley; Capt. M. G. Brown, Can. A.M.C.; Capt. B. T. Cato, Aust.
A.M.C.; Capt. H. T. Chatfleld; Temp. Capt. T. Clapperton; Capt.
(acting Maj.) H. B. Dive; Temp. Capt. B. Donald ; Capt. L H. Fraser,
Can. A.M.C.; Temp. Capt. W. B. Gourlay; Temp. Capt. N. F. Graham;
Capt. G. W. Grant, Can. A.M.C.; Temp. Capt. B. P. Hadden; Capt.
J. M. Henderson, Aust. A.M.C.; Temp. Capt. A. Hunter; Temp. Capt.
W. B. Jack; Temp. Capt. M. J. Johnston; Capt. C. T. Lewis, Can.
A.M.C.; Temp. Capt. C. W. B. Littlejohn; Capt. I. H. Lloyd Williams;
Temp. Capt. A. Mason; Capt. H. C. Moses, Can. A.M.C.; Capt. J. A.
Nicholson; Capt. K. C. Purnell, Aust. A.M.C.; Capt. A. M. Purves.
Aust. A.M.C.; Temp. Capt. £. Rogerson ; Temp. Capt. J. Scott; Temp.
Capt. T. McC. Sellar; Capt. (acting Maj.) A. L. Shearwood; Capt.
C. H. K. Smith; Capt. G. A. Smith, Can. A.M.C.; Capt. J. Stirling;
Capt. J. T. Stirling, Can. A.M.C.; Capt. B. C. Weldon, Can. A.M.C. ;
Temp. Capt. G. B. Wilkinson._
The following awards to and promotions of medical
officers, all members of the R.A.M.C. except where other¬
wise stated, in connexion with operations in Mesopotamia,
are announced
C.R.-Lt.-Col. and Bt. Col. M. H. G. Fell, C.M.G.
C.B.E.— Lt.-Col. (temp. Co'.) J. H. R. Bond, D.S.O.; Col. S.F. St. D.
Green, A.M.S.; Lt.-Col. W. B. Lane, C.I.M., I.M.S.
O.B.E.— Maj. J. H. Brunskill, D.S.O.; Temp. Capt. W. A. Cardwell;
Maj. (acting Lt.-Col.) G. B. Cathcart; Capt. R. A. Chambers, I.M.S.;
Temp. Capt. L. W. Davies; Temp. Capt. G. H. Davy; Capt. J. B.
Harris ; Maj. H. L. Howell. M.C.; Capt. C. J. H. Little; Temp. Capt.
G. 8. Marshall; Capt. J. P. Mitchell; Capt. J. J. H. Nelson, M.O.,
I.M.S.; Capt. C. J. Penny; Capt. H. G. Robertson ; Temp. Maj. M. B.
8oott; Capt. F. T. H. Wood.
To be Major General.— Col. (temp. Maj.-Gen.) A. P. Blenkinsop, C.B.,
qUq AMS
To beBrevet Colonel.— Maj. and Bt. Lt.-Col. C. M. Goodbody, C.I.B.,
D S O IMS
To be Brevet Iieutenant-Colonel.— Maj. T. G. F. Paterson, D.8.O.,
I.M.8.; Maj. B. A. Roberts. D.8.O., I.M.S.
To be Brevet Major.— Capt. A. G. J. Macllwaine, C.I.B.; Temp. Capt.
H. H. Baw; Capt. A. Shepherd.
Military Cross.—Temp. Capt. J. A. G. Burton; Capt. C. B. Knowles;
Capt. 8. W. Blntoul. _
Brought to Notice.
The names of the following medical officers in the Royal
Air Force have been brought to the notice of the Secretary
of State in respect of the valuable services they have rendered
in connexion with the war:—
Capt. O. H. Gotch ; Capt R. Johnson; 8urg.-Gen. Sir W. H. Norman,
K. O.B.; Capt. C. R. M. Pattlson ; Capt. H. B Whittingham.
THB SERVICES.
BOXAIi HAVAI. MBDICAL SBRVICH.
To be temporary Surgeon-Lieutenant: J. M. Blckerton.
ARMY MEDICAL SBRVIOB.
Temp. Col.'Sir Almroth B. Wright, K.B.E.,^O.B. ( relinquishes his
commission and retains the rank of Colonel.
Temp. Col. Sir A. B. Garrod, K.C M.G., (Lleut.-Ool., B.A.M.C.,
T.F.). relinquishes his temporary commission on re-postlog.
TKBRITOBIAX. FORCE.
The undermentioned Lieutenant-Colonels, from the R.A.M.C.(T.F.),
to be Colonels i A. 1. L. Wear, C. Averlll, H. D. Brook, R. Pickard
(acting Col.), A. B. Soltau, F. Kelly (acting Col.), L. J. Bland ford
(acting Col.), J. Clay (acting Col.), F. C. Burgess, H. H. C. Dent,
G. H. Bdington, J. M. Bogers-Tillstone.
Davies, J. G. Moseley; while specially employed: J. F. Venables, A. H.
Thomas, S. A. W. Munro.
Capt. B. L. Puddicombe relinquishes the acting rank of Major on
rejpostlng.
Temporary Lieutenants to be temporary Captains: M. P. Thomas,
G. R. Bickerstaff, W. P. Philip, C. I. Ilderton, J. W. Robertson. C. M.
Bradley, C. Fletcher, B. J. Blewitt, H. B. Kitchen, H. G. G. Nelson,
H. C. Attwood. J. D. MoKelvle, A. M. Clare, F. L Rigby, W. Rigby,
B. G. Brooke, H. K. Waller.
Officers relinquishing their commissions: Temp. Majors E. D. Hancock
(on ceasing to be employed with Guildford War Hospital, and retains the
rank of Major), G. H. W. Humphreys and G. P. B. Simpson (retain
the rank of Majors); Temp. Cants. J. L. Menzies, J. Lamont (and are
granted the rank of Major); Temp. Capts. retaining the rank of
Captain: A. N. E. Rodgers, A. B. Northcote, H. Peters, T. B. Jobson,
A. Drouln, T. 8. G. Martin, E. L. MacKenzIe, H. Boyers, T. D. Miller,
J. V. Brown. H. Crassweller, A. W. Allan. J. B. O’Reilly, R. N.
Berman; Temp. Capt. R. 8. Topham (on transfer to the H.A.F.),
E. B. T. Nuthall (late temporary Captain. Is grantod the rank
of Captain); Temp. Hon. Capt. H. F. Bold-Williams (and retains
the honorary rank of Captain); Temp. Lieut. J. M. Flavelle(and retains
the rank of Lieutenant); Temp. Hon: Lieut. J. O'B. Hod nett (and
retains the honorary rank of Lieutenant).
SPECIAL RESERVE OF OFFICERS.
Captains relinquishing their commissions and retaining the rank of
Captain: A. C. Court, N. L. Joynt.
TERRITORIAL FORCE.
Officers relinquishing the acting rank of Lieutenant-Colonel on
ceasing to be specially employed: Capt. H. F. Wilkin. Majors A.
Cal lam, B. Turton and A. A. Martin.
Officers to be acting Lieutenant-Colonels whilst specially employed;
Majors J. Scott and W. A. Thompson, Capt. (acting Major) D. G. Rloe-
Oxley.
Capt. (acting Major) H. J. Dunbar to be acting Lieutenant-Colonel
whilst specially employed.
Ciptalns to be acting Majors whilst specially employed: J. A.
Willett, C. D. Law, H. Henry, H. P. Ashe, J. G. Hill, F. S. Bedale,
A. M. Gibson, G. E. J. A. Robinson, J. G. Morgan.
Capts. (acting Majors) A. M. Johnson, M.C., A. G. T. Hanks, J. W.
Dale, M.O., and W. H. Milligan, and Capt. (acting Lleut.-Ool.) G. H.
Spencer relinquish their acting rank on oeaslng to be specially
employed.
Capt. (acting Major) C. D. 8. Agassiz Is granted the pay and allowances
of his acting rank.
Capts. B. H. Bingley and T. R. Bowen relinquish their commissions
and retain the rank of Captain.
1st London Sanitary Company: Lieut. S. 0. Rigg to be Captain.
2nd London Sanitary Company: Capt. (acting Major) J. Chalmers
relinquishes his acting rank on vacating the appointment of Deputy
Assistant Director of Medical Services; Lieut. D. M. Neil to be Captain.
2nd London General Hospital: Capt. A. S. Daly is seconded for
service with a Military Hospital.
4th Northern General Hospital: Capt. G. J. R. Lowe to be acting
Major whilst specially employed.
2nd Eastern Hospital: Majors T. H. Ionldes and W. Broadbent are
restored to the establishment.
1st Western General Hospital: Capt. (Bt. Major) R. B. Kelly is
restored to the establishment.
1st Northern General Hospital: Capt. N. Hodgson to be acting Major
whilst specially employed aud to remain seconded.
5th Southern General Hospital: Capt. C. H. Saunders to be acting
Major whilst specially employed.
3rd London General Hospital: Capt. 8. M. Smith ia reatored to the
establishment.
2nd Western General Hospital: Capt. G. Wright to be acting Major
whilst specially employed and to remain seconded. Capt. (acting
Major) G. Wright relinquishes his acting rank on oeaslng to be specially
employed.
2nd Scottish General Hospital : Lieut.-Col. Sir J. Fayrer, Bt., is
retired on completion of tenure of command aftd retains his rank with
permission to wear the prescribed uniform.
TERRITORIAL FORCE RK8RRVB.
Major A. Cal lam, from 2nd Bast Lancs. Field Ambulance, to be
Major.
Capt. A. M. Johnson, from 3rd Bast Lancs. Field Ambulance, to be
Captain.
Capt. J. W. Dale, from 3rd Welsh Field Ambulance, to be Captain.
INDIAN MBDIOAL SBRVIOB.
BOYAL ARMY MEDICAL CORPS.
Lieut.-Col. J. B. Brogden Is placed temporarily on the Half Pay List
on account of ill-health contracted on active service.
Lieut.-Col. W. L. Steele, C.M.G., to be acting Colonel whilst
employed as Assistant Director of Medical Services of a Division.
Tfcmp. Maj. C. V. Mack ay and Majors F. J. Garland, G.G. Tabuteau,
and J. M. B. Rahllly relinquish the acting rank of Lieutenant-Colonel
on re-posting.
To be acting Lieutenant-Colonels whilst specially employed: Maj.
A. C. Osburn, Temp. Capt. H. R. Hunt.
To be acting Lleatenant-Colonels whilst in command of a Medical
Unit: Temp. Maj. n. M. Chasseaud, Majors L. V. Thurston, A. O. H.
Gray, Capt. (acting Major) G. F. Allison. Capt. B. A. Odium.
Capt. and Bt. Major J. Gilmour retires receiving a gratuity.
Relinquishing the acting rank of Major on re-posting: Capts. J. P.
Lltt. C. J. O’Reilly; Temp. Capts. H. B. Atlee, R. S. Frew, J. A. Jones,
F. M. Heath, D. M. Ross. H. D. Led ward, J. L. Gordon, W. Anderson,
0. A. H. Gee, B. L. M. Hackett, B. H. Barton, S. J. Rowntree, H. W.
Qebe, J. R. Craig, W. H. W. Attleo, A. M. Caverhlll.
Temp. Maj. <5. P. Mills (Capt. R.A.M.C., T.F.) relinquishes his
temporary commission.
To be acting Majors: Capts. W. D. Anderton, W. W. MacNaught,
A. L. Aymer; Temp. Capts. A. Mathleson, D. Cowin, W. M. Oakden,
T. Winning, A. T. W. Forrester, N. B. Kendall, A. C. Renton, A.
£*Mlng, A. Farquhar, ▲. Grant, W. B. R. Dlmond, A. Scott, 8. B.
Ftckin, F. O. Clarke, A. V. Craig, J. Morrison, B. Pickering, H. R.
Major-Gen. G. G. Glffard has been appointed an honorary surgeon to
the King, vice Surg.-Gen. T. Grainger. •
Temporary Lieutenants to be temporary Captains i P. V. R. Murty,
D. C. McNair. P. M. Masina.
Lieut. R. A. Murphy relinquishes his temporary rank.
ROYAL AIR FORCB.
Medical Branch.— W. F. Jones (temp. Surg.-LIeut., B.N.) is granted
a temporary commission as Captain.
R. 8. Topham (temp. Capt., R. A.M.C.) Is granted a temporary com¬
mission as Captain.
Capt. R. D. Goldie (Capt. R.A.M.C., S.R.) relinquishes his commis¬
sion on ceasing to be employed. _
PROMOTION IN THB R.A.M.C. (TERRITORIAL).
Sir F. Blake having asked the Secretary for War whether he would
state the number of lieutenant-colonels and majors. Royal Army
Medical Corps (Territorial Force), who had been promoted since the
promotion or seniority list was compiled last year. Captain Guest
replied: Twelve lieutenant-colonels, R.A.M.C. (T.F.), have been
selected for promotion under the rules governing authorised increases
in the establishment. (See under Army Medical Service, Territorial
Force, above.) It is anticipated that the publication of the names of
majors selected for promotion to the rank of lieutenant-colonel will take
place within the next three weeks.
<400 Thi Umoit;]
MEDICAL NEWS.
[Margo 8, 1010
Utetfral Jjtefos.
Thb Fellowship op Medicine.— The Fellowship
Of Medicine has arranged with the majority of the medical
schools in London and other hospitals for an emergency
post-graduate course of three months for qualified medical
officers from the R.N., R.A.M.C., and R.A.F., from the
Dominions and the United States and Allies, admitting to
their general practice, including clinical instruction in the
wards and out-patient departments, clinical lectures and
demonstrations, post-mortem demonstrations, laboratory
work, <fcc. The London medical schools and hospitals
available for emergency poBt-graduate study, and the special
courses already in progress, are given in the following list
Medical schools.— St. Bartholomew's Hospital and College, West
Smithfield, E.C. 1; St. George’s Hospital. Hyde Park Corner, S.W.l;
Guy's Hospital, St. Thoraas’s-street, London Bridge, S.E. 1; King’s
College Hospital Medical School, Denmark HLI1I, S.B. 3; London
Hospital, Mile Rnd, E. 1; London (Royal Free Hospital) School of
Medicine for Women, 8, Hunter-street, Brunswick-square, W.C 1;
Middlesex Hospital, Berners-street. W. 1; St. Thomas’s Hospital.
Albeit Embankment. Westminster Bridge, S.E. 1; University College
Hospital Medical School, Gower-street, W.0.1; Westminster Hospital,
opposite Westminster Abbey. S.W. 1.
Special hospitals.— Cancer Hospital, Fulham-road, S.W. 3; "Chelsea
Hospital for Women, Arthur-street, Chelsea, S.W.; Hospital for
Children, Great Ormond-sfreet. W.C.l: National Hospital for Diseases
of the Hwt, Westmoreland-street, W. 1; "National Hospital for the
Paralysed and Epileptic. Queen-square, W.C. 1; Queen's Hospital for
Children, Hackney-road, Bethnal Green. E.2; Prince of Wales General
Hospital (N.E. London Post-Graduate), Tottenham, N. 15; St. Mark’s
Hospital for Diseases of the Rectum. City-rosi, E.C. 1 ; St. Peter’s
Hospital, Henrietta-street, Covent Garden, W.C. 2; "West London
Hospital (West London Post-Graduate College), Hammersmith-
road, W.6.
* Members wishing to attend these hospitals most ask for special tickets.
Special courses already in progress. — King's College Hospital Medical
School, Jan. 24th-Marcb 29fch ; National Hospital for the Paralysed and
Bplleptio, Feb. lOth-Aprll 10th ; London (Royal Free Hospital) School
of Medicine for Women, special 14 days’ course. March 15th-31st:
" Medicine and Surgery of Liver and Gall-Bladder,” May 5th-16th :
“Diseases of the Thyroid-* and Parathyroids”; West London Post-
Graduate College, Feb. 17th-Aprll 17th. At the North-East London
Post-Graduate College, National Hospital for Diseases of the Heart,
and Cancer Hospital, special lectures will be arranged.
Time tables and syllabuses of the various courses and
daily programmes will be posted in the entrance ball at
1, WimpoTe-street, and can be seen at any time. Arrange¬
ments are being made for a definite course of daily lectures
and demonstrations in general and special subjects at the
same address. As soon as sufficient applications are received
a detailed programme will be published and sent to
applicants. The honorary secretaries of the Fellowship
are Mr. Philip Franklin, Mr. J. Y. W. MacAlister, and
Mr. Herbert J. Paterson. Tickets for the whole course, or
for one or two months, at the rate of £3 10«. for each month,
can now be obtained from Miss Willis, secretary to the
Fellowship, who is in attendance daily from 10 a.m. to 5 p.m.,
and to whom all inquiries can be addressed at 1, Wimpole-
street, London, W. 1. The card of membership for any
period of the course admits the holder to any, or all, of
•he hospitals available, including their special courses.
Royal Institution.— Captain G. P. Thomson will
deliver his postponed lecture on “ The Dynamics of Flying ”
on March 10th, at 3 o’clock.—Professor A. Keith will deliver
a lecture on March 14th, at 5.30p.m., on the Organ of Hearing
from a New Point of View.
Rontgen Society— Professor W. M. Bayliss will
deliver the second “Silvanus Thompson Memorial Lecture”
in May next. Members requiring invitations for friends are
requested to make application to the Honorary Treasurer,
33, Newton-street, London, W.C. 2.—A joint meeting of the
Rdntgen Society and the Faraday Society is being arranged
for the purpose of a joint discussion on “ Radiometallo-
graphy " (the radiography of metals by X rays).
British Scientific Products Exhibition, 1919.
—The King has consented to act as President of the British
Scientific Products Exhibition, 1919, which will be held at
the Central Hall, Westminster, during the month of July.
The President of the exhibition is the Marquess of Crewe,
K.G., and Professor R. A. Gregory is chairman of the
organising committee. The British Science Guild has been
encouraged to organise this exhibition by the success which
attended that held at King’s College last summer and the
more recent exhibition at M&nohester. Now that many
inventions can be shown which could not be put before
the public during the war, there is every prospect that
this year’s exhibition will be even more successful
than its predecessors. The objects of the exhibition
will be to illustrate recent progress in British science
and invention and to help the establishment and develop¬
ment of new British industries. Such an exhibition
will enable new appliances and devices to be displayed
before a large public, and will provide progressive manu¬
facturers with an opportunity of examining inventions likely
to be of service to them, thus serving as a kind of clearing
house for inventors and manufacturers, as well as illustrat¬
ing developments in science and industry. The exhibition
will include sections dealing with chemistry, metallurgy,
physics, agriculture and foods, mechanical and electrical
engineering, education, paper, illustration and typography*
medicine and Burgery, fuels, aircraft and textiles. Firms
desirous of exhibiting are invited to communicate with the
organising secretary, Mr. F. 8. Spiers, 82, Victoria-street*
London, S.W.l.
The Faculty of Insurance: Annual Public
Conference. —This conference is to be held in the Central
Hall, Westminster, on Friday, April 4th, morning aud after¬
noon. Sir L. Worthington Evans, M.P. (Pensions Minister),
will speak on “The Training and Treatment of Disabled
Service Men” and Captain J. O’Grady, M.P., will open the
discussion. Sir Walter Fletcher (secretary to the Medical
Research Committee) will speak on “ Medical Research and
the State ” and Major-General Sir William Leishman will
open the discussion on this subject. Mr. J. H. Thomas,
M.P., will speak oo “The Urgent Necessity for au Increase
in National Health Insurance Benefits” and Mr. John
Hodge, M.P., will open the discussion. The chair will be
successively occupied by Mr. P. Rockliff, President; Sir
Kingsley Wood, M.P., chairman; aud Mr. W. S. Bennett,
vice-chairman of the Faculty. A dinner in connexion with
the conference will be held the same evening.
Donations and Bequests.—B y the will of the late
Mr. Henry Alfred Jones, of Eastbourne, the testator left
£500 to the London Hospital, and £250 each to Guy’s Hospital,
Dr. Barnardo’s Homes, St. John’s Hospital for Skin Diseases*
St. Peter’s Hospital for Stone, Covent-garden, Westminster
Hospital, the Royal Hospital for Incurables, Putney, the
City of London Hospital for Diseases of the Chest, the
Brompfcon Hospital for Consumption, Sir William Tralnor**
Crippled Children’s Home at Alton, the Queen’s Hospital for
Children, Hackney-road, the Cancer Hospital, Fulham, the
Royal National Orthopaedic Hospital, the Royal London
Ophthalmic Hospital, the London Lock Hospital, the
Surgical Aid Society, the National Hospital for Paralysed
and Epileptic, and the Princess Alice Memorial Hospital,
Eastbourne.
Brighton and Wounded Soldiers.— Brighton
was one of tbe first towns to have established in it a hospital
for wounded soldiers, and siuce September, 1914, when the
2nd Eastern General Hospital was opened, the institutions
for the care of the sick were of rapid growth. The
smaller hospitals, however, are now gradually being closed
down, cases that arrive now—like a convoy of 251 fropi
Salonika that reached Brighton on the last day of February—
being received at the larger institutions. Taking the four
and a half years of war right through, so it wasanuounoed
at the annual meeting of the Brighton Ambulance Division
of the St. John Ambulance Brigade, no fewer than 32,1060
wounded soldiers were brought to Brighton, and it is
to the Credit of all concerned that not a single mishap
occurred in detraining them aud removing them to hospital.
85 convoys were dealt with in 1918, these comprising 8945
cot cases aud 4850 sitting cases.
The Ministry of Health Bill and Ireland.—
It is a source of sincere satisfaction, an Irish oorrespondeat
writes, that the President of the Local Government Board'
(Dr. Addison), who fi&tly refused last session to allow
Ireland to come under the advantages of the new health
measure, and who even early this session announced that
tbe Bill would not extend to Ireland, has, by the weight of
facts as to the backward public health oonaitions of that
country, been compelled to give way. The North of Ireland.
Members substantiated in the House of Commons all the facts
that have appeared in your columns; and what has specially*
impressed M.jP.’s is tbe wretched permissive wav in whioh any
public health reforms have been applied to Ireland. The
whole value of the notification of tuberculosis was rendered
abortive through a clause by which a member of a family
—no matter how far advanced the disease—oould olaim
that his doctor should not notify him provided be slepkalose
in a room. It is difficult to Bay yet whether the English
Bill will be modified so as to make it applicable to Ireland,
or whether—as in the case of Scotland—a separate measure
will be passed. In the meantime schemes are being
prepared by the Irish Local Government Board and by the
Insurance Commissioners, which are markedly antagonistic
bodies. Three things are needed : (I) the medical profession
will insist on being consulted ; (2) strongadvisory committees
will need to be formed; and (3) an English or a Scotch
medical officer of health should be appointed to take chavge
of tbe scheme in Ireland, where we have really no one con¬
versant with the practioal details of moderxt.publio health^as
it exists in either of those countries.
TIM UKOBf f ]
PARLIAMENTARY INTELLIGENCE.
[11a BOH 8,1919 401
parliamentary $nkl%iia.
NOTES ON CURRENT TOPICS.
Ministry of Health Bill.
The proceedings in Committee on the Ministry of Health
Rill wjJI commence on Tuesday next. It comes before one
of the Standing Committees of the House of Commons.
Medical Treatment of Children in Ireland.
flit. Macpherson, Chief Secretary for Ireland, on March 5th
introduced in the House of Commons a Bill designed to
make provision for the medical treatment of children
attending elementary schools in Ireland and for other
matters incidental thereto. It was read a first time. The
title of the Bill is Public Health (Medioal Treatment of
Children) (Ireland) Bill. _
HOUSE OF COMMONS*
Wednesday, Feb. 26th.
Industrial Fatigue Research Board.
Captain Loseby asked the Minister of Labour why women
were not represented on the recently appointed Industrial
Fatigue Reseaach Board*—Mr. Fisher (Presidentof the Board
of Education) replied : It was recognised when the board was
first established jointly by the Medical Research Committee
and the Department of Scientific and Industrial Research
that its original membership would need to be extended.
Additional members have, in fact, been appointed on two
ocoasions. Women investigators have been appointed and
employed from the beginning, and the inclusion of women
on tbe board was intended from the first. Particular
appointments are at present under consideration by the
Medical Research Committee and the Advisory Council for
Scientific and Industrial Research. It is probable that an
announcement will shortly be made.
Grants to Panel Practitioners.
Mr. Kenyon asked the Secretary to the Local Government
Board whether it was proposed to make any special grants
in respect of the medical officers of institutions approved
under the National Insurance Acts on the lines of the grants
to medical practitioners whose incomes did not exceed £500
per annum of 12* per cent., and between £500 and £1000 per
annum of 10 per cent., or of the additional grant to medical
practitioners who undertook the supply of medicines to the
persons on their lists which represented about 5 id. per
insured person on such lists, where the certified expendi¬
ture of such institutions had not bean received from the
respective Insurance Committees in whose area or areas
such institutions were approved; if so, whether suoh a grant
was intended to be paid to institutions in respect of tbe extra
cost of medicines supplied to insured persons on the lists of
institutions; and, if not. why institutions were speoifioallv
excluded therefrom in view of the fact that they undertook
the supply of medicines to all the persons on their lists.—
Major Astor answered : From the terms of the question the
honourable Member would appear to be under a mis¬
apprehension as to tbe basis and purpose of the war
allowances to which I understand him to refer. These
were granted in response to application made to the
Chancellor of the Exchequer by the Insurance Acts
Committee of the British Medical Association in re¬
spect only of practitioners working under contract with
the Insurance Committees in England, Scotland, and
Wales, and the selection of the particular practitioners who
were to receive the allowances depended in no way what-
erer upon any considerations of a rise in the price of drugs,
but upon two’ factors only—namely, the amount of the indi¬
vidual practitioner’s income and tbe rural or semi-rural
nature of the area in which his practice lay as affecting the
amount of travelling involved. Doctors in the employ of
institutions approved under Section 15 (4), to which the
honourable Member’s question alone refers, were not
included in that application to the Chancellor of the
Exchequer, and were not therefore covered in the grant
given in response thereto. In reply to the conclud¬
ing paragraph, it will be seen from the foregoing that
the honourable gentleman is incorrect in speaking of
this latter class of doctors having been excluded by tbe
Department from the war allowances referred to, and
also in suggesting that the supply of medicines by the said
institutions affords any ground for their inclusion. In reply
to the second paragraph of the question, I can only say that
the arrangements for the work and payments of such
doctors are so different from those of the doctors under con¬
tract with the Insurance Committees that I am unable to
say whether or not any of such practitioners could possibly
be regarded as eligible for those allowances without first
considering in consultation with the Treasury the precise
circumstances of any particular doctor by or in respest to
whom the application might be made. cm jk
Thursday, Fbb. 27th.
Women and Methylated Spirits.
Major Nall asked the Home Secretary whether bis
attention had been drawn to the increased drinking of
methylated spirits amongst women; and what steps he pro¬
posed to take to discourage or prevent this regrettable
practice.—Mr. Shortt replied: I am aware that cases of
methylated spirit drinking have recently been attracting
public attention. It is unfortunately not a new evil. The
question whether further preventive measures are practi¬
cable has received most careful consideration, but it is to be
doubted whether any means can be found of protecting
against themselves those addicted to the habit.
Patent Medicines.
Sir H. Norman asked the Parliamentary Secretary to the
Local Government Board whether his attention had been
called to the increase of advertisements of patent and pro¬
prietary medicines of the classes described as contrary -to
the public interest by tbe Report of the Select Committee
on Patent Medioines, 1914; whether a Bill to give effect to
the recommendations of that committee had been drafted;
and whether it was the intention of the Government to
introduce such a Bill.—Major Astor answered: My atten¬
tion has been called to tbe advertisements referred to as
contrary to the public interest in the Report of the Select
Committee of 1914. By the Venereal Disease Act, 1917, effeot
was given to the recommendation in paragraph 573 of the
report of that committee, and it was enacted that medioines
and medicaments for the prevention or cure of venereal
diseases should be prohibited. My right honourable friend
has the whole question under consideration.
Influenza.
Replying to Sir H. Norman, Major Astor (Parliamentary
Secretary to the Local Government Board) said: Researches
into various points relating to the nature and cause of
influenza and the measures which are of practical value in
preventing its spread are being actively undertaken by my
own Department, by investigation of thB Medioal Research
Committee, and by many other observers in different
countries. The present position of these researches was
referred to in tbe Memorandum on Prevention of Influenza
issued by the Local Government Board last week. The
electrolytic disinfectant referred to as produced in large
quantities by the authorities of the borough of Poplar is
supplied by the public health department of the Poplar
borough council for use, after suitable dilution, as a gargle
or for irrigation of the nose. A weak solution of chlorine,
such' as is made by this disinfectant, or the weak solution
of permanganate of potash recommended in the Board’s
circular or other similar antiseptics, are of value in the pre¬
vention of influenza when used as a gargle or for nasal
irrigation. Local authorities are authorised to provide such
solution within their districts with the Board’s sanction,
which was signified in the circular letter to local authorities
of Nov. 4th, 1918.
Influenza Patients in the Army.
Visoount Wolmer asked the Secretary for War whether
he was aware that soldiers who reported sick with
influenza were obliged to parade at 7 a*m. outside the
medical officer’s hut and, having been diagnosed as suffering
from influenza with a high temperature, had to return to
their quarters, pack up their kit, return it to store, parade
a^ain, and march to hospital; and whether, in view of the
high death-rate among influenza cases in the Army, he
would consider the advisability of altering this procedure.—
Captain Guest (for Mr. Churchill) answered: I am not
aware that such a procedure is followed, but telegraphic
instructions have been issued to all military commands in
case tbe practice does exist in any unit.
Discharged Tuberculous Soldiers.
Replying to Lord H. Cavendish-Bentinck, who asked
whether work centres and village settlements for tuberculous
ex-soldiers would be extended. Major Astor stated that the
Insurance Commissioners and the Local Government Board
had been and were most anxious to encourage under suitable
conditions and on approved standards of efficient working
such centres or colonies as were referred to.
London County Mental Hospitals.
Sir Cyril Cobb asked the Secretary tor War whether he
could indicate at what date the three London county mental
hospitals at Epsom, which the Loudon County Council had
voluntarily placed at the disposal of the War Department
for use as war hospitals—viz., the Horton Hospital, the
Manor Hospital, and the Ewell Colony—would be returned
to the Council for renewed use for the accommodation of
civilian mental cases for which they were seriously needed;
whether be would take steps to secure that these hospitals
were demobilised and restored to the Council at the earliest
possible moment; and whether he oould indicate at what
date the Maodskey Hospital buildings at Denmark. Hill,
which were taken over from the London County Counoil
402 The Lancet,]
PARLIAMENTARY INTELLIGENCE.
[March 8 t 1919
by the War Department at the commencement of the
war and were now being need as a neurological clear¬
ing hospital, would be returned to the Council for use for
the purpose for which the buildings were designed.—
Captain Guest (for Mr. Churchill) answered: The Manor
Hospital will be closed from March 15th next. Every effort
is being made to close the other hospitals as early as possible,
but it has to be remembered that the sick are still being
returned from France at the rate of 1000 a day, and a very
large number required special treatment. As regards the
Maudsley Hospital buildings, this hospital is a neurological
centre and a busy one, and, so far, it has been impossible to
reduce its activity. Efforts are, however, being made to find
another hospital into which the whole centre oan be moved,
and it is hoped that it will be possible to do this and to close
the Maudsley Hospital at an early date.
Medical Women and the War Office.
Mr. Raper asked the Secretary for War whether, in view
of the Government’s undertaking to remove all existing
inequalities in the present law as between men and women,
he would give his sympathetic consideration to support the
claim of women doctors serving under or attached to the
War Office for recognition of the rank and privileges to
which they were entitled.—Mr. Churchill replied: The
general policy of the Government in seeking to remove the
existing inequalities between men and women cannot be
held to commit them to immediate action in this sense in
every sphere, and I am not prepared to introduce legislation
during the present session on the point raised by my
honourable friend.
Promotions in the B.A.M.C.
Sir P. Magnus asked the Secretary for War whether he
would give the number of members of the Royal Army
Medical Corps who, having the rank of major, had been
promoted to that of lieutenant-colonel; and whether, as
regards such promotions, due consideration had been given
to the character of the duties performed by members of the
Royal Army Medical Corps who had given their services to
the sick ana wounded of HiB Majesty’s Forces in our home
hospitals.—Captain Guest (on behalf of Mr. Churchill)
answered: If, as I presume is the case, my honourable
friend is referring to officers of the regular Royal Army
Medical Corps, the present number of substantive lieutenant-
colonels is 2o7, and promotion to the rank is made by selec¬
tion based on the records of the whole service of the officers.
If the question refers to acting 'promotion among Regular,
Speoial Reserve, Territorial Force, and temporary officers,
Buoh promotion is governed by the establishments of the
various units in which officers are serving, and the appoint¬
ments are made by the local authorities concerned from the
officers considered most suitable for the duties required.
Medical Officers in Army of Occupation.
Colonel Burn asked the Secretary for War whether
medical officers who after general demobilisation volun¬
teered to serve with the Army of Occupation would be
allowed to bring their wives to the towns in which they were
serving.—Captain Guest (for Mr. Churchill) replied: This
point is being considered. I will let my honourable and
gallant friend Know the decision arrived at.
B.A.M.C. Officers and Government Employment.
General Croft asked the Parliamentary Secretary to the
Local Government Board what steps were being taken to
secure that doctors who had served in the Royal Army
Medical Corps should have first claim for medical employ¬
ment in Government offioes or in part-time work; and
whether he would give an assurance that such members of
the medical service who had made considerable professional
sacrifices would have due consideration for any such appoint¬
ments.—Major Astor answered : A list is kept at the Board’s
offices of medical officers who have served in the R.A.M.C.,
Naval, or Royal Air Force Medical Services and who wish to
apply for medical employment on the Board, and due con¬
sideration will be given to such officers when medioal
appointments are being made.
General Croft asked the Parliamentary Secretary to the
Ministry of Labour whether the officers’ employment
bureau was placed in touch with the various Government
departments with a view to finding employment for medical
officers who bad served in the war.—Mr. Wardle answered:
It is presumed that the honourable and gallant Member
refers to the Appointments Department of the Ministry of
Labour. The Ministry of National Service is responsible for
the demobilisation of qualified medioal men in His Majesty’s
Forces. Medical men are registered and informed of open¬
ings for Government or private appointments.
Babies in Cornwall and Devon.
In the course of a debate on supplementary estimates for
the Board of Agriculture and Fisheries, Sir A. Griffith
Bobcawen (the Parliamentary Secretary to the Department)
said that there had been 119 cases of rabies—95 in Devonshire
and 24 in Cornwall. It had been necessary to impose very
severe restrictions. He could give no date when the restric¬
tions would be taken off. They had got to wait until the
disease was stamped out. He believed that the general rule
was that restrictions oould not be taken off in any oase
until at least six months after the last reported oase. There
was a case reported only a few days ago.
Monday, March 3rd.
Spirits for Medicinal Uses.
Replying to Sir J. Harmood-Banner, who asked regarding
the releases of spirits from bond to meet cases where these
were ordered by medical men, Mr. McCurdy (Parliamentary
Secretary to the Ministry of Food) said: The increase in the
percentage of spirits permitted to be withdrawn from bond
for home consumption—namely, 50 per cent, of the quantity
withdrawn in 1916 to 75 per cent, of that quantity—operates
as from Feb. 24th. The additional quantity permitted to be
withdrawn for the unexpired one-tenth of the excise year—
namely, from Feb. 24th to March 31st is one-tenth of the
additional 25 per cent. The Cabinet and the Food Controller
have at present no reason to Buppose that these additional
releases will not prove reasonably sufficient for the needs of
the public.
Medical Inspectors of Home Office .
Sir P. Magnus asked the Home Secretary how many
members of his staff were engaged in the medical inspection
or treatment of persons employed in factories or workshops,
or otherwise engaged in matters relating to such doctors.—
Mr. Shortt replied : I understand the honourable baronet
to refer only to the medical side of the Factory Department.
The present established staff, which numbers about 200,
includes three medical inspectors who supervise the work
of the factory certifying surgeons. There are also three
temporary women inspectors with special hospital training.
Medical Women and War Office Employment.
Major Tudor-Rees asked the Chancellor of the Exchequer
whether the women doctors serving at the military hospital,
Endell-street, London, drew their pay and allowances under
the Royal Warrant, were paid from Army funds by the
command paymaster, were appointed by the War Offioe, and
were under the command of the Deputy Director of Medical
Services, London District; whether, for purposes of pay,
they were graded according to the ranks of the Royal Army
Medical Corps; if so, whether they came within the terms
of Schedule E of the Income-tax Return as persons who had
served during the year as members of any of the naval or
military forces of the Crown, and as such liable only to the
service rate of income-tax; whether up to now they had not
been allowed the relief, although the Income-tax Com¬
missioners determined that they were entitled to it;
and whether he would give instructions for the grant¬
ing of the relief as from the year 1914.—Mr. Baldwin
(Secretary to the Treasury) (on behalf of Mr. A. Chamber¬
lain) answered: The ladies employed upon medioal duties
as described in the question are civilian medical practi¬
tioners and are not serving as members of any of
the naval or military forces of the Crown. As regards
the latter part of the question the honorary Member is under
a misapprehension An appeal was lodged on behalf of these
doctors to the District Commissioners of Taxes, whose
decision was that they were not entitled to the servioe rate of
income-tax.
Dental Surgeons and the Army Gratuity .
Replying to Mr. Perkins, Mr. Churchill (Secretary for
War) said that the gratuity provided under Pay Warrant,
1914, paragraph 497, was not payable to dental surgeons.
Dental surgeonB had been engaged under a special contract
which did not carry a right to the Pay Warrant gratuity,
but as a special concession & gratuity of £50 for each year, or
part of a year, had recently been approved for these offioers.
Tuesday, March 4th. „
Glen Lomond Sanatorium.
Replying to Colonel Sir A. Sprot, Mr. Churchill
(Secretary for War) stated that orders had been given for
the evacuation at once by the War Department of the Glen
Lomond Sanatorium, Fife, the number of patients there
being now sufficiently reduced to admit of it being handed
baok for the treatment of tuberculosis.
Medical Inspection in Factories.
Replying to Sir P. Magnus, Mr. Shortt (Home Secretary)
stated that he would consider the advisability of transferring
the medical inspection or treatment of persons employed in
factories or workshops to the oharge of the new Ministry of
Health.
Broncho-Pneumonia in the Army.
Replying to Lieutenant-Colonel W. Guinness, Mr.
Churchill (Secretary for War) said the number of
admissions to hospital from broncho-pneumonia among
i the British Expeditionary Force in France daring the week
ended Feb. 8th was 238 and the number of deaths was 84.
The Lancet,]
APPOINTMENTS.—VACANCIES.
[March 8,1919 403
Strict instructions were issued in October last as to the
isolation of broncbo-pneumonia oases, and he was informed
as a result of special inquiry that these instructions had
been strictly complied with. He would be glad to investigate
any specific instances of casualty clearing stations or general
hospitals where tbeee cases were not properly isolatea.
Medical Men in Military Service.
In answer to Mr. Lyle, Mr. Churchill said that there
were 11,193 medical men and 23,931 nurses employed in the
Army on Nov. 11th last, and 9593 medical man and 20,141
nurses were at present serving. The proportion of doctors
in November was 1 to 318 all ranks, ana was now 1 to 314 all
ranks. The proportion of nurses in November was 1 to 148
all ranks, ana was now 1 to 149 all ranks. He would point
out that the demobilisation of medical men and nurses bore
little relationship to the demobilisation of the Army as a
whole; it was dependent at the bases and at home on the
discharge of the hospital population, and in the field on
reduction in units and formations. A very large number of
civil doctors and nurses who were employed in the Voluntary
Aid Detachment hospitals which had been closed and who
had been released were not included in the figures he had
given.
Releasing Panel Practitioners.
Sir Kingsley Wood asked the Parliamentary Secretary
to the Local Government Board representing the National
Health Insurance Commissioners whether he would state
the number of medical men on the panel lists on the date of
the signing of the armistice and the number of medical
men who had been demobilised since that date, and what
steps he was taking to secure a more efficient medical
service for insured persons by obtaining an early demobilisa¬
tion of medical men.—Major Astor replied : The number of
practitioners working for the Insurance Committees in
England on Oct. 1st, 1918, was 8084, besides a certain
number holding commissions in the R.A.M.C. who
were free to do some part-time work for their Com¬
mittee. Since Nov. 11th the number of insurance prac¬
titioners on panels in England who have been notified
to the Commissioners by the War Office up to Feb. 21st as
definitely released from service was 647. In reply to the
last paragraph of the question, I must remind the honour¬
able Member that the responsibility for arranging with the
Military, Naval, and Air Force authorities for the demobilisa¬
tion of doctors needed for the civil population rests with the
Ministry of National Service. My department makes
periodical representation to that department for expediting
the rate of release of doctors for civil needs, and for securing
the release of particular doctors required for specially urgent
necessities in individual areas. The Commissioners are in
constant communication with the various Insurance Com¬
mittees as to the needs of their areas in this respect. I am
sending the honourable Member copies of circulars addressed
to these Committees which will explain the procedure
adopted since the armistice.
Insurance Practice.
Sir Kingsley Wood asked the Secretary of the Local
Government Board whether he was aware that there had
been a serious diminution in the total number of panel
doctors taking place continuously since the beginning of the
war; whether he could state the number of such decrease
as on the first day of January last; and what action he
proposed to take m the matter.—Major Astor answered:
Yes, sir; it must be remembered that besides the large
numbers of insurance medical men serving with the forces,
the normal diminution of medical men by age retirements
from practice and by deaths during the five years have not
(as in peace time) been made good by new entrants, because
newly qualified doctors have been taken into the military
forces throughout the period. It is believed that the number
of medical men actually carrying on insurance practice in
England on Oct. 1st last was some 3800 less than at the end
of the year 1914. My department has in the last few days
had further conference on the subject with the Ministry of
National Service, and that department is in communication
with the War Office who have stated that the Secretary of
State is taking steps to expedite the release of doctors from
the Army.
Bonus to Panel Practitioners .
Sir Kingsley Wood asked the Secretary to the Local
Government Board whether, with reference to the £250,000
bonus the Insurance Commissioners had agreed to pay to
doctors on the panel lists, statutory authority had yet been
obtained for such payment; and whether it was contem¬
plated that such payment would be made for the present
year only.—Major Astor replied: The statutory authority
in the Appropriation Act, embracing the moneys provided
by Parliament under Votes of Credit, covers the payments in
question, the necessity for which arose from conditions due
to the existence of a state of war. As regards the second
part of the question, the payments now being made are in
respect of the calendar year 1918 only; no undertaking has
been given that similar payments will be made in respeot of
the year 1919, but financial provision for that contingency
will be proposed in the Parliamentary Estimates for 1919-20
shortly to be issued.
The Size of Panel Practices.
8ir Kingsley Wood asked the Parliamentary Secretary
to the Local Government Board whether he was aware that
certain doctors on the insurance panel had over 6000
patients on their panel list and at the same time carry on a
private practice; and whether he proposed to take any
steps to secure a better provision for medical services to the
insured population.—Major Astor answered: No, sir ; I am
not aware of any case in which an insurance practitioner
has a list of over 6000 insured persons for whose treatment
he is responsible single-handed. If my honourable friend
has any such case in mind perhaps he will be good enough
to furnish me with particulars. As regards the second part
of the question, preliminary discussions with representa¬
tives of the medical profession preparatory to a general
revision of the conditions of medical services for the insared
have been taking place for some time, and careful con¬
sideration is being given by the department to the question
of bringing about various improvements in those servioes.
Successful applicants Jor vacancies , Secretaries oj Public Institutions
and others possessing information suitable for this column , are
invited to forward to The LawcsT Office, directed to the Sub-
Editor, not later than 9 o'clock on the Thursday morning of each
week, such information for gratuitous publication.
Cumbkrlidgb, W. I., Capt., R.A.M.C. (T.), has been appointed
Honorary Surgeon to the Leicester Royal Infirmary.
Do bras hi ah, Margaret, M.B., B.S. Lond., City Pathologist,
Nottingham.
Foster, A. H., M.R.C.8.. L.R.C.P.Lond., Certifying Surgeon under
the Faotoiy and Workshop Acts for the Hitchin district.
Nutt all, W. w., M.D. Durh., Certifying Surgeon under the Factory
and Workshop Acts for the Folkestone district.
Stanms.
For further information refer to the advertisement columns.
Aylesbury , Royal Buckinghamshire Hospital.— FL&.
Bfrmingham University Faculty of Medicine.—Asst. Prof, of Anatomy.
Bodmin, Cornwall County Asylum.— Jun. Asst. M.O. £300.
Bradford Children’s Hospital.— H.S. £170.
Bradford Union.— Asst. M.O. £400.
Brighton, Royal Sussex County Hospital.— H.P. £100.
Bristol Central Hospital.—C m. H.8., Obstet. O., and H.S. £175.
Cardiff, King Edward Vll.'s Hospital.— H.8. £200.
Carlisle, Cumberland Infirmary.- H.S. and H.P. £250.
Carlisle , Cumberland and Westmorland Asylum, Garlands.— Jun. Asst.
M.O. £300.
Chartham, near Canterbury, Kent County Lunatic Asylum.— Med.
Superintendent. £800.
Coventry and Warwickshire Hospital. —Res. H.P. £250.
Dudley, Guest Hospital and Eye Infirmary.— Asst. H.8. £120.
East African Medical Appointments.— M.O. £400-£20-£5Q0.
Guy’s Hospital , S.E.— Surg. Radlog. Also Med. Radios. 50 gs.
Hackney Union Infirmary, Homerton, A.—Jun. Asst. M.O. £250.
Hampshire County Council.— Temp. Asst. M.O.H. £400.
Hospital for Sick Children, Great Ormond-street, W.C.—P.
Huntingdon County Hospital— Res. M.O. £120.
Manchester, Baguley Sanatorium for Tuberculosis.—Tint and Second
AsBt. M.O. £400 and £350.
Manchester, Booth Hall Infirmary for Children , Charlestown-road ,
Blackley, near Manchester.— Med. Supt. £500. Also Asst. Res. M.O.
£250.
Manchester Children’s Hospital. Pendlebury, Outpatients' Department,
Gartside-street, Manchester.— Asst. M.O. £200.
Manchester Royal Infirmary Convalescent Hospital, Cheadle.—Be s. M.O.
£300.
Middlesbrough County Borough.—Female M.O. for Maternity and Child
Welfare. £350.
Middlesex County Council— Tuberc. M.O. £600.
Noruich, Norfolk and Norwich Hospital.— H.S. £200. Also Asst.
Hon. P.
Nottingham Children's Hospital .—Female Res. H.8. and Res. H.P. and
Amestb. £250 and £200 respectively.
Nottingham City Asylum.—Second Asst. M.O. £300.
Queen Mary’s hospital Jor the East End, Stratford.—Ron. Gynsecol.and
Obstet.
St. Mary’s Hospital for Women and Children, Plaistow, E.— Res. M.O.
£250.
Salford Cou?Uy Borough. —M.O. for Maternity and Child Welfare £400.
Samaritan Frte Hospital for Women, Marylebone-road. —H.S. £150.
Scarborough Hospital and Dispensary .—Two H.8.
Shanghai Municipal Council Health Department.— Asst. Health Officer.
£900.
Sheffield City Hospital.— Asst. M.O.
Sheffield Royal Infirmary.— Oss. Officer. Also Oph. H.S. £150.
Staffordshire Education Committee.—Female Asst. M. Inspectors. £400.
Stannington, Northumberland, Children’s Sanatorium.— Female Res.
Doctor.
Stroud General Hospital.— H.S. £250.
404 The Lancet.]
BIRTHS, MARRIAGES, AND DEATHS.—MEDICAL DIARY.
[Mabch 8,1919
Tottenham Maternity and Child-Welfare Committee, Ante-Natal Clinic .—
Female M.O. £1 11*. 6d. per session.
Tunbridge Wells General Hospital.—Two H.S.
Union of South Africa Mental Hospital Service. —Six Amt. Phye. £380.
Warwickshire and Coventry Joint Committee for Tuberculosis.—Aset.
Tubere. Officer. £400.
Western Ophthalmic Hospital, Mary 1 ebon e-road. N. W. —Two Asst. S.
Whitehaven and West Cumberland Infirmary.— Res. H.S. £180
Wolverhampton and Midland Counties Eye Injirmary.—H.S. £200.
In Chief Inspector of Factories, Home Office, 8.W., gives notice of
vacancies for Certifying Surgeons under the Factory and Workshop
Aete at Mattock, Bent ham, Perranporth, Brynamman, and Den by
Dale, Yorks. __
Jprfjp, Carriages, anb jtatjp.
BIRTHS.
Flstcheb.— On Feb. 25th. at Oldfield Farm, Maidenhead, the wife of
8urgeon B. T. Fletcher, M.B., R.N., of a son.
Green.— On Feb. 28t h, at The Ferns, Romford, the wife of Charles D.
Green, M.D., F.B.C.S.. of a daughter.
Wood.— On March 1st, at Blenheim House, North Berwick, the wife of
Captain Pereival Wood, R.A.M.C., of a daughter.
MARRIAGES.
Archibald—Cant.— On March 1st, at Colchester, by Canon Brunwin-
Hales, Robert George Archibald. D.S.O., R.A.M.C., to Olive
Chapman, only child of Mr. and Mrs, Arthur Cant, of Claremont
House, Colchester.
Wallace—Keexb.— On Feb. 26tb, at St. Mary’s Church, Bast Molesey,
Surrey, Captain H. K. Wallace, M.D., R.A.M.C., to Alice Freda,
youngest daughter of Rev. C. V. P. Keene and Mrs. Keene, of
Cross wood. East Mclesey. _
DEATHS.
Chick.— On Feb. 2Sfcb, at 21, Bndsloigh-street, W.C., Dorothy Chick,
M.D., B.S., Resident Medical Officer, Marlborough Maternity
8eotlon of the Royal Free Hospital, youngest daughter of Samuel
and Bmma Chick, of Cheatergate, Baling, and Branacombe, Devon,
aged 31.
Evans.— On Feb. 22nd. at The Firs, Lyndhurst, Hants, Colonel Arthur
Owen Evans, late I.W.S.
Hemingway.— On Feb. 27th, at Prinees-road, Wimbledon, from pneu¬
monia, John Hemingway, M.R.C.S., L.R C.P. Lend., aged 51.
Pole.— On Feb. 27th, at Oxford, Charles Kingsley Pole, M.B., Ch.B.,
aged 30.
Prtck.— On Feb. 21st, at 35 General Hospital, Calais, of broncho¬
pneumonia, Captain Arthur Meurig Pryce, R.A.M.C., aged 41.
Sharpe.— On St. Chad’s Day, at his residence. Marylands, Swanage,
from influenza, Cyril Herbert Sharpe, L.R.C.P., L.K.O.S., aged
68 years.
N.B.—A fee of 6s. is charged for the insertion of Notices of Births,
Marriages , and Deaths.
MANAQBR’8 NOTICE.
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Professoe J. A. Lindsay, M.D., has been elected
chairman of the board of management of the Royal Victoria
Hospital, Belfast, in succession to the late Sir William
Crawford.
A meeting of the Marylebone Division of the
British Medical Association will be held on Wednesday,
March 12th, at 5 p.m., at the rooms of the Medioal Society of
London, U, Chandoa-street, W., to discuss the Ministry of
Health and the attitude of the medioal profession in relation
thereto.
JBebital $iarjr for % ensuing fflhdu
SOCIETIES.
BOYAL 80CIBTY. Burlington House, London. W;
Thursday, March 13th.—Papers s—Dr. A. D. Waller: Oonoernlng
Emotive Phenomena. Part III., The Influence of Drugs upon
the Electrical Conductivity of the Palm of the Haod^Dr.
W. L. Balls: The Existence of Daily Growth-Rings In the Ceil
Wall of Cotton Hairs (communicated by Dr. F. F. Blackman).
ROYAL SOCIETY OF MEDICINE, 1. Wimpole-street. W.l.
Wednesday, March 12th.
SOCIAL EVENING: at 8.30 p.m.
Dr. Henry Head, F.R.S., will discourse on Disease and Diagnosis.'*
(Light refreshments and smoking).
MEETINGS OF SECTIONS.
Tuesday. March nth.
PSYCHIATRY (Hon. Secretaries—Bernard Hart, G. F. Barham):
at 5 p.m.
Paper r
• Dr. O. Stanford Read : War Psychiatry.
Thursday, March 18th.
NEUROLOGY (Hon. Secretaries—C. M. Hinds Howell. H. G. Fleam-
sides): at 8.30 p<m.
Paper :
Dr. A. B. Carver: Some Biological Effects due to High Explosives.
Friday. March 14th.
EPIDEMIOLOGY AND 8TATB MEDICINE (Hon. Secretaries—
William Butler, M. Greenwood): at 5.30 p.nl
Paper:
Dr. H. M. Vernon : Industrial Accidents.
Members wishing to dine are requested to communicate with
Captain Greenwood, 7, Nortbumbsrland-street, W.C. 2, not later
than March 12tb.
The Royal Society of Medicine keeps open house for
R.A.M.C. men and M.O.’e of the Dominions and Allies. The
principal hospitals in the metropolis admit medical ottoers
to their operations, lectures, flac. Particulars on application
to the Secretary at l, Wimpole-street, London, W. 1.
MEDICAL SOCIETY OF LONDON, 11. Chando*afc.,Oeven<ll«h-eq.iW.
The Lettsomlan Lectures by Col. W. H. Wlllcox, announced to
begin on March 10th, have been postponed for a few weeks.
LECTURES, ADDRESSES, DEMONSTRATIONS, Ac.
ROYAL COLLEGE OF PHYSICIANS OF LONDON, Pall Mall Bosh.
Thursday, March 13th.—5 p.m., Milroy LecturesDr. J. C.
Me Vail: Half a Century of Small-Pox and Vaccination.
POST-GRADUATE COLLEGE, West London Hospital, Ha mi e raa tth-
road, W.
Special Eight Weeks’ Course of Post-Graduate Instruction. (Details
of Lhe Course were given in our Issue of Feb. 15th).
NORTH-EAST LONDON POST-GRADUATE COLLEGE, Prince of
Wales’s General Hospital, Tottenham, N.
Out-patients each day at 2.30 p.m.
LONDON HOSPITAL MEDICAL COLLEGE.
▲ Special Course of Instruction in the Snrgioal Dyspepsias will be
given at tho Hospital by Mr. A.‘J. Walton. Lectures, given in the
Clinical Theatre :—
Monday, March 10th.—4.30 p.m., Lecture V.:—Dev Hutchison: Con¬
ditions Simulating Dyspepsia.
Friday.— 4 30 p.m.. Lecture VI.:—Dr. Hutchison: The Differential
Diagnosis of Medioal from Surgical Dyspepsias.
UNIVERSITY OF LONDON, KING’S COLLEGE. AND KING'S
COL LEG B FOR WOMEN.
Course of Six Public Lectures arranged In conjunction with the
Imperial Studies Committee of the university on Physiology end
National Needs:—
Wednesday, March 12th.—5.30 p.m., Lecture VI.:—Prof. A. Dendy*.
The Conservation of our Cereal Reserves.
ST. THOMAS’S HOSPITAL MEDICAL SCHOOL ( University of
London), Governors' Hall, St. Thomas’s Hospital, 8.B.
▲ Series of Ten Lectures on Diseases met with in the Sub-tropfeal
War Areas (Illustrated with lantern slides, charts, diagrams and
microscopical preparations).
Wednesday, March 12th, and Friday. — 5 p.m;, Lectures lILaod-IT.:
Dr. L. 8. Dudgeon : Malarial Fever.
ROYAL INSTITUTB OF PUBLIC HEALTH, in theLeetnee HaHof
the Institute, 37, Russell-square, W.C.
Course of Lectures and Discussions on Public Health Problems under
War and After-war Conditions :—
Wednesday, March 12th.—4 p.m., Prof. Sir Thomas Oliver: After*
War Reconstruction —Social and Medical.
CHADWICK PUBLIC LECTURES, at the Technical College HalL
Bradford.
Thursday, March 13th.—7.30 p.m., Prof. LeggerlnduetriaJ Polaoaia*
and its Prevention—11., Aeroplane Manufacturing; Dyes ana
Dyeing (Illustrated by lantern slides).
ROYAL INSTITUTION OF GREAT BRITAIN, Albemarle**!**
Piocadilly, W.
Monday, March 10th.—3 p.m.. Lecture:—Capt. G. P.Thomson: The
Dynamics of Flying.
Friday.—5.30 p.m., Prof. A. Ktlth: The Organ of Hearing flrom
a New Point of View.
ROYAL SANITARY INSTITUTE,90. Buckingham Paiaoe*oed, S.W.
Thursday, March 13th, Friday and Saturday.—1030 a.m. each
day, Confereeoe on Post War Developments relating to Public
Health.
ThhLanobt,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [Maboh8, 1919 405
Stotts, Sjprit Comments, into Jnsfoers
to Correspondents.
THE VITAL NEED: A THIRD FACTOR.
Professor A. Harden, F.R.S., head of the Biochemical
Department of the Lister Institute, delivered on Feb. 26th,
at King’s College, London, the fourth of a series of lectures
on Physiology and National Needs, Scurvy : A Disease Due
to the Absence of Vitamines being the subject of his dis¬
course. In the previous lecture Professor F. G. Hopkins
enumerated three mysterious substances, of unknown
composition, necessary for the continued life of most
animals, one of these being the antiscorbutic principle.
This principle, Professor Harden said, would form the
subject of his own lecture. The absence of this substance
both inhibited growth and induoed the disease scurvy, long
known to be due to defective diet. The British were always
a sea-going people, and as soon as voyages came to exceed a
period of 1-2 months scurvy made its appearance among the
sailors. The records of sixteenth and seventeenth century
explorers were full of references to this disease, and fruits and
vegetables came to be looked upon as remedial. At the present
day adult scurvy was only known in times of war or of famine.
Less rare than adult scurvy was infantile scurvy, first
differentiated from rickets by Cheadle and Barlow. Recently
owing to the shortage of vegetables outbreaks of the disease
had occurred both here and in America, in this country
particularly after the shortage of potatoes in the spring of
f 1917. Similar outbreaks had been recorded—e.g., during the
> potato famine in Ireland (1847) and in Norway (1904). During
the American Civil War 30,000 cases of scurvy were reported.
Result* of Experimental Investigations.
s Little progress had been made in regard to the exact know-
, ledge of the disease until it was experimentally treated in
the laboratory. In 1907 the Danes, Holst and Frolioh, used
guinea-pigs for this purpose, and their work had been
followed up in America and in this country at the Lister
Institute. Guinea-pigs fed on a diet free from antisoorbutios,
consisting, for instance, of oats, bran, and water, or, better
still, autoclaved milk, developed scurvy in about three weeks,
and died with all the characteristic symptoms of the disease.
On adding antiscorbutio substances to the diet the animal, if
not too far gone, would recover and grow in a normal
manner. The following table was exhibited, showing the
4 relative value of certain foodstuffs against beri-beri and
scurvy:—
it
U
|i
a
li
ii
< 8
<£
* Cereals —
Fruit juices—
Whole wheat
4-4-
0
Freeh orange or
Wisest, germ ... ...
+++
0
lemon.
...
4-4-4-
Wheat bran.
4-4-
0
Commercial lime...
0
White wheat flour
i Pultes —
0
0
Rags— Fresh .
Dried .
+ +
+ 4-
Whole peaa or lentils
Germinated do., do.
Vegetables—
Freeh cabbage ...
4-4-
+ +
+
0
+ f+
4-4-4-
.Meat— Freeh .
Tinned .
JfilJfc—Freeh .;. ...
+
0
4-
+
0
+
Freeh potatoes.
Dried .
4-
0
carrots, 4a.
+
+
Yeeat pressed .
4-4-4-
0
Dried (any) .
+
0
Extract marmite ...
4-4-4-
0
It would be seen, therefore, that the green leaves of plants,
the tubers of potatoes, and the juioes of fruits were the chief
Bouroe of antiscorbutics. The relative quantities of the anti¬
scorbutic substance contained in various foodstuffs was indi¬
cated by some hitherto unpublished work of Dr. Harriette
Chick and her colleagues, which showed that taking cabbage
i as 100, lemon juice came out at 66, orange juice at 33,
swede juice at 40, cooked cabbage, germinated lentils, and
, runner beans at 20, lime juice 10-5, meat juice 5, grape juice
less than 5, cooked potato 5, dried cabbage 1-2, and milk 1.
' The fact that germinating seeds contained the principle was
important in providing a supply of the necessary substance
r where green vegetables were unobtainable.
i Prevention and Treatment.
f Investigation was hampered, Professor Harden went on,
by the fact that the antisoorbutic principle was rendered
* inactive by beat, and therefore difficult to preserve, a fact
which was important because most of our foods were cooked.
It was better to cook vegetables at a high temperature for a
I short period than for a long time at a lower temperature. If
stews were the staple diet orange juice should be added to
? the menu to.make good the loss of vi tamine s. Vegetables
t dried in the air or otherwise lost a large part of their anti¬
scorbutic principle. Alkalies 1 destroyed the principle and
soda should not be added to the water used for boiling
vegetables. In monkeys symptoms could be produced
closely similar to those of infantile scurvy, and these yielded
promptly to lemon juice deprived of its citric acid. Orange
juice had a similar effect. Lime and lemon juice were
judged aforetime by the amount of acid which they con¬
tained. Lemon juiee, after removal of free citrio acid with
chalk, retained its antiscorbutic properties. Beer, it had
been suggested, owed its appetising and tonic properties to
one or more of the vitamme accessory food factors, but
modern beer was totally devoid of any antineuritic or anti¬
scorbutic principle. The effect of scurvy on the bones and
teeth of growing animals had been observed by Dr. Zilva
and Major Wells, of the Canadian Medioal Force. Guinea-
pigs fed on an antiscorbutic-free diet might in some
instances increase in weight normally, but on post-mortem
examination the teeth showed complete destruction of the
odontoblastic cells and of the structure of the pulp.
Incipient scurvy had been studied by the American observer.
Dr. Hess, who found that children fed on different prepara¬
tions of milk might have scurvy in a subacute or latent
form. In sterilising or pasteuring milk there was a danger
that its already small antiscorbutio property would be lost
altogether, and the same applied to dried milk. Dr. Harriette
Chick and Miss M. Rhodes had produced definite evidence 2
that guinea-pigs brought up on dried milk suffered from
scurvy. Swede juice could be substituted for orange juice.
An advantage of the neutralised lemon juice was that it
might be administered in large quantities without causing
gastric disturbance.
Dr. Norman Moore, who presided, referred to the preva¬
lence of scurvy in past times, not only on board ship
but in ordinary life. A William Clowes, surgeon to
St. Bartholomew's and Christ’s Hospitals, had reported it
to be common amongst the boys at the latter hospital. Dr.
Budd, a physician to Christ’s Hospital, induoed the authori¬
ties to put potato upon the regular diet, when presumably
scurvy came to an end. Clowes also in his writings
mentioned the case of a ship that had started its voyage
with a crew of 90 putting into Plymouth with an effective
orew of only 28, the others being down with scurvy.
TWO XVII. CENTURY PHYSICIANS.
Mr. G. C. Peachey contributed last year to Janus, the
organ of the Soci^t£ Historique des Sciences M6dicalee, pub¬
lished at Leyden, articles on the two John Psaobeys, the
seventeenth oentury physicians. These articles have now
been reprinted. The family of Pechey, Peachie, earlier
Peche, according to the whim of the family branch or of the
individual, belonged to the yeoman cIbbs of England,
and during the sixteenth century were settled in villages
of West Sussex, throughout the Fen district, and 'in
East Anglia. From the Sussex branch was descended
John Peachy, Licentiate of the College of Physicians,
and through the other branches John Peachie, M.D. Caen,
Extra-urbem Licentiate of the College of Physicians.
They were not related except through some far distant
ancestor. John Peachy, the son of a physician, was baptised
at Chichester on Dec. 11th, 1654, and at the age of 17
matriculated at Oxford as a member of New Inn Hall, one
of the “ nests of Preoisans and Puritans,” another being
Magdalen Hall, of which Sydenham was a member. He
graduated B.A. and M.A. respectively in 1675 and 1678, but
there is no record of his having taken a degree in medicine.
Probably he studied under his father, and afterwards at
the hospitals in London. In 1684 he was admitted to the
lioentiateship of the College of Physicians and practised
in the neighbourhood of Cheapside. As the translator
of the first English version of the works of Sydenham
he is certainly entitled to fame, but it is curious to note that
his Collections of Acute Diseases, now an extremely rare
work, and his Collection of Chronical Diseases were them¬
selves extracts from Sydenham’s writings, and part of them
were published in Sydenham’s lifetime. It is suggested that'
Peachy’s delenoe of the great physician and his opinions
against the rancour of his opponents might have been
reciprocated by Sydenham in giving his tacit consent to
the publication of his works in English. Peachy must have
been a man of phenomenal industry, for in the dozen years
between 1686 and 1696 he published no less than 12 distinct
medioal works, all with one exception in English, though
he was a competent Latin soholar. His fame, however,
really rests on his association with Sydenham’s works, and
possibly his association with Sydenham himself. His inde¬
pendence of thought and action are ebown by his courage in
defying at the outset of his career the time-honoured
tradition that works of medioine should appear in Latin, and
by his aggressive attitude towards the College of Physicians
in respect of fees and fines, which he refused to pay. He
was openly contumacious to the College, and, regardless of
professional ethics, he unwarrantably assumed the title df
1 The Lancet, 1918, U., 320. 3 The Lancet, 1918, ii., 774.
406 Tn LANCET,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [March 8, 1919
M.D., charged low fees, and did not disdain to advertise.
He died in 1718.
John Peachie, M.D. Caen (1632-1692) was born in Lincoln¬
shire, and was descended through a line of clergymen. He
was intended for the ministry, and in 1649 he was admitted
a sizar at St. John’s, Cambridge, bat probably did not take
a degree. His early years were spent under the stern
discipline of Puritanism, and refusing to “ oonform ” he was
for 17 years the victim of the persecution of the times.
During the plague year he was in prison, but was probably
released in order that he might render service to the
afflicted and add to the number of the heroic practitioners
who remained at their post to fight the foe. Nothing more
is heard of him, however, till 1672, when two months after
the declaration of indulgence he went to Caen, where
he may have taken bis degree about 1676, and afterwards
in 1679 he published an account of Cassummuniar, “ the most
proper corrector of the Jesuits Powder rend’ring that medi¬
cine safe and harmless.” In 1683 he became a Licentiate of
the College of Physicians, extra urbem. His self-appointed
r61e was to minister to the needs of others, and, to use his
own words : “ If what I have written may tend to the public
advantage I have my end; and I could wish that all phy¬
sicians would so far consult the good of mankind as to com-
munioate what they have singular to the world, and so noble
a science might be completed and health be the better
preserved and restored.”
SUMMER TIME.
Summer time will be brought into force this year on the
morning of Sunday, March 30th, and will continue until the
night of Sunday-Monday, Sept. 28th-29th. It began on
March 24th last year and ended on Sept. 29th-30th. In France
and Italy summer time began on Feb. 28th.
TOTAL DEATHS FROM WOUNDS IN THE
GREAT WAR.
From figures compiled by the Chief of Staff of the United
States Army it appears that the number of men of all
nations killed in battle or who died of wounds during the
warfare beginning August, 1914, was 7} millions. The losses
are divided very unequally between the two opposing sides,
as Germany, Austria, Turkey, and Bulgaria are credited with
22 million deaths and the eight principal opposing countries
with 44 millions, a proportion of ll: 18. Measuring in
hundreds of thousands, Russia heads the list with 17,
Germany with 16, and France with 13. There follow:
Austria, 8; British Empire, 7; Italy, 44; Turkey, 24*; Belgium,
Bulgaria, Rumania, and Serbia (with Montenegro), 1 each;
the United States, 4-
CONFERENCE ON INFLUENZA AND ITS
PREVENTION.
At a conference on this subject held at the Institute
of Hygiene on Feb. 28th Sir Malcolm Morris, the President,
spoke of the remarkable differences of opinion which existed
in regard to the prevailing epidemio. He propounded a
series of questions which he asked the speakers to answer.
Was there any relation between climate and influenza? The
disease was rife in England, Australia, India, and America.
Was it due to crowdB? It attacked individuals in isolated
f >laces, and in November the employees of the tubes suffered
ess than drivers of omnibuses. What was the relation of
the common cold to influenza? What was the value of
maskB? Was alcohol necessary? If so, at what stage of the
disease should it be taken? He thought it was necessary
neither for prevention nor treatment. What was the value
of prophylactic vaccines, especially as regards streptococcic
infection? What was the value of the Local Government
Board regulations?
The answers given showed the considerable differences of
opinion which existed among those present. Sir StClair
Thomson said that all who were suffering from the disease
should be isolated and required to wear masks or veils
when anybody came near them. He was opposed to the use
of irritating solutions for washing out the nose. Sir
Kingsley Wood said that the steps taken by the Government
were of a voluntary educational character. No power
existed for ordering the discontinuance of meetings or
the closing of schools. If the disease continued to
spread he thought disciplinary action should be taken.
Dr. Carnegie Dickson drew attention to the existence of
carriers among persons with chronic infection of the air-
passages. He considered that masks were useful. Prophy¬
lactic vaccines did not prevent but determined a milder
attack of the disease. Dr. Hector Mackenzie laid stresB on
the need for improved hygiene of the mouth. Influenza
being due to an ultra microscopic virus, vaccines could hardly
protect against the disease itself, but were advisable against
complications. The wearing of masks was unpractical, the
minute germ readily passing through the finest me&hes. Dr.
R. Murray Leslie thought vaccines were helpful in warding
off complications. Dr. D. C. Kirkhope did not think that the
Local Government Board regulations with regard to cinemas
were effective. Nurses, he said, required more rest. Alcohol
was useful as a stimulant. Dr. Stuart-Low objected to solu¬
tions for the nose, and advanoed the theory that the poorness
of food might have something to do with the epidemio.
BOOKS, ETC., RECEIVED.
Allen, George, and Uxwix. London.
The Kingdom of Serbia. By B. A. Reiss. 3s. 6d.
Bailu&rb, Tindall, and Oox, London.
▲ids to Surgery. By J. Gunning, F.B.O.8., and 0. A. Jell. F.B.C.S.
4s. 6 d
Bale, John, Sons, and Danielsson, London.
Malaria and its Treatment in the Line and at the Base. By Captain
A. C. Alport, R.A.M.C.(T.). 2ls.
Bryce, William, Edinburgh.
Pocket Notes on Nerves. Compiled and arranged by T. Mulrhead
Martin. M.D. Edin. 2s.
Cassell and Co., London, New York, Toronto, and Melbourne.
Elements of Surgical Diagnosis. By Sir A. Pearce Gould, K.O.V.O.,
and E. Pearce Gould, F.R.C.S. 5th ed. 12s. 6d.
Macmillan and Co., London and New York.
Typhoid Fever Considered as a Problem of Scientific Medicine.
By F. P. Gsy, Professor of Pathology, California. 12s. 6d.
Nisbet and Co., London.
War Pern-ions Past and Present. By His Honour Judge Parry and
Lleutenaut-Goneral dir A. B. Codrington. 6s.
University of London Press, Ltd., London; and Masson et Gie.
Paris.
Mental Disorders of War. By Jean Lupine. Edited, with a Preface,
by C. A. Mercier, M.D. 7s. 6d.
Wounds of the Pleura and of the Long. By R. Grdgolre and
A. Coureoux. Translated by C. H. Fagge, F.B.C.S. 7s. 6a.
Electro-Diagnosis in War. By A. Zimraern and P. Parol. Edited,
with a Preface, by E. P. Cumber batch, B.M. 7s. 6<2.
Disabilities of the Locomotor Apparatus the Beiult of War Wounds.
By A. Broca. Translated by J. R. White, Temp. Captain, &.A.M.C.
Edited, with a Preface, by Major-General Sir B. Jones. 7s. 6d.
Year Book Publishers, Chicago.
Practical Medicine Scries. Edited by C. L. Mix, M.D. Voi. VI.:
Pharmacology and Therapeutics. By B. Fantus, M.D. Preventive
Medicine. By Wm. A. Evans, M.D. Series 1918. |1.
Practical Medicine Series. Vol. VII. 8kin and Venereal Diseases.
Bdlted by O. S. Ormsby, M.D., and J. H. Mitchell, M.D.
Series 1918. $1.40__
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THE LANCET,
AN
detrimental $nbestigaiion
ON
RICKETS.
Troo Lectures Delivered at the Royal College of Surgeons of
England
By EDWARD MELLANBY, M.A., M.D. Cantab.,
ACTING SUPERINTENDENT OF THE BROWN INSTITUTE,
LONDON UNIVERSITY.
LECTURE I.
Haying described in the first two lectures of this course
the experimental results obtained in a Research on Alcohol
for the Central Control Board (Liquor Traffic), I propose in
the next lectures to deal with another social evil—rickets—
and to give an account of an experimental investigation
made for the Medical Research Committee with the object
of finding the essential cause of this disease.
Thb Serious Results of Rickets.
It is but little realised how great and how widespread is
the part played by rickets in civilised communities. If the
matter ended with bony deformities obvious to the eye it
would be.bad enough, but investigations have demonstrated
that such deformities only represent a small part of the cases
affected. Schmorl’s histological investigations on children
dying before the age of 4 years showed that 90 per cent, had
had rickets. Again, Lawson Dick’s examination of the
children in London County Council schools, and more
particularly the examination of their teeth, led him to
state that 80 per cent, of such children had had rickets.
The relation between rickets and defective teeth has been
placed on an experimental basis recently by the work of my
wife, 1 and there can be little doubt that any remedy which
would exclude the one would almost certainly improve and
might eradicate the other. The rachitic child, in fact,
carries the stigma of the disease throughout life in the
form of defective teeth.
Nor is this the most serious part of the evil, for the
reduced resistance to other diseases of the rachitic child
and animal is so marked that the causative factor of rickets
may be the secret of immunity and non-immunity to many
of the children’s diseases which result in the high death-rate
associated with urban conditions. It is a striking fact to
remember that in the West of Ireland, where the death-rate
is only 30 per 1000, rickets is an unknown disease, whereas
in poor urban districts of this country where rickets is rife
the death-rate in children varies from 100 to 300 per 1000.
It is at least suggestive that there may be some relation
between rickets and the enormous death-rate of towns, even
although the disease in itself does not kill.
The experimental work I wish to describe in these lectures
has shown that the rachitic condition need not be at all
advanced before the animal’s whole behaviour is transformed.
It becomes lethargic and is far more liable to be affected by
distemper and broncho-pneumonia and is very susceptible to
mange. The low resistance of animals which develops as
the result of conditions which ultimately lead, under favour¬
able circumstances, to rickets is impressive.
So many of the conclusions regarding the aetiology of rickets
have been based on a small number of experiments that it
may not be out of place to record that this investigation,
undertaken for the Medical Research Committee, has already
involved the use of 200 puppies and is still incomplete.
On referring to the literature at the beginning of the
research it was soon obvious that the number of hypotheses
put forward to explain the aetiology of rickets was legion,
while discussion on the subject with those having clinical
knowledge only emphasised the completely speculative nature
of the ideas held by those whose business it is to deal with
the disease.
A considerable number of experiments were firslt made in
an attempt to see whether the aetiology of rickets was to be
sought along non-dietetic lines and it was only after failure
that the dietetic solution was resorted to. This type of
work has continued and has clearly shown that, however
important other factors may be, and that there are other
i Tax Lancet, 1918, ii., 767.
March 15 , 1919 .
factors is not denied, the dietetic problem is the primary key
to the situation. In the next lecture some of the more
commonly held hypotheses of rickets will be mentioned and
discussed in relation to the results obtained in this work.
Experimental Methods.
Although it is well recognised that different breeds of
dogs vary considerably in their susceptibility to rickets, no
special type has been used in this work. In some ways this
may be disadvantageous ; but, on the other hand, to be driven
to associate rickets with a particular breed is in itself unsatis¬
factory and obviously leads the investigator into a blind alley
if the ultimate object is to extend the results to children.
The experimental methods used to detect *rickets have
depended on (1) X ray examination of the bones ; (2) calcium
estimation of the bones after death; (3) histological pre¬
parations of the bones.
The calcium estimation of the bones has been made by
Cahen and Hurtley's modification of the oxalate method. In
comparative estimations it is useful; but, since it is well
recognised that the calcium content of bones varies con¬
siderably and independently of the rachitic condition, this
method can never be used alone and must always be con¬
trolled by histological examination. [In the lecture further
details of the methods were described and X ray photographs
and histological specimens were demonstrated by means of
the epidiascope].
In these lectures I propose to illustrate the normality and
degree of rickets obtained by means of the calcinm oxide
content of the bones. Histological preparations can be seen
if desired and also the X ray photographs of many of the
dogs. In all cases histological preparations of the bones
were made and corresponded, in comparative experiments,
with the CaO results given.
[ A series of puppies with and without rickets was then
shown]. In the puppies exhibited it will be observed that
the differences between normal and rachitic puppies are
similar to the differences between normal and rachitic
children. Like the rachitic child, the puppy shows abnor¬
mally large swellings at the epiphyseal ends of the bones;
it has a marked rickety rosary, its tendons and ligaments
are loose, the bones lend to bend, and thereby help to
exaggerate the leg deformity. The amount of deformity
often depends on the weight of the animal. Again, the
rachitic puppy is lethargic and does not jump about; its
power to run, apart from the leg deformity and before this
develops, is comparatively limited ; there is, in fact, a
general loss of tone of the musculature. Similarly, just as
the rachitic baby is a good baby and does not cry much, so
also the dog in this condition seldom barks or makes the
superfluous efforts practised by the normal healthy puppy.
The puppies were started on their diets after leaving the
mother, the ages varying between 5 and 8 weeks, the latter
being the more usual. They were kept for varying periods
according to the type of experiments. In the earlier periods
they were usually killed after five to six months, but as the
work progressed and the diets became more raohitic this
time was considerably shortened.
Determination of Rachitic Diet.
Having determined to see what part diet played as a
causative factor in rickets, it was necessary to get a standard
diet which would always produce this condition in the experi¬
mental animals. The first diet used consisted of whole
milk (175 c.cm. per diem) and porridge made up of equal
parts oatmeal and rice, together with 1-2 g. NaCl. The
oatmeal and rice was later replaced by bread and found to be
as effective and easier to use. This second diet was after¬
wards modified as the experimental results were obtained.
The following four diets (Table I.) have therefore been used
Table I.—Rachitic Diets.
Diet I.
Diet II.
Diet III.
Diet IV.
Whole milk,
175 o.cm.
Oatmeal, rloe.
1-2 g. NaCl.
Whole milk,
175 c.cm.
Bread ad lib.
Separated milk,
176 c.cm.
Bread (70 percent,
wheaten) ad lib.
Linseed oil, 10c.cm.
Yeait, 10 g.
NaCl, 1-2 g.
Separated milk,
250-360 o.cm.
Bread (70 per oent.
wheaten) ad lib.
Linseed oil, 5-15c.cm.
Yeast, 5-10 g. *"
Orange juice, 3Jc.cm.
NaCl, 1-2 g.
NO. 4986
L
408 ThbLanoit,] DR. E. MELLANBY: AN EXPERIMENTAL INVESTIGATION ON RICKETS. [March 15, 1919
daring the course of the work, each one of which is a
rachitic diet under laboratory conditions.
The modifications of the diets were carried out in order
to : (1) ensure a more rapid development of rickets ; (SS) to
be oorapatible with better health and better rate of growth.
As will be seen later, the better the animal grows on a
rachitic diet the more easily is rickets produced or rather
the more difficult it is to stop. In the close examination of
foodstuffs from this point of view, this is eminently desirable.
It is undesirable in such work to have animals in a semi-
starved condition involving a high mortality due to broncho¬
pneumonia and marasmus. Puppies, like all young animals,
tend to develop these diseases unless the diet is well chosen.
Results -of Addition of Various Substances to
Rachitic Diet.
Having obtained diets which normally produce rickets,
various substances were added and the effect on the develop¬
ment of the disease noted. In the following tables the
quantity of calcium estimated as CaO present in the shaft of
the femurs of the animals fed on these diets is given. In
the last column the histological findings of the bones
examined are added.
Table II. —Diet I. plus more Whole Milk.
°s
©"E
©
Diet.
l
Duration.
Months.
Initial
weight.
a-s
s !
Gain.
Cal
femur
Dry.
D In
shAft.
Fresh
Histology
results.
43
Diet I.
4
§)5
2?87
1282
2^5
V.
Rickets.
52
ft
8
1746
5200
3455
235
—
,,
53
M
7 i
1765
4245
2480
225
—
56
+ 325 c.cm. milk.
5
1810
5280
3470
31-8
—
Normal.
57
r+ 325 „ ..
5
1330
498013650
29 2
-
,,
TABLE I II.—Diet II. plus Meat and Meat Extracts.
73
L Diet II.
4
39506110
2160i 20 7
_
Rickets.
96
2 + dog biscuit.
54
1905
4200
2295 22 1
9-38
M
97
i »*
54
1375
3295
1920
1603
5-90
„
68
& Wat. ext. of meat.
4
4000
6540
2540 32 8
—
Normal.
69
( -f Meat protein.
5
4840
7630
2790! 21*7
—
Rickets.
70
( ~t- 80^ ale. ext. of
5
4577
6695
2118 30-2
_
Normal.
meat.
93
-f 10 g. meat.
54
1220
7460
6230! 29-53
15-43
..
Table IV. — Diet II. plus Yeast and Malt Extract.
96
Diet II.
54
1905
4200
2295
1603
5-90
Rickets.
94
■ + 10-20 g. yeast.
54
1590
5000
3410
23-05
11-33
95
i
«•
6
2U0
6000
3590
1802
9-75
75
■f Malt ext.
4
3350
5240
1890
31-2
—
Normal.
86
„
7
1810
4500
2690i 18-68
1264
Slight
rickets.
Table V.-
-Diet II.
plus Different Fats.
73
Diet II.
4
3950
6110
2160
20-7
—
Rickets.
71
+ 10-20 g. butter.
6
215 :
6930
4780
29 04
15-5
Normal.
76.
. + 10 c.cm. cod-
9
2715
8000
5285
27-41
16-82
J liver oil.
80
-1- 10 c.cm. linseed
5
2535
6115
3580
16-22
808
Rickets.
oil.
81
V It »•
5
2876
5320
24451
13-33
6-08
ft
109
+ lOc.cm. peanut.
64
26-35
15-60
Normal.
102
4- Wat. ext. of
6
1664
6-95
Rickets.
butter.
1
Table VI .—Diet Ilf.
with Various Eats instead of Linseed Oil.
138
Diet 1IL
3
1755 2685
9301 16-58
714
Rickets.
140
«•
3
1060 2100
940
20-46
7*36
ft
Weeks.
148
With cod-liver oil.
17
1735 3890
2155
27-78
16-51
Normal.
146
With butter.
17
19203765
1845
26-95
15-89
•»
147
With olive oil.
17
1445 2625
1180
23-79
13-22
Slight
rickets.
163
With peanut.
17
2350 4020
1670
1888
13-81
ft
146
Diet III.
17
1830 3605
1775
2160
12-35
Rickets.
Table VII. — Diet III. Plus Meat and Meat Extracts.
141
Diet III. + 5g.
17
2490
5820
333C
17 48
719
Rickets.
meat.
143
+ 20 g. meat.
17
2890
4400
1510
17-88
948
t«
144
4- 50 g. meat.
17
3630
8825
5135
15-74
10-72
tf
160
4 Watery ext. of
12
2006
3825
182C
13-88
7-20
50 g. meat.
_
Using Diet I., we see in Table II. that increasing the
whole milk from 175 to 500 c.cm. per diem prevents the
development of rickets. In other tables are experimental
results obtained by means of Diet II.
On Diet II. not only does meat but both the watery and
alcoholic (80 per cent.) extracts have an inhibitory effect.
(Table III.) On the other hand, the protein residue after
loss of extractives allows rickets to develop.
Table IV. shows the effect of adding malt extract and
yea^t to Diet II. Yeast therefore has no protective influence.
Malt extract has some inhibitory action and delays the onset
of rickets when added to Diet II.
A large number of experiments were now made in which
the effect of different fats were analysed. A few of the
results are given in Table V. Many other fats and
margarines, animal and vegetable, were tested, but almost
uniformly they prevented rickets, the only undoubted excep¬
tion being linseed oil. The results allowed the evolution of
Diet III., in which separated milk' was used in order to
eliminate the milk fat, whose place was taken by linseed
oil. Yeast was also added to the diet. Using this diet, a
closer analysis of the effect of different fats was possible.
(Table VI.) Now we see from the calcium results, which are
an accurate indication in this case of the rachitic picture,
that the value of the oils is graded, cod-liver oil being the
best and linseed oil the worst; the vegetable oils, olive and
arachis, are not so good as butter.
It was found that adding orange juice orange per diem)
did not prevent rickets. Further, that the addition of 5g.
calcium phosphate, or doubling the separated milk and so
increasing the calcium intake in this form was without pre¬
ventive action on the development of the disease. In
Diet IV., therefore, the separated milk was doubled and
3 c.cm. orange juice per diem also given. On Diet IV. the
growth and general health of the puppies seemed better, and
both these factors are of importance in such an investigation.
Another improvement was to substitute 5 g. of yeast by a
small quantity of a commercial yeast extract (3-4 g. per
diem).
On Diets III. and IV. it was found that small quantities
of meat and meat extract did not prevent rickets developing,
as they have previously been observed to do when used in
addition to Diet U. Table VII. illustrates some of these
results. Although meat did not prevent rickets, a closer
analysis of these and other results showed that it did have
some inhibitory effect. It will be noticed, for instance, that
the CaO present in the fresh femur shaft of Exp. 144, where
50 g. of meat was eaten, is higher than in Exp. 141. where
only 5 g. of meat was added to Diet III. The action of small
quantities of meat (10 g. per diem) is best seen when given
with quantities or types of fat otherwise ineffective in
preventing rickets. It will often be seen to keep the growth
normal, whereas in its absence rickets would develop. This,
no doubt, explains the experimental results obtained when
meat was added to Diet II. The small amount of butter—
i.e., about 5 to 7 g.—in the milk of this diet had its anti¬
rachitic effect enhanced by the small amount of meat.
On Diet III. it was seen that the action of the fats as
regards rickets was graded, the animal fats being more anti¬
rachitic than the vegetable fats and the latter differing from
each other greatly. The best of the vegetable fats in pre¬
venting rickets are arachis (peanut) and olive oils. The
worst of those examined include linseed, cottonseed, babassu
oils, a hydrogenated fat, and cocoanut oil. These oils were
all refined.
Importance of Dietetic Factor.
The above dietetic results indicate that diet plays an
important part in the etiology of rickets. An examination
of the results obtained suggests that rickets is a deficiency
disease which develops in consequence of the absence of
some accessory food factor or factors.
Of the three factors known, fat-soluble A, water-soluble
B, and antiscorbutic, two of these can be at once excluded.
Yeast has no preventive influence on the development of
the disease, and in consequence water-soluble B cannot be
considered as of importance. Again, orange juice, sufficient
to exclude any possibility of scurvy when considered with
the rest of the diet, did not inhibit the disease, and this
therefore allows the exclusion of the antiscorbutic factor.
On the other hand, the anti-rachitic substances for the most
part have been found, so far as the rickets experiments have
gone, to be similar to those in which, according to the
!m LahCBT,] DR. E. MELLANBY: AN EXPERIMENTAL INVESTIGATION ON RICKETS. [March 15,1919 409
experiments on growth, of McCollum, Osborne, Mendel,
said others, fat-soluble A is present. It therefore seems
probable that the cause of rickets is a diminished intake
of an anti-rachitic factor which is either fat-soluble A, or
has a somewhat similar distribution to fat-soluble A. The
facts are not all in favour of this hypothesis as it stands, and
these will be discussed in the next lecture.
Another point which has been definitely established in the
ooorse of this work is that rickets develops much more
readily in the fast-growing puppies than in those growing
■lowly. As might be expected, therefore, the prevention of
rickets in a rapidly growing dog requires more anti-rachitic
factor to keep the growth straight. This point is brought
out in the case of two puppies of the same litter (Exps. 173
and 174) fed on the same diets (Diet IV. -f-10 g. meat).
The larger puppy grew much more rapidly than the other.
Puppy (K) 173 increased from 1130 to 2240 g.—i.e., a gain
of 1110 g. in 10 weeks, whilst L (Exp. 174) increased in
weight from 1800 to 3970 g.—i.e., a gain of 2170 g. in the
same period. It will be seen in the X ray photographs that
rickets is more strongly developed in the faster growing dog,
although both are rachitic, the diets being deficient in the
anti-rachitic factor. Poppies of the same litter whioh
received 10 g. of butter in addition to the diets received by
Nos. 173 and 174 were normal.
LECTURE II.
We saw in the last lectnre the manner in which the
experiments were carried ont, together with some of the
m a in results. Substances which had no preventive action
on the development of rickets included separated milk,
bread, the protein of meat, yeast, linseed and babassu oils,
and hydrogenated fat. Substances with well-marked
preventive action included cod-liver oil, butter, aDd suet.
Then there were other substances whose preventive action
was definite but not so great as that possessed by the above
animal fats. In this group were meat, meat extraot, malt
extract, lard, arachis and olive oils.
The Part Played by Fat-Soltjblb A.
The results seemed to favour the hypothesis that experi¬
mental rickets can be prevented by diets containing an
abundance of anti-rachitio factor and that the anti-rachitic
factor and fat-soluble A have somewhat similar distributions.
There are, however, several points which are not in harmony
With the ordinarily accepted views about fat-soluble A.
Three of these will be discussed.
Relation of Rapidity of Growth to Development of Rickets.
Rickets develops best in rapidly growing animals, this
fact being in harmony with the clinical observation that
large and rapidly growing children most often suffer from
rickets, whereas mamsmic children generally escape. It is,
therefore, difficult at first sight to associate a disease of
rapid growth with a deficiency of fat-soluble A which is,
according to accepted teaching, necessary for growth. For
it has been shown, in the case of rats by McCollum, that
both fat-soluble A and water-soluble B are essential for
growth. Before fat-soluble A and the anti-rachitic factor
can be held to be the same thing, further consideration is
necessary.
The first point to emphasise is that some of the fastest
growing dogs in these experiments have had very little
fat-soluble A in their diet. Here are two examples:—
Bxp. 144. Bxp. 175.
Diet III. + 60 g. of meat per diem ... — —
Initial weight. 3690 g. —
Increase In weight In 13 weeks. 6135 g. 4586 g.
Rickets .. Marked . Very slight.
If the milk were completely separated, Diet III. ought to
have contained no fat-soluble A. Meat is reputed to
contain little or no fat-soluble A when devoid of fat. The
fait was dissected off as completely as possible, but there
was undoubtedly a little not removed.
The following experiments show that when only 10 or 5 g.
of meat were added, or even without any meat, good growth
was obtained.
In experiments 186 and 185 no meat was present in the
diet and yet the puppies grew considerably, though, it is
traa, not to quite the extent of Exp. 190 where the fat eaten
was cod-liver oil, which is known to contain fat-soluble A.
-
1 Bxp. 176.
Bxp. 141.
Exp. 186.
Bxp. 185.
Bap. 190.
Dioh .|
D. III.
+ 10g. |
meat.
D. III.
+ 5g.
meat.
D. IV.
(Linseed
oil).
D.IV.
(Olive for
linseed).
D. IV.
(Oed-ttver
for linseed^
Increase Inj
weight ...(
2930 g. In
10 weeks.
2720 g. in
10 weeks.
1200 g. in
5 weeks.
llOQg.ki
5 weeks.
1626 g. in
5 weeks.
Condition ... j
1 Rickets.
Rickets.
Rickets.
?
Normal.
These results cannot fail to raise the question as to the
necessity of fat-soluble A being present in the diet before
growth is possible. As the experiments were not carried
out from the point of view under discussion I do not
naturally deny that fat-soluble A is necessary for growth,
more especially as the separation of the milk in the
diets was not always perfect. I think, however, that it
can be definitely stated that the amount of growth a puppy
experiences has no relation to the amount of fat-soluble A
in the diet, although a small minimum amount may b*
necessary. It is, of course, possible that puppies can make
use of considerable stores of fat-soluble A in their own
tissues, which will allow growth for some months even in the
circumstances of deficient fat-soluble A in the diet.
It has, however, been already pointed out in this work
that large and rapidly growing puppies require more anti¬
rachitic factor to prevent the development of rickets. If,
therefore, fat-soluble A and the anti-rachitic factor are
identical the presumption is that the function of fat-
soluble A in the diet of puppies is not so much to ensure
growth as to promote correct growth; in other words, to
keep the growth straight: and the greater the amount of
growth in any period the greater is the amount of fat-
soluble A necessary to keep it along normal lines. If this
view is correct, then it can hardly be claimed that fat-
soluble A is in any different category from the point of view
of growth than the antiscorbutic factor, for, even in the
absence of tbis latter, the rate of growth diminishes and
there is often rapid loss of weight.
The Action of Meat and Meat Extracts.
The second difficulty involved in considering the anti-,
rachitic factor and fat-soluble A as identical is the part
which meat and meat extracts play in the development of
rickets. It has been seen that, although when added to
Diet II. these substances prevent rickets, in the case of
Diet III. rickets develop. Yet even in the Diet III. and IV.
experiments, the action of meat is undoubtedly inhibitory in
nature and, when 50 g. of meat are given, will almost prevent
rickets in a small puppy. Just as in the last section it was-
seen that meat has a stimulating action on the growth of
puppies far beyond its fat-soluble A content, so also it
appears now that the anti-rachitic action of meat is in a
greater measure than any fat-soluble A it is reputed to
contain. Either we must recognise that meat contains more
fat-soluble A than the rat-feeding experiments have led us
to believe or we must endeavour to find another explanation
of the action of meat in rickets. It seems to me that another
explanation is possible.
It is known that meat has one action on metabolism,
which is more strongly developed than in any other food¬
stuff. This is its specific dynamic action or power to
stimulate the total chemical exchanges taking place in the
body. In having this stimulating action it will increase the
effectiveness of any fat-soluble A in the diet and will tend to
prevent the storing up and deposition of this substance in
the subcutaneous and other tissues. Again, any fat-soluble A
in the tissues will be more readily mobilised under the stimu¬
lating influence of the metabolising meat. It is probable
that the anti-rachitic action of meat may therefore be due
more to its making the • fires born more brightly, and thereby
increasing the effectiveness of any fat-soluble A present in
the body, rather than to the fat-soluble A it possesses in
itself. If this explanation of the action of meat be true,
then it is still possible to regard fat-soluble A and the anti¬
rachitic factor as identical.'
The Different Effects of Vegetable Oils ,
The third difficulty, which is probably of less importance
than the two foregoing, is the widely different action of the
vegetable fats as regards the development of rickets. In
the growth experiments of previous workers all the vegetable
fats are described as deficient in fat-soluble A, and the
impression is received that there is but little difference
410 The LANORT,] DR. E. MELLANBT: AN EXPERIMENTAL INVESTIGATION ON RICKETS. [March 15, 1919
between them. On the other hand, their anti-rachitic
influence varies considerably, being obviously present in
arachis and olive oils and absent in linseed and babassu oils.
Other vegetable oils like cocoanut and cottonseed occupy an
intermediate position. If the anti-rachitic factor is fat-
soluble A, then it must be accepted that the type of experi¬
ment described in this work is a more delicate test for fat-
soluble A than previous work involving the growth of rats.
The difficulties have now been stated and briefly discussed.
On the whole, it will probably be agreed that they are not
formidable, and not more than might be expected under the
circumstances.
Since this is probably the first research on growth factors
carried out on dogs, it might be expected that the facts
would not be identical with those met with in rats. Again,
a superficial survey of the question suggests that particular
difficulties would be met with. For we know something of
the part played by accessory food factors in such deficiency
diseases as beri-beri and scurvy, and we know something of
the part played by these substances in growth, but in the
case of rickets we are apparently up against a combination
of both a deficiency disease and growth, rickets, in fact, being
a’disease accompanying growth. Whether the anti-rachitic
factor is fat-soluble A as previously understood is therefore
undecided, but, on the whole, these substances appear to be
identical. It is at least certain that the distribution of the
two substances is remarkably similar.
Review op Some Earlier Hypotheses as to .Etiology.
It is interesting to see how the facts brought out in this
work fit in with some of the most commonly held hypotheses
of the aetiology of rickets. I think it will be agreed that the
accessory factor hypothesis allows many of these older
hypotheses to be so focussed that a common and simple
image is visible.
Dietetic Hypothesis.
Rickets as a disease due to deficiency of fat .—The work of
Bland-Hutton on the lion cubs at the Zoological Gardens has
left its impress on English thought as regards rickets and.
together with the acknowledged efficacious results that
follow the treatment of rachitic children with cod-liver oil
send other fats, has brought about a general acceptance of
the view that rickets is due to deficient fat in the diet. The
results recorded here make it clear why this view is so
commonly held, but demonstrate that the efficacy of the
treatment—curative or preventive (as regards the latter the
work of Hess and Unger is of particular interest)—does not
depend on fat per so, but rather on the type of fat, and
whether it contains an abundance of the anti-rachitic factor,
animal fats being superior to vegetable fats.
Excess at carbohydrate in the diet ..—When a diet contains
excess of carbohydrate it means that it is made up largely of
oereals. Now cereals, and more particularly cereals like
wheat, rice, and oats, which have undergone transformation
in the course of manufacturing processes, are most deficient
in anti-rachitic factor. A diet, therefore, of such substances
is quite unbalanced and most effective in producing rickets.
Deficiency of fat and excess of carbohydrate .—This condition
comprises the first two hypotheses, and what is said about
them can be extended with further emphasis to this sug¬
gestion. Such a combination would most certainly involve
a deficiency of anti-rachitic factor.
Deficiency of calcium, salts in the diet .—It has been seen
previously that abundance of calcium in the diet, either in
the form found in separated milk or in calcium phosphate,
will not prevent rickets when the diet is deficient in anti¬
rachitic factor. Similarly, it has been found by some workers
that a diet deficient only in calcium salts, but otherwise
adequate, will not produce rickets. It Is, however, more
than probable that a deficient calcium intake associated
with deficient anti-rachitic factor win bring about a more
acute production of rickets, and must always be an adjuvant
factor to be considered in the aetiology of rickets.
The “ Domestication ” Theory of Rickets.
Von Hansemann’s “ theory of domestication ” includes in a
comprehensive way all the unhygienic conditions associated
with life in civilised and more particularly in crowded com¬
munities. The difficulty is that we have not yet complete
knowledge as to what is unhygienic in the environment of
civilisation. There is something subtle about the problem,
and many of the factors about which we hear so much may
be of little or no importance when compared with factors
about which nothing is at present known. Modern mode of
life, and particularly of urban life, has involved two main
changes in environment: (1) diet; (2) greater confinement
and lack of fresh air. My experimental results have indi¬
cated that the dietetic changes are of prime importance in
bringing about the widespread development of rickets,
although, according to the researches here described, diet
must be considered from an entirely new point of view.
Effects of Confinement.
At this point I wish to consider the part played by con¬
finement in the etiology of rickets, more particularly
because in recent years the experimental work of Findlay
has indicated that it may be of importance. Findlay’s
work involved the use of 12 dogs fed on a diet of oatmeal
porridge and milk (amount not stated). It will be seen
that this diet is similar to Diet I. used in my experiments, a
diet which normally produced rickets in experimental
puppies. (Diet I. was composed of whole milk 175 o.cm.,
oatmeal and rice, and 1-2 g. NaCl.) On this diet, then,
the confined dogs were rachitic, the dogs obtaining exercise
normal.
It seems to me that, working with suoh a diet, which
approaches a rachitic diet, experimental results can only
show that want of exercise is a factor in the production of
rickets, but cannot be regarded as proof that it is the
primary factor. Before the acceptance of this hypothesis is
possible it must be shown that confinement on an adequate
diet—that is to say, one compatible with the best health,
always brings about rickets. Certainly the porridge and
milk diet, unless the milk is large, cannot be considered
healthy (in three months two of Findlay’s confined puppies
died of broncho-pneumonia and one of marasmus).
The beneficial effect of freedom in the case of dogs on an
inadequate diet is what might be expected and is not, in my
opinion, discordant with a dietetic hypothesis. The constant
movement must raise the whole metabolic changes in the
body and, in the first place, prevent or delay the deposition
of fat with its accessory food factor in the subcutaneous and
other depots and, secondly, bring into activity any anti¬
rachitic factor normally stored away and ineffective.
Exercise, in other words, must give a greater opportunity to
any anti-rachitic factor in the food or tissues of the animal
to play its part in the animal economy. In addition to this,
exercise or the possibility of exercise undoubtedly improves
the animal’s health, and it is almost certain that a rachitic
diet is more effective in producing rickets when the animal’s
health is subnormal as it may be following continuous
confinement.
A strongly rachitic diet after a few weeks has a decided
effect on the animal’s activity, and it is difficult to give any
real exercise to a puppy that is rachitic even though the
bony and ligamentous changes may not be the disability
which limits the movement. On the other hand, confinement
generally fails to prevent a well-fed puppy from taking
abundant exercise. The analogy can probably be applied
with greater force to children; a well-fed child between
9 months and 2 years can get exercise whatever its environ¬
ment, whilst a child with active rickets will show the same
lethargy in a slum or the middle of Hyde Park. The
activity of an infant is not to be measured by the amount
of running it performs, but by its small movements.
My own experience is that confinement will not produoe
any symptoms of rickets in adequately fed puppies.
Results of Investigation in Glasgow.
It may not be out of place to refer to the recent statistical
account of an investigation made by Miss Ferguson ou
rickets, more particularly in Glasgow. The results of this
work are against the hypothesis that rickets is a dietetic
deficiency disease and the general conclusion, although
undetermined in a definite sense, is that the factors favour¬
ing the development of rickets are: (1) Insufficient space
in houses ; (2) confinement in such houses; (3) imperfect
parental care. No support is given to the dietetic hypo¬
thesis. It is interesting, however, to examine some of the
results relating to family budgets in this paper.
Below are given the tables relating to the (1 average con¬
sumption of food” (p. 68) in rachitic and non-raohitic
families.
Now let us consider the tables, obtained by Miss Feiguson,
in the light of the accessory factor hypothesis. First, what
are the substances in the diets which allow rickets—i.e., are
The Lancet,] DB. E. MELLANBY : AN EXPERIMENTAL INVESTIGATION ON RICKETS. [MARCH 15, 1019 411
Average Consumption per “ Man ” per Day of the Chief
Articles of Diet in Grammes.
(1) Rachitic families. (2) Non-rachitic families.
—
(1)
(2)
—
(1)
(2)
Flour.
387*9
376-2
Other oereals .
15*6
26-9
Potatoes.
291*0
236-8
Margarine or butter
32 6
38-5
Milk.
256*0
309 0
Fish .
15*7
35-9
Meat.
891
92*6
.
15-1
30*4
Sugar.
91-4
Bara
Cheese.
6-7
8*2
Oatmeal ... ... ...
40*4
36*0
deficient in anti-rachitic factor? The answer is flour,
potatoes, sugar, oatmeal, and other cereals. On the other
hand, what are the anti-rachitic substances? Milk, meat,
margarine or butter, fish, eggs, and cheese. The following
table shows how the diets of rachitic and non-rachitic
families differ as regards these articles. The rachitic
families received:—
. SntaUnoes allowing rickets.
11*7 g. more flour.
54 2 g. ,, potatoes.
7*4 g. „ sugar.
4 4 g. „ oatmeal.
11*3 g. less other cereals.
Substances delaying or preventing
rickets.
53-0 g. less milk.
3 5g. ,, meat.
5 9 g. „ margarine or butter.
20*2 g. „ fish.
15*3 g. „ eggs.
1*5 g. ,, cheese.
Is it a coincidence that except as regards “ other cereals ”
there is an increase in the diet of the rachitic families of
the substances allowing rickets and, what is of greater
importance, a decreased amount of substances having an
anti-rachitic influence ? It will, of course, be answered that
the differences are too small in amount to be regarded as of
importance. As a matter of fact, a moment’s consideration
will show that the real state of affairs is probably more
emphatic than the figures represent. The outstanding fact
brought out in Miss Ferguson’s paper is that rickets is often
associated with the more careless parents. It is clear that
the infants below 2 years old will not get from such parents
their proper share of the “good things” of the articles of
the above budgets. The good things happen to be those
substances containing the anti-rachitic factor. The children
will undoubtedly be put off with an undue proportion of bread
and the commoner foodstuffs which produce rickets.
It is improbable, however, that family budgets will ever
decide the course of rickets in individual cases, but sufficient
has been said to make it clear that in the appraisement and
criticism of this statistical work too little attention has been
given to this side of the problem and too much to the
exercise and confinement factors.
General Consideration of Rickets as a Deficiency
Disease.
It will be noticed that, although rickets has been inter¬
preted on the basis of my experimental results as primarily
a deficiency disease of a dietetic nature, this has not pre¬
vented other conditions from receiving attention and being
considered as of some impoi tance. A knowledge of general
metabolism would not allow the exclusion of other factors ;
for dietetic problems must always be regarded as a whole,
and the idea that accessory food factors can be considered
separate and apart from other elements of the diet and from
the general metabolism is unsound.
An adequate diet is itself a unit, and its soundness, to a
large extent, consists of the mutual assistance and interplay
in the metabolic changes the elements experience in the
body. The absence of, or deficiency in, one element means
the ineffectiveness of another. For instance, the absence of
carbohydrate involves a defective oxidation of fat, and
probably an inefficient protein metabolism. Similarly, it is
possible to imagine an abundance of accessory food factors
in the diet which may, however, be ineffective because of
some wrong balance in the energy-bearing materials. The
same argument applies where the metabolism varies for
reasons other than diet.
These few words are all the more necessary because recent
work on accessory food factors has appeared too self-
contained and, if persisted in, may be responsible for a
period of disbelief in their existence with subsequent lack
of progress in the study of a subject which is obviously of
prime importance both from the academic and practical
points of view.
The Dietetic Problem.
•
There is some danger in applying laboratory results to a
clinical condition, more especially when the results are new
aud for the most part uncontrolled by clinical observation.
But some remarks are necessary in this connexion, for, if
experimental research can point to the real cause of a
disease, then not only is the curative treatment controlled,
but, what is of much greater importance in the case of
rickets, it ought to be possible to indicate why rickets is
widespread and to direct knowledge along preventive lines.
It appears, then, from this work that the foodstuffs of an
infant ought to contain a maximum amount of anti-rachitic
factor. Since, further, the dietetic problem is one of balance,
foodstuffs which contain no anti-rachitic factor cannot be
considered as neutral, but as positively rickets-produciDg,
for the more of them that is eaten the greater is the
necessity for foods containing the factor. Since there
is a limit to what a child can eat, the inference is obvious.
It is probaole that bread is the worst offender, and to allow
bread to form too large a part of an infant's dietary seems
to me to be courting disaster. The same statement may
apply to other oereals, but this has not been worked ont to
any extent.
Another point of importance is the type and amount of fat
eaten by children. Since the above remark as to the limited
amount of food a child can eat applies with even greater
force to fat, it is necessary to give childreo the best fat from
the point of view under consideration. They should there¬
fore not be given vegetable margarines or any other vegetable
fat. The natural fat for a child is the fat of milk, and to
give it a vegetable fat not only limits th<* amount of butter
it can eat. even if procurable, but also weighs down the diet
in the rachitic direction. If additional fat is given to that
normally eaten, then cod-liver oil is the best.
Milk at an Anti-rachitic Factor.
Undoubtedly milk ought to remain the staple article of
diet not only until weaning, but for some years after this
time. Milk is undoubtedly better than the corresponding
amount of butter. Under normal circumstances the child
would then be assured of a good supply of anti-rachitic
factor. Not, however, under all circumstances is this
certain, for the work of McCollum, Simmonds, and Pitz
has shown that before an abundance of fat-soluble A
appears in the milk the mother must have a good supply
of this substance in her food. This means that the animal’s
power of synthesising these accessory food factors is small
or absent. Grass is a good source of fat-soluble A for the
cow, and a well-fed cow, from this point of view, will
give good milk. The mother drinks this milk, and the
accessory food factors are passed on to her mammary glands,
thereby allowing the breast-fed child to get an adequate
supply.
The problem therefore reverts largely to the feeding of
the cow, and it is probable that the cow fed in the stall
largely on vegetable oil-cakes will give a milk deficient in
accessory food factors. If. therefore, a nursing mother’s
diet is deficient in the anti-rachitic factor, it is easy to
understand how the breast-fed child develops rickets, for
it is probable that the same argument applies even if it
should subsequently prove that the anti-rachitic factor and
fat-soluble A are not identical. Recently Hess and Unger
have shown that the diet of the negro women in New York,
whose breast-fed children are nearly always rachitic, is very
often deficient in fat, the amount of milk they drink being
small. These suggestions may also explain why rickets
develops more commonly in the winter months, when the
cow’s diet is more artificial.
Other Foodstuff.
As for the aotion of other foodstuffs, it has been pointed out
that meat has an anti-rachitic effect to some extent and even
in small quantities (10 g. a day to a puppy) will render a
slightly rachitic diet safe, probably by making the anti¬
rachitic factor in the diet more effective. Vegetable juices
seemed also to have some inhibitory aotion on the develop¬
ment of rickets.
In these days, when proprietary articles are so commonly
used as foods for children, it is of vital importance that
these substances should be judged by their accessory food-
factor content in addition to the ordinary analysis as to any
protein, fat, carbohydrate, and salts they may contain.
l 2
412 TheLancki,] MB. H. J. GAUV4JN: CHEMOTHERAPY IN CUTANEOUS TUBERCULOSIS. [March 15, 1919
Synthetic milks, especially such as contain linseed and other
vegetable oils, ought to be discountenanced as foodstuffs
unless it can be satisfactorily shown that their accessory
food factors are abundant. Similarly, the dispensing of
vegetable oils instead of ood-liver oil to children, often
rachitic when the oil is given, may do much more harm than
good. This is most certainly the case, as 1 pointed out at
the Physiological Society's meeting in January, 1918, when
the type of Marylebone cream containing linseed oil is
given. If children are to have the best chance for a healthy
existence, until further work extends or modifies my experi¬
mental results, it would be safer to exclade all vegetable
oils from their dietary.
Finally, it is necessary to point out that this experimental
work is far from complete, and no doubt in the near future
much further knowledge will be forthcoming. The subject
is of great importance and will not end with rickets. For
instance, the researches of my wife on the action of
accessory food factors on the development of teeth show
how necessary it is that throughout the whole period of
calcification of the teeth—i.e., up to the eighteenth year—
there should be abundance of anti-rachitic factor in the diet,
and a deficiency at any period will be reflected in the
calcifioation and probable uneven arrangement of the teeth.
Still further points of practical interest will come to light
soon.
HBVKaBNCBS.
Bohmorl: Verhxndlungen der deutach. path. GeMUaoh., 1900, 58.
Dick: Proe. of Roy. Snc. Med.. 1915.
Caheu and Hurtley: Blochem. J., 1916, x., 908.
Osborne and Mendel: Various papers In J. Biol. Chem., 1912-19.
McCollum and co-workers: Various papers ip J. Biol. Chem. and
Amer. J. Physiol.. 1912-19.
Hess and Unger: J. Amer. Med. Assoc., 1917, Ixlx., 1583; and 1918,
Ixx., 900.
Von Hamemann -. Berliner kiln. Woch., 1906, 20 and 21.
Findlay: Brit. Med. J.. 1938, July 4th.
Ferguson: Pub. of Mel. Research Comm., 8pec. Report Series. 20.
McCollum, SImmonds. and Pltz: J. Biol. Chem., xxvii., 33.
CHEMOTHERAPY IN CUTANEOUS
TUBERCULOSIS,
WITH REPORT ON TWO CA8E8 TREATED WITH ELLIS’S
PICRIC-BRASS PASTE.
By H. J. G AUVAIN, M.A., M.D., M.Ch. Cantab.,
MEDICAL SUPERINTENDKNT, LORD MAYOR TRELOAR CRIPPLES’ HOSPITAL
AND COLLEGE, ALTON.
By the generosity of Dr. H. A. Ellis 1 have been permitted
to collaborate with him and make use of the brass preparations
he has introduced and employed with marked success in the
treatment of cutaneous and other forms of tuberculosis. He
has further placed me in his debt by very kindly sending
an advance copy of his contribution to this number of
The Lancet. In it I note he apologises for what he
describes as empirical deduction. I venture to think that
he is to be congratulated on a research which may be of far-
reaching importance, and which will remain an example of
persevering investigation calling for the highest attributes of
the scientific searcher for the truth.
Worh of Continental Investigators.
Dr. Ellis was not aware that his researches have been to
some extent forestalled by lengthy investigation on the
continent, particularly in Germany, following, I believe,
French inspiration, and stimulated later by the brilliant
results attained by Ehrlich and his school. In France in
1894 two preparations of copper had been successfully used
by Luton, father and son, cuprum phosphoricum insoluble
in water, and cuprum acetioum soluble in water. 1
Of the German investigators, Finkler and von Linden
working at Bonn in collaboration used with some success on
tuberculous guinea-[ tigs preparations belonging to two dis¬
similar groups ; on the one hand, the chlorine—and iodine—
hydrogen salts of methylene blue, and on the other, certain
copper salts, especially copper chloride. To Professor
Meissen was entrusted the task of testing these preparations
on lung tuberculosis, to Strauss that of testing them on
lupus and other external tuberculous affections. 2
Von Linden demonstrated that while the living tubercle
bacillus takes up other colouring matters slowly, it quickly
stains with the two salts of methylene blue, to which stains
it is tenacious, and though not slain loses its faculty of
development.
Strauss showed that various copper compounds, notably
copper-lecithin compounds, 3 are capable in a 1 per cent,
solution of inhibiting the tubercle baoilltis after five hours
and killing it after 24 hours. Rabbed up with a lecithin
soluble copper salt the tubercle bacilli became green but
retain their specific colouring power. After one hoar they
show morphological changes. Later they lose their colour¬
ing faculty and show brown granules in their interior and
after several hours further disintegrate.
Farther investigation showed that by injection into gninea-
pigs infected with tuberculosis, both the methylene bine and
the copper salts could be demonstrated in the tubercle
bacilli.
These researches are of fundamental importance and
represent a great advance in the chemotherapy of
tuberculosis.
Leoutyl and Other Copper Compounds.
Without detailing the laborious experiments of the German
investigators, it may be stated that their experiments led to
the introduction of a compound composed of copper, lecithin,
and cinnamic acid, to which was given the name lecutyl. 1
Following encouraging animal experiments with controls,
this and other copper compounds have been used, in some
cases with notable success. The preparations have been
administered by month, snbcntaneonsly, intravenously,
intramuscularly, and as local applications.
As to the toxicity of copper, 8trauss reports as follows:—
“The harmlesmesa of copper may be demonstrated on the basis of
experiments oarried out both in animals and the human snbjeot as
recordet In literature when the d*es as applied in the case of man
remain below the level of toxic action. Professor Meissen has reaen lj
gone into this question thoroughly, and it should be sufficient to direct
attention to this exhaustive work. In spite of that, we should not
omit to mention that experience hitherto acquired iu the oase of more
than 150 persons affected with external tuberculosis has strengthened
our belief in the innocuoumess of copper. An objectively demon
strable nephritis which was soonest to hive been expected has never
made Its appearance. It must be emphasised how well the human
organism tolerates small dose9 even when they are Introduced for an
uninterruptedly long period. Injurious secondary effeots might arise
through coagulation of albumin similar to those that are to be expected
from the action of mercury. These might set up resistance react Iona
in the excretory organs; just as with meroury, stomatitis, nephritis,
and enteritis are experienced, so with copper which is most likely
stored up In the liver, hepatitis and after that nephritis might be
expected. These phenomena have not been observed to follow doses
which have been given in the caae of man. Reactions affecting the
gastro-intestinal tract have noer and then been observed, such as
eructations and in rare cases vomiting. The stomach protects itself
alnst the precipitation of albumin and then requires an intermission
the treatment. What one has to fear, especiallv In the case of Intra¬
venous administration, are attacks of acute rather than of chronio
intoxication."
Strauss’s last work, to which I have had access, appeared
in 1915. ' In it he describes the specific action of lecutyl on
tuberculous tissue as follows :—
“ In lupus only the nodules and infiltrations are destroyed. In the
very firs', days of treatment they are laid bare, like a sieve , and later go
on to atrophy when all tuberoulous tissue has been destroyed.”
This article is accompanied by a series of striking
illustrations of the end-results of treatment as applied to the
face.
The great objection to the lecntyl treatment is that it is
very painful. Administration of lecntyl by a painless method
has so far been impossible of attainment.
In addition to the lecutyl treatment Strauss advocated the
intravenous injection of diamide glycooal copper, employing
a eolation whioh he calls “ H.” With faultless technique it
is claimed that this method will become completely painless.
Solution H contains 0 01 pure Cu per c.mm. From 0'5 to
5 c.om. may be injected twice a week, slowly increasing
from 0*5 c.cm.; half doses in the case of children. He states
that in general 1 mg. Gu per kilo body-weight is to be
reckoned an innocuous dose. In combined general treatment
only small doses should be given intravenously in order to
avoid cuamlative effects.
This work apparently attracted little attention in England,
but shortly before the war I went to Germany particularly to
ascertain what sneoess had been obtained and to what extent
these preparations could be safely and wisely applied. I
saw the preparations in use in certain German clinics,
notably at the sanatorium at Hohenlychen, near Berlin, but
the onset of hostilities and the impossibility of obtaining
the German preparations, together with pressure of work
resulting from the war, led me to abandon temporarily any
attempt to procure or employ them.
THE Lancet,] MR. H. J. GAUVA1N : CHEMOTHERAPY IN CUTANEOUS TUBERCULOSIS. [March 15, 1919 418
1
2
3
4
1. A. B., on admission. 2. Aft^r sun treatment alone. 3. After application of brass |>aste; note crater!form ulceration in actively
diseased area. 4. On discharge.
The Bras* Treatment of Tuberculosa.
In 1917 I had the good fortune to meet Dr. Ellis.
Unconscious of the work already done by German and other
workers, he had alone and independently discovered the
value of suitable copper preparations, and had evolved and
elaborated a treatment and technique which was apparently
safe in operation and produced results more convincing and
more favourable than any I had observed in Germany.
Single-handed he had performed the necessary animal
experiments essential before his preparations could be applied
to the tuberculous human subject. His preparations caused
comparatively little pain in application, and in addition had
always proved innocuous. The combination he introduced
of trinitrophenyl with brass represented a very considerable
advance, inasmuch as it appears to have limited the danger
of constitutional disturbance, of activation of distant
tuberculous foci, or of metastatic development.
Many of the results obtained at Alton have been
impressively favourable. Caution has been exercised in the
application of this new therapeutic measure and the cases
have been very carefully selected. Probably even more
striking results might have been obtained had greater
boldness been permissible, but the necessity of the greatest
care has been ever borne in mind. In cases where rapid
improvement has not been obtained this method of treat¬
ment has been abandoned until further experience justifies
more extended trial, but in no case with the caution
exercised have any ill-results been discoverable, and it
appears that we may reasonably hope that a substantial
advance has been made in the treatment of tuberculous
disease. Further investigation is proceeding on the treat¬
ment of deep-seated lesions which will be the subject of
; later reports.
It may be here mentioned that the chemotherapeutic
treatment of tuberculosis appears to be most effective when
associated with the simultaneous application of helio-
therapeutic measures effected under favourable hygienic
conditions.
In this paper I present reports of two cases of external
tuberculosis ; in the first the result has been entirely
favourable ; in the second treatment has not been completed,
but substantial progress has been made and treatment is
proceeding.
Details of the technique are given in Dr. Ellis's contribu¬
tion and need not here be repeated. As to the final results
and possibilities of relapse, no opinion can jet and for some
5
6
7
5. I. J., on admission. 6. After application of picric-brass paste; note sieve like ulceration. 7. Condition on Jan. 15th, 1919;
treatment still proceeding.
414 The Lancet,] MR. H. J. GAUVAIN: CHEMOTHERAPY IN CUTANEOUS TUBERCULOSIS. (March 15,1919
time be authoritatively expressed. It has always to be
remembered that tuberculous disease is a generalised infec¬
tion of which any particular lesion should but be regarded
as a local manifestation. The cure of such a lesion cannot
therefore be necessarily associated with elimination of the
disease, but there are indications that by the chemo¬
therapeutic method it may be possible eventually to rid the
sufferer from tuberculosis as effectually of his infection as
specific drugs can eradicate the disease in syphilis. Very
much must be done before this can be accomplished, too
great caution cannot be observed, but even with these limita¬
tions optimism is permissible, and the brass treatment of
tuberculosis foreshadows possibilities in the future which
may be hoped for if not expressed.
It may be observed that Dr. Ellis uses cod-liver oil as the
base of his preparations. Confirmation of the specific effect
of cod-liver oil, used in a form known as sodium morrhuate,
is afforded by Sir Leonard Rogers’s recent work, which is
supported by the observations of others. 0
Account of Cates.
The following are the notes of Case 1:—
Cask 1.—A.B., admitted April 27th, 1916, with tuberculous
ulceration of the plantar surface of the right foot extending
round to the dorsum. (See Fig. 1.) Condition said to have
existed for eight years, and to have resisted all treatment.
Amputation of little toe had been performed and amputation
of foot had been advised. Patient was sent to Alton in the
hojpe that amputation might be avoided.
On admission the child’s general condition was fair; he
bad a tuberculous eruption on the trunk and a tuberculous
ulcer over the external condyle of the left femur.
With graduated sun treatment the patient’s general con¬
dition greatly improved, the eruption on the trunk gradually
disappeared, the uloer on the femoral condyle healed com¬
pletely, but, though heliotherapy was well tolerated and
pigmentation satisfactorily established, the plantar ulcer
oould not be completely healed. Both during the summer
of 1916 and of 1917 the improvement in the condition of the
foot became marked, but though healed in the centre it con¬
tinued to slowly extend at the periphery, and with the
cessation of heliotherapy retrogression was always noted.
The condition of the foot on Dec. 15th, 1917, is shown in
Fig. 2.
On Dec. 28th, 1917, brass paste was first applied and there¬
after every two days, alternating occasionally with brass
oil, until Jan. 23rd, 1918. The uloer bad not then
healed, but it was healthy in appearance and treatment with
brass was discontinued for one month. Thereafter only
occasional applications of brass paste were made, to observe
more closely the effects produced. The condition at the
beginning of April, 1918, is shown in Fig. 3.
The reaction whioh followed the application of the paste
may be described as follows. The diseased area to which the
paste bad been applied became red, engorged, the former
purulent discharge was replaced by a clear exudate and
there was marked orateriform destruction of the tuberculous
infiltration. In other words, in the part diseased there
appeared the phenomena associated with aseptic inflamma¬
tion proceeding to cellular necrosis in the tuberculous
tissues. With the simple brass paste used in this case
inflammation was at times associated with pain, but in sub¬
sequent cases, when using the picric-brass paste prepared by
Dr. Ellis the absence of considerable pain was notable.
Neither in this nor in any other case have looted any
exceptional constitutional disturbance; the liver was not
enlarged, there was no tenderness in the hepatic area.
Nothing abnormal was found at any time in the urine.
Especially noteworthy was the selective action of the paste,
healthy tissue being in no way affected. The clean cut
ulcers formed after the paste bad been applied had healthy
granulating surfaoes, in some cases the areas immediately
surrounding became somewhat livid in appearance, were en¬
gorged, ana exuded clear serum. Subsequently rapid healing
oocurred except in those areas where the tuberculous tissue
had not been completely destroyed. It was notable that in
some oases the ulcers formed healed, but subsequently
broke down. Doubtless, owing to imperfect contact
some tuberculous nodules had not been attacked and dis¬
integrated. This fact makes it important that treatment
should be continued sufficiently long to obtain access to and
completely eradicate the tuberculous infiltrate.
The leBion was soundly healed by midsummer. 1918, but
the patient was detained until August 19tb, 1918. The
condition of the foot on discharge is shown in Fig. 4.
The ulcerated surfaoe was covered with sound, healthy skin,
softer in texture and lighter in colour than that covering the
rest of the sole, but already beginning to take on the
character of the uninjured.Bkin of the Bole. Sensation was
normal and the boy able to walk naturally without limp and
with no discomfort.
It should be added that heliotherapy was combined with
the chemotherapeutic measures employed in this case with,
I believe, great advantage to the patient. Sun treatment
aided in the healing of the ulcer and was of great advantage
to the general condition of the patient. There was no
keloid at all in the scar. It will be also observed that there
was an indication of commencing normal pigmentation in
the skin covering the formerly ulcerated area.
The chief points of interest in this case are :—
1. The brass paste was chemotherapeutic in action; it
instantly attacked and speedily destroyed the tuberculous
infiltrate to which it had access ; it was specific and selective;
it had no action on the healthy skin ; it was innocuous.
2 With chemotherapy alone the ulcer would probably
have healed, but the combination of chemotherapy and helio¬
therapy was particularly advantageous.
3. Sun treatment alone healed the trunk lesions and
small femoral ulcer and immensely improved the general
condition of the patient.
4. The plantar ulcer improved under sun treatment and
possibly would have eventually healed by this method of
treatment alone, but the very slight penetrability of the
ultra-violet light rays only permitted very slow improvement
and did not prevent some extension of the ulcer at its
periphery.
The second case is now recorded.
Case 2.—Patient I. J. admitted with extensive lupus of right
oheek and two separate lupus areas, one below right ear, the
other under the chin. Fig. 5 illustrates appearance before
treatment commenced. I reproduce the following extract
from my notes of this case Sept. 12th, 1918: Treatment
commenced. Picric-brass paste applied. Sept. 18th : The
whole of the affected areas are markedly inflamed;
there are many bleeding points on the surface. The
periphery is less “ heaped up.” There are numerous
punched-out ulcers, most marked at the periphery.
Sept. 30th: The affected areas are not so inflamed. They
are pale piok at the periphery and more ansmic centrally.
There are numerous small punched-out ulcers oircular or
irregular in shape. There is no pun, but a film of glairy
fluid over each ulcer (Fig. 6). Oct. 12th; Marked improve¬
ment. Periphery still slightly thickened, some keloid, no
ulceration. Subsequently improvement was slower, occa¬
sionally ulcers again formed. Skin remained injected, but
the redness and thickening was markedly diminished after
application of blue paste (copper oleate), as advised by Dr.
Ellis. Jan. 15th, 1919: While condition has very markedly
improved and there is no ulceration the tubercle is not yet
eradicated (Fig. 7). The skin remains somewhat injected
and nodules can be seen and felt, most marked at the
periphery. In fairness it should be explained that the photo¬
graph (Fig. 7) does not do adequate justice to the improve¬
ment effected.
Treatment is being continued and picric-brass paste agpin
being applied. Farther nodules are being broken down and
improvement is maintained. The lupus patches below the
ear and under the chin are now hardly visible.
In this case no light treatment was employed. When
treatment is completed it is hoped to report the case further.
A number of other oases are now under treatment. With
improved technique and greater experience more rapid
improvement is being effected.
References.—1. Luton, Ernest: Tr&ttement de la Tuberoulose par lea
Sals de Cuivr*, Paris, 1894, G. Stelnbetl. 2. Contributions to the 0hemo»
thereoy of Tuberculosis (Prof. Dr. C. von Linden, Bonn. Vaccina¬
tion Tuberculosis; Prof. Dr. B Meissen, Hohennef, Lung Tuberculosis;
Dr. A. rtrauas, Barmen, External Tuberculosis); Contributions to the
Olinto of Tuberculosis xxlll., vol 11., 19’2. published by Curt Kabitzsob,
Wuerzburg Tenth Internul nal Tuberculosis Conference and the
Seventh Tuberculiwls Congress at Rome. April, 1912. 3. Strauss, A.:
Chemothernpy of External Tuberculosis. Technical Supplement to the
Urologio and Cutaneous Review, New Series, 1. (No. 1), 84, 8t. Louis,
J«n., 1913 4. Strauss, A., u. Bilerlrioh, Fr. : Die GrundiAtze elner
rations lien Behaodlung der Hsuttuberkulose unter besonderer Beriick-
slchtigung das Lecuiyl. Arch. f. Dermatol, u. Sypb., 1914, oox., 149.
5.Strauss: Die Beh&nrllungdea Lupus rait Kupferleolthiuverblndungen.
Tuberculosis (Benin), xlv., 193. 6 . Rogers, Sir Leonard: A Note on
S Hllum Morrhuate In Surgical Tuberculosis, Brit. Med. Jaur., Feb. 8th.
1919.
Aberdeen Royal Infirmary.—A t the annual
meeting of this institution tne report submitted stated
that daring the year 1918 15,810 patients were treated, or
an increase of 349 in-patients and 6 out-paiients on the
previous year. Since the outbreak of the war 987 sailors
and 773 Boldiers had been treated. The expenditure showed
a deficiency over ordinary income of £6236, of which £4400
were refunded by the Government for naval and military
tients. The convalescent hospital still showed an aooumtr-
The Lancet,] DB. H. A. ELLIS: PIOBIO-BB ASS. PREPARATIONS IN TREATMENT OF LUPUS. [March 15,1910 415
PICRIC-BRASS PREPARATIONS IN THE
treatment OF LUPUS
AND OTHER FORMS OF TUBERCULOSIS. 1
By HENRY A. ELLIS, M.B., Ch.B.Dub.,
TVRRRCT7LOSIS MEDICAL OFFICER FOR MIDDLESBROUGH; LATE SUPER¬
INTENDENT, OOOLGARDIE SANATORIUM, W. AUSTRALIA.
The more exact scientist looks with suspicion on
empiricism, and yet empiricism has been the road that
medicine has most generally followed. This is by way of
apology for the present paper, the result mainly of empirical
deduction, and though the road has been long, tortuous, and
inexact it has opened up possibly a path of some importance.
Earlier Observations.
The control of the damage caused by the Bacillus tubercu¬
losis and its products has always appeared to me exception¬
ally difficult. Some 30 years ago, before opsonic indices and
antibodies, I said: “The direct destruction of the bacillus
was unthinkable, as it seemed impossible to suggest any¬
thing for its elimination without destroying the tissue in
which it was embedded.” So in investigations then I
gave up all study of germicidal action and devoted my
attention to increasing the resistance of the tissues. Even
when Koch’s tuberculin came out I was not swept away
with the current, and it was not till reading Riviere’s and
Morland’s work on tuberculin that I grasped the true
inwardness of Koch’s discoveries.
I had long held that, even if some method of eliminating
tuberculous conditions was discovered, it mast be demon¬
strated b? the cutaneous manifestation. When first attack¬
ing the problem in England I was glad to have an oppor¬
tunity of doing so in the many forms of lupus seen at the
dispensary, for studying which in Australia I had little
opportunity. For th« last four years most of my original
work has been devoted to that side of the disease. I looked
on the lupus question as the direct progression of the study
I had given to the cutaneous reactions to tuberculin,
already published. 2 The study of these cutaneous reactions
led to a general recognition that tubercalous cutaneous
deposits were of much wider distribution than was generally
supposed, that nearly all cases of phlyctenular disease and
manycases of blepharitis were hypersensitive, suggesting the
recognition of their tuberculous origin. Treatment on these
lines leads to rapid and permanent cure. This time has
amply confirmed.
But the question still remained unsolved how to get rid
of heavier and more extended deposits displayed in more
regular forms of lupus. The question here was the destruc¬
tion of the tuberculous tissue, even if it entailed the healthy
tissue in which it was embedded. Most modern methods
aim at this destruction, and they all destroy a certain
amount of the healthy tissue. An attempt was made to
achieve this result by pressing the destructive action of
tuberculin to the limit. In the cases where failure or auto¬
intoxication was produced a considerable series of observa¬
tions led to the conclusion that a certain combination of
basic salts of sulphate of copper and zinc, when combined in
an oily medium at definite temperature, gave a much more
regular result than anything I had used up to date. I call
this preparation brass paste.
Brass Paste.
The combination is definite and chemical and approxi¬
mates an old formula for making brass. It is formed by
combining basic copper sulphate with basic zinc sulphate
in the proportion of 86 per cent, basic copper to 14 per cent,
basic zinc The basis of the preparation has been used by
me for many years in intractable chronic eczema, nearly
always with success. It had considerable restrictions in
lupus, but a continuous series of experiments has gradually
eliminated them. This paste is easy to apply. When the
covering plaster is removed after 48 hours the tuberculous
tissue will be found extensively destroyed and removable
as small caseating nodules, while the uninfected tissue is
uninjured. The caseons material is often stained with the
preparation, but the healthy tissue is not. This localised
1 A paper read before the North of Bogland Tuberculosis Asso¬
ciation.
* The Lancet, 1916,11., 638.
destruction gives a curious and characteristic appearance,
especially in verrucosa. Where the tuberculous deposit is
superficial and limited comparatively few applications destroy
the growth, but in the majority of cases many applications
are necessary. The problem is only one of contact; if
contact can be obtained the result is always assured.
The paste is quite innocuous to healthy tissue, it can be
placed in the eye without causing other than temporary
irritation, easily controlled by first instilling eucaine and
adrenalin. This is shown in a case cured by the application
of the paste to the conjunctiva of the everted eyelid, result¬
ing in removal of all tuberculous tissue. The case was of
over 20 years’ duratiqp, and as she was employed in a
hospital, had had many treatments. The paste can also be
applied to the nasal mucous membrane without producing
any reaction unless the tissue is invaded by tubercle. But
if the nasal mucous membrane be involved caution must be
used or it is apt to produce headaches, which may be very
serious if the nasal foss® are involved. Ordinary ulcerated
non-tuberculous surfaces are not affected by the application,
and it has apparently little effect on their progress. In case
of doubt an application of the brass ointment will soon settle
the matter.
In the earlier investigations, as has been so frequently
the case with lupus, the results were unequal; and certain
disadvantages delayed the publication of the method. The
most serious and difficult was a tendency to light up some
quiescent focus. These local manifestations were sometimes
accompanied by certain constitutional results. This position
has now been remedied by the addition of trinitrophenyl.
Brass Oil: Addition of Trinitrophenyl.
It was at first difficult or impossible to reach the deeper
deposits. Then there were also the various thiokenings of
the cutaneous and other tissues of a lymphatic or glandular
nature so intimately associated with tuberculous lesions,
which were uninfluenced by the earlier preparations. The
superficial tubercular abscess presented certain problems, all
its own, especially the cold, small, non-spreading tubercular
abscess formation limited to the skin entirely, which is not
usually accompanied by glandular enlargement. It is
often multiple, and this condition, for purposes of differen¬
tiation, I call intradermic abscess, as a distinct division of
lupus. The nature of their tubercle bacilli is now being
investigated by Dr. Stanley Griffiths, of Cambridge. These
abscesses are surrounded by healthy tissue, and there is
little or no tendency to invade the adjacent area. They are
very difficult to heal and leave many of the unsightly scars.
They are placed under the head of scrofuloderma, but the
absence of glandular enlargement precludes that term. They
are invariably tuberculous, and the majority up to the present
have been due to the bovine bacillus.
For these conditions a suitable medium is a fluid
preparation called brass oil, or, shortly, “bro.” Its
extensive and general application has produced many un¬
expectedly favourable results. This oil, transparent and green
in colour, is produced at a definite temperature, over a con¬
siderable period, and is applied on gauze covered with
jaconet and left on from two to seven days. Definite
constitutional symptoms indicated that it is partly absorbed
along the line of the lymphatics, though these may largely
be due to the resolution and absorption of the tuberculous
materials. The conditions which yield most readily to its
influence are those produced by lymphatic thickening, espe¬
cially the condition constituting pseudo-elephantiasis, of
which one case is illustrated (Figs. 1-4), as well as the
general thickenings in scrofuloderma. The swellings in the
neighbourhood of joint or bone disease are also reduced by
it; in fact, all swellings produced by lymphatic obstructions,
the result of tuberculous invasion. It was the early investiga¬
tions of the bro treatment that brought most into prominence
the lighting up of distant foci and the constitutional
disturbances.
On farther investigation it was found that the trinitro¬
phenyl or picric acid series had a distinct action in con¬
trolling these conditions, and extended observations—not
yet completed—resulted in a further addition of a definite
proportion of trinitrophenyl to the brass preparations. After
this addition metastatic developments entirely ceased, and
cases of pallor and loss of weight no longer occnrred, but
distlnot improvement of the general appearance and health.
The specific action of the brass treatment was materially
increased, an unlooked-for and very gratifying attainment.
416 Thk Lancet ,] DR. H. A. ELLIS: PICRIC-BRASS PREPARATIONS IN TREATMENT OF LUPUS. [March 16,1919
1. Before treatment, showing comparative size. 2. Side view, showing warty growth before treatment. 3. Showing discrete caseating
nodules of tuberculous matter produced by treatment ; elevations are »oft and mseous. 4. Leg after eight month?*' treatment; wart gone;
tissue soft and pliable; size reduced, but still larger than the other; present condition almost normal.
Extensive Lupus Verrucosa both sides of forearm.
Fifteen months' duration.
5. Showing character of growth, with islands of resolving tissue
during treatment. 6. Islands further developed. 7. Pitting caused
by caseation of tuberculous deposits caused by application of
brass paste. 8. Case completely cured; time between Plates 5
and 8, four months.
| But in certain individuals a superficial dermatitis limited
the use of the new remedy, although the condition was very
rapidly relieved by soda-bicarbonate solution. No effect is
exerted on the deeper tissues, as was seen when trino or
picric bro was injected into abscesses or sinuses.
By the time these experiments were completed a most
valuable clinic had been acquired by the gradual selection of
refractory cases, out of some 150 examples of cutaneous
tuberculosis. At the present time there are still some six
or eight more or less refractory cases of extreme value for
observation purposes, but they are a rapidly diminishing
series. [Recent observations have diminished these now to
the vanishing point.]
Efficacy of Remedy.
One of the means of testing the efficiency of the remedy is
as follows. When a smear of caseous material from a
tuberculous deposit is made on ordinary Dorset egg medium,
a slight guttering is often produced due to its solution.
This is probably due to the action of trypsin or some other
ferment released by the process of caseation. This guttering
did not occur when the brass media were mixed with the
pus of ordinary abscesses. Accurate determination has yet
to be made, but it has proved a good rough-and-ready
method of testing the efficiency of the various products
during the search for increased efficiency, and when com¬
pared with the tissue destruction effect proved fairly
reliable.
By using these preparations it was easy to obtain pure
cultures of the particular organism causing the disease,
proving also that the remedy was not immediately
destructive to the life of the bacillus, but a series of
observations showed the gradual breaking up of the
organism. Time has only allowed this casual observation,
but the process of obtaining pure culture from tubercular
growths by this method is so accurate that I was recently
able to forward 16 out of 17 successful cultures to Dr.
Griffiths to have the variety of tubercle definitely classified,
and if possible to have the attenuation or otherwise
determined.
After considerable investigation the preparations have
been found innocuous except when tubercle has been
present. The various preparations have been injected in
man and animal, both intravenously and subcutaneously,
in considerable quantities without producing unpleasant
symptoms. The subcutaneous application of the paste in
large doses in the guinea-pig demonstrated that the material
was decomposed, and apparently some variety of yellow
material (copper ?) was deposited along the course of
the lymphatics, showing a very interesting pathological
preparation.
The next step was to see if it was successful in the hands
of others. I first asked Mr. H. J. Gauvain, of Lord Mayor
Treloar Cripples’ Hospital, to cooperate with me, as his
This Lancet,] MR. C. H. L. RIXON: THE HYSTERICAL
unrivalled material in bone tubercle cases and his wide !
experience made him an ideal judge. My own cases of bone
tuberculosis, limited in number, have been successful,
sometimes dramatically so. Mr. Gauvain has investigated
in this direction much more extensively, and his reports to
date have been most encouraging. Several of those present
have also seen the results in visits to my dispensary, and
some have made tests, and up to now all reports but one have
been favourable.
Led by the results of the effect in experimental tuber¬
culosis in animals, I have for some time been using it in
Face Lupus Vulgaris. Nine years' duration.
9 1C
PERPETUATION OP SYMPTOMS. [March 15, 1919 41 7
lymphatic engorgement, and is applied twice weekly, and
should cover all round the neck from ear to collar bone. The
staining of the skin is easily removed with vaseline. The
trino-bro is the best preparation for these cases unless they
are picric sensitives, which is rare.
The lighting-up of phlyctens must always cause temporary
discontinuance of the treatment. They should be treated
with tuberculin as described in The Lancet, 1 or by a dilu¬
tion of picric bro 1 part, to cod-liver oil 3 parts, brushed
on with a small camel-hair brush after the eye has been made
anaesthetic. These phlyctens are liable to occur in nasal
Previously treated by A" rays, freezing , <fv.
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9. Before treatment. 10. During progress ; ulceration defined. 11. Five months after.
other forms of tuberculosis, notably abdominal, with satis¬
factory results. The exact method and dosage is still a
matter for investigation. Observations have shown that
very small doses by the stomach produce gastric irritation.
The whole question is a matter for a further communication.
Methods of Treatment.
So far one may say that the brass treatment leaves
available four preparations of specific potency in tuberculous
deposits. These preparations are : (1) Brass paste, an oily
preparation of a compound of basic sulphate of zinc and
copper ; (2) brass oil or bro, a preparation of the soluble
portions ; (3) and (4) both these preparations, in combination
with approximately 1 per cent, of trinitrophenyl, called
respectively trino-brass and trino-bro. Great care is needed
in preparation as they are easily decomposed and rendered
inert at comparatively low temperatures, the whole process
going into weeks. Instability is naturally a condition, for,
if the combinations were not weakly allied they presumably
would not obtain their specific action. These preparations
are more efficient, especially in facial cases, when mixed with
adrenalin and cocaine or eucaine.
As far as ascertained, the remedies are entirely innocuous
to the non-tuberculous except when given by the mouth.
With the tuberculous hypersensitive care in applying the
simple brass preparation must be taken to avoid auto¬
infection from tuberculous absorption, producing loss of
health, lowered weight, pallor, and metastatic abscesses.
But generally ample warning is given. This danger does
not hold of the trinitrophenyl remedies, but here the picric
sensitiveness of the external cutaneous layers must be
watched for. I am inclined to think that picric sensitive¬
ness encourages local tuberculous extension in cases
showing it.
The application of the brass paste is made every two or
three days under zinc plaster. The bro is applied either as
a foment on gauze with jaconet covering once, twice, or
thrice weekly, as indicated, or only painted on the skin
when a rest from active treatment is required. The bro
collar is the most efficient way of dealing with glands of
the neck or scrofuloderma ; it very rapidly diminishes the
I lupus, especially of the interior mucous membrane. Outside
these precautions I know of none other, when the remedy
may be used with the greatest freedom. Another refractory
condition amenable to treatment is dactylitis. The swelling
reduces, and unless the bony enlargement is great the finger
returns largely to a usable condition.
Note .—Arrangements have been made whereby a supply of
these preparations can be obtained from Mr. Jack L. Robinson,
pharmaceutical chemist, Middlesbrough, Yorks.
3 The Lancet. 1917, II., 157.
THE HYSTERICAL PERPETUATION OF
SYMPTOMS.
By C. H. L. RIXON, M.H.CTS. Eng., L.R.C.P. Lond.,
CAPTAIN, R.A.M.C. ; NEUROLOGIST, READING WAR HOSPITAL.
Much has recently been written concerning the treatment
of hysterical disorders in soldiers, especially at neurological
centres. There is great scope for similar work in general
hospitals; the same methods will effect very marked im¬
provement, and even cure, in cases not usually regarded as
hysterical.
All surgeons are now familiar with the type of case in
which improvement, not amounting to complete recovery,
follows a nerve suture, yet there may be much more recovery
than is apparent, masked by what is now an hysterical dis¬
ability. Similarly, many abnormal gaits, following severe
organic lesions, are hysterical. Rapid improvement, even
amounting to cure, can be obtained in a few minutes or
hours by methods similar to those employed to-day in the
treatment of hysterical disorders, and summed up in the
word “ psychotherapy.”
In treating these conditions there is one factor indis¬
pensable to success—i.e., the patient's own belief that he
can be cured. At neurological centres this point is gained
by the “atmosphere of cure” prevailing. The patient is in
a ward with others who until recently were, they tell him.
418 The Lancet,] MR. C. H. L. RIXON : THE HYSTERICAL PERPETUATION OF SYMPTOMS. [March 15, 1919
just as bad as he is. They have been cured, everybody who
comes there is cured, and the newly admitted patient soon
views his own case as one in which cure will be effected
also.
My own experience has been gained largely at an
orthopaedic centre, and at such centres there is apt to be an
atmosphere of chronicity. A patient with, say. an hysterical
drop-foot is mixed with the crippled and patients whose
recovery must be a matter of months. It is hard for him to
believe that his foot is curable in an hour, and it is
impossible for him to expect it. But by putting him into a
ward amongst others like himself, some already cured, his
views may be altered. Such a patient if put to bed in these
surroundings for 48 hours will be found confident of speedy
recovery when he goes to the treatment-room at the end of
that time. All that are then needed are persuasion and
re-education and a large store of patience.
Hysterical Disabilities.
As examples of hysterical disabilities thus treated I will
cite the following case :—
Case 1. Scoliosis of nearly four years' duration with 21 in.
apparent shortening of left leg, cured in 70 minutes. —Fig. 1 A
shows a patient with well-marked scoliosis of nearly four j
years’ duration, following a blow on left side of pelvis. The
f jelvis was tilted; 2i inches of apparent shortening of the
eft leg. For three years a surgical boot with a sole 2^ inches
thick had been worn on the left foot. Whilst wearing this
boot be did not limp, but the scoliosis was more marked.
He believed himself to be a permanent cripple. Fig. 1 b
shows the spine perfectly straight after one hour and ten
minutes’ treatment by manipulation and persuasion. He
could then walk and run normally with no limp, in ordinary
boots.
Case 2. Contracture of hand of three years' duration cured
in 40 minutes.— Fig. 2 a shows a contracture of right hand of
three years’ duration, following a through-and-through
bullet wound of the arm. Patient was seen in conjunction
with Major J. L. Joyce, R.A.M.C.fT.). Patient had been
deafness, mutism, tremors, vomiting, abnormal gaits, &c.,
with which the war has made all medical officers familiar.
Hysterical Perpetuation of Symptoms after Organic Lesions.
The point I wish to emphasise is the wide scope for such
work in cases not usually regarded as hysterical, and which
seldom reach the neurologist. There has been some severe
organic disability with only partial recovery. There is a
Tremor, patient also stammered. Duration 16 months. Treatment
40 minutes. Stammer also cured (Case 3).
tendency to ascribe this remaining disability to permanent
organic damage, and the cure is much slower or less perfect
than need be. But it is frequently functional. The following
case is an example :—
Case 4.—Wounded in October, 1917. Bullet entered the
chest at posterior axillary border about 2J inches below
acromion process on left side. It passed forwards and
inwards, damaging circumflex nerve, and lodged just behind
second rib on left side, near sternum. When first seen bv
me 13 months later, he was able to perform only limited
A Fig. 1. B
Fig. 4.
Fig. 2.
A
B
A, “ Wooden ” rigidity of hand ; no movement
at all; duration 3 years. B shows the result
of 40 minutes’ treatment (Case 2).
Musculo -pir*l nerve divided bv missile; nerve
su-ure. (Ca«e5.) B shows extension volun
tartly performed after 35 minutes' persuas’on
and education.
A, Lateral curvature (spine marked out with
grease pencil); duration 4 years. B shows
the condition after 70 minutes’ treatment
(Case 1).
invalided out of the Army as a permanent cripple with
pension for 40 per cent, disablement over a year before he
was sent to an orthopaedic centre for treatment. The band
was blue, cedematous and shiny, and absolutely rigid, the
fingers being immovable owing to intensity of spasm. In
Fig. 2 B he is bolding bis hand open, after 40 minutes’ treat¬
ment. He was then able to perform all movements of the
hand normally, and the photograph shows the wrinkling of
the skin of the fingers which followed the disappearance of
the oedema.
Case 3. Hysterical tremor oj 16 months' duration cured in 40
minutes.— Fig. 3 A is the signature of a man with tremor which
he had had for 16 months following a fall down a ravine in
the dark. The tremor was very quickly overcome (Fig. 3 b)
as soon as full muscular relaxation was obtained by mani¬
pulation and persuasion in 40 minutes.
8uch cises are purely hysterical. Many other cases could
be quoted of the hysterical paralyses, contractures, blindness,
abduction of the left shoulder, the arm not coming up to the
horizontal in spite of obvious efforts. Very marked wasting
of the deltoid, which only responded feebly to strong
faradism; some blunting of sensation over it. Improve
ment having ceased, he had been discharged from hospital
many months previously; the loss of power was thought to be
due to the wasted deltoid. After a quarter of an hour’s treat¬
ment by manipulation and persuasion he was able to raise
both arms smartly and bring his hands together over his
head without flexion of the elbows or wrists. The left
deltoid was still much weaker than its fellow aod there was
still imperfect sensation, bat recovery had been masked by
a superimposed hysterical condition.
The following case illustrates a similar state of affairs
following nerve suture :—
Cask 5.—Wounded by a shell on April 8th, 1917. The
wound was 3 inches above the left elbow; compound com-
A
B
The Lancet.] DR8. J. A. B. HICK8 fc E. GRAY: INVESTIGATION OF INFLUENZA OASES. [March 15, 1919 419
minuted fracture of humerus and complete division of
musculo-spiral nerve. The wound was septic; after about
three weeks several small pieces of bone were removed under
an anaesthetic. In three months the humerus was soundly
united, with practically perfect movements at the elbow-
joint; the wrist-drop was controlled by a “cock-up” splint.
In August, 1917, suture of musculo-spiral. Nerve found com¬
pletely divided; bulb at each cut end. The two bulbs were
excised, leaving a gap of about 2 inches; end-to-end suture;
considerable tension at point of union. The wound healed
by first intention. Three months later there was some
return of voluntary movement in the extensors and the
analgesia was less marked. Twelve months after the nerve
suture there was 50 per cent, of recovery in the extensors
and sensation was normal. Massage, galvanism, faradism,
ionisation, and electric baths, persisted in all this time, pro¬
duced no further improvement and he was discharged from
the Army in October, 1918.
When I saw him first, soon after Christmas, 1918, there
had been no further improvement since August, 1918. He
was able to make some extension of the wrist and of the
fingers; movements were jerky, accompanied by some
spasmodic contractions of the flexors. In Fig. 4 a the scar
of the operation for nerve suture can be seen above the
external condyle. The photograph was taken whilst the
maximum amount of extension of the wrist and fingers was
being made. He was treated by persuasion, manipulation,
and re-education for 35 minutes, when voluntary extension
was as shown in Fig. 4 b. Movementts were now smooth and
easy, and he was able to use bis hand normally, the total
recovery from the original lesion being practically 100 per
cent.
Case 6.—Patient, aged 37, sent to me with the following
history.:—Three and a half years previously he had had an
acute illness; the main characteristics were slight pyrexia
and general malaise, pains in legs, some difficulty with
bladder, afid increasing weakness of legs. He was in bed for
about three months. The symptoms largely subsided, but
he was left with the “weak legs,” and his back was bent.
On examination be was very bent, and hobbled with two
sticks. The legs showed the signs of a lesion of the lateral
tracts, weakness, spastipity, exaggerated tendon jerks,
clonus, and a bilateral extensor response; abdomipal
reflexes absent. His condition bad been in statu quo for
about two years; yet a great part of this, iu spite of its
organic basis, proved to be the perpetuation of symptoms
by suggestion. After manipulating the legs and back, with
persuasion to increase the range of movement voluntarily,
for half an hour, the patient was able to stand upright and
to walk without sticks. There was still some spast 4 city of
the legs, but it was not very noticeable except when he tried
to run. He was delighted with his improvement, and took
some pride in exhibiting it to others. The physical signs
were, of course, unaltered.
Conditions in which Functional Disabilities Occur,
The last three cases are instances of the hysterical
perpetration of symptoms long after the original causes
for them had disappeared. This is really a very common
occurrence, and many similar cases might be cited.. In a
multiplicity of conditions this is liable to occur, especially
in those which run a chronic course ; nerve suture, neurolysis
and capsulotomy of a traumatic neuroma must be especially
mentioned. Disordered gaits are perpetuated after fractures
and injuries of the lower limbs ; sciatica is also specially
liable to produce this condition of affairs, and many other
diseases with a chronic or semi-chronic course.
Several factors help in suggesting the perpetuation of
symptoms, as, for instance, the use of crutches and sticks. An
officer had his foot severely crushed by a motor lorry, but there
was no fracture or dislocation. An extensive ecchymosis of
the dorspm cleared up in some three weeks, but be was unable
to bear any weight at all on the foot when he got out of bed,
and he asked for a pair of crutches. After 10 minutes’ practice,
however, with persuasion and encouragement, he was able to
walk and even to run normally without limping, and there
was no pain in the foot. On the following day he volun¬
tarily went for a walk of six miles. In this case, only one of
many, it is probable that had the patient been given a pair
of crutches the idea of the disability would have been con¬
firmed, and a disordered gait would have resulted when he
discarded them after, perhaps, many weeks or months.
Many other things may be the means of suggesting a per¬
petuation of a disability, and in some cases it is, no doubt,
due to auto-suggestion.
A very large number of chronic cases of all kinds will
amply repay time spent in treating what are really hysterical
disabilities. Much patience and painstaking are needed, but
great improvement can be effected, and sometimes complete
cure.
AN INVESTIGATION OF CASES OF
INFLUENZA
OCCURRING IN THE WOOLWICH DISTRICT DURING
SEPTEMBER, OCTOBER, NOVEMBER, 1918.
By J. A. BRAXTON HICKS, M.D , M.R.C.P. Lond.,
* D P.H.,
TEMPORARY LIEUTENANT, R.A.M.C. ;
AND
ELIZABETH GRAY, M.B., Ch.B. Aberd.,
ATTACHED R.A.M.C.,’
BACTKKIOLOUISTS, ROYAL HERBERT HOSPITAL, WOOLWICH.
Introductory. —During the summer of 1918 it fell to the
lot of one of ns (B. H.) to investigate the then prevailing
and mild epidemic of “influenza.” The results were not
published, but briefly, though proving interesting as regards
the effect of this disease on the leucocyte counts, they were
entirely negative as regards the isolation of B. influenza.
In making this the second series of researches on influenza
the first thing that we wish to insist upon is that we have
used exactly the same methods and the same blood medium
(Gordon’s trypagar plus rabbit’s blood) in investigating this
epidemic, as in the mild one dealt with in the summer,
in addition, we have examined the claims of a medium
which was highly recommended by Dr. John Matthews 1 as,
suitable for B. influenza.
Our researches have been conducted without selection
of cases. That is to say, except for refusing to examine
material sent under conditions impossible for good bacterio¬
logical work, we have taken and examined anything sent
down to us that seemed to offer possibilities.
General technique. —Sputum has been collected where
possible in wide-inouthed sterile bottles with rubber corks.
These were distributed to the ward sisters with instructions
to send the first sample coughed up and not to collect a lot.
This sample was then washed in sterile broth and plated out
on trypagar pla9 rabbit’s blood. The broth washings were
also incubated. In some cases it was plated out also on Dr.
Matthews’s medium. Direct smears were examined also in
every case. Naso-pharyngeal cultures were made with
West's swabs and inoculated on to the media at once where
p >ssible.
Blood cultures were taken by venepuncture in the ordinary
way and 10. c.cm. was distributed in varying amounts into
broth tubes.
Results.
Naso-pharyngeal swabs — The naso-pharynx in all cases
seen by ns has been injected and very sloppy. A prominent
feature Is the greatly swollen and elongated uvula, and to
this uvula must partly be attributed the irritable cough and
retching in many cases. Some cases have epistaxis from the
great engorgement of the parts. Naso-pharyngeal swabbings
have been positive iorB. influenza in 80 per cent, of cases.
Other organisms have been present, such as M. oatarrhalis ,
pneumococcus, streptococcus.
Sputum. —The sputum has varied greatly. Some speci¬
mens have been thick, sticky, and stained with blood to
varying degrees. This blood staining is not the “rusty”
staining of croupous pneumonia, but something much
brighter and iu some cases amounting almost to haemoptysis..
Other specimens have been of a yellow-green “nummular”
type, while others have been white and slimy. Generally
speaking, we consider the white slimy specimens occur just
at the beginning and when the case is clearing up, particularly
the latter. The blood-stained ones indicate pneumonia, or
at least severe capillary bronchitis, and that the man is a
case to be anxious about. The yellow “ nummular ” ones
seem to be chiefly where the trouble is mainly bronchial or
where only a small broncho-pneumonia patch or so is present.
We have seen rather more of the yellow “ nummular ” than
the blood-stained type in the laboratory.
The result of examination of direct films of sputum has shown
70 per cent, positive for B. influenza, and of cultures from
these same cases 75 per cent, positive. It has been interest¬
ing to us to find in some oases negative for B. influenza
by direct film that the organism has turned up on culture.
In one or two cases we failed to grow the organism iu spite
of its obvious prevalence as seen in the direct film. One may
* The Lancet, July 27th, 1918.
420 Thb Lancbt,] DBS. J. A. B. HICKS k B. GRAY: INVESTIGATION OF INFLUENZA CASES. [March 15,1910
say unhesitatingly that the pneumococcus has been present
in 100 per cent, of the cases. In practically every sputam
we have examined it has been predominant over B. influenza.
Other organisms have been present, M. catarrh alia and month
streptococci, bat we have not been able to confirm the
presence of any particular haemolytic streptococci in our
cultures as has been mentioned by some observers.
We would like to point out here what have been to us
very interesting features in the bacteriology of the sputum. At
first it was comparatively rare to find B. influenza in direct
films, the pneumococcus always predominating, but as the
number of admissions grew and the severity of the epidemic
increased we began to find B. influenza readily, and isolated
it easily. Even in mild cases now at the decline of the
epidemic the B. influenza is readily found. This is in acoord
with what occurred in the great pandemic of 1888-92, for
the bacillus was only found towards the end of the epidemic
in 1892 by Pfeiffer.
Another interesting feature is the pleomorphic character
of the bacillus in culture. It occurs in rods of very varying
length (0-5-1 *5/*), and sometimes the bacillus is almost a
oooous, so short is it. Again, it tends in some cultures to
occur in pairs and short chains.
As regards the medium recommended by Dr. Matthews,
we oonsider it fully bears out its claims, but we do not con¬
sider it superior to Gordon’s trypagar enriched with rabbit’s
blood except in one useful detail, and that is that it does
seem to inhibit for a time the growth of other organisms,
enabling B. influenza to be readily isolated. Gordon’s
medium tends to grow everything with equal intensity, and
so B. influenza is not so easily isolated free from other
organisms.
Pleural fluids .—In the early part of the epidemic empyema
was uncommon, probably because the cases with extensive
lung ohanges did not live long enough to develop one. In
the latter part of the epidemic empyema was more common.
The fluids were of a ye! low-green colour and rapidly separate
out into a layer of slimy pus below and bright yellow fluid
above. In direct- films cocci in pairs and short chains have
occurred in practically every case ; capsulation was observed
also. In one case chains of great length occurred, but the
chains had the appearance of being made up of a series of
pairs of cocci. In culture the coed always grew in pairs
and chains, these chains always being very much longer
than any seen usually in the direct film, and some were of
great length. Where the chains were of great length they
always had the appearance of being built up of a regular
series of pairs , and the appearance was quite different to
the ordinary streptococcus. This organism appears to be
either the Streptococcus muoosus or closely allied to it, and
probably 8. mueosus is a variant of S. pneumonia. We had
great difficulty in getting most pleural cultures to sub¬
culture freely even on blood media. In two of our cases we
found B. influenza in the pleural fluid as well as 8. mueosus.
As regards haemolytic properties on blood-smeared agar, our
cultures varied even with cultures of apparently similar
morphology. Some hsemolysed fairly; others showed no
signs of haemolystng; none hmmolysed well.
Blood cultures .—Of all our cases these may be regarded
as the only ones in which it may be said that they were
selected, *ince medical officers only requested this in severe
cases. We obtained 50 per cent, positive cultures, and these
cultures showed cocci with somewhat similar characteristics
as those described in the pleural fluids. In no case, how¬
ever, did we observe such long chains as in the pleural
cultures, and the chains more closely resembled those of
8. pneumonia. For some reason which we were unable to
explain we could not get the oiganisms of the blood cultures
td grow in subculture. The blood in the blood-broth
mixture, however, did not undergo any marked haemolysis
even after four days.
Leucocyte counts .—We were able to confirm our previous
results (summer epidemic) as regards the cases only affected
by high temperature, pains, and no chest symptoms—viz.,
little or no leucocytosis, and generally a qualitative Increase
in the mouonuolears.
In pneumonic cases ending fatally or cases of great severity
we noticed that the leucocytes showed no increase, and in
most cases a leucopenia, but that there was a qualitative
increase of the polymorphonuclear cells. In one fatal case
in which the blood culture was positive (pneumococcus) the
oount was as low as 3000 per c mm.
In the average severe bronchitis or mild pneumonia Case
there was a quantitative and qualitative polymorphonuclear
leucocytosis. The leucocytosis was moderate, averaging
18,000 per c.mm. 80 per cent, of our cases showed a
leucocytosis.
Post-mortem and histological findings .—The first point we
wish to make is that in no oase did we see those appearances
conjured up by the term “ grey hepatisation.”
The average appearance of the lungs when removed from
the thorax was that of an infant suffering from broncho¬
pneumonia. In the very acute cases they resembled acute
haemorrhagic broncho-pneumonia. As a rule, one lobe
(usually a lower lobe) was more affected than the rest, and
if the case had lasted some days this lobe might be solid.
The cut section of a solid area was firm, of a deep-red colour,
more resembling liver tissue, and a frothy purulent fluid
oozed from the bronchi. Here and there a small greyish
area with a wavy outline might be seen, but we saw no
evidenoe of actual breaking down of tissue. This greyish
area marked, however, an intense exudate into the alveoli.
In the very acute cases there was no particular affection of
any one lobe, all lobes usually showing areas, varying in
size, of intense engorgement resembling haemorrhagic infarc¬
tion. The pleura was usually involved over the lung or lobe
most affected, forming in some cases a thick gelatinous
layer of 1 to 2 inches. The trachea and bronchi were always
intensely engorged and covered with a tenacious muoo-
purulent coating. The liver and kidneys usually showed
slight toxic changes.
Microscopical sections showed intense engorgement and
dilatation of capillaries and blood-vessels. In places,
particularly in the acute cases, the blood has escaped
into the alveoli, and gives the appearances seen in ordinary
haemorrhagic infarction (of mitral stenosis. Ice.). The
exudate in the alveoli is chiefly of alveolar cells and mono¬
nuclear oells. Polymorphonuclear cells are relatively few,
and this is a very striking feature, even in the solid portions.
In sections of bronchioles and neighbouring alveoli in
apparently non-affected areas the capillary engorgement is
very well marked. It is also evident from any section how
the completely solid state of a lobe is arrived at; for one
can Bee that certain neighbouring areas are more involved
than others, and that the inflammatory oondition has spread
peripherally till such areas coalesced, and where such areas
are numerous in any lobe it is obvious that the lobe will
become eventually solid.
We would suggest that the mode of infection is probably
as follows. Infection of pharynx and trachea (nearly all
oases complain of rawness over larynx and sternum at
onset) with B. influenza which rapidly spreads to bronchi,
bronchioles, and alveoli. This “ lowered resistance ” of the
respiratory tract leads to a secondary infection with pneumo¬
coccus and perhaps other organisms—i.e., 8. muoosus. It is
a well-known fact that mixed infections are more severe
than pure infections, and to this we may attribute the
severity and mortality of this epidemic. In short, we
regard the infection as an acute capillary bronchitis and
alveolitis.
We cannot confirm in our work the presence of any con¬
stantly haemolytic streptococcus as has been described by
some workers. We may have been unlucky, but it does not
seem essential to oonsider a haemolytic streptococcus as con¬
stantly necessary to produce the intense blood engorgement
seen in the lungs: The microscopic appearances alone show
that the blood in the alveoli has resulted from a rhexis of
the enormously dilated capillaries. Again the epistaxis that
oocurs can be seen to come from intensely engorged naso¬
pharyngeal vessels, and also the blood in the sputum is
bright recent blood, not altered blood. This streptococcus
is said by some to have been superadded as the result of the
numbers cf war wounds about, yet in peace time such
appearances were familiar to every morbid anatomist.
We have been able to identify the “pneumococcus”In
sections of the lung, but not B. influenza.
Summary of Results.
1. B. influenza was present in the sputum by direct film
in 70 per cent, of cases and by culture in 75 per cent, of
cases. Pneumococcus was present in 100 per cent. Other
organisms of the oatarrhalis type were present, and mouth
organisms.
2. B. influenza was present in naso-pharyngeal Bwabs in
80 per cent, of cases.
ThbLaho»T,J DR. F. G ROSE; THE INFLUENZA EPIDEMIC IN BRITISH GUIANA. [March 16, 1919 421
3. In plearal fluids we found a pleomorphic streptococcus
having many characteristics of the pneumococcus, but often
occurring in chains of great length. Some cultures showed
h»molyiic properties, others did not. We regard this as
S. muoosus , which is a “ variant ” of pneumococcus probably.
4. Blood cultures were positive in 50 per cent, of cases
and the organism was a pneumococcus, or a close ally of
S. muoosus type.
5. A leucopenia was usually present in severe or fatal
cases. In the average pneumonic case a moderate poly¬
morphonuclear leucocytosis was present.
6. Post-mortem and histological appearances show the
disease to be an acute capillary bronchitis and alveolitis.
We cannot conclude without reference to the assistance
we have received from our laboratory attendant, L/Cpl. L. G.
Blore. Our laboratory necessities throughout the whole of
the epidemic were always forthcoming, and since this work
was thrown on to the laboratory in addition to the routine
work of the district, his success in this matter is one for
which we desire to express our appreciation, and, indeed,
was no small achievement on his part.
THE INFLUENZA EPIDEMIC IN BRITISH
GUIANA.
By V. G. KOSB, B.A., M.B Cantab., M.K.C.S.,
GOVERNMENT BACTERIOLOGIST.
The recent influenza pandemic appears first to have made
itself manifest in Georgetown, the capital of the colony, in
'November, 1918. Clinically the symptoms do not appear to
differ from those characteristic of the disease in other centres
which have suffered its ravages. The disease has taken a
fearful toll, more particularly of the lower classes of the
community, the poor East Indian and black, generally
already debilitated by the ravages of chronic malaria or
filarial infection. Death has been due, in the vast majority
of cases, to a rapidly fatal broncho-pneumonia, and the
purpose of this article is to give a short account of the
pathology and bacteriology of the disease in this country.
Post-mortem findings .— These are based on post-mortem
examinations carried out on 24 fatal cases of influenza at the
height of the epidemic. Generally marked cyanosis was
present externally. Internally the pathological changes
appear to centre in the respiratory tract; naso-pharynx,
pharynx, larynx, trachea, and bronchi show congestion of
the mucous membrane, with exudate varying to a certain
extent in character, but generally tenacious and sometimes
stained with blood. Pleurisy was rare, only being present in
two oases, and then of the rfbute fibrinous variety.
The heart and pericardium showed no particular change.
The lungs showed generally a broncho-pneumonia of the
diffuse variety. If only a portion of a lung were involved,
it was invariably the base, and a constant feature was the
intense congestion of the lungs; the broncho-pneumonic
areas, on section, are hard and reddish-grey in colour.
The brain was involved in only one case in a meningitis
which proved to be of pneumococcal origin. The empyema
and pyopericaidium described as occurring in other parts
of the world were never found. The spleen, when showing
no evidence of malarial infection, was slightly enlarged,
congested, and firm in consistence. An acute parenchyma¬
tous nephritis was present in a few cases. The liver showed
frequently some fatty change.
Bacteriology .—An investigation was first carried out into
the bacteriology of 13 cases of well-marked clinical type by
means of post-nasal swabbing, as recommended by Matthews, 1
as well as by making films and cultures from the sputa.
In these cases the culture-medium used was Matthews's
tryp8inised blood-agar, using sheep's blood. From 9 cases
of the 13 a bacillus morphologically indistinguishable from
Pfeiffer’s bacillus was isolated, in 2 cases in pure culture. A
haemolytic streptococcus was present in only one case,
Friedlander’s bacillus in one case, while pnenmococcns
co-existed with Pfeiffer's bacillus in 6 cases, and with
Staphylococcus alhns in one case in which they were the
only pathogenic organisms isolated. Oat of 4 cases which
gave a negative result in culture films made from a post¬
nasal swab revealed the presence of an influenza-like bacillns
in two. __
i The Larcet, 1918, H., 1(M.
Bacteriological examination of the lung tissue and exndate
in the 24 cases mentioned above gave the following results.
In these cases the medium used was Levinthal’s, as
described by Fildes, Baker, and Thompson.* From 15 cases
a bacillus morphologically identical with Pfeiffer’s bacillus
was isolated. In 10 cases pneumococcus was present along
with Pfeiffer’s bacillus, while from 3 cases it was isolated
in pure culture. Staphylococcus alhvs was present in
3 cases along with pnenmococcns and Pfeiffer’s bacillus,
while a haemolytic streptococcus was found in 2 cases, Cnee
in pure culture and once in conjunction with the influenza
bacillus of Pfeiffer.
Prophylactic inoculation.— In view of these results a mixed
vaccine was quickly prepared, containing Bacillus influenza ?,
pneumococQus, streptococcus, and staphylococcus, using
strains isolated during the outbreak and following closely
the recommendations of the War Office Committee. 3 Nearly
one thousand people have received this inoculation, and
reactions appear as a rule to be mild or almost completely
absent. It is as yet too early to judge of the efficacy of this
procedure. ^
INFLUENZAL INTRA-ABDOMINAL
CATASTROPHES.
BY REGINALD ECCLES SMITH, M.B., F.R.C.S. E DIN.,
LATE TEMPORARY SURGEON, R.N., BOYA1. NAVAL HOSPITAL, PLYMOUTH.
During the recent epidemic of influenza which has passed
along through the hospital in three successive waves from
June to December, several important abdominal complica¬
tions have been observed. They may be divided into three
classes, comprising those directly due to a specific bacillus,
those to associated toxaemia, and those which are coincident
and noted as a warning to the surgeon.
Simulation of Severe Abdominal Lesion by Influenzal Lung
Complications.
In the earlier days cases were being constantly sent in to
the surgical section with the diagnosis of perforated gastric
or duodenal nicer, less frequently as an acute appendicitis,
and this latter mainly on account of the youth of the patient
rather than from minute clinical observation, and even as
empyema of the gall-bladder. The onset has in almost all
cases been sudden. The patient has come in with a history
of malaise for a short period followed by acute generalised
pain in the abdomen, associated with generalised rigidity,
often vomiting, a temperature raised two or three points
above normal, and a running pulse.
In a number of such cases there have been no clinical
signs in the chest to lead to a definite diagnosis, and hints of
diaphragmatic pleurisy have been hesitatingly offered. Careful
observation has shown that the rigidity and the. pain in these
pseudo-abdominal lesions are not absolute, but in most oases
are referred to the upper zone of the abdomen, and in a
minority to the lower zone, inoluding the right iliac fossa.
The pain and rigidity in the upper zone are referred along
the eighth, ninth, and tenth intercostal nerves and when
traced are muoh more severe on that side of the abdomen
which corresponds to the chest lesion either definitely
present or appearing later. On two occasions I blocked the
eighth and ninth intercostal nerves in a supposed upper
abdominal catastrophe and the symptoms disappeared. Less
frequently the eleventh and twelfth intercostal nerves have
caused the referred pain and a perforated appendix has been
very closely simulated, especially as no other physical signs
could be found anywhere.
The true diagnosis is often difficult, especially as true
abdominal complications can arise either directly or ooind-
dently, for which the physician and surgeon must always be
on the alert. Apart from the knowledge that a devastating
epidemio is abroad in which chest lesions are common and
therefore kept in the surgeon’s mind, three valuable points
have been observed in the influenzal pseudo-abdominal
catastrophe which differ from the true surgical abdominal
lesion. These points may not, of course, hold good in a
superimposed surgical lesion dne to and grafted on to
the original influenzal infection.
(a) The movement of the alse nasi. In cases of influenza
with acute abdominal pain, even when no physical signs
* The Lancet. 1918, li, 099. » Tee Larckt, 1913, II., 585.
422 The Lancet,] DR. R. R. SMITH : INFLUENZAL INTRA-ABDOMINAL CATA8TROPHES. [March 15.1919
have appeared in the longs and the respirations are only
slightly increased, if the alas nasi are working the condition
is never abdominal. In only occurs in late true abdominal
lesions when general peritonitis is well advanced. The
movement of the aim nasi may not be very marked when the
patient is recombent, but can be elicited with a little exertion.
(b) Dullness in the flanks is never present in inflaenzal
pseudo-catastrophes except in Class A where it is an early sign.
( o ) The facies of the influenzal victim 1 dominates the
scene. The anxious, terror-stricken look of the true abdo¬
minal lesion is not present as a rule. The anxiety is more
lethargic and resigned, and of the medical rather than the
surgical type.
In some cases an unusually high temperature associated
with acute abdominal pain should be regarded with suspicion
by the surgeon.
Acute Abdominal Catastrophes.
The true types of acute abdominal catastrophes associated
with infiaenza which have come under my notice may be
divided Into three classes.
Class A includes infections of the general peritoneal
cavity by organisms associated with the influenza epidemic.
The infecting agent has always been the streptococcus, and,
as far as can bs stated, it is a blood-borne or embolic lesion
and takes the form of an acute streptococcic general peri¬
tonitis. The following is an illustrative ca«e:—
Patient, aged 26, had been treated for typical influenza for
a fortnight before admission. He had recovered from the
acute stage and the temperature had not quite settled until
Oct. 2nd. He was then Beized with acute pain in the upper
abdomen, with vomiting, and a temperature suddenly raised
to 104° F., the pulse being 120. On admission on Oct. 2nd
the pain was generalised throughout the abdomen, which
was markedly rigid; marked dullness in both flanks. The
evidence in the chest suggested a resolving consolidation at
the right base. The aim nasi were working vigorously. Oa
Oct. 3rd the picture remained as above, with the addition of
beginning abdominal distension.
Operation: Para-median incision opposite the umbilicus.
A quantity of sero-purulent fluid esoaped. The whole of the
viscera was acutely inflamed and the kidney pouches full of
the fluid. No organic lesion of any viscus could be dis¬
covered. Free drainage established. The fluid revealed a
pure culture of streptococcus. Death ensued on Oct. 4th.
Class B. —The following case Is an example of acute
toxaemic dilatation of the stomach.
Patient, aged 26, was admitted to the sick list on June 26th
with a tvpical history, symptoms, and signs of influenza.
Admitted to hospital on .June 28th. It was then noted that
he was of the types associated with marked toxaemia. On
June 29th he complained of aoute pain of a colicky nature
in the abdomen; this was at once complicated by occasional
vomiting of fair quantities of stomach content. On
June 30th the vomiting became persistent, the quantities
increased, and diarrhoea was added. The temperature
dropped to subnormal; condition of profound toxaemia.
The physical signs in the abdomen were exceedingly slight,
and with the extreme poorness of the general condition did
nbt justify surgical interference. At night th® abdomen
became distended generally and rigid,and dullness in the
upper zone replaced the usual tympanioity. Diagnosis was
made of acute intestinal obstruction, but no laparotomy
was performed owing to rapid failure of the pulse, and he
died the same night.
Post-mortem.— Lungs: Some patchiness and infiltration at
the bases suggested a recovering broncho-pneumonia.
Kidneys and liver: Cloudy swelling of an acute toleemia.
Stomach : Enormously enlarged and contained about 5 pints
of non offensive, stagnation stomach content, together with
some altered blood. Numerous petechial haemorrhages were
seen in the mucous membrane. No organic obstruction
was found.
In view of my later experience I think the following case
would probably have gone on to the type of the later fatal
cases had not care and discretion of diet been observed.
Patient, aged 25, U.S. Navy, was admitted on August I5tb
with a history of having been “off colour” for several days
before going sick. On the morning of the 15th he was
suddenly seized with acute pain in the upper abdomen,
severe enough to require his being carried to bed. No vomit¬
ing occurred, and after the reaction following collapse the
pain became generalised. He was sent to hospital after
eight hours ana was then admitted with a diagnosis of acute
perforation of the stomach. On admission T. 101*5° F.,
P. 115, R. 24. On examination the first noticeable point was
vigorous action of the alas nasi. The whole abdomen was
rigid and fixed and apparently tender to palpation. No
* The Lanckt, 1919, 1,1.
physical signs could be found in tbe chest. The liver
dullness was completely obliterated and there was dullness
in the right flank. A slight history of prior gastric mischief
made it advisable with the above signs to explore the
abdomen. The movements of the aim nasi were marked,
but insufficient to justify waiting for the possible develop¬
ment of signs in the chest.
Operation .—Abdomen opened in the usual manner. No
gas or free fluid detected. The stomach rose from the
abdomen like a balloon and tbe liver dullness at once
reappeared. No orgtnic lesion could be found. The
stomach was massaged and emptied of its gas three or
four times. Hot saline was applied and pituitrin injected
into the arm. The abdomen was closed and patient returned
to the ward. Pituitrin and atropine were continued and the
feeds by month carefully restricted. After five days of
typical influenzal chart and symptoms the patient recovered,
no signs appearing to examination in the chest.
Surgeon Commander F. Bolton reported to me a case
similar to the abjve, with recovery. Surgeon Lieutenant
R. Carey had a death from influenza, with acute dilatation of
tbe stomach, but I am unable to find the completed notes.
Class C. —In this class are placed coincident acute
abdominal lesions occurring in the influenzal attack or
during convalescence.
Patient, aged 16, was admitted on Sept. 15th, 1918, in a
semi-conscious condition with the virulent form of influenza.
Tne next day the condition was slightly improved and patient
more alive to his surroundings. He h -d consolidation at the
right base without any fluid in the pleura. The sputum con¬
tained streptococci and the influenza bacillus. On Sept. 18tb
he complained of acute pain in the lower abdomen espe¬
cially located in the right iliac fossa. Operation was
deferred by the surgeon consulted owing to the possibility
of a pseudo catastrophe arising from referred chest pain.
On Sept. 19th th** condition remained tbe same until 3 P.M.,
when he was seized with further acute pain in the abdomen.
The rectal examination suggested a pelvic appeudix, and
the further pain a ruptured appendix with early general
peritonitis. I advised immediate surgical interference in
spite of the chest lesion and general condition.
Operation. —Battle’s incision. A large gangrenous appendix
which had perforated was found in the pelvis. Early
general peritonitis was noted. Appendicectomy was oarried
out and the pelvis and right kidney pouch were drained
and abdomen closed. (B. coli found in culture; no strepto¬
cocci noted.)
On Sept. 23rd the left lung became consolidated although
the abdomen was satisfactory. On Sept. 25tb the patient’s
condition was almost hopeless from general inflaenzal
toxaemia and consolidation of boti lungs. However, by
Ojt. 15th there was complete resolntion of both lungs and
patient made an uninterrupted reoovery. He was discharged
on Dec. 30th, 1918.
In one case a condition of long-standing tubercular peri¬
tonitis found, with much matting of the small bowel. A
large encysted collection of pus'was found between adjacent
coils of the ileum. Death ensued. The case is of interest
because of the possible lighting up of an old encysted
collection by a recent organism.
Conclusions and Observations.
1. That during the present epidemic of influenza the chest
should become more the province of the surgeon than is
usual and should be minutely searched for any physical
signs when a suspected abdominal lesion arises.
2. The three points I have already put forward will be
found of great assistance in such cases, and may save a
laparotomy in a patient who is already not in good condition.
3. The infection of the peritoneum is blood borne and is
not due to direct extension through the diaphragmatic
lymphatics. Streptococcic endocarditis is a jumping off
ground for peritoneal infection, but is not necessarily always
present.
4. Surgical interference so far has been of no avail, but
it is not surprising when one studies the mortality in (he
present epidemic, in which as yet intra-abdominal lesions
have not been recorded.
5 Discretion in dietary is very neoessary in the toxaemic
types, as an overloaded stomach may become a danger.
6. Persistent vomiting in cases of influenzal toxmmia
should be regarded with suspicion. Although the evidence
is as yet small, the condition of aoute dilatation is proved,
hence early stomach washing and the use of pituitrin may
save a patient where a laissez faire attitude will certainly
end in death.
7. The incidence of true Abdominal catastrophes in a
patient with inflaenza must always be kept in mind, and
suitable measures promptly undertaken.
CLINICAL NOTES.
[Maroh 15,1910 4S3
Tin Lanott,)
Climtal Sates:
MEDICAL, SURGICAL, OBSTETRICAL, AND
THERAPEUTICAL.
■ ♦
▲ NOTE ON
THE USE OF INTRAVENOUS IODINE IN
INFLUENZAL BRONCHO-PNEUMONIA.
By D. M. Baillie, M.D.Aberd., D.P.H. Lond.,
CAPTAIN, B.A.M.C.; PATHOLOGIST, MILITARY HOSPITAL, WARLINQHAM.
The idea of using tincture of iodine intravenously was
suggested to me by Major S. M Cox, R. A.M.C., Chinese Hos¬
pital, Moulle. While I was pathologist to No. 4 Stationary
Hospital, France, I had been struck by the apparent
futility of ordinary routine treatment for bad cases of
influenzal pneumonia, and by the fact that many of these
cmies were septictemic in type with comparatively limited
involvement ot the lungs, evidenced by extreme toxicity and
cyanosis with comparatively few physical signs in the chest.
This latter conclusion was confirmed by the cultivation in
many cases of pneumococci from the blood stream. It
seemtd to me, therefore, that intravenous administration of
iodine would be a rational method of treatment.
The B.P. tincture was used in doses of from 20-30 minims
(22 m. = i gr. of iodine). This was diluted with 9 c.cm. of
a 0*85 per cent, solution of salt in freshly distilled water and
given into a vein at the bend of the elbow in the same fashion
as a neokbarsivan injection. This was preferably given in
the morning, repeated next day, and if necessary the day
after.
Ten bad cases with definite signs of broncho-pneumonia
were treated. Of these nine recovered and one died; the
latter, in addition to pneumonia, hsd severe purulent
bronchitis for a week before being treated. The drug was
tolerated very well, and there were no untoward symptoms
except that two patients had a rigor about an hour after the
first injection (one of these gave a history of seven attacks
erf malaria), and another case developed a typical iodine
rash. This man had a dose of m. xx. on two successive days,
and a final dose of in. xx. after an interval of four days. The
rash appeared on the day after the last dose, but rapidly
cleared up in the course of a few days.
The therapeutic effect of the iodioe was generally shown
within 24 hours by a marked fall in the pulse-rate
and temperature (the latter resembling a crisis) and a marked
: change for the better on the part of the patient. The
temperature remained normal except, usually, for a slight
rise on the evening of the first or second day after. The
tongue cleaned rapidly, but tbe physical signs in the chest
cleared up more slowly. The presence of albuminuria
was no contra-indication as to the use of iodine; dense
albuminuria in one case cleared up two days after the
first dose.
It is highly improbable that the iodine given thus into the
blood stream has any direct bactericidal action ; the dilution
is too high. It is feasible, however, to think that it may
have an inhibitory effect on the reproduction of the
organisms, at any rate in the blood stream. Taking the
total quantity of blood in the circulation as 12 pints, a
half-grain dose of iodine would represent a dilution of
roughly 230,000. It may, perhaps, be feasible to suggest
that the organisms in the act of cell-division would be
vulnerable to a solution of that strength.
However, it is impossible and qui'e unjustifiable to draw
conclusions from a series of so few cases, but circumstances
at the time prevented me from going on with this line of
work. 1 can say, however, that I was much impressed by
the way in which these ca«es reacted to the iodin**. The
only excuse I have in publishirg this is the hope that some
member** of the profession will take the method up and try
it out fully.
I would like to take this opportunity of thanking
Lieut.-Colonel E. T; Inkson, V.O., D.S.O., R.A M.O.,
O.G. 4 Stationary Hospital, for his unfailing- courtesy and
kindness.
A CASE OF
SPONTANEOUS RUPTURE OF AN OVARIAN CYST.
By D. N. Kalyanvala, M.R.C.S. Eng.,
ASSISTANT MEDICAL SUPERINTENDENT, CHELSEA IN FIRM ART, LONDON.
Spontaneous rupture of an ovarian cyst is distinctly rare,
bub was evidently due in this case to the softening of the
cyst wall, the actual exciting cause being in all probability
an act of coughing. In view of the quantity of effused blood
found at the operation the absence of any clinical sign of
intra-abdominal haemorrhage is interesting.
Mrs. A. B., aged 61, was admitted with the diagnosis of
ovarian cyst for operation. There was a history of abdominal
enlargement of four months’ duration, with increasing
dyspnoea. The lower abdomen was found ocoupied by a
median swelling, obviously an ovarian or parovarian cyst;
circumference round biggest diameter 47* inches. As there
was some bronchitis with slight pyrexia, operation was post¬
poned for a week; the condition rapidly improved. No
change in the signs or symptoms of tbe tumour was noted;
no pain or faintness.
At the operation it was evident that the contour of the
abdomen had changed, and on opening the abdominal cavity
there was a gush of blood-stained cystic fluid containing
large clots. After sponging this away a vertical tear 4 by
k incbeB was found in anterior cyst wall. It was a unilocular
cyst the size of a football, and firmly adherent to the
omentum and numerous coils of intestine, and was fixed
deeply in the pelvis by adhesion to the rectum. The cyst
wall, soft and pulpy, was with difficulty separated from the
adjoining structures. It was fonnd to be growing from the
left side by a short pedicle which had not undergone torsion.
The whole cyst was removed, together with both Fallopian
tubes to which it was adherent. Tbe peritoneal cavity was
swabbed dry; large drainage-tube inserted for 48 hours.
Uninterrupted recovery followed and the patient was quite
well when seen ten months later.
Sections of tbe cyst were examined by Dr. Knyvefct Gordon,
of the Virol Research Laboratories, who reported as follows :
“ The specimen is a good example of a cyst-adenoma pneudo-
muoinoaum. No evidence of malignancy was found.”
It is probable that the rupture took place during tbe two
days between my last inspection of the abdomen and the
operation. Owing to the high intra-abdominal pressure tbe
cyst was partially compressed against tbe abdominal wall
and sudden evacuation of flu*d prevented. As the contents
were neither purulent nor gelatinous peritonitis did not
develop.
A CASH OF
NYSTAGMUS CAUSED BY MUSTARD GAS.
By R. P. Ratnakar, D.Ch.O. Liverp.,
RESIDENT SURGICAL OFFICER, MANCHESTER ROYAL BYE HOSPITAL.
As I have not yet notioed in the medical press any case of
nystagmus ooourring as a result of mustard gas poisoning I
think the following case worthy of record.
A man, aged 25, came to Dr. A. Hill Griffith as an out¬
patient in beptember, 1917. He had served in the Army
since tbe beginning of the war as a signaller and was gassed
on July 3Lst, 1917. He Baid that he could not see or open his
eyes for two days, but after that he could gradually open
his eyes and could see fairly well. About a fortnight after
he was gassed his attention was drawn to the oscillations of
his eyeballs, as tbe patient described the condition, by the
medical man at the military hospital to which he was
removed. Patient was a microphotographer at one of the
largest hospitals in London before he j lined up. His vision
was excellent, and he had no nystagmus then ; there is no
reason to doubt his statement considering his work before
and after joining the Army. On examination the condition
was as follows:-Nature of nystagmus lateral. Pdpils
regular, active, medium. Movement of tbe eyeballs, con¬
junctiva, cornea, and media normal. The fundi were also
normal. Nystagmus constantly present, but more marked
oo extreme outward and inward movements. Vision in both
eyes 6/18 partly, not improved by glasses. Letters run into
one another. Retinoscopy after a mydriatic: R. and L.
-f 1 sph. Fields of visioo and colour perception normal; no
central scotoma. The patient came to the hospital for
re-examination after three months as directed, and the
condition was found to be practically the same.
Dr. Hill Griffith had pr$viou>-ly seen two cases. of
nystagmus after mnst&rd gas poisbnihg, but being 'Sceptical
424 The Lanoht,] TUBERCULOSIS SOCIETY_SOOlfcTfc OE BIOLOOIB, PAR 18.
[Mira 16, 1M9
of the patient's statements that their eyes were normal
before they were gassed he did not take any notes, and the
patients never oame for re-examination. Bat this third case
was so definite that he asked me to take notes of the case.
I am greatly indebted to Dr. Hill Griffith for permitting me
to report this interesting case.
Stt&kal jtetitf.
TUBERCULOSIS SOCIETY.
The Treatment of Tnberoulout Glands.
A meeting of this sooiety was held at the Royal Society
of Medicine on Feb. 24th, Dr. Halliday Sutherland, the,
President, being in the chair.
Dr. H. de Carle Woodcock, senior tuberculosis officer, v
Leeds, gave an address upon the treatment of tuberculous
glands. He devoted his early remarks to some of the recent
work by pathologists upon the different types of N the
tubercle bacillus, especially the types found in different
lesions, in the several age-periods of life, and the possi¬
bility of the transmutation of the bovine into the human
type. Bovine tuberculosis, so frequent in childhood, he
said, is practically not found after the sixteenth year, the
Iranian type being responsible for the adult disease. He
considered that as bovine disease tended to run a mild
course and eventually to die out, it acted as a form of
inoculation, protecting the individual against infection with
the human type in later life.
In an examination of a large number of elementary school
children in Leeds he found 25 per cent, with tuberculous
glands, in Edinburgh 33 per cent, had been found, which he
thought was probably accounted for by the higher incidence
of bovine disease in that city. Of the children sent
to the dispensaries as selected cases nearly all had
tuberculous glands. The practice of removing all enlarged
tonsils and adenoids he thought was not justified and should
be limited to those cases where there is definite injury to
the associated glands and the general health. He was
strongly opposed to the surgical removal of tuberculous
glands, in the first place, because with treatment most cases
healed spontaneously, and, secondly, because of the danger
of opening up fresh channels of infection and causing
miliary disease. He advocated aspiration in cases with large
masses of glands and injections of the following mixture
Oil of Peppermint ..• ... mi.
, Ether . mv.
Spirit . mvi.
used undiluted in adults, and with an equal part of saline
in children. This was useful in oases where softening had
begun and was found most satisfactory. He had also
practised multiple puncture with the galvano-cautery with
favourable results.
. In conclusion, Dr. Woodcock spoke highly of the value of
tuberculin, which approached the position of a “ specific,”
and was followed by a reduction in the size of the glands.
Tuberculin was not to be ,uaed when chest disease was also
present, as this tended to become worse.
At the next meeting of the Tuberculosis Sooiety, on
March 24th, 8.30 p.m.. Sir William Osier will give an
address on Acute Pneumonic Tuberculosis.
Sooi£t£ de Biologie, Paris.—T he following is
a summary of some of the papers read at the meetings of this
sooiety held on Feb. 22nd ana March 1st.
Bossan et Guieysse-Pelliasier.—Penetrating Power of
Traoheal Injections.
Lee auteurs ont fait des recherche* sur la penetration d’une substance
m<$dleamenteuse dans le poumon sain ou tuberculeux par injection
tracb^ale. Sur dee lapius sains ou tuberculeux, uue substance medlca-
menteuse dlssoute dans de I'hulle est injeotee dans la trachee. L'hulle
eat recherohee sur des coupes aprds action de l’aolde osmlque. Cher, le
lapin sain, l’huile ae repand dans toute la hauteur du poumon et pent
<*tre retrouvee dans lee alviolet six heurea aprds. Chez le lapin tuber-
culeux, on la retrouve dans l’lnterleur des nodules et des oavernee.
P. Brodin, G. Loiseau, et F. Saint Girons.—Relative Anti¬
toxic Power of Plasma and Serum.
Die reoherohes effoctules par les auteurs sur le sang da 8 chevaux
antttftanlques at 2 ohavaux anttdlphtlrlquee, 11 rfeulta qua strain at
plasma ont exactement le mome poirvolr antltoxlque. Des reoherohes
paralleles faites jI lour demande par M. Nicolle 6ur le sang de ohevaux
immunise cmtre le pneumocoque ont montrl qi e scrum et plasma ont
Igalement le meme pouvolr agglutlnant.
E. Weill et G. Mouriquand.—Antiscorbutic Substances in
Germinating Barley.
Les auteurs ont fait des recherohee sur le moment d'appaiitlon de la
substance antlsoorbuttque et sur les accidents provoques ohez le oobaye
par les grains d'orge aux different* stadee de leur germination. lies
auteurs montrent: (1) Que les 'grains d'orge germls 3 jours sont
■corbutiques. (2) Que l’herbe d'orge germle 10 jours entralne une
mort brusque ou rapide. (3) Que rassociation de graines germles
3 jours a l'herbe dc graiue gerrat'e 10 jours, permet une exoellente
nutrition <1u cobaye.
A. Benoit.—The Daily Ration of Nitrogen.
L'auteur a eu l’oeeaslon d'observer quantltativement le regime strict
d’un camp d'offioiers rueaee prisonnlers en Allemagne. Aveo 1700
oalorles et 7 a 8 grammes d’azote par jour, la sante et "activity ee sont
matntenuee malgrT: un amalgrlseement notable. La proportion d’addes
amines etalb conforme aux neoeesltes physiologiques connues.
Madsen.—Phagocytosis.
La vltesse de reaction de la phagocytose suit la lot des reactions
bimoleculalres. Les relations entre la vltesse de reaction de la
phagocytose et la temperature sulvent les lots de Vant’Hoff-Arrhdnlus.
La phagocytose a un maximum, dependant de la temperature de
l’organisme qul a fourni les phagocytes.
Society de Therapeutjque, Paris. —At a meeting
of this society held on Dec. 11th, 1918, Dr. J. Laumonier
reported a case of Typhoid Fever Treated by Colloidal Iron.
5 c.cm. were injected intravenously every three days, each
c.cm. containing 1 mg. of pure iron. Six injections were
given in all. The treatment appeared to have a moderating
effect upon the fever and to prevent the occurrence of
amemia and leucopenia usually present in typhoid.—Dr. L.
El non and Dr. R. Mignot read a note on the Inefficaoy of
Injections of Saccharose in Human and Experimental
Tuberculosis. A solution containing 5 g. of saccharose and 2 eg.
of novocain was injected subcutaneously or intramuscularly
in cases of pulmonary or surgical tuberculosis without the
slightest improvement being observed after 30 to 40 days’
treatment. Sacoharose was also injected into guinea-pigs
previously infected with tuberculosis, but the course of the
disease was not affected, and one of them even died before the
controls.—In a paper on the Treatment of Influenza and In
fectious Diseases in General by Lymphotherapy and Hramato-
therapy Dr. 8. Arnault de Vevey stated that lymphotherapy
consisted in producing a bulla by any blistering agent and
injecting 5 to 6 c.cm. into the patient’s shoulder or buttock.
As this process was not very rapid,'and as sometimes the
patient’s skin was refractory to blistering agents, in oases
where a blister did not form at the end of 10 hoars the
speaker had been in the habit of-removing 10 to 15 c.cm.
of blood and re-iniecting it at onoe. To prevent clotting
2 to 3 c.om. of a 10 per cent, solution of sodium citrate
was first drawn into the syringe. This operation pf
hsematotherapy was ‘easy in the adult, whereas in
the child lymphotherapy was the best method. Within
a few hours of the injection of serum or blood the
patient feels considerable relief; in the simple and abdominal
forms the temperature becomes normal in 10 to 12 hoars;
and in patients with nervous complications or broncho¬
pneumonia in 36 to 48 hours.—Dr. A. Challamel read a note
on Hypodermic Injections of Eucalyptus Oil in the Present
Epidemic of Influenza. Daring the last few months he had
been treating soldiers poisoned by mustard gas with hypo¬
dermic injections of eucalvptus oil (1 in 10) in doses of 2 c.cm.
morning and evening. The treatment was started before
any signs appeared in the lungs with the object of intro¬
ducing an antiseptic into the finest ramifications of the
bronchi. Eucalyptol was chosen owing to its proved value
in the prophylaxis of oontagious diseases. The suooess
obtained in this class of case enoouraged the speaker to
adopt the same treatment in influenza with equally
satisfactory results.
Literary Intelligence.— Messrs. P. Blakiston's
8on and Go., of Philadelphia, annonnoe a revised edition of
Stitt’s Diagnostics and Treatment of Tropical Diseases.
Presentations to Medical Men. —Mr. Scott
Riddell, M.V.O., C.B.E., who has retired after 27 years’ |
service for the Aberdeen Royal Infirmary, having been for 20
years full surgeon in charge of the wards, was on Feb. 12tb
presented on behalf of the medio&l staff with an illuminated
address.—Mr. Lockhart Stephens, medical officer of health
for Warblington and county director for Hampshire British
Red Cross Society and Order of St. John, has reoeived from
his colleagues of the auxiliary hospitals in the county an
illuminated address on the occasion of his retirement from
the post of connty director. Mr. Stephens was one of the
early pioneers of the connty association movement, with
which ne had been connected sinoe 1909.
Mb Lancet,]
REVIEWS AMD NOTICES OF BOOKS.
[Maroh 16,1019 425
Jebietos into Jjtoiitts of Jocks.
The History of St^nBartholomm's Hospital. , By Norman
Moorb, M.D.Camb., F.R.C.P. Lond. London: C. Arthur
Pearson, Ltd. 1918. In two volumes. Vol. I.: Pp. 614;
Vol. II.: Pp. 886 and Index, 106. £3 3*. net.
A well-known passage of Virgil runs:—
Venisti tandem .
Vioit iter doram pistes!
And we learn from Dr. Moore's preface that the work has
taken some 30 years to bring to completion. The journey
most, indeed, have been laborious, but every page is a
witness to the tried and worthy reverence which the learned
author feels towards the ancient and holy house of which he
has been for many years so faithful a servant.
- To write an accurate chronicle of the history of a corporate
body which has existed for close upon 800 years is no easy
task, but St. Bartholomew’s Hospital has fortunately been
able to preserve a very large number of its charters and other
documents, either the original documents themselves or
copies made in the year 1456 by John Cok, who became a
Brother of the Hospital in 1421 and wrote a Rental or
Cartulary of the Hospital. The last entry is dated 1468, so
giving the record of the hospital down to the early years
of Edward IV. Other original charters dealing with the
business of the hospital are preserved in St. Paul’s Cathedral,
the Record Office, the British Museum, and Wells Cathedral.
Dr. Moore has printed 234 charters in full, and given
abstracts of over 270, in all cases with the names of the
witnesses. Other sources of information are the Liber
Fnndacionis of the hospital, various notes by John Cok, and
the Bishop’s Register kept in Dean’s-yard, St. Paul’s. For
later centuries the authorities are the Letters Patent of
Henry VIII. for 1544 and 1547, together with the manu¬
script journals, ledgers, and Repertory Book, and the
printed * 1 Order ” of the hospital. It may be seen from this
recital that the information contained in the work has
all been garnered from official and accurate sources so as to
form an unimpeachable record of the hospital.
And how vivid a picture of the life of bygone times
is here presented. In the first chapter we have an account
of Smithfield “in the suburb of London ” as it appeared in
Fite Stephen’s time. He was the biographer of Thomas
Becket, Archbishop of Canterbury, afterwards St. Thomas
of Canterbury, and wrote an account of London as a prologue
to the biography. Smithfield was then an open swampy
place where cattle and horses were sold. Becket was
murdered in 1170, so the hospital and priory had been
founded some 50 years when Fitz Stephen wrote. At the
time of the foundation Smithfield was anything but a
desirable residential neighbourhood. It was marshy and wet,
and the only habitation, if we may so call it, was the public
gallows; the site, indeed, is a perpetual rebuke to that
school of controversialists who maintain that the religious
orders always sought out the pleasant places of the earth for
their monasteries. 8uch persons think of Tintern and
Beaulieu, forgetting the Grand Chartreuse and the Hospice
6t Bt. Bernard.
The story of the foundation of the hospital and priory is
to be found in the Liber Fundacionis written by one of the
Augustinian canons of the priory between 1174 and 1189,
who gives an account of Rahere, of his early life, his con¬
version and journey to Rome, his illness and his vow to
found a hospital, should God grant him recovery and return
to his own country. He did recover, and on his way home
had his vision of St. Bartholomew commanding him to
found a church in »Smithfield. On arriving in London
he at onoe set about a twin works of piety; land was
granled by the king, and the hospital and priory were
commenced simultaneously in the year 1123, Rahere being
the founder, Richard de Belmeis, Bishop of London, a warm
supporter, and Henry I. giving the land. The hospital was
built on the execution ground, being the highest part of
Smithfield and having a gravel subsoil, the church and
priory a little to the north of the hospital. The latter cor¬
poration owed certain duties to the priory, but had its own
chapter and its own separate seal and administration. The
original staff of the hospital was eight brethren and four
sisters, observing the rule of St. Augustine. Rahere died
in 1145 and within a year of his dfeath Thomas, a canon of
Bfe. Osytb, was elected prior. Under his rule the number
of canons was increased from 13 to 35 and improvements
were made in the hospital. He also obtained a charter
from the Archbishop of Canterbury, giving confirmation
of all rights and privileges granted by Henry I. Thomas
the Prior died in 1174, at the age of nearly 100. Early in
the reign of Richard I. Henry Fitz-Ailwin became Mayor
of London and held office until his death in 1212. He was
a generous benefactor of the hospital, as were many others
of his contemporaries. Among the many charters of this
period whioh survive there is one of particular interest: it
is a chirograph , both parts of which are preserved, and sets
forth that Stephen, the procurator of the hospital, granted
to William, son of Simon of Rainham, certain land
in the vill of Rainham, which he was to farm on
condition of delivering to the hospital every year
five quarters respectively of wheat, rye, barley, and
beans; also eight quarters of oats and four cartloads of
hay. Such was the rent; in return for it William and his
heirs were confirmed in the use of the land, arable meadows,
pastures, roads, paths, waters, gardens and brushwood, and
all things without any reservation, including a house with
two bedrooms, stalls for cattle and horses, a barn, a brew-
house, an oven, and a fowl-house. The hospital gave
William 10 marks of silver towards paying his debts and
William gave 1 silver mark “in gertumam” for confirma¬
tion of the charter. The whole charter, the text of which is
given in full at p. 240 of Vol. I., gives a most interesting
picture of an Essex farm in the twelfth century, and shows
that a religious house was not afraid to advanoe money to
a good tenant.
It may be as well to explain the meaning of two terms
mentioned above—namely, chirograph and gertnma. The
former is the technical term for a charter or agreement*
written in duplicate upon one piece of parchment. The
two copies were written head to head or side by side and
in the interspace was written in large letters the word
*• chirographum.” The parchment was out through this
word longitudinally, and one party kept one half and the
other the other, both parties thus having a complete oopy of
the charter and also a test of the authenticity of their copies.
Sometimes the line of division was made wavy or indented;
hence the term “ indenture.” “ Gersuma ” was a payment
on the conclusion of a transaction paid by the beneficiary.
It varied according to the magnitude of the transaction and
the richness of the beneficiary. Thus in the time of Master
Adam, 1147-1168, the hospital reoeived an important addition
of land and gave the donors three talents of gold “in
gersumam,” while in a charter written by William de Bipa,
chaplain of the hospital in the reign of Henry III., Everard
the outler was granted by Ralph of Frowio, the goldsmith,
some land for whioh he paid seven shillings per annum, and
Everard gave Ralph one pound of pepper “ in gersumam.”
As the years went by both hospital and priory con¬
tinued in good works and were enriched by the offerings
of the faithful until the great spoliation by Henry VIII. In
1536 priory and hospital were dissolved, and in 1537 the
hospital property was given into the King’s hands. So
many were the sick turned loose into the streets owing to
the dissolution of St. Bartholomew’s and other hospital*
that in 1538 the Mayor, aldermen, and commons of London
presented a petition to the King that sundry hospitals and
the 'buildings of other foundations might be handed over to
them to be applied to religious and charitable uses. Aa
regards St. Bartholomew’s, this petition was granted in
1544, and in 1547 a new charter was granted drawing
up a constitution for the hospital in all essentials the same
as that existing to-day.
We have dwelt particularly upon the earlier part* of
Dr. Moore’s interesting work, but it is throughout permeated
with the same scholarship and picturesque knowledge.
The history of the hospital from the new foundation
onwards is drawn from the ledgers, the repertory, and
the journals of the house. A chapter is devoted to that
famous son of Cambridge, Dr. Cains, who lived in the
hospital from 1547 until his death in 1573, and another to
Harvey, who was elected physician in 1609. Other chapters
deal with the successors of Harvey, with the surgeons,
beginning with those of the Old Guild, with the apothe¬
caries and other members of the staff, with the nursing
staff, the officials, the administrators, the, school, the
buildings, and, finally, with the patients.
Bo and* Dr. Moore's labour of love, a free gift by him to
that body for whioh he has laboured faithfully for many
4,26 The Lancet,}
REVIEWS 4ND NOTICES OF BOOKS. , [March 16, 1919
years ; and the gift is in every way worthy of the recipient.
Only a portion of Rahere's churoh still stands, and not one
stone of the hospital as he bailt It exists. Bat the present
baildiogs are on the identical site of 1123, and for nearly
800 years the hospital has been a place of which we may
sorely say, “ sedentibos in regione mortis, lax orta est els.”
_ ' H. P. C.
Vaccines and^Sera: Tkeir Clinical Value in Military and
Civilian Practice. By A. Geoffrey S*bra, B.A., M.D.,
B.O. Gatnb., Clinical Pathologist to the British Red Cross
Hospital. Netley. With an Iatrodaction by Sir Clifford
Allbutt. Oxford War Primers. London: Henry
■ Frowde and Hodder and Stoughton. 1918. Pp. 226.
7s. 6 d.
Sir Clifford Allbott, whose aim in writing an introdactory
note to Dr. Shera’s book is to bring together the bacterio¬
logist and the medical practitioner; has elsewhere described
clinical pathology as the physician’s handicraft. We find
Dr. Shera an able and stimulating guide to one section, and
that a very important one, of this handicraft. The day, he
says, U passing when yoo either believe in specific therapy
of yon do not. We hope so, and the passing is likely to be
accelerated by snoh a frank exposition as the author’s.
Specific therapy, he admits, is in parlpns danger of being
discredited owing to fonr deadly sins on the part pf patho¬
logists. These are : (1) nndue optimism, dne to a lack of
perspective; (2) incoherence; (3) intolerance of the views of
others; (4) c>mmercial exploitation. We doubt ourselves
whether the fault is 4 * solely due” to the pathologists them¬
selves, for what about the blind faith of the practitioner in a
report which he does not always take the trouble to under¬
stand? Even now there are some who avail themselves of
the help of clinioal pathology who have never thought out
the different importance of a positive and a negative result.
The very object for which he asks the pathologist to search
may be absent solely because the material has not been
properly handled by the clinician.
* After a pleasant autobiographical chapter on the
present position of specific therapy the author goes on to
discuss in turn vaccines—their preparation, administration,
and use in various disease groups ; sera, giving special
attention to anaphylaxis and the special case of filter-
passing viruses ; specific therapy as apiplied to the special
diseases of women and of children ; and, finally, some
miscellaneous topics, such as the use of normal and 44 auto-’*
serum. Three useful sections, including r6sum6, glossary,
and references, complete the volume.
Dr. Shera states his individual experience throughout, and
in a subject which bristles with controversial points many will
disagree with him, some in one direction, some in another.
In the treatment of gunshot wounds he considers the case for
therapeutic vaccines to be overwhelming, quoting a series
of 25 consecutive cases in which autogenous vaccine was
used, leaving the reader to draw his own conclusion.
44 Controls,” he submits, are unnecessary, as 44 any military
surgeon can form an ’opinion as to the average duration of
treatment of his cases.” He enunciates the 44 curious fact”
that the presence of sequestra in a sinus ban almost be
diagnosed by the way in which the patient reacts to
vaccines. The statistician irks him ; no two cases, he says,
are alike and percentages are therefore 44 otit of plabe.”
Sometimes he may be frankly hoist with his own petard.
Endotoxins, he says, demand vaccines, but in tuberculosis
the typical endotoxic disease, he will have none of the only
vaccine available —namely, tuberculin. Conviction, how¬
ever, as the author reminds us, comes of experience, and
Dr. Sbera’s only experience of tuberculin appears to be in
the published writings of Dr. Batty ShaW.
We have said enough to indicate that this little war
primer is a useful contribution to a vital subject and we
hope enough to induce our readers to study it carefully.
An Enquiry into the Medical Curriculum by the Edinburgh
Pathological Club has now been reprinted from the Edinburgh
Medical Journal , the expenses of issuing it having been
defrayed by a grant from the Carnegie Trust for the
Universities of Scotland. As we have dealt at length with
many of the valuable contributions to the Enquiry at the
time of their appearance, we need not do more than call
attention to their appearance in handsome book form, and
to the summary of concrete proposals at the end of the
volume, whioh is now indexed. The reprint and the report
on the curriculum separately may be obtained on application
to Dr. H. M. Traqaair, 16. Manor-place. Edinburgh.
JOURNALS.
Parasitology. Edited by G. H. F. Nuttall, F.R.8., assisted
by Edward HinDle, Ph.D. Vcl. XI. No. I. November,
1918. Cambridge University Press. 12*. 6 d. net. (Yearly
subscription, £1 158.)— Spirocliceta icteroh(cmorrhaguc in the
Common Rat in England, with remarks on the minute
structure of these leptospira (Noguchi), by Alfred C. Coles,
comprises the results of an examination of rats in the
neighbourhood of Bournemouth to see if spirochmtes could
be found. The kidnevB of 100 rats were examined and 9 of
them contained a spirochaBbe morphologically identical with
the S. icteroluemorrhaguc of the guinea-pig. 1 The question
naturally suggests itself: Does so-called 11 Weil’s disease,”or
44 infective jaundice” oocur in England? In addition, one
of the rats contained another species, which there is little
doubt may be the spirochaete of rat-bite fever, S. morsus muris.
—The Biology of Amblyomma dissimile Koch, by G. E. Bodkin,
contains a description of methods of rearing this tick which
occurs parasitic ou the bull-frog in British Guiana. The life-
history is described in detail, together with the longevity of
the various stages. The total life-cycle takes roughly
153 days, assuming that each stage promptly finds a host.
In addition, this species was found, to be capable of reproduc¬
ing parbhenogenetically, and the author’s results suggest t
that these parthenogenetic generations are entirely female.
—Lerrueopoaa scyllicola , n.sp., a Parasitic Copepod of
Scyllium Canicula, by W. Harold Leigh Sharpe, is a
description of a new species of parasite from the dog fish,
together with a detailed account of the male.— Lemaopoda
globosa , n.sp., a Parasitic Copepod of Scyllium Canicula,
by W. Harold Leigh-Sharpe, contains the description of.
another new species from the same host.—Trypanosomiasis
of Camels in Russian Turkestan, by W. L. Yakimoff and
others, is a lengthy account of camel trypanosomiasis from
Bokhara, the Ural, and the Astrakhan regions. The trypano¬
some is described in detail and compared with the other
pathogenic trypanosomes, from whioh it appears that it is.
very closely related to T. evansi of India. The writers then
roceed to consider the various changes taking place in the
lood of infected animals, and the article concludes with a
short account of some therapeutical experiment*, using
mice infected with the virus from Bokhara camels.—
Hibernation of Flies in a Lincolnshire House, by G. S.
Graham-Smith, ooutaios a record of the speoies of insects
occurring in a house which had suffered from a plague of
flies every autumn and winter for 24 years. The most
numerous and troublesome fly was Musca corvina;
Limnophora septemnotata , Culex pipiens , and a ohaloid,
Stenomalus muscarum , were also abundant.—Bilharziasis in
Natal, by F. G. Cawston, is a description of the present
state of our knowledge of this disease in Natal and the
result of some personal observations extending over the last
seven years. Bilh&rzia oercarisB, similar to those whioh
cause bilharziasis in Egypt, were found in specimens of
Physopsis africana,a, snail which abounds in infected localities.
The experimental infection of animals was unsuccessful, in.
spite of numerous attempte to infect rats, guinea-pigs,
rabbits,'Ac. The writer states that it is rare to come across a
person whose life has been shortened, or whose death has
been caused, by the disease in Natal.—The Cercarire of the-
Transvaal, by F. G. Cawston, contains a description of three
new species of cercari® found in various snails. The latter,
when living in flowing rivers, are considerably lesB infected
with trematodes than those occurring in stagnant pools, and
in addition, the presence of lime seems to have an'ad verse'
effect on the parasites.—The structure of the Mouthparts
and Mechanism of Feeding in Pediculus humanus, by A. D.
Peacock, contains a detailed account of the structure of tbe^
head of this important human parasite, primarily under¬
taken with the idea of finding out through which channel
the organisms of disease may find passage on the way from
the insect to man. The article is illnstrated by numerous
diagrams, and in addition contains an account of the manner
of feeding.— Clavclla sciatherica, n.sp., a Parasitic Copepod of
Gadus morrhua , by W. Harold Leigh-Sharpe, contains the
description of a new species of the family lernreopodid®,
taken on a codling at Plymouth.
The American Journal of Care for Cripples becomes a
monthly with its Janaary issue, under the editorship of
Dr. Douglas C. McMurtrie. Although dealing extensively
with the rehabilitation of the invalided soldier,the journal
is in no sense a war product, as it is now entering upon its
eighth volume. It will contain in the future the studies,
translations, and abstracts produced by the research depart¬
ment of the Red Cross Institute for Crippled and Disabled
Men, which material has hitherto appeared in a special
series of publications. The journal also continues as the
official organ of the Federation of Associa tions for Cripples.
~ 1 The Lancet, 1918, i„ 468.
Ths Lancjmt,]
TUB RAPID CUBE OF HYSTERICAL DISABILITIES.
[March 15,1919 427
THE LANCET.
LONDON: SATURDAY, MARCH 15, 1919.
The Rapid Cure of Hysterical
Disabilities.
One of the many peculiarities of hysteria is that
the methods in vogue for its treatment are almost
as diverse as its clinical manifestation*. While the
suggestionist extols his technique as the method
par excellence for hysterical cures, the psycho¬
analyst regards suggestion as a positive hindrance
in the way of therapeutic success.' There is also
the hypnotist, who claims 90 per cent, cures, or
over, by his particular ceremonial, and the faradic-
battery expert, who gets 100 per cent, cures; there
is the advocate of simple persuasion and re-educa¬
tion combined with manipulation, who, similarly,
is disappointed if complete recovery does not occur
at a single seance, measured often only in minutes.
Meanwhile, it may be supposed, the psycho-analyst,
accustomed to delving in the unconscious for
months, not to say years, wonders what sort of
“ cures ” these may be, as the man in the street
may wonder at the apparent uselessness of all
methods alike, when he reads in his morning paper
that the hysterically mute soldier suddenly
recovers, after two years* resistance to all thera¬
peutic endeavour, because someone stands on his
favourite corn in a crowded tramcar.
It would be easy to quote chapter and verse for
the conflicting statements of these exponents of
rival procedures who thus pusb*their wares in the
medical market-place; but the dissimilarities are
more apparent than real. The essence of cures by
hypnotism, electricity, laying on of hands, and
what not, is the influencing of the patient’s mind
by the mind of another, call it what we will. Even
in regard to psycho-analysis it is by no means clear
that suggestion can be put out of court as a
therapeutic factor; for that matter there is some¬
thing almost painful in the determined effort of
Ferenc hi and others to reduce suggestion to a
sexual phenomenon and to delete the word from
the therapeutic vocabulary. No doubt the trouble
lies in the variety of meanings attached to the
word “ cure.” The suggestionist holds that dis¬
appearance of symptoms constitutes a cure, in
hysteria above all diseases, since somehow the fact
of this disappearance reacts, or seems to react, on
the patient’s mind in a salutary way, so that much
more is thereby effected than mere symptomato-
logical improvement; the soldier who recently
recovered his speech at a cinema and who
was heard to utter a heart-felt 44 Thank God,
I can speak! ” has surely undergone a more
radical change than is implied in return of
innervation in an isolated neural mechanism.
If we bear in mind the fact that the vast majority
of the war cases of hysteria are comparatively
simple in type, relatively short in duration, not
obscure in causation, and uncomplicated by elusive-
ness of unconscious motive, we can readily under¬
stand both the ease with which cases clear up in
expert hands and the claim the operators make for
permanence in results. We see no special reason
to doubt the likelihood of the cures persisting, but
the majority of those who have had much to do
with civil cases in private and hospital practice
will, we believe, be inclined to hold that not all
cases can thus be summarily treated, or, at least,
that the disappearance of a symptom or symptoms
under the force majeure of persuasion does not
necessarily entail a favourable modification of the
underlying psychical basis of the affection. There
are certain important varieties of the psycho-
neurosis to which treatment by persuasion re¬
education, and manipulation does not appear to
be specially applicable. Cases of hysterical fits,
hysterical fugues, and alternating personality are
among the more difficult and complex manifesta¬
tions of the disease, and often call for the most
persistent and painstaking treatment. To get at
the underlying, the hidden, springs of the affection,
to unmask the unconscious trends and motives
perpetuating the clinical phenomena, to solve the
apparently insoluble contradictions between the
patient’s overtly expressed desire to get better and
his unconscious desire not to, is surely to reach a
more permanent basis of cure. It is, perhaps,
scarcely an exaggeration to say that hysterical
cases, therapeutically considered, are either very
easy or very difficult. When all is said, the chronic
hysterical patient may resist every therapeutic
endeavour, and, nursing infirmity to the end,
defeat the physician by very feebleness.
One of the interesting questions aroused by a
consideration of rapid cures in cases of some little
duration is, How comes it that the nervous
mechanisms are, as it were, ready to resume duty
at a moment’s notice—ready after, it may be, some
years of disuse ? The matter must not, of course,
be taken too literally; experience shows there is
commonly a period of awkwardness of use—e.g., in
the case of hysterical paraplegia the patient
usually requires an appreciable time to take
up his bed and walk. But in other oases, say
of aphonia, apparently no such interval of transi¬
tion is necessary. In most oases there can
be no doubt that unconscious or subconscious
innervation keeps the mechanisms in working
order; the hysterical paraplegic will draw up his
legs in sleep. For other cases, possibly, no such
explanation is quite feasible, though at least some
hysterical aphonies and mutes are known to have
muttered in their dreams. As permanently un¬
conscious nerve mechanisms are kept in tone
by proprioceptive stimuli, so may conscious
mechanisms, deprived temporarily of the conscious
element, be played on by automatic or involuntary
processes arising from centres normally in abey¬
ance. Be all this as it may, we must admit that
in chronic cases active trophic changes may take
place, from disuse mainly, handicapping full and
428 The Lancet, Jj
scientific Education and itIs' oost.
[Mabch 16,1914
rapid restoration and necessitating physical as
well as psychical treatment. Comparatively little
attention has been directed to the actual physio¬
logical nature of the production of hysterical sym¬
ptoms, although the late Dr. Charlton Bastian and
the late Dr. T. D. Savill devoted much thought
to this topic, and their conclusions are worthy of
consideration. The disadvantage of psychological
theories of hysteria is that the physiological
anomalies are apt to be ignored owing to pre¬
occupation with the psychical anomalies. In
Babinski’s minute examination of the phenomena
of so-called reflex paralysis we have a useful illus¬
tration and precedent for research, notwithstanding
that, or because, reflex paralysis may really be a
form of hysteria.
Scientific Education and its Cost.
The minutes of the proceedings of the deputa¬
tion of representatives of the universities of the
United Kingdom received on Nov. 23rd, 1918, by the
President of the Board of Education and the
Chancellor of the Exchequer, Mr. H. A. L. Fisher
and Mr. Bonar Law, have been printed by the
Universities Bureau of the British Empire, in
order, no doubt, to preserve a fuller record of the
speeches than is to be found in the newspapers.
The names of those who were present to represent
the universities, and other institutions doing work
of university standard, show that the occasion of
the deputation was not regarded lightly by any of
the interested parties, and this was what might have
been expected,seeing that the subject brought before
the Chancellor of the Exchequer and the President
of the Board of Education—namely, the financial
needs of higher education—is one that at no time in
our national history has deserved closer and
more anxious attention.
We are living in a period full of opportunity for
new progress and for development upon original
lines in every direction, and we, as medical men, need
not be ashamed to continue to remind ourselves of
this obvious fact, so long as we see that there is a lack
of unity and of promptitude in grasping the oppor¬
tunity. It should not be necessary to point out that
it is essential to recognise the facts and circum¬
stances of the situation at the outset; if failure
ocours in obtaining for medicine its just claims now,
fresh reconstruction and reorganisation in the near
fniiure cannot be avoided; but time slips by and
intteh yet wants discussion by the medical profes¬
sion. In general and in brief the deputation, to use
a popular expression, was <( out for money.” Its
object was to secure State assistance in order
to obtain in our country’s interest the best brains
and the best apparatus for instructional purposes,
and in order to bring in among the learners the best
of the young brains available. The coming Ministry
of Health and the part which the medical profession
must necessarily play in the carrying out of a health
policy make the question of medical education of
almost paramount importance. The fact that a
well-educated and. enlightened medical profession
i8u.a national need should not want to be empha¬
sised at this juncture, but though medical men
may be tired of hearing it said, public repetition is
necessary. We must go on affirming these things
until there is no doubt that a Government
responsible to the nation for the rebuilding of
its forces in a far-reaching and enlightened
manner is awake to what lies before it. The
development of sciences growing in number and
extent every year, each adding to the need for
a larger and increasingly skilled staff of scientific
workers, has to be provided for. Each new discovery
adds to the expense of teaching medicine and
makes it more dependent upon outside financial
aid. Each year medical knowledge grows and
becomes more expensive to impart, and medical
education will lag behind unless adequately
endowed.
But it is not to be expected that such aid as the
State may afford to scientific education will fulfil
all requirements, and wealthy and patriotic citizens
who desire to see the future progress of their
country assured among the nations of the world
have now an unequalled opportunity for personal
generosity. The facts in respect to medical educa¬
tion display the debt of the public under this head
ing, and they should be brought forward regularly
and plainly. If the facts were understood we
believe money would be forthcoming at once both
from State and private sources. First, medical
men pay a large sum for their professional educa¬
tion, which lasts at least six years, a sum which, as
we have seen, will in the near future inevitably
be larger; it is now about £1000. Secondly, this
education is conducted partly by lecturers on
special subjects, mainly ancillary to medicine, and
partly by medical men in practice, who are members
of the honorary staffs of the hospitals attached to the
educational centres. The first class of teachers is
very inadequately paid, the second class is at any rate
to-day hardly paid at all, save indirectly, and though
we admit that this indirect payment is in some
cases quite large, in most it is nothing of the sort.
Thirdly, medical men are not drawn from a wealthy
class of the community; despite all the brave talk
about the splepdour of our profession, only those
who desire to work hard care to start on the medical
life. The promising list of entrances, however,
among the students shows that the value of medical
cooperation in the great war has caused medicine
to appear as our most potent influence in the resist¬
ance to national disasters. Fourthly, medical educa¬
tion is regulated and controlled by an important
statutory body, but the expenses of maintaining
the Medical Register and standardising the exa¬
minational tests are borne entirely by the medical
profession. Yet the Medical Acts, under which
the General Medical Council was called into being,
were devised and are worked for the protection of
the public and not for the aggrandisement of medi¬
cine. These are the things which we should like
our readers to keep steadily before such public
men and women as they come into contact with;
they all converge to one point—that the public
owes a debt to medical education. Those in charge
of the Bill, for the erection of the Ministry of
Health ought to find the public ready to pay this
debt.
Thi Lanoxt,]
THE SLUM-DWELLBB AND THE SLUM-OWNER.
[March 15. 1919 429
Annotations.
" He quid nlml*."
THE SLUM-DWELLER AND THE SLUM-OWNER.
A lecture delivered at Halifax by Dr. J. T.
Neech, medical officer of health for that borough,
has since been printed, and serves to ventilate
some of the difficulties which are likely to delay
the provision of suitable homes for the working
classes in the United Kingdom. We are all agreed
{hat a large number of workers are compelled to
live in surroundings and in buildings which are in
no sense suitable, except perhaps in point of price
and of contiguity to their work. We also see, as
the result of this, working men who can afford to
do so living at a distance from the factories and
places where they are employed, and travelling to
them by trains, tramways, and omnibuses. This
happens wherever the place of employment
is in a large town, so that land is too muffi
sought after for other purposes to leave it
to any extent available for workmen’s dwellings.
Thus, streets and buildings, within the boundaries
of a town where great industries are carried
on, tend to become filled with workers who
prefer to live near their place of employment,
or whose 9employment makes it necessary for
them to do so; by workers who cannot afford
a cottage at a distance, with a journey as an addi¬
tional expense; and by the large class of human
beings in precarious employment, or in chronic
unemployment, whom we find it difficult to
picture as anything else than “ slum-dwellers ”■«—
their main chance of casual jobs lies in being “ on the
spot.” Dr. Neech advances the proposition that these
“ slum-dwellers ” constitute one of the main
difficulties of the situation, and that the hope¬
less and recalcitrant slum-dweller is a person
who will remain . as such and who cannot
be compelled to be clean, industrious, and a
decent member of society. He believes, however,
that the slums and slum-dwellers of to-day are
not what they were 50 or 25 years ago, that
gradual improvement has taken place, and that up
to a certain point it may be expected to continue.
His suggestion here is that when the removal of
the better class of its inhabitants from the slum
has taken place, and the opportunity for reform and
more wholesome conditions of living has been
given, the children of those who prove to be beyond
reform should be taken from them and be brought
up in decent circumstances at the public expense.
This he submits as a better investment from the
national standpoint than the building of good
houses for those not fit to live in them. To a
certain extent he will win assent for his opinion as
to the failure of surroundings and of opportunity
to improve the worst cases now discoverable in the
slums of our great cities. It is to be hoped,
however—and indeed it may be believed—that
surroundings and opportunity will effect some¬
thing even with those who now appear to be
hopelessly intemperate, thriftless, and indolent.
As to the provision of houses, Dr. Neech is of the
opinion that the industries employing the workers
should bear as a legitimate charge the cost of
building homes for them or a considerable
proportion of it. Why, he asks, should the public
at large provide houses for the working men
gathered ' in a particular locality for the benefit
of the manufacturers of motor-cars? Or why in
another place should persons who may disapprove
of alcoholic beverages provide houses for those
profitably employed by a large brewery? There
is something attractive in a suggestion, which
Dr. Neech follows up, that the existing building
societies, in which the manufacturers might
become large shareholders, should be the medium
through which extensive building operations
for industrial workers might be financed. One
of the questions which future experience must
decide is, whether, under the industrial con¬
ditions of the future, there is to be a large class
of industrial workers who are unable to provide
themselves with decent homes or to set aside a
proportion of their incomes sufficient for the rent
asked, even though such rent represents far less
than the normal interest to-day upon capital more
safely invested. So stated the difficulty appears
merely financial, though other sociological factors
are at play. But the decent housing of the
industrial classes is one of the greatest require¬
ments of modern medicine. To spare any effort
to secure housing reform is to impede preventive
medicine in a terrible proportion. The public
debt incurred for carrying out adequate re-housing
schemes would have to be crushingly heavy before
it proved to be anything but a public asset,
manifested by increased national vigour and pro¬
ductiveness.
THE TREATMENT OF AMOEBIC DYSENTERY.
The treatment of amoebic dysentery by hypo¬
dermic injection of emetin, introduced by Sir
Leonard Rogers, has been considered a great
advance on the time-honoured treatment by
ipecacuanha, as the serious drawbacks of the latter
method, particularly vomiting, are avoided. In the
Journal of the American Medical Association,
Professor S. K. Simon, however, contends that the
older treatment is, after all, the better in the more
chronic and intractable infections. The prompt
action of emetin is striking and its amoebicidal
effect on free organisms is undoubted, but in the
destruction of encysted amoebm it fails, opening
the way for relapses. Unless large doses of
ipecacuanha or emetin are given the amoebae
seek protection by encysting themselves. In con¬
sidering the dosage necessary for completely over¬
whelming them the toxicity of the drug must be
taken into account. Crude ipecacuanha in amounts
as high as 75 gr. daily for ten days has been found
singularly devoid of toxic effects, but not so the
alkaloids in equivalent dosage. In 1916 two
American investigators, Pellini and Wallace,
showed that emetin depresses and may event¬
ually paralyse the heart, that it is a powerful
gastro-intestinal irritant, whether given orally
or subcutaneously. Because of the failure of
emetin to destroy encysted amoebae and its
toxic properties attempts have been made to
devise higher chemical formulae of the alkaloid,
such as emetin bismuthous iodide, and these have
been extolled by British writers in the more
intractable forms of dysentery and in the freeing
of carriers from infection, but the Be claims have
not been endorsed in America. In the treatment
of dysentery in the Southern States Professor
Simon therefore reverted to the old treatment.
He U6ed salol-coated ipecacuanha pills with gratify¬
ing results both in treating the active disease and
preventing relapses. But he insists on careful
attention to detail, and to want of this ascribes the
prejudice against ther crude drug. The. patient
430 The Lancet,)
THE HEALTH OF LILLE DURING GERMAN OCCUPATION
[March 15,1919
must be put to bed for the whole course, usually
extending over ten days, and restricted at first to
foods which leave no residue, such as broths,
whey, and albumin water. Milk is to be added only
after the fifth or sixth day. A dose of castor oil
should be given on the morning of the first day
and in the evening 10 to 15 pills, each containing
5 gr. of ipecacuanha. They are to be swallowed
slowly with a little water. No nourishment is to
be allowed for two hours preceding and for six
hours following administration of the pills. Each
.succeeding night the same plan is repeated. It
may be necessary, especially if there is any
depressing effect, to discontinue the pills for one
night. The nurse records the number of pills
which may be passed undissolved in the stool, so
as to determine the total amount of ipecacuanha
retained. The complete dosage includes the reten¬
tion of 100 pills (500 gr. of ipecacuanha). This
is usually accomplished in 10 days and only rarely
requires two weeks. If vomiting is troublesome an
extra coating of salol should be given to the pills.
For reasons not clear a large number of pills may
be passed undissolved, even with a diminished
coating. One or two punctures may then be made
in the pills. When under rare conditions the
ipecacuanha is not tolerated in pill form, daily
instillations of 30 gr. of ipecacuanha, suspended in
water, may be given by duodenal intubation, using
Gross’s method of introducing the tube. The
problem of effective treatment hinges on concen¬
tration of the active constituents of the drug at the
site of infection in the large bowel. When emetin
* is administered hypodermically or by mouth it
is enormously diluted before it is brought by the
blood stream into actual contact with the affected
intestinal wall. _
THE HEALTH OF LILLE DURING GERMAN
OCCUPATION.
Professor A. Calmette, who has now left the Pasteur
Institute at Lille to direct the parent institute in
Paris, has recently laid before the Academy of
Medicine his first-hand impressions of the effect
of the German occupation of Lille upon the health
of its inhabitants. He remained at his post during
the whole of this period. Before the war the popu¬
lation of the city was 220,000, but at the time of its
liberation by the Allies the number had decreased
to precisely one-half. In 1914, when the Germans
were advancing through Belgium on Northern
France, about 60,000 persons fied from Lille in
, panic to seek safety in other parts of France or in
adjoining neutral countries. When, the Germans
arrived they deported about 25,000 young women
mid youths to Germany to work there in factories
and workshops; others were compelled to do
forced labour in the trenches or work in some
other way in the war zone under conditions
of great danger to life and health. Those who
remained were naturally the elderly and weakly, as
well as a large proportion of children. The annual
death-rate from all causes in the city before the
war averaged 19T per 1000, but it rose gradually in
the altered population from 27*7 in 1915 to 415
in 1918. Among the chief causes of death were
tuberculosis, diseases of the heart, epidemic
dysentery, and scurvy, as also those other diseases
which are provoked or aggravated by insufficient
nourishment. The death-rate from tuberculosis
had been, before the German occupation. 3*3 per
1000, but from 1916 to 1918 it rose to 5*7. Professor
Calmette states on high authority that examination
of the children and young people after the libera¬
tion of Lille showed their development to have
been arrested and about 20,000 young subjects to
have become “degenerates” as a result of insuffi¬
cient or bad food, the high prices of which during
the German occupation were, to quote M. Calmette,
“fantastic.” As might have been expected in the
circumstances, births rapidly declined, although
not quite to vanishing point, falling from a total of
4885 in the year 1913, to 602 in 1917, and 609 in
1918. Infant mortality diminished considerably at
the same time owing, M. Calmette suggests, to the
lack of cow’s milk in the city and the consequent
disappearance of infantile gastro-enteritis. Mothers
suckled their own infants or fed them on the con¬
densed milk provided by the American Committee-
These are only some of the points of interest
contained in M. Calmette’s study.
SELECTIVE TISSUE DESTRUCTION.
The paper on Picric-Brass Preparations in the
Treatment of Lupus contributed to our present
issue by Dr. H. A. Ellis covers a good deal of
unexplored territory. The selective destruction of
tissue is an aspect of the antiseptics question
which has attracted the attention of bacterio¬
logists and clinicians alike since the early days of
the antiseptics controversy. It has long been
recognised that the various tissues of the body have
widely differing powers of resistance, and that this
difference has a very practical bearing on matters
so diverse as the laboratory standardisation of
antiseptics on the one hand and phagocytosis on
the other. The work of Ehrlich and his colleagues
on the salvarsan compounds gave unmistakable
indications of differences existing between the
selective destruction of tissue in diseases due to
protozoa, such as syphilis, and diseases due to the
pyogenic organisms. Again, the recent work of
Lorrain Smith, Dakin, Browning, and others on
the newer antiseptics has shown that free hydrogen
ion concentration, electrolytic dissociation, and
numerous other physico-chemical phenomena enter
very largely into tihe question. In applying similar
principles to tuberculosis difficulties arise, the
chief of which is that the histological tuberole is
an avascular growth. We await further details
of Dr. Ellis’s work with interest.
PLANT STIMULATION BY ULTRA-VIOLET RAYS.
Some remarkable experiments have recently been
made in regard to the influence of ultra-violet rays
on the development of the sugar cane, the pine¬
apple, and the banana, which seem to show that if
it were not that the atmosphere largely absorbed
these rays from sunlight the world’s production of
vegetable foodstuffs would be very materially
increased. For example, three lots of sugar cane
were planted, the first being covered with coloured
glass to exclude 50 per cent, of the sun's ultra¬
violet rays, the second being exposed normally
to sunlight, and the third to the combined action
of sunlight* and of the ultra-violet rays from a
mercury vapour lamp. Beyond this distinction
other things were equal, as, for example, supplying
the plant with the same kind and amount of
fertiliser. After several months the second lot was
found to contain as much as 30 per cent, more
sugar than the first, and the third lot contained
8 per cent, more sugar than the second. It is
suggested that, according to this experiment, the
time taken normally for the development of
Lanob*,]
THE WORK OF THE AMERICAN MEDICAL CORPS.
[MARCft 15,1919 431
the cane to maturity, which is as a rale 20
months, would be very considerably reduced if
only an economic and practical source of ultra¬
violet rays could be found. The use of mercury
lamps on any scale is, of course, impracticable, but
there is a possibility of producing the rays perhaps
by less expensive means. Pineapples submitted to
the rays for 40 minutes each morning developed a
fruit riper, juicier, and larger than that exposed to
sunlight only. It was further noticed that banana
leaves and stalks which had been cut and placed in
water kept their original freshness even after two
weeks when they had been exposed to ultra¬
violet rays, whereas the same materials untreated
faded completely after six or seven days. This
treatment when carefully carried out there¬
fore delays the deterioration of the fruit, and
so would help its export to a remote destina¬
tion in sound condition. The ultra-violet rays, of
course, are weU known for their germicidal
properties and have been used as a mean# of
sterilising drinking water even on a large scale, as
at several towns in France. It would be interest¬
ing if some relationship were proved to exist
between this sterilising action of the rays and
their stimulating effect on plant development.
THE WORK OF THE AMERICAN MEDICAL CORP8.
In the United States of America some millions
of men were recruited within the space of a few
months. Between March and December, 1917, the
number of enlistments increased 8-fold, and in
September of that year alone 462,000 were mobi¬
lised. Camps were set apart for them, and after
a period of training they were sent to England or
France. A large majority of the recruits came
straight from city life and were in soft condition.
At the outbreak of war the Medical Corps of the
United States Army was totally inadequate to deal
with anything but a small expeditionary force.
Volunteers from among civilian medical men were
available, but they needed training in army methods
before they could become serviceable. The problem
was, in fact, a difficult one to solve. But the
medical profession of the United States rose to the
occasion, and a sufficient number voluntarily offered
their services to put the newly-raised army under
effective medical and surgical care—a result largely
due to the energy and initiative of Colonel Franklin
Martin, of Chicago. The response of highly skilled
surgeons and physicians to their country's call was
prompt and general, and it was their assistance as
organisers, and especially the example set by them
to their fellow practitioners, that melted away
difficulties. When all the circumstances of the
campaign are taken in review there remains no
doubt that the exceptionally good health of the
new American Army on both sides of the Atlantic
has been a testimony to the success of medical
mobilisation. With the exception of influenza, no
widespread epidemic has prevailed. Lobar pneu¬
monia and cerebro-spinal fever were prevalent for
a time in certain camps, but never attained large
proportions. As in the Allied armies, the enteric
fevers formed an almost negligible factor in pro¬
ducing military inefficiency, and diseases the spread
of which is mainly due to defective hygiene and
sanitation were conspicuous by their absence.
These facts are confirmed in a report recently
isstied by the U.S. Secretary for War dealing with
the health of the American troops up to the end of
August last. For the year preceding that date the
death-rate from disease among troops in the United
States was 6*4 per 1000; in the Expeditionary
Force it was 4*7; in the combined forces it was
5*9. The male civilian death-rate at the same
period for the age-groups most nearly corresponding
to the Army age was substantially the same as the
rate for the Expeditionary Force. What the low
figure means in lives saved is shown by a com¬
parison with the rate of 65 per 1000 in the Union
Army during the Civil War, and one of 26 per 1000
in the whole American Army during the Spanish
War. With the changing personnel of the Army
the incidence of disease changed too. In 1916
tuberculosis accounted for 14 per cent, of deaths,
pneumonia for 11, and cerebro-spinal fever for 4.
In 1917 the figures were 4, 25, and 10 respectively.
Pneumonia, either primary, or secondary to measles,
was in fact responsible for 56 per cent, of all the
deaths among the troops in the year under con
sideration. In the subsequent period the sky was
clouded by the influenza epidemic. During the
eight weeks from Sept. 14th to Nov. 9th 316,000
cases of influenza were reported amongst troops in
the United States, and over 53,000 cases of pneu¬
monia. Of the 20,500 deaths notified during this
period probably all but about 700 were the result of
influenza. In another direction the good health of
the Army was in no small measure due to the
vigorous anti-venereal campaign waged by the
U.S. War Department. The measures put into
force included the repression of prostitution and of
the liquor traffic in zones near cantonments, pro¬
vision for a sensible social environment and
proper recreation, education of soldiers and
civilians with regard to the risks of venereal
disease, the provision of prophylactic remedies,
and prompt medical treatment in case of infection.
During the year under review the number of
venereal admissions to Bick report was 126 per
1000 men, the figure including duplicate entries.
It is stated that in a majority of cases the disease
was contracted before entering the Army. Among
the troops in France, where there were no recruits
fresh from civil life, the record was better than at
home, and the incidence of venereal disease fell
rapidly and continuously. All these facts are set
out at length in the report of the Surgeon-General,
U.S. Army, for the fiscal year ended June 30th,
1918, although the record does not contain the
recent figures given above.
Something of the total achievement may be
gleaned from the statistical part of the report.
In the States the Army had at disposal 80
fully equipped hospitals, with a capacity of
120,000 beds. At the time of the armistice there
were 104 base hospitals and 31 evacuation hos¬
pitals belonging to the Expeditionary Force, in
addition to an evacuation hospital in Siberia.
Army hospitals in the States dealt with nearly a
million and a half patients during the war; those
with the Expedition had approximately half this
number under their care. It will be remembered
that, over and above furnishing the medical
personnel for the units detailed, the War Depart¬
ment, through its chief surgeon, released 931
American medical officers to serve with the British
forces at the most critical period of the campaign,
and a further 169 officers for service in base hos¬
pitals turned over to British troops. The total
number of the civilian medical profession in
America is, however, so large that, taken all in all,
up to the end of July only about 15 per cent, were
counted as having gone on active service. The
432 Thu Lancmt,]
THE PSYCHOPATHIC CRIMINAL.
[March 15,1919
reservoir on which to draw was much greater than
oars, and although, as we have seen, the satisfactory
health of the American Army during the war was
due to the devotion and self-sacrifice of a goodly
proportion of the civilian medical profession, this
was done without dangerously depleting the
number of those on whom still rested the responsi¬
bility tor health and hygiene at home.
THE PSYCHOPATHIC CRIMINAL.
We are glad to learn that the justices of the city
of Birmingham have taken further steps to give
effect to the scheme for the psychiatric examina¬
tion and differential treatment of psychopathic
offenders,* to which reference was made in The
Lancet of Jam 25th. The justices have obtained
from the Prison Commission the promise of the
appointment to Birmingham Prison of a whole-time
medical officer with special expert knowledge of
mental diseases; and they have also secured the
services of Dr. W. A. Potts to act qa court doctor to
advise in cases not coming under the examination
of the prison medical officer, as, for instance, cases
where accused persons are remanded on bail or
charged on summons. It is proposed that in all
prosecutions when there is . reason to suspect that
the alleged offender is mentally abnormal the court
shall postpone action until full inquiry on this
point has been made by either the prison medical
officer or the court doctor, or by both these experts
in consultation. On the further hearing of the case,
if the justices decide to convict, this expert evi¬
dence will be brought out in court, and will be
taken into account in settling the mode of treat¬
ment which, will best serve the interests of the
individual offender and of the community. The
justices anticipate that, even ip the existing state
of the law, they will be able to give effect in a con¬
siderable measure to the principle of individualised
treatment by using their very wide powers under
the Probation of Offenders Act. Thus, it will be
possible to include in the conditions of probation
that the person placed under probation shall report
himself periodically to, the court doctor, shall
observe such instructions regarding his mode of
life, and shall accept such medical advice and treat¬
ment as the court doctor may give him. The
Birmingham justices are setting an excellent
example to the country, and the results of their
experiment cannot fail to be extremely valuable ; in
view of the growing recognition of the need to
ensure the more efficient treatment of mental
invalids by the organisation of psychopathic clinics.
TUBERCULOSIS IN FEMALE MUNITION WORKERS.
Towards the end of 1917 it became evident that
the mortality from tuberculosis among women was
on the increase. This increase was small, but
appreciable ; and it was the more significant in the
light of the fact that before, the war the mortality
from tuberculosis had been steadily decreasing.
In his analysis of the vital statistics of England and
Wales for 1916, Dr. T. H. C. Stevenson has noted
that the increased mortality from tuberculosis did
not affect women over 45. Hence his suggestion that
the cause of the increased mortality is to be sought
in the war-time industrial employment of women
on an unprecedented scale. To test the validity
of this suggestion, an inquiry was instituted, under
the auspices of the Medical Research Committee, as
to the prevalence and etiology of tuberculosis among
industrial workers, with special reference to female
munition workers. The report 1 on this inquiry by
Captain M. Greenwood and Dr. A. E. Tebb tends to
confirm Dr. Stevenson’s views, but, as they point out,
it is impossible to put the accuracy of these views
to any absolutely rigid test. The report deals with
the available evidence in the following sections:
(1) Occupational Tuberculosis, as revealed by the
statistics of male operatives, the Registrar-General's
decennial supplements including the unpublished
data for 1910-12; (2) Occupational Morbidity and
Mortality of Women; (3) Regional Distribution of
Mortality .in England and Wales during 1911;
(4) War-time Statistics of; England and Wales;
(5) Factory Conditions in Birmingham in 1917.
Investigations in Birmingham showed a relatively
great incidence of phthisis among employees in
unhygienic factories and serious overcrowding in
industrial dwellings. But no evidence was „found
of any specific trade habit amongst munition,
workers specially apt to favour conveyance of,
phthisis from one person to another.
FACTORY SURGEONS AND THE MINISTRY
OF HEALTH.
The Association of Certifying Factory Surgeons
has circularised the members of the Standing
Committee appointed to consider the Ministry of
Health Bill regretting that the Bill, as it stands at
present, does not include a well-defined policy of .
improved medical supervision for factories and
workshops. While the Bill certainly enables the
Ministry to take over factory inspection, the decision
would apparently depend on agreement between
the different Government Departments concerned.
The Association recommends that the powers and
duties of the Secretary of State with respect to
control of sanitation in factories and workshops,
the appointment of medical men as inspectors of
factories, and the appointment and duties of
certifying surgepns, should be among the power?
which can bp transferred to the Ministry of Health
by Order in Council. The Association also desireB ;
the appointment of a Board of Hpalth on the lines,
laid down in the original Bill, to advise the,
Government on all legislative and administrative
points concerning public health.
In view of the approaching retirement of John.
A. Turner, C.I.E., M.D., D.P.Hi,. executive health
officer to the municipality of Bombay, the corpora¬
tion has placed on record their, recognition of his
long and arduous services extending over a period.
of 18 years, especially in connexion with the
Bombay Sanitary Association, the King George
Anti-Tuberculosis League, the Lady Willingdon.
Scheme Maternity Homes, and the Anti-Venereal
League. All these useful institutions owe their
establishment largely to Dr. Turner’s efforts.
1 An Inquiry Into the Prevalence and vKbtology of Tuberculosis
among Industrial Workers, with special reference to Female Munition
Workers. H.M. Stationery Office. 1919. Is. 6 d. net.
Sib Charles Burtchaell Honoured.— The hono¬
rary degree of LL.D. Dublin was recently conferred upon
Sir Charles H. Burtchaell, D.G. A.M.S. in France, when the
orator described him as: Medicum inter medicos, bellatorem
inter bellatores eminentes eminentem. On March 3rd he *
was admitted to the honorary fellowship of the Royal
College of Surgeons in Ireland, and on March 7th received a
like honour from the Royal College of Physicians of Ireland.
Addressing a medical audience on the latter date on Disease
and Suocess in War, General Bnrtohaell paid a tribute to
the work of the 11 Dublin Hospital ” at Boulogne.
The Lancet,]
SCOTLAN D.—PARIS.
[March 15,1919 433
SCOTLAND.
(From our own Correspondents. )
The Scottish Ministry of Health Committee.
When the Ministry of Health Bill was first introduced a
■temporary council or committee was formed in Scotland
drawn from recognised official medical bodies, with the view
of collecting and formulating the opinions of Scottish doctors
on the establishment of the Ministry and the problems of
medical reconstruction. At a conference, held on Jan. 4th,
representatives were present of the Scottish Branch, General
Medioal Council, the Scottish Universities, the Scottish
Royal Medical Corporations, the Scottish Committee,
B.M.A.,and the Association of Medical Officers of Health,
when it was agreed to form a committee—to be known as
the Scottish Ministry of Health Committee—for the above
purpose. It was decided that the committee should consist
of 44 members, made up as follows:—
Scottish Members of the Scottish Committee of the British
Medical Association . 18
Members of the Scottish Branch of the General Medical Council 9
One representative from each of the Medical Faculties of the
Scottish Universities . 4
Two representatives from each of the other Licencing Bodies in
Scotland . — .. ... ... . 6
Two representatives from the Association of Medical Officers of
• Health. 2
One representative from the Scottish Association of Medical
Women. 1
Four members to be codpted later 4
At the first meeting office-bearers were appointed as
follows:—Chairman: Sir Donald MacAlister. Vice-chair¬
men : The Presidents of the Royal Medical Corporations ;
The Direct Representative for Scotland on the General
Medical Council; the chairman of the Scottish Committee ;
and Dr. Goff, Both well. Secretary: Dr. Fredk. K. Smith,
Aberdeen. It was agree that the office-bearers shonld form
a business subcommittee to prepare business for the fall
committee.
The committee has met twice to oonsider the Ministry of
Health Bills as published in November, 1918, and February,
1919. Each clause m the Bills was discussed and varions
suggested amendments were considered. Ultimately it was
resolved to communicate the following to the authorities
concerned :—
1. That provision ought to be made by direct enactment
in the Ministry of Health Bill for the transfer to tbe Minister
of Health of the Administration of tbe Anatomy Acts, and
to the Scottish Board of Health of the Administrative Work
of the Highlands and Islands Medical Servioe Board.
2. That with regard to the constitution of the Scottish
Board of Health, the proposed minimum of medical repre¬
sentation—namely, one member—is totally inadequate, and
that not less than one-third of tbe members of the Board
ought to be registered medioal practitioners; and also that
tbe special provision that a medical member of the board
shonld be tbe holder of a ia diplohaa in sanitary science,
£ ublio health, or State medicine under Section 21 of the
[edioal Act, 1886,” is unnecessary and shonld be omitted.
Chair of Therapeutics , Edinburgh University,
The necessary preliminaries having been concluded, it is
understood that the Edinburgh University Court will shortly
proceed to the appointment of a professor of therapeutics. An
entirely new scheme for the teaching of materia medica will
thus be completed, the appointment of Professor A. R. Cushny
to the Chair of Pharmacology having recently been made. The
new professor will, in addition to his systemic lectures, teach
clinical medicine in the wards of the Royal Infirmary recently
under the charge of Sir Thomas Fraser, emeritus professor of
materia medica. He will be debarred from private practice.
Influenza Epidemic in Edinburgh and District.
There is every indication that the epidemic is rapidly
abating; new cases are not so frequent, admissions to hos¬
pitals are much less numerous, and the cases which are
occurring seem to be definitely less acnte in most instances.
Active investigation of the disease is being carried on in tbe
laboratory of the Royal College of Physicians, bnt results
have not yet been reported.
March 10th.
The Dorset Comity Council has increased the
'salary of Dr. W. T. G. Robinson, their medical officer of
health, by £100 to £600 per annum.
PARIS.
(From our own Correspondent.)
Professor Chantemesse.
Andr6 Chantemesse succumbed on Feb. 26th to a sudden
attack of angina pectoris coming on daring influenza, at the
age of 67 years. He was born at Pay on Oct. 13th, 1851,
and, soon coming under the influence of Cornil and Pa-teur,
decided to devote his life to pathological anatomy and
bacteriology. He became in succession physician to the
hospitals, professor of hygiene in the Faculty of Medicine,
and Inspector-General of Sanitation at the Ministry of the
Interior. His best-known works dealt with mosquitoes in
relation to yellow fever, flies in relation to cholera, prophy¬
laxis on frontiers, while he was looked upon as an authority
on the enteric fevers. It was Chantemesse, in fact, who
instituted the first researches on antityphoid inoculation.
By means of heated caltures he produced a vaccine which
gave good results in animals but produced no decisive effect
on man. Hence his discovery led no further until Wright
used a lower temperature for sterili ation and Vincent sug¬
gested ether for the same purpose, when he modified his
procedure with resulting sucoess. Professor Chantemesse
was a member of the Academy of Medicine and a Com¬
mandant of the Legion of Honour.
Phthisis among Coloured Troops in Fra/noe.
M. L. Moreau has noted during the war the frequent
occurrence of tuberculosis amongst the men of the yellow
and black race in the French Army. The disease is apt
to escape discovery, as the general health of the men often
remains good for long. Strange climatic conditions,
physical overstrain in subjects wont to live a life of
indolence, and changes in their usual alimentary rfigime,
are among the causes adduced to explain the rapid
development of tuberculosis. When the disease is clinioally
latent the X ray soreen at once gives the cine. In many
coloured labour battalions influenza has aided the develop¬
ment of the disease, and has frequently been the cause of a
fatal issue. M. Moreau suggests that these men should be
submitted to careful radioscopic examination before being
employed in Europe.
The Late Results of Gassing.
Professor Achard directs a special gas service at the
HOpital Necker, in Paris, receiving there the patients sent
down from casualty clearing stations as convalescent,
although many of them were found to be still insufficiently
recovered at the end of their leave. He has followed the
subsequent history of 3525 patients, of whom 2958 had been
submitted to blistering gas and 567 to suffocating gas, the
proportion being 85 per cent, of the former to 15 per cent,
of the latter, blistering gas having been employed by the
Germans on a larger scale than the other. The frequency of
late accidents was, however, much greater in the case
of suffocating gas, which leaves the graver and more
lasting results. Chief of these is the diminution in respira¬
tory exchange. Normally the amount of 00 a exhaled honrly
per kilo of body-weight is 0*55g. After gassing this figure
continues to drop considerably for a prolonged period, demon¬
strable by placing the patient in a closed chamber in
which the quantity of carbonic acid gas produced is
measured. The figure mentioned may drop to 0 34 g.
in a man who has been submitted to suffocating gas, and this
low value may persist, it may be, for as much as two years.
After blistering gas the results are less grave and lasting;
the diminution of the fignre mentioned rarely lasts more
than seven to eight months, nor does it fall below 0 40g. The
reduction in CO a output is not regular; it is considerable at
tbe outset owing to pulmonary oedema. The output gradually
rises for two weeks or so, during which the bronchi become
patent and falls anew for a very extended period, in
which the lung lesion is undergoing sclerosis. Another
subject studied by M. Achard, both clinically and experi¬
mentally, is the relation between tuberculosis and gassing.
He concludes that tuberculosis does not develop more
frequently in gas victims than in other subjects, but that
when latent lesions exist they are apt to undergo rapid
development. A number of gassed patients, owing to per¬
sistent cough, wasting, apical ifiles, and even haemoptysis,
give the impression of being tuberculous, but their sputum
434 TM LAN01T,] NOTES FROM INDIA.—CONTROL OF VENEREAL DISEASES.
[MAB€H 15, 1919
TuLancbt,]
MATERNITY AND GUILD WELFARE.
[Mabgh 16,1019 435
Oaptein Bates gave as his opinion that if legislation was
to be useful farther organisations would be necessary to back
op its provisions. He has advocated a Federal Department of
Health in order to stimulate and coordinate action in the
different provinces.
Venereal Disease in Montreal.
In Montreal the situation as regards prostitution is very
different from that in Toronto. Here commercial prostitution
prevails. The preliminary report of the Committee of
Sixteen of Montreal (the committee of an unofficial organisa¬
tion which investigated the vice conditions of Montreal)
made the following statement with regard to the number of
houses of prostitution in existence at the time of its survey.
The estimate as to the number of houses of commercialised
prostitution, given by the officers of the morality squad, is
that there are between 250 and 300, and they state that about
six or eight hotels are operated almost exclusively as houses
of assignation.
Venereal disease is very prevalent in Montreal. Over and
above the numerous facilities for contracting infection
supplied by commercialised prostitution, there are other cir¬
cumstances which tend to favour the spread of venereal
infections. Montreal is the only large port of Canada, as
compared with the large ports of the world. Sailors from all
parts sail in and out, and of course convey infection. Since
the beginning of the war Canadian troops have come into
Montreal to sail for their European destinations, and those
who have returned have come back by the same route.
Ho prohibition law has here been in force, and it is
generally allowed that there is a close relationship
between the incidence and prevalence of venereal infection
and the consumption of alcoholic beverages. Many drcum-
stanoes seem to combine to render the situation in'
Montreal, so far as the prevalence of venereal disease
is concerned, of a very serious and menacing character.
In the Province of Quebec there is no law to control the
spread of venereal infection. At the General Hospital in
Montreal three clinics are held each week at which there is
an average attendance of 125 men and women suffering
from venereal. disease, of whom about 60 per cent, are
suffering from gonorrhoea and 40 per cent, from syphilis ;
and this is only one of the hospitals of the city.
The Problem in Eastern Canada.
From this short account it will be seen that venereal
disease is unduly prevalent in Eastern Canada, and that in
Ontario and Quebec the conditions differ widely. Organised
commercial prostitution is easier to cope with successfully
than is clandestine prostitution. If civil authorities would
act firmly, organised prostitution could be abolished, but the
civil authorities have not learned to recognise the relation¬
ship between prostitution and venereal disease, and there¬
fore frequently will take no adequate action, and prostitution
is essentially a matter for the courts to deal with. It
behoves the members of the medical profession, there¬
fore, not only to concern themselves with the diagnosis
and treatment of venereal disease in prostitutes, but to
make it clear to the civil authorities that to allow
prostitution to continue is a menace to the public health,
and thus urge them rigidly to enforce the laws. Clandestine
prostitution is also a difficult problem to solve. Members of
this class are more numerous, are almost impossible to trace,
and, being young, are more apt to be acutely infected.
There is little doubt that the war has increased the spread
of venereal disease in Eastern Canada, but to what extent
it is impossible to say. With the demobilisation of troops
on a large scale the menace will be intensified unless effective
preventive measures are put into force, but the general
public is being educated as to the dangers of uncontrolled
prostitution with its consequent aftermath of venereal
disease, and preventive measures are now demanded. Women
are taking a prominent part in the movement.
Thb Aviation Insurance Association. — This
association has been formed to accept at home and abroad
all risks in connexion with both heavier and lighter-than-air
craft. The association consists of Underwriting Members
of Lloyds, the Eagle, Star, and British Dominions Insur¬
ance Company, Ltd., and the Excess Insurance Company,
Ltd* The business will be controlled by a oommittee of five
and offices have been opened at No. I, Royal Exchange-
avenue, E.C.
MATERNITY AND CHILD WELFARE.
Conditions of Childbirth in India.
Thb unhappy conditions of childbirth among Indian
women have long been a matter of concern. • In 1885 the
Countess of Dufferin’s Fund was organised to meet the need.
As time went on the number of medical wo nen practising in
India, both Dufferin and missionaries, increased, midwives
and nurses were trained, and a number of Indian assistant
and subassistant surgeons finished their course and left
the schools and hospitals. This but served to bring into
relief the enormous amount of preventable mortality which
occurred both among mothers and children, due to puerperal
sepsis, pelvic contraction—sometimes extreme—misplace¬
ments, accidents occurring during labour, pregnancy
diseases, and ignorance on the part of the people as
to methods of artificial feeding of infants in cases where
the mothers had died during childbirth.
Viet or ia Memorial Scholarships Fund. In order to combat
this unnecessary suffering and loss of life the Victoria
Memorial Scholarships Fund came into being in 1903, formed
by Lady Curzon, for the improvement of the conditions of
childbirth in India. It was expressly stated in the nineteenth
annual report of the National Association for Supplying
Female Medical Aid to the Women of India for the year 1903
(p. 27) that the funds were to be applied to the training of
the hereditary dai caste as opposed to dais and midwives
taken from other classes whose training might be left to the
agencies already carrying it on. A fund was collected
amounting to Rs.6,86,784.15.8, from which an annual income
of Rs.34,000 was derived. ThiB was distributed among the
different provinces, sufficient being retained to carry on the
central expenses and to assist special enterprises in the
interests of the objects of the Fund. The money was kept
apart from the Dufferin Fund and the organisation was
carried on by an executive committee selected from among
the members of the central committee of the Dufferin Fnnd.
In each province the Fund was administered by the Inspector-
General, and in each centre where operations were started a
local committee was formed.
Endeavours were then made to induce dais to attend
courses of instruction. Many of these women were 40,
50, 60, or even 70 years of age; some were deaf, some
were blind; none had any previous education or had
ever exercised their mental faculties; they were very pre¬
judiced and jealous of their reputation, and, in addition,
were honestly convinced that no one could teach them any¬
thing as regards normal labour. The results of these efforts
were variable ; in some oases the classes had ceased to exist
or could not be formed, and it was suggested that the grants
might be used for the training of women not of the dai
caste. This has by degrees led to the almost total abandon¬
ment of the objects of the Fnnd, which in many cases has
been used for different but allied objects.
Deport of Fund for 19IS .—The report for 1918 gives a
large amount of information, including reports and sug¬
gestions from centres, papers by medical women on
improvement of the conditions of childbirth, several of
which are published in complete form, together with extracts,
from the annual reports. The following is a summary :—
The greatest success In the training of indigenous dais has been met
with in the Punjab whore training combined with supervision Is being
carried on at Amritsar, Ambala, Ferozepore, Bhiwani, Multan, and
Lahore; in addition at Ludhiana 124 indigenous dais have been
trained. The report of the Inspector-General of Civil Hospitals.
Punjab, shows that a large extension of this work is contemplated
in the near future.
Next most successful are the Indian States where large numbers of
the hereditarv dal oaste have been trained at Bhopal, Patiala, Indore,
Hyderabad, Baroda, Gwalior. In some of these States supervision Is
also carried on.
In some stations in the United Provinces large numbers of
hereditary dais have been trained, but with the exception of Agra there
is no Bystem of supervision, and the Inspector-General in his
memorandum expresses the opinion that i he work has been useless and
says that it Is his intention to discontinue it.
In Baluchistan training and supervision are carried out at Quetta.
In the Central Provinces training and supervision are carried out at
Nagpur. In Bengal and Bihar and Orissa Indigenous dais have been
trained, but there has been no supervision. The general opinion is that
no Improvement has resulted, and the Surgeon General and other
medical officers in Calcutta recommend that operations should oesse
and all efforts should be concentrated on the endeavour to replace the
hereditary dai by a better educated woman. The Bombay and Madrat
Presidencies are outside the operations of the Fund.
Several of the peoers written by medical women describe snoo oo s f al
work among dais. Otben'give graphic accounts of the difficulties to he
436 Th&Lanokt,]
MATERNITY ANt)' CHIlii) WELFARE!
[March 15, 1919
========^
overcome, and especially of the enormous amount of sepsis which In
two papers received is estlmved as c tuning (at times) a mortality of
83 per cunt. of natural labour! There Is also a number of useful
suggestions for methods by which Improvement can be secured.
Suggestions for improvement. —Many questions are dis¬
cussed concerning the education of the public, such as the
need for instruction to women of all classes on care
during pregnancy and labour and care of young children;
instruction to men in essentials of the same, and instruction
to boys and girls in primary schools on the same to a
modified extent; baby shows; trained health visitors
employed systematically in towns and villages, Ac. The
miscellaneous suggestions for improvement are important,
and as follows :—
1. Women’s hospital! should be more attractive, and more care should
be taken to make labour c mduotei there absolutely safe.
2. We should specialise so as to eliminate painful labour as much as
possible.
3. There should be hospitals for infectious diseases, with provision for
puerperal fever.
4. Trained dais should be subsidised and should work in connexion
with hospitals.
5. They should be provided with outfits for proper work.
6. Mothers should be provided with maternity packets.
7. Training of dais should be carried out by women doctors (or of her
teachers) specially set apart for the purpose, livery training school
should be Inspected.
8. Standards of training should be laid down, and eipeclally a
sufficient number of ca«es of labour conducted should be insisted on
before examine* ton.
9. An effort should be made to link up all present methods of training.
10. Maternity centres should be started; also milk depdts, baby
clinics, and baby shows.
11. Prevention of puerperal fever should be taken op by the Anti-
Tuberculosis League so stving two organisations.
12. Certificated dais sh >uid be allowed to bring tbetr cases Into
maternity hospitals and conduct them according to rules, taking the
naual fee from the patient.
13. Notification of puerperal fever should be required.
14. Free •*eternity homes should he provided.
15 leeches for young children should be provided.
16 State-aided maternity benefit is needed.
17. A Central Mid wives Board for India is required.
18. A book should be prepared for girls’ schools on the lines of
'Might, life, and cleanliness.”
Id. The organisations now engaged in war work should after the
conolosion of the war take up the question of maternity welfare.
Class of women trained. —A point regarding which there is
much difference of opinion is whether work among the
hereditary dai class should be continued, or whether it
should be given up and all effort concentrated on providing
a better class of midwife.
There is a general agreement that this last would be the simplest
and easiest solution of a difficult problem; but while the Surgeon-
General and other officers of tue Indian Metical Service in Bengal
and the Inspector-General, United Provinces, give a definite pronounce¬
ment that this course should be followed, the majority of the
medical women who'discuss the question declare it impossible as a
practical measure.
The oplnon of most of the medicxl women Is that for general improve¬
ment of childbirth in India work amongst hereditary dais mint
be continued, but that it is useless unlesi it Is combined with some
scheme of continued supervision of their‘ work by means of midwife
supervisors or health visitors. The registration and supervision or
mid wives is recommended In a Urge number of papers Ibe Inspector
General, United Provinces, on the other hand. Is of opinion that the
day for regl-tratlon and supervision In India is still far distant. The
medical women who recommend the measure, however, do not
pro*»a ly Intend that a Bill identical with the Bnglish Midwives Act of
1905 making registration and supervision everywhere compal-ory
should be immediately introduced into provincial legislatures, but
ra'her that powers should be given to municipalities to lot-oluce
reg I strati m and supervision where publto opinion is ready f >r it.
Several municipalities have alresd« started schemes whl-h recognise
this necessity, the dai- being persuad'd to submit to supervision by
means of a notifying fee. These municipalities would probably be
glad to have m<rre power In order that the schemes mlaht be mo*e
effectively carried out and the notifying fee either reduced or dis¬
oon* lnued. Experience has shown, moreover, that in wo r k among
dais no amount of p»r»uasion. kindness, or money rewards will bring
about a successful result, unless combined with very definite orders
from the representatives of Government. T»*e measure about to be
lntroduc-d into the Punjab is recommended to the notice of all looal
Governments. This provides for ths registration and supervision of all
dais and mid wives in the orovinoe who receive a Western training, and
It ensures a definite staadaid ct training and examination.
Improvement of the condition of childbirth in India ia a
problem at least as difficult and at least as important as the
prevention of plague; and it ia only by patient work fre¬
quently unsuccessful and experiments constantly repeated
that a successful issue can be expected.
As regards the class of women to be trained the committee f *els the
warmest intare-t in all effort to train and assist midwives of a superior
cl«e but It, fee's th«t, until proof is given that the majority of women
in a province, rli*h and p or alike are employing these midwives for
natural Ubour, t ie funds of the Victoria Memorial Scholarships must
be expended entitely for the Impnvemem of the hereditary dai class.
It is felt that more might be done both by the Imoerial and local
Governments to * el leva the terrible conditions, the suffering, and loss
of life endured by so large a section of the population.
1 8tar.lsti -s show that in reoent years the birth-rate in Ind a has. been
falling, with a tendency for the death-rate to rise. If the wantage
of intent life is to be taken In hand tie first step is undoubtedly
Improvement of the oovittions of childbirth. Measures to provide'
milk depors, creches, and baby clinics are of little use to children who
die before ordu ing birth, or within the fimfc raon h afrer.
One very 6*1 tent fact la ibe lack of statistics relating to childbirth.
It ought not to te more difficult to discover the number of deaths
following childbirth than the number following plague, and the dis¬
covery that certain cities were peculiarly affected in this way could be
used as a strong ino mttae to the-r municipalities, and to their principal
residents, to - ffect improvements.
The committee b tpes that medical women will send Inform itionaa
to success or non-suocess, and from time to time further ideas and
suggest ons which may be of service.
It Is proposed in future to publish the Victoria Memorial Scholar¬
ships Fund report as a booklet, separate from that of the Uuffertn
Fund, and to make it a« far a- possible an accurate account of measures
taken for Improvement of the conditions of childbirth in differeut parts
of the country.
Maternity Nursing in London .
A recent meeting of the Central Council for District
Nursing in London confirmed the findings of the conference
held last Jane on the sabjeot of maternity nursing in
London, with special reference to the position of district
nursing associations in relation thereto. This conference
was attended by representatives of Government depart¬
ments, of the London County Connell and other
municipal services of London, of the Central Mid wives
hoard, by representatives of the medical profession,
voluntary hospitals and district nursing association*, and
by others interested in the subject. Sir William
Collins, M.P., who presided, summed up the result nnder
the* three head* of the debate. There was a consensus
of opinion : (a) That it is desirable that maternity naming
should be undertaken by district naming associations in
London, (b) That there should be cooperation with the
hospitals for the purpose of nursing the extern maternity
cases. There was some difference of opinion in regard to
(o) the relation of maternity nursing to midwifery, and in
particular whether it is essential that the maternity nurse
should hold the C.M.B. certificate. The last part of this
question has been practically settled by the decision of
the Looal Government Board that, in order to qualify
for a grant nnder the Maternity and Child-Welfare Aot,
1918, “the maternity nursing should be undertaken by
a woman with the certificate of the C.M.B ; failing
this qualification the Board should be furnished with
evidence of her competency if a grant is claimed/’
It appeared to the council that the possession of the
C.M.B. certificate would be especial'y necessary if, and
when, the maternity nurse was expected to attend at the
time of the delivery.
A second conference was held on Sept. 30th, when the
conclusions of the June meeting were discussed, the general
opinion arrived at being that the names would willingly
undertake the maternity district work, but owing to war
conditions there was an insufficiency of staff for the purpose.
The combining of maternity and general nnrsing was con¬
sidered from experience to be safe. Night work was regarded
as a possible difficulty to be overcome, and might require
additional staff. The employment of home helps would be
u*eful, but this should be apart from the associations. The
difficulties of small associations and the single-handed
parochial nurse might be met by federation of the smaller
a*sociations. or their affiliation to a central association for
the supply of special nurses. The council has been in com¬
munication with the Local Government Board as to the
conditions on which a grant might be forthcoming, and
some practical outcome is expected.
Memorial on Diet and Influenza.— The Bread
and Food Reform League has sent a memorial to the Local
Government Board asking for pablic attention to be drawn
to the following points: (1) That dietaries laoking in anti-
neuritic vitamine found especially in the germ and alenrone
cells of cereals; (2) that dietaries also lacking in anti¬
scorbutic vitamine, found abundantly in fruits and
vegetables, produce deficiency diseased conditions which make
people although apparently in excellent health physically
unfit, and less able to resist epidemic infection; and (3) that
a memorandum published by the Food (War) Committee of
the Royal Society states that wrong methods of cooking
impair tue value of antiscorbutic vitamine. The memoruu
is signed by a number of medical men. Farther particulars
may be obtained from the honorary secretary of the league*
Miss May Yates, at 37. Essex-street, London, W.C. 2.
Thb Lancet, ] OBITUARY. ~X
ARTHUR CONNING HARTLEY, M.D., F.R.O.S. Edin.
WE regret to announce the death of Dr. A. C. Hartley, of
Bedford, which took place on March 5th, at the age of
54 years. He was the second son of the late William
Hartley, of Comlongon, Dumfriesshire, and was educated at
Edinburgh University, graduating M.B., C.M. in 1888. As
a student he took honours in most of his classes, and entered
Uurgely into the life of the University, in the work of the
Students’ Representative Council, and in the direction of the
rifle company of the Queen’s Brigade, in which he obtained
many shooting prizes. He obtained his l> full blue” for
running, drilling, and shooting. After qualifying he was
for a year resident medical officer of Chalmers Hospital
Edinburgh, and was also house surgeon at the Royal
Maternity and Simpson Memorial Hospi'al, Edinburgh. In
1891 he took the degree of M D. with honours at Edinburgh
University, and in 1893 became a Fellow of the Royal
College of Surgeons, Edinburgh.
Dr. Hartley began his practice in Bedford in 1893. and he
soon secured the confidence of a large number of patients
in the town and county. He was a firm believer in post¬
graduate courses for practitioners, and paid frequent visits,
during his holidays, to Edinburgh for this purpose. He was
medioal examiner and referee for a large number of life
assurance companies and held the post of Admiralty surgeon
for Bedford and district. In 1896 the Mayor of Bedford
presented him with the testimonial of the Royal Humane
Society for resouing a girl from the flooded Ouse. Later he
was elected president of the Bedford Medical Society, and
in 1912 he presided over the South Midland Branch of the
British Medical Association. He took an active part in
starting the Bedford District Nursing Association and the
Bedfordshire Rural Nursing Association, and acted for a
number of years on the executive committee of the local
branch of the Society for the Prevention of Cruelty to
Children. His scanty leisure he spent in various forms of
field sports—golf, tennis, shooting, skating, or curling.
Dr. Hartley was enthusiastic on the subject of universal
military service. He himself served 28 years in many
capacities in the Volunteer and Territorial Corps under three
Sovereigns, having taken his part at Queen Victoria’s
Edinburgh visit and at her funeral, and at the Coronations
of King Edward VII. and King George V. In 1917 the King
conferred on him the Territorial Decoration. He received
King Edward’s silver medal for long service in 19 ‘9, and
was on service as major in the R.A.M C. (T.), attached to the
Headquarters Staff of the East Anglian Royal Engineers, at
the beginning of the war. In November, 1917, he relin¬
quished his commission on account of ill-health. Dr.
Hartley was a life-long believer in the principles of total
abstinence from alcoholic drinks.
In 1902 Dr. Hartley married Miss Margaret Stewart,
eldest daughter of the late Mr. James Stewart, and he
leaves three daughters and one son.
RICHARD WHISH BRIGSTOCKE, M.R.0.8. Eng.,
L.M., L S.A.
By the death of Richard Whish Brlgstocke, affectionately
known as the “ old doctor,” which took place recently at
his residence, Scole, Norfolk, there has passed away a well-
known practitioner who, in his early days, formed one of
the party sent out to Africa to find Livingstone, and who
formed an interesting link with Sir Thomas Browne, of
“Religio Medici ” fame.
Mr. Brigstocke received his medioal education at St.
Bartholomew’s Hospital in the years when the late Sir James
Paget was warden, and afterwards enjoyed the personal
friendship of that great surgeon. He qualified in 1859 by
taking the M.R.C.S. Eng., L M., and L.S.A., when he entered
the Navy, in which service he remained till 1866. It was
while engaged in operations for the suppression of
the slave trade that he joined the party which went
in search of LiviDgtone, and he afterwards spent some
time with the famous missionary and traveller. On leaving
the Navy Mr. Brigstocke went to Beyrout, where for 40 years
he had a large and cosmopolitan clientele. As an accoucheur,
he acquired a wide reputation, and was frequently called in
consultation to widely separated parts of Syria, often taking
WAR.4NP AFTER. [March 15, 1919 f 437 t
long journeys on horeeback into the mountainous parts
of the country. From 1870 to 1882 he was lecturer on,
obstetrics and diseases of women and children and medical
jurisprudence at tbe Syrian Protestant College and Medical
School at Beyront, lecturing both in Arabic and English.
He also spoke French fluently. For services rendered to the
Turks during the cholera epidemic in 1875 he received from
the Sultan the Order of the Medjidie, and for similar
services to the Italian colony at Beyrout in 1896 he was
awarded by the King of Italy the Chevalier Order of
St. Maurice and Lazare. An enthusiastic gardener and
woodman. Mr. Brigstocke spent his retirement in strenuous
work of this kind, wielding the axe with skill and power.
He leaves a wife, four daughters, and two sons, the eldest of
whom has seen service with the R.A.M.C. in Egypt and
France.
Dr. Michael Beverley, as a personal friend, writes :—
It will interest many of yonr readers to learn that the
Brigstockes are descendants by marriage with the author
of tbe “ Religio Medici.” It is recorded in the preface of
the “ Posthumous works of the learned Sir Thomas Browne,
Kt., M.D., late of Norwich, the public is here presented with
manuscripts for which we are obliged to Owen Brigstocke,
Esq., grandson by marriage to tbe author.” This is clearly
seen on reference to the Tate Mr. Charles Williams’s genea¬
logy of Sir Thomas Browne. “ Owen Brigstocke married
Anne, the daughter and co heiress of her grandfather, Sir
Thomas Browne, who left his property to his grand-nephew,
Owen Brigstocke.” My old friend, although ignorant of his
connexion with so distinguished an ancestor, told me that
he was descended from this Owen Brigstocke, and promised
to try to get the pedigree up-to-date. His long illness and
death has prevented this.
Mar anlr
Casualties among the Sons of Medioal Men.
Thb following additional casualties among the sons of
medical men are reported:—
Capt. N. H. Owen, Rifle Brigade, died at Sheerness from
pneumonia, third son of Dr. J, M. Owen, J.P., of Fish¬
guard, Pembrokeshire.
Major H. C. R. Saunders, D.8.O., East Yorkshire Regfc.,
previously reported wounded and missing, now believed
killed on March 30tb, 1918, eldest son of the late Mr.
A. R. Saunders, F.R.C 3., of Kingston, Jamaica.
Lient.-Commander G. S. Parsons, R.N., died at Portsmouth,
sixth son of Dr. C. Parsons, of Tunbridge Wells.
Mr. F. C. Godding, died at Brisbane, Australia, from disease
contracted at Anzac, son of Surg.-Gen. C. C. Godding,
C.B., R.N. _
The Honours List.
The following awards to medical officers, for services in
connexion with the military operations in Mesopotamia, are-
announced:—
Lt -Ool. P. F. Chapman, I.M.S.; Maj. and Bt. Lt.-Col. H. J.
Crossley, R.A.M.C.; Maj. and Bt. Lt.-Col. J. D. Graham, I.M.S.; Maj.’
and Bt. Lt.-Col. W. Q. Hamilton, D.S.O., I.M.S.; Maj. \temp. Lt.-Col.)
C. A. Sprawaon, I.M.S. _
Mentioned in Despatches.
The names of the following medioal officers are mentioned
for distinguished and gallant services and devotion to duty
in a despatch received from the Commander-in-Chief of the
Mesopotamian Expeditionary Force
Armu Medical Service. Col. (temp. Maj .-Gen.) A. P. Bltnkinsop,
0.8 , C.M G.; Col S. F. St. D. Green.
Royal Army Medical Corps.— Temp. Capt. 0. G. Adams; Capt. B. B.
Alabaster; Capt. C. W. Arms'ron*; T* np. Capt. K. DAuerldge;
Temp. Capt. T. Batbuir; Capt. W. 0. P. Bam-tt; Temp. Capt. B B. A.
Batt; Temp. Capt. P. G. A. Bott; Capt. J. M. H. Campbell; Temp Capt..
J. M. Clements; Capt. W. MacC. Conley; Cap', (acting Maj.) P. C.
Covrtan; Maj. and Bt. Lt.-Col. (acting Lt.-Cul.) H. J. Cross ley ; Temp.
Oap'.L. W. Davies; Capt. and Bt. Maj. L. Dunbar; T-mp. Cant A.
Felling; Lt.-0<«1. and Bt. Col. M. H. G. Fell, C.M G.; Cap'. G Finch;
Temp. Capt. K. Fraser; Capt. J. U. M. Frobisher; Capt. A. H. Goss**; Maj.
(iCtlng Lt.-Col.) R. Grlffitn; Capt. (actmg Maj.) T. J. Uallinan; Temp;
Maj. F. N. II drlen ; Temp. Capt. A. H. H. Howard ; T^mp. Capt. A R.
Jen lngs; Temp Capt. E Kidd; Capt. C. J H. lUt'e; Capt. (temp.
Maj.) A. G. J. Macllwalnn, C.I.E.; Temp. Capt. O. G. Mtckav ; Temp.
Cbp'-. G. d. Marshall; Capt. and Bt. Maj. W. McNaugh on; Lt. W.
McWUllam; Temp. Capt. W. M. Mei.zb-s; CKpt. J. P. Mitchell; 0*pt.
J. J. Molyneaux; Capt. J. M. Morrison; Lt.-Col. (temp -Col.) H tf.
Morton, D.S.O.; Capt. W. H. 0’R<>»rdsn. M.C.; Capt. O. J. Penny;
Temp. Capt. H. H. Haw; Capt. H G. Robertson; Cajt C. O.
Shackleton; Temp Cap'. W, A. Sbaftn; Capt A. Shepherd ;Temp.
Capt. W. J. D. Smyth ; Temp. Cant. B H. Udall; Capt. J *. Weddell;
Capt. K. J. T. Wilson; Oa M t. J. H. Wiseman ; Capt. P. A. W>th; Map
T. J. Wright, D.S.O.; capt. R; H. Yoiland ; Capt. J. R. Yourell.
438 The Lancwt,]
OBITUARY OF THE WAR.
[March 15,1919
Indian Medical Service.— Capt. H. W. Acton; Temp. Capt. P. B.
Ambler; Maj. (temp. Lt.-Col.) W. M. Anderson ; Lt. B. C. Ashton;
Lt.-Col. W. K. Battye, D.S.O.; Lt.-Col. P. P. Chapman; Capt. B.
Cotter; Capt. A. M. Dick; Lt.-Col. A. Fenton; Lt.-Col. F. W. Gee.
C.I.B.; Temp. Capt. E. A. M. J. Goldie; Maj. and Bt. Lt.-Col. C. M.
Goodbody. C.I.K., D.S.O. : Maj. and Bt. Lt.-Col. J. D. Graham; Mai.
and Bt. Lt.-Col. W. H. Hamilton, D.S.O.; Lt.-Col. W. Lethbridge;
Capt. R. B. Lloyd ; Maj. F. P. Mackle; Lt.-Col. H. G. Melville, C.I.B.;
Maj. J. Morlson ; Temp. Capt. S. B. Muker jee; Capt. J. J. H. Nelson,
M.U.; Capt. C. M. Plumptre; Maj. E. A. Roberts, D.S.O. ; Mai. (temp.
Lt. Col.) C. A. Sprawson ; Maj. J. Taylor, D.S.O.
Indian Medical Department .—2nd Cl. Asst. Surg. W. R. Bennett;
1st Cl. Asst. Surg. G. W. Cearns ; 2nd Cl. Asst. Surg. M. G. Coombes;
1st Cl. Asst. Surg. A. W. Dyer; 2nd Cl. Asst. Surg. E. S. Feegrade;
1st Cl. Asst. Surg. H. J. J. Garrod; 2nd Cl. Asst. Surg. A. W. Ha/Ie ;
4th Cl. AsBt. Surg. G. D. Rodrigues; 4th Cl. Asst. Surg. W. J. Rowe.
In a despatch received from the Vice-Admiral, Dover
Patrol, dealing with the operations at Zeebrugge and Ostend,
in April and May last year, the medical arrangements are
referred to in the following terms
I desire to make a special reference to the praiseworthy manner in
which the medical officers and their staff, and volunteer helpers,
devoted their skill and sympathy to those who were wounded in these
operations. Fighting at such close quarters, the casualties were bound
to be numerous, and the wounds likely to be severe. Staff Surgeon
James McCutcheon. M.B., was the senior medical officer of the force.
In an able report that officer outlines the work of his staff and the
circumstanoes in which it was done, and I trust that the Lords Com¬
missioners will agree with me in thinking that no branch of the naval
service surpassed In zeal and ability the efforts of the medical branch
to prove itself worthy of its profession, and of the occasion. I have
selected with difficulty from a number of very deserving officers the
names of three to be representative recipients of such promotion as
their Lordships may be able to award for these operations to the
medical branch of the Royal Navy.
Civil Medical Practitioners’ War Services.
Under date March 4th the War Office has issued the
following list of civil medical practitioners whose names
have been brought to the notice of the Secretary of State for
War for valuable medical services rendered in the United
Kingdom in connexion with the war
J.McK Ackland; G. Alexander; C. W. Alford; C. M. Anderson;
W. D. Anderson; W. M. A. Anderson; J. F. Atkins; S. ,B. Atkins-
J. P. Atkinson. ’
W. Baigent; W. E. Baker; G. F. Barnes; W. R. Bstes; R. A. Bennett •
P. H. Benson; H. Bentley; H. W. Bethell; J. Black-Mllne- R H
Blaikie; J.F. Blood; C. Bolton; V. Bonney; H. Bott; RO Bowman ^
;ury; F. Brightman; T. B. Broadway; E. H. Brock-
i.Bryson ; H. M. Bundey ; W. F. R. Burgess; M. Burnet
H. B. Butler; W. B. Butler.
ell; J. E. G. Calverley; W. K. Cant; J. W. Carr-
l \ G ’,F a l!’ er . : J * W - Caton = B- Cautley; W. L. Chubb;
i I. M. Clarke; J. J. Clarke ; T. W. Clay; P. P. Cole ;
J- 0.0. Bradbury; F. Brightman; T. B.' Broadway ;"e7 if ° Brock •
T. H. Brown ; M. Bryson ; H. M. Bundey; W. F. R. Burgess; M. Burnet
A. C. Burrows; H. B. Butler; W. B. Butler.
G. Y. Caldwell; J
A. J. Carter; B
J. Chute; Miss
L. Cole-Baker; D. W. Colllngs; E. G. Colville; C. T. T. Comber j
C. J. Cooke; J. G. Cooke; H. P. Cos'obadle; E. A. R. Covev- G
Cran ; E. P. Cumberbatch ; C. Curd; F. C. Curtis. y ’
H. G. Dain; J. D. Davies; H. C. Dent; L. G. Dinon; L. C. T.
Dobson; J. A. Drake; C. E. Drennan; D. Drummond; R H W
Dunderdale ; M. A. Dutch.
_, H - F o B ^ an m ; » Al M S 114 ^ W * F ' Hr8kln e: W. J. Essery; C. J.
Evers; R. W. T. Ewart; H. L. Ewens; E. H. Ezard.
G. Faria; K. Farr; F. Fawssett; G. VV. B. Featherstone; R. A.
Fegan ; E. C. Fenoulhet; A. C. Ferguson; W. A. Fogertv- S C .
Fowier; T. W. Fowler; A. D. Fraser; A. M. Fraser; L. Fraser; A. L. 1
Fuller; P. Pumlval). '
M. H. Gardiner; A. T. B. Gavin ; Miss G. Gazdar; H W Cell • W D
Glmson; B. Glendining; L. G. Glover; H. J. Godwin ; R. M. Going!
T. ▲. Goodfellow ; W. A. Gordon ; T. P. Goatling ; R. Grant; Miss K
Gray; H. T. Grav; G. R. Green ; E. C. Greenwood ; G. Grindlay; R. m!
Grogono; C. N. Groves; G. Gunn; L. G. Guthrie y
G R. HaHand; H. Head; J.W. Heekes; W. Hern; H. T. Herring;
Q.H. J H & : B 8.B.HuUr er: ^ ^ H1CkU!y: D - W H0Od:
J. Ingram ; W. S. Inman.
A. Jackson; P. S. Jaklns; J. R. Jeffrey; R. C. Jewesbury R G
Johnson; G.J. Johnston ; G. Jonckheere (Louvain); S. B. Jones - J f’
Jordan; N. H. Joy. ’
K^M^^.V/Knox 1 ' 6 "" 6 ^ 1 J C ' K ‘ nR; T - S - K ’ rk; Mi " *•
F. Lace; J. H. W Laing; G. J. lane; F. C. Langford; C. P
Lank eater ; J. B. Law ford ; P C W. Laws ; A. Lawson; C F. Le Sage;
E. B. Lewis; P. G. Lewis; J. E Linnell; F. S. Lloyd; J. D. Lloyd •
T. E. Lloyd; G. H. Lock; J. P. Lockhart-Mummery; H. L. Lowis-
A. Lyndon; E. Lynn. * ’
R - Macdonald ; J. Macdonald; H. J. Macevoy; G. MacGill-
2l5' B w M £° e £ d : ?• *■ ““:H. Marshall; F. E. Maraton: w'
Ni£i«l. G ' P ‘ Ne " bolt; W Nor bury ; A .Si. NormingtlmS W. W.
B. J. P. Olive; W. W. Ord ; D. R. Oswald.
T. B. Pallett; F. S. Palmer; J. I. Palmer; T. W. Parkinson; A R
Parsons; A. G. Paterson; B. le F. Payne; H. G. Pennell- B V
Perry; J.P. Philip; T. B. Poole; J. F. Porter ; J. C. Potter - R. h!
Pcmers; G. L. Proton; W. A. Pride; B. L. Pritchard; B. G. Pnllin.
' H W Ba °2 #1 V E t V ZJ P Rcndan • J Richardson ; G. A.
A?I?P'Russell A ^ L C Robson; J. D. Robson; W. Roughton;
Sti: i“’i ! &j-.
BAST W- H- Shenton; dTa. ; S J* d!
Sinclair; J. A. Small ; C. W. Smeeton; G. Smith; J. A. Smith; Sir
7's B 'c H Vk mith A B S rt o ; J * C * 8m 5 rth ! B - V. Solly; T. F. Southaib ;
J. A. Southern; G. B. Sparrow; H. J. Spon; E. Stainer ; L. K. Stamm;
n w 8 m? n n5 e,d; B-de« Stawell; O. T. Stephenson ; G. St. George
U. W. M. atrover ; A. J. Swallow.
«r F 'J' S? lbofc : c - Taunton ; A. Tennyson-Smitb; G. C. Thomas;
W E. Thomas; W. T. Thomas; A. Thompson; C. Thompson; J.
Thomson; M. Thomson; N. F. Tieeburst; S. A. Tidey; H. T. M.
Townsend-Whitling; R. H. Trotter; A. J. Troughton ; R. Turner.
T? Q ^ B 'n W wK Wr f Kht ^ K o A „ Walfcer: A - H - Warde; W. Washbourn,
S' i e S S?® eler * Whitcombe; C. P. White; E. K. White;
wu?i' M ' 5f h T te W^,',. Wightwick; L - E - Wigram; S. M. Wilcox; B.
Wilkins; D.J. WiHiams; H. C. Williams; J. A. Wilson; M. S.
Wilson; G. M. Winter; G. V. Worthington; R. B. Wright. D. T.
ii. C. Young; J. C. Young.
OBITUARY OF THE WAR.
SAMUEL COWELL PHILSON. L.R.C.P. Eimn.,
M.R.C.S. Eng., C. I.E.,
COLONEL, ARMY MEDICAL SERVICE.
Colonel S. C. Philson, who died of pneumonia following
influenza on Nov. 4th, 1918, at the age of 58 years, was son
of the late Dr. William Philson, of Cheltenham. He pursued
his medical studies at King’s College, London, and at
Edinburgh, graduating in 1883, and taking the M.B. degree
in 1884, and joined the Army Medical Service—afterwards
the Royal Army Medical Corps—in 1885. He took part in
the Burmese and Chin Hills expeditions of 1889 and 1890.
for which he received the Frontier medal and three clasps.
In 1897 he was promoted to the rank of major, and was
stationed at the Base Hospital, Rawal Pindi, during the
Tirah campaign. In 1900 he accompanied the Earl of
Hopetoun—afterwards Marquis of Linlithgow—to Australia,
and remained on His Excellency’s staff during Lord
Hopetoun’s tenure of the Governor-Generalship. In 1902
he was placed in medical charge of the special camp at the
Alexandra Palace for Colonial troops who came to England
to represent the over¬
seas dominions at the
late King’s Coronation,
and for this he received
the King Edward
Coronation medal. In
1905 he was promoted
lieutenant-colonel, and
in 1911, being again
stationed in India, he
was awarded the Coro¬
nation Durbar medal.
He was promoted full
colonel in 1915 and in
August, 1916, was ap¬
pointed Assistant
Director Medical Ser¬
vices, Karachi Brigade,
to reorganise the medi¬
cal arrangements there
after the “troop train
tragedy.’ 1 His success¬
ful work during the past two years has just been recog¬
nised by the award of the C.I.E., but the publication of
this honour came too late for him to know of it before his
death. A friend writes in the Pioneer : “ ‘ Sammy ’ Philson
was a man of great administrative ability and was transferred
from Lucknow to Karachi shortly after the Sind train
disaster, since when he has been responsible for the whole
of the medical arrangements connected with the war base
at that port. In December, 1917, having reached the age
for retirement, he should have retired by the order of the
War Office, but at the request of the Commander-in-Chief (in
India) he agreed to remain at his post in Karachi until the
end of the war.”
Colonel Philson married in 1896 the second daughter of
Brigade Surgeon Lieutenant-Colonel J. H. Condon, I.M.S.,
who survives him. He leaves no children.
Lieutenant Frank P. Y. Huet, A.A.M.C. (Dental Services),
who died from the effects of broncho-pneumonia on Feb. 3rd
at No. 1 Australian General Hospital, Sutton Veny, was
educated at Sydney Grammar School, New South Wales,
and enlisted in the 1st Battalion A.I.F. Upon the demand
for an increase of dental unit6 in the A.A.M.C. Lieutenant
Hnet was transferred to the Dental Services and granted a
commission on March 1st.
The Lancet,]
THE POSITION OF THE DEMOBILISED PRACTITIONER
[March 15, 1919 439
WILLIAM PEARSON COWPER, L.R.C.P. »<c S. El>in.,
TEMPORARY SURGEON,H N.
Temporary Surgeon W. P. Cowper, R.N., who died on
Feb. 1st at the age of 38 years from illness contracted
nearly three years previously while serving on board H.M.S
Valiant , was second son of Mr. William Cowper of Hendon,
and formerly of Kirkwall. Educated at the Edinburgh
Academy he took the Scottish triple qualification in 1903,
_ after which he filled the
posts of house surgeon
x x to St. Mary’s Hospital,
/ Plaistow, house phy-
jpP ' M sician to the West End
/ 1 \ Hospital for Nervous
Diseases, house surgeon
and house physician to
the Hampstead General
\ Hospital, and house
3 urgeon and anaesthetist
t the Royal West-
I minster Ophthalmic
/ Hospital, where he was
\ A J k, / assistant surgeon at the
J time of his death. He
\ dflS5 fV V x had been in practice in
London as an ophthal-
Twv mic surgeon, but
the outbreak of war he
was at once granted a
commission as surgeon in the Royal Navy. He was first
appointed to the R.N. Barracks, Devonport, in 1915» to the
R N Hospital, Devonport, and later to the R.N. College,
Keyham ; in 1916 he joined H.M.S. Valiant. He was a keen
sportsman, and was for several seasons one of the forwards
of the 1st London Scottish Rugby team. In 1908 he played
for the Barbarian team, and in 1915 captained a Navy team
at Plymouth. Golf and fishing were also favourite pastimes,
the latter of which he had an opportunity of enjoying when
off duty during the time he served with the Grand Fleet at
Scapa. jqhn STANLEY COCKS, M.R.C.S., L.D.S.,
CAPTAIN, R.A.M.C.
Captain J. 3. Cooks, who died on Jan. 29th at Beyrout from
broncho-pneumonia following typhus, aged 29 years, was
voungest son of Mr. J. W. Cocks, of Torquay. Educated at
Mill Hill School and Guy’s Hospital, he took his L.D.S.
diploma in 1912, and on the outbreak of war offered himself
as a dental surgeon and was refused. He took his Final
Conjoint Examination in 1914 and joined the Special
Reserve. He was attached to the 9th Y ork and Lancashire
Regiment and remained with them until June, 1915, when
he proceeded to Alexandria and was attached to a hospital in
Cairo. Early in 1916 he joined the 7th Mounted Brigade Field
J Ambulance, which he
f accompanied to
Salonika. After about
18 months in Greece
and Macedonia the
Ambulance returned to
Egypt and was
disbanded, the trans¬
port being torpedoed
and sunk without loss of
life on the voyage from
Salonika to Alexandria.
Captain Cocks then
became attached to
the 3rd Lowlanders
Mounted Field Ambu¬
lance, and took part in
the operations around
Beersheba at the com¬
mencement of Allenby’s
drive into Palestine. At
this time his health gave
way and be was invalided back to the base, being in hospital
at Port Said for some weeks. After recovering he was
appointed to take charge of No. 1 Egyptian Detention Hos
pital, then at Gaza, but later at Jaffa and Beyrout. During
his illness he was removed to the American College Hospital,
where he was under the care of Dr. Graham until his death.
He was in the Near East for three years and seven months
wthout being granted any home leave.
Cflrresjjonbtiut.
“ Audi alteram part era."
THE POSITION OF THE DEMOBILISED
PRACTITIONER.
To the Editor of The Lancet.
Sir,— One of the conditions arising in the course of
demobilisation does not seem to have received sufficient
attention, that of the status and prospects of the medical
practitioners who have been serving abroad. In spite of the
efforts which have been made by the Committee of Reference
of the Royal College of Physicians and of the Royal College
of Surgeons, and of the Central Medical War Committee, to
make the best possible temporary arrangements to preserve
the interests of practitioners called to the service of the
country abroad, the future of many of these is precarious.
We know that those medical men who have been working
at home have generally behaved with the utmost fidelity
towards those who have been called away, but it is not upon
them alooe that the future depends. Public bodies, it is
hoped, will reinstate as far as possible to their former posts
the medical officers who before the war held appointments in
their service. It will be an important aid to the returning
men if their former patients will continue to call them in,
and it may be pointed out that the practitioners returning
from service with the Army will come home with an enlarged
experience and are likely to be of greater value than before
to the patients to whom they return. They have in most
cases been engaged in duties which have increased their
professional knowledge and skill.
We are, Sir, yours faithfully,
Norman Moore,
President of the Royal College of Physicians of London ;
G. H. Makins,
President of the Royal College of Surgeons of England.
March 11th, 1919. _
To the Editor of The Lancet.
Sir, —May we ask attention to one of the problems of
demobilisation which we think deserves sympathetic con¬
sideration from the general public? Many doctors who
throughout the war have held commissions in the Navy, the
Army, or the Air Force have now to face the question of
return to civil practice. This is for them far from an
easy matter. The natural growth of their practices has
ceased during their absence. In spite of loyal help given,
in most cases, by their colleagues—who deserve all thanks
for their ungrudging efforts—and by professional committees,
to hold together the practice in the interest of the absentee,
the normal wastage due to deaths, changes of residence,
Sc c., has had the effect of materially reducing the practice
from what it was in 1914. Beyond such unavoidable
influences there is risk of curtailment from other causes.
It is known to us that many of those who have been
absent with the Forces of the Crown view their future
with grave anxiety. In a profession like medicine, where
the work is essentially personal, the future of those men
evidently depends laigely on the attitude of the general
public. It is greatly to be hoped, therefore, that every
patient will feel it an honourable duty to return, whenever
possible, to his old doctor, and that public institutions will
re-instate, as far as they can, to their former positions those
medical officers who have sacrificed so much at the call of
the Empire —We are. Sir, yours faithfully,
R. W. Philip,
President of the Royal College of Physiolana of
Edinburgh ;
R. McKenzie Johnston,
President of the Royal College of Surgeons of
Edinburgh, March 11th, 1919. Edinburgh.
THE ASSOCIATION OF PANEL COMMITTEES
AND NOTIFICATION FEES.
To the Editor of The Lancet.
SIR,—I have to inform you that at their last meeting the
Executive Committee of the Association of Panel Committees
resolved :—
That the committee are of opinion that, in view of the fact that the
reduction n fees for the notification of notifiable diseases was to be
440 Thb Lancet,]
A PUBLIC DENTAL SERVICE.
[March 15,1918
regarded as a war measure, the fee for such notifications should be
res o*ed from 1«. to 2s.bd forthwith; and that the President of the
Local Government Board be so Informed.
The committee regret that medical men as a class should
be marked out for a decrease of remuneration in such times
as these. I am. Sir, yours faithfully, ,
B. A. Richmond,
Staple House, Chancery-lane, W.G., Secretary.
Maroh 10th. 1919.
A PUBLIC DENTAL SERVICE.
To the Editor of Thb Lanobt.
Sir,—I n your issue of March 8th you commented, in a
leading article dealing with the report of the Departmental
Committee on Dental Practice, on the proposal to establish
a Public Dental Service. Sect. XII., par. 135 of the
Departmental report runs as follows:—
"If it is accepted that it is the duty of the State to ensure,
in the national interest, that its citizens shall be maintained
in a state of good health and working efficiency, we have no
hesitation in stating that adequate arrangements for keeping
the teeth of the people in a sound condition are one of the
essentials to this end.”
. The report then proceeds to consider the matter under two
headings: (1) treatment for children; (2) treatment for
adults. With the former I do not propose to deal, but with
reference to the latter I would call your attention to an
article written by me, and published in Pnbdo Health of
April la't year; this was reprinted in the British Dental
-Journal in the following September, and has caused con¬
siderable interest and controversy, owing chiefly to the fact
that the appalling condition of the mouths of the masses of
the population was not appreciated by many of the corre¬
spondents, who mostly objected to the comparatively small
provision made for conservative dentistry and the emphasis
laid on the extraction of septio teeth, to furnish a clean
mouth, and the provision of dentures.
Now in this report it is expressly stated that—
“ Satisfactory conservative treatment of the teeth of the
present adult population is not possible owing to past
neglect; a large amount of dental work iB, however, needed
for extractions and the provision of dentures.”
The scheme drawn up by me was the result of considerable
experience as a command dental inspector in the Army, I
having been chiefly instrumental in bringing about the
reorganisation of the dental treatment in the service. This
was accomplished by taking the work out of the hands of the
civilian dentist, which was hot h unsatisfactory and expensive,
and undertaking all the work by whole-time Army < fficers.
The pivot of the scheme was a large central workshop for
the provision of dentures, and dental officers with clinics in
the camps and towns where troops were stationed, the
impressions and bites being taken in the clinic and sent
through the post to the central workshop and the finished
denture returned to the clinic. This method of centralising
mechanic work proved a great success so far as speed,
efficiency, and economy were concerned, and the workshop
in my command produced about 80.000 dentures in three
years, all of a very high character.
In my original article I gave, with permission of the* War
Department, my balance-sheet for two years' working,
showing that these dentures had been made at a workshop
cost of 7 1 6d. each, and in certain months this had been as
low as 5s 6d. t and I pointed out that with a larger turnover
this could be reproduced under civil control. I then pro¬
ceeded to sketch a Bcheme for a State service, showing bow,
if these were sold for 15s. each to the public, the surplus of
payments over ooet would be sufficient to run a servioe,
doing extractions and fillings free of charge, without going
to the Treasury for a grant. I purposely "sailed as near
the wind ” as possible, "keeping my figures and estimates
as low as 1 could, so as to arrest attention and cause con¬
troversy, and in this I succeed beyond expectation. As an
answer to criticisms one of my dental officers, Mr. Percy
Millican. and my*>elf recast my balance-sheet, and in an
article published under his name in the British Dental
Journal of Feb. 15r.h last, we have what I believe to be a
scheme, sound financially, stable, and one that would be
acceptable to the majority of the profession. This, with
certain extiacts from the paper, I append.
The following is an estimated prospectus for an area
dentally served by a series of clinics, under the safbe
inspectorate, with a central workshop Cipable of supplying
70,560 dentures for 42,336 patients, and completing 212,562
fillings per annum.
Receipts. £ i Expenditure. £
70,560 Dentures st 2 Inspectors, salary at £900 . 1,800
£1 10«. 105,840 Insurances for pension* and sickness 650
212 562 fillings | 20senior dentlstaat £600 . 12.000
without fee ... — j Insurances, bonus and sickness ... 2.000
50 junior dentists at £450 . 22.500
, Insurances, bonus, and sickness ... 4,000
< | * Mechanics' pay, bonuses, and insur*
, ance. 29.240
, Upkeep of surgeries . 6.000
I Upkeep of w orkshop .. 1,000
i Cost of materials .. 17.640
I Central administration. 2.000
Balanoe . 7.010
£105,8401 £105,840
* Mechanics' Pay, d*e.
Workshop superintendent, salary at £450, pension, and sick- £
ne-a insurance . 620
T*n foremen mechanics at £250, pensions, and insurance ... 4,430
60 A class mechanics at £200. insurance for bonuses. 14,560
40 B cla«s mechanics at £166, insurance for bonuses. 7,280
Sickness insurance f>»r A and B mechanics . 800
20 A class boys at £35 • 20 B class boys at £26; insurances for
bonus and sickness. 1,560
£29,240
The points to be borne in mind in reading this prospectus
are chiefly as follows:—
1. Each dentist works 33 hours a week, there being
49 weeks to the working year.
2. Each dentist doing conservative work only is able to
average three fillings an honr.
3. The average time taken to prepare a mouth for dentures
(fillings excepted) is one hour per patient.
4. A foreman mechanic assisted by ten mechanics and
four boys can complete 144 dentures a week.
5. The average ratio of " prosthetic" patients to dentures
is as 3 : 5 (some patients needing two).
6. The inspectors, workshop superintendent, and foremen
mechanics would be life servants of the Service, retiring on
a pension after 25 years' servioe, whereas the dentists and
junior mechanics would contract for a limited period and
receive a bonus on retirement, or the option of filling
vacancies on the permanent staff.
If such a scheme were adopted under State guarantees
we oould in a limited number of years give clean mouths to
the people, with the improvement in health and efficiency
which your readers will appreciate, at the minimum cost to
an overburdened Treasury. Its educating influence with the
masses would be enormous, the improved professional out¬
look would attract the right class of student, the unqualified
(to be taken on the Register) would work under a scientific
inspectorate, to the advantage both to themselves and their
patients, and, above all, the very elasticity of the scheme
would allow a universal service to be built up which could,
in the future, take over the necessarily increased con¬
servative treatment for a dentally educated public, which,
when dentures on this enormous scale were no longer
needed, could be financed out of the insurance benefit by a
very small additional contribution which the beneficiaries
would, by then, be willing to pay.
I am, Sir. yours faithfully,
F. W. Brodbrick, M.R.G.S., L.R.C.P., L.D 8. Eng..
Bournemouth, Maroh 9th, 1919. Major, B.A.M.C
TRIMETHENAL-ALLYL-CARBIDE IN
INFLUENZA.
To the Editor of Thb Lanobt.
Sir,—M y attention was drawn to trimethenal-allyl-oarbide,
which is manufactured by Clement and Johnson, chemists,
13. Sicilian-avenue, London, and I was struck by their
announcement that no complications occurred in influents
if this remedy were used early enough. So with a perfectly
open mind I sent for half a gallon and began the treatment
of all influenzas occurring amongst my staff at the Borough
Sanatorium for Infectious Diseases and in those admitted as
patients to that institution. My experience has been very
limited, but I can certainly say that where the remedy was
given daring the first day or two of the disease there were
no complications, and all made very satisfactory recovery.
In such a terrible visitation as we had at that time (October
to December, 1918)1 felt glad to try a remedy that would act
The Lancet,] ESSENTIAL PRINCIPLES OF 8UC0E88FUL MEDICAL ADMINISTRATION. [March 15, 1919 441
as a prophylactic or curative agent in the disease. I wrote
to Messrs. Clement and Johnson asking them if they would
give me the names of any medical men who had used the
drug. They did do so, and I wrote them with the enclosed
questionnaire. They all answered these questions with the
exception of one medical man who, you will remember,
had a letter in Thb Lancet a good many weeks
ago on the same subject. Those who replied in nearly
every case sent me very full information as to what they
had done. I have made extracts from all these replies
and I am sending them to you, hoping that you will be
good enough to insert them in The Lancet at an early
date, and I shall be glad if you would ask that any
other medical men who have used “yadil” in influenza
would give their experience. It is only by a method of
this kind that we can arrive at the truth as to the effioacy of
the drug when given in influenza.
I am, Sir, yours faithfully.
Town Hall, Sunderland, Peb. 20th, 1919. H. RENNET.
%* Dr. Renney sends us extracts of letters which he has
received from 10 doctors who have been using yadil, and
who have answered the questions which he sent to them.
The general conclusions may be summarised somewhat as
follows:—
1. In about how many cases of influenza have you used " yadil ” f—
Information hta been received from doctors of 1623 cases of Influenza
which have been treated by yadil.
2. What was the dose given to adults , and how often f —The dosage
varied between 15 minim* and half an ounce. The majority preferred
to give 31 every three hours or three times a day. One observer gives
■115 to 30 every four hours, and considers that larger doses are of no
additional value; another gives 31 three times a day to 5£ every four
hours or three times daily, well diluted, and says that he has never had
any signs of overdose. In some cases the medicine is ordered to be
£ ven before food, in others, either immediately before or afterwards,
others, no definite time for administration is given.
3. In how many of the*e cases was treatment by “ yadil" commenced
an the first or second day of the disease f From two doctors no intorma*
tlon was given on this point. In about 915 casea yadil was given during
the fir st or second day of the disease.
4. Were there any complications in cases treoted early by “ yadil" 1 -
Of the 915 cases which were treated early by yadil six developed com¬
plications. Of those, four were cases ot slight bronchitis, one waa a
delicate woman with heart disease in whom pneumonia supervened,
and the sixth was that of a man who went out of doors against orders.
5. If so, what other remedy was given for the pneumonia f Creosote,
■either with or without pot. iod f Parke Davis’s pneumonia phylacogen f
Influenza vaccine ( Pfeiffer's bacillus, pneumococcus, streptococcus) f—
One doctor says: -‘In cases met too late garlic plus pot. iod. and
•dlgalen were given for pneumonia.”
6. In your cases of influenzal pneumonia how many recoveries had you
under "yadil” treatment Only three doctors give information on
this point. One had four cases of pneumonia, three of which recovered.
In the fatal case yadil was not given regularly. Another reports 18 cases
of influenzal pneumonia, all of which recovered. Only one had
the drag before becoming desperately ill. Most of these cases were
very inadequately nursed ; many could not obtain the necessary mlik,
ana many could not have the necessary fresh air. Another bad two
cases of pneumonia in his own family. Yadil was not commenced
until several days had elapsed. Both recovered.
7. Any other information “ A combination of aqua menth. pip. and
aqua chlorof. masks the odour ot yadil.” ** In three oases yadil h*d to
he discontinued, as it seemed to produce bowel irritation. He generally
used yadil In combination with sod® sal.” Ed. L.
THE ESSENTIAL PRINCIPLES OF SUCCESSFUL
MEDICAL ADMINISTRATION.
To the Editor of The Lancet.
Sir,— Whilst it may be well at all times to keep in view
the duties of the medical profession—the members of
which are probably more loyal to dnty than are hnman
beings engaged in any other pursuit—would it not be better
-at this juncture to insist a little more upon the peculiar and
vital rights of “ the profession ” itself ? To me the constant
repetition of “the duties” of the medical profession, and
the apologies which seem to follow any mention of its own
rights, smacks of hypocrisy. We, the present generation of
medical men, must realise that we are the trustees of a noble
function ; and that upon ns, who alone know this function,
•devolves, as surely as does the care of the stricken, the duty
of ensuring, as far as lies within our power, that the con¬
ditions under which, and the men by whom this function
in future will be exercised, shall not be such as will menace
the efficient performance of it.
Dr: W. Gordon in your issue of March 1st has enunciated
41 four points ” which are vital. With singular precision and
breadth of view he has outlined the essential'first principles
of medical professional efficiency. Let any one of these be
abused in practice, and sooner or later the function of the
profession will be impaired. If we do not demand of the
candidates for medical licence high standards of general
education, and for those who obtain it the same emoluments
and freedom which are enjoyed by men of ability, character,
integrity, and education in other fields of endeavour, the
status of the profession will certainly fall, and it will cease
to attract to it the only class of men to whom should be
entrusted its sacred functions. The results to humanity it is
needless to elaborate.
Surely our d#ty is clear. If impending or future legisla¬
tion is calculated to produce these results we must be in a
position to guide and re-direct it. For this purpose con¬
certed action of the present members of the profession is
imperative. If we cannot prevail upon the people’s Parlia¬
mentary representatives to safeguard what is at once the
interest of medicine and of the people, we must have an
effective organisation of our own. If only a trade union is
effective in these socialistic days, then it must be considered.
We must insist upon the rights of the profession as much
as upon its duties, for if the first are ignored, the latter
will cease to be fulfilled. We must not fear the charges
of self-interest which may be levelled at us. There
are truly occasions on which apparent egoism is in reality
altruism. The rescuer is not egoistic when he beats into
insensibility the clutching drowning man whom he would
save. The would-be husband is not egoistic when he insists
that his intended wife, whose future he desires to be happy,
must be one who loves him dearly. In such instances
apparent egoism is in reality the essential fonndation of
benevolent altruism. So is it at this juncture with our pro¬
fession. We must insist that it be not hampered or harmed
by the ill-directed acts of those whom it is verily its religion
to save. We must see to it that no legislation be effected
which will render the life or working conditions of the
medical man such that medicine will cease to attract to it
men of that high integrity, character, education, and
honour to whom alone the inexorable “laws of necessity”
require that the functions of an exalted and sacred
calling must ever be entrusted.
I am, Sir, yours faithfully,
Milford, Surrey, March 3rd, 1919. W. J. GRANT, M.D., &0.
DISLOCATION OF TEETH.
To the Editor of The Lancet.
Sib,—W ith reference to the two oases of dislocation of
teeth reported in The Lancet of March 1st by Dr. H. M.
Savery the following case will perhaps prove of interest.
Corporal I. fell whilst lifting an aeroplane engine and
struck his face against a projecting part. He sustained a
cut tongue and one of his upper central incisors was knocked
out. He reported to me immediately, bringing the tooth
with him, and as it looked quite clean I at once simply
replaced it, exerting firm pressure. After suturing the
tongue and arranging for him to have milk diet for some
days I sent him back to work. This took place in
September last, and npon examining him to-day prior to his
demobilisation I found the tooth quite firm, and he informed
me that for months past he has been able to bite with it in
the ordinary way and without pain or discomfort. I find,
however, he has had two “ gumboils ” since the accident.
These have left no trace, and at the present time there is no
sign of inflammation, and the man is quite satisfied with
the result. I may add that his upper incisors are very large
and prominent.—I am. Sir, yours faithfully,
Walter H. Anderson,
K.A.F., Shoreham-by-Sea, March 3rd, 1919. Captain, R.A.F.M.S.
Royal Devon and Exeter Hospital.— The annual
meeting of the friends of this institution was recently held.
The committee has decided to erect a new wing to the
hospital, primarily for the reception and treatment of dis¬
charged soldiers and sailors, and secondarily to provide
additional accommodation for young children, <&o. An
appeal will shortly be made to the residents for £29,000 lor
the purpose of carrying out the scheme.
While it is now becoming quite common for
women to secure seats on the governing authorities, the
election of Dr. Florence Erin Smedley to the Worthing
town council on March 4th provides the first instance in the
county of Sussex of a woman doctor becoming a town
councillor. Mrs. Smedley has for some time been acting
medical officer of health for West Sussex, also school medical
officer. She took her degrees in London in 1905, and waa
at one time surgeon at the Children’s Hospital, Sheffield.
442 Thu Lancet,]
PARLIAMENTARY INTELLIGENCE.
[March 15, 1919
jjarliamtntarg Intelligence.
NOTES ON CURRENT TOPICS.
Ministry of Health Bill . %
It was not found possible to commence the Committee
stage of the Ministry of Health Bill on Tuesd^, Maroh 11th,
as originally contemplated.
HOUSE OF COMMONS.
Wednesday, March 5th.
Women Medical Officers in Military Hospitals.
Mr. Acland asked the Secretary for War whether he had
considered the disabilities suffered by women medical
officers employed in military hospitals owing to their not
being allowed, under the Army Act, to hold Army rank;
and whether he would have this legal disability removed in
view of the pledge in the Government’s election manifesto to
remove all existing inequalities in the law as between men
and women.—Mr. Churchill replied : I am not aware that
women doctors employed in military hospitals suffer dis¬
abilities on this account. A large number of civil medical
practitioners are employed full time in such hospitals
under exactly similar conditions. As regards the latter
part of the question, it is not proposed to introduce legisla¬
tion on this point during the present session.
Physicians' and Surgeons' Voluntary War Service.
Replying to Viscount Wolmer, Mr. Churchill stated that
be regretted that he could not publish a list of physioians
and surgeons who had given voluntary service at military
and auxiliary hospitals during the war and the periods for
which they had given their services, as there was no list of
the kind available.
Thursday, March 6th.
Lunatic Asylum Discharges.
Captain Tudor-Rees asked the Pensions Minister whether
it was in conformity with bis instructions for parish doctors
to certify a discharged soldier or sailor for a lunatic asylum ;
and, if so, whether he would abolish this practice, which
attached a taint of pauperism to the patient, and would
order that before a discharged man was removed to an
asylum he should be certified by a medical board of not
less than three members.—Sir L. Worthington-Evans
answered: The Lunacy Acts require a certification to be
made by registered medical practitioners; the medical
practitioner m&y happen also to be the parish dootor, but
it would only be as registered medical practitioner and not
as parish doctor that bis services would be required. I
am sending my honourable and gallant friend a copy of a
circular issued to local committees last year, in which the
procedure to be adopted for certification is explained.
Captain Tudor-Rees : Will the right honourable gentle¬
men promise to consider the proposal with regard to dis¬
charged men having to be certified by a board of not less
than three medical men?—Sir L. Worthington-Evans : If
the honourable gentleman will do me the honour of reading
the circular he will see that steps are taken to keep the
patient from all Poor-law taint.
Tuberculous and Shell Shock Cases.
Sir M. Barlow asked the Pensions Minister whether
any and, if so, what effective steps had been taken for the
general open-air treatment of tuberculous and shell shock
oases by means of farm colonies or otherwise ; whether he
had approached the Board of Agriculture in the matter;
and, if not, whether he would consider, with the Board of
Agriculture, the appointment of a small interdepartmental
committee, with an outside chairman, to consider the whole
matter.—Sir L. Worthington-Evans answered: I am
making arrangements for the treatment of shell shock
cases on the lines suggested. At the present disabled
soldiers suffering from shell shock are admitted to military
neurological hospitals, where in nearly every case land is
available and is utilised for this treatment. With regard to
tuberculosis, I am taking steps in conjunction with the
President of the Local Government Boara to appoint such a
committee as my honourable friend suggests. All the
Government Departments concerned are being taken into
consultation.
Monday, March 10th.
Grants for Medical Referees.
Mr. Joseph Johnstone asked the Secretary to the Looal
Government Board whether be was now prepared to
reoommend to the Treasuiy that the supplementary
giants approved of by Parliament in August, 1914, for
medical referee, consultants, &c., supplementary medical
services, and nursing grants, should now be paid; and
whether he would be prepared to consult with the repre¬
sentatives from societies and Insurance Committees as to
the administration of these special grants.—Major ASTOR
(Parliamentary Secretary to the Local Government Board)
replied: Preliminary conferences are at the present time
taking place between representatives of the medioal pro¬
fession and the Commissioners preparatory to a general
review of the medical services for insured persons includ¬
ing questions of possible extensions. When the results of
these conferences are available and of further conferences
on the same subject with representatives of Approved
Societies and Insurance Committees, I hope to be in a
position to consider what action can best be taken ia
regard to special grants of the kind referred to in the
question.
Salaries of Irish Poor-law Medical Officers.
Sir William Whitla asked the Chief Secretary to the
Lord Lieutenant of Ireland whether his attention had been
called to the conditions of service and the absence of a
uniform graded scale of payment to Poor-law medical officers
in Ireland; and whether he proposed to take any steps to
improve their conditions of service with a view of provisivu
being made therefor in the Ministry of Health legislation.—
Mr. Macpherson answered : The Local Government Board
have urged all the boards of guardians throughout Ireland to
make graded scales of payment to the Poor-law medical
officers, with the result that 143 boards out of a total of 154
have granted improved remuneration to their medical
officers. There are only 11 boards of guardians which have
not improved the salaries of their medical officers, and these
are again being urged to adopt graded scales of salary. With
regard to the latter part of the question it will reoeive my
consideration.
Ministry of Health for Ireland .
Mr. Devlin asked the Chief Secretary to the Lord Lieu¬
tenant of Ireland whether he had received a resolution
from the National Association of Insurance Committees In
Ireland, representative of 900,000 industrial workers,
demanding the establishment of a separate Ministry of
Health for Ireland; and whether, in view of this and other
recommendations from similar representative bodies
throughout the country, he would consider the advisability
of carrying out the suggestion contained in the resolution.—
Mr. Macpherson replied: The resolution referred to has
been received. The Government was strongly urged by
very important sections of the medical profession in Ireland
and by Irish representative societies and bodies interested
in health matters to extend the provisions of the present
Bill to Ireland, and having regard to such representations
agreed to do so.
Whisky for Medical Purposes.
Replying to Captain Sir B. Stanier, Mr. McCurdy (Parlia¬
mentary Secretary to the Ministry of Food) stated that the
Food Controller was satisfied that the release of an additional
50 per cent, of Spirit recently sanctioned was resulting in*
very material inorease in the quantities available for the
general public; and that it should be normally possible for
spirits to be purchased, at any rate in small quantities, when
required for medical purposes.
Qualification of Apothecaries' Assistants.
Sir James Agg-Gardnek asked the Home Secretary
whether be could now state what action, if any, had been
taken under Section 4 (b) of the Poisons and Pharmacy Aot,
1908, to enable certified assistants to apothecaries to be regis¬
tered as pharmaceutical chemists or chemists and druggists.
—Mr. Shortt (Home Secretary) replied: This matter is now
under the close consideration of the Pharmaceutical Society,
and it is hoped that before long a by-law in the seose indi¬
cated will be submitted for the approval of the Privy
Council.
Influenza and Cholera in Bombay.
Mr. Bennett asked the Secretary for India whether he
would give the latest information that had reached him as
to the recent epidemics of influenza and cholera in the oity
of Bombay, together with the number of deaths from cholera
in that city, and the total number of deaths from influenza
in India in 1918 and the present year.—Mr. Fisher ^on
behalf of Mr. Montagu) answered: The Secretary of State
has received the following telegram from the Government
of India: The first influenza epidemic in Bombay city was
in June last, and was responsible for over 1600 deaths;
subsequent virulent outbreaks occurred in September,
October, and early in November, during which period the
mortality in Bombay city exceeded the normal by 14,676.
Besides bacteriological investigation, relief measures con¬
sisted of treatment in hospitals, house-to-house visitation,
free supply of milk and woollen jackets to prevent pneu¬
monia, opening of roadside dispensaries in several wards,
and supply of free medicine. Cholera appeared in epidemic
form during the second week of December and continued
till the third week of February. The disease was mainly
confined to mill districts, and recent strikes not only
aggravated it but prolonged its duration. Deaths reported
Thb Lancet,]
PARLIAMENTARY INTELLIGENCE.—MEDICAL NEWS.
[March 15,1919 443
in Bombay city from cholera during the period number
9589. In view of the scarcity prevailing in neighbouring
districts steps were taken to segregate immigrant labour in
special camps, Ac. Deaths from influenza in India as a
whole in 1918 are calculated at 5,000,000 for British India,
and 1,000,060 for Indian States.
Oatmeal and Influenza.
Mr. Sturrock asked the Food Controller whether he was
aware that widespread dissatisfaction existed in Scotland
over the price of oatmeal, still the staple food of the great
bulk of the people; whether it was the case that oatmeal
costs at least 50 per cent, more than flour; whether the
health-giving properties of oatmeal were such that with the
present danger of the influenza epidemic it was urgently
desirable that the price of oatmeal should be brought down
to a better standard; and whether he could promise early
aotion in this matter.—Mr. McCurdt replied : It is the case
that at the present time the price of oatmeal is greater by
approximately 50 per cent, than that of flour, and I hope
that it will be possible to make an early announcement of a
reduction of price. lam not, however, aware of the wide¬
spread dissatisfaction to which the honourable Member refers.
The Opium Convention of 1912.
Sir J. Agg-Gardner asked the Prime Minister whether he
would state what action bad been taken, or was in oontem-
elation, with a view to bringing before the Peaoe Conference
the need for international cooperation in putting into force
the articles of the Opium Convention of 1912 for the control
of the production and distribution of cocaine, morphine,
heroin, opium, and other drugs of addiction.—Mr. Harms-
worth (Under Secretary for Foreign Affairs) answered : His
Majesty's Government hope to be aole to bring this question
before the Conference with a view to the adoption of a reso¬
lution binding the Powers represented at the Conference to
the speedy enactment and enforcement of the laws, regula¬
tions, and measures contemplated by the Opium Convention
*£1912 for the purpose of confining to medical and legitimate
purposes the manufacture, sale, and use of opium, morphine,
cocaine, and similar noxious and habit-forming drags, such
a resolution to be made binding on the enemy Powers.
Tuesday, March 11th.
Demobilisation of Doctors and Nurses.
Mr. Leonard Lyle asked the Secretary for War whether, in
view of the fact that there were still 9593 doctors and 20,141
nurses in the Army, he would arrange for at least 500 of the
former and 2000 of the latter to be granted immediately
indefinite leave pending formal demobilisation, so that their
services might be utilised in coping with the serious amount
of’illness amongst the civil population.—Captain Guest (on
behalf of Mr. Churchill) answered: As my right honourable
friend explained to the honourable Member a week ago,
every endeavour is being made to release as many doctors
and nurses as can be spared. It is considered that if the
proposal to give leave to doctors and nurses pending demobi¬
lisation were concurred in, it wonld seriously interfere with
the steps that have been taken to release all those whose
services can be spared. The latest retnrns available give
the total number of trained aud untrained nurses demobilised
as 7441 sinoe the armistice, and steps have been taken to
demobilise large numbers of medical officers. This has
now become possible owing to the removal of certain
restrictions which delayed demobilisation.
Institutions for Mental Defectives.
Sir Kingsley Wood asked the Home Secretary whether
he would state how many institutions had been established
under Section 35 of the Mental Deficiency Act for defectives
of dangerous and violent propensities, and the number that
were available to-day for such cases.—Mr. 8hortt (Home
Secretary) replied: Three such institutions have been pro¬
vided by the Board of Control. The first at Farmfleld is
intended for females only and is fully available. The second
at Warwick is available for females only, but males will also
be received there as soon as staff and houses can be pro¬
vided. The third at Moss Side is at present in the occupa¬
tion of the War Office, but the Board of Control hope that it
will be available in a few month* for the reception both of
male and female patients.
Death of Dr. C. H. Wise.— Charles Henry Wise,
M.D. Irel., L.R.C.P., M.R.C-S., L.S.A., J.P., died recently at
Launceston, Cornwall, in his sixty-fifth year. The deceased
was the eldest son of the late Mr. C. P. Wise, architect, of
Launceston. He practised at Walthamstow, London, for
many years, he held many publio appointments, was deputy
coroner for one of the Essex districts, a barrister-at-law, and
a justice of the peace for Essex. He took a great interest in
public affairs at Walthamstow, and was formerly a mayor
lot the borough. His health broke down some few years ago,
and since then he has resided at Launceston.
Oxford Ophthalmological Congress. — The
congress will assemble at Keble College, Oxford, on the
evening of Wednesday, July 9th, and meetings will be held
on the following Thursday and Friday. A discussion on
Preventive Ophthalmology will be opened by Mr. J. Herbert
Parsons on Thursday. Friday will be given up to papers
and demonstrations of cases. The annual general meeting
will be held in the evening of July 10th. Members desirous
of taking part are invited to communicate with the honorary
secretary, Mr. Bernard Cridiand, at Salisbury House,
Wolverhampton.
Special Post-Graduate Course : London School
of Medicine for Women.— In conjunction with the Fellow¬
ship of Medicine the London (Royal Free Hospital) School
of Medicine iB arranging a special post-graduate course on
the Medicine and Surgery of the Liver and Gall bladder.
The lecturers are Dr. M. F. Lucas Keene, Dr. W. C. Cullis,
Mr. J. H. Gardner, Dr. F. Ransom, Dr. Douglas Firth, Mr,
Joseph Cunning, Mr. James Berry, Mr. Willmott Evans, and
Dr. M. Schofield, and practical demonstrations will be
included in the course. The first class will be given on
Monday, March 17th, at 10 a.m., at the Royal Free Hospital,
and the oonrse will continue over two weeks following at
the Hospital and at the Medical School, 8, Hun ter* street*
London, W.C. I. Further particulars from Miss L. M. Brooks,
warden and secretary, at the above address.
Royal Sussex County Hospital.— Speaking at
Hove, at the annual meeting of the Royal Sussex County
Hospital, on Feb. 27th, Mr. R. Ball Dodson, chairman of
the governors, announced that the cost per bed occupied
in 1918 reaohed £116; this was £22 per bed more taan
in 1917, while the cost in 1917 was itself £22 higher than
in 1913. The hospital was called upon to deal during
1918 with 173 fewer soldier and sailor cases than in the
previous year, but the institution’s war record stood at
nearly 3300 patients. The War Offloe, it was stated, had
just sanctioned demobilisation of 50 beds. The year 1918
ended free from debt, thanks to the marked success of the
emergency fund, for which an appeal was made by Bari
Brassev, president, and the trustees. The sum of
£10,554 10s. 1(M. was received, and thus the deficit at the
close of 1917 was liquidated. A permanent expenditure of
25 or 30 per cent, above pre-war figures is anticipated
in the future. On the subject of venereal diseases the
annual repQrt referred to the present arrangement for
the treatment as “temporary and provisional,” and Mr.
Dodson hoped the local authorities interested would con¬
sider the situation with a view to future provision
without delay. While the hospital did the correct thing in
founding the clinic, as it did at the request of the Local
Government Board in a time of crisis, Mr. Dodson said
it wonld be doing the wrong thing to continue the work
under present conditions for a longer period than was
necessary for the local authorities to make proper provision
for its inevitable development. In view of tfie ever-
increasing work he did not think the clinio should be
continued under present conditions for more than another
year. Personally, Mr. Dodson declared himself of the
opinion that there was very little prospect of these diseases
being stamped out until they were made notifiable.
Association of Public Vaccinators. —The
annnal meeting of this association was held on Feb. 14tb,
Mr. J. Foster Palmer, the President, in the chair. ■ The
President gave an address on “Our Foes: Psychical and
Physical.” Our psychical foes, of course, arose from the
strange psychological character of the German race. It
was held by certain of the Stoics that all who were driven
to any disastrous action through their vicious folly or blind
ignorance of known facts or sequences were insane. This
definition, as Horace points out, may include entire nations
as well as their rulers. Is it not possible that some psycho¬
logical processes similar tothat which exercised the minds
of the Stoics may have evolved in certain rulers and nations
during the nineteenth and twentieth centuries among the
areas of Western civilisation ? But we are face to face with
a far more formidable foe on the physical plane in the
influenza microbe which is now making such havoc in
many countries. The importance of special attention being
directed to this organism is evident on account of the well-
known fact that epidemics of influenza have usually been
followed by other epidemics of a more severe type. Is
this the result of microbic evolution, of a ohange of
type in the organism resulting in one of a more
severe and virulent character, or is it only that the
vitality of the victims of influenza has been so under¬
mined that they fall an easy prey to other forms of
444 The Lancet,]
URBAN VITAL STATISTICS.-THE SERVICES.
[March 15,1919
zymotic disease? The question is by no means a simple one,
as there appear to be two different, and apparently opposite,
conditions which favour attacks of influenza. One is a con¬
dition of reduced vitality from any depressing cause, and the
other is a prolonged freedom from microbic infeotion,
leading to loss of the immunity conferred by repeated slight
attacks of microbic disease—a condition known as auto-
inoculation and well recognised in the treatment of
tubercle. The microbic-free overseas contingents suffered
more severely and in greater proportion than those already
in the trenches. In addition to bacterial research, notifica¬
tion of influenza ought to be generally insisted on, supple¬
mented by a series of questions on the clinical aspect of cases,
which might serve to shed some further light both on the
prophylactic and curative treatment of the disease.
The annual court of governors of the Royal
Hospital for Diseases of the Chest, City-road, London, will
be held at the Mansion House on Tuesday, March 18th, at
3.30 p.m.
The fiftieth annual general meeting of the
governors of the Royal National Hospital for Consumption,
Ventnor, will be helaat33, Port lan dp lace, W., on Wednesday,
March 19th, at 3.30 p.m.
The fourteenth annual meeting of the Associa¬
tion for Promoting the Training and Supply of Midwives
will be held, by permission Of Mrs. Mackinnon, at
10, Hyde Park-gardens, W.,on Thursday next, March 20th,
at 3 p.m., when the chair will be taken by Her Royal Highness
Princess Christian.
Royal Institution.— Next Tuesday, March 18th>
at 3 o’clock. Professor A. Keith will deliver the first of a
course of four leotures at the Royal Institution on “ British
Ethnology—the People of Scotland.”
Royal Microscopical Society.— At the meeting
of the society to be held at 20, Hanover-square, London,
W. 1, on Wednesday, March 19th, at 8 p.m., Lieutenant-
Colonel Clibborn, O.I.E., will read a paper on “ A Standard
Microscope,” and opportunity will be provided for the
exhibition of new models and designs. The lecture-room
will be available from 7 p.m. for the display of such exhibits
by Fellows of the society, by manufacturers, and by others
wishing to take part.
URBAN VITAL STATISTICS.
(Week ended March 8th, 1919.)
English and Welsh Towns .—In the 96 Engllah and Welsh towns,
with an aggregate civil population estimated at 16,500,000 persona, the
annual rate of mortality, which had been 35’7 per 1000 in each of
the two preceding weeks, fell to 31*9 per 1000. In London, with a
population alightly exceeding 4,000,000 peraona, the annual death-rate
was 26'6, or 5'8 per 1000 below that recorded in the previous week;
among the remaining towns the rates ranged from 11*6 in Acton,
11*8 In Gillingham, and 12*6 in Edmonton, to 53*8 in Great Yarmouth,
54*5 in Wakefield, 58*3 in Bury, 60*7 In Blackburn, and 61*2 in
Salford. The principal epidemic diseases caused 189 deaths,
which corresponded to an annual rate of 0*6 per 1000, and
included 48 from measles, 43 each from whooptng-oough and
diphtheria, 38 from Infantile diarrhoea, 11 from scarlet fever, and
6 from enteric fever. Measles caused a death-rate of 1*6 In Sheffield,
3*1 in Middlesbrough, and 7*3 in Rotherham ; and diphtheria of 1*5 in
Tottenham. The deaths attributed to influenza, which had increased
from 224 to 3889 in the six preceding weeks, declined to 3218, and in¬
cluded 697 in London, 210 in Manchester, 149 in Liverpool, 134 in
Birmingham, 119 in 8alford, 106 In Bradford, and 96 in Leeds. There
were 6 cases of small-pox, 1062 of scarlet fever, and 1182 of diphtheria
under treatment In the Metropolitan Asylums Hospitals and the
London Fever Hospital, against 0, 1095, and 1172 at the end of the
previous week. The causes of 75 deaths in the 96 towns were un¬
certified, of which 14 were registered in Liverpool, 10 in Birmingham,
8 in Manchester, and 5 each in South Shields and Gateshead.
Scotch Towns .—In the 16 largest Scotch towns, with an aggregate
population estimated at nearly 2,500.000 persons, the annual rate of
mortality, which bad increased from 17*0 to 40*0 In the seven preceding
weeks, fell to 34*5 per 10Q0. The deaths from Influenza numbered
62, while In 450 deaths classified as due to other conditions Influenza
was a contributory cause; in the previous week these numbers
were 78 and 618 respectively. The 920 deaths in Glasgow corresponded
to an annual rate of 42*9 per 1000, and included 38 from whooping-
cough, 9 from measles, 4 each from diphtheria and Infantile
diarrhoea, and 1 from enteric fever. The 180 deaths In Edinburgh
were equal to a rate of 27*9 per 1000, and included 11 from
whooping-cough, and 1 each from measles and diphtheria.
Irish Towns (Week ended March 1st).—The 466 deaths in Dublin
corresponded to an annual rate of 60 0, or 14*8 per 1000 above that
recorded in the previous week, and included 153 from influenza, 4 from
Infantile diarrhoea, 2 from measles, and 1 from whooping-cough. The
238 deaths in Belfast were equal to a rate of 30 9 per 1000. and included
a fatal case each of whooping-cough, diphtheria, and infantile diarrhoea.
(Week ended Maich 8th.)—The 489 deaths in Dublin corresponded to an
annual rate of 63*0, or 3*0 per 1000 above that reoorded in the previous
week, and Included 148 from loll uenza, 3 from measles, 2 from whooping-
cough, and 1 from Infantile diarrhoea. The 233 deaths In Belfast
were equal to a rate of 30*3 per 1000, and Included a fatal case each of
whooping-cough and diphtheria.
THE SERVICES.
HOTAL NAVAL MBDIOAL 8BRVIOH.
Temp. Surg.-Lieut. J. A. Stirling, who was Invalided on aocount of
ill-health contracted in the Service, to retain rank.
ARMY MEDICAL SERVICE.
Col. H. D. Rowan is placed on retired pay.
Col. H. C. Thurston retires on retired pay.
Temp. Col L. S. Dudgeon relinquishes his commission and retains
the rank of Colonel.
The undermentioned temporary Lieu tenant-Colonels to he temporary
Colonels : H. Wade^Capt., R.A.M.C., T.F.), C. C. Ohoyoe.
ROYAL ARMY MEDICAL CORP3.
Lieut.-Col. D. B. Ourme retires on retired pay.
Major (acting Lteut.-Col.) B. L. Moss to be acting Colonel whilst
specially employed as Assistant Director of Medioal Services.
The undermentioned relinquish the acting rank of Lieutenant-
Colonel on re-posting: Major and Bt. Liout.-Col. P. Davidson and O. R.
8ylvaster-Bradley; Major F. A. Stephens; Temp. Major R. A. Chartres;
Cunts. E. C. Lambkin, J. G. Gill, W. J. Tobin.
To be acting Lieutenant-Colonels ^whilst In command of aMedteal
Unit: M*i;rs B. G. Pfrencb, S. E. Lewis; Capt. (acting Major) J. R.
Hill.
The undermentioned relinquish the acting rank of Major on re¬
posting: Cspts. A. R. Wright. H. F. Joynt, A. B. Richmond ; Temp.
Capts. G. D. Mathewson. S. B. B. Campbell, J. B. Hay craft, A. G.
Hamilton, J. Hendry, J. W. Elliott, A. Leemtng, C. H. S. Webb, A. L.
Saunders, J. W. Dew. W. R. P. McNelght.
To be acting Maj t«.—O apt. B. C. Lambkin, Temp. Capts. R.
MacDonald, R. L. Crabb, J. C. Robb, F. W. Diamond, G. G. Adeney,
A. Gray, A. T. T.idd, C. F. Strange, W. K. A. Richards, A. G. Gilchrist,
J. A. Uurrell, 0. L. Fordo, V. D. C. Wakeford, J. Buchanan, R. S.
Barker, F. G. Ralphs, D. G. Wishart, B. E. Chipp, P. K. McCowan.
Temp. Major F. E. Watts, Can. A.M.C., to be acting Lieut.-Ool. while
employed at a Canadian General Hospital.
Temp. Capt. B. Hogan relinquishes the acting rank of Major on
re posting.
Capts. J. M. MacKenzie and J. B. Hepper, to be acting Majors whilst
specially employed.
Capt. R. G. Sbaw to be acting Major.
A. Griffiths, late temp. Capt. (acting Major) Is granted the rank ot
Ma.)or.
B. H Shaw, late temp. Capt., is granted the rank of Captain.
Lieutenants (temp. Capts.) to be Captains.—O. D. Jarvis, J. La P.
Lauder (acting Major) (to retain his acting rank). T. H. Sarsfietd, J. A.
Binning, J. F. Bourse (acting Major) (to retain his acting rank), J. B.
Rusbv.
Temp, lieutenants to be temp. Captains.—W. W. Pearce, F. O.
Stedmao, J. H. Whiteside, G. R. Wilson, W. Robertson, O. Weinman.
A. Whitley, late temp. Captain is granted the rank of Captain.
Officers relinquishing their commissions:-Temporary Lieutenant-
Colonels retaining the rank of Lieutenant-Colonel: A. Stewart*.
H. B. G. Newham; Maj. M. C. Wcthereil, Temp. Maj. (sctlng Lieut. -
Col.) H. MacCormac (retains the rank of Lieutenant Colonel); Temp.
Majs. F. 8. Lang mead, F. C. Hart-Smith, and E. Blaek (retain the rank
of Major). Retaining the rank of Ma jor : Temp. Capts. (acting Majors)
G. Buchanan, J. P. Cahlr, F. C. Greig, Tomp. Hon. Major C. McNeil
(retains honorary rank), D. W. Torrance, Temp. Hon. Maj. R. F.
Kennedy (retains honorary rank); Temp. Capts. (retaining the rank
of Captain) F. W. Bartlett. A. H. John, V. J. Bstteson, J. A.
Marsden, D. G. MacArthur. M. H. Pears »u, W. B. Walker, H. H.
Carter, R. C. Begg, H. H. Stiff, S. B Nathan. R. S. Scott, S. Bn*e,
S. R. Mackenzie, F. G. Chandler, G. H. Wilvinson, A. W. S. Sfchel.
J. H Addinaell, J. B. Alexander, R. L. Rea, J. Hogg, R. M. Hewitt,
H. C. Fox, T. J. Kelly, D. F. Currau, T. Tierney, J. R. Williamson,
J.. Tate, G. P. Barff, Hi H. V. Welch, A. J. L. 8peechly, W. 8.
Lindsay. C. P. Symonds. H. C. Mulholland, J. R. Magee. C. F.
Nicholas. G. Y. Caldwell, H. U. Leembruggen, A. B. Fiddian,
G W'. Huggins. M. S. Fraser, D. M. Hunter. J. H. Wilkinson,
E L. Councell, W. A. Ress, W. A. Anderson, H. Yellowlees, D. Haig,
C. B. Redman, C. M Willmott, I. M. B<Bs, J. Elliott, H. A. R. B.
Unwin, L. S. Davison, C. B. Goulden, 0. R. Reckitt, N. Glegg, B. Kelly,
V. L. Connolly, A. L. Vaughan. C. S. Thomson, A. S. Wilson, F. A.
Anderson, W. F. Brskine, M. J. Johnston, H. D. Bridger, C. Butler,
Temp. Capt. J. E. Briscoe, Temp. Hon. Capts. 8. Wicks, G. 8 .
Peppers. D. H. D. Oran (and retain the honorary rank of Captain),
Temp. Hon. Lieut. C. E. Fearn (granted honorary rank of Captain),.
Temp. Lleuts. retaining rank of Lieutenant: J. G. Glasgow, B. H.
Stewart, J. Clarke, C. Bdwards, R. H. Watt, R. Theron. ▲. S. Ransome,
G. C. Maguire, A. L- Sutherland.
SPECIAL RESERVE OF OFFICERS.
Captains relinquishing the acting rank of Major on re-posting: C. V
Nicoll, T. O. Graham, J. C. Brash, G. V. Stockdale, G. G. Jack, H. D.
Rolllnson, W. Murdock.
Captains to be acting Majors: L. J. Bhetl. C. 8. Staddon, D. Colombo!,
W. Broughton-Alcock. S. W. Lund.
Capts. H. T. Lamb, C. L. Gaussen, 8 A. Lane relinquish their com¬
missions and retain the rank of Captain.
Lieutenant * to be Captains: W. P. Nelson, B. H. Chadwick, J. G.
McCann, a. P. M. Fuoss, G. B. MaoAlevey. I. H. Zortman, C. 8. Parker,
R B. Britton, H. B. Rhodes, A. 8. Westmorland.
To be Lieutenants: W. B. Watson (from Edinburgh University Con¬
tingent, O.T.C.), L. H. Bertram.
TERRITORIAL FORCE.
Major C. R. Laurie relinquishes his commission and retains the rank
of Major.
Major H. A. Leebody to be an Assistant Director of Medical Services
and to be acting Colonel whilst so employed.
Capt. (acting Major) F. J. Green to be Major.
Capt. (acting Lieut.-Col.) H. F. Humphreys relinquishes his acting
rank on oeaslng to be specially employed.
The Lancet,] APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS. [March 15, 1919 445
Capfc. (acting Major) H. G. W. Dawson Is granted the pay and allow¬
ances of his acting rank whilst bolding the appjintment of Deputy
Assistant Director nf Medical Service*.
Capts. (acting Majors) D. C. L. Fitzwllllams, G. H. Domtny, H.
Henry to be acMng Lieutenant-Colonels whilst specially employed.
Capt. M. G. Foster to be Major.
Oapts (acting Majors) E. L. Martin and R. 0. Clarke relinquish
their acting rank on ceasing to be specially employed.
To be acting Majors whilst specially employed: Oapt. ▲. M. Jones,
Capt. P. J. Smyth.
Oapt. B. Smeed relinquishes his commission and retains the rank of
Captain.
1st London Gene al Hospital: Lieut.-Col. Sir A. B. Garrod is
restored to the establishment. #
1st London Sanitary Company: Capt. (acting Major)F. B. W. Rogers
relinquishes blB acting rank on ceasing to be specially employed.
Lieut. R. W. Brearey to be Captain.
2nd London Sanitary Company: Capt. A. G. G. Thompson to be a
Deputy Assistant Director of Medical Services, and to be acting Major
whilst so employed. .
Capt. D. Smith is now seconded whilst employed aa Education
Officer.
territorial force reserve.
Capt. J. Derbam-Reid, from Welsh Border Mounted Brigade Field
Ambulance, to be Captain.
Capt. T. H. Peyton, from 1st Home Counties Field Ambulance, to be
Captain. _
BOTAL AIR FORCE.
Medical Branch.—L lent. Oscar Hilton is transferred to Unemployed
List.
Dental Branch.—Capt. G. Dawson is transferred to Unemployed List.
INDIAN MEDICAL SERVICE.
Majors to be Llentenant-Colonels: J. C. H. Leicester, H. Innea. W. 8*
Willmore, A. B. Walter, C. Hudson, L. T. K. Hutchinson, A. M. Fleming*
E. L. Ward, J. N. Walker, V. H. Roberts, T. S. Ross, W. MacM. Pear son-
Captains to be Majors: O. A. B Berkeley-HiU, W. L. Harnett, J. D-
Sandes, A. H. Napier, A. £. G rise wood, D. L. Graham. R. B. Nicholson,
J. A. Cruickshank, J. A. 8. Phillips (Bt. Major), P. M. Rennie, H. M.
Inman, E. B. Munro, F. O’D. Fawcett.
Tne King has approved the retirement, with the grant of honorary
rank, ot Lteut.-Col. A. R. S. Anderson.
The services of Major J. R. J. Tyrrell have been replaced at the dis¬
posal of the Government of India for employment In the Foreign and
Political Department.—The services of Lieut.-Col. D. C. Kemp have
been placed at the disposal of the Madras Government.—Ms jor R. B.
Lloyd has been appointed Civil Surgeon of Serampore.—Lleut.-Col.
J. G. Hulbert (retired), Civil Surgeon, has been transferred from
Fyzabad to Gonda; Lleut.-Col. Z. A. Ahmed (retired). Civil Su geon,
from Gonda to Bahraich.—Lleut.-Col. K. G. Turner, whose services
have been placed by the Government of India, Army Department, at
the disposal of this Government, has been appointed Civil Sufgeon,
Fyzabad.
Greenock C’orporateVm.—M.O.H. £700.
Hampshire County Council.— Temp..Asst. M.O.H.
Hospital for Sick Children. Great Ormond-strcet, W.C.— P. Also H.3.
£50. Also Cas. M.O. £200. _
Liverpool City.—H O. for Police Force. £750.
Liverpool. Royal Southern Hospital.—Hen. P. and S. Also Non-
London Lock Hospital and Rescue Home, Harrow-road, W„ and
91 Dean-street, W.— Hon. Surg. to Out-patients.
Manchester, Ancoats Hospital.— M.O. £25. . _
Manchester, Baguiey Sanatorium for Tuberculosis. —First and Second
Asst. M.O. £400 and £350. „ o 010A
Manchester Royal Eye Hospital.— Jun. H.S. £120. n
Manchester Royal Infirmary Convalescent Hospital, Chcadle. —Res. M.O.
£300.
Middlesex County Council— Tuberc. M.O. £600.
Newcasllt-on-Tyne Dispensary.- Re B . M.O. £300.
Neucastle-on-Tyne, Hospital/or Sick Children.— Rea. M.O. £200.
Northampton General hospital.— H.8. £200.
Noru ich, Norfolk and Norwich Hospital. —H.S. £200.
Preston. County Asylum, Whittingham.-L .T. 7 gs. per week.
Prince of Wales’s General Hospital, Tottenham. Lo*<ton, A.—Hon.
Asst. P. in Out-patients' Dept. Also 8en. H.P. and Sen. H.S. £200.
Also Jun. H.P. and Jun. H.S. £120.
Ramsgate Borough.—M.O. and 8chool M.O. £500; _ _
Rhondda Urban District Council.—hast. School M.O. and M.O.H.
£400. Also Dent. S. £350. „ „ ^ . _
Royal Free Hospital , Marlborough Maternity Section* Gray s Inn-road*
W.C.— Female Res. M.O. £150.
Royal Lyndon Ophthalmic Hospital, Ctty-road, E. C.— Refrac. Asst. £100.
St. Mary’s Hospital for Women and Children, Piaistow* E.—Res. M.O.
£250
Salford County Borough. -M.O. for Maternity and Child Welfare. £400.
Scarborough Hospital and Dispensary.—' Two H.S.
S Sha^hai°MuniJpal Council Health Department-hast. Health Officer.
£900.
Sheffield Royal Hospital.—Css. O. £130. _ . „ 0
Sheffield Royal Infirmary.— Cas. Officer Also Oph. H.8. £150.
Southampton. Free Eye Hospital.- H.S. £150.
Stafford Staffordshire County Mental Hospital.— See. Aast. M.O. £300.
Staffordshire Education Committee—Female Aast. M. Inspectors. £400.
Stroud General Hospital.-H S. £250. _
Swansea General and Eye Hospital.—Hue. H.P. £200. Also Sen.
Student. £120. t
Tiverton Hospital, Devon.— H.S. and Dispenser. £100.
Tunbridge Wells General Hospital.— Two H.S.
Union of South Africa Mental Hospital Service .—Six Aaat. Phys. £380.
Wakefield. West Riding Asylum.- L.T. 7 guineas per week.
Wallasey County Borough.— Tuberc. O. and Asst.. M.O.H. £500.
West Riding of the County of York.— District Tuberc. O. £500-
Whitehaven and West Cumberland Infirmary.— Res. H.S. £180-
Wolverhampton and Staffordshire General Hospital .—Two H.S. £200.
The Chief Inspector of Factories, Home Offioe. S.W., gives notice of
vacancies for Certifying Surgeons under the Factory and Workshop
Acts at Harwich, Nantgaredtg, and at Bridgnorth, in the county of
Salop.
Successful applicants for vacancies. Secretaries of Public Institutions
and others possessing information suitable for this column, are
invited to forward to The Llncet Office, directed to the Sub-
Editor, not later than 9 o’clock on the Thursday morning of each
week, such information for gratuitous publication.
Allah, J., M.D., M.O. Edln., has been appointed Medioal Officer to
the Bxeter Dispensary.
Brash, B. J. Y., B.A., M.B., B.C. Cantab., Medioal Officer to the
Exeter Dispensary.
Coombe, R., F.R.C.S., Honorary Consulting Surgeon to the Bxeter
Dispensary.
Bllistok, C. B., M.D., Ch.B. Edln., Medical Officer and Public
Vaccinator for the Sithney District by the Helston (Cornwall)
Board of Guardians.
Hutt, C. W., M.D., B.C.Camb., Whole-time Medical and School
Medical Officer for Dudley.
Loosely, A., B.M., B.Ch. Oxon., Assistant Surgeon in the Ophthalmic
Out-patient Department at the London Temperance Hospital.
9aomms.
For further information refer to the advertisement columns.
Bath. Royal Mineral Water Hospital.—Has. M.O.
Bermondsey Parish Infirmary , Lower-road , Rotherhithe, S. E.— Med.
Supt. £550.
Birmingham University Faculty of Medicine.—List. Prof, of Anatomy.
£500.
Bodmin , Cornwall County Asylum— Jun. Asst. M.O. £300.
Brighton , Royal Sussex County Hospital.— H.P. £100.
Buxton, Derbyshire, Devonshire Hospital.—Ant. H.S. £120.
Cardiff, King Edward VII.'s Hospital.— H.8. £200.
Carlisle, Cumberland Infirmary.- H.S. and H.P. £250.
Carlisle, Cumberland and Westmorland Asylum* Garlands.— Jun. Asst.
M.O. £300.
Coventry and Warwickshire Hospital.—Res. H.P. £250. *
Croydon County Borough, Cheam Tuberculosis Sanatorium.—Has. M.O.
£400.
Derbyshire Hospital Jor Sick Children.— Female Res. M.O. £150.
East African Medical Appointments. —M.O. £4Q0-£20-£500.
Federated Malay States Government.—Seven M.O.,. Grade II., and
Three Female M.O. £350.
Glenties Union (Ireland). Doocharry Dispensary District.— M.O. £100.
Gloucester County Boroug h.— Asst. School M.O. and Asat M.O.H. £400.
ftirtK glarriagts, aub gtatfrs.
BIRTHS.
Heark.— On March 4th, at Goldhurst-terraoe, South Hampstead, the
wife of R. H. Hearn, M.B. Cantab., Captain. R.A.F., of a daughter.
Hodges. —On March 6th, at the Woodlands, Bishop’s 8tortford, the
wife of Arthur Noel Hodges, M.B. Cantab., Captain, R.A.M.C., of a
son. _
MARRIAGES.
Aitken—Garrett-Smith.— On March 6th,at Saint Columba's (Church
of bootland), Pont-stieet, 8.W., David MoOrae Aitken, F.R.C.S..
temporary Captain, R.A.M.C., to Alice Garrett-Smltb, only daughter
of the late Godfrey Garrett-Smith, and Mrs. Garrett-Smith, of
Roehampton. „ .
Price-Harbis—Twemlow-Cooke.— On March 4tb, at Parish Church.
Sidmouth. Major L. Price Harris, M.O., R.A.M.C.T., to Amy
Victoria Mary, only daughter of the late Rev. D. J. Twemlow-
Cooke, M.A. Cantab., and Mrs. Twemlow-Cooke. of Sidmouth.
Shield—Mafaeh.— On March 1st, at ©ondamine-Chatelard. Baases-
Alpee, France. Major Hubert 8bleld, M.O., R.A.M.C., T.F.,
1st Northumbrian Field Ambulance, to Leontlne, daughter of
M. le Capltaine H. Maesen, Croix de Guerre, of Condamine-
Chatelard, Basaes-Alpes, Prance. , _ , _ . _
Taylor—Burke.— On March 3rd. William Alfred Taylor, B.A.. M.B.,
B.Ch., medical officer, Straits Settlements Medical Service, to
Constance, widow of Captain Bernard Burke, Grenadier Guards.
DEATHS.
oldstrkam.— On Feb. 26th, at Florence, Alexander Robert Coldstream,
M.D., F.R.C.S. E.. In his 67fch year. _ 0 4
Lartley.— On March 6th, at De Parys-avenue, Bedford, Arthur
Conning Hartley, T.D.. M.D.. O.M., F.R.G.8., aged 54 years.
ollock. —On March 7th, at Penton Dodge, lull Hill-park, W.,
Rowland Pollock, L.B.C.P. I., L.M., L.R.0.8.1.
N.B.—A fee of Be. is charged for Cut insertion of Notices of Births*
Marriages , and Deaths.
The examinations for the Diploma m Psycho¬
logical Medicine are now being resumed by the University of
Cambridge. It is the aim of the managing committee for
this diploma to make its acquirement a habit among
psychiatrists in the same way as a public health diploma is
part of the equipment of the sanitarian.
446 The Lancet,]
MEDICAL DIARY.—NOTES, SHORT COMMENTS, ETC.
[March 15, 1919
Utebital $iarj far % ensuing 8®eek.
SOCIETIES.
ROYAL SOCIETY OF MEDICINE. 1 . Wimpole-street, W. 1 .
Tuesday. March 18th.
GENERAL MEETING OF FELLOWS: at 5 p.m.
Ballot for Election to tte Fellowship. (Names already circulated.)
Wednesday March 19th.
SOCIAL EVENING: at 8.30 p.m
Mr. Walter G. Spencer will discourse on “ Larrey and War Surgery."
MEETINGS OF SECTIONS.
Wednesday, March 19th.
HISTORY OF MEDICINE (Hon. Secretaries — Charles Singer, Arnold
ChapUn): at 5 P.M.
Paper*:
Dr. Ralph Leftwich: The Evidence of Disease in Shakespeare's
Handwriting.
Rev. Father Fletcher: The Medical Book of Sfc. Isidore.
Thursday, March 20th.
DERMATOLOGY (Hon. Secretary—S. B. Dore): at 4.30 p.m.
Cases :
Dr. Graham Little-. (1) Multiple Neuromata of Skin ; (2) Dercum’s
Disease; (3) ? Section of Mycosis Fungoldes.
Dr. Barber: (1) Case for Diagnosis ; (2) Granulosis Rubra Nasi;
(3) Alopecia of the Scalp and Eyebrows associated with Graves’
Disease. •
Dr. George Pemet: (1) Arrested Development of Hair in a Girl;
(2) Unilateral Band Sclerodermia; (3) Melanotic N»vo-car-
cinoma (previously Rhown).
Dr. S. B. Dore: Case for Diagnosis.
Friday. March 21st.
OTOLOGY (Hon. Secretaries—J. F. O'Malley, H. Buckland Jones):
at 5 p.m.
Demonstration:
8ir Thomas Wrlghtson, Bart., and Prof. Arthur Keith : Demonstra¬
tion on the New Theory of Hearing.
Specimen$ and • axes will be shown by :—
Mr. Sydney Scott, Ur. Richard Lake, Mr. Stuart-Low, Dr. Watson
Williams, Mr. Lawson Whale, and Mr. O'Malley.
RLBCTRO-THKRAPBUTICS (Hon. Secretaries—RobertT. Knox, Walter
J. Turrell): at 8 p.m.
Joint Meeting with the Institution of Electrical Engineers.
The Discussion will be opened by papers by Mr. R. S. Whipple on
** Some Notes of Electrical Methods of Measuring Body Tempera¬
ture,’’ and “Some Notes on the Electrocardiograph."
In addition there will be an Exhibition of X-Ray and Electro-
therapeutic Apparatus.
Advanoe copies of the papers will be ready a few’ days before the
meeting, and will be sent on application to the Secretary, Institution
of Electrical Engineers, 1, A lhemarle-street, W. 1.
The Royal Society of Medicine keeps open honse for
R.A.M.C. men and M.O.’s of the Dominions and Allies. The
principal hospitals in the metropolis admit medical officers
to their operations, lectures, ftc. Particulars on application
to the Secretary at 1, Wimpole-street, London, W. 1.
ROYAL METEOROLOGICAL SOCIETY, at the Lecture Room of the
Geological Society. Burlington House. Piccadilly, W.
Wednesday, March 19th.— 5 p.m., Lecture :— Prof. L. Hill : Atmos¬
pheric Conditions whioh Affect Health.
BOYAL MICROSCOPICAL SOCIETY, 20, Hanover-square, W. 1.
Wednesday, March 19th.—8 p.m.. Dr. J. B. Gatenby: An Account
of Work on Cytoplasmic Inclusions of the Cell.—Lieut.-Col. J.
Cllbborn, C.I.E.: A Standard Microscope.—Dr. N. Mutch : A
Simple Method for the Isolation of Single Bacteria for the
• Preparation of Pure Cultures (Demonstration).
CHILD-STUDY SOCIETY LONDON, at the Royal Sanitary Institute,
90, Buckingham Palace-road, S.W.
Thursday, March 20th.— 6 p.m.. Discussion on Training of the
School Girl in Infant Care (opened by Mrs. K. Truelove).
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
ROYAL COLLEGE OF PHYSICIANS OF LONDON. Pall Mall Bast.
Tuesday, March 18th, and Thursday.— 5 p.m.. Milroy Lectures :—
Dr. J. O. McVail: Half a Century of Small-Pox and Vaccination.
POST-GRADUATE COLLEGE, West London Hospital, Hammersmith-
road, W.
Special Btght Weeks’ Course of Post-Graduate Instruction. (Details
of the Course were given in our issue of Feb. 15th).
LONDON HOSPITAL MEDICAL COLLEGE.
A Special Course of Instruction in the Surgical Dyspepsias will be
given at the Hospital by Mr. A. J. Walton. Lectures, given in the
Clinical Theatre:—
Monday, March 17th.—1 p.m.. Lecture VII.:—Gastric Ulcer;
.Etiology and Pathology.
Friday.— 10 a.m.. Lecture VIII.:—Gastric Ulcer; Symptoms,
General and Special.
ST. THOMAS’S HOSPITAL MEDICAL SCHOOL (University of
London), Governors' Hall, St. Thomas's Hospital, S.B.
■ A Series of Ten Lectures on Diseases met with in the Sub-tropical
War Areas (illustrated with lantern slides, charts, diagrams and
microscopical preparations).
Wednesday, March 19th.— 5 p.m., Lecture V.: Dr. L. S. Dudgeon:
Black water Fever.
Friday.—5 p.m.. Lecture VI. j— Dr. L. S. Dudgeon: Bacillary and
Amoebic Dysentery.
BOYAL INSTITUTION OF GREAT BRITAIN. Albemarle-street,
Piccadilly. W.
Tuesday, March 18th.—3 p.m.. Lecture II.:—Prof. A. Keith:
British Ethnology—The People of Scotland.
Friday.— 5.30 p.m., Prof. W. W. Watts: Fossil Landscapes.
jtotes, j%rt Comments, aifa Jnstoers
fa Correspifaents.
A PICTORIAL SYMBOLISM OF REPRODUCTION.
The puerile and primitive anthropomorphic attempts of
the ancients to explain the origin and continuity of vege¬
table, animal, and human life in pre-Christian tijnes are well
known. The common concepts of a divine fusion of both
Axes led. in Mesopotamian and in much of Hellenic mytho¬
logy, to a pandemonium of eroticism and stories of
impossible intercourse. When, as in Syria, and perhaps
in some of the tableaux of the Greek mystery plays, the
sexual subject of generation was mingled with religion
gross indecencies were suggested and practised—in some
Egyptian myths mankind was said to have been created
from the spittle of Osiris, whilst in others it was accom¬
plished by his masturbation. Isis also was said to have
filled up again the depopulated Delta by a similar process.
The reproductive element in life was a mystery to these
early races, although they knew sufficient about the sexual
fertilisation of plants to take the male date palm pollen and
shower it over the female flowers. But alongside much
erode imaginings there was a somewhat better-thonght-ouc
and reasonable speculation as to the reproduction of life
based on the knowledge then available. This explanation
appears only to have been accepted by the Phoenicians,
racially close allies of the Hebrews, and is to be found in
fragmentary excerpts from Sanchuniathon and other Semitic
sages.
It has been difficult clearly to comprehend the inter¬
pretation of reproduction which the wise Phoenicians
professed to give, as we have only Greek translations
of their writings; but a vivid light has been thrown
upon what they intended to convey—and it confirms the
renderings the classics had given—by the discovery in
Spain of a Phoenician picture, or tableau, setting
forth their view pictorially. This relic forms the
major part of a circular plaque, showing the sun. and
stars at top, with a border of fish figures, indicating that
the whole design depicts the Cosmos surrounded by water.
Prominent in the foreground are two palm trees, male aud
female, and two serpents, the horned male beside the
staminate male tree and the female snake with teats and
bird wings near the pistillate palm. The heat of the earth
is represented by a flame rising in the foreground, the solar
heat being typified by the rayed sundisk. By this description
it is clear that the tableau concerns nature’s reproductive
forces, the serpents being selected because of their reputation
for copulative powers, the trees to illustrate the vegetable
kingdom, and the solar heat aud warmth of the soil as
productive of vegetation. This knowledge guides us to the
correct interpretation of the two central figures completing
the picture, which are two deities of human form, the
feminine form beside the female animal and tree, and the
male one opposite. They are represented as producing
life, both bodily and spiritual, from two sources of their
T&hLamckt,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [March 15,1919 447
persons. The sperm from the male body, whom we may
call Baal—if this is really Phoenician work—passes from
ham and enters and leaves again Tanith’s body, flowing
with a spiral motion, terminating in a figure of a human
embryo. This spiral fluid is made up of animal corpuscles,
and iB nourished by a stream of milk flowing from Tanith’s
breasts. Her body is decently clothed in a skirt with zones
ctf various figures, as we know was the case with Diana’s
robe at Ephesus. But a further form of vital interaction
is represented by flying bodies passing between the open
mouths of the two figures. These are alternately tiny
winged creatures and circular objects, and evidently refer to
the creation of the soul. The primitive words for breath
and for the spirit were frequently the sume, and the
emblems for the soul often a butterfly, or some small winged
creature. Archroological evidence for the widespread pre¬
valence of these concepts is forthcoming.
PHYSIOLOGY AND THE STUDY OF DISEASES.
At King’s College, London, on March 5tb, Professor D. Noel
Paton delivered a lecture on Physiology and the Study of
Diseases, being the fifth of the series of lectures on
Physiology and National Needs. Physiology, he said, was
the basis of the study of disease, for disease was simply
normal physiological action gone wrong. It was the duty of
the physician to discover what the fault was and why it had
oocurred. Until he had investigated these two points any
rational treatment was hopeless. To study disease without
this constant reference to normal physiological conditions
was one of the greatest mistakes which had been made in the
past. There was a tendency to group symptoms together
without an adequate consideration of their significance in
terms of normal physiological action, or of their mode of pro¬
duction. It followed as a result that too often treatment was
based upon the authority of others without considering how
the patient would be benefited. This opened the door to
credulity and credulity ought not to enter into medicine.
It was hardly realised how empirical medical treatment was
even at the present day. It was impossible to onre disease
when structural changes had developed. Slight divergences
from the normal physiological action, resulting in the first
stages of real disease, were too often ignored. The naming
of diseases had perhaps obstructed advance in medicine. If
a child’s head were enlarged by an accumulation of fluid
some might be content with a diagnosis of hydrocephalus
without considering why the fluid was there. The student
too often studied physiology as a means of passing certain
examinations rather than as a preparation for the study of
disease. He required to be shown how scientific methods
could be carried into practice at the bedside. For example,
physiological methods had been applied to the study of
disease, in the investigations which had been carried out on
gassing and wound shock, and on tetany, in which the
action of the parathyroid glands was involved. There
was a strong tendency at present to place utility in
the forefront, but experience had shown that the most
important advances in the application of soience to
medicine had been based upon investigations which
primarily seemed to have no direct bearing on benefits to
humanity. A knowledge of osmotic pressure, viscosity, and
colloids, which had been studied withont any reference to
remedial measures, bad proved of great value in initiating
various forms of treatment. The real scientist found his
greatest joy in overcoming difficulties. The general
public must realise that knowledge gave ub power to fight
with more success against the adverse forces of life, and
that consequently facilities should be given to those who
sought to obtain knowledge.
14 Ignorance is the curse of God,
Knowledge the wing wherewith we fly to heaven.”
Sir George Newman, who presided, considered the neglect
of physiology in our schools and colleges throughout the
country to be one of the principal causes of the large
amount of disease and disablement which was found
among the school children of England and Wales. The
fact that 10 per cent, of them were Buffering from an
avoidable degree of malnutrition whioh prevented them
from taking full advantage of their educational facilities, and
that about 20 to 30 per cent, failed to see with their eyes what
they might see if the teachings of physiology had been under¬
stood, showed the enormous loss to the country which
resulted from a failure to put physiological laws into
practice. A study of fatigue and disablement had shown
that the same neglect of adolescent and adult life had led to
a reduction of output in munition factories at the maximum
cost to the life and strength of the worker. Wages and
social conditions were important, but it was still more
the right understanding and right practice of the
principles of physiology whioh secnred a maximum out¬
put. We had established in England, he said, a great school
of physiology, but it was one of the defects of English
medicine that we failed to carry the principles discovered
and taught into the daily practice of medicine at the
bedside and in the ward. Until English physiology entered
into its kingdom in English medicine we should not reap
the full harvest whioh was ours by right as the result of
the work of English physiologists. In his Government work
he had met precisely the same problems. In the schools,
the workshops, and the universities we were in greater need
of a right understanding and right practice of the principlea
of physiology than of almost anything else.
SPHAGNUM MOSS.
The secretary of the Devon Sphagnum Moss Central Depdt
reports that since the spring of 1915 up to the present time
830,520 moss dressings had been forwarded to 165 base hos¬
pitals, casualty clearing stations, &c.
OSTEOARTHRITIS.
To the Editor of The Lancet.
Sir,—C an any of your readers suggest a remedy for a case
of osteo-arthritis in right hip-joint of a practitioner aged
50 years, otherwise healthy ? Teeth sound. Pain is nob
troublesome during the day, but is getting severe at nigbfc-
for the past month or so. Any suggestions as to treatment
will be gratefully received.
I am, Sir, yours faithfully,
ARTHRITIS.
THE MOSQUITO PROBLEM IN BRITAIN.
The possible danger from the importation of malaria in
this country is emphasised by the Order of the Local
Government Board making that disease notifiable, and the
question arises as to how far the methods of fighting the
anopheline mosquitoes adopted in the tropics are practicable
in the British Isles. In the January issue of the Royal Army
Medical Corps Journal Captain Allan C. Parsons and Lanoe-
Corporal G. R. Brook, of the same corps, contribute a joint
paper containing suggestions for a winter campaign in this
country against the mosqnito, pointing out that the condi¬
tions, political, physical, and social, existing at home in
regard to the mosquito problem are altogether different from
those of the tropics. Their method, based on the seasonal
habits of mosquitoes, whioh they describe in detail, consists
in catching or destroying the insect, some species of whieb
pass the winter in the adult stage and some in the larva)
stage, by means of swatting, flares or blow-lamps, electro¬
cution, and fumigation. Of these last-mentioned agents the
general use of hydrocyanic acid, chloroform, and chlorine
on a large scale is not recommended on account of the danger
involved in their employment, though it is pointed out thab
cbloriue is a very powerful insecticide and might be used
with good results at small cost at stations where the services
of gas officers are available. Where a safe domestic remedy
is required the authors recommend campho-pbenique ana
the various cresylic compounds.
THE FACTORY MEDICAL OFFICER IN WAR
AND PEACE.
Dr. W. J. O’Donovan, chief medical officer of the Welfare
and Health Section of the Ministry of Munitions, delivered
a lecture at the Royal Institute of Public Health on
March 5th on the War-time Experience of Factory Medioa)
Officers and the Position of Factory Medicine under
Peace Conditions. Lord Cbetwynd, who presided, said that
in a factory with which he was connected medical super¬
vision had proved itself of benefit not only to the
operators, bat to the administrative side of the work,
both the amount and quality of production being increased
when the health and physical needs of the workers were
properly attended to. Women workers, as a rule, did not
feed themselves properly and, as a consequence, often
suffered from faintiDg attacks; at one time in his factory
as many as 50 to 60 cases would occur in a day, whioh meant
the stoppage both of the patient’s work and that of those
who attended to her. When the women were properly fed
fainting fits became rare. About 9000 people were employed*
of whom 3000 were women, And for these a staff consisting
of two doctors, one dentist, and four trained nitrses was not
too large. By keeping the workers cheerful, preventing
monotony in their work, and by providing recreation and a
complete change during meal-times, casualties were reduced
enormously, the money saved on better production amply
providing for such supervision.
Dr. O’Donovan said that the beginning of the war found
the country unprepared to deal with the needs of industrial
medicine, and the problem became acute when T.N.T. was
first handled in bulk. Industrial health in this connexion was
more important than tberecognition and treatment of disease.
The medical officer of the factory admitted the employees,
selected those best suited for the work which was being
carried on, and supervised all the working conditions. He
was the friend and consultant of everyone within the
factory gates, and often saved much anxiety by solving
difficult problems which presented themselves to the manage¬
ment. Knowing the conditions under which the worker was
448 Tin Lancht.] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [March 15,1919
employed, the factory officer was in a position to under¬
stand the nature of the illnesses of workers better than
•could the outside doctor, who might quite easily be imposed
upon by the patient, and where sick benefit was concerned
he thus saved money to the country. It was necessary that
he should be a member of the factory staff. Sickness among
the workers might be caused by drink, industrial occupation,
or illness, but before the occurrence of disease the effects
of fatigue might make themselves felt, and this could only
be properly dealt with by the factory officer who knew the
•conditions of work. It had been said that the lawyer took a
broad outlook upon life, whilst the doctor was a pure
individualist. If medicine was to progress the community
most be regarded as a whole, and it was in industrial
medicine that the medical profession would And its best
recognition. In the future we should be guided by our war
experiences, which showed that success could be assured by
a combination of methods. There was a peripheral medical
staff in each industrial area, a headquarters medical staff
travelling from oentre to centre, and a headquarters medical
staff whose members could remain in any area over a long
•period when necessity arose. Every case of difficulty was
carefully considered, whilst coordination of research had
been most fruitful in its results. It was, however, important
that the findings of research should be adapted to industrial
conditions in the factory.
Factory medical officers, he continued, being disbanded,
employment was passing from the State to private manage¬
ment, and the services of the certifying surgeon would again
have to be relied upon; but his duties were so multifarious
that any practical work on industrial conditions was
impossible. Pathologists should be appointed whose main
dufy would be to inquire into industrial deaths, for if
olinical industrial medicine was to be put on a sure founda¬
tion it must be supplemented by observation in the post¬
mortem room. WmlBt there were chairB in all departments
cf medicine in our universities, there were none which had
for their object the maintenance of industrial health,
though there was an increasing demand for skilled
industrial physicians. The factory doctor must be
assisted by tne factory nurse and the factory dentist. To a 1
large extent health depended upon the state of the mouth,
but the working hours of the registered dentist were never
available to the working-class patient, the quack only
being regularly a worker in the evening. For this reason
facilities should be given for the employment of a factory
dentist. The same applied to the doctor. As a rule the
worker could only see the general practitioner either when
be was ill in bed, or in the evening when both he and the
doctor were tired, and the surgery was perhaps crowded.
It should be the privilege of every worker to see his medical
attendant in the daylight.
A SIMPLE AID IN REDUCING PARAPHIMOSIS.
To the Editor of The Lancet.
Sir,—P araphimosis, whether secondary to inflammatory
changes in the adult or to manipulations in children, is
common in general practice and very common in urogenital
clinics, but when one looks up the literature as to the
treatment of this painful condition all authors suggest a
similar mode of procedure as to its reduction—namely, to
grasp the oedematous portion of the penis between the
index and middle fingers of both hands, making traction
forwards, while the thumbs press the glans backwards.
The process is painful, the operation often fails, especially
in old-standing cases, and then operative measures are
necessary.
By the simple means of punoturing the cedematous tissue,
and so draining the waterlogged tissue, I have been success¬
ful in reducing the most severe cases practically painlessly.
The skin is sterilised in the usual way or by painting with
iodine; a few stabs are made in the 'swollen tissue
with a needle sterilised by passing through the flame
of a spirit lamp or bunsen burner. Gentle pressure is
made and the codematous fluid will ooze from the punc¬
tures. The prepuce can then be easily drawn over the
shrunken tissues. I have never had any complications
following, but the precaution must be taken to give the
patient some antiseptic lotion to wash out the preputial sac.
If practitioners will adopt this simple plan I am certain
very few cases will be Been in out patient departments of
hospitals or in the private consulting-rooms of specialists.
I am. Sir, yours faithfullv,
Manchester, Feb. 25th, 1919. M. W. BROWDY, M.B. Glasg.
F. H. A/.—We presume that varix of the common femoral
vein is referred to. Varix of deep veins is extremely rare,
and we know of no recorded case of a dilated femoral
vein being mistaken for femoral hernia. Varicosity of the
laphenous vein as it passes through the saphenous opening
is not rare and has been mistaken for femoral hernia. If it is
desirable to interfere at all, the dilated portion of the
saphenous vein may be tied and exoised, asepsis being
observed, and special care being taken while tying the smaller
vessel at its point of entry into the larger to avoid the
production of a thrombus protruding into the common
femoral vein. Should varicosity of the femoral vein be
present ligature shoald not be tried, as nearly all the
blood from the lower limb returns by this vein, and its
ligature would almost certainly be followed by great
oedema of the leg and probably by gangrene. Nothing
more can be done than to give the dilated vein the support
of a bandage. _
Communications, Letters, frc., to the Editor have
been received from—
A.—Association of Panel Com- , R. B. Low, Lond.; Dr. C. B.
mittees. Lond., Sec. of; Associa- | Lakln, Load,
tlon for Promoting the Training i M.—Dr. H. A. Maoewen, Lond.;
and Supply of Midwives, Lond.; , Dr. H. Mackenzie, Lend.; Lieut.-
Maura Allen and Hanourys,
Lond.; Dr. A. J. Anderson. Cape¬
town ; Dr F. E. Appleyard,
Salisbury, Rhodesia; Association
of Certit) iog Factory Surgeons,
Manchester, Sec of.
B. -Mr. W. G. Ball. Lond.; British
Medic *1 Association, M&rylebme
Division; Miss L. M. Brooks,
Lond.; Messrs. P. Blaklstons
Son and Oo., Philadelphia; Board
of Agriculture and Fisheries,
Lond.. Board of Agriculture and
Ministry of Food, Joint Com¬
mittee of, Lond.; Dr. A. C. Begg,
Swansea; Dr. F. W. Broderick,
Bournemouth.
C. —Ur B. Grid land. Wolverhamp¬
ton; Mr. B. M. Corner, Lond.;
Capt. W. B. Cooke. R.A.M.C.;
Dr. B. A. Constable. Lond.; Mr.
G. W. F. Clark, Plymouth.
D. —Dr. L. Drage, Hatfield; Mr.
R. Davies, Lond.; Dr. J. R.
Day. Lond.; Meurs. A. and F.
Denny, Lond.; Dr. A. F. Dixon,
Dnblin.
E. -Col. T. R. Blliott, A.M.S.;
Mr. W. H. Evans, Lond.
F. —Capt J. G. Forbes, R.A.M.C.:
The Field. Lond.; Faculty of
Insurance, Load., Sec. of; Fac¬
tories, Chief Inspectorof, Lond.
G. —Dr. S. K. Gloyne, Lond.; Mr.
S. H. Gill. Birkdale.
H — Dr. J. A. B. Hicks. Lond.;
Prof. W. Hall, Bristol; Dr. 0. W.
Hutfc, Brighton; Dr. B. Hicks.
Lond.
L—Institution of Electrloal En¬
gineers, Loud.
J. - Journal oj Bacteriology, Balti¬
more.
Col. C. 8. Myers. R.A.M.C.; Mr.
C. Mac Mahon. Lond.; Dr. F. H.
Maberly, Crosshaven; Dr. B.
Mel Ian by, Lond.
N. —Mr. R. Naim Hastings, N.Z.
O. —Oliver-Pell Electric and Mann-
• factoring Co., Lond.
P. —Dr. F. R. Parakh, Bombay!
Dr. R. H. Paramore, Rugby;
Mr. R. H. A. Pilmmer, Lond.;
Dr. R. M. F. Ploken, Glasgow;
Major J. Parkinson, R.A.M.O.;
Capt. B. T. Panons-Smith,
R.A.M C.
R.—Royal National Hospital for
Consumption, Lond., Sec. of;
Royal Institution, Lond.; Royal
Sanitary Institute, Lond.; Royal
Meteorological Society, Lond.;
Dr. W. Russell, Edinburgh;
Royal College of Physicians of
Edinburgh and Royal College of
Surgeons of Edinburgh, Pre¬
sidents of; Royal Society, Lond.;
Royal Society of Arts, Lond.
8.—Mr. R. B. Smith, Exeter; Mr.
Shepherd, Lond.; “S. R.”; Dr.
F. K. Smith, Aberdeen: Mr.
R. A. Stoney, Dublin; Dr. J.
Searson, Lond.; Lieut. V. G.
Sanders, A.I.F.
T.—Tuberculosis Society, Lond.;
Col. A. H. Tubby, C.B., C.M.G.,
A.M.8 ; Dr. W. W. C. Topley,
Lond.. Major G. Taylor, R.A.M.C.;
Mr. P. N. Turner, Lond.; Mr. G.
Taylor, Lond.
U —University College, Lond.,
Provost of.
V. —Mr. A. L. Vischer, Bale; Mr.
R. M. Vick, Lond.; Major P. N.
Vellacott, H.A.M.O.
W, —Mr. W. N. White, Lond,;
Burg.-Lieut. F. A. Williamson,
K. —Dr. C. Kidd, Bromagrove.
L. —Sir J. Lynn-Thomas, Cardiff;
Dr. A. Lowers, Melbourne; Dr.
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THE LANCET, March 22, 1919.
JSilntt Jtttnres
[IM ABRIDGED FORM],
O*
HALF A CENTURY OF SMALL POX AND
VACCINATION.
Delivered before the Royal College cf Phytieians of London on
March 13th, 18th , and SOth, 1919 ,
By JOffN C. Me VAIL, M.D., LL.D.
The lecturer began on a personal note. It was just 50
years since he had entered on the study of medicine, and the
pandemic of small- pox reached Glasgow in 1871. Students
had opportunities of seeing the disease at the Royal
Infirmary until infection spread to the wards and cases
were excluded. In 1873-74 small-pox reached Kilmarnock,
where the leoturer had began practice, and the whole
epidemic was witnessed. Afterwards a local register of
mortality of the eighteenth century came into his hand,
showing the ravages of small-pox at that time. Publication
of the facts led to further discussion, and lengthy evidence
was given before the Royal Commission on Vaccination.
Subsequently, as medical officer of health for Kilmarnock
and afterwards for the counties of Stirling and Dumbarton,
various opportunities had come to him for dealing with the
disease from the preventive and administrative side, and
now at the end of half a century his thanks were due to the
Royal College of Physicians of London for giving him the
opportunity of summing up the opinions or conclusions which
had formed themselves in his mind.
The subject would be treated in three sections: —
1. Small-pox as it was and is.
2. Vaccination as it was and is.
3. Control of small-pox in the present day.
Small-pox as it Was and Is.
This was considered in respect of: (a) fatality ; (6) infec-
tirity; and (c) prevalence.
Fatality .
It had always been recognised that small-pox differed
greatly in its fatality or case mortality rates as between one
time and another and one place and another. Previously to
the passing of the Acts for the notification of infectious
diseases fatality rates had to be obtained almost wholly from
the records of hospitals, and prior to 1870 practically the
only institution of this kind in this country was the London
Hospital for Small-pox and Vaccination. By the end of
1870 the first of the institutions of the Metropolitan Asylums
Board was used for small-pox and other hospital data became
available.
The gross fatality rates of small-pox, including both
unvaocinated and vaccinated, had been in 1836-51 21*38
per cent.. and in the pandemic of the * * seventies ” about 18 per
cent.—in Dublin about 21 per cent. The next extensive
epidemic was in 1892-95. but intermediately two local
epidemics occurred—one in Sheffield having a fatality rate of
10‘1 per cent., and a similar one in Bristol of 11*3 per cent.
The epidemic of 189 4-95 was extensive, and its fatality rate in
the M.A. B. H >spitals was 8 per cent. In 28 populations in
the provinces, Scotland, and Dablin the fatality rate was
8*5 per cent. The same general type of disease had there¬
fore prevailed throughout the country as a whole, and small¬
pox was much less fatal than it had been in the pandemic
of the 44 seventies.* 1 The next extensive epidemic was that of
1902-05, and an important distinction emerged between
London and the rest of the country. In London the
fatality rate reverted practically to the high figures of the
outbreaks previous to 1892-95, as the following series of rates
shows:—
1870-72 1876-78 1879-83 1884-85 1892-93 1901-02
18*8 ... 18*2 ... 16*5 ... 15*9 ... 8*0 ... 16*8
In the provinces, instead of reversion to a higher rate,
there was a still further diminution in fatality. In the
years 1902-06 inclusive, in areas for which returns had
been obtained by the Local Government Board, 23,883 cases
Bad 1649 deaths, or 6*9 per cent. In many places the rates
»nied round 3 per cent., 4 per cent., and 5 per cent. This
No. 4966
epidemic of the early years of the present century showed
lower fatality than had been met with in small-pox since
reliable statistics on any extensive scale had become avail¬
able. The statistics did no more than support clinical
observation of the change that had taken place in small¬
pox. Every physician whose experience went back far
enough had seen with his own eyes the contrast between
past and present. To some extent comparison of fatality
rates was affected by the systematic contact hunting which
now brings to light many Rlight cases, and at the same time
contact hunting results in many cases being vaccinated
daring incubation and just too late for complete protection
but with much modification of the disease. Making allow¬
ance for these considerations the diminution in fatality was
quite unquestionably very great.
The simultaneous appearance of two types of infection,
one in London and the other in the prorfnees, raised the
important question of the source of the two varieties.
Available facts indicate that the London small-pox bad
come from France, especially from Paris. Spain, France,
and Italy, all with a Mediterranean littoral, were con¬
tinually liable to infection from North Africa, where small¬
pox was habitually severe. In Paris in 1900-01 there were
4505 cases with 758 deaths, or 16*8 per cent. This happens
to be exactly the London fatality rate of the same period,
and Sir Shirley Murphy in his Report to the London
County Council for 1902 wrotg: 44 In summary it maybe
stated that during 1900 and 1901 small-pox had been
frequently introduced into London from abroad, especially
from Paris.”
Of the mild type which prevailed in the provinces the
source was to be found in the New World. In America the
disease had prevailed in a very remarkably attenuated form.
In Trinidad in 1902-03 there were 5256 reported cases with
only 28 deaths, or 0*53 per cent. In the United States very
mild small-pox had prevail*! for many years, percentage
fatalities on a very large*basis of facts being 2*3 per cent, in
1901, 3*7 per cent, in 1902 and 3‘4 in 1903. Dr. Boobbyer, of
Nottingham, in The Lancet and British Medical Journal in
1901 related how small-pox had been introduced into Notting¬
ham by means of a Mormon conference, and the disease had
been communicated to various towns in England. Similarly,
Mormon activities bad been asserted to be responsible for
New Zealand small-pox in 1913-14. The fatality rates above
mentioned have been even farther diminished since 1901-03.
Dr. Bruce Low’s recent report to the Local Government
Board contains a most valuable collection of statistics relating
to small-pox throughout the world, and many of the figures
submitted by the lecturer were based on that report. New
South Wales had also shared in the mild American type.
In 1913 14 it had only two deaths in 1661 cases, and
infection was supposed to have been imported from
Vancouver.
Intercnrrently, however, there had been various outbreaks
of comparatively high severity in New York, in Canada,
and in our own country, as in Hull in 1899-1900, where the
disease had been introduced apparently from Southern
Russia. Dr. Franklin Parsons had related that in one town
in Lancashire there were outbreaks from the two sources
concurrently, one mild from America and the other severe
from Paris via London. The change from severe to mild
had occurred on the whole somewhat suddenly, the epidemic
of the early 44 nineties ” being the first of the mild type on
an? extensive scale. To the question whether the two
diseases were both really variolous or differed from each
other as typhoid and paratyphoid differ, vaccination seemed
to supply the answer. It prevents the mild type just as it
prevents the severe, and Chapin had said : 41 The crucial test
of the identity of the two forms is, however, to be found
in their immunity relation. Persons who have had small¬
pox or who have been successfully vaccinated are at least as
immune to the mild as to the severe type. ” At first the mild
type was naturally regarded as a 44 sport,” but if it were to
displace throughout the civilised world the severe type, then
by and by the latter would have to be regarded as the
44 sport.”
The conditions under which sraall-pox assumed high
virulence in one part of the world at one time and attenua¬
tion in another part at another time were well worthy of
study, say by the Medical Research Committee.
The fatality cf natural small-pox was discussed in con¬
nexion with the statistics of the eighteenth century,
M
450 Thb L angbt, ] DR. J. 0. MoVAlL: HALF A OBNTURY OF SMALL-POX AND VACCINATION. [Maboh 22. 1919
when there was no vacoi nation, and with the fatality
rates of the disease amongst the nnvaccinated since
the beginning of the nineteenth century. Reservations,
however, had to be made in respect of age-incidence
because small-pox was very fatal in infancy, reached
its lowest natural fathlity in the third quinquennium
of life, and rose again in adult life. Epidemics occurring at
different intervals would include different numbers of cases
at the several groups of ages, and were not, therefore, always
strictly comparable. Also, in the eighteenth century,
chicken-pox may sometimes have been confused with small¬
pox. Such reservations apply to the earliest available
figures, those of Dr. Jurin of the Royal Society in the period
1720-30, when the fatality rate was stated at about 16 or
17 per cent. Bearing them in mind, however, for what they
were worth, the next available figures were those of the
London Small-pox Hospital, where from 1746 to 1763 the
fatality rate was over 25 per cent, and in the last quarter of
the eighteenth century it had risen to over 32 per cent.
Small-pox was, therefore, becoming a more severe disease
throughout the eighteenth century. In the nineteenth
century among the unvaccinated there had been in the early
years a further rise, the period 1836-51 having a hospital
fatality rate among the unvacciuated of 37*5 per cent.,
though at that time the severer cases were often sent to
hospital and some proportion of milder oases might be kept
at home. In # the epidemic vear 1838 the unvaccinated rate
was 40*1 per cent., but the reservation iust mentioned has to
be borne in mind. In the epidemic of 1870-73 the Metro¬
politan Asylums Board Hospitals had an unvaccinated
fatality rate of 44 8 per cent , say 45 per oent. This
appeared to indicate the maximum virulence in respect of
epidemic fatality which small-pox has reached in this
oountry during the past 200 years. It is not merely
statistics which justify this view. Dr. Munk and Mr.
Marson, the medical officers^to the London Small-poX
Hospital, which was then still in use, referred to the
malignancy of the disease as being very largely in excess of
anything within their experience, and Dr. Seaton, reporting
to the Local Government Board, wrote similarly. During
the half century which is neatly completed since the epidemic
of 1870 73 there has been, with the exception of London in
1901-02, great and practically continuous diminution in the
fatality of natural small-pox in this country. In 1873-84
the metropolitan hospital*’ nnvaccinated fatality rate fell
to 38*6 per cent., and in 1892-93 the London rate was 24*2
per cent. In 1892-95 a large number of populous places had
amongst them 2349 unvaccinated cases, with 602 deaths, or
25 2 per cent., practically the same as in London. In the
most recent epidemic, that of the early years of the present
oentury, it had already been pointed out that the London
area suffered from the African type of small-pox, and the
fatality rate among the unvaccinated was 33* 1 per cent. In
the provinces, however, in fully a thousand unvaccinated
sales the rate was 19*3 per cent. Subject to the reservations
previously noted, this would indicate that the wave of
fatality which for want of earlier data has been taken as
beginning in 1720, kept on increasing until the pandemic of
1871 72, and since that time has been decreasing. Sub¬
sequent to the epidemic of 1901-05 there has been little
prevalence of the disease, but such figures as exist, broadly
looked at, continue to point in the same direction. The
diminution depended largely, though not entirely, on the
substitution of the American type for the African type.
Infactivity.
Two factors go to make up infeotivity—one the quality of
the infection and the other the quantity. Bacteriology
had not yet conclusively identified the organism of small-pox,
bat observation showed that in respect of the quality of ir-s
infection it has more resemblance to scarlet fever and
diphtheria than to measles and whooping-cough. In measles
there are practically no sporadic cases. A single case means
an epidemic. Whooping-cough tends in the same direction.
In scarlet fever, on the other hand, sporadic cases, not
necessarily portending an epidemic, are frequent. In
diphtheria Dr. D. S. Davies of Bristol found that change from
the sporadic to the epidemic type of the disease was accom¬
panied by definite change in the characters of the organism.
In small-pox “sporadic ” cases in inter-epidemic periods are
not uncommon. Epidemics sometimes begin very slowly, but
sometimes break out very suddenly. London in 1901 and
Gloucester in 1895-96 are examples of a slow onset. On the
other hand, Edinburgh in 1903-04 had a rapid onset of its
epidemic.
Leaving quality aud dealing with quantity, the amount of
the eruption, both Cutaneous and buccal, is, broadly speaking,
the measure of infectivity. But the amount of eruption is
also related to the fatality rate. It has steadily diminished.
So also has the average amount of eruption, and so again the
infectivity. Small-pox, therefore, has been in recent years a
much less infectious disease than half a century ago.
Prevalence.
As to prevalence, fatality and infectivity being reduced,
it follows that other things being equal prevalenoe must also
have diminished, and Dr. Bruce Low's Report gives abundant
evidence of the fact. In England and Wales tne deaths
have remarkably diminished. In five successive decades
they have been—
1867-76' 1877-86 1887-96 1897-1906 1907-16
58,614 18,026 -4892 4763 139
The notifications since 1911 have been very few, an! In
1917 the extraordinarily low figure was reached of 5 cases
for the whole of England and Wales, 2 of the 5 being in
port towns. In Edinburgh and Glasgow, in the five years
1912-16 inclusive, there was not a single notification, and in
the 12 years 1905-16 the two cities had only 37 cases with
1 death. In Ireland, in the 12 years 1906-17, there has
been 1 death. The Scandinavian countries have shared in
this remarkable absence of small-pox, and so also has
Holland, but in several European countries—France, Spain,
Portugal, Italy, aud Russia—there has been no snch dis¬
appearance of the disease. In Britain, however, during -the
last half-oentury there has been, with the exception of the
metropolitan epidemic of 1901-02, a fairly steady diminution
in the fatality, the infectivity, and the prevalence of small¬
pox. This diminution has progressed at an increasing rate
of speed, and since the mild epidemic of 1901-05 the oountry
has shown an * unparalleled degree of freedom from the
disease.
LECTURE II.
Vaccination ab it Was and Is.
Neither infantile vaccination nor revaccination has ever
been really compulsory in the United Kingdom. The utmost
penalty has been the infliction of fines, and non-payment of
a fine has sometimes involved imprisonment, but the law has
never allowed a child to be taken oat of its mother’s arms and
forcibly vaccinated.
In 1898 an exemption danse for objectors was enacted.
Procedure for exemption was made easier in 1907. Domici¬
liary vaccination has been, to a great extent, substituted for
vaccination at public stations since 1898. The age for
obligatory vaccination has been raised in England from
3 months to 6 months, as in Scotland. Revaccination it
entirely voluntary in both countries. The practice of
infantile vaccination has greatly diminished, owing partly to
the remarkable absence of small-pox, and partly to the
provision for exemption. In England in 1912 only about
half the infants born were being vaccinated, and no doubt
there has been farther diminution since then. In Scotland
in 1916 the percentage of infants remaining unvaocinated
was 41.
The doctrine of vaccination has altered in respect of
increased recognition of the need for revaccination, and the
value of recent vaccination when the disease prevails. Opinion
as to the proper age for systematic revaccination has changed
in the direction of earlier repetition, 9 or 10 years being sub¬
stituted for adolescence, especially in presence of small-por,
and when there is appreciable risk of infection vaccination
should again be repeated.
In Germany up till the beginning of the war such few
cases of small-pox as had occurred were largely on the
frontiers of the Empire, which were subject to infection
fr Russia or other ill-vaccinated countries. The intern¬
ment of two or three millions of Russian prisoners daring
the war has permeated Germany to an unparalleled degree, and
in Berlin in 1917 there were about 4000 cases of small-oox
with 400 deaths. Previous to the war the general standard
of vaccinal protection was so high that the section of the
population which was drifting towards return of susceptibility
was largely protected from exposure to infection, but the
to LAVOTR,] PR. J. 0. MoVAIL : HALF A CENTURY OF 8MALL-P0X AND VACCINATION. [Mahqp 22, 19X9 451
war has changed that. The male population of Germany, in
so far as it serves in the army, had received the protection
of a second revaccination on joining the forces, while the
rest of the population has bad a single revaccination.
Probably most of the recent small-pox has occurred in the
latter section. As in this country the civil population of
Germany was never subject to forcible vaccination or
revaccination. The highest penalty was by money fine or
three days' imprisonment, but vaccination and revaccination
have been on the same legislative footing, and the population
has been well-drilled in obedience to the law.
Call lymph .—The substitution of glycerinated calf lymph
fpr humanised lymph has been of great value, not merely in
relieving parental anxiety, but in making it possible on
the shortest notice to provide vaccine lymph to meet the
most extensive epidemic. In the pandemic of the early
44 seventies,” not nearly enough lymph could be obtained
from the children presented weekly for vaccination to meet
the necessities of the general population requiring protection.
The Local Government Board is now understood to store
lymph to the extent of half a million tubes.
Diminution of infantile vaccination has to some degree
been balanced by the increase in re vaccination, and the
war will have added greatly to the protection of the male
adult population, but on the whole the country is distinctly
less protected by vaccination than it was even 20 years ago.
Infantile vaccination and the spread of small pox. —It had
been argued in recent years by Dr. G. Ktllick Millard that
while recent vaccination can be thoroughly relied on to
protect the individual, infantile vaccination is on balance
disadvantageous because it often makes subsequent small-pox
so mild as to be unrecognisable, with consequent spread of
infection by missed cases. The lecturer did not agree with
this view. It would surely be wrong to refrain from protect¬
ing one individual against severe or fatal small-pox in order
that other individuals, adults or children, shoald escape the
result of omission by themselves or by their parents to
secure a safety which is open to all. It was unquestionable
that modification, as well as prevention, of small-pox was
one of the results of vaccination, and, indeed, was claimed
as one of its virtues. It was true also that an eruption of
10 pustules would be more readily overlooked than an
eruption of 100 or 1000 pustules, but it must never be
forgotten that the quantity of inherent infectivity was
correspondingly less—was only a tenth or a hundredth.
While a medical officer reporting on small-pox might
naturally think of mild oases only as increasing his diffi¬
culties in the way of diagnosis, he ought to bear in mind that
small-pox is not by any means always recognised in its
early stages even if it is severe, and that a single missed
case of high infectivity—say, in a vagrant—may make all the
difference in the spread of infection. Also, non-notification
was sometimes due to oonoealment, and a mild concealed
case would be much less dangerous than a severe concealed
case.
The epidemics of 1862-65 and 1902-05 had been so mild
that independently of vaccination the difficulty of diagnosis
was greater than ever before, so that missed cases were often
referred to in medical officers’ reports. But easy diagnosis
oould be obtained at too great a cost. If a missed case is
naturally mild it will tend to spread a modified disease. If it
is artificially mild there will be reversion to the natural type,
aad if it be mild the difficulty of diagnosis will correspond.
If, on the other hand, it be severe, the desired facility of
diagnosis will be achieved in the first group, but at the
cost of a heavy attack with disfigurement or even death as
a frequent result. Sometimes a mild case does cause con¬
siderable spread of infection, but in other instances various
medical officers had recorded their surprise at the remark¬
able absence of infection. 8o far as mild cases did spread
the disease, it was mainly by indoor infection. Out¬
side, in the streets of a town, they seemed to do
little harm. The lecturer gave various examples in
support of this view—in Bristol, Derby, Halifax, Dundee,
Sydney, Dunbartonshire, and Stirlingshire. In the metro¬
politan area the type in the epidemic of the early “nineties”
was mild, while in 1902-05 it was severe. In the latter period
public health organisation was better developed, and with
the severe, and therefore easily diagnosed, type of the disease
the oases, according to the thesis under discussion, should
harfe been much fewer than in the mild epidemic of 1891-92,
with its difficult diagnosis and its inferior protective organisa¬
tion. Bat, in fact, the very opposite had been the oase.
There was much larger prevalence in 1901-02 than in 1892-93.
Possibly, however, other unknown factors were at work.
The very mild small-pox of America, notwithstanding the
constant traffic across the Atlantic (the journey taking less
than the incubation period of the disease), had not resulted
in any epidemic in this country since 1902-05. The similar
mild type in Sydney in 1913 had been carried into 27
country towns or districts, but the total diagnosed cases in
all these amounted only to 52. Gloucester’s epidemic of
1895-96 was severe, and therefore ea>ily diagnosable, but
Glouce-ter would have been much better if its population
had had the benefit of systematic vaccination in infancy.
Spread of scarlet fever through unrecognised cases furnished
a false analogy. The infection of scarlet lever was now
believed to be much more from the throat than from the
skin, and there might be a scarlatinal throat with practically
no skin eruption. The anal gy of small-pox inoculation was
also unsound. Inoculated variola was an infectious disease,
vaccinia is not.
The effect on the condition of the community of the dis¬
continuance of infantile vaccination had to be borne in mind.
Under exposure to small pox the proportion of vaccinated
pemons infected is much less than of unvaccinated. For
nine or ten years after infantile vaccination, especially
if sufficiently performed, the individual has a large
degree of immunity not only against death but also
against attack, and the protection in diminishing degree
continues much longer, especially against death. The
fatality rate of small-pox in childhood is exceptionally
high, but it Is childhood which is specially protected by
infantile vaccination, and children allowed to remain unvac¬
cinated in the interests of easy diagnosis would be more
likely to have a fatal attack than if the disease were deferred
till later years. This would be part of the price of easier
diagnosis.
There was, however, one conceivable condition which
would not only justify, but demand, the cessation of vac¬
cination. If small-pox were to disappear, so also manifestly
would the need for vaccination, and the marvellous decrease
of the disease since the close of the outbreak with which this
century began makes such a possibility, however remote still,
yet apparently less remote than ever before.
Control of Small-pox in the Present Day.
In discussing the control of small-pox in the present day
it was necessary to take account alike of attack and of defence.
As to the former, small-pox is a less fatal, a less infectious,
and a less prevalent disease than it was half a century ago.
The disease is not infectious in the incubation stage. Its
infectivity is limited in the pre-eruptive stage and does not
reach the maximum until vesioulation and pustulation. It
is not conveyed by water-supply or drainage; milk epidemics
are unknown ; and there are no chronio carriers. Epidemics
often begin slowly and allow an appreciable period for urgent
preventive measures. The modern method of small-pox
control consisted of the following items: Vaccination,
compulsory notification, a sufficient publio health staff,
surveillance of contacts, isolation of cases, disinfection,
local cooperation and central coordination.
Vaccination and revaocination claim the first place, and
under the system of calf-lymph supply, material was very
quickly available to meet any emergency. Also the vaccinal
process runs a shorter course than the incubation stage of
small-pox, and if the operation be performed within
two or three days after infection vaccinia gets home first.
Revaccination, however, may fail and adults engaged In
manual labour may have some inflammation around the
vesicles, though this can largely be guarded against. To
enable a newly vaccinated workman to get a few days' rest
many health authorities make a small money payment. The
immunity obtained by recent vaccination is of the highest
degree, as was strikingly exemplified in Glasgow in 1901-02.
Vagrants are a special source of danger and a constant
difficulty against which legislation has not yet provided any
sufficient remedy. *
Notification.
Notwithstanding opposition various local authorities, by
means of local Acts, began to obtain powers of compulsory
notification from 1876 onwards Under the adoptive Act
of 1889 any local authority could obtain these powers, and
the law became compulsory in 1899. Notification is of
452 The Lancet,] DR. J. 0. MoVAIL: HALF A CENTURY OF SMALL-POX AND VACCINATION. [March 22,1919
essential importance. Fifty years ago the knowledge which
came to the public health officer was casual and frag¬
mentary. Now there is no disease which the medical prac¬
titioner is more certain to report than small-pox;, whether
actual or suspected. Diagnosis is essential to notification,
and every opportunity should be taken of demonstrating the
characters of the disease alike to students and practitioners.
Action taken by the Royal College of Physicians in 1887 had
resulted in the Metropolitan Asylums Board’s hospitals being
made available for education, and so also it is now in respect
of small-pox hospitals throughout the country generally.
Public Health Staff.
Here there had been great improvement since 1870. At
that date there was in Scotland only a single whole-time
medical officer of health. Facilities for the study of disease
prevention had immensely increased, and medical officers
and sanitary inspectors were infinitely better acquainted
with their duties now than half a century ago; also there
were far more of them.
Surveillance of Contacts.
Surveillance of contacts was no doubt attempted in
rudimentary fashion even in the epidemic of the “ seventies,”
but there could be nothing in the least approaching thorough¬
ness until notification became compulsory. The first period
in which surveillance could be practised on any large scale
was in the epidemic of 18921-95 by authorities who had
adopted the Notification Act, and reports show that it was
well carried out in many places. Investigation was required
as to the source from which the first notified case had been
infected, and also as to every contact, indoor and outdoor,
the indoor contacts being under much greater risk of
infection than the others. Contacts did not require to be
seen daily during the incubation period, nor even to remain
off work, until the critical days had arrived. There is at
present no power to compel them to remain under conditions
permitting regular observation, and in common lodging-
houses it will often profit a health authority to make a small
payment to induce contacts to remain.
Reception houses for individuals and for families are
useful in large towns, but are much less necessary in the
country.
School closure is a question of circumstances. The
lecturer had never himself dosed a school for small-pox.
Contacts are naturally more difficult to supervise in the case
of a migratory population, in the East-end of London, for
example, as compared with the residential parts of the
metropolis.
Isolation.
One of the earliest advocates of isolation as a supplement
to vaccination was Sir James Y. Simpson in 1868. Simpson
stated that Jenner’s immortal discovery was saving from
death probably 80,000 lives annually, but that about 5000
still died from the disease, and though better attention to
vaccination would reduce this number, yet in the meantime
the disease still revelled with fatal power. He proposed
four regulations :—(1) Notification ; (2) seclusion at home
or in hospital; (3) the surrounding of the sick with nurses
and attendants immune by cow-pox or small-pox; and
(4) disinfection. He thought isolation might be conducted
either at home or in hospital, and that the stage of infec¬
tion of small-pox was not reached for some days after the
eruption appeared. In this he was mistaken, but except¬
ing that he made no mention of contacts, his scheme
showed a characteristic grasp of essentials. Simpson’s
proposal had been put before the Royal Commission on
Vaccination without any hint that he had made any
reference whatever to vaccination, and the dissentient
members of the Commission had not been aware of this,
so that in their Statement they also made no reference to
Simpson’s views on vaccination. Their statement again
had been relied on by Dr. Millard, and so the omissional
error was being perpetuated. Others, Dr. George Buchanan
and his successor. Dr. Thome Thorne, had also urged the
value of isolation, which at that time was being denounced
by antivaccinationists no less violently than vaccination
itself. Nowadays, however, it is advocated by them almost
as if it were a discovery of their own, and could be a
substitute for vaccination. Small-pox hospitals would be
needless if vaccination and revaccination were universal,
and would be useless if there was no protected population
from which a hospital staff and all connected with isolation
measures could be recruited. Hospitals at first, owing to
their situation and management, had been centres of infec¬
tion, but now they were themselves isolated as well as
isolating their patients. The amount of accommodation
required for any given community could not be specified
beforehand, but there should be a sufficient administrative
block and a sufficiency of ground to eoable rapid extension.
Their proper management involved many details which were
dealt with in the lecture.
Occasionally, even yet, a local authority was without
separate accommodation for small-pox, and in emergency
the medical officer had to devote to small-pox a hospital for
ordinary infectious disease. This could sometimes be done
by setting apart for separate purposes the several hospitals
in a given area. If, in the absence of any alternative,
small-pox had to be treated in a pavilion in the same grounds
with wards for other infectious diseases, the vaccinal con¬
dition of all patients had to be noted and such action taken
as was required. Where a small-pox epidemic gets out of
hand, as was the case in Gloucester, Dewsbury, and Middles¬
brough, hospital isolation breaks down, and control has to
depend solely on vaccination and revaccination.
Disinfection.
Disinfection in small-pox has to be very thorough, and in
the case of bedding destruction is safer than disinfection,
though the problem is difficult in a common lodging-house or
navvies’ hut, where the same individual may have used two
or three beds in succession, or where the sleepers may
change from night to night.
Local cooperation and central coordination must not be
neglected. The medical officer should inform his colleagues
in surrounding areas and should intimate the date of
exposure of contacts, so as to guide action and save
time. The Local Government Boards of England and
Scotland require that every case be reported to them, and
they intimate to such authorities as may be - concerned.
Also, they usually send an inspector to assist both in
diagnosis and in administrative and preventive measures
generally.
In illustration ot the application of the modem method of
control in rural areas an account was given of a small-pox
outbreak among navvies during the construction of the West
Highland railway in Dunbartonshire in 1892-93.
Leicester and smallpox .—No survey of the present-day
control of small-pox would be complete without reference to
what had come to be known as the Leicester method. In 1887
the lecturer had ventured on a prophecy as to what might
befall Leicester under its method, and the prophecy had
been repeatedly quoted, but always with omission of the
fact that it was a conditional prophecy, the test stipulated
being the recurrence of an epidemic like that of 1870-73.
That test had never been applied. But as regards Leicester
the essential facts were, that small-pox is not now in
respect of fatality or infectivity or of prevalence the same
virulent disease that it was formerly, that glycerinated naif
lymph is now easily available for any amount of emergency
vaccination, and that the Leicester method as expounded by
its protagonists a quarter of a century ago differed in
fundamentally important respects from the method now
followed. In addition to the excellent practice of observation
of contacts, which was creditable to the medical officers
concerned from about 1877 onwards, it had been claimed
for the Leicester method (1) that it was without recourse to
vaccination; (2) that the whole method was voluntary;
(3) that the same hospital was used for small-pox and all
other infectious diseases at the same time; (4) that the
same hospital was also used for the (voluntary) quarantining
of contacts ; and (5) that compensation for loss of time of
contacts was not offered. Every one of the-*e five items had
been given up, though indeed as to the first, vaccination
never had been entirely dispensed with, and the extent to
which it was now used was indicated by the fact that in the
last epidemic the medical officer had induced nearly 800 out
of 1084 contacts living in infected houses to submit to
vaccination.
As to compulsion it is unbelievable that the medical
officer lets any patient fit for removal remain at home if
the public is thereby endangered. The use of the same
hospital for small-pox and all other infectious diseases was
abandoned in 1892, and the quarantining of contacts at the
hospital was given up in the following year. Compensation
for loss of time is now declared to be one of the special
The Lancet,}
MR. P. 0. VARRIER-JONES; FUTURE OF THE TUBERCULOSIS PROBLEM. [March 22,1919 453
features of the method, while originally the declaration was I
just the opposite. It is not vaccination but the Leicester
method in most of its features, which has been abandoned
in Leicester. At the same time small-pox has become less
fatal, less infections, and less prevalent, and under these
conditions Leicester had only 355 cases in the epidemic of
1892-93 and 715 in 1903-04, showing that with the mild type
of small-pox which prevailed in the provinces in these two
epidemics the modern method, which has taken the place of
the Leicester method, can achieve some measure of success
even where there is a large unvaccinated population, and
where pressure towards recent vaccination is applied only to
contacts.
The Leicester medical officer of health had in 1904
prudently made the reservation that perhaps Leicester had
been lucky in having so mild a type of small-pox in its two
epidemics. More recently he had scouted his own reserva¬
tion as to luck. But in fact Leicester, just like the pro¬
vinces in general, had been visited by mild small-pox of the
American type. Leicester, however, had really been for¬
tunate in respect of the skill, activity, and vigilance which
had distinguished the work of Dr. Joseph Priestley in the
earlier epidemic and Dr. Killick Millard in the later. That
had constituted Leicester’s luck.
What of the Future ?
More than a quarter of a century ago the lecturer had
speculated as to whether small-pox might not die out in
the future as leprosy had done, but he had argued then that
epidemics had been too recent and too severe to justify any
assumption to that effect. During the quarter of a century
that had elapsed since that speculation had been indulged
in the position haid vastly improved, but even yet one did
not dare to assume that the danger had become negligible or
frail disappeared. No epidemic, such as had followed the
Franco-Prussian War, had up till now been a sequel to the
European War, and the return of the revaccinated armies to
this country would really improve the general position as
regards national protection. There is, however, a sub¬
stantial risk of importation by persons from countries like
Russia or Poland, with which communication is again
opened up.
Wars have been followed by various pestilences amongst
the civil population. As recorded by Dr. Prinzing, bubonic
plague, typhus fever, dysentery, typhoid fever, and small¬
pox have been concomitants of great world struggles. The
virulent pandemic of influenza has so far been the only out-
standing accompaniment of the greatest of all wars, though
in Germany, as already noted, the enormous number of
Russian prisoners introduced the infection of small-pox,
which obtained more hold than that country has ever experi¬
enced since it adopted its great system of vaccinal pro¬
tection. It is too soon yet to prophesy that we have seen
the last consequences of the European War in respect of
epidemic disease. If, however, small-pox were to invade
this country the measures at our disposal and our preventive
equipment generally should enable us to deal with it,
despite the fact that on the whole we are going back on.
rather than developing, our position in regard to general
protection obtained beforehand. If the disease is of the
mild or American type with low infectivity it is all the less
to be feared. If, on the other hand, the old European type
of the 1 ‘ seventies ” should begin to develop the means for
meeting it are at hand. If vaccination and observation of
contacts, supplemented by isolation, disinfection, and other
measures for checking epidemics, were to prove insufficient,
then he had no doubt that the spread of infection would
result in the general adoption of the one solitary measure
capable of controlling an extensive epidemic. That measure
is vaccination, but it will be all the greater triumph of
vaccination if even a limited resort to it under the modem
method suffices to prevent any outbreak from assuming
epidemic or p an demic proportions. Just as Lister s antiseptic
system finds its greatest triumph in the aseptic system which
evolved from it, in the same way success of the modem
method of small-pox control will be the greatest triumph of
the Jennerian prophylaxis. _
THE FUTURE OF THE TUBERCULOSIS
PROBLEM.*
By P. C. VARRIER-JONES, M.A. Camb., M.R.C.S.,
L.R.C.P.,
HOX. RES ID EXT MEDICAL OFFICER, CAMB RIDGES KIRK TUBERCULOSIS
COLO ST, PAPWORTH.
Bristol Children’s Hospital.— Mr. H. H. Wills
han recently presented over an acre of land- immediately
adjacent to the Children’s Hospital for the benefit of that
institution. It is proposed to erect a nurses’ home for the
staff of the hospital.
In his opening remarks the speaker said :—I will attempt
to deal with a part of the problem only—a part in my eyes
perhaps assuming undue proportions and importance, but a
stone which, if built into the building we are all striving to
erect, may assist in strengthening the structure and help to
make the work of others easier and its completion somewhat
nearer of attainment. A broad view of the whole of our
problem is essential, but at bottom the problem is one of the
individual. One consumptive may resemble another in the
extent of the lesion in the lung, but differences of tem¬
perament, character, social position, not to mention varying
degrees of resistance to the disease, exist and have always to
be considered. Of course, the problem has its financial side,
and a very important side it is, but it cannot be insisted too
strongly that the question at issue is of far greater com¬
plexity, and unless this is recognised all our calculation is
work in vain. All of us are aware of the extent of the
problem. The question is, can we prevent the spread of
infection without which there can be no further extension
of the disease 7
Inadequacy of Pretent Measures.
It is unfortunately necessary at this stage to clear the
ground somewhat, for there still exists at the back of the
minds of some a doubt as to the infectiousness of the
disease. We here, no doubt, are firm believers in the
infectivity of tuberculosis—that it is contagious, that the
spread of human tuberculosis (i.e.» infection v^ith the human
bacillus) 1 is by direct, or in some cases indirect, means
from one human being to the other. We give this hypothesis
our lip service. Our words do not come up to our faith.
We have certainly honoured the statement, but in the breach
rather than in the observance. How often do we hear that
the chief r61e of sanatoriums is that of education ; that the
patients who are discharged after a short stay have been
instructed in the way of life and know how to live a life
perfect in hygiene and adapted for the prolongation of work¬
ing days. But what opportunity have they to put the
precept into practice ? Are not veritable sources of infection
everyday, sent broadcast over the land ? What steps are
taken to prevent the spread of infection when we allow
these unfortunates to wander at will 7 No doubt we keep the
spark of life Alight by small doles of money or food, we
find underpaid jobs for them, we allow them to be
exploited in the labour market, and we give all these
endeavours a name of high-sounding Quality and cAll it
“ After-care.” 1 '
We all know how rapidly a consumptive who has had
treatment at a sanatorium descends the social scale. The
interval between treatment in an institution and the case
becoming “advanced” is often very considerable, and it is
throughout this time that nothing, absolutely nothing,
adequate is done to prevent infection. Of course, 1 shall be
told that I have forgotten our important service of health
visitors and sanitary officials, who are daily making strenuous
efforts to prevent the spread of infection and with much
labour are paying daily visits to the homes of these people
and instructing them in the way they should go. I agree,
but they are engaged on a superhuman task ; the patient’s
life is so varied, the circumstances so changeable, that it is
impossible to secure an amount of supervision that can have
any appreciable effect upon the spread of infection.
The middle case, coughing often—whether at work or in
the home, or in places of amusement,—-is an ever present
source of danger and, unless sufficiently isolated, must be a
centre from which dissemination of the disease takes place.
The treatment—a term as elastic as it is vague, for in its
true sense it can have no meaning when it refers to a con¬
sumptive patient in bad surroundings—is of no‘avail in
preventing the spread of infection.
* A paper read before the Royal Institute of Publlo Health,
i The bovine bacillus being responsible for a very small proportion of
pulipouary tuberculosis, probably not more than 1 per cent. (Corbett).
454 Thb Lancet,] MR. P. C. VARRIER-JONES: FUTURE OF THE TUBERCULOSIS PROBLEM. [Match 22,1919
The Difficulty of the Problem .
If it were oar object to perpetuate the disease, there could
surely be no more certain method than the one we now
adopt. We have, indeed, adopted a faith blindly, or we do
not accept a faith we profess. To say that it is difficult to
oonvert our faith into works is to beg the question. That it
is difficult should not make us shut our eyes and go gaily on
in the opposite direction.
It may, of course, be the fear that after all we are not
quite sure that the disease is infectious, for what is the
evidence ? Or, again, it may be the knowledge that the task
to which we have put our hand is, indeed, impossible of
attainment. In other words, we aooept it as quite impossible
to control the sources of infection, and that these sources are
so numerous and unknown that no method of segregation
could be devised to include not all, but even a small
proportion, of them.
Is it a fact, for example, that just as there are carriers of
the germ of diphtheria, so there are carriers of the tubercle
bacillus, who go through life without any symptoms which
might at any time attract attention, and yet are the means
of handing on the disease to several, nay/nany, persons. I
might illustrate the point by a concrete example. A
Cambridge undergraduate, a fine athletic man, developed
what was diagnosed as an attack of influenza. Its course
was prolonged and there was cough and expectoration. The
sputum was repeatedly examined, with negative results. The
patient recovered completely. Some months afterwards he
suddenly coughed up a mass of sputum, and being of a
carious turn of mind brought it to the pathological labora¬
tory with a request that it should be examined. Under the
microscope the specimen was almost a pure culture of
tubercle bacilli, so numerous were the rod-shaped organisms.
The patient was apparently in the best of health.
It may be argued that such a case would be very difficult
to discern, very difficult to isolate, and it may well be that
amongst the well-to-do, those who live under the best con¬
ditions, the disease is spread by such an individual as I have
just described.
Tuberculosis Does Not Weed Out the Unfit,
That insanitary houses, want of food, lack of the
necessaries of life are not the only predisposing causes of
tuberculosis seems clear, for tuberculosis takes its toll from
the rich as well as from the poor, from the athletic as well
as from the poorly developed. This leads me to another
point. It is often argued that tuberculosis is the great
means adopted by nature to weed out the unfit. Such a
statement is grossly inaccurate; it has done incalculable
harm in preventing our legislators and the publio at large
from seeking the adoption of right methods of dealing with
the problem. Tuberculosis never has been, and never will
be, the means of improving the race—no disease him ever
helped to such an end, and no disease ever will. It is the
victim of tuberculosis, when that disease has worked its
will, and not until then, who is the unfit. He has been
made unfit by the disease, he was not unfit before he was
attacked.
Recently, making a careful examination of the histories of
all the patients admitted to the Cambridgeshire Tuberculosis
Colony, it came as a surprise to me to find how high was the
percentage of men who had led an athletic life before they
were attacked by the disease. Many were conspicuous for
the skill they had once displayed either on the football field
or in some other strenuous pursuit. Looking back at one’s
own undergraduate days one is struck by the news of the
illness, or even in some cases of the death from tuberculosis,
of those whose physique was universally admired and whose
prowess in athletics was specially commented upon.
Again, amongst soldiers discharged from the Army
suffering from pulmonary tuberculosis it is the exception to
find that those who are admitted for treatment are those
who were placed by the Recruiting Medical Boards in
Grade 3. Upon investigation it is clear that the men who
are now invalided out of the Army on account of tuber¬
culosis are those whose physique was particularly good and
whose general condition gave no easy or obvious clue to the
presence of a lesion of a tuberculous nature in the lung.
Would it not be well that this investigation should be prose¬
cuted in other localities ? Were this done I have little doubt
that my Cambridgeshire results would be confirmed.
We know that those who have an exceptionally well-
developed brain, those endowed with mental capacity far
above the average, fall a prey to the disease in no fewer
numbers than do those not so endowed. We have merely to
call to mind such names as John Adington Symonds, John
Richard Green, Shelley, Keats, Chopin, Mozart, Robert Louis
Stevenson, Jane Austen, Charlotte Bronte, and Washington
Irving, amongst a host of others, to convince ourselves that
if the brainless ones are often attacked by the tubercle
bacillus, those to whom genius has been attributed are
attacked in equal, if not in greater, proportion.
Look at the question how we will, we are forced to the
conclusion that the tubercle bacillus is no respecter of
persons, the strong and .the weak alike are attacked; there
is no question of any special susceptibility of the feeble and
the weeding out of suoh in order that the race may be
improved. The error so widely promulgated has done
incalculable harm.
The Method of Attack.
The crux of the question is the problem of the “middle
case.” First the spread of infection must be limited. Onr
energies should be concentrated not so completely on the
symptoms of the diseased—those who have well-defined
symptoms and signs, in whom the lung tissue has broken
down and by whom the bacilli are freely expectorated—in
futile attempts to “cure” individuals. Rather must we
devise and press forward a comprehensive scheme whereby
the individual for whom we are arranging to care shall be
placed in a position in which he may have the advantages of
treatment which may bring about the arrest of the disease
whilst at the same time he shall be rendered inert as an
infective centre to the community. When we as a
community realise that the segregation of consumptives
during treatment can be made a practical proposition we
shall have advanced a long way towards the elimination of
infection. The advice to treat early cases is excellent, but
until the mass of medical knowledge accumulated is sufficient
to ensure this advance little progress along these lines can
be made, though all efforts to attain it should be encouraged.
The greatest difficulty met with in carrying out after-care
of the majority of these “middle” cases is the provision
of suitable employment and occupation for them. Any
frequently recurring breakdown, any lack of sustained
energy, any want of power and physical force must unfit
the worker to “carry on” under the ordinary workaday
conditions in which the normal person works. No one
realises this more fully than does the consumptive. Why,
then, does he try to exist under such conditions? Simply
because there are no others under which at present he can
exist. No practical proposition has been placed before Mm.
To maintain these cases in moderate health the equivalent
of a living wage they must have, although they cannot be
employed when a profit-and-loss Bheet has to be drawn up
and balanced. We cannot expect them to be a paying pro¬
position. I have always maintained, and I believe that I
have been justified in maintaining, that the labour of a middle
case of consumption must be subsidised and that many of
our failures in the past have been dne to the faot that,
consciously or unconsciously, we have always taken the
consumptive at his face value. We have been too much
influenced by appearances and feel that he ought to do more
work than can really be expected of him.
We have only to glance at a group of consumptives to feel
almost convinced unless we are “ on guard ” that they are a
group of slackers. They appear so fit. Yet on applying the
stethoscope our opinion is, or ought to be, instantly modified.
Patients suffering from epilepsy are utterly incapable of
earning a living under present economic conditions; a
consumptive with moderate disease is in exactly the same
position. We must bring our minds to realise this. When
we have also educated the consumptive to realise this, we
shall soon recognise that both from the individual point of
view and from that of the community we must call into
existence a set of conditions suitable to the patient's needs .
Such conditions are to be found in a colony. We must
realise, difficult though that may be, that the medioine of
yesterday has been satisfied with the treatment of symptoms,
with the relief of individual suffering. In tuberculosis, at
any rate, is it not time we started at the right end, to give up
trying to heal symptoms, to catch up in a losing race ?
Provisions Required at Colonies.
Colonies to be successful, to meet present needs, mart
include the sanatorium or rest house, and must extend the
activities of sanatoriums both downwards and upwards. They
TnL AMO**,] MR P. 0. VARRIER-JONES: FUTURE OF THE TUBERCULOSIS PROBLEM. [March22,1919 455
must receive advanced cases that will not consent to enter
a home for the dying, bat will grasp at the last straw of
hope such as can be held oat at a sanatorium. Opportunity
for healthfal work and healthful surroundings must be offered
to those unfortunates who can no longer compete with the
fit men in the world at large.
The early cases receive treatment and training, and with
the added inducement of remunerative work may be kept
under prolonged treatment and fitted to return to the world
with the disease arrested. But the whole system must be
linked together into a concrete whole. The usual conception
of a colony is a place where tuberculous cases can be sent,
there to work for a wage which is little more than pocket
money, but where there is no room for cases that present
any physical signs of disease. Indeed, so limited becomes
the selection, due to the rigid medical examination, that
few cases can be submitted to this special building-up process;
and when to this is added the enormous difficulty of per¬
suading a man to undergo training while a wife and family
live on the bare necessities at home, we see that if this con¬
ception be accepted the scheme must be of very limited
scope, more limited even than that of the sanatorium.
When, further, we consider that no practical man believes
that he can be trained as a practical farmer or small-holder
in a few months, and that even 12 months is not sufficient,
we begin to appreciate the reason that so few men will
consent to undergo the ordeal.
We know and they know that a poorly trained man stands
no possible chance of earning a living wage in the open
labour market, and a poorly trained consumptive even less.
It is obviously far better for such an early case (I am
speaking of the tubercle-free patient, devoid of physical
signs—Hie usual candidates for such a colony) to be so
financed by an after-care association on the Cambridge
principle that he may oontinue to work at his own or some
allied trade. As yet (he is not a danger to the community ;
when he does become so, if under dispensary supervision, he
can be persuaded again to enter an institution. *
The Case with Active Disease.
When we come to deal with cases of the next category the
story is very different. The man has active disease, albeit
somewhat retarded by treatment at a sanatorium. He is
refused admission to a colony such as that just described, he
cannot without a serious relapse return to his original trade,
he cannot be suitably helped from outside by an after-care
association as his relapse is certain, and because of the
extreme difficulty of finding suitable employment for him.
These are the cases which, unfortunately, are now assisted
with small doles of money and food and an underpaid job.
Better far that such assistance should cease and the patient
become an inmate of an institution. The man receives but
palliative treatment, and the community no real protection
against infection.
The pity of it is that we do not realise that under favour¬
able and well-defined conditions the patient is capable of
doing more work. Such a case should, indeed, excite our
sympathy. Here a man obtrudes himself on our notice
six days out of seven—a man who cannot find his place in
the world, but who, left to his own devices, disseminates the
disease to his family or neighbours and fellow members of
the community. He is the central factor in the problem of
tuberculosis, a far more important factor than the advanced
case—the bedridden case—where, although the danger of
direct and concentrated infection is greater, it is so circum¬
scribed that it is limited to a small—family—circle.
In the past we have been content to limit our endeavours
to the favourable case and to leave untouched—untouched
as far as effective treatment and the prevention of infection
are oonoerned—the middle case. The reason for this is not
far to seek, we have been blinded by the transitory results of
sanatorium treatment and have shut our eyes to the wreckage
which such treatment has left in its trail. Very naturally
wo have no liking for disappointing results. The individual
case which goes steadily downhill is, it must be confessed, a
disheartening proposition if we are content to focus our
attention on the treatment of the individual.
It is obvious that our attention should not be so focussed,
but that we should survey the whole field in order that we
may make up our minds, for if we do not so make up our
minds somebody else will soon do it for us, that it is neces¬
sary, in the name of humanity and to protect ourselves, to
oaie for these oases. Once we view the problem from this
standpoint and grasp the essential fact that the disease is
spread by the middle case, we cannot escape the logical
conclusion that such cases demand our care and attention,'
and at once.
Admitting all this, the fear still possesses us that^so
gigantic a problem requires almost superhuman effort for
its solution. Sir Arthur Newsholme holds that by the
admission of advanced cases from amongst the poorer classes
into the wards of certain infirmaries the spread of the
disease has to a certain extent been lessened. Surely this
points the way to the next step—the segregation of these
middle cases in colonies, where, with the best chance
possible of recovery, they also cease to be a source of
infection to others. If by the voluntary segregation of
advanced cases a perceptible improvement has been made,
ia it not logical to assume that we may expect still greater
improvement when some method of segregation is found for
the middle cases, those who find themselves stranded and
unfitted for the struggle of existence in the world as^at
present constituted.
The Method Adopted at Papworth Colony.
Objections and reasons that such a proposal as that of
the Cambridgeshire Tuberculosis Colony must be difficult of
realisation are, of course, put forward. Allow me to take,
as a concrete example, Papworth Colony, where experiments
are in progress to test the conditions under which men will
remain in the country although used to town life, and not
town life only, but London life.
My experience is that the first great question to be con¬
sidered is that of a wage, or payment for work done. The
difficulties surrounding this question are many and complex.
To begin with, we are confronted by certain provisions of
the National Insurance Act in which it is expressly stated
that any man working for a wage forfeits his sickness benefit.
Latterly, however, since it has been the practice in some
institutions to allow patients to work, the dividing line
between remunerative and non-remunerative occupation
becomes difficult of definition. No objection can be raised
to the institution paying to an after-care association a sub¬
scription equivalent to the value of the work done, nor can
there be any objection to that association paying over to the
patient a sum of money to supplement the sickness benefit
and thus enable his dependents to live in decent circum-.
stances while the man is under treatment.
This plan has been adopted at Papworth with success.
This method of procedure opens out very considerable possi¬
bilities, especially for the ordinary insured person. The
usual plea put forward by an insured person, especially a
married man with dependents, is that it is impossible for
him to live in luxury at a sanatorium while his wife and
children at home are asked to exist on 10s. a week, a sum
sometimes supplemented by a dole from the Charity
Organisation Society, but an extremely unsatisfactory
method. In the method adopted at Papworth, the sickness
benefit can be augmented within limits by the man's own
earnings , and he has the satisfaction of feeling that even
whilst undergoing treatment he is making a definite con¬
tribution towards the upkeep of his family. This method
is new, but I hope and believe it will be found to be
thoroughly sound.
It will thus be seen that a very definite link is forged
between the colony and the after-care association. The
inducement to earn a wage is so great, however, that it is
difficult to restrain the men from doing more hours of work
than are prescribed. So contrary is this experience to that
of sanatoriums that I fear I may not be believed, but it is a
fact. In our boot-repairing department during the first two
months, while the patients were apprentices, it was a matter
of surprise that the men could earn 12s. per week of
32 hours, at the rate of pay ourrent for boot repairing in
Cambridge, and this rate the men receive. Further, the two
apprentices, one a Limehouse labourer, the other a college
cook, have been taught by a practical boot repairer—a
London patient. This man has not only taught these men,
but has earned his money as an instructor at the same time.
The Solution of the Question.
. This makes clear four points: (1) That to change a man’s
trade is a practical proposition; (2) that the work can be
carried on under proper hygienic conditions; (3) that the
public have no objection to having their boots repaired by
consumptives ; and (4) that the labour must be subsidised to
456 THl Lanobt,] DR. K. D. BARDSWELL: Y.M.O.A. AGRICULTURAL TRAINING COLONY. [Mabc? 22, 1919
make it a practical proposition for the working man. The
moral to be drawn from this is, that once a practical pro¬
position is placed before these men—a sound commercial
proposition, not one from which they think the institution
is making a profit out of their labour—they will seize the
opportunity, for they know they are benefiting both from a
health point of view and financially; but unless you can
make the latter clear you can expect no success. I must
again insist that these men are “middle ” cases ; that they
have tubercle bacilli in their sputum, and are cases which,
left in their ordinary surroundings, would soon fall to the
bottom of the scale.
When we take into consideration the fact that these men,
being ex-soldiers, have a full pension of 27 s. 6d. per week,
it cannot be a matter of surprise that they consent to remain.
We have stated that the colony can and does offer better
conditions of work and that these involve no impairment of
a man’s self-respect. Applicants, of course, are not wanting,
but the State has the assurance that in return it is getting a
good bargain in the elimination of infection,
Similar results are being obtained in other departments,
and from them it is possible to draw only the same deduc¬
tions. The difficulty is that of demand and supply, and it
is here that great effort is needed and a very good business
brain required, but at present inquiries for goods and orders
placed with us keep the departments busy. It will be said
that this is the greatest difficulty of all, but it has been
repeatedly stated that the greatest difficulty was to get the
men to work. Having demonstrated that this is not the
case, I have confidence that the other difficulty will also be
got over.
The real solution of the question is a State subsidy for
tuberculous labour and the introduction of labour-saving
appliances to lessen the disadvantage under which a con¬
sumptive suffers. If that labour can be turned to account,
not in the way of reducing the oost of running an institu¬
tion—who ever thought of reducing the cost of a hospital
by employing chronic invalids on the staff ?—but in making
it contribute to the wage of such labour, the other part
being forthcoming from the State as its share of payment in
return for the prevention of infection, it seems to me that
the problem is well on the way to solution.
In any case, let us get rid of the fallacy that tuberculous
labour can be made to pay; of the idea that all the money
paid by the State it for the alleviation of tymptomt. Further,
let us concentrate on humane and voluntary segregation by
making it so attractive that few- consumptives will face the
difficulties and dangers of open competition if they can take
advantage of the facilities now provided. Public opinion,
educated on these lines, will soon insist on being rid of a
source of infection so dangerous to its well-being. Once the
facilities are offered, if offered in no miserly spirit, we may
see the dawn of a new era in the treatment (using the term
in the widest sense) of the disease.
Work in Other Departments.
The results of the carpentry and joinqry departments are
of considerable interest. At the head of the carpentry
department is a trained carpenter and joiner, who directs
the work and instructs the patients. We are now convinced
that useless work put forward merely as training is waste of
time and energy, but we find that immediately a patient
comes to the shop he is ready for light work on a definite
job. We have, however, to reverse the usual process of
training, for in the colony workshop he is instructed in the
fitting together of parts which have already been prepared by
those who have been longer at the work and have been
passed on to the heavier grades of labour. In other words,
the process is reversed, but by means of a method whereby a
patient is set to make one particular part—in fact, is placed
on repetition work—no time is lost and his labour is at once
remunerative. His interest is also immediately aroused, as
his skill develops so his strength increases, and the two
factors combined place him on a higher soale of productive
work.
It is my experience that very few patients fall below the
25 per cent, standard even at the beginning of their
instructional career, and the percentage increases monthly.
On repetition work they may ultimately attain an average of
50 per cent, and even rise to 75 per cent. I suspect that our
method has, perhaps unconsciously, been based on the experi¬
ence of munition works, but from whatever source it has
Come it undoubtedly meets with very considerable success.
Up to the present time disposing of our produce—shelters
—at the price quoted in the open market, we could during
the major portion of the time have paid a wage not muoh
below the trade-union rate. As an example, I would take
the accounts of the last year to illustrate the financial side
of our industry. The total receipts of the carpentry depart¬
ment allowed of a profit of 20 per cent, to be paid in wages.
There were working in the shops during this period 12
unskilled patients, and after paying instructors’ wages there
was a considerable sum available for division, as a wage,
amongst the 12 patients. In order to safeguard ourselves
when we come to undertake other work—we have brought
the shelter-making repetition methods almost to a fine
art—we stipulate that if we must turn out work at a
competitive price we must have a subsidy of 10 per cent, to
15 per cent, in order that we may pay our patients the wage
desirable and necessary. We have not needed this subsidy
so far, but our success must not blind us to the fundamental
fact that tuberculous labour must be subsidised, and even
considerably subsidised.
The Question qf a Subsidy.
The working day is but six hours, and even if the labour
could be paid for at a rate equal to that of a trained healthy
person, the total at the end of the week would be insufficient
to support a man, his wife, and family in the way in which
they should live. It will thus be seen that the question of a
subsidy is a very necessary and urgent factor in the problem.
We must not look upon this subsidy as a dole for the relief of
the patient, for on this the amount would, according to our
past ideas, be too great; rather must we look upon it as
money expended for the protection from infection enjoyed by
the community. Far better to have this assurance, than to
have the depressing pioture of a family in poverty and
distress, vainly endeavouring to struggle on with a varying
amount of poor relief and charity without any such protec¬
tion. In a colony such as we are trying to build up at
Papworth it is probable that the families of our colonists,
being easily accessible, may be so trained and educated that
they may be made stronger and safer for the struggle of life
than if they were allowed to remain under undesirable
surroundings of poverty and want. However that may be,
there is hope of a brighter future even though time may
unveil some of our errors.
May I close by quoting the words of a consumptive—
Washington Irving.
“ What after all is the mite of wisdom that I could throw Into the
mass of knowledge? Or how am I sure that my sageat deductions may
be safe guides for the opinion of others ? But In writing.if I fait
the only evil Is my disappointment. If, however, I can by any luoky
chanoe. In these days of evil, rub out one wrinkle from the brow of
care or beguile the heavy heart of one moment of sorrow. If I oan
now and then penetrate through the gathering film of misanthropy,
prompt.a benevolent view of human nature and make my reader more
m good humour with his fellow beings and himself, surely, surely,
then, I shall not have written In vain."
THE Y.M.C.A. AGRICULTURAL TRAINING
COLONY, KINSON, DORSET.
Bt NOEL D. BARDSWELL, M.V.O., M.D.Edi*.,
F.R.C.P. Lonu.,
MAJOR, R.A.M.C.(T.) ; MEDICAL ADVISER, LONDON INSURANCE
COMMITTEE.
During the summer of 1917 the Council of the Y.M.C.A.
established a farm colony at Kinson in Dorset for recently
discharged Army men with early or arrested tuberculosis.
The Council secured a small property which had served as a
private sanatorium, situated some five miles from Bourne¬
mouth and Poole, upon sand and gravel soil and enjoying a
good record of sunshine and rainfall. The land consists of
a farm of 33 acres, made up of 20 acres arable land, 9 of
grass, 2 of woodland, and 2 devoted to poultry. The farm
buildings include a small house, granary, hay and corn
barn, stabling for three horses, cart shed, chaff-cutting and
root-pulping shed, cow-house with standing for ten cows,
three calf booseys, piggeries, and other buildings.
The colony buildings consist of a central block constructed
of brick and tile comprising dining-room to seat 50 persons,
recreation-room, lecture-room, kitchen, scullery, stores,
linen-room, and other offices. Sleeping accommodation for
22 patients is provided in wobden chalets, each in two
sections, containing two beds. The Quarters for the resident
The Lancet,] DR. N. D. BARDSWELL: T.M.O.A. AGRICULTURAL TRAINING COLONY.' [Maboh 22, 1919 457
staff consist of wooden buildings and a small farm-house.
Water and gas are obtained from the local main. The
capital expenditure in purchase of property and erection of
additional buildings amounted to £4000 approximately.
When the colony was started it was intended to provide
the inmates with life under sanatorium conditions and a
training to fit them for permanently taking up work on the
land. An officer recently discharged from the Army, who
bad been trained as a farmer, and also had practical experi¬
ence of sanatorium routine, was appointed resident super¬
intendent. Medical supervision and direction were secured by
a weekly visit from Dr. E. Hyla Greves, of Bournemouth. The
resident staff included a male nurse and a working foreman.
The men admitted mostly came direct from various military
hospitals, chiefly upon certificates by the medical officers.
Whether at work or not, the men received Is. a day as
pocket money.
Scope of Scheme.
Several months’ experience showed that the objects of the
institution were not generally appreciated by the medical
officers who recommended patients for admission. A large
proportion of the patients sent to the colony were not such
as would benefit from the special educational facilities
offered. In consequence, early in 1918, after consultation
ferith the Ministry of Pensions, the training scheme was re¬
organised, as described in the following leaflet issued by the
Y.M.C.A. and the Ministry of Pensions :—
The Hinson Farm Colony, situated about five miles from
Bournemouth, provides accommodation for 21 ex-soldiers
who have been invalided from the Army on aooount of
pulmonary tuberoulosis. It iB designed to provide an agri¬
cultural training for men who wish to settle on the land
either in this oountry or in the colonies.
1. Applicants for admission must be suffering from quite
early or arrested pulmonary tuberculosis, provided that
tubercle bacilli have been found in the sputum, or if they
have not, the occurrence of an attack of pleurisy with
effusion or an unquestioned haemoptysis (of definite amount)
must leave no room for doubt as to the correctness of the
diagnosis.
2. They must be men whose previous work has been such
as would probably aggravate disease and who are, therefore,
desirous of receiving an agricultural training.
3. They will only be received from a sanatorium, and must
be able to work for at least six hours a day without pyrexia,
malaise, or undue acceleration of pulse.
4. They must have shown themselves to be intelligent
hard-working men, of good character.
5. They must enter into an undertaking to remain 12
months at the colony.
6. During the year’s treatment and training, the pension of
the colonist will be in abeyance, but an allowance at the
rate of 21s. 6 d. per week will be made for him from which
12*. per week will be deducted towards the payment of his
board and lodgihg. He will, therefore, be entitled to a sum
of 15s. 6 d. per week, during the twelve months he is at the
colony; of this sum it is proposed to pay over to him
5s. weekly, leaving the remainder to accumulate to his
benefit until he is discharged from the colony, or, should he
desire it, the balance may be paid weekly to such dependants
as he may select. 1 * It must be understood that the amount
accumulated will not be payable if the man leaves the colony
before the termination of his year, unless the medioal super¬
intendent of the institution certifies that there are special
reasons justifying it.
In addition to the above allowance, the colonist will be
entitled during the last six months of his course to a bonus
of 5*. per week, provided that he satisfactorily completes the
full year’s course of (treatment and) training. This accumu¬
lated bonus will be paid to each man at the termination of
the year’s course. And at the same time he may in addition
hope to receive a small sum, representing half of any net
profits which may have acorued from the farming operations
m which he has been engaged; the exact amount of this must
depend upon the sum due to him as his share of the profits
made on his section of the farm.
Applicants who, from the information famished on the
forms supplied, appear to be suitable are examined by me
on behalf of the Y.M.O.A. and the Ministry of Pensions. 3
The staff of the colony is made up of Mr. Richard Hunt,
who has long experience of farming, and as honorary com¬
1 Married men with dependants receive maintenance allowance on
the nsu&I scale.
3 As from JaiT. 1st, 1919, the arrangements for admission and period
of treatment are being made by the National Health Insurance Com¬
mission Instead of by the Ministry of Pensions, but this will not
materially affect the general conditions of employment in the colohy
described in this paper.
mandant directs the work of the institution ; Mrs. Richard
Hunt, honorary matron and housekeeper; a secretary, an ex-
service man discharged on account of tuberculosis; an
orderly, also an invalided soldier; a cook, a kitchen-maid,
and a staff-maid. The outside personnel consists of a con¬
sumptive ex-soldier, who holds the post of handy-man and
instructor in carpentry and engineer’s repairs, a “ stock-
man,” and a “ horse-man ” or “ carter.”
The Council of the Y.M.C.A. are responsible for the
maintenance of the settlement, the administration of which
they have delegated to the following committee:—Hon.
Mrs. Stuart Wortley, O.B.E. (chairman); Cornelia, Lady
Wimbome; Corisande, Lady Rodney; Lady Leitrim;
Lieutenant-Colonel T. D. Acland, R.A.M.C. ; Dr. Noel
Bardswell, M.V.O. ; Mr. Vivian Young; Mr. F. J.
Chamberlain, C.B.E. The Y.M.C.A. management receives
from the Ministry of Pensions 30s. per week per head, the
balance being defrayed by the Y.M.C.A.
The colony has not been established on its present lines for
sufficient time to allow of the preparation of a balance-sheet;
however, the weekly cost per oolonist for maintenance and
training does not exceed 30#. It is also impossible as yet
to estimate the financial result. During the past six months
the value of the stock, crops, See., has appreciated at least
50 per cent., and there is no doubt that the farm is more
than paying its way.
The Working of the Colony.
In the spring of 1918 the particulars just given were rant
to the superintendents of most of the leading sanatorium s
with a request to bring the information to the notice of
ex-sailors and soldiers. Daring the following six months a
large number of applications were received, mostly in regard
to men not up to the required physical standard ; it was not
until the late summer that the full complement of 21 colonists
was obtained. The following particulars of the first 25
selected candidates may be of interest:—
Salesman, 32. widower.
Mechanic, 37, married.
Shoemaker, 45, ,,
Seaman, 21, single.
Clerk, 24,
Policeman, 30, married
Journalist, 27, single.
Clothing designer, 33,
married.
Grocer's assistant, 22,
single.
Bailway clerk.23, single
Hairdresser, 23, single.
Clerk, 23, ,,
Newspaper vendor, 31,
single.
Dispenser, 27, single.
Assistant in surveyor's
office, 26, single.
Hairdresser, 32,
married.
Shop. assistant, 19,
single.
Clerk, 24, single.
Under gardener, 83»
single.
Clerk, 24, single.
Electrical engineer,24,
single.
Shop assistant 20,
single
Moulde^, 28, married.
Power, 27, single.
Customs agent, 25,
widower.
A small waiting list is maintained in case some of the
colonists are unable to complete their training. The care
in selection has been well justified, since from the point of
view of physical capacity, character, and intelligence the
colonists represent a most satisfactory class of sanatorium
patient. The proportion of married men with dependants,
6 out of 25, is noticeable ; but for their pensions and allow¬
ances none of these men could have undertaken to stay for
12 months at the colony.
It was decided so to model the scheme of training
as to fit the men more particularly for the management
of small holdings. The farm was divided into three
self-contained 10-acre holdings, each stocked adequately by
the Y.M.O.A. in respect of live-stock, implements, building,
Sec. To each holding were allotted seven patients who
worked under the direct supervision of the resident com¬
mandant. Careful accounts and records of periodical valua¬
tions were kept with a view to profit-sharing. The patients
were guaranteed any risk of loss. The advantage of this plan
is that it develops the initiative of the patients, encourages
industry and interest, and secures practical training.
The produce of the farm after the current needs of the
colony are met finds a ready market in Bournemouth, where
it is sold by auction. All the colonists in turn load up the
transport and attend the sales, so as to gain experience of
marketing.
The theoretical training includes lectures on soils (varieties
of), crops, manures, implements and machinery (of a farm),
feeding stuffs, live-stock (horses, cattle, pigs, poultry,
rabbits, bees), and fruit culture.
Of the features of sanatorium life there are maintained in
the colony routine the three “square” meals, the rest
before dinner and supper, and the early bed hour. Tempera¬
tures are not taken regularly ; should a man feel unwell he
reports to the commandant before proceeding to work. The
commandant, though not qualified in medicine, has seen
458 The Lancet,]
DR. R. V. bOLLY: RAT-BITE FEVER.
[March 22, 1919
much hospital service during the war and is an efficient
house physician ; further, he can communicate by telephone
with Dr. Hyla Greves. There is little sickness, and practi¬
cally no time is lost on this account. The arrangements at
the colony are proving the success anticipated. The progress
of the patients, as evidenced by gain of strength, the
clearing up of symptoms and physical signs of disease, and
the disappearance of sputum, is uniformly satisfactory.
Subject to the somewhat exacting nature of farm work,
the colonists enjoy a large measure of liberty. There are no
bounds, and such amenities and social life as the country¬
side offers are open to the men. On Saturday afternoons
and Sundays, with the exception of the weekly rota of men
who carry out essential duties, such as feeding stock, &c.,
the colonists can go further afield. It is encouraging to
note that the men tend more and more to spend their free
hours in the country rather than in the neighbouring towns.
The colony recreation-room is provided with two small
billiard tables, a piano, a gramophone, and other amuse¬
ments, also the daily papers and farming journals. Without
exception the men express their marked preference for the
life at Kinson to that at a sanatorium.
Several months’ running of the colony on the lines just
described revealed some unanticipated difficulties. It was
impossible so to divide the farm as to secure land of equal
quality for the three holdings. After consultation with the
men, whose opinion was almost evenly divided, the three-
holding system was, not without reluctance, abandoned
in favour of a scheme whereby all the land is worked as
a small farm. As now constituted the farm consists of
9 acres of grass and pasture, inclusive of 2 acres devoted
to poultry, and 25 acres of arable land, the latter of which
includes acres of orchard, 4 acres under four-course
rotation, 2\ acres of market garden, and 1$ acres of per¬
manent catch-crop. The stock consists of 9 cows, several
calves, 2 horses, 3 breeding sows, with their litters, and 300
head of pure-bred poultry.
The 21 colonists are divided into four parties which in
rotation are appointed to: (1) stock—care of all animals,
dairy work, &c. ; (2) carting, ploughing ; (3) general farm
work—all operations save ploughing and horse work; (4)
market gardening and marketing; and (5) poultry. Approxi¬
mately, a squad is engaged under skilled supervision for a
week at a time in each department.
A Provisional Estimate of the Prospects of the Colonists.
Briefly, the record up to Dec. 20th, 1918, is as follows:
8 patients have left the colony, 1 on account of disinclination
for the life, 3 for breaches of discipline, and 4 owing to
physical incapacity. Thus, only 4 men have shown them¬
selves definitely unequal to the work which, day in and day
out, is somewhat strenuous and extends from seven to
eight hours.
With respect of the adaptability of the men and their
prospects, the opinion of Mr. Hunt as practical farmer is
of interest. Of the 21 men now in residence, four, in his
opinion, are not physically capable of the full training and
are unlikely to make independent smallholders. For these
men a simple training is indicated such as will enable them
to supplement their pension ; for example, the care of pigs,
fowls, and goats, and some knowledge of vegetable growing
and bee-keeping. The remaining 17 men, granted favour¬
able conditions of settlement, all promise to make good ;
several of them, men of education, would do well to study
at an agricultural college with a view to farming on a larger
scale.
Taking the men collectively the training has to begin
with the veriest A B C of country life. Again, the men,
although working for from some seven to eight hours daily,
cannot by a considerable margin compass the output
of a normal person. Education is slow, and Mr. Hunt
states that 12 months’ training will not be sufficient save in
exceptional cases with previous experience. It is his
opinion, also, that to judge by their present standards of
knowledge and physical endurance, a small number of the
men only on completion of their training in September,
1919, will, if single-handed, be able to earn their living
on the land. This renders the settlement of the men a
matter for serious consideration. He suggests that on com¬
pletion of the 12 months’ training the most efficient men be
found positions as paid assistants upon established holdings
in the neighbourhood of Kinson with a view to gaining
further experience. But the men are all impatient to start
for themselves when their year is up. Another proposal is
that the picked men be settled on holdings and that the less
proficient be allotted to them as assistants. It is evident
that special provision must be made for settling the
colonists. To allow them to leave the colony and to trust
to their own resources would in many instances spell failure.
The conditions of settlement cannot be too favourable; good
land, easily worked, markets of easy access, generous land¬
lords, and opportunities for obtaining skilled advice are
essential. It is to be noticed that the experience of Kinson
supports the view that the vocational re-education of the
consumptive, to be of use, must be associated with a scheme
for the provision of employment subsequently.
The plan which seems best to meet the requirements of
men trained on farm colonies is their settlement as they
become sufficiently skilled upon holdings within easy access
of the colony, for preference, as tenants of the colony
management. This would permit of the cooperation of the
several holders and the continued supervision and direction
by the expert farmer in charge of the colony ; another
material advantage would be that when, as will certainly
happen, a tenant has need of rest for some days, assistance
upon which may depend the success or failure of a season,
could be provided by the pupils at the colony. •
The ideal that should be kept in view is to enable a tuber¬
culous man, after proving himself on a small holding, to pass
in turn to progressively larger holdings, and eventually to
become a large farmer employing his own labour. In view
of the youth of the general run of the Kinson colonists, this
ideal is quite possible. The whole question of the future of
the trained colonist and the best means of providing for his
settlement is now under consideration by the council of the
Y.M.C.A.
RAT-BITE FEVER:
TWO CASES TREATED WITH APPARENT SUCCESS
BY A SINGLE DOSE OF NOVARSENOBENZOL
INTRAVENOUSLY.
By R. V. SOLLY, M.D., M.R.C.P. Lond., F.R.C S.Eng..
PATHOLOGIST TO THE ROYAL DETOX AND EXETER HOSPITAL
AND TO THE GROUPED WAR HOSPITALS, EXETER.
The two cases here described were undoubtedly examples
of rat-bite fever.
Notes of Cases.
Case 1.—Patient aged 20. Had suffered from pulmonary
tuberculosis for last four or five years. Previous to the
present attack his lung trouble was quiescent; appetite
good; temperature normal; some dullness at right apex
in front; no crepitations or signs of activity. Nine weeks
before admission to nursing home he was bitten on the left
little finger by a rat. Wound not washed for about one and a
half hours. Three weeks later the present attack began. Every
two or three days the temperature rose to about 104° F. and
Periodic rises of temperature in Case 1.
sometimes 105°. He had severe aching in back and legs;
felt cold and shivered; no actual rigor; no rash; skin felt
itchy during attack. He occasionally felt sick; latterly
mouth was very dry. The lymphatic glands above left elbow
and in axilla became enlarged, but now can hardly be felt.
The wound healed in a few days.
Blood culture, aerobically and anaerobically, was nega¬
tive. White cells, 17,000 per c.mm.; polymorphs 90 5;
lymphocytes, 7*5; large mononuclears, 2 per cent.; no
Thb Lancet,]
DB. V. BORLAND: CONSTIPATION IN CHILDREN.
[March 22,1919 459
eosftiophiles. No spiroohetes or other parasites seen in
stained films. On dark-ground illumination of citrated
blood no definite spirochetes were found. One peculiar
body was seen—a round body rather smaller than a red
blood cell with two long narrow processes which exhibited a
wavy motion. I cannot say whether it was an artefact.
At the height of temperature, on June 27th, 0*45 g.
•novarsenobenzol was given intravenously. The tempera¬
ture fell and was down for a month. Then for about a week
It rose at night; also some swelling of left arm. Sinoe
then, up to October, he has been quite well; no rise of
temperature.
This case was complicated by the patient having suffered
from pulmonary tuberculosis, but previous to the rat-bite this
was quiescent. I did not ste him in the attack a
month after the novarsenobenzol injection, but the attack
seemed to have had no resemblance to the former ones.
Case 2.—Pte. C. H., aged 30, a patient in a war hospital,
Exeter. On Jan. 7th, 1918, he was bitten on the finger by a
rat. He reported sick in February, and since has had
.rises of temperature lasting about 24 hours, generally with
intervals of four days. During the attacks he lost his
appetite, felt sleepy, and had maddening headaohe. Distinct
sain eruption; large raised erythematous patches all over
the body; itching severe. He generally vomited during the
ettaok. The temperature rapidly rose (103° or 105° F.), rarely
lasting more than 24 hours. The wound healed in three
•or four days; apparently no enlargement of lymphatic
.glands.
At Exeter it was discovered that he had been bitten by a
rat. On July 12th, 1918, an injection of 0*45 g. novarseno¬
benzol. Temperature remained normal for a month, then
went up to 101*8°. No treatment was applied; since quite
^rell except for a slight attack of influenza.
A A differential blood count showed a polymorph percentage
of 80. No malarial or other parasites seen in stained films,
or by dark-ground illumination of citrated blood. On blood
.culture in one tube a Gram-negative bacillus was obtained
Blightly motile, forming indol, no liquefaction of gelatin,
'forming aoid and gas with gluoose, lactose, and mannite,
and negative with sucrose; litmus milk, aoid and dot.
Evidently a coliform baoillus.
In this case the pyrexia occurred about every five days
-for over five months. There were no signs of the disease
wearing itself out till the intravenous injection.
Captation,
In The Lancet of Sept. 8th, 1917, I reported a case of
+*periodic attacks of pyrexia” ; a single dose of galyl given
intravenously was followed by complete recovery. Professor
Tanner Hewlett 1 said how much it resembled rat-bite fever,
but there was certainly no history of a rat bite. In
The Lancet of Feb. 16th, 1918,- Captain S. R. Douglas,
Dr. L. Colebrook, and Mr. A. Fleming report a case of
rat-bite fever. A streptococcus having the characters of
Streptococcus pyogenes Was isolated on anaerobic culture from
the enlarged glands of axilla. After vaccine treatment com¬
plete recovery took place ; there seemed every reason to
suppose that this organism was the cause of the pyrexia.
In my oases I could not find any spirochaates, unless the
peculiar body described might have been a couple of these
adhering to a red cell. Its appearance is somewhat sug¬
gestive of the Spirochasta icterohamorrhagia r, found by
Dr. Alfred C. Coles in the blood of the common rat. 3 In
my second case, on blood culture, in one tube a bacillus
having the cultural characters of B. coli communis was
obtained, but I‘think this must have been a contamination.
In these cases of rat-bite fever so many different kinds of
organisms have been found on blood culture, sporozoa,
streptothrix, Micrococcus tetragenus , Ac., that one cannot
help feeling suspicious, considering the fallacies of blood
cultures. Spirochmtes have, no doubt, been found in blood
and fluid from enlarged glands, by Japanese observers, in
cases of rat-bite fever. Cases have consequently been
treated by salvarsan, which is advised by Professor William
Osier. 8 Whether this disease is caused by spirochastes or
other unknown protozoon, or is a bacterial infection due to a
streptococcus or other organism, is certainly not settled.
The marked leuoocytosis of polymorph type is perhaps in
favour of the latter view.
It would be interesting if in a case of rat-bite fever a
definite organism such as a streptococcus could be obtained
1 fHB Lancet. 1917, il.. 562.
* The Laxobt, March 30th, 1918.
• Principles of Medicine, 1918%
from blood or gland juice, and then a cure produced by
salvarsan. There is, I suppose, no doubt that salvarsan is of
great benefit in many cases of pernicious anssmia, supposed
by Dr. W. Hunter to be due to a streptococcus. Dr. G.
Stopford Taylor 4 describes the benefit of intravenous
injections of neokharsivan in cases of tuberculous skin ulcers,
lupus, sycosis and eczema, and blepharitis. Many diseases
other than syphilis might be successfully treated by salvarsan
or its substitutes.
PROPHYLACTIC TREATMENT OF CON¬
STIPATION IN CHILDREN.
By VYNNE BORLAND, M.B.,CH.B.,B.Sc.GLA8a.,D.P.H.,
ASSISTANT MEDICAL OFFICER, WILL BSD EH URBAN DISTRICT COUNCIL.
The frequent occurrence of constipation in children is a
fact which soon obtrudes itself upon the notice of any
doctor conducting an infant welfare consultation. And con¬
sidering the bearing this condition has on the health of the
child in later years, an endeavour is made here to give a few
suggestions which may prove helpful to those in charge of a
welfare clinic.
Definition of the Term .
First of all the exact meaning of the term “ constipation ”
must be clearly understood. Inqniry often elicits the
information that a child’s bowels move every day. But this
is not enough. A sufficient motion should occur each time.
A child may pass a small stool each day and still have a
loaded rectum. If the stool consists of small dry pieces it
is almost certain that the rectum is not being emptied
thoroughly. Constipation means that, for some reason, the
rate of propulsion of the bowel oontents and the amount
expelled are below normal.
t Before constipation—threatened or present—can be
diagnosed, a knowledge of the characters of a normal
stool is necessary. For the first few days the infant’s
bowels may move two to six times per day. The stool
oonsists of meconium—a viscid, tarry-looking substance,
almost odourless or only possessing a faint inoffensive smell.
The colour gradually changes to an orange-yellow. In
bottle-fed babies the oolour may be lighter at first owing to
dilution of the feeds, but the oolour becomes darker as the
feeds become stronger and contain more fat. The number
of stools per day is not so important as their character. If
the colour is good, smell inoffensive, consistence soft, an.
no straining, one motion per day is satisfactory.
Care of the Child: Cultivation of Regular Habits .
In the prevention of oonstipation, satisfactory hygiene in
the home is of paramount importance. Too often a child is
given a purge without any inquiry into the home conditions
or as to how it is cared for, with the result that its bowels
are only temporarily relieved. The child should have
abundant fresh air and sunlight during the day and should
sleep alone in a fresh airy room protected from draughts.
No fire is necessary. The position of the child in the cot
should be changed at intervals. The child will be healthier,
and consequently the bowel will share the benefit in tone
given to the whole system.
Exercise should play a prominent part in the daily routine.
Regular periods should be reserved for this, the time and
amount being regulated according to the ohild’s age. At
first freedom in kicking its legs about at intervals during the
day is sufficient, and as age advances it should be allowed
to crawl about in a little pen.
The importance of cultivating regular habits as early as
possible cannot be exaggerated. Feeding times should be
at definite hours, the child being wakened if necessary. The
longer the interval between the feeds the better. Almost
any child can begin right away with 3-hourly feeds, receiving
six feeds per day. Others do well on 3}- or 4-hourly feeds,
receiving five feeds per day. The writer has found that in
a large number of cases even four feeds per day, with
4-hourly intervals, produce satisfactory results. But the
essential point is that, whatever periods are chosen, strict
regularity must be adhered to, and in no case should the
child be fed during the night.
« Brit. Med. Jour., Oct. 19th, 1918.
460 Thb Lanott,]
DR. V. BORLAND: CONSTIPATION IN CHILDREN.
[March 22,1919
The bowels tend to move more readily after a feed, and
advantage of this should be taken by training the child into
the habit of a morning stool after the bath feed. This can,
in the majority of cases, be accomplished by about the end
of the second month. The bath should be given at the same
time every morning, and if there is any tendency to con¬
stipation the abdomen should be massaged gently with some
warm oil—to facilitate rubbing—over the tract of the colon,
oommencing in the right groin and ending in the left. After
the feed the child should be held over a small pot, and if
this stimulus is insufficient the anus should be lightly
tickled with the finger. This acts as a suggestion that
something is required.
Some help to peristalsis may be requirsd in some cases to
begin with. A dose of syrup of figs, or other mild laxative,
given at night is usually effective. If a lubricant is required
the best is liquid paraffin. Olive oil is not satisfactory,
since a large proportion is absorbed. Whatever is employed
the dose should be gradually decreased each night. If the
bowels have not moved in the preceding 24 hours, a warm
normal saline enema, 1 drachm to an ounce, is best; this
increases the tone in the bowel. Large enemas should not
be given, as these tend to produce distension and loss of
tone. If soap is used, either as an enema or as a supposi¬
tory, only a mild superfatted soap should be employed, as
ordinary soap is liable to set up catarrh and proctitis, and
consequently constipation. Either method should not be
pushed for any length of time, otherwise actual constipation
will result owing to impairment of the normal rectal
reflex.
A warning should be given about that unnecessary evil,
the binder. Most mothers cannot explain why it is used.
They imagine that it is the proper thing to do, as all the
babies they have ever seen wear one. A few have the idea
that it supports the child’s back when, as a matter of fact,
it prevents the proper development of the muscles of the
baok and abdomen. When it is properly applied and stays
in its intended position—i.e., round the abdomen—it acts as
a constricting barrier to the bowel contents. When fixed
loosely, as it usually is, it slips up the body and prevents
proper development of the chest. The binder should not
be used after the navel has healed, but should be replaced
by a woolly vest.
Treatment of Constipation in the Mother.
The expectant mother should be taught the importance of
regulating her bowels and carrying out necessary treatment
throughout the nursing period. It is practically hopeless to
treat a constipated baby by purging the mother, but if she
avoids constipation both during pregnancy and after parturi¬
tion it will be of advantage to the child. All abdominal
oonstriction should be avoided. If the habit of stooling
after breakfast has not been practised, attempts should be
made to develop it. A glass of hot water half an hour
before breakfast, made more palatable by adding a pinch of
salt, often acts beneficially. Fresh vegetables should be
taken freely. If this is not sufficient small doses of senna at
night are good. A favourite form is the infusion from the
pods, or some mothers prefer to chew one or two pods.
It Is more satisfactory to take small doses every night, thus
ensuring the morning stool, than to take larger doses once
or twice a week. Many expectant mothers take regular
weekly doses of castor oil, not only to keep their bowels
regular, but occasionally from a mistaken belief that it
confers an easy labour. Needless to say, they become more
and more constipated.
Improper Use of Castor Oil for Children.
Castor oil is first favourite as a purge in children. One is
frequently told with pride by the mother that baby’s bowels
are regular as she gives it a dose of castor oil every week.
The first fault is made in some cases almost as soon as the
child is born. A dose of castor oil is given to clear out the
meconium, and the mildly stimulating effect of the colostrum
is lost, since the bowel is already tired out. This, unfortu¬
nately, is the starting point in a great many cases of con¬
stipation in ohildren, for if the child’s bowels do not act
well the mother immediately repeats the dose. When a
oonstipated baby is brought to the clinic one almost
invariably finds that one or more doses of castor oil have
been given. A safe rule to adopt is : Nefoer give castor oil
unless there is diarrhoea.
The Food of the Infant: Quantity and Quality.
The quality and quantity of the food require great
attention. It is not sufficient that the child gains from
4 to 7 ounces per week, but inquiries should always be made
as to the character of the stools. Underfeeding in breast¬
fed babies is comparatively frequent. This is evidenced in
the character of the stool which is small and insufficient.
Besides studying the progress in weight the best guide is the
test-feed. The baby should be weighed before and after a
feed and, if the quantity is too little, there should be no
hesitation in supplementing the feeds with artificial feeding.
It is much better to give small quantities of milk after each
feed than to replace one or two feeds by a bottle-feed. In
this way the natural stimulus of sucking is not interfered with.
Insufficient fat is liable to produce constipation. This
occurs more particularly in cases where cows’ milk is too
freely diluted. For the first few weeks the child can only
with difficulty digest fats other than that of breast-milk.
Small amounts in the form of cream, an emulsion, or a
compound like virol should be cautiously added. As the
feeds are made stronger the tendency to constipation passes
off. Too much fat is to be avoided, and if the stools
become pasty and greasy the quantity should be reduced or
even temporarily stopped. If it should be a case of faulty
fat digestion some pancreatic extract should be given.
When curds appear in the stool these should be examined
to find if they are really composed of undigested milk, as
very frequently they consist of small rolls of dried mucus
from an insufficiently lubricated bowel. If found to be the
former, humanised milk or citrated milk should be given;
if the latter, an emulsion of liquid paraffin should be
employed as a lubricant.
In bottle-fed babies, as in breast-fed, the appropriate
quantity of feed should be regulated according to the
weight-chart and the amount of the stool. If the gain does
not amount to at least 4 ounces in the week and the stool is
too small an Increase in the feed is required.
Overfeeding must be guarded against. If a child assimi¬
lates its food well; care should be taken that the amount of
feed is not too much. The weight-curve will show too great
an increase, and although the child may remain in perfectly
good condition for some weeks, if diarrhoea does not super¬
vene before, the stools will become too copious, light-
coloured, greasy, and lumpy. If this occurs the condition
very often corrects itself by keeping to the same quantity of
feed for the following week or so.
Other Matters.
Insufficient water is harmful. If the stools become too
dry the feed should be further diluted, or the child may be
given sips of water between feeds when awake. It is
important that the water should first be boiled, as if
there is a high degree of temporary hardness it will tend
to produce constipation instead of preventing it. The
addition of a little fruit juice daily is often of great benefit
Too much water is to be avoided, as with the continued
passage of watery stools the bowel in time becomes lazy
and will only respond with difficulty when it really has
to work. A similar condition results after an attack of acute
diarrhoea. It should be remembered that the secretions
have become greatly dried up and the musculature of the
bowel wall so enfeebled that great care is required in order
to avoid chronic muoous colitis or chronic constipation. The
tone of the bowel wall should be gradually restored. If
simple hygienic measures as outlined do not suffice a bowel
tonic should be given, such as a mixture of cascara, nux
vomica, and liquid paraffin. Drugs to increase secretion
should be used with great care, for if there is any tendency
to chronic mucous colitis the condition may be aggravated.
All mothers should be warned of the danger of the indis¬
criminate use of soap suppositories. Too often this temporary
remedy is resorted to, with the result that after a time the
bowels will not move witliout this stimulus. The normal
stimulus of the rectal reflex is the presence of faeces in the
rectum, and if soap suppositories are given indefinitely the
natural stimulus has no effect.
The prevention of constipation in mentally deficients,
cretins, and infantilism is greatly dependent on the early
diagnosis of the case. Simple hygienic measures, though
helpful, will in all probability be insufficient alone. Tbe
early administration of thyroid extract in most oases acts
b 3neficially.
Thb Lancbt,]
MR. G. TAYLOR: DOUBLE RESECTION OF BOWEL.
[March 22,1919 461
DOUBLE RESECTION OF BOWEL.
FOUR SUCCESSFUL CASES OF GUNSHOT INJURY,
WITH A NOTE ON DOUBLE AND TRIPLE
RESECTIONS. 1
By GORDON TAYLOR, M.A., M.S., B.Sc. Lond.,
F.R.O.S. Eng.,
SEHIOB ASSISTANT 8UBGEO*. MIDDLESEX HOSPITAL; LATE TIMP.
MAJOB, B.A.M.C.
The published results of abdominal operations for gun¬
shot injury and conversations with other surgeons at the
various casualty clearing stations have given me the impres¬
sion that double resections of bowel for wounds of gunshot
origin are but rarely successful. I have, therefore, been
perhaps unduly fortunate with four cases of my own in
which a successful result was obtained.
Note* of Cates.
Case 1. Perforating wound of abdomen by revolver bullet;
double resection of small intestine; pulmonary infarct;
recovery — Private, admitted into casualty clearing station
on Feb. 23rd, 1918, had been shot with a revolver at a
distance of a few feet. The wound of entry was in right
iliac region, of exit in left iliac fossa; bullet found in
clothing. He was in poor condition when placed upon the
operating table about five hours after wound ; pulse 126.
The abdomen was opened by a paramedian incision;
about 2i pints of blood evacuated from peritoneal cavity.
Twelve large wounds of lower jejunum necessitated resec¬
tion of three feet of small bowel. Four severe wounds of
segment of upper jejunum and corresponding mesentery
demanded further resection of a foot of intestine, the lower
limit being some 20 inches above first junction. End-to-end
union in eaoh case. In view of condition of patient and
nature of missile, entry and exit wounds were not excised.
The patient made an excellent recovery so far as concerned
his bowel injuries, but some deep tenderness on the right
side was interpreted as tbrombo-phlebitis of deep epigastric
vein, probably due to spread of infection from original track
of missile in parietes. The diagnosis seemed confirmed by the
sudden development of a small pulmonary infarct in lower
lobe of left lung on tenth day after operation. Fluid in left
pleural cavity was aspirated on three occasions; each time
bacteriological findings negative. The whole left lower lobe
was now solid, and an alarming intermittent temperature
developed; pulse good and appetite unaffected. A “ crisis
evacuation ” on March 21st, 1918, sent him to the base, and
he reached England the beginning of April.
An exploring needle now revealed pus; a small empyema
was evacuated after resection of portion of ninth rib; tube
removed 10 days later. On April 18th he developed a small
abscess of abdominal wall in right iliac region; this was
opened. The patient was then sent to his native country,
Ireland, and after an operation for the repair of a weak
abdominal scar by Captain Herbert Crawford, R.A.M.C.,of
Dublin, he was discharged from the Service.
The exact causation of the thoracic manifestations was
rather obscure, as the patient had previously received a
severe penetrating wound of the left chest with resulting
empyema, which had been very slow to heal. The sudden
onset of the symptoms, however, the date after operation on
which they appeared, the thrombosed deep epigastric vein,
the latent sepsis in the right iliac region which “flared”
two months later, the prune-juice expectoration seemed to
confirm the view that it was a septic pulmonary infarct.
CASE 2.— Penetrating wound of abdomen; resection of
jejunum; resection of distal part of transverse colon , splenic
flexure and descending colon; temporary c<ecostomy. —Lance-
Corporal, admitted into C.C.S. in the early hours of a
February morning. A shell fragment had entered the left
flank, completely dividing descending colon and shattering
adjacent edges for some distance. In upper jejenum were
several large perforations; mesentery also perforated and
bleeding. Three feet of jejunum were resected ; end-to-end
junction. Large rent on posterior aspeot of transverse
colon, anterior surface just penetrated. Excision of damaged
portion of transverse colon, splenic flexure, descending and
iliac colon; end-to-end junction between proximal portion
of transverse colon ana sigmoid flexure. The wound of
entry was widely excised and “ Carrelled ”; temporary
cseoostomy performed. Apart from massive collapse of
lower lobe of left lung and some trouble with laparotomy
wound the patient made a good recovery and was evacuated
to the base a month later, and later to England.
1 Being a portion of the Hunterian Lecture delivered at the Royal
College o( Surgeon* of England, Feb. 7th, 1919.
The patient has been invalided from the Service, and is
now at work in an office.
Case 3. Penetrating wound of abdomen ; perforations of
jejunum sutured; resection of ileum; resection of sigmoid ;
temporary cacostomy.— Private, admitted into C.C.S. in
d&rly hours of January morning in 1917 with penetrating
wound of abdomen by shell fragment. After resuscitation
for two hours the abdomen was opened, and nine or ten
perforations of the jejunum were sutured; also a resection
of 18 inohes of ileum. Four wounds of the sigmoid were
found, two on mesenteric border. As the bowel was in a
state of infarction the damaged portion of sigmoid was
resected; end-to-end junction. The foreign body was
removed from the musculature of the left flank; damaged
tissue around track of missile widely excised; temporary
caBoostomy performed. Recovery was uneventful. The
caBcostomy closed in 10 days, the rectum was then noting
satisfactorily. He was evacuated to the base in three
weeks, and subsequently went to England.
By a curious coincidence this patient’s father had under¬
gone an abdominal operation at my hands in Middlesex
Hospital some few years before the war. The patient has
now been invalided with a rather weak abdominal wall and
has resumed his occupation.
Case 4. Penetrating wound of abdomen; hernia of small
bowel; wound of bladder; fracture of rib , anterior portion of
iliac crest , and pubic bone; double resection of bowel; recovery .
—Private, admitted into C.C.S. on Sept. 18fch, 1918. Opera¬
tion 8& hours after being hit. Hernia of shattered strangled
small intestine through a wound in the right hypo-
chondriom; about 18 inches of bowel prolapsed. A large
piece of shell had then passed down between the internal
oblique and transveraalis muscles on the right side, and had
shattered the anterior part of the crest of the ilium. Tbenoe
its course was deflected again into the peritoneal cavity, and
it had become impacted in the posterior surface of the right
S ubic bone, transfixing the bladder and impaling a coil of
eum against that bone. A considerable pull was required
to dislodge the projectile.
The patient, when placed upon the operating table, had a
surprisingly good pcuse of 96. On enlarging entry wound,
releasing constriction of neok of prolapsed bowel, pulse at
once rose to 130. The wound was filthy, and parietes and
bowel alike were covered with grease ana dirt. Four feet of
badly damaged and perforated jejunum were resected, and
the other coils of jejflnum and upper ileum were assiduously
cleansed of grease and clothing. The coil of lower ilenm
impaled against the pubic bone was gangrenous; resection
of 2& feet. The posterior wall of the bladder was sutured;
glove drain passed down into cave of Retzius towards
wound on anterior vesical surface. Very wide excision of
the damaged abdominal muscles was performed after closing
peritoneum ; a defect in the latter was filled in by a graft of
fascia from anterior layer of sheath of rectus. The anterior
end of crest of ilium was widely exsected. The wound was
packed with ganze soaked in flavine ; frequent instillations
with flavine through Carrel’s tubes. 900 o.om. of blood were
transfused by Captain G. R. B. Puree, M.C.; usual resnsoita-
tory measures. The gauze and Carrel’s tubes were removed
on the fifth day, and skin wonnd sutured. He was evacuated
to the base on the fourteenth day, and subsequently to
England.
This case is of interest (1) as a successful doable
intestinal resection ; (2) as a oase of prolapsed bowel; and
(3) the injury was produced by a missile weighing 3 oz.
Remarks.
The pulse-rate in three of my four successful oases was
126 and over when the patient came to operation ; the
pulse in the fourth was slower until the wound was enlarged.
In Case 1 operation was performed five hours after the
patient was hit; in Oases 2 and 3 after six hours, and in
Case 4 eight and a half hours had elapsed.
Another successful double resection case oomes from
No. 17 C.C.S. and is quoted in their paper by Major B. Meyer,
M.C., and Major D. 0. Taylor, M.C. The patient was 15} years
of age, and he had bowel injuries necessitating a resection
of 9 inches of jejunum (a lateral junction being made) and
another resection of 4 inches of ileum (end-to-end junction).
In addition an isolated rent was sutured. He developed
broncho-pneumonia, the wound broke down and required a
secondary suture, but he was sent to the base in good
condition on the sixteenth day.
Majors J. J. M. Shaw, G. H. Stevenson, and Colin
Mackenzie record a successful case of double bowel resection
from No. 2 O.0.8. Nineteen perforations of small intestine
were found and a double resection with double end-to-end
462 Thb Lanoht,]
CLINICAL NOTES.
[March 22,1919
ThsLanok,]
OLINIOAL NOTES.
[March 22,1919 403
.a provisional working hypothesis. The Wassermann reaction
•of the cerebro-spinal fluid and of the blood (twice repeated),
however, proved negative. This would apparently exclude
syphilis as the aatiologioal factor, for even if the view be
adopted that a few remaining spirochsetes might fail to
yield a positive result, the infection of the central nervous
system was too severe and widespread to be explained on
this basis.
It will be noted that there was a well-marked excess of
•cells of the cerebro-spinal fluid, and that the cells were
almost exclusively lymphocytic in character. Lymphocytosis
of the oerebro-spinal fluid is typical of subacute and chronic
infections of the cerebro-spinal meninges, especially in
parenchymatous cerebro-spinal syphilis. It also occurs in
mumps and in herpes zoster. In the early stages of acute
poliomyelitis lymphocytes are in the majority, as also in the
later stages of acute meningitis when recovery has commenoed. 1
There is also occasionally an excess of lymphocytes in the
cerebro-spinal fluid in cases of cerebral neoplasm.
Landry's paralysis.— The case has certain features in
common with this group—viz., ascending motor paralysis.
The typical case of Landry's paralysis, however, does not
show marked constitutional symptoms or bo profound an
involvement of sensation and loss of sphincter control.
. Acute toxic polyneuritis. —The sensory involvement in the
case above described was not limited to glove and stocking
areas, the proximal limb muscles were affected as severely as
the peripheral musoles and anorexia was extreme. This
diagnosis was therefore excluded.
Acute poliomyelitis. —Passive movement of limbs did not
produce pain. There was marked sensory loss and the
affected muscles did not show atrophy. In these points the
case is atypical of acute poliomyelitis.
Subacute combined degeneration. —This was excluded by the
subsequent history, the patient rapidly recovering his normal
health.
The general facts point towards a fairly acute and wide¬
spread invasion, presumably via the blood stream, of the
cerebro-spinal nervous system, involving the pyramidal tracts,
posterior columns, and optic nerve. The case would appear
to be one of acute ascending myelitis, probably infective but
cot so proved. $
TWO GASES OF
INTERMITTENT HYDROPS ARTICULORUM.
By R. MacLelland, M.D. Edin.,
BKSIDKMT PHVSIOIAH, SMKDLKY’S HYDRO, MATLOCK.
Thb comparative rarity of this affection makes the
following two oases worthy of publication.
Cass 1.—A female, aged 23, single, complained in
November, 1917, of swelling in the right knee which had
appeared the previous day. There was discomfort in the
joint rather than pain, no redness or heat, practically no
tenderness, no fever; the joint was distended with fluid. It
was painted with iodine pigment and appeared to be well in
three or four days. A day or two later a synovitis of the
same character developed and again rapidlv subsided. From
that time up to April29th, 1918, when I last heard of her,
periodical attaoks recurred every tenth day. An attack
took three days to develop to a maximum, slowly subsided
for five or six days, and then another attack began. Occa¬
sionally the fluid completely disappeared before the next
attack. At times an attack began on the ninth or eleventh
day. There was no history of injury; the only previous
illness had been scarlatina years ago. Except for slight
passing neurasthenio symptoms a few months before the
synovitis began the general health had been excellent.
Absolute zest in bed for six weeks, local treatment, laotate
of calcium, adrenalin, arsenic, quinine, and other drugs had
no appreciable influence on the condition.
In the light of the other case the diagnosis was easy and
the prognosis hopeful.
Case 2.—The patient was under the care of and diagnosed by
Dr. G. C. R. Harbin son, senior physician here, and I have his
kind permission to publish the following notes. The patient,
a male, aged 60, from June, 1908, till late spring, 1909, had
attacks of synovitis in the left knee, reourring every eleventh
day on an average. They were- at their height on the third
day, and then subsided in three or four days. There was
slight tenderness on the inner side of the joint; no acute
pain, redness, heat, or fever. Between the attacks move¬
ments of the joint were good, and the patient walked about
with a stick, only slightly lame. D uring the earlier attaoks
1 Porvea Stewart: Diagnosis of Nervous Diseases, 4th ed., pp. 443,444.
the joint became tensely distended, but later the dis¬
tension was less. On Dec. 1st, 1908, there was a slight
attack in the right knee, lasting four days only. Alter
this date both' knees were affected periodically, but not
synchronously. After nine months the disease came to an
end, leaving the knees well, and there has been no recur¬
rence. No treatment seemed to have any effect. Exercise
did not affect the periodicity, but increased the intensity.
The general health of the patient was good and there was no
organio disease. Previous history: (l) A series of Bimilar
attaoks, 23 in all, with the same periodicity, beginning in
August, 1904, and ending in May, 1SW5, in complete recovery,
the joint remaining well until June, 1908: (2) a history of
overflexion of the left knee in November, 1873, while
stepping out of a railway carriage, followed by synovitis
lasting for eight months, with intermissions, and then
ending in complete recovery. There is no history of
asthma or angeio-neurotio oedema or Raynaud's disease,
and except in 1873 no history of any injury.
SCARLET RED POWDER AS A TISSUE
STIMULANT.
By A. J. Turner, M.B., B.S. Durh.,
OAPTAPV, R.A.M.O.
That toluol-aso-toluol-aso-/3-naphthol (scarlet red) has a
powerful effect in stimulating the growth of granulation
tissue and epithelium is well known. It may, however, be
suggestive of new applications of the principle if some of
the cases in which it has been used in my practice be
mentioned.
Ectropion .—After making a V-shaped incision below the
lower lid, sufficiently deep to allow of the lid being freely
brought up into its normal* position, the two lids were
stitched together, scarlet red ointment was applied to the
raw surface until granulations had filled up the hiatus and
the skin had grown over. The lid was then found to maintain
its new position and a scarcely perceptible scar remained.
The results in a series of these oases were excellent.
Oriental sore .—My custom has been to scrape these ulcers
very thoroughly under chloroform till nothing further could
be brought away by the spoon, and then to dress daily with
scarlet red ointment. The cavity left by soraping was
speedily filled up with granulation tissue to the surrounding
level, and when the skin had grown over the scar was quite
faint.
Bums. —1. A lady, the back of whose hand had been burnt
to the fourth degree and who had neglected it for a week,
was treated with applications of scarlet red ointment on
lint twice a week for three weeks. The discharge qniokly
ceased, the green sloughs disappeared, and the septic pita
granulated up. When the skin had extended over she
surface no scarring was visible and there was no limitation
of movement.
2. A Pathan who had been badly burnt about the face
some years previously could not open his mouth sufficiently
to take solid food. I made several inoisions radiating from
each corner of the mouth. It was impossible to get the
mouth very widely open, as the soar tissue had narrowed the
aperture as well as reduced its depth. The furrowB produced
by the inoisions and stretching were dressed with scarlet
red ointment; granulation tissue filled them up level with
the surrounding areas and prevented any relapse. The final
result was that the patient could separate the teeth suffi¬
ciently to introduce and masticate small quantities of solid
food.
Vesico perineal sinuses .—A Punjabi came to me in Dera
Ismael Khan. He had no less than six sinuses by whioh
urine dribbled away. He was very miserable and greatly
debilitated. An indiarubber catheter was tied into the
urethra. A piece of gauze impregnated with scarlet red
ointment was introduced daily into the whole length of each
sinus. After a few days this was omitted, as it was very
difficult to insert even a very narrow piece of gauze. The
sinuses closed up and recovery was perfect.
Corneal ulcers.—I have used the ointment with success for
these.
Wound cavities .—In open wounds with considerable loss of
tissue I have found au antiseptic paste containing scarlet
red powder prevent ugly scarring and crippling contractions,
where the latter were not due to nerve lesions.
With regard to the strength of the ointment employed, I
began with one of 8 per cent, on alternate days, but sub¬
sequently found that 2 gr. to the ounce of Vaseline, applied
daily, was equally effective, and I have never had occasion
to revert to the stronger preparation. Where it is desired
merely to hasten the growth of epithelium a very successful
method Is to apply the ointment for two days and then apply
a daily hot fomentation for four days, these alternations to
be repeated as long as necessary.
464 The Lancet,]
ROYAL SANITARY INSTITUTE.
[Maroh 22, 1910
ROYAL SANITARY INSTITUTE.
Conference on Pott - War Development Delating to Public
Health .
At the Royal Sanitary Institute on March 14th, Dr. L. 0.
Parses being in the chair. Dr. N. D. Bardswbll, M.Y.O.,
opened a discussion on the Pablio Health Aspeot of Tuber¬
culosis. He said that at the Hereford sessional meeting of
the Institute in May last, Dr. D. D. Gold reviewed the
position of the treatment and certain aspects of the pre¬
vention of tuberculosis, and he proposed to take up the
theme much as Dr. Gold had left it, considering in greater
detail the various measures which had been referred to as
matters of experiment. Prevention and cure could not be
separated. The object of all administration was the pre¬
vention of the disease and the cure of the individual. The
first thing to be done was to ameliorate those conditions of
faulty environment which predisposed to infection. That
the circumstances of the industrial classes should be
improved was now recognised as necessary for the future
welfare of the country, and when this was done the prospects
of recovery of those suffering from the disease would be
greatly increased. Social reform was urgently needed. It
was not sufficient, however, to deal wijbh predisposing factors
alone; there still remained the infective agent, the tubercle
bacillus. Infection passed from one person to another, and
those suffering from tuberculosis ought to be controlled.
This was not being done at the present time. Existing
arrangements for the treatment of tuberculosis had met with
very small success. In many patients first coming under
observation the disease had so far advanced that cure was out
of the question; those for whom cure was possible often
declined treatment on the ground that if they were deprived
of their incomes their dependents would suffer, while the
incompletely cured consumptive could not compete in the
ordinary labour market; finally, the whole working
conditions of many patients were such as to destroy all
hope of cure. In regard to diagnosis the public
ought to be better informed, the general practitioner
should make greater use of the skilled tuberculosis officer,
and a more liberal scale of sickness benefit should be
allotted. In factories suspected cases should be selected
for diagnosis. Care committees could not secure proper
housing or suitable employment for their patients if
neither were available. Aftei-care at the present moment
was merely palliative and in some parts of the country did
not exist.
Colonies for the Tuberculous.
Experience at present showed that the life of the
consumptive worker who was compelled to live in a
city might be prolonged by treatment, but, generally
speaking, his cure as a working unit was an impossi¬
bility. Any measure which was likely to succeed must
include the removal of the patient from an unsuitable to
a suitable environment. That was the principle underlying
the modern idea of colonies, as planned by Professor Sims
Woodhead and Mr. Yarrier-Jones. Such colonies admitted
patients suffering from all degrees and forms of tuberculosis,
workshops were provided under expert guidance, so that
the patients could be taught trades, and it was hoped that
many after a prolonged sojourn would be discharged in good
health and subsequently follow their newly-acquired occupa¬
tion. Permanent settlement was encouraged and cottage
accommodation provided for those with families. Generally
speaking, it was hoped that consumptive patients would be
induced to live under healthy conditions where supervision
could be exercised, so that their prospects of reoovery and of
becoming productive units of society would be greatly
increased.
It was impossible as yet to judge how far the principle
could be extended. Several sanatoriums had dealt satis¬
factorily with the problem of employing patients by
absorbing them into the personnel of the institution, but
obviously what could be done for 40 or 50 people would
be impossible for perhaps tens of thousands. Attempts
had been made to establish trades for consumptives,
and it was to be deplored that the support of public
authorities was lacking. Industries staffed by tuber¬
culous labour required substantial subsidies, but such
subsidies would in the end prove economical. Other
points which had to be considered were the sise to
which the colony could grow and still remain a manageable
unit, the employment of dependents and provision for their
education, and the preservation of discipline and enforce¬
ment of hygienic rules both for patients and their healthy
relatives.
Difficulties occurred with Friendly Societies on the
question of siok benefit for consumptives employed in
remunerative work. Nevertheless, a scheme of this sort
presented such enormous possibilities that funds should be
forthcoming to permit the undertaking of experiments of
this kind. The present was a favourable time for such
experiments, as there were thousands of ex-service men in
the country who would be able to enter the colony free
from anxiety with regard to their dependents and retain the
wages they earned, which varied from 30s. to 12s. a week.
If these men, however, had the grit to go to a oolony and learn
a trade, their pensions should not be reduced. A reduction
of pension was detrimental to men seeking treatment, and
they often refused treatment on these grounds. A tuber¬
culous person, so long as he was a tuberculous person,
should have the full rate of pension.
Sanatorium Factories.
With regard to introducing some of the colony prin¬
ciples into city life. Dr. Bardswell thought that it should
be possible to introduce sanatorium workshops under
the direction of the tuberculosis officer. The small wage
which the patient earned, in addition to that of his
wife and children, would keep the family above the
poverty line. If these men worked in crowded factories
they formed centres of infection for others. It had
been suggested that trade-unions should set up workshops
for their consumptive members, but the establishment
of sanatorium workshops was only possible where one or
two trades were carried on in particular areas—in a
bootmaking centre, fdk example. Labour officials did
not approve of subsidised labour. The idea of such
factories was not new, for in New York a sanatorium
factory had been run for the past two years chiefly in
connexion with the clothing industry: The wages earned
cancelled the sum which in previous years the society had
paid to dependents and in the sustenance of patients. Why
should England be behind America ? Something should be
done in the way of organising home employment, and it
ought not to be impossible to devise some.means of dis¬
tributing work to consumptives and so prevent them working
with their fellow men. The moral value of work for a con¬
sumptive was extraordinary, but it was important that he
should not regard himself as working for the sanatorium.
He should be shown clearly that the work is for his benefit
and the money earned should go into his own pocket.
It was useless to introduce oolony ideas into city life in order
to control consumptives during the day-time if they re-entered
the slums at night, and perhaps slept four in a bed, but
housing would come in time to remedy that state of things.
For such patients after-care funds should pay the difference
between a miserable and a suitable house, and every public
health authority should have the disposal of a certain
number of beds which would be available for working men
of good character, who would thus be given every chance of
getting well. In Paris, in connexion with a dispensary,
they had hospitals where patients with bad homes could be
provided with a bed at a very small fee. Such hospitals
ought to have a communal kitchen in connexion with them,
where the patient could get a good breakfast before going
out in the morning. Throughout the country and in London
the lack of adequate institutional accommodation for cases
of advanced disease was a most serious blot on our adminis¬
tration. Sanatoriums were quite unsuited for such cases,
and there was a great dislike on the part of the people to
Poor-law institutions; they would put up with the most
appalling conditions rather than go into the workhouse
infirmaries.
Discussion.
Mrs. Handel Booth, speaking from the purely social side
of the work, and from a large experience inside the homes
The Lancet,]
ROYAL SANITARY INSTITUTE.
[If arch 22,1919 465
of the people as well as of sanatorinms, said that she was
more than ever convinced that a great deal of the money
spent in large towns on sanatorium treatment was wasted.
The patient returned home looking very well and felt
anxious to work, but in two or three months he broke down
and went on the funds of the Approved Societies. If sana¬
torium treatment in this country was to be efficient some¬
thing more drastic would have to be done. More coordination
was sequired between members of the medical profession,
and more human interest in the individual case. The
incidence of tuberculosis had increased under war con¬
ditions. Propaganda among the working classes was
needed, for they did not seem to realise at all that con¬
sumption was in any way infectious. Practically nothing
was done in the majority of homes to prevent. infec¬
tion spreading amongst other members of the family,
and sometimes the accommodation was such that it was not
possible to take proper care of the patients in the home.
There ought to be larger powers under the Local Government
Board to segregate infectious patients. There was no
reason why arrangements could not be made to convert the
workhouses that had been used for our soldiers during the
war into hospitals for consumptive patients' in whom the
disease was advanced. A large number of manufacturers
were willing to give home employment, but the public
objected to buying goods made by consumptives. To make
this a commercial success a Government subsidy was
necessary. Some method of compulsion should be adopted
for segregating consumptives, otherwise the fringe of the
subject only would be dealt with.
Dr. H. Card ale (chairman of the London Panel Com¬
mittee), speaking on the housing problem, said that before
better environment was provided it would be necessary to
educate the people. The practitioner had an important duty to
perform in this respect, but he could not perform it in the best
way. This was not so much his fault as that of his educators.
Those responsible for his education should lay at least as
much stress on the prevention of disease as on its cure. The
health of the child could not be built up at too early an age.
If more attention were paid to this question a larger amount
of tuberculosis would be prevented. An extension of the
valuable work of the Children’s Country Holidays Fund would
do a vast amount of good by preventing the development of
tuberculosis. He agreed that more coordination between
the various branches of the medical profession was needed. In
the vast majority of instances the early cases of consumption
came to the general practitioner, who had been blamed for
not being sufficiently alert in the detection of such cases.
But when he had detected them he had the greatest difficulty
in persuading the patient that there was anything seriously
the matter with him.
Dr. R. M. F. Pigken (Assistant M.O.H. Glasgow) said
that with regard to early diagnosis a specialised tuberculosis
officer was more or less undesirable. The dispensary should
be a consultative place, and a specialist was here necessary
who should be in touch with every side of disease, as there
was a tendency to diagnose tuberculosis when the patient
was suffering from something else. At the present time the
number of consumptives requiring segregation was probably
very small. ,
Councillor Lansby (Lanarkshire) thought the housing
conditions had very much to do with the spread of disease.
Views of Other Speakers.
Professor Sims Woodhbad said the lecturer had been able
to stimulate a large number of people to make advances
along scientific lines. He felt that in the treatment of this
very serious problem we were not courageous enough. It
had been said that we wasted a good deal of money
on sanatorinms, but we had to realise that at the
outset the sanatorium was an experiment. It arose on
the open-air treatment principle—a good and sound one
—and although money had been apparently wasted on
it, it had Opened the way for further advance. The
spending of the money would be justified in future.
We had to take tuberculosis as we found it and not expect
that patients in different stages of the disease would be
made for us to order. The disease would either advance or
the patients recover, and if we were going to carry them
about the country in order exactly to fit them into places
prepared for them a large number of expensive institutions
would be required. The patient must be attracted and
made to see that it was to his advantage to go into an
institution. He had first to realise that he was suffering
from a disease and that under certain conditions he would
be capable of living a useful life for a considerable period ol
time. Pensions should not be taken away because he was
earning a small sum of money. The fact that he was earning
made a great difference in prognosis.
Mr. Walker (North Wales) said the matter required to
be investigated in a more serious spirit and the people
must be educated. A man had no more right to be carrying
tuberculosis through the land than he had to wander about
the country if he were insane. The tuberculosis patient
should be controlled.
Dr. F. G. CaleY (Tuberculosis Officer, Wandsworth) said
that after four years’ absence he had returned to find that
the dispensary sanatorium as it existed now was very dis¬
appointing. Tuberculosis was an infectious disease, and we
were dealing with it as though it were non-infections.
Colonies must be made attractive. It was the system of the
future, and we had to adopt it if we wished to get rid of the
disease.
Dr. D. 0. Kirkhope (M.O.H. Tottenham) said that housing
alone would not solve the problem of consumption. Isolation
was needed.
Dr. S. G. Moore (M.O.H. Huddersfield) thought that
earlier notification was required and the Local Government
Board ought to have returns showing the average duration
of the disease at the date of notification. The only chance-
of restoring a consumptive patient to useful working capacity
was that treatment should be undertaken while there was
sufficient lung tissue present for normal life to be carried
on. When the disease was advanced there was an actual
destruction of lung tissues which arrested every effort to
rehabilitate the man.
Mrs. Keen (Papworth Colony Committee) thought that
segregation should not be compulsory, but made attractive
and gradually adopted. Such centres as those at Papworth
were required in all parts of the country.
Councillor Loojdon (Manchester) believed that effective-
propaganda work among the public was necessary. The
main cause of the generation of consumption lay in the
habits of the people. In Manchester industrial conditions
disposed to consumption, which was followed by a great
loss of money and productive power. Consumption should
be treated in the same way as other infective diseases^and
where isolation was not possible in the home a patient
should be sent to an institution, compulsion being used if
necessary.
Dr. Bardswbll, in his reply, said he was glad to see so
many interests represented, and that the general feeling of
the meeting showed that there was a desire for something
more to be done with regard to the treatment and prevention
of this disease. Professor Sims Woodhead had struck the
right note when he expressed the opinion that experiment
must be extended. A general wish for segregation had been
expressed, but he thought it should be done by attracting the
patients and not by compulsion. Such an enthusiastic con¬
gress as the present one would have been impossible a
quarter of a century ago owing to lack of interest, and he
regarded the present meeting as an indication of the
earnest intention of the country to deal with the matter on
a more comprehensive basis.
London Association of Medical Women.— A
meeting was held on March 11th, at 11, Chandos-atreet, when
Lady Barrett, the President, showed a case of Deficiency of
the Pituitary Body in a girl aged 19. The patient had
primary amenorrhcea, and on examination was found to have
a vei^ small, undeveloped uterus. She had no thyroid
deficiency, and was well developed except in the size of
the skull. The circumference was 19 inches, the occipito¬
frontal measurement was 6& inches, and the transverse was
5 inches. A skiagram showed a very small pituitary fossa
with the anterior part especially undeveloped.—Dr. Rhoda
Adamson opened a discussion upon the Effect of Industrial
Employment upon Women. She spoke from experience
as medical officer for seven years to a maternity
hospital, most of the patients having been factory
workers before marriage, and many of them char¬
women afterwards. She also spoke from the point of view
of three years’ supervision of some thousands of women in
engineering work, most of whom were wives of men in the
Navy, Army, or Air Force. She emphasised the need of
grading by a doctor with opportunities of seeing the
466 The Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[March 28,1919
different kinds of work, and the importance of giving suit¬
able work to pregnant women, who should be taken off all
night work and all work involving sndden strain. She
found that the children born under these conditions were as
healthy as those whose mothers did no outside work.
An interesting point was brought out in the fact that out of
4000 women doing heavy work only two developed hernia.
On the whole, Dr. Adamson found that industrial work was
good for women, and that some who had never gone out to
work before brightened up mentally, developed hobbies,
and improved in health.—Dr. Janet M. Campbell spoke of
some of the effects of munition work on women. She said
that industrial occupations were less injurious to women
than to men, and that they were less liable to aooident,
bat that women suffered more from overstrain, 50 lb.
being the maximum weight which it was found advisable
for most of them to handle. She said that the tuber¬
culosis rate had risen since the war in the case of
urban females, probably owing to the entrance of more
women into conditions which had previously accounted for
the greater incidence in urban males. The greater incidence
of sickness among working women must be attributed to
poverty, laok of fresh air, long standing, and improper food.
In munitions work, the results upon health were found to
be good owing to good wages, healthy conditions, and welfare
supervision. Dr. Campbell said that the results showed that
light sedentary work was by no means best, and that many
women would have better health if they followed more active
occupations.—Dr. Josephine L. D. Fairfield spoke from her
experience in the Q.M.A.A.C. and W.R.A.F., and referred to
the great value of grading for work. She attributed the
higher sickness rate in women to the strain of household
management being added to that of outside work, and said
that women suffered more from lack of a good mid-day
meal and good ventilation, and stood continued strain
and “dope” less well than men. In her opinion the
unreliability of the health of women about the age
of 40 was chiefly due to want of care at childbirth, and to
chronic toxsBmia due to dental disease, and both of these
causes should be prevented. She said that no industrial
work was harder than a woman’s work in a poor home, with
-all the washing and cleaning and half-a-dozen children to
mind.—Dr. Cioely M. Peake spoke of her experience in the
-Q.M.A.A.C. She said that as women had less muscular
power and less leverage owing to less height there was a
need of adapting machinery to their use.—Dr. Pillman
Williams gave some interesting statistics in reference to her
three years’ work in a filling factory where 9000 girls were
•employed. She found that the sickness rate in one section
went down when night work was stopped from 24*2 per cent,
to<20*24 per cent, per week.
Liverpool Medical Institution.—A t a patho¬
logical meeting held on Feb. 13th, Mr. Thelwall Thomas,
the President, in the chair, Dr. J. P. McGowan read a pre¬
liminary note on Mutation of Organisms of the Coliform-
typhoid Groups. Several cultures of a paratyphoid-like
non-laotose-fermenting organism grown on ordinary agar
euboultures infrequently and kept in the dark at room
temperature were found after two to three years to have
mutated into lactose-fermenting coli-like organisms. The
converse also occurred, but much less frequently. The same
change was brought about in a few days by a particular
method of passage through the body of an animal.—Professor
J. M. Beattie read a paper on the Diagnostic Value of the
Wassermann Reaction m Syphilis. He claimed that the
test, when carried out with a full and accurate technique,
was of extreme value, and referred to the very consistent
Tesults obtained by three experienced workers selected at
the instanoe of the Medical Research Committee. The
results in 1000 cases were analysed, and it was shown that
negative results could in almost every case be reconciled
with the history of the cases, treatment, Ac., and that in
positive cases the olinioal and serologioal diagnosis almost
invariably agreed. In clinically obvious cases—e.g.,
chancres, condylomata, gummata—every negative result
could be satisfactorily explained by the cases being either
very early ones, fully treated or undergoing treatment at
time the test was done. In other cases where dependence
had to be placed on a very imperfect history the agreement
between clinical diagnosis and serological was not so close,
but there was sufficient agreement to justify the opinion
that the reaotion was of the greatest value.
Tuberculosis Society.— The address on Acute
Pneumonic Tuberculosis will be delivered by Sir William
Osier on April 28th at 8.30 p.m., and not, as announced, on
March 24th. In its place Dr. Halliday Sutherland will open
a discussion on Tuoeroulosis Officers and Panel Practi¬
tioners on March 24th at 8.30 p.m. at the Royal Society of
Medicine. Discussion at this meeting is open to all members
of the medical profession.
auk Jjtofa lf Jtoofes.
'TV
Roentgen Diagnosis of Diseases of the Read. By Dr. Arthur
Schuller, Head of the Olinio for Nervous Diseases at
the Franz-Joseph Ambulatorium, Vienna. Translated by
Fred F. Stocking, M.D., with a Foreword by Ernest
Sachs, M.D., Associate Professor of Surgery in
Washington University. London: Henry Kimpton.
1918. Pp. 305. 21#.
This is a valuable and important contribution to the study
of craniology, and while appealing specially to surgeons and
radiologists it will prove helpful to the physician. The X ray
investigation of the head demands the highest degree of
perfection in equipment and in technique, and the subsequent
interpretation of the plates is attended with unusual
difficulties. In addition, opportunities for subsequently
ascertaining the correctness, or otherwise, of the X ray
findings are not always obtainable, so that it is scarcely to be
wondered at that the subject has been of slow development.
In collecting the necessary material for a work of this kind
the author seems to have been very fortunately placed, and
he has succeeded in giving us a thoroughly systematic
treatise that is certain to exercise a profound influence on
the investigation of cranial lesions.
The author is careful to point out that radiography is only
an addition to existing methods, though its possibilities are
much greater than is usually supposed. The basis of the
whole subject lies in the fact that intracranial diseases are
so frequently associated with changes in the bones of the
skull, and it is the purpose of this work to study these
changes from which so much valuable evidence is to be
obtained. After a consideration of the normal skull at
various ages and in different varieties, Chapter II. treats of
the irregularities in development following disturbances in
the growth of the skeleton, changes in the structure of the
bone and injuries to the skull. Chapter III., in addition to
pathologic changes in the brain that can be shown directly
radiographically, deals with the changes in the skuli
produced by intracranial pressure, tumours, epilepsy,
migraine, and psychoses.
Very properly the author advocates the use of stereoscopic
plates in all cases. Numerous radiographs are reproduced to
illustrate the text, and each is accompanied with a line
drawing that makes the interpretation quite dear. We
would draw special attention to the section relating to
changes in the sella turcica, which is most oomplete. The
author handles his subject in a way that is entertaining as
well as instructive, and it is to be hoped the work will
receive the attention it deserves.
Intensive Treatment qf Syphilis and Loo/motor Ataooia by
Aachen Methods. By Reginald Hayes, M.R.O.S.
Third edition, revised. London: Baillifere, Tindall and
Oox. 1919. Pp. 92. 4#. 6 d. net.
'In the third edition of his brief study of Aix-la-Ohapelle
methods the author recommend, as the result of further
experience, shorter intervals between the salvarsan injections.
The illustrative cases have been brought up to date, and
illustrations have been added to show the position assumed
by patient and rubber during treatment.
The Whole Duty of the Regimental Medical Officer. By
Captain P. Wood, R.A.M.O. London: Forster, Groom,
and Ck>., Ltd. 1919. Pp. 78. 2s. Qd.
This little book contains a series of maxims which should
be taken in by the embryo regimental medical officer. It
does not pretend to be more than a first-aid in sanitation and
prevention of disease in the field. The duty of the medical
officer to the State, to his unit, and himself is dealt
with. Certain criticisms of existing conditions as they
appealed to the author are worthy of consideration. This
officer, who has served in Balonika, describes a successful
scheme for dealing with oases of malaria, amongst a variety
of other routine duties. No doubt if the book had appeared
a little earlier it would have been of service, and there is no
reason why it should not be so now for those stationed in
similar dimes.
Tn Lancet,]
REVIEWS AND NOTICES OF BOOKS.
[March 22,1019 467
Manual of Baeteri tgy. By Robert Muir, M.D. Edin.,
F.R.8., Professor of Pathology, University of Glasgow;
and * James RriDHiB, M.D. Edin., Irvine Professor of
Bacteriology, University of Edinburgh. Seventh edition,
with 200 illustrations in the text and six coloured plates.
London: Henry Frowde and Hodder and 8toughton.
1919. Pp. 753. 16#. 8
The war has stamped itself Indelibly on medicine and the
ancillary sciences. New diseases have appeared and their
etiology has been investigated, and in some cases solved,
while on the other hand many subjects on which our informa¬
tion was still incomplete have passed, under the exceptional
conditions of the war, into the region of definitely acquired
knowledge. As the last edition of this excellent text-book,
undoubtedly one of the best for the purpose of the medical
student and praotitioner, was produced in 1913 the new
edition naturally reflects this war influence, though the
additions made are by no means confined to those sections
which are concerned with diseases which have been specially
prominent during the war. As with former editions, there
has been a thorough revision of the book and the new
m a teri a l is not simply added to but incorporated with the
old, so that this latter is modified by the knowledge sub¬
sequently obtained. By pursuing this sound but trouble¬
some method the authors are able to assimilate all the really
important new material available without unduly enlarging
the book.
Dealing first with the war subjects, the section on cerebro¬
spinal fever has been revised and the chapters treating of
the enteric group of diseases, including the amoebic as well
as the bacillary, form of dysentery, have been rearranged
and extended. More attention has naturally also been given
to the important group of anaerobic organisms which were
associated with the grave complications of wounds, and there
are corresponding additions to the methods of anaerobic
culture. For the first time sections deal with the spirochsete
of infectious jaundioe and the allied spirochete of rat-bite
fever. The information on trench fever hM been epitomised
from the reports of the English and American Committees,
and the important pioneer work of McNee and Renshaw is
duly appreciated.
In matters not directly arising out of the war, the ohapter
on pneumonia now contains the American work on the
differentiation of pneumococci, with its practical bearing
on treatment. The organisms found in actinomycosis are
definitely described as belonging to three distinct main
groups—aerobio, anaerobic, and actinobacillary. ■ Polio¬
myelitis is treated at considerably greater length and
Rosenow’s theory as to its origin discussed, while a section
on epidemio encephalitis has been added. The chapter on
influenza will require attention in the next edition; blood-
smeared agar is still described as the most suitable medium
for culture of the organism. Other modifications too
numerous to mention have been made, but all with good
intent and result.
The number of illustrations has been increased, and the
additions include several of anaerobic organisms, the new
gplrochaetes, and one figure of the organisms found in
Vincent’s angina. The misdescription of one of the malarial
plates has now been altered. The general appearance of the
book remains as in former editions, and though one or two
typographical errors have crept in, the printing and paper,
considering present conditions, are very satisfactory.
Tropical Surgery and Dieeatet of the Far East. By John R.
McDill, M.D., F.A.C.S. London: Henry Kimpton.
1918. Pp. 302. 24#.
dearly depioted by good photographs. Indeed, it is a merit
of the latter that the majority do show what they are stated
to do and are not smudges. About 100 pages are devoted
to the replies to a “ questionnaire ” Bent out by the author
in 1911. What the questions were is not stated, and how
far the replies are of value it is difficult to judge, but at any
rate they afford evidence of the diseases that a medical
is confronted with and of the material awaiting the research
worker. An appendix of 40 pages deals with the surgery
of the spleen.
Modem Urology . Edited by Hugh Cabot, M.D., F.R.C.S.
Philadelphia and New York: Lea and Febiger. 1918.
Vol. I., pp. 744. Vol. II., pp. 708. $14.
This book consists of a collection of monographs written 1
by some 30 American authors, each of whom has a world¬
wide reputation, and is a master of the particular section
with which he has to deal. The editor is to be congratulated
in having obtained such a combination of men to help
to send forth into the surgical world the views of American
genito-urinary surgeons relative to the science of urology.
It is only natural that the excellence of the various articles
should vary considerably, and it is not to be wondered at
that there is a good dead of overlapping, leading in some
cases to widely varying opinions of theoretical character
which at times lead to confusion. On the whole, however,
it is a good book and redounds greatly to the credit of Hie
editor. An attempt has been made to ensure that each
article is complete as regards points of historical interest,
pathology, diagnosis, and treatment. In some instances
elaborate discussions are made when there is a difference of
opinion as to the theoretical origin of certain conditions,
many of which are stimulating and demonstrate well-balanoed
coordination on the part of the authors.
We do not attempt to single out for praise particular-
articles amongst so many to which the names of men of
world-wide repute are attached ; it is sufficient to say that
the high standard of accomplishment whioh might have
been expected has been obtained. One interesting feature
is the prefacing of the book by an historical account of
the rise of genito-urinary surgery in America, with a short
life-history of the important men who have raised it to its
present high standard. It is a little disconcerting to find
that so little credit is given to surgeons in this country in
aiding this progress.
The drawings, photographs, X ray photographs, anatomical
and pathological illustrations and coloured prints are
excellent both in their number and reproduction. Especially
is this the case of the coloured cystoscupic views, whioh
are numerous and representative. The book also contains a
good bibliography. As a record of theoretical and practical
genito-urinary surgery, as observed from the American point
of view, there oan be no doubt that the editor has product
a notable addition to literature and one whioh will remain
for a long period the best available authority.
The Science and Art of Deep Breathing. By Shozaburo
Otabb, M.D. Basle. London: John Bale, Sons, and
Danielsson, Ltd. 1919. Fp. 114. 5#.
In this little book the author strongly urges the practice of
deep breathing for ten minutes every morning and evening as
a preventive against consumption and other diseases. He
ascribes the salutary effect produced, not so much to the
inhaling of an increased amount of oxygen as to the changes
produced alternately in thoracic and abdominal pressure.
During deep inspiration the thoracic pressure decreases and
the abdominal pressure increases:—
The title of this book hardly conveys an idea of its
peculiarities. It is not a humdrum text-book, as witness
the following passage :—
•‘Thw* are no dangerous wild beasts (in the Philippines) except the
wild Carabao or winter buffalo, whioh, when hostile, has no match for
ferocity; one must either kill him or take to a tree, and that forth-
**Hed, for although weighing about a ton, he is as quick as
It is curious to find “ calabar swellings ” in a book dealing
with the Far East and no mention of Schistotomum
japonicum , or, more remarkable still, of ancylostomiasis or
sprue. But although the plan of the book is hard to
discover yet it contains some valuable matter. The surgical
portions are interesting, the operation for liver abscess being
“Henoe the blood circulating in the abdominal oaviiw
flows into the thorax with greater rapidity, and the blood
circulation in the abdominal organs beoomes very rapid..
Daring deep expiration, when the abdominal pressure
decreases, tne thoracic pressure increases, and the blood
whioh was drawn up into the thorax during inspiration flows
back again into the abdominal cavity with great speed. In
this manner the nerve function and btood circulation in the
abdominal organs are strengthened by deep breathing, and
the physiological activity of these organs increases.”
The author dpes not reoommend the method if the disease is
in an advanced stage, if there is haemoptysis or severe cough,
or if the temperature is over 100° F. Method and its
rationale are described in detail.
468 The Lancet,]
NEW INVENTIONS.
[March 22, 1919
Electro-Diagnosis in War. (One of the series of Military
Medical Manuals issued under the general editorship of
Sir Alfred Keogh, G.C.B., and Lieutenant-General
T. H. J. C. Goodwin, C.B., C.M.G., D.S.O.) By A.
Zimmern, Professor Agr6g6 of the Faculty of Paris ; and
Pierre Perol, formerly Intern of the hospitals of Paris.
Edited with a Preface by E. P. Cumberbatch, M.A.,
M.R.C.P., Medical Officer in Charge of Electrical Depart¬
ment, St. Bartholomew’s Hospital, &c. London: Univer¬
sity of London Press, Ltd. 1918. Pp. 212. Is. 6 d.
Electrical testing is one of those several subjects that
have suffered much at the hands of their friends, and unfor¬
tunately claims prompted by early enthusiasm frequently
lead to a prolonged stiffing in the development of a new
line of investigation.; this undesirable state is accentuated
in the case of a subject that is both highly technical and
difficult. This volume should do much to place electrical
testing in its proper place among other methods of clinical
investigation. The authors are at some pains to show that
the method is only an accessory to others, though at times
an indispensable one. They further show that electrical
testing has not failed in any given case simply because it
has been gone over by someone armed with a faradic coil.
Profound knowledge and extensive experience are required
before the proper technique can be carried out and correctly
interpreted, and the authors emphasise the necessity for
repeated tests since abnormal reactions are not permanent
but vary from week to week or month to month. An
important contribution is an electrical method of testing
cutaneous sensation in which the stimulus is measured and
can be repeated on subsequent occasions. There are other
methods of equal importance, making the work the most
complete account that has yet appeared of the uses of
electrical methods in the investigation of paralysis occurring
in war and in peace.
JOURNALS.
Medical Quarterly. Vol.I.,No. 1. January, 1919. Department
of Soldiers’ Civil Re-establishment, Canada.—The aim of this
new journal is to disseminate medical knowledge of a general
nature as applied to the rehabilitation of the ex-soldier, not
only as it affects his physical condition, but his mental
attitude towards social and economic life. The number
includes three papers on tuberculosis and a paper on an
outbreak of influenza at a sanatorium.—Dr. J. H. Holbrook
points out that the extent of fibrosed lung in discharged men
should be taken more fully into account by the Pension
Boards: with a pension of only $10 a month the man is
tempted to exceed his working capacity and breaks down.
In men who have been gassed he has observed that
it takes very little exertion to manifest shortness of
breath; the men readjust themselves to their disability,
but if they are not dealt with very generously
during the readjustment period, not on the basis of
actual disease but on the basis of fibrosis, they will
run great risk of repeated breakdowns. He suggests that
the Canadian Red Cross Society should, as in the United
States, lend their assistance to antituberculosis organise
tions.—Captain A. T. Bond, C.A.M.C., considers that the
pensions of men with consumption, a disease so liable to
relapse, should be fixed every six months ; the evil of over¬
work must be prevented by sufficient pension.—Lieutenant-
Colonel J. L. Biggar, one of the co-editors, writes an interest¬
ing summary of recent articles on war neuroses; each of the
authors quoted appear to have invented a different set of
terms; the general conclusion, however, seems to be that
the neuroses arise as the result of the mental strife between
the emotion of fear and the men’s “ higher selves.” As a
result of the mental strain thus set up the patient becomes
hyper-suggestible.—Dr. C. B. Farrar describes the arrange¬
ments made for dealing with Canadian soldiers dis¬
charged with nervous and mental disorders. He considers
with a careful and judicious elimination of recruits with
a definite psychotic history or potential the number of
psychoses among returned soldiers might have been
reduced by at least a half.—In a paper on the medical
services of the department Lieutenant-Colonel F. McKelvev
Bell, the other co-editor^points out that wherever possible
the vocational medical officer should have some knowledge
of the various industries in which the men are about to
engage. “ It is a matter of considerable difficulty for the
average physician to estimate just what disabilities or
diseases preclude the various occupations, but experience
in this branch is being rapidly gained by the physicians
who have undertaken this important and interesting phase
of the work of rehabilitation.” Reports frpm these phy¬
sicians on this branch of the work would be very valuable ;
so important are they that we would suggest that the
department should require periodic returns showing the
work found suitable and unsuitable for men with various
defects.
The American Review of Tuberculosis. Baltimore : National
Association for the Study and Prevention of Tuberculosis.
35 cents.—The November number is mainly devoted to the
complement-fixation test, the first four papers dealing with
various aspects of this test. The verdicts passed on it are
not unanimous. Dr. Lawrason Brown and Dr. S. A. Petroff,
for example, with a material of 540 cases, conclude that this
test is of value to the clinician, and, like the subcutaneous
tuberculin test, is more instructive when it is negative than
when it is positive. Dr. B. Stivelman, on the other hand,
concludes his paper with the judgment that this test, when
negative, does not exclude clinical tuberculosis, and, when
positive, does not necessarily indicate the presence of
clinical tuberculosis. In fact, it gives no better informa¬
tion than the subcutaneous tuberculin test.—Dr. H. Kennon
Dunham’s paper on the X ray examination of the chest
contains much useful information, and is a plea for the more
extensive employment of the stereoscopic principle.
The Military Surgeon (Washington, D.C., U.S.A.) for
November has a note by Surgeon Chas. E. Riggs, of the
Medical Corps, U.S. Navy, telling of eight cases of small-pox
which occurred in U.8. ships on their China station between
August, 1917, and April, 1918. Half of them were severe
cases and fatal, half were slight. It is doubtful if the first
case had been recently vaccinated. There is a history of
vaccination and recent vaccination in all of them, but it
seems that in the United States a single vaccination scar
satisfies everyone, but it does not appear to secure immunity,
or did not in these cases, which support the English practice
of four vaccine marks at each vaccination. It is difficult to
understand the table of relation of dates of vaccination and
outbreak of small-pox, until it has been recognised that
9.4.17 is not intended to mean 9th April. 1917, as one
expects, but 4th September, 1917.— Major Sidney J.
Myers gives an account of a convalescent camp for 800
patients in Kentucky, a camp to reside in which
was meant to be both a pleasure and a profit.
The patients received have been in the base hospital
adjacent and are getting well. They have no temperatures,
and are able to walk from their wards to the mess-house.
No infectious cases are transferred nor any wanting special
diets. On admission patients are classified in four groups:
(1) resting, who go to lectures only; (2) light exercise, who
go short walks, Arc., always accompanied by a medical
officer and ambulance; (3) drill group; (4) reconstruction
group, who have just not passed into the Army but can be
made fit by a couple of months’ physical training. All
duties are voluntary, but by nearly all are eagerly under¬
taken. Lectures are well attended. There is much material
in each barrack to interest the men between times,
signalling apparatus, rifles dissected, military maps, and
so on. Band concerts are given on holiday afternoons.
It is concluded that the time of convalescence lost in ordi¬
nary hospitals is here put to profit for teaching hygiene,
diseases, military law, and sketching, &o .; 90 per cent, of
the patients have taken to the system quite readily, and men
go back to duty more quickly this way. . .
JjUfo Jnfrentnms.
A “DROP-FOOT” APPLIANCE.
Messrs. Allen and Hainburys, Limited, Wigmore-street,
London, W., call our attention to the appliance shown
in the illustration, which has been
made by them for the past two
years. Their letter is in reference
to a similar apjmance recently
noted in our columns (see The
Lancet, Feb. 15th, p. 284). The
appliance can easily be attached
to an ordinary boot by means
of screws and in certain
cases should prove
efficient. Pressure over
the tendo Achillis
would, in our opinion,
however, be likely to
produce discomfort not¬
withstanding the fact
that the strap is padded. The intelligent cooperation of
the wearer is needed to make any such orthopaedic assistance
permanently comfortable. A little ingenuity on the part
of the wearer can generally obviate painful pressure,
wherever manifested.
The Lanoht,]
STATE SUBSIDY OF TUBERCULOUS LABOUR.
[March 22,1919 469
THE LANCET.
LONDON: SATURDAY, MARCH ft, 1919.
State Subsidy of Tuberculous
Labour.
In a paper which we publish elsewhere in our
columns the author, Mr. P. C. Vabribb-Jones, makes
a step forward along a track paved with a dreary
mosaic of failures. The first principle he would
have us recognise is this: It is not the unfit that
become tuberculous, but the tuberculous who
become unfit. Hence his concentration on measures
"to protect the community from the infectious case.
His programme may be summed up in the one word
segregation, a term for which we devoutly wish
there was a kindlier synonym, not suggestive of the
leper. Mr. Yabbieb-Jones’s scheme for segregation
is, however, kindly as well as sensible; and, as its
workings have already shown at the Papworth
Colony, it offers not a prison but a city of refuge to
the tuberculous patient. At present the patient
with a tuberculous lesion of any gravity cannot
successfully compete in the open labour market, and
when his services are accepted they are often merci¬
lessly exploited by the employers who reward part-
time work with a pittance. According to Mr. Vabrier-
Jones’s scheme the patient would be delivered alike
irom the sweating of the thrifty employer and from
the doles of the philanthropist, and by a State
subsidy would be enabled to continue work under
conditions most favourable to himself as well
as to the community. As the experiments at
Papworth show, this subsidy need not be large.
But even a modest subsidy, representing only a
fraction of the patient's earned income, may make
all the difference. 41 The little more and how much
it is." After all, it is the pace that kills, and the
investment which enables the tuberculous to amble
happily through life without endangering the lives
of others is surely a wise one.
As Dr. Noel Bards well has pointed out at a
meeting of the Faculty of Insurance on Feb. 27th,
it may be long before any London authority can be
persuaded to establish special communities for
the thousands of tuberculous subjects requiring
subsidy. We doubt not that he is right. The initial
outlay would be too enormous for any public
body to take the initiative in incurring it. And
were it a matter of philanthropy only, or of
mere justice, the realisation of this ideal
would probably be postponed indefinitely. Even
the argument that it is “ good business," an invest¬
ment that will ultimately pay the community hand*
some dividends, may fall on deaf ears. But let
the taxpayer learn that he is defending himself
and his family from a deadly scourge and he will
pay readily, if not gladly. The old policy of patch-
work, of niggardly doles, is bankrupt. And the more
closely it is scrutinised the more does its futility
become evident. But till the community realises
that three months' treatment in a sanatorium is but
one link in a long chain, the temptation to stop
short at forging this one link will be invincible.
As matters now stand, sanatoriums are falling into
disrepute because the impossible is being de¬
manded of them. The aphorism/ 1 Once tuberculous,
always tuberculous," is so true as to be almost
a truism. Yet it is, unfortunately, often ignored
or forgotten, though a realisation of this elementary
fact is essential to the success of any scheme for
dealing with tuberculosis. Were this and other
essential features of the tuberculosis problem
common knowledge, its solution would be com¬
paratively simple. It is impossible to picture
statesmen and leaders of the people spending
less on a war against bacterial foes than on a
war against fellow beings were the facts generally
known. If this argument is sound, as we believe
it to be, the crying need at present is for a
campaign of enlightenment conducted with skill
and vigour.
Let us turn from principles and ideals to a
scrutiny of facts. Mr. P. Rockliff, president of
the Faculty of Insurance, speaking at the meeting
on Feb. 27th already referred to, said that the
treatment of consumptives on an insurance basis
had failed. It may provide residence for a few weeks
in a sanatorium; after that the patient returns to
his former unhygienic surroundings. Again, the
claims of the discharged sailors and soldiers have
largely led to the exclusion of the civilian
patient from Sanatorium accommodation— 44 an
expropriation of other people’s money which one
would only have expected from a Bolshevik govern¬
ment." In consequence of this state of affairs, Mr.
Rockliff assured his audience, the institutional
treatment of the insured civilian is not only
farcical but tragic. His indictment of Government
departments is, no doubt, deserved up to a certain
point; but we suspect that, they have not mono¬
polised all the sins of omission and commission,
and that local authorities are not innocent of the
gentle arts of obstruction, reaction, and circumlocu¬
tion. The public, too, must shoulder some degree
of responsibility for evils arising from general
ignorance and lack of interest in the public
welfare. A perusal of Dr. Noel Babdswell’s
paper, which we publish in our present issue,
on the training colony at Kinson for early
cases of tuberculosis, gives the critical reader
no rosy illusions. The task undertaken is
evidently full of difficulties, some unanticipated.
A considerable proportion of the colonists left
the settlement before their term had expired.
Others, though still in residence, are not
expected to be fit enough to become inde¬
pendent smallholders. Twelve months’ training,
it has been found, is not sufficient save in excep¬
tional cases with previous experience. And what
of the marketable value of the patient who has
mastered his new profession ? Dr. Bardswbll does
not venture any optimistic forecast, and we
gather that he has come to the conclusion that
this scheme, too, is a link, not a complete chain; and
that if permanent success is to be achieved the
470 The Lancet, J
THE PROGRESS OF CHEMISTRY IN 1918.
[March 22.1919
training colony must not be satisfied with turning
out its inmates to sink or swim in the open market,
but must provide sheltered conditions of labour—
subsidised labour, in other words. So we come
back to the inevitable conclusion: Once tuber¬
culous, always tuberculous* And the scheme that
fails to provide for the tuberculous throughout
their lives can only be a partial success.
■ ■
The Progress of Chemistry in 1918.
It is interesting to learn that during the terrible
times of war, and despite the depletion of personnel,
ohemistry, in all its branches, has been able to
make advances. The Council of the Chemical
Society may be congratulated on the policy which
it adopted a few years ago of issuing annual
reports of the progress of chemistry. The Society’s
journal, published monthly, is the medium through
which important papers read before the society
are communicated to its Fellows, and the abstracts
contained in it from contemporary and foreign
literature occupy the majority of its pages and
oover a wide range of subject matter contributed
by a staff of distinguished chemists, physicists,
and physiologists. The materials, therefore, from
which to compile an annual report are excellent,
while the compilation is left in good hands by the
selection of a certain number of these abstractors
to whom the task of recording the progress of
ohemistry during successive years has been allotted,
and making them responsible for the report.
The progress made in 1918 is of peculiar interest
when it is remembered that the shadow of war
for most of that period darkened all peaceful
scientific effort. Enough emerges from the report
to show that while the part played by ohemistry in
the war was of supreme importance, problems have
also been solved*in a valuable manner for the
ordinary days of peace. For example, interesting
reoords of work done on questions of ionisation, of
osmotic pressure, and of colloid constitution, will
prove as valuable to a world of peaceful develop¬
ment as munition work was valuable to a world
of ruin. In his review of the developments
which have taken place in general and physical
chemistry Professor H. M. Dawson expresses
the hope that the demobilisation of chemists
engaged on war work will be quickly followed by a
revival of activity in the investigation of the
many non-technical physico-chemical problems
which call for inquiry. This is an assured sequence
. of events, and we may go further and assert that the
lessons learnt in military exigencies will have their
fruit in civil results. The review of the develop¬
ments during the year in the field of inorganic
chemistry contributed by Professor E. C. C. Baly,
shows that in this division there was a marked
diminution in the number of papers published.
Generally speaking, the work has been restricted
to the preparation of new substances which have
no direct interest to medicine. Exception occurs
in the case of the preparation of inorganic colloids,
as, for example, nickel and mercury, in which
glycerol containing gelatin or gum-arabic is
employed as a protective colloid. For the employ¬
ment of colloidal metals in medicine is increasing.
In. the region of organic chemistry, in spite of
original ability being largely directed into emergency
channels, there are signs of research work entering
on a more active phase, to quote Professor J. C. Irvine
on the aliphatic division of the science which,
of course, comprises the hydrocarbons, alcohols, and
carbohydrates, including the sugars. Catalysts have
here played a strong part, notably in the case of
alcohol, reducing that complex to aldehyde, or as
far as a hydrocarbon, ethylene. The isolation
referred to in this section of an oil from shark
liver containing 90 per cent, of an unsaturated
hydrocarbon has already been mentioned in our
columns. It is the first time, we believe, that a
hydrocarbon or non-saponifiable oil has been found
in the animal organism.
During the year considerable attention appears to
have been given to the study of natural produots
mainly in the alkaloid group, and Professor A. W.
Stewart regards it as a hopeful sign that organic
chemistry is once more turning back to its original
field, leaving a little aside the purely synthetic
research which at one time threatened to. divorce
the general science from naturally occurring
materials. The investigations centering about
the connexion between chemical constitution and
physiological action in the cocaine series are of
interest. In the course of this investigation a useful
compound has been isolated; it has been termed
eccaine, and is reported to be more active than
cocaine as a local anesthetic, with the additional
advantages of being non-toxic and sufficiently
stable to render its sterilisation easy. Further
progress is reported towards the complete synthesis
of quinine, and the constitution of the ipecacuanha
alkaloids has been successfully studied. Analytical
chemistry has suffered through shortage of
materials and apparatus, which has led to the
devising of more economic methods and the
recovery of reagents. One carious example of this
is the use of an alloy of 11 per cent, of platinum
with 89 per cent, of gold as a substitute for platinum
in analytical work. Dr. F. Gowland Hopkins, in
reviewing the progress of physiological chemistry,
reports that the papers dealing with the dynamic
side of physiological chemistry—the process of
metabolism—have been few. He deals chiefly with
the contributions that have been made on emulsoid
colloids, chemical factors in shock (gum-arabic
solutions in the treatment of circulatory failure),
the phosphorus complexes of living cells, and the
degradation of carbohydrates. With regard to radio¬
activity Professor Frederick Soddy writes that the
most important advances are concerned with the dis¬
covery of the parent of actinium—proto-actinium—
which, in addition to adding an interesting chemi¬
cally new element to those discovered by radio-active
methods, completes probably the long sequence of
changes suffered by the radio-elements. We are
glad to know that these annual reports, containing
as they do a valuable and authoritative epitome of
the principal definite steps in advance made in
each successive year, are available to medical men.
TnLuroax.) MINISTRY OF HEALTH BILL: INSPECTION OF SCHOOL CHILDREN. [March 22, 1918 471
The Ministry of Health Bill: The
Inspection of School Children.
A S tandin g Committee of the House of Commons,
which is now considering the clauses of the Ministry
of Health Bill, adopted on Tuesday last an important
amendment without a division, and in the face of
protests from Dr. Addison and Mr. H. A. L. Fisher,
the two Cabinet Ministers whose functions
were immediately concerned. The amendment
provided for the immediate transfer to the
Ministry of Health of the functions of the Board
of Education in regard to the medical inspection
and treatment of children and young persons.
The Bill, it will be remembered, proposes to
combine under one State Department the existing
responsibilities of the Local Government Board
as far as health is concerned and all the functions
of the Insurance Commissions for England and
Wales, and also proposes to include the duties of
the Board of Education in respect of the health of
expectant and nursing mothers and children under
school age. But with regard to the medical inspection
of school ohildren and young persons, a duty which
now appertains to the Board of Education, it was
understood that that Board would not resign without
real regret its responsibilities in this direction;
and on the introduction of the Bill it was stated
that no such step would be found immediately
necessary. Mr. G. Locker-Lampson, however, pro¬
posed an amendment in the sense indicated above
—namely, to provide that all the powers and duties
of the Board of Education with respect to the
medical inspection and treatment of children and
young persons should be transferred to the new
Ministry of Health. A brief account of the debate
which followed will be found in our report of Parlia¬
mentary proceedings, from which it is clear that the
amendment was carried in deference to a practically
unanimous feeling on the part of the Committee
in its favour. The Committee held the view that
as the object of the Bill was to take over the health
services from the various departments of the State,
and thus to prevent overlapping, medical inspec¬
tion and treatment of school children could not be
left outside its scope. In any case it is only during
school hours—a small part of the child’s day—
that the Board of Education exerts its influence.
Dr. Addison pointed out that under the Bill there
were two categories of services—those to be trans¬
ferred forthwith, and those for which room would
be made later on; and he warned the Committee that
to put too much on the shoulders of the new Ministry
at the outset might be to risk a breakdown. But
as a matter of fact it was felt by many medical
men on the introduction of the Ministry of Health
Bill that the medical inspection of school children
and young persons formed a necessary part of the
duties of any Ministry of Health ; while it may be
recalled that dissatisfaction with the provision for
Hie medical treatment of school children under the
Board of Education was strongly expressed in the
House of Commons in July last, on the report stage
of Hie Education Bill, and led to its recommitment
in this respect. The Standing Committee of the
House of Commons have moved, perhaps, with
more directness than was anticipated, but when the
Bill was drafted no doubt those in charge of the
task expected to encounter opposition at this spot.
The amendment, which we welcome as a step taken
now which it was intended to take in the near
future, will be reviewed on Report.
Jjnurtatim.
"Ho quid nlmle."
MUSTARD GAS: ITS BRIEF BUT INGLORIOU8
CAREER.
Sir William Broadbent is credited with the
remark that a health resort, as soon as it became
well known as such, ceased to be a health resort.
Something similar has been the case of mustard-
gas poisoning. The military censor kept from all
except a very small circle all information regarding
the gas as a deadly weapon of offence, and now
that we are allowed to learn about it, it has
ceased to be a deadly weapon. Mustard gas began
its inglorious career as a constituent of * yellow
cross ” shells on July 12th, 1917, and ended. it, we
presume for ever, last week, when the Paris Con¬
ference decided to make the cessation of . its manu¬
facture a condition of renewing the armistice with
Germany. Most of the clinical and all the experi¬
mental information is available in the reports of
the Chemical Warfare Medical Committee, of which
Professor Leonard Hill is chairman and Dr. J. S.
Edkins secretary, issued by the Medical Research
Committee. The contributions of Dr. T. G.
Moorhead and Dr. William Boxwell, read before the
Royal Academy of Medicine in Ireland, 1 give a
useful survey of the whole field, and we have had
before us the report of remarks on the eye lesions
following exposure to the gas made by Dr. G.
Viner, Captain, R.A.M.C., at the Le Tr6port Medical
and Surgical Society.
Chemically,mustard gas is di-chlor-ethyl sulphide.
Watts’s Dictionary of Chemistry (1890 edition) gives
particulars of its preparation from glycol chlor-
hydrin, potassium sulphide, and phosphorus
pentachloride, the product being described as
very poisonous and violently inflaming the skin.
Although popularly called a gas, it is an oily
liquid, boiling at 217° C., with a slight but agreeable
ethereal odour resembling pineapple. Some, claim
to notice a faint aroma of mustard, but unlike the
suffocating gases known from earlier experience,
mustard gas was unsuspected by our troops, who,
misled by the latent period before the onset of
symptoms, suffered irom poisoning. in an acute
form ere its evil properties were realised. Nearly
insoluble in water and only slowly decomposed by
it, mustard gas naturally exercises its principal
effect upon the moister areas of the skin, especially
the bathing-drawers area and the axillary.folds,.as
well as on the mucous membranes, beginning with
the conjunctiva, nose, and mouth,and soon extending
downwards throughout the whole respiratory tract.
Even conjunctivitis does not set in for three hours
or more, vomiting and epigastric pain, when they
occur, are delayed for five or six hours, burns take
12 hours or more to develop, and the laryngitis,
tracheitis, and bronchitis do not reach their full
degree until 48 hours or even longer after exposure.
The lateness of the cutaneous and mucous symptoms
has suggested to some observers that they are due
to excretion by the skin and membranes after
absorption in the lungs rather than by direct action.
But the slow decomposition in the presence of
moisture is a more likely explanation. The ill-
effects reach a maximum in the first two or three
days and, if the resulting anoxaemia does not then
prove fatal, late results are much less common than
l Dublin Journal of Medical Science, Jan. let, 1919.
472 The Lancet,] COLLOID METALS AND PHENOL IN TREATMENT 07 INFLUENZA. [March 22,1919
when suffocating gas has been inhaled, a fact
which emerges from Professor Achafd’s abundant
experience, as our Paris Correspondent recorded
last week. The nature of the dangerous pulmonary
lesions was made clear early by the experimental
work carried out by H. M. Carleton in the Oxford
Physiological Laboratory. In the acute stage he
found desquamating tracheal epithelium, within its
lumen an inflammatory plug of leucocytes and red
blood cells, a similar but more advanced condition
throughout the whole bronchial tree with swelling
and shedding of the cells lining the alveoli. In
the stage of recovery the alveolar walls were still
thickened, many of them collapsed, and the blood¬
vessels in a state of dilatation. The latter changes
are evidently the commencement in milder form of
the pulmonary sclerosis which is such a lasting and
disabling sequel of exposure to suffocating gas.
The treatment of the immediate effects of
exposure to mustard gas is simple and obvious.
An immediate warm alkaline bath to neutralise
any oil left on skin, warm isotonic alkaline washes
for the throat and nose, menthol steam inhalation
for the respiratory tract. In cases with severe
involvement of the respiratory tract the diminished
surface for absorption of oxygen demanded the
same measures as for the victims of suffocating
gas. The burns produced on the skin were
often found intractable to any form of treatment.
It soon became evident that the physical effects of
the poisoning were liable to be supplemented by a
functional element due to the appalling nature of
the experiences undergone by the exposed man.
The acute onset of symptoms long after the
exposure to the gas, and the tension of expecta¬
tion thus produced, were factors likely to upset the
mental balance of all except the most phlegmatic.
It became a rule among medical officers to return
patients making good progress to army discipline
with the least possible delay, and to avoid pro¬
longed stay in hospital, which was found specially
Apt to establish neurotic conditions. Every effort
. was made to deflect the patient’s attention from the
condition of his eyes, shades and coloured glasses
being only exceptionally used. Vomiting of per¬
sistent and troublesome type appeared to be a
neurotic symptom and its occasional recurrence
after intervening months of recovery confirmed
this view of its nature. The whole distressing
story of mustard-gas poisoning teems with
medical interest. But while its lessons are worth
taking to heart, we may well hope that the disease
itself need only appear in the future text-books of
medicine as a curiosity an£ the relic of a savage
age destined never to return.
COLLOID METAL8 AND PHENOL IN THE
TREATMENT OF INFLUENZA.
During the recent epidemic many different
opinions have been expressed by writers in the
Italian medical press as to the value and efficacy
of various methods of treatment in severe cases
of influenza. Of these methods two claim, perhaps,
special notice as being more frequently adopted by
our Italian colleagues than they are in this country.
Dr. Miggiano 1 draws attention to the value of
injections of ethylhydrocuprein into the gluteal
region, and states that he has noticed areas of
broncho-pneumonia rapidly clear up in 24 hours
after a single injection, the characteristic signs of
infiltration of the pulmonary tissue being replaced
1 II Morgagni (Part II.), Feb. 16th, 1919,
by a group of crepitations and consonant r&les.
Two or three injections on successive days, in doses
appropriate to the age of the patient, sufficed to
improve the general condition, reduce the tem¬
perature to normal, and induce resolution of tlie
pneumonia. Much the same results are claimed
for colloidal gold by Professor P. Kathery, of Paris,
and three collaborators, in an important study a of
riie pulmonary manifestations of influenza. The
chute thermique which occurred sometimes after
the first dose was associated in their experience
with a complete change in the patient’s general
condition. Dr. Sebastiano Orlando 8 obtained
very striking results at the Military Hospital
in Florence by intravenous injections of phenol
in troops sent from the front with influenza com¬
plicated by severe bilateral broncho-pneumonia, and
was equally successful in the administration of this
drug by intramuscular injection and by mouth.
He gave two daily injections of 5 c.cm. of a 2 per
cent, solution of phenol, and by mouth 1 g. daily
of phenol in 300 g. of water and 50 g. of syrup of
aniseed. The results were equally good, but the
curative processes occupied a much longer time by
the oral method. This treatment had no injurious
effect on the kidneys, but, on the contrary, the
albuminuria which so often accompanies severe
cases of influenza tended to disappear. Dr. Orlando
claims as a result that while in October, 1912, in
the province of Massa he had a death-rate among
his influenza patients treated on the usual lines
of 6*4 per cent., with phenolisation he obtained
100 per cent, cures, except in those cases where
treatment was delayed until too late.
THE WARBLE FLY.
The damage caused to cattle, meat, and hides by
the ravages of the warble fly has at last been made
the subject of Government inquiry, and a scientific
subcommittee has been appointed to supervise and
control experiments, which are to be carried out in
different parts of the country in order to discover,
if possible, a method of eradicating this pest. Two
species of warble flies, Hypoderma lineatum ,and
H. bovis , occur commonly in this country, and
though they have been studied for nearly half a
century it is only during the last two or three
years that the details of their curious life-cycle
have been elucidated. The female fly attaches her
eggs to the hairs of cattle, invariably on the legs or
lower part of the body. If the cattle become aware of
the presence of a warble fly they show much excite¬
ment and run about in a peculiar frightened manner
known as “ gadding,” which may often be observed
on sunny days in early summer. About three days
later the egg hatches, and a tiny maggot emerges
and climbs down the hair, burrowing its way into
the hair follicle, whence it apparently enters the
blood stream and eventually reaches the gullet.
The fact that the next stage occurs in this site led
to the belief that the cattle licked off the eggs
from the hairs and that the young larvae hatched
in the gullet, but it has been shown that careful
muzzling does not prevent cattle from becoming
infected. The maggots appear in the wall of the
gullet towards the autumn and remain there all
the winter. About March they go to the back by
travelling through the tissues of the animal. One
route is for the maggots to leave the gullet
near its junction with the paunch and enter
a Paris M&lleale, March l«t, 1919. .
» La Blform* Medloa, Jan. 18th, 1919.
Tot Lanc**,]
INDUSTRIAL DISPUTES IN ASYLUM 8 .
[March 22,1919 473
the connective tissue of the diaphragm, which
they follow between the strands of muscle
downwards and outwards till they reach the
cartilage of the ribs. They then proceed along
the posterior border of a rib, always in the
connective tissue, and either go straight to the hide
of the back, or find their way into the spinal canal,
from which they emerge nearer the animal’s tail.
Established in the hide, a cyst, or “ warble,” is
formed round the maggot, which now makes a hole
to the exterior for breathing purposes. In due time
the larva comes to maturity and falls out of the
warble to turn to a chrysalis in the ground. The
adult fly appears about five weeks later, the whole
life-cycle taking about one year for completion.
The chief damage caused by these flies is that to
the hides of cattle, resulting from the perforations
of the warbles. A moderate estimate puts the
annual loss in damaged hides at upwards of
£300,000 in this country alone. In addition, the
presence of the cysts in the back causes the flesh
to develop an unpleasant appearance known as
“ jellied beef,” which considerably reduces its market
value. Add to this the loss of condition in ' the
animals attacked and it will be realised how serious
are the ravages of this pest. It is to be hoped,
therefore, that the efforts of the Government will
result in the discovery of some method of dealing
with the warble fly and preventing these losses.
INDUSTRIAL DISPUTES IN ASYLUMS.
That third parties should suffer in consequence
of a dispute for which they are not responsible has
been such a customary experience during the past
few years that an additional instance may attract
only a moderate degree of attention, even though
some of the victims of it are more helpless than
usual. The contest between the various asylum
authorities throughout the country on the one
hand, and the National Asylum Workers Union on
the other, appears likely to prejudice the interests
of those whose needs are ostensibly the care of
both parties, and there have already been cases in
which the issue has been fought out irrespective of
the well-being of the insane in the asylums, or of
the general community outside. Since the brunt
of any trouble which arises in this way has to be
borne primarily and chiefly by the medical men
in charge of the institutions affected, it is but
natural that these gentlemen should be feeling
some anxiety as to the course of events, and
that the body which is, in a measure, repre¬
sentative of them should be displaying a
certain liveliness. On two occasions recently, at
weU-attended meetings of the Medico-Psychological
Association, attempts have been made to And
some satisfactory way of ensuring for medical
superintendents a voice in deciding questions
with which they are intimately concerned and in
regard to which they are especially qualified to
speak. A resolution adopted on Feb. 20th urged
“ the provision of an advisory board of experienced
medical officers of asylums to indicate how any
alterations proposed would affect the welfare of
tiie patients,” but it seemed to be generally realised
that however valuable this expression of opinion
might be as such it would not advance matters
very considerably unless one or other belligerent
should show some disposition to ask for advice. The
attitude of those who were present at the second
meeting appeared to be that to bring about
effective intervention it would be necessary for
medical superintendents to obtain representation
on any committee of local authorities which might
be constituted, though it was felt that this
proceeding might introduce its own peculiar
difficulties by setting a medical superintendent
in opposition to the staff nominally under his
control. Looking at the matter from the stand¬
point of the national welfare, there can be no doubt
as to the expediency of giving full weight to the
opinions of asylum superintendents in relation to
matters of asylum administration, and since the
general public needs the assistance of the super¬
intendents the general public should take steps to
get it. Probably the most effective method would
be to bring pressure to bear on the Minister of
Labour and on the Minister of Health, when
appointed, through the instrumentality of Members
of Parliament. The Medico-Psychological Associa¬
tion could then appoint an advisory body with some
hope of its services being utilised, and the members
of the association might escape from the uncom¬
fortable position between the devil mid the deep
sea in which circumstances have placed them.
DANGEROUS CHLOROFORM APPARATUS.
Thb possibility of causing liquid chloroform to*
issue from the exit tube of some forms of pumping,
apparatus has long been recognised. The fatal
consequences of such an accident need no demon¬
stration. All apparatus capable of providing suchi
a mishap should be avoided, and for many years it
has been possible to obtain instruments removed by-
construction from such a perilous contingency. Im
a fatal case recently recorded in the daily press
the instrument used is described as a “ Hunter ”*
inhaler. Presuming that “Junker’s” inhaler is-
intended, it may be said at once that in the original
form of this apparatus the escape of liquid chloro¬
form to the patient was fairly easily possible*,
either by fixing up the tubes incorrectly or by over¬
tilting the bottle. The late Sir Frederic Hewitt*
devised a modification of Junker’s inhaler which*
is perfectly safe as regards this particular accident,,
and there are others in which, if not absolutely
impossible, the accident can occur only by very-
excessive overfilling of the chloroform bottle*.
Such are Buxton’s modification of Junker’s inhaler
and Shipway’s warm vapour apparatus. We would*
most warmly recommend young anaesthetists to
examine any pumping apparatus from which they
propose to administer chloroform very carefully
before they use it, and to bear in mind the accident,
alluded to above. , _
AN ANALY8I8 OF 8670 OPHTHALMIC CASES:
TREATED AT A HOME HO 8 PITAL . 1
Major A. W. Ormond here analyses the ophthalmic
cases at the 2nd London General Hospital down to*
the end of 1917. Of 684 cases of “ blindness ” (most,
of whom were transferred to St. Dunstan’s) 340*
were completely without sight, and 175 of them
had no eyes, both having been either destroyed by
the injury or removed subsequently on account of
pan-ophthalmitis, pain, Ac. The cause ot blindness-
was, in general, either the passage of a bullet or
piece of shrapnel through the face in contact with
one or both orbits, or else the bursting of a shell
or bomb in front of the face; the proportion due
to the latter cause exceeded that due to the
former in the proportion of 32, and* showed a
tendency to increase in the later stages of the war>
» Medioel Reoeereh Committee Statistical Report, No. 3..
474 Th> Lanoht,]
THE NURSING REGISTER.
[March 22.1919
Deliberate malingering was, during the period
dealt with, very rare indeed. On the other hand,
Major Ormond records 39 cases of what he terms
“ concussion blindness," but which might more
appropriately be called psychical blindness, since
they are neither cases following the passage of
missiles in the vicinity of the globe and producing
ophthalmoscopioally recognisable results, nor cases
in which a concussion of the cerebral cortex may
fairly be assumed as the cause. These cases are
usually the result of an explosion in the immediate
vicinity of the patient rendering him unconscious.
On regaining consciousness the patient is unable
to open his eyes, and believes himself to be blind.
He is not a malingerer. At the same time, if the
true nature of the condition is not recognised in the
early stage by the surgeon the prognosis of the case
is enormously prejudiced. Other points in the
analysis which may be noted are the rarity of
sympathetic ophthalmia in this war, the dis¬
appointing ultimate results of the Extraction of
foreign bodies from the vitreous by the electro¬
magnet, and the too great proportion of cases
invalided on account of such conditions as high
myopia and nystagmus, which, if the medical
inspection of these cases on enlistment had been
anything more than a farce, should have prevented
them from ever entering the army. The rather high
proportion of injuries due to accidents not attribut¬
able to enemy action is also commented upon.
THE NURSING REGISTER.
Controversy centres at present around the pro¬
pose to grant supplemental registration to nurses
trained exclusively in children’s hospitals, and there
is considerable opposition to including the nurses
with special hospital training only in any scheme
for State registration. The Central Committee for
State Registration will not consider the proposal,
but the Bill drafted by the College of Nursing
contains a clause empowering the General Nursing
Council, when set up, to institute supplementary
registers to include nurses trained in other than
general hospitals, the assent of the Privy Council
being obtained to the conditions of training.
Although this clause does not definitely establish
a register for children’s nurses, it grants power to
the General Nursing Council to do so, and in this
respect goes one stage further than any other
association working for State registration of
nurses. Although the nursing of children is not
identical in every respect with the nursing
required by adults, because the range of disease
is different, a three-years’ course of training in a
children’s hospital has the whole framework of a
liberal nursing education, and we think that it
would only be fair to nurses so trained to grant
them the status conferred by entry upon a
supplementary register. The other nursing
specialties might then be pigeon-holed by the
State, and in this way justice would be done to
the special nurse and protection granted to the
general-hospital-trained nurse, and the one would
be less likely to encroach on the province of the
other. It seems likely that a Parliamentary Com¬
mittee will be appointed to consider the two regis¬
tration Bills which are now being promoted, and
one of which has just been read a first time in the
House of Commons. A compromise may then be laid
before Parliament. The position of the College of
Nursing is strengthened by the fact that beyond
the promotion of State registration it has a
definite programme of education. A scheme of
affiliating children’s hospitals with particular
general hospitals is the policy of the College, and
has already been adopted in one or two instances.
The time spent by the nurse at the children’s
hospital is then counted as part of her general
training. To those who are outside the actual
arena of conflict a compromise on these lines would
seem not difficult of arrangement. Given a working
scheme of State registration as a basis the rest
should soon follow.
A LARGE WASTE OF ACCESSORY FOOD MATERIAL.
Now .that it has been shown that the anti¬
scorbutic properties of lemon juice are in no way
connected with the citric or other acids present,
and that the accessory factor can readily be
separated from these acids, attention may well be
directed to the manufacture of citric acid from lemon
juice on a large scale in such a way as to save the
vitamine for special dietetic purpose. The world’s
yearly output of citric acid so prepared runs into
many hundreds of tons. The acid itself is separated
and recovered by a very simple process. Chalk
is added to the juice, when insoluble calcium
citrate is formed. The precipitate is removed and
treated with an equivalent amount of dilute
sulphuric acid, which liberates the citric acid,
leaving behind insoluble calcium sulphate, part
of which is deposited and the rest removed by
filtration. Concentration and crystallisation of
the clear fluid complete the process. It is obvious
that the liquor strained off from the calcium
citrate must be rich in the antiscorbutic factor,
but as far as we know it has not been utilised.
Here is a valuable source of accessory substance
which should be saved. We suggest to manu¬
facturers of citric aoid from lemon juice that they
devise some simple means of recovering the
vitamine in a convenient form for transport and
administration. In so doing a supply of essentially
useful nutritive material would be rendered avail¬
able without interference with the citric acid
manufacture. Should the process, however, involve
prolonged heating, the vitamine would possibly not
survive, but steps might conceivably be taken to
avoid such an occurrence.
A DIMINISHING POPULATION.
With the cessation of slaughter on the Western
Front pestilence took up the task of keeping down
the surplus population, and in the last quarter of
1918 the number of civilian deaths in England and
Wales, as stated in the Registrar-General’s returns,
exceeded the number of births by 79,443. An
actual diminution in the population in any quarter
of the year was previously unknown during the
whole period for which exact figures are available.
It was, of course, principally the result of the
influenza pandemic, which is officially credited with
a casualty list of 98,998, or 41 per cent, of the total
deaths registered. And this figure is more likely
to be under-estimated than exaggerated. In the
face of such a violent quake to the whole apparatus
of vital statistics it seems hardly worth the
trouble to attempt to estimate the effect of the
customary .small oscillations in birth and death
rate. Suffioe it to note .the encouraging fact that
8000 more births were recorded than in the corre¬
sponding quarter of 1917/ But here, too, the
aftermath of war is seen in the unusually high
proportion of illegitimates.
The Lancet,]
ROYAL INSTITUTE OR PUBLIC HEALTH.—IRELAND.
[March 22,1919 475
ROYAL INSTITUTE OF PUBLIC HEALTH.
The Council of the Royal Institute of Public
Health are arranging for a conference in the
Guildhall, London, on “Problems of Reconstruc¬
tion in Relation to Public Health,” from June 25th
to 28th. The opening meeting will be held in
the Egyptian Hall of the Mansion House on
Wednesday, June 25th, qjb 3 p.m., when the
Lord Mayor of London will preside. The con¬
ference will mainly consider the following
matters: (a) “The Work of the Ministry of
Health ”; (b) “ The Prevention and Arrest of
Venereal Disease”; (c) “Housing in Relation to
National Health ”; {d) “ Maternity and Child
Welfare”; (c) “The Tuberculosis Problem under
After-war Conditions.” Further particulars will
be supplied by the secretary of the institute,
37, Rus8ell-square, W.C. 1.
KING EDWARDS HOSPITAL FUND FOR LONDON.
Hospitals in the County of London or within
nine miles of • Charing Cross desiring to participate
in the grants made by King Edward’s Hospital Fund
for London for the year 1919 must make application
before March 31st to the Honorary Secretaries,
7, Walbrook, E.C. 4. Applications will also be con¬
sidered from convalescent homes which are situated
within the above boundaries, or which, being
situated outside, take a large proportion of patients
from London. Applications will also be considered
from sanatoriums for consumption which take
patients from London or which are prepared to
place beds at the disposal of the Fund for the use
of patients from London hospitals.
Colonel A. H. Tubby, A.M.S., has relinquished his
duties as consulting surgeon to the Egyptian
Expeditionary Force and resumed his private work.
Mr. Edred M. Corner will deliver the Harveian
lecture of the Harveian Society at the rooms of the
Medical Society of London, 11, Chandos-street, on
Thursday next, March 27th, at 8.30 p.m., taking as
his subject “Nerves in Amputation Stumps.” Invita¬
tion is extended to all members of the medical
profession. -
With the April issue the Medical Supplement to
the War Office Daily Revieiv is being discon¬
tinued, but we are glad to learn that the change
is only one of name and outward form. The
Medical Research Committee have arranged to
continue the issue of a Centralblatt, and hope to
extend its range to cover British as well as foreign
medical literature. An early announcement will
be made on the subject.
Kidderminster Infirmary : Proposed War
Memorial.— A representative meeting of the burgesses of
Kidderminster has been held at the Town-hall, under the
presidency of the Mayor, to consider a proposed extension of
Kidderminster Infirmary as a war memorial. It iB suggested
that the children’s department should be extended, a new
out-patient department and laundry built, and various addi¬
tions made which will result not only in a building of
architectural beauty, but provide at the same time accom¬
modation for returned soldiers and their dependents who
may need treatment, for work in connexion with the Child’s
Welfare Centre, for expectant mothers, and for tuberculous
and venereal diseases, as well as for the general work of the
hospital in connexion with the sick poor. Next year the
infirmary will celebrate its hundredth anniversary, and the
S resent is considered an opportune time to make an appeal.
'he cost of additional buildings and alterations is estimated
at about £25,000, and Mr. Stanley Baldwin, M.P., has already
given £5000 for the new children’s ward.
IRELAND.
(From our own Correspondents.)
A Ministry of Health for Ireland.
The question of a Ministry of Health for Ireland is one
which looms large in the minds of those who have the good
of the country and the welfare of its inhabitants at heart.
The housing problem in Ireland is not more acute than it is
in England only because the people themselves do not realise
that their dwellings need improvement. Much has been done
in the past through the Department of Agriculture, the
moving spirit of which was Sir Horace Plunkett, in assisting
by means of grants and in other ways the erection of
labourers’ cottages, but much more remains to be done. The
slums of parts of Dublin and their equivalent in many out¬
lying rural districts will bear comparison with the worst
which can be found in London, Cardiff, or Glasgow, but no
one bemoans them in the Irish press, probably because they
are out of sight. It might be thought that a country
with such large rural areas as Ireland would show a
low mortality from tuberculosis, but precisely the opposite
is the case.
Irish Vital Statistics : Conditions of Medical Service in
Ireland.
At a meeting of the Statistical Society of Ireland held
on Feb. 28th the Registrar-General, Sir William Thompson,
who presided, said that between one-seventh and one-eighth
of the total number of deaths occurring in Ireland were
caused by tuberculosis in its various forms. The deaths
from this disease in England and Wales during the quin¬
quennial period 1911 to 1915, compared to 1866 to 1870,
showed a reduction of 56 per cent., whereas in Ireland the
reduction was only 13 per cent. In 1916 the death-rate from
tuberculosis for England and Wales was 1*53 per 1000 of the
population ; in Ireland for the same year the rate was 2*15,
a difference of 0 62. In Ireland in 1917 the total death-rate
was 16*8 per 1000, or 2*4 per 1000 higher than England and
Wales. The infant mortality rate in England and Wales in
the quinquennium 1911-15 compared to that of 1866-70
showed a reduction of 30 per cent.. whereas in Ireland the
reduction was only 4 per cent. Experts were agreed, he
said, that the infant mortality rate should fall between
40 and 50 per 1000 births. In Ireland the rate for the ten
years 1907 to 1916 was 92.
Comparing the same quinquennial periods Dr. M. F. Cox, in
the course of a paper which he read, said that the death-rate
in England and Wales had decreased by 36 per cent., in
Scotland by 29 per cent., whereas in Ireland it had risen by
2 per cent. Dr. Cox also drew attention to the fact that,
though the Poor-law officers rendered splendid services to the
poor, they were wretchedly underpaid at all times, but more
especially at present. Many of the dispensaries were, he
said, utterly and disgracefully unsuitable for the ministration
to the wants of the sick poor; the space afforded was in¬
adequate, and provision for privacy and for proper examina¬
tion was entirely wanting.
Sir John William Moore drew attention to the fact that
only two county boroughs in Ireland had medical officers of
health—namely, Dublin and Belfast. Every hospital in
Dublin was in debt and required State aid. It was an outrage
he said, that men acting as labourers should get as much i
or more than the dispensary medical officers.
Sir T. W. Russell thought that it would be wiser to press
for a separate Bill for Ireland than to extend the present
Ministry of Health Bill. The fact that they were legislating
in the absence of over 70 Irish Members would have to be
considered, and what these men would say would have to be
taken into account. It was possible that they could get the
opinion of the country without them. There can be no doubt
that Ireland needs a Ministry of Health, and this should not
be withheld from her because certain of her Members have
refused to attend at Westminster.
Proposed Establishment of Irish Public Health Council.
The Chief Secretary for Ireland, in whom is vested all
questions of policy and administration for the Irish health
measure, has tabled an official amendment in reference to the
establishment of an Irish Public Health Council. It is to
consist of the vice-president (Sir Henry Robinson) and two
other commissioners of the Local Government Board (as the
476 Thi lakobt,]
AUSTRALIA.
[March 22,1919
Chief Secretary is president this means that the Local
■Government Board would have four members on this Irish
Public Health Council), one or more of the Irish Insurance
Commissioners, nominated by the Chief Secretary, the
Registrar-Qeneral, and such number of registered medical
practitioners—not exceeding three—as may from time to time
be nominated by the Chief Secretary; one is to be a woman
•and one a medical practitioner holding a diploma in public
health, sanitary science or State medicine.
An Irish Public Health Council so constituted will never
satisfy the medical practitioners of -Ireland. They feel (1)
that they will not have sufficient numerical representation
on such an advisory health board ; (2) they will demand the
right of electing their own members rather than having
them nominated by other boards in Dublin ; (3) they
argue that the Local Government Board would have a pre¬
ponderating influence, and that such an Irish Public Health
Oounoil must not be made a subcommittee of the Local
Government Board, as occurred in the case of the Mid wives
Board for Ireland. It should be a committee with medical
practitioners representative of the whole country, north and
south, and not o£ Dublin alone. In the past whatever
official guidance in public health matters there was emanated
from Dublin, with the result that Ireland is half a century
behind Great Britain in public health progress.
A Separate Bill for Ireland,
On the whole, opinion is hardening that Ireland, as in the case
of Scotland, must have a Health Bill of her own suited to her
backward (public health) condition. If the Chief Secretary
is to be successful in passing a Health Bill for Ireland which
will work he will have to consult the medical profession and
frame his measure on broad democratic lines.
Unfortunately, at the present moment the Irish medical
profession is speaking with an uncertain voice. The authority
of the Irish Medioal Committee, which represented the pro¬
fession in the struggles arising out of the Insurance Act, has
been challenged by the Irish Medical Association, which is
endeavouring to take the controlling part. An influential
deputation from the Royal College of Physicians of Ireland,
appointed to wait on the Chief Secretary, has not yet been
received by him. Doubtless there are little, if any, differ¬
ences of opinion among Irish medical men on the general
question of a Ministry of Health and the need for reform and
unification of all the public services concerned with health
matters. But the lack of the moment is a representative
medical body to initiate a clear line of policy.
March 18th. _
AUSTRALIA.
(From our own Correspondent.)
The Influenza Pandemic.
For the last six weeks the public mind has been greatly
perturbed by the possibility of an outbreak of so-called
Spanish influenza. The authorities have been on the alert
since the first danger threatened from New Zealand, and at a
conference of officials it was decided to call the disease
“ pneumonic influenza,” and certain common preventive
measures were agreed upon. The chief strain has fallen on
the Sydney quarantine staff, as several vessels arrived in
quick succession from New Zealand and the Islands with
severe outbreaks among passengers and crew, in addition to
one or more transports. West Australia was also oalled on
suddenly to deal with overseas cases, in transports, of very
severe type. Up to the new year the effort of the quarantine
authorities to confine the disease within the quarantine
hospitals has been successful, and no case has been reported
on shore with the exception of a soldier who suffered a
relapse after being discharged from quarantine. Up till the
end of December the total number of cases dealt with at the
different quarantine stations was between 1200 and 1300, and
there was a death-rate of some . 5 per cent. Three nursing
sisters have contracted the malady in quarantine and died.
The most virulent cases were among those from the Atua,
a steamer from Fiji and the Pacifio Islands. Generally
speaking, the medical experience of the disease has been
similar to that reported from other parts. Some of the
8ydney cases exhibited hsematemesis as a prominent
symptom, and the suddenness of onset has occasionally
been dramatic. The Federal Quarantine Department issued
a vaccine which was used both as a prophylactic and thera¬
peutic measure. It does not yet appear that it had any
controlling influence, but it was stated that severe symptoms
were modified. This vaccine was also available to the pro¬
fession, and many thousands of persons have been inooulated.
It is now hoped that the danger of shore infection is over as
far as the cases already dealt with are concerned, and for
the present the outlook is good. On the whole, the organisa¬
tion of the Quarantine Department appears to have been
satisfactory, but there have been many individual complaints
of hardship and discomfort. In Victoria and elsewhere the
Red Oross officials helped materially by sending food and
medical comforts to the troopships. For a time the Director
refused to admit clergy to minister to the dying in quarantine,
but subsequently permission was given for clergy from outside
to be allowed into the stations under regulation.
Influenza Vaccines.
In Sydney there has been a popular response to the
proposal of inoculation against influenza, with the natural
result that many patients suffering from complaints other than
influenza declare that they have been cured by the vaccine.
Many disorders, from chronic catarrh to acute neuritis, are
stated to have miraculously disappeared after inoculation.
Ready belief in the mysterious and novel is not unknown
here. Two vaccines have been in use differing somewhat
in composition. One was issued by the Federal Depart¬
ment, the other by the Health Department of New South
Wales. Professor H. G. Chapman, of the Sydney Uni¬
versity, has publicly deprecated the employment of vaccines
without a knowledge of the infection they are presumed to
combat, stating that from his experimental work inoculation
appears to lessen the resistance of the patient to an attack
of influenza if the organisms used in the vaccine are not
those infecting the patient.
Nationalisation of Medicine,
The nationalisation of medicine is a growing topic of
public interest and discussion, particularly in Victoria, where
the lodge dispute has been acute. The present dual control of
public health administration by Federal and State authorities
renders it improbable that any comprehensive scheme is
likely in the immediate future. At the same time there
seems a real danger that individual States may attempt some
immature suggestions designed to supply cheap medical
attendance. The Federal authority at present only extends
to matters of quarantine, and every State has an existing
department of public health controlled by a Minister and
directed by expert officials. Any nationalisation scheme of
Federal extent would require an amendment of the constitu¬
tion. The subject is set down for consideration at the forth¬
coming meeting of the Federal Medical Committee. The
attitude adopted by this body, which is composed of delegates
from the State branches of the British Medical Association, is
that no hostility to any proposal is at present desirable, but that
the Association should be prepared to suggest some scheme if
need arises. The Victorian branch recently appointed a sub¬
committee to report on the general attitude advisable. This
report has not yet been adopted, but it is an open secret
that while advocating a wide extension of public health
'activity, the establishment of a State-controlled clinical
service is viewed as a retrograde step both from the public
and professional points of view, and the retention of the
voluntary hospitals system is strongly advised.
Ankylostomiasis.
Dr. Waite, of the Rockefeller Institute, has been engaged
for some time in investigating the incidence of hookworm
disease in North Queensland, and has arrived at the conclusion
that the local population is being seriously affected. The
subject has been brought under the notice of the Federal
Government and a sum of £35,000 has been voted to assist
the further investigation by Dr. Waite of the best methods
for overcoming the danger. At present it is clear that the
sanitary conditions are very primitive in the towns and that
the proper disposal of nightsoil is an elementary need. Dr.
Waite concludes that those children affected by the parasite
suffer not only from anaemia, but are stunted physically and
mentally and deficient in sexual development.
Australian Army Medical Corps .
Surgeon-General R. H. Fetherston has resigned the post
of Director-General of the Australian Army Medical Servioe,
which he held from the outset of the war, and has resumed
The Lancet,]
?ARIS.—THE FELLOWSHIP OF MEDICINE.
[March 22,1919 477
private practice. He will be succeeded by Surgeon-General
(temporary) G. Cuscaden, who was Principal Medical Officer
3rd Military District of Victoria, and acted as Director during
Surgeon-General Fetherston’s absence in France and Great
Britain.
Jan. 8th. _
PARIS.
(From our own Correspondent.)
The Protection of Medical Practice in France.
French law admits to the practice of medicine in France
only those who possess the State diploma, and this diploma
in its turn can only be obtained by graduates of a French
university who have entered for the full course of medical
study. On the other hand, a university degree in medicine,
while it includes the same technical examinations, does
not demand from foreign candidates as an entrance
condition any other diploma than that obtained in
their own country, but the possession of such a degree
does not oonfer any right to practise in the country and has
only academic value. During the war a large number of
foreign doctors have visited France and given their care to
the civilian population, some of them also working in the
military hospitals of the Red Cross in the absence of French
colleagues on aotive service. Some who have now filled
these places for years do not desire to return home and are
asking that the tolerance exceptionally granted to them
during the war shall be transformed into a regular authorisa¬
tion. These individuals have readily acquired a University
diploma which they now ask to have changed into a State
diploma. This change is provided for by the law, but
requires the candidate to pass anew his last examina¬
tions with a resultant delay of years. The foreign
doctors in question are asking to be dispensed from
these legal formalities on the ground of services rendered
to France during the war. Some of them have, in
fact, rendered real service to the country; they have
been mentioned in despatches, have received decora¬
tions, even wounds, but the larger number have simply
used the opportunity afforded by the withdrawal of French
doctors on mobilisation to obtain situations which they
judged better than those available in their own country.
French doctors now returning to their own practices see in
this foreign invasion a grave personal danger, and on the
intervention of a Deputy, M. Georges Bonnefons, the
Minister has decided not to grant the exchange of a Uni¬
versity diploma into a State diploma, conferring the right
to practise, nor the dispensation from the examinations
necessary to acquire this diploma, except in very special
cases justified by unusual circumstances. Up till now two
suoh authorisations alone have been given.
Medical Demobilisation.
The return of practitioners from active service to take up
civilian practice again is slow but sure. The same rule
applies to them as to other branches; they are demobilised
according to class—that is to say, at the same time as the
private soldiers of the same age-group, obtaining with them
the same benefit of an advance of a year in age for each child
beginning with the fourth. Some who hold appointments
near home have asked to be allowed to remain at their
present work until the signing of peace. This proposal has
only been accepted in the case of a small number, whose
presence as special consultants is declared indispensable by
their commanding officers; indeed, Parliament has directed
the saving of money by every possible reduction in the
number of those drawing military pay. Too much may
have been sacrificed to this spirit of equality and
economy, since even now there is an obvious shortage of
doctors for the existing hospitals. There are still many
soldiers requiring treatment. The recent epidemic of
influenza quickly filled the hospitals still available,
those installed in large hotels and educational buildings
having already been closed. Numbers of wounded men still
need prolonged treatment, others will require physico-
therapeutic treatment, massage or electrical treatment,
lasting over many months. All who have been discharged
on account of wounds and are drawing State pensions have
the right to lifelong gratuitous treatment in the military
hospitals. Under these circumstances it is plain that doctors
have been demobilised too quickly, the services having been
refused of many who disinterestedly offered to continue
their good offices. The new appeal for volunteers betrays
a certain inconsistency in method. Another question which
still engrosses the Under Secretary of the Service de Sant6
is that of the medical service for the region of the Nord,
now liberated from enemy occupation. In these regions
the inhabitants are returning to ruined villages in which
most of the houses are uninhabitable. The unfortunate
people cannot be deterred from reoccupying mere ruins
where they live under deplorable conditions. Illness due to
cold, lack of hygiene, and defective alimentation is of
frequent occurrence, and no medical aid is at hand. The
practitioners of the districts have either been mobilised and
do not intend to return, or have migrated to other places
where they have settled down provisionally, and begun to
build up practices. To attract doctors anew to the forsaken
regions the Ministry has decided that all doctors who take
up their pre-war work shall receive a monthly salary of
500 francs for two years, and travelling facilities will be
supplied to them in the form of motor-car or cycle. The
Under Secretary of State has also given instructions that
instruments are to be loaned to doctors who return to their
own district.
A French Orthopaedic Society.
A French Orthopaedic Society has just been founded in
Paris with Professor Kirmisson as its president, and Professor *
Broca and Professor Denuc6 (Bordeaux) vice-presidents.
Elected members alone will have the right of reading
papers at the annual October session, due notice being
given in advance of the subject-matter. Three topics sug¬
gested for discussion in October, 1919, are: (1) prosthesis after
amputation ; (2) war spondylitis; (3) surgical treatment of
pseudarthrosis. The general secretary of the society is
Professor Nov6-Josserand, of Lyon.
March 15th. __
THE FELLOWSHIP OF MEDICINE:
EMERGENCY POST-GRADUATE COURSE.
The soheme 1 for an emergency post-graduate course of
three months for qualified medical officers, now approaching
maturity, cannot fail to be of much present and prospective
value to teachers as well as students. The executive com¬
mittee is fortunate in having Professor Sir William Osier as
chairman.
The approaching release of the various members of the
Medical Services attached to the Canadian, Australian, and
American Armies has offered an opportunity for post¬
graduate study in England which the Directors of those
Services have not been slow to realise. There is much
clinical material and many schools in London and the
provinces. Together they form the material for a teaching
faculty which has never yet been properly coordinated and
made use of even by the British members of the profession.
Medical men from overseas now on military service in Europe
are keen in their appreciation of a privilege which in many
cases is not likely to be repeated. The Fellowship erf
Medicine has been quick to formulate a scheme to supply
their needs. Members of the staffs of many hospitals in
sympathy with the movement have consented to cooperate
with the Fellowship. The Royal Society of Medicine has
offered hospitality and formed the finest of headquarters. A
programme is now being drawn up which will inaugurate a
new era in the rather troubled and disappointing history of
pent graduate work in London. Facilities have been offered
by the directors of the overseas medical services whereby
members of their staffs are allowed three months’ leave for
post-graduate study before demobilisation or return to their
home units. Those men will shortly be flocking into London
eager to make the utmost use of their furlough. The
problem has been how best to conserve their time and
energy; how to obviate an unsatisfactory wander from
medical school to medical school, inevitably ending in loss
of objective, waste of endeavour, and disappointment.
The obvious solution rests in centralisation. The Fellow¬
ship of Medicine, in conjunction with many of the medical
schools 3 and hospitals of the metropolis, and with the
assistance of the Royal Society of Medicine, has arranged a
1 See Thk Lanobt, March 8th, p. 400.
* St. Mary’s Hospital Is Included In the soheme. It was erroneously
. omitted from the fist of oo6persting medical schools supplied to ns.
478 Thb Lancet,]
PUBLIC HEALTH.
[March 22,1919
course of daily lectures and demonstrations on general and
special subjects to be held five days a week for several
months at Mo. 1, Wimpole-street. The advantage of holdiog
the complete course under one roof is clear. Students
attracted by special subjects and individual teaching will
naturally complete their course by specialised work under
their demonstrators at the respective hospitals. And the
scheme of centralisation under such conditions has appealed
strongly to men who have little time to lose, and who desire
to devote every possible moment of their short leave to the
furtherance of their medical education. The number of
applications to join the course already received from members
of the Canadian, American, and Australian Medical Services
is so large as to assure the complete success of the course.
The programme of the lectures and demonstrations is now
in an advanced stage of preparation and must be definitely
completed within the next few days. Those London faculties
which have not yet signified their support of the scheme
and a willingness to take their share in the programme
should communicate with the secretaries of the Fellowship
without delay. The course now being arranged for the
benefit of medical men from overseas is likely to form the
groundwork of a scheme which is likely to change radically
the post-graduate work of the future.
REPORTS OP MEDICAL OFFICERS OF HEALTH.
City of Manchester,
Dr. James Niven’s recently issued annual report for 1917
differs from its predecessors in this particular, that a portion
of the usual statistical matter has been suspended. Neverthe¬
less, the omitted tables have been prepared and are available
for reference. The ordinary details of natality and mortality in
Manchester have already appeared in the Registrar- General's
returns, consequently they are not reproduced in the present
review, in which only the more important vital statistics are
referred to. In some respects local conditions have been
favourable to the health of the civil population. A keen
outlook has been maintained on the changing circumstances
of families, and wages have been adjusted accordingly, from
time to time.
It is important to observe that war conditions have led to
an enormously reduced consumption of alcohol, and this fact
has powerfully tended to the improvement of the public
health. The local birth- and death-rates have never been
so low as in 1917, and the conspicuous fall in infant
mortality experienced in 1916 has been continued in the
succeeding year. From all ordinary infectious diseases the
death-rate has been comparatively low, whilst the recent
upward trend of tuberculous fatality has apparently ceased.
On the other hand, the following factors may be regarded as
prejudicial to health and general well-being : (a) the strain
of work has been excessive on considerable sections of the
community; (ft) there has been a noticeable increase of
overcrowding; (c) a marked deficiency has been experienced
in Che medical services generally.
The Homing Problem. —An interesting section is that which
deals with the problem of housing the labouring classes,
who are still clamouring for dwellings within reach of their
work. Has this question become more pressing in Lancashire
than in other parts of England ? If it has, this may be
partially accounted for as follows: Ever since the rise of
the cotton industry in this country there has been a natural
tendency among workers to congregate in the larger
towns, and the neighbourhood of Manchester almost
immediately beoame the chief centre for that industry.
Consequently, a large number of dwellings were hurriedly
constructed for the use of the workers. In the absence of
building by-laws these structures were erected according
to the oaprioe of property owners, and without regard either
for the health or the convenience of the tenants. In these
circumstances serious overcrowding rapidly appeared, both
of persons in rooms and of houses on area. In large
industrial centres like Manchester the municipal authorities
are now confronted with the enormous task of sweeping away
huge aggregations of dilapidated property which can never
again be made fit for human habitation.
Theirs also is the obligation to provide suitable accommo¬
dation for the large number of soldiers returning from the
front, who will naturally refuse to be satisfied with dwellings
defective in the essentials of health, comfort, and decency.
Within the last 30 years or so considerable groups of slum
property in Manchester have been cleared away. But recent
war conditions have enforced the official declaration that * ‘ in
the present famine for houses it is impossible to condemn
houses unless they are unfit even to shelter the inhabitants.”
Owing to an increase of 29,000 in the population since
the last Census, a great housing scheme is needed,
and a large number of dwellings are imperatively demanded
at the present time. It is estimated that after the war
17,000 houses will be required to deal with about 80,000
persons. Three schemes of housing are at present under
consideration, under which it is intended to build, in
addition to 2600 workmen’s cottages, a considerable number
of cottage flats, some of which are to be fnrnished. More¬
over, an estate of 50 acres has been acquired in South
Manchester, which will eventually oontain 700 houses.
Child- Welfare Work. —Under the direction of the infant
life preservation committee home visitation has proceeded
apace. In 1908 the splendid voluntary work of the Ladies
Public Health Society was taken over by the corporation,
who now employ 36 health visitors, most of whom are fully
certificated nurses. . Little change is recorded in the general
duties of these officers during the year beyond the fact that
the medical officer has handed over to them the investigation
of cases of whooping-cough.
With the fall in the birth-rate a reduced number of
notified births are referred to the visitors. Effort is made to
bring all new births under observation as speedily as possible
so that the health visitors may have accurate knowledge
of all infants confided to their charge, and also with
the hope of encouraging the habit of breast-feeding which
is so often discontinued unnecessarily. In this connexion,
however, it is satisfactory to learn that approximately 83 per
cent, of the infants born in 1917 are known to have been
breast-fed when first seen by the visitors.
Close cooperation obtains between health visitors, child-
welfare centres, and the babies’ hospital in Levenshulme.
The health visitors regularly attend the doctors’ consulta¬
tions at the nearest centres. Apart from the instruction
thus derived by the visitor there is the additional advantage
that a diffident mother may often be persuaded to attend
the consultations on being assured that her own health
visitor will be present. Through the centres the visitors are
in touch with the Manchester Babies’ Hospital. Delicate
and ailing infants are referred by them to the centres, and,
if suitable, are at once passed on to the hospital. l . Moreover,
on the discharge of an infant, it is promptly visited at home
by the district health visitor, who is thus able to judge
personally of the progress being made.
Towards the end of 1916 the school for mothers began to
distribute milk at the chief centres! under cost to mothers
not able to pay the full price. !From November, 1917,
the supply of milk under these circumstances passed from
the control of the school for mothers to that of the corpora¬
tion, the financial liabilities being transferred at the same
time. The members of the sohool for mothers, however,
still continue their valuable aid by administering the milk-
supply scheme.
Two observation nurseries have been established, and have
proved effective in dealing with children not thriving. The
doctors at the centres recommend cases for admission, and
continue to attend them at the regular consultations, giving
instructions to the matron and the mothers. The aims
of these nurseries are twofold—first, to re-establish the
children in good health ; and secondly, to teach the mothers
how to keep them well, when discharged. The mothers of
children requiring massage are taught the necessary
technique by the matron, while the mothers learn to
appreciate the importance of open-air life with regular sleep
and suitable food.
Tuberculosis: Public Health Administration. —At the
request of the medical officer of health, Dr. D. P.
Sutherland has undertaken the administration of public
health tuberculosis work, insurance work, and the work
of the care committee—a serious addition to his other
duties. In reviewing the past year’s work Dr. Sutherland
refers to the crippling of clinical activity due to the
shortage of medical staff. No extension of the work
The Lancet,]
URBAN VITAL STATISTICS.
[March 22,1919 479
is possible, and certain important investigations already
commenced have for the present been unavoidably
suspended. An effort is now being made by the
Government to secure adequate treatment, with hospital
provision if necessary, for all tuberculous sailors and soldiers
on their discharge from service. Further steps have been
taken for the colonisation of discharged men and for their
training in agricultural work. This appears, however, to be
regarded as a preliminary to a return to the “ rough and
tumble ” of ordinary industry. Until it is recognised that many
cases are quite unfit for such return this policy will fail to
produce permanently good results on the tuberculosis problem.
Attention is desirable to the unsatisfactory position of Man¬
chester as regards the treatment of tuberculous children, and it
would appear that one of the first extensions of the present
scheme should be in that direction.
Upon notification every case of tuberculosis is seen by a
trained visitor. The source of infection is sought for and
attempts are made to discover contacts. Printed advice is left
with the patient, who, if insured, is instructed how to apply for
sanatorium benefit. The family income is in all camm ascer¬
tained, and if this is inadequate a grant may be made from
the funds of the care committee. The success of this scheme
depends upon the completeness with which the tuberculosis
officer retains touch with the constantly wandering patients
in the area. This constitutes what is termed the “after-care
system.” The work of the care committee has been carried
on in the city for many years. It comprises all efforts
for.the maintenance of health among tuberculous persons. «It
involves provision of additional food where a shortage exists,
advice in respect of work, and generally the protection of
the patient and his family from the results of the
disease. The question of finding suitable employment
for tuberculous patients is a difficult and complicated one.
A number of men in whom disease is arrested have been
established in work under the corporation; but Dr.
Sutherland sees no way of solving the difficulty until a
scheme for widespread colonisation is established. In such
a colony provision would have to be made for the varying
strength and activities of the workers, for otherwise any
training for gardening or light gardening pursuits alone
would be attended with disaster.
The Venereal Diseases Scheme .—A Royal Commission was
appointed in 1913 to review the position of venereal
diseases in relation to the civil population. Their report
contained the startling announcement that, in the opinion
of the Commission, some 10 per cent, of the populations
of our large towns suffer from the results of syphilis, while
over 10 per cent, suffer from gonorrhoea or its effects.
The Commissioners direct attention to two matters of
exceptional urgency in the provision of free treatment to
all persons suffering from venereal diseases, and the need for
education of the public as to the extent of the evil, and as
to the remedies proposed. Among several suggestions of
the Commission one requires special mention—viz., that all
advertisements of remedies for these diseases should be
prohibited by law. This has already been done by the
Venereal Disease Act of 1917, which has been applied to
Manchester among other localities, and which, in addition,
prohibits the treatment of venereal diseases by unqualified
persons.
In pursuance of an Order by the Local Government Board,
based on the recommendations of the Royal Commission, a
scheme was submitted to the City Council in April. 1917,
which provided «for the establishment of venereal disease
clinics in Manchester, and for treatment at the several
hospitals of the city. The scheme was adopted by the
City Council and sanctioned by the Local Government
Board.
County Borough of St. Helens.
Dr. H. J. Cates's annual report for the year 1917 shows that
there is still much left to be desired in the sanitary circum¬
stances of this Lancashire town. The general death-rate
for the year under review (16*53) was slightly less than that
of the preceding year, but still in excess of the rate for the
whole of England and Wales. So long as the inhabitants of
the borough are permitted to occupy dwellings which are,
for one cause or another, injurious to their health, an
abnormally high death-rate will prevail in the district.
Owing to the war practically no action has been taken
under the provisions of the Housing Acts, and property I
generally is falling into a condition of disrepair. The |
accommodation at the corporation's isolation hospital,
inadequate in non-epidemic periods, was quite in¬
sufficient to meet the demand occasioned by the
continuance of diphtheria and scarlet fever for the third
successive year. The usual biennial outbreak of measles
began in the second quarter of 1917 and continued for
about 12 months. The disease in the beginning was
moderately mild in type, but in the autumn and winter
became severe. During 1917 4628 cases of measles came to
the knowledge of the health department, every patient
notified to the medical officer of health was visited, and home
nursing was provided by the corporation in 711 instances.
Dr. Cates expresses the view that efficient nursing can
undoubtedly prevent the occurrence of complications in
measles, and he thinks that there is every reason to believe
that the extremely low death-rate of 1*4 per cent,
during the epidemic can be attributed in part to the
systematic employment of trained nurses in the homes of
the patients.
During the year 1917 important progress was made
in work connected with maternity and child welfare.
Two new centres were opened and a total of 10,247
mothers and infants attended and received advice, while
152 patients were taken into the corporation hospitals.
Apparently the value of dried milk is appreciated by the
mothers in St. Helens. In 1914 1202 lb. of milk powder
were distributed from the corporation depot, in 1917 the
amount had increased to no less than 13,8321b. The
facilities thus provided by the depot insured the food-supply
of a large proportion of artificially-fed infants and young
children during the difficult times experienced on account of
the war. Dr. Cates summarises the chief needs of the
district as follows: the provision of houses for the working-
class and the closing and clearance of certain insanitary
a^pas; the provision of adequate hospital accommodation
for maternity and infectious diseases ; the conversion of the
pail-closets and privies now in use; the abolition of the
bricked ashplaces and the provision of closed ashbins; the
paving of yards. It is to be hoped that, when the times
beoome more normal, the corporation of St.-HelenawiU^iva
effect to Dr. Cates’s recommendations.
URBAN VITAL STATISTICS.
VITAL STATISTICS OF LONDON DURING FEBRUARY, 1919’
lx the accompanying table will be found summarised statistics
relating to sickness and mortality in the City of London and in
each of the metropolitan boroughs. With regard to the notified
cases of infectious disease it appears that the number of persons
reported to be suffering from one or other of the ten diseases
specified in the table was equal to an annual rate of 4*1 per
1000 of the population, estimated at 4,026,901 persons; in the
three preceding months the rates had been 4*0, 4*2, and 4*5 per 1000.
Among the metropolitan boroughs the lowest rates from these notified
diseases were recorded in Kensington, Chelsea, the City of West¬
minster, Hampstead, Islington, Holborn, and the City of London; and
the highest in Fulham, Bethnal Green, Southwark, Bermondsey,
Deptford, and Greenwich. The prevalence of scarlet fever was slightly
less than in the preceding month; this disease was proportionally most
prevalent in Fulham, Bethnal Green, Southwark, Bermondsey, Dept¬
ford, and Greenwich. The Metropolitan Asylums Hospitals contained
10% scarlet fever patients at the end of the month, against
1107, 1087, and 1045 at the end of the three preceding months;
the weekly admissions averaged 139, against 146, 136, and 128 in the
three preceding months. The prevalence of diphtheria was about
12 per cent, lower than in January; the greatest prevalence of
this disease was recorded in Stoke Newington, Haokney, Southwark,
Deptford, Greenwich, and Woolwich. The number of diphtheria
patients under treatment in the Metropolitan Asylums Hospitals,
which had been 1000,1069, and 1170 at the end of the three preceding
months, numbered 1163 at the end of February; the weekly
admissions averaged 163, against 129, 146, and 164 in the three
preceding months. Bnterlc fever was somewhat less prevalent than
in the preceding month; of the 13 cases notified in February, 3
belonged to Battersea, 2 to Wandsworth, and 2 to Woolwich. There
were 18 oases of enteric fever under treatment in the Metropolitan
Asylums Hospitals at the end of the month, against 33, 23, and 23
at the end of the three preceding months; the weekly admissions
averaged 2, against 3, 1, and 3 in the three preceding months.
Erysipelas was proportionally most prevalent in Paddington,
St. Marylebone, the City of London, Shoreditch, Bethnal Gireen,
Southwark, and Deptford. Nine cases of puerperal fever were notified
during the month; of these 3 belonged to Fulham and 2 to Wands¬
worth. Of the 16 cases of oerebro-splnal meningitis 3 belonged to
Islington and 2 to Lewisham.
The mortality statistics in the table relate to the deaths of civilians
belonging to the several boroughs, the deaths occurring in institu¬
tions naving been distributed among the boroughs in which the
deceased had previously resided. During the four weeks ended
March 1st the deaths of 8809 London residents were registered,
equal to an annual rate of 28*5 per 1000; In the three preceding
months the rates had been 42*3,18*5, and 15*6 per 1000. The death-
rates ranged from 22*3 in Bethnal Green, 23*5 In Greenwich, 23*7 in
480 The Lancet,]
URBAN VITAL STATISTICS.
[Mabch 22, 1919*
ANALYSIS OF SICKNESS AND MORTALITY STATISTICS IN LONDON DURING} FEBRUARY, 1919.
(Specially compiled for The Lakckt.)
Notified Cases of Infectious Disease.
| Deaths from Principal Infectious Diseases.
P
Cities ahd
Boroughs.
T* OB
•S-
H
•£ a.
*&
M
s,
Cfl
Scarlet fever.
•
i
3
cL
5
Typhus fever.
Enteric fever.
Other con¬
tinued fevers.
Puerperal
fever.
i
&
*3
W
f!
If
I s
•sJ
1
1
*
i
Annual rate
per 1000
persons living.
i
l
"
Measles.
Scarlet fever.
Diphtheria.*
Whooping-
cough.
Enteric fever.
Diarrhoea and
enteritis (undei
2 years).
I
Annual rate
per 1000
persons living.
Deaths from al
causes.
LONDON.
4,026,901
—
524
571
_
13
9
124
16
_
1257
41
30
18
51
14
1
56
170
0*6
8809
28-5
West Districts :
Paddington .
122,507
_
12
21
_
_
6
_
_
39
4*1
3
_
2
__
_
1
6
0*6
302
32*1
Kensington .
161,535
—
9
11
—
—
—
6
1
—
27
2*3
1_
2
—
1
—
—
2
5
0*4
352
30*3
Hammersmith
114.952
—
14
13
—
—
_
2
_
—
29
3*3
_
5
1
1
—
_
4
11
1*2
299
33*9
Fulham .
145,186
—
34
25
—
—
3
3
1
—
66
5*9
_
6
2
2
—
—
1
11
1*0
271
24*3
Chelsea .
57,368
—
3
8
—
—
—
—
—
11
2*5
_
2
2
1
—
1
6
1*4
141
320
City of Westminster
122,046
—
5
12
—
1
—
5
1
—
24
2*6
—
—
1
1
1
_
2
5
0*5
304
32*5
North Districts:
St. Marylebone ...
92,796
_
13
13
_
1
5
_
32
4*5
1
1
3
_
4
9
1*3
254
35*7
Hampstead .
75.649
—
3
4
—
—
—
3
—
—
10
1*7
—
1
_
—
—
1
2
0*3
163
28*1
St. Pancras .
186,600
—
29
25
_
—
1
7
—
—
62
4*3
_
—
1
2
2
—
3
8
0*6
526
36*7
Islington.
297,102
—
16
16
—
—
—
12
3
—
47
2*1
| -
—
1
4
1
—
5
11
0*5
678
29*7
Stoke Newington...
47.426
—
1
14
—
—
—
—
1
1
—
17
4*7
| -
—
—
3
1
—
1
5
1*4
104
23*6
Hackney.
Central Districts :
196,598
—
33
48
—
—
—
—
2
—
83
5*5
1
—
6
1
—
—
8
0*5
396
26-3
Holborn ..
55,303
—
3
4
—
—
—
—
—
_
7
2*6
—
—
—
—
—
—
—
—
—
126
46*5
Finsbury .
City of London ...
68,011
—
8
6
_
—
_
_
1
—
15
2*9
_
—
—
—
—
—
1
1
0*2
189
36 2
16,138
—
1
—
—
—
_
1
—
2
1*6
_
—
—
—
—
—
—
—
_
30
24 2
East Districts:
Bhoreditch .
89,675
_
7
12
_
6
_
25
3*6
_
_
1
1
4
6
0*9
201
29*2
Bethnal Green
107,362
—
29
17
_
—
—
_
5
1
—
52
6*3
—
—
—
1
—
—
2
3
0*4
184
22*3
Stepney .
232.010
—
35
36
—
—
—
_
5
—
76
4*3
—
—
—
4
—
—
3
7
0*4
447
25*1
Poplar .
143,443
—
12
14
—
—
—
1
4
1
—
‘ 32
2*9
—
—
—
2
—
—
2
4
0*4
325
29*5
South Districts:
Southwark .
167,936
_
34
46
_
_
1
15
1
97
7*5
_
1
1
2
2
_
2
8
0*6
384
29*8
Bermondsey ... ...
107,635
—
24
22
—
1
—
—
3
—
50
61
—
1
2
—
1
4
0*5
237
28*7
Lambeth.
272,038
—
45
27
—
1
—
1
3
1
—
78
3*7
—
4
3
1
2
1
6
17
0*8
595
28*5
Battersea.
150,023
20
15
—
3
—
_
4
_
—
42
3*6
—
3
—
3
—
—
6
0*5
341
296
Wandsworth.
300.787
—
34
18
_
2
—
2
8
1
—
65
2*8
—
—
—
1
—
—
2
3
0*1
561
24*3
Camberwell .
239,461
—
31
35
—
1
6
—
73
4-0
—
—
1
1
1
—
4
7
0*4
467
25*4
Deptford.
103,527
—
25
26
—
1
_
5
—
57
7*2
—
—
1
4
—
—
—
5
0*6
226
28*5
Greenwich .
90,440
—
18
27
—
_
_
2
_
—
47
6*8
—
1
1
1
—
—
1
4
06
163
22-i
Lewisham .
161,406
—
14
23
—
—
_
3
2
—
42
3*4
—
—
1
1
1
—
1
4
0*3
294
23*7
Woolwich. ...
Port of London ...
131,942
-
12
33
-
2
—
2
1
:
50
4*9
-
1
1
2
4
0*4
249
24*6
* Including membranous croup.
Lewisham, 24*2 In the City of London, 24*3 In Fulham, and 24*3 In
Wandsworth, to 32*5 in the City of Westminster,33’9 In Hammersmith,
35'7 in St. Marylebone, 36 2 in Finsbury, 36 7 in 8t. Pancras, and 46*5 in
Hoi bom. The 8809 deaths from all causes lnoluded 170 which were
referred to the principal Infectious diseases ; of these, 30 resulted from
measles, 18 from scarlet fever, 51 from diphtheria, 14 from whooping-
cough, 1 from enteric fever, and 56 from diarrhoea and enteritis among
children under 2 years of age. No death from any of these diseases
was recorded during the month in Holborn and the City of London.
Among the metropolitan boroughs the lowest death rates from these
diseases were recorded in Hampstead, Finsbury, Wandnworth, and
Lewisham ; and the highest death-rates in Hammersmith, Fulham,
Chelsea, St. Marylebone, Stoke Newington, and Shoreditoh. The
30 deaths from measles were less than a fifth of the average number
in the corresponding period of the five preceding years, and
Included 6 in Fulham, 5 in Hammersmith, 4 in Lambeth, 3 in
Paddington, and 3 in Battersea. The 18 fatal cases of scarlet fever
were equal to the average number; of these, 3 belonged to Lambeth
and 2 to Fulham. The 51 deaths from diphtheria were 10 below the
average ; this disease was proportionally most prevalent in Chelsea, St.
Marylebone. Stoke Newington, Hackney, and Deptford. The 14 fatal
cases of whooping-cough were about a ninth of the average number; of
these, 2 belonged to St. Pancras, 2 to Southwark, and 2 to Lambeth.
One death from enteric fever was registered during the month, against
an average of 9 in the corresponding period ot the five preceding
years. The 56 deaths from diarrhoea and enteritis among children
under 2 years of age were 13 less than the average; of these, 6
belonged to Lambeth, 5 to Islington, 4 to Hammersmith, 4 to St.
Marylebone, 4 to Shoreditch, and 4 to Camberwell. In conclusion, It
may be stated that the aggregate mortality from these principal in¬
fectious diseases in London during February was 62 per cent, below the
average. _
(Week ended March 15th, 1919.)
English and Welsh Towns .—In the 96 English and Welsh towns,
with an aggregate civil population estimated at 16,500,000 persons, the
annual rate of mortality, whloh had been 35*7 and 31*9 in the two
preceding weeks, further declined to 26*4 per 1000. In London, with a
population slightly exceeding 4,000,000 persons, the annual death-rate
was 21*4, or 5 ; 2 per 1000 below that recorded for the previous week;
among the remaining towns the rates ranged from 8*1 in Eastbourne,
10*7 in Acton, and 12*7 in Tynemouth, to 44*8 in 8methwick, 45*5 in
Middlesbrough, 49*4 in Stoke-on-Trent, 63 3 in Bury, and 55*5 in
Barnsley. The principal epidemic diseases caused 186 deaths,
which corresponded to an annual rate of 0*6 per 1000, and
Included 64 from measles, 41 from whooplng-oough, 38 from diph¬
theria, 29 from infantile diarrhoea, 9 from scarlet fever, 4 from
enteric fever, and 1 from small-pox. Measles caused a death-rate
of 1*3 in Sheffield, 1*4 In Ilford, 1*5 in Southend-on-Sea, 4*8 in
Middlesbrough, and 5*6 in Rotherham; and whooping-cough of 1*9 in
Stoke-on-Trent. The fatal case of small-pox belonged to the metro¬
politan borough of St. Pancras. The deaths attributed to influenza,
which had been 3064, 3889, and 3218 in the three preceding weeks,
further fell to 2320, and Included 435 In London, 157 in Birmingham,
117 in Manchester, 93 in Liverpool, 71 in Leeds, and 67 In Salford;
There were 5 cases of small-pox, 1020 of scarlet fever, and 1153 of
diphtheria under treatment in the Metropolitan Asylums Hospitals
and the London Fever Hospital, against 5, 1062, and 1182 at the
end of the previous week. The causes of 5 6 deaths in the 96 towns
were uncertified, of which 16 were registered in Birmingham, 5 in
Gateshead, 4 in Liverpool, and 3 each In Stoke-on-Trent and Blackpool.
Scotch Towns— In the 16 largest Scotch towns, with an aggregate
population estimated at nearly 2,500,000 persons, the annual rate of
mortality, which had been 40*0 and 34*5 in the two preceding weeks,
further declined to 28*1 per 1000. The deaths from Influenza numbered
39, while in 257 deaths classified as due to other conditions Influenza
was a contributory cause; in the previous week these numbers'
were 62 and 450 respectively. The 701 deaths in Glasgow corresponded
to an annual rate of 32*7 per 1000, and included 35 from whooplng-
oough, 12 from measles, 4 from Infantile diarrhoea, 3 from diphtheria,
and 2 from enteric fever. The 152 deaths in Edinburgh were equal to a
rate of 23*6 per 1000, and included 10 from whooping-cough, 4 from
diphtheria, and 1 from infantile diarrhoea.
Irish Towns .—The 371 deaths in Dublin corresponded to an annual
rate of 47*8, or 15*2 per 1000 below that recorded in the previous
week, and lnoluded 104 from Influenza, 3 from scarlet fever, 2 from
measles, and 1 each from diphtheria and infantile diarrhoea. The
261 deaths in Belfast were equal to a rate of 33*9 per 1000, and included
2 from infantile diarrhoea and 1 from diphtheria.
West London Medico-Chirurgical Society.—
At a meeting held at the West London Hospital on March 7th,.
with Lieutenant-Colonel E. M. Wilson, C.B., C.M.G., in the
chair, the West London triennial medal was presented to
Surgeon-Commander Francis Bolster, R.N., for hdroism
during the battle of Jutland.—Dr. F. G. Crookshank read a
paper entitled “ The Importance of Symptoms,” the author
stating that although during the last 30 years almost
incredible advances in surgery had been achieved, and in
tropical medicine vast new tracts had been explored, in.
ordinary medical practice progress bad been but slight. The
tendency had been to discard symptoms as guides to
diagnosis and treatment, and to place relianoe instead on
mechanical, chemical, and biological tests. But since what
we call particular diseases are in reality mental concepts o£
special symptoms, linked or correlated by ideas of particular
kinds of causes, known or postulated, the study of
symptoms should take precedence over investigation of
the secondary organic changes and even of the special causal
agents. Social reformers recognised this better than doctors
for they directed campaigns, not against organisms as the
cause of the malady, but againBt the circumstances which,
favoured the disorderly reaction.—A discussion followed.
The Lancet,]
THE LOWER UTERINE SEGMENT AND UTERINE TENDONS.
[March 22,1919 481
Ctmsgpowfcme.
“ Audi altenun partem."
THE LOWER UTERINE SEGMENT AND
UTERINE TENDONS.
To tho Editor of The Lancet.
Sib,—I n his paper on the above subject in The Lancet
of March 8th Professor Hastings Tweedy states: “ Gynaeco¬
logists are, or should now be, agreed that the uterus owes its
stability to its connexion with the fibromuscnlar bands
which surround the cervix at the level of the os internum
and radiate in all directions to their attachments in the
pelvis.” Professor Tweedy calls these structures the “ uterine
tendons ” ; believes they support the uterus ; that they keep
the uterus in equilibrium, and 1 * take up all abdominal strain ”;
and that “ the oervix lying beneath them is thus freed from
pressure.” Professor Tweedy states that these structures
behave ‘ ‘ as tendons do in other parts of the body”—whence the
name he gives. On a priori grounds this is unacceptable ; for
they have not the same structure as tendons. At this time
of day we are not going to believe that tissues of a different
structure, and, indeed, of a different order, behave similarly.
Without questioning their continued existence during preg¬
nancy, which there is reason to doubt, he refers to them in
connexion with the formation of the lower uterine segment
in that condition. And he makes some statements, which,
I think, show the invalidity of his position. The following
argument may be constructed from them : 1. The tendons of
the uterus are inserted into the organ at the junction of the
cervix and body of the uterus, and “constitute the one and
only division between .” these two parts. 2. “When
pregnancy occurs the internal os opens and the ovum finds
room for its increasing growth in the upper region of the
cervix immediately beneath the uterine tendons.” 3. “The
opening of the os permits a slackening of the fibrous
diaphragm ”—which is made up in part by these tendons.
4. Therefore, with the occurrence of pregnancy, the cervix
brinks in the pelvis—a conclusion which is not in harmony
with fact.
Further, like many writers with a similar point of view.
Professor Tweedy, in discussing the statics of the non¬
pregnant uterus, ignores the rdle of adjacent parts. He
takes no note of the bladder, which—it is known—with its
variation in volume, influences the position of the uterus
(both of body and of cervix). Nor does he refer to what
keeps the bladder in place. The idea that the “ tendons of
the uterus ” do this and that they take up all abdominal-strain
is untenable in the presence of the results of panhysterec-
tomies as done for carcinoma, and is shown to be untrue by
-the manometer. When the patient coughs, a great rise of
pressure in the vagina is found to occur. This would not
happen if the “ tendons of the uterus ” sufficed to resist the
visceral downthrust. And after Wertheim’s operation the
tendons of the uterus do not exist, yet the visceral down-
thrust is met. Such considerations show at once that the
cervix does not normally “ escape pressure ” by lying beneath
a portion of the uterine tendons, as Professor Tweedy avers.
Another statement in this paper calls for comment. The
author states that “ in procidentia uteri ”—I suppose he
means by that partial prolapse of the uterus, the cervix being
Outside whilst the body of the uterus is within the pelvis—an
hypertrophy of the supravaginal portion of the cervix occurs.
“ In spite of its greater length, its diameter,” he says, “ does
not diminish, which clearly shows that the process is one
of hypertrophy.” In your annotation on the paper you, Sir,
do not accept this statement, and I think the large majority
-of gynaecologists will agree with you. The thinness of the
part referred to as felt on examination, and the very great
vapidity with which a shortening of the organ oocurs on
replacing the prolapse, show that the statement is not true.
Hie change is not an hypertrophic change, but with the
elongation of the uterus there is a corresponding diminution
in sectional cross area.
It Is commonly believed that this elongation is due to
stretching, and your annotation refers to it as suoh. It is
thought that some force keeps the body of the fundus of the
uterus in place within the pelvis, whilst some other force
drags the cervix down (e.g., gravity). I submit that the
weight of the cervix, when we come actually to estimate it,
cannot possibly be supposed to cause this elongation; and,
what other force can be in operation 1 The real explanation,
I am sure, is that the part of the cervix (or it may be of the
body of the uterus) at the aperture of exit from the pelvis is
constricted—just like the rectum and vagina at this plaoe in
the normal, and just like the part of the bladder similarly
situated in cystocele, causing an hour-glass shape of that
organ. With this constriction (which prevents the advance
of the prolapse) the fundus and cervix are naturally caused
to recede from the place of constriction and so from each
other, whereby the organ becomes longer.
I am, Sir, yours faithfully,
Rugby, Maroh 14th, 1919. R. H. PARAMORE.
EPISTAXIS AND HEMOPTYSIS IN INFLUENZA.
To tho Editor of The Lanoet.
Sir,—I would like to draw the attention of your readers
to the value of pituitrin and infundin in epistaxis and
haemoptysis, so common in the present epidemic of influenza.
Using 0*5 c.cm. of one or other preparation hypodermically,
it has been unnecessary to resort to any local treatment
other than cold sponging of head and neck. Generally the
haemorrhage stops almost immediately, and is followed in
some hours by another and very slight attack, which, in my
oases, has not been repeated. The use of pituitrin in these
cases has given the patient a feeling of well-being which
suggests to me that a previous internal secretory exhaustion
had been present. It would be interesting to know if your
readers have had similar experiences.
I am, Sir, yours faithfullly,
W. P. Kelly, F.R.G.S.Irel.
Arklow, Oo. Wicklow, March 18th, 1919.
THE EPIDEMIC OF SEPTIC PNEUMONIA.
To tho Editor of The Lanoet.
Sir,—I n the various reports of septic pneumonia cases
which have appeared in The Lanoet I have not seen any
allusion to a peculiar ashen grey sputum observed in the
following oases, the notes of which may, therefore, be worthy
of record:—
Case 1.— Seen by me in consultation on Feb. 14th, a
female, aged 25, with history of five days’ illness, which came
on gradually with symptoms of gastro-intestinal disturbance,
vomiting, slight diarrhosa, &o. Typhoid was suspected. Tem¬
perature 103*5° F. (had been 105°), respirations 45, pulse 130.
There was consolidation with bronchial breathing over the
whole of the left lung. The sputum was an ashen grey colour
resembling a thiok mixture of cigar ash; the tongue and
lips were dry and coated; the patient was listless and
indifferent, but fully conscious, and answered questions
intelligently and concisely. She died on the following day.
Case 2.— Seen by me in consultation on Feb. 18th and on
three subsequent occasions, a man, aged 29, with consolida¬
tion over the left base, hurried breathing, &o. This
patient was also markedly listless, with dry and coated lips
and tongue, and a similar ashen grey sputum as described
in Case 1 was observed. This oase appeared to improve
greatly under injections of mixed vacoine, but subsequently
symptoms of apical pneumonia developed, and he died on
llaroh 4th. j am> , our> faithfully,
Welbeck-ctreet, W., M&roh 17th. 1919. , JAMES SBARSON.
Dr. Saint Ren6 Bonnet, M.D. Paris, M.R.C.S.Eng.,
who is now discharged from military duties, has resumed
his practice as consulting physioian at Chatel-Guyon-les-
Bains, Auvergne, France.
Mr. Muirhead Bone, who has been an official
artist since August, 1916, and whose war drawings we have
often taken occasion to praise in these columns, proposes to
set aside the proceeds from the sale of his signed lithographs
in order to purchase the work of other artists for presenta¬
tion to the Imperial War Museum, where his own work
will be preserved. The sum thus generously given away
amounts to about £2000.
Charing Cross Hospital Medical School :
Post-Graduate Studt.— The special course, commencing
on April 7th, will inolude lectures and demonstrations of
{ general and special medical and surgical subjects, bacterio-
ogy, and radiology. Affiliation with the Royal Westminster
Ophthalmic Hospital having been completed, the ophthalmio
clinic there is now open to students. Further details in our
advertisement oolumns.
482 The Lancet,]
PARLIAMENTARY INTELLIGENCE.
[March 22,1919
parliamentwjf Jnielligenrt.
NOTES ON CURRENT TOPICS.
Ministry of Health Bill.
The Standing Committee of the House of Commons has
now made considerable progress in the consideration of the
Ministry of Health Bill.
The Committee began consideration of the Bill on
Thursday, March 13th, Sir A. Williamson being in the
chair.
Clause 1, which deals with the establishment of a Minister
of Health, was agreed to.
Clause 2 provides that it shall be the duty of the Minister
to take all such steps as may be desirable to secure the
effective carrying out and coordination of measures con¬
ducive to the health of the people, including measures for
the prevention and cure of diseases, the treatment of
physical and mental defects, the collection and preparation
of information and statistics relating thereto, and the
training of persons engaged in health services.
Powers of Minister of Health.
Major McMicking moved an amendment designed to
limit the powers of the Minister of Health to the powers
transferred to the Minister. He said that they had to
remember that Governments came and went, and they
had to provide against any chance of future Ministers
exercising new powers under this Bill which were not
covered by the existing law.
Major J. W. Hills said that what he was apprehensive
of was that under this clause the Minister would get power
to enforce treatment or to make regulations for which
otherwise he would have to get Parliamentary powers. He
instanced as an example the well-known regulation, 40 D.
Major Astor (Parliamentary Secretary to the Local
Government Board) said that people had read Clause 2 and
nterpreted it in different ways. Some hoped it would give
the Minister new powers to do all sorts of new things,
while others feared that it might give the Minister those
powers. In view of the fact that there was some doubt
about the meaning of the clause as now drafted, he wished
to explain that there was no intention whatever on the part
of the President of the Local Government Board to give or
take, or to try to give or take any new powers. The
clause was governed by the word coordination. The
intention of the Government was to transfer to one
Department under one Minister the existing powers
relating to health matters. The language of the clause
simply suggested, without pretending to give any detailed
list of, the powers it was proposed to transfer to the Minister
of Health. But it would be his duty to take an interest in
other matters concerning health the control of which would
not necessarily be transferred to him, as, for example,
medical education. It should also be borne in mind that
Parliament in the past had given certain powers to local
authorities, and all the Local Government Board did was to
supervise the exercise of those powers. The idea of this
Bill was not a centralised bureaucraoy, but rather decentral¬
isation of local administration. If the honourable Member
would withdraw his amendment he would move a form
of words which would convey what he had in his mind.
This form was as follows: After the word Minister insert
“ in the exercise of any powers and duties transferred to him
by or in pursuance of this Act.”
Major McMicking withdrew his amendment, and the
amendment suggested by Major Astor was agreed to.
Notification of Venereal Disease.
Mr. 8tewart moved an amendment to include the
notification of venereal disease among the powers conferred
on the Minister of Health. They had seen the lamentable
results as regards the nation’s physique as shown by the
medical examination of recruits for the Army, ana he
thought it was a mistake when they had an opportunity
as they had in this Bill if they did not attaok the enemy
of venereal disease in front and do great good to coming
generations. It was too important a matter to be interfered
with bv any feelings of false modesty.
Dr. Addison (President of the Local Government Board)
pointed out that his department already had powers to make
venereal disease notifiable, but as a matter of fact the
problem at the present time was to provide a sufficient
number of early treatment centres. The governing con¬
sideration was to provide such facilities for treatment that
the patients would readily go and make use of it. He was
afraid that there was overwhelming evidence that com¬
pulsory notification might keep large numbers from taking
advantage of these earlv treatment centres, which were the
very things they wanted to encourage. He hoped therefore
that the amendment would not be pressed. There were now
about 140 treatment centres throughout the country.
Mr. Stewart said that, while he was unconvinced by Dr.
Addison’s speech, he would withdraw the Amendment.
Health Propaganda: Voluntary Hospitals: Subsidy of Labour
of Consumptives.
Captain Barnett moved an amendment to make explicit
the right and duty of the Minister of Health to run health
propaganda.
Major Astor said that, while in sympathy with the
intention of the amendment, he thought it would be out of
place in this clause.
Dr. Addison said that steps had been taken within the last
month to assist propaganda in connexion with venereal
disease. Within the laBt two months they had contributed
£8000 towards propaganda of a sensible and practical kind in
regard to that and allied matters.
The amendment was withdrawn.
The Chairman ruled out of order an amendment standing
in the name of Mr. Swan, Mr. Sitch, and Mr. Thomas,
which related to the establishment of national hospitals
and other institutions for the treatment of the sick and
disabled, and the nationalisation of existing institutions
dependent upon voluntary contributions for their main¬
tenance. Clause 2, he said, did not seek to confer new
powers, as this amendment did, and the proper method
would be to put down a new clause.
Major Farquharson moved an amendment to include
“ scientific investigation” among the duties imposed upon
the Ministry of Health.
It was urged that this subject had better be discussed in
connexion with the question of medical research, whioh
would arise later, and on this understanding the amendment
was withdrawn.
Mr. Godfrey Locker-Lampson had an amendment on the
paper to include the subsidy of the labour of consumptives
within the powers of the Ministry of Health.
The Chairman ruled it out of order, as it ought really to
be the subject of a new clause.
Major Astor pointed out that if the subsidy was a part
of treatment the Government could deal with it already.
If, however, it involved new powers beyond that it was out
of order. This matter was one which the Government had
very much at heart, and the President of the Local Govern¬
ment Board had set up one committee and was setting up
another to look into the different aspects of this important
matter. He hoped the amendment would be withdrawn,
since the Government fully realised that more had got to be
done both as regards civilians and ex-soldiers. It was par¬
ticularly the latter for whom the new committee had been
set up.
The amendment was withdrawn.
Training for Health Services.
Sir P. Magnus moved to leave out the words “ and the
training of persons engaged in health services.” It certainly
did not need a clause of this kind to give power to the Minister
to take an interest in the training of persons engaged in health
services. But as the clause now stood it might be inter¬
preted as giving the Minister power to interfere with the
courses of instruction in the medical schools attached to
hospitals as well as those attached to universities. He did
not think that was the intention of the Government,
therefore these words ought to be omitted.
Major Astor said there was no intention implied or
expressed to transfer the functions of the General Medical
Council or any of the functions of the President of the Board
of Education in connexion with the grants to universities
and schools. The wording of the danse merely showed that
when the Ministry was set up it was hoped that it would
keep in touch with the other bodies that were dealing with
these matters. He did not think that there was anything
endangering the training of the medioal profession 7 in the
clause as now drafted.
The amendment was withdrawn.
Major Astor moved to leave out the words “ engaged in ”
and to insert the word “ for,” making it read “ and the train¬
ing of persons for health services.”
Major Farquharson opposed the alteration, whioh, he
said, opened up all sorts of possibilities, whioh he was certain
would lead to great conflict in the future.
Sir Kingsley Wood said he hoped that honourable
Members would not press opposition to this very simple
amendment, which was obviously a desirable one, and which
he was positive was in the interests of all people who were
interested in the Bill.
The amendment was agreed to.
Conscientious Objections.
Major Hills moved at the end to add the words “provided
nothing in this section shall compel any person to reoeive
treatment who makes a statutory declaration that upon
conscientious grounds he objects to medical treatment.” He
said that he thought it would be a great disaster if an Act of
this sort, which he most cordially supported, were to break
down upon a question of this kind, if persons did not want
Thb Lancet,]
PARLIAMENTARY INTELLIGENCE.
[March 22,1919 48?
to undergo any special form of treatment no Act of
Parliament would make them do so. In his judgment
there were no measures more clearly justified on medical
and on social grounds than the Vaccination Acts. Yet
before conoientious objection was allowed they had local
authorities refusing to enforce the Aots and local authorities
returned on the sole issue as to whether the Act should
be enforced or not, and they got a narrower ambit of the
Aots because of it. They would be doing a very beneficial
thing if from the start they said to the people who for Borne
reasons, medical or religious, sincerely objected to treatment,
“ the State will not compel you.”
Dr. Addison said it was quite obvious that they could not
force treatment on people which they did not wish to
accept, and be would he the last person in the world to try
to do so. But that was quite a different thing from putting a
proviso of this kind in the Act. For instance, the com¬
munity had said for its own protection that people suffering
from certain infectious diseases must be isolated. He was
advised that if this amendment were accepted it would cut
right across the powers which already existed in respect to
infectious fevers. He was quite sure his honourable friend
did not want to do that, any more than he did. The
Government had no power now to force treatment on
unwilling persons, ana they were given no fresh powers
under this clause.
Sir A. Warren said that he was not in favour of
allowing persons suffering from infectious disease to run
amok or go about at their own sweet will, but there were
a large number of persons who had conscientious scruples
to the enforcement of particular kinds of treatment.
Might he say, with great respect as a layman, that such
people think that they have just as efficacious means of
treatment as a bottle of doctor’s medicine.
Colonel Weigall said that although a number of persons
had these conscientious objections he felt that unless they
had some powers of compulsion they would produce a
etate of chaos.
Sir Courtney Warner thought that the amendment
would be a great blot upon the Bill, and would tend to a
weakening of its powers.
On a division the amendment was rejected by 33 votes to 14.
Clause 2 as amended was then passed.
Transfer of Powers and Duties .
Clause 3 deals with the transfer of powers and duties to
and from the Minister.
Mr. Leslie Scott moved to add the transfer of “all the
E jwerB and duties of the Secretary of State under the
unacy Acts. 1890 to 1911, and the Mental Deficiency Act,
1913.” No difficulty, he said, would stand in the way of this
transfer, and the only chance of getting these Acts linked
up with the general medical service of the country was
through such a transfer as he advocated.
Major Astor said he did not think that it would be in
■accordance with the intentions of Parliament that all the
powers should be transferred, because some of them affected
the liberty of the subject, and these were placed under the
Lord Chancellor or the Home Office.
The amendment was withdrawn.
8ir A. Warren moved as an addition to the proviso that all
the powers and duties of the Local Government Board should
be transferred the following: “except as relating to the
administration of the Poor-law, which administration Bhall
be transferred to the Home Office.”
Sir Kingsley Wood said that the amendment, if accepted,
would mean that all the persons working under the present
-system would be taken away from the administration of
relief. If they desired to disentangle the medical side of the
Poor-law it would take considerable time. They must either
postpone the Ministry of Health until the medical side of
the Poor-law was disentangled or they must take over the
Poor-law.
After some discussion the amendment was withdrawn.
Medical Research .
Sir P. Magnus moved that in addition to taking over all
the powers and duties of the Insurance Commissioners and
the welsh Insurance Commissioners the danse should
include “ the duties hitherto performed by the Medical
Research Committee.” Medical research in the future
would, he said, depend largely on the result of discoveries
made by research committees; and research and methods
•of research must form an important part of medical educa¬
tion wherever it might be carried on, either in universities
or elsewhere. He need only refer to the discovery of radium
in France, and of the Roentgen rays in Germany, which had
had such an important influence on medical practice. It
was very difficult to distinguish between researches carried
•on for the purposes of pure science and those which might
happen to be applicable to medical science or medical educa¬
tion. For that reason it seemed to him most desirable that
the Ministry of Health should have under its own control
and direction a researoh department to which it could refer
problems as they arose. He saw no valid reason why the
Research Department should not be at once affiliated to the
new Ministry.
8ir Kingsley Wood pointed out that they were dealing
with a Bill that applied to England and Wales alone. As
the President of the Local Government Board had stated in
the House of Commons, medical research was not a matter
of geographical limits, and he thought all of them were
hoping that medical research in the future would not be
limited to this country alone, but might prove to be a truly
Imperial department. If that were so the proper depart*
ment which should supervise it, at any rate at the present
time, was the department named in the Bill—namely, the
Privy Council.
Major Hills urged that men of science should be entirely
free and independent to carry on research in their own way.
Research could only take place by conflict with existing
institutions. The one administration with which the
Research Department would be in conflict if progress was to
be made was the Ministry of Health. The Medical Researoh
Committee under the Privy Council had done some extra¬
ordinarily good work, and he submitted that it would be a
step backwards if that work were taken away from them.
Lieutenant-Colonel Raw strongly urged that the Research
Committee should be brought under the control of the
Ministry of Health. The Bill would not be complete if the
Ministry had not at its immediate disposal the very best
advisory research committee. In the event of a great
epidemic the Ministry ought to be able to ask its own
Research Committee to investigate the disease instantly.
They could not do that if the Research Committee remained
outside the Ministry.
National and Imperial Medical Research .
Major Farquharson thought that they might hope that
the Medical Research Committee would have a very much
wider and more effective scientific horizon if it were placed
within the jurisdiction of the Privy Council than if it were
attached to the Ministry of Health. He was perfectly certain
that the medioal men—of a committee of whom he had the
honour to be secretary—did not wish to press for the inclu¬
sion of the Medioal Research Committee within the Depart¬
ment of the Ministry of Health, but they did press for some
real live thing which within the walls of the Ministry might
take the place of the Research Committee. He urged the
Government to insert in as simple language as they pleased
such words as would effect that compromise, which he
thought would completely meet the view of the medical men.
Sir William Whitla also believed that under the Privy
Council medical research would have a wider scope than
under the Ministry of Health. He advocated that by way of
compromise the Ministry Bhould have its own researoh
department. There could not possibly be too much com¬
petition in original researoh. He was not clear whether
the Minister of Health could get large grants-in-aid for the
purpose of setting up a research department, but if he could
he thought the Committee should not hesitate for a moment
to start on the project of two departments of research, one
under the Privy Council and one under the Ministry of
Health.
Sir Kingsley Wood pointed out that the Local Govern¬
ment Board already had its research work and this would
be transferred under the Bill.
After further discussion,
Major Astor said it was a fallacy to imagine because in
the illustrative words in Clause 2 the word “ researoh ” was
not specifically included that therefore it was excluded.
The Minister of Health, like the President of the Local
Government Board, would be able to do his research in his
own laboratories. He had that power now. The money
that was going to be devoted to research in the future was
going to be a special vote. They wanted the Ministry of
Health to go on with its own research in all parts of the
kingdom, but over and above that they wanted the Research
Committee, which was international and inter departmental,
to continue. There would be Ministerial responsibility, but
let them not break up the Medical Research Committee,
which dealt not only with England and Wales but with the
whole of the United Kingdom and the whole Empire. He
thought that Major Farquharson had made a very fair
suggestion, and he would put it to the President that on the
Report stage they should insert the following words: “ the
initiation and direction of research.”
Sir P. Magnus, on this understanding, withdrew his
amendment, and also a further one which provided for
“ the medical inspection and treatment of children and
young persons.”
The School Medical Services.
On Tuesday, March 18th, the Standing Committee of the
House of Commons further considered the Ministry of
Health Bill. Sir Archibald Williamson was in the chair.
Mr. G. Locker-Lampson moved an amendment to
Clause 3 to transfer to the Ministry of Health “all the
powers and duties of the Board of Education with respect
484 The Lancet,]
PARLIAMENTARY INTELLIGENCE.
[Maboh 22,1019
to the medical inspection and treatment of children and
young persons.”
Mr. Fisher (President of the Board of Education) resisted
the amendment. The Board of Edacntion were anxious to
cooperate with the new Ministry of Health, but it would be
difficult and inadvisable to cut out School Medical Services
from the Board of Education. The administration of the
health services was an integral part of sohool life and part
of the functions of the local Education Committees.
Sir P. Magnus said that the arguments of the President
of the Board of Education went to the very root of the Bill,
whose object was to take over all the various health
services from the different departments of State so as to
consolidate them and prevent overlapping. So far as
gymnastics were concerned, he saw no reason why they
should not remain in the bands of the Board of Education,
because they did not require the skill of the Ministry of
Health to deal with. If these educational health services
were not transferred they would have medical men and
nurses under the Board of Education overlapping with those
under the Ministry of Health.
Sir Ryland Adkins said there were perfectly genuine
arguments on both sides of this question. It would be quite
impossible to separate public health considerations from
education. But on the whole he asked the Government and
the Committee to arrange for the transfer of these powers to
the Ministry of Health at once.
Dr. Addison (President of the Local Government Board)
said that the functions that were to be transferred under the
Bill were divided into two categories, viz. (1) those which
were to be transferred forthwith, and (2) those which it
would be lawful to transfer hereafter. As an administrative
proposition it would be a great mistake to thrust upon the
Minister of Health right away all these duties because he
would become overloaded and the administrative machine
might tend to break down. The next step was to formulate a
general health policy, the establishment of olinics, labora¬
tories, midwifery, Ac , and this would be a gigantic task and
one that was quite Buffioient to put upon the shoulders of the
Minister at first, and he asked the Committee not to burden
bim with having to discharge these functions as well. As
regarded physical training, he thought it was impossible
administratively to divorce it from inspection.
Sir E. Jones said that* be thought that the control
of the medical men in the various localities, and pro¬
bably some of the olinios already set np by the Education
Committees, could eventually be put under the Ministry of
Health. They must leave the Minister time to work these
things out into a coordinated system and not plunge Head¬
long into a .proposal of this kind, which would produce
difficulties in every sohool and undo much of the good work
that bad been done.
Sir Watson Chryne said that be was much disappointed
her the speech of the President of the Board of Education.
He confessed that he conld not see what difficulty there was
in transferring these powers to the Ministry of Health. He
had had a good deal of experience of schoolmasters, and he
was not sore that be would trust them to be the judge as to
what sort of physioal exercise was good for a boy. What
they ought to aim at was the best system, and if it did npset
the local authorities he was afraid they mult make np their
minds to it.
Amendment Carried.
Mr. Fisher said he hoped to make a proposal which would
mitigate some of the bitter feelings which bad been raised
by his first speech. The Bcbool Medical Service had been a
most snocessfnl part of the administration of his department.
The Committee ought to think before they interfered with
a department whioh was doing magnificent work, which bad
secured the confidence of the local authorities. C oder the
Education Act, 1918, special stress was laid upon the
physical side of education. They were therefore particularly
interested not to interfere with the excellent work whioh
was being done and which was to get fresh encouragement
from the new Education Act. He proposed to the Com¬
mittee that words sbonld be inserted to make it possible to
transfer these powers by an Order in Council.
There were cries of dissent from all parts of the Committee
room at Mr. Fisher’s proposal.
Major Barnston said that it should be realised that this
was not a matter of detail, but one of principle.
Captain Barnett said that to bring forward half baked
legislation of this kind which had not reoeived proper con¬
sideration from the Government amounted, in his opinion,
to an abdication of the rights and duties of the House of
Oommons.
Dr. Addison said there was no desire to pot before
Parliament a Bill that was a sham. But the reason for
the Bill appearing in its present form was that it was
considered to be the most practical and businesslike pro¬
posal. If the amendment were carried it would not be
practicable for the Minister to set up aud propose to
Parliament that general extension of the health services of
the country, ana at the same time to assume all these
other duties. He would suggest that Mr. Fisher’s proposal
was a reasonable one (“ No, no ”). If the amendment were
oarried he would suggest that the Minister should be able
to review the question between now and the report stage so
as to see whether it would work administratively, aud, if
necessary, insert words on report to meet the difficul&ie*
which he was afraid the amendment would involve.
The amendment was carried without a division.
Medical Supervision of Factories and Workshops.
Sir P. Magnus moved an amendment to transfer ttm
powers and duties of the Home Office relative to public
health, including the sanitary condition of factories and
the investigation and prevention of industrial diseases to
the Ministry of Health.
Dr. Addison resisted the amendment and said that the
question of industrial conditions should come under the
Ministry of Employment as the Ministry of Labour would
ultimately become* These matters involved controversies
which were inseparable from industrial administration.
The amendment was withdrawn.
Clause 3 was still under consideration when the Com¬
mittee adjourned till Thursday.
Nurses' Registration BiU .
Captain Barnett has introduced in tbs House of Commons
a Bill “to provide for the State registration of nurses.” It
has been read a first time.
The Homing Bill.
Dr. Addison (President of the Local Government Board),
on Tuesday, March 18th, presented a Bill to amend the
enactments relating to the bousing of the working classes,
town planning, and the aoqnisition of small dwellings. It
has been read a first time. _
HOUSE OF OOMMONS.
Wednesday, March 12th.
Vacrination.
Mr. Waterson asked the President of the Local Govern¬
ment Board whether be was aware that there was a growing
opinion that, in consequence of altered social conditions ana
improved sanitary administration, it was not now necessary
to enforce vaccination ; and whether he wonld consider the
advisability of introducing legislation with a view to the
repeal of the compulsory clauses of the Vaccination Acts.—
Major Astor (Parliamentary Secretary to the Local Govern¬
ment Board) replied: I have no information to show that
public opinion bas changed. My right honourable friend is
not contemplating legislation.
Mr. Lunn asked the President of the Local Government
Board, in view of the tendency of modern methods of
vaccination to produce only faint soars or marks, what value
the Government now attached to scars or marks as an
evidence of efficient vaccination.—Major ASTOR replied:
Efficient vaccination of obildren by modern methods pro¬
duces scars or marks whioh have a definite and charac¬
teristic appearance and are readily recognisable. In modern
practice the appearance, number, and area of marks or soars
furnish evidence of the degree of protection afforded by
vaccination.
8maU-pox.
Mr. Tyson Wilson asked the President of the Local
Government Board how many cases of and deaths from
small-pox occurred in England aud WaleB during the year
1918; how many of the cases and deaths were under 10 years
of age; and how many of the cases and deaths, nnder10 and
over 10 years of age, were vaccinated and uovaccinated,
respectively —Major Astor answered: In 1918 there were in
England aud Wales 53 cases of small pox and two deaths, in
both of which, however, the diagnosis was open to some
doubt. There were 12 cases under 10 years of age. The two
fatal cases were over 10. Of the total oases under 10 one
was vaccinated and 11 unvaooinated. Of the total cases over
10, 33 were vaccinated and 8 unvaooinated. In addition
to the 53 cases there were 13 cases imported in ships.
Thursday, March 13th.
Lymph for Public Vaccination.
Mr. Frederick Green asked the President of the Looaf
Government Board whether the Government were prepared
to guarantee that the lymph issued by them for publio
vaccination purposes would not produce unintended com¬
plications; and, in the event of suob complications arising,
would they consider the advisability of giving compensation
to the sufferers.—Mr. Pratt (for Dr. Addison) replied : The
lymph issued from the Government lymph establishment to
public vaccinators is prepared by methods which prevent it
from being contaminated by septic organisms. 1° the rela¬
tively rare cases where vaccination is complicated by the
occurrence of septic conditions the complications usually
result from accidental infection of the vaccinated surface
TB* LANCWf,}
MEDICAL NEWS.
[March 22,1919 4
i
and are not attributable to the lymph. I cannot accept the
priaoijpie that compensation should be paid by the Govern¬
ment in oases where complications arise after vaccination.
Salvarsan Substitutes.
Mr. Frederick Green asked the President of the Local
Government Board if be would state what guarantee the
Government had that the remedies approved by them as
substitutes for salvarsan were exactly similar, or even
approximately similar, to the remedy as discovered and
pat* nted by Ehrlich.—Mr. Pratt (for Or. Addison) answered:
All the approved substitutes, except galyl, are manufactured
under licences issued by the Board of Trade for the express
purpose of allowing the manufacturers to employ the pro
cesses which are used in the manufacture of the original
salvarsan, and which are protected by patents. The pre¬
sumption is therefore that the drugs produced by these
manufacturers are similar to the original article. For the
protection of the public all the approved substitutes are
tested on bebalf of the Medical Research Committee before
being placed on sale. I understand that the Salvarsan Com¬
mittee appointed by the Medical Research Committee have
already considered the question, and that they will shortly
issue a report in regard to it.
Mr. Robert Young asked the President of the Local
Government Board whether he would consider the advis¬
ability of appointing a committee of experts to investigate
the whole question of the supposed value of salvarsan as a
cure for syphilis, seeing that it had been stated by eminent
authorities on the use of salvarsan and its substitutes that
deaths had taken place through its use.—Mr. Pratt (for Dr.
ADDISON) replied: A special committee was appointed in
1918 by the Medical Research Committee to consider the
matters referred to in the question. It comprises repre
eetotatives of the Medical Departments of the Admiralty and
War Office, of the Medical Research Committee, and of the
Local Government Board. Its constitution and terms of
reference are set out in the Board’s V.D. Circular 22. With
that circular the Board, at the request of the Medical
Research Committee, circulated copies of a memorandum
prepared by the Salvarsan Committee, in which a definite
opinion aa to the value of salvarsan was expressed. I am
forwarding to the honourable Member copies of these
documents.
Tuesday, March I8th.
Outbreak of Cerebrospinal Fever.
SirC. Kinloch-Cooke asked the Secretary to the Admiralty
whether his attention had been called to the serious out¬
break at Cambridge of cerebro-spinal fever among the
jouug naval officers; whether several deaths had occurred
at the Military Hospital ; and whether he could make auy
statement on the subject—Mr. Macnamara replied: I
regret to say that there has been an outbreak of cerebro¬
spinal fever amongst the young naval officers at Cambridge.
Xhe facts are as follows : Naval officers went to Cambridge
on Jan. 31st. On Feb. 5th there were 60 cases of
influenza, of whom 54 were treated in one ward
in No. 1 Eastern General Hospital. These were all
making a good recovery until on Feb. 13th and 14th eight
developed cerebro spinal fever. At this time there was no
Cerebro-spinal fever in Cambridge and the disease was
Apparently contracted from a“oarrier.” Two other cases
developed cerebro-spinal fever and the infection of one was
braced to a previous case of this disease; the other was con¬
tracted outside Cambridge. It will thus be seen that nine
out of the ten contracted the disease whilst in No. 1 Eastern
General Hospital. Of these ten cases 1 am sorry to say
five have died. All these cases have been isolated
and nursed in the Military Hospital at Cambridge and
Colonel Griffiths, A.M.S., allowed them to be treafced
in that hospital and not sent to the usual hos¬
pital 1 at Tring, thus saving a long journey by ambu¬
lance. The military authorities placed the services
of Captain E. H. Shaw, R.A.M.C., military specialist in
cerebro-spinal fever, at the disposal of Colonel Griffiths
for the treatment, and Surgeon Rear-Admiral Sir Humphry
Bolleston was sent up by onr medical authorities on
receiving the first report from Cambridge and has made
frequent visits since. The Medical Research Committee
have supplied the special serum used in the treatment. I
am advised that the epidemic is considered to be well in
band, and everything possible bas been done for the patients.
The last case was notified on Feb. 24th at Cambridge, and
there have been no fresh cases since March 7th, and that was
the one which was infected outside Cambridge.
Demobilisation of Medical Officers.
Major Molson asked the Secretary for War tl) whether in
view of the fact that doctors and nurses had been
demobilised at a slower rate than other ranks he would
state whether all field ambulances and casualty clearing
stations bad been demobilised in areas where hostilities had
ceased; (2) Whether in view of the fact that'medical men
and nurses were demobilised at a slower rate than the rest
of the Army during the first four mouths since the Armistice
and that Territorial and temporary commissioned doctors
could only be demobilised on application being received
from the Ministry of National Service he would give orders
to remove that restriction in order to meet the present
argent needs for medical service, and also that the medical
men’s own applications for discharge be considered.
Lieutenant-Colonel Weigall also asked the Secretary for
War what was the reason for the slow rate of demobilisation
of Army doctors?—Mr. Churchill replied: I was informed
that the delay in the more rapid demobilisation of medical
officers was in the main due to the fact that since the
armistice military hospitals have had to deal with large
uumbers of repatriated prisoners of war, the greatly
increased numbers of enemy prisoners, and with hospital
population which was transferred to military hospitals
both at home and abroad, on the closing of the
auxiliary American hospitals and those belonging to
the Dominions. It was also stated that the large
number of civil medical practitioners released by the
closing of the other hospitals mentioned was not included
iu any returns of the numbers demobilised. However,
as I told the House, I did not consider these reasons
sufficient to explain the proportion of medical men and
soldiers respectively demobilised. I have therefore given
directions for a prompt and more general demobilisation of
medical officers from the Royal Army Medical Corps. In
consequence, the Minister of National Service bas agreed
with the War Office that the restricted procedure of selection
of individuals for release shalI be discontinued. There has
not been much time for the fruits of these measures to
become apparent, but I may add that, as the resalt of the
directions given, the rate of releases both of dootors and
nurses has greatly increased. In the past week, for example,
about 700 dootors have been released.
Wednesday, March 19th.
Gratuities to Temporary Naval Medical Officers.
Sir Robert Woods asked the Secretary to the Admiralty
whether war gratuities to temporary naval medical officers
would be on the same scale as those to temporary offioera of
the R.N.R. and R.N.V.R.; and, if not, would he state the
reasons for differential treatment.—Mr. Macnamara replied :
Following the practice of the Army, the gratuities of the
temporary naval medical officers holding the rank of
sargeon-lieutenant are at the rates of £60 and £50 for each
year or part of a year’s service for officers of the medical
and dental branches respectively. The war gratuities of
temporary medical officers above the rank of surgeon-
lieutenant are based on their pav and are on the same scale
as those of other temporary officers R.N.R. and R.N.V.R.
The reason for the differentiation is that temporary surgeon-
lieutenants are on special rates of pay, while those above
that rank are on service.
Ministry of Health for Egypt.
Sir H. Craik asked the Secretary for Foreign Affair**
whether any steps had been taken to constitute a Ministry
of Health in Egypt as nrged by a recent Committee of
Inquiry.—Mr. Dudley Ward (for Mr. Balfour) replied :
Administrative changes of considerable importance are
already taking place on the lines recommended by the
Committee of Inquiry, and other steps are under con¬
sideration, but expausion of the Department of Pnblic
Health to the fall extent urged by the Committee requires
farther examination by the authorities concerned.
Hhftusl JJttos.
At a special meeting of the President and
Fellows of the Royal College of Physicians of Ireland,
held on March 14th, Dr. Harold Pringle, chief assistant to
the professor of physiology and leoturer in histology,
University of Edinburgh, was elected King’s Professor of
Institutes of Medicine in the School of Physic in Ireland.
Public Health (Tuberculosis) Regulations.—
The obligation placed upon medical officers of health to
furnish particulars of male persons between certain specified
ages who have been notified as suffering from tuberculosis
to the Ministry of National Service has been rescinded by an
Order of the Local Government Board.
London Temperance Hospital.— The general
meeting of members and governors will be held on
Thursday next, March 27ch, at 3.30 p.m., and at 5p.m. the
forty-sixth annual public meeting will be held in the out¬
patient hall, wheD the chair will be taken by the Marquie
of Lincolnshire. The speakers will inolude the Bishop of
WiResden, Dr. J. Porter Parkinson, Mr. Arthur Evans, and
Sir T. Vezey Strong, chairman of the board of management.
486 The Lancet,]
THE WAR AND AFTER.
[March 22,1919
attir Jfitar.
The Casualty List.
The names of the following medical officers appear among
the casualties announced since our last issue :—
Previously Reported Missing, non Reported Killed.
Capt. W. C. D. Wilson, R.A.M.C., qualified at Aberdeen in
1915, and thereupon joined up.
Died.
Capt. W. R. Allen, R.A.M.C., qualified at Dublin in 1909, and
held appointments at Mookstown Hospital, Dublin, and
at the Nottingham City Asylum. Prior to joining up he
was assistant medical officer at the Broadmoor Asylum,
Crowthorne, Berks.
Capt. H. C. R. Chowdhury, l.M.S.
Casualties among the Sons of Medical Men.
The following additional casualties among the sons of
medical men are reported:—
Lieut. C. O. B. Buokmasfcer, Duke of Cornwall’s Light
Infantry, died at Belfast of influenza, only son of Dr.
G. A. Buck master, of Hampstead, London.
Lieut. F. C. Stovin, R.A.F., reported missing April, 1918,
since reported by German Red Cross killed in aerial
action over German lines, youngest son of Dr. C. F.
Stovin, of Westcliff on-Sea, Essex.
Lieut. H. H. K. Danlop, R.A.S.C., died in Italy of pneu¬
monia following influenza, youngest Bon of the late
Professor J. Dunlop, of Glasgow.
THE SERVICES.
ABMY MEDICAL 8BEVIOB.
Col. C. K. Morgan relinquishes the appointment of Assistant
Director of Medical Service* as the War Office.
Col. S. F. Clark, on completion of four years’ service in his rank, to bo
retained on tbe Active List.
Temp. Col. C. H. S. Frankau (Capt. and Bt. Major, E.A.M.C., T.F.),
relinquishes his temporary commission on re-postlng.
Major A. B. Smallman to .be an Assistant Director-General and to be
temporary Lieutenant-Colonel, vloe Bt. Col. A. L. A. Webb, C.M G.
Major G. A. D. Harvey to be a Deputy Assistant Director-General,
vice Major A. B. Smallman. _
BOYAL ARMY MEDICAL CORP3.
Temp. Major B. G. Coward to be temporary Lieutenant-Colonel and
Temp. Capt. R. H. Rigby to be temporary Major whilst employed with
the Huddersfield War Hospital.
Temp. Capt. H. D. Robb relinquishes tbe acting rank of Major on
re-posting.
To be acting Lieutenant-Colonels while specially employed : Major
A. H. 8. Irvine, Capt. (acting Major) A G. Well*.
The undermentioned relinquish the aoMng rank of Major on
re-postlng: Capts. E. A. Strachan. K. P. A. Smith, F. A. Robinson,
J. C. A. Dowse; Temp. Capts. W. Anderson. R. S. Renton. C. A. Boyd.
W. M. Badenoch, M. W. Baker, G. Buchanan, H. R. Msdntyre, A. T.
Edwards, W. A. Curry, J. H. Legge, J. B. Cooke, M. W. B. Oliver,
8. W. McLellan.
H. Emerson, late temp. Capt. (acting Major), is granted the rank of
Major.
Temp. Capt. A. G. Southoombe to be acting Major, whilst com¬
manding troops on a Hospital Ship.
To be acting Major: Capt. P. G. M. Blvery ; Temp. Capts. J. M.
Clements, C. A. Weller, J. B. Tombieson, T. Kelly, C. C. Irvine.
B. Biddle, E. Scott, G. Wilson. J. W. Tocher. J. G. Aokland. J. Klrton,
M R. MacKay, T. W. Melhulah. L. M. Smith. K. R. 8turrldge, G. A.
Lilly. Whilst specially employed: Capts. G. W. 8. Paterson (Home
Hospital Reserve), K. C. Priest; Temp. Capts. E. A. C. Beard, A. C.
Pickett, E. A. Lindsay, A. C. Keep.
Capt. W. Tyrrell to be seconded for service with the R.A.F.
Late temporary Captains granted the rank of Captain: W. J.
Macdonald, T. Dunoan. J. Singer.
Temporary Lieutenants to be temporary Captains: J. A. Aitken.
J. Loftus, W. Blight, H C. Sutton, S. Wilton.
Officers relinquishing their commissions: Temp. Lieut.-Col. W. L. W.
Marshall, and retains the rank of Lieutenant-Colonel; Temp. Lieut. -
Ool. J. A. Walt (Lieutenant-Colonel. R.G.A. T.F.); Temp. Maj. B. L.
Gowlland, D.S.O. (granted the rank of Lieutenant-Colonel); Temp.
Qapt-s. (granted the rank of Major) W. G. Johnston, A. H. Spicer,
▲. B. Cardew, W. T. Hessel; Temp. Capts. (retaining the rank of
Captain) J. P Broughton, J. N. Clark, O. H. Booth, J7F. Dow, V. J.
Woolley, A. W. C. Drake, L. H. F. Thatcher, R. H. Smythe, R. Row¬
lands, T. H. G. Shore. D. M. Ross, W. Templeton, F. P. Wlgfield,
T. Whitehead. D. 8. Robertson, G. D. Lalng. W. 8. Stalker, J. Robertson,
W. J. Paramore, A. T. Moon, D. R. Williams, J. C. Mann, A. Allison,
T. A. Watson, J. 8. Crichton, F. J. Alien, B A. Lumley, W. A. Hislop,
G. M. 8haw. O. D. B. Mawson, A. C. Farltnger, J. Cairns, U. B. F.
Belt, 8. K. Vines, J. J. Boyd.
Temp. Cspt. V. J. P. Clifford, on appointment under the Ministry of
National Service.
Temporary Lieutenants retaining the rank of lieutenant: J. D.
Bussell, T. B. Hill, M. Wheeler, R. M. Randall, J. Taplin, C. J.
Middleton.
SPECIAL RESERVE OF OFFICERS.
Captains relinquishing the acting rank of Major on re-postlng: G.
Dalzie), R. MacKinnon, W. W. Wagstaffe.
Captains t*> be acting Majors: W. H. Dye (Hon. Lieut.-Col.) D. J.
Armour, A. Winfield, R. H. Williams.
Capt. (acting Major) R. Green relinquishes his commission and retains
the rank of Major.
Capts. J. W. Brash and I. G. M. Firth relinquish their commissions
snd retain the rank of Captain.
TERRITORIAL FORCE.
Major A. Fowler resigns his commission.
Capts. (acting Lieut.-Cols.) A. W. B. Loudon and N. C. Rutherford
relinquish their acting rank on ceasing to be specially employed.
ROYAL AIR FORCE.
Medical Branch.— Lieut. J. Walker-Brash to be Captain.
The undermentioned are transferred to unemployed list: Lieut.
W. Cahill, Capt. R. B. V. Hale, Capt. H. G. Su therland.
Lieut. O. 8. Martin relinquishes bln commission and retains his rank.
TERRITORIAL FORCE DECORA.TIOX.
The King has conferred the Territorial Decoration upon the under¬
mentioned officers:—Lieut.-Cols. L. J. Blandford, J. M. Rogers-
Tillatone, F. Kelly. H. W. Thomson, G. B. Ma*son. Tamp. Ueut.-Col.
W. Hind, Majors (Tamp. Lleut.-Cols.) J. Gray, C. Stonhsm (deceased).
Major (acting Lieut -Col.) R. T. Turner, Major and Bt. Lieut -Col. A. B.
Harris. Majors A. C. Oldham, J. Callao, H. Dodgson. W. A. Taylor,
A. J. Naylor, A. Thomas, W. J. M&okinnon. W. B. N. 8mi bard, Capts.
H. C. Okill, A. H. Hartshorn, and J. Wallace, (T.F.B.) (attached 2nd
Welsh Field Ambulance).
BOOKS, ETC., RECEIVED.
Constable akd Co., London.
The Great War Brings it Home: the Natural Reconstruction of an
Unnatural Bxi*tence. By J. Hargrave. 10*. 6d.
Clartdoe and Co., G., Bombay.
A Primer of Tropical Hygiene. By Colonel R. J. Blaokham, C.M.G.,
A.M.S. 5th ed.
Dskt, J. M.. London and Toronto.
The Voice Beautiful in Speech and Soond. By B. G. White. 5*.
Frowdk, Henry, akd Hodder k Stoughton, London.
A Medical Service Handbook. By C. M. Page, F.R.C.8. With
Foreword by Major-General Sir G. Mskins. 6*.
Surgical Aspects of Typhoid and Paratyphoid Fevers. By A. B.
Webb-Johnson, M.B. With Foreword by Lieutenant-General T. H.
Goo twin, Director-General, A.M.S. 1C*. 6d.
Harrison and Sons, London.
Memorandum on the Industrial Situation After the War: the
G&rton Foundation. Revised and enlarged edition. 2*.
Communications, Letters, &c v to the Editor have
been received from—
A. —Oapt. J. H. Aitken. R.A M.O.; Disease, New York, Managing
Answers, Lond., Editor of; Mr. Editor of.
B. J. Albery, Lond BL—Mr. W. P. Kelly. Arklow;
B. -Dr. J. Blomfield, Lond.; Mr. King Bdward’s Hospital Fond
F. W. Broderick. Bournemouth; for London, Hon. Secs. of.
Dr. F. G. Bell, Edinburgh ; Miss L.—Dr. R. B. Low, Lond.; London
Bllgh, Lond.; Mr. T. W. Bassett, Temperance Hospital, President
Cork; Dr. A. C. Begg, Swansea ; of; Major N. C. bake, R.A.M.C.;
Mr. G. Bethell, Load.; Dr. G. Major J. H. Lloyd, R. A.M.C.(T.);
Blacker, Lond.; Dr. B. G. M. Miss B. Lowry, M.B., Lond.
Baskett. Rayleigh ; Mr. J. J. M.—Dr. H. L. Murray, Liverpool;
Bates. Bournemouth; Dr. F. G. Mr. J. Y. W. MacAlister, Lond.;
Bell, Bdinburgh ; Board of Agri- Mr. P. Mlllican, Lond.; Dr. A.
culture and Fisheries, Lond.; Macphall, Lond.; Mr. F. Milton,
Dr. N. Bardswell, M.V.O., Lond.; Ooonoor; Medical Research Com-
Mrs. O. Brereton, Lond. mtltee, Lond ; Dr. I. Moore,
0.—Cambridge Literary Agency, Lond.; Capt. J. MoKie, R.A.M.C.
Lond.; Dr. I. G. Cobb, Lond.; N.— Caps H.L. O. Noel, R.A.M.C.;
Chadwick Trust, Lond.; Chicago National Oounoll of Publie
School of Sanitary Instruction ; Morals. Lond.
Capt. 8. W. Coffin, K.A.M.C.; 0.—Bt. Major A. W. Ormond.
Capt. W. G. H. Cable, R.A.M.C. B.A.M.O.(f.); Dr. H. Oppen-
(S R.); Major B. M. Corner, heimer, Lond.; Mr. J. Offord,
R.A.M.C.(T.) Lond.; Dr. G. W. Ord, Bexhill-
D.— Dr. H. Dally, Lond.; Dr. V. on-Sea.
Dickinson, Lond.; The Decimal P.~Dr. R. H. Paramore, Rugby.
Association, Lond.; Capt. F. H. B.—Dr. W. Russell, Bdinburgh;
Diggle, O.B.B., R.A.M.C.; Cant. Royal Statistical Society, Lond.;
A. Devonald, R.A.M.C. (T.); Dr. G. H Rutter. Bournemouth ;
Lieut.-Col. J. Dorgan, R.A.M.C. Dr. M. J. Rowlands, Lond.; Mr.
B.—Dr. J. Byre, Lond.; Mr. W. H. H. O. Ross, Lond.; Royal Society
Evans, Lond.; Dr. H. A. Bills, of Arts, Load.; Royal Society,
Middlesbrough. Lond.
F. —Flat Co , Lond.; Capt. J. G. 8.— Mr. R. A. Stoney, Dublin; Dr.
Forbes. R A.M.O.; Factories, A. G. Shera, Netley; Dr. M. H.
Chief Inspector of, Lond. Bmlth, Portland; Sanator (Man-
G. —Mr. H. J. Gauvaln. Alton; chaster).
Dr. J. Gairdner, Crieff; Dr. T.—Maj.-Gen Sir Alex. TaDoch,
A. K. Gordon, Lond.; Dr. H. L- K.C.B., O.M.G., Torquay; Ool.
Gordon, Lond. A. H. Tubby, A M.S.; Dr. J.
BL—Capt. O. Heath, R.A.M.C.; Taylor, Lond.; Dr. B. J. Tyrrell,
Mrs. M. Hobbs, High Wycombe; Lond.
Lieut.-Col. C. B. Harrison, I.M.S.; V.—Miss Vickers, Lond.; Major
Major C. A. F. Hingston, I.M-S., P. N. Vellacott, R.A.M.C.
Madras; Harveian Society of W.—Mr. P. R. Wallis, Manor Park;
London. Oapt. A. A. Wilson, R A.M.O.;
I. —Imperial War Museum. Lond. Dr. S. A K. Wilson, Lond.; Oapt.
J. —Journal oj Nervous and Menial 8. Wiokendeo, R. A.M.O.(3.R.)
Communications relating to editorial business should be
addressed exclusively to The Editor of Thb Lamgbt,
423, Strand, London, W.O. 2.
The Lancet. ]
APPOINTMENTS.—VACANCIES —MEDICAL DIARY.
[March 22,1919 487
Xirt|p, Carriages, mb featfes.
Abraham, B. C.. M.B. Durb.. has been appointed Certifying Surgeon
under the Factory and Workshop Acts for the Wolston District
of the County of w*rw»ck.
Omnr, A A., M.B. B*lln., Certifying Surgeon under the Factory and
W>*rksh p Acts for the Blackburn (North) District of the County of
Lancaster.
Waterhouse, B., M.D. Lend., Physician to the Boyal United Hospital,
Bath.
9acannes.
For further information refer to the advertisement columns.
Aberdeen Oitv. Mother and Child Welfare.— M.O. £500.
Bath Royal Mineral Water Hospital.— Rea. M.O.
Bedford County Hospital.— H.S. £175.
Birkenhead Union Infirmary and Institution, Tranmere.— Med. Supt.
£600.
Birmingham General Dispensary — Res. M.O. £360.
Birmingham University Faculty of Medicine.— Aist. Prof, of Anatomy.
Blackburn and East Lancashire Roi/al Infirmary.— H.8. £250.
Bodmin. Cornwall County Asylum.—Jun. Asst. M.O. £30U.
Bradford city.-Ve n. Dis. O.
Brecon and Radnor Asylum, Talgarth, Breconshire.— Temp. Asst. M.O.
£7 7s. pe^ week.
Burnley County Borough.— Asst. M.O. £550.
Chester City and County.— Asst. M.O.H. £400.
City of Loudon Hospit- i for Diseases of the Chest, Victoria Park, E .—
S. Also M.O. £200.
Coventry and Warwickshire Hospila’, Coventry.—Ur*. H.P. £250.
Derbyshire Hospital Jor ,>ick Children.— Female Re*. M.O. £150.
East African Medical Appointments. -M.O. £400-£20-£500.
East Dm don Hospital for Children and Dispensary for Women ,
ShadueU.. E. - ms*t.. Phys. Also M.O. for Electrical Department.
Elizabeth Garrett Anderson Hospital, Euston-road.— Female H.P., also
Ob*i er. Asst.. £50.
Essex County Mental Hospital, Brentwood.— Asst. M.O. £210.
Federated Malay Suite* Government.—Seven M.O.. Grade II., and
Three teniKi. M.i>. £350.
Fiji Me icnl Appoinlment*.-F\ve M.O £300.
Gloucester County uorongh.— Asst. School M.O. and Aset M.< ).H. £400.
Greenock Corporation.—M.O H. £700.
Guildford, Royal Surrey County JIospitnl.—H.Q.
Hospital for Sick Children, Great Ormond-street, W.C .—H.S. £50.
Also Cas. M O £200.
Keighley Borough Education Committer.—Female Asst. M.O. £300.
Lincoln Mental Hospital, The Lawn, Lincoln.— Asst. M.O. £250.
Liverpool . Royal Southern Hospital.— Res. P. and S. Also Non*
Res. Cas. O.
Lond n Ijock Hospital and Rescue Home, Harrow-road, W ., and
91, Dean-street, W.- Hon. Surg. to Out-patients.
Manchester, Ancoats Hospital.— Jun. lies. £50. Also M.O. £25.
Manchester Corporation— Asst. Tuberc. O. £150.
Manchester Royal Infirmary (Central Branch), Roby-slreet .—Res. S.O.
£ 200 .
Metropolitan Ear, Nose, and Throat Hospital, Fltzroy-square, W .—
H.S. £100.
Middlesex Relocation Committee.— 8ch. Dent. £300.
Newaistle-on-Tyne Dispensary— Res. M.O. £300.
Ncwcastle-upon • Tyne, Royal Victoria Infirmary and the University of
Durham C 'Uege Medicine.—hast to Prof, of Path.
N.ewcoslle-on-Tyne, Universi'y of Durham College of Medicine.— Demon¬
strator of Anatomy. £300 to £400.
Northamptonshire County * ouncil .—Female M.O. £400.
Northampton General Hospital.—H.S. £200.
Northern hospital Sanatorium. Winchmorc Hill. N.—Tyro Temp.
Asst. M.O S «en guineas per week and £3 Is. per week.
Portsmouth County Borough — Asst. Tuberc. O. £100.
Preston, Ctmnty Asylum, Whittinghnm.— L.T. 7 gs. per week.
Prince of Wales’s General Ilosjjital, Tottenham, London, N.— Hon.
Asst. P. in Out-patients' Dept. Also Sen. H.P. and Sen. H.S. £200.
Also Jun. H.P. and Jun. H.S. £120.
Queen's H spital for Children, Hackney-road, Bethnal Green, E. —8.
Queen Mary’s Hospital for the East End, Stratjord, London, E.— Hon¬
orary Gvnae -oioglst and Obstetrlolau.
Rhondda Urban District Council.— Asst. School M.O. and M.O.H.
£400. AIho Dent. S. £350.
Royal Free Hospital, Marlborough Maternity Section, Gray's Inn-road ,
W.C. — Female Res. M.O. £150.
Royal WaUrl»o Hospital for Children and Women, Waterloo-road,S.E.
— Honorary Gynecologist to Out patients.
Scarborough Hospital and Dispensary.—Trro H.S.
Shanghai Municipal council Health Department.—host. Health Officer.
£»X).
Sheffield Royal Hospital.—< Cas. O. £130.
Sheffield Ro yal Infirmary.—Ilea. b.O. £20C.
Southampton. Free Eye Hospital.— H.S. £150.
Stafford. Staff ordshire County Mental Hospital.— Sec. Asst. M.O. £300.
Straits Settlement Government.— Six M.O. £360.
Swansea General and Eye Hospital.—H ob. H.P. £200. Also Sen.
Student £120.
Wakefield, West Riding Asylum.— L.T. 7 guineas per week.
Wallasey County Borough.— Tuberc. O. and Asst. M.O.H. £500.
War ford, elder ley Edge, Dadd Lewis Epileptic Colony.— Med. Asst.
Director. £400.
Wcihaiwei Government.— Jun. M.O. £400.
West Riding of the County of York.— District Tuberc. O. £500.
Wigan Infirmary —Jun. H.S. £225.
Wolverhampton and Staffordshire General Hospital.—Two H.S. £200.
The Chief Inspector of Factories, Home Office, 8.W., gives notloe of j
vacancies for Certifying Surgeons under the Factory and Workshop
Acts at Poole and Skegness. I
BIRTHS.
Forsyth.— On March 14th, at Coates-crescent, Edinburgh, Maisie, the
wife of Lieutenant-Colonel W. H. Forsyth, D.S.O., R.A.M.O., of a
daughter.
Hitchcock.— On March 13th, at Avon more, Netley, the wife of Captain
0. O. Hitchoook, R.A.M.O.. of a son.
MARRIAGES.
Soltau—Wright. —On March 13th, at St. Mary’s Church, Stafford,
Captain H. K. V. Soltau, R.A.M.C., to Nora Bamscar. youngest
daughter of Mr. Charles fl. Wright, of niliugton Hall, Stafford.
DEATHS.
Alexandrr. —On* March 9th, suddenly, William Alexander, M.D.,
F R.C.S., of Holestone, Heswall, Cheshire, and Rodney-street,
Liverpool.
Galloway.— At 16, Saltwell View, Gateshead-on-Tyne, on March 15th.
Walter Galloway. L.K.C.P. A 8. Bdin., late of Wrekenton and Low
Fell, County Durham. Cremated at Darlington, March 20th.
N.B.—A fee of 6s. is charged jor the insertion of Notices of Births*
Marriages, and Deaths .
Utoiital for % tnsning W&tth
SOCIETIES.
ROYAL SOCIETY, Burlington House, London. W.
Thursday, March 27th.—Papers:—Dr. R. McCarrison: The Genesis
of (Edema in Bert beri (communicated by Prof. J. G. Adam!).—
Mr. H. L. Hawkins: The Morphology and Bvolution of the
Ambulacrum in the Bcbinoidea (communicated by Dr. H.
Woodward). -
ROYAL SOCIETY OF MEDICINE, 1, Wimpole-Street, W. L
Wednesday, March 26th.
SOCIAL EYBNING: at 8.30 p.m.
Mr. Walter G. Spencer: On Larrey and War Surgery.
MEETINGS OF SECTIONS.
Monday. March 24th.
ODONTOLOGY (Hon. secretariat—F. N. Doubleday, G. Baton Pollitt,
J. Howard Mummery): at 8 p.m.
Paper:
Captain Kelsey Fry: The Prosthetic After-treatment of War
Injuries of the Maxilla.
Casual Communication:
Mr. F. N. Doubleday: A Case of Extensive Loos of the Mandible
treated by the Oolyer Method. 4
Friday, March 28th.
STUDY OF DISBASB IN OH1LDRBN (Hon. Secretaries—G. B. O.
Pritchard, H. C. Cameron, C. P. Lapage): at 4.30 P.M.
Abdominal Cases will be shown.
Members wishing to exhibit cases are asked to give notloe to the
Senior Hon. Secretary, Dr. G. B. C. Pritchard, 35, Harley-
■treet, W. 1.
OPHTHALMOLOGY (Hon. Secretaries—Leslie Paton, Malcolm.
Hepburn): at 8 p.m.
Papers:
Captain Max ted: Malignant Tumour of the Pituitary Body.
Mr. J. Herbrrt Fisher: Migraine.
Captain E. M. Baton, H.A.M.O.: Stereosoopto Vision,
Cases:
Mr. Elmore Brewerton : Angeoid Streaks In the Retina.
Miss Rosa Ford: (1) Congenital Pigmentation of the Cornea; (2)
Pituitary Tumour.
The Boyal Society of Medicine keeps open house for
R.A.M.C. men and M.O.’s of the Dominions and Allies. The
principal hospitals in the metropolis admit medical officers
to their operations, lectures. 6c. Particulars on application
to the Secretary at l, Wlmpole-street, London, W. l.
TUBBBCULOSIS SOCIETY, ^it tbe Royal Society of Medicine,
1, W1mpole-street, W.
Monday, March 24th.— 8.30 p.m.. Discussion on Tuberculosis
Officers and Panel Practitioners (opened by Dr. H. Sutherland).
LECTURES, ADDRESSES, DEMONSTRATIONS, &c.
ROYAL OOLLBGH OF PHYSICIANS OF LONDON. Pall Mall Bast.
Tuesday, March 25th, and Thursday.—5 p.m., Goulstonian
Lectures:—Dr. W. W. C. Topley: The Spread of Bacterial
Infection.
POST-GRADUATB COLLEGE, West London Hospital, Hammersmith-
road, W.
Special Bight Weeks Course of Post-Graduate Instruction. (Details
of the Oourse were given in our issue of Feb. 15th).
LONDON HOSPITAL MBDIOAL COLLEGE.
A Special Course of Instruction In the Surgical Dyspepsias will be
g iven at the Hospital by Mr. A. J. Walton. Lectures, given in the’
linlcal Theatre:—
Monday, March 24th.— 1 p.m.. Lecture IX.:—Gastric Ulcer;
Complication’ . Treatment.
Friday.— 1 p.m., Lecture X.:—Surgical Anatomy of the Duodenum
and Pancreas. (In the Dissecting Room.)
ST. THOMAS’S HOSPITAL MBDIOAL SCHOOL (UNIVERSITY or
' London), Governors' Hall, St. Thomas’s Hospital, 8.B.
▲ Series of Ten Lectures on Diseases met with in the Sub-tropical
War Areas (illustrated with lantern slides, charts, diagrams and
microscopical preparations).
Wednesday, March 28th, and Friday.—6 p.m.. Lectures VII. and
VIII.:—Dr. L. 8. Dudgeon: Bacillary and Amoebic Dysentery.
488 Tut* NOTES, SHORT COMMENTS, AND
States, Sfeort Comments, sift Jitstom
to (Komspoiftents.
RAFFAELE PAOLUCCI.
On Nov. 1st the Austrian Dreadnought Flagship, Viribus
ZJnitis, was sunk in the harbour of Po)a by two young Italian
officers, RaffaeIe Rossetti and Raffae! Paolncci. The idea
<of so destroying this ship, which in the days of Caporetto had
eent out wireless messages insulting to Itsly, occurred to
these officers independently. Rossetti was a naval engineer,
hut the Annali di Medicina Navale for September-October,
appearing a little late, takes great pleasure in emphasising
that Raffaele Paolncci was a lieutenant in the Naval Medical
Department. He had served at the beginning of the war,
htihig unqualified, as sergeant of a sanitary section, where
he distinguished himself in a cholera epidemic, and later,
having qualified, was sent to a Regiment of Bersaglieri,
where again he came to notice for attention to the wounded
under fire, then four months later he joined the Navy.
The two officers simultaneously submitted proposals for
efiteriag Pola harbour; authority, approving their schemes,
brought them together; they workea with enthusiasm, and
themselves were the only crew of the boat which secured
the triumph. The decree of the King of Italy promoting
them is in almost identical terms to each, so similar were
TOtiir ideas and achievements. The medical officers of the
Italian Navy may well be proud of the skill and daring of
tftefr young brother officer.
COLONIAL HEALTH REPORTS.
St. Vincent.—A report on the Blue-book of this colonv for
1917-18, written by Mr. Anthony de Freitas, acting adminis¬
trator, has bt-en received at the Colonial Office and presented
to Parliament. It gives the present estimated population as
50,669. The birth-rate for the year was 36*64 per 1000 of the
eetimated population and the death-rate 20 99 per 1000.
Illegitimate births numbered 1224, or 65-yl per cent, of the
total number of ail births. During 1917-18 there were 1055
Admissions to the colonial hospital and 168 operations were
performed. The death-rate was 6*3 per cent, of the cases
treated. The casualty hospital at Georgetown, with four
beds, continued to fulfil its purpose of providing the means
of treating emergency cases; 23 cases were dealt with. At
the yaws hospital 99 cases were treated, and 57 of these were
discharged cured. At the usual district dispensaries and at
special travelling dispensaries 1178 other yaws patients were
treated during the year. During the last two years a campaign
Against yaws has been maintained at these dispensaries with
the following results: cases treated, 2308; cured, 1152; still
under treatment, 619. In the leper asylum eight patients were
maintained; none died. The campaign undertaken by the
Rockefeller International Health Board for the eradication
of the ankylostomiasis or hookworm disease was carried
on by Dr. P. B. Gardner for nine months in 1917. Of 6295
persons examined in that period, 4118 were found to be
infected with hookworm; the number treated was 4453, of
>Vhom 4159 were cured. In connexion with the campaign
measures for faecal sanitation under the public health regu¬
lations were carried out for preventing soil pollution, so as
to avoid re infection and new infection. New latrines to the
number of 414 were erected at homes located within the area
in which the campaign was conducted during the nine
months. The rainfall for the year was 92*96 inches, and the
mean monthly temperature 79° F.
A CRETAN LIBRARY.
* Manuscript No. 3574 B of the Hebrew collection in the
University of Bologna contains several medical treatises,
ail but one of which are translations from the Arabic, mode
in the fourteenth and fifteenth centuries. One bears the
translation date of 1306. In addition to these there is a
catalogue of the medical books in the library of Levi
Novioo, a medical man of a well-known Cretan family who
resided at Candia early in the sixteenth century.
This list is of importance for the history of medical litera¬
ture, because it discloses what works upon the science
were obtainable by an ordinary well-to-do practitioner (for
the Novico family were highly respected at Cretei and
thought to be worthy of study and also of being translated
from the Arabic in the later Middle Ages. The Hebrew
titles in the catalogue cannot be given here, neither is it
necessary to specify works enumerated which are not now
extant or of whose contents we are ignorant, but a summary
is made of those of which we still possess versions either iu
Hebrew or the original language in which they were com¬
posed. The first of Levi’s medical books is stated to be by
R. Vidal, which is merely a pseudonym for Moses of
Norton Be. A oopy of it is to be found, bearing the same
title, in a Munich manuscript, according to Sfceinschneider’s
ANSWERS TO CORRESPONDENTS. [Ma*OH‘2&, 1314
Catalogue of Hebrew Codices there. An interesting text
was that of the “ Aphorisms " of Hippocrates with the com
men tar y of Moses Maimonides. The compiler of the
catalogue notes that its Hebrew translator was Moses-ibn
Tibbon, and he executed the work about a.d. 1260. A oopy
of this is at the Bodleian Library, Oxf >rd, and is No. 1319 of
Dr. Neobauer’s catalogue. Another hook was a treatise upon
fevers and the urine by a certain Isaac ha-Isreeli. Another
book enumerated was entitled “Mansourian Medicine.” This
is the work which Mohammed ben-Ztkh&fiya-al-Rhazi dedi¬
cated to Abu-Djafir-EI-Mansouri, an Abbasid Caliph. There
is a copy in the Bodleian, No. 2090. Levi Novioo’s transla¬
tion of it was by Rabbi Sohem Tob, and a recension of this
is in the Vatican Library.
The next medical work in the list of which we know some¬
thing was a commentary upon Galen’s by Isaac ben
Hosein, or Honein. This waB rendered into Hebrew by
Moses-ibn Tibbon. Apparently it was identical with a
treatise in a manuscript at Ferrara, which Rabbi Jare calls
“ Compendio di Honein ibi Isaac di quanto trattasi nel oom-
mentodeGalenosuHaopera d’Ippoorateiutornoallemalattra
acute.” There is an Oxford mftnnsor.pt of it, No. 2088.
Levi also bad secured a copy of Gera** ! of Cremona’s Latin
edition of Avicenna’s “Canon,” published at Venice in 1596
under the title of “ Tabulae isagogrc* in universatn medi-
cinam ex Arte Hamaoi id est Joamtii Arabis.” Another
work of which a copy is at Oxford, Bodleian 2111, and another
at Munich was called “ Viaticum uerigriiiaiitis ” by Ibn 01
Djez*. The Hebrew version Levi h,+d was by Moses-ibn
Tibbon. Another book was a treatise upon Simples by a
Spanish Arab, Omoiah Abd el Aziz Andaluzzi. According
to Herbelob he knew of an Arab'o text of this. Among works
of which we are ignorant, a well known one occurs, the
“ Lilium Medicines ” of Master Bernard Gordon. HebWW
versions of this are extant. Avicenna is also represented by
a translation of his “ Medicameuta Cordialia.” This may
be identical with the Hebrew version of this work now in
the Leiden library. The Bodleian p< >sb^ sees a commentary
upon it, No. 2109.2. More interesting must have been Levi’s
Manuscript No. 4, for it contained Avicenna’s treatise on
levers, being the fourth book of that author’s “Canon”
and with it was inolnded the explanation of Averoes. The
translator into Hebrew was Solomon ben Abraham ibn
Daod, and a copy is in Neubauer’s Bodleian Catalogue,
No. 2112. Next may be noticed a work which is extant in
various versions, by the elder Serapion of Damascus. It is
a well-known book, because of paraphrases of it having been
published by Albanns of Turin and Gerard of Cremona, who
called it “Practica” and “ Breviarum.” The Bodleian
No. 7182 has a Hebrew version of it by Rabbi Moses of
Capua. In conclusion should be noticed a Hebrew work
entitled 1 “ Observations upon Bodily Afflictions.” ThiswOs
probably a treatise upon diagnosis.
OSTEOARTHRITIS.
To the Editor of This Lancet.
Sir,— In answer to an inquiry under the above heading in
your issue of March 15th, a patient who had been treated
ineffectually for a pain in his hip for two years had bis
morning urine acidulated with 10 per oent. of strong hydro¬
chloric acid, and after a few hours a great excess of tffio
acid was precipitated. Four tablets of phenoquin (phenyl-
cincboninic acid) had been taken overnight. The treatment
was continued for 14 days, when the pain bad completely
disappeared and the urine, being examined, was found free
from excess of uric acid. The same good results have
followed other similar instances and in cases of neuritis,
migraine, iritis, conjunctivitis, eczema, Ac., some of very
long standing. But in typical cases of osteo-arthritis there
is no relief and no deposit.
I am; Sir, yours faithfully,
London, 8.W., March 16th, 1919. DtXNCAN DUNCAN.
LIFE AND HEALTH IN THE HIGHLANDS.
Under this title Dr. Lachlan Grant has contributed to the
Caledonian Medical Journal an article, now reprinted, which
shows that the growth of new ideaB and the revivifying of
old ideas, which have taken place during the war on all
hands, have affected the Highlands of Scotland in a marked
way. In an eoonomioal sense the Highlands and Islands are
only now being discovered, says Dr. Grant, who indicates
their latent possibilities of production in agriculture, quarry¬
ing, fisheries, forestry, and manufacturing and cottage
industries. The bousing problem is, of course, as acute in
this part of Scotland as in other parts of tne country and the
United Kingdom, and considerations of public health, social
amenities, justice to mothers, and welfare of children make
it imperative, he thinks, to launch an elastic comprehensive
scheme and to carry this out as soon as labour and materials
are available. With regard to the Highlands and Islands
, Medical Service, for the improvement of which Dr. Grant
has always been a front-rank advocate, he appeals for a more
. generous scheme.
THE LANCET, March 29, 1919
% f fttnre
OH THK
LESSONS OF THE WAR
AND ON SOME NEW PROSPECTS IN THE FIELD OF
THERAPEUTIC IMMUNISATION.
Delivered at the R*yal Society of Medicine , Feb. 2oth, 1910 ,
By Sir ALMROTH E. WRIGHT, K.B.E.,
C.B., M.D., F.R.S.
(Embodying Research Work done in conjunction irith
Dr. Leonard Co lb brook.)
Gentlemen, —The war has taught two great lessons in
immunisation. It has taught the surgeon that if he provides
the requisite conditions— and he does provide them when he
excises all devitalised and heavily iufected tissues and
brings together the walls of the wound—the protective
mechanism of the body can, without any antiseptics, deal
successfully with every kind of infection. I say advisedly
every kind of infection. For the experiments with leuco¬
cytes—which I shall presently show you—and experience
with retarded suture (where we can count on emigration
into the wound) have conclusively shown that leucocytes can
kill, and that one can successfully dose upon streptococcic
infections.
The second great lesson of the war has been learned in
connexion with antityphoid inoculation. The signal success
of that procedure has made it manifest to everybody that
the natural powers of resistance of the human body can be
powerfully reinforced by inoculation.
I propose here to take as my text those two teachings
of experience; and I shall try to show you that when we
have arrived at a proper comprehension of these, we shall
have realised the principles upon which therapeutic
immunisation, and practically all treatment of bacterial
disease, must proceed.
First Principles.
Let me start quite at the beginning. Long after the
principle of prophylactic inoculation had established itself
in medicine, it was accepted that to inoculate microbes
into the already infected system would be as illogical as
to instil further poison into an already poisoned system.
Pasteur was the first to teach us here a distinction. He
pointed out, in connexion with immunisation against rabies,
that a vaccine might legitimately come into application in
the incubation period. That was the beginning of thera¬
peutic immunisation ; and from that time forth it was
recognised that you may legitimately inoculate in the
incubation stage, and try to get in advance of the infection.
Bnt it was in everybody’s mind that immunisation took
10 days to establish itself. When I showed in connexion
with antityphoid inoculation that bactericidal substances
were very rapidly elaborated, it became plain that
this involved shifting the old land-marks and taking
in farther territory for therapeutic immunisation, and
one had to ask oneself all sorts of penetrating questions.
One had to ask oneself in connexion with “ generalised
infections" at what particular stage of the infection one
was to regard the body as overmastered by the bacterial
poison, and incapable of further immunising response.
Again, in connexion with “localised infections ” one had to
inquire whether they should not be envisaged as general
infections indefinitely arrested in their incubation stage, and
whether they might not, in consonance with that, be brought
within the sphere of inoculation.
Further consideration suggested that the problem of thera¬
peutic inoculation cap be approached also from a point of
view different from that taken up by Pa’-teur With respect
to immnni-ing response, the body had been visualised as a
single and undivided unit. That is clearly erroneous. One
region of the body may be making immunising response
while the other is inactive. For instance, in the stage of
incubation it is presumably only the region which is actually
harbouring the microbe, and in the stage of generalised
infection it is presumably the entire body which is incited
No. 4987
to respond. And again, in localised infections we may¬
making here some reserves—assume that we have only
localised response.
Placing ourselves at this point of outlook, therapeutic
immunisation will, it is clear, be theoretically admissible
so long as there remains in the body any part which is not
already making its maximum immunhing respo* se. And the-
programme of therapeutic inoculation would accordingly
consist in exploiting in the interest of the infected regions
of the body the immunising responses of the regions which
are uninfected.
Results of Vaccine Therapy.
Keeping that now in view, let me try, very briefly, to telT
you what are, in my view, the results which have been
achieved by applying this therapeutic method. I can do
that in a very few words.
In every form of infection a certain quota of unequivocal
successes may be credited to the method, and especially
successful results have been obtained in furunculosis and
acute inflammatory sycosis; in “poisoned wounds"—
meaning by that localised cellulitis set up by a streptococcus
infection ; in streptococcal infections taking the form of
lymphangitis, in erysipelas ; in tubercular adenitis, tuber¬
cular joint infections, tubercular dactylitis, tubercular
orchitis, and tubercular affections of the eye, especially in
phlyctenules of the conjunctiva ; again in bronchitis, in coll
cystitis, and gonorrhoeal rheumatism. The most dramatic
and convincing—convincing because here no other thera¬
peutic measure are employed as adjuncts—are the successes
obtained in streptococcal lymphangitis, in streptococcal
cellulitis —I am thinking of those cases which have already
been incised without striking benefit—and in conjunotival
phlyctenules.
When we analyse the successes and failures 1 of vaccine
therapy the following points come out quite clearly :—
(1) Vaccine therapy is generally unsuccessful where the
infection—as in phthisis—is producing constitutional dis¬
turbance and recurring pyrexia.
(2) Vaccine therapy is also generally unsuccessful where
we have to deal with unopened abscesses, or sloughing
wounds with corrupt discharges.
(3) In long-standing infections vaooine therapy is much
less successful than in recent infections.
To see what auxiliary measures should be applied In these
cases, I must take you back for a moment to the region of
general prinoiples. And here I want you to allow me the
use of some new technical terms.
A Few Words on Technical Terms.
May I preface the bringing forward of these by a few
words of discnlpation. I am not unaware that the natural
man has an acute disrelish for new technical terms. He
feels at the mere suggestion of them the same sort of ennui
as when asked to learn a string of surnames before he
1 I here, as clear thinking exacts, exclude from the failures of
vaccine therapy the failures of that preventive inoculation agahsefc
individual Infections to which vaccine therapy is the usual precursor..
Toe efficacy of such prphv actio procedure Is a question apart. But
I may u*efull' point out to you t hat the superior credit which attache*
to antityphoid Inoculation, and preventive in culation ag Inst infec¬
tive diseases generally, as compared with preventive inoeulatinn
against, what I may call individual infections . is probably attributable
to the fact that, in the case where we are dealing with an infeetlvw
dir ease, the external circumstances are as favourable to suecesa a*
they are in the cane of inoculation against “individual infections’*'
unfavourable.
Let us reflect that In the case of inoculation against an infective^
disease it is not usually a requirement that the patient should!
come Into h'i immunity lmmediatel or that a negative pbaaw
should be avoided. That will be essential only when in eulntioit
is undertaken In the actual presence of JnfecMon. On the other-
hand, in inoculation against an “ind vldual infec ion,” since Mr*
the pathogenic micro'.e Is always knocking at the door* the*
avoidance of a negative phafe and immediate iminunisalioft art*
always indispensable and eve-y failure wdl s* might way notify itself.
Again.in preventive inoculation against infective disease we admirwabar-
inoculations to all and sundry—to the susceptible and the unsus¬
ceptible. In preventive immunisation agaimt in lvidual infection*
we apply inoculation only to the susceptible. For .example. pr«-
ve»'tlve Inoculation against furunculi sis is applied «niy to the-
susceptible—to those who have suffered from bolls. Lastly, shirs
inoculate a community against an epidemic disease pari passu wfcfe
the number of men successfully inoculated, the chances of infectvnas
are for the others reduced. In other words, the succes fully inoculated*
give protection to the unsuccessfully inocnlat-d ; and we obtain- »)*•>
benefits of what I have, in contrast with a drculus r iiiosus, csHfed a»
circulus felix. Nothing of that kind comes to our aio in Immunisation
against, an individual infection-for here we inoclate the patieafc
•gainst a microbe which he constantly bears about with him.
490 The Lanoit,]
SiR ALMROTH E. WRIGHT: LESSONS OF THE WAR.
[March 29,1919
has any interest in the persons who bear them. Bat let
me ask you to look also on the other side, apd. to.
reflect how unsatisfactory an experience it is to have
had intellectual traffick with an interesting man and to
have been left in ignorance of his name. We then experi¬
ence a definite want; we want a labelled pigeon-hole in our
minds into which to put away for safe keeping our new
mental record, and we are conscious that we shall have
difficulty in remembering and turning up that record unless
we have it properly registered under a name. I would
further have you reflect that if any one of us were this
moment invited to give an account of the people we bad
met in the course of the day we should find that we
remembered practically only those few who happened to be
known to us by name. Now, with ideas it is exactly the
same as with men: only those which have been fitted out
w ith names occupy any place in our thoughts. All unnamed
concepts, even though they may have formulated themselves
quite clearly in our minds, immediately go out of our
thoughts and get lost. So for every new concept that has a
utility there must be devised a technical name. Especially
will that name be required for introducing the concept to
others. The new technical term is the missionary of the idea.
One more point I want you to consider. Technical
terms are distasteful not only because they are unfamiliar,
but because they are foreign and difficult. We should,
however, bear it in mind that the store of short and simple
and native words has long since been exhausted, and* very
nearly every Latin word has already been incorporated into
our language, and also nearly all the simpler Greek words
have been taken into service. So there remain over only
the longer composite Greek words—the terms that are so
distasteful. But if we refuse to accept these, it will become
impossible to put into currency any new ideas. When you
want to specify a particular man or concept you cannot get
on without the use of a label. For, in default of a label, you
have every time to resort to a full specification.
Let me now return to my exposition asking you to let me,
in connexion with it, introduce to you the new technical
terms which 1 have prepared for you—hoping that they will
be helpful.
The Defensive Mechanism of the Body.
To combat bacterial infection the organism must have
defensive powers. That power of guarding itself against infec¬
tion we may—the suggestion is Lord Moulton’s—call pkylaotic
power. The leucocytes and the bacteriotropic substances in
the blood fluids we may call phylactic agents. But phylactic
power in the blood will not be all that is required. Military
similes become stale ; but let me here just indicate that
the requirements for the defence of a State are not limited to
the possession of a standing army. There is required also
efficient staff work to bring your defensive force to the point
attacked. The self-same thing applies to the body. You
must have not only phylactic power in the blood, but also
provision for the transport of your leucocytes an 1 bacterio¬
tropic blood fluids to the site of infection. Let me call this
transport of phylactic agents to the site of infection
kata-phylaxis. 2 (You have a similar use of the prefix kata in
cataplasm and kataphoresis); and let me term any con¬
dition which interferes with that transport an anti-kata-
phylactic influence.
Now in tbe body, when in sound physiological condition,
we have efficient kataphy lactic arrangements—blood fluids
and leucocytes have unrestricted access to every portion of the
body. But when anti-kataphylactic influences are brought
to bear ; when the arterial supply is interrupted, or is closed
down by collapse, or the body is petrified by cold, and the
alkalinity of the lymph is blunted off by acid metabolites
derived from the muscles : then the emigration of leucocytes
is arrested, and the transport of blood fluids into the tissues
comes to a standstill. And with that all pathogenetic
microbes which may find entrance—even microbes like gas-
gangrene bacilli which grow with immense difficulty in the
healthy blood fluids—flourish unopposed.
* While this paper wu under revision for the press I discovered that
the term “ kataphylaxls " had already been employed by Bullock and
Cramer in a paper whloh had already appeared In the form of an
abstract. With a graceful courtesy, for whloh I am very grateful, these
authors are now replacing the term kataphylactic in their paper by
the term aphylaclic, thus generously ceding to me their rights of prior
■ser, and leaving the field free for the employment of the former term
with the signification which is here assigned to it.
Phylaxis and kata-phylaxis—these are thenormaj, defences
of the body. Butr there are also tesources in reserve. By a
process comparable to a mobilisation for the reinforcement
of a standing army, the phylaotio powers of the blood fluids
can be increased. We may call that epi-pkylactic reinforce¬
ment, or epi-pkylactic response. Such epiphylactic response
manifests itself, as you know, in connexion with, we may
say, all infections that give rise to constitutional disturb¬
ance. And such response follows, as you know also, upon
bacterial inoculations when conducted with appropriate
doses. But, as I pointed 3 out already in connexion with one
of my first batches of experimental antityphoid inoculations,
there follows directly upon the inoculation of a large dose
always a phase of diminished blood resistance—I called it a
negative phase. It would be more conformable to the
system of terminology I am advocating to employ here the
term apo-phylactic phase.
Ec-phylaxis.
We now come to something which is much less familiar-
less familiar, but, I think, even more important.
I have in view here conditions which I drew attention to
20 years ago 1 in connexion with typhoid and Malta fevers,
coining for my propagandist purposes the terms “regions
of diminished bacteriotropic pressure,” 4 ‘ non-bacteriotropic
niduses,” and “ non-bacteriotropic envelopes.” These terms
may perhaps have been unsuccessfully coined ; they have, at
any rate, not proved effective missionaries of the idea, and
I would propose now to try to pnt into currency instead the
terms ec-phy taxis, ec-phy laci ic region, and eo-phylactic envelope.
When 1 speak of an ec-phylactic region yon will understand
me to mean a region in wtrch the guardian elements of the
blood have been rendered impotent or, as the case may he,
have been excluded. A moment ago,, in,, djptertblng the
effects produced by the abolition or suspension of the
circulation by injury to the blood-vessels or exposure to
cold, I was picturing to you an ec-phylactic region. Much
more commonly—and these, of course, are the conditions X
described in typhoid and Malta fever—the ec-phy lactic region
has been fabricated by a bacterial colony. You. will
appreciate that every living bacterial colony must become
the centre of an ec-phylaotic sphere. It will become so
(a) by radiating out toxins which will (when of sufficient
strength) repel leucocytes; (A) by absorbing bacterio¬
tropic substances from the blood fluids; and, probably
(<?),* by abstracting anti-tryptic power from the blood fluids
and so converting these into a congenial culture medium.
Types of Ec-phylactic Foci.
In the diagrams I here show you, I have depicted three
different types of ec-phylactic foci. In Diagram 1—repro¬
duced here as Fig. 1—we are dealing with serum
implanted with gas-gangrene bacilli in moderate numbers.
Ou looking at Tube A, where by occasional shaking the
microbes have been kept dispersed, you will see no indica¬
tions of a change in the medium, or growth. Id the
companion tube, B, where the microbes were carried down
and compacted by centrifugal Ration, the chemical action of
the microbes has at the bottom of the tube produced the
ec-phylactic region, which is indicated upon the figure by
lighter shading. In this region, by the diminution of its
anti-tryptic power and a blunting off of its alkalinity, tbe
serum has been converted into a congenial culture medium
for the gas-gangrene bacilli, and if incubation had been
continued longer we should have bad after this preparatory
process massive growth with gas-formation.
Tubes C and D represent another pair of companion
tubes that have been kept longer in the incubator. In Tube
D, where to prevent conglomeration of the microbes the test-
tube has, as suggested by Dr. Fleming, been blown out into
a bulb; there are, as you see, no indications of growth. In
C, owing to the circumstance that the microbes could here
collect together by gravitation, opportunity was afforded for
the development of an ec-phylactic focus; and here as an
after result we have a massive culture with abundant
production ot gas. 4
Diagram 2 (which reproduces figures already published 5 )
shows the second type of ec-phylactic focus—that produced
by negative chemotaxis. You have represented what
3 Thf. Lancet, Sept. 14th, 1901.
* The Lancet, Dec. 23rd, 1899, and Wright t Stndlea on Inununlaa-
tlou< Constable. London.
5 Tbe Lancet, Jan. 26th, 1918, Fig. 1.
492 The Lancet,]
SIR ALMROTH E. WRIGHT: LE880N8 OF THE WAR.
[March 29,1919
incomplete draining away of the eo-phylactlc fluid. The
same holds, of course, of aspiration.
(2) Iiu'isio a and cupping. —This procedure, which Was
brought forward by Klapp, might at first sight appear to
be calculated to draw off all the ec-phylactic lymph from
the focus of infection. In actual practice the method fails,
when, as in carbuncle, we have to deal with lymph spaces
blocked with leucocytes and coagulated exudate. And in
any case, in extracting lymph by Klapp's method the same
difficulties will confront us as when we employ negative
pressure to draw a coagulable fluid through a paper filter.
The filter very soon becomes obstructed—and then it is very
likely to tear—and we never can get much fluid through.
(3) Application of hypertonic salt solution to a naked tissue
surface. — We have here instead of a local lymphagogue, which
acts by direct mechanical pressure, one which functions by
what I may call “diffusion pressure.” In other words, we
have here an agent into which fluids of lower »>alt content
will be drawn in. By virtue of this power it will suck out
eo-phylactic lymph from infected tissues.
(4) Application of irritant solutions to naked tissue surfaces.
—My fellow-worker, Dr. Alexander Fleming, has shown that
an outpouring of lymph—which is very cl-arly differentiated
from that produced by hypertonic salt in the respect that it
is delayed instead of immediate - is obtained from a wound
also by the application of solutions of the hypochlorites—
such as Dakin’s ft iid. Ho doubt this lymph outflow is
attributable to the hypersemic reaction produced. A massive
transudation—of, I think, similar derivation—supervenes
upon the application of concentrated carbolic acid and also
of certain other antiseptics to the wound.
2. Procedures for Restoring Normal Conditions hy Augmenting
Transudation from the Blood and deploring and Driving
Out the Ec-phy lactic bluidfrom the Focus Infection.
Under this heading may be enumerated three procedures :
the application of hot fomentations , the application of a Bier's
bandage , and massage. In the first two we make use of
increased transudation—obtaining that increased transuda¬
tion in the one case by active and in the other by passive
congestion. In massage we use mechanical propulsion. It
will generally be inapplicable to an active foens of infection.
3. Procedures for Restoring Physiological Conditions in the
Focus of Infection, by Spontaneous Diffusion of Protective
Substances from the Blood.
If we had under Sjoratic cross-examination the man who
expects benefit indiscriminately from every therapeutic
inoculation it would be elicited that he had a confused
expectation that the protective substances obtained by
inoculation would diffuse into and do effective work in every
focus of infection. In the case of a focus which has attained
a certain magnitude that cannot by any possibility happen.
For the infecting microbes are incessantly obstructing the
work of immunisation. They are continuously paralysing
and repelling the lenoocytes and depraving the blood fluid
to their advantage, and thus they neutralise and more than
neutralise the in-streaming protective substances. Added
to that, when infection induces effusion, and the effusion
gathers balk, and the infecting microbes transform it, that
transudation fluid is less and less affected by diffusion from
the surrounding blood-vessels. We have here assuredly the
explanation of the fact that we get as good as no success
from therapeutic inoculations when dealing with large and
unopened foci of infection ; that we get much better results
when the infective foci have attained only moderate
dimensions ; that we get very good results when dealing with
very small foci ; and our very best when, as in prophylactic
inoculation, we are dealing with infecting microbes before,
they have had time to fabricate round themselves any
ec-phylactic focus.
Of such dominating importance is efficient kata-phylaxis
in the conflict with bacterial disease that I do not hesitate
to assert—and these are views with which every surgeon will
fall in—that if we were to putonr election, on the one hand,
between efficientepiphylaxis without kata-pbylaxis; and, on
the other hand, efficient kata-phylaxis without epi-phylaids,
we ought every time to choose the latter.
Septic War Wounds.
Up to the point to which I have now carried you, we had
arrived already years before this war, and I had in a
succession of papers reprinted in my Studies in Immunisation 1
explained the broad therapeutical principles which I have
here been laying before you. But these—it was perhaps
for lack of the right words to serve as missionaries of the
ideas—had not won for themselves any general recognition
when on a sadden, with the outbreak of this war, there was
thrust upon the whole medical profession the task of
combating bacterial infections in wounds.
Yon know only too well the situation which confronted
us in the early days of the war. Every wound was
indescribably septic. We were back again—as Sir Alfred
| Keogh told me as he sent me oat—to the gross septic
infections of the Middle Ages. Where the projectile had
left only small external openings the wound by the time
it arrived at the base had been converted into a putrid
unopened abscess. When the projectile had made a large
opening tearing away the tissues, the entire surface waa
covered with foul sloughs. And when amputations had
been sewn up at the front, and everything was sealed up
tight, the sepsis was even more acute and the conditions
more deplorable.
Such conditions required—as we now all of us have
learned—not the exhibition of antiseptics, nor yet epi-
phylactic treatment by vaccines, but instead efficient
kata-phylaxis. The wound with a putrid abscess and the
sutured amputation stood in need of free opening and
efficient drainage—drainage both of pas from the wonnd
cavity, and of ec-phylactic lymph from the surrounding
infected tissues. And the putrid slough covered wound
required digestive cleansing, followed again by extraction
of ec-phylactic lymph from the subjacent tissues. It was for
the attainment of these objects that I recommended applica¬
tions of hypertonic salt solution ; and it is not, I believe,
open to question that applied for these specific objects 8 the
hypertonic treatment is qnite eminently efficacious.
I will not, however, here take np your time with discuss¬
ing details of treatment; what I want yon to realise is that
we have in the putrid wound an ec-phylactic focus, and an
ec-phylactic focus which lies open to study. Figs. 2 and 3
bring before ue the essentially important facts relating to the
characters of the fluid in such a focus.
In Fig. 2 is represented a foal suppurating wound with a
pool of pus in its dependent portion. In this pus—as you
see represented in the inset in No. 1—the microscope shows
broken-down leucocytes and a collection of every conceivable
species of microbe—streptococoi, staphylococci, coliform
organisms, and, despite this being an open wound, all sorts
of anaerobic microbes, including gas gangrene and tetanus
bacilli.
Io the main diagram we have further represented what I
call a lymph-leech. In its essence this is a small capping
apparatus which, as soon as a negative pressure is established
in its interior, fixes itself tightly to the walls of the wound
and then sucks iu fluid.
In inset No. 2 we see a sample of the fluid taken from the
lymph-leech after it has been left in poeition over-night
Here, as you see, the leucocytes are sparingly present, bat
they are in good condition, and in the fluid—though it
of course exsuded through a wound sur'ace soiled with
every kind of microbe—we have, as you see, a pure or
practically pure culture of streptococci.
Another type of experiment which is, as you will recognise
in a moment, essentially similar to this is represented in
Fig. 3. Here we take a corrupted pus from a wound, draw
one flnit volume into a capillary pipette, and then follow on
with a series of unit volumes of normal serum, separating
these off by air-bubbles. I call that a sero-culture made by
the wash and after-wash method. Of the trail of infected
pus left behind upon the walls of the capillary stem the first
* I need not here come heck upon the fact that strong salt solution
draws out lymph from the tissues, nor upon the fact that. It liberates
the trypsin required for digesting <-ff the sloughs These points I hsve.
I feel, estab Inhed (vide The Lajccet, June 23rd, 1917, Seotlons entitled
Drawing Action of, and Setting Free of Trypsin by. Hypertonic Salt-
Solution). I may. however, deal here with a supplementary point. It
hasmor^ than once be*n objected that the lymph which the hytiertonle
solution extracts from thew*lls of the wound must assuredly by virtue
of its anti tryptic power antagonise the trypsin which Is liberated from
th leucocytes, with the result that the digestion of the slough
will be arrested befo e it has well begun. It has, however, been
shown by the ob ervations of my fellow-worker, D . Fleming, that
the lymnh which the hypertonic s »lutton extracts from the walls
of the inf-cied wound is a lymph of reduced autl-tryptic power-
in other words, a lymph.which Is Incapable of neutralising the action
of the tripsin. And clearly, so long as the slough remains Iti plase.
and maintains the Infection In the underlying tissues, so long at «
leant will the extracted lymph be an eo-pbylactto and non-antltrypOo
lymph.
7 Constable, London.
The Lancet,]
SIR ALMROTH E. WRIGIIT: LESSONS OF THE WAR
[March 29. 1919 493
unit volume of serum will carry away the greater part, and
there is progressively less pus left behind for the after
following unit volumes of serum.
When we now incubate our pipette and blow out the
volumes one after another; we find, in the most heavily j
implanted and most corrupted serum volume, conditions
essentially similar to those shown in the pus from the putrid
open wound ; and, in the progressively less heavily implanted ,
and less corrupted serum volumes, conditions identical with !
those in the exudate taken from the belly of the lymph-leech.
Types of Infection.
We have here a fundamental fact relating to microbic
infections. Of the infinitely numerous varieties of microbes
which exist in nature it would seem that nearly all can grow
in the blood fluids when their anti-tryptic power has been
sufficiently reduced by an addition of trypsin ; and the gas
gangrene bacilli in particular can grow not only in the blood
fluids which have been, as I call it, “corrupted” by trypsin.
experiment, shown in these diagrams, directly coutiims that
inference. We have in the first centrifuged defibrinated
blood—showing three layers—a layer of serum above, then
a layer of leucocytes, and below a stratum containing
practically only red corpuscles. In the second (Fig. 4)
we have a drop from each of these layers imposed upon
an agar surface implanted with a serophytic organism (in
this case with staphylococcus). Each drop is then covered
in with a cover-glass and the containing Petri dish is
then incubated. You see that the microbes have grown
freely in the specimens made from the upper and lower
layers of the blood, and that the colonies are here quite
as numerous as on the rest of the plate. But you see that
in the central area of the middle preparation where we
have an aggregation of leucocytes every microbe has been
killed off.
We can refine upon this, and operate upon microbes with
isolated leucocytes—leucocytes which have emigrated from
the blood. We proceed as follows: We withdraw some
Fig. 2.
Inset 1. Inset 2.
Diagram showing a foul wound with a lymph-leech in situ. Inset 1: Mlcro3coplc film from the pool of corrupted pus with a sero-sapro-
phytic and serophytic infection. Inset ~ : Microscopic film of t he uncorrupted fluid from the belly of the lymph-leech showing a purely
serophytic Infection (streptococci).
but also in blood fluids whose alkalinity has been blunted
off. Only a few species of microbes, and of these the strepto¬
coccus and the staphylococcus are the most important, can
grow also (but grow of course less freely) in the unaltered
blood fluids. I have suggested that we should call the first
of these classes of microbes seru saprophytes; and the others,
which can grow in unaltered serum, serophytes.
All this has brought borne to you that we have in wounds
two distinct types of exudate and two distinct types of infec¬
tion. In a “ foul wound ” we have an exudate with reduced
anti-tryptic power and a multiform sero-saprophytic infec¬
tion. In a “clean wound” we have an exudate with
undiminished anti-tryptic power and a purely serophytic
(i.e., generally a strepto- or staphylo coccic and occasion¬
ally a diphtheroid) infection.
We come therefore here to a broad therapeutic principle.
A “foul” wound can be rendered “ clean,” and a sero-
saprophytic can be converted into a purely serophytic
infection, by bringing into the wound wholesome blood
fluids. But there is also a corollary to this. When we have
converted a primitively “foul” into a “clean” wound, we
can gain nothing from flooding the wound with blood fluids.
We shall, in fact, by such treatment only be supplying fresh
culture medium for serophytes.
Serophytic Infections.
How, then, does the body combat serophytic infections ?
Manifestly it must do so by the aid of the leucocytes. The
j blood from the finger, fill it into a narrow glass tube sealed
at the end, introduce into this a glass lath (i.e., a slip cut
from a microscopic slide), then centrifuge until we have a
stratum of red corpuscles below with an overlying layer of
leucocytes, and above this clear plasma ; and then inoubate
at blood temperature for three-quarters to one hour. 0 The
leucocytes will now have emigrated and will have arranged
themselves as a belt across the middle. 10 We now extricate
j our lath from the, clot and remove any adhering red cor-
puscles by washing with either serum or, as the case may
be, physiological salt solution, and now impose our lath
I upon an agar surface implanted with staphylococcus or
' streptococcus.
Shall I tell you to what we can liken that experiment ? It is
as if a great number of small slugs had attached themselves
across a sheet of glass in the form of a belt, and we had
then, leaving the slugs just space to move, laid down that
pane upon a surface of earth thickly implanted with grass
seed. You will appreciate that the slugs would round about
them eat up the sprouting grass, giving us a bare band which
would contrast with the green background of the surrounding
field. Now the effect as you see it in this drawing (Fig. 5.
A and B) is just like that. We have across the middle of
I both these laths a clear band of agar and everywhere else a
luxuriant microbic growth.
9 Vide The Lancet, June 15th, 1918, Fig. 2.
l © V'lde The Lancet. June 15th, 1918, Fig. 3.
494 The Lancet,]
SIR ALMROTH E. WRIGHT: LESSONS OF THE WAR.
[March 29, 191r
There is here another point
I want you to notice. It is a
subordinate point, but at the
same time a point of far-
reaching importance. In the
preparation we have on the one
hand a lath which was washed
off by serum and alongside it a
lath which was washed off with
salt solution. As you see,
there is substantially the same
amount of bactericidal effect
under the one as under the I 2 3 4-567
other. I want you to reflect Method ot sero-cutture irilh icath atid after-truth iiiijtlantdlion. —In the series of medallions are micro
that that means that we get scopic films showing in 1 soro-saprophytes and serophytes, In 2 and 3 serophytes only (streptococcus and
substantially the same amount staphylococcus), and 4, 5, and 6 again serophytes only (streptococcus).
of bactericidal effect where the leucocytes are brought into
operation in the absence of serum as when they are brought
into operation in serum.
Destruction of Microbes by Leucocytes.
This experiment in full of instruction. It teaches us what
we must do when
* IG- we want to ex-
Drawing showing the effect of im[>osing on
agar implanted with staphylococcus material
from A. the upper la\er (serum), B. the
middle layer (teuoocytic cream), and C. the
lowest layer (red corpuscles), ot centrifuged
defibrinated blood.
tinguish a sero-
phytic infection
in wounds. It
also, as I must
explain, throws
important light
upon microbic
destruction by
leucocytes.
Fig. 6, which
reproduces a
careful drawing
of the surface
of the two laths
seen under an oil
immersion, re¬
veals that the
microbic de¬
struction was, in
the case where
the leucocytes
were operating in
serum, effected
by phagocytosis;
and in the case
where the leuco¬
cytes were opera¬
ting in salt solu¬
tion, independ¬
ently of phago¬
cytosis. This is
a new form of
microbic de¬
struction a
form which
must be distin¬
guished from
that achieved by
phagocytosis. I
would, since we
have here action
exerted at a dis¬
tance, propose to
call this telergic
destruction. 11
These experi¬
ments, which
show that leuco¬
cytes can kill
micro-organisms,
and what here
interests us most —serophytic micro-organisms—can be
repeated with freshly emigrated leucocytes obtained froir. a
“ clean wound ” previously cleansed with physiological salt
solution. These confirmatory experiments I owe to my
fellow-worker, Dr. Fleming.
My next figure (reproduced here as Fig. 7) furnishes you
with a precis of what is important to know about microbic
destruction by pus. A drop of pus obtained from a clean
wound recently washed out is taken and spread out on the
surface of nutrient agar by the pressure of a cover-glass. In
A, B, and C the pus was imposed upon a sterile surface, in
D and E upon a surface implanted with staphylococcus. In
A, B, and D we have what I have called necro-pyo-cnltures or
nexyro-oyto-cnltures —that is, cultures made from a pus whose
cells are dead. In A and D the cells were killed by heating’
A Fig. 5. B
Drawing showing the effect of imposing leucocytes (adhering in
the f.*rm of a belt to glass laths) upon an agar surface Imp'anted
with staphylococcus. In A the leucocytes were brought into
operation in serum ; In B in normal salt solution.
to 48° C., which is the thermal death-point of leucocytes : in
B the pus cells were killed by simple desiccation. In C and B
we have bio-pyo or bio-cyto-culturrs —i.e., cultures made from
a pus whose cells are alive and active.
You will see at a glance that in necro-cultures A and B
the microbes of the pus have grown out into very numerous
colonies. In sharp cor trast with this is the event in the
bio-culture C. Here the living pus oells have killed all the
microbes with the exception of a few upon the circum¬
ference which have grown out in a marginal ring of serum
expres-ed from the pus by the weight of the cover-glass.
In D—which is again a necro-culture—we have a dense
growth consisting of the microbes originally contained in the
11 Telergic destruction of microbes is witnessed also when we study
what happens in the case where we implant microbes Into blood, then,
after centrifuging In flat emigration tubes, Incubate for a few hours.
We find then at the foot of the white c ot emigration of leuoocytes and
phagocytic destruction of microbes, and immediately above the level
at which this is occurring, in the majority of cases", a band which is
bare of btcterinl colonies mid wh ch contrasts in this respect sharply
with all the region above it. The bare hand here in question is clearly
comparable to that obtained when the washed glass lath of the experi¬
ment described in the text is laid down on an infected surface.
pus with, in addition, those from the implanted agar surface.
, And finally in E—which, again, is a bio culture—the pu*
has killed off not only its contained microbes but. in addition,
those with which the agar surface was implanted.
Let me show you the next figure (Fig. 8). and you have
then, I think, the full story of the growth and destruction
of serophytes in pus from a clean wound recently washeo
out. In A, which serves as the control, you have, aa you set.
Thb Lancet,]
SIR ALMROTH K. WRIGHT: LESSONS OF THE WAR.
[March 29, 1919 495
A
Fig. 6.
B
Drawings of the microscopic appearances seen on glass laths A and B shown in Fig. 5. In A leucocytes operating in serum-phagocytic
destruction of microbes. In B leucocytes operating in physiological salt solution—telerglc destruction of microbes.
only the customary few colonies round the margin of the
bio-pyo-culture. In B a pellet of pus has been stirred up
with the serum. Here you have a voluminous growth of
micro-organisms in thj serum surrounding the islands of
pus. And once things have gone so far. as they have gone
here, it will not be long before all the cells are poisoned off
and microbes re-invade the substance of the pus.
Suture of Wounds
As I have been telling you these things your minds have
no doubt been running ahead, and you have been thinking
of the bearing of all
this upon the suture
of wounds. It has,
of course, obvious ap¬
plications. It shows
you in the first
place that if the
surface of the wound
is not sterile, that
is po reason for defer¬
ring suture. The pus
with which we operated
in these experiments
was, when taken from
the wound, full of
living microbes ; and
none the less it turned
out that this pus was,
when we provided
proper conditions for
the leucocytes, com¬
petent to kill not only
the contained microbes,
but also that large
number more that we
added. Now when we
bring together two
surfaces of a wound
each furnished with
active leucocytes fresh
from the blood-vessels
we are providing for
those leucocytes far
more favourable con¬
ditions than when we
impose them in
nutrient agar and cover
them in with a cover-
glass ; and, moreover,
when we operate in
Fig. 7
B
vivo, we can count upon the continuous new arrival of
leucocytes from the blood stream.
Successful suture of an infected wound is therefore not a
thing to be wondered at. Failure is what stands in need of
explanation. There are three main sources of failure. The
first is the leaving behind of corrupted pus. This, if a
suffi3ient exudation of wholesome lymph does not intervene
to prevent such event, will little by little corrupt the local
exudate; and there will then come into existence in the depth
of the wound an ec-phylactic focus in which not only sero-
phytic, but also a'l manner of sero-saprophytic micro¬
organisms will grow
Drawing made after 24 hourB of specimens of pus from a dean wound (recently washed
out with normal salt sdution) Imposed under covei-glasses <>n sterile agar and agar
implanted with staphylococcus. A, pus heated to flS- 1 U. B, dried pus. C, living pus.
D, pus heated to 48° C. K. living pub.
unrestrained. T h i s-
was wont to happen
in the early period
of the war with
amputations that were
sent down from the
front sutured. The
second source of
failure is the leaving
of dead spaces. For
dead spaces rapidly fill
up with exudate ; and
such exudate, even if
it be of full anti-
tryptic power, will
create an ec-phylactic
focus in which the
streptococcus and
staphylococcus will
grow. The third source
of failure—and to this
and the last mentioned
is to be traced the
erroneous doctrine of
the impossibility of
successfully suturing
over a streptococca 1
infection—is default of
leucocytic emigration
into the wound. When
we consider the success
of retarded primary
suture, and the failure
of early primary suture
in streptococcic wound
infections, we cannot v
I think, doubt that
the difference must
lie in the fact that
496 Th b Lancet,]
SIR ALMROTH E. WRIGHT: LESSONS OF THE WAR.
[March 29, 1919
in the former rise an abundance of, and in the
latter few or no leucocytes are brought into operation.
Anti-microbic Powers of Serum.
You have by this time very clearly appreciated where lies
the weak point in our defence against micro-organisms. The
A Fig. 8. B
■Specimens or pus from a clean wound Imposed on sterile agar under
.-over-Blisses and cultivated 2 \ hours. A, living pus. B, ditto
which had been stirred up with a little sterile serum.
weak point in our armour lies in this that the normal blood
fluids provide a culture medium in which serophytic microbes
-can grow and multiply.
Is Nature then—so we asked ourselves—incompetent to
.-firengtheo that weak place in her defences l It does not
come into consideration here that an increase in the opsonic
power of the blood is obtained in response to inoculations
and auto-inoculations of staphylococcus and streptococcus.
For that could be useful only in the case of the leucocytes
having access to the microbes. But it does come under
consideration that the body responds to all wound infections
<1 drew attention to this early in the war), to many other
Fig. 9.
A B CO E
ever acquired we should expect to find it in patients
suffering from septic infection with severe auto¬
inoculations.
We accordingly examined the serum of such patients,
employing the wash and after-wash implantation into serum
which I have already described to you in connexion with
making cultures from pus. Here I employed as my implant¬
ing fluid instead of pus a 20-fold diluted 24-hour broth
culture of streptococcus to which was added what I call
i wash of one day old broth culture of staphylococcus. The
serial cultures obtained from such plantings into the sera of
septic patients, after remaining over-night in the incubator,
were examined microscopically and by subculturing on agar.
We obtained in this way evidence that the serum in septic
infections does acquire a power of killing serophytic
organisms. That bactericidal effect was exerted both upon
the staphylococcus and upon the streptococcus concurrently.
You appreciate what a large issue this last-mentioned fact
opens up. It brings up the issue of non-specific immunisation.
To make any further advance it was obviously incumbent
to proceed by the method of inooulition. We chose rabbits
tor our experiments, and we planned to observe not only the
circulating blood, but also a sample of blood which should
be shut off from contact with the tissues, and also samples
of lymph obtained from the subcutaneous tissue. We also
arranged to institute tests immediately, and then at short
intervals, after the vaccine had entered the blood. This, of
course, involved inoculating intravenously.
In order to obtain blood cut off from contact with the
tissues we isolated the jugular vein, ligaturing off all lateral
affluents, and passing ligatures under the vein some little
distance apart so as to tie off the included portion of the
vessel as soon as the vaccine had been carried round the
circulation. To collect the lymph from the subcutaneous
tissues we introduced pieces of sterile lint aseptically, and
when these had remained in position for the desired period we
removed them, and pressed oat
the contained fluid aseptically.
F G The pieces of lint were inserted
either some time before the
inoculation was given, or imme¬
diately after, or later—accord¬
ing to the particular stage at
which we wanted to begin the
collection of lymph. The animal
received in each case either a
dose of staphylococcus or strep¬
tococcus vaccine ; and the pro¬
cedures employed in testing the
bactericidal power of sera or
lymphs were identical with
those employed in testing the
sera of the septicsemic patients.
Bactericidal Parvers of Serum
and Lymph after Vaccination.
The results obtained in an
experiment of this kind con¬
ducted with a dose of staphy¬
lococcus vaccine containing
2£ million microbes are shown
in the drawing (Fig. 9). We
have here agar slopes divided
up horizontally into compart¬
ments and implanted, in each
case proceeding from above
downwards, with material from
a series of wash and after-
wash sero- or lymph cultures
made in a capillary pipette.
On the left hand side of
the figure we have cultures
made from (A) serum- and
(B) lymph-cultures, the serum
and lymph in question having
Sero- and lymph cultures from a rabbit inoculated with staphylococcus. Description in text. been obtained from the
infections, and also, so far as we know, to inoculations, by animal immediately before, intravenous injection of the
the development of increased anti-tryptic power in the vaccine. We have here in each case a growth of both
serum. That renders the serum a less favourable culture streptococcus and staphylococcus in the whole 13 compart-
rnedium for serophytes. It remained, however, to be ments. In the centre of the figure we have cultures
determined whether the blood fluids ever acquire a positive I derived from samples of blood and lymph withdrawn two
power of killing serophytic microbes. If such power is hours after inoculation and implanted with the same
Thi Lancit,]
SIR ALMROTH E. WRIGHT : LESSONS OF THE WAR.
[March 29, 1919 497
mixture of microbes used for the first serum and lymph, shall presently furnish you with further evidence of such
We have at C a tube implanted with the series of sero- non-specific immunisation. But I want before going further
cultures from the circulating blood showing growth only to bring out three points. The first is that we are not yet
in 7 out of the 13 compartments ; at D a tube implanted sufficiently masters of the conditions to obtain with constancy
with the sero-cultures from the blood isolated in the results like those here shown. In particular, when we employ
jugular vein, with growth only in four compartments; and too large doses of vaccine we get instead of an epi-phylactic
at E a tube implanted with a series of lymph cultures [ an apo-phylactic result. The second point is that my fellow -
Fig. 10.
Illustrates Experiment 1 in the Table.—On the left hand are the results obtained with the serum of the control blood ; In the middle those
obtained with the serum of the blood Inoculated in vitro with 1000 staphylococci per c.cm.; and on the right those obtained with the serum
of the blood inoculated with 3300 staphylococci per c.cm. In the drawing of this plate a few small colonies of streptococcus ought to ha\e
been Inserted in Compartments 3 and 4.
from the subcutaneous tissue with growth in all 13 com¬
partments. The result in the first of these tubes shows
that the serum of the circulating blood—i.e., of the blood
which is in chemical interchange with the tissues, has
developed bactericidal properties. 12 The results of the third
tube show that these bactericidal properties are not derived
from the subcutaneous tissue. And the middle tube shows
that bactericidal properties can be developed in the fluids of
a sample of blood tied off in a vein.
On the right of the figure are cultural results obtained
with samples of serum from the circulating blood and lymph
from the subcutaneous tissues taken 48 hours afterwards and
implanted with a mixture of microbes similar to that
employed before. It will be seen that the circulating
worker, Dr. Leonard Colebrook, has in a series of control
experiments in which lint was implanted aseptically into
rabbits without any administration of vaccine, obtained a
lymph with a bactericidal potency quite comparable to that
obtained in vaccinated animals. Lastly, I would remind
you of that non-phagocytic, or as I have called it, telergic
destruction of microbes which is obtained when leucocytes
are imposed upon a surface implanted with microbes. It
would seem probable that there is a close relation between
this and the non-specific bactericidal effect exerted by the
fluid expressed from the implanted lint; also possibly
between this and the development of non-specific power in
the serum after intravenous inoculation of vaccines; and
possibly between all these and what I am now about 1 6
Illustrates Experiment 2 in the Table.—On the left are the results obtained with the serum of the control blood ; in the middle those obtained
with the serum of a blood inoculated with 30 streptococci per c.cm.; on the right those obtained with the serum of blood inoculated with an
overdose of vaccine (500 streptococci per c.cm.).
Fig. 11.
blood has, so far as can be judged, returned to its original
condition. We have a culture of staphylococcus and strepto¬
coccus in all the 13 compartments. The subcutaneous lymph,
on the other hand, has killed all the implanted microbes.
It will be seen that the results furnish clear evidence
that here in response to inoculations of a staphylococcus
vaccine the serum and lymph have acquired bactericidal
powers for both the staphylococcus and streptococcus. I
11 The blood of the rabbit here in question' had begun to manifest
bacterioidal power already within two minutes after the injection of
the vaccine.
describe to you—the acquirement of bactericidal power
by the serum when we add vaccine to blood in vitro.
Immunisation in Vitro.
Let me before I pass on to deal with this explain to you
the lines of thought which led us to look for such immunisa¬
tion in vitro. The results obtained with blood confined in
the jugular vein immediately invited us to ask: Seeing that
bactericidal power is developed in blood which is after inocu¬
lation isolated and incubated in vivo, should not the same
result be obtained when after inoculation we withdraw blood
n2
498 The Lancet,]
SIR ALMROTH E. WRIGHT: LESSONS OF THE WAR.
[March 29, 1919
and incubate in vitro ? And if it should prove that bacteri¬
cidal power is also under these conditions obtained, should it
not also be obtained when we work entirely in vitro? In
both these directions expectation has been borne out by
experiment. When we have inoculated in vivo we get our
result whether we confine the blood in the jugular and
incubate in vivo; or bleed and incubate the blood in vitro.
And again we get our result just as well when we inoculate
in vitro and incubate in vitro, as when we inoculate in vivo
Table of Experiments showing that the Serum Acquires Non-
Specific Bactericidal Powers when the Blood is Inoculated
in vitro with a Variety of Vaccines.
Experiment I. (vide Fig. 10).
Con. bl. = Control blood. Vac. bl. — Vaccinated blood.
and incubate in vitro. That is, we get when we employ
large doses of vaccine an apophylactic change which renders
the blood fluids a better cultivation medium for serophytes;
or we get, but less regularly (for all the factors are not
known to us), an epi-phylactic change in the form of a
development of bactericidal power in the serum. The
Experiment VI.
Number of
sill
1 microbes added
per c.cm. of
« ^5 g
blood.
' -
a S s &
~a
Experiment VII.
_
_
A
A
—
-
P
P
_
_
A
A
-
-
P
P
A
A
A
A
P
P
P
P
A
A
A
A
P
P
P
P
A
A
A
A
P
P
P
P
A
A
A
0
P
*
P
P
A
A
A
A
P
P l
P
P
derived
TpLanoii,]
SIR ALMROTH X. WRIGHT: LB880NS OF THE WAR.
[March 29,1919 499
Experiment IX.
experiments which are here tabulated (those cited are.
t I am Indebted to Colonel Olemeoger for this experiment.
of coarse, selected experiments) supply 'exemplification of
apo-phy lactic and epi-phylactic changes—i.e., positive and
negative phases produced by the inoculation of vaooines in
blood in vitro.
The technique employed was as follows. A series of dilu¬
tions of the vaccine were made in physiological salt solu¬
tion. Blood was then obtained 13 by a puncture made into a
sterilised finger or it was drawn off from a vein. In the
former case it was collected on a paraffin-coated slide. Then
nine volumes of blood and one volume of the first dilution
of vaccine were mixed and aspirated into a pipette and
sealed up. And so on throughout the series until finally
(for the purposes of control) 9 volumes of blood were mixed
with 1 volume of physiological salt solution. The bloods
were then placed in the incubator for periods of 2 to 3 hours
(Experiments 1, 3, 4, and 6), or 6 hours (Experiment 9), or
18 to 24 hours (Experiments 2, 5, 7, 8, 10, 11, and 12).
They were then centrifuged and the supernatant serum
drawn off. This was implanted by the wash and after
wash method with a dilution of a staphylococcus culture ;
or with a mixture of staphylococcus and streptococcus
(a 16-24-fold dilution of a 24-hours broth culture of strepto¬
coccus with wash of staphylococcus); or in one
instance with a mixture of staphylococcus and pneumo-
ooocus. The capillary pipettes containing the implanta¬
tions into serum were then incubated overnight, and the
contents blown out in separate drops on to sterilised slides.
Preparations were then made for microscopic examination,
and subcultures were made either upon agar slants divided
up as shown in Fig. 9, or upon agar poured into Petri
dishes divided up after the manner of a dial (Figs. 10 and 11).
Non-Specific Immunisation.
Let us just glance at the prospects which are here opened
up. In the foreground stands the question of non-specific
immunisation. That immunisation is always strictly specific
counts as an artiele of faith ; and it passes as axiomatic that
microbic infections can be warded off only by working with
homologous vaccines ; and that we must in every case before
employing a vaccine therapeutically, make sure that the
patient is harbouring the corresponding microbes. I confess
to having shared the conviction that immunisation is always
striotly specific. Twenty years ago, when it was alleged,
before the Indian Plague Commission, that antiplague
inoculation had cured eczema, gonorrhoea, and other miscel¬
laneous infections, I thought the matter undeserving of
examination. I took the same view when it was reported in
connexion with antityphoid inoculation that it rendered the
patients much less susceptible to malaria: Again, seven years
Experiment XII. f
t I am Indebted to Colonel Olemenger for thie experiment.
ago, when applying pneumococcus inoculations as a preventive
against pneumonia in the Transvaal mines, I nourished
exactly the same prejudices. But here the statistical results
which were obtained in the Premier Mine 14 demonstrated that
the pneumococcus inoculations had, in addition to bringing
down the mortality from pneumonia by 85 per cent., reduced
also the mortality from “ other diseases” by 50 per cent.
From that on we had to take up into our categories the
fact that inoculation produces in addition to “ direct ” also
“ collateral ” immunisation. This once recognised, presump¬
tive evidence of collateral immunisation began gradually to
filter into our minds. Among, I suppose, many thousands of
patients treated by vaccine therapy in private and in hospital,
it happened every now and then that a patient was treated
with a vaccine which did not correspond with his infection,
and that that patient indubitably benefited. Again, it was
not an uncommon experience for the subjects of a very
chronic infection (such as pyorrhoea) who were treated first
by a stock vaccine, and afterwards with an auto-vaccine, to
assert that they derived more benefit from, and to ask to be
put back upon treatment by, the stock vaccine.
From such cases hints are conveyed to us that there may
exist a useful sphere of application for collateral immunisa¬
tion ; and that such sphere may, perhaps, be found in those
cases where the infection is of very long standing, and where
the patient has become very sensitive to, and has probably
come very near the end of his tether in the matter of
13 In Experiments 1 to 8 the blood was obtained from A. B. W. ; in
Experiments 9 to 11 from other- laboratory workers, and in Experi¬
ment 12 from a patient.
14 Wright: On the Pharmako-therapy of and Preventive Inoculation
against Pneumonia. Constable, London, p. 110.
500 Tra Lancet,]
SIR ALMROTH S. WRIGHT: LESSONS OF THE WAR.
[March 29* 1919
immunising response to, the particular species or strain of
miorobe with which he is infected. It will, with regard to
■such patients, be remembered that they constitute the third
of those three classes of cases to which I referred at the
outset of this lecture as very intractable to vaccine therapy.
We are, however, here considering primarily the question
of principle; and in connexion with this what is of funda¬
mental importance is : that we should discard the confident
dogmatic belief ; that immunisation must be strictly specific,
and that we should in every case of failure endeavour to make
our immunisation more and more strictly specific. We should
instead proceed upon the principle that the best vaccine to
employ will always be the vaccine which gives on trial the
best immunising response against the microbe we propose to
combat.
I would point out that this would almost certainly not
involve any revolutionary change in the accepted practice in
either serum therapy or in prophylactic or ordinary thera¬
peutic inoculation. But it would mean taking into account
in cases which proved intractable to treatment with the
homologous vaccine the possibility of seeking for collateral
immunisation by inoculating a microbe or mixture of microbes
other than that with which the patient is infected. The trial
of this procedure might perhaps recommend itself where from
the outset there is very little immunising response to the
homologous vaccine, and also where, as in very long-standing
cases of tubercle or streptococcus infection, the power of
direct immunising response to the corresponding vaccines is
becoming exhausted.
Practical Applications op the In Vitro Method.
I spoke above of the vaccine which gives on trial the best
immunising response against the microbe we want to combat.
What was in my mind was immunising response in vitro, and
I have it in view that it may become a practicable routine
measure to test the response of the patient's blood in vitro
by experiments such as those which are incorporated in the
Table of experiments. You will appreoiate that as soon
as we shall have learned all the determining factors which
here come into play, we shall be in a position not only to
test the efficaoy of vaccines on normal blood in vitro (as
was done, for instance, in Exps. 8a and 86), but
also in a position to determine upon the patient’s blood
in vitro—thus avoiding the necessity of tentative experi¬
ments in vivo—what vaccine, and what dose of that vaccine,
will give us the desired effect. I did this in a case of
which I shall presently have to tell you. But let us note in
the present connexion that in choosing the dose of vaccine
for addition to the blood in vitro we shall have to take a
submultiple of the dose we should tentatively employ upon
the patient. If we were operating upon 1 c.cm. of blood
we should obviously have to consider that we were dealing
with 1-5500 approximately of the patient’s blood volume,
and since the fluid in the tissues must also come into con¬
sideration we should probably have to take into our calcula¬
tions the relation which our 1 c.cm. of blood bears to the
patient’s body-weight.
There is still one other therapeutic prospect which I want
you to consider. And again the practicability of exploiting
this method will depend upon our obtaining constant
immunising response to vaccine added to blood in vitro.
When we have to deal with a general infection, and when
surgical operations undertaken to abolish the ec-phylactic
focus have failed, and where immunising responses cannot
be obtained, there still remains, as a last resource—trans¬
fusion. But simple transfusion—and the method has been
extensively tried in this war—has in. these cases proved
unavailing. It has even been held to do positive harm.
That should not be a matter for wonder when we reflect that
the normal blood fluids provide for serophytic microbes an
excellent cultivation medium—generally a more favourable
medium than the blood fluids of the patient. And from
another point of view also the failure of simple transfusion
should not surprise us, for though leucocytes, as I have
shown you, do effective bactericidal work outside the blood,
the conditions where the leucocytes are suspended in blood
fluids are, as we have learned, unfavourable to their bac¬
tericidal operations. Appreciating these points you will see
that the outlook for the patient would be much more favour¬
able if we could take the donor’s blood and immunise it
in vitro, and so render the plasma bactericidal for the
microbe with which the patient is infected.
Immuno-Transfusion.
I had not very long before coming home an opportunity
of putting this plan of campaign into execution.
The case I have here in view was that of a patient who
was the subject of streptococcal wound infection with exten¬
sive involvement of the sacrum and ilium, and who was
suffering from a continuous high temperature, which had
reduced him to such a condition that his life was despaired
of. A secondary very radical operation with chiselling of
bone having under these conditions been undertaken without
any improvement in his condition, it was determined to try
a transfusion of blood which should be immunised in vitro
against the patient’s streptococcus. With a view to ascer¬
taining whether such a blood could be obtained for the
patient a syringeful of blood was taken from the appointed
donor on the day before that fixed for the operation, and
different portions of this blood were digested for three
hours in vitro with a series of graduated dilutions of a
staphylococcus and also of a streptococcus vaccine. The
centrifuged sera with controls were then implanted by the
wash and after-wash method with a mixture of staphylo¬
coccus and the patient’s own streptococcus. Of all the
sera thus obtained that of the blood portion which had been
digested with 1000 staphylococci per c.cm. gave the best
result. While the serum from the control blood grew
staphylococcus up to the thirteenth and streptococcus up to
the fourteenth dilution, the serum from the blood which had
been digested with 1000 staphylococoi per c.cm. grew the
staphylococcus up to the ninth and streptococcus only up to
the sixth dilution. In view of this result we added to the
litre of blood, which was drawn off from the donor into a
paraffin-coated receptacle, a quantum of vaccine correspond¬
ing to 1,000,000 staphylococci. After the transfusion of this
blood a very striking change came over the patient’s con¬
dition. His temperature promptly fell and he rapidly became
apyrexial. The wound also rapidly healed; and his serum,
which before provided for the streptococcus a much better
culture medium than our normal sera, was found after trans¬
fusion to inhibit the growth of this organism.
The therapeutic method here employed is, as you see. a
combined method of serum therapy and transfusion. We
may perhaps call it 1 ‘ immuno-transfusion. ” Over the ordinary
methods of serum therapy which have been tried for septi¬
cemic cases it has, of course, the advantage that we are
dealing with compatible human blood, and can therefore, if
we succeed in obtaining protective substances, incorporate
these in indefinitely large quantities.
Knowledge Gained bt Research during the War.
With this I have completed what I have to say about the
new outlook in the field of immunisation, opened up by the
work in which Dr. Leonard Oolebrook and I have collaborated.
Let me, in conclusion, take you back to the point from which,
this lecture set out. I began, you will remember, by pointing
out to you that this war has demonstrated to all two facts
in connexion with immunisation : first, that when proper con¬
ditions have been established in infected wounds and these
are thereupon sutured the protective agencies of the body can
(except in the case of a streptococcus infection in a wound
that has not yet reacted) be trusted to extinguish the
infection ; and secondly, that resistance to typhoid fever
can be greatly reinforced by the inoculation of typhoid
vaccine.
Now it lies with each of us to say how much or how little
he proposes to learn from these favourable positive results—
from this bright side of the picture—and also from the dark
side of the picture which presented itself in the sepsis and
gas gangrene of the earlier period of the war. If we put out
of sight everything but the crude data of clinical experience
we shall have learned nothing except what to do and leave
undone when we are dealing with wounded men in war; or,
as the case may be, with a population which is exposed to risk
of typhoid infection. We shall, in other words, have carried
away from the welter of this war only an empirical knowledge,
which will be of very little utility for the purposes of peace;
or, indeed, for any emergency other than the recurrence
of war. If, on the other hand, we manage to penetrate to
the principles which underlie our experience we shall have
possessed ourselves of that kind of knowledge which will
find continual new applications ; and we shall have learned
all that is of really fundamental importance in relation to
the treatment of bacterial infections. To tha|i end let me
The Lancet,]
SIR WILLIAM OSLER: INFLUENZAL PNEUMONIA.
[March 29,1919 501
try to summarise for you in a very few words what research
has taught ns with respect to the nexus of events in this
war.
We can now see that the septic catastrophes of the earlier
period of the war—the putrid abscesses of the wounds that
had not been opened up at the front, and the frequent
gangrene of the amputated stumps which had been there
sutured, were due to the fact that there was left behind an
ec-phylactic focus in which all the defensive agencies of the
body—both the serum and the leucocyte defence—were
abolished—in other words, a focus in which all serophytic
and sero-saprophytic microbes could freely multiply. Exactly
the same applies to the open sloughing wound. Here the
original bruising of the tissues, and the superadded desicca¬
tion—which closes down the capillary circulation—created
an ec-phylactic focus.
The felicitous results which have in the latter period of the
war been achieved by timely opening up of the wound and
the excision of all devitalised tissues have been due to the
fact that there was now not left behind any ec-phylactic
focus in which sero-saprophytic microbes could cultivate
themselves. And we have seen that the failures which
have occurred when immediate primary suture was under¬
taken in presence of a streptococcus infection may almost
certainly be set down to default of leucocytic emigration and
exudation of blood fluids into the wound ; while the success
of retarded primary suture in cases of streptococcus infec¬
tion is almost certainly due to free leucocytic emigration and
the limitation of exudation.
With respect to inoculation, it is important to grasp the
principle that, whether we are dealing with preventive or
therapeutic immunisation, we can expect results only when we
have good epi-phylactic response in combination with efficient
kata-phylaxis. To this combination we owe the success
which has attended antityphoid inoculation. It is, moreover,
important to realise that the inefficacy of all forms of
inoculation as applied to such septic conditions as presented
themselves in wounds in the earlier period of the war abates
nothing from the legitimate claims of vaccine therapy. For
it is a first principle of that method that in ec-phylactic
conditions, such as those of gravely septio wounds, the
defensive agents of the blood cannot, until the proper kata-
phylactio measures have been taken, come into operation.
INFLUENZAL PNEUMONIA:
BILATERAL RIGIDITY, SPINAL MENINGITIS WITH
HAEMORRHAGE INTO THE THECA VERTEBRALIS
AND NERVE ROOTS.
By Sir WILLIAM OSLER, Bart., M.D. Oxford.
Meningitis has been a common complication in the
pneumonia of the present epidemic. In ordinary pneumonia
the incidence is only from 2 to 3 per cent, of the
fatal cases, sometimes much higher, as in my Montreal
series. The cerebral meninges, particularly of the cortex,
are more often involved than the spinal. Spasticity, a well-
marked feature of the epidemic form, was not present in any
one of the 25 cases of pneumonic meningitis that occurred in
my clinic at the Johns Hopkins Hospital. I have no per¬
sonal experience of an influeDzal meningitis. In my
“System of Medicine’' Lord refers to 11 cases in which
the Pfeiffer bacillus was found in the exudate. The follow¬
ing case is wdrth recording from the unusual character of
the lesions and from the possibility of its influenzal nature.
Notes of Case.
I was making “ rounds” with my class at the Raddiffe
Infirmary on Jan, 26th, when Colonel W. Collier sent for us to
out-patients’ as a man with remarkable symptoms had just
been sent in by Dr. Rice. I dictated the following note :—
A fairly well nourished man, aged about 43, with a sallow
complexion and a distressed appearance ; he answers ques¬
tions clearly and says he has been ill for three days.
Respirations 44, with a marked expiratory rattle ; pulse 132,
regular; temperature 99? F. Facial muscles move freely, no
paralysis, opens mouth readily and protrudes tongue ; pupils
are equal, dilated, and react to light; no ocular paralysis.
The neck is so rigid that he cannot lift the head from the
pillow. The spine is arched, the muscles strongly contracted.
Both upper limbs are in tonic spasm, the arms more than the
forearms; he can extend and flex the fingers ; he cannot move
the arms from the side; at intervals there is slight tremor.
Both legs are rigid ; the right is deformed from an old infantile
paralysis; the left cannot be bent, the muscles stand out
prominently, and the foot is extended ; slight ankle clonus,
knee-jerks not obtainable, nor the Babinski sign. On the
skin of feet and ankles is a crop of fresh purpura. The
breathing is largely abdominal, movements of the chest very
slight, but more on the right than the left side. Dullness
shading to flatness from the fourth left rib, extending into
axilla and as high as angle of scapula behind; intense
tubular breathing with fine crepitant r&les. The heart
sounds are clear.
The story was that he had been ill for three days with
fever and cough, but there was no note about the rigidity.
The suggestion had been made that the case was tetanus,
but there was no wound; the spasms were extensor and tonic
in character, and not unlike those seen sometimes in
cerebro-spinal fever. Then he had, in addition, well-
marked purpura. Pneumonia is very rare as an early
complication of cerebro-spinal meningitis. Altogether, as
the pneumonia was so pronounced, I thought the spinal
meninges were involved without, as is usual, the cortex of
the brain. The lumbar puncture made by Dr. Lloyd was
negative. Next day he remained very ill ; the rigidity
persisted ; the temperature rose to 103°, the respirations 52.
When I saw him at 2 p.m. he was still conscious, the face
dusky and a little sallow, the back was very rigid, and on
attempting to lift his head, the arms went into extensor
spasm. The left leg could not be moved, and muscles and
tendons stood out prominently ; the lung condition was
unchanged. The purpura had extended slightly over thighs
and shoulders. The lumbar puncture by Major A. G. Gibson
was again negative. He died at 3 o’clock. The blood cultures
were negative.
Post-mortem .—Next morning, in the absence of Major
Gibson, I made the post-mortem. The skin had a tinge
of yellow; marked rigor mortis; purpura in parts men¬
tioned ; colour of muscles very deep red. Left lung
airless, dark red in oolour, pleura spotted with haemor¬
rhages, but no fibrinous exudate. On section much blood
which, when washed off, left a mottled surface, with
areas of greyish consolidation, surrounded by very dark
red tissue—not the appearance of an ordinary lobar pneu¬
monia, but the type of lesion seen in the present outbreak.
Lower half of upper lobe in the same condition ; the right
lung was normal except for congestion at the base; very
little exudate in the bronchi. The heart was normal;
there were not the very dense blood clots in the cavities and
in the vessels such as are seen in ordinary pneumonia.
Abdominal organs showed no special changes; the spleen
was small and the capsule wrinkled. The retroperitoneum
presented a uniform Meeting of blood clot surrounding the
vessels and extending over the psoas muscles.
The cortical vessels of the brain were engorged, the
membranes very moist, but no exudate on cortex or base,
except on the posterior surface of cerebellum there was a
yellowish-white patch the size of a penny. The spinal cord
had a thick buttery exudate over the cervical enlargement,
less in the dorsal region and very abundant over the lumbar
swelling and the cauda equina. There were no hemor¬
rhages; substance of the cord cut at different levels was
moist and looked normal. Into the spinal theca and
extending along the nerve-roots into the foramina was a
uniform sheeting of hemorrhage obliterating the spinal
veins, in some places dense enough to cover completely the
nerve-roots and involving their sheaths ; it was more marked
in the postero-lateral than in the anterior portions. There
was no free blood in the spinal canal; the haemorrhage was
entirely into the theca.
The lumbar puncture on both occasions was “ dry.” The
smears from the spinal exudate were negative ; nothing
grew on any of the ordinary media, and the blood cultures
made by Major Gibson were negative. Sections of the lungs
showed the lesions corresponding to the influenzal type of
broncho-pneumonia, but Pfeiffer’s bacillus was not isolated.
I do not remember ever to have seen the haemorrhage
into exactly the situation here described. It was probably
responsible for the bilateral rigidity—a very variable feature
in cerebro-spinal meningitis, but rarely so extreme or so
tonic in character.
502 The Lancet,]
DR. C. F. WHITS k OTHERS: THE WASHERMAN N TEST.
[Maboh 29,1919
THE WASSERMANN TEST: A CRITICISM
OF ITS RELIABILITY.
Bt CHARLES F. WHITE, M.B.,
MAJOR, R.A.M.C., nr CHARGE OF 8YPHILIS DIVISION ;
AND
A. T. McWHIBTER, M.B.GLASG., and HUGH BARBER,
M.D. Lond.,
CAPTAINS, R.A.M.C.(T.C.) ; PATHOLOGISTS, NO. 39, GENERAL
HOSPITAL, B.B.F.
A firm faith in the reliability of the Wassermann test,
well justified by the very large number performed here, may
not be too easy to express on paper; bat we think the
attempt may be of general interest at a time when the
medical profession are especially interested in this question.
We have tried in this hospital to criticise very closely the
accuracy of our results. It would seem best to consider the
question from two points of view: first, clinically; and
secondly, a criticism of technique. Under the latter head¬
ing we wish to publish some laboratory results more purely
technical, which we have obtained when titrating each
complement in the presence of antigen.
Part I.—Clinical Criticism.
A great m a ss of figures could be obtained from the records,
but the odd, apparently exceptional, results are the important
ones for such au investigation as this ; and they can only be
criticised fairly by close stndy of the cases at the time.
Daring the first 10 months of 1918 the usual routine has
made about 5800 Wassermann tests necessary. The figures
we quote below will seem a small proportion, but from time
to time, when opportunity has allowed, starting from the
provisional diagnosis coming into the laboratory with the
serum, we have studied closely batches of tests for several
weeks on end; they have in no way been specially selected,
and the conclusions we draw from them are quite in accord¬
ance with the accumulated experience of the clinical side of
the hospital.
We are only able to study the readings required for routine
Work, and have not had the opportunity to make special tests
for this paper because we have only sufficient accommoda¬
tion in the Wassermann trays for the minimum number of
tests that are required for the efficient diagnosis and treat¬
ment of so many patients; and many sera are sent to ns
from distant parts which we do not include here as we
cannot see the cases clinically.
1. Cates Clinically Syphilitic.
(a) Primary syphilitic seres.—Oat of a series "of 117
primary sore cases 99 gave strong positive reactions, 8 gave
partial positive results, and there were 10 negative readings,
explained by the test being performed early in the disease.
With spirochsstes demonstrated in the sore an early test to
obtain a negative result may confirm the clinical opinion that
the case is one of re-infection, in a patient with syphilis
before and cured, and that it is not a relapse. 1
(b) Secondary syphilitic cases and relapsed oases with
secondary lesions , such as condylomata, mucous patches,
rash,'&c.—In a series of 177 such oases 174 gave strong
positive reaotions, 2 gave partial positives, and one weakly
positive. The three partial results were from relapsed oases
treated formerly with “806”; they were not tested again
after provocative injections.
(c) Tertiary oases.— Of 125 tertiary oases of all varieties
117 gave strong positive reaotions, 5 gave partially positive,
and 2 cases of leucoplakia, apparently syphilitic in origin,
were negative; it is not impossible for cases with such
healed lesions to give negative reaction. There remains one
case of what appeared to be tertiary ulceration of the throat
whioh gave a negative reaction here, and also at two other
hospitals ; the condition did not clear up very quickly under
antisyphilitic treatment, but it healed, and the case was
regarded as one of gummatous ulceration with a negative
Wassermann.
(d) After-treatment results. —In a series of oases classified
as primary syphilis, the result after the end of a
course (consisting of seven intravenous injections of “606”
and seven Hg injeotions), was negative in 83*5 per cent.
The total quantity of “ 606 ” was 2 *8 g.
In a series of cases of secondary syphilis the percentage
of negative results after a similar course was 58*1. The
cases classified as secondary are those with condylomata,
mucous patches, or a rash, so some of those under the head¬
ing of primary may be very late ones. The Wassermann
test is taken quite soon after the last injection and may be
more positive than it will be a few weeks later. We have
only a small number of records where this point oan be
studied, but it has been noted a few times.
The figures under this sub-heading of after-treatment have
only a small value as a criticism of the test, but they give a
striking example of the need for early diagnosis. To
summarise the clinically syphilitic cases, only one case with
an active lesion failed to react at all (paragraph (<?)), except
the primary sore cases, where time must be allowed. It is
not possible to make any definite statement from our own
records as to the limits of this time, with or without a pro¬
vocative injection. Most of our cases give some sort of
positive reaction at the end of two or three weeks, but in
some the delay has been exceptionally long. Fu* primary
oases the finding of spirochsstes is the routine method and
the Wassermann test secondary. The change of a doubtful
partial reading in a primary case to a strong positive after
one injection of “ 606 ” is demonstrated regularly as a matter
of routine.
2. Cases whioh Clinically are not Syphilitic.
(a) Soft sore oases. —Oases clinically soft chancre are not
finally diagnosed as such until the patient has been under
observation for a month from appearance of sore and then
gives a negative Wassermann reaction. Though not
practicable under present war conditions, we think that
such cases should be under observation for not less than
two months, and have the test repeated at end of second
month.
We have analysed 547 cases, divided into two series: The
first of 337 oases showed 12 positive Wassermann results ;
the cases were not specially studied at the time for this
investigation, but the clinical cards for about half of these
12 were traced and showed that the cases were accepted for
antisyphilitic treatment.
The second series of 209 cases was carefully studied to
test the reliability of the Wassermann reaction, each un¬
expected result being investigated at the time. The patho¬
logists frequently obtained a provisional diagnosis of soft
sore in the laboratory, which was somewhat out of date or
made before the patient was admitted, and by no means the
clinical opinion at the time of the test; but the reading was
given by them without any indication that the oase might be
syphilitic. Twenty-one such cases gave a positive result;
and were very carefully investigated. Four were proved
syphilitic by finding spirochaetes; 3 other cases showed
evidence of syphilis as follows : one gave a definite history,
with knowledge that his blood had been positive before, the
second showed a tertiary skin lesion, and the third the
scar typical of a primary granulating syphilitic sore on the
penis. Of the remaining 14 cases 7 were sent by the
clinician as venereal sores for diagnosis, very suggestive of
primary syphilis, and after the result were accepted as
such. Those of these cases tested after treatment gave a
negative result, suggesting that a recent syphilitic infection
had been cured. The 7 other cases were typical soft Bore
cases, with no evidence of syphilis, and there is no clinical
explanation of the result. They were tested more than once,
and those tested after treatment gave a positive result, as
would be expected of a latent syphilitic, in contrast to the
cases above, grouped as primary sores for diagnosis. There
is no explanation, in the way of proof, but 7 such out \>f 209
men with venereal sores would not seem a very high pro¬
portion of latent syphilitics.
This series of 547 soft sore oases, whioh represents the
whole batch for six months, is the most valuable one by way
of normal control. A critic, the most prejudiced against the
reliability of the test, could only object to about 3 per cent,
of positive results. Considering that they all admittedly
have venereal sores of some sort, it would not appear to
show nndue bias in favour of the test to claim so small a
percentage as latent syphilitics.
(b) Cases from, the skin wards. —Eighty-nine cases were
sent in six months from these wards; in the laboratory when
the reading is taken the presumption is that the oase is not
syphilitic. Of the 89 cases 78 were negative, being all
The Lancet,]
DR. G. F. WHITE fc OTHERS : THE WAS8ERM ANN TEST.
[March 29,1919 503
varieties of skin lesions, not syphilitic. The 11 remaining
were as follows: Four strongly positive were tertiary skin
lesions, quite obvious, being tested before treatment; four
more strong positives were readily explained, a case of
psoriasis gave a history of syphilis in 1917, a case of vitiligo
the same, a case of impetigo showed tuberosities on the
tibia and admitted syphilis, and another case of impetigo
showed the scar of a primary granulating sore on the penis.
One case of psoriasis gave a doubtful reading, with a bad
serum control, and a case of psoriasis and another of vitiligo
gave strong positives, which could not be explained. So that,
finally, if the result is accepted as a sign of syphilis in these
two cases it only means two latent syphilitics in 89 soldiers.
Of special skin cases one of the most interesting is the
following. A case of papulo-squamous eruption, serpiginous
and circinate in outline, on both arms, very suggestive of a
tertiary syphilide, gave a negative reaction three times, the
later ones after “606” injection; the condition was proved
tubercular by microscopical examination of a section of the
lesion.
It has been stated that psoriasis is a condition which may
perhaps give a positive Wassermann reaction. As we quote
one or two cases of this disease in our exceptions, it will
give our figures a truer proportion to state that in one series
of 110 consecutive cases of psoriasis tested in this laboratory
there were 106 negative results ; of the 4 other cases, 3
were obviously syphilitic, and there was 1 case with positive
result which could not be explained.
We are indebted to Captain W. H. Brown, skin specialist
to the hospital, for his clinical opinion, and for permission
to publish these results of his cases.
3. A Group of Cates which Appeared to Give Exceptional
Readings.
At a time when we were not taking the opportunity to
follow and record all the laboratory readings, the following
results, which appeared exceptional in the laboratory, were
traced. They are not specially selected, because, although
they are only taken irregularly, all those which were traced
are recorded.
1. A case of psoriasis gave positive, retested positive, re¬
examination showed Argyll Robertson pupils, and the cerebro¬
spinal fluid 68 cells per c.mm. with positive Wassermann
reaction.
2. A case of psoriasis gave positive reading twice; the
c.s.f. showed nine cells per c.mm., and was positive in five
and two volumes.
3. A chancroid case gave positive result; there was a
history of syphilis nine years ago, with typical syphilitic
scar on penis.
41 A venereal sore, more follicular in appearance, gave
positive; the patient then gave a history of syphilis
formerly, and the diagnosis was made of gumma.
5. A follicular sore, quite typical, gave positive, but there
was a history of syphilis in 1912.
6. A rash, practically indistinguishable from that of
secondary syphilis, gave a negative result three times (the
last one after a provocative) ; the c.s.f. was normal. There
was no history of syphilis, no condylomata, mucous patches,
or adenitis; spirochsetes could not be demonstrated from
the papules ; a definite diagnosis was not made, but it was
•considered that syphilis was excluded ; microscopical exa¬
mination of a section of the papule showed no evidence of
syphilis, but suggested psoriasis.
7. A rash, suggesting papulo-squamous syphilide, on the
penis gave negative result four times; the final diagnosis
was lichen planus.
8. Two cases of vitiligo gave positive results ; one gave
positive in c.s.f. in the more concentrated amounts ; in the
other case there were no evidences of syphilis.
9. A case of soft sore gave positive result; after provo¬
cative injection the result was negative ; the first result was
regarded as a mistake in technique (see Paragraph B in
Part II.).
10. A partial positive result was negative after provocative
injection ; this was another technical error.
This small number, of wbat appears at first sight to be
exceptional results, was picked out while some hundreds of
routine tests were reported on. It is a very incomplete way
of recording, but with the other readings agreeing with the
clinical diagnosis such findings as the above give one great
confidence in the test. They were, of course, recorded by
name and number at the time, and could again be verified
by looking up the card.
A mass of statistics could be collected from the records
of the hospital, speaking of thousands where we quote
hundreds, but not necessarily of such general interest or so
suitable for our investigation of the reliability of the
Wassermann reaction.
Part II.—Criticism of Technique.
The routine method is almost identical with that described
as the Rochester Row method, 2 using dropping pipettes to
measure out the reagents, but in the last few months we
have titrated the complement in the presence of antigen.
The results of this control have been very striking, and we
think a detailed account may be of interest.
A. Titration of Complement in the Presence of Antigen. 3
The complement is titrated alone in the usual way, dilu¬
tions .varying from 1/10 to 1/120 being put up with two
volumes of saline and one volume of sensitised cells ; it is
incubated in the bath at 37° C. for half an hour and then the
reading taken. Another row of tubes is set out with
complement as above, plus one volume of antigen and one
volume of saline. The complement and antigen are left
for half an hour at room temperature and then half an hour
in the bath (as they would be in the test proper), and then
the sensitised cells are added. The reading is taken at the
end of half an hour.
We have tested the complements of 50 guinea-pigs in this
way, and find that the individual complements vary extra¬
ordinarily in the way they are absorbed by the antigen. We
have classified them according to whether more or less than
one minimal haemolytic dose is absorbed. For example, if
the complement titrated alone gives complete haemolysis in
1/60 and titrated in the presence of antigen if 1/30 does not
give complete haemolysis, there is absorption of more than
one M.H.D. There is the greatest variation, some
complements being only slightly absorbed, most tending
towards the absorption of one M.H.D., and our most
striking example being a complement giving complete
haemolysis in dilution 1/60, which in the presence of antigen
gave practically no haemolysis in a dilution of 1/10.
Of the 50 guinea-pigs, the extract absorbed less than
one M.H.D. of complement in 34, about one M.H.D. in 7,
and more than one M.H.D. in 9. Out of these 9 there were
4 complements which were very markedly absorbed.
We have, as far as possible, investigated the errors which
occur when there is excessive absorption of complement by
antigen, and although the presence of serum in the test
proper undoubtedly neutralises the effects of this absorption
power in most cases, we have been able to change some of our
readings by using a fresh complement not abnormally
absorbed, and have no doubt that this titration of comple¬
ment in the presence of antigen is an essential routine
control of the test. And further, although the sera give
better results than one might expect, we have found that
cerebxo-spinal fluid has little or no power of neutralising this
absorption, and it is quite useless to attempt to test the
Wassermann reaction of this fluid with a complement
readily absorbed by antigen. For convenience we call com¬
plement titration alone control A, and in the presence of
antigen control B.
Of the complements too much absorbed we have been able
to make the following notes:—
1. Guinea-pig No. 3; complement control A, 1/60 tube
practically clean, control B (in presenoe of antigen) 1/20 only
partial haemolysis. Two vitiligo cases and one chancroid
case, which gave positive reactions, were proved negative ly
using a good complement. One chancroid case giving
partial reaction was also proved negative.
2. Guinea-pig No. 5; complement A, 1/60 complete
haemolysis, control B, 1/10 practically no haemolysis. Two
cases of balanitis, giving positive reactions, proved negative
with a good complement; and two more positives became
partial reactions, one an early primary, and the other an
after-treatment case. One c.s.f. showed no haemolysis in
any tube from 5 vols. to 1/5 vol., although there was no
excess of cells.
3. .Guinea-pig No. 15; complement A, 1/50 practically
clean, control B 1/10 only partial haemolysis. Two positive
readings were changed to negative, one a case of optic
neuritis, and the other, from another hospital, with no
504 The Lancet,]
DR. 0. F. WHITE k OTHERS: THE WA8SERMANN TEST.
[March 29, 1919
history. Six c.s.f. all gave positive and partial resalts,
although only one showed excess of cells. The readings
showed no grading with the dilutions of c.s.f. Retested
with a good complement, four of the fluids were absolutely
negative; one (an after-treatment case) showed some
reaction in the 5 vols. tube, and the one case with excess
of cells remained positive in the undilated fluid, with partial
haemolysis in the tubes with diluted fluid.
4. Guinea-pigs Nos. 18 and 19 both gave absorption of
rather more than one M.H.D. With the former four c.s.f.,
and with the latter five c.s.f. gave partial reactions in high
dilutions, as strong as in the more concentrated fluid, which
were due to the complement antigen reaction.
5. Guinea-pig No. 21; complement A, 1/50 practically
clean, control B 1/20 not quite complete haemolysis. Two
partial reactions and one positive were changed to negative.
Eight c.s.f. were tested ; one, with 58 cells per c.mm., was
positive, grading from strong in 5 vols. to partial in 1/5 vol.
of o.s.f. In the other 7, where the cells were normal, there
were signs of complement extract reaction.
6. Guinea-pig No. 36; complement A, 1/60 nearly clean,
oontrol B 1/30 not quite so clean. One c.s.f. showed partial
reactions, not grading with the fluid.
7. Guinea-pig No. 48; complement A, 1/60 nearly clean,
control B 1/30 only partial. Nine positive sera were done
again with a good complement, but all remained positive.
We have introduced one row of three tubes into the test
proper as an antigen control, in which a volume of saline
replaces the diluted serum of the other rows ; we have called
this control D. With a marked absorption of complement
by extract these tubes may give little or no haemolysis, and
it is noticeable (as stated above) that on these occasions
many tubes with sera present, give complete haemolysis;
but we have usually found that cerebro-spinal fluid shows
much the same failure of haemolysis as is recorded in
Control D without grading according to the amount of
cerebro-spinal fluid; for example, such a reading as this
5 vols. 2 vols. 1vol. 1/2 1/3 1/5
±± ±± ±+ ± + + + ±±
with a good complement this fluid was negative in all
dilutions.
With the complement most completely absorbed (Guinea-
pig 5), there were 12 tubes containing varying amounts of
the one cerebro-spinal fluid, without any haemolysis, although
the fluid was normal in other respects.
In the back records of the hospital we find record of six
cerebro-spinal fluids, all tested with the same complement,
only one of them showing excess of cells, which are recorded
as positive in all dilutions—that is to say, there are 72
tubes, where antigen was present, without any haemolysis.
It would seem probable that this complement, titrated with
the antigen, would have shown much absorption, and if an
antigen oontrol had been in use the results might have been
rejected.
With the worst complements, from this point of view,
meet normal sera will give negative results ; with guinea-pig
No. 5 there were 34 negative readings and 9 trace negative
out of 77 bloods tested. We have tested the unsatisfactory
complements with different antigens, but we find it is the
complement which varies.
We have had a few opportunities of comparing absorption
of complement in this routine Wassermann test with a
method in which the antigen, much weaker, is incubated
with the complement overnight in the ice-chest, and our
limited experience would lead us to think there is not much
difference.
We have had many opportunities—at the least 15—of
re-testing the amount of complement absorbed by antigen
when the complement has been preserved by freezing, and it
does not appear to vary.
Practically, we should conclude that, if more than one
M.H.D. of the particular complement is absorbed, all the
positive sera results should be re-tested.
The chief inconvenience is in regard to cerebro-spinal fluid,
because it does not keep well for the next day. We have
found that it is quite reliable to trust to a frozen complement
which we know is a good one, or else to test previously the
guinea-pigs by bleeding from the ear, which latter proceeding
is possibly the most convenient way of ensuring that there
will be no delay on the day of the test.
B. Other Sources of Technical Error.
Anyone with practical experience of the test must know
that, when the results of the report may be so far-reaching,
it is not wise or fair to place absolute reliance on one result,
because the nature of the test is such that the possibilities of
human error are by no means negligible. But apart from such
mistakes, and when a result is confirmed by a second test, it
is probably one of the most certain things in medicine.
To compare a new antigen with the one in use, and to con¬
firm an unexpected result, we have repeated the test or put
the sera up in duplicate very many times. In a consecutive
batch of *140 such readings which we studied at the time
the readings were unchanged in 114. There were ten where
partial readings were changed by becoming stronger after a
provocative injection of “ 606 ” ; these were taken as correct.
Among the remainder there were some changes from doubtful
and practically negative to negative, and a few cases where
a partial positive result immediately after the last injection
of a course became negative a week or two later. Three
cases which might have been reported as positive were
corrected to negative, and were explained by absorption of
complement by extract; these, of course, were corrected
before they were sent to the clinician. One case of typical
soft sore reported positive was proved negative four days
later. This last is the only definite error in the series.
At other times there have occasionally been such errors
equally inexplicable from a pathological point of view, but
in our opinion undoubtedly due to human element.
We have interchanged the readings once between two
patients, the clinician accepting the second, when the
bloods were not taken in the laboratory and came in a batch
of six. We have received blood sera by post unlabelled
occasionally, and a batch of several may be mixed before
it reaches, us, and equally easily a similar mistake may be
made by the pathologists or assistants; or even a clerical
error cannot be traced when the day’s results have been
thrown away. We have put down the small number of altered
readings to such mistakes, or to a mistake in dividing out
the sera during the test. It may seem that this point is
rather elaborated, but one has seen letters in the journals
which presume to criticise the whole test on one mistaken
reading.
It is generally accepted in medicine that there should be a
close association between the clinician and the pathologist.
We would emphasise the point that in the Wassermann test
this association must be something really practical; for
with the test reagents standardised and tested one against
the other the final decision that they are efficient is that
syphilitic sera give positive results, and non-syphilitic
negative.
We have not attempted any elaborate grading of the exact
strength of positive and partial reactions, but we have
satisfied ourselves that syphilitic serum gives a positive
result, and non-syphilitic serum a negative, in such an over¬
whelming majority of cases that any apparent exceptions
must be very closely studied before they are accepted.
The reliability of our results has been due in no small
measure to the careful work in the laboratory of Sergeant
Atkinson and Corporal Bates.
References — 1. White: Brit. Med. Jour., October, 1917. 2. Research
Committee’s Report, Wassermann Test, March, 1918. 3. Ibid., Slides and
McIntosh.
Donations and Bequests.— Lady Markham,
president of the Mansfield and District Hospital, has given
£1000 for the endowment of a bed in memory of her late
husband, Sir Arthur Markham, M.P. for Mansfield.
Royal Sussex County Hospital. —“ Pound Day,”
together with contributions from the county, realised
£662 19s. lid. in money and £175 in kind. The expenses
were £72 6s. 7d. y or 8g per cent, of the total amount. The
annual exhibition of the Blanket, Linen, and Work Guild
was held on March 20th in the Ralli memorial theatre at the
hospital. Miss Blanche Fair started the guild in 1912, its
object being to supply household linen, blankets, ward
clothing, &c. t for the hospital and convalescent home.
ItB success can be gauged by the fact that year after year it
meets the calls of the institution without any charge upon
the hospital. There were only 196 beds in 1912, against 265
at the present time, but the financial support to the guild
him not been commensurate with the growth of the calls
upon it, and every effort is being made to raise the income
to £350 a year.
Tin Lanobt,J SIR LEONARD ROGERS : COLLOID ANTIMONY SULPHIDE IN KALA-AZAR. [March 29, 1919 505
COLLOID ANTIMONY SULPHIDE
INTRAVENOUSLY IN KALA-AZAR,
WITH A NOTE ON ANTIMONY OXIDE ORALLY.
By Sir LEONARD ROGERS, Kt., C.I.E., M.D., F.R.O.P.
Lond., F.R.8.,
LIKUTKNAHT-COLOITKL, I.M.8.
In a previous paper 1 1 drew attention to the occasional
danger from the toxicity of tartar emetic intravenously
in the doses necessary for the cure of kala-az&r, and have
recommended sodium antimony tartrate, Plimmer’s salt, as
being slightly less toxic and at least equally efficient as the
potassium salt. Since that paper was published I have met
with serious symptoms and death in one instance following
the use of the sodium salt, but found that the sterilised
solution in a small flask plugged with cotton-wool had
become contaminated with micro-organisms in the hands of
an assistant surgeon who gave the injections. It is note¬
worthy that both this and the accident I previously reported
ooourred in the damp, hot, rainy season in Bengal, when
fungi often grow through cotton-wool plugs. I now either
only use freshly sterilised solutions, as advised by Dr. E.
Muir, or add £ per cent, carbolic acid to the solutions.
Doses put up in sterile ampoules by reliable chemists can
also be safely used as long as they remain perfectly dear in
doses up to 5 c.cm. of a 2 per cent, or 10 c.cm. of a 1 per
cent, solution.
During the last six months I have been trying intravenous
injections of solutions of colloid antimony sulphide, very
kindly prepared for me by Mr. F. L. Usher, B.Sc., at the
Central College, Bangalore, at the suggestion of Dr. J. L.
Simonsen, to both of whom I am greatly indebted for their
invaluable help in the matter. Mr. Usher has kindly supplied
me with the following account of his method of preparing
the new drug, while he will record further details of his
researches.
Preparation of Colloid Antimony Sulphide in 1 in 500 Solution.
“A solution of tartar emetic, strength 1 in 900, is saturated
with sulphuretted hydrogen which has been well washed
so as to deprive it of aoid spray. The originally oolourless
liquid becomes deep red, but does not throw down any
precipitate. The solution thus obtained is one of colloidal
antimony sulphide, mixed, however, with potassium
bitartrate, which has next to be removed. This is done
by dialysing against distilled water at a temperature of
80° to 100°, preferably through a membrane of goldbeater’s
skin, in default of which parchment paper may be used.
The length of time required for this operation depends
on several factors, and its progress is best followed by
measuring the .electrical resistance of the solution from
time to time. When it has reached 10,000 ohms the
dialysis may be stopped. The liquid is then tested by
titration with a standard solution of iodine in the presence
of a little sodium bicarbonate, and its strength being thus
determined, the amount of dilution required to bring it to
a strength of 1 in 500 oan be calculated. There are still
three substanoes to be added—namely, glucose to make the
solution isotonic with blood (salt cannot be used for this
purpose, since it would oause precipitation), gum arabio to
render it more stable, and phenol to preserve it. The
final solution should contain 5 per cent, glucose, and
0*5 per cent, each of gum and phenol, so the calcu¬
lated amounts of these are dissolved in water and added to
the solution, which is finally made up to the required
volume with distilled water, and is then ready for use.
The two most important points to bear in mind are
(1) that only distilled water must be used throughout (tap
water would sooner or later cause precipitation); and
(2) that the titration of the liquid with standard iodine
must be done after dialysis and before the addition of
gluoose, gum, and phenol. The solution when properly
made keeps well and may be boiled in order to sterilise it.”
Mr. Usher also sent me some 1 in 260 solution, but it was
of a dark red colour, making it more difficult to see when
blood had entered the syringe when giving an intravenous
injection. It is also more difficult to prepare and less
stable, so, as experience showed that sufficient doses to be
effective of the 1 in 500 solution could conveniently be
injected intravenously, the latter strength has been used in
all but a few of the injections. In calculating the quantities
given in the cases shown in Table II., 1 c.cm. of the
i Iod. Med. Gm.. May. 1918.
1 in 250 solution has been counted as 2 c.cm. of 1 in 500, as
both solutions will be so rapidly diluted when injected slowly
into the blood stream that their action will be similar on the
parasites of kala-azar. The carbolised solution keeps well
and remained sterile in flasks after use for several weeks in
the rainy season.
Toxioity in animals .—The toxicity of the solutions of
colloid antimony sulphide is remarkably low as compared
with tartar emetic and sodium antimony tartrate, as shown
in Table I.:—
Table I— Toxicity in Pigeons of Antimony Solutions
Intravenously.
Preparation. Recovered. Died.
Tartar emetic. 0 015 g. 0*0175 g.
Sodium antimony tartrate . 0*02 g. 0*0225 g.
Equivalent of oollold antimony sulphide ... 0*16 £. V
Grammes per kilo.
Mr. Usher informs me that the oolloid antimony sulphide
contains twice as much antimony as the soluble tartrates,
allowance for which has been made in Table I. No less than
20 c.cm. per kilo of the 1 in 250 colloid antimony sulphide
solution (equivalent in antimony to a 1 in 125 solution of tartar
emetic) was injected intravenously in a pigeon of 270 g.,
or 5*4 c.cm. of the 1 in 250 solution, without any toxic
symptoms arising. Beyond this I did not go owing to the
technical difficulties of injecting such large amounts and the
toxicity of the J per cent, carbolic acid the solution contains,
while it is clear from the above figures that the sub-minimal
lethal dose of the colloid antimony sulphide is not less than
about 10 times as high as that of tartar emetic, and not less
than eight times as great as that of sodium antimony tartrate—
a matter of the greatest practical importance. The solution
of colloid antimony sulphide is therefore very much less toxic
than those of the soluble antimony salts hitherto used in the
treatment of kala-azar a and sleeping sickness.
Toxioity in man .—Up to 20 c.cm. doses of the first solution
of slightly weaker than 1 in 500 and up to 9 c.cm. of the
1 in 250 solution have been repeatedly given intravenously
without the least toxic effect and with excellent results in
kala-azar. A later supply of a 1 in 500 solution, however,
has sometimes produced pain in the loins and flushing of the
face of a few minutes’ duration, although 2 c.cm. of the
same solution from the same flask produced no visible signs
in a rabbit when injeoted intravenously, so these symptoms
are evidently not dangerous as is the collapse sometimes
following the use of soluble antimony tartrates. In one
patient, with an enormous spleen extending six inches
beyond the navel, the above symptoms were followed by
drowsiness and, later, excitement after a c.cm. dose.
Table II. — Colloid Antimony Sulphide Intravenously in
Kala-Azar.
although the same dose a week previously bad no 111-effect;
so this patient appears to have developed an intolerance to
the drug. Possibly these symptoms may be due to the slow
precipitation of the antimony sulphide, due to contact with
the chlorides in the blood, and a slightly weaker solution
such as 1 in 750 to 1 in 1000 might be preferable, but I have
not yet been able to test this. With the single exception
• Th* Luioet, 1916, li., 788. ~~ ~~
506 Thb Lancet,] SIR LEONARD ROGERS: COLLOID ANTIMONY SULPHIDE IN KALA-AZAR. [March 29,1919
recorded above the unpleasant symptoms have been quite
slight and transitory, but require further study in order to
eliminate them, as they restrict the use of large and more
rapidly efficient doses.
Clinical Trials in Kala-Azar.
Clinically, the use of oolloid antimony sulphide in kala-
azar has been very tetisfactory, apart from the one case
with prolonged toxic symptoms already noted, who is still
in hospital although he has improved considerably.
Table II. shows the main points of all the cases thus treated
who have been discharged from hospital, drawn up on
similar lines to those illustrating the use of tartar emetic
and sodium antimony tartrate respectively in my previous
papers, 1 a while the average figures relating to the most
important points of all three series are- shown in Table III.
for convenience of comparison. The most noteworthy
features are the following.
Table III.— Comparison of Average Bata of Treatment of
Kala-azar with Tartar Emetic , Sodium Antimony Tartrate t
and Colloid Antimony Sulphide .
-
Tartar
emetio.
Sodium
antimony
tartrate.
Colloid
antimony
sulphide.
Days in hospital .
62-4 days.
73*6 days.
76 days.
Days fever cinder treatment ...
262 „
21*2 „
13*9 ,,
Cgs. of drug to oessation of fever
103 eg.
54 eg.
6*6 og.
Total drug in eg*.
165
160 „
j 20*8 „
Decrease in spleen in inohes ...
2*5 in.
2*2 in.
2 4 in.
Increase in weight in lbs.
7 lb.
81b.
1 14*8 lb.
Max. dose of 2 per oent. solution
5*9 o.em.
5*7 e.em.
2 c.cm.*
# 20 o.on. of a 1 In 500 solution equal to 2 c.cm. of a 2 per cent,
solution.
Temperature reactions are much less frequent and severe
after intravenous injections of the colloid preparation than
after the soluble tartrates, and are commonly absent alto¬
gether after the first few injections, indicating less toxicity,
although also probably partly due to the smaller amount of
antimony injected. No such toxic symptoms as sickness,
nausea, and collapse were seen, although they are often
present after tartar emetic injections.
Gain in weight. —The most striking clinical feature was
the much more rapid gain in weight under the oolloid
antimony sulphide treatment than with the antimony tar¬
trates previously used. This is illustrated by the figures in
Table III., showing an average gain in weight of 14* lb. in
approximately the same average time in hospital, against
7 and 8 lb. respectively under tbe tartar emetic and sodium
antimony tartrate, or nearly double the amount. This is
also probably largely due to the slight toxicity of the oolloid
preparation.
Diminution in size of spleen. —This was approximately the
same under all three forms of treatment, the average figures
only varying between 2*2 and 2*5 inches. In the earlier
colloid cases in the first part of Table II., treated with the
largest doses before any toxic symptoms had been met with,
the reduction in the size of the spleen was greater than in
the later oases on smaller doses.
Quantity of antimony administered. —Still more striking is
the total quantity of the different antimony preparations
required to bring about cessation of the fever and to produce
recovery, as indicated by the absence of fever for a consider¬
able time, accompanied by steady gain in weight and
diminution in the size of the spleen, which long experience
has shown usually results in permanent cure. It appears
from Table III. that the total average amount of tartar
emetio and sodium antimony tartrate used per case was
respectively 155 and 160 eg., while of colloid antimony
sulphide the average was 20 8 eg., equivalent to 41-6 g. of
the tartrates, but still only containing approximately one-
fourth the amount of antimony in the latter salts. When
the greatly lesser toxicity and much more rapid gain in
weight are also taken into account, the marked superiority
of colloid antimony sulphide over tartar emetic and sodium
antimony tartrate in the treatment of the formerly deadly
* kala-azar is very evident.
Slower renal excretion of colloid antimony sulphide .—
Dr. Satendra Nath Sen, assistant chemical examiner to
tbe Government of Bengal, has very kindly carried out a
number of observations on the presence of antimony in the
urine after the intravenous administration of the three solu¬
tions I have used in kala-azar with interesting results.
When the soluble antimony tartrates are injected intra¬
venously, even in small doses, rapid excretion takes place in
the urine, especially during the first two days. With the
1 in 500 oolloid antimony sulphide no antimony showed in
the urine during the three days following the intravenous
injection of 5 c.cm. doses and only traces after 15 c.cm. On
injecting 20 c.cm. a well-marked re-deposit on copper was
obtained during the first two days and traces on the third
day. These data indicate that the colloidal antimony
sulphide is retained in the blood longer than the soluble
tartrates of antimony, as might be expected on theoretical
grounds, and would thus presumably act longer on the kala-
azar parasites, and so be effective in smaller doses, as I have
shown to be the case.
Conclusion .—1. Colloid antimony sulphide therefore
appears to be a distinct advance on soluble antimony
tartrates in the treatment of kala-azar.
2. It would also be well worth trying in sleeping sickness*
Antimony Oxide Orally in Kala-azar in Young Children,
The great drawback to the intravenous injections is the
difficulty of giving them in young children. Several yearn
ago I reported 8 good effects in kala-azar in children from
the daily inunction of 5 per cent, finely divided metallic
antimony in lanoline, although they are far inferior to
intravenous injections when the latter are practicable. I
also reported a trial of Martindale’s solution of antimony
oxide in glycerine hypodermically, but with very dis¬
appointing results. Recently I have tried if adults with
kala-azar would stand hypodermic and intramuscular injec¬
tions of sodium antimony tartrate with the addition of
urethane to lessen the pain, but although the pain was
reduced and no sloughing or abscess formation occurred (as
happens after tartar emetio subcutaneously), and analyses
of the urine showed that the drug was absorbed as it was
excreted by the kidneys, yet the still painful injections
could not be continued long enough to obtain material
benefit.
Recently I have tried another and simpler method of
administering antimony in kala-azar based on the fact that
antimony oxide is soluble in weak hydrochloric acid, and
found that when this compound is given with food it is
absorbed and excreted through tbe kidneys, Dr. Satendra
Nath Sen having kindly made analyses of the urine for me.
I was also able to give muoh larger doses than I had
anticipated without causing nausea or vomiting by
administering the drug in lgr. and ±gr. pills, beginning
with lgr. three times a day and increasing each dose by
£ gr. every third day as long as it was well tolerated. By
this means I worked up the daily quantity taken to 15 gr. in
an adult and to 6gr. and 7£gr. respectively in two boys of
II and 12 years old. The results, however, were disappoint¬
ing, for in the adult patient the spleen puncture was again
positive after seven weeks, and the spleen half an Inch
larger, although he subsequently did very well on colloid
antimony sulphide. In the boy of 12 the fever and the
disease steadily progressed, although in his case also it
yielded rapidly to the colloid injections, and in the other
boy spleen puncture also remained positive, although he
gained 4 lb. in weight. In patients of these ages the
treatment by itself therefore failed.
As I had no opportunities of trying antimony oxide in
quite young children I sent some to Dr. Dodds Prioe, in
Assam, who has kindly given it in addition to 5 per oent.
metallic antimony inunctions over the abdomen every other
day in 12 children, selected on acoount of the difficulty of
treating them intravenously, and has kindly sent me the
following report: “ One case died, two are hanging fire, and
nine are either cured or have lost their fever and are
greatly improved." He adds that the doctor babu, in
whose care the cases are, is convinced that the antimony
oxide, in pill form, combined with inunctions, is a great
advance on the older methods of treatment, of which he
had had a former experience of some hundreds of oases.
Considering how deadly kala-azar is in young children the
above record is a very encouraging one.
This plan would appear to be worth trying in infantile
kala-azar of the Mediterranean littoral.
* Brit. Med. Jour., Feb; 26th, 1916.
The Lancet,] MAJOR SINCLAIR : RETROGRESSIONS IN TREATMENT OF FRACTURES. [March 29, 1919 507
RECENT RETROGRESSIONS IN THE
TREATMENT OF FRACTURES.
By M. SINCLAIR, C.M.G., M.B., Ch.B. Edin.,
MAJOR, R.A.M.C. ; MEDICAL OFFICER, SPECIAL MILITARY SURGICAL
HOSPITAL, SHEPHERD S BUSH.
The very appreciative letters in The Lancet bearing on
my work on fractures have been read by me with interest,
and I hope the eminent surgeons who have so compli¬
mented me will accept the expression of my extreme
gratitude for pointing out that my efforts have appealed to
them in a favourable light.
Whilst we have all been able to note considerable advances
during the war in fractures treated by British, French, and
American surgeons, I for one have been, until recently, quite
in the dark as to the methods and results of German surgeons
in this branch of surgery.
Since my return from France I have received notes from
my colleague, Captain H. D. H. Willis-Bund, R.A.M.C., at
No. 8 Stationary Hospital, giving the particulars embodied
in this article of the German treatment of British prisoners
of war with fractured femurs. The advent of the armistice
and the consequent repatriation of prisoners of war have
given us an insight into the appalling methods used and the
terrible results obtained by some at any rate of the German
surgeons.
Primitive German Methodt of Treating Fracture*.
“At No. 8 Stationary Hospital during December, 1918, and
the early part of January, 1919, 41 repatriated prisoners
with fractured femurs have been admitted. The truly
shocking results obtained and the primitive methods employed
have seemed of sufficient interest to put on record.
None of the patients had any notes giving detail of treat¬
ment or progress of case during captivity. I have not been
able to identify the names of any of the surgeons responsible,
though one officer states that he was under the care of a
professor who seemed to be treated with the respect due to
an eminent surgeon.
I have no facts at my disposal to show the German
results and mode of treatment of their own wounded, but
interrogation of these prisoners, both officers and men, con¬
vinces me that on the whole they were kindly treated, that
the lack of food which often obtained was not the fault of
the surgeons, and that in many cases they tried to the limit
of their ability to get the patients better.
As evidence of the fact that the surgeon took interest in,
and trouble in treating, the patient, the officer mentioned
above, who was wounded in March, 1918, states that the
professor five times re-fractured his leg and set it again.
The guiding principles for treatment would seem to have
been lack of extension and indefinitely prolonged im¬
mobilisation.
The majority of the cases were treated on a trough-like
metal back-splint with foot-piece, the splint being of the
same length in every case. It was the wounded man’s mis¬
fortune if he received no posterior support to his fracture,
and due entirely to the fact that he had been so misguided
as to incur a fracture at a higher level on his thigh than the
splint would reach to.
Apparently the continuation of hostilities was sufficient
indication to persevere with this immobilisation of the limb
without extension, as the patients wounded in March were,
when released, still in the same state of splinting as those
whose legs were broken in October.
One enthusiast apparently tried an original method of
extension on some of the cases. A sharp-pointed rigid metal
hook, shaped somewhat like a note of interrogation, was put
into the anterior surface of the tibia, with its straight
unpointed end lying in the long axis of the bone and
directed towards the foot. Another of these hooks was
passed in the opposite direction through the anterior superior
spine of the ilium. A rope working over a pulley with a
brick at the end was attached to each hook to establish the
extension.
A patient treated in this manner stated that every time his
posterior wounds were dressed the weights were removed
and he then noticed grating of the bones and shortening of
the limb.
It was unfortunate that it did not occur to the genius who
evolved this form of torture that if he had raised the foot of
the bed after applying the hook in the tibia the body
weight would have obviated the necessity of using the
hook in the anterior superior spine. Had this been done the
life of one patient at any rate might possibly have been
saved. In this
case, as far as
could be gathered
from the account
of another patient
in a neighbouring
bed, the hook in
the anterior
superior spine
tore out, and
death occurred
some days later
from peritonitis.
Some typical
X ray photo¬
graphs are
appended.
Fig. 1 shows
very marked ab¬
duction of the
upper fragment in
a fracture at the
junction of the
upper and middle
thirds of the
thigh. There is
union with very
marked angula¬
tion at the site
of fracture and
consequent short¬
ening of 16 centi-
metres. The
upper end of the
lower fragment is
through the skin of
the external sur¬
face of the thigh.
Figs. 2 and 3 are the antero-posterior and lateral views of
a patient who in March, 1918, sustained a compound
fracture of the middle of the shaft of his right femur. The
bones are overlapping each other and the limb is 17 centi¬
metres short. The knee is absolutely stiff and there is
Fig. 2.—Antero-posterior view. Fig. 3.—Lateral view.
apparently fibrous organisation between the two pieces of
bone, as the limb is quite flail in the middle of the thigh.”
I think that these photographs justify the title of this
article. Every fractured-femur patient fortunate enough to
fall into the hands of Allied or American surgeons has more
to be thankful for than he is probably aware of.
608 The Lanobt,] MR. PINTO t DB. BA1LLIB: GONORRHOEA TREATED BY P08 VACCINES. [Maboh 29, 1919
THE TREATMENT OP GONORRHOEA BY
PUS VACCINES.
By E. G. D. PINEO, M.R.C.S. Eng., L.R.C.P. Lond.,
CAPTAIN, R.A.M.C. (T.C.);
AND
D. M. BAILLIE, M.D. Aberd., D.P.H. Lond.,
CAPTAIN, R A.M.C. (T.C.) ; NO. 4 STATIONARY HOSPITAL, B.E.F., FRANCK.
During the last two years we have been dealing with
large numbers of oases of V.D.G. among soldiers of the
Expeditionary Force. All recognised methods of treatment
have been tried extensively, generally against control cases,
provided they could be partially carried out by the patient
under close supervision. If the whole treatment could be
carried out by th» medical officer personally much better
results would doubtless be obtained.
The general routine treatment of uncomplicated V.D.G.
cases was based on that so successfully inaugurated by
Colonel L. W. Harrison, A.M.S., in 1914-15, slightly modified.
Irrigation of the urethra with 1 in 8000 or 1 in 4000 pot.
permanganate for the first two days of only the anterior
urethra, and then irrigation into the bladder of the same
dilutions. During this initial irrigation the urine is closely
examined; on signs that the posterior urethra has become
attacked, through-and-through irrigation into the bladder
is immediately started.
Standard of Care.
In fixing a “ standard of cure ” we had to bear in mind
ihe importance to get men back to the fighting line. The
standard of cure we set ourselves was as follows: (a) The
man should show no signs of urethral discharge after
thoroughly stripping the urethra at examination early in
the morning and after urine held for three hours. ( b ) The
urine, passed into two glasses, must be entirely free of
shreds or filaments. ( e ) Freedom from all signs of compli¬
cations. (d) Morning smear negative to G.O. If he passed
this test he was taken off all treatment, given physical
drill, placed on heavy fatigues, and again put through the
above test. If again no sign of disease he was sent to duty.
Out of some 2700 cases discharged to duty on this
standard only 9 “were known” to have relapses (one
twice), showing a “ known average ” of about 0-3 per cent.
It is believed that the majority of readmissions into hos¬
pital of these men were known. The laboratory proved of
little assistance in deciding on cure. For smears taken from
an apparently dry urethra (even if taken at reveille before
passing urine), smears from the prostate secretion after
massage, and attempts to obtain cultures from centrifuged
deposit of urine in such cases almost invariably proved
negative. Where positive the man was regarded as not
cured, in spite of all other negative evidence. The absence
of gonococci in a definite deposit of shreds in the urine,
even on two or three occasions, was not of itself regarded as
proof of a cure.
Treatment with Gonorrhoeal Put Vaccine.
The vaccine treatment of V.D.G. has been extensively
used by wne of us. The Rochester Row stock exogenous
vaccine has been tried, Havre vaccine (gon. vaccine with
some addition of staph, vaccine), the French vaccine
“Dn&gon,” prepared by Messieurs Nichol and Blazot at
Tunis, and, to limited extent, autogenous vaccines. Many
gave fair results, particularly in rheumatic oases, yet all
failed in a considerable number of cases.
The idea of making gonorrhoeal pus vaccine was suggested
to us by Captain J. L. Lickley, R.A.M.C., and a trial was
made of one from the pus of five cases. The results in
gonorrhoeal rheumatism and epididymitis were encouraging,
and a vaccine was next made from 21 acute cases ; in
each a preliminary microscopic examination was done for
density and purity of growth. About 1 c.cm. of pus was
pipetted from the urethra of each case and mixed with
10 c.cm. of 0 5 per cent, carbolised normal saline in a sterile
test-tube. The 21 emulsions were transferred to a 500 c.cm.
flask and well shaken. Glacial acetic acid in the propor¬
tion of 0 5 per cent, solution was added to dissolve the pus
cells, a rubber cap put on and the whole shaken well for one
hour. Emulsion then diluted by equal part of 0 5 per cent,
carbolised normal saline, making acetic acid 0-25 per cent.,
and put aside for four days to allow carbolic to kill .off
gonococci. The emulsion, counted against blood cells, was
found to contain approximately 600 million per c.cm. It
was tested aerobically and anaerobically for sterility, and
finally diluted with 0*5 per cent, carbolised normal saline
and put up in 50 c.cm. vaccine bottles—giving a dose of
24 millions per c.cm.
The advantages claimed are: 1. Ease and simplicity of
manufacture. 2. High degree of polyvalency. The caBes
selected were infected in England, Scotland, Ireland, and
France—in places as widely apart as Aberdeen. Belfast,
Bristol, Hull, London, Paris, and Poperinghe. Torrey 1 has
shown by cross-agglutination and agglutinin absorption
experiments that gonococci fall into about 14 groups.
3. The high degree of virulence. The organisms have not
been vitiated by growing on artificial media, but are fresh
and virulent.
For chronic cases this vaccine was combined with emulsion
of ten strains of Gram-positive diphtheroid bacilli and of
seven strains of Staph, albus isolated from chronic cases.
The minimum doses of these were 60 million and 240
million respectively. The vaccine, plus diphtheroids, seemed
to be more efficacious than G.C. alone in gleets.
We were struck all through by the almost entire absence
of the so-called “negative phase,” even though doses were
given every three days. Possibly the gonococci were to some
extent sensitised in the body before discharge.
Results of Experience.
Whilst recognising that other workers have not always had
similar results, we report the following as the chief points of
experience gained:—
(a) Nothing is gained, and possible harm done, by giving
vaccines in the acute stage, except where the infection has
become generalised—viz., in V.D.G. multiple arthritis,
endocarditis, pericarditis, &c.
(Z>) That the vaccine treatment of V.D.G. differs from
other diseases in the possible production of a prolonged
negative stage if too large a dose is given. The avoidance
of this prolonged negative phase is the key to the successful
use of a vaccine in V.D.G. cases, in our opinion. If the
negative stage develops it is generally several weeks, some¬
times months, before improvement is brought about. The
indications of over-dosage are: 1. Local—increased urethral
discharge with increase of pus cells. Increase of extra¬
cellular gonococci not due to a breakdown of purulent folli¬
culitis. 2. General—increased evening temperature (any
temperature over 99° F. should be regarded as dangerous),
malaise, headache, <fcc. An evening temperature even of 99°
for more than one night should be regarded as an indication
of an overdose. Of these two indications the looal we regard
as the more serious.
To avoid these dangerous effects it is necessary to com¬
mence with very small doses, very gradually increasing doses.
The doses mentioned below are much smaller than those used
by many other workers—and also smaller than we formerly
used—but experience of several thousands of cases treated
with vaccines, in acute or chronic stage, has convinced us
that these doses give the best results with the least number
of relapses. Possibly the use of sensitised vaccines would
obviate the dangerous “negative phase.”
Types of Cases Benefited.
The type of cases most benefited by vaccines are:
( a ) Chronic gleet stage coming on about 20 to 25 days
after commencement of discharge, with gonococci, intra¬
cellular and extra-cellular, in the discharge; ( b ) relapses
generally stirred into activity by recent and repeated sexual
connections, with drinking bouts; (c) cases of V.D.G.
rheumatism in acute or chronic stage; (d) gonorrhoeal
ophthalmia, either metastatic or local infection type;
(<?) the rare cases of gonorrhoeal septicaemia.
The necessity of transferring men from one unit to another
after acute stage, so as to be suitably employed, has inter¬
fered with keeping complete statistics as to the final results
of any particular treatment, but as far as could be traced
our results were as follows:—
(a) Chronic gleet. —Twenty-five cases were previously
treated unsuccessfully for an average of 106 days before
being put on this particular vaccine. Of these, 21 were cured
1 Torrey: Journal of Medical Research, Nov., 1907, xvi., 329. league
and Torrey: Journal of Medical Research, Deo., 1907, xvii., 223.
ThRLaNCRT,] DR. B. PARS0N8-8MITH : FITNESS AND UNFITNESS IN CONVALESCENCE. [March 29,1919 509
on an average of 31 days’ further treatment, or 84 per cent.
Foot transferred elsewhere after an average of 27 days’
vaooine treatment.
(b) Relapses. —Forty-five were treated with vaccine.
These cases had relapsed after an average period of
16 months following previous treatment. They had been
under treatment prior to starting the vaccine course on an
average 30 days. At the end of 23 days’ farther treatment
23, or 51 per cent., were cared, and 22 had been transferred
elsewhere. These cases were all of the most obstinate type
who had failed to be oared after many other methods had
been used.
(<?) Multiple aoute arthritis .—Eight severe cases were
treated. Four of these were cored and sent back to doty,
two were transferred elsewhere (one on the third day improved
and temperature normal, one on the tenth day much improved),
and two still under treatment with chronic vesiculitus, but
rheumatism cured.
It has been suggested that the above-mentioned method is
liable to inoculate the patient with other bodies besides
active gonococcal antigen, such as spores, Ac., or even
active organisms not destroyed in the preparation of the
vaccine.
The method is not entirely new (it has been tentatively
tried by several workers without untoward results), but as
far as we are aware it has never been tried systematically as
above. The cases were kept under close observation whilst
being treated, temperatures taken twice daily, and the men
seen daily by the medical officer.
About 3000 doses have altogether been given of this
vaccine by us —five cases had rises of temperature, about 99°,
on the evening following injection, one on three occasions.
All the cases had normal temperatures next morning and
remained so. All injections were given into the muscles of
the arm or forearm (not subcutaneously). There was no pain
and no local inflammation. All injections were given with
usual aseptic precautions.
Dosage.
The scheme of dosage most satisfactory was as follows:
6 million, 12 million, 18 million, 24 million, 36 million,
60 million, 72 million, 90 million, 120 million, and 150
million doses given at three-days’ interval. If a rise of
temperature occurred after any dose that dose was repeated
on the next occasion, and, in one or two cases, one dose
lower in the scale. Most patients were cured by the time
they reached the 60 to 72 million doses. The most obstinate
were cases of relapse after a long interval from their
previous treatment. The majority of these were admitted
with chronic gleet, with a few fine shreds in their urine.
They show, according to our figures, a high resistance to any
vaocine. We are unable to show control cases of other
vaccines, but in our hands this vaccine has given incom¬
parably better results than any previously used by us.
A COMPARATIVE NOTE ON
FITNESS AND UNFITNESS IN
CONVALESCENCE.
By BASIL PARSONS-SMITH, M.D. Lond.,
CAPTAIN, R.A.M.C., T.O. v
Op the several phases of an incapacitating illness the
convalescent stage demands and amply repays the utmost care
and precision on the part of the clinician. During this period
one takes careful stock of the patient’s several resources
according to the face value they present, and their inter¬
pretation as deduced from experience; the opinion arrived
at needs to be well judged at all times, more especially so,
for obvious reasons, in the practice of military medicine; this
latter admits only of certainties ; from the Army point of view
two main classes only are recognised—viz., the “ fit ” and the
** unfit,” During convalescence an opportunity arises for
the study of the indications and signs which characterise
the merging of these two great classes. Apart from
special cases the difference between the civil and the
military convalescent is not great. In both we recognise a
depression in general vitality, lowered functional activity,
and visceral derangement in varying degrees. The cir¬
culatory mechanism is involved, and well-marked signs and
symptoms justify particular attention to the cardiac functions.
4 4 Soldier's Heart . ’ ’
By the strain of modern warfare on the heart and vessels
latent disease is disclosed, while so-called functional and
neurotic conditions appear. It is to these latter types that
attention is mainly directed in the present communication,
together constituting the greatest proportion of known
varieties of 44 soldier’s heart.” The symptom-complex is
extensive, and includes a series of phenomena significant of
nervous and circulatory debility, associated with lack of
reserve energy. So persistent are the nervous symptoms
and so obscure the pathology that one is disposed to regard
the condition as one of the types of the war neuroses.
The nervoui element appears to involve the entire system.
Most patients complain of palpitation both at exercise and
when resting. An exaggerated sympathetic control seems the
more likely factor. The symptoms indicate a definite nervous
element, but it is well to examine the circulatory manifesta¬
tions. Taken collectively these may be interpreted as an
expression of rebellion on the part of the circulatory
mechanism, which is for the time being below par.;
symptoms of fatigue and exhaustion are incited prematurely,
the patient tends to dwell unduly upon these symptoms
and to multiply them far in excess of the actual physical
signs. To gain the patient’s confidence one must listen
attentively to all he may say, and perform a thorough and
accurate physical examination. The details of the latter
should be noted so as to estimate the result of treatment;
this cannot be too strongly insisted upon.
Examination of Heart: Physical Signs.
The writer’s aim is to record briefly a comparison between
the states of a healthy fit man and one* whose cardiac
mechanism has suffered on active service. Certain features
call for mention : the rate of heart beat, the pulse-respira¬
tion ratio and its variation with test exercises should be
observed in each case. The object is to estimate the heart’s
mechanical value and to recognise any signs indicative of
definite trouble. For instance, abnormalities or eccentricities
of the apex beat, excessive diffusion, tenderness to per¬
cussion and palpation evidenced by involuntary flinching,
deficient mobility with change of position, systolic retrac¬
tions and other evidences of right ventricular preponderance;
also such a combination as a vigorous apex beat with a
feeble and easily compressible pulse. The sounds, especially
at the apex, must be examined as to purity and relative values
and one should endeavour to recognise the return not only of
healthy tone and quality, but also the restoration of the values
of the first and second sounds. One has only to consider the
clinical picture in the early stage of one of the functional
cardiac neuroses to appreciate the foregoing remarks. The
expression is anxious and restless, involuntary movements
are frequently noted, the heart’s action is accelerated,
diastole is cut short, the sounds are accentuated, high
pitched and valvular, vaso-motor irritability is evident,
dyspnoea, and excessive perspiration. Murmurs, both
exocardial and endocardial, are frequently present; the
latter belong typically to the so-called fluid vein variety
rather than that which owes its origin to the vibration of
valve curtains.
The murmurs which are noticed to appear most frequently
are the following :—1. The card io-respiratory bruit,'usually
best heard at the apex, varying with (but at times apparently
independent of) the respiratory phases, and always systolic
in time. 2. The systolic bruit at the pulmonary area
possibly due to loss of tone and dilatation of the conus of
the right ventricle. 3. The systolic bruit which appears
at the apex after exertion and is inaudible at rest, indicative
possibly of temporary valvular incompetence during exercise.
(The complete absence of diastolic murmurs is important;
they never appear in D.A.H. cases.) Such murmurs, how¬
ever, in themselves are quite insignificant; the general state
and prognosis will be arrived at and decided by an inquiry
into the exercise tolerance, the presence or absence of early
enlargement, persistent tachycardia, and hypertension.
Exercise Tests.—Blood Pressure.
One does not tend nowadays to dwell solely upon the
physical signs, but rather to make inquiry into the heart’s
behaviour during and after exertion. Frequent observations
are necessary, both detailed and general. One watches the
patient’s condition to determine his capacity for work,
testing his physical state both before and after definitely
prescribed exercises, as marches. A knowledge is also
51Q ThrLanort,]
ROYAL 80G1ETY OF MEDICINE: 8ECTION OF OTOLOGY.
[March 29,1919
needed of the effort response of healthy controls and an idea
of the duties the patient may later perform. It is our
business to correlate these facts. Broadly defined, fitness
for duty entails a capacity to perform exercise without undue
evidence of fatigue, palpitation, breathlessness, giddiness,
Ac. Doubtful cases will occur, obscure symptoms will need
verification, and blood examinations, hemoglobin percentage,
visoosity, 01 cell counts may be called for. In general
tracings, polygraphic and elecbro-cardiographio, are not
helpful, but the manometric readings are of great service.
The blood-pressure variations in the fit and healthy are
nowadays clearly recognised, similarly, too, the range of
reflex adaptability of the heart and vessels. These self¬
regulating qualities are mainly concerned with the varying
adjustments in arterial output, contractile force, rate,
rhythm, and blood pressure. Effort of any kind reacts upon
the vascular mechanism in a perfectly definite fashion ; the
rate of heart beat is increased and, partly by reason of this,
partly owing to the diminution in area of the venous channels
by the contracted state of the muscles, the venous inflow is
increased; now we know that the arterial output is governed
by the venous input, and that, with a constant inflow, the
output tends to remain unaltered in spite of changes in heart
rate or blood pressure; exercise, however, increases the
venous inflow, and the heart muscle responds by contracting
more vigorously, at the same time raising directly the arterial
output and pressure—by so doing making provision for the
higher standard of nutrition which must be realised if effort
is to be satisfactorily maintained. This compensatory power
of the heart muscle is sufficient in the fit and healthy to cope
with all ordinary demands, but it has its limitations. The
muscle fibres possess an optimum of distension and a
maximum. If the latter be exceeded by excessive venous
inflow compensation fails and dilatation ensues. We are
able to estimate with some accuracy the cardiac com¬
pensatory power. Manometric readings furnish definite
facts. Both diastolic and systolic pressure need to be
recorded. The difference between the two (the pulse
pressure) indicates the actual driving power.
Result* of Exercise in Fit and Unfit.
The accompanying table is prepared from an analysis of
the charts of 20 patients and 20 controls. In the table are
set out the more salient details which assist us to dis¬
Age..
24
31
19
27
31
24
Subject resting—
Heart rate.
116
140
80
89
100
76
Respiration rate .
23
36
20
19
24
16
Diastolic B.P.
93
100
85
85
90
75
Systolic B.P..
126
140
100
122
140
110
On adoption of erect position—
Increase In heart rate.
22
30
14
9
12
4
One minute after effort test—
Heart rate.
136
160
120
101
112
80
Respiration rate .
34
48
28
a
32
16
Diastolic B.P...
99
110
95
85
90
80
Systolic B.P.
Five minutes after effort test—
140
160
120
133
145
iao
Heart rate.
128
148
100
88
100
76
Respiration rate .
29
40
24
19
22
16
Diastolic B.P.
96
100
90
85
90
75
Systolic B.P.
134
160
104
122
140
110
criminate between fitness and unfitness. The controls were
men whose physical state reached the normal standard, and
whose history was untainted by disease hereditary or acquired.
They include athletes, first-class footballers, professional
boxers, gymnasts, and others convalescent from wounds,
selected as really healthy subjects. The patients were all in
the early stage of functional heart disease, caused by modern
warfare. As is usual in these cases the symptoms far out¬
weighed the physical signs. The characteristic features of
debility and incompetence were present in varying degrees.
Anyone with even a moderate experience of soldiers suffer¬
ing from heart disorders rapidly realises how misleading are
the symptoms, when compared with careful observation and
with the reaction produced by ordinary effort. In practice
one finds it advantageous to note the main symptoms, and,
if possible, correlate them with the physical findings, and
blood-pressure tests. For example, a patient may complain of
shortness of breath, excessive throbbing, and palpitation,
pain and oppression in the chest, giddiness and faintness.
E x a mina tion reveals myocardial degeneration. In another
patient with identical symptoms physical examination elicits
nothing beyond possibly a mild tachycardia and a diminished
response to effort tests, slightly exaggerated blood pressure
reactions, but an entire absence of distress and the facial
expression typical of true cardiac incompetence.
For this and other reasons one approaches the subject of
“soldier’s heart’' in a most guarded and tactful manner.
At the outset of treatment one must gain the patient's con¬
fidence, if possible. During the cure one must devote the
maximum of attention both to the general bearing and
appearance during effort; and, equally important, to the
response on the part of the heart muscle. The practical
interpretation of the latter is impossible without a full and
complete appreciation of the capabilities of a normal heart.
SStrtrcral Satieties.
ROYAL SOCIETY OF MEDICINE.
SECTION OF OTOLOGY.
At the meeting of this section, held on March 21st, under
the presidency of Mr. Hugh Jones, Sir Thomas Wrightson
and Professor Arthur Keith gave an account of a new
theory of hearing.
A New Theory of Hearing.
Professor Keith explained that the theory was Sir Thomas
Wrightson’B; he himBelf was merely responsible for the
anatomical details of the inner ear. The theory had been
outlined in a presidential address given to the Cleveland
Institution of Engineers in 1876, but it had been quite over¬
shadowed by the glamour attached to the theory of Helmholtz.
In the Helmholtzian theory the internal ear was a sort of
microscopic piano furnished with resonating strings almost
ultramicrosoopic in size, and some 16,000 in number. Each
string or set of strings was supposed to pass into a state of
vibration when its sympathetic note entered the ear. Each
string or set of strings was supposed to have a corresponding
nerve fibre, and we roust suppose that these nerve fibres led
ultimately to a central nerve-cell station or exchange, where
16,000 nerve cells received messages from their correspond¬
ing ear strings. However satisfactory from the 'point of
view of a physicist, Helmholtz's theory from the standpoint
of the psychologist, the physiologist, or the anatomist was
an impossibility. The strings were there, but they were
so placed and so conditioned that the one thing they
could not do was to vibrate: Nature had taken the
utmost care to render individual vibration an im¬
possibility. In Sir Thomas Wrightson's theory, the ear
acted as a single machine; it was the most minute and
most delicately adjusted spring balance ever evolved, one
designed not only to weigh the simplest sound wave, but
also the most complex and voluminous. The ear not only
weighed every fluctuation in pressure, but automatically
registered and recorded the minutest variation through the
hair cells or semaphores which form an intrinsic part of the
machine. The system of messages or semaphorio signals
transmitted from the ear may be compared to the dot-and-
dash system of the Morse code; the whole of the organ of
Corti is involved in the production of the code of signals.
All the fibres of the auditory nerve are concerned in its
transmission from the ear to the brain. It was a legitimate
inference to suppose that the time signals carried on this
code could be deciphered and sorted out at nerve synapses
in the cerebral nervous system. Thus, Sir Thomas
Wrightson's theory brings hearing into line with smell,
taste, sight, and touch, whereas Helmholtz's theory, by
presupposing that each fibre in the auditory nerve has its
speoial function, breaks the most elementary law we know
regarding the nature of nerve conduction.
The Evolution of the Cochlea and Organ of Corti.
Recent advances in our knowledge of the evolution of the
internal ear throw a most definite light on the mechanism
of the cochlea and organ of Corti. The ear was evolved
from the balancing apparatus of the primitive labyrinth;
the principle which had been adopted by Nature in working
out the organ of hearing was merely an extension of the
principle used in the primitive labyrinth. In the lowest fishes
a closed vesicle on each side of the head, filled with fluid,
serves as the central part of the labyrinth. On its floor is
The Lancet,]
ROYAL SOCIETY OF MEDICINE: SECTION OF OTOLOGY.
[March 29,1919 511
a nest or island of cells; on the hairs is balanced an
otolith; nerve fibres commence in or around the hair cells.
So long as a fish swims on an even keel, the ciliary sema-
phoric system is at rest, but if it heels over ever so slightly,
then gravity comes into play; the otolith, as it answers to
gravity, bends the hairlets right or left, as the case may
be, and in bending the hairlets, sets np certain tensions or
changes in the living cells to which they are attached,
and these changes are transmitted as signals or
impulses along the attached nerves. In this simple
semaphoric apparatus there are four elements: (1) the
otolith or titillator, (2) the hairlet or lever on which the
titillator acts, (3) the sense cell on which the lever acts,
(4) the nerve fibres which are acted on, or stimulated by,
the sense cells.
In the sense organs or signal stations of the semicircular
canal 3 , which have been evolved for the registration of
body movements, we find the same four elements. The
cupola represents the titillator, but it is no longer acted
on by gravity, but by mass movements of fluid, set up in the
during movements of the head. B&rAny was the first
to show that movement of the fluid in one direction gave one
set of signals; movements in the reverse direction another
and reverse set of signals. With the evolution of the cochlea
and the organ of hearing the same four elements were used.
The titillator is the tectorial membrane ; the hairlets or
levers, the sense cells, and nerves are as before, save
that the sense cells are now set in an elastic scaffolding
of fine elastic rods and fibres. But one novel change
has been introduced: in the balancing apparatus of
the vestibule the sense cells are fixed: the titillator is
movable. In the ear Nature has reversed the arrangement
and set the sense cells on a movable membrane—the basilar
_a membrane which responds to every displacement of fluid
set up by waves of sound impinging on the inner ear. On
the other hand, the titillator is no longer free, but is tethered
to the containing wall. Thus, in the utricular system the
hairlets or levers were worked by gravity; in the c anal icular
system mass displacements of fluid set up by movements of
the head bent the levers and gave rise to signals. In the
cochlea the force employed in working the lever system was
the minute displacements set up by sound waves, and the
levers were bent by the field of hair cells working against
the titilator or tectorial membrane.
The Processes Underlying Hearing.
The essential modifications required to make the otic
vesicle into an organ of hearing are, first, a dosed vesicle
filled with fluid, and everywhere surrounded by bone of a
peculiarly dense nature—all except at one area, where a
minute window, the fenestra rotunda, is established. That
window is essential; without it there can be no mass dis¬
placement of the fluid, and no hearing as sound waves sweep
through the bony walls of the veside. In the passage lead¬
ing to that window is placed the organ of Gorti, the
apparatus for recording the displacements of fluid set up by
the bone-conducted sound waves. To make the ear a more
sensitive machine another window is established in the bony
wall of the veside—the fenestra ovalis—into which is fixed
a movable piston, the stapes. By a bent lever formed by
the ossicles of the ear this piston is yoked to the membrana
tympani, ancl thus the ear is rendered infinitely more sensi¬
tive to sound impulses carried by the air. Closure of the
fenestra ovalis by fixation of the stapes renders the ear more
sensitive to bone-conducted waves; closure of the fenestra
rotunda produces complete deafness. These facts cannot
be explained on the hypothesis put forward by Hdmholtz,
but find a complete answer in the new theory.
Four phases are to be recognised in the completed
movement of the lever or hairlet of a sense cell. Its upright
eft* vertical position may be regarded as one of rest, its zero
position. In the first phase of a complete movement the
hairlet bends towards one side, towards the right we shall
suppose; in the second it returns to its upright or zero
position; in the third it bends towards the left; in the fourth
it again returns to its starting position or zero. It is clear
that different conditions of tensions and pressures will be set
up within the hair cell in each of these four phases, and
each phase, we may postulate, gives rise to a nerve impulse
or signal. The signals set up will vary with the duration
and force of each hairlet movement. In each sound wave
Sir Thomas Wrightson recognises four corresponding phases.
Two of these lie in the part of the wave where the air
particles are being condensed—the part in which there is a
plus pressure; two of them lie in the part where the air
particles are being rarefied—where there is a minus pressure.
In Phase l. the pressure is rising}; in Phase II. the plus
pressure is falling; in Phase III. the minus pressure is
increasing ; in Phase IV. the minus pressure is decreasing.
Explanatory Value of the Nero Theory.
Sir Thomas Wrightson’s original discovery, announced in
1876, was the recognition of the fact that if it could be
supposed that each phase of sound wave did give rise to an
effective stimulus in the ear, then the brain was supplied,
through the ear, with a sufficiency of data to give a com¬
plete analysis of the most complex sound. Helmholtz had
supposed that such an analysis could be accomplished only
on the principle of resonance. Sir Thomas Wrightson
showed that there was an alternative method. That each
phase of a sound wave is effective in producing a most
distinctive movement of the auditory hairlets was a later
discovery, but formed a very essential part of Sir Thomas
Wrightson’s theory. It was a sequel to a neglected dis¬
covery of Sir William Bowman’s, made about the year
1846, that the basilar membrane is made up of two
parts, a striate zone and a hyaline zone, the latter
resembling the capsule of the lens in structure and in
staining reaction, and which must be regarded as elastic in
nature. Sir Thomas Wrightson has demonstrated that the
displacements which sound waves set up in the fluids within
the ear act against the elastic resistance of the basilar
membrane, and that thus each of the four phases of a sound
wave, which he had originally postulated on a theoretical
ground, do thereby become effective in producing a separate
and distinctive movement of the hairlets. In Professor
Keith's opinion the various parts of the cochlea, of the organ
of Oorti, and the conformation of the various liquid passages
of the ear which were left unaccounted for on Helmholtz's
theory, now received a satisfactory explanation.
Transmission of Pressure through the Cochlea.
Sir Thomas Wrightson said that from Professor Keith's
remarks no idea could be gathered as to how much is owing
to him in the presentation of this theory of hearing. As a
distinguished anatomist who understands every detail of the
parts involved, he grasped the idea that if a machine was
required to transmit the varying pressures of a sound wave
to the nerve terminations, that transmission must be of a
dead-beat character. In the cochlea this transmission,
according to the theory, is conveyed from the comparatively
large area of the outer drum on which this air pressure acts
through the bent levers of the ossicular chain to the smaller
area of the stapes. The stapes is about one-fifteenth the
area of the drum, so that, according to a principle well
known to hydraulic engineers, the unit pressure is increased
in the proportion of 1 to 16 in the cochlea, and a further
increase is effected by the leverages of the ossicles.
These increases in pressure imply a corresponding decrease
in displacement of the stapes. By the laws of equilibrium
in fluids, demonstrated 200 years ago by the distinguished
French philosopher Blaise Pascal, we are bound to admit
that every momentary change of unit pressure in the air
wave would be thus multiplied considerably in the liquid of
the cochlea between the stapes and the basilar membrane,
and these varying unit pressures are instantaneously carried
throughout the whole of the cochlea above the basilar
membrane. If two separate pistons are placed in a cylinder
with liquid entirely filling the space between them, pressure
on the left piston will be transmitted right through the
intervening fluid and move the second piston, exactly as
though a solid connexion existed between the pistons ; and
this is also true however the area of the passage between the
two pistons may vary, so long as the total space between the
two pistons is entirely occupied by fluid.
Hon the Transmission is Effected.
We shall see that the transmission of pressure through
the cochlea is effected sometimes by displacement of fluid,
sometimes by the action of levers, but the effective units of
work impinging on the drum membrane are all to be
accounted for on the bending of the hairlets or nerve
terminations, so that a dead-beat transmission of power
exists from drum to hairlet. The basilar membrane is
tapered in breadth from nil at the fenestral end to a
maximum at the heliootremal end. One-fourth of Its
breadth throughout its length of 35 mm. is highly elastic.
512 ThbLanobt,]
ROYAL SOCIETY OF MEDICINE : SECTION OF OTOLOGY.
[Marh 29,1919
while the remaining three-fourths of its breadth is inelastic
and rigid. The inelastic part is hinged along one of the
sloping sides of the tapered opening which forms the
frame of the whole membrane, and the elastic or
subarcuate zone is hinged on the opposite sloping side.
When, therefore, the pressure comes upon the whole
surface of the membrane, a triangular prism of liquid
is displaced which at each moment is exactly equal
to the displacement of the stapes. To the inner edge
of the pectinate or rigid zone are attached the inner
legs of the Corti arches, and as the outer legs rest as
a pivot upon the sloping edge of the tapered aperture to
which the elastic zone is also attached, the up-and-down
motion of the membrane causes the apex of the Corti arch
to move transversely to and fro. As the pressure—and
therefore the motion—is nil at the fenestral end no motion
is transmitted at that point, but as the arches approach
nearer the helicotremal end of the basilar membrane, the
pressure and displacement, and therefore the transverse
motion, of the apices of the arches increase to a maximum at
the helicotrema. The whole of this up-and-down motion
of the basilar membrane is carried into the bent levers of the
Corti arches, where it is once more carried through rigid
levers. From the apex of the Corti arches the pressures pass
into the reticular membrane which carries the hairlets. The
upper ends of the hairlets penetrate the surface of the
tootorium, and the to-and-fro transverse motion of the
reticular membrane causes a bending of the hairlets, and
such bending will be in proportion to the reactionary
pressure at the tip of the hairlet resting in the tectorium.
The basilar membrane being 13 times the area of the stapes,
the total pressure will be, at each moment of time, 13 times
that on the stapes, according to Pascal’s law, but this
pressure and displacement divides itself, as explained, from
nil to maximum over the whole length of the basilar
membrane, and the bending of each elastic hairlet is the
measure of the pressure between its end and its contact
with the tectorium, according to its position in the whole
length of the basilar membrane.
Rmiltant Curvet of Preuure.
Sir Thomas Wrightson also pointed out how the resistance
of the elastic portion of the subarcuate zone and of the
deflecting hairlets and other portions of bending solids in
the cochlea act in accordance with the laws of elastic solids,
as demonstrated about 200 years ago by our great scientist
Robert Hooke. The difference between the pressure of the
sine wave and that of the combined Hooke resistances causes
a change in the residual curves and introduces indica¬
tions of fresh impulses in the four phases of the sine curve.
Diagrams were shown of the resultant curves of pressure
in the liquid of the cochlea, and in these the time positions
of the impulses were seen to coincide not only with the well-
known time positions of the simple gine wave forms, but of
compounded tones, where the time positions of the differ¬
ential tones, the summational tones, the octaves, and other
harmonics are revealed, all being confirmatory of the theory.
The residual time pressure represented by the final liquid
curve has to reach the brain by some process, and the
weaker suggested that this might be explained by assuming
a*nerve current always passing through the point where the
hairlets and tectorium meet. Professor Hughes’s great dis¬
covery of the action of the microphone—in which, where an
electric current was passing through a circuit in which a
slender point of contact was subjected to the varying
pressures of a sound wave, the sound wave was transformed
into an electric wave, which, after passing through a
telephone wire to a receiving telephone, could there be re¬
converted into a sound wave—such a condition is, perhaps,
worthy the consideration of physiologists as a means of
carrying the wave form to the brain. The means by which
such transmission rises into consciousness, God alone knows.
Disomtion.
The Prbsidbnt, in inviting discussion, said he did not
feel clear as to the explanation of bone conduction on the
new theory. The fact of the stapes being quite fixed, and
possibly the foramen rotundum also, would presumably
oonvert the canal walls into a rigid inelastic structure, and
it was difficult to see how the suggested mechanism acted
when stimulation was through bone conduction.
Sir R. H. Woods thought the theory fitted in with what had
been known anatomically for a long time. He did not think
the question of bone conduction need present much diffi¬
culty. If bones were in a state of vibration they must
agitate the internal nervous mechanism and shake up the
intracochlear fluids, and so there must be some movement
between the hair cells and the organ of Gorti.
Professor Kbith said that in certain conditions whioh
fixed the stapes, or when the drum was perforated, there was
often quite considerable hearing when pressure was put on
the stapes to keep it fixed. Helmholtz’s theory gave no
explanation of that.
Professor Albbrt A. Gray (Glasgow) said it was common,
in regard to all theories, to speak of the labyrinth as a
closed cavity, but in some animals it was far from being a
closed cavity. The present theory also assumed the same
thing, but he did not think the assumption was justified.
He had difficulty in accepting this theory from the stand¬
point of the physiologist also. The Helmholtz theory oould
not be right, but it might be modified. By the new theory
as now propounded people were asked to believe that
nerve fibres could transmit sound vibrations varying in rate
from 30 to 30,000 per second, and transmit them without
fusion with a very accurate perception of pitch, especially
in the middle range. This meant that they passed through
the various media without interruption and the brain
analysed them out. And what must be said when the
skilled ear was able to analyse several simple tones com¬
pounded together ? He did not think this marvellous
power of sound analysis could be located in the brain ; it
was more likely to reside in the cochlea. There was still
much to be learned about nerve conduction.
Mr. Sydney R.: Scott, after discussing the new theory in
detail, said he had a case in which the patient had lost
perception of low tones, and suffered from tinnitus. He
operated on the middle ear in the hope of destroying the
tinnitus, and found the stapes absolutely normal, as well as
the malleus and incus and the drum. The stapes came out
perfectly, yet the Weber and Rhine tests indicated what was
termed fixation of the stapes. He oould not see whether os
not the round window was closed ; but in some such ca s es
the round window would be found to be ossified.
Mr. Richard Lake expressed surprise that no one had
referred to the ossicular chain as an accommodating mechanism
in the conveyance of sound. But good hearing was possible
without that chain. In America the stapes was removed in a
number of cases, and the hearing was often improved after¬
wards. He believed the ossicular chain was intended partly
for protection, and partly as an accommodating medium, so.
that shock due to a sudden loud noise was prevented from
damaging the vestibule. The drum was not important for
hearing, but it kept the middle ear moist, so that sound waves
could pass through well.
Dr. W. Hill asked whether otologists were to believe
that the labyrinth was of no use as an analysing organ. And
surely the cochlea was as much a functioning apparatus in
this theory as in that of Helmholtz. He had held the view
that part of the hearing function not only was conducted
through the ossicles, but aerial conduction across the
tympanum to the membrana secundaria, and that seemed
to stand in the way of acceptance of any theory which had.
been advanced up to the present time.
Dr. Dundas Grant said one of the difficulties he had felt
in regard to the Helmholtz theory was in trying to see the
wave running up the scala vestibuli, round the helicotrema,
and down the scala tympani again, whereas a movement
must have taken place at the base of the cochlea long before
that. The fact that the pressure was equalised all the way
up owing to the membrane being wider at the part where the
pressure of the fluid had become almost extinguished was
a basis of truth likely to stand for all time.
The discussion was continued by Mr. JBNKINS, Mr. W.
Stuart-L ow, and the President.
Sir Thomas Wrightson, in the course of his reply,
reminded members that the middle ear was connected with
the air through the medium of the Eustachian tube. When
the drum moved inwards that must make a difference in the
motion getting through to the hairlets: the connexion was
through solids which were articulated together. With regard
to the difficulty as to the analysis of compound sounds, one
had only to remember the analogy of the telephone wire,
through which every tonal character of the speaker’s voice
was easily recognised by the receiving ear.
Cases were shown. • j
Thb Lancet,]
REVIEWS AND N0TI0E8 OF BOOKS.
[March 29, 1919 513
|Ubitfau stir Static# at Joaks.
Physiology and Biochemistry in Modem Medicine. By
J. J. R. Macleod, M.B., Professor of Physiology in the
University of Toronto, Canada, formerly Professor of
Physiology, Western Reserve University, Cleveland,
U.S.A., assisted by Rot G. Pearce, B.A., M.D., and
Others. London: Henry Kimpton. 1918. Pp. 903. 37*. 6d.
■ Thb principal advances in modern physiology have been
made by the application of chemistry and physios to the
study of vital phenomena. This may be the reason for the
inclusion of the term biochemistry in the title, for the
volume before ns deals with the chemistry and physios of
physiology and omits histology and the usual description of
the central nervous system, those portions of the subject
which in the opinion of many belong to anatomy.
The book is divided into nine parts. Part 1 is a summary
of those portions of physical chemistry intimately related to
physiology. This subject to most readers is difficult, and
possibly might well be slightly enlarged in a future edition.
We find that not only in this part, but also elsewhere, is
there a short description of experiments, a description quite
insufficient for practical work, and, moreover, not enough to
make the problem clear. It would be better to exclude
these entirely and use the space for amplification of the
theory. An elimination of the description of the chemical
formulas would also save space. The structural formulas of
the substances should be a sufficient reminder to the student,
who nowadays is usually well instructed in organic chemistry
and should understand how the formulas are built up.
Parts 2 and 3 are on blood and its circulation. The final
chapter of this part is on shock, the main symptom of which
is a pronounced lowering of the blood pressure. As Bayliss
has pointed out in his book on 44 wound shock,” the cause
here is partly nervous and partly chemical, and the shock is
exaggerated by hasmorrhage. He has shown experimentally
that the blood pressure can be effectively raised by the
injection of gum solution ; in this way proper circulation is
maintained, so that toxic products arising from damaged
tissue are oxidised and exoreted; a free supply of oxygen also
prevents damage to the nervous system. Professor Macleod’s
book mentions the injection of gum solution to raise the
blood pressure, and this is an example of the care he has
taken to produce a book which is really up to date, as well as
to show the value of physiological research in its application
to medicine. Part 4 is on respiration. Mention is herein
made of recent work on the transportation of carbon dioxide.
Though the bulk of the carbon dioxide is contained in the
plasma as carbonate it appears that the exchange of the gas
is effected by haemoglobin (G. A. Buck master).
Parts 5, 6, and 7 are concerned with digestion, excretion
of urine, and metabolism. Under metabolism we read of
the independent value of the several units composing the
protein molecule. The value of lysine for the growth of
young animals is fully appreciated ; this unit is fortunately
present in abundance in lact-albumin. The problem of
accessory food substances is also well described. We think
that too much stress has been laid upon the work of
American investigators. The results of British workers are
not sufficiently mentioned, and they are of far-reaching
importance. The symptoms of beri-beri can be eliminated
and prevented by the addition of yeast extracts to the food.
The symptoms of sourvy are removed and prevented by the
addition of orange and lemon juice, swede juice, and
germinated peas, and are not prevented by the popular
lime juice and grape juice. The antiscorbutic value of fresh,
unboiled milk as described by the author is confirmed by the
reoent British experimental evidence from monkeys. Part 8
treats of the endocrine organs, one of the most interesting
sections of the book. The best known of these internal
secretions is that of the adrenal gland. The active substanoe
wasisolatecTlong ago, and we read that so small an amount as
0*00008 mg. per kilo, of bodyweight will produce a distinot
rise in arterial blood pressure. Snoh figures should encourage
chemists to attempt the isolation of the active substance in
the other endocrine organs and to prooeed to the toxins pro¬
duced by bacteria, although smaller doses than the above
appear to produce the specific toxic effect. They are tangible
quantities, but it will mean working with kilos, of dried
bacteria!
The last part describes the modern researches on the
central nervous system. The whole most certainly brings
out the varied aspects of modern physiology, and connects
them to clinical observation, a valuable adjunct to a text¬
book of physiology. Both student and clinician will find the
book extremely helpful, and it should command a wide circle
of readers. But the price is excessive even in these days of
difficulty and will prevent many from learning the dose
connexion between physiology and medicine as it has been so
clearly presented by Professor Macleod.
The Early Treatment of War Woundi. By Colonel H. M. W.
Gray, F.R.C.S. London: Henry Frowde and Hodder
and Stoughton. 1919. Pp. 299. 10*.
This book is replete with sound, general principles,
set down by one who, as a consultant surgeon in France
for three and a half years, has had great opportunities of
coordinating his ideas and seeing that they have been
carried out. It is very interesting to find in print those
principles which have led to tha well-earned reputation of
the author as a war surgeon.
The book commences with a sketch of the method of
dealing with wounded men in the advanced units, and in the
main describes how to deal with the condition of shock from
various causes, and insists on the desirability of dealing with
this prior to transference to units farther behind the linp.
It passes on to describe the treatment of cases in the
C.C.S. during the pre-inflammatory stage, and especially in
an excellent chapter deals with the question of secondary
shock. A short discussion on the use of various antiseptics
is given, with special reference to the salt-pack treatment,
which was first instituted by the author in France. The
remainder of the book deals with the general principles of
the treatment of wounds, first as a whole, and later in
sections. One notable omission is the treatment of abdo¬
minal wounds, for which the author refers the reader to
other authors. Had this book appeared two years ago it
would, no doubt, have had a wide circulation and have
proved of immense value to those working in the field,
whereas now it will mainly serve as an excellent record and
as a guide to general principles of treatment, many of which
can be applied to civilian surgery.
Lenzmann's Manual of Emergencies , Medical , Surgical , and
Obstetric: Their Pathology , Diagnosis, and Treatment. By
J. Snowman, M.D. Brux., M.R.C.P. Loud. London : John
Bale, Sons, ancUDsnlelsson, Ltd. 1919. Pp. 345. 15*.
Thb present manual is based upon the English edition of
Lenzrnann’s 44 Emergencies in Medical Practice,” which
appeared in 1914. This work dealt with the diagnosis,
pathology, and treatment of dangerous emergencies which
suddenly threaten life. It therefore expressly excluded such
injuries as fractures, dislocations, and other morbid con¬
ditions not in themselves dangerous to life. Lenzmann’s
excellent scheme has been closely followed by the present
writer, but the text itself has been entirely re-written and
the subject matter revised so extensively that the manual
may fairly claim to be a new work, representative of the
teaching of standard British authorities on medical, surgical,
and obstetric emergencies.
The book is composed of seven sections, dealing
respectively with dangerous emergencies arising in con¬
nexion with diseases of the respiratory, circulatory, and
nervous systems, with the digestive and urinary tracts, and
with midwifery practice and poisoning. To take, for further
example, one system in detail—the circulatory—the following
are the conditions dealt with: cardiac asthma, syncopal
attacks, auricular fibrillation, angina pectoris, toxic in¬
fection of the heart, rupture of the heart, wounds of the
heart, and acute pericardial effusion.
The trend of the book is eminently practical, and what is
more the practice advocated is based upon sound principles.
Constant reference is made to anatomical, physiological,
and pathological facts in elaborating the treatment of the
particular 44 emergency” under consideration. The book is
adapted to the needs of the general practitioner, and it would
be difficult to find one of greater use to the man who has
reoently qualified or who is holding a resident appointment.
It is written in an easy and pleasant manner, and what
especially commends itself to us is the absence of vagueness
in the sections concerned with treatment. The author is not
likely to fail one at the critical moment. All the necessary
514 The Lancet,]
NEW INVENTIONS.
[March 29, 1919
directions for carrying out the treatment which he recom¬
mends are supplied, and there are few directions which are
not well within the scope of the general practitioner’s
means.
i( t One of the most interesting sections is that devoted to
infantile convulsions, where the recent conception of the
part played by calcium in the body metabolism receives
due notice. Experiment has shown that the irritability of
the cerebral cortex is greater when the calcium content of
the blood is low than when it is high. It is also known
that removal of the parathyroid glands in animals is
followed by lowering of the calcium content of the blood
and by the convulsions of tetany. It is suggested, therefore,
that certain toxaemias such as occur * in rickets may produce
parathyroid insufficiency and an abnormal calcium metabolism
and thus predispose to convulsions.
An excellent chapter deals with the practical side of
serum sickness and the prevention of anaphylactic pheno¬
mena. The book is printed in good type, and there is a full
index.
Essentials of Medical Electricity. By Elkin P. Cumber-
batch, M.A., B.M., B.Ch. Oxon., M.R.C.P., in charge of
the Electrical Department, St. Bartholomew’s Hospital,
&c. Fourth edition. London: Henry Kimpton. 1919.
Pp. 368. Is. 6d.
That this volume has met a decided want in a satisfactory
manner is proved by the appearance of this, the fourth,
edition. The whole subject of the medical and surgical use
of electricity has received a great impetus during the war,
with the result that it is in a state of flux, and what may be
thought true to-day will not be necessarily the truth of
to-morrow. This edition has been thoroughly revised and
many parts rewritten, particularly the chapter on the elec¬
trical testing of the reactions of muscles and nerves. The
physiological and pathological principles underlying this
matter are fully dealt with, and some additional notes on
the use of condensers have been added. Further experience
in the applications of diathermy has enabled the author to
give a more complete account of the value of this important
agent in medicine and surgery.
Recent additions to the electro-therapeutist’s equipment,
such as the Tripier coil, the water rheostat, the latest forms
of high-frequency apparatus, and many others are described.
These, with other minor additions, bring the book up to date
as far as is humanly possible.
The Examination of Milk for Public Health Purposes. By
Joseph Race, F.I.C., City Bacteriologist and Food
Examiner, Ottawa, &c. First edition. London:
Chapman and Hall, Ltd. ; New York: John Wiley and
Sons. 1918. Pp. 224. 8 s. 6 d. net.
This book has been written as a practical guide for those
engaged in the chemical and bacteriological examination of
milk for public health purposes. It is, perhaps, more
detailed than the ordinary student will require, but will be
found valuable to those who are interested in the production
and control of milk. A full description is given of milk and
its constituents ; a chapter is devoted to the consideration of
the normal composition of milk, and the influence on it of
suoh factors as the breed of the cows, the various types of
food, season, the interval between the milkings, and the
stage of lactation. Milk standards are discussed, the author
holding the opinion very strongly that milk should comply
to a definite standard and not be regarded as 4 * the secretion
of cows, without additions or abstraction,” as in the latter
case a premium is placed on quantity regardless of quality,
and encourages the breeding of cattle secreting large
quantities of milk of a comparatively poor quality.
“In both the United States and Canada milk standards are of an
entirely different nature to those obtaining in Great Britain; the
mlnlmnm limits of composition are olearly defined by ordinance or
statute, and admit of no appeal to the cow. These standards are to be
regarded as specifications of what is required to be sold as milk and not
the minimum quality that might reasonably be expected by the
purchaser. This is equitable, as the purchaser, for a given price,
should receive an article of definite quality and not something that
may be the minimum quality produced by natural variations. To
achieve this, the dairyman must so grade his herd that the mixed milk
will at aU times comply with the standard.”
A full account is given of methods of chemical examina¬
tion ; the question of bacteria in milk is discussed, and the
sources of contamination, both intra- and extra-mammary;
contaminating organisms are described, together with the
methods employed for isolating them ; the influence of
various factors, such as bodily cleanliness, housing, litter,
feeding before or after milking, thoroughly stripping the
udder, &c., on the bacterial count is treated fully, and many
useful tables are given to illustrate the facts which are
brought forward. Now that the standardisation of milk is
so much in the mind of everybody, this volume will be
found useful in supplying a clear account of what milk is
and ought to be. An excellent bibliography is added to
each chapter.
Sanitation in War. By P. S. Lelean, C.B., F.R.C.S.,
F.C.S., D.P.H., Lieutenant-Colonel R.A.M.C., Assistant
Professor of Hygiene, Royal Army Medical College.
With an Introduction by Surgeon-General Sir Alfred
Keogh, G.C.B., M.D., F.R.C.P. Third edition. 1919.
London : J. and A. Churchill. Pp. 368. Is. 6 d.
The third edition of this admirable manual has been
prepared by Professor Lelean while on active service in
Palestine. We call attention again to the brief but com¬
plete account which he gives of the causes of sickness
in the Army, together with the means of prevention,
including descriptions both of the older methods of disinfect¬
ing and of those evolved during the present campaign.
The Thresh apparatus is figured alongside the 44 Field
Sterilising-box ” and the 44 Serbian Barrel,” and the scheme
for using these barrels for de-lousing of units is detailed, as
also the use of the boiler-and-sack de-lousing apparatus and
the disinfesting train. The role of insects in war is fully and
practically handled, and protective measures against fly-borne
infection and anti-vermin measures are duly set out. The
chapter on Conservancy in the Field is of particular value ;
the various means for the disposal of refuse are con¬
sidered, and the several types of destructors are included.
Chapter VIII. is nearly entirely devoted to illustrated
descriptions of a number of sanitary innovations evolved
during the last four years, including latrines, incinerators,
de-lousing apparatus, camp kitchens, and improvised cold
storage; the examination of water and its purification by
means of sterilisers, filtration, or by chemical means, are
fully described. The whole makes an essential sanitary
handbook.
Jfefo Indentions.
A URETHRAL NOZZLE.
The accompanying illustration shows a nickel urethra 1
nozzle which I have designed in order to overcome certain
defects that appear to me to occur in existing models. It
consists of a nozzle and shield in one piece which plugs on to
the stem containing a stopcock on its shank. Nozzles which
consist of a single piece are, after sterilisation, liable to be
soiled in fitting them to the tube. In my model the front
portion, after sterilisation by boiling, is picked up with a
square of sterile lint and fits snugly and very easily on to
the stem. Undesirable handling is thus reduced to a
minimum. Extra front portions may be purchased to fit the
stem for use in busy out-patient departments. The stem
portion is kept attached to the tube of the irrigator and
when not in use these lie in an antiseptic bath. The instru¬
ment has a bore of good size throughout to allow of sufficient
flushing. The bevelled anterior end of the stem is so shaped
that it can be used to fit the funnel-shaped extremity of a
rubber or gum-elastic catheter, and is thus very useful for
bladder washing.
The instrument has been made for me by Messrs. Allen
and Hanburys, 48, Wigmore-street, London, W., to whom
my thanks are due for carefully carrying out my instructions.
James B. Maoalpinb,
Hon. Surgeon, Salford Royal Hospital; Surgeon in Charge
of Genito-Urlnary Department, Salford Royal Hospital.
TO LltNOBT*]
THE POSITION OF THE DEMOBILISED PRACTITIONER.
[March 29,1919 515
THE LANCET.
LONDON: SATURDAY, MARCH 99, 1919.
The Position of the Demobilised
Practitioner.
Until a week ago the demobilisation of civilian
doctors from the Royal Army Medical Corps was
directed by the Minister of National Service on the
lines of a priority scheme drawn up by the Central
Medical War Committee. This scheme took into
careful consideration the interests of the candidate
in regard to length of service and the claims of his
practice and financial position. In the last few
days the pace of demobilisation has been speeded
np to such an extent that all these niceties have
gone by the board, and, as will be seen in another
column, the Central Medical War Committee has
laid down its advisory function in demobilisation.
This being so, we would draw attention again to
the letter which appeared in The Lanoet of
March 15th, signed by Dr. Norman Moore, the
President of the Royal College of Physicians of
London, and Sir George Marins, the President of
the Royal College of Surgeons of England, in which
it was pointed out that certain of the conditions
arising in the course of demobilisation have not
received sufficient attention from the authorities.
For it is a fact that the status and prospects
of the medical practitioners who have been
serving abroad have attracted slight considera¬
tion in spite of the activities of the Central
Medical War Committee and of its Committee of
Reference, formed from the English Royal Cor¬
porations. These statutory committees made the
best temporary arrangements which they could to
preserve, while the war was on, the interests
of practitioners who had been called to the service
of the country abroad. Their work is now
honourably ended, and yet the future of many of
the men whose interests they have protected is
precarious.
The medical profession as a whole resents the fact
that this should be, and the representations of Dr.
Norman Moore and Sir George Marins have been
clearly designed to arouse the public conscience to
the position. They point out that the medical men
who have been working at home have generally
behaved with the utmost fidelity to those who have
been called away, and we believe it is a fact
that the majority of the medical men who
remained in the country conformed to the
various plans that were suggested for the main¬
tenance of the interests of their colleagues abroad.
Cases there have been where the man at home has
not played so generous a part, but their number
has been exaggerated; and even when they have
occurred the fault has primarily lain with the
public, who were quite unable to see that by
exercising their right to a choice of doctor in too
strict a manner they might be severely injuring
men who were fighting the cause of the country on
foreign soils. The difficulties attendant upon
dividing up into their original constituent parts
practices that have become conglomerated, and
that have changed in environment and per¬
sonnel, are many and obvious. During four and
a half years of war many patients have died
and many have been born, while small neigh¬
bourhoods have become very large and large
neighbourhoods have shrunk. Houses are empty
that were overfull; houses are sought for where no
such accommodation exists; so that there is no
return to a general pattern in correspondence
with which a division of existing practices can be
made in any strict manner. For these reasons it is
obvious that the future position of the demobilised
practitioner can only be ensured by a public com¬
prehension of the conditions. Public bodies may
be trusted to reinstate, as far as possible to their
former posts, the medical officers who before the
war held appointments in their service; but it is
essential that the public should aid the demobilised
practitioners by the promotion of a general feeling
that their former patients should continue to call
them in; and it may be pointed out that in most
instances those who have served with the forces
are returning with an enlarged experience, a
broader outlook, and a more intimate knowledge of
men and manners—qualities which are likely to be
of great value to their patients.
Simultaneously Sir Robert Philip, President of
the Royal College of Physicians of Edinburgh, and
Mr. R. McKenzie Johnston, President of the
analogous College of Surgeons, drew attention in
these columns to the problems of demobilisa-
tioh as they affect the general practitioner of
medicine, and they too ask for sympathetic con¬
sideration from the general public.
** Many doctors,’ 1 they say, “ who throughout the war have
held commissions in the Navy, the Army, or the Air Force
have now to faoe the question of return to civil practice.
This is for them far from an easy matter. The natural
growth of their practices has ceased during their absence.
In spite of loyal help given, in most oases, by their oolleagues
—who deserve all thanks for their ungrudging efforts—and
by professional committees, to hold together the praotioe
in the interest of the absentee, the normal wastage due
to deaths, changes of residence, &o.« has had the effect of
materially reducing the practice from what it was in 1914.
Beyond such unavoidable influences there is risk of curtail¬
ment from other causes."
The Scottish Presidents further make the good
point that in a profession like medicine, where the
work is essentially personal, the future of the
demobilised medical men must depend on the
attitude of the general public; and they would
have the public interpret this personal feeling
rather less narrowly than is expressed by tEb
admitted right of the public to employ whatever
doctor they choose. Where the personal relations
of the patient to his medical man were, before the
war, of the properly trustful and confidential sort*
the patient should be ready—indeed, should feel it
an honourable duty—to return to his old adviser,
whose absence from his practice has been at the
call of the country. It is true that in the mean¬
time similar pleasant relations may have arisen
between the patient and the medical man acting on
behalf of his absent brother; but while the sub¬
stitute doctor is ready with all loyalty to hand over
the patients to their former adviser, the delicate
task of transference will be enormously simplified
if the public acquires the feeling that such trans¬
ference is right.
516 The Lancet,]
IMMUNITY: A FURTHER ADVANCE.
[March 29 ,1919
Immunity: A Further Advance.
This week we publish a notable contribution by
Sir Almboth Wright and his collaborators con¬
cerning the methods and reinforcements of the
wonderful bodily mechanisms of defence against
germ invasion. Sir Almboth Wright dealB
meticulously with the details of these mechanisms
and illustrates them characteristically by ingenious
experiments of extreme simplicity. The war has
taught us lessons in immunity and the writer
induces therefrom much which experienced workers
in vaccine therapy have long noted empirically and
only subconsciously attempted to explain, and the
view-point always to be upheld is that of Tennyson
when he wrote: “ ’Tis better to fight for the good
than rail at the ill.” Sir Almboth Wright very
clearly condemns those who illogically expect
indiscriminate magic at the hands of the con¬
structive bacteriologist.
This lecture, delivered at the Royal Society of
Medicine, opens with the hardly accepted assertion
that “ if the surgeon provides the necessary condi¬
tions the protective mechanism of the body can,
without any antiseptics (the italics are ours), deal
successfully with every kind of infection.” This is
followed by the second axiom to the effect that “ in
connexion with antityphoid inoculation the signal
success of the procedure has made it manifest to
everybody that the natural powers of resistance of
the human body can be signally reinforced by inocu¬
lation.” One of the corollaries which follow from
these axioms was illustrated by Pasteur when he
showed that vaccination during the incubation
period of rabies can be effective despite the already
existing infection. But, as Wright continues,
“it was in everybody’s mind that immunisation
took ten days to establish itself”; yet he has
shown that protective substances in antityphoid
inoculation are formed much earlier than this.
Moreover, one region of the body may be making
immunising response while the other is inactive,
as in the incubation period of infective disease.
Bearing these principles in mind, the lecturer
proceeds briefly to review the results, good and ill,
of vaccines generally, and he lays special stress
upon the excellence of streptococcal vaccines and
also upon tuberculin (called by some “ the mother
and the father of vaccines,” by others “a poison
pure and simple ”) in certain joint conditions and
also in phlyctenular conjunctivitis. Three reasons
for the failure of vaccines are clearly denominated.
First, when the infection, as in phthisis, is pro¬
ducing steady toxsemia; secondly, where pent-up
pus or gross necrosis obtains unremoved; and,
thirdly, where the infection is long standing. It
is well to have clear statements like these to guide
us, although some would perhaps prefer to qualify
them. The lecturer emphasised the extreme import¬
ance of the transport of leucocytes and antibodies to
the site of infection (kata-phylaxis), yet when this
transport breaks down, as it may, and the alkalinity
**#f the lymph is blunted by acid metabolism, even
microbes like the gas-gangrene bacilli may flourish
unopposed, though ordinarily they grow with
immense difficulty in the blood. Reinforcement,
as by leucocytosis, is named “ epi-phylaxis ”; our
old friend “ the negative phase,” which we had
rashly thought to be as extinct as the dodo,
revives, like the phesnix, from the fire of controversy
and becomes the “ apo-phylactic phase.” An “ ec*
phylactic region ” occurs where a strong focus of
infection entrenches itself and defends itself by
radiating toxins, and so on. We are aptly
reminded that leucocytes “ can only crawl
along surfaces and creep along the trellis-work
of the tissues ” and hence we may induoe
their impotency when drowned in an effusion.
Through all this we can now see why preventive
inoculation, unhindered as it is by all these
antagonisms, is so successful, and also we note
the probability that curative inoculation is likely
to be no easy matter. Sir Almboth Wright does not
add that this may incline the medical man to lean
more to serums, but this point seems borne upon
us. Vaccine therapy will less frequently make ship¬
wreck through default of epi-phylaxis than through
deficient kata-phylaxis, as with an unopened abscess.
The surgeon’s responsibility is made plain by the
laws of nature ! Flooding with fresh lymph, pre¬
ferably drawn in by hypertonic saline, is preferable
to cupping for mechanical reasons. Massage is
of little use in such circumstances. Hypo¬
chlorites benefit only in virtue of the hyper-
cBmia they produce, as the Germans hold,
and are not too trustworthy. Hot fomenta¬
tions and passive congestion are more logical as
common aids to our hand. In relation to wounds,
Wright shows that by neutralising the acid
metabolites with wholesome blood the organisms
can be reduced to a few aerobic types (serophytes),
which are incidentally eminently amenable to leuco¬
cytosis, and therefore to vaccine therapy. Leuco¬
cytes, we are told, can radiate their lethal powers
to a distance under proper conditions (telergic
action).
Sir almboth Wright has a gift envied by the
playwright—his last act is as good as, or better
than, the rest of the play. In the latter part
of his lecture some most novel and arresting
experiments are detailed and deductions advanced.
These constitute an immense assistance to our
better understanding of immunity. In relation
to wounds the lecturer shows that as the result
of inoculation the ant&ryptic power of the blood
is collaterally increased, and thus the hardy sero¬
phytes can be eliminated. Within even two minutes
of giving a vaccine a rabbit developed marked bac¬
tericidal powers in its blood which, however, sub¬
sided completely in 48 hours as regards the blood,
but left the subcutaneous lymph with antiseptic pro¬
perties. An overdose of vaccine, as we should expect,
produced a definite lowering of bactericidal power,
and this is why dabbling in vaccines is so dan¬
gerous. Benefit from vacoines is additionally
non-specific. Dr. Leonard Colebrook shows that
even a foreign body such as lint, when sterile,
will produce an antiseptic zone. These remarkable
results were reproduced in the test-tube, and as a
logical sequence in a very chronic and severe case
of streptococcal necrosis, a donor’s blood was
immunised in vitro by an autogenous vaccine from
the case and then the serum was separated and
transfused with immediate therapeutic success.
This process Wright calls “ immuno-transfusion.”
The vaccine added to the serum in vitro
was graduated to body-fluid-weight in order
to secure the optimum result. The prospects
opened up are most promising. In the future
we may be able thus to secure the optimum
vaccine and its dosage by simple laboratory
tests, and in the event of the failure of auto¬
genous vaccines we are encouraged to try less
homologous strains. Numerous examples of the
success, prophylactic and curative, of non-specific
vaccination, such as the protection against malaria
MEDICAL BBSBABCH AND ITS PLACE IN THE STATE.
[March 29,1919 517
The Lancet,]
conferred by antityphoid inoculation, are quoted, not
forgetting the classical example of cow-pox vaccine
Hence it is not too much to say that this latest
contribution to our knowledge of therapeutic
immunity is immensely valuable, and the profession
‘“"increasing debt to the brilliant pioneers
nf h vaccine therapy led by Sit Almroth Wbi
T neTGfTxvw, q4,^qo 1 of constructive bact*** 010 ^
deserved well or ilh cutmiry.
has
Medical Research and its Place in
the State.
Discussion has arisen inside and outside Parlia¬
ment as to the position of research in relation to
the Ministry of Health. The Medical Research
Committee, set up in 1911 by Mr. Lloyd George
as an integral part of a complete system of National
Health Insurance, had no more than felt its feet
when the claims of the war diverted its activities
into other channels. The last five years have
witnessed an increasing estrangement of insurance
research from insurance practice, for which regret
has been expressed in each successive annual
report. The Committee has in the meantime
become responsible for a vast field of research
in connexion with matters arising indeed out of
the war, though in many cases the connexion
existed because war acted as a stimulus to a torpid
hygienic conscience and made the impossible
capable of realisation. The Ministry of Health
Bill proposes to make the estrangement into a
decree absolute of divorce—at any rate if there
are no words excluding medical research from
the activities of the Ministry of Health, there
are no words which contemplate the support of
medical research. The Bill, as drafted, separates
the Research Committee permanently from the
Insurance Commission so soon as the latter is
taken up into the Ministry, of Health, and places
medical research under ttie aegis of the Privy
Council, which already controls, in name at least,
medical education and medical discipline. In a
memorandum issued as a Parliamentary paper last |
week by Dr. Addison, to which Sir Walter
Fletcher contributes a technical appendix, the
separation of research from a Ministry of Health
and its attachment to a central administrative
department is justified on the ground that research
knows no territorial boundaries and that medical
investigation should be in close association with
other scientific and with industrial investigations.
The Privy Council already has its Advisory
Council for Scientific and Industrial Research, and
experience has shown that incidental discoveries
often arise in pursuit of the main objects of a
particular research which need to be brought to
the notice of other interested departments. The
non-medical work of Rontgen, it is pointed
out, gave X rays to medicine, and Pasteur's
classical experiments in crystallography led to the
discovery of fermentation, and thence to the con¬
ception of bacterial action, which is the basis of
half modern pathology. Certainly to outward
seeming ad hoc research in cancer has not led to
dazzling results. All these things, and many others
which will occur to the minds of our readers,
prove $he value of a Medical Research Committee
working on general or—if we prefer the adjective—
Imperial lines, but they do not remove the need
for medical research as inspiration, check, and
guide to the maintenance of national health under
the Ministry of Health.
Within Parliament Sir Philip Magnus and the
three representative medical Members who followed
him in the recent discussion on the Ministry of
Health Bill, were urgent in their desire to keep
the Research Committee in association with the
Ministry of Health. Their arguments were un¬
assailable and to some extent prevailed. It can
evidently be nothing short of a calamity if, just
when the time and labour spent on furthering the
public health are no longer to be dissipated by
incoordination and overlapping, research is to be
excluded on principle, or even by implication, from
the coordinating authority. The exclusion would,
rightly or wrongly, be taken as a slap in the
face to scientific medicine. In the event of a great
epidemic the Ministry of Health must be in
a position to ask its own research committee at once
to investigate the conditions under which the
disease originated, and the means to be employed
to meet it. In the view of many keen sanitarians
and reformers medical research is not so recondite
a field that it cannot safely include the everyday
problems with which a Ministry of Health will be
called upon to deal. Medical research kept thus
in close contact with practice should retain
enthusiasm and continue in practical channels to
a greater degree than some of the existing founda¬
tions for medical research have succeeded in doing.
Until quite recently the reproach was often levelled
at physiology that, like pure mathematics, it
gloried in the absence of mere material results,
and was dominated largely by the nerve-muscle
preparation school. War drew the physiologist into
touch with urgent everyday problems, with results
fruitful both to industrial life and physiological
science, but the diseases of peace are more multi¬
farious, threatening, and deadly than those of war.
The position will, we think, largely be determined
by the view that is taken of the processes under¬
lying research. Research with a big R, appearing
with growing frequency in the columns of our lay
contemporaries, seems totally distinct from the
research going on all and every day in the practice
of medicine and hygiene. It has something of the
transcendental atmosphere in which. the sons of
men waited while God and Satan devised schemes
for the patient Job to put to the test of experience.
But research, and we state it ad nauseam, is no
prerogative of the laboratory or the side-room or the
experimental ward. It depends on an attitude of
mind which may or may not be found in these places,
but which must be found in the daily practice of
medicine, if medicine is to remain a living reality.
The chief characteristic of the spirit of research
lies in the retention of alertness of mind and of
purity of motive in the pursuit of knowledge for
the sake of knowledge. It may be a fact that in
the serene atmosphere of the Privy Council the
minds of the originators of research are set free
from sordid questions of finance; on the other
hand there is something stimulating in the keen
competition of the party system at its best, which
leaves no place for the inertia which may follow
upon permanent officialism. Parenthetically, we
regret Dr. Addison’s fear of departmental jealousies
and interested Ministers, working against a medical
research bureau belonging to the Ministry of
Health.
It is on the internal organisation of a medical
research service as much as on its external
position that the value of such a service depends.
In no other service is an esprit de corps so
essential, for each of its members should be
at the disposal of the service, for such research
518 TmLanobtQ CLINICAL MEETING OF THE BRITISH MEDICAL ASSOCIATION.
[March 29, 1919
work as is needed, under the direction of any I
senior member of the service or in collaboration
with a team of workers attached to other depart¬
ments. We are here almost predicting, and certainly
advocating, a regular service of medical research,
wherein the best men receive life appointments,
and where a probationary service might be needed
for confirmation of the appointment. A service con¬
ducted on these lines might well constitute a
reservoir from which professors and teachers in
pathology, bacteriology, and biological chemistry
would be selected, and in the future we may
presume also the assistant physicians to hospitals.
We may be still far from the concentration of a
research service round an institutional school
where periodical conferences of all grades of
workers would suggest fruitful directions for
research—this being the text of an interesting
memorandum which many of our readers may have
seen; but certain it is that the more directions in
which medical research is employed the more
valuable, though unexpected, will be the results.
The war proved, as has been said above, that inven¬
tion follows on necessity, but over and over again
it has been found that necessity in one direction
has led to invention which proved more useful
in another. For this reason it is valuable that
problems in medical research should be put up to
the workers so that they may receive the exciting
stimulus of a difficult question to answer. So
many of these difficult questions remain un¬
answered in the province of domestic medicine that
it seems to us absolutely necessary for the Ministry
of Health to have at its command a bureau of
medical research. In deference to this feeling, it is
understood, in the report stage of the Ministry of
Health Bill a suggestion of Dr. A. C. Farquharson,
that there should be included in the Bill provision
for a research department under the Ministry of
Health, was accepted.
Clinical Meeting of the British
Medical Association.
We publish this week the programme of the
Clinical Meeting of the British Medical Association,
tfhich will be held in London from April 8th to
llth inclusive. The sectional meetings will be held
at the Imperial College of Science and Technology,
South Kensington, by the courtesy of the Rector, Sir
Alfred Keogh. As will be seen by the programme,
and as would be only natural in the circumstances,
the scientific activities centre around the war and
its results, and it must happen that those who open
the'discussions will go over ground much of which
has been traversed by themselves and others
previously. This, however, should afford all
the better opportunity for valuable debate.
With the cessation of hostilities a term was
put to much of the medical work undertaken
during, and developed because of, the war,
and such work can be closely reviewed as it made
good up to a certain point. The question at issue,
of course, is not so much what is the qualita¬
tive and quantitative value of the proceedings
taken during hostility, as the question to what
extent will these proceedings be useful in a world
of peace, where there is no abatement from the
trials of disease and the shocks of injury. How
best to adapt the lessons learned in war to
ameliorate the conditions prevalent in peace must
be the objective of all medical congresses in the
immediate future.
We have been asked to draw the attention of
those of our readers who intend to take part
in the proceedings of the Clinical Meeting of
the British Medical Association to the fact
unfortunately too well known to metropolitan
dwellers, that it is exceedingly difficult
nouse-ioom i n London, while private a-V*
has been curtailed through tfc- a^oenty of finding
adequate domestic seiri/>e. Those who intend to
be present at the meeting should take th« earliest
steps possible to nbiM« accommodation. In
the meantime Sir Arthur Stanley, treasurer to
St. Thomas’s Hospital, has come to the rescue in
a very practical manner. In the event of members
of His Majesty’s Forces and others attending the
Clinical Meeting of the British Medical Associa¬
tion in London being unable to obtain sleeping
accommodation, the treasurer and governors of
St. Thomas’s Hospital have set aside 60 beds in two
vacant wards, and they will be able to provide
breakfast for their guests. Early application should
be made to the honorary general secretaries of the
Special Clinical Meeting, 429, Strand, W.C. 2.
JnMtahans.
"I« quid nimU.”
MINIMUM FOOD REQUIREMENTS.
The food requirements of man and their varia¬
tions according to age, sex, size, and occupation are
dealt with in a report issued last week by the Food
(War) Committee, Royal Society, and couched in
simple terms such as should be easily grasped by
the lay reader. It presents no new contributions
on the general questions of nutrition, showing
rather how very inadequate is our present know¬
ledge of the science of nutrition, and demonstrating
the necessity, in the opinion of the writers, of
renewed investigations of almost every point
discussed. The document, however, is valuable in
setting out the views of our leading authorities on
the subject, and such calculations as are included
are all based on scientific data so far as they
exist. Thus at the outset the constituents
of food are defined, and later their r61e in
metabolism; next follows a section on food require¬
ments of the average man and influence of external
temperature, on the relation of requirements to
size and weight, and on the requirements of women,
children, adolescents, and brain-workers of every
sort. It is pointed out that the growth vitamine
is present in especially large quantity in the fats
of milk, and that on this account, if on no
other, milk is of vital importance for the nourish¬
ment of children, no child’s diet being considered
satisfactory in which milk or milk fat is not
present. Examples of foods deficient in growth
factors are quoted, and amongst these are men¬
tioned white bread, polished rice, the majority
of patent breakfast foods, preserved meats, and
preserved vegetables. The writers make some
interesting observations on the needs of brain¬
workers. While the most careful experiments,
they observe, have failed to show any increase in
the energy output of the body as a direct result
of brain-work, yet the quality of the brain-worker’s
diet requires more consideration than that of the
bodily labourer. The former cannot digest fats
and carbohydrates in excess of his muscular
requirements, and in a cold climate may suffer
from defective heat production. In such a case a
The Lancbt,]
MENINGEAL HEMORRHAGE IN TYPHOID FEVER.
[March 29,1919 519
relatively high protein diet, it is suggested, is of
advantage, since protein alone among food¬
stuffs directly stimulates the oxidative processes of
the body, and therefore by its mere ingestion
increases the heat production in the body.
Greater outlay on the relatively expensive animal
foods is therefore justified for the brain-worker.
Finally, the effects of a general diminution of the
food-supply on the population is discussed, and
reference is made to the effect of a course of semi-
starvation as studied by Benedict. Put in a sentence,
he showed that it is possible for large masses of
men to live and to carry on their normal employ¬
ment on a diet very much less than that to which
they were accustomed.
The food situation as it has recently affected
Switzerland was discussed at a meeting of the
Basle Medical Society on Jan. 31st, Dr. Ernst
Hagenbach presiding. Dr. Gigon, who introduced
the subject, started from the conventional daily
standard or Normalkost of albumin 90 to 130 g.,
fat 60 to 100 g., carbohydrate 400 to 550 g., total
calories 2900 to 3300. Recent Swiss experience has
led him to regard these figures as optional and to fix
the daily minimum proper to a hygienic existence
at albumin 70 to 80 g., total calories 2300 to 2500,
but this, he thinks, would mean privation if con¬
tinued over a period of more than two to three years.
While in Basle itself the total calories available per
head of population had diminished from 3180 in 1912
to 2300 in 1917, principally through diminution in
fat and carbohydrate, the manual worker did his
utmost to keep his albumin ration at its previous
height in spite of the enhanced cost, hnd
in most cases he ioBt weight in so doing.
Dr. Gigon suggested that when in any country
rationing of a particular foodstuff became neces¬
sary it was essential to ration all foodstuffs in
order to ensure fair distribution of those remaining
unrationed. Experience in this country has cer¬
tainly confirmed the wisdom of the suggestion.
For patients he would like to see a special system
in force ; diabetics, for instance, being granted 50 g.
of butter in place of sugar, bread, and milk ; cases
of kidney and heart disease to be allotted extra
sugar, "potato, and rice ; and a quantity of milk—
half a litre of milk would suffice—being assigned
to each hospital bed. Professor Staehelin, and
others who followed Dr. Gigon in the debate,
confirmed the impression that the Swiss pre-war
consumption of albumin had been more than
sufficient for physiological needs, and that no
appreciable evidence of hypo-nutrition had yet
shown itself on the reduced diet.
MENINGEAL HEMORRHAGE IN TYPHOID FEVER-
At a meeting of the Society Medical® des Hdpitaux
of Paris M. Emile Sergent and Mile T. Bertrand
reported a case of a very rare complication of
typhoid fever—meningeal haemorrhage. A married
woman, aged 35 years, was admitted into the Charite
Hospital on July 11th, 1918, |for an illness of
10 days’ duration, marked by lassitude, insomnia,
vomiting, and, above all, by violent headache, which
gradually increased. On admission she was
prostrate and immobile, the face was covered
with perspiration, the features were drawn. She
complained of violent headache, but there was no
rigidity of the neck and Kernig’s sign was absent.
The temperature was 102*2° F. and the pulse 104.
The tongue was furred and the abdomen tympanitic.
There was bilious vomiting, but neither constipa¬
tion nor diarrhoea. The spleen was enlarged and
palpable. In the chest sonorous and sibilant rales
were heard. The general condition became worse,
the temperature rose to 104’9°, and Kernig’s sign
with rigidity of the neck and spine appeared.
Meningitis was suspected. Lumbar puncture
yielded haemorrhagic fluid, not under increased
tension. Bacteriological and cytological examina¬
tion of the fluid showed only -the presence
of normal blood. The cause of the haemor¬
rhage remained obscure until July 15th, when
Widal’s reaction was found positive and the
typhoid bacillus cultivated from the blood. On
the 18th defervescence began. On the 20th lumbar
puncture yielded limpid fluid, of which only the last
drops were haemorrhagic. Bacteriological and cyto¬
logical examination were still negative. From this
time the patient improved gradually and the rigidity
diminished. On the 24th lumbar puncture yielded
normal fluid. Meningeal haemorrhage does not
appear to have been described as a separate
complication of typhoid fever, though it is
mentioned as one of the phenomena of haemor¬
rhagic typhoid. Meningeal complications of typhoid
fever are fairly common and well known, but they
take the form of meningitis with a more or less
marked leucocyte reaction of the cerebro-spinal
fluid, in which the typhoid bacillus can be found,
or of “ meningism,” which shows itself only by
functional troubles, the cerebro-spinal fluid being
normal. This meningism is associated with a
congested state of the meninges. M. Sergent and
Mile. Bertrand suggest that this in their case
brought about the haemorrhage, thus comparing it
with the epistaxis, metrorrhagia, and early intes¬
tinal haemorrhages of typhoid fever, which are
due respectively to congestion of the nasal, uterine,
and intestinal mucous membranes.
SUSCEPTIBILITY TO ENVIRONMENT.
In the first special hospital arranged in this
country for officers suffering from functional
nervous disturbances the patients were at first
placed in “ austere little rooms,” with plain, grey
walls, devoid of pictures or ornaments, and with
nothing to attract or distract the attention of the
tired man. In such a quite haven, we were then
told, fatigue, as a rule, passed off rapidly and con¬
valescence began. The effect of this environment
on the sick man’s nervous system was thus duly
recognised. But it is self-evident that this effeot
is a very varying quantity. The nature of the
surroundings in which people work or play iB of far
more importance to some than to others, and the
most susceptible people are not always those who
are u nervy,” or who possess the artistic tempera¬
ment in high degree. It is doubtful, too, how long,
even in extreme cases, the normal daily environ¬
ment continues to be operative. The attendants at
the National Gallery soon get over the effect of
living among the old masters. Wall-papers with
startling patterns have been known to irritate
patients convalescing from acute iUness, but it
must be possible to live within the deplorable wall¬
papers seen in the tradesman’s book of samples
without the loss of reason, or our asylums would
be fuller than they are. It is difficult to suppose
that the widely advertised colour scheme which
is on its trial in a section of the Maudsley
Hospital can be any exception to this
law of rapid habituation to environment. Dr.
E. N. Snowden, who gives a report upon the
scheme on another page, states that there is less
crime in the military sense in the section so
520 Thb Lanott,] DOES EPIDEMIC INFLUENZA AFFECT THE LOWER ANIMALS? [March 29,1919
decorated than in any of the other wards of the
hospital; but he rightly goes on to suggest other
possible explanations of this observation—e.g.,
coincidence, the tact of the sister-in-charge, the
pride induced by living in a show ward, and so on.
Moreover, the effect of suggestion cannot be over¬
looked ; a patient with neurasthenia lost his head¬
ache after living in the purple room in which he
had been told that his headache would disappear.
The same thing would possibly have happened if the
presence of Venetian blind6 or the smell of hyacinths
in the room had been the curative factor emphasised.
We agree with Dr. Snowden's conclusion that a
happily decorated hospital must be a more cheerful
place to live in than one that is decorated with the
usual dull colours chosen for utility and economy;
but much more evidence of the curative value of a
particular colour scheme is required before any
conclusion can be drawn upon its merits.
DOES EPIDEMIC INFLUENZA AFFECT THE
LOWER ANIMAL8P
In former days there was a general impression
that influenza when epidemic in man spread to
some of the lower animals, such as the horse, for
example. In more recent times this view was con¬
sidered to be untenable, and it has to be admitted
that little evidence of any scientific value has ever
been brought forward to support the contention
that any of the domestic animals were susceptible
to the disease. During the course of the present
pandemic the question has again been raised,
chiefly in the lay press. A Central News message,
published in a London newspaper on Nov. lBt,
1918, from Johannesburg, mentioned that “ an
extraordinary development ” of the influenza
epidemic, then raging in South Africa, had been
the excessive mortality that had occurred among
the African monkeys. Reports from areas in which
these animals abounded stated that the monkeys
were “ dying in hundreds," and that in some places
whole troops of baboons had been found dead, the
result apparently of “ pneumonic complications."
These statements were supplemented by the Cape
Town correspondent of the Times on Nov. 5th, who
said that influenza had spread to baboons, of which a
large number existed in the kloofs and hills around
Magaliesburg, in the Transvaal. These animals
were “ dying in scores " and their dead bodies were
being found on the roadsides and in the vicinity of
homesteads, the epidemic having apparently led
them to forsake their usual haunts. Recent experi¬
ments in France, conducted by British research
workers, have proved that influenza can be trans¬
mitted to monkeys by the inoculation of infective
material; so that it may be concluded that these
animals are susceptible to the disease, but whether
they can contract it also in the natural way is not
yet clear. Reports from Canada, at the end of 1918,
stated that woodmen employed in clearing the bush
in Northern Ontario had observed an unusual
mortality among moose, and this they believed to
be due to the current influenza epidemic. The
Times of Jan. 10th supports this statement and says
that in Northern Canada influenza was “ deci¬
mating the big game," and that for some time
smaller animals had also shown marked symptoms
of the disease. The Times of Feb. 20th contains a
communication from its correspondent at Butte,
Montana, mentioning the fact that the Yellowstone
National Park, in which bison, elk, and other
animals are strictly preserved by the United States
Government, had been “ swept by an epidemic of
influenza," and that already 31 “buffaloes" had
been found dead as a result. On March 10th it was
reported by the Times that a veterinary surgeon at
Kirkby Stephen, who was inspecting officer for the
Westmorland County Council and for the Board of
Agriculture, had lately observed an epidemic illness
among sheep in the district, and that he had
diagnosed it as u influenza" ; it was also stated that
this veterinary surgeon during his 30 years of pro¬
fessional life had never, till now, met with an out¬
break of a similar kind. Several flocks were at
present affected, and many sheep had died as a
result of the epidemic.
It cannot be said that in any of the above-
mentioned instances have definite proofs been
brought forward to show that these outbreaks were
caused by epidemic influenza. It is difficult to
understand how wild animals like the moose or
the bison could primarily get infected by influenza.
With domestic animals it is conceivable that they
could get infected by their human owners or other
persons attending to them. It seems desirable that,
when suitable opportunities occur, some careful
investigation of alleged outbreaks of influenza in
the lower animals should be undertaken, and espe¬
cially of such occurrences among domestic animals
like the dog and the cat, which are in more intimate
association with [man. Such investigations might
settle the question, once and for all, whether the
lower animals are really susceptible to influenza,
and whether, if attacked, they are capable of trans¬
mitting the infection to man or to other species of
animals. _
FEEBLE-MINDEDNESS FROM TWO STANDPOINTS.
Sooner or later, it may reasonably be anticipated,
a Ministry of Health will take over all the powers
and duties of the Local Government Board, the
Home Office, and the Board of Education, in regard
to lunacy and mental deficiency. When that time
comes there will arise some pretty problems in
harmonising the practice of the different depart¬
ments. As an illustration there may be taken the
different attitudes adopted by the Local Govern¬
ment Board and the Home Office towards the less
marked degrees of mental defect which are covered
by the term “ feeble-mindedness." Under the
Lunacy Act, 1890, certain classes of lunatics, not
defined exactly but in practice comprising the
quiet and harmless insane, together with imbeciles
and idiots, can be received into workhouses by
means of a much simpler procedure than applies in
the case of asylums. For detention two medical
certificates and an order under the hand of a
justice are required, but the justice need not see
the patient if he does not think it necessary,
and the order is valid, without renewal,
for an indefinite period. Following out this
principle of imposing less exacting conditions in
less marked cases of defect the Local Government
Board, through the instrumentality of orders made
in 1897 and 1911, allows feeble-minded persons
under the age of 21 and chargeable to London
parishes to be received into the institutions con¬
trolled by the Metropolitan Asylums Board without
any order made by a justice, if an application
supported by the guardians' medical officer is made
by their clerk. Under the Mental Deficiency Act,
1913, the tendency is to increase the stringency of
the conditions regulating admission to an institu¬
tion as the intellectual status of the patient rises.
The feeble-minded person, like the idiot or
The Lancet,] INTESTINAL BNTOZOA AMONG NATIVE LABOURERS IN JOHANNESBURG. [March 29,1919 521
imbecile, may be dealt with either by means of an
order made by a justice, after the presentation of
a petition, a statement of particulars, a statutory
declaration, and a couple of medical certificates,
or, if below the age of 21, as the result of
an application by his parent or guardian. In
this latter case, however, there are required not
only two medical certificates but also two certifi¬
cates by “ a judicial authority.” The contrast in
methods does not end with the reception of the
patient. Gases under the Mental Deficiency Act
have to be seen from time to time by visiting
justices, reports about them have to be sent to the
Board of Control, and, generally, they are responsible
for the consumption of much paper and ink. Local
Government Board cases carry on quite satisfactorily
without these refinements. There is no authority
for their detention—they simply stay. It is rather
striking to find in one institution and in the same
ward of the institution two patients of similar type
yet under such diverse conditions. We are not, at
the moment, concerned to point the moral, but the
situation is worthy of the attention of those who
may have to reconcile the vagaries of the law
relating to mental defect.
INTESTINAL ENTOZOA AMONG THE NATIVE
LABOURERS IN JOHANNESBURG.
The South African Institute for Medical Research
has recently published an interesting report by
Miss Annie Porter, D.Sc. Lond., parasitologist to
the Institute, entitled “ A Survey of the Intestinal
Entozoa, both Protozoal and Helminthic, Observed
Among Natives in Johannesburg from June to
November, 1917.” 1 The natives employed in
Johannesburg are gathered from various parts of
Africa, including the East Coast, Cape Province,
the Transvaal, Basutoland, and Natal, and among
them infestation by endoparasites, both protozoa
and helminths, is common. As many as six kinds
of parasitic organisms have been found simul¬
taneously in a single intestine. The parasitic
protozoa found in the stools of the natives
include Entamoeba histolytica , Giardia intestinalis ,
Trichomona& intestinalis , and Chilomastix mesnili ;
the first of these is associated with amoebic
dysentery and the last three with various flagellate
diarrhoeas; and Isospora bigemina , which can
cause coccidial diarrhoea. Entamoeba coli and
Spirochata eurygyrata are very widely distributed
parasites; they have long been habituated to life
in the human intestine, but nevertheless it has
been found that they multiply more abundantly in
an unhealthy intestine, and their presence in large
numbers may serve as an indication of intestinal
disorder. Miss Porter regards the number of
infections with E . histolytica as some index of the
number of sporadic cases normally present among
a population living under normal conditions; and
also as an indication of the possibilities of amoebic
dysentery occurring in epidemic form should con¬
ditions of living lower the standard of health now
prevailing. It is suggested that under less favour¬
able conditions it is possible for diseases, now rela¬
tively quiescent and sporadic, to become fulminating
and epidemic. The main modes of transmission of
E . histolytica to man are by direct infection of food
and water and indirectly by the agency of flies.
Carriers of cysts are serious sources of danger to
persons with whom they may associate. The same
' 1 Publications of the South African Institute for Medical Research.
Edited by W. Watkins-Pltchford, M.D. Lond. Nfe XI. Pp. 58. 5«.
remarks apply to such parasitic flagellata as
Giardia intestinalis , Trichomonas intestinalis , and
Chilomastix mesnili , each of which is capable of
producing flagellate diarrhoea; each of them also
is difficult of elimination from the alimentary
tract when once established there. Distressing
diarrhoea in adults and some forms of “green”
or infantile diarrhoea in Johannesburg have been
traced to the presence of these parasites, and
with their elimination by treatment the diarrhoea
has ceased. There is a possibility that many
obscure intestinal troubles, difficult to deal with,
may be due to these organisms. Natural reservoirs
of these flagellates are found in such domestic
vermin as rats, mice, and cockroaohes, whose
excrement may infect cereal or farinaceous food.
The other source of infection is the cysts voided in
the stools of human carriers. The danger from the
promiscuous habits of some of the natives is
evident; they may by their evacuations con¬
taminate water and foliage, as well as afford oppor¬
tunities for transmission of infection by flies.
Helminthic infections are widely distributed
among the native workers of Johannesburg; eosino-
philia and anaemia are common results of worm
infestation, and generally lower the vitality of the
infected person. For eliminating worm infec¬
tions it is necessary to inculcate sanitary habits
not only as regards the preparation of food but
also with respect to the disposal of excrement.
Numerous cases of infestation by Tania saginata
and T. solium were detected arising from the eating
of imperfectly cooked beef or pork. The disposal
of infected human excrement containing tapeworm
eggs should be effected in such a way that no con¬
tamination occurs of herbage on which pigs or
cattle may feed. By preventing the development
of tapeworm eggs into bladder-worms in pigs and
cattle, the development of tapeworms in man is
rendered impossible. The presence of Hymenolepsis
in man is the result of defective protection of food
from contamination by rats and mice, the fleas
infesting these animals conveying the bladder-
worms to human food. Nematode infections in the
natives were common, especially ankylostomiasis;
Ascaris lumbricoides and TrichuHs trichiura were
also found frequently. A few cases of trematode
infection were discovered—namely, Schistosoma
mansoni . Miss Porter concludes her paper by
saying that “ No animal parasite is entirely harm¬
less to man,” so that neither protozoon nor helminth
can be disregarded. _
LARGER SCOPE FOR THE RED CROSS.
An Inter-Allied Conference of Red Cross Societies
will shortly be held in Cannes to consider the
programme of a meeting to be called at Geneva 30
days after the signing of peace, for the purpose of
extending the scope and broadening the basis of
Red Cross work throughout the world. A number
of important medical and surgical questions will
come up at the Conference and require expert
discussion; among those who have placed their
services at the disposal of the British Red Cross
Society for this purpose are Sir Arthur Newsholme,
Sir Ronald Ross, Sir Robert Philip, Dr. F. N. Kay
Menzies, Dr. F. Truby King, Sir Walter Fletcher,
Sir Leslie MacKenzie, Colonel S. Lyle Cummins,
and Colonel L. W. Harrison. As was pointed out
by Sir Arthur Stanley in an address given before
the Brighton Division of the British Red Cross
Society on March 14th, wherever distress and
suffering exist there the symbol of the Red
522 Thb Lancet,]
DR E. N. 8N0WDEN : KEMP PR0S80R COLOUR SOHBME.
[March 29,1919
Cross should be. Numberless ways in which the
Red Cross could help in the rebuilding of the
world will suggest themselves, two of the most
pressing needs being the prevention of tuberculosis
and the promotion of child welfare. The suggestion
has been made that some of the 1300 hospitals
which are now being disbanded should be retained
by the Red Cross for the treatment of tuberculous
cases, along with the provision of proper home
accommodation. The formation of a central council
of child welfare under the presidency of the Red
Cross Societies, coordinating all the efforts at
present widely scattered, is engaging sympathetic
consideration. In these and other ways the generous
response of comfortable humanity to want and
suffering, manifested during the war, will not be
allowed to fade away in peace.
THE MEDICAL SUPPLEMENT OF THE MEDICAL
RESEARCH COMMITTEE.
With reference to this publication we have been
asked to call attention to the following statement
of the Committee:—
“ Since the end of hostilities the Medioal Research Com¬
mittee have had under consideration the question of con¬
tinuing in another form the compilation of abstracts and
reviews of foreign publications in medical science which,
with a view to special war conditions, have hitherto been
issued in the Medical Supplement to the Daily Review of the
Foreign Press. The Medical Supplement as such will be dis¬
continued after the April number, but representations have
been made to the Committee from many quarters urging
the continuation upon a permanent basis of a summary
of a similar kind. It appears to have been found in
many directions that the Supplement has served a
, useful purpose in aiding both the progress of research
and its application to practical problems. The Medical
Research Committee have made arrangements accord¬
ingly to publish in monthly issues periodical collec¬
tions of abstracts and reviews of work done in the medical
sciences and recorded either in British and American
publications or in those of other countries. It is intended
to leave a short interval between the cessation of the
Supplement and the beginning of the new periodical, and it is
hoped that the first number will appear on Oot. 1st next, at
the beginning of the academical year. Its size will be a large
8vo, uniform with that (for instance) of the Quarterly
Journal of Medicine and of an increasing number of other
scientific journals. The contents will be in the form of
abstracts of individual papers, with occasional oritical
summaries of grouped results, taken from published work
making advance in particular branches of medical science.”
A detailed prospectus of the new publication will
shortly be prepared, when it will be sent upon
application made to the Medical Research Com¬
mittee, 15, Buckingham-street, Strand, W.C. 2.
Sir Robert Jones will act as honorary consultant
to the Ministry of Pensions for orthopaedic cases.
In view of the impending retirement of Sir
Horace Monro, K.C.B., Permanent Secretary to the
Local Government Board, and in order to facilitate
the unification of the departments which will be
brought together in the Ministry of Health on the
passage of the Bill now before Parliament, the
President of the Local Government Board has
appointed Sir Robert Morant, K.C.B., chairman of
the National Health Insurance Commission, and
Mr. John Anderson, C.B., secretary to that Com¬
mission, and at present acting as secretary to the
Ministry of Shipping, to be additional Secretaries
to the Local Government Board, with special func¬
tions and responsibilities in relation to the organi¬
sation of the new Department, continuing their
Insurance functions. Sir Robert Morant and Mr.
Anderson have been designated as First and Second
Secretary respectively in the new Ministry.
REPORT ON THE
KEMP PROSSOR COLOUR SCHEME.
By E. N. Snowden, M.B., B.S. Lond., M.R.C.S.,
OA.PTA.IV, R.A.M.C. (T.).
(From the Maudsley Neurological Clearing Hospital, R.A.M.C.)
The Kemp Prossor colour method for treatment of neuro¬
logical patients at the Maudsley Hospital is exhibited in the
decoration of a section of the hospital—the officers’ flat for
11 officer patients and Ward 4 for other ranks.
The following is a brief description of Ward 4 and serves
to illustrate the whole scheme. The ward consists of three
rooms. Room A is decorated with a ceiling of sky bine,
with yellow walls (the so-called “ sunlight” yellow). The
bed-covers and locker curtains are green. It has bine
flower vases and screen covers. The whole scheme of decora¬
tion is intended to represent spring, the yellow being said to
be stimulating. Room B: The ceiling is bine, the walls yellow,
the bed-covers and locker curtains are purple, and the screen
covers are blue. This also is intended to be stimulating.
Room C : The ceiling is blue, the walls are coloured, the
upper part pink with a yellow dado. A narrow green line
divides these colours. It has blue bed and screen covers.
This scheme is intended to assist concentration. There are
three chief side rooms: (1) Yellow and green, stimulating
effect; (2) purple and blue, soothing effect; (3) yellow and
blue, stimulating effect. The corridor is yellow and green.
Effects of Colour Soheme on Patients.
The colours are well ohosen and the whole effect of the
wards is bright and pleasing, if somewhat unrestful to the
ordinary observer. With regard to the effect of this scheme
of decoration on the patients, oareful inquiry from the
medioal officers, sisters, and patients has elicited the
following facts:—
1. There is less crime (in the military sense) in Ward 4
than in any of the other wards. This fact is of importance
and needs further trial and investigation, as it appears to be
a strong point in favour of the colour scheme. It may be
mere coincidence. It may be due to the influence on the
men of a tactful and suitable charge sister. A measure of
the value of the sister’s management in a neurological ward
is the presence or absence of military offences. Further, it
is possible that the men have a pride in the ward as being a
show place, and their conduct consequently improves. If
this last factor is of importance it would naturally disappear
if the whole hospital were treated in the same way. These
comments indicate a path for further investigation of the
fact.
2. A patient diagnosed as “hysteria” was put into the
purple side room. In two days be became hopelessly
depressed and was removed to Ward A, where he recovered.
3. A patient with ” neurasthenia ” was told that his
headaches would be removed if he were living in the purple
room, and he stated that this occurred. I will comment on
i this fact later.
I 4. Two patients who were placed in Ward A (yellow)
declared that they would go mad if they were left there.
After two days this attitude of mind was changed to,
acquiescence with their surroundings. It is a common
experience that we can become accustomed to any surround¬
ings, and that the mind has the capacity of dissociating
from consciousness any conditions that are unpleasing and
by that means protecting itself from disturbance.
5. A young officer who had been unable to sleep for many
nights unless with the help of sedative drugs while in
France was placed in a room in which purple predominated.
He slept soundly all night without any drug. This case has
been quoted as an example of the soothing effect of the
purple room, but any medical officer who has dealt with
neurological cases can quote dozens of similar instances
where the patient gave the credit for his improvement to the
fact that he was back in England and his anxiety removed,
and where there was nothing in his surroundings that was
peculiar.
6. The patients who occupy beds in the pink room (0)
show a tendency to sit there rather than in the other rooms.
7. Medical officers who have had cases under treatment in
this ward, and in other wards simultaneously, find that there
is no difference in the results achieved. The patients do not
THS LANCER,]
SCOTLAND.—NEW YORK.
[March 29,1919 523
get better more quickly in one than in the other, and the
proportion of cured cases is the same.
Taking all these facts into consideration, it does not appear
that the particular scheme of decoration here described has
any more effect than would be achieved by any cheerful
decoration chosen by an expert in the blending of colours.
It is generally recognised that the effect of colour in our
surroundings is a personal one, and except in the widest
sense cannot be imposed upon us by another person
successfully.
It is obvious that an unfamiliar decorative scheme may be
utilised as a means of producing a state of suggestibility in
a patient and assist in the removal of Bymptoms, as is
instanced in a case mentioned under paragraph 3. This fact
is capable of extensive use, but the result is not obtained by
any virtue in the colour chosen, but by the suggestion which
it is made to convey.
There can be no doubt that a happily decorated hospital
must be a more cheerful place to live in than one that is
decorated with the usual dull colours chosen for utility and
economy, but it would be incorrect to state that the scheme
of colours which is the subject of this report can in any
sense replace the recognised psychotherapeutic methods to
be employed in the treatment of the psychoneurosis.
SCOTLAND.
(From our own Correspondents. )
Ministry of'Health: Resolutions of the Scottish Medical
Profession.
At a recent meeting of the medical profession in Edin¬
burgh and Leith, called to consider questions in regard to the
proposed Ministry of Health, resolutions were submitted to
the following effect:—
(1) While approving of the establishment of a Ministry of Health, in
view of the fact that such a Ministry is of primary importance to the
medical profession, this meeting endorses the resolution of the Royal
Colleges of Physicians and Surgeons, Bdlnburgh, that before the Bill is
enacted it should be submitted to the medical profession for con¬
sideration .
(2) That there should be a separate Ministry of Health for Scotland
with direct access to Parliament.
(3) That the Scottish Board of Health should contain not less than
one-third of its members registered medical practitioners not holding
any other appointment under the Ministry.
(4) That there should be a Medical Advisory Council elected by the
medical profession itself, to which all matters directly or indirectly
affecting public health should be referred by the Board for considera¬
tion and report. It should also be competent for the Advisory Council
to submit such matters of its own initiation to the Board. This council
should have power to meet jointly with any council, medical or lay, as
occasion arises.
(6) That there should be representation of the dental profession on
the Advisory Council.
All these resolutions were passed unanimously by the
meeting.
Ministry of Health: Statement by the Royal College of
Physicians of Edinburgh.
The Royal College of Physicians of Edinburgh has recorded
its approval of the Government’s action in giving a primary
place to legislation in the interest of the health of the
people, and of its intention to introduce a measure establishing
a separate Health Ministry for Scotland. The statement
goes on to lay stress on several points essential to the smooth
working of a Health Act.
1. The College desires to emphasise the view that, what¬
ever form the Ministry for Scotland may take, it is essential
for the development of the Ministry that responsibility for
the initiation and control of health measures applicable to
Scotland should be vested ultimately in one official , specially
appointed and responsible for this office only—whether as
President or Vice-President of the Board of Health—who
should be a Member of Parliament.
2. The College is of opinion that in constituting the Board
regard should be had to the selection of its members on grounds
of experience and interest in matters pertaining to health.
This implies a larger medical membership than the Bill
seems to contemplate. In view of the extent of the health
interest involved, the proposed inclusion of one medical
member iB quite inadequate. Further, in the selection of
medical members, it is undesirable to require the possession
of one or other special diploma. The members should be
chosen on the ground of their capacity and experience in
medicine.
3. With regard to the consultative councils to be erected,
the College favours the proposal. Their establishment will
tend to ensure the effective cooperation of the profession
with the Ministry in the carrying out of preventive and
curative measures, conducive to the health of the people.
The College strongly recommends that the medical members
of the consnltative council should be chosen by the medical
profession. Having regard to the extent and variety of
questions which have arisen and will arise in connexion
with a Ministry of Health, it is essential that these consulta¬
tive councils should be really effective bodies, initiating as
well as qualifying proposals, and that they should have
ready access to the Minister.
The statement concludes with the expression of the belief
that the establishment of consultative councils on these
lines will be found capable of further development locally in
connexion with the practical administration of the Act.
Post-graduate Medical Teaching in Qlasgon.
In March, 1914, at a meeting of the medical teaching
staffs of the University and other medical schools and of
the general and special hospitals of Glasgow a committee
was appointed to promote cooperation between the various
bodies concerned and an executive committee was formed to
complete arrangements and draw up a syllabus for the
purpose of instituting & general scheme of post-graduate
medical teaching early in 1915. In February of this year it
was agreed to institute an emergency course of post¬
graduate medical teaching during the ensuing summer
session, particularly to meet the needs of graduates who have
been on service. Arrangements have now been made to
carry out such a course in medicine, surgery, obstetrics, and
special subjects, in various hospitals in Glasgow. The
course, which will be clinical and practical, will be held
during the months of May and June, 1919, and graduates
may enrol for either or both months. Two schemes of
teaching have been arranged.
Scheme A .—Graduates will be distributed among the
clinics in the proportion of five or six to eaoh, each
graduate to have under his charge a certain number of beds
and to be responsible for the dne investigation and recording
of the cases and for all special investigations in connexion
with them, working directly under and along with the
phvsician or surgeon in charge, and in connexion with the
ordinary clinic.
Scheme B— Special post graduate classes for graduates
alone.
No fee will be oharged for instruction under Scheme A,
but for the special classes under Scheme B, there will be
an inclusive enrolment fee of 5 guineas for the two months’
course, and of 2* guineas for one month. For this fee
graduates may attend as many classes as they wish.
Further particulars may be had on application to the
acting secretary, General Committee for Post-graduate
Medical Teaching in Glasgow, Dr. A. M. Kennedy, Patho¬
logical Institute, Royal Infirmary, Glasgow. As certain
of the special classes nnder Scheme B may be limited in
numbers, and as the appointments under Scheme A are also
limited to 6-8 to each clinic, graduates wishing to attend
the course are advised to send their names to the acting
secretary as soon as possible.
March 25th. _
NEW YORK.
(From an Occasional Oorrrspondbnt. )
Prohibition and the Medical Profession.
Prohibition was discussed somewhat warmly at a
meeting of the Medical Society of the County of New York
held In the New York Academy of Medicine Building on
the evening of Feb. 24th. It was not anticipated that the
prohibition question would be taken under consideration at
this meeting, as Dr. E. Elot Harris, chairman of the Com¬
mittee on Public Health, had announced that the committee
unanimously desired that no action be taken on the resolu¬
tion by the society. The resolution as finally adopted was
as follows: —
That the Medical Society of the County of New York opposes the
ratification by the Legislature of New York of the measure now before
it for national prohibition as irrational, unscientific, and in opposition
to the aooepted usage of all civilised nations elsewhere throughout the
world, and as putting upon the medical profession the burden ot
prescribing ana dispensing alooholic beverages of proved therapeutic
worth, while allowing the unlimited sale to the public of patent pro¬
prietary and quack remedies containing alcohol in varying amounts
without control or hindrance by the officers of the State.
Among those who took part in the debate were Dr.
Daniel S. Dougherty, secretary of the society, and Dr, Max
The Lancet,]
SOUTH AFRICA.
[March 29,1919 525
At first, great difficulty was found in obtaining coffins and
labourers to dig graves, the usual staff of the cemeteries
being much affected with the disease. A special committee
dealt with this matter. This shortage was overcome by the
corporation workshops working day and night, by the
assistance of the railways and harbours administration, and
by orders given to different contractors. In this way
2000 coffins were provided gratuitously by the committee.
The difficulty of providing labourers to dig graves was
extreme and was not overcome until a number of men from
a Nigerian regiment were supplied to assist.
Owing to the impossibility of obtaining medical advice
it was decided to distribute medicine at the Oity Hall
and the various depdts, and in this way to reassure
the patients. A mixture containing 10 gr. of salicylate
of soda and liq. ammonii acetatis was most appreciated
by the patients. Aspirin tabloids, gr. 5, were also used.
▲ mixture of ammoniated tincture of quinine in 1 drachm
doses was also distributed. An expectorant mixture con¬
taining ammon. carb., sod. bicarb., sodium salicyl., aa. gr. 5,
tinct. nux vom. in 5; the same without sodium salicylate,
and a tonic containing strychnine and dilute nitro-hydro-
chloric acid were added to the list. Epsom salts, camphorated
oil, castor oil, linseed oil, tincture of iodine, ootton-wool,
Ac., were also available.
The oity was divided into 45 areas, each being, as far
as possible, in charge of a doctor. There was a dep6t in
each area which was placed under a controller, and
here the volnnteers and nurses who were undertaking
house-to-house visitation reported serious cases of illness
where medical attendance was needed, and messages
from the publio of the existence of such cases were
also received. At the dep6t foodstuffs and medicines
were distributed, advice was given, and wants attended
to. Hospital accommodation was provided. Military tents
were supplied, together with a large staff of military
orderlies, and marquees and bell-tents were erected at
various places for the reception of patients. In addition
to the two motor ambulances and one horse ambulance
belonging to the municipality, many motor lorries (loaned
by various mercantile firms) and two motor omnibuses were
altered for the purpose. The serious cases were removed as
rapidly as possible, considering the large number to be
dealt with. Small bottles filled with disinfectant were dis¬
tributed in order for disinfectant to be placed in spittoons,
and the city engineer’s department undertook the disinfection
of the streets, pavements, and lanes of the city, and, later, the
places of amusement before they were allowed to be reopened.
Arrangements were made for the accommodation of children
left destitute by the death of both parents, or the death of
one, the other being in hospital. The Royal Automobile
Club organised amongst its members a department of motor
transport to carry food to depdts and to the houses of the
sick, to carry supplies to the hospitals, and to convey
workers round their districts and generally to help in the
epidemic.
Dr. Anderson thought that fully half the European popu¬
lation and 75 per cent, of the coloured were affected during
the epidemic. At the urgent request of medical practitioners
the Minister for the Interior simplified the form for signing
death certificates, and, in cases of death where a medical
man had been unprocurable, ministers of religion, the police,
and controllers of depots were allowed to give certificates if
the death was obviously due to the disease. From Oct. 1st
to Nov. 15th there had been 660 deaths of European males
and 450 European females, total 1110; during the same
period 1875 coloured males had succumbed and 1317
females, total 3192, the total deaths from the epidemic up
to Nov. 15th being 4302. In spite of difficulties owing to
the want of a definite diagnostic sign and the confusion
which exists between ordinary colds and influenza, Dr.
Anderson recommends that this disease should be made
notifiable, so that the earliest information of its existence
can be obtained and a careful examination made of the
sputum and of naso-pharyngeal swabs. In his opinion,
notification in inter-epidemic periods would be useful; as
soon as an extensive outbreak occurred this could be dropped
and reliance placed upon house-to-house visitation.
Dr. Anderton's Main Recommendations.
Dr. Anderson makes certain recommendations with regard
to the remedy of defects either known to exist or which
have been found during the epidemic, and which will help
in preventing its recurrence and leave the municipality
prepared should an outbreak occur.
1. Overcrowding was one of the greatest difficulties
which had been met with, for it was no use turning
people out of one overcrowded house to overcrowd another,
and for humanitarian reasons they could not be turned
into the streets. Since the epidemic the council have
decided to ask authority from the ratepayers to spend
a further sum of £250,000 over and above the £50,000
already granted for the erection of about 122 houses
for municipal employees, which, in the same ratio,
would supply about 610 houses to accommodate about
3000 people. Every encouragement should be given to
firms to build houses for their employees, either singly or
by combination. The Government ought at least to house
its own employees. If a public utility company could be
formed for the purpose of building houses of this class, the
interest on the money invested not to exceed 6 per cent., a
valuable addition to the means for overcoming the scaroity
of houses would be created. A scheme is under considera¬
tion of the council for advancing money to enable persons
desiring to build houses on land in their possession or to
let sites on municipal land on leases of 99 years. Efforts
are being made for the introduction of an ordinance in the
next session of the Provincial Council to authorise loans for
this purpose, the total amount not to exceed 75 per cent, of
the expenditure. The present intention is not to advance
loans on a house proposed to cost more than £600, and
that no advance be made to a person whose income exceeds
£30 per mensem.
2. Provision is necessary for the supply of medical
outdoor relief to those people who are too poor to pay for
medical attendance, a system which prevails in England.
Many people who are not paupers cannot afford to pay for
medical attendance, and provision should be made for their
medical care. A well-considered Poor-law is urgently needed.
3. Increased general hospital accommodation should no
longer be delayed. The plea that there is no money should
not be allowed to exercise influence, because apart from the
loss of valuable lives these epidemics cause great expense to
the community not only in actual expenditure, but in loss to
business generally. The additional pavilion already asked
for in the estimates of next year should be erected without
delay. A cumber of marquees of the E.P. pattern would be
found of service in case of need.
4. A system of lectures and instruction in home nursing
would be useful, the instruction to be as practical as
possible. Homely lectures might be delivered by the
health visitors in the poorer districts whenever the disease
threatened to recur; the use of handkerchiefs in pre¬
venting the spread of the disease, and the value of nasal
douches might be pointed out, and warning should be
given against spitting on pavements, floors, and public places.
5. Influenza and pneumonia in an inter-epidemic period
should be made compulsorily notifiable.
6. The male inspectors should be increased from 16 to 24,
and a chief sanitary inspector appointed. Some sections
of the community required their ideas of cleanliness con¬
siderably raised. The number of female inspectors, there¬
fore, should be increased from 5 to 11 and include a woman
chief inspector to supervise the work. One of the principal
duties of these inspectors would be to instruct housewives
on the cleanliness of the house and see that regulations
were carried out.
• 7. An additional medical assistant might be appointed
to assist in investigating suspect cases of influenza and
other special infectious cases. Besides this he thought
it would be necessary to have an organisation ready to
deal with a widespread epidemic, and to be called into
operation as soon as required. In each ward there should
be appointed a central dep6t, and the councillors of
each ward should form a committee to manage the same and
prepare a list of voluntary helpers from those who
have gained experience during the present epidemic.
Each ward should be divided into blocks of houses, so small
that a helper oould visit the houses in that block daily.
8. The medical officer of health should be kept informed
of the existence of disease on all steamers arriving in the
bay, so that he may be on his guard against any disease
being introduced in that manner.
9. Preventive inoculations should be made as soon as
there is any evidence of cases of the disease in the city or
in the Union of South Africa.
526 Thb Lancet,] SPECIAL CLINICAL MEETING OF BRITISH MEDICAL ASSOCIATION. [March 39,1919
Tbe Lancet,] CENTRAL MEDICAL WAR COMMITBE.—URBAN VITAL STATISTICS. [Mabch 29, 1919 527
Demonstrations at 2.90 p.m. Wednesday, April 9th : On MaU’ia by
the London School of Tropical Medicine, at Endsletgh Pilacc Hotel,
Qower-atreet, W.C.l. Thursday, April 10th; On lhe Pathology of
Dysertery, at S r >. Thomas's Hospital, Albert Embankment. Friday.
April 11th : On the Anaerobic Bacteria which infeot Wounds, and on the
subject «>f Filler passing Viruses In Influenza and other Diseases, and
Rickettsia Bodies; at the Lister Institute of Preventive Medicine,
OhrUea Gardens.
Secretaries of Section: Dr. J. A. Arkwright and Maj. A. M. W. Ellis,
C.A.M.U.
The War Collection or Pathological Specimens from the seat
of war in France will be on view daily from 10 to 6 (on
Saturday 10 to 1) at the Royal College of Surgeons, Lincoln's
Inn-fields, W.C. 2. It comprises a large and complete series
of gunshot fractures of the bones ; and another series,
equally complete, of gunshot injuries of the different organs
and soft structures, as well as specimens of disease incident
to warfare, the effects of gassing, trench nephritis, gas gan¬
grene, Ac. Tbe entire collection is systematically arranged,
and each preparation is furnished with a brief description
and history. Three demonstrations have been arranged, to
be given from 3 30 to 4.30 p.m. Sir George Makins:
Injuries of Arteries (Wednesday); Prof. Arthur Keith:
Fractures of the Skull (Thursday) ; Mr. C. S. Wallace:
Abdominal Injuries (Friday).
CENTRAL MEDICAL WAR COMMITTEE:
ITS WORK IN DEMOBILISATION ENDED.
At a meeting of the Central Medical War Committee, held
on March 21st, the following letter, dated March 19th, from
the Ministry of National Service, addressed to the chairman
of the Committee, was read :—
I am directed by the Minister of National Service to
inform yon that, in view of the fact that a more general
demobilisation of medical officers from the Royal Army
Medical Corps is now understood to be imminent, it has
been decided to discontinue tbe functions of this Ministry in
the selection and nomination of medical officers for release
for the Service Departments concerned. This decision will
take effect as from the 1st April next. *
It follows that such responsibility as this Ministry has
hitherto undertaken in regard to the safeguarding of the
Medical Service throughout the country, and which it has
been able to exercise by means of its powers and functions
in connexion with the demobilisation of medical officers,
will cease on the same date.
You will appreciate that this decision does not affect
the position of your Committee as a medical tribunal, so
long a3 tbe Military Service Acts and the Military Service
(Medical Practitioners) Regulations, 1918, remain in force.
Hteps are being taken to terminate on or about the same
date the arrangements which have been in force in regard
to secretarial and clerical assistance.
It will be remembered that at the request of the Ministry,
and in consultation with it, the Committee drew up a scheme
for demobilisation of medical men on personal grounds,
which was based primarily on length of service and age with
due consideration for special claims which might be put
forward. The Secretary of State for War has stated that the
Ministry of National Service had agreed with the War Office
that the restricted procedure of selection of individuals for
release should be discontinued. It follows from this that the
Gentral Medical War Committee is no longer in a position to
secure the release of doctors either on public or private
grounds, and that in future their demobilisation will be
regulated solely by the consideration of whether the War
Office can dispense with their services.
On receipt of the above letter the Committee came to the
conclusion that its duties as advisory body to the Ministry of
National Service were necessarily terminated, and it was
stated by representatives of the Royal Colleges present that
the Committee of Reference had decided to adjourn sine die.
The Scottish committee, it is understood, will in due course
issue its own statement.
National Work of Central and Local Medical War Committees.
The following letter has been received by the Chairman of
the Central Medical War Committee, dated March 24th,
from Sir Auckland Geddes, Minister of National Service;
and its message has been conveyed to the Local Medical War
Committees with an expression of thanks from the Central
.Medical War Committee for the devoted and public-spirited
work which they have carried on for the'past four years in
the interests of their professional brethren and of the
country : —
Now that the functions of the Ministry of National Service
are terminating, I wiBh to express to you my high apprecia¬
tion of the* services which the Central Medical War Com¬
mittee and its Local Medical War Commi tteea have rendered
in association with my Medical Department. These services
have been continuous and often arduous, but they have been
of very real value and assistance to the work of the Ministry.
I have always felt that through the Central 'Professional
Committees, with their local organisation, my Medical
Department has been able to keep in touch with the medical
situation tbrougnout the country, and with the needs and
views of the profession itself, in a' manner which has greatly
facilitated its administrative work.
I shall be grateful if you will convey my own personal
thanks and the thanks of the Government to the members of
the Central Medical War Committee, and also to the Local
Medical War Committees throughout England and Wales for
the important national work which they have done.
Although the Central Medical War Committee has thus
finished its work in connexion with demobilisation, it will
not be dissolved until the annual representative meeting in
July next, and in the meantime will continue, through its
General Purposes Subcommittee, to assist so far as it can
those members of the profession who are still on service
or recently discharged from it. Local Medical War Com¬
mittees are therefore being advised not to dissolve, but to
adjourn and hold themselves in readiness in case any
business arises which may call for their consideration.
The Committee of Reference.
The Ministry of National Service having informed the
Committee of Reference that it will discontinue to exercise
its functions at the end of this month, the Committee will
be unable to put forward, through the Ministry, the names
of members of the staffs of the London Hospitals and
Medical Schools for early demobilisation. The Committee
have already applied for the release of all those whose names
have been supplied to them, and will still endeavour by
direct application to the Admiralty and War Office to
facilitate the release of those who may yet be asked for by
the hospitals and medical schools. Looking to the more
general demobilisation determined upon by the Secretary of
State for War, the duties of the Committee of Keferenoe,
except as a Tribunal of Appeal, may now be considered as
completed. Nevertheless, the Committee will remain in
existence for tbe present with a view to afford ahy assist¬
ance which may be necessary to H.M. Government, and for
tbe consideration of other matters, incidental to tbe war,
which may be referred to them.
URBAN VITAL STATISTICS.
(Week ended March 22nd, 1919.)
English and Welsh Tovms .—In the 96 English and Welsh towns,
with an aggregate civil population estimated at 16,600,000 persons, the
annual rate of mortality, whloh had declined from 35*7 to 28*4 In
the three preceding weeks, further fell to 20*9 per 1000. In London,
with a population slightly exceeding 4,000,000 persons, the annual
death-rate was 18 0, or 3*4 per 1000 below that recorded in the previous
week ; among tbe remaining towns the death-rates ranged from 9*6 in
ItsHam. 9 8 In Oxford, and 10*5 in Eastbourne, to 37*9 in Darlington,
39 2 In Burv. 40*2 In Stoke-on-Trent, 42*4 in Barnsley, and
49*0 in Middlesbrough. The principal epidemic diseases oansed
206 deaths, which corresponded to an annual rate of 0*6 per
1000, and Included 73 from measles, 46 from infantile diar¬
rhoea. 38 from diphtheria, 29 from whooping-cough, 15 from
scarlet fever, and 5 from enteric fever. Measles caused a death-rate
of 1*7 in Sheffield. 8*1 In Rotherham, and 8*3 in Middlesbrough; and
scarlet fever of 1*2 in Birkenhead. The deaths from Inflnensa, which
had been 3889. 3218, and 2320 in the three preceding weeks, further
declined to 1361, and Included 230 In London, 107 in Birmingham,
74 in Manchester, 59 In Liverpool, 45 In Leeds, 42 in Stoke-on-Trent,
and 37 in Bristol. There were 5 cases of small-pox, 1010 of scarlet
fever, and 1191 of diphtheria under treatment in the Metropolitan
Asylums Hospitals and the London Fever Hospital, against 5, 1020.
nnd 1153 at the end of the previous week. The causes of 53 deaths
in the 96 towns were uncertified, of which 14 were registered in
Birmingham, 9 in Liverpool, 6 In Manchester, and 4 in London.
Irish Toums .—The 288 deaths in Dublin corresponded to an annual
rate of 371, or 10 7 per 1000 below that recorded in the previous
week, and Included *77 from Influenza, 6 from measles, 5 from
infantile diarrhoea, and 1 from diphtheria. The 238 deaths in Belfast
were equal to a rate of 30*9 per 1000. and included 2 from diphtheria
and 1 oich from whooping-cough and infantile diarrhoea.
Londonderry Infirmary.— Mrs. A. G. G. McCay
has contributed £1000 to endow a bed in the County and
County Borough Infirmary, Londonderry, in memory of her
husband, the late Dr. J. S. McCay, of Troy, Londonderry,
formerly sub-sheriff of that city.
r>28 T*1 Lancet,]
THK NURSING REGISTER.
[March 29,1919
dOsmspiibenre.
“ Audi alteram partem/*
THE NURSING REGISTER.
To the Editor of Thb Lancet.
Sir,—I t is stated in the annotation under this heading in
your issue for March 22nd that the Central Committee for
State Registration will not consider the proposal that any
scheme for State registration should include nurses who
have special hospital training only. I desire to point out
that the writer of the annotation has apparently overlooked
Clause 11, (1) (/>) of the Central Committee's Bill, which
distinctly provides for what is known as “ reciprocal train¬
ing.” Under this clause the training in a special hospital
(e.g., a children's hospital) would be allowed, subject to
certain conditions, to count as part of the general training
required under the Act; the clause allows, in fact, just such
a scheme as is outlined by your annotator himself towards
the end of his note.
1 am, Sir, yours faithfully,
E W. Goodall,
Hon. Medical Secretary, Central Committee for
the State Registr«tlon of Nurses.
Grove Military Hospital, S.W., March 22od, 1919.
Colonel Goodall’s explanation of the significance of
the clause In the Central Committee's Bill is a welcome con¬
firmation of our view that the aims of the two rival Parlia¬
mentary measures should readily be reconciled. We bave
been asked to publish a letter addressed to an enquirer by
Sir Arthur Stanley, Chairman of the College of Nursing,
Limited, in which he states the attitude which the College
will take towards the Nurses’ Registration Bill now before
the House of Commons. Sir Arthur Stanley writes :—
The Council of the College of Nursing has had this matter
under its consideration, and it has decided that as the Bill
affirms the principle of State recognition of the nursing pro¬
fession it should, so far, be supported. I am quite aware,
and so are the members of the Council, that a few of the
principal supporters of the Nurses' Registration Bill have
constantly misrepresented the aims and objects of the
College, and have insulted those who were in any way assist¬
ing it. We hold, however, that no personal feeling should
be allowed to interfere with thb attainment of State regis¬
tration, which means so much for nurses, and you will be
glad to know that its members are sufficiently broad-minded
to disregard petty personalities and to work with a single
mind for the good of the nursing profession. Ed. L.
CULTIVATION OF A FILTER-PASSING
ORGANISM IN INFLUENZA.
To the Editor of The Lanoet.
Sir,—T o avoid the possibility of misunderstanding, I desire
to amplify a perhaps obscure paragraph in my obituary
notice of the late Major H. G. Gibson, R.A.M.C., published
in your issue of March 8th. Referring to the cultivation, by
the Noguchi technique, of a minute filter-pa«sing coccus, I
stated that the independent findings of Majors Gibson and
Bowman and Captain Connor had been confirmed by the
work of Captain J. A. Wilson, R.A.M.C., a note on which
was published by Sir John Rose Bradford, Captain E. K.
Bashford and Captain J. A. Wilson in The Lancet and the
British Medial Journal of Feb. 1st. This paragraph, though
intended merely to show that similar findings, mutually
confirmatory, had been arrived at independently by two
groups of investigators, has been construed as an implica¬
tion that priority was claimed by me for Majors Gibson and
Bowman and Captain Connor. No such implication was
intended. Though Captain Wilson’s work was not considered
by Sir John Rose Bradford to be sufficiently complete to
justify publication until the latter part of January, 1919,
this officer had been successful in making “Noguchi”
cultures of what appears to have been thb d&me orgatafsm
some months before this was done by Gibson, Bawman, and
Connor.
At the same time full credit for independent and original
work must be given to the latter workers who were unaware
that the “ Noguchi ” technique had already been employed
in cultare work in influenza. As the paragraph in question
has already given rise to misunderstanding, 1 hoperihat,. in
justice to Captain J. A. Wilson, this letter maybe given
early publicity.—I am, Sir, yours faithfully,
S. L. Cummins,
Oolooet, A.M.S.; Advlter in Pathology.
March 19th, 1919. B.E.F., France.
THE COPPER TREATMENT OF LUPUS.
To the Editor of Thh Lancet.
Sir,— Mr. H. J. Gauvain and Dr. H. A. Ellis are to be
congratulated upon the successful results they have obtained
with brass paste in the treatment of cutaneous tuberculosis. 1
In my paper upon the subject, read before the Brighton
meeting of the British Medical Association in 1913,1 pointed
out the hopefulness of the copper method in cases of lupus
vulgaris.- I then employed copper-potassium tartrate, in
the form of Fehling’s solution, injecting hypodermically,
directly into the lupoid tissue, from £ to 2 c.cm. of a 1 per
cent, solution, or, as an alternative, copper chloride was
used in the same strength. Some slight local reaction was
observed, but three days later the lupoid nodules were seen
to be paler and flatter, and ultimately to become necrotic.
If the brass preparations will prove to be so completely
selective m tbeir action, without any destructive effect upon
healthy tissue, a valuable remedy will indeed have been
found. It will be interesting to observe the effect of these
newer combinations of copper upon lupus of the mucous
membranes.- 1 am, Sir, yours faithfully,
G. Norman Meachen, M.D., M.R.C ?.
Braintree, March 20th, 1919.
ABSENCE OF CANCER IN THE ARCTIC
REGIONS.
To the Editor of THE LANCET.
Sir,—M r. Vilbjalmur Stefansson has returned from his
expedition to the Arctic and has written to me from Alaska
to state that cancer does not exist among the Esquimos. He
kindly undertook this investigation at my request when he
left in 1914. Previous to this Sir W. MacGregor, Dr. W. T.
Grenfell, Mr. Frank Bezley, and more recently Rear Admiral
Peary, have all told me that they had never seen a case of
cancer among the native tribes of the Far North ; and it was
their observations whioh prompted me to ask Mr. Stefansson
on the eve of his departure in 1914 to make a special investi¬
gation. Mr. Stefansson also sends opinions to the same
effect from Dr. Grafton Burke and the late Dr. George Howe,
who worked for years on the Yukon River. It may be
remembered that I’anum half a century ago remarked that
the disease was either extremely rare or did not exist in
Iceland and South Greenland.
I think therefore we may safely assume that cancer does
not exist in the Arctic. It is a point of great importance to
cancer research, f jr it has been generally accepted that the
disease is ubiquitous. This evidently is not the case, and
the question now arises as to how far this new fact may
alter onr conceptions as to the causes of the disease. It
seems to me that the absence of cancer in the Arctic can
only have one of three explanations—racial, dietetic, or
climatic The Esquiraos were originally Asiatics like all the
Indians of the American Continents, and there is no reason
to suppose any physical or physiological difference which
will exempt them from cancer. Moreover, Panum’s observa¬
tions were on Europeans—Norwegians and Danes. Dietetic -
ally the E<quimos are enormous meat-eaters, but until 20
years ago did not have vegetables ; otherwise their food dor*
not differ from that of other natives, and Panum s
observations again negative a dietetic explanation. The
climatic explanation seems the best, for the climate
of the Arctic differs frpm any other part of the
inhabited globe; but it revives the parasitic theory.
The cold is so intense that saprophytic organisms cannot
exist. Nothing putrefies if left in the open. While
contagious diseases (venereal; &c.) are common, disease*
which are contracted from the general atmosphere, such as
a “ ooM,” are unknown. It would appfear,"therefore, that
-canoer may come into a similar category, and that part at
least of the canse of it is dne to an organism which invades
the body from without, whioh is air-borne in part of its life-
history, and which cannot exist in the Arctic climate.
i Thk Lancet, Maroh 15th, 1919.
* Brit. Med. Jour., 191?, ii., 1005.
The Lancet,]
HjEMATEME8I8 AFTER ABDOMINAL OPERATION.
[March 29,1919
Although I have tried to correlate them, all the other
theories as to the causation of cancer appear to me to fail in
view of the new-proved fact that the disease does not exist
in the Far North.
I have sent all the details to the Journal of Cancer Research ,
but think that those interested in the cancer problem in this
country might also like to hear briefly of Mr. Stefansson's
discovery. I am, Sir, yours faithfully,
Clinical Laboratory, Ministry of National 8ervlce, H. 0. R06S.
Conduit-street, W., March 18th, 1919.
MUSK IN INFLUENZA.
To the Editor of The Lancet.
Sir, I think it would be well if you called attention to
the value of muBk as a heart stimulant in severe cases of
influenza. My friend, Dr. Humphrey Davy, reminds roe
that it was used as such in typhus fever in Ireland with good
effect in the second week of that disease. It certainly
seemed to do good when I gave it in grain doses in the
influenza epidemic of 1890. Several cases of double pneu¬
monia in octogenarians so treated recovered. The only
objection to its use is its high cost, which at that time was
Is. per grain. I am informed that it is now selling at 6d.
per grain. It was well worth the expenditure, but friends
of patients should be warned of the price in advance.
I am, Sir, yours faithfully,
Arthur Ransomb, M.D., F.R.C.P., F.R.S.
Bournemouth. March 23rd, 1919.
HASMATEMESIS AFTER ABDOMINAL OPERA-
TION. •
To the Editor of Thb Lancet.
Sir,— In The Lancet of Dec. 21st, 1918. there is an
article by Dr. J. V. Arkle, of Kalgoorlie, on Hnematemesis as
a Complication of Appendicectomy. I have bad two cases
following hysterectomy similar to the cases he records, but
unfortunately one of them died.
Case 1.—I was consulted by a woman of 35 for pain in the
back and some leucorrhcca. There was no history of
menorrhagia, but she had two abortions previously, each of
about three months’ gestation. A diagnosis of uterine
tumour was made, and an operation was suggested, which
was agreed upon and soon after performed under spinal
anaesthesia. The operation was uneventful, inasmuch as
the uterus was free from any adhesions, though there were
several small fibroids invading the whole of the uterus. A
complete hysterectomy was performed, and for four davs
after the operations the patient was makiDg an uninter¬
rupted recovery when suddenly she started complaining of
great thirst and looked pale and restless. Alter a few
hours she vomited a large quantity of blood, and in spite of
best precautions she continued vomitiDg blood and finally
succumbed. A second exploration was not done as the
hicmatemesis was distinctly the cause of the mischief.
Case 2.—In October last a patient of about 42 was brought
to me by a local medical practitioner with a distinct history
of uterine tumour. A supravaginal hysterectomy was per¬
formed under spinal anesthesia and, as in the previous
case, the operation presented not many difficulties. About
40 hours after the operation I was suddenly asked by the
night nurse to see the patient, as she had vomited a "large
quantity of very dark blood. A hypodermic injection of
adrenalin was immediately given and continued with
20 minims of ext. ergot, liej. by the mouth for 24 hours. The
vomiting of blood gradually diminished and the patient was
discharged on the twenty-fourth day perfectly well.
It is suggested that these haemorrhages occur as the result
of interference with the omentum, but in neither of these
oases was there the slightest cause to disturb the omentum
to any great extent.—I am. Sir, yours faithfully,
F. K. Pahakh. M.D.Vict., M.R.C.S., &c.
The Parakh Hospital. Khetwadl, Bombay, Feb. 8tb, 1919.
ARTIFICIAL CYANOSIS OF THE LIPS.
To the Editor of The Lancet.
Sir, —The war has brought to light not a few instances of
malingering, and it is important that all such cases, whether
connected with the war or not, should be brought to the
not ice o f the professiot^. Heart affections, especially in the
absence of recognisable organic disease, are among those
which easily lend themselves to this form of deception.
About ten yeara since a young woman came under my
care as an out-patient at the National Hospital for Diseases
of the Heart for cardiac ftymptoms; she was also of neurotic
temperament. Mitral regurgitation with a fairly com¬
pensated heart was found. After a few months she was-
admitted for hysterical paraplegia, which rapidly yielded to
electric baths. Later on she was again admitted for heart
failure with the usual complications. Recovery took place
and attendance at the out-patient room was resumed.
Several months elapsed when, on a dark winter's day, she-
appeared looking very ill and having intense cyanosis of the
lips, and she was promptly admitted. In the course of a
thorough examination the following morning it was noticed
that although there were some general duskiness of the skin
it did not correspond with the intense blueness of the lips.
I placed a thermometer in the patient’s mouth and on with¬
drawing it purposely rubbed the lips with my finger, which
was found to be slightly coloured. I directed the nurse to*
watch her during the morning toilet, and she was seen to
rub her lips with an aniline pencil. I subsequently discovered
that the relations between the patient and her stepmother
were greatly strained owing to the latter having persuaded the
girl’s father that there was nothing the matter with her.
I was led to my suspicion by a previous experience. A
man called in an awful fright because, on wiping his mouth
after having eaten a bath bun, he found the handkerchief
deeply stained and, on looking at his face in the glass, saw
that his mouth was also blue. Examination of the hand¬
kerchief revealed the presence of small pieces of grit which
marked paper like an aniline pencil. The man noticed some¬
thing hard when eating the bun and promptly spat the contents
of his mouth in his handkerchief. How the piecte of pencil
found its way into the bun was never discovered, though 1
related the circumstance to the baker at whose shop the
bun was purchased.—I am. Sir, yours faithfully,
Harley-street, March 20th, 1919. CHARLES W. CHAPMAN.
ARE RELAPSES OF BACILLARY DYSENTERY
FREQUENT ?
To the Editor of The Lancet.
Sir,—I t is stated that of some 1300 cases of dysentery
sent baok as cured to England since the war not a single
one was found to show signs of bacillary dysentery, whilst
some 12 per cent, were found with Amoeba histolytica,
I write to ask whether it is the general experience of
practitioners in England that cases of bacillary dysentery
returned from abroad as cured do not relapse. The matter
is of obvious importance, for one is called on to state
whether a patient is liable to a relapse of the disease when
he returns home.
1 am, Sir, yours faithfully,
J. C. McWalter, M.D., LL.I)., D.P.H
Alexandria, Egypt. March 8th, 1919.
IMMUNITY IN “ INFLUENZA. ’
To the Editor of The Lancet.
Sir,—A mong 269 cases of “ influenza,” mainly childron,
occurring in three schools in the summer, autumn, and
winter waves of the disease there were two children with
definite second attacks and six further alleged second
attacks. Taking all six as genuine, the rate of second
attack is (approximately) 3 per cent. If further investiga¬
tions confirm these figures, it would appear that for practical
purposes one attack of “influenza” confers immunity for
some six months, at least among children.
I am, Sir, yours faithfully,
Colwoll, Malvern, March 2Ut, 1919. MARY H. WILLIAMS.
National Hospital for the Paralysed and-
Epileptic.— At the annual meeting on March 25th of the
National Hospital for the Paralysed and Epileptic, Queen-
square, W.C., when Sir Frederick Macmillan took the chair,
it was reported that the expenditure of the hospital and its*
Finchley branch had increased from £19,108 in 1914 to £30,230
in 1918. Throughout the war 70 beds had been provided for
soldiers suffering from nerve injuries and affections, and this
work was being followed up by special provision, in three
branch hospitals, for discharged men in connexion with the
Ministry of Pensions. The hospital and its branches suffered
acutely in the influenza epidemic, and the board room was
utilised as a special isolation ward.
.530 Thb Lanobt,]
OBITUARY.—THE WAR AND AFTER.
[March 29, 1919
WILLIAM ALEXANDER, M.D. R.U.I., F.R.C.S. Eng., I
LECTURER ON CLINICAL SURGERY AT THE UNIVERSITY OF
LIVERPOOL.
Dr. W. Alexander, who died at Heswall, near Liverpool,
on March 9th, was born at Antrim, and received his medical
-education at Queen’s College, Belfast, where as a gold
medallist and exhibitioner he graduated at the Royal
University of Ireland in 1870. He became a Fellow of the
Royal College of Surgeons of England seven years later,
and in 1881 wrote the Jacksonian prize essay on the
Pathology and Surgical Treatment of Diseases of the
Hip-joint, and in 1883 the Sir Astley Cooper prize essay
at Guy’8 Hospital on the Pathology and Pathological
Relation of Chronic Rheumatic Arthritis. He was lecturer
on Clinical Surgery at the University of Liverpool,
and honorary surgeon to the Royal Southern Hospital,
Liverpool, for 22 years, which post he resigned in 1910 He was
visiting surgeon to the Liverpool Workhouse Hospital from
1875 to 1910, ex-President of the British Gynaecological
Society, Fellow of the Hoyal Society of Medicine, and a
member of the Liverpool Medical Institution. He was a Lieu¬
tenant-Colonel in the Territorial Force and was on the staff of
the 1st Western General Hospital. Dr. Alexander’s name is
associated with the treatment of epilepsy, on which subject
he contributed a paper on the Surgical Treatment of
Epilepsy, published in Thb Lancet in 1878, and one on the
Treitment of Epilepsy, which was published in Brain in
1882. He was medical officer to the Home for Epileptics at
Maghull, which was founded for the cure of this disease.
Dr. Alexander was a very accomplished and capable man,
who never filled in the public eye the place for which he was
equipped. _
ALEXANDER ROBERT COLDSTREAM, M.D. Edin.,
F R.C.S. Edin.
Dr. Alexander Rooert Coldstream, who died at his resi¬
dence in Florence on Feb. 26th, was well known to many
English and American visitors to the Tuscan capital. He
was born in Edinburgh on August 4ih, 1852, the son of a
medical man, and was educated first at the Edinburgh
Academy and later at the University, where he graduated
M.B., C M. in 1874. He held resident appointments at the
Royal Infirmary and at Chalmers’ Hospital, and for a time
practised in Leith and Edinburgh. But having proceeded
to the M D. degree of his University in 1881, he went to
Florence two years later, where he practised for more than
30 years and made a large number of permanent friends,
while he enjoyed a big practice among sojourners, and wrote
a popular monograph on “ Florence as a Health Resort.” On
his retirement in 1914 he received from his many friends and
patientsa presentation which may be described as thoroughly
well earned, but not unlike other testimonials. But in 1917 he
was the recipient of a compliment of a unique character
an illuminated address for his “ characteristic British
action ” in saving an Italian girl from drowning by
plunging into deep water and holding her up until means
of safety arrived. Dr. Coldstream was then 65 years
of age.
During the war Dr. Coldstream devoted much of bis time to
works of philanthropy, one of his particular interests being
the British Home for Italian Wounded, to which he acted as
treasurer throughout the period of hostilities, contributing
much to the success of this excellently organised Red Cross
Hospital by his energy, tact, and complete knowledge of
Italian affairs. He was also honorary acting secretary to the
British Relief Fund for helping poor English men and women,
And secretary to the Patriotic League of Britons over seas.
ROBERT SYDNEY MARSPEN, M.B., C.M. Edin.,
D.Sc., F.R S.E.
Dr. R. S. Marsden, who died on March 8th, at the age of
€2 years, was educated at Edinburgh and on the continent,
took the B Sc. degree in 1877, the D.So. two years later,
and qualified in 1885. For a time he practised at Malton,
in Yorkshire, where he was afterwards medical officer of
health, and in 1891 he was appointed medical officer of
health for Birkenhead, which post he held for more than a
quarter of a century. In 1892 he took the D.P.H. diploma
-of the Royal College of Surgeons of Edinburgh. In his
endeavour to promote the health and well-being of the town
which he represented one of his early achievements was the
substitution of the water-closet for the privy midden on
about 4000 premises, mainly in the centre of the town. He
was also instrumental in the establishment of the fever hos¬
pital and the introduction of refuse destructors, whilst the
improvement of housing conditions and of school hygiene,
the abolition of underground bakeries, and adequate meat
inspection were other directions in which his activities were
engaged. He carried out important work in maternity and
child-welfare schemes, tuberculosis dispensaries, the treat¬
ment of cases of mental deficiency, and the campaign
against venereal diseases.
Dr. Marsden, who was a Fellow of the Institute of
Chemistry, was particularly interested in this science, and
was a pioneer of the artificial production of diamonds, on
which subject he wrote a treatise in 1881 entitled, “ Artificial
Preparation of the Diamond.” For some time he was lecturer
on chemistry at the University of Bristol, and carried on
research work in chemistry and physics. He was a Fellow
of the Royal Society of Edinburgh, of which he was a past
President, and had contributed papers on chemistry, physics,
public health, and sanitary science. Literature and art
also interested him, and in spite of his many scientific
activities he found time to speak at, and to take part in, the
debates at the Birkenhead Literary and Scientific Society;
he was also a member of the Birkenhead Art Club. Since
1898 he had been instructor and lecturer on Meat Diseases
to the officers of the Royal Army IService Corps.
Mar anb ^ftcr.
The Casualty List.
The names of the following medical officers appear among
the casualties announced since our last issue :—
Died.
Capt. J. W. Bingham. U.A.M.C., qualified at Edinburgh
in 1907, and afterwards practised at Blytb, North
umberland. He joined up in the earlv part of 1915.
Major H. H. Griffith, Australian A.M.C., died at the
3rd (London) General Hospital of pneumonia following
influenza.
OBITUARY OF THE WAR.
ROLAND AUGUSTUS HOBBS, M.R.C.S. Eng.,
TEMPORARY SURGEON-LIEU TEN ANT, ROYAL NAVY.
Surgeon-Lieutenant R. A. Hobbs, who died of pneumonia
on Feb. 13th at the Royal Naval Hospital, Haslar, aged
33 years, was second son of Mr. F. A. Hobbs, of High
Wycombe, Bucks. Educated at the Portsmouth Grammar
School and at St. Mary’s Hospital, he took the Conjoint
Diploma in 1908. He
was house surgeon and
anaesthetist to the Royal
Surrey County Hospital.
Guildford in 1911, and
in the same year his
paper on “ Tetanus
Treated by Chloretone
—Recovery” was pub¬
lished in the British
Medical Journal. He
went into practice
at High Wycombe.
Bucks, where he was
honorary medical officer
to the High'"Wycombe
and Earl of Beaconsfield
Memorial Cottage
Hospital. He joined the
Navy as a temporary
surgeon on August 4th.
1914. After serving in the North Sea and in the West Indies
he was appointed senior medical officer to the Royal Naval
Hospital, Hull. His last appointment was to H.M.A.S.
Melbourne.
Surgeon-Lieutenant Hobbs married, in 1917, Marjorie,
elder daughter of the late Mr. Justice Cargill, of Kingston.
Jamaica, and leaves a widow and one daughter.
The Lancet,]
OBITUARY OF THB WAR.
[March 29, 1919 531
CHARLES MACKIE BEGG, C.B . C.M.G., M.D.,
F.R C P. A S. Edin.,
COLON KL, NEW ZEALAND EXPEDITION A HY FORGE.
Colonel C. M. Begg, who died suddenly from pneumonia
following influenza at the age of 39 years, was born at
Dunedin, New Zealand, and was fourth son of the late
Alexander Campbell Begg. Educated at Edinburgh Uni¬
versity, where he had a distinguished career as a student, he
took the M B., Ch.B. degree in 1903, a'ter wards gaining
the M D. and F.R.O S., and about 12 months ago the
F.R.C.P. He served as medical officer on the Transport
ftaura during the Somaliland campaign in 1903. and on his
return to New Zealand built a large and lucrative practice
in Wellington, taking at the same time a great interest in
the Territorial Service. On the outbreak of war he
volunteered for overseas
service, and left New
Zealand with the main
body N . Z . E. F . as
Lieutenant - Colonel in
charge of the ambu¬
lance. • He was present
at the fighting on the
Canal in 1915, and t hen
proceeded to Gallipoli
with the New Zealanders
and Au strali ans ,
landing on the Penin¬
sula on the memorable
April 25th, 1915. On
June 27th he was
slightly wounded in the
knee by a shell. He
returned to duty after
a few days’ absence,
and later on developed
dysentery and was invalided after the heavy fighting in
August. He was sent back in November and became
temporary Colonel and Assistant Director of Medical
Services to the New Zealand and Australian Division, and
remained on Gallipoli till the evacuation. Returning to
Egypt, he was promoted to the rank of Colonel, and was
appointed Assistant Director of Medical Services to the New
Zealand Division. For his services on Gallipoli he was men¬
tioned in despatches and awarded the C. M.G. After further
service in Egypt he landed in France with the New Zealanders
and saw fightiDg around Armentieres and the 8ommein 1916.
On Oct. 20th, 1916, he became Deputy Director of Medical
Services to the Second Anzac Corps. With this corps, which
became later the 22nd Corps, he saw fighting around Ypres,
Messines, La Bass6, Ville, and later on, in the great German
offensive, he worked in conjunction with the French Army
attacking west of Rheims. For his services in France he
was twice mentioned in despatches and awarded the C.B.
He was also mentioned in the French Ordre de Jour and
awarded the Croix de Guerre. In November, 1918, he became
Director''of Medical Services of the New Zealand Expe¬
ditionary Force, which post he held at the time of his death.
Even in the darkest days of the war his cheerful optimism
was a constant inspiration to all the officers and men who
worked with him. A man of conspicuous ability and
iudgment, an excellent organiser and administrator, his
death will be a serious loss to the medical services of
New Zealand.
In 1909 he married Miss Treadwell, of Lower Hutt, New
Zealand. He leaves a widow and two sons.
The Honours List.
The following awards to medical officers (all members of
the R.A.M.C. except where otherwise stated), in recognition
of their gallantry and devotion to duty in the field, are
announced. The acts of gallantry for which the decorations
have been awarded will be given later : —
Bar to Distinguished Service Order.
Mai. O. A. Elliott, D.S.O.. C*n. 4..M.C. ; Capt. (acttng Lt.-Col.)
W R Gvdner, D.S.O.; Lt-Col. D. P. Kipoele, D.S.O., Can A.M.C.;
Lt.-Col. T. McO. Leask. D.S.O., Can. A.M.C.
Distinguished Service Order.
Capt. (acting Lt.-Col.» W. W. Boyc*; Maj. R. P Craig. Austr. A.M.C.;
Oapt. (acting Lt.-Col.) W. H. L. McCarthy, M.C.; Temp. Capt. C. B.
Young, M.C.
Second Bar to Military Cross.
Temp. Capt. (acting Maj.) G. Rinklne, M.C.
First Bar to Military Cross.
Capt. J. K. Barry, M.C., Can. A.M.C ; Temp. Capt. M. C. Burke, M.C.
Temp. Capt. G. M. Cameron, M.C.; Capt. F.T. Campbell. Can. A.M.C.;
Capt. H. C. Davis, Can. A.M.C. ; Lt. (temp Capt.) W H. Fergu on.
M C.; Lt. (acinic Maj ) J. La F. Laud*r. D.S.O.; Cant, (acnng Maj.)
n. B Low, M.C.; Capt. U. C. Moses. Can. A.M.C.; Temp. Capt. J C-
Ogllvie, M.C.: Temp. Capt. J. Rodger, M.C.; Capt. (actinic Maj.) J. B-
Scott. MC.; Temp. Cant. D. C. Suttie, M.C.; Temp. Capt. G. D.
Watklna, D.S.O., M.C.; Temp. Capt. W. B. Wilson. M.C.
The Military Cross.
Capt. L. T. Allsop. Aust. A M.C ; Capt. J. R. Anderson, Aust
A M.C.; Capt. (acting Maj.) H. M. Barrett. Can. A.M.C. ; Temp. Capt
H. J. B nste<l; Temp Ca .t. G. A Beyers, S A'r. M.C.; Temp. Capt.
G. S. Brown ; Temp. Capt. (acting Msj ) S. B. B. Campbell; Capt. J. S.
Clarke; Terno. Capt. G. O. Connell; Capt. L D. Donsmore, Can
A.M.C ; Temp. Capt. C. L. Dold ; Temp. Capt. (acting Maj.) J. A
Don 1 •; Temp Capt (acting Maj.) S. Fenwick; Capt. A. G. Fleming.
Can. A.M.C.; Capt. (acting Maj) W. D. Frew; Temp. Capt-
C. M. Ganapathy. IMS. ; Temp. Capt. G. A. C. Gordon ;
Temp. Capt. K. H. H. Granger; Temp. Capt. Z. A. Green;
Temp. Capt. A. P. Hart; Temp. Lt. W. Hickey; Temp. Capt.
St. G. M L. Homan; Temp. Capt. G Jackson ; Capt. F. McN.
Johnson. Can. A M.C ; Capt. A. P. Lawrence. Austr A.M.C.; Temp.
Capt. H. H. Lawrence. S Air. M.C.; Capt. G W. Longheed. Cao.
A M.C.; Temp. Capt. M. Man son; Temp. Ca it. R. C. McMillan;
Capt. A Y. McNair. Can. A.M.C.; Lt. W. G F. Owen-Morris; Capt.
(acting Maj.) H. P. Rudolph; Temp. Capt. (acting Maj) R B.
Rutherford ; Lt S. L. Bhatia, I.M.S.; Lt (temp Capt. an 1 acting
Maj) G. K Spicer; Temp. Capt. F. R 8turrHge ; Temp. Capt-
(icing Maj.) C. Sullivan; Temp. Cant. B. C. Tamp'in; Capt. J
Thomps in ; Temp. Capt. W. Tudhope ; Temp. Capt.(acting Maj.) A. W
Uloth; Temp. Capt. tt. W L Wallace; Capt. K. B. A. Weston, Can
A. * .C.; Capt. (acting Maj.) M. White ; Capt. H. P. Whitworth.
The following awards to and promotions of medical officers
are also announced :—
C.B.E —Lt.-Col. (temp. Col.) A. B. Soltau. C.M.G., O.B E (auhati-
tut*d for the notice which appeared in The Lancet of Jan. 11th, 1919_
P To ) ’f>« Brevet Major.- Capt. R. D. F. MacGregor. M.C., I.M.S.
Capt. J. Scot-, D.S.O . I.M S.; Capt. C. W WIrgman. R.A.M.C.
Distinguished Service Cruss .—Surg -Sub.-Lt. A. A. Osman, K.N.v.R.
Mentioned in Despatches.
The names of the following medical officers of the
R. A.M.C. (except where otherwise stated) have been brought
to notice for valuable services rendered on hospital ships-
during the war :—
Temp. Maj. W. G. K. Barnes; Maj. A. Bird; Temp. Maj. J. A.
Devine, D.SO.; Lt.-Col I. B Bm**r*on ; Capt. (acting Maj.i H P
Everett; Lt.-C *1. (temp. Col.) R S. H. Fuhr, C M.G., D 8.0 ; Lt^-Col.
P. B. Haig, C.B.. I.M S. : T-mo. Capt. D. J. Jones; Temp. Maj. T. M.
Kendall ; Lt.-Col. C. W. S. Magrath ; Lt.-Col. C. Milne, I.M S.:.
Temp. Capt. H. T. L. R>ber s; Temp. Capt. W. V. Robinson ; Lt. Col.
B. W.Sibery; Temp. Cant. A G. Southenmbe; Temp. Capt. W. H.
Stott; Maj P. C. Whitmore; Temp. Maj. R. Wilson; Temp. Maj.
S. W. Wooilett.
And the following for valuable services rendered on the
occasion of the sinking or damage by enemy action of
hospital ships, transports, and store ships
Temp Capt. (acting Lt.-Col.) G. W. Milne ; Temp. Capt. W. G.
Silvester; and Temp. Capt. T. D. Webster.
The name of Surg.-Lieat.-Comdr. G. D. Walsh, R.N.,
been mentioned in despatches, aud the names of Temp.
Capt. W.N. Montgomery, R.A.M.C., and of Dr. J. E.Creswel)
have been brought to notice for valuable services rendered
in connexion with military operations.
Foreign Decorations.
French.
Union d’Honneur: Croix de Chevalier —Lt.-Col. (temp. Col.) H.
Col i in son, C.M.G.. D.S.O., R A.M.C. (T.F.Jj Mhl (temp Lt.Col)
D. Rorie. D.S O.. RA.MC. (T.F.); Capt. (acting Maj.) J. M. Smith.
Croix de Guerre .—Col. A. B. Snell, C.M.G., D.S.O., Can. A.M.C.
Lt.-Col. R W. Knox, D.S.O.,
Italian.
Order of the Crown of Italy.— O near: Lt,
I.M S.; Lt -Co». J. K\ tSn, R.A.M.C. (T F.). _
Crcce di Gu-rra —Temp Capt T W. Mason, R.A.M.C. (T.F.).
Roumanian.
Order of the Star ol Roumania. -Commander: Surg.-Vice-Adml. Sir
W. H. Norman. K.C.B „ ,, 4 „
O' der of the Crown of Roumania. - Officer : Snrg.-Lleut -Corner. G B.
8cott. D.a.O., R.N. Coevaher: Surg.-Lieut. W. L. Clegg. D.S.O., tt.N.
Belgian.
Order of the Crown of Belgium. ‘ Commmder: Surg.-Vlce- Adml. Sir
W. H. Norman. K.C B.; Surg.Gcn. J. J. Deunis, C.B., R.N. Ofhoer :
Surg.-Comdr. J. O’Hea, R.N.
Casualties among the Sons of Medical Men.
The followi g additional casualty among the sons of
medical men is reported :—
Lieut. M. Hayes, Cheshire Regiment, died at Horsham, of
malaria and pneumonia, youDgest son of the late.
Surg.-Major W. H. Hayes, LM.8., of Farnbam, 8urrey.
5S2 Tub Lakoht.) _ PARLIAMENTARY INTELLIGENCE. [March 29,1919
$ srliamtirtarj Jirttlligenre
NOTE8 ON CURRENT TOPICS.
Ministry of Health Bill.
The Standing Committee of the House of Commons
further considered the Ministry of Health Bill on Thursday,
March 20th, 8ir Archibald Williamson in the chair.
The Committee resumed the discussion of the subsection
to Clause 3, which provides for the transfer by Order in
Council from the Minister of Health to other Government
ilepartments of such powers and duties relating to the relief
of the poor as appear to His Majesty to be more conveniently
exercisable by such other departments. The excision of the
subsection was moved at Tuesday’s sitting by Captain
Barnett.
After some discussion Dr. Addison agreed that before the
report stage he would confer with those who had acted with
hrm in framing the clause, and on this understanding the
amendment was withdrawn.
On the question that Clause 3 as amended stand part of
the Bill objection was taken to procedure by Orders in
Council as placing an autocratic power in the hands of
Ministers.
Dr. Addison admitted that Orders in Council were a little
unpopular nowadays, no doubt owing to the operation of the
Defence of the Realm Act. They must adopt some method
for carrying into effect the provisions of the Bill, and he
thought the most business-like method had been adopted.
Sir Ryland Adkins thought they ought jealously to
maintain the use of Orders in Council for purely adminis¬
trative work. He thought Parliament ought to have a voice
in saying to which Minister powers of importance should
be transferred by Order* in Council, and that’an’Order in
Council should be laid in draft before each House and not
be submitted to His Majesty until a resolution of each
House had been passed approving or modifying it.
Dr. Addison said he thought this suggestion a useful one,
and it might be considered when Clause 8 was reached
which relates to Orders in Council.
Clause 3 as amended was then added to the Bill.
Consultative Councils.
On Clause 4, the first section of which deals with the
establishment of consultative councils,
Sir W. Watson cheynk moved that for the words “it
shall be lawful for His Majesty by Order in Council to
establish consultative councils” there should be substituted
“it shall he the duty of the Minister to set up advisory
councils.” There were two things which were of the
greatest importance for the success of the Ministry. The
first was the question of the research department
because that was the eyes of the Ministry, and without
that it would not do what it ought to do. The second
was * to obtain the agreement of everyone who was
involved in the work of the Ministry, and perhaps the most
important body of men were the medical profession. The
question of the Ministry of Health had been before the
medical profession for a long time. It had been discussed
all over the country in various societies and under various
conditions, and for once in a way the medical profession
seemed to be pretty well agreed. They were all in favour of
the Ministry of Health and the point that had concerned
them was how to get it on the proper lines from the medical
point of view, and they had all centred themselves on
this question of consultative councils, so that anything
which would make them suspicious that these councils
might be delayed for some time would go very much to
undermine the confidence of the medical profession in this
project. What they feared was that as this was left more
or leas a permissive question in the Bill a future Minister
might not take the same view as Dr. Addison in regard to
these councils. His suspicions were still added to by the
power given in Clause 8 to revoke or vary any Order in
Council by a subsequent Order. As things stood he did not
feel that they could place absolute reliance on the con¬
sultative councils as a permanent part of the Ministry, and
as forming a safeguard for the medical profession and the
carrying out of the medical requirements in accordance
with the wishes of those in the profession. That was
an extremely important point, because the medical pro¬
fession were the people who had to carry out the Ministry of
Health, and the Ministry must have their complete con¬
fidence. That could only be obtained bv making these con¬
sultative councils integral parts of the Bill which could not
be altered by any Minister.
“ Advisory " or “ Consultative .”
Sir F. Magnus heartily supported the amendment. Dr.
Addison knew very much better than he did how unanimous
the medical profession were with regard to the importance
of establishing a counoil which would advise the Ministry
on all health matters. The clause as now worded would
not satisfy the bulk of the medical profession. He spoke ou
behalf of some hundreds of toe medical profession
including even Dr. Addison himself. Some 1500 or 2000
medical men were members of the constituency which be
had the honour to represent, and he had received from them
repeated statements as to the importance of including in thU
Bill the establishment of a council to advise the Ministry,
which council should be a necessary and essential part of
the Bill. Unless the Ministry were well advised by members
of the medical profession the whole of their work might not
be 6o satisfactory as it otherwise would be. He urged that
the councils should be advisory and not consultative.
“ Advise ” was a stronger term than “ consult.”
Dr. Addison : Do you suggest that the Minister should be
compelled to accept their advice ?
Sir P. Magnus said that was not absolutely necessary.
The word “advise ” implied that they had power to give the
Ministry information which they might not otherwise
possess, while the word “ consult ” meant that they might
merely refer to them. The medical profession attached verv
great importance to the word “advisory” instead of * con¬
sultative.” The medical profession desired that their advice
be taken and that they should have direct access to the
Minister in giving their advice, and, if necessary, access to
Parliament in order to enforce the advice that was given.
He attached very great value to the advice given by experts
in a matter of this kind, and he hoped that any advice given
by these experts to the Minister would be carefully con¬
sidered and not be, in their own words, “ pigeon-holed” on
the understanding that it would be considered some time or
other.
Sir A. Warren, speaking as a layman who had had some
experience on the advisory committee set up under the
National Insurance Act, said that if the Advisory Committee
under this Act was not to be of more importance than that
under the Insurance Act, it was not going to be of much
importance. This was a very vital part of the Bill, and he
asked that in setting up either a consultative or advisorv
committee due regard should be had to representation.
While they would not presume to trench upon the ground
rightly occupied by the medical profession, he urged that in
other matters that would have to be considered there should
be most careful consideration given to representation accord*
ing to the interests that would be involved.
Criticism of the Amendment.
Major Astok said there were three ways in which these
bodies could be set up. There was the way proposed in the
Bill now drafted. If it was to be done by His Majesty this
was the correct way in which it should be set out in the Bill.
The amendment proposed, if inserted, would not have the
safeguard which he understood the honourable Member
desired -namely, an opportunity of being consulted as a
Member of Parliament as to the way in which the Ministry
should consult these bodies. It was to ensure that safeguard
that the Government had adopted the method proposed in
the Bill. If the amendment were carried it would defeat
the object which the mover and all of them had in mind—
namely, that they should all work together as far as posible.
The third alternative would be to specify in the Bill the exact
nature of these councils and where they should be set up
and the number of times thev should meet in tb^year. The
Minister in charge of the Bill was of the opinion that the
consultative councils should be an integral part of the
Ministry and should be able to assist them. It was quite
possible that when they first set out thev might find that
they had not been able to set them up in the final shape or
form. They wanted to get the value of the experience ad
they went on, and it might be necessary to after certain
matters, say, in regard to procedure. If they were to try to
define exactly how often the councils were to meet, ana so
on down to the last detail, it would not be possible to get the
advantage of their experience. The amendment would mean
that they would have to come to Parliament and ask for a
Bill if they wanted to alter anything in connexion with these
oouncils, and this would mean delay. He did not think that
the word “advisory” had behind it as much as had been
suggested. He understood that the two words had been dis¬
cussed while the Bill was being drafted, and that the word
“consultative” was accepted in preference to the word
“advisory.”
Sir R. Adkins : Does the Minister recognise any difference
between them?
Dr. Addison : No.
Sir P. Magnus said he had reason to believe that the
medical profession recognised a distinction.
Dr. Addison said he had consulted the most representative
body that the medical profession ever got together, and
they deliberately advised him that they wanted the word
! “consultative.”
Major Farquharson said that he wanted to say, on behalf
of the medical profession, there was no desire whatever,
either in the name of the counoil to be set np, or in the
The Lancet,] PARLIAMENTARY
_
action of the council, to in any way attempt to invade
ministerial authority or responsibility. There was not the
slightest intention on the part of the medical profession to
place any degree of compulsion on the Minister to accept
the advice of the council. He did not think that if the
amendment were adopted and the word “ advisory ” sub¬
stituted it would be acceptable to the profession. He
thought that they were quite satisfied that the procedure
should be bv Order in Council.
Sir C. Warner and Major Lane-Fox appealed to the
Minister in charge of the Bill to give the Committee an
explanation as to wbat these councils were to be like.
The Council* Described.
Dr. Addison said he thought that if the procedure was by
Order in Council they must have faith that the Minister would
feel it his duty to carry out the intentions of Parliament. He
certainly would, and he was sure he would be promptly called
over the coals if he did not. As to the councils themselves,
he thought they ought to be as small as possible. He was a
thorough believer in these bodies. He believed that many
departments had suffered in the past because there had been
no machinery in existence whereby they could have readily
available expert counsel and advice in the stages when they
were producing something and gradually getting it together,
and before they became committed to a form of operations
which they might subsequently desire to change. They
suggested that the number of members of the council should
not exceed 20. Their general conception was that there
wOuld probably be at least four bodies. He did not say that
they would be distinct separate bodies, but there would
certainly be one connected with the main problems of Local
Government, and clearly one relating to insurance questions
and the big financial questions connected therewith. And
he thought whatever might be its form it was necessary to
have one representing the general public composed of people
of good sense and experience. It was clear that in framing
their future health-schemes they'would have to'consult
freely with representatives of the great local authorities,
with medical men, and with those who were experienced in
insurance questions. He thought it desirable that this form
of organisation should be brought into the body of the
Ministry as part of its beiDg, so that the Minister would have
gradually available a body of experienced advisers who were
accustomed to see things from the administrative point of
view, the point of view of the Minister, and so forth.
On the Committee resuming at 4 p.m.,
Sir P. Magnus said he wished to make it perfectly clear
that bis remarks at the morning sitting referred only to the
medical consultative council. He had not been aware till
that morning that there was to be more than one consulta¬
tive council.
Responding to further appeals for information from
members of the Committee,
Dr. Addison stated that the committees would not be
salaried, but paid the usual travelling and out-of-pocket
expenses which the Government allowed to all committees,
and he thought it should include payment for loss of
remunerative time. Whatever might be the recommenda¬
tions of these committees—and they would differ sometimes
—the Minister could never be bound by whatever they voted;
he eventually must accept responsibility for following their
advice or rejecting it, or getting it qualified, as the case
might be. He was proposing that they should have a Welsh
Advisory Committee, but they did not propose that they
should be formed up and down the country. It would
never do to set up these committees on the basis of the
representation of any interests, and he would set his face like
flint against any suggestion of that kind. Nor did he think
they should be constituted on the basis of the representation
of districts.
Alter further discussion,
Sir Watson Cheyne said his object had been attained
entirely. He therefore withdrew his amendment.
The amendment was withdrawn.
On the motion of Dr. Addison, an amendment was agreed
to to insert the words “ England and Wales,” in the clause,
enabling the Minister to set up councils in both countries.
Proposed Women's General Consultative Council.
Lieutenant-Colonel Sir S. Hoare proposed the insertion of
the words, “One such council, to be called the Women’s
General Consultative Council, shall consist entirely of
women.’’ That afternoon he had received, as other Members
had received, a communication from an organisation that
represented 500,000 women, presided over by Lady Rhondda,
in favour of his proposal. They were also anxiouB that
women should have the fullest and freest opportunity of
expressing their views on the Bill.
sir Kingsley Wood assured the Committee that there
would be adequate and due representation of women on the
council. On the general administrative oouncil there would
also be ample opportunity of giving women adequate
representation.
INTELLIGENCE. [March 29, 1919 533
Dr. Addison said that there must be certain committees
which would be composed for certain purposes solely of
women, whether the amendment was put in the Bill or not.
It was also dear that in respect of general purposes some of
tue councils would have to consist mostly of women ; but all
the same he should be disappointed if the Committee
passed the amendment. It was not desirable to tie the
hands of the Minister.
On a division the amendment was negatived by 22 votes
to 14.
Consideration of Clause 4 Resumed.
On Tuesday, March 25th, the consideration of Clause 4
was resumed.
Mr. Godfrey locker-Lampson moved an amendment
providing that the reports of a consultative council should
be published within two months of presentation to the
Ministry unless it made a recommendation to the contrary.
Major Astor said if the amendment were carried the
tendency would be for the Minister to hold back certain
points possibly of a confidential nature in consulting these
councils, or he might even be discouraged from consulting
them at all.
The amendment was withdrawn.
Major Barnes moved to add a new section as follows
” No such council shall bo established or sit in any area administered
by a county or county borough council without tho^onsent of the
county or county borough council of that area ; and where such content
is given every such council shnll consist only of persons elected by the
county or county borough council, as the case may be.”
Dr. Addison said that the Local Government Board were
continually consulting with the great local authorities, and
the last thing he desired to do was to bring himself and the
Ministry needlessly into conflict with those authorities.
The amendment was withdrawn, and Clause 4 was then
agreed to.
Provision* a* Regard* Wales.
On Clause 5, which deals with provisionals regards Wales,
Dr. Addison moved an amendment giving the Minister
power, subject to the provisions of the Act, to appoint Buch
officers as he might think fit to constitute a Board of Health
in Wales, through whom he might exercise and perform in
Wales his powers and duties; the Board and any officer who
was a member thereof should act under his directions and
comply with the instructions of the Minister. He said if there
was to be any step taken in the direction of devolution for the
separate parts of the United Kingdom it must be done by
specific legislation and not through the provisions of this
Bill, bub he wanted the Committee to understand that these
words were necessary m the Bill under our present form of
Government, inasmuch as the Minister of Health would be
responsible for the administration of health affairs in Wales
as well as in England. The experience of the past few years
had shown that there were local and national considerations
which required special machinery to deal with them
adequately. In the gigantic task they had got before them
they must look to some form of decentralisation. As the
Bill was originally drawn the machinery, so far as Wales
was concerned, was limited to purposes relating to the
National Health Insurance. But they were already starting
separate administrative machinery for Wales in connexion
with housing. Therefore, he asked the Committee to agree
to this amendment.
The amendment was agreed to, and Clause 5 was then
passed.
Staff and Remuneration.
On Clause 6, which deals with staff and remuneration,
Mr. George ThoRnk moved an amendment providing that
“ no discrimination should be made for reasons of sex between
men and women."
Major Astor said that in the opinion of the Government
this amendment was unnecessary, but if the Committee felt
that it should be adopted they would not oppose it.
Dr. Addison said that in setting up a women’s branch of
the medical department at the Local Government Board he
had actually discriminated in favour of a woman in the
appointment of Dr. Janet Campbell.
Dr. Murray said that in view of the new conditions of
our political life this might operate as a protection for men.
On a division the amendment was agreed to by 26 votes
to 22.
Major Astor moved an amendment to provide that
members of subcommittees of the general councils under
the Act should have equality of treatment as regards p&yv
ment of expenses and so on with the members of the mam
councils.
The amendment was agreed to.
Mr. Locker-Lampson moved an amendment to the
effect that no money should be paid to members of con¬
sultative councils other than in respect of travelling and
out-of-pocket expenses and reasonable compensation for
loss of remunerative time. He Baid he was entirely
against the payment of the members of these councils, but
atthe same time he did not want to rule out travelling
expenses and out-of-pocket expenses.
534 The Lancet,]
PARLIAMENTARY INTELLIGENCE.
[Maboh 29,1919
Major Astor said that if the honourable Member would
withdraw his amendment he would be prepared to move one
as follows: “ That no payment shall be made to members of
consultative councils and committees other than the repay¬
ment of travelling expenses and the payment of subsistence
allowances and compensation for loss of remunerative time.’*
This would bring the procedure in this matter in line with
what was already done under the Insurance Act. It would
not necessarily mean that all members of these councils
would be paid for loss of remunerative time.
Sir William Whitla suggested that there should be a
scale such as that adopted for medical men attending
assize courts, Ac., of so much per day, or in other words,
a system of taxed costs.
Siajor J. W. Hills said he did not think there would
be any difficulty about the medical men in this matter, but
there must be some piovision of the kind for persons who
could not afford to give their time for nothing.
Mr. Locker-Lampson withdrew his amendment and Major
Astor' s amendment was agreed to.
Clause 6 as amended was then agreed to.
Clause 7 was agreed to, with an amendment providing if
necessary for two secretaries as Members of the House of
Commons.
Orders in Council: Insurance Acts : Other Amendments.
On Clause 8, which deals with provisions as to Orders in
Counoil, an amendment was accepted and agreed to requir¬
ing the specific assent of both Houses of Parliament to
Orders in Counoil transferring certain departmental powers
and duties to and from the Ministry.
Clause 8 was agreed to.
Clause 9, which applies the Bill to Scotland, was deleted
from the measure in view of the Government's intention to
introduce a separate Bill for Scotland.
On Clause 10, which deals with consequential modifications
of the Insurance Acts,
Dr. Addison gave an assurance that the deputy of the
Health Minister in Scotland would be the chairman of the
Scottish Insurance Commissioners. He gave the same
assurance in regard to Ireland.
Clause 10 was agreed to.
On Clause 11, which deals with the commencement of
the Act,
Dr. Addison accepted an amendment providing that the
latest day for the transfer of powers to the Minister as set
oat in Subsection 1 of Clause 3 should not be later than one
year after the passing of the Act.
The amendment was agreed to.
On the motion of Dr. Addison an amendment was agreed
to providing that for the purposes of the Act Monmouthshire
should be deemed to be part of Wales.
An amendment was proposed by Major Astor deleting
the words “ the Soottisn Insurance Commissioners ” from
Section 3 of Clause 11.
The amendment was agreed to.
Clause 11 was agreed to.
The Attorney-General for Ireland (Mr. A. W. Samuels)
moved to apply the Bill to Ireland in a clause to be inserted
after Clause 10. The discussion was proceeding when the
Committee adjourned until Thursday, March 27th.
HOUSE OF COMMONS.
Thursday, March 20th.
Port Hospital Accommodation.
Mr. Leslie Scott asked the President of the Local
Government Board whether he was aware that the Army
Medical Council had, in conjunction with the Local
Government Board, expressed the view that the port
sanitary authorities at Liverpool should provide hospital
accommodation for influenza cases; and whether he was
aware that a grave recurrence of the influenza epidemic
there was attributed by the local, medical officer of health to
re-importations of the disease by patients for whom hos¬
pital accommodation could be found only after delay and
with difficulty.—Major Astor (Parliamentary Secretary to
the Local Government Board) replied: The Local Govern¬
ment Board asked the Liverpool Port Sanitary Authority
and other port sanitary authorities in October last to do
everything possible to provide hospital accommodation for
cases of influenza and other infectious illnesses requiring
isolation amongst the crews of transports and other vessels
arriving at the port, and the naval and military authorities
promised their assistance. My right honourable friend has
no information as to the statement in the last part of the
question, but he has communicated with the port sanitary
authority with regard to it.
Mr. Leslie Scort-asked the President of the Local Govern¬
ment Board il) whether he was aware that repeated appeals
to the War Office by the Port Sanitary Authority to release
the largest Liverpool fever hospital, the only place in which
suitable accommodation for influenza patients during an
epidemic could be provided, from the present military occu¬
pation had been without result, in spite of the fact that ward
pavilions in that hospital were being used for storage, for
olerical staff, and in other inappropriate ways ; (2) whether
he was aware that the acceptance by the War Otfice of the
offer of the American Red Cross Hospital at Mossley Hill,
which was no longer required for its purposes, would meet
all local military needs and permit the release from military
occupation of the fever hospital, for which the need in
the city and port of Liverpool was at present exception¬
ally great.—Major Astor replied: My right honourable
friend is aware of the requests of the Port Sanitary and
Hospitals Commit r ee of the Liverpool Town Council to the
War Office that the Fazakerley Fever Hospital, wnich has
been in military occupation since the beginning of the war,
might be at once released, and the Local Government Board
have already supported this request and have suggested to
the War Office that they should at onceoonsider whether the
American Red Cross Hospital at Mossley Hill might not
serve the purposes of the military authorities.
Mr. Leslie Scott asked the President of the Looal
Government Board if he could state what practical assist¬
ance he could offer to the port sanitary authorities of the
country towards providing hospital accommodation for
influenza cases, as urged by the Army Medical Council and
the Local Government Board; and whether he would use
every effort to assist them in making such provision.—
Major Ast'»r replied : A conference has been arranged with
representatives of the port Baoitary authorities, at which
this question, amongst others will he discussed.
Monday, March 24th.
Venereal Diseases.
Major Courthope asked the President of the Local
Government Board whether he had statutory powers to
schedule venereal disease as notifiable disease; and whether
in view of its prevalence he would immediately exercise this
power?—Major Astor (Parliamentary Secretary to the Local
Government Board) replied: The Local Government Board
are empowered by the Public Health Acts to make regula¬
tions with a view to the provision of facilities for the treat¬
ment of persons affected with any epidemic or infectious
disease, and for preventing the spread of suoh diseases.
Regulations have already been made for the provision of
treatment for persons suffering from venereal diseases, and as
at present advised my right honourable friend is not pre¬
pared to propose regulations providing for the compulsory
notification of such persons.
Major Courthope asked the Secretary for War whether
be was aware that on the 4th inst. the registrar of Cherry-
hinton Military Hospital reported to the local medical officer
of health that on tne previous day a soldier had been dis¬
charged from hospital at his own request suffering from
venereal disease and in an infectious condition; whether
under the existing regulations the officers in charge of
military hospitals were unable to retain a venereal patient
who was dne for demobilisation, in order to complete the
treatment of the disease; and whether in the interest of the
public health be would prohibit the release of men suffering
from venereal disease in ao infective condition ?— Mr.
Churchill replied: Inquiry is being made, and I will
communicate with my honourable and gallant friend as
soon as I am in a position to do so.
Medical Treatment of Children (Ireland) Bill.
Mr. A. W. Samuels (the Attorney-General for Ireland)
moved the second reading of the Public Health (Medical
Treatment of Children—Ireland) Bill. He said the measure
extended to Ireland the benefits of medical treatment
already enjoyed by children in English elementary schools
and enabled local authorities to have medical inspection of
children in elementary schools in Ireland. He under¬
stood that the Bill was not opposed in Ireland and, in
fact, was largely weloomed. The councils of the oounty
and county boroughs were to be the local authorities
for carrying out the purposes of the Act, and it would apply
to elementary schools, either National Schools or those
recognised by the Local Government Board, as providing
efficient elementary education. The Treasury would provide
an amount not exceeding one-half the expenses as might be
incurred by the looal authority in setting this medical relief
in operation and carrying it into effect. It was hoped that
it wonld be largely availed of in the country.
Lieatenant-Colonel W. Guinness asked why the Bill was
drafted in a weaker form than the English Bill. It was
imposed as a duty on the local education authority in
England to provide medical inspection. In Ireland public
opinion was much more backward than In England, and it
was undesirable that this question Bhould be left optional in
Ireland. . „
Mr. M‘Guffin expressed objection to the Bill, as it was
permissive. Unless the Government took the Bill in band
seriously there was little hope that any good would attend
the legislation they had in view.
I
ThbLangbt,]
THE SERVICES.
[March 29,1919 535
53tf Thb Lancet,]
MEDICAL NEWS,
[March 29, 191fl
Major J. W. Keay Is restored to the establishment.
Cnpt*. (acting Majors) P. Hauxwell, L. A. Mackenzie, A. Radford,
T. J. T. Mollattle, II. F. E erelt. P. Coleman, Q. B. Fleming.
W. Red path. J. MeL. Macfarlane. R. Batat, 9. McCausland, W. D.
Frew, J. W. Kemp. R. J Chapman. W. Briggs, J. B. G. Thomson, O. K
Wright relinquish their acting rank on ceasing to be specially
employed.
Capts. (acting Lieut -Cols.) J. MacMillan. R. Burgess. A. Rarasbottom
relinquish their acting rank on ceasing to be specially employed.
Capts. (acting Majors) to be acting Lieutenant-Colonels whilst
specially employed : K. Darlow, J. D. Fiddes. J. A. Davies.
Capts. L. A. Mackenzie. F. P. Gibs n. W. G. Mackenzie, C. G. K.
Sharp, F. W. Burn. K. C. Plummer^ J. G. F. Hoaken, to be acting Majirs
whilst, specially employed
Opt. P. H. Mitohiner, from 5th London General' Hospital, to be
Captain.
Capt. (acting Major) J. D. Wells relinquishes his acting rank on
vacating the appointment of Deputy Assistant Director of Medical
Services.
C&pt. (Brevet*Major) C. H. S. Frankau is restored to the establish-
Ulvllb.
Capts. A. C. Devereux and W. A. Salter relinquish tbelr commissions
and retain tho rank of Captain.
Capt. (acting Major) A. L. S. Tuke to he Major.
Capt. (acting Lieut.-Col.) H. Henry to be Major and to retain his
acting rank.
Capt. (acting Major) H. B. Fox relinquishes hla commission and
retains the rank of Major.
1st Scottish General Hospital: Capt. A. W. Falconer is restored to
the establishment.
2nd Scottish General Hospital: Capt. W. J. Stuart is restored to the
establishment.
4th Scottish General Hospital: Capt. (aoting Major) D. Lamb
relinquishes his acting rank on ceasing to be specially employed.
1st Bastern General Hospital: Capt. K. C. Oanney is restored to the
establishment.
2nd Northern Field Ambulance: Capt. (acting Major) Wi H.
Morrison relinquishes his acting rank on ceasing to be specially
employed.
5th London General Hospital: Capt. (acting Major) P. H. Mitcblner
relinquishes his acting rang on ceasing to be specially employed.
4th Battalion. Northern General Hospital: Capt. H. J. Smith la
restored to the establishment.
Lowland Casualty Clearing Station : Capt. (acting Lieut.-Col.) G. B.
Fleming reverts to the acting rank of Major on ceasing to command a
Casualty Clearing station.
TKRRtTORia.Ii FORGE RKSKRVE.
Capt. S. McCausland, from 1st West Lancs Field Ambulance, to be
Captain.
Capt. D. Lamb, from 4th Scottish General Hospital, to be Captain.
Capt. J. K. G. Thomson, from 1st Highland Field Ambulance, to be
Captain. -
ROYAL AIK FORCB.
Medical H ranch.— G. Dreyer (temporary Honorary Lleutenant*
Colonel. H.A.M i.) Is granted a temporary commission as Honorary
Lieutenant-Colonel.
Lieut. J. A. Johnson to he Captain.
Major F. H. Stephens (Staff Surgeon. R.N.) relinquishes his com¬
mission on ceasing to he employed.
Tho undermentioned are transferred to unemployed list: Captain
D. H. Kraser, Captain A. MacLmnan t K.A.M.C.. T.F.), Lieuts. J,. G. W.
Balls, J. J. Savage, G. D. M. Beaton, and P. M. Roberts.
DEATHS IN THE SERVICES.
Deputy Surgeon General Samu< 1 Jardine W>ndowe, M.D. A herd.,
I M.S.. retired, who died at Beneombe House. Uley. GIos., on
March 19th, was a son m ('apt. S. Wyndowe, of tlie 1st Dragoons. He
was born on April 3rd. 1830. and was educated at Cheltenham, which
school he entered In 1843. In October, 186'J, he came up to St. Gorge's
Hospital, where he was a contemporary of the late H. W. Bellew,
Vandyke Carter, W. Ji. Cornish (all of whom joined the I.M.S.),
and of other well-known students; as a dresser he served under Prank
Buokland, who was house surgeon to the hospital in 1862. Having
taken the M.K.C.S. in 1854, he immediately joined the H.E.I.C.3.
(Madras establishment >. He saw active service in the Mutiny, tor
which he had the medal and received the thanks of the Indian Govern¬
ment. From 1867 to 1881 he was residency surgeon at Hyderabad,
superintend* nt of the Hyderabad Medical School and of the civil dis¬
pensaries in the Nizam's dominions ; he retired in 1881 with the rank
of Deputy burgeon General.
Brig. Surg.-Lieut.-Col. J. Robinson, Army Medical Staff, retired, died
at his residence at Reading on March 23rd, aged 84. He entered t he
Army Medical Service in 1858, and subsequently stwed in the Afghan
War of 1878-80 (medal), the Egyptian War of 1882 (rnedal with c'ajp
and bronze star), and in India, China, and Zululand. He retired in
1889, and in 1892 be took charge of the medical depot at Reading
Barracks, a position which he held for several years.
The Royal Sanitary Institute.—A congress will
be held at Newcastle-upon-Tyne from July 28tb to
August 2nd, under tbe presidency of the Duke of
Northumberland. Papers will he read and discussions
held on sanitary science and preventive medicine, engineer¬
ing and architecture, hygiene of maternity and child
welfare, and on personal, domestic, and industrial hygiene.
In connexion witn the meeting a health exhibition will be
held specially illustrating hygiene of infants and child
welfare; housing, including laying out of estates, planning,
materials and construction, fittings and appliances; ship
sanitation, Ac., as well as matters relating to mnnicipal
sanitation and domestic health and comfort. Visits will be
made to water works, sewage disposal works, isolation and
other hospitals, and other places of sanitary interest. The
address of the secretary is the Royal Sanitary Institute,
90, Buckingham Palace-road, London, S.W.
Utefaifal Sttos.
University of Manchester.— At examinations
held recently the following candidates were.succe&ful:—
Third M.B. and Ch.B Uxajvunatiok.
General Pathol my and forbid Anatomy —Simon Almond. Martha F.
Barritt. Phylus M. Cong.ion. Margaret McF. Corbold, Dorothy
M. L. Dyaon, A. M El-A«uizy, Perclval Fildes, Joshua Harris,
Bmest Jones, Gertrude B. Leigh, H. A. Lomax, Alexander Maude,'
J. S. Hobinaon, Annie Roth well. Geoff rey Talbot, and S. J. Woodall;
Diploma iw Public Health.
Part /.—A. W, Baker, G. H. T. N. Clarke, G. J. OniwMfd, A. Heath*
M. E. A Latif J. L. Meyuell, E. N. Rams bottom, H. F. Sheldon,
an i E. H Walker.
Part 11.-3 Walker.
Diploma iw Dentistry (Third Examinnlion).
Physiology, and Dental Anatomy and Histology.— H. Walmaley.
University of Liverpool.— At a congregation
held recently degrees were conferred as follows
Degree of M.D.
Stanley Fox Linton (in absentia i.
Degrees of M B.. Ch.B.
Stuart Douglas MoAnsland (honours). William Thomas Davies, Philip
Bldon Gorst, and Richard Randall Bernard Roberts.
Royal College of Surgeons of Edinburgh*—
At the recent Deutai Examinations just concluded the
following candidates passed the Final Examination aw}
were granted the diploma L.D.S., R.C.S. Edin.
John Bruoe Watson Telford, Leith ; Nieo Hofmeyr Alhsrtyn, Paarl*
South Atric*; Andrew John Molyneaux, Kimberley, South Africa,;
George L&lng, Keith; John Storey, Alston, Cumberland: Egbert-
John Charles Steyn, Rlversdale, South Africa; Robert Mitchell
riu Preez, Eiversdale, South Africa; and William Harvle Kerr,
Bdinburgn.
Royal Medical Benevolent Fund.— The annual
meeting of this Fund was held at 11, Chandos-street, W.„
on March ilth, Dr. Samuel West, the President, being
in the chair. The annual report, which was submitted
and approved, showed the continued prosperity of the
Fund, which had not suffered from tbe success of
the War Emergency Fund. The latter, now regis¬
tered under the War Charities Act, had yielded on a.
first appeal nearly £3900 and on a second £22,000 with
promises of £680 more. Expenses of collection amounted to.
£1687, or 7 per cent, of tho total. A special subcommittee,
under the chairmanship of Sir A. Pearce Gould, investigated
cases, made grants, and put applicants iu touch with Govern¬
ment departments providing resources. With demobilisa¬
tion taking place, applications were becoming numerous,
and it was hoped to obtain another £7000 to bring up
the total to the £30,000 which had been asked for.
In the grant department the subscriptions and donations
for the year 1918 showed a decrease of £42. On the other
hand, £256 more than last year had been distributed, the
difference being made up by contributions from the special
dinner account. Of this £i20 was given in the form of a
Christmas gift to the most necessitous of tbe cases. In the
annuity department the income for tbe year was £4332,
showing an increase of £585 on last year’s figures. Of this
£3)0 10*. 10d. is accounted for by legacies received, which
with the returned income-tax and balance enabled £1000
National War Bonds to be purchased as an investment.
Though in the accounts the number of annuitants in 1918
remained the same, six more annuitants were elected since th*
books were closed, bringing the total up to 167, against last
year s 161. The amount distributed was £3128, showing an
increase of £47 over 1917. A sum of £L had been sent a»
usual to each annuitant as a Christmas-box. Dr. West waa
re-elected President, Colonel Charters Symonds honorary
treasurer, and Dr. G. Newton Pitt honorary secretary. The
following were elected mem hers of the committee of manage¬
ment: Dr. G. E. Jlaslip. Dr. W. Collier, Sir Hugh Rigby,
Dr. R. O. Moon, Mr. Charles Kyail, Dr. Arnold Chaplin,
Dr. W. Pasteur, Mr. Warren Low, Mr. Percy Sargent,
Dr. C. W. Chapman, Mr. Raymond Johnson, and Mr. R. 8.
Souttar.
At the last meeting of the committee, held on Marob Utb,
25 cases were considered and £293 8*.- voted to 24 of the
applicants. The foi lowing is a summary of some of the cases
relieved:—
Widow, acred 84, of M.D. Lond. who practised at Carnarvon and died
in 1872. Only income old-agn pension. Lives with widowed sister
who cannot nfford to kc» p her Voted £18 in 12 Instalments.—Widow,
aged 59. of M.R.C.S. Kng. who practised at Bristol, and at the time of
htsdeaih in 1917 was a civilian Army doctor. Applicant’s only certain
income a pension oi £75. and derives a little fmm letting her cottage
in July and August. Has two daughters, age* 33 and 31; the youngest
has to look a'ter her mother, who has receutly developed an incurable
disease. Voted £10 in 2 instalments.—W'dow,aged 35, of M.R.C 8. hug.
who practised at Witney mni died in 1918. Applicant left, with three
children ag**s 8 to 11. Income from Investments £200 to £300 a j car
After April rent will he 30*. per week for furnished rooms. A ks for help
I towards education nt children. Voted £5 and referred to tbe Guild.—
I M.B. Abend., aged 75, who practised at Upper Tooting. Married. Four
Thb Lanobt,] APPOINTMENTS.—VACANCIES.—BIRTHS, MARRIAGES, AND DEATHS. [March 29, 1919 537
children, ages 6 to 12. Had to give up practice through age and cluoiiic
ill-health. Eldest boy suffering from abdominal tuberculosis, wh'cli
necessitated hm removal to the seaside. Income about £J50. Rent for
furnished house ISO a year. Owing to high cost of living finds tie
cannot manage. Voted £5 and referred to the Guild. — Widow, aged 38,
of M B. Lond. who practised In Lancashire and died in 1918. Lett
totally unprovided for with three children, ages 1 to 4 years. Has
a paying guest, at 25*. per week. Some help from the Gudd and her
brother pays the rent. Relieved once. £ 10. Voted €10 in two instal¬
ments.— M R.C.S. Eng., aged 52, who practised in Liverpool and abroad.
Buffered from sunstroke when abroad and has not. U;en able to work
aiuoe. Lives with an aunt, who is unable to keep him. No income, but
has occasional help from friends. Relieved six times, £50. Voted £10
in two Instalments.-.Widow, aged 61, of M D. Ivlin. who practised at
Wethenit and died in 1908. Endeavours to earn a living by taking in
lodgers. Four children, three man led. and the eldest helping with the
house work. Eldest son allows £15 a year. Rent and rates £30
Relieved 13 times. £154. Voted £15 in 12 instalments.—Widow,
aged 65, of M.D Ediu. who practised at Edinburgh and died In
1909. Applicant, baa four children, but. none aMe to help at
roeaent. Pension from another charity of £15. Rent £18.
Relieved ten times, £104. Voted £12 in 12 instalments.—Widow,
aged 58. of M.R.C.S Kng. who practised in Devonshire and
died In 1914. Was left entirely without means, and has had to unoer-
take domestic service. One daughter, aged 27, a nurse. Applicant at
present out of employment. Relieved six times, £52. Voted £12 m
12 instalments. — Daughter, aged 72, of M.R.C.S. Eng. who practised
In.London and died in 1875. Applicant was a governess for 40 years,
and was in Russia when the war commenced, and lost all her savings.
Has an Epsom pension of £30 and help from the Guild. Relieved
6 times. £61. Voted £12 in 12 instalments.—Widow, aged 71, of
M.D Kdin. who practised at Bolton and died in 1905. Lost the
greater part of her income through a fraudulent, trustee. Income
from property £71. Rent and rates £20. Two children, one married,
rand the youngtst, aged 43. a shop asslsrant, earning £l a we-'k.
Relieved three times, £26. Voted £12 In 12 instalments.—Daughter,
aged 72. of M D. Edin. who practised at Cheltenham and died in 1879.
Applicant's income about £40 from another charily, and pays 4*. Sri
per w’eek rent. Falling eyesight prevents her from earning. Relieved
foor times, £48. Voted £15 In 12 Instalments.
’Subscriptions may be sent to the acting honorary treasurer.
Dr. Samuel West, at 11. Chandos-sfcreet, Cavendish-square,
Loudon, W. 1.
Dr. W. H. Willcox will deliver his postponed
Lettsomian lectures ou Jaundice on April 28th ana 30th
•od May 2nd, at 9 p.m., at the Medical Society of London,
11, Ohandos-Btreeb, W.
Royal Institution. —On Tuesday, April 1st, at
3 p.m., Professor A. Keith will deliver the last of a series of
lectures on British Ethnology—the People of Scotland. On
Thursday. April 3rd, at 3 p.m., Professor A. Findlav will
deliver the first of a course of two lectures at the Royal
Institution ou Colloidal Matter and its Properties.
The Lord Chancellor has sanctioned the re¬
appointment by Dr. F. J. Waldo, H.M. Coroner for the City
and J3orough of Southwark, of Major Danford Thomas, to act
as his deputy. Major Thomas rejoined the Territorials in 1914,
and was gazetted to the 7th Battalion, London Regiment,
and has served in France during the last^three years of
the war.
Evkrv-ClavI 'N. L. E. V.. M.D. bond., ha* been appointed Certifying
Surgeon under the Factory and Workshop Acts for tlie Clovo<i<>n
District of Somerset .
Ma!R, J, Certifying Surgeon under the Factory ant! Workshop Acts
for the Harrogate District (West. Riding).
Thomson, F. G., M.A., M.D., M HOP. Lond., Physician to the Royal
United Hospital, Bath.
Wai.kkr. E. H.. M.K.C.S., L.R.C.P. Lond.. Certifying Surgeon under
the Factory and Workshop Acts for the Wrotham District of Kent.
Vacancies.
Ftyr further information refer to the advertisement column*.
Aberdeen City. Mother and Child, Welfare.— M.O. £500.
Bedford County Hospital.— H.8. £175.
Belfast, iqueen's University.— Prof, of Anat. £900.
Birkenhead Union Infirmary and Institution, Tranincre.—Med. Supt.
£600.
Birminghaui University Faculty of Medicine.—At at. Prof, of Anatomy.
Blackburn and Fast Lancashire Royal Infirmary.— H.S. £250.
Bradford Childrens Hosfrital. —H.S. £170.
Bradford City. —Ven. Dis. O.
Bradford Royal Infirmary.— H.P. £200.
Brecon and Radnor Asylum. Talgarth, Breconshire.—Temp. Asst. M.O.
£7 7s. per week.
Burnley County Borough.— Asst. M.O. £550.
Burton-on-Trent Infirmary.—ties. H.S. £200.
Chelsea. L.C.C. School Treatment Centre Minor Ailment Department.—
M.O. £50.
Chester City and County.—Asst. M.O.H. £400.
City of London Hospital for Diseases of the Chest, Victoria Park, E.—
JLO. £200.
Colchester, Essex County HoxpitaL.— H.8. Also H.P. Bach £200.
Croydon General Hospital.—Hm. H.S.
Derbyshire Hospitaler .sick Children .—Female Res. M.O. £150,
Dnrshury and District General Infirmary. — H S. £250.
Dvhl'n University EuhKien Mission, (C.M.S .).— Female Doctor for
Furling, S. China
East Lonion Hasp ital for Children and Dispensary for Women,
shadu-eU. A’. —arm, Fliys. Al*. M.O. for Electrical Department.
Falkland Island*.— Colon la l S £40 \
Federated Malay Suites Government.— Seven M.O.. Grade II., and
Three KeniHie M.« >. £350.
Fiji Me' ical Appointments. — Five M.O £300.
G’n iinirpun • ‘aunty Asylum. Bridge ml . — Fourth Asst. M.O. £400.
Guildior . Royal Surrey U mou IlospiUd. — H.S.
Hosjdml for Uonsumpti n and Discount of the Chest, Brovipton. - H.P.
and Asst, Tulare. O 30 gs.
Hospital for Sick Children. Great Ormond-street, W.C .—H.8. £50.
A 1-0 (’as. M O £c00.
Hu Irtersfit Id Royal In firmary. --Asst. H.S. £100.
Unit ('i y | sylnut -ii'f m l .(„?. '1 <) c259.
Keighley Hnnotgh Education Committee .— Female Asst. M O. £300.
Kensington Board, of Gun. dians. -5e <*nd Asm. Res. O. £325*.
Ktrkmuhri ck. Greet own. Kirkrnabrightshi rr. -M.O. £40.
Ijud* general Infirmary -Res < as (>. £L25
London County Mental Hospital, Bexley, Kent.— ABSt. M.O. £7 7*.
) er week
London Temperance Hospital, Hampstead-road, .V. W .—Asst. Hcs.
M.O £ 1 >0.
Manchester f'hddren's Hospital, Pendlehnnt, G art side-street .—Asst.
Ml), £200.
Manchester Corporation —Asst. Tuherc. 0. £450.
Manchester Royal Infirmary (Central Branch), Roby-street .—Rea. S.O.
£200.
Manchester and Salford Hospital for Skin Diseases.— H.8. £100.
Mclb ume Australia. Walter and Eliza Holt Institute of Research in
Pathology and Medicine. —Med. Research Director. £1000. Also
First Asst. £6C0.
Metropolitan Ear, Nose, and Throat Hospital, Fitzrgy-sf/uare, W.—
H.S. £100.
Newcastle-upon-Tyue. City Hosjrital for Infectious Diseases, Walker
Gate —Bos. M. Asst. £2o0.
Newcastle-on-Tyne Dispensary — Res. M.O. £300.
Newcastlf’-Uf/on Tyne, Royal Victoria Infirmary and the University of
Durham C liege of Medicine .--Asst to Pro!, of Path.
Ncwcasde-on-Tync, Unice' *n y of Durham College of Medicine .—Demon-
st.iator of AiiHtoin> . £300 to £4 j0.
Northamptonshire County * ouncil. — Ye male M.O. £4C0.
N ■ rwir.fi. Norfolk and Norn ich Hnsgi.nl. Ron. S.
Paddington Green Children's Hospital —Hon. P., Hon. S., and Hon.
Opht h S. m Out paiients
Plymouth, South Devon and East Cornwall Hospital .—H.P. £150.
Prince of Wales's General Hospital, Tottenham, Ixmdon, N.— Hon.
Asst. P. in Out-patients'Dept. A so Sen. H.P. and Sen. H.S. £200.
Abo Jun. H.P. and Jun. H.S. £120.
Royal Free Hospital, Gray’s Inn mad, W.C.— Rrs. Asst. Atuesth. £50.
Royal Waterloo Hospiuil (or Children and, Women, Waterloo-road, S.E.
— Honorary Gynaecologist t.<> Out patients.
St. Georges Hospital, S W .—Two Rea. M O.
Saiid Lucia. - M.O. £350.
Seycln lbs Government -Amt. M.O. and Vi. Ring Magistrate. £200.
Sheffield, East End Branch of th Child<aIs Hospital.— H.S. £150.
Shi'field. Royal Hospital.— Cas. O. £l3e.
ShtjtieUl Royal Infirmary.- Res i.O. £20C.
Southampton. Free Eye Hosjrital.— H.S. £150.
Smith port General Infirmary.— Hon. Opbtb. S. and Hon. Amrsth.
Straits Settlements Government. —Six M.O. £*50.
Surrey County Council.— School Dentist. 4 350.
Swansea County Borough.— Asst. M.O. £500 and £400.
Univers ty College Hospital.— Clin. Path. £5C0. Also Clin. Asst.
Walsall General Hosvtlai. — Female H.S. and Anaeeth. £175.
Warlord. Alderley Edge, David Lewis Epileptic Colony.—Med. Asst.
Dire* tor. £4,0.
Weihaiwei Government.—Jun. M O. £400.
Wellington College. Berkshire.—M.O. £800.
Thk Cniet liiHja-otnr of Factories, Home Office, 3.W., given notice of
vacancies for Certifying Surgeons under the Factory and Workshop
Acts at New Southgate, and at Thome (West Riding).
Iffftriages, xrt Jhstjjs.
BIRTHS.
Irvine.— On March 9th. at Bareilly, United Provinces. India, the wife
of Captain Maurice L. C. Irvine, Indian Medical Service, of a son.
(By cable.)
Fowi- Li..— On March 19th, at Reading, to Dr. and Mrs. Leslie Powell—
a son.
Woous - On March 18th, at Bramfield, Abbeville-road, Claphara Park,
the wile of Dr. M. M. Wood*, of a son.
Youmjkh.—O n March 25th, 1919, at 2, Mecklenburgh-square, the wife
of G. C. Nelson Younger, M.R.C.S., L.R.C.P., of a daughter.
DEATHS.
Brookf,.—O n March 19th. at Talma House, Victoria-park, Manchester,
Henry Ambrose Grundy Brooke, M.B., B.A. Lona.
Dk Dknnk.—O n March 17th, at Fareh-m, Thomas Vincent de Deane,
M.K.C.S., L.R.C.P.. of Siolands Lodge, Sldmouth.
Dickson.-O n March 17th, at Hulmwood, Grove-crescent, Klngston-on-
Thames, Thomas Hugh Dickson, M.A., M.B. Cantab., Medical
Inspector H.M. Customs and Excise, London, aged 55.
Hartley - On March 20th. of heart failure following influenza, Colonel
Edmund Baron Hartley. V.C., C.M.G., formerly Principal Medical
Officer, Cape Coloulal Forces, and Surgeon, Cape Mounted Rifles,
In his 72nd year.
Watson.—O n March 20th. at Chlltem Home. Princes Rlsborough,
Bucks. Frank Spencer Watson. M.R.C.S., L.R.C.P., in his 64th year.
Wyn now k.—O n March 19th, at Beucombe House, Uley, Glos.,
Dy. Surg.-Gen. b. Jardine Wyndowe, M.D., I.M.S., retd., aged 89.
HM. —A fee of 5s. is charged for the insertion of Notices of Births ,
Marriages, and Deaths.
Thb Lancet,] NOTES, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [March 29,1919 539
A doll was used for tbe teaching, and the apparatus and
furniture were of the simplest character and such as the girls
oould obtain and make for themselves. A spring balance
fras used for weighing. For dressing the baby the three
garments suggested in Mrs. Sims’s book were admirable,
and during needlework lessons the children were taught to
out out and make them. Girls were encouraged to ask ques¬
tions, and every opportunity was given for each to take part
in the demonstration. For this purpose classes were divided
np into sections, and the girls in tnrn took the part of demon¬
strator. Where possible additional instruction should be
given at a school for mothers.
Teaching in Secondary and Continuation Schools:
Practical Pesults.
Miss Turner said that Sir George Newman’s report in
1911 had stimulated interest to a great extent, and there was
now hardly an elementary school where the subject wa9 not
taught in some way. In some of the elementary schools the
need for such teaching was appalling. The subject was
remarkably well taught in women’s institutes, but evening
classes in London were devoted principally to commercial
snbjects. She hoped in the future that at continuation
schools and in evening classes hygiene in some form or
other, and civics—for the two subjects could not be separated
—would be taught. If a woman was going to look after the
babies she was going to be a good citizen. Tbe subject
should be compulsory in all secondary and continuation
schools. Welfare work would provide a good and useful
career for girls, and as under a Ministry of Health welfare
oentres would be established in all parts of the country, a
large number of nurses would be required, and private
people were beginning to value tbe qualified children’snurse.
In nursery schools the teacher should possess both tbe
teacher’s and nurse’s training. There were, therefore, likely
to be a number of well-paid posts for girls in this direction.
Those who left school at 14 could not take up nursing
because the limits of age for that profession were generally
18 to 20.
Mrs. Randall explained the methods adopted at a school
in introducing the subject about six years ago. A class of
old and backward gi Is were initiated into tbe work with
Buoh success that the teachers in the higher classes became
interested, and at the present time all tbe classes in the
school received the instruction. The opening of a day
nursery had been taken advantage of, and six girls, either in
the morning or afternoon, attended there for a mcnth.
Certificates were given after a month’s work at the nursery
in order to encourage both girls and their parents.
Miss Wright, who bad charge of the class referred to by
Miss Randall, said that everything required for the instruc¬
tion was made by the girls, and when they left her they
were efficient in bathing, dressing, and feeding a baby.
Girls who gave the most trouble at school seemed to become
reformed as soon as they came under the influence of the
teaching of infant care. During needlework hours all kiuds
of garments were made, and mothers frequently gave orders
for their expected babies. Notebooks were kept during tbe
lessons on infant care, and tbe books were retained for use
by the girls at home.
Need and Value of Mothercraft.
Dr. Truby King said that he had had an opportunity of
visiting tbe Loudon County Council school at North
Islington with wnich Mrs. Truelove was connected, and he
was very much struck by the simplicity and direct nature
of tbe teaching. It was obvious that all the girls were
thoroughly interested in their work, and those who demon¬
strated the various phases of it bad learned something of
very great value. llis experience in helping mothers and
nurses for a great many years was that if they had been
trained at school we should not meet with the appalling
Ignorance that confronted us every day. He thought there
was as much ignorance on these matters in one class of
Booiety as in another. Most highly educated women lacked
all knowledge of these fundamentally important matters.
It was common for girls to know nothing about babies
except that they were more or less of a nuisance. Mother-
oraft was important and ought to be taught in schools, but
more ought also to be done for the mothers. After receiv¬
ing instruction in school, opportunities ought to be available
for girls to take practical charge of a baby for a few days;
some system of that kind would, he hoped, soon become
part of a girl’s education in New Zealand. Mothercraft
teaching helped to relax the strain caused by the tendency
of modern education to put pressure on the pupils with
regard to the accumulation of knowledge. This particular
work acted as relaxation and refreshment, and the more it
exercised tbe emotions the more it lessened tbe great strain
of the ordinary school work. There was danger of the subject
becoming too academic, for it was practical, and ought to
be taught in a simple commonsense wav. Tbe necessary
spirit for the work was that which inspired Florence
Nightingale.
Miss Jobson and Miss Robins also spoke, the latter
emphasising the importance of training in a day nursery for
a month or a week in the teaching of mothercraft.
A vote of thanks to Dr. Truby King was passed on the
motion of Dr. Kimmins. of Chailey.
CAUSE OR COINCIDENCE?
Dr. C. J. Hill Aitken, R.A.M.C., sends us the following
contribution based on the old dilemma: Post hoc t aut
propter hoc ?
1. A South African native with well-marked pulmonary
tuberculosis was one evening at the point of death—
comatose and almost pulseless. Strychnine was not in¬
jected. In fact, nil was done. He survived the night and
lived for a month.
2. A young girl was suffering from boils and her hair was
falling out. Various remedies had been tried in vain. A
course of colloidal manganese was recommended, but owing
to a supply not being available the treatment was not carried
out. About the time the fourth injection would have been
due the boils healed and ceated to appear, and the hair
stopped falling out.
Had drugs been used they would have gained much credit.
In the first case tbe reason of tbe native’s temporary recovery
was beyond my clinical powers. In the second case oure
coincided with a happy engagement.
A UNIVERSAL LANGUAGE OF QUANTITY.
It is suggested by Mr. Hany Allcook, M.I.E.E.,
A.I Mecb.E., writing for the Decimal Association, that
with big schemes of industrial reconstruction afoot the
opportunity is favourable for the adoption of tbe metrio
system and for making it international. If it is true that
sooner or later Great Britain must abandon the British
Imperial system (because even its stoutest supporters would
refuse to undertake tbe impossible task of inducing the
world to adopt it) the sooner a beginning is made tbe
better. There can be little doubt that education, science,
and industry would alike benefit* under an international
metric system. Science has already adopted it. Com¬
mercial circles in this country have so far been opposed to
it, but the hope may be expressed that these will harden
their hearts no longer if they can be convinced of the un¬
doubted economic advantages which the introduction of the
metric system would ultimately secure. It would be an
immense reform, and the inevitable inconveniences which
the change would at first bring would soon be forgotten.
Other apparently dangerous innovations have recently been
made with success. The introduction of summer-time was
looked upon by many as a risky experiment, but it has
worked out in practice to the advantage of all.
GRAIN PESTS AND SCIENTIFIC ACCURACY.
The last of the series of lectures on Physiology and
National Needs was delivered by Professor A. Dendy,
F R.8., at King’s College on March 12th, when 8ir James
Kingston Fowler presided. In giving an account of the
results of the experiments on the Conservation of Wheat
which he, in conjunction with Mr. H. D. Elkington, had
undertaken for tue.Grain Pest War Committee of the Royal
Society, Professor Dendy insisted upon the extreme import¬
ance of scientific accuracy, and referred to an interesting
physiological fact in regard to the asphyxiation of weevils.
All grain was liable to be damaged by mites, moulds, mice
and rats, and probably by bacteria. Mankind depended to a
great extent on grain for existence, the storage of wheat
being a very ancient practice. It was now necessary to store
it for a longer time than formerly in order to provide against
emergencies. Vast quantities of wheat had recently been
held up in Australia owing to tbe scarcity of ships, the con¬
sequence being that a large part of it had become damaged
or completely destroyed. The problem of conserving cereal
reserves, either in the form of dried grain or manufactured
products, was of great national importance, and the devising of
reliable methods for storing such reserves was attracting con¬
siderable attention. The best known and most destructive
enemies of wheat were weevils, but the larvro of certain
moths which feed upon the debris of weevils also did
much damage. Those whose duty it was to inspect ware¬
houses where quantities of food were stored should have a
knowledge of the habits of these pests, because they
damaged other foods as well as graiu. One experiment
which had been carried out showed that a single pair of
rice weevils multiplied 700-fold in about 16 weeks. Such
multiplication, however, only took place in this country
during tbe warmer months of the year; the grain, there¬
fore, should be kept as cool as possible. The weevil required
a certain amount of moisture in order to support life,
and wheat, unfortunately, appeared to be a very hygro¬
scopic substance. The eggs of the weevils were laid within
the wheat grain itself, and developed until the adult stage
was reached. During the process large quantities of the
grain were eaten, the exoreta accumulated and attracted
€40 Thi Lancet,] NOTE8, SHORT COMMENTS, AND ANSWERS TO CORRESPONDENTS. [MARCH 29, 1919
moisture, and moulds and bacteria grew vigorously. Some¬
times the grain was in tbis way converted into a black
mass resembling manure and giving off a large amount of
summon ia.
Wheat was also damaged by a kind of fermentation
which was technically known as “heating” and which
Always occurred when the grain was stored in large
quantities. The various methods of cure for infected grain
'Which had been suggested were troublesome and expensive.
What was required was some method by means of which
deterioration of the grain could be prevented, even after
storage for a large number of years. A system of air-tight
•storage seemed to be the remedy; an approximation to this
method had been employed for a long time both in
India and in other parts of the world. The wheat was
■stored in pits, and, though the method was not always
carried out satisfactorily, it was thus often free from
Attacks of weevils. In Malta wheat was kept in under¬
ground brick-lined granaries and in this way was immune
from insect attacks and did not deteriorate. The beneficial
results of the method were due to the generation of COa.
In academic circles it had long been believed that weevils
Could live under circumstances which precluded ventilation.
But this belief could not stand the test of precise experiment,
ior if placed in hermetically sealed jars containing wheat
weevils died within a few days, whatever their stage of
development. Thus, wheat might be completely sterilised
eo far as insects were concerned by hermetically sealiug the
.grain for a short time. The origin of the widespread belief
in the miraculous physiological powers of grain insects was
probably due to the fact that so-called hermetically sealed
vessels were not hermetically sealed at all. Tins of Army
biscuits had been passed by the inspector as intact even
though thev showed obvious rents in their sides. Tins of
“weeviled” barley had been brought to the lecturer with
the intention of showing that weevils would live in air
tight tins, but on placing the tins in hot water all save
one bubbled at the seams, and that one when opened was
perfectly free from “ wefeviling.” Airtight sealing also pre¬
vented the formation of moulds, and the process known as
4< beating.'' Native peoples who had no idea of the scientific
explanation had known the secret of airtight storage fora
Aorprisingly long time. Certain Natal farmers stored their
grain in large tanks of galvanised iron in which they burned
oandles before closing up the tanks. It was easy to demon¬
strate that grain at ordinary times gave off quantities of
CO*; when insects were present the percentage was greatly
increased, as they themselves gave off a considerable amount
in respiration. Experiments bad been carried out in order
to discover whether the death of the insects was due to some
poisonous action of the gas or simply to deprivation of
oxygen, and it had been found that, whilst the absence of
oxygen was sufficient to kill the weevils, the COa also
produced a poisonous effect. Weevils that bad simply
been aniEsthetised by the CO 2 for some days could
be resuscitated by supplying them liberally with oxygen.
If, on the other "hand, a little oxygen were mixed with
the carbon dioxide, the weevils did not remain alive
for long. While the oxygen present seemed to support
life, it appeared to enable the COa to exercise its poisonous
effect; with pure carbon dioxide the living machinery was
shut down at once and the gas had no chance of exercising its
poisonous effects. The insect was asphyxiated, not poisoned.
If the grain was stored in airtight receptacles in the country
of origin for a few months before shipment it would become
completely sterilised aud, with care, would not become
re-infected on the voyage, while if the grain was landed in
this country uninfected there would be less risk from insect
invasion.
THE MORTALITY IN THE FRENCH AUXILIARY
ARMY MEDICAL CORPS.
A recent communication made bv M. Gilbert Laurent to
the French Interparliamentary Medical Gronp put the total
number of civilian medical practitioners mobilised for war
purposes at 2169. Of these 372, or 17 per cent., had died
during the war, 259 of wounds, and 113 from other causes.
NERVE STRAIN IN LONDON CHILDREN.
OtJR attention has been called to a resolution pnt down on
the Agenda of the newly elected London County Council in
the name of the Labour Party. The resolution runs
“That in view of the high nervous strain imposed on the children
of the working class during the war. and their diminished vitality
arislng from the shortage of food and its lack of variety, which, added
to the normal conditions of social inferiority borne by the workers’
children, has greatly reduced the stamina of the school population in
the County of London, it be referred to the Education Committee to
advise the'Coundl at tbo next meeting of the Council as to the steps
necessary for the purpose of securing that all children attending the
Connell’s elementary schools shall have a holiday of one month at the
seaside or in the country Without charge to the parents.”
While we have the greatest possible sympathy with the
suggestion, it is only fair to add that, according to the
mAaicAl evidence, London children have been, on the whole,
better fed during the war than they were previously, while
there is not the slightest evidence that the children in
elementary schools have been subjected to a greater strain
than other children. It is, in fact, difficult to find evidence
of strain at all; and wb&t there is certainly is not wide¬
spread. But it would be an excellent thing for all London
children to be taken to the seaside for a month, granted the
necessary precautions could be exercised.
SACCHAROSE INJECTIONS IN PULMONARY
PHTHISIS.
To the Editor of The Lancet.
Sir,—S hould any of your readers have had any experience
of saccharose injections iu cases of pulmonary phthisis
I should be glad of some informatiou as to the success or
otherwise of this form of treatment. Thanking you in
anticipation for the hospitality of your columns,
lam, Sir, vours faithfully,
J. Lavbns West, L.R.C.P. A 8. E.,
March 25th, 1919. Avista.. Tuberculosis Officer, Stoke-on-Trent.
ViDerug .—The treatment of adder-bites in England was
referred to in The Lancet of August 21st, 1909 (p. 585), and
in France in the Pans letter in The Lancet of Sept. 20tb,
1913 (p. 896). A 1 per cent, solution of permanganate of
potash or of chromic acid has been used, bat the only
really efficacious and rational method, aooording to French
authorities, is the use of Calmette’s serum.
BOOKS, Kl'C., RECEIVED.
Hkinemawn, William. London
Technique of tne Irrigation T ext.ment of Wounds by the Carrel
Method. By J. Duma* an 1 A ne Cartel. Translated by A. V. 8.
Lambert. M.D With Intro iu -.tion by W. W. Keen. M.D. 6#.
The Unmarried Mother. By P. G. K im merer. With Introduction
by W. Mealy. M.D.
Ke«an Paul, Trrnch, TrUbnkr, and Co., London.
What is Pwch -t-Analysm? By I. H Oorlat, M.D 3*. 6<f.
Lauhir. T. Wkrwkr, Lond >n
A Textbook of Sex Education f *r Teacher* and Parents. By W. M.
Oallichan. 6*.
A Broken Journey. By Mary Gaunt. 18*.
Masson kt Cie., Paris.
Le Tmitement des P^vohonevroses de Guerre. Par G. Bouaay,
J. Bnlssoau, et M. d (JElsniU. Pr.4.
Rivkrsidk Press, Cambridge. Boston. U.S.A.
The Ht niue S xnety of th * Commonwealth of Massachusetts,
1785-1916. By M. A de Wolfe Howe.
Communications, Letters, dec., to the Editor have
been received from—
A. —Dr. H. G. Adamson. Lond ;
Messrs. Allen and Hanburys.
Lond.; Dr. P. S. Arnold, Berk-
hamated.
B. —-Dr. G. Blacker. Lond.; Mrs.
C. B. Bridgeman, Lond.; Dr
A. G. Begg, Swansea; Brorapton
Hospital for Consumption. Lond.,
8ec. of: Capt. J. S. K. Boyd,
K.A.M.C.; Mr. J. Burns, Edin¬
burgh ; Dr. M Benaroya, Lond.;
Prof. A. Bain bridge, Lond.
C. —Cancer Hospital (Free), Lond.,
President and Committee of: Dr.
0. W. Chapman, Lond.; Mr. B. M.
Corner, Lond.; College of Am¬
bulance, Lond.; College of
Nursing. Lond., Sec. of; Dr.
W. A. Chappie. Lond.
D. —Lieut. B. Dunlop. R.A.M.C.;
Prof. S. Dele.pine, Manchester;
Mr. H. Dickinson. Lond.
E. —Major W. MoA. Eccles,
R.A.M.C.(T.)
V.—Flying, Lond., Bdltor of: Dr.
J. A. Francis, Lond.; Capt. J. G.
Forbes, R.A.M.C.; Major P. K.
Fraser, K.A.M.C.
O.-Capt. P. A. Galpin, R.A.M.C.;
General Medical Council, Lond.,
Registrar of; Lt.-Col. B. W.
Good all, R.A.M.C., Lond.; Dr.
H. L. Gordon, Lond.; Dr. A. K.
Gordon, Lond.
H.— Dr. 0. W. Hutt, Brighton ;
Dr. C. F. Hadfield, Lond.
L—Insurance Committee for the
County of London; Illuminating
Engineering Society, Lond.
J. —Mr. G. L. Johnston, Bridge of
Allsn ; Dr. F. W. Jones, Lond.
K. — Dr. L. Kidd. Enniskillen.
Au—Maj.-ilen. Sir W. B. Letshman,
K. C.M.G., C.B.; Local Govern¬
ment Board, Lond., Asst. Sec. of;
Mr. W. A. Loxton, Birmingham ;
Mr. R. Lake. Lond.; Liverpool
Post and Mercury ; Local Govern¬
ment Board. Loud., P.M.O. of.
M. —Mr. I. Moore Lond.; Dr. G. N.
Meachen, Braintree: Medical
Research Committee, Lond.;
Medico; Mr. J. B. Maealplne,
Manchester; Dr. J. C. Mo Walter,
Alexandria.
N. —Nurses’ Co operation, Lond.;
National Food Reform Associa¬
tion, Lond.
O. —Mr. J. F. O’Malley, Lond.;
Sir William Osier, Bart.. M.D.,
Oxford
P. —Pauel Committee for the
County of London; Dr. B. K.
Prest, New Cumnock: Miss Z. L.
Puxley, Lond.; Messrs. G.
Pulman and Sons, Lond.
R. —Dr. H. Rah met Bey, Cairo;
Dr. A. Kansorae, Bournemouth;
Mr. V. K. Russom, Lond.; Dr.
R J. Kowlette, Dublin; Royal
Academy ot Medicine in Ireland,
Dublin; Royal Sanitary Insti¬
tute. Lond.; Dr. W. C. Riven,
Wore boro’ Dale; Royal Institu¬
tion. Loud.; Registrar General
for Ireland, Dublin; Sir EL D.
Holies ton, K.C.B., Lond.
S. —Prof. A. L. Sorest, Rome; Dr.
P. 8aha, Lond.; Dr. B. B. Sher¬
lock, Lond.; Dr. A. G. Shorn,
Eastbourne; Dr. E. Schuster,
Loud.
T. —Mr. P. Turner, Land.; Dr.
C. J. Thomas, Loud.; Dr. A. H.
Thompson, Lond.
U. —University of Liverpool, Regis¬
trar of.
W.—Dr. J. P. Williams, Lond.;
Dr. P. J. Waldo. Lond.; Messrs.
Witherby and Co., Lond.; Dr. P.
Wlgfleld, Lond.; Mr. T. W.
Watson, Middleton-ln-reesdaie;
Mr. H. T. Warner, Loud.; Dr.
M. H. Williams. Col wall; Mr.
G. W. Wilton, Edinburgh; Dr.
F. J. Waldo, Loud.
Y.—Dr. M. Young, Chester.
Gottimunicatioua relating to editorial business should be
addressed exclusively to The Editor of The Lancet,
423, Strand, London, W.C. 2.
Tke'Lxkcet, July 5,1919.
INDEX TO YOLDME I , 1919.
Uf Readers in search of a given subject will find it useful to bear in mind that the references are in several eases
distributed under two or more separate but nearly synonymous headings—such, for instance , as Brain and Cerebral,
Heart and Cardiac, Liver ami Hepatic, Bicycle and Cycle , Child and Infant, Bronchocele , Goitre, and Thyroid,
Diabetes, Glycosuria and Sugar, Eye, Qphthalmic, and Vision, cfo., cf"c. (Py Q)~ Parliamentary Question .
i Pages.
Date of issue.
No.
1-50 ..
... Jan. 4th ..
... 4975
51-90 ..
... „ 11th ..
... 4976
91-128 ..
... „ 18th ..
... 4977
129-164 ..
... „ 25th ..
... 4978
165-202 ..
... Feb. 1st ..
... 4979
203-242 ..
... 8th ..
... 4980
243-284 ..
... „ 15th ..
... 4981
285-324 ..
... ,, 22nd ..
... 4982
325-364 ..
... March 1st ...
... 4983
INDEX TO PAGES.
Pages.
Date of issue.
'No.
365-406 ..
... March 8th ...
.. 4984
407-448 ..
,, 15th ...
.. 4985
449-488 ..
... ,, 22nd ...
.. 4986
489-540 ..
. 20th ...
.. 4987
541-592 ..
... April 5th ...
.. 4988
693-644 ..
... „ 12th ...
.. 4989
645-688 ..
... „ 19th ...
.. 4990
689-728 ..
,, 26th ...
.. 4991
729-772 ..
... May 3rd ...
.. 4992
Pages.
Date of issue.
No.
773-826 ..
.... May 10th ...
..4993
827-868 ..
.... „ 17th ...
..4994
869-922 ..
.. 24th ...
.. 4995
923-964 ..
. 31st ...
.4996
965-1012
.... June 7th ...
.. 4997
1013-1054 ..
.... „ 14th ...
.. 4998
.1055-1098 ..
.... „ 21st ...
..4999
1099-1140 ..
.... „ 28th ...
.. 5000
A |
Abderbalden’s pregnancy reaction. 111
Abdominal operation, haematemeaia after. 629;
reflexes, significance and surgical value of !
fMr. D. Lfgat), 729; tuberculosis, 940 j
Aberdeen Royal Infirmary, meeting, 414
Aberdeen University, pass- lists, 87.584; spring
graduation, 684; Prof. C. R. Marshall
'appointed to the Regius chair of materia
medica and therapeutics, 854; club dinner,
862
Abiotrophy of the retinal neuro epithelium or
11 retinitis pigmentosa," 893 j
Abortlfaclent, quinine as (Prof. W. 0. S wayne
'and Mr. E. Russell), 841
Abrahams, Dr. A.. Dr. N. Hallows, and Dr. H. I
Trench, Influenzal septlctemla, 1 :
Abrahams, Maj. A., epidemic perinephric sup¬
puration, 1044
Abscess In flbromyoma, 22; pyosalpinx and
ovarian, 265
Abscess, peritonsillar (Dr. A. Wylie), 178
Abscesses, fixation in Influenza, 895
Absentee, practice of the, 45, 80
Accommodation for hospital nurses (Py Q), 770
Acetone, alcohol, and benzene In the air of
certain factories, 772
ACh&rd, Prof. 0., Review of Studies on Renal
Function in Chronic Nephritis (thesla by
•Pastenr-Vallery-Radot), 752
Acidosis and Its significance, 30
Atkerley, Dr. R., “ hot liquids and cancer,”
636
Adaml, Prof. J. G., prevention and arreet of
•venereal diseare In the Army, 109; War Story
of the Canadian Army Medical Corps
(review). 111
Adams, Dr. D. K., acute ascending myelitis,
462
Adams, Mr. J., new pattern gland dissector,
‘868
Adams, Mr. J. E., maldevelopment of the
• liver, 744; carcinoma of appendix, 845
Adamson, Dr. Rhoda, effect of Industrial
employment upon women, 465
Adenoids, treatment of, 284. 323
Advanced Suggestion (Neuro-induction) (Mr.
’H. Brown) (review), 302
After-care of tuberculous ex-servlco men, 767
Agglutination test, standard, permanent
criterion for (Mr. A. D. Gardner), 21
Agglutinins, other, formation o', in cases of
Malta fever (Dr. L. T. Burra), 64
AMs to Medical Diagnosis (Dr. A. Whiting),
second edition, 1918 (review), 112; to Sur¬
gery’(Dr. J. Cunning and Mr. C. A Joll),
fourth edition, 1919 (review), 659; to the
Analysis of Foods and Drugs (Mr. C. G.
Moor and Mr. W. Partridge), fourth edition,
1918 (review), 848; to Histology (Dr. A.
Ooodall), second edition (review), 848
Air for oxygen In anesthesia (Dr. J. H. Fryer),
216
Altken, Capt. R , B. V.M.C. (see Obituary of
the war)
Altken, Dr. C J. H., invalidism for 15 years
through nasal blockage, 156
Albert medal, award, 915
Alberta Health Department, 232
Aldridge, Dr. C., death of, 843
Alexander, Dr. W., obituary;530
Allahabad, new medical school, 760
Allbutt, Sir C., portrait of, 814, 910
Allen, Capt. W. R., R.A.M.C. (see Obituary of
the war)
Allotments and health, 284
Alport, Capt. A. C., Malaria and its Treatment,
in the Line and at the B&m (review), 616
Amar, Prof. J., Physiology of Industrial
Organisation (review), 265
Amibi&slne, 898
Ambulances, Red Cross, utilisation of, 187
America, visit of foreign medical men, 1091
American Journal of Care for Cripples (review),
426
American Journal of Ophthalmology (review),
1029
American Journal of Public Health (review),
660
American Medioal Corps, work of, 431
American Public Health Association and
Influenza, 230; gifts, 318; post-graduates in
London, 943
American Review of Tuberculosis (review), £65,
468, 566, 747, 1029
Amoebic and bacillary dysentery, diagnosis of
(Dr. G. M. Findlay), 135; dysentery carriers,
a correction, 157; dysentery, treatment, 429 ;
dysentery, 674
An as mi a, severe, 700; aplastic, 744 ; jaundice
In (Dr. W. H. Willcox), 932
Anaerobic tube, Buchner's, modified, 226
Anaesthesia, spinal (Dr. F. S. Rood), 14 ; air for
oxygen in (Dr. J. Q. Fryer), 216; safe, 231;
surgical, iacrymal gland in (Dr. L.T. Ruther¬
ford), 792; rectal ether (Mr. J. C. Clayton),
793; for ophthalmic operations (Mr. C. T. W.
HIrsch), 1068
Anaesthetics, a nasal air-way, 1030; Dr. J.
Regaault on. 1037
Aiulttioal Records trom “The Lxitckt ”
Laboratory—
Amlblasine, 898
Aniodol. 384
“ Cofectant lozenges, 24
Digalcn, 384
Ethyl chloride films, 24
Feroxal,24
Genasprin, 24
Influenza vaccine (mixed), 24
Italian ichtbyol, 24
Omnopon, 384
Petroleum jellies (“ Semprolla ” brand), 898
Sedobrol, 384
Solution pot. iodide (Souffron), 384
Strophanthus and strophanthine (esia-
tallie£e), 384
Thioeol, 384
Valenda spray, 898
Veronidia, 24
Anaphylaxis (Dr. J. K. Gaunt), 889
Anatomical films, 1125
Anatomy, chair of. University College, London.
•969
Anderson, Dr. H. G., Medioal And Surgical
Aspects of Aviation (review), 982
Anderson, Mr. W. H., dislocation of teeth,441
Andrews, Dr. H. R., four cases of full-Mxne
ectopic pregnancy, 611; removal of eub-
. mucous fibroid with Hegar’s dilators, 1073
Aneurysm, traumatic, of external carotid
(Dr. S. ,C. Dyke), 21; aortic, 7C0; cirsoidi
700
Angeiold streak in retina, 613
Angioma of retina, 300 ; of the choroid, 886
Animal ailments in 1918,1088
Animal Life and Human Progress (Prof. A.
Dendy) (review), 1120
Animals (Anssthetics) Bill, 821
Aniodol, 384
Ankylostomiasis, oil of chano podium in, 80;
in Australia, 476
Annals of Medical History (review), 566
Anthrax, appointment of Advisory Committee,
200 ; prevention of, 821
Anthrax Bill, Prevention of, 685, 865, 969
Anti-hookworm campaign in tea districts, 998
Antimony in bllharziasis, 79; tartrate lor
bilharziasis (Dr. J. B. Chrlstophereon),
1021
Antiplague serum in influenza, 663
An^pynn, persistent pigmentation due to,
Ant«rablc treatment (Py Q), 918; eentcee,
1138
Aortic aneurysm, 700
Aplastic anaemia, 744
Apothecaries’ assistants, Qualttkutteas of
(Py Q), 442
Apotheoaries Society of Loudon, pase-ltsts,
48,584
Apparatus, new "606," 618
Appendicitis, acute, and acute appendicular
obstruction (Mr. S. T. Irwin), 98, 197;
accurate diagnosis in (leading article), 114,
197 ; X rays in diagnosis, 279; coexistence of
Bmall gut reflex in oases of <Mr. D. Ligat),
731; acute (Dr. R. A. Barlow). 844
Appendix, vermiform, examination by
(Dr. E I. Spriggs), 91; carcinoma of, 845
Apperly, Mr. R. E., heart failure, 658
Appointments, weekly lists of, 49, 89,127,(162,
200, 240. 321, 362, 403, 445, 487, 537. 589,642,
726, 824,865, 919,961, 1009, 1051,1096,1138
Apyrexlal symptoms of malaria, 222
" Arellanoinfluenza mask, 90
Armour, Col. D., cirsoid aneurysm, 700
Army huts for tuberculous patients (Py Q).
641; medical equipment, surplus (Py Q), 664
Arthritis and rheumatism, meulngoooceal (Dr.
P. Sainton), 1080
Artificial limbs (Py Q>, 320. 321
Ascending paralysis, acute (Dr. H. Sutherland),
841
Ashe, Dr. J. S., endothelioma of the ovary, 264
Aspirin, intolerance of (Dr. E. J. Tyrrell), 1118
Aspirin poisoning (Dr. F. W. Lewis), 64
iv Thb Lancet]
INDEX TO VOLUME I., 1919.
[July 5,191*
Assessments, disability, and medical boards
(Py Q). 918
Association of Factory Doctors and Managers,
768
Association of Panel Committees and notifica¬
tion fees, 439
Association of Pablic Vaccinators, meeting,
443
Astley Cooper prize, 282
Astragalus, fracture-dislocation of (Mr. H. C.
Orrln). 20
Asylum Workers’ Association, meeting, 956
Atmospheric pollution, monthly record, 81;
Meteorological Office Advisory Committee
on, report on obfcrvations in the year
3917-1918 (see Supplement, June 14th);
Investigation of, 1035
Bastian. Surg.-Com. W.. origin of life, work of
the late Charlton Bastian, 951
Basu, Maj. B. D., Diabetes and its Dietetic
Treatment, ninth edition, 1918 (review),
383
Bateman, Dr. A. G., death of, 679
Bath, the new, 1037
Batten, Mr. B., disease of both maculae,
613
Baufle, Dr. P., Dr. R. Coope, and Dr. E.
Joltraln, chronic oolopathles, 933
Bay 11s, Mr. U. A., incidence of Entamceba
hi‘tolytica, Ac, in naval entrants, 64;
amoebic dysentery carriers, a correction, 167;
Bay lisa, Prof. W. M., wound shock, 668;
and Dr. H. H. Dale, shock, discussion,
256
Australia, Correspondence from — In¬
fluenza pandemic; Influenza vaoclnes;
Nationalisation of medicine; Anky¬
lostomiasis ; Australian Army Medical
Corps, 476—Influenza epidemic; Inoculation
and masks; Unseemly disputes, 681-
Influenza ; Federal and State quarantine,
760
Australian Army Medical Corps in Egypt in
1914-15 (Sir J. W. Barrett and Lieut. P. B.
Deane) (review), 66
Autonomic nervous system, arrangement of,
951
Autotherapy or bleeding, 124
Autumn influenza epidemic (1918) (Dr. J.W. H.
Byre and Dr. B. C. Lowe), 563
Aviation candidates, medical examination of,
46; Insurance Association, 435
Aviation, medical aspects of (Dr. L. B. Stamm)
206; Medical and Surgical Aspects of (Dr.
H. G. Anderson) (review).
Aviators, nasal obstruction in (Dr. D. Guthrie),
136; visual requirements of, 894
B
Babies in Peril, or Mother and Infant Wel¬
fare Centres (Miss E. M. Bennett) (review),
618
Bacillary dysentery: are relapses frequent,
629; dj Hcntery, 673; dysentery, mild (Dr. J.
Ryle), 937
Bacilli, tubercle, human, bovine, and avian,
attenuation of (Dr. N. Raw), 576
Bacillus infiucnzx, simply prepared culture-
rntdla for (Mr. A. Fleming), 138
Bacillus multlfermcnlans tenalbus.( Dr. J. L.
Stoddard). l3
B.paratyphosus B, an atypical strain of (Dr.
W. Broughton-Alcock), 1023
Bacteriology, Manual of (Prof. B. Muir and
Prof. J. Ritchie), seventh edition, 1919 (re¬
view), 467; endowed chair. 988
Bacteriology of Influenza, 760; epidemic In
Lower Egypt, (Dr. G. M. Findlay), 1113
Bailey, Cspt. J. C. M., R.A.M.O., O.B.B. (see
Obituary of the war)
Balllle. Dr. D M., use of Intravenous iodine
in Influenzal broncho-pneumonia, 423; and
Mr. B. G. D. Pineo, treatment of gonorrhcea
by pus vaccines, 508
Baines, Mr. A. K., Studies in Biectro-pbysio-
logy (Animal and Vegetable) (review), 701
Baldwin, Mr. A., plastic operation on faoe for
deep scarring, 300
Balfour, Dr. A., sanitary and insanitary make¬
shifts in the Eastern war areas, 604
Balgamle. Dr. W., rupt ured rectus abdominis,
influenzal, 843
Ballance, Sir C., and Dr. H. Campbell, general
paralysis of the Insane, treatment, 6C8
Barber. Dr. H., Dr. C. F. White, and Dr. A. T.
McWhlrter.Wascermann reaction, a criticism
of its reliability, 502
Bards well. Dr. N. D„ Y.H.C.A. Agricultural
Training Colony, Hinson, Dorset, 4o6; public
health aspect of tuberculosis. 464
Barium salts administered for radlologioal
examination, death from. 943
Barlow, Dr. R. A., acute appendicitis, 844
Baron, Sir B. J.. death of, 1095
Barrett. Lad y, deficiency of the pituitary body
in a girl. 4&
Barrett, Sir J. W., and Lieut. P. B. Deane,
Australian Army Medical Corps in Egypt in
1914-15 (review), 66; management of vene¬
real diseases in Egypt during the war, 140,
193
Barton, Mr. E. A., quality of commercial
vaccine lymph. 313
Bashford, Capt. B. F., Cspt. J. A. Wilson, and
Maj.-Gen. Sir J. R. Biadford, filter-passing
virus in certain diseases, 169; acute infective
polyneuritis, 348
Bassett, Lieut. R J., B.A.M.C. (we Obituary
of the war)
Baasett-Sraltb, Surg. Cant. P. W„ sprue
associated with tetany, 178
Bayly, Mr. B. W., laboratory methods and
diagnosis of venereal diseases. 817
Beattie, Prof. J. M., diagnostic value of the
Wassermann reaction in syphilis, 466
Bed for fractures and general hoapltal pur¬
poses, 266
Bedside and Wheel chair Occupations (Dr.
H J. Hall) (review), 800
Begg, Col. 0. M., C.B., C.M.G., New Zealand
M.C. (see Obituary of the war)
Belfast, health of, 121; strike in, 193; Hospital
for Skin Diseases, meeting, 193; Royal Vic¬
toria Hospital, resignation of Sir W. Whit la,
M.P., as senior physician. 274; Queen’s Uni¬
versity, Col. T. Sinclair elected registrar,
358; doctors and Ministry of Health. 577;
Ophthalmic Hospital, meeting, 997; Dental
Clinic, 1040
Belgian Doctors’ and Pharmacists’ Belief
Fund, 37, 125, 384, 618; (leading article),
228 ; close of the fund, 235; decorations, 915
Bell, Dr. B., abscess in fibromyoma, 22
Bell, Mr. A. S. G., oerebro-splnal meningitis,
887 ■
Bes&roya, Dr. M., lung puncture in treatment
of influenzal pneumonia, 742
Benn Ulster Bye. Bar, and Throat Hospital,
Belfast, mooting, 722
Bennett, Miss E. M., Babies in Peril, or Mother
and Infant Welfare Centres (review),
618
Bennett, Mr. L. H., obituary, 125
Bennett, Dr. R. A., intestinal obstruction by
Meckel's diverticulum, 1117
Benson, Mr. C. M., obituary, 358
Berkeley, Dr. C., Gynaecology for Nurses and
Gynaecological Nursing, third edition. 1918
(review), 848
Bertrand, Mile. T., and M. Emile Sergent,
meningeal haemorrhage in typhoid fever, 519
Bliharziasis (Dr. N. H. Fairley), 1016 ; its pre¬
vention and treatment (leading article), iQ32
Bliharziasis, antimony in, 79; antimony
tartrate for (Dr. J. B. Christopherson), 1021
" Billie Carleton,” inquest on, 236
Bing, Prof. R., and Dr. A. L. Vlscher, psycho¬
logy of Internment, 697
Bingham, Capt. J. W., R.A.M.C. (see Obituary
of the war)
Biochemistry and Phj siology In Modem Medi¬
cine (Prof. J. J. R. Maeleod and Dr. B. G.
Pearce) (review), 513
Biological Chemistry. Study of (Dr. S. B.
Schryver) (review), 659
Biology and the medical corricnlnm (Mr. T. G.
Hill), 273. 312
Biology, Experimental, Monographs on, the
Elementary Nervous System (Prof. A. H.
Parker) (review), 702
Bird’s brain, the. 616
Birmingham University, post-graduate study,
725
Births, marriages, and deaths, weekly lists of,
49. 89, 127, 162. 200. 240, 283, 322. 362, 404,
445, 487, 537. 590, 642, 686, 726, 771, 825, 866,
919, 962. 1009, 1052,1097, 1138
“ Birthplace of gynaecology,” 189
Bismuth Order, the, 128
Black, Dr. Guy, the late, 1003
Blackwater fever (Mr. J. P. Williams), 886
Blake, Lieut.-Col. J. A., Gunshot Fractares
of Extremities (review), 184; Fractures
(Gunshot Fractures of Extremities)(review),
702
Blakeway, Mr. H., obituary, 358
Blanchard, Prof. R., obituary, 315
Bland-Sutton. Sir J., gizzards and counterfeit
gizzards, 203; missiles as emboli, 773
Bleeding or autotherapy, 124
Blind men on committees, 868; subject., the
case of, 964 ; In Ireland, treatment of (Py Q),
1051
Blood, diseases of, transfusion in, 379; volume
and related blood changes in haemorrhage,
852; transfusion by the citrate method (Mr.
A. Fleming and Dr. A. B. Porteous), *973,
988; transfusion (Dr. B. L. Hunt and Dr.
Hfl^n Tnglety), 975, 988; transfusion, Pepys
on, 1098
Blood-supply of muscles (Dr. J. Campbell and
Dr. C.M. Pennefather), 294
Board of Customs, medical ^officer to (Py Q) r
Boards of guardians, powers of '(Py Q), 918
Bock, Airlle V.. and O. H. Robertson, blood-
volume and related blood changes after
haemorrhage, 852
Bodily Deformities (Mr. B. J. Chance) (review^
Body temperature, electrical methods of
n ensuring, 564
Boerhaave. Hermann, 576
Boissean, J., G. Boussv, and M. D’OeIsnitx r
Traltement dee Fsychonlvrotes de Guerre
(review), 1119
Bolduan, Dr. 0. F., and Dr. J. Koopman r
Immune Sera, fifth edition, 1917 (review),
746
Bone grafts, mandibular, 181; sinuses, treat¬
ment by solid metal drains (Mr. C. J.
Symonds), 971
Bone-grafting operations (Mr. W. M. Munbs
and Mr. A. D. B. Shefford), 1070
Bonney, Mr. V., continued high maternal
mortality of childbearing, 775,796
Bonus to nurses in South Africa, 1026
Books. Ac., received, 87. 162, 241, 334, 406,
486. 540, 771, 825, 866, 920, 963, 1016,.
1096
Books of reference, 324 ; for Serbia, 398, M3 v
in large libraries, care of, 826
Booth, Dr. J. M., obituary, 860
Borland, Dr. V., prophylactic treatment o
constipation in children. 459
Bottles, medicine, shortage (Py Q), 957
Boulenger, Dr. M. F., phthisis in factory and
workshop, 156
Boulogne as a military medical base,
664
Boulogne, Dr. P., lymphadenitis in right Iliac.
fossa simulating appendicitis, 968
Bowel, double resection (Mr. G. Taylor), 46Ii
Bowlby, Sir A., Hunterian oration on British
military surgery in the time of Hunter and
in the great war, 285
Bowman lecture on plastic operations on the
orbital region (Prof. Morax), 894
Boycott, Prof. A. B., biology and the medical
curriculum, 312
Boyd, Dr. W. R., heroin poisoning, 755
Boyden, Dr. P. H., and Sir A. Reid, treatment
of venereal disease, 212, 314
Boves. Q.M.-Sergt. J. T., and the late Dr. A. H*
Carter, cerebro-spinal fever, 1066
Boyle, Mr. H. E. G., a warning, 164; nltrous-
oxirfe-oxygen-etber outfit, 226, 231; l&ryngo-
fisaure with removal of lntra-laryngcal
growth, 659
Bradford, Maj.-Gen. Sir J. R., Capt. B. F
Bashford, and Capt. J. A. Wilson, filter¬
passing virus in certain diseases, 169; acute
infective polyneuritis, 348
Brain and the vaso-motor system (Dr. L»
BroWn), 967
Brain-worker’s diet (leading article), 601
Brandy and whisky, medical supplies of (Py Q)#
1060
Branson, Dr. W. P. &., haemorrhagic spinal
effusions, 888
Breathing, Deep, Science and Art of (Dr. S*
Otabe) (review), 467
Brentnali, Mr. E. S., and Mr. H. Platt, farmdie
stimulation, 884, 989
Brewerton, Mr. K., angioma of retina, 300;
angeloid streak in retina, 613
Brierley, Mr. W. B., origin of life, work of the
late Charlton Bastian, 1001
Briggs, Dr., radical cure of complete pro¬
cidentia, 22
Brighton Hospital Sunday Fond, 24; and
wounded soldiers, 400 ; 2nd Eastern General*
Hospital closed down, 950; hospital for
women and children, 1140
BrlgBtocke, Mr. R. W., obltusry, 437
Briscoe, Mr. J. F., meatless dietary in epilepsy,
1093
Bristol Royal Infirmary, annual meeting,.
972
Bristol University, pass-lists, 318; post¬
graduate study, 724
Bnstow, Maj. W. R , physical treatment in
relation to orthopaedic surgory, 671
British and German psychology, 1002
British East Africa, lack of medical facilities,
725
British Guiana, Influenza epidemic in (Dr.
F. G. Rose), 421
British Journal of Children's Diseases (reviewX
225, 660
British Journal of Ophthalmology (review),
1029
British-made morphia (Py Q), 864
British Medical Association, special clinisal
meeting, 146, 272; (leading article), 518,
526, 662. 665; war neuroses (leading article),
619; exhibits. 625; conference ol medloal
bodies, £08, 855; scholarships and grants In
sin of scientific research, 915; Ulster branch,
1040
The Lancet,]
INDEX TO VOLUME I., 1919.
[July 5. 1919 v
British: Medical Association (Special
Clinical Meeting).— Reception at the
Gnildhall; The fellowship of man and the
felljwship of medicine, 665—' The Lancet
lnncheon at Ilyde Park Hotel, 666—Popular
4eeture; Reception at the Royal Society of
.Medicine Exhibition. 666, 718
Section of Medicine. — Dr. F. W.
Mott, war neuroses, 709—Maj.-Qen. Sir W.
Herrlngham, clinical aspects of influenza,
711—Brevet Col. L. W. Harrison, venereal
disease, 713—Sir J. Mackenzie, prognosis in
oardlo-vascular affections, 715—Demonstra¬
tions, 716
Section of Surgery.— Col. T. R. Elliott,
-gunshot wounds of the chest, 666-Col. G. E.
Gask, surgical aspects, 667—Prof. W. M.
Bayllss, wound shock, 668—Maj. R. C.
Blmslie, surgical treatment, 670—Maj.
W. R. Bristow, physical tre itment in rela¬
tion to orthopaedic surgery, 671—Demonstra¬
tions by Col. J. G. Adaml. Sir G. Maklns,
Col. Sir J. Lynn-Thomas, Maj. M. G. Pearson,
Lieut.-Col. F. S. Brereton, 672, 673
Section of Preventive Medicine and Patho¬
logy.—Co\. L. S. Dudgeon, bacillary
-dysentery, 673—Prof. W. Yorke, amoebic
dysentery in England, 674—Lieut.-Col.
-8. P. James, risk of the spread of malaria in
England, 677—Demonstrations, Col. L. S.
Dudgeon. 679
Exhibition .—Surgical instruments and
hospital appliances, 718—Drugs, 719
British Psychological Society, 391 (see also
Medical Societies)
British Science Guild Exhibition, 625; annual
meeting. 1138
Broca, Prof. A., Disabilities of the Locomotor
Apparatus the Result of War Wounds
(review), 799
Broderick, Mr. F. W., a publio dental service,
440
Brodie, Dr. G. B., obituary, 1042
Brompton Hospital for Consumption, report,
581
Broncho-pneumonia, purulent, associated
with the meningococcus, 81; meningo¬
coccus. in influenza (Dr. W. Fletcher),
104, 124; pneumonia in the Army
(Py Q), 402; pneumonia. Influenzal, use of
Intravenous iodine in (Dr. D. M. Baillie),
423
Broncho spirochetosis, 116
Broughton-Alcock, Dr. W., atypical strains of
B. paratvphosiw B, 1023 *
Browdy, Dr. M. W., simple aid in reducing
paraphimosis, 448
Brown, Capt. W. S., R.A.M.C. (see Obituary
of the war)
Brown, Dr. L., r61e of the sympathetic nervous
system in disease, 827, 873, 923, 965
Brown, Dr. T. G.. and Dr. R. M. Stewart,
fa “ heterestbesla,” 79
Brown, Dr. W., war neurosis. 833
Brown, Mr. H., Advanced Suggestion (Neuro-
induction) (review), 302
Browne, Capt. W. S., R.A.M.O. (see Obituary
of the war)
Browning, Dr. G. H., and Dr. B.L. Kennaway,
Waasermann tests, 785
Bruce, Dr. J. M., and Dr. W. J. Dllling,
Materia Medics and Therapeutics, an Intro¬
duction to the Rational Treatment of
Disease, eleventh edition, 1918 (review),
112
Bruce, Maj.-Gen. Sir D., tetanus treated in
home military hospitals, 331
Brussels University, resumption of medical
courses, 353
Bubonic plague at home (leading article),
986
Buchner’s ameroblc tube, modified, 226
Buckley, Dr. Winifred F., comminuted fracture
of humerus, 961
Bnntine, Dr. R. A., memorial service In
memory of, 190
Burial certificates and midwives (Py Q),
959
Borland, Dr. G., Ship Captain’s Medical Guide
(review), 23
Burma Medical Council, 760
Burnell. Dr. G. H., primary pneumococcic
meningitis, 623
Burnett, Sir E. N., address on hospital accom¬
modation, 362
Burnford, Dr. J., the epidemic, with reference
to pneumonia in Macedonia, 794
Burra, Dr. L. T., formation of other sgglutlnins
in cases of Malta fever, 64
Burtchacll, Sir C., honoured, 432
Butcher, Mr. H. H., and Dr. A. J. Bagleton,
treatment of complicated influenza, 560
Buttar, Dr. C., and Dr. A. Latham, Medical
Parliamentary Committee, arrangement of
conference, 634, 817
Butter for invalids (Py Q), 641
Buzzard, Dr. T., obituary, 82
0
Cabot, Dr. H., Modern Urology (review), 467
Cabot, Dr. R. O., Differential Diagnosis,
second edition, 1918 (review), 112; Training
and Rewards of the Physician (review*), 224
Cadham, Dr. F. T., vaccine in Influenza, 885
Caecum, cancer of (Dr. J. K. Haworth), 140
Cairo, Public Health Laboratories, reports and
notes. 682
Calcutta mortality in, 760,997 ; vital statistics
of, 233, 857, 913
Calmette, Prof. A., health of Lille during
German occupation, 430
Calves reared on whey and meals, Interesting
experiment, 964
Cambridge University, pass-lists, 724 ; vacation
course in advanced pathology, 862; diploma
of psychological medicine, 955
Caminidge, Dr. P. J., prevention and treat¬
ment of diabetic coma, 60 ; improved method
for estimation of sugar in urine and blood,
939
Campbell, Capt. J., R.A.M.O. (see Obituary of
the war)
Campbell, Dr. H., causes and incidence of
dental caries, 46, 123, 198; and Sir C.
Ballance, treatment of general paralysis of
the insane, 608
Campbell, Dr. J., and Dr. C. M. Pennefather,
blood-supply of muscles, 294
Camus, Dr. J., and others, Physical and
Occupational Re-education of the Maimed
(review), 183
Canada, Correspondence from.— Influenza
scourge, 38—Some mental statistics in
Canada; Canadian Association for the pre¬
vention of tuberculosis, report; National
Sanatorium Association; Tuberculosis toll
in Canada ; New Military College. 39—Lepers
in Canada; Pensions to Canadian soldiers ;
Health Department, Province of Alberta;
Improving the health of Canada, 232—
Military medical officers and civilian practice,
233—Medical gatherings; Osteopathy; Pree
hospital movement In Western Canada;
Federal Department of Publio Health for
Canada; Menace of vonereal disease in
Ontario; Prescribing of liquor in Ontario,
949—Canadian Public Health Association,
annual meeting; Ontario Medical Associa¬
tion, address in medicine; ULivers'ty of
Montreal; Public health campaigns, 11SZ
Canada, Department of Health for, 767
Canadian Association for the Prevention of
Tuberculosis, report, 39; Army Medical
Service, work of, 946
Cancer and hot liquids, 583, 635, 683
Cancer, lingual, etiology, 75, 123; of cecum
(Dr. J. K. Haworth), 140; intrinsic, of
larynx, 263, 271; of the stomach, perforation
in, 272 ; absence of, In the Arctic regions, 528,
1045 ; district in France, 853
Candidates, medical, for Parliament, 35
Candy, Dr. G. S , National Medical Service.
what is it worth ? 279
Cannabalism in Sind, allegations of, 311
Cape Medical Council, election, 395
Carcinoma of appendix, 845
Carcinoma, primarv, of duodenum. 1128
Cardiac valves, rupture of, due to explosion, 231
Cardiogram, first lead of, inverted "T" in,
significance of (Dr. I. Harris), 168
Cardlo-vascular affections, prognosis in (Sir J.
Mackenzie), 715
Cargill, Mr. L. V;, pituitary tumour, 613;
injuries and diseases of the orbit and
accessory sinuses, 614; pigmented connec¬
tive tissue, 1072
Canes, dental, causes and incidence, 40,80,123,
155, 198, 238
Carnwath, Capt. T.,lessons of a great'epldemto,
Carotid, external, traumatic aneurysm of (Dr.
S. C. Dyke). 21
Carr, Dr. J. W., polyeythaemia. 700; congenital
morbus cordis with polycythtemia, 700
Carr, Mr. J. C., unregistered dental
practitioners, 724
Carrel, Anne, and J. Dumas, Technic of the
Irrigation Treatment of Wounds by the
Carrel Method (review), 617
Carruthers, Maj., intra-ocular growth, 613
Carry On (review), 566
Carson, Mr. H. W., ruptured rectus abdominis,
912
Carter, Mr. H., Control of Drink Trade In
Great Britain: A Contribution to National
Efficiency, 1915-18, second edition, 1919
(review), 1119
Carter, the late Dr. A. H., and Q.M.-Serg. J.T.
Boyea, cerebro-spinal fever, 1066
Carter, Dr. H. B., medical examination of
aviation candidates, 46
Case-taking, Clinical (Dr. R. D. Keith)
(review), 112
Casserole, lead in the, 905, 1002
Castellain, Dr. H. G. R., Association of Factory
Doctors and Managers. 768
Casualties among the sons of medical men
(see Casualties under War and After)
Casualty list (see Casualty list under War and
Alter)
Catalyst, the rdle of (leading article), 141
Catarrhal jaundice, epidemlo (Dr. W. H.
Willcox), 930
Cause or coincidence, 539
Caussade, Dr., and others, action of hypo¬
chlorites on pleural false membranes. 895
Cautley, Dr. E., aortic aneurysm, 700; severe
anaemia, 700 ; cceliac disease. 700
Cavendish lecture on the role of consulting
surgeon in war (Sir G. H. Makins), 1099
Centenarians. 198, 584, 860. 998, 1098
Centipede bite, Mr. S. W. Coffin, 1117
Central Health Department, proposal for, 273
Central Medical War Committee, scheme for
demobilisation, 84, 193; Interests of those
who have been on service, 357; Its work In
demobilisation ended, 527
Central Midwives Board, meeting, 48, 199, 361,
585 . 956
Cerebral cortex, the, and sensation, 389
Cerebro-spinal Fever (Dr. C. Worster-Droughfc
and Dr. A. M. Kennedy) (review), 1073
Cerebro-spinal fever, outbreak of (Py Q), 485;
Lumleian lecture on (Sir H. Rolleston), 541,
593, 645; fever casee as carriers (Ur. D.
Embleton and Dr. G. H. Steven). 788; fever
(the late Dr. A. H. Carter and Q.M.-Serg.
J. T. Boyee), 1066; fever (Prof. C. Dopter),
1075
Cerebro-spinal fever regulations, 1126
Cerebro-spinal meningitis (Mr. A. S. G. Bell),
887
Cervical nerve roots, gunshot Injuries of (Dr.
J. S. B. Stopford). 336
Cervix, sarcoma of, 110
Chaikin, Mr. G., Medical Offloers of Schools
Association, 47
Challamel, Dr. A., hypodermic injections of
eucalyptus oil in influenza, 424
Chambers, Dr. Helen, Dr. Gladwys M. Scott,
Dr. J. O. Mottram, and Dr. S. Russ, experi¬
mental studies with small doses of X rays,
692
Chance, Mr. B. J., Bodily Deformities (review),
800
Chantemesse, Prof. A., death of, 433
Chapman, Dr. C. W., artificial cyanosis of lips,
529
Chappie, Dr. W. A., stretching tables for flexed
thigh stumps after amputation, 984
Charing Cross Hospital Medical School, post¬
graduate study, 481
Charter of Science for the Army Medical
Department (leading article), 753
Chemical work in India, organisation of, 434
Chemistry at Cambridge, 852
Chemistry of Synthetic Drugs (Dr. P. May),
second edition, 1918 (review), 224; Inorganic,
Introduction to (Prof. A. Smith), third
edition, 1918 (review), 225 ; in 1918, progress
of (leading article), 470; Organic, Recent
Advances in (Mr. A. W. Stewart), third
edition, 1918 (review), 617; Physical and
Inorganic, Recent Advances in (Mr. A. W.
Stewart), third edition, 1919 (review), 617;
Biological. Study of (Dr. S. B. Schryver)
(review), 659; Physiological, Practical (Prof.
P. B. Hawk), sixth edition, 1919 (review),
983
Chemists, professional, and the Scottish Board
of Healtli, 910
Chemotherapy in cutaneous tuberculosis (Mr.
H. J. Gauvain), 412
Chenoy, Capt. F. B., I.M.8.(see Obituary of the
war)
Chepmell. Dr. I. D., death of, 31,157
Cherrett, Dr. B. W., death of, 200
Chesser, Dr. Elizabeth S., (?) congenital Bynos-
tosis, 298
Cheat, opening up of, 663 ; gunshot wounds of
666, 667; gunshot wounds and other affec¬
tions of (Mr..C. MacMabon), 697
Chicken-pox, contact Infection, 397
Chief Secretary for Ireland and the medical
profession, 812
Child bearing, continued high maternal mor¬
tality (Mr. V. Bonney), 775, 796; (leading
article), 802
Child Study Society (see Medical Societies)
Child, the, as an Impediment, 692; as an
inducement, 644
Child welfare and maternity, 191, 192, 435, 430,
811, 995(PyQ),321
Child welfare in India, 857
Children of devastated Serbia, 963
Children's Convalescent Home, Weston-super-
Mare, meeting, 922
Children’s Hospital for Bermondsey, 682
Children’s teeth, 905
vi The Lancet,]
INDEX TO VOLUME I., 1919.
[July 5,1919
Chloroform apparatus, dangerous, 473
Cholera In India, 434 ; and influenza in Bombay
(Py Q), 442
Choroldo-retinitla, bilateral, 895
Chowdhury, Capt. H. C. B., I.M.S. (see
Obituary of the war)
Christie, Maj. A. C., X Bay Tcehuio (review),
184
Christopherson, Dr. J. B., antimony in
bilharzlasls, 79; antimony tartrate for
bllharzlasis, 1021
Chronlcity of dysentery infection, 1038
Chylolhorax, recurrent, following trauma (Dr.
A. K. Malone and Dr. J. G. Wardrop),
1116
Chyme infection and disease, 766
Cirsoid aneurysm, 700
Civil medical practitioners’ war service, list,
438
Clarke. Dr. R. 0., medical men and share •
holding, 1015
Clarke, Mr. E., Crookes’s lenses, 237; presby¬
opia, 895
Clarke, the late Dr. J. M., memorial to, 20
Claude, Henri, and Jean Lbermltte, gunshot
concussion of spinal cord, 67
Olaxton ear-cap, 863
Ciayton-Greene, Mr. W. H., Pve’s Surgical
Handicraft, eighth edition, 1$19 (review),
Clifford, Dr. H* “ cyclops foetus,” 301
Clinical Medicine. System of (Dr. T. D. Savill),
fifth edition, 1918 (review), 66; Case-taking
(Dr. R. D. Keith) (review). 111; Medicine,
Treatise on (Dr. W. H. Thomson), second
edition, 1918 (review), 383; Microscopy and
Chemistry (Prof. F;A. McJunkin) (review),
Clinical research; coordination by the State
(Dr. D. C. Watson). 992; position of
psychiatry, 1092; pathology en detail.
Clinical thermometer testa (Py Q), 587
Coal-getting, hygienic conscience in relation
to (loading article), 900
Cobb, Dr. I. G., Organs of Internal Secretion,
their Diseases and Therapeutic Application,
second edition, 1918 (review). 111
Oooalne, prescribing of, 910; the possession of,
948
Gookayne, Dr. H. A., congenital absence of
lower portion of left pectoralis major muscle
and left mammary gland, 565 ; a case for
diagnosis, 940
OockTn, Dr. R. P., obituary. 83
Cooks, Capt. J. 3., KA.M.G. (see Obituary of
the war)
Ooddngton, L4©ut.-0ol. Sir A. B., and Judge
Parry, War Pensions, Past and Present
(review), 796
Oceliac disease. 7C0
'* Oofectant’' lozenges, 24
Coffin, Mr. 3. W., centipede bitdi 1117
Cbhen, Dr. M. W., case of, 680
Coldstream. Dr. A. R.. obituary, 530
Cole, Mr. P. P., fistula of the parotid, 971
Coles, Dr. A. C., spiroohaotes in the blood in
trench fever. 375. 338
Colitis, secondary, chronic, 1045
College of Ambulauceand future of the V.AJD.,
271
OoRlus, Dr. J., Neurologijal Clinics (review),
Oollius, Mr. R. T., abiotrophy of the retinal
neuro-epithelium or “ retinitis pigmentosa,”
893; an 1 Mr, L. Baton, angioma of the
choroid, 895
Collis, Dr. B. L., appointed Talbot professor of
preventive medicine at Cardiff, 854
Colloid antimony sulphide Intravenously in
kala-azar (Sir L. Rogers). 505
Colloid metals and phenol in the treatment of
influenza, 472
Colloidal sliver in trench fever, 583
Colloids in medicine and in Industry,f906
Colopathies, chronic (Dr. E. Joltraln, Dr. P.
Baufio. and Dr. R. Ooope),933
Colonial health repoits, 50.89,202, 242,324.488,
591,644. 772,825,1011,1054
Coma, diabetic, prevention and treatment
(Dr. P. J. Cammidge). 60
Comber, Mr. A. W., place aux embusques,
Comminuted fracture of humerus (Dr. Winifred
F. Buckley), 981
Complement-fixation tests in gonococcal In-
fecth ns (Dr. A. H. Priestlej). 787
Composite neurosis* analysis of (Dr. F. Dillon),
57
Concussion, gunshot, of spinal cord (Henri
Claude and Jean Lhermitte), 67
Conference of representatives of various
medical bodies, 808-Representatives, 855-
Common action; Medical Consultative
Cout.cil to Ministry of Health; National
Insurance Defence Trust, 856
Constable. Dr. Evelyn Ah Influenza and diph¬
theria, 563
Constipation in children, prophylactic treat¬
ment (Dr. V. Borland), 459
Consumptive, the advanced, care of, 706
Consumptives In the Army (Py Q). 641
Contact Infection of chicken pox, 397
Convalescence, fBneas. and unfitness In (Dr.
B. Parsons-Smith), 509
Cooke, Dr. W. H., polyorrhomenitls, 562
Coope, Dr. R., Dr. E. Joltraln, ani Dr. P.
Baud", chronic colopathies, 933
Copper treatment of lupus. 528
Cord, vocal, a plastic (Dr. F. N. Smith), 103
Core, Dr. D. B., dreams of the terror-neurosis,
155
Cornea, congenital pigmentation, 613
Comer, Mr. B. M. t infective scar tissue,
840
Coras on babies’ noses. 583
*• Corps, esprit de." 1124
Corpus striatum, the, and paralysis agitans,
77
Correction, 1012
Cobrespokdbhts, Answers to.—B nqulrer. 50
—D. R. H., 164—Croix de Guerre, 202—
H. W, C M 324- F. H. Mi, 448-Vlperus, 540-
A. B. C.. 592—Enquirer, 728-R. K.B., 868-
X. Y. Z. # Ex-Medico, 964-F. C., 1012-
H. T. B., 1C64
Cotterill, Capt. D., R.A.M.C. (see Obituary of
the war)
Cottle, Dr. W., death of, 991
Coussleu, De. H.. migration of a round worm
into the ear, 28
Cowper, Temp. Surg. W. P„ R.N. (see Obituary
of the war)
Cralk* Dr. R., leuoooyte- count in influenza,
156
Crawford, Dr. Bjubara G. R-, and Dr. W. J.
Rutherford, hereditary malformation of the
extremities, 979
Cream. Bupply of, new regulations, 48
Cremation Society of England, report, 883
Creosote in influenza, use of, 128
Cretan library. 488
Crewe, Lord, books for Se bla, 398
Crime and Criminals (Or. 0. Meroler) (review),
382
Crime, detection of, and medical practitioners,
120. 198
Grime and responsibility (leading article),
1121
Criminal or moral imbecile, 1041
Criminal, the psychopathic (leading artlole),
143, 432
Criminology (Mr. M. Parmelee) (review), 982
Cripples, a survey of, 27; motor mechanics
for, 76
Crocker, Dr. W., Veterinary Post-mortem
Technic (review), 225
Crofton, Dr. W. M., Abderhaldens pregnancy
reaction. Ill
Crombie, Lieut. W. M., I.M.S. (see Obituary
of the war)
Crookes, Sir W., death of, 624
Crookes’s lenses, 124, 237
Crookabank, Dr. F. G., epidemic enoephalo-
royelltis and influenza, 79; presence of a
filter-passing virus in influenza, 313; import¬
ance of symptoms, 480
Croonian lectures on the r61e of the sym¬
pathetic nervous system in disease-(Dr. L.
Brown), 827, 873, 923, 965
Cruise, Mr. U. R., contracted sockets, 893
Culture media for B. intbicHzx, simply pre-
ptred (Mr. A. Fleming), 138
Cumber batch, Dr. E. P , Essentials of Medical
Electricity, fourth edition, 1919(review).514
Cummins, Col. S. L,, and Maj. H. G. Gibson,
analysis of cases of tetanus. 325 ; cultivation
of a filter-passing organism in influenza,
528
Ounliffe, Maj. E. N., R.A.M.C. (see Obituary of
the war); obituary, 634
Cunning. Mr. J., and Mr. C. A. Joli, Aids to
Surgery, fourth edition, 1919 (review), 659
Cunning, Mr. J., epidemic perinephric
suppuration, 1001, 1135
Cuuningbam, Mr. J. F., cartilaginous tumours
of roof of the orbit, 300
Cures, war, 116
Curl, Dr. S. W., and Dr. H. B. Roderick, re¬
curring effusion into the pericardial sac.
980
Curtis, Mr. H., etiology of lingual canoer, 123 ;
saccharose injections in pulmonary phthisis,
636
Cushny.tDr. A. R., Text-book of Pharmacology
and Therapeutics, seventh edition, 1918 (re¬
view)^
Cutaneous tuberculosis, chemotherapy in (Mr.
II. J. Gauvalo),412
Cyanosis, artificial, of lips, 529
“ Cyclops fa‘tus,”300
Cyst, ovarian, spontaneous rupture (Mr. D. N.
Kaiyanvala), 423
Cystic tumours of the* vulva, 22
D
Dalby, Sir W. B., obituary, 83
Dale, Dr. H. H., and Prof. W. M. Bay lias,
shock, discussion, 256
Daly, Mr, A., direct massage of the heart.
Darre, Dr. H.. hsemoglobinuric billon*.fever,
treatment, 940
Davidson, Sir J. M., obituary. 633
Davies, Dr. S., causes and incideuoe of dental
caries, 124; hot liquids and cancer. 683
Daw, Dr. S. W., Orthopaedic Effects of Gunshot
Wounds and their After Treatment (review),
847
Deaeon, Mr. J, F. W., Mr. J. B. Lane,and Lbrd
Kinnaird, residential treatment for pregnant
women suffering from venereal cUseanes,
80
DeafneFs, war, 157, 198, 238 ; associated, with
the stigmata of degeneration, 182
Deane, LJeut. P. E., and Sir J. W. Barnett,
Australian Army Medical Corps in Egypt to
1914-16 (review). 66
Death from barium salts administered for
radiological examination, 943
Death-rate of mental defectives in institu¬
tions, 78
Deaths, total, from wounds in the Great Ukr,
406
Decentralisation at the Ministry of Pensions,
665
Decorations, foreign (see Decocations under
War and After)
Deformities, Bodily (Mr. B. J. Chance)
(review), 800
Delusions, genesis of, 1023
Demobilisation, medical appointments in
Ireland during, 18; medical, in France»38,
477; of the British Red Cress, 41; medical,
84; scheme of Central Medical War Com-
mitlee, 84. 193; of medical men (Py Q>. 32L
360, 535, 631; of pzuel practitioners (Py QJ,
359; of doctors and nurzes (Py Q>, 443; of
medical offioers (Py Q), 4S5, 641; men,
. medical treatment of (Py Q), 640; of fink)
ambulance officers (Py Q , 918; and Territorial
medical officers (Py Q), 918, 960.
Demobilised practitioner, the position, of, 439;
(leading article), 515
Dendy, Prof. A., Animal Life and Unman
Progress (review), 1120
Dental caries, causes and incldenee, 46,80,123,
155, 198. 238; practice, qualified and un¬
qualified (leading article), 386; practice, un¬
qualified. evils of, 359; praetitioners. unregis¬
tered, 724; surgeons and the army gratuity
(Py Q>. 4C2 ; eervice, a public, 440
Denial Congress, Sixth International, Trans¬
actions of (review), 24
Department of health for Canada, 767
Despatches, mentioned in (see Despatches
under War and After)
Destroyers and Other Verses (Dr. H. R6ri
(review), 1120
Detoxicated vaccines (Dr. D. Thomson), 374 k
with special reference to gonorrhoea, nasal
*j»rt bronchial catarrh, and Influenza, 1102.;
In treatment of gonorrhoea (Df. D. Lees),
11C7
)evaux, A., nervous complications • of
exanthematic typhus 567
Devon and Exeter Royal Hospital, meeting.
441 ; and Cornwall Sanatorium for Con¬
sumptives, Didworthy, meeting, 1007
Devota, Mr. F. J., iutravenous injection of
potassium iodide in tabes dorsalis, 239
)ewey. Lieut. E. W., need for physical educa¬
tion. 867 _ .
diabetes and Its Dietetic Treatment (Ma).
B. D. Buu), ninth edition, 1918 (review),
333 ; indications for operation, 945
Diabetes Innocens and renal glycosuria (Dr.
L. Brown), 923; luslpldus and circulatory
diseases in relation to the sympathetic. 965
[Diabetic coma, prevention and treatment
(Dr. P. J. Cammidge), 60
[Diagnosis, accurate, In appendicitis (leading
article), 114 ; a case for, 940
Diagnosis, Differential (Dr. R. O. Cabot),
second edition. 1918 (review), 112; MCdiCal,
Aids to (Dr. A. Waiting), second edition.
1918 (review), 112; Surgical, Elements of
(Sir A. P. Gould and Mr. E. P. Gould), fifth
edition. 1919 (review), 659
Diagnostic Clinique (Examens et Symptomes)
(Dr. A. Martinet) (review). 984
Diagnostic Hospital, New York, 980
Diaphragm, disease below, unilateral hydue-
thorax due to (Mr. W. G. Nash). 378
Diaphragmatic hernia (Mr. K. Warren), 1069,
1089
Diarrhoea! outbreak In Aberdeen, 560
Dickinson, Mr. W. H., Influenza and chronic
lung disease, 314
Diet and influenza, memorial on, 436
The* L angst,]
INDEX TO VOLUME I., 1919.
[July 5, 1919 vil
Diet kitchens for military hospitals, 37
Differential Diagnosis (Dr. R. C. Cabot),second
edition. 1918 (review), 112
Dlgalen. 384
Digestive jalces, secretion of (Dr. L. Brown),
873
Dill, Dr. J. F. G., Medical Parliamentary
Committee. 858
Dllling, Dr. W. J , and Dr. J. M. Bruce,
^Materia Medica and Therapeutics, an Intro*
duction to the Rational Treatment of
Disease, eleventh edition, 1918 (review),
112
Dillon, Dr. F., analysis of a composite neurosis,
57
Dinner fork in the stomach and duodenum
(Mr. K. A. Lees). 293
Dinnick, Dr. O.T., treatment of syphilis, 1055
Diphtheria and influenza (Dr. E. A. Constable),
563
Diplithoria bacillus, staining (Dr. P. >L.
Sutherland), 218
Diphtheria in New York City, 524
Directory of District Nursing and Streets List
for London (review), 660
Disability, medical assessment of (Py Q). 1137
Disabled, Rehabilitation of, International Con¬
ference on.761
Disablement, problem of. 851
Disease and Remedy of Sin (Mr. W. M. Mackay)
(review), 302 ; and chyme infection, 766
Disease, organic, hysterical element in, and
in jury” of central nervous system (Dr. A. F.
ELuist and Dr. J. L. M. Symus). 359
Disease, sympathetic nervous system in, rdle
•of (Dr. L. Brown), 827, 873, 923
Diseases, Epidemic. Order, new, and its effect
(leading article), 303,309
Diseases of the Skin (Dr. J. M. Sequeira), thUd
edition, 1919 (leview), 798
Diseases, physiology and the study of, <447;
i epidemic, observed in Rumania during the
campaign of 1916-17 (Dr. Henri Vulllet),
- 689
Disinfectant, electrolytic, in influenza,
90
Disinfectants, germicidal valuation of,
676
Disinterested prescriptions, 1036
Dislocation of teeth (Mr. H. M.JSavery), 339,
441
Dispensary doctors, salaries of, 221
Dispersal b ards, medical men on (Py Q), 820
Disposal of dysentery carriers. 626
District nursing associations and public
health (Pv Q), 686
Dixon, Prof. F , special supports of the uterus,
m
Dockyard workmen, medical examination of
(Py Q>, 917
Doctor, woman, sued by < member of the
Q.M.A.A.C., 1040
Doctor's .welcome in Uganda, £18
Sectors, French, and the excess profits tax, 38;
dispensary, salaries of, 121 ; demobilisation
,nf, 631; aeed for more. 997
Doctors’ fees, rise in. 997
D’Oelsnitz, >M., G. Roussy, and J. Bolssean,
Traltement des Psjchonevroses de Guerre
(review), 1119
Dog as test object, 625, 854, 945
Dogs* Protection Bill, 763, 957; resolution from
the Royal Society of Medicine, 764 ; resolu¬
tion passed by the Royal Faculty of Phy¬
sicians and Surgeons of Glasgow, 915 ; resolu¬
tion passed by the Royal College of Surgeons
of Edinburgh, 939; memorandum by the
, Medical Research Committee, 947
Donaldson, Dr. R , presenoe of a filter-passing
virus in influenza, 280
Donations and bequests, 47, 88, 102, 282, 311
. 368, 400, 504, 527, 769, 879, 910, 1023, 1005,
1133
Diopter, Prof. C., cerebro - spinal fever,
1075
Dove, .Dr. S. E., treatment of lupus vulgaris
with picric-brass, 635
Osage. Dr. L., Ministry of Health, 281
Drake Brockman, Lieut.-Col. E. F., obituary,
:S60
Dreams of the terrormeurosls, 155
Drew, Dr. C. L.. obituary, 998
“Dropped-foot ” appliance, 142, 284, 468
Dr. John Fobhergill and His Friends (Dr. R. H.
t Fox) (review), 1118
Drink Trade (Control of) in Great Britain:
i Contribution to National Efficiency, 19.5-18,
second edition, 1919 (H. Carter) (review),
1119
Drug law, new narcotic, for New York State,
353; situation in New York, 813; hnbit,
• national Investigation, 950; addiction in
the United States, 1QS0
Drugs, illicit traffic in, 36; indigenous, of
India, 307; ix la mode, 945; supply of,
B34
Drug-*, Synthetic. Chemistry of (Dr. P. May',
second edition, 19.3 (review), 244
Drummond, Mr. J. C., fat • soluble A,
990
Dry sweeping in railway carriages, 844
Dublin housing, report, 154; meeting of
delegates, 1040
Dublin University, Trinity College, Sehool of
Physic, pass-lists, 48, 639
Duoroquet, Dr., Prothdse Fonqtionelle des
Blesses de Guerre (review), 848.
Dudgeon, Col. L. S., bacillary dysentery,
673
Dudley. Dr. S. F., diagnosis of primary
syphilis, 737
DafTy. Capt, J. V. R.A.M.C. (see Obituary of
the war)
; Dumas, J., and Anne Carrel, Teebnic of the
Irrigation Treatment of Wounds by the
Carrel Method (review). 617
Duncan, Mr. D. f oateo-arthritis, 488
Duodenum, primary carcinoma of, 1128
Durham University, Facuky of Medicine, pass-
llbts, 584, 639
Dwyer, Capt. J. J., D.S.O., R.A.M.C. (see
Obituary of the war)
Dyke, Dr. S. O., traumatio aneurysm of
external carotid, 21 ,
Dysentery, amccbic and bacillary, diagnos's Of
(Dr. G. M. Findlay), 135; amcebic, carriers,
a correction, 157 ; aimebic, treatment, 429;
bacillary, are relapses frequent, 529; in
Germany in 1918, 622; bacillary, 673;
•amoebic, 674 ; notification of. 723; bacillary,
mild (Dr. J. Ryle), 937
Dysentery carriers, disposal of, 626; infection,
chronicity of, 1C38
Dyspepsia, reflex (Dr, L. Brown), 875
E
Eagleton, Dr. A. J., and Mr. H. H.
Butcher, treatment of complicated In¬
fluenza, 660
Ear, Diseases of, in Children,Essay on Preven¬
tion of Deafness (Dr. J. K. Love) (review),
896
Bast Sussex Hospital, meeting, 1095
Eaton, Mr. B. M„ visual perception of soltd
forms, 1072
Echo Personalities (Mr. F. Wstts) (review),
983
Eclampsism, aoeidentsl haemorrhage in con¬
nexion with (Sir S. Smyly), 133
Bctoplc gestation, 22; gestation, with an
apparently imperforate hymen (Dr. S. G.
Papadopoulos), 140; gestation (Dr. B. T.
Rose and Mr. B. H. Shaw), 175; pregnancy,
full-time, four eases, 611
Bdlble Gils and Fate (Mr. 0. A. Mitchell)
(review). 848
Edinburgh, meeting of the medloal profession
in, 1040
Bdinburgh University, report, 87; Dr. D.
Turner appointed additional examiner in
medical physios, 141; chair of therapeutics,
433; affairs of, 910; prospective vacant
chair, 1040
Bdmond, Mr. W. 8., and Dr. J. Taylor,
advances in the treatment of fractures,
46
Bduoatlon In ophthalmology, report, 578
Kducatlon, scientific, and its cost (leading
article), 428; medioal, reform of (leading
article), 571; Experimental (Dr. R. R. Rusk)
(review), 618 ; medical, post-graduate
(leading article), 703.; physical, need for, 867
Edwards, Dr. P. W., “mass meetings” and
their representative character, 314
Effusion, recurring, into the pericardial sac
(Dr. H. B. Roderick and Dr. S. W. Curl), 930
Effusions, spinal, haemorrhagic (Dr. W. P. S.
Branson), 888
EffJPti Public health work, 146; Public
Health Department, annual report for 1916,
681
Egyptian Fellaheen .Medical Service (Py Q),
Electrical methods of measuring body
temperature, 564 ; training for disabled men,
.728
Electricity, Medical, Essentials of (Dr. B. P.
Gumberbatch), fourth edition, 1919 (review),
514
Electro-cardiograph, the, 564
Electro-Diagnosis in War (Prof. A. Zlmmern
andM. Pierre Perol) (review), 463; Pathology,
Studies in (Dr. A. W. Robertson) (review),
7C1; Physiology (Animal and Vegetable)
(Mr. A. E. Baines) (review), 701
Electrolytic disinfectant in Influenza, 90
Elements of Surgical Diagnosis (Sir A. P.
Gould and Mr. E. P. Gould), fifth edition,
1919 (review), 659
Elias, Dr. H.. and Dr. Richard Singer, war
cures, 116 m
Elizaheth Girrett Anderson Hospital appeal,
1026
Elliott, Col. T. R.. gunshot wounds of the
chest, 666 ; and Capt. D. S. Lewis, Maj. J. H.
Thursfleld, Maj. A. J. Jex-Blake, and Maj.
M. Foster, invalidism caused by P.U.O. and
trench fever, 1060
Elliott, Dr. G.. radium treatment of epithe¬
lioma of the lip, 388
Ellis, Dr* H. A, picric-brass preparations > in
treatment of lupus, 415, 430
Ellis, Mr. W. A., obituary, 125
! Eli is ton, Mr. G. S. t after-care of tuberculous
ex-service men. 767; After-Treatment of
Wounds and Injuries (review), 886
Elmtlie, Maj. R. C., surgical treatment, 670
Embleton, Dr. D., and Dr. G. H. Steven,
cerebrospinal fever oases as carriers, 788
i Emboli, missiles as (Sir J. Bland Sutton), 773.
913
Emergency hospital, private, 977
Bmigratiou of tuberculous soldiers (Py Q),
■ 821
i Emotional shock on the battlefield (Cl.
Vincent), 69
Emphysema, diffuse, of wall of small intestine.
Employment Opportunities for Handicapped
Men in the Opt leal Goods Industry (Mr. Bi J.
Morris) (review), 082
:Empyemt, “medical treatment” of, 1127
Encephalitis lethargica and typhus, 166
Encephalitis and poliomyelitis, notification ef,
76
Hnoephalo-myelitis, epidemic, and influenza.
79
Endothelioma of the ovary, .264; oftheteazil,
300
Bn bam Village Centre, vocational training,
1053
Entamcrba histolytica , Ac., in naval. entrants
(Mr. H. A. Baylls),54; a correction, 167
Enteralgla, pancreatitis a cause (Dr.L.Brown),
876
Bntozoa, intestinal, among the native labourers
of Johannesburg, 521
Environment, susceptibility to, 619
Epidemic diseases observed in Romania du ring
the campaign of 1916-17 (Dr. Henri VuHlet),
569
Epidemic Diseases Order, new. and its effeet
(leading article', 303, 309
Bpidemio perinephric suppuration (Mr. J.
Cunning), 1134
Epididymitis and orchitis (Sir H. Rolleeten),
601
Epilepsy, meatless dietary in, 1046, 1093
Epilepsy, the “spectrum of, 157
Episcopal Hospital, Medical and Surgical
Reports (review), 23
Epistaxis and haemoptysis in Influenza, 481
Epithelial oell. malignant, polymorphism of,
743
Epithelioma of the lip, radium treatment,
3®8
Epstein, Prof. A., death of, 30
Epuiides, multiple, 744
Erythema, acute, resembling measles (Dr.
F. H. Kelly). 255; nodosum, reactivation by
tuberculin, 7C5
Erythremia, case of (Dr. Margaret H, Fraser),
“ Esprit de corps.” 1124
Essentials of Medical Electricity (Dr. E..P.
Gumberbatch), fourth edition, 1919 (review),
614
Ether anesthesia, rectal (Mr. J. C. Clayton),
793
Ethyl chloride Altos, 24
European food situation, 148, 306, 387
Euthanasia (leading article), 803
Kvalt, Capt. J. M., R.A.M.C. (see Obituary of
the war)
Evulsion of optic nerve, 895
Examining Board in England by the Royal
Colleges of Physicians of London and
Surgeons of England, pass-lists, 239, 639,
724
Exanthematic typhus, nervous complications
(A. Devaux), 567
Exeter City Asylum, meeting, 183
Experimental Education (Dr. B. B. Rusk)
(review), 618
Extra uterine pregnancy, 22, 611; advanced,
301; continuing to term, 611
Extremities, Gun-Shot Fractures of (Lieut. -
Ool. J. A. Blake) (review), 184, 702;.mal¬
formation of. hereditary (Dr. W. J.
Rutherford and Dr. Barbara U. R. Crawford),
979
Eye, Hygiene of (Dr. W. C. Pos«y) (review),
184; Refraction of, Manual for Students
(Mr. G- Hartrklge), sixteenth edition, 1919,
(review), 984
Eyes Right, Papers for Teachers and Parents
on the. Hygiene and Treatment of the Eye
(Or. J. M. Maephail) (review), 984
Eyesight and education, 894
Eyre, Dr. J. W. H., and Dr. E. C. Lowe,
autumn influenza epidemic (1913), 553
viii The Lancet,]
INDEX TO VOLUME I., 1919.
[July 5,1919
Factories, medical Inspection In (Py Q), 402
Factory surgeons and the Ministry of Health,
432; medical officer In war and peace, 447
Fairley, Dr. N. H., bilharziaais, 1016 •
Faradic stimulation (Mr. H. Platt and Mr. B. S.
Brentnall), 884,989
Fat-soluble A, 990
Fazakerley Hospital, release of (Py Q), 821
Feat of endurance (leading article), 1085
Fedorb, Surg.-Cmdr. F., E.N. (see Obituary of
the war)
Feeble mindedness from two standpoints, 520
Feeding, Phs-slological, of Children (Dr. H.
Pritchard) (review), 1028
Fees for notification of infections diseases, 577
Fellowship of medicine (leading article), 26; of
medicine, emergency, post-graduate facili¬
ties, 189, 400, 477
Femoral hernia, strangulated (Dr. 8. M.
> Lawrence), 64
F 7^ U8 ’ A * P ’ 11111161 °P hthalmIc practice,
Ferguson, Maj.'A. B., Capt. T. J. Maokie. Capt.
L. F. Hirst, and Col. A. H. Tubby, action of
flavine, 838
Feroxal, 24
Fever, pseudo-paratyphoid (Dr, R. Paton),
Fibroid, sessile red, 22; submucous, removal
with Hegar’s dilators, 1073
Field Service Book, Medical (Mr. C. M. Page)
(review), 383
Flelding-Ould, Dr. R. t medical profession and
the trade-union question,397
Flessinger, M. Ch., treatment of paroxysmal
tachycardia by respiratory effort, 853
Filarial infection in Macedonia (Dr. J. 6,
Forbes), 654
Fikles, Lleut.-Cmdr. P., and Lient.-Cmdr.
R. J. 6. Parnell, Wassermann reaction, 807
Films, anatomical, 1125
Films, ethyl chloride, 24
Filter-passing virus in certain diseases (Maj.-
Pen. Sir J. R. Bradford, Capt. B. F. Bash ford,
and Capt. J. A. Wilson), 169; In lnfluenia.
280,313,528
Findlay, Dr. G. M., differential diagnosis of
amoebic and bacillary dysentery from the
blood, 135; bacteriology or influenza epidemic
in Lower Egypt, 1113
Finger-prints as signatures, 1132
Fisher, Dr, T., hilus tuberculosis in children
and adults, 8l4
Fisher, Mr. J. H., migraine, 613; exhibition of
case, 1072
Fisher, Surg.-Lient, B. G., B.N. (aee Obituary
of the war)
Fistula of the parotid (Mr. P. P. Cole), 971
Fitness and unfitness in convalescence (Dr. B.
Parsons-Smith), 509
Flack, Dr. M., Bimple tests of physical
efficiency, 210
Flavine, action of (Col. A. H. Tubby, Maj.
A. R. Ferguson, Capt. T. J. Mackie, and
Oapt. L. F. Hirst), 838; in ophthalmic
surgery, 895; (Mr. A. Lawson), 1112
Fleming, Mr. A., simply prepared culture
media for B. influenzal, 138; and Dr. A. B.
Porteous, blood transfusion by the citrate
method, 973, 988
Flemming, Dr.C. E. S„ general practitioners'
hospital, 1042
Flemming, Mrs. E. E., medical inspection of
secondary schools, 616
Fletcher, Dr. W., meningococcus broncho-
K monia in influenza. 104; and Dr. Doris
Innon, chroniclty of dysentery infec¬
tion, 1038
Flint, Dr. H. L., advances in polygraphic
technique, 176; and Dr. M. J. Stewart,
ulcerative endocarditis, 1114
Flint, Mr. E. R., Intussusception treated by
resection, 938
Florence, Mr. P. 8., Use of Factory Statistics
In the Investigation of Industrial Fatigue
(review), 301
Florence Nightingale Hospital for Gentle¬
women, report, 584
Fluids, puncture, tboraclo (Dr. 8. B. Gloyne),
935
Flying, medical aspects of (leading article),
Foetus during spontaneous evolution, 610
Folley, Dr. B., “Spanish influenza,”666, 663
“ Food poisoning,” epidemic, 348
Food situation, European, 148, 306, 387;
inspection, Local Government Board, 189;
problem and physiology, 283; material,
accessory, large waste, 474; minimum re¬
quirements, 518 ; Board, the need for, 591;
in relation to health, 591
Foods and Drugs, Aids to Analysis of (Mr.
C. G. Moor and Mr. W. Partridge), fourth
edition. 1918 (review), 848
Foods, perishable, carriage of, 592
Foramen lace rum posted us, syndrome of, 188
Forbes, Dr. J. G., filarial Infection in
Macedonia, 654
Forced Movements, Tropisms, and Animal
Conduct (Monographs on ExDerimental
Biology) (Dr. J. Loeb) (review), 745
Ford, Miss Rosa, congenital pigmentation of
cornea, 613; pituitary tumour. 613
Formalin spray in checking influenza (Dr. A.
Wylie). 256
Foster, Maj. M., Col. T. R. Elliott, Capt. D. 8.
Lewis, Maj. J. H. Thursfleld, and Maj. A. J.
Jex-Blake, invalidism caused by P.U.O. and
trench fever, 1060
Foster, Prof. G. C., death of, 282
Fothergill, Dr. W. E , institution of maternity
hospitals, 912
FothergUl (Dr. John) and His Friends (Dr.
R. II. Fox) (review), 1118
Fracture-dislocation of astragalus (Mr. H. 0.
Orrin), 20
Fracture, “propeller" (Lieut.-Col. A. L.
Johnson), 293; of humerus, comminuted
(Dr. Winifred F. Buckley), 980
Fractures, advances in treatment, 46, 80; of
thigh, suspension treatment (Dr. W. H.
Johnston), 170; occupational, 349; com¬
pound, of the upper limb (Mr. B. G.
Sleslnger). 365; retrogressions In treatment
of (Maj. M. Sinclair), 507
Fractures, Gunshot, of the Extremities (Lieut.-
Col. J. A. Blake) (review), 184,702
Fractures treated in Germany, results. 760
Fraser, Dr. Margaret H., erythrasmla, 338
Fraser, Mr. J. S., and Mr. W. T. Garretson,
radical and modified radical mastoid opera¬
tions, 339
Fraser, Sir T., retirement of, 631
Freak of nature, 675, 723, 963
Free hospital movement in Western Canada.
949
French, Dr. H., Dr. A. Abrahams, and Dr. N.
Hallows, influenzal septicaemia, 1 ; appointed
Physician to His Majesty’s Household, 854
French doctors and the exceis profits tax, 38 ;
Orthopaedic Society, 477; Auxiliary Army
Medical Corps, mortality in, 540; anti¬
small-pox campaign during the war, 759
French Supplement to The Lancet (leadlmr
article), 347 *
French Supplement to “ The Lancet
Achard, Prof. 0„ Review of Studies on Renal
Function In Chronic Nephritis (thesis by
Paateur-Vallery-Radofc), 752
Claude, Henri, and Jean Lhermitte, gunshot
concussion of spinal cord, 67
Devaux, A., nervous complications of exan-
thematic typhus, 567
Dopter, Prof. C., cerebro-spinal fever, 1075
Jeanselme, Prof. E., distribution of soldiers,
temporarily unfit through malaria, in
agricultural colonies, 751
Lhermitte, Jean, and Henri Claude, gun¬
shot concussion of spinal cord, 67
Moure, Dr. P., and Dr. E. Sorrel, surgical
complications following exanthematlo
typhus, 341
Palsseau, G., malaria during the war, 749
Sainton, Dr. P., meningococcal rheumatism
and arthritis, 1080
Sorrel, Dr. B., and Dr. P. Moure, surgical
complications following exanthematlo
typhus, 341
Vincent, Cl., contribution to the study of
manifestations of emotional shook on the
battlefield, 69
Valllet, Dr. Henri, epidemic diseases observed
In Roumania during the campaign of 1916-
1917, 669
Fremantle, Dr. F. B., medicine, Parliament,
and public, 312
Fresh Air Fund, 1064
Freud, Prof. S., Psychopathology of Hveryday
Life (review), 234
Frey-Bolli, Dr. B., the retained placenta,
Friedenwald, Dr. J., and Dr. A. McGlennan,
perforation In cancer of the stomach,
272
Friend, Mr. G. B., apparent immunity from
Influenza, 105,119
Friends for sick children, 946
Frost v. King Edward VII. National Memorial
Association for the Prevention, Treatment,
and Abolition of Tuberculosis, 37
Fry, Dr. H. J. B., Buchner’s anaerobio tube,
modified, 226
Fry, Mr. W. B, endothelioma of tonsil, 300
Fryer, Dr. J. H., air for oxygen in anaesthesia,
Fryer, Mr. P. J., and Mr. F. B. Weston,
Technical Handbook of Oils, Fats and Waxes
(review), 897
Fullerton, Dr. A., missiles as emboli, 913
GaUighan, Mr. W. M., Text-book of Sex
Education for Parents and Teachers (re¬
view), 617
Gangrene, gas (Dr. W. J. Wilson), 657; lung.
collapse tlierapy of, 902 j
Gardner, Mr. A. D., permanent criterion for
the standard agglutination test, 21
Garretson, Mr. W. T.. and Mr. J. S. Fraser,
radical and modified radical mastoid opera¬
tions, 339
Gas, mustard, nystagmus caused by (Mr.
5;„ P * ? a iPo kftr )‘ 42 *• gangrene (Dr. W. J.
Wilson), 657
Gask, Col. G. E., gunshot wounds of the
chest, surgical aspects. 667
Gassing, late results of, 433
Gaatroptosis (Dr. L. Brown), 878
Gaunt, Dr. J. K., anaphylaxis, 889
Gauv&ln, Mr. H. J., chemotherapy in
cutaneous tuberculosis. 412
Gedge, Mr. A. J., “ourselves only”858
Gemmell, Dr. W., death of, 823
Genasprin, 24
General Council of Medical Education
and Registration (Summer Session).—
President’s address, 954—Yearly tables and
appointment of committees, 955—Case of
I. B. Barclay; Case of N. O. McConnell;
Case of H. Mowat; Case of R. R. Coyle,
1004—Case of W. H. Fawcett; Report by the
Dental Education and Examination Com¬
mittee, 1006 — Report from the Education’
Committee; Report from the Examination
Committee; Report from the Examination
Committee, analysis of tables, 1006-Report
of Public Health Committee; Report of thn
Pharmacopoeia Committee; Report of
Dental and Examination Committee on
applications for exceptional registration^
Reappointment of General Registrar, 1007
General paralysis of the Insane (Dr. H.
Campbell and Sir 0. Ballance), 608
General practice, a personal retrospect (Dr.
J. Pearse), 129, 197; practice, some pitfalls
of (Dr. H. M. McCrea), 1010, 1053; practice,
how to start and how to succeed (Dr. G.
Steele-Perklns), 1097. 1140
General practitioner’s hospital, 1042
Genlto-urinary passages, gonorrhoea of. 219
Germicidal valuation of disinfectants, 576
Gestation, ectopia, t2 ; ectopic, with an appa¬
rently imperforate hymen (Dr. S. G. Papa-
dopoulos), 140; ectopic (Dr. B. T. Rose and
Mr. E. H. Shaw), 175
Gibbon, Dr. J. G., acquired immunity in
Influenza, 583
Gibson, Dr. H. E., early treatment of gonor¬
rhoea, 739; laboratory methods and the
diagnosis of venereal diseases, 859
Gibson, Maj'. H. G., and Col. S. L. Cummins,
analysis of cases of tetanus, 325
Gibson, Maj. H. G., R.A.M.O. (see Obituary of
the war); obituary, 395
Gibson, William, research scholarship, 1130
Gizzards and counterfeit gizzards (Sir J.Bland-
Sutton), 203
Glalater, Mr. J. N., case of a blind subject, 964
Gland, lacrymal, in surgical anaesthesia (Dr.
L. T. Rutherford), 792; disseotor, new
pattern, 868
Glands, tuberculous, treatment, 424
Glasgow University, pass-lists, 639, 725;
appointments, 1094
Glaucoma, double sclerectomy operation, 893
Glen Lomond Sanatorium (Py Q), 369, 402
Glossitis and stomatitis, lemon as a specific.
760 -
Glover, Dr. J. A., purulent broncho-pneumonia
associated with the meningococcus, 124
Gloyne, Dr. 8. B„ thoracic puncture fluids,
935
Glycerine and other media, restoration to the
Pharmacopoeia, 350
Glycosuria, sympathetic nervous system In
relation to (Dr. L. Brown), 923
Goadby, Sir K., latent infection of healed
wounds, 879
Goat as a milk supplier, 1053
Gonococcal Infections, complement-fixation
test In (Dr. A. H. Priestley) 787
Gonorrhoea complicated by acute gonorrhoeal
arthritis aud keratosis Dr. N. P. Lalng). 377;
early treatment of (Dr. H. E. Gibson). 739
Gonorrhoea of genito-urinary passages, 219
Gonorrhoea, treatment by pus vaooines (Dr.
E. G. D. Pineo and Dr. D. M. Balllle), 508;
urethrae haemorrhagica, 756
Goodall. Dr. A., Aids to Histology, second
edition (review), 848
Goodall, Dr. E., coordination of olinical
research, position of psychiatry, 1092
Goodall, Dr. B. W., the Nursing Register, 528
The Lancet,]
INDEX TO VOLUME I., 1919.
[.July 5, 1919 ix
Goodall-Copes'ake. Beatrice M., Massage as a
Career for Women (review), 617
Goodwin, Lleut.Gen. Sir J , war memorial to
officers and men of tho It A.M.C., 766
Gordon, Dr. W., essential princip'es of suc¬
cessful medical administration, 356
Goring, Dr. C. B.. obit uary, 914
Gotto, Mrs. 8., medical practitioners and the
detection of crime, 198
Gould, Sir A. P., and Mr. E. P. Gould,
Elements of Surgical Diagnosis, fifth edition,
1919 (review). 659
Graham, Mr. J. H. P., primitive agents in
treatment , 45; Sta'e Meulcal Service. 312
Grain pests and scientific accuracy, 539
Grant, Dr. I)., tuberculosis in relation to
upper air and food passages, 223
Grant, Dr. L., life and health in the Highlands,
488
Grant, Dr. W. J., essential principles of suc¬
cessful medical administration, 441
Grants to panel practitioner* (Py Q), 401, 403;
for medical referees (Py <^), 442
Gratuities to temporary naval medical officers
(Py Q). 485; war. to nurees (Py Q), 1008
Gray, Col. H. M. W., Early Treatment of War
Wounds (review), 513
Gray, Dr. Elizabeth, and Dr. J. A. B. Hicks,
investigation of ii fiuenza cases, 419
Great Britain and Denmark, 187
Great Northern Hospital, cinema, 965
Greek, a smattering of, 991; compulsory, at
Oxford, 1000, 1C45, 1089
Griffith, Dr. W. S. A., reconstruction in the
teaching of obstetrics and gynacology to
medical students, discussion, 258; retro¬
peritoneal lipoma, 1072
Griffith, Ma.j. II. II., Austr. A.M.O. (see
Obituary of the war)
Griraadale. Mr. U. £., pulsating tumour of
orbit, 613
Grocers’ gift to the blind, 955
Grove, Dr. W. tt., metrorrhagia in influenza,
156
Gruner, Dr. O. C., origin of life, work of the
late Charlton Bastian, 1044
Guardianship Society, 1012
Gunshot concussion of spinal cord (Henri
Claude and Jean Lhermitte), 67; wounds,
treatment (Mr. A. H. Tubby, Dr. G. R.
Livingston, and Dr. J. W. Mackie), 251;
Injuries of 'the cervical nerve roots (Dr.
J. S. B. Stopford). 336; wounds of the chest,
666; wounds of the chest, surgical aspects,
667; wounds and other affections of the
chest (Mr. C. Mac Mahon), 697
Gunshot Injuries, Orthopaedic Treatment (Dr.
L. Mayer (review), 23 ; Fractures of Ex¬
tremities (Lieut.-Col. J. A, Blake) (review),
184, 702
Guthrie, Dr. D., nasal obstruction in aviators,
136
Guthrie, Dr. L. G„ obituary, 44
Gynaecology for Nurses and Gynaecological
Nursing (Dr. C. Berkeley), third edition,
1918 (review), 348
Gynaecology, the birthplace of,” 189
H
Haematemesis after abdominal operation, 529
Haematology, literature of, 817
Haemoglobin uric bilious fever, treatment, 940
Haemoptysis, post-influenzal (Dr. H. Wilson),
137; and epistaxis in influenza, 481
Haemorrhage, accidental, In connexion with
eclamp'lsin (Sir W. Sinyly), 133; meningeal,
in typhoid fever, 519; blood volume and
related blood changes after, 852
Haemorrhagic spinal effusions (Dr. W. P. S.
Branson), 888
Haln Capt. C. C., Austr. A.M.C. (see Obituary
of the w-tr)
Hall, Dr. H. G., Bedside and Wheel-chair
Occupations (review). 808
Halliburton, Prof. W. D., physiology and the
food problem, 283 ; origin of life, work of
tbe late Charltpn Bast Ian, 10C0
Hallows, Dr. N., Dr. H. French, and Dr. A.
Abrahams, influenzal septicaemia, 1
Harden, Prof. A , Mr. S. S. Zilva, and Dr. G. F
Still, infantile scurvy, 17
Harris, Dr. I., significance of inverted “T” in
first lead of the cardiogram, 168; correction,
218 ; some forms of irritable heart, 787
Harris, Mr. J. N„ parasitic mange in horses,
280
Harrison. Brevet-Col. L. W., gonorrhoea of
gen l to-urinary passages, 219; venereal
disease, 713
Hart, Mr. J. H., pelvic sarcoma, 378
Hartley, Col. K. B., V.C., obituary, 633
Hartley, Dr. A. C., obituary, 437
Hartridge, Mr. G., Refraction of the Eve,
Manual for Students, sixteenth edition, 1919
(review), 984
Harvard medical unit (leading article), 115
Hawrs, Mr C. S., obituary, 45
Hawk, Prof. P. B.. Practical Physiological
Chemistry, sixth edition, 1919 (revtew), 983
Hawkins, Mr. W. R. T., death of, 972
Haworth, Dr. J. K., cancer of ctecum wUh
pelvic abscess and gangrene of rectum, 140
Hay, Mr. W. A. K., death of, 199
H yes, Mr. R., Intensive Treatment of
Syphilis and Locomotor Ataxia by Aachen
Methods, third edition, 1919 (review), 486
Head, Diseases of. Roentgen Diagnosis of (Dr.
A. Schuller) (review), 466
Head. Ur. H., sensation and the cerebral cortex,
389 ; Destroyers and Other Verses (review),
1120
Headaches, pituitary, and their cure, 6S4
Healed w unds, latent infection of (Sir K.
Gnadbyi. 879
Health Conference of Insurance Organisa¬
tions: Presidential address; Ministry of
Pensions; Sanatorium treatment, 629 —
Niggardly grant for medical research;
Medical research and tho State; Medical
research and the lessons of the war, 630 —
National Health Insurance, 631
Health, modicine, and sanitation in India,
127, 163; and life in the tropics, 644;
Department of, for Canada, 767; report of
New York, 950
Health, public, campaigns in Canada. 1132
Health Header for Girls (Agnes L. and B.
Stenhouse) (review), 142
Health reports, colonial, 50, 89, 202 . 242, 324,
488, 591, 644.772. 825, 1054; Malay States.
1011; teaching, 90; of Belfast, 121; and
radiant heat. 164 ; of Canada, improving the,
232; and allotments, 284; of Lille during
German occupation, 430; In South Africa,
524 ; visitors, salaries of (Py Q). 685; Council
for Wales (Py Q), 865; of the Navy and
Marine Corps of the U.S., 950
Healthy, disadvantage of being, 307
Hearing, new theory of, 510
Heart disease and distress, left scapular pain
and tender ness in (Dr. J. Parkin?on), 550,575;
direct massage of, 653; failure, 658; Irritable,
some forms of (Dr. I. Harris), 787 ; in hyper¬
tension (Dr. L. Brown), 968; perforating
wound of (Maj. F. C. Pybus), 1026
Heart. Soldier’s, and the Effort Syndrome (Dr.
T. Lewis) (review). 142 ; and Aorta, Diseases
of (Dr. A. D. Hirschfelder), third edition,
1918 (review), 383
Hearts of Man (Dr. R. M. Wilson) (review), 701
Helller, Prof. J. B., retirement of, 282
Hemlanopia, transient, 574
Henderson, Mr. E. B., bilateral choroldo-
retinitls. 895
Henley, Capt. E. A. W., N.Z M.C. (see Obituary
of the war)
Henry, Dr. A. K., destruction of mosquito
larvtc in streams, 908
nerb growing, medicinal, 1053
Hermann Boerbaave. 576
Hernaman-Johnson. Dr. F., X rays in diagnosis
of appendicitis, 279
Hernia, femoral, strangulated (Dr. S. M.
Lawrence), 64; diaphragmatic (Mr. R.
Warren). 1069, 1089
Heroin poisoning, /55
Herrlngbam. Maj.-Gen. Sir W„ clinical aspects
of Influenza, 711
" Heterresf hesia.” 78
Hlbbert, Mr. C. H., death of, 977
Hicks, Dr. J. A. B., and Dr. Elizabeth Gray,
investigation of cises of Influenza, 419
Hill, Mr. T. G., biology and the medical
curriculum, 273
Hilus tuberculosis In the adult (Dr. C. Riviere),
213. 68?, 814
Hlne, Capt. M. L , and Col. W. T. [Lister,
evulsion of optic nerve, 895
Hirsch. Mr. C. T. W., anaesthesia for oph¬
thalmic operations, 1068
Illrschfeld, Dr. L , new germ of paratyphoid,
296
Hirschfelder, Dr. A. D., Diseases of the Heart
and Aorta, third edition, 1918 (review), 383
Hirst. Capt. L F., Capt. A. H. Tubbv. Maj.
A. R. Ferguson, and Capt. T. J. Mackie,
act ion of flavine, 838
Histology, Aids to (Dr. A. Goodall), second
edition (review), £48
Ilobbs, durg.-Lieut. R. A , R.N. (see Obituary
of the war)
Hobhouse, Dr. E., lysorophus, 1093
Ilodgetts, Dr. C. A., Department of Health for
Canada, 769
Hojel, Lieut.-Col. J. G., C.I.E., I.M.S. (see
Obituary of the war)
Holland, Dr. B., syphilitic placentae, 1073
Home, at, in the War (Mr. G. S. Street)
(review), 142
Home, Kleet-Surg. W. B., lemon juice or lime
juice, 128
Home for men disabled by the war, 45
Home Office, medical inspectors of (Py Q), 402
Home v. Institutional training of young
children. 615
Honours, 88, 200; New Year, 31. 73; New
Year, deferred. 755; Order of the Indlsn
Empire, 47; Belgian, 915; birthdav, 999 r
1039, 1046 ; war (see Honours under War and.
After)
Hookworm disease In Bengal, 318
Ilopewell-Smitb, Mr. A., Nfrmnl and Patho¬
logical Histology c.f the Mouth (review), 897
Hopkins, Prof. F. G., vitamlnes. unknown but
essential accessory farters of diet, 363
Horder, Sir T., epidemic perinephric suppura¬
tion, 1044
Horses, parasitic mango In, 280
Hospital for Bogimr, 242; accommodation aft
West Ham (Py Q). 820; accommodation for
civil needs (Py (^). £65; treatment for
soldiers, pallors, and pensioners (Py Q), 865 ;
for tropical diseases, new, 946; geneml prac¬
titioner’s, 1042; nurses, accommodation for
(Py Q). 770
Hospital officers, pecuniary position of (leading
article), 573
Hospital stoppages fn India. 998
Hospital Sunday Fund, Metropolitan (leading
article), 103?, 1C93 : Brighton, 24
Hospital wards as hotels, 998
Hospitals and dispensaries in India, 1917-18. 50
Hospitals, military, closing the smaller (Py Q),
640; Government control of (Py Q), 641;
civilian, pressure on (Py Q). 641; for disabled
men, 813; voluntary, and the work of the
almoner (leading article). 849
Hot liquids and cancer, 583, 635, 683
Household refuse, 526
Housing problem, 28; in Mesopotamia, 301;
Bill, 484; and infant mortality, 643 ; rural*
987 ; conference in Belfast, 1138
Howell, Mr. B. W., lymphangeioma of tor guo,
940
Howell, Prof. W. H., Text-book of Physiology
for Medical Students and Physicians, f eventh
edition, 1918 (review), 984
Hudson. Mr. A. C., retinal degeneration
following Intra ocular foreign body. <99
Huerre, Dr. R., chemical com posit’ou of lemcn
. juice. 895
Huet, Lieut. F. P. Y., Austr.A.M.C. (see Obit¬
uary of the war)
Human, bovine, and avian tubercle bacilli*
attenuation of (Dr. N. Raw), 376
Human Machine and Industrial Efficiency
(Prof. F. S. Lee) (review), 847
Humerus, comminuted fracture of (Dr.
Winifred F. Buckley), 980
Hunger and disease In Central Europe,
Hunf, Dr. B. L., and Dr. Helen IngTeby,
transfusion of blcod, 975. 988
Hunt, Dr. J. R., paralysis agitans and the
corpus striatum. 77
“ Hunter, John, Phases In tLe Life and Work
of’’(Prof. A. Keith), 269
Hunterian oration on Britirh military surgery
in the time of Hunter and in tbe great war
(Sir A. Bowlby), 285; lecture on compound
fractures of upper limb (Mr. E. G. Sleslnger)*
365
Hurst, Dr. A. F., war deafness, 238; and Dr.
J. 1. M. Symns, hysterical element in
organic disease and injury of central nervous
system, 369
Huts, a-my, for tuberculous patients (Py Q),
Hydrology, Instruction In. 635
Hydrops articulorum, intermittent (Dr. K.
MacLelland). 463
Hydrothorax, unilateral, due to disease bclow
the diaphragm (Mr. W. G. Nash), 378
Hygiene and the Frenchman’s house as his
castle, 274
Hygiene for school teachers. 804
Hygiene of the Eye (Dr. W. C. Posev>
(review), 184
Hygienic conscience in relation to coal-getting
(leading article), 9(0
Hvgienic reconstruction of war devastation,.
Inter-Allied Conference i t Paris, 856
Hygienic repair o' the roads, 202
Hyperchlorhydria,causation o: (Dr.L. Brown'
877
Hypertrophic stenosiB of pylorus, 389
Hypochlorites, action of, on pleural false*
membranes, 895
Hypnot'c Suggestion and P^ycho-therapeutlca
(Mr B. Taplin) (review), 3 2
Hypothermia in ii fiuenza, 398
Hypothermic, or depression, stageof influenza,
HyBterlcri clement In organic disease and
injury of central roivom system <Dr. A. F.
Hurst and Dr. J. L. M. Symns). 369
Hysterical perpetuation of symptoms (Mr.
C. H. L. Rixon), 417 ; disabilities, rapid cure
(leading article), 427
Hysterical vomiting in soldiers (Dr. W. R.
Reynell), 18,118
x The Lancet,]
INDEX TO VOLUME I., 1919.
[Jolt 5,191$
Ichthyol, Italian, 24
Illumination, standard, of Snellen's types, 34
Imhotep (Asclepioe), new records concerning
128
Immune Sera 'Dr. C. P. Boldus»n and Dr. J
Koopman), fifth edition, 1917 (review), 746
ImmuLity, a further advance (leading article)
516
Immuno transfusion, 814
Imperial Antarctic Expedition, 8©
Impersonator, an ingenious, 36
Incision of tympanic membrane, new method
(Mr. K. Lake), 977
income limit under the Insurance Act (Py Q)
Income-tax and medical men (Py Q). 360
(Consolidation) Act, 1918 (revlewj, 566
India, Correspondence from.-— Indian
system of medicine; Medical research in
India; Sick pay for Indian nursing sisters
Wew honorary surgeon to the Viceroy.
Allegations of Cannibalism in Sind; Simla
Mid -Delhi health officers, 311-Indian
Science Congress; Supply of subassistant
surgeons; Next war, man v. Insects;
Plague; Organisation of chemical work in
India ; Cholera, 434—New medical school at
Allahabad ; Burma Medical Council ; Plague
inoculation statistics ; Mortality In Calcutta;
Mission to lepers; Smallpox epidemic
expected in Bengal, 760—Juvenile smoking
761—Medical Services Committee.
813.857—Sanitation in Lahore; Small pox at
Decca; Possible recrudescence of influenza;
Lady Hardinge Medical College, 813-Child
welfare in India; Infant mortality In Bengal •
Vital statistics of Calcutta. 857 -Mortality hi
Calcutta; Need for more doctors, 997—Hos¬
pital stoppages in India ; Hospital wards ns
hotels ; Indian Defence Force Me ileal Corps •
Anti hookworm campaign in tea districts \
Indian Ministry of Health, 998
In Ha, health, medicine, and sanitation in, 127,
163
Medical Service, pay in, 278.444 589
Iff 857 i committee’
Indian systems of medicine, 311; nursing
sisters, sick pay for, 311, 764; Science Con-
gress 431; Defence Force Medical Corps,
998 ; Ministry of Health, 998 ; future of, 1087;
India and, 1135
Industrial accidents, causation and preven-
i !f 0n , ( P r * 11 M v ernon), 549
e $°^ney and preventive medicine
(leading article), 113; unrest and the new
public health, 202; Fatigue Research
Board (Py Q). 401; emp’oyment, effect
upon women, 465 ; disputes In asylums,
473; medical sorvice (leading article). 1084
Industrial Organisation. Physiology of (Prof.
J. Armv) (review). 265; Fatigue, Use of
Statistics In the Investigation of (Mr. P. S.
Florence) (review), 301; Situation afterdhe
War, Memorandum on, the Garton Founda¬
tion (review), 617; Efficiency and the
Human Machine (Prof F. S. L e) (review),
847
Infant mortality and housing, 643; mor¬
tality in Bengal, 857
Infantile scurvy (Prof. A. 11 irden, Mr. S. S.
Zilva, and Dr. G. F. 3til»). 17
Infant’s tenacity of life, 324, 364
Infection, contact, of chicken-pox, 397 ; latent,
of healed wounds (Sir K. Goadby), 879;
mixed, in hi us phthisis. 1128
Infectious diseases, notification of, fees for,
575
Infective scar tissue (Mr. K. M. Corner), 840
Influenza and chronic lung disease, 281,314;
Combating (Pv Q). 321. 359, 350; prevention
of (loading article), 346 ; the toll of, 350;
f irevent-lve inoculation against, 357; patients
n the Army (Py Q). 401; and Infectious
difeas's, treatment (jv lvmphotherapy and
hsematotherapy, 424; treatment by hypo¬
dermic Injections of eucalyptus oil. 424 ;
prophylactic in' dilation of (leading article),
672
Influenza compirative pa’ ho'ogy of (Dr. G. R.
Murray ), 12 ; pathology of, loasons of a great
epidemic (leading article), 25. 242; its epi¬
demiology and clinical as »rets (leading
article) 72; and enceph ilo myelitis, 79;
mr>ningo.'occu f i lirorclm pneumonia in (Dr. |
FiCt' h‘*rKi; apparent immunity from
( Mr. G. K. Fries.dh 105. 119, 529, 533;
h>rl<>c<x-CUJ a areas septicaemia in (Dr. A.
Patrick 1 , 137; met rorrhagia in* 156; hypo
thermic, or depression st age, 196 ; the return
of, 305; ptndemic deal ing article 1 ** 336; pro¬
phylaxis in (Mr. F. T. Marchant), 353;
hypothermia in. 398; and its prevention, con
ference on. 406; investigation of cases (Dr.
J. A. B. Hieks and Dr. Elizabeth Gray), 419;
and diet memorial on, 436; and oatmeal
(Py Q). 443; treitraent by colloid metals and
S henol, 472; vaccines, 476; epistixis and
wmoptysls In, 481; epidemic, does It affect
the lower animvls ? 520 ; inusk in, 529;
autumn epidemic (1918) (Dr. J. W. H. Byre
and Dr. E. C. Lowe), 553; complicated, treat¬
ment (Dr. A. J. Bagieton and Mr. H. H.
Butcher), 560; present epidemic (Dr. M. J.
Rowland*), 563; and diphtheria (Dr. B. A.
Constable), 563 ; “ Spanish,"635; “Spanish ’’
(Dr. B. Folley), 656, 663
Influenza, electrolytic disinfectant in, 90;
mask, the “ Arellano,” 90; use of creosote in,
128; leucocyte count In. 156 : formalin spray
in checking (Dr. A. Wvile), 256; filter-passing
virus In, 280, 313, 528; trimethenal-allyl-
carbide in, 440; intrapulmonary injection of
serum in, 1067
Influenza epidemic (Dr W. Bussell), 689;
preventive vaccinei fo", 707; clinical aspects
of (Msj. Gen. Sir W. Herrlngham), 711;
bacteriology of, 760; with reference to pneu¬
monia in Macedonia, 794 ; possible recrudes¬
cence, 813; national campaign against, 813;
vacMne in (Dr. F. T Cadham), 855; fixation
abscesses In, 895 ; infecting agent In (Prof.
T. lamanouchi. Dr. K. Sakakvral, and Dr.
S. Iwashlma). 97l
Influenzv In France, 38; scourge in Canada,
39; victims, medical, in South Africa, 78;
and American Public Health Association,
230; recrudescence in New York, 353; mor¬
tality in South Africa, 395, 720; epidemic in
Hdinburgh and district, 433; and cholera in
Bombay (Py Q’, 442; In Australia, 476, 681,
760; in Cape Town, 524; in British Guiana
(Dr. F. G. Rose), 421; epidemic In Lower
Kgjpt, bacteriology of (Dr. G. M. Findlay),
Influenza vaccine (mixed), 24
Influenza’. 13 , simply prepared culture media
for (Mr. A. Fleming), 138
Influenzal septicaemia (Dr. A. Abrahams, Dr.
N. Hallows and Dr. H. French). 1 ; epidemle,
Ies«ons of, 242; intra abdominal catastrophes
(Dr. R. E. Smith), 421; broncho-pneumonia,
use of intravenous Iodine in (Dr. D. Bf.
Baillie), 423; pneumonia (Sir W. Osier), 5GQ ;
pneumonia, lung-puncture in (Dr. M.
Benaroya), 742. 816
Ingestion of adrenalin and intravenous injec¬
tion of colloidal quinine. 760
Ingleby, Dr. Helen, and Dr. B. L Hunt, trans¬
fusion of blood, 975, 988
Inoculation and masks, 681
Inorganic and Physical Chemistry, Recent
Advances in (Mr. A. W. Stewart), third
edition, 1919 (review), 617
Inorganic Chemistry, Introduction to (Prof~
A. Smith), third edition, 1918 (review), 225
Insane, general paralysis of, treatment (i>r. n.
Campbell and Sir C. Ballance), 608
Insurance Act medical benefit (Py Q), 820 1
practitioners’ terms (Py Q), 821
Insurance Acts Memorandum, dieeuasion on,
at Norwich, 1138
Insurance BiP, Health, and the medical pro¬
fession of New York, 524
Insurance, health, compulsory, opposition toy
1090
Insurance Medical Service, proposed exten¬
sions, 351; practice (Py Q). 403
Insurance Organisations, Health Conference
of, 629
Insurance practitioners, pool for (Py Q), 1008;
Increased war b mus to. 1129
Inter-Allied Fellowship of Medicine, 152
Internal Secretion, Organs of, their Diseases
and Therapeutic Application (Dr. I. G. Ctbb),
seoond edition 1918 (review), 111
International Conference on Rehabilitation of
the Dls.tblrd. 761
InternaDonal Opium Convention (Py Q), 443,
726
Internment, psychology of (Prof. R. Bing and
Dr. A. I . Vischer), G96
Intestinal entnzoa among the native labourers
in Johannesburg, 521
Intest in d obst ruction by Meckel’s diverticulum
(Dr. It. A. Bin mV th 1117
Inf est in vl Stasis, Cnrontc, Operative Treat¬
ment ('*ir W. A. Lane), fout'h edition, 1913
(review). 65; stasis, chronic (Sir W. A.
Lane), 333; stasis (Dr. L. Brown) 878
Intes iiie, small, diffuse emphj sema of, 263
Iiura-e.b'niinal catastrophes, in finer zal (Dr.
R. K. SniiMD. 421
Intracardivl Injection, 1035
Intra ocular growth, 613
IntrapuliU'iuary injection of serum In in¬
ti ieozv, l r, :’7
Intrinsic cancer of larynx, 263, 271
Intu^-.i-c'H'tl -n trea'ed by resect ion (Mr. E. It.
Flint), V3-;; mortality fr. in, 94)
Invalid Children’s Ail Association, 946
Invalidism caused by P.U.O. and trench fever
(Col. T. R. Elliott, Oapt. D. 6. Lewis,'Msj
£ Thursfleld, Maj. A. J. Jex-Blake, and
Msj. M. Foster), 1060
Invalidism for 15 years through nasal blookage,
156
In-erted “ T" in flrst lead of the cardiogram,
* gnl oio noe of tDr ’ L Harris), 188; correct
Lion, clo
Ioiline, Intravenous use of, in Influenzal
broncho-pneumonia (Dr. D. M. Baillie), 423
Ireland, Correspondence from. — Irish
Medical Committee; Ministries of Health
Bill; Salaries of dispensary doctors; Health
of Belfast, 121—Milk-supply of Dublin, 192—
Strike In Belfast; Belfast Hospital for Skin
Diseases, 193—Medical reform for Ireland:
Sir W. Wbltla. M.P.; Royal Victoria Hoe-
pltal, Belfast, 274—Ministry of Health for
Ireland; Irish vital statistics, condition Of
medical service in Ireland; Proposes
establishment of Irish Public Health
Council, 475—Separate Health Bill for
Ireland, 478, 909-Medical inspection Of
schools in Ireland, 577, 997—Ireland and the
Ministry of Health Bill; Belfaet doctors and
the Ministry of Health, 677—Ireland and
the Ministry of Health Bill, 631-Ireland
and public health reconstruction; Chief
Secrelary for Ireland and the medical pro¬
fession, 812—Rainfall in the North Of
Ireland, 910—Belfast Ophthalmic Hospital,
997—Ulster branch ol British Medical
Association; Ministry of Health Bill;
Belfast Dental Clinic; Meetings of delesatee
in Dublin. 1040
Ireland, medical appointments during de¬
mobilisation, IS; and the Ministry of
Health, (Py Q) 321, 359, 400, 442. 475, 577,
532, 1040; medical inspection of school
children (Py Q), 641, 997; medical treatment
of children, 819
Irish Medical Committee, Ml; dispensary
doctors’ agitation, 160; housing (Py Q). 320;
Poor-law medical officers (Py Q9..442; vital
statistics, conditions of medical service
in Ireland, 475; Public Health Council, pro¬
posed, 475; children, medical inspection and
treatment, 685 ; Medical Association* *»»>— 1
meeting. 1091
Irrigation Treatment of Wounds by IbeOarral
Method, Technic of (J. Dumas and Anne
Carrel) (review), 617
Irritable heart, some forma of (Dr. 1. Harris).
787
Irwin, Mr. 8. T., acute appendicitis and acute
appendicular obstruction, 98
Italian iebthyol, 24
Ivory Cross, the, 1011
Iwashlma, Dr. S., Prof. T. YaoMUMucbl, and
Dr. K. Sakakaml, Infecting agent in
influenxa, 971
Jeffrey, Mr. F.. obituary, 963
James, Lieut.-Col. SL P., risk of the spread of
malariA in England, 677
James, Mr. W.. multiple epuIMes, 744
Jameson, Maj. D. D., M.C., Austr.A.M.C. (see
Obituary of th© war)
Jaundice (Dr. W. H. Wllleox), 869; toxic (Dr.
W. H. Willcoxi,871,929; catarrhal,epidemic
W. H. WiUcox), 939; (leading article),
Jeanselme, Prof. E., distribution of soldier*,
temporarily unfit through malaria, in agri¬
cultural colonies, 751
Jellett, Dr. H., pyosalplnx and ovarian abiceas,
266
Jessel, Dr. G., North-Western Tuberculosis
Society, 859
Jex-Blake, Maj. A. J., Maj- M. Foster. CoLT. R.
Elliott, Cant. D. 3. Lewis, and Mai J. H.
ThuiaficM, Invalidism caused by P.U.O.and
trench fever, 1060
“John Hunter, Phases In the Life and Work
of" (Prof. A. Kofth), 269
Johnson, Lieut.-Col. A. L., “propeller”
fracture, 293
Johnston, Dr. W. H., suspension treatment of
fractures of thigh, 170
Johnston, Maj T. R. St., appointed Colonial
Secretary of Falkland Islands, 282
Johnston, Mr. R. McK., and Sir R. W. Philip,
position of the demobilised practitioner,
439
Johnstone, Dr. R. W., Text-boc<k of Midwifery
for St uden's and Practitioners, second
edition, 1918 (review), 982
Joints, swelling of, 940
Joil, Mr. C. A., and Dr. J. Cunning, Aids to
Surgery, fourth edition, 1919 (review),
659
Thb Lancet,]
INDEX TO VOLUME I., 1919.
[July 5, 1919 xi
Joltraln, Dr. B., Dr. P. Baufie and Dr. R.
Ooope, chronic colopat hies, 933
Jones, Dr. A. B.. and Dr. L. J. Llewellyn,
Pensions and the Principles of their Evalua¬
tion (review), 799
Jones, Dr. K., Papers on Psycho-Analysis,
second edition, 1918 (review), 234
J6nes, Dr. G., medical men and shareholding,
1093
Jones. Mr. H. B., deafness associated with the
stigmata of degeneration, 182
Jones, Surg.-Lidut. M?S. t K N. (see Obituary
of the war)
Journal of General Physiology, 807
Journal of Physiology (review), 746
Journal of the Bast African and Uganda
Natural History Sooiety (review), 225
Journal of the Royal Army Medical Corps,
916
Juler, Mr. F. A., obstruction of retinal vessel*,
1072
Jang, Dr. C. G., Studies in Word-Association
(review), 234; Theory of Psycho-Analysis
(review), 234
K
Kala-dzar, Its Diagnosis and Treatment (Dr.
B. Muir) (review). 142; colloid antimony
sulphide intravenously in (Sir L. Rogers),
505
Katyanvata, Mr. D. N., spontaneous rupture of
ovarian cyst, 423
Keith, Capt. G. K., R.A.M C. (see Obituary of
the war)
Keith, Dr. R. D., Clinical Ca9e-taklng (review),
112
Keith, Prof. A., “ Phase* in the Life and Work
of John Hunter,” 269; and Sir T. Wrigbtson,
new theory of hearing, 510
Kelly, Dr. F. H., acute erythema resembling
measles, 255
Kelly, Mr. W. P., epbtaxis arid haemoptysis in
Influenza, 481
Kemp, Dr. W. G., death of, 239
Kemp Pressor colour scheme (Dr. E. N
Snowden), 622
Kennaway, Dr. B. L , and Dr. 0. H. Browning,
Wassermann tests, 785
Kennedy, Dr. A. M., and Dr. C. Wonder-
Drought. Cerebro-splnal Fever (review), 1073
Kennedy, Lieut.-Col. J. C., mucoid forms of
paratyphoid, 237
Keogh, Surg.-Cora. J. A..R.N. (seoObltuu-y of
the war)
Mettle, Dr. E, H., polymorphism of malignant
epithelial cell, 743
Khaki monotony, 90
Kidd. Dr. W., the word “ psychology,” 1093
Kidderminster Infirmary, proposed war
memorial, 4 5
King, Dr. Chari >tte A., swelling of joints. 94)
King, Dr. W. W., two cystic tumours of the
vulva, 22; recurrent sarcoma after removal
of apparently simple myomata, 301
King Edward's Hospital Fund for London,
meeting, 87, 475,86Z
King Edward VII. Sanatorium, Midhurst,
report, 688
King George’s Fund for Sailors, meeting, 87
Ktnnalrd, Lord, Mr. J. F. W. Deacon, and Mr.
J. B. Lane, residential treatment for preg¬
nant women suffering from venereal diseases,
80
Knapp, Dr. A., Medical Ophthalmology (Inter¬
national System of Ophthalmic Practice)
(review), 23
Koopman, Dr. J., and Dr. C. F. Bolduan.
Immune Sera, fifth edition, 1917 (roview), 746
L
Laboratory methods and diagnosis of venereal
diseases, 817, 859
Labyrinthitis, circumscribed, 893
Lhcrymal gland in surgical anaesthesia (Dr.
L. T. Rutherford), 792
Lady Chichester Hospital for Women and
Children, Brighton; 1140
Lady Hardinge Medical College, 813
Laing, Dr. N. P., gonorrhoea complicated by
aoute gonorrhoeal arthritis and keratosis, 377
Lhke, Mr. R,, new method of incision of
tympanic membrane, 977
La Medicina Ibera (review), 226
Lancrt, The, luncheon at Hyde Park Hotel,
666
Lane. Mr. J. E., Lord Ktnnalrd, and *Mr.
J. F. W. Deacon, residential treatment for
pregnant women suffering from venereal
dise ises, 80
Lane, Sir W. A., Operative Treatment of
Chronic Intestinal Stasis, fourth edition,
1918 (review), 65; chronic intestinal stasis,
333; disease and chyme infection, 76S
Langley, Prof. J. N., arrangement of the
autonomic nervous system, 95
Language, universal, of quantity, 539
Langworthy, Mr. G. V., death of, 200
La Perdita Sanitaria, 1054
Larrev and war surgery (Dr. W. G. Spencer),
867,‘920. 962
Laryngo-fissure and oancer of the larynx, 271;
with removal of intra-laryngeal growth, 659
Larynx, intrinsic cancer of, 263, 271
Latent sepsis, eradication of (Mr. H. PUtt),
175
Latham, Dr. A., and Dr. C. Battar, Medical
Parliamentarv Committee, arrangement of
conference, 634, 817
Laumonier, Dr. J., typhoid fever treated by
colloi lal iron, 424
Lawrence, Capt. H. R., M C., South African
M.C. (Bee Obituary of the war)
Lawrence, Dr. S. M., strangulated femoral
hernia, f 4
Laws of life, 323
Lawson, Mr. A., (1) new method of applying
radium in diseases of the eye; (2) flavine in
ophthalmic surgery, 895,1112
Lay members of mixed committees and
me lical questions, 1041
Lea, Dr; O. E., obituary. 963
Lead in the casserole, 9! 5, 1002
LEADING ARTICLES
Appendicitis, accurate diagnosis In, 114
Belgian Doctors’and Pharmacists' Relief Fund,
228
Bilharzlasis, it* prevention and treatment,
1032
Brain-workter’s diet, 901
British Medical Association, clinical meeting,
518, 662 ; war neuroses, 6!9
Bubonic plague at home, 986
Catalyst, the role of, 144
Charter of Science for the Army Medical
Depart ment, 753
Chemistry in 1918, progress of,470
Childbirth, maternal mortality of, an! the
teaching of midwifery, 802
Coal-getting, hygienic conscience in relation
to, 900
Criminal, the psychopathic, 143
Demobilised practitioner, position of,515
Dental practice, qualified and unqualified.
385
Detoxicated vaccines, 1123
Diagnosis, accurate, in appendicitis. 114
Education, scientific, and Its cost, 428 . medical.
reform of, 571; medical, post-graduate, 703
Epidemic Diseases Order, new, and its effect,
303
Euthanasia, 803
Feat nf endurance, 1035
Fellowship of Medicine, 26
Flying, medical aspects of, 227
French Supplement to Thk Lascet, 347
Harvard Medical Unit, 115
Hospital officers, pecuniary position of, 573
Hospital Sunday Fnnd, Metropolitan, 1032
Hospitals, voluntary, and the work of the
almoner, 849
Hygienic conscience in relation to coal-getting,
900
Hysterical disabilities, rapid cure of, 427
Immunity, a further advance. 516
Industrial efficiency and preventive medicine,
113
Industrial medical service, 1084
Influenza, pathology of, lessons of a great epi¬
demic, 25; epidemiology and clinical aspects,
72 ; the prevention of, 346 ; pandemic 386
Influenza, prophylactic inoculation in, 572
Jaundice, Lettsonaian lectures on, 94?
Lessons of a great epidemic, the pathology of
influenza, 25; epidemiology and clinical
aspects, 72
Lettsomian lectures on jaundice, 942
Maternal mortall'y of childbirth and the
teaohing of midwifery, 802
Medical aspects of flying, 227
Medical education, reform of, 571 ; evidence
and trials in camera, 620
Medical Parliamentary Committee, progress
of. 801
Medical practitioner, outlook of, 145
Medical profession and the trade-union ques¬
tion, 345
Medibal research and Its place in the State.
517
Medloal Services Bill, 941
Medicine and the State, 185; Parliament, and
public, 267
Mediciue, teaching of, 227
Meningocoocus, the, a recent chapter, 1C83
Metropolitan Hospital Sunday Fund, 1032
Ministry of Health Bill, inspection of school
children, 471; the next stage, 1031
Neuroses of the war, 71
New houses for old, 753
Near Year's wish, 25
Outlook of the medical practitioner, 145
Outlook, the, 1121
Parthenogenesis In vertebrates, 1033
Pecuniary position of hospital officers, 573
Pensioners, war, in civil hospitals, 186
Pneumonia, recent advances in treatment,
704
Post-graduate medical education, 703
Practitioner, the demobi ls»d. position of, 515
Preventive medicine and industrial efficiency,
113
Prophylactic inoculation In influenza, 572
Psychopathic criminal, the. 143
Hablesand its treatment in this country, 74
Radium Institute, 850
Red Cross, past, future, and present, 661
Kefo.m of medical education, 571
Research, medical, and its place in the State,
517
Sanitation in the Near East, 621
Scientific education and i's cost, 428
Services Bill, medic*!, 941
State subsidy of tubereulom labour, 469
Sugar control in the body, 9:5
Tuberculosis ser\ ice, 304
Voluntary hospitals and the work of the
almone-, 849
War pensioners in civil hospitals, 186
Women in industry, 899 •
Lead line on tailors’ gnms, a dangerous prac¬
tice, 644
Leber’s atrophy, changes in the sella turcica,
300
Lee, Dr. J. R., pelvic-femur splint and arm
splint, 103
Lee, PW>f. F. S., The Human Machine and
Industrial Efficiency (review)847
Leeds Workpeople's Hospital Fund, 618
Lees, Dr l).. detoxicated vaccines in treatment
of gonorrhea, 1107
Lees, Mr. K. A., dinner fork iu the stomach
and duodenum. 298
Leeson, Mr. C , prls -n re f orm,1002
Leete. Dr. II. M., experiments on masks, 392
Leftwich, Dr. R. W , obituary. 580
Legal profession and woman, 680 ; definition of
*• rags,” 991
Le'gb, Mr. T., death of, 634
Leighton, Dr. P. A., and Dr. S. A. Owen,
medullary symptom-complex, 1024* 1087
Lelean, Prof. P. S., Sanitation in War, third
edition, 1919 (review). 514
Lemarchand, Surg Sub -Lieut. F. W., R.N.V.R.
(see Obituary of the war) •
Lemon as a specific for glossitis and stomatitis,
760
Lemo.i juice or lime juioe, 128, 164; juice,
chemical competition. 895
Lenzmann’s Manual of Emergencies. Medical.
Surgical, and Obstetric (Dr. J. Snowman)
(review), 513
Lepers in Canada, 232; in India, 240, 760
Lcpine, Prof. J , Mental Disorders cf War
(review), 1074
Leprat, Dr. L., bacteriology of influenza, 760
Lessons of a great epidemic, the pathology of
influenza (leading article), 25, 242; epidemio¬
logy and clinical aspects (leading article), 72
Lessons of the War (Sir A. E. Wright). 489
Lettsomian lectures on jaundice (Dr. W. H.
Willcox), 869, 929; (leading art icle), 942
Leucocyte count in Influenzv, 156
Leven, Dr. G., lemon as a specific for glossitis
and stomatitis, 76); increase of weight
effected by diet of 1 >w calorific value, 940
Levithln and Allied Substances, the Lipins
(Dr. H. Maclean) (review), 745
Lew in, Dr. Octavia, treatment of adenoids,
323
Lewis, Capt. D. S., M»j. H. J. Thursfteld, Maj.
A J. Jex-Blake, Capt. M. Foster, and Col.
T. R. Elliott, InvaUdism caused by P.17.0,
and trench fever, 1060
Lewis, Dr. F. W. aspirin poisoning, 64
Lewis, Dr. T., Soldier’s Hcirt and the Effort
Syndrome (review', 142
Ley, Mr. G., extra-uterino pregnancy con¬
tinuing to term, 611
Leyton, Dr. O., transfusion in diseases of the
blood, 379
Lhermltte. Jean, and nenri Clnide, gunshot
concu slou of 6plrml cord, 67
Library, a Cretan. 488
Life and health in the Highlands, 483
Life, origin of. work of the late Charlton
Basiian, 951, 952, 1000, 1001, 1044, 1092,
1133
Ligat, Mr. D., significance of surgical value of
certain abdominal reflexes, 729
Lille, health of, during German occupation,
430
Lllllng*ton, Dr. C.. women chiefs, 635
Limb, lower, prosthesis of, 149; upper, com¬
pound fractures of (Mr. B. G. Sieaingcr).
365; in lifu of, 921
Limbs, artificial (Py Q). 320. 321
Lingual cancer, etiology, 75, 123
xii Thb Lancet,]
INDEX TO VOLUME I., 1919.
Up, epithelioma cf, radium treatment, 388
Lipoma, aubperitoneal. 1072
Lip#, artificial cyanosis of, 529
Liquor In Ontario, prescribing of, 949
L, ni e w Capt, rS*i B " M C -» Al * 8 tr. A.M.O. (
Obituary of the war) v
Lister, Col. W. T., and Capt. M. L. Hine v
evuUion of optic nerve. 895; appointed
anr«eon oculist to His Majesty's Household
Lister Institute of Preventive Medicine
(annual ropor t), 1C89 jucuicujo
L’ltalia Sanitaria (review), 748
Llveing. Dr. E , obituary, 633
Liver, maldevelopment of, 744
S°tli,) Mod ' C * 1 Ia,1Uutlon (•« Medical
ffrfX ' 10 . 01 u ^ ve " u /' Paae*Iiate, 126. 636
Lirtogston. Dn O It., Dr. J. W. Macklc, and
woinde .^1 y> tr “ tment ot «““ b <*
LtWng.tone College, Leyton, appe.Kor (unde.
Llewellyn, Dr. L. J., and Dr. A. B. Jones
Pension# and the Principles of their
Evaluation (review), 799 tce,r
“H&. wi J ' ? ■ "liver In trench
fever, 583; subacute trench fever, 791
L oyd, Mr. LI.. lessor sof the louse, 118
Local Government Board food in&D?ctIon IRQ •
Regulations, new, for control and treatment
of certain epidemic diseases, 309
Local Government (Ireland) Bill, 1008
Lockhart-Mummery, Mr. J. P., ^ Dr< D
Pennington, adhesions of the sigmoid 254 •
ehronfc secondary colitis, 1045 ** '
Looomotor Apparatus the Result of War
We^, 7 D ^ abilit5eS ° f the (Prof ‘ A. BroL)
P r : Movements, Troplsms
and Animal Conduct (Monograph on Experi¬
mental Biology) (review), 745 ^
theVaT' 4 d ' S " *' A M C - (, “ 0bU “O’ °*
London Association of Medical Women, dinner
943; (see also Medical Societies) ’
London County Mental Hospitals (Py Q),
“?ty“?d. C lT3 n 7 ,M M#dlCaI
*T« d r.^ 8pltal Medi “' coii ®*»' i “ tnr «-
London Inter-Collegiate Scholarahlp Board
|ntrance scholarships and exhibitions, 232,’
London Panel Committee, meeting, 955
London School of Medicine for Women, post¬
graduate course, 725; scholars hip# gS?.
prize-giving, 1098 p8> *
l School
[July 6,1919
London School of Tropical Medicine, paae-Utta,
.£®“ d °” Temperance Hospl al, meeting. 485
•London J2 nl Y or *lty, appointments, & • nass-
llsts, 687, 1003, 1051; Senate of Pnf T
Schuster and Dr. W. C. Unwin reappointed
members 577; King’s College. Department
5*, Psychology, lectures, 769; University
College, Prof. (j. E. 8 m 1th appointod to
%&$££**!**' 989; 0 ,llege Bxwpital and
Medical School war memorial, 999
Louping ill, 350
J'°“*t'‘ e , 5 , s , on " O' the. 118 ; hatching of. 1132
Louvain library, re-stocking of. 1042
Love. Dr. J. K Diseases of the Ear In School
Swlrevie "',^ 7 on the Preveutlon of Deaf-
Lozenges, “cofectant,” 24
Luckes, Miss Eva, death of, 306
Obitul^of thewm) M ' Austr ’ AMa <*«
to £'lXs 1 ^^a^55 bro • 8,,lDa, ,0VW (8,r
Lumsden, Dr. T.,immunotranafusion ,814
Lunacy In Egypt, 117
Lunacy reforms, suggested, 229
Lunatic asylum discharges (Py Q), 442
Lunatics, pauper, treatment of (Py Q). 686
Lung disease, chronic, and influenza 281 314 •
8 an fi r ©ne. collapse therapy of, 902 ’ ' *
Lung-puncture in treatment of Influenzal
pneumonia (Dr. M. Bcnaroya', 742,816
Lupus treatment of. picric brass preparations
_ (Ur. H. A. Ellis), 415, 430,528, 635 p * w,ona
Elements of the Science of
Nutrition, third edition (review) 745
Luton, Capt. W. F., Can. A.M.C. (see
Obituary of the war) ' 8ee
Lymph for public vaccination (Py Q). 484
Ly .X“^ rlsht mao
Lymphangeloma of tongue, 940
'Lymphoid tissues, tuberculosis, and Bunligh*,
Lysorophus, 946, 1093
MacAIIster, Sir D., reappointed member of
S'?s^ ernin f of the Imperial College
of Science and Technology, 585
Mscalpine, Mr. J. B., Wheelhouse'a operation,
334 ; urethral nozzle, 614
McBride. Dr. P., war deafness. 157
McCaul. Mr. G. B., death of, 368
MacCombie, Dr. J.. death of, 823
P«“ce D 10ia 1«3 8 ° me Pltf,IU 0f 8#neral
M of n th'; ^r J K H .;t T (Z!rw) Su 43i ,> ' 7 and DlM “ e8
AiVbuu. siS 1 " 10t *" r8 ' portnUt 01 s,r
MeDougall, Dr. A., the “,pectram”of epilepsy,
M 1028™"’ Dr ‘ F ' P -’ «“<»'* of delusions,
M r„ <rf 0 t rr‘ 1 V Ml f , , M,,r *'. r ® t .'. Slm P ,eBe J5 ln nln8>
Js,., 1 * 1 ,® Training of Mentally Cefectlfe
Children (review). 566
McEnt«re, Lieut. Col. J. T.. Mona Star
E.A.M.O. (see Obituary of the war) '
P r ' A „ W Loc » l Government
Board food Inspection, 189
Macfie, Dr. R 0., Odes and Other Poems
(review), 1117; War (review), 1119
? r A *’ Rnd Dr - J - Prledenwald,
perforation in cancer of the stomach, 272
McGowan, Dr. J. P., mutation of organisms of
the coliform-typhoid groups, 466
"chemlatry preview)*: Kfi 8 Mi°ro"copy and
D,8ea “ * nd Eam6d y° f
Ste-I., prognosis In cardiovascular
affections, 715
M o kl £ D r T i f A - H. Tubby, and Dr.
woundsf25^ ^^?,,fc0n, tre&tmeat of « UMhot
Mackie. Capt. T. J., Capt. L. F. Hirst, Col. A. H.
flivirie' 83^ A ' R - F ®>*guson, action of
M Sf the n wSr) CaPt ‘ P> L * R A M ° ( 8e « Obituary
M«ckinnon, Dr Doris, and Dr. W. Fletcher,
chroniclty of dysentery infection, 1038
Maclean. Dr. H., Lecithin and Allied Sub-
stances, the Lipina (review), 745
Marine Hand, Dr B., intermittent hydrops
artlculorum, 463 ^ p
Mwleod, Dr. N., whooping-cough, treatment,
Macleod, Prof. J. J. R., Rn d Dr. R. G. Pearce.
? og 7 Rnd B,0 chemlstry in Modern
Medicine (review), 513
MacMahon, Mr. C. f gunshot wounds and other
affections of the chest, 697
Macnamara, Mr. N. C., obituary 43
MacpbaH, Dr. J. M., Eyes Right, Papers for
Teachers and Parents on the Hygiene and
Treatment of the Eye (review), 984
dlsesaB ^81 D ‘ M ’ influenza and chr< >nic lung
Macul®, disease of both, 613
Me Vail, Dr. J. C., half a century of small-pox
and vaccination, 449 p
McWalter, Dr. J. C., are relapses of bacillary
dysentery frequent ? 529 y
M C W fwm , ,J ) w A - T -- Dr - H - B ' rb « r - *"<1 Dr.
or react,on - * Cr,Uc,m
Magistrates, medical, 87
M Sf th 8 ew^ spt ' JH ' H - A - M - c - outmr y
Msklns, Sir G. H., r61e of consulting surgeon
i"tWe\ < U 2 ? n<1 ' 8h '* CtUr0> ' 1099;
M * b 'V. 8 ’S |r H . And Dr. N. Moore. po.ltlo D
of the demobilised practitioner, 439
Malaria and Its Treatment, in the Line snd at
th| Base (Capt. A. O. Alport) (review),
M i5? ,r,a and Wassermann reaction (Dr. J G
Thomson and Mr. C. H. Mills), 782
symptoms, 222 ; recurrent,
60S ; and trench fever (Dr. G. Ward), 609; in
England, risk of, 677; during the war (G
Palsseau), 749; care and treatment (Sir
R. Ross), 780; distribution of soldiers
temporarily unfit through (Prof. B
Jeanselme), 751: studies in treatment, 756 •
’"V 903 ,:. ma,, * n «nt tertian, 1126 '
Malay States health reports, 1011
Mr ‘ J 'a D ; 8 fa>tU8 and Placenta, 612
Maldevelopment of the liver, 744
v* re K Pa,r k°Ii? r * B - D. Telford and
Mr. F. G. Norbury), 177
^aUormatlon of the extremities, hereditary
Crawford), 979 b9r,ord “ d ^ G. Z
Malignant tertian malaria, 1126
MaBett, Dr. F. B., practice of tl e absentee.
Malone, Dr. A. E., and Dr. J. G. Wardrpp,
m 6 ,renk chyIothorax following trauma,
Malta fever, other agglutinins In oases of.
formation of (Dr. L. T. Burra), 64
323 h08ter and DlstrIct Eadlnm Institute.
Manchester Literary and Philosophical Society
(see Medical societies) J
Manchester University, pass-lists, 536
Mandibular bone grafts, 181
Mange, parasitic, in horses, 280
“evioW^®' J " M °- A 8Urg “ n In A ™“
^* 393 hanf ’ P * T '' pr °P hylaxl8 l n Influenza,
Marriage-rate of South Australia, 350
Marsden Dr H S., obituary, 530
Sundiy. W93 ^ M,y0r - Ho •P“ , ‘ ,
Marshall Prof. C. R., appointed to the Regius
chair of Materia Medics and Therapeutlos ln
the Utilverslty of Aberdeen, 854. 1003
Martin, Capt. S., R.A.M.C. (see Obituary
I of the war) J
M ^i n ’ L r 0, f!f’ L. a - nd Au « us te Pettit, Splro-
chetose Icterohemorragique (review), 800
Martinet, Dr. A., Diagnostic Clinique
(lixamens et Syraptomes) (review), 984
C&l?ona;;tl 0 a r nfn33 Ot “ ,e - W ° rk rf Ut#
Masks, experiments on (Dr. H. M. Leete) 392
TharleS* 8 '' th6,r
Mwsage as a Career for Women (Beatrice M.
Goodall-Copestake) (review). 617
Massage, direct, of the heart, 658
“ 1002 ™’ MtM HeleD ’ ,ead ln the casserole,
M “diSl, 339 raW ° M ' radIoal and modified
M H rt ®J ia fi I ^ ,Ca n a M d Th ®»Pentics,an Introduc-
tlon to the Rational Treatment of Disease
(Dr. J. M. Bruce and Dr. W. J. DIIIIm)
eleventh edition, 1918 (review), 112 *
Maternel and Infantile protection In Paris
th ® war 38; mortality of childbirth
“tlel*). e 8<K ,C * °' mlt,wl,6r y ('""ding
Maternity and Child Welfare: Mothers'
pensions in the United States of America,
191—International Congress of Babv Weeks-
SavingchHdHfo in U.^A., 192-CondltioSi
of childbirth in India, 435— Maternity
nursing ln London, 436-Child welfare in
New Jersey; Importance of pre-school
period to the school child; Maternal nursing
considered from its evolutionary and
biological aapecta, 811-Instruotioh and
York r cIty°996 f expectant “ethers In New
Maternity and child welfare (Py Q), 321
M 5£? rn ? ty of L° nd °n, Royal, report,
765 ; hospitals, institution of, 9J2^
of t the W w,? Pt - 8> R A M C - (*« OW‘“vy
Maudsley leotureshlp, 1023
Maxted, Capt. G., malignant tumour of the
pituitary body, 613
May, Dr. P. f Chemistry of Synthetic Drugs.
second edition, 1918 (review), 224
Mayer, Dr. L„ Orthopaedic Treatment of Gun¬
shot Injuries (review), 23
M 528 hen> Dr ’ N,,co PP ertreatm e n t of lupus,
M £b 11 j) ^ mbHng erythema (Dr. F. H.
Meatless’ dietary in epilepsy, 1046,1093
Medical administration, successful, essential
principles of, 356, 441
Medical appointments In Ireland during de-
moblllsation, 18; reform In Ireland, 274;
demobilisation in France, 477; men, denuv
blllsation of (Py Q 1 ,321,360. 535
Medical aspects of flying (leading article), 227 •
314 8 ur 8 i c *l developments of the war)
“ggi- “ rr '°“l“m »nd biology (Mr. T. G.
Hill). p3, 312; research In India, 311-
r ® 8 f a f c v h PlHce in the State (leading
article), 517; Research Committee, medlciS
6 ?? ! , re8 ® arch * coordination
by the State (Dr. D. 0. Watson), 989, 992
Medical Defence Union, notification and pre¬
vention of specific diseases, 362
Medical Diary, 49. 88 . 126,162,201.241 28’ 329
354, 404, 44$. 487, 538, 590, 642, 686 , mV 771
824, 866 , 920, 961, 1012, 1052, 1097, 1138
Medici education, reform of (leading article),
ofI; evidence and trials in camerd (leading
S?U(P^i,M 8 ,d ‘ and dl “ b " ity
Medloil men and income-tax (Py Q), 360;
students, supply of, 391; men inemllltary
^ ^ V men on Dispersal Boards
(Py Q), 820; mission to Poland, 944; and
share holding, 1045, 1093
Medical Missions (United) Exhibition, 1140
The Lancet,]
INDEX TO VOLUME I., 1919.
[July 5, 1919 xiii
Medical officer, factory, in war and peace, 447 ;
Regimental, the Whole Duty of (Capt
P. Wood) (review). 466; to the Board of
Customs (Py Qi, 1009
Medical officers of hea th, reports, 478, 581
Medical Officers of Schools Association, 47;
assistant, of asylume (Py Q). 359; officers in
Army of Occupation (P\ r Q), 402; officers, t
women, in military hospitals (Py Q). 442;’
Irish Poor law, salaries of (Py Q), 442 ; de¬
mobilisation of (Py Qf, 485, 641 ; naval,
temporary, gratuities to (Pv Q\ 485;
temporary, release of (Py Q), 686; Scottish
parochial (Py Q), 918; Territorial, and
demobilisation (Py Q). 918, 960 ; officers
abroad, relief of (Py Q), 959
Medical Ophthalmology (Dr. A. Knapp)
(review), 23; and Surgical Reports of the
Episcopal Hospital (review), 23; Curriculum,
Enquiry into, by the Edinburgh Patho¬
logical Club (review), 426 ; Electricity,
Bsseutials of (Dr. E. P. Cumberbatch),
fourth edition, 1919 (review), 514
Medical Parliamentary Committee, 120;
Members of Parliament, dinner. 281;
arrangement of conference, 634, 705, 808,
817, 858 ; progress of (leading article), 801 ;
candidates for Parliament, 35; representa¬
tion in the House of Lords, 819
Medical practitioner, outlook of (leading
article), 145; practice in France, protection
of, 477
Medical practitioners’, civil, war services, list,
438
Medical profession, future of, 141 ; meeting at
Wigmore Hall. 240, 362 ; and the trade union
question (leading article:, 345, 397; and
Chief Secretary for Ireland, 812; meeting
of, In Edinburgh, 1C40
Medical Quarterly (review), 468
Medical service, State, 141, 312; school In the
Far East, 308; in the Highlands and Islands,
819; scheme for development of, 820;
Services Bill (loading article), 941; Bill
(Py Q), 959; service, industrial, 1129
Medical Sickness, Annuity, and Life Assurance
Friendly Society’s report, 637, 915
41 Medical treatment" of empyema, 1127
MEDICAL SOCIETIES.
British Psychological Society.— Psycho¬
logy end medicine, 889
Child Study Society.— Home v. institu¬
tional training of young children, 615
Liverpool Medical I institution.— Annual
meeting and report, 183 —Mutat'on of
organisms of the coliform-typhoid groups ;
Diagnostic value of the Wassermann reaction
In syphilis, 466
London Association ok Medical Women.—
Future of the medical profession, 141—
Exhibition of cises, 616, 847—Effect of
industrial employment upon women, 465-
Medical inspection of secondary schools, 616
Manchester Literary and Philosophical
8ociety.— The bird's brain, 616
Medical Society of London.— Gonorrhoea
of genito-urinary passages, discussion, 219 —
Intrinsic cancer of larynx, 263—Congenital
stenosis of pylorus, 380—Exhibition of cases,
700—Annual oration, 846—Election of officers,
847
Medico-Legal Society.— Position of medicine
in the State, 797
Medico-Psychoi.ooicalAssoctation of Great
Britain and Ireland.— Quarterly meeting,
362—Maudsley lectureship; Genesis of delu¬
sions, 1028
JJorth London Medical and Chirurgical
Society.— Relation of pathology to clinical
medicine, 300
North of England Obstetrical and
Gynaecological Society.— Exhibition of
cases and specimens, 22, 301—Extra-uterine
pregnancy; Radical cure of complete
procidentia, 22—Advanced extra-uterine
pregnancy, 301— Tuberculosis service, resolu¬
tions passed, 665
©PHTHALMOLOCICAL SOCIETY OF THE UNITED
Kingdom.— Abi trophy of the retinal
neuro-epithelium or “retinitis pigmentosa” ;
Results of double scler.ciomy operation for
glaucoma; Future o* ti aucoma operation;
Contracted sockets, 893—Stereoscopic vision ;
Bowman lecture on plastic operations on the
orbital region ; Eyesight and education, 894
Hoyai. Academy of Medicine in Ireland
(8ECTION) —
Obstetrics.— Exhibition of cases and speci¬
mens ; Abierhalden’s pregnancy reaction,
110—Endothelioma of ovary; Exhibition of
specimens, 264
Boyal Institute of Public Health.— Pre¬
vention and arrest of venereal disease in the
Army, discussion, 109
Royal Sanitary Institute.— Conference on
postwar development relating to public
health, 464
Royal S hifty of Medicine (Sections).—
Management of venereal diseases in Egypt
during the war, 140—Admission of pensioners
to civil hospitals, 179-Shock, discussion,
256
Jmesthetie r .— Exhibition of cases, 658
EUctro-therapeutics. — Electrical methods
of measuring body temperature; Electro¬
cardiograph, 564
Medicine — Apyrexlal symptoms of malaria,
?22—Transfusion In diseases of the blood,
379—The epidemic, pneumonia in Macedonia,
794
Obstetrics and Gynxcology. — Reconstruc¬
tion in i ho teaching of obstetrics and gynae¬
cology to medical students, discussion, 253—
Foetus during spontaneous evolution ; Extra-
uierine pregnanov continuing to term;
Specimen shown 105 years ago; Four cases
ol full-time ectopic pregnancy, 611— Con¬
tinued high maternal mortality of child¬
bearing, 796—Obsteffic helper. 797—Exhibi¬
tion of c vses and specimens; Subperitoneal
and retroperitoneal lipoma, 1072
Ophthalmological and Laryngological .—
Injuries and diseases of the oibltand acces¬
sory sinuses, 614 , 699-Exhibition of slides,
699
Ophthalmology. — Retinal degeneration ;
Ivory exostosis of orbit, 299—Exhibition of
cases and drawings; Leber's atrophy,
changes in solla turcica; Sympathetic oph¬
thalmitis, 300 —Exhibition of cases and
specimens, 613, 1072—Malignant tumour of
the pituitary body ; Migraine, 613
Otology. —Deafness associated with the
stigmata of degeneration, 182—Radical and
modified radical mastoid operation, 339—
Septic infection of lateral sinus after Injury
at operation, 340—New theory of bearing,
510— Exhibition of cases and specimens, 893
Pathology.— Diffuse emphysema of the
wall of small Intestine, 263—Polymorphism
of malignant epithelial cell. 743
Study nj Disuse in Children.— Exhibition
of cases, 665, 744, 940
Surgery. — D ne-graftiDg, 181—Carcinoma
of appendix, 845
Scottish Otological and Laryngolooical
Society. — Clinical meeting; Election of
officers, 1131
SocitfTfe de Biologie. Paris.-S ummary of
papers, 21, 223, 301, 424, 565, 798, 847, 940
Soct£te de Thkrapeutique, Paris. —
Typhoid fever treated by colloidal Iron;
Treatment of Influenza and Infectious
diseases of lymphotherapy and hremato-
therapy; Hypodermic injections of euca¬
lyptus oil in Influenza, 424—Ingestion of
adrenalin and intravenous injection of
colloidal quinine ; Bacteriology of Influenza;
Lemon as a specific for glossitis and stomat¬
itis, 760—Chemical composition of lemon
juice; Action of hypochlorites on pleural
fahe membranes; Fixation abscesses In
influenza, 895—II.Tinatoglobinuric bilious
fever ; Increase of weight effected by diet of
low calorific value, 940
Tuberculosis Society.— Practical remarks on
tuberculosis in relation to the upper air and
food passages, 223— Treatment of tuberculous
glands, 424— Acute pneumonic tuberculosis,
615— Tuberculosis officers and panel practi¬
tioners, 895— Tuberculosis In relation to a
Ministry of Health, 1027
West London Mfdico-ChirurgicalSociety.
—Exhibition of cases and specimens, 300-
Importance of symptoms, 480
MedicAl Society of London and women, 851,
894, 989 ; (see also Medical Societies)
Medical treatment of children in Ireland, 401;
Bill (Py Q), 534. 685, 770, 819; inspection In
factories (Py O), 402; women and the War
Office (Py Q), 402; inspectors of Home Office
(Py Q), 402; profiteering, alleged, 526; in¬
spection of schools in Ireland, 577; (PyQ),
641, 6S5 ; demobilised men (Py Q), 640
Medical unanimity and public spirit, the State
and the doctor (Sir H. Morris), 165; tradition,
the. 846
Medicinal herb-growing, 1053
Medicine and the Law.— Illicit traffic In
drugs; An ingenious impersonator, 36-
Frost v. King Edward VII. National
Memorial Association for the Prevention,
Treatment, and Abolition of Tuberculosis,
37—Irregular sale of poisons; Medical
practitioners and the detection of crime,
120—Inquest on “Billie Carleton,” 236—Dr.
A. G. Biteman, death of, 679—Case of De
Veulle; Woman and the legal profession;
Trial of Col. Rutherford ; Case of Dr. M. W.
Cohen, 680—Possession of cocaino; Incon¬
clusive inquest: Notification of ophthalmia
neonatorum, 948—*• Ragging ” cf a nurse,
949 - Lay members of mixed committees and
medioAl questions ; Case of Henry Perry ;
Crimiual or moral imbecile; Ritter v.
Godfrey, 1041
Medicine, a fellowship of (leading article), 26;
Fellowship of, emergency post-graduate
facilities. 189.400,477; Inter-Aided Fellow¬
ship of, 152; teaching of (Dr. W. H. White),
31; sanitation, and health in India, 127,163 ;
and the St*te($ir H. Morris), 165; and the
State (leading article), 185
Medicine, the Practico of (Sir F. Taylor)
eleventh edition, 1918 (review), 22; Clinical,
System of (Dr. T. D. Savill), fifth edition,
1918 (review). 66
Medicine, teaching of (loading article), 227 ;
Parliament, and public (leading article), 267,
312; In the House of Commons. 320;
nationalisation of, 476; position of, in the
State, 797 ; social, in Vienna, 921
Medicines, patent (Py Q), 401
Medico-legal Society (see Medical Societies)
Medico Psychological Association of Great
Britain and Ireland (see Medical Societies)
Medullary symptom complex (Dr. S. A. Owen
and Dr. P. A. Leighton), 1024, 1087
Mellai.by, Dr. K., rickets, experimental investi¬
gation on, 407
Melville, Col. H. G., I.M.S. (see Obituary of
the war)
Memorandum, revised, on tetanuB, 1125
Meningeal hremorrhage in typhoid ftver, 519
Meningitis, pneumococcic, primary, 623;
eerebro-spinal (Mr. A. S. G. Bell), 887
Meningococcal rheumatism aud arthritis (Dr.
P. Sainton), 1080
Menlngococcic septicaemia (Sir H. ltolleston),
541
Meningococcus, purulent broncho pneumonia
associated with, 81; broncho-pneumonia in
influenza (Dr. W. Fletcher). 104,124
Meningococcus, the, a recent chapter (leading
article), 1083
Mental defectives in institutions, death-rate,
78; (Py Q). 443; After-care Association, meet¬
ing, 395, 462; disorders associated with old
age (Sir G. H. Savage). 1013
Mental Disorders of War (Prof. J. L<?pine)
(review), 1074
Mental statistics in Canada, 39
Mentally deficient, accommodation for (Py Q),
359; Defective Children, Simple Beginnings
in Training (Miss M. Macdowell) (review),
566
Mercier, Dr. C., Crime and Criminals (review),
382
Mercury In malaria, 903
Merklen, Dr. P. t fixation abscesses in influenza,
895
Mesentery, two tumours of. 111
Mesopotamia, housing in, 301
Metcalfe, Capt. G. C., K.A.M.C. (see Obituary
of the war)
Methylated spirits and women (Py Q), 401
Metropolitan Hospital Sunday Fund (leading
article), 1032; the Lord Mayor and, 1093
Metropolitan water supply during July,
August, and September, 1918, 90; during
October, November, and December, 1918,363;
during January, February, and March, 1919,
1098
Metrorrhagia in Influenza, 156
Meyer, Prof. H. H., and Dr. F. Ransom,
tetanus without trismus, 117
Microscopic slides, method of obtaining good
surface, 922
Microscopy and Chemistry, Clinical (Prof.
F. A. McJunkin) (review), 1028
Middlesex Hospital, meeting, 639
Midwifery, Text-book of, for Students and
Practitioners, second edition, 1918 (review),
982
Midwives and burial certificates (Py Q), 959
Migraine, 613
Migration of a round worm into the ear, 28
Military College, new, Toronto. 39 ; medical
officers and civilian practice, 233
Military Surgeon (review), 112, 468
Milk, Examination for Public Health Purposes
(Mr. J. Race), first edition, 1918 (review),
514
Milk-supply of Dublin, 192; pure (Py Q) t
864
Miller, Dr. H. C., war neuroses, 766
Mills. Mr. C. H., and Dr. J. G. Thomson,
malaria and Wassermann reaction, 782
Milne, Capt-. A. J., South African M C. (see
Obituary of the war)
Milne, Mr. J. S , Neurasthenia, Shell Shock,
and a New Life (review), 702
Milroy lectures on half a centuiy of small pox
and vaccination (Dr. J. 0. McVail), 449
Ministries of Health Bill, 121
xhr The Lancet,]
INDEX. TO VOLUME I., 1919.
[July 5,1919
Ministry of Health Bill. 319, 359. 360. 401, 442,
483. 532, 586, 641. 818, 863, 917, 957, 959, 1008;
Action of the General Medical Council; Con¬
joint action of the English Colleges, 351 —
Views of the Society of Me Ileal Officers of
Health, 394— Inapection of school children
(loading article), 471—Action in Belfast,
687
Ministry of Heilth, 281; (Py Q), 320 ; aepnate
Bill for Scotland (PyQ). 361; and Ireland
(Py Q). 359, 400, 442, 475. 476. 577, 582. 631,
909,1040; and factory surgeons, 432; Soottisb
Committee, 433; for Egypt (Py Q), 485;
resolutions of the Scottish medical profession,
523; statement by the Royal Cj liege of
Physicians of Edinburgh, 523; and Belfast
doctors, b 77; and liquor control (Py Q>, 587;
-Indian, 998 ; the next stage (leading article),
1031
Ministry of National Service, medical w >rk of,
319; Sir A. Geddcs thanks the Medical
Department, 580
Ministry of Pensions, decentralisation at, 665;
medical appointments under, 931
Missiles as emboli (Sir J. Bland-Sutton), 773*
913
Missing officers and men (Py Q). 320
Mitchell, Mr. C. A., Ellble Oils and Fats
(review), 848
Mobilisation and demobilisation, medical work
of the Central Madid d War Committee,
193
Model Homes Exhibition, 963
Molr, Mr. J. R., a freak of nature,
723
Molybdeno-tungsten arc in treatment of
suppurative lesions (Mr. B. M. Young),
Montreal, University of, 1132
Moor, Mr. C. G., ami Mr. W. Partridge, Aids to
the Analysis of Foods and Drags, fourth
edition, 1918 (r.-view), 848
Moo-e, Dr. N., History of St. Birtholomew’s
Hospital (review), 425; and Sir G. H. Makins,
position of the demobilised practitioner.
439
Moore; Mr. R. F., sympathetic ophthalmitis
with fundus changes, 300
Mdrat, Prof. J.-P., Traits do Physiologic
(review), 702
Morsx, Prof., plastic operations on the orbital
region, 894
Morbus cordis, congenital, with polyeythtomla,
Morgan, Cspt. W. P. t adjustable pipette for
automatically measuring out ’small volumes
of liquid, 1120
Morison, Oapt. R. McK., 1U.H.O. (see
Obituary of the war)
Morphia, British-made (Py Q>, 864
Morris. Mr. B. J., Employment Opportunities
for Handicapped Men in the Optical Goods
Industry (review), 982
Morris, Sir H., plea for medical unanimity and
public spirit, the State and the doctor,
165
Mortality and the French Auxiliary Atony
Medical Corps, 540
Mortimer, Mrj J.* D. f '‘shook" (so-called),
Morton, Dr. R., malignant stricture of the
(esophagus, 300
Mosquito problem in Britain, 447; lsrv* In
streams, destruction of (Mr. A. K. Henry).
O Q *
Mothercraft training for girl?, 538
Motor mechanics for cripples, 76 ; nerves during
operations, testing of. 989
Mo* orlng—present and future, 29
Mott, Dr. F. W., Archives of Neurology
and Psychiatry (review), 302; war neuroses,
Mottram, Dr. J. C., Dr. 8. Russ, Dr. Helen
Chambers, and Dr. Gladwys M. Scott
experimental studies with small doses of
X rays, 592
Moure, Dr. P., and Dr. E. Sorrel, surgical com¬
plications following exanthematlc typbu*.
Mouth, Normal and Pathological Histology of
(Mr. A. Hopeweil-Smtth) (review), 897
Mucoid forms of paratypho'd, 237
Muir, Dr. K„ Kala-azir, its Diagnosis and
Treatment (review), 142
Muir, Prof. H., and Prof. J. Ritchie; Manual of
Bvcterlology, seventh edition, 1919 (review).
467
Multiple epulldes, 744
Munby, Mr. W. M., and Mf. A. D. E. Sbefford,
bone-grafting'operations, 1070
Munition workers, female, tubnrculosis In. 432
Murphy, Sir S. F., appointed to represent His
Majesty’s Government at the forthcoming
congresses of the Ontario Medical Associa¬
tion and the American Medical Association,
9C8
Murray, Dv. G. R., comparative pathology of
Influenza, 12
Murray, Dr. L., sessile red fibroid, 22
Murray, Capt. R. W. S., R.A.M.C. (see
Obituary of tho war)
Musoles, blood-supply of (Dr. J. Campbell and
Dr. C. M. P<mnefa’her), 294
Musk in influenza, 529
Mustard gas, nystagmus caussd by (Mr. R. P.
Ratnaker), 423; its brief but inglorious
career, 471
Mutation of organisms of the coll form-typhoid
groups, 466
Myelitis, acute ascending (Dr. D. K. Adams),
462
Myers, Dr. B. E., instruction in hydrology.
635
Myers, Dr. C. S.. study of shell Bhock,5l
N
Nairn, Mr; R., recent epidemic of “ Spanish ”
influenza, 635
Nasal douche, 50; obstruction in aviators (Dr.
D. Guthrie), 136; blo<*age, invalidism forl5
years, 156
Nash, Mr. W. G., unilateral hydro!horax due
to disease beh>w the diaphragm, 378
National Couferenoe on Infant Welfare, 895
National Food Reform Association, dietaries,
22
National Hospital for the Paralysed and
Epileptic, meeting. 539; postgraduate
oourse in neurology, 769
Nati >nal League for Health, Maternity, and
Child Welfare, meeting,728
National Medio*! Service, what is it worth ?
279
National register of population, 147
National Sanatorium Association, Canada, 39
Naval medioal officers, temporary, gratuities
to (Py Q). 485
Neecb, Dr. J. T., the slum-dweller and the
slum-owner, 429
Nephritis, Chronic, Renal Functions In,
Studies on (theaiB by Pasteur-Vallory«Radot)
(reviewed by Prof. C. Achard), 752
Nerve and muscle, faradic stimulation of,
during operations (Mr. H. Platt and Mr.
B. 3. Brentnall), 834
Nerve-strain in London children, 540.727
Nerves, motor, testing during operations, 939
Nerves, Peripheral, Anatomy of (Prof. A. M.
Paterson) (review), 1074
Nervous system, central, hysterical element In
organic disease and injury of (Dr. A. F.
Hurst and Dr. J. L. M. SyranB), 369; com-
pllcitions of exanthematic typhus (A.
Dovaux),567; system, the sympathetic. In
disease, role of (Dr. L. Brown), 827,873, 923.
9^5; system, autonomic, arrangement of,
951
Neurasthenia, Snell Shock, and a New Life
(Mr. J S. Milne) (review), 702; and shell
shook (Py Q). 725
Neurological Clinics (Dr. J. Collins) (review),
302
Neurologv and Psychiatry, Archives of (Dr.
F. W. Mott) (review), 3)2
Neuroses of the war (leading article), 71; war
(Dr. F. W. Mott). 709, 768
Neurosis, composite, analysis of (Dr. F. Dillon),
57 ; war (Dr. W. Brown), 833
Neuroayphilia, Modern Systematic Diagnosis
and Treatment in 137 Case-histories (Dr.
B. K. Southard and Dr. H. C. Solomon)
(review), 301
Newcastle Medical Institute and Social Club,
1098
Nowoistle-on-Tyne Royal Victoria Infirmary,
address by Sir K. N. Burnett, 362
New houses for old (leading article), 753
New Hunteriana, 269
New IxvEtrrioits-
Anesthetics, a nasal air-way, 1030
Apparatus, new “ 606,” 618
Bed for fractures and general hospital
purposes, 266
Buchner's ana?rcbic tube, raolifted, 226
*• Dropped-foot" appliance, 142. 284, 468
Glanl dissector, new pattern, 858
Nltrous-oxide-oxygen ether outfit, 226*
Pipette for automatically measuring oat
Binall volumes of liquid, 1120
Stretching tables for tlsxed thigh stumpe
after amputation, 984
Suture holder, 772
Urethral nozzle, 514
Newlln, Ms.j. G. E., future of American Red
Cross in Paris, 155
Newman, Sir G., appointed Principal Medical
Officer to the Local Government Board, 305;
status of (Pv Q). 918
New Year honours deferred, 755
Nbw Year's wish (leading article), 25
New York, Correspondence from —Recru¬
descence of influenza; New narcotic drag
law for New York State, 353—Prohibition in
the United States; Prohibition regulations
for New York, 354—Prohibition and the
medical profession; 523—Diphtheria in New
York City; Ssr A. Pearson in New York;
Health Insurance BUI and the medioal pro¬
fession of New York State. 524—International
Conference on Rehabilitation of the Disabled,
761; Hospitals for disable! men; National
campaign against Influenza; Drug situation
in New York, 813 - In aid of the tuberculous
poor; Medical and surgical developments of
the war, 814—Health of the Navy and Marine
Corps; National investigation .of the drug,
habit; Health report of New York; Dia¬
gnostic Hospital, New York; Venereal
disease and crime; Death of a well-known
war nurse; Prevention of typhoid fever, 950
—Drug addiction in tho United States;
Opposition to compulsory health insurance,
1090—VUit of foreign medical men to
America; Bill to restrict vivisection, 1091
Nias, Dr. J. B., obituary, 396
Ntcholls, Mr. F. L., born in a well. 364
Nltch, Mr. C. A. R., and Prof. S. G. Shattock,
diffuse emphysema of wall of small intestine;
263; the late Dr. Guy Black, 1003
Nitrous-oxide-oxygen eth-r outfit, 226, 231
Noble, Dr. T. P.', and Dr. A. B. Vine, peri¬
cardiotomy, 107
Noel, Mr. H. L. O., encephalitis letha-gica and
typhus,-156
Norbury, Mr. P. G., and Mr. E. D. Te’ford,
repair of the male uret hra, 177
Norman, Sir W., recent retirement of; 932
North of England Obstetrical and Gynaeco¬
logical Society (see Medical Societies)
Notes and Suort Comments.— Hospitals and
dispensaries in India, 1917-18; Treatment of
scurvy; Nasal douche, 50—Colonial health-
reports, 50, 89, 202, 242.324:433,591.644,772,
825, 1011, 1054 - Elec* rol> tic disinfectant in
1. fluenza; Oil of obenopodium for anky¬
lostomiasis ; Health teaohing; Metropolitan
water-supply during July, August, and
September, 1916, 90-; during October,
November, and December, 1918, 363—
During January. February, and March. 19U^.
1093—“ Arellano ’’ influenza mask ; Khaki
monotony, 90 — Health, medicine, and.
sanitation in India, 127,163—B smuth order;
Lemon juice or lime juice, 128, 164-New
methods concerning Imhotep (Asclepioo);
Use of creos >te in influenza, 123—Health and
radiant heat; A warning, 164 — Industrial
unrest and the new public healt h: Hygtenie
repair of the roads, 202—Lessons of the
influenzal epidemic; H >spital for Bngnor,
242—Physiology and the food problem. 283 —
Droppei-foot appliance; Health and alftt-
meats; Queen Mary’s Needlework Guild;
Treatment of alenol Is, 284—Laws of life;
Treatment of adenoids; Manchester andr
District Radium Institute, 323—Infanta'
tenacity of life, 324, 364—3 wksof reference.
324- The vital need, 363-Born in a well, 364
—Vital need, a third factor; Two XVII.
century physicians, 405-Summer time;
Total deaths from wounds in the great war;
Conference on influenza and its prevention,
406—Pictorial symbolism of reproduction,'
446 -Physiology and the study of diseases;
Sphagnum moss; Osteo-arthritis, 447, 592-
Mosquito problem In Britain; Factory
medical officer in war and peace. 447-Simple
aid In reducing paraphimosis. 448—Raffaele
Faolucd ; Cretan library; Osteoarthritis;
Life and health In the Highlands, 488 —
Mothercraft training for girls, 538—Cause-
or coincidence; Universal language of
quantity; Grain pests and scientific
accuracy, 539-Mortality in the Frenob
Auxiliary Army Medb-*i Cm; a; Nerve strata
in London children, 54*\ 727—Saccharose
injections in pilmonarv' phthisis, 540—
Need for a Food Board, 591—Safety of picrio-
brass preparations; Trie vn i • ss an impedi¬
ment; Carriage oi perishable foods; New
designs in surgied r^ ptim.* • ; Wanted, a
bungalow, 592— Infa'ii mortality and*hous¬
ing, 643-Practical war memorial; Lead line
on tailors’ gums, a dangerous practice; The
child as an inducement; Health and life in the
tropica ; Dry sweeping in railway carriages,
644—Composition of potatoes. 727—Electrical
training for disabled men ; National League
for Health, Maternity, and Child Welfare,
128—Acetone, alcohol, and benzene In the air
of certain factories; Suture holder; Queen
Alexandra’s Hospital for Officers, 772—Spirit
duty (voluntary hospitals) grant; A tensor;
Phbllc house reform ; Saccharose injections
In pulmonary phthisis; Chre of ' books in
Thb Lanobt,]
INDEX TO VOLUME I., 1919.
[July 5,1919 xv
large libraries, 825—Lanrey and war surgery
(Dr. W. G Spencer). 867, 923, 962-Need for
physical educate n, 867—New pattern gland
•dissector; Blind men on committees;
Claxton ear-c p; Imperial Antarctic Bxpedl-
‘tton; Wanted, a home; New reflex, 868 -
Social medicine in Vienna; Royal St. Anne’s
'School, Redbill ; In lieu of a limb. 921-
Bpidemlology of “ Spanish disease,” trans¬
mission of infection through fleas ; Ventila¬
tion in the tropics; Method of obtaining a
, good surface on microscopic slides;
Children’s Convalescent Home, Weston-
super-Mare; Toothless mother; Small hold¬
ings and the returned soldier, 922—Model
Homes Exhib'tlon ; Children of devastated
8erbla; Freak of Nature, 963—Society for
Relief of Widows and Orphans of Medical
Men; Case of a blind subject; Interesting
• experiment in rearing of calves on whey and
meals ; Supply of drugs, 964—Some pitfalls
•of general practice (br. H. M. McCiea),
1010, 1053—Medical students In Switzerland;
Ivory Cross; Malay States health reports,
1011 -Roman oculist seals; Guardianship
Society ; A correction, 1012-Medicinal herb¬
growing ; Typhus in Europe; Goat as a
milk supplier; Enham Village Centre,
1053—La Perdlta Sanitaria ; Fresh Air Fund;
Spare time service of the R.A.M.O., 1054-
How to start, and how to succeed, in general
practice (Dr. G. Steele-Perkin*), 1097—
Medical institute and social club for New¬
castle ; Prize-giving at the London School of
Medicine for Women ; Pepys on blood trans¬
fusion, 1038-Cornish centenarian, 1098
Notice, brought to (see Notice under War and
After)
Notification fees snd the Association of Panel
Committees, 439 ; of venereal diseases (Py Q),
685; of dysentery. 723 «
Nurses, hospital, sccv>mmodfttion for (Py Q),
770; Scottish, resettlement of, 812; war
gratuities to (Py Q). 1008; in South Africa,
bonus to, 1026;’ Nurses’ Registration Bill,
484, 587 , 640, 685, 819. 957; Cooperation,
meeting. 535 ; war, resettlement of, 1090
Nursing Register, the, 474,528; associations,
district, aud public health < Pv l^>, 686;
service, Inadequacy of (Py Q>, 82l
Nursing sisters as anaesthetists, 584
Nutrition. Elements of the Science of (Prof.
G. Lusk), third edition (review), 745
Nystagmus caused by mustard gas (Mr. R. P.
(Ratnaker), 423
O
Leftwicb, Ralph Wlnnington, M.D., O.M.
Aberd., 583
Llvelng, Edward, M.D. Comb., F.R.C.P.
Lend., M.R.C S., 633
Macuamara. Nottldge Charles, F.R.C.S.
Eng., F.R.C.S. Irel., 43
M*r»den. Robert Sydney, M.B., C.M. Biin.,
D So., F.R.S B, 530
Nias, Joseph Baldwin, M.D. Oxon., M.R.C.P.
Lend,, 395
Ogilvie, George, M.B., C.M., B.Sc. Blin.,
F.R.C P. Lond., 44
Paterson, Andrew Melville, M.D. Bdln.,
F.R.C.S. Eng., 314
Rouquette. Stewart Henry, M.A., M.B.,
M.Ch Cantab., F.R.C.S. Bng.. 579
Sawyer, Sir J., M.D., F.R.C.P. Lond,,
F.R.S. Edin., 239
Smith, Frederick John, M D. Oxon.,
F.R.C.P. Lond., F.R C S. Bng.. 860
S urge. William Allen, M.V.O., M.D.,
F.R.C.P. Lond., 633
Wiglesworth, Joseph, M.D., F.R.C.P. Lond.,
1012
Obituary or the War—
Ail ken, Cap*. R.. R.A.M.C., 275
Allen. Capt. W. R.. R.A.M.C., 436
Bailey, Capt. J. C. M., R.A.M.C., O.B.B.,
722
Bassett, Lieut. R. J.. R.A.M C., 581
Begg. Col. C. M.,C.B., C.M.G , N. Z. M.O.,
315, 531
Bingham. Capt.J, W., R.A.M.C.. 530
Brown, Capt. W. S.. H.A.M.C., 581
Browne, Capt. W. S., K.A.M.C.,683
Campbell, Capt. J.. R.A.M.C.. 912
Chenoy, Capt. F. B., I.M S., 398
Chowdhury, Cspt. H. G R., 486
Cocks, Capt. J. S., R.A.M.C.. 275, 439
Cotterlll, Capt. D.. R.A.M.C., 42
Cowper, Temp. Burg. W. P., R.N., 275,
439
Cromble, Lieut. W. M., I.M S., 358
Cunl ffe, Maj. E. N., R.A.M.C., 6J2
Duffy, Capt. J. V„ R.A.M.C., 194
Dwyer. Capt. J. J., D.S.O., H.A.M.O., 358
Kvntt, Capt. J. M., R.A.M C.,1091
Fedoxb.. Surg.-Cmdr. F.. R.N., 1091
Fisher, Surg. Lieut. B. G., R.N., 1046
Gibson, Maj. H. G„ R.A.M C. 315
Griffith, Maj. H. H., Austr. A.M.C.. 630
H&in*, Capt. C. C . Austr. A.M.C.. 768
Henley, Capt. K. A. W., N. Z M.C.,275
Holibs, Surg. Lieut. R. A., R.N.. 398, 530
Hojel, Lieut. Col. J. G., C.I.B., 683
Huet, Lieut. F. P. Y., Au6tr. A M.C., 438
Jameson, Maj. D. D., M.C., Austr. A.M.C.,
43
Oatmeal and Influenza (Py Q), 4*3
Obituary—
Alexander, William, M D. H.U.J., F.R.C.S-
Bng.. 530
Bennett, Lawrence Henry, M.A., M.B Oxon.,
M R.C.S. Eng.. 125
Benson, Charles M., M.D. Dub., F.R.C.S.
Irel., 858
Blakeway, Hsrry, B.Sc., M.9. Lend.,
F.R.C.S. Eng., 858
Blanchard, Prof.,315
Booth, James Mackenzie, M.A., M.D.,
C.M. Aberd., 860
Brlgstocke, Richard Whlsh, M.R.C.S. Bog.,
L. M., L.S.A., 437
Brotlie. George Bernard, M.D. St. And.,
F.R.C.P. Lond., 1042
Buzzard, Thomas, M.D. Lond., F.R.C.P.
Lond.. 82
Coekln, Reginald Percy, M.D. Cantab., 83
Coidstream, Alexander Robert, M.D. Bdln.,
F.R.C.S. ' n .5VI
Cuultff.*, J rnest Mchobon, M.D. Manch ,
M. B . B.S.Lor.d., M.R.C.P., 634
Dalby, William Bartlett, M.A. Cantab.,
F.li.C.S. Eng , P3
Davidson, Sir James Mackenzie, M.B.,
C.M. Ab'rd , 633
Drake-Bro’Um in, Edward Forster, F.R.C.S.
Bng.. 860, 963
Drew, Clifford Luxmore. M.B , C.M. Aberd ,
993
Bills, Wildara Ashton, M.R.C.S. Eng ,125
Gibson, Howard Graeme, M.R.C.S. Eng., 395
Goring. Charles Buckm<n, M.D., B.Sc.
Lond., 914
Guthrie, Leonard George, M.D., B.Ch.
Oxon., F.R.C.P. Lond . 44
Hart ley, Arl hur Conning, M.D., F.R.C.S.
Bdln , 437
Hartley, Edmund Baron, C.M.G , V.C.,
M R.C.S., 633
Hawes, Colin Sadler, M.R.C.S. I3ng., 45
Jeffrey, Francis, F.R.C.S. ling., 963
Le«, Charles Edgar, M.D. Manch., M.R.C.P.
Load., 953
Jones, Surg. Lieut. M. B., R.N.. 315
Keith, Capt. G. B., R.A.M.C., 122
Keogh. Surg. Com. J. A., R.N., 275
Lawrence, Capt. H. B., M.C., S. Afr. M.O.,
41.194
Lemarchand, Surg. Sub-Lieut. F. W.,
R.N.V.R., 398
Lister, Capt. C. R., M.C., Austr. A.M.C.,
195
Logie, Capt. A. G. 8.. R.A.M.C„ 275
Luett, Lieut. F. P. M., Aus*r. A.M.C., 315
Luton, Capt. W. F.,Can. A.M.C.,85,194
McEntire, Lieut.-Col. J. T, Mons Star,
R.A.M.C., 122
Mackinnon, Capt. F. I., R A.M.O., 85
Magoveny, Capt. J. H., R.A.M.O.,952
Martin,Capt. J. S.. R.A.M.C., 84
Matthews. Capt. S. W.. R A.M.O., 238
Melville, Col. H. G.. I.M.S , 194
Metcalfe, Cspt. G. C.. R.A.M.C , 580
Morison, Capt. R. McK.. R.A.M.C., 952
Murray,Capt. R. W. S.. R.A.M.C.. 952
O’Keefe, Capt. W. R., R.A.M.C., 194
Parsons-Smith, Capt. K. M., It A.M.C., 1C46
Perrin, Maj. M. N., R.4.F. Med. Serv., 768
Philson, C »1. S.C., A.M.S., 438
Plckthal. Surg. J. M., R.N.. 84
Pryce, Capt. A. M.. ll.A.M.C., 398
Ilobinaon, Maj. H. H., M.C. with bar, 859
Sharraa. Lieut. J. K., I.M.S., 952
Spurred, Capt. II. G. F.. R.A.M.O.. 43
Sturdy, Capt. A. C., M.C., R.A.M.C., 859,
999
Taylor, Map F. M..R.A.M.C., 952
Whitworth, Capt. H. P., R.A.M.C., 122
Whyte, Capt. G. T., R.A.M.C., 1091
Wilson. Cap'. W. C. D., R.A.M.C., 4«6. 722
Young, Capt. R. P., Austr. A.M.C, 238
Obstetric helper, 797
Obi-tetrles ami gynecology, teaching of, to
medical students, discussion, 258
Occupational fractures, 349
Odes and Other Poems (Dr. R. C. Macfie)
(review), 1119
G-lsophagus, malignant stricture of, 300
Ogilvie, Dr. G., obi', nary, 44
Oil ot chonopodium in ankj lostomiasis, 90
Oils and Fats, Edible (Mr. C. A. Mitchell)
(review). 848; Fate, and Waxo*, Technical
Han’.book (Mr. P. J. Fryer and Mr. F. K.
Weston (review). 897
O'Keeffe, Capt. W. R., R.A.M.C. (see Obituary
of the war)
O’Malley, Mr. J. F., circumscribed laby¬
rinthitis. 893
Omnopon, 384
one-eyed man, the, 1085
Onslow, Mr. H., origin of life, work of the late
Obalton Bastian, 1C01
Ontario Medical Association, address in
medicine, 1132
Operations, 500 consecutive, at Mercer’s Hos¬
pital, 265 ; nerve and muscle during, faradlc
stimulation of (Mr. H. Platt and Mr. E. S.
Breiitnall). 384
Ophthalmia neonatorum, notification of, 948
Ophthalmic cases, 8670, analysis of. 473;
operations, anaesthesia for (Sir. C. T. W.
Hlrtch), 1C68
Ophthalmic prac’ice, panel (Dr. A. F. Fergus),
Ophthalmitis, sympathetic, with fundus
changes, 300
Ophthalmological Society of the United King¬
dom, Congress (see Medical Societies)
Ophthalmology, education In. report, 578
Ophthalmology, Medical (Dr. A. Knapp)
(review), 23
Ophthalmoscope, familiarity with, 232
Opium Convention of 1912 t Py <y>, 443, 726
Optic nerve, evulsion of. 895
Op leal G ods Industry. Employment Oppor¬
tunities for Handicapped Men (Mr. B. J.
Morris) (review), 982
Orbit and accessory sinuses. Injuries and
diseases of. 614, 699
Orbital region, plastic operation on, 884
Organic Chemistry, Recent Advances in (Mr.
A. W. Stewart), third edition, 1918 (review),
617
OrgAiis of Internal Secretion, their Diseases
and Therapeutic Application (Dr. I. G.Oobh),
second edition, 1918 (review). Ill
Ormond, Maj. A. W., analysis of 8670 oph¬
thalmic cases, 473; pituitary tumour, 613
Orrln, Mr. H. fracture-dislocation of
astragalus. 20
Orthopaedic surgery, physical treatment In
relation to, 6/1; conference in Liverpool,
1003
Orthopaedic Treatment of Gunshot Injuries
(Dr. L. Mayer) (review), 23; Effects of Gun¬
shot Wounds and their After Treatment
(Dr. S. W. Daw) (review), 847
Osier, Sir W., influenzal pneumonia, 601;
acute pneumonic tuberculosis. 615; re¬
stocking of Louvain Library, 1042; presenta¬
tion to, 1128 ; anniversary book, 1138
Osteo-arthrltis in rigiit hip-joint. 447, 488,592
Osteomyelitis, Traumatic, Chronic, its Patho¬
logy and Treatment (Dr. J. R. White)
(review), 1074
Osteopathy, 949
Ostitis, new method of incision of tympanic
membrane for (Mr. R. Lske), 977
Otabe, Dr. S., Science and Art of Deep
Breathing (review), 467
Otitis, chronic adhesive, 893
“ Ourselves only,” 858, 913,951
Outlook of the medical practitioner (leading
article), 145
Outlook, the (leadI d g art!del, 1121
Out-of-school employment, 907
Ovarian cyst, spontaneous rupture (Dr. D. N.
Kalyanvala). 423
Ovary, endothelioma of, 264
Overy, Dr. H. B., causes and incidence of
dental caries, 47
Owen, Dr. 8. A., and Dr. P. A. Leighton,
medullary symptom-complex, 1024. 10i7
Oxford Ophthalmological Congress, 443, 1135
Oxygen in anaesthesia, air for (Dr. J. H.
Fryer), 216
P
Page, Mr. C. M., Medical Field Service Book
(review), 383
Paine, Dr. S. G., origin of life, work of the
late Charlton Bastlan, 1092
Palsseau, G., malaria during the war, 749
Palmar faseia, unusual contracture of (Dr. G.
de Swietochowski), 293 •
Palmer, Mr. J. F., hypothermia in Influenza,
398
Pancreatitis a cause of enteraigia (Dr. L.
Brown), 876
Panel practice, the size of (Pv Q), 403 ; oph¬
thalmic practice (Dr. A. F. Fergus), 758
Panel practitioners, war bonus to (Py (^6 321,
401, 403 ;' releasing (Py Q), 403; practitioners
and tuberculosis officers, 895; Committee,
London, meeting, 955; practitioners’ re¬
muneration (Py Q), 959
xvi The Lancet,]
INDEX TO VOLUME I., 1919.
[July 5.1919
Paoluccl, Raffiele 488
Papadopoulos, Dr. S. G., ectopic gestation
with an Aj.parenrly imperforate hymen, 140
Parrakh, Dr. P. It., hannatemesis after abdo¬
minal operation. 529
Paralysis aglt*ns and the c rpus striatum, 77
Paralysis, general, of the insane, treatment
(Dr. H. Campbell and Sir C. Balance). 608;
ascending, acute (Dr. H. Sutherland), 841
Paramore, Dr. it. H., lower uterine segment
and uterine tendons. 481
Paraphimosis, simple aid in reducing, 448, 815
Parasitic mange in horses. 280
Parasitology (review). 420. 748
Paratyphoid, mineral forms, 237; new germ
(Dr. L. Hirschreld). 2%
Pardee, Dr. I. H., pituitary headaches and
their cure. 664
Paris Academic des Sciences, award of prizes.
Paris, Correspondence. from.— Diet kitchens
for military hospitals, 37—Medical demobili¬
sation in Franco; Influenza in France;
Maternal and infantile protection in Paris
during the war; French doctors and the
excess profits tax, 38—Bill to provide treat¬
ment for tuberculous patients; Compulsoty
notification of tuberculosis. 233—Proposal for
a Central Health Department, 273—Hygiene
and the Frenchmans house as bis castle;
Recrudescence of rabies in Paris, 274—Prof.
Chantemesse, death of; Phthisis among
coloured troops in France; Late results of
gassing, 433—Protection of medical practice
In France ; Medical demobilisation ; French
Orthopaedic Society, 477—French anti small¬
pox campaign during the war, 759—Results
of fractures treated in Germany; Sdctete de
Therapeutique. 760—Compulsory notification
of tuberculosis; Rise in doctor’s tees, 997 —
Finger-prints as signatures; Strabismus;
Hatching of the louse, 1132
Parker, Prof. A. H., Monographs on Experi¬
mental Biology, the Elementary Nervous
System (review), 702
Parlcinson, Dr. J., left scipular pain and
tenderness in heart disease and distress, 550,
675
Parkinson, Dr. J. P.. aplastic anaemia, 744;
swelling of joints, 910
Parliament, medical candidates for, 35
Parliamentary Intelligence.
Notes on Current Topic*.
New Parliamentary Session ; Ministry of
Health Bill, 319. 359. 401. 442,482, 532, 586,
1008—Evils of unqualified dental practice,
360—Medical treatment of obildren in
Ireland. 401. 685-Nurses' Registration Bill,
484, 640. 685-Housing Bill. 484—Scottish
Board of Health Bill 645, 1038-Prevention
of Anthrax Bill. 685 — Public Health (Medical
Treatment of Children (Ireland) Bill, 685-
Budget, 770—Pension administrations and
medical boards, 770, 818-Pensions Com¬
mittee, 917—Local Government(Ireland)BHl.
1008—Pensions and medical assessment, 1137
Houte of birds.
April 2nd —Venereal infection, 587
April 15th. -Shell-shock patients; Neur¬
asthenia and shell shock, 725
April 29th. — Public Health (Medical Treat¬
ment of Children) Ireland) Bill, 770
May 1st.— Ministry of Health Bill, 818-
Medical representation in the House of
Lords; Nurses’ Registration Bill; Medical
treatment of children in Ireland, 819
May 6th.— Scottish Board of Health Bill;
Medical service in the Highlands and Islands,
819—Scheme for development of medical
service; Public Health (Medical Treatment
of Children) (Ireland) Bill. 820
May 8th. —Ministry of Health Bill, 863
May loth.— Scottish Board of Health Bill,
917
May 16th. —Medical examination of dock¬
yard workmen ; Rabies treatment, 917
May .Mu.— Ministry of Health Bill,917
May 22nd.— Ministry of Health Bill, 967
May 27th.— Nurses’ Registration Bill;
Scottish Board of Health Bill, 957
IL>me of Commons.
Medicine in the House of Commons, 320
Feb. i.ith. —Artificial limbs; After-care of
tuberculous ex-f-crvlce men; Ministry of
Health : Missing officers and men, 320
Ftb. J/,/A—Tuberculous ex-service men.
320
Fib. 17th — Irish housing, 320—Ireland and
the Ministry of Health; Artificial limbs;
War bonus to panel practitioners; Maternity
and child welfare, 321
Feb. 18th —Demobilisation of medio »1 men;
Combating venereal disease; Combating in¬
fluenza. 321
Feb. 19th —DemobiliiaMon of medical men,
321— Ireland and the Ministry of Health;
Raties in Devou and Cornwall; Medical
treatment of discharged soldiers ; Accommo¬
dation for the mentally deficient, 359
Feb. 2<Hh. —Supply of spirits; Assistant
medical officers of asylums; Influenza; Glen
Lomond Sanatorium, 359
Feb. 2 V/i. — Demobilisation of panel practi¬
tioners, 359—Influenza; Discharged tuber¬
culous soldiers. 360
Feb. 25tli. — Demobilisation of medical men;
medical men and income-tax; Spirits for
medical use, 360
Feb. 26th.— Ministry of Health Bill (second
reading), 360—S-parate Bill for Scotland, 361
—Industrial Fatigue Research Board; Grants
to panel practloners. 401
Feb 27th. —Women and methylated spirits;
Patent med clnes; Influenza; Influenza
pa'ients in tbo Army; Discharged tuber¬
culous soldiers; London County Mental
Hospitals, 431—Medical women and the War
Office; Promotion in the R.A.M.C.; Medical
officers in Army of Occupation; R.A.M.C.
officers and Government employment; Rabies
la Cornwall and Devon, 402
March 3rd. —Spirits for medicinal uses ;
Medical Inspectors of Home Office; Medical
women and War Office employment; Dental
surgeons and the Army gratuity, 402
March 4 th. —Glen Lomond Sanatorium ;
Medioal Inspection in factories; Broncho¬
pneumonia in the Army, 402 —Medical men
in military service: Releasing panel practi¬
tioners ; Insurance practice ; Bonus to
panel practitioners ; Size of panel practices,
403
March 5th.— Women medical officers in
mllitiry hospitals ; Physiciaas’and surgeons'
voluntary war service, 442
March 6th.— Lunatic asylum discharges;
Tuberculous and shell-shock cases, 442
March 10th. -Grants for medical referees;
Salaries of Irish Poor-law medical officers;
Ministry of Health for Ireland; Whisky for
medical purposes; Qualification of apothe¬
caries’ assistants; Influenza and cholera in
Bombay, 442 — Oatmeal and influenza;
Opium. Convention of 1912, 443
March Uth —Demobilisation of doctors and
nurses; Institutions for mental defectives,
443
March 11th.— Vaccination ; Small-pox, 484
March 15th.— Lymph for public vaccina¬
tion 484 — Salvars&n substitutes, 485
March 18th.— Outbreak of cerebro-splnal
fever; Demobilisation of medical officers,
485
March loth. — Gratuities to temporary
naval medical officers; Ministry of Health
for Egypt. 4 r 35
March 20th.— Port hospital accommoda¬
tion. 534
March 2Uth.— Venereal diseases; Medioal
Treatment of Children (Ireland) Bill, 534
March 2olh. — Demobilisation of medical
men, 535
March 26th.— Ministry of Health and
liquor control; Clinical thermometer tests;
Physicians' and surgeons’ war service, 587
March 27th.— Physical training in schools,
587
March 28th. —Nurses’ Registration Bill, 587
April 1st.— Tuberculous officers ; Scottish
Board of Health Bill, 588
April 2nd .— Medical treatment of demobil¬
ised men ; Closing the smaller military hos¬
pitals, 640-Butter for invalids; Government
control of hospitals, 641
April 3rd. — Pressure on civilian hospitals;
Egyptian Fellaheen Medical Service; Con¬
sumptives in the Army, 641
April 7th.— Medical inspection of school
Children in Ireland, 641
April Sth. — Demobilisation of medical
officers; Army huts for tuberculous
patients, 641
April 9th .— Ministry of Health Bill, 641
April 10th,— Salaries of health visitors;
Notification of venereal disease, 685; Release
of temporary medical officers; Treatment of
pauper lunatics; District nursing associa¬
tions and public health. 686
April V',th. —Tetanus among British troops,
725-International Opium Convention,726
April 'nth. —Accommodation for hospital
nurses, 770
May 1st.— Vivisection of dogs; Insurance
Act medical benefit-; Medical men on dis¬
persal boards ; Port sanitary authorities and
hospital accommodation for infectious cases;
Hospital accommodation at West Ham;
8urgical appliances for disabled soldiers,
820—Release of Fazakerley Hospital, 821
Jfay fad.—Animals (Anaesthetic) Bill; Pre¬
vention of anthrax, 821
May 5lh.— Petrol supplies, 821
May 6th.— Emigration of tuberculous
soldiers; Inadequacy of the nursing rervloe;
Pensions and the medical referee; Insurance
practitioners’ terms, 821
May 7M.-BdiUh-mademorphia; Sanitary
officer and service in Hus da, 864
May Sth. — Tuberculosis treatment in
Load >n ; Surplus army medical equipment;
Shall shock treatment; Venereal disease;
Pure milk-supply, 864
May 12th.— Prevention of Anthrax Bill;
Physical unfitness of the nation; Spirits in
oases of illness; Health Council for Wales;
Hospital accommodation for oivit neeis;
Hospital treatment for soldiers, sailors, and
pensioners, 865
May lUlh.— Status of Sir George Newman.
918
May loth.— Antlrabic treatment; Powers
of boards of guardians, 918
May 19th.— Red Cross nurses and war
G ratuities; Demobilisation of field arabu-
ince officers; Vaccine lymph; Rome lies
for venereal disease; Scottish pirochlal
medioal officers, 918
May 20:h.— Territorial medical officers and
demobilisation; Medical boards and dis¬
ability assessments, 918
May 21st.— Shortage of medicine bottles.
May 22nd.— Midwives and burial certi¬
ficates, 959
May 23rd.— Dogs’ Protection Bill. 967;
Panel practitioners' remuneration. 959
May 26th —Ministry of Health Bill, 969
May 27 Lh. — Relief of me ileal officers
abroad ; Prevention of Anthrax Bill, 959
May 2Sth.— Medical Service Bill, 959;
Demobilisation of Territorial medical efficers.
960
June 2nd.— Ministry of Health Bill;
Scottish Board of Health Bill; Pool for
Insurance practitioners; War gratuities to
nurses; Piague in Central and Eastern
Europe, 1008
June 3rd.— Medical officer to the Board of
Customs. 1009
June Uth.— Income limit under the Insur¬
ance Act; Services of medical m*n in the
war; Venereal diseases among the troops;
Medical supplies of brandy and whisky, 1060
June 5th.— Vaccination prosecutions in
Wexford ; Treatment of the blind in
Ireland, 1051
June 2Uth. —Tuberculosis in the Navy;
Medical assessment of disability, 1137
Parliamentary Committee, Medical, 190;
dinner to medical members, 281; arrange¬
ment of conference, 614 , 705. 808, 817, 858;
progress of (leading article), 801
Parmelee, Mr. M., Criminology (review). 982
Parnell, L<eut.-Cmdr. R. J. G., and Lieut.-
Gmdr. P. Fildes, Wassermann reaction,
807
Parotid, fistula of (Mr. P. P. Co’e), 971
Paroxysmal tachycardia, treatment by respira¬
tory effort, 853
Parry, Judge, and Lieut.-Col. Sir A. E.
Codrlngton, War Pensions, Past and Present
(review), 799
Parsons-Sraitb, Capt. E. M., R.A.M.C. (see
Obituary of the war)
Parsons-Smith, Dr. B., fitness and unfi'mess In
convalescence, 509
Parthenogenesis in vertebrates (leading
article). 1033
Partridge, Mr. W., and Mr. C. G. Moor, Aids
to the Analysis of Foods and Drugs, fourth
edition, 1918 (roview), 848
Pass-lists s Apothecaries S xflefcy of London,
48, 584—Dublin University, Trinity College,
School of Physic, 48, 633-Aberdeen
University, 87, 584-Liverpool University,
126, 536—Royal Colle/e of PhvBfcians of
Edinburgh, Royal College of Surgeons of
Edinburgh,and Royal Faculty of Physicians
and Surgeons of Glasgow, 199, 768 —Royal
College of Surgeons of Edinburgh, 5 6, 955—
Examining Board in England by the Royal
Colleges of Physicians of Lvulon and
Surgeons of England, 233, 639. 724 -Royal
College of Physicians of London, 239, 768-
Royal Colleges of Physicians of London and
Surgeons of England, 862—Royal College of
Surgeons of England, 862, 914, 1094— Cam¬
bridge University, 724—Bristol University.
318—Manchester University, 536—Durham
University, Faculty of Medicine, 584, 639 —
Glasgow University. 639, 725— London
School of Tropical Medicine, 633—London
University, 687, 1003, 1051—St. Andrews
University, 1137
Pasteur, Dr. W., epidemic perineph lo sup¬
puration, 1092
Thb Lancet,]
INDEX TO VOLUME I., 1919.
[July 5,1919 xvii
Pasteur-Vallery-Radot, Theda on Studies on
Ben&l Function In Chroni* Nephritis
(reviewed by Prof. C. Achard), 752
Patent Medicines (Py Q),401
Paterson, Mr. H. J., Queen Alexandra’s
Hospital for Officers. 772
Paterson, Prof. A. M., obituary, 314; Anatomy
of the Peripheral Nerves (review), 1074
Pathology, relation of, to clinical medicine,
300
Paton.-Dr. B., pseudo-ps ratyphold fever, 1071
Paton, Mr. L., *nd Mr. T. Collins, angioma of
the choroid, 896
Patrick, Dr. A., Staphylococcus aureus
septicaemia in Influenza, 137
Paul, Mr. N., persistent pigmentation due to
anti pyrin, 1036
Pauper lunatics, treatment of (Py Q), 686
Pearce, Dr. R. G., and Professor J. J. B.
Macleod, Physiology and Biochemistry In
Modern Medicine (review), 513
Pearse, Dr. J., personal retrospect of general
practice. 129
Pearson, Dr. M. G., bed for fractures and
general hospital purposes, 266
Pearson, Sir A., in New York, 524
Pectoralis major muscle, left, and left
mammary gland, congenital absenoe of lower
portion, 565
Pecuniary position of hospital officers (leading
article), 573
Pedley, Mr. R. D., causes and incidence of
dental caries, 80,155
Pelvic-femur splint and arm splint (Dr. J. B.
Lee), 103
Pelvic sarcoma (Mr. J. H. Hart). 378
Pembrey, Dr. M. S., physical training of the
open-air life. 323
Pennefather, Dr. O. M., and Dr. J. Campbell,
blood supply of muscles, 294
Pennington, Dr. D., and Mr. J. P. Lockhart-
Muturnery, adhesions of the sigmoid, 254
Pension administration and medical boards,
770
Pensioners, admission to civil hospitals, dis¬
cussion, 179 ; (leading article), 186
Pensions and the Principles of their Bvalua*
tlon (Dr. L. J. Llewellyn and Dr. A. B.
Jones) (review), 799; War, Past and Present
(Judge Parry and Lieut.-Col. Sir A. E.
Codrlfngton) (review), 799; and medical
boards, 818; and the medical referee (Py Q),
821; Committee, 917; and medical assess¬
ment, 1137
Pensions to Canadian soldiers, 232; widows’,
in the Navy, 724
Pepys on blood transfusion, 1098
Perforating wound of the heart (Maj. F. 0.
Pybus), 1026
Perforation In cancer of the stomach, 272
Pericardial sac, recurring effusion into (Dr.
H. B. Roderick and Dr. 8. W. Curl), 980
Pericardiotomy (Dr. T. P. Noble and Dr. A. B.
Vine), 107
Perinephric suppuration, epidemic, 1001,1044,
1092
Peripheral Nerves, Anatomy of (Prof. A. M.
Paterson) (review), 1074
Peritonsillar abscess (Dr. A. Wylie), 178
Perol, M. Pierre, and Prof. A. Zimmern,
Electro-Diagnosis in War (review), 468
Perrin, Major M. N., R.A.F. Med. Serr. (see
Obituary of the war)
Perrin, M.. and G. Richard, rupture of cardlao
valves due to an explosion, 231
Perry, Henry, the case of, 1041
Petrol supplies (Py Q), 821
Petroleum jellleB( ‘ Semprolia” brand), 898
Pettit, Auguste, and Louis Martin, Spiro-
chetose Icterohemorragique (review). 800
Petty, Dr. M. J., hot liquids and cancer, 583
Pharmacology and Therapeutics, Text-book
(Dr. A. R. Cushny), seventh edition, 1918
(review), 22
" Phases in the Life and Work of John
Hunter ” (Prof. A. Keith), 269
Philip, Sir R. W., and Mr. B. McK. Johnston,
position of the demobilised practitioner, 4^9
Phillips, Mr. J., the burled sequestrum, a
post-war problem, 291
Phllson, Col. S. C., A.M.S. (see Obituary of
the war)
Phthisis In factory and workshop, 153; among
ooloured troops In France, 433; pulmonary,
saccharose lnjoctions in, 636; hilus, mixed
infection in, 1128
Physical and Occupational Re-education of the
Maimed (Dr. J. Camus and others) (review),
183
Physical efficiency, some simple tests (Dr. M.
Flack), 210
Physical training In schools (Py Q), 587;
treatment in relation to orthopaedic surgery,
671
Physical training ot the open-air life (Dr. M. S.
Pembrey), 323
Physical unfitness of the nation (Py Q), 865;
education, need for, 867
Physicians' and surgeons’ voluntary war
service (Py Q), 442, 587
Physicians, two XYli. century, 405
Physics of shock, 269
Physiological Chemistry. Practical (Prof. P. B.
Hawk), sixth edition, 1919 (review), 983
Physiological Feeding of Children (Dr. B.
Pritchard) (review), 1028
Physiology and the food problem, 283
Physiology for Medical Students and Phy¬
sicians (Prof. W. H. Howell), seventh
edition, 1918 (review), 984
Physiology of Industrial Organisation (Prof. J.
Amar) (review), 265; and the study of
diseasf s, 447 ; and Biochemistry in Modern
Medicine (Prof. J. J. R. Macleod and
Dr. R. G. Pearce) (review>, 513 ; (Traits de
Physlologie) (Prof. J. P. Morat) (review), 702
Picric-brass preparations in the treatment of
lupus (Dr. H. A. Ellis), 415, 430, 528, 592, 635
Pictorial symbolism of reproduction, 446
Pigmentation, persistent, due to antipyrin,
1036
Pigmented connective tissue, 1072
Pineo, Mr. B. G. D., and Dr. D. M. Balllie,
treatment of gonorrhoea by pus vaccines, 508
Pitfalls of general practice (Dr. H. M. McCrea),
1010, 1053
Pituitary body, deficiency of, In a girl aged 19,
465; tumour, 613; body, malignant tumour
of, 613; headaches and their cure, 664
Place aux embueques. 157,198
Placenta, the retained. 806
Plague In India, twenty years of, 349, 434, 760;
in Central and Eastern Europe (Py Q), 1008
Plant stimulation by ultra-violet rays, 430
Plat tic vocal cord (Dr. P. N. Smith), 108;
operation on face for deep scarring, 300;
operation on orbital region, 894
Platt, Mr. H., eradication of latent sepals, 175 ;
and Mr. B. S. Brentnall, f&radte stimulation,
884,989
Pieuro-typhoid, 990
Pneumococcic meningitis, primary, 623
Pneumonia, broncho,- Influenzal, use of Intra¬
venous iodine in (Dr. D. M. Balllie), 423;
septic, epidemic, 481; influenzal (Sir W.
Osier), 501; recent advances In treatment
(leading article), 704; Influenzal, lung-
f mneture in (Dr. M. Benaroya), 742, 81o;
ii Macedonia and the epidemic, 794
Pneumonia, epidemic, study of, 1086
Pneumonic tuberculosis, acute, 616
Poisoning, aspirin (Dr. F. W. Lewis), 64;
heroin, 755
Poisons, irregular sale of, 120
Poland, medical mis* ion to, 944
Police Medical Servloe, appointment of com¬
mittee, 665
Poliomyelitis and encephalitis, notification of,
76
Polycythemia, 700; with congenital morbus
cordis, 700; rubra with splenomegaly, 700
Polygraphlo technique, advances In (Dr. H. L.
Flint), 176
Polymorphism of malignant epithelial cell,
743
Polyneuritis, acute infective, 348
Polyorrhomenitls (Dr. W. B. Cooke), 562
Pool for Insurance practitioners (Py Q), 1008
Poona Seva Sedan, 805
Poor law dietary, 187
Population, national register of, 147; a
diminishing, 474; figures and the war,
1038
Porteous, Dr. A. B., and Mr. A. Fleming,
blood transfusion by the citrate method, 973,
'988
Porter, Miss A., Intestinal entozoa among the
native labourers In Johannesburg, 521
Port hosp'tal accommodation (Py Q). 534, 820
Portrait of Sir Clifford Allbutt, 814, 910
Portsmouth Koval Hospital, meeting, 632
Posey, Dr. W. C., Hygiene of the Eye (review),
184
Postgraduate Association, scheme for post¬
graduate medical education, 393, 757
Post-graduate facilities, development of, 268
Post-graduate medical fetching in Glasgow,
523 ; medical education (leading article), 70S
Post-graduates, American, in London, 943
Post-influenzal heeinoptysis (Dr. H. Wilson),
137
Potatoes, composition of, 727
Powell, Dr. L. “ twilight sleep,” 658
Powell, Mr. W., death of, 953
Power, Mr. D'Arey, {etiology of lingual cancer,
75
Poynton, Dr. F. J., accurate diagnosis In
appendicitis, 197
Practice, general, a personal retrospect (Dr. J.
Pearse), 129, 197; civilian, and military
medical officers, 233; general, some pitfalls
of (Dr. H. M. McCrea). 1010, 1053; general,
how to start and how to succeed (Dr. G.
8teelePerkic8), 1097
Practice of the absentee, 45, 80
Practices, buying, 398; disposal of, 913
Practitioner, the demobilised, position of, 439;
(leading article), 515
Pregnancy, extra uterine, 22. 611; tubal, 110;
reaction, Abderbalden's, 111; extra-uterine
advanced, 301; extra-uterine, continuing to
term, 611; ectopic, full time, four cases, 611;
full-time, In a rudimentary uterine born
612
Pregnant women suffering from venereal
diseases, residential treatment, 80
Presbyopia, 895
Prescriptions, disinterested, 1036
Presentations and testimonials: to Dr.
Veimylen. 20 ; to Mr. S. Riddell, 424 ; to Dr.
N. Raw, 781; to Mrs. S. Payne, 844 ; to Dr.
L. V. Laurie, 879; to Dr. J. Culross. 879;
to Sir J. Barr, 1007 ; to Sir W. Whltla, 1095
Pressure on civilian hospitals (Py Q», 641
Prest, Dr. E. E., future of the tuberculosis
problem, 636
Prevention of Anthrax Bill, 685, 865, 959
Preventive medicine and Industrial efficiency
(leading article), 113
Prideaux. Mr. E., war deafness, 198; stam¬
mering in war psycho-neuroses, 217
Priestley, Dr. A. II., complement-fixation test
in gonococcal Infections, 737
Primary svphills, diagnoa’s of (Dr. S. F.
Dudley), 737
Primitive agents In treatment, 45
Prince, Dr. N. C., Roentgen Technic
(Diagnostic), (rovlew), 184
Prison reform, policy of the Howard Associa¬
tion, 1002
Pritchard, Dr. E., home v. Institutional
training of young children, 615; abdominal
tuberculosis, 940; Physiological Feeding of
Children (review), 1028
Procidentia, complete, radical cure, 22
Profiteering, alleged medical, 526
Prohibition in the United States, 354; regula¬
tions for New York, 354 : and the medical
profession of New York. 523
Propaganda, a study in, 622
“Propeller” fracture (Lieut.-Ool. A. L.
Johnson) 293
Prophylactic measures against influenza at a
{ mbllc school, 119; treatment of eonstipation
a childten (Tr. V. Borland), 459; inocula¬
tion in influenza (leading article), 572
Prophylaxis iu influenza (Mr. F. T. Marchant),
393
Prosthesis of the lower Jimb, 149
Pryce. Capt. A. M., K.A.M.C. (see Obituary of
tne war)
Pseudo paratyphoid fcver(Dr. R. Paton), 1071
PsoiUris of 13 years' duration, 847
Psychiatry, word-a-soclation test in, 234
Psycho-analysis, Papers on (Dr. B. Jones),
second edition, 19.8 (review), 234; Theory of
(Dr. C. G. Jung) (review), 234; aspect of,
7C8
Psycho-neurosis, stammering in (Mr. B.
Ptideaux), 217; and protective mimicry
(Dr. L. Brown), 832
Psychology of Internment (Prof. B. Bing and
Dr. A. L. Vlschor), 696; and medicine, 889;
British and German, 1002
“Psychology,” the word, 1093
Psychonevroses de Guerre, Traltement des
(G. Roussy. J. Boisseau, and M. D'Oelsnltz)
(review), 1119
Psychopathic criminal, the (leading article).
Psychopathology of Bveryday Life (Prof. S.
Freud) (review), 231
Public health aspect of tuberculosis, 464
Public Health Council, Irish, proposed, 475
Public health, reports of medical offioera of
health, 478,581 ; work in Egypt, 146; Depart¬
ment, Egypt, 1916, annual report, 681;
Laboratories, Cairo, reports and notes, 682
Public Health (MedicAl Treatment of Children)
(Ireland) Bill, 685,770,819,820; reconstruction
and, Ireland, 812 ; for Canada. Federal Depart¬
ment of, 949; Bill, South Africa, 996
Public Health, Royal Institute of, lectures and
discussions, 81; the new, and industrial
unrest, 202; new regulations for the control
of epidemic disease, 281; (Tuberculosis)
Regulations, 485 ; and district nursing asso¬
ciations (Py Q). 686
Public-house reform, 826
Public spirit and medical unanimity, the State
and the doctor (Sir II. Morris), 165
Pulmonary tuberculosis, saccharose injections
in, 540, 636, 826 ; trauma therapeutic, 851
Pulsating tumour of orbit, 613
Puncture fluids, thoracic (Dr. S. R. Gloyne),
935
P.U.O. and trench fever, invalidism caused by
(Col. T. B. Elliott, Capt. D. S. Lewis, May.
J. H. Thursfield, Msj. A. J. Jex-Blake, and
Maj. M. Foster), 1(60
Purefoy, Dr. H. D., tubal pregnancy, 110
Pure mllk-supyly (Py Q), 864
Purulent broncho-pneumonia associated with
the meningococcus, 81
xviii The Lancet,]
INDEX TO VOLUME I., 1019,
[Jury 6,1919
Pus vaccines in 'the treatment of gonorrhoea
(Mr. B. Q. D. Pineo and Dr. D. M. BallUe),
Pybus, Maj. F. 0., perforating wound of the
heart. 1026
Pye’s Surgical Handicraft (Mr. W.'H. Claytson-
Greene), eighth edition, 1919 (review),
385
Pyloric stenosis, congenital, surgical treat¬
ment. 380, 389
Pyosalpinx and ovarian abscess, 265
Q
Qualifications of apothecaries assistants (Py Q),
442
Quantity, universal language of, 539
Quarterly Journal of Microscopical Science
(review), 897
Queen Alexandra’s Hospital for Officers, High-
irate. 688,772
Queen Mary’s Needlework Guild, 284
Queen's University of Belfast, honorary de¬
crees. 1137
Quinine as an abortlfecient (Prof. W. U.
Swayne and Mr. B. Russell), 641
Sables and Us treatment in this country (lead-'
ing article). 74; atypical, 852; treatment
(Py Q). 917,918
Babies in Paris. 274; in Devon and Cornwall
(Py Q), 359,402 ; return of, 706,756.806
Race, Mr. J., Examination of Milk for. Public
Health Purposes, first edition, 1918 (review),
614
Radiant heat and health, 164
Radium Institute (leading article), 850
Radium treatment of epithelioma of the lip,
388; new method of application In diseases
of the eye, 895
Radical and modified radical mastoid opera¬
tions (Mr. J. 8. Fraser and Mr. w. .T.
Garretson), 339
Raffaele Paoluccl. 488
■" Ragging’’ of a nurse, 949
“Bags,” legal definition of, 991
Railway carriages, dry sweeping In, 644
Rainfail in the northnf Ireland, 910
Ramsay Memorial Laboratory, 634
Ramsay, Mr. R. A., surgical treatment of con¬
genital pyloric stenosis. 380, 389
Ransom, Dr. F., and Prof. H. H. Meyer,
tetanus without trismus. 117
Ransome, Dr. A., musk In influenza, 529
Rat-bite fever (Dr. R. V. Solly), 458
R&tnakar, Mr. R. P., nystagmus caused by
mustard gas, 423
Raw, Dr. N., attenuation of human, bovine.
. and avian tubercle bacilli, 376; position of
medicine In the State, 797
Reactiva' Ion of erythema nodosum by tuber-
. culin, 705
Reconstruction, hygienic, of war devastation,
Inter-Allied Conference in Paris, 856
Reconstruction (review), 112
Rectal ether anaesthesia (Mr. J. C. Clayton),
793
Rectus abdominis, ruptured, Influenzal (Dr.
W. Balgarnie). 843, 912
RedOross, American, in Paris, future of, 155;
Inter-Allied Conference, 521; workers,
Scottish branch, training scheme for, 813;
nursos snd war gratuities (Py Q), 918
Red Cross, British, demobilisation, 41; ambu¬
lances, utilisation of, 187 ; past, future, and
present (leading article), 661; ambulances
for home service, 683; Hospital at Netlev,
856
Redhill, Royal St. Anne's Schools, appeal, 921
Keflex, a new, 868
Reflexes, abdominal, significance and surgical
value of (Mr. I). Ligat), 729
Reform of medical education (leading article),
571
Refraction of the Eye, Manual for Students
(Mr. G. Hurtridge), sixteenth edition, 1919
(review), 984
Regimental Medical Officer, the Whole Duty
of (Capt. P. Wood) (review), 466
Register, national, of population, 147
Keguauit. Dr. J., anaesthetics, 1037
Reguia’ions, cerebrospinal fever, 1126
Rehabilitation of the Disabled, International
Conference on. 761
Reid. Sir A., and Dr. P. II. Boydcn, treatment
of venereal disease 212
Renal Function in Chronic Nephritis, Studies
in (thesis by Pa-Mteur-Vallery-Ridot) (re¬
viewed by Prof. C. Achard). 752
Renoey, Dr. H., trimethcnal-allyl-carbide in
lulluenza, 440
‘Reproduction, pictorial symbolism of, 443
(Research, medictl, and its place in the State
(leading article), 517; Committee, Medical,
and the medioal supplement, 522; the spirit
o f , 624; clinical, coordination by the State
(Dr. D. 0. Watson), 989, 992
iResection, double, of bowel (Mr. G. Taylor),
461; in’ussusception treated by (Mr. E. R.
Flint), 938
(Resettlement of war nurses 1090
i Responsibility, crime and (leading article),
t Retina, angioma of, 300; streaks in, 613
(Retinal degeneration following intraocular
foreign body, 299
(Retinal vessels, obstruction of, 1072
(Reyista Bsp&nola de Cirugia (review), 748
Revista Espanola de Medicine y Cirugiif
(review), 66
Reynell, Dr. W. R., hysterical vomiting in
soldiers, 18.118
Rheumatism and arthritis, meningococcal (Dr.
P. Sainton), 1080
Richard, G., and M. Perrin, rupture of cardiac
valves due to an explosion, 231
Richmond, Dr. B. A.. Association of Panel
Committees and notification fees, 439
Rickobs, experimental Investigation on (Dr. E.
Mellanby), 407
Rideal, Dr. S., germicidal valuation of dis¬
infectants, 576
Risdon, Cap*’-. B. F., and Maj. C. W. Waldron,
mandibular bone grafts, 181
Ritchie, Prof. J , and Prof. R. Muir, Manual of
Bacteriology, seventh edition, 1919 (review).
Ritter v. Godfrey, 1041
Rivers, Dr. W. H. B., appointed prelector in
natural sciences at St. John’s College,
Cambridge, 158; psychology and medicine,
Rivers, Mr. W. C., women chiefs. 533, 683
Riviere, Dr. C., hllus tuberculosis in the adult,
213; lung-puncture in treatment of influenzal
pneumonia. 816
Rixon, Mr. C. H. L., hysterical perpetuation of
symptoms, 417
Roads, hygienic repair of, 202
“Rnase Sligwick" Fellowship, 1095
; Roberts, Dr. B , death of, 688
Robertson, Dr. A. W., Studies in Electee-
path >Iogy (review), 701
(Robertson, Dr. O. H., and Dr. Airlie V. Book,
blood volume and related blood changes after
haemorrhage, 852
(Robinson, Maj. H. H., M.C. with bar (see
Obituary of the war)
.Roderick, Dr. H. B., and Dr. S. W. Curl,
recurring effusion into the pericardial sao,
. 960
Roentgen Technic (Diagnostic) (Dr. N. jC.
Prince) (review). 184
Rogers, Sir L., tribute to, 112; cblloid anti¬
mony sulphide intravenously in kala-azar,
505
Rolleston, Sir H., oerebro-spinal fever, 541,593,
645
Rom in oculist seals, 1012
Hood, Dr. F. 8., spinal anesthesia, 14
Rose, Dr. B. T., and Mr. E. H. Shaw, ectopic
gestation, 175
Rose, Dr. F. G., influenza epidemic in British
Guiana, 421
Rosenthal, Dr. G., ingestion of adrenalin and
intravenous injection of colloidal quinine,
763
Rois, Mr. H. C.. absence of cancer in the
Arctic regions, 628, 1045
Roes, Sir R., care and treatment of malaria,
780; origin of life, work of the late
Charlton fiastian, 952
Roubicr, M., tetanus without trismus, 117
Rouquette, Mr. S. H., obitu v, 6.9
Boussy, G., J. Boisseau. mui M. D’Oelsnitz,
Traitemtnt des Psych > novroses de Guerre
(review), 1117
Rowlands, Dr. M. J., present epidemic of
influenza, 563
Roworth, Mr. A. T., commercial vaccine
-lymphs, 357
Royal Academy of Medicine in Ireland (see
Medical Societies)
Royal Array Medical Corp< (for list of casualties
and honours see Royal Army Medical Corp*
under War and After); auxiliary funds, 238,
632; promotion in (Territorial). 399; pro¬
motion in (Py Q /, 402; officers and
Government employment (Py Q), 402;
war memorial to officers and men,
766; Fund and R.A.M.C. Officers' Bene¬
volent Society, 858; Journal, 916; $|> ire-
lime service, 1054; temporary officers,
1137
“ Ho 3 ’rD’ Army Veterinary Corps, 29
Royal College of Physicians of Edinburgh,
Royal College of Surgeons of Edinburgh, and
Royal Faculty of Physicians and Surgeons of
Glasgow, pass-lists, 199, 763 J
i Royal College of Physicians of Ireland, DrJH.
Pringle elected King’s Professor of Institutes
of Medicine in the 3cbool of Physic in
Irelanl, 485
i Royal College of Physicians of London and
Surgeons of England. pa6a-lists, 862
i Royal College of Physicians of London, comitis,
236, 687, 768, 862, 1004 ; pass lists. 239,768
(Royal College of Burgeons of .Hdinbmxh, pass-
lists, 536, 955
: Royal College of Surgeons of jh ghniit . ino^ing ,
126, 318, 687,862, 1094 special ftmmin«Hnqi
for the primary F.R.C.S. Bog., 200: Baa¬
lists. 862, 914, 1094
i Royal Faculty of Physicians and Surgeons «f
Glasgow, meeting. 282
Royal Free Hospibd Fair, 16
Royal Infirmary, Edinburgh: new appoint¬
ments, 1131
Royal Imtitute of Publio Health, lectures and
discussions,81; (see Medioal Societies)
Royal Institution, meeting, 206,639
Royal Medical Benevolent Fuad, meeting,
199, 361, 536, 769, 956, 1095; War Emergency
Fund, 315, 358, 684, 999 ; danoe,iU37
Royal Sanitary Institute (see Medioal
Societies)
Royal Society conversazione, 894
Royal Society of Medicine, social evenings,
270; Sommer Congress of Laryngology, 306;
the post-graduate scheme, 757 ; close of the
season, 1036; (see also Medical Societies)
Rudolf, Col. R. D., subacute trench fever, 658
Rupture of cardiac valves due to explosion,
231; spontaneous, of ovarian cyst (Mr. D. S.
Kalyau ala), 423
Ruptured rectus abdominis. Influenzal (Dr. W.
Balgarnie), 843,912
Rural housing, 987
Rusk, Dr. R. R., Experimental Education
(review), 618
Russ, Dr. 8., Dr. Helen Chambers. Dr. Gladwys
M. Soott, and Dr. J. 0. Mofctram, experi¬
mental studies with small doses of X cam,
692
Russell, Dr. W., influenza epidemic, 689
Russell, Mr. B., and Prof. W. C. Swayne,
quinlne.as an ab jrtlfaclent, 841
Rutherford, Dr. L. T., lacrymal, gland in sur¬
gical anaesthesia, 792
Rutherford, Lieut. Col. N. C., trial of, 680
Rubherfurd, Dr. W. J., war injury from ajgn sl
lights, 741; and Dr. Bacbara G. JJ. Crawford,
hereditary malformation of the extremities
979
Ryle, Dr. J., mild bacillary dysentery, 937
S
(Sac, pericardial, recarting effusion Into (Dr.
H. B. Roderick and Dr. S. W. Ourl), ffiD
Saccharose injections in pulmonary phthisis,
540,635,826
St. Andrew’s Hospital, Doills Hill, report,
394
St. Bartholomew’s Hospital, History of (Dr. N.
Mooie) (review), 425
St. George's Hospital, future of. 906
St. John of Jerusalem, Order of, appointments.
826, 1008
St. Mark’s Hospital, the Lord Mayor's
challenge, 318
Sainton, Dr. P., meningococcal rheumatism
and arthritis, 1080
Sakakami, Dr. K., Dr. S. I wash Una, and Prof.
T. Y&manouchi, infecting agent in Influenza,
971
Salaries of dispensary doctors, 121; of Irish
Poor-law medical officers (Py Q), 442; of
health visitors (Py Q), 685
Salvarsan substitutes (Py Q 485
Sanatoria for discharged soldiers and sailers
suffering from tuberculosis, 859
Sandford, Mr. H., death of, 30,125
Sanitary and insanitary makeshifts in the
Eastern war areas (Dr. A. Balfour,, 604
Sanitary officer and service In Russia (Py Q\
864
Sanitation, health, and medicine in India, 127,
163 ; iu the Near East (leading article), 621;
at Lahore, 813
Sanitation in War (Prof. P S. Lei can), third
edition, 1919 (review), 514; Perfectly Applied
(review), 659
Sanatoriums for soldiers and sailors, 1035
Sarcoma of cervix, 110; recurrent, after
removal of apparently simple myomata,
Sarcoma, pelvic (Mr. J. H. Hart), 378
Savage, Sir G. H., Isaac Dobree Chepmell, 157;
mental disorders associated witn old age,
1013; meatiesi dietary in epilepsy', 1046
Savory, Mr. H. 51., dislocation of teeth, 339
Savill, Dr. Agnes, medical effects of the tube
strike. 279
Savill, Dr. T. D., System of Clinical Me liclne.
fifth edition, 1918 .review), 66
THB ItANOBTi]
INDEX TO VOLUME L, 1919.
[July 5,1919 xix
Sawyer, Sir J., obituary, 239
Scapular pain and tenderness, left, In heart
disease and distress (Dr. J. Parkinson), 550,
575
Sear tissue, Infective (Mr. E. M. Corner), 840
Searlet red powder as a tissue stimulant (Dr.
A. J. Turner), 463
School b:ard medical officer mobbed In
Aberdeen, 1131
School children, medical Inspection of. 199;
In Ireland, medical inspection (Py Qj, 641
Schools, secondary, medical inspection of, 616;
In Ireland. 997
Schryver, Dr. 8. B., Introduction to the
Study of Biological Chemistry (review), €59
Schuller, . Dr. A., linen* gen Diagnosis of
Diseases of the Head (review), 466
Science laboratories, new, at Edinburgh. 812
Scientific education and its cost (leading
, 428 ; accuracy and graiu pests, 539
stings, death from (Capt A. Watson),
article)
Scorpion
Scotland (Correspond utcr. from).— Scottish
Ministry of Health Committee; Chair of
Therapeutics, Edinburgh University ; Influ¬
enza epidemic in Edinburgh and district,
433—Ministry of Health, resolutions of the
Scottish medical profession; Ministry of
Health, statement of the Royal College of
Physicians of Edinburgh; Post-graduate
medical teaching in Glasgow, 523—Demob¬
ilisation of doctors; Scottish Universities
Entrance B ard; Retirement of Sir T.
Fraser, 631—New science laboratories at
Edinburgh: Scottish Western Asylums
Research Institute; Resettlement of Scottish
nurses, 812—Venereal treatment centres in
Glasgow'; Training scheme for Red Cross
workers, 813; Prescribing of cocaine ; Pro¬
fessional chemists and the Scottish Board of
Health; Affairs of Edinburgh University,
910—Prospective vacant chair at Edinburgh
University; Meeting of the medical pro¬
fession in Edinburgh; Woman doctor sued
by member of the Q.M.A.A.C., 1040—Royal
Infirmary, Edinburgh, new appointments;
Scottish Otological and Lsryngologioal
Sooiety; School board medical officer
mobbed in Aberdeen, 1131—Winding up df
1st Scottish General. Hospital Gifts Com¬
mittee, 1132
Scott, Dr. Gladwys H., Dr. J. C. Mottrara. Dr.
8. Russ, and Dr. Helen Chambers, experi¬
mental studies with small doses of X raj b,
692
Scottish Poor-law Medical Officer.*’ Associa¬
tion, report, 200; Ministry of Health Com¬
mittee, 433; Board of Health Bill, 588,640,
688. 819, 863, 917, 957, 1008; Universities
Entrance Board, 631; Western Asylums
Research Institute, 812; nurses, resettlement
of, 812; parochial medical officers (Py (^).
918
Scurvy, infantile (Prof. A. Harden, Mr. S. S.
Zilvaand Dr. G. F. Still), 17; treatment of,
50; teeth, 1229
Searson, Dr. J., epidemic of septic pneumonia,
481
Secondary schools, medical Inspection of, 616
Secondary suture of wounds (MTr . R. A. Stoney),
978
Secretan. Dr. W. B., limitations of voluntary
hospitals. 952
Sfedobrol, 384
Sella turcioa, changes in, 300
Sensation and the cerebral cortex, 389
Sepsis,latent, eradication of (Mr, H. Platt), 175
Septic infection of lateral sinus after Injury at
operation, 340; pneumonia, epidemic, 481
Septicaemia, influenzal (Dr. A Abrahams, Dr.
N\ Hallows, and Dr. H. French) 1; Staphy¬
lococcus aureus, in influenza (Dr. A. Patrick),
137; meningococcic (Sir H. Rolleston), 548
Sequeira, Dr. J. H. Diseases of the Skin, third
edition, 1919 (review), 798
Sequestrum, the buried, a post-war problem
(Mr. J. Phillips), 291
Sera, Immune (Dr. C. F. Boldu&n and Dr. J.
Koopman fifth edition, 1917 (review), 746
Serbian libraries, restoration of, 388; books for,
398
Sergent, M. Emile, and Mile. T. Bertrand,
meningeal hemorrhage in typhoid fever, 519
Seram disease (air H. Rolleston), 651; anti¬
plague in influenza, 663; intrapulmounry
Injection in influenza, 1087
Scrums and vaooines supplied to the Royal
Navy, 145
Set vices Bill, Medical (leading article), 941;
(Py Q), 959
Services, deaths in: Surg.-Gen. Sir J. H.
Thornton, 125; Deputy Surg.-Gen. S. J.
Wynlowe, Brig. Surg. Lieut. Col. J.
Robinson, 536; JUettt.-Ool. J. G. Hojel, 638 ;
Lieut.-Col. K. F. Drake-Brockman, I.M«S.,
823 ; Maj -Gen. PI M. Kills, A.M.S.,950
Services, naval and military medical, 47, 86,
125, 157, 195, 278, 317, 354 , 399, 444, 486.535,
5S9, 633, 684, 722, 764, 822, £61,915.96-:. 1007,
1049; Indian Medical, pay in, 278. 441,589,
638, 764 , 765. 823, 861, 916, 960, 1008, 1095.
1135
Services of medical men in the war (Py Q),
1050
Sessile red fibroid, 22
Seta, Dott. Kachllo Della, saccharose injections
in pulmonary phthisis, 826
Sex Education for Parents and Teachers (Mr.
W. M. Galllgban) (review). 617
Share holding and medical men, 1045, 1093
Sharma, Lieut. J. K., I.M.S. (see Obituary of
the war)
Shattock, Prof. S. G., and Mr 0. A. R. Nitch,
diffuse empbysemaof waU of small intestine,
263
Shaw, Dr. F., extra-uterine pregnancy, 22
Shaw, Mr. B. H., and Dr. B. T. Rose, ectopic
gestation, 175
Shaw. Mr. E.. relation of pathology to clinical
medicine. 300
Sheen, Mr. A. W., " trivial ” cases at voluntary
hospitals, 196
Shefford, Mr. A. D. E., and Mr. W. M. Munby,
bone-grafting operations, 1070
Shell shock, study of (Dr. C. S. Myers). 51;
and tuberculoui cases (Py Q). 442; patients
(Py Q). 725: and neurasthenia (Py Q', 725;
treatment (Py Q), 864
Shera, Dr. A. G., Vaccines and Sera, their
Clinical Value In Military and Civilian Prac¬
tice (Oxford War Primers) (review), 426
Shettie, Mr. H. W.,death of, 688
Ship Captain’s Medical Guide (Dr. C. Borland)
(review), 23
Shipway, Dr. F. E., oil-other anaesthesia, 659
Shock discussion (Prof. W. M. Bayllss and Dr.
H. H. Dale), 256, 375; physics of, 269
Shock, shell, study of (Dr. C. S. Mvera), 51 •
emotional, on the battlefield (Cl. Vincent).
69 ; shell, and tuberculous cases (Py Q), 442;
wound, 668
“ Shock ” (so called), 397
Shufeldt, Maj. R. W., adaptation of tool
handles to crippled hands, 664
Sigmoid, adhesions of (Mr. J. P. Look hart-
Mummery and Dr. D. Pennington), 254
Signal lights, war Injury from (Dr. W. J.
Rutherford), 741
Silicosis scheme, the, 907
Silk. Dr. J. F. W., anesthesia,, a nasal air-way,
1030
Simon, Prof. S. K., treatment of amoebic
dye eatery, 429
Simple Beginnings In the Training of
Mentally Defective Children (Miss M.
Macdowell; (review), 566
Sin, Disease and Remedy of (Mr* W. M.
Mackav) (review'), 302
Sinclair, Maj. M., retrogressions In the- treat¬
ment of fractures, 507
Singer, Dr. R., and Dr. H. Elias, .war cures,
116
Sinuses, bone, treatment by solid metal
drains (Mr, C. J. Symonds), 971
Skin, Diseases of (Dr. J. H. Sequeira), third
edition, 1919 (review), 798
Slesinger, Mr. E. G., compound fractures of
the upper limb, 365
Slum-dweller and the slum-owner, 429
Small holdings and the returned soldier, 922
Small pox, recent incidence of, 388, 902; and
vaccination, half a century of (Dr. J. C.
McVail), 449; in England and Wales (Py Q),
484; in London, €88; epidemic expected in
Bengal, 760 ; at Dacca, 813
Smith, Dr. E. t “ ourselves only,” 961
Smith, Dr. F. J., obituary, 860
Smith, Dr. F. N., plastic vocal cord. 103
Smith, Dr. L., th3 obstetric helper, 797
Smith, Dr. R. K., influenzal intra-abdominal
catastrophes, 421
Smith, Lieut. Col. J. B , appointed honorary
surgeon to the Viceroy of India, 311
Smith, Mr. CL B., extra-uterine pregnancy,
Smtth, Mrs. A. II., treatment of scorvy, 60;
lemon juice or lime juice, 164
Smith.. Pr-jf. A. Introduction to Inorganic
Chemistry, tl.irl edition, 1918 (review),
225
Smith, P of. f}. T, the bird’s brain, 616;
appointed to chaii of anatomy at University
College. Lone! n. €89
Smoking, juvenile, in. India, 761
Smyly, Sir W., two tumours of the mesentery,
111; accidental haemorrhage in connexion
with eclam psism, 133
Snellen’s types, standard illumination of, 34
Snowden, Dr. E. N., Kemp, Prossar colour
soheme, 522
Snowman, Dr. J., Lencmann’s Manna’ of
Emergencies, Medical, Surgical, and. Ob¬
stetric (review), 513
Social medicine.in Vienna* 921;
Socldtd de Biol ogle, Parte (soe Medical
Societies)
Socidte de Thlrapeutique, Paris (see Medical
Societies)
Society for Relief of Widows and Orphans of
Medical Men, meeting, 964
Society for the State Registration of Trained
Nurses, 956
Sockets.contracted, 893
Soldier’s Heart and the Effort Syndrome (Dr.
T. Lewis) (review), 142
Soldiers, discharged, medical treatment (Py Q),
359, 360; tuberculous, discharged (Py Q),
401
Soldiers’, Invalided, Commission, Canada,
Report (review), 332
Solly, Dr. R. V., rat-bite fever. 458
Solomon, Dr. H. C., and Dr. E. E. S mthard,
Neurosyphilis, Modern Systematic Dia¬
gnosis and Treatment in 137 Case-histories
(review), 301
Solomons, Dr. B., sarcoma of cervix, 110; 500
consecutive operations at Mercer's Hospital,
265
Solution pot. iodide (80ufTron),364
Sonnt&g, Dr. C. F., temperature environment
and thermal debility, 836
Sons of medical men, deaths of. in the war
(see Sons under War and After); of medleal
men (see- Casualty Lists under War and
After)
Sorrel, Dr. R, and Dr. P. Moure, surgical
complications following exant hematic
typhus, 341
South Africa, Correspondence from.—
Influenza mortality in South Africa; Cape
Medical Connell; Maj. H. W. Sykes,
R.A.M.C-, the late, 395—Health In South
Afrioa; Influenza epidemio in Cape Town,
524—Household refuse; Alleged medical
profiteering, 526 — Influenza epidemic';
Death of Dr. S. B. Syfret, 720
South Africa Public Health Bill, 996
Southard, Dr. B. K., and Dr. H. 0. Solomon,
Neurosyphilis, Modern Systematic Dia¬
gnosis and Treatment in 137 Case-histories
(review), 301
South Devon and East Cornwall Hospital,
report, 862
Spanish-American medical fellowship, 76
“ Spanish disease*” epidemiology of, trans¬
mission of infection through fleas, 922
Specimen shown 105 years ago, 611
“Spectrum ” of epilepsy, 167
Spencer, Dr. H. R., corns on babies' noses, 583
Spencer, Dr. W. G., Lanrey and war surgery,
867. 920, 962
Sphagnum mo6S, 447
Spinal arises'hesia (Dr. F. S. Rood), 14; gun¬
shot concussion of (Henri Claude and dean
Lhermitte), 67; cord, surgery of, in peace
and war (Mr. A. J. Walton), 243
Spinal injury with retention of urine (Mr.
P. N. Vellacott), 733; effusions, haemorrhagic
( Dr. W. P. S. Branson), 888
Spirit duly (voluntary hospitals)grant, 826
Spirit of research, 625’
Spirits, supply of (Py Q). 359, 360; for
medicinal use (Py Q), 402, 865
Splrocbetose Icterohemorrnglque (Louis
Mat tin and Auguste Pettli) (review), 800
Spirochfctes in the blool in trench fever (Dr.
A. 0. Coles), 375, 388
Splrochsetosis ieterohaunorrhaglca, inactive
jaundice due to (Dr. W. H. Willcox), 931
Splenomegaly with polycytbn?mia rubra, 700
Splint, pelvic-femur, and armsplint (Dr. J. R.
i ee), 103
Spriggs, Dr. E. I., examination of vermiform
appendix by X raj s. 91
Sprue associated w it h tetany<3urg. Oapt. F.W.
Bassett-Smith) 178
Spurrell, Capt; H. G. F.» R.A.M.C. (see
Obituary of the war)
Squire, Mr. R. H., ad vanoes in treatment of
fractures, 80
Staining diphtheria bacillus (Dr. P; L. Suther¬
land), 218
Stamm, Dr. L. R, medical aspects of aviation,
2C6
Stammering in war psycho-neuroses (Mr. R
Prldeaux), 217
Staphylococcus auretis septlccemfe kv influenza
(l>r. A. Patrick), 137
Starling, Prof. E. H., food 111 relation to health,
591
S.asis, Intestinal, Chronic, Operative- Treat¬
ment (Sir W: A. Lane), fourth edition, 191E
(review ), 65; intestinal, chronic (Sir W. A.
Lane), 333; Intestinal (Dr. L. Brown)*
878
State and the doctor, medical unxninaltynnd
public spirit (Sir H. Morris), 165 ; (leading
article), 185; subsidy of tubereulous labour
(leading article), 469
State Medical Service,. 14V 312.
yt The Lancet,]
INDEX TO VOLUME I., 1919.
[July 5,1919
fcteele-Perkins, Dr. G., how to start, and how
to succeed. Id general practice. 1097, 1140
Btenhouse, Agnes L. and B., Health Header
for Girls (review), 142
Btenosls, pyloric, congenital, surgical treat¬
ment, 380^ 389
Stephen, Lleut.-Col. G. N., Boulogne as a
military modi cal base, 664
Stephens, Dr. G. A., lead line on tailors’ gums,
a dangerous practice, 644
Steven, Dr. G. H., and Dr. D. Bmbleton,
cerebro-spinal fever, cases as carriers, 788
Stevens, Mr. T. G., subperltoneal lipoma, 1072
Stewart, Dr. M. J., and Dr. H. L. Flint, rapidly
fatal ulcerative endocarditis, 1114
Stewart. Dr. B. M.. and Dr. T. G. Brown,
** hetenrstheaia,” 79
Stewart. Mr. A. W„ Recent Advances in
Organic Chemistry, third edition, 1918
(review), 617 ; Recent Advances in Physical
and Inorganic Chemistry, third edition, 1919
(review). 617
Still, Dr. G. F., Prof. A. Harden, and Mr. S. S.
Ztlva, infantile scurvy, 17
Stimulation, faradlc (Mr. H. Platt and Mr.
B. S. Brentnall), 884
Stockman, Sir S., louplng 111, 350
Stoddard, Dr. J. L, B. multi fermcntaru
teruilbus . 13
Stoicheiometry (Prof. 8. Young), second
edition, 1918 (review), 224
Stomach and duodenum, dinner fork in (Mr.
K. A. Lees), 293
Stom&ch, perforation in cancer of, 272; atonic
dilatation of (Dr. L. Brown), 877
Stomatitis and glossitis, lemon as a specific,
760
Stoney. Dr. Florence, psoriasis of 13 years
duration, 847
Stoney, Mr. R. A., secondary suture of wounds,
978
Stopford, Dr. J. S. B., gunshot injuries of the
cervical nerve roots, 336
Strabismus, new theory, 1132
Streaks in retina, 613
8treatfeild Research Scholarship, 584
Street. Mr. G. S., At Home in the War
(review), 142
Stretching tables for flexed thigh stamps after
amputation, 984
Stricture, malignant, of the oesophagus, 300
Strike in Belfast, 193
Strong, Dr. H. J., death of, 315
Strophanthus and strophanthine (oristallisle),
384
Students, medical, supply of, 391; in Switzer¬
land, 1011
Sturdy, Capt. A. C., M.C., R.A.M.O. (see
Obituary of the war)
Sturge, Dr. W. A., obituary, 633, 708
Sugar in urine and blood, Improved method
for estimation (Dr. P. J. Cammidgo), 939;
oontrol in the b^dy (leading article), 985
Suggestion, Advanced (Neuro-induction) (Mr.
H. Brown) (review), 302; Hypnotic, and
Psycho-therapeutics (Mr. A. B. Taplin)
(review), 302
Summer School of Civics and Bugenics, 549
Supplement, medical, of the Medical Research
Committee, 522
Suppuration, perinephric, epidemic, 1001,1044,
1092
Buppurative lesions, rnolybdeno-tungsten are
treatment (Mr. B. M. Young), 108
Surgeon in Arms (Cspt. R. J. Manion, M.C.)
(review), 1074
Surgeons, sub-assistant, supply of, 434
Surgery, Aids to (Dr. J. Cunning and Mr.
C. A. Joll), fourth edition, 1919 (review), 659
Surgery of the spinal cord in peace and war
(Mr. A. J. Walton), 243; British military,
in the time of Hunter and in the great war
(Sir A. Bowlby), 285
Surgical Treatment (Dr. J. P. Warbasae)
(review). 184; complications following
exanthematic typhus (Dr. P. Moure and Dr.
E. Sorrel), 341; appliances, new designs, 592;
treatment, 670; appliances for disabled
soldiers (Py Q), 820
Surplus army medical equipment (Py Q), 884
Suspension treatment of fractures of thigh
(Dr. W. H. Johnston), 170
Sussex Royal County Hospital, meeting, 443;
“ Pound Day,” 504
Sutherland, Dr. H., autotherapy or bleeding,
124; acute ascending paralysis, 841; tubercu¬
losis officers and panel practitioners, 895
Sutherland, Dr. P. L.. staining diphtheria
bacillus, 218
Suture holder, 772; secondary, of wounds (Mr.
R A. Stoney), 978
Swayne, Prof. W. C., and Mr. B. Russell,
quinine as an abortifadent, 841
Sweet, Dr. J. E., and Dr. H. B. Wilmer, treat¬
ment for trench fever, 252
Swletochowski, Dr. G. de, unusual contracture
of palmar fascia, 296
Swiney prize, award, 158,800
Syfret, Dr. S. B , death of, 720
Sykes, Maj. H W., R.A.M.C., death of, 396
Sym, Dr. W. G., familiarity with the ophthal¬
moscope, 232
Symbiosis, 622
Symns, Dr. J. L. M., and Dr. A. F. Hurst,
hysterical element in organic disease and
Injury of central nervous system, 369
Symonds, Mr. C. J., practice of the absentee,
45 ; treatment of bone sinuses by solid meted
drains, 971
Symptoms, hysterical perpetuation of (Mr.
C. H. L. Rixon), 417; Importance of, 480
Syndrome of the foramen lacerus posterius,
188
Synostosis, (?) congenital (Dr. Elizabeth S.
Chesser). 298
Synthetic Drugs, Chemistry of (Dr. P. May),
second edition, 1918 (review), 2214
Syphilis, treatment of (Dr. O. T. Dlunick),
1055
Syphilis, Wassermann reaction, diagnostic
value In, 466; and Locomotor Ataxia,
Intensive Treatment by Aachen Methods
(Mr. R. Hayes), third edition, 1919 (review),
466; primary, diagnosis of (Dr. S. F. Dudley),
737
Syphilitic placentae, 1073
T
Tabes dorsalis. Intravenous Injection of
potassium iodide in (Mr. F. J. Devota), 339
Taohycardia, paroxysmal, treatment by
respiratory effort, 853
Taplin, Mr. A. B., Hypnotic Suggestion and
Psycho-therapeutics (review), 302
Taylor, Dr. J., and Mr. W. S. Bdmond,
advances in the treatment of fractures, 46;
changes in the sella turcica In association
with Leber’s atrophy, 300
Taylor, Maj. F. M., R.A.M.C. (see Obituary of
the war)
Tsylor, Maj. J., teratoma of testicular relic,
1027
Taylor, Mr. G., double resection of bowel, 461
Taylor, Sir F., Practice of Medicine, eleventh
edition, 1918 (review), 22
Teeth, dislocation of (Mr. H. M. Savery), 399,
441; children's, 935 ; scurvy, 1129
Telford, Mr. B. D., and Mr. F. G. Narbury,
repair of the male urethra, 177
Temperature environment and thermal debility
(Dr. 0. F. Sonntag), 836
Tenaor, a, 826
Teratoma of testicular relic (Maj. J. Taylor),
1027
Territorial medical officers and demobilisation
(Py Q), 918, 960
Terror-neurosis, dreams of, 155
Testicle, undescended, 565
Tetanus, analysis of cases (Col. S. L. Cummins
and Maj. H. G. Gibson), 325; treated in
home military hospitals (Maj.-Gen. Sir D.
Bruce), 331; among British troops (Py Q),
726
Tetanus, revised memorandum on, 1125
Tetanus without trismus, 117
Tetany, associated with sprue (Surg.-Capt.
P. W. Bassett-Smith). 178
Therapeutic pulmonary trauma, 851
Thermal debility and temperature environ¬
ment (Dr. C. F. Sonntag), 836
Thigh, fractures of, suspension treatment (Dr.
W. H. Johnston), 170
Thiocol, 384
Thomson, Dr. F.,contact Infection of chicken-
pox, 397
Thomson, Dr. D., detoxicated vaccines, 374,
1102
Thomson, Dr. J. G., and Mr. C. II. Mills,
malaria and Wassermann reaction, 782
Thomson, Dr. W. H., Treatise on Clinical
Medicine, second edition, 1918 (review), 383
Thomson, Prof. A., compulsory Greek at
Oxford, 1045
Thomson, Sir J. J., O.M., appointed s member
of the Advisory Council to the Co i mlttee
of the Privy Council for Sclent it o and
Industrial Research, 90S
Thomson, Sir St Clair, intrinsic cancer of
larynx, 263, 271
Thoracic puncture fluid (Dr. S. R. Gloyne),
Thursfield, Maj. J. H., Maj. A. J. Jex-Blake,
Maj. M. Foster, Col. T. R. Elliott, and Capt.
D. S. Lewis, invalidism caused by P.U.O.
and trench fever, 1060
Thyroid gland and the sympathetic nervous
system (Dr. L. Brown), 831
Tirard, Sir N., appointed consulting physician
to King’s College Hospital, 350
Tissue destruction, selective, 430; stimulant,
scarlet red powder as (Dr. A. J. Turner), 463
T.N.T. poisoning, advisory committee on, 47
Tod, Mr. H., septic Infection of lateral qlnus
after injury at operation, 340
Tongue, lymphangeioma of, 940
Tonsil, endothelioma of, 300
Tool handles, adaptation to crippled hands,
664
Toothless mother, the. 922
Toxaemia, traumatic, 805
Trade-union question and the medical pro¬
fession (leading article', 345, 397
Training and Rewards of the Physician (Dr.
R. C. Cabot) (review). 224
Traltement des Psychonevroses do Guerre (G.
Roussy. J. Bolsseau, and M. D’Oelsnitz)
(review), 1119
Transactions of the Sixth International Dental
Congress (review), 24
Transfusion in diseases of the blood, 379;
blood, by the citrate method (Mr. A. Fleming
and Dr. A. B. Forteous). 973, 968; of blood
(Dr. R. L Hunt and Dr. Helen Ingleby), 975,
988 ; blood, Pepys on, 1098
Transient hemianopla, 574
Trauma, t herapeutic pulmonary, 851
Traumatic aneurysm of external earotld (Dr.
8. C. Dyke), 21; lesions, pathological
changes In (Mr. A. J. Walton). 243; toxaemia,
805
Traumatic Osteomyelitis, Chronic, its Patho¬
logy and Treatment (Dr. J. R. White)
(review), 1074
Trench fever and P.U.O., invalidism cause!
by (Col. T. R. BUIott, Cspt. D. 8. Lewis,
Maj. J. H. Thursfield, Maj. A. J. Jex-Blake,
and Maj. M. Foster), 1060
Trench fever, treatment (Dr. J. E. Sweet end
Dr. H. B. Wilmer), 252; spirochetes in the
blood in (Dr. A. C. Coles). 375, 388; colloidal
Bllver In, 583; and malaria (Dr. G. Ward),
609; suhaoute (Dr. J. H. Lloyd), 791; sub¬
acute, 858
Treves, Mr. B , death of, 823
Trlmethenal-allyl carbide In influenza, 440
Tritton, Sir B., death of, 45
" Trivial ” cases at voluntary hospitals, 196
Tropical Surgery and Diseases of the Far Bast
(Dr. J. R. Mo Dill) (review). 466
Tropical disease), new hospital for, 946
Tropics, health and life in, 644
Tubal pregnancy, 110
Tubby, Col. A. H., Dr. G. R. Livingston, and
* Dr. J. W. Mackie. treatment of gunshot
wounds, 251; and Maj. A. R. Ferguson, Capt.
T. J. Mackie, and Capt. L. F. Hirst, action
of flavine, 838
Tube strike, medical effects, 279
Tuberculosis, hilus, in the adult (Dr. C.
Riviere), 213, 682, 814; Service (leading
article), 304; ex-Servlce meD, after-care of
(Py Q), 320: cutaneous, Chemotherapy in
(Mr. H. J. Gauvaln), 412; in female muni¬
tion workers, 432 ; public health aspect of,
464 ; pulmonary, saccharose Injections in,
540, 636, 826; pneumonic, acute. 615;
problem, future of, 636; abdominal. 940
Tuberculosis Society (see Medical Societies)
Tuberculosis toll in Canada, 39; service, con¬
ference on, 119; in relation to upper air- and
food-passages, 223; In France, control of,
229; compulsory notification of, 233. 997;
problem, future of (Mr. P. C. Varrier-Jones),
453; treatment in London (Py Q>, 864;
officers and panel practitioners, 895; in rela¬
tion to a Ministry of Health, 1027; In Navy
(Py Q), 1137
Tuberculosis: Tuberculous ex-Servlce men;
Suggested scheme for a tuberculosis service;
Government contributions to residential
treatment of tuberculosis; Hull After Care
Colony; Bournemouth After-Care Colony;
Welsh National Memorial Association, 310—
Compulsory notification of tuberculosis In
France; Decline of tuberculosis In Trinidad,
311-Colonisation of the tuberculous; Local
Government Board standard sanatorium, 628
—Tubercle, 629—Institutional treatment for
Insured persons; Prevalence of tuberculosis
In France; Tuberculosis pensions in South
Africa; American Red Cross Society In
France; Tuberculous reports, 854—American
Review of Tuberculosis; North of England
Tuberculosis Association, 855
Tuberculous patients, Bill to provide treat¬
ment, 233; soldiers, discharged (Py Q), 401;
glands, treatment of, 424; and shell shock
cases (Py Q), 442; officers (Py Q). 588;
patients, Army huts for (Pv Q). 641; ex-
service men, after-care of, 767; poor, in aid
of, 814 ; soldiers, emigration of (Py Q), 821
Tumour, cartilaginous, of roof of the orbit,
300; pituitary, 613; pulsating, of orbit, 613;
malignant, of the pituitary body, 613
Tumours, cystic, of the vulva, 22; two, of the
mesentery, 111; spinal, clinical manifesta¬
tions in (Mr. A. J. Walton), 244
Turner, Dr. A. J., scarlet red powder as a
tissue stimulant, 463
Turner, Dr. A. L., Sir William Turner, K.C.B.,
F.R.8., a Chapter in Medical History
(review), 896
The Lancet,]
INDEX TO VOLUME I., 1919.
[J uly 5,1919 ttt
Turner, Mr. Percival, buying prac'icea, 398
Turner, Mr. Philip, undescended testicle, £65
Turner, Sir William. K.C.B., F.R.S., a Chapter
in Medical History (Dr. A. L. Turner)
(review), 896
Tweedy. Prof. E. H. t leaver uterine segment
and uterine tendons, 376, 390, 723
Tweedy, Sir J., the late Henry Sandford 125 ;
annual oration at Medical Society of London,
846
"Twilight sleep,”658
Tympanic membrane, new method of Incision
(Mr. R. Lake). 977
typhoid and Paratyphoid Fever, Surgical
Affects (Mr. A. E. Webb-Johnson) (review),
Typhoid fever treated by colloidal iron, 424;
meningeal haemorrhage in, 519; (ever, pre¬
vention, 950
Typhus a*>d encephalitis lethargies, 156
Typhus, exanthematic, surgical complications
following (Dr. P. Moure and Dr. E. Sorrel),
341; exanthematic, nervous complications
(A. Devaux),567 ; in Europe, 1053
Tyrrell, Dr. B. J., intolerance of aspirin, 1118
U
Ulcerative endocarditis, rapidly fatal, due to a
Gram-positive pleomorphic dlplococcus (Dr.
- M. J. Stewart and Dr. H. L. Flint), 1114
Ulster branch of British Medloal Association,
1010
Ultra-violet rays and plant stimulation, 430
Unholy holidays, 904
Unilateral hydrothorax due to disease below
the diaphragm (Mr. \V. G. Nash), 378
United States X Kay Manual (review), 224
University College Hospital, report, 585; and
hospital war memorial, 999
Urethra, male, repair of (Mr. B. D. Telford and
Mr. F. G Norbury),177
Urethral nozzle, 514
Urology, Modern (Dr. H. Cabot) (review), 467
Uterine fibroid, spontaneous enucleation, 301 ;
segment, lower, and uterine tendons (Prof.
B. H. Tweedy), 376. 390, 481. 723, 815
Uterus, special supports of, 904
V
Vacancies, weekly lists of, 49, 89,127.162, 2G0,
240. 283, 321, 362. 403. 445, 487, 537, 689, 642,
686. 726, 770, 824,865,919,961,1009.1061,1096,
1138
Vaccination (Py Q), 484; public, lymph for
jP^Q), 484; prosecutions in Wexford (Py Q),
Vaccination and small-pox, half a century of
(Dr.J.C. Me Vail), 449
Vaoclne, Influenza (mixed), 24; lymph, com¬
mercial, quality of. 306, 313, 357; therapy,
causes of failure (Sir A. B. Wright), 491; use
of. In Influenza (Dr. F. T. Cadham), 855;
lymph (Py Q), 918
Vaccines and Sera, their Clinical Value in
Military and Civilian Practice (Dr. A. G.
Shera) (Oxford War Primers) (review), 428
Vaccines and serums supplied to the Royal
Navy, 145
Vaccines, detoxicated (Dr. D. Thomson), 374 ;
with special reference to gonorrhoea, nasal
and bronchial catarrh, and influenza,
1102; Influenza, 476; pus. In the treatmentof
gonorrhoea (Mr. B. G. D. Ptneo and Dr. D. M.
Baillle), £08; preventive, for influenza,
707
Vaccines, detoxicated (leading article), 1123
Vaccinia, generalised,-fatal cats, 906; in treat¬
ment of gonorrhoea (Dr. D. Lees), 1107
V.A.D., the future of, 77; and the College of
Ambulance, 271
Valenda spray, 898
Varrier-Jones, Mr. P. 0., future of tuberculosis
problem, 453
VellacoU, Mr. P. N., spinal injury with reten¬
tion of urine. 733
Venereal disease in the Army, prevention and
arrest, discussion. If9; treatment (Sir A.
Reid and Dr. P. H. Boyden), 212 314 ; com¬
bating (Py Q), 321; disease (Brevet Col . L. W.
Harrison), 713; treatment centres in Glasgow,
813; disease (PyQh 864; remedies for (Py Q),
918 ; and crime, 950; among the troops
(Py Q), 1050
Venereal disease, control of: Comprehensive
programme of the National Council; Antl-
venereal campaign in the United States, 352
—In Ontario, 434,949—In Montreal; Problem
in Bas'ern Canada, 435—National Council
for Combating, ; Red Cross Conference at
Cannes; syphilis number of Paris Medical;
Flekner’s " Prostitution in Europe,” 1130
Venereal diseases, pregnant women suffering
from, residential treatment. 80; in Egypt
during the war, management of, 140. 198;
mobilisation of, 230; (PyQ). 534; infection
(Py Q), 587 ; notification of (Py Q), 685;
diagnosis of, and laboratory methods, 817,
859
Ventilation In the tropics, 922
Vermiform appendix, examination by X rays
(Dr. B. I. Spriggs), 91
Vernet, Dr. M.. syndrome of the foramen
lacerum posterlus, 188
Vernon. Dr. H. M , causation and prevention
of industrial accidents, 549
Veronidla, 24
Veterinary Post-mortem Technic (Dr. W.
Crocker) (review), 225
Veulle, De, case of, 680
Vevey, Dr. S. A. dc, treatment of Influenza and
infectious diseases by lyxnphotherapy and
hsematotherapy, 424
Vincent, Cl., manifestations of emotional
shock on the battlefield, 69
Vine, Dr. A. B.. and Dr. T. P. Noble, peri¬
cardiotomy, 107
Virus, filter-passing, in certain diseases (Maj.-
Gen. Sir J. R. Bradford, Capt. B. F. Bash ford,
and Capt. J. A. Wilson), 169; In Influenza,
280, 313
Vischer, Dr. A. L., and Prof. R. Bing, psycho¬
logy of internment, 696
Visual perception of solid forms, 1072
Vital need, the, 363 ; a third factor, 405
Vital statistics, Irish, conditions of medical
service in Ireland, 475
Vital statist ica of England and Wales for 1918,
196 ; of Calcutta, 233. 857, 913
Vital statistics of London during November,
1918, 39; during December, 161; during
January, 1919, 355; during February, 479;
during March, 721; during April, 911 ;
during May, 1136; during the year 1918,
637
Vital statistics of 1917, 1034, 1126
Vital statistics, urban, English, Scotch, and
Irish towns. 40. 83.126,161. 237, 275,311, 354,
391, 444, 4E0, 527, 582, 636, 720, 769, 823, 859,
911, 950, 1000,1051, 1091,1136
Vitamlnes, unknown but essential accessory
factors of diet (Prof. F. G. Hopkins), 365;
the instability of, 623
Vivisection of dogs(Py Q), 820; BUI to restrict,
1091
Vocal cord, a plastic (Dr. F. N. ’Smith),
108
Voeickcr, Dr. A. F., polycj thcmla rubra with
splenomegaly, 700
Voluntary hospitals and the work of the
almoner (leading article), 849; hospitals,
limitations of, 952
Vomiting, hysterical, in soldiers (Dr. W. R.
Reynell), 18, 118
Vuillet, Dr. Ueuri. epidemic diseases observed
in Rumania during the campaign of 1916-17,
569
Vulva, cystic tumours of, 22
W
Waldo, Dr. F. J., reappointed ooroner for the
city and borough of Southwark, 537
Waldron. Maj. C. W.. and Capt. E. F. RIsdon,
mandibular bone grafts, 181
Walker, Dr. E. W. A., compulsory Greek at
Oxford, 1000
Walker, Dr. Jane. State medical service, 141
Wallace, Dr. J. S., causes and incidence of
dental carles, 238
Walls, Dr. W. K., advanced extra-uterine
pregnancy, 301
Walton, Mr. A. J., surgery of the spinal cord in
peace and war, 243
Wanted, a bungalow, 692; a home, 868; a
medical "Labour Exchange,” 1001
War (Dr. R. C. Macfie) (review), 1119
War bonus, increased, to insurance practi¬
tioners, 1129
War cures, 116; deafness, 157, 198, 238; Office
and medical women (Py Q), 402; memorial, a
practical, 644; neuroses (Dr. F. W. Mott),709,
766; neurosis (Dr. W. Brown), 833; injury
from signal lights, 741; memorial to officers
and men of the K.A.M.C., 766; gratuities to
nurses (Py Q), 1008 ; nurses, resettlement of,
1090
War pensioners in civil hospitals (leading
article). 186
War, role of consulting surgeon in (Sir G. H.
Maklns), 1099
War Story of the Canadian Army Medical
Corps (Col. J. G. Adami) (review), 11!;
Wounds, Early Treatment (Col. H. M. W.
Gray) (review), 513; Wounds, Locomotor
Ataxy tbe Result of, Disabilities of (Prof. A.
Broca) (review), 799
War, the, axd After s—
Brompton Hospital for Consumption*
report, 581
Caau<ea among the sons of medlcaAinen*
41, 122, 158.193, 275. 315. 358. 3*8. 4371486,
531, 581, 683. 722, 768. 817, 912
Casualty list, 41, 84.158. 275.315, 358,398,486,
530. 580. 632, 683, 722, 768. 817, 859, 962*
1046, 1091
Central Medical War Committee, medical
mobilisation and demobilisation, 193; the
interests of those who have been on.
service, 357
Civil medical practitioners’ war services,
list. 438
Decorations, foreign, 160, 193, 317. 531, 632*
956, 1000,1068, 1091
Demobilisation of the British Red Cross, 41;
medical, 84; scheme of Central Medical
War Committee, 84; and mobilisation*
medical, work of the Contral Medical War
Committee, 193
Despatches, mentioned in, 41. 86, 195, 277,
437, 331, 683 768, 912. 1048, 1091
Honour* list, 41. 85. 1?2, 158, 275, 315, 398*
437, 531, 632. 768, 999, 1046, 1091
Medical practitioners', civil, war services,
list, 438
Ministry of National Service, Sir. A. Geddea
thanks the Medical Department, 580
Mobilisation and demobilisation, medical,
work of the Central Medical War
Committee, 193
Notice, brought to, 160, 399
Portsmouth Royal Hospital, meeting, 632
Red Cross, British, demobilisation, 41;
ambulances for home service. 683
Royal Army Medical Corps, casualties, 41*
84. 158, 275, 315, 393. 486, 530, 581. 632, 683.
722, 817. 859, 952. 1046. 1091 ; honours, 41*
85,122,158. 275, 315, 398. 437. 531, 632. 999,
1046; auxiliary funds, 238, 632 ; temporary
officers, 1137
Royal Medical Benevolent Fund War
Emergency Fund, 315, 358, 684, 999
Sanatoria for discharged soldiers and sallon
Buffering from tuberculosis, 859
Sons of medical men. deaths In the war, 41,
122, 158, 193, 275, 315. 358, 3S8, 437, 486,631*
581, 683, 722. 768, 817, 912
University College and Hospital War
Memorial, 999
Webb, Col. A., A.M.S., appointed Director-
General of tbe Medical Branch of Ministry
of Pensions, 238
War, tbe great, total deaths from wounds In*
406; the next, man verms insects, 434;
lessons of (Sir A. E. Wright). 489
War, weather, and water-supply, 1128
Warbaase. Dr. J. P., Surgical Treatment
(review), 184
Warble fly, tbe. 472
Ward, Capt. Gordon, apyrexlal symptoms of
malaria, 222; malaria and trench fever, 609;
notification of dysentery, 723; literature of
b somatology, 817
Wardrop, Dr. J. G., and Dr. A. B. Malone,
recurrent cbylothorax following trauma, 1116
Waring, Mr. H. G., admission of pensioners
to civil hospitals, 179
Warning, 164
Warren, Mr. R., diaphragmatic hernia, 1069*
1089
Wassermann reaction, diagnostic value in
syphitis, 466; a criticism of its reliability
(Dr. C. F. White. Dr. A. T. McWhlrt r, and
Dr. H. Barber), 502; and malaria (Dr. J. G.
Thomson and Mr. C. H. Mills). 782; testa
i Dr. C. H. Browning and Dr. E. L.
tennaway), 785 ; significance of, 807
Water-supply, Metropolitan, during July,
August, and September, 1918, 80; during
October, November, and December, 1918,
363; during January, February, and March*
1919,1098
Water-supply, war, weather, and, 1128
Watson, Capt. A., death from scorpion stings*
884
Watson, Dr. D. C., coordination of dlnical
research by the State, 989, 992
Watson-Williams, Dr. P., chronic adhesive
otitis, 893
Watts, Mr. F., Echo Personalities (review)*
983
Webb, Col. A. W., A.M.S., appointed Director-
General of the Medical Branch of the
Ministry of Pensions, 238
Webb-Johnson, Mr. A. E., Surgical Aspects of
Typhoid and Paratyphoid Fevers (review)*
383
Weight, increase effected by diet of low
calorific * alue, 940
West, Dr. S., the hypothermic, or depression,
stage of Influenza, 196
West, Mr. J. L„ saccharose injections in pul¬
monary tuberculosis, 540
xxti The Lancet.]
INDEX TO VOLUME I., 1919.
IJunrS, 19W
West London Medioo-CMrurgical Society (see
Medical Societies)
Westminster Hospital, future Of, 272
Weston, Mr. F. E., and Mr. P. J. Fryer,
Tedinical Handbook of Oils, Fats, and Waxes
(review), 897
Wheelhouse's operation (Mr. J. B. Macalplne),
Wilson, Capt. J. A., Maj.-Gen. Sir J. R.
Bradford, and Capt. E. F. Bash ford, filter
passing virus in certain diseases, 169; acute
infective polyneuritis, 348
Wilson, Capt. W. D. C., R.A.M.O. (see Obituary
of the war)
Wilson, Dr. H., post-influenzal haemoptysis,
Whipple, Mr. R. S., electrical methods of
measuring body temperature, 564; the
electro-cardiograph, 564
Whisky and water, 270
Whisky for medical purposes (Py Q), 442
White, Dr. C. F., Dr. A. T. McWnlrter, and Dr.
H. Barber, Wassermann reaction, a criticism
of its reliability, 502
White, Dr. J. R., Chronic Traumatic Osteo¬
myelitis, its Pathology and Treatment
(review), 1074
White, Dr. W. H., teaching of medicine, 31
White, Maj. F. N., twenty years of plague in
India, 349
White, Mr. C., foetus daring spontaneous
evolution, 610; full-time pregnancy in a
rudimentary uterine horn, 612
Whitoford, MrC. H., discussion on shook at the
Royal Society of Medicine, 357; a sntnre
holder, 772
Whiting. Dr.. A., Aids to Medical Diagnosis,
second edition, 1918 (review), 112
Whitworth, Capt. H. P., R.A.M.O. (see
Obituary of the war)
Whom the Klngdellgnteth to honour, 1039
Whooping cough, problem In treatment (Dr.
N. Macleod), 254
Whyte, Capt. G. T., R.A.M.C. (see Obituary
of the war)
Widows’ pensions In the Navy, 724
Wiglesworth, Dr. J., death of, 915,1042
Wigmore Hall, medical meeting, 240,362
Wilkie, Dr. D. P. D., acute appendicitis and
acute appendicular obstruction, 197
Wlllcox. Dr. W. H., jaundice, 869, 929; toxic
jaundice, 871
Willett, Dr. J. H., ectopic gestation, 22;
spontaneous enucleation of uterine fibroid,
301
William Gibson Research Scholarship for
Women, 585
Williams, Mr. J. P., blaekwater fever, 886
Williams, Dr. Mary H., Immunity in
"influenza," 529; hllus tuberculosis in
Children and adults, 682'
Williamson, Dr. EL, specimen shown 106 years
ago, 611
Winner, Dr. H. B., and Dr. J. B. Sweet, treat¬
ment for trench fever, 252
• Wilson, Dr. R. M., Hearts of Man (review),
Wilson, Dr. W. J., gas gangrene, 657
Wilson. Lleut.-Ool. B. M., H.A.U C. Fund and
R.A.M.G. Officers’ Benevolent Sooiety,
858
Wingfield, Dr. R. C., tuberculosis in relation to
a Ministry Of Health, 1027
Winter, Mr. F. I., aspect of psycho-analysis,
708
Wirgman, Dr. C. W., preventive Inoculation
against influenza, 357
Wise, Dr. C. H., death of, 443
'Woman and the legal profession, 680; doctor
sued by member of the Q.M.A.A.C.. 1040
Women and methylated spirits (Py Q), 401;
medical, and the War Office (Py Q), 402;
medical officers in military hospitals (Py Q),
442 ; chiefs, 583. 636 683; and the Medical
Society of London, 851
Women in industry (leading article), 899 ; and
the Medical Society of London, 851, 944,
989
Wood, Capt. R., Whole Duty of the Regi¬
mental Medical Officer (review), 466
Wood, Dr. H. B., Sanitation Perfectly Applied
(review). 659
Woodcock, Dr. H. de C., treatment of tuber¬
culous glands, 424
Word-association test in psychiatry, 234;
Studies In (Dr. C. G. Jung) (review), 234
Words causing physical Injury, 270
Worm, round, migration into the ear, 28
Worster-Drought, Dr. 0.. and Dr. A. M.
Kennedy, Certbro-spinal Fever (review),
1073
Worth, Mr. B. H., •• ourselves only,’* 913
Wound shock, 668
Wounds, gunshot, treatment (Mr. A. H. Tubby,
Dr. G. R. Livingston, and Dr. J. W.
Mackle), 251; Infected, treatment (Mr. E. G.
81<?8inger), 367; war, septic (Sir A. B.
Wright', 492; War, Early Treatment (Col.
H. M. W. Gray) (review), 513; gunshot, of
the chest, 666, 667; guushot, and other
affections of the chest (Mr. O. MacMahon),
697; Gunshot, and their After Treatment,
Orthopaedic Effects (Dr. S. W. Daw) (review),
‘Wounds, healed, latent infection of (Sir K.
Goartby), 879 ; and Injuries, After-Treatment
(Maj. K. C. Elmslie) (review), 896; secondary
suture of (Mr. R. A. Stoney), 978
Wright, Sir A. E., lessens of the war, 489
Wright, Oapt. A. F., new " 606 ” apparatus,618
Wright son. Sir T., and Prof. A. Keith, new
theory of hearing, 510
Wylie, Dr. A., peritonsillar abscess, 178;
formalin spray in checking influenza, 866
X
Xray examination of vermiform appendix (Dr.
E. I. Spriggs), 91
X Ray. Technic (Maj. A. 0. Christie) (review),
184 ; Manual, United ‘States (review),
224
X rays in diagnosis of appendicitis, 279
X rays, experimental studies with small doses
(Dr. S. Ross, Dr. Helen Ch am bers, Dr.
Giadwys M. Scott, sad Dr. J. O. Motts—u),
692
Y
Yamsnouohi, Prof. T., Dr. K. Sakakaml, and
Dr. 8. Iwashtma, infecting agent in in¬
fluenza, 971
Y.M.C.A. Agricultural Training Colony,
Klnson, Dorset, 456
Yorko, Prof. W., amceblo dysentery, 674
Young, Capt. R. P., Aust. A M.C. (see Obituary
Of the war)
Young, Mr. B. M., molybdeno-tungsten are In
treatment of various suppurative lesions,
108
Young, Mr. G., double sclerectomy operation
for glaucoma, 893
Young, Prof. S., Stoleheiometry, seoond
edition, 1918 (review), 224
Yovanovitob, Mr. Y., children of devastated
Serbia, 963
Z
Zilva, Mr. S. S., Dr. G. F. Still, and Prof. A.
Harden, infantile scurvy, 17
Zimmem, Prof. A., and M. P*eire Perol,
Electro-Diagnosis in War (review), 468
END OF THE FIRST VOLUME FOR 1919.
PnurrsD and Published by the Proprietors, Waxley awd Sow (1912), Ltd., at No. 423, Strand, and Nos. 1 and 2, Bedford-street, Staan\
in the Perish of St. Martln-in-the-Fields. Westminster, In the County of London.—Saturday, July 5th, 1919.
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