342 general practitioners, so that we still see patients who have suffered from the commonest of all hand infec- tions, that of the pulp of the finger, crippled by an ill-chosen median incision. Either there remains a scar too sensitive to pressure for use, or deforming scar- tissue has destroyed the delicate tactile sensibility of the pulp. Early lateral incisions are just as effective in checking the infective process without these draw- backs. The unsightly nails we still see after the healing of a whitlow result from delay in removing the nail and the unnecessary incision of the matrix. When the infection has reached the tendon sheath the prognosis as regards future mobility is rather poor, for the tendon is very likely to slough or form such adhesions that it becomes immovably fixed, whilst extension to an interphalangeal joint will almost certainly lead to a stiff finger. Here early lateral incisions are essential, but though they may pass with advantage through the subcutaneous tissue along the whole length of the finger, the sheath should only be opened opposite the shafts of the phalanges, or a troublesome prolapse of the flexor tendons will occur. The after-treatment of these thecal whitlows is exceedingly difficult and an issue with good movement is the exception rather than the rule. Sir HENRY GRAY’S recommendation that WILLEMS’S mobilisation treatment should be instituted from the first deserves attention. After the incision the patient must be encouraged, threatened, or cajoled i into active movements whilst his hand remains in a i bath of weak antiseptic or saline solution. Passive movements are wrong and do harm. Drainage by this method is good. Tubes, gauze, or rubber tissue drains are seldom necessary. The worst of all infections are those which travel up from the thumb or little finger to the anterior carpal sheath. The operative treat- ment of this condition is a major surgical procedure and should always be carried out very deliberately under general anaesthesia, with a tourniquet applied. The areas of infection must be reached by the proper anatomical route, injury to the nerves and vessels of the palm being sedulously avoided. Even with the greatest care, the infective process may spread to the fascial planes of the forearm, and the general condition of the patient be so grave that an amputation becomes the only life-saving operation. Mr. D. P. D. ’WILKIE called attention to those streptococcal infections which show such a great tendency to generalisation. With a non-suppurative limited area of infection in the hand are associated a lymphangitis up the arm, an axillary adenitis, and septicsemic symptoms. Early incision is not indicated in this condition, the principles of treatment being to aid the general resistive powers of the body, encourage elimination, and locirv to institute Bier’s hypersemia. DOCTORS AND UNCERTIFIED MIDWIVES. A CASE of some interest, decided earlier in the year but only lately appearing in the Law Reports, throws light on the amount of supervision which a doctor should exercise over a woman who acts as a midwife without being certificated. The Midwives Act of 1902 declares that, if a woman is not certified under the Act, she commits an offence punishable by fine if she " habitually and for gain " attends women in child- birth " otherwise than under the direction of a qualified medical practitioner." An exception is made for emergencies, but in the case to which we draw attention (D 4vgs v. MoRRis, Law Times Reports, vol. cxxix., p. 88) there was no suggestion of an emergency. The facts were that five expectant z, mothers had engaged an uncertified midwife’s I services ; qualified medical practitioners were also I retained in each case, but they did not pay any professional visits until after the confinements which were attended by the woman alone. In these circum- stances she was prosecuted under the section. The doctors who had been retained came and gave evidence on her behalf. They said she was in their opinion capable and trustworthy; they had given her no specific instructions ; it was unnecessary to do so ; she was acting, they said, under their direction in attending the confinements. The magistrates had to consider whether this was sufficient supervision under the Act, or whether " direction " did not mean special instructions suitable to the particular case. They came to the conclusion that no offence had been committed and they dismissed the prosecution. It turns out, however, that they were wrong. The Lord Chief Justice pointed out that in no case was there any professional visit by the doctor ; in no case was there any professional inquiry or any specific instruction. There was thus no evidence on which the magistrates could find that there had been any direction at all. Direction must be real and not nominal. " The medical practitioner should accept more than the nominal responsibility for the case. He must make himself acquainted with the particular requirements of the patient. It is not enough that there should be a qualified figure-head in the back- ground ; the unqualified person must be acting under the real direction of a medical practitioner." This judicial homily deals, we take it, not so much with the abstract standard of doctors’ conduct as with the conditions necessary to be established in a court of law if an uncertified midwife is to be found not guilty of an offence against the Act. But as there is no statutory definition of " direction," the decision is. valuable. It is only fair to add that the woman whose action was in question had formerly been a certified midwife, but her certificate had been with- drawn. In the eye of the law she may have been uncertified and unqualified, but the skill and experience which in time past had been sufficient to earn her certification were, doubtless, well known to the doctors under whom-if not under whose " direction " - she was serving. ALTERATIONS OF VIRULENCE BY PASSAGE. IT is commonly held-and on sound experimental grounds-that when a dose of many millions of bacteria is given to an animal the great majority of the organisms are soon killed and disposed of, and that fatal infection, if it occurs, is due to the survival- and multiplication of the relatively infrequent individuals which are able to withstand the attempts of the animal to destroy them. If after the death of the first animal this new race of exalted virulence is inoculated into a second host a similar selection occurs, and so on through successive animals until the capacity of resisting the mammalian body, in other words the virulence, of the organism has by this- selective breeding been developed to the highest possible degree. Whether the mean virulence of the- race which is finally obtained is greater than that of the most virulent individual of the original inoculum is unknown, but if there is any such progress in absolute individual virulence selective breeding seems- to be the basis of this pasteurian exaltation of virulence by passage. It seems likely, too, that the same process- goes on during the course of a natural epidemic. Several experimental observations have, however, lately been made which indicate that this is not always the sequence of events. Prof. C. H. BROWNING and Miss R. GULBRANSEN 1 noticed that very small doses of pneumococci, which 1 Journal of Pathology and Bacteriology, 1923, xxvi., 122.
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general practitioners, so that we still see patients whohave suffered from the commonest of all hand infec-tions, that of the pulp of the finger, crippled by anill-chosen median incision. Either there remains ascar too sensitive to pressure for use, or deforming scar-tissue has destroyed the delicate tactile sensibility ofthe pulp. Early lateral incisions are just as effectivein checking the infective process without these draw-backs. The unsightly nails we still see after the healingof a whitlow result from delay in removing the nailand the unnecessary incision of the matrix. Whenthe infection has reached the tendon sheath the
prognosis as regards future mobility is rather poor, forthe tendon is very likely to slough or form such adhesionsthat it becomes immovably fixed, whilst extension toan interphalangeal joint will almost certainly lead toa stiff finger. Here early lateral incisions are essential,but though they may pass with advantage through thesubcutaneous tissue along the whole length of thefinger, the sheath should only be opened opposite theshafts of the phalanges, or a troublesome prolapse ofthe flexor tendons will occur. The after-treatment ofthese thecal whitlows is exceedingly difficult and anissue with good movement is the exception rather thanthe rule. Sir HENRY GRAY’S recommendation thatWILLEMS’S mobilisation treatment should be institutedfrom the first deserves attention. After the incisionthe patient must be encouraged, threatened, or cajoled iinto active movements whilst his hand remains in a ibath of weak antiseptic or saline solution. Passivemovements are wrong and do harm. Drainage by thismethod is good. Tubes, gauze, or rubber tissue drainsare seldom necessary. The worst of all infections arethose which travel up from the thumb or little fingerto the anterior carpal sheath. The operative treat-ment of this condition is a major surgical procedure andshould always be carried out very deliberately undergeneral anaesthesia, with a tourniquet applied. Theareas of infection must be reached by the properanatomical route, injury to the nerves and vessels ofthe palm being sedulously avoided. Even with the
greatest care, the infective process may spread to thefascial planes of the forearm, and the general conditionof the patient be so grave that an amputation becomesthe only life-saving operation.
Mr. D. P. D. ’WILKIE called attention to those
streptococcal infections which show such a greattendency to generalisation. With a non-suppurativelimited area of infection in the hand are associated a
lymphangitis up the arm, an axillary adenitis, andsepticsemic symptoms. Early incision is not indicatedin this condition, the principles of treatment being toaid the general resistive powers of the body, encourageelimination, and locirv to institute Bier’s hypersemia.
DOCTORS AND UNCERTIFIED MIDWIVES.A CASE of some interest, decided earlier in the year
but only lately appearing in the Law Reports, throwslight on the amount of supervision which a doctorshould exercise over a woman who acts as a midwifewithout being certificated. The Midwives Act of 1902declares that, if a woman is not certified under theAct, she commits an offence punishable by fine if she" habitually and for gain " attends women in child-birth " otherwise than under the direction of a
qualified medical practitioner." An exception ismade for emergencies, but in the case to which we drawattention (D 4vgs v. MoRRis, Law Times Reports,vol. cxxix., p. 88) there was no suggestion of an
emergency. The facts were that five expectant z,mothers had engaged an uncertified midwife’s Iservices ; qualified medical practitioners were also I
retained in each case, but they did not pay anyprofessional visits until after the confinements whichwere attended by the woman alone. In these circum-
stances she was prosecuted under the section. Thedoctors who had been retained came and gave evidenceon her behalf. They said she was in their opinioncapable and trustworthy; they had given her nospecific instructions ; it was unnecessary to do so ;she was acting, they said, under their direction inattending the confinements. The magistrates had toconsider whether this was sufficient supervision underthe Act, or whether " direction " did not mean specialinstructions suitable to the particular case. Theycame to the conclusion that no offence had beencommitted and they dismissed the prosecution. Itturns out, however, that they were wrong. TheLord Chief Justice pointed out that in no case was
there any professional visit by the doctor ; in no casewas there any professional inquiry or any specificinstruction. There was thus no evidence on whichthe magistrates could find that there had been anydirection at all. Direction must be real and notnominal. " The medical practitioner should acceptmore than the nominal responsibility for the case. Hemust make himself acquainted with the particularrequirements of the patient. It is not enough thatthere should be a qualified figure-head in the back-ground ; the unqualified person must be acting underthe real direction of a medical practitioner."
This judicial homily deals, we take it, not so muchwith the abstract standard of doctors’ conduct as withthe conditions necessary to be established in a court oflaw if an uncertified midwife is to be found not guiltyof an offence against the Act. But as there is nostatutory definition of " direction," the decision is.valuable. It is only fair to add that the womanwhose action was in question had formerly been acertified midwife, but her certificate had been with-drawn. In the eye of the law she may have beenuncertified and unqualified, but the skill and experiencewhich in time past had been sufficient to earn hercertification were, doubtless, well known to thedoctors under whom-if not under whose " direction "
- she was serving.
ALTERATIONS OF VIRULENCE BY PASSAGE.IT is commonly held-and on sound experimental
grounds-that when a dose of many millions ofbacteria is given to an animal the great majority ofthe organisms are soon killed and disposed of, andthat fatal infection, if it occurs, is due to the survival-and multiplication of the relatively infrequentindividuals which are able to withstand the attemptsof the animal to destroy them. If after the death ofthe first animal this new race of exalted virulence isinoculated into a second host a similar selection occurs,and so on through successive animals until thecapacity of resisting the mammalian body, in otherwords the virulence, of the organism has by this-selective breeding been developed to the highestpossible degree. Whether the mean virulence of the-race which is finally obtained is greater than that ofthe most virulent individual of the original inoculumis unknown, but if there is any such progress inabsolute individual virulence selective breeding seems-to be the basis of this pasteurian exaltation of virulenceby passage. It seems likely, too, that the same process-goes on during the course of a natural epidemic.Several experimental observations have, however,lately been made which indicate that this is notalways the sequence of events.
Prof. C. H. BROWNING and Miss R. GULBRANSEN 1
noticed that very small doses of pneumococci, which
1 Journal of Pathology and Bacteriology, 1923, xxvi., 122.
343
in large quantities were rapidly fatal, might set upa chronic pneumococcal septicaemia in mice lastingat least several weeks, during which time theorganisms can hardly have been engaged in selectivebreeding for virulence. The results in this instancemay have been due to the original dose having beenonly a small sample of the pneumococcus populationwhich by random sampling did not happen to containany highly virulent individuals. If that were theexplanation, the experiment would not come offevery time, for some of the samples would includethe most virulent cocci. The same authors2 laterpointed out that the virulence of the pneumococcipresent in the heart’s blood of a mouse dying within48 hours of inoculation may be actually less thanthose inoculated into the animal, and they haverecorded a similar loss of virulence in fatal infectionsof mice with tubercle bacilli. Dr. W. MAIR3 alsorecords some very significant observations. Rabbitsreceived a prolonged course of inoculation with deadpneumococci and their serum protected mice againstmany fatal doses of live organisms. The animalsthen received doses of living pneumococci ; aftersome months they deteriorated in general health, andon examination were found to have a pneumococcussepticaemia with extensive vegetations on the heartvalves, reproducing broadly the picture of chronicinfective endocarditis in man. The organisms isolatedfrom the blood proved to have lost their virulence forrabbits and mice in the sense that large doses nolonger caused acute death. Dr. F. GRIFFITH4 hasalso shown that these results may be reproduced invitro. By growing pneumococci in their own immuneserum he finds that a fresh race develops with differentcultural characters, resistant to agglutination (as inDr. E. W. A. WALKER’S classical experiments withtyphoid bacilli5), impotent as antigen, and with amarked loss of virulence. These modifications suggestthat the organism has been selected into a formwhich to a large extent fails to interact with the host,which is " naturally " immune to it to a certaindegree, and which will set up local changes only insuch places as the avascular heart valves, where thenormal mechanism of response and resistance isdefective. It is of much interest in this connexion torecall that Sir THOMAS LEWIS and his collaboratorshave latelv shown6 that the incidence of chronicinfective endocarditis in man is largely determinedby the occurrence of small congenital valvulardefects.There are evidently here a series of instances where
bacteria will live for a long time in the body, and maycause death, without on the one hand being destroyedby phagocytosis or other defensive mechanism, oron the other reaching an exalted virulence by aprocess of selective breeding. No explanation of thephenomena is obvious, but it is plain that the factsare of importance and may open up a fruitful field ofinquiry. " Virulence " may be too comprehensivea term, and it is possible that it should be dissectedinto capacity to cause damage in the body andcapacity to resist what the body does to destroythe parasite. Such a distinction was foreshadowedby Dr. W. W. C. TOPLEY in his Goulstonian lecturesof 1918 on the Spread of Bacterial Infection. The Ipneumococci in Dr. MAIR’S rabbits, for example,have a considerable virulence in causing a particularsort of damage and a high virulence in escapingdestruction. Which suggests that " virulence " ofthe first kind may require qualification in respect ofdifferent sorts of lesions, a view which finds supportin the tissue and species specificity of many bacteria.Our knowledge of the relations between host andparasite is derived mostly from the observation ofacute infections ; it may well require re-examinationin respect of chronic fatal conditions, such as infective I,endocarditis. ’
2 Ibid., p. 428. 3 Ibid., p. 426
4 Reports on Public Health and Medical Subjects, No. 18,Ministry of Health, 1923.
5 Journal of Pathology and Bacteriology, 1903, viii., 34.6 Heart, July, 1923.
Annotations.
PROF. LEONARDO BIANCHI ON OLD AGE.
"Ne quid nimis."
Leonardo Bianchi, the great master of Italian neuro-pathology and psychiatry, is this year relinquishingthe professorial chair at the University of Naples tothe profound regret of his colleagues and students.Prof. Bianchi took for his farewell addressl the subjectof old age, perhaps in reference to the fact that hisretirement was occasioned by the age limit, and it ischaracterised by much interesting material and appositeremarks. Life is regulated, says Prof. Bianchi, bylaws of whose nature we are only partly cognisant.We do not know why certain individuals developprecociously, or why the germ of a great talent arrivesat maturity only after a long time in the most diversechanges and circumstances of life-and he went on todraw an eloquent picture of old age as it might be,which we render in his own words:-How many men lay down their arms in life’s struggle
before reaching the age of 60 ! Without any more
enthusiasm, or eagerness, or even a new thought or applica-tion, with no longer any artistic thrill, nor any ambition,not even a hymn to Life or to beautiful and generous Nature.Such men shut themselves in the spiral recesses of an inerthabit. What is the reason why one man is degenerate at 60years and another preserves his mental faculties at 85 oreven 90 or more ? There is no biological law which fixes theterm when decadence of the mental life begins ; there isnothing absolute in this matter. The absolute is found inhuman laws, often inspired by extraneous interests, associatedwith profound ignorance of the infinite resources of Nature.Meanwhile let us respect this law, our Duty. There issomething which watches over individual interests, andthat is Discipline. Obedience, in proportion as the socialorganism becomes more complex, is the greatest humanvirtue 1 Erect an altar to it and let it be your law.As for myself, as long as I have strength and energy I
will dedicate to you my whole thought. We were and areall enthusiasts of youth. I might almost say by occupation.Countless times it has incited my thoughts and renderedverdant year by year my existence with spring-like fertility.Living for several decades among you I have felt year byyear the reflex of your spirit in myself, with the enthusiasmsand generous impulses of youthful years, the hopes wooedby severe struggles, and the anxieties of work animated byan innate yet indefinite force which rendered even joyousthe privations hidden under a chaste and sometimes painfulgaiety. Youth must tend to become sublimated as itpushes forwards towards maturity and old age, which giveforce and experience to the prosperous life of the race.Happy are they who reach without much travail or severe
losses the extreme limit of life ; and fortunate is the countrywhere a lucid and cheerful longevity is not an isolated andexceptional phenomenon. And remember that the founda-tions of a strong old age are laid in the vernal years of life.Let me before taking leave of you give you this advice.Keep a part of your youthful energies for maturity and oldage, whose activities are the right of the civilisation of therace. With all the respect due to certain researches onrejuvenation, do not delude yourselves as to the results.The rejuvenation of rats and fowls may be nothing elsethan a firefly for man ; just as illusory as the vital sunthat Brown-Sequard dreamt of as standing still in order to.carry on victoriously the battle of life. The conception ofGoethe will remain eternal as regards humanity, and themodern Mephistopheles, decked out by the laboratoryexperimenter, will in vain bring you an amorous Margheriteif your vital balance results in a deficit in the years of youthfulenthusiasm. Devote yourselves to the work of the com-munity, and you will be very happy to feel yourselves even-at the age of 75 useful to your country. This is my mostfervid wish for you.
Prof. Bianchi cited many celebrated men whosemental vigour in old age was proverbial, such asHobbes, Michelangelo, Kant, Verdi, and Cardarelli,and quoted the instance of Voltaire, who, two yearsafter he had completed the tragedy " Irene," at theage of 83, wrote to a, friend, a professor of philosophy,who had apprised him of his dyspeptic troubles:" Your stomach cannot be in a worse condition thanmy head ; my little apoplectic attack at the age_ of 83.
