1800 THE ANNUS MEDICUS 1906.

are probably due to the action of the poison on the musclesrather than on the nerves.CHARRIN and GOUPIL, in an article in the Omnptes .

Rendus, have adduced some facts which are suggestive of I

a glandular function in the placenta, evidence having beenobtained that it contains a glycolytic agent producing 1alcohol from glycose and that it also possesses a proteolyticpower. J. E. LANE-CLAYPON and E. H. STARLING have Imade experiments to determine whether the growth andactivity of the mammary glands can be artificially in-duced by the injection of fluids obtained from theovaries, placenta, uterus, and foetus into the skin or peri-toneal cavity of a virgin rabbit. They thought that thespecific mammary hormone might be produced from a pre-cursor or mother substance in some of these organs. At Ipresent, however, though the existence of such a hormone 3proceeding from the fertilised ovum is rendered probable, it I

is uncertain whether the amount of this substance increases Iwith the growth of the foetus. Lactation is due to the 1removal of this substance, which must therefore be regarded Ias exerting an inhibitory influence on the gland cell", 1

hindering their secretory activity, and furthering tht-ir 1growth.

Lectures.The seventh Huxley memorial lecture of the A.nthropo-

logical Institute was delivered by Professor FLINDERSPETRIE on Nov. 1st on Migrations in their AnthropologicalAspect. He showed that whilst immigration into England

C

was taking place at the present time the effects could be ]

better followed out in Egypt where the changes occurringin ten thousand years could be traced. History, supported by

]

skull measurements and aided by inquiries directed to the ‘

colour, physiognomy, language, and culture, demonstrated

that no less than 13 changes could there be followed, the ‘

general tendency being that the more capable races sup- ‘

planted those who were less capable ; and he strongly main- 1tained that the ideals of the present-day such as the

equality of wages, maintenance of the incapable by the

capable, equal opportunities of life for children of bad stockas well as for those of good stock, and the exclusion of more

1

economical labour were the surest means of national extinc- ‘

tion, whilst, on the contrary, the only way to save acountry from immigration was to increase the capabilities (of its inhabitants by thorough weeding so that other races ‘

could not get a footing by competition or by force.

1Obituary. ,

LIONEL SMITH BEALE, F.R.S., a well-known physiciar, ‘who was formerly president of the Royal Microscopical (

Society, died on March 28th, 1906.

Bibliograph,y. Recent works in physiology are :-A Text-book of Physio-

logy, by Proftssor W. H. HOWELL. Principi de Fisiologia: i

1. Chemica Fisica, by F. BOTAZZI. Chemistry of the Froteids, I

by GUSTAV MANN. Recent Advances in Physiology and Bio- t

Chemistry, by LEONARD HILL. Physiology of the Nervous aSystem, by J. P. MORAT, translated by H. W. SYERS. Recent <

Work on the Digestive System, by Professor E. STARLING. It may be mentioned that a professorship of Protozoology i

has been established at the University of London and that (

Mr. E. A. MINCHIN has been appointed to it, with as his (

assistants Dr. J. D. THOMSON and Dr. H. M. WOODCOCK. Dr. D. NOEL PATON has been appointed professor of physi- (

ology in the University of Glasgow.

AN&AElig;STHETICS.

General An&oelig;sthetics.A considerable amount of work has been accomplished

a

during the past year and much light has been thrown upon s

the subject of the action of anaesthetics. This is true more

particularly in the case of chloroform.

Chloroform.&mdash;Ether.Professor F. J. KEEBLE, in the course of a lecture delivered

before the Society of Anmsthetists in February, an abstractof which appeared in THE LANCET, showed that an&aelig;sthetic

vapours ultimately arrested movement and destroyed func-tion in the lower forms of life. Chloroform in this respect ismore potent than ether or other anaesthetics. Thus, recentobservations have confirmed the classical research of M.

JOLYET and M. BLANCHE who demonstrated that plant lifewas affected by narcotic vapours in a way similar to thatwhich obtains in the case of animals. In this connexiona paper by Mr. A. SCHAPIRO may be noticed. Youngmammals were subjected to the continuous action of chloro-form and the effect on their growth was noticed. Delayeddevelopment resulted, but this was compensated by abnormalgrowth as soon as the animals were freed from the effect ofthe an&aelig;thetic. The ultimate growth of the kittens which hadbeen influenced by the an&aelig;sthetic equalled that attained bythe animals in the control experiment. That the tissues ofthe body are profoundly affected by the inhalation of an&aelig;s-

thetics has been recognised for a long time and the truth ofthis has been brought into prominence by the work of Dr.H. E. RoAF and Professor BENJAMIN MOORE These

observers, in the course of communications made to the

Royal Society and noticed in THE LANCET, have shownthat chloroform and other anaesthetics possess the powerof forming segregations with proteids and lipoids, with theresult that the chemical activity of the tissues undergoesretardation or even passes into abeyance. The point ofinterest is that this limitation of physiological activity variesdirectly with the tension of the anaesthetic in the tissues.Thus it is seen that both in the case of unicellular

organisms and in that of the higher and complex tissues,anaesthetics are able to retard and ultimately to abolish

physiological activity.

Complications follorving An&oelig;sthesia.&mdash;Delayed ChloroformPoisoning.

Many of the researches and investigations which havebeen carried out during the past year throw some lighton the causes of deaths following inhalation of chloro-form and other anaesthetics which appear to be asso-

ciated with acetonuria and the presence of diaceticacid in the urine. Some of the earliest papers upon this

subject appeared in THE LANCET and were written byDr. LEONARD GUTHRIE. Recently 2 Mr. E. D. TELFORD andDr. J. L. FALCONER have published some cases of delayedchloroform poisoning and have reviewed the subject from theclinical side. Papers dealing with this subject have appearedby Mr. LEWIS BEESLY, J. ARNHEIM of Berlin, and Mr.D’ARCY POWER, as well as an excellent summary in the Thera,-peutic Gazette for August. Although cases of delayed chloro-form poisoning are rare, extremely so when it is recollectedhow very large is the number of patients who take chloroform,they yet require a close scrutiny and the papers mentionedas well as numerous others which have appeared in thecontinental press merit careful study. The condition of the

patients appears to be associated with acidosis or acidintoxication. It is pointed out that acetonuria is a

common, if not constant, sequela of the inhalationof chloroform and is related in some way with the

perversion of the metabolism of carbohydrates and withoxygen starvation. Acute and chronic acid- intoxicationsare recognised, but as yet it is impossible to say what

determining cause or causes are at work in bringing aboutthe fatalities from delayed chloroform poisoning. Dr.

GUTHRIE, an accepted authority upon the subject, suggestsa pre-existing perversion of nutrition-the association bysimilarity between these cases and those of acute yellow

1 Journal of Physiology, February, 1906.2 THE LANCET, Nov. 17th, 1906, p. 1341.

1801THE ANNUS MEDICUS 1906.

atrophy of the liver is patent-and Mr. TELFORD and Dr.FALCONER notice the fact that in their cases rickets existed.What is very striking when the literature of the matter istaken into consideration is the fact that the phenomena ofthe cases are associated with pathological conditions-per-verted tissue function, delayed or even destroyed physi-ological activities of glandular cells, such as have been shownby Dr. ROAF and Professor MOORE to occur as an inevitableresult of a certain tension of anaesthetics being allowedto act upon the proteid and lipoid constituents of the

organism. It has yet to be shown whether anaesthetics

possess a double danger-in the one case killing bydestruction of the vital centres, as in respiratory failure, andin the other by a slower but none the less fatal manner

through inhibition and ultimate annihilation of the physi-ological activities of the tissues concerned in nutrition,metabolism, and excretion. But we know that death throughfailure of respiration or cardiac inhibition is the result ofover-dosage, indeed, during the year the work of M. J.

TISSOT, published in the Revue Scientifique and noticedin THE LANCET of Nov. 3rd, p. 1232, has demonstratedthat there is a certain and definite dosage of chloroformrepresenting in its lower grades the phases of anaesthesia,and in its higher abolition of the respiratory function anddeath. So it would appear from Dr. ROAF and ProfessorMOORE’S work and from the researches carried out by Pro-fessor C. S. SHERRINGTON and Miss SOWTON, Mr. VERNONHARCOURT, Professor T. G. BRODIE, and Miss WIDDOWS,3that the question of dosage is one of first importance, notonly in regard to the safety of the conduct of producingand maintaining anaesthesia, but also as affording a safe-guard to the patient against deleterious after-effects. Dr.H. G. WELLS 4 submits arguments in support of this viewand explains these cases of delayed chloroform poisoning bythe assumption that the anaesthetic actually exerts an in-hibitory effect upon the proteolytic action of certain cellenzymes. This occurs only when a certain tension of chloro-form is attained. Autolysis, however, persists and this withan accumulation of toxic material in the blood, since ex-cretion by the liver and kidneys is impaired, leads to

poisoning and that procession of phenomena which are nowso well recognised in cases of fatal acidosis. M. NICLOUx s

has also discussed the question of dosage from the experi-mental side and his conclusions may be cited. He gives50 milligrammes of chloroform per 100 cubic centimetresof blood as an average anaesthetic dose, placing the limitsof variation between 45 and 60 milligrammes, while therange of lethal dose lies between 55 and 70 milligrammesof chloroform per 100 cubic centimetres of blood. If these

figures can be relied upon it will be evident that BEIT’Szone of safety is a very narrow one, far less than has beengenerally accepted. M, GR&Eacute;HAUT 6 states that from experi-ments made upon dogs he is so impressed by the corre-spondence between the phenomena evinced and the doses

given that he insists that in all cases methods of accuratedoses should be employed and graduated according to thevigour and physique of the patient.

Professor G. A. BUCKMASTER and Mr. J. A. GARDNERin a communication made to the Royal Society (Nov. 1st)have also investigated this point and their results inthe main agree with those of M. NICLOUX. Theyfound that the anaesthetic dose and the lethal dosewere in the case of cats only separated by a very narrowmargin. Their experiments showed also that the chloroformwas closely associated with the red corpuscles and onlyentered the plasma when pushed to an extreme extent andadministered rapidly. In the case of dogs, however,

3 Brit. Med. Jour., July 14th, 1906.4 Journal of the American Medical Association, Feb. 3rd, 1906.

5 La Presse M&eacute;dicale, January, 19C6.6 Le Bulletin Medical, May 3rd, 1906.

it enters the plasma more readily when the anaestheticis given in full doses. Dr. N. H. ADCOCK’S research

upon the Action of Anaesthetics on Living Tissues 6

dealing with the action of chloroform upon (a) isolated

nerve, and (b) the frog’s skin, is of interest, althoughof less practical importance. M. NICLOUX has communi-cated to the Obstetrical Society of Paris a note in which heshows that chloroform passes rapidly from the mother to thefoetus, the liver of the latter actually containing more

chloroform than the liver of the mother, a fact explained bythe greater amount of fatty material contained in the foetalliver. It is a practical matter of importance that, as M.BUDIN asserts, the fcetus does not evince signs of chloroformintoxication. The milk, also, as showrf by experiments upongoats, rapidly takes up chloroform and retains more thanthe blood, but very soon parts with it, the secretion not beinginjuriously affected. The work of Dr. GRANISS07 may bementioned in this connexion. This observer has shown that

the extent of corpuscular destruction depends upon theamount of chloroform inhaled and may be estimated by theurobilinuria which, in his experience with children, alwaysfollows the inhalation of this anaesthetic.

Pulmconary and Renal Com.plaoations.BIBERGEIL 8has analysed several thousand cases in which

abdominal sections had been performed and has attemptedto trace the cause of post-operative pneumonia or other lungcomplications occurring among the patients. His conclu-sions are of much interest. He regards the condition of thewound as of no causal significance as the pathway of infec-tion is not that of the lymphatics ; nor does he think thatcold due to exposure of the patient or from irrigation of theabdomen is the determining factor. He also eliminates theanaesthetic and traces the source of trouble to auto-infection

through aspiration of vomit or buccal secretions. The inter-ference with respiration arising from bandaging, the postureof the patient, and the voluntary breath holding to avoid thepain associated with abdominal respiration all tend, he thinks,towards bringing about the results. Dr. G. E. ARMSTRONGin a thoughtful paper 9 traverses very much the same groundand arrives at similar conclusions. These and other observersadmit that although the anaesthetic is not a determiningcause it is of importance in that when an undue quantity ofthe anaesthetic is given or a faulty method adopted thepatients are more prone to vomit, to secrete large quan-tities of mucus, and to remain unconscious for an unnecessaryperiod after the completion of the operation. It is pointed outthat when lavage is adopted and the anaesthetic is skilfullyadministered by an experienced person; when the postureof the patient is properly adjusted and oral asepsis insuredthe liability to lung complications is greatly reduced. An

important paper on this subject has appeared by Dr.LE DENTU.10 His conclusions are similar to those givenabove and it is noteworthy that he says that his experienceleads him to attach more importance to the way in which theanaesthetic is administered than to the nature of the an&aelig;s-

thetic itself.Professor W. H. THOMPSON has conducted a prolonged

and careful research upon the influence exerted uponrenal activity by anaesthetics. Chloroform, he finds, whengiven in a manner to produce light anaesthesia increasesthe volume of the urine but decreases the volume when

profound narcosis exists. The diminution of urine mayeven culminate in suppression. The total nitrogenousexcretion is also lessened and in a greater degree than thevolume of urine, so that urine secreted during narcosis ismore dilute and contains less nitrogenous material than it

6 Proceedings of the Royal Society, B. vols. lxxvii. and lxxviii.7 Riforma Medica, May 19th, 1906.

8 Archiv f&uuml;r Klinische Chirurgie, Band xxiii., Heft 27.9 Brit. Med Jour., May 19th, 1906.

10 Archives G&eacute;n&eacute;rales de M&eacute;decine, March 26th, 1906.

1802 THE ANNUS MEDICUS 1906.

should under normal conditions. In the period followinthe return to consciousness the volume of urine is greatlincreased and the increment reaches its maximum in tbrehours. Professor THOMPSON has noted a correspondencbetween the blood pressure, the urinary outflow, and thvolume of the kidney. One of the phenomena of prolonge(narcosis is marked diminution in the volume of urine, anIwith this is associated an exudation of leucocytes into therenal tubules. The chlorides are increased and there i

occasional albuminuria, while the presence of reducingagents other than glucose can be detected. Com

paring these results with those found in the case o:

ether we learn that under ether the results are similarbut suppression of urine is more common. In othe

respects the effect of ether appears to be connected more

closely with variations in blood pressure than with the an&aelig;s-

thetic per se. As we should expect, the effects of combina.tions of ether and chloroform reveal similarities to these an&aelig;s-

thetics, in some cases resembling the effects of chloroformand in some those of ether. These results confirm much of thework of earlier experimenters and again emphasise the truththat it is the amount of an an&aelig;sthetic which leads to harmfulresults rather than its specific action. In this connexion maybe mentioned two papers, one written by Dr. PAUL CHAPMANand the other by Dr. A. G. LEVY, which deal respectivelywith the percentages of chloroform given off when Junker’sinhaler is employed, or when the anaesthetic is dropped upon,and allowed to evaporate from, woven fabrics. Several paperstreating of the practical side of the administration of thesean2esthetics have appeared. Thus HAGEN11 reports 700cases of chloroform-oxygen narcosis by the Roth-Dr&auml;germethod which allows a certain measured quantity of

chloroform to be evaporated in an atmosphere of oxygenand inhaled by the patient. He speaks favourablyof the method. The rectal etherisation of patients has

been again revived by a Russian military surgeon, Dr.

KRUGILINE,12 and he states that if care is taken to make surethat no intestinal lesion exists, that the colon has been

thoroughly cleared before the vapour is made to enter, andthat no liquid ether finds its way into the bowel, no unfavour-able complications need be apprehended.

Dosimetric Precautions.As a reaction against the reckless over-dosage by ether

which has led many continental surgeons to discontinue theuse of that anaesthetic various methods which may be groupedunder the heading of dosimetric have been introduced. Ofthese that suggested by SuDECH 13 has been carefully workedout. The ether is given drop by drop and sensation is tested.As soon as it is judged that insensibility has been producedthe operation is commenced. Dr. MYRON METZENBAUM14has adopted the drop method and regards it as more satis-factory since it is followed by fewer deleterious effects thanis the case when ether is given from a closed or semi-closedinhaler. Dr. J. GWATHMEY 15 advocates the plan associatedwith his name which consists in supplying the vapours ofchloroform and ether, both being carefully warmed and

mixed with air or oxygen. He regards accurate dosage asbeing fully secured by his apparatus.

Heart Massage.THE LANCET has published from time to time parti-

culars concerning caes in which heart massage byPrus’s and other methods has been carried out. M.

LENORMANT16 in a careful review of the 25 recorded

cases, pleads the value of the proceeding in desperate casesof heart failute under anaesthetics. He regards the best

11 M&uuml;nchener Medicinische Wochenschrift, May, 1906.12 Der Frauenartz, December, 1906.

13 M&uuml;nchener Medicinische Wochenschrift, Octobcr, 1906.14 Journal of the American Medical Association, Nov. 17th, 1906.

15 Ibid., Oct. 27th. 1906.16 Revue de Chirurgie, No. 3, 1906.

: plan of gaining access to the heart to be by opening the, abdomen and compressing the heart from below through the

diaphragm. It is true, he asserts, that only four successfulcases are known, and of these possibly three might haverecovered without heart massage, yet the remaining 17 affordonly negative evidence and should nct be allowed to dis-

credit the proceeding. The method is mentioned by Mr.G. S. HAYNES as having been tried but without effect upon apatient who died under chloride of ethyl in Addenbrooke’sHospital,11 It has often been pointed out in the pages ofTHE LANCET that patients frequently die ecndcr, but not

from., chloroform. A curious example of this has been

reported by M. GUINARD18 to the Society of Surgery ofParis. The patient died, it was assumed, from chloroformpoisoning but the necropsy revealed an embolus in theventricle which had been detached from the hypogastric veinduring examination by manipulation.

Ethyl Cliloride.A large number of papers dealing with this anaesthetic

have appeared. Dr. E. H. EMBLEY has investigated its

pharmacology in a communication made to the RoyalSociety (June 28th). Ethyl chloride, he finds, is a cardiacand vaso-motor paralyfant acting similarly to chloroform butdiffering from that anaesthetic in that it does not seriouslyimpair the heart’s spontaneous excitability. Although it

increases vagal action it is less liable to kill throughvagus inhibition of the heart, since that organ, retainingits excitability, is able to escape from the inhibition. This,however, can only occur when the heart is sound ; in patientswith failing circulation and in morbid states Dr. EMBLEY

regards chloride of ethyl as dangerous. Respiratory failure, hethinks, is usually secondary to circulatory failure and con-secutive to fall of blood pressure. A death under this ana;s-

thetic, reported in THE LANCET of March 3rd, p. 615, led tomuch discussion. A similar occurrence at Addenbrooke’s

Hospital has been reported but in this case the ethyl chloride-ether sequence was employed. Mr. H. J. FAIRLIE CLARxE"records a case of serious danger with ethyl chloride whichseems to bear out Dr. EMBLEY’s contention. A prolongeddiscussion upon the death-rate under this anaesthetic followed

a luminous paper by Dr. W. J. MCCARDIE20 which seems toindicate the need of more care in the nse of the drug. Largedoses are certainly dangerous and even small ones, unless

employed by those who are thoroughly cognisant with thepeculiarities of ethyl chloride, are by no means free fromdanger.

Spinal An&oelig;sthesia and -Local Analgesia.Many papers have been written during the year upon

the use of various drugs for injection into the spinal canal;especially have stovaine, novocaine, and alypin receivedattention. Mr. G. L. CHIENE21 describes the use of stovainewith hemisine. Mr. CHIENE appears to have met with fewafter effects, although he mentions rise of temperature andome neuralgia. On the other hand, BAISCH22 states that ifan absolutely safe dose of stovaine is employed the resultingn&aelig;sthesia is insufficient, and if larger quantities are em-loyed severe headache and persistent vomiting occur. Manyvriters refer to the obvious disadvantage of the patienteing conscious during a long and serious operation, and3AISCH suggests that preliminary injection of scopolamine,nd morphine should be made before spinal injection is

.ttempted. KoENIG of Freiburg also has adopted this plan.Mr. H. P. DEAN23 advocates the employment of spinal injec-ion in cases of acute abdominal diseases. He, like others,as found it difficult to estimate the probable duration of an

17 Brit. Med Jour., March 10th, 1906.18 THE LANCET, Jan. 6th, 1906, p. 64.19 Brit. Med. Jour., March 24th, 1906.

20 Ibid., March 17th, 1906.21 THE LANCET, Jan. 27th, 1906, p. 227.

22 Deutsche Medicinische Wochensibrift, Sept. 20th, 1906.23 Brit. Med. Jour., May 12th, 1906.

1803THE ANNUS MEDICUS 1906.

operation, and so it is frequently not easy to calculate the c

dose of anaesthetic for injection in any given case. He meets a

this difficulty by leaving the injection cannula in place and r

reinjects if the necessity arises for so doing. We can t

only note the papers of E. VARV ARO,24 LAZARUS,25 MELTZER,21 and FREUND,27 all bearing upon this subject. Stovaine has been used in ear and throat surgery with 1

success by Dr. DAN McKENZIE, but many observers have c

found that this analgesic and novocaine and alypin are liable to produce severe irritation and even gangrene ifallowed to act for long upon mucous or subcutaneous struc-tures. KOELLNER’s experience with alypin in ophthalmic practice is favourable and MARCHETTI agrees with him. fH. BRAUN, who has done so much for local and intra-spinalmethods of anaesthesia, has introduced, and speaks strongly in favour of, novocaine, which he combines with suprarenin. He compares it with alypin and stovaine. With regard tothe power which suprarenal extracts are stated to possess, in i

virtue of which they render cocaine and allied bodies lesstoxic, Dr. BERRY of New York has investigated the questionand has arrived at a less favourable opinion of the safeguardso afforded. Indeed, he points out that the suprarenalextracts, unless very cautiously used, are liable to producefurther toxsemia.

It is impossible to do more than to epitomise the wideliterature upon spinal injection. The records differ very muchand results advanced as being favourable include severaldeaths&mdash;FREUND, for example, had a death in 209 cases,-suggest limitations, and give a somewhat alarming list ofafter-effects. These deaths are, we are assured, the result offaulty technique, but the facts remain and accentuate theneed of caution before the adoption of methods which appearneither to be free from danger nor to eliminate severe

after-suffering to the patient. CHAPUT, PREINDISBERGER,PENKERT, and BARDET have each shown, in speaking ofspecial analgesics, the need for extreme care and further

investigation before it can be said that the methods and

drugs employed are capable of being regarded as safe or Iwholly trustworthy. --

THE NAVAL AND MILITARY MEDICAL SERVICES.

The End of 1905 folloned by the great Political Changeof 1906.

The end of 1905 found the nation in the throes of awholesale reorganisation of its army system and somewhatbewildered by several radical and comprehensive schemes ofarmy reform, army sanitation, the organisation and provisionof a medical reserve, and, with a view to increased efficiency,the systematic and progressive development of the medicalservices on their then existing lines. Nor will it be for-

gotten that towards the end of 1905 came the resignation of Mr. BALFOUR and the succession of Sir H. CAMPBELL- IBANNERMAN to the post of Prime Minister, with the appoint- Iment of a new Ministry and of Mr. HALDANE as the newSecretary of State for War. These changes were soon

to be followed by the decisive results of the General

Election in favour of the present Government. There stillremains at the end of the present year, as everyone knows,almost everything to be done in these respects, and notwith-standing the enunciation on the part of the Government ofnumerous vitally important principles, together with severalindications of the direction which these will probablytake, the nation must nevertheless be content to wait

until the year 1907 for the promised declaration of whatis to be our future army and navy policy. The task of

formulating any national army scheme suitable to the natureand complex requirements of this country is confessedly

24 Il Policlinico, June, July, and August, 1906.25 Zeitschrift f&uuml;r Physiologie und Di&auml;tet Therapie, April, 1906.

26 Medical Record of New York, August 25th, 1906.27 Deutsche Medicinische Wochenschrift, October, 1906.

one of enormous difficulty. There has not, however, beenany lack of expression -of opinion in regard to the medicalrequirements entailed by modern systems of warfare and asto the absolute need for our preparedness for war if we areto escape a recurrence of some of thise blunderings andreprehensible breakdowns which might have been preventedhad they been foreseen and provided against. We wish wecould believe that the truth of this has even yet been fullyrealised.

The Director-General and the War Office.Let us take, for example, the official position of the

Director-General of the Army Medical Service. That

service, from its special nature, duties, and responsibilities,is not as other departments. It is not enough that itshead may on oocasion be summoned and consulted as an

expert by a war council. He should, in our opinion, bea member of that council and thus should have the oppor-tunity of representing the views of the medical servicewith all the influence attached to such a p’sition at a timewhen these opinions would be of real use. In June last Mr.

BRODRICK, under the heading of " Medkal Science and Mili-tary Strength," and Sir FREDERICK TREVES in connexiontherewith, published some very pertinent communications inthe Times as to the limitations under which medical sciencelabours in actual war. These authorities fully recognisedthat the views and recommendations of the Director-General

regarding the sanitation and health of the army in prepara-tion for war should be of a direct and personal kind with theArmy Council and not have to be filtered through the headsof any military department in order to reach it.

The Qnestion of a Medical Reserve.There is also the question of a medical reserve, and espe-

cially for war. Have all the needful arrangements in thisrespect yet been put upon any adequate and satisfactoryfooting? We cannot regard the Royal Warrant of Oct. 23rdlast,l containing the revised regulations respecting appoint-ment to the Army Medical Reserve of officers, as otherwisethan a partial and tentative effort to do so ; and we are mean-while hopefully content to await Mr. HALDANE’S declarationof his army scheme for further information.. In connexionwith this subject of army medical expansion in war in rela-tion to volunteer training we may refer to Sir ALFRED

KEOGH’S address to the Manchester companies of the RoyalArmy Medical Corps in November last, in which the Director-General stated some of the problems of the Medical Servicewith which he had to cope.2

The Royal Navy Medical Nervice.In a leading article on the Health or the Royal Navy

which appeared in THE LANCET of Jan. 20 h, p. 169, we saidthat sufficient time had not elapsed to show what had beenthe full effect of the improvements in this service in affording

; increased advantages and a better scope for the pursuit of,

scientific work. We were, however, enaled to point to thevery satisfactory health conditions of the navy as recorded inthe last published statistical report and to the excellence of

’ the professional papers in its appendix as strong evidence ofthe valuable work that was being done by naval medical

’ officers, and especially perhaps in regard to Mediterranean: fever. With all that concerns this disease the me ical officers,

of the Mediterranean fleet and those of the army stationed in’

local garrisons are unhappily only too well acquainted. It’

was evident, we declared, that naval medical efficers are-

ready to avail themselves of the increased means andE opportunities of special and systematic research which have

of late been introduced into their service and that manyof them possess the necessary scientific qualifications for

successfully turning these opportunities to the best account.

1 THE LANCET, Dec. 8th, 1906, p. 1620, and March 31st, 1906, p. 923.2 THE LANCET, Dec. 15th, 1906, p. 1673.