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being suspended under water by a line connected to aspring balance, and kept down with a lead belt. Themain sources of error are the air in the lungs and in theabdominal viscera. The volume of residual air in thelungs varies considerably in different people, so that thismust be estimated, if any individual accuracy is aimedat, and it was done in all the 99 subjects studied by ahelium-dilution method. The error from abdominal

gases was minimised by doing the weighings beforebreakfast. One man weighed 183 lb. in air and 23-2 lb.at full expiration in water. The weight of his lead beltwas 13-75 lb., and the correction for residual air 2-65 lb. ;so that his net weight in water was 23-2 - 13-75 + 2-65 ==12-10 lb. His specific gravity was therefore 183/(183-12-10) = 1-071. In these subjects-healthy Americansailors-the specific gravity ranged from 1-020 to 1-099,and on the whole the lightest men, having least fatabout them, had the highest specific gravity. Thus theaverage weight of the men with specific gravity between1-020 and 1.030 was 16 st. 9 lb., and of those between1-090 and 1-099 it was 10 st. This relationship did notalways hold for the supermen, the professional football-players. One man, for instance, weighed 15 st. 10 lband even though he was 6 ft. 3 in. would have beenlabelled overweight, but his specific gravity of 1-081showed that his weight was beef and not blubber.Behnke and his colleagues propose a specific gravity of1-060 as a dividing line for the elimination of the obese.On this standard only 2 of the 20 footballers would beoverweight. Weighing in water, and more particularlythe estimation of residual air, could hardly be appliedto all recruits who look on the plump side, nor to candi-dates for life insurance. When groups of men weretaken together Welham and Behnke 2 demonstrated aclose correlation between specific gravity and thedifference between the circumferences of chest andabdomen. In the athletes the chest measurement

averaged 6.9 in. more than the abdominal, and in thelean naval men 6-8 in., whereas in the group with a lowspecific gravity the average difference was only 4-5 in.Unfortunately this correlation does not hold for indi-viduals, so that th investigation has not given us anysimple way of filling the gap in present methods of

body measurement. Height-weight tables might bemore helpful if they were based on sitting height.

DIAGNOSIS OF CORONARY DISEASECORONARY disease has become such a commonplace

diagnosis of recent years that there is a chance of thephrase becoming meaningless. Marvin has emphasisedthe features which alone justify this diagnosis. Clinicallythey consist of angina pectQris, coronary thrombosis,or congestive heart-failure for which no other causecan be found. Of these the last is much the rarest.The symptoms of angina pectoris are characteristic,though the important differential diagnosis of leftinframammary pain is sometimes difficult. Anginapectoris found with severe anaemia, paroxysmal tachy-cardia, hyperthyroidism, or great enlargement of theheart need not necessarily be due to, or even associatedwith, coronary sclerosis. Coronary thrombosis is ofcourse the outstanding manifestation of coronary disease.Diagnosis of coronary disease on the presence of con-gestive heart-failure can only be made by exclusion ofother causes of failure, such as hypertension, rheumaticand syphilitic disease and vitamin-B deficiency. Radio-

logy is of comparatively little help in the diagnosis ofcoronary disease, though Master and his colleagues 4have claimed that in 58 of their 80 patients with myo-cardial infarction they detected localised abnormalitiesin pulsation of the ventricle. Screening is obviouslyimpracticable in the acute stage of coronary thrombosis2. Ibid, p. 498.3. Marvin, H. M. New Engl. J. Med. 1942, 226, 251.4. Master, A. M., Gubner, R., Dack, S. and Jaffe, H. L. Amer.

Heart J. 1940, 20, 475.

and probably there are not many cases in which it willgive more information than can be obtained from clinicaland electrocardiographic investigations ; in the case ofcardiac aneurysm, of course, the position is entirelydifferent. Marvin is perhaps too sweeping in his com-ments on the electrocardiographic findings in bundle-branch block. Provided all three criteria are present(duration of Q RS greater than 0- sec., notching or slurringof QRS, and T in the opposite direction to QRS) thisdiagnosis nearly always indicates myocardial disease,though naturally other aetiological factors such as

diphtheria, acute rheumatism and syphilis must beexcluded before coronary sclerosis can be incriminatedas the cause. That low ’voltage of the ventricular

complex by itself is of little if any value as an indicationof heart disease is generally agreed ; such extracardiaccauses as inadequately applied electrodes, subcutaneouscedema, and the thickened skin of myxoedema must beexcluded. Nor must prominence of Q3 by itself be takento signify a myocardial lesion. It is in the interpretationof alterations in the ST segment and the T wave that,most mistakes are made ; Marvin quotes a list of 41different conditions, other than coronary sclerosis, inwhich such changes may occur, and only 33 of theseimply heart disease. As he points out, " if myocardialinfarction is excluded, there is no change in the electro-cardiogram that in itself justifies the diagnosis of coronarydisease." Coronary disease may often be suspected,but unless we accept definite criteria and observe theextent to which the single case complies with, or variesfrom, these we shall never attain that accuracy in earlydiagnosis which is essential now that coronary diseaseis taking a steadily increasing toll of life.

ANÆSTHETIST TAKES THE BLAME

THE liability of the anaesthetist as distinct from thesurgeon has recently been the subject of a decision bythe High Court of New South Wales1 and is of interestas proceedings were taken against both. The plaintiffclaimed damages for joint negligence by which his wife’shand was burnt during an operation. At the date of theoperation the weather was cold and the theatre, withwhich both defendants were familiar, was heated by" an electric radiator of the cone type, the heating ele-

ment of which consisted of wires exposed to the air,which became red-hot when the current was turned on."The first hearing arose on a technical objection that underthe old English Common Law Procedure Acts, whichare still in force in New South Wales, proceedings couldnot be taken against joint tortfeasors. Jordan, C. J.,giving the judgment of the court, laid down for guidanceon the new trial which was ordered that " except wherecombination is the gist of the tort, in an action broughtagainst two persons as joint tortfeasors, one may beconvicted and the other acquitted." At the re-hearingthe Supreme Court gave judgment against the surgeonand the anaesthetist. On appeal the High Court decidedin favour of the surgeon and (by a majority) againstthe anaesthetist. The case did not turn entirely on theadministration of the anaesthetic. It was administeredby dropping ether out of a glass bottle from time to timeon to gauze stretched on a wire frame placed over thepatient’s face. The anaesthetist was sitting at the sideof the operating table near her head. He had a tablealongside on which the bottle was placed when he wasnot using it to drop the ether on to the mask. Some-body knocked the bottle of ether on to the floor. Thefumes of the ether formed a combustible mixture, whichwas exploded by the heating element in the radiatorsituated about six feet from the operating table. The

explosion caused a fire on the floor which spread tothe bottom of the table and severely burned the patient’sright hand which was hanging down over the side.Starke, J., in delivering the judgment of the court, said

1. Paton v. Parker. Aust. Law J. 1942, p. 285.

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that the surgeon and anaesthetist " could not relieve orexcuse themselves from the performance of their dutybecause the hospital or the nursing staff or some of themfailed to perform their duties with due care and caution."The surgeon was entitled to rely upon the careful adminis-tration of the ether by a skilled and competent anaes-thetist. No fact was proved which suggested that heought reasonably to have anticipated negligence, whetherwilful or accidental, on the part of the anaesthetist.Indeed the proximate cause of the injury was not inthe administration of the ether but in the dropping of thebottle on the floor, which broke it and allowed the etherto escape. Such an untoward event was not one whichthe surgeon ought reasonably to have anticipated, norwould any jury be justified in making any finding tothat effect. On the other hand " an accident such as

happened does not ordinarily occur if those in controlof the anaesthetic use proper care." Thus the court

distinguished between the surgeon and the anaesthetistand found that the latter was negligent although nothingin the reported evidence showed that the bottle had beenknocked over by him. Incidentally, however, it didshow that an unusual number of staff were present inthe small theatre. °

The operation was performed in the Mater Miseri-cordiae Hospital, a public hospital in North Sydney,and it is remarkable that the hospital authorities werenot joined as defendants. One report states that themother superior and the matron were present and anotherthat the medical superintendent was also in the theatre.But apart from the presence of representatives of theadministration there is the fact that the only means ofheating was this electric radiator, and, as Jordan, C. J.,observed, " there is evidence that in this country[New South Wales] ether is the universal generalanaesthetic." In England a-hospital might have difficultyin escaping liability under these circumstances, especiallyhaving regard to the warning memorandum issued sixyears ago by the Ministry of Health on the dangers ofexplosion. The annual report of the Medical DefenceUnion for 1938 mentions a claim arising out of an opera-tion under direct vision by a laryngoscope with distallighting. The patient’s personal representatives suedthe hospital as well as the surgeon. The latter had care-

fully tested the apparatus ; nevertheless there was anether explosion, attributed to one lead of a flex havingbeen loosened. The case was settled out of court.

SEVERE CHICKENPOX THE administrative problems of varicella are vexatious

but its risk to the patient is slight ; fortunately so,since control is extremely difficult, particularly in closedcommunities containing children. In the rare fatalcases death normally results from intercurrent infection,usually in debilitated subjects, and to this generalityforms such as varicella gangrenosa are strictly not

exceptions. Nevertheless the staff of one Americanhospital record two quite unrelated cases of severevaricella occurring within a short time of each other andboth in adults. One patient recovered after a seriousillness complicated by bronchopneumonia, pleurisyand osteomyelitis of the lower jaw. The other, a man’of 40, died in coma within 4 days of admission. A verycomplete post-mortem examination revealed broncho-pneumonia of a mononuclear and proliferative type,diffuse encephalitis with some areas of perivasculardemyelination, and acute nephritis. The lesions in thecentral nervous system are of particular interest.Neurotropism is not a rare feature of the varicellavirus, and Underwood,2 from a survey of recorded cases,concluded that encephalitis was the commonest singlemanifestation. However, examples have usually beenmet in children and the tendency is on the whole towards1. Waring, J. J., Neubuerger, K. and Geever, E. F. Arch. intern. Med.

1942, 68, 384.2. Underwood, E. A. Brit. J. Child. Dis. 1935, 32, 83, 177, 241.

recovery. This, and the presence of other severe compli-cations in the present fatal case, raises the importantissue as to whether this was in fact an atypical attackof smallpox. In support of their diagnosis Waring andhis colleagues cite a known exposure to varicella and avesicular eruption without umbilication appearing incrops, concentrated most heavily over the head and trunkand absent from the palms and soles. More detail onthe important question of distribution would have beenhelpful, but the available data do indicate that this wasa genuine attack of varicella.

SAVING ALCOHOL WITHOUT BOTHER

THE change over from the familiar tinctures to liquidextracts or the concentrated tinctures introduced in thefifth addendum to the BP (Lancet, April 25, p. 518) isnot easy for prescribers, but a Scarce Substances Ordernow made by the Ministry of Health puts the burdenon dispensers instead. In this order alternatives approvedby the Medical Research Council are laid down for mostof the BP tinctures, the main absentees being digitalis,iodine, opium and ammoniated quinine, and for spiritsof nitrous ether, ammoniated spirits of ammonia andspirits of chloroform and peppermint. In future whenone of these preparations is ordered the chemist will befree to dispense the alternative without reference to theprescriber, unless the prescription has been marked NA,meaning " no alternative." This means that the doctorcan if he likes order tinctures exactly as before, and itis hoped that NA will rarely be seen. A few minor changeshave been made in the National War Formulary, includ-ing a reduction in the menthol and camphor in nebulaephedrinae and nebula mentholis et thymolis co. fromgr. 8 to gr. 4 per fl. oz. A new haustus chloralis has alsobeen added to the formulary, containing chloral hydrategr. 20, elixir of saccharin min. 5 and water to 1 fl. oz.This is in addition to the existing draught of chloraland bromide.

A SECOND SCOTTISH NEUROSURGICAL UNIT

ON May 15 Mr. Thomas Johnston, M.P., secretary ofstate for Scotland, opened a neurosurgical unit some 13miles outside Glasgow to serve the west side of the

country. The east side is served by a convenient centrein Lothian. The new unit, which is one of the EMShospitals, has been organised under the chairmanshipof Sir Hector Hetherington by the central health

department in cooperation with Glasgow corporationand the three main voluntary hospitals which have allcombined to provide staff and equipment. The staffincludes two neurosurgeons-Mr. J. Eric Paterson, whohas administrative charge of the unit, and Mr. J. SloanRobertson-a neurologist (Dr. J. B. Gaylor), whole-timeanaesthetist and pathologist, while the general staff ofthe hospital will lend a hand when needed. The unit isavailable for all types of neurosurgical case, includinghospital and private patients, " scheme patients " underthe EMS, and members of H.M. Services. It will beadministered by the health department, liaison with

Glasgow hospitals being maintained through an advisorycommittee under the chairmanship of the regionalsurgical director, Prof. C. F. W. Illingworth, who, at theopening ceremony, described the scope and purpose ofthe unit. Of the conditions they would have to deal withtwo were of particular importance. Many brain tumours,although not inherently malignant, are extremelydangerous ; improved technique has made it possible toremove them completely or to give a considerable measureof relief. In war-time of course injuries to the brainclaimed precedence. For both of these the unit wouldprovide the means of research. Mr. Johnston stated hispreference for cooperative over competitive units. Ifthe teaching hospitals, the Glasgow municipality, and thecentral authority had all set up units of their own theymight well have proved inefficient as teaching instrumentsowing to the comparatively small number of cases at each.