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Annotations

KNIGHTS HOSPITALLERS

SOME time in the eleventh century a band of Italianmerchants obtained from the Caliph of Egypt permissionto build a hospital in Jerusalem for the care of pilgrims.They called themselves the Poor Brethren of the Hospitalof Saint John, and their order quickly spread to includeknights of almost every country in Europe. They werevowed to the twofold task of fighting against the Turks,and of tending those whom they charmingly termedour lords the sick " irrespective of creed or race. Thesecond of these duties they have performed unremittinglyup to the present day. In his well-documented andbeautifully illustrated bookl Colonel Erskine Hume, him-self a knight of the order, has traced its history throughnine stormy centuries. The knights were driven fromtheir original foundation in Jerusalem to one island afteranother, but whether at Cyprus, Rhodes, or Malta, theynever failed to establish their hospital, the " Palace of theSick." Colonel Erskine Hume gives in full the regula-tions for the great hospital at Valetta in the sixteenthcentury. Although its patients fed off silver and werenursed by knights of sixteen quarterings the administra-tion was essentially similar to that of a great modernhospital. There were elaborate arrangements for thereception and care of patients-including the somewhatdepressing rule that they should make their wills forth-with-there was an outpatient department, a dispensary,a resident medical staff and daily rounds by the physiciansand surgeons, as well as a sort of district-nursing serviceamong the poor of the island. By one curious regulationtwo years service as prior of the hospital was equivalentto an expedition against the Turks. In many respectsthe knights were far ahead of their time, as in the

separation of the different types of disease, and in theirinsistence on the study of anatomy and dissection, at atime when this was accounted almost criminal in therest of Europe.The later work of the order is well known. After they

had lost their head quarters in Malta the knights continued,and continue, the work in their separate countries, underone grand master, at present Prince Chigi-Albani.Colonel Erskine Hume gives us many interesting detailsof their modern activities, and it is refreshing in thesetimes to encounter an international foundation with sucha record, which has weathered the storms of ninecenturies and still shows no sign of decay.

SPREAD OF PARADOXICAL METASTASES

UUR knowledge of the spread of cancer is still incom-plete, as the appearance of the so-called " paradoxical "metastases in the skull, vertebral column, and limbgirdles remind us. Dr. 0. V. Batson not satisfied withthe suggested methods of spread by nerve sheaths orlymph vessels, has carried out experiments to discoveranother route, and finds that the vertebral veins appearto be implicated. The dorsal vein of the penis in anadult cadaver was injected with Weber’s vermilion,which is radiopaque and readily followed in the tissuesunder the fluoroscope ; 20 c.cm. was injected withoutresistance, the material spreading readily out in theveins in and about the sacrum. The veins of the iliumand lower lumbar spine also became injected, butsurprisingly, none of the material reached the inferiorvena cava. As the injection material was increased itwas seen to progress up the spine through successivesegmental regions until 200 c.cm. had been used, bywhich time it had reached the base of the skull andentered the cranial cavity. It had also penetrated to

1. Medical Work of the Knights Hospitallers of St. John of Jeru-salem, by Edgar Erskine Hume, Lieut.-Colonel Medical Corps,United States Army : Knight of Honour and Devotion of theSovereign Military Order of Malta. Baltimore : The JohnsHopkins Press. Pp. 371. $3.

2. Ann. Surg. July, 1940, p. 138.

the venae vasorum of the femoral vessels, thus givinga composite picture of the metastatic pattern of advancedcases of carcinomatosis with primary origin in the

prostate. Repeated experiments have shown that thiscourse of spread was not accidental. The vertebral

system of veins has a rich anastomosis at each spinalsegment with the veins of the thorax and abdomen ;moreover it is a system almost without valves, in whichthe pressure is very low. It seemed likely that when, asin lifting and coughing, pressure in the abdomen andthorax was raised, blood would flow not into the inferiorvena cava but into the vertebral system of veins. Tosimulate an increase of intra-abdominal pressure, suchas occurs in coughing, a towel was tied round the abdo-men of an anaesthetised monkey, and an injection madeinto the dorsal vein of the penis, colloidal thoriumdioxide being used instead of vermilion. Here, in theliving animal, the flow was similar to that in the humancadaver and again demonstrated the pattern of car-

cinoma spread from the prostate.The vertebral veins are thin-walled and have consider-

able volume but are difficult to identify when empty.They are storage lakes where stagnation is frequent, andhave many connexions with veins of the body cavities ateach intervertebral space. They also communicate withthe veins of the body wall, including those of the breast,and with the azygos system of veins. Injections intobreast venules seemed to follow the pattern of breast.cancer spread-i.e., into the spine, ribs, shoulder-girdle,and skull. It seems possible that tumour and abscessmaterial from many regions may be squeezed, by strain-ing or by coughing, into the vertebral system withoutinvolving the portal, caval, or pulmonary system, andthis would explain why the lungs are not involved, aconstant stumbling block to current theories. Thedisasters following perirenal injections of air for purposesof diagnosis and the cases of blindness after pneumothoraxare certainly due, Dr. Batson thinks, to air embolism inthe vertebral venous system.

ASPIRIN AS A GARGLETHE value of antiseptic gargles has always been more

or less suspect. Prof. David Campbell in his " Hand-book of Therapeutics " says bluntly : " Gargles are

really of very little use in throat affections, as they donot reach beyond the anterior pillars of the fauces."Some grant that they are often soothing to the patient,but say that to be of any value they must be hot, whenthey act merely as fomentations ; what the hot watercontains is of little moment so long as it is harmless.Still others back their own fancy mixture of phenol andbicarbonate, or what you will. Lately the curious

practice of employing powdered aspirin stirred in luke-warm water as a gargle has been gaining in popularity.It is true that aspirin in solution has an antiseptic powerabout equal to that of phenol, but since acetylsalicylicacid is non-volatile and is soluble only to the extent of1 in 300 in cold water, though it is more so in warm waterand possibly in saliva, there seems to be little to recom-mend it as an antiseptic in a gargle. The aspirin gargleis esteemed also as a local analgesic in sore throat andafter tonsillectomy, but the relief of pain may be partlydue to the central action of the drug after absorption,for the instructions are explicit that the aspirin shouldeventually be swallowed. A totally unexpected in-crimination of aspirin when used in this manner comesfrom a chemical study by Dott, who has investigated theeffects of aspirin solutions on the teeth. His brief paperdemonstrates beyond doubt that appreciable quantitiesof the calcium of the teeth go into solution when anaspirin gargle is used. Dott’s analyses, confirmedsubstantially by the independent observations of Dr.J. C. Thompson of the clinical laboratories of the Edin-burgh Royal Innrmary, suggest that aspirin used as a

1. Dott, D. B. Edin. med. J. October, 1940, p. 700.

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gargle over a number of years might well result in per-manent damage to the teeth. The faintly alkaline solu-tion of sodium salicylate obtained by dissolving equalweights of aspirin and sodium bicarbonate has no

appreciable effect on the teeth, and the same presumablyapplies to calcium, lithium and magnesium aspirins.

ÆTIOLOGY OF ACTINOMYCOSIS

IT used to be taught-and the belief is not quite dead-that actinomycosis was caused by a streptothrixcarried in from the soil on ears of oats and wheat or endsof straw, but when it was shown that the pathogenicactinomyces requires anaerobic conditions and body heatfor its maintenance this view had to be abandoned.The frequency of the clinical condition among the farm-ing community suggested that infection was transferredfrom cattle or pigs to man, but the occurrence of infectionwhere there has been no such association and the demon-stration by Erikson 1 that the human strains have cul-tural differences from the animal strains indicated thatdomestic animals were certainly not the only sourcesof the pathogenic actinomyces. Sullivan and Golds-

worthy have lately published the results of a bacterio-logical investigation of 100 periodontal pockets and 24carious teeth from these sources they isolated 6 strainsof micro-aerophilic actinomyces which were identical intheir cultural and fermentation reactions with those of5 strains recovered from actinomycotic lesions. Theythus confirm earlier work that the Actinomyces ismeli(the name suggested by Erikson for the human strain) ispresent in the mouth as a normal saprophyte, but readyto initiate infection when the oral mucous membraneshave suffered any trauma. This is doubtless the reasonfor the not infrequent occurrence of actinomycosis afterteeth extractions-e.g., impacted wisdom teeth-andprobably explains some at least of the cases associatedwith ears of wheat and the like which may lacerate themucous membrane. The case for an animal origin ofsome of the human lesions must be regarded as still notproven.

DENTURES AND INDENTURES

UNTIL the eighteenth century the dentist madedentures with his own hands and it was only when hewanted to use sheet gold that he called in a craftsmanto help him. During the nineteenth century the de-velopment of accurate casting, vulcanising, the use ofimpression materials and of porcelain teeth increased thedemands on the dentist’s time and led him to employ amechanic, who carried out work-room processes whilethe dentist was engaged directly with the patient. A

highly skilled body of dental mechanics appeared in

response to this need, men with a wide knowledge ofmetallurgical processes. But of late years mere repeti-tion work in mechanical dentistry has abolished thedemand for craftsmen, and where his predecessor serveda long and necessary term of apprenticeship the dentalmechanic of today is often inadequately trained evenin the simple processes required of him. This situationled the three dental associations in 1938 to set up, withthe cognisance of the Ministry of Labour, a committeeunder the chairmanship of Mr. R. E. HeegaardWarner,L.D.S., to inquire into the training, conditions of serviceand wages of dental mechanics.

In their report 3 they examine practices which havecontributed to the present situation. They trace weak-ness in the training of mechanics to the decline of theapprenticeship system. The dentist himself studies themechanics of his profession as part of his training :indeed, he puts in nearly two years work on this aspectof dentistry but when he goes into practice it is moreeconomic for him to employ a mechanic or, if he cannotafford that, to make use of the services of the laboratory1. Spec. Rep. Ser. med. Res. Coun. Lond. 1940, No. 240.2. Sullivan, H. R. and Goldsworthy, M. E. J. Path. Bact. September,

1940, p. 253.3. To be had for 1s. 6d. from 13, Hill Street, London, W.1.

of an owner mechanic and his staff of juniors. Theselaboratories tend to specialise, so that mechanics workingin them get no general training and very little individualtuition, especially in new or costly processes where

bungling might mean the loss of expensive material.In contrast, teaching schools like the Borough Poly-technic and the hospitals give the student mechanicgood training ; but dental laboratories are costly toequip and the numbers attending classes are relativelysmall, so that few education authorities are willing toestablish training schools. The committee recommend that candidates should be

selected for training after a trial period of three months,and then apprenticed by indenture for a term of not lessthan five years. They do not recommend that employersshould charge a premium. The indenture, they consider,should require the apprentice to attend, at some stage. atechnical school for additional instruction in dentalmechanics and related subjects. Where temporaryjuvenile labour must be used by a master mechanic, theboy should be warned of the lack of prospects and notengaged for more than three years. The committeebelieve that if the apprenticeship system were restoreddentists would seek the services of mechanics who hadtaken out indentures and undergone a recognised periodof training ; a training-school certificate would beadditional evidence of skill. They consider that a

trained mechanic should receive a wage of not less thanjE3 10s. for a forty-four hour week.

CONTROL OF MALARIA IN MALAYA

OF forty-one species and subspecies of Anophelesrecognised in Malaya, only five are malaria carriers.Their control, however, is a major problem whichwas discussed during the sixth international course

in malariology at the Institute of Medical Research ’.Kuala Lumpur, in 1939. The five offenders havedistinctive breeding characteristics which are a guide tocontrol. A. macuZatus breeds in the sunlit-streams andseepage of rubber estates in hilly land. Suitable breed-ing places have been unintentionally created by theextensive replanting programme begun in 1936 ; oldrubber trees were removed leaving holes in the groundand terraces were constructed on hilly lands for contourplanting, in order to minimise soil erosion. Othervectors are A. umbTosus and noizcrrLb7°osus which are

shade breeders with a predilection for jungle swamps ;A. sundaicus is an addict of brackish water and A.barbiTOstris a pool breeder in overgrown borrow pits andmining holes. In devising a system of antimalarial

organisation the area to be protected must be defined ;the breeding places of anopheline vectors within it mustbe ascertained and a system of weekly records of anti-malaria work kept. The anopheline vectors have aneffective range of about half a mile, but unfortunately, asobservations made in 1937 and 1938 by Dr. W. E.Holmes show, under the conditions brought about byreplanting 1. maculatus can cover about three times thatdistance in sufficient numbers to cause a serious outbreakof malaria. The area must be mapped with a primarycircle of a radius of half a mile, the centre being thelabourers’ lines ; secondary circles are then taken fromstaff bungalows, so that the intervening ravines can beadequately supervised. All streams, seepages and poolswithin the defined area are examined for anopheles larvae,and if the survey is made between early March and June,the most active breeding season of A. maculatas, it willafford a reliable idea of the malaria potentialities of thearea. One valuable measure is to drain the subsoil byplacing all visible water in pipes underground ; this canbe reinforced by open earth drains and the use of

- larvicides, such as prepared oil mixtures or Paris green.Control of urban malaria requires special measures, being1. Howard, S. C., Holmes, W. E. and Wilson, T., Bull. Inst. med.

Res, F.M.S. 1939, No. 2.