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negative phase which has hindered the use of vaccinesin acute infections. In chronic infections specificantibodies are present, the patient is sensitised, andreactions are easily produced, so that when vaccinesare used for delayed resolution in pneumonia, or
are not used until the patient has been ill for morethan five days, caution is required, and the initialdose should be small-for example, 5 millions. The
early administration of vaccine necessarily entails
early diagnosis. The abrupt onset and strikingsymptoms of lobar pneumonia should make its
recognition possible before consolidation occurs, butwith broncho-pneumonia the onset is often insidious,and the fact that a case has taken on a graver aspectis not always recognised at once. It is not, however,necessary to wait for undoubted signs of pneumonia,since injection in the prepneumonic stage will, inmost cases, cut short the infection and prevent theonset of the grave complication.With early specific treatment, absolute rest, and
fresh air, much can be done to prevent circulatoryfailure, the treatment of which occupies so much
space in text-books. The heart is best helped byfeeding it, and the best foods are oxygen and glucose.With the slightest indication of cyanosis, oxygenmust be freely administered through a nasal catheteror with a mask. The futile method of the funnel,however, still survives and brings oxygen treatmentinto discredit. When circulatory failure occurs
the patient is in a parlous condition. One by onethe drugs upon which we formerly relied have beendiscredited, and the difficulty of treating poisonedorgans incapable of response is now recognised. Theseat of circulatory failure has passed with ourincreasing knowledge from the heart to the medullarycentre and the capillaries. When the heart is atfault adrenalin is the most useful drug since it
augments and accelerates its contractions. For
capillary dilatation pituitary extract is available,and when failure of the vasomotor centre occurs
strychnine has a certain limited field. Alcohol, themost popular of all drugs in pneumonia, has a fleetingreflex action upon the heart from irritation of themucous membrane of the mouth and stomach, butafter absorption it has no apparent action upon theheart or blood pressure and it is difficult to see howits action in increasing the flow through the skin atthe expense of the internal organs is required. Circu-latory failure is a complicated matter, and it is at
present impossible to assess the various factorsconcerned, each of which requires a different line oftreatment. Our hope lies in the prevention of
circulatory failure and not in its treatment.Convalescence may be a tedious matter and rales
a long time disappearing, but the patient should notbe allowed to pass from care until the chest is clear.Chronic fibrosis is perhaps the commonest chroniclung disease, and the most frequent cause is a broncho-pneumonia. Much future ill-health could be pre-vented by greater care during convalescence, and thElungs after broncho-pneumonia should be as carefullywatched as the heart after acute rheumatism.
INTERNATIONAL HOSPITAL CONGRESS. - ThisCongress will assemble at Atlantic City, New Jersey, U.S.A.,on the morning of June 13th. It will be immediatelyfollowed by the annual convention of the American HospitalAssociation. The Congress is the first of its kind and in Iconnexion with it there will be an exhibit of plans and models Iof modern hospitals, of various types of hospital equipmentand supplies, and of statistical data relative to the care ofthe sick throughout the world. The purpose of the Congressis to bring together those interested in hospital administra-tion, construction, and organisation.
Annotations.
CONDITIONS OF CHILDBIRTH IN INDIA.
11 Ne quid nimis."
THE disturbance created by Miss Mayo’s book," Mother India," has by no means died down, andacrimonious controversies arise from time to timeover one or other of its criticisms of Indian social life.It is not our purpose here to reopen any generaldiscussion of the merits of this work, but an articleby Miss Eleanor Rathbone in a recent HibbertJournal, entitled " Has Katherine Mayo slandered’Mother India,’
"
lays especial stress on her remarkson childbirth, and it seems worth while to considerwhat the present position really is, and whether anypractical means of improvement exist or can be intro-duced. That there is abundant evidence of veryexcessive mortality of both mothers and infants mustbe at once conceded. Indian vital statistics are
notoriously inaccurate, but as Miss Rathbone pointsout, any error in the calculated death-rate can safelybe assumed to lie in the direction of deficiency ratherthan excess. When, therefore, it is stated on goodauthority that a maternal mortality of 20 per 1000births is a very conservative estimate we may regardthe figure as certainly not an exaggeration of the facts.It has to be compared with a British figure of between4 and 5 per 1000 ; similarly the infant mortality ofabout 300 per 1000 for urban and 175 for ruraldistricts in India compares unfavourably with a generalrate of 70 for England and Wales and 35 in Dunedin,New Zealand. These figures leave so large a marginfor any possible error that they can be allowed tospeak for themselves. Besides, the main propositionhas long ago been conceded by the leading Indianreformers themselves.The causes of this sad and discreditable state of
things are not far to seek, for anyone with experienceof Indian maternity work knows that the conditionsunder which labour occurs-with comparatively fewexceptions amongst the more prosperous and bettereducated people of the towns-are truly appalling.This is a matter on which Miss Mayo could hardly haveexaggerated, even had she intended to do so. Whenshe says that the lying-in woman, being conventionallyunclean, is installed in the darkest and dirtiest closetavailable, and provided with filthy rags that have beenspecially set aside for her use, that air and light arecarefully excluded and the room is filled with thefumes of a charcoal brazier ; that the dai or hereditarymidwife in attendance is not only illiterate but notablydirty in her person, and regardless of the mostelementary rules of cleanliness ; and that the patient’diet is on starvat,ion lines and utterly unsuitable-when she savs all this, and also points out that themother is herself usually the product of an earlymarriage, and often of the purdah system, she is onlystating what is a commonplace to every practitionerin India. All these factors react more or less on theinfant as well as the mother, and what chance it hasof making good is still further weakened by its beingfed on poor breast milk, or over-diluted cow’s milkI drawn and kept under more than doubtful conditions,and often also by the administration of opium to stillits cries of hunger and pain. The purdah system,coupled with a general defiance of every law ofhygiene, is also responsible for more than vagueill-health. Osteomalacia and rickets are common, asone would expect, and the zenana is naturally ahotbed of tuberculosis. What, asks Miss Rathbonein effect, can be done to secure the mitigation of theseand other similar ills in the future ? And must not
Westerners, who have been responsible for thegovernment of the country for so long, take blameto a certain extent for their continuance ?
There has certainly been a tendency in the past toaccept Indian social customs as inevitable, and todisclaim responsibility for their perpetuation, and so
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far we believe the British administration must bearits share of the discredit. The official efforts that havebeen made to improve maternity conditions have inthe past been mostly feeble and sporadic. In the lasthalf century, however, some significant changes have eoccurred, in this as in other social departments. TheParsees of Bombay are, of course, not actually Indianin origin, but they have assimilated many Hinducustoms, and their communal life is still largelydominated by a comparatively illiterate priesthood.In spite of this, however, and the violent oppositionhe at first encountered from a large proportion of hiscompatriots, the campaign initiated by Sir TemuljiNariman, M.D., for the introduction of modernmaternity measures, has long ago been brought to atriumphant conclusion, and the Parsees, who used tobe as archaic as the Hindus in this respect, have nowas good obstetric facilities as any community in theworld, and make use of them to the full. This advancecould not have been made without a parallel introduc-tion of education, particularly for the women, andMiss Rathbone justly observes that this is thefirst and most pressing need of India. Alongwith this general educational movement must gothe supersession or training of the dais. It hasbeen the fashion until recently, particularly amongstthe medical profession, to contend that the attemptto make them into responsible assistants to dealwith the dai is hopeless. We think this viewis wrong. India, in spite of the legendary pagodatree, is a poor country, and to wait for an ade-quate supply of midwives trained on conventionallines would be to wait for a very long time. The daiis an awkward problem, but experimental schemes ona small scale have lately shown that it is not impos-sible to persuade her to undergo short courses ofpractical training which, in successful cases, converther from a deadly menace into a useful adjunct ofvillage life. Rural midwifery presents a task whosevery fringe the regular nursing profession will neverbe able to touch, and the regularisation of someinferior maternity agency, such as the dai.<;, is evenmore necessary than the provision of elementarymedical aid in the smaller villages, where fullyqualified doctors are not available. The establish-ment of infant welfare centres in the larger towns hasalready done much to open up the allied question ofantenatal instruction and to supplement the work ofthe hospitals as regards infants and young children,and the same principle might with advantage beextended to the districts, where it would be a valuablereinforcement to the existing medical agencies.
OPERATION FOR CONGENITAL STENOSIS OF
THE BILE-DUCTS.
WHEN there is congenital abnormality of the bile-ducts the smallness of the structures involved and theassociated jaundice have usually deterred surgeonsfrom operating, and comparative failure seems to haveattended the efforts of those who have made theattempt. But a fresh stimulus to the surgical treat-ment of this condition is given by the work of W. E.Ladd,’ of Boston. He operated on 11 out of a seriesof 20 children with narrowing of the ducts, and foundthat eight were suitable for surgical treatment, sixof whom recovered. These six include one infant of3 months with atresia of the common duct, for whichcholedochoduodenostomy and cholecystostomy wereperformed ; one of 5 months with the same abnorm-ality which was cured by cholecystgastrostomy; one
of 3 months with stenosis of all three ducts, successfullytreated by cholecystostomy and dilatation with aprobe ; and one of 4 weeks in which obstruction ofthe common and cystic ducts was relieved in the sameway. In the other two cases partial obstruction of thecommon ducts was satisfactorily treated by chole-cystduodenostomy, but the patients were 5 years old,and the condition hardly seems to deserve the term
1 Jour. Amer. Med. Assoc., 1928, xci., 1082.
congenital stenosis of the bile-ducts as it is understoodin the literature. As Ladd remarks, both the natureand degree of abnormality vary considerably, so thatdifferent operations are necessary in different cases.For small infants with an obstructed common ducthe recommends anastomosis of the common duct tothe duodenum over a catheter, pointing out thatintroduction of a catheter into the duodenum throughthe gall-bladder and common bile-duct is an importantpart of the technique, as it ensures patency of theanastomosis which is otherwise difficult to obtain onaccount of the smallness of the structures. He thinksthat operation is desirable as soon as the diagnosisseems reasonably certain, before there is wasting orconcurrent disease, and he says it may be undertakenwith expectation of success in any case in which eitherthe common duct or the gall-bladder has a patentconnexion with the liver. Only those who have seensuch cases in life and examined the structures atautopsy can fully realise the technical difficulties ofthe operations which he advocates. But the fact thatinactivity means certain death, while interventionevidently can be successful, undoubtedly justifies hisplea that it should be tried more often. It will beinteresting to learn the subsequent history of the casesoperated on successfully.
THE ÆTIOLOGY OF PELLAGRA.
IT is now more than a year since the fact wasestablished that vitamin B is a dual entity, of whichone part only, now called vitamin B 1, representsthe previously recognised antineuritic or anti-beri-beri factor. The two factors have a somewhatsimilar distribution among foodstuffs, and yeast isparticularly rich in both. Since yeast in some formhas been almost universally used as the source ofvitamin B in dietary experiments, it has come aboutthat nearly always the two factors have inadvertentlybeen given together. The second factor, vitamin B 2,has been further protected from discovery by thecircumstances that, in experiments on the rat,when both factors are withheld the animal alwayssuccumbs first to the neuritic symptoms, and diesbefore any sign of the second syndrome has time todevelop. In other words, the reserve of vitamin B 2always outlasts that of vitamin B 1, when neithervitamin is offered in the food. H. Chick and M. H.Roscoe found, last year, that an alcoholic extractof yeast, in which vitamin B 1 alone is present,cures the neuritic symptoms and keeps the rat aliveuntil the second deficiency has time to manifest itself.The latter is marked by ophthalmia and skin symptoms-i.e., loss of hair and a characteristic dermatitis onpaws, ears, and neck. The most interesting featureof the discovery lies in the identification, .by J.Goldberger 2 and his colleagues, of this syndromewith the well-known disease of pellagra. Theyhave proved that pellagra in man may be cured andsubsequent relapses prevented by the administrationof dried brewers’ yeast, as well as by a number ofother foodstuffs. They used a commercial prepara-tion of the Harris Laboratories, Tuckahoe, N.Y., atfirst in a daily dose of about 50 g.,3 but later 15 g.was found sufficient.4 4 In the outbreak of pellagrawhich followed the deprivation caused by the Missis-sippi floods,5 yeast was prescribed as the routinetreatment, with canned salmon, beef, or tomatoes asan alternative. The aetiology of pellagra is not,however, completely cleared up by these experiments,since the exact relation of pellagra to maize-eatingis not yet fully established. The disease occurs ona large scale entirely in maize-eating countries, butit is not yet known whether the whole maize grain ispellagra-producing or whether only a certain fraction,
1 H. Chick and M. H. Roscoe : Biochem, Jour., 1927, xxi., 698.2 J. Goldberger and R. D. Lillie: U.S.A. Public Health
Reports, Washington, 1926, xli., 1025.3 Goldberger and W. D. Tanner- Ibid., 1925, xl.. 54.4 Goldberger, G. A. Wheeler, Lillie, and L. M. Rogers : Ibid.,
1926, xli., 297.5 Goldberger and E. Sydenstricker : Ibid., 1927, xlii., 2706.