1395UNQUALIFIED MEDICAL MEN IN BENGAL.

to close, and in a few days the wound healed com-pletely. Permanent recovery followed. This case

is the more convincing as it corresponds in severalpoints with one of Vincent’s cases in which a poly-valent typhoid vaccine was given to a patient who hadcontracted typhoid fever six years earlier and who,after infection with paratyphoid B, had developedosteitis of the lumbar vertebrae. Vaccine treatmentof typhoid bone disease is the more worthy of trial asthe results of surgical and medicinal treatment oftenleave much to be desired. Altogether about 30 caseshave been recorded in which vaccines have been givenfor typhoid bone disease.

CONGENITAL ABSENCE OF THE SPLEEN.

ACCORDING to Dr. S. McLean and Dr. H. R. Craiglof the Babies Hospital, New York, who report anillustrative case, congenital absence of the spleen isone of the rarest visceral anomalies. It may occur asan isolated abnormality, or, as more frequentlyhappens, be associated with other congenital malfor-mations. In nine of the cases collected by thewriters the individual with this defect reached middlelife without recognisable disturbance, and one womanwho had four normal pregnancies died of pulmonarytuberculosis at the age of 73. Adami and Nichols,who state that the place of the spleen is more oftentaken by nodules of splenic tissue in various parts,allude to Albrecht’s case in which the normal spleenwas absent, but nearly 400 splenunculi ranging insize from a pin’s head upwards were found scatteredthroughout the abdominal cavity. In the case

reported by the present writers, and in the four otherinfants recorded with congenital absence of the spleen,there was apparently no hyperplasia of lymphoidtissue, while in only two out of the nine adult caseswas there a definite lymphoid hyperplasia which wasregarded as compensatory. The present case was thatof a male infant, aged 3 months, admitted to hospitalfor broncho-pneumonia. Death took place threeweeks later, and in addition to broncho-pneumoniathe autopsy revealed congenital absence of the spleen,congenital malformation of the heart (patent auricularand ventricular septa and transposition of veins),supernumerary lobes in the lungs (three lobes in theleft and four in the right), and transposition of theright and left lobes of the liver. In spite of a prolongedsearch no supernumerary spleens were found. Thecoeliac axis had been removed, so that search for thesplenic vessels could not be made. From a review ofthe literature and a study of their own case thewriters conclude that congenital absence of the spleenis not a serious handicap.

UNQUALIFIED MEDICAL MEN IN BENGAL.

OF recent years there appears to have been a Irapid growth in the number of unqualified medicalpractitioners in Calcutta. Their shops are foundscattered all over the city, sometimes well stockedwith patent medicines. The less prosperous membersof the fraternity have invaded the districts of Bengal,creating many jealousies among the practitionersof the indigenous system of medicine. The Govern-ment can do nothing to deal with this large army ofquacks so long as the quacks keep on the right sideof the law. There are many " kavirajes " and otherdoctors using indigenous systems who are not registeredby law. These are free to practise and, in fact, thereis no restriction on those who choose to follow themedical profession according to any system-Western,Ayurvedic, Unani, or Homoeopathic-so long as theydo not break the law either in the treatment of casesor in the supply of drugs. The Bengal Medical Actof 1914, which provides for the registration of dulyqualified medical practitioners through the BengalCouncil of Medical Registration, is working well.Registration is optional at present, but the Govern-1 American Journal of the Medical Sciences, November, 1922.

ment intend eventually to make it compulsory. Anexamination of a table showing the number of personswhose names were entered on or removed from theofficial list of registered practitioners for the period1915 to 1920, inclusive, shows that a high standardis maintained in Bengal. Out of 3538 names registeredduring those years only 138 were removed, of which137 were on the grounds provided for in Section 28 ofthe Act (evidence of death) and one for ceasing topractise. There were no erasures for fraudulent orincorrect entry, or for criminal non-bailable offencesending in conviction, or for infamous conduct.

A PIONEER MENTAL HOSPITAL

THE 125th annual report of The Retreat, York,a registered hospital * for the treatment of mentaldiseases, records the retirement of Dr. Bedford Piercein the early part of 1922, and includes a short retro-spect of the far-reaching changes which have takenplace during his 30 years of office as medical superin-tendent. An example of these changes is the institu.-tion of systematic training for mental nurses, whoseefficiency and status at the present day owe muchto Dr. Pierce’s influence. As the first institution inEngland to merit the description of " mental hospital,"unknown though this term was at the foundation in1796, the Retreat is a place where high tradition hasbeen maintained and amplified over more than acentury. We wish Dr. Henry Yellowlees every successon his appointment as Dr. Pierce’s successor. Interest-ing features in the report are a clear pronouncement onthe vexed question of certifying voluntary boarders,and a summary of the conclusions as to the correlationbetween the causative factors in insanity furnished bycompiling a table of setiological factors in first-attackcases over a period of 17 years-a feature of statisticalwork which elsewhere is commonly neglected. Millfieldis a large country house, adapted for the treatment ofborderland cases, situated at some distance from TheRetreat, and entirely distinct from it, although staffedby the same medical officers. We are glad to readthat this annexe, although not hitherto a successfinancially, is to continue its work. It represents atype of enterprise which deserves success ; the class ofpatient is by no means small for whom a compromisebetween mere rest at home and strict supervision ina mental hospital is the ideal treatment.

EPIGASTRIC PAIN IN APPENDICITIS.

THE recognition of epigastric pain in appendicitisis now universal. Although absent in some cases, itis present in the great majority, and a detailedattention to the history will reveal it as a forerunnerof the right-sided appendix pain. Dr. J. Vorschutz,of Eberfeld,l attempts to explain this epigastric pain.It is, in his opinion, due to irritation of the solarplexus, brought about by a lymphangitis originatingin the appendicular inflammation. He has drawnthis inference from the results of certain animalexperiments. First, he demonstrates that the solarplexus of rabbits contains sensory nerve fibres, byexposing the plexus and then pulling or squeezing it.Splanchnic anaesthesia also demonstrates satisfactorilythat the sensory impulses passing to the cord from thesolar plexus can be interrupted and pain prohibitedby the injection of novocaine into the region of thesplanchnic nerves. Secondly, Dr. Vorschutz seeks toexplain how the solar plexus is stimulated in appen-dicitis. The answer is to be found in a study of theanatomy of the lymphatics. The latter can be seenin the rabbit to run from the appendix, the ascendingcolon, and from the right half of the transverse colonradially towards the solar plexus, and from the restof the intestine and from the pelvis along the vesselstowards this central point, where they unite to formthe receptaculum chyli. After injecting Indian inkinto the region of the appendix, black lymph-vessels

1 Deutsche medizinische Wochenschrift, August 11th, 1922.

1396 A NEW ERUPTIVE 14EVER.-THE SERVICES.can be seen stretching radially towards the solar plexus,and if one of the lymph-vessels in the neighbourhoodof the plexus be directly injected the plexus can beseen to be entirely surrounded and embedded in blackstrands. From these facts it will easily be conceivedthat an inflammatory process in the appendix canlead to irritation of the plexus and its accompanyingepigastric pain. Dr. Vorschütz thinks that such anirritation affecting the vagal secretory fibres in theplexus may also account for the hyperacidity of thegastric contents often associated with appendicitis.May it not also similarly explain the condition ofileus paralyticus which sometimes accompanies appen-dicitis when general peritonitis is absent ? Thepresence of epigastric pain will therefore depend onthat of a lymphangitis following appendicitis. Butas in other parts of the body a local inflammationmay be manifest and even lead to gangrene withoutany signs of lymphangitis, so in the appendix theprocess may remain local, and no epigastric pain willbe caused. Conversely, and as in other parts ofthe body, a slight, hardly perceptible lesion in theappendix may lead to extensive lymphangitis andsigns of irritation of the solar plexus, giving rise tosymptoms which appear out of all proportion to thelesion found at operation. Dr. Vorsehiltz points outthat the theory that the appendicular pain arises inthe solar plexus is borne out by the fact that otheraffections of the abdominal cavity cause pain in thesame spot. The epigastric pain in cholecystitis istypical, and it is also not infrequently present inkidney affections (renal colic from stone, pyelitis, ormovable kidney). He relates a case of pyelitis inwhich he washed out the pelvis of the kidney. Eachtime the .pelvis was distended the patient complainedof severe pain in the epigastrium. In this case thepain was evidently due to stretching of the pelvis,and not to an inflammatory process, and was thereforeprobably more in the nature of a true reflex painthan due to a lymphangitis irritating the plexus.The epigastric pain present in some cases of pelvicdisease can be explained on Dr. Vorschiltz’s theory,especially when it occurs in cases of continuedinfirmity where an inflammatory condition has notbeen radically treated. Pelvic inflammation, un-accompanied by fever, can set up a condition of chronicirritation of the whole sympathetic system, which isoften labelled hysteria. But, as Dr. V orschützpoints out, how often do we see cases of girls inperfect physical and mental health before marriage,become the victims of pelvic disease and developinto the ever-complaining irritating individuals towhom there is no more joy or interest in life. Hesuggests that the intimate relation between thesympathetic system and the psychology of the beingis to blame, and that insufficient attention has beengiven to the vegetative nervous system, to whichperhaps we may look for a better understanding ofmany conditions hitherto shrouded in mystery.

A NEW ERUPTIVE FEVER.

Dr. A. M. Stevens and Dr. F. C. Johnson.1 of the IDepartment of Diseases of Children of ColumbiaUniversity, report two cases of a generalised eruptionwith continued fever, inflamed buccal mucosa, andsevere purulent conjunctivitis which were recentlyunder treatment at the Bellevue Hospital, New York.Both cases occurred in boys aged 7 and 8 yearsrespectively, who came from widely separated partsof New York City, without any possibility of contact.Both cases showed a purulent conjunctivitis which inone led to panophthalmitis and total loss of vision, andin the other responded to treatment but left a cornealscar. The pus showed pyogenic organisms only butno gonococci. In both cases there was a high andcontinuous fever, which in one patient was explainedby the existence of lobar pneumonia, while in theother there was no apparent cause but the skineruption. The eruption, which was identical in each

1 American Journal of Diseases of Children, December, 1922.

case, was accompanied by fever from the onset, andfirst appeared on the back of the neck and chest,spreading to the face, arms, and legs during a periodof 18 days, the soles and palms being last affected.The eruption consisted of oval, dark-red and purplishmacules, which in a few days became converted intofirm, brownish-purple papules, some of the largest ofwhich showed a yellow, dry, necrotic centre. Therewere no pustules or vesicles. The scalp was alwaysfree from lesions, but the mouth and lips were intenselysore and inflamed. After the third week the lesionssubsided, resolving into horny crusts, which, as theydropped off, left a faint pigmented area withoutpitting or scarring. The resolution of the lesions wasaccompanied by a fall of temperature. In discussingthe diagnosis the writers exclude (1) a drug eruption,as no drugs had been given in either case ; (2) food-poisoning, owing to the entire absence of gastro-intestinal symptoms ; (3) syphilis by the character ofthe lesions, negative history, and negative Wassermannreaction ; (4) haemorrhagic measles by the previoushistory of measles in each case and the character ofthe lesions ; (5) sepsis by negative blood cultures, thesuperficial nature of the lesions, their character andprogressive nature over nearly three weeks, and thepresence of leucopenia ; (6) erythema multiforme fromsome unknown toxic cause by the character anddistribution of the lesions, the lack of subjectivesymptoms, the prolonged high fever, and the terminalincrustation. The writers conclude that the conditionis a distinct disease which has not hitherto beenrecognised, and express the hope that their report maylead to the study of similar cases which may throwlight upon the aetiology.

The Services.COMMISSIONS IN THE ROYAL ARMY MEDICAL

CORPS.AN examination for not less than 15 commissions in the

Royal Army Medical Corps will be held on Jan. 31st, 1923.The presence of candidates will be required in London fromJan. 29th. Intending candidates can obtain a full state-ment of the duties and emoluments of the service on

written application to the Secretary (A.M.D.1), War Office,Whitehall, S.W. 1, and applications to compete should bemade to the Secretary not later than Jan. 21st.

ROYAL NAVAL MEDICAL SERVICE.The following appointments have been notified : Surg.

Comdrs. H. E. R. Stephens to Victory, for R.N. Hospl.Haslar ; W. G. Edwards to President, addl., for Hospicourse ; and W. H. Hastings to President, addl., for Hospl.course. Surg.-Lieuts. P. J. Maguire to Ganges, for R.N.Sick Quarters, Shotley, temp. ; and W. McCoach to Benbow,

L. McGolrick and P. J. A. The O’Rourke to be Surg. Lts.

INDIA AND THE INDIAN MEDICAL SERVICE.On expiry of his leave Lt.-Col. H. H. Broome has resumed

charge of the office of Medical Superintendent, MayoHospital, Lahore ; and Maj. II. V. W. Cox has resumedcharge of the office of Superintendent, Punjab LunaticAsylum. On transfer to the Punjab Maj. A. M. Dicken,O.B.E., has taken over charge of the office of Principal,Medical School, Amritsar ; and Maj. D. R. Ranjit Singh hasbeen reappointed Hon. Surgeon and Physician at the ColviaHospital, Allahabad, for a further period of three years ;and Maj. D. D. Kamat has been appointed Civil Surgeon.Maj. H. S. Hutchison has been granted extension of eightmonths’ furlough. The Viceroy has selected Col. R. Heard,Inspector-General of Civil Hospitals and Prisons, Assam,for the appointment of Inspector-General of Civil Hospitals,Punjab, in succession to Col. R. C. Macwatt.

Temp. Capt. T. E. Hincks, R.A.M.C., has been grantedpermission to wear the Médaille des Epidémies en Bronze,awarded to him by the President of the French Republicfor distinguished service rendered during the war 1914-19.

Capt. W. Hunt, O.B.E., R.A.M.C., attached EgyptianArmy, has been appointed Brevet-Maj. for distinguishedservice in connexion with military operations in Southernand Western Darfur, 1921.