188 glanders made in these two cases may be carried out on a single case. In view of the manifesta- tions of the disease here met with-a perivascular lymphatic and embolic infection-it might, perhaps, be well to speak of the condition described as chronic farcy. It is interesting to note that of 21 chronic cases of farcy in man recorded by HOWARD BENDALL as early as 1882, 15 recovered or were partially cured, the six that died succumbing in periods between 50 days and 14 months. In one of those that recovered the disease lasted as long as 2 years. A disconcerting feature about the Nottingham case, but one that in future must be borne in mind, is that the tissues of the udder of a milch cow may become the temporary nidus of the B. mallei and that a condition of mild chronic farcy may there be set up from which the milker may become infected. It then becomes possible for a glanders infection to be contracted by those who partake of the milk, even though in its passage through the bovine carrier host the organism has become greatly attenuated in virulence. The mild disease process thus set up may through its very modification be difficult of diagnosis, and yet from this mild infection centre a much more virulent type may be developed by passage. Annotations. CARBON MONOXIDE IN COAL-GAS. "Ne quid nimis. " CARBON monoxide has been described by Brouardel as holding first place amongst the toxic gases-he was speaking of accidental poisoning and not of the deliberate use of respiratory noxae ; and the Registrar-General attributes 704 deaths in 1919 to the absorption of deleterious gases. It is, therefore, not merely a question of fuel value what proportion of carbon monoxide should be contained in the coal-gas supplied to us; it is a matter on which medicine is entitled to raise its voice. The number of cases in which coal-gas has been employed for suicidal purpose have shown some signs of increasing lately; such acute poisoning would be difficult in any case to prevent, but it is well known that carbon monoxide, by its peculiar power of monopolising haemoglobin, is a cumulative poison, and it is important to limit its possibilities of harm. The question of the post-war basis upon which gas shall be sold, as well as the standard of quality to be applied to it, have both been the subject of considerable inquiry and discussion. The matter originated within the gas industry itself during the war, when it was found that the total yield of gas from a ton of coal could be greatly increased by combining the usual process of carbonising in retorts with the simultaneous production of water-gas by passing super-heated steam over the incandescent coke. Unfortunately, the resulting mixture of coal- and water-gas is not only of considerably lower heating power (a matter which can be adjusted by grading the price) but also contains much more of the poisonous carbon monoxide. The whole subject was taken up and reported upon by the Fuel Research Board; and, finally, the British Association Fuel Economy Committee, of which Pro- fessor W. A. Bone, F.R.S., is chairman, considered it and made certain recommendations. One of these recommendations was that in no circumstances should it be permissible for a public gas undertaking to supply to its consumers a product containing more than 20 per cent. of carbon monoxide. This recommendation was in harmony with the findings of a Home Office inquiry held in 1899, at which Dr. J. S. Haldane took part. It was then agreed that, in view of the imperfect state of the fittings in the poorer houses of urban districts, the only effective method of pre- venting danger from leakage was to fix a limit which the carbon monoxide should not exceed. When the Gas Regulation Act, 1920, became law last July the Board of Trade was instructed to hold a special public inquiry into the question, and a committee, consisting of Sir William Pearce, M.P. (chairman), Dr. T. Carnwath, Mr. William Doig Gibb, and Mr. T. Gray, D.Sc., will pro- ceed in the immediate future to take evidence with a view to arriving at a decision which, under the pro- visions of the Act, will have statutory effect. In view of the importance of the decision from the hygienic standpoint, we trust that this committee will give due weight to the need of limiting the carbon monoxide proportion. Health must come first in such a matter, and due consideration for health will prove in the long run to be justified economically. VOLUNTARY HOSPITAL FINANCE; A LAY COMMITTEE. IT will be remembered that when the Ministry of Health (Miscellaneous Provisions) Bill was before Standing Committee a debate ensued over Clause 11, which was intended to regularise the taking over or founding of general hospitals by municipalities. It was, and is, an obvious responsibility of the Ministry of Health to further a general scheme for the country under which all classes of the population may obtain the benefits which can only follow upon institutional treatment, but the particular clause of the Bill was challenged from so many directions that Dr. Addison withdrew its criticised portion and offered to appoint forthwith a Committee " to inquire into and report upon the financial position of the voluntary hospitals throughout the country," adding that the Committee would consist of ftve members only, none of them being medical men or connected with hospital arrangements in any way. The Committee has now been constituted as follows: Viscount Cave (Chairman), Sir Clarendon Hyde, Mr. R. C. Norman, and Mr. Vernon Hartshorn. A fifth member, who will be a representative for Scotland, remains for appointment, while it has also been decided to include a chartered accountant of high standing, a very welcome addition. - HEREDITY IN CONGENITAL HIP DISLOCATION. I IN a recent bulletin of the Paris Academy of Medicine’ 1 L. Dubreuil-Chambardel discusses the hereditary factor in the incidence of congenital dislocation of the hip, and traces the later histories of five cases operated upon for this deformity. Judging by this and two previous papers by the same author, heredity is evidently regarded by him as playing a larger part in the production of this deformity than most surgeons would be ready to admit. Tubby certainly says " heredity is a marked feature " in this de- formity, and he quotes Marath 3 as finding a history of heredity in 40 per cent. of his cases and Vogel in 30 per cent. of his. On the other hand, Whitman 5 says " hereditary influence can be established in a few instances" only, while Bradford and Lovett 6 and Taylor 7 would seem to - agree with him. H. A. T. Fairbank found signs of hereditary influence in only 8 of 200 cases. It is probable that more extensive investigation into the family histories of these cases would have added to this figure, but the percentage could not have approached those given by Vogel and Marath. There does not appear to be any reason for regarding congenital dis-’ location of the hip as being the result of hereditary influences to a greater extent than other congenital 1 Bull. de 1’Acad. de Med., 3e Série, vol. lxxxiv., p. 281. 2 A. H. Tubby : Deformities, vol. i., p. 129. Macmillan and Co. 1912. 3 Marath: Quoted by Tubby, ibid. 4 Karl Vogel: Zeitsch. f. Orth. Clin., 1905, p. 132. 5 Royal Whitman: Orthopædic Surgery, p. 533. Lea and Febiger, New York. 1917. 6 E. H. Bradford and R. W. Lovett: Orthopedic Surgery, p. 318. Baillière, Tindall, and Cox, London. 1912. 7 H. L. Taylor: Orthopædie Surgery for Practitioners, p. 247. D. Appleton and Co., New York. 1909.
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glanders made in these two cases may be carriedout on a single case. In view of the manifesta-tions of the disease here met with-a perivascularlymphatic and embolic infection-it might, perhaps,be well to speak of the condition described as
chronic farcy. It is interesting to note that of 21chronic cases of farcy in man recorded by HOWARDBENDALL as early as 1882, 15 recovered or were
partially cured, the six that died succumbing inperiods between 50 days and 14 months. In oneof those that recovered the disease lasted as longas 2 years. A disconcerting feature about theNottingham case, but one that in future must beborne in mind, is that the tissues of the udder ofa milch cow may become the temporary nidus ofthe B. mallei and that a condition of mild chronicfarcy may there be set up from which the milkermay become infected. It then becomes possiblefor a glanders infection to be contracted by thosewho partake of the milk, even though in its passagethrough the bovine carrier host the organism hasbecome greatly attenuated in virulence. The milddisease process thus set up may through its verymodification be difficult of diagnosis, and yet fromthis mild infection centre a much more virulenttype may be developed by passage.
Annotations.
CARBON MONOXIDE IN COAL-GAS.
"Ne quid nimis. "
CARBON monoxide has been described by Brouardelas holding first place amongst the toxic gases-he wasspeaking of accidental poisoning and not of the deliberateuse of respiratory noxae ; and the Registrar-Generalattributes 704 deaths in 1919 to the absorption ofdeleterious gases. It is, therefore, not merely a questionof fuel value what proportion of carbon monoxide shouldbe contained in the coal-gas supplied to us; it is amatter on which medicine is entitled to raise its voice.The number of cases in which coal-gas has beenemployed for suicidal purpose have shown some signsof increasing lately; such acute poisoning would bedifficult in any case to prevent, but it is well knownthat carbon monoxide, by its peculiar power of
monopolising haemoglobin, is a cumulative poison, andit is important to limit its possibilities of harm.The question of the post-war basis upon which gasshall be sold, as well as the standard of quality to beapplied to it, have both been the subject of considerableinquiry and discussion. The matter originated withinthe gas industry itself during the war, when it wasfound that the total yield of gas from a ton of coalcould be greatly increased by combining the usualprocess of carbonising in retorts with the simultaneousproduction of water-gas by passing super-heated steamover the incandescent coke. Unfortunately, theresulting mixture of coal- and water-gas is not only ofconsiderably lower heating power (a matter which canbe adjusted by grading the price) but also containsmuch more of the poisonous carbon monoxide. Thewhole subject was taken up and reported upon bythe Fuel Research Board; and, finally, the BritishAssociation Fuel Economy Committee, of which Pro-fessor W. A. Bone, F.R.S., is chairman, consideredit and made certain recommendations. One of theserecommendations was that in no circumstances shouldit be permissible for a public gas undertaking to
supply to its consumers a product containingmore than 20 per cent. of carbon monoxide. Thisrecommendation was in harmony with the findingsof a Home Office inquiry held in 1899, at which Dr. J. S.Haldane took part. It was then agreed that, in view ofthe imperfect state of the fittings in the poorer houses
of urban districts, the only effective method of pre-venting danger from leakage was to fix a limit whichthe carbon monoxide should not exceed. When the GasRegulation Act, 1920, became law last July the Board ofTrade was instructed to hold a special public inquiryinto the question, and a committee, consisting of SirWilliam Pearce, M.P. (chairman), Dr. T. Carnwath, Mr.William Doig Gibb, and Mr. T. Gray, D.Sc., will pro-ceed in the immediate future to take evidence with aview to arriving at a decision which, under the pro-visions of the Act, will have statutory effect. In viewof the importance of the decision from the hygienicstandpoint, we trust that this committee will give dueweight to the need of limiting the carbon monoxideproportion. Health must come first in such a matter,and due consideration for health will prove in the longrun to be justified economically.
VOLUNTARY HOSPITAL FINANCE; A LAYCOMMITTEE.
IT will be remembered that when the Ministry ofHealth (Miscellaneous Provisions) Bill was beforeStanding Committee a debate ensued over Clause 11,which was intended to regularise the taking over orfounding of general hospitals by municipalities. Itwas, and is, an obvious responsibility of the Ministryof Health to further a general scheme for the countryunder which all classes of the population may obtainthe benefits which can only follow upon institutionaltreatment, but the particular clause of the Billwas challenged from so many directions that Dr.Addison withdrew its criticised portion and offeredto appoint forthwith a Committee " to inquireinto and report upon the financial position ofthe voluntary hospitals throughout the country,"adding that the Committee would consist of ftvemembers only, none of them being medical men orconnected with hospital arrangements in any way.The Committee has now been constituted as follows:Viscount Cave (Chairman), Sir Clarendon Hyde, Mr.R. C. Norman, and Mr. Vernon Hartshorn. A fifthmember, who will be a representative for Scotland,remains for appointment, while it has also been decidedto include a chartered accountant of high standing, avery welcome addition. -
HEREDITY IN CONGENITAL HIP DISLOCATION.
I IN a recent bulletin of the Paris Academy of Medicine’ 1L. Dubreuil-Chambardel discusses the hereditary factorin the incidence of congenital dislocation of the hip,and traces the later histories of five cases operatedupon for this deformity. Judging by this and twoprevious papers by the same author, heredity is
evidently regarded by him as playing a larger partin the production of this deformity than mostsurgeons would be ready to admit. Tubby certainlysays " heredity is a marked feature " in this de-formity, and he quotes Marath 3 as finding a historyof heredity in 40 per cent. of his cases and Vogelin 30 per cent. of his. On the other hand, Whitman 5
says " hereditary influence can be established ina few instances" only, while Bradford and Lovett 6and Taylor 7 would seem to - agree with him.H. A. T. Fairbank found signs of hereditaryinfluence in only 8 of 200 cases. It is probablethat more extensive investigation into the familyhistories of these cases would have added to this
figure, but the percentage could not have approachedthose given by Vogel and Marath. There does not
appear to be any reason for regarding congenital dis-’location of the hip as being the result of hereditaryinfluences to a greater extent than other congenital
1 Bull. de 1’Acad. de Med., 3e Série, vol. lxxxiv., p. 281.2 A. H. Tubby : Deformities, vol. i., p. 129. Macmillan and Co. 1912.
3 Marath: Quoted by Tubby, ibid.4 Karl Vogel: Zeitsch. f. Orth. Clin., 1905, p. 132.
5 Royal Whitman: Orthopædic Surgery, p. 533. Lea and Febiger,New York. 1917.
6 E. H. Bradford and R. W. Lovett: Orthopedic Surgery, p. 318.Baillière, Tindall, and Cox, London. 1912.
7 H. L. Taylor: Orthopædie Surgery for Practitioners, p. 247.D. Appleton and Co., New York. 1909.
189
deformities. In all we find an occasional case giving ahistory of the same or other congenital deformitiesaffecting other members of the family, but this is theexception and not the rule. In the case of congenitaldeformities of the hand A. Steindler, in a series recentlypublished, traced an hereditary factor in only 20 percent. The five cases detailed by Dubreuil-Chambardeltend to show that reduction of the dislocationhas no influence whatsoever on the incidence of thedeformity in the offspring of the cases so treated.Treatment of a condition which is, at most, only theresult of an inherited tendency, could hardly be
expected to influence the possible transmission of thattendency.
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EDUCATION AND DEMENTIA PRÆCOX.
Dr. Deroitte, of Brussels, when on a visit recently inthis country had the opportunity of comparing Britishasylums with those in his own country. He was greatlystruck by the comparative rarity of dementia prsecoxin our institutions, and, casting about for an explana-tion, has hit upon the English educational system asthe secret of our "solid nervous systems, the emotionsalways reined in by an ever-calm judgment." InLe Scalpel for Jan. 1st he devotes ten pages to a com-parison of the English and Belgian methods of secondaryeducation and an exposition of the wearing effect of thelatter upon Belgian nerves. Long hours of monotonouswork in school, work taken home in the evening (athoroughly reprehensible system!) and," sad to relate,"long written punishments as well, all help to wear outthe overtaxed brain. Corporal punishment is tooviolent and is one of the causes of mental shock. TheEnglish system avoids this danger by relegating punish-ment to a monitor or at least assuring that it is notadministered by the same master who has cause forannoyance. Instead of punishing a boy for laziness heshould be made to feel the sense of responsibility forhis own mental and physical development. Dr. Deroittequite rightly lays emphasis on the possibility of psychicshock through the careless exposure of sexual vices andtheir danger at the susceptible age of puberty. Publicaddresses on these subjects he condemns categorically.Strangely enough, he omits to mention that a childwho has been properly educated in the years beforepuberty is not liable to shock from the discovery of hisown sex mechanism. The practical deductions of thisstudy are two: in school, the development of spontaneity,the exercise of the will, the culture of self-confidence ;out of school, the encouragement of physical exercise Iand of hobbies.
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THE CIRCULATORY FAILURE OF DIPHTHERIA.
THERE are a dozen ways in which the heart can bebrought to admit defeat at the hand of disease, yet inthe last resort it is true that all these diverse processeskill by the effect they produce on the metabolism ofthe myocardiac cell. In a recent elaborate study ofcirculatory failure in diphtheria Dr. Esther Harding 1suggested a similar wealth of processes busy at thetask of killing the patient and an ultimate convergenceof all those processes on the one point of interferingwith the peripheral circulation in such a way that thevital tissues, and particularly those of the brain, areno longer able to maintain their metabolic balance.According to Dr. Harding, whose studies were carriedout in 1918 at the Plaistow Fever Hospital, neithermyocardial degeneration, profound though it is indiphtheria, nor vascular relaxation, is sufficient toaccount for that failure of the circulation which is thelethal factor in diphtheria. She is impressed by a faintgeneral oedema which is present early in diphtheria, towhich she gives the name of "lymph-logging." This isaccompanied by a rise in the specific gravity of theperipheral blood, and is ascribed by her to alteredosmotic conditions and increased permeability of thecapillary walls. A state of oligaemia, or shortage ofblood in circulation (comparable to that observedin surgical and other forms of shock), is thus
1 The Circulatory Failure of Diphtheria. By M. Esther Harding,M.D. University of London Press, Ltd. 1920. Pp. 176. 10s. 6d.
induced early in diphtheria, and is aggravated laterin the disease by diminution in the cardiac outputand by vascular relaxation. Each of these latterphenomena is traceable to a number of sources, whichare examined carefully by Dr. Harding in an argumentdemanding close attention. Her tentative conclusionsas to the actual nature and correct treatment of thecirculatory failure have recently received supportfrom experimental researches which she has been
carrying out in the department of biochemistry andpharmacology in the National Institute for MedicalResearch at Hampstead. The condition has been foundto resemble the experimental ’’ shock’’ produced byhistamine. In the words of the annual report of theMedical Research Council,
" evidence has already beenobtained pointing clearly to the possibility of savinglife by symptomatic treatment of the circulatory condi-tion in cases in which specific treatment by the anti-toxin alone is of no avail." It is to be hoped that theclinical testing of these ideas, which is promised in thereport, will confirm these anticipations, for it is
possible that if so we shall be furnished with newmeans of saving life, not only in diphtheria, but also inother forms of infective disease.
RECENT RESEARCHES ON PELLAGRA IN EGYPT.
WITH surrender of the defeated Turkish Army inPalestine and arrival in Egypt of many thousands ofprisoners of war for internment, unexpectedly favour-able opportunities became available in 1918 to BritishArmy medical officers for investigating pellagra. Itmay be mentioned that from their arrival in Egypt upto the end of 1919 there occurred among 105,668 Turkishprisoners some 9257 recognised cases of pellagra, butthere were probably many other undiagnosed instances.A committee of investigation was appointed in 1918 bythe Army Medical Department, consisting of ColonelF. D. Boyd, A.M.S., and Lieutenant-Colonel P. S.Lelean, R.A.M.C., with whom were associated a numberof experts of various kinds. In their report, on whichwe commented in THE LANCET of Sept. 13th, 1919, it isstated that no aetiological relationship of the malady tobacteria, protozoa, or to blood conditions had been dis-covered, and that as regards food there was so constantan association between the biological value of diet andthe occurrence of pellagra, they considered the lack ofsufficient biological value of protein stood in setiologicalrelationship to pellagra, certainly as an exciting factor,and possibly as the determining factor.As some uncertainty existed on several points
connected with the disease another committee wasappointed 1 by the Army Medical Department early in1920, consisting of Major A. C. Hammond-Searle,R.A.M.C., and Captain A. G. Stevenson, R.A.M.C.,with Lieutenant-Colonel P. J. Marett, R.A.M.C., as
bacteriologist. The Committee began work in thespring of 1920, and their report, now issued, bearsthe date of Sept. 15th of that year. Some of thematters which were investigated could not be com-pleted owing to the rapid repatriation of the Turkishprisoners during 1920, and the consequent disappear-ance of much of the material on which the inquiry wasbeing carried out. One of the conclusions arrived atwas that all the aetiological factors in pellagra are notto be explained solely on the theory of deficiency ofprotein of high biological value, and that thereforepellagra cannot be regarded in itself as a true" deficiency disease." There was evidence that anunhealthy or ulcerated intestinal mucous membranebecomes infected by anaerobes, with their resultinggrowth and toxic action. In post-mortem examinationof fatal pellagra cases the intestine showed ulcerationin a large percentage of them; the mucous mem-brane of the small intestine almost invariablyshowed denudation with, in certain instances, super-ficial ulcers, the pigmentation of which was a feature.Cultures, from faeces of definite pellagra patientsand from the small intestine of post-mortem cases,
1 Report on Investigations of Pellagra among Turkish Prisonersof War in Egypt in 1920. Pp. 65. With numerous charts and tables.Published at Alexandria. (Not on sale.)
