574 HIGH ALTITUDES AND WANT OF OXYGEN.

for the production of artificial leucocytosis, statingboldly in so many words that cure can be reached clinically certain cases of G.P.I. by this route

Naturally enough, he has to admit the essentially"

unspecinc " nature of this treatment, and here, ai

will be seen at once, lies the crux of the whole matterIn the face of pathological conditions so desperatelintractable, according to common experience, al

dementia paralytica we should welcome any effortshowever empirical, however speculative, to inhibit itprogression, and we believe, with Prof. FiscHER, in thtunwisdom of discarding anything merely because of itsnot fitting in with existing systems of therapy. The

neurologist is aware, for example, how frequentlyepileptic phenomena are abated, or actually disappear,in the course of exanthems such as measles or chicken-pox, yet as far as we know inoculation of chronicepileptics with exanthematous material has nevei

been seriously proposed. Who shall say there is hereno suggestive therapeutic path to be explored ? ‘? Ifthe clinician is averse to "curing" one disease bythe development of another he ought not at the sametime to minimise the significance of the clinical facts,however little he is for the moment able to put themto practical use. Similarly with the problem of

general paralysis; the deliberate production ofleucocytosis is not only scientific, and can be paralleledby various techniques in other therapeutic fields, butit should be submitted to long and fair trial. Itwould, however, still leave unsettled the questionwhether for the specific germ of syphilis specifictreatment is not the ideal. Those with considerable

experience can justifiably claim for specific methodsmost encouraging results in tabes dorsalis, in earlycases at least, and Prof. FiscHER can say no more forleucocytic procedures. In general paralysis, further,recent workers have been obtaining favourablemodifications by intracisternal technique with salvar-sanised serum, and we see no reason to doubt thatwith further advances in treatment by mercurial andarsenical compounds still better results will besecured. ’

We should as a profession be glad to appreciate thereal significance of all the above facts, standing asthey do for a serious, patient, and imaginative studyof the problem of so-called parasyphilis. We shouldacclaim any evidence which seems to demonstrate

ability to modify the all-too-invariable downwardcourse of a common disease, the cause of which isabsolutely established, and only the treatment ofwhich is, metaphorically speaking, hanging fire.

’

High Altitudes and Want of

Oxygen.Jb OR centuries the increasing feats of mountaineering

have been followed with vivid interest by the medicalprofession, and the past few months have witnessedthe latest and greatest accomplishment. The MountEverest expedition has stimulated the imaginationboth by the boldness and perseverance of its concep-tion and execution and by the magnificent evidenceit affords of the power of the human organism to varyits physiological functions to meet abnormal conditionsto which it may be subjected. In all ascents ofgreat altitudes atmospheric conditions have to bereckoned with, as it is just in so far as the reducedbarometric pressure influences the respiratory functionin its broadest sense that the danger and difficultylie. PAUL BERT was the first definitely to point outthat the percentage composition of the atmospherevaries but little at different altitudes. He showedthat it was not the composition of the atmospherewhich was of importance but the partial pressures

of the gases, particularly of oxygen, which determinedthe efficiency of respiration. The air at sea-levelcontains 20-93 per cent. of oxygen, 0-03 per cent.carbon dioxide, and 79.04 per cent. of nitrogen andother indifferent gases. At a barometric pressure of760 mm. of mercury (allowing for aqueous vapourtension of 47 mm. at 37°C.) the partial pressure ofoxygen of the inspired air would be 149 mm. ofmercury. But the oxygen partial pressure of thealveolar air is the governing factor in so far as therespiratory function of the lungs is concerned, and thisis approximately 100 mm. Jig at sea-level. If for anyreason the percentage of oxygen were reduced andthe barometric pressure remained at 760 mm., so theoxygen partial pressure would be reduced. If theoxygen in the mixed alveolar air were 6 per cent.,then the partial pressure would be approximately

760 - 47 6.0 ..43 mm. Hg (760 - 47/1 x 6.0/100) = 43). Sudden subjec-tion of the human organism to an atmospheric environ-ment producing such an alveolar air would rapidlyinduce unconsciousness and probably death. Thereduction of the barometric pressure equivalent toan altitude of 27,000 ft. would similarly reduce thepartial pressure of oxygen of the alveolar air to

357 - 47 14.0 . ,

about 43 mm. Hg ( 357-47 x -100 = 43). Sudden

subjection to such an environment would producevery disastrous results, as has been frequently witnessedin high altitude aeroplane flights during the past fewyears. On the other hand, flights of great height,even greater than that of the summit of MountEverest, have been accomplished without untowardeffects by the use of oxygen. By varying the condi-tions of the inspired air the partial pressure of oxygenin the alveoli, and thus the oxygen saturation of thehaemoglobin, may be raised to almost a normal level,and that either by increasing the percentage of oxygenor by raising the barometric pressure. Mice havebeen kept alive submerged in water provided thewater were charged with oxygen at a sufficientpressure.

In the case of an expedition such as that to MountEverest other factors come into operation. It wasamply demonstrated on Pike’s Peak and lately bythe Royal Society’s physiological expedition to theAndes that the animal organism, if given sufficienttime, may adapt itself by various physiologicalchanges to the new environment. Many observa-tions have been made on the disastrous results whichensue when too sudden ascents are made. As in allphysiological adaptations, time must be given forthe organism to accommodate itself to the new environ-ment. It takes not only time but a certain constantand gradual stimulation to bring about a completemarshalling of the forces which are necessary to meetthe new conditions. Furthermore, it is importantto bear in mind not only the needs of the organismwhen at rest under such circumstances but also underconditions of increased metabolism. As the meta-bolism increases, so the demand for oxygen increases.The increase of metabolism may not only result fromincreased work, but also from increased tissue con-sumption due to infectious and other processes indi-cated by fever, which is itself evidence of increasedmetabolic activity. Oxygen supply must meet theoxygen demand. When there is deficiency of supplyand increase of demand the outlook is serious., Thisapparently was the disaster which overtook a memberof the Mount Everest expedition in 1921. It is a well-known experience of all communities at high alti-tudes that acute febrile disturbances are best treatedby removal to sea-level. This applies particularlyto those diseases which interfere with the properrespiratory function. Should this change of altitudebe impracticable, then the addition of oxygen to theinspired air is indicated in order to supply the greaterdemand for oxygen by the organism as a whole. Inacute febrile pulmonary disease, even at sea-levelthere is a similar indication for increasing the supplyof oxygen in the inspired air, particularly if the

575THE PRINCE OF BEGGARS.-CERTIFYING FACTORY SURGEONS.

pulmonary lesion interferes with the supply of oxygento the arterial blood. The insidious effect of acutewant of oxygen is seldom appreciated by the victim,and is therefore apt to be overlooked by those inattendance, but the importance of preventing cyanosisand other indications of oxygen-want in acute illnessesrests on the fact that the condition, although insidious,may suddenly reach a disastrous climax.A good example of acute oxygen-want is seen in

those who take high altitude flights in aeroplaneswithout proper means of increasing the oxygen supply.’The onset of unconsciousness may be very suddenand the subject quite oblivious to the danger of hisposition. In the more gradual ascent of mountain-.eermg, the organism is given an opportunity ofaccommodating itself. The Andean expeditiondemonstrated that in spite of an actual deficiency inthe oxygen saturation of the arterial blood, certaincompensating mechanisms might render the organismcapable of accomplishing considerable feats of physicallabour without untoward symptoms. Compensation,however, has its limits; so that it may be necessary,for additional work to be accomplished, to increasethe partial pressure of oxygen in the inspired air. - Asthis cannot be done by change of pressure it must bedone by increasing the oxygen percentage. Certainmembers of the recent Everest expedition took advan-tage of these facts and carried with them means ofincreasing the oxygen percentage. It appears fromaccounts so far available that their task was accom-plished with greater ease. The comparison betweenthe efficiency of those who had oxygen and those whohad not ’will be of great scientific importance whenthe report of the expedition is made available.

THE PRINCE OF BEGGARS.1

THIS is the title of an intimate record of the adven-tures of Viscount KNUTSFORD in begging for theLondon Hospital. It tells the story of systematic andshameless mendicancy extending over 25 years ofOffice as chairman of the charity, and the author isLord KNUTSFORD’S private secretary, Mr. NEVILLELANGTON, who has allowed himself to be frank to thepoint of well-mannered indiscretion. He was unableto obtain permission to publish Lord KNUTSFORD’Sportrait in front of the book, but he gets over thisdifficulty in the simplest manner by telling two episodesin which Lord KNUTSFORD was mistaken respectivelyfor Mr. ARTHUR ROBERTS and Lord ROSEBERY-wemay endorse the episodes bv saying that some timeago, a good many years, the errors were possible.Many of the humorous stories with which the book.is packed have already been widely quoted in thedaily papers, and some of them were current inmedical circles before Mr. LANGTON’S collection waspublished, but we do not wish to confine this briefreview to a grateful recognition of a humorous book.We see in it, also, a record of sustained, serious, andhigh effort. To make a million by begging is in anycircumstances a remarkable feat, but Lord KNUTS-FORD’S success was due in only a secondary degree to’his love of fun, his prompt use of opportunity, and hiswit in letter-writing. The grand object of his work.and the transparent sincerity of his devotion to itwere the things which made his methods fruitful.

1 The Prince of Beggars. By Neville Langton. London:Hutchinson and Co., Paternoster-row. Pp. 224. 6s. net.

MEASLES EPIDEMIC IN MANCHESTER.—For theweek ending August 26th 449 fresh cases of measles (with 12- deaths) were reported, as against 31 in the correspondingweek last year.

END OF SMALL-POX EPIDEMIC IN COLNE VALLEY.The last small-pox patient has been discharged from thesolation hospital at Moor Top, Meltam so that it is concluded:that the small-pox epidemic which began in the Colne Valleyon Oct. 20th last year has come to an end. At Moor Tophospital about 140 patients were treated, and 18 at the’hospital in Hudderifield.

Annotations.

CERTIFYING FACTORY SURGEONS.

" Ne quid nimis."

Tnn post of certifying factory surgeon, whichreceived statutory recognition 80 years ago, is theoldest in the field of preventive medicine. The workdone by the 2300 doctors who hold these appointments,distributed all over the kingdom, although criticismis levelled at it from time to time, is of substantialvalue. Attention is drawn to this work in the annualreport for 1921 of the Association of CertifyingFactory Surgeons, and particularly to the importance,when minor defects are found, of being permitted toattach conditions to certificates of fitness for employ-ment. The Association desire the Home Office topublish information as to the extent to which certifyingsurgeons avail themselves of this permission, and, inorder to facilitate collection of data, have preparedconvenient record forms for use.That part of the report which deals with the future

of the certifying surgeon is perhaps the most interest-ing. Here national economy is recognised to be astumbling-block in the way of ofucial action ; on theother hand, welfare work, especially in relation to theprovision of first-aid and ambulance equipment, isextending without recognised medical supervision ;and an appalling amount of industrial sickness andmortality, due to unhygienic conditions of occupation,continues unchecked with no effort at establishing thefaults or devising remedies-work which the certifyingsurgeon on a properly thought-out plan of actioncould perform admirably. The ordinary course ofevolution should be for the certifying surgeons to begiven more work by employers until they develop intoindustrial surgeons of the type which has so usefullycome into existence in America. In that country,however, medical supervision is mainly provided bylarge industrial concerns ; in this country by correctuse of the certifying surgeon the small factory andworkshop can be catered for. The larger concerns intheir own interests are bound sooner or later toestablish their medical departments as the economicvalue of industrial hygiene dawns upon the entre-preneur. To-day this country holds a curiouslyanomalous position. Owing to the work set on foot bythe Ministry of Munitions in war-tirne, and nowcontinued by the Industrial Fatigue Research Board,we stand far ahead of other countries in our availableknowledge and scientific research, but meanwhile thereis lack of appreciation of the economic value of thisknowledge and of efforts to give it practical application.There is grave danger lest we stand by and leaveothers to benefit from our own discoveries, even

though in the certifying factory surgeons we possessready made for use a working oragnisation throughwhich action can advantageously be taken.

Given official support and encouragement, thecertifying surgeons can themselves do much to savethe situation, and they are urged so to help themselves.The report under notice in this respect gives a lead,and is more farseeing than any of its forerunners.

THE ASSOCIATION OF A SPINAL DISEASE WITH

HUNGER OSTEOMALACIA.

Dr. Richard Hoffmann,l from the medical clinicdirected by Prof. Pal in Vienna, describes in detail acondition which occurred frequently during theperiod of famine in Vienna. Twenty-three cases

(14 women, 9 men) were seen between September,1920, and April, 1921. The disease occurred chieflyin persons of middle age, and gave the following

1 Report of the Council of the Association of CertifyingFactory Surgeons for the Year 1921. Coöperative PrintingSociety, Manchester. 1922.

1 Wiener Archiv für Innere Medizin.