1309DUODENAL CATHETERISATION.

under training, and benefit so rapidly from it. Indeed,he talked so much and so enthusiastically about itthat it was heard of by the King of Egypt, whoordered that his bodyguard should be examined andtreated forthwith. In all, treatment was extended to1214 serving soldiers, while 969 were told off to betreated when the training period was at an end.The reports from regiments were that recruits thisyear did not faint on parade, nor did they, as formerly,complain of schistosomiasis. This very interestingstory is detailed by Major Spence in a thesis for thedegree of M.D. Edin., which appears with illustrationsin the Journal of the R.A.M.C. for May, and is wellworth reading, particularly if taken along with hisprevious paper, on the Wady Halfa Quarantine toprotect the Sudan against worm-infected labourersfrom Egypt, in the same publication for last November.

DUODENAL CATHETERISATION.

THE merit of being the pioneers of this method ofinvestigating the contents of the duodenum belongs,perhaps, to J. C. Hemmeter and Max Einhorn.Various observers have from time to time modifiedthe procedure and the nature of the instrumentsrequired, and recently Dr. Alberto Trossarelli haspublished the results of his work in this respect at theMauriziano Hospital at Turin.’ He makes use of arubber tube of 5 mm. diameter and 1-25 metre long,with a metallic perforated extremity. The tube isfilled with an emulsion of barium sulphate which byrendering it opaque facilitates its passage by meansof the screen across the stomach and through thepylorus, which is induced to relax by the introductionof sodium bicarbonate according to Jutte’s method.The duodenum is reached rapidly, and by means of anordinary glass syringe the barium emulsion is aspiratedfirst and then the duodenal fluid ; the small quantityof the former which remains in the tube in no wayinterferes with the ultimate investigations. Themethod is valuable both from a clinical and therapeuticstandpoint.As a rule, the duodenal contents consist of the

duodenal juices, bile, and pancreatic juice, butby injecting 25-30 c.cm. of a 25 per cent. solutionof magnesium sulphate contraction of the gall-bladderensues and at the same time relaxation of Oddi’ssphincter. Bile thus obtained may be of normalaspect or thick and dark, indicating the presenceof cholecystitis, or containing a large quantity ofmucous flakes, evidence of catarrhal jaundice.Fine sand points to biliary lithiasis, while a

definite amount of blood suggests the presence of agrowth either in the duodenum, biliary passages, orpancreas, and especially in the latter organ if the

liquid is colourless, and there has been no colicand if pancreatic ferments are absent. Microscopic

Iexamination of the extracted fluid sometimes dis-closes the presence of a large quantity of polynuclearleucocytes with red corpuscles associated with mucusand cellular elements and various micro-organisms;such a condition indicates some inflammatory process,cholecystitis or choledochocystitis either simple or

calculous if there are many cholesterin crystals seen.In catarrhal jaundice there may be an enormousquantity of epithelial cells accompanied by poly-nuclears and cylindrical cells of the biliary ducts.Chemical examination will show that there is completeabsence of urobilin in obstructive jaundice, while onthe other hand, it is increased in cases of abnormaldestruction of red cells such as in hsemolytic jaundice,pernicious anaemia, and malaria. Usually the amountof albumin in the bile varies largely from case to case,and also in individuals who subjectively and clinicallymay be considered normal, and even varies in thesame individual, according as the bile comes fromthe gall-bladder or biliary passages. Although someobservers have claimed that the presence of a definitequantity of albumin is an indication of inflammatoryprocesses of the bile passages, and particularly of

l Policlinico, Surgical Section ,April 15th, 1925.

catarrhal jaundice, Prof. Trossarelli’s researchesseem to show that the presence of albumin in thebile is an unsolved problem as an element of diagnosisand cannot be relied on in the absence of other

symptoms. In fact, there are individuals who havenever suffered from any kind of gastro-intestinal orhepatic disturbance whose bile contains as muchalbumin as those suffering from jaundice of variouskinds. Examination for the presence of pancreaticferments, diastase, trypsin, and steapsin has failed toafford any definite diagnostic help, partly because theduodenal fluid rapidly loses its fermentative power,whether kept in ice or in a thermostat at 37°C.,andpartly because the presence of bile largely increasesits activity. It is only with the greatest circumspectionthat it is possible to admit a functional debility of thepancreas in the sense of a diminished excretion offerments based on a quantitative examination ofthese substances in the duodenal juice.

Catheterisation is also useful in treatment, sinceby means of the tube various remedies can be broughtinto contact with the duodenal mucosa withouthaving to pass through the stomach. One method oftreatment which has given good results, particularlyin cases of cholecystitis, hepatic calculus, ulcerativecolitis, and in some cases of ankylostomiasis, consistsin free duodenal lavage with astringents and anti-septics. Among the substances which have beenused beneficially may be mentioned argyrol andprotargol in 0’75 per cent. to 1-5 per cent., nitrate ofsilver 1 in 20,000, sulphate of magnesia and Jutte’ssolution, the latter composed of 0-9 per cent. sodiumsulphate and 0’9 per cent. sodium chloride, using1 to 1 litres for a lavage. Excellent effects seemto have been obtained by these methods, resulting inthe elimination of large quantities of biliary sand andeven small calculi with disappearance of symptoms.In other cases, individuals suffering from inter-mittent fever of obscure origin, where after catheterisa-tion the duodenal fluid was found to contain bacillibelonging to the paratyphoid group, a complete curewas obtained after two or three washings. Thismethod has also been used with solutions ofnovarsenobenzol in syphilis and emetine in amcebicdysentery. Recently Bottner and Verner practisedduodenal lavage with decoction of linseed and 5 percent. magnesium sulphate in patients affected withpernicious anaemia. Out of six subjects treated theyobtained clear improvement in five of them. Prof.Trossarelli’s observations and researches demonstratethe great importance that duodenal catheterisationmay acquire in the diagnosis and treatment of certaindiseases of the liver, bile-ducts, pancreas, andduodenum. When technical difficulties have beenovercome it will doubtless obtain its fitting place inpractical medicine. ____

HOSPITAL PROVISION FOR CHRONICS.

NOT long ago Dr. E. P. Boas, medical director of theMontefiore Hospital in New York, brought to thenotice of the New York Academy of Medicine theproblem of the hospitalisation of the chronic case.There are, it appears, few institutions in New Yorkwhere adequate care is given to the treatment ofchronic disease, and at existing institutions there islittle if any differentiation made between cases simplyrequiring custodial care and those which would respondto specialised medical and surgical treatment. Thesubject is further dealt with in a report by thePublic Health Committee of the Academy which hasjust reached us. The type of case for which the NewYork hospitals under present circumstances do notarrange includes the various rheumatic diseases,cardiac and visceral troubles of many kinds anddegrees, mucous colitis and other gastro-entericdiseases which do not readily respond to hometreatment, disturbances of the neuro-muscular system,renal affections and the large group of orthopaediccases. Shelter is provided for those who have reachedthe incurable stage, but the need is felt for the careof those who are not yet hopeless. The staff should

1310 THE CONTROL OF THE TSETSE-FLY.

it is argued, be made up only of physicians who areinterested in the study and treatment of chronicdisease. In a recent survey,t made at the instance ofthe same public health committee, it is stated thatthere are only three hospitals in New York with anentirely independent staff of physicians for the out-patients’ department, and two of these are now

contemplating a reorganisation which will bringabout closer coordination between the hospital andthe dispensary work. The survey closes with a idefinite indictment of the lack of " community policy,"

I

which, it is stated, has resulted in a heterogeneousaccumulation of hospital services more or less suitedto the needs of the community, but inelastic in theirorganisation, not fully adjusted to meet the economicstatus of the several classes of the population, andfor the most part not coordinated with the existinghospital facilities in the city as a whole. This isan indictment which, with necessary amendments,probably applies to most hospital services everywhere,and one of the great works of the not distant futurewill be the removal of a state of things almost inevit-able in the past, but which is now in danger of becomingan avoidable reproach. ____

UNPLEASANT BOOKS.

- THE 135th anniversary dinner of the RoyalLiterary Fund was held at the Hotel Victoriaon June llth, when the Spanish Ambassador,Don Alfonso Merry del Val, presided and made inidiomatic English an admirable speech on the positionof English literature in Spain. He spoke, he insisted,as a diplomatist representing the views of the Spanishsovereign, but the training of the English publicschool was apparent throughout. To the toast ofliterature proposed by Sir Robert Kindersley, MajorIan Hay Beith responded in eloquent terms, pleadingthe cause of all writers great and small and apologisingfor " a great deal of stuff that is about " by pleadingthat the unpleasant books for which there is a maniain certain circles represented a passing phase and oneat which many people were already bored. MajorBeith was as serious as he was funny in his excellentspeech, and he put unpleasant books, we think, intheir right place as a transient nuisance. Medicalmen at least must hope so, but this implies that thepropaganda of the voluntary custodians of publicmorality must often advertise what had better havebeen ignored. The mass of illiterate readers-andthe mass will always be illiterate-is only stirredto emotional attention by the primary human needsof birth and death and mating. The writer whosestyle falls just short of the living touch may gaineffect by overstepping ever so little the conventionalbounds of plain speaking and by producing the firstdegree of shock, which may be pleasant. The factthat the second degree brings nausea and satietyshould not be forgotten.

THE MATHEMATICS OF INTERNALRESPIRATION.

ON June 10th Prof. L. J. Henderson, of Harvard,delivered the first of a series of three lectures uponBlood as a Physicochemical Svstem in the Physio-logical Institute of University College, London; Prof.A. V. Hill being in the chair. The size of his audience z’

may be explained by the memory of a lecture beforethe Physiological Society in 1920, at which Prof.Henderson introduced his own particular method ofattacking the physicochemical properties of the blood.The present series of lectures record progress madeduring the intervening five years. The lecturerbegan by summarising the various physicochemicalinvestigations already performed on the blood. Hepointed out the great importance of the work ofJ. Barcroft upon the dissociation curve of oxyhsemo-globin, since it demonstrated that one of the mostimportant respiratory functions of the blood could

1 The Hospital Situation in Greater New York. G. P.Putnam’s Sons. Pp. 356.

be reduced to a mathematical problem. The subse-quent investigations of A. V. Hill proved that itwas possible to express the conditions in the form ofa simple and now familiar equation. The nextinvestigations of importance were those of Christian-son, Douglas and Haldane, who made clear themarked difference in the carbon dioxide absorptionbetween oxygenated and reduced blood. Van Slyke,Wu, and F. C. Maclean’s investigations of the variousalterations in the water content of cells and plasmawere also summarised. Prof. Henderson thendescribed his own investigations into the relationsbetween free, total, and fixed CO 2 of the blood, con-cluding that the following variables constituted themain factors in the physicochemical equilibrium ofthe blood: free oxygen (02), total oxygen (Hbû2).free CO 2 (CO s), total CO2(BHC03) hydrogen-ion con-centration of serum (H), volume of corpuscles (V),and the ratio of the anions within and without thecells (r)-i.e., Donnan’s equilibrium factor. Pre-vious work had suggested that these variables mightbe grouped in threes, when it would obviously bepossible to define the five following equations :-

i1’ (H) . (H2Cûs) . (BHC03) = 0.

J 2. (0 2) (HbÛ2) (]El 2CO 3) = O.

f,. (H2Cûs) . (BHCO,) . (HbO,) = 0.

f4’ (H) . .(Hb0,).(r) = 0.

is. (H) (Hbû2) (V) = 0.

The possible permutations of the series evidentlypreclude any attempt at algebraic solution. Prof.Henderson’s thesis might be summarised by statingthat he believed that if some solution could be offeredto these equations, the conditions of the blood’sequilibrium would be defined. There are seven

variables, and it ought to be possible, by fixingany two of the seven, to define the other five. Inhis second lecture Prof. Henderson dealt with amethod of solution by means of a graphical repre-sentation on the following principle. A series of curvesfor the five equations can be plotted on the basis oftwo of the variables being fixed, and by super-imposition a comprehensive diagram thus obtained.The result, however, would be a mass of confusionif the ordinary type of graph were constructed.Prof. Henderson has called to his aid the Cartesiannomogram, extensively used in mathematical circles,which has, in his hands, yielded information of thegreatest value. To construct a nomogram for theequation a; +y =Z, the ordinate and abscissae are firstgraduated in terms of x and y. The numerals onthe co-ordinates are joined by means of straightlines with the result that a series of diagonals areproduced, joining like values of x and y. Theselines are numbered according to the values whichthey unite. To use the nomogram, perpendiculars.are dropped from the particular values selected forx and y on the co-ordinates, and it will be found thatthe point of intersection will lie on one of the

diagonals or contour lines. This will correspond tothe value of z. By superimposing a series of contoursupon such a Cartesian background it is possible toread off the points of intersection.

THE CONTROL OF THE TSETSE-FLY.

I As against the hope expressed at the recent League

of Nations Conference on Sleeping Sickness in Africa,that international coordination would do much tofurther progress in combating this disease, Prof.Warrington Yorke has rather focused attention on

our own " kail-yard " in his paper read to. the

Imperial Entomological Conference on June 15th.In this paper he put forward a case for coordinationof effort among our own African colonies in tsetse-flyinvestigation, principally in the experimental deter-mination of the relationship of game to fly. Theproblem, he said, was to coordinate the four factors con-cerned in the disease-namely, (1) the pathogenic virusor trypanosome ; (2) the population and the domesticstock; (3) the transmitting agent or tsetse-fly; and