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for it implies considerable scarcity of medical servicein some districts. For it must be remembered thatthe large class of officiers de santé, abolished in 1892,is very nearly extinct, something under 500 namesonly now remaining on the official list. In the time ofLouis-Philippe, that is to say, about 80 years ago,there were less than 8000 doctors and many districtswere totally deprived of them. At the time of theFranco-German war, in 1870, France had 14,000doctors, showing a rise in the numbers which had norelation to increase of population. On the eve of therecent war there were 20,000 qualified medical men inFrance, and complaints of the overcrowding of theprofession were heard, but, of course, chiefly in thetowns. In Paris to-day there is one doctor for fewerthan 900 inhabitants, which is much the proportionthat prevails in this country save in particular centres.But certain departments have not enough doctors todeal with disease in modern manner, allowing thatconditions of life in the mountainous districts willalways be difficult, as they still are difficult with us inScotland, despite special legislation to meet the needsof the Highlands and Islands." How many doctors," asks M. Lecoq, " have

vegetated in the Paris suburbs who might have hada larger and happier life in the country if they hadnot allowed themselves to be caught by the bait of thelarge town with its often illusory promise of fortuneand glory." And he proceeds to point out thatconditions of country life are now different, " for nolonger does the doctor’s old nag joggle the life out ofhim and restrict his range of visits ; his little motor-cartakes him at his ease for miles and, moreover, thecountry populations are now more prosperous andcan pay better. They no longer consult first thebone-setter and the old wife’ who knew how to setthe saints to work and which saints to appeal to forsuch and such complaints." Cherville, in his book" Village Studies," depicts the wrath of a peasantwho was asked by the doctor three francs for fiveminutes’ advice, a sum which was as much as hegained the whole day guiding the plough. He oughtto have had a quarter of an hour at least, hethought; but nowadays, says M. Lecoq, the peasantunderstands that time does not enter into the matterlike that, and that science has its value and should bepaid for. In short, with more general well-being, morelight has entered the rural world, which is so much thebetter for the country sick and the country doctor.M. Lecoq’s peroration is : " Thy profession, gooddoctor, was for centuries hard and profitless, but thefuture will be better than the past. Be, like thypredecessors, the curer of the body and the consolerof the spirit, following the resolution expressed by thepoet, François Fabie, in beautiful lines which thoudidst inspire :

Sauve, le plus que tu pourras,De la Faucheuse aux maigres brasLe paysan qui plante et seme,Jusqu’à 1’heure ou tu t’en irasSans regret la trouver toi-meme.’ "

THE HUMAN FACTOR IN ACCIDENTCAUSATION.

A REPORT has just been issued by the IndustrialFatigue Research Board which may frighten off manyreaders on account of its statistical appearance ;nevertheless, it contains much of great interest.Some years ago the Board published an investigationby M. Greenwood and H. M. Woods 2 in which aneffort was made to measure the influence of thepersonal factor upon accident causation. Thisinvestigation was confessedly only a preliminary one.The report now issued attacks the problems again,making use of new and more extensive data. Over

1 A Contribution to the Study of the Human Factor in theCausation of Accidents. By E. M. Newbold, Industrial FatigueResearch Board. H.M. Stationery Office, 1926. Report No. 34.5s.

2 Greenwood, M., and Woods. H. M. (1919): The Incidenceof Industrial Accidents upon Individuals, with Special Referenceto Multiple Accidents, Industrial Fatigue Research Board. ReportNo. 4.

16,000 minor accidents which occurred in a varietyof factories are submitted to careful statistical analysis.The writer, Miss E. M. Newbold, appears at times tobe over-cautious in drawing her deductions. Sufficeit to say that the conclusions arrived at in every waysubstantiate those of previous inquiry. The averagenumber of accidents is found to be influenced by acomparatively small number of multiple accidentpeople, individuals with an innate tendency to sustainaccidents. Nevertheless, on the whole the people withmost accidents have usually been a shorter time infactory employment. Possibly those predisposed toaccidents become naturally eliminated. The chanceof an accident occurring appears to differ for eachperson, even though employed on the same work.A useful table is given from which an answer canquickly be obtained to the question whether theaccidents in any department are due mainly to theaccident risk associated with the work, or to thepresence of a few people who have many accidents ; themethod of using the table is explained. Experienceis an important factor, and the level of the accidentrate varies inversely with the experience of theworkers, but even after allowance is made for this,a definite tendency is found for younger workers tohave more accidents than older ones. This tendencyhelps to explain why sudden rises in accident-rates areassociated with increased trade, due to the engagementof young as well as green labour. A curious fact

emerges that the accident-rate and the dea.th-ratewith respect to age are opposed ; whereas the formerfalls with age, the latter rises. The accident death-rate rises, due to increased " tendency to die

"

amongolder people, rather than to any increased " tendencyto have accidents." The same fact holds true forillness-viz., the average duration of any single caseincreases with age. Another interesting point is theevidence found that the number of accidents anindividual has is positively associated with the numberof times he falls sick. So that in the saying " what isthe matter with the sick is their tendency to be sick,"the word " sick " must be held to include a tendencyto accidents. Many attendances at factory ambulancerooms are on account of accidents which take placeaway from the works. Examination of these recordsbrings out the fact that the same people who areunfortunate in the factory seem also to be unfortunateat home, and that there really are some people inwhose hands knives and plates are not safe. Theimportance of the personal factor in accident causationis difficult to exaggerate, since over 80 per cent. ofall accidents have no mechanical origin, and not morethan 5 per cent. can be attributed to factors outsidehuman control. What holds good for accidents takingplace within the factory walls is presumably alsotrue for the occurrences of ordinary life, but theselatter do not lend themselves to careful investigation.Moreover, the association between sickness andaccidents is significant. How few of us appreciatethat when we sustain some slight injury we are reallynot quite fit, and that such incidents as multiplelosses of property, such as leaving an umbrella in thetrain, have the same meaning. While congratulatingMiss Newbold on the way in which she has overcomethe difficulties inevitable to such an intricate investiga-tion, we are glad to learn that the whole subject isbeing further investigated, particularly to ascertainhow far a tendency to sustain minor accidents may betaken as a criterion to succumb to major accidents.

MEDICAL AND DENTAL REGISTERS.

WE have just received copies of the Medical andDental Registers for 1926 and of the Medical andDental Students’ Register for the correspondingperiod. The total number of persons registered underthe Medical Acts from the beginning of registrationin 1858 up to Jan. 1st, 1926, is 98,308, and 52,531 aresaid to remain on the Register as made up on the lastday of 1925. These are 2673 more than in the 1925Register, distributed over the three sections into

which the Register is still divided, although some of

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this increase may be illusory, for an error seems tohave crept into the number in the Foreign List asgiven in Table D, where the total of 232 is 121 inexcess of the 111 names given in the 1925 table,.although only 8 names have been added byregistration. These two figures have, it seems,inadvertently been added together, and the numbershould therefore, in accordance with our calculations,be reduced by 111. The same oversight seems tohave affected a figure of 3243 given in the same tablefor the Colonial List. From a study of Table E wededuce the total number of registered persons as

50,035 on Jan. lst, 1925, and 51,737 on Jan. 1st, 1926,an increase of 1702 names. The excess of numbers inany year over the previous is, of course, due to abalance between the number added by registration andthe number removed. The numbers added by registra-tion are given in Table E as 1246 for England, 736 forScotland, 406 for Ireland, 173 for Colonial, and 8 forForeign, while, of the 947 names removed, 794 wereremoved on evidence of death, 1 on ceasing topractise, 146 under Section XIV., and 6 underSections XXVIII.-IX. of the Medical Act. We elearn that 1602 copies of this Medical Register havebeen printed, 872 of which have been earmarked formedical practitioners registered in 1925, of which it iscurious to note the expectation that 472 will beclaimed by Scottish practitioners. The number ofcopies available for sale is 400, an edition which islikely to melt away under the demand due to thepresent interest in the General Medical Council andits doings. The only substantial addition to thecontents of the book is a reprint of the Medical Act,1925 (Irish Free State), passed on Feb. 21st, 1925, tocontinue in force for one year only from that date.The Register contains, as everyone knows, the fulltext of all the Medical Acts from the first Act of1858, the names of members of the Council, and copiesof the warning notices issued to registered personswhether medical men or dentists. We cannot helpregretting that the admirable memorandum writtenby the Registrar of the Council on the constitution,functions, and procedure of the Council has not beenincluded in the volume. The Dentists Registercontains 14,199 names, of which 14,111 are UnitedKingdom dentists, and of these 5841 possess licencesor degrees in dentistry. There is an increase of 381names on the 1925 Register; during the year1925, 546 names were removed, 115 on evidence ofdeath and 425 under Section 7 of the Dentists Act,1921 ; and 400 names were restored, mostly under the.same section. This Register contains no importantadditions in the text, apart from the revised list, andenclosed with it as usual is the list of bodies corporatecarrying on the business of dentistry and the namesof the directors of these bodies. The lists of medicaland dental students registered during the year 1925contain the names of 1070 medical students and191 dental students, being respectively 27 more and9 less than the corresponding figures last year.All these three volumes are published for the GeneralMedical Council or the Dental Board by Constable-and Co., Ltd., the prices being respectively 21s.,12s., and 7s. 6d.

DONATIONS AND BEQUESTS.—Among other bequeststhe late Mr. Warley Pickering, of Hutton Hall, Guisborough,Yorks, left 1500 to the North Riding Infirmary, Middles-brough, and JE1500 to the North Ormesby Hospital, Middles-brough.-Mr. William Alfred Sammes, Windsor, who left£ 23,888, after various bequests amounting to 22000, left’the residue of his property between St. Andrew’s Hospital,Clewer, St. John’s Home, Clewer, and King Edward VII.Hospital, Windsor.-Miss Laura Lushington, of Reading,Berks, left 2100 to the Samaritan Fund of Guy’s Hospital.- mars. Elizabeth Crawford-Hayes, Clarges-street, Mayfair,W., widow of Dr. Thomas Crawford-Hayes, left the residueof her property to King’s College Hospital, London, forCrawford-Hayes beds. The amount available for thispurpose will be about .?19,000.—Miss Amelia Broadbent,of Buxton, left 22000 in trust for her cousins for life, andthen 21000 to the Manchester Royal Infirmary and- S500 each to St. Mary’s Hospital, Manchester, and Ancoats.Hospital and Dispensary.

Modern Technique in Treatment.A Series of Special Articles, contributed by invitation,on the Treatment of Medical and Surgical Conditions.

CLXV.-ACUTE EMPYEMA IN CHILDREN.SUCCESS in the handling of a child’s empyema

depends in no small measure upon early diagnosis.Speedy detection of the pus and prompt applicationof requisite treatment minimise the risk to life andpromote the early and complete re-expansion of thelung, which is essential to the obliteration of thecavity and the final cure of the disease. Fatalities,unhealed sinuses, and chest deformities-" chronicempyemata "-are the penalties more often of casualclinical observation than of ineffectual treatment.Before deciding upon what treatment is applicableto any individual case, it is necessary to appreciatethe type and virulence of the abscess and its precisesignificance in the general clinical picture. In everyempyema evacuation of the pus from the pleuralcavity is urgently called for, but the way in whichthis is done may make all the difference betweensuccess and failure ; one routine treatment for allcases-e.g., opening the chest and inserting a

drainage-tube-while it may cure many, will certainlyprove unavailing in some. When the exploring needlehas confirmed the presence of pus, the following pointsmust be carefully considered before deciding uponthe wisest method of evacuation : (1) The age of thechild. (2) The size and situation of the empyema.(3) The general condition of the patient, especiallyas to whether we are dealing with an empyema whichis : (a) synpneumonic (Cameron and Osman )—i.e.,coexisting with an active pneumonia ; (b) metastatic-i.e., a local manifestation of, or metastasis from,some distant focus, the child being gravely ill fromthe generalised infection ; (c) metapneumonic.The primary object is to save the child’s life and

in many cases-notably in infants and in the syn-pneumonic and metastatic types-immediate thora-cotomy is attended with grave risk. Fortunately,in these cases the exudate is often conveniently thinand aspiration mechanically simple.

For evacuating an empyema the following methodsare available: (1) Aspiration: (a) intermittent;(b) continuous. (2) Thoracotomy-with or withoutresection of rib and followed by : (a) closure of theopening; (b) with drainage either " closed" or" open." (3) A combination of (1) and (2).

Intermittent Aspiration.Potain’s apparatus is commonly employed. The

needle or trocar of the aspirator is introduced alongthe tract of the original exploring needle. The chestwall should be locally infiltrated with t per cent.novocaine, or, better still, the child anaesthetisedwith N20 and oxygen. The pleural cavity is emptiedas completely as possible, the needle withdrawn,and the puncture sealed. The aspiration is repeatedas necessary. This simple procedure may sufficewhere the chest contents are merely turbid serum,but where the empyema is frankly purulent it isvery unlikely that all the pus and debris will bereally evacuated from the cavity even by repeatedaspirations of this type ; and though the case mayrecover, it is almost certain that some deficiencyof expansion and chest deformity will remain. Never-theless, it may be of life-saving value as an adjunct totreatment in certain cases. In very large empyemata-where there is considerable cardiac displacementand the child’s respiration is seriously embarrassed-it is always wise to aspirate by this method a quantityof the pus 12 to 24 hours before proceeding to thoraco-tomy. The operative risk in such cases is therebysensibly diminished. In bilateral empyemata, in thesynpneumonic or metastatic type of case, where animmediate thoracotomyis dangerous,timelyaspirations

1 THE LANCET, 1923, i., 1097.