1017

theory to the test of figures, he examined 1578recruits, and he classified them according as theywere perfectly healthy or subject to serious or slightmorbid conditions. By " serious morbid conditions "he means practically every disease which may affectthe lower half of the body, and his long list includesmarked deformities of the spine, appendicitis, hernia,varicocele, traumatic and other diseases of the hipand knee, genu valgum, varum and recurvatum, severeflat-foot, hallux valgus, persistent or relapsing poly-arthritis, varicose veins, and general static weakness.By " slight morbid conditions " he means similarbut less serious divergences from the normal. Heinquired of each recruit as to the occurrence, past orpresent, of sciatica, lumbago, and other forms ofbackache, and found that in 117 cases, or 7-4 percent., the object of the inquiry had suffered fromlumbago. But while this was the case in as high aproportion as 24-5 per cent. of the recruits in thecategory " serious morbid conditions," only 1-7 per-cent. of the healthy recruits had suffered from lumbago.In other words, lumbago was 14 times more commonamong recruits suffering from one or more of thediseases referred to than in perfectly healthy recruits.The incidence of lumbago among recruits in theintermediate category suffering from minor ailmentswas 6-1 per cent. Similar figures were obtained inthe case of sciatica, the incidence of which was ashigh as 3-46 per cent. in recruits subject to " a seriousmorbid condition," and only 0-12 per cent. in healthyrecruits. Dr. Lindstedt is so impressed by theimportance of this reflex mechanism in the provocationof lumbago that he suspects this mechanism to haveplayed a part even in the 15 cases of lumbago foundamong healthy recruits. Their freedom from anymorbid process capable of exciting a reflex lumbagowas, he thinks, probably more apparent than real,and such a condition as spina bifida occulta is apt tobe overlooked, although its capacity for excitingreflex disturbances cannot be ignored. If Dr. Lind-stedt’s conclusions are correct, a valuable clue to thesuccessful treatment of lumbago and allied diseasesis indicated, and in attempting to cure them the

physician will extend his activities to comparativelydistant parts of the body.

LIFE INSURANCE IN THE TROPICS.’

AT the first sessional meeting of the Royal Societyof Tropical Medicine and Hygiene, which we brieflyreported in our issue of Oct. 29th, Sir James Cantlieand others discussed the subject of life insurance in thetropics. It was pointed out that conditions of life inhot climates had recently greatly improved, that it wasunjust in many cases for insurance companies to adda substantial percentage to the ordinary premiumssimply because the party insuring resided withincertain zones. That life in tropical and hithertounhealthy countries has greatly improved both incomfort and freedom from risks is certain, and for thismany factors are responsible. The most important,it would appear to us, is the greater knowledge ofhow the maladies peculiar to the warm countries arespread, an outcome of the advance in medical know-ledge during the last quarter of a century. Apartfrom this, the motor-car and the electric fan exert aninfluence that it is hard to estimate in percentages,but is none the less real. A medical officer of a largetown in India, who had some 29 years to his credit,once remarked that the hot weather had no terrorsfor him now as, thanks to the fan, he could alwayssleep at night and could go about in comfort in hiscar during the day. It is impossible for anvbodywho does not remember India in the pre-fan and pre-motor days fully to appreciate the force of this remark.As was pointed out by the speakers during thediscussion, insurance companies are in the hands oftheir actuaries, and actuaries deal with figures, whichare presumably founded on facts. Those responsiblefor fixing premiums have, in most cases, never beento the tropics and are not medical men. In the

annual Government reports vital statistics affectingEuropeans are necessarily brief and perfunctory ; thenative returns are more fully discussed and thesereports are much too long as it is. Hence, owing tolack of exact data and the need of insurance com-panies to play for safety, an addition of 2, 3, or 5per cent. is made to the ordinary premium, which inmany instances is quite unjustifiable. Insurancecompanies who wish to deal fairly by the Europeanresident abroad would do well to appoint expertadvisers in tropical conditions, even if the numbersinsured would hardly for the moment justify the

expense incurred. American companies appear to bebetter informed as to health conditions in hot climates,and have a much more flexible system of working.During the discussion it came out that the first fiveyears of the colonist’s residence were still regarded asthe danger period, Sir Leonard Rogers remarkingthat even this assumption was now largely untrueowing to the effect of antityphoid inoculation.Apart from the enteric fevers, the risk of death is notgreater at this period than at any other. TheEuropean’s power of resistance is never so high aswhen he has just left England.

MOTOR EXHAUST GAS IN CONFINED SPACES.

A REPORT of considerable interest to the users ofmotor-cars appears in recent issues of the Journal ofIndustrial Hygiene, based upon an investigation madeby Y. Henderson, H. W. Haggard, M. C. Teague, A. L.Prince, and R. M. Wunderlich, undertaken to deter-mine the limits of safety of ventilation in the projectedtunnel under the Hudson river between New Yorkand Jersey City. The tunnel is to be 1100 yardslong between ventilating shafts on the two sides ofthe river, and 2830 yards from portal to portal ;it is to be used for motor traffic, and danger arisesfrom carbon monoxide given off in exhaust gas.Exhaust gas contains on an average 6 per cent.-i.e.,600 parts per 10,000, of carbon monoxide. This gasis stated to be the only considerable toxic constituentfrom gasoline, but exhaust gas from coal distillate(benzol) contains accessory toxic substances. Theproblem of the research was to ascertain what per-centage of carbon monoxide could be permitted for anexposure of 45 minutes, the maximum period likelyto be occupied by the slowest vehicle in traversing thetunnel, a period during which no energetic exercisewould be taken. Incidentally attention is drawn tothe danger from which fatalities have resulted arisingin small garages, or to a man crawling under a carwhen its engine is running, or when the engine of acar standing ahead is " idling." Under such con-ditions slight headaches are frequent, while severeheadaches, nausea, and emotional disturbances up tohysterical mirth, anger, or grief, or even maniacalmanifestations, are not very unusual. Several cases

of severe poisoning from exhaust gas have been

recorded 1 in our own columns. In the Americaninvestigation a large number of experiments, in whichindividuals were exposed in a chamber to atmospherescontaining varying amounts of carbon monoxide,were carried out to determine the rates at whichthis gas, at different concentrations, is absorbedand subsequently eliminated. The results showedthat after one hour’s exposure at rest, the concen-tration of carbon monoxide in the blood reached

approximately half what would be reached byindefinite exposure, but that by doubling the volumeof breathing through exercise this concentrationmight be reached in half an hour. Elimination infresh air was found to take place at the rate of 30 to 50per cent. per hour. The conclusion is arrived at, forpassengers with an exposure of 45 minutes in thetunnel, that complete safety and an assurance offreedom from disagreeable effects can be obtained ifthe carbon monoxide content does not exceed fourparts per 10,000. General standards are also given.When the time in hours multiplied by the concen-

1 THE LANCET, 1920, i., 1334.

1018

tration of carbon monoxide in parts per 10,000 of airequals three, there is no perceptible physiologicaleffect. When it equals six there is just a perceptibleeffect. When it equals nine headache and nausea areinduced. When it equals 15 or more the conditionsare dangerous to life. ————

INTRAVENOUS COPPER IN TUBERCLE.

MANY investigators, especially in Japan, have, inthe treatment of human and animal tuberculosis,found advantage in using cyanides and coppersalts, copper salts apparently stimulating the growthof fibrous tissue, while cyanides are better toleratedthan other copper salts and do not coagulate albumin.In the Annali di Mediri.,na Navale for August, Prof. E.Trocello, of the Royal Italian Navy, reports experi-ments he has made on the cure of tuberculosis inguinea-pigs by the intravenous injection of " cupro-cian," a double cyanide of copper and potassium.Prof. Trocello inoculated guinea-pigs with virulenttubercle bacilli in the thigh, and, two or three weekslater, when it was clear that infection had occurred,he began to administer the salt. Its lethal dose is3 milligrammes per kilo of guinea-pig : his curativedose was 1 or 2 mgm. per kilo every three or four days.Of eight animals, five died of general tuberculosis,three others survived four, seven, and seven and a halfmonths. The weight of those which survived so

long increased for a month or more after the injections(subcutaneous) were begun, and the ulcer or sinuswhich had formed at the seat of inoculation healed intwo cases. No tubercle bacilli could be found afterdeath in the bodies of these three, either by histologicalexamination or by inoculation. The inguinal glands ’,were always enlarged before the treatment was begun, ’,and only in these glands could giant cells be found(nowhere else in the body), and even here there wasno caseation. Tubercle formation was not observedin any other organ or tissue. There was greatlyincreased formation of fibrous tissue, particularlynoticeable in the other lymph glands ; and thespleen, which, in the tuberculosis of guinea-pigs,usually increased to two or three times the normalweight, was here reduced in size by a half and wascirrhosed and hard. Some small areas in the lungsthat might have been taken for tubercles containedno lymphoid cells, but only epithelial cells withdeeply staining nucl ei and no caseation. Theseappearances are not due to the cuprocyanate itself butto its influence on the tuberculous infective process,whose noxa, the living tubercle bacillus, is killed, andthe life of the infected guinea-pig is thereby prolonged.Prof. Trocello is proceeding with further researcheson the precise meaning of these observations, in thehope of eliciting information of value in the treatmentof tuberculosis in man.

____

RUDOLF VIRCHOW.PROFESSORS of pathology are not in the list of

professors of medicine and the allied sciences who areallowed by law to sign certificates under the Crueltyto Animals Act, 39 and 40 Vict. c. 77, for the exemp-tion from its provisions of experiments made onliving animals for the discovery of new knowledge.It is often supposed that their exclusion was due to asuspicion that they were too deeply involved andinterested to be trusted ; in fact, they were left outbecause in 1877 they did not exist. And now we arereminded that it is only 100 years since the father ofmodern pathology was born, and many will rememberthat it is but 19 years since that he died. It wasVirchow’s great achievement in biology to conceive-and his still greater achievement to convince the world-that the cells of the body are one thing and theintercellular substances another, that cells arise fromcells and not from unorganised fluids, and that theprocesses of pathology are fundamentally cellularprocesses. It is difficult for us to grasp clearly whatthis must have meant, because we cannot reallyvisualise a time when cells and lymph were thoughtto be interchangeable and when the histologicalarrangements of the body were not much clearer than

the Yorkshireman’s summary of the anatomy ofslugs, " just moosh." The fertility of the Cellular-pathologie has been of something like the same orderas that of the Origin of Species, published a year later.The ideas of both have become so incorporated inour common daily thought that we are apt to forgetthat they were ever found out as something new.And if in recent years Virchow’s concept of the bodyas a congeries of cells has to some extent receded, ithas done so only by forming a sure foundation for asuperstructure in which organs and organisms are

the effective units rather than their component bricks.Virchow began to teach us how to understand the"

body as a whole " by taking it to pieces ; may thesynthesis which is now reared on his analysis prove aswell grounded and enduring.

STILLBIRTH, ITS PREVENTION.

THE importance of adequate antenatal supervision isnow well recognised by all those concerned in theadministration of large lying-in clinics. Unfor-tunately, the means available for carrying out suchsupervision are largely inadequate. Most of theaccidents and toxaemias of pregnancy and childbirthcan be prevented if only the pregnant woman isproperly safeguarded during her pregnancy, and suchcare is even more important than that actually exer-cised at the time of her confinement. At the presentday, when so much attention is being paid to thewelfare of the new-born child, there is some dangerof the even greater necessity for the care of thechild before it is born being overlooked. Antenatalclinics are still few and far between, and it is probablethat a very small percentage only of pregnant womenconsult their medical attendant before the birth oftheir child, and even when they do so, only too oftenno steps are taken to watch and supervise their healthduring the whole of this important period. In a well-conducted lying-in clinic every woman who applies foradmission to the clinic for her confinement is seen andexamined during her pregnancy, but even in thesefavourable circumstances many women will not attendas they ought, or only do so when they feel ill.Such neglect is the main cause not only of most ofthe accidents of childbirth, but even to a greaterextent of the toxaemias of pregnancy and parturitionwith their attendant dangers. If we must confessthat even in properly conducted clinics many womenescape the care and attention which they shouldall receive during their pregnancy, how much greateris the failure in this respect in ordinary practice. Ina paper which is published in the current issue of theEdinburgh 111 medical Journal, on stillbirth its causes

and prevention, Dr. F. J. Browne has shownclearly that a very large percentage of stillbirths andneonatal deaths could be prevented by adequateantenatal supervision. Deaths, for example, fromsuch causes as craniotomy, asphyxia, and cerebralhaemorrhage as a result of difficult breech and forcepsdeliveries are all preventable, and the conditionsgiving rise to them are readily recognisable by themedical attendant, if the patient is only properlyexamined before her confinement. It must beremembered that in many of these cases the fatalresult is due to disproportion between the foetus andthe pelvic canal, and that the child is often particularlywell nourished and before birth quite healthy; itis precisely the fact that the child is large and welldeveloped that leads to the extra danger to its life.In the same way the recognition and treatment ofsyphilis, so potent a cause of stillbirth, is easilycarried out if the patient comes under observa-tion during her pregnancy, and the results that havebeen obtained show that healthy children maycertainly be born if treatment is carried out onmodern line.?. The real danger to the child’s lifearises from the fact that only too often the women donot come under observation until the time of theirdelivery, when prevention is impossible and treatmentis too late. To remedy this Dr. Browne pleads forthe compulsory, or better, the voluntary notificationof the pregnancy of every expectant mother. With