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PERIODICAL MEDICAL EXAMINATION

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347 the respiratory centre has become sluggish and needs further stimulation although the tension is high; whilst in carbon monoxide poisoning the tension is low and 5 per cent. C0 is given to stimulate the centre and promote greater oxygenation of the blood. After respiration has been re-established by artificial means this mixture should be given for 30 to 40 minutes, oxygen being used as a diluent because carboxyhsemoglobin dissociates more readily if the partial pressure of oxygen is raised. In normal people inhalation of the gas is said to cause no disagreeable sensation beyond a slight feeling of fullness in the head ; the blood pressure and pulse- rate are slightly raised. In cardio-renal disease with acidosis, however, the respiratory response to CO2 is considerably increased and may be doubled, so that the greatest caution is required. In emphysema, on the other hand, there is little response even to air containing 11 per cent. of the gas. There seems to be a misconception abroad that the cyanosis even of anaesthesia, brain trauma, or morphia poisoning is due to an increase of CO2 in the blood. This is not so. Lack of oxygen is the cause, and this can often be relieved by the hyperpnoea which small quantities of CO2 in the inspired air produce. The use of the gas for eliminating poisonous substances can be extended to alcoholic intoxication-for alcohol, like ether, is eliminated by the lungs-and rapid recovery from deep coma, with lessened after-effects, has been reported, though it should be noted that mildly intoxicated patients do not benefit to a propor- tionate degree. In hiccup, which may be due to an abnormal stimulus reaching the respiratory centre via the phrenic nerve, CO2 can be utilised to produce a stronger and regular stimulus to displace the weaker one that causes the spasm. 9 Carbon dioxide may also be employed (5 per cent. dilution in oxygen) to revive newly born infants ; whilst depression of the respira- tory centre after cerebral operations, Cheyne-Stokes breathing, diminished coagulability of the blood, and collapse of the lung following thoracotomy are other conditions in which it has been of value. Whatever the object of its administration, caution is desirable to prevent the gas being given in cases of acidosis where the blood already contains an excess of it. Otherwise, however, its use in low dilutions and with care seems to be without danger, and may sometimes prove to be of the greatest possible assistance. RETIREMENT OF SIR FREDERICK WILLIS. ON the last day of next month Sir Frederick Willis will cease to preside over the Board of Lunacy Control, his place being taken by Mr. L. G. Brock, who has been appointed a Commissioner of the Board for this pur- pose. Sir Frederick Willis succeeded Sir William Byrne as chairman seven years ago, after having been one of the principal assistant secretaries in the Ministry of Health practically from its formation, and on the permanent staff of the Local Government Board since 1890. He has, in fact, 42 years of public service behind him. His period of office at the Board of Control has covered a time of great changes and difficulties, and the Board owes much to his wise guidance. He was able in a high degree to hold the balance fair between the liberty of the subject and the need for efficient medical treatment and control, and his work was made the easier by the fact that he was a grateful personality both to the local authori- ties and to his medical colleagues on the Board. It may also be recalled that during the war he was in charge of the arrangements for the reception and care of Belgian refugees, and was honoured by the King of the Belgians for this service. 9 Vide THE LANCET, 1927, ii., 1144. Annotations. PERIODICAL MEDICAL EXAMINATION. 99 Ne quid nimis." THE value of regular medical examinations of the healthy has been urged with much eloquence recently on both sides of the Atlantic, and it has become a serious question for medical men and insurance officers whether or not the adoption of periodical examination in this country should receive their support. Dr. H. G. Turney, in his presidential address delivered at the Assurance Medical Society on Feb. lst, took a definite stand against the proposal, on the ground that the question was tending to become the infiltrating edge of propaganda for impressing on the popular mind the urgent necessity for watchfulness on the part of any individual who hopes to retain his health. Dr. Turney felt that there was a real danger that these vociferous warnings might help to establish something approaching a system of terrorism among the weaker-kneed section of the community. While expressing the conviction that the scheme in the States is in the hands of capable and honourable men, he doubted whether its introduction into this country would be attended by the success which it had met in America. We have not over here the large "Babbitt class who have made a fortune in strenuous business, and have retired while still in the prime of life. They have unlimited leisure with little outside interest, and the advertisement columns of the newspapers give evidence of a stupendous demand for every kind of solace for bodily trouble which results from their tedium vitae. One might be tempted to infer that the majority of American people live on a combination of patent medicine and semi-digested foods, and it is evident that a scheme of periodical stock-taking at the expense of the insurance company would be extra- ordinarily attractive. The investigation made by the Metropolitan Company of New York into the working of the system showed that hygienic sins were being committed by 99 per cent. of those examined. " One in three," said Dr. Turney, " ate too much meat, another third took too little water, a still larger pro- portion too much tea and coffee, and, horrible to relate, nearly half the whole number committed other import- ant but unspecified errors in diet....From a study of the literature one might almost be led to infer that a rigid observance of all these hygienic prescriptions would ensure complete immunity from all bodily ailments except those of old age, and even as regards these, that they would be deferred to such a remote epoch of time as to be hardly worth considering." Unfortunately every doctor knows that the people who enjoy the best health are often those who take no heed of what they eat or drink, and who make a practice of defying the laws of health ; and we have, as Dr. Turney pointed out, reluctantly to admit that there are as many different standards of health which are beyond our control, as there are of intellect and morals. Some people seem to have poor health from birth or adolescence for no reason, and have to live on the dole of hope offered by some enthusiast who promises that if they will take brown bread or give up butter, all will be well. Unfortunately the effect soon wears off, and the sufferer starts on a new voyage of discovery for a cure-all. The singular thing is that this congenital incapacity to make that smooth adaptation to environment which constitutes health, has very little influence upon the expectation of life, or upon the incursion of organic disease. The introduc- tion of a free system of examination would pander to those morbid cravings, and so far from improving health would, in Dr. Turney’s opinion, concentrate people’s thoughts on their internal processes and tend to perpetuate what is morbid. The second fallacy exposed by Dr. Turney is that a slight bodily disturbance, to which the best of us is subject from time to time, will, if neglected, lead to serious disease. Doctors are constantly being exhorted
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the respiratory centre has become sluggish and needsfurther stimulation although the tension is high;whilst in carbon monoxide poisoning the tension islow and 5 per cent. C0 is given to stimulate thecentre and promote greater oxygenation of the blood.After respiration has been re-established by artificialmeans this mixture should be given for 30 to 40minutes, oxygen being used as a diluent becausecarboxyhsemoglobin dissociates more readily if the

partial pressure of oxygen is raised.In normal people inhalation of the gas is said to

cause no disagreeable sensation beyond a slight feelingof fullness in the head ; the blood pressure and pulse-rate are slightly raised. In cardio-renal disease withacidosis, however, the respiratory response to CO2 isconsiderably increased and may be doubled, so thatthe greatest caution is required. In emphysema, onthe other hand, there is little response even to air

containing 11 per cent. of the gas. There seems to bea misconception abroad that the cyanosis even ofanaesthesia, brain trauma, or morphia poisoning isdue to an increase of CO2 in the blood. This is not so.Lack of oxygen is the cause, and this can often berelieved by the hyperpnoea which small quantitiesof CO2 in the inspired air produce. The use

of the gas for eliminating poisonous substancescan be extended to alcoholic intoxication-for alcohol,like ether, is eliminated by the lungs-and rapidrecovery from deep coma, with lessened after-effects,has been reported, though it should be noted thatmildly intoxicated patients do not benefit to a propor-tionate degree. In hiccup, which may be due to anabnormal stimulus reaching the respiratory centrevia the phrenic nerve, CO2 can be utilised to producea stronger and regular stimulus to displace the weakerone that causes the spasm. 9 Carbon dioxide may alsobe employed (5 per cent. dilution in oxygen) to revivenewly born infants ; whilst depression of the respira-tory centre after cerebral operations, Cheyne-Stokesbreathing, diminished coagulability of the blood, andcollapse of the lung following thoracotomy are otherconditions in which it has been of value. Whateverthe object of its administration, caution is desirable toprevent the gas being given in cases of acidosis wherethe blood already contains an excess of it. Otherwise,however, its use in low dilutions and with care seemsto be without danger, and may sometimes prove to beof the greatest possible assistance.

RETIREMENT OF SIR FREDERICK WILLIS.ON the last day of next month Sir Frederick Willis

will cease to preside over the Board of Lunacy Control,his place being taken by Mr. L. G. Brock, who has beenappointed a Commissioner of the Board for this pur-pose. Sir Frederick Willis succeeded Sir WilliamByrne as chairman seven years ago, after having beenone of the principal assistant secretaries in theMinistry of Health practically from its formation, andon the permanent staff of the Local GovernmentBoard since 1890. He has, in fact, 42 years of publicservice behind him. His period of office at the Boardof Control has covered a time of great changes anddifficulties, and the Board owes much to his wiseguidance. He was able in a high degree to hold thebalance fair between the liberty of the subject andthe need for efficient medical treatment and control,and his work was made the easier by the fact thathe was a grateful personality both to the local authori-ties and to his medical colleagues on the Board. Itmay also be recalled that during the war he was incharge of the arrangements for the reception andcare of Belgian refugees, and was honoured by theKing of the Belgians for this service.

9 Vide THE LANCET, 1927, ii., 1144.

Annotations.

PERIODICAL MEDICAL EXAMINATION.

99 Ne quid nimis."

THE value of regular medical examinations of thehealthy has been urged with much eloquence recentlyon both sides of the Atlantic, and it has become aserious question for medical men and insuranceofficers whether or not the adoption of periodicalexamination in this country should receive theirsupport. Dr. H. G. Turney, in his presidential addressdelivered at the Assurance Medical Society on Feb. lst,took a definite stand against the proposal, on theground that the question was tending to become theinfiltrating edge of propaganda for impressing on thepopular mind the urgent necessity for watchfulness onthe part of any individual who hopes to retain hishealth. Dr. Turney felt that there was a real dangerthat these vociferous warnings might help to establishsomething approaching a system of terrorism amongthe weaker-kneed section of the community. Whileexpressing the conviction that the scheme in theStates is in the hands of capable and honourable men,he doubted whether its introduction into this countrywould be attended by the success which it had met inAmerica. We have not over here the large "Babbittclass who have made a fortune in strenuous business,and have retired while still in the prime of life. Theyhave unlimited leisure with little outside interest, andthe advertisement columns of the newspapers giveevidence of a stupendous demand for every kind ofsolace for bodily trouble which results from theirtedium vitae. One might be tempted to infer that themajority of American people live on a combination ofpatent medicine and semi-digested foods, and it isevident that a scheme of periodical stock-taking at theexpense of the insurance company would be extra-ordinarily attractive. The investigation made by theMetropolitan Company of New York into the workingof the system showed that hygienic sins were beingcommitted by 99 per cent. of those examined. " Onein three," said Dr. Turney, " ate too much meat,another third took too little water, a still larger pro-portion too much tea and coffee, and, horrible to relate,nearly half the whole number committed other import-ant but unspecified errors in diet....From a studyof the literature one might almost be led to infer thata rigid observance of all these hygienic prescriptionswould ensure complete immunity from all bodilyailments except those of old age, and even as regardsthese, that they would be deferred to such a remoteepoch of time as to be hardly worth considering."Unfortunately every doctor knows that the peoplewho enjoy the best health are often those who takeno heed of what they eat or drink, and who make apractice of defying the laws of health ; and we have,as Dr. Turney pointed out, reluctantly to admit thatthere are as many different standards of health whichare beyond our control, as there are of intellect andmorals. Some people seem to have poor health frombirth or adolescence for no reason, and have to live onthe dole of hope offered by some enthusiast whopromises that if they will take brown bread or giveup butter, all will be well. Unfortunately the effectsoon wears off, and the sufferer starts on a new voyageof discovery for a cure-all. The singular thing is thatthis congenital incapacity to make that smoothadaptation to environment which constitutes health,has very little influence upon the expectation of life,or upon the incursion of organic disease. The introduc-tion of a free system of examination would pander tothose morbid cravings, and so far from improvinghealth would, in Dr. Turney’s opinion, concentratepeople’s thoughts on their internal processes andtend to perpetuate what is morbid.The second fallacy exposed by Dr. Turney is that

a slight bodily disturbance, to which the best of us issubject from time to time, will, if neglected, lead toserious disease. Doctors are constantly being exhorted

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to seek disease in its small beginnings, but while it istrue that the great diseases must have their beginnings,it is also true that the world is full of human beingswho do not feel absolutely well all the time, and whooutnumber those who are incubating organic diseaseby a hundred to one. Every sensible man knows thatnothing perpetuates these troubles more thanconstant inquiries and sympathy, for they are in themain of psychical origin. The worst thing a doctorcan do for a patient is to suggest, either by word ofmouth or by meticulous examination, that thesethings generally lead to serious diseases, or indeed toany recognisable diseases at all. It is not well thata man should look too closely into his plate, and theless he thinks about it the better he is likely to digestwhat food he eats. Dr. Turney would hold thatwithin very wide limits it does not matter a bit whata man eats, provided he does not eat too much.

Dr. Turney illustrates his thesis by the quietrevolution which has been in progress in the incidenceof dysmenorrhoea which is dropping to vanishingpoint. It has been found that this trouble prevails indirect proportion to the notice taken of it and to themultiplicity of precautions taken against it. This,he feels, carries a lesson of the importance of healthythinking for healthy living, and by healthy thinkinghe does not mean thinking about health, but ratherthe reverse.

____

PROGNOSIS OF TUBERCULOUS PERITONITISIN CHILDREN.

OPINION is still divided on the prognosis in tuber-culous peritonitis, a subject which Dr. P. Nobecourtand Dr. Ilitch Dragolioub discuss in the Revuede la Tuberculose for last December. Physicians of aformer generation, basing their opinion on a study ofthe caseous forms of the disease, considered that theoutlook was usually unfavourable. Their successors,recognising the tuberculous nature of what hadbeen known as essential ascites, took a less gloomyview, whilst more recently Armand-Delille hasclaimed 100 per cent. of cures in a series of selectedcases treated by heliotherapy. In this country ageneral impression prevails that the prognosis in thecaseous form is grave, whilst recovery may be expectedin the ascitic type. Accurate statistics, however,are difficult to obtain. The child of poverty who ispoorly nourished, and who complains of vagueabdominal symptoms, usually finds his way sooner orlater to the dispensary, where the tuberculosis officerobserves the pale face, thin frame, and flaccidabdomen. The condition may be due to tubercu-losis, but is more probably due to faulty diet andunsatisfactory home conditions. A diagnosis alonestands between the child and recovery. If the child ispronounced to be tuberculous the whole machineryof the public health department is set in motion onhis behalf. The diagnosis is accordingly made, andwisdom is justified of her children ; but the cause ofscientific accuracy is not so well served.

During the six-year period, 1921-26, 25 childrensuffering from tuberculous peritonitis were cared forby the Children’s Medical Clinic at Paris. No casein which the diagnosis was doubtful was included inthe series and an attempt has been made to ascertainthe after-history of each child. The result may besummarised as follows :-

The cases thus show a mortality-rate of 32 per cent.,but this is a minimal estimate, for it is improbablethat all the untraced patients survived, whilst of thesurvivors several still showed signs of active diseaseat the end of the period under review. Five of the

children, it is stated, were suffering from the caseous

form and all of these died. Ascites was a prominentsymptom in 14 cases, among which were five recoveriesand one death, two patients being seriously ill, andthree improving at the time the paper was written.This evidence suggests that peritonitis is not, as somehave assumed, a relatively benign form of tuberculousinfection. Its immediate results may be grave, andthe possibility of relapse or obstruction due toadhesions make the future uncertain.A brief account is given of the methods of treat-

ment employed. During the feverish phase, oftenassociated with the onset of symptoms, Dr. Nobecourtand Dr. Dragolioub recommend rest, the local applica-tion of hot or cold compresses, and painting theabdomen with glycerine, iodine, and guaiacol. Whenpyrexia has subsided heliotherapy, open-air treat-ment, and exposure to ultra-violet rays is advocated.Calcium phosphate or carbonate and tincture ofiodine may be given internally. Under this treatmentin favourable cases pyrexia declines, ascitic fluid andtumours are absorbed, while return of strength,improvement in appetite, and gain in weight heraldthe return of health.

TEACHING OF ANATOMY.IMPORTANT changes are gradually being introduced

in many medical schools in the teaching of anatomy,and an interesting discussion of this subject tookplace recently at the meeting of the Association ofAmerican Colleges. I In an account by Prof. J. C. B.Grant of the methods employed at the University ofManitoba emphasis is placed on the value of display-ing persistently to the student the general principleswhich govern structure. As Prof. Grant rightly main-tains, the necessary details can only be rememberedwhen they are fully understood : for this purposeit is clear that the teacher must appeal constantlyto function, phylogeny, embryology, and clinicalexperience to explain various morphological points.If the curriculum permits of a reasonable time beingdevoted to this mode of anatomical study, whichdemands systematic supervision and guidance ofthe student in his practical work rather than extensivelecture courses, he learns to correlate structure andfunction, and gains anatomical knowledge bypersonal observation and reasoning. The student isultimately in a position to generalise from his ownobservations and to understand the meaning andsignificance of structure. This is a far more useful,inspiring, and stimulating education than the oldinterest-killing method of memorising innumerablefacts with little or no reference to the factors influenc-ing structure. In a second paper,2 Prof. E. J. Careymakes a strong plea for the teaching of living anatomy,and shows how the medical student requires informa-tion about the form of the living, and not the morpho-logy of the dead, which is practically the onlyknowledge presented by pure descriptive anatomy.To procure this, dissection, which is undoubtedlystill a necessity, must be supplemented by everyavailable method which will reveal the conditionsduring life, and the modifications in form which

result from functional processes. From the responses

to a questionaire sent out by Prof. Carey to the leadingmedical schools in Europe and America, it was foundthat as yet in only about 50 per cent. was there anyserious attempt to study anatomy in the living subject.or to employ such means as the X ray and fluorescentscreen to correct the erroneous impressions createdby studies of the cadaver. British readers may berelieved to learn that the replies to the questionaireshowed that British-trained anatomists, more thanthose of other countries, do appear to emphasise theanatomy of the living. There has been an appreciableforward movement in this country in recent years,and probably none of our anatomy departments nowfails to make good use of the living model. Neverthe-less, too few have yet employed other means whichare available to make anatomy live. and to demonstrate

1 Bulletin of the Association of American Medical Colleges,1928, iii., 1. 2 Ibid., 1928, iii., 10.


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