995

venous administration, and in moderately advancedcases in which intravenous injection is not considerednecessary or advisable, but where more rapid absorp-tion is desired than can be obtained by the intra-muscular method. Further observations are requiredto confirm the value of the intraperitoneal method,but in the meantime it is obviously desirable in viewof the possibility of infection of the peritoneum thatthe method should not be employed as a routine inall cases of diphtheria, but should be reserved for theworst cases, especially those in which the intravenousroute cannot be employed.

THE PERIODICAL EXAMINATION OF LIFE

POLICY-HOLDERS.

AT a largely attended conference convened by theFederation of Medical and Allied Services at 12,Stratford-place, Oxford-street, London, W., on

Oct. 24th, an interesting discussion took place on thevalue of the periodical medical examination of theapparently healthy as a factor in preventive medicine.Sir Malcolm Morris presided, and representatives,both lay and medical, of the following societies werepresent, together with prominent members of theorganisation of the Federation :—

Eagle Star and British Dominions Insurance Company,Standard Life Assurance Company, Prudential AssuranceCompany, Legal and General Assurance Society, Wesleyarand General Assurance Society, Australian Mutual ProvidentSociety, National Provident Institution, Royal ExchangeAssurance, Refuge Assurance Company, Atlas AssuranceCompany, London and Manchester Assurance Company,Sun Life Assurance Company of Canada, Royal LondonMutual Insurance Society, Royal Liver Friendly Society,Commercial Union Assurance Company, Medical SicknessAnnuity and Life Assurance Society, Cooperative InsuranceSociety, Hearts of Oak Assurance Company, AssuranceMedical Society, Guardian Assurance Company, PublicHealth Advisory Committee, Clinical Research Association,Medical Sickness Annuity and Life Assurance Society, andthe Sydenham District Medical Society.

In opening the conference the chairman pointedout that the Federation was a union of the varioussocial activities concerned with health, and that itexists to promote the interests of the community asdistinct from the interests of any professional section.The object of the conference was to serve the interestsof the individual citizen-the policy-holder--whileextending among the people the wise practice ofseeking periodical examination or overhaul, in orderthat the early signs of departure from the standard ofnormal health might be detected. Already, he said,most sensible people visit their dentists regularly forexamination of the teeth ; why not of other bodilysystems ? Major L. G. S. Molloy, M.P., submitted aresolution stating : "That this conference approvesthe principle of periodical medical examination oflife assurance policy-holders," remarking that such Ia principle, if carried out, would tend to the prevention Iof disease and would be a great advantage to the ’,policy-holder if he did not have to pay for the examina- ’,tion. The medical profession would also benefit, but hefeared that the insurance companies would be involvedin expenses which they would not consider advan-tageous to themselves. Dr. Neville Spriggs, whoseconded, was of opinion that periodical medicalexaminations would be for the benefit of all concerned.A long discussion followed as to the advantages ordisadvantages to the public generally, and to theinsurance companies, of such a principle as thatadvocated in the resolution, and a letter was read byMr. N. Howard Mummery, Medical Director of theFederation, from Sir William Schooling, suggestingthat the most beneficial and economical arrangementfor both the original examinations for life assuranceand for periodical re-examinations, would be theestablishment of insurance medical institutes in theprincipal towns throughout the country. Finally,on the motion of Dr. Charles Buttar, seconded by Mr.Eric B. Nathan, the following resolution was unani-mously carried-: " That this conference approves

the principle of voluntary periodical medical examina-tion of citizens, and presses upon life assurance officesthe desirability of the adoption of this course with thepolicy-holders." ____

THE CAMBRIDGESHIRE TUBERCULOSIS

COLONY.

THE report on the Papworth Colony for 1922 is abeautifully illustrated work, printed by the membersof this community. The outstanding event of 1922was the formal opening of 31 new cottages, twohostels, and a nurses’ home by Sir Alfred Mond who,in his address, referred to Papworth as the mostwonderful institution of its kind in the world. He

hoped that Papworth would be a model which wouldbe copied in other parts of the country. Every pageof this report is full of the author’s vigorous optimism,and it is certainly to be hoped that the maker ofPapworth, if not Papworth itself, will be used as amodel and pattern by many imitators. Dr. P. C.Varrier-Jones, who further elaborated his ideas onvillage settlements on p. 912 of our issue of Oct. 20th,believes that all the progress made during 1922

has pointed to the soundness of the settlementidea. Of its success, if we are to judge bythis report, there can be no doubt. It is moredifficult to form a correct opinion of the reasons forthis success. Dr. Varrier-Jones would have us

believe that the principles on which he has workedare in themselves sound enough to warrant success.If this is so, and the problems of the TuberculosisSettlement have been long enough studied fora mass production of Papworths to be attempted,such a procedure might be considered justifiable,provided adequate means are available. But if,as some suspect, the success of the first Papworthdepends largely, and even mainly, on the personalityof its founder, we should do well to delay creatingreplicas of Papworth till we can be assured of anadequate supply of replicas of its founder. To return.to the first Papworth, it is worth noting that it is nolonger in its infancy ; 1922 was the seventh year ofits existence and the fifth since the transfer to PapworthHall. Cases of surgical as well as pulmonary tubercu-losis are admitted, and no patient is refused admission,however advanced the disease, if accommodationallows. The account given of the various industriesshows that the presiding genius of Papworth isblessed with a business instinct. He has come to theconclusion that chicken farming is an occupationsuitable only for those with marked resistance to thedisease. The notion that poultry farming consists ofdispensing grains of corn at odd hours to hens pouringout a steady stream of eggs is not quite correct.Boot-making and repairing is a trade the profits ofwhich are mulcted by the heavy charge of employinga canvasser for the collection and distribution ofrepairs. But portmanteau and other leather workhas yielded an annual turnover of nearly 24000 atPapworth, and this industry seems to be establishedon a firm basis. The total number of inhabitantsin the village is now 152.

PREGNANCY COMPLICATED BY HEARTDISEASE.

Prof. W. Frey, of Kiel, has published in Zentralblattfiir Gynäkologie for Oct. 6th a paper on the prog-nosis of heart disease complicated by pregnancy.His review of the literature of this subject shows onlytoo plainly that though it has been discussed formany generations, anything but unanimity has beenreached. He suggests that the observations ofvarious authorities are contradictory, partly becausethe material on which their observations were basedwas not similar, and therefore not comparable. Healso suggests that the material available in an out-patient department is more suitable for an investiga-tion of this problem than the inmates of a hospital,and he has, accordingly, conducted examinations of

996

the cardio-vascular system of 1000 consecutive casescoming to his gynaecological out-patient departmentin 1917-18. In 49 cases definite valvular diseasewas found, but only one of these 49 women diedduring pregnancy as the result of heart disease.Only 32 of these women were traced two or fouryears later, when it was found that five had died. Butit was very doubtful if any of these deaths were dueto pregnancy. Prof. Frey has found that the expec-tation of life for men and women suffering fromheart disease is practically the same. For women theaverage duration of compensation was 12 years, andfor men it was 13. Necropsies told the same tale.There were very few cases in which the cause of thedeath of patients suffering from heart disease couldbe traced to pregnancy. Prof. Frey does not sub-scribe to the opinion that aortic disease is moreserious than mitral disease in pregnant women. The

prognosis depends, in his opinion, mainly on thevitality of the muscles of the ventricles. It does notso much matter whether the mitral or the aorticvalve is involved as whether the disease is severeand acute or not. Among 29 cases of valvulardisease examined post mortem there were as manyas 24 in which signs of acute disease were found.This observation suggests that death from valvulardisease of the heart is usually due to an acute exacer-bation of the infectious process rather than to thepurely mechanical factors associated with endo-carditis. With regard to treatment, Prof. Freyclassifies his cases according as pregnancy is asso-

ciated with (1) recent inflammatory disease of theheart; (2) heart disease inadequately compensated,but not showing signs of active inflammation ; and(3) compensation of the heart disease. The correctprocedure in the third class is obvious ; pregnancyneed not be interrupted. But in the first class Prof.Frey advocates interrupting pregnancy whatever stageit has reached, whether the patient be a primiparaor multipara, and even when there is satisfactorycompensation. As a guide to the detection of activeendocarditis he recommends taking the temperaturein the rectum, and noting whether or not the patientis subject to tachycardia even at rest. The choiceof procedure to be adopted in his second class of caseis a difficult matter, but he is in favour of pursuing aconservative course as long as possible, in the hopethat rest of body and mind and the administrationof such drugs as digitalis may restore compensationand enable the patient to go to term.

THE MORISON LECTURES.To a Scottish doctor must the credit be given of

first instituting in this country special lectures on thediseases of the mind, and that at an early date whenthe conception of mental disease had barely advancedfrom the definition : " true madness, what is’t, butto be nothing else but mad? " In 1823 Dr. (later Sir)Alexander Morison gave the first lecture on mentaldisease in Edinburgh. Five years previously he hadstudied under Esquirol in Paris, together with two orthree eminent compatriots, for owing to the " auldalliance " Scotsmen even at that time were regardedin France with a certain friendliness. So impressedwas Morison with Esquirol’s teaching that on hisreturn he made a strong endeavour to have a lecture-ship or professorship on this subject instituted inEdinburgh. One of his proposals was that the visitingphysicians at Morningside Asylum-which hadrecently been built to supersede the barbarous cityBedlam--should deliver the lectures. This proposalwas not adopted, but so keenly did he realise theimportance of his subject that by a grant of privateproperty to the Royal College of Physicians ofEdinburgh he founded a lectureship in perpetuity, andfor the next 30 years he or his son lectured annually.This year the centennial course of the Morison lectureswas delivered in the Royal College of Physicians ofEdinburgh on Oct. 15th, 16th, and 17th by Dr.Alexander Blackhall-Morison, his grandson. The

subject of the course was, fittingly, a review of theprogress of neurology, psychology, and psychiatryduring the century since the foundation of thelectureship. In sketching the progress of neurology,Dr. Blackhall-Morison made a preliminary referenceto the previous work of Whytt on reflex actions, toHaller’s on organic action, and to the influence ofBichat as an interpretive anatomist, followed by th&epoch-making experiments of Charles Bell andMagendie on the differing functions of the nerve-

roots. The work of John Abercrombie, philosophicaland medical, was referred to, and Gaskell’s morpho-logical investigations were especially dwelt upon.He then outlined the rise and progress of embryology,and the work of von Baer, Kö1liker, His, Balfour andothers was referred to. The results of the experimentalwork of Flourens, Marshall Hall, the Webers, ClaudeBernard; Brown-Sequard, Schiff, and Ludwig weregiven, and the localisation of cerebral function byFritsch, Hitzig, and Ferrier discussed, together withthe clinical anticipation of such by HughlingsJackson. The clinical discoveries of Todd, Duchenne,Charcot, Romberg and others of the German schoolwere assessed, and the lecture closed with a con-sideration of the modern neural surgery of suchpioneers as Horsley, Macewen, and Cushing. Thesecond lecture dealt with psychology as a biology,and the growth of mental philosophy in the Scottishschool was sketched. Dr. Blackhall-Morison con-

sidered the work done on mental faculties by Gall,Combe, and other phrenologists in the localisation ofmental faculties, described the localisation of thespecial senses, and discussed the origin of language.Mind, he contended, was a living organism not aneural habit, and the importance of the persistenceof the ego in general, and of the human ego inparticular, was dwelt upon. The claims of the newpsychology were examined and the place of judiciouspsycho-analysis in practice indicated. In the thirdlecture, the history of psychiatry from the end of-the eighteenth century was outlined and the work ofHaslam, Pinel, and Esquirol especially mentioned.In dealing with the aetiology of mental disorder, thelecturer estimated the influence of bacteriology andendocrinology, and special reference was made to thework of Mott.The supreme importance of the care of the mind

is becoming widely recognised among physicians,and the importance of early and adequate treatment.of mental disorder is at last receiving some measure-of consideration. In this connexion a paper byDr. J. C. Porter Phillipsl on the early treatment ofmental disorder deserves attention. Asylum reformis going hand in hand with advancing knowledge, and.special lectures on mental disease now form part ofthe curriculum in every medical school.

Sir Humphry Davy Rolleston has been appointedPhysician-in-Ordinary to the King in the room

of Sir James Reid, deceased, and Dr. EdwardFarquhar Buzzard has been appointed Physician-Extraordinary to His Majesty.

THE Nobel prize for medicine for 1922 has been-divided between Prof. Archibald V. Hill, UniversityCollege, London, and Dr. Otto Meyerhof, professorof physiology at Kiel University. Prof. Hill has,.since 1910, been engaged on research on theformation of lactic acid in muscle during exercise,and in particular, its removal on recovery fromfatigue, a continuation of the work done by Sir WalterFletcher and Prof. F. G. Hopkins in 1908. As a.

mathematician and a physicist, Prof. Hill introducedinto his investigations a totally different physicaltechnique to that employed hitherto. Prof. Meyerhof,a close personal friend of his co-medallist, has pursueda similar course of research. The prize for 1923 hasbeen divided between Prof. J. J. R. Macleod, F.R.S.,and Dr. F. G. Banting for their work on insulin.

1 THE LANCET, Oct. 20th, 1923.