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inferior to that of streptomycin. Clinical trials with ithave been made by continental workers. According toMoncorps and Kalkoff 6 it produced clinical improve-ment in 80% of patients with lupus vulgaris. Equallyencouraging are the reports of its effect,in intestinaltuberculosis and tuberculosis of bladder and of bone.7TB 1-698 is apparently effective in early exudative casesof pulmonary tuberculosis,8 but not in miliary tuber-culosis or tuberculous meningitis. The drug appears tobe somewhat toxic, since it may cause vomiting, albu-minuria, jaundice, and cerebral oedema. These reportsmust be accepted with reserve, for the investigations havenot been submitted to such rigid statistical control asthe recent M.R.C. trials with streptomycin.9 Evaluationof an accumulation of individual clinical experienceswith a variety of types of tuberculosis takes a considerabletime, and the conclusions, being based on clinical

impression, are far less reliable than those formed by ateam of investigators whose individual reports are

analysed by an experienced medical statistician.

A RACKET IN NURSING

THE opinions expressed in our leading article of

July 30 on the Dangers of Uniformity had no referenceto the Ministry of Health’s circular, dated July 27,forbidding the engagement of nurses at more than thestandard rates.10 In this case the Ministry have excellentreasons for the action they have taken ; for the circularis designed to end a long-standing abuse. A cooperationorganised to hire out private nurses for genuinely privatework is one thing ; but when hospital nurses resignfrom hospital work, join the cooperation, and are thenhired back to the hospitals at a fee considerably higherthan the salary they were receiving from the hospital;and when moreover they thereby set themselves freefrom hospital discipline by an attitude to authoritywhich may be summarised as

"

Very well then, I shallgo," it is obvious that something must be done. This isnot a new practice ; already before the war it was causingserious trouble in London hospitals. In a report as longago as June, 1938, the Voluntary Hospitals Committeefor London said :

" Many of the private cooperations appear to have

outgrown their original function (supplying of nurses fortemporary private work either in the patient’s own home,a nursing-home, or private ward in hospital) and advertisefor nurses to take general duties in hospitals. They havelarge numbers (in one case, several hundreds) on theirbooks engaged solely in general duties in hospitals. Suchnurses are employed to supplement the permanent hospitalstaffs at salaries of £2 2s. or jb3 3s. per week, plus residence.Some years ago a few of the ’ special ’ and smaller hospitals,experiencing difficulty in keeping their staffs at full strength,employed a small number of nurses from private coöpera-tions in emergency and during holiday periods, but recentlythe practice has grown and new agencies have sprung up,often on a 10% or 15% commission basis, so that nowhundreds of nurses, attracted by the higher remunerationand greater freedom from restraint, join the private coöpera-tions expressly for hospital duties. Many of the permanentstaff become dissatisfied and unsettled, feeling it an injusticethat temporary staff performing exactly the same dutiesshould be getting in some cases more than double theirsalary, while free to terminate their engagement at anytime by giving twenty-four hours’ notice. Moreover, theconstant changes in the staff make it extremely difficult tomaintain a good tone or high standard in the hospitals."With a shortage of nurses, and disparity between the

rates paid in hospital and the rates demanded andobtained for nurses hired out by the cooperations, ithas naturally been difficult for authority to intervene.In reaching its decision to do so the Ministry has had to

6. Moncorps, C., Kalkoff, K. W. Med. Klin. 1947, 42, 812.7. Ravina, A. Pr. méd. 1949, 57, 343.8. Heilmeyer, L. Dtsch. med. Wschr. 1949, 74, 161.9. Lancet, 1948, i, 582 ; Brit. med. J. 1948, ii, 769.

10. See Lancet, Aug. 6, p. 264.

strike a balance between, on the one hand, the embarrass-ment that will be caused to hospitals still desperatelyshort of staff, which have come to regard the employmentof " private

" nurses as a regrettable necessity, and, on

the other hand, the probability that a good many nurseswill return to hospital work under conditions decidedlymore satisfactory to the hospitals. Taking into accountthe improvement in the rates of recruitment of nursesto hospital work, and the somewhat increased rates ofpay, the Ministry has decided that the racket should nowbe ended.

THE HYGE B.C.G. STATISTICS

Dr. Tage V. Hyge’s schoolgirls in Denmark promiseto become as famous in the history of B.C.G. vaccinationas Dr. Heimbeck’s nurses at the Ullevaal Hospital inNorway. In both cases several of the requirements ofan experimental investigation are fulfilled, and in bothcases follow-up studies are being pursued. It will beremembered that Hyge’s schoolgirls, numbering severalhundreds, belonged to a large school in Copenhagenwhere the story began in October, 1941, with the

discovery of a case of cavernous pulmonary tuberculosisin a girl of 15. This discovery led to systematic tuberculinand other investigations of the scholars and theirteachers. Early in 1943 there was an almost explosive,influenza-like, outbreak of tuberculosis in the school,and the source of the infection was found to be a teacher.The children were classed according to whether they wereoriginally tuberculin-positive or tuberculin-negative, thelatter being put in two groups according to whetherthey were or were not vaccinated with B.c.G. Like,Heimbeck, Hyge found a low tuberculosis-rate among theoriginally tuberculin-positive girls, and among thosewho, originally tuberculin-negative, were vaccinatedwith B.c.G. On the other hand, the tuberculosis-ratewas very high among the originally tuberculin-negativewho were not vaccinated with B.C.G.From time to time Hyge has published furtherobserva-

tions, and now, after an observation period of five years,he brings his figures up to date.! Of the 94 originallytuberculin-negative girls exposed to infection and notvaccinated with B.C.G., 70 became tuberculin-positive,and 41 of them showed definite signs of tuberculosis.Of the 106 originally tuberculin-negative girls exposedto infection and vaccinated with B.c.G., only 2 developedpulmonary tuberculosis. Of the 105 originally tuberculin-positive girls exposed to infection, 4 developed pulmonarytuberculosis. Hyge concludes : " We ought therefore tovaccinate with B.c.G. all who are tuberculin-negative."

REMOVAL OF THE AURICULAR APPENDIX FOREMBOLISM

PERIPHERAL arterial embolism is a common complica-tion of mitral stenosis, and in over 90% of such cases theemboli arise in a thrombus attached to the wall of theleft auricle, or more usually its appendix. The arterialembolus can be successfully removed, but recurrence iscommon because the auricular mural thrombus remains,and recurrent embolism is often fatal because thecerebral arteries are apt to be involved. The onlyradical cure lies in removal of the thrombus.American workers 2 have shown that in dogs it is

feasible to resect the appendix of the auricle and that thescar in a short time has a complete internal covering ofendothelium. Following this approach Madden 3 has

operated on two patients. The first, a woman of 38,had had an embolism of the left common iliac artery,treated by embolectomy, in 1946. Over a year later the

right popliteal artery was similarly affected and success-1. Nord. Med. June 17, 1949, p. 1058 ; Ugeskr. Laeg. May 19, 1949,

p. 560.2. Hellerstein, H. K., Sinaiko, E., Dolgin, M. Proc. Soc. exp.

Biol., N.Y. 1947, 66, 337.3. Madden, J. L. J. Amer. med. Ass. 1949, 140, 769.

292

fully treated. Further emboli seemed likely, so after aninterval of six weeks the left auricular appendix wasexcised. During the operation the heart stopped andcardiac massage was required, and a cerebral embolusprobably occurred, leaving a left hemiparesis. But therewas almost complete recovery, and there have been nofurther emboli. In the second patient, a man of 52, asuccessful embolectomy at the bifurcation of the abdo-minal aorta in December, 1947, was followed by resectionof the left auricular appendix in March, 1948. The

postoperative course was satisfactory until the ninthday when the patient suddenly died. Pathologicalstudy of the resected auricular appendix showed thatit was almost certainly the origin of the thrombus.The clinical’ diagnosis of an intracardiac thrombus

may be very difficult, and no one sign or symptom ispathognomonic. Madden says that the condition maybe suspected in cases of (1) coronary thrombosis withperipheral arterial embolism, or (2) chronic valvularheart-disease with auricular fibrillation and either

pulmonary or peripheral arterial infarction. In thecases with coronary disease the thrombus is usually,ventricular, and it is only in cases of rheumatic heart-disease with mitral stenosis and one or more peripheralarterial occlusions that resection of the left auricular

appendix is worth considering.YOUNG MEMBERS

" ALL education is social education," Mr. GeorgeTomlinson remarks in a foreword to a new Ministry ofEducation pamphlet,’

"

simply because we are membersone of another." The pages which follow are a studyof the meaning of citizenship, and its practice in theschools and in after-life. To be a citizen in Athens- inthe fifth century B.C. was to have clear civic responsi-bilities. Today we do not live so entirely for and in theState ; and this may be a good thing if it leaves usfree to grow to be citizens of the world. Nevertheless,the difficult art of living in a community must be acquiredin a small way first, even by citizens of a world State.The child encounters the rule of authority and law

first in his own home ; he also encounters justice, andperhaps injustice. The kind of injustice-or whatseems like injustice-which most children experienceat one time or another is the revenge of a parentexasperated by some trivial last straw. Perhaps thisin itself is not such bad social training (though thepamphlet does not discuss it), being an epitome ofsociety’s response to prolonged irritation ; and perhapsthe child had better get used to it early, and learn toconduct himself with tact. But such moments of humanfailure apart, if he is to have a fixed sentiment of respectfor justice later, he should be able to count securelyon justice as his portion in the home. Even more certainlyhe should be able to count on affection ; and if his homein addition supplies forbearance and understandinghe is in a favourable position to build up a stable systemof human values.The pamphlet is remarkable in being the first official

document for some time -to relate these values directlyto religion, and especially to Christianity. Despitethe imperfections of Christians and Christian Churches,it suggests, Christianity has been the most enduringcivilising force seen in the world. Nevertheless thewriter concedes that the love of justice and truth, theappreciation of beauty, with a sense of duty and com-passion, can be responsible for achievements

" of which all

good citizens, without distinction of belief, may be proud."On the standards formed in the home the child must

superimpose the wider and in some ways more exactingstandards of the school, since the moral values and idealshe acquires there are generally higher than those of

1. Citizens Growing Up. Ministry of Education Pamphlet no. 16.London : H.M. Stationery Office. 1949. Pp. 55. 1s.

society at large: " the transition from school to workis often something of a moral shock." The remedy forthis, the pamphlet suggests, is not less idealism in homeand school, but more in daily work and daily pleasures.For hundreds of thousands of young people work is adull routine, and leisure means the cinema or the grey-hound track, the palais-de-danse and the pavement.They are bored, listless, emotionally hungry. The

girls, especially, have no hope of escape from the boringpattern except through marriage, as Pearl Jephcotthas pointed out.2 Better use of leisure time will partlyredress the balance; but the real answer, the pamphletargues, is better human relations on the spot :

" To understand other people’s point of view ; to giveorders persuasively as between one human being and anotherand to give the reasons that make orders intelligible andacceptable ; ... to give a good day’s work as a matter ofordinary honesty and to ... reward a good day’s work withdecent working conditions and a fair share of the rewards ; ...to make a bigger sacrifice oneself than those asked of otherpeople and to take no credit for it-these are the simple humanmaxims for the lack of which the work of a big organisationmay jolt along with unnecessary friction and waste."

But of course they are not simple at all. To achieve thisatmosphere in an industry-or for that matter in anygroup of people working together, whether in a hospital,a college, a ship, a theatrical company, or anywhereelse-is a complex feat, depending on such things as thegood will and determination of a small group, a commoninterest and purpose, and a tradition of service andcooperation. It is a weakness of this pamphlet that ittakes universal good will for granted, and attends tothe disruptive forces in society only sufficiently to

imply that we should be better without them.This one-sided approach is perhaps justified, however,

when the practice of citizenship in the schools is discussed,for teachers need no reminders of the disruptive forcesin their midst. In our preoccupation with the problemsof our day, the pamphlet warns us, we must not assumethat they have a like fascination for the young, and socarry into the classroom " matters which are beyond theunderstanding.and fail to arouse the interest of children."They do need, however, to know something of the localand national institutions through which we are governed,earn our living, and manage our affairs ; and an under-standing of these things can be gained through local

studies, in which the children map their own neighbour-hood, examine its industries and agriculture, and study itstransport system and the goods it exchanges with otherplaces. They may visit local institutions and industries ;and wider horizons still are opened when the school"

adopts " a farm or a ship, or when-for example-a girls’ school council manages a scheme of part-timehelp in hospitals, homes, and small local shops. Educa-tion for home life could well extend to household repairs,which interest children of both sexes, and can be used tointroduce them to facts about items of food, clothing,and household equipment-where they come from andwhy some are scarce. Gardening, poultry-keeping, andthe care of pets, and questions of design and style inhouse equipment, are topics round which teaching,explicit or implicit, can range. A science course canteach method, and is often used for that purpose only ;but it can also be used to teach the scientific back-

ground of our civilisation, and the effects of science onworld food-production, population increase, soil erosion,and pest control. Sex education is allowed its placeamong other studies ; but, as the London County Councilhas put it in some recently published notes quoted in thepamphlet, "

reproduction is an important, but not a

preponderant feature of the living organism at work ;it should take its place, but no more than its place, inthe teaching of biology."

2. Rising Twenty. London, 1948. See Lancet, 1948, ii, 698.