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nature of a gastro-enteritis with fever. At one timethe disease suggested typhoid, and later it was

thought to be possibly bacillary dysentery.The patient, a girl aged 17 years, had been working for

three weeks for two or three days a week as a daily girlon a farm. No information is obtainable as to the precisesource of the infection. She was taken ill on July 14thwith diarrhoea and abdominal pains, and when first seen by adoctor on July 16th was in bed with a temperature of 10 l’ F.On August 1st she was still very ill, the temperature havingcontinued between 100° and 102°, and was having at leastfive motions in the 24 hours. The case was notified as adoubtful enteric on August 10th, and blood then taken wasfound to give no agglutination with emulsions of typhoid,paratyphoid A, and paratyphoid B bacilli. On August 14ththe patient was becoming very weak, with rapid pulse andnumerous loose motions, one of which contained some iblood. This specimen was sent to the laboratory for exami-nation, and in view of the negative agglutination reactionwas thought that the case might possibly be one of bacillarydysentery.

After August 17th she began to improve, the temperatureand pulse gradually falling to normal during the next fewdays. After August 23rd she was able to take more foodand became convalescent, but was very emaciated. Shefinally made a complete recovery.The sample of faeces arriving at the laboratory on

August 16th was examined by direct plating on McConkeyplates, and by the brilliant green enrichment method.Direct plates showed no non-lactose fermenting colonies,but the plates planted after brilliant green enrichmentshowed a few such colonies. These colonies (522) were ofa motile Gram-negative bacillus which gave the sugarreaction of the salmonella group-viz., acid and gas inglucose, mannite and dulcite ; no change in saccharose andlactose and slight acidity followed by alkalinity of litmusmilk, and no indol (after 14 days’ incubation). Gelatinwas not liquefied. Broth cultures of this organism failedto agglutinate with any one of the following sera : B. para-typhosus Band C, B. enteritidis Gaertner, B. aerl1’yckeMutton and Newport, but it was agglutinated to 1 in 50 bythe serum of the patient taken on August 23rd, which wasagain negative to typhoid and paratyphoid A and B. Theorganism was subcultured in broth for four days and thereaction repeated with the same result.The following cultures and serum having been obtained

from Dr. W. M. Scott, (1) B. morb. bovis, specific ; (2) B.mof6. bovis, Furseman specific ; (3) serum B. morb. bovis,group and specific, it was then found that the patient’sblood taken on Sept. 3rd gave the following reactions :—

In addition, after saturation of this serum with theisolated culture 522, all the agglutinins to both culturesof B. morb. bovis were removed (from dilution of 1 in 250)as well as for the culture 522 itself. It was further notedthat the organism 522 rapidly fermented inosite (24 hours)with the production of acid, but only very little gas, thestock cultures giving similar results but with more gas-production. Arabinose was also fermented with the pro-duction of acid and gas in 24 hours, and lead acetate brothwas blackened. It is of interest to note that, as we havepreviously found with other members of the salmonellagroup, brilliant green enrichment (1 in 200,000) facilitatedthe isolation of the organisms.

I wish to thank Dr. J. G. Walker, medical officerof health for Lanchester, Co. Durham, for the historyand specimens, and Dr. W. M. Scott, of the Ministryof Health, for cultures and serum of B. morbificans

Ibovis. I

Medical Societies.ROYAL SOCIETY OF MEDICINE.

COMBINED SECTIONS OF UROLOGY, PATHO-LOGY AND THERAPEUTICS.

A JOINT meeting of these Sections was held onMarch 21st, Mr. SwiPT JOLY, President of the Sectionof Urology, in the chair. Dr. W. LANGDON BROwNopened a discussion on

URINARY ANTISEPTICS.

He said that it would be convenient if the term" bacilluria " were reserved for the passage of bacteriathrough the renal system without inflammatoryreaction, which was constantly occurring and calledfor no treatment. When pus accompanied bacteriain the urine some inflammatory condition had beenset up and needed treatment. Bacilluria might beturned into cystitis by any obstruction to the flow ;by an organic lesion of the nervous system ; bytrauma, such as a blow over the kidney in football,and by focal sepsis. In the last-named the besttreatment was to deal with the source of the trouble.The large intestine provided a source of extendedsepsis, especially if there were some obstruction suchas diverticulitis, and the relation of the hepaticflexure to the right kidney made infection by thisroute easy. In these cases intestinal antiseptics,kaolin, and Plombieres douches were as important astreatment of the urinary tract. The only organismsof practical importance for renal infections were theBacillus coli, B. proteus, streptococci, staphylococci,gonococci, and the tubercle bacillus. Ascending infec-tion was more common in women and babies ; thecolon bacillus was said to inhabit the vialva of 50 percent. of normal women. It was rare in men, but ineither sex might arise from the peri-urethral lym-phatics. There was an enormous preponderanceof B. coli infections, but it was important to guardagainst concluding that a case was one of simpleB. coli infection because only coliform bacilli werefound in the urine ; a tuberculous infection or a newgrowth might be concealed behind this. As a generalrule a case that proved very resistant to treatment,in that signs and symptoms persisted, should not beregarded as a simple infection. There was somedoubt whether the " coliform " infection was reallythe ordinary B. coli comintinis or some organism likeit, but, as it had been shown that the bacillus in theurine might be strongly hsemolytic at the height ofthe infection and gradually return to a form typicalof B. coli communis, it was hard to resist theconclusion that the ordinary bacillus could pro-duce pathogenic effects when outside its normalenvironment.

I Antiseptics ’in ConmlOn Use.Many substances had been found successful in

vitro that were not so good clinically ; the bladder,unfortunately, was not lined with glass. The benefitsof intravenous administration were not solely due tothe germicidal action of the drug. H. H. Dale thoughtthat they were partly due to modification of viru-lence or lowering of the resistance of the invaderto the natural defences, partly to the formation inthe body of some substance directly antagonistic tothe germ, and partly to the formation of a depotfrom which a curative substance was slowly distilled.Mercurochrome and gentian violet were the sub-stances chiefly used ; at the Mayo clinic the formerwas given in doses of 4 mg. per kg. of body-weightin 1 per cent. solution, but even this dose occasionallyled to rigors, vomiting, and diarrhoea, and should onlybe used as a last resort. Helmholz and Field main-tained that hexamine was definitely superior ; Braaschand Bumpus claimed good results from doses of5 c.cm. of a 10 per cent. solution. It was extra-

ordinary how little general agreement there was as

662

to the efficacy of the various drugs given orally for ’urinary antisepsis. Hexamine was rapidly absorbed 1

and appeared in the urine, bile, and cerebro-spinal Ifluid about 20 minutes after administration. It was 4

said to form formaldehyde in an acid urine, but if ’

so there seemed no reason why it did not also form iformaldehyde in the presence of the gastric hydro- 1

chloric acid. At any rate, the amount liberated wassmall, and some authorities said that the patientfound the drug intolerable just as soon as the formal-dehyde began to appear. No doubt hexamine couldbe very irritating and cause hoematuria. Dr. LangdonBrown had found it less irritating when given withmethylene-blue; the combination diminished sub-

jective symptoms and reduced the amount of pus andorganisms, but the infection persisted. Acid sodium

phosphate had been recommended by R. Hutchisonas the natural acidifying agent ; only half the dosewas absorbed, the rest passing out through thebowel. This drug could prevent the post-prandialalkaline tide and the slow ammoniacal decompositionresulting from bacterial infection, though it couldnot correct a strongly ammoniacal urine. It wasusually given with hexamine. Blaustein held thatcalcium and ammonium chlorides were strongeracidifiers in an alkaline cystitis ; he gave ammoniumchloride in doses of grs. 15, t.d.s., up to grs. 30 everythree hours. Benzoic acid was synthesised in thekidney with glycin and excreted as hippuric acidwhich, according to Stockman, took up so muchalkali to be excreted as hippurate that more phos-phate was able to take the form of acid phosphate.The ammonia split off from urea by ammoniacaldecomposition combined with this acid salt and theurine became clear. Stockman preferred to giveammonium hippurate, as a smaller dose of this waseffective. The latest drug was hexyl resorcinol; thiswas inactive when given with sodium bicarbonate-according to Leonard and Frobisher because ofalteration of surface tension, so that the drug couldnot enter the crevices of the mucosa. In any casemost of the drug was conjugated and only smallamounts excreted in an active form. Great claimswere made for it which, if justified, were some set-off for its prohibitive cost. D. A. Brown had saidthat the chief feature was relief of bladder irritations ;he gave it in 0-15 g. capsules, 9 to 12 a day for 7 to30 days in acute cases and 30 to 60 days in chroniccases. Half the patients had suffered from gastro-intestinal disturbance. Stockman agreed that itreduced the number of organisms and the symptoms,but did not find it effective in eradicating the infec-tion. Salicylic acid was never found free in the urine,being excreted as inert salicyluric acid. Salol appearedas sodium salicylurate and sulphocarbolate. Stock-man was unable to understand the reputation of salolas a urinary antiseptic ; it might perhaps be dueto its action as an intestinal antiseptic. Boric acid, i

given in five-grain doses, was a weak antiseptic inboth acid and alkaline urine. It was best given inkeratin capsules together with salol, and seemed torelieve the symptoms of chronic B. coli infection.Acriflavine, a grain and a half three times a day inkeratin capsule, had been recommended by Browningand Gulbransen. The difficulty was to get the keratinthe right thickness : if the drug was absorbed success-fully it gave the urine a deep yellow colour. Copaibaand sandalwood oil had been used, and sometimesrelieved the symptoms ; -, they were most useful ingonococcal cystitis.

Change of Reaction, Vaccines, Lavage.One of the most important methods of treatment

was to change the reaction of the urine, altering thehabitat which suited the microbe in question. Itwas easier to make an acid urine alkaline than vice

versa. The patient found alkalis more tolerablein acute infections. Potassium citrate and sodiumbicarbonate on the one hand, and ammonium andcalcium chloride and acid sodium phosphate on theother, were used to make the change ; it might benecessary to change the reaction more than once.

We needed to know a great deal more about theurine reaction ; some urines became sterile by them-selves if obstruction were removed. Large quantitiesof water were useful, but should not, of course, beprescribed while an attempt was being made tosterilise the urine by antiseptics. Vaccines nevermade the urine sterile, but might relieve a toxaemia ;they were more successful in coliform than in coccalinfections. Dr. Langdon Brown said he had some-times been greatly impressed by the effects of lavage,application of silver nitrate, and irrigation of therenal pelvis. Any case which did not respond rapidlyto medical measures should be examined by thecystoscope.

A Pathological Experiment.Dr. CUTHBERT DUKES described an investigation

into the value of urinary antiseptics in 28 cases ofcystitis produced by a tie-in catheter in patientswhose rectum had been excised for carcinoma. Thecystitis had appeared invariably in four or five daysso long as the catheter had been stopped with awooden peg, the infection arising at the junction ofpeg and catheter and spreading up the column ofurine in the catheter. There had been no symptomsexcept irritability of the bladder ; in the earlystages the organisms were pyogenic cocci, usuallystaphylococci, but in the later stages coliformorganisms had predominated on agar culture, thoughthe cocci remained predominant in broth. Milduncomplicated cases recovered without treatment infour to six weeks. The effects of the antisepticshad been judged by clinical observation, by dailyquantitative estimations of pus in the urine, and byrepeated bacteriological examinations. The amountof pus had been found to be an expression of the natureand not of the severity of the infection. Of sevencases treated with hexyl resorcinol, one recovered in30 days and another in 25 days ; the remaining fivederived no benefit. Of 12 cases treated with hexa-mine only one recovered more rapidly than wasexpected. Most of the patients complained of thediscomfort of the treatment. In four cases treatedwith methylene-blue there was no sign of any benefit.The best results were obtained in five cases treatedwith alkalis, which made the patient more comfort-able and might perhaps shorten the natural duration.At present the best treatment for catheter cystitiswas to give non-stimulating diet with large quantitiesof water and to keep the urine faintly alkaline tolitmus. A glass of water should be drunk everyhour ; no medicine was required at all if the urinewere already alkaline.

Lzscuss2on.

Dr. PHILIP HAMILL pointed out that few coccalcases fell to the lot of the ordinary physician, whogenerally found that he could not push hexamineand acid medication because of the pain. He hadbeen satisfied that cases cleared up just as quicklyon water alone. The great value of alkaline treat-ment was that it rendered micturition painless, sothat the patient could be persuaded to take fluids.Methylene-blue made the patient more comfortable,

and so did flavine and caprokol, but the former didnot reduce the pus. Dr. Hamill then described someexperiments on the cultivation of organisms withthe urine of a normal subject who had taken hexyl

resorcinol. They showed that the urine became veryhighly bactericidal to Staphylococcus aU1’eus, but hadno antiseptic effect on B. coli until it became fairlyalkaline.

Mr. F. A. JEANS said that in his experience hexa-, mine made tuberculous kidneys worse. It was onlyirritating if there were no albumin to counteract it;

if the pelvis were full of pus, formaldehyde caused, no discomfort. Empirically it was a good thing to

, alter the reaction of the urine, whichever it was.Dr. L. P. GARROD said that colon bacilli grew very

much faster in alkaline than in acid urine, and thatthis was not due to nutrient substances present atthe time of the alkaline tide after meals. To inter

fere with the growth of B. coli in urine the urine mus

663

be made strongly acid, but this caused the patienttoo much discomfort. The growth of organisms inthe sterile urine of a normal person who had takenan antiseptic drug would give an accurate idea ofthe value of the drug in question.

Mr. F. E. FEiLDrN said that few conditions weremore difficult to treat than uncomplicated B. coliinfection; in his experience hexamine, acid sodiumphosphate and flavine were the best drugs. Hexa-mine accentuated the symptoms in many cases, andhe had been more impressed by flavine, in doses ofhalf a grain three times a day, with an alkali. Amountsof 1 in 300,000 were enough to inhibit the growth ofthe gonococcus.

Dr. KINGSTON BARTON held that the easiest andmost comfortable drug to give was hexamine, but theacidity of the urine must be known. It should neverbe given in large doses, especially at night, but insmall amounts every few hours, for it passed throughvery quickly. The more of it that was given beforenoon, the more efficacious it was. Formalin mustget into the gastro-intestinal tract, for many patientscomplained of " indigestion " when taking hexamine.This could be obviated by giving the drug beforemeals.

Mr. JOHN EVERIDGE said that without questionhexamine was a most valuable drug, and gainedadditional value by being given about an hour afterthe acid sodium phosphate. The urologist frequentlytied in a catheter, but did not get catheter-cystitis ;he wondered if the infection described by Dr. Dukeswas really a urethritis. Hexamine was believed tofail in pyelitis because it did not remain long enoughin contact with the inflamed area ; this might alsoapply to urethritis.

Dr. GEORGE GRAHAM thought there was no scientificevidence for the value of hexamine, which he nolonger used. It was often given with an alkali or inalkaline urine, and it was the alkali that did the good.

Dr. ELIZABETH LEPPER said that experiments shehad done had shown that hexamine was on theborderline of useful antiseptics. Just enough of itwas dissociated in the urine to produce some effect;probably it acted on some coliform organisms andfailed to touch other more resistant strains.The PRESIDENT said that he had become very

pessimistic about chronic infections of the kidney;if they persisted more than a few months they wouldpersist indefinitely, become bilateral, and eventuallykill the patient. Coccal infection with renal stonecalled either for primary nephrectomy or at any ratefor removal of the kidney if the infection persisteda year after removal of the stone.

Dr. LANGDON BROWN, replying, said that there Iwas, in fact, very little satisfactory pathological 11evidence of the efficacy of the drugs in common use,but there was a good deal of clinical evidence thatthe patient could be made comfortable.

Dr. DuKEs, in reply, emphasised that his resultsmust only be taken to apply to the particular formof catheter cystitis in question ; he was convincedthat it was a cystitis and not a urethritis. It mightspread to the kidneys and cause grave complications.Though symptomless, it produced much ill-health.

SECTIONS OF DERMATOLOGY ANDEPIDEMIOLOGY.

ON March 21st a joint meeting of these Sections washeld, with Dr. J. M. H. MACLEOD, President of theSection of Dermatology, in the chair, to discuss theCausation, Recognition, Prevention, and Treatment of

INDUSTRIAL DERMATOSES.

The CHAIRMAN said the subject was important notonly to the medical profession, but to the wholeindustrial world. If, as a result of the discussion, akeener interest was aroused in the problems ofindustrial dermatitis and methods of prevention, itwould have served a very useful purpose. Celsus andAgricola referred to the dangers of ulceration of the

skin from contact with corrosives. Agricola alsomentioned the baneful action of a kind of " cadmia,"which Mr. Hoover, President of the United Statesand a distinguished modern engineer, recognised asarsenical cobalt. Robert Willan was the first todescribe the psoriasis palmaris of shoemakers,dermatoses in metal workers, grocers’ itch, andwasherwomen’s eczema.

Dr. SIBYL OVERTON began by speaking of thegrowing importance of these dermatoses, both to thenation and the individual. Many thousand man-hours were lost annually through this form of dis-ability, and even one attack of dermatitis mightprevent a skilled worker from pursuing his trade again.In 1927 a minimum of 3000 days’ work was lost onaccount of trade dermatitis in factories. Since thepassing of the Workmen’s Compensation Act in 1906the claims on this account had largely increased. In1908 the claims numbered 19, on account of ecze-matous ulceration of the skin, while in 1927 the figurehad risen to 897. The number of substances beingused in various manufactures had largely increased oflate, as had the proportion of skin irritants so used.The most important single event in the causation ofthese dermatoses was injury to, or destruction or

separation of, the horn cells of the epidermis. Aprominent place in the aetiology was taken by alkalis ;the horn cells were more tolerant of acids, in thestronger solutions, than of alkalis. In bakers’dermatitis the phosphoric acid in the sweat was saidto form acid aldehyde which, in the presence of oxygen,broke down to produce formic acid. Over-lubricationof the skin by oil served to swell the number of cases.Dermatitis levied a heavy toll on engineers, perhapsbecause of the fine particles of metal in the oilymixtures handled. The dyeing industry and calico-printing were responsible for many cases of tradedermatitis annually. Painters acquired skin diseasenot from their paint, but from the turpentine and itssubstitutes they used to remove paint from hands andarms after work ; the paraffin so used took its placeamong the irritative agents. She suggested that herethere was scope for the work of the experiencedchemist. Cotton-seed oil was a good substitute formore irritating cleansers.

As a result of inquiry into thousands of cases theconclusion reached was that most of these cases werepreventable. More knowledge was needed of harmlessyet effective methods of removing stains from the skin,and certainly there should be a daily removal ofirritants from the surfaces concerned. The primeobject was always to preserve the protective layer ofhorn cells. Emollients should be used before and afterwork. After work any irritant must be completelyremoved by harmless methods. An experiencedobserver should be allotted the task of inspecting thehands and arms of the workers with power to enforcethe early treatment of minor injuries, such as cuts andburns. Dermatitis was often preceded by such smalldamage, and this damage was often the starting placefor the more widespread skin eruption. Hands, arms,and overalls must be scrupulously cleansed on leavingwork. Forearms were often rubbed over with acontaminated overall. After the Government Orderof 1919 cases still continued to come up, but there wasa steady diminution. In wet processes the feet andlegs were often the parts first affected. Patentcleaners for boots and shoes contained ammonia, andcases of dermatosis were attributed to that, and alsoto the oil used by tobacco workers.

Dr. WILLIAM DYSON (Manchester) confined hisattention to cases whose condition was, clinically andhistologically, indistinguishable from the dermatitisknown as eczema-in other words, a superficialnon-microbic inflammation of the skin caused byexternal irritation in a predisposed subject. It wascommonly seen in bleachers, dye-workers, chemicalworkers, plasterers, French polishers, and hair-dressers. The predisposing causes of this must beheld to be hyperidrosis, xeroderma, ichthyosis, seniledegenerative changes, debility, tuberculosis, an&;mia.I Once the condition had been set up in a person relapses

664

were frequent, and the question of relapse brought intothe discussion that of sensitisation. Sensitisation toa specific irritant was very rare in trade dermatitis;but a general supersensitiveness of the skin afterlong-standing or repeated attacks of dermatitis wascommon. This was certainly contributed to by theabsorption of toxins through inflamed and damagedepithelium. In over 50 cases he had had blood-sugarestimations done, and the results suggested that whensensitisation was present a high blood-sugar was to beexpected. Also that when the products of inflamedepithelium were being absorbed, the blood-sugarcontent was higher than when these products werebeing discharged on the surface. On the hypothesisthat this supersensitiveness might be an anaphylacticphenomenon, he had treated 17 patients with injectionsof their own blood so as to produce an anaphylacticstate. Fifteen of these cases had suffered from

relapsing dermatitis, for periods ranging from threemonths to 20 years. The result of this procedure wasmuch the same as that from small doses of X rays-namely, the production of an antianaphylactic state.He considered that the prognosis in a first attack of Ithis dermatitis was good in the absence of an obviouspredisposing cause ; it was bad if of long standing orif there had been repeated attacks. For prevention,or lessening the incidence, he advocated medicalexamination before a man was employed, and aperiodic inspection of all the factory’s employees.

Dr. N. HOWARD MUMMERY spoke of industrial der-matoses as seen in the clinic of a large food manufactur-ing and catering firm, which also carried out transporton a large scale. His aim as medical officer to that firmwas to prevent recurrence of these dermatoses, andto make the period of absence from work as brief aspossible. He sent to hospital only such cases asseemed to need in-patient treatment. The employers’liability in respect of these dermatoses did not seemto rest on any scientific or practical basis, but ratherupon certified opinions of private or panel medicalpractitioners or factory surgeons, who in the mainhad an inadequate knowledge of these diseases. His

own view was that most dermatoses met with inindustry were not due to the employment, neitherwere they more prevalent in industrial than in otherwalks of life. Rather were they due to constitutionalsusceptibilities of all degrees. Exclusion from aparticular employment of those unfitted for it was afirst necessary step. He rejected from duties requiringthe handling of food all who had a skin disease, andthose showing marks of seborrhoeic and other states.The commonest predisposer to dermatitis was anunusually dry and inelastic skin. For many yearshe had carried out at the firm in question a weeklyinspection of the workers. The initial lesion was adry patch of interdigital or extensor coccogeniceczema. He recently had two cases arising from thecheese used in the production of Welsh rarebit.A person might work in a factory for years withoutskin trouble, and then suddenly develop a dermatitis,without having had any change of occupation.When that subsided he might remain clear for anotherseries of years. Usually he had concluded that thefault lay with the worker rather than with his work.He did not think bakers’ itch could be regarded as aclinical entity, and cases of it were rare in a modernbakery. In the staff of 5000 there had been 170 casesof skin disease in one year, and the lost time onthat account averaged 18 days per case. ,

VI’. J:11ii.N1:tY IVIACUORMAC suomU,LeQ tliati ùllere were

two groups of cases. In one, the eruption was dueto a known external agent, the reaction from thatagent being of a specific type; instances were

chromium ulceration and tar-workers’ cancer. Inthe second group were cases much more difficult tounderstand. They were the non-specific types oferuption, generally eczematous, which occurred in

people working at various occupations. Examples ofthis were bakers’ and grocers’ dermatitis. In manyof the cases in this class it seemed likely that thepatients were people who developed eczema whileworking at a certain trade ; whether the work

caused the eczema was not clear. He tried to arriveat some conclusions about this second group byinquiring among photographers who used metol oramidol. In one firm there were four men. One ofthem worked for ten years and kept free from derma-titis ; another worked there six years before develop-ing it, and since then had kept himself free by wearinggloves ; another worked five years with freedom ;another worked three years, had an attack after thefirst year, and was able to protect himself withgloves. The head of one firm said he had himselfworked with metol for 20 years and had been quitefree from any eruption ; but on two occasions whileon holiday he had developed eczema. If this eczemahad occurred during his work it would probablyhave been attributed to the chemical. In one largeschool of photography 250 students had been con-stantly working at photography with metol andamidol, but there were only four cases of dermatitis,probably due to amidol. He carried out cutaneoustests in two of the cases, and neither of them gaveevidence of specific sensitisation to metol.

Sir THOMAS LEGGE said there were people, -incapaci-tated by trade dermatitis, who were receiving nocompensation for it, simply because they did notknow how to get it. Some were receiving the bestform of treatment, but had been told nothing about thecompensation to which they were entitled. Applica-

111UIl UU me Uel’LIiyliig -LZTUUUFY surgeon lul’ Liie u.isL’nu.with the payment of 5s., was the only formalityrequired. He urged that it was the duty of the doctorseeing such cases to tell the patients what they werewere entitled to. Dr. Howard Mummery had shownhow much good could be done by whole-time medicalofficers of factories ; but how many factories had awhole-time doctor ?-probably not 50 in the wholecountry.

Dr. W. J. O’DONOVAN said he feared that if- thismatter had been solely in the hands of the profes-sional dermatologist the great mass of occupationaldermatitis would have remained undiscovered. Now,however, the pendulum seemed to be swinging in thewrong direction, resulting in the figures beinginflated. A prominent cause of this was the incursionof administrators, lawyers, and accountants. If aworkman presented a certificate stating that he couldnot work because of dermatitis, he was at once asked(with a strong suggestion that dermatitis was usuallyoccupational) to go to the certifying surgeon. In thisway cases were almost forced into the occupationalgroup. He had in his ward cases of chilblains andlupus erythematosus which had been certified as ofoccupational cause.

Dr. R. PROSSER WHITE agreed about the importanceof the horn cells of the epidermis as a barrier againstdermatitis and infection. He was convinced, however,that it was necessary to know the exact physico-chemical action on the skin of the particular drugused. The reason alkalis loomed so large in the causa-tion of these dermatoses was that alkalis were solventsof the horn cells. The question of sensitisation was avery difficult one, but he thought the present tendencywas not to assign a very great importance to it.

Dr. ALLAN PARSONS referred to an investigation ofbakers’ itch which he had carried out a few yearsago for the Ministry of Health. Dr. Overton’sremarks had convinced him that this subject wasbeing carefully watched. He had also inquired intothe dermatitis which occurred among hop-pickers.These people suffered from cracks and abrasions ofthe skin due to pulling the hops off the vines. A bandof workers was giving attention to the subject.

Dr. G. H. LANCASHIRE gave an analysis of 100 cases,diagnosed as occupational dermatitis, which he hadexamined ; 13 per cent. were not due to trade con-ditions, though they were certified to be so by thefactory inspector ; 20 per cent. of the cases were dueto exposure to aniline dyes ; 7 per cent. to bakers’itch ; 18 per cent. were in rubber workers ; 12 percent. were among painters, largely due to turpentineor its substitutes, used for hand cleansing after work.Other trades represented in the list were cement

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workers, hairdressers, grocers, electro-platers, brass-tube moulders.

Dr. F. E. FREMANTLE (President of the Section ofEpidemiology), proposing a cordial vote of thanksto the speakers, referred to the value of the Societyas a body of experts to whom the Government couldrefer on subjects such as that now discussed. Hehoped this would be done in the future in increasingdegree.

_________

MEDICO-LEGAL SOCIETY.

AT a meeting of this Society on March 21st, thechair was taken by Sir WILLIAM WILLCOX, thePresident, and a paper on the

INVESTIGATION OF FiBE-ARM INJURIES

was read by Prof. SYDNEY SMITH. The investigator,he said, often wanted to know whether a given injurywas due to fire-arms or not; the type of fire-armresponsible ; the direction taken by the shot, and thedistance of the muzzle from the body. Sometimesit was necessary to say whether one particular weaponhad been used. The effects of fire-arms were veryvariable ; a rifle bullet at the beginning of its tra-jectory, before it had settled into its regular spin,would wobble and cause a wound like a severe explo-sive injury ; similarly a spent bullet, turning over andover, would cause injuries quite unlike those of a

bullet wound. A small high-velocity bullet bored aclean hole; a slow large bullet often made a ragged one.Besides the projectile, the weapon produced a waveof gas, wads, unburnt powder, smoke, and flame, allof which (when the discharge was close enough) lefttheir distinctive marks to aid diagnosis. Powdermade tattoo-like marks on the skin, and left traceswhich could be chemically analysed. At a slightlylonger range the wound made by a rifle bullet wasa round, clean, punched-out hole surrounded by azone of tissue denuded of its epithelium but showinglittle sign of blackening or burning ; outside this theremight be powder-tattooing. The hole itself might besurrounded by a black ring due to fouling from thebullet; this was sometimes mistaken for powder-marking. Local bruising due to hydrostatic pressurewas also apt to be mistaken for the marks of a closedischarge. These distinctions were important, as

they might turn the scale between the theories ofsuicide or murder. Automatic pistols caused verymuch less blackening and burning than any othertype of weapon, because of the completeness of thecombustion of their " smokeless " powder. Theyproduced a typical clean entrance wound. Exitwounds were nearly always torn, as the bullet wasforced through the tissues. A low-velocity bulletcaused the same kind of wound that might be madeby a poke from a stick. In bone, such as that ofthe skull, the entrance was clean-cut and the exithad an excavated appearance. A line betweenentrance and exit, if produced, nearly always gave agood indication of the track of the bullet, but deviationsometimes occurred within the body if the projectilestruck a bone. The appearance might give a guideto the direction ; when the bullet entered at an anglethe wound tended to be oval, and if the dischargehad been at close range there might be much bruisingand burning on the angle of fire. A shot-gun dis-charged within one yard caused a single wound, andwithin three yards slight scattering with burningand blackening, but above that distance the woundsof the separate shot were discrete and there waslittle discoloration. A sharp-pointed bullet mightoften inflict a wound very like that of a stabbingweapon, but the latter when pulled out tended todisturb the tissues, and their outward deviationdistinguished the stab from the bullet wound. Inbone the excavation effect of the dagger would beboth inwards and outwards. Bullet wounds madeat an angle might simulate cuts, but some portionof the tissue was generally removed, and there was

often denudation of epithelium and bruising. More-over, the bullet often left metallic traces. Bulletswere sometimes marked by the cloth through whichthey passed. X rays were often valuable in demon-strating the absence of a bullet where the site ofentrance escaped notice, or when great deviation hadoccurred within the body. When more than oneinjury was found it was important to pay carefulattention to all the anatomical possibilities beforedeciding whether one projectile or more had been

responsible. A bullet had been known to pass in astraight line through the back of a running man,through his abdomen, into the front of his leg, andremain embedded in the back of the leg.

Identification of F’ire-a7°ryas.Even if no projectile were found, a chemical and

microscopical examination of the traces of metal andpowder at the wound might give a clue to the kindof weapon which had been used. Some powderswere filled with barium or bichromate. If an auto-matic pistol had been used, cartridge cases were oftenfound at the scene of the crime, and the marks onthe sides of these caused by the action of the weapon-might be sufficient to identify one particular nre-arm. The distinguishing marks on a cartridge-casefired in an ordinary revolver were mostly on the base.A bullet which had passed through the bore of aweapon received not only the marks of the rifling,but also many minute scratches caused by individualfaults. From the gross markings it was generallypossible to tell the type of weapon which had beenused, while from the smaller individual markingsit was possible to prove whether or not a given weaponhad fired the bullet. A bullet found in the body wasweighed, had its specific gravity estimated, and itsbase examined for signs of the maker’s name. Thetip sometimes showed other signs which mightidentify it. The murderers of Sir Oliver Lee Stackin Cairo had been detected entirely by this means,and certain instruments with which they had notchedthe tips of their bullets had been found with metalstill adhering that was identical with that of thebullets used. The apparatus used for the identifica-tion of bullets consisted of two microscopes fitted witha common eyepiece, so that the images of the twobullets to be compared were shown side by side.For macroscopic examination bullets were rolledon a sheet of plasticine ; rifling was examined bytaking a casting in sulphur and rolling the castingon plasticine. Bullets, however, were not alwaysfired from weapons of the same calibre as themselves ;a small bullet might be made to fit a large barrel bywrapping it in paper.

Some Extraordinary Projecfile8.Criminals had been known to pick up a bullet on

a rifle range and fire it from a shot-gun. In onevictim’s body the investigators had found two

shilling-pieces ; the bullet had struck them when theywere in his pocket and had driven them in withoutitself entering. A shot fired at a railway train hadentered the dining-car and nearly killed an importantpersonage. The projectile found had puzzled theofficials, for it had appeared to be made of bronze, andto be roughly of 16-calibre. Many persons had beenarrested, and all the guns in the district had beenexamined for traces of a bronze bullet. Closerexamination, however, had shown that the projectilewas flat on one side and rounded on the other, andthat it had a splash of lead at its base. It had proved,in fact, to be a fragment punched cleanly out of ahinge of the table in the dining-car. The actualbullet had then passed through the door of thecarriage. Traces of lead had been found, and alsotraces of some other substance which had at firstbeen thought to be cupro-nickel and which hadsuggested a rifle bullet. This had thrown suspicionon the troops in the district, but analysis had provedthe substance to be steel, a fact which had shownconclusively that the assailant had been the owner