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body temperature. The busy practitioner may ask,How much better off are we for knowing these facts ;what application have they to disease and its treat-ment ? It is no exaggeration to say that an entirelynew field of treatment can be seen in the near future,and the following example will bring home theimportance of the new observations. Let us con-sider what is loosely included under the termacidosis, a common and serious enough condition towarrant the practitioner’s close attention. Leavingout controversial points, we are justified in saying thatthe common clinical form of acidosis, whether a result ofdelayed chloroform poisoning, toxaemia of pregnancy,or diabetes, is a ketosis-that is to say, it is due to thepresence of certain fatty acids. In normal metabolismthe complicated fatty acids, such as stearic andpalmitic acids, are desaturated and carbon atoms areoxidised away, two at each step, until the compoundis reduced from 18 carbon atoms to 2 or 3, which intheir turn disappear in the form of CO and water.In acidosis, however, the oxidative processes are

deficient, with the result that the degradation stops atthe 4-carbon-atom stage. Derivatives of butyric acid,such as /3-oxy-butyric acid and aceto-acetic acid,circulate and produce the symptoms of acidosis. Now,the degradation of these fatty acids is accomplishedby desaturation and oxidation, both oxidativeprocesses, and presumably both dependent on somebody such as glutathione.

It is not going too far to suggest that acidosis inthe future will be controlled clinically by the adminis-tration of some such substance, and in any caseinvestigations on Prof. Hopkins’s lines are bound tothrow light on the treatment of this condition. Theinborn errors of metabolism afford further examples.Research on oxidative catalysts may cure cystinuria,which is merely an expression of lack of oxidation.Prof. Hopkins could have chosen no more topicalsubject for his lecture, quite apart from the fact thatit is to his particular interest and personal work inthis branch of medicine that our progress has beenlargely due.

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CHINA’S LEGITIMATE DRUG NEEDS.

THE proceedings of the League of Nations OpiumCommittee at Geneva during the past weeks and theirattempt to find out the world’s medical requirementsof morphia and cocaine give importance to a pamphletjust issued by the International Anti-Opium Associa-tion of Peking, in which the secretary of the Associa- Ition, Dr. W. H. Graham Aspland, makes an attemptto formulate an estimate of the yearly amount of Inarcotic drugs required for medical use in China.Dr. Aspland, who was for many years professor of 4

obstetrics at Peking University Medical School and 4president of the North China Medical Association,recognises the extreme difficulty of getting accuratedata, and his own figures are based upon calcula- 1

tions made from details supplied mainly from the Fmission hospitals and dispensaries, of which there are 709 in China, employing 657 foreign and Chinese 1doctors, and treating annually about 1,400,000 patients. Replies to his questionnaire were received from hospitals and dispensaries representing a yearly (

treatment of 850,000 patients. The sickness incidenceof China was calculated at 5 per cent. " It may be <

higher but it certainly cannot be lower," says Dr. *

Aspland. " In European countries it is considerablylower and in U.S.A. only 2 to 2-5 per cent. Now if we <

may work on this hypothesis, then China, with i

400,000,000 people, ought to have a sickness incidence Iof 20,000,000 yearly, and presuming that all these sick <<

people were under treatment by qualified doctors eitherin homes, hospitals, or dispensaries, then accordingto our estimate of 15 g. per thousand patients basedon the statistics already dealt with, a total of 300,000 g. ior 10,000 oz. of morphia and narcotics would be required." However, in reporting to the League ofNations Dr. Aspland says that it was thought advisable ]to double this amount in order to cover all con- !tingencies, for with an increasing medical profession j

more narcotics would be scientifically used. Amoderateestimate of the present illicit traffic in drugs cannotbe less than 30 times that of the suggested medicalrequirements on the generous basis outlined. Asregards cocaine, Dr. Aspland’s estimate of the totalyearly requirements for China is 2000 oz. "It isnot proposed to leave any margin, for except in thehands of qualified doctors there cannot be other thanaddictive use."

In a supplementary letter which we have seen Dr.Aspland gives some figures regarding the seizures inthe Customs during 1922. The amount taken atShanghai, Tientsin, Peking, and Shansi amounted to80,000 oz. The seizures of narcotics in the ShanghaiCustoms for the quarter ending March, 1923, aloneshow over 3000 oz. originally manufactured inGermany, 464 oz. from London, and 176 oz. fromFrance. This does not, of course, imply that thedrug in the first instance was not perfectly justifiablysold under licence to a purchaser, who subsequentlydealt in it in an illicit manner.

SELECTION OF OPERATION FOR GLAUCOMA.THE operative treatment of glaucoma has for many

years been debatable ground for ophthalmic surgeons.The object of all operations is to provide a freer exitfor the intra-ocular fluid and so bring down the intra-ocular tension. The classical operation of iridectomyattempts to do this by opening up the angle of theanterior chamber and so providing an easier access tothe lymph channel known as Schlemm’s canal, whichlies near the junction of cornea and sclerotic. It wasvery soon recognised, however, that only in acutecases and in those chronic cases where the angle of theanterior chamber was not much altered by the growthof fibrous tissue, was this operation very successful,and, further, it was noticed that in many cases wherethe operation was faultily performed from the surgicalpoint of view, leaving a tag of iris entangled in the scar,the result in stopping the glaucomatous process wasfar better than in other cases where no fault could befound with the surgical technique. The reason wasfound to be that in the operation where the iris wasentangled the scar became permeable, and thedrainage, which was insufficient through Schlemm’scanal, was supplemented by drainage into the sub-conjunctival space. Unfortunately, this method ofobtaining drainage-by unprotected iris prolapse-was by no means a safe one, for it afforded a possiblechannel for septic infection and was even sometimesfollowed by sympathetic irido-cyclitis. Hence it hascome about that many minds have been turned to theproblem of how to afford a safe passage for the intra-ocular fluid into the subconjunctival space. Theearliest attempt was a simple incision through thesclera, an operation which had its vogue for manyyears, but the scar that follows is in most cases onlytemporarily permeable, and this operation is nowseldom performed. Colonel H. Herbert was one of thepioneers of more efficient procedures, and in a recentlypublished volume’ he describes two of his earliermethods, each of which is still practised by some ofhis followers. These are the " wedge isolation "

operation and the " small-flap sclerotomy " ; thelatter was very popular a few years ago and is stillalmost exclusively practised by some surgeons.Colonel Herbert himself, however, has made what beconsiders an important advance by his presentoperation, in which a tag of iris is deliberately includedin a scleral scar, the whole operation being performedsubconjunctivally. This operation has now been advo-cated by him for a good many years and has broughthim into sharp conflict with the advocates of themore generally performed operation devised by ColonelR. H. Elliot, sclero-corneal trephining. " Deliberateiris-inclusion," he says, " has never made the leastheadway in this country ; ; it has hardly made a

1 The Operative Treatment of Glaucoma. By H. Herbert,F.R.C.S. Eng., Lieut.-Colonel, Indian Medical Service (retd.):Consulting Surgeon to the Nottingham and Midland EyeInfirmary, &c. London: Bailli&egrave;re, Tindall, and Cox. 1923.Pp. 152. 10s. 6d.

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beginning. This is due to a series of misapprehensions."To dispel these misapprehensions is the main object ofhis book. The fact that an unprotected prolapse ofthe iris is dangerous is, in his view, no argumentthat a protected one is so. There is no doubt, he says, ’that this question of effective conjunctival covering ’’iis the main one. That early infective danger is a graveobjection he admits, but only in the absence of thenecessary precautionary measures. On the otherhand, this form of treatment is definitely put forwardas the most promising means of abolishing lateinfection in the higher-grade glaucomas. It is truethat a certain number of surgeons of late years haveabandoned the operation of trephining on this veryground of the danger of late infection. It will beenough here to indicate that arguments in favour of arival procedure can be found in this book. In Colonel IHerbert’s view a conjunctival fistula such as is

provided by the trephining operation is dangerous if ’,it causes a localised conjunctival bleb over thetrephine hole. In his own operation his aim is toavoid all trace of conjunctival vesiculation. ColonelHerbert’s operation has already given rise to a gooddeal of debate and is not likely to be generally adopted ’,without further controversy. It is at any rate a gainthat his views should be made easily accessible toall who desire either to test or to criticise theirsoundness.

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RINDERPEST IN INDIA.

CATTLE plague has frequently decimated herds inIndia to the extent of 40 per cent. Mr. W. A. Pooland Mr. T. M. Doyle, veterinary surgeons, of theImperial Bacteriological Laboratory, Muktesar, havebeen studying means of prevention ; for over 20years the method of inoculation with serum alonehas been used, answering its purpose fairly well,but falling far short of real efficiency, and theseinvestigators have been testing the efficacy of whatis known as the " serum simultaneous " method,which consists of subcutaneous injection of a smallamount of virulent cattle plague blood on one sideof the animal and on the other a suitable dose of anti-serum. Over 450,000 cattle have been inoculatedby this method, and the mortality-rate from allcauses has only been 0-98 per cent. It has beenfound that cattle were immune for long periods, upto a year and even six years after inoculation. The Ieconomic aspect of outbreaks of rinderpest is serious ; ’’

abortions and deaths of cows arise, and the losses ofmilk-supply and dislocation of agricultural opera-tions at critical seasons are considerable. In Indiamethods for the control of disease must be made aspopular as possible, especially where cattle are con-

cerned. In reporting their work Mr. Pool and Mr. Doyleconsider that sufficient experience has now beengained to warrant a start with the simultaneous methodon a small scale in each province, and suggest thatcompensation should be paid to the owners of animalsthat die as a result of the inoculation.

MULTIPLE PEPTIC ULCERS.

IN a paper read before the annual meeting of theRadiological Society of North America Dr. Miller M.Portis and Dr. Sidney A. Portis,2 of Chicago, whoreport two illustrative cases, state that before theintroduction of X rays the diagnosis of more thanone peptic ulcer occurring at the same time was madeonly in the operation room or in the dead-house,whereas at present this diagnosis can be made withaccuracy before operation. The following statisticsgiven by various pathologists and clinicians are

quoted, relating to the frequency of multiple pepticulcers. Rokitansky found that among his 79 cases ofgastric ulcer no fewer than 17, or about 20 per cent.,showed two or more open ulcers post mortem. In a

1 Memoirs of the Department of Agriculture in India : Studiesin Rinderpest. By W. A. Pool and T. M. Doyle, AgriculturaResearch Institute, Pusa.

2 Journal of Radiology,May, 1923.

series of 638 cases of gastric ulcer at the Mayo Clinic28, or 4! per cent., had more than one ulcer present.Fenwick, in an analysis of 867 post-mortem records ofgastric ulcer, found that one ulcer was present in80-5 per cent., two in 12-1 per cent., three in 3’1per cent., and four or more in 4-2 per cent. Accordingto Fenwick, chronic gastric ulcer is multiple in 13per cent. of all cases, while acute ulcer is multiple in50 per cent. On the other hand, Goldschmid, in areview of 1300 autopsies at Frankfort, among whichthere were 25 gastric and 21 duodenal ulcers, did notobserve a single case with more than one ulcer present.In rare instances an excessive number of gastric ulcersis found&mdash;e.g., 60 (Hewitt), 34 (Osler)-or they mayeven be too numerous to count (Lange). Such cases areusually associated with septic infection or secondarysyphilis. Duodenal ulcer, though usually solitarylike gastric ulcer, may be multiple. Carman reportedthat among 139 cases of gastric ulcer, and 490 ofduodenal ulcer, operated on in the Mayo Clinic in 1916an ulcer was found both in the duodenum and stomachin 16 instances. The histology of multiple pepticulcers resembles that of the single gastric or duodenalulcer. The first of the two cases reported by thepresent writers occurred in a woman aged 54, who hadbeen suffering from gastric trouble for years, withacute symptoms of eight weeks’ duration. X raysshowed two penetrating ulcers in the lesser curvature,and their presence was confirmed at the operation,when they were resected and the stomach anastomosedto the jejunum. The gall-bladder, which was full ofstones, was removed at the same time. The patientmade a good recovery. In the second case, whichoccurred in a woman aged 43, the X rays showed twoulcers on the lesser curvature and some deformity ofthe duodenal bulb. Posterior followed by anteriorgastro-enterostomy was performed with some relief ofthe symptoms.

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ATTACKS ON ALIENISTS BY THE INSANE.

ON March 6th last Dr. K. 0. Olander, the distin-guished Swedish alienist, was assassinated outside hishouse in Stockholm by an insane patient, who emptiedhis revolver into Dr. Olander’s chest, killing himinstantly. Taken by itself, this incident was notparticularly extraordinary, and it was certainly notunique. As Prof. Laehr has shown in his work" Gedenktage der Psychiatrie," the toll taken by theinsane from the medical profession runs into hundreds,and the risk of assassination taken by the medicalprofession in general, and alienists in particular, is onewith which every educated person is familiar. Butthere were certain attendant circumstances in the caseof Dr. Olander’s assassination which merit comment.Some years ago Dr. Olander and a colleague wererequested to investigate the mental state of a bankerwho had accused two banks of nefarious actions, andwho was a notoriously refractory and dangerous person.Dr. Olander and his colleague, Dr. Bilstrom, wereconcealed in a room in which this patient and anotherbanker had a conversation, and on the strength of whatthe alienists heard the suspect banker was certifiedas insane. It transpired that he carried a loadedrevolver, and that it would have been impossible toinvestigate his mental condition by more directmethods. The procedure adopted in this case was,however, censured by the medical authorities, and,most unfortunately, this censure was published in thelay press a few days before Dr. Olander’s assassina-tion. The inquiry which followed it showed that themurderer had read this censure. Naturally thesecircumstances have raised a storm of protest from theSwedish medical profession, and the fact that theofficial censure of Dr. Olander’s action was not intendedby the medical authorities for publication in the laypress has only partially exonerated them from blame.Dr. Olander’s many medical friends are collecting afund, the proceeds of which will first be devoted to theeducation of his two children and will later be devotedto some permanent memorial. So much for the moreor less personal aspect of this case. It has, however,