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develop whenever a lung is collapsed for too long aperiod. It has been remarked that any fool can curean acute empyema, but to induce the re-expansion ofa collapsed lung may tax the resources of the mostexperienced. Sometimes the thickened pleura thatprevents re-expansion may be removed by a decorti-cation operation, but this will have no effect on thesecondary pulmonary fibrosis which may have resulted.As Dr. Coquelet 1 rightly maintains, the chief cause ofchronic empyema is prolonged pulmonary collapse, anda wide openiag into the pleura may go far to discouragere-expansion of the lung. Coquelet would try to getover these difficulties by emploving closed drainage inevery case of empyema treated under conditionswhich allow continuous supervision and after-care.This proviso is necessary, for continuous drainagedemands special experience on the part of the

practitioner as well as skilled nursing. He maintains,however, that when these conditions are fulfilled themethod of closed drainage with pleural lavage andbreathing exercises in its later stages reduces mortality,prevents chronic empyema, permits the slow evacua-tion of pus without shock or mediastinal displacement,and shortens the period of illness. Hence he holdsthat closed drainage should be the rule, whether as ameasure of emergency in syn-pneumonic, or as a

means of cure in meta-pneumonic, empyema due toinfective organisms. His technique and the methodshe uses are fully described in a paper that will repaya careful studv.

THE DOCTOR IN OTHER SPHERES

THE examination of the achievements of medicalmen in other directions than in the practice ofmedicine has long been a favourite pursuit of theRegius professor of medicine in the University ofGlasgow, and he has now epitomised the labour ofmany years.2 Prof. Monro has evidently searched theavailable sources of information, from the Dictionaryof National Biography downwards, with great careand has spared no pains to get further information,with the result that he is able to present our professionwith a valuable record of its members who have wondistinction in other spheres. He includes within hispurview the doings of men who became medicalstudents, but failed to qualify, as well as of those whowere members of another profession before taking upmedicine. The field surveyed covers not only thechurch and the law, but scholars, soldiers, adminis-trators, explorers, inventors, musicians, and even thosewho have distinguished themselves as pirates andcriminals. Although the persons dealt with are

chiefly British subjects, Dr. Monro takes note also ofthe achievements outside their profession by Americanand foreign medical men. As regards the church,according to one authority there are as many as40 canonised saints, as well as three popes, who aresaid to have been physicians. The list also includesseveral bishops ; the most versatile of these was FrancisMcDougall a colonial bishop, an Oxford rowing blue,an F.R.C.S. who further distinguished himself by hisskill in shooting with a double-barrelled breachloaderwhen a ship on which he was a passenger was attackedby a superior force of Chinese pirates. Many will agreewith Prof. Monro that John Keats, who passed withcredit as L.S.A. in 1816, is the greatest British medicalpoet; others will favour Robert Bridges, or OliverGoldsmith " the most beloved of English writers "to whom Oxford University appears to have grantedan ad eundem degree of M.B. in 1769, because he was

1 Arch. méd.-chir. de l’app. respir., 1933, viii., 289.2 The Physician as Man of Letters, Science, and Action. By

Thomas Kirkpatrick Monro, M.A., M.D. Glasgow: Jackson,Wylie and Co. 1933. Pp. 212. 10s. 6d.

already a medical graduate of Dublin. It is not

generally known that Auenbrugger’s treatise on

percussion of the chest, issued in 1761, was madeknown in England by a review published by Goldsmithin the same year. Of minor poets, medicine appearsto have supplied a very large number ; the best knownare probably Abraham Cowley and George Crabbe.Among the novelists and writers we learn that TobiasSmollett was an M.D. of Aberdeen, and Samuel Smilesa medical graduate of Edinburgh. In the list ofdiscoverers and inventors it is of interest to note thatthe first diamond at Kimberley was identified in1867 by Dr. W. G. Atherstone, who examined it witha polariscope and tested its hardness on a window.The diamond thus identified sold subsequently for800. Timothy Bright, who invented modern short-hand and died in 1615, was a medical graduate ofCambridge. Henry Faulds, the inventor of the

fingerprint method of identification, qualified at

Glasgow in 1871, and published his fingerprintmethod of identification in Nature in 1880, thus

obtaining priority over Bertillon who described asomewhat different and less valuable procedure in1881. Another medical inventor who has not receivedhis due credit is Charles Morrison, who in 1753 whenin practice at Renfrew successfully demonstrated thatmessages could be conveyed by the passage of anelectric current along insulated wires. Of medical

pirates no less than a dozen are cited by Dr. Monro,the greatest of them being Thomas Dover.

SHORT-WAVE DIATHERMY IN EXPERIMENTALSYPHILIS

A FORTNIGHT ago a correspondent in our columnsreferred to good results obtained in treating syphilisby short-wave diathermy which induces pyrexia.C. Levaditi and H. de Rothschild have tried thismethod in the treatment of Treponema palliduminfection in mice and rabbits and are not enthusiastic.The wave-length used was 22 metres, and the fre-quency about 15,000,000 cycles a second. The resultslead them to suppose that when the current doeshave a therapeutic effect it does not kill the parasitemerely by raising it to a temperature incompatiblewith life. On the whle its value was not equal tothat of bismuth, organic arsenic compounds, or evenmercury, and it seemed to have no appreciableadjuvant effect in conjunction with liposolublebismuth compounds. No matter how many applica-tions were given, the parasites contained in theresidual chancre were unharmed. When appliedduring the period of incubation short-wave diathermyprevented the development of the disease in 50 or60 per cent. of animals, or at any rate modified itto an occult form. It appeared also to have a favour-able influence on the humoral reactions, though sero.logical relapse was sometimes noted even when thechancre had apparently healed and the peripherallymphatic ganglia were free from the parasite. Itwas also noted that it seemed to be more efficaciousin long-standing syphilis than when the disease hadbeen freshly introduced under the skin. The remedywas tried not only in experimental syphilis but alsoin spirochsetosis of rats and mice, toxoplasmosis inrabbits, and trypanosomiasis, lymphogranulomatosis,and other diseases in mice. Summing up their

experiences, Levaditi and de Rothschild maintainthat short-wave diathermy has a definite therapeuticaction in certain infective processes, either bringingabout a cure or transforming an acute condition intoa chronic one ; it is of no use, however, in the acuteand quickly fatal infections produced by spirillse,

1 Ann. de l’Inst. Pasteur, 1934, lii., 23.

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trypanosomes, and ultra-microscopic viruses. Its cura-tive and preventive action in established syphilis seemsto them to be beyond doubt, but is unfortunately farfrom constant. Like other forms of thermotherapy,perhaps, it does not act directly on the infectiveagent but indirectly by stimulating the infectedorganism. They hold that it cannot be yet con-

sidered a competitor with the metallic compounds.

EPIPHYSEAL INJURIES OF THE LONG BONES

INJURIES to the epiphyses of the long bones aregenerally viewed with apprehension ; the possibilityof interference with the growth of a limb looms largein the surgeon’s mind. It is encouraging thereforeto find that Dr. Ernst Bergenfeldt, after an extensivestudy of epiphyseal lesions at the Maria Krankenhausin Stockholm, does not think this complication is

greatly to be feared. Altogether 310 epiphysealinjuries, in 295 patients, were studied. The patientswere under treatment, either as in-patients or as

out-patients, during the years 1919-1928, and mostof the cases were followed for several years ; onlyseven, indeed, were entirely lost sight of. Radio-

graphic records are available of the end-results, andmany of these are reproduced by Bergenfeldt in hismonograph.l The immediate prognosis seems to bevery good. Union and consolidation of the fracturedends and functional results were satisfactorv in allbut four cases (1-3 per cent.), in three of which therewas shortening of the injured bone. Subsequentshortening, due to interference with growth, developedin 5 per cent. of cases ; no case of stimulation of

growth was found. Very considerable degrees of

epiphyseal displacement were observed to be com-patible with perfectly good results--a conclusionwhich has also been reached by E. L. Eliason andL. K. Ferguson,2 of the University of Pennsylvania.The latter found that partial reposition of a singleepiphysis was followed by normal growth and thatdeformity was not apparent finally. Because of thecomplicated form of its joint surfaces, accuratereduction is of great importance, however, in thecase of the epiphysis at the lower end of the humerus.Where growth is definitely inhibited the most

probable cause is a direct lesion of the actively pro-liferating cartilage itself, though in compoundinjuries sepsis may be a factor. From the evidenceof animal experiments, methods of fixation of juxta-epiphyseal fractures or of dislocation of epiphyseswhich involve transfixing the epiphyseal cartilage,have been suspect. Bergenfeldt believes that the

danger to the growth cartilage involved in such

operations has been exaggerated. He points out,that, on the one hand, the cartilage is much moreresistent to injury in man than in animals, and, onthe other, that in the experimental animals employedthe period of growth is relatively short and rapid,so that injury to the epiphysis has a relatively greatereffect. He thinks that if care is exercised to causethe minimum of damage to the cartilage, it may betransfixed without undue risk. Of 24 cases withperforation of the epiphyseal cartilage only two hadsubsequent shortening.

Epiphyseal lesions at the upper end of the femur,of the type that give rise to coxa vara, have not beenincluded in Bergenfeldt’s monograph, because hehas formed the definite opinion that trauma plays avery minor part in their causation. In this parti-cular he distinguishes them from all other epiphysealinjuries, for in all other cases (with four tentative

1 Beitrag zur Kenntnis der traumatischen Epiphysenlösungenan den langen Röhrenknochen der Extremitäten. Acta. chir.Scand., 1933, vol. lxxiii., suppl. xxviii.

2 Surg., Gyn., and Obst., January, 1934, p. 85.

exceptions) the cause is held to be definitely trau-matic, without any concomitant pathological changein the bone. It is interesting to note that the lowerradial epiphysis has suffered much more commonlythan any other site. In Eliason’s and Ferguson’s.series of 110 cases, 48 were lesions of the lower radial

epiphysis. In Bergenfeldt’s series it was separatedin 137 cases, with the lower humeral epiphysis second(70 cases), and the lower end of the tibia third (44).Boys suffer much oftener than girls, the figuresbeing 232 and 63 respectively, and the injury isfound most often between the ages of 10 and 17.Pure epiphyseal separation, without fracture ofeither diaphysis or of epiphysis, is a lesion of veryearly childhood. In half the cases the separation ofthe epiphysis was combined with a fracture of thediaphysis, but in only 6 per cent. with a fractureof the epiphysis. The worst prognosis seems to bein the cases (about 4 per cent. in this series) withepiphyseal injury accompanied by fracture of both

diaphysis and epiphysis. A third of these showedultimate shortening.

TOBACCO AS AN OCCUPATIONAL RISK

THE International Labour Office, in the latestnumber of its encyclopaedic

"

Occupation and Health,"publishes an article on the effects of tobacco on thosewho manufacture it. Mild tobacco contains 1 to 2 percent. of nicotine and strong tobacco 6 to 10 per cent.The poisonous substances include several alliedalkaloids besides nicotine. Tobacco cultivators neversuffer from poisoning, because nicotine is onlylibera,ted during fermentation. During the process ofsorting, workers inhale the dust ; during the fermen-tation they breathe injurious fumes, and in themanufacture they come into contact with the wetleaf. The local action on the skin and mucousmembranes is an irritation. The consensus of opinionsuggests that tobacco workers do not suffer morefrom tuberculosis or other diseases than workers in

any other trade. They do not seem to suffer frompneumoconiosis, and there is no conclusive evidencethat women workers miscarry more frequently orthat their children are below the average of health.Natural fermentation does not usually contaminatethe air sufficiently to affect the health of the workers,but artificial fermentation has been shown to producea higher sickness-rate among the workers engaged onit than that recorded among workers on the slowprocess. The symptoms are those of typical nicotinepoisoning. Beginners often suffer from an acuteform of poisoning, with cerebral congestion, nervoussymptoms, precordial pains, and intestinal disorders.Dermatitis has been described, generally on the backsof the hands, and an allergic condition can beestablished. The nails may be damaged ; the free

edge of the nail becomes thin, the nail comes off, andthe dust causes a painful hyperkeratosis. Someauthorities say that most workers suffer from soregums and mouth. The workshop should, accordingto this article, be maintained under the best possiblehygienic conditions and all possible dust should beremoved. Contact with tobacco in any form shouldbe limited as far as possible, especially in drying,stemming, maturing cigars, and manufacturing snuff.The fermentation premises should be separate andwomen and young persons should be excluded. Thehealth of the women should be carefully watched, andpregnant women should leave work some weeks beforeconfinement and not return for four or six weeksafterwards. Some French and Italian factories havefound creches extremely useful. Many countriesforbid the employment of children altogether, and-