978 SUBACUTE INFECTIVE ENDOCARDITIS.

degree of accuracy except the possible demand ; butthat is the crux of the problem, and it can onlybe satisfactorily solved by experiment on a largescale.

Faced with the problem of how to provide as muchof a desired benefit as possible, the Commissionersnaturally showed a tendency to explore what appearedto be attractive avenues of economical administra-tion, and the relative merits of " panel " and

" clinic "

service took up no little time when the dental wit-nesses attended. Here a number of the dental witnessesshowed to some disadvantage. The interests of thedental profession are undoubtedly necessary con-

siderations, but if no more potent arguments againstthe establishment of whole-time dental clinics can beadduced, it is to be feared that the public interestmust prevail. On the other hand, undue emphasisshould not be laid on the success of such clinicswhere they are obviously the most suitable meanswhich can be employed, as, for example, in thedental treatment of elementary school-children or

in similar treatment at maternity and child welfarecentres. These are special cases which have nothingnecessarily in common with the dental treatment ofadults as part of an insurance scheme. The feelingof the dental profession is at present opposed to thesetting up of whole-time dental clinics. There is nocertain knowledge that they would provide moreefficient or economical dental treatment for theindustrial classes than the 10,000 private practi-tioners who are able and willing to give it andwho have voluntarily organised themselves for thepurpose. Clinics cannot be a success unless they areestablished with the hearty support of the dentalprofession, and common sense appears to favour acontinuance of the panel system in dentistry as inmedicine in the immediate future. The methods ofcontrol at present applied to medical benefit couldbe easily duplicated or modified to suit the require-ments of dental benefit. On the whole it would seemfrom a dispassionate review of the evidence givenbefore the Commission that it would be a matter oflegitimate surprise and regret should there not emergein the report of the Commission a strong recommenda-tion for the early institution of a definite measure ofdental treatment as a statutory benefit under anamended Act. Without imposing further contribu-tions on the already heavily burdened employeror employee this would soon effect such a reduc-tion of the cost of sickness benefit as to liberatefunds for the completion of the scheme.

SUBACUTE INFECTIVE ENDOCARDITIS.NOT much was heard of subacute infective endo-

carditis till the latter part of the war and since. Itwas known as something of a rarity, but its symptomswere not understood and its differentiation from othersimilar conditions was not clear. Since the war ithas become a commonplace and many observers havedescribed and attempted to explain it. This increasingprevalence might be due either to more acute diagnosisor to the fact that very large numbers of men weresifted through more or less efficient filters or to someactual aetiological relation between war conditions andthe disease. This last alternative seems to receivemost support, and the apparently marked decline inthe prevalence of the disorder during the last twoyears is giving another reason for believing that thewar had a large share in causing it. The conditionappears to be essentially a chronic bacterial poisoning,and its fatality is due at least as much to this as

to the mechanical interference with the circulationproduced by the valvular lesion. Its fatality, too, isextraordinarily high ; with a few doubtful exceptionsevery case which has been definitely diagnosed hasdied within a period between a few months and twoor three years. An inevitably fatal issue is extremelyrare in parasitic diseases, and its occurrence in subacuteinfective endocarditis may mean only that diagnosishas not yet advanced beyond the point of being ableto recognise the beginning of the end. No form oftreatment has proved of any value. Any new infor-mation about it is therefore welcome, and there ismuch of interest in a paper on some of its bacterio-

logical aspects in the current number of the Journalof Pathology and Bacteriology by Dr. H. D. WRIGHT,who has worked at it at University College Hospitalin conjunction with Sir TiiOMAS LEWis and his

colleagues in the cardiographic clinic, where theclinical aspects have been thoroughly investigated.

It has puzzled many people that it should be sodifficult to isolate organisms from the blood in acondition which is so obviously symptomatically amild septicaemia, especially as the heart valves arethe chief-indeed the only known-focus of the non-haemolytic streptococci which are always obtained ifanything is. The proportion of positive blood cultureshas varied widely with different observers. In America

it has been 70 per cent. or more, though LIBMAN hasnoted that they are not so easy to get now as they usedto be. In Germany some workers report positivecultures in almost every case, while another group getfigures round about 30 per cent., which is similarto the English experience. Dr. WRIGHT addresseshimself particularly to the obvious proposition thatnegative results are due to imperfect technique. He

points out that repeated examinations of the samecase practically always give the same result, eitherpositive or negative, and that there is no difficultyin isolating streptococci over and over again from ablood in which they occur in very small numbers.He adds to this a variety of experiments on media andmethods, and comes definitely to the conclusion thatthe failure of a reasonably competent worker to isolatethe cocci means that they are not there. Turning tothe question of how and where the organisms live inthe body, he points out that one is here confrontedwith very serious technical difficulties. Patients dyingfrom a subacute endocarditis may suffer from a

terminal invasion by other organisms, and if this doesnot occur during life a general spread of non-haemolyticstreptococci through the blood occurs so commonlyafter death that it is impossible with ordinary post-mortem material to get any certain and satisfactoryinformation about the distribution of the causativeorganisms in the various tissues and organs. Thecocci obtained from the blood during life, and towhich the patients produce antibodies, are not

demonstrably different from those which may befound in the blood post mortem in about a thirdof random autopsies. And it follows from thisthat agonal and post-mortem cultures are quiteunreliable.How this obstacle is to be surmounted is not at all

clear; till it is we must remain in ignorance ofwhether the valves are really the main location ofthe cocci or whether they live somewhere else withoutproducing recognisable anatomical lesions. Histo-logically, cocci can be readily stained and seen in thevalvular lesions in cases where blood cultures have been

positive. Where they have been negative cocci aresometimes easily found microscopically, but generallya finely granular material is alone present whichmight well pass for degenerated organisms or their

979CAMERON PRIZE LECTURES.-HEALTH OF THE NAVY.

dead remains, and is so interpreted by Dr. WRiGHT.His careful observations by no means solve the problemof the disease, but they help considerably to define it.Clinically it appears to make little difference whethera case shows septicaemia or not, though a good dealof fever is more often associated with a positive bloodculture than not. The cocci seem to live in the recessesof the fibrosing thrombi on the heart valves whencesomething or somethings emerge which stimulate theproduction of specific antibodies and kill the patient.MAIR has produced an apparently analogous statein rabbits with pneumococci, and it is perhaps alongexperimental lines that the solution is to be expected.Meanwhile, it is satisfactory to note a diminution inthe prevalence of a disease in which therapy is helpless.

THE CAMERON PRIZE LECTURES.THE third of the Cameron Prize Lectures is pub-

lished in our columns to-day, completing an interestingseries dealing with various conditions in relation tobrain surgery. The lectures were prefaced on theirdelivery by a brief statement from the orator, Prof.HARVEY CUSHING, in which he pointed out that every-day symptomatic treatment of patients was, at leastin the American medical schools, neglected in thecurriculum, the expansion of scientific methods havingsomewhat crowded the art of medicine to the back ofthe stage. Prof. CUSHING acknowledged the fascina-tion of modern laboratory procedures for both theteacher and the taught; they lead to diagnosis andindicate treatment along the right lines of progression,but for many of the pathological conditions thusexactly discovered there is as yet no specific remedy,and we shall all agree with him in his suggestion that" more emphasis is laid in our schools on the methods

of finding out what is wrong than on what shouldbe done for it when it happens to be found." Thiswas, presumably, the exact frame of mind whichDr. ANDREW ROBERTSON CAMERON, of Richmond,New South Wales, was displaying when he foundedthe Cameron Prize in 1878 with a bequest of 22000to the University of Edinburgh for certain specifiedpurposes. We know little beyond what Prof. CUSHINGwas able to tell us of CAMERON himself. The son ofa Tarland farmer, he began his medical studies atMarischal College, Aberdeen, migrating in 1859 to Edin-burgh, where for his graduation thesis in 1861 he tookthe subject of " the corporeal sympathies of certainmental conditions "—a remarkably modern theme inall its relations. He went to Australia to practise hisprofession and died there some fifteen years later.Prof. CUSHING imagines that, pitch-forked into a newcountry and unable to fall back upon consultantadvice for therapeutic suggestions, he determinedthat practical therapeutics should be emphasised atEdinburgh so far as an endowed lectureship couldbring this about, and the object he had in view wasas shrewd a look into the future as was the subjecthe chose for his graduation thesis. For more than

ever the young man who goes out to practise, versedin the lore of modern medical science and perhapsconsiderably expert in the advanced work of thelaboratory, is at a loss when confronted with thesick. The regulations governing the award of theprize were remodelled by the Educational Endowments(Scotland) Commission, with the result that theproceeds of CAMERON’s bequest are now awardedannually to a selected person who in the course ofthe five years immediately preceding has made anyhighly important addition to practical therapeutics,and the Senatus of the University is entitled to request,as a condition precedent, that the chosen prizemanshould deliver a lecture or course of lectures givingan account of his particular contribution to thepractical side of medicine. Prof. CUSHING decidedto give an account of the recent developments ofcerebral surgery in different directions, and dedicated

his lectures to a long list of his collaborators, includingthose successively appointed at the Johns HopkinsMedical School, Baltimore, and the Arthur TraceyCabot Fellows since 1912 whose function it is to takecharge of the Research Laboratory at Harvard. Tothis group he added his resident assistants both inBaltimore and Boston, making an important categoryof men who have contributed greatly to the progressof neurology and surgery, and in associating theirnames with his lectures he insisted modestly that hisown position as a Cameron Prizeman was due toa generous stretching of the conditions in his favour,his activities having been mainly in the directionof the teaching from which the notable contributionsof his pupils was derived. But no such apologeticwords were necessary for, apart from the value ofProf. CUSHING’S personal work, his centrifugalinfluence as a teacher has been and is of supremeimportance. The name of CUSHING rightly finds aplace in the list of Cameron Prizemen, which includesPASTEUR and LISTER, FERRIER and HORSLEY, DAVIDBRUCE, MANSON and ROSS, FINSEN, BIER, EHRLICH,FLEXNER, and many other pioneers of medicine.

THE HEALTH OF THE NAVY.FOR 85 years the Admiralty published an uninter-

rupted series of annual reports on the health of theNavy. The sequence was concluded in 1922 by thebelated issue of a report for 1915, and it was thendecided to allow the intervening years 1916-1’920 togo by the board and to begin a new series of statisticswith the report for 1921. The figures for that yearhave already been summarised in THE LANCET,! andin the table on p. 987 of this issue they are comparedwitb those for 1922, which are now available. Theresult is interesting. It would, of course, be rashto base much argument on the differences betweentwo consecutive years, but for what they are worththe figures are encouraging. In 1922 deaths andaccidents diminished in number ; fewer men wereinvalided out of the service, and the daily sick-listwas smaller. The total naval establishment fell fromabout 116,000 in 1921 to a little more than 100,000in 1922. About half was allotted to the Home Stationand a quarter each to the Atlantic Fleet and thefleets abroad. The death-rate was 4-4 per 1000 inthe fleets abroad and 2-7 on the Home Station, andthe most fatal single disease was tuberculosis, fromwhich there were 36 deaths.The incidence of tuberculosis for the Atlantic

Fleet was 2 -2 per 1000, and it is interesting to note thatwhilst marines at headquarters had a liability of1’16 per 1000, the figure for those at sea was 157 ;the sick-berth staff had a liability of 3-18 per 1000,which represented an improvement. In generalit is remarkable that the amount of tubercle in apopulation of young strong men, well clothed, wellfed, and well housed, should remain the same in spiteof every effort. The naval figures for venereal diseaseare particularly useful for they distinguish firstinfections from others. In this report they reflectthe general diminution in syphilis without corre-

sponding decrease in gonorrhoea. The fact that thenumbers of fresh gonococcal infections per 1000were respectively 60, 85, and 46 in the Atlantic Fleets,the fleets abroad, and amongst the men on theHome Station, suggests that the vaunted prophylacticmethods in use in the Navy are not really effective.In the opinion of the medical officers the victims areapt to be intoxicated and too careless to use them.At any rate, these figures are very high. During 1922,178 men were discharged on account of gonorrhoeaand there seem to be some grounds for the opinionrecently expressed by a correspondent in our columns 2that the civil authorities should take steps to preventuncured cases returning without restriction to civillife.

1 THE LANCET, 1924, i., 1227.2 THE LANCET, Sept. 26th, p. 673.