83

an inefficient kidney on the opposite side. Of the34 patients operated upon, uretero-lithotomy wasperformed in 22, nephrectomy in 10, and ureterectomyin 2, with one fatal result occurring in a haemophilicwho had a uretero’-nephrectomy. The cystoscopicmanipulations were simple ureteral catherisation,dilatation by multiple catheters or a Garceau catheter,ureteral meatotomy, ureteral anaesthesia, and theinjection of oil; but Smith doubts the efficacy of thelast two methods, and he did not use them in thesecond 100 cases. In 38 cases the ureteral orifice

required division by scissors or fulguration which wascarried out without any troublesome haemorrhage.In 79 cases the condition was relieved by the firstdilatation, in 36 by the second dilatation, and in 9by the third. If multiple catheters are insertedand then twisted round several times, the calculusoccasionally comes with them on withdrawal ; thisis a method similar to one sometimes used in theremoval of a urethral stone. In the after-treatmentwhat is of most importance is the relief of any obstruc-tion in the urinary tract and the administration oflarge quantities of fluid.

ŒDEMA OF THE LARYNX

(EDEMA of the larynx, though fortunatelyuncommon, is a very serious and important affection,for it may come on suddenly and cause death byasphyxia with great rapidity. The swelling, ofcourse, occurs most in those regions where the sub-mucous tissue is lax, on the arytenoids, ary-epiglotticfolds, epiglottis, and in the subglottic region. Thelatter is the situation in which it most readily causesdyspncea ; it cannot affect the firm structure of thevocal cords to any great extent, and the old term" cedema of the glottis " is therefore a misnomer.(Edema of these regions may be produced by a greatvariety of causes, and these may be grouped intoinflammatory and non-inflammatory. Of the inflam-

matory class, simple laryngitis hardly ever causessufficient cedema to produce dyspnoea in adults,though it may do so in children. The very severe

streptococcal invasion of the throat, known as septicpharyngo-laryngitis, may cause great cedema ; butit overwhelms the patient by togaemia more often thanit kills by suffocation. (Edema occurs as a complica-tion of the laryngitis of small-pox, scarlet fever,measles, enteric, and diphtheria, and as a result ofseptic infection of tuberculous, syphilitic, or cancerousulcers ; it also spreads to the upper aperture of thelarynx from such lesions in the neighbourhood asquinsy or any form of ulceration of the fauces andpharynx. Finally, cedema follows various kinds oftraumatism, surgical instrumentation, foreign bodies,scalds from steam and hot fluids, stings in thethroat by wasps or other insects, corrosive poisonsor irritating vapours, such as gases used in the war.Non-inflammatory oedema occasionally comes on

with great suddenness as a result of either acute orchronic nephritis, of which it may be the first symptomto attract attention. Angeioneurotic oedema of thelarynx is an important variety in this class, for itmay produce severe, and even fatal dyspnoea ; itcomes and goes with peculiar rapidity, and usuallyalternates with swellings in other regions. Thecause is often undiscovered, but in some people itresults from certain articles of diet such as lobsteror other shell-fish. A similar swelling may be causedby the administration of iodides in susceptibleindividuals, and is generally associated with othersymptoms of iodism. Many remedies are availablefor the treatment of the slighter cases, but the more

severe forms cause asphyxiation so rapidly that theonly hope is that a doctor can arrive in time to

open the trachea. A low or middle tracheotomy isadvisable, for a subglottic swelling may extend forsome distance down the trachea, but in the mosturgent cases the windpipe can be most quicklyopened through the crico-thyroid membrane.

VACCINATION IN THE ARMY

IT will be seen from the Parliamentary columns ofour issue of June llth that the Financial Secretaryfor the War Office was asked in the House why armyofficers had been instructed to discontinue the use ofboracic lint and of vaccination pads. The answer wasgiven that " The decision not to issue further suppliesof boracic lint and vaccination pads was made inthe interests of economy " ; the Minister adding thatboracic powder and plain lint were being issuedinstead. The way in which the question was askedseems to have led to wrong impressions as to thesignificance of the answer. The following is extractedfrom the Regulations for the Medical Services of theArmy, 1932 (Appendix No. 18, para. 11) :-

After vaccination the lymph must be allowed to drybefore application of the dressing which should be sterilegauze secured in position by a bandage or by zinc oxide-strapping applied above and below the vaccination area.The strapping must not be applied directly over the siteof vaccination. If unsuitable strapping is. used to secure-the dressing, urticarial or scarlatiniform rashes may beproduced.The boracic powder and plain lint are obviously

to be issued in substitution of boracic lint if requiredfor general purposes.

THE AMERICAN HOSPITAL SYSTEM

THE American Medical Association admits to)a hospital register only those institutions whichfulfil certain requirements.l Those seeking registra-tion must be " approved for interns and residenciesin specialities

"

by the Association, and approvaldepends on the following criteria : s (1) a supremegoverning body with an executive officer to carryout its policies ; (2) a staff of physicians who are" properly qualified as to training, licensure, andethical standing " ; reservation of staff membershipfor persons with an orthodox medical qualification ;.(3) a competent nursing staff employing an adequate-number of registered nurses ; (4) an adequate recordsystem; (5) pathological examination by a com-

petent pathologist of all tissues removed in theoperating room ; (6) ready access to radiologicalequipment and service ; (7) a staff and managementconforming to the principles of medical ethicsaccepted by the Association. The registration of

hospitals is carried on by the Council on MedicalEducation and Hospitals of the Association. Among.these registered hospitals only 691 are approved forinternships ; an interesting condition of approvalis an average of 15 per cent. autopsies on deaths inhospital. The average number of beds per internis now 42, the ideal ratio suggested being 25. To,have held a post as intern is naturally regarded asan essential part of the training of a physician plan-ning to specialise, but it is not suggested that suchexperience is held to be valueless unless gained ina hospital approved for this purpose. It may be

presumed, however, that an internship held in a

non-approved hospital might not be recognised as

adequate preliminary training for admission by a post-graduate medical school. The situation in Americadiffers from that found in this country in that the

1 Jour. Amer. Med. Assoc., June 11th, p. 2077.

84

vacancies for interns, which correspond to house

surgeons and physicians, far exceed the number ofgraduates annually available to fill them ; this yearthe 691 approved hospitals offered 6054 internships incompetition between 4735newly qualified practitioners.There appears to ba an increasing demand for certi-fication of specialists in America, and " residencies "in specialties to follow internship are regarded as adesirable preliminary to further training. Mosthospitals offer 12 months’ service under consultantsin the special subject to be studied, but in the leadingteaching hospitals the period is extended to three oreven five’ years.A development of the hospital service which was

started in November of last year is described in thesame issue of the journal by Dr. George Baehr.This is a diagnostic clinic for patients of moderatemeans which has been established in connexion withthe Mount Sinai Hospital, New York. Patients areaccepted only if referred by their physicians, and thework is limited to diagnosis. After investigation,the patient is referred back to his own doctor, whois given as complete a report as possible, togetherwith detailed advice on appropriate therapy. Thissounds like medicine made easy. A flat fee of$35is charged for all patients, without regard to thenumber of investigations required. This, it is said,has been purposely made about double the averagefee charged by a specialist for one consultation ora major laboratory examination, so as not toattract the patient who would otherwise normally goto an individual consultant. It is rather difficult tofollow the argument on which the fee is based. Its

advantage to the patient is that he knows in advancethe cost of diagnostic procedures, and to the doctorthat he need not limit his demands for investigationsout of consideration for his patient’s pocket ; butsince a conscientious doctor would only refer patientswho need several investigations, the service maynot be easy to provide without loss. At present, halfthe gross income is used to pay the medical staff,the other half goes towards non-professional expenses ;so far it has been run at a loss, but five months isnot long enough to judge the merits of the schemefrom the hospital’s point of view. It has theadvantage that many ambulatory cases which wouldpreviously have been admitted to hospital have beeninvestigated through the centre ; in this way cost tothe hospital and loss of time to the patient has beenavoided.

____

SECRETION OF MUCUS BY THE TRACHEA

THE two types of tracheal cells which secretemucus-the goblet cells of the mucosa and theacinar cells of the submucosa-are controlled bydifferent mechanisms, and these have lately beenstudied experimentally by Prof. H. Florey andcollaborators.1 In experiments on cats, the amountof secretion poured into the trachea was estimatedby means of an oil manometer connected to a lengthof the trachea which was itself filled with oil. Stimula-tion of the peripheral ends of both the vagus andthe recurrent laryngeal nerves produced a secretionwhich could be inhibited by atropine. In additiona reflex secretion could be produced by stimulatingthe central end of the vagus. After a pilocarpineinjection-which likewise is inhibited by atropine-there is a secretion which can be seen collecting indroplets on the surface.of the mucosa and this probablyindicates its origin from the submucous glands.

1 Brit. Jour. Exp. Path., June, 1932.

lucosal stimulation by chemical irritants calls forthnucus, but no evidence was obtained to show that’his was the result of a reflex. The drying effect onhe mucous membrane of a current of dried air wasshown to be much the same before and after atropinenjection, but there was an alteration in the character)f the fluid after the injection, and it appears to haveeen a transudate from blood-vessels rather than amucous secretion. The importance of mucus as avehicle for ridding the large air-passages of foreignbodies was well brought out in these experiments ;mall particles will adhere to the sticky mucus andbhis is constantly propelled by ciliary movementbowards the larynx, while a less sticky and thinnersecretion is not so effective in taking up the particles.Apparently the important function of mucus is toassist in the extrusion of foreign material, and it

might be expected that any chronic irritation of theair-passages would lead to its production in greaterquantity. Thus it is interesting to find that in casesof chronic bronchitis examined post mortem therewas a great increase in the number of goblet cells.In animal experiment it was found that a more

intense irritation of the trachea caused the columnarand goblet cells to be replaced by a stratified epitheliumsimilar to that of the urinary bladder.

CENTRES AND TIMES OF OSSIFICATION IN

DIFFERENT COUNTRIES

ONE of the inevitable consequences of the intro-duction of X rays as a laboratory aid was a change inthe accepted views on centres and times of ossification :the method which could give many and quick resultswas bound to supersede and correct the findings of theolder and more laborious anatomical investigations.A contribution on skeletal development from theradiological side by Dr. Ruckensteiner does not borethe reader with lists of variations or conglomerationsof cases, but gives the general average results of theauthor’s experience of the human skeleton; sexualand other differences are indicated, and also theoccasional varieties and accessory centres which maybe encountered. A special feature of the book is theintroduction of some large " curves " of ossificationtimes ; the reader who realises that these are curvesof time-periods, and not of progress of any particularossification, will find these graphic records stimulating.We would like to have seen sexual differences notedon the curves. There is no unanimity in this countryon the times of appearance of ossinc centres, but itis noteworthy that the statements which appear inour recent text-books differ considerably, especiallyin the limbs, from those set out by Dr. Ruckensteiner.It seems possible that this is the expression of a realdifference, racial or environmental. If such differencesexist, they afford an explanation for Dr. J. W. Pryor’sossification dates (Kentucky), which are earlier thanthose accepted as normal in Russia and Mid-Europe.It may be that the different dates found by observersworking in different parts of this country can bereferred in some way to environmental influence,which may also affect tables of dentition. It doesnot seem likely that any agreement on the " normal "and on the meaning of differences can be reacheduntil a concerted radiological and anatomical inquiryinto centres and times of ossification is made. Dr.Ruckensteiner’s records provide a useful pattern, and

1 Radiologische Praktika. Bd. XV. Die normale Entwicklungdes Knochensystems im Röntgenbild. By Dr. E. Ruckensteiner,Assistant in the Röntgen Institute of Vienna. Leipzig: GeorgThieme. 1931. Pp. 79. M.18.60.