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his responsibilities ? Even this exalted mandarin has hisfeelings, and would like as far as possible to be a consentingparty to his own mutilation.

I am, Sir, yours faithfully,EDWIN GOODALL.

City of Cardiff Mental Hospital, April 15th, 1912.

THE FORMATION OF LOCAL MEDICALCOMMITTEES.

To the Editor of THE LANCET.SIR,-Provisional Medical Committees have been formed

for the boroughs of Deptford, Greenwich, and Lewisham,which together form the Greenwich Division of the BritishMedical Association. At the first meeting of the LewishamProvisional Medical Committee, which was held on April 4th,as announced in your columns. Dr. C. T. T. Comber waselected chairman and Dr. Edgar Dn Cane appointedhonorary secretary. The following rules and regulationswere adopted :-

1. That the committee shall not have power to deal with mattersother than those pertaining to the National Insurance Act.

2. That the Council of the Metropolitan Counties Branch of theBritish Medical Association or a committee appointed by it for thepurpose be recognised as the coordinating centre, and that the com-mittee shall not enter into any dealings with the authorities underthe Act nor seek recognition from any such authority until it hasreceived the sanction of the Branch Council for so doing.

3. That the committee shall not apply for the sanction of theBranch Council for the purpose mentioned in Rule 2 until it shall havecalled a meeting of all medical practitioners resident in the boroughand obtained the sanction of that meeting for so doing.

4. That the committee shall keep the Branch Council fully informedas to its course of action and the results obtained in order that thevarious divisions may be brought as much as possible into line.

5. That the committee be compelled to call a meeting of all themedical practitioners in the borough within 14 days of the receipt of arequisition to that effect signed by at least 20 of the medical practi-tioners in the borough who shall give satisfactory security for theexpenses of that meeting.

6. That the committee be empowered to call at any time a meetingof all the medical practitioners resident in the borough.

7. That the committee be empowered to fill any vacancies that mayoccur upon the committee.

Subcommittees for (1) Blackheath and Lee, (2) Brockley,Forest Hill, and Sydenham, and (3) Catford and Lewishamwere appointed to organise the local profession and secureunited local action. It was decided to ask every medicalpractitioner in the borough to subscribe 5s. towardsthe expenses of the committee. A local guarantee wasdrawn up ’’ not to accept any work under the Act, nor anyother medical contract work at lower terms than those

acceptable to the committee and sanctioned by the BritishMedical Association."

I am, Sir, yours faithfully,EDGAR DU CANE, B.A., M.B.,

Honorary Secretary.

THE BED ISOLATION OF CASES OFINFECTIOUS DISEASE.

To tAe Editor of THE LANCET.

SIR,-I must thank Dr. F. G. Crookshank for his kindappreciation of the preventive work done at PlaistowHospital. My letter, I can assure him, was not intendedto raise the question of absolute priority as regardsbed isolation. That he applied and developed the methodsome years ago is well known, but as he himself remarks,Dr. Rundle and Dr. Barton have been able to do at

Fazakerley Hospital what he wishes he could have done; inother words, they have shown, with not much room fordoubt, that under given conditions the system is safe.

It did not seem to me that Dr. Crookshank was sneering atthe barrier. On the other hand, I felt that having hit on theterm ° symbolic he was making too much of its connota-tions. That this was the case is made plainer by his furtherexplanation, and I need only say that his theory of a

dwindling utility as applied to physical barriers in general isnot borne out by experience.

Dr. F. Thomson takes somewhat similar ground relative topartitions and asks a question. My statement that, admittinga standard of nursing short of the best, partitions are saferthan the barrier or bed isolation is based on comparativeresults obtained respectively with barrier and cellular

nursing at Plaistow Hospital. There is no theory to backthese results, which are empirical in so far as they differ,but none the less convincing on that account.The isolation block at Plaistow Hospital is built on the

cellular plan, small wards opening side by side on to acommon landing. Except that the landing is partly opento the air, there is no point of difference from glass cells, andas aerial convection can now be excluded as a factor in

cross-infection, except possibly in rare instances, this onepoint is immaterial. Varnished brick walls between thewards have no preventive virtue as against glass ones.

Nurses are not selected from the staff for the barrier andthe isolation block ; they differ in efficiency, and, as someare beginners, widely, of course, in experience. The sisters

keep to their divisions, but the other nurses are frequentlymoved, and while the barrier is in use throughout thehospital, at one time or another every nurse works in thecellular block. Further, the sister of this block is not chosenfor the quality of her preventive nursing, as other duties gowith the post. Daring the time in question six sisters, varying in capacity, have been in charge. The preventivemethods used for the barrier, again, are such that they canbe, and are, applied in every detail to cellular nursing.

So, the nursing being of the same quality and the methodsthe same, if different results are yielded by barrier andcellular work, this difference can only be attributed to onefactor : the infections dealt with in the isolation block are in

separate compartments. Such a difference does exist, and itis important to note that it has been consistently maintainedfor a period of ten years. When the barrier was in itsearliest stage, limited in scope and often unsuccessful, thecellular system did more, although not what it does now.Meanwhile preventive nursing has greatly improved, but isnot at its best, because there is no selection of nurses, and thepreventive chain is no stronger than its weakest links. To-

day, it is still unsafe to barrier scarlet fever, and

attempts to isolate measles through the developed stageby its means, or to control chicken-pox, do notsucceed. Yet this failure is on the part of the same nurseswho, in the cellular block, handle the common fevers,including chicken-pox, measles, and scarlet fever, with safetyand employ the same methods. There has been no instanceof cross-infection in the division for several years. Before a

systematic barrier was thought of the treatment of irregularinfections in side wards, in contrast with 11 unit " nursing inmain wards, where isolated cases were indicated by a redcard, foreshadowed this issue. Such diseases as ringwormaffecting scarlet fever patients, whooping-cough, and rubellacould easily be controlled in side wards, but there was alwaysa chance that they would spread in a main ward. The

evidence, therefore, that separation reduces the chance ofcross-infection, although the cases are nursed in common,and eliminates it in all the ordinary fevers (except small-pox,with which no tests have been made in this country) ifefficiency reaches a certain point, is overwhelming. Absolute

efficiency implies the safe isolation of these fevers withoutseparation, and it has been achieved by bed isolation.

I am, Sir, yours faithfully,JOHN BIERNACKI.

To the Editor of THE LANCET.

SiR,-In reply to a letter in THE LANCET of April 13thI may say that Dr. Rundle will shortly be reading a paper onthe subject of bed isolation before the Royal Society ofMedicine, and will then no doubt give his attention to Dr.Crookshank’s remarks. In the meantime, however, thestatement of the latter that his work has not been franklyacknowledged cannot be passed unnoticed.

In the first place, none of Dr. Crookshank’s ‘6 details " ofbed isolation were improved upon," because none were

adopted from him. The figures given of our work start inJanuary, 1910, while Dr. Crookshank’s paper was publishedin February of the same year. The Fazakerley system had,moreover, been in operation in a modified form for at leasta year previously, and must be considered as more a

modification of Dr. Biernacki’s well-recognised ’’ barrier’" "isolation system than modelled on Dr. Crookshank’s paper.In fact, it was not till our figures were being prepared forpublication that Dr. Crookshank’s work came before ournotice, and seeing that he was unable to give any statisticsof diseases treated together in the same ward, or ’to state

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definitely what diseases, except diphtheria, typhoid fever,and erysipelas, he had been prepared to treat together, wedid not obtain that assistance he wishes to assume.The account of the work at Fazakerley was given under

Dr. Crookshank’s title of bed isolation, as it appeared tohave developed along similar lines ; also, of only two refer-ences to original papers one was made to that of Dr.Crookshank. It is to be regretted that these two proceedingsdid not give to Dr. Crookshank’s work the prominence hedesires.

Further, it must be pointed out that the emphasis which helays on " aerial dissemination," and hence on an attempt todisinfect the throat and nose, is entirely opposed to theresults of the Fazakerley system. If aerial dissemination isof such importance as to require this treatment the advantageof glass partitions over simple bed isolation is obvious. Forthe rest, Dr. Biernacki sufficiently states the case when hesays that by the routine cleansing of the mouth, throat, andnose, ’6 while the immediate output of profuse discharge islargely controlled, the chance that the nurses may infectother patients becomes greater." The fact that routine localtreatment has been entirely withheld at Fazakerley supportsthis statement. Dr. Crookshank states that he admits that’’ routine treatment of throats with watery solutions and abig glass syringe is dangerous and improper." Yet in his

original article in THE LANCET he provides each of hispatients with a "spray or syringe," and states that izal,,shaken up with water or paroleine is used for spraying,syringing, or douching the mouth, nose, &c., every fourhours during the first week and three times a day later." 1

It was probably the memory of this integral part of theplan of Dr. Orookshank, who there laid no stress on oilysolutions or on the confining of mechanical cleansing to

septic cases, that caused Dr. Biernacki to make the remarkshe did on local treatment. Dr. Crookshank’s statement thata nurse can spray a patient’s nose or throat without

.. touching the patient supposes the existence of a type ofchild and of nurse with which few must be able to claimacquaintance. I am, Sir, yours faithfully,

A. H. G. BURTON.

INTERNAL SECRETIONS AND THEPRINCIPLES OF MEDICINE.

To the Editu’f’ of THE LANCET. I

Sm,-The review of my work on the " Internal Secretions Iand the Principles of Medicine," published in THE LANCETof March 23rd, contains statements which, with your kindpermission, I should like to amend. I am representedtherein as the would-be father of "a new physiology." Imust disclaim any such idea. An inveterate antagonist ofthe empirical methods which disgrace even present-daypractice, my purpose has ever been, as editor of the " Annualof the Universal Medical Sciences," of its successor, the

6° yclopedia of Practical Medicine," and of the New YorkMedical J01l’l’nal (of which I assumed the editorial manage-ment last year), and also as a teacher, to encourage the use ofanalysis, that is to say, of analytic and synthetic reasoning,in applied medicine, with physiology as starting point. Thatthis indicates due appreciation of the value of physiology isself-evident. It was this attitude, in fact, which caused mesome years ago to invade its field in the hope of elucidatingcertain admittedly obscure topics. My associates in the11 Annual " having found it impossible to carry out my requestconcerning the use of analysis in the preparation of theirdepartments, asserting that physiology failed to affordsufficient information upon the functions of the various organsto enable them to do so, my efforts to establish a rationalmedicine, one in which the relations of cause to effect wouldbe clearly defined, were for the moment thwarted.

Rather than attribute this-to me a most regrettable-result to the weakness of physiology taken collectively, Iascribed it to the possible influence on this auxiliary branchof some obscure, all-embracing function, connected perhapswith the vital process, the absence of which caused con-

fusion in every direction. I deemed it my duty to try atleast to discover this hidden factor, and devoted manyyears, including six spent in Europe, to a systematicresearch in which practically every branch of natural science

1 THE LANCET, Feb. 19th, 1910, p. 480.

was scrutinised. The work reviewed in your issue ofMarch 23rd is the product of this research. Far from

pretending to introduce a " new physiology," it aims only toshow that when the functions I have attributed to theadrenals, thyroid and parathyroids, and the pituitary bodyare added to the vast array of sound knowledge physiologistshave placed at our disposal, the obscurity surrounding manyfunctions, and which obscurity they themselves acknowledge,seems to be dispelled.

Again, your reviewer speaks as though my views had justseen light. It is nine years since the first edition (thepresent being the fourth) was published. Since then the

strength of my deductions has been sustained independentlyin many particulars. The participation of the adrenalsecretion in oxidation and metabolism-so evident inAddison’s disease-for example, is no longer subject todoubt ; the presence of the adrenal principle in the redcorpuscles has also been established ; this may also be saidof a suggestion which at the time seemed almost pre-posterous ; the fact that emotions, shock, &c., could react onthe adrenal system (through its centre, in my opinion),recently confirmed as to the adrenals by Cannon andHoskins. In the practical field I might cite the confirmationof my view by Fassin, Stepanoff, and Marbe (the two latterworking in the Pasteur Institute) that the thyroid (includingthe parfathyroida) not only increased the alexins in theblood, but also its opsonin, which I assimilate to the thyro-parathyroid secretion, a fact of considerable practicalimportance in the medical and surgical fields.

Finally, permit me to call attention to the fact that thetrend and development of the whole question of internalsecretions in recent years, and particularly the better resultsobtained in practice by those who have conscientiouslystudied my work-all supplemented by the readiness withwhich obscure functions, pathological states, and the effectsof various drugs can be explained-indicate clearly that Idid not err when I urged nine years ago that the empiricismwhich characterises present-day medicine will, to a greatextent, disappear when certain internal secretions, especiallythose of the thyrc-parathyroid apparatus and the adrenals,will be regarded as active factors in all vital activities andmorbid changes in the body at large, and also as the mediathrough which some of our most useful therapeutic agents.including the bacterial vaccines, produce their beneficialeffects. I am, Sir, yours faithfully,

C. E. DE M. SAJOUS.

THE NOMENCLATURE OF DISEASES.To the Editor of THE LANCET.

SIR,-Sir Clifford Allbutt says that the parasitism of thetyphoid microbe is, " in any particular case of typhoid, butone of an infinite complexity of causes." This is the crux ofthe situation. When we see a patient acutely ill, we correlatethe symptom-group shown with the parasitism of a specificmicrobe, and on the strength of this we " diagnose typhoidfever." Not only is the parasitism of this particular microbethe " cause " of the symptoms ; it is the only possibleI I cause" of the typhoid symptom-group. The physicianoften makes his diagnosis while ignorant of all antecedentconditions ; and it is the antecedent conditions that are

infinitely variable ; they are, in fact, never twice alike, butthey do not enter into our definii ion of the concept which wecall "the disease typhoid fever." The only essentialdifference between modern and ancient medicine consists inknowledge of causation. This f act is embodied in my defini-tion. " The disease " (typhoid fever, e.g.) is nowadays amental conception drawn from th9 observation of a series ofsymptom-groups of determinate and similar causation. Sodefinite a concept was clearly not attainable prior to Eberth’sdiscovery.

You, Sir, ask me to suggest a generic term to describe con-cepts drawn from recurrent symptom-groups, uncorrelatedwith a cause, such as Hodgkin’s disease, Graves’s disease,insular sclerosis, glaucoma, psoriasis. The word " dyscrasia "was at one time used as a synonym of the specific term.. disease" ; it has dropped out of our vocabulary. I sug-gested some six months ago in (hbY’S Hospital Gazette thatthe word" dyscrasia " should be reintroduced for the purposeof differentiating " spurious diseases

" from " true diseases."This would enable us all to realise that to detect a