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Annotations.

DARWIN’S HOUSE.

"Ne quid nimlt."

Down House in which Charles Darwin lived duringthe greater part of his life, and where " TheOrigin of Species " was written, was opened to thepublic on Saturday last. The house was presentedto the British Association by Mr. Buckston Browne,F.R.C.S., on condition that it and the surroundinggrounds shall be maintained in the state given tothem by Darwin and that the public shall have freeaccess to the public rooms. Sir Arthur Keith, whodeclared the house open, spoke of the way in whichCharles Darwin quite unwittingly had made thesefew acres of Kentish upland an international posses-sion. It was just because he permitted the bareunbusked truth to speak for itself, going only sofar as the light of reason would carry him. Onlymen who taught thus, said Sir Arthur, continuedto teach for all time. What Darwin’s achievement

, has meant to the study of natural history is set outnowhere better than in his own words, which wehere reproduce from the concluding chapter of-the " Origin " :

" When we no longer look at an organic being as a savagelooks at a ship, as something wholly beyond his comprehen--sion; when we regard every production of nature as onewhich has had a long history; when we contemplate every;complex structure and instinct as the summing up of manycontrivances, each useful to the possessor, in the same wayas any great mechanical invention is the summing up of thelabour, the experience, the reason, and even the blunders ofnumerous workmen ; when we thus view each organic being,how far more interesting-I speak from experience-doesthe study of natural history become ! "

Mr. Browne’s gift will enable many to recapturethe atmosphere in which Darwin thought and workedfor 40 years-the phrasing is in the words of aninscription now erected outside the entrance gate.No student would ever know Darwin, said SirArthur Keith, until he knew Down, and to see Downwas the best way to obtain an introduction to Darwin’sworks. Most of the furniture and other objectsin the rooms are those used by Charles Darwin andhis family, including the snuff jar which he keptnot in his study but in the hall, in the vain hope ofbreaking himself of the habit. An American com-mittee is cooperating with the British Association Iin an endeavour to recover Darwiniana now inAmerica.

POST-OPERATIVE RUPTURE OF THE

ABDOMINAL WALL.

RUPTURE of the abdominal wall after operation is amuch neglected complication, and the reason for itsneglect may be that surgeons think it a reproach totheir technique. A similar obscurity-now fortunately,dispelled-has until recently been the fate ofVolkmann’s ischaemic contracture. An attempt toelucidate some of the problems connected with repairof the abdominal wall has lately been made byMonod and Kiraly,! who base their conclusions oncases of their own and on series collected by Chavannaz Iin 1900 and Madelung in 1905. The subject has a verysmall modern literature and not much that is-old.Post-operative rupture may occur soon after the

operation, usually within the first fortnight, or it mayfollow years afterwards. Delayed rupture is, of course,extremely rare, and is not of the same practical impor-tance as the post-operative form. Of generalcauses thought to predispose to the condition, canceris usually placed first, but in none of the three series-of cases reviewed did it account for more than one-fifth of the total. Syphilis is also said to be a pre-disposing cause, and Monod and Kiraly found that

1 Presse Méd., 1929, xxvii., 253.

active syphilis was present in two out of the threecases in their series in which a Wassermann test hadbeen done. Among local causes which may predisposeto rupture, infection of the wound, abdominal disten-sion, premature removal of the sutures, and a longincision are all common; but most importantof all is incomplete suture of the peritoneum. Theorigin of some of these cases can be easily seen duringthe operation of re-suture when the rupture has notbeen complete, and it is often found that a piece ofomentum has worked its way through a gap in theperitoneal suture, thus apparently starting the cleavage.The actual rupture is usually brought about by aneffort on the part of the patient, coughing and vomitingbeing the commonest causes. It is interesting to notethat there is rarely any pain at the time of rupture, andnever any haemorrhage. In fact the patient may onlyfeel that there is something under the dressing, or,indeed, the accident may not be noticed until it isobserved that the dressing is soiled by a pinkish serouseffusion. When the condition is recognised early theprognosis is not so serious as might be supposed fromthe nature of the accident. Immediate suture of theabdominal wall is successful and, whether it is done inseveral layers or in one, the result should be a firmscar if the patient survives.

THE DOCTOR-CORONER.

RECENT correspondence in the Times has containedcriticism of the procedure at coroner’s inquests.Coroners are tending, it is suggested, towards themethods of the French examining magistrate;voluntary witnesses are cross-examined by the courtitself in a hostile manner ; suspects are at the disadvan-tage that they are not definitely charged with thecommission of a crime nor are they warned (as theywould be by a police inspector) that what they saymay be used against them in another place. Whileone correspondent points out that all this is contraryto ideas of British justice and fair play, anotherascribes the supposed malpractices of the court to theappointment of medical practitioners as coroners.

Such appointments mean, it is said, that the coronerhas no legal training ; even if he has sought tosupplement his qualifications by undertaking theexaminations which a barrister has to pass, his know-ledge of the law of evidence is theoretic and notpractical.

These criticisms ignore the fact that Parliament hasnever said that a coroner must be a practising barristeror solicitor. The qualification is five years professionalstanding as a barrister, solicitor, or medical practitioner.Nor has Parliament declared that the procedure at aninquest must in every way resemble that which is usedat other criminal courts. For obvious reasons theinquest cannot be assimilated to the assize court. Theinquest is held to inquire into the cause of death.Until it has made some headway with its investigation,it is impossible that a definite accusation against adefinite person can be formulated. There is thereforeno charge, no defendant, no prosecuting or defendingcounsel ; the tribunal itself must undertake theresponsibility of eliciting the facts and must necessarilyrove over a wide field. The coroner, using thediscretion which the law permits him, is-as Mr. JusticeWills observed in the Crewe murder case-" fetteredby no precise rules of evidence " ; he is " bound tocollect, so far as he can, all information and knowledgeof disasters from neighbours and others who can throwany light upon the cause of death... he can often-times collect evidence, facts and statements which,whether or not they may ultimately be capable ofbeing turned into evidence against the parties whoare to be put on their trial, are often very valuable assupplying material for investigation by the police andM affording clues which may lead to successfulnquiry." If, continued the learned judge, a coronerconfined himself to the strict rules of evidence, hewould throw away a great deal of the remainingusefulness of the inquest. These observations, utteredlearly 30 years ago, are of full force to-day.

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The coroner, perhaps, on his side, has a right toprotest that his least considered remarks in court are,-sometimes torn from their context and reported withunnecessary elaboration. He tries to deal with all theaspects of the case but the reporter may be interestedonly in the case against a particular suspect. Doubtlessthere are coroners, as there are judges and stipendiarymagistrates, who<!e running comments are no greathelp to the administration of justice, and whoseindividual views on certain favourite topics of theirown (whether medical or legal) are apt to find a-tediously constant expression. But the critics of theprocedure at inquests make a profound mistake if theyignore the historical and popular associations of the.coroner’s office, or if they commit themselves to thetheory that the only good coroners are lawyers and theonly bad coroners are medical practitioners.

THE RED CELLS IN PERNICIOUS AN&AElig;MIA.

THE work of Price-Jones has established that in

pernicious anaemia there is an abnormally widevariation in the size of the red cells, and the presenceor absence of this phenomenon may now be regarded.as the absolute criterion for diagnosing the condition.’The plotting of the Price-Jones curve, however, isL,so laborious as to be hardly feasible in a busy labora-tory, whilst the " halo " method of Adrianus Pijper,2though affording means of demonstrating optically-the same variation and the approximate averageincrease in size of the red cells, demands special.apparatus and somewhat formidable calculations.Some time ago Haden2 pointed out that a relatively’J3mall increase in the average diameter of the redcells causes a relatively great increase in the total i"red cell volume, and various workers have brought Iforward evidence to show that much of the valuableinformation to be gained from the Price-Jones curvecan be got by calculations based on the total volume,and total number of red cells. Wintrobe, whose work,on blood standards has already been referred to in ourcolumns, has recently dealt with the subject in acomprehensive way.3 He points out (what has beenrecognised for some time) that the average corpuscular"volume in cubic millimicrons may be obtained bydividing the total volume of red cells per litre, asdetermined by the haematocrit, by the total numberof red cells per c.mm. The figure thus obtained heTefers to as the corpuscular volume. This cor-

puscular volume he finds in healthy young adults tolie between the figures of 70 and 98 cubic millimicrons,with the average round about 83. In strong con-tradistinction to this, Haden found the corpuscularvolume in pernicious anaemia to lie between 108 and163 cubic millimicrons with an average of 128. The.difference between the normal red cells and those fromcases of pernicious anaemia is conspicuous, and inas-much as determination of the corpuscular volumeonly demands the use of a haematocytometer and aIiaematocrit, this particular determination bids fairto be of considerable use in establishing the diagnosisof pernicious anaemia. Wintrobe further draws,attention to the interesting fact that, although thesize’of the red cell is increased in pernicious anaemiaand though it carries a greater load of haemoglobinthan the normal red cell, the actual proportion of thevolume of the red cell occupied by the haemoglobinis no greater than in normal blood. Haden foundthe percentage of haemoglobin in the red cell inpernicious anaemia to range between 16 and 35per cent. ; Wintrobe in normal blood finds verysimilar figures, the actual average being about 33 percent. The proportion of haemoglobin in the red cells isdetermined by dividing the haemoglobin, expressedas grammes per cent., by the volume of red cells per100 c.cm. of blood. Both for this calculation and forthat of the corpuscular volume a h&aelig;matocrit isrequired ; the importance of centrifugation until the

1 THE LANCET. 1924, ii., 367.2 Haden, R. L. : Arch. Int. Med., 1923, xxxi., 164.

3 Wintrobe, H. M. : Amer. Jour. Med. Sci., April, 1929, p. 513.

column of red cells has reached a final level ispresumably apparent. Wintrobe, however, drawsattention to a source of error which has possibly notbeen sufficiently considered. He finds that the additionof potassium oxalate to the extent of 20 mg. to 10 c.cm.of the blood under estimation caused a decrease incell volume of 3-7 per cent., while addition to theextent of 40 mg. to 10 c.cm. of blood brought abouta diminution of 6-7 per cent.

OBSERVATIONS ON UNILATERAL DIURESIS.

To the April number of Guy’s Hospital Reports,Mr. H. 1. Maister, Mr. W. H. Ogilvie, and Prof. M. S,Pembrey contribute a paper on a case of total cystec-tomy in which certain investigations were made ofurinary secretion. The patient had a carcinoma of thebladder and at operation the ureters were brought tothe surface. The urine excreted by the two kidneys wascollected separately by an apparatus which kept thepatient dry and allowed her to get about. Variationsin the activity of the two kidneys were shown byestimating the volume and specific gravity of samplescollected in consecutive periods of half an hour. Themost interesting observation was that the applicationof warmth to the loin did not, as is usually supposed,produce diuresis but rather the reverse. When a hotpoultice was placed over the right kidney the amountof urine excreted on that side was diminished and adiuresis was noted on the opposite side. On anotheroccasion as a control the poultice was applied to theleft side and a diuresis from the right kidney wasobtained. It appears, therefore, that warmth over theloin produced a vaso-constriction of the underlyingkidney and since the skin, apart from the poulticedarea, was cold, a compensatory dilatation occurredwith increased excretion on the opposite side. Theseobservations are of a special interest in view of thecommon practice of applying warmth and cuppingover the lumbar region for the purpose of stimulatingurinary secretion-a method which seems likely todiminish rather than stimulate the activity of thekidneys. It may, indeed, be deduced that the applica-tion of warmth over a kidney might be of use in thosecases of renal heematuria in which diminution ofactivity is thought desirable.

BOOTS AND SHOES.

ONE of the disadvantages of civilisation is to befound in the degradation of the human foot which iscaused by the use of footgear. Many writers havepointed out the evils wrought by boots and shoes,and by stockings, too, for that matter, and many anessay has been written on the proper form andmaterial of foot covering. The last contribution to theliterature of this subject comes from Dr. J. D. Adams,!of Boston, who holds views on the footgear of thechild which are sound as far as they go, but hardlyseem to go far enough. A study of the history ofboots and shoes and of the current practice in shoeingof many peoples all over the world, such as was inpart attempted in our columns by Mr. MuirheadLittle2 in 1914, shows that, with the exception ofsandals, all footgear tends to cause abduction of thegreat toe and gradual loss of the power of voluntaryadduction of its phalanges. The Greek or Romansandal with a thong between the great and secondtoes did not have this pernicious effect, and the sameis true of certain sandals worn in India and elsewhereat the present time. The most primitive form ofprotection was probably a strip of the skin of ananimal or some flexible leafs and the result of windingthis or any other bandage round the foot and toeswould be abduction of the great toe, involving intime loss of the support afforded by its phalanges.This tendency is evident in Red Indian mocassins,

1 Jour. Amer. Med. Assoc., May 25th, p. 1753.2 Boots and Shoes from Historical and Surgical Points ofView, THE LANCET, 1914, i., 1738.