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THE EMPLOYMENT OF MARRIED WOMEN

THE LANCET.

LONDON: SATURDAY, MAY 14, 1927.

THE lIarried Women (Employment) Bill, which came to an untimely end in the House of Commonson April 20th, was of interest to the medical professionfrom at least two direct points of view. It concerned,t large number of medical women now engaged in lGovernment and municipal service on contractswhich terminate automatically with marriage, and,further, the arguments which secured its rejectionwere mainly of a medical character. Both the moverund seconder of the motion for rejection made greatplay with the disabilities of pregnancy which theyappeared to consider not only the natural, but theinevitable, result of marriage. One speaker evendeclared that " in normal cases a woman was notas efficient a few years after marriage as before,"and reminded us portentously that the sexes were notequal in all respects. The Government spokesman,Mr. RONALD McNEILL, elaborated the same point,and complained that supporters of the Bill were

increasing " enormously " the sickness risk and therisk of discontinuance of service by employingmarried women, with a corresponding

" immenseloss " of efficiency. The one medical speaker in thedebate, Dr. GRAHAM LITTLE, found himself unableto support these gloomy prognostications and, statingthat he knew of no medical authority for the argumentsused, told the House that the universities of this

country had found it perfectly practicable to makeno distinction whatever between the sexes in thematter of marriage. But he implied, and correctly,that data concerning the sickness-rates of marriedwomen, as compared with single women and menworking under similar conditions, are very hard toobtain.In the days when the largest educational authority

in the world gave women teachers the free choiceof remaining after marriage,l it was found that thenumber of days absence for married women was9-3 per annum, as against 8’2 for single women and4-6 for men. It may be noted that the differentialrate against married women was found exclusivelyat the lower and upper extremes of age, for between30 and 55 years of age married women actuallyshowed less absence than single. As for interruptionsdue to pregnancy, the last census revealed that the

average number of children in the professional man’sfamily was 0-98. The married woman Civil servant

might well contribute double her quota of disabilitywithout seriously dislocating the work of a well-organised department. The bogy of the woman otficialhandicapped by recurrent pregnancies and a " lot oflittle children" need not be taken too seriously. It wasfound in the teaching profession that very few womenwith more than two children attempted to remainat work, and medical women in a similar situationcommonly give up practice, at any rate, until thechildren are at school. Mothers are at least as awareof what is due to young children as are Members of

1 J. V. Hart: Sickness Data of Elementary School Teachersin London, 1904-19. Journal of the Royal Statistical Society,1922.

Parliament. Even if it could be established that asubstantially greater sickness risk has to be debitedagainst the married women, it by no means followsthat the last word has been said on the efficiency ofthe woman as worker. marriage has been describedas a

" battlefield " ; it is certainly an education,and anyone can imagine that this education mayoften be an asset. This is especially true of positionswhere the woman official has to deal with otherwives and mothers in some educational capacity,either as a teacher or in the public health service.Working women not unnaturally prefer to deal withone of their own status on mattors affecting marriedlife, and they listen more readily to advice in respectof children from a woman who has, or who might havehad, children of her own. Such all attitude on thepart of a large proportion of the public is not a

negligible factor in the conduct of great serviceswhich ultimately depend for their success on the

cooperation of the public. It may further be arguedthat working mothers are not the only persons whowould benefit if the atmosphere of some schools anddepartments staffed by single women, which tends tobe too spinsterish, were mitigated by a leavening ofthe mated.The point of view of the woman lierselt was well

put in the debate by Mr. PETIIICK-LAWRENCE. Hespoke feelingly of the sad waste entailed on both sideswhen an expensively trained and experienced officersuddenly found herself thrown out of employmentand deprived of pension rights just at the time whenthe most valuable earning period of her career wasbeginning. This is an aspect which closely concernsmedical men who have given their daughters a costlyeducation for which they and the community areentitled to expect some return. Recently the DurhamCounty Council has dismissed a woman medical officer,appointed last August, on the sole ground that shehas since married, no question of resignation on

marriage having arisen at the time of her appoint-ment. This sort of prophylaxis against possibleinefficiency can hardly be defended. In other depart-ments of life a married woman is now at libertyto use her gifts in any manner she and her husbandplease, and (as Sir HENRY SLESSER suggested) it isdifficult to see why the established services shouldremain the one exception. When the matter nextcomes before the House it is to be hoped that broaderand more scientific views will prevail.

THE ENDOTHERM KNIFE.BLOODLESS surgery was the expression formerly

applied to the manipulation of bones and jointsunder anaesthesia, no incision being made in theskin. The term has made a wide appeal to the public,whose dread of " the knife " is largely due to animaginary picture of an operating theatre, basedon observation of the mass of blood that maywell or spurt from a single accidental cut. It

practice the amount of blood lost by the patientunder a modern surgical team is surprisingly small,and if primary haemorrhage under these conditionsdoes the patient any harm it is only by prolongingthe period of anesthesia. For even with the mostefficient swabbing and clamping the surgeon’s fieldof vision may be temporarily obscured by oozing,and if hæmatomata are to be avoided the time spentin ligaturing small vessels is not negligible. For thesereasons alone a technique promising a bloodless fieldof operation is to be welcomed; if, as is claimed byits exponents, it has also other signal advantages,

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such as the promotion of healing by first intention,and the sealing of lymphatics and very small vesselsin the very act of incision, it certainly deserves theattention of surgeons. The technique to whichwe refer is the alternate use through the same electrode-a needle mounted on a I ard rubber or fibre handle,known as the endotherm knife (G. WYETH) or theacusector (H. A. KELLY)—of an undamped high-frequency (H.F.) current for division of the tissues,and a damped H.F. current to secure hemostasis ofthe larger vessels.

A brief excursion into nomenclature is desirableif the relation between these methods and theolder electro-cautery is to be understood. Atpresent the word diathermy is often used indis-

criminately to indicate medical diathermy, wherethe aim is to warm the tissues to a point short ofdestruction, or surgical diathermy, which includesthe various methods of adapting the high-frequencycurrent to disintegrate or destroy animal tissue.These methods, whereby heat is generated within thetissues in response to the oscillations of a H.F. current,differ radically from the transmitted heat given outby the electric or galvano-cautery, the Paquelincautery, and the Percy cautery. The effect of thetransmitted heat is to cauterise or burn the tissues,the heat being generated in the applicators which arehot when applied. The sharp-pointed active electrodecarrying H.F. current, on the other hand, is alwayscold when applied, and the heat generated in thetissues themselves does not char or burn. It can,however, be used to destroy by desiccation, to destroyby coagulation, or to incise by cellular disintegration.Dr. G. WYETH, in a book which we review on anotherpage, suggests that the term diathermy shall in futurebe used only in the sense of medical diathermy,while the term endothermy (heat from within) shallbe used to include (1) monopolar H.F. used for

desiccation ; (2) bipolar H.F., used for coagulation ;and (3) the endotherm knife, being a II.F. oscillatorycurrent produced by means of a triode which, whenmaking contact with the tissues through a mountedneedle, produces a cutting effect, sealing lymphaticsas it cuts. The method of electro-desiccation is

applicable to a wide range of superficial lesions,including malignant ones which do not involvethe deep tissues, and also warts, moles, nævi,and pigmented areas. Dr. W. L. CLARK firstdescribed the technique as long ago as 1911.1 Ilestarted from the axiom that since the effect ofheat on animal tissues ranges from simple hyperæmiato chariing, there must be between those extremesa point where desiccation of the tissues would takeplace. His idea was to produce, control, and sustaina degree of heat sufficient to cause a rapid desiccationof the part to be treated, sterilising it and convertingit into an inert mass. His experiments on cakes ofsoap-drying a marked area to pulverising pointwithout charring or discolouring the paper in whichit was wrapped, and without drying the soap in thesurrounding areas-led to others on potatoes and onraw liver, and, finally, to a successful use of the

monopolar damped H.F. current on superficial lesionsin human subjects. For deeper lesions bipolar endo-theymy may be used ; the heat is generated by connect-ing one pole of the apparatus to a wet, indifferentelectrode under the patient’s buttocks, the operatormaking contact with the active electrode. Thed’Arsonval current used is of comparatively low-

voltage and high ampèrage—200 to 5000 milli-

ampères—and a deep penetrating coagulation results.

1 New York Med. Jour., 1911, xciii., 1131.

It is claimed that secondary hæmorrhages rareiyoccur in experienced hands, but operators workingnear a large vessel are advised to ligature it in advance.The third type of endotherrny, using Dr. WYETH’S

classification, is the one to which we wish tu

draw special attention. H. A. KELLY and (. E. *

WARD 2 report excellent results in the surgeryof carcinoma of the breast from the use of tilt.endotherm knife devised by Dr. WYETH. This is nota true knife, but a current operating throughthe same type of needle as is employed for

the application of bipolar damped high frequencycurrents. The underlying principle of its action is theapplication of undamped high-frequency current,which causes a cellular disintegration of the tissue atthe point of contact, an arc being formed betweenthe tissue and the tip of the needle which is held justover it. This introduces a ne’w technique which isnot easy to acquire, the impulse to make some pressure.as in using the scalpel, being difficult to resist. Th&

exponents of this technique claim that there is healingby first intention, an immediate closure of lymphatics,capillaries, and small blood-vessels, and a diminutionin the risk of local recurrence. The number of clampsand ligatures necessary during an operation is con-siderably reduced and in some cases may be entirelyeliminated, for in order to seal the larger blood-vessels, which are clamped in the usual manner,the current is switched over to damped highfrequency and a short application made to the clampcontrolling the vessel. The measure of the dura-tion and amount of the current to he appliedis a slight ring of coagulation at the point ofthe clamp. This procedure is said to be quicker-and just as efficient in stopping hemorrhage as

is the tying of a ligature. KELLY and WARD warnthe surgeon that the current used in the endothermknife, which they prefer to call the acusector, causesmuscular contractions when applied to nerves or

muscles, but such contractions can be made almostnegligible by reducing voltage according to directionsgiven. The coagulating current must also be usedwith the utmost caution near a muscle. The greatadvantage of the combined use of the two forms ofcurrent is that, since so few ligatures are required, theoperator neco. naraiy ever toucn tne wound with mahands. The necessity for having coagulation high-frequency current at hand during the operationled Dr. WYETH to design the eudutlierm,3 an

instrument. equipped for the production of currentsused in monopolar and bipolar endothermy andin operations with the endotherm knife. The

undamped high-frequency oscillations are developedby means of a triode oscillation, the grid and anodecircuits being coupled together and timed to ;l,

frequency of approximately 1000 kilocycles. Veryfew details of the undamped high-frequency apparatusare set out in Dr. WYETii’s original description of theapparatus or in his book, a disappointing omissionsince doubtless many surgeons will be anxious to

investigate the possibilities of the combined method,without having to instal an expensive completeequipment when their existing damped high-frequencyapparatus could be modified and extended to functionfor the use of the endotherm knife. In this conmexionit may be noted that an error has crept into thediagram of the electrical connezions of the triodeoscillation found on p. 30 in Dr. WYETH’S book; iffollowed out it would lead to a considerable displayof fireworks. The success which has already attended

2 Annals of Surgery, Part 397, January, 1926, p. 42.3 American Journal of Electrotherapeutics and Radiology,

1924, xlii., 186.

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the use of the endotherm knife in certain operationsleads us to hope that further investigations will becarried out in this country. There is especial needfor the correlation of the wave form of the high-frequency oscillations and the resulting changesproduced in the various types of tissue cells. Apartfrom the destruction of neoplastic growth, thedesirability is obvious of pursuing investigations intoa technique by which no drop of blood is spilled."Prepare thee to cut off the flesh," said Portia,"Shed thou no blood." It would seem that we areapproaching an era of surgery when Portia’s dictumwill not be accepted as a conclusive argument.

BRONCHIECTASIS.THE discussion on bronchiectasis at the Royal

Medico-Chirurgical Society of Glasgow reported inanother column illuminates a number of issues uponwhich physicians and pathologists alike are still indoubt. Sometimes we may feel inclined to wonder ifour knowledge of this obstinate and unpleasantdisease is advancing at all. The treatment of the

malady has certainly not made rapid strides, andthe new major operations of surgery-thoracoplasty,and the like-have not been attended with that measureof success which has been noted in similar operationsfor pulmonary tuberculosis. Perhaps such success washardly to be expected. The disease is usually faradvanced when the patient readies the surgeon andthe whole field of operation is saturated with the

organisms of suppuration from which the numerouspleural adhesions are generally not exempt. It isclear, therefore, that if radical rneasures are to be

adopted earlier diagnosis is essential, and along thisline, at any rate, some advance has been made withthe introduction of lipiodol. The technique of thisdiagnostic measure is safe and easy, and there isreason to believe that the employment of the substancewill go far to increase the value of diagnosis. It

presupposes, of course, the possession of an up-to-dateX ray plant and a skilled technician to use it, and likeso many of the modern diagnostic methods, it addsyet another demand for increased facilities for theinstitutional diagnosis and treatment of disease. Buteven with this addition to our armamentarium weare still faced with many problems in the causationof bronchiectasis. At the discussion in GlasgowDr. JAMES ADAM mentioned the cases traceable tonasal sinusitis, a group not generally recognised in this icountry though described in American literature, Iwhilst Prof. LEONARD FINDLAY, quoting Prof.ARMAND DELILLE in support, emphasised thedifficulties of those cases in childhood which hadsymptoms but no signs, or even a complete absenceof either. There is abundant evidence, indeed, forrecognising non-tuberculous fibrosis of lung inchildhood as the starting-point for many of thesecases, and physicians who work in chest hospitalsnot infrequently have the mortification of watchingcases pf fibrosis of lung in children slowly goingdownhill from fibrosis to bronchiectasis withoutany clear line of demarcation and without beingable to call a halt in the disease. It seems unjustifiableto resort to drastic surgical measures as long as thecondition is merely one of fibrosis and once sepsis-in other words bronchiectasis—has become establishedsurgical aid may well be too late. Probably, however,only a certain proportion of these cases of fibrosis goon to bronchiectasis, and it would be a great boon ifWe knew definitely what was the deciding factor.Meanwhile it is essential not to confuse the cases

with pulmonary tuberculosis, but to watch carefullyfor the insidious onset of any signs of pulmonary sepsiswhich undoubtedly spell bronchiectasis. Children canbe taught not to swallow their sputum, and thefrequent bacteriological examination of their expectora-tion should never be neglected. In the late stages theonset of lardaceous disease seems to be a landmarkin the slow progress of disease not infrequentlyoverlooked ; frequent examinations of the urinewould appear to be just as important as sputumtests. On the morbid anatomy side of the picturewe are inclined to think that the frequency of cerebralabscess as a complication of bronchiectasis hasbeen exaggerated. Of much more importanceis the frequency with which a full bronchiectaticcavity is mistaken for an empyema, often with disas-trous surgical results. The histological picture ofbronchiectasis, too, is essentially disappointing. Bythe time these long-standing cases reach the post-mortem room all hope of elucidating any satisfactoryinformation as to causation has long since passed.In conclusion, therefore, we have frankly to acknow-ledge that although there are some recent signs ofadvance in knowledge, notably in the matter of

lipiodol, the condition of bronchiectasis has not been.a conspicuous example of the advance of modernmedicine, especially as regards the purely medicalgroup of cases. That the purely surgical variety of thedisease, associated with a traumatic factor or foreign.body, is a separate entity requiring separate considera-tion was well brought out in the Glasgow discussion.

JOHN LYDEKKER.

A SMALL book written by Mr. W. R. Dawson and.published by the Seamen’s Hospital Society tellsthe story of a great hospital benefactor. JohnLydekker, merchant of London and shipowner-(1778-1831), had almost as great an influence on thisSociety as would entitle him to the prayers usual onbehalf of a pious founder. His father left New Yorkwhen it ceased to be an English colony and broughthis children to London. Here the eldest son was at onetime an eminent physician, and the third son, John,became a merchant in Cheapside, concerning himselfmainly with cane and whalebone, then wanted forcorsets and the ribs of umbrellas. Naturally he tookan interest in whaling ships in the South Seas, and heowned four in 1829. In 1830 he made a handsomedonation to the Seamen’s Hospital in recognitionof their kindness to some Polynesian seamen fromhis ships. In those days, less than a hundred yearsago, life in London was much less secure than now ;water was often drawn from shallow, contaminated:wells, drainage was by open sewers to the Thames,.burials were apt to be made in the crypts of churchesto avoid the resurrectionists. In July, 1832, Lydekker-went from his house in the Strand to stay with a friendin Fenchurch-street, fell sick of cholera which wasthen prevalent, and feeling himself near his end,wrote out a short will which he signed, leaving theresidue of his property to the Seamen’s HospitalSociety. This will, although unwitnessed, was notcontested by his family, and brought the Societya sum of £58,729. At that time the Seamen’s Hospitalwas situated in the 104-gun ship Dreadiioi4rlht lying inthe Thames off Greenwich, but in 1870 a 99-year leaseof the old infirmary of Greenwich Hospital wasacquired, and in 1926, with the help of the Lydekkerbequest, 1!23,00O left by B. T. Crichton, and otherbenefactions, patients to the number of 28.264 were-treated in one or other of its eight establishments.The Seamen’s Society owes many of its opportunitiesof usefulness to the munificence of shipowners. ofwhom Lydekker was the most bountiful. There isa marble monument to his memory at Lloyds anda stained glass window in the chapel at Greenwich.