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the base of the left lung. At 3.35 exploratory punctureshowed the intrapleural pressure to be +17. Thebarometel measured 656, or 56 less than the barometerin Chamonix. Ducing the patient’s short sojournat Montenvers, the respiratory discomfort andcough rapidly diminished, and had completely dis-appeared by 4.10. He left Montenvers at 4.40, reachingChamonix at 5.25, when the barometric pressure was709. At 5.55 the pleural rub was found to havedisappeared, and the intrapleural pressure to havefallen to nil ; on the injection of 100 c.cm. of nitrogenthe pressure was again brought up to +9, withoutcausing respiratory distress or the recurrence ofa pleural rub and pain. Although it is evident fromthese observations that the rise in the intrapleuralpressure caused by an ascent to a high altitude israpidly neutralised by the absorption of the gas,some distress may be experienced in the intervalby patients with a total pneumothorax which hasrecently been refilled. A comparison of the baro-metric with the intrapleural pressures showed thatthe actual rise of the intrapleural pressure was muchless than that which would have occurred had notthe gas been rapidly absorbed, and, perhaps, therelation cf the bag of gas to the other contents of thethorax changed somewhat. The usual rate of absorp-tion of nitrogen by this patient was 0-25 c.cm. perhour. On the present occasion, however, he hadabsorbed 100 c.cm. in about four hours. In otherwords, the rate of absorption had been increaseda hundred-fold. The pleural rub heard over the leftbase had been heard on an earlier occasion when theintrapleural pressure on the right side had been raisedto +17, and it was thus evident that this basal pleurisywas a response to an intrapleural pressure on theopposite side exceeding the optimum-an observationwhich may prove a useful guide when the optimumintrapleural pressure in a given case is being sought.

THE LISTER WARD AT GLASGOW.ALL hope of the retention of his ward in the Royal

Infirmary, Glasgow, as a permanent memorial toLord Lister would seem to have disappeared withthe beginning of its demolition. For more than aweek, we are informed, the work of destruction hasbeen in progress, and there does not appear to be anylikelihood of its suspension ; for the decision of themanagers passed unquestioned at the annual meetingof the subscribers on Feb. llth. If the whole matterbe examined impartially, two facts of importanceemerge. In the first place, the final decision of themanagers to demolish the ward was made in spiteof world-wide protest from a large number of medicaland scientific societies. The signatures to theseformal protests include those of surgeons of inter-national repute, and of high academic dignitaries inmany countries. It is evidently their consideredopinion that no more suitable monument to LordLister and his work could be found than the ward inwhich his fundamental clinical data were obtained.It must be admitted that the majority of the signa-tories could not but be in ignorance of the localcircumstances which forced the managers to theirdecision ; their protests are therefore based uponsentimental grounds. On the other hand, there hasperhaps been a tendency to see in the policy of themanagers a continuance of the undoubtedly incon-siderate treatment which Lord Lister experiencedat the hands of the controlling body of his time. Wefeel that the managers must be acquitted of any suchcharges. The Faculty of Medicine is well repre-sented on the Board, and there can be no doubt thatthe final decision has been reached from no othermotive than an earnest desire to further the economicand scientific weal of the infirmary. Moreover,thorough consideration must have been given towhat may be termed

" middle course " solutions ofthe problem, outlines of which have appeared inour columns and in the lay press of the city, andalthough Mr. James A. Morris (whose first appealfor the preservation of the ward we discussed in

October) has issued a further plea, mainly on historicalgrounds, in which he states that the offer of .82000’for the cost of reconstruction still holds good, noaction has as yet been taken on these lines. Whilethe passing of Lister’s workshop can only be regardedas the disappearance of a structure which symbolisedthe most important contribution to surgical sciencethat has ever been made, the decision to demolishthe ward has been reached after much considerationby a thoughtful and unbiased body of men. Inthese circumstances surgical science, and indeedhumanity, must accept as his monument, now andin the future, the world-wide continuous applicationof his principles. From no lips more fittingly thanLord Lister’s might there have come the prouddeclaration :

"Exegi monumentum aere perenniusRegalique situ pyramidum altius."

THE PHYSIOLOGY OF THE STOMACH ANDDUODENUM.

Ix England and the United States the advent ofthe duodenal tube has been the occasion for a revivalof interest in the physiology of the stomach and upperalimentary canal more important than any whichhas occurred since the publication of the originalobservations of Pavlov. While the limitations ofintubation of the human subject are definite, and thegreatest ingenuity can never secure experimentalconditions as exact as those given by a healthyanimal with an accessory stomach-pouch, the value ofexperiments done actually upon human beings com-pensates for this to a considerable degree. The mostimportant contribution to this subject publishedduring the present year is that of M. McC. Baird,J. M. H. Campbell, and J. R. B. Hern, which appearsin the current issue of the Guy’s Hospital Reports.lNot only does this article contain very valuableoriginal observations, but the writers have carriedout most painstaking investigations on lines sug-gested by the work of other researchers. Of these-the more important are the experiments in whichthe total chlorides of samples of gastric contentswere estimated at varying periods after meals, con-firming the work of C. Bolton and G. W. Goodhart,who proved the importance of regurgitation ofduodenal contents into the stomach as the mainfactor in diminishing gastric acidity in the laterstages of gastric digestion. This mechanism wasfirst described by Boldyreff3 following observationsupon animals; its importance was emphasised byT. Izod Bennett and J. A. Ryle4 in their observationson normal human digestion ; and the work of Boltonand Goodhart, confirmed by the present observations,establishes it as a normal part of the gastric digestive-function. At the same time Baird, Campbell, andHern produce new evidence of the action of thepyloric portion of the stomach itself acting as analkali-secreting medium ; here they make use of aningenious method by which two tubes are employedsimultaneously. One, lying in the stomach, enabledthem to withdraw fractions of the stomach contents ;.the other, in the duodenum, was subjected to con-tinuous syphonage, so that the duodenal contentswere aspirated and regurgitation into the stomachprevented. This method, which has been employedfor somewhat similar purposes by R. K. S. Lim,A. R. Matheson, and W. Sclùapp,5 has the advantageof giving much less complex information, but requiresgreat patience on the part of the subjects experi-mented on.

In the course of the series of experiments underdiscussion the observers were again confronted bythe paucity of our present knowledge concerningthe mechanism of control of the pyloric sphincter

1 Guy’s Hospital Reports, vol. lxxiv., No. 1, January, 1924.London : Wakley and Son. 12s. 6d. net.

2 THE LANCET, 1922, i., 420.3 Boldyreff: Quarterly Journal of Experimental Physiology,

1914, viii., 1.4 Guy’s Hospital Reports, 1921, lxxi., 286.

5 Edin. Med. Jour., 1923, xxx., 265.

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The acid-control of the pylorus described by Cannonhas been criticised by many workers. Baird, Campbell,and Hern, in their experiments, found that the

emptying of the stomach occurred at rates by nomeans dependent upon the acidity of the contentsof the pyloric antrum, and often in the presence ofduodenal contents of a reaction definitely acid. Thelast part of their work deals with the problems ofachlorhydria. They found that of 60 normal studentsexamined only one showed this phenomenon whensubjected to repeated observations, and close examina-tion of this subject threw doubt on the question ofhis normality. It is admitted that for any adultthe definition of health is almost impossible, and onemay question whether the other 59 subjects examinedwould all have stood the test of searching clinicalinquiry in this respect. Large numbers of subjectsmust still be examined before a final answer to thisproblem can be given ; it remains certain that thereare a considerable number of persons with achlor-hydria living apparently normal lives. It is inconnexion with the aetiology of pernicious anemiathat this subject finds its most immediate interest.

OCCUPATIONAL MORTALITY AND INDUSTRIALUNREST.

THE student of medical sociology who turns tomortality records for some light upon the recentunrest among locomotive engine-drivers finds himselfat a loss. The most recent figures published (samplesfrom which are here given) refer, it is true, to 1910-12,but the comparative figure of the Registrar-General’sCornparatit’e illortality (England and Wales) in Certain

Occupations. (Ages 25-64.)

occupational group, "

engine-driver, stoker, cleaner "was equally satisfactory in 1900-02 and in 1890-92.At no period of life was the mortality experiencedexcessive, nor was any constituent cause of deathin excess. In the Statistical Bulletin of the Metro-politan Life Insurance Company of New York forDecember, 1923, some statistics of the longevity of" locomotive engineers " are quoted, from which theauthors infer that engine-drivers have an expectationof life " about as good as that for the average Americanmale of corresponding age," and remark that thespecial hazards of the occupation " seem not to reducehis longevity prospect below that of males in thegeneral population." We are rather surprised thatthe American experience is not more favourable.The group, as we have seen, enjoys in this countryone of the lowest rates of mortality of any group,a much lower rate than all occupied and retired males,and an appreciably lower rate than members of thecivil service. Calling the rate for all males 100,that for engine-drivers was 68, and for the civil service(clerks and officers) 77. This is hardly surprising,since the duties of the occupation can only be per-formed by physically select men, so that the rate ofmortality is hardly a simple criterion of the salubrityof the occupation itself.On the other hand, mortality data present real

excuse for unrest among dock labourers. Thisoccupational group has always stood high for death-rate ; in 1910-12 (the last published records) theirmortality was only exceeded (omitting occupationalgroups with special risks, such as silicosis among tin-miners and metal-grinders, and alcoholism among inn-servants and brewers) by costermongers, seamen, andmessengers. Dock labour is not a skilled industry,

and the unsuccessful of other trades tend to drift to it,as well as to messengering and cost ermongering.Here lies a reason for much of the high mortality ;but low wages, uncertainty of employment, andconditions of work undoubtedly also contribute theirshare, for these persons need a better rather than aworse environment than obtains under other occupa-tions. The dock labourer suffers in excess from alcoholicdiseases and has a reputation for industrial drinking.The contrast between dock labour, shipbuilding, andagriculture is great, although the weather exposurein each is similar. Reference to the great causes ofdeath which contribute to the total mortality disclosesthat, although all are high, the death-rates of docklabourers from respiratory diseases are particularlyexcessive.

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THE AFTER-CARE OF THE CANCER PATIENT.

THERE are few more tragic figures in human lifethan the sufferers from malignant disease who dailypresent themselves for treatment in our hospitals.Apart from the few fortunate ones, in whom a cureis effected, their days will often be numbered ;yet how often are they the most cheerful and courageousof patients. Any schemes for after-care, therefore,which shall make for a less distressing end should havea full measure of our sympathy. In the fourteenthreport of the Cicely Northcote Trust (October, 1922-October, 1923), recently issued by the Almoner’sDepartment of St. Thomas’s Hospital, a lead is givenin this direction. The cancer patient, unlike thephthisic, is often a person of middle age, and thereforeoften with a young family. Struck down in the yearsof greatest responsibility he must face the prospect ofa long illness with an ominous prognosis. Someoneis needed, therefore, who can " stand by," who willhelp the family to carry on and to make thosereadjustments to life which such a situation necessarilyentails. And here the almoner gets her chance-andher privilege. The patient may return home fromhospital with a wound to dress or with an inoperablesecondary or recurrent growth to deal with, and in theend there may be a long struggle with secondaryinfection, haemorrhage or bedsores.A small booklet on " Howto Nurse Cancer Patients,"i

by the late matron of Chelsea Infirmary, recentlypublished, well emphasises these points. Readingbetween the lines we can realise how the district nursewho sees the cancer patient in his last stages mustimprovise again and again to make bricks withoutstraw in the homes of the poor. The Cicely NorthcoteTrust report also stresses this point; not only medicalattendance, but nursing appliances such as hot-waterbottles, bed-pans, air-cushions, draw sheets, nlackin-tosh sheets, unlimited supplies of dressings, &c., are

required. Very little imagination is needed tovisualise the plight of these cases, and we wonder ifthe time has not come when no case of malignantdisease shall be discharged from hospital withoutdefinite provision being made for after-care. Suchprovision would naturally fall under two heads :(1) Adequate arrangements for watching and followingup the successful operation cases in view of thepossibilities of recurrence ; (2) suitable preparationsfor the last painful months of the inoperable casewho will require careful nursing-preparations whichmust envisage all the possibilities of sepsis. secondaryhaemorrhage, and the like. In these matters we mightfollow the lead of the after-care workers of maternity,child welfare, and tuberculosis schemes, in whichdepartments much valuable work is now being done.It is possible also that a systematic after-care schemefor patients with malignant disease might ultimatelyproduce useful statistics as to complications andsequelae, duration of life. and even errors of diagnosis.At present we class all these patients together in onegroup as cases [with a hopeless prognosis, whereascareful following up might shed a new light on someof these questions. In tins matter medical officers of

1 How to Nurse Cancer Patients. By E. S. Barton, R.R.C.London : The Scientific Press, Ltd. 1s. 3d.