1021" THE NEW INFANTRY SWORD EXERCISE."

is to increase the alkalinity of the blood is based Dr.

Haig’s entire theory of the cause of fatigue-a theorythat seems to be completely borne out by the experiments headduces. But in the article which follows, "The ClinicalIntimation of the Alkalinity of the Blood," Dr. Hutchisonmakes the following explicit assertion : "The effect of severemuscular work is to cause a fall in the alkalinity of theblood, this being probably due to the production of consider-able quantities of lactic acid by muscular metabolism."How can these two statements be reconciled ? Dr. Haig, itwill be seen, attributes the rise in the alkalinity to theincreased excretion of acids by the skin, while Dr. Hutchisonthinks that the reverse result is probably due to the pro-duction of lactic acid by muscular metabolism. Which isthe correct view ? As I have said before, I can lay claim toabsolutely no qualification that would entitle me to expressany opinion upon the subject, but the question as to whatreally is the effect of muscular work upon the alkalinity ofthe blood is one of such great interest and importance thatI may possibly be excused for calling attention to it in thisinstance. I am, Sirs, yours faithfully,

W. B. FOTHERINGHAM.March 16th 1893.

"THE NEW INFANTRY SWORD EXERCISE."To the Editors of THE LANCET.

SIRs,-In a letter published in THE LANCET of March 28thDr. Ritchie takes exception to my criticisms, founded onanatomical and physiological grounds, of the new infantrysword exercise. With your permission I will reply briefly tothe points he raises. I endeavoured to show that in theMasiello system--a more accurate term, I understand, than1 Italian " for the newly-adopted exercise-a greater expendi-ture of force is necessary to effect the required movementsthan in the French system ; that fatigue, in consequence,will ensue earlier; that the chief muscles concernedhave to act at an undue mechanical disadvantage ; andthat rapidity, variety, and delicacy of movement are to

a great extent sacrificed in order to ensure a more

powerful thrust. It does not appear to me that Dr.Ritchie effectively traverses these propositions. Withregard to the "on guard " position, Dr. Ritchie argues thatthe wider separation of the feet in the Masiello attitudeallows greater rapidity in the "advance" and "retire,"because a greater pressure can be exerted in the left foot inthe " advance " and from the right in the " retire." I cannotagree with him. The more the feet are separated the

greater is the exertion necessary in the initial stage of eithermovement and the less perfect is the balance. Additionalexertion is therefore required to preserve the balance. Ifwe accept Dr. Ritchie’s view it should follow that withthe feet still more widely separated than is prescribedin the Masiello ’’on guard" position the movementsof "advance" and "retire" are still further facilitated.We are then brought face to face with a very obvious reductioad absura2cm. Dr. Ritchie admits frankly the greater exer-tion needed when he writes that the advantage of "greaterrapidity of movement backwards from the Italian than fromthe French attitude " (retiring) is " well worth the extraeffort entailed by the further separation of the feet." Butto my mind the removal of the resistance of the left foot in

retiring leads not to greater rapidity of movement so muchas to loss of balance. The further the supporting leg (inthis case the right) is from the line of gravity passingthrough the trunk, the less perfect is the balance and the

greater is the effort required to maintain it. Comparisons ofdiagrams of the Masiello and French attitudes will makethis point obvious at once. The greater the exertion themore quickly will fatigue ensue.Next, as to recovery from the lunge. Dr. Ritchie considers

that the raising of the body to the vertical position is effectedby the hamstring muscles rather than by the gluteals, as Istated. I think this criticism is sound. I noticed the errorbefore my letter appeared in print, but when it was too lateto correct it. The correction makes my case stronger. Itis unnecessary for me to call attention again to themechanical disadvantage under which the hamstringmuscles act and the disproportion between the two arms ofthe lever, for Dr. Ritchie himself points this out very clearly.As the muscles act at such a mechanical disadvantage theexpenditure of force necessary to effect the recovery is very

1 THE LANCET, Nov. 30th, 1895.

great, far greater than in the recovery from the Frenchlunge. And for the same reason the initial velocity of thebackward swing is comparatively low. By " backwardswing," it must be noted, is meant the raising of the bodyfrom the inclined position forwards to the vertical attitude;beyond this the body is not allowed to swing. The chieffunction of the erector spinæ in this action is to preservethe rigidity of the longer arm of the lever. To the

opinion that the backward swing does not increasethe rapidity of recovery I must still adhere. The

experiment mentioned by Dr. Ritchie only illustrates the

greater force needed in recovery from the Masiello lunge.The extra exertion and the consequent fatigue again arepractically conceded. Dr. Ritchie makes no allusion tothe fatigue entailed on the sword arm by the extended posi-tion of the limb in the " on guard" position, and I may takeit, therefore, that he concedes this point also, which, indeed,it seems impossible to question. He does not deal with theremarks I made on the movements of pronation and supina-tion on the ground that in the Masiello system these move-ments are not concerned, supination being only required inone of the parries ; that is to say, that all the advantages tobe obtained in the French system from the various move-ments of the fingers and the actions of pronation and supina-tion are thrown away in the Masiello method. The greatervariety of movements, and the fact that they can be madewith less expenditure of force and so entail less fatigue,seem to me, on anatomical and physiological grounds, tomake the French system incomparably the more scientific ofthe two. I am, Sirs, yours faithfully,

C. T. DENT.Brook-street, W., April 6th, 1896.

THE SANITARY INSTITUTE AND THEISOLATION OF CASES OF INFECTIOUS

DISEASE IN THE METROPOLIS.To the Editors of THE LANCET.

SIRS,-The interesting paper on the above subject readat the sessional meeting on March llth by Mr. AugustusCharles Scovell could not have failed to impress the audiencewith the importance of this subject as regards the pro-tection of the public against zymotic diseases and con-sequently the reduction of the death-rate. But while I deeplyappreciated the interesting discussion and the importantcontribution thereto by the eloquence of Dr. Thorne ThorneI was disappointed that little or nothing was said as to theworking of the Notification Act. My presence as a guestmade me feel some diffidence as to the etiquette of per-sonally calling attention to the subject, the importance ofwhich alone juttifies my now drawing attention to it. Mr.Scovell, in speaking of scarlet fever in connexion withthe future demands for hospital accommodation, saidthat "the accumulating statistics of notification oughtto prove useful." And it is to this disease alone that Ishall confine my comments. Mr. Scovell is right, but Ifeel sure as long as the Act remains as it is, and as long aseven its present provisions are not strictly carried out, theMetropolitan Asylums Board will not benefit by the collectedstatistics as much as they desire, nor will the diseasebecome less prevalent ; nay, even the contrary effect willbe produced. I am confident that the Act is not thoroughlycarried out and that it wants amending so that the fullbenefit it was intended to convey to the public may besecured. I would ask, first, why is the Act not strictlycarried out and, secondly, what defect, if any, conducesto render it incompetent to deal with this disease as we alldesire ? Now, Sirs, in answer to the first question I would say that

the Act places a penalty on the head of the family whichmight become so severe that he deliberately, and perhapsnot unnaturally, tries to avoid coming under its provisions ;and owing to the notification having in many instances to goto an opposing general practitioner it is felt to be a grievancein provincial towns-where there is much prejudice againstemploying a medical man who is known to be in attendanceon a patient suffering from an infectious dise&e—that one

practitioner should be placed in possession of informationthat sooner or later leaks out (not by the medical officer ofhealth divulging information he has officially received) andwhich will bring temporary loss on the notifying practitioner.Tha,t part of the question relating to the head of the familyis by far the more serious. No medical man would abstain

1022 " DEATH UNDER CHLOROFORM AT A DENTIST’S ROOMS."

from notifying a case of the diagnosis of which he was is

confident ; and parents know this, so that in times of al

epidemics, large or small, the medical man is not sent for ri!until some serious complication has arisen. The latter may clthen feel morally certain that the patient’s symptoms are the tlsequelae of scarlet fever, but when he is met by a negative blreply to all his definite questions he may well be excused, a)

with legal actions so prevalent, if he lets the matter drop. picontenting himself with treating the present symptoms. I m

do not imply that honourable members of the profession,when once satisfied as to the nature of the case, would even irlet this fear stand in the way of duty ; but I do assert that a:

the case of a large tradesman whose keenest opponent in the ptrade is on the sanitary board and whom publicity of the afact of there being fever on his establishment will affect o

seriously (added to the fact that he is a constant and good o

all-round patient of the medical man) presents a combination pof circumstances that may enable the medical man not to be b

reasonably satisfied that he has a case of scarlet fever to r

deal with. And in the case of the lower classes a more painful v

and a sadder state of things confronts the medical man. He e

sees a case and informs the parent it must be notified, which fmeans that no children must go to school, causing a pro- Ilongation of the time before A and B can pass the necessary t

standard and take their part as partial bread-earners of the 1

family. A and B, too, who get 2s. a week each and their Nbreakfast by cleaning boots and knives before going to ischool, must relinquish this work for several weeks.The mother must not go out charing, &c. Is it surprising,then, that among this class the medical man rarely sees therash or any other early symptoms ? Hundreds of cases are somild that the little patients have no medical attendance, andwhen they do it is for scarlatinal nephritis, dropsy, or someother sequel which has frightened the parents. The tale is

always the same : they have seen no rash, noted nothing,know of no adjacent cases, and even when the desquamatingpart.s of the body are pointed out the utmost surprise is

expressed and the medical man is asked if he is certain ofhis diagnosis.The answer to the second question is brief. Let the Act

be so altered or amended that no general practitioner shallbe eligible for the post of medical otlicer of health. Let an

indemnifying clause be added to protect all practitionersfrom the annoyance of any legal action consequent on thenotification of cases of infectious disease. and give pro-tection to the public in case of their disputing the

diagnosis by empowering them to demand a consultationwith the medical officer of health free of charge. Makeit a good action at law for libel for any member of a

sanitary board to divulge information obtained underthe Act ; and, most important of all, insert a com-

pensation clause so that parents shall not suffer pecuniaryloss by having to isolate the sick child as well as othermembers of the family. I am confident with this clause

every member of the community would help the profes-sion to stamp out the disease, instead of as now spreadingit far and near. Let the poor man lose nothing by theisolation of the little patient and his whole family and hewill help in the matter. Increased hospital accommodationwould not be necessary, and I feel sure that highly satisfac-tory results would shortly be obtained.

I am, Sirs, yours faithfully, -- - - n

ELLIOT DAUNT, L.R.C.P.Lond., M.R.C.S.Eng., D.P.H.March 23rd, 1896.

"DEATH UNDER CHLOROFORM AT ADENTIST’S ROOMS."

To the, Editors of THE LANCET.

SIRs,-The reasons for avoiding the sitting posture forthe patient in the administration of chloroform have not, Ithink, been recently given.

It is clcar from the exhaustive experiments of Dr. LeonardHill’ and of the Hyderabad Chloroform Commission 2 that Ithe force of gravity has a marked effect upon the circulation,especially under the influence of certain anæsthetics, pro-ducing a fall of blood pressure in the carotid arteries in thevertical and sitting postures, which can be restored byplacing the body in a horizontal position ; also, that whenthe compensatory vaso-motor mechanism of the splanchnics

1 Proceedings of the Royal Society, vol. lvii., No. 342.2 Lauder Brunton : Transactions of the Medical Society, vol. xiii.,

p. 271.

is paralysed the sitting posture is dangerous, because itallows dilatation of the abdominal veins, emptying of theright heart, and failure of the cerebral circulation.3 Nowchloroform lowers the blood pressure and rapidly paralysesthe splanchnic vaso-motor mechanism. It cannot, therefore,be safe (with our knowledge of the limits of chloroform

anaathesia) to add the lower blood pressure of the sittingposture to the lowered blood pressure and paralysed vaso-motor mechanism of chloroform narcosis.

Beside these considerations the mortality from chloroformin any position is five times that of ether.’ Nitrous oxideand ether cause a rise of blood pressure and do not readilyparalyse the splanchnics even in large doses; they can beadministered together or ether can be given alone by meansof Clover’s inhaler, and will yield complete, quiet anaesthesiaof any required duration without danger in the sittingposture. This is a matter of every-day experience, supportedby all the above experiments and authorities. For thesereasons-and I write in the hope that they may be morewidely recognised among dental operators-I would urge veryearnestly that it is not justifiable to administer chloroformfor dental operations when ether can be obtained, unless thepatient is prepared beforehand, laid fiat upon a couch, andthe risks are clearly recognised as in all sugical procedures.In my opinion cases obliging the use of chloroform in dentalwork are extremely rare, and if they do arise the risk to lifewill be reduced by such precautions.

I am, Sirs, yours faithfully,H. BELLAMY GARDNER,

Assistant Anæsthetist to Charing-cross Hospital and tothe Dental Department.

Welbeck-street, Cavendish square, W. r

" THE DUTIES OF DIVISIONAL SURGEONSIN CASES OF INFECTIOUS DISEASES."

To the Editors of THE LANCET.SlRS.—Mr. Harnett’s letter is no answer b0 my inquiry,

although he admits the two llagrant breaches of professionaletiquette I specified. I regret to see no word of apology.Whatever he may write to the contrary, I emphatically denyhaving ever given him any cause for his behaviour. I amnot aware that a tu quoque argument exonerates a manfrom following the well-established rules which governthe behaviour of one professional man to another. I proposeto adduce several other instances of similar misconduct

occurring in my practice that your readers may judge of thisgentleman’s procedure. Some months ago a mild scarlet feverepidemic existed here and attacked several families of the

police force. In one instance the father was told to have the

patients’ heads shaved or cut close. This was objected to-and the divisional surgeon reported the man to the inspectorto enforce his prescription. It appeared to be ultra vires,however, and was dropped. In another instance the divisionalsurgeon ordered the family out into the garden at the end ofa fortnight--at least, so the mother told me. I was also toldthat the inunction of a medicament which I had ordered hadnot the sanction of his approval. In a case of diphtheriathe divisional surgeon got the child out of bed and made itwalk to the window that he might examine the throat-surely an unnecessary punishment for being the patient ofanother practitioner. When this uncalled-for and irritatinginterference is indulged in on every possible occasion itinclicates to my mind an animus which must be destructiveto a man’s judgment on other matters. Other divisionalsurgeons whom I have consulted disclaim any mission to.offend professional propriety and have no such difficulties.The limits of my letter will not permit me to discuss theirrelevant matter and inaccuracies introduced into Mr.Harnett’s letter. As there is no promise of amendment Ishall consider it my duty for the protection of my patientsand myself to call the attention of the Chief Surgeon ofPolice to this correspondence in the hope that Mr. Mackellarmay be able to render the divisional surgeon’s self-imposedduties less onerous. It is not my intention to prolong this-correspondence further.

1 am, Sirs, yours faithfully,D:1rIlet, Herts, April 6th, 1896. W. TlIYKB, M.B., C.M. Edin.

3 Hewitt : Royal Medical and Chirurgical Society, Oct. 22nd, 1895.4 Hewitt : Anæsthetics and their Administration, p. 62. Neyraud:

Lyons Thesis, Statistics from over a Million Cases from Seven different.Authorities — Étude Comparative sur l’Éther et le Chloroforme.J. Campbell, Paris Thesis, 1894 : De l’Emploi de l’Éther.