350

Annotations.

PROFESSIONAL SECRECY.

"Ne quidnimis."

WE understand that certain of our readers haveconcluded from a sentence in a leading article whichappeared in THE LANCET of July 23rd, that we urgedthe General Medical Council in the exercise of itspowers with regard to infamous conduct in a profes-sional respect to remove from the Register the nameof any practitioner who gave evidence against a

patient in a court of law, whether ordered to do soby the judge or not. We did not make any so directrecommendation, and the motive of a purely tentativesuggestion has been misunderstood. In a briefreference to the discussion at the meeting of the BritishMedical Association, we wrote :

" As it is, the lawyerand the priest are not protected by statute, but noone questions the lawyer as to what the prisoner hastold him and the priest would be punished for divzlgi7zg.Possibly the General Medical Council ’might assist byoffering to remove from the official register the nameof any practitioner who laid bare his patient’s secretson the invitation of a judge." This was intendedto convey, and in our opinion was only calculated toconvey, the suggestion that, at present, the oftenreferred to case of the Roman Catholic priest offers noparallel to that of the medical man. If the formerenjoys any special privilege or protection in thewitness-box, as to which we are sceptical, it is due tothe belief (1) that he has solemnly pledged himselfnot to reveal the secrets of the confessional ; (2) thathe would incur ecclesiastical penalties by so doing.We consequently suggested that as no such pledge or

"

penalties exist for the doctor, his refusal to giveevidence might " possibly " be strengthened by his possible " being able to point to the danger that he would incur ’ ’.in giving it. We frankly agree with one correspondent correspondent that the High Court of Justice might resent such iaction on the part of the General Medical Council. <The mention of what ’* possibly" might be done was, <however, a suggestion only. It was made in accord- aance with the view developed in a leading article in (

THE LANCET of July 30th, that at some future date E

a test case calculated to arouse a strong combined c

protest by the medical profession, should call attention r

to the whole subject. Moreover, the suggestion, tas another correspondent has pointed Qut to us, i

was made at the meeting of the British Medical a

Association. --

I

THE INTERNATIONAL ASPECTS OF CHILD

WELFARE WORK.

Ax informal conference on the InternationalAspects of Child Welfare Work was called by theFriends’ Relief Mission in Vienna on Julv 18th. The

honorary president was Frau Marianne Hainisch,mother of the President of the Austrian Republic,Miss K. D. Courtney acting as chairman in the morning

. and Dr. Hilda Clark in the evening. Other speakersincluded Prof. von Pirquet. Miss Jane Addams,president of the Women’s International League forPeace and Freedom, Dr. Poerner, and Dr. Horneck,as well as representatives of child welfare agencies inSwitzerland, France, Austria, and Germany. The valueof relief work in promoting international understand-ing was dwelt on by several speakers, Dr. Hilda Clarkpointing out that, while international legislation wasvitally important, the interest and goodwill of ordinarypeople, especially of those concerned with questionsof family life, might have far-reaching effects in theeconomic welfare of nations. Miss Jane Addamsadvocated an international standard of child welfarebelow which no country should go, which wouldprevent children from starving in one country whileabundant food was available in an adjacent one. Prof.von Pirquet, dealing with the incidence of tuberculosis

in Vienna, said that, while it had been very preva-lent before the war, the years of under-nourishmenthad given it a terrible impetus. It had been found that90 per cent. of the children examined reacted to thecutaneous test, and as soon as symptoms of tuberculosisdeclared themselves in an individual it was necessaryto take active steps to increase the powers of resistance.Prof. von Pirquet described the means taken to supple-ment the insufficient sanatorium accommodationin Austria. The roof of a hospital for tuberculouschildren had been adapted to take 100 patients, whothus spent their whole time in the fresh air, the bedsbeing placed under a roof shelter. By this simple andinexpensive device the accommodation of the hospitalhad been doubled, and remarkably good results hadbeen obtained. Dr. Poerner said that, whereasdiseases of the digestive tract formerly accounted forthe greatest number of infant deaths, general debilitynow ranked first as a cause of infant mortality, sug-gesting an embryonic weakness resulting from badhealth conditions in the parents. The decrease indigestive disorders was mainly due to the fact that,owing to the scarcity of fresh milk, a far greater pro-portion of mothers nursed their babies than in pre-wardays. in spite of their own under-nourishment.Pyaemia and skin diseases showed an increase as acause of death, while a falling-off in nervous diseasesmight be accounted for by a reduced consumption ofalcohol on the part of parents.

THE TEACHING OF OBSTETRICS AT LEEDS.

THE Leeds Maternity Hospital is one of the youngestand most useful of the Leeds charities. Founded in1905 by the Leeds Ladies’ Hospital and MaternityFund, it began its work with 33 beds ; in 1910 thehospital was transferred to the present buildings,which are well situated and not far from both themedical school of the University and the infirmary.There are now 70 beds, and material enlargement isneeded. During 1920 the number of patients treatedat the hospital was 1540 ; of these 1314 were cases ofconfinement. the balance being made up of cases

attended elsewhere, in which complications had arisenas a direct result of labour. In addition to the workdone within the walls of the hospital, there is anextern department in which. last year, the number ofconfinements was 1366. Five subsidiary homes aremaintained in connexion with this extern department;the managers of the hospital have from the firstrecognised the importance of the teaching of midwivesas a part of their work, and during the year 98 pupilmidwives received training, 83 obtaining the certificateof the Central Midwives Board. In connexion withthe training of nurses at the General Infirmary anarrangement has been made by the board of theinfirmary for 20 of the infirmary nurses to receivethree months’ training at the Maternity Hospital, sothat they may obtain the midwifery certificate. Tocarry this arrangement out the infirmary grants tospecially selected nurses scholarships which cover

fees and expenses during training. Nurses are alsoreceived for training from the Poor-law infirmary,from the West Riding Nursing Association, from thegeneral infirmaries at Halifax and Nottingham, andfrom other institutions. The work is under the con-trol of the members of the honorary staff, of whichthe Professor of Midwifery at the University is anex-officio member.The presence of this well-equipped hospital in Leeds

has enabled some great improvements to be broughtabout in the instruction of students ; prior to 1885the latter had to rely on the private practitioners fortheir experience in practical midwifery, while a fewwent to special institutions such as the Rotunda.At the request of the board of the medical school anextern maternity department was instituted at theinfirmary ; after some years the desire for moresystematic teaching in practical midwifery led tosome few cases of special difficulty being admitted tothe infirmary, and subsequently a very small intern

351

but not until the development of the MaternityHospital was the present arrangement made possible.The University and the Maternity Hospital have eentered into an agreement by which the hospitalundertakes the whole of the practical teaching of thestudents in midwifery. This instruction is directedby a committee, which consists of the Dean of theFaculty of Medicine and the honorary staff ofthe hospital, including, of course, the Professor ofObstetrics. The University and the hospital combinein the election of a resident medical officer andobstetric tutor ; the University regulations requirethat all students shall attend the intern work of the

hospital for a period of one month before doing anyduty in the extern department, and from the residentofficer the students will receive their earliest practicalinstruction. It will soon become necessary to appointa junior to assist in the work. It is very desirablethat all students, during the time they are on internduty, be provided with accommodation close to thehospital so that they may be summoned by telephoneto see all cases of difficulty and of interest. Strenuousefforts are being made in this direction, and it is

hoped that these will shortly prove successful.

PAYING POOR-LAW PATIENTS IN MANCHESTER.

THE result of conferences between the ManchesterBoard of Guardians and representatives of the medicalprofession has been agreement upon a scheme for theuse, by paying patients, of beds in Poor-law hospitals.Amongst other provisions of the scheme, which is tobe controlled by the medical superintendent of thehospital in which the beds are provided, are thefollowing :-The beds shall be available for cases sent in by any medical

practitioner who shall be allowed, if he desires, to attend,treat, or operate on them himself, with the assistance of theresident medical and nursing staff of the hospital.

Patients shall be admitted to anv of the beds with therecommendation of a medical practitioner, where possible,subject to the final approval of the medical superintendentof the hospital.Any practitioner may, if he desires, attend and treat

gratuitously any patient recommended for admission byhim who can only afford the standard hospital fees formaintenance and treatment. Intention to do so must bestated at time of admission.

It is felt by the representatives of the ManchesterMedical Committee that the arrangement may notonly prove of great value to a number of patients, butwill also provide an opportunity for general prac-titioners to participate in institutional treatment.The tariff of fees will be arranged by the local MedicalAssociation.

--

COMPOSITION OF HUMAN FAT.

ALTHOUGH a good deal is known regarding thechemical composition of the fatty tissue of animalsand its relation to the fats in the food, little work hasbeen done on the constitution of human adiposedeposit. It is agreed that the fats of infants have ahigher melting point and contain less oleic acid thanthe fats of adults. In a recent article 0. Schirmerldescribes the results of his investigations to determinewhether the state of nutrition and conditions ofdisease affect the composition of the fats of the humanbody. He examined the fat of the abdominal wall.It showed extraordinary variation in water content,from 5 to 71 per cent., so that there can be no questionof anything like a mean water content of 29-9 percent. as given by Vierordt. In fat persons the fattytissue contains less water than the fat of lean indivi-duals, so that there would appear to be a relation,hitherto unobserved, between the fat and watermetabolism of the body. From his observations theauthor concludes that in certain cases of disease verylarge amounts of fat in adipose tissue are replaced bywater, and in this condition the absorptive connectivetissue plays an important part, especially as the test

1 Arch. f. Exp. Pathol. u. Pharmakol., vol. lxxxix., 1921.

tissue which contained most water showed the largestamount of connective tissue. In the fats themselvesthe consistence diminishes with increase in the iodinenumber. Fats with a high iodine number-about 70-are fluid at room temperature. On standing thereis formed gradually a solid deposit consisting of

tripalmitin. In fat individuals the iodine indexrises very considerably and the fat is much more fluidthan in spare individuals. The amount of cholesterolis much higher in fats with a low iodine number. Anormal iodine number in a person of normal nutritionmay be taken as 65 to 66-5, corresponding to anolein content of 59 per cent. In very fat personsthe corresponding iodine number lies in the regionof 70. Tables are given to show the influence ofdiseases and constitution on the quantity and com-position of the fats, but no simple rules can be deducedfrom them. Nephritis, diabetes, and castration seemto lessen the iodine number. Experiments on rabbitsand ducks were undertaken to study the effects offood fats on the body fats. The composition of thefats given in the food modified the composition of thebody fats, even when the food contained no excessiveamount of fat. The administration of oil increasedthe iodine number, while tallow diminished it. Humanfat with an iodine number of 69 melts at 16&deg; to 20&deg; C.,and rabbit fat with the same iodine index at 400 C.

A MODEL VILLAGE IN U.S.A.THE first annual report on the health department

of the model village which the United States PublicHealth Service has been developing for nearly twoyears on the 516-acre Government reservation atPerryville, Maryland, contains some interesting in-formation. The reservation was used during the waras a site for a large nitrate plant; the buildingsincluded 200 cottages, two general stores, a modelschool house, club, firehouse, and theatre for the work-people, and the whole property was handed over byCongress for use as a hospital site and for storage ofthe medical supplies of the Public Health Service.The Public Health Service promptly transformed agroup of cottages into one hospital and set out tobuild another ; the two together now accommodate430 patients. Not including the variable hospitalcontingent, the reservation now has a population of839 persons, the sexes being, roughly, equally repre-sented. The birth-rate on the reservation was 39-33 per1000, as against 21-39 in the whole State and 28-78in the county. The death-rate was only 3-67, an excessof children being roughly balanced by the smallnumber of aged persons. While this low death-rateis partly due to the favourable age constitution ofthe population, much of the credit is laid at the door ofthe efficient health administration. Careful work haskept down the figures of cases of communicabledisease, particularly diphtheria, of which 30 cases

occurred during the year in the county and three onthe reservation ; one of these last was a new-comer,one a young sister of a boy who was found to be acarrier, and one an adult. The low prevalence ofcontagious disease is ascribed directly to close watchand prompt isolation, laboratory diagnosis, andprophylaxis, and indirectly to pasteurised milk,filtered and chlorinated water, school medical super-vision, and good living conditions, including sewers,screens, and covered garbage cans. A physicalexamination of the children showed that 93-5 percent. had physical defects of teeth, tonsils, adenoids,eyes, or hearing, this large percentage probably beingdue to the lack of facilities for remedial correctionnearer than Baltimore. Similar percentages are foundin the county outside the reservation. Many of thesedefects have recently been corrected. BetweenNov., 1919, and Nov., 1920, the percentage of under-weight children was reduced from 1:2.7 to 13-8. Thedrinking water is drawn from the SusquehannaHiver, and is, unluckily, in bad condition, being con-taminated in several highly variable ways. The geo-logical formation of the country, the daily conflict ofthe tide and the river current, and the strong winds on