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through other Governments having made no shippingarrangements for the return of their nationals tocountries north of Suez. Obviouslv the whole of theprecautions of the Egyptian Government with regardto Egyptian pilgrims will be of little avail if foreignreturning pilgrims are allowed to trickle through thecountry uncontrolled. The Governments concernedshould either provide direct sea transport or makefinancial provision for controlled land transport andrepatriation of their own nationals. Medical controlof a pilgrimage from each country of origin, on thelines of the existing Egyptian arrangements, would domuch to reduce the present constant menace to theworld’s health.

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THE PATHOLOGY OF LEGG’S DISEASE.

THE disease of the hip-joint associated with the Inames of Legg, Perthes, and Calve has been recognisedas a clinical entity since 1909, but its causation andpathology are still in doubt. The disease is not fatal,nor does it, as a rule, necessitate operative interven-tion, and therefore material for examination has beendifficult to obtain. Histological examination of onecase (Frund) showed that the spongy tissue of thehead of the femur was completely necrosed, while thecartilage remained intact and living. Prof. A.Nussbaum,’ of Bonn, confirms this statement, andhas produced exactly the same result in young dogsby division of the blood-vessels supplying the head ofthe femur. Microscopic examination revealed necrosisof the spongy tissue of the epiphysis, characterisedby lack of staining of the nuclei of the bone cells inthe marrow and cortex. The cartilage, on the otherhand, remained in good condition, as shown byperfect staining of the nuclei and thickening of thecartilage, thus demonstrating that cartilage can livewithout its direct blood-supply, and must be nourishedby the synovial fluid. In healthy well-nourishedepiphyses the newly-formed cartilage is ossified bythe endochondral type, and growth progresses evenly ;but when the circulation is interfered with the columnsof cartilage cells are no longer ossified by the ingrowingblood-vessels, but grow irregularly on top of the bonealready formed, producing tongues and islands ofcartilage dipping down into the spongy tissue. Thesetongues and islands correspond to the clear areasseen in the X ray. The diminished ossification ofthe cartilage explains its thickening, which is shownin the X ray by increase in the width of the jointcavity. Later, regeneration of the head takes placeby new blood-vessels growing in with connectivetissue developed from the synovial membrane. Theseexperiments prove that Legg’s disease is due to aprimary necrosis of the head of the femur caused byan interference in the blood-supply, the cause of thelatter being still unknown. Prof. Nussbaum suggeststhat the name the disease usually bears on thecontinent (osteochondritis coxae juvenilis) is false,and should be replaced by necrosis capitis femoris.

ATMOSPHERIC POLLUTION.

THE eighth report of the Committee for the Investi-gation of Atmospheric Pollution provides much (valuable information obtained from systematic

Ianalyses of impurity deposited from the air at about I30 experimental stations in different parts of thecountry. The first six reports appeared as supplementsto THE LANCET ; the present report covers observa-tions for the year ended March 31st, 1922. Asinvestigations on these lines have been carried outfor a series of years it has been possible in the case ofmost stations to include in the report a comparisonbetween the deposit collected during the currentyear and the average results of the past five years.In nearly all stations the quantities deposited duringthe year were below the average. Comparisonbetween summer and winter deposits show that the

1 Deutsche medizinische Wochenschrift, June 29th, 1923.

summer total was less than the winter in 14, equal inthree, and greater in five cases. From the records ofDr. J. S. Owens’s automatic instrument figuresshowing the amount of suspended matter at eachhour of the day and night have been prepared forLondon and Rochdale, and graphs of the averagevalues over long periods indicate the remarkableparallelism between impurity and the periods ofactivity of domestic fires. Other curves showingthe variation of pollution at three London stations ondifferent days of the week bring out the effect of localsmoke production on the state of the air. The effectof the coal strike of 1921 upon the maximum amountof suspended impurity in London air is shown inanother figure. Experiments in Rochdale to ascertainwhat proportion of the impurity was produced locallyand what was carried there by air currents show thatonly 15 per cent. of the matter deposited at the centreof the town was brought there by the wind. Dr.Owens’s new portable instrument has proved of gooduse for the rapid collection of suspended atmosphericdust in a suitable form for examination and countingunder the highest power of the microscope. Photo-micrographs of some typical specimens of impuritymagnified up to 2000 diameters are given in the report,and a useful bibliography of the measurement ofdust by various methods is added. Special interestattaches to this report owing to the hope that theproblem of atmospheric pollution is to receive seriousconsideration in Parliament in the near future. TheGovernment are pledged to legislate upon the matter,and one of the proposals of the Bill introduced intothe House of Lords by Lord Onslow on behalf of theMinistry of Health runs as follows :-

" The powers of the urban authority... shall extendto the making of bye-laws requiring the provision in newbuildings other than private dwelling houses of such arrange-ments for heating as are calculated to prevent or reducethe emission of smoke."

This Bill will come before Committee when theHouse of Lords reassembles in November, and,although it is an earnest of official interest, themeasure as drafted falls short of what is regardedby some as essential. At present Government premisesenjoy a complete immunity from prosecution as

regards nuisances ; they should be brought into linewith other industrial concerns. Suggested concessionsin favour of the iron and steel trades arouse misgiving,for clearly the Bill should retain such advantages asthe present law possesses until replaced by somethingbetter. The report deals exclusively with measure-ment and makes no suggestions as to the mitigationof the smoke evil, which is a problem outside the sphereof the Advisory Committee. But exact measurementis an essential step towards improvement and theusefulness of the report cannot be questioned.

THE TRAINING OF MIDWIVES.

THE numbed bewilderment of a flock of prospectivemidwives being questioned by a member of thehonorary staff on an official round has often excitedthe compassion of the more hardened medical studentswho may be present at the ordeal. The recommenda-tion by Dr. Janet Campbell in her report on theTraining of Midwives (H.M. Stationery Office, Is. 3d.)that the minimum training period for unqualifiedwomen should be 12 months, and that for trainednurses should be extended from four to six months,will be -welcomed by all who have watched thesepitiful rounds. For untrained women, who have togain practical experience of asepsis and antisepsis,as well as to grasp the principles of midwifery, tomaster in six months the present curriculum is

obviously too heavy a task. The examination embraces17 essential subjects, of which one alone, the symptoms,mechanism, course, and management of natural labour,must include a clear conception of the stages of oneof the most elaborate physiological processes in thebody, almost as puzzling to the clinical student as

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were the folds of the peritoneum in his dissecting-roomdays. Dr. Campbell does not advise the extensionof the time period without careful consideration ofpossible disadvantages, which she enumerates, butconcludes that it is inevitable if higher standards ofpractice are to be expected. In considering thecurriculum she notes that the nursing of puerperalwomen is often less efficient than it should be ; insuch concentrated training it is easy to neglect theunsensational routine of maternity nursing apartfrom actual delivery. Antenatal work has also beendealt with too lightly in the past; comparatively fewmidwives now in practice have had any useful trainingin this respect, and probably for this reason fail tomake full use of the maternity welfare clinics. Thefeeding, care, nursing, and management of prematureor diseased infants are special branches of her pro-fession of which the midwife should also have practicalexperience. Unfortunately the colleague responsiblefor her training is not always really qualified to impartsuch complete equipment. To provide against thispossibility, Dr. Campbell suggests the institution ofa special certificate for teachers, not necessarily to,eliminate the approval of practical midwives in thiscapacity, but to ensure that a teacher shall havethe necessary degree of personal education and aknowledge of more recent developments of midwifery,as well as facilities and equipment for undertaking a12 months’ course of training. The majority ofpractising midwives, though competent and success-ful in their work, have not these qualifications ;their teaching is still further limited by thepossible susceptibilities of their patients, and theycannot afford to risk damaging their own practices bysuch methods as, for example, systematic antenatalsupervision, which might annoy or alienate the womenattended. The certificate for teachers would not

I

imply any overstepping of the legitimate functionsof a midwife and would, we consider, be an excellentstep. Of more doubtful utility is Dr. Campbell’ssuggestion to register and thus recognise " handy-women." She does not propose that any qualifica-tion should be required for registration, but merelythat suitable women engaged in maternity nursingshould be accepted. Any unregistered woman foundundertaking this work would then be liable to prosecu-tion. The only requirements upon which it wouldbe possible to insist in all cases are good character,personal cleanliness and physical fitness, temporaryor permanent suspension from the register followingproved unfitness in any of these respects. Dr.Campbell does not believe that registration wouldenhance the status of the handy-woman, but thatthe inconvenience of being subject to suspension by,say, the inspector of midwives, would act as a dis-couraging factor on her employment. We have somequalms, however, about her hopeful suggestion thatdifficulties would not arise over the inspection ofunqualified women working directly under a doctor;nor do we anticipate that those fully trained monthlynurses who are not midwives would appreciate beingenrolled in the same list as quite untrained women.It is not easy to see how best to relegate the handy-woman to her proper function of home-helper, butthough the advantages of registration, as outlined byDr. Campbell, are not inconsiderable, we do not thinkthis proposal will meet with general approval. Asection on the midwife and the public health serviceconcludes an admirable report.

Dr. Andrew Balfour resigns on Oct. 31st his postas Director-in-Chief of the Wellcome Bureau ofScientific Research to take up other important duties.He will be succeeded by Dr. C. M. Wenyon, who forthe past nine years has been Director of TropicalResearch at the Bureau.

WE regret to announce the death, on Sept. 8th, ofMr. Gustavus Hartridge, ophthalmic surgeon toWestminster Hospital, and gratefully known to manygenerations of students for a lucid manual on therefraction of the eye.

Modern Technique in Treatment.A Series of Special Articles, contributed by

invitation, on the Treatment of Medicaland Surgical Conditions.

XXXVI.

MENORRHAGIA IN YOUNG WOMEN WITHOUTGROSS LESION.

THE menstrual function is governed by internalmetabolic changes of which haemorrhage from theendometrium is but the outward and visible sign.The unseen and little understood metabolic processesnaturally tend to be overlooked and the uterus,particularly its mucous lining, regarded as the organat fault in menstrual disorder. It is curious thatwhile amenorrhcea and scanty menstruation are

accepted as due rather to general bodily states, suchas malnutrition, anaemia, &c., excessive or painfulmenstruation is usually ascribed to deviation in theposition of the uterus or disease in the endometrium,so that alteration of position and curetting have hadan undue prominence in treatment.

It is essential in the first place to make sure of theprecise nature of the trouble. Patients often seekadvice because their normal habit is in excess of theaverage and, though perfectly well, think the loss isgreater than it should be. Such patients require notreatment; it should be explained to them that theirtype is natural to them, although above the averagein quantity or duration. On the other hand, definitechange in the menstrual habit in the direction ofexcess is an indication of disturbance whether itcauses symptoms or not, and the general health andcircumstances of the patient call for investigation.If the menorrhagia is a symptom of organic disease,renal, cardio-vascular, or suchlike, the treatment willbe that of the primary condition, but the vast majorityof cases do not exhibit serious organic disease, and themost common provoking factors are those of a nervousand psychical origin or a change in the mode of lifeor occupation, as, for example, from a healthy outdoorlife in the country to a sedentary occupation in town.Here treatment must consist chiefly in advice on howbest to order the patient’s present mode of life so asto remove the causes predisposing to her trouble.Unless this can be done no medicinal or other treat-ment will avail. The shop assistant or waitress onher feet all day in a stuffy atmosphere may obtainsome benefit from physical exercise at her off times, ifnot too tired to enjoy it, from regulation of the bowelsand other general hygienic measures, but unless shecan continue at work through her periods she willnot be able to keep her place. If the menorrhagiapersists she must, at any rate for a time, give up work,when probably her natural habit will soon return.Ergot, calcium lactate, and the cotarnine salts aredisappointing; generally the most valuable drugs arethe bromides, but they are rarely successful unless thepatient can rest at the time of the period. Improve-ment of the physical condition is essential, and thebest possible use must be made of the intermenstrualperiod. The cases that respond most readily tohygienic treatment are those with excessive loss withnormal intervals ; the troublesome cases are thosewith shortened clear intervals.Though less serious in its effects, the type in which

a slight discharge-often termed " draining " or" dregs " by the patient-persists after the free losshas ceased is particularly difficult to treat ; it iscommon in nervous women and causes them muchmental distress. The continuance of a slight dischargeshould not be allowed to interfere with outdoorpursuits, and if once the patient can be persuaded toconcentrate on her physical condition and not on herailment, the likelihood of her recovery will be greatlyincreased. Curetting is rarely of use, but may betried in those over the age of 25, in whom othermeasures have failed ; the possibility of an intra-