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work of fiction, we need only refer to Mr. SomersetMaugham’s grim story " Mackintosh," where such acondition is admirably described. Mackintosh wasanxious to kill a man, by name Walker, or shall werather say, that such a man should be killed. Anenemy of Walker, a Polynesian native, came to seeMackintosh for some medicine, and saw a revolverlying on the table. Mackintosh saw that he saw it,and went out of the room ; " it was this other personthat possessed him that drove him out of the room,but it was himself that took a handful of muddledpapers and threw them on the revolver in order tohide it from view." When he came back he did notdare to look to see whether the revolver was there,but that night Walker was shot and next morning therevolver was back on the table with four emptychambers. To many people lonely places, the desertor mountain, seem particularly favourable environ-ments for the attacks of the unconscious mind or evil Ispiritual influences, whichever they may be called.To others, as Dean Inge says in his second series of" Outspoken Essays," 1 snow-peaks and glaciers open" avenues of communication with the magnalia Deiwhich are less easy to maintain amid the dark andgrimy surroundings " of a London home. Physicalconditions are, however, not to be put on one sidealtogether, and it may be that the abnormallyreceptive condition of the mind might, in the visionsof the devil which came, say, to St. Dunstan andLuther, have been dissipated by a dose of calomel.But for all that demoniacal possession or obsession isnot a matter which either physician of soul or of bodycan afford to put on one side as superstition.

PROTECTIVE GLASSES FOR METAL-WORKERS.

THE fact needs wider recognition that the greatmajority of accidents which happen to the eyes happento metal-workers working with eyes unprotected,and that they could easily have been prevented bythe simple expedient of wearing goggles. Dr. vanKirk, of Pittsburgh, reports that in a steel millemploying about 8000 men the vision of one or

both eyes has been saved in from 20 to 25 cases ayear by the use of goggles, and that this alone savesthe company about$50,000 or$60,000 a year incompensation. a As was to be expected, it took sometime to obtain the cooperation of the men, but nowthey realise the value of goggles as a protection, andthe penalty of discharge for failure to wear them whenso ordered is rarely necessary. There is no moreimpressive proof of their efficacy than the demonstra-tion of a pair of goggles cracked by a splinter whichotherwise would have inevitably injured, and possiblydestroyed, the eye of the wearer. The injuries thatoccur from this cause may be divided into two classes :First, those in which the foreign body actually pene-trates into the globe and lies either in the anteriorchamber, the lens, or the vitreous. These are allserious, and the great majority of cases where theforeign bodies penetrate into the vitreous, even if theparticle itself is successfully removed, end with thetotal loss of sight in the affected eye. In the secondclass of cases, which includes the vast majority, pene-tration of the globe does not occur and the splinter lieseither in the conjunctival sac or in the cornea. Inthese cases it is a good rule to make that unless thesplinter can be removed by the use of a soft pledget ofcotton-wool-i.e., in all cases in which it is embeddedin the cornea-the case should be from the earliestpossible moment under the care of a specialist. Thegreat danger of these cases lies in the frequencywith which, owing to lack of efficient treatment, aspreading corneal ulcer arises after the apparentlysuccessful extraction of the foreign body. In the steelmill already referred to the number of corneal ulcersdeveloping after these injuries was reduced after theintroduction of the system of prompt treatment by a

1 Longmans, Green and Co. 1922.2 Journal of the American Medical Association, Sept. 16th,

1922.

specialist to about one-quarter of what it had been,and in each of seven cases in which an ulcer did developthe occurrence could be traced either to a lack ofpromptitude in seeking treatment or a failure to carryit out when given. The most frequent source ofinfection is a diseased lacrymal sac, but in any casethe eye should be protected and kept under observa-tion until the injured epithelium of the cornea hasre-formed, as shown by its no longer staining withfluorescein. In the majority of cases it will not benecessary to occlude the eye for more than 24 hours,whereas if an ulcer is allowed to form the treatmentmay last for weeks and the vision may be permanentlyimpaired or even, in bad cases, lost.

RURAL ENDEMIC TYPHOID FEVER.

EPIDLMIOLOGICAI. workers familiar with Dr. RalphJohnstone’s report to the Local Government Board,in which he traced a series of typhoid cases in a hamletto a chronic carrier, will be interested in a valuablestudy of the same subject by Dr. Norment, of theUnited States Public Health Service, which appearedin the Public Health Reports (Washington) forSept. 1st, 1922. These relate to two counties in theState of Maryland which were made the subject ofintensive study. Spot maps giving the incidence oftyphoid cases in four consecutive years showed somestriking features in the distribution of the cases. Incertain areas decided clumping of cases was noted.and this was found to be due, in several instances, tothe occurrence of cases year after year, indicatingchronic endemic conditions rather than transientepidemic conditions. Careful case histories were

obtained, including contact histories, for 63 cases ofrural typhoid in nine months of 1920 ; 57 of thesecases appeared to have originated locally, and of thisnumber 32 gave a history of contact with specificallylocated sources-viz., either demonstrated carriers orunrecognised clinical cases. The general importanceof investigations of the kind indicated above isinsufficiently recognised. More careful case historiesand field study would probably demonstrate manyof these specific connexions with previous cases. Theadvantage of such inquiries and of the action takenon the findings is that it can secure a readier andquicker and, furthermore, a more complete result inreduction of disease than can be hoped from themere pursuit of remedial measures against localinsanitation.

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THE VALUE OF ALBEE’S OPERATION FOR

TUBERCULOUS SPINE.

WITH the exception of those complicated by nstulse,phthisis, or paralysis, all cases of tuberculous spineadmitted to the clinic of Dr. H. Gorres at Heidelbergare treated by Albee’s operation. In reporting on120 cases subjected to this operation, he states! thatimmobilisation in bed for three to four months after theoperation was the rule, and although in the early days aplaster jacket was worn for a further 18 months, recentexperience has shown that it is safe for the patient toget up without support, and to return to work withoutany jacket. Of the first 60 cases, 3 died in the firstyear after operation, and 8 could not be traced. Of theremaining 49, 42 were well and working, and of these29 were operated on more than three years previouslyand therefore could be regarded as permanentcures. From the re-examination of all the cases, itwas demonstrated that the implanted bone producedneither limitation of growth nor diminution in themovements. It is true that the bridged-over portionwas completely stiff, but the general movementsof the spine were scarcely affected. Childrengrew apparently normally in height. The kyphosisremained, but cases operated on before kyphosis hadappeared showed no bending of the spine, suggestingthat kyphosis may be prevented by the operation.

1 Deut. med. Woch., June 30th, 1922.

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Early cases, with little or no kyphosis, are the mostfavourable for the operation, and abscess formationseems to be beneficially influenced. In the early daysDr. Gorres only operated on children, but latterly hehas been operating on adults with encouraging results.He maintains that Albee’s operation is the treatmentof choice, rendering long after-treatment in plasterjackets unnecessary, and that in most cases a per-manent cure may be expected in four to five monthsafter the operation. ————

PREVENTIVE DENTISTRY.

EVEN when the pathology of a disease is reasonablycertain, the prevention of that disease depends on somany considerations, social, economic, and financial,that the path of the hygienist is a peculiarly difficultone and his progress must be slow. Preventivedentistry, like preventive medicine, is necessarilydependent on a sound pathology of dental disease ;until this is achieved any efforts must inevitably beempirical and incomplete. Preventive dentistry isstill in an embryonic stage, and Mr. W. R. Ackland,in his presidential address to the OdontologicalSection of the Royal Society of Medicine on thisdifficult subject, was unable to formulate any veryprecise code for general adoption. He laid stress onthe general factors of nature and nurture in theproduction of dental disease, especially of pyorrhoea,rather than on the local factors. The aetiology ofpyorrhoea has always been keenly debated, but oflate years the protagonists of a local origin of thatdisease have been in the ascendant. While generalconditions doubtless influence pyorrhoea, its wide-spread incidence, its independence of social con-

ditions, and its occurrence at all periods of life,make it difficult to imagine that an absence of theantiscorbutic vitamin can be mainly reponsible,as Mr. Ackland maintains. The possibility of a

dietetic element in the production of the acutestomatitis so prevalent in the late war is a differentmatter, and though difficult to prove may have anelement of truth. The same disease was noted by aFrench observer as common among the troops in theNapoleonic wars, when tinned foods were unknown,but the antiscorbutic elements in the diet may yethave been inadequate. Racial degeneration, usingthe term to connote only a physical inferiority tomore primitive types of man, has often been invokedas a predisposing factor in the production of pyorrhoea.The alveolar process, being an end-organ, is especiallyliable to be affected by systemic conditions, themore so as the masticatory apparatus is steadilylosing its functional efficiency, and, as Sir ArthurKeith has shown, is undergoing a change in shape.Mr. Ackland touched on this aspect, and pointed aregretful contrast between the " natural " life ofprimitive man, who escaped so many dental ills, andthat of his civilised and degenerate successor. Yet evenassuming this hypothesis of the causation of pyorrhoeato be true, and it is a big and dubious assumption,it offers but small hope to preventive dentistry.Dental caries offers a more encouraging prospect-atleast, we know more of its wtiology-and it is possibleto frame the principles of prevention along relativelysimple lines which are still compatible with our

civilisation, imperfect and irrational though it may be.The work of Sim Wallace, based on experiment,seems in accord with our knowledge of the pathologyof dental caries. Given that the disease is due to thefermentation of carbohydrate food in contact with ;,the teeth, it follows that if the lodgment of such ’,food between the teeth could be controlled, the ’,incidence of dental caries should be diminished. Inthis respect foodstuffs differ in their detergentproperties as apart from their nutritive qualities ;the dietary should be so arranged that while fulfillingall the requirements of the physiologist, it shouldinclude a sufficiency of detergent foodstuffs. Further-more, in order to allow the self-cleansing action of themouth its fullest effect, the meals should be so arrangedthat there is a proper interval between the last mealand going to bed, since during slumber the activities

of the tongue, lips, and salivary glands are largely inabeyance, thus allowing food in contact with theteeth to remain undisturbed. Experience has shownthat these rules, though not completely effective, arecertainly beneficial in lessening the incidence ofdental caries. The experimental work of McIntosh,James, and Barlow on the bacteriology of dental cariesdoes not as yet offer any weapon to the dental hygienist,but the evidence which supports their conclusionsaffords a hope that light may soon be thrown onthe oral conditions which favour or antagonise theproduction of dental caries. There remains one con-solatory feature of the problem to which Dr. A. E.Carver in our present issue draws attention-that thepublic are more alive than formerly to the benefits ofsuch preventive dentistry as is implied by a periodicalvisit for inspection. This might be described on theanalogy of V.D. terminology as early rather thanpreventive treatment, but we cannot guard againsta disease the aetiology of which is obscure in any morelogical way. Reference to Dr. Carver’s addressimpels us to recommend its perusal to all our readers,as a moderate but forceful appeal to mutualunderstanding between the public and the medicalprofession. ____

CANCER RESEARCH IN GENERAL PRACTICE.

IT is not uncommon for consultants and hospitalteachers to assure general practitioners that they enjoyunrivalled opportunities for the study of disease.Theirs is the privilege of being able to follow manypatients from the cradle to the grave and to compilea family history of disease, following it from onegeneration to another, and observing its incidence inseveral members of the same generation. An illuminat-ing example of this form of research is to be found in arecent paper by Dr. K. Isager,l who, when he settleddown to practice in 1892 in a country district inDenmark, set himself the task of making copious notesof his cases, not realising at the time the purpose orpurposes they might ultimately fulfil. Thirty yearslater he took stock of his material, which includedpractically all the deaths from malignant diseasein his district, and his analysis of his materialis of value both for the immediate informationit yields, and for the stimulus it gives to futureresearch on the same lines. Among his 120 cases

of fatal cancer there were 116 in which there couldbe no doubt as to the correctness of the diagnosis.Seventy of these patients had been under his observa-tion before the cancer developed, and among thesecases rheumatism, neuralgia, and dyspepsia figuredprominently. It was characteristic of the 46 patients,who had not been under medical observation beforethe outbreak of malignant disease, that they had beenfit for work and leading active lives. On the otherhand, it was noticed that patients with disease of theheart, emphysema, chronic bronchitis, bronchiectasis,hypertrophy of the prostate, and slight forms ofapoplexy were singularly immune to cancer, althoughthey had reached the cancer age. Dr. Isager was alsostruck by the comparative benignity of cancer whenit was associated with tuberculosis ; the tuberculosiswas always the first to appear, and among the sevencases in which the two diseases occurred in the sameperson, there were as many as four who recovered afteroperative or X ray treatment. Another curiousobservation was the frequency with which cancerdeveloped shortly after an accident associated with aconsiderable degree of shock, although the cancer didnot necessarily develop in the organ directly injuredby the accident. There were at least eight such cases,in some of which the shock lasted several days afterthe accident. It is also remarkable that in seven ofthese eight cases the digestive system, notably thelower part of the gut, proved to be the seat ofthe malignant disease. It is, of course, conceivable,when the interval between severe shock and thediagnosis of cancer is only half a year, as in three ofDr. Isager’s cases, that the malignant disease may have

1 Hospitalstidende, July 26th and August 2nd, 1922.