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carried an X ray apparatus and two operators, anengineer with four complete chlorinator units,ten days’ provisions, medical and surgical stores,clothing, ten 100-lb. cylinders of chlorine, and a tonof chloride of lime. The director had a headquartersstaff of 12 ; two assistant directors, a railroad man,a liaison officer, a secretary, two motor-cycle policeas messengers, and the sanitary and X ray personnel.Organisation and discipline was on the strictestmilitary lines, and the unit was therefore mobile,highly efficient, and completely self-supporting. Thedirector maintained full telegraphic communicationwith the civic authorities of the disaster area, andreported on arrival to the chief medical officer ofthe Citizens’ Relief Organisation at his emergencyheadquarters. Before daybreak the expedition wastransported in squads of 7-12 to the stations wheretheir work could be of most value. Some squadsworked in 12-hour shifts at emergency hospitals, othersmade house-to-house calls in outlying villages, relievedthe staffs of regular hospitals or fed, clothed, andhoused the destitute. In ten days the 100 membersof the unit between them did 3945 dressings, per-formed 4426 operations, and gave 14,651 prophylacticinjections.The work of the sanitary staff was no less strenuous
and important. The wells which supply Miami hadall been polluted by flood-water. Chlorinators werepromptly installed at two of the plants and at theprincipal station at Hialeah, which was waiting forits power to be restored. Next day the chief sanitary.engineer was horrified to learn that Hialeah hadcome to life and had pumped half a million gallonsof raw canal-water into the main to test it. Hepromptly arranged for chlorination at two pointsbetween Hialeah and the city distribution valve, butthrough some error of the local staff none of thechlorinators were operated and all this contaminatedwater entered the distribution system, just as thenewspapers had sounded the " all clear." It soonappeared also that the operators of the pumpingstations were neglecting to use their chlorinators.The director of the unit had to request the MiamiCommissioners of Health to appoint shifts of super-vising engineers at all stations, with authority to seethat no unsterilised water was pumped through.Three days later the water was at last safe to drink.The inhabitants had, however, subsisted on flood-water for five days, and this fact may explain thevery large number of antityphoid inoculations givenby the medical staff.The work of the Chicago train was so much
appreciated, that when the Miami Commissioner ofHealth informed the director that the city couldcarry on by itself, the Mayor and other members of thelocal relief committee sent lengthy and urgent telegramsto Chicago for a two days’ extension of its stay, whichwas granted. The American Red Cross described theunit officially as the best in every way that anydisaster had yet produced, and, indeed, by everylocal account, it saved the situation.
THE DECLINE OF SYPHILIS IN EUROPE.
AT the first international congress for sexuology heldin Berlin a week or two ago, Prof. Josef Jadassohn,lthe well-known syphilologist of Breslau, reportedthe result of a questionnaire addressed by him to51 specialists in 19 countries as to their views on thedecline of syphilis and its relation to treatment bysalvarsan. Almost all the syphilologists agreed with theexplanation proposed at the German DermatologicalSociety in 1923 when the paramount importance ofsalvarsan in combating syphilis was emphasised aswell as its relative harmlessness, provided proper carewas taken in its manufacture and administration.In 14 countries there was unanimity as to the declineof the disease ; in Italy six out of seven repliesindicated a decline ; in Russia statistics suppliedby the Government showed a diminution of syphilis,
1 Forschungen und Fortschritte, Nov. 10th, 1926.
but three practitioners returned a doubtful or negativeanswer, and one an affirmative ; in Hungary andBulgaria the decline of the disease was doubtful;in France there had been an undoubted decline tothe extent of 50 per cent. from 1919 to 1923, but ofrecent years Jeanselme had observed a, recrudescencein Paris and other centres which he attributed to theenormous immigration of foreign workmen and thesubstitution of bismuth for salvarsan. The declineof syphilis showed a considerable variation in thefollowing countries--viz., in Denmark, Bulgaria, andSweden by four-fifths, in England and Switzerlandby a half, in Holland by three-quarters, and in Italyby a third. In 16 countries gonorrhoea had notdiminished or had even actually increased, or lastlyshown a decline, but by no means to such an extentas syphilis. Almost all the specialists were unanimous _
as to the cause of the decline of syphilis, which wasto be found pre-eminently in the use of salvarsan.This explanation accounted for the difference betweenthe decline of syphilis and that of gonorrhoea, inwhich disease treatment had not made any essentialprogress. More or less importance was attributed toaccessory factors such as popular enlightenment,improvement in medical training, and the creationof treatment centres, especially of a gratuitous kind.The question as to whether salvarsan had exercised aninfluence on the frequency of tabes, general paralysis,and aortitis in a favourable or unfavourable sensewas in many cases met by the reply that it was stilltoo early to decide. Several observers declared thatthey had never seen a case which had been systematic-ally treated with salvarsan from the first developsuch sequela?, and in no instance was an increase ofgeneral paralysis attributable to salvarsan. Inconclusion, Prof. Jadassohn emphasised the impor-tance of education, abstinence from alcohol, andimprovement in housing conditions in the campaign.
against venereal disease.EPIDEMIC PREVENTION IN CHINA.
SINCE the establishment of the National Epidemic-Prevention Bureau at Peking in 1919 only twoannual reports have been issued. This year the report.has been replaced by a general review of the historyand progress of the Bureau, with the object of makingits aims better known and its services more extensivelyutilised throughout China. The establishment ofthe Bureau was authorised in June, 1918, by an orderof the then Minister of the Interior, Ch’ien NengHsun, in an endeavour to follow the lead of theWestern nations, and to prevent the recurrence ofserious epidemics, such as that of pneumonic plaguewhich swept the country in 1910 and again in 1917.The Bureau, which is directly under the Ministry ofthe Interior, is situated in the grounds of the Templeof Heaven. Its sphere of action has graduallyincreased until, in June, 1926, its four-fold functions.were set out as follows : (a) research and teaching-in connexion with the causes, prevention, and treat-ment of communicable diseases ; (b) the examinationand standardisation of materials pertaining to the-prevention, disinfection, and treatment of these-diseases ; (c) the manufacture of vaccines, sera, andother therapeutic bacterial products ; (d) theapplication of preventive measures against communic--able diseases, and public health teaching and propa--ganda among the people. Distinguished Chinese andforeign specialists in preventive medicine andbacteriology are to be invited to act as advisers tothe Bureau as occasion arises. The Bureau has-already done useful work in cutting short epidemicsof plague, cholera, typhoid, typhus, and small-poxin various parts of the country. During the warbetween the Kuominchun and the Fengtien factions.in 1925-26, over 3000 wounded soldiers were segregatedat the emergency hospitals at Nanyuan. Severalmedical officers from the Bureau went down toNanyuan and gave tetanus antitoxin injections to1352 wounded soldiers, most of the patients receiving-1500 units ench. Of those immunised, not one-
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’developed tetanus, while 30 out of 2000 men who werenot injected died from the disease. This was thefirst time in China that extensive immunisationagainst tetanus has been given to the wounded.The administration of local public health measureshas hitherto been almost entirely neglected in China.In May, 1925, the Bureau obtained permission fromthe Peking Metropolitan Police Department toestablish a public health demonstration station inPeking. The type of work undertaken at this stationincludes a division of general sanitation ; a divisionof public health medical services-e.g., infant welfareand industrial hygiene ; a division of communicablediseases ; and a division of vital statistics. Preven-tive inoculation against small-pox has been steadilygrowing, 4812 persons having been vaccinated bythe Bureau last winter as against 27 in the year 1923.The importance of trustworthy vital statistics as abasis for national public health work is beginningto be recognised in China, although in the absence ofa strong centralised Government the work is besetwith difficulties.
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AUTUMN SESSION OF THE DENTAL BOARD.IN his address from the chair at the opening of the
eleventh session of the Dental Board of the UnitedKingdom (the name has this week become an
anachronism), Sir Francis Dyke Acland spoke of theimportant event in the dental world which hadmarked the period since he last addressed the Board-namely, the universal adoption of dental treatmentas an
,. additional benefit " under the National HealthInsurance Act, accompanied by a new scale andconditions of service. This, he said, wouldundoubtedly mark a very great advance towardsthe improvement of the health of our nation if thescheme was properly utilised. But in spite of thecareful and admirable work of the Dental BenefitJoint Committee it would take time for the newsystem to settle down into good working order. Thedental profession, he doubted not, would endeavourto work under the scheme with loyalty to it, andwould even welcome the assistance of the regionaldental officers in deciding questions which must needarise. But on occasions of this sort he could not helpwishing that there were a higher standard of generaleducation among a greater proportion of our peopleso that they might be more ready to utilise fully andproperly the skilled services which are now at theirdisposal. Even if all the schemes of our education,health, and insurance authorities were to work aswell in practice as they were meant to work on paper,their best efforts were liable to be undermined duringthe ages 14 to 16, between the times when the goodhabits of school days were apt to cease, and whenemployment within the sphere of Health Insurancebegan. " I believe," he said, " that the Board mightusefully devote a considerable amount of its propa-ganda work to impressing upon juveniles at this veryimportant period of their lives the importance ofcare for their teeth, and to explaining to insuredpersons, even more than we have hitherto done, thenew duties and opportunities which the extensionof dental benefit presents to them." In pursuanceof this object the Dental Board decided to allot 4000out of its available surplus of 31,100 to dentalhealth education, along with any unspent balancefrom the previous year. The remainder was allottedthus : grants to students 221,000, grants for researchjob5000, post-registration lectures 2600, and post-graduate lectures .E500.
THE LATE Dr. E. M. DE JONG.-On Nov. 15thDr. Edward Meyer de Jong, died at Manchester in hissixty-sixth year. A son of Mr. Edward de Jong, theflautist, he was educated at London University and Owen’sCollege, Manchester, qualifying in 1880. After a houseappointment at Ancoats Hospital he took up generalpractice, and for some years had been medical officer ofhealth for Lymm. He took the D.P.II, at Manchester in1915. One of his sons, Dr. 0. M. de Jong, was a pathologistin Manchester, and died a few years ago.
Modern Technique in Treatment.A Series of Special Articles, contributed by invitation,on the Treatment of Medical and Surgical Conditions.
I
CXCIX.
TREATMENT OF STRANGULATED HERNIA.
STRANGULATED hernia is a variety of intestinal, obstruction, which, compared with other forms, hasmany favourable features. Cases are seen early, andaccurate diagnosis is usually possible. The site ofobstruction is known, and the part of the intestineinvolved can often be inferred ; also, from the physicalcharacter of the swellmg, it is possible to form anestimate of the condition of the strangulated loop.
Inguinal, femoral, and umbilical hernia provide thegreat bulk of strangulations, in that order of frequency.Proportionately, however, strangulation is commonerin femoral hernia. Strangulation, which implies aninterference with blood-supply, is only liable to occurwhere the loop of intestine passes through an aperturewith rigid walls. Such an aperture is present fromthe commencement in femoral hernia and in mostumbilical herniae. In inguinal hernia it is of secondaryformation, the result of repeated attacks of inflamma-tion, usually at the neck of the sac. Thus inguinalstrangulation arises in an old-standing hernia, andcan hardly escape observation. The same process’may not be discovered if it occurs in a smallumbilical or femoral hernia of recent developmentand completely hidden by subcutaneous fat. Wheresymptoms of intestinal obstruction are encountered,it is therefore important to search these regions withgreat care. Tenderness on deep pressure above theumbilicus or in Scarpa’s triangle may give the clue,even where no lump is revealed by careful palpation.
Preliminary Treatment.Once the diagnosis of strangulation has been made,
immediate operation is called for. Only when apatient is first seen when already in a condition ofextreme collapse is delay justified. This conditionis due to the absorption of toxic bodies, not as
yet identified, from the obstructed intestine. It isstrictly comparable to that of chemical shock, such ashas been produced experimentally in animals by theinjection of histamine or by gross damage to thetissues. The essential feature of chemical shock isthat the circulatory system is starved of fluid owingto a widespread dilatation of the capillary bed;another effect of the sluggish flow in dilated capillariesis a rapid loss of heat from the limbs and body-surface.Warmth is required to combat stasis in the
peripheral circulation; if an electric cradle is notavailable, a liberal supply of hot-water bottles, or ofblankets heated at a fire and wrapped round thetrunk and limbs will serve. An effective cradle maybe extemporised by placing a stove under the bed, anddraping blankets on each side so that the hot air isconducted to the patient. The foot of the bed shouldbe raised 12 inches on blocks. Fluid must beadministered by rectum, by subcutaneous infusion, ordirectly into a vein. Since in intestinal obstructionthere is probably an alkalosis in the portal circulation,3 drachms of ammonium chloride should be added tothe saline solution given by the rectum. Whereshock is really severe saline solutions are useless, anda pint of 6 per cent. gum solution should be givenintravenously. Solutions of gum made fromcommercial preparations often contain highly toxicbodies, and only those which have been physiologicallytested can be given without risk. *
The Aitcesthetic.Gas and oxygen is undoubtedly the safest method
of general anaesthesia for administration to collapsedpatients, and in such cases is very effective. Where
* Sterile solution of gum fwacia ready for use can be obtainedfrom Evans, Lescher and Webb, 50, Bartholomew-close, E.C. 1.
