559THE EYES IN HOT CLIMATES.

fractured clavicle occurred, but this is not realevidence of repair in a malignant growth. P,tientswho have suffered a pathological fracture of thefemur secondary to breast cancer have even beenknown to get union and walk for a time. Thesimplest explanation is that only a portion of thethickness of the bone was destroyed by the growth.The remaining unaffected area, after fracture, wasable to throw out so much callus as to form a supportof weight bearing capacity. It has been frequentlyobserved that bone metastases occur in cases where theoriginal growth is quite small, so it would be of greatpractical imp rtance to be able to ascertain whetherthe bones are affected or not when the patient seekssurgical aid. According to A. Piney! certain charac-teristic blood changes occur when the growth invadesthe bone-marrow, by which this invasion can be ,,

recognised. Whilst this statement is true in somecases, it does not seem to be so invariably ; thecharacteristic blood picture was absent in the caseunder discussion. It is, however, important onoccasion to make the blood examination, for positiveevidence might show that operative interferencewould be useless.

____

THE PRESENT POSITION OF THE DENTAL

PROFESSION IN ITALY.

WE have received from Dr. F. Montuschi, dentalsurgeon to the Italian Hospital, a report on the recentlegislation in Italy to regulate the practice of dentistry.’The Royal Decree of Oct. 16th, 1924, made thepossession of a degree in medicine and surgery com-pulsory for the practice of dentistry. This compulsiondates back 34 years from the Boselli decree, butsubsequently all those who had practised dentistryby virtue of minor diplomas granted by variousuniversities continued to do so and, as is the case

now in England, many who had practised withouta diploma were allowed to continue after an examina-tion in the subject. The Boselli decree did notbecome law until 1912 with the concurrence of bothbranches of the legislature. There was, however, inItaly an absence of good schools for the teaching ofdentistry and such medical men as wished to practiseit conscientiously were obliged to go abroad. Manyof them came to our Royal Dental Hospital untilthe foundation of three dental institutes at Milan,Bologna, and Florence, each of which has a curricu-lum of one year’s duration. In Rome a small butinfluential group continued to ask for a doctorate indentistry independent of medicine and surgery,somewhat after the type of the American D.D.S. 1They wanted the medical student after his fourthyear to relinquish his studies and join the school ofdentistry and dental mechanics which was to beestablished in Rome, and after a curriculum of twoyears to pass an examination which would confer onhim a doctorate in dentistry and dental prosthesis.These ideas found sympathy from the Minister ofPublic Instruction in Signor Mussolini’s Cabinet, who,owing to the full powers conceded by Parliament,secured at the end of 1923 the approval of the Councilof Ministers for a decree establishing a national schoolof dentistry and dental mechanics in Rome; thismeant the institution of a degree in these subjects atthe end of the prescribed course of study and thepassing of a special examination. This decreearoused violent opposition, as medical opinion hadpronounced in favour of a compulsory degree in medi-cine and surgery for dentists. Augosto Murri wroteexpressing his views as to the indivisibility of dentistryand general medicine and advocating that the formermust be considered as belonging to the same categoryas other medical specialties, and a few months laterthe Minister who had approved of the decree wasreplaced by Senator Casati; then the MussoliniCabinet rescinded the decree and substituted a newone which re-affirmed the principle of a compulsorydegree in medicine and surgery for the practice of

1 Brit. Jour. Surg., 1922, x., 235.

dentistrv. The new decree stiffens the statute ofMarch 31st, 1912, since it not only requires all dentiststo be previously qualified in medicine and surgery, butenjoins upon all future medical practitioners theundergoing of a practical test in dentistry andmechanics to enable them to practise the art ofmedicine. It is not that the medical graduates ofthe universities, to which the new statute allowsfreedom in regulating their special studies, will all befinished dentists, but they will at least know enoughto guide them in investigating each case and adoptingproper treatment, especially in rural districts wherethere is no expert dentist.

In Italy the future medical practitioner will havea knowledge of the fundamentals of dental science,as he has of ophthalmology and dermatology. Fordentists in the future-i.e., medical specialists indentistry and prosthesis-the general university reformactuated by Gentile efficiently provides in the sameway as it does for all other specialists. This measure

enjoins that no one can arrogate to himself the titleof " specialist " in any branch of medicine without

having acquired the relative diploma granted byeach university. Anyone who does not conform tothis rule will be suspended from practising, so thatin the near future the public will be able to distinguishthe true from the false specialist. In fact, this samereform allows each university to establish specialpost-graduate schools in any subject, equipped forgranting, after examination, specialists’ diplomas.As far as dentistry is concerned, there already existin Italy the three dental schools of Milan, Bologna,and Florence with a yearly curriculum; and now,in order to ma,rch with the times, these have profitedby the present didactic legislation and have biennialcourses, while other schools will of necessity spring up.Italy will thus be the first among progressive nationsto require all medical practitioners to know at leastthe principles of dentistry and dental mechanics andto insist that all who practise other medico-chirurgicalspecialties shall, after having obtained their degree,pass a special examination which will be proof ofa real knowledge of the specialty they intend to

practise. ____

THE EYES IN HOT CLIMATES.

IN a paper on Ophthalmology in Egypt, read at arecent meeting of the Section of Tropical Medicine ofthe Royal Society of Medicine, Mr. A. F. MacCallan,at one time Director of the Egyptian GovernmentOphthalmic Hospitals, gave some valuable instruc-tion on the care of the eyes in hot climates.While fatigue, ill-health, and worry bring out latentdefects in the eyes in any country, a hot climatecauses greater fatigue than a temperate one, and thisfatigue, lie pointed out, may lead to fatigue-indigestionwith resulting physical depression. Worry, whetherof official or of private origin, similarly may causeill-health. Under these conditons he found thattrifling errors of refraction, or slight degrees ofheterophoria, exerted effects quite out of proportionto their actual severity, and he emphasised theimportance of careful correction of these errors,generally under a cycloplegic such as homatropine. Ina highly sensitive patient, whose nerves were con-stantly being jarred by physical or mental discom-forts, the correction of a very small degree ofastigmatism might make all the difference betweenhappiness and misery. In a country such as Egypt,the healthy emmetropic eye of the European becomespainfully affected by the sun’s glare in the summerwhen motoring or riding along dusty roads or overthe desert. It is the heat rays from the red end ofthe spectrum which cause this. To prevent theeffects of glare, Mr. MacCallan advises the wearing ofprotective goggles of Crookes B or B 2 material; butif discomfort is complained of the refraction of thepatient should be verified under a cycloplegic.There are, he states, other varieties of protectiveglasses, which theoretically are more absorbent ofthe heat rays than Crookes glasses, such as peacock

560 SURGICAL TREATMENT CENTRES.—THE ANATOMY OF I’WINS.

blue, Fieuzal, and amber, but in his own expcr&Iuml;< neeof a large number of cases he found that ordinary glassin which was included, if necessary, a very smallametropic correction, was all that was required.Sun, dust, and wind might also cause pin guecula andpterygium. In dust,y seasons it is most advisableto wash from the eyelids the dust which collects thereand which may contain septic material. This shouldbe done three times a day. In many cases he foundthis simple precaution sufficient to prevent constantlyrecurring attacks of conjunctivitis.

’

SURGICAL’ TREATMENT CENTRES.THE medical profession and the lay public are

alike apt to associate the Ministry of Pensions withmedical boards and claims and awards rather thanwith any idea of treatment of war disabilities. Thearticle which we publish in another column by Dr.C. V. Mackay and Mr. D. D. Pinnock on the treatmentof war injuries at special surgical clinics, dealingwith this lesser known but very important side ofthe Ministry’s activities, shows that valuable workis still being done up and down the country in thetreatment of those disabling effects of the war whichin so many cases continued for a long time afterthe crippled men left the services. The organisationand work of these special clinics are clearly set out.It will be seen that the whole scheme is closely linkedup with the surgical hospitals of the Ministry ofPensions and with the centres for the provision ofsurgical appliances and artificial limbs. Existingfacilities at civil hospitals have also been utilised,and it will be seen that every encouragement is givento pensioners to make use of the treatment thusoffered by the payment of travelling expenses andof allowances for time lost from work on accountof treatment. Apart from the clinics at civil andMinistry hospitals, surgical treatment centres havebeen established in various parts of the country atthe following places :-Northern Region.-B;shop Auckland, Bradford, Carlisle,

Hull, Stockton, Sunderland.North-Western Region.-Birkenhead, Manchester.Midlands Region.-Birmingham, Coventry, Nottingham.South-Western Region.-Bnstol, Exeter.London Region.-Brighton, Westminster, Camberwell,

Tooting, Portsmouth, Reading, Southampton.Scotland Region.-Aberdeen, Dundee, Edinburgh, Glasgow,

Kirkcaldy, Stirling.Wales Region.-Bridgend, Pontypridd, Wrexham.The majority of these clinics deal also with the

supply of surgical boots and appliances. In additionto these centres, the British Red Cross Society hasalso established " Curative Posts," for the benefitof ex-Servi e men, which are recogni ed by theMinistry of Pensions. For example, in the county ofSurrey alone five were established by the countybranch of the British Red Cross in 1919. The posts Iare fully equipped with electrical apparatus, and in Isome cases X ray photographs can be taken. Thevoluntary staff consists of an officer in charge, analmoner, registrar and treasurer. and V.A.D. helpers.The professional staff consists of a medical officer,one or more trained nurses, and a varying numberof masseurs and masseuses according to the number Iof cases on the books. Since the diminution in thenumber of ex-8ervice patients the 1 osts have beenused for civilians, to the great benefit of the inhabi-tants of the various towns and villages concerned.The payments from civilian patients are supposedto vary from 2s. 6d. to 10s. 6d., the latter for severaltreatments combined, but unfortunately all patientsare not able to afford even the minimum charge, andin these cases various expedients have to be resortedto ; under certain conditions the funds of the branchare used to supplement the payments. Two of theposts, Woking and Kingston, have also openedorthopaedic clinics for children under the care of anorthopaedic s rgeon from a London hospital who makesperiodical visits. These are said to be a great success,and the medical officer of health reports that the Surrey

County Council consider it to be one of the mostsatisfactory services in the county. A good numberof children from the London hospitals are treatedin the Surrey posts, some of these attending theirown surgeons at the London hospitals. The Countyof London branch established similar clinics in 1919and at one time there were 13 such treatment centresfor disabled ex-Service men in various parts ofLondon. With the decrease in the number of menrequiring treatment certain of these centres have beenclosed and only five remained at the end of 1924.In February, 1922, a civilian clinic was opened inKensington to meet the needs of those who are

unable to afford the full fees obtaining for massageand electrical treatment. A maximum fee of 5s. pertreatment is charged, the fees graduating down toIs. 3d. per treatment. Towards the end of 1924 asimilar clinic was opened in Hackney. From this briefsummary it will be seen that the treatment aspect ofwar disabilities is receiving the consideration itwarrants from both voluntary and official bodies,and the extension of the Red Cross Society’s activitiesto civilian patients forms an important and interestingdevelopment. ____

THE ANATOMY OF TWINS.r TwiN bodies of the uniovular type do not often1

come to the anatomist for examination. I3ence not

. much is known with certainty or conclusive definiteness about the relations existing between the twinsof this form, and the views advanced from time to" time about the cause of twinning are little more than assumptions adopted to fill the void of ignorance on, the subject. The theory of polyspermy as a causeis an example of such assumption ; it is probably; quite unsound and untenable from the nuclear andcytological point of view, and it can be pointed out’ that, in animals in which polyspermy normally orfrequently occurs, the additional spermatozoa are

non-ettective to all appearance, while in a case like’ that of the armadillo, in which normally more thanone embryo is formed from a single ovum, there does

, not seem to be polyspermy. All that can be saidwith certainty is that the uniovular twin is an end-product of the process of dichotomy affecting the

,

embryonic contents of the developing ovum, and thecause of its occurrence will be known when theexplanation and meaning of dichotomy is under-stood. The result of dichotomy may be incompleteor complete division, and, in its axial form, rangesfrom the parasitic foetus and other monstrosities,through the partially attached individuals to thecompletely separated twins. In this last case theembryonic division may stop at this point, leavingthe amnion undivided, or may even involve this, sothat each individual possesses his or her own amnion.

I It is theoretically conceivable that the dichotomousprocess, beginning at the earliest possible moment,.might lead to complete division of the whole ovum,so that each foetus would have its own chorion andplacenta; but the occurrence of such a condition hasnever suggested itself to any observer, and a singlechorion and placenta may thus be considered a

proper accompaniment of uniovular twins. This, infact, seems to be the most valuable criterion, in

practice, in deciding on the nature of twin births.-Those of opposite sex are not uniovular ; when ofthe same sex they may or may not be so, but whenthey are enclosed in a common chorion, or-thesame thing-have a common placenta, they are

uniovular. When such details as these are lackingin the birth history, it is not possible to give morethan the negative pronouncement that twins ofdifferent sex are not uniovular. The subject oftwins is always fascinating, and Prof. G. R. Murray,in a presidential address published in this issue ofTHE LANCET, has ranged far afield and gatheredmany little-known items of information on thesubject. Prof. Murray refers to one matter, theoccurrence of situs inversus in certain individuals,.which, in the past, has perhaps had more valuettrlh1lt(’(! o it than is .justifiable. It has been