THE CRAFT OF SURGERY.

1062 The necessary preliminary to the production of immunity against small-pux is that it must be shown that the immunisation by vaccinia virus which has been rendered innocuous will protect against living "Audi alteram partem." vaccinia virus, and in this we have met with considerable success. One point must be stressed-namely, that if a living virus is used for immunising, only a THE MEDICAL REGISTER. small dose may be required, the immunity really To the Editor of THE LANCET. being developed by reproduction in the tissues of the virus inoculated, whereas with a dead virus very the elecwith in connexion SiR,-Voting papers tion of Direct Representatives are being issued on much larger doses may be necessary. It is not Thursday, the 14th inst., to all practitioners having possible to standardise a living virus unless in terms registered addresses in England and Wales. Any of infectivity for some laboratory animal-always an such practitioner who does not receive a voting paper, uncertain method-while it is not difficult to he wishes to vote in the election or not, standardise, in the physical sense at least, the dose of should immediately communicate with the office the killed virus ; on the other hand, such physical

Correspondence.

whether

standardisation must be correlated with

in order to ascertain that his address is correctly entered in the Register. I am, Sir, yours faithfully, NORMAN C. KING, Registrar, General Council of Medical Education and Registration of the United Kingdom. 44, Hallam-street, Portland-place, London, W.,

physio-

logical activity. Our observations are not yet sufficiently numerous permit of a definite statement being made, but the indications so far obtained from our work are that a living virus, after modification in vitro without the employment of either antiseptics or heat, may fulfil

to

Nov. 12th. 1929.

the

required conditions, these conditions being adequate protection unaccompanied by untoward local reactions or danger of post-vaccinal sequelae. We are, Sir, yours faithfully,

VACCINATION OR INOCULATION AGAINST SMALL-POX ?

W. J. TULLOCH.

To the Editor of THE LANCET. SIR.—In your issue of Nov. 2nd Dr. H. T. Gillett asks whether any experiments are being done on the production of immunity by killed vaccinia virus. In the same issue Dr. S. P. Bedson points out that I am conducting an investigation here into this question. This work has the approval and assistance of the Ministry of Health. My research is, at present, in its earliest experimental stage and few conclusions can be drawn from it. The majority of the experiments have been done on rabbits and have proved

J. CRAIGIE. Bacteriological Department, University College, Dundee, Nov. 5th, 1929.

THE

CRAFT

OF

SURGERY.

To the Editor of THE LANCET. SiR,-Though I have left the profession I have not lost my interest in medicine, and my experience in the war certainly increased this interest; I hope, therefore, I shall not be considered presumptuous if I about surgery, considered as a craft, very discouraging but, recently, experiments with say something and even make some suggestions. Surgery is a craft, have more results. These guinea-pigs given hopeful very skilled craft, requiring much natural ability findings are in accord with those of Iwanoff who also aand practice in its leaders, the surgeon being the found guinea-pigs easier to immunise than rabbits. With reference to your editorial comment upon principal craftsman in the medical profession, who Dr. Gillett’s letter I cannot see that, should a method is called on to act, when action is considered necessary. That he is much more than a craftsman hardly ever be evolved for protecting man against variola needs stating. The uses of surgery are increasing with killed virus, this would require a stock of real and good surgeons are required all over every day, of virus. The viruses vaccinia smalland small-pox the and no medical man out of touch with a Empire ; pox are immunologically identical and mutually town can ever be exempt from being called on to large from and the killed vaccine be would made protective, the- former virus just as is the living vaccine in present operate ; it is becoming more and more important that every medical student should be trained in the use. craft of his profession. of from virus infections I would add to your list Is this craft constantly and systematically taught, which a killed vaccine confers immunity yellow for it certainly was not in my day ? The surgeon’s which both formolised and phenolised fever, against viruses are effective, and fowl-pox from which even craft, owing to the fact that the work is done on living The length bodies,does not exactly correspond to any other, but a heat-killed virus provides immunity. of your list reinforced by my additions strongly it is closely allied to others. The instruments of though to-day very numerous, largely suggests that the production of immunity by killed surgery, vaccinia virus only awaits the discovery of the correct consist of forms of knives, saws, scissors, forceps,

technique.-I

am.

Sir,

yours

drills, chisels, files, hammers, screw-drivers, and These form in varying forms the tools of other crafts, such as carpentry, stone cutting, leather cutting and sewing, and upholstery. It would not therefore be very difficult to

faithfully,

needles and thread.

JOHN BLAND,

Freedom Research Fellow. Hale Clinical Laboratory, London Hospital, E., Nov. 7th, 1929.

To the Ed’itor

of

THE LANCET.

SiR,-The suggestive and valuable Observations on Vaccination by Dr. Bedson, and the letter from Dr. Gillett, both of which appeared in your issue of Nov. 2nd. indicate the need for the elaboration of a method of vaccination which will be devoid of the inconvenience unavoidably associated with the

technique so far employed. At present we are engaged in an investigation of the question raised by Dr. Gillett-viz., the (possible) production of immunity against small-pox by inoculation of killed

vaccinia virus. This work is being conducted on behalf of the Medical Research Council and is a natural corollary of our observations already published in Special Report Series No. 143 of that body.1.

find masters to teach what may be called the fundamental use and upkeep of these tools, the pupil practising upon the various materials. I feel safe in saying that a course of stone cutting, even if it onlv consisted of lettering under, say, Mr. Eric Gill, the sculptor, would be useful to the future orthopaedic surgeon. This constant practice of the hand would give a confidence to the young surgeon, which in my day he had to acquire chiefly on the living body, besides being a great relief from the reading of books. No one can cram up a craft, so that the good man would feel he could not fail in this part of his examination, while the poor craftsman would be told by his instructors that he had no chance. Even in the Final Fellowship Examination in the ’eighties, the test of skill in operating did not keep out the " butter

I fingers."

-

1063 The born surgeon, though he probably would be the first to take advantage of this kind of instruction, can look after himself, for he can pick up what he wants anywhere ; but there are not enough born surgeons to go round, and the more ordinary man must be taught the craft of surgery in exactly the same way as a carpenter or stone cutter is taught his particular craft, by learning the use of hisoftools under In one branch a good instructor. medicine, dentistry, the necessity of high-class craftsmanship is well understood, and ingenious methods have been devised to teach the student the use of his hands. Dissecting would form a useful link between fundamental craftsmanship and operating first on the dead

THE HEALTH AND CONDITIONS OF WORK OF MEDICAL STUDENTS. To the Editor of THE LANCET.

SIR,-Mr. Corner cannot, I think, have paid me the compliment of reading my paper, for he entirely misinterprets its purpose. As Mr. Corner seems under a misapprehension with regard to the object of my address, which was to consider the health and mortality, not the careers, of medical students, I cannot but be doubtful

as

to

whether the papers that he cites, his own and one by Sir Squire Sprigge, would have helped me materially. When I wrote asking for information on my subject, then on the living. We are not naturally accurate, we make ourselves the Dean of St. Thomas’s Hospital did not mention A painter, if Mr. Corner’s paper, which Mr. Corner tells me was accurate because necessity drives us. he is an artist, will always try to express himself published in the St. Thomas’s Hospital Gazette. The before he knows anything of the craft of painting ; Dean of St. George’s Hospital similarly did not refer he will force himself to learn to draw and paint, me to Sir Squire Sprigge’s contribution regarding because he finds out the necessity. Perhaps my only St. George’s students. Clearly these authorities, who valid excuse for daring to write this letter is that I were in a better position than I was to be familiar with have practised and instructed in two callings, both of the articles referred to-St. Thomas’s Hospital Gazette which, for their fullest expression, require such infinite is little read outside St. Thomas’s-did not regard labour from the apprentice. them as being pertinent to my inquiry. I am, Sir, yours

faithfully,

I am, Sir, yours faithfully, E. GRAHAM LITTLE.

HENRY TONKS. Slade School of Fine Art, University College, Gower-street, W.C., Nov. 11th, 1929.

BROWN

v.

WHITE BREAD.

To the Editor of THE LANCET. SIR,-Hartwell and Mottram found that their mice "

did not do well on an Essex " diet, that is, a diet based on one which Dr. A. B. Hill found to be an average one for Essex agricultural labourers and their families. Miss Brad and I have been inbreeding a stock of mice for six years and we have found the mice do very well and breed very well on an Essex diet. Our diet consists of meat, 5-8 ; potatoes, .

28-2 ; greens or peas or beans, 6-2 ; cheese, 0-8 ; tangerine, 2-8; sugar, 5-4; rolled oats, 0-8; milk, 8-3; white bread, 41-7. The food is got as cooked for our canteen lunch and is crumbled, shredded, and mixed together, and then minced. No water is added. We have come to regard this diet as excellent for producing fine-looking and well-breeding mice, better than what we call our "Alild" diet, three

I

THE DIAGNOSIS OF LARYNGEAL CANCER. To the Editor of THE LANCET.

SIR,-Mr. Layton has evaded my question as to why my cases illustrated by lantern slides of microscopical sections " afforded a strong argument against

biopsies." erroneous

The cases illustrated the correction of clinical diagnoses by means of the microscopical examination of portions of tissue removed for the purpose. The assurance afforded by the unmistakable evidence of the microscope led to the prompt adoption of energetic treatment and the preservation of lives which would otherwise have been lost. Mr. Layton may have justification for his objection to microscopical biopsies, but surely not founded on these cases. I am, Sir, yours faithfully, JAMES DUNDAS-GRANT.

inevitably

and raw green stuff. kinds I am, Sir, vours faithfully. tbhEof grain -’-

AVERTIN ANÆSTHESIA.

LEONARD HILL.

INTERPRETATION OF FERTILITY TESTS. To the Editor of THE LANCET. SiB,—May I make two observations

upon the

excellent article in your Clinical Interpretation Series by Mr. Kenneth Walker last week. Incompatibility or relative fertility is often due to lack of sexual orgasm in the female with a certain male partner. Women respond with varying intensity to different males, and consequently there is a variation in quantity and quality of their sexual secretions during intercourse. This also explains why a woman will often infect one man with gonorrhoea and not others. In other words she suffers from a type of impotency.

The second point is of great medico-legal importance, particularly in cases of disputed paternity. Mr. Walker quotes the numerical calculations of spermatozoa by Comber and Sanders, and points out that conception very rarely took place when the figure was below 60 million. I would suggest some other factor was operating. Bearing in mind that usually only one spermatozoon penetrates an ovum, and that simply spraying the vulva with semen has caused pregnancy, I at least would hesitate to give a negative reply unless I found 60 million in a specimen. T

anr)

Cir

-x7,niipQ

f",1t.’hf"lhr

M. W. BROWDY.

To the Editor

of

THE LANCET.

Sin,—I hope you will allow me to draw attention to some errors and omissions in your report of my paper on Avertin (THE LANCET, Nov. 9th, p. 979). Firstly, when speaking of the strengths of the solutions used I tried to make it clear that it is the manufacturers who now recommend a 2’5 per cent. in preference to a 3 per cent. solution on the grounds that absorption from a 2-5 per cent solution is more even and gradual but that I preferred the stronger solution for children as the smaller quantity of fluid to be injected is more readily retained by them. Secondly, the sentence beginning " fatal cases " misrepresents me, for only one death occurred in my series of 106 administrations, and I gave reasons for my belief that avertin was

not

responsible.

The omissions are more serious; no mention is made of the importance of testing the solution for impurities before injection, although this was emphasised. Again, no mention is made of the need for care in dosage, although a considerable part of my paper was devoted to the discussion of this essential ; the result is that I am reported as saying that avertin is " a safe means of induction," whereas my statement was that it is safe if used in the doses recommended by Prof. Eichholtz. I am, Sir, yours faithfully, FRANCIS SHIPWAY.