- Email: [email protected]
THE TUBERCLE BACILLUS IN BOOKS
81
been in contact with those
having a high incidence of mammary cancerAnd can it be obtained from mammary tumours due to the chemical carcinogens?, If experiments designed to answer such questions lead towards some unifying principle (as they seem likely to do), then, even if our knowledge still remains incomplete, we shall have learned something more about the cause, though not the incidence, of cancer. RECOVERY FROM INJURY THE beautiful complexity of compensation cases makes them an adventure in surgery, psychology and social medicine ; it is a considerable achievement to be able to look back on such a case and to feel that the best has been done for the patient at every stage in his story. Dr. Henry H. Jordan in a book1 addressed mainly to those doctors who have occasion from time to time to examine and report on injured workmen, and to the officials of insurance companies which cover employers’ liability risks, disclaims any intention of writing a comprehensive textbook of traumatic surgery. He confines himself to a discussion of practical problems arising in his own extensive experience as associate orthopaedic surgeon to Lennox Hill Hospital, New York, which includes some 30,000 cases seen during 18 years. It is, as St. Denis is reputed to have remarked when his head was cut off, the first step that counts : no-one can foresee how complicated any case may become, or how valuable it may eventually be to have a record of the exact condition immediately after the accident, and besides this is the best time to plan treatment as a whole, and to obtain an accurate history of the accident. He believes in exact measurements whenever possible, so that the injured and the uninjured side of the body can be compared and the range of movement in the joints recorded ; and he directs attention to muscle groups which activate more than one joint, such as-the ischiocrural and gastrocnemius groups. Many cases will benefit from reference to a specialist-a fractured wrist for reduction and immobilisation, or a knee with a strained internal lateral ligament for fixation in plaster-of-paris ; after such treatment the patient may well continue under the care of the general practitioner. He agrees with the usual experience in industrial accident practice, that deliberate exaggeration of symptoms and malingering is rare in workmen, but that tact and sympathy may be required to- understand the nature and origin of the e,om-nl.q,int,q of
a,
na,tifBl1t when these do not
arynear
to
accord with the clinical findings. Greed is by no means the only motive which may prompt a man to claim an excessive degree of disability-a subconscious craving for sympathy or an urge to vindicate his real or supposed rights, or merely a reaction to what is felt to be a harsh or unjust attitude on the part of his employer or an insurer may lead to an overemphasis of symptoms difficult to distinguish from a fraudulent claim. Thorough and repeated examinations may be required in some cases before clinical signs can be detected to account for pain, where this is due to an early bone tumour or deep-seated infection. A form of atrophy, first described by Sudeck in 1900, may supervene after even slight injury, leading to decalcification of the limb bones and pain. Jordan is rightly critical of the schedules introduced in different parts of the United States as a guide to the evaluation of disability, and reports favourably on a system which has been followed for many years in Switzerland, under which the injured workman is re-examined at fixed intervals of 3, 6, 12, and 24 months after the accident, and the rate of his compensation adjusted accordingly. Griffiths and others, over here, consider that no opinion as to working capacity can be of much value unless the examiner is conversant with the condition of the patient, and the nature and physiological
1. Workmen’s
Compensation and the Physician. London: Humphrey Milford, Oxford University Press. Pp. 172. 16s.
demands of his work. Jordan insists on the need for rest to an injured part at the beginning -of treatment, by immobilisation in plaster or otherwise, coupled with active use of the rest of the body ; this applies not only to fractures, but to many kinds of injury to soft parts. The risk of joints becoming stiff in bad position must be avoided ; for instance, the shoulder should be kept at rest on an abduction splint rather than in a sling, and talipes decubitus should be prevented"by
adequate
suitable supports. In a chapter on so-called traumatic neuroses Paul Hoch notes the significance of the constitutional factor in the development of neurosis after injury. Early diagnosis and treatment are important ; not every patient who appears anxious and apprehensive is suffering from neurosis, but many are given treatment in the absence of a physical defect, which can only have the effect of prolonging the disability. Thus it may be disastrous to prescribe a long course of physiotherapy or the wearing of an appliance to correct some physical disorder which does not in fact exist. He has noted recovery from neurosis in only 25-35% of cases, but he quotes the finding of Lewandowsky that there was recovery in 70% of people affected by traumatic neurosis who received a lump sum compensation, as compared with a recovery-rate of 7% in those who received continuous compensation in the form of a monthly allowance. No doubt early settlement of a claim will often avert or abort neurosis, but to suggest that such a- result may be expected in as much as 70% of cases is to ignore the experience of our Ministry of Pensions or of such AmeriIn fact the therapeutic value can authorities as Norcott. of the lump sum has been greatly over-estimated ; it may be a convenient way of terminating the liability of the employer or’of his insurer, it seldom does any lasting good to the recipient. But it is quite true, as Jordan says, that " the quick settlement of a compensation claim is essential, otherwise the neurosis becomes ingrained and very difficult to eliminate." .
THE
TUBERCLE
BACILLUS
IN
BOOKS
BACTERIOLOGISTS specialising in tuberculosis are often asked by laymen whether books and magazines used by sputum-positive patients are infectious, and if so what There has been singularly little can be done about it. effort to find out what is the actual risk apart from general research on the survival of the bacillus outside the body ; indeed, Smithy who has lately answered the question after undertaking experiments with books, papers and catalogues artificially infected with sputum and tubercle cultures, was able to quote only two previous studies on the subject. In its inquiry into books as fomites fifteen years ago the consultative committee to the Board of Education was dealing with school books and the common infections of school life. In conveying these Brincker2 agreed with the view expressed by McCartney3 that books are insignificant as compared with other agents. But neither was considering the special question of tubercle. Smith found that at room temperature tubercle bacilli survived only a few days in room light, and from 2 weeks to 3 months in the dark. Printer’s ink seemed to have no effect on survival, bacilli living as long on printed as on blank paper. Almost all papers are composed of wood pulp chemically treated in one way another with acids and alkalis, bleaching agents, sizings and loadings ; and printing ink is equally full of chemicals ; but Smith believes that with most varieties of paper and printing ink the active chemicals likely to kill the tubercle bacillus have usually been removed or neutralised. All the papers he tested, however, had pH values between 5 and 6, well below the optimum level for the cultivation of the tubercle bacillus. Natural or
1. Smith, C. R. Amer. Rev. Tub. 1942, 46, 549. 2. Brincker, J. A. Books in public schools. HMSO, 1928. 3. McCartney, J. E. Lancet, 1925, ii, 212.
82
TH
by patients is presumably much lighter than deliberately planned experimental infection ; most likely it takes place by droplet infection or direct contact, or as as a result of moistening a thumb in order to turn a page (a practice which should be as obsolete as shuttle-kissing). Smith suggests that a book quarantine would be effective ; storage for a month should be enough in most cases to infection
allow for natural death of the bacilli, and in ’lllany cases the books doubtless remain on the shelves for longer than this. Active sterilisation could not be carried out without damage to the books, and even the use of ultraviolet lamps would require the methodical exposure of each page. The risks in the case of lending libraries are probably not very alarming : there are much graver risks, of transmission of tuberculosis in everyday life which have not yet been explored. But hospital libraries and book-trollies in tuberculosis institutions need special consideration. The supply of books is usually limited and their circulation intensive, so that long quarantine of books may seem impossible. Replaceable or washable covers could be used with advantage ; and it would be wise to get rid of well-worn books. A ragged book is likely to be an infected book. NUTRITION IN PREGNANCY DEBATES on nutrition generally reveal what enormous tracts remain to be covered in this field, and the meeting of the Scottish group of the Nutrition Society, held. in Edinburgh on Dec. 12, was no exception. Prof. R. C. Garry, who presided, discussed the influence of diet during pregnancy. This physiological strain may bring latent defects into the open ; but the rational treatment of such disturbances must wait for a fuller understanding of maternal and fcetal physiology. Prof. A. St. G. Huggett was equally cautious about the placenta-a secretory, storage and transfusion organ controlled by factors as yet little understood. This endocrine structure reaches its maximum development relatively early in pregnancy, but nearly three-quarters of the final weight oT the foetus is built up in the last three months of pregnancy when the placenta has ceased to grow and may even be showing signs of regression. In animal experiments, restriction of the mother’s carbohydrate intake causes a fall in her liver glycogen but does not affect the liver glycogen of the fcetus ; on the other hand if the mother is given excess of carbohydrate her own liver glycogen rises only slightly, whereas the foetal liver glycogen shows a great increase. Through all these fluctuations the glycogen content of the placenta remains almost unchanged. Dr. H. M. Sinclair reviewed what evidence we have of nutritional deficiencies during pregnancy. Supplementary feeding with vitamins A and D is said to lower the incidence of puerperal sepsis, but it is doubtful if the action is Reports are conflicting on the effects of the vitamin-B. complex in preventing the togaemias of pregnancy, gestational polyneuritis and Wernicke’s encephalopathy. Claims that vitamin E prevents abortion have still to be substantiated, and it is not yet clear whether vitamin C or vitamin K or both play any part in preventing accidental haemorrhage during pregnancy or excessive bleeding at parturition. Hyperplasia of the gums is not uncommon during pregnancy but does not yield to vitamin C, and there is some evidence that it is due to excessive quantities of oestrogens in the tissues: Iron-deficiency anaemia is often seen in pregnant women but he pointed out that the physiological hydraemia of pregnancy must be taken into account in assessing the severity of this anaemia. The demands of the foetus for calcium during the second half of pregnancy are large enough to deplete the maternal reserves ; yet supplementary feeding with calcium may prolong pregnancy and harden the infant’s skull. Prof. Dugald Baird remarked that stillbirths and neonatal deaths are more common in hospital than in specialist practice (3’3% as against 0.6%). Standards of medical
specific.
and nursing care are comparable in the two groups and the responsible factor is probably dietetic ; diet is also probably responsible for the greater percentage of premature labours-9 as against 2-in hospital as compared with specialist practice. The diet of pregnant women often falls short of the standard of the League of Nations technical commission, and evidence is accumulating that by raising diets to this standard it is possible to lower prematurity and stillbirth-rates. Mr. W. Godden, FIC, discussed some deficiencies in farm animals. Iron deficiency, especially it seems in the sow, does not affect fertility but does reduce the viability of the young during the suckling period. Adequate supplies of vitamins A and D are essential for successful pregnancy in cattle, sheep and pigs, but the evidence about vitaminB complex is equivocal and there is no clear proof that vitamin-E deficiency affects animals other than the rat. Miss I. Leitch, DSc, drew attention to the high stillbirth and neonatal death-rates in Scotland-80 per 1000 as compared with 66 for England and Wales and 51 for New Zealand-another phenomenon presumably due to unexplained dietary factors. PIONEERS OF
INDUSTRIAL MEDICINE
senior medical inspector of factories is a historical event. The post was created in 1898 and its first occupant was Sir Thomas Legge who resigned in 192fi because he believed the Government had let him down on precautions about the use of white lead. Bridge succeeded Legge with whom he had already worked since 1913. For the past 44 years therefore the inception and development of industrial medicine in this country has been directed successively by two outstanding public servants. The present intense and widespread interest in the health of the industrial worker and in occupational medicine is a tribute to the soundness of the foundations which these pioneers have laid, and they have shown the way not only to this country but to the rest of the world. Dr. Bridge associated himself with no special subject, but-like Francis Bacon who took all knowledge for his province-with all those subjects whether medical,
chemical, engineering, legal, industrial, sociological or humanitarian, which have any bearing on,the health and _well-being of industrial workers. And naturally he has had a place on all the committees, and they are many, that have the worn 11 industrial " in their titles.
During his 15 years in command problems have become more complex, and the number of medical inspectors has increased steadily; these he has guided with a sure hand and the affection with which they regard him bears witness to his qualities as a chief. One attribute which has endeared him to those who work with him is his capacity for listening with sympathy and without condescension. He is fond of saying that he continually learns from his junior colleagues and his modesty in this respect covers an unrivalled knowledge of industrial and occupational health matters. But perhaps his most striking qualities are
his
common
sense-really
an uncommon
quality-
and his flair for picking out the essentials of a complicated subject which in his case really does include ships and shoes and sealing wax. His sense of humour and love of a fair deal, coupled with a legal training and a prodigious memory make him the ideal chairman who ensures a hearing for the timid, tactful suppression of the vociferous, and the right decision at the end of the discussion. Unassuming himself, he is somewhat impatient of pretentiousness and pomposity. His work at Geneva has brought him into touch with continental authorities, his reputation being deservedly international. It seems a pity that such an experienced leader should have to step down at a time like this on account of the age-limit ; and it is to be hoped that his retirement will not deprive the country, industry and the medical profession of his wise counsel.
been in contact with those
having a high incidence of mammary cancerAnd can it be obtained from mammary tumours due to the chemical carcinogens?, If experiments designed to answer such questions lead towards some unifying principle (as they seem likely to do), then, even if our knowledge still remains incomplete, we shall have learned something more about the cause, though not the incidence, of cancer. RECOVERY FROM INJURY THE beautiful complexity of compensation cases makes them an adventure in surgery, psychology and social medicine ; it is a considerable achievement to be able to look back on such a case and to feel that the best has been done for the patient at every stage in his story. Dr. Henry H. Jordan in a book1 addressed mainly to those doctors who have occasion from time to time to examine and report on injured workmen, and to the officials of insurance companies which cover employers’ liability risks, disclaims any intention of writing a comprehensive textbook of traumatic surgery. He confines himself to a discussion of practical problems arising in his own extensive experience as associate orthopaedic surgeon to Lennox Hill Hospital, New York, which includes some 30,000 cases seen during 18 years. It is, as St. Denis is reputed to have remarked when his head was cut off, the first step that counts : no-one can foresee how complicated any case may become, or how valuable it may eventually be to have a record of the exact condition immediately after the accident, and besides this is the best time to plan treatment as a whole, and to obtain an accurate history of the accident. He believes in exact measurements whenever possible, so that the injured and the uninjured side of the body can be compared and the range of movement in the joints recorded ; and he directs attention to muscle groups which activate more than one joint, such as-the ischiocrural and gastrocnemius groups. Many cases will benefit from reference to a specialist-a fractured wrist for reduction and immobilisation, or a knee with a strained internal lateral ligament for fixation in plaster-of-paris ; after such treatment the patient may well continue under the care of the general practitioner. He agrees with the usual experience in industrial accident practice, that deliberate exaggeration of symptoms and malingering is rare in workmen, but that tact and sympathy may be required to- understand the nature and origin of the e,om-nl.q,int,q of
a,
na,tifBl1t when these do not
arynear
to
accord with the clinical findings. Greed is by no means the only motive which may prompt a man to claim an excessive degree of disability-a subconscious craving for sympathy or an urge to vindicate his real or supposed rights, or merely a reaction to what is felt to be a harsh or unjust attitude on the part of his employer or an insurer may lead to an overemphasis of symptoms difficult to distinguish from a fraudulent claim. Thorough and repeated examinations may be required in some cases before clinical signs can be detected to account for pain, where this is due to an early bone tumour or deep-seated infection. A form of atrophy, first described by Sudeck in 1900, may supervene after even slight injury, leading to decalcification of the limb bones and pain. Jordan is rightly critical of the schedules introduced in different parts of the United States as a guide to the evaluation of disability, and reports favourably on a system which has been followed for many years in Switzerland, under which the injured workman is re-examined at fixed intervals of 3, 6, 12, and 24 months after the accident, and the rate of his compensation adjusted accordingly. Griffiths and others, over here, consider that no opinion as to working capacity can be of much value unless the examiner is conversant with the condition of the patient, and the nature and physiological
1. Workmen’s
Compensation and the Physician. London: Humphrey Milford, Oxford University Press. Pp. 172. 16s.
demands of his work. Jordan insists on the need for rest to an injured part at the beginning -of treatment, by immobilisation in plaster or otherwise, coupled with active use of the rest of the body ; this applies not only to fractures, but to many kinds of injury to soft parts. The risk of joints becoming stiff in bad position must be avoided ; for instance, the shoulder should be kept at rest on an abduction splint rather than in a sling, and talipes decubitus should be prevented"by
adequate
suitable supports. In a chapter on so-called traumatic neuroses Paul Hoch notes the significance of the constitutional factor in the development of neurosis after injury. Early diagnosis and treatment are important ; not every patient who appears anxious and apprehensive is suffering from neurosis, but many are given treatment in the absence of a physical defect, which can only have the effect of prolonging the disability. Thus it may be disastrous to prescribe a long course of physiotherapy or the wearing of an appliance to correct some physical disorder which does not in fact exist. He has noted recovery from neurosis in only 25-35% of cases, but he quotes the finding of Lewandowsky that there was recovery in 70% of people affected by traumatic neurosis who received a lump sum compensation, as compared with a recovery-rate of 7% in those who received continuous compensation in the form of a monthly allowance. No doubt early settlement of a claim will often avert or abort neurosis, but to suggest that such a- result may be expected in as much as 70% of cases is to ignore the experience of our Ministry of Pensions or of such AmeriIn fact the therapeutic value can authorities as Norcott. of the lump sum has been greatly over-estimated ; it may be a convenient way of terminating the liability of the employer or’of his insurer, it seldom does any lasting good to the recipient. But it is quite true, as Jordan says, that " the quick settlement of a compensation claim is essential, otherwise the neurosis becomes ingrained and very difficult to eliminate." .
THE
TUBERCLE
BACILLUS
IN
BOOKS
BACTERIOLOGISTS specialising in tuberculosis are often asked by laymen whether books and magazines used by sputum-positive patients are infectious, and if so what There has been singularly little can be done about it. effort to find out what is the actual risk apart from general research on the survival of the bacillus outside the body ; indeed, Smithy who has lately answered the question after undertaking experiments with books, papers and catalogues artificially infected with sputum and tubercle cultures, was able to quote only two previous studies on the subject. In its inquiry into books as fomites fifteen years ago the consultative committee to the Board of Education was dealing with school books and the common infections of school life. In conveying these Brincker2 agreed with the view expressed by McCartney3 that books are insignificant as compared with other agents. But neither was considering the special question of tubercle. Smith found that at room temperature tubercle bacilli survived only a few days in room light, and from 2 weeks to 3 months in the dark. Printer’s ink seemed to have no effect on survival, bacilli living as long on printed as on blank paper. Almost all papers are composed of wood pulp chemically treated in one way another with acids and alkalis, bleaching agents, sizings and loadings ; and printing ink is equally full of chemicals ; but Smith believes that with most varieties of paper and printing ink the active chemicals likely to kill the tubercle bacillus have usually been removed or neutralised. All the papers he tested, however, had pH values between 5 and 6, well below the optimum level for the cultivation of the tubercle bacillus. Natural or
1. Smith, C. R. Amer. Rev. Tub. 1942, 46, 549. 2. Brincker, J. A. Books in public schools. HMSO, 1928. 3. McCartney, J. E. Lancet, 1925, ii, 212.
82
TH
by patients is presumably much lighter than deliberately planned experimental infection ; most likely it takes place by droplet infection or direct contact, or as as a result of moistening a thumb in order to turn a page (a practice which should be as obsolete as shuttle-kissing). Smith suggests that a book quarantine would be effective ; storage for a month should be enough in most cases to infection
allow for natural death of the bacilli, and in ’lllany cases the books doubtless remain on the shelves for longer than this. Active sterilisation could not be carried out without damage to the books, and even the use of ultraviolet lamps would require the methodical exposure of each page. The risks in the case of lending libraries are probably not very alarming : there are much graver risks, of transmission of tuberculosis in everyday life which have not yet been explored. But hospital libraries and book-trollies in tuberculosis institutions need special consideration. The supply of books is usually limited and their circulation intensive, so that long quarantine of books may seem impossible. Replaceable or washable covers could be used with advantage ; and it would be wise to get rid of well-worn books. A ragged book is likely to be an infected book. NUTRITION IN PREGNANCY DEBATES on nutrition generally reveal what enormous tracts remain to be covered in this field, and the meeting of the Scottish group of the Nutrition Society, held. in Edinburgh on Dec. 12, was no exception. Prof. R. C. Garry, who presided, discussed the influence of diet during pregnancy. This physiological strain may bring latent defects into the open ; but the rational treatment of such disturbances must wait for a fuller understanding of maternal and fcetal physiology. Prof. A. St. G. Huggett was equally cautious about the placenta-a secretory, storage and transfusion organ controlled by factors as yet little understood. This endocrine structure reaches its maximum development relatively early in pregnancy, but nearly three-quarters of the final weight oT the foetus is built up in the last three months of pregnancy when the placenta has ceased to grow and may even be showing signs of regression. In animal experiments, restriction of the mother’s carbohydrate intake causes a fall in her liver glycogen but does not affect the liver glycogen of the fcetus ; on the other hand if the mother is given excess of carbohydrate her own liver glycogen rises only slightly, whereas the foetal liver glycogen shows a great increase. Through all these fluctuations the glycogen content of the placenta remains almost unchanged. Dr. H. M. Sinclair reviewed what evidence we have of nutritional deficiencies during pregnancy. Supplementary feeding with vitamins A and D is said to lower the incidence of puerperal sepsis, but it is doubtful if the action is Reports are conflicting on the effects of the vitamin-B. complex in preventing the togaemias of pregnancy, gestational polyneuritis and Wernicke’s encephalopathy. Claims that vitamin E prevents abortion have still to be substantiated, and it is not yet clear whether vitamin C or vitamin K or both play any part in preventing accidental haemorrhage during pregnancy or excessive bleeding at parturition. Hyperplasia of the gums is not uncommon during pregnancy but does not yield to vitamin C, and there is some evidence that it is due to excessive quantities of oestrogens in the tissues: Iron-deficiency anaemia is often seen in pregnant women but he pointed out that the physiological hydraemia of pregnancy must be taken into account in assessing the severity of this anaemia. The demands of the foetus for calcium during the second half of pregnancy are large enough to deplete the maternal reserves ; yet supplementary feeding with calcium may prolong pregnancy and harden the infant’s skull. Prof. Dugald Baird remarked that stillbirths and neonatal deaths are more common in hospital than in specialist practice (3’3% as against 0.6%). Standards of medical
specific.
and nursing care are comparable in the two groups and the responsible factor is probably dietetic ; diet is also probably responsible for the greater percentage of premature labours-9 as against 2-in hospital as compared with specialist practice. The diet of pregnant women often falls short of the standard of the League of Nations technical commission, and evidence is accumulating that by raising diets to this standard it is possible to lower prematurity and stillbirth-rates. Mr. W. Godden, FIC, discussed some deficiencies in farm animals. Iron deficiency, especially it seems in the sow, does not affect fertility but does reduce the viability of the young during the suckling period. Adequate supplies of vitamins A and D are essential for successful pregnancy in cattle, sheep and pigs, but the evidence about vitaminB complex is equivocal and there is no clear proof that vitamin-E deficiency affects animals other than the rat. Miss I. Leitch, DSc, drew attention to the high stillbirth and neonatal death-rates in Scotland-80 per 1000 as compared with 66 for England and Wales and 51 for New Zealand-another phenomenon presumably due to unexplained dietary factors. PIONEERS OF
INDUSTRIAL MEDICINE
senior medical inspector of factories is a historical event. The post was created in 1898 and its first occupant was Sir Thomas Legge who resigned in 192fi because he believed the Government had let him down on precautions about the use of white lead. Bridge succeeded Legge with whom he had already worked since 1913. For the past 44 years therefore the inception and development of industrial medicine in this country has been directed successively by two outstanding public servants. The present intense and widespread interest in the health of the industrial worker and in occupational medicine is a tribute to the soundness of the foundations which these pioneers have laid, and they have shown the way not only to this country but to the rest of the world. Dr. Bridge associated himself with no special subject, but-like Francis Bacon who took all knowledge for his province-with all those subjects whether medical,
chemical, engineering, legal, industrial, sociological or humanitarian, which have any bearing on,the health and _well-being of industrial workers. And naturally he has had a place on all the committees, and they are many, that have the worn 11 industrial " in their titles.
During his 15 years in command problems have become more complex, and the number of medical inspectors has increased steadily; these he has guided with a sure hand and the affection with which they regard him bears witness to his qualities as a chief. One attribute which has endeared him to those who work with him is his capacity for listening with sympathy and without condescension. He is fond of saying that he continually learns from his junior colleagues and his modesty in this respect covers an unrivalled knowledge of industrial and occupational health matters. But perhaps his most striking qualities are
his
common
sense-really
an uncommon
quality-
and his flair for picking out the essentials of a complicated subject which in his case really does include ships and shoes and sealing wax. His sense of humour and love of a fair deal, coupled with a legal training and a prodigious memory make him the ideal chairman who ensures a hearing for the timid, tactful suppression of the vociferous, and the right decision at the end of the discussion. Unassuming himself, he is somewhat impatient of pretentiousness and pomposity. His work at Geneva has brought him into touch with continental authorities, his reputation being deservedly international. It seems a pity that such an experienced leader should have to step down at a time like this on account of the age-limit ; and it is to be hoped that his retirement will not deprive the country, industry and the medical profession of his wise counsel.