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WELFARE OF THE BLIND.
507
HEAT IN THE RELIEF OF PAIN. THE medical profession owes an increasing debt
Annotations.
of
gratitude to the chemists and biochemists of the great manufacturing houses for their labours in making available so many lines of treatment in the handy There is a danger, form of tablet or ampoule. however, that this " treatment made easy " may lead us to forget the use of, and method of using, some of
"
Ne
quid nimis."
WELFARE OF THE
BLIND.
THE yearly reports of the Advisory Committee on the Welfare of the Blind show a steady improvement in their condition since the passing of the Blind Persons Act of 1920, and the latest1 of them states that 14,563 blind persons between the ages of 50 and 70 are in receipt of Government pensions-i.e., 84 per cent. of those within the eligible age. Schemes for promoting the welfare of the blind have been submitted by all the 146 local authorities concerned, and having been approved by the Minister of Health are now in operation. In all but 30 cases the arrangements made
the older therapeutic measures which have stood the test of time. Blood-letting, cupping, and the rest were powerful weapons in the careful hands of the older physicians, and Dr. JOHN HARVEY KELLOGG has done a service by drawing attention in the American Journal of Surgery for December last to the value of heat for the relief of pain. He traces the therapeutic use of heat in this connexion from the lower are working quite satisfactorily, the difficulties in the animals, through children and the primitive people minority of cases being due partly to the want of an of all countries, to the present day. The exact mode efficient voluntary organisation and partly to the of action is not fully understood. Heat may relieve difficulties of administration in rural areas with a local congestion by producing a collateral hyper- widely scattered population. The expenditure incurred by local authorities in this connexion and the grants semia, it may break down a vascular stasis, and it is in aid from the of Health have both been suggested that it causes an inhibition of the sensory steadily growing,Ministry the amounts under these headings nerves and so relieves pain by acting through the for the financial year 1926-27 under the former head thermal nerves of the skin. This power of relieving being £173,828 and under the latter £112,510. The pain seems to be a specific property of heat, common bulk of this money was spent on workshops, hometo heat waves of all lengths but most marked in the workers, home-teaching, and books. The statistics short infra-red rays, possibly on account of their given show that the Blind Persons Act has led to the discovery of a large number of blind who were hitherto greater penetrative power. To obtain the best results unknown. Apparently the granting of free wireless the heat must be intensive, or as " hot as the patient licences to the blind in 1926 has led to the discovery of can bear," and to apply it, careful and continuous a considerable number who were unregistered. Another attention is required either from doctor or nurse. thing that comes out is a slight decrease in the It is not just a prick with a hypodermic needle and number of the blind under the age of 21 in spite of a away. Heat can be applied by compress, poultice, considerable increase in the later decades, a decrease hot-water bag, hot stones, heated air or electricity which presumably indicates some degree of success in in various forms, and may be given either dry or the measures in operation for the prevention of infantile The intensity of dose may be greatly blindness. Apropos of these statistics it is difficult to moist. the figure 0-5 per cent. which purports to strengthened by combining some method of cooling accept the total blindness existing under the age of represent the skin surface, such as evaporation or the inter- 5 years, compared-with what exists at all later ages. mittent use of cool air. Treatment of this nature, This figure appears to be quite inconsistent with the like every form of therapy, requires a knowledge of figures in another table showing the percentage of the when and how it should be employed, and it ought total of blind persons who became blind at various not to be left to a nurse or an attendant as being ages. It is true that between 1919 and 1927 the below the personal attention of the physician. percentage of those who became blind under the age of one year compared to the total number diminished Unfortunately this is often done because the somewhat, it was still 17.4. but in the latter physician is not skilled in the niceties of its use. We made a similar criticism of year the figures of the sixth Sir LAUDER BRUNTON, in his ’’Action of Medicines," report published in 19262 and suggested as an explanapublished over 30 years ago, gave minute directions as ti on that a considerable proportion of children under to the proper making of a poultice and advised his school age escape registration. It must be a very large readers to connect in their minds " the two p’s : proportion. Other figures show that although the in remunerapain and poultice." Does poultice-making still find a total number of blind persons employed tive work has increased between’ 1919 and 1927, the modern medical in the curriculum It is doubtplace ful. The apprentice system had much to commend percentage in relation to the total number of the blind had decreased from 24-6 to 19-6. This is accounted for it, and one of its virtues consisted in the handing by the large number of blind persons over 50 added down from generation to generation of a number to the register. One of the favourite occupations is of practical points in what might be called minor piano-tuning. " It would appear," says the report, medicine and surgery, the knowledge of which made that the general remunerativeness of this occupation the distinction between the master and the apprentice. has attracted a number of persons who are not really No one who has seen the relief which follows a good suitable or competent, and in the interests of the qualified tuner we think it desirable that in future only poultice in a case of abdominal colic, or who has those persons with the highest technical and personal obtained for his pneumonia patient a couple of hours’ should be encouraged to take up this qualifications with a will ever well-timed mustard sleep paste, We are glad to observe that an occupation." doubt the value of heat therapy. Besides, it reduces section of the report is devoted to the important the drug bill and lessens that chance accident whichdifficult problem of partially blind children. The every true physician dreads-the formation of a partially blind are outside the scope of the benefits conferred by the Blind Persons Act. It is estimated drug habit. "
that there are some 7000 partially blind children in A MEDICAL CRUISE.-Every year the BruxellesEngland and Wales, and at present there appears to Medical organises a cruise for doctors, their families, and be accommodation for only 1500 of them in special. their friends. This year it will start at Bordeaux onschools for myopes and the partially blind. Meantime July 29th and end at Marseilles on August 18th, the places 1there is considerable pressure put on the managers of to be visited including Vigo, Funchal, Santa Cruz deblind schools to admit these children, for whom the Teneriffe, Las Palmas, Casablanca, and Ajaccio. Informs- tion may be had from the Section de Voyages de Bruxelles Mèdical, 29, Boulevard Adolphe Max, Brussels.
1 H.M. Stationery Office. 1928. Pp. 33. 2 THE LANCET, 1926, ii., 760.
6d.
508 not altogether suitable. The report rightly work. Like most altruistic services, this one suffers deplores the fact that so-little has as yet been done to much from popular ignorance. The belief that transequip persons of this class for taking their place in the fusion is dangerous and harmful to the donor is industrial life of the country. The suggestion is made almost universal; and only many years of public that there is ample scope for voluntary enterprise to education will eradicate it. The truth is, as medical take up and develop what is really a new social service. men well know, that the operation is never dangerous
regimen is
and is often beneficial to the donor.
The rules of the
Society protect donors from being operated
on
by
students and from any but the needle method of COLLOID CANCER OF THE STOMACH. extraction. The lay press is generally very helpful IN a thesis submitted to the Graduate School of in appealing for volunteers, but occasionally prints Minnesota Dr. J. W. Stinson,! of the Mayo Foundation, indiscreet paragraphs about " heroism," which lead to states that the first statistical studies of gastric and a number of withdrawals. Further in the British and carcinoma were published Foreign apprehension economies in the service could be effected by hospitals Medical Review of 1857 by Brinton, who in a series of if they would take more care to eliminate the 135 cases found that 9-4 per cent. were of the colloid of a relative before calling up possibility type. In a series of 2516 pathologically proved cases the service, andobtaining avoid as far as possible calling would of carcinoma of the stomach examined at the Mayo on universal donors (Group 4). The scheme has been Clinic from March 1st, 1913, to May 1st, 1925, colloid financially self-supporting from the start. Two changes were found in 121, or about 5 per cent. hospitals subscribe each a year, but the 10 Twenty-five were in women and 96 in men ; the bulk of the revenue is guineas derived from donations from average age of the women was 50-5 years, and of the private patients and the sale of tinfoil, ;S60 worth The of which was collected in 1926. men 53-3 years, the general age being 52-7 years. Although there oldest patient was aged 79 and the youngest 31. As is still need for volunteers, the London service urgent regards the symptoms, Dr. Stinson says that there was is well set upon its feet, but the provinces are not nothing to differentiate colloid carcinomata from other so well since, apart from a few local services, types of gastric cancer. The only certain method of there issupplied, no regular organisation at work. One great distinction consisted in exploratory operation and is the lack of facilities for grouping patients difficulty The and microscopical examination of the tissue. donors, and even of surgeons competent to carry structure of colloid carcinoma is similar to that of out transfusion without pain and inconvenience to ordinary adenocarcinoma of the stomach except that the donor. No volunteer, however altruistic, will a large amount of mucus is present. In typical cases submit to a series of incisions which he knows are the whole wall of the stomach is almost completely unnecessary. That a service of such value should be the of colloid that so changed by presence material, wasted on this account is a reproach which we hope the cut surface is clear and gelatinous and of a soft the provincial hospital staffs will do their utmost to consistency. Colloid changes may be noted in the remove. earliest stages of the carcinomatous process and are frequently found on microscopical examination when STANDARDISATION OF REMEDIES. they are not visible to the naked eye, especially in cases with small ulceration in which the diagnosis THE second annual report of the laboratories of lies between benign ulcer and carcinoma. In the the Pharmaceutical Society of Great Britain show a present series 97 cases, or 80 per cent., were operable, steady continuance and expansion of the invaluable and the growth was removed ; 19 were inoperable work they perform for the public health. The two and 5 were suitable for palliative measures. The main purposes of this work are pharmacological percentage of cases still alive three and five years after research, especially into methods of assay, and the operation is about the same as in the non-colloid types biological testing of manufacturers’ products. Two of carcinoma, but the incidence of late recurrence is events particularly marked 1927. At the beginning greater in the colloid variety. The post-operative of March the new department for vitamin tests began mortality-rate is about the same as in the non-colloid to receive samples, and at the beginning of August types, the post-operative life expectancy being less the laboratory began to take its part in the adminisin young patients. tration of the new Therapeutic Substances Act, a duty which meant a great increase in the number of THE RED CROSS BLOOD TRANSFUSION samples of pituitary extract submitted for examination. Alongside this work research has been carried SERVICE. out at Queen Charlotte’s Hospital to relate the new ONE day in 1921 the Camberwell division of the system of dosage of this extract to clinical requireLondon Branch of the British Red Cross Society was ments. The Act enjoins that manufacturers shall asked for a blood .donor for an emergency case. state the strength of their preparation in units, but Four members immediately volunteered, and the leaves them free to sell as many units as thev like in secretary of the division, seeing that the work was each ampoule. The majority, following the United eminently suitable for the Society, instituted a States Pharmacopoeia, put up 10 units in 1 c.cm. roster. One of those who responded to the appeal was The preliminary observations of the laboratory staff a Rover Scout, who induced his colleagues to adopt show that 10 units is a wasteful and occasionally blood transfusion as one of their forms of service. dangerous dose, and that 5 units in 1 c.cm. is sufficient In 1925 the Red Cross headquarters took over the for general purposes. A suggestion that is to be organisation, and appointed a committee consisting further tested is that manufacturers should prepare of representatives from the Society, the Rovers, and doses of 2 units only, a quantity which appears to the Hospitals Association. In 1926 no fewer than be safe at any stage of labour where there is no 737 applications for donors were received, and on mechanical obstruction. In addition to this work, the three occasions onlv had the request to be refused. staff have been examining the action on the parturient The report of the Blood Transfusion Service for 1926 uterus of the various constituents of ergot, and have contains a very interesting account of its working. come to the conclusion that, as the action of histamine The office is open day and night ; in fact, 198 of the is powerful but evanescent, and as tyramine is inert, calls during the year were urgent. Most donors are the value of ergot lies in its specific alkaloid ergotamine called up by telephone at their place of business, or ergotoxin alone. The report goes on to say that, and for this reason6 P.M. is the best time to make the since the water extract of the British Pharmacopoeia appeal, as it obviates special leave. Until the post contains none of this alkaloid, not one ounce of the offices close, express messages are sent, and after thousands of gallons made since 1914 can have had that summonses are transmitted through hostels any medicinal value.1 An assav by the Broom and and private persons with telephone facilities. There Clark method of several samples of ergot prepared is great need for more volunteers for this part of the ____
____
1
1 Surgery, Gynecology, and Obstetrics, February, 1928.
These
cussed in
investigations of uterine stimulants have been disleading article in THE LANCET (1927, ii., 560).
a
HEAT IN THE RELIEF OF PAIN. THE medical profession owes an increasing debt
Annotations.
of
gratitude to the chemists and biochemists of the great manufacturing houses for their labours in making available so many lines of treatment in the handy There is a danger, form of tablet or ampoule. however, that this " treatment made easy " may lead us to forget the use of, and method of using, some of
"
Ne
quid nimis."
WELFARE OF THE
BLIND.
THE yearly reports of the Advisory Committee on the Welfare of the Blind show a steady improvement in their condition since the passing of the Blind Persons Act of 1920, and the latest1 of them states that 14,563 blind persons between the ages of 50 and 70 are in receipt of Government pensions-i.e., 84 per cent. of those within the eligible age. Schemes for promoting the welfare of the blind have been submitted by all the 146 local authorities concerned, and having been approved by the Minister of Health are now in operation. In all but 30 cases the arrangements made
the older therapeutic measures which have stood the test of time. Blood-letting, cupping, and the rest were powerful weapons in the careful hands of the older physicians, and Dr. JOHN HARVEY KELLOGG has done a service by drawing attention in the American Journal of Surgery for December last to the value of heat for the relief of pain. He traces the therapeutic use of heat in this connexion from the lower are working quite satisfactorily, the difficulties in the animals, through children and the primitive people minority of cases being due partly to the want of an of all countries, to the present day. The exact mode efficient voluntary organisation and partly to the of action is not fully understood. Heat may relieve difficulties of administration in rural areas with a local congestion by producing a collateral hyper- widely scattered population. The expenditure incurred by local authorities in this connexion and the grants semia, it may break down a vascular stasis, and it is in aid from the of Health have both been suggested that it causes an inhibition of the sensory steadily growing,Ministry the amounts under these headings nerves and so relieves pain by acting through the for the financial year 1926-27 under the former head thermal nerves of the skin. This power of relieving being £173,828 and under the latter £112,510. The pain seems to be a specific property of heat, common bulk of this money was spent on workshops, hometo heat waves of all lengths but most marked in the workers, home-teaching, and books. The statistics short infra-red rays, possibly on account of their given show that the Blind Persons Act has led to the discovery of a large number of blind who were hitherto greater penetrative power. To obtain the best results unknown. Apparently the granting of free wireless the heat must be intensive, or as " hot as the patient licences to the blind in 1926 has led to the discovery of can bear," and to apply it, careful and continuous a considerable number who were unregistered. Another attention is required either from doctor or nurse. thing that comes out is a slight decrease in the It is not just a prick with a hypodermic needle and number of the blind under the age of 21 in spite of a away. Heat can be applied by compress, poultice, considerable increase in the later decades, a decrease hot-water bag, hot stones, heated air or electricity which presumably indicates some degree of success in in various forms, and may be given either dry or the measures in operation for the prevention of infantile The intensity of dose may be greatly blindness. Apropos of these statistics it is difficult to moist. the figure 0-5 per cent. which purports to strengthened by combining some method of cooling accept the total blindness existing under the age of represent the skin surface, such as evaporation or the inter- 5 years, compared-with what exists at all later ages. mittent use of cool air. Treatment of this nature, This figure appears to be quite inconsistent with the like every form of therapy, requires a knowledge of figures in another table showing the percentage of the when and how it should be employed, and it ought total of blind persons who became blind at various not to be left to a nurse or an attendant as being ages. It is true that between 1919 and 1927 the below the personal attention of the physician. percentage of those who became blind under the age of one year compared to the total number diminished Unfortunately this is often done because the somewhat, it was still 17.4. but in the latter physician is not skilled in the niceties of its use. We made a similar criticism of year the figures of the sixth Sir LAUDER BRUNTON, in his ’’Action of Medicines," report published in 19262 and suggested as an explanapublished over 30 years ago, gave minute directions as ti on that a considerable proportion of children under to the proper making of a poultice and advised his school age escape registration. It must be a very large readers to connect in their minds " the two p’s : proportion. Other figures show that although the in remunerapain and poultice." Does poultice-making still find a total number of blind persons employed tive work has increased between’ 1919 and 1927, the modern medical in the curriculum It is doubtplace ful. The apprentice system had much to commend percentage in relation to the total number of the blind had decreased from 24-6 to 19-6. This is accounted for it, and one of its virtues consisted in the handing by the large number of blind persons over 50 added down from generation to generation of a number to the register. One of the favourite occupations is of practical points in what might be called minor piano-tuning. " It would appear," says the report, medicine and surgery, the knowledge of which made that the general remunerativeness of this occupation the distinction between the master and the apprentice. has attracted a number of persons who are not really No one who has seen the relief which follows a good suitable or competent, and in the interests of the qualified tuner we think it desirable that in future only poultice in a case of abdominal colic, or who has those persons with the highest technical and personal obtained for his pneumonia patient a couple of hours’ should be encouraged to take up this qualifications with a will ever well-timed mustard sleep paste, We are glad to observe that an occupation." doubt the value of heat therapy. Besides, it reduces section of the report is devoted to the important the drug bill and lessens that chance accident whichdifficult problem of partially blind children. The every true physician dreads-the formation of a partially blind are outside the scope of the benefits conferred by the Blind Persons Act. It is estimated drug habit. "
that there are some 7000 partially blind children in A MEDICAL CRUISE.-Every year the BruxellesEngland and Wales, and at present there appears to Medical organises a cruise for doctors, their families, and be accommodation for only 1500 of them in special. their friends. This year it will start at Bordeaux onschools for myopes and the partially blind. Meantime July 29th and end at Marseilles on August 18th, the places 1there is considerable pressure put on the managers of to be visited including Vigo, Funchal, Santa Cruz deblind schools to admit these children, for whom the Teneriffe, Las Palmas, Casablanca, and Ajaccio. Informs- tion may be had from the Section de Voyages de Bruxelles Mèdical, 29, Boulevard Adolphe Max, Brussels.
1 H.M. Stationery Office. 1928. Pp. 33. 2 THE LANCET, 1926, ii., 760.
6d.
508 not altogether suitable. The report rightly work. Like most altruistic services, this one suffers deplores the fact that so-little has as yet been done to much from popular ignorance. The belief that transequip persons of this class for taking their place in the fusion is dangerous and harmful to the donor is industrial life of the country. The suggestion is made almost universal; and only many years of public that there is ample scope for voluntary enterprise to education will eradicate it. The truth is, as medical take up and develop what is really a new social service. men well know, that the operation is never dangerous
regimen is
and is often beneficial to the donor.
The rules of the
Society protect donors from being operated
on
by
students and from any but the needle method of COLLOID CANCER OF THE STOMACH. extraction. The lay press is generally very helpful IN a thesis submitted to the Graduate School of in appealing for volunteers, but occasionally prints Minnesota Dr. J. W. Stinson,! of the Mayo Foundation, indiscreet paragraphs about " heroism," which lead to states that the first statistical studies of gastric and a number of withdrawals. Further in the British and carcinoma were published Foreign apprehension economies in the service could be effected by hospitals Medical Review of 1857 by Brinton, who in a series of if they would take more care to eliminate the 135 cases found that 9-4 per cent. were of the colloid of a relative before calling up possibility type. In a series of 2516 pathologically proved cases the service, andobtaining avoid as far as possible calling would of carcinoma of the stomach examined at the Mayo on universal donors (Group 4). The scheme has been Clinic from March 1st, 1913, to May 1st, 1925, colloid financially self-supporting from the start. Two changes were found in 121, or about 5 per cent. hospitals subscribe each a year, but the 10 Twenty-five were in women and 96 in men ; the bulk of the revenue is guineas derived from donations from average age of the women was 50-5 years, and of the private patients and the sale of tinfoil, ;S60 worth The of which was collected in 1926. men 53-3 years, the general age being 52-7 years. Although there oldest patient was aged 79 and the youngest 31. As is still need for volunteers, the London service urgent regards the symptoms, Dr. Stinson says that there was is well set upon its feet, but the provinces are not nothing to differentiate colloid carcinomata from other so well since, apart from a few local services, types of gastric cancer. The only certain method of there issupplied, no regular organisation at work. One great distinction consisted in exploratory operation and is the lack of facilities for grouping patients difficulty The and microscopical examination of the tissue. donors, and even of surgeons competent to carry structure of colloid carcinoma is similar to that of out transfusion without pain and inconvenience to ordinary adenocarcinoma of the stomach except that the donor. No volunteer, however altruistic, will a large amount of mucus is present. In typical cases submit to a series of incisions which he knows are the whole wall of the stomach is almost completely unnecessary. That a service of such value should be the of colloid that so changed by presence material, wasted on this account is a reproach which we hope the cut surface is clear and gelatinous and of a soft the provincial hospital staffs will do their utmost to consistency. Colloid changes may be noted in the remove. earliest stages of the carcinomatous process and are frequently found on microscopical examination when STANDARDISATION OF REMEDIES. they are not visible to the naked eye, especially in cases with small ulceration in which the diagnosis THE second annual report of the laboratories of lies between benign ulcer and carcinoma. In the the Pharmaceutical Society of Great Britain show a present series 97 cases, or 80 per cent., were operable, steady continuance and expansion of the invaluable and the growth was removed ; 19 were inoperable work they perform for the public health. The two and 5 were suitable for palliative measures. The main purposes of this work are pharmacological percentage of cases still alive three and five years after research, especially into methods of assay, and the operation is about the same as in the non-colloid types biological testing of manufacturers’ products. Two of carcinoma, but the incidence of late recurrence is events particularly marked 1927. At the beginning greater in the colloid variety. The post-operative of March the new department for vitamin tests began mortality-rate is about the same as in the non-colloid to receive samples, and at the beginning of August types, the post-operative life expectancy being less the laboratory began to take its part in the adminisin young patients. tration of the new Therapeutic Substances Act, a duty which meant a great increase in the number of THE RED CROSS BLOOD TRANSFUSION samples of pituitary extract submitted for examination. Alongside this work research has been carried SERVICE. out at Queen Charlotte’s Hospital to relate the new ONE day in 1921 the Camberwell division of the system of dosage of this extract to clinical requireLondon Branch of the British Red Cross Society was ments. The Act enjoins that manufacturers shall asked for a blood .donor for an emergency case. state the strength of their preparation in units, but Four members immediately volunteered, and the leaves them free to sell as many units as thev like in secretary of the division, seeing that the work was each ampoule. The majority, following the United eminently suitable for the Society, instituted a States Pharmacopoeia, put up 10 units in 1 c.cm. roster. One of those who responded to the appeal was The preliminary observations of the laboratory staff a Rover Scout, who induced his colleagues to adopt show that 10 units is a wasteful and occasionally blood transfusion as one of their forms of service. dangerous dose, and that 5 units in 1 c.cm. is sufficient In 1925 the Red Cross headquarters took over the for general purposes. A suggestion that is to be organisation, and appointed a committee consisting further tested is that manufacturers should prepare of representatives from the Society, the Rovers, and doses of 2 units only, a quantity which appears to the Hospitals Association. In 1926 no fewer than be safe at any stage of labour where there is no 737 applications for donors were received, and on mechanical obstruction. In addition to this work, the three occasions onlv had the request to be refused. staff have been examining the action on the parturient The report of the Blood Transfusion Service for 1926 uterus of the various constituents of ergot, and have contains a very interesting account of its working. come to the conclusion that, as the action of histamine The office is open day and night ; in fact, 198 of the is powerful but evanescent, and as tyramine is inert, calls during the year were urgent. Most donors are the value of ergot lies in its specific alkaloid ergotamine called up by telephone at their place of business, or ergotoxin alone. The report goes on to say that, and for this reason6 P.M. is the best time to make the since the water extract of the British Pharmacopoeia appeal, as it obviates special leave. Until the post contains none of this alkaloid, not one ounce of the offices close, express messages are sent, and after thousands of gallons made since 1914 can have had that summonses are transmitted through hostels any medicinal value.1 An assav by the Broom and and private persons with telephone facilities. There Clark method of several samples of ergot prepared is great need for more volunteers for this part of the ____
____
1
1 Surgery, Gynecology, and Obstetrics, February, 1928.
These
cussed in
investigations of uterine stimulants have been disleading article in THE LANCET (1927, ii., 560).
a