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A NEW ANTIPRURITIC
83 MITRAL STENOSIS
MEDICAL knowledge has been built up largely by clinicopathological correlations based on necropsy studies. But this method, however well it -served our ancestors, had many disadvantages. It only revealed the state of affairs at the time of death, and the accompanying physiological conditions had to be reconstructed by simple clinical observation supplemented by shrewd guess-work. The advent of cardiac surgery in mitral stenosis has persuaded many physicians to adopt the bolder method of cardiac catheterisation in order to assess the physiological effects of valve disease likely to be amenable to surgical treatment. In Stockholm 49 cases of mitral stenosis have been carefully investigated in this way.1 The patients were subdivided according to degrees of breathlessness on effort into four functional grades. By passing a catheter down the branches of the pulmonary artery to a point at which it occludes one of the subdivisions, a pressure record can be obtained which is probably the pressure in the pulmonary capillaries and which also reflects to some extent the pressure changes in the pulmonary veins. This information, together with pressure records taken from the pulmonary artery and right ventricle, and also the cardiac output, gives a remarkably complete picture of the dynamics of the circulation. In groups 1 and 2, with little limitation of physical activity, cardiac output was normal and there was only slight abnormality in pulmonary arterial and pulmonary capillary pressures. In groups 3 and 4, with incapacitating dyspnoea, cardiac output was reduced and pulmonary arterial pressure was raised ; while in group 4 pulmonary capillary pressure averaged 29 mm. Hg (close to the osmotic pressure of the plasma-proteins). In these two groups exercise increased the pulmonary capillary pressure to a level above the protein osmotic pressure at which oedema of the lungs could readily occur. In each functional group auricular fibrillation was associated with a lower average cardiac output than in the patients with sinus rhythm. A diffuse " cardiac impulse was taken to indicate right ventricular hypertrophy, and in patients with this clinical manifestation the mean pulmonary arterial pressure was nearly always above 30 mm. Hg (normal 13 mm.). Other clinical signs said to indicate pulmonary hypertension (accentuated pulmonary second sound, pulmonary systolic murmur 2) were found to be unreliable. The electrocardiogram was unreliable as evidence of absent right ventricular enlargement. Bifid p waves suggested hypertrophy of the left auricle, since they were associated with a high presystolic pressure wave in the pulmonary capillary pressure tracing. A loud apical systolic murmur was evidence of mitral incompetence, as indicated by a high systolic wave in the record of pulmonary capillary pressure, though sometimes pulmonary capillary tracings showed a high systolic wave in the absence of such a murmur. Gorlin and Gorlin 3 have suggested a hydraulic formula for calculating the area of the mitral valve orifice ; but the Swedish workers point out certain fallacies in this, particularly when the mitral valve is incompetent. In this connection it is interesting that Brock4 holds that in mitral stenosis the mitral valve is nearly always ovalshaped and measures about 1 by 0-5 cm. This nearly standard size is encountered whether the symptoms are mild or severe ; he holds that the fusion of the valves always takes place at the critical areas of insertion of the chordae tendineoe, which are at the junction of the middle and outer thirds of the valve edges. If this is true, then we cannot picture the course of mitral stenosis as related to progressive narrowing of the valve ; the "
1. 2. 3. 4.
Wade, G., Werkö, L., Eliasch, H., Gidlund, A., Lagerlöf, H. Quart. J. Med. 1952, 21, 361. Bedford, D. E. Proc. R. Soc. Med. 1951, 44, 597. Gorlin, R., Gorlin, S. G. Amer. Heart J. 1951, 41, 1. Brock, R. C. Brit. Heart J. 1952, 14, 489.
clinical course in different types would depend various physiological adaptations, perhaps determined by different effects of the rheumatic process on other valves and on different parts of the myocardium. Another interesting point brought out by the Swedish investigators is the relatively slight increase in bloodcontent of the lungs even in the presence of high pulmonary vascular pressures. This agrees with the findings of Kopelman and his associates in this country 56 and is possibly7 related to reactive narrowing of the pulmonary vessels. While the Swedish work lays an excellentpractical foundation for further studies of mitral stenosis, it leaves many questions unanswered. Why do some patients develop such an extremely pulmonary arterial pressure, which may reach or even exceed that in the systemic arteriest Why do those patients who develop massive left auricles or tricuspid insufficiency have such a relatively benign course ? 8 If the stenosed valve orifice is of Brock’s standard size, why are there such varied courses of different clinical severity ? Closer study of the various subvarieties of mitral valve disease will be necessary, and each individual patient will be found to vary in some respect from his neighbour.
varying
on
high
A NEW ANTIPRURITIC
THE best treatment of an itching dermatosis is to the cause ; and to do so an accurate diagnosis and the choice of an appropriate remedy are essential. Unfortunately, there is as yet no specific treatment for a large number of pruritic conditions, which must be dealt with empirically and largely symptomatically. Of the older local antipruritics, many are messy or relatively ineffective, or they smell disagreeably. Local-anesthetic ointments of the benzocaine class often sensitise the skin, and the contact dermatitis so provoked may become very severe before the doctor or the patient realises that it is being caused by the supposed remedy for the itching. Such a patient may be sensitised to related chemicals such as the sulphonamides, p-aminosalicylic acid, and hair dyes. In the absence of a really effective antipruritic which can be given by mouth, we need good local applications of low sensitising power. 1T-ethyl-o-crotonotoluide, which is on the market in a vanishing-cream base, seems to be highly effective and relatively harmless. This compound was developed after the discovery that certain substituted crotonamides increased the "knock-down and kill " power of insecticides. It was found to have a potent action in vitro on rabbit itch-mites,9and extensive trials in human scabies gave excellent results.10-12 During these trials, the application was shown to have a considerable antipruritic action, and this observation led to its use in non-parasitic itchy dermatoses. Hitch,13 who usedEurax,’ a preparation of N-ethylo-crotonotoluide, on 200 patients suffering from a variety of skin disorders, said that over 75% found greater relief from this preparation than from any of the others previously used. The improvement in the itching was described as excellent or good in 65%. He had 4 patients who were sensitised by the application, but only one of them was affected by the active principle itself. Similarly, Peck.and Michelfelder,14 reported 1 case of sensitisation to 1‘T-ethyl-o-crotonotoluide in a series of 400 patients. A further case has been seen by Bereston,15 in which remove
5. Kopelman, H., Lee, G. de J. Clin. Sci. 1951. 10, 383. 6. Ball, J. D , Kopelman, H., Witham, A. C. Brit. Heart J. 1952, 14,
363. 7. Goodwin, J. F., Steiner, R. E., Lowe, K. G. J. Fac. Radiol., Lond. 1952, 4, 2. 8. McMichael, J. Brit. med. J. 1952, ii. 525, 578. 9. Domenjoz, R. Schweiz. med. Wschr. 1946, 76, 1210. 10. Burckhardt, W., Rymarowics, R. Ibid, p. 1213. 11. Couperus, M. J. invest. Derm. 1949, 13, 35. New Engl. J. Med. 1950, 243, 74. 12. Appel, B. Brit. J. Derm. 1952, 64, 408. 13. Hitch, J. M. N. Y. St. J. Med. 1950, 50, 1934. 14. Peck, S. M., Michelfelder, T. J. Arch. Derm. Syph., Chicago, 1952, 65, 100. 15. Bereston, E. S.
84 after only twenty-four hours’ treatment. The ointment was not tolerated by acute or oozing lesions, possibly because of the nature of the vehicle. Topical applications are unexpectedly difficult to assess, for no two skin conditions are identical and all are subject to changes independent of treatment. Moreover, symptoms cannot be measured objectively, and they can be influenced- by the enthusiasm of the doctor armed with any new preparation. Treating a symmetrical eruption on one side only might seem to be the answer, but it has been found in various skin diseases that the untreated side may respond as well as the treated. The effect of the vehicle must be considered :-: for example, Reiss and Kern,16when testing an anti-histamine ointment, found that over 28% of their patients were relieved of itching by the base alone. In these investigations the main control has been the patients’ experience with previous preparations, which may have had quite dissimilar bases. The reports are therefore open to criticism, but they can at least be taken as an indication that the substance is useful and safe. It seems unwise to use it combined in an ointment with an anti-histamine (as is the case in’Teevex’), for antihistamines can also cause sensitisation dermatitis after repeated local applications. On the other hand, it would be helpful to have the pure substance available for incorporation in different media.
sensitivity developed
CHOROIDEREMIA PROGRESSIVE degenerative lesions of the retina that have been grouped as " abiotrophies " include the different kinds of retinitis pigmentosa, gyrate atrophy of the retina, choroideremia, and several types of macular dystrophy. In choroideremia the earliest symptom is night-blindness ; then peripheral vision is gradually lost and finally central vision, so that the patient is blind. In advanced cases ophthalmoscopic examination shows that the choroidal vessels have disappeared and there is extensive retinal atrophy, affecting the central area least. At necropsy the choroidal vessels are either sclerosed or absent, and the outer layer of the retina is extremely degenerate. Earlier workers thought that this condition might be a variant of retinitis pigmentosa, with which it shares several features-the strong genetic determination, the progressive nature of the lesion, and in some instances pigmentation of the retina. Furthermore some of the female relations of patients with choroideremia were thought to have retinitis pigmentosa.17 described a family A few years ago American workers of some 600 of whom 33 had choroideremia. Sorsby and his colleagues 18 have now given an account of three further affected families. These studies show clearly that the condition is distinct from retinitis pigmentosa, which did not occur in these families. They also show that the condition is progressive ; and in different members of the family at different ages all stages can be seen from symptomless pepper-and-salt changes in the periphery of the retina to the unmasking, sclerosis, and finally disappearance of the retinal vessels. Professor Sorsby found advanced choroideremia in a boy aged only 41/2’ and one man was blind at 25 ; but blindness is rare before the age of 40, central vision being well retained ’while peripheral vision is gradually lost. Only males have symptoms of choroideremia, but many of the females in these families had retinal changes typical of the earliest stages of the disease in males. There is thus no doubt that the condition is due to a sex-linked gene which is intermediate between a dominant and a recessive ; it produces a severe lesion in 16. Reiss, F., Kern, B. B. J. Allergy, 1950, 21, 160. 17. McCulloch, C., McCulloch. R. J. P. Trans. Amer. Acad. Ophthal. Oto-laryng. 1948, 52. 160. 18. Sorsby, A., Francheschetti, A., Joseph, R., Davey, J. B. Brit. J. Ophthal. 1952, 36, 547.
"
"
carrier state in the the male, but in the heterozygous female it produces only a mild and apparently nonprogressive disturbance. Sorsby and his colleagues show that the exceptions to this mode of inheritance described in earlier reports are due to errors in diagnosis, and that the carrier state in the female relations of men with choroideremia was mistaken for retinitis pigmentosa. With any genetically determined disorder the ability to recognise the carrier state is most helpful in advising parents on the chance that their children will be affected. The sisters of men with choroideremia have an even It is chance of being normal or of being carriers. important to them to know which they are, since half the sons of carriers on the average will go blind. Those with normal retinae can be reassured that there is no risk that their sons and grandsons will be affected. NEW YEAR HONOURS
IN the select company of the members of the Order of Merit the place left vacant by the death of Sir Charles Sherrington is filled by the appointment of a surgeon, Prof. Wilder Penfield, F.R.S., of the Montreal Neurological Institute. A leader in neurosurgery, he has done classical work on cerebral localisation and the related problems of epilepsy, and the profession in this country, as in Canada, will welcome his new distinction. Of the doctors to be created knights bachelor, three are Australians-Mr. N. M. Gregg, the Sydney ophthalmic surgeon who first drew attention to the relation of congenital cataract to maternal rubella ; Dr. E. Britten Jones, of Adelaide, who has been vice-president of the Royal Australasian College of Physicians and president of the Medical Board of South Australia ; and Dr. Peter MacCallum, professor of pathology at Melbourne for 26 years and chairman of the Australian National Research Council and of the Australian National Red Cross. Nearer home it is a pleasure to see a knighthood conferred on Mr. Zachary Cope, of St. Mary’s Hospital, who has so well earned this honour as a teacher, as a former vice-president of the Royal College of Surgeons, as chairman of the Cope Committees-and simply as Zachary Cope. Another welcome name is that of Prof. Arthur Ellis, once of Toronto but afterwards of the London Hospital and the regius chair at Oxford, whose uncommon sense-whether directed to the kidney or the curriculum-has done so much, in quiet ways, for medicine and its students. We are happy to note that Dr. Pridie’s notable and far-flung work as chief medical officer of the Colonial Office since 1948 has been recognised by promotion in the Order of St. Michael and St. George, and that the distinguished medical heads of the Navy and Army, Admiral MacKenzie and General Harris, receive knighthoods in the Order of the British Empire. Many other familiar and respected names will be found in the list we publish oh p. 87 ; and to these we would add that of Mr. A. Landsborough Thomson. D.sc., now knighted, whose long service as second secretary of the Medical Research Council makes us almost able to claim him as a member of our profession. VACANCIES READERS who reached the issue will have noticed
concluding pages
of
oW’
the
analysis of vacant which was so appointments printed conspicuously there. As we explained in an annotation, this analysis is to serve as a key, and will be published weekly. But now that we haveprominently drawn attention to its existence, we are’ transferring it to our advertisement last
columns, where it will be found this week
on
p. 30.
Dr. G. F. ABERCROMBiE has been elected chairman of the foundation council of the College of General Practitioners.
MEDICAL knowledge has been built up largely by clinicopathological correlations based on necropsy studies. But this method, however well it -served our ancestors, had many disadvantages. It only revealed the state of affairs at the time of death, and the accompanying physiological conditions had to be reconstructed by simple clinical observation supplemented by shrewd guess-work. The advent of cardiac surgery in mitral stenosis has persuaded many physicians to adopt the bolder method of cardiac catheterisation in order to assess the physiological effects of valve disease likely to be amenable to surgical treatment. In Stockholm 49 cases of mitral stenosis have been carefully investigated in this way.1 The patients were subdivided according to degrees of breathlessness on effort into four functional grades. By passing a catheter down the branches of the pulmonary artery to a point at which it occludes one of the subdivisions, a pressure record can be obtained which is probably the pressure in the pulmonary capillaries and which also reflects to some extent the pressure changes in the pulmonary veins. This information, together with pressure records taken from the pulmonary artery and right ventricle, and also the cardiac output, gives a remarkably complete picture of the dynamics of the circulation. In groups 1 and 2, with little limitation of physical activity, cardiac output was normal and there was only slight abnormality in pulmonary arterial and pulmonary capillary pressures. In groups 3 and 4, with incapacitating dyspnoea, cardiac output was reduced and pulmonary arterial pressure was raised ; while in group 4 pulmonary capillary pressure averaged 29 mm. Hg (close to the osmotic pressure of the plasma-proteins). In these two groups exercise increased the pulmonary capillary pressure to a level above the protein osmotic pressure at which oedema of the lungs could readily occur. In each functional group auricular fibrillation was associated with a lower average cardiac output than in the patients with sinus rhythm. A diffuse " cardiac impulse was taken to indicate right ventricular hypertrophy, and in patients with this clinical manifestation the mean pulmonary arterial pressure was nearly always above 30 mm. Hg (normal 13 mm.). Other clinical signs said to indicate pulmonary hypertension (accentuated pulmonary second sound, pulmonary systolic murmur 2) were found to be unreliable. The electrocardiogram was unreliable as evidence of absent right ventricular enlargement. Bifid p waves suggested hypertrophy of the left auricle, since they were associated with a high presystolic pressure wave in the pulmonary capillary pressure tracing. A loud apical systolic murmur was evidence of mitral incompetence, as indicated by a high systolic wave in the record of pulmonary capillary pressure, though sometimes pulmonary capillary tracings showed a high systolic wave in the absence of such a murmur. Gorlin and Gorlin 3 have suggested a hydraulic formula for calculating the area of the mitral valve orifice ; but the Swedish workers point out certain fallacies in this, particularly when the mitral valve is incompetent. In this connection it is interesting that Brock4 holds that in mitral stenosis the mitral valve is nearly always ovalshaped and measures about 1 by 0-5 cm. This nearly standard size is encountered whether the symptoms are mild or severe ; he holds that the fusion of the valves always takes place at the critical areas of insertion of the chordae tendineoe, which are at the junction of the middle and outer thirds of the valve edges. If this is true, then we cannot picture the course of mitral stenosis as related to progressive narrowing of the valve ; the "
1. 2. 3. 4.
Wade, G., Werkö, L., Eliasch, H., Gidlund, A., Lagerlöf, H. Quart. J. Med. 1952, 21, 361. Bedford, D. E. Proc. R. Soc. Med. 1951, 44, 597. Gorlin, R., Gorlin, S. G. Amer. Heart J. 1951, 41, 1. Brock, R. C. Brit. Heart J. 1952, 14, 489.
clinical course in different types would depend various physiological adaptations, perhaps determined by different effects of the rheumatic process on other valves and on different parts of the myocardium. Another interesting point brought out by the Swedish investigators is the relatively slight increase in bloodcontent of the lungs even in the presence of high pulmonary vascular pressures. This agrees with the findings of Kopelman and his associates in this country 56 and is possibly7 related to reactive narrowing of the pulmonary vessels. While the Swedish work lays an excellentpractical foundation for further studies of mitral stenosis, it leaves many questions unanswered. Why do some patients develop such an extremely pulmonary arterial pressure, which may reach or even exceed that in the systemic arteriest Why do those patients who develop massive left auricles or tricuspid insufficiency have such a relatively benign course ? 8 If the stenosed valve orifice is of Brock’s standard size, why are there such varied courses of different clinical severity ? Closer study of the various subvarieties of mitral valve disease will be necessary, and each individual patient will be found to vary in some respect from his neighbour.
varying
on
high
A NEW ANTIPRURITIC
THE best treatment of an itching dermatosis is to the cause ; and to do so an accurate diagnosis and the choice of an appropriate remedy are essential. Unfortunately, there is as yet no specific treatment for a large number of pruritic conditions, which must be dealt with empirically and largely symptomatically. Of the older local antipruritics, many are messy or relatively ineffective, or they smell disagreeably. Local-anesthetic ointments of the benzocaine class often sensitise the skin, and the contact dermatitis so provoked may become very severe before the doctor or the patient realises that it is being caused by the supposed remedy for the itching. Such a patient may be sensitised to related chemicals such as the sulphonamides, p-aminosalicylic acid, and hair dyes. In the absence of a really effective antipruritic which can be given by mouth, we need good local applications of low sensitising power. 1T-ethyl-o-crotonotoluide, which is on the market in a vanishing-cream base, seems to be highly effective and relatively harmless. This compound was developed after the discovery that certain substituted crotonamides increased the "knock-down and kill " power of insecticides. It was found to have a potent action in vitro on rabbit itch-mites,9and extensive trials in human scabies gave excellent results.10-12 During these trials, the application was shown to have a considerable antipruritic action, and this observation led to its use in non-parasitic itchy dermatoses. Hitch,13 who usedEurax,’ a preparation of N-ethylo-crotonotoluide, on 200 patients suffering from a variety of skin disorders, said that over 75% found greater relief from this preparation than from any of the others previously used. The improvement in the itching was described as excellent or good in 65%. He had 4 patients who were sensitised by the application, but only one of them was affected by the active principle itself. Similarly, Peck.and Michelfelder,14 reported 1 case of sensitisation to 1‘T-ethyl-o-crotonotoluide in a series of 400 patients. A further case has been seen by Bereston,15 in which remove
5. Kopelman, H., Lee, G. de J. Clin. Sci. 1951. 10, 383. 6. Ball, J. D , Kopelman, H., Witham, A. C. Brit. Heart J. 1952, 14,
363. 7. Goodwin, J. F., Steiner, R. E., Lowe, K. G. J. Fac. Radiol., Lond. 1952, 4, 2. 8. McMichael, J. Brit. med. J. 1952, ii. 525, 578. 9. Domenjoz, R. Schweiz. med. Wschr. 1946, 76, 1210. 10. Burckhardt, W., Rymarowics, R. Ibid, p. 1213. 11. Couperus, M. J. invest. Derm. 1949, 13, 35. New Engl. J. Med. 1950, 243, 74. 12. Appel, B. Brit. J. Derm. 1952, 64, 408. 13. Hitch, J. M. N. Y. St. J. Med. 1950, 50, 1934. 14. Peck, S. M., Michelfelder, T. J. Arch. Derm. Syph., Chicago, 1952, 65, 100. 15. Bereston, E. S.
84 after only twenty-four hours’ treatment. The ointment was not tolerated by acute or oozing lesions, possibly because of the nature of the vehicle. Topical applications are unexpectedly difficult to assess, for no two skin conditions are identical and all are subject to changes independent of treatment. Moreover, symptoms cannot be measured objectively, and they can be influenced- by the enthusiasm of the doctor armed with any new preparation. Treating a symmetrical eruption on one side only might seem to be the answer, but it has been found in various skin diseases that the untreated side may respond as well as the treated. The effect of the vehicle must be considered :-: for example, Reiss and Kern,16when testing an anti-histamine ointment, found that over 28% of their patients were relieved of itching by the base alone. In these investigations the main control has been the patients’ experience with previous preparations, which may have had quite dissimilar bases. The reports are therefore open to criticism, but they can at least be taken as an indication that the substance is useful and safe. It seems unwise to use it combined in an ointment with an anti-histamine (as is the case in’Teevex’), for antihistamines can also cause sensitisation dermatitis after repeated local applications. On the other hand, it would be helpful to have the pure substance available for incorporation in different media.
sensitivity developed
CHOROIDEREMIA PROGRESSIVE degenerative lesions of the retina that have been grouped as " abiotrophies " include the different kinds of retinitis pigmentosa, gyrate atrophy of the retina, choroideremia, and several types of macular dystrophy. In choroideremia the earliest symptom is night-blindness ; then peripheral vision is gradually lost and finally central vision, so that the patient is blind. In advanced cases ophthalmoscopic examination shows that the choroidal vessels have disappeared and there is extensive retinal atrophy, affecting the central area least. At necropsy the choroidal vessels are either sclerosed or absent, and the outer layer of the retina is extremely degenerate. Earlier workers thought that this condition might be a variant of retinitis pigmentosa, with which it shares several features-the strong genetic determination, the progressive nature of the lesion, and in some instances pigmentation of the retina. Furthermore some of the female relations of patients with choroideremia were thought to have retinitis pigmentosa.17 described a family A few years ago American workers of some 600 of whom 33 had choroideremia. Sorsby and his colleagues 18 have now given an account of three further affected families. These studies show clearly that the condition is distinct from retinitis pigmentosa, which did not occur in these families. They also show that the condition is progressive ; and in different members of the family at different ages all stages can be seen from symptomless pepper-and-salt changes in the periphery of the retina to the unmasking, sclerosis, and finally disappearance of the retinal vessels. Professor Sorsby found advanced choroideremia in a boy aged only 41/2’ and one man was blind at 25 ; but blindness is rare before the age of 40, central vision being well retained ’while peripheral vision is gradually lost. Only males have symptoms of choroideremia, but many of the females in these families had retinal changes typical of the earliest stages of the disease in males. There is thus no doubt that the condition is due to a sex-linked gene which is intermediate between a dominant and a recessive ; it produces a severe lesion in 16. Reiss, F., Kern, B. B. J. Allergy, 1950, 21, 160. 17. McCulloch, C., McCulloch. R. J. P. Trans. Amer. Acad. Ophthal. Oto-laryng. 1948, 52. 160. 18. Sorsby, A., Francheschetti, A., Joseph, R., Davey, J. B. Brit. J. Ophthal. 1952, 36, 547.
"
"
carrier state in the the male, but in the heterozygous female it produces only a mild and apparently nonprogressive disturbance. Sorsby and his colleagues show that the exceptions to this mode of inheritance described in earlier reports are due to errors in diagnosis, and that the carrier state in the female relations of men with choroideremia was mistaken for retinitis pigmentosa. With any genetically determined disorder the ability to recognise the carrier state is most helpful in advising parents on the chance that their children will be affected. The sisters of men with choroideremia have an even It is chance of being normal or of being carriers. important to them to know which they are, since half the sons of carriers on the average will go blind. Those with normal retinae can be reassured that there is no risk that their sons and grandsons will be affected. NEW YEAR HONOURS
IN the select company of the members of the Order of Merit the place left vacant by the death of Sir Charles Sherrington is filled by the appointment of a surgeon, Prof. Wilder Penfield, F.R.S., of the Montreal Neurological Institute. A leader in neurosurgery, he has done classical work on cerebral localisation and the related problems of epilepsy, and the profession in this country, as in Canada, will welcome his new distinction. Of the doctors to be created knights bachelor, three are Australians-Mr. N. M. Gregg, the Sydney ophthalmic surgeon who first drew attention to the relation of congenital cataract to maternal rubella ; Dr. E. Britten Jones, of Adelaide, who has been vice-president of the Royal Australasian College of Physicians and president of the Medical Board of South Australia ; and Dr. Peter MacCallum, professor of pathology at Melbourne for 26 years and chairman of the Australian National Research Council and of the Australian National Red Cross. Nearer home it is a pleasure to see a knighthood conferred on Mr. Zachary Cope, of St. Mary’s Hospital, who has so well earned this honour as a teacher, as a former vice-president of the Royal College of Surgeons, as chairman of the Cope Committees-and simply as Zachary Cope. Another welcome name is that of Prof. Arthur Ellis, once of Toronto but afterwards of the London Hospital and the regius chair at Oxford, whose uncommon sense-whether directed to the kidney or the curriculum-has done so much, in quiet ways, for medicine and its students. We are happy to note that Dr. Pridie’s notable and far-flung work as chief medical officer of the Colonial Office since 1948 has been recognised by promotion in the Order of St. Michael and St. George, and that the distinguished medical heads of the Navy and Army, Admiral MacKenzie and General Harris, receive knighthoods in the Order of the British Empire. Many other familiar and respected names will be found in the list we publish oh p. 87 ; and to these we would add that of Mr. A. Landsborough Thomson. D.sc., now knighted, whose long service as second secretary of the Medical Research Council makes us almost able to claim him as a member of our profession. VACANCIES READERS who reached the issue will have noticed
concluding pages
of
oW’
the
analysis of vacant which was so appointments printed conspicuously there. As we explained in an annotation, this analysis is to serve as a key, and will be published weekly. But now that we haveprominently drawn attention to its existence, we are’ transferring it to our advertisement last
columns, where it will be found this week
on
p. 30.
Dr. G. F. ABERCROMBiE has been elected chairman of the foundation council of the College of General Practitioners.