- Email: [email protected]
Alimentary Rest in Diabetes.
MILl’lARY MEDICAL HOME SERVICE.
25
possibly be spared should be serving with the armies in the field. The older medical officers will be employed with troops which are not intended to go abroad, and we are certain that they can meet all the requirements of any army prepared and retained in these islands against the risks of invasion. The hospitals staffed by the men of over 45 would be in perfectly safe hands, especially as here the part-time man can be employed, as he can be in the garrisons of the ports and military stations. It is impossible to estimate how large a number of medical practitioners there may be in the country between the ages of 45 and 55 who are available to take whole-time commissions with the Royal Army Medical Corps, but the information possessed by the Central Medical War Committee is now of very precise and detailed character, so that in any given locality the needs of the community can be carefully watched-far more carefully, indeed, than at one time seemed possible. In these circumstances the supply of middleaged men to take whole-time commissions in the Royal Army Medical Corps who are prepared to serve with military units anywhere in the British Isles, and who can be spared from the civilian community in which they practise, ought, we think, to be forthcoming. In our belief there are a good many medical men who fall within this category and who will be very pleased to avail themselves of the opportunity thus given of serving their country, and when they present themselves in substantial numbers there will, it seems to us, be very little excuse for the retention of the younger officers in this country. They will also leave the garrison duty for part-time men, an important point, as it is one of the many criticisms to which the Army Medical Service has been subjected that not sufficient use has been made of the part-time man. As a matter of fact, the local nature of the help that he can offer is a bar to his employment save in certain capacities. can
THE
LANCET.
LONDON: SATURDAY, JULY 1, 1916.
Military Medical
Home Service.
THE demand for medical officers in the army still continues acute, though the number of certificates of enrolment issued by the Central Medical War Committee is now considerably over 4000, while commissions have been posted at an average over 40 a week for nearly a year. When, leaving our huge navy out of count, the size of our armies at home and abroad is considered, and when we remember the enormous scope of the operations entailed upon the Allies by their widely separated fronts, there should be no surprise either that the medical profession should be numerically strained by the circumstances, or that at any moment an excess of medical officers may exist at one place coincident with a demand at another place. The categorical statements of the Director-General of the Army Medical Service, as well as the detailed information which has gradually reached the country from the various seats of war, have, we think, dispelled the idea that our army has been hitherto rather enjoying a plethora than resenting a shortage of medical officers. We are glad to notice that statements to this effect have ceased to be made in responsible quarters, and this should have an effect upon chatterers in Parliament. To meet the acute calls for medical officers with the army vigorous steps have been taken in many directions by the Central Medical War Committee and the other committees recognised by the State as responsible for the supply of medical officers to the Navy and Army. The personnel of the medical profession in England and Scotland has been scrutinised, local and educational authorities have dispensed with the services of many of their officials, and all over the country there are districts which have been gravely depleted of medical men. And as the urgent demand yet remained unsatisfied, some believed that a breaking point had been reached, when a wise decision not to limit the offer of commissions in the Royal Army Medical Corps to medical practitioners under 45 years of age was arrived at. Many Territorial medical officers and members of a la suite staffat hospitals were, of i course, serving in the Royal Army Medical Corps at a more advanced age, but the offer of commissions to other practitioners did not until a few days ago extend to those who were more than 45 years of age. Now, under altered circumstances, an appeal is made for men to accept commissions in the Royal Army Medical Corps, being between the ages of 45 and 55. The military medical service of these middle-aged officers will be at home, and they will be employed especially to free the younger medical men, of whom every one who
of
Alimentary
Rest in Diabetes.
THE treatment of diabetes by fasting is not a GUELPA strongly advocated it on the one. that the disease was due to alimentary ground
new
toxaemia. His method yielded good results, although the theory on which it is based is not necessarily correct, and indeed is not generally accepted. He recommended cautious return to the usual diet after the fast, although he did not lay down a definite plan for doing so. VoN NooRDEN interpolated days of fasting and also days of vegetable and egg diet; but here, again, there was no definite plan of building up the diet after such days. ALLEN, in America, made a decided advance in our treatment of diabetes by making the fast the first step and following it up by a scheme regulated by urinary analysis. Briefly, the method is that the patient should fast till free from He is allowed to drink water freely, sugar. and can take tea, coffee, and clear meat broth as desired. When the 24-hour specimen of urine is
26
ALIMENTARY REST IN DIABETES.
free from sugar 150 grammes of vegetables con- be detected. Attention has been focussed on these taining not more than 5 per cent. of carbohydrates fasting procedures by the recent discussion opened are added, and then 5 grammes more are added by Dr. 0. LEYTON at the Therapeutical Section of every day until 170 grammes are reached; the the Royal Society of Medicine, when Dr. E. I. intake is then increased by 5 grammes every other SPRIGGS reported on the experience gained at Duff day, foods richer in carbohydrate being gradually House. It was generally agreed by the participants added, until bread is reached, unless sugar appears in that debate that the milder cases in later life or the tolerance reaches 3 grammes of carbohydrate usually respond rapidly to some such method of per kilogramme of body weight. When the urine fasting. As to the more severe cases, it may be has been free from sugar for two days three eggs are possible to free the urine from sugar for a time, added, equivalent to 20 grammes of protein, and but sometimes at too high a cost for the general Even in the severer thereafter 15 grammes daily in the form of well-being of the patient. meat until the patient is receiving 1 gramme cases, however, a modified fasting plan, not on of protein per kilogramme of body weight, or, such drastic lines as ALLEIJ’S, will probably help if the carbohydrate tolerance is nil, only more than any treatment hitherto followed. other than 4 gramme per kilogramme. Fat, The influence of fasting on acidosis in diabetes that contained in the eggs and meat, is only is interesting and rather unexpected. Whereas added when this point is reached, and then fasting causes some acidosis in a healthy individual, 25 grammes of fat are added daily until the patient it diminishes acidosis in diabetes. But then the ceases to lose weight or receives not more than acidosis in diabetes reaches a muchhigher figure 40 calories daily per kilogramme of his weight. If than is ever met with in healthy persons. What sugar returns, fasting is resumed for 24 hours or appears to happen is that the slight acidosis of until the urine is free from sugar. The diet is then starvation continues in the fasting diabetic, but increased twice as quickly as before, but the carbo- the dangerous toxic acidosis is greatly lessened. hydrate is not allowed to exceed half the former This points to the high degree of acidosis tolerance until the urine has been free from sugar in diabetes being caused by the lavish use of for two weeks, and it should not then be increased proteins, and possibly fats, in the old-fashioned more than 5 grammes per week. He also advised strict diabetic diet. Instead of saying that because that when the tolerance for carbohydrate is less a patient cannot assimilate carbohydrate therefore than 20 grammes of carbohydrate fasting should be he must take more protein and fat, we must practised one day in each week. When the toler- conclude that because his tolerance for carboance is between 20 and 50 grammes vegetables conhydrate is low it is not safe for him to indulge in taining 5 per cent. of carbohydrates and one-half an unlimited amount of other foods in the absence the usual quantity of protein and fat are allowed on of carbohydrates. In other words, a diet carefully If the balanced at a lower level is better than a lopsided one day in the week instead of the fast. tolerance is more than 100 grammes of carbo- diet. On such a plan as this coma is much less hydrate, the intake of carbohydrate is merely likely to occur than on the old method, and halved one day each week. alkalies will not be found so necessary. While As often happens, different observers have been it is by no means true that fasting procedures reaching a somewhat similar conclusion indepen- are a panacea in diabetes, it is true that a short dently by another route. GARROD and GRAHAM have fast followed by careful graduation of the diet mapped out a plan, largely by observations on the to the assimilative power of the individual is a sugar content of the blood. Their method is less decided advance on any treatment hitherto introdrastic, and therefore easier for the patient. They duced. This can be said without hesitation, do not make him fast for more than 48 hours, even although the method has not been employed if the urine still contains some sugar. Then two long enough yet for us to gauge its ultimate days of vON NooRDEN’s vegetable and egg diet effect. follow. After this the protein intake is gradually increased. Thus 2-3 oz. of ham and 3 oz. of fish ROYAL MICROSCOPICAL SOCIETY.-At a meeting of are added after the vegetable and egg days. Next the Royal Microscopical Society held on June 21st Miss 3 fish. oz. of meat are substituted for the day G. Lister,F.L.S., made a communication on the Life-history Another fast is advised at the end of three to of Mycetozoa, with Special Reference to Ceratiomyxa, in In both which she referred to the work of Dr. Jahn, of the Berlin four weeks if sugar is still present. methods the diet is cautiously pushed up, but while University, proving that the amcebulaa produced by division ALLEN’S plan involves a longer fast, that of GARROD of the swarm-spores united in pairs as gametes to produce which the plasmodia grew. The nuclei of the and GRAHAM demands more prolonged abstention zygotes, from zygotes had twice as many chromosomes as the nuclei of the from starchy foods. LANGDON BROWN has combined gametes. In Ceratiomyxa Dr. Jahn was the first to observe the two procedures by testing the tolerance of thei the division of nuclei in the young sporophores prior to this was found to be a reduction division, patient to potatoes soon after the meat stage is; spore-formation; and took place during the " network " stage of the maturing reached if the patient is then free from sugar, sporophore. To illustrate these observations lantern slides The tolerance of a number of carbohydrate foods: taken from the preparations lent by Dr. Jahn were shown on is tested in succession, such as Jerusalemthe screen, as well as a series of slides showing the more with among the Mycetozoa. artichokes, green peas, apples, and milk. In this; striking forms of sporangia met and drawings illustrating the Microscopical preparations way a varied diet can be arrived at fairly quickly,’ development of Ceratiomyxa and other Mycetozoa were and as individual tolerance to various carbohydrates! exhibited by Miss Lister, and also a number of drawings and differs, the offending item in the diet can speedilyrspecimens of the principal genera. ,
MILK PROBLEMS.
27
where milk is the sole dietary, adding that there is no evidence to show that these substances are destroyed by boiling, especially when the heat is not applied for prolonged periods and when a tem"Ne quid nimis." perature not exceeding boiling point is used. The loss of vitamine, she says, if it occurs, is evidently not sufficient to affect the nutritive value of milk, MILK PROBLEMS. " as has been abundantly shown in the preceding THE issue of a work’ which on the authority of Ichapters." This statement in defence of boiled the Medical Research Committee (National Health milk would appear to indicate that Dr. LaneInsurance) gives a general view of the state of the retention of vitamines intact Claypon regards knowledge on the subject of milk in its relations to as important and that no objection can be made to public health will attract considerable attention; boiling inasmuch as this process does not destroy it may do much to clear the air and help us in regard these substances. The report threatens to revive to the problems still ahead. Milk problems are full the whole controversy of the merits and demerits of difficulty, and it is well to have before us the data of boiled milk, in connexion with which, amongst in a collected form, which will enable us to appre- other the facts collected in this volume matters, ciate exactly the position. Such a stocktaking is valuable It is noteworthy that Dr. evidence. give necessary from time to time in many matters where Lane-Claypon dismisses practically all biological public considerations and scientific procedures influences, so that enzymes or ferments are ruled meet, and the Medical Research Committee were out as playing any possible role in nutrition. well advised to choose the milk question as one These conclusions do not on their face appear of the first importance to elucidate, so far as to harmonise with modern work on the subject researches and experience have gone. With this of nutrition, nor do they quite fit in with the object in view they invited Dr. Janet E. Lane- view that ferments or enzymes are essential as Claypon, assistant medical inspector under the activators in the great nutritive processes. Local Government Board-who, our readers may Recent observations tend to show that a chemiremember, made valuable reports upon certain cally ideal or physiologically balanced diet does portions of the subject in 1911-to collect all the not necessarily nourish its consumer unless there known materials and to make any comment which are present certain substances ; while it is difficult her wide experience enabled her serviceably to do. to believe, to take a familiar example, that a hardIt is quite obvious that with the ominous position boiled egg, with its albumin stiffly coagulated, can be of infant mortality, when war also is sacrificing dietetically as serviceable as a raw or lightly cooked lives on a very serious scale, particular attention egg. Too much stress, however, cannot be laid on this should be directed to nutritional questions in regard as one of the first stages in the natural argument, to milk the replies to which may save thousands of of milk is the coagulation of the caseinogen. digestion infant lives. Infant nutrition needs to be more But research has in fact shown, as we should expect, seriously taken in hand than ever before, and it is that from an absorption point of view all is in somewhat of a reproach to our scientific observers favour of the raw egg, while boiled milk means that the present state of our knowledge is not more that take place not only in regard changes multiple satisfactory. We know that infant mortality bears to the albumin of the fluid, but also to its other a decided relationship to methods of defective feedconstituents. Boiling as a safeguard against ing, but we are still in need of more accurate bacterial infection is, of course, sound enough, but information in combating the waste of life from it cannot be that milk so treated is chemically, physiothis ,cause. Physiology, chemistry, bacteriology, or physically the same as the milk direct logically, and other branches of science have been equally from the breast. Yet, in spite of these consideraappealed to for assistance, and a certain amount of tions, the evidence of practical experience appears real practical help has been furnished, but we still to show that certainly in a large number of cases lose too many children from what, for want of a milk does not lose any of its nutritive value by better name, we call malnutrition. When it is conDr. LaneClaypon shows that some children boiling. sidered that milk is merely an emulsion of fat, thrive better on raw milk, others on boiled milk, associated with proteins, carbohydrate, and mineral and therefore we must conclude that individuality salts, the constitution of which is definitely known, is a grand factor in the situation. the physiological chemistry would appear to be simple. It is not, however, the chemistry alone of milk that is concerned, for milk is not made THE INFLUENCE OF SPINAL ANÆSTHESIA ON in the chemical factory, but is the product of a BLOOD PRESSURE. highly organised mechanism in which so many SPINAL anaasthesia is not so generally adopted as vital factors are concerned. Dr. Lane-Claypon is it deserves to be owing to the variable and perhaps inclined to discount any vitalistic theory in regard results obtained, some surgeons having, contradictory to the efficiency of natural milk as a construotive after repeated trials, abandoned the method. In in infant feeding. Thus in reviewing the subanaesthesia has order to ascertain whether ject she refers to the so-called" biological pro- any undesirable effect on the spinal blood pressure in com" perties of milk, to the alleged" production of parison with general anaesthesia by ether and chloroBarlow’s disease and rickets by the use of heated Dr. Pietro Amaglio made a series of observations milk for infants, and to vitamine theories form, which are recorded in Il Morgagni (Part 1, No. 5, which give results that are " somewhat frag31st, 1916). The anaesthetic used was a 5 to mentary." But she admits that milk contains May 10 per cent. solution of novocaine, and observations substances of (at present) unknown composition were made with a Riva-Rocci sphygmomanometer which are essential for the life of the animal on 37 cases. It was found that the arterial pressure 1 Milk. and its Hygienic Relations. By Janet E. Lane-Claypon, M.D., was sensibly affected in 16 of the cases, in some D.Sc. Lond. Published under the direction of the Medical Research slightly, not exceeding a diminution of 5 mm. and Committee (National Health Insurance). London : Longmans, Green, and Co. 1916. Pp. 348. Price 7s. 6d. net. of small duration, returning to normal towards the
Annotations.
"
25
possibly be spared should be serving with the armies in the field. The older medical officers will be employed with troops which are not intended to go abroad, and we are certain that they can meet all the requirements of any army prepared and retained in these islands against the risks of invasion. The hospitals staffed by the men of over 45 would be in perfectly safe hands, especially as here the part-time man can be employed, as he can be in the garrisons of the ports and military stations. It is impossible to estimate how large a number of medical practitioners there may be in the country between the ages of 45 and 55 who are available to take whole-time commissions with the Royal Army Medical Corps, but the information possessed by the Central Medical War Committee is now of very precise and detailed character, so that in any given locality the needs of the community can be carefully watched-far more carefully, indeed, than at one time seemed possible. In these circumstances the supply of middleaged men to take whole-time commissions in the Royal Army Medical Corps who are prepared to serve with military units anywhere in the British Isles, and who can be spared from the civilian community in which they practise, ought, we think, to be forthcoming. In our belief there are a good many medical men who fall within this category and who will be very pleased to avail themselves of the opportunity thus given of serving their country, and when they present themselves in substantial numbers there will, it seems to us, be very little excuse for the retention of the younger officers in this country. They will also leave the garrison duty for part-time men, an important point, as it is one of the many criticisms to which the Army Medical Service has been subjected that not sufficient use has been made of the part-time man. As a matter of fact, the local nature of the help that he can offer is a bar to his employment save in certain capacities. can
THE
LANCET.
LONDON: SATURDAY, JULY 1, 1916.
Military Medical
Home Service.
THE demand for medical officers in the army still continues acute, though the number of certificates of enrolment issued by the Central Medical War Committee is now considerably over 4000, while commissions have been posted at an average over 40 a week for nearly a year. When, leaving our huge navy out of count, the size of our armies at home and abroad is considered, and when we remember the enormous scope of the operations entailed upon the Allies by their widely separated fronts, there should be no surprise either that the medical profession should be numerically strained by the circumstances, or that at any moment an excess of medical officers may exist at one place coincident with a demand at another place. The categorical statements of the Director-General of the Army Medical Service, as well as the detailed information which has gradually reached the country from the various seats of war, have, we think, dispelled the idea that our army has been hitherto rather enjoying a plethora than resenting a shortage of medical officers. We are glad to notice that statements to this effect have ceased to be made in responsible quarters, and this should have an effect upon chatterers in Parliament. To meet the acute calls for medical officers with the army vigorous steps have been taken in many directions by the Central Medical War Committee and the other committees recognised by the State as responsible for the supply of medical officers to the Navy and Army. The personnel of the medical profession in England and Scotland has been scrutinised, local and educational authorities have dispensed with the services of many of their officials, and all over the country there are districts which have been gravely depleted of medical men. And as the urgent demand yet remained unsatisfied, some believed that a breaking point had been reached, when a wise decision not to limit the offer of commissions in the Royal Army Medical Corps to medical practitioners under 45 years of age was arrived at. Many Territorial medical officers and members of a la suite staffat hospitals were, of i course, serving in the Royal Army Medical Corps at a more advanced age, but the offer of commissions to other practitioners did not until a few days ago extend to those who were more than 45 years of age. Now, under altered circumstances, an appeal is made for men to accept commissions in the Royal Army Medical Corps, being between the ages of 45 and 55. The military medical service of these middle-aged officers will be at home, and they will be employed especially to free the younger medical men, of whom every one who
of
Alimentary
Rest in Diabetes.
THE treatment of diabetes by fasting is not a GUELPA strongly advocated it on the one. that the disease was due to alimentary ground
new
toxaemia. His method yielded good results, although the theory on which it is based is not necessarily correct, and indeed is not generally accepted. He recommended cautious return to the usual diet after the fast, although he did not lay down a definite plan for doing so. VoN NooRDEN interpolated days of fasting and also days of vegetable and egg diet; but here, again, there was no definite plan of building up the diet after such days. ALLEN, in America, made a decided advance in our treatment of diabetes by making the fast the first step and following it up by a scheme regulated by urinary analysis. Briefly, the method is that the patient should fast till free from He is allowed to drink water freely, sugar. and can take tea, coffee, and clear meat broth as desired. When the 24-hour specimen of urine is
26
ALIMENTARY REST IN DIABETES.
free from sugar 150 grammes of vegetables con- be detected. Attention has been focussed on these taining not more than 5 per cent. of carbohydrates fasting procedures by the recent discussion opened are added, and then 5 grammes more are added by Dr. 0. LEYTON at the Therapeutical Section of every day until 170 grammes are reached; the the Royal Society of Medicine, when Dr. E. I. intake is then increased by 5 grammes every other SPRIGGS reported on the experience gained at Duff day, foods richer in carbohydrate being gradually House. It was generally agreed by the participants added, until bread is reached, unless sugar appears in that debate that the milder cases in later life or the tolerance reaches 3 grammes of carbohydrate usually respond rapidly to some such method of per kilogramme of body weight. When the urine fasting. As to the more severe cases, it may be has been free from sugar for two days three eggs are possible to free the urine from sugar for a time, added, equivalent to 20 grammes of protein, and but sometimes at too high a cost for the general Even in the severer thereafter 15 grammes daily in the form of well-being of the patient. meat until the patient is receiving 1 gramme cases, however, a modified fasting plan, not on of protein per kilogramme of body weight, or, such drastic lines as ALLEIJ’S, will probably help if the carbohydrate tolerance is nil, only more than any treatment hitherto followed. other than 4 gramme per kilogramme. Fat, The influence of fasting on acidosis in diabetes that contained in the eggs and meat, is only is interesting and rather unexpected. Whereas added when this point is reached, and then fasting causes some acidosis in a healthy individual, 25 grammes of fat are added daily until the patient it diminishes acidosis in diabetes. But then the ceases to lose weight or receives not more than acidosis in diabetes reaches a muchhigher figure 40 calories daily per kilogramme of his weight. If than is ever met with in healthy persons. What sugar returns, fasting is resumed for 24 hours or appears to happen is that the slight acidosis of until the urine is free from sugar. The diet is then starvation continues in the fasting diabetic, but increased twice as quickly as before, but the carbo- the dangerous toxic acidosis is greatly lessened. hydrate is not allowed to exceed half the former This points to the high degree of acidosis tolerance until the urine has been free from sugar in diabetes being caused by the lavish use of for two weeks, and it should not then be increased proteins, and possibly fats, in the old-fashioned more than 5 grammes per week. He also advised strict diabetic diet. Instead of saying that because that when the tolerance for carbohydrate is less a patient cannot assimilate carbohydrate therefore than 20 grammes of carbohydrate fasting should be he must take more protein and fat, we must practised one day in each week. When the toler- conclude that because his tolerance for carboance is between 20 and 50 grammes vegetables conhydrate is low it is not safe for him to indulge in taining 5 per cent. of carbohydrates and one-half an unlimited amount of other foods in the absence the usual quantity of protein and fat are allowed on of carbohydrates. In other words, a diet carefully If the balanced at a lower level is better than a lopsided one day in the week instead of the fast. tolerance is more than 100 grammes of carbo- diet. On such a plan as this coma is much less hydrate, the intake of carbohydrate is merely likely to occur than on the old method, and halved one day each week. alkalies will not be found so necessary. While As often happens, different observers have been it is by no means true that fasting procedures reaching a somewhat similar conclusion indepen- are a panacea in diabetes, it is true that a short dently by another route. GARROD and GRAHAM have fast followed by careful graduation of the diet mapped out a plan, largely by observations on the to the assimilative power of the individual is a sugar content of the blood. Their method is less decided advance on any treatment hitherto introdrastic, and therefore easier for the patient. They duced. This can be said without hesitation, do not make him fast for more than 48 hours, even although the method has not been employed if the urine still contains some sugar. Then two long enough yet for us to gauge its ultimate days of vON NooRDEN’s vegetable and egg diet effect. follow. After this the protein intake is gradually increased. Thus 2-3 oz. of ham and 3 oz. of fish ROYAL MICROSCOPICAL SOCIETY.-At a meeting of are added after the vegetable and egg days. Next the Royal Microscopical Society held on June 21st Miss 3 fish. oz. of meat are substituted for the day G. Lister,F.L.S., made a communication on the Life-history Another fast is advised at the end of three to of Mycetozoa, with Special Reference to Ceratiomyxa, in In both which she referred to the work of Dr. Jahn, of the Berlin four weeks if sugar is still present. methods the diet is cautiously pushed up, but while University, proving that the amcebulaa produced by division ALLEN’S plan involves a longer fast, that of GARROD of the swarm-spores united in pairs as gametes to produce which the plasmodia grew. The nuclei of the and GRAHAM demands more prolonged abstention zygotes, from zygotes had twice as many chromosomes as the nuclei of the from starchy foods. LANGDON BROWN has combined gametes. In Ceratiomyxa Dr. Jahn was the first to observe the two procedures by testing the tolerance of thei the division of nuclei in the young sporophores prior to this was found to be a reduction division, patient to potatoes soon after the meat stage is; spore-formation; and took place during the " network " stage of the maturing reached if the patient is then free from sugar, sporophore. To illustrate these observations lantern slides The tolerance of a number of carbohydrate foods: taken from the preparations lent by Dr. Jahn were shown on is tested in succession, such as Jerusalemthe screen, as well as a series of slides showing the more with among the Mycetozoa. artichokes, green peas, apples, and milk. In this; striking forms of sporangia met and drawings illustrating the Microscopical preparations way a varied diet can be arrived at fairly quickly,’ development of Ceratiomyxa and other Mycetozoa were and as individual tolerance to various carbohydrates! exhibited by Miss Lister, and also a number of drawings and differs, the offending item in the diet can speedilyrspecimens of the principal genera. ,
MILK PROBLEMS.
27
where milk is the sole dietary, adding that there is no evidence to show that these substances are destroyed by boiling, especially when the heat is not applied for prolonged periods and when a tem"Ne quid nimis." perature not exceeding boiling point is used. The loss of vitamine, she says, if it occurs, is evidently not sufficient to affect the nutritive value of milk, MILK PROBLEMS. " as has been abundantly shown in the preceding THE issue of a work’ which on the authority of Ichapters." This statement in defence of boiled the Medical Research Committee (National Health milk would appear to indicate that Dr. LaneInsurance) gives a general view of the state of the retention of vitamines intact Claypon regards knowledge on the subject of milk in its relations to as important and that no objection can be made to public health will attract considerable attention; boiling inasmuch as this process does not destroy it may do much to clear the air and help us in regard these substances. The report threatens to revive to the problems still ahead. Milk problems are full the whole controversy of the merits and demerits of difficulty, and it is well to have before us the data of boiled milk, in connexion with which, amongst in a collected form, which will enable us to appre- other the facts collected in this volume matters, ciate exactly the position. Such a stocktaking is valuable It is noteworthy that Dr. evidence. give necessary from time to time in many matters where Lane-Claypon dismisses practically all biological public considerations and scientific procedures influences, so that enzymes or ferments are ruled meet, and the Medical Research Committee were out as playing any possible role in nutrition. well advised to choose the milk question as one These conclusions do not on their face appear of the first importance to elucidate, so far as to harmonise with modern work on the subject researches and experience have gone. With this of nutrition, nor do they quite fit in with the object in view they invited Dr. Janet E. Lane- view that ferments or enzymes are essential as Claypon, assistant medical inspector under the activators in the great nutritive processes. Local Government Board-who, our readers may Recent observations tend to show that a chemiremember, made valuable reports upon certain cally ideal or physiologically balanced diet does portions of the subject in 1911-to collect all the not necessarily nourish its consumer unless there known materials and to make any comment which are present certain substances ; while it is difficult her wide experience enabled her serviceably to do. to believe, to take a familiar example, that a hardIt is quite obvious that with the ominous position boiled egg, with its albumin stiffly coagulated, can be of infant mortality, when war also is sacrificing dietetically as serviceable as a raw or lightly cooked lives on a very serious scale, particular attention egg. Too much stress, however, cannot be laid on this should be directed to nutritional questions in regard as one of the first stages in the natural argument, to milk the replies to which may save thousands of of milk is the coagulation of the caseinogen. digestion infant lives. Infant nutrition needs to be more But research has in fact shown, as we should expect, seriously taken in hand than ever before, and it is that from an absorption point of view all is in somewhat of a reproach to our scientific observers favour of the raw egg, while boiled milk means that the present state of our knowledge is not more that take place not only in regard changes multiple satisfactory. We know that infant mortality bears to the albumin of the fluid, but also to its other a decided relationship to methods of defective feedconstituents. Boiling as a safeguard against ing, but we are still in need of more accurate bacterial infection is, of course, sound enough, but information in combating the waste of life from it cannot be that milk so treated is chemically, physiothis ,cause. Physiology, chemistry, bacteriology, or physically the same as the milk direct logically, and other branches of science have been equally from the breast. Yet, in spite of these consideraappealed to for assistance, and a certain amount of tions, the evidence of practical experience appears real practical help has been furnished, but we still to show that certainly in a large number of cases lose too many children from what, for want of a milk does not lose any of its nutritive value by better name, we call malnutrition. When it is conDr. LaneClaypon shows that some children boiling. sidered that milk is merely an emulsion of fat, thrive better on raw milk, others on boiled milk, associated with proteins, carbohydrate, and mineral and therefore we must conclude that individuality salts, the constitution of which is definitely known, is a grand factor in the situation. the physiological chemistry would appear to be simple. It is not, however, the chemistry alone of milk that is concerned, for milk is not made THE INFLUENCE OF SPINAL ANÆSTHESIA ON in the chemical factory, but is the product of a BLOOD PRESSURE. highly organised mechanism in which so many SPINAL anaasthesia is not so generally adopted as vital factors are concerned. Dr. Lane-Claypon is it deserves to be owing to the variable and perhaps inclined to discount any vitalistic theory in regard results obtained, some surgeons having, contradictory to the efficiency of natural milk as a construotive after repeated trials, abandoned the method. In in infant feeding. Thus in reviewing the subanaesthesia has order to ascertain whether ject she refers to the so-called" biological pro- any undesirable effect on the spinal blood pressure in com" perties of milk, to the alleged" production of parison with general anaesthesia by ether and chloroBarlow’s disease and rickets by the use of heated Dr. Pietro Amaglio made a series of observations milk for infants, and to vitamine theories form, which are recorded in Il Morgagni (Part 1, No. 5, which give results that are " somewhat frag31st, 1916). The anaesthetic used was a 5 to mentary." But she admits that milk contains May 10 per cent. solution of novocaine, and observations substances of (at present) unknown composition were made with a Riva-Rocci sphygmomanometer which are essential for the life of the animal on 37 cases. It was found that the arterial pressure 1 Milk. and its Hygienic Relations. By Janet E. Lane-Claypon, M.D., was sensibly affected in 16 of the cases, in some D.Sc. Lond. Published under the direction of the Medical Research slightly, not exceeding a diminution of 5 mm. and Committee (National Health Insurance). London : Longmans, Green, and Co. 1916. Pp. 348. Price 7s. 6d. net. of small duration, returning to normal towards the
Annotations.
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