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CARCINOMA OF THE PROSTATE.
291 very serious drawback in its slow and sometimes very irregular absorption, which may in some cases produce severe intoxication, and in other cases a Treatment by inunctions feeble therapeutic effect. possesses the advantage of being reliable, effective, and painless. To obtain a rapid saturation of the body, the author suggests that it may be of advantage to give at the beginning of the inunction treatment an injection of the soluble salt of mercury, or simply a dose of 0’5 g. of calomel per os. The daily dose of ointment to be used should vary from 3 to 5 g. according to the size, &c., of the patient. The injection of soluble compounds of mercury is not employed very much nowadays owing to the necessity of daily treatment, but it is specially indicated in idiosyncrasia mercurialis, where a tendency to " hydrargyria cutanea " prevents the use of inunctions. a
-
LONDON
PANEL PRACTICE.
THERE are just over 1million insured persons on the lists of insurance practitioners in London. Of these 4060, or 1 in 380, gave notice at the New Year that they were desirous of making a change of doctor. The names of 207 insured persons were removed from practitioners’ lists at request of the latter. During the third quarter of last year just over 1 million prescriptions were given to insured persons, an average of 0’67 a head at a cost of 9’64d. each prescription, the expense being almost equally divided between the cost of ingredients and the fee for dispensing. One practitioner, whose prescriptions for the first quarter of the year averaged I’ll (instead of 0’92) a head at a cost of 11’91d. (instead of 9’25d.) each prescription, was surcharged X24s. 8d. by the Insurance Committee on the ground that the drugs ordered were in excess of what was reasonably necessary for adequate treatment. Several of his patients received 25 or more mixtures each during this period. Only 47 insured persons applied to be allowed to make their own arrangements for medical benefit. Over 1,650,000 cards were issued for the new form of medical record which came into operation on Jan. 1st. The current issue of the London Panel Committee Gazette replies to certain general questions which have arisen as to the use of these cards. Practitioners are only required to record such clinical notes as they consider will be of use to them or to any practitioner who may subsequently have the care of an insured person. Where an independent record is kept of visits or attendances available for inspection by the regional medical officer it is allowed that after the first visit, or first three attendances, the total number of these may be entered weekly or monthly ; the date of the first (or initial) certificate and that of the last (or final) certificate only require to be recorded. THE CONCENTRATING ACTIVITY OF THE
GALL-BLADDER.
the common duct. From this it was collected into a, rubber balloon placed in the peritoneal cavity, the abdominal cavity being then closed. A control experiment was made by substituting a similar balloon for the gall-bladder, which showed that the separated portions of bile differed little in their pigment content, which was taken as the index of concentration. After 24 hours the gall-bladder, still undistended, was regularly found to contain only one-sixth to onetenth as much fluid as was shown on calculation to have reached it, but this, thick and dark, was six to ten times as concentrated in pigment as the control specimen in the rubber balloon. The results were the same when, without other variations in the experiment, the gall-bladder was fllled to the normal distension with sterile bile of known character prior to withdrawal of the catheter. At the autopsy the branches of the hepatic duct always contained a thin bile like that in the balloon, a direct proof that the thick contents of the gall-bladder had It is therefore not come as such from the liver. evident that the gall-bladder can concentrate bile with very great rapidity, and this raises the question whether concentration of the bile in periods of intermittent or partial stasis may not be an important favouring element in the formation of gall-stones.
FRIEDMANN’S VACCINE. THE controversy over the merits of Friedmann’s vaccine appears to be raging as vehemently as ever in the German medical press and at medical meetings, the discussions at which are marked rather by heated partisanship than a judicial preference for truth. In the Deutsche medizinische Wochenschrift for Jan. 6th Professor W. Kruse, of Leipzig, complains bitterly of the open hostility with which his address on the subject of Friedmann’s vaccine at the Medical Society of Berlin was greeted by his audience. He found it most galling, while voicing his conviction that this vaccine is of incalculable importance both as a prophylactic and as a remedy for tuberculosis in the early stages, to be constantly interrupted by cries of " Keep to the point." Professor J. Schwalbe’s answer to this complaint in the same number of this journal is to the effect that when a provincial professor comes to Berlin to teach his colleagues wisdom he should not exasperate them by mouthing platitudes. The audience at the meeting of the Berlin Medical Society had come to hear what the director of the Hygienic Institute of the University of Leipzig had to tell them of his experimental investigations into the action of Friedmann’s vaccine, and only after they had listened for some time to such truisms as "...... the germ of tuberculosis is evidently widely distributed and easily transmitted " had silent attention given place to interruptions. To outsiders unfamiliar with the petulant atmosphere in which the Friedmann controversy has been enveloped for several years, it must seem strange that after more than eight years’ trial the remedy should still hold such an equivocal position in the medical world.
IT has long been recognised that the gall-bladder must have a concentrating function, since bile from the gall-bladder is more concentrated or inspissated than that in the bile-ducts of the same animal. Previous experiment1 has shown that the fluid which collects in bile-ducts artificially obstructed is an inspissated CARCINOMA OF THE PROSTATE. tarry bile when the ducts communicate with the gallDr. H. C. Bumpus,1 of Rochester, Minnesota, has bladder, whereas in ducts unconnected with this viscus the fluid is thin and soon becomes free from made a study of 362 cases of carcinoma of the prostate pigments and bile salts. Mr. P. Rous and Mr. P. D. observed at the Mayo clinic from 1914 to 1919 inclusive, McMaster, of the Rockefeller Institute, taking with special reference to metastases. He considers advantage of the disposition of the bile-ducts in the that metastasis to the glands occurs more frequently dog, have sought to determine the rate of concentration. than is demonstrable clinically-in his series it was There are three hepatic ducts in the dog, which found in only 37, or 10’2 per cent.-because of the unite to form a common bile-duct, with the cystic inaccessibility of the glands first involved. He states duct opening high up into the central one. Through that clinically and microscopically carcinoma of the an opening near the lower end of this last a prostate presents two fairly distinct types of enlargecatheter was pushed into the neck of the gall- ment. In the first and more malignant type the gland bladder, which was emptied and washed with salt is so slightly enlarged, and gives rise to so few local solution, the duct being ligated after the catheter was symptoms, that the condition is often only recognised withdrawn. The bile from the middle lobes of the by the symptoms produced by metastasis. In the more liver thus had no escape save into the gall-bladder, common type of carcinomatous prostate urinary symwhile that from the lobes to either side still reached ptoms are more pronounced, and metastases occur later -
1 THE LANCET, 1920, ii., 864.
1
Surgery, Gynecology, and Obstetrics, January, 1921.
292 than in the first type. Owing to its lesser degree of malignancy this type is more amenable to radiumtherapy. Dr. Bumpus estimates that one-third of the patients with carcinoma of the prostate have osseous metastases demonstrable by X rays, the most frequent sites being the pelvis, vertebrae, and femora. Pulmonary involvement is rare and occurs late in the disease, probably never without metastases elsewhere. In Dr. Bumpus’s three patients in whom metastases were found in the lungs there was also pelvic and spinal involvement, and in two the ribs, and in one the femora were also affected. Spinal cord involvement which occurred in eight of his cases closely simulates primary spinal cord tumours, and is apt to occur when the prostate is only slightly enlarged, giving rise to pain simulating intracostal neuralgia or aneurysmal pains. Owing to the absence of urinary symptoms in a considerable proportion of all cases with metastases11’5 per cent. in the present series-the possibility of carcinoma of the prostate should always be considered in men above middle age who complain of neuralgia and rheumatic pain, even in the absence of urinary
more urgent cases, and the ordinary hospital routine will not be disturbed. In all the cooperating hospitals in which private beds are reserved at present for paying patients, members will be admitted to these beds if available, should they desire it, at a uniform reduction of 1 guinea a week from the usual price of the bed. The specific rules, which have been very carefully thought out for local needs, are as follows :over
1. No one will be accepted as a single member except an unmarried man or woman, or a widower or widow without children under the age of 16. The subscription for a single member will be ae1 per annum 2. Married people without children, or a widower or widow with only one child under the age of 16 years, may only subscribe jointly at a rate of ae11Os. per annum for the two, although each shall be accounted a member. 3. Married people with a child or children under the age of 16, or a widower or widow with children under the age of 16 years, may only subscribe at a family rate of ae2per annum, which shall include the whole family, however large, except children over the age of 16, who must be accepted as single members, although each individual in the family shall be accounted a member. N.B.-These rates are subject to revision by the cooperating hospitals after due notice. 4. All candidates for membership must be approved by the Committee of Reference"formed by the cooperating hospitals. except in the case of those insured under the National Health Insurance Acts, who will produce their medical card. In the event symptoms. of the eligibility of any member being questioned, the matter will be submitted to the "Committee of Reference," whose decision shall be final. MEDICAL PROVIDENT SCHEMES. 5. Cards of membership, bearing the date, will be issued on the first day of each month to those who have become members THE Sussex Provident Scheme for Benefits the preceding month, and the benefits will begin on the dateduring of the and Additional Medical Services, of which we were card, and continue for one calendar year. These cards can be able to the details in our issue of Jan. 15th, has produced as evidence of membership. 6. At the end of one from the date of issue of the membernot only gained the of all branches of the ship card the benefits year will cease unless the subscription has been medical profession in the county of its but is renewed. Fourteen days grace will be given for renewal (during a good deal of attention elsewhere. And which no benefit will be available), but, after this, renewed membership will only be possible from the beginning of the next ___
Hospital
give
approval
origin, attracting rightly, for, given a comprehensive medical service quarter. 7. When the number of members has reached the limit of the debarring no one from obtaining every known means of of the cooperative hospitals the list will be closed. diagnosis and treatment, it does not much matter capacity 8. When a member is leaving the county within the first six whether it is paid for by a subscription or premium months of membership, and in consequence wishes to resign, oneaccording to means, or by a tax or rate. The essential half of the subscription will be repayable upon application’. aim in either case is to organise a service which the Consultation fees are to be drawn from a pool formed patients can afford and which will at the same time by deducting 25 per cent. of the moneys allotted to each afford fair remuneration to the doctors. The claims hospital, and it is obvious that the plan can be made on behalf of the Sussex Provident Scheme may similarly applied to the conditions ruling in other areas. be briefly summarised thus :It should be carefully noted that the Sussex scheme does 1. That it calls for no capital expenditure and entails no not include general practitioner services and is restricted expense either to the State, the rates, or the hospitals, nor to a maximum yearly income limit at present fixed at does it ask for charitable contributions. j6260 for single members and 500 for a family. We 2. That it provides the hospitals with a new source of publish this week for comparison a scheme for a London revenue which has great financial possibilities and may help cooperative polyclinic drawn up by Mr. C. A. Parker, to.save the voluntary system. honorary secretary of the State Medical Service Assointerfere with the 3. That it does not materially present which is of a still more inclusive nature and is work or the established routine of the hospital. 4. That, although not offering general practitioner attendance, it supplies its members with all those facilities which may be necessary for their efficient treatment in illness, and which are not provided under the National Health Insurance Acts. 5. That the ready access to these facilities must tend to the prevention and early arrest of disease, and so to an improvement in the standard of national health. 6. That it benefits the general practitioner by giving him wider facilities for diagnosis and treatment ; by keeping in his hands many patients whom he would otherwise lose in hospital; and inasmuch as the members of the scheme can only obtain its benefits through their doctor, by giving him a position of greater influence and prestige. 7. That it benefits the consultant by providing remuneration for those members of the honorary staffs of hospitals who are willing to carry out its provisions with regard to consultations, whether personal or by correspondence, at the hospital; and by giving full fees for consultations at the patient’s house, instead of the reduced fees which are now so often accepted. It is also obvious that these consultations are likely to be much more numerous when the general practitioner knows that they will entail no expense to his
patient.
8. That it gives an opportunity of profiting by hospital treatment to people of many classes whose circumstances are really as necessitous as those of the manual worker, but who have hitherto felt themselves debarred from accepting charity, and have shrunk from the publicity of a hospital.
These ends
are
to be attained in the Sussex scheme
by bringing in all the nine cooperating general and special hospitals on a uniform basis. Urgent cases will be admitted to hospitals as at present, other cases requiring operation or other hospital treatment will, after consultation, be admitted to hospital, or be placed upon the waiting list of the hospital until there is a vacant bed, but a member will not take precedence
ciation,
intended also to cover the general practitioner service, and is not limited as regards maximum income. In each case the principle of assurance is the same, the fortunate by their annual contributions helping their less fortunate brethren, adhesion being on a voluntary basis. ___
THE ACTION OF SUPRARENAL TOXIC SERUM ON ATHEROMA. THERE are two theories which hold the field with reference to the pathology of arterio-sclerosis, one which regards hypertension as the principal factor in the arterial lesions, the other which considers these lesions to be directly toxic in nature. Josue found that intravenous injections of adrenalin were followed by increase of arterial pressure, and subsequently produced atheromatous lesions in the arteries. Certain observers explain this experimental atheroma by the vasomotor, others by the toxic, action of the adrenalin, while others again, such as Lucien and Thevanot, hold that this substance acts simply through an atheromatogenous action independent of the two preceding. Observations by Etionne and Parisot, I who, by submitting animals to intravenous injections of adrenalin and at the same time of vasodilatory substances, such as iodine and trinitrin, invariably obtained atheromatous lesions of the aorta, seem to indicate that increase of arterial pressure is not a necessary condition to the production of atheroma, and that this is, on the contrary, due to the atheromatogenous action of the adrenalin. Dr. Fabio Marabotto1 has lately undertaken
1 Annali dell’ Istituto Maragliano, vol. viii., Fasc. 4, August, 1916.
,
-
LONDON
PANEL PRACTICE.
THERE are just over 1million insured persons on the lists of insurance practitioners in London. Of these 4060, or 1 in 380, gave notice at the New Year that they were desirous of making a change of doctor. The names of 207 insured persons were removed from practitioners’ lists at request of the latter. During the third quarter of last year just over 1 million prescriptions were given to insured persons, an average of 0’67 a head at a cost of 9’64d. each prescription, the expense being almost equally divided between the cost of ingredients and the fee for dispensing. One practitioner, whose prescriptions for the first quarter of the year averaged I’ll (instead of 0’92) a head at a cost of 11’91d. (instead of 9’25d.) each prescription, was surcharged X24s. 8d. by the Insurance Committee on the ground that the drugs ordered were in excess of what was reasonably necessary for adequate treatment. Several of his patients received 25 or more mixtures each during this period. Only 47 insured persons applied to be allowed to make their own arrangements for medical benefit. Over 1,650,000 cards were issued for the new form of medical record which came into operation on Jan. 1st. The current issue of the London Panel Committee Gazette replies to certain general questions which have arisen as to the use of these cards. Practitioners are only required to record such clinical notes as they consider will be of use to them or to any practitioner who may subsequently have the care of an insured person. Where an independent record is kept of visits or attendances available for inspection by the regional medical officer it is allowed that after the first visit, or first three attendances, the total number of these may be entered weekly or monthly ; the date of the first (or initial) certificate and that of the last (or final) certificate only require to be recorded. THE CONCENTRATING ACTIVITY OF THE
GALL-BLADDER.
the common duct. From this it was collected into a, rubber balloon placed in the peritoneal cavity, the abdominal cavity being then closed. A control experiment was made by substituting a similar balloon for the gall-bladder, which showed that the separated portions of bile differed little in their pigment content, which was taken as the index of concentration. After 24 hours the gall-bladder, still undistended, was regularly found to contain only one-sixth to onetenth as much fluid as was shown on calculation to have reached it, but this, thick and dark, was six to ten times as concentrated in pigment as the control specimen in the rubber balloon. The results were the same when, without other variations in the experiment, the gall-bladder was fllled to the normal distension with sterile bile of known character prior to withdrawal of the catheter. At the autopsy the branches of the hepatic duct always contained a thin bile like that in the balloon, a direct proof that the thick contents of the gall-bladder had It is therefore not come as such from the liver. evident that the gall-bladder can concentrate bile with very great rapidity, and this raises the question whether concentration of the bile in periods of intermittent or partial stasis may not be an important favouring element in the formation of gall-stones.
FRIEDMANN’S VACCINE. THE controversy over the merits of Friedmann’s vaccine appears to be raging as vehemently as ever in the German medical press and at medical meetings, the discussions at which are marked rather by heated partisanship than a judicial preference for truth. In the Deutsche medizinische Wochenschrift for Jan. 6th Professor W. Kruse, of Leipzig, complains bitterly of the open hostility with which his address on the subject of Friedmann’s vaccine at the Medical Society of Berlin was greeted by his audience. He found it most galling, while voicing his conviction that this vaccine is of incalculable importance both as a prophylactic and as a remedy for tuberculosis in the early stages, to be constantly interrupted by cries of " Keep to the point." Professor J. Schwalbe’s answer to this complaint in the same number of this journal is to the effect that when a provincial professor comes to Berlin to teach his colleagues wisdom he should not exasperate them by mouthing platitudes. The audience at the meeting of the Berlin Medical Society had come to hear what the director of the Hygienic Institute of the University of Leipzig had to tell them of his experimental investigations into the action of Friedmann’s vaccine, and only after they had listened for some time to such truisms as "...... the germ of tuberculosis is evidently widely distributed and easily transmitted " had silent attention given place to interruptions. To outsiders unfamiliar with the petulant atmosphere in which the Friedmann controversy has been enveloped for several years, it must seem strange that after more than eight years’ trial the remedy should still hold such an equivocal position in the medical world.
IT has long been recognised that the gall-bladder must have a concentrating function, since bile from the gall-bladder is more concentrated or inspissated than that in the bile-ducts of the same animal. Previous experiment1 has shown that the fluid which collects in bile-ducts artificially obstructed is an inspissated CARCINOMA OF THE PROSTATE. tarry bile when the ducts communicate with the gallDr. H. C. Bumpus,1 of Rochester, Minnesota, has bladder, whereas in ducts unconnected with this viscus the fluid is thin and soon becomes free from made a study of 362 cases of carcinoma of the prostate pigments and bile salts. Mr. P. Rous and Mr. P. D. observed at the Mayo clinic from 1914 to 1919 inclusive, McMaster, of the Rockefeller Institute, taking with special reference to metastases. He considers advantage of the disposition of the bile-ducts in the that metastasis to the glands occurs more frequently dog, have sought to determine the rate of concentration. than is demonstrable clinically-in his series it was There are three hepatic ducts in the dog, which found in only 37, or 10’2 per cent.-because of the unite to form a common bile-duct, with the cystic inaccessibility of the glands first involved. He states duct opening high up into the central one. Through that clinically and microscopically carcinoma of the an opening near the lower end of this last a prostate presents two fairly distinct types of enlargecatheter was pushed into the neck of the gall- ment. In the first and more malignant type the gland bladder, which was emptied and washed with salt is so slightly enlarged, and gives rise to so few local solution, the duct being ligated after the catheter was symptoms, that the condition is often only recognised withdrawn. The bile from the middle lobes of the by the symptoms produced by metastasis. In the more liver thus had no escape save into the gall-bladder, common type of carcinomatous prostate urinary symwhile that from the lobes to either side still reached ptoms are more pronounced, and metastases occur later -
1 THE LANCET, 1920, ii., 864.
1
Surgery, Gynecology, and Obstetrics, January, 1921.
292 than in the first type. Owing to its lesser degree of malignancy this type is more amenable to radiumtherapy. Dr. Bumpus estimates that one-third of the patients with carcinoma of the prostate have osseous metastases demonstrable by X rays, the most frequent sites being the pelvis, vertebrae, and femora. Pulmonary involvement is rare and occurs late in the disease, probably never without metastases elsewhere. In Dr. Bumpus’s three patients in whom metastases were found in the lungs there was also pelvic and spinal involvement, and in two the ribs, and in one the femora were also affected. Spinal cord involvement which occurred in eight of his cases closely simulates primary spinal cord tumours, and is apt to occur when the prostate is only slightly enlarged, giving rise to pain simulating intracostal neuralgia or aneurysmal pains. Owing to the absence of urinary symptoms in a considerable proportion of all cases with metastases11’5 per cent. in the present series-the possibility of carcinoma of the prostate should always be considered in men above middle age who complain of neuralgia and rheumatic pain, even in the absence of urinary
more urgent cases, and the ordinary hospital routine will not be disturbed. In all the cooperating hospitals in which private beds are reserved at present for paying patients, members will be admitted to these beds if available, should they desire it, at a uniform reduction of 1 guinea a week from the usual price of the bed. The specific rules, which have been very carefully thought out for local needs, are as follows :over
1. No one will be accepted as a single member except an unmarried man or woman, or a widower or widow without children under the age of 16. The subscription for a single member will be ae1 per annum 2. Married people without children, or a widower or widow with only one child under the age of 16 years, may only subscribe jointly at a rate of ae11Os. per annum for the two, although each shall be accounted a member. 3. Married people with a child or children under the age of 16, or a widower or widow with children under the age of 16 years, may only subscribe at a family rate of ae2per annum, which shall include the whole family, however large, except children over the age of 16, who must be accepted as single members, although each individual in the family shall be accounted a member. N.B.-These rates are subject to revision by the cooperating hospitals after due notice. 4. All candidates for membership must be approved by the Committee of Reference"formed by the cooperating hospitals. except in the case of those insured under the National Health Insurance Acts, who will produce their medical card. In the event symptoms. of the eligibility of any member being questioned, the matter will be submitted to the "Committee of Reference," whose decision shall be final. MEDICAL PROVIDENT SCHEMES. 5. Cards of membership, bearing the date, will be issued on the first day of each month to those who have become members THE Sussex Provident Scheme for Benefits the preceding month, and the benefits will begin on the dateduring of the and Additional Medical Services, of which we were card, and continue for one calendar year. These cards can be able to the details in our issue of Jan. 15th, has produced as evidence of membership. 6. At the end of one from the date of issue of the membernot only gained the of all branches of the ship card the benefits year will cease unless the subscription has been medical profession in the county of its but is renewed. Fourteen days grace will be given for renewal (during a good deal of attention elsewhere. And which no benefit will be available), but, after this, renewed membership will only be possible from the beginning of the next ___
Hospital
give
approval
origin, attracting rightly, for, given a comprehensive medical service quarter. 7. When the number of members has reached the limit of the debarring no one from obtaining every known means of of the cooperative hospitals the list will be closed. diagnosis and treatment, it does not much matter capacity 8. When a member is leaving the county within the first six whether it is paid for by a subscription or premium months of membership, and in consequence wishes to resign, oneaccording to means, or by a tax or rate. The essential half of the subscription will be repayable upon application’. aim in either case is to organise a service which the Consultation fees are to be drawn from a pool formed patients can afford and which will at the same time by deducting 25 per cent. of the moneys allotted to each afford fair remuneration to the doctors. The claims hospital, and it is obvious that the plan can be made on behalf of the Sussex Provident Scheme may similarly applied to the conditions ruling in other areas. be briefly summarised thus :It should be carefully noted that the Sussex scheme does 1. That it calls for no capital expenditure and entails no not include general practitioner services and is restricted expense either to the State, the rates, or the hospitals, nor to a maximum yearly income limit at present fixed at does it ask for charitable contributions. j6260 for single members and 500 for a family. We 2. That it provides the hospitals with a new source of publish this week for comparison a scheme for a London revenue which has great financial possibilities and may help cooperative polyclinic drawn up by Mr. C. A. Parker, to.save the voluntary system. honorary secretary of the State Medical Service Assointerfere with the 3. That it does not materially present which is of a still more inclusive nature and is work or the established routine of the hospital. 4. That, although not offering general practitioner attendance, it supplies its members with all those facilities which may be necessary for their efficient treatment in illness, and which are not provided under the National Health Insurance Acts. 5. That the ready access to these facilities must tend to the prevention and early arrest of disease, and so to an improvement in the standard of national health. 6. That it benefits the general practitioner by giving him wider facilities for diagnosis and treatment ; by keeping in his hands many patients whom he would otherwise lose in hospital; and inasmuch as the members of the scheme can only obtain its benefits through their doctor, by giving him a position of greater influence and prestige. 7. That it benefits the consultant by providing remuneration for those members of the honorary staffs of hospitals who are willing to carry out its provisions with regard to consultations, whether personal or by correspondence, at the hospital; and by giving full fees for consultations at the patient’s house, instead of the reduced fees which are now so often accepted. It is also obvious that these consultations are likely to be much more numerous when the general practitioner knows that they will entail no expense to his
patient.
8. That it gives an opportunity of profiting by hospital treatment to people of many classes whose circumstances are really as necessitous as those of the manual worker, but who have hitherto felt themselves debarred from accepting charity, and have shrunk from the publicity of a hospital.
These ends
are
to be attained in the Sussex scheme
by bringing in all the nine cooperating general and special hospitals on a uniform basis. Urgent cases will be admitted to hospitals as at present, other cases requiring operation or other hospital treatment will, after consultation, be admitted to hospital, or be placed upon the waiting list of the hospital until there is a vacant bed, but a member will not take precedence
ciation,
intended also to cover the general practitioner service, and is not limited as regards maximum income. In each case the principle of assurance is the same, the fortunate by their annual contributions helping their less fortunate brethren, adhesion being on a voluntary basis. ___
THE ACTION OF SUPRARENAL TOXIC SERUM ON ATHEROMA. THERE are two theories which hold the field with reference to the pathology of arterio-sclerosis, one which regards hypertension as the principal factor in the arterial lesions, the other which considers these lesions to be directly toxic in nature. Josue found that intravenous injections of adrenalin were followed by increase of arterial pressure, and subsequently produced atheromatous lesions in the arteries. Certain observers explain this experimental atheroma by the vasomotor, others by the toxic, action of the adrenalin, while others again, such as Lucien and Thevanot, hold that this substance acts simply through an atheromatogenous action independent of the two preceding. Observations by Etionne and Parisot, I who, by submitting animals to intravenous injections of adrenalin and at the same time of vasodilatory substances, such as iodine and trinitrin, invariably obtained atheromatous lesions of the aorta, seem to indicate that increase of arterial pressure is not a necessary condition to the production of atheroma, and that this is, on the contrary, due to the atheromatogenous action of the adrenalin. Dr. Fabio Marabotto1 has lately undertaken
1 Annali dell’ Istituto Maragliano, vol. viii., Fasc. 4, August, 1916.
,