CHRONIC ULCERATIVE COLITIS IN CHILDREN.

86 bulletin of the Office International. In addition to the settlement of matters affecting its future as an advisory body to the League of Nations, while remaining otherwise autonomous, the delegates " Ne quid nimis." decided on the final text of the international nomenclature of causes of death, which had been left in doubt owing to the death of Mr. J. 13ertillon. They PUBLIC HEALTH WORK AT THE LEAGUE established the existence of a wide difference of OF NATIONS. expert and administrative opinion on the American THE Council of the League of Nations at its session proposal that heroin should be prohibited for medical in Paris last month decided on the names of the six purposes, and settled the form of the proposals to medical members of the new Health Committee of be made to the Governments represented regarding the League who were required to supplement those international agreements relating to the composiwho had already been nominated by the Office tion of anti-diphtheritic serum and the adoption International d’Hygiene Publique. The six members of a uniform pattern of Bill of Health for shipping thus chosen were Dr. Th. Madsen (Denmark), who has purposes. been President of the provisional Health Committee TUBERCLE IN THE FRENCH ARMY. of the League since 1921, Prof. Léon Bernard (France), Prof. Ottolengli (Italy), Dr. J. Jitta (Holland), Dr. THE Archives of Military Medicine, which is the Pittaluga (Spain), and Dr. Chagas (Brazil). The official of the French Army Medical Corps, members already appointed by the Office Inter- devotedjournal its last number (vol. lxxix., No. 1) wholly to were its national d’Hygiene Publique President, the consideration of tuberculosis in the army, the Mr. 0. Velghe (Belgium), Dr. Raynaud (France), chief paper being a long and careful discussion of Sir G. Buchanan (Great Britain), Dr. Lutrario (Italy), the from the practised pen of Medecinquestion Surgeon-General H. Cumming (United States), Dr. principal M. J. L. R. A. Jeandidier, who with all his A. Granville Pasha (Egypt), Prof. Ricardo Jorge study is not very hopeful. He concludes that tuber(Portugal), Dr. H. Carriere (Switzerland), and Dr. culosis in the army only reflects the conditions of Mimbela (Peru), an additional nomination for a civil life, the morbidity being lessened, however, in medical representative of Japan being left open. the army by the selection which goes on when the The constitution of the Health Committee of the recruits come up to join. What, then, is doing in League provides for only 16 members in the first civil life to get rid of this plague ? We cannot instance, but the Council recommended the Com- destroy the infection ; vaccinations have so far mittee to add to itself two other nominees, Prof. failed ; now we are trusting that if we ward off Nocht, of Hamburg, and Dr. Chodzko, late Minister massive infections, the small doses that will be of Health at Warsaw, who represented Germany and received will set up a relative immunity. " Unable Poland respectively on the former organisation. as yet to prevent tubercle," Colonel Jeandidier puts The membership of the new Committee, which it, " we await protection by universal tuberculinisais appointed for three years, is distinguished and tion." The army might be protected by the exclusion influential. It may, however, be objected that of all unsound recruits, but that weapon is possibly its personnel is too exclusively derived from the blunted from the start, for France, though she has official public health services of the countries conHence a small population, needs a large army. only cerned, consisting as it does so largely of Government the army cannot get rid of this scourge, but can delegates of those countries to the older international only lessen it. This it can do in several ways : office. This circumstance, however, follows naturally (1) In liaison with civil agencies ; (2) by giving antifrom the fact that the activities of the League of tuberculous instruction to the soldier in barracks, Nations in health matters must in the main be not to the sick in hospital ; (3) by early diagonly carried on through the government public health nosis, and swift isolation and discharge of the services of the world which the older office represents. infected ; selection as careful as possible (4) by making It may be recalled that under its new constitution at entry ; (5) by constant, assiduous observation of the Health Committee of the League is expected to the doubtful whom the army has to receive ; (6) by act when necessary through special committees on strict of hygienic measures ; methodised application which experts on particular subjects have been training ; sufficient, varied, and well-cooked food, co-opted, and it may be anticipated that this practice healthy housing, sufficient warming, enough clothing, will be extensively followed. A more serious and good medical treatment. But having enumerated obvious criticism is that on the basis of representa- all these points Colonel Jeandidier comes back again tion by countries no place is found in the present to the basic fact that since a definite number of list for any member of the important public health recruits are required every year, they cannot be services of India, of the several British Dominions, obtained if all the suspicious are excluded ; so far or of British colonies. Steps should be taken, with the balance has been found from colonial troops, as little delay as possible, to rectify this omission themselves very susceptible to tubercle. The alterfrom the constitution of a body which demands, and native-namely, long service for sound men-is too has hitherto received, welcome participation from expensive. Every hygienic measure means more all parts of the British Empire. The Health Com- expense, for the new watchword " Selection and mittee will hold its first session under its new con- hygiene " is just the familiar " Men and money." Can stitution at Geneva in the course of February, when they be found ? Or must it be admitted that the reports of the League’s commissions on quarantine watch-dog costs so much that the house must be left on the unification of measures in the Far East, Colonel Jeandidier leaves it at open to the thieves ? standards for therapeutic sera and of serological tests, that. on the opium traffic, on standardisation of " bioULCERATIVE COLITIS IN CHILDREN. logical " remedies, and on international comparisons of cancer mortality will be taken. The Office InterIN a paper read before the last annual meeting national d’Hygiene Publique at Paris now acts of the American Pediatric Society, Dr. Henry F. as the health council of the officially advisory League, of the Mayo Clinic, has recorded fivecases and at its regular sessions will in future have an Helmholz,1 of chronic ulcerative colitis in children aged from account of the work of the Health Committee of the 8 to 15 years. Four of the cases had been under his it for before and the League consideration, oppor own observation, and one had already been published tunity of making proposals for increasing the useful- by Logan, who in 1919 had defined the condition ness of the League’s organisation for promoting as a chronic inflammation of the large bowel of international measures of public health. unknown aetiology, and showing all grades of inflamwork of the A summary of the last session of mation from a reddened, congested, easily bleeding the permanent committee of the Paris office was included in the November number of the monthly 1 American Journal of Diseases of Children, November, 1923.

Annotations.

-

I

_____

CHRONIC

87 membrane to superficial and deep ulceration with constant or recurring dysentery lasting from In none of Dr. many months to several years. Helmholz’s cases was it possible to demonstrate the

E. C. Rosenow, which at first appeared to throw a flood of light on many pathological problems of magnitude, have, as far as we are aware, never been adequately confirmed. Lord Dawson, speaking from the chair of the Medical Society of London, referred some 12 months ago to the importance of this omission. Rosenow’s work seemed to show that streptococci, cultivated from .the septic teeth of a patient with gastric ulcer, would, on injection, often produce such ulcers in rabbits. This, and many similar observations by the same worker, seemed to supply the long-sought evidence. Published in 1919, the experiments are not yet accepted by the majority of pathologists. At the same time there is no ground for entire scepticism on the subject. The Wassermann reaction gives us evidence of a general infection from a small primary syphilitic sore, which it would be impossible to obtain otherwise. Yet Prof. Fourneau,

mucous

presence of any pyogenic, dysenteric, amoebic, or tuberculous infection. In four cases the colitis started acutely with a bloody diarrhoea, and in only one instance was the condition chronic and not accompanied by diarrhoea. The ulceration begins in the lower part of the bowel, and in the course of the illness the entire colon is involved. The ileum is rarely aftected. On proctoscopic examination the ulcers are usually most marked in the rectum and lower part of the sigmoid. The colon as a rule is thickened. In severe cases only small islands of normal tissue are left, the entire surface being ulcerated and presenting a granular appearance. X rays show marked narrowing and absence of haustrations of the colon. The stools are usually five to ten in number daily, and contain a considerable amount of muco-pus and blood, frequently in clots. If there are no complications the temperature is usually not raised. Acute arthritis, which is frequent in adults, was seen in only one of the present series. The diagnosis is based on the occurrence of muco-purulent diarrhœa, with the passage of considerable amounts of blood, usually in clots, the persistence of the dysentery in spite of all medical treatment, and the absence of any of the usual ætiological factors. The prognosis under medical treatment is bad, as was illustrated in the present series of cases which did not show any improvement until after surgical intervention. The operation of choice is Brown’s method, which consists of an ileostomy, with the establishment of a complete faecal fistula through which the colon can be irrigated.

of drug taken orally, will prevent which, Institute, thePasteur has been able to synthesise syphilitic in human when the a

infection

FOCAL SEPSIS. NOT the least useful of the functions performed by a medical congress is that of concentrating general attention on the more outstanding problems of the moment. This was reflected at the recent Australasian Medical Congress of the British Medical Association in Melbourne, the first of its kind ever held in Australasia, which covered six days, and One of the was concluded on Saturday, Nov. 17th. most interesting discussions was that on Friday afternoon, dealing with focal infection in relation to general disease. Dr. R. Scot Skirving, of Sydney, who opened the discussion, urged that all definite septic foci should be treated by radical removal, whether they were thought to be responsible for general disease or not, a conclusion with which it is difficult to quarrel; but the scanty nature of the evidence linking such foci as dental abscesses even with diseases such as rheumatoid arthritis and pernicious anaemia was rightly emphasised by several subsequent speakers, including Prof. A. E. Mills, of Sydney, and Dr. S. 0. Cowen, of Melbourne. In our last issue we reported a discussion on pneumococcal infections which took place at the meeting of the Manchester Pathological Society on Dec. 12th, Dr. J. H. Dible’s opening paper appearing in full in the same number. The opinion of the pathologists, including Profs. Shaw Dunn and Matthew Stewart, appears to be trending strongly towards the view that such infections are more often due to local spread than has hitherto been believed. Dr. Dible in his concluding remarks crystallised such belief by saying that he felt that the hæmatogenous theory of invasion had been overthrown in two of the chief pneumonic infections, and that bacteriologists as a whole realised that the blood in most bacterial infections was well able to look after itself. The whole theory of the l’esponsibility of oral, pharyngeal, and intestinal sepsis for general arthritis, anaemia, gastric and duodenal ulceration, and a host of other diseases, still rests upon the

dermatitis,

flimsiect

of

bases.

The

1 Journ. of Dental

experimental studies1 of

Research,

1919 i., 205.

beings

or

monkeys

spironema is inoculated into a skin lesion. This is the latest result of a belief in the relation of general to local infection which is clearly sound though not based upon microscopic bacteriological evidence. The consolidation of the dental profession presents a fitting occasion for a more thorough investigation of the problem of focal microbic infections, and we suggest that, in view of the importance of the subject, the Ministry of Health would be well advised to organise a complete inquiry into the matter. "THE KIND OF NURSE SHE WANTS." A LETTER with this heading was published in our issue of Dec. 1st, 1923, from a writer who complained that the employment of trained nurses was very embarrassing to small householders, and indicated that there were many illnesses where the patient only needed " someone to wash me, to bring me my food, to make my bed, and in fact to attend to my physical needs " for which services a trained nurse was not required. The writer gave expression to, a really great public need, but made no suggestion how it should be met, and we confess that our own position is somewhat similar. Once again we have an example of social progress where in the course of the progress certain of the old amenities are lost,. For the last 40 or 50 years the whole course of opinion, we may say of civilisation, has tended to develop a nurse highly educated in theory and highly trained in practice. Such a nurse can be trusted not only to take the patient’s temperature and pulse,, to keep an accurate note of excretions, and to make simple analyses, but also to record with intelligent comprehension much clinical observation. Further,. the modern nurse is familiar with the details of aseptic surgery, and thoroughly capable to assist a surgeon in a difficult operation This highly finished product is valuable, is properly aware of the fact, and has developed a sense of professional self-respect. For the cases that need her she is exactly what is needed. But for the writer of the letter in our columns she is And where not " the kind of nurse she wants." serious sickness is not in question the position and capacities of the modern-trained nurse may provee an embarrassment, especially if she be without tact. She is herself well educated in her own subject, but often ignorant of the world from other points of view, owing to the semi-conventual life of a hospital. although we belive1 his is less so than a few ears ago. She may find herself unwelcome in a house, and be aware that her emolument is adding to the cost of an already expensive illness. Her waysare not the ways of her employers, any more than her people are their people. And employers are often selfish and tactless, when the illness is not one where every detail in the life of the household has to be subordinated to the claims of the sick and the sick-nurse. It is not, therefore. a matter of wonder if those who arc invalids rather than acutely ill, should desire