- Email: [email protected]
EMETINE AND THE HEART
617
Annotations AFTER DISCHARGE FOR NEUROSIS DURING the recent war the arrangements for preventing and handling neurosis were such as to reduce greatly the ill-effects that might have been anticipated from earlier experience. Nevertheless the aftermath of neurosis among Service personnel was still a ground for concern among those who saw the patients during the first two or three years of the war. In 1943 two reports appeared, by Ferguson1 in Scotland and by Lewis in London,2 which revealed a disturbing situation. The Ministry of
Health decided on a follow-up study embracing a wider sample, and they entrusted it to Dr. E. Guttmann, of the Maudsley Hospital, whose findings have now been published.3 In conjunction with an experienced psychiatric social worker, Miss Elsie Thomas, who did the field work, Guttmann made a thorough "investigation into the readjustment in civil life of a sample of men who during the first quarter of 1943 were discharged from the Army on account of neurosis. The areas selected for study were Berkshire, Buckinghamshire, and Somerset (as examples of predominantly rural districts), Birmingham, Hull, and Leicester (as industrial cities of varying size), and also Lancashire, Essex, and Warwickshire. The visits to ascertain each man’s subsequent condition were made, on the average, fifteen months after his discharge from the Army. Three-quarters of the men, it was found, had required medical attention during the period since discharge, and nearly all had lost working time through sickness, the absence-rate being between 9% and 13% of the time at risk. The reduction of occupational efficiency in these The proportion unemployed at the men was striking. time of the inquiry was 6%, and 13% of the total sample had changed their job three or more times-a much less stable employment record than that of an average war-time factory population. Besides these occupational signs of their continuing neurosis, 10% showed evidence The of serious domestic and social maladjustment. of the social influences in determining degree importance of incapacity could be recognised : for example, those who returned to their previous employers did better than the others, whereas a personal history of neurotic illhealth apparently had no predictive value as regards readjustment. Guttmann and Thomas point out that the occupational and social incapacity of this group of men is not to be interpreted without regard to their preenlistment record, which showed that their adjustment to work and to the ordinary stresses of life was less satisfactory than in the rest of the population ; the effect of changing social conditions moreover is so great that conclusions based on this group could not safely be applied to those discharged at- other periods of the war or from other Services. For example, the group studied contained few men whose neurosis could be regarded as a battle casualty; a sample chosen at another stage of the war might have included many such men, and their subsequent history would probably have been different. The outstanding conclusion from this study is that the social organisation for dealing with the problems of the neurotic ex-Service man is, in conjunction with an appropriate medical service, a powerful agency in determining and limiting the amount of incapacity, and that the critical period for readjustment is the first few months after discharge. Much in the detailed tables and comments is relevant to the whole problem of reablement. 1. Ferguson, T. Health and Industrial Efficiency. H.M. Stationery Office. 1943. 2. Lewis, A. J. A Study of the Social Effects of Neurosis. Lancet, 1943, i, 167. 3. Guttmann, E., Thomas, E. L. Readjustment in Civil Life of Soldiers discharged from the Army on account of Neurosis. Rep. publ. Hlth med. Subj., Lond. no. 93. H.M. Stationery Office. 1946.
Particularly valuable is the evidence which the report affords of how necessary a thorough survey is, and of the lines on which it must be undertaken. The common difficulty of all such surveys is the loss of a number of persons in the sample, who for one reason or another do not afford the necessary data ; in Guttmann’s inquiry, however, every person among the 382 included in the sample was traced and yielded information—an almost unprecedented achievement in a study of this type. The account in the text shows how much this was due to the method employêd and to the tact A and experience of the psychiatric social worker. comparison of the results obtained by the field investigator using her expert training, with the data obtained by a postal inquiry, showed that the latter were less complete, less accurate, and less reliable. Although skilled’ personal field work makes heavy demands on those who carry it out, and is clearly much more expensive, the fullness of the material it provides makes it an essential instrument in such investigations. EMETINE
AND
THE HEART
EMETINE is a general protoplasmic poison, and ever since Magendie and Pelletierisolated the alkaloids of ipecacuanha there has been a steady flow of articles describing its toxic effects. Dyce Duckworth2 was one of the first to draw attention to its toxic action on the heart in animals, but he was unable to demonstrate any definite effect on the blood-pressure. ZVild,3 on the ’ other hand, using the pure alkaloids, found experimentally that emetine lowered the blood-pressure and caused diastolic arrest of the heart. In dogs, Levy and Rowntree4 found that emetine produced a striking fall in blood-pressure, acute dilatation of the heart, and occasionally ventricular fibrillation. Histological changes in the myocardium, ranging from degeneration to necrosis, have also been described,5and Rinehart and Anderson 6 reported histological changes in the myocardium resembling those found in rheumatic fever. In cats and dogs, Boyd and Scherfobserved that emetine given intravenously produced a variety of changes in the electrocardiogram, including prolongation of the QRS interval, auricular extrasystoles, and tachycardia ; large doses led to ventricular extrasystoles, with ventricular fibrillation as a terminal phenomenon. Most of the textbooks stress the dangers of toxic effects on the heart, but it is difficult to findconfirmation in the original articles on the subject. Brown,8 for instance, encountered no cardiac effects in 554 cases of amoebiasis treated with emetine subcutaneously, while Heilig and Visveswar,9in 45 cases of acute amoebic dysentery, found that even intravenous administration of emetine had no serious effect on the cardiovascular system, although they point out that intramuscular therapy is safer than intravenous. In some of their patients whose electrocardiograms were abnormal on admission to hospital, the administration of emetine was even followed by an improvement in the record. Two reports of experience during the 1939-45 war seem to support the view that the toxic action on the heart is negligible. In 72 cases of amoebic dysentery treated at the Gorgas Hospital in the Panama Canal Zone,lO electrocardiograms were taken before, during, and after treatment with gr. 2 of emetine hydrochloride subcutaneously twice daily for ten days, and only temporary 1. 2. 3. 4. 5.
changes
were
found in the
electrocardiograms.
Magendie, F., Pelletier, P.-J. J. Pharmacie, 1817, 3, 145. Duckworth, D. St Barts Hosp. Rep. 1869, 5, 218 ; 1871, 7, 91. Wild, R. W. Lancet, 1895, ii, 1274. Levy, R. L., Rowntree, L. G. Arch. intern. Med. 1916, 17, 420. Chopra, R. N., Ghosh, B. N., De, P. Ind. med. Gaz. 1924, 59, 338. Epstein, D. Quart. J. Pharm. Pharmacol. 1932,
5, 21. 6. Rinehart, J. F., Anderson, H. A. Arch. Path. 1931, 11, 546. 7. Boyd, L. J., Scherf, D. J. Pharmacol. 1941, 71, 362. 8. Brown, P. W. J. Amer. med. Ass. 1935, 105, 1319. 9. Heilig, R., Visveswar, S. K. Ind. med. Gaz. 1943, 78, 419. 10. Hardgrove, M., Smith, E. R. Amer. Heart J. 1944, 28, 752.
618 In just under half the cases temporary changes occurred in the T waves, and in 7 cases there was some prolongation of the per interval, only once exceeding the upper limit of normality and then only to 0.24 second. In one case the electrocardiographic changes were slightly more definite, and, with the clinical findings, suggested the possibility of " mild myocardial infarction," but the evidence is far from convincing. Comparable findings are reported by Cottrell and Hayward 11 in an electrocardiographic study of 32 New Zealand troops receiving emetine intramuscularly (gr. 1 daily for 10-12 and 8 receiving emetine bismuth iodide. Temporary diminution or inversion of the T wave occurred in 25 of the records after emetine, and in 12 there was slight prolongation of the P-R interval. No significant change The was noted in the blood-pressure or pulse-rate. consulting physician, Middle East Forces, remarked that he knew of only one certain case and one doubtful case of toxic action of emetine on the heart occurring in that Command up to the end of 1944." If the recognised limits of dosage are not exceeded, and if the patient is always kept in bed while emetine is being given, there seems to be little risk of toxic effects on the myocardium. If it is forgotten that emetine is a potentially dangerous substance in large doses accidents may happen.
days)
"
THE INSTITUTIONAL CHILD ,
A YEAR ago the Government appointed a committee, with Miss Myra Curtis as chairman, to inquire into the provision made for children who by loss of parents or otherwise have been deprived of a normal home life. This committee, which includes Mr. Somerville Hastings, F.R.C.S., and Prof. J. C. Spenoe, F.R.C.P., has now published an interim report on one group of workers having care of such children-namely,’ resident staff of the house-mother type in charge of groups of children in small residential homes or in subdivisions of large homes. This group was studied first because, though they hold a key position in relation to the children, none of the present arrangements for training staff in child care are quite suited to their needs. There are courses for nursery nurses and nursery assistants, but for the housemothers or house-fathers the only training offered is by some voluntary bodies for their own staff, and before the war by some local authorities, the Battersea Polytechnic, and the Vocational Training School, Bristol. During the war the Ministry of Health ran courses of training, but these lasted only a week and were designed for wardens and matrons of hostels for children in reception areas.
House-mothers, like other mothers of families, have
to undertake a good deal of domestic work, but those at present appointed-often capable housewives and temperamentally fit to look after children-have rarely had the chance to learn much about the development and needs of the child, especially if he fails to conform to usual standards. The house-mother should be taught
compensate
him for the loss of his secure home TLe danger even in a good residential home is that children will be treated as groups rather than as individuals. The committee was warned by some that formal training would rob workers of their homely touch and unfit them for domestic work ; but such predictions have not been borne out among workers trained by voluntary organisations. The committee therefore recommends that a Central Council for Training in Child Care should be set up to prescribe a curriculum, choose suitable residential homes for the training of students, arrange teaching centres for the theoretical part of the course, appoint examiners, select students, and approve a course for tutors in the theoretical work. It is suggested that two years’ instruction, culminating how to
background.
11. Cottrell, J. D.,
Hayward, G. W.
Brit. Heart J. 1945, 7, 168.
in a certificate in child care (part I), would fit the student for a post as a house-mother or assistant house-mother, according to her age ; while a further year, leading to part 11 of the certificate, would fit her for senior work and for promotion. A house-mother, the committee thinks, should be able to take charge of a family group of 12 children ranging in age from 2 to 14 or 15. The corresponding male worker must be able to play the father’s part; he needs an equal understanding of children though he will share more in their outdoor pursuits and recreation than the house-mother. Candidates must have enough education to profit by the course, and they should be over 18 and usually under 5, though some widows above this age who have brought up families are well fitted for the work. In order to attract suitable candidates grants will be needed to help them to take the course. Their salary on qualifying should be commensurate with their training ; though not on a level with teachers or State-registered nurses, it will be above the level for domestic workers,. at whose rates they are at present paid. The scheme is attractive. Visitors to residential schools sometimes notice a reserved wary look on the faces of the children, not compatible with a sense of security. House-mothers are often kind, well-meaning, and able, but harassed by lack of help-as the committee noteand inclined to have an appearance of anxiety unsettling to the children who live beneath it. In the last few years we have seen some dreadful consequences befalling children taken from their parents, and though these must not weigh unduly against many happy and successful foster relationships, we should keep them in mind when planning to do better. The committee believes that its scheme will not cost more than 1:5000 a year-a small price to pay for a very wise measure. TINEL’S SIGN
OF
NERVE
REGENERATION
THE central problem in the treatment of nerve injuries is to estimate the extent of the damage to the nerve. This conclusion began to emerge in 1914-18 and has been reinforced by the experiences of 1939-45. The problem arises from the fact that in the early stages after injury similar signs appear when the nerve is completely divided (neurotmesis in Seddon’s terminology) and when the axons only have been interrupted, leaving the supporting tissues of the nerve intact (axonotmesis). If the nerve is not operated on spontaneous recovery will take place in the latter case, but not in the former. Of course intermediate conditions may occur: some bundles in a nerve may have suffered only axonotmesis whereas others may be so badly damaged (without loss of continuity) that they will not recover spontaneously. It is especially important for those managing such cases to make a correct decision in good time, because with every week of delay the condition of the denervated tissues becomes less favourable for regeneration. Since the manifestations of degeneration and denervation are similar in the two cases the surgeon must make as much use as possible of the earliest signs of regeneration. In this issue are published two studies of the hyperexcitability to mechanical stimuli which is characteristic of the very thin young axons. Unfortunately, the controversy as to the value of Tinel’s sign, which is based on this hyperexcitability, is not fully resolved by these papers. Dr. Konorski and Dr. Lubinska, of Poland, have succeeded, under the difficult war-time conditions of evacuation to the U.S.S.R., in .making a quantitative analysis of the excitability at various periods of regeneration in animals. Their suggestion that the ambiguities of Tinel’s sign might be overcome by testing the mechanical excitability of the exposed nerve meets the serious difficulty that one can hardly examine any great length of nerve in this way. Moreover, the time of examination is so critical that it is.
Annotations AFTER DISCHARGE FOR NEUROSIS DURING the recent war the arrangements for preventing and handling neurosis were such as to reduce greatly the ill-effects that might have been anticipated from earlier experience. Nevertheless the aftermath of neurosis among Service personnel was still a ground for concern among those who saw the patients during the first two or three years of the war. In 1943 two reports appeared, by Ferguson1 in Scotland and by Lewis in London,2 which revealed a disturbing situation. The Ministry of
Health decided on a follow-up study embracing a wider sample, and they entrusted it to Dr. E. Guttmann, of the Maudsley Hospital, whose findings have now been published.3 In conjunction with an experienced psychiatric social worker, Miss Elsie Thomas, who did the field work, Guttmann made a thorough "investigation into the readjustment in civil life of a sample of men who during the first quarter of 1943 were discharged from the Army on account of neurosis. The areas selected for study were Berkshire, Buckinghamshire, and Somerset (as examples of predominantly rural districts), Birmingham, Hull, and Leicester (as industrial cities of varying size), and also Lancashire, Essex, and Warwickshire. The visits to ascertain each man’s subsequent condition were made, on the average, fifteen months after his discharge from the Army. Three-quarters of the men, it was found, had required medical attention during the period since discharge, and nearly all had lost working time through sickness, the absence-rate being between 9% and 13% of the time at risk. The reduction of occupational efficiency in these The proportion unemployed at the men was striking. time of the inquiry was 6%, and 13% of the total sample had changed their job three or more times-a much less stable employment record than that of an average war-time factory population. Besides these occupational signs of their continuing neurosis, 10% showed evidence The of serious domestic and social maladjustment. of the social influences in determining degree importance of incapacity could be recognised : for example, those who returned to their previous employers did better than the others, whereas a personal history of neurotic illhealth apparently had no predictive value as regards readjustment. Guttmann and Thomas point out that the occupational and social incapacity of this group of men is not to be interpreted without regard to their preenlistment record, which showed that their adjustment to work and to the ordinary stresses of life was less satisfactory than in the rest of the population ; the effect of changing social conditions moreover is so great that conclusions based on this group could not safely be applied to those discharged at- other periods of the war or from other Services. For example, the group studied contained few men whose neurosis could be regarded as a battle casualty; a sample chosen at another stage of the war might have included many such men, and their subsequent history would probably have been different. The outstanding conclusion from this study is that the social organisation for dealing with the problems of the neurotic ex-Service man is, in conjunction with an appropriate medical service, a powerful agency in determining and limiting the amount of incapacity, and that the critical period for readjustment is the first few months after discharge. Much in the detailed tables and comments is relevant to the whole problem of reablement. 1. Ferguson, T. Health and Industrial Efficiency. H.M. Stationery Office. 1943. 2. Lewis, A. J. A Study of the Social Effects of Neurosis. Lancet, 1943, i, 167. 3. Guttmann, E., Thomas, E. L. Readjustment in Civil Life of Soldiers discharged from the Army on account of Neurosis. Rep. publ. Hlth med. Subj., Lond. no. 93. H.M. Stationery Office. 1946.
Particularly valuable is the evidence which the report affords of how necessary a thorough survey is, and of the lines on which it must be undertaken. The common difficulty of all such surveys is the loss of a number of persons in the sample, who for one reason or another do not afford the necessary data ; in Guttmann’s inquiry, however, every person among the 382 included in the sample was traced and yielded information—an almost unprecedented achievement in a study of this type. The account in the text shows how much this was due to the method employêd and to the tact A and experience of the psychiatric social worker. comparison of the results obtained by the field investigator using her expert training, with the data obtained by a postal inquiry, showed that the latter were less complete, less accurate, and less reliable. Although skilled’ personal field work makes heavy demands on those who carry it out, and is clearly much more expensive, the fullness of the material it provides makes it an essential instrument in such investigations. EMETINE
AND
THE HEART
EMETINE is a general protoplasmic poison, and ever since Magendie and Pelletierisolated the alkaloids of ipecacuanha there has been a steady flow of articles describing its toxic effects. Dyce Duckworth2 was one of the first to draw attention to its toxic action on the heart in animals, but he was unable to demonstrate any definite effect on the blood-pressure. ZVild,3 on the ’ other hand, using the pure alkaloids, found experimentally that emetine lowered the blood-pressure and caused diastolic arrest of the heart. In dogs, Levy and Rowntree4 found that emetine produced a striking fall in blood-pressure, acute dilatation of the heart, and occasionally ventricular fibrillation. Histological changes in the myocardium, ranging from degeneration to necrosis, have also been described,5and Rinehart and Anderson 6 reported histological changes in the myocardium resembling those found in rheumatic fever. In cats and dogs, Boyd and Scherfobserved that emetine given intravenously produced a variety of changes in the electrocardiogram, including prolongation of the QRS interval, auricular extrasystoles, and tachycardia ; large doses led to ventricular extrasystoles, with ventricular fibrillation as a terminal phenomenon. Most of the textbooks stress the dangers of toxic effects on the heart, but it is difficult to findconfirmation in the original articles on the subject. Brown,8 for instance, encountered no cardiac effects in 554 cases of amoebiasis treated with emetine subcutaneously, while Heilig and Visveswar,9in 45 cases of acute amoebic dysentery, found that even intravenous administration of emetine had no serious effect on the cardiovascular system, although they point out that intramuscular therapy is safer than intravenous. In some of their patients whose electrocardiograms were abnormal on admission to hospital, the administration of emetine was even followed by an improvement in the record. Two reports of experience during the 1939-45 war seem to support the view that the toxic action on the heart is negligible. In 72 cases of amoebic dysentery treated at the Gorgas Hospital in the Panama Canal Zone,lO electrocardiograms were taken before, during, and after treatment with gr. 2 of emetine hydrochloride subcutaneously twice daily for ten days, and only temporary 1. 2. 3. 4. 5.
changes
were
found in the
electrocardiograms.
Magendie, F., Pelletier, P.-J. J. Pharmacie, 1817, 3, 145. Duckworth, D. St Barts Hosp. Rep. 1869, 5, 218 ; 1871, 7, 91. Wild, R. W. Lancet, 1895, ii, 1274. Levy, R. L., Rowntree, L. G. Arch. intern. Med. 1916, 17, 420. Chopra, R. N., Ghosh, B. N., De, P. Ind. med. Gaz. 1924, 59, 338. Epstein, D. Quart. J. Pharm. Pharmacol. 1932,
5, 21. 6. Rinehart, J. F., Anderson, H. A. Arch. Path. 1931, 11, 546. 7. Boyd, L. J., Scherf, D. J. Pharmacol. 1941, 71, 362. 8. Brown, P. W. J. Amer. med. Ass. 1935, 105, 1319. 9. Heilig, R., Visveswar, S. K. Ind. med. Gaz. 1943, 78, 419. 10. Hardgrove, M., Smith, E. R. Amer. Heart J. 1944, 28, 752.
618 In just under half the cases temporary changes occurred in the T waves, and in 7 cases there was some prolongation of the per interval, only once exceeding the upper limit of normality and then only to 0.24 second. In one case the electrocardiographic changes were slightly more definite, and, with the clinical findings, suggested the possibility of " mild myocardial infarction," but the evidence is far from convincing. Comparable findings are reported by Cottrell and Hayward 11 in an electrocardiographic study of 32 New Zealand troops receiving emetine intramuscularly (gr. 1 daily for 10-12 and 8 receiving emetine bismuth iodide. Temporary diminution or inversion of the T wave occurred in 25 of the records after emetine, and in 12 there was slight prolongation of the P-R interval. No significant change The was noted in the blood-pressure or pulse-rate. consulting physician, Middle East Forces, remarked that he knew of only one certain case and one doubtful case of toxic action of emetine on the heart occurring in that Command up to the end of 1944." If the recognised limits of dosage are not exceeded, and if the patient is always kept in bed while emetine is being given, there seems to be little risk of toxic effects on the myocardium. If it is forgotten that emetine is a potentially dangerous substance in large doses accidents may happen.
days)
"
THE INSTITUTIONAL CHILD ,
A YEAR ago the Government appointed a committee, with Miss Myra Curtis as chairman, to inquire into the provision made for children who by loss of parents or otherwise have been deprived of a normal home life. This committee, which includes Mr. Somerville Hastings, F.R.C.S., and Prof. J. C. Spenoe, F.R.C.P., has now published an interim report on one group of workers having care of such children-namely,’ resident staff of the house-mother type in charge of groups of children in small residential homes or in subdivisions of large homes. This group was studied first because, though they hold a key position in relation to the children, none of the present arrangements for training staff in child care are quite suited to their needs. There are courses for nursery nurses and nursery assistants, but for the housemothers or house-fathers the only training offered is by some voluntary bodies for their own staff, and before the war by some local authorities, the Battersea Polytechnic, and the Vocational Training School, Bristol. During the war the Ministry of Health ran courses of training, but these lasted only a week and were designed for wardens and matrons of hostels for children in reception areas.
House-mothers, like other mothers of families, have
to undertake a good deal of domestic work, but those at present appointed-often capable housewives and temperamentally fit to look after children-have rarely had the chance to learn much about the development and needs of the child, especially if he fails to conform to usual standards. The house-mother should be taught
compensate
him for the loss of his secure home TLe danger even in a good residential home is that children will be treated as groups rather than as individuals. The committee was warned by some that formal training would rob workers of their homely touch and unfit them for domestic work ; but such predictions have not been borne out among workers trained by voluntary organisations. The committee therefore recommends that a Central Council for Training in Child Care should be set up to prescribe a curriculum, choose suitable residential homes for the training of students, arrange teaching centres for the theoretical part of the course, appoint examiners, select students, and approve a course for tutors in the theoretical work. It is suggested that two years’ instruction, culminating how to
background.
11. Cottrell, J. D.,
Hayward, G. W.
Brit. Heart J. 1945, 7, 168.
in a certificate in child care (part I), would fit the student for a post as a house-mother or assistant house-mother, according to her age ; while a further year, leading to part 11 of the certificate, would fit her for senior work and for promotion. A house-mother, the committee thinks, should be able to take charge of a family group of 12 children ranging in age from 2 to 14 or 15. The corresponding male worker must be able to play the father’s part; he needs an equal understanding of children though he will share more in their outdoor pursuits and recreation than the house-mother. Candidates must have enough education to profit by the course, and they should be over 18 and usually under 5, though some widows above this age who have brought up families are well fitted for the work. In order to attract suitable candidates grants will be needed to help them to take the course. Their salary on qualifying should be commensurate with their training ; though not on a level with teachers or State-registered nurses, it will be above the level for domestic workers,. at whose rates they are at present paid. The scheme is attractive. Visitors to residential schools sometimes notice a reserved wary look on the faces of the children, not compatible with a sense of security. House-mothers are often kind, well-meaning, and able, but harassed by lack of help-as the committee noteand inclined to have an appearance of anxiety unsettling to the children who live beneath it. In the last few years we have seen some dreadful consequences befalling children taken from their parents, and though these must not weigh unduly against many happy and successful foster relationships, we should keep them in mind when planning to do better. The committee believes that its scheme will not cost more than 1:5000 a year-a small price to pay for a very wise measure. TINEL’S SIGN
OF
NERVE
REGENERATION
THE central problem in the treatment of nerve injuries is to estimate the extent of the damage to the nerve. This conclusion began to emerge in 1914-18 and has been reinforced by the experiences of 1939-45. The problem arises from the fact that in the early stages after injury similar signs appear when the nerve is completely divided (neurotmesis in Seddon’s terminology) and when the axons only have been interrupted, leaving the supporting tissues of the nerve intact (axonotmesis). If the nerve is not operated on spontaneous recovery will take place in the latter case, but not in the former. Of course intermediate conditions may occur: some bundles in a nerve may have suffered only axonotmesis whereas others may be so badly damaged (without loss of continuity) that they will not recover spontaneously. It is especially important for those managing such cases to make a correct decision in good time, because with every week of delay the condition of the denervated tissues becomes less favourable for regeneration. Since the manifestations of degeneration and denervation are similar in the two cases the surgeon must make as much use as possible of the earliest signs of regeneration. In this issue are published two studies of the hyperexcitability to mechanical stimuli which is characteristic of the very thin young axons. Unfortunately, the controversy as to the value of Tinel’s sign, which is based on this hyperexcitability, is not fully resolved by these papers. Dr. Konorski and Dr. Lubinska, of Poland, have succeeded, under the difficult war-time conditions of evacuation to the U.S.S.R., in .making a quantitative analysis of the excitability at various periods of regeneration in animals. Their suggestion that the ambiguities of Tinel’s sign might be overcome by testing the mechanical excitability of the exposed nerve meets the serious difficulty that one can hardly examine any great length of nerve in this way. Moreover, the time of examination is so critical that it is.