EXTRACTION OF A BULLET FROM THE BLADDER BY THE URETHRA.

504 T] those suggested will but rarely occur. They may Public Health Acts remains the administrative unit do so without any negligence of the prescrib- for much essential public health work, some of ing practitioner in connexion with the habit of it particularly difficult and thankless. Medical officers of health of these districts have the primary some members of the public who again and again make use of old prescriptions long after the occasion for which they were given; and perhaps When any such even hand them to their friends. a suffers person by causing prescription given in be made up under the new or before 1914 to Pharmacopoeia interesting questions, not so much of law as of who was in fact guilty of negligence, may arise. Meanwhile, as we have already pointed out, there are differences between the new Pharmacopoeia and the old, among which the case of tincture of strophanthus has been selected as a striking example, and most medical men and druggists will by now have carefully noted them. They include the altered strength of tincture of nux vomica and of tincture of opium, of which the former has passed from Part I. to Part II. of the schedule relating to poisons, whereas the latter, under the officially recognised title of laudanum, finds itself in Part I. owing to an increase of the percentage of morphine which it must contain.2

responsibility for- dealing with outbreaks of infectious disease, the survey of sanitary conditions, the closure of unhealthy dwellings, and many other details of daily work for the health and amenities of their areas. These responsibilities have increased and become more complicated, and the district medical officer of health often needs to be able to turn to other persons in authority for advice and assistance. Dr. Thresh considers that the county staff can give greater aid to progress in this way by acting as advisers than by attempting to dominate as supervisors; leading rather than driving has given the community the most benefit in the past and offers most hope for the future. The question of remodelling public health administration bristles with difficulties, but there will be general agreement that the prospect of effective reforms at a later date should not prejudice local authorities in any efforts to make the best use of the powers and opportunities which they already possess. ____

COUNTY COUNCILS AND PUBLIC HEALTH MATTERS.

A

this subject, read by Dr. J. C. Thresh the County Councils Association on Feb. 23rd, deserves close attention from local authorities concerned with public health administration. Taken as a whole, this administration in England and Wales at the present time is full of at

a

PAPER on

meeting of

anomalies, unwieldy, and often needlessly

com-

plicated. The duties and mutual relation of officers in the public health service need much revision and consolidation before public medical work can be brought into any sort of system which is theoretically defensible; while a reconstitution of the local bodies themselves and of the areas over which they have jurisdiction must also be in the forefront of any comprehensive reform. Dr. Thresh realises, however, that sweeping proposals for new local government legislation, for the establishment of a Ministry of Health, or for the consolidation of public medical services are unlikely to make progress whilst the country is at war or remains dominated by the consequences of war. Meanwhile he relies upon the British capacity for adjustment and compromise, and invites county councils to consider whether they themselves are making the best use of their present powers and opportunities. In all counties, it is urged, the several medical services should be so organised, under the headship of the county medical officer, that the various departments for school medical - work, maternity and infant welfare, tuberculosis, general medical inspection, and possibly also for laboratory work, are in each case efficiently staffed and equipped. There is probably room for better organisation of this kind even in the large English counties, while some of the smaller need to join with their neighbouring county councils or boroughs if the various duties now put on the county authorities are to be properly carried out. Such a process of organisation might well precede application to Parliament for new powers, particularly for powersto enable the county councils to coerce the local authorities of their constituent districts. The sanitary district of the 2

THE

LANCET, Jan. 9th (p. 83)

and 30th

(p. 192),

1915.

EXTRACTION OF A BULLET FROM THE BLADDER BY THE URETHRA. THE arrest of a bullet in the bladder must be rare, for the projectile must have sufficient force to penetrate the pelvis and not more than sufficient to carry it into the bladder. This is an exceptional combination of conditions, for pro. jectiles which enter the bladder usually pass through it. At a meeting of the Academie de Medecine of Paris on Jan. 26th M. George Luys reported a case in which he removed by the urethra a bullet which had lodged in the bladder. The patient was a soldier, aged 33 years, who, while firing in the lying-down position, was shot in the centre of the right buttock on Nov. 17th, 1914. Supported by two comrades he was able to walk to the ambulance station, a distance of 4 kilometres. As there was complete retention of urine he was catheterised and bloody urine was withdrawn. For five days he passed spontaneously urine of this character, and for two days bloody stools. He then showed symptoms of a foreign body in the bladder. When he attempted to micturate, especially at the time of defæcation, the stream of urine was suddenly arrested, and it was necessary to pass a catheter in order to push back into the bladder a body in the posterior urethra. He was examined by M. Luys on Dec. 17th, when he presented the following symptoms pointing to foreign body in the bladder. 1. Complete inability to micturate in the

standing position, micturition being possible only when lying down. 2. Sudden arrest of the stream with pain at the end of the penis. 3. Sometimes after the effort of defaecation the foreign body entered the urethra, but was easily made to return to the bladder by raising the pelvis. There no were symptoms of cystitis ; the urine was merely a little cloudy on emission. The wound in the buttock had healed, leaving a scar 0’5 centimetre in diameter. A radiogram showed a bullet in the middle line behind the symphysis with the point directed downwards. With the cystoscope the bullet was seen in a depression on the right side of the bladder. The point was directed to the left and downwards behind the plane of the ureters. The bullet was brilliant and did not appear to be encrusted with salts. Its

.

505 was urgently necessary. The only method this has become the universal practice in the previously used to accomplish this end was supra- hospital, although at first there was prejudice pubic cystotomy, but the invention of M. Luys’s against it. This is important, as it shows cystoscope with direct vision opened the prospect that the other physicians have been con-

removal

of removal per vias naturales. The cystoscope was passed and the bullet was seized with forceps passed down the tube and removed with the latter. It proved to be a deformed German bullet. There was a slight calcareous deposit in its grooves. DRUG FUND SHORTAGE IN

LONDON.

THE London Insurance Committee

on

Feb. 25th

considered the position of the drug fund, which

amounted, it

was reported, to about £140,000, while the total demand would be approximately £193,000. In the discussion it was suggested that the deficiency of oB53,OOO was due to excessive prescribing by practitioners, but Dr. B. A. Richmond, the secretary of the Panel Committee, pointed out that at the present rate at which excess was being found by the Panel Committee in its investigations into

prescribing

no

sum

even

remotely approaching

JE53,000 would be refunded to the drug fund, when all the allegations of excess had been examined. Dr. Richmond urged that a mistake had been made by the Government in basing the drug fund on the Plender Report-itself founded upon conditions of contract practice which bore no resemblance to those obtaining under the National Insurance Act. Under the present scheme large numbers of women received benefit, and persons suffering from or predisposed to tuberculosis, who under contract practice were excluded, caused under the Insurance Act a heavy drain upon the drug fund in respect of specially expensive articles. The committee decided to call the attention of the Insurance Commissioners to the shortage which had arisen in spite of the action taken in regard to allegations of excessive prescribing, and to ask that steps should be taken to ensure that the chemists receive adequate remuneration for the drugs and appliances supplied by them during 1914.

even

value of the treatment. Howof the mortality statistics before and after the introduction of the treatment does On the contrary, the not show any advantage. mortality for the six years before the introduction was slightly lower than the mortality after it14’4 against 15’3 per cent. But Dr. L. Teece, the house physician who analysed the records, says : " It was but rarely that pneumonia of itself killed a healthy adult, in whatever manner he was treated, as in practically every fatal case some other factor turned the scale against the patient." A perusal of the histories convinced him that the cases treated by the open-air method more quickly reached a state of comparative comfort, were less subject to post-critical rises of temperature, and showed more rapid resolution than those treated by the old Dr. method. Teece examined minutely the histories of 60 cases before the introduction of the open-air treatment and compared them with 60 cases treated after its introduction. In the former the average duration of the pyrexial period was 11’4 days, the maximum 52 days, and the minimum 3 days. In the latter the corresponding figures were 9’9 days, 34 days, and 4 days. Dr. Rennie adds that " these cold statistics," although they bear out the view that the open-air treatment is an improvement, do not bring out the facts which have been learned by experience, that the patients show much less cyanosis and distress in breathing, that oxygen is rarely necessary, and that unless there is some cardiac complication heart tonics are not required. The patients sleep better and sedatives are rarely necessary. The tongue is cleaner, the appetite is better, and convalescence is rapid. Patients who on admission were extremely ill, some with puerperal complications, recovered rapidly-cases which when treated on the old lines would have been considered inevitably fatal. vinced ever,

of

the

comparison

____

THE OPEN-AIR TREATMENT OF ACUTE PNEUMONIA.

plea for the open-air treatment of acute been made by Dr. George E. Rennie has pneumonia in the llleclical Journal of Australia. He points out that not only is the imperfect aeration of the blood an indication for the supply of as much fresh pure air as possible, but that also the bacterial content of the air of the best ventilated room or ward is always much higher than that of the outside fresh air. The air of hospital wards is likely to be laden with numerous pathogenic microbes. In such an atmosphere the patient may acquire a secondary infection. At any rate, the conditions are favourable to the growth of the pneumococcus. Further, the air of the ward is laden with organic impurities which must impair the oxygenating power of the respired air. Hence open-air treatment is the most rational procedure. It used to be the custom .at the Royal Prince Edward Hospital, Sydney, to surround the patient suffering from pneumonia with curtains to keep off draughts, and, incidentally, to prevent the access of much fresh air. When he became cyanosed oxygen was administered, and when the heart began to fail alcohol, strychnine, and digitalis were used. For the last seven years Dr. Rennie’s practice at this hospital has been to treat all cases of acute pneumonia in the open both by day and night. More recently A STRONG

PUBLIC HEALTH IN

BRITISH COLUMBIA.

THIS

province of the Canadian Dominion is an example of the wonderful development that is taking place in the Greater Britain beyond the seas, a development that depends primarily on increase in population. At the last census in 1911 British Columbia had more than doubled the population of 1901; its largest city, Vancouver, had almost qnadrupled its numbers in the same period. These rapid developments, however satisfactory from a commercial and industrial point of view, are associated with public health problems that are far more important in their consequences and more difficult to deal with successfully than is commonly appreciated by the authorities who have the control of finance and administration. The report of the Department of Public Health for the province is a document of three pages in length, which seems exiguous for a population of some 400,000 that has grown with the remarkable rapidity just mentioned. No detailed statistics are furnished and very few diseases are referred to. Tuberculosis is the most fatal disease, having caused 422 deaths, of which 295 were due to pulmonary consumption. The Department of Agriculture is endeavouring to stamp out the disease in dairy herds. Notification of tuberculous cases is compulsory, but apparently is not universally carried out. Propagation is