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GRAINS AND SCRUPLES
169
GRAINS AND SCRUPLES Under this various
appear week by week the unfettered thoughts of doctors in Each contributor is responsible for the section for a month ;; his name can be seen later in the half-yearly index.
heading occupations.
Since then my
FROM A PUBLIC HEALTH CLINICIAN
practitioner’s belief.
III
told me her husband had visited her and she saw him " more clearly than I see you now," though she had never seen him since death, and was not at the time thinking of him. Within 12 hours that patient had died also, and it has happened similarly with 2 other patients. It is not only husbands or wives that are seen, but any intimate friend or relative who is no longer alive. Speaking to a clergyman, with a far more intimate experience of dying folk than I am ever likely to acquire, he told me of several similar instances he had met with and believed that if the patient was sufficiently conscious to describe it such an experience would be found to be usual. As this is not a theological lecture I will pass over the explanations he offered; for myself I have no explanation and am left wondering. My own experience of such events is too limited for any generalisation, errors of observation or narration may have crept in. I wonder.
THIS is coronation year and different coronation
thoughts pass through our minds-to nearly all a procession is one of the foremost. If we personally do not want to see the procession it is certain that some members of our family will so wish. Granted the time, I should like to see the coronation procession if that were all, but there will be crowds and crowds and a very early start will be necessary ; unluckily it is not possible to take a seat at 11.25 for an 11.30 procession and then leave quietly. Everyone in their lifetime should see one great processionmine was the funeral procession of King Edward VII. The night before I had spent over 4 hours in a queue to see the lying in state at Westminster Hall and then came away disappointed. Fortunately the crowd was not, as the papers declared, "pervaded by a spirit of silent reverence," and there were many humorous incidents, but it was tiring for all that, and left me determined never again to queue up for anything. So next day I arose late and set off to see the procession. Walking in mid-road along the route the vastness of the crowds impressed me. Now and again I sidled one way or the other to secure a stance, but a chorus of protests moved me on. Suddenly it struck me that when the procession passed the side roads would be closed, so I took up a humble position at the back of the crowd, at a point where a side road entered, confident that, when that road was closed, I should be propelled willy-nilly into a front place; and so indeed it
befell.
Passing through life one has at times similarly useful inspirations, or experience suggests something that has not yet occurred to others ; at the large cheap restaurants where I take my meals I have noticed that small waitresses are usually the quickest, an observation that has proved time saving. Another similar discovery was that if when waiting, and waiting, to be served in a crowded room I sat back and obviously read a large evening paper steps were soon taken to secure service. It would be interesting if others would give us the advantage of similar discoveries among the smaller things of life. *
*
*
Most practitioners can narrate experiences outside the routine of normal medical practice. Thirty years ago, when acting as locum in a Hampshire practice, I had as temporary partner a wise and observant practitioner. Called one day to see a blind woman in later middle age, the patient told me that during the night her husband, dead some 10 years, had visited her, stood at the foot of the bed and conversed pleasantly. She had been blind for some 15 years, but averred that on this occasion she had seen her husband as clearly as she had ever seen in her best years. During the afternoon I told my partner the story, and he remarked, " She’ll be dead before to-morrow." I asked why" The patient was ailing, but there was nothing to justify such a prognosis. " They always die when they tell those stories "
was
his
reply.
experience has confirmed that An old lady, 10 years a widow,
*
*
*
Ornithology is rather a favourite pastime for doctors with botany a close second. We are speaking of course of the active-minded members of the profession, or would it not be more correct to say natural history minded ; for many, if not the majority, who find an alternative solace in bridge or golf have equally active minds. The study of bryology and mycology, meaning by that mosses and fungi, is less popular and yet equal in interest to botany. The mosses are difficult because a proper study entails low-power microscopy, but if the observer remains a dilettante, as previously advised, and intelligent recreation is his chief objective, resort to the microscope will be seldom needed. For fungi a pocket lens should suffice, but this form of life presents a field quite equal to that of botany. My first discovery of Clathrus cancellatu8, a large fungus showing a wide grey network with large mesh, was indeed a red letter day; and then there are various staghorn and stink-horn fungi, some of them bearing ancient and almost lewd latin names. It is interesting also to note the varied forms of parasitism displayed, and how the death of trees and other vegetation is caused. The ways of nature are indeed ruthless. The difficulties of the fungus hunter are that wet weather is always best and may be essential for certain forms, and that many fungi have a distinct smell, sometimes a most offensive distinction. My children, trained in natural history methods, will stop suddenly when passing through a wood and call out " stink-horn somewhere near." And there are others almost as bad as the stink-horn. The hunt for fungi is called for some reason a foray, though I know not why, akin perhaps to the special namesflocks, droves, coveys-of groups of various animals, or to names given to different nests, as earth, dray, or holt. I should like to see more doctors interested in fungi. *
Apart : a
*
*
from natural history, history itself provides if more sedentary hobby. Gibbon’s
fascinating
170 " Decline and Fall " presents useful pabulum for a train journey, far better than most novels provided always that the reader has not already read it, as so many have done, when too young fully to appreciate the charm. I read Gibbon’s " Decline and Fall" for the first time in trains, and it took quite a long time. I am now engaged on Grote’s " History of Greece " which has not quite the same attractions and will take longer, in fact it seems possible that when death overtakes me, Grote’s History will still be unfinished. The secret of enjoyment of such reading is never to read for instruction, never to regard the reading as a lesson, never to attempt to remember, but to read purely for amusement and recreation. Novels and films show us life as it might be but certainly is not, history presents life as it was and still very much is. Gibbon is not the only work commended ; there are English histories, French histories, and period histories. Then a similar field is covered by biographies which may give an interesting high-power view of some special time or place. A knowledge of human nature is of the highest importance to any doctor, and his life’s work presents
constant opportunities for but to know human nature history may assist. *
his knowledge, lifetime is not enough;
expanding one
*
*
attracts many devotees ; it used to and many pilgrimages have I made to old buildings and well-known churches, but to-day the taste has passed, as tastes will sometimes, possibly the result of too many archaeological excursions. The study has its limitations and has not the attraction of natural history, but it is interesting to form conceptions of the habits and life of our ancestors disclosed by a study of their buildings and remains. The past deserves respect and may provide lessons and examples useful to-day, but if the sixteenth century had been solely devoted to the past we should have missed many of the renaissance productions which receive homage to-day, and should still be admiring rush-covered floors and the rather clumsy architecture of the Dark Ages. Perhaps teamwork here, as in medicine, is best. Those who feel so impelled will produce for us new forms of art and architecture while the archaeologists criticise these from their knowledge of the past.
Archseology
attract
me
CORRESPONDENCE INFECTION AND DISINFECTION
To the Editor
of
THE LANCET
SIR,-The lecture by Sir Weldon Dalrymplein your issue of Jan. 9th will be read with interest by practitioners other than medical officers of health and should appeal to the educated layman. I should like to refer to three
Champneys reproduced
points. First, whooping-cough. If it is true that the patient has already ceased to be infectious by the time the " whoop " appears, then many young prisoners may be liberated safely and much domestic inconvenience ended. We all know that the whoop may persist long after infection has disappeared, but experience (apparently fallacious) has suggested that the early convalescent may be a source of infection. Moreover, if this be correct, our present efforts at prevention are futile. The inclusion of infectious disease blocks in general hospitals is not peculiar to Scandinavia. It has long been the practice in our naval hospitals without, far as I know, any untoward results. Doubtless it would have been adopted more widely were it not for the fact that local authorities provide for infectious disease and, for the most part, voluntary bodies for other sickness. Nevertheless the idea is valuable on the grounds that small isolation hospitals are usually uneconomical and inefficient, and that unduly long journeys are not in the interest of the patient even under modern transport conditions. Lastly current and terminal disinfection. There is no doubt that " a good spring cleaning " is all that is necessary in most diseases when the patient has been treated at home throughout his illness, but I suggest that the full ritual is desirable in the case of diphtheria patients removed to hospital while still highly infectious, and when any infectious disease In scarlet occurs in a boarding house or hotel. fever practice varies. Admitting that infection in this disease is mainly personal to the sufferer, undetected cases and carriers, there still remains so
sufficient evidence in the opinion of many to full disinfection. I am, Sir, yours faithfully, G. B. PAGE,
justify
Medical Officer of Health, Exeter. Public Health Department, Exeter, Jan. 11th.
NASAL SINUSITIS IN CHILDHOOD
To the Editor
of
THE LANCET
SiR,—Your leader on this subject draws attention to a common malady but one not very familiar to those in charge of young children and school-children, judging from the regular stream of cases referred to hospital for removal of tonsils and adenoids, when the underlying condition is a nasal sinusitis. Complete nasal obstruction in infants and children is most commonly associated with a nasal discharge due to a sinusitis, which is also a fertile cause of a recurrent otitis, chronic cough, and relapsing chest conditions. A large mass of adenoids produces only intermittent nasal obstruction. In my experience the mucoid nasal discharge arises more frequently from the ethmoidal cells than from the antra. Cases of nasal sinusitis may often be recognised by the presence of nodules of lymphoid tissue scat. tered on the posterior pharyngeal wall, visible below the level of the uvula. A blob of mucus depends from the post-nasal space, coming into view when the child gags. In the presence of these signs, a cure of the nasal symptoms cannot be obtained by removal of tonsils and adenoids. The incidence of " clinical" nasal sinusitis is certainly more common than is realised, but percentages are deceptive. Anyone interested in the subject-especially if he is known to have some " new " treatment-soon becomes inundated with cases that are referred from all quarters, with the result that an exaggerated idea is obtained as to its real prevalence. In the last five years at the Queen’s Hospital for Children I have made it a routine to wash out the antra in all cases with a nasal discharge. I can only recollect some half a dozen cases in which pus was washed out of the antrum. (I exclude cases of
GRAINS AND SCRUPLES Under this various
appear week by week the unfettered thoughts of doctors in Each contributor is responsible for the section for a month ;; his name can be seen later in the half-yearly index.
heading occupations.
Since then my
FROM A PUBLIC HEALTH CLINICIAN
practitioner’s belief.
III
told me her husband had visited her and she saw him " more clearly than I see you now," though she had never seen him since death, and was not at the time thinking of him. Within 12 hours that patient had died also, and it has happened similarly with 2 other patients. It is not only husbands or wives that are seen, but any intimate friend or relative who is no longer alive. Speaking to a clergyman, with a far more intimate experience of dying folk than I am ever likely to acquire, he told me of several similar instances he had met with and believed that if the patient was sufficiently conscious to describe it such an experience would be found to be usual. As this is not a theological lecture I will pass over the explanations he offered; for myself I have no explanation and am left wondering. My own experience of such events is too limited for any generalisation, errors of observation or narration may have crept in. I wonder.
THIS is coronation year and different coronation
thoughts pass through our minds-to nearly all a procession is one of the foremost. If we personally do not want to see the procession it is certain that some members of our family will so wish. Granted the time, I should like to see the coronation procession if that were all, but there will be crowds and crowds and a very early start will be necessary ; unluckily it is not possible to take a seat at 11.25 for an 11.30 procession and then leave quietly. Everyone in their lifetime should see one great processionmine was the funeral procession of King Edward VII. The night before I had spent over 4 hours in a queue to see the lying in state at Westminster Hall and then came away disappointed. Fortunately the crowd was not, as the papers declared, "pervaded by a spirit of silent reverence," and there were many humorous incidents, but it was tiring for all that, and left me determined never again to queue up for anything. So next day I arose late and set off to see the procession. Walking in mid-road along the route the vastness of the crowds impressed me. Now and again I sidled one way or the other to secure a stance, but a chorus of protests moved me on. Suddenly it struck me that when the procession passed the side roads would be closed, so I took up a humble position at the back of the crowd, at a point where a side road entered, confident that, when that road was closed, I should be propelled willy-nilly into a front place; and so indeed it
befell.
Passing through life one has at times similarly useful inspirations, or experience suggests something that has not yet occurred to others ; at the large cheap restaurants where I take my meals I have noticed that small waitresses are usually the quickest, an observation that has proved time saving. Another similar discovery was that if when waiting, and waiting, to be served in a crowded room I sat back and obviously read a large evening paper steps were soon taken to secure service. It would be interesting if others would give us the advantage of similar discoveries among the smaller things of life. *
*
*
Most practitioners can narrate experiences outside the routine of normal medical practice. Thirty years ago, when acting as locum in a Hampshire practice, I had as temporary partner a wise and observant practitioner. Called one day to see a blind woman in later middle age, the patient told me that during the night her husband, dead some 10 years, had visited her, stood at the foot of the bed and conversed pleasantly. She had been blind for some 15 years, but averred that on this occasion she had seen her husband as clearly as she had ever seen in her best years. During the afternoon I told my partner the story, and he remarked, " She’ll be dead before to-morrow." I asked why" The patient was ailing, but there was nothing to justify such a prognosis. " They always die when they tell those stories "
was
his
reply.
experience has confirmed that An old lady, 10 years a widow,
*
*
*
Ornithology is rather a favourite pastime for doctors with botany a close second. We are speaking of course of the active-minded members of the profession, or would it not be more correct to say natural history minded ; for many, if not the majority, who find an alternative solace in bridge or golf have equally active minds. The study of bryology and mycology, meaning by that mosses and fungi, is less popular and yet equal in interest to botany. The mosses are difficult because a proper study entails low-power microscopy, but if the observer remains a dilettante, as previously advised, and intelligent recreation is his chief objective, resort to the microscope will be seldom needed. For fungi a pocket lens should suffice, but this form of life presents a field quite equal to that of botany. My first discovery of Clathrus cancellatu8, a large fungus showing a wide grey network with large mesh, was indeed a red letter day; and then there are various staghorn and stink-horn fungi, some of them bearing ancient and almost lewd latin names. It is interesting also to note the varied forms of parasitism displayed, and how the death of trees and other vegetation is caused. The ways of nature are indeed ruthless. The difficulties of the fungus hunter are that wet weather is always best and may be essential for certain forms, and that many fungi have a distinct smell, sometimes a most offensive distinction. My children, trained in natural history methods, will stop suddenly when passing through a wood and call out " stink-horn somewhere near." And there are others almost as bad as the stink-horn. The hunt for fungi is called for some reason a foray, though I know not why, akin perhaps to the special namesflocks, droves, coveys-of groups of various animals, or to names given to different nests, as earth, dray, or holt. I should like to see more doctors interested in fungi. *
Apart : a
*
*
from natural history, history itself provides if more sedentary hobby. Gibbon’s
fascinating
170 " Decline and Fall " presents useful pabulum for a train journey, far better than most novels provided always that the reader has not already read it, as so many have done, when too young fully to appreciate the charm. I read Gibbon’s " Decline and Fall" for the first time in trains, and it took quite a long time. I am now engaged on Grote’s " History of Greece " which has not quite the same attractions and will take longer, in fact it seems possible that when death overtakes me, Grote’s History will still be unfinished. The secret of enjoyment of such reading is never to read for instruction, never to regard the reading as a lesson, never to attempt to remember, but to read purely for amusement and recreation. Novels and films show us life as it might be but certainly is not, history presents life as it was and still very much is. Gibbon is not the only work commended ; there are English histories, French histories, and period histories. Then a similar field is covered by biographies which may give an interesting high-power view of some special time or place. A knowledge of human nature is of the highest importance to any doctor, and his life’s work presents
constant opportunities for but to know human nature history may assist. *
his knowledge, lifetime is not enough;
expanding one
*
*
attracts many devotees ; it used to and many pilgrimages have I made to old buildings and well-known churches, but to-day the taste has passed, as tastes will sometimes, possibly the result of too many archaeological excursions. The study has its limitations and has not the attraction of natural history, but it is interesting to form conceptions of the habits and life of our ancestors disclosed by a study of their buildings and remains. The past deserves respect and may provide lessons and examples useful to-day, but if the sixteenth century had been solely devoted to the past we should have missed many of the renaissance productions which receive homage to-day, and should still be admiring rush-covered floors and the rather clumsy architecture of the Dark Ages. Perhaps teamwork here, as in medicine, is best. Those who feel so impelled will produce for us new forms of art and architecture while the archaeologists criticise these from their knowledge of the past.
Archseology
attract
me
CORRESPONDENCE INFECTION AND DISINFECTION
To the Editor
of
THE LANCET
SIR,-The lecture by Sir Weldon Dalrymplein your issue of Jan. 9th will be read with interest by practitioners other than medical officers of health and should appeal to the educated layman. I should like to refer to three
Champneys reproduced
points. First, whooping-cough. If it is true that the patient has already ceased to be infectious by the time the " whoop " appears, then many young prisoners may be liberated safely and much domestic inconvenience ended. We all know that the whoop may persist long after infection has disappeared, but experience (apparently fallacious) has suggested that the early convalescent may be a source of infection. Moreover, if this be correct, our present efforts at prevention are futile. The inclusion of infectious disease blocks in general hospitals is not peculiar to Scandinavia. It has long been the practice in our naval hospitals without, far as I know, any untoward results. Doubtless it would have been adopted more widely were it not for the fact that local authorities provide for infectious disease and, for the most part, voluntary bodies for other sickness. Nevertheless the idea is valuable on the grounds that small isolation hospitals are usually uneconomical and inefficient, and that unduly long journeys are not in the interest of the patient even under modern transport conditions. Lastly current and terminal disinfection. There is no doubt that " a good spring cleaning " is all that is necessary in most diseases when the patient has been treated at home throughout his illness, but I suggest that the full ritual is desirable in the case of diphtheria patients removed to hospital while still highly infectious, and when any infectious disease In scarlet occurs in a boarding house or hotel. fever practice varies. Admitting that infection in this disease is mainly personal to the sufferer, undetected cases and carriers, there still remains so
sufficient evidence in the opinion of many to full disinfection. I am, Sir, yours faithfully, G. B. PAGE,
justify
Medical Officer of Health, Exeter. Public Health Department, Exeter, Jan. 11th.
NASAL SINUSITIS IN CHILDHOOD
To the Editor
of
THE LANCET
SiR,—Your leader on this subject draws attention to a common malady but one not very familiar to those in charge of young children and school-children, judging from the regular stream of cases referred to hospital for removal of tonsils and adenoids, when the underlying condition is a nasal sinusitis. Complete nasal obstruction in infants and children is most commonly associated with a nasal discharge due to a sinusitis, which is also a fertile cause of a recurrent otitis, chronic cough, and relapsing chest conditions. A large mass of adenoids produces only intermittent nasal obstruction. In my experience the mucoid nasal discharge arises more frequently from the ethmoidal cells than from the antra. Cases of nasal sinusitis may often be recognised by the presence of nodules of lymphoid tissue scat. tered on the posterior pharyngeal wall, visible below the level of the uvula. A blob of mucus depends from the post-nasal space, coming into view when the child gags. In the presence of these signs, a cure of the nasal symptoms cannot be obtained by removal of tonsils and adenoids. The incidence of " clinical" nasal sinusitis is certainly more common than is realised, but percentages are deceptive. Anyone interested in the subject-especially if he is known to have some " new " treatment-soon becomes inundated with cases that are referred from all quarters, with the result that an exaggerated idea is obtained as to its real prevalence. In the last five years at the Queen’s Hospital for Children I have made it a routine to wash out the antra in all cases with a nasal discharge. I can only recollect some half a dozen cases in which pus was washed out of the antrum. (I exclude cases of