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HEALTH AND EMPIRE.
HEALTH AND EMPIRE.
581
The granules have been shown to pass through and also may be expected to throw light upon the collodion membranes. These positive observations relationship between disseminated sclerosis, neuror have been controlled by culturing the cerebro-spinal myelitis optica, and other forms of demyelinating fluid from 269 persons suffering from other conditions, encephalitis. The isolation of a causative organism with negative results. Miss CHEVASSUT, suggests the therapeutic employment of an autogenous then, appears to have demonstrated the presence of vaccine, and Sir JAMES PuRVES-STEWART contributes certain bodies in cultures made from the cerebro- a weighty paper setting forth the results achieved by spinal fluid of patients with disseminated sclerosis. means of killed cultures of Miss CHEVASSUT’S organism. Is she entitled to conclude that these bodies constitute He wisely emphasises the need of caution in drawing the causal organism of the disease ? We must now conclusions as to the effects of any therapeutic measure His patients have consider how this conclusion might be criticised, not in disseminated sclerosis. necessarily as incorrect, but as requiring further apparently only been under treatment for one or two evidence before it can be regarded as proved. The years, a time too short to permit one to speak with bodies have never been demonstrated in the cerebro- confidence of clinical arrest. The clinical improvespinal fluid itself. There may be good technical ment which occurred in the four cases fully reported Sir reasons for this, as Miss CHEVASSUT suggests, but if is not greater than may occur spontaneously. these difficulties could be overcome it would go far JAMES PuRVES-STEWART lays stress upon improveto remove the possibility that the supposed organisms ment in the colloidal gold and globulin reactions in may be products of the interaction of the fluid and the the cerebro-spinal fluid. The significance of these culture medium. It may be strange to regard the changes could have been better appreciated if controls uniformity of the success of an experiment as evidence had been investigated. J. D. AYER and H. E. against its validity, but workers with the filtrable FOSTER have observed spontaneous variations in the viruses may be inclined to regard the demonstration colloidal gold-curve corresponding to progressive and of the virus in 93 per cent. of the specimens examined stationary phases of the disease, and ADAMS, BLACKas almost too good to be true, especially when the LOCK, DUNLOP, and SCOTT have found a diminution material is derived from quiescent as well as from in the curve following treatment with salvarsan. The active cases. It may be suggested that some bio- disappointing feature of the vaccine treatment is the chemical change in the fluid is more likely to be thus fact that after treatment the organism was still constant than the presence of the organism. It seems obtainable from the fluid in 62 out of 70 cases. This desirable, too, that some attempt should be made to fact, of course, has no direct bearing upon the question ascertain whether the virus is obtainable from nervous of the specificity of the organism. The discovery of tissue as well as from cerebro-spinal fluid. It is the tubercle bacillus and the Treponema pallidum naturally the aim of all who claim to have isolated has not led to the cure of tuberculosis and syphilis an organism to transmit it to animals, to show that by means of vaccines. Disseminated sclerosis, another in inoculated animals it produces the symptoms and relapsing disease, seems to offer a rather unpromising histological changes of the disease in man, and that field for such treatment, for natural immunity, at it can be recovered and cultivated from animals least, appears to be short-lived. thus infected. The evidence that these tests have Miss CHEVASSUT, Sir JAMES PURVES-STEwART, and been successfully carried out with Miss CHEVASSUT’s their collaborators have laid before the medical organism is at present inconclusive. profession observations of great interest, involving Sir JAMES PURVES-STEWART, in the paper on p. 560, matters of technical difficulty in more than one departsummarises expeiiments which he has carried out in ment of science. The work required for their conjunction with Dr. BRAXTON HiCKS and Dr. F. D. M. confirmation must necessarily take many months. HOCKING, and which will be fully reported in our next In the meantime, the wise (among whom we may issue. It is disappointing that more striking results include the lay press) will suspend judgment. were not obtained from such drastic inoculations as the intravenous and intracisternal injections of cultures of the virus into monkeys. Possibly the monkey is not a susceptible animal, though G. STEINER HEALTH AND EMPIRE. has described the successful inoculation of a monkey THE Hastings Lecture delivered by Sir ANDREW with the disease. Perhaps intracerebral inoculation would yield better results. There is nothing in BALFOUR in the Hall of the British Medical Association Miss CHEVASSUT’S observations inconsistent with last Wednesday, a brief abstract of which will be her view that she has isolated the organism of found in our front pages to-day, is an eloquent plea disseminated sclerosis, but the proof of her contention for the development of medical research, with the can hardly as yet be regarded as complete. We development of the British Empire as the source of will that further sincerely hope investigations prove her the information given and of the arguments set out. right, and neither she nor Sir JAMES has spared pains He paints a picture of a great battle between man and disease as witnessed in the various phases of the in their admirablework. We turn now to the practical applications of the expansion of British rule. The story of tropical observations we have been discussing. An exceed- disease to-day is sufficiently tragic, but the ravages ingly important one is entirely independent of their of endemic, epidemic, and incidental disease which interpretation and, curiously, has not been mentioned occur within our borders in the twentieth century either by Miss CHEVASSUT or by Sir JAMES PURVES- represent but a small fraction of the horrors which STEWART. Whether or not the Spherula insularis in the previous epochs decided the fates of armies and is the cause of the disease, if the existence of these navies, and slew, or harassed to the point of death, bodies is confirmed their diagnostic value is clearly the pioneers of colonial expansion. And when we very great. A test applicable to the cerebro-spinal speak of previous epochs it should be recalled that fluid which yields a positive result in 93 per cent. many of the diseases, now labelled tropical, until the of cases and is pathognomonic of disseminated sclerosis, middle of the nineteenth century flourished in our will be an even more valuable aid to the diagnosis midst. Sir ANDREW BALFOUR reminded his hearers of this disease than is the Wassermann reaction in that as late as 1866 cholera was present in England neurosyphilis. It will be of great use in early cases, and that three years later relapsing fever was claiming
always
582
THE REGISTRATION
OF INDIAN MEDICAL DEGREES.
victims in the poorer parts of London. As a matter THE REGISTRATION OF INDIAN of fact, at Somerset House deaths were registered MEDICAL DEGREES. from this cause over England for the next thirty years, it that was is there here a THE and sometimes probable though patient negotiations between the long confusion between relapsing fever and other forms of Government of India and the General Medical Council, infantile fever. Malaria may be considered as absent in respect of the recognition by the Council of Indian now from the home shores, but the part played by medical degrees, have, at any rate for the time being, in the ague country practitioner’s responsibilities broken down. Since 1922 the Council has been iinds record up to mid-Victorian days. striving to secure the registration of Indian graduates Truly we have but just passed from the shadow of on a plan which will guarantee that their place is due these diseases, and a pertinent lesson to be derived to the possession of a professional training up to the from the Hastings Lecture is that it was an standard required for practice in Great Britain and apathy bred of ignorance which left us, in common Ireland. The story, therefore, is a long one, but to with the rest of the world, so long their prey. detail its closing phases will be sufficient to make the Are we learning our lesson Some two generations situation clear. have now gone by since the establishment of comAt the meeting of the General Medical Council last pulsory education in this country, and with the November the President pointed out that the period disappearance of the illiterate it has become possible for which the recognition of Indian medical degrees to diffuse general ideas of sanitation and general for registration in Great Britain and Ireland had been instructions for the preservation of health to a popula- provisionally guaranteed was fast running out, while And during the appointment of a Government Commissioner of tion who can follow the teaching. the last 15 years a remarkable impulse to the propaga- Medical Qualifications and Standards had not been tion of such teaching has been given by the experi- made. The appointment of this officer was itself a ences derived from the recent war. Those who expected provisional measure designed to furnish the Council that a newly educated public would at once become with a responsible nominee, whose reports they docile and receptive of wise teaching must have been could accept, until the promised institution of an sanguine, for the first result of popular education was All-India Medical Council came into material being. the creation of a large class whose equipment just Apparently it was hoped by the Indian Government encouraged them to criticise what they did not that the appointment of separate inspectors ad hoc understand, while it provided them with no would be accepted by the General Medical Council as opportunities and no incentives for pursuing their a substitute for the Government Commissioner, but studies in such a way as to render their imperfect the reports of these inspectors which had been knowledge of greater use to the community, or of more received were found to contain no reference to solid comfort to themselves. That at any rate was any common standards comparable with those which the position which, until lately, the bulk of the popula- hold good in this country, while they disclosed tion occupied in respect of medical science and medical individual deficiencies in regard to Indian methods of endeavour. The nineteenth century may have been training and testing which could not be overlooked. slow to organise the national fight against disease, To put it briefly, the position was that the General but until recently the public conscience has not been Medical Council, though furnished with these ad hoc roused by medical warnings. Now on all sides there reports, remained without evidence that the requisites, are signs that the general public is awakening to the demanded by the Medical Act of 1886 before legal fact that in its own hands lies much of the power practice in Great Britain and Ireland can be underto prevent disease, to limit its spread, and to alleviate taken, would be forthcoming. The Government of its miseries. The significance of their freedom from India, although informed of this, and repeatedly much of the sufferings of their parents and grand- warned that the existing position could not continue, parents is perceived. At home we are reaching a remained inactive. The appointment of a Governstage when real cooperation between medicine and the ment Commissioner of Medical Qualifications and public is taking place, but much time must elapse before I Standards was not made, although the Council said such a state of affairs can be expected in many vast plainly that registration for practice in this country tracts of the Empire where tropical diseases are rife. of the medical graduates of certain Indian universities What might be achieved by the education of the must otherwise cease early this year. Then, at the native in elementary hygiene was set forth persuasively beginning of this year, a letter was received from by Prof. B. BLACKLOCK in a recent Chadwick public the India Office saying that the appointment of the For the present reliance must be placed Commissioner was not possible, but stating that lecture. largely upon the efforts of experts, and for the training the Government of India proposed to proceed with the of these the London School of Hygiene and Tropical appointment of a Board to discharge the duties of Medicine, whose activities Sir ANDREw BALFOUR the All-India Medical Council until that body came into existence. This Board, the India Office stated, directs, is the great new centre. Research is the weapon which, wisely yielded, can would consist of the Director-General, I.M.S., and open up for us paths in the jungle of ignorance, representatives of the medical faculties of the Indian dispelling darkness and gloom and revealing vistas Universities, and one of its duties would be to appoint of hope and cheerfulness, health, and longevity. certain inspectors as intermediaries between the Board The Hastings Lecture demonstrated how good an and the General Medical Council. The Council, in ally to health the British Empire had been as a the meantime, had received telegrams from the civilising and colonising power. With pride in our Viceroy stating that the appointment of the Commisvast possessions, however, we must own to world sioner was not possible, but putting forward a responsibilities. We possess unique and often tragic recommendation, received from a conference of the opportunities of becoming intimately acquainted with Indian Universities that, pending the creation of an tropical disease, and it becomes to us a national duty All-India Medical Council, a Board consisting of not only to alleviate and where possible remove the representatives of the Government of India and the burdens of sickness in the interests of our own citizens, medical faculties of the Universities should be but to collect and sift the evidence by which the world appointed as a temporary measure. A further telegram from the Viceroy indicated that this Board, may benefit.
581
The granules have been shown to pass through and also may be expected to throw light upon the collodion membranes. These positive observations relationship between disseminated sclerosis, neuror have been controlled by culturing the cerebro-spinal myelitis optica, and other forms of demyelinating fluid from 269 persons suffering from other conditions, encephalitis. The isolation of a causative organism with negative results. Miss CHEVASSUT, suggests the therapeutic employment of an autogenous then, appears to have demonstrated the presence of vaccine, and Sir JAMES PuRVES-STEWART contributes certain bodies in cultures made from the cerebro- a weighty paper setting forth the results achieved by spinal fluid of patients with disseminated sclerosis. means of killed cultures of Miss CHEVASSUT’S organism. Is she entitled to conclude that these bodies constitute He wisely emphasises the need of caution in drawing the causal organism of the disease ? We must now conclusions as to the effects of any therapeutic measure His patients have consider how this conclusion might be criticised, not in disseminated sclerosis. necessarily as incorrect, but as requiring further apparently only been under treatment for one or two evidence before it can be regarded as proved. The years, a time too short to permit one to speak with bodies have never been demonstrated in the cerebro- confidence of clinical arrest. The clinical improvespinal fluid itself. There may be good technical ment which occurred in the four cases fully reported Sir reasons for this, as Miss CHEVASSUT suggests, but if is not greater than may occur spontaneously. these difficulties could be overcome it would go far JAMES PuRVES-STEWART lays stress upon improveto remove the possibility that the supposed organisms ment in the colloidal gold and globulin reactions in may be products of the interaction of the fluid and the the cerebro-spinal fluid. The significance of these culture medium. It may be strange to regard the changes could have been better appreciated if controls uniformity of the success of an experiment as evidence had been investigated. J. D. AYER and H. E. against its validity, but workers with the filtrable FOSTER have observed spontaneous variations in the viruses may be inclined to regard the demonstration colloidal gold-curve corresponding to progressive and of the virus in 93 per cent. of the specimens examined stationary phases of the disease, and ADAMS, BLACKas almost too good to be true, especially when the LOCK, DUNLOP, and SCOTT have found a diminution material is derived from quiescent as well as from in the curve following treatment with salvarsan. The active cases. It may be suggested that some bio- disappointing feature of the vaccine treatment is the chemical change in the fluid is more likely to be thus fact that after treatment the organism was still constant than the presence of the organism. It seems obtainable from the fluid in 62 out of 70 cases. This desirable, too, that some attempt should be made to fact, of course, has no direct bearing upon the question ascertain whether the virus is obtainable from nervous of the specificity of the organism. The discovery of tissue as well as from cerebro-spinal fluid. It is the tubercle bacillus and the Treponema pallidum naturally the aim of all who claim to have isolated has not led to the cure of tuberculosis and syphilis an organism to transmit it to animals, to show that by means of vaccines. Disseminated sclerosis, another in inoculated animals it produces the symptoms and relapsing disease, seems to offer a rather unpromising histological changes of the disease in man, and that field for such treatment, for natural immunity, at it can be recovered and cultivated from animals least, appears to be short-lived. thus infected. The evidence that these tests have Miss CHEVASSUT, Sir JAMES PURVES-STEwART, and been successfully carried out with Miss CHEVASSUT’s their collaborators have laid before the medical organism is at present inconclusive. profession observations of great interest, involving Sir JAMES PURVES-STEWART, in the paper on p. 560, matters of technical difficulty in more than one departsummarises expeiiments which he has carried out in ment of science. The work required for their conjunction with Dr. BRAXTON HiCKS and Dr. F. D. M. confirmation must necessarily take many months. HOCKING, and which will be fully reported in our next In the meantime, the wise (among whom we may issue. It is disappointing that more striking results include the lay press) will suspend judgment. were not obtained from such drastic inoculations as the intravenous and intracisternal injections of cultures of the virus into monkeys. Possibly the monkey is not a susceptible animal, though G. STEINER HEALTH AND EMPIRE. has described the successful inoculation of a monkey THE Hastings Lecture delivered by Sir ANDREW with the disease. Perhaps intracerebral inoculation would yield better results. There is nothing in BALFOUR in the Hall of the British Medical Association Miss CHEVASSUT’S observations inconsistent with last Wednesday, a brief abstract of which will be her view that she has isolated the organism of found in our front pages to-day, is an eloquent plea disseminated sclerosis, but the proof of her contention for the development of medical research, with the can hardly as yet be regarded as complete. We development of the British Empire as the source of will that further sincerely hope investigations prove her the information given and of the arguments set out. right, and neither she nor Sir JAMES has spared pains He paints a picture of a great battle between man and disease as witnessed in the various phases of the in their admirablework. We turn now to the practical applications of the expansion of British rule. The story of tropical observations we have been discussing. An exceed- disease to-day is sufficiently tragic, but the ravages ingly important one is entirely independent of their of endemic, epidemic, and incidental disease which interpretation and, curiously, has not been mentioned occur within our borders in the twentieth century either by Miss CHEVASSUT or by Sir JAMES PURVES- represent but a small fraction of the horrors which STEWART. Whether or not the Spherula insularis in the previous epochs decided the fates of armies and is the cause of the disease, if the existence of these navies, and slew, or harassed to the point of death, bodies is confirmed their diagnostic value is clearly the pioneers of colonial expansion. And when we very great. A test applicable to the cerebro-spinal speak of previous epochs it should be recalled that fluid which yields a positive result in 93 per cent. many of the diseases, now labelled tropical, until the of cases and is pathognomonic of disseminated sclerosis, middle of the nineteenth century flourished in our will be an even more valuable aid to the diagnosis midst. Sir ANDREW BALFOUR reminded his hearers of this disease than is the Wassermann reaction in that as late as 1866 cholera was present in England neurosyphilis. It will be of great use in early cases, and that three years later relapsing fever was claiming
always
582
THE REGISTRATION
OF INDIAN MEDICAL DEGREES.
victims in the poorer parts of London. As a matter THE REGISTRATION OF INDIAN of fact, at Somerset House deaths were registered MEDICAL DEGREES. from this cause over England for the next thirty years, it that was is there here a THE and sometimes probable though patient negotiations between the long confusion between relapsing fever and other forms of Government of India and the General Medical Council, infantile fever. Malaria may be considered as absent in respect of the recognition by the Council of Indian now from the home shores, but the part played by medical degrees, have, at any rate for the time being, in the ague country practitioner’s responsibilities broken down. Since 1922 the Council has been iinds record up to mid-Victorian days. striving to secure the registration of Indian graduates Truly we have but just passed from the shadow of on a plan which will guarantee that their place is due these diseases, and a pertinent lesson to be derived to the possession of a professional training up to the from the Hastings Lecture is that it was an standard required for practice in Great Britain and apathy bred of ignorance which left us, in common Ireland. The story, therefore, is a long one, but to with the rest of the world, so long their prey. detail its closing phases will be sufficient to make the Are we learning our lesson Some two generations situation clear. have now gone by since the establishment of comAt the meeting of the General Medical Council last pulsory education in this country, and with the November the President pointed out that the period disappearance of the illiterate it has become possible for which the recognition of Indian medical degrees to diffuse general ideas of sanitation and general for registration in Great Britain and Ireland had been instructions for the preservation of health to a popula- provisionally guaranteed was fast running out, while And during the appointment of a Government Commissioner of tion who can follow the teaching. the last 15 years a remarkable impulse to the propaga- Medical Qualifications and Standards had not been tion of such teaching has been given by the experi- made. The appointment of this officer was itself a ences derived from the recent war. Those who expected provisional measure designed to furnish the Council that a newly educated public would at once become with a responsible nominee, whose reports they docile and receptive of wise teaching must have been could accept, until the promised institution of an sanguine, for the first result of popular education was All-India Medical Council came into material being. the creation of a large class whose equipment just Apparently it was hoped by the Indian Government encouraged them to criticise what they did not that the appointment of separate inspectors ad hoc understand, while it provided them with no would be accepted by the General Medical Council as opportunities and no incentives for pursuing their a substitute for the Government Commissioner, but studies in such a way as to render their imperfect the reports of these inspectors which had been knowledge of greater use to the community, or of more received were found to contain no reference to solid comfort to themselves. That at any rate was any common standards comparable with those which the position which, until lately, the bulk of the popula- hold good in this country, while they disclosed tion occupied in respect of medical science and medical individual deficiencies in regard to Indian methods of endeavour. The nineteenth century may have been training and testing which could not be overlooked. slow to organise the national fight against disease, To put it briefly, the position was that the General but until recently the public conscience has not been Medical Council, though furnished with these ad hoc roused by medical warnings. Now on all sides there reports, remained without evidence that the requisites, are signs that the general public is awakening to the demanded by the Medical Act of 1886 before legal fact that in its own hands lies much of the power practice in Great Britain and Ireland can be underto prevent disease, to limit its spread, and to alleviate taken, would be forthcoming. The Government of its miseries. The significance of their freedom from India, although informed of this, and repeatedly much of the sufferings of their parents and grand- warned that the existing position could not continue, parents is perceived. At home we are reaching a remained inactive. The appointment of a Governstage when real cooperation between medicine and the ment Commissioner of Medical Qualifications and public is taking place, but much time must elapse before I Standards was not made, although the Council said such a state of affairs can be expected in many vast plainly that registration for practice in this country tracts of the Empire where tropical diseases are rife. of the medical graduates of certain Indian universities What might be achieved by the education of the must otherwise cease early this year. Then, at the native in elementary hygiene was set forth persuasively beginning of this year, a letter was received from by Prof. B. BLACKLOCK in a recent Chadwick public the India Office saying that the appointment of the For the present reliance must be placed Commissioner was not possible, but stating that lecture. largely upon the efforts of experts, and for the training the Government of India proposed to proceed with the of these the London School of Hygiene and Tropical appointment of a Board to discharge the duties of Medicine, whose activities Sir ANDREw BALFOUR the All-India Medical Council until that body came into existence. This Board, the India Office stated, directs, is the great new centre. Research is the weapon which, wisely yielded, can would consist of the Director-General, I.M.S., and open up for us paths in the jungle of ignorance, representatives of the medical faculties of the Indian dispelling darkness and gloom and revealing vistas Universities, and one of its duties would be to appoint of hope and cheerfulness, health, and longevity. certain inspectors as intermediaries between the Board The Hastings Lecture demonstrated how good an and the General Medical Council. The Council, in ally to health the British Empire had been as a the meantime, had received telegrams from the civilising and colonising power. With pride in our Viceroy stating that the appointment of the Commisvast possessions, however, we must own to world sioner was not possible, but putting forward a responsibilities. We possess unique and often tragic recommendation, received from a conference of the opportunities of becoming intimately acquainted with Indian Universities that, pending the creation of an tropical disease, and it becomes to us a national duty All-India Medical Council, a Board consisting of not only to alleviate and where possible remove the representatives of the Government of India and the burdens of sickness in the interests of our own citizens, medical faculties of the Universities should be but to collect and sift the evidence by which the world appointed as a temporary measure. A further telegram from the Viceroy indicated that this Board, may benefit.