- Email: [email protected]
HOSPITAL PROVISION FOR CHRONICS.
DUODENAL CATHETERISATION.
under training, and benefit so rapidly from it. Indeed, he talked so much and so enthusiastically about it that it was heard of by the King of Egypt, who ordered that his bodyguard should be examined and treated forthwith. In all, treatment was extended to 1214 serving soldiers, while 969 were told off to be treated when the training period was at an end. The reports from regiments were that recruits this year did not faint on parade, nor did they, as formerly, complain of schistosomiasis. This very interesting story is detailed by Major Spence in a thesis for the degree of M.D. Edin., which appears with illustrations in the Journal of the R.A.M.C. for May, and is well worth reading, particularly if taken along with his previous paper, on the Wady Halfa Quarantine to protect the Sudan against worm-infected labourers from Egypt, in the same publication for last November. DUODENAL CATHETERISATION. THE merit of being the pioneers of this method of investigating the contents of the duodenum belongs, perhaps, to J. C. Hemmeter and Max Einhorn. Various observers have from time to time modified the procedure and the nature of the instruments required, and recently Dr. Alberto Trossarelli has published the results of his work in this respect at the Mauriziano Hospital at Turin.’ He makes use of a rubber tube of 5 mm. diameter and 1-25 metre long, with a metallic perforated extremity. The tube is filled with an emulsion of barium sulphate which by rendering it opaque facilitates its passage by means of the screen across the stomach and through the pylorus, which is induced to relax by the introduction of sodium bicarbonate according to Jutte’s method. The duodenum is reached rapidly, and by means of an ordinary glass syringe the barium emulsion is aspirated first and then the duodenal fluid ; the small quantity of the former which remains in the tube in no way The interferes with the ultimate investigations. method is valuable both from a clinical and therapeutic
standpoint. As a rule, the duodenal contents consist of the duodenal juices, bile, and pancreatic juice, but
catarrhal jaundice, Prof. Trossarelli’s researches to show that the presence of albumin in the bile is an unsolved problem as an element of diagnosis and cannot be relied on in the absence of other symptoms. In fact, there are individuals who have never suffered from any kind of gastro-intestinal or hepatic disturbance whose bile contains as much albumin as those suffering from jaundice of various kinds. Examination for the presence of pancreatic ferments, diastase, trypsin, and steapsin has failed to afford any definite diagnostic help, partly because the duodenal fluid rapidly loses its fermentative power, whether kept in ice or in a thermostat at 37°C.,and partly because the presence of bile largely increases its activity. It is only with the greatest circumspection that it is possible to admit a functional debility of the pancreas in the sense of a diminished excretion of ferments based on a quantitative examination of these substances in the duodenal juice. Catheterisation is also useful in treatment, since by means of the tube various remedies can be brought into contact with the duodenal mucosa without having to pass through the stomach. One method of treatment which has given good results, particularly in cases of cholecystitis, hepatic calculus, ulcerative colitis, and in some cases of ankylostomiasis, consists in free duodenal lavage with astringents and antiseptics. Among the substances which have been used beneficially may be mentioned argyrol and protargol in 0’75 per cent. to 1-5 per cent., nitrate of silver 1 in 20,000, sulphate of magnesia and Jutte’s solution, the latter composed of 0-9 per cent. sodium sulphate and 0’9 per cent. sodium chloride, using 1 to 1 litres for a lavage. Excellent effects seem to have been obtained by these methods, resulting in the elimination of large quantities of biliary sand and even small calculi with disappearance of symptoms. In other cases, individuals suffering from intermittent fever of obscure origin, where after catheterisation the duodenal fluid was found to contain bacilli belonging to the paratyphoid group, a complete cure was obtained after two or three washings. This method has also been used with solutions of novarsenobenzol in syphilis and emetine in amcebic dysentery. Recently Bottner and Verner practised duodenal lavage with decoction of linseed and 5 per cent. magnesium sulphate in patients affected with pernicious anaemia. Out of six subjects treated they obtained clear improvement in five of them. Prof. Trossarelli’s observations and researches demonstrate the great importance that duodenal catheterisation may acquire in the diagnosis and treatment of certain diseases of the liver, bile-ducts, pancreas, and duodenum. When technical difficulties have been overcome it will doubtless obtain its fitting place in practical medicine. seem
by injecting 25-30 c.cm. of a 25 per cent. solution of magnesium sulphate contraction of the gall-bladder ensues and at the same time relaxation of Oddi’s sphincter. Bile thus obtained may be of normal aspect or thick and dark, indicating the presence of cholecystitis, or containing a large quantity of mucous flakes, evidence of catarrhal jaundice. Fine sand points to biliary lithiasis, while a definite amount of blood suggests the presence of a growth either in the duodenum, biliary passages, or pancreas, and especially in the latter organ if the liquid is colourless, and there has been no colic and if pancreatic ferments are absent. Microscopic examination of the extracted fluid sometimes dis-I closes the presence of a large quantity of leucocytes with red corpuscles associated with mucus and cellular elements and various micro-organisms; such a condition indicates some inflammatory process, cholecystitis or choledochocystitis either simple or calculous if there are many cholesterin crystals seen. In catarrhal jaundice there may be an enormous quantity of epithelial cells accompanied by polynuclears and cylindrical cells of the biliary ducts. Chemical examination will show that there is complete absence of urobilin in obstructive jaundice, while on the other hand, it is increased in cases of abnormal destruction of red cells such as in hsemolytic jaundice, pernicious anaemia, and malaria. Usually the amount of albumin in the bile varies largely from case to case, and also in individuals who subjectively and clinically may be considered normal, and even varies in the same individual, according as the bile comes from the gall-bladder or biliary passages. Although some observers have claimed that the presence of a definite quantity of albumin is an indication of inflammatory processes of the bile passages, and particularly of
polynuclear
l Policlinico, Surgical Section ,April 15th, 1925.
1309
____
HOSPITAL PROVISION
FOR CHRONICS.
NOT long ago Dr. E. P. Boas, medical director of the Montefiore Hospital in New York, brought to the notice of the New York Academy of Medicine the problem of the hospitalisation of the chronic case. There are, it appears, few institutions in New York
where adequate care is given to the treatment of chronic disease, and at existing institutions there is little if any differentiation made between cases simply requiring custodial care and those which would respond to specialised medical and surgical treatment. The subject is further dealt with in a report by the Public Health Committee of the Academy which has just reached us. The type of case for which the New York hospitals under present circumstances do not arrange includes the various rheumatic diseases, cardiac and visceral troubles of many kinds and degrees, mucous colitis and other gastro-enteric diseases which do not readily respond to home treatment, disturbances of the neuro-muscular system, renal affections and the large group of orthopaedic cases. Shelter is provided for those who havereached the incurable stage, but the need is felt for the care of those who are not yet hopeless. The staff should
THE CONTROL OF THE TSETSE-FLY.
1310
it is argued, be made up only of physicians who are be reduced to a mathematical problem. The subseinterested in the study and treatment of chronic quent investigations of A. V. Hill proved that it disease. In a recent survey,t made at the instance of was possible to express the conditions in the form of The next the same public health committee, it is stated that a simple and now familiar equation. there are only three hospitals in New York with an investigations of importance were those of Christianentirely independent staff of physicians for the out- son, Douglas and Haldane, who made clear the patients’ department, and two of these are now marked difference in the carbon dioxide absorption contemplating a reorganisation which will bring between oxygenated and reduced blood. Van Slyke, about closer coordination between the hospital and Wu, and F. C. Maclean’s investigations of the various The survey closes with a iI alterations in the water content of cells and plasma the dispensary work. Prof. Henderson then definite indictment of the lack of community policy," were also summarised. which, it is stated, has resulted in a heterogeneous described his own investigations into the relations accumulation of hospital services more or less suited between free, total, and fixed CO2 of the blood, conto the needs of the community, but inelastic in their cluding that the following variables constituted the organisation, not fully adjusted to meet the economic main factors in the physicochemical equilibrium of status of the several classes of the population, and the blood: free oxygen (02), total oxygen (Hbû2). for the most part not coordinated with the existing free CO2 (CO s), total CO2(BHC03) hydrogen-ion conhospital facilities in the city as a whole. This is centration of serum (H), volume of corpuscles (V), an indictment which, with necessary amendments, and the ratio of the anions within and without the probably applies to most hospital services everywhere, cells (r)-i.e., Donnan’s equilibrium factor. Preand one of the great works of the not distant future vious work had suggested that these variables might will be the removal of a state of things almost inevit- be grouped in threes, when it would obviously be able in the past, but which is now in danger of becoming possible to define the five following equations :an avoidable reproach. 0. "
i1’ (H) . (H2Cûs) . (BHC03) J 2. (0 2) (HbÛ2) (]El 2CO 3) f,. (H2Cûs) . (BHCO,) . (HbO,) f4’ (H) ..(Hb0,).(r) is. (H) (Hbû2) (V)
____
UNPLEASANT BOOKS. - THE 135th anniversary dinner of the Royal Literary Fund was held at the Hotel Victoria on June llth, when the Spanish Ambassador, Don Alfonso Merry del Val, presided and made in idiomatic English an admirable speech on the position of English literature in Spain. He spoke, he insisted, as a diplomatist representing the views of the Spanish sovereign, but the training of the English public school was apparent throughout. To the toast of literature proposed by Sir Robert Kindersley, Major Ian Hay Beith responded in eloquent terms, pleading the cause of all writers great and small and apologising for " a great deal of stuff that is about " by pleading that the unpleasant books for which there is a mania in certain circles represented a passing phase and one at which many people were already bored. Major Beith was as serious as he was funny in his excellent speech, and he put unpleasant books, we think, in their right place as a transient nuisance. Medical men at least must hope so, but this implies that the propaganda of the voluntary custodians of public morality must often advertise what had better have been ignored. The mass of illiterate readers-and the mass will alwaysbe illiterate-is only stirred to emotional attention by the primary human needs of birth and death and mating. The writer whose style falls just short of the living touch may gain effect by overstepping ever so little the conventional bounds of plain speaking and by producing the first degree of shock, which may be pleasant. The fact that the second degree brings nausea and satiety should not be forgotten. THE MATHEMATICS OF INTERNAL RESPIRATION. ON June 10th Prof. L. J. Henderson, of Harvard, delivered the first of a series of three lectures upon Blood as a Physicochemical Svstem in the Physiological Institute of University College, London; Prof.z’ A. V. Hill being in the chair. The size of his audience may be explained by the memory of a lecture before the Physiological Society in 1920, at which Prof. Henderson introduced his own particular method of attacking the physicochemical properties of the blood. The present series of lectures record progress made during the intervening five years. The lecturer began by summarising the various physicochemical investigations already performed on the blood. He pointed out the great importance of the work of J. Barcroft upon the dissociation curve of oxyhsemoglobin, since it demonstrated that one of the most important respiratory functions of the blood could
I
1 The Hospital Situation Putnam’s Sons. Pp. 356.
in
Greater New York.
G. P.
=
=
=
=
=
O. 0. 0.
0.
The possible permutations of the series evidently preclude any attempt at algebraic solution. Prof. Henderson’s thesis might be summarised by stating that he believed that if some solution could be offered to these equations, the conditions of the blood’s equilibrium would be defined. There are seven variables, and it ought to be possible, by fixing any two of the seven, to define the other five. In his second lecture Prof. Henderson dealt with a method of solution by means of a graphical representation on the following principle. A series of curves for the five equations can be plotted on the basis of two of the variables being fixed, and by superimposition a comprehensive diagram thus obtained. The result, however, would be a mass of confusion if the ordinary type of graph were constructed. Prof. Henderson has called to his aid the Cartesian nomogram, extensively used in mathematical circles, which has, in his hands, yielded information of the greatest value. To construct a nomogram for the equation a; +y =Z, the ordinate and abscissae are first graduated in terms of x and y. The numerals on the co-ordinates are joined by means of straight lines with the result that a series of diagonals are produced, joining like values of x and y. These lines are numbered according to the values which they unite. To use the nomogram, perpendiculars. are dropped from the particular values selected for x and y on the co-ordinates, and it will be found that the point of intersection will lie on one of the diagonals or contour lines. This will correspond to the value of z. By superimposing a series of contours upon such a Cartesian background it is possible to read off the points of intersection.
CONTROL OF THE TSETSE-FLY. As against the hope expressed at the recent League of Nations Conference on Sleeping Sickness in Africa, that international coordination would do much to further progress in combating this disease, Prof. Warrington" Yorke has" rather focused attention on our own in his paper read to. the kail-yard Imperial Entomological Conference on June 15th. In this paper he put forward a case for coordination of effort among our own African colonies in tsetse-fly investigation, principally in the experimental determination of the relationship of game to fly. The problem, he said, was to coordinate the four factors concerned in the disease-namely, (1) the pathogenic virus or trypanosome ; (2) the population and the domestic stock; (3) the transmitting agent or tsetse-fly; and THE
under training, and benefit so rapidly from it. Indeed, he talked so much and so enthusiastically about it that it was heard of by the King of Egypt, who ordered that his bodyguard should be examined and treated forthwith. In all, treatment was extended to 1214 serving soldiers, while 969 were told off to be treated when the training period was at an end. The reports from regiments were that recruits this year did not faint on parade, nor did they, as formerly, complain of schistosomiasis. This very interesting story is detailed by Major Spence in a thesis for the degree of M.D. Edin., which appears with illustrations in the Journal of the R.A.M.C. for May, and is well worth reading, particularly if taken along with his previous paper, on the Wady Halfa Quarantine to protect the Sudan against worm-infected labourers from Egypt, in the same publication for last November. DUODENAL CATHETERISATION. THE merit of being the pioneers of this method of investigating the contents of the duodenum belongs, perhaps, to J. C. Hemmeter and Max Einhorn. Various observers have from time to time modified the procedure and the nature of the instruments required, and recently Dr. Alberto Trossarelli has published the results of his work in this respect at the Mauriziano Hospital at Turin.’ He makes use of a rubber tube of 5 mm. diameter and 1-25 metre long, with a metallic perforated extremity. The tube is filled with an emulsion of barium sulphate which by rendering it opaque facilitates its passage by means of the screen across the stomach and through the pylorus, which is induced to relax by the introduction of sodium bicarbonate according to Jutte’s method. The duodenum is reached rapidly, and by means of an ordinary glass syringe the barium emulsion is aspirated first and then the duodenal fluid ; the small quantity of the former which remains in the tube in no way The interferes with the ultimate investigations. method is valuable both from a clinical and therapeutic
standpoint. As a rule, the duodenal contents consist of the duodenal juices, bile, and pancreatic juice, but
catarrhal jaundice, Prof. Trossarelli’s researches to show that the presence of albumin in the bile is an unsolved problem as an element of diagnosis and cannot be relied on in the absence of other symptoms. In fact, there are individuals who have never suffered from any kind of gastro-intestinal or hepatic disturbance whose bile contains as much albumin as those suffering from jaundice of various kinds. Examination for the presence of pancreatic ferments, diastase, trypsin, and steapsin has failed to afford any definite diagnostic help, partly because the duodenal fluid rapidly loses its fermentative power, whether kept in ice or in a thermostat at 37°C.,and partly because the presence of bile largely increases its activity. It is only with the greatest circumspection that it is possible to admit a functional debility of the pancreas in the sense of a diminished excretion of ferments based on a quantitative examination of these substances in the duodenal juice. Catheterisation is also useful in treatment, since by means of the tube various remedies can be brought into contact with the duodenal mucosa without having to pass through the stomach. One method of treatment which has given good results, particularly in cases of cholecystitis, hepatic calculus, ulcerative colitis, and in some cases of ankylostomiasis, consists in free duodenal lavage with astringents and antiseptics. Among the substances which have been used beneficially may be mentioned argyrol and protargol in 0’75 per cent. to 1-5 per cent., nitrate of silver 1 in 20,000, sulphate of magnesia and Jutte’s solution, the latter composed of 0-9 per cent. sodium sulphate and 0’9 per cent. sodium chloride, using 1 to 1 litres for a lavage. Excellent effects seem to have been obtained by these methods, resulting in the elimination of large quantities of biliary sand and even small calculi with disappearance of symptoms. In other cases, individuals suffering from intermittent fever of obscure origin, where after catheterisation the duodenal fluid was found to contain bacilli belonging to the paratyphoid group, a complete cure was obtained after two or three washings. This method has also been used with solutions of novarsenobenzol in syphilis and emetine in amcebic dysentery. Recently Bottner and Verner practised duodenal lavage with decoction of linseed and 5 per cent. magnesium sulphate in patients affected with pernicious anaemia. Out of six subjects treated they obtained clear improvement in five of them. Prof. Trossarelli’s observations and researches demonstrate the great importance that duodenal catheterisation may acquire in the diagnosis and treatment of certain diseases of the liver, bile-ducts, pancreas, and duodenum. When technical difficulties have been overcome it will doubtless obtain its fitting place in practical medicine. seem
by injecting 25-30 c.cm. of a 25 per cent. solution of magnesium sulphate contraction of the gall-bladder ensues and at the same time relaxation of Oddi’s sphincter. Bile thus obtained may be of normal aspect or thick and dark, indicating the presence of cholecystitis, or containing a large quantity of mucous flakes, evidence of catarrhal jaundice. Fine sand points to biliary lithiasis, while a definite amount of blood suggests the presence of a growth either in the duodenum, biliary passages, or pancreas, and especially in the latter organ if the liquid is colourless, and there has been no colic and if pancreatic ferments are absent. Microscopic examination of the extracted fluid sometimes dis-I closes the presence of a large quantity of leucocytes with red corpuscles associated with mucus and cellular elements and various micro-organisms; such a condition indicates some inflammatory process, cholecystitis or choledochocystitis either simple or calculous if there are many cholesterin crystals seen. In catarrhal jaundice there may be an enormous quantity of epithelial cells accompanied by polynuclears and cylindrical cells of the biliary ducts. Chemical examination will show that there is complete absence of urobilin in obstructive jaundice, while on the other hand, it is increased in cases of abnormal destruction of red cells such as in hsemolytic jaundice, pernicious anaemia, and malaria. Usually the amount of albumin in the bile varies largely from case to case, and also in individuals who subjectively and clinically may be considered normal, and even varies in the same individual, according as the bile comes from the gall-bladder or biliary passages. Although some observers have claimed that the presence of a definite quantity of albumin is an indication of inflammatory processes of the bile passages, and particularly of
polynuclear
l Policlinico, Surgical Section ,April 15th, 1925.
1309
____
HOSPITAL PROVISION
FOR CHRONICS.
NOT long ago Dr. E. P. Boas, medical director of the Montefiore Hospital in New York, brought to the notice of the New York Academy of Medicine the problem of the hospitalisation of the chronic case. There are, it appears, few institutions in New York
where adequate care is given to the treatment of chronic disease, and at existing institutions there is little if any differentiation made between cases simply requiring custodial care and those which would respond to specialised medical and surgical treatment. The subject is further dealt with in a report by the Public Health Committee of the Academy which has just reached us. The type of case for which the New York hospitals under present circumstances do not arrange includes the various rheumatic diseases, cardiac and visceral troubles of many kinds and degrees, mucous colitis and other gastro-enteric diseases which do not readily respond to home treatment, disturbances of the neuro-muscular system, renal affections and the large group of orthopaedic cases. Shelter is provided for those who havereached the incurable stage, but the need is felt for the care of those who are not yet hopeless. The staff should
THE CONTROL OF THE TSETSE-FLY.
1310
it is argued, be made up only of physicians who are be reduced to a mathematical problem. The subseinterested in the study and treatment of chronic quent investigations of A. V. Hill proved that it disease. In a recent survey,t made at the instance of was possible to express the conditions in the form of The next the same public health committee, it is stated that a simple and now familiar equation. there are only three hospitals in New York with an investigations of importance were those of Christianentirely independent staff of physicians for the out- son, Douglas and Haldane, who made clear the patients’ department, and two of these are now marked difference in the carbon dioxide absorption contemplating a reorganisation which will bring between oxygenated and reduced blood. Van Slyke, about closer coordination between the hospital and Wu, and F. C. Maclean’s investigations of the various The survey closes with a iI alterations in the water content of cells and plasma the dispensary work. Prof. Henderson then definite indictment of the lack of community policy," were also summarised. which, it is stated, has resulted in a heterogeneous described his own investigations into the relations accumulation of hospital services more or less suited between free, total, and fixed CO2 of the blood, conto the needs of the community, but inelastic in their cluding that the following variables constituted the organisation, not fully adjusted to meet the economic main factors in the physicochemical equilibrium of status of the several classes of the population, and the blood: free oxygen (02), total oxygen (Hbû2). for the most part not coordinated with the existing free CO2 (CO s), total CO2(BHC03) hydrogen-ion conhospital facilities in the city as a whole. This is centration of serum (H), volume of corpuscles (V), an indictment which, with necessary amendments, and the ratio of the anions within and without the probably applies to most hospital services everywhere, cells (r)-i.e., Donnan’s equilibrium factor. Preand one of the great works of the not distant future vious work had suggested that these variables might will be the removal of a state of things almost inevit- be grouped in threes, when it would obviously be able in the past, but which is now in danger of becoming possible to define the five following equations :an avoidable reproach. 0. "
i1’ (H) . (H2Cûs) . (BHC03) J 2. (0 2) (HbÛ2) (]El 2CO 3) f,. (H2Cûs) . (BHCO,) . (HbO,) f4’ (H) ..(Hb0,).(r) is. (H) (Hbû2) (V)
____
UNPLEASANT BOOKS. - THE 135th anniversary dinner of the Royal Literary Fund was held at the Hotel Victoria on June llth, when the Spanish Ambassador, Don Alfonso Merry del Val, presided and made in idiomatic English an admirable speech on the position of English literature in Spain. He spoke, he insisted, as a diplomatist representing the views of the Spanish sovereign, but the training of the English public school was apparent throughout. To the toast of literature proposed by Sir Robert Kindersley, Major Ian Hay Beith responded in eloquent terms, pleading the cause of all writers great and small and apologising for " a great deal of stuff that is about " by pleading that the unpleasant books for which there is a mania in certain circles represented a passing phase and one at which many people were already bored. Major Beith was as serious as he was funny in his excellent speech, and he put unpleasant books, we think, in their right place as a transient nuisance. Medical men at least must hope so, but this implies that the propaganda of the voluntary custodians of public morality must often advertise what had better have been ignored. The mass of illiterate readers-and the mass will alwaysbe illiterate-is only stirred to emotional attention by the primary human needs of birth and death and mating. The writer whose style falls just short of the living touch may gain effect by overstepping ever so little the conventional bounds of plain speaking and by producing the first degree of shock, which may be pleasant. The fact that the second degree brings nausea and satiety should not be forgotten. THE MATHEMATICS OF INTERNAL RESPIRATION. ON June 10th Prof. L. J. Henderson, of Harvard, delivered the first of a series of three lectures upon Blood as a Physicochemical Svstem in the Physiological Institute of University College, London; Prof.z’ A. V. Hill being in the chair. The size of his audience may be explained by the memory of a lecture before the Physiological Society in 1920, at which Prof. Henderson introduced his own particular method of attacking the physicochemical properties of the blood. The present series of lectures record progress made during the intervening five years. The lecturer began by summarising the various physicochemical investigations already performed on the blood. He pointed out the great importance of the work of J. Barcroft upon the dissociation curve of oxyhsemoglobin, since it demonstrated that one of the most important respiratory functions of the blood could
I
1 The Hospital Situation Putnam’s Sons. Pp. 356.
in
Greater New York.
G. P.
=
=
=
=
=
O. 0. 0.
0.
The possible permutations of the series evidently preclude any attempt at algebraic solution. Prof. Henderson’s thesis might be summarised by stating that he believed that if some solution could be offered to these equations, the conditions of the blood’s equilibrium would be defined. There are seven variables, and it ought to be possible, by fixing any two of the seven, to define the other five. In his second lecture Prof. Henderson dealt with a method of solution by means of a graphical representation on the following principle. A series of curves for the five equations can be plotted on the basis of two of the variables being fixed, and by superimposition a comprehensive diagram thus obtained. The result, however, would be a mass of confusion if the ordinary type of graph were constructed. Prof. Henderson has called to his aid the Cartesian nomogram, extensively used in mathematical circles, which has, in his hands, yielded information of the greatest value. To construct a nomogram for the equation a; +y =Z, the ordinate and abscissae are first graduated in terms of x and y. The numerals on the co-ordinates are joined by means of straight lines with the result that a series of diagonals are produced, joining like values of x and y. These lines are numbered according to the values which they unite. To use the nomogram, perpendiculars. are dropped from the particular values selected for x and y on the co-ordinates, and it will be found that the point of intersection will lie on one of the diagonals or contour lines. This will correspond to the value of z. By superimposing a series of contours upon such a Cartesian background it is possible to read off the points of intersection.
CONTROL OF THE TSETSE-FLY. As against the hope expressed at the recent League of Nations Conference on Sleeping Sickness in Africa, that international coordination would do much to further progress in combating this disease, Prof. Warrington" Yorke has" rather focused attention on our own in his paper read to. the kail-yard Imperial Entomological Conference on June 15th. In this paper he put forward a case for coordination of effort among our own African colonies in tsetse-fly investigation, principally in the experimental determination of the relationship of game to fly. The problem, he said, was to coordinate the four factors concerned in the disease-namely, (1) the pathogenic virus or trypanosome ; (2) the population and the domestic stock; (3) the transmitting agent or tsetse-fly; and THE