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HOSPITALS AND THE LAW
1142 The second case was of a man, aged 34, who felt dizzy after breathing the smoke for 30 minutes. He then left the train ; and very soon he began to have pain in the back and head and to feel shivery. There was no albumin in the urine, and no alteration of pulse-rate or temperature. The symptoms disappeared after 24 hours, and when I saw him the next day he had no signs. ,
Serum from blood taken on the 13th day showed negative results to these and also to L. grippotyphosa, L. sejrQe, L. A further test against L. icteropomona, and L. batavice. haemorrhagiae and L. canicola 2 months later also proved
negative.
The results of white blood-cell counts
were as
follows : ’
White Day of cells illness per
These cases seem to resemble those described by Dr. Harris. There would presumably be some plastic - among the insulating material involved in the fire, as well as metal. R. N. COMPTON SMITH. Ilford, Essex.
Differential white-cell count (%)) llTet. 161on. Lymph. Poly.
Platelet-count MMMt-coMM
WEIL’S DISEASE TREATED WITH PENICILLIN
This case was clinically one of Weil’s disease, and though the agglutination tests failed to substantiate the diagnosis there was no reason to doubt it. Unfortunately antileptospiral serum was given on the - same evening as the first dose of penicillin, but the - patient’s condition improved so greatly in the next 12 hours that it is reasonable to suppose that the penicillin was responsible. This assumption is further supported -by Cross’s experience with a case where little change was noticed after serum treatment but penicillin caused rapid improvement ; this dramatic improvement occurred even though the treatment was started after the appearance of jaundice. In our case the increase in the total white blood-cell count coincided with the clinical improvement. Although the leucopenia was general the polymorphonuclear leucocytes suffered more than the lymphocytes. The marked leucopenia was associated with a diminution in the number of platelets, which were greatly increased in size. We gratefully acknowledge the help given us by Dr. C. N.
biR,—Several workers have reported that penicillin is effective in the treatment of Weil’s disease. Cross1 described a case in which antileptospiral serum was from the 9th day of the disease with little change in the condition even after 60 ml. had been given over a period of a few days. On the 14th day a penicillin drip was set up which delivered 120,000 units intramuscularly in 24 hours. After this time no leptospira were found in the urine. A total of 800,000 units was given in 7 days. Patterson2 had dramatic results with the transfusion of blood from patients wha had recovered from Weil’s disease, but he had equally dramatic results with six patients treated with penicillin from the lst day of illness. Barron and Mills3 started penicillin treatment on the 6th day of the disease and before jaundice had developed. They gave 50,000 units 3-hourly and noted that after 48 hours the urine was free of leptospira ; there was jaundice on the 2nd day of treatment. Clinical improvement was not marked until the dosage was increased to 100,000 units 3-hourly. They gave a total of 8 million units. Moser4 treated a case with penicillin from the 4th day of illness but before jaundice had developed. He gave 50,000 units 2-hourly for twelve doses, and then 3-hourly. He noticed a rise in temperature to 104°F almost immediately after the second dose, but the temperature returned to normal after 1 hour. The patient became jaundiced 2 days after the start of treatment, but in spite of this the response to penicillin was dramatic. Moser records a leucopenia with a normal differential count on the 2nd day of illness. Others record either a normal white-cell count or a leucocytosis with a normal differential count early in the course of the disease.
given
The
following case illustrates three main points : (1) the effectiveness of penicillin in treatment ; (2) leucopenia, which sometimes occurs in these cases ; and (3) thrombocytopenia. A labourer, aged 42, employed in a cattle-cake store, sought medical advice on the 4th day of his illness. He complained of severe headache, muscular pains, shivering, and nausea and vomiting. He was febrile and had photophobia. The urine was found to contain bile and albumin, and the stools were said to be dark in colour. On the following morning the temperature was 102°F ; the eyes showed slight conjunctival hyperasmia and an icteric tinge ; there was slight tenderness in the right hypochondrium, and the right kidney was easily felt. The liver, spleen, and left kidney were not felt. That evening blood was taken for pathological examination, and 30 ml. of antileptospiral serum and 200,000 units of penicillin The next morning (the 6th day were given intramuscularly. of illness) he was markedly improved and afebrile. He was admitted to hospital. Penicillin treatment was continued as from 4 P.M., 200,000 units being given 6-hourly. The temperature rose to 100.2OF at 6 P.M. that day but returned to normal within a few hours, and it remained normal or subnormal except for a rise on the 12th, 14th, and 16th days of illness when he developed an urticarial rash and seemed to be suffering from penicillin sensitivity. Penicillin was stopped on the 9th day of illness and recommenced for 1 day on the 12th day. On the 6th day the liver and spleen were felt to be enlarged and there was slight icterus of the skin. On the 5th day the urine was found to contain spiroohaetes. The serum from blood taken on the same day did not or L. canicola. agglutinate Leptospira M
even
.
.
Partington, able to
on whose
experience
of this disease
we
draw, and by Dr. J. C. Broom, who carried
agglutination
reactions for
were
out the
us. -
--
J. HERBERT-BURNS H. C. G. FLAVELL.
Dorchester.
HOSPITALS AND THE LAW
SIR,-According’to your report (Dec. 1) of Dr. 0. R. Marshall’s lecture, he stated that section 265 of the Public Health Act, 1936 (the reference should be to the Public Health Act, 1875), in effect conferred upon officers of hospital boards or management committees an immunity against personal liability for torts committed by them in the execution of their duties under the National Health Service Act, 1946, provided only that -they acted in good faith. This statement clearly implies that a doctor on the staff of a hospital board, acting in good faith, cannot be made personally liable to a patient for damages for negligence arising out of treatment for which he is responsible in the hospital. Whatever may be the law of Scotland upon this point there is nothing in the law of England to support such a comforting conclusion. The section almost certainly affords no protection against actions for negligence. It is significant that no attempt has yet been made in England to invoke its aid; although there have already been a number of cases in which plaintiffs have recovered damages for negligence against doctors employed by hospital boards, and some in which the board itself has recovered damages from a doctor on its staff. The reason for this is to be found, I think, in a judgment of Lord Campbell (C. J.) in the case of Arthy v. Coleman (1857) in which he said : " where there is no negligence a party doing an act in obedience to the Board of Health is not liable-in that case he is very properly absolved and the superior alone is liable ; but if he is guilty of negligence in doing the act and damage ensues, he is personally liable." Z3-
’
.
-
1143 It is true that this
case was
decided under
an
earlier
Act, but the wording of the relevant section is closely similar to the words of section 265. So far as mv researches go, the English courts have never been called upon to interpret section 265 although it has been on the statute book since 1875. There is, however, no reason to suppose that they will not follow Lord Campbell’s decision if and when the point is raised. The Scots cases referred to by Dr. Marshall afford no guidance to the interpretation of the English Act, and are most unlikely to have any persuasive effect on English In the first place the section of the Scottish courts. Act (Public Health [Scotland] Act, 1893) under which they were decided is in different terms from section 265 of the English Act. In the second place the common law of Scotland differs from the common law in England in its attitude to the liability of hospital authorities for the negligence of their staffs. The three cases referred to by Dr. Marshall, in which the hospital authority escaped liability, would probably have been decided the other way by English courts, which no longer recognise a distinction between negligence in the performance of professional duties and negligence in the performance of ministrative acts. This distinction is, however, still preserved in the law of Scotland which holds that hospital authorities are not liable for " professional " negligence by doctors or nurses or other similarly qualified persons on their staffs. The relevant cases in England are collected in Cassidy v. Ministry of Health, 1951, 2 K.B. 343. The leading case in Scotland is Lavelle v. Glasgow Royal Infirmary, 1932, S.C. 245. ROGER ORMROD. Temple, London, E.C.4. PERIPHERAL NEURITIS DURING AUREOMYCIN THERAPY
Sin,—Peripheral neuritis does not yet seem to have been reported as a side-effect ofAureomycin ’ therapy. The following case may therefore be of interest. A woman, aged 22, was admitted to hospital with acute disseminated lupus erythematosus, the diagnosis being confirmed by the presence of lupus erythematosus cells in the blood. Treatment with intravenous A.c.T.H. was stopped after one week owing to the development of a staphylococcal pneumonia. The lupus erythematosus improved in this period and subsequently. For the treatment of the pneumonia chloramphenicol 1 g. followed by 500 mg. 6-hourly was given for 48 hours, after which aureomycin 500 mg. 6-hourly was given for the next 12 days together with a vitamin-B preparation (’ Becosyn ’) 2 tablets three times a day. During this time the patient passed 4-5 loose stools per day and complained of soreness of the mouth. She had no other symptoms until the 12th day of treatment, when she complained of cramp-like pain, burning, numbness, and pinsand-needles in both feet and the lower part of the legs, and found contact with the bedclothes very unpleasant. There were no symptoms referable to the upper limbs. Examination of the legs revealed marked hyperaesthesia to pin-prick and cotton-wool over a stocking distribution, but no other sensory disturbance and no reflex changes. There was no wasting or weakness of the foot and leg muscles, and no other abnormal neurological signs were detected. The burning sensation was considerably relieved by exposing the legs to the air. Inspection of the mouth revealed a7 hairy tongue. There was no sign of recurrence of the disseminated lupus
peripheral
"
"
erythematosus. With the onset of this peripheral neuritis aureomycin was and vitamin B was given intramuscularly. The diarrhoea ceased and the paraesthesiae have gradually decreased, and now, one month after stopping aureomycin, are very mild and are confined to the big toes.
stopped
The association of peripheral neuritis with lupus has only rarely been reported ; and it Was felt that these symptoms might have been due to aureomycin alone or to this and diarrhoea. It is interesting to note that throughout the treatment with aureomycin vitamin B by mouth was being administered.
erythematosus
The sensory symptoms in this case seem to be like those reported by Astley Clarke and Sneddonand Spillane and Scott2 in prisoners-of-war. It would be interesting to know whether others have observed similar neurological complications during aureomycin ’
therapy.
-
Rupert Hallam Department of Dermatology, Royal Infirmary, Sheffield.
R. H. MARTEN.
RESPONSE TO RELAXANT DRUGS cannot let pass unchallenged the statement by Dr. Gray and Dr. Dundee (Dec. 1) that : (1) it is folly to mix thiopentone with a muscle relaxant, and (2) it is important to give a test dose of gallamine triethiodide before inducing anaesthesia. In the hospitals of this district these drugs have been mixed and injected in thousands of cases without causing any harm that I know of. I have been using curare or gallamine triethiodide since 1944 and have never given a test dose ; nor, I believe, do my colleagues here. It is true that the dose injected has proved excessive on extremely rare occasions-when the diagnosis of myasthenia gravis has been overlooked, and cesophagoscopy or bronchoscopy has been carried out because the-presenting symptom of this condition has been dvsphagia or atelectasis. But this excess is readily countered by neostigmine. I believe that at the end of any operation neostigmine (preceded by atropine) should be given almost as a routine to counteract any residual effect of curare or gallamine triethiodide. The injection is made slowly and continued until respiratory exchange is obviously adequate. In my experience 2-5 mg. spread over a minute is an average dose, but this may have to be increased-very rarely to
SIR,-I
much as 7-5 mg. One factor which determines the dose of neostigmine is the response of the patient to
as
curare.
Nuffield Department of Anæsthetics, University of Oxford.
R. R. MACINTOSH.
THE ARTLESSNESS OF MEDICINE
SIR,-Tucked away in a corner of your issue of Nov. 17, below the brilliant and cathartic address of Dr. F. M. R. Walshe, is an excerpt from the report of the Medical Officer of Health at Wolverhampton which looks like an ironic addendum to that address. As W. S. Gilbert would say, " Here’s a state of things ! " We have a National Health Service which is presumably designed to benefit society as a whole; yet its medical social services in Wolverhampton cost 3s. per caput, whereas the medical personal services cost 815s., taking specialist and general-practitionerservices together. I have spent some 28 years of my life in preventive medicine, 20 of them in the Colonial Service and 8 in industrial medicine. In the one, as in the other, I have witnessed the wide economic and social influence of medicine. I spent 3 years in general practice and I saw no faintly comparable economic importance in such a pursuit ; indeed, I saw a considerable wastage of medicines and ill-fitting surgical appliances, and I am seeing this wastage grow greater every day. If this argument savours of an excess of pragmatism, it is none the worse for that. No-one will deny the great need for the individual services, but must there be such a shocking disparity in the attitude displayed to the two services as is indicated by the financial provisions When I spoke in these terms to a young colleague, he told me that we had now progressed so far that the medical officer of health’s job had ceased to be important and that he was now little more than a glorified sanitary inspector. In other words, the public-health authorities had achieved nearby perfection in a hundred years;
preventive
.
1. Clarke, C. A., Sneddon, I. B. 2. Spillane, J. D., Scott, G. I.
Lancet, 1946, i, 734. Ibid, 1945, ii, 261.
Serum from blood taken on the 13th day showed negative results to these and also to L. grippotyphosa, L. sejrQe, L. A further test against L. icteropomona, and L. batavice. haemorrhagiae and L. canicola 2 months later also proved
negative.
The results of white blood-cell counts
were as
follows : ’
White Day of cells illness per
These cases seem to resemble those described by Dr. Harris. There would presumably be some plastic - among the insulating material involved in the fire, as well as metal. R. N. COMPTON SMITH. Ilford, Essex.
Differential white-cell count (%)) llTet. 161on. Lymph. Poly.
Platelet-count MMMt-coMM
WEIL’S DISEASE TREATED WITH PENICILLIN
This case was clinically one of Weil’s disease, and though the agglutination tests failed to substantiate the diagnosis there was no reason to doubt it. Unfortunately antileptospiral serum was given on the - same evening as the first dose of penicillin, but the - patient’s condition improved so greatly in the next 12 hours that it is reasonable to suppose that the penicillin was responsible. This assumption is further supported -by Cross’s experience with a case where little change was noticed after serum treatment but penicillin caused rapid improvement ; this dramatic improvement occurred even though the treatment was started after the appearance of jaundice. In our case the increase in the total white blood-cell count coincided with the clinical improvement. Although the leucopenia was general the polymorphonuclear leucocytes suffered more than the lymphocytes. The marked leucopenia was associated with a diminution in the number of platelets, which were greatly increased in size. We gratefully acknowledge the help given us by Dr. C. N.
biR,—Several workers have reported that penicillin is effective in the treatment of Weil’s disease. Cross1 described a case in which antileptospiral serum was from the 9th day of the disease with little change in the condition even after 60 ml. had been given over a period of a few days. On the 14th day a penicillin drip was set up which delivered 120,000 units intramuscularly in 24 hours. After this time no leptospira were found in the urine. A total of 800,000 units was given in 7 days. Patterson2 had dramatic results with the transfusion of blood from patients wha had recovered from Weil’s disease, but he had equally dramatic results with six patients treated with penicillin from the lst day of illness. Barron and Mills3 started penicillin treatment on the 6th day of the disease and before jaundice had developed. They gave 50,000 units 3-hourly and noted that after 48 hours the urine was free of leptospira ; there was jaundice on the 2nd day of treatment. Clinical improvement was not marked until the dosage was increased to 100,000 units 3-hourly. They gave a total of 8 million units. Moser4 treated a case with penicillin from the 4th day of illness but before jaundice had developed. He gave 50,000 units 2-hourly for twelve doses, and then 3-hourly. He noticed a rise in temperature to 104°F almost immediately after the second dose, but the temperature returned to normal after 1 hour. The patient became jaundiced 2 days after the start of treatment, but in spite of this the response to penicillin was dramatic. Moser records a leucopenia with a normal differential count on the 2nd day of illness. Others record either a normal white-cell count or a leucocytosis with a normal differential count early in the course of the disease.
given
The
following case illustrates three main points : (1) the effectiveness of penicillin in treatment ; (2) leucopenia, which sometimes occurs in these cases ; and (3) thrombocytopenia. A labourer, aged 42, employed in a cattle-cake store, sought medical advice on the 4th day of his illness. He complained of severe headache, muscular pains, shivering, and nausea and vomiting. He was febrile and had photophobia. The urine was found to contain bile and albumin, and the stools were said to be dark in colour. On the following morning the temperature was 102°F ; the eyes showed slight conjunctival hyperasmia and an icteric tinge ; there was slight tenderness in the right hypochondrium, and the right kidney was easily felt. The liver, spleen, and left kidney were not felt. That evening blood was taken for pathological examination, and 30 ml. of antileptospiral serum and 200,000 units of penicillin The next morning (the 6th day were given intramuscularly. of illness) he was markedly improved and afebrile. He was admitted to hospital. Penicillin treatment was continued as from 4 P.M., 200,000 units being given 6-hourly. The temperature rose to 100.2OF at 6 P.M. that day but returned to normal within a few hours, and it remained normal or subnormal except for a rise on the 12th, 14th, and 16th days of illness when he developed an urticarial rash and seemed to be suffering from penicillin sensitivity. Penicillin was stopped on the 9th day of illness and recommenced for 1 day on the 12th day. On the 6th day the liver and spleen were felt to be enlarged and there was slight icterus of the skin. On the 5th day the urine was found to contain spiroohaetes. The serum from blood taken on the same day did not or L. canicola. agglutinate Leptospira M
even
.
.
Partington, able to
on whose
experience
of this disease
we
draw, and by Dr. J. C. Broom, who carried
agglutination
reactions for
were
out the
us. -
--
J. HERBERT-BURNS H. C. G. FLAVELL.
Dorchester.
HOSPITALS AND THE LAW
SIR,-According’to your report (Dec. 1) of Dr. 0. R. Marshall’s lecture, he stated that section 265 of the Public Health Act, 1936 (the reference should be to the Public Health Act, 1875), in effect conferred upon officers of hospital boards or management committees an immunity against personal liability for torts committed by them in the execution of their duties under the National Health Service Act, 1946, provided only that -they acted in good faith. This statement clearly implies that a doctor on the staff of a hospital board, acting in good faith, cannot be made personally liable to a patient for damages for negligence arising out of treatment for which he is responsible in the hospital. Whatever may be the law of Scotland upon this point there is nothing in the law of England to support such a comforting conclusion. The section almost certainly affords no protection against actions for negligence. It is significant that no attempt has yet been made in England to invoke its aid; although there have already been a number of cases in which plaintiffs have recovered damages for negligence against doctors employed by hospital boards, and some in which the board itself has recovered damages from a doctor on its staff. The reason for this is to be found, I think, in a judgment of Lord Campbell (C. J.) in the case of Arthy v. Coleman (1857) in which he said : " where there is no negligence a party doing an act in obedience to the Board of Health is not liable-in that case he is very properly absolved and the superior alone is liable ; but if he is guilty of negligence in doing the act and damage ensues, he is personally liable." Z3-
’
.
-
1143 It is true that this
case was
decided under
an
earlier
Act, but the wording of the relevant section is closely similar to the words of section 265. So far as mv researches go, the English courts have never been called upon to interpret section 265 although it has been on the statute book since 1875. There is, however, no reason to suppose that they will not follow Lord Campbell’s decision if and when the point is raised. The Scots cases referred to by Dr. Marshall afford no guidance to the interpretation of the English Act, and are most unlikely to have any persuasive effect on English In the first place the section of the Scottish courts. Act (Public Health [Scotland] Act, 1893) under which they were decided is in different terms from section 265 of the English Act. In the second place the common law of Scotland differs from the common law in England in its attitude to the liability of hospital authorities for the negligence of their staffs. The three cases referred to by Dr. Marshall, in which the hospital authority escaped liability, would probably have been decided the other way by English courts, which no longer recognise a distinction between negligence in the performance of professional duties and negligence in the performance of ministrative acts. This distinction is, however, still preserved in the law of Scotland which holds that hospital authorities are not liable for " professional " negligence by doctors or nurses or other similarly qualified persons on their staffs. The relevant cases in England are collected in Cassidy v. Ministry of Health, 1951, 2 K.B. 343. The leading case in Scotland is Lavelle v. Glasgow Royal Infirmary, 1932, S.C. 245. ROGER ORMROD. Temple, London, E.C.4. PERIPHERAL NEURITIS DURING AUREOMYCIN THERAPY
Sin,—Peripheral neuritis does not yet seem to have been reported as a side-effect ofAureomycin ’ therapy. The following case may therefore be of interest. A woman, aged 22, was admitted to hospital with acute disseminated lupus erythematosus, the diagnosis being confirmed by the presence of lupus erythematosus cells in the blood. Treatment with intravenous A.c.T.H. was stopped after one week owing to the development of a staphylococcal pneumonia. The lupus erythematosus improved in this period and subsequently. For the treatment of the pneumonia chloramphenicol 1 g. followed by 500 mg. 6-hourly was given for 48 hours, after which aureomycin 500 mg. 6-hourly was given for the next 12 days together with a vitamin-B preparation (’ Becosyn ’) 2 tablets three times a day. During this time the patient passed 4-5 loose stools per day and complained of soreness of the mouth. She had no other symptoms until the 12th day of treatment, when she complained of cramp-like pain, burning, numbness, and pinsand-needles in both feet and the lower part of the legs, and found contact with the bedclothes very unpleasant. There were no symptoms referable to the upper limbs. Examination of the legs revealed marked hyperaesthesia to pin-prick and cotton-wool over a stocking distribution, but no other sensory disturbance and no reflex changes. There was no wasting or weakness of the foot and leg muscles, and no other abnormal neurological signs were detected. The burning sensation was considerably relieved by exposing the legs to the air. Inspection of the mouth revealed a7 hairy tongue. There was no sign of recurrence of the disseminated lupus
peripheral
"
"
erythematosus. With the onset of this peripheral neuritis aureomycin was and vitamin B was given intramuscularly. The diarrhoea ceased and the paraesthesiae have gradually decreased, and now, one month after stopping aureomycin, are very mild and are confined to the big toes.
stopped
The association of peripheral neuritis with lupus has only rarely been reported ; and it Was felt that these symptoms might have been due to aureomycin alone or to this and diarrhoea. It is interesting to note that throughout the treatment with aureomycin vitamin B by mouth was being administered.
erythematosus
The sensory symptoms in this case seem to be like those reported by Astley Clarke and Sneddonand Spillane and Scott2 in prisoners-of-war. It would be interesting to know whether others have observed similar neurological complications during aureomycin ’
therapy.
-
Rupert Hallam Department of Dermatology, Royal Infirmary, Sheffield.
R. H. MARTEN.
RESPONSE TO RELAXANT DRUGS cannot let pass unchallenged the statement by Dr. Gray and Dr. Dundee (Dec. 1) that : (1) it is folly to mix thiopentone with a muscle relaxant, and (2) it is important to give a test dose of gallamine triethiodide before inducing anaesthesia. In the hospitals of this district these drugs have been mixed and injected in thousands of cases without causing any harm that I know of. I have been using curare or gallamine triethiodide since 1944 and have never given a test dose ; nor, I believe, do my colleagues here. It is true that the dose injected has proved excessive on extremely rare occasions-when the diagnosis of myasthenia gravis has been overlooked, and cesophagoscopy or bronchoscopy has been carried out because the-presenting symptom of this condition has been dvsphagia or atelectasis. But this excess is readily countered by neostigmine. I believe that at the end of any operation neostigmine (preceded by atropine) should be given almost as a routine to counteract any residual effect of curare or gallamine triethiodide. The injection is made slowly and continued until respiratory exchange is obviously adequate. In my experience 2-5 mg. spread over a minute is an average dose, but this may have to be increased-very rarely to
SIR,-I
much as 7-5 mg. One factor which determines the dose of neostigmine is the response of the patient to
as
curare.
Nuffield Department of Anæsthetics, University of Oxford.
R. R. MACINTOSH.
THE ARTLESSNESS OF MEDICINE
SIR,-Tucked away in a corner of your issue of Nov. 17, below the brilliant and cathartic address of Dr. F. M. R. Walshe, is an excerpt from the report of the Medical Officer of Health at Wolverhampton which looks like an ironic addendum to that address. As W. S. Gilbert would say, " Here’s a state of things ! " We have a National Health Service which is presumably designed to benefit society as a whole; yet its medical social services in Wolverhampton cost 3s. per caput, whereas the medical personal services cost 815s., taking specialist and general-practitionerservices together. I have spent some 28 years of my life in preventive medicine, 20 of them in the Colonial Service and 8 in industrial medicine. In the one, as in the other, I have witnessed the wide economic and social influence of medicine. I spent 3 years in general practice and I saw no faintly comparable economic importance in such a pursuit ; indeed, I saw a considerable wastage of medicines and ill-fitting surgical appliances, and I am seeing this wastage grow greater every day. If this argument savours of an excess of pragmatism, it is none the worse for that. No-one will deny the great need for the individual services, but must there be such a shocking disparity in the attitude displayed to the two services as is indicated by the financial provisions When I spoke in these terms to a young colleague, he told me that we had now progressed so far that the medical officer of health’s job had ceased to be important and that he was now little more than a glorified sanitary inspector. In other words, the public-health authorities had achieved nearby perfection in a hundred years;
preventive
.
1. Clarke, C. A., Sneddon, I. B. 2. Spillane, J. D., Scott, G. I.
Lancet, 1946, i, 734. Ibid, 1945, ii, 261.