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LONDON SANITATION.
483 was a great outcry ill this country during the South African war when it became known that the number of medical officers and nurses was insufficient and that there was a lack of proper hospital equipment and appliances. Civil surgeons and nurses w ere hurriedly entrained, additional field hospitals were despatched, and the timely aid afforded by private persons was eagerly accepted. But the fact remains that for the first few months of the war the medical arrangements ere quite unequal to cope with the strain put upon them. For this I do not think anyone can be blamed. Certainly not the medical officers, who were most devoted and untiring in their endeavours to overcome the enormous difficulties with which they had to contend. It had been generally accepted that the mM’mttm strength of any force despatched from this country would not exceed two army corps-sav, 75.000 men—whereas the force actually employ ed amounted to bstween 300,000 and 400,000 scattered over a vast area with inadequate rail transport, and for the greater part without roads. But it will not be possible on any future occasion to make allowances for failure in the medical arrangements. We have been taught by sad experience that we must be prepared for a much larger force being sent into the field than was contemplated before the -South African war and a much larger percentage of disease. Yet at present we are not, much better off as regards medical requirements than we were in 1899; for although the Royal Army Medical Corps was increased bv 125 officers and 1200 other ranks under Mr. Brodrick’s régime. out of its own establishment it can now only provide for an expeditionary force 55,000 strong. It has been proposed to suppleinent the personnel by the addition of 45 per cent. of civil surgeons ancl 37 per cent. of civil subordinates, which would provide for a force 73,000 strong; and certain further proposals have been made bv the Advisory Board which if adopted would enable the Royal Army Medical Corps to deal with a force 140,000 strong. But both these proposals are still only under consideration, nothing has been done. and, as matters now stand, the balance of any larger force than 55,000 would have to take the field ithout any properly trained establishment whatever. No help could possibly be afforded to the army in India, which would be sadly in need of medical aid in the event of a prolonged war.
Correspondence. 11
Audi alterslm
partem,"
MISTAKES IN THE DIAGNOSIS OF INFECTIOUS DISEASE. To the Editors of THE LANCET. SiRs,-The statement of the chairman of the statistical committee of the Metropolitan Asylums Board last week and the pointed prominence given to it by the press (with respect to the 2000 mistakes and loss of 12,000 of the ratepayers’ money), on the face of it implies, and is no doubt intended so to do, a grave reflection on the competency of the London medical men and draws marked attention to the:r inability to diagnose correctly the various infectious disorders to which they may in their daily round be called and the consequences thereof to the public. I am willing to acknowledge that it is unfortunate so many should have occurred and that not only has the money been to all intents and purposes wasted but also that the patients have been needlessly brought into contact with diseases which they themselves did not suffer from-a much more serious matter than loss of money and time ; but is there nothing to be said on behalf of the poor practitioner who is called on suddenly to make an immediate diagnosis of the case and to act on it? As one of these latter, and one whose diagnosis having been reviewed has been found wanting, may I be allowed to plead extenuating circumstances in mitigation of judgment and explain some of the possible circumstances in which some of these errors occur ? The case to which I was called was apparently one of diphtheria and I gather from the general statement in the newspapers that many or most of the errors occurred in diagnosing this disorder. I say apparently it was one of diphtheria, for all the clinical symptoms were identical with those of that disorder. It occurred in the house of a training home for servant girls, with no possible accommodation for isolation. What was one to do? Theoretically one ought to have isolated the patient until one had taken a swab from the throat and had this examined and the diagnosis confirmed or otherwise. In the circumstances, however, I took on myself the responsibility of notifying the case and of having it immediately removed, and with all that I now know (and I have had a very considerable acquaintance with diphtheria) I should in the circumstances assume the risk again, and I have the approval of the medical officer of health for the action. Now, Sirs, not only is there considerable difficulty in the correct recognition of the various membranous sore-throats but since joining the profession (I am sorry to say a good many year" ago) the typical symptoms of various of the infectious diseases have been more or less altered. For instance, how
do we meet with the fulminating death-dealing scarlet fever epidemics that used to be prevalent ?7 Scarlet fever is now a mild, almost non-pyrexial exanthem. More frequently than not the child has little or no ra&h, is perfectly well after a couple of days’ slight feverishness, and returns to school in a week. Typhoid fever is now as often accompanied with constipation as with diarrhoea, and smallpox as modified by vaccination is almost unrecognisable except by an expert. In these circumstances mistakes do and will occur, giving cause for the uninitiated layman to blaspheme and the profession to be condemned in consequence. Recognising this fact and that the mistakes are not always due to ignorance alone, what means have we as a profession or what means have the various sanitary bodies for the more effectual checking or stopping of these errors and their results ?7 With the profession, of course, the encouragement of more perfect study of the various infectious disorders and the modifications met with will immediately occur to one. With regard to the various sanitary bodies, the provision of shelters for observation, of some provision for bacteriological investigation, for the examination of slides, for the supply of tubes for Widal reaction, the examination and staining of sputum, the supply of antitoxin (how many have done these ?), and lastly, the willing cooperation of the medical officer of health in friendly consultation in difficult cases. With regard to the Metropolitan Asylums Board, could not it provide some observation wards where cases of doubtful nature could remain under observation for a few hours and not be pushed straight into the wards ?7 It must be remembered, too, that cases admitted with one kind of dit-ea-e have been inoculated with others during their stay in these hospitals, so that errors occur inside as well as outside. To lessen the evil effects of these errors and the disrepute that they bring to the profession must be my excuse for ventilating my protest and urging the necessity of finding a I am, Sirs, yours faithfully, remedy if possible. RICHARD BEVAN. Kensington, August 8th, 1905.
rarely now
ANATOMICAL PECULIARITIES OF A
GALL-BLADDER. To the Editors
of THE LANCET. of interest in count xion with be SIRS,-The following may Dr. Fergmon Lemon’s case of abnormality of the gall-bladder reported in THE LANCET of May 13th, p. 1265. I had occasion recently to make a necropsy on the body of an Italian who was killed by an explosion of dynamite in a mine in this district. On opening th abdomen I noticed that the’gallbladder was apparently absent. On turning up the liver a slight elevation of the usual colour of the gall-bladder was seen on the under surface of the right lobe about two inches from the anterior border. On incision it proved to be a normally sized gall-bladder containing bile, almost entirely embedded in the liver substance. As in Dr. Lemon’s case, the coat of the gall-bladder was marked off very definitely from the liver substance but unlike his case was of normal thickness. The cystic duct ran for some distance through the liver substance, emerged at a small fissure of its own near the transverse fissure, and joined the hepatic duct in the usual situation. The fissuring and lobulation of the liver were most irregular but the gallbladder, liver, and all other organs were quite healthy. I am,
Sirs,
yours
faithfully, H. GERALD LOUGHRAN.
Western Australia,
July 7th, 1905.
LONDON SANITATION. To the Editors /1 THE LANCET. SIRS,-I desire to bring under your observation a most objectionable and insanitary practice which takes place on six days of the week during the fruit season in London. Carts bring to Covent Garden Market from the surrounding country baskets of strawberries, other fruits, and vegetables, and return to the country with the empty baskets packed with, and in contact with, horse dung and other manure. I have not the least doubt that these same baskets are again filled up the following day with market produce to be brought to Covent Garden and that the same thing is repeated day after day, the only cleansing that the baskets get being probably a washing with cold water, if even that. This practice may be constantly seen on the roads that lead.out of London and more particularly on the Hounslow-road. I returned from West Africa a few weeks ago and was
484
public authority to satisfy an obvious public demand. Perhaps the ancient Romans managed matters better. When this part of the country was annexed to the Roman Empire the natives, said to have been Celts, were making use
amazed to find this state of afEairs, which I understand has gone on for at least several years, in the very centre of civilisation, where one would expect to see sanitation made as perfect as possible. It is ridiculous, almost laughable, to visit a hospital and see the elaborate preparations that are made for disinfecting purposes and then to compare it with this filthy custom. Certainly, camels are swallowed, while gnats are strained at, and one is inclined to ask, Where is the I am, Sirs, yours faithfully, sanitary official ?
any
of the mineral waters to extract salt from them. The Romans did not fail to employ the waters for bathing purposes. The whole country around is rich with Roman remains. Close to Homburg, within an easy tramway ride, under the able direction of Professor L. Jacobi, the Roman fortress of Saalburg has been restored. This is one of the long line of forts that stretched from the Danube to the Rhine and is a great attraction to all who are interested in Roman history and in archaeology. After the departure of the Romans during the dark ages and up to the seventh century but little is known of Homburg. The waters seem to have been used merely for the salt
C. B. HUNTER.
Charles-street, St. James’s, S.W., August 7th,
1905.
HOMBURG. THE PROBLEM OF MINERAL WATER HEALTH RESORTS.— WHAT SHOULD. AND WHAT DOES. DETERMINE
which they contained and which was employed for culinary In 1622 the Landgraviate of Hesse-Homburg purposes. His successor, was created under Prince Frederick I. (FROM OUR SPECIAL SANITARY COMMISSIONER ) Fredeiick II., known as the Silver Leg, enlarged the town and built its present castle or princely residence. In 1766 the PART 1. Landgrave Fredeiick Lewis came to power and by devoting e THE HOMBURG OF THE PAST. especial attention to the mineral springs laid the foundattion of the town’s future renown. He also succeeded Bad-Homburg, August lst, 1905. in attracting various celebrities to live at, or to visit, THERE is no disguising the fact that of late Homburg has r But these German princes were notoriously poor Homburg. been under a cloud-a light, passing cloud, perhaps, but still gand could not do much. The next Landgrave, Prince a cloud. Yet it is also equally evident that Homburg has Frelerick I Joseph, was, however, fortunate in marrying in never before possessed so many resources for the treatment 1818 1 Princess Elizabeth of England, one of King George IlL’s c daughters. This princess brought with her a settlement of of various and serious diseases. Why with an increase a year which was a substantial addition to the 20,000 facilities and advantages there should be a decrease of .r.1O,000 c or so florins which constituted the civil list of the Landgrave. r] Princess Elizabeth made her:,elf very popular and for this popularity is a problem for which there is no one all-covering The i the principal spring at Homburg was named the reply. Many causes have been at work and among them reason political estrangements have played their part. Then there 1Elisabethbrunnen. Gardens and walks were laid out, old One year it is houses 1 are the ever tickle changes of fashion. we ’e pulled down, and a deliberate attempt was made thought " good form " or the " proper thing " to go to some tby the reigning family to render the mineral waters available i well-advertised resort ; and at another time it is some for the treatment of disease. These efforts so far succeeded Where it is only a that other place that comes in vogue. t it became worth while to keep a record of the persons i matter of pleasure and pleasure-seekers this ficklenesswho were now beginning to resort to Homburg for their does not do so much harm but when it is a question health. } The first such record is dated 1834 and in that year of health this is not only regrettable but mischievous.
I
of
c
’
,
-
-
Correspondence. 11
Audi alterslm
partem,"
MISTAKES IN THE DIAGNOSIS OF INFECTIOUS DISEASE. To the Editors of THE LANCET. SiRs,-The statement of the chairman of the statistical committee of the Metropolitan Asylums Board last week and the pointed prominence given to it by the press (with respect to the 2000 mistakes and loss of 12,000 of the ratepayers’ money), on the face of it implies, and is no doubt intended so to do, a grave reflection on the competency of the London medical men and draws marked attention to the:r inability to diagnose correctly the various infectious disorders to which they may in their daily round be called and the consequences thereof to the public. I am willing to acknowledge that it is unfortunate so many should have occurred and that not only has the money been to all intents and purposes wasted but also that the patients have been needlessly brought into contact with diseases which they themselves did not suffer from-a much more serious matter than loss of money and time ; but is there nothing to be said on behalf of the poor practitioner who is called on suddenly to make an immediate diagnosis of the case and to act on it? As one of these latter, and one whose diagnosis having been reviewed has been found wanting, may I be allowed to plead extenuating circumstances in mitigation of judgment and explain some of the possible circumstances in which some of these errors occur ? The case to which I was called was apparently one of diphtheria and I gather from the general statement in the newspapers that many or most of the errors occurred in diagnosing this disorder. I say apparently it was one of diphtheria, for all the clinical symptoms were identical with those of that disorder. It occurred in the house of a training home for servant girls, with no possible accommodation for isolation. What was one to do? Theoretically one ought to have isolated the patient until one had taken a swab from the throat and had this examined and the diagnosis confirmed or otherwise. In the circumstances, however, I took on myself the responsibility of notifying the case and of having it immediately removed, and with all that I now know (and I have had a very considerable acquaintance with diphtheria) I should in the circumstances assume the risk again, and I have the approval of the medical officer of health for the action. Now, Sirs, not only is there considerable difficulty in the correct recognition of the various membranous sore-throats but since joining the profession (I am sorry to say a good many year" ago) the typical symptoms of various of the infectious diseases have been more or less altered. For instance, how
do we meet with the fulminating death-dealing scarlet fever epidemics that used to be prevalent ?7 Scarlet fever is now a mild, almost non-pyrexial exanthem. More frequently than not the child has little or no ra&h, is perfectly well after a couple of days’ slight feverishness, and returns to school in a week. Typhoid fever is now as often accompanied with constipation as with diarrhoea, and smallpox as modified by vaccination is almost unrecognisable except by an expert. In these circumstances mistakes do and will occur, giving cause for the uninitiated layman to blaspheme and the profession to be condemned in consequence. Recognising this fact and that the mistakes are not always due to ignorance alone, what means have we as a profession or what means have the various sanitary bodies for the more effectual checking or stopping of these errors and their results ?7 With the profession, of course, the encouragement of more perfect study of the various infectious disorders and the modifications met with will immediately occur to one. With regard to the various sanitary bodies, the provision of shelters for observation, of some provision for bacteriological investigation, for the examination of slides, for the supply of tubes for Widal reaction, the examination and staining of sputum, the supply of antitoxin (how many have done these ?), and lastly, the willing cooperation of the medical officer of health in friendly consultation in difficult cases. With regard to the Metropolitan Asylums Board, could not it provide some observation wards where cases of doubtful nature could remain under observation for a few hours and not be pushed straight into the wards ?7 It must be remembered, too, that cases admitted with one kind of dit-ea-e have been inoculated with others during their stay in these hospitals, so that errors occur inside as well as outside. To lessen the evil effects of these errors and the disrepute that they bring to the profession must be my excuse for ventilating my protest and urging the necessity of finding a I am, Sirs, yours faithfully, remedy if possible. RICHARD BEVAN. Kensington, August 8th, 1905.
rarely now
ANATOMICAL PECULIARITIES OF A
GALL-BLADDER. To the Editors
of THE LANCET. of interest in count xion with be SIRS,-The following may Dr. Fergmon Lemon’s case of abnormality of the gall-bladder reported in THE LANCET of May 13th, p. 1265. I had occasion recently to make a necropsy on the body of an Italian who was killed by an explosion of dynamite in a mine in this district. On opening th abdomen I noticed that the’gallbladder was apparently absent. On turning up the liver a slight elevation of the usual colour of the gall-bladder was seen on the under surface of the right lobe about two inches from the anterior border. On incision it proved to be a normally sized gall-bladder containing bile, almost entirely embedded in the liver substance. As in Dr. Lemon’s case, the coat of the gall-bladder was marked off very definitely from the liver substance but unlike his case was of normal thickness. The cystic duct ran for some distance through the liver substance, emerged at a small fissure of its own near the transverse fissure, and joined the hepatic duct in the usual situation. The fissuring and lobulation of the liver were most irregular but the gallbladder, liver, and all other organs were quite healthy. I am,
Sirs,
yours
faithfully, H. GERALD LOUGHRAN.
Western Australia,
July 7th, 1905.
LONDON SANITATION. To the Editors /1 THE LANCET. SIRS,-I desire to bring under your observation a most objectionable and insanitary practice which takes place on six days of the week during the fruit season in London. Carts bring to Covent Garden Market from the surrounding country baskets of strawberries, other fruits, and vegetables, and return to the country with the empty baskets packed with, and in contact with, horse dung and other manure. I have not the least doubt that these same baskets are again filled up the following day with market produce to be brought to Covent Garden and that the same thing is repeated day after day, the only cleansing that the baskets get being probably a washing with cold water, if even that. This practice may be constantly seen on the roads that lead.out of London and more particularly on the Hounslow-road. I returned from West Africa a few weeks ago and was
484
public authority to satisfy an obvious public demand. Perhaps the ancient Romans managed matters better. When this part of the country was annexed to the Roman Empire the natives, said to have been Celts, were making use
amazed to find this state of afEairs, which I understand has gone on for at least several years, in the very centre of civilisation, where one would expect to see sanitation made as perfect as possible. It is ridiculous, almost laughable, to visit a hospital and see the elaborate preparations that are made for disinfecting purposes and then to compare it with this filthy custom. Certainly, camels are swallowed, while gnats are strained at, and one is inclined to ask, Where is the I am, Sirs, yours faithfully, sanitary official ?
any
of the mineral waters to extract salt from them. The Romans did not fail to employ the waters for bathing purposes. The whole country around is rich with Roman remains. Close to Homburg, within an easy tramway ride, under the able direction of Professor L. Jacobi, the Roman fortress of Saalburg has been restored. This is one of the long line of forts that stretched from the Danube to the Rhine and is a great attraction to all who are interested in Roman history and in archaeology. After the departure of the Romans during the dark ages and up to the seventh century but little is known of Homburg. The waters seem to have been used merely for the salt
C. B. HUNTER.
Charles-street, St. James’s, S.W., August 7th,
1905.
HOMBURG. THE PROBLEM OF MINERAL WATER HEALTH RESORTS.— WHAT SHOULD. AND WHAT DOES. DETERMINE
which they contained and which was employed for culinary In 1622 the Landgraviate of Hesse-Homburg purposes. His successor, was created under Prince Frederick I. (FROM OUR SPECIAL SANITARY COMMISSIONER ) Fredeiick II., known as the Silver Leg, enlarged the town and built its present castle or princely residence. In 1766 the PART 1. Landgrave Fredeiick Lewis came to power and by devoting e THE HOMBURG OF THE PAST. especial attention to the mineral springs laid the foundattion of the town’s future renown. He also succeeded Bad-Homburg, August lst, 1905. in attracting various celebrities to live at, or to visit, THERE is no disguising the fact that of late Homburg has r But these German princes were notoriously poor Homburg. been under a cloud-a light, passing cloud, perhaps, but still gand could not do much. The next Landgrave, Prince a cloud. Yet it is also equally evident that Homburg has Frelerick I Joseph, was, however, fortunate in marrying in never before possessed so many resources for the treatment 1818 1 Princess Elizabeth of England, one of King George IlL’s c daughters. This princess brought with her a settlement of of various and serious diseases. Why with an increase a year which was a substantial addition to the 20,000 facilities and advantages there should be a decrease of .r.1O,000 c or so florins which constituted the civil list of the Landgrave. r] Princess Elizabeth made her:,elf very popular and for this popularity is a problem for which there is no one all-covering The i the principal spring at Homburg was named the reply. Many causes have been at work and among them reason political estrangements have played their part. Then there 1Elisabethbrunnen. Gardens and walks were laid out, old One year it is houses 1 are the ever tickle changes of fashion. we ’e pulled down, and a deliberate attempt was made thought " good form " or the " proper thing " to go to some tby the reigning family to render the mineral waters available i well-advertised resort ; and at another time it is some for the treatment of disease. These efforts so far succeeded Where it is only a that other place that comes in vogue. t it became worth while to keep a record of the persons i matter of pleasure and pleasure-seekers this ficklenesswho were now beginning to resort to Homburg for their does not do so much harm but when it is a question health. } The first such record is dated 1834 and in that year of health this is not only regrettable but mischievous.
I
of
c
’
,
-
-