MEDICAL AND DENTAL REGISTERS.

613 for it implies considerable scarcity of medical service in some districts. For it must be remembered that the large class of officiers de santé, abolished in 1892, is very nearly extinct, something under 500 names only now remaining on the official list. In the time of Louis-Philippe, that is to say, about 80 years ago, there were less than 8000 doctors and many districts At the time of the were totally deprived of them. Franco-German war, in 1870, France had 14,000 doctors, showing a rise in the numbers which had no relation to increase of population. On the eve of the recent war there were 20,000 qualified medical men in France, and complaints of the overcrowding of the profession were heard, but, of course, chiefly in the towns. In Paris to-day there is one doctor for fewer than 900 inhabitants, which is much the proportion that prevails in this country save in particular centres. But certain departments have not enough doctors to deal with disease in modern manner, allowing that conditions of life in the mountainous districts will always be difficult, as they still are difficult with us in Scotland, despite special legislation to meet the needs of the Highlands and Islands. " How many doctors," asks M. Lecoq, " have vegetated in the Paris suburbs who might have had a larger and happier life in the country if they had not allowed themselves to be caught by the bait of the large town with its often illusory promise of fortune and glory." And he proceeds to point out that conditions of country life are now different, " for no longer does the doctor’s old nag joggle the life out of him and restrict his range of visits ; his little motor-car takes him at his ease for miles and, moreover, the country populations are now more prosperous and can pay better. They no longer consult first the bone-setter and theold wife’ who knew how to set the saints to work and which saints to appeal to for such and such complaints." Cherville, in his book " Village Studies," depicts the wrath of a peasant who was asked by the doctor three francs for five minutes’ advice, a sum which was as much as he gained the whole day guiding the plough. He ought to have had a quarter of an hour at least, he thought; but nowadays, says M. Lecoq, the peasant understands that time does not enter into the matter like that, and that science has its value and should be paid for. In short, with more general well-being, more light has entered the rural world, which is so much the better for the country sick and the country doctor. M. Lecoq’s peroration is : " Thy profession, good doctor, was for centuries hard and profitless, but the future will be better than the past. Be, like thy predecessors, the curer of the body and the consoler of the spirit, following the resolution expressed by the poet, François Fabie, in beautiful lines which thou

didst inspire :

Sauve, le plus

que tu pourras, De la Faucheuse aux maigres bras Le paysan qui plante et seme, Jusqu’à 1’heure ou tu t’en iras Sans regret la trouver toi-meme.’ "

THE HUMAN

FACTOR IN ACCIDENT CAUSATION. A REPORT has just been issued by the Industrial Fatigue Research Board which may frighten off many readers on account of its statistical appearance ; nevertheless, it contains much of great interest. Some years ago the Board published an investigation by M. Greenwood and H. M. Woods2 in which an effort was made to measure the influence of the This personal factor upon accident causation.

investigation was confessedly only a preliminary one. The report now issued attacks the problems again, making use of new and more extensive data. Over 1 A Contribution to the Study of the Human Factor in the Causation of Accidents. By E. M. Newbold, Industrial Fatigue Research Board. H.M. Stationery Office, 1926. Report No. 34. 5s. 2 Greenwood, M., and Woods. H. M. (1919): The Incidence of Industrial Accidents upon Individuals, with Special Reference to Multiple Accidents, Industrial Fatigue Research Board. Report No. 4.

16,000 minor accidents which occurred in a variety of factories are submitted to careful statistical analysis. The writer, Miss E. M. Newbold, appears at times to be over-cautious in drawing her deductions. Suffice it to say that the conclusions arrived at in every way substantiate those of previous inquiry. The average number of accidents is found to be influenced by a comparatively small number of multiple accident people, individuals with an innate tendency to sustain accidents. Nevertheless, on the whole the people with most accidents have usually been a shorter time in factory employment. Possibly those predisposed to accidents become naturally eliminated. The chance of an accident occurring appears to differ for each person, even though employed on the same work. A useful table is given from which an answer can quickly be obtained to the question whether the accidents in any department are due mainly to the accident risk associated with the work, or to the presence of a few people who have many accidents ; the method of using the table is explained. Experience is an important factor, and the level of the accident rate varies inversely with the experience of the workers, but even after allowance is made for this, a definite tendency is found for younger workers to have more accidents than older ones. This tendency helps to explain why sudden rises in accident-rates are associated with increased trade, due to the engagement of young as well as green labour. A curious fact emerges that the accident-rate and the dea.th-rate with respect to age are opposed ; whereas the former falls with age, the latter rises. The accident" deathrate rises, due to increased " tendency to die among older people, rather than to any increased " tendency to have accidents." The same fact holds true for illness-viz., the average duration of any single case increases with age. Another interesting point is the evidence found that the number of accidents an individual has is positively associated with the number of times he falls sick. So that in the saying " what is the matter with the sick is their tendency to be sick," the word " sick " must be held to include a tendency to accidents. Many attendances at factory ambulance rooms are on account of accidents which take place away from the works. Examination of these records brings out the fact that the same people who are unfortunate in the factory seem also to be unfortunate at home, and that there really are some people in whose hands knives and plates are not safe. The importance of the personal factor in accident causation is difficult to exaggerate, since over 80 per cent. of all accidents have no mechanical origin, and not more than 5 per cent. can be attributed to factors outside human control. What holds good for accidents taking place within the factory walls is presumably also true for the occurrences of ordinary life, but these latter do not lend themselves to careful investigation. Moreover, the association between sickness and accidents is significant. How few of us appreciate that when we sustain some slight injury we are really not quite fit, and that such incidents as multiple losses of property, such as leaving an umbrella in the train, have the same meaning. While congratulating Miss Newbold on the way in which she has overcome the difficulties inevitable to such an intricate investigation, we are glad to learn that the whole subject is being further investigated, particularly to ascertain how far a tendency to sustain minor accidents may be taken as a criterion to succumb to major accidents. MEDICAL AND DENTAL REGISTERS. WE have just received copies of the Medical and Dental Registers for 1926 and of the Medical and Students’ Register for the corresponding period. The total number of persons registered under the Medical Acts from the beginning of registration in 1858 up to Jan. 1st, 1926, is 98,308, and 52,531 are said to remain on the Register as made up on the last day of 1925. These are 2673 more than in the 1925 Register, distributed over the three sections into which the Register is still divided, although some of

Dental

614 this increase may be illusory, for an error seems to have crept into the number in the Foreign List as given in Table D, where the total of 232 is 121 in excess of the 111 names given in the 1925 table, .although only 8 names have been added by registration. These two figures have, it seems, inadvertently been added together, and the number should therefore, in accordance with our calculations, be reduced by 111. The same oversight seems to have affected a figure of 3243 given in the same table for the Colonial List. From a study of Table E we deduce the total number of registered persons as 50,035 on Jan. lst, 1925, and 51,737 on Jan. 1st, 1926, an increase of 1702 names. The excess of numbers in any year over the previous is, of course, due to a balance between the number added by registration and the number removed. The numbers added by registration are given in Table E as 1246 for England, 736 for Scotland, 406 for Ireland, 173 for Colonial, and 8 for Foreign, while, of the 947 names removed, 794 were removed on evidence of death, 1 on ceasing to practise, 146 under Section XIV., and 6 under Wee Sections XXVIII.-IX. of the Medical Act. learn that 1602 copies of this Medical Register have been printed, 872 of which have been earmarked for medical practitioners registered in 1925, of which it is curious to note the expectation that 472 will be claimed by Scottish practitioners. The number of copies available for sale is 400, an edition which is likely to melt away under the demand due to the present interest in the General Medical Council and its doings. The only substantial addition to the contents of the book is a reprint of the Medical Act, 1925 (Irish Free State), passed on Feb. 21st, 1925, to continue in force for one year only from that date. The Register contains, as everyone knows, the full text of all the Medical Acts from the first Act of 1858, the names of members of the Council, and copies of the warning notices issued to registered persons whether medical men or dentists. We cannot help regretting that the admirable memorandum written by the Registrar of the Council on the constitution, functions, and procedure of the Council has not been included in the volume. The Dentists Register contains 14,199 names, of which 14,111 are United Kingdom dentists, and of these 5841 possess licences or degrees in dentistry. There is an increase of 381 names on the 1925 Register; during the year 1925, 546 names were removed, 115 on evidence of death and 425 under Section 7 of the Dentists Act, 1921 ; and 400 names were restored, mostly under the .same section. This Register contains no important additions in the text, apart from the revised list, and enclosed with it as usual is the list of bodies corporate carrying on the business of dentistry and the names of the directors of these bodies. The lists of medical and dental students registered during the year 1925 contain the names of 1070 medical students and 191 dental students, being respectively 27 more and 9 less than the corresponding figures last year. All these three volumes are published for the General Medical Council or the Dental Board by Constable -and Co., Ltd., the prices being respectively 21s., 12s., and 7s. 6d. DONATIONS

AND

BEQUESTS.—Among other bequests

the late Mr. Warley Pickering, of Hutton Hall, Guisborough, Yorks, left 1500 to the North Riding Infirmary, Middlesbrough, and JE1500 to the North Ormesby Hospital, Middlesbrough.-Mr. William Alfred Sammes, Windsor, who left £ 23,888, after various bequests amounting to 22000, left ’the residue of his property between St. Andrew’s Hospital, Clewer, St. John’s Home, Clewer, and King Edward VII. Hospital, Windsor.-Miss Laura Lushington, of Reading, Berks, left 2100 to the Samaritan Fund of Guy’s Hospital. - mars. Elizabeth Crawford-Hayes, Clarges-street, Mayfair, W., widow of Dr. Thomas Crawford-Hayes, left the residue of her property to King’s College Hospital, London, for Crawford-Hayes beds. The amount available for this purpose will be about .?19,000.—Miss Amelia Broadbent, of Buxton, left 22000 in trust for her cousins for life, and then 21000 to the Manchester Royal Infirmary and - S500 each to St. Mary’s Hospital, Manchester, and Ancoats .Hospital and Dispensary.

Modern Technique

in Treatment.

A Series of Special Articles, contributed by invitation, on the Treatment of Medical and Surgical Conditions.

CLXV.-ACUTE EMPYEMA IN CHILDREN. SUCCESS in the handling of a child’s empyema depends in no small measure upon early diagnosis. Speedy detection of the pus and prompt application of requisite treatment minimise the risk to life and promote the early and complete re-expansion of the lung, which is essential to the obliteration of the cavity and the final cure of the disease. Fatalities, unhealed sinuses, and chest deformities-" chronic empyemata "-are the penalties more often of casual clinical observation than of ineffectual treatment. Before deciding upon what treatment is applicable to any individual case, it is necessary to appreciate the type and virulence of the abscess and its precise significance in the general clinical picture. In every empyema evacuation of the pus from the pleural cavity is urgently called for, but the way in which this is done may make all the difference between success and failure ; one routine treatment for all cases-e.g., opening the chest and inserting a drainage-tube-while it may cure many, will certainly prove unavailing in some. When the exploring needle has confirmed the presence of pus, the following points must be carefully considered before deciding upon the wisest method of evacuation : (1) The age of the child. (2) The size and situation of the empyema. (3) The general condition of the patient, especially as to whether we are dealing with an empyema which is : (a) synpneumonic (Cameron and Osman )—i.e., coexisting with an active pneumonia ; (b) metastatic -i.e., a local manifestation of, or metastasis from, some distant focus, the child being gravely ill from the generalised infection ; (c) metapneumonic. The primary object is to save the child’s life and in many cases-notably in infants and in the synpneumonic and metastatic types-immediate thoracotomy is attended with grave risk. Fortunately, in these cases the exudate is often conveniently thin and aspiration mechanically simple. For evacuating an empyema the following methods are available: (1) Aspiration: (a) intermittent; (b) continuous. (2) Thoracotomy-with or without resection of rib and followed by : (a) closure of the opening; (b) with drainage either " closed"or " open." (3) A combination of (1) and (2). Intermittent

Aspiration. employed. The needle or trocar of the aspirator is introduced along the tract of the original exploring needle. The chest wall should be locally infiltrated with t per cent. Potain’s apparatus is commonly

novocaine, or, better still, the child anaesthetised N20 and oxygen. The pleural cavity is emptied as completely as possible, the needle withdrawn,

with

sealed. The aspiration is repeated This simple procedure may suffice where the chest contents are merely turbid serum, but where the empyema is frankly purulent it is very unlikely that all the pus and debris will be really evacuated from the cavity even by repeated aspirations of this type ; and though the case may recover, it is almost certain that some deficiency of expansion and chest deformity will remain. Nevertheless, it may be of life-saving value as an adjunct to treatment in certain cases. In very large empyemata -where there is considerable cardiac displacement and the child’s respiration is seriously embarrassedit is always wise to aspirate by this method a quantity of the pus 12 to 24 hours before proceeding to thoracotomy. The operative risk in such cases is thereby sensibly diminished. In bilateral empyemata, in the synpneumonic or metastatic type of case, where an immediate thoracotomyis dangerous,timelyaspirations and the

as

puncture

necessary.

1 THE LANCET, 1923, i., 1097.