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MEDICAL RESEARCH COUNCIL ANNUAL REPORT FOR 1934-35
621
SPECIAL ARTICLES MEDICAL RESEARCH COUNCIL ANNUAL REPORT FOR 1934-35
THE
Introduction
to the
report
of the Medical
Research Council provides year by year in 30 brief pages an index, a record, and a forecast: an index
to the trend of medical research during the period under review; a record of results achieved to the date of its close; and a forecast, often already confirmed in the intervening six months, of the conclusions reached as the outcome of work essentially complete but not yet published. It is a peculiar merit of this annual report to steer between the policy, unfair to other workers in the same field,
of staking out claims for discoveries of which full details are not available and that of supplying a mere summary of communications already familiar to the readers of scientific periodicals. This year a dozen subjects from among those on which work has been actively pursued are selected for review. Pride of place is given to
Nutrition:
Application of Modern Knowledge There have been many recent indications of greater public interest in nutrition. Though this interest may have been aroused not solely nor even primarily because of the intrinsic practical importance of proper feeding in its relation to health, but largely because of the probable economic effects on agriculture and industry, the Council express satisfaction that the discoveries of their own and other investigators of nutritional problems are likely in the near future to play their due part in advancing human welfare. HISTORICAL SURVEY
In view of this change in attitude they enumerate of the more practical discoveries which they have assisted during the 20 years of their existence. some
In the first year of their work they initiated research rickets which led to the elucidation of its nutritional aetiology, and in particular to the discovery of a calcifying vitamin (vitamin D), a substance which was ultimately prepared in its pure form by workers at the National Institute for Medical Research. They also promoted, in association with the Lister Institute, clinical investigations on rachitic children at Vienna, which confirmed the laboratory investigations and placed the methods for the prevention and cure of the disease on a firm basis. Later they supported work, arising from the rickets investigations, as a result of which it is now practicable to improve greatly the structure of the teeth of the rising generation by proper feeding in infancy and childhood. They are also responsible for the clinical investigations which demonstrated that, apart from dental structure, decay of the teeth can be slowed down by diet. This work has led to a new outlook on what is probably the commonest disability of civilised man-namely, dental decay--and has supplied facts ready and feasible for widespread translation into practice. One of the most important practical investigations initiated by the Council demonstrated the effects of supplementing the diet of growing children with milk and other substances. Through their Accessory Food Factors Committee the Council have initiated and financially supported investigations made with the object of standardising the different vitamins. Vitamin D was first standardised in this country, and the whole series of investigations later made it possible for international conferences, convened by the Health Organisation of the League of Nations in 1931 and 1934, to establish international standards and units for vitamins A, B1, C, and D. Thus people throughout the world can now discuss these
vitamins in terms of units, in the same way as they can discuss time and distance in units of hours and metres. Other inquiries supported by the Council called attention to the high incidence and significance of anaemia both in pregnant and lactating women and in their infants in this country, and showed how the condition could be avoided or mitigated. Certain nutritional investigations have been directed to the study of goitre, and others have had as their object the determination and close analysis of the usual dietaries of different sections of the
community. These are only a few of the more important contributions to knowledge in nutrition for which the Council have been responsible. Throughout their existence they have realised the fundamental importance of this rapidly developing subject, and have placed it in the foreground of their programme. THE NEW TEACHINGS
It is fortunate that the essential teachings can be reduced to a few simple statements. The first is that the younger the child the more essential is correct feeding for proper growth and health. It is thus necessary to apply the new teachings of nutrition to the case of the pregnant and lactating mother; and, despite the great importance of improvement in the dietary of school-children, proper feeding of the infant and child of pre-school age is an even greater need. Breast feeding is of even higher value than has been previously believed, and ought to be more extensively adopted and continued for
longer periods. On the dietary side, the broad requirements can be simply stated to the public-without mention of calories, vitamins, or other technicalities necessary to the investigator-by saying that much more milk (" safe" milk), cheese, butter, eggs (especially eggyolk), and vegetables (especially green vegetables) ought to be consumed. In particular, milk ought to be the chief drink for children, and especially in the first years, while bread and other cereals should in these early years be greatly reduced.
on
CURRENT WORK
Prof. E. P. Cathcart and Mrs. A. M. T. Murray have completed the analysis of data on family diets collected from various towns in Great Britain over a period of years, particular attention being given to the iron, calcium, and phosphorus contents of the diets. A quantitative survey of the diets of crofters and others in remote Highland areas is contemplated for purposes of comparison. A quantitative study of the ordinary diets of 120 men and women has been completed by Miss E. M. Widdowson, working under Dr. R. A. McCance, who R. B. Shackleton has also continued with Dr. his observations on the chemical composition of fruits and vegetables and their losses in cooking. It appears that most of the iron of vegetables and bread, and little of the iron of meat are utilised in human nutrition, and that about half the phosphorus of cereals, nuts, and pulses is in a form which cannot be absorbed.
L.
Prof. S. J. Cowell has done further experiments on the factors controlling the excretion of calcium in the intestine. It appears that the rate of excretion depends on the degree of saturation of the tissues generally with calcium, but that it is not much affected by sudden variations in the calcium content of the blood. Miss E. M. Hume, assisted by Mrs. I. Smedley MacLean, D.Sc., have made further observations on the effects of fat deficiency which were noted by Burr and Burr in rats. Experiments are
622
MEDICAL RESEARCH COUNCIL REPORT
in progress to determine what substances in lard and linseed oil are responsible for curing the lesions produced and for restoring the rate of growth to normal. An inquiry is also being made into the influence of the fats in the diet on reproduction. Under the general direction of Prof. W. W. C. Topley and Prof. Cathcart, Dr. Marion Watson has obtained preliminary results which indicate that diet and various environmental factors have specific effects on the fertility, growth, and survival-rates of young mice. Attempts are now being made to determine whether it is possible by dietetic means to increase the resistance to Bact. aertrycke. Dr. Helen Mackay is examining the value of a soya bean preparation as a supplement to milk in the diet of infants. The iron content of the bean is comparatively high, and it is thought that it may possibly replace inorganic iron salts for the prevention and treatment of nutritional ansemia. An inquiry at the North Eastern Tottenham, showed that the addition of extra Hospital, rations of vitamins A and D to the diets of children with measles was without effect on the course of this disease or on the incidence of the minor skin infections.
The method devised by Mr. C. 0. Harvey to measure minute quantities of iodine in biological substances has been used by Miss M. G. Crabtree to study the iodine content of samples of milk, pasture, and drinking water from different parts of England with the idea of obtaining definite proof whether the incidence of goitre in certain districts is actually related to the iodine-content of the local milk and water supplies. The findings so far indicate that the iodine-content of milk from the non-goitrous districts of Suffolk is higher than of that from the goitrous districts of Somerset.
Examples of Combined Clinical and Laboratory Research
Ergot in childbirth: isolation of ergometrine.The end of the fascinating story, extending over 30 years, of the struggle to reconcile clinical and pharmacological experience in respect to the activity of various preparations and derivatives of ergot is here recalled. Again and again, during this period, new constituents have been isolated from ergot which, although of great physiological interest, failed to replace in the confidence of the practising doctor the watery extracts of the whole drug. He continued to rely, for the purpose of stimulating contractions of the uterus, on these extracts given by the mouth, though he was assured that they contained none of the alkaloids found to be pharmacologically active when injected. This discrepancy between clinical practice and pharmacological evidence lasted till 1932 when Dr. Chassar Moir was able to demonstrate by objective records the powerful contractions of the human uterus induced by the popular watery extract of ergot. Close cooperation between the late Mr. W. H. Dudley, D.Sc., working on the chemical side, and Dr. Moir enabled them jointly to announce in March, 1935, the discovery of ergometrine as the substance in ergot responsible for thee most familiar of the actions of ergot.
As part of an inquiry into the vitamin Bl content of human diets Mr. P. C. Leong has measured the amounts of this vitamin present in genuine wholemeal wheat and in ordinary brown bread and has found the difference between them to be surprisingly small. By arrangement with physicians at several hospitals trials are being made of the therapeutic effects of vitamin-B concentrates in " pink disease " in children ; encouraging results have been obtained in a few cases, although caution is required in their interpretation. Application of the work of Mr. L. J. Harris, Sc.D., and Mr. S. N. Ray, Ph.D., on the diagnosis of vitamin-C deficiency to children under the care of Prof. L. G. Parsons and of Dr. E. Pritchard suggests that a suboptimal intake of vitamin C is common in artificially fed infants but not in breast-fed ones, human milk being three or four times richer in this vitamin than cow’s milk. Observations on adults by Dr. M. A. Abbasy and Dr. Harris indicate that one or two oranges a day suffice rapidly to bring reserves of vitamin C up to normal in persons whose diet has been deficient in this respect, but there is evidence that mothers often disobey instructions to give orange juice regularly to their infants.
The Council point out that these researches, while illustrating how results of equal or even greater importance may be attained by the laboratory as by-products of the chase, also illustrate how vital to the solution of a problem, originating in and concern. ing clinical practice, may be the guidance provided by continued investigation upon the clinical material itself. The curative agent of pernicious (MKpmm.—Another example of the need for continuous clinical guidance is in the testing of the therapeutic activity of preparations derived from liver. It is as yet impossible to foretell whether any particular preparation will be active until it has been tested on patients suffering from pernicious anaemia. No effective laboratory test of activity has yet been established, in spite of world-wide endeavours, while the chemical complexity of the liver principle has prevented the discovery of any chemical or physical property which can be regarded as a measure of its therapeutic influence. The Council were able to organise last year clinical trials by Prof. Stanley Davidson, Prof. E. J. Wayne, and Dr. C. C. Ungley of a preparation of liver extract made by a British firm according to the method of Dakin and West, published in America ; the result of these trials (published in THE LANCET, Feb. 15th, 1936, p. 349) demonstrated the extremely high degree of potency of this preparation. Injections of from 0.1 to 0-2 gramme of it once weekly, brought about a large increase in the red blood corpuscles of the patients tested and in the course of a few weeks restored them to health. Prevention of child-bed fever.-Here also the combination of clinical and laboratory research has been effective.
The only mention of work on vitamin D in this section of the report is on that of Miss Fischmann, who is studying its influence on ossification in tissue cultures. Elsewhere (p. 137) reference is made to the observations of Prof. J. B. Duguid, assisted by Dr. M. R. P. Williams, on the experimental production of a form of nephritis by giving large quantities of orthophosphates by mouth, in the presence of hypervitaminosis D ; and (p. 110) to the study by Dr. Dorothy Russell of the vascular, renal, and pituitary changes found in this condition.
The fact that the morbid agent known to be responsible for puerperal sepsis is a streptococcus characterised by ability to hsemolyse red blood corpuscles has of recent years been supplemented by the knowledge that the cocci having this property comprise several groups and sub-groups, of which only certain members are harmful to human beings. It emerges moreover that the hsemolytic streptococci occasionally found in the genital tract of healthy parturient women are not, as was formerly supposed, identical with those causing puerperal fever, which latter come from some outside source. Dr. Dova Colebrooke has recently tracked down the probable sources of infection. She has confirmed the view that the strep-
VITAMIN STUDIES
The seven pages devoted to vitamin studies in this year’s report record much work on various components of the vitamin-B complex, and on vitamin C (ascorbic acid) with short sections on the chemistry of vitamin E and notes on the storage and on the standardisation of vitamin A.
623
MEDICINE AND THE LAW
respiratory tract bear an intimate relation puerperal fever ; and her results suggest that the respiratory tract of the mother must be taken into account tococci of the
to
well as that of her attendants, and that familial of infection may also be looked for. as
sources
from her work is the lesson that it is for any person suffering from an acute infection of this tract to engage in maternity work, and that maternity and surgical cases should not be treated under the same roof unless the nursing staffs can be kept separate. Standards for sex hormones.-Under this heading the Council urge medical men using sex hormones in their work to insist on knowing the exact nature and strength of the preparations supplied. The market is flooded with different preparations, and each manufacturing firm has given a proprietary name to its own particular product. While some of these proprietary preparations are good, both their composition and activity being controlled, others are of a semi-bogus nature. The situation lent itself both to quackery and to ignorant treatment of disease until last year a conference, convened by the Permanent Standards Committee of the Health Section of the League of Nations, met in London under the chairmanship of Sir Henry Dale, and made important decisions in respect of nomenclature and standardisation.
Arising dangerous
A uniform scientific nomenclature and standard units have been adopted for three important natural substances of which therapeutic preparations are now available. These are : (1) "oeatrone,"" " cestriol,and " cestradiol," the oestrus-producing hormones (the alternative names and dihydroxy applying to hydroxy-ketonic, trihydroxy " progesterone," the preparations, respectively) ; (2) hormone of the corpus luteum which produces in the female the changes associated with pregnancy and pseudo" androsterone," a chemical subpregnancy ; and (3) stance closely related to that responsible for the development of the secondary sex characteristics in the male.
The effectiveness of the proposals must ultimately depend on the attitude of. those who use the substances. The Council point out that clinical knowledge of the actions of these sex hormones is still very elementary, and it is certain that they are physiologically potent, often in unexpected directions. Miscellaneous
Inquiries.-Travelling Fellowships Other studies reviewed editorially by the Council are the researches into the value, effects, and possible dangers of different methods of producing anaesthesia ; the artificial cultivation of living tissues ; iodine and thyroid disease ; industrial pulmonary disease; bed-bug infestation and the toxicity of industrial solvents.
We shall have occasion from time to time to comment on some of these and on work in progress at the National Institute for Medical Research, at the clinical research units, and under the external research schemes subsidised by the Council. Regret is expressed that in consequence of a change in policy of the Rockefeller Foundation, the system of international fellowships is being abandoned in favour of concentration upon a more restricted programme for the promotion of research. The Council had been privileged to award five or six whole-time fellowships every year, of the value of between f350 and f450 each ; analyses showed that of the 70 men and women who had completed their tenure of these fellowships 12 are professors, 36 others are engaged full-time, and a further 16 half-time in higher teaching and research. The organisation of a new scheme of the same kind is thus
considered highly desirable. A start has been made in the establishment of one such fellowship by the trustees of the late Lord Leverhulme, and the Council suggest that other potential benefactors have here a great opportunity of performing an important national service.
Mr. Ramsay MacDonald, who as Lord President introduces this year the report of the Committee for Medical Research of the Privy Council, announces that the grant-in-aid provided by Parliament for the expenditure of the Medical Research Council last year amounted to 165,000, compared with 139,000 in each of the three previous years. The increase has made it possible to proceed with plans for new research work which had been temporarily in abeyance and to undertake additional investigations required for the purposes of administrativedepartments. Prof. J. A. Ryle and Prof. Matthew Stewart have replaced respectively Lord Dawson of Penn and Prof. A. E. Boycott as members of the Council, and the impending retirement of the chairman, Lord Linlithgow on his appointment as Viceroy of India is announced with warm appreciation of his services.
.,
MEDICINE
AND
A Fatal Dose of
THE LAW
Paraldehyde
IN Strangways-Lesmere ’. Clayton and others Mr. Justice Horridge has refused to hold a district hospital at Weymouth liable for the negligence of its nurses. The negligence consisted of administering 6 ounces of paraldehyde to the plaintiff’s wife before an operation in mistake for 6 drachms. The honorary surgeon to the hospital gave instructions to the house surgeon for the patient to have per rectum 6 drachms in 9 ounces of water. The night nurse made a the on the bed-board note of instructions pencilled and handed it to Nurse A when the latter came on duty. The judge accepted the evidence of the day sister and the night sister that this pencilled note, thrown away after the operation, specified 6 drachms and not 6 ounces. It was the duty of Nurse A to administer the drug and of Nurse B to check the quantity. The bottle of paraldehyde was taken from a locked cupboard ; the label stated that the dose was to 2 fluid drachms. Nurse A poured out 6 ounces (half the bottle) and mixed it with 9 ounces of water ; Nurse B watched her do so. The patient died of heart failure due to an overdose of paraldehyde. Mr. Strangways-Lesmere sued the general committee and trustees of the Weymouth District Hospital and also Nurses A and B. He contended that a hospital was, like any other employer, liable for the negligence of its servants. The test was the power of the governors of the hospital to control the nurses’ work. A hospital authority was, he contended, protected in respect of the negligence of its nurses only where the negligence occurred in the course of work demanding professional nursing skill over the performance of which the governing body could have no control whatever. Here, said the plaintiff, the hospital authority had clearly assumed control over the measuring and checking of dangerous drugs by nurses because a hospital regulation had been made which required the sister on duty to check the dose. This regulation appeared not to have been properly published to the staff ; it was not known to Nurse A or Nurse B ; no precautions had been taken to see that the rule was carried out. On the other hand the hospital authorities argued that their
.
SPECIAL ARTICLES MEDICAL RESEARCH COUNCIL ANNUAL REPORT FOR 1934-35
THE
Introduction
to the
report
of the Medical
Research Council provides year by year in 30 brief pages an index, a record, and a forecast: an index
to the trend of medical research during the period under review; a record of results achieved to the date of its close; and a forecast, often already confirmed in the intervening six months, of the conclusions reached as the outcome of work essentially complete but not yet published. It is a peculiar merit of this annual report to steer between the policy, unfair to other workers in the same field,
of staking out claims for discoveries of which full details are not available and that of supplying a mere summary of communications already familiar to the readers of scientific periodicals. This year a dozen subjects from among those on which work has been actively pursued are selected for review. Pride of place is given to
Nutrition:
Application of Modern Knowledge There have been many recent indications of greater public interest in nutrition. Though this interest may have been aroused not solely nor even primarily because of the intrinsic practical importance of proper feeding in its relation to health, but largely because of the probable economic effects on agriculture and industry, the Council express satisfaction that the discoveries of their own and other investigators of nutritional problems are likely in the near future to play their due part in advancing human welfare. HISTORICAL SURVEY
In view of this change in attitude they enumerate of the more practical discoveries which they have assisted during the 20 years of their existence. some
In the first year of their work they initiated research rickets which led to the elucidation of its nutritional aetiology, and in particular to the discovery of a calcifying vitamin (vitamin D), a substance which was ultimately prepared in its pure form by workers at the National Institute for Medical Research. They also promoted, in association with the Lister Institute, clinical investigations on rachitic children at Vienna, which confirmed the laboratory investigations and placed the methods for the prevention and cure of the disease on a firm basis. Later they supported work, arising from the rickets investigations, as a result of which it is now practicable to improve greatly the structure of the teeth of the rising generation by proper feeding in infancy and childhood. They are also responsible for the clinical investigations which demonstrated that, apart from dental structure, decay of the teeth can be slowed down by diet. This work has led to a new outlook on what is probably the commonest disability of civilised man-namely, dental decay--and has supplied facts ready and feasible for widespread translation into practice. One of the most important practical investigations initiated by the Council demonstrated the effects of supplementing the diet of growing children with milk and other substances. Through their Accessory Food Factors Committee the Council have initiated and financially supported investigations made with the object of standardising the different vitamins. Vitamin D was first standardised in this country, and the whole series of investigations later made it possible for international conferences, convened by the Health Organisation of the League of Nations in 1931 and 1934, to establish international standards and units for vitamins A, B1, C, and D. Thus people throughout the world can now discuss these
vitamins in terms of units, in the same way as they can discuss time and distance in units of hours and metres. Other inquiries supported by the Council called attention to the high incidence and significance of anaemia both in pregnant and lactating women and in their infants in this country, and showed how the condition could be avoided or mitigated. Certain nutritional investigations have been directed to the study of goitre, and others have had as their object the determination and close analysis of the usual dietaries of different sections of the
community. These are only a few of the more important contributions to knowledge in nutrition for which the Council have been responsible. Throughout their existence they have realised the fundamental importance of this rapidly developing subject, and have placed it in the foreground of their programme. THE NEW TEACHINGS
It is fortunate that the essential teachings can be reduced to a few simple statements. The first is that the younger the child the more essential is correct feeding for proper growth and health. It is thus necessary to apply the new teachings of nutrition to the case of the pregnant and lactating mother; and, despite the great importance of improvement in the dietary of school-children, proper feeding of the infant and child of pre-school age is an even greater need. Breast feeding is of even higher value than has been previously believed, and ought to be more extensively adopted and continued for
longer periods. On the dietary side, the broad requirements can be simply stated to the public-without mention of calories, vitamins, or other technicalities necessary to the investigator-by saying that much more milk (" safe" milk), cheese, butter, eggs (especially eggyolk), and vegetables (especially green vegetables) ought to be consumed. In particular, milk ought to be the chief drink for children, and especially in the first years, while bread and other cereals should in these early years be greatly reduced.
on
CURRENT WORK
Prof. E. P. Cathcart and Mrs. A. M. T. Murray have completed the analysis of data on family diets collected from various towns in Great Britain over a period of years, particular attention being given to the iron, calcium, and phosphorus contents of the diets. A quantitative survey of the diets of crofters and others in remote Highland areas is contemplated for purposes of comparison. A quantitative study of the ordinary diets of 120 men and women has been completed by Miss E. M. Widdowson, working under Dr. R. A. McCance, who R. B. Shackleton has also continued with Dr. his observations on the chemical composition of fruits and vegetables and their losses in cooking. It appears that most of the iron of vegetables and bread, and little of the iron of meat are utilised in human nutrition, and that about half the phosphorus of cereals, nuts, and pulses is in a form which cannot be absorbed.
L.
Prof. S. J. Cowell has done further experiments on the factors controlling the excretion of calcium in the intestine. It appears that the rate of excretion depends on the degree of saturation of the tissues generally with calcium, but that it is not much affected by sudden variations in the calcium content of the blood. Miss E. M. Hume, assisted by Mrs. I. Smedley MacLean, D.Sc., have made further observations on the effects of fat deficiency which were noted by Burr and Burr in rats. Experiments are
622
MEDICAL RESEARCH COUNCIL REPORT
in progress to determine what substances in lard and linseed oil are responsible for curing the lesions produced and for restoring the rate of growth to normal. An inquiry is also being made into the influence of the fats in the diet on reproduction. Under the general direction of Prof. W. W. C. Topley and Prof. Cathcart, Dr. Marion Watson has obtained preliminary results which indicate that diet and various environmental factors have specific effects on the fertility, growth, and survival-rates of young mice. Attempts are now being made to determine whether it is possible by dietetic means to increase the resistance to Bact. aertrycke. Dr. Helen Mackay is examining the value of a soya bean preparation as a supplement to milk in the diet of infants. The iron content of the bean is comparatively high, and it is thought that it may possibly replace inorganic iron salts for the prevention and treatment of nutritional ansemia. An inquiry at the North Eastern Tottenham, showed that the addition of extra Hospital, rations of vitamins A and D to the diets of children with measles was without effect on the course of this disease or on the incidence of the minor skin infections.
The method devised by Mr. C. 0. Harvey to measure minute quantities of iodine in biological substances has been used by Miss M. G. Crabtree to study the iodine content of samples of milk, pasture, and drinking water from different parts of England with the idea of obtaining definite proof whether the incidence of goitre in certain districts is actually related to the iodine-content of the local milk and water supplies. The findings so far indicate that the iodine-content of milk from the non-goitrous districts of Suffolk is higher than of that from the goitrous districts of Somerset.
Examples of Combined Clinical and Laboratory Research
Ergot in childbirth: isolation of ergometrine.The end of the fascinating story, extending over 30 years, of the struggle to reconcile clinical and pharmacological experience in respect to the activity of various preparations and derivatives of ergot is here recalled. Again and again, during this period, new constituents have been isolated from ergot which, although of great physiological interest, failed to replace in the confidence of the practising doctor the watery extracts of the whole drug. He continued to rely, for the purpose of stimulating contractions of the uterus, on these extracts given by the mouth, though he was assured that they contained none of the alkaloids found to be pharmacologically active when injected. This discrepancy between clinical practice and pharmacological evidence lasted till 1932 when Dr. Chassar Moir was able to demonstrate by objective records the powerful contractions of the human uterus induced by the popular watery extract of ergot. Close cooperation between the late Mr. W. H. Dudley, D.Sc., working on the chemical side, and Dr. Moir enabled them jointly to announce in March, 1935, the discovery of ergometrine as the substance in ergot responsible for thee most familiar of the actions of ergot.
As part of an inquiry into the vitamin Bl content of human diets Mr. P. C. Leong has measured the amounts of this vitamin present in genuine wholemeal wheat and in ordinary brown bread and has found the difference between them to be surprisingly small. By arrangement with physicians at several hospitals trials are being made of the therapeutic effects of vitamin-B concentrates in " pink disease " in children ; encouraging results have been obtained in a few cases, although caution is required in their interpretation. Application of the work of Mr. L. J. Harris, Sc.D., and Mr. S. N. Ray, Ph.D., on the diagnosis of vitamin-C deficiency to children under the care of Prof. L. G. Parsons and of Dr. E. Pritchard suggests that a suboptimal intake of vitamin C is common in artificially fed infants but not in breast-fed ones, human milk being three or four times richer in this vitamin than cow’s milk. Observations on adults by Dr. M. A. Abbasy and Dr. Harris indicate that one or two oranges a day suffice rapidly to bring reserves of vitamin C up to normal in persons whose diet has been deficient in this respect, but there is evidence that mothers often disobey instructions to give orange juice regularly to their infants.
The Council point out that these researches, while illustrating how results of equal or even greater importance may be attained by the laboratory as by-products of the chase, also illustrate how vital to the solution of a problem, originating in and concern. ing clinical practice, may be the guidance provided by continued investigation upon the clinical material itself. The curative agent of pernicious (MKpmm.—Another example of the need for continuous clinical guidance is in the testing of the therapeutic activity of preparations derived from liver. It is as yet impossible to foretell whether any particular preparation will be active until it has been tested on patients suffering from pernicious anaemia. No effective laboratory test of activity has yet been established, in spite of world-wide endeavours, while the chemical complexity of the liver principle has prevented the discovery of any chemical or physical property which can be regarded as a measure of its therapeutic influence. The Council were able to organise last year clinical trials by Prof. Stanley Davidson, Prof. E. J. Wayne, and Dr. C. C. Ungley of a preparation of liver extract made by a British firm according to the method of Dakin and West, published in America ; the result of these trials (published in THE LANCET, Feb. 15th, 1936, p. 349) demonstrated the extremely high degree of potency of this preparation. Injections of from 0.1 to 0-2 gramme of it once weekly, brought about a large increase in the red blood corpuscles of the patients tested and in the course of a few weeks restored them to health. Prevention of child-bed fever.-Here also the combination of clinical and laboratory research has been effective.
The only mention of work on vitamin D in this section of the report is on that of Miss Fischmann, who is studying its influence on ossification in tissue cultures. Elsewhere (p. 137) reference is made to the observations of Prof. J. B. Duguid, assisted by Dr. M. R. P. Williams, on the experimental production of a form of nephritis by giving large quantities of orthophosphates by mouth, in the presence of hypervitaminosis D ; and (p. 110) to the study by Dr. Dorothy Russell of the vascular, renal, and pituitary changes found in this condition.
The fact that the morbid agent known to be responsible for puerperal sepsis is a streptococcus characterised by ability to hsemolyse red blood corpuscles has of recent years been supplemented by the knowledge that the cocci having this property comprise several groups and sub-groups, of which only certain members are harmful to human beings. It emerges moreover that the hsemolytic streptococci occasionally found in the genital tract of healthy parturient women are not, as was formerly supposed, identical with those causing puerperal fever, which latter come from some outside source. Dr. Dova Colebrooke has recently tracked down the probable sources of infection. She has confirmed the view that the strep-
VITAMIN STUDIES
The seven pages devoted to vitamin studies in this year’s report record much work on various components of the vitamin-B complex, and on vitamin C (ascorbic acid) with short sections on the chemistry of vitamin E and notes on the storage and on the standardisation of vitamin A.
623
MEDICINE AND THE LAW
respiratory tract bear an intimate relation puerperal fever ; and her results suggest that the respiratory tract of the mother must be taken into account tococci of the
to
well as that of her attendants, and that familial of infection may also be looked for. as
sources
from her work is the lesson that it is for any person suffering from an acute infection of this tract to engage in maternity work, and that maternity and surgical cases should not be treated under the same roof unless the nursing staffs can be kept separate. Standards for sex hormones.-Under this heading the Council urge medical men using sex hormones in their work to insist on knowing the exact nature and strength of the preparations supplied. The market is flooded with different preparations, and each manufacturing firm has given a proprietary name to its own particular product. While some of these proprietary preparations are good, both their composition and activity being controlled, others are of a semi-bogus nature. The situation lent itself both to quackery and to ignorant treatment of disease until last year a conference, convened by the Permanent Standards Committee of the Health Section of the League of Nations, met in London under the chairmanship of Sir Henry Dale, and made important decisions in respect of nomenclature and standardisation.
Arising dangerous
A uniform scientific nomenclature and standard units have been adopted for three important natural substances of which therapeutic preparations are now available. These are : (1) "oeatrone,"" " cestriol,and " cestradiol," the oestrus-producing hormones (the alternative names and dihydroxy applying to hydroxy-ketonic, trihydroxy " progesterone," the preparations, respectively) ; (2) hormone of the corpus luteum which produces in the female the changes associated with pregnancy and pseudo" androsterone," a chemical subpregnancy ; and (3) stance closely related to that responsible for the development of the secondary sex characteristics in the male.
The effectiveness of the proposals must ultimately depend on the attitude of. those who use the substances. The Council point out that clinical knowledge of the actions of these sex hormones is still very elementary, and it is certain that they are physiologically potent, often in unexpected directions. Miscellaneous
Inquiries.-Travelling Fellowships Other studies reviewed editorially by the Council are the researches into the value, effects, and possible dangers of different methods of producing anaesthesia ; the artificial cultivation of living tissues ; iodine and thyroid disease ; industrial pulmonary disease; bed-bug infestation and the toxicity of industrial solvents.
We shall have occasion from time to time to comment on some of these and on work in progress at the National Institute for Medical Research, at the clinical research units, and under the external research schemes subsidised by the Council. Regret is expressed that in consequence of a change in policy of the Rockefeller Foundation, the system of international fellowships is being abandoned in favour of concentration upon a more restricted programme for the promotion of research. The Council had been privileged to award five or six whole-time fellowships every year, of the value of between f350 and f450 each ; analyses showed that of the 70 men and women who had completed their tenure of these fellowships 12 are professors, 36 others are engaged full-time, and a further 16 half-time in higher teaching and research. The organisation of a new scheme of the same kind is thus
considered highly desirable. A start has been made in the establishment of one such fellowship by the trustees of the late Lord Leverhulme, and the Council suggest that other potential benefactors have here a great opportunity of performing an important national service.
Mr. Ramsay MacDonald, who as Lord President introduces this year the report of the Committee for Medical Research of the Privy Council, announces that the grant-in-aid provided by Parliament for the expenditure of the Medical Research Council last year amounted to 165,000, compared with 139,000 in each of the three previous years. The increase has made it possible to proceed with plans for new research work which had been temporarily in abeyance and to undertake additional investigations required for the purposes of administrativedepartments. Prof. J. A. Ryle and Prof. Matthew Stewart have replaced respectively Lord Dawson of Penn and Prof. A. E. Boycott as members of the Council, and the impending retirement of the chairman, Lord Linlithgow on his appointment as Viceroy of India is announced with warm appreciation of his services.
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MEDICINE
AND
A Fatal Dose of
THE LAW
Paraldehyde
IN Strangways-Lesmere ’. Clayton and others Mr. Justice Horridge has refused to hold a district hospital at Weymouth liable for the negligence of its nurses. The negligence consisted of administering 6 ounces of paraldehyde to the plaintiff’s wife before an operation in mistake for 6 drachms. The honorary surgeon to the hospital gave instructions to the house surgeon for the patient to have per rectum 6 drachms in 9 ounces of water. The night nurse made a the on the bed-board note of instructions pencilled and handed it to Nurse A when the latter came on duty. The judge accepted the evidence of the day sister and the night sister that this pencilled note, thrown away after the operation, specified 6 drachms and not 6 ounces. It was the duty of Nurse A to administer the drug and of Nurse B to check the quantity. The bottle of paraldehyde was taken from a locked cupboard ; the label stated that the dose was to 2 fluid drachms. Nurse A poured out 6 ounces (half the bottle) and mixed it with 9 ounces of water ; Nurse B watched her do so. The patient died of heart failure due to an overdose of paraldehyde. Mr. Strangways-Lesmere sued the general committee and trustees of the Weymouth District Hospital and also Nurses A and B. He contended that a hospital was, like any other employer, liable for the negligence of its servants. The test was the power of the governors of the hospital to control the nurses’ work. A hospital authority was, he contended, protected in respect of the negligence of its nurses only where the negligence occurred in the course of work demanding professional nursing skill over the performance of which the governing body could have no control whatever. Here, said the plaintiff, the hospital authority had clearly assumed control over the measuring and checking of dangerous drugs by nurses because a hospital regulation had been made which required the sister on duty to check the dose. This regulation appeared not to have been properly published to the staff ; it was not known to Nurse A or Nurse B ; no precautions had been taken to see that the rule was carried out. On the other hand the hospital authorities argued that their
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