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OPERATIVE TREATMENT OF PILES.
598
spoke a courageous word about that prejudice against post-mortems which only too often stands in the way of the complete investigation of disease. While emphasising the absolute necessity, in the changed conditions of hospital service, of careful coordination between the local authorities and the voluntary institutions, Lord Dawson uttered a useful word of warning. Coordination is, no doubt, a blessed word, but it must be practised by the right people in the right way, and the authority responsible for the smooth and effective running of the new system must comprise " people with the necessary skilled knowledge " that " flexibility and promptness in administration " may be assured. Regional hospital service, if the most and best is to be made of it, will involve the pooling of scientific
and the results of specialised of the provincial The number of hospitals yet medical schools must always be comparatively restricted, but every hospital of any importance will be compelled in the near future to be, within limits, a centre of investigation in all that is comprised in the word pathology. Not otherwise can they hope to deal knowledgeably with the vast increase of difficult and specialised work which the changed conditions of the time are forcing upon them.
knowledge
an extent to which many are as unaccustomed.
research to
fatality-rate. Jurgens emphasised the importance of early administration of antitoxin and of not delaying this treatment until a bacteriological report had been received. As regards the value of immunisation he drew attention to the fact that antitoxin had never been found in the blood of diphtheria convalescents or in cases of diphtheria after death. There was therefore, in his opinion, no certain proof of the value of immunisation against diphtheria. On the strength of his observations during a recent visit to America von Drigalski declared that American statistics concerning immunisation were not so untrustworthy as Friedberger had maintained. Moreover, a comparison. of the diphtheria morbidity in Berlin among the immunised and non-immunised had convinced him that a large number of children had been completely protected and that at least 40 children’s lives had
been saved. ____
OPERATIVE TREATMENT OF PILES. A
clamp-and-cautery operation described by D. Warshawresembles the classical operation except that the coagulation is carried out by diathermy, a monopolar current being recommended. Evidently Warshaw does not hesitate to include external piles in the clamp as well as internal, and this is a departure from the usual practice, for with DIPHTHERIA IN BERLIN. the ordinary clamp-and-cautery method there is THE extraordinarily severe epidemic of diphtheria usually much pain and external oedema if skin i& which has recently occurred in Berlin and the high included and cauterised. He does not seem to be case mortality in spite of large doses of antitoxin concerned about this, however, and in a series of given at an early stage of the disease led to an animated 200 cases he has had good results. The routine debate last month1 at the Berlin Medical Society on of preparation is very simple ; a cathartic is given on the efficacy of diphtheria antitoxin and active im- the night before operation and a sodium bicarbonate munisation, in which Profs. Friedberger, Königsberger, enema two hours before. operation if there is chronic Friedemann, Jurgens, and von Drigalski, among constipation. The patient is kept in bed for only two others, took part. Friedberger maintained that the days and is usually able to return to work on the remarkably favourable results that followed the fourth day. This seems rapid work, for the average introduction of antitoxin in the ’nineties of last period of hospitalisation in this country after century were really due to a natural decline in the haemorrhoidectomy is 12 days. Warshaw advocates severity of the disease. As the result of a study of operation under sacral anaesthesia, but the general a large series of European and American statistics experience of this is that it is unreliable, with probablyhe had come to the conclusion that the diphtheria 20 per cent. of failures. The objections that might’ curve had been in no way affected by the introduction be advanced against his method are that it takes a of antitoxin. He therefore suggested that a greater long time (15 to 30 minutes) and that there is a risk use than hitherto should be made of non-specific of the diathermy burn extending into the tissues deep therapy, as in the case of gonorrhoea, syphilis, and a to the clamp. On the other hand the rapid connumber of other diseases whose causal organisms valescence should be a great gain to the patient. were well known. As regards active immunisation W. L. Secorcommends the modified excisionalso convinced was and-suture diphtheria, against Friedberger operation. His disapproval of the injection that its introduction had not caused any change in the method is somewhat surprising, for it is now being occurrence of epidemics, and that all the statistics as used in most rectal clinics, and the injection of to its success, which mainly emanated from American phenol in oil is widely practised and found effective. sources, were based on the erroneous conclusion that Every rectal surgeon will agree with him, however, the decline in the incidence of diphtheria was due to that radical operation should be advised when, as a immunisation, whereas the immunisation was being result of thrombosis, internal piles have become carried out when the disease was already showing a transformed into fibrous piles or polypi. The method tendency to abate. Konigsberger, while admitting the he advocates is a modification of the excision and suture excellent results obtained by Bie at Copenhagen from operation commonly known as Earle’s. He recomthe use of very large doses of antitoxin-e.g., 100,000- mends a special fenestrated clamp which makes it 120,000 units intravenously and 500,000-800,000 possible to crush the haemorrhoid proximally to the intramuscularly-was not convinced that such high suture line, and in this respect it should be an improvedoses were entirely responsible for the good results. ment on the simple forceps of the Spencer Wells typeFriedemann, who had also had an opportunity of which is generally used. It is doubtful if Secor’& observing the Danish cases, urged that only carbolic- idea of this clamp sealing the veins and making free antitoxin should be used as in Denmark for ascending infection impossible is accurate, but in any intravenous injection. He had invariably found that case the danger of transfixion of a vein with ascending the malignant cases showed a serous meningitis and infection and portal pyaemia, on which he lays much that after lumbar puncture there was always a decline stress, is extremely remote. The method of excision in the cerebral symptoms, though he would not go and suture has never been popular in this country, so far as to say that lumbar puncture lowered the the feeling being that a simple method, such as the 1 Medizinische Welt, Feb. 14th, p. 241.
MODIFIED
1 Amer. Jour. Surg.,
1931, xi., 45.
2
Ibid., 1930,
x., 344.
599
ligature operation, is preferable elaborate suturing.
to any which involves
The methods of both Warshaw and
Secor, if
population figures by
sex
and civil state, and
approxi-
mate ages, births and infant mortality-rates, deathrates and their causal and seasonal variations. By such means, too, the native peoples would become
properly carried out, are efficient in practice and might well be tried by surgeons who, although well satisfied familiar with their usual operation, have no objection to testing frequent alternative method. It is very clear that this branch of surgery demands much care and attention to detail in the preparation and after-treatment, as well as at operation itself.
an
CENTENARY OF THE BRITISH MEDICAL ASSOCIATION. ARRANGEMENTS are now being made to celebrate the hundredth anniversary of the British Medical Association at its annual meeting in London next year. Lord Dawson has accepted the presidency and a large attendance of members and guests from overseas is expected. Outstanding events of the meeting will be a pilgrimage to Worcester, where the Association was founded, and the unveiling of a memorial The president to Sir Charles Hastings on July 24th. will give his address in the Queen’s Hall on the 26th, and this will be followed by a reception in the Albert Hall, where there will be accommodation for 5000 or 6000. The centenary dinner will be in the same place, and arrangements are being made for 2000 diners. The scientific sections are meeting in the South Kensington buildings of the University of London from July 27th to 29th, and it is hoped that the contributors will be widely representative of medicine at home and abroad. The honorary organising secretaries of the centenary meeting are Dr. E. A. Worley and Dr. H. Gardiner-Hill. This year the annual meeting of the Association is to be at Eastbourne under the presidency of Dr. W. G. Willoughby, the medical officer of health. The sections meet from July 22nd to 24th. VITAL STATISTICS IN THE TROPICS. is no exaggeration to say that the vital statistics available from many of our tropical iT
The difficulties are valueless as such. of administration in large native territories, the absence of encouragement on the part of central authorities, the lack of interest on the part of medical officers, are all probably contributing factors. Yet in civilised countries vital statistical records are recognised as essential adjuncts of public health work as evidence both of the success of such work and the directions in which further preventive measures are required. Their value in the tropics can, at the least, be no less. That such records of considerable accuracy and value could, and should, by degrees be obtained was very ably argued by Major Granville Edge in a paper on the Scope and Uses of Vital Records in the Tropics, read on March 5th before a joint meeting of the Sections of Epidemiology and Tropical Medicine of the Royal Society of Medicine. It is a case in which the best may be the enemy of the good. It is obviously impossible to transplant immediately to the tropics the highly intricate systems of recording vital statistics that have slowly developed in cooler and more civilised countries. But this must not be used as an argument against the adoption of less intricate means. Major Edge puts forward the suggestion that, as a beginning, small scale inquiries should be persistently and regularly made, strictly limited in their scope and confined, perhaps, at first to particular tribes, villages, or even to selected families. Within these limitations he believes it would be possible to obtain accurate
dependencies
with the details such inquiries entail, the visits of officials come to be regarded as matters of mere routine, and any suspicions aroused during the early stages would gradually disappear. It would be only a matter of time before the area and scope could be extended. The investigation must be made by a worker completely versed in the habits and belief of the natives or, as one of the contributors to the discussion graphically said, " one false move on the part of the medical officer and his demographic unit will disappear into the bush." But to say that any such inquiry is impossible is merely to invite Major Edge’s retort that it has been done-by the Dutch. In such publications as the Proceedings (Tropical Section) of the Koninklijke Vereeniging Koloniaal Instituut Amsterdam, the Geneeskundig Tijdschr,ift voor Nederlandseh--hzdie, and the Xededeelingen of the Pathological Laboratory of Medan (Sumatra) there is to be found a wide range of epidemiological studies discussing a variety of health problems peculiar to the tropics, and presenting in great detail data relating to the mortality and morbidity of both European and native people. It is difficult to believe that the difficulties in tropical countries are any greater than were the difficulties with which workers in Europe had to contend 200 years ago. Yet, as Prof. Major Greenwood suggested in the discussion, John Graunt, a London linen-draper, living 280 years ago, discovered by admittedly crude methods a very great deal about the causes of death, perhaps more than any medical officer of health in
the
tropics has yet done.
Gross
errors were
made
then and gross errors will be made in the tropics, but unless some such small sampling inquiries are attempted, and interest is taken in them by superior officers, no progress will ever be achieved. It was Prof. W. W. Jameson’s view that more interest will be taken in such work in the future; that up till now there has been no tradition in the colonies, such as exists in this country, for the medical officer of health to concern himself in matters of vital registration ; that this, in process of time, will change. At present, as Major Edge pointed out, in the absence of reliable statistics, the effects of civilising influences upon native health must remain largely conjectural. EXEMPTED HEROIN PREPARATIONS. WHEN the Geneva Convention was ratified in 1928 the section of the Dangerous Drugs Act, 1923, which gave power to add all preparations of diamorphine to Part III of the Act of 1920, came into operation. The Pharmaceutical Society of Great Britain however approached the Home Office with a request that certain preparations should be exempt from the Act. We have received from the Home Office a copy of an Order-The Dangerous Drugs (Consolidated) Amendment Regulations, 1931-from which it is seen that this request has now been granted. The delay was due to the fact that it was necessary for the application to be approved in succession by a Committee in Paris, passed on to the Opium Advisory Committee, and the Council of the League of Nations. This process having been completed, and confirmation obtained from the League, the Home Office was duly authorised to promulgate the Order. In anticipation of the publication of the new regulations, and by arrangement with the Home Office, the formulse of the five exempted preparations have been published
spoke a courageous word about that prejudice against post-mortems which only too often stands in the way of the complete investigation of disease. While emphasising the absolute necessity, in the changed conditions of hospital service, of careful coordination between the local authorities and the voluntary institutions, Lord Dawson uttered a useful word of warning. Coordination is, no doubt, a blessed word, but it must be practised by the right people in the right way, and the authority responsible for the smooth and effective running of the new system must comprise " people with the necessary skilled knowledge " that " flexibility and promptness in administration " may be assured. Regional hospital service, if the most and best is to be made of it, will involve the pooling of scientific
and the results of specialised of the provincial The number of hospitals yet medical schools must always be comparatively restricted, but every hospital of any importance will be compelled in the near future to be, within limits, a centre of investigation in all that is comprised in the word pathology. Not otherwise can they hope to deal knowledgeably with the vast increase of difficult and specialised work which the changed conditions of the time are forcing upon them.
knowledge
an extent to which many are as unaccustomed.
research to
fatality-rate. Jurgens emphasised the importance of early administration of antitoxin and of not delaying this treatment until a bacteriological report had been received. As regards the value of immunisation he drew attention to the fact that antitoxin had never been found in the blood of diphtheria convalescents or in cases of diphtheria after death. There was therefore, in his opinion, no certain proof of the value of immunisation against diphtheria. On the strength of his observations during a recent visit to America von Drigalski declared that American statistics concerning immunisation were not so untrustworthy as Friedberger had maintained. Moreover, a comparison. of the diphtheria morbidity in Berlin among the immunised and non-immunised had convinced him that a large number of children had been completely protected and that at least 40 children’s lives had
been saved. ____
OPERATIVE TREATMENT OF PILES. A
clamp-and-cautery operation described by D. Warshawresembles the classical operation except that the coagulation is carried out by diathermy, a monopolar current being recommended. Evidently Warshaw does not hesitate to include external piles in the clamp as well as internal, and this is a departure from the usual practice, for with DIPHTHERIA IN BERLIN. the ordinary clamp-and-cautery method there is THE extraordinarily severe epidemic of diphtheria usually much pain and external oedema if skin i& which has recently occurred in Berlin and the high included and cauterised. He does not seem to be case mortality in spite of large doses of antitoxin concerned about this, however, and in a series of given at an early stage of the disease led to an animated 200 cases he has had good results. The routine debate last month1 at the Berlin Medical Society on of preparation is very simple ; a cathartic is given on the efficacy of diphtheria antitoxin and active im- the night before operation and a sodium bicarbonate munisation, in which Profs. Friedberger, Königsberger, enema two hours before. operation if there is chronic Friedemann, Jurgens, and von Drigalski, among constipation. The patient is kept in bed for only two others, took part. Friedberger maintained that the days and is usually able to return to work on the remarkably favourable results that followed the fourth day. This seems rapid work, for the average introduction of antitoxin in the ’nineties of last period of hospitalisation in this country after century were really due to a natural decline in the haemorrhoidectomy is 12 days. Warshaw advocates severity of the disease. As the result of a study of operation under sacral anaesthesia, but the general a large series of European and American statistics experience of this is that it is unreliable, with probablyhe had come to the conclusion that the diphtheria 20 per cent. of failures. The objections that might’ curve had been in no way affected by the introduction be advanced against his method are that it takes a of antitoxin. He therefore suggested that a greater long time (15 to 30 minutes) and that there is a risk use than hitherto should be made of non-specific of the diathermy burn extending into the tissues deep therapy, as in the case of gonorrhoea, syphilis, and a to the clamp. On the other hand the rapid connumber of other diseases whose causal organisms valescence should be a great gain to the patient. were well known. As regards active immunisation W. L. Secorcommends the modified excisionalso convinced was and-suture diphtheria, against Friedberger operation. His disapproval of the injection that its introduction had not caused any change in the method is somewhat surprising, for it is now being occurrence of epidemics, and that all the statistics as used in most rectal clinics, and the injection of to its success, which mainly emanated from American phenol in oil is widely practised and found effective. sources, were based on the erroneous conclusion that Every rectal surgeon will agree with him, however, the decline in the incidence of diphtheria was due to that radical operation should be advised when, as a immunisation, whereas the immunisation was being result of thrombosis, internal piles have become carried out when the disease was already showing a transformed into fibrous piles or polypi. The method tendency to abate. Konigsberger, while admitting the he advocates is a modification of the excision and suture excellent results obtained by Bie at Copenhagen from operation commonly known as Earle’s. He recomthe use of very large doses of antitoxin-e.g., 100,000- mends a special fenestrated clamp which makes it 120,000 units intravenously and 500,000-800,000 possible to crush the haemorrhoid proximally to the intramuscularly-was not convinced that such high suture line, and in this respect it should be an improvedoses were entirely responsible for the good results. ment on the simple forceps of the Spencer Wells typeFriedemann, who had also had an opportunity of which is generally used. It is doubtful if Secor’& observing the Danish cases, urged that only carbolic- idea of this clamp sealing the veins and making free antitoxin should be used as in Denmark for ascending infection impossible is accurate, but in any intravenous injection. He had invariably found that case the danger of transfixion of a vein with ascending the malignant cases showed a serous meningitis and infection and portal pyaemia, on which he lays much that after lumbar puncture there was always a decline stress, is extremely remote. The method of excision in the cerebral symptoms, though he would not go and suture has never been popular in this country, so far as to say that lumbar puncture lowered the the feeling being that a simple method, such as the 1 Medizinische Welt, Feb. 14th, p. 241.
MODIFIED
1 Amer. Jour. Surg.,
1931, xi., 45.
2
Ibid., 1930,
x., 344.
599
ligature operation, is preferable elaborate suturing.
to any which involves
The methods of both Warshaw and
Secor, if
population figures by
sex
and civil state, and
approxi-
mate ages, births and infant mortality-rates, deathrates and their causal and seasonal variations. By such means, too, the native peoples would become
properly carried out, are efficient in practice and might well be tried by surgeons who, although well satisfied familiar with their usual operation, have no objection to testing frequent alternative method. It is very clear that this branch of surgery demands much care and attention to detail in the preparation and after-treatment, as well as at operation itself.
an
CENTENARY OF THE BRITISH MEDICAL ASSOCIATION. ARRANGEMENTS are now being made to celebrate the hundredth anniversary of the British Medical Association at its annual meeting in London next year. Lord Dawson has accepted the presidency and a large attendance of members and guests from overseas is expected. Outstanding events of the meeting will be a pilgrimage to Worcester, where the Association was founded, and the unveiling of a memorial The president to Sir Charles Hastings on July 24th. will give his address in the Queen’s Hall on the 26th, and this will be followed by a reception in the Albert Hall, where there will be accommodation for 5000 or 6000. The centenary dinner will be in the same place, and arrangements are being made for 2000 diners. The scientific sections are meeting in the South Kensington buildings of the University of London from July 27th to 29th, and it is hoped that the contributors will be widely representative of medicine at home and abroad. The honorary organising secretaries of the centenary meeting are Dr. E. A. Worley and Dr. H. Gardiner-Hill. This year the annual meeting of the Association is to be at Eastbourne under the presidency of Dr. W. G. Willoughby, the medical officer of health. The sections meet from July 22nd to 24th. VITAL STATISTICS IN THE TROPICS. is no exaggeration to say that the vital statistics available from many of our tropical iT
The difficulties are valueless as such. of administration in large native territories, the absence of encouragement on the part of central authorities, the lack of interest on the part of medical officers, are all probably contributing factors. Yet in civilised countries vital statistical records are recognised as essential adjuncts of public health work as evidence both of the success of such work and the directions in which further preventive measures are required. Their value in the tropics can, at the least, be no less. That such records of considerable accuracy and value could, and should, by degrees be obtained was very ably argued by Major Granville Edge in a paper on the Scope and Uses of Vital Records in the Tropics, read on March 5th before a joint meeting of the Sections of Epidemiology and Tropical Medicine of the Royal Society of Medicine. It is a case in which the best may be the enemy of the good. It is obviously impossible to transplant immediately to the tropics the highly intricate systems of recording vital statistics that have slowly developed in cooler and more civilised countries. But this must not be used as an argument against the adoption of less intricate means. Major Edge puts forward the suggestion that, as a beginning, small scale inquiries should be persistently and regularly made, strictly limited in their scope and confined, perhaps, at first to particular tribes, villages, or even to selected families. Within these limitations he believes it would be possible to obtain accurate
dependencies
with the details such inquiries entail, the visits of officials come to be regarded as matters of mere routine, and any suspicions aroused during the early stages would gradually disappear. It would be only a matter of time before the area and scope could be extended. The investigation must be made by a worker completely versed in the habits and belief of the natives or, as one of the contributors to the discussion graphically said, " one false move on the part of the medical officer and his demographic unit will disappear into the bush." But to say that any such inquiry is impossible is merely to invite Major Edge’s retort that it has been done-by the Dutch. In such publications as the Proceedings (Tropical Section) of the Koninklijke Vereeniging Koloniaal Instituut Amsterdam, the Geneeskundig Tijdschr,ift voor Nederlandseh--hzdie, and the Xededeelingen of the Pathological Laboratory of Medan (Sumatra) there is to be found a wide range of epidemiological studies discussing a variety of health problems peculiar to the tropics, and presenting in great detail data relating to the mortality and morbidity of both European and native people. It is difficult to believe that the difficulties in tropical countries are any greater than were the difficulties with which workers in Europe had to contend 200 years ago. Yet, as Prof. Major Greenwood suggested in the discussion, John Graunt, a London linen-draper, living 280 years ago, discovered by admittedly crude methods a very great deal about the causes of death, perhaps more than any medical officer of health in
the
tropics has yet done.
Gross
errors were
made
then and gross errors will be made in the tropics, but unless some such small sampling inquiries are attempted, and interest is taken in them by superior officers, no progress will ever be achieved. It was Prof. W. W. Jameson’s view that more interest will be taken in such work in the future; that up till now there has been no tradition in the colonies, such as exists in this country, for the medical officer of health to concern himself in matters of vital registration ; that this, in process of time, will change. At present, as Major Edge pointed out, in the absence of reliable statistics, the effects of civilising influences upon native health must remain largely conjectural. EXEMPTED HEROIN PREPARATIONS. WHEN the Geneva Convention was ratified in 1928 the section of the Dangerous Drugs Act, 1923, which gave power to add all preparations of diamorphine to Part III of the Act of 1920, came into operation. The Pharmaceutical Society of Great Britain however approached the Home Office with a request that certain preparations should be exempt from the Act. We have received from the Home Office a copy of an Order-The Dangerous Drugs (Consolidated) Amendment Regulations, 1931-from which it is seen that this request has now been granted. The delay was due to the fact that it was necessary for the application to be approved in succession by a Committee in Paris, passed on to the Opium Advisory Committee, and the Council of the League of Nations. This process having been completed, and confirmation obtained from the League, the Home Office was duly authorised to promulgate the Order. In anticipation of the publication of the new regulations, and by arrangement with the Home Office, the formulse of the five exempted preparations have been published