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PELLAGRA IN EGYPT.
1037 for 1906-07 appeared a year ago. Of these, the German is particularly interesting with its well-prepared clinical and etiological accounts of the diseases observed. The Japanese report, very well printed, and in English, has less clinical interest, but its two striking diagrams are very useful, exhibiting graphically and immediately the causes of the chief losses to the service by invalidings (phthisis, 167 18) ; and by deaths men ; pleurisy, 103 ; injuries, (typhoid fever, 34 ; suicide, 30; burns, 27 ; phthisis, 27 ; pleurisy, 9). Their total force was 40,429 men, of whom, per 1000, 4-77 died, and the daily sick-rate was 58. The z, number "sick"" appears large, but includes men doing their I work while attending for treatment as well as men on light duty. The recruiting tables show the average height, weight, chest expansion, hand grasp (left and right), &c., of the recruits from the various Japanese prefectures. These should in time be of great anthropological interest. The weight of the men in the fleet (average 129 pounds) is obtained from the weighing of 38,029 men in March, when their weight is a maximum, and also in September, when it This lessened weight after summer is is a minimum.
Correspondence. "
noted in the German report, and ascribed to the strenuous life duiing the manoeuvres. The Japanese report nowhere indicates the age incidence of the disease which occurred. This is fully stated in the very elaborate Italian report ; But indeed, in too great detail to be of much use. these lavishly provided tables are interesting, showing the incidence of disease on the various groups of officers and men, executive officers, doctors, stokers, ship’s stewards, and It is so on, both according to age and month by month. surprising to find (pp. 160-161) that there were 201 officers in 1905 between the ages of 20 and 25, but in 1906 only 56, making one wonder what became of the others since the preceding year. The preliminary remarks are mainly confined to the statistics repeated later in the tables ; it would be more instructive to have essays on the cause and treatment of the diseases as in the German report. There were in the Italian navy in 1906 27,358 men, of whom per 1000 3 47 died, and the daily sick-rate was 49. The parallel figures were for Germany in 1906-07, 45,776 ; 2 4 ; 27. for the British navy in 1907, 108,740; 3-35; 29. Venereal disease causes 30 to 40 per cent. of the daily sick list of all four navies, of which syphilis is roughly onethird. The loss from tubercle is most marked in Japan and Italy. Japan besides lost many men from pleurisy. If in the periods stated the total loss of service from tubercle be calculated by Gatewood’s method,1 which associates sick list, invalids, and deaths, and gives perhaps a better measure of the morbidity than any other, they work out at : Japan, 3’3 men daily per 1000 ; Italy, 2 - 5 ; England, 1- 8, and Germany, 12. But these figures cannot be at all exactly weighed against one another when we are without information as to the age distribution and the periods of service in each case. h would be easier to compare the health conditions of other navies if they all published an abstract of their statistics like that in the English Blue-book, Total force, No. 1, which gives the best statistical summary. 1 See review of his book On Naval
Hygiene,
THE
LANCET, Dec. 4th
1909, p. 1673.
HEALTH
OF
DEvoN
IN
1909.-The medical
partem."
PELLAGRA IN EGYPT.
I
I
Audi alteram
To
the
Editor
of THE
LANCET.
taken in the etiology of pellagra encourages me to put forward the views which I have long held on the subject, and which may be worthy of attention by the Commission which is, I believe, at work in Egypt. My remarks apply only to pellagra in Egypt, as I have had no experience of it in other countries. During the winter of 1902 I was resident medical officer of Kasr-el-Ainy Hospital, and showed several of the visitors to the Medical Congress round the wards. While so engaged the first doubt as to the reality of pellagra as a definite disease arose in my mind. Professor Bouchard of Paris was one of the visitors, and at his request I showed a case of pellagra which he said was not the same thing as he had seen in the Landes. This statement, coupled with the opinion of the late Dr. Seymour Toller, that pellagra was nothing but a rash due to wind and dirt acting on the skins of the poor and ill-nourished, made me wonder how far the generally accepted opinion was correct. Another point which served to strengthen my doubts was that the rash disappeared, without active treatment, after a day or two of hospital life, but without any corresponding amelioration of the patient’s condition. After more than a year of large opportunity and close observation, I was convinced that the patients who showed symptoms, attributed to the eating of diseased maize, were invariably suffering, and had for prolonged periods suffered, from one of the numerous debilitating diseases which prevail in Egypt. I refer chiefly to ankylostomiasis and bilharziasis, though multiple infections with these and other worms are
S]IR,-The great interest
exceedingly
now
common.
A report on three fatal cases account of the examination of the
of pellagra, spinal cords,
with was
an
pub-
by Dr. F. M. Sandwith in 1901 in the Journal of Pathologqy and Bacterioloqy, and in each of these cases lished
there was some distinct pathological lesion in addition to the skin condition. In Case 1 there were 200 ankylostoma The worms and the patient died from cerebral hoemorrhage. examination of the cord showed marked pallor of the posterior median column with a root degeneration at the This patient had great level of the first lumbar root. Case 2 was anaemia, and an enlarged malarious spleen. extremely acsemic, had markedly cirrhotic kidneys, and weighed 67 pounds. There is no record in this case that The worms were found at the post-mortem examination. examination of the cord showed well-marked degeneration of the posterior columns, but in view of the general wasting of tissue it is not to be wondered at that there was some alteration from the normal in such highly specialised tissue as the nervous system. Case 3 had been ill for four years and in this time had had ankylostomiasis, and on admission his fasces contained eggs of uncinaria duodenalif, ascaris lumbricoides, and distomum heterophyes. His weight was 109 pounds. He died from acute pericarditis, and Dr. Batten, who examined the cord, reported it as normal. It is quite clear from these cases that there is no definite pathological picture in pellagra, but I submit that all the changes reported are compatible with a condition of prolonged infection which produces profound anaemia. The excellent illustration which faces p. 314 of Scheube’s Diseases of Warm Countries depicts a characteristic pellagrous rash, but it also carries with it the typical appearance of a patient suffering from one of the common worm infections. On p. 34 of the fifteenth annual report of the Egyptian Hospital for the Insane the following sentence apppears:"Nearly every case of pellagra suffers from bilharzia disease, very many from ankylostoma also, and very many from extreme favus of
officer of health of Devon (Mr. G. Adkins) in his annual report for 1909, which has just been issued, states that-during the year 9007 births were registered, giving a birth-rate of 20 per 1000, compared with 20- 3 in 1908. 6047 deaths were registered, the death-rate being 13° 4 per 1000, against 13-66 in the preceding year. The death-rate from infectious diseases was 0- 34 per 1000. 1490 cases of notifiable diseases occurred, giving a rate of 3’ 3 per 1000, the same as in 1908. Three cases of small-pox were notified, two of which were brought to the port of Plymouth. 708 cases of scarlet fever were notified, 474 of diphtheria, and 93 of enteric fever. 412 deaths were due to pulmonary tuberculosis, compared BBith 479 in the previous year. 133 deaths occurred from other forms of tuberculosis, against 142 in 1908 scalp,"" &- c. Mr. Adkins states that 327 midwives were registered In a letter recently received from the Medical Registrar in the county during the year, against 350 in 1908, of Kasr-el-Ainy Hospital, Dr. H. B. Day, it is stated and of these 75 were certificated. The district medical that out of 80 cases of pellagra 54 had demonstrable officers of health perform the duties of the inspection of evidence of other infections in which ankylostoma premidwives. dominated; that these figures only record the leading
1038 clinical characteristics ; and that a more thorough investigation would undoubtedly show a greater prevalence of concomitant infection. In this connexion I might point out that some cases of bilharziasis do not pass eggs either in the urine or faeces. It is evident that I I concomitant infection" is common, but to my mind this so-called exceedingly I concomitant infection " is the real infection, and the rash which has called attention to the patient is nothing more than evidence of exposure to sharp winds of the skin of a person in an extremely debilitated condition. The patients reported on by Dr. Sandwith all died from some definite and wellknown disease, and neither the pathological changes recorded by him or described by Scheube, who follows Tuczek, are sufficientlydefinite to convince the sceptic that a pathological entity is being described. The quality of nutrition supplied to the tissues by the blood stream in these cases of severe and prolonged worm infection is not likely to be productive of a high standard of health or efficiency, and it is to me by no means surprising that there should be decay of the more specialised tissues as shown by altered reflexes and mental degenera. tions. It is stated in Scheube’s book that I I Winternitz goes so far as to deny the existence of pellagra as a specific disease peculiar to a limited area. What is described as pellagra is in his judgment only the conditions of disease induced by want and misery." I am only at variance with this opinion in that I look on some active disease as a necessary factor in the production of the pellagrous condition. I should like to make my position quite clear by stating that in my opinion pellagra in Egypt is only a rash arising in patients who have been the subjects of prolonged ana3mia, and that it is in most cases due to persistent worm infections, and occurs in the worst cases of these infections in association with poverty and malnutrition. In support of this opinion I produce (1) the three fatal cases reported by Dr. Sandwith, in all of which some cause such as I have described was at work; (2) the fact that the rash disappears after a few days of hospital without active treatment; (3) that a large number of so-called pellagrous patients carry the active cause of their ansemia still with them in the shape of ankylostoma worms, &c.; and (4) that the typical pathological picture of pellagra is what one would expect in cases of prolonged and profound anaemia. Pellagra in Egypt may, I think, be neglected except in so far as it indicates a severe anasmia caused in most cases by a parasitic infection. It is on these terms useful as a symptom, but has, I consider, no claim to be ranked as a disease.
Now I have looked out the first professional examination for the Conjoint Board, for the London University, and for Cambridge University, and find the subjects are confined to inorganic chemistry, physics, and biology. These are sub. jects which can just as well be studied at institutions other than medical schools as at them, and this has been recognised by the General Medical Council, as it allows study of these subjects at, amongst others, the Polytechnic Institute, West. field College, Central Technical College, City of London College (day classes), and some others, but not at the great public schools. Full of belief in the power of the General Medical Council to enforce its regulations, I wrote to the Registrar to ask him to register my son as a medical student, he having passed his London matriculation, and asking him (in my innocence) if St. Paul’s School would be recognised as an institution in which the lad could work up for his next professional exa. mination-viz., the Preliminary Scientific. His reply is :DEAR SIR,-In answer to your letter, I have to state that as the Council does not approve of medical study until ordinary school education has ceased, it will not be possible for your son to be registered while he remains at St. Paul’s School. He should begin study at one of the institutions on the enclosed list. Yours faithfully,
H. E. ALLEN, Registrar The only possible inference to be drawn from this reply is that I must either take the boy away from the school, or he cannot count the year towards the required five-an alternative altogether too serious for me to contemplate. Of course, what applies to St. Paul’s School applies to all the other great public schools up and down the country, and it has a very serious meaning to the parents of those boys at these public schools who are intended to enter the medical profession ; who, having passed a preliminary examination in arts, wish to proceed to the purely science portion of their career while remaining at the school-they must take them away. It also has its serious side for the public schools. The authorities of most of these schools have gone to endless expense in fitting up the laboratories of the schools, and in appointing as instructors the most competent science teachers to be found, yet they are to lose these boys just when they are likely to be of credit to the school and most able to avail themselves of the material provided by the school. And the boys themselves, are they not also losers in being thus early thrust as it were into the turmoil of hospital life, in losing the discipline, individual attention, and compulsory attendance consequent on a prolongation of school life for another T am Rir vnnrc faithfnilv year or part of a year ? " Cui Bono!"" Who does really gain by these regulations! V. S. HODSON, M.R.C.P. Lond. it is not the lad ! I am afraid that as a parent I Surely Khartoum. cannot appreciate the concentrated wisdom which produced for it does seem grossly unfair that a public these THE REGISTRATION OF THE MEDICAL schoolregulations, boy who wishes to learn the scientific portion of his work at school, where the staff and equipment are admirable, STUDENT AND THE REGULATIONS should be penalised to the extent of losing that year in comOF THE GENERAL MEDICAL puting the necessary five years of study-that is, if the reguCOUNCIL. lations I have quoted mean what they say. If they do, I am that the public school authorities have not publicly surprised To the Editor of THE LANCETprotested against the arbitrariness (and to my mind foolishSIR,-" What to do with our boysis as pressing a ness) of regulations which are devoid of benefit to the boy, to question now as ever it was, and parents have the same the school, to the parent, and to the profession generally. difficulties in guiding and guarding and finding openings for If these regulations regarding registration do not mean what their precious charges as their forefathers most probably did they say, and are not enforced or enforceable, the sooner the in their own cases. Like many others just at this season of public and parents of boys intended for the medical prothe year I had occasion to scan and puzzle over the regula- fession know it the better. tions laid down by the General Medical Council for the registration of those lads who are seeking to enter the RICHARD BEVAN, L.R.C.P. Lond., D.P.H. medical profession. With a view of making my arguments London. Sept. 1st. 1910. clear I have made the following extracts as embodying the 0B-** Our correspondent sets out very clearly one side of a principal regulations as to registration. As I understand question which has been much discussed in our them, they disclose a glaring anomaly upon which I should like the opinion of parents, masters of the great public L. schools, and of any others who feel an interest in the medical profession. Now for it. The course of professional study after registration shall occupy at AN INTERESTING CASE OF APPENDICITIS. March 3rd, 1910.
M.B., B.Ch. Oxon.,
,
difficult columns.—ED.
least five years....... 1’nery medical student shall be registered in the manner prescribed by the General Medical Council....... Every person desirous of being registered as a medical student shall produce or forward to the Branch Registrar a certificate of his having passed a preliminary examination as required by the General Medical Council, and evidence that he has attained the age of 16 years, and has commenced medical study. The commencement of the course of professional study recognised by any of the qualifsing bodies shall not be reckoned earlier than 15 days In addition to the Universities and before the date of registration. Schools of Medicine there are many institutions where medical study may be commenced.
To the Editor of THE LANCET.
Sm,-I
venture to send you
a history of what happens poor devil now and again in regions so far unblebsed by the presence of specialists. More or less a fortnight ago, at 5 P.nt., after an ordinary day’s work with cases of neurasthenia, syphilis, gonorrhoea, nephritis, lung, heart, skin, &c., the writer was called to see a young German, said to be suffering from colic.
to
a
Correspondence. "
noted in the German report, and ascribed to the strenuous life duiing the manoeuvres. The Japanese report nowhere indicates the age incidence of the disease which occurred. This is fully stated in the very elaborate Italian report ; But indeed, in too great detail to be of much use. these lavishly provided tables are interesting, showing the incidence of disease on the various groups of officers and men, executive officers, doctors, stokers, ship’s stewards, and It is so on, both according to age and month by month. surprising to find (pp. 160-161) that there were 201 officers in 1905 between the ages of 20 and 25, but in 1906 only 56, making one wonder what became of the others since the preceding year. The preliminary remarks are mainly confined to the statistics repeated later in the tables ; it would be more instructive to have essays on the cause and treatment of the diseases as in the German report. There were in the Italian navy in 1906 27,358 men, of whom per 1000 3 47 died, and the daily sick-rate was 49. The parallel figures were for Germany in 1906-07, 45,776 ; 2 4 ; 27. for the British navy in 1907, 108,740; 3-35; 29. Venereal disease causes 30 to 40 per cent. of the daily sick list of all four navies, of which syphilis is roughly onethird. The loss from tubercle is most marked in Japan and Italy. Japan besides lost many men from pleurisy. If in the periods stated the total loss of service from tubercle be calculated by Gatewood’s method,1 which associates sick list, invalids, and deaths, and gives perhaps a better measure of the morbidity than any other, they work out at : Japan, 3’3 men daily per 1000 ; Italy, 2 - 5 ; England, 1- 8, and Germany, 12. But these figures cannot be at all exactly weighed against one another when we are without information as to the age distribution and the periods of service in each case. h would be easier to compare the health conditions of other navies if they all published an abstract of their statistics like that in the English Blue-book, Total force, No. 1, which gives the best statistical summary. 1 See review of his book On Naval
Hygiene,
THE
LANCET, Dec. 4th
1909, p. 1673.
HEALTH
OF
DEvoN
IN
1909.-The medical
partem."
PELLAGRA IN EGYPT.
I
I
Audi alteram
To
the
Editor
of THE
LANCET.
taken in the etiology of pellagra encourages me to put forward the views which I have long held on the subject, and which may be worthy of attention by the Commission which is, I believe, at work in Egypt. My remarks apply only to pellagra in Egypt, as I have had no experience of it in other countries. During the winter of 1902 I was resident medical officer of Kasr-el-Ainy Hospital, and showed several of the visitors to the Medical Congress round the wards. While so engaged the first doubt as to the reality of pellagra as a definite disease arose in my mind. Professor Bouchard of Paris was one of the visitors, and at his request I showed a case of pellagra which he said was not the same thing as he had seen in the Landes. This statement, coupled with the opinion of the late Dr. Seymour Toller, that pellagra was nothing but a rash due to wind and dirt acting on the skins of the poor and ill-nourished, made me wonder how far the generally accepted opinion was correct. Another point which served to strengthen my doubts was that the rash disappeared, without active treatment, after a day or two of hospital life, but without any corresponding amelioration of the patient’s condition. After more than a year of large opportunity and close observation, I was convinced that the patients who showed symptoms, attributed to the eating of diseased maize, were invariably suffering, and had for prolonged periods suffered, from one of the numerous debilitating diseases which prevail in Egypt. I refer chiefly to ankylostomiasis and bilharziasis, though multiple infections with these and other worms are
S]IR,-The great interest
exceedingly
now
common.
A report on three fatal cases account of the examination of the
of pellagra, spinal cords,
with was
an
pub-
by Dr. F. M. Sandwith in 1901 in the Journal of Pathologqy and Bacterioloqy, and in each of these cases lished
there was some distinct pathological lesion in addition to the skin condition. In Case 1 there were 200 ankylostoma The worms and the patient died from cerebral hoemorrhage. examination of the cord showed marked pallor of the posterior median column with a root degeneration at the This patient had great level of the first lumbar root. Case 2 was anaemia, and an enlarged malarious spleen. extremely acsemic, had markedly cirrhotic kidneys, and weighed 67 pounds. There is no record in this case that The worms were found at the post-mortem examination. examination of the cord showed well-marked degeneration of the posterior columns, but in view of the general wasting of tissue it is not to be wondered at that there was some alteration from the normal in such highly specialised tissue as the nervous system. Case 3 had been ill for four years and in this time had had ankylostomiasis, and on admission his fasces contained eggs of uncinaria duodenalif, ascaris lumbricoides, and distomum heterophyes. His weight was 109 pounds. He died from acute pericarditis, and Dr. Batten, who examined the cord, reported it as normal. It is quite clear from these cases that there is no definite pathological picture in pellagra, but I submit that all the changes reported are compatible with a condition of prolonged infection which produces profound anaemia. The excellent illustration which faces p. 314 of Scheube’s Diseases of Warm Countries depicts a characteristic pellagrous rash, but it also carries with it the typical appearance of a patient suffering from one of the common worm infections. On p. 34 of the fifteenth annual report of the Egyptian Hospital for the Insane the following sentence apppears:"Nearly every case of pellagra suffers from bilharzia disease, very many from ankylostoma also, and very many from extreme favus of
officer of health of Devon (Mr. G. Adkins) in his annual report for 1909, which has just been issued, states that-during the year 9007 births were registered, giving a birth-rate of 20 per 1000, compared with 20- 3 in 1908. 6047 deaths were registered, the death-rate being 13° 4 per 1000, against 13-66 in the preceding year. The death-rate from infectious diseases was 0- 34 per 1000. 1490 cases of notifiable diseases occurred, giving a rate of 3’ 3 per 1000, the same as in 1908. Three cases of small-pox were notified, two of which were brought to the port of Plymouth. 708 cases of scarlet fever were notified, 474 of diphtheria, and 93 of enteric fever. 412 deaths were due to pulmonary tuberculosis, compared BBith 479 in the previous year. 133 deaths occurred from other forms of tuberculosis, against 142 in 1908 scalp,"" &- c. Mr. Adkins states that 327 midwives were registered In a letter recently received from the Medical Registrar in the county during the year, against 350 in 1908, of Kasr-el-Ainy Hospital, Dr. H. B. Day, it is stated and of these 75 were certificated. The district medical that out of 80 cases of pellagra 54 had demonstrable officers of health perform the duties of the inspection of evidence of other infections in which ankylostoma premidwives. dominated; that these figures only record the leading
1038 clinical characteristics ; and that a more thorough investigation would undoubtedly show a greater prevalence of concomitant infection. In this connexion I might point out that some cases of bilharziasis do not pass eggs either in the urine or faeces. It is evident that I I concomitant infection" is common, but to my mind this so-called exceedingly I concomitant infection " is the real infection, and the rash which has called attention to the patient is nothing more than evidence of exposure to sharp winds of the skin of a person in an extremely debilitated condition. The patients reported on by Dr. Sandwith all died from some definite and wellknown disease, and neither the pathological changes recorded by him or described by Scheube, who follows Tuczek, are sufficientlydefinite to convince the sceptic that a pathological entity is being described. The quality of nutrition supplied to the tissues by the blood stream in these cases of severe and prolonged worm infection is not likely to be productive of a high standard of health or efficiency, and it is to me by no means surprising that there should be decay of the more specialised tissues as shown by altered reflexes and mental degenera. tions. It is stated in Scheube’s book that I I Winternitz goes so far as to deny the existence of pellagra as a specific disease peculiar to a limited area. What is described as pellagra is in his judgment only the conditions of disease induced by want and misery." I am only at variance with this opinion in that I look on some active disease as a necessary factor in the production of the pellagrous condition. I should like to make my position quite clear by stating that in my opinion pellagra in Egypt is only a rash arising in patients who have been the subjects of prolonged ana3mia, and that it is in most cases due to persistent worm infections, and occurs in the worst cases of these infections in association with poverty and malnutrition. In support of this opinion I produce (1) the three fatal cases reported by Dr. Sandwith, in all of which some cause such as I have described was at work; (2) the fact that the rash disappears after a few days of hospital without active treatment; (3) that a large number of so-called pellagrous patients carry the active cause of their ansemia still with them in the shape of ankylostoma worms, &c.; and (4) that the typical pathological picture of pellagra is what one would expect in cases of prolonged and profound anaemia. Pellagra in Egypt may, I think, be neglected except in so far as it indicates a severe anasmia caused in most cases by a parasitic infection. It is on these terms useful as a symptom, but has, I consider, no claim to be ranked as a disease.
Now I have looked out the first professional examination for the Conjoint Board, for the London University, and for Cambridge University, and find the subjects are confined to inorganic chemistry, physics, and biology. These are sub. jects which can just as well be studied at institutions other than medical schools as at them, and this has been recognised by the General Medical Council, as it allows study of these subjects at, amongst others, the Polytechnic Institute, West. field College, Central Technical College, City of London College (day classes), and some others, but not at the great public schools. Full of belief in the power of the General Medical Council to enforce its regulations, I wrote to the Registrar to ask him to register my son as a medical student, he having passed his London matriculation, and asking him (in my innocence) if St. Paul’s School would be recognised as an institution in which the lad could work up for his next professional exa. mination-viz., the Preliminary Scientific. His reply is :DEAR SIR,-In answer to your letter, I have to state that as the Council does not approve of medical study until ordinary school education has ceased, it will not be possible for your son to be registered while he remains at St. Paul’s School. He should begin study at one of the institutions on the enclosed list. Yours faithfully,
H. E. ALLEN, Registrar The only possible inference to be drawn from this reply is that I must either take the boy away from the school, or he cannot count the year towards the required five-an alternative altogether too serious for me to contemplate. Of course, what applies to St. Paul’s School applies to all the other great public schools up and down the country, and it has a very serious meaning to the parents of those boys at these public schools who are intended to enter the medical profession ; who, having passed a preliminary examination in arts, wish to proceed to the purely science portion of their career while remaining at the school-they must take them away. It also has its serious side for the public schools. The authorities of most of these schools have gone to endless expense in fitting up the laboratories of the schools, and in appointing as instructors the most competent science teachers to be found, yet they are to lose these boys just when they are likely to be of credit to the school and most able to avail themselves of the material provided by the school. And the boys themselves, are they not also losers in being thus early thrust as it were into the turmoil of hospital life, in losing the discipline, individual attention, and compulsory attendance consequent on a prolongation of school life for another T am Rir vnnrc faithfnilv year or part of a year ? " Cui Bono!"" Who does really gain by these regulations! V. S. HODSON, M.R.C.P. Lond. it is not the lad ! I am afraid that as a parent I Surely Khartoum. cannot appreciate the concentrated wisdom which produced for it does seem grossly unfair that a public these THE REGISTRATION OF THE MEDICAL schoolregulations, boy who wishes to learn the scientific portion of his work at school, where the staff and equipment are admirable, STUDENT AND THE REGULATIONS should be penalised to the extent of losing that year in comOF THE GENERAL MEDICAL puting the necessary five years of study-that is, if the reguCOUNCIL. lations I have quoted mean what they say. If they do, I am that the public school authorities have not publicly surprised To the Editor of THE LANCETprotested against the arbitrariness (and to my mind foolishSIR,-" What to do with our boysis as pressing a ness) of regulations which are devoid of benefit to the boy, to question now as ever it was, and parents have the same the school, to the parent, and to the profession generally. difficulties in guiding and guarding and finding openings for If these regulations regarding registration do not mean what their precious charges as their forefathers most probably did they say, and are not enforced or enforceable, the sooner the in their own cases. Like many others just at this season of public and parents of boys intended for the medical prothe year I had occasion to scan and puzzle over the regula- fession know it the better. tions laid down by the General Medical Council for the registration of those lads who are seeking to enter the RICHARD BEVAN, L.R.C.P. Lond., D.P.H. medical profession. With a view of making my arguments London. Sept. 1st. 1910. clear I have made the following extracts as embodying the 0B-** Our correspondent sets out very clearly one side of a principal regulations as to registration. As I understand question which has been much discussed in our them, they disclose a glaring anomaly upon which I should like the opinion of parents, masters of the great public L. schools, and of any others who feel an interest in the medical profession. Now for it. The course of professional study after registration shall occupy at AN INTERESTING CASE OF APPENDICITIS. March 3rd, 1910.
M.B., B.Ch. Oxon.,
,
difficult columns.—ED.
least five years....... 1’nery medical student shall be registered in the manner prescribed by the General Medical Council....... Every person desirous of being registered as a medical student shall produce or forward to the Branch Registrar a certificate of his having passed a preliminary examination as required by the General Medical Council, and evidence that he has attained the age of 16 years, and has commenced medical study. The commencement of the course of professional study recognised by any of the qualifsing bodies shall not be reckoned earlier than 15 days In addition to the Universities and before the date of registration. Schools of Medicine there are many institutions where medical study may be commenced.
To the Editor of THE LANCET.
Sm,-I
venture to send you
a history of what happens poor devil now and again in regions so far unblebsed by the presence of specialists. More or less a fortnight ago, at 5 P.nt., after an ordinary day’s work with cases of neurasthenia, syphilis, gonorrhoea, nephritis, lung, heart, skin, &c., the writer was called to see a young German, said to be suffering from colic.
to
a