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"UNQUALIFIED PRACTICE."
DIPHTHERIA AND ITS CAUSATION. of others has been in regard to the very grave disease in question, and to hear of alternative or superior plans of treatment. The one thing I am specially anxious about is that members of the profession who have the opportunity of observing cases of acute endocarditis should give this method a fair trial during the early stage of the malady." In the first place, as regards the occurrence of acute endocarditis in the course of, or as a sequel to, a more or less acute rheumatic attack, I doubt if there is any very general recognition of the condition apart from the existence of murmur, and even when murmur is present it is of course a question whether it is or is not due to inflammatory changes in the endocardium. This question, along with some others, I dealt with ten or eleven years ago in a little volume entitled "Investigations into some Morbid Cardiac Conditions," and I do not enter into it now. Most of us will be prepared to accept Dr. Caton’s opinion of his own cases as the expression of a reasonable diagnosis. At page 144 of the book referred to I mention that I had treated three cases of what I i believed to be active endocarditis by blistering the prsecordia ’, and giving iodide of potassium internally, and that the result in these cases was different from others I had not so treated in that they recovered. Since that book was published I have been confirmed in my then expressed opinion that active endocarditis was capable of being diagnosed even when superadded to a previously damaged endocardium ; and eleven years of additional experience have only tended to establish in my mind the value of the treatment which Dr. Caton has advocated.-I am, Sirs, yours truly, WM. RUSSELL,
experience
Assistant
Edinburgh, Aug. 26th,
1895.
Physician, Royal Infirmary.
DIPHTHERIA AND ITS CAUSATION. To the Editors of THE LANCET. SIRS,-The two chief views put forward to account for the various outbreaks of diphtheria that occur from time to time are (1) defective sanitation, and (2) the aggregation of children in schools. This latter has been specially put forward by Mr. Shirley Murphy, medical officer of health to the London County Council; but with regard to school attendance Mr. Biddle has shown that, though the number of cases increases (as Mr. Shirley Murphy asserts) immediately after the holidays, they decrease I again as the term drags on its course. At first sight it appears as if these two ideas are utterly irreconcilable, but I cannot help thinking both may possibly be right. It must be considered that there is no flushing of the school drains during the holidays, and that they only get properly scoured and disinfected after the children meet. I dare say others besides myself have noticed the prevalence of continued dry weather prior to an outbreak of diphtheria, and in this case no doubt deficient flushing of drains is an important factor.-I am, Sirs, yours faithfully, F. P. ATKINSON. Surbiton, Aug. 26th, 1895.
THE ANTISEPTIC SYSTEM. To the Editors of THE LANCET. that the benefits derived from
SIRS,-Now in practice
measures
desirable that
a
known and word of caution be uttered are
widely
antiseptic accepted it is
as
to how far
adopted unnecessarily and unjustiwho has followed the progress of the treatment of disease will admit that such measures have played a prominent part in the great forces of evolution, which for better or worse are inevitable. I have before me two instances taken from THE LANCET which exemplify the points above mentioned. 1. In THE LANCET of March 2nd, 1895, the following case is recorded :-A child aged three years was accidentally subjected to carbolic acid treatment, the acid being rubbed into the scalp for three minutes, being mistaken for the ointment, and producing unconsciousness in five minutes, followed by coma in one hour, which lasted five hours. 2. In THE LANCET of June lst, 1895, the following cases are recorded :-(a) A boy aged fifteen years on Aug. 24th, 1894, was being prepared for an operation to take place in the evening. At 12 P.M. a carbolic compress was applied over the right thigh. At 2.30 A.M. the patient was found to be comatose. At 10 A.M. on the 28th he was still comatose. At 10.30 he partially regained his consciousness. On Sept. 1st he had recovered. On Sept. 3rd
their
uses are
sometimes
fiably. Anyone
553
he
was again subjected to a compress, an operation being in view ; but, again suffering from the effects of the drug, the operation was postponed. (b) A boy aged six years and a half on Jan. 30th, 1895, at 12.20 r.M., had a carbolic compress (1 in 20) applied over the skin in the right iliac
fossa. At 1.30 P.M. the child was noticed to groan and shortly afterwards found to be comatose. At 6 P.M. the child was recovering consciousness. At 7.30 P.M. consciousness. returned, and the history states that he was a few days in regaining his original health. These last two cases, recorded, in THE LANCET of June lst, 1895, are instructive in pointing. out the unjustifiable uses of the antiseptic system in subjecting patients of the ages of fifteen and six years respectively to the action of a common poison for two hours and one hour, when all that was necessary from an aseptic point of view could have been done five minutes prior to the operation by ordinary washing with soap and water, to be followed by bathing with some antiseptic solution. I believe there is no record of any case known where infection has taken place through a healthy and unbroken skin, and therefore it is reasonable to infer that any extraneous matter upon the skin. likely to interfere with the success of the operation would not be found to penetrate beyond the epidermis. The writer talks about "peculiar susceptibility" of patients. There seems to be nothing peculiar, except that of surprise at not hearing of more such cases. And if by the use of the carbolic compress the full effects are sometimes reached, what; relation will a milder dose bear to the state of anaesthesia? The unnecessary application of the ’’ system " is also carried out in midwifery practice. 1 am, Sirs, yours faithfully, A. P. WALTERS. Chiddingfold, Aug. 24th, 1895.
"UNQUALIFIED PRACTICE." To the Editors
of THE L.ANCET. SIRS,-I have observed in the pages of THE LANCET several letters regarding unqualified assistants. As this subject will yet, I believe, be taken up and dealt with by the General Medical Council, there is an aspect of the question, which I hope that learned body will not overlook-viz., the advantages of an unqualified assistantship to the student of’ to-day who is the practitioner of to-morrow. Is not one of the defects of modern medical education that it is too, theoretical ? In this it does not excel or come up to the old apprenticeship days. A student does not gain at lectures or even in the hospital that experience so necessary to the general practitioner, and during his long holidays a medical student could not do better than gain a practical knowledge of drugs by dispensing, attend simple cases in surgery, and attend If he is trusted to do these in dispensary cases of labour. at practice college, why should he not be allowed to do so,. perhaps to have a comfortable home during holidays while his resources are limited, or to assist some old practitioner whose means forbid him employing a fully qualified medical man ? Of course, it is undoubtedly abused, but that is no’ argument against the practice. I am, Sirs, yours truly, JAS. ANDERSON. Edinburgh, Aug. 27th, 1895.
"THE PARASITE OF MALARIA AND MALARIAL FEVER." To the Editors of THE LANCET.
SIRS,-In THE LANCET of July 6th you publish an articleby Dr. G. Thin on the above subject, supplying to someextent the much wanted detailed information as to the methods of staining that organism. There are one or two, points (which may be of interest) not mentioned : 1. In using eosine and methylene blue for its demonstration the test of a sufficiently well-stained preparation, to be of value as negative evidence, is that the eosinophil corpuscles must show as blue corpuscles with the eosinophil granules as sharply defined red without a tinge of purple. Ifthey are blue the plasmodium will also be stained blue, but if the eosinophil granules are ir.. the least purple the eosin in the red corpuscles will be to’ some extent replaced by methylene blue, and the plasmodium. will be difficult to distinguish. 2. For the preparation of the vessels in the brain and other organs a simple, though rough, method is to take a small portion of the cortex and crush it between two cover glasses. These brain ’° squashes"’ can be fixed by heat or any other method and stained with *
experience
Assistant
Edinburgh, Aug. 26th,
1895.
Physician, Royal Infirmary.
DIPHTHERIA AND ITS CAUSATION. To the Editors of THE LANCET. SIRS,-The two chief views put forward to account for the various outbreaks of diphtheria that occur from time to time are (1) defective sanitation, and (2) the aggregation of children in schools. This latter has been specially put forward by Mr. Shirley Murphy, medical officer of health to the London County Council; but with regard to school attendance Mr. Biddle has shown that, though the number of cases increases (as Mr. Shirley Murphy asserts) immediately after the holidays, they decrease I again as the term drags on its course. At first sight it appears as if these two ideas are utterly irreconcilable, but I cannot help thinking both may possibly be right. It must be considered that there is no flushing of the school drains during the holidays, and that they only get properly scoured and disinfected after the children meet. I dare say others besides myself have noticed the prevalence of continued dry weather prior to an outbreak of diphtheria, and in this case no doubt deficient flushing of drains is an important factor.-I am, Sirs, yours faithfully, F. P. ATKINSON. Surbiton, Aug. 26th, 1895.
THE ANTISEPTIC SYSTEM. To the Editors of THE LANCET. that the benefits derived from
SIRS,-Now in practice
measures
desirable that
a
known and word of caution be uttered are
widely
antiseptic accepted it is
as
to how far
adopted unnecessarily and unjustiwho has followed the progress of the treatment of disease will admit that such measures have played a prominent part in the great forces of evolution, which for better or worse are inevitable. I have before me two instances taken from THE LANCET which exemplify the points above mentioned. 1. In THE LANCET of March 2nd, 1895, the following case is recorded :-A child aged three years was accidentally subjected to carbolic acid treatment, the acid being rubbed into the scalp for three minutes, being mistaken for the ointment, and producing unconsciousness in five minutes, followed by coma in one hour, which lasted five hours. 2. In THE LANCET of June lst, 1895, the following cases are recorded :-(a) A boy aged fifteen years on Aug. 24th, 1894, was being prepared for an operation to take place in the evening. At 12 P.M. a carbolic compress was applied over the right thigh. At 2.30 A.M. the patient was found to be comatose. At 10 A.M. on the 28th he was still comatose. At 10.30 he partially regained his consciousness. On Sept. 1st he had recovered. On Sept. 3rd
their
uses are
sometimes
fiably. Anyone
553
he
was again subjected to a compress, an operation being in view ; but, again suffering from the effects of the drug, the operation was postponed. (b) A boy aged six years and a half on Jan. 30th, 1895, at 12.20 r.M., had a carbolic compress (1 in 20) applied over the skin in the right iliac
fossa. At 1.30 P.M. the child was noticed to groan and shortly afterwards found to be comatose. At 6 P.M. the child was recovering consciousness. At 7.30 P.M. consciousness. returned, and the history states that he was a few days in regaining his original health. These last two cases, recorded, in THE LANCET of June lst, 1895, are instructive in pointing. out the unjustifiable uses of the antiseptic system in subjecting patients of the ages of fifteen and six years respectively to the action of a common poison for two hours and one hour, when all that was necessary from an aseptic point of view could have been done five minutes prior to the operation by ordinary washing with soap and water, to be followed by bathing with some antiseptic solution. I believe there is no record of any case known where infection has taken place through a healthy and unbroken skin, and therefore it is reasonable to infer that any extraneous matter upon the skin. likely to interfere with the success of the operation would not be found to penetrate beyond the epidermis. The writer talks about "peculiar susceptibility" of patients. There seems to be nothing peculiar, except that of surprise at not hearing of more such cases. And if by the use of the carbolic compress the full effects are sometimes reached, what; relation will a milder dose bear to the state of anaesthesia? The unnecessary application of the ’’ system " is also carried out in midwifery practice. 1 am, Sirs, yours faithfully, A. P. WALTERS. Chiddingfold, Aug. 24th, 1895.
"UNQUALIFIED PRACTICE." To the Editors
of THE L.ANCET. SIRS,-I have observed in the pages of THE LANCET several letters regarding unqualified assistants. As this subject will yet, I believe, be taken up and dealt with by the General Medical Council, there is an aspect of the question, which I hope that learned body will not overlook-viz., the advantages of an unqualified assistantship to the student of’ to-day who is the practitioner of to-morrow. Is not one of the defects of modern medical education that it is too, theoretical ? In this it does not excel or come up to the old apprenticeship days. A student does not gain at lectures or even in the hospital that experience so necessary to the general practitioner, and during his long holidays a medical student could not do better than gain a practical knowledge of drugs by dispensing, attend simple cases in surgery, and attend If he is trusted to do these in dispensary cases of labour. at practice college, why should he not be allowed to do so,. perhaps to have a comfortable home during holidays while his resources are limited, or to assist some old practitioner whose means forbid him employing a fully qualified medical man ? Of course, it is undoubtedly abused, but that is no’ argument against the practice. I am, Sirs, yours truly, JAS. ANDERSON. Edinburgh, Aug. 27th, 1895.
"THE PARASITE OF MALARIA AND MALARIAL FEVER." To the Editors of THE LANCET.
SIRS,-In THE LANCET of July 6th you publish an articleby Dr. G. Thin on the above subject, supplying to someextent the much wanted detailed information as to the methods of staining that organism. There are one or two, points (which may be of interest) not mentioned : 1. In using eosine and methylene blue for its demonstration the test of a sufficiently well-stained preparation, to be of value as negative evidence, is that the eosinophil corpuscles must show as blue corpuscles with the eosinophil granules as sharply defined red without a tinge of purple. Ifthey are blue the plasmodium will also be stained blue, but if the eosinophil granules are ir.. the least purple the eosin in the red corpuscles will be to’ some extent replaced by methylene blue, and the plasmodium. will be difficult to distinguish. 2. For the preparation of the vessels in the brain and other organs a simple, though rough, method is to take a small portion of the cortex and crush it between two cover glasses. These brain ’° squashes"’ can be fixed by heat or any other method and stained with *