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RECTAL EXAMINATION DURING LABOUR
624 recovery of function from any form of treatment, but the position as regards surgery may be summed up by saying that rather more than half the patients are likely to derive benefit from the operation, and that a quarter may die from post-operative infection. It is matter for consideration whether a patient should be exposed to such a risk except when severe pain or a block in the subarachnoid space does not disappear after a course of X ray treatment.
RE-EDUCATION IN SQUINT ONE of the chief differences between A. Cantonnet, the French ophthalmologist who has devoted much of his life to the study of strabismus, and British authorities is as to the most favourable age at which to practise re-education. Worth found that the most favourable age for convergent squinters was before five or at any rate seven years old. Cantonnet puts five or seven not as the upper but as the lower limit of age, and claims good results in adults up to about 30 years of age. We review on another page the translation of an important work in which, with two collaborators, he expounds his main thesis of re-education. In the re-education of squinters Cantonnet’s main idea is what he calls the mental effort. Of course the deviating eye must not be too amblyopic, but if the vision in it is about as good as 6/24 he considers it possible, by means of mentally fixing a distant object placed above the level of the horizon, gradually to effect a cure even in cases of a high degree of deviation. Adolescents, he says, are better able to make a mental effort than children, and it requires a certain maturity of intelligence to develop one’s imaginative powers. He seems to ignore Worth’s powerful argument that the fusion sense is best trained during the early years when it should normally be perfected. Moreover, the interest aroused in children by amusing pictures, &c., is found to be at least the equivalent of the mental effort demanded by Cantonnet of adults. The various steps in the orthoptic treatment of a squinter are as follows : to correct as exactly as possible refractive error which any may exist; (2) to conquer the amblyopia of the squinting eye if any is present; (3) to overcome the neutralisation of the squinting eye so as to secure simultaneous vision ; (4) to pass from simultaneous to binocular vision ; (5) to obtain the sensation of relief-i.e., stereoscopic vision. Of course all this takes time, and it is of no use entering on a course of orthoptic training unless the necessary time can be given. As to operation, Cantonnet is inclined to minimise its utility, and yet it would seem self-evident that in many cases an efficient advancement of a muscle must materially shorten the time necessary for orthoptic training to achieve Cantonnet himself states that, a successful result. the re-education of convergent roughly speaking, a week or a week and a half necessitates squint per degree of deviation, the patient attending regularly his seances of exercises at least once a week, and in the intervals carrying on the home exercises which are a sine qua non condition of success. It is true that in those cases where the process of re-education ceases to progress Cantonnet does operate, but in his opinion re-education should constitute the beginning and the end of the cure where it does not constitute the whole of the treatment. In the opinion of most authorities only a minority of convergent squinters are capable of re-education, but Cantonnet holds the proportion to be at least 70 per cent. The main points of difficulty are: (1) To prevent the development of amblyopia in a squinting eye. Measures for this purpose must obviously be under-
(1)
taken at the earliest possible age. (2) To overcome neutralisation and establish simultaneous vision; at this stage there must be diplopia. (3) To pass from simultaneous to binocular vision, or, in other words, to cultivate the fusion sense by appropriate devices. When this is once obtained it must be frequently practised in order that it may be retained. The final stage, the attainment of the sense of relief or stereoscopic vision, does not present nearly such
great difficulty. RADIUM
RESEARCH: TWO GENEROUS DONATIONS
A PAPER was read by Prof. Berven of Stockholm before the section of laryngology of the Royal Society of Medicine on March 1st, dealing with the progress being made in Sweden with the treatment of certain forms of cancer by radiation from large masses of radium. This report of Swedish work lends particular interest to the news that two generous donations have recently been made towards scientific research of a similar nature now in progress in this country. The sum of E2500 now given by the J. G. Graves Charitable Trust (founded by Alderman J. G. Graves of Sheffield) and nooo from Mr. Harry Oakes of Canada, come at an opportune time, since the research work, which by its nature is extremely costly, is now entering upon its second year. It will be recalled that this research was instituted under the auspices of the Medical Research Council and the Department of Scientific and Industrial Research, who, together with the Prophit Trust (through the Royal College of Surgeons) and the Royal College of Physicians, have hitherto met the costs by generous grants. The work was further assisted by the loan of radium in the necessary large quantity the Union Miniere du Haut Katanga of Brussels. It is directed by the Radium Bean Therapy committee set up in July, 1933, of which the members are Lord Dawson of Penn, Sir Holburt Waring, Mr. Wilfred Trotter, F.R.S., Lord Rutherford, F.R.S., Prof. A. J. Hall, Sir George Blacker, and Sir Cuthbert Wallace, under the chairmanship of Sir Gowland Hopkins, P.R.S., with Prof. J. C. McLennan, F.R.S., as secretary-treasurer.1In the last annual report of the Medical Research Council it is stated (p. 116) that attention is at present being concentrated on the treatment of malignant conditions of the mouth and throat.
by
RECTAL EXAMINATION DURING LABOUR
FROM time to time obstetric teachers have declared that rectal examination should be preferred to vaginal examination for routine use during labour. Sciclounoff2Z reports that, in search of a ruling on this point, he has circulated a questionnaire to some 280 obstetric specialists in different countries, and has received over 100 replies. Statistical evidence, he believes, for no help ; although there have been many gives and extensive investigations, some of them show that maternal morbidity is higher with vaginal examination, while others demonstrate the exact In the questionnaire information was opposite. as to whether rectal examination was used ; required to what extent it could be relied upon; whether midwives should be allowed to perform vaginal examinations ; whether students were taught to perform pelvic examinations per vaginam or per rectum ; and whether it was thought that vaginal examinations were associated with a raised morbidity compared with rectal. The replies showed that the 2
Sciclounoff, 1935, p. 1.
1 See THE LANCET, 1933, ii., 135. T.: Rev. franç. de gyn. et d’obst.,
January,
625 rectal examination was used by only a few obstetricians, and that it was considered by the great majority to be insufficient in both normal and abnormal cases. Furthermore three out of every four that answered felt that vaginal examinations could not be prohibited to midwives. Students, almost universally, were taught to practise the vaginal examination, and provided they were thoroughly drilled in technique the procedure was held to be harmless. Sciclounoff observes that even the most ardent advocates of examination by the rectal route advise resort to the other in doubtful cases, and that if such an examination is performed but rarely the technique is going to be far less perfect than if it is used as a routine. It is harder to acquire information from the rectal examination-H. W. Mayer3 estimates that a man must follow at least 100 patients through labour before being sure of his rectal findings-and medical students in their short training have difficulty enough already in interpreting what they encounter per vaginam. Lastly, it is suggested that rectal examination at this time is disagreeable both to patient and doctor. In collecting so many facts and opinions, not only from his questionnaire but from published papers, Sciclounoff has undoubtedly helped to establish the value of a careful examination and to emphasise the need for a rigorous technique in its performance. A CHINESE SCIENTIFIC ACHIEVEMENT THOSE who have faith in the scientific attributes of the Chinese people will be heartened by the appearance of a magnificent volume, printed and bound in China by the Mercury Press of Shanghai, containing the transactions of the Ninth Congress of the Far Eastern Association of Tropical Medicine 4 held in Nanking, China, from Oct. 2nd to 8th, 1934. It is edited by two distinguished medical officers of the National Quarantine Service, Wu Lien-Teh and C. Y. Wu, and has been produced to a great extent by Chinese labour and brains. The frontispiece is a message from His Excellency Lin Sen, president of the National Government of the Republic of China, in native script. The scope of the work is evident from the first 80 pages, which contain a list of the agenda, the composition of the various committees, a list of the representatives of the countries taking part, and a resume of the speeches made, of the minutes, and of the resolutions passed at the various meetings of the delegates. The list of delegates and members is a formidable one, and consists mainly of native medical
practitioners. The scientific matter is divided into headings dealing with bacteriology, biochemistry, cholera, dermatology, medical entomology, helminthology, kala-azar, and leprosy. C. E. Lim and T. J. Kurotchkin have studied the sensitising properties of gramnegative and gram-positive bacteria. The studies on typhoid agglutinins occupy many pages, and include a comparative investigation by S. M. Tao of the virulence and antigenic properties of B. typhosus and an inagglutinable Chinese strain. D. H. Wong has two papers upon the " 0 " agglutinins of the
enteric fevers, and also upon the occurrence of dysentery agglutinins amongst the Chinese people. A most interesting and complete study of dysentery in the Japanese Navy comes from the pens of T. Shibata and S. Murakami. Typhus exanthematicus in the north of China has been studied by J. Tchang and S. Lotsong, whilst R. Lewthwaite and S. R. 3 Surg., Gyn., and Obst., 1932, lv., 771 ; see THE LANCET, 1933, i., 33. 4 Published by the National Health Administration of the Republic of China, Nanking. 1935. Vol. I. Pp. 790. £2(for two volumes).
Savoor
typhus
resume of their studies on tropical tsutsugamushi disease as encountered Federated Malay States. In the biochemical
publish
a
and the
in the section J. L. Rosedale writes with C. J. Oliveiro upon the fat-soluble vitamins of tropical food oils, and with L. P. Chong-on the relationship of vitamins B and C to beri-beri. Eric Reid has studied the nutritive properties of soybean-egg powder as a substitute for cow’s milk in the infant dietary. Cholera in India is discussed by A. J. H. Russell, and an analysis of disease in China is made by J. W. H. Chun. Among the remaining papers one on the histology of Filariasis bancrofti by D. Y. Ku and Z. M. Kao is noteworthy, and there is also a remarkable study, containing novel observations by S. Yoshida, on the life-history of Gnathostoma spinigerum which apparently takes place to some extent in the body of the cyclops. A second volume which will complete the record of the congress is in preparation, and will be welcome. THE JAMES MACKENZIE INSTITUTE
"WE define our object as the prevention of the diseases that are common amongst the people" wrote Sir James Mackenzie of the Institute for Clinical Research at St. Andrews which now bears his name. The principles which guide us are, first, to clearly recognise each individual symptom and differentiate it from others which it resembles ; second, to understand the mechanism of its production; and third, to assess its value, so far as it has a bearing on the future course of the disease-in other words, its prognostic significance," The methods which Mackenzie elaborated to achieve that object, and the lines of study which he suggested, are still followed in St. Andrews, although increasing knowledge has, in some instances, led to the adoption of shorter routes than those originally devised. The town and its neighbourhood provide ample material for research into ailments, temporary and otherwise, affecting the population as a whole or individually. It has frequently been found that the most valuable information is to be derived from an intensive study of individual cases. Thus records of life-histories from birth onwards, and of special cases, continue to be kept in order that signs which reveal disease, show its progress, or indicate danger can be recognised. Staff meetings are held weekly at which cases and groups of cases are submitted for discussion. These meetings are regarded as one of the most important parts of the work of the Institute, since they afford an opportunity of pooling the knowledge and experience of the members, and where possible, of correlating the information thus acquired with the application of broad principles. As noted in the fifteenth annual report (mentioned last week, p. 558, in a leading article) individual members of the staff are engaged in investigating such subjects as hyperpiesis in women, the bacteriology of catarrhs, and the aetiology of gastric and duodenal ulcers. Other subjects discussed at the weekly meetings include blood pressure, otitis media, scarlet fever, preservation of life of the unfit, pain, diverticulitis, and epilepsy. A prominent place is given to the consideration of the various manifestations of cardiac disease. Recent publications have dealt with ocular manifestations of the onset of disease, the mechanism and significance of pain, the prognostic significance of sinus arrhythmia, recognition of the cardinal signs of influenza and its differentiation from common catarrhal illnesses, and the relation between disease and excessive consumption of carbohydrates. It has been the endeavour of the members of the Institute to adapt Mackenzie’s principles and methods to the various departments of clinical research, "
RE-EDUCATION IN SQUINT ONE of the chief differences between A. Cantonnet, the French ophthalmologist who has devoted much of his life to the study of strabismus, and British authorities is as to the most favourable age at which to practise re-education. Worth found that the most favourable age for convergent squinters was before five or at any rate seven years old. Cantonnet puts five or seven not as the upper but as the lower limit of age, and claims good results in adults up to about 30 years of age. We review on another page the translation of an important work in which, with two collaborators, he expounds his main thesis of re-education. In the re-education of squinters Cantonnet’s main idea is what he calls the mental effort. Of course the deviating eye must not be too amblyopic, but if the vision in it is about as good as 6/24 he considers it possible, by means of mentally fixing a distant object placed above the level of the horizon, gradually to effect a cure even in cases of a high degree of deviation. Adolescents, he says, are better able to make a mental effort than children, and it requires a certain maturity of intelligence to develop one’s imaginative powers. He seems to ignore Worth’s powerful argument that the fusion sense is best trained during the early years when it should normally be perfected. Moreover, the interest aroused in children by amusing pictures, &c., is found to be at least the equivalent of the mental effort demanded by Cantonnet of adults. The various steps in the orthoptic treatment of a squinter are as follows : to correct as exactly as possible refractive error which any may exist; (2) to conquer the amblyopia of the squinting eye if any is present; (3) to overcome the neutralisation of the squinting eye so as to secure simultaneous vision ; (4) to pass from simultaneous to binocular vision ; (5) to obtain the sensation of relief-i.e., stereoscopic vision. Of course all this takes time, and it is of no use entering on a course of orthoptic training unless the necessary time can be given. As to operation, Cantonnet is inclined to minimise its utility, and yet it would seem self-evident that in many cases an efficient advancement of a muscle must materially shorten the time necessary for orthoptic training to achieve Cantonnet himself states that, a successful result. the re-education of convergent roughly speaking, a week or a week and a half necessitates squint per degree of deviation, the patient attending regularly his seances of exercises at least once a week, and in the intervals carrying on the home exercises which are a sine qua non condition of success. It is true that in those cases where the process of re-education ceases to progress Cantonnet does operate, but in his opinion re-education should constitute the beginning and the end of the cure where it does not constitute the whole of the treatment. In the opinion of most authorities only a minority of convergent squinters are capable of re-education, but Cantonnet holds the proportion to be at least 70 per cent. The main points of difficulty are: (1) To prevent the development of amblyopia in a squinting eye. Measures for this purpose must obviously be under-
(1)
taken at the earliest possible age. (2) To overcome neutralisation and establish simultaneous vision; at this stage there must be diplopia. (3) To pass from simultaneous to binocular vision, or, in other words, to cultivate the fusion sense by appropriate devices. When this is once obtained it must be frequently practised in order that it may be retained. The final stage, the attainment of the sense of relief or stereoscopic vision, does not present nearly such
great difficulty. RADIUM
RESEARCH: TWO GENEROUS DONATIONS
A PAPER was read by Prof. Berven of Stockholm before the section of laryngology of the Royal Society of Medicine on March 1st, dealing with the progress being made in Sweden with the treatment of certain forms of cancer by radiation from large masses of radium. This report of Swedish work lends particular interest to the news that two generous donations have recently been made towards scientific research of a similar nature now in progress in this country. The sum of E2500 now given by the J. G. Graves Charitable Trust (founded by Alderman J. G. Graves of Sheffield) and nooo from Mr. Harry Oakes of Canada, come at an opportune time, since the research work, which by its nature is extremely costly, is now entering upon its second year. It will be recalled that this research was instituted under the auspices of the Medical Research Council and the Department of Scientific and Industrial Research, who, together with the Prophit Trust (through the Royal College of Surgeons) and the Royal College of Physicians, have hitherto met the costs by generous grants. The work was further assisted by the loan of radium in the necessary large quantity the Union Miniere du Haut Katanga of Brussels. It is directed by the Radium Bean Therapy committee set up in July, 1933, of which the members are Lord Dawson of Penn, Sir Holburt Waring, Mr. Wilfred Trotter, F.R.S., Lord Rutherford, F.R.S., Prof. A. J. Hall, Sir George Blacker, and Sir Cuthbert Wallace, under the chairmanship of Sir Gowland Hopkins, P.R.S., with Prof. J. C. McLennan, F.R.S., as secretary-treasurer.1In the last annual report of the Medical Research Council it is stated (p. 116) that attention is at present being concentrated on the treatment of malignant conditions of the mouth and throat.
by
RECTAL EXAMINATION DURING LABOUR
FROM time to time obstetric teachers have declared that rectal examination should be preferred to vaginal examination for routine use during labour. Sciclounoff2Z reports that, in search of a ruling on this point, he has circulated a questionnaire to some 280 obstetric specialists in different countries, and has received over 100 replies. Statistical evidence, he believes, for no help ; although there have been many gives and extensive investigations, some of them show that maternal morbidity is higher with vaginal examination, while others demonstrate the exact In the questionnaire information was opposite. as to whether rectal examination was used ; required to what extent it could be relied upon; whether midwives should be allowed to perform vaginal examinations ; whether students were taught to perform pelvic examinations per vaginam or per rectum ; and whether it was thought that vaginal examinations were associated with a raised morbidity compared with rectal. The replies showed that the 2
Sciclounoff, 1935, p. 1.
1 See THE LANCET, 1933, ii., 135. T.: Rev. franç. de gyn. et d’obst.,
January,
625 rectal examination was used by only a few obstetricians, and that it was considered by the great majority to be insufficient in both normal and abnormal cases. Furthermore three out of every four that answered felt that vaginal examinations could not be prohibited to midwives. Students, almost universally, were taught to practise the vaginal examination, and provided they were thoroughly drilled in technique the procedure was held to be harmless. Sciclounoff observes that even the most ardent advocates of examination by the rectal route advise resort to the other in doubtful cases, and that if such an examination is performed but rarely the technique is going to be far less perfect than if it is used as a routine. It is harder to acquire information from the rectal examination-H. W. Mayer3 estimates that a man must follow at least 100 patients through labour before being sure of his rectal findings-and medical students in their short training have difficulty enough already in interpreting what they encounter per vaginam. Lastly, it is suggested that rectal examination at this time is disagreeable both to patient and doctor. In collecting so many facts and opinions, not only from his questionnaire but from published papers, Sciclounoff has undoubtedly helped to establish the value of a careful examination and to emphasise the need for a rigorous technique in its performance. A CHINESE SCIENTIFIC ACHIEVEMENT THOSE who have faith in the scientific attributes of the Chinese people will be heartened by the appearance of a magnificent volume, printed and bound in China by the Mercury Press of Shanghai, containing the transactions of the Ninth Congress of the Far Eastern Association of Tropical Medicine 4 held in Nanking, China, from Oct. 2nd to 8th, 1934. It is edited by two distinguished medical officers of the National Quarantine Service, Wu Lien-Teh and C. Y. Wu, and has been produced to a great extent by Chinese labour and brains. The frontispiece is a message from His Excellency Lin Sen, president of the National Government of the Republic of China, in native script. The scope of the work is evident from the first 80 pages, which contain a list of the agenda, the composition of the various committees, a list of the representatives of the countries taking part, and a resume of the speeches made, of the minutes, and of the resolutions passed at the various meetings of the delegates. The list of delegates and members is a formidable one, and consists mainly of native medical
practitioners. The scientific matter is divided into headings dealing with bacteriology, biochemistry, cholera, dermatology, medical entomology, helminthology, kala-azar, and leprosy. C. E. Lim and T. J. Kurotchkin have studied the sensitising properties of gramnegative and gram-positive bacteria. The studies on typhoid agglutinins occupy many pages, and include a comparative investigation by S. M. Tao of the virulence and antigenic properties of B. typhosus and an inagglutinable Chinese strain. D. H. Wong has two papers upon the " 0 " agglutinins of the
enteric fevers, and also upon the occurrence of dysentery agglutinins amongst the Chinese people. A most interesting and complete study of dysentery in the Japanese Navy comes from the pens of T. Shibata and S. Murakami. Typhus exanthematicus in the north of China has been studied by J. Tchang and S. Lotsong, whilst R. Lewthwaite and S. R. 3 Surg., Gyn., and Obst., 1932, lv., 771 ; see THE LANCET, 1933, i., 33. 4 Published by the National Health Administration of the Republic of China, Nanking. 1935. Vol. I. Pp. 790. £2(for two volumes).
Savoor
typhus
resume of their studies on tropical tsutsugamushi disease as encountered Federated Malay States. In the biochemical
publish
a
and the
in the section J. L. Rosedale writes with C. J. Oliveiro upon the fat-soluble vitamins of tropical food oils, and with L. P. Chong-on the relationship of vitamins B and C to beri-beri. Eric Reid has studied the nutritive properties of soybean-egg powder as a substitute for cow’s milk in the infant dietary. Cholera in India is discussed by A. J. H. Russell, and an analysis of disease in China is made by J. W. H. Chun. Among the remaining papers one on the histology of Filariasis bancrofti by D. Y. Ku and Z. M. Kao is noteworthy, and there is also a remarkable study, containing novel observations by S. Yoshida, on the life-history of Gnathostoma spinigerum which apparently takes place to some extent in the body of the cyclops. A second volume which will complete the record of the congress is in preparation, and will be welcome. THE JAMES MACKENZIE INSTITUTE
"WE define our object as the prevention of the diseases that are common amongst the people" wrote Sir James Mackenzie of the Institute for Clinical Research at St. Andrews which now bears his name. The principles which guide us are, first, to clearly recognise each individual symptom and differentiate it from others which it resembles ; second, to understand the mechanism of its production; and third, to assess its value, so far as it has a bearing on the future course of the disease-in other words, its prognostic significance," The methods which Mackenzie elaborated to achieve that object, and the lines of study which he suggested, are still followed in St. Andrews, although increasing knowledge has, in some instances, led to the adoption of shorter routes than those originally devised. The town and its neighbourhood provide ample material for research into ailments, temporary and otherwise, affecting the population as a whole or individually. It has frequently been found that the most valuable information is to be derived from an intensive study of individual cases. Thus records of life-histories from birth onwards, and of special cases, continue to be kept in order that signs which reveal disease, show its progress, or indicate danger can be recognised. Staff meetings are held weekly at which cases and groups of cases are submitted for discussion. These meetings are regarded as one of the most important parts of the work of the Institute, since they afford an opportunity of pooling the knowledge and experience of the members, and where possible, of correlating the information thus acquired with the application of broad principles. As noted in the fifteenth annual report (mentioned last week, p. 558, in a leading article) individual members of the staff are engaged in investigating such subjects as hyperpiesis in women, the bacteriology of catarrhs, and the aetiology of gastric and duodenal ulcers. Other subjects discussed at the weekly meetings include blood pressure, otitis media, scarlet fever, preservation of life of the unfit, pain, diverticulitis, and epilepsy. A prominent place is given to the consideration of the various manifestations of cardiac disease. Recent publications have dealt with ocular manifestations of the onset of disease, the mechanism and significance of pain, the prognostic significance of sinus arrhythmia, recognition of the cardinal signs of influenza and its differentiation from common catarrhal illnesses, and the relation between disease and excessive consumption of carbohydrates. It has been the endeavour of the members of the Institute to adapt Mackenzie’s principles and methods to the various departments of clinical research, "