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SOLDIER'S HEART.
316
Correspondence. "Audi alteram partem."
SENIOR MEDICAL MEN AND NAVAL AND MILITARY SERVICE.
by bruits or murmurs, which may be regarded by the examiner as physiological, but which are quite possibly permanent and organic lesions. As Sir James Mackenzie has written a memorandum for the guidance of those examining recruits,’ it would be interesting to learn more precisely from him what he considers a physiological or functional bruit as distinct from one denoting permanent mechanical lesion. The point is important and not dealt with in the memorandum referred to. In any case, we know he attributes little importance to valvular lesions as such. The criteria of the memorandum were criticised by some, among others by myself,2 who, in the opinion of its author, had succeeded in "muddling"the matter, to use his own term,3 and thereby, of course, like all muddled media, causing some obscurity of vision ; but Sir James Mackenzie’s chief exception was taken to an innocent contribution of Sir J. K. Fowler’s in terms which left nothing to be desired in
of THE LANCET. SIR,-I have recently received several letters from senior medical men who have retired from serving: in the Indian Medical Service, the Colonies, &c., and who lament that at present no place can be found for them in the national service of the sick: and wounded of our navy and army. These gentlemen have mostly occupied high positions; they possess great experience in medical and surgical diseases and injuries, and, although they have retired, still enjoy an amount of health and energy which might be placed at the disposal of the nation. From the most patriotic and laudable of motives, explicitness.’ Sir J. K. Fowler’s reply was a charming they chafe under the restrictions which prevent example of " heaping coals of fire " on the head of them from devoting their energies to the service his assailant, who had " held him up to scorn." of the country in connexion with the navy and The episode would have been complete if the latter army, while they naturally feel that these would be had confessed to having experienced some capital wasted were they, after the prominent positions warmth in consequence. The more important which they have occupied and the exceptional point, however, in the present connexion is that in experience which they have acquired, to adopt the the paper in which he deals with Sir J. K. Fowler, only course which is available to them at Sir James Mackenzie relates a case of his own with present, that, namely, of offering to relieve general a systolic apical bruit, in illustration of his theme, practitioners and panel doctors who have left to which passed through much exertion until invalided, serve in the Royal Army Medical Corps. unnecessarily in his opinion, by the military It may be asked, Why do they not apply to the authorities. He regarded the bruit as " physioCentral Medical War Committee, who are conferring logical." The history of the case shows that this on such subjects with the Director-General of the sign was persistent and probably therefore organic, Army Medical Service ? To this I would answer: in the sense used by Dr. Trotter. It may appear That is the proper course to take, but not until it presumptuous on my part to express that opinion, has been ascertained in what numbers and in what as I have not seen the case in question. But I have capacities these highly trained men are prepared to seen others which Sir James Mackenzie has conserve. Were this made certain, and were it evident sidered negligible and which were unquestionably that a considerable and valuable contingent were at organic. It is this admission, without careful disthe disposal of the nation, then the Central Medical crimination of the permanently damaged nature War Committee should be approached in order that of these so-called functionally murmurous hearts, it might confer with the heads of the Navy and with a history of being able to endure strenuous Army Medical Services, so as to discover in what exertion, which causes the admission of many of manner and to what extent these men could be the organically affected hearts into the army, to utilised, either now, or when coming events may which Dr. Trotter refers. I have at present under have increased the strain on the physicians and my care in the soldiers’ wards of the Great Northern Central Hospital a young soldier who had been a surgeons of the country. If any of those interested in this subject will footballer and, till the time of his enlistment, communicate with me I shall be glad to have their capable of lifting and moving heavy furniture withsuggestions, and perhaps arrange to have a meeting out inconvenience, who broke down in route marchcalled, should the response to this letter seem to ing and now shows a largely dilated heart, with warrant it.-I am, Sir, yours faithfully, aortic regurgitation and Flint’s murmur. All must ALEX. OGSTON, have seen many similar cases, both aortic and President of the British Medical Association. invalided from a service to which they mitral, Jan. 1916. Aberdeen, 30th, 252, Union-street, should never have belonged. On the other hand, cases occur, such as that mentioned by Sir James SOLDIER’S HEART. Mackenzie, if I may venture to regard it as having To the Editor of THE LANCET. been organic, and also cases of the organic nature his letter in THE LANCET of Jan. 29th of which there can be no dispute, which endure Dr. R. H. Trotter remarks that " no inconsiderable much exertion without disaster. But they are number of men with organically impaired hearts exceptional. The cause of this difference is rather but it is rationally explicable in a are being passed into the new armies," and he obscure, measure. To try to do so here would be out out the these of the of history desirability points cases being carefully investigated, lest they should of place. Valvular lesion in the youth is. conduce to those of " soldier’s heart," recently so often of rheumatic origin that the lesion dealt with in a paper by Sir James Mackenzie at the may be said to carry with it the history of Medicine. Dr. In There a Trotter desiderates. older men, if is which Society certainly Royal and without rheumatic history, it is with considerable possibility of organically impaired hearts being accepted for military service at present, considerable frequency of specific origin and in view of the small importance attached by some, 1 Brit. Med. Jour., Oct. 16th, 1915. and notably by Sir James Mackenzie, to hearts 2 Ibid., Oct. 30th, 1915. 3 4 Ibid. manifesting evidences of mechanical imperfection Ibid., Dec. 4th, 1915. To the Editor
,
.
.
SIR,-In
aortic
;
317 indicative of vascular change. Both classes
properly rejected by
the examiner of
are
very
recruits,
or
should be, whatever the functional capacity of the heart at the moment. With greater care in determining cardiac integrity in the recruit and exercis-
disease; after the examination Dr. Samuel Wilks spoke to me about the work of Wunderlich, and said only two of the candidates seemed to have read up the subject. This may interest your I am, Sir, yours faithfully, readers. GEO. H. SAVAGE, SAVAGE. Devonshire-place, W., Jan. 28th, 1916. in
ing much scepticism as to the physiological nature of cardiac bruits, much trouble and expense may be avoided, and the efficiency of the soldier secured. The man invalided with the soldier’s heart, properly so-called, may, of course, possess a perfectly sound organ, the heart being only one of the features of a
LYING-IN HOMES. To the Editor of
general condition. I am,
Sir, yours faithfully, ALEXANDER MORISON.
Upper Berkeley-street, W.,
Jan.
THE
LANCET.
SIR,-I obliged to you for publishing my letter of Jan. 4th and for so kindly taking the trouble to make a note with regard to it. It is perhaps unfortunate that all of us, " Fair Play," your annotator, and myself, referred to two matters in our first communications-viz., the question of am
29th, 1916.
ON THE USE OF THE CLINICAL THERMOMETER.
notification of pregnancy and the supervision of lying-in homes. In my previous letter I tried to To the Editor of THE LANCET. show that it was the second matter, that relating to homes, that interested me most. In " Fair lying-in THE LANCET of Jan. nd 176) ProSIR,-In (p. " mind and that of your annotator, and, it fessor Sims Woodhead and Dr. P. C. Varrier-Jones Play’s would now seem, also yours, the other, the notificadismiss the claims of Galileo to the invention of tion of pregnancy, occupies the most important thermometers rather summarily in a footnote, but " 1 think these claims are supported by the fact that position. Personally, I take no exception to Fair the Italian Government lent thermometers made Play " or your annotator taking up the cudgels on by Galileo to the collection of scientific instruments behalf of the midwives in this connexion if they shown in South Kensington in (I think) 1878, and I think it worth while. They may also be justified believe they are described in the catalogue, to in attempting to induce medical practitioners to believe that they’are in as great danger as midwives which unfortunately I have at present no access. In reference to the introduction of the thermo-are being told they are. Probably the psychological meter into clinical practice in this country, my own moment for "doing so had arrived, theclamour recollections are definite. I held the appointment (the word is Fair Play’s ") raised in the periodical of house physician in the clinical wards of the catering for midwives having reached the stage Royal Infirmary of Edinburgh from October, when it might conveniently be brought before the 1866, to the end of July, 1867. These wards medical practitioner in one of his periodicals. These things may be so; I do not know. To my were for the teaching of clinical medicine to Unimind, however, neither the facts nor the claims of versity students. The professors of clinical medicine journalism justify " Fair Play" in attempting to were Dr. (afterwards Sir) Douglas Maclagan, Dr. Hughes Bennett, and Dr. Laycock, who each held help forward the campaign by suggesting that if office for three months. When I entered upon my local authorities are given duties that may bring duties as house physician I found, amongst other them into contact with midwives, since her work apparatus for use in the ward, a case containing will inevitably be mixed up with " nuisances " and of status will result to the two clinical thermometers, one straight and the "eating houses," loss " Fair Play " may be ignorant; other somewhat bent. Each was about ten inches certified midwife. witnesses representing the midwives who or more in length and took about five minutes or the more to reach the temperature of the body when it appeared before the House of Lords Committee on This thermometer case behalf of the London County Council certainly was placed in the axilla. I used to carry under my arm as one might carry were ignorant of the constitution of the public health staff employed by borough councils. There a gun, and most of the thermometric readings I took myself, rarely entrusting the thermometers to may be excuse for " Fair Play " ; there might have the clinical clerks. The thermometers were known been reasons for the ignorance of the witnesses The referred to. It cannot, however, be ignorance of as Aitken’s thermometers in the hospital. the public health departments and of the medical of thermometers and character these clumsy officers of health, the representative officers of rise them from time took to long they prevented coming into general use, and it was only after their these departments, that induces you to partisan reduction in size, at Sir Clifford Allbutt’s sugges- the London County Council against these departments and officers. tion, that their use became common. It must be that you are unaware of the objects I am, Sir, yours faithfully, aimed at in relation to the supervision of lying-in LAUDER BRUNTON. New Cavendish-street, W., Jan. 31st, 1916. homes and of the reasons underlying the claims of the borough councils that they are capable of doing To the Editor of THE LANCET. all that is necessary to attain these objects. In SIR,-I was ward clerk to Sir William Gull about pressing their claims the councils aim no blow at 1864, who brought two long thermometers into the the midwives or at the status of the certified midclinical wards and requested my colleague and me wife. They recognise that there are two classes of to take the temperature of some cases of typhus lying-in homes : one good and desirable, the other fever. This we did with these non-registering unsuitable, undesirable, and dangerous. In the thermometers. We thus sat, for rather long periods, former class is that conducted by the certified midover the beds of the patients. In due course my wife to whom status means something; in the colleague contracted the fever, and the use of the latter, that run by persons, generally without thermometers was discontinued for a time. Dr. qualifications and commonly without morals or Samuel Wilks examined in medicine at the Uni- conscience. versity of London in 1867. I was a candidate, My own experience of lying-in homes conducted there was a paper on the use of the thermometer by the certified practising midwife shows them to "
I
and
Correspondence. "Audi alteram partem."
SENIOR MEDICAL MEN AND NAVAL AND MILITARY SERVICE.
by bruits or murmurs, which may be regarded by the examiner as physiological, but which are quite possibly permanent and organic lesions. As Sir James Mackenzie has written a memorandum for the guidance of those examining recruits,’ it would be interesting to learn more precisely from him what he considers a physiological or functional bruit as distinct from one denoting permanent mechanical lesion. The point is important and not dealt with in the memorandum referred to. In any case, we know he attributes little importance to valvular lesions as such. The criteria of the memorandum were criticised by some, among others by myself,2 who, in the opinion of its author, had succeeded in "muddling"the matter, to use his own term,3 and thereby, of course, like all muddled media, causing some obscurity of vision ; but Sir James Mackenzie’s chief exception was taken to an innocent contribution of Sir J. K. Fowler’s in terms which left nothing to be desired in
of THE LANCET. SIR,-I have recently received several letters from senior medical men who have retired from serving: in the Indian Medical Service, the Colonies, &c., and who lament that at present no place can be found for them in the national service of the sick: and wounded of our navy and army. These gentlemen have mostly occupied high positions; they possess great experience in medical and surgical diseases and injuries, and, although they have retired, still enjoy an amount of health and energy which might be placed at the disposal of the nation. From the most patriotic and laudable of motives, explicitness.’ Sir J. K. Fowler’s reply was a charming they chafe under the restrictions which prevent example of " heaping coals of fire " on the head of them from devoting their energies to the service his assailant, who had " held him up to scorn." of the country in connexion with the navy and The episode would have been complete if the latter army, while they naturally feel that these would be had confessed to having experienced some capital wasted were they, after the prominent positions warmth in consequence. The more important which they have occupied and the exceptional point, however, in the present connexion is that in experience which they have acquired, to adopt the the paper in which he deals with Sir J. K. Fowler, only course which is available to them at Sir James Mackenzie relates a case of his own with present, that, namely, of offering to relieve general a systolic apical bruit, in illustration of his theme, practitioners and panel doctors who have left to which passed through much exertion until invalided, serve in the Royal Army Medical Corps. unnecessarily in his opinion, by the military It may be asked, Why do they not apply to the authorities. He regarded the bruit as " physioCentral Medical War Committee, who are conferring logical." The history of the case shows that this on such subjects with the Director-General of the sign was persistent and probably therefore organic, Army Medical Service ? To this I would answer: in the sense used by Dr. Trotter. It may appear That is the proper course to take, but not until it presumptuous on my part to express that opinion, has been ascertained in what numbers and in what as I have not seen the case in question. But I have capacities these highly trained men are prepared to seen others which Sir James Mackenzie has conserve. Were this made certain, and were it evident sidered negligible and which were unquestionably that a considerable and valuable contingent were at organic. It is this admission, without careful disthe disposal of the nation, then the Central Medical crimination of the permanently damaged nature War Committee should be approached in order that of these so-called functionally murmurous hearts, it might confer with the heads of the Navy and with a history of being able to endure strenuous Army Medical Services, so as to discover in what exertion, which causes the admission of many of manner and to what extent these men could be the organically affected hearts into the army, to utilised, either now, or when coming events may which Dr. Trotter refers. I have at present under have increased the strain on the physicians and my care in the soldiers’ wards of the Great Northern Central Hospital a young soldier who had been a surgeons of the country. If any of those interested in this subject will footballer and, till the time of his enlistment, communicate with me I shall be glad to have their capable of lifting and moving heavy furniture withsuggestions, and perhaps arrange to have a meeting out inconvenience, who broke down in route marchcalled, should the response to this letter seem to ing and now shows a largely dilated heart, with warrant it.-I am, Sir, yours faithfully, aortic regurgitation and Flint’s murmur. All must ALEX. OGSTON, have seen many similar cases, both aortic and President of the British Medical Association. invalided from a service to which they mitral, Jan. 1916. Aberdeen, 30th, 252, Union-street, should never have belonged. On the other hand, cases occur, such as that mentioned by Sir James SOLDIER’S HEART. Mackenzie, if I may venture to regard it as having To the Editor of THE LANCET. been organic, and also cases of the organic nature his letter in THE LANCET of Jan. 29th of which there can be no dispute, which endure Dr. R. H. Trotter remarks that " no inconsiderable much exertion without disaster. But they are number of men with organically impaired hearts exceptional. The cause of this difference is rather but it is rationally explicable in a are being passed into the new armies," and he obscure, measure. To try to do so here would be out out the these of the of history desirability points cases being carefully investigated, lest they should of place. Valvular lesion in the youth is. conduce to those of " soldier’s heart," recently so often of rheumatic origin that the lesion dealt with in a paper by Sir James Mackenzie at the may be said to carry with it the history of Medicine. Dr. In There a Trotter desiderates. older men, if is which Society certainly Royal and without rheumatic history, it is with considerable possibility of organically impaired hearts being accepted for military service at present, considerable frequency of specific origin and in view of the small importance attached by some, 1 Brit. Med. Jour., Oct. 16th, 1915. and notably by Sir James Mackenzie, to hearts 2 Ibid., Oct. 30th, 1915. 3 4 Ibid. manifesting evidences of mechanical imperfection Ibid., Dec. 4th, 1915. To the Editor
,
.
.
SIR,-In
aortic
;
317 indicative of vascular change. Both classes
properly rejected by
the examiner of
are
very
recruits,
or
should be, whatever the functional capacity of the heart at the moment. With greater care in determining cardiac integrity in the recruit and exercis-
disease; after the examination Dr. Samuel Wilks spoke to me about the work of Wunderlich, and said only two of the candidates seemed to have read up the subject. This may interest your I am, Sir, yours faithfully, readers. GEO. H. SAVAGE, SAVAGE. Devonshire-place, W., Jan. 28th, 1916. in
ing much scepticism as to the physiological nature of cardiac bruits, much trouble and expense may be avoided, and the efficiency of the soldier secured. The man invalided with the soldier’s heart, properly so-called, may, of course, possess a perfectly sound organ, the heart being only one of the features of a
LYING-IN HOMES. To the Editor of
general condition. I am,
Sir, yours faithfully, ALEXANDER MORISON.
Upper Berkeley-street, W.,
Jan.
THE
LANCET.
SIR,-I obliged to you for publishing my letter of Jan. 4th and for so kindly taking the trouble to make a note with regard to it. It is perhaps unfortunate that all of us, " Fair Play," your annotator, and myself, referred to two matters in our first communications-viz., the question of am
29th, 1916.
ON THE USE OF THE CLINICAL THERMOMETER.
notification of pregnancy and the supervision of lying-in homes. In my previous letter I tried to To the Editor of THE LANCET. show that it was the second matter, that relating to homes, that interested me most. In " Fair lying-in THE LANCET of Jan. nd 176) ProSIR,-In (p. " mind and that of your annotator, and, it fessor Sims Woodhead and Dr. P. C. Varrier-Jones Play’s would now seem, also yours, the other, the notificadismiss the claims of Galileo to the invention of tion of pregnancy, occupies the most important thermometers rather summarily in a footnote, but " 1 think these claims are supported by the fact that position. Personally, I take no exception to Fair the Italian Government lent thermometers made Play " or your annotator taking up the cudgels on by Galileo to the collection of scientific instruments behalf of the midwives in this connexion if they shown in South Kensington in (I think) 1878, and I think it worth while. They may also be justified believe they are described in the catalogue, to in attempting to induce medical practitioners to believe that they’are in as great danger as midwives which unfortunately I have at present no access. In reference to the introduction of the thermo-are being told they are. Probably the psychological meter into clinical practice in this country, my own moment for "doing so had arrived, theclamour recollections are definite. I held the appointment (the word is Fair Play’s ") raised in the periodical of house physician in the clinical wards of the catering for midwives having reached the stage Royal Infirmary of Edinburgh from October, when it might conveniently be brought before the 1866, to the end of July, 1867. These wards medical practitioner in one of his periodicals. These things may be so; I do not know. To my were for the teaching of clinical medicine to Unimind, however, neither the facts nor the claims of versity students. The professors of clinical medicine journalism justify " Fair Play" in attempting to were Dr. (afterwards Sir) Douglas Maclagan, Dr. Hughes Bennett, and Dr. Laycock, who each held help forward the campaign by suggesting that if office for three months. When I entered upon my local authorities are given duties that may bring duties as house physician I found, amongst other them into contact with midwives, since her work apparatus for use in the ward, a case containing will inevitably be mixed up with " nuisances " and of status will result to the two clinical thermometers, one straight and the "eating houses," loss " Fair Play " may be ignorant; other somewhat bent. Each was about ten inches certified midwife. witnesses representing the midwives who or more in length and took about five minutes or the more to reach the temperature of the body when it appeared before the House of Lords Committee on This thermometer case behalf of the London County Council certainly was placed in the axilla. I used to carry under my arm as one might carry were ignorant of the constitution of the public health staff employed by borough councils. There a gun, and most of the thermometric readings I took myself, rarely entrusting the thermometers to may be excuse for " Fair Play " ; there might have the clinical clerks. The thermometers were known been reasons for the ignorance of the witnesses The referred to. It cannot, however, be ignorance of as Aitken’s thermometers in the hospital. the public health departments and of the medical of thermometers and character these clumsy officers of health, the representative officers of rise them from time took to long they prevented coming into general use, and it was only after their these departments, that induces you to partisan reduction in size, at Sir Clifford Allbutt’s sugges- the London County Council against these departments and officers. tion, that their use became common. It must be that you are unaware of the objects I am, Sir, yours faithfully, aimed at in relation to the supervision of lying-in LAUDER BRUNTON. New Cavendish-street, W., Jan. 31st, 1916. homes and of the reasons underlying the claims of the borough councils that they are capable of doing To the Editor of THE LANCET. all that is necessary to attain these objects. In SIR,-I was ward clerk to Sir William Gull about pressing their claims the councils aim no blow at 1864, who brought two long thermometers into the the midwives or at the status of the certified midclinical wards and requested my colleague and me wife. They recognise that there are two classes of to take the temperature of some cases of typhus lying-in homes : one good and desirable, the other fever. This we did with these non-registering unsuitable, undesirable, and dangerous. In the thermometers. We thus sat, for rather long periods, former class is that conducted by the certified midover the beds of the patients. In due course my wife to whom status means something; in the colleague contracted the fever, and the use of the latter, that run by persons, generally without thermometers was discontinued for a time. Dr. qualifications and commonly without morals or Samuel Wilks examined in medicine at the Uni- conscience. versity of London in 1867. I was a candidate, My own experience of lying-in homes conducted there was a paper on the use of the thermometer by the certified practising midwife shows them to "
I
and