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THE BRITISH RED CROSS IN THE BALKAN WAR.
235 carbonate of soda. The actual practicability of the process in the field was demonstrated by Captain Nesfield in connexion with the following events : (1) The Tibet Expedition ; (2) the Cameronians, 1905; (3) the Barchacha Artillery Campaign ; (4) the Agra concentration of troops for the Amir of Afghanistan ; (5) famine relief operations in the United Provinces 1906-07, when over a million gallons of water were sterilised by this process ; and (6) the Mohmund Expedition. Captain Nesfield has appealed to the sanitary department of the army to give the process a fair trial. His favourable experiences in regard to the simplicity, efficiency, but above all, practicability of the process seem to us to offer very good reasons why his appeal should be granted.
AORTIC ANEURYSM RUPTURING INTO THE PULMONARY ARTERY.
The vessels of the neck were full, especially on the side. In the carotids was a systolic thrill, and on auscultation a continuous hum with systolic accentuation The pulse was collapsing, the left being smaller was heard. than the right. A definite tracheal tug was felt. There was a diffuse systolic heave of the chest with a pulsating prominence above the left prsecordium. In the first four interspaces was an expansile impulse, a continuous thrill with systolic accentuation was felt, and a continuous rough There were murmur with systolic accentuation was heard. dulness in the flanks and oedema of the extremities. He grew weaker and died on Jan. llth. The necropsy showed an aneurysm of the ascending arch of the aorta containing recent clot collected round a silver wire and communicating with the pulmonary artery by a hole 6 mm. in diameter. In the third case a coloured man, aged 45 years, was admitted on Jan. 5th, 1892, complaining of dyspnoea and weakness of the legs. His illness commenced in October, 1891, with cold and cough. Four weeks before admission dyspnoea with occasional attacks of nausea and vomiting began. He could not sleep lying down. The legs had been swollen for a few days. Chest resonance was good except for dulness at the right base. Cardiac dulness began at the upper border of the third rib and extended to the right border of the sternum. The cardiac impulse was 2 cm. outside the nipple line. The first sound was faint ; the second was replaced by a dull prolonged murmur which became louder on passing upwards to the third rib. He grew weaker and died on Jan. llth. The necropsy showed an aneurysm of the aortic arch communicating with the pulmonary artery by an opening half a millimetre in diameter. In the first two cases the opening into the pulmonary artery was large; in the third it was tiny. In the two former there were enlargement of the heart to the right and a collapsing pulse; in the latter these were absent. Moreover, there were a continuous thrill and murmur in the carotid and subclavian arteries in the former, while in the latter there were a single murmur and thrill.
pale. right
A RARE result of aortic aneurysm is rupture into one of the great veins-superior cava, inferior cava, or pulmonary artery. In the Joh7ts gop7ains Hospital Bulletin for July Dr. H. N. Stevenson has reported three cases of rupture into the pulmonary artery-the only ones observed amongst 3900 necropsies at the hospital. In the first case a coloured man was admitted on Sept. 19th, 1912, complaining of He of a several attacks of gonorrhoea, gave history dyspncea. but not of syphilis. His illness began about Christmas, 1911, with sudden dyspnoea, which had become worse. There were also prsecordial pain and swelling of the legs and abdomen. Lately he had suffered from severe fits of coughing, with haemoptysis and nausea. The veins in the neck were greatly dilated, and a whirling murmur was heard There was no definite over the subclavian arteries. tracheal tug, but a transmitted pulsation was felt over the trachea. The percussion note was dull and breath sounds were absent over the right base and above the spine of the left scapula. The point of maximum intensity of the heart’s impulse was not very definitely localised in the fifth interspace in the mammary lina. There was a diffuse heave of the whole sternum. In the third left interspace was a localised BRITISH RED CROSS IN THE BALKAN WAR. pulsation and friction fremitus was felt. Cardiac dulness MEDICAL reports from the seat of war, wherever it may began at the second rib and extended 14½ cm. to the left in the fifth interspace and 5gcm. to the right in the fourth. At be, present a striking family likeness. The mortality among the apex a systolic murmur accompanied the first sound. the earlier cases to reach the base hospitals is always conAt the base a diastolic murmur was heard. The pulmonary siderably greater than that at a later period ; the prevalence In the area where the of epidemic disease is apparently inevitable ; and the ques. second sound was accentuated. fremitus was palpable a machinery-like whirl, made up of a tions of transport of the wounded, of nursing, and of rough systolic murmur, an accentuated second sound, and a amateur help always present themselves in somewhat blowing sound running through both systole and diastole, similar form. Mr. C. Max Page and Mr. S. V. Appleyard was heard. The radial pulses were equal but collapsing. conclude in this issue of THE LANCET an account of their There was shifting dulness in the flanks. On the second medical and surgical experience in the Balkan war, and as day after admission a little blood-streaked sputum was ex- that war may now be resumed in serious form at any pectorated, and was followed by a gush of pure blood and moment their story is worth close attention. It may be death within a few minutes. The necropsy showed syphilitic possible in future developments to guard against some of the mesaortitis, aneurysm of the transverse arch of the aorta, troubles in organisation that occurred a few months ago. two communications with the pulmonary artery, of which the Th%y state that the mortality of the first 130 cases dealt larger was 1 cm. in diameter, hypertrophy of the right with at the British Red Cross base hospital in the Musee ventricle, passive congestion of the viscera, ascites, and des Beaux Arts, Stamboul, corresponding to the early stages rupture of the aneurysm into the left lower bronchus. In of the war, was 41’ 6 per cent. This was partly attributable the second case a white man, aged 26 years, was admitted to the defective condition of the transport, whereby many on Jan. 10th, 1910, complaining of pulsation of the heart. days of exposure and starvation elapsed between the There was no history of venereal disease, but one of incidence of the wound and arrival at the hospital. In the frequent exposure. He had been previously admitted, in later period, when the men were better fed and in better conDecember, 1908, for aortic aneurysm, which was wired dition generally, and the time of transport from the front had by Dr. J. M. T. Finney. He improved and was dis- been reduced to from one to four days, this heavy mortality charged in June. Four weeks before his second admission was reduced to 4 per cent. out of 448 cases. As to epidemic he became puffy under the eyes and he suffered from disease, the tale of dysentery, cholera, enteric fever, and attacks of vomiting and dyspnoea. When examined he was typhus fever kept up the tradition of war, but everything sitting up in bed by preference, resting on his arms. The seems to have been done to make the best of local conditions, lips and ears were cyanotic and the mucous membranes were and to fight disease with modern weapons and determination.
THE
236 The numerous orderlies proved, it seems, a great stumbling not be suddenly changed. Many children must be trained block, native labour being more satisfactory for the ward work. before they can eat enough of strange dishes to maintain their
This remark is in line with the observations made by Sir Alexander Ogston before the Royal Commission on the Boer The dressers, also, were too numerous. The authors war. suggest that they should rank rather as assistant surgeons with special duties. A point worthy of notice is the replacing of shallow cesspool latrines by bench latrines with old kerosene tins as reservoirs. In this connexion mention may be made of a -comment by THE LANCET’S Special Correspondent in the Russo-Japanese war, who remarked in reference to the Japanese latrines, which appear to have resembled the native latrines in Constantinople, that it will some day be recognised that it is better to substitute half a kerosene tin for the fixed open pan and to change it for a clean one every day. Carbolic acid is bulky in relation to its disinfecting power, and the authors suggest the substitution of some antiseptic of greater disinfecting power in proportion to its bulk-e.g., lysol or some kindred substance. The authors’ professional experiences bear out those of other observers in recent wars. To the temperate habits of the Moslem are ascribed the absence of excitement, of respiratory obstruction, and of post-operative vomiting in regard to anaesthesia. The wounds from the modern small-bore rifle bullets are usually benign and aseptic, while shrapnel wounds usually suppurate. It will be remembered that during the Russo-Japanese war the rule was laid down with regard to bullet wounds, " if in doubt do not operate,"and that the result was satisfactory, but that shrapnel wounds, owing to their greater liability to suppurate, demanded operation more frequently. In gunshot wounds of the skull, however, the authors’ experience leads them to counsel operation as soon as proper conditions are available. While their experience in regard to abdominal wounds confirms the general trend of experience towards conservatism, their figures do not bear out the conclusions of many previous observers as to the comparative benignity of wounds of the thorax.
bodyweight and growth, and if forced at once into a recognised standard would lose in weight." Two record cards are suggested in the bulletin, one dealing with economic and family conditions, the second with the child individually, and charts of increase of weight and of gain in haemoglobin are given. The results recorded in America areuniformly of 875 children reported on only 70 showed a loss in good " ; and most of these were cases of active tuberculosis weight, admitted too late to expect success. Attendance is good and percentage of absentees much less than in the public schools, coupled with which the children made remarkable progress in school. We are very glad to see that this excellent bulletin concludes by advocating open-air schools for all children, and prophesies wonderful results for normal children in which the application of the plan has not initial difficulties to contend with. ____
BERI-BERI THE
dietary
IN SIAM.
Siamese, like other nations in the Far East in whose white rice bulks
largely,
have suffered
considerably
of late years from beri-beri. In Bangkok, the capital, with a population of half a million, there have been 1278 deaths
ascribed to the disease during the 2gyears ended March 31st, 1912. As the suggestion had also been made that possibly Siam rice possessed special beri-beri producing qualities, the Ministry of Local Government decided to institute an official inquiry into the matter, and Dr. H. Campbell Highet, principal medical officer of health of Bangkok, was instructed to conduct the investigations, assisted by members of his scientific staff. His report has now been published, and it confirms the conclusions generally arrived at by Eraser and Stanton, as well as by other experts in the Malay Peninsula and elsewhere, and which we have from time to time reported in the columns of THE LANCET. Dr. Highet and his colleagues by their experiments demonstrated that Siam rice, when not over-milled, compares very favourably with PREVENTION OF TUBERCULOSIS AMONG rice from other places, such as Rangoon and Saigon, and that " CHILDREN. a beri-beri preventing rice can be prepared from Siam "padi " THE Public Health Bulletin No. 58 of the United States either by hand or steam mill and without the padi being Public Health Service deals with "Open-Air Schools for previously parboiled. Thephosphorus content of a rice should the Prevention and Cure of Tuberculosis among Children," not be less than 4 per cent., and this should be taken as the and is a document which should prove of interest and indicator of the safety or otherwise of the rice. In view of value to all concerned with preventive or curative medical the overwhelming evidence incriminating over-milled rice in work among the child population. The report is by Dr. connexion with beri-beri, some reformers have strongly B. S. Warren, passed assistant surgeon, United States urged that the law should interfere to prohibit the sale of Public Health Service, and is based on experience gained this rice which has by milling been deprived of certain in St. Louis, Mo., and on reports of open-air schools elements necessary for normal nutrition, but Dr. Highet in other parts of the United States. He states that the expresses the opinion that, for the present at least, legislatwo main points to be considered in selecting a site for a tion in that direction in Siam is not advisable, more school ,are accessibility and hygienic environment, and especially as it is not yet admitted what the actual substance mentions the flat top of a large city building as a is, the removal of which from the exterior of the rice grain possibility, but thinks it better to sacrifice accessibility if by the process of milling leads to the development of berione of the points must be given up. The type of building beri in the consumers of such rice. Meanwhile, the use of recommended is that open on all sides with canvas drop white, over-milled rice has been prohibited in the Siamese curtains for protection against severe cold winds. A school navy and in all the Government institutions, including suitable for 30 children is described, and detail plans are asylums and prisons, as well as among the provincial given with photographs of a school erected from these plans. gendarmery, a force which comprises about 9000 men. The He advises separate schools for pretubercular or "closed result of this prohibition has been the almost complete discases"with no tubercle bacilli in sputum or other discharges, appearance of beri-beri from these various bodies ; and were and for the open cases"with tubercle bacilli present. One the Siamese army to follow suit the disease would, of the photographs shows the open-air school being carried on Dr. Highet says, be practically extinguished from the whole with snow on the ground, and the children are provided with of the public service of the country. As regards the general Eskimo suits, looking very warm and cosy. A curious point population which has come to prefer the white rice and to which has been noted in England is commented on by Dr. reject any that is not well milled and polished, it is hoped Warren when he says :‘ Habits of life of the child should that in time the force of education of the people in matters of diet and as to the danger arising from the consumption of 1 THE LANCET, Jan. 28th, 1905, rice deprived of some of its essential constituents will lead to 256. p. ____
AORTIC ANEURYSM RUPTURING INTO THE PULMONARY ARTERY.
The vessels of the neck were full, especially on the side. In the carotids was a systolic thrill, and on auscultation a continuous hum with systolic accentuation The pulse was collapsing, the left being smaller was heard. than the right. A definite tracheal tug was felt. There was a diffuse systolic heave of the chest with a pulsating prominence above the left prsecordium. In the first four interspaces was an expansile impulse, a continuous thrill with systolic accentuation was felt, and a continuous rough There were murmur with systolic accentuation was heard. dulness in the flanks and oedema of the extremities. He grew weaker and died on Jan. llth. The necropsy showed an aneurysm of the ascending arch of the aorta containing recent clot collected round a silver wire and communicating with the pulmonary artery by a hole 6 mm. in diameter. In the third case a coloured man, aged 45 years, was admitted on Jan. 5th, 1892, complaining of dyspnoea and weakness of the legs. His illness commenced in October, 1891, with cold and cough. Four weeks before admission dyspnoea with occasional attacks of nausea and vomiting began. He could not sleep lying down. The legs had been swollen for a few days. Chest resonance was good except for dulness at the right base. Cardiac dulness began at the upper border of the third rib and extended to the right border of the sternum. The cardiac impulse was 2 cm. outside the nipple line. The first sound was faint ; the second was replaced by a dull prolonged murmur which became louder on passing upwards to the third rib. He grew weaker and died on Jan. llth. The necropsy showed an aneurysm of the aortic arch communicating with the pulmonary artery by an opening half a millimetre in diameter. In the first two cases the opening into the pulmonary artery was large; in the third it was tiny. In the two former there were enlargement of the heart to the right and a collapsing pulse; in the latter these were absent. Moreover, there were a continuous thrill and murmur in the carotid and subclavian arteries in the former, while in the latter there were a single murmur and thrill.
pale. right
A RARE result of aortic aneurysm is rupture into one of the great veins-superior cava, inferior cava, or pulmonary artery. In the Joh7ts gop7ains Hospital Bulletin for July Dr. H. N. Stevenson has reported three cases of rupture into the pulmonary artery-the only ones observed amongst 3900 necropsies at the hospital. In the first case a coloured man was admitted on Sept. 19th, 1912, complaining of He of a several attacks of gonorrhoea, gave history dyspncea. but not of syphilis. His illness began about Christmas, 1911, with sudden dyspnoea, which had become worse. There were also prsecordial pain and swelling of the legs and abdomen. Lately he had suffered from severe fits of coughing, with haemoptysis and nausea. The veins in the neck were greatly dilated, and a whirling murmur was heard There was no definite over the subclavian arteries. tracheal tug, but a transmitted pulsation was felt over the trachea. The percussion note was dull and breath sounds were absent over the right base and above the spine of the left scapula. The point of maximum intensity of the heart’s impulse was not very definitely localised in the fifth interspace in the mammary lina. There was a diffuse heave of the whole sternum. In the third left interspace was a localised BRITISH RED CROSS IN THE BALKAN WAR. pulsation and friction fremitus was felt. Cardiac dulness MEDICAL reports from the seat of war, wherever it may began at the second rib and extended 14½ cm. to the left in the fifth interspace and 5gcm. to the right in the fourth. At be, present a striking family likeness. The mortality among the apex a systolic murmur accompanied the first sound. the earlier cases to reach the base hospitals is always conAt the base a diastolic murmur was heard. The pulmonary siderably greater than that at a later period ; the prevalence In the area where the of epidemic disease is apparently inevitable ; and the ques. second sound was accentuated. fremitus was palpable a machinery-like whirl, made up of a tions of transport of the wounded, of nursing, and of rough systolic murmur, an accentuated second sound, and a amateur help always present themselves in somewhat blowing sound running through both systole and diastole, similar form. Mr. C. Max Page and Mr. S. V. Appleyard was heard. The radial pulses were equal but collapsing. conclude in this issue of THE LANCET an account of their There was shifting dulness in the flanks. On the second medical and surgical experience in the Balkan war, and as day after admission a little blood-streaked sputum was ex- that war may now be resumed in serious form at any pectorated, and was followed by a gush of pure blood and moment their story is worth close attention. It may be death within a few minutes. The necropsy showed syphilitic possible in future developments to guard against some of the mesaortitis, aneurysm of the transverse arch of the aorta, troubles in organisation that occurred a few months ago. two communications with the pulmonary artery, of which the Th%y state that the mortality of the first 130 cases dealt larger was 1 cm. in diameter, hypertrophy of the right with at the British Red Cross base hospital in the Musee ventricle, passive congestion of the viscera, ascites, and des Beaux Arts, Stamboul, corresponding to the early stages rupture of the aneurysm into the left lower bronchus. In of the war, was 41’ 6 per cent. This was partly attributable the second case a white man, aged 26 years, was admitted to the defective condition of the transport, whereby many on Jan. 10th, 1910, complaining of pulsation of the heart. days of exposure and starvation elapsed between the There was no history of venereal disease, but one of incidence of the wound and arrival at the hospital. In the frequent exposure. He had been previously admitted, in later period, when the men were better fed and in better conDecember, 1908, for aortic aneurysm, which was wired dition generally, and the time of transport from the front had by Dr. J. M. T. Finney. He improved and was dis- been reduced to from one to four days, this heavy mortality charged in June. Four weeks before his second admission was reduced to 4 per cent. out of 448 cases. As to epidemic he became puffy under the eyes and he suffered from disease, the tale of dysentery, cholera, enteric fever, and attacks of vomiting and dyspnoea. When examined he was typhus fever kept up the tradition of war, but everything sitting up in bed by preference, resting on his arms. The seems to have been done to make the best of local conditions, lips and ears were cyanotic and the mucous membranes were and to fight disease with modern weapons and determination.
THE
236 The numerous orderlies proved, it seems, a great stumbling not be suddenly changed. Many children must be trained block, native labour being more satisfactory for the ward work. before they can eat enough of strange dishes to maintain their
This remark is in line with the observations made by Sir Alexander Ogston before the Royal Commission on the Boer The dressers, also, were too numerous. The authors war. suggest that they should rank rather as assistant surgeons with special duties. A point worthy of notice is the replacing of shallow cesspool latrines by bench latrines with old kerosene tins as reservoirs. In this connexion mention may be made of a -comment by THE LANCET’S Special Correspondent in the Russo-Japanese war, who remarked in reference to the Japanese latrines, which appear to have resembled the native latrines in Constantinople, that it will some day be recognised that it is better to substitute half a kerosene tin for the fixed open pan and to change it for a clean one every day. Carbolic acid is bulky in relation to its disinfecting power, and the authors suggest the substitution of some antiseptic of greater disinfecting power in proportion to its bulk-e.g., lysol or some kindred substance. The authors’ professional experiences bear out those of other observers in recent wars. To the temperate habits of the Moslem are ascribed the absence of excitement, of respiratory obstruction, and of post-operative vomiting in regard to anaesthesia. The wounds from the modern small-bore rifle bullets are usually benign and aseptic, while shrapnel wounds usually suppurate. It will be remembered that during the Russo-Japanese war the rule was laid down with regard to bullet wounds, " if in doubt do not operate,"and that the result was satisfactory, but that shrapnel wounds, owing to their greater liability to suppurate, demanded operation more frequently. In gunshot wounds of the skull, however, the authors’ experience leads them to counsel operation as soon as proper conditions are available. While their experience in regard to abdominal wounds confirms the general trend of experience towards conservatism, their figures do not bear out the conclusions of many previous observers as to the comparative benignity of wounds of the thorax.
bodyweight and growth, and if forced at once into a recognised standard would lose in weight." Two record cards are suggested in the bulletin, one dealing with economic and family conditions, the second with the child individually, and charts of increase of weight and of gain in haemoglobin are given. The results recorded in America areuniformly of 875 children reported on only 70 showed a loss in good " ; and most of these were cases of active tuberculosis weight, admitted too late to expect success. Attendance is good and percentage of absentees much less than in the public schools, coupled with which the children made remarkable progress in school. We are very glad to see that this excellent bulletin concludes by advocating open-air schools for all children, and prophesies wonderful results for normal children in which the application of the plan has not initial difficulties to contend with. ____
BERI-BERI THE
dietary
IN SIAM.
Siamese, like other nations in the Far East in whose white rice bulks
largely,
have suffered
considerably
of late years from beri-beri. In Bangkok, the capital, with a population of half a million, there have been 1278 deaths
ascribed to the disease during the 2gyears ended March 31st, 1912. As the suggestion had also been made that possibly Siam rice possessed special beri-beri producing qualities, the Ministry of Local Government decided to institute an official inquiry into the matter, and Dr. H. Campbell Highet, principal medical officer of health of Bangkok, was instructed to conduct the investigations, assisted by members of his scientific staff. His report has now been published, and it confirms the conclusions generally arrived at by Eraser and Stanton, as well as by other experts in the Malay Peninsula and elsewhere, and which we have from time to time reported in the columns of THE LANCET. Dr. Highet and his colleagues by their experiments demonstrated that Siam rice, when not over-milled, compares very favourably with PREVENTION OF TUBERCULOSIS AMONG rice from other places, such as Rangoon and Saigon, and that " CHILDREN. a beri-beri preventing rice can be prepared from Siam "padi " THE Public Health Bulletin No. 58 of the United States either by hand or steam mill and without the padi being Public Health Service deals with "Open-Air Schools for previously parboiled. Thephosphorus content of a rice should the Prevention and Cure of Tuberculosis among Children," not be less than 4 per cent., and this should be taken as the and is a document which should prove of interest and indicator of the safety or otherwise of the rice. In view of value to all concerned with preventive or curative medical the overwhelming evidence incriminating over-milled rice in work among the child population. The report is by Dr. connexion with beri-beri, some reformers have strongly B. S. Warren, passed assistant surgeon, United States urged that the law should interfere to prohibit the sale of Public Health Service, and is based on experience gained this rice which has by milling been deprived of certain in St. Louis, Mo., and on reports of open-air schools elements necessary for normal nutrition, but Dr. Highet in other parts of the United States. He states that the expresses the opinion that, for the present at least, legislatwo main points to be considered in selecting a site for a tion in that direction in Siam is not advisable, more school ,are accessibility and hygienic environment, and especially as it is not yet admitted what the actual substance mentions the flat top of a large city building as a is, the removal of which from the exterior of the rice grain possibility, but thinks it better to sacrifice accessibility if by the process of milling leads to the development of berione of the points must be given up. The type of building beri in the consumers of such rice. Meanwhile, the use of recommended is that open on all sides with canvas drop white, over-milled rice has been prohibited in the Siamese curtains for protection against severe cold winds. A school navy and in all the Government institutions, including suitable for 30 children is described, and detail plans are asylums and prisons, as well as among the provincial given with photographs of a school erected from these plans. gendarmery, a force which comprises about 9000 men. The He advises separate schools for pretubercular or "closed result of this prohibition has been the almost complete discases"with no tubercle bacilli in sputum or other discharges, appearance of beri-beri from these various bodies ; and were and for the open cases"with tubercle bacilli present. One the Siamese army to follow suit the disease would, of the photographs shows the open-air school being carried on Dr. Highet says, be practically extinguished from the whole with snow on the ground, and the children are provided with of the public service of the country. As regards the general Eskimo suits, looking very warm and cosy. A curious point population which has come to prefer the white rice and to which has been noted in England is commented on by Dr. reject any that is not well milled and polished, it is hoped Warren when he says :‘ Habits of life of the child should that in time the force of education of the people in matters of diet and as to the danger arising from the consumption of 1 THE LANCET, Jan. 28th, 1905, rice deprived of some of its essential constituents will lead to 256. p. ____