THE MECHANISM OF PULMONARY COLLAPSE.

482 the private masseuse, for which the ordinary had consistently warred on the process of infection, fees were necessarily high. The masseuses had but one result of each movement for the betterment decided to start a clinic for people of limited means of the people was that certain diseases had been who wished to pay but could not afford the full fees, extinguished in this country long before medicine and by the kindness of the Pleasance Trust they had had discovered their causes or found specific methods been allowed to start it in the Pleasance. The clinic of control. was meant to be self-supporting. Patients were The return by Dr. Pratt Yule, the county medical as a rule recommended to come by their own doctors, officer of Fife, states that 335 cases of tuberculosis and the work was done under medical supervision. were notified in the county during 1929, that 315 were confirmed, that the number of known cases on Dec. Housing Improvements in Edinburgh. 31st was 911, and that the number of cases in instituThe new housing improvements proposed for I tions was 97. Edinburgh involve the provision of 1557 houses for At the annual meeting of the Edinburgh Juvenile displaced tenants, and the scheme is the largest of Organisations Committee Lord Linlithgow commended its kind ever undertaken by the Corporation. The the work of the association, and put emphasis total cost would be about jS854,000, which amounts strongly on the need for careful case-recording. This organisato about a penny per pound on the rates. The reports tion acts as a for the societies affiliated of the medical officer of health, the burgh engineer, with it. But clearing-house it also does direct work. It keeps close and the sanitary inspector furnish abundant justifica- touch with the police-courts and with the sheriff tion for the Corporation’s action in framing the court. proposals. The general death-rate per 1000 for the area is 19, as against 14-3 for the whole city. The pulmonary tuberculosis death-rate is 1-3, as against 0-9 for the city. The death-rate for other forms of tuberculosis is 0-7 for the area, as against 0-3 for the city, and the respiratory diseases death-rate is 4-2 Audi alteram partem." for the area, as against 2-2 for the city. The infantile mortality is 120, as against 84 for the city. Under five deaths were 36-2 per cent. of total deaths, against THE MECHANISM OF PULMONARY COLLAPSE. 17-1 for the city. These facts are reinforced by the To the Editor of THE LANCET. details of overcrowding. The sanitary inspector quoted cases of common stairs which included from SIR,-Why do not open wounds of the visceral 29 in one case to 49 " houses " in another, and pleura involve collapse of the lung ? In your leading provided accommodation for from 107 to 119 people. article last week on Surgical Access to the Chest That, he said, made decent and healthy living reference is made to recent discussions involving impossible. The stairs were of the spiral variety, and answers to this question, as well as to Sir John Rose were so dark as to be dangerous. Bradford’s valuable address on Massive Collapse of The area chosen contains some of the oldest houses the Lung. May I explain what appears to me to be in Edinburgh. It was on passing some of these that the solution of this and many other problems arising Edmund Parkes said that these were not houses but out of various clinical phenomena ? It is over thirty years ago that I first directed villages standing on end. Those ancient and illconstructed tenements are the supreme difficulty of attention to the clinical importance of the physiological the great Scottish cities. In the new schemes the rhythmical dilatation and contraction of the bronCorporation intends to take care that the general chioles.1 In utero the lungs of the full-time child are historical landmarks shall not be too seriously inter- solid and the trachea and bronchi are collapsed, or fered with. This area of St. Leonards has been any potential space is occupied by secretion. At crying for improvement for two or three generations. birth the dilatation of the nostrils and glottis aid free The success of the other Edinburgh housing schemes inspiration and this air soon occupies the trachea and has, no doubt, had an influence in inducing the larger bronchi. The contraction of the glottis on Corporation to make this great further effort. expiration impedes the escaping breath, hence the air is in part retained, only to be increased in volume at The Blind of Dundee. the next breath. This rhythmical dilatation and The Dundee and Lochee Mission for the Outdoor contraction of the nostrils and glottis is associated Blind are peculiarly fortunate in receiving under the with corresponding rhythmical dilatation and conwill of the late Sir James Duncan, of Coupar Grange, traction of the bronchioles, which get quickly filled Perthshire, a sum amounting to jB59,901. Within the and overfilled and thus the alveoli too become filled last ten or twelve years the whole problem of the with air. blind has been placed on a much more satisfactory The same physiological rhythmical dilatations and footing. One does not know the conditions of this contractions of the broncbioles ensure the continued large bequest, but it seems a pity that the money full dilatation of the pulmonary vesicles against the could not be controlled by some central body in the contractile force exercised by the elastic fibres in the interests of the Scottish blind as a whole, or even of lung, and thus, too, under normal conditions the air the Dundee blind as a whole. The problems of work pressure and oxygen tension in the vesicles is mainand teaching have given a great deal of trouble to the tained. Consequently, a shell wound ripping open the authorities, but those problems are working towards a chest wall and its parietal pleura is not followed by satisfactory solution. Under the Statute, the Health collapse of the lung, provided the visceral pleura Department for Scotland is guided by a large Advisory remains intact. Hence, too, the surgeon operating for Committee, which includes general and technical empyema need not fear to open the chest wall and members. No doubt the developments in Dundee parietal pleura even in the absence of adhesions will be supervised in such a way as to ensure that this between the pleural layers, provided the visceral pleura is uninjured. relatively large sum shall be equitably administered. On the other hand, a minute perforation (very much Glasgow Corporation Lectures. smaller that the glottis) of the visceral pleura results Prof. John R. Currie, of Glasgow University, in a in acute pneumothorax, the lung collapses unless, of recent lecture on Infection and Progress, gave some course, adventitious adhesions suffice to prevent this Once collapsed, the striking instances of how disease disappears not from otherwise inevitable sequence. direct attack but incidentally as a result of social minute perforation of the visceral pleura usually soon movements. He referred to two forms of infection heals and closes, and then again the physiological as of special importance. The two principal ways in 1 Encyclopædia Medica, 1st ed., vol. ii., 1899, p. 117, and which infection spreads were, he said, by spray from Bristol Medico-Chirurgical Journal, March. 1903, on the Probable the act of in or and the mouth speaking coughing, Rhythmical Contraction of the Bronchial Muscular Coat as a by blood-sucking insects. Medical and social progress Factor in Pulmonary Disease.

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rhythmical dilatation and contraction of the bronchioles will make that lung dilate up and reoccupy the normal space belonging to it in the chest. This but repeats what caused that lung to dilate at birth and become a normally distended lung. If my theory is correct this rhythmical dilatation and contraction of the bronchioles explains why it is that sometimes distension of the pulmonary alveoli occurs beyond the site of obstruction by a close-fitting foreign body like a bean in a bronchus. Inspiratory

in the Army V.D. hospitals wisely includes compulsory rest in bed during the acute stage of the disease, and this is of psychological as well as physical importance in bringing home to a man the necessity of taking the disease seriously. May I also briefly refer to Dr. Sequeira’sletter of Jan. 18th on compulsory treatment of V.D. and the rejection by Parliament of various Bills thereon ? In approving its action, he dwells entirely on the debatable ground of the relative curative value of salvarsan, but surely the case for compulsory treatment rests as much on the fact that salvarsan therapy is the quickest and most efficacious method of rendering a patient non-infective to others as on 2

dilatation allows the air to pass into the bronchus past the bean, but on expiratory contraction the bronchiolar muscle clings so tightly to the surface of the bean that no air escapes, or at any rate less than the permanency of the cure of the individual. was inspired into that pulmonary area. I am, Sir, yours faithfully, I am, Sir, yours faithfully, PATRICK WATSON-WILLIAMS. W. H. DICKINSON PRIEST,

Late M.O. i/c Venereal Diseases, British Army of the Rhine. Royal Waterloo Hospital, Feb. 24th, 1930.

Clifton, Bristol, Feb. 24th, 1930.

"A PERNICIOUS TYPE OF ANÆMIA." To the Editor of THE LANCET.

pernicious type of

HOUSING AND RHEUMATIC DISEASE.

To the Editor of THE LANCET. SIR,-Dr. Avery’s report anaemia following erythraemia, appearing in your issue is certainly an important factor of Feb. 15th (p. 342), presents points of great hsemato- in SiR,—Environment the rheumatic diseases, including producing logical interest. Is it not, however, time that the rheumatoid arthritis, which are responsible for a large term " pernicious type of anaemia " be discarded ? amount of in this country. R. H. Miller It is,I think, commonly agreed that the essential has indeed invalidity remarked that environment, taken as a haematological characteristics of pernicious anaemia whole, is of such importance that rheumatism may are : reduction in the number of red corpuscles, with be regarded as an environmental disease. Of these a high colour-index; leucopenia ; and relative environmental conditions housing occupies the first lymphocytosis, together with an invariable megalo- place, and a survey of housing since the end of the cytosis. In Dr. Avery’s case the leucocytes were never great war throws much light on this subject. The below 8600 per c.mm., and at this time the lymphoshortage of houses at the end of the war necessitated cytes were 6’67 per cent. Then again, as Addison rapid erection. Wooden houses at first took the place was the first to point out, emaciation does not occur of more permanent structures, and this was followed in pernicious anaemia, whereas Dr. Avery’s post- I the adaptation of army huts. Then came jerryby mortem report states that the body was wasted. The built houses of cheap brick with walls of minimum indefinite character of the ferro-cyanide reaction in thickness, ready made staircases, doors and windowthe spleen is certainly an unusual finding in the frames of unseasoned wood. Foundations were laid typical disease. It seems that the only reason for with inefficient ventilation, no tongue and grooved regarding the aneemia as being of pernicious type is boarding was used for in low lying districts the fact that the patient improved when given houses were built on flooring; soils without efficient marshy half a pound of liver daily. One can picture what must be the condidraining. I find untenable Dr. Avery’s explanation of anaemia tion of clothing, bedding, and furniture in such houses, due to excessive irradiation as being the result of and how the plaster, the ground gases passing destruction of erythropoietic tissue and impairment between thesweating floor boards, thetimber warping and of the haemolytic function of the spleen. Mayneord leaving spaces for the admission of damp must affect and Piney (Brit. Jour. Rad., 1928) showed an extreme the health of the inhabitants. degree of haemosiderosis in the spleen of rabbits that These new houses are, I believe, a definite cause of had been exposed to large doses of X rays. Further- rheumatism and fibrositis. Rheumatism may be more, in cases of chronic myeloid leukaemia with induced in an individual in one district, whereas living severe secondary anaemia irradiation of the bones in another district not many miles away he may be only is often followed by reduction in the number of quite free from pain and inconvenience. There are, leucocytes and a rise in the number of red corpuscles. for instance, two places in the Thames valley within I in that conclusion May express my gratification reach of London less than a mile apart but there still remain writers who, in spite of the modern easy the river. In one of these districts separated fashion, will publish accounts of singular cases of rheumatismbyis almost unknown, while in the other it such great interest as the one under discussion. is extremely prevalent. The former is flat with gravel I am, Sir, yours faithfully, soil and a limited number of trees. It is on the level A. PINEY. of the river. The latter abounds with trees, has a The Cancer Hospital, Fulham-road, S.W., Feb. 21st, 1930. heavy loam and gravel soil, and is 40 feet higher than the river. They have the same water-supply, and the climate is identical. A man well known to REST IN THE TREATMENT OF GONORRHŒA. me removed from the former to the latter, and within a few weeks could only roll out of bed in the mornings. To the Editor of THE LANCET. Six months later he moved back again on account of SiR,-Dr. Byles’s insistence on the importance of the rheumatism which had become so severe. Within rest in bed in gonorrhoea cannot be too strongly two days he could rise in the mornings without emphasised. Surely, however, the time has hardly discomfort, and except for a few fibrous nodules the yet come when " the onus of refusing to lie up must rheumatism disappeared. In another district 250 be put on the unhappy victim." " Propaganda and miles from London rheumatism is very prevalent. leanets " may, as Dr. Byles says, have " made these This district is flat with the subsoil water only a few complaints a subject of ordinary conversation in inches below the surface ; there are few trees and the mixed companies’," but in the previous sentence he town is bleak and windswept. It is surrounded by admits the " still persisting taboo, disgrace, and miles of flat marshy land and is at sea-level. At one I secrecy " involved. There are few walks of life in ’i point where numerous dwellings abound the subsoil which the required rest in bed can always be carried water is 4 inches from the surface; ground gases out without disclosing the real nature of the illness, are most prevalent. The soil is sandy and the watersooner or later. The routine treatment of gonorrhoea supply is derived from artesian wells, the water being on a

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