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THE PATHOLOGY OF BURNS.
1269 fusion of neighbouring foci of the later stages give rise to
proliferation may in technical apparently single It should
an
Moreover, at the margin or neck of the .adenoma the adjacent epithelium presents pronounced chronic inflammatory changes. In course of time malignancy supervenes in these irritated cells, as well as in the cells of the adenoma itself. Dr. Dukes suggests that a cancrogenic agent causes a more than usually vigorous growth in many separated spots in a considerable area of mucous membrane. Later, - a crop of adenomata arise from this sensitive field, .and some of these become surrounded by secondary tumours. The mucosa between these primary and secondary tumours becomes irritated, hampered in its growth, and folded inwards. Whether the malignant change develops in these dislocated cells or whether in the cells of the actual adenomata is uncertain, but the cancer makes its appearance when .a crop of simple tumours has arisen in an irritated field and in close association with one of them. The author’s conclusions are supported by excellent figures and diagrams, and his article is as convincing .as’ it is interesting. .growth.
____
RESEARCH IN BREWING.
BREWING, like the agriculture of to-day and the medicine of yesterday, is one of those ancient crafts which the patient labour of the scientific investigator is slowly raising from the status of an empirical art to that of a science. It is to the credit of the brewing .trade, at a time when many industries are accepting or seeking help from some outside source, that its own Institute has financed a research scheme by a system of voluntary contributions based on output Results of considerable from nearly 300 firms. technical and scientific value appear in the fifth report of the Institute of Brewing Research Scheme, covering the period April, 1924, to April, 1926, which has just been issued. Beer needs for its -manufacture four main ingredients-water, barley malt, hops, and yeast-and each of these materials .forms the chief subject-matter for investigation by the Until the Institute .four subcommittees of experts. .shall have appointed a director-general of research .the chairman of the Research Fund Committee, Mr. J. S. Ford, F.R.S.E., is acting in that capacity. Field experiments, carried on all over England on the influence of soil, season, and manures on the yield and quality of barley grown for malting, are supervised by Sir John Russell, F.R.S., director of the Rothamstead Experimental Station. After .malting the analytical work is in the hands of Mr. H. Lloyd Hind, whose results promise well for both farmer and brewer. Investigations on hops comprise the systematic breeding and crossing of new varieties at the South-Eastern Agricultural College, Wye, by Prof. E. S. Salmon, and their testing at the East Malling Research Station and at Horsmonden. ’The objects in view are to procure for the grower new and prolific varieties of hop more able to resist disease, while at the same time securing for the brewer the qualities he considers valuable. Chemical investigations on the preservative and antiseptic -properties of hops have engaged the attention of Prof. F. L. Pyman, F.R.S., and Dr. T. K. Walker at Manchester since 1921. It may not be generally known that apart from the agreeable flavour conferred - own beer by hops, they are a valuable ally to the brewer in his fight against the invasion of his beer by the foreign organisms which cause turbidity, fret and acidity. Valuable work is being done on the keeping properties of the yeast used for fermentation and the effect of hydrogen-ion concentration on the character and stability of beer. The - measurement of the true " free acidity " is becoming recognised as an essential procedure in the various stages of brewing. Over and above the actual staff of the Institute a large body of farmers, brewers, -chemists, maltsters, and hop-growers-all busy menvoluntarily give their services on numerous com:mittees supervising the researches, while expert .annual
assistance is engaged where required. not be forgotten that it was on the basis of Pasteur’s researches on the disease organisms of wine and beer that arose the superstructure of modern surgery and preventive medicine.
FLUORINE AS A SLOW POISON. THE toxic effects of long-continued small doses of iodine and bromine and their derivatives are well known. Recently Prof. H. Cristiani has described1 chronic poisoning by another member of the halogen series, fluorine. This element is apparently present in minute quantities in many of our foodstuffs, and was at one time frequently used as a preservative, although its use as such is now prohibited in most countries. In the neighbourhood of certain factories the food of animals may contain toxic quantities of fluorine, and this element may also be present in excess in water into which certain industrial products have been allowed to pass. In some districts in Switzerland where these conditions are present an enclemic disease occurs among animals, characterised by wasting and cachexia, with a special localisation in the regions of the vertebral column and lower limbs, while the bones become softened and frequently show spontaneous fractures. On account of this last symptom the disease has usually been considered by veterinarians as a form of osteomalacia, and farmers and others seeking compensation for their diseased cattle have been met by the statement that there is no evidence that osteomalacia can be caused by the ingestion of poisonous substances. Prof. Cristiani has set himself to disprove this, and he has established that the disease from which these animals suffer can be separated from true osteomalacia and should be " " designated by a separate name such as fluorism or " fluorine cachexia." His experiments consisted in feeding animals on diets which, while maintaining perfect health in control animals, produced the syndrome described above when there was added in small doses (a) hay which was suspected of having produced the disease in cattle ; (b) hay mildly .impregnated with certain salts of fluorine, or (c) grass submitted to the action of fluorine in one of its gaseous forms and used either fresh or as hay. The time of appearance of symptoms was variable and depended to a certain extent on the dose of fluorine employed. The experimental animals wasted and eventually died with symptoms of bulbar paralysis and respiratory failure. At autopsy the bone-marrow was found to be extremely scanty ; the bone-tissue showed much rarefaction, and the bones on analysis showed a high fluorine content. Prof. Cristiani is at present studying the question as to whether chronic fluorine poisoning occurs in man. Its symptoms are so slow in appearing and in progressing that it may possibly be present sometimes among the inhabitants of industrial areas where much fluorine is produced. ____
THE PATHOLOGY OF BURNS. was for a long time a good deal of difficulty in explaining the toxaemia and death which may follow burns, and it is only comparatively recently that our knowledge of the subject has determined to a satisfactory explanation which brings the ill-effects of burns into line with the shock due to tissue injury. The evidence, along with an interesting discussion of burns of all kinds, is well summarised by Dr. G. T. Pack in the Archives of Pathology and Laboratory Medicine (1926, i., 767). In the first place, it is clear that the poisonous substance comes from the burned tissue and is carried in the blood; if the tissue is excised toxemia is prevented, and if burned skin is transplanted from one animal to another the latter has symptoms and dies. If one of a pair of experimental Siamese twins is burned, both have symptoms, and experiments with crossed circulations show that the THERE
1 La Presse Médicale, April 14th, 1926, p. 469.
1270 animal which is poisoned is the one in which the blood from the burned tissue circulates and not the one of which the burned tissue forms a part. In the second place, it has been shown that the poison is not generated in the process of burning but subsequently. Symptoms in man do not appear till, perhaps, 24 hours after the actual burning, and if parabiotic twin animals are separated within 12 hours after one has been burned the other does not develop symptoms. The facts are strikingly in accord with those by which Cannon, Dale, and others have shown that secondary shock is due to the absorption of histamine and similar bodies which arise in the dis-
integration of smashed-up tissues. They also give a satisfactory explanation of why the danger of a burn depends more on its surface area than its severity. The poisonous products of autolysis do not come from the tissues which are thoroughly destroyed-charring or anything near it breaks them up beyond the possibility of that-but from the tissues in the next zone where the cells are killed by heat but not actually burned. These dead cells autolyse and break up ; this takes some time and explains the delay in the onset of symptoms. And it is evident that a severe carbonising burn does not necessarily produce more dead cells capable of a poisonous autolysis than a comparatively superficial lesion of the same surface The dangerous tissues are those which area. have been heated just enough to kill them without destroying the autolytic ferments or causing much chemical decomposition. THE ROYAL SOCIETY CONVERSAZIONE. THE deferred annual conversazione given by the Royal Society was held at Burlington House on June 16th, when leading scientists took the opportunity offered to display the results of their investigations, and a very large circle of interested visitors was enabled to gain an insight into recent developments of scientific inquiry. The majority of the exhibits shown on this occasion related to problems in physics, some of them of direct interest to radiologists. Prof. 0. W. Richardson showed an apparatus for the investigation of soft X rays varying in wave-length from about 20 to 400 Angstrom units. For this purpose a highly exhausted X ray tube of transparent silica was excited by constant potentials of from 300 to 600 volts. Owing to the low penetrating power of the rays produced by these voltages, the means for measuring them was incorporated in the tube. A series of photographs of 13 ray tracks produced by X rays in different gases was shown by physicists These tracks of Victoria University, Manchester. may be divided roughly into two groups according ’to their length. The long tracks are due to electrons ejected from atoms which have absorbed a quantum of X rays, whilst the short ones are supposed to accompany the process of scattering by matter. Of these two phenomena the latter is of more importance in light gases and is one which will probably engage the attention of radiologists in the near future. Radiography was represented by a series of plates taken at the Royal Arsenal, Woolwich. A radiograph showing a cavity 0-3 in. wide in a piece of steel 4 in. thick, served to illustrate the high penetrating power of the X rays which may now be produced and of the differentiation in density which is possible with them. A number of electrical instruments for physiological research were shown by Mr. A. C. Downing, who has determined the heat values for muscle and nerve actuated by a variety of stimuli. An exhibit of Mr. T. S. P. Strangeways and Dr. H. B. Fell marks an advance in tissue culture, shown by the development in vitro of the isolated eye of the embryonic fowl. For these experiments one eye dissected out from a fowl embryo of 64 to 70 hours’ incubation was explanted into a medium composed of fowl plasma and embryonic tissue extract, whilst the other eye served as a control. The specimens exhibited showed the growth of the lens, the ’formation =of’ pigment, the .differentiation,
of the iris and the development of the reticular, ganglion cells, nuclear and " rods and cones " layer of the retina. The eyes under cultivation were thus seen to grow in a surprisingly normal manner. Of historical interest was an early microscope of the Leeuwenhoek type and possibly the only example of its kind in England. The instrument was made by Butterfield, who, in 1678, communicated to the Royal Society a paper on the Making of Microscopes with Small Single Glasses. The instrument shown was made of silver and consisted of one lens and a movable pair of forcepR for supporting the specimen under observation. A microscope of this type was used by Leeuwenhoek for most of his classical work.
BELATED HOSPITAL REPORTS.
IT is an old complaint that Government reports and statistics are published so long after the dates to which they refer that their usefulness is much diminished. Similar disabilities are inflicted in full measure upon those who, of necessity or from inclination, are concerned with hospital affairs and hospital figures. A few days hence the first half of 1926 will have passed, yet we are still receiving hospital reports for the year ending Dec. 31st, 1925, provincial newspapers are still reporting belated annual meetings, and similar things will happen for some time to come. We are well aware that hospital staffs, medical and lay, are always pressed with work; but an annual report is part of that work, and it is not more arduous to undertake it in January than in March or April, or even later. It cannot often chance that important material is unavailable for many weeks or several months after the end of the year, and we are quite sure that it is difficult to avoid languor and weariness when dealing with facts and figures which lapse of time has robbed of their freshness. Moreover, the student of these reports and statistics has an uneasy sense that he is conning ancient history and that his reflections and conclusions may be to a greater or less extent vitiated by delay and the emergence of new circumstances. Once upon a time these delays were of comparatively small moment, but are the most outstanding fact in the domain of public health. They are watched more carefully than ever before; since the war the number of people interested in their individual fortunes and in the voluntary system generally has enormously increased, and it would seem to be only businesslike prudence to publish the results of their year’s work as speedily as possible. The reports issued by many of the larger hospitals are volumes of real scientific, social,- and statistical importance, and it is’ much to be regretted that information of obvious comparative value should be withheld both from specialists and the general public until it is growing stale and, perhaps, halfway towards being superseded by later experience.
to-day hospitals
GLASGOW ROYAL INFIRMARY AUXILIARY HOSPITAL. The pressure upon the wards and the long waiting list have made it imperative that an auxiliary hospital should be established at an early date. Some time ago Mr. James Macfarlane, the chairman of the board, and his brother, Mr. George W. Macfarlane, provided a site of 22 acres at Canniesburn, some five or six miles outside the city. The trustees of a recently deceased testator have now given 210,000 to the cost of building ; a similar sum was given last year by Miss Margaret Clarke, the daughter of a former
Glasgow physician.
A GARDEN HOME
FOR PRE-TUBERCULOUS CHILDREN. Liverpool Hospital for Consumption will shortly open at Frankley, in Cheshire, a garden home, with 40 beds, in 18 acres of land, for pre-tuberculous children. It is hoped
The
later on to extend the home considerably, as 150 beds are needed for Liverpool alone, apart from those required for Cheshire. During the past year a nurses’ home has been built in Delamere Forest, separate from the sanatorium there. Dr. H. A. Clarke has just retired from the active medical staff of the hospital after 33 years’ service,’ and has been
appointed consulting physician.
,
proliferation may in technical apparently single It should
an
Moreover, at the margin or neck of the .adenoma the adjacent epithelium presents pronounced chronic inflammatory changes. In course of time malignancy supervenes in these irritated cells, as well as in the cells of the adenoma itself. Dr. Dukes suggests that a cancrogenic agent causes a more than usually vigorous growth in many separated spots in a considerable area of mucous membrane. Later, - a crop of adenomata arise from this sensitive field, .and some of these become surrounded by secondary tumours. The mucosa between these primary and secondary tumours becomes irritated, hampered in its growth, and folded inwards. Whether the malignant change develops in these dislocated cells or whether in the cells of the actual adenomata is uncertain, but the cancer makes its appearance when .a crop of simple tumours has arisen in an irritated field and in close association with one of them. The author’s conclusions are supported by excellent figures and diagrams, and his article is as convincing .as’ it is interesting. .growth.
____
RESEARCH IN BREWING.
BREWING, like the agriculture of to-day and the medicine of yesterday, is one of those ancient crafts which the patient labour of the scientific investigator is slowly raising from the status of an empirical art to that of a science. It is to the credit of the brewing .trade, at a time when many industries are accepting or seeking help from some outside source, that its own Institute has financed a research scheme by a system of voluntary contributions based on output Results of considerable from nearly 300 firms. technical and scientific value appear in the fifth report of the Institute of Brewing Research Scheme, covering the period April, 1924, to April, 1926, which has just been issued. Beer needs for its -manufacture four main ingredients-water, barley malt, hops, and yeast-and each of these materials .forms the chief subject-matter for investigation by the Until the Institute .four subcommittees of experts. .shall have appointed a director-general of research .the chairman of the Research Fund Committee, Mr. J. S. Ford, F.R.S.E., is acting in that capacity. Field experiments, carried on all over England on the influence of soil, season, and manures on the yield and quality of barley grown for malting, are supervised by Sir John Russell, F.R.S., director of the Rothamstead Experimental Station. After .malting the analytical work is in the hands of Mr. H. Lloyd Hind, whose results promise well for both farmer and brewer. Investigations on hops comprise the systematic breeding and crossing of new varieties at the South-Eastern Agricultural College, Wye, by Prof. E. S. Salmon, and their testing at the East Malling Research Station and at Horsmonden. ’The objects in view are to procure for the grower new and prolific varieties of hop more able to resist disease, while at the same time securing for the brewer the qualities he considers valuable. Chemical investigations on the preservative and antiseptic -properties of hops have engaged the attention of Prof. F. L. Pyman, F.R.S., and Dr. T. K. Walker at Manchester since 1921. It may not be generally known that apart from the agreeable flavour conferred - own beer by hops, they are a valuable ally to the brewer in his fight against the invasion of his beer by the foreign organisms which cause turbidity, fret and acidity. Valuable work is being done on the keeping properties of the yeast used for fermentation and the effect of hydrogen-ion concentration on the character and stability of beer. The - measurement of the true " free acidity " is becoming recognised as an essential procedure in the various stages of brewing. Over and above the actual staff of the Institute a large body of farmers, brewers, -chemists, maltsters, and hop-growers-all busy menvoluntarily give their services on numerous com:mittees supervising the researches, while expert .annual
assistance is engaged where required. not be forgotten that it was on the basis of Pasteur’s researches on the disease organisms of wine and beer that arose the superstructure of modern surgery and preventive medicine.
FLUORINE AS A SLOW POISON. THE toxic effects of long-continued small doses of iodine and bromine and their derivatives are well known. Recently Prof. H. Cristiani has described1 chronic poisoning by another member of the halogen series, fluorine. This element is apparently present in minute quantities in many of our foodstuffs, and was at one time frequently used as a preservative, although its use as such is now prohibited in most countries. In the neighbourhood of certain factories the food of animals may contain toxic quantities of fluorine, and this element may also be present in excess in water into which certain industrial products have been allowed to pass. In some districts in Switzerland where these conditions are present an enclemic disease occurs among animals, characterised by wasting and cachexia, with a special localisation in the regions of the vertebral column and lower limbs, while the bones become softened and frequently show spontaneous fractures. On account of this last symptom the disease has usually been considered by veterinarians as a form of osteomalacia, and farmers and others seeking compensation for their diseased cattle have been met by the statement that there is no evidence that osteomalacia can be caused by the ingestion of poisonous substances. Prof. Cristiani has set himself to disprove this, and he has established that the disease from which these animals suffer can be separated from true osteomalacia and should be " " designated by a separate name such as fluorism or " fluorine cachexia." His experiments consisted in feeding animals on diets which, while maintaining perfect health in control animals, produced the syndrome described above when there was added in small doses (a) hay which was suspected of having produced the disease in cattle ; (b) hay mildly .impregnated with certain salts of fluorine, or (c) grass submitted to the action of fluorine in one of its gaseous forms and used either fresh or as hay. The time of appearance of symptoms was variable and depended to a certain extent on the dose of fluorine employed. The experimental animals wasted and eventually died with symptoms of bulbar paralysis and respiratory failure. At autopsy the bone-marrow was found to be extremely scanty ; the bone-tissue showed much rarefaction, and the bones on analysis showed a high fluorine content. Prof. Cristiani is at present studying the question as to whether chronic fluorine poisoning occurs in man. Its symptoms are so slow in appearing and in progressing that it may possibly be present sometimes among the inhabitants of industrial areas where much fluorine is produced. ____
THE PATHOLOGY OF BURNS. was for a long time a good deal of difficulty in explaining the toxaemia and death which may follow burns, and it is only comparatively recently that our knowledge of the subject has determined to a satisfactory explanation which brings the ill-effects of burns into line with the shock due to tissue injury. The evidence, along with an interesting discussion of burns of all kinds, is well summarised by Dr. G. T. Pack in the Archives of Pathology and Laboratory Medicine (1926, i., 767). In the first place, it is clear that the poisonous substance comes from the burned tissue and is carried in the blood; if the tissue is excised toxemia is prevented, and if burned skin is transplanted from one animal to another the latter has symptoms and dies. If one of a pair of experimental Siamese twins is burned, both have symptoms, and experiments with crossed circulations show that the THERE
1 La Presse Médicale, April 14th, 1926, p. 469.
1270 animal which is poisoned is the one in which the blood from the burned tissue circulates and not the one of which the burned tissue forms a part. In the second place, it has been shown that the poison is not generated in the process of burning but subsequently. Symptoms in man do not appear till, perhaps, 24 hours after the actual burning, and if parabiotic twin animals are separated within 12 hours after one has been burned the other does not develop symptoms. The facts are strikingly in accord with those by which Cannon, Dale, and others have shown that secondary shock is due to the absorption of histamine and similar bodies which arise in the dis-
integration of smashed-up tissues. They also give a satisfactory explanation of why the danger of a burn depends more on its surface area than its severity. The poisonous products of autolysis do not come from the tissues which are thoroughly destroyed-charring or anything near it breaks them up beyond the possibility of that-but from the tissues in the next zone where the cells are killed by heat but not actually burned. These dead cells autolyse and break up ; this takes some time and explains the delay in the onset of symptoms. And it is evident that a severe carbonising burn does not necessarily produce more dead cells capable of a poisonous autolysis than a comparatively superficial lesion of the same surface The dangerous tissues are those which area. have been heated just enough to kill them without destroying the autolytic ferments or causing much chemical decomposition. THE ROYAL SOCIETY CONVERSAZIONE. THE deferred annual conversazione given by the Royal Society was held at Burlington House on June 16th, when leading scientists took the opportunity offered to display the results of their investigations, and a very large circle of interested visitors was enabled to gain an insight into recent developments of scientific inquiry. The majority of the exhibits shown on this occasion related to problems in physics, some of them of direct interest to radiologists. Prof. 0. W. Richardson showed an apparatus for the investigation of soft X rays varying in wave-length from about 20 to 400 Angstrom units. For this purpose a highly exhausted X ray tube of transparent silica was excited by constant potentials of from 300 to 600 volts. Owing to the low penetrating power of the rays produced by these voltages, the means for measuring them was incorporated in the tube. A series of photographs of 13 ray tracks produced by X rays in different gases was shown by physicists These tracks of Victoria University, Manchester. may be divided roughly into two groups according ’to their length. The long tracks are due to electrons ejected from atoms which have absorbed a quantum of X rays, whilst the short ones are supposed to accompany the process of scattering by matter. Of these two phenomena the latter is of more importance in light gases and is one which will probably engage the attention of radiologists in the near future. Radiography was represented by a series of plates taken at the Royal Arsenal, Woolwich. A radiograph showing a cavity 0-3 in. wide in a piece of steel 4 in. thick, served to illustrate the high penetrating power of the X rays which may now be produced and of the differentiation in density which is possible with them. A number of electrical instruments for physiological research were shown by Mr. A. C. Downing, who has determined the heat values for muscle and nerve actuated by a variety of stimuli. An exhibit of Mr. T. S. P. Strangeways and Dr. H. B. Fell marks an advance in tissue culture, shown by the development in vitro of the isolated eye of the embryonic fowl. For these experiments one eye dissected out from a fowl embryo of 64 to 70 hours’ incubation was explanted into a medium composed of fowl plasma and embryonic tissue extract, whilst the other eye served as a control. The specimens exhibited showed the growth of the lens, the ’formation =of’ pigment, the .differentiation,
of the iris and the development of the reticular, ganglion cells, nuclear and " rods and cones " layer of the retina. The eyes under cultivation were thus seen to grow in a surprisingly normal manner. Of historical interest was an early microscope of the Leeuwenhoek type and possibly the only example of its kind in England. The instrument was made by Butterfield, who, in 1678, communicated to the Royal Society a paper on the Making of Microscopes with Small Single Glasses. The instrument shown was made of silver and consisted of one lens and a movable pair of forcepR for supporting the specimen under observation. A microscope of this type was used by Leeuwenhoek for most of his classical work.
BELATED HOSPITAL REPORTS.
IT is an old complaint that Government reports and statistics are published so long after the dates to which they refer that their usefulness is much diminished. Similar disabilities are inflicted in full measure upon those who, of necessity or from inclination, are concerned with hospital affairs and hospital figures. A few days hence the first half of 1926 will have passed, yet we are still receiving hospital reports for the year ending Dec. 31st, 1925, provincial newspapers are still reporting belated annual meetings, and similar things will happen for some time to come. We are well aware that hospital staffs, medical and lay, are always pressed with work; but an annual report is part of that work, and it is not more arduous to undertake it in January than in March or April, or even later. It cannot often chance that important material is unavailable for many weeks or several months after the end of the year, and we are quite sure that it is difficult to avoid languor and weariness when dealing with facts and figures which lapse of time has robbed of their freshness. Moreover, the student of these reports and statistics has an uneasy sense that he is conning ancient history and that his reflections and conclusions may be to a greater or less extent vitiated by delay and the emergence of new circumstances. Once upon a time these delays were of comparatively small moment, but are the most outstanding fact in the domain of public health. They are watched more carefully than ever before; since the war the number of people interested in their individual fortunes and in the voluntary system generally has enormously increased, and it would seem to be only businesslike prudence to publish the results of their year’s work as speedily as possible. The reports issued by many of the larger hospitals are volumes of real scientific, social,- and statistical importance, and it is’ much to be regretted that information of obvious comparative value should be withheld both from specialists and the general public until it is growing stale and, perhaps, halfway towards being superseded by later experience.
to-day hospitals
GLASGOW ROYAL INFIRMARY AUXILIARY HOSPITAL. The pressure upon the wards and the long waiting list have made it imperative that an auxiliary hospital should be established at an early date. Some time ago Mr. James Macfarlane, the chairman of the board, and his brother, Mr. George W. Macfarlane, provided a site of 22 acres at Canniesburn, some five or six miles outside the city. The trustees of a recently deceased testator have now given 210,000 to the cost of building ; a similar sum was given last year by Miss Margaret Clarke, the daughter of a former
Glasgow physician.
A GARDEN HOME
FOR PRE-TUBERCULOUS CHILDREN. Liverpool Hospital for Consumption will shortly open at Frankley, in Cheshire, a garden home, with 40 beds, in 18 acres of land, for pre-tuberculous children. It is hoped
The
later on to extend the home considerably, as 150 beds are needed for Liverpool alone, apart from those required for Cheshire. During the past year a nurses’ home has been built in Delamere Forest, separate from the sanatorium there. Dr. H. A. Clarke has just retired from the active medical staff of the hospital after 33 years’ service,’ and has been
appointed consulting physician.
,