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infection. There is one point in connexion with voluntarynotification that Dr. Raw mentions which we think re-

quires further explanation. He considers that notification

should be made compulsory in cases of public institutionswhere patients suffering from the disease come under thenotice of the officials. Would he apply this rule to

patients attending the out-patient rooms of the hospitals. 7Here, again, we think a clear distinction should be madebetween notification of "closed" and "open" cases of

tuberculosis. If the medical officer in charge consideredthat the circumstances of the individual rendered close super-vision necessary, then the case should be notified; but it

would frequently happen that unnecessary hardship wouldbe placed on individuals who had no tubercle bacilli in thesputum or who clearly appreciated the nature of the diseaseand who were willing and able to take all necessary pre-cautions. We still maintain, however, that constant andincreased attention to hygiene and education of the patientare the strongest measures that can be adopted in the pre-vention of the disease and we echo Dr. Raw’s concludingwords: The final victory over tuberculosis will not be gainedby compulsion but by the earnest and steady cooperation ofscience and perseverance."

THE WORK OF THE PIONEER MOTOR AMBU-LANCE OF LONDON.

IN the issue of THE LANCET of May 18th last, p. 1373,we fully described the excellent electric motor ambu-

lance which had then been recently installed in the Cityof London under the control of the City police. On

Oct. 17th we had an opportunity of again inspecting it onthe occasion of a demonstration of its working given beforeMr. Henry Morris, President of the Royal College of Surgeonsof England, and other gentlemen interested in ambulance

work, the display being under the control of Captain J. NottBower, Commissioner of the City police force, who with Mr.Reginald Harrison, the president of the Metropolitan StreetAmbulance Association, and Mr. F. Gordon Brown, the Citypolice surgeon, has been largely responsible for the successfulinstitution of the motor system. At the display last week atelephone message was received at the Old Jewry PoliceOffice at 3.3 P.M. that there was an accident in

Guildhall yard; the ambulance which is stationed in

King Edward-street, next to St. Bartholomew’s Hospital,was summoned by telephone and arrived in a few minutes atthe Guildhall, where it was met by the inspecting party. A

"dummy" patient was provided who was supposed to havea fractured femur and this the constables on duty pro-ceeded to put up in a workman-like and efficient manner.The patient was conveyed to the St. Bartholomew’s stationin the ambulance which glides so smoothly through thetraffic that it has been dubbed the White Swan," the timefrom the receipt of the first call at the central police office tothe arrival of the patient at the hospital being only 13minutes. At present there are 52 call-boxes in the City ofLondon operated only by the City police, all of whom havehad a first-aid training. The following return shows thenumber of cases taken to hospital by electric ambulance andhand litters since the establishment of the motor ambulance

system on May 13th:-

As Captain Nott Bower says in his report, from a police pointof view the saving of 11 minutes for each case is most im-portant. It clears crowds and obstruction from the streets I

for that period and saves the time of the police for otherduties. The contrast to an accident patient between thejolting of a hand litter and the smooth travelling in theambulance is great and in this way the saving of sufEeringsto the sick and injured must have been considerable, as hasbeen warmly acknowledged by many of those whom thepolice have conveyed to St. Bartholomew’s Hospital in theelectric car. Mr. Anthony A. Bowlby, C.M.G., surgeon tothe hospital, has written as follows on the subject : "Thepatients who have been brought in the new ambulance havebeen very well looked after by the police. They have evi-dently been very carefully lifted and moved and havesuffered much less pain in transit than if they had beenconveyed in any ot’o.er way. I think the new ambulanceis a complete success." And Mr. Ludlam, superintendentof the New York Hospital and superintendent of theambulance service of New York, writes from that city:" I saw the new motor ambulance at St. Bartholomew’s, andwas deeply interested in it, and pleased at the enthusiasmand intelligence displayed by the men in charge. The

vehicle itself is admirably adapted to the purposes for whichit is intended, and is, in some respects, I think, in advanceof the type in use in New York. Its record is excellent. I

was told it had been in commission for three months withoutbreakdown and without expenditure for repair. This speaksvolumes for the excellent construction, and for the intelli-gent care taken of it. Evidently those in charge of theambulance are proud of it, and of the fact that they arriveat the scene of accident within a very few minutes after

the receipt of the call. The fact that the time from the

occurrence of an accident to the delivery of the patientat the hospital is thus reduced to a very few minutes,and that the transportation is made with a minimum of

suffering to the patient, should be unanswerable argumentin favour of the new system."

A CASE OF POISONING BY POTASSIUMCHLORATE.

A FATAL case of poisoning by potassium chlorate studiedin the wards of Professor Klemperer at the Moabit Hospitalat Berlin is recorded in the Allgemeine Medioinisohe Cent’J’aZ-Zeitnng of July 6th by Dr. Hans Hirschfeld, the changesproduced in the blood being given in detail and with specialcare. The influence of the drug upon the red blood corpusclesis well known but in this case some changes were found inthe white corpuscles which have not hitherto been observed.The patient was a young woman, aged 19 years, who hadtaken 20 grammes of potassium chlorate on June 4th.Two days later she was admitted into hospital show-

ing the typical bluish-grey tinge of the skin with

slightly icteric conjunctivas and passing scanty dark-

brown urine containing large quantities of methsemoglobin.Venesection was at once performed and a transfusion ofdefibrinated human blood was carried out, as a result of

which the general condition was somewhat improved. In

the next few days but very little urine was passed andoedema, vomiting, and signs of cardiac weakness rapidlydeveloped. At the same time, however, the condition of theblood improved and the bluish-grey colouration of the facegave place to great pallor. The treatment adopted includedinfusion of salt solution, hot-air baths, pilocarpine injections,and administration of oxygen. The patient died on June 13th,having lived nine days after taking the chlorate of potas-sium. In regard to the result of the examination made of theblood, the most severe changes were observed on the day ofadmission-i.e., on the third day after the poisoning. A

large proportion of the erythrocytes showed a more or lessadvanced decolourisation of the stroma and the small

pigmented bodies containing methsemoglobin first describedby Ehrlich, appeared within them. They were observed

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either singly or in groups in many erythrocytes, sometimesoccupying the centre of the corpuscle and at other times

lying near the periphery. It appeared that they some-times escaped and were found free in the blood plasma.An enumeration of the erythrocytes at this stage is

not of any value owing to the fact that many dis-

integrated cells are likely to be included. Three days laterthe number of degenerating red cells was much lessand on the next day they had entirely disappeared. Thenumber of erythrocytes was then found to be 1,500,000 percubic millimetre and nucleated red blood corpuscles werealso observed to be present. As regards the leucocytes,when the case was first seen Dr. Hirschfeld counted 30,000per cubic millimetre, while four days later their number hadfallen to 15,000. The most noticeable increase was found tobe in the polymorphonuclear leucocytes but myelocytes werealso seen. In regard to the changes observed in the

structure of the leucocytes, as a result of poisoning bychlorate of potassium, only very few observations are onrecord. Krönig observed a fibrillation of the protoplasm ofthe lymphocytes and Jacob stated that a large number

of the leucocytes appeared to be swollen. The former

of these observations Dr. Hirschfeld was not able to

confirm and the latter he explains as due to pressurein the method of preparation as he did not find

the swollen appearance in fresh specimens. Someof the leucocytes may contain the remains of de-

generated erythrocytes. Other cells show variation in their

neutrophile granulations which may be in clumps in someparts, leaving gaps in others. A very noticeable form wasalso a neutrophile cell with several spherical nuclei, a formusually observed in pus, especially that due to gonorrhoea.Other cells were seen which were identical with the pseudo-leucocytes of Ehrlich and were due to breaking up of thepolymorphonuclear cells. Although known to occur in

exudates they have only once before been seen in blood, viz.,in a case of hsemorrhagic small-pox studied by Ehrlich.The interest of this case lies in the great care with whichthe changes in the blood were observed and in the evidenceit affords that potassium chlorate affects the white corpusclesinjuriously as well as the red.

ELECTION TO THE SENATE OF THEUNIVERSITY OF LONDON.

OWING to Dr. Lauriston E. Shaw’s retirement from theSenate there is a vacancy which will shortly be filled by a repre-sentative elected by the Faculty of Medicine. The date of

the election has been figed for Thursday, Nov. 21st, and*already Professor E. H. Starling has issued an address tothe electors. The latest date for sending in the names ofcandidates to the Dean of the Faculty is Nov. 7th. Judgingfrom the great interest taken in the senatorial elections last

spring there seems likely to be another keen contest on thepresent occasion. Until additional candidates are in the fieldit is impossible to forecast the lines upon which the presentelection will be fought. Professor Starling makes the twochief points in his programme the greater accessibility of themedical degree and an increase in the period devoted to clinicalstudy. On both these questions Professor Starling shouldhave the warm support of a very large number of the teachers,though no doubt there will be some who will be drawn intothe opposite camp by the cry that this is an attempt to lowerthe standard of the degree. On the vexed subject of theconcentration of the earlier studies Professor Starling is pre-pared to support what seems to be a reasonable com-

promise affording at once an opportunity for thoseschools which desire to relinquish these subjects to do

so, while bringing no pressure, direct or indirect, uponothers to participate in the movement. This pro-posal, which is likely to commend itself as equitable to i

the majority of teachers, would enable the Senate to extricateitself from the difficult position created by the change offeeling upon this question shown in the Faculty at the last.election. By some it may be considered a disadvantage thatProfessor Starling is not a clinical teacher. It must, how-

ever, be recognised that the reorganisations necessary to,

carry out the immediately pressing reforms in medicaleducation fall within the earlier period of the curriculumof which physiology at present occupies so large a share.

Unfortunately the committee work of the Faculty repre-sentatives upon the Senate is extremely exacting and it is

likely to become increasingly difficult to find physiciansand surgeons able to devote the necessary time to thes&

positions. -

DEATHS UNDER ANÆSTHETICS AT GENERALHOSPITALS.

THE report of an inquest upon a death under chloroformwhich we publish in another column ventilates a question ofgreat importance alike to hospitals and to the general public.The facts of this particular case are briefly these. The

patient suffered from exophthalmic goitre and to relieve herurgent symptoms the surgeon in charge of the case decidedto perform an operation and to do so in two stages. Thefirst stage, that involving the ligation of the arteries to thethyroid gland, was successfully accomplished, a house surgeongiving chloroform, and no dangerous symptoms appeared. Onthe day when the second stage of the operation was to havebeen carried out-the removal of the tumour-another house

surgeon, a recently qualified man who had not previouslyanaesthetised for a case of the kind, undertook the administra-tion of the anassthetic. The patient, however, died when theincision into the skin was made. There appears to have beensome discrepancy in the opinions expressed as to the cause ofthe death. One view advanced was that the retching andvomiting which occurred caused interference with respirationand death arose from suffocation. Another contention was

that the result was due to reflex failure of the heart, while thepathologist who made the necropsy found a persistentthymus and this he regarded as possibly a determining causeof death through syncope. It thus appears that the condi-tion of the patient was recognised as a very grave one and thesurgeon who operated was keenly alive to the special dangerwhich the patient ran through taking an anaesthetic. Local

analgesia was even thought of but had to be given upowing to the nervous condition of the patient. The

question which naturally arose and was strongly insisted

upon by the coroner was : Why did not one of the expertanaesthetists attached to the charity attend for the purpose ofgiving the chloroform instead of a junior house surgeon ofadmittedly small experience ? Authorities were cited which

supported the coroner’s view that in such grave operationsthe anaesthetic should be given by the staff anaesthetist,or at least in his presence. The answer to these contentionsdoes not seem to us to be wholly convincing. Naturallysurgeons in large operative practice must be, in theory at least,cognizant with anaesthetics. Yet it can hardly be admittedthat they can direct the inexperienced anaesthetist or watchhim as he applies each fresh supply of the anaesthetic. In

theory such a shared responsibility is possible; in practicewe doubt whether such supervision can protect the patientfrom grave dangers. If a serious operation has to be per-formed the house surgeon does not, we believe, undertake it,even under the guiding advice of his principal. In cases suchas the one which we are considering the patient’s life was asmuch in jeopardy from the anaesthetic as from the operation,and if the latter required expert performance, is it too muchto say that the conduct of the anaesthetisation should havebeen undertaken by a staff officer of special experience ? It isunfortunately true, as was pointed out at the inquest, thatthe operations performed at the large hospitals af Londom