THE PREVENTIVE SIDE
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1332 THE OBSTETRIC FORCEPS AND ITS USE DR. ALFRED COX TESTIMONIAL FUND To the Editor of THE LANCET SIR,-We feel sure that many of your readers would like to be reminded that the end of the current I month closes the term of contribution to the above fund, which is being raised as a token of recognition of the devoted services of Dr. Alfred Cox to the interests of the medical profession. The response has been good ; the excellent portrait, by Sir Arthur Cope, is in the Royal Academy, and the committee are now especially concerned that a larger number of names may be inscribed in the presentation book, which we know Dr. Cox will particularly value. We would urge those who have not already sub- .scribed to send in their names and addresses, together with a small contribution (in no case to exceed 10s., and the amount does not appear in the list) to the hon. treasurer of the British Medical Association, ’Tavistock-square, W.C.I. We are, Sir, yours faithfully, June 6th, 1932. HUMPHRY ROLLESTON, Chairman, General Committee. EWEN J. MACLEAN, Chairman, Executive Committee. *** Dr. Cox claim on the respect and regard of the medical profession is such that no words from us - could make it stronger. Intending subscribers to the Testimonial Fund, which should imply all medical men who have not yet subscribed, will surely heed the request here made.-ED. L.] TRAINING IN TUBERCULOSIS To the Editor of THE LANCET SiR,-It is to be hoped that Dr. Davidson’s timely letter and the discussion it has aroused will result in some practical solution of a grave problem. So far back as 1912, in the report of the Departmental Committee on Tuberculosis, special reference was made to medical education. The Committee were of opinion that additional facilities should be afforded to medical students and practitioners to acquire familiarity with the methods of diagnosis of tuber- -culosis, more especially in its earlier manifestations, and with its treatment. And they made these I recommendations, among others : 1. Medical students and practitioners should be afforded "facilities to attend at tuberculosis dispensaries and sanatoria. 2. It is advisable that the tuberculosis dispensaries should, where possible, be directly associated with schools of I, medicine. Despite these recommendations, medical training in tuberculosis is still deplorably bad and, with few - exceptions, there is little or no cooperation between hospital and dispensary. Unless steps are taken to remedy this lack of organisation, the present mortality figures (over 700 deaths per week in England and Wales alone) of a preventable disease are likely to remain at a standstill. There is another point on which I would lay emphasis. At the tuberculosis dispensaries there is an abundance of clinical material illustrative of all diseases of the respiratory tract, including many of the most important non-tuberculous conditions. My own experience of work at a chest clinic is that the latter form 50 per cent. of the new cases sent up for opinion, though they are frequently labelled as tuberculous. Students would therefore have the best opportunity at such clinics of learning the ,differential diagnosis of pulmonary disease with special :.reference to pulmonary tuberculosis. The machinery for cooperative organisation exists, and only needs to be put in motion. It may be that the hospital authorities would demand some altera- tions as regards the details of dispensary work, and indeed I believe that some reorganisation of the dis- pensary system as such is necessary, and that I have already advocated (Brit. Jour. Tub., July, 1931). I am, Sir, yours faithfully, Harley-street, W., June 6th, 1932. PHILIP ELLMAN. THE OBSTETRIC FORCEPS AND ITS USE To the Editor of THE LANCET SIR,-I have read the very interesting paper written by my late colleague Mrs. Dobbin Crawford and I should like to comment upon the sentence :- " The application of forceps is only a success-as stated by Berkeley—when their use leaves the mother no worse off than she was before their application, and when the child is born alive." In my opinion these words under-estimate the high standards which Mr. Comyns Berkeley, Mrs. Crawford, and all other expert obstetricians demand of them- selves and, therefore, are not the best teaching to give to students. From the baby’s point of view the success of a forceps operation is measured not merely by his life but by his health; he must be born alive and ’tMM<MM-6Kj’e. Neonatal medicine has made great strides in recent years and the status of the new-born infant is advancing rapidly ; it is possible to record great improvements in both diagnosis and treatment of the various injuries which may be suffered by the baby during delivery. But prophylaxis must always be the main object in view, and it is essential that students should be taught the ideal towards which they must strive. No student could do better than learn, as so many have in the past, by attending Mrs. Crawford in her practical work ; but those who can learn from her only by reading this paper might fail to grasp the full meaning contained in the one sentence to which I call attention. I am, Sir, yours faithfully, Liverpool, June 13th, 1932. NORMAN B. CAPON. THE PREVENTIVE SIDE To the Editor of THE LANCET SiR,-The medical profession are frequently criti- cised for paying insufficient attention to the preventive side of medicine. Sir Arthur Newsholme, Sir George Newman, and now Mr. Somerville Hastings are prominent in stressing this failure. Let us examine this criticism a little more closely. What diseases are, in fact, preventable wholely or in part ? Excluding diseases preventable by public sanitation, port quarantine, good housing, and suffi- cient food, there remain a moderate number of preventable diseases which can be grouped as follows: Group I.--Small-pox, diphtheria, and possibly tuberculosis, which can be prevented by immunisation. Group II.-Industrial diseases. Group III.-Venereal disease, which can largely be pre- vented by individual prophylaxis. Group 7V.—Hereditary mental disease and deficiency, which can in part be prevented by sterilisation and segre- gation. Group V.-Diseases which are essentially within the province of general practice, such as arise from focal sepsis, overfeeding, overdrinking, oversmoking, obesity ; from improper food, clothing, and footwear ; from obstetrical injuries. Now practitioners are constantly urging their patients to have their infected teeth or tonsils dealt
Transcript of THE PREVENTIVE SIDE
1332 THE OBSTETRIC FORCEPS AND ITS USE
DR. ALFRED COX TESTIMONIAL FUND
To the Editor of THE LANCETSIR,-We feel sure that many of your readers
would like to be reminded that the end of the current Imonth closes the term of contribution to the abovefund, which is being raised as a token of recognitionof the devoted services of Dr. Alfred Cox to theinterests of the medical profession.
The response has been good ; the excellent portrait,by Sir Arthur Cope, is in the Royal Academy, andthe committee are now especially concerned that alarger number of names may be inscribed in thepresentation book, which we know Dr. Cox willparticularly value.We would urge those who have not already sub-
.scribed to send in their names and addresses, togetherwith a small contribution (in no case to exceed10s., and the amount does not appear in the list)to the hon. treasurer of the British Medical Association,’Tavistock-square, W.C.I.
We are, Sir, yours faithfully,
June 6th, 1932.
HUMPHRY ROLLESTON,Chairman, General Committee.
EWEN J. MACLEAN,Chairman, Executive Committee.
*** Dr. Cox claim on the respect and regard ofthe medical profession is such that no words from us- could make it stronger. Intending subscribers tothe Testimonial Fund, which should imply all medicalmen who have not yet subscribed, will surely heedthe request here made.-ED. L.]
TRAINING IN TUBERCULOSIS
To the Editor of THE LANCETSiR,-It is to be hoped that Dr. Davidson’s timely
letter and the discussion it has aroused will resultin some practical solution of a grave problem. Sofar back as 1912, in the report of the DepartmentalCommittee on Tuberculosis, special reference wasmade to medical education. The Committee wereof opinion that additional facilities should be affordedto medical students and practitioners to acquirefamiliarity with the methods of diagnosis of tuber--culosis, more especially in its earlier manifestations,and with its treatment. And they made these Irecommendations, among others :
1. Medical students and practitioners should be afforded"facilities to attend at tuberculosis dispensaries and sanatoria.
2. It is advisable that the tuberculosis dispensaries should,where possible, be directly associated with schools of I,medicine.
Despite these recommendations, medical training intuberculosis is still deplorably bad and, with few- exceptions, there is little or no cooperation betweenhospital and dispensary. Unless steps are takento remedy this lack of organisation, the presentmortality figures (over 700 deaths per week in Englandand Wales alone) of a preventable disease are likelyto remain at a standstill.
There is another point on which I would layemphasis. At the tuberculosis dispensaries there isan abundance of clinical material illustrative of alldiseases of the respiratory tract, including many ofthe most important non-tuberculous conditions. Myown experience of work at a chest clinic is that thelatter form 50 per cent. of the new cases sent up foropinion, though they are frequently labelled as
tuberculous. Students would therefore have thebest opportunity at such clinics of learning the,differential diagnosis of pulmonary disease with special:.reference to pulmonary tuberculosis.
The machinery for cooperative organisation exists,and only needs to be put in motion. It may be thatthe hospital authorities would demand some altera-tions as regards the details of dispensary work, andindeed I believe that some reorganisation of the dis-pensary system as such is necessary, and that I havealready advocated (Brit. Jour. Tub., July, 1931).
I am, Sir, yours faithfully,Harley-street, W., June 6th, 1932. PHILIP ELLMAN.
THE OBSTETRIC FORCEPS AND ITS USE
To the Editor of THE LANCET
SIR,-I have read the very interesting paperwritten by my late colleague Mrs. Dobbin Crawfordand I should like to comment upon the sentence :-
" The application of forceps is only a success-as statedby Berkeley—when their use leaves the mother no worseoff than she was before their application, and when thechild is born alive."
In my opinion these words under-estimate the highstandards which Mr. Comyns Berkeley, Mrs. Crawford,and all other expert obstetricians demand of them-selves and, therefore, are not the best teaching to giveto students. From the baby’s point of view the successof a forceps operation is measured not merely by hislife but by his health; he must be born alive and’tMM<MM-6Kj’e.
Neonatal medicine has made great strides in recentyears and the status of the new-born infant is advancingrapidly ; it is possible to record great improvementsin both diagnosis and treatment of the variousinjuries which may be suffered by the baby duringdelivery. But prophylaxis must always be the mainobject in view, and it is essential that students shouldbe taught the ideal towards which they must strive.No student could do better than learn, as so manyhave in the past, by attending Mrs. Crawford in herpractical work ; but those who can learn from heronly by reading this paper might fail to grasp the fullmeaning contained in the one sentence to which I callattention. I am, Sir, yours faithfully,
Liverpool, June 13th, 1932. NORMAN B. CAPON.
THE PREVENTIVE SIDE
To the Editor of THE LANCET
SiR,-The medical profession are frequently criti-cised for paying insufficient attention to the preventiveside of medicine. Sir Arthur Newsholme, Sir GeorgeNewman, and now Mr. Somerville Hastings are
prominent in stressing this failure. Let us examinethis criticism a little more closely.What diseases are, in fact, preventable wholely or
in part ? Excluding diseases preventable by publicsanitation, port quarantine, good housing, and suffi-cient food, there remain a moderate number ofpreventable diseases which can be grouped as follows:
Group I.--Small-pox, diphtheria, and possibly tuberculosis,which can be prevented by immunisation.
Group II.-Industrial diseases.Group III.-Venereal disease, which can largely be pre-
vented by individual prophylaxis.Group 7V.—Hereditary mental disease and deficiency,
which can in part be prevented by sterilisation and segre-gation.Group V.-Diseases which are essentially within the
province of general practice, such as arise from focal sepsis,overfeeding, overdrinking, oversmoking, obesity ; fromimproper food, clothing, and footwear ; from obstetricalinjuries.Now practitioners are constantly urging their
patients to have their infected teeth or tonsils dealt
1333FREE TREATMENT AT VENEREAL CLINICS.-VITAL STATISTICS
with. How often do patients take their advice beforethe actual onset of rheumatism 7 Very seldom in myexperience. To point out the disfigurement from badteeth is ten times as effective. How often do patientsdiet themselves rigorously to prevent the onset ofobesity ? Very seldom. Yet, when fashion so decrees it, ieveryone diets at once. It is the same story with footdeformities, the result of narrow pointed shoes. Theindividual is equally indifferent to possible futureill-health to himself or his children resulting fromsmall-pox, diphtheria, industrial diseases and acci-dents, and mental diseases. An exception is venerealdisease, for the prevention of which individual prophy-laxis has had a very definite success.The lesson is that the individual will only bestir
himself for an immediate danger to health, but moredistant dangers are ignored and probably always willbe. Is the medical profession to be blamed for thisfundamental trait in human beings ’? The State cancompel the individual to take the necessary pre-cautions as is done in industrial diseases and, half-heartedly, in small-pox. But the record of our Statemedical officials is none too brilliant. They did nothingfor the prophylaxis of venereal disease, being contentthemselves to treat end-results, and in the preventionof the increasing menace of mental deficiency andinsanity their record is bad.. They obstructed thedissemination of contraceptive knowledge to the poor.
I am, Sir, yours faithfully,Bridlington, June 13th, 1932. P. D. H. CHAPMAN.
THE KING’S COLLEGE HOSPITAL SCHEME
To the Editor of THE LANCET
SiR,-The attention of the medical board of King’sCollege Hospital has been directed to the articlepublished in your issue of May 28th (p. 1172) and tosubsequent correspondence upon this subject. Whilenot admitting the accuracy of all the statementsmade, I beg to inform you that the arrangements areunder discussion by the committees concerned. Thesteps which are being taken will, I confidently hope,remove the objections raised. I need not assure
you that the medical staff at King’s CollegeHospital would strongly discountenance any pro-cedure not in accordance with the traditions ofmedical practice.
I am, Sir, yours faithfully, I
June 14th, 1932.
W. GILLIATT, M.D., F.R.C.S.,Chairman of the Medical Board, King’s
College Hospital.
FREE TREATMENT AT VENEREAL CLINICS
To the Editor oj THE LANCET
SiR,—While endorsing the remarks of Dr. WanseyBayly and Dr. Browdy, I am inclined to add the tritecomment that in lean periods, which we have hadbefore, it is possible to become over-pessimistic. A
greatly esteemed surgeon and teacher, interested insocial phenomena, used to point out to his classes theclose relationship existing between the rise and fallin the incidence of venereal disease and similar move-ments in the graph of business activity. In itseconomic effects business depression attacks all fluc-tuating incomes, including those of medical andsurgical specialists without exception, dentists, bar-risters, architects, and others. It is undoubtedly truethat there are V.D. patients attending public clinicswho in ordinary circumstances would demand some-thing better ; but when a pukka chartered accountant
sells you your ticket for the greyhounds is it, after all,so very surprising ? ’?
A reform considerably overdue is the removal ofthe crude V.D. advertisements from public lavatories,an illustration of bureaucratic medicine at its worst.Unless meant to direct strangers in London or else-where the posters serve no useful purpose, for theyoffend many well-disposed persons and by promotingribald remarks are very largely self-destructive,cost the public something, and constitute a standingoffence to many decent-minded people. Largenumbers of children visit public conveniences, andI know of nothing more embarrassing than trying toevade the searching questions of small boys and girlscurious to know, " What are secret diseases *? " and" What sort of a place is St. Swithin’s Hospital "
I am, Sir, yours faithfully,H. D. L. SPENCE.
Great Russell-street, W.C., June 13th, 1932.
INFECTIOUS DISEASEIN ENGLAND AND WALES DURING THE WEEK ENDED
JUNE 4TH. 1932
Notifications.-The following cases of infectiousdisease were notified during the week :-Small-pox,49 (last week 68) ; scarlet fever, 1502 ; diphtheria,709 ; enteric fever, 23 ; acute pneumonia (primary orinfluenzal), 675 ; puerperal fever, 54 ; puerperalpyrexia, 96 ; cerebro-spinal fever, 51 ; acute polio-myelitis, 4 ; encephalitis lethargica, 14 ; dysentery,13 ; ophthalmia neonatorum, 102. No case of cholera,plague, or typhus fever was notified during the week.The number of cases in the Infectious Hospitals of the
London County Council on June 7th-8th was as follows :Small-pox, 81 under treatment (last week 84 under treat-ment and 2 under observation) ; scarlet fever, 1526 ;diphtheria, 1317; enteric fever, 10 ; measles, 2211 ;whooping-cough, 396 ; puerperal fever, 15 (plus 5 babies) ;encephalitis lethargica, 227 ; poliomyelitis, 3 ; " otherdiseases," 99. At St. Margaret’s Hospital there were
15 babies (plus 8 mothers) with ophthalmia neonatorum.Deaths.-In 117 great towns, including London,
there was no death from small-pox, 2 (0) from entericfever, 73 (29) from measles, 7 (3) from scarlet fever,32 (10) from whooping-cough, 21 (5) from diphtheria,59 (11) from diarrhoea and enteritis under two years,and 33 (5) from influenza. The figures in parenthesesare those for London itself.
The fatal cases of enteric fever outside London occurredat Manchester and Ipswich. Liverpool reported 18 deathsfrom measles and 6 from diphtheria. Four fatal cases ofwhooping-cough occurred at Liverpool, 3 each at Birminghamand Walsall.
The number of stillbirths notified during the week was294 (corresponding to a rate of 39 per 1000 totalbirths), including 40 in London.
FATAL CASE OF SMALL-Pox.-The case in which small-poxwas mentioned as the cause of death in the return for theweek ended May 28th was that of a man, aged 56, admittedto Queen Mary’s Hospital, Sidcup, on April 19th, fromLambeth Hospital, where he had been since March 9thsuffering from myeloid epulis, which was being treatedwith radium. On arrival at Queen Mary’s Hospital, Dr. C.Ellingworth informs us, he had considerable radium reactionabout the face and swallowed food with difficulty. Hehad some pyelitis and had been treated with hexamine.On May 3rd he complained of headache, and he was foundto have a temperature of 103° F., with some slight abdominalpain and crepitations at the base of both lungs. The urinewas free from albumin. On the morning of May 7th hedeveloped a papular rash on the forehead and hands whichwas rather mixed up with the radium irritation. Dr. H. M.Pereira, who was called in consultation, confirmed thediagnosis of small-pox, and the patient was removed toLongreach Hospital, where he died. Dr. D. M. Connan tellsus that the cause of death was certified thus : 1. (a) Myeloidepulis. (b) Pyelitis. 2. Small-pox discrete vaccinated ininfancy.
