is clonorchis a health menace in china? -...

( C h i n a | i l f i l i a l J m i n i a l .

Vol. X L I . M A RC H , 1927. No. 3

IS CLONORCHIS A HEALTH MENACE IN CHINA?

F r a n k O l d t , M .D., D .P .H ., Canton Hospital.

Introductory. Siu Laam is ju st within the southern border of the m ulberry producing region of K w angtung, where growing of m ulberry leaves, raising of pigs and fish, constitute an interrelated triang le to form the chief industry of the region. T he fish ponds and m ulberry fields alternate, while the pigs are kept as pigs are in China.

T he fish ponds are made by excavations of d irt used' to elevate the m ulberry fields that they m ay be above w ater, for in this delta region the land is lower than the surface of the river. The elevation of the fields is m aintained by mud from the bottom of the ponds being thrown up on the fields. T his is done each year when the ponds are drained and fish harvested at the end of the m ulberry season. The pig has a smaller though im portant role in that he shares with man the part of fu rn ish ing m anure, an im portant part of the food for the fish. Excreta a f te r doing its part in producing fish settles down in the bottom of the ponds to make a very valuable fertilizer out of the mud.

T he w riter was for m any years a resident of Siu Laam. W hen the life cycle of clonorchis was published with the part snails and fish played, he a t once felt that this region was an im portant factor in the spread of clonorchis in K w angtung. T his was further confirmed when in 1924 in the m aking of egg counts as p a rt of the survey of K w angtung for the H ookw orm Commission headed by D r. Cort, a very heavy in festation was found am ong the farm ers in m any of the places around Siu Laam.

I t was a special pleasure in 1925 to have D r. E . C. Faust of P .U .M .C . spend a m onth or more in Canton in the study of this problem . T he results of this investigation are ably given by D r. Faust w ith conclusive proof th a t there is a human reservoir of clonorchis infestation in this region and tha t fish sold from there to Canton, H ongkong and other places is the source of clonorchis infestation in th is part of K w angtung.

T his paper gives the results o f a clinical study of the records of Canton H ospital w ith data from 94 cases from the Gregg Memorial H ospital of H ackett Medical College included. Since there has been no opportunity for post m ortem s in Canton, the w riter had the kind assistance of D r. E . P . M innett, of the Governm ent Bacteriological

186 The China Medicai Journal.

Institu te of H ongkong in giving pathological data to com paré w ith the clinical. T he hospital records also furn ish some epidemiological data, seme have been obtained from D r. Cook at Siu Laam , and others from the d a ta of the H ookw orm Survey. Published reports of other w orkers in China will be used also. T he question as to w hether clonorchis infestation is a health menace will be attacked from the epidemiological, clinical, and pathological standpoints.

Epidemiology. The life cycle of Clonorchis sinensis is complicated. T here m ust be an unusual com bination of factors before it can be complete. In order to hatch, the eggs m ust reach w ater (o f righ t quality and tem perature) before they become devitalized. T he w ater m ust have in it the righ t species of snails. T he w ater m ust have fish in it also and the cercarioe a fte r leaving the snail m ust reach these fish before they die. T he fish m ust he eaten by a suitable m am m alian host, and they m ust be eaten raw.

F rom w hat is known of the life h istory and the epidemiology of clonorchis it is possible to estim ate the danger of its being introduced in to other countries. T here is strong epidemiological evidence to support the fact brought out in life h istory th a t there can be no in festation of the m am m alian host w ithout eating flesh of fish in which are living cysts, or, stated for the purpose of this paper, there can be no hum an infestation except am ong those people who eat raw fish. D ata in regard to regions in China other than K w angtung is obtained from the published papers of F au st and F aust and Barlow.

Geographical Distribution. In N orth China there is no hum an infestation , but 25% of dogs, and 37% of cats have clonorchis. H ere fish is eaten cooked by hum ans, but dogs and cats eat the viscera and scales raw.

In Central China there is occasional hum an infestation in H unan , H upeh, A nhwei, K iangsu, and Chekiang, while dog infestation is 80% , and. cat infestation 100% . H ere again hum ans do not eat raw fresh fish, (they sometimes eat smoked fish raw ) but scales and viscera are fed to dogs and cats.

In K w angtung around Canton there is 20-30% hum an infestation , while it is neglible in diogs and probably less than 20% in cats. H ere hum an consum ption of raw fish is prevalent but the price is so high as to preclude its being fed to dogs or cats. T he only fish tha t a re eaten raw are the kinds which come from the infested ponds of the m ulberry districts.

F u rthe rm ore in N orth and Central China w here the flesh is cooked and the cats and dogs eat the scales, the cysts are found on the under side of the scales. In the South w here the flesh is eaten raw the cysts are found in the flesh.

Is Clonorchis a Health Menace in China? 187

Since infested people from K w angtung often go to N orth and Central China and dogs and cats there are heavily infested , while no hum ans get infected, and infestations in K w angtung and elsewhere always coincide w ith consumption of raw infected fish, the presum ption is that there is no danger of hum ans becoming infested, or that clonorchis will become endemic, except w here raw fish is consumed. T hus we see that th roughout the whole clonorchis region of China from Peking to K w angtung, w hatever mam m alian hosts eat infested parts of raw fish have clonorchis and only those; cats and dogs in the N orth , humans in the South.

F u rth e r confirm atory evidence is found in the data of the H ookw orm Commission, from the m ulberry farm ers in the vicinity of Siu Laam . The places nam ed w ith the exception of Kau Chau Kei and K u Chan are not villages, but are sections of land bounded by canals, made up of m ulberry fields and fish ponds, and would contain hardly a square mile each, and the samples taken represent a large proportion of the people living there. K au Chau Kei is a village of about 5,000 people, and K u Chan 10,000 people. A rough diagram of the relative positions of these places might be useful.

Kjv ong Wa i

M ei Po Kau

*

Ku Chan X

Ngau. Kok

Kau. Chau Kei ' XKu Chan iB 6 m i. s f,u L^ srnM e i Po K a u I Kau Ch.au K i 1 ’’N gau K o k Sha 3 "

Kwong Yitc wai i s a b o u t Z m i l e * from S i u laam.

T a b l e I.

Show ing distribution of Clonorchis in festation in tlu- vicinity o f Siu Laam.

P lace T o ta lE x a m in e d N e g a tiv e % Hubitivc °//o

Y e Kwan 31 0 0. 31.1 100.Ngau K ok Sha 36 1 2.3 35 97.3Tai Kwan 19 1 5.3 18 94./K o Sha 29 6 20.7 23 79.3Lo Sha 29 10 34.5 19 65.5Mei Po Kau 28 11 39.3 17 60.7Ku Chan 59 33 56. 26 44.Lai Sha 19 17 88.2 2 11.8K w ong Y ik W ai 114 104 91.2 10 8.8Pak K ong Sha 31 30 96.8 1 3.2Kau Chau Kei 62 62 100. 0 0.Chung Sha 28 28 100. 0 0.0

188 The China Medical Journal.

H ere is a region w here as fa r as possible in every way conditions are sim ilar, occupation, economic state, habits, food, and close approxim ation, yet the infestation varies from 0-100% . People have been observed to harbor clonorchis fo r as long as 20 years a fte r rem oval from any source of re-infestation. I t is to be expected th a t the degree o f infestation would be the same in each of these places. W hy the great difference? T hese people are all poor. T hey cannot afford to buy but eat the fish they raise themselves and which fo r some reason is not m arketable. T his would tend to localize the infestation and lim it it to those places w here the complete life cycle was possible, and thus it would no t be spread evenly over the whole region. K now n facts fit in w ith this idea.

In K au Chau Kei where none exam ined had clonorchis the ponds are too d irty for Bythinia stria tu la to live. T here is possibly some clonorchis in the place as it is com paratively large and the samples taken may have happened not to have any positive cases, but the num ber ex am ined is large enough to have some positive if there were more than a neglible am ount of infestation.

Mei P o K au adjacent to K au Chau Kei had clean ponds. P lenty of Bythinia striatu la were found there. T he infestation there is 60% . T he low infestation rate, less than 9% , a t K w ong Y ik W ai may be due to the fact that the Bythinia striatu la snails there are only 2% of the total. F u rth e r investigation would find adequate reasons why Chung Sha. and P aak K ong Sha are practically negative and Ye K w an and Tai K w an, and N gau K ok Sha are alm ost 100% infested. E ating of raw fish is universal. D r. Cook reports infestation in a baby 13 m onths old. T he fish ponds all have fecal contam ination, yet in this region should a single link in the chain of the life cycle be absent a locality will be free from infestation, while a neighboring place where the cycle i> complete will have 100% infestation. Clonorchis does not spread widely and it lim its itself sharply to those places w here conditions are absolutely right. E vidently the infestation will travel no farther than to w here fresh fish can be carried to be eaten raw , and the in festation would die out of the Canton region if the life cycle could be broken in the fish ponds of the m ulberry region.

Record is kept of all patients in the Canton H ospital of name, hospital num ber, age, sex, address, and diagnosis. T his record is copied from case histories when patients leave the hospital, also record of fecal exam inations is kept in the laboratory in which are given, nam e, hospital num ber, age, sex, address, findings. By combining these two records, tak ing only the cases in which the common items were the same, we secured a fairly large list giving nam e, address, age, diagnosis, and w hether they w ere positive or negative for clonorchis. T hese are

Is Clonorchis a Health Mcnacc in China? 189

analyzed in respect to age, sex and the relation of diagnosis and of clonorchis positive and negative cases to geographical distribution. T he num ber of cases of various diseases is too small, taken by themselves, to draw conclusions therefrom . Taken in connection with clinical and pathological evidence they have a real value.

T a b l e II.

D istribution of clonorchis infestation as compared with area devoted to silk industry and fish production.

C lonorchisy um ber Clonorchis m inus

Group I

eases N o . % .Vo. %

Shan Tak 139 43 31 96 69

Group IIH eung Shan 61 19 31 42 69Nam H oi 281 58 21 225 79Total 342 77 23 265 77

Group IIISan W ui 129 29 22 100 78Sam Shui 42 13 31 29 69H ok Shan 29 8 28 21 72Pun Yue 169 31 18 138 82Si W ui 12 2 17 10 83Chung F a 5 1 20 4 80K o M eng 6 3 50 3 50K o Yiu 39 12 31 27 69W an Fau 4 1 25 3 75W at Naam 1 0 0 1 100Lo Teng 7 2 29 5 71Tung Kun 54 13 21 41 76T sang Shing 45 6 13 39 87W ai Yuen 20 3 15 17 85Pok Lo 3 0 0 3 100P o On 3 0 0 3 100Y ing Tak 14 3 21 11 79T sing Yuen 24 3 13 21 87Totals 606 130 21 476 79

Group IVToi Shan 51 6 12 45 88Others 215 17 8 198 92T ot 1 266 23 9 243 91

Group VK\v ng Sai 48 1 2 47 98Hun m 124 3 2 121 98Yunnan 119 4 3 115 97Others 103 6 5 97 5Tot.i' 394 14 3.5 380 96.5

190 .The China Medical Journal.

T here a re over 90 districts (Y uen or H sien ) in K w angtung P ro vince. F rom tw enty, Clonorchis positive as well as Clonorchis negative cases came to C anton H ospital. Tw o districts had positive cases only. T w enty -four districts had negative only. T he E astern end or Swatow region was scarcely represented. T he South w estern coast region in cluding H ainan had m ore, but most of the patients are from the P earl river basis including E ast. N orth and W est Rivers. 1,353 of the patients studied were from K w angtung. 294 of those studied w ere extra-provincial, from 15 other provinces. T here w ere 287 positive cases and 1,460 negative. T he d istricts w ere divided into four groups w ith ex tra provincial cases form ing a fifth group, according to the ex ten t of their involvement in m ulberry culture as reported by H ow ard and Buswell. T he first group was the Shan T ak D istrict devoted wholly to sericulture. The second, H eung Shan and N am H oi D istricts 30-50% to sericulture. The th ird group com prised the rem ainder in which there were some m ulberry areas perhaps averaging 10% . T he fourth group consisted of those districts in which' the silk industry was absent or negligible. T he fifth or ex tra provincial is also considered non m ulberry.

In G roups I I and I I I the patients would largely come from m ulberry producing regions as this area borders on the river and Canton is better known and m ore accessible for them.

N am H oi (G roup I I ) and P u n Y ue (G roup I I I ) have a lower percentage than would be expected of them as Canton is in these two d istricts and is not p a rt of the m ulberry area, although fish from the m ulberry area is shipped to Canton and in season eaten raw.

F o r Ko M eng in Group I I I the high percentage of clonorchis is probably due to the small num ber of cases studied.

The patients in Group V are chiefly soldiers and had been long enough in K w angtung for infestation to occur provided they had eaten the raw fish.

Group I has an infestation rate of 31% , Group I I of 23% . G roup I I I of 21% , the average of the th ree m ulberry groups is 23% . G roup IV has 9% , and Group V 3.5% , w ith a per cent fo r both groups of 5 .5% , indicating a clear relationship between the m ulberry and fish com bination and clonorchis infestation.

'Age.

T he follow ing table shows the distribution according to age. T his includes cases from records mentioned above and from such case histories as we could find from 1914 to 1923; also from the H ookw orm Com mission R eport.

Is Clonurchis a Health M ature in China?

T able I I I .

A g e .

0— 45— 9

10— 14 15— 19 20— 24 25— 29 30— 34 35— 39 40—44 45—49 50— 54 55— 59 60— 64 65— 69 70— 74 75— 79 80—84 85— 90

X o . o f /» js i / ir r cases, C lon orch is.

6 7

18 68

150 182 141 96 85 58 76 29 27 14 3 1 0 1

T he total num ber of cases is 962 with an average age of 34.S. T he greater num ber is between the ages of 15-55, with the largest num ber in the age group 25-29. T he youngest is 2 years ami the oldest is 88. T here were 2 two years old and 4 three years old. .

Sc.r.T he following table shows the distribution according to sex. The

figures are from the Laboratory records and show the preponderance of male over female.

T able IV .

Y e a r A To. o f m ales Pos. % jY u . o f fem ales Pos. %1921-22 2,626 247 9.4 1,800 27 241923 1,056 54 5.1 774 24 3.11924 816 61 7.4 424 30 7.1925 940 160 17 377 44 12.Totals 5,438 522 9.6 2,675 125 4.6

Men would eat the raw fish in restaurants, women do not patronizethese restaurants. In the home, the women consider it a duty for the m en to eat first when any delicacy is served and they be helped second.

Occupation.

F rom the case histories of Canton H ospital a comparison was made of occupation w ith residence, divided according to the five groups before described. T hey w ere divided according to occupation into farm ers, laborers, business, professional, soldiers, artisans, servants, none. The professional group included teachers, preachers, nurses, doctors, etc.

Place e io n -orchis Farmer Laborer B usiness P rofes

sional S old ier

N o % N o % N o % No % N o %

ShanTak

Po^.

N eg .

7 18

12 23

3 8

9 18

17 45

15 29

5 13

4 8

1 2

1 2

T a b l e V . t S

Show ing the Relation o f Occupation and Residence to Clonorchis infestation. Taken from Canton H ospital Records, 1914-1925.

Artisan Servant N o n e Totals

No %

4 10

3 6

H eu n gShan Pos. 10 17 16 27 17 29 2 3 3 5 8 14and NamH oi N eg . 11 14 14 18 18 24 9 11 3 4 8 11

OtherD istricts Pos. 15 19 16 20 22 27 8 10 1 1 11 14withM ulberry N eg . >54 14 49 21 57 2 t 37 16 14 6 20 8

O therD istricts Pos. 0 0 1 7 17 7 4 26 6 40 3 20w ithoutM ulberry N eg . 10 9 5 4 19 17 30 27 31 27 5 4

E xtra Pos. 0 0 1 6 2 11 2 11 12 66 1 6

Provincial N e g . 0 0 6 2 10 3 11 3 316 89 3 1

No % No % N o

1 2 2 39

3 6 4 8 51

1 2 2 3 59

5 8 8 10 78

4 5 3 4 80

7 3 18 8 236

0 0 0 0 15

2 2 10 9 112

0 0 0 0 18

2 1 4 1 352

The China

Medical

Journal.

Is Clonorchis a Health Menace in China?

A rtisans were skilled w orkm en, as masons, carpenters, mechanics, pain ters, etc. In in tra provincial d istricts the business group is largest, while in ex tra provincial, soldiers predom inate. The soldiers have most positive in group V . because the group is almost entirely soldiery. T he significance of the large proportion of business people is that raw fish is expensive and poorer people cannot a fiord to eat it. A significant exception to this conclusion found is in the m ulberry districts. H ere m ore than 18% of the positive are farm ers while in the non mulberrv groups no farm ers are infested though the negative group shows (>% of the non m ulberry patients are farm ers. In group V of course there are no farm ers. These figures therefore are in accord with known facts, w here farm ers raise and eat their own fish they become a part of the cycle which keeps clonorchis in South China. The farm ers who do not raise fish cannot afford to buy it, hence are clonorchis free.

Racc.T here is not much data available as to race or nationality. In the

Canton H ospital from May 1923 to M ay 1925 there were 195 patients of European or Am erican nationality. Only one of them, a Portuguese who was fond of the raw fish dish, showed clonorchis infestation. F o r more than three centuries Europeans and American have lived in this region where 20 to 30 % of the people are infested with clonorchis. W ith the one exception ju st nam ed none have been known to harbour this parasite, neither is there any record of any one in any country acquiring the infestation from any infested Chinese who may be residing abroad. It is safe to say that if there is any chance of non raw fish eaters becoming infested there would have been cases ob.M/rvcd long ago.

D r. Cook’s report from the U nited Brethren Hospital ih given here verbatim , as it is in the reservoir of clonorchis infestation, patients coming from Shan T ak, H eung Shan and San W ui.

T a b l e V I.U uited B re th re n M ission

H o sp ita l , Siu L aam .N u m b er C lono rch is ,

K x am in ed . p o s itiv e . % A v e ra ;e Ar p . Kfimu ks.

H ospital LaboratoryReport. 1924,-25,-26 306 112 36.6 2S.2Hosp. Lab. Record,1925-26, M ales E x. 123 73 59.35 hea\ yFem ales Ex.1925-26 ........................... 110 27 24.54 lightFarmers E x.1925-26 ........................... 73 50 71.42 high rateO ldest patients Yes 70

71 73

should be verified.

Youngest patient . . Yes 13 Mo.


(1 ) I f a person were infested w ith Clonorehis sinensis in infancy and should ca rry the infection until he was 73 years of age, we could not call it a very dangerous disease.

(2 ) Sym ptom s of this disease are often entirely lacking. T he presence of the infestations is only shown by eggs of clonorchis sinensis being found in the routine stool exam ination.

(3 ) Sym ptom s observed w here heavy clonorchis infection was present. ;

( a ) P ain in the abdomen.(b ) Stools yellow, fro thy, frequent.(c ) Ascites.(d ) Oedema.(e ) Anasarca.( f ) L iver not enlarged.

Checking the Canton H ospital records w ith his findings is confirm atory. H is patients are younger, average 28.2 as com pared with 34.8. H e records a heavier infestation rate 36.6% as com pared with 31% .

H is records for sex incidence shows males m uch m ore heavily infected than females.

D r. Cook rem arks, “ the incidence am ong farm ers seems high and should be verified.” T hey correspond w ith 'th e H ookw orm Comm ission’s data and are confirm atory of the evidence of the Canton H ospital data, th a t the farm er of the m ulberry-fish district is the reservoir for this Canton area of clonorchis infestation. It w ould be w orth while to survey other places in this m ulberry district to see if the reservoir extends over the whole area, or is lim ited to the Shan T ak , H eung Shan area around Siu Laam . H is points in regard to symptoms should be kept in mind in the discussion of the clinical aspects of clonorchiasis. P articularly , frequent absence of symptoms, gastro intestinal symptoms, ascites, and anasarca, liver not enlarged.

Conclusions from Epidcmiological S tudy .

1. Clonorchis infestation in Canton area is lim ited to the m ulberry- fishpond region and to those places supplied w ith fish from th a t area. I t is m aintained by the completion of the life cycle th rough farm ers, bu t is spread by sale of fish to other places. The infestation goes no fa r th e r than the fish go. T here is little danger of those infested': by sold fish spreading the infestation.

2. T he evidence from the geographical distribution and ascertained facts as to m atter of infection indicates tha t (a ) there is no danger of hum ans becoming infested or of clonorchis becoming


endemic except w here raw flesh of infested fish is consumed and(b ) clonorchis is a sharply lim ited disease. There is no danger of spreading except where all conditions are fulfilled for producing infested fish and opportunity given for eating it raw.

3. A ge and sex d istribution are confirm atory of the conclusion in regard to eating raw fish. T he heaviest infestation occurs in those age periods w here raw fish are eaten, and among males who would have the greatest opportunity to eat raw fish.

4. T he evidence from occupation is also confirmatory that infestation is due to eating raw fish and raw fish only. W here infestation is from fresh fish bought in the m arket only those occupation groups are affected who can afford to buy the fish. Poorer groups as farm ers and laborers are infected only where infested fish is produced.

5. T here is no case on record of any one of other nationality or race acquiring clonorchis infestation except in the one Portuguese who adm itted eating raw fish, although many have resided in the endemic region and there are m any cases of infested Chinese residing for long periods in other countries.

6. All the epidemiological data point to the conclusion that there is no danger under present conditions of clonorchis infestation spreading beyond its present boundaries or of being introduced into other countries.

S t u d y o f C l i n i c a l D a t a .

All the case histories tha t could be found since 1914 which were positive for clonorchis, were tabulated according to the following item s: hospital num ber, age, sex, residence, occupation, diagnosis, secondary diagnosis or complications, diarrhea, constipation, color of stool, other helm inths, ascites, jaundice, urine albumen, bile and sugar, hemoglobin, pain, other symptoms, treatm ent and result. T here were 251 cases from the Canton H ospital and 94 m ore similar case histories were secured from H ackett Medical School. F o r purposes of comparison a la rger series of positive and negative cases were taken at random from


the same source. H ere were chiefly negative cases but there w ere a small proportion of positive cases.

Since the habitat c f this fluke is the liver though it is sometim es found in the pancreas, sym ptom s would naturally be looked fo r tha t are connected w ith that organ. U sing the records, laboratory and office, the distribution of cases of liver disease of w hatever nature , both clonorchis, positive and negative will first be considered in relation to m ulberry and non m ulberry districts, divided into groups as in previous tables.

T a b l e V II.

Table show ing distribution of liver disease according to mulberry and non m ulberry areas comparing clonorchis positive with negative cases.

C lonorch is positive C lo n o rch is n e g a tiv e T o ta ls

L iv e rD isease T o ta l % L iv er

D isease T o ta l % L iv e rD isease T o ta l %

G roup I. 2 43 4.6 3 96 3.1 5 139 3.6

G roup I I ........................

H eu n g Shan and N ani Hoi — 4 77 5.2 11 265 4.1 15 342 4 .4

G roup III .

Partial Mulberrj' ... 7 130 5.4 27 477 5.6 34 607 5 6

T ota ls M ulberry ... 13 250 5 .2 41 838 4.8 54 1,088 4.9

Group IV .

N on m ulberry 0 23 0. 6 253 2.4 6 276 2.2

Group V.

E xtra Provincial 0 14 0. 3 370 .8 31 384 .8

T otal ........................... 0 37 0. 9 623 1.4 9 660 1.36l

Grand Total 13 287 4.5 50 1,461 3.4 63 1,748 3.6

In order to get as large a num ber of cases as possible for com parison of the liver troubles in positive and negative clonorchis cases, the laboratory and office records w ere taken from M ay 1922 to Decem ber 1925, giving the following figures. In 334 positive clonorchis cases there w ere 17 cases of liver trouble or 5.1% . In 3,275 negative clonorchis cases there w ere 77 or 2.4% cases in which there was a diagnosis of liver troubles.

Is Clonorchis a Health Menace in9 China f 197

T a ble V I I I .

In 287 Clonorchis In 1461 ClonorchisPositive Cases. Negative Citsis.

Number Number XTum or 0 0 1 .07Cirrhosis 0 0 3 .21A b s c e s s ............................. 0 0 .14Gall Stones 1 0.38 1 0.07Cancer 1.14 5 0.35A trophy 1 0.38 10 0.70Hypertrophy 0 , 0 ? 0.14Liver D isease and A scites 6 2.28 7 0.49Spleen and Liver Large 0 0 13 0.91Banti's D isease 2 0.6 6 0.42

Total . . ........................... 13 50T here are several things to be noted in these tables.1. In the positive clonorchis group all the liver cases are in the

mjulberry-fishpond area. In the negative clonorchis group 41 out of 50 are also there. In this connection it is well to consider the possibility of missed cases of infestation in the negative group. The technicians looked m ore carefully for clonorchis in 1924-5 than in earlier years. Com pare Table IV . Also the incidence rate for hospital cases is below th a t for the region as can be seen by Table II and by Dr. Cook’s Siu Laam report. Does the distribution in both clonorchis positive and negative cases indicate that there is some other cause than clonorchis infestation intim ately related to seri culture for these liver cases?

2. The incidence of liver troubles is more than twice as great in positive clonorchis as in negative cases, 5.1% as compared with 2.4%. Does this mean that clonorchis is a cause of these liver troubles? Should we consider that this small percentage indicates that clonorchis infection is of small im portance.

3. In the classification of liver diseases the preponderating ones in the clonorchis negative group a re ; tum or, abscess, atrophy, hypertrophy, and those accompanied with spleen enlargement. Cirrhosis is not included as it should be w ith liver disease and ascites, bringing that g roup up to 0.7% in the negative clonorchis cases. Gallstone, B anti’s D isease, cancer and liver disease with ascites predominate #in the clonorchis positive cases. T he atrophy and hypertrophy findings are in accord with the observations of Dr. Cook and the findings of Dr. A lm nett to be reported later. The preponderance of liver disea.se with ascites and of cancer in the clonorchis positive group is of significance, the form er when it will be seen later that ascites or anasarca as a sym ptom occurs twice as often in clonorchis positive cases as in negative. T he cancer group is significant in that clonorchis infestation should be considered seriously as an exciting cause of cancer.


4. T hese figures are not large, and standing alone would not have so great weight, but fitting in w ith all pathological, clinical, and epidemiological findings they attain m uch greater significance than their m ere num bers w arran t.

In cases of liver disease it is claimed there are o ften gastro-intestinal disturbances. I f the presence of clonorchis would cause any considerable derangem ent of liver function, gastro-in testinal sym ptom s are to be expected. Table IX and X give the d istribution of gastro-in testinal diseases, not including typhoid and dysentery.

T a b l e IX .

Show ing distribution of gastro-intestinal diseases according to mulberry and non m ulberry areas for positive and negative clonorchis cases.

C lo n o rc h is P ositive C lono rch is N eg a tiv eG ro u p No. No. G astro -

I n te s t . D is. T o ta l %

I 6 43 14II 9 77 11.7

III 5 130 3.8Total 20 250 8.0

IV 1 23 4.3V 2 14 14.3

Total 3 37 8.0

Grand Total 23 287 8.0

N o. G astro - In te s t . Dis.

102434

202646

114

T otal X96 10.4

265 9.0477 7.1838 8.2

253 7.9370 7.0623 7.3

1461 7.8

which there arem arked digestive disturbances are m ore frequent in clonorchis positive than in clonorchis negative cases.

T a b l e X .

Show ing relation o f gastro-intestinal diseases to positive and négative clonorchis cases.

C lo n o rc h is P o sitiv e C lo n o rch is N eg a tiv e287 cases

N u m b e r X1461 cases

N u m b erIndigestion 3 1.14 46 3.22Enteritis . . 1 0.38 21 1.47G a s t i ÿ t i s ............................. 4 1.52 17 1.19G astro-enteritis 2 0.76 4 0.28G astric U lcer 4 1.52 13 0.91G astralgia 4 1.52 6 0.42Flatulence 0 0 1 0.07C olitis ............................. 1 0.38 2 0.14Abdominal P a in .. 1 0.38 1 0.07Constipation 1 0.38 2 0.14G astric H em orrhage 1 0.38 0 0Cancer o f Stom ach 1 0.38 0 0Total ............................. 23 8.0 114 7.91

T here is nothing in these figures to indicate that clonorchis in festation has any effect on the gastro-intestinal tract.

A scites and anasarca follow im pairment of liver function. T aking this condition w hether it w as recorded as the primary or secondary diagnosis or as a com plication, its frequency o f occurrence in positive and negative clonorchis cases and its distribution in regard to mulberrv and non mulberry regions is shown in Table X I.

Is Clonorchis a Health Menace in Chinaf 199

T a b l k XI.

C lo n o rch is P ositive C lonorch is N egativeG ro u p No. A scites 8:

A nasarca T o ta lL X A seiles & A nasarca T o ta l

I . . 5 43 11.6 2 % 2.1II . . 5 77 6.5 12 265 4.5

I l l . . 5 130 3.8 23 457 5.0Total 15 250 6.0 37 838 4.4IV . . 0 23 .0 5 253 2.3A7 1 14 7.1 5 370 1.3

Total 1 37 2.7 10 623 1.7Grand Total 16 287 5.5 47 1461 3.2

A lm ost tw ice as many positive clonorchis cases show ascitesanasarca as negative. T here is m ore from the mulberry area of both positive and negative clonorchis than from the non mulberry area. H ere again m ust be considered the possibility of missed cases in the negative clonorchis group.

T a b l e X II.

Show ing distribution of conditions other than liver diseases, digestive disturbances and ascities and anasarca.

C lonorch is Pos. D iseases

C lonorch is N eg. D iseases

T otals

Pos. N eg . T o ta l % Pos. N eg T ota l % Pos N C R . 7.G roup I. ... 24, 19, 43, 55.8 77, 19, 96 80.2 101, 139 13Group I I , ... 61. 16, 77, 79.2 223, 42 265 84.1 2hi, :M2, 83Group I I I , . . I l l , 19 130 85.4 399 78 477 81.-5 610 607 84

- --- ----------- ■- » - ----- .------ ~ ----- ------ —Total 194 56 250 77.6 699 139 838 82.2 895 1.088 82

G roup IV ... 23 0 23 100 198 55 253 78.1 221 276 80Group V . ... 12 2 14 85.7 311 59 370 84. 325 384 85Total of non ----------- — ----------- ----------- ----- ----------- ----- ----------- ■--------- -----------

82m u lb e r ^ . 35 2 37 94.6 509 114 623 81.6 544 660

G rand totals 229 58 287 80.1 1,208 253 1,461 82.6

T h is table show s a very even distribution for other cases. T his w ould not be true i f an analysis for som e o f the diseases were made as in venereal diseases the predominance w ould be in Xam H oi and P un Y ue districts, w here Canton is located, and in the extra provincial group because o f its large proportion o f soldiers. M alaria


and wounds would likewise predom inate in these tw o g roups; other than these exceptions there would be a very even distribution.

T h e histories of 250 cases in the C anton H ospital and 94 in the G regg M emorial H ospital of the H ackett M edical College w ere studied. T here w ere no cases of liver disease in the group reported from the G regg M em orial H ospital. T here w ere 40 cases of liver disease positive for clonorchis in the group from the Canton H ospital including 2 6 cases of cirrhosis, 2 of abscess, 2 of cancer, 2 of hypertrophy, 2 of jaundice, 1 of hepatitis, 4 of B an ti’s disease, and one labeled liver disease. Table X II I does not give the true proportion of liver cases to positive clonorchis as it does not give either the num ber of positive clonorchis or liver cases which came into the H ospital during tha t time. T he figures previously given, 17 cases or 5.1 in 334 positive clonorchis cases, is a more accurate proportion as it gives all the liver cases and all the cases diagnosed positive clonorchis in the given time.

H istories of 71 cases of liver disease in which no clonorchis was found were taken for sake of com parison. These include 30 cases of cirrhosis 5 of abscess, 4 of hypertrophy, 19 of B an ti’s disease, 2 of tum or, 1 of jaundice, 10 of liver disease with ascites probably cirrhosis.

T a b l e X III .

C irrh o s is A b scesses, B an ti’s O th e r T o ta lsan d T u m o rs D isease, D iseases,

T o ta l No. Pos. N eg. Pos. N eg. Pos. N eg. Pos. N eg. Pos. N eg .Cases C lonorch is. £6

%40%

4%

7%

4%

19 r . 6

%5%

40%

71%

C onstipation 7.6 1 0 . 0 0 25. 0 0 2 0 . 7.5 7.1Diarrhea 7 6 15.

d - 20 0 0 0 0 20 .

d—15. 1 0 .

Color of stool y y — 38,• y y y y y v—3g - 1

A trophy ................ 11.5 65. 0 0 0 — 17. 0 10 37.H ypertrophy 15.4 0 50. 0 — — 33. 80. 2 0 . 5.6Jaundice 7.6 0 0 0 0 0 50. 2 0 . 1 2 5 1.4

A lbum en in u r in e .. 3.8 5. 0 14.3 0 0 33. 2 0 . 7.5 5.6Bile in urine 3.8 5. 25. 14.3 0 0 33. 2 0 . 10. 5.6Sugar in urine 3.8 0 0 0. 0 0 0 0 0 2.5 0

H em oglob in 62. 59. 55. 49. 65. 60. 67. 57 62.3 59.1Pain ................. 11.5 0 50. 14.3 0 0 50. 0 2 0 . 1.4A scites 76. 88. 0 00 50. 79. 33. 60. 60. 77.5E m aciation 34.2 88 100. 72. 75. 47. 17. 100. 42.5 86.

d = d a r k g = g r e e n y = y e l lo w

Comparing symptoms o f 40 cases o f liver trouble positive for clonorchis w ith 71 cases negative for clonorchis. Expressed in percentage o f total number o f cases.


T here is no great difference in the clonorchis positive and clonorchis negative liver troubles. Pain , bile in urine, hvpertrophv. jaundice, is worse in the clonorchis positive, while hemoglobin, ascites, em aciation, atrophy are worse in clonorchis negative. There are no sym ptom s that would especially distinguish the clonorchis positive.

T here were four cases diagnosed clonorchiasis. This was in the earlier days chiefly in 1914. They were probably so called for the lack of better diagnosis. Judging from the history in one gall stones w ere suspected, another had a hypertrophied liver. Three had abdom inal pain referable to the liver.

All the patients, if we except the four mentioned above, enteredthe hospital for causes other than clonorchis infestation. Besides theliver cases already mentioned sixteen were for pulmonary tuberculosis, six for other form s of tuberculosis, ten for chronic nephritis, twenty for m alaria, three for ascites, ten for splenomegaly, seven for typhoid, six for dysentery, ten for beriberi, sixteen for syphilis, nine were heart troubles, and seventy-four others, one to f o u r cases each, with no relation to clonorchis infestation.

From Gregg M emorial there were (M cases of which 48 weregynecological. 20 obstetric, X beriberi, 4 venereal disease, 3 each of typhoid and m alaria, and the rem ainder various. Xone of these gave any observable symptoms of having clonorchis infestation. There were no cases of liver diseases.

In the Canton Hospital cases, there were 23 who had constipation. 9 of which were m alaria, and 4 had a diagnosis of constipation. There were 15 cases with d iarrhea, of which 6 were dysentery and 2 colitis.

F rom the Gregg M emorial Hospital 32 had constipation, 1 oi which was diagnosed constipation. 1 typhoid. 1 malaria, 1 nephritis, the rem ainder obstetrical and gynecological, mostly disorders ot the uterus. O ne patient only complained of diarrhea. Neither constipation nord iarrhea could be considered especially characteristic of clonorchis infection. F o r most cases yellow stools are recorded. T his seems characteristic.

T here was complete absence of atrophy or hypertrophy except where other conditions seemed to demand it. In J lackett only o n e c a se was reported, that of slight hypertrophy.

Jaundice was recorded in two of the cirrhosis c a se s , in the one case of amoebic hepatitis, in the two cases diagnosed jaundice, in one ascites case with hookworm, and in two other cases ot ankylostomiasis. T he two diagnosed jaundice may have been due to obstruction by the flukes, as also the three hookworm cases.

T he urine seemed to be without significance for albumen bile, or sugar. The average hemoglobin is 66.3 for 192 cases.


Em aciation seems to be the m ost outstanding sym ptom but probably not m ore than ordinary, being recorded in but 75 of the Canton H ospital cases and in 12 of the G regg M emorial H ospital.

P ain is mentioned in 2<S instances but of these only 15 are referab le to abdom en or liver. O f these 15 cases, 2 a re in constipation, 2 in colitis. 1 in tubercular peritonitis. 1 in nephritis, 1 in splenomegaly.1 in typhoid, and 7 in liver troubles, including 1 in cancer, 1 in hepatitis,2 in hypertrophy, 3 in cirrhosis. Xo pain referable to clonorchis was found in the G regg M emorial H ospital cases except possibly 2 stom achache and one heartache.

Conclusions from Clinical S tudy.T he conclusion to be draw n from this clinical data is tha t ordinarily

there are no symptoms due to the presence of clonorchis and tha t there is no group of symptoms that could be called Clonorchiasis. O nly in heavy infestations is there observable harm done to the person infested. Considering all factors clonorchis infestation is probably less harm ful than ascaris.

T here is evidence, however, to show that heavy infestations produce serious pathological conditions in the liver in some cases. T hey seem to be a causal factor in liver disease with ascites, and may be strongly suspected of being an exciting cause in some instances of cancer of the liver.

Pathology. T he w riter has had no opportunity in Canton for autopsies. M any cases come for autopsy to the Governm ent Bacteriological Institu te in H ongkong. D r. E . P . M innett in charge of the Institu te has kindly given the result o f his experience. H e does not especially look for clonorchis except when it is desired to collect specimens, yet since December 1922 he has been able to observe 150-200 clonorchis cases a year.

D r. M innett states that there is neither hypertrophy nor atrophy except in old heavily infested cases. “ The liver presents a smooth norm al appearance. I t is impossible to tell which livers contain the parasites and which do not until the livers are cut open and the worm s are actually squeezed out. T he worm s are found in the hepatic ducts, w hich are distended by them. T here is form ation of fibrous tissue around the ducts m aking the walls of the ducts appear m uch thicker. T here is a fa ir am ount of occlusion found when there is a sufficiently large numl>er of worms. Sometimes secondary ducts are form ed in the thickened wall when there is occlusion of the original duct.

T here are occasionally small areas of destruction of liver cells. T h ere is never enough to destroy function completely or to a g reat degree. Judg ing from pathological findings it is possible to have enough in terference w ith function of the liver, either by occlusion of the ducts

Is Clonorchis a Health Mcnacc in China? 203

=or destruction of cells to cause jaundice. However, heavily infested livers are found yet with no jaundice in the patient."

Sometimes reports of isolated cases are made, usually Chinese in foreign countries, w here grave clinical symptoms and serious pathological lesions are said to be due to clonorchis or are reported in clonorchis ■cases. These cases never exclude definitely other conditions that may cause these symptoms, for example, "Chinese, aged 31. a native of Canton, who had lived in Cuba for S years, in a condition of otherwise ■perfect health. F or the past four vears. however, pain had been felt with a sensation of weight in the region of the liver to which had more recently been added vomiting afte r meals an 1 abundant diarrhea. On .admission to the H ospital, patient exhibited much emaciation and lo ss

of flesh. The skin and conjunctiva had a slight icteric tint. The m uscular system showed great flacciditv.”

Cancer was not excluded in this case, nor is there any suggestion th a t cancer had been considered as a cause of the above symptoms. T here is a possibility of clonorchis being an exciting cause of cancer.

The w riter is able to report one autopsy with clinical history that is a good illustration of clonorchis infestation complicated by another liver condition. T his auto])sy was made by Dr. \V. \Y. Cadbury on one of his patients in Canton H ospital in 1(,16.

P atien t Xo. 16/1172, entered Canton Hospital, October 27, l l)16, aged 35. male, silkworker. father living, healthy, mother died 15 years .ago of dropsy, sisters and brothers well, married 10 years, no children, w ife well. H istory of chills when young, no venereal disease, fond of drinking w in e , 20 oz. daily. Patient had an attack of chills and fever 24 days before, w ith swelling of abdomen and lower limbs. Abdomen contains a large am ount of fluid. U rine is acid cloudy, sp. gr. 1,025, no glucose, no albumen, blood cells. Feces contain clonorchis ova. Spleen palpable. O ctober 2<S 4.500 cc. fluid aspirated, Xovember 6

.5,000 cc. fluid aspirated. Patient in great distress lrom gas. Xovember l (i pain in both legs and abdomen. Vomiting. Xovember 20 marked .tympany. 100 cc. cream y fluid aspirated. Died Xovember 21.

A utopsy, X ovem ber 21, 1916. Body is fairly well nourished. O n opening peritoneum there is found a moderate am ount ot yellow fibrin and free yellow cloudy fluid.

L eft pleural cavity contains yellow purulent fluid. Both lungs are •congested, no areas of consolidation.

H ea rt has slight thickening of mitral and tricuspid leaflets, but no o rganic disease.

T here is a typical hobnail liver, surface roughened and nodular. Volum e of liver reduced. The gallbladder has thickened walls and contains yellow tenacious bile. O n section there is seen to be m arked


thickening of the fibrous tissue and the lobules are clearly dem arked. Scores of clonorchis sinensis can be expressed from the biliary passages, th roughout the liver.

T he spleen is enlarged and the capsule is much thickened.T here is m oderate passive congestion of the kidneys. T he capsule

peels off easily.X o parasites can be seen in the intestines.Pathological diagnosis. Acute peritonitis, acute purulent pleurisy,

atrophic cirrhosis of the liver, clonorchis sinensis infestation of the biliary passages.

B ib l k m ;r a ? h y .Faust, E. C.

Syllabus o f Helm inth Infestation in China.Som e recent Aspects o f the Kpidemiology of Clonorchis Infection in China.

C.M.J. April, 1925.F aust E. C. and Barlow , C. H.

Prelim inary N ote on the L ife-h istory o f Clonorchis sinensis in Chekiang Province. Am . Jour. H yg. Vol. 4. N o 1, January, 1924.

Faust, E. C. and Khaw, O. K.Studies on Clonorchis sinensis (Cobbold) Am. Jour. H yg. Monograph 8.

chap. 3. 1927.H oward. H . W . and Busw ell, K.

A Survey o f the Silk Industry of South China. A gric. Bull. 12. L ing Nan A gric. Coll. Canton.

T he Occurrence o f Clonorchis sinensis in Eastern Cuba.N ew Orleans Med. Surg. Jour. December 1917. Vol. 70. No. 6. p. 500.

Reviewed in Trop. D is. Bull. Vol. 2, N o. 2. 1918.

D i s c u s s i o n .D r. E. C. Faust.

I am sure that we are all very greatly indebted to Dr. Frank Oldt for the detailed inform ation which he has provided from the hospital data on Clonorchis infection in the Canton area. Such inform ation may be considered as basic data which is altogether too rare as source material for the compilation of reports on parasitological infections in China. Perm it me to make some remarks withregard to the various aspects o f the Clonorchis problem which Dr. Oldt hasconsidered. •

1. In the first place, the experimental work which has just been com pleted in the parasitology o f the Peking Union M edical College and which has been paralleled by the work of Dr. K. N agano in the Government M edical School, Okayama. Japan, indicates that in all probability the miradicium o f Clonorchis does not hatch from the egg in the pond or canal water, but that the unhatchedegg is passively ingested by the appropriate mollusc and, after a certain periodof time, hatches in the esophagus o f the mollusc, and penetrates through the. esophageal wall where it becomes metamorphosed into the sporocyst in the periesophageal lymph spaces. Later, as it matures and produces the succeeding generations o f rcdiae and cercariae, it m igrates into the perihepatic lymph spaces. W hile we have been able to hatch the Clonorchis miracida under laboratory

Is Clan orchis a Health Menacc in China? 205

conditions, by utilizing abrupt changes from cold to warm temperature and by physical shock, such conditions arc probably never met with 111 nature in the heavy endemic areas. Furthermore, the larva when hatched is entirely too delicate and its free-living existence too short to accomplish active penetration of the mollusc.

2. W ith respect to the longevity of Clonorchis in the body of man, we have calculated from the autopsy findings o f Heanley in H ongkong and Katsurada 111 Japan, both of whom have furnished data on the number of parasites obtained from autopsies at various periods o f life, that the probable minimum life o f the parasite is not less than 5 years while the maximum is not over IS years. Thus an infection incurred in childhood would have been lost before middle life if the host had moved out of an endemic area or had refrained from eating infected raw fresh-water fish during this period.

3. There are several instances on record of the presence o f Clonorchis worms in the pancreas. H ow ever, the pancreas is undoubtedly not the normal habitat of this worm. In controlled experiments we have found that the larvae taken in with a rawfish meal excyst in the duodenum from which they m igrate into the common duct, whence in ordinary infections they proceed directly into the bile passages, continuing their m igration until they reach the distal bile capillaries where they take up their residence and grow to maturity. Cases of Clonorchis infection in the pancreas apparently all belong to the category in which the liver itself has first been completely filled with the parasites, and the invasion o f the pancreatic duct is due to an over-supply of the worms or p ¡ssibly to obstruction in the biliary passages.

4. W ith reference to the great mass o f lightly positive cases, it is incorrect to assume priori that Clonorchis infection is noil-pathogenic because it ordinarily presents no striking signs or symptoms. Closer examination and study of the ilin ical. as o f the pathological picture, may lead to the discovery of mild chronic symptoms, which, after ruling out other possible causes, may point to the presence t;f a definite disease entity referable to hepatic lesions produced by Clonorchis in the bile passages.

The Japanese clinician, Inouye, after careful study, has outlined the types of symptoms referable to Clonorchis infections which go hand in hand with the pathological picture.

(a ) The m ild type, without appreciable symptoms.(b ) Secondary stage, attended by diarrhea, edema and hypertrophy of the liver.(c ) S evere type, with the symptoms of the secondary stage but aggravated by

involvement o f the hepatic portal circulation.

Granted that the severe type is found only in exceptional cases, careful ex amination and study of the patient by Inouye indicated liver enlargement in 50 per cent o f the cases, the surfaces of this organ being usually smooth, seldom irregular or indicative o f portal c irrh osis; dull pressure pain in 33 per cent, sharp pain as in gall stone obstruction being very rare; spleen enlargement in 12.2 per cent of the cases; ascites in from 15 to 40 per cent of the cases. depending on the amount o f endemic infection in the locality from which the patient came; diarrhea in 66.8 per cent o f the Okayama cases; normal stools being found in only 3.9 per cent o f the patients; irregularity o f appetite with discom fort after meals in 50 per cent or more o f the infected individuals. Icterus is relatively a rare occurrence. It is evident, therefore, that in the Japanese series o f cases which have been carefully studied for a number of years, there are definite gastrointestinal symptoms accompanying Clonorchis infection. I feel that until similar


cases o f C lonorchis-infected patients in China are carefu lly studied w ith this inview at the tim e the patient is in the hospital, we have no right to rule out the possibility o f such concom itant and resultant symptoms in Clonorchis infections.

5. Dr. Oldt has secured data from the Canton area of K w angtung Province. 11 seems altogether likely that his epidem iological findings are referable to other places in China where man harbors Clonorchis. H ow ever, w ith respect to the amount o f the human infection in China as compared with Japan. Southern Korea and French Indo-China, comparative studies must be made before any direct inferences can be drawn. It is quite probable that the average number o f worm s per patient in endemic areas in Japan. Southern Korea and French Indo-China is conspicuously more than in similar areas in China. Therefore, conclusions can not be drawn as to the pathological or clinical significance o f clonorchiasis w h o lly on the basis of Chinese histories.

6. A nsw ering the question proposed by Dr. Oldt in the title of his paper. I feel that if the inquiry is restricted to clonorchiasis in China the answer is " N o ;’’ if it involves adjacent endemic areas, no such unqualified answer can be given.

A SURVEY OF THE HYGIENIC CONDITIONS OF THE MISSION PRIMARY SCHOOLS IN THE PROVINCE

OF SHANTUNG.*

D r. C. H. H a x , Department of H ygiene & Public H ealth, School o f Medicine, Shantung Christian University.

In the past few years much has been talked about the question of public health in China. Sometimes it seems that this problem is getting on its feet and going well in certain directions. O nly experience- wili tell w hether or not we have started on a w rong track, and. if so. m uch energy and money will have been spent in vain.

I have reluctantly come to the conclusion that our present methods- of publicity and education are not being directed along right lines. F o r instance, in the T sinan Institu te , models o f m any kinds are exhibited, am ong them pictures and models for health dem onstration purposes. M any visitors go th rough every year, but most, if not all of them walk by the show cases, looking at them as i f the}' were m erelv curios- T he general Chinese public does not take the- exhibits as an exam ple to be followed in their daily life. T hey fail to make any application of the models to themselves.

T o-day. people interested in th is phase o f Christian activity have very properly changed the direction o f their efforts from the mass- of the people tow ards the schools, for it is an established fact tha t unless good health habits are form ed during childhood, it is extrem ely hard for anyone to change his ignorant attitude tow ards his own and

* Read at the China Medical Conference in P ek in g , September. 1926.

Hygienic Conditions of Mission Primary Schools. 207

the public health. T his is especially true in China where the ofthe population is illiterate and knows nothing about hygiene.

T here is 110 question but that .school children should be healthy.N o m atter w hat kind of a prim ary school is under discussion, if itsobject is sound and tends tow ards the common good, hygiene should be given an im portant place in its time-table, the planning of its buildings and environm ent. T o quote Dr. Sundwall's word- in his article 0 x1 Constructive H ealth Activities in Public Schools:---

“The most far-reaching results to be anticipated in our nation-wide health movement will come from effective health activities in our schools,— in our graded schools, high schools and universities. Kspeci- ally is this true for our public schools. The impression of childhood and the habits formed in early life are tenacious. Ingrain in our boys and girls health hab its; correct physical conditions which are actual or potential handicaps; give them, by means of appropriate, wisely planned and graded instruction throughout their school periods, an understanding of the fundam ental principles of health promotion and disease prevention ; instil in them a keen and impelling appreciation of the fact that the m aintenance of sound, active, vigorous and harmoniously developed bodies is a norm al obligation they owe to themselves, to their friends, to society and their country. Acquaint them with the m ethods and facilities at our command for promoting health and dealing w ith diseases and subnorm alities."

H ealth work in the schools, hitherto, has been an interest in the m inds of some Christian educators and a few health worker-* not directly connected with the schools in the mission field, but so far the local m issionary doctors have taken no responsibility in the m atter. Country p rim ary schools are generally not within sight of mission workers and for this reason during the last 20 years they have improved very little, if a t all. in the direction of better sanitation.

Hygiene is a special kind of work. If it is lett to educationalists only, eager though they are to change school conditions, their efforts are likely to be futile because of difficulties arising from lack of proper knowledge. T herefo re it is true to say that the hygienic conditions of school children should be in the charge of medical men. In other words, i t is the duty of the local m issionary doctors.

In a school health program m e the most im portant thing is to understand what the existing health conditions are. ( Hherwise our advice m ay tu rn out to be impracticable. This is why Dr. Peter in his article “ T he Field and .Methods of Public H ealth work in the M issionary E n te rp rise ’’ suggested that this work should begin with a survey.

A fte r going into the question of the present hygienic conditions o f the schools, we cannot but agree with D r. \ \ akefield in his article


“ The School \ \ a its ,” in which he saws tha t the conditions in the p rim ary schools are simply appalling. F o r this very reason the w riter undertook th is survey to present to the medical profession in China the actual conditions of the mission schools and to show w hat an im portant question school hvgiene is.

According to the report of the China Educational Commission in 1(>22. the num ber of mission prim ary schools in Shantung appeared to be larger than in any of the other provinces; i.e., there w ere 942 schools, having a total enrollm ent of over 17,000 pupils. In W25 the num ber of schools was understood to be over 1,000, but the num ber varies every year. I t was found that m any of the schools could not be reached by post, therefo re the results revealed by the present survey can only be regarded as a reflection of the conditions of schools to which a questionnaire could be sent bv post.

A questionnaire was prepared, based on the general requirem ents of a modern prim ary school. E ffo rts were made to avoid obscure questions and unreliable answers.* One was sent to everv possible school and addressed to the principal teacher. As will be seen from Table I, questionnaires were sent to 388 schools. Replies have been received from all but 121. or 31%.

T a b l e I. B a s i s Upon W h i c h S t a t i s t i c s H a v e B e e n C a l c c l a t e d .

Number of schools to which questionnaires were sent . . . . 388Forms filled in and included in statistics . . . . 267N o replies from . . . . . . . . . . 121

388

Number of schools in villages . . . . . •• . . 217Num ber of schools in towns . . . . . . . . 47Tow n or village not specified . . . . 3

267

Number o i pupils enrolled in 267 schools . . 7,576Number of pupils in village schools . . . . ."',715Number of pupils in town schools . . • • • • • 1.861

7,576

Number of teachers in 267 schools . . . . •• 386Number of teachers in village schools . . . ■ • • 280Number of teachers in town schools . . . . . 106

386

* A letter accompanied the questionnaire requesting each principal teacher only to put down the actual condition in his school. Teachers were inform ed that no comparison would be made between any individual schools. The purpose o f the survey was explained to be a simple presentation to m issionary doctors o f the general hygienic conditions o f schools. T he questionnaire was prepared in such a w ay that onlv replies o f ■yes" or "no" or numbers were needed.

Hygienic Conditions of Mission Primary Schools.

Xumber o f schools having sleeping facilities tor pupils Num ber o f schools not having sleeping facilities for pupils Number of schools not replying

121

1433

267

Number of schools having sleeping facilities for teachers . Number of schools not having sleeping facilities for teachers Number of schools not replying

2184o

Percentage of schools sending in returns Percentage of schools not replying 31 '/

Percentage of schools in villages out of total considered Percentage of schools in townsPercentage o f schools town or village not specified

V' >(■/

lie-tore attem pting to investigate the mass of inform ation which these replies have produced, there are two or three farts which should be made clear.

In the first place, it is noticeable that the large m ajority ( 82'/i ) of schools are in the villages, but it is unnecessary to make distinction between village and town schools, for. as a m atter of fact, there is very little différence in hygienic conditions. In the second place, many replies did not accord with the questions asked or were so obscure as to be useless. These are put together with those unanswered questions under the heading “ Xot replying.” Lastly, since 218 out of the 2(>7 schools report teachers living in school premises without specifying in what room they sleep, no use can be made of this inform ation in its relation to school hygiene. T he same inaccuracy occurred in answers referring to the living accommodation of pupils.

The questionnaire was divided into a number of different sections and it will be convenient to follow these sections in considering the replies which were received.

A s stated in the preceding paragraphs the schools under consideration are mostly located in villages (82% j. The buildings were generally not originally built for school purposes. In many instances the rooms are borrowed from one of the Christian fanners, in this case, very often not the slightest im provem ent can be made without the ow ner’s serious objection, as he wants to use the rooms for other purposes, such as store rooms, etc.

Section 1. School Premises.


School Surround ings :—N u m b e r o f Class R oom s in cach Schoo l :—

T a b l e II. N u m b e r o f C l a s s R o o m s i x E a c h S c h o o l .

Number o f schools Number o f roomsSchools having 1 room 177 177

2 rooms 54 1083 .. 7 21

„ 4 ............................... 11 44,, ,, 5 ,t 2 10

6 „ 1 r.N ot replying . . 15

Total 267 366

It must he noted that the number of rooms per school bears no necessary relation to the questions o f crowding or ventilation. These points w ill be dem onstrated in other sections.

School . ¡spccts:— The large preponderance of southern aspects is In accordance with the usual Chinese custom. It is the best possible one for a school in this province.

Section 2. Building Materials.

Floors:— O ut of the 240 reporting schools eighty per cent have ord inary earth floors. T his obviously means that there is no protection against dam pness or organic gases rising th rough the floors in thc^e schools. Eleven per cent have brick floors. Brick floors are com paratively easier to clean but they also afford no protection against gases or damp. Cement and wooden floors are rare, only two per cent each, because of their relatively heavier cost. O nly five per cent have m ortar clay, a m ix ture of sand, lime, earth and water. In the country this is the cheapest form of floor and is more practical than any other but is not yet in extensive use.

W a l l s : - - As far as hygiene goes, there is no choice am ong these k inds of walls, but bricks are the strongest and the most expensive. T h e stone walls are not made of blocks of stone, but small pebbles held together by m ortar clay.

R o o fs : — I Jay. which is the com monest, is also the best m aterial fo r school roofs. It is cheap and easily obtained in any of the villages, and is both cooler in sum m er and w arm er in w inter. Tile roofs are usually found in town schools. F la t roofs made of lime m ortar are hot in sum m er and crack easily. Schools having flat roofs are as a ru le low and have less cubic space than the others.

Interior Wall Surfaces:— A lthough 129 out of the 169 schools reporting have plastered walls and smooth surfaces, only very few

Hygicnic Conditions of Mission Primary Schools. 211

m entioned that the walls are white washed. This affects the lighting of the schools greatly. As will he seen from later sections there is a large percentage of schools (8 0 % ) which have defective lighting and non-whitew ashed walls make this condition still worse. 38 schools actually complained of d irty and rough wall surfaces.

Section 3. Ventilation and A i r Spaces.

JVindozi's:— Chinese paper windows, although they cannot be opened, are not air-tight. A ir, therefore, can gel through slowlv. M oreover, such windows will have some holes in the course of time and they afford unintentional opportunity for constant ventilation. It is a fact that m ore and more schools are changing the ordinary paper windows for glass ones. T his does not necessarily mean that hygienic conditions will he improved in relation to ventilation. If such w indows are not opened, they are worse than paper ones, as no holes come in them and they are more air-tight than paper. Fixed w indows are distinctly bad as far as ventilation goes, as they cannot be opened even if desired.

Through Vcntila-tion:— Schools are here listed under the heading “ V entilation can be secured” if they reported windows and doors on any two of the four walls of the schools. W hile 221 reported that through ventilation can be secured, there are still 29 having d o ors

and windows only on one side of the walls. It is a serious m atter for a crowd of children to remain in such stuffy rooms every day throughout the school term s.

"Bird Holes" (ventilation h o le s ):— It is customary in so m e parts of the country to build houses with small holes situated just below the eaves in the fron t and back walls. Sometimes there is one on each end wall near the roof ridge. The original purpose of these holes m ight have been to dry the houses when newly built. \ \ hat interests us is that these holes provide natural inlets and outlets 1or air at all times. These are specially useful in schools without through ventilation, or schools which do not set special times for complete changes ol air. I t is a pity to note that only 92 schools reported having these holes, while in 105 schools they do not exist.

Special T im es set fo r the Changing o f .-Hr:— Any school reporting a special time, m orning or evening, for opening the windows and doors is listed under this heading. T here are still 60 out of the 211 reporting schools in which such arrangem ents are lacking.

Cubic A ir Space:— It will he seen from the accompanying diagram that when 120 cubic feet per pupil is set as a minimum standard for air space. 127 ( 56% ) out of a total of 22<> reporting school* come up


to requirem ents, while 99 (44% ) are still below this standard . This standard is the lowest perm itted in England for children under seven years old. As a m atter of fact not one of the reporting schools is a K indergarten and the age of the pupils is between 7 and IS. T h ere fore, the standard thus set is not strictly applicable to the schools under investigation, and the replies simply show that a large percentage of these schools do not even meet the ordinary requirem ents of a K indergarten.

If we take the very low standard of ISO cubic feet per pupil as ‘'ideal.” we find that 163 ( 7 2 %) schools do not meet this requirem ent and only 63 (28%. ) come up to the standard.

Considering the question of ventilation as a whole, the inadequacy of their window space, the shortage of air space and the lack of proper ventilation periods, we cannot but feel that the children in these schools are w orking under conditions which do not make for mental or physical efficiency.

Section 4. Crowding.

It is a well established fact that adequate floor space in schools is m ore im portant than a ir space. Com paring the present conditions with the lowest English standard (9 square feet per pup il), we find that 148 ( 65% ) of the 229 reporting schools are up to standard, while only SI i 35% ) do not meet the requirem ents, and it appears that the p ercentage of schools wdth inadequate floor space is lower than the p ercentage of schools with inadequate cubic space. T his is because Chinese houses are rarely m ore than 10 feet high, and consequently cubic air space is limited.

T ak ing 15 square feet per pupil as an ideal standard for these schools, only S3 (3 6 % ) of the 229 schools come up to it. while no le s s than 146 (64% ) are well below standard. T herefore over-crow ding is one of the serious problem s in the prim ary schools of Shantung.

Scctioji 5. Lighting.

11 in doze Space :— T he source of light in 70% of 210 schools is a Chinese paper window. L ight coming through this kind of window is poor. Considering the inadequate window space which occurs in 144 out of 180 reporting schools and the presence of non-whitewashed wall surfaces, the question of lighting is a grave one. These conditions are m ostly found in village schools. One im portant point m ust be noted, which is that, although some school buildings are designed for this purpose, they still have inadequate window space.

Artificial L ig h t:— A s will be seen in later sections, 70% of 243 reporting schools have pupils studying at night. A lthough kerosene oil


lamps are largely used in these schools (159 out of 224 reporting schools) there are still 62 ( 28% ) using the old-fashioned lamps w ithout chimneys. These not only give poor light but also produce unburned carbon in the form of black smoke. E lectric light is only found in three schools; this kind of illumination is not practicable in the country.

Direction o f L i g h t -N o less than 59% of the reporting schools have their light com ing from the left. T he teachers seem to know which is the right direction, but considering the large percentage i 80% ) of schools whose total light is inadequate, a proper direction in what light there is does not necessarily give good working conditions. The 21 schools (1 1 % ) reporting light from the right side are, of course, still w orse off. W hen desks are arranged so as to face the windows, light naturally comes from the front. T h is is w rong for both teaching purposes and the avoidance of direct rays. L ight coming from the left and back is ideal but only three schools so reported.

Seetion 6. Heating.

One of the most significant things in connection with heating i> the type of stove used in the schools. O ut of the 161 reporting schools 126 ( 72% ) use ordinary Chinese stoves without chimneys, while only 35 (28% ) have foreign style stoves to warm the class rooms. The use of these Chinese stoves may be due to the shortage of financial support, but if that is the reason, no stove at all would be much better as far as the health of the pupils is concerned. The Chinese stoves produce a large am ount of smoke and m any varieties of poisonous gases which are diffused through the rooms. However, the benefit of the heat given out by this kind of stove is small in comparison with the harm done by its poisonous products.

Section 7. Scats and Desks.

The Provision o f Scats and Desks:— W hen seats and desk> are provided by the pupils (44% ) their type is never uniform . \ s a rule none of this fu rn itu re is fit for school use. W hen furn itu re provided by pupils is ad justed according to their age and height, some of the objections to its use are removed. But. owing to the fact that these seats and desks are the pupils’ personal effects, only 35% of the schools using such fu rn itu re are able to ad just them, while 50% cannot do so, in spite of their unfitness for school use.

A lthough 135 (5 4 % ) out of the 252 reporting schools have their seats and desks provided by the school, only 64 ( 4 7 % ) of them are of unsuitable un iform height, while the remaining 57 (4 2 % ) reported tha t the school provides seats and desks adjusted to the needs of their users.


The A rrangem ent o f Scats and D esk s :— N inety-three per cent of the 239 reporting schools have their seats and desks so arranged tha t they face one direction. T his is convenient for teaching purposes, hu t in some cases such arrangem ents are disadvantageous for lighting, if the windows are too few in num ber.

Section 8. Play-grounds.

Provision and Size o f P lay-ground :— It is noticeable that most of the reporting schools (175 out of 267) are provided w ith p lay-grounds: only 60 are w ithout them. Since most of the schools are situated in villages, a piece of land is usually obtainable, often a fa rm er’s threshing ground, yet 132 out of 204 schools w ere unable to get their play-grounds large enough, i.e., less than 20 square feet per pupil, or have none at all.

Section 9. Sanitation.

A . Dining Quarters:— T he question of food is too complicated to • consider in detail. Suffice it to say that in most cases the d ining room and the kitchen are one. Schools w ith sleeping accommodation for pupils alm ost invariably use some part of the school prem ises for eating purposes. W hile 121 schools out of a total of 264 (see Table I ) have sleeping facilities for pupils, only 54 (2 4 % ) out of 221 have separate dining-room s. Am ong the 167 schools which reported not having dining-room s there are, presum ably, some w7here food is cooked and eaten out in the court-yard. 29 schools actually stated that the pupils and teachers eat in the class-rooms. In these cases it may mean that one room serves as a common class-room, dining-room and kitchen.

B. Water. Sources o f JJ'atcr:— Shallow wells, which are generally polluted w ith organic m atter under the present conditions, are the main sources of w ater supply (217 out of a total of 250 reporting schools). R iver w ater, as used in 14 schools, is definitely unsafe fo r drinking purposes if not boiled. T h e only possible clean source of w ater is a spring. T his is used only by th ree schools. A nother 8' schools use both shallow well and spring w ater.

Drinking W ater:— 61% of the 237 reporting schools insist on their pupils d rink ing boiled w ater. O f the rem aining 39% , the teacher’s attitude is irresponsible. In 1% the pupils habitually drink cold un boiled w ater and in 38% the choice is optional. I t is, therefo re , m ore than probable that the last, optional, group mostly use unboiled w ater. T h is is especially true for the sum m er m onths since children, naturally th irsty , do no t understand the im portance of not drinking unboiled w ater.

Drinking Cups:— W ith regard to the use of individual drinking -cups, it will be seen that only 40% of the sohools have them. B ut even

hyg ien ic Conditions of Mission Primary Schools. 215

this does not necessarily mean that the cups are always used hv their owners. It is probable that they are indiscriminately changed about.

C. Washing Basins and Towels, ¡¡'ashing luisins:- 1t is an astonishing fact that no less than 83% of the 134 reporting schools use com mon basins for washing purposes, and there is no doubt that this is a m aterial factor in the spread of trachom a. The extensive use of common basins, revealed by this questionnaire, is probablv justified by the m anagem ent on financial grounds, but it is well known that suitable earthenw are basins are easily obtainable in the country at a very low cost.

T o w e ls :— T hat '>4% of the 160 reporting schools insist on the individual possessing his own towel is an encouraging feature, but il is m ore likely that the question of ownership counts for more than sanitation.

D. Latrines. Provision o f La tr ines :— The material in the latrines, both urine and faeces, is used by the local farm ers as a fertilizer, lo r this reason there is no difficulty in obtaining latrines. The figures show th a t only 29 out of 256 schools fall below7 the standard set.

Type o f L a tr ines :— Open latrines which are accessible to animals, flies and rain, are used in 146 out of the 208 schools reporting. Dogs very often come in and act as scavengers, and beetles spread the laeces all over the place. T he worst part of it is that flies make the latrines .an ideal nursery for breeding. W hen unemptied, as is often the case in the sum m er, flies swarm. T hus intestinal infections are carried. Conditions in the roofed latrines of the 59 schools are but slightly better for the roof only prevents rain from falling in. Screened latrines are obviously not practicable in small villages. The three schools possessing them are all situated in towns.

T he Disposal o f X ig h t S o i l :— The present survey d o e s not include statistics on this subject, but the latrines are as a rule emptied by one ■or the other of two methods. F irs t, most o f the schools keep th e night soil and urine in the pit for so m e length o f time— a few weeks to a few m onths— then em pty it when fertilizer is required on the land. 1 he other method is to em pty the latrine once every few days. The contents of all the latrines are used on land or for fertilizing vegetables.

Section 11. Health Education.

Physical E xerc ises :— T he large proportion oi schools i 'X)% out of a total of 2 6 % ) having physical exercises as a regular item in their schedule is probably due to the fact that the school curriculum cannot ■omit it since it is required by the regulations for prim ary school educa


tion. The length of tim e taken up by these exercises varies between 15 m inutes and one hour each day. T h e tim e of day set fo r physical exercises also varies; some are in the m orning and others in the a f te r noon. None of these schools have organized games and it seems that none of the teachers are trained to conduct these exercises.

Hygiene Recitations :— H ealth teaching is only carried out in 47% of schools while 37% do not teach any thing about this subject. A lthough this 47% have hygiene instruction, the tex t books used are far from correct. O nly 74 of the 127 schools use them at all. O f these only five schools use D r. A ppleton's “ H ygiene and Sanitation for China” and 28 use the text book on Hygiene published by the Com mercial P ress. O thers use books which are quite unsuitable for teaching purposes in P rim ary Schools. It is. therefore, obvious that, although instruction in H ygiene is carried on in some schools, the m aterial for such instruction is far from adequate.

Credits fo r Personal H y g ie n e :— B efore they enter the school very few of the country school boys know anything about conducting their lives on a reasonable hygienic basis. I t is, therefore, a really difficult task even for an enthusiastic teacher to create an atm osphere in which his pupils would be willing to lead a healthy life.

A lthough 54% of the 267 schools state that attem pts are made to attain this ideal, it appears tha t w hat is being done is to enforce a series of a rb itra ry rules by means of punishm ent rather than to create a sanitary atm osphere.

Section 72. Health o f Pupils.

The care of pupils’ health in the p rim ary schools is deplorable. T hough 33 of the 236 reporting schools stated that they have a medical officer, there is not one school which has a regular or paid physician for the eare of its pupils’ health. T he medical officer, in the ir sense, is merely a medical m an who can be consulted w ithout much difficulty whenever pupils are sick. T herefo re these medical officers are physicians when pupils are sick and have no responsibility beyond this.

M odern treatm ent of disease is only available in 36 of the 167 reporting schools, while in 118 the teacher takes no responsibility w hatever for his pupils' health. In 13 schools cases of illness can only be attended by an old-fashioned Chinese doctor. T his is to be expected since m odern doctors are extrem ely rare in the villages.

M edical exam ination of pupils is alm ost absent. In all these 222 reporting schools only 26 reported tha t they m ake exam inations of this n atu re and none of them keep any records whatsoever.


W ith regard to control of infectious diseases no preventive m easures w hatever have been carried out in any of the schools. Only 5 out of the 230 reporting- schools have pupils w earing spectacles and in each of these five schools there is only one pupil who wears them. Com paring the total num ber of pupils involved in this questionnaire <7,57<>) with the num ber of pupils w earing glasses, we can say that delects oí evcsight in pupils receive practically no attention. Such things as bathing, food, sleep and the w ashing of their clothes,— in fact, all m atters of personal hygiene are practically outside the teachers’ control.

I t is an astonishing fact that in nearly all the schools < 70% out of 243) the pupils are expected to study at night in winter time. Xot onlv do these children go to bed much too late, but it is probable that tliev also get up early in the m orning in order to be in time for school which often opens at dawn. These facts speak for themselves.

Section 13. Tcachcrs’ Views on School Hygiene.

T he practice of hygiene (as revealed by this questionnaire) in the schools is almost nil. I t is really a question as to whether the teacher’s enthusiasm and. zeal can obtain the necessary co-operation of those who are in adm inistrative charge. \11 the teachers to whom questionnaires w ere sent were asked to express their views regarding the question of school hygiene. Only 41% of the total of 2(v schools made any reply a t all. Financial difficulties are their chief complaint. ( )thers complained of the ignorance and reactionary attitude of the school m anagers. In m any instances the schools are in rooms borrowed from farm ers and no im provem ents can be made at all. It appears that some of the teachers confuse m odern hygienic conditions with the relatively costly equipm ent they have seen in some foreign controlled institutions and have no idea as to how the simple materials obtainable in the country can be adapted to their needs.

O n the whole, the teachers feel that the insanitary environm ent of their pupils ' homes represents an obstacle too great to be overcome, and even the best of them slowly get discouraged.

A gain, an enthusiastic teacher inevitably has to face serious criticism from parents and m anagers the moment he wishes to make any sanitary reform . P aren ts do not see the necessity for the expense involved in providing such ex tras as an adequate supply of boiled w ater, chimneys to stoves, etc. T hey regard the regular exercise which should form part o f a well planned curriculum as a waste of good time.

T here is, however, one teacher who seems to have given a great deal of thought to this subject. H e holds tha t the lighting, ventilation and cleanliness of any school-room can be improved without involving heavy expense.


\ teacher who knows how to conduct his own life on sound hygienic principles can. by his own example and a little daily sympathetic attention to his pupils’ needs, bring about a complete change in the atm osphere of his school, Given such teachers, there need be no fear for the ultim ate fu ture of village school hygiene.

D i s c u s s i o n .

A consideration of ihe conditions revealed by this questionnaire brings out the deplorable fact that there is hardly any mission school the sanitary conditions of which can. by any stretch of im agination, be called satisfactory. The pupils are w orking under everv kind of disadvantage. Poor lighting, bad ventilation and overcrow ding in dirty dam]) rooms is their common lot. The health of pupils receives no care. T he form ation of good health habits is left entirely to the pupils’ own choice, and although health education is conducted in certain schools, the teaching is more in fashion than in fact. F inancial difficulties are. of course, grave obstacles to a health program m e but the ignorance of both teachers and school m anagers is really the chief factor which blocks the progress of hygiene reform in the schools to-day.

Shantung is not the only province whose1 schools are in such a bad condition. T hroughout the whole country we can only find a few schools where hygienic conditions can be called satisfactory. The missions in China, although they have a large num ber of p rim ary schools under their charge, have not yet taken any practical steps for im proving their hygienic conditions.

T he outlook seems almost hopeless, for any im provem ent is entirely dependent on the ideals and personal exam ple of the teachers. D r. M iller exam ined 130 men and women teachers in C'h’angli and found that 57 had defective vision, 13 bad teeth, 106 w ere personally unclean and 35 had contracted trachom a. Given such teachers, how can we expect them to teach hygiene in the schools ?

It is useless to com pare schools under m issionary m anagem ent w ith those in foreign countries. The economic and political conditions of the latter are too different. I t is. therefore, a waste of tim e to suggest a program m e of reform which is based on conditions in the west. A lthough we recognise the im portance of such things as nu trition , air pollution, room tem perature and sex hygiene, the conditions in this country are too backward and their discussion would have no useful purpose to-day.

D uring the last few years, the Christian Church has, a fte r a period of activity in the cities, again tu rned its attention to the ru ra l com munity. I t is once m ore telling itself that about 85% of the population of China

H ygicmc C auditions oj Mission Primary Schools. 219

lives in villages, and is undertaking an extensive study of rura l conditions. But up to the present tim e the Chinese C hristian com m unity has almost entirely failed to realise its responsibility for medical work. Fundam entally its members do not believe in W estern medicine, either in its preventive or curative aspects.

Foreign doctors can and do materially alleviate a large am ount o f unnecessary suffering, but the really im portant preventive work can only be done by enlightened Chinese Christian doctors working in conjunction with the local church. In this way and only in this wav can the education of church members be carried out. Then im provem ents ii ̂ school and home sanitary conditions will be within sight, for it is a fact tha t most of the school teachers are members o f the church.

At present a great deal of energy is being wasted in curing a few- isolated cases when wisely planned measures could be instituted to prevent a large num ber of the population contracting disease.

W e all believe that the fu ture of China and the church lies in the schools where leaders of Christian character are produced. \ \ e also believe that education is the key to public health. Hut it is bad economy to neglect the care of students' health, and in the past too little attention has been paid to this. Many of our best students die of preventable disease afte r they have completed their school training. To quote Dr. Simon W oo’s w ords: —

“ If the missionaries are content to have schools ju.st as good as th e general run of schools in China, thev may justly and proudly feel that they have done pretty good work, but if they cherish any higher am bition, then thev should quickly do something to improve the health conditions of their students. By improving the health conditions they will not only do credit to their schools, but they will raise the efficiency of the students, both in their present study and in their fu tu re work, thus conserving the very result for which the educators w ork."

T herefo re only educators who realise the importance of health questions and who put their principles into action can be considered modern. T his cannot be achieved without the doctors’ co-operation. In the past, doctors w ere only occasionally invited to help in mission schools and have never taken any responsible adm inistrative positions. In mission com pounds it is quite common to find a fairly well equipped hospital, side by side with a school whose sanitary conditions are appalling. Everyone realises that the doctors in charge of these hospitals are overworked in every way, but it is now tim e for them to change their point of view and to take some direct adm inistrative re sponsibility for the sanitary conditions in the schools.

W ith rare exceptions, it is only C hristian universities which have a medical officer. In the few p rim ary schools where they exist, the ir


work is regarded as experim ental, but the Christian colleges are, according to the educational report, only 40 in num ber and have only2.W 8 students. T he mission prim ary schools, on the o ther hand, num ber and have 184,481 pupils. T his large num ber of pupilsscattered over the country presents a problem in public health education m uch m ore difficult to solve than that of a few universities situated in large centres. The form er problem is hitherto untouched.

Good citizenship is our object in C hristian education. T he best seeds should be sown in the minds of children. I t is very hard for even a college student to change his health habits. Aly own teaching experience in the college gives me the im pression that teaching and ^he practice of hvgiene am ong the college students are two separate things.* U nless we bring these two together, a thing which can only be done in the p rim ary schools, we can never expect either m ore efficient or happy citizens in the future.

W hen the doctors on the mission field realise the prim ary im portance of school hygiene, wre shall be able to step in and take up the w ork at the best and most fru itfu l en'd of the C hristian enterprise.

R e c o m m e n d a t i o n s .

In December 1(J24. for the first time in the history of Christian Education in China, a conference of medical and educational m issionaries was called. As the result of this conference, a school health program m e was proposed. .Many valuable suggestions were incorporated in this program m e, but in practice each part of the country will have to decide its own m ethods of carry ing on school hygiene work. T he existing conditions in the schools of Shantung, and presum ably in other provinces as wrell, are far from ideal. It will take very m any years for the schools to meet the requirem ents of tha t program m e.

At the present tim e any program m e which dem ands a sudden change in school policy is not practical. W e must do w hat can be done w ithout involving heavy cost. Considering the situation as a whole, the following recom m endations are suggested as a first step along the path of r e fo rm :—•

1. Each mission station to set aside a doctor to investigate the ex isting conditions in its schools and to grade them in a report according to their hygienic standing.

2. Special vacation courses should be held once a year in which teachers can receive the necessary instruction in school hygiene.

* A course o f lectures on personal hygiene was given to a class o f college students in Shantung Christian U niversity. A visit to their dormitories afterwards showed that not one o f them made any personal application o f w hat he had heard.

Hygienic Conditions of Mission Primary Schools. 2 2 1

3. Special conference of teachers and managers to lie called at or shortly a fte r the Xew Y ear to im press upon them the im portance ■of health schemes in the schools.

4. Each mission to have a visiting doctor, preferably Chinese, to d o the following th in g s :—

(a ) V isit all the schools annually and try tu persuade the school m anagers to make up the most glaring deficiencies in their hygienic conditions.

(b ) H e should have some travelling medical equipment for the treatm ent of the m inor illnesses he sees and have power to exclude the really dangerous cases from the school.

(c ) T o check up the teachers’ health work in the school.

5. The Provincial Board should issue an order directly to the teachers and principals as to what tex t book should be used in schools.

(\ The Provincial Board should open one school as a model for the whole province. T his school should he of the minimum standard and use the cheapest material with the best arrangem ent, so that it can be followed by any school w ithout much difficulty.

I have to express my thanks to all those Chinese and foreignfriends who have spent much tim e and trouble in correspondence withm e over this questionnaire.

R efkrkn ' c k s .

Christian Education in China,— a Report o f China Educational Commission, 1922.

K nox. J. H„ '“Prevention in Pediatric Practice."- X n v York State Jour.of Med., October 1. 1925. p. 925.

Peter, \Y . \ Y . “The Field and Methods o f Public Health Work in the M issionary Enterprise,"— China Med. Jour., Mar. 1926. p. 185.

School H ealth Programme, Bulletin N o. 6., China Christian Educational Association.

Sunclwall, John, "Constructive Health A ctivities in Public Schools,”—Jour.A .M .A ., A ugust 4. 1923. p. 373.

W akefield, Paul. -‘The School Wait*."— Health. March. 1924, p. 1.W oo, S. M. “The H ealth o f M ission Students,"— The Educational Review.—

China Christian Educational Association, January, 1924, p. 65.

The China Medical Journal.

THE HEALTH OBLIGATION OF MISSION HOSPITALS.*

K. H . L i. Sonchow.

The fact that Mission H ospitals possess a recognized place in China to render a distinctly beneficent service is proved beyond the shadow of doubt. L ike mission schools they have done a great deal ol good w ork in the past. But unfortunate ly much of this good work has been done at the sacrifice of the m ore vital and evidently m ore im portant phase of the medical mission, namely, health cultivation and disease prevention. I call it un fo rtunate because medicine can never hope to be of as much value in the treatm ent of diseases as it can in the ir prevention. M oreover it is in the study and application of disease prevention that our m odern medicine lias no rivals. In fact, ours is t-he only one of the m any medical arts existing that is not invaded by charlatans, quacks and w itchcrafts. It is this that distinguishes the so-called1 P reventive medicine from anv other types of medical practice. I feel tha t if in the past we had possessed this viewpoint of medicine as the basis of our medical mission work, our achievement m ight have been even greater than it has been and the attitude of the people tow ard our hospitals m ight have been m ore favorable. Instead of being “ hospitals” in which only the advancedly diseased seek life out of death, they would be probablv health centers from which health and happiness radiate.

( )i course, prim arily the mission hospital is a healing institution and as such it has succeeded in a varying degree. But let us ask ourselves frankly, is healing the most im portant object of medical service? I f so, in the face of China's great m orbidity, w hat p ro portion of those who need medical attention seek the mission hospital for trea tm en t? .And out of those who do come to us, what num ber of them are susceptible to healing? If they are healed, (tha t is according to the results obtained on patien t’s date of discharge from hospital) what percentage of them will rem ain healed?

Take for example the most prevalent diseases such as tuberculosis of all kinds, dysenteries, m alaria, venereal affections and organic disease? of heart and kidney which are constantly presenting themselves for our treatm ent in large num bers day in and day out and which cause by fa r the largest bulk of the total m ortality and m orbidity in the country! W hat are we doing for this great mass of suffering millions?' W hat have we done that is appreciable in the fight against the sum total of these hum an ailments in China? Superstition and prejudice still

* Read at the ’China Medical Conference in Peking. September. 1926.

The Health Obligation of Mission Hospitals.

keep a large portion of these people from r e c e iv in g - mission hospital trea tm en t at a ll; while ignorance holds not a few hack from seeking medical attention early. O n account of the lack of charity funds in m ost mission hospitals m any of the destitu te sick have to he turned aw ay w ithout hospitalization. The rem ainder, are. as ia rule, the well advanced cases which are heyond the best of modern medicine to rem edy b u t’which in their early stages might have been either checked or prevented. Rut the w orst of all is that out of the limited number in whom we proclaimed a cure on leaving hospital, many of them retu rn into their original condition. If we analyse the medical work in every mission hospital, I believe such is the average condition of affairs under which the w ork has to be carried on.

T his being the case let us ask ourselves how can we reinedv the situation, so that our beneficent service to China may be enhanced to its highest degree?

T he experience of five years’ work in a mission hospital makes me believe that the solution of this problem will lie in the t o o commonly repeated but mi little practise:! proverb : "An ounce o f prevention isbetter than a pound of cure .” In other words we have to change the entire attitude of the hospital from the curative point of view ¡o the m ore vital function of disease prevention. To be sure it is im portant and necessary to adm inister healing to those who are sick but let us no t forget the greater aim of keeping the well from being sick. It means that the mission hospital should combine available preventive and curative methods into a single instrum ent for the advancement of m odern medicine in China. Mealing should not be the end itseli but rather the means to that which is even nobler and more perm anent than healing, in other words we should heal the sick s o that we m ay gain an opportunity of teaching them and the community how to m aintain health and to avoid sickness. That is the spirit of modern medicine and certainly should be the first motive of the mission hospital likewise. I believe the time has come when we should regard the hospital no m ore as a "sick house” but a health center irom which will radiate continuous stream s of inform ation about health and disease prevention to the com m unity in which it is located'. In order to realise this, the first and forem ost condition is the creation of a strong health m orale or health conscience among the members of the hospital staff. T his m ust be cultivated gradually by continuous teaching and preaching and practising of the fundamental principles of health and o f disease prevention. It is not sufficient merely to talk about health ru les and health habits, but to practise them. R egular health exercise should be encouraged and sanitary inspection of the hospital plant m ade so as to keep the spirit going right. Simple health habits should


he inculcated w ith regard to coughing, sneezing and spitting. W hen w earing a mask, the object and reason for so doing should be explained that it is not the foul breath but rather the infectious m aterial that showers from the coughing spell that we are protecting ourselves against. In this way health practices which m ay arouse suspicion and m isunderstanding to a stranger, will not only be dissipated but replaced by confidence and appreciation by those who come into contact w ith us.

H ospital rules and regulations, which to the unacquainted may seem to be harsh and unreasonable, when explicitly explained in the spirit oi service and the viewpoint of disease prevention will eliminate much m isunderstanding between the hospital and the comm unity as a whole.

In this way every contact between the doctor and the nurse, the nurse and the patient, the patient and the doctor will be an opportunity for practical health instruction. W hen this sort of spirit and a tm osphere perm eates the entire hospital from the superin tendent down to the coolie there will be no necessity for special cam paigns fo r health or against disease.

I t is needless to point out how m uch m ore readily knowledge pertain ing to health is assimilated when one is sick and therefo re d u rin g the period of convalescence from illness each patient is psychologically receptive to health education to a degree not otherw ise obtainable. T hat means th a t hospitalization should be seized as an opportunity for giving to each patient a brief period of schooling in m atters of health and disease which m ost concern him or her as the case may be.

Now let me tu rn to another group of persons who by reason of circum stances are apt to be quite susceptible to the appeal of health inform ation. They are the friends and relatives who daily make their visit to the sick in the hospital. Instead of m aking them wait idly for adm ittance to the ward, parlors and w aiting room s should be decorated w ith charts, posters, autom atic lantern slides, depicting the causes, recognition and prevention of such diseases peculiar to each locality which the hospital is to serve. T his will not only utilize their spare m om ents to the best advantage but also serve to catch their attention along m atters of hygiene and health— the violations of which, have probably brought their dear ones to the hospital.

In this connection I rnay express my opinion regard ing the well intended religious w ork in the mission hospitals. I am sorry to say tha t much of this w ork done by the Bible-women and pastors had better be undone. I do not mean to condemn the spirit that is backing the original idea of religious w ork, but I do criticise the m anner of its routine presentation. I t irrita tes the prejudiced mind and cultivates

The Health Obligation of Mission Hospitals.

no friends for Christianity. Religion will be more real and impressive if it is expressed in the life one leads and the work one does and it is the fault of the mission hospital if Christianity is not presented in this way. W e do not need any religion that only appeals to the dying for happiness in the next world but we do need the messages tha t will strengthen our carriage so that living and life in the present will be m ade m ore w orth while.

T he Gospel of H ealth is the fir^t and fundamental requisite for those who are ignorant, weak and sick and if that is properly supplied the rest will take care of itself. So the present need in the mission hospital is not religion but the spirit of i t ; and this spirit will he best

'expressed in the social medical service with special modifications to suit the individual needs and dem ands of each community where the hospital is located. T his will not only add another strong instrument to the positive and practical teaching of health but also supply a real ¡personal element between the doctor and the patients, and maintain a close relationship between the hospital and patients which otherwise would be impossible. T hat this is feasible and will fu rther increase the efficiency and good work of the hospital as a whole may he judged from accom plishments rendered by the visiting nurses through some of the institutional churches utilized as child health centers and m others' clubs.

O utside, but situated immediately around the hospital, we have a group of people— the general church constituency of the mission to which heretofore very little public health effort has been directed. T hey may have been very good followers of the Bible. But as to the knowledge and its application o f m atters regarding health and disease they are as ignorant as the uneducated public. \ certain m inim um am ount of health education and care should be im ported to them through the offices of the minister, pastors and their assistants. R egular and systematic prophylactic measures, as vaccination against sm allpox and typhoid fever, and habits directed tow ards the prevention of gastro-intestinal diseases should be the realizable objectives o1 health conservation amongst one's own constituency. Xo amount of health talking is as of much value as the actual application ot such m easures.

T here is still a fourth group of individuals who come into frequent •contacts w ith the mission hospitals and they are the students in the mission schools. H ere one has an opportunity of dealing with the groups who represent the privileged class in the community. By reason of their m ental background they are m ore favorable and susceptible .to the reception of that part of knowledge w ithout which no am ount •of best education will be of great value either to the individual or


to the society. I f the introduction of health w ork is w orthy of sy stematic, effort at all, it will be am ong this group of boys and girls, because in every respect they are natu rally favorably predisposed to the acceptance of health in form ation and instruction. In age they are ju s t at a plastic stage for moulding, and in mental capacity, they are fertile for any thorough teaching. ^Moreover each individual re]»resents a home, the health refo rm of which is largely dependent upon him or her. H ence if the seeds of health habits and activities are sown properly here, the harvest in fu tu re will be m anifold.

H itherto some attem pts have been done to this group of young people along the line of physical exam ination, but little has been attem pted in the follow-up work, especially the correction of defects found as a result of the physical exam ination or to utilize intelligently the physician 's contact with the student as an opportunity of educating him in the m aintenance of health and the avoidance of disease.

■In order to do this im portant piece of health propaganda effectively, not only the closer cooperation between the teachers and doctors are necessary but also in case of larger institutions, a full tim e school physician should be secured as an integral p a rt of the teaching faculty. T his mem ber should preferab ly serve a threefold purpose of general medical supervision, teaching of physiology and hygiene and physical education as a whole. W ith him as a head and with the facilities of the mission hospitals and cooperation of the medical staff at his com mand, a thorough and systematic health program w ith special em phasis on the correction and positive phase of the w ork could be carried out w ith ease and efficiency.

F inally there is one m ore larger group of heterogeneous make up— the general public, upon whom the popularity of mission hospitals largely depend, and which m ust not escape our attention. In the past, a certain am ount of medical aloofness has l)een held by the hospital tow ard the com m unity for two reasons. The first is because the financial status of the mission hospital is independent of local support and the second is because this general public is by nature m ore or less indifferent even to our w arm est enthusiasm . As a result little effort has been made to cultivate understanding and acquaintance between the hospital and the com munity. But conditions are changing and people are now eager to seek the prophylaxis which m odern medicine alone can supply. Here and there requests are made for vaccination and prophylactic injections for cholera, typhoid, diphtheria and scarlet fever. H ere is a golden opportunity for the dissemination of health in form ation and m odern means of disease prevention. Unless we seize this opportunity now becoming generally available and give the public an intelligent appreciation of health and disease they will fall-

The Health Obligation of Mission Hospitals. 227

into the hands o f charlatans and quacks, a result which will require years to remedy.

Among- this general public we find a special group of so-called' private medical practitioners to whom the rest of the public look for care and counsel. F o r the sake of the advancement of modern medicine in China, we owe to them a service which hardly necessitates* emphasis. T hey need guidance and inspiration to practise modern medicine in its proper spirit and standard. Medical societies should be form ed so as to tear down the class distinctions of the so-called Germ an. F rench. English. Japanese trained doctors and unite them under the co -lra tern ity of m odern medicine. Hospital privileges for diagnosis and treatm ent of diseases should be extended to them all alike, while in tu rn they should introduce their patients for hospitalization when necessary. I think this the best and most effective means that will bring about a better understanding between the hospital and the community.

In order to prove to the public the real purpose of preventive medicine, ex tram ural clinics and health activities such as prenatal clinics, child health centers, m others’ clubs and midwifery classes should be initiated in connection with the regular hospital work or the nearby institutional churches. Experience has already shown that the tim e pu t into these will be amply repaid' by the support and response shown by the public.

T im e does not perm it detailed description of the various health activities advocated so tha t the hospital in addition to being a healing mission may become a constructive influence in the community, but the above will serve as suggestions to stimulate the work already started or yet to be instituted in the different mission hospitals th roughout China so that their power to do good may be further increased; and while we are here attending this conference having health as its m ajor topic m ay we not urge the necessity of action speaking louder than our words. Should this not be an opportune moment for this Association to place itself on record as to what should be the minimal health activities of its m em bers? The C.M .M .A., p rio r to 191 possessed no health policy. As again this year. Health was the m ajor topic of the Conference held then and as a result was born the Council on H ealth Education. The logical initial step was to create intelligent public opinion. Xow afte r a lapse of a decade would it not be appropriate, in line with the enlightened policy o! this Association as seen in its change of name at the Hongkong meeting, to proceed a step fu rther in regard to health policy and suggest something of a concrete natu re! A minimal program m e might lie something as the follow ing:


I. System atic positive health and prophylactic m easures should be introduced w ithout delay am ongst specific groups of people. These should include (a ) the hospital staff and their families starting with the professional and then reaching the non-professional; (b ) the students upon whom physical exam inations should be carried out em phasizing the subsequent follow up as the correction of defects, and detection and isolation of contagion as well as preventive inoculations against disease—taking care to utilize the opportunity for health education created by such m easures; (c ) the salaried and th e re fore the m ore strategical members of the church and mission and their families.

II. Specific preventive m easures for the general com munity m ight be initiated with the hospital undertaking certain functions of a “ H ealth C enter” for a lim ited population in its vicinity or in conjunction w ith a com m unity center. W ith the allocation of a trained public health nurse and utilizing the medical facilities of the hospital, such activities could include prenatal and well baby clinics, m others’ clubs, the instruction of midwives, etc. T he added expenses of such preventive m easures would not reach a thousand dollars a year. The hospital, by initiating this, would not only be undertaking systematized preventive services for the com m unity at large, but. more im portant, would be dem onstrating preventive principles of medical science to the public.

I I I . Then, in the mean time, there could lie taken up according to the need m anifested and opportunity presenting, the list of positive health activities which will depend upon educational propaganda among the patients and their relatives, the general church constituency, the general practitioners and the com m unity at large.

I believe that this preventive aspect of modern medicine is so vitally im portant to the very existence and development of our mission hospitals that 1 deem it proper and fitting to present it as a comm endation to the Conference for consideration. I would therefore move that this body recommend to the chairm an the appointm ent of a committee to draw up a resolution on hospital health policy for deliberation by the Association.

Hospitals and Health. 229

HOSPITALS AND HEALTH*

S. H . C h i a n , M .D., Peking.

A medical man who rests content only with alleviating or curing diseases and fails to realize that his main duty is to keep people well, commits nothing short of a crime against his clients, his country and hum anity. Yet. this sacred duty has not been upheld by quite a numljer of the hospital authorities in this country.

T he unwillingness of these hospital authorities to permit their resources to be used for health educational purposes arises partly out of the fact that they have not yet outgrown the idea that the hospital is intended only to help the man who happens at the moment to be ill. F ifty years ago this might have been the case, but today all disease should be approached from an entirely different point o f view. M any physicians are still disposed to consider that they have done their full duty when they have given skilful attention and careful nursing to their patients, not appreciating that their new and greater responsibilities are in the field of preventive medicine.

In order that the facilities of the hospitals may be used for the present day m ore constructive dem ands of human welfare, the staffs of hospitals m ust be suitably prepared for undertaking such dutiesto society. H ow ever, the field of medicine has become so extensivethat it is absolutely impossible for any one individual to lie thoroughly educated and trained in all its departm ents, hence the very natural division of physicians into general practitioners and specialists. We are all educated prim arily as general practitioners, that is, we are taught something in all the medical specialities and we only become specialists later because of our own inclinations or the circumstances and opportunities which surround us.

But, the circum stances, opportunities and demands especially in this country are such that we all need to be more or less healthspecialists. T here are constant demands on the health knowledge ofthe physicians during their daily rounds in the wards and clinics. The dem ands from local governm ental authorities and lay organizations have grow n trem endously. Individuals come at all tim es for consultation and enlightenm ent on m atters pertaining to preventive medicine and hygiene in respect to the insanitary conditions of the homes and the prevention of communicable diseases. It thus becomes absolutely necessary for the physician to have some comprehensive train ing in preventive medicine and hygiene, in order tha t he may at the same tim e become a com petent health teacher and adviser if not an actual w orker.

* Read at the China M edical Conference in Peking, September, 1926.

230 The China Medicài Journal.

Those phy sicians who ,are now in active service in the hospitals may not have the tim e for the study of the science of preventive medicine, but a year or six m onths of special study would prepare them adequately for routine dem ands, leaving- the difficult and complicated cases and problem s for health specialists. In fact, all general practitioners can prepare themselves for doing the w ork by devoting to the study of preventive medicine and hygiene the same am ount of tim e devoted by them in the past to the study of gynecology, derm atology, and either specialities, which they are daily practising.

The chief responsibility for the preparation of the practitioner lies w ith the medical school authorities, nor will the present defective outlook be rem edied until the undergraduate colleges are caused to realize that their graduates will not be qualified until they possess a w orking knowledge of the essential principles o f preventive medicine and hygiene. I t is. certainly, first in order th a t we m ust look to the medical schools for the train ing of men and women who as doctors of the future1 may be counted upon to proclaim and adm inister the gospel of health.

T he setting up of a H ealth D em onstration Station under police auspices in Peking in cooperation with the Peking Union Medical College and H ospital is a step in the righ t direction. I t serves a needed and useful purpose of affording a practical dem onstration of a m odern health organization w ith its records, clinic, visiting rnr.'se service, and health educational features. T he establishm ent of ?uch a close active alliance betw een 'the G overnm ent and people on one hand and the school and hospital on the other for the prom otion of the health of the com munity, is tru ly a step in the righ t direction, and is in harm ony with the spirit of progress tha t characterizes the tw entieth century medical activity fo r the protection and betterm ent of hum an w elfare.

It is true tha t not all the medical institutions can cooperate in large dem onstrations as the foregoing, on account of the lack of tim e or money ; but none of them 1 can afford to neglect entirely doing some phase of sim ilar work. T he least is definitely to allocate p art of their tim e to the preaching of the gospel of health as they are already preaching the Gospel of the C hristian church. As it is. a physician holds a fixed and honourable position am ong his people, and there he will rem ain, a no lesser confidant than the spiritual adviser of the fam ily or com munity, not only in tim e of distress bu t at all tim es as a health evangelist in instructing, guiding and advising his people in th e science of conservation of health. H e should, therefore, live up to the requirem ents and expectations of the public. F urtherm ore , the exhibition of health posters, special health talks, school health clinics,


baby shows and clinics, and m any other kinds of public health services may be done without costing much in tim e or money, and such services rendered to the people all tend to give m ore prestige and confidence to the hospital, and thus gain more interest and support from the Governm ent and the general public.

Another m atter of g reat importance which every hospital should consider itself as in duty bound to perform is to render all possible assistance to those who are collecting data or inform ation relating ■to m atters of health interest. M any doctors are ready and willing to give their help to the Governm ent or private individuals in their efforts in collecting or compiling statistics for one thing or another, yet a g reat num ber of hospitals fail to discharge this im portant duty. As a m atter of illustration, we find in the M onthly R eturns of the Pre\-alence of Communicable Diseases in China to the National Epidem ic P revention Bureau, about four hundred and fifty cards are sent out m onthly to the hospitals in the country, but only about one- th ird respond. Since statistics and all events that are related to public health are in a greater part supplied by the hospitals in foreign lands, one fails to understand the reason why this duty is not perform ed by m any of the doctors in this countrv. is it because the task is too troublesom e or is it lack of time or money which prevents the giving of cooperation to professional colleagues and to medical science ?

The results of a hospital service should not be reckoned only by the num ber of patients treated but also by diseases prevented. As soon as the latter is shown, it will impress the people, arouse their interest, and opportunities of widening the scope of preventive work will follow. A case of small-pox treated involves more time and money than a thousand or m ore cases prevented by vaccination. D uring the. recent w ars around the Capital, some ten thousand wounded soldiers were brought into the hospitals in and around Peking. H alf of this num ber who had been given anti-tetanus serum soon afte r entering the hospital escaped infection, three per cent of the rem aining five thousand died of tetanus. T he striking result of this prophylactic treatm ent has been m uch commented on and appreciated by not only the m ilitary authorities but the general public in the Capital.

E very hospital should be a health center serving its community. T here are difficulties, but each one should do the utm ost w ith an altru istic professional spirit.

I t is hoped tha t some definite plan may be arrived at during th is conference to bring about a useful service of this kind.

In order to pave the w ay for discussion, the following may be suggested :

232 The China Medictil Journal.

1. Steps should be taken to prepare the hospital staff for ordinary health service.

2. T o determ ine the minimum requirem ent in preventive medicine and hygiene for teaching of undergraduates in Medical schools.

3. T o draw up a practical preventive program for the hospitals to c a r r y out regularly along with the established curative service.

4. A com mittee may be form ed to prepare literature and timely topics to be presented by the hospital members in a m anner that will not alone im part inform ation but also arouse the people to active efforts in health work.

5. Discussion might be made during this conference on what efforts should be made by the hospitals to cooperate w ith the G overnm ent and other lay organizations in dealing w ith health problem s at ordinary tim es and during emergency.

D i s c u s s io n o n D r . S. H. C h u a n a n d D r . K. H . L i ’s P a p e r s .

D r. IJ’it Lieu Teh w ished to express his appreciation of the two papers which they had just heard from Drs. Chuan and Li. to which Dr. James M axwell had taken exception. Perhaps some o f Dr. L i’s statements were overdrawn, but there was no doubt that the time had arrived when our ideal of medicine should be revised to suit the needs o f the times. In Great Britain, thanks to the leading of Sir George Newm an the General Medical Council had directed that all subjects in medicine, including' Anatom y and P hysiology, should be taught with a view to the preventive side. I f hospitals in China were to serve the best uses for the masses, they should be adapted for the same purposes in China as in Europe, and he hoped that the P .U .M .C ., which had instituted pr:st-graduate courses in Ophthalmology, O tolaryngology, D erm atology and such like m ight with advantage inaugurate a similar class for Public H ealth needs. A t the C M .A . last m eeting in Shanghai he suggested the allotment of 10 per cent mission hospital funds and staff for public health work, le'aving the other 90 per cent for treatment.

D r. H ’ A . H em in gw ay reported a little o f the public health activities connected with the Taiku Hospital, Taiku, Shansi.

There is a Health A ssociation, o f which our local m agistrate is chairman and one o f our Chinese physicians of the H ospital is E xecutive Secretary. This Association combines with the H ospital in em ploying a graduate nurse who gives all his time to lecturing to students and giving prophylactic treatment. H e travels all through the region enlightening the people on health subjects, using literature prepared by Dr. Appleton and charts and tracts from the Council on H ealth Education. H e comes in contact w ith m any people who are sick, and urges them to go to the H ospital for treatment, or attend a clinic held once a month on Sunday by one of the H ospital doctors in each o f the country Churches.

D r. H . Owen Chapm an: W e are much indebted to Dr. L i for the courageouspaper he has read. Such papers arrest our attention and do us good.

But when he stated that “the attitude o f our hospitals should be changed from curative to preventive” and that “it w ould have perhaps been better if this had been the attitude in the past’’ he probably stated more than he really- intended.

"We m ust admit that many of us have been far too backward in preventive work, but it can never be substituted for curative work: that is not possible. The healing work of the doctor has since the days o f Christ been a most essential and important witness to the value o f the individual: in China it has been a strong factor in arousing the national consciousness to its duty and preventive w ork .v-on it preventive medicine depends step by step for all its advances. . . .

: ' D rr Ewers:-. W e in W eihsien- have full authority to set any quarantine we think best. The school' authorities have given us complete control. Dr. Grant says- w e with authority could stop one-half of a ll diseases. In mission stations w e feel that it must be a matter o f finance. Dr. Stuckey says our duty is stil! curative, thus to propagate the gospel o f health. I agree most heartily with him and now see public health buds germ inating in our community.

D r. E. J. S t u t k r y : There is a relation between methods used in our hospitaliv. the Tiealing o f disease and the introduction of preventive measures. I suggested to the manager o f one o f the largest carpet factories in Tientsin that he should introduce among his employees the prophylactic measures which we found so successful in France in the prevention of eye disease among the Chinese coolies. H e said to me "That’s all very well, doctor, but we have to be very careful how w e introduce changes among our em ployees: for a much smaller matter than that all our men in one factory went on strike.” So it is clear that until in our curative work we have commended our methods to the people, we cannot hope to introduce preventive measures with any hope o f success.

D r . J. H . W y l ie : One of the problems of preventive medicine is theexpense involved. W ould it not be wise for those interested in public health to set about finding funds to place at the disposal of country hospitals to aidin preventive medicine? I feel that it would be a great feature o f this worktc aid in this financial support o f preventive medicine in our Mission Hospitals.

D r. J. E . Gossard: Step by step we study disease! Step by step pointout sin and w rong doing and give place to prevention.

H ealth and sanitation, public and otherwise, are great specialiti'.-s. \ \ e m ust have th e m ! Just as we need the specialities in the various departmentso f medicine. H ow ever no such speciality or no one speciality must take theplace o f the others.

In tim e o f war we care for the injured very carefully, but at such a time w e don’t begin to stop all w ar!

“Prevention” seeks now to enlist the full time of doctors. H ow ever they must enlist workers from other fields also, you must appeal to the public and the officials tq get good laws passed.

■Dr. James L . M axzvcll complained that a new ideal o f very doubtful merit w as set before us in these papers. W e are presented with a new version of the Good Samaritan in which he throws the “oil and w in e ' to the wounded man to do his best with w hile he him self rushes off to attack the robbers with the slogan on his lips “A n ounce o f prevention is worth a pound o f cure.” To the wretched man he says “You m ay die, but I may be able to save three others from being sim ilarly assaulted.”

Dr. M axw ell maintained that the first paper showed appalling ignorance o f the, w ork o f the country hospitals. H e him self had been a doctor o f a country hospital for over tw enty years and the type of cure and the kind o f w ork done by these hospitals had been quite, misrepresented. Chronic tuberculosis and other chronic' cases were, on account o f the pressure on beds, but a small



proportion o f the whole, the acute cases in which com plete cure resulted formed the bulk o f cases admitted.

D r. John K irk . In connection with this discussion I would like to say- just three things:

F irst, I want to thank Dr. Chuan and D r. Li for their stim ulating and interesting papers. T hey have tooth reminded m e that m y H ospital is not doing enough in the w ay o f preventive medicine, and that more ought to be done.

Second, with reference to the tw o speakers who have dealt with the parable o f the Good S'amaritan I think they have both emphasized a truth, but the w hole truth is that w e D octors in China have got to do both things,— heal and help the wounded man lying at the side o f the road, and get after the robbers who have done the damage.

Third, I believe the secret o f getting this work dene is to get it done by co-operation. N o reasonable person w ill dispute that it is desirable that more w ork in preventive medicine should be done in connection with our M ission H ospitals, nor w ill anyone dispute the fact that some doctors m ust o f necessity give all the tim e and strength they have to the work o f healing unless large numbers of sufferers, who can be cured or relieved, are to be turned aw ay from our hospital doors.

A verse o f Scripture occurs to m y mind which, I think, sums up the m atter in a nutshell. “This ought ye also to have done, and not have le ft the other undone.” Dr. Oldt, as a Public H ealth expert, has put his finger on the spot when he has described his own work on Trachoma in co-operation with the ophthalmic surgeon on the staff.

A proper system of distribution o f labour between ourselves 'and our colleagues or assistants w ill surely enable many o f us to accom plish more in preventive medicine than w e have done.

THE USE OF THE HAMSTER IN THE DIAGNOSIS OF CERTAIN FORMS OF TUBERCULOSIS

J o h n H . K o r n s , M .D . and Y. C. L u , M .D .

K och dem onstrated tha t the field m ouse (species not sta ted ) is m ore susceptible to tuberculous infection than is the w hite mouse. In certain prelim inary experim ents, as yet unpublished, we have found the ham ster (C ricetulus g riseus) to be likewise decidedly m ore susceptible than the white mouse to this infection. In fact we have shown it susceptible to such a degree th a t it m ay be used to advantage in the clinical laboratory as a culture medium for inoculum thought to contain viable tubercle bacilli.

T he advantages the ham ster shows for this w ork, so fa r as N orth China is concerned, lie in th ree fa c to rs :

* From the Department o f M edicine, P ek ing U nion M edical College, Peking, China.

f Read at the China M edical A ssociation C onference in Peking, September, 1926.

Hamster in Tuberculosis. 2 3 5

(1 ) Its availability. T he ham ster is readily found throughout N o rth China. I ts m ortality, in captivity, if precautions against cannibalism are taken, is not high.

(2 ) I ts cost. T h e m arket price of the ham ster in Peking is about $0.06 while tha t of the guinea pig is about $0.80. Tlu> expense of keeping the ham ster is almost negligible, from $0.02 up a month, while a guinea pig costs $0.64 or m ore a month. W here the animals must be observed for m onths and several used for one patient, a considerable saving is thus effected bv using the smaller animal.

(3 ) Its susceptibility to tuberculous infection. W hile the gross pathology in the ham ster is less striking than in the guinea pig, histological evidence of tuberculosis is easily found. Moreover tubercle bacilli are more readily found in the ham ster's tissues than in those of the guinea pig. O ften a diagnosis may be m ade easily from a smear prepared from pus a t the site of inoculation or from a lymph node, so tha t it may be quite unnecessary to prepare microscopic sections. In spite of this degree of susceptibility we have seen only one instance of w hat appeared to be spontaneous tuberculosis in 37 controls. This ham ster showed no gross lesions, but presented histological evidence of early tubercles. T he reason for not saying dogmatically that this was tuberculosis is tha t no acid-fast bacilli could be found in more than a dozen sections a fte r prolonged search, and in all the other hamsters, diagnosed as tuberculous, acid-fast bacilli were easily found.

The following protocols are selected, not with the idea of comparing the ham ster’s susceptibility to tuberculosis with that of the guinea pig. as doses w ere not standardized, but merely to show that the ham ster may often serve in the clinical laboratory, especially of a small hospital, as a practical substitute for the guinea pig. The hamster weighs about 30 gram s, one-tenth the weight of a guinea pig, hence its use is limited to instances in which the inoculum is not bulky.

P r o t o c o l s.

T he ham sters cited below were all injected subcutaneously into the righ t groin.

1. H am ster No. 48.

Inoculum: 1 cc. of saline emulsion of pus, negative on smear exam ination for tubercle bacilli, taken from a post-auricular abscess. F inal diagnosis (O .P .D . No. 63 ,731): tuberculosis of cervical lymph nodes.

Findings: The ham ster maintained its weight until it was sacrificeda fte r 2 m onths. A t autopsy the right groin contained a yellow, firm , non-caseating mass. This, unfortunately, was not examined by the

236 77ft?7 China Mrdicat- Journal.

sm ear m ethod’ 'for-acid-fast bácilli. T he'spleen and liver were of norm al size aiM showed! several'p in-head sized: vellcw areas'. M icroscopically there w ere a m oderate num ber of tubercles with acid-fast IrácillÜ The lifngs grossly 'show ed a ; few translucent tiny spots near the hiluni. and m icroscopically there w ere’ m any accum ulations 'of epithelioid cells, not confined to the lymph follicles', hut no acid-fast bacilli were seen.' The traeheo-broncTrial lymph nodes were enlarged, they showed conglom erate tubercles' w ith caseating centers and a few acid-fast bacilli!

2. H am ster No. 49. «•

Inoculum: 1 cc. of sediment of 50 cc. of urine centrifugalizedrapidly for 25 minutes. T his sediment showed no tubercle bacilli on sm ear exam ination, although at another titilé the urine was found to Be'positive. D ischarge ' diagnosis (H ospital No. 12.998') : m oderately advanced' pulm onary tuberculosis; tuberculosis of the pericard ium ; tuberculosis of the kidney and bladder.

Findings: T he ham ster lost only 1 gram of weight in 2 m onth-and was then sacrificed. No gross pathology was noted. M icroscopic ex am in a tio n : the liver, spleen and tracheo-bronchial lym ph nodes showed extensive proliferative tuberculosis w ithout necrosis, and in the lymph nodes and spleen sections acid-fast bacilli were seen. T he lun¿ showed a few tubercles in or around the lymph follicles.

3. H am ster No. 50.

Inoculum: 1 cc. of centrifugalized sediment from 4 cc, of purulentsputum which had been digested with 2>°/o sodium hydrate for 1 hour a t 37° C. and then neutralized w ith dilute HC1, This sputum , so prepared, showed no acid-fast bacilli in smear .preparations. .Discharge diagnosis ( H ospital No. 13 .431): chronic pulm onary tuberculosis far advanced ; pneum othorax. L ater tubercle bacilli were found in the sputum .

Findings: The ham ster m aintained its weight for 2 m onths andwas then sacrificed. A utopsy showed pus, containing many,-acicl-fas:, bacilli, at the site of injection, otherw ise no gross pathology. M icroscopically : lung, liver, tracheo-bronchial nodes and spleen showed the presence of tubercles >and the' last two showed acid-fast bacilli.

4'. H am ster No. 66.

Inoculum: 0.4 cc. of a salt emulsion of half of the left tonsilg round in a m ortar. H istological examination! of tonsil was negative fo r tuberculosis. D ischarge diagnosis "(Hospital' No. 13,472) : tuberculosis o f skin and tonsils'.

The -̂ M.at entity Prubicut uf Clnna. 237

Findings: H am ster gained 3.4 gin. in weight. Death on 50thlay. : A t autopsy an abscess a t the site of injection, containing acid- fast bacilli, was found. The spleen ^.nd.lung showed a few tubercles grossly, and microscopically, and the tracheo-hronchial lvmph nodes were, enlarged. (H am ste r Xo. 67, injected with a similar preparation from the right tonsil also showed tuberculosis and tubercle bacilli in the abscess at site of in jection.)

5. H am ster Xo. 49.

Inoculnm: 1 cc. of sediment from 100 cc. of pleural fluidcentrii'ugalized Tapidly for 30 minutes. ¡This • sediment was negative for tubercle bacilli in smear preparation and a guinea pig inoculated in- :raperitonealiy in another laboratory with 'the centriiugalized sediment :rom 14 cc. of this fluid removed on the same date,’ showed no tuberculosis a fte r 2 m onths. .Discharge diagnosis (Hospital .\'o. 1-1.0N7): pulm onary tuberculosis m inim al; tuberculosis of the p leura; sero- nhrinous p le u risy ; pletiral adhesions.

Findings: H am ster’s weight increased 3.2 gm. in 2 month.s.Autopsy showed the lymph nodes in right groin and in mediastinum enlarged and a smear from the form er showed acid-fast bacilli. The spleen showed a few yellowish-spots.

THE MATERNITY PROBLEM OF CHINA.-

J. P r e s t o n M a x w e l l , \1 .D ., F.R.C.S.

“ To put one’s life into the hands of a quack is to ask an ignoram us to correct an elegant essay.” So the Chinese proverb runs; what then if there be two lives at stake instead of one?

One of the most im portant question's .facing public health in ( hina js the inadequate provision for m aternity and child welfare. ( >ne has to rem em ber that one cannot speak of the country as an integer. The problem s and facts of the country districts and the towns are very different.

In the towns there is a certain amount of provision for m aternity work. In the country this practically does not exist. W ith the exception of a few m issionary schools and one or two other schools, m aternity train ing as such may be said to be nonexistent in the Republic; and in th e literature of China devoted to the subject 'of obstetrics, so much speculation and superstition a re intermingled that the old b o o k s a re of very little Use in the train ing and developing of midwives.

* Read- at the China Medical Conference in Peking, September, 1926. ■>


In a few places there has b^en an attem pt at the tra in ing and reg istra tion o f midwives, such for exam ple as in Shansi, but it has been done in a haphazard w ay w ith very little thought as to the question o f skill and w ith no provision w hatever, as fa r as I know, for the checking of illegitim ate and bad practice. I have known, for instance, a half-trained m idw ife to kill th ree cases of transverse presentation , one a f te r the other. I then warned her tha t if I heard of her killing another one, I would rqDort her to the m agistrate. She sent fo r m e on the nex t occasion, but only a fte r she had rup tured the uterus. T h is patient recovered, w ith gauze packing of the u terine ren t a f te r replacing the bowels. H ere is the record of another m idw ife during one m o n th : th ree cases of tetanus neonatorum , one case of postpartum haem orrhage, one case of puerperal septicoemia, all ending in death for the child or the m other respectively.

W hen you consider tha t in a city like Peking, it is possible in a given area for approxim ately eighty per cent of the people to die w ithout having seen a m odern-trained doctor, one can readily realize th a t the vast m ajority of the wom en of the N orth have no skilled help at all in childbirth. L isten to w hat the w riter of the T a Sheng P ’ien says about midwives :

“ N ow we come to the necessity of having a m idwife. Sometimes we have to use them, but as the m ajority of them are fools and know little about obstetrics, one m ust take the responsibility oneself and not follow all the orders given by the m idwife. W hen they come to a house, they ask the patient to bear down in labour a t once, and say th a t the child’s head is ju s t above the perineum , and rub the abdom en and back, paying no attention to the stage of labour.

Sometimes they rup tu re the m em branes artificially, and th is m ethod m ay do much harm to the patient. In a word, they do their best to exhibit their skill. T he w orst class of midwives sometimes charge an ex tra fee for the delivery.

T he m eaning of the w ord ‘m idw ife’ is as fo llow s:— A s they are old and have some experience of deliveries, people ask them to receive the child and take it to b e d ; not to deliver the child. R ich fam ilies have the ir own private m idwives, and sometimes a fam ily will have m ore than one, each of them has her own m ethod, and between them they th row the house into a m arket.

A ll these troubles are one’s own fau lt.”A dded to this, in m any places custom s prevail, relics of the dead

past, but a very present menace to the life of the people. Go to certain areas in S hantung an d ,y o u will find the new born baby pu t in to a bag w ith earth from off th e road, w ith the result tha t num bers die of te tanus neonatorum . In F ukien, I have know n cow dung to be used as

The Maternity Problem o f China. 239

a cord dressing, w ith very m uch the same result. H ere in Chihli, there are villages w here the m ortality from te tanus neonatorum runs from th irty to eighty per cent of the children born. One has onlv also to mention ophthalm ia neonatorum , to be at once confronted with n problem which not only leads to much blindness but also to a vast am ount of neonatal death, a blind child not being worth rearing, and especially if it is a girl. T here are no proper statistics available on either of these diseases, but w ere the cases to be gathered together, there is no doubt that the ir total num ber would move any people to begin to m ake provision w hereby such an appalling calamity could Ik? avoided.

W hat shall one say about puerperal fever? H ere again one is confronted w ith the fact tha t there are no proper statistics on the matter. F rom w hat one has personally seen, however, there is no doubt that the m ortality is very heavy, and as for the results short of death, one m eets m any cases of vesicovaginal fistulae, atresia of the vagina, and the like, show ing that the m orbidity following labour is unusually high. W e have to rem em ber tha t by improved m aternity work vesicovaginal fistula and atresia of the vagina following labour have almost been wiped out in England and Am erica, so that it is nearly impossible at the present date to get much except theoretical training on these diseases in these countries.

X or m ust one forget the m ortality am ong mothers and the mortality am ong children caused' in the provinces of Shansi. Shensi, and Kansu, and in M anchuria by the disease osteomalacia. By our computations, th e re m ust be a t least fo rty thousand cases in N orth China, and when one considers tha t this is a preventable disease, one realizes what a g rea t problem is before us. I know of one case where three daughters- in-law died one a f te r the other in labour from obstruction due to this disease.

Xow, how are these problem s to be m et? There are four main w a y s :—

The first is by broadcasting inform ation on the subject of m aternal w elfare and the dangers of neglected labour. Popular articles in the daily papers and* broadsheets, such as the one I show you, can and ought to be w ritten on such subjects as tetanus neonatorum , ophthalmia neonatorum , puerperal sepsis, and osteomalacia, and freely distributed.

Second , one needs to have adequate train ing both for the medical profession and for nurses on these four subjects, and this will involve a g rea t developm ent o f obstetrical literature.

Third, one needs to initiate a midwives’ movement for China. T he p resen t class of midwives should be registered, gathered in, and given

,240 T h e C h in a Medicai Jonrnak

as m uch tra in ing as is possible, and no .new unskilled m idw ives should be allowed to take up the..subject as a life work.

Fourth, antenatal clinics should be established, free t© all who cannot, afford fees, and presided over by doctors w ho-have had special obstetric train ing.

T h is fu rth e r involves the opening o f proper m atern ity schools by the Chinese themselves. H ow are^these schools to be taugh t? T here a re 'v e ry few outstanding Chinese O b ste tr ic ia n s , and the need' is urgent. T o my mind, it can only be m et by the train ing in m idw ifery of graduate nurses in such a way that they shall be able to staff Chinese m atern ity schools. These schools should be registered under the Chinese governm ent and their pupils exam ined and registered by governm ent, so tha t y o n would have on the register not only the old m idwives but the new tr a in e d : ones, and as the okl m idwives died off or . retired , you would have a body of women able to deal w ith the great bulk of the; m atern ity work of China. They should be under the governm ent of a board sim ilar .to the C entral M idw ives’ Board in England, and owing to the wide area of this country it is probable th a t the reg ister would have to be treated as a provincial one.

W hat should be the length of such a course? A ssum ing that the candidates have a fair general education, the length of course laid down by the M idw ives’ Board for Scotland, viz., six m onths, seems to m eet the need. T he practical side ought to be specially stressed, and the schools for m aternity teaching should have medical women or men attached to. them , so as to obviate, as fa r as possible, m idwives dealing w ith cases of abnorm al labour.

T he strain and difficulty of abnorm al labour cases is very severe even on a qualified practitioner, and one has to guard against the danger of m idwives setting themselves up as an in ferio r class of medical p rac titioners and so spoiling the aim which one has, v iz :— the helping of the people in norm al labour. This side has been carefully guarded by those nations, such as E ngland and Scotland, which have set up a class of trained m idw ives; and not only are all the m idwives registered but no one save a doctor and a registered m idw ife can attend women in labour for gain and compel paym ent, and infractions of the law regard ing the reporting of cases of abnorm al labour, puerperal fever, and ophthalm ia neonatorum by the latter class are severely dealt w ith by a G overnm ent appointed Board.

It m ay be asked w hat staff is needed for a m aternity school, and w hat w ould be the approxim ate cost of the equipm ent needed, and w hat m ay be considered a good scheme of study for such a school? A ppended to th is paper a re answ ers to these questions, and it will be readily seen th a t the provision of staff and the cost of such a scheme a re not a

The'-Maternity. Préb'lcul'of <China. 241

very expensive m atter. O n e WCmld like to see Chinese gentlem en and ladies realize that here is a way in' which wealth can be readily usecl for benefit of the country, besides bringing down on their heads the blessings ■it m any happy m others and children who have profited by the fru its of their generosity. .

To sum up:1. China needs to face the problem which other countries have been

facing w ithin the last century, tha t is, that the loss to a nation through preventable diseases and accidents connected w ith child birth is enorm ous and can and must be arrested.

2. T he only way to do this speedily and well is to establish a trainedclass of midwives, trained, licensed, and supervised bv the G overnm ent, with penalties for any who try to pose as doctors.

3. T he general public needs to be instruct«.' 1 by popular articles, broadsheets and the like, as to the dangers to be avoidéd and howto avoid them.

4. Special train ing schools for midwives should .be established, wellequipped and staffed, which can provide the instruction needed for those whom the Government may license. .

.'L'HEME FOR A SlX MONTHS’ Coi'USE IX MIDWIFERY FOR MlDWIVKS IN TrAININü.

It is understood that except in grave emergency, a m idw ife certified underthis scheme will call in the aid o f a qualified mediçal practitioner in the follow ingcircumstances :

Pregnancy: pelvic deform ity; haem orrhage; fits; sw elling of the legs andgenitals; purulent discharge from the genitals.

L abour: presentation other than the uncomplicated head or breech ; fits or convulsions ; where no presentation can be made out; where the placenta fails to come away.

Lying In: fits; temperature over 38 for more than 24 hours; white leg.

The Child: injuries during birth; inflammation of the eyes; serious skineruptions.

She is not allowed to do destructive operations, except in conditions o f extreme emergency.

S u b j e c t s for S ix M o n t h s ’ M a t e r n it y C ou rse (w ith credit haurs).*

T hese presuppose that the M aternity Center will start a proper antenatal department at least tw ice a week.

Didactic zi<ork on(a ) Anatom y and physiology o f female generative organs, including breast

and pelvis.(b ) Em bryology. The growth of the ovum, formation of placenta and uses

o f the same. The foetal circulation.

* T he term credit hour is used here in a different sense to that commonly employed in medical educational work in China.— Editor.

242 The China Medical. Journal.

( c ) T he foetus, presentation, position, and the conduct o f normal labour.(d ) Abnorm al labours: face, breech, transverse, etc.(e ) l ia em o rrh ig e in pregnancy, labour, and the puerperium.( f ) Puerperal sepsis.( g ) Pregnancy toxaem ia and eclampsia. H eart disease and tuberculosis.(h ) T he use o f instruments. Induction o f labour. Caesarean section.

D estructive operations.( i ) T he use o f drugs during pregnancy, labour, and the puerperium.( j ) Spurious and extrauterine pregnancy.(k ) T w ins and monsters.(1) A ntenatal care. U rinalysis.(m ) Care o f the infant and diseases o f the newborn.

(136 credit hours).N o t e :

T o these should be added a course in Chinese “character.” (C redit hours have not been allotted for th is.)

Practical w o r k — T eaching on 10 cases in the M aternity Center or outside.Conduct under supervision, o f at least 10 cases outside or inside the Center. T esting o f urine.

(120 credit hours. A verage 5 hrs. a case.)

D em onstrations— On pathology, by arrangement at a hospital with a museum.(1 credit hour.)

A ntenata l practice— A t the Center itself or in a public health dem onstration area. (40 credit hours.)

Caesarean section— B y arrangement at some hospital. T o see at least one done, i f possible.

(1 credit hour.)Total

T w o trim esters o f 12 w eeks each—24 weeks.22 lectures a week for 1 m onth = 88 credit hours. Practical work,

(120 hours.)6 lectures a week for 2 month s = 4 8 credit hours. Antenatal practice

(42 hours.)Caesarean Section and

P athology D em onstrations, (2 hours.)

S ta ff N eeded

1 H ead m i d w i f e .................................. 34 lectures and primary labour teaching.2 A ssistant m idwives . . . . 34 lectures each; supervision out and inside.1 V isitin g £ h in ese lady doctor . . 34 lectures with charge o f antenatal w ork

in Center, to be called as a consultant by the head m idw ife in abnormal cases of labour.

P ath ology and Caesarean Section to be given at a teaching hospital.Child w elfare training by arrangement w ith a Public H ealth Center.General training and supervision by H ead m idw ife. V isits by invitation, where

possible, to other maternity hospitals and training centers.136164 >

300

The Maternity Problem of China. 243

T e c h n i c a l E q u i p m e n t N e e d e d f o r a S m a l l M a t e r n i t y C e n t e r .

Steri l ization

Bramhall Deane, U .S .A . Steriliz ing outfit with petroleum heating and No. 1 B D ressing Sterilizer.

U tensil sterilizer. N o. 3. to be heated by petroleum. Approx. $1,200. jWr.r.

Instruments

(a ) T w o sets o f instruments for in and out use, consisting o f :B arnes’ m idw ifery forceps with Sim pson’s handles 'and N eville A x is

Traction.Sim pson’s straight perforator.Sharp decapitating hook.B arnes’ craniotom y forceps.Churchill’s craniotom y forceps.B raxton H ick s’ cephalotribe.B lunt hook 'and crochet.L ong curved scissors, 10 inch.Champetier de R ibes’ bag and introducer, 2 bags. Approx. $ 200. Mex.

(b ) D iagnostic instruments consisting o f :M artin’s Pelvim eter, three.W illiam s’ Pelvim eter, three. Approx. $ 60. Mex.

( c ) M inor instruments for labours in and out, as fo llow s:4 rubber catheters.4 metal fem ale catheters, long.

12 pairs Rochester Carmault clamps.6 pairs blunt pointed scissors,

needles.3 needle holders.

12 sponge holding forceps.4 pinch forceps with teeth.

Approx. $ 200. Mex.

(d ) Other instruments, as fo llo w s: Apparatus for infusion o f saline. U terine packers, tw o.

M atern i ty Outfi ts

Cases, etc., for outside work. Two.

Approx. $ 15. Mex.

Approx. $ 100. M ex.

Teaching A pparatusPhantom e (M aison Mathieu, P a r is). Foetus, w ith com pressible head. Fem ale pelvis.Foetal head at term.

T ota lsSterilizers Instruments O utside Cases T eaching Apparatus

A pprox. $ 200. Mex.

Approx. $1,200. Mex. 475.100.200.

(C arriage and customs not included.) $1,975. M exv

244 Th e China . M edi calt Journal. . (. ■ • y

Pictures «f£ sections o f-p elv is , etc.. could be copied by a ,Chines£ artist from li:us. ..r bought in Europe or Japan.

A metal pelvis on stand would be a very great advantage. (T h is m ight o.-m-Mv be cast here)'.

a lending library to students.

C It' ; . V . \ V

I h- Lee. Obstetrics. Phillips.('»ynaecological and M onthly Nursing. Row ley. M idw ifery for' Nurses, Lyon. (A n drew s). M idw ifery for N urses. (Supplem ent). Operative M idw ifery for Nurses. Rowley.The- Reproductive System.

Anat. & Phys. Chap. X X V I.

^ I l i ' i i s h

W illiam s’ Obstetrics.V'in B larcom ’s Obstetric Nursing.

Students to purchase.

ChineseE vans’ O bstetrics.

N iles.

PUBLIC HEALTH PROBLEMS IN KOREA, AS SHOWN BY A STUDY OF CHILD MORTALITY.*!

J. D. V A N B u S K i R K , M .D\

In fa n t m ortality is often used as an index of sanitary conditions, ‘uii V anB uskirk & M ills (F .E .A .T .M .) consider th a t child m ortality is a truer index, the in fan t being protected by helplessness from eating eom arninated food and from exposure to contagion. They report the In fan t M ortality R ate for K oreans as about 180, which is less than double the rate for the U . S. for the corresponding years— previous to 191/, but the death rate for ages 2 to 10 is from 3 to 8 tim es as high as in the U . S. A careful study of child m ortality should als" reveal specific conditions as well as relative progress in sanitation.

The data used in this paper was presented by V anB uskirk and Mill.- at the F ar E astern Association of Tropical M edicine (1925) and will appear in the Proceedings now in the press. A sum m ary of the iata m ust be given here.

D ata as to births, num bers of living children, and ages and causes if deaths of children were secured by personal canvass in homes. 5,000

wives gave answ ers tc the questions. 20,454 births w ere reported, and 9.325 deaths up to “ 10 years o f age” ( “ K orean count,” i.e., a child is “one year old” until Xew Y ear, then 2 years old, etc., the average “ 1C year old” child would be only full 9 years of age).

* A rt. N o. 44, Research Dept., Severance Union Medical College, Seoul, Korea, •j* Read at the China M edical Conference in Peking, September,, 1926.

Public Health" Problems in K orca>— C h ild Mortalit y 2 *'

■ W e calculated the death rate for the various age groups as ’epi*iritAi t u t we realize that this is only an approxim ate. the true rate is pmfuiliiy higher. The table below shows the D eath rate, as adjusted..

T a b l e 1. C h i l d M o m .m .i t v A m o n g I v o r k a x s . .

Age InNo. alive at beginning Xu. of Deaths for Interval Annual Mortality Rule

terval of Interval Male Female Total Male Female liotiii•0— 1 20454 . 2102 1580 3682 193 166 LSu1 — 2 16772 117;; 954 2127 133 126 1272__3 14645 792 638 i4:;o 11)5 91 1 * >23 — 4 13215 ■432 344 776 63 54 -’>!14— 5 12489 26D 220 481» 41 37 ; i; >5— 6 11959 167 ' 145 3 L 2 27 25 2 i6 — 7 11647 111) 98 208 18 18 is7— 8 11439 75 61 136 13 11 128— 9 1130«. 66 6') 126 11 10 109— ld 11179 33 43 76 6 s 7

T he principal causes of death “as reported” are shown in 11 alilebelow, for the “ first year," "second to fifth ’’ vears. and "six th to o-ml ” years. The ages are taken as reported, i.e., Korean count. Hen. «- ihe “ first year" only averages si>: m onths, and the num ber of ‘‘'‘firsi year dea th s’’ is correspondingly low. more than half the "second vea"” deaths really occurred in the first 12 m onths. But since this dism s-i, >1 is not concerned with rates, but w ith causes of death, it is thought I»--' to present the data as reported.

T a b l k II. C a u s e s o f D e a t h A m o r , K o k k a k C h i l d r e n .

A ges “Korean Count."

D iseases—as reported 4lIst year*’ 2—5 year 6—10 year Total“ C o n v u ls io n s” ................. 1,841 2 237 l5o l .”2sS m all p o x ................. 81 1,118 207 1,406M easles . . 47 4t6 lv2 MÎ ~S carlet F ever ............... 15 55 13 fviD ip h th eria ...“ F e v e r s ” ..............................

. . . 14 71 248 6<i 25

C holera ................. 42 29 71D y s e n t e r y .............................. 27 473 . 137 . i»;:7D iarrhoea ... 114 18 j-“iT yp h oid (or T yphus) ... 3 2 5C holera N ostras ... • •• . . . 8 1 . if“ I n d ig e s t io n ” ... 77 52 9 135 7 í 1M alaria 28 401 76 :,i »5,T uberculosis 1 19 7E m p v e m a ............................. 2 5 2“ C o ld s” .. ................ 39 188 39“ C o u g h ” .............................. 7 78 21

T he first thing one notices in the above table is the great number of deaths attribu ted to ' ‘Convulsions.” i.e., 46% of the total deaths in to “ 10 years old.” T here are several term s in common use anion- the people of K orea that are 'practically synonymous, meaning sanu k ind o f convulsion or m arked nervous disturbance if 0 Jjjl,, §£ $$ ¿,i-


^ $ i ) . T his indefinite diagnosis reveals the first and all-inclusive Public H ea lth Problem in K orea— Ignorance, the need fo r Health Education .

82% all deaths for the “ first year” (K orean count) w ere a ttribu ted to “ convulsions,” and all the deaths under one m onth w ere so assigned, including 517 deaths on the “ first day .” T h is term ' can re fe r to no specific disease. I t refers to sym ptom s that arise in the course of m any d iseases: tw itchings, unusual eye-movements, sometimes convulsions and1 coma. N ervous instability in children is probably the only common factor. T he te rm probably covers a few deaths due to some form of m eningitis, and m any due to acute infectious fevers, and to gastro in testinal disorders, as well as “congenital debility.” T his term is an index, not of the frequency of an}- disease, but of the degree of ignorance. W ith the probable exception of 759 deaths “under 1 m onth ,” it seems reasonable to assum e tha t the real causes of deaths reported as due to “ convulsions” w ere the common diseases tha t follow it in the table, and probably in approxim ately the same proportions.

T he “ first yea r” of Table I I , being “ K orean C ount” averages about 6 m onths, so it is clearly seen tha t there is a high In fa n t M ortality in K orea. I have taken the G overnm ent G eneral figures for b irths and deaths for the year 1917-22 and calculated the In fa n t M ortality ra te thus shown, it is only 61.5 per 1,000 births. T here was reported an average of 29.85 b irths per 1,000 population. These rates seems too low, the rates for Jap an during the corresponding period w ere 34.26 b irths per 1,000 population, and 172 deaths per 1,000 births. T h e birth rate for K oreans is not likely lower than for Japanese, and the In fa n t M ortality R ate can not be so m uch low er; it is clear tha t the reports are incom plete; particu larly the death reports. I t is a m atter of general knowledge that the K oreans dislike to m ake such reports to the police— they are the sanitary officials. So tha t vital statistics tha tm ay be relied on are still lacking in K orea, in spite of the good w orkof the S anitary Division. In passing, I will say that all figures as to prevalence of Infectious Diseases in K orea are probably based on very incom plete retu rns, due to lack of cooperation writh the S anitary officials on the p a rt o f the general public. T his clearly reveals a specific Public H ea lth Problem , that of arousing a sense of public responsibility th a twill m ake for p rom pt reporting of vital statistics and of reportablediseases. Intelligent Public H ea lth adm inistration needs the facts as to diseases and deaths, as well as births. D octors and nurses in particu lar, and m issionaries in general, should use their influence to secure better cooperation w ith the pubic health adm inistrators.

A n In fa n t M ortality rate of about 180 as found by V anB uskirk and M ills, is not unusually high, only the m ore advanced countries have

lower rates and m any countries have higher, and some cities o f E urope and A m erica have h ig h er; e.g., the ra te for Japan is 172 for 1917-22: fo r 1906-10 the rate was 165 for T oronto , and 261 for M ontreal, C an ad a ; fo r all Ind ia th e rate was 250 in 1910; the rate for M oscow 1906-10 was 313, and for St. P etersburg 256. But compared to the U .S ., G reat B ritain and A ustralia, the rate for K orea is 2 or 3 times as high.

K orean m others are usually able to nurse their babies so they are protected from much exposure to g rastro-in testinal infection. But the habit of nursing babes any tim e they cry is not good, and there are other custom s th a t need correction, such as carrying the .infant tied onto the back of the m other or sister a good part of the day instead of p roviding a quiet place for it to sleep in peace; babies are not usually protected from flies. I f the m other is not able herself to nurse the in fan t, there is alm ost no adequate method of feeding, it being common for an adult to chew rice and then put it into the babe’s mouth. There is a real need for the usual w ork along In fa n t W elfare lines, but this is not the most im perative Public H ealth P roblem o f K orea.

A s stated above, the death-rate for the ages 2 to 10 is 3 to 8 tim es as high as in t<he U . S. and other countries, and relatively 2 to 4 tim es worse than the In fa n t M ortality. A fte r the first year a child begins to eat foods less safe than its m other’s milk and leaves the protection of its m other’s or sister’s back— being thus exposed to the risks of infection and im proper foods. T he results are clearly seen in Table II.

Sm allpox was the most commonly reported cause of death a fte r “ convulsions,” but this disease is not at all common in K orea now. T he universal practice of vaccination, has made this disease com paratively rare, though it was very common not many years ago. I have heard it said that paren ts did not count the child until a f te r it had had the smallpox. T his is not literally true, but it expresses a fact. M ost of the older K oreans have pox-m arks on the face, but few of the school children are so m arked to-day. Sm allpox is no longer a serious public health problem in K orea, though the disease occurs frequently enough to dem and vigilance and continued care to keep up the practice of vaccination. Sm allpox was assigned as the cause of death in 27% o f deaths under 10, if we exclude “convulsions.” But to m ore tru ly represent the present problem-, we should give our main atten tion to the other causes of death.

“ Indigestion” in some fo rm was assigned as the cause of death of 741 children, 10 and under (K orean co u n t), tha t is 20% of the deaths— om itting “convulsions” and sm all-pox for reasons set fo rth above. T h is probably includes some cases of infectious diseases bu t even

Public Health Problems in Korea— Child Mortality. 247

248 ' ’ ' * The China Médical Tournai.' "

so it clearl}' reveals the need fo r instruction o f the people as to Diet and N utrition . T here are' no common “ch ild ren’s foôds” in K o rea ; the young child is given food from the p aren t’s dièt w ithout knowledge or thought as to its digestibility o r fitness for a child. F o rtuna te ly rice, the great K orean food, is good for ch ild ren ; b u t there are other foods not s o ’good. T h e “kim chi"— pickled cabbage or tu rn ip , strong with salt and red pepper, is not so good for the young stomach, besides it is quite likely to be contam inated. W e who have seen the youngsters toddling around eating unpeeled green cucum bers, green melons, green peaches, and even green persim m ons, from roadside shops or booths, from fields ‘fertilized with “night-soil”— we do not wonder at the prevalence o f ’gastro-intestinal troubles. Milk and butter are not used by ordinary K oreans, so the young child has to depend on adult food and m other’s milk, the latter being given up to 3 or 4 years of age. I used to th ink this a serious w rong to the' m other, but I now better realize the need of the child for milk and the K orean child has p ractically no other source. Fortunate ly in the larger cities there a re a few dairies and some K oreans are giving the children cow’s milk. Also condensed milk and milk pow ders are becoming generally available, but the ordinary K orean is too poor to buy them . All of this reveals the need for a p rogram for teaching Dietetics and N utrition in the schools, and to the general public.

T he K oreans do no t carefully d ifferentiate between D ysentery and D iarrhoea, so these should be considered together. T hey were assigned as the cause of 791 deaths up to 10 years of age, tha t is 21.2% excluding “convulsions’' and smallpox. Cholera was form erly fairly common in K orea, but only a few epidemics have occurred in the last 20 years-; but it is frequent enough to dem and vigilance.

T he great prevalence of D ysentery and D iarrhoea is a hard public health problém . I t shows the extent o f ’ fo od 'and w ater contam ination. T he K oreans eat a good m any fresh vegetables and melons, and “night- soil” is the com m on' fertilizer. V egetables are commonly washed in little stream s that are contam inated from the fertilized gardens and fiélds and polluted soil. U ntil they adopt some safe way of sterilizing “ night-soil” before using it as a fertilizer it will be impossible to solve the problem s o i intestinal infections. In passing it m ay be said th a t the prevention of intestinal parasitic infestation aw aits the solution o f th is problem . The F ly is also-a big factor in these infections, and its ex term ination is no easy problem.

'M e a s le s and Scarlet fever a re not commonly differentiated by the K oreans: T here were 698 deaths, 18.8% , (excluding “convulsions”ànd sm allpox), due to these tw o diseases. D iphtheria w as assigned as the causé o f “ 109 deaths ( 3 % ) . ' W e thus see tha t over 20% of-

Public Health Problems in Korea— Child Mortality. 249

the deaths of K orean children seem to be due these specific infectious diseases.

Tuberculosis was not recognized as a considerable factor in Child M ortality . But it is undoubtedly of real im portance, being about the most common disease am ong K orean adults. N either pneumonia, bronchitis, nor influenza were mentioned by the m others as a cause of death in this series. “ Colds” and Coughs" undoubtedly include these diseases, and probably some cases o f tuberculosis. 372 deaths were assigned to .“Colds” and “ C ough.” 10% of all. T he R espiratory infections fall behind the general Infectious Diseases and G astro-intestinal infections as causes of death— not because the}- are in frequent but because of the g rea t prevalence of the other infections.

M alaria was assigned as the cause of 507 deaths, (1 3 .7 % ). When we know the abundant breeding places, such as rice fields and ponds and pools and springs and wells and stream s; we may often wonder that there are not more mosquitoes and more m alaria. I t would be interesting to know if there are natu ra l enemies of the larvae that are common in K orean waters. I t is a common observation that M alaria is recently becoming much m ore prevalent than it was a few years ago. and it was reported m ore frequently 20 or 30 years ago than now. W hy there should have been a reduction and again an increase, would be an interesting problem. M alaria prevention in a rice-grow ing country is a problem w orthy of the best talent.

T o sum up the problem ; we see that a t least 75% of the deaths of children w ere due to infectious diseases. T he control of these infectious diseases is the most u rgent public health task. And this control would also be the most p rom pt and effective method of lowering the high death rates. T his is m ore than a m atter of police or sanitary regulations, the people do not realize the value of such regulations and do not know how to intelligently cooperate in their enforcem ent, but seek to evade them. I t is rather a task of education. Sanitary regulations are themselves of educational value, but teaching is needed. T h e easiest and m ost p rom pt and effective method of spreading health education is by getting to the children in schools and night classes and daily vacation schools. Bible classes for adults bring together groups of m en and women tha t a re interested in hygiene and better living, and they offer a field for work along th is line. P osters, articles, books, cam paigns are all needed. T he public health problem of Korea is H ea lth Education by any and all means, and K orea is not unique in this. T he problem of health education is the fundam ental one.

Special Acknowledgment. T he w ork of collecting and m uch of the tabulating of the data here used, was done by m y


form er colleague D r. R . G. Mills, now of the M ayo Clinic. O nly the impossibility of proper consultation and discussion has prevented his nam e from appearing as jo in t au thor of this paper. I t is a keen regret to me tha t he was unable to complete the w ork he began.

A CHILD WELFARE CLINIC.*

M a r g a r e t T a y l o r R o s s , M .D ., Canton.

Anyone, who in a large city has undertaken w ork fo r sick children has realized how great are the odds against which the poor m ites m ust struggle, whose life has never known the rest and care and wise feeding so necessary to real vigor. Because we w ere constantly seeing babies in Canton, handicapped in the ir chances for recovery by previous poor hygiene, we felt that we m ust do som ething to safeguard and build up the chances o f health for children.

O n M arch 9, 1924, the D avid Gregg H ospital in C anton opened a Baby W elfare Clinic. T he plan to have such a clinic had been m ade known to patients in the O bstetrical D epartm ent in the hospital, but was not widely advertised. F o r the first th ree m onths only five or six babies w ere brought each clinic day, all the children having come from the O bstetrical D epartm ent. A fter tha t tim e, the num bers began rapidly to increase and the group they came from to widen, until during June of last year the num ber of babies attending the clinic averaged well over tw enty each time, and not all the children have been referred from the O bstetrical D epartm ent. Some have cotne as follow-up cases from the D epartm ent of Pediatrics, and others have been brought by women already attending the clinic. T h e total enrollm ent from M arch, 1924, to June, 1926, was 525 babies.

W hile in actual' num bers the results are small, w here we look into them , there is great cause for encouragem ent. In the first place, w ithout any determ ined advertising, the clinics have been growing. T his points not only to the tendency to self propagation th rough the in te rest of the m others them selves, bu t to a m ore in teresting fact,— tha t m any Chinese women are ready to believe a t once in the w isdom of seeking expert advice for healthy children. Indeed, their enthusiasm was so g rea t tha t even in times, of unrest such as this past year, they have regularly undergone w hatever risk there was in coming out into the streets to attend the clinic.

In our work we exam ine the child thoroughly on registration , using the blanks pu t out by the Council on H ealth E ducation in Shanghai.

* Read at a m eeting o f the South China Branch o f the C .M .A ., January, 1927.

A Child Welfare Clinic. 2 5 1

These blanks, by the wav, are more satisfactory for children over two than for in fan ts. N evertheless, we have been glad to have them to use and to be freed from the necessity of p rin ting our own. L ittle - ra y booklets, also put out by the Council on Health Education, we have found very useful. T he m others take them home, and bring them at each visit to be w ritten tip. These booklets contain rules for care of the baby, and several blank pages where the weight and length of the child is recorded, and others, where directions for feeding formulae or m edication can be w ritten out in full. These booklets seem to form one of the clinic’s m ost valuable assets, m aking definite the directions from the doctor, creating in terest in the steady gain of the child, p roviding som ething quite w orth showing to the neighbors. T he desire to have the records in these little books complete, quite certainly brings about regularity in attendance on the part of some of the mothers.

Tw o sets of reading lists have also been used The first, simply feeding schedules for babies from the tim e of birth to four years, were published by the Y .M .C .A . for use in a Child W elfare Campaign held last w inter. L ater, ill connection w ith the M ental H ygiene Campaign, held at the John G. K err H ospital for the Insane, these lists were republished, in a little folder, w ith some suggestions for habit training of children and have since been constantly used, selling for t w o coppers ■each.

The charge for attending the clinics is almost nominal. 50 cents for three m onths, paid on registration, w ith a small charge for any drugs prescribed. T his makes it possible for poor and wealthy to attend on the same basis. W e have been very g ratefu l for the advice ;given us by D r. A ppleton of the Council on H ealth Education, not to separate the groups w hether according to ability to pay or to read, until the groups could be fairly large— because of the added interest and g rea ter educational value of w ork with groups as over against that with individuals. T his was sound advice, for if a young m other, desiring to care, in a m odern way for her child, has not only the doctor’s advice, but the stories of children she has seen w ith her own eyes at the clinic, to pu t up against her own doubts, as well as against the counter-advice of her m other-in-law and .other relatives, her chances of successfully carry ing out the advice are m uch g reater and her influence in her neighborhood m ore pow erful for good.

The clinic this year has had the assistance of the F ourth Year S tudents in the H ackett M edical College. O w ing to my other work, I could give very little time to the clinic this year, and credit for its success this year belongs to my assistant, D r. Leung Kgai M an, who w ith the internes and students gave such faith fu l service. The students .assisted in the exam ining and recording w ork and also took tim es in


ta lk ing w ith the m others in the w aiting room, using the H ealth C harts as points of contact in explaining principles of hygiene and in en couraging questions on the p art of the m other. T his w ork not only benefited the clinic bu t gave opportunity to the students to follow convalescent cases discharged from the hospital, and, perhaps m ore im p ortan t, the opportunity to know a norm al and well developed baby at sight, which sad to say. is not always acquired during the tim e of medical school experience.

T h e nurses of the hospital have from the beginning rendered splendid service in weighing, m easuring and taking tem peratures and in assisting in the patient explanation o f directions and their reasons, w ithout which our work is useless. P reparation to bathe the babies was made, but except fo r a very few cases only, the standard of cleanliness was such that only a very few baths w ere necessary because of neglect on the p a rt of the m others. T he baths th a t w ere given by the nurses were for dem onstrations only.

O ur w ork as yet, has had no scientific value. A cold snap, w ith consequent unwillingness on the part of the m others to reduce the child’s clothes to the necessary m inim um for weighing and the alm ost inevitable inaccuracy in m easuring of length of a squirm ing baby by assistants who are constantly changing, m ake our records no t usable. B u t the w ork is going on-—m others are being educated— and we still hope to perfect our system until our m easurem ents shall lie of use.

W ith the developm ent of Public H ealth N ursing, we hope the clinic will serve as a laboratory for the nurses and wall profit by their widened field of activity. A side from the following w ork, fo r which we thank our Bible-women, tha t most im portant aspect has been lacking. W ith trained social w orkers to help, the attendance should be m ore regular. As it is. less than tw enty of our babies have a p e rfect record of attendance shown on our attendance blanks. Those, also published by the Council on H ealth Education, are very useful, having spaces for nam es and addresses of tw enty babies on one sheet— w ith space to record attendiance over a long period of tim e and can give to the doctor at a glance, the nam es of the patients to be expected back on a certain day, together w ith their past record of attendance.

O u r aim was to have a clinic fo r children of Pre-school age. I t is gradually becoming such a clinic th rough the retu rn of form er patien ts w ith their new baby b ro thers or sisters. I t is very m uch to be hoped tha t the time is not fa r off when there shall be a system established w hereby children of school age shall be cared for in school clinics and such clinics as this one shall watch over them until they enter school.

T h e T rea tm e n t o f Faseiolopsiasis.

THE TREATMENT OF FASCIOLOPSIASIS.

C. H . B aklow, M .D., Ningpo.

In ancient tim es the disease produced hy infestation by the intestinal fluke, Fasciolopsis buski. was known and was treated with varying degrees of success by Chinese physicians. They called the worm “Ginger-slice W o rm ” l whicli is unusually descriptiveof the w orm afte r it has been passed long enough to become dead and extended. In a recent letter to me. D r. D. D uncan Alain states, “The Chinese, who know anything about the disease, tell me that filly years ago it was not recognized.” This opinion. I am sure, is incorrect because the Chinese have treated the disease for a much longer time than this.

Yr e c a X U T .

F or a long period of tim e the native practitioners have used Areca nu t ( Betel nu t) very finely ground and adm inistered in little folders of tissue made from bean curd. T he dosage was never very stable or accurate but varied with the practice of different doctors. It was given a fte r a fast and the pow der usually had some cathartic incorporated with it. On one point nearly all seem to have followed the same mode o f ' adm inistration. The medicine was given in three doses at close intervals. Some doctors gave the drug neat and then followed it w ith a purge, which was given a fte r a few hours, to facilitate the removal of the worms. The native practitioners still give the ancient treatm ent but it is being rapidly superseded by W estern methods, in m ost places.

W estern practitioners have come into contact with the worm only incidentally, a fte r using anthelm inthics for other infestations and hence their treatm ent has continued and extended along the lines of these incidental treatm ents. Generally speaking, drugs effective lor rem oving hookworm s are effective for flukes.

T u r i’e x t i x I'-.

T he .treatm ent now used by most Native P ractitioners is one which was introduced by D r. D. Duncan Main of H angchow , some time prior to 1893. T he in terest which attaches to his treatm ent is that it is original. I quote from a recent letter from him on the subject, “O ur first treatm ent was tu rpentine and castor oil, and then later we added a little chloroform . T hat treatm ent was continued for many years w ith very good effect, and as a m atter of fact is still carried on by the Chinese in the Siao San district for the treatm ent of the fluke.


T he cases that I treated did not suffer from nephritis a s ’ a result of using the tu rpentine. At any ra te I cannot recall tha t we had any cases of nephritis in connection w ith the treatm ent. T he tu rpentine was m y own suggestion, and before th a t the Chinese did not use any trea tm en t that I could find out beyond w hat they used for abdominal dropsy, which they call the d isease /’ M ain’s m ethod of adm inistration w as as follows :

W ithou t a prelim inary fast, he gave from one to four drachm s of oil of tu rpentine the first th ing in the m orning on an em pty stomach. T his was not followed by a purge except in the case of adults, when he gave C astor oil. H e got from 10 to 700 worm s a t a treatm ent.

T his trea tm en t was given extensive!)* throughout the Shaohsing field in the K o Chiao and Siao San regions, both by D r. M ain and by his native helpers. Some of these men, a f te r leaving D r. A lain’s employ, established and passed on to the native practitioners, the tu rpen tine treatm ent. T he exact dosage, mode of adm inistration , and physiological dangers due to treatm ent, have never been very clearcut in their m inds and there are m any cases of tu rpentine nephritis due to overzealous adm inistration of the drug. T hen, too, tu rpentine is not one hundred per cent efficacious and it is repeated too often in the attem pt to free the patient from all worm s, w ith the result th a t an acute, bloody, nephritis is established, from which the patient often dies.

E u c a l y p t u s O i l , C a s t o r O i l , a n d C h l o r o f o r m .

In A larch, 1907, G oddard used the following trea tm en t for a case which he supposed to be ankylostom iasis but which proved to be fasciolopsiasis. 1 quote from his p ap e r; "C oncluding th a t I had a case of ankylostom iasis to deal w ith, and having no thym ol on hand. I w ent to her home (som e forty miles aw ay) arm ed W ith the fo llow ing :

If E ucalyptus Oil . . . . . m xlC hloroform . . . . . . . . . . m lC astor Oil . . . . . . . . d r x

a rem edy for tha t disease, given by S. P . Philips in the Journal of T ropical M edicine for Decem ber, 1905. I gave the above in twn doses a t half hour interval, preceded and followed by Epsom salts. As a result twelve parasites w ere p assed ; the single specimen ( for unfo rtuna te ly I had been compelled to re tu rn ) being a D istom um rathouisi, the eggs of which w ere also found in the stool.”

Case I I . “E xam ination of the feces showed num erous eggs of D istom um rathouisi, and the E ucalyptus oil prescription given as before produced ten or twelve of the parasites a t once, and six m ore two or' th ree davs la ter.”

The Treatment of Fasciolopsiasis. 255

Case 519 under A. F . Cole, July, 1910. (Cole 1()22.)“E ucalyptus oil dr.ss w ith C hloroform dr.ss and Oleum ricini oz.ss

was given, and five hours later lie was said to lie in agony, which was relieved by vom iting.”

Case (>72. under D r. G. J . Evans. H angchow , September, 1(>11. (Cole 1922.)

“ He was given on an em pty stomach the fo llow ing:—-

Oleum eucalypti ' . . 5 ss ^C hloroform . . o ss - Repeated afte r an hour.Oleum ricini . . 5ss (

H e passed the same day about 100 flukes.”

M a l e - f e r x E x t r a c t .

Case 502 under .A. F Cole. 1908. (Cole 1922.)“ Large doses of m ale-fern extract, no effect."

T h y m or..

Most of the early instances of discovery of Fasciolopsis buski, as recorded in the literature, make no record of the drug used in treatment. T he original D istom a btiskii of L ankester was found at post m ortem . T he next case was reported by Leidy and the material was furnished by K err, from vomited worm s, in 1873. The next cases w ere reported by O dhner and' were obtained from an English M issionary. w orking in In terio r China, who was suffering from a bloody diarrhoea. Xo record of treatm ent is given. In 1887 Poirier described the worm as Distom a rathouisi from a single specimen sent to him from Shanghai by F a th e r R athouis. T here is only one reference to treatm ent. T he wom an was suffering- from hepatic pain which was no t am enable to treatm ent. T he nex t record is a case reported by M oore and T errill in 1905 and was found at the necropsy of a sailor. T h is brings us to the first case of adm inistration of Thymol for a know n infestation by Fasciolopsis buski which I have been able to find recorded in the literature. G oddard (1907) reported a case in which he gave thym ol in a case which he had previously treated with E ucalyptus oil. Chloroform , and Castor oil for hookworm infestation and in which he had discovered flukes. A w are of the presence of the flukes he treated the same case about a m onth later. “April 3, J again visited the patient and found her apparently better. This time I adm inistered two th irty -grain doses of thymol followed by salts. O ne m ore parasite sim ilar to the others was passed before I left. The n ex t day she passed several m ore but this time the Fasciolopsis buski. w hich w ere forw arded to me in alcohol.


A pril 5, the oedema was reported less but there was some abdom inal d istress. P atien t died on the 6 th .”

B arrios and Noe (1908) report the finding of 16 cases o f fasciolopsiasis and the ir treatm ent w ith thym ol.

Cole (1922) reports the use of thym ol in th ree cases, two under his own and one under D r. A. C. H utcheson’s care.

“ Case 502, 1908. “T hree doses of thymol, am ounting to 45 grains on an em pty stomach produced 113 flukes per anurn.”

“ Case 729, under care of D r. A. F . Cole, A pril. 1911.A pril 10, A fter 45 grains of thym ol 11 flukes passed.A pril 21, a fte r two courses of B -N aphthol (BAY. and C o.) grs. 45

each divided into th ree doses, w ithout the use of a purgative, th ree m ore flukes passed.”

April 28, Alay 12, M ay 14, and Alay 21 added courses of thym ol w ere given w ith varying results until he was finally discharged on Ju n e 3. “ H e is allowed1 to return to college having passed a grand to ta l of 485 flukes whilst under treatm ent, six distinct courses of thym ol or B -N aphthol having been given. Thym ol seemed to give better results.”

“ Case 606 under Dr. A. C. H utcheson, June, 1911.Thymol grs. xii on th ree occasions brought away some fifty

flukes. Child left H ospital in fine condition, im proving rap id ly .”R efe rring to Case 729 1 would criticise by saying tha t he gave

B -N aphthol very inadequately. H ad he given B -N aphthol in th ree large doses followed by a purge, he would probably have rid his patient of all his flukes at the one treatm ent.

O i l o f C h e n o p o d i u m .

In 1915 I used oil of chenopodium w ith varying success but found its chief fault la}- in the fact th a t it brought away only a p a rt of the infestation at a treatm ent and repeated treatm ents w ere necessary. AI}- technique m ay have been at fau lt but I had in B -N aphthol a d rug so much superior in its action on these flukes tha t I did not persist long with chenopodium.

B - N a p h t h o l .

A s early as 1910 I used B -N aphthol for fasciolopsiasis and th is is the first use of tha t drug tha t I can find definite record of though I suspect tha t D r. F . \Y. G oddard may have used it before th a t date. H e has no records of the use of the d rug by him self at- an earlier date than 1916 but I am certain tha t it was used by him as early as 1914. In a recent letter to me he makes this statem ent, “ I am afra id I can’t answ er your question about the use of B eta-N aphthol here. O ur

The Treatment of Fasciolopsiasis. 257

in -patien t records for years before 1919 have never been catalogued and filed. T he drug was used as far back as any cases that I find (1916) and probably earlier. Q uite likely in the dispensarv before the in-patient service started. But those records are lost. Anyhow. I did not do anything original in using B eta-X aphthol, for it was used brothers for hookworm s, and 1 had learned at the beginning that hookw orm treatm ent did also for flukes.” The earlier dates, to which he refers, are from 1906 onward. H is first crises, and the ones he reported ( Goddard, 1907) he had not yet used B-X aphthol but it is m ore than likely, indeed m ight almost be stated positively, that he used the drug from 1908 onw ard, since 1 found that he had it in stock in the hospital when 1 took it over in 1CM0. In his series of cases Cole (1922) records the use of B-X aphthol as early as A pril, 1911. O ther w orkers may have used the drug earlier than either Goddard or m yself but there is no record of it in the literature 1 have at hand. F rom the first it has been the drug of choice in the treatm ent of fasciolopsiasis because of its relative safety and ease of adm inistration. U nder ordinary conditions it is both safe and effective as well as fairly cheap. In very rare instances there have been bad effects from its adm inistration and in a very few cases it produces a decided drug rash and occasionally some depression. These untow ard results are so rare as com pared with the hundreds of cases in which no unusual effects are noticed tha t one may consider it a safe1 drug, even when used in excessive doses. I f the precaution w ith regard to theeating of oils, previous to the adm inistration of the drug, be •observed there is little danger of absorption and subsequent poisoning. I have taken 120 grains of B-X aphthol (B arlow , 1925) w ithout ill effects and have repeatedly given 75 grains in routine treatm ent. Personally, I incline to the largest indicated dosage, in order to evacuate as m any worm s at one dose as possible. Susceptibility to the drug is very uncommon and may be controlled by giving the doses half an hour apart thus m aking it possible to withhold one or two of the doses if untow ard effects are observed. Such rases of death as have occurred m ight well be laid to some other factor than to the drug itself. I t is decidedly uncommon for patients to show ill effects other than those due to the burning taste of thedrug and its peppery nature in the digestive tract. The drug rash, which occurred in four of my cases, resembled a generalized urticaria and it passed off soon a fte r free catharsis. The large vdoses of the drug evacuate all or nearly all of the worms at one.treatm ent, due to the fact that the worm s are more sensitive to thedrug at the first dose and hence one gets a larger proportion of them w ith large dosage than with small. In some instances, in which small


doses were given and repeated often , the parasites became N aphthol- fast and could not be evacuated except by using some other drug. O ne m ust rem em ber th a t he is not trea ting the patient but is trea ting the w orm and that it takes ju s t as m uch B -N aphthol to trea t a thousand worm s in a child as it does for a thousand w orm s in an adult, except tha t the intestinal trac t in a child is shorter and smaller and there is a consequent concentration of the d rug in the child’s in testine. I use a dosage for children far in excess of tha t given in the pharm acopoea as the adult dosage. In a very weak child. I usually give from 12 to 21 grains in three doses. In a sturdy child I have given as m uch as 60 grains w ithout bad results of any kind and effecting, a com plete cure in the one treatm ent. T he dose which is the most effective in adults is 75 grains adm inistered in th ree half-hourly doses. I t is seldom necessary to repeat this treatm ent as it usually cures. In one adult the dose given was only ten grains given in four doses. The condition of the patient undergoing treatm ent m ust be carefully taken in to consideration before giving the drug but the largest dose consistent w ith safety will produce the. best results.

P atien ts mostly p re fe r to take the drug neat, in a little w ater, but some find the use of bean-curd w rappers or gelatine capsules quite acceptable. T he patient should be fasted the day previous to tak ing the treatm ent. A light b reakfast of soft rice is allowed, a very light m idday meal, avoiding all oils, and no evening meal at all. A dose of M agnesium sulphate should be given at bedtime. T he following m orning th ree doses of B -N aphthol are given half an hour apart, or even an hour apart, in cases in which there m ight be question as to the dose advisable fo r a given patient. T his should be given rigidly fasting. Tw o or three hours a f te r the last dose of B-N aphthol one ounce of m agnesium sulphate is given. T h is evacuates the d ru g and the w orm s at the same tim e and a fte r three or four good purgings the patient m ay take thin rice again. I t is seldom necessary to repeat th is trea tm en t as it usually cures. B -N aphthol leaves the intestinal trac t in an uncom fortable condition which lasts for days. T here is a revulsion for the d rug which lasts for weeks or even for months. T he anus is actively irrita ted by the drug, leaving a burning sensation fo r days. T h is may be largely prevented by anointing the anus w ith vaseline ju st p rio r to the last dose o f B -N aphthol.' I have insisted on the hospitalization of all patients trea ted w ith th is d rug because it is not a drug which can safely be pu t into the hands of the ignorant or the careless.

C a r b o n T e t r a c h l o r i d e .

I began the use of carbon tetrachloride fo r trea ting fluke disease in 1922. I t is fa r m ore active and produces a greater num ber of

F A S C IO L O P S IA S IS .

FASCIOLOPSIS BUSKI.

The Treatment of Fasciola psiasis. 259

cures than any other drug- I have used hut its use w a s discontinued because of the ill effects it seems to have upon these patients. C adbury has used it for trea ting hook-worm infestations and he docs not give, the same unfavorable results which seem to attend its use in fluke infestation. I t may be tha t the cases selected for its adm inistration w e r e

not suitable but I have had very bad effects from its use. Two deathsand several cases of profound intoxication have resulted from givingthe drug in the dosage recommended to the pound of body weight. Jncases which have taken the drug well, the cure has been prom pt andcomplete and no a fte r effects have been apparent from its u se .

A drug which is at the same tim e prom pt in action, cheap in price, safe in the hands of the ignorant, and efficacious in the cure of fasciolopsiasis has not yet been found but it would be of great use in ridding the endemic area of the hum an end of the infestation whenever the eradication of the disease is seriously undertaken. To l>e indiscrim inately distributed it m ust be some drug which is fool-pm oi.

L ittle treatm ent is required, even in severe cases, for the combatting of concom itant symptoms even though they may seem, at times, truly alarm ing. Once the worm s are evacuated the oedema and ascites clear at once as is shown in the pictures, taken only 24 hours apart.

T he seeming anaem ia goes with the other symptoms without the use of any haematonics whatsoever, which is one of the chief argum ents against the theory that there is any prim ary anaem ia. If there is asthenia this m ust be treated and it requires a much longer tim e to remedy.

W . A .— d. aged 23, December 12, 1910.

December 12, 1910. Light tiffin, no supper, magnesium sulphate Yz oz. fasting.

December 13. B-N aphthol grains 75 in 3 half-hourly doses o f 25 grains each follow ed in 2 hours by 1 ounce o f M agnesium sulphate.

T h e I d e a l D ruc;.

A b b r k v ia t e ii C a s k H i s t o k i i -

C ask I.

Stool Xo. 1 . .

Flukes411

1834 18

9156 .................................

6 stools . . * . .the hospital ova-free and cured.

478 worms. H e left


C a s e I I .Name. W ang A .-f.H ospital N o. 1140.May 3. 1917. Light tiffin, no supper, magnesium sulphate y 2 ounce.M ay 4, 1917. X o breakfast, B-X aphthol grains 60 in 3 half-hourly doses follow ed

in 2 hours by M agnesium sulph'ate. ounces 1.

M av 4.

M ay 5,

Stool No. 12 ..3 . .4 . .5 . .

5 stools . .

Stool No. 1 .

2 . .2 stools . .

Flukes104

1834

38167 flukes.

Flukes121527 flukes.

M ay 7, 1927. Patient still showed ova in stool so a second treatment was given fo llow in g the same routine as before except that 75 grains o f B-napbthol was used instead o f 60 grains.

M ay 8, 1917. Stool Xo.1 .. 23 . .4

4 stools . .

Flukes326

1122 flukes.

Follow ing this treatment careful examination of all stools was made and a dim inishing egg-count writh a final disappearance of all ova showed that cure w as complete. F ollow ing cure all previous symptoms disappeared, leaving no trace o f oedema or secondary anaemia, at the end of the fourth day.

C a s e III.Xam e W ang K .-f.Hospital N o. 1141.M ay 3. L ight tiffin, no supper, magnesium sulphate ounce.M ay 4. 1917. X o breakfast, B-N aphthol grains 75 in 3 half-hourly dos

in 2 hours by M agnesium sulphate, ounces 1.follow ed

M ay 4,

M ay 5, M ay 6,

Stool No. 1 .. 2 . .3 . .4 .56 .. 7 . .

11

10 stools

Flukes10666450

44318462416

341 flukes.

The Treatment of Fascìola psiasis. 261

Second treatment,May 7. The treatment o f May 3, was repeated giving- on May 8 the same

dosage o f B -X aphthol as given on M ay 4.

M ay 8, Stool N( 1 .. 2 ..3 .4 . .

Total5 stools

15 ..

Flukes863

52436

24988 flukes.

1329

N ote how the continuation o f flukes in stools May 5 and 6 suggests the presence of more in the intestinal tract. A fter May 8 the ova gradually diminished and disappeared at the end of three days, leaving the patient cured and free from symptoms.

C a se IVNam e, D zi A.-d.A g e 53.H ospital N o. 1245.Ju ly 19, 1917.

H is w ife, aged 47; his daughter, aged 12; his son, aged 7; and his son, aged 3, all died of fluke infestation during the year 1917. H is son aged 23, took treatment March, 1918 and was cured.

July 19, 1917. Light tiffin, no supper, magnesium sulphate y2 ounce.July 20, 1917. N o breakfast, B -X aphthol grains 75 in 3 half-hourly doses.

follow ed in 2 hours by M agnesium sulphate, ounces 1.

Stool No. Flukes1 11022 222

Julv 21. 1 ........................................................................ 1032 ..................................................................... 305

4 stools . . . . . . • • . . 1732 flukes.

H e le ft the hospital in good condition but with many ova still appearing in the stools and evidently not cured.

Re-admitted under

H ospital N o. 1551.M arch 16, 1918. Treatment as before except that the dosage of B-Naphthol

was 60 grains instead of 75 grains.

M arch 17, 1918. Stool N o. Flukes 1 ..................................................................... 179 2 ..................................................................... 193

March 18, „ 1 ........................................................................ I 4

2 16 3 ..................................................................... 44

5 s t o o l s ..................................................................... 446 flukes.

H e le ft the hospital w ith few ova still in the stool, but in poor condition. Later he w as found to be cured and in good condition.

.262 The China Medicai Journal.

C a s e V.Nam e, Dzin P .-i.A g e 10.H ospital No. 2037.February 14, 1920.

Milk diet every tw o hours. From 4.00 p.m. ate nothing. M agnesium sulphate Y ounce at bedtime.February 15. N o breakfast, B-N aphthol grains 30 in 3 half-hourly doses, follow ed

in 2 hours by M agnesium sulphate, ounces 1.H e passed 52 flukes in 3 stools and left the hospital cured.

C a s e VI.Nam e, B. A .-v.Sex. Female. (S la v e g ir l) .A g e 14.H ospital N o. 881..September 9, 1918. M agnesium sulphate ounces Y> at 10.00 a.m. fasting.

N o tiffin. B-N aphthol grains 30 at 12.00 p.m., 12.30 p.m. and 1.00 p.m. follow ed in 2 hours by M agnesium sulphate, ounces 1.

R esult 35 flukes.September 19, 1918. Treatm ent as above w as repeated.

Result 50 Flukes.September 29, 1918. She was given a treatment o f ol. Eucalypti Co. oz. 1 in two

doses at 7.00 and 7.30 p.m.Result 25 flukes.

From September 30 to October 7 she was given a haematonic but she showed marked signs o f failing. She was put on a m ilk and egg diet to which w as added lemon juice in very sm all quantities.

October 9 she began to have bloody stools and died in the evening o f the same day. A utopsy showed little except a marked conjestion in the small intestine four inches before entering the ileo-cecal valve and a large elongated ulcer on the transverse colon.

C a s e VII.Nam e, N y in g T.-k. Laboratory f in d in g s ...S ex , male, M ay 12, stool. . .ova of Fascio-A ge, 22. lopsis buski.H ospital N o. 1159. U r in e .. .S p . gr. 1.010M ay 12, 1917. Acid.

N o sugar.N o albumen.

M ay 13, 1917. L ight tiffin, no supper, M agnesium ounce.Vom ited 8 flukes.Passed 11 „

M ay 14. N o breakfast, B -N aphthol grains 54 in 3 half-hourly doses, follow ed in 2 hours by M agnesium sulphate 1 ounce.

Stool N o. F lukes1 21 2 .................................................................. 7 3 ..................................................................... 14 4 ...................................................................... 47

T h e T re a tm e n t o f Fascìola psiasìs.

M ay 15. 1 . . . .M ay 16, 1 . .

23 . .

M ay 17, 1 . .23 ................................................

May 18. 1 ..................................13 stools and 1 vomitus

1064247

2638

232 flukes

From May 17 he received treatment for a marked asthenia. l i e complained o f being very weak, on June 4, and o f having a sensation as if the parasites w ere very active, com ing up into the stomach, and eating inm the intestines. H e died June 5, 1917 of a general asthenia. It is interesting to note that tin- dosage o f B-N aphthol was very small and was probably not contributory to his death.

T w o C a s e s T r e a t e d W i t h C a k b o n T e t r a c h l o r i d e .

C a s e I.W ang D a-gu.Female.A g e 15 years.W eigh t 80 pounds, pulse 90, respiration 18, temperature 98.6. Fahr.M arch 22, 1923. 2 cc. Carlxjn tetrachloride brought no results.

., 23, „ 20 minims Carbon tetrachloride, no results, pulse 105.24, ,. 30 ., „ , pulse 71-74 full and regular,

temperature 98.6° Fahr. Respirations 26 per minute. Pupils react norm ally


to light. Severe abdominal griping. An hour after taking the drug she became dizzy and fell on the grass unconscious. A t 11.30 a.m. she was nauseated and vom ited after which consciousness returned. •

S tool N o. F lukes1 . . . at 12.05 p.m. . . . 232 . . . at 12.30 p.m. . . . 12 and 1 A scaris lumb.3 . . . at 12.45 p.m. . . . 54 . . . at 2.15 p.m. . . . 3 and 1 A scaris lumb.

4 stools . . . . . . . . . . 43 flukesand 2 Ascarids.

A fter the first full stool the pain and other alarm ing symptoms lessened and all danger was past. M arch 25, stool at 6.30 a.m. showed no worms. M ay 24,. 1923 a washed stool showed no ova. The cure was complete.

C a s e II.S. A .-s.Male.A ge, 24 years.W eight, 130 pounds.Temperature, pulse, respiration, a ll normal.Ova of Fasciolopsis buski found in the stool.M ay 11, 1923. 3 cc. Carbon tetrachloride, taken in water before breakfast.M ay 12, 1923. There w as a w ell-form ed stool early in the m orning but no flukes

were passed. N o other stool all day.M ay 13, 1923. A w ell-form ed stool at 10.00 a.m. which contained several dead

and thoroughly extended and m acerated flukes o f a large size.D uring treatment there was not much discom fort and he did the regular

duties o f house-boy with seem ingly no inconvenience. T his case seemed to demand a cathartic in addition to the Carbon tetrachloride but none w as given.M ay 16. N o ova in stool, cure was complete.

The author’s case, using Carbon tetrachloride, (B arlow 1925) is fu lly described in the L ife Cycle o f the H um an Intestinal F luke Fasciolopsis Buski (L ankester)pp. 61-62.

In a group o f 14 people w ho took Carbon tetrachloride all w ere much m ore uncom fortable than they w ere on a previous occasion when they took B-N aphthol. .O ne child o f five, half an hour after taking cc. o f the drug, died in m y arms in spite o f all I could do to save him. One man who took 60 minims developed a marked urticarial dermatitis.

S u m m a r y .

T he disease has been long known to the Chinese doctors and has been treated by them w ith A reca N u t combined w ith cathartics.

T urpen tine was introduced in treatm ent by D r. D. D uncan M ainof H angchow and has largely superseded the use of A reca nu t by thenative practitioners, but it is ap t to produce nephritis.

D rugs w'hich are useful for the treatm ent of hook-worm infestations are also useful fo r treating fasciolopsiasis.

Hospital Technology Section. 265

In my hands Carbon tetrachloride has not found favor, for, although it is the m ost efficacious drug which I have employed, it ha^ been attended w ith untow ard consequences.

\ n ideal drug, em bodying safety, cheapness, and efficacy has not been found, but would assist greatly in ridding the endemic a rta s of this parasite.

L it e r a t u r e C it e d .Barlow , C. H .

1921. Experim ental ingestion o f the ova of Fasciolopsis buski; also, Theingestion o f adult F. buski for the purpose of artificial infestation.

Jour. Parasit., September, 8, 40-44.1925. T he life cycle o f the human intestinal fluía' Fasciolopsis buski

(L an k cster).Am . Jour. H yg\, M onographic Series N o. 4, July, 1925.

Barrios, Th., and N oc, F.1908. Sur la frequence du Fasciolopsis Buskii (Lank., 1859) en Cochinchine.

Bull. soc. path, exot., Paris, i, 216-221.Cole, A . F.

1922. F ive cases o f Fasciolopsis infection, with remarks.China Med. Jour., June.

Goddard, F . W .1907. T w o rare Fasciolidae. China Med. Jour., '¿1, 195-198.

Ibospital {technology Section.

DEVOTED TO THE GENERAL INTERESTS AND PRACTICAL N EEDS OF THE SMALLER HOSPITALS.

Edited by the Institute o f Hospital Technology.

RECORDS.

T he I .H .T . particularly directs the attention of the Association to the new edition of the C .M .A. H ospital F orm s, of which eleven new o r revised sheets are now in the Press. They represent nearly twelve m onths of very real w ork on the part of the Records Committee of the Council on A dm inistration, with the invaluable assistance of D rs. Cousland, and M cAll, of the Council on Publication. W e hope at an early date to survey the whole new series in some detail.

In the m eantim e, members of the Association will be more than ordinarily interested in the new schedule of prices, which appeared for t h e first tim e in the January N um ber of the J o u r n a l ( See the Council on Publications’ Book-list, pp. x x and x x i) , and which reduces t h e price


from $5.40 to $4.80 for the standard sheets. T h is reduction has been made possible by the. ever increasing sales, as shown in the list p repared for the Council, and prin ted below.

W ith the new edition, and a reduced price, there should be a new in terest in our C .M .A . form s, which now com pare favourably in quality with any series in the W orld, and are probably w ithout an equal in the m atter of price.

H o s p it a l F o r m s — S a l e s .

1924 1925 1926N o 8 months only

T em p. Chart 1 95.700 x 110.000 95.000H istory S h eet ... 2 23.200 45.000 31.000C om bination S h eet ... 8 21.500 22.000 17.000M edication ,, ... 4 27.000 38.000 42.500Lab. ,, ... 5 14.000 40.300 28.000O. P. D. ... ... 6 70.000 87.500 79.500Sum m ary Card ,, ... / 17.000 8.200 11.000N u rsin g ,, ... 8 55.000 80.000 60.000O peration ,, ... 9 6.500 11.500 6.000O bstetric ,, 19 2.100 5.900 5.500P uerperium ,, ........... 20 3.000 3.500 12.500

HOW TO MAKE A “ VACUUM ” WASHER.

I find that it is not quite so easy to buy these V acuum W ashers(See “T he Salving of Surgical D ressings,” “ C .M .J.’’ January , 1927) in Shanghai as I had thought. I t m atters the less since they are easily m ade locally, of Galvanised iron. O ur own is home made.

T he m ain cone m easures 9 in. high, by 8 j4 in. across the m outh. T he inner circlet is a truncated inverted cone, m easuring about 2>y2 in. across its lower opening, and a t its base soldered to the inner surface of the m ain cone. Its purpose is to ensure the com pression of all the clothes or dressings th a t lie writhin the circle of the m ain cone when in use.

T he angle between the inner and outer cones is filled in w ith a ring of galvanised iron, carefully soldered all round, and the inner cone itself is closed a t about the same level w ith a sim ilar diaphragm , also carefully soldered. T he soldering m ust be airtigh t, because leaks would spoil the vacuum during the up-pull, on which the w asher depends fo r its efficiency.

T he th ree little ears (each about 3 in. long) soldered around the apex of the m ain cone are there only to check splashing. T hey have no abstruse connection w ith the m echanism of the w asher. T h e handle itself is about 3ft. long, and lin . thick.

For illustration see January J o u r n a l , page 77. , . , . . -» .

Hospital Technology Scction. 2 67

I.H.T. INQUIRY SERVICE.

To the I . H . T .— I have had a number of cases o f what 1 diagnose- as Spring Catarrh this year. A horrible thing. Can blind a patient as quickly and as surely as Gonorrhoea. D oes not seem to be any hope for treatment in lx>oks. I gave M ilk injections with possibly a little success. Can you find out for me if there is any recent treatment for it?— E. C.

Ajiszccr .— T his is a very in teresting condition. It is the Koch- W eeks bacillus causing the acute infectious conjunctivitis popularly known as "P ink . E y e /’ I t has had an unusual virulence this year. T here is apparently a cycle, either due to a time element, or to unusually favorable circum stances for its development, or to both. As nearly as I can trace back, there have been th ree years out of the past f i f teen

in N anking that have been so m arked. D uring these years there is a tendency to early corneal involvement, especially in cases complicated w ith T rachom a. In our experience this association of a highly virulent K och-W eeks infection with T rachom a is more dangerous to the integrity of the Cornea than G onorrhoea itself.

T reatm ent includes thorough elimination, protection from dust and light in a dark room, or with dark glasses. A rgyrol 10-15% . four tim es daily a fte r boric irrigation in the m ore severe cases; Silver N itrate 1% , a fte r cocainization (4% Cocaine) once daily. The Silver N itrate should be thoroughly applied and thoroughly neutralised by normal saline. Corneal complications dem and A tropine, and a firm dressing that will prevent the opening of the lids w ithout undue pressure on the eve. R. A. P.

( T he above inquiry and answ er were received and dealt with last sum m er by post, but got crowded out o f the J o u r n a l . It will be understood tha t the season in question was the Spring of 1926. Sect. E d .) .

T c the I .H .T .— I have been reading a rather startling article by a German worker reporting molds and other infections flourishing in nearly everything in the Pharmacy, including the acids, and alcholic preparations. H is thesis was that the Pharm acy ought to be run on strict ascptic principles. The article certainly suggested how, and why old stock deteriorates—but surely asepsis in the Pharm acy is impracticable? D oes good pharmacy practice .demand a

, sterilizer?— E. G.

Anszi’cr .— In the P .U .M .C . we only sterilize by boiling the solutions as we m ake them up. W e have no pressure sterilizer for general purposes in our Pharm acy. ,

O n the other hand, distilled w ater ought to be used in all Pharm acies. A ccording to all the Pharm acopoeias it is the only official water,— though

268 The China lìledicaì Journal.

in practice o rd inary “tap ” w ater, if free from contam ination, is used fo r m ost preparations. B ut distilled w ater m ust be conscientiously used fo r all eve lo tions; fo r Salvarsan, and Neo S alvarsan ; for all H ypoderm ic in jections; and,— as we have found from experience,— for diluting A lcohol (9 5 % ) . Common tap or well w ater causes cloudiness.— J. C.

JEfcitoriate

OUR PUBLIC HEALTH NUMBER.T h e cu rre n t issue o f the J o u r n a l is the one an n u a lly devoted

to P u b lic H ea lth sub jects. D esp ite a critic ism th a t w e recen tly received o f the m u ltip lica tio n o f special n u m b ers o f the J o u r n a l .

\vc believe th a t they have a real place in m edical lite ra tu re in C hina w h ich can be m et a t p resen t in no o th e r w ay. G enerally speak ing these n u m b ers a re n o t m erely a source o f in sp ira tio n to ourselves in the w ay in w hich th ey can tem p o rarily focus o u r a t te n tio n on special aspects o f o u r w o rk w hich o therw ise m ig h t be som ew hat neglected , b u t they have a real educative value ou ts ide th is co un try . T h e dem and fo r copies o f th e special issues is considerab ly g re a te r th a n fo r the o rd in a ry ones.

T h e E d ito r is m ore th an usually conscious o f the fa ilu re to m ake these special n u m b ers all th a t th ey m ig h t be, b u t th is is h a rd ly sufficient reason fo r n o t p u b lish in g them . H e w ould w elcom e very h e a r tily co n stru c tiv e c ritic ism in th is d irection .

I t h ad been hoped th a t th is nu m b er m ig h t have been devoted ¡largely to the w o rk o f th e C hinese P u b lic H e a lth C en tres in d iffe ren t cities. V e ry rem arkab le w o rk o f th is n a tu re is b e in g ca rrie d on in P ek in g , S h an g h a i an d ce rta in o th e r cities, b u t th e difficulties o f th e tim e have m ade it im possib le to ge t th e in fo rm a tio n th a t woul'd h ave m ade th is w o rth w h ile fo r th is y e a r ’s P ub lic H e a lth Issue.*

T h e bu lk o f th e J o u r n a l is th e re fo re m ade up o f som e o f the m o re im p o rta n t papers on P u b lic H e a lth aspects g iven a t the C onference in P e k in g las t S eptem ber.

HOSPITALS IN CHINA.B e fo re th is copy o f the J o u r n a l is issued a confiden tia l rep o rt

o f th e ac tio n o f th e E x ec u tiv e C om m ittee in re g a rd to th e reg u la tio n s p ro m u lg a te d f o r the conduct o f hosp ita ls u n d e r th e N a tio n a lis t G o v ern m en t w ill have been sen t to aill th e M em bers o f the A ssoc ia-

* Since this .was printed, w e ! have . received, an interesting: account o f the Shanghai H ealth Centre which w e hope to publish in a later issue.

Editorials. 269

tio n . S h o u ld an y have failed to o b ta in a copy o f th is, one will be sen t on receip t by th e S ecre ta ry o f a po stcard requesting it.

A s n eg o tia tio n s a re in h a n d it h as been th o u g h t w ise th a t, fo r th e p resen t, no w ide pub lic ity should be g iven to th is action and th e E x ecu tiv e C om m ittee m in u tes published in the Section fo r A ssociatio n N ew s th e re fo re appear in a very abbrev ia ted form .

CAFFEINE.

T h e question o f the use an d abuse o f Caffeine in China has been m en tioned several tim es o f recen t m on th s in the J o u r n a l . T h a n k s to the in te res t th a t h as been aroused an d the in fo rm ation th u s ob ta ined we are now in a position to com e to som e d d m i t r

conclusions.T h e su b jec t has been o f special in te rest to us ow ing to the

q uestion h av in g been pu t to us by a lead ing firm o f B ritish im porters as to w h eth er the im p o rta tio n o f C affeine w as objectionable per sc o r likely by abuse to increase the num ber o f m o rp h ia addicts. T h e firm in question w as p repared in th a t case to w ith d raw fro m trade in th is d rug .

W e w ere no t ou rselves p repared to give an im m ediate answ er and suggested re fe r r in g it to a scientific body such as the S hanghai M edical Society , w hich w as done. A t the sam e tim e we received a le tte r f ro m P ro fe s s o r B. E . R ead o f P ek in g w hich is p rin ted in th is m o n th ’s C orrespondence.

A f te r co n s id erin g the m a tte r an d in view o f the fac ts given in P ro fe s s o r R e a d ’s le tte r th e S h an g h a i M edical S ociety in a reso lu tion d a ted 2 6 th J a n u a ry , 1 9 2 /, exp ressed its op in ion as co incid ing w ith th e view s su b m itted in th a t le tter.

F in a lly we have been g ran te d perm ission to publish a le tte r fro m D r. N oel D av is , C om m issioner o f P u b lic H ea lth , S hanghai, w ritten to the S ecre ta ry o f th e S h an g h a i M edical S ociety w hich, w ith the fu r th e r in fo rm a tio n th a t it p resen ts, ad d s considerab ly to our know ledge o f the sub ject. T h is le tte r a lso is published in th e C orrespondence C olum n o f th is m o n th 's J o u r n a l .

S om e in te re s tin g fac ts em erge fro m th is enquiry.

1. T h o u g h th e re is a s tr ik in g s im ilarity in the m ake up o f th e n arco tic pills ex am in ed in P e k in g and S hanghai, the am o u n t o f n a rco tic in those f ro m th e fo rm er place is very m uch la rg e r th a n is m et w ith in the S hanghai pills.

2. T h e am o u n t o f C affeine is alm ost exactly the sam e in p ills fro m b o th places.

270 The Chinn ,Medical Journal.

3. T h is am o u n t is e x tra o rd in a r ily sm all a m o u n tin g to only ab o u t Ya g ra in per pill an d it is inconceivable th a t th is can h av e an y physio log ical effect on th e consum er.

4. In v iew o f the above we m ay confiden tly affirm th a t all th e evidence w e h av e is d irec tly opposed to the sta tem en t th a t C affe ine is an y w ay c o n tr ib u to ry to th e co n su m p tio n of n a rco tics in C hina.

W e w ish to ex p ress o u r th a n k s to th e rea d ers o f th e J o u r n a l

f o r th e in te re s t they have tak en in th is ques tion an d fo r the fac ts th a t have em erged in th is correspondence.

SCHOOL HYGIENE.

W e w ish to call the a tte n tio n o f o u r read ers to th e v e ry valuable p a p e r by D r. C. H . H a n on th e C o n d itio n o f M ission P r im a ry S choo ls in th e P ro v in c e o f S h a n tu n g , w h ich w e pub lish in th is issue o f th e J o u r n a l .

I t is un p leasan t rea d in g an d th e re fo re p robab ly all th e m o re va luab le and p a rticu la rly so a s it co n ta in s som e very excellent p rac tica l recom m enda tions a t th e d o se .

T h e re are , how ever, several po in ts in th is p ap er w h ich lay it open to critic ism an d th e re is one o f these on w h ich w e have no h es ita tio n in say in g th a t D r. H a n does se rious in ju s tic e to M ission D o c to rs in C hina. T h is w ou ld be a sm all th in g in itse lf b u t it becom es a m a tte r o f considerab le im p o rtan ce w hen th e fa ilu re in ac cu ra te d ia g n o sis o f th e com plain t leads to a s im ila r fa ilu re in su g g e s tio n s fo r tre a tm e n t o f th e disease.

T h e ch arg e a g a in s t the d o c to rs ap p e a rs in several p laces in th is paper, b u t is m o st clearly ex p ressed in th e fo llo w in g w o r d s :— “ E v ery o n e realises th a t the d o c to rs in ch a rg e o f these h o sp ita ls a re o v erw o rk ed in every w ay, b u t it is now tim e f o r th e m to change th e ir p o in t o f view an d to ta k e som e d irec t ad m in is tra tiv e resp o n sib ility fo r th e sa n ita ry co n d itio n s in th e schools.

T h is w e m a in ta in is a n en tire ly m is tak en d iag n o sis o f th e case a n d it is a fa ta l one to th e p ro g re ss th a t D r. H a n an d w e all so m u ch desire . Wre sug g est th a t he d irec t h is n e x t series o f in v es tig a tio n s to th e prob lem o f “a d m in is tra tiv e resp o n sib ility ” fo r it is h e re m o re th a n an y w h e re else th a t th e need fo r re fo rm is g re a test. W e sta te w ith little fe a r o f co n tra d ic tio n th a t th e m ission d o c to rs all over the c o u n try have f o r m an y y ea rs been a sk in g fo r su ch resp o n sib ility an d have been re fu se d an d u n til th is is freely a n d fu lly g iv en th e m th e re can be littile im p ro v em en t in th e cond itio n s th a t D r. H a n depicts. F ro m o u r ow n perso n a l know ledge

Editorials. 271

w e w ou ld s ta te th a t m ission docto rs a re ( 1 ) X ot sent ou t as s a n ita ry officers: ( 2 ) N o t asked fo r th e ir advice on the situation , n a tu re o f th e b u ild in g s o r cond itions o f ligh ting : space, and w ater supply o f th e schoo ls; ( 3 ) T h a t w hen they p ro ffer such advice it is in m an y cases cu rtly re fu se d and they a re to ld to m ind the ir ow n business.

W e do n o t say th a t th is is by any m eans universal, but it is so com m on th a t it seem s doub ly h a rd to have to subm it on the one h a n d to ch arg es such as th is an d on the o th er to the denial o f w hat shou ld be th e ir p r im a ry r ig h t as hea lth officers.

FASCIOLOPSIASIS.

W h ile we apologise to read ers fo r the above nam e w hich, though w e believe it to be s tric tly co rrec t, is pain fu lly lack ing in euphony, w e co n g ra tu la te ourselves on the paper b ea rin g th is title in this issue o f th e J o u r n a l .

S om e tim e ago a M em ber appealed to us fo r an account of th e clinical tre a tm e n t o f F asc io lopsis in fec tion . T o o u r surprise w e fo u n d th a t w hile th e re w ere m any papers in past num bers ot th e J o u r n a l o n th e T re m a to d e itself, its place an d developm ent, th e re w as a com plete lack o f any au th o rita tiv e account o f the tre a tm e n t-o t th e in fec tion .

T h is lack is fu lly m et by D r. B arlow h im self in the article we n o w publish .

THE CHINESE JOURNAL OF PHYSIOLOGY.

O u r v e ry h e a r ty co n g ra tu la tio n s to the E d ito rs o f our new co n tem p o ra ry ,— the Chinese Journal o f P hys io logy— the first num b e r o f w h ich appeared in Ja n u a ry .

T h e artic les in th is issue a re p rin ted in E n g lish w ith sum m aries in Chinese. T h e nam es o f th e E d ito rs , D rs . R .K .S . L im , H . G. E a rle , B. E . R e ad an d H sie n W u a re sufficient to guaran tee a Jou rn a l o f in te re s t an d h ig h s ta n d a rd a n d the firs t num ber am ply fu lfills th is p rom ise . O f special in te rest to physicians is the account o f B a s ta rd A n ise P o iso n in g an d its A n tid o ta l M easures.

I t seem s a p ity th a t th e E d ito rs shoul'd be so m odest th a t they ca n n o t g ive in th e firs t n u m b er an account o f th e inception and ideals o f th is new Journa l , w h ich th u s seem s th ro w n som ew hat naked on a cold w o rld in a cover th a t is ra th e r suggestive o f a case o f l i n e a V ersico lo r.

O u r read ers a re re fe r re d how ever to a le tte r fro m D r. R . K . S. L im in th e C orrespondence co lum ns o f th is issue w hich g ives


fu r th e r p a rtic u la rs o f the new Journa l an d f ro m th e b o tto m o f o u r h ea rts w e w ish it every success. W e tak e its ap p earan ce a s a good om en th a t w h a tev er m ay be am iss w ith th e po litica l w o rld o u t here< science is fo rg in g - fu ll steam ahead .

Z bina r©et>ical association Section.

MINUTES OF EXECUTIVE COMMITTEE.

Three meetings have been recently held as noted below. The main topic o f these meetings has been the posit ion o f the hospitals in South and Central China, and the discussion o f the action that the Association zvould take in connection zvith this. Full defuils o f this arc already in the hands o f M e m bers in a confidential circular, and the minutes dealing with this question are omitted here.

A m eeting of the E xecutive Com mittee was held in the Association offices on T hursday , 10th F ebruary . 1927, at 9 a.m.

Present:— D rs. Fow ler (in ch a ir), Iva M iller, M orris, R obertson, Cousland, N ew and M axwell.

T he m eeting was opened w ith prayer.T he Secretary read a letter of apology from D r. G ordon T hom pson

for absence owing to the critical position of affairs in H angchow .T he m inutes of the previous m eeting w ere approved.

Committees■—-personel.— T he Secretary reported tha t the following m em bers of the N u rses’ A ssociation of China had been appointed to the C .M .A; com mittees.

I .H .T . C om m ittee:— M isses E . H ope Bell and E . Bowne.

Jo in t C .M .A. and N .A .C . C om m ittee:— M isses N ina D . Gage, M aud M arten, Gladys H odges and E . H ope Bell, (ex-officio.)

C. M . B. Appropriation .— T he Secretary reported the receipt of a letter from D r. N . G ist Gee on behalf of the China M edical B oard prom ising a fu rther contribution to the funds of the China M edical A ssociation of M ex. $10,000 a year for a period of five years on condition th a t the China M edical Association itself raised not less than a corresponding sum each year.

T he Secretary was instructed to convey to the China M edical B oard th rough D r. N. Gist Gee the very hearty thanks and w arm appreciation of the E xecutive Com m ittee for the continued generous support of the Board which was of special value a t th is critical period of medical w ork in China.

Chhio Medical Association Section. 273

Council on Research.— T he Interim report of the Council on R esearch was received and approved. W ith regard to the fu ture work of the Council the Executive Committee adopted the following m in u te :—

1. T h a t the Executive Committee approve of the lines laid down by the Council as regards the prosecution of research work.

2. T h a t the Executive Com mittee empowers the Council to act in the nam e of the China Medical Association in seeking to obtain a w orker specially qualified in m alarial research to initiate the malaria surveys in selected districts and to approach any scientific bodies in G reat B rita in or A m erica 'with a view to securing such a worker a n d /o r the necessary funds fo r carry ing on research in this and other directions.

3. T h at in view of the expressed intention of the British Boxer Indem nity Commission to provide funds for the establishment of an Institu te of Research, which, however, as outlined in the Report would not include medical rese a rch :— the Council on Research be empow ered :—

(1 ) T o approach the N ational Medical Association with a view to strengthening the Council by the addition of members from the N ational M edical Association,

(2 ) T o approach the Board of T rustees when appointed urging them to include M edical Research in the m atters to be dealt with by the Institu te ,

(3 ) T o offer the assistance of the Council on Research in organising the Medical D epartm ent of the Research Institute.

C .M .A . Balance Sheet fo r 1926.— T he Executive Committee adopted the audited balance sheet presented by the T reasurer.

T he T reasu re r was instructed to convey to M r. W . M ilward the hearty thanks of the Com mittee for again auditing the Association’s accounts.

T he T reasu re r presented a report of the Finance Committee with regard to the Balance sheet and the budget for the coming year. The Com mittee urged tha t the question of raising the membership dues, institu ting an entrance fee, etc., should be considered by the Executive Com m ittee before the next Conference. Certain retrenchm ents were recommended.

T he R eport was adopted.

Council on Publication— Financial Statement.— The financial sta tem ent o f - th e Council on Publication for 1926 and budget for 1927 were received and approved.


Representatives at Medical Conferences.— T he Secretary w as instructed to secure suitable representatives of the A ssociation to attend the annual C onferences of the B ritish, A m erican and Canadian Medical Associations. T he nam e of D r. J. C. M cCracken was suggested for the second of these.

T he m eeting was ad journed at 3.45 p.m.

A d j o u r n e d M e e t i n g , 1 9 t h F e b r u a r y , 1 9 2 7 .

P re se n t: D rs. Fow ler (in ch a ir), Iva M iller, Robertson, M orris.Xew and M axwell.

A pology for absence was received from D r. Cousland.T he m eeting was opened w ith prayer.T he C hairm an welcomed M iss E . H ope Bell, S ecretary of the

N u rses’ Association of China, to the m eeting to take p art in the discussion on behalf of the nurses in China who w ere equally w ith o u rselves involved in the present labour difficulties.

T he C hairm an expressed on behalf of the A ssociation the sym pathy of the Com m ittee w ith D r. Robertson on the recent loss of his father.

A g e n d a .

T he Secretary stated the business before the m eeting as fo llo w s:—1. T o receive a report from D r. W . S. N ew as regards the action

taken by the. N ational M edical Association.2. T o make final decision on the action of the C.M .A.3. T o in struc t the Secretary on m atters relating to publicity and

w ith regard to in fo rm ing the CAT.A. m em bers as to action taken.T he m eeting closed a t 10.15 a.m.

8 t h M a r c h , 1927.*

A m eeting of the E xecutive Com mittee w as held on 8 th M arch, 1927, a t 9 a.m. in the A ssociation’s offices.

Present:— D rs. F ow ler (in ch a ir) , Iva M iller, M orris. New, G ordon Thom pson, R obertson and M axwell.

T h e m eeting was opened w ith prayer.

M iss H ope Bell.— T h e Chairm an welcomed M iss H ope Bell, Secre ta ry of the N u rses’ A ssociation of China, to the meeting.

M inu tes o f last meeting.— T he m inutes of the last m eeting w ere approved.

* For explanation o f these abbreviated minutes see this month’s editorials.

China Medical Associafion Section.

CHINA MEDICAL ASSOCIATION.

F i n a n c i a l S t a t e m e n t fo r 1926.

Receipts.Balance from 1925 . . . . . . . . . . . . $ 4.443.0'>M em bership Dues . . . . . . . . . . . . 4,531.07Subscriptions . . . . . . . . . . . . . . 1.078.11Sales (R eceipts less E xpend itu re ) . . . . . . . . 24'>.00A dvertisem ents (less Com m ission) . . . . . . 3,505.13A ppropria tion (C hina M edical B oard) . . . . . . 10,000.00P ek ing Conference . . . . . . . . . . . . 454.07M edical Schools (R eg istration F ee) . . . . . . 20.00B ank In terest and D ividends . . . . . . . . 852.'

T o ta l ..............................$25.134.'w.

Expenditure.

Jou rna l P rin tin g . . . . . . . . . . $ 7,606.04Office P rin tin g . . . . . . . . . . . . 790.17Salaries and W ages . . . . . . . . . . . . 11,690.00T ravelling . . . . . . . . . . . . . . 044..-'"Postage, T elegram s, etc. . . . . . . . . . . 383.88E xchange of Cheques . . . . . . . . . . 5.1<>Councils and Com mittees . . . . . . . . . . (>80.03Office F urn ish ings and Sundries . . . . . . •• 241.70R en t and T axes . . . . . . . . •• •• 1,340.3?Special Reserve . . . . . . . . • • • • 350.00

T otal ................................... $23,740.'«Balance . . . . •• 1,384.08

$25.134.90

A udited and found correct,

(S igned ) : W a l t e r M i l w a r d .

7th F cbm ary , 1927.


fnM55foitar\> Section.

COUNCIL OF THE MISSIONARY DIVISION.A m eeting of the Council was held in the A ssociation’s Offices

on Sth M arch, 1927, a t 10.30 a.m.

Present: D rs. Fow ler (in ch a ir), Iva M iller, N ew, R obertsonM orris, G ordon Thom pson, and M axwell.

T he S ecretary presented a report from a m eeting sum m oned by the N ational C hristian Council asking for advice on the question of the form ation of Jo in t B oards of M anagem ent of the Chinese C hurch, Local Com m unity, and M ission for hospitals in areas w here the Chinese Church w ere as yet unable to pu t in eifect the full scheme for D evolution recom m ended by the M issionary Division at the G eneral M eeting at P eking. A fte r discussion a Com mittee was appointed as fo llo w s:—

D rs. G ordon Thom pson,J. H . Lechler,F . R . C raw ford ,Stephen LewisJ . L. M axwell (chairm an) w ith pow er to add to their num bers.

MISSIONARY DIVISION.

Corrections and Additions to the Prayer Cycle.W e have received a certain num ber of corrections to figures, etc.

in the P ray er Cycle which we append be low ; also a few cards and in form ation for it reached us too late fo r the first publication. T h is we also give here and perhaps readers could w rite them into th e ir own copies, so th a t they could be rem em bered during the rem ainder of the year.

O w ing to the presen t unsettled state of the country a num ber of the H ospitals are tem porarily closed, but we are not m aking any list of these.

C o r r e c t i o n s

Page 1 T unki W om en ’s H osp ita l sh ou ld read G eneral H osp ita l.

Page 5 C huanchow fu Beds 25 sh ou ld be 52 in W om en’s H osp ita l.

P age 14 Jaochow B eds 10 sh ou ld be 40

P age 22 K ongm oon E rase the nam e of D r. Jessie M acBean and en terit on page 41 as on the staff o f the H ack ett M edica l C ollege for W om en.

P a g e s 28, 30 L,intsing, T ehchow and T aibu . F or A .B .F .M .S . read A .B .C .F .M ,

Missionary Section. 277

P age 39

P age 6

P age 7

P age 18

P age 21

P age 23

P age 33.

P age 34.

T sinan For 13 C o-operating M issions read 10.

,, E . G. Struthers read E . B. Strutbers,, F rances C. Heath. „ Frances J. Heath.,, A nnie B. S cott ,, Annie V . Scott

F or graduates 86 read 268.

A d d i t i o n s

After L ungyen enter Dongkau

W om en’s H osp ita l D r. L. H . H. ByrneC .E .Z .M .S . N urses F . 1. C. 3. Pupils 4. School.’

Beds 50. Inpat. 379. D isp. 6,S»33.

ShanghangG eneral H ospital D r. W . Chalm ers D ale

E .P .M . N urses 2 (U ntrained;Beds 40. Inpat. 300. Disp. 5,000.

After Suchow fu Christian H ospita l enter Suchow fu

M ary Irwin R ogers Drs. N ettie D . Grier, (others C. 2.)M em orial H osp ita l Beds 35

P .S .

After L ing N an H ospital enter L eun g K w ong H osp ita l Drs. C. A. H ayes, E . Dargan Sm ith.

S.B .C . N urses and P upils 20. SchoolBeds 100. Inpat. 100 (d ) . D isp. 60 (d)

A fter Y eu n gk on g enter W nchow

Stou t M em orial Dr. J. M . BaileyH osp ita l N urse F . J . School.

S .B .C .

ChungkingSyracuse H osp ita l Dr. W. M . G entry

G eneral N urses F . 1. C. 1. Pupils 11. School.*M .E .F .B . Beds 45. Inpat. 600.

PaoningH enrietta Bird M em orial Drs. T. L ucas H illier, (others F. 2 .)

C .I.M . N urses 1.Beds 70. Inpat. 400. D isp. 3,000.

After S u in in g enterH w eilichow Dr. E . R. K illm ier.

C .C.A. N urses F . 2. C. 1. D isp. 26 id)H osp ita l not yet built, using Chinese house.

278 The China Mediccil Journal.

Current ADeMcal ^Literature.

DOES INFANT WELFARE WORK PRESERVE THE UNFIT?

T he fu tu re of the hum an race is th e them e of lively speculation, w ith depressing forecasts considerably outnum bering the a llu ring vistas. A favorite subject fo r lam entation concerns the alleged deterioration , p resent and prospective, brought about by m easures designed to save hum an life. In the w ords of one who considers th a t m ankind stands at the c ro ssro ad s:

Successful efforts to lower in fan t m ortality will result in a somewhat higher child m orta lity ; nevertheless, lowered death rates of in fan ts and children and young m others will eventually bring past the rep roductive age m any weaklings who would otherw ise have left no offspring. In o ther w ords, increased medical skill and the spread of preventive m ethods will tend to result in a race w eaker naturally than before |E . AI. E as t] .

T his som ewhat jaun ty deliverance apparently finds support in certain statistical analyses of in fan t and child m ortality , notably those by P earson and his colleagues; other analyses are distinctly contradictory.

I f in fan t w elfare w ork is essentially dysgenic, then the sooner the fact is established the better. E ven superficially, however, m any facts w arn against the hasty assum ption th a t the saving of the lives of babies in te rferes w ith the action of natu ra l selection. G erm s are not respecters of germ plasm. T here is not any reason to believe that babies w ith an outfit of qualities of great potential value to the hum an race are any r.»:ore or any less resistan t to m ilk-borne typhoid or scarlet fever than babies destined to be hew ers of wood and draw ers of w ater. O n the purely physical side, evidence is lacking to indicate tha t the in fan t whose life is saved by suitable feeding or by protection against excessive heat or cold is “less fit to survive” than the in fan t fed w ith partly decomposed milk or swaddled in thick garm ents in m idsum m er and allowed to be chilled in w inter. S partan m ethods of upbringing m ay conceivably w eaken those tha t survive and render them less resistant to the hazards o f adult life. A pneum ococcus-carrying osculation seems to the casual observer an accident tha t an in fan t should be protected from rather than a desirable step in the process o f natu ra l selection. I t has certainly never been shown in a convincing w ay tha t exposure to disease germ s is a m ethod of evolving efficient and happy races or individuals. I t would be a reductio ad absurd um to suggest th a t one in terferes w ith natural selection when one requires tha t dogs be muzzled to prevent the spread of hydrophobia.

Current Medical Literature. 279

W hile considerations of this sort are of course familiar enough and have had sufficient w eight w ith the average human being to prevent the abandonm ent of in fan t w elfare measures, it is obviously desirable to secure a m ore compelling variety of evidence. An important study of the statistical relations between m ortality in infancy and in the subsequent years of life apparently furnishes inform ation of this character.

An exam ination o f the infant and child death rates in Chicago over a period of tw enty-six years with calculation of the correlation coefficients indicates, so fa r as these data perm it a judgement, that the effects of in fan t w elfare w ork have not been dysgenic as alleged by Pearson, Snow and some other statisticians. The positive values of correlation coefficients as com puted by Falk dem onstrate that in Chicago the m ortality has generally been high in the subsequent years of childhood am ong children tha t survived the year of infancy in a period in w hich in fan t m ortality was high and vice versa. T he probable interpretation of this relation is that in fan t w elfare work not only achieves the direct saving of life, but in addition operates to preserve subsequent bodily fitness and resistance by reducing the incidence of illness that in jures when it does not kill. The study is significant and will be specially welcomed by the large body of nonmathematical readers who, themselves unable to refu te the argum ents of Pearson and his followers, have yet felt that the last word has not been said.— Jour, of A m . M ed. Ass., January 22, 1927.

A PLEA FOR THE MORE RATIONAL MANAGEMENT OF THE UNDER-NOURISHED CHILD.

F r a n k V a n D e r B o g e r t , M . D .

T he m anagem ent of the undernourished child is still a problem.T he in terp re tation and clinical application of the more recent

knowledge of nu trition have apparently failed to take into account two very im portant and, I think, unquestioned facts: that the size of the individual is not an infallible index of his health and that it is not the am ount of food ingested, however rich in essential constituents, which determ ines physical development.

T he real fau lt is the m anagem ent of these children seems to lie in the effort, a t least upon the part of the lay worker, to make all children conform to a weight and height standard, a standard which has been proven unreliable by several investigators including Dublin and Gebhart, who, corrobated by others, have shown that the use of the tables fails seriously in selecting the undernourished. F rom two-fifths to three- fourths of their series, though conform ing to generally accepted stand-


ards of w eight and height w ere shown upon carefu l physical exam ination to be defective. T hese observations point to a very real e rro r in the direction of overlooking ill health in the child of so-called norm al w eight fo r height but m ay also be in terpreted to m ean tha t the result in gain of w eight shown a f te r high calorie feeding cannot in itself be considered as evidence of im provem ent. F urthe rm ore , there are still some of us who believe tha t there are hered itary factors to be taken into account. Personally . I cannot but feel that the A m erican child,a conglom erate of m any racial stocks, m ust to a certain ex ten t beinfluenced by inherited traits. Certainly biology teaches us th a t stature is inherited.

T here is, of course, danger of laying too m uch stress upon the so-called fam ily build, but it is un ju st to brand its consideration as an attem pt to establish an alibi to save the reputation of the doctor when he fails in his efforts to correct an undernourishm ent problem .

O w ing to our desire to make all children conform to standard, the tendency has been to depend upon a m ethod of m anagem ent, theprinciples of which are unquestionably basically w rong, nam ely, thatso fa r as diet is concerned, undernourishm ent is always prim arily due to a deficiency in food intake and that food essentials swallowed in sufficient am ount can prevent and rem edy the defect.

W hat has been term ed the newer knowledge of nu trition has caused so m uch stress to be laid upon food values and vitam ine requirem ents th a t forced feeding has become the generally accepted m ethod of tre a tm ent and little consideration has been paid to the ability of the digestive trac t to do its p a rt in conversion and assim ilation. T he trite but very ap t analogy of the furnace has been forgotten and fuel tha t is absolutely unburnable is expected to produce heat and pow er. T he efforts of the nu trition w orker have resolved them selves into an attem pt to force the estim ated num ber of calories, vitam ines and lime salts down the th roats of th e ir charges w ithout respect to digestive capacity and often to the destruction of digestive functions. Tem pting, coaxing, bribery and deception are resorted to w ith gain in weight as their only justification, a gain which is by no m eans always perm anent and which in itself is not p roof of nu tritional im provem ent.

A standard which m ust have a fa r deeper appeal, it seems justifiable to suggest, would be one of general appearance of well being, accom panied or not by a so-called norm al w eight— height ratio. By fa r the best indices of health in childhood a re w hat we are in the habit of calling “pep.” in terest in surroundings, w hether w ork or play, lack of tendency to early fatigue, color of skin and mucous m em branes, appetite and, above all, a good disposition. Indeed, if one wishes ito depend Upon a single sym ptom he will do well to choose the disposition, 'fhfe reaction


to environm ent. Its im provem ent, under treatm ent, means infinitely m ore than a gain in weight and will invariably be followed by such a gain if the individual is actually below standard. The term "spoil” im plies lack of restra in t in those things which influence health and n u trition. T he spoiled child is. therefore, in most instances a sick child.

A steady increase in body development is, of course, to be desired, but unless accom panied by other evidences of improving health the hope of race betterm ent can never become a realization.

T he previous histories of severe and distressing cases, severe enough in them selves and distressing enough to the parents to encourage the consultation of a pediatrist, should, it seems, convince the advocate of forced feeding that it is not more food but less that is required. These unhappy youngsters have practically all been overfed in their earlier life, the ir desire for norm al food is gone and it is only by pampering and deception that they can be encouraged to eat at all. 1 have been told o f a child of about two years who was fed salt herring by its mother in order to get it to drink the am ount of milk advocated by the United S tates D epartm ent of Labor and of another whose mother buried a piece of sugar in its baked potato to encourage its consumption. I have seen children bribed, tem pted, coaxed and even threatened into taking food which they knew instinctively they could not digest. I have been told of soft boiled eggs refused yet greedily taken when beaten up with milk and sugar, and I have seen a child of two still being allowed the bottle between meals although apparently consuming p len ty 'o f general diet because the m other thought she ought to have the milk and it was the only way that she could get it down.

W ith a p roper feeding on a general mixed diet, milk as a vitamine or lime carrier is. I think, not essential. Milk is a food prepared by n a tu re for the undeveloped alim entary tract of the infant and in later years development m ust be norm ally stimulated. Small quantities ot m ilk w ith the meals are probably beneficial, large quantities, 1 believe are deleterious. M ilk is not a necessity to the older child, vitamines and lime salts are supplied elsewhere. No animal in its natural existence obtains milk a f te r leaving the m other’s breast. Xo one would question the vigor of a lion or tiger in the wild and an elephant develops a tusk tw o to ten feet long.

Instead of the addition to an already excessive daily ration of more vitam ine and salt containing foods the ideal would be a period of almost absolute starvation to relieve the digestive tract tem porarily of its burden and to allow .recuperation. In practice, however, the absolute w ithdraw al of food is unnecessary because of the child’s refusal for a time to accept the changed condition. W ith proper control they are soon glad to get and willing to consume the vitamine and salt containing foods


which the body requires. Gain in weight produced by such m ethods m ust be perm anent, the gain of forced feeding is likely to be tem porary.

M y conception of the proper trea tm en t of the undernourished child is to feed him as you feed a good horse or dog and I believe th is to be the best preventive m easure and therefo re the best feeding m ethod in childhood. P u t the oats in the m anger and let him take or leave them. Xo one w ould consider for a m om ent, sweetening a horse’s oats w ith sugar in order to make him take them. At a recent “ B etter Food D em onstra tion” held by the S tate T eacher’s College in M ichigan a poster which apparently created some interest read “U se horse sense, eat oatm eal.” M ore practical advice m ight be “ Use horsem an’s sense, feed oats w ithout sugar.” A healthy appetite needs no tem pting. G overnm ent th rough fear, as Judge L indsay expresses it, produces the im pulse to do the other thing.

Tw entv-five years of experience w ith these problem s has convinced me tha t w hat these children need is not more food but less, less effort to cause simple consum ption of calories and vitam ines, m ore sym pathy for the digestive o rg a n s ; less desire for size, m ore desire for health. In private w ork, 1 am sure, the elim ination of between meals feeding, of tem pting and coaxing, absolute ignoring of likes and dislikes will result in an appetite and digestion most efficient in the production of what we call health.— K n c Y o rk State Jour, o f Med., September 7, 1926.

AUBURN’S EXPERIENCE WITH TOXIN-ANTITOXIN.

G e o r g e C. S i n c e r b e a u x , A u b u r n , X .Y.

A report given at the annual meeting o f the Seventh District Branch o f the Medical Society o f the Sta te o f Xczc Y o r k ,

held in Geneva, on Sep tem ber 29, 1926.

T his report of our experience w ith tox in-an titox in in the City ofA uburn , was w ritten from the standpoint of the. general physician. T he im m unizations w ere begun in 1922, when the w ork, a t least outside of the big centers, was in its infancy, and it was no small task to sell it to the medical men and the public as well.

T he use of T ox in -A ntitox in was recom m ended by V on B ehreng in 1913 and was first carried out extensively by P a rk and Z ingher in X ew Y ork. D r. Sears, the D istric t S tate H ealth Officer, thoroughly believing in this prevention of diphtheria and w ith the S tate of X ew Y ork H ealth D epartm ent ready to help dem onstrate its efficacy, selected A uburn for its trial, first because of the considerable num ber of cases of diphtheria which persisted in spite of the ord inary m easures for its suppression; second, because of its size (a th ird class city) ; and th ird ,

Current Mcdical Literature. 28 3

because of the variety of its industries and its diversity of nationalities and home conditions: W e had a school population of over 7,000.

T he first problem was to sell the idea to the physicians, and then to the public. T his was done through the city and county medical society in order to enlist the in terest of the doctors. The people were reached th rough a public m eeting at which Dr. Zingher of Mew York told of the w ork done there. I t goes without saying that the physicians of A uburn w ere solidly behind the project.

A fte r the prelim inary interest was secured. Dr. Sears, backed by the medical men, w ent to w ork on w hat seemed to be a thankless job. A g rea t deal of publicity was given to it through the papers and in m eetings w here it was possible. E very child, first in the public school and then in parochial schools, was listed, and cards were sent to each paren t who had a child in school, for consent to be Schicked and imm unized. T he result was tha t 58 per cent of the pupils in the schools w ere allowed to be tested.

T o give you an idea of the prevalence of diphtheria in Auburn, I will give you the num ber of cases by years previous to this time, so tha t you may m ore accurately see the need of this work.

Y cai- N o. o f Cases Deaths

m S 55 61916 39 71917 49 91918 32 71919 54 61920 90 191921 131 13

By these figures you can see there was a real problem of life and health, to say nothing of the am ount of time lost in school. The work of Schicking and im m unizing was begun in February, 1922, and over 50 per cent of the children w ere Schicked and 90 per cent showing positive reactions w ere imm unized. I f by taking the 40 per cent, or over which w ere not tested or imm unized as a control, striking results m ay be shown. In those cases not imm unized there were 80 cases of d iph theria w ith 13 deaths in that yea r; while in the negative to theSchick test, or im m unized, there were 5 cases of diphtheria diagnosedclinically and by the laboratory, out of which 4 were later proven to be V incent’s angina in diphtheria carriers. T he other one occurred in a child too soon to have obtained his imm unity.

Cam paigns have been carried on each year since that time untilthe percentage of im m unized children in the school is over 85 per cent w ith these resu lts:


Y ear No., o f Cases , Deaths

19 22 98 151923 43 71924 22-. 11925 ,18 01926 6 0

T he last death from diphtheria was in M arch 1924. In the six cases so fa r this year, none had been imm unized.

O u r first question on seeing a red th roat or one which has the spotted th roat of a follicular tonsillitis is, have they been im m unized? ancl, if they have, while we take cultures to play safe, we do not feel they are going to have diphtheria— still we play safe and take cultures.

I rem em ber a case of one of my own patients, a boy of 8 years, w ho had been imm unized a year before. S ix m onths later he was Schicked but was positive. H is th roat was red and had some follicles present. A culture was taken and was positive, but yet he never developed diphtheria clinically. T his was a case of a d iphtheria carrier on a follicular tonsillitis. H is Schick test taken later was shown to be negative, one year a fte r im m unization. I t would seem that he would have developed a diphtheria with the condition of his th ro a t had he not been imm une.

O ur w ork now is w ith the pre-school children. I f we can keep them im m unized, the problem has been solved; but we m ust keep everlastingly a t it. I f we do not, in a few years there will be the same problem again.

I t was not so long ago tha t every child was obliged to be vaccinated before entering school, or a t least high school. Y et to-day in spite of the fact tha t we are supposed ta .vbe an enlightened nation, we stood th ird am ong the nations as having the largest num ber of cases of sm all-pox.

T he public opinion in A uburn , and I suppose in other cities, is a g rea t deal different from what it was in 1922. T o-day paren ts are b ring ing their children to us and. asking us to im m unize th e m ; but it is up to us doctors to keep up the enthusiasm . In regard to Schicking all cases, the re is a tendency not to Schick children under seven years o f age, or some say ten, before im m unizing. P a rk says it may be om itted before im m unization, first, because tw o-th irds of the children will require im m unization in any case; second, betause it is uncertain w hether a negative Schick reaction is the result of transien t im m unity transm itted from the m other, or is produced. I t has been found tha t in Polish or Italian children the percentage of positive reactions is m uch less than in E nglish speaking children. In A uburn, P o lish children


showed 26 per cent positive; Italian children 36 per cent; while tin- E nglish speaking about 82 per ccnt. T his would indicate that it would save a lot of toxin-antitoxin if the foreign children were Schicked before im m unization.

Ml children should be re-Schickecl in from six to twelve m onths a f te r im m unization. Reviewing some of the cases here who did not show im m unity until one year, it would seem that the one year interval would be the safer. I cannot give you the num ber of cases that were re-im m unized. Among the first num ber immunized. 80 per cent were negative to the Schick; 319 were given the second immunization dose; and 174 were re-Schicked and 5 were found positive. 3 of whom were given a th ird im m unization dose and all were negative.

In all the num ber of cases Schicked, or immunized, there was not a single severe reaction or infection.

F rom the results of w hat we have done in A uburn, we concluded first, that diphtheria is p reventable; second, that immunizations can be done safe lv ; th ird , that it is im portant to keep the pre-school child im m unized ; fourth , that Schicking may be omitted in young children of English speaking parents, but should always be done afte r immunizatio n .— N e w Y ork State Journal o f Medicine, Octobcr 15, 1926.

REPORT ON THE EFFECT OF TONSILLECTOMY ON RHEUMATIC INFECTION IN CHILDREN.

R e g i n a l d M i l l e r , M .D., F .R .C .P .

R e s u l t s o f P r e s e n t I n v e s t i g a t i o n .

F o r this report the rheum atic symptoms occurring in 45 tonsillectomized children over periods of one to five years have been subjected to analysis. These have been compared with the symptoms in the same children before operation and controlled by an analysis of the symptoms of 133 children w ith tonsils.

A nalysis of these cases produces evidence strongly in favour of the value of tonsillectomy. Sore throats, arth ritis, and carditis in all its form s, are found to be greatly diminished in the tonsillectomized cases. M uscular pains rem ain frequent, though largely uncomplicated by more serious symptoms and tending to disappear gradually afte r operation. Chorea, on the other hand, appears to be totally uncontrolled by previous tonsillectom y; the great m ajority of first and later in patient attacks of rheum atism occurring in tonsillectomized children consist of chorea, usually uncomplicated.

B efore these results can be accepted two provisos must be no ted :(1 ) The num ber of cases is small (4 5 ).


(2 ) T he cases subm itted to tonsillectom y and reviewed later were fo r tbe most p art early, though not necessarilv mild, cases.— Supplement to B .M .J . , July 3, 1926.

T H E SC H IC K T E S T :

A S c h e m e fo r A c t i v e I m m u n i z a t i o n a g a i n s t D i p h t h e r i a i n

P u b l i c H e a l t h P r a c t i c e .

E r i c D o n a l d s o n , M . D . . C a n t a b .,

a s s i s t a n t m e d i c a l o f f i c e r , c o u n t y o f s u r r e y .

C o n c l u s i o n s .

I. T h a t the Schick test has been proved to be a reliable test for susceptibility or non-susceptibility to diphtheria, and that the im m unity conferred by in jecting tox in-an titox in m ix tures is lasting. M y own experience in testing and im m unizing an institu tion agrees w ith the experiences of others.

I I . T h a t w ith careful preparation of the public by fully explaining th e facts about diphtheria, and' w ith the co-operation of the general practitioners m odern m ethods of diphtheria prevention could lie employed on a national scale ; and tha t a cam paign on these lines, resolutely carried out, would result in the reduction of diphtheria incidence to negligible proportions. I f properly organised the cost of such a cam paign would be extrem ely small, com pared w ith the enorm ous cost of trea ting thousands of cases annually. I t is interesting to note tha t the outbreak a t an orphanage in Surrey , already referred to. involved an expenditure of £500. Schick testing and active im m unization (w ith swabbing of Schick cases) cost about ¿25— certainly not m ore than ¿30— and the cost of testing the new-com ers each year will be negligible.— British Mcdical Journal, Sep tem ber 25, 1926.

3Booh IRepiews.

M ateria M edica and T herapeutics.— J. M itchell Bruce, C.Y .O . M .A.. LL.D.Aberd., M .D ., F .R .C .P Lond. and P ro f. W alter J. Billing:. Published byC assell & Company, Limited, London. P rice: 10/6 net.

This new edition o f such a w ell known tex t has continued its original aim o f being a rational guide to therapeutics by incorporating most o f the m ore recent investigations upon the pharmacology o f usefu l remedies. Space has been found for the essential facts concerning newer remedies such as Insulin, Sanocrvsin, N ovasurol, Carbon Tetrachloride, Chaulmoogrates, etc.

The first part o f the book could be w ell used by pharmacy or nursingschools in teaching materia medica, attention being confined to the detaileddescriptions o f drugs and their preparations, and just the heavy type under their

B ook R ci'iezi’s. 287

action and uses. The Introduction has an excellent outline of pharmacy and dispensing suitable for medical students.

The third part upon General Therapeutics is well suited to the use of the general practitioner, for it is obvious every effort has been made to provide up to date inform ation upon such newer things as M ercurodirome, and Tryparoamide. upon Light Treatm ent and methods of activating vitamins.

There has been no apparent effort made to delimit the number of drugs, nor to indicate those which which are of greater importance. Modern practice certainly w ould demand from any teacher using this manual a careful pruning o f the m aterial to suit local needs. This can be easily done because the drugs are well grouped according to their action and certain typical ones can be chosen from each group. The therapeutic section deals with the drugs as they are related to the physiological systems, each system being discussed according to its physiology, pharmacology, pathology, therapeutics, and spontaneous prevention and recovery.

The use o f the metric system in posology and in prescript ion writing is to be highly commended but it is not set forth herein in the most practical way. T he term mil is pedantic, and the men are few who in regular practice cling to each sub-division o f the system. K ilos, grams, and milligrams, litres and ccs w ith their decimal parts meet all ordinary requirements.

T his book is a live product. It shows in its many editions since 1KK4 the ability to m etabolize old and new drugs in a way that brings progress to scientific medicine. It politely awaits the new British Pharmacopoeia before burying in the past the obsolete material which has now been purged from the U .S .P .X . For an old book it is remarkably up to date upon the practical subjects of m ateria m edica and therapeutics, and its pharmacology is attractively concise and explicit.

P.. E. R.

S h ort N o tes and M nem onics of A natom y.— A. S. Irving. E. and S. Livingstone,16/17 T eviot P lace, Edinburgh. Price 1 /3d.

T hese M nemonics are intended to assist students o f Anatomy who may find difficulty in remembering certain parts. T he short notes comprise a number of popular questions

It is useless to attempt to m oralise on a system of education that requires helps like these to pass examinations. It seems to us that the need for a publication like this, the evident need from the fact that it has reached a third edition, is in itself sufficient condemnation.

T he fact remains that probably all o f us have used Mnemonics in our student days and have found them o f real value in our struggle with the examiners. T his being so, and for this purpose only, no one can question the value of the book. It is excellently and clearly got up and of a size that fits easily into the vest pocket.

J. L. M.

T u b ercu losis. (C atechism S er ie s ).— James Crocket, M.D.. D .P .H ., F .R .C .P.E .E. and S. Livingstone, 16/17 Teviot Place, Edinburgh. Price 1/6.

Generally speaking w e must confess to some doubts as to the value of this type o f book as engendering mere cramming by the medical student. W e must allow however that this little volume has very nearly converted us to a different w ay of thinking. It is an excellent compendium of knowledge, very clearly ex pressed and gives a review o f the present position of the Tuberculosis problem,— diagnosis, prognosis and treatment that is as valuable to the practitioner as it is to the student. It successfu lly evades the pitfalls on the one hand o f too great compression and on the other o f appearing to pose as a substitute for works on medical treatment. W e heartily recommend it, not only as a book for students, but equally for the ordinary physician in general hospital work in China.

Such a volum e necessarily lends itself to criticism more easily than does the ordinary medicai treatise. It speaks much for this little book that our criticisms are few , and on points o f relatively small importance. W e do feel, however, that words like eugonic and dysgouic are unnecessary in a work of this natuie, and if used should be translated. T o test this ourselves we tried the ordinary medical dictionaries and it was on ly in the third volume that we found the words


given. W e feel inclined also to criticise the paragraphs on B ovine Tuberculosis. T his perhaps is hardly fair as it is no fault o f the book that all w riters on this subject in the W est are so painfully ignorant o f the great frequency o f the so called bovine type o f disease in lands where cows' milk does not form a staple article o f diet.

J. L. M.

H ydrogen Ion C oncentration .— Leonor M ichaelis, M .D . Translated into E nglishby W illiam A . Perlzw eig, M .A., P h .D . The W illiam s and W ilkins Company. Baltimore. P rice $5.00 Gold.

The volum e under review is the E nglish translation of the first V olum e o f P rofessor M ichaelis’ book, the second edition of which was published in 1921.

T his first volume deals with the subject from a purely theoretical standpoint. It is decidedly not a book for the dilettante in the subject. A sound know ledge of the principles o f physical chem istry and o f mathematics arc essential for an understanding of this book. Thus the circle o f readers to which it w ill appeal will be a com paratively small one, but, we 'believe, an appreciative one.

T he book is divided into tw o main parts— the first dealing with the chemical equilibrium o f the Ions and the second with the Ions as a source o f electric potential differences. O f m ost interest to medical readers w ill be the chapter on the theory of the quantitative determination of acidity and alkalinity. In no other book that we know, does one find such a clear and succinct explanation of the principles o f titration, o f the choice of indicators and of the action o f buffers.

The translator deserves a word of congratulation on the accomplishment o f a very difficult piece o f work.

The printing and binding are in harmony with the high traditions o f the W illiam s and W ilk ins Company. W e came acroses one m is-spelling— “acqueous” for “aqueous.”

The remaining volumes, which will deal with methods, and with physiological and medical applications w ill be eagerlv awaited.

D . S. R.

The S u rgica l T reatm ent o f G oitre.— W illard Bartlett, A .B ., A .M ., M .D .. D . Sc.,F .A .C .S . (S t. L ouis.) Published by the C. V. M osby Company. Price G.S8.50.

The author of this book gives a good account o f the treatment o f Goitre from the Practical Surgeon's point o f view. T he account is clearly and fu lly set out, drawing freely from his own experience; it is also w ell illustrated by diagram and drawing.

Chapter I is a brief but interesting account o f the history o f Thyroid treatment.

In Chapter III the pathology is dealt with, many illustrations being given.In succeeding chapters w e find discussed, among other subjects, the condition

of the heart in different types o f g o itr e ; the preparation of the patient for operation, the different operative procedures whieh m ay be adopted, anaesthesia, after treatment, and results.

In some places w e find curselves asking for statistics instead o f the generalized statem ent; the tex t is, however, freely illustrated by references to individual cases in the author’s experience.

In the chapter on the preparation o f the patient for operation, advice is given on diet for thyroid cases.

A s an indication of the number of illustrations in the book, the operation o f ligature o f the superior thyroid artery is illustrated bv fourteen draw ings shew ing m inutely each step of the operation.

In the operation of Lobectomy, the author describes a method o f applying a ligature around the base o f the thyroid, to prevent hemorrhage when the thyroid tissue is divided.

The author, although favouring the usual collar incision, recommends an anterior sterno-m astoid incision for certain types, as offering a shorter approach to the enlarged thyroid.

WThen thyroid tissue is to be removed by tw o operations through a collar incision, it is recommended that half a collar incision be used on each occasion,

Correspondant\ 289

thus avoiding the necessity o f opening the wound and operating through tissue altered by a previous operation.

In Chapter X IV the question of drainage is considered, together with the problem o f how to leave the best scar with drainage.

T w o chapters are devoted to the relative merits o f, and several indications for, the different types o f excision operation.

In com plications which may occur after operation, a whole chapter is devoted to laryngeal complications. The diagnosis and treatment of these complications is discussed, together with a long compendium o f references on this subject.

One praiseworthy feature o f this book is the list o f references appended to each chapter, dealing with the subject matter of that chapter.

This book is written from a practical point o f view and will be useful bothto the general practitioner and the surgeon.

D. J. E.

O rthopedic Surgery.— W . A. Cochrane, M .B., Ch.P., F .R .C .S.E . E. & S. Livingstone, Edinburgh. 2 1 /- .

In his preface the author states “this book is designed to give the studentan understanding of the scope, principles, and essential details o f the speciality ofthe surgery o f the locomotor apparatus in relation to the study of pathology, and general medicine and surgery,” and “it is not an exhaustive compendium of secondary facts about disease, but, in adopting in part a mountain-top-view, it is desired to make the student appreciate that in the chronic class o f case, especially, there lies a wide field of endeavor in striving after an ideal . . . o f reconstruction and rehabilitation.” In this book of five hundred pages and an equal number of illustrations the author has done well what he states in the preface to be his object. It is essentially a book for the student and it gives him a bird's-eve-view o f orthopedics.

The first part, the first three chapters, one sixth of the book, is devoted to the principles of body mechanics and posture with reference to the body as a w hole and in connection with the structural and functional conception of disease as presented by Dr. J. E. Goldthwait, o f Boston. T his part of the book is very valuable for the practitioner as well as the student and it is good to see these principles o f the structural and functional conception of disease which have a definite relationship to clinical medicine and surgery, especially to the chronic joint diseases, static and other acquired deform ities, chronic nervous diseases and the symptoms ascribed to visceroptosis, principles so earnestly set forth by Dr. Goldthwait, put so clearly in this book. This makes the hook quite unique. Every practitioner should understand these principles and we heartily recommend a thorough study of this part o f the book. The chapter on disabilities of the foot and ankle is especially well done for the purpose o f the student.

Correspondence.

A buse of D rugs.

To the E d i to r o f C.M.J.D e a r D r . M a x w e l l : — Some time ago

in the J o u r n a l D r . Aspland wrote concerning strychnine and caffeine: “W illsom e pharmacologist enlighten us as to the addictive effect o f these drugs?” T he recent letter by K. T. Chung concerning the abuse o f drugs has again raised the question o f the use o f s t r y chnine and caffeine in China. In writing this note it m ight be well f c r me to attempt to answer both o f these points.

It is well known to-day that caffeine and strychnine are extensively imported and widely used in anti-opium treatment. There is "no doubt that the stimulating action o f both drugs is helpful to opium addicts. Their continued use has a very definite effect. W ith regard to strychnine, Sollmann in his Manual o f Pharm acology p. 196, summarizes the scientific evidence in the follow ing phrase: "The continued use o f strychnine does not lead to a tolerance; on the contrary the repetition o f its action addicts the nervous system to respond more and


m ore readily." W ith regard to caffeine it is a w ell knowni thing’ that the habitual consumption o f caffeine produces a limited tolerance.

Aspland has pointed out that not only are those alkaloids used to assist in the treatm ent o f opium addiction but they also are used combined with heroin or morphia compounds. T o m y knowledge such pills w ere originally introduced into China in regular anti-opium treatm ait by the gradual w ithdrawal process, in which process strychnine and caffeine pills w ith and without morphia, exactly sim ilar in appearance, w ere used.

Even if caffeine and strychnine were only used for their stim ulating effects, as an anti-opium remedy. I agree with Dr. W u Lien-teh that it is hard to give any figure as the minimum need, or even the m aximum need. Strychnine is a common rat poison and a very large amount m ight be consumed com m ercially for this purpose. U ntil there is far more evidence as to the particular use o f these drugs it would appear to be unwise to do anything in the matter. I f these drugs are actually in use in large quantities and if their effects are serious, surely we should have at least one case appearing in our large hospitals for treatment and this as far as I know is not the case.

V ery truly yours,( S ig n e d ) B e r n a r d E . R e a d .

P eking U nion M edical College.Peking, China.

December 23, 1926.

D r . A . D . Wall,

Secre tary , Shanghai Medical Society.

D ea r D r . W a l l :— I h a v e t o a c k n o w - le d g e y o u r le t te r c o n c e r n in g t h e im p o r ta t io n o f c a f fe in e in to C h in a a n d t h e q u e s t io n w h e th e r m e d ic a l o p in io n c o n s id e r s th is d r u g e ith e r d e le te r io u s o r l ik e ly t o e n c o u r a g e th e m o r p h ia h a b it.

W ith regard to caffeine in narcotic pills, many specimens of such pills have been examined in the M unicipal Laboratory and they all approximate closely in composition.

T he com position o f a typical specimen, in respect o f the active ingredients, is

In one P ill In io.noo P i ltsH e ro in o r M o rp h in e

n.002 g ra m = i/32 g r a in 20 g r a m ‘!= 7 / io oz.C in ch o n a A k » lo id s

0.004 g r -111 = 1/16 g r a in 40 g r a m s = i 3/5 oz.C affe 1 tie

0.015 s rra m = ?i g r a ’ n 150 e r n is = 5 1/3 oz.

Each pill w eighs about 4 grains.

The pills are generally o f a bright pink- colour (an aniline d y e ). Quinine is rarely present, cinchonine being the usual alkaloid present w hilst brucine is som etim es substituted for strychnine.

The labels generally describe them as “Cough” or "Tonic” pills. T hey are reliably stated to be smoked in an opium pipe in a sim ilar manner to opium and to give the sam e satisfaction to the smoker that opium does. The smoking of the pills has been demonstrated in the laboratory and in the M ixed Court by a police witness.

A lthough these pills may have been originally introduced as part o f a genuine anti-opium treatment, there is little doubt but that they are now being manufactured and sold in large quantities and used without any medical control, and the use of them can therefore be considered a? substituting the use o f opium.

It is extrem ely unlikely that a ban 0 1 1

the importation o f Caffeine, even if it could be effectively enforced (consider the amount o f morphine, etc., sm uggled into C hina), would result in any considerably smaller amount o f morphine or heroin being consumed than is now consumed in the form of these pills. Restriction should be enforced firstly on the importation o f morphine and heroin and secondly on the m anufacture and sale o f pills and other preparations containing morphine or

1 heroin. I f restriction cannot be effectively i enforced on the drugs o f m ajor import- 1 ance then it would appear futile to con

sider the imposition o f restrictions 0 11

caffeine o f w'hich the w orst that can be said at the present tim e is “it is conceivable that it m ight make it possible for the addict to take a larger dose o f narcotic than would otherw ise be the case.” I f the larger dose o f narcotic w ere not available, little notice would be taken o f caffeine.

Yours truly,C. N o k l D a v i s ,

Commissioner o f Public Health. 28 th February-, 1927.

***[T his letter, though not addressed directly to the Journal contains so much o f interest that we have requested and kindly obtained permission to publish it. Further reference to this question is made in this m onth’s Editorials.— E d it o r . ]

T he C hinese Journal o f P h y sio lo g y .

To the E d i to r o f C.M.J.D e a r S i r : — I beg to bring before your

notice, the Chinese Journal o f P hysiology,

Correspondence.

which is to be issued quarterly by the Chinese Physiological Society. T he S ociety is composed o f the physiologists, biochem ists and pharmacologists o f China. M embership is by ballot and is open to all w orkers (Chinese and F oreigners) in the Physiological Sciences in China.

An apology is necessary for the addition o f one more journal to the number in existence. It has been felt, however, that the publication o f scientific works in China is an essential means o f stim ulating interest in scientific research in this backward country, and if in doing so, the medium o f publication is in a language readily understood by the international scientific public, it is hoped that not only will China benefit but that she may be led to assume her share in m aking contributions to the scientific progress o f humanity.

In issuing the Journal at this difficult period in the history o f the country, the. Society wishes to dem onstrate the desire o f the Chinese to help them selves but in .the spirit o f international good-w ill and co-operation m anifested by all men of Science.

A copy o f the first number of the Journal is being forwarded to you under separate cover.

Believe me,Yours very truly,

R o b e r t K. S. L im .Chairman o f the Editor ial Board.

February 10th, 1927.

S tovarso l.

To the E d i to r o f C.M.J.D e a r S i r :— Our Laboratory has e x

amined the P .U .M .C . report on Stovarsol as well as the article o f Dr. Julia M organ inserted in your Novem ber, 1926, issue. The series o f observations contained therein, so far from furnishing arguments against the use o f our product, on the contrary, Dr. M eleney in his report confirms our opinion as to its relative harm lessness, in view o f its high arsenical contents, when its administration is w arranted and carefu lly watched.

In Dr. M eleney’s four cases, the patients have all undergone a full 10 days’ course o f treatment in spite o f premonitory symptoms which would have warned an attentive observer that it should be discontinued.

It appears therefore to be a question o f errors o f administration to which full consideration w as not given until the fu ll course o f treatment had been undergone.

T w o o f the patients (N os. 1 and 4 ̂were suffering from skin eruptions

; previous to treatment, which would sug- ! gest the possibility o f their being particularly susceptible to arsenical

i poisoning. Further, there is no evidence ! o f any previous functional examination

of the kidneys and liver having first been ' made in any o f the four cases.

The three patients Nos. 1, 3 and 4 have nevertheless recovered, without further

i complications, after having eliminated their arsenic.

i Let us now examine the circumstances regarding the death of Patient No. 2.

............... W e have sold hundreds ofthousands of Stovarsol tablets, in all parts o f the world, and this is the very first case of this kind which has been brought to our notice. Acute dermatitis and the typical symptoms of arsenical poisoning were not noticed until the tenth day. It appears to us to be very strange that mild symptoms of this were not apparent before then so that the treatment might have been stopped in time.

It must therefore be admitted:(1 ) that the patient did not receive

close medical surveillance during the first ten days and

(2 ) that her previous condition rendered her particularly susceptible to the effects o f arsenic. The chronic multiple arthritis and feverish condition noted at the beginning of the report, in regard to the nature o f which exact details are lacking, give very strong support to the above assumptions.

W e wish, in conclusion, to reassure you as to the toxicity o f Stovarsol. This medicament, together with the majoritv of arsenical compounds, gives rise, it administered in too large doses or to intolerant patients, to slight signs of poisoning of such a nature as to be readily noticeable before serious result?, occur. This fact renders it definitely possible to stop the treatment in time, after which the patient will become normal. It is, however, absolutely necessary that the patient should come daily under careful medical observation, until it is proved that the medicine is being assimilated without harm.

W e agree with all D octors in advising that when Stovarsol is administered in doses of more than 2 tablets (0,50 gr. ) per diem, the treatment should be discontinued for three days eyery four days. When smaller doses are given, the treatment should not be continued for more than 15 days. W e repeat, however, that a medical examination must be made before treatment and that the sm allest


sign of intolerance m ust be carefully looked for. I f these conditions are observed, there is no danger in the adm inistration o f Stovarsol.

Y ours fa ithfully ,S t e . A m e . R a c i n e & C ie .

Pour Adm inis trâ t cur Dclagnc.

J. D o n n e .

General A g e n ts f e r L es E tab l is sements Poulenc F reres.

Shanghai, M arch 7th, 1927.Boite P osta le 859.

C ancer in China.

To the E d i to r o f C.M.J.D e a r D r . M a x w e l l : — I have just

finished reading' the C h i n a M e d i c a l J o u r n a l , January number, and my attention has been called to a statement in the editorial “Cancer in China.” To quote it is as fo llow s,— “of a country w here food is so well cooked that tapeworm infection is extra-ordinarily rare and trichiniasis is unknown.”

D oes the word food which is used refer to all kinds of food or to meats only? H ere in the-South, in the districts around Canton one would say that the food of the Chinese is not w ell cooked in a great many instances and some dishes are served where no heat whatsoever is used in their preparation. I refer especially to that delicacy that the Chinese eat called “yue shang” ( M Æ ) or fish salad I suppose w e would call it.

T o m ake this salad they use the flesh o f one of the three varieties o f fish which are found in the ponds in this district, the pin yue (SS & ) , the shang vue (Ú. f à ) , or the waan yue (g^ M.). T his fish flesh is cut up into v e fy fine pieces with a chopper on a wooden chopping board. Then they take some loh paak ( é k Ù ) or p’o pik (ïjfî ) , a vegetable growTi in this distri.ct, onions, fresh ginger root, and peppers. A ll these vegetables are cut into very fine slices w ith a very sharp k n ife and are then m ixed w ith the chopped fish. T o this m ixture peanut oil and salt are added and the dish is ready to serve. N ative wine is drunk along w ith this dish as well.

N o doubt a great deal o f the in fection with the Clonorchis sinensis which is so prevalent in K w angtung is due to this practice o f eating uncooked fish since the fish come from the ponds where the intermediate host o f the fluke

is to be iound. D uring the past week w e have had tw o patients writh very heavy infections o f Clonorchis sinensis, and both of them w ere fond o f eating “yue shang.” One patient lived beside a fish pond. H e had many visitors and would give them this fish salad as a treat, helping him self liberally. H is major symptoms w.ere sw elling o f the extrem ities, watery diarrhoea (no blood or m ucus), no fever, and progressive emaciation. The other patient died of uraemia due to prostatic envolvement. H e also had a’ very heavy infection of ;he Clonorchis sinensis.

The Chinese in this district also eat lettuce uncooked. A piece o f lettuce leaf is taken to wrap up a m outhful o f some cooked food and with chopsticks it is conveyed to the mouth. Onions are also served uncooked being added to other vegetables after they have been cooked. Other vegetables are also eaten uncooked as “t’ung sam ” ( ji. i t ') - and parsley ( « ® ) .

W ith regard to meats, pork is always w ell cooked and accounts no doubt for the very few cases o f trichinosis seen here. B eef is l.ot w ell cooked. Various kinds o f crabs and shrimps are eaten uncooked.

Several months ago w e had a patient in the hospital w ho gave a history of passing segments o f worm. A fter giving a verm ifuge o f male fern, a worm over 30 feet in length was expelled including the head, and on exam ination under the m icroscope it was diagnosed as taenia saginata.

About three years ago Dr. M cDonald removed a very small tumour which was situated in the calf m uscles o f the leg. The grow th caused a good deal o f pain out o f proportion to its size. On exam ination after removal an encysted trichina was found.

I realize that this enquiry has nothing to do with the editorial “Cancer in China” but only with the statement that “foods are w ell cooked in China.” Our observations here are that many foods are not w ell cooked and possibly tfhe few cases o f taeniae that are reported may be due to som e other factor than the amount o f heat used in the cooking o f the food.

Y ours truly,W . B. M c C l u r e .

K onjm oon, January 31st, 1927.

***W e must plead guilty to having used the word “food” som ewhat carelessly in the Editorial referred to. Raw

Wanted Coin inn.

vegetables are certainly quite commonly eaten over a large part o f China and are supposed t<> explain to som e extent the frequency o f A scaris infection. W itb regard to fish, we believe that the area o f raw fish consumption is com paratively limited, and with respect to meat w e hold that our statement is substantially true. In proof o f this wre have, as remarked

before, the rarity of Taenia infection which Dr. McClure himself confirms. C:nurastecl with this is the great frequency o f infection with Taenia Snginata :-mong the aboriginal tribes o f Yunnan among whom beef raw, or nearly so, is constantly eater.,

E i i it ok .

WANTED COLUMN.

Irish P resbyterian Mission H ospital for Men, K irin. A foreign m issionary Doctor. (M andarin speaking) needed for six months or more. Foreign nursing superintendent.

A nsw er t o Rev. A n d r e w W e i r ,

P resbyterian Church of Ireland Changchun, A1 anchuria.

M a r g a r e t W i l l i a m s o n H o s p i t a l . T here is a vacancy on the hospital staff for an interne and a resident in the departm ent of obstetrics.

F o r P articu lars apply to :T he Superintendent,

• ' M a r g a r e t W i l l i a m s o n H o s p i t a l

W est Gate,Shanghai.

J o u r n a l s W a n t e d . T he E ditor is still requiring lor the Office fu rth e r copies of the Journal for January and February , 1(J25. H e also desires a re tu rn of copies of January and F ebruary , 1926. Ow ing to the recent large increase of M embers he has exhausted his usual supply. 50 cents per copy will be paid for these.


®bttuar\>.

N ew s has been received of the death o f D r. M ary F ulton at her home at Pasadena on January 8th, 1927. Dr. Fulton was the Founder o f the H ackett M edical C ollege in Canton and lived to see the w ork she started in a small w ay grow to a fine institution w'hich has provided many doctors for M ission service, especially in South and Central China.

TRIBUTE TO DR. J. S. GRANT OF NINGPO.

It w'as w ith a feeling o f real loss that I learnt o f the death of Dr. Grant. A s an old friend who knew him well, may I be allowed to place a wreath o f affectionate tribute on his grave.

It is now tw enty-tw o years ago since I first reached N ingpo as a young medical m issionary, Dr. Cole o f the C.M .S. also arriving there about the same time. T o us both it was a very happy circum stance, to find in our first Station, such a genial senior medical m issionary as Dr. Grant. The memories o f s ix years in N ingpo, w ith Dr. Grant and Dr. Cole, are those o f unbroken good fellow ship and mutual help. W e all belonged to different M issions, each working his own H ospital, but the kindly good feeling which existed between us w as a feature upon which one looks back with gratitude and pleasure.

One has grateful recollections o f the unfailing kindness and cheerfulness o f D r. Grant. H e did not seek for popularity, but probably no one w as better loved by the Chinese, Community people and M issionaries. H e was such a thoroughly sincere Christian, that h is life and spirit w ere just as natural an outcom e o f his being, as fruitbearing is to a good tree. I remember on one occasion, he invited m e to g ive the anaesthetic for an operation on one of the Custom s’ Staff, a notorious young drunkard name H .— B efore beginning the operation, as naturally as though he w ere in the operating room o f his own H ospital, he addressed h im self to Mr. H , on this wise,—'“N o w H . before I operate on my Chinese patients, I usually have a word o f prayer. W e’ll do the same here” ; he thereupon poured out his soul to God, including the petition that H e would make Mr. H . a good man.

I do not think that we can overestim ate the good that can be done by a doctor

o f Dr. Grant's type, who brings a gracious Christlike influence to bear on the patients w ith whom he comes into contact. It has been a privilege to have enjoyed his friendship, and his memory remains a fragrant and up lifting one.

(S ign ed )J o h n J o n e s .

T aiyuanfu, Shansi, N . China.February 23rd 1927.

A TRIBUTE TO REV. JOSEPH CLARKE THOMSON,

M.A., M.D., D.D.

It is a p riv ilege to know a good m an and to realize that the effect on one’s own life is to m ake life m ean m ore. G reater still is it to know a leader in C hristian service, especia lly one, wdio, to a certain exten t at least, has been a pioneer and in that serv ice has done his part in the w onderfu l tran sform ation of the greatest people on earth, the C hinese. From my childhood until his death it has been my p riv ilege to know quite in tim ately Dr. Joseph Clarke T hom son. H e and my father w ere com rades in serv ice and for him m y father a lw ays had the h igh est respect and greatest affection.

Seldom is a man fitted as w as Dr. T hom son, to com bine in his labor of love the sk ill of “the beloved p h ysic ian ” w ith the ev a n g e listic fervor of h is associa te the A postle P aul, yet here w as a m an wrho fitted h im self for both form s of serv ice in the days w hen a m ission ary had to be a ll th in g s t o 'a l l men. T he day of sp ec ia lization had not arrived on the m ission field.

Dr. Thom son w as born of' good Scot^Ji. stock. H is parents cam e over and settled in C incinnati, w here he w^as born. H e wras the first in fant baptized in the church erected on land given by his m other. G raduating from H u gh es H ig h S chool, C incinnati, and H anover C ollege w here he a lso received his M.A., he w ent first to D a n v ille T h eo log ica l Sem inary for tw o years, then graduated from U nion T h eo lo g ica l Sem inary in 1878. In 1881 he graduated from the U n iv ersity and B e llev u e H osp ita l M edical C ollege, of N ew York.

Obituary. 295

In N ew Y ork he becam e m uch in- i erected in the Student M ovem ent started by L. D . W ish ard of P rinceton . C om ing in touch w ith som e C hinese sa ilors from H ain an , h is in terest in C hinese w as begun. S ch ools w ere started for C hinese in w hich D r. T hom son took great interest. In th is w ork he m et M iss A gn es L ou ise D ornin , a m ember of the F ifth A venue P resbyterian Church. T h ey w ere m arried by Dr. F F. Ellinwood, Secretary o f the Board o f Foreign M issions, assisted by Dr. H . M. Scudder, in 1881.

Sent out by the B oard of F oreign M ission s o f the P resbyterian Church, they sa iled from San F ran cisco on the C ity of T okyo. A rr iv in g in Canton

they resided first with Dr. A. P. Happer, one of the pioneer m issionaries o f that B oard and later w ith Dr. J. G. Kerr. In 1882 w ith Rev. W . J. W h ite lie and

his fam ily went to Lin Chow. Later the two men went to w ork to establish a station, and w ere later jo ined by their w ives. T he com mon people wrere friend ly but officials posted threatening placards ordering the m ission aries to leave in one w eek’s tim e or to forfe it their lives.

D u rin g Dr. K err's furlough in 1884 and 1885. Dr. T hom son w as placed in charge o f the H osp ita l in Canton. It w as a tim e of great excitem en t because the F ran co-C h in ese W ar w as on. Prices were placed on foreigners’ heads and Chinese who were associated w ith them w ere in grave peril. M obs

gathered threateningly, but the cool courage of the doctor d ispersed them. T he attendance in the hosp ita l w as sm aller but it w'as carried on. Chang Chih Tung, the V iceroy, asked for m edical assistan ce . A foreign doctor and som e hosp ita l a ssista n ts w ere sent. It is a lso in terestin g that in this period D r. T hom son cam e in touch w ith Dr. Sun Y at Sen w ho w as for a tim e in the m edical c la ss carried on in connection u'ith the hosp ita l.

In 1886, M acao w as m ade the headquarters for D r. Thom son’s work. W ith Dr. C. R. H a g a r o f the A m erican B oard M ission , he m ade a survey of the coast to the w est as far as the K o Chow region. Y eu n g K on g seem ed to him a good c ity for work. T he people w ere friend ly , so places for a chapel and d isp en sary w ere rented. A place for residence w as a lso secured. O utside the c ity an attem pt w as m ade to erect a sm all hosp ital. T h is w as razed to the ground and the tim ber burned. A placard w as posted ca llin g

on the peopk- to drive out the intruders and k ill a ll who m ight have em braced C hristianity. T h is w as probably inspired by local Chinese doctors, because the dispensary was receiv in g tw o hundred patients a day.

In 1888 Dr. and Mrs. T hom son w ith their three children and M iss Baird w ent to Au T suen, eight m iles from Y eung K ong. It was a v illage of the Taam Clan. This village claimed the A m erican Taam s as members of their clan. It w as not long until students returning from their exam inations in Canton endeavored to drive out the m issionaries. T hese students actually forced their way into the house but an irate Chinese wom an turned them out. U ntil 1892 this field was worked as far w est as Mui Luk. M acao had again becom e headquarters ow ing to the opposition of the people to the residence o f foreigners in Yeung Kong. During these years the doctor w as a collabnrator oi the Journal o f the China M edical M issionary A ssocia tion . H e also wrote for the Recorder. “H istorical Landmarks o f M acao” ran through 1887-1889. P rior to 1886 he had prepared m edical vocabularies and h istorica l sketches of the China M edical A ssociation .

A fter a furlough, the fam ily m oved to Canada in 1894 to take up work am ong the Chinese resident in Canada. T hese numbered 25,000 at that time. O w ing to these efforts and due to D r. T hom son’s advice, the Canadian P res- bvterian Board began w ork in South China with headquarters in M acao. T his was in 1902. Later K ong M oon becam e the centre. Shek K i in the H eungshan D istrict becam e a second station. H eungshan as w ell as the section from which Chinese come to Canada had been surveyed and wrorked in part by Dr. Thom son w h ile still in China. It seemed fitting that there should be a conservation of the w ork done in Canada by a fo llow up workout in China from w hence the C hinese came.

O f this period in the work, a quotation from Rev. R. P. M acK ayr, D .D ., the Senior Secretary, for years in the Canadian Presbyterian Board, and w ho knew Dr. T hom son intim atelv is not amiss. “For unselfish devotion. D r. Thom son w as unique. H e alm ost seem ed to live the digem bodied life . R egard less of bod ily com fort he w*as found anywhere and everywhere that Chinese w ere to be found. H is own interests w ere identified w ith them. H e w as their friend, counsellor and


gu ide, and w henever a group, how ever sm all, w as d iscovered , he sought to ex c ite in terest and en list w orkers on their behalf.

In scores of con gregation s through out the D om in ion w here any definite in terest in the C hinese ex is ts , its orig in m ust be cred ited to D r. T h om son ’s persisten t devotion. T o this passion for souls all denom inational con sid eration s w ere subordinate. H e dreaded d iv ision in the ranks, and prom oted cooperation w herever possib le , and w ith a goodly measure o f success.” ("Nezv O u tlook” U nited Church w eek ly ).

From 1918 until h is death, N ovem ber 18th, 1926, Dr. Thom son served in South China, v is it in g prisoners and other unfortunates, a id in g in the ev a n g elistic w ork in the Canton H osp ita l, stay in g by it a ll a lone in the hot season of 192i>, w hen it had been closed by the labor unions, g o in g dow n to v is it in the hom es of the converts of h is, either resident in Canada or w ho had returned to their hom e land and so right up to the c l a y of his death he w as hard at w ork ; he passed away peacefully in the sleep that proved to be h is la st sleep on earth. H e rests from h is labors.

A t the m em orial serv ices held for him at different points in E astern Canada, Chinese and Canadian speakers spoke m ost lov in g ly of him , w ho had

brought many to righteousness, with the assurance that like the stars he shall forever and forever shine.

Rev. G. D. T hom son, D .D ., F .R .G .S., took up the w ork h is fa th er had begun and carried on until h is overtaxed body gave w ay to tub ercu losis. In a sanitorium in N ew M exico , 1924, shortly after his m other’s death he passed aw ay. Dr. J. O scar T hom son took up wfork in the Canton H o sp ita l w'here h is father had served. The youngest son, Mr. H erbert F. T hom son has been serving in the D epartm ent for boys and students in connection w ith the Y.M .C.A. in Canton. M iss A v is P. Thom son long associa ted w ith her parents in the w'ork in C anada is now in South China, teach in g and m aking evan g e listic trips in the K w an gtu n g Province. Can a higher tribute be paid to a man than to find a ll h is children seek ing w ith like devotion to carry on to final su ccess w hat the father has laid down ? A s w e pause to pay our respects to this man who pioneered for us, lay in g the foundation for our work, m-;y we not rededicate our lives, catching a bit o f the spirit o f the man and putting it into our work.

W . D . N o y e s .

Toronto, Ontario, Canada,January 26th, 1927.

NEW MEMBERS ELECTED.

D r. S. W . Brow n . . Shanghai Dr. P E. Louden-D r. C. M. Canwright M .E .F .B . Chengtu, slager . . . . L .U .M . Peking.

Sze. i

is clonorchis a health menace in china? -...

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