92

by the inoculation of a cell-free tumour extract. Thisseemed to establish a difference of aetiologicalimportance between the malignant growths whicharise in fowls and mammals including man in responseto chemical substances on the one hand, and on theother the group of filtrable tumours discovered byRous which can be propagated by an "extrinsic

agent " or " virus." Prof. E. Mellanby appears to

have had a similar experience but the experimentaldetails of his work have not yet been published.Prof. J. McIntosh now states that he has succeededin producing in fowls by tar a number of sar-

comata, three of which proved to be filtrable, anda similar result is reported by Dr. A. Haddowfrom Edinburgh. These results are a strong argumentin support of the view that the filtrable fowl tumoursrepresent true malignant neoplasms, and that theyshould not be set aside as an atypical form of

malignancy with an entirely different aetiology. Inthe introductory summary to the report the conclusionis drawn from these findings that the behaviour ofthe filtrable fowl tumours is due to some characteristicproperty peculiar to fowl cells ; that, however, isnot the only possible explanation.

In Leeds Prof. R. B. Passey has begun a reinvesti-gation of the classical experiments of Fibiger onspiroptera cancer, in which the experimental produc-tion of cancer was demonstrated for the first time.Prof. Passey’s work indicates that other subsidiaryfactors, not suspected at the time by Fibiger, playa part in the process. Dr. R. E. Havard and Dr.

Sylvia Dickenson have tested the truth of thestatement frequently made that the blood of patientssuffering from cancer is abnormally alkaline. Usingarterial blood and an exact physical method theyfailed to find any change. Dr. J. W. Orr has carriedout experiments showing that fibrosis of the dermisfacilitates carcinogenesis, presumably because itinterferes with the blood-supply. The action of radiumand X rays has been investigated in a number ofcentres, both from the experimental and from theclinical side, notably at St. Bartholomew’s Hospital,the Westminster Hospital, the Mount Vernon Hospital,the Strangeways Research Laboratory, and theChristie Hospital and Holt Radium Institute inManchester. It is noteworthy that the question ofchanges in the leucocyte count following irradiation,on which we commented last year, has been reinves-

tigated in the Manchester centre, and as a result twopoints are emphasised : (1) there is a lymphopeniain patients treated by radium which increases withthe dose ; (2) blood counts repeated at least once amonth have been found of definite value in keepinga check on the health of the staff engaged in

radiotherapeutic work.The eleventh report of the Campaign is commend-

ably free from exaggeration of the value of the resultsobtained, nor do these need exaggeration. Thereport represents a real advance both in our under-standing of the aetiology and in our efforts towardsthe treatment of the disease, and is the best possibleargument for the continued support of the work bythe general public for whose benefit it is done.

RADICAL SURGERY OF THE MAXILLARYANTRUM

IN the surgical treatment of suppuration of the

maxillary antrum rhinologists in this country ofrecent years have favoured the intranasal operation,by which an aperture is made in the antronasalwall large enough to remain open permanentlyand the drainage thus established is relied on to

effect a cure. The Caldwell-Luc operation, which

exposes the antral cavity through its anterior wallas a preliminary before making the opening into thenaris, is usually reserved for the more intractablecases and for those in which a portion of tooth orof dead bone is lying in the antrum, or in which thereis definite polyposis. Dr. Edward F. Ziegelman,lof San Francisco is now advocating the lattermethod, together with removal of the entire mucousmembrane lining the cavity and of the anteriorethmoidal cells, also in all those cases where there isdisease in the neighbourhood of the natural ostium.He strongly objects, however, to the usual trans-verse incision with elevation of the premaxillarysoft structures from the bone, and makes an invertedT-shaped incision of which the vertical branch runsobliquely upwards and outwards parallel to thefibres of the facial muscles. Since these musclesrun in the upper lip, and the incision is placed deeplyto this, it is difficult to see how it can be a matterof any great importance. The most noteworthypart of his communication is concerned with anaes-thesia for the operation. He prefers a local anaes-thetic and considers that nerve-blocking is theideal method. This he produces by injection throughthe external aspect of the face, passing a long needleinto the neighbourhood of Meckel’s ganglion in thespheno-maxillary fossa. The needle is inserted ata point on the inferior margin of the zygoma two-fingers’ breadth external to the outer bony angleof the orbit, and directed towards the external angleof the opposite orbit to a depth of approximately7 cm. ; 3 c.cm. of 1 per cent. novocain are

injected. As the injection does not always catchthe main trunk in its entirety, a second injectionof 2 c.cm. is made into the infra-orbital nerve at itsexit from the foramen. Since the anterior ethmoidalcells often have to be opened during the operation,these are anaesthetised by a pack of 5 per cent.cocaine beneath the middle and inferior turbinals,or by injection of 1 c.cm. of the novocain solutioninto the region of the anterior ethmoid foramen

through the skin at the inner angle of the orbit.Dr. Ziegelman mentions that the patient often objectsto the insertion of the needle into the spheno-maxillary fossa by way of the external surface;such objections, which are hardly surprising, maybe met by injection via the posterior palatine canalby means of a curved needle inserted through themouth. In addition to the novocain injections,the patient is given, two hours before operation,grs. 10 of one of the barbiturate salts by the mouth,and an hour later a hypodermic injection of morphinesulphate gr. 4 with scopolamine gr. 1/200. Probablysurgeons in this country will prefer a general anoes-thetic in cases where it is not definitely contra-in dicated.

PUBLIC HEALTH IN THE IRISH FREE STATE

AN extensive account of the activities of the

Departments of Local Government and Public Healthin the Irish Free State is given in the 1932-33 reportof the Minister.2 Sanitary surveys, it is reported,were carried out by the medical inspectors of the

department in 37 different areas (the majority urban),and where serious defects in the sanitary administra-tion were discovered they were brought to the noticeof the local authority, special attention being paid towater-supplies and sewerage systems. Despite theconstant intercourse with England and Wales the lastappearance of small-pox in the country was, it is

1 Western Journal of Surg., Obstet., and Gynæcol.,February, 1934.

2 P. No. 1154. 1934. 2s. 6d. net.

93

noted, as long ago as November, 1923, and no fatalcase of the disease has been registered since 1907. Onthe other hand, 30 cases of typhus, with 8 deaths,were recorded in 1932, whereas in England and Walesthere were only 9 deaths from this cause in the wholeof the ten years 1923-1932. Twenty-five of the 30cases occurred in Kerry County and 22 from threefamilies affected in an outbreak in November. A

general campaign of delousing and disinfection wasinstituted and no further extension took place.Notifications and mortality from diphtheria bothshowed in 1932 an appreciable rise over the figures ofthe previous year, and immunisation schemes havebeen organised in numerous areas. In Cork CountyBorough, where a prolonged epidemic has been

experienced, nearly 7000 children were immunisedbetween 1929 and 1932, and the high record of 626cases in 1930 fell to 282 cases in 1931, and to 90 casesin 1932. The case-mortality rate, however, has notkept pace with the reduction in notifications and wasas high as 19 per cent. in 1932, though, it is importantto note, no immunised child died. With the declinein the incidence of the disease in Cork there wasobserved a marked falling off in the number of childrenbrought to the immunisation clinic, so that the

consequent increase in the number of non-immunisedchildren may provide a new field for the extension ofthe disease.An unsatisfactory feature of the registration returns

for 1932 was a slight rise in the infant mortality-rateto 72 per 1000 births, chiefly attributable to an

increased mortality from diarrhoea and enteritis andpneumonia. Nursing associations to attend to thehealth of the infant and young children, as well as ofexpectant and nursing mothers, are being organised,and with the help of the sweepstake surplus a numberof such associations were launched during the year.Rapid development has also been made in the schoolmedical inspection arrangements which in 1929covered only 146,000 children and in 1932 extendedto 378,000, or 75 per cent. of the elementary schoolpopulation. Many of the medical officers commentupon the incidence of malnutrition, and in June, 1932,the Dail voted 100,000 to assist local authorities toprovide free milk and so ensure that during the periodof economic distress children in the poorest familiesshould not suffer from a lack of food essential totheir healthy growth and nourishment. In spite ofthe economic position a new low record was registeredfor tuberculosis mortality, though the crude death-rate of 1’24 per 1000 is considerably higher than thatin England and Wales. Other sections of the reportare devoted to local finance and administration, tohousing, public assistance, and to roads.

SILICOSIS IN THE SOUTH WALES MINER

FEw diseases require a more comprehensive surveybefore diagnosis than silicosis. In the June issue ofthe Practitioner Dr. A. J. Amor and Dr. R. G. ProsserEvans made a brief assessment of the various factorsof this disease as it affects the South Wales coal-miner. Although they admit that W. R. Jones’srecent suggestion of sericite as a causative factor needscareful consideration, they do not appear to regardthe evidence as it stands at present as convincing. In

dealing with the all-important matter of X rayexamination, the authors stress the necessity foraccurate standardisation of films, especially the exactcentring of the patient, a speed of exposure whichwill avoid blurring, and standard developing. Apre-X ray stage of the disease is recognised in additionto the first, second, and third stages of the shadowingon the film. Details are also given of a method of

chemical examination which they adopt in investi-gating the silicotic lung after removal from thecadaver. The lung is first X rayed with a soft tubeand areas which appear to be suspicious in the filmare selected for pathological examination, togetherwith immediately adjacent areas. The portions thusremoved are divided into two so that as far as possiblemacroscopically identical portions can be used bothfor section work and for estimation of silica content.Whilst recognising that this method is open to somecriticism, the authors believe that it enables a fairlyfull and accurate description of the pathologicalcondition to be made. Chemical determinations ofsilica content are considered to be of value and

importance when assessed together with the otherdiagnostic factors ; but taken alone they are, in theopinion of the authors, of little use because a highsilica content may be found in lung tissue in which nogross lesion is present. Two methods of silica deter-mination are used : (1) the modification of thecolorimetric method of Isaac; and (2) the gravimetricmethod of Treadwell and Hall. A representativeseries of determinations of silica content from sixareas of a lung are given in a table, showing a rangefrom 16-32 to 28-15 per cent. in two upper lobe

portions.

ORGANISATION IN THE OPERATING THEATRE

Dr. Eugene H. Pool, of New York, a surgicalteacher of great experience, writing of the part playedby the nurse in the organisation of the operatingtheatre, says "her cooperation, skill and goodwill areusually taken for granted." It is substantially truethat where the work of the nursing staff is efficientits importance to the success of the operation isunrealised, or at least forgotten, by the surgeon-until her cooperation breaks down in some detail.If this detail is of sufficient importance-as, forinstance, a miscount of the swabs in an abdominaloperation, or a muddle over the contents of the bottleson the anaesthetic table-the surgeon is made sharplyaware of the degree of responsibility he is delegatingto the nursing staff. Such an incident may stimulatehis interest in the manner and material of the instruc-tion given to the theatre nurse ; but, for the mostpart, the responsibility for such instruction is left

entirely in the hands of the theatre sister, who isnot necessarily appointed to her post on a definiteknowledge of her powers of training those workingunder her. Dr. Pool’s remark, which we have quotedabove, occurs in a foreword to the revised edition ofa book by Prof. Henry C. Falk, F.A.C.S. Thebasis of the book is a course of lectures given to thetheatre nurses of the French Hospital of New YorkCity. The book has been brought up to date andmade as comprehensive as possible. Any doctorunfamilar with the amount of detail and specialisedknowledge involved in the efficient conduct of a

theatre behind the scenes would do well to look

through this book, which contains many suggestionsfor increased efficiency.

In organising the work of an operating theatre, thefirst essential is a clear understanding about thedelegation of responsibility. On the surgeon rests the

responsibility for the patient’s life. It is for thisreason that, during the conduct of the operation, hemust receive active and willing cooperation fromeveryone assisting him. All his orders and requests-reasonable or unreasonable as they may appear toothers-must be obeyed at once. This is a point ofview which is obvious when stated, but is not always

1 Operating Room Proeedure for Nurses and Internes.London : G. P. Putnam’s Sons. 1934. Pp. 413. 12s. 6d.