952

child welfare clinics, tuberculosis, and simp]health exhibitions. In Hungary, the fine StatInstitute of Hygiene at Budapest, founded i:1927, gives a nine months’ course to 24 studentand includes a nurses’ school: nurses and healt]visitors undergo the same training in its earl;stages. Conditions are similar in Czechoslovakiabut in the districts of Bohemia there are fa:too many small hospitals and specialised clinic;of various sorts-one district of 50,000 inhabitant;in Prague having 11 different health organisation!in charge of it. Thus concentration is necessar3and it is perhaps unfortunate that hospitals ancpharmacies are under the control of a legal department and not under the Ministry of Health.

Of all the Eastern European countries Yugo-slavia, in the opinion of Prof. Prausnitz, is pro-ceeding on the best plan and the most suitableand energetic lines, although of course poverty,racial and religious differences, and a low level ofeducation mean that some time must elapse beforethe effects will have been felt all over the country.The mainspring of this work is Dr. Stampar, thedirector of the School of Hygiene at Zagreb, andso impressed were the League of Nations’authoritieswith the work done there that they asked Dr.Stampar and his assistant to be at the disposal ofthe Nanking government when they recentlyappealed to the League for help in reorganising thehealth services of China. The points which

particularly excited Prof. Prausnitz’s admirationwere first, that the whole of the health servicesare unified under the Ministry of Health and SocialWelfare ; secondly, that each commune with a

population of over 6000 has or will have a properlyqualified M.O.H. and a " tertiary health centre " ;thirdly, that the training in hygiene of the ordinarymedical student is the finest in Europe, includingas it does six months’hygiene, of which two monthsare spent in field work ; fourthly, that architectsand engineers taking the sanitary engineer’s coursestudy alongside the physicians taking the course forM.O.H. ; and lastly, the splendid work done by thePeasants’ University by which peasants come upfor courses to Zagreb and return to their villagesto become leaders of health education.

It is in Russia, as might be expected, thatthe most striking and original departures havebeen made from the generally accepted schemesof medical education. The problem before theauthorities is how to produce a large numberof adequately trained doctors as quickly as possibleand an attempt is being made to shorten the t

curriculum by specialisation from the very beginning 1of the course. The scheme is as follows :— :

1. Medical prophylactic faculty : physicians, sur- ]igeons, and dentists.

2. Sanitary prophylactic faculty : M.O.H., com- I

munal M.O.H., epidemiologists, nutritional medical 2officers, and factory medical officers.

3. Maternity and child welfare : women, infants,and children.

4. Physical culture. v

Before beginning his studies the student has to achoose or has chosen for him the faculty which hewill enter, the proportionate numbers allotted

to each faculty being 24, 13, 15, and 2. A choicewhich turns out to be unsuitable can be remedied

bya course at an institute forpost-graduate training.Students are of two different classes; one class enterafter they have completed their ten years’ educationin the ordinary way, the others, in approximatelyequal numbers, are drawn direct from the ranksof the working-classes and are often, of course,somewhat older. Instruction is far more practicalthan with Western European nations and thesecond class of student do not appear to be inferiorto the others. Students are housed, fed, and paidby the State and live in

" messes

" of half a dozenor so, great use being made of the spirit of com-petition between different groups. It should benoted that some 60-70 per cent. of the students arewomen. The original plan of 1930 was supersededlast year by the plan outlined above, so that it isfar too early to criticise any results, but it is certainthat all who are interested in the teaching of

preventive medicine will watch the developments.in the U.S.S.R. with the greatest attention.

THE DRINKER RESPIRATOR IN ASPHYXIANEONATORUM

THE construction of the Drinker respirator hasalready been described in our columns,’ and itsvalue in the treatment of respiratory failure inanterior poliomyelitis has been emphasised.2 Itwill be recalled that the apparatus is designed toprovide artificial respiration over a long periodwith a minimum of trauma to the respiratorysystem ; the patient’s body is placed within aclosed tank, his head passing to the exterior

through a closely fitting rubber collar, and bymeans of electrically driven blowers a negativepressure is produced within the tank, alternatingwith a return to atmospheric pressure. The

negative pressure causes the patient’s chest to

expand and air to be inhaled, whilst on return toatmospheric pressure the recoil of the thorax andelasticity of the lungs result in expiration. Therate and depth of respiration can be varied at will.The method is of proved value in the treatment ofcarbon monoxide poisoning and in the respiratoryfailure in anterior poliomyelitis, and is extensivelyused in America ; in this country an apparatusis available on application to Sir Robert Davis(187, Westminster Bridge-road, London, S.E.1).Besides the full-size model, a much smaller

apparatus of similar design has been constructed-or infants. As indicated in the illustrationsalready published,1 this can be heated if necessaryand the child can be closely observed in it. Dr.D. P. MURPHY and Dr. J. V. SESSUMS 3 have now’eported the results of treatment of 66 cases ofsphyxia neonatorum with the Drinker respiratorn the University of Pennsylvania and Phil-,delphia Lying-in Hospitals. The cases selectedvere those showing entire absence of respiratory,ctivity (owing to which a number of stillborn

1 THE LANCET, 1931, i., 1187 ; also 1150.2 Ibid., 1932, i., 1211.

3 Surg., Gyn., and Obst., October, 1932, p. 432.

953

infants were unintentionally treated) or very feebleand infrequent respirations ; all treatments werestarted within ten minutes of birth. From ear’ierobservations MURPHY and SESSUMS had foundthat in moderate degrees of asphyxia neonatorumalternation of negative and atmospheric pressureswas sufficient to bring about adequate ventilat:onof the lungs; but in cases of severe asphyxia theyconclude from measurement of the air moving toand from the lungs that alternation of negativeand positive pressure is an advantage. Theytherefore recommend the use of both positive andnegative pressures (preferably equal) in all suchcases, whether the asphyxia is severe or not. Ofthe 66 infants treated, 15 failed to breathe at anytime, 5 breathed before but not after treatment,and of the 46 that breathed at least once duringtreatment, 39 developed finally an adequate degreeof respiratory activity. Thirty of these lastsurvived and nine died in hospital. A detailed

analysis is given of the causes of the asphyxiaas far as they could be determined on clinicaland pathological grounds, and it is found thatnarcosis or injury (either due to breech or forcepsdelivery) accounted for the condition in nearly64 per cent. of the series. Of the 36 infantswhich died, 19 (14 autopsies) suffered from cerebralinjury ; 15 were stillborn.

It is concluded from the obse-vations madethat narcosis is the most common single cause ofasphyxia neonatorum, and that if possible maternalnarcotics should be given not later than four tofive hours before the expected time of delivery.Breech deliveries, on the other hand, were followedby the greatest number of deaths. It was foundin general that treatment with the respirator wasof greatest value in infants suffering from excessivenarcosis (since these showed the lowest mortality),and in premature infants which seemed to survivetheir initial asphyxia although they did not alwayslive long after birth. As far as the effect ofartificial respiration on cardiac action could bedetermined, it appeared to be decidedly beneficial.In no case was there any evidence of injury havingbeen caused by use of the respirator.

THE ÆTIOLOGY OF TRACHOMATHE letter from our Budapest correspondent in our

issue of Oct. 15th reminds us that the long drawnout campaign against trachoma in Eastern Europeshows few signs of drawing to a close. In some

parts of Hungary the disease has long been endemic,but largely owing to the efforts of Prof. E. DEGROSZ the proportion of trachoma among eyecase, presenting themselves at the universityclinic in Budapest fell from 7-2 per cent. in 1891to 2 per cent. in 1910. During the years 1914-1918the segregation of trachoma in special regimentswas successful in limiting infection, but whenpeace was restored the disbanded men carried thedisease to areas hitherto immune, and in 1926among the 8 z million inhabitants of Hungary 10,000cases of trachoma were brought to light. Inwestern Canada the position is equally unsatis-

factory. Prof. G. M. BYERS, of McGill, warned 1the last meeting of the Canadian Medical Associa-tion of the gravity of the situation in Saskatchewanand especially Manitoba where trachoma was

introduced by the Mennonites who came fromRussia to settle in the Red River Valley in theearly seventies. The eastern provinces into whichtrachoma was introduced by settlers returningfrom Napoleon’s Egyptian campaign are now

practically free of the disease as the result offavourable climate, better social conditions, andthe work of oculists such as BULLER andDESJARDINS, assisted by the absolute exclusionsince 1927 of trachomatous immigrants. Thedisease does not now exist in Quebec city and forfive years it has been found impossible todemonstrate a case of acute trachoma at McGill

University. In the western provinces cases are

now being rounded up and brought to the clinicsby public health nurses. The disease howeverremains prevalent among the Indians of BritishColumbia and the prairie provinces ; it is believedthat 10,000 or more of the estimated Indian

population of 110,000 have suffered from thedisease.

Progress still awaits exact knowledge of ætiology.One of the last communications of the Japanesepathologist NOGUCHI, from the Rockefeller Institutewhere he spent the closing years of his life, was theannouncement of the discovery of a bacillus whichhe believed to be the causative agent of the disease.Five years have passed and of the many patho-logists who have repeated NOGUCHI’s experimentsin many countries only a very few have been ableto produce evidence purporting to confirm hisresults. Among these few, however, were someof the Rockefeller workers, and it is worth remem-bering that the late ERNST FucAS, visiting Americain 1930 after examining some of the monkeyswhich had been inoculated with the Bacteriumgranulosis, gave it as his opinion that they weresuffering from undoubted trachoma. On the otherhand, Dr. ROWLAND P. WILSON, director of theGiza laboratories, has pointed out 2 that the form ofgranular folliculitis produced in monkeys by variousexperimenters with B. granulosis is indistinguish-able from that which can be induced by simplemeasures or the form which occurs spontaneously.Most decisive is his observation that pannus hasnever been observed. An extended investigationof the bacteriological aspects of trachoma has beencarried on for some years by Dr. IDA A. BENGTSONfor the U.S. public health service.3 Attempts toisolate B. granulosis were made in 73 cases ofhuman trachoma, principally from the State of

Missouri, between the time when cultures of theorganism were made available by the RockefellerInstitute in 1929 and July, 1931, but the resultswere negative in all cases. With regard to the

experimental production of granular lesions in

monkeys and apes by means of inoculation withcultures of the organism, the results of variousworkers (there are records of some 300 of such

1 Canad. Med. Assoc. Jour., October, 1932, p. 372.2 Brit. Jour. Ophth., 1931, xv., 433.

3 Public Health Reports, Washington, Sept. 16th.