1561

of recruiting, for example, is not systematically taught 4

at Haslar. In two recent articles we have called i

attention to the importance of a thorough knowledge of I

this important duty and it would save much money I

and would largely promote efficiency if the navy followed i

-the commonsense practice of the army and placed this i

branch of the service entirely in the hands of the

medical department, under the supervision of a competentsenior medical officer responsible to the Admiralty alone.

The curriculum at Haslar is not the only thing on theeducational side of their calling of which the young navalmedical officers complain; the absence of adequate clinical

teaching in the three large naval hospitals is also alleged.While it must be emphasised that these institutions existprimarily for the cure and comfort of patients and not forthe instruction of naval medical officers who are supposedalready to have received their professional education, wehave often thought that a skilled pathologist might be

appointed to each institution whose duty it would be to

give demonstrations on selected cases to’ those surgeonswho could be spared from the duties of the service afloat.Bat in harbour ships, in gunnery and torpedo schools, and indockyards large bodies of men are constantly employed indangerous work, and professional assistance must ever be athand in case of emergency. Uninteresting and often

irksome as being confined to ship or barracks must often

be, it cannot be avoided. To do nothing in constantexpectation of having to do much must ever remain the

attitude of many a naval officer, medical or other, andclasses of advanced pathology can never be instituted atthe hospitals upon any scheme which would detach navalmedical officers from their actual routine.

The question of foreign service was referred to in one com-munication which we have received from a naval medical

officer who was aggrieved at not going abroad in what heconsidered his due turn. The recent redistribution of the

different fleets has, no doubt, altered the conditions of

service for all officers. We well remember the time when

the chief complaint among naval medical officers was

founded upon their excessive service abroad. The reverse

seems now to be the case and at present there is difficulty in

getting service abroad when it is desired. These matters

are determined by other than purely medical considerationsand we have no suggestion to offer as to their alteration.

la every profession, in every part of the world, in every age’interest, favour, and influence have affected, and ever will

affect, to a greater or less degree the career of individuals.What is equally certain is that a really good man usuallysucceeds in the end in securing the recognition of his meritsand never sinks to the level of the idle or the unintelligent.It would seem unfortunately that complete impartiality inthe matter of appointments can never be secured in anyservice while man is man, but with regard to the othergrievances in the Royal Navy Medical Service we are of

opinion that for the most part they are capable of

easy reform and inexpensive removal if the authoritiescan be persuaded to set earnestly about the task. We

greatly desire to see the highest class of young medical

men attracted to the navy as a career. The life certainlypossesses many advantages-e.g., a secure income, a liberal,pension, and small expenses ; genial comrades and prospect

of travel in many lands amongst many peoples. Especiallysuch a life should attract those who have had the advantageof a public school and University education and who feeldrawn to a career which offers chances of sport andadventure. Not that the Royal Navy Medical Service

should be entered merely from this point of view. It

is a scientific service and there is no reason why its

position as such should not vastly improve. The scientific

physician will find now, as HUXLEY did in earlyVictorian days, that there is in the service abundant

work for his energies. The distribution of disease through-out the world, its effects on the different races of mankind,the vicissitudes of climate, and the growth and health ofthose under his immediate charge will afford him ampleopportunity for the exercise and development of his

faculties of observation. If his professional work in hisnew sphere of duty differs much from that to which he hasbeen accustomed in his hospital pupilage, the naval

medical officer will find the application of his know-

ledge neither less important nor less interesting. One of

the most philosophical and best educated members of

our profession, the late Dr. P. M. LATHAM, remarked,"that the practice of medicine is, upon the whole, largelyindebted to service physicians, because, from the nature ofthe surroundings under which they are often obliged to dotheir work, they must skilfully adapt their practice to

circumstances, and gather how much successful treatmentis concentrated in one chief indication and one chief

remedy."

The Influence of Pregnancy uponCertain Medical Diseases.

THE enect proaucea by tne occurrence ot pregnancy uponthe course of any one of the acute diseases i a matter of

great importance not only to the obstetric physician butalso to the general physician. A large amount of literaturehas been published dealing with the subject but it is

contained mainly in papers scattered through the medical

journals and the transactions of various medical societies,and Dr. HERBERT FRENCH has conferred a considerable

benefit upon those interested in this matter by devotinghis Goulstonian Lectures to considering the Influence of

Pregnancy upon Certain Medical Diseases, and of CertainMedical Diseases upon Pregnancy. 1 As he points out,in those cases in which the pregnancy is allowed to run its

natural course the responsibility for the patient’s healthmust rest with the physician, and it is important, therefore,that he should be acquainted with the possible influence ofthe disease on the pregnancy and of the pregnancy on the

disease. As there are but few medical diseases met with in

women in which the occurrence of pregnancy is impossibleit is evident that the subject is a very wide one and the

lecturer has therefore been compelled to consider only someof the more important affections which may complicate thiscondition.

As an interesting example of a disease for which

pregnancy appears to be directly responsible Dr. FRENCHdescribes herpes gestationis. The curious manner in which

this disease returns in successive pregnancies and at other

1 THE LANCET, May 2nd (p. 1257). 9th (p. 1321), and 16th (p. 1393), 1908.

1562

times only during the puerperinm is pointed out, and themarked relationship which seems to exist between the

bullous dermatoses, including herpes gestationis, and

eosinophilia, first called attention to by BETTMANN and

others, has been confirmed by Dr. FRENCH himself. The

etiology of this disease is very obscure but it seems certain

that its cause is to be sought within the body and that it isnot due to any irritant acting directly on the skin. It

seems likely, indeed, that it is one of the manifestations of

the so-called tozaemia of pregnancy. The many interestingproblems connected with this and similar conditions, suchas the likelihood of its transmission to descendants, are

questions which, in Dr. FRENCH’S opinion, could be settledbest by the method of collective investigation. Without

doubt there are many problems in medicine which

can only be solved in some such way, and nothing is

more disheartening to the investigator of some particularcondition than the frequency with which in the histories andclinical reports of cases compiled by others the specialpoint on which information is desired is found to have been

overlooked entirely. After a short account of that grave and

fatal disease impetigo herpetiformis which is almost limitedin its incidence to pregnant women and which, like herpes,appears to be a manifestation of a toxic condition, Dr.

FRENCH passes on to a consideration of the pyelonephritisof pregnancy, in connexion with which a large amount ofwork has been done in recent years. The most importantfactor in its causation is held to be the dilatation of the

ureters which is so constantly found and which is considered

usually to be due to the pressure of the pregnant uterus onthese structures at the brim of the pelvis; and the

subsequent infection by the bacillus coli, the organismmost usually present, of the urine through the blood

stream. The dilatation of the ureters which has been

demonstrated in most of these cases raises an importantanatomical point. The researches of BARBOUR and others

by the study of frozen sections of the anatomy of the

pregnant uterus have shown that it is impossible for it

to press on the ureters at the pelvic brim, but it is

possible for such pressure to be exerted at a spoton the ischium in the true pelvis. This fact, no

doubt, is an explanation of the discrepancy between

the statements that the ureter in such cases is usuallydilated about one inch from the bladder and that such

dilatation is produced by the pressure of the uterus at thebrim of the pelvis. Whether the entrance of the colon

bacillus into the general circulation is favoured by some

accompanying condition such as chronic constipationremains for future investigators to decide.One of the most difficult problems in medicine is un-

doubtedly the relation of non-suppurative renal affections topregnancy. A good deal of the confusion which has arisenis, we think, due to a loose use of terms and the failure to

distinguish between cases of kidney disease directly due topregnancy and cases of the same kind merely coincidingwith that condition. When we consider how difficult it

often is to determine whether or no the pregnancy is the

real and only cause of the renal affection this is not

to be wondered at. Almost every variety of pathologicalchange in the kidney has been described, for example, as

occurring in cases of eclampsia and a source of error to

3 which too little attention is often paid is the possibility of3 many of the degenerative changes found in the kidneysI and attributed to various toxic bodies being in realityI the results of post-mortem autolysis. Dr. FRENCH allies

himself to those observers who regard the kidney changes inpregnancy as essentially similar to those which may occur inscarlet fever, and believes that there is a difference only in

degree and acuteness between the renal changes in eclampticcases and these in cases where renal oedema is a prominent.symptom early in the pregnancy and in which no eclampticconvulsions occur. He brings forward a strong argument infavour of this view in the fact that out of 71 cases.

admitted into hospital for the cedema type of nephritis noless than four had had a typical acute attack of eclampsia in.a previous pregnancy. To the very important question as towhether if a pregnant woman develops evident cedema ofrenal type with albumin and tube casts in the urine during:the eighth month of pregnancy is she likely to develop.eclampsia no certain answer can be given. It is clear,however, that if the cedema develops early in the pregnancy-it is unlikely that eclampsia will occur and that the

majority of cases of eclampsia do not have any oedema ; thusin 49 per cent. of the cases of eclampsia collected by Dr.FRENCH there was no cedema at all and in 35 per cent. it was

but slight. There are many other interesting questions in,connexion with this subject, such as the effect of multiparity,the influence of twins, and the occurrence of albuminuricretinitis and its significance, all of which Dr. FRENCH,

considers. The association of tetany with pregnancy

presents many curious features, not the least of which is thefact that the disease is one of extremely local occurrence ;.

for example, it is not uncommon in Heidelberg and Vienna,was formerly common in Paris and is now rare there, and is

very rare in Great Britain and America. Not only does thisdisease seem to be almost endemic in some places but it,

appears to be markedly more common in the late winter and

early spring than at other times of the year.There are perhaps no cases which are a source of such

great anxiety to the general physician and to the obstetrician,as those in which an attack of appendicitis complicatespregnancy. The difficulties in deciding whether an

operation should be undertaken or not may be, verygreat, and the operation itself may present exceptionallygrave dangers to the patient. Here, again, there are

many questions concerned with the treatment of such

cases to which it is extremely difficult to give a correct

answer and upon which a collective investigation mightthrow much light. The influence of the attack upon the

pregnancy and vice versd, the likelihood of suppurationoccurring, the danger to the foetus, and the question as towhether a recent attack of appendicitis should be any bar tomarriage are only some of the questions to which a certainanswer may be very difficult to give. The balance of evidenceseems to show that an attack of appendicitis during preg.nancy is likely to be severe and that an early operation isusually indicated. In connexion with the relation of certain

of the acute fevers to pregnancy a large number of mostinteresting problems present themselves for solution, moreespecially with regard to the transmission of such conditionsto the foetus. A large number of observations have been

carried out in relation to enteric fever, notably by Dr.

1563

FRENCH himself working in conjunction with Mr. H. T.

HICKS. This variety of an acute specific fever is of specialimportance because it furnishes an example of a natural

experiment in human beings upon the simultaneous

placental transmission both of chemical substances, such

as agglutinins, and of bacteria-viz., the typhoid bacilli.

’These organisms have been demonstrated in the foetal

tissues and Widal’s reaction has been obtained with the

fcetal blood. Whether the foetus manufactures its own

.agglutinins or not is a problem awaiting solution, as are alsothe many questions concerned with the immunity of thefoetus to the disease from which the mother is suffering. It

.seems that the so-called barrier action of the placenta, by- which it exercises a selective power on the substances which-"t ,2 allows to pass into the foetal circulation, can become

impaired when the mother is in poor health, and in thesecircumstances not only chemical substances in solution butalso concrete bodies such as bacteria may gain access to thechild. There are other possibilities of injury being causedto the child who, even if escaping enteric fever when

the mother has acquired the disease during her preg-

nancy, may suffer in other ways after birth as he or she

grows up. Such a possibility is of necessity exceedinglydifficult to prove, though it has been said, we know not withwhat truth, that enteric fever in the mother may be the

oause of intellectual peculiarities in the offspring years later.A perusal of these lectures only demonstrates very clearlyhow great is our ignorance of many of these matters andwhat a large amount of work is necessary in this branch of

Imedicine before we can hope to be in a position to answer

I

all the questions which arise. It is especially men in generalpractice, who are able to follow family histories over many.years, who are in a position to assist in the acquisition ofsuch knowledge and we should welcome gladly any attempt*to carry out such a collective investigation as is suggestedby Dr. FRENCH. The very excellent summary of our know-

ledge contained in these valuable lectures will serve to showthe lacunas in that knowledge which exist and the direc-

tions in which further investigation is required. Theycannot fail in the meantime to be of very great help to allthose who are constantly meeting with cases of generaldiseases occurring in pregnant women, and it was a happythought of Dr. FRENCH to devote his lectures to this com-

paratively neglected branch of medicine.

Compulsory Instruction in the Useof Anæsthetics.

FEW discoveries, if any, have changed the aspects of

medicine and surgery as much as that of anaesthesia. The

widening of the range of practicable surgery and the

possibility of rendering patients insensible not only to the’knife but to careful examination as an aid to diagnosis havemade the administration of anaesthetics an everyday occur-rence in the life of most medical men. Nearly all dis-

coveries in medicine have been the gradual outcome of yearsof thought and so have taken their place naturally in thecurriculum of the medical schools, but in the case ofanaesthesia this has not been so. Those who introducedit were perhaps unaware of its wide-reaching possibilities

and hardly recognised that while its uses were benignits employment involved the greatest care, needed no smallamount of physiological knowledge, and required expertnessin manipulation. Although such men as SNOW, CLAUDE

BERNARD, and PAUL BERT appreciated these things themedical profession and the public made no special pro-vision either for the education of students in the use of, orthe safeguarding of the employment of, drugs which in-volved the issues of life and death. Instruction in the

administration of anaesthetics up to a few years ago can be

characterised only as haphazard; many medical men com-menced practice without any practical knowledge and experi-ence of anaesthetics. From time to time efforts have been

made to remedy this. Some teachers attached to generalhospitals in London urged the necessity of including definiteinstruction in anaesthetics as a concomitant part of the curri-culum and petitioned the Royal Colleges of Physicians ofLondon and of Surgeons of England to insist upon evidenceof the definite instruction of candidates before their admis-

sion to the final examination. The Society of Anaesthetistsmoved in a similar manner and the London Colleges at oncerecognised the importance of the matter and required the

production from their examinees of a proof of instruction inthe processes of anaesthesia. The evils of inefficient teachingand the absence of any penal enactment protecting the publicfrom incompetent persons employing lethal drugs to produceanaesthesia were not wholly removed by these steps even if

they were remedied in part, for the Conjoint Board of the

Royal Colleges does not control all students. In our columns

and elsewhere have appeared strongly worded protests againstthe unsatisfactory state of the law as regards the employ-ment of anaesthetics, and at a recent meeting of the Medico-

Legal Society the question has been considered in many ofits bearings upon the initiative of Dr. F. W. HEWITT.1We understand that the following resolution has been

sent to the General Medical Council from the Medico-LegalSociety, having been proposed by Dr. HEWITT, seconded byMr. R. HENSLOWE WELLINGTON, and passed by the membersunanimously :-That in view of the importance of the administration of

anaesthetics this society is of opinion that it is highlydesirable in the public interest that every member of themedical profession before he is registered shall have re-

ceived instruction in the administration of anaesthetics. It

therefore earnestly begs the General Medical Council to

consider whether they can see their way to include a courseof instruction in anaesthetics amongst their "requirements inregard to professional education."

The General Medical Council, of course, has no control

over the licensing bodies so far as regulation of the curriculais concerned unless it invokes the aid of the Privy Counciland is able to demonstrate that the course of instruction or

system of examination is inadequate. Some two years agothe General Medical Council issued a recommendation to the

licensing corporations that the subject of anaesthesia shouldbe included in the curriculum but the result has been

disappointing. The Conjoint Board of Examination of

the Royal College of Physicians of London and the

Royal College of Surgeons of England and the Societyof Apothecaries of London require candidates to produce

1 THE LANCET, April 4th, 1908, p. 1008.