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652 engaged in the work of national health. We do not feel certain that those steps will have that result; the whole medical profession is included" among those who are actively engaged in the work of national health," and considerable divergence of opinion seems to mark their views as yet. For example, a large number of those most critical in days gone by of the working of the National Insurance Act are now prepared to regard that Act more favourably; they would give to the National Insurance Commission a predominant part in the future Ministry of Health. Dr. W. A. Brend, on the other hand, will have much support for the views which he puts forward in the current number of the Edinburgh Review. He premises in a short essay on the future of the Public Health Services that experience of the working of the Insurance Act has shown that measure to be seriously defective, and considers that it is an open secret that the National Insurance Act has not fulfilled in many directions what was hoped of it. The creation of a Ministry of Public Health is certain to take place, though the difficulties in the way of so important a piece of Parliamentary work are immense at the present moment. We trust that there will be no long delay, but we realise that to undertake so critical a piece of work, when due opportunity is wanting for full consideration of the accompanying difficulties, would not be promptitude on the part of any Government, but only mischievous yielding to the view of the muddler that something had better be done, whether for good or for evil. As we have pointed out several times in these columns, the position of National Insurance presents consider- able difficulties to the designers of a Ministry of Public Health., The general view, and one which we have endorsed, is that the Local Government Board should become the over-authority for National Insurance, but Dr. Brend believes that the office of the Registrar-General should be enlarged and should take over the work of the Insurance Commissioners as well as the whole scien- tific and statistical work in public health at present performed not only by the Local Government Board but by the Home Office and the Board of Education. We admit that the Depart- ment of the Registrar-General could make a good claim if its scope were widened and its staff re- inforced by experts, but we remain of opinion that if the National Insurance Commission does not remain a separate bureau, its right place is in a Ministry of Public Health, forming a department of the Local Government Board, and working in that department alongside of the machinery now employed to discharge the medical work of the Home Office and the Board of Education. There seems no doubt that we must not expect any con- crete proposals from the Government for the creation of a Ministry of Public Health just yet, but this appears to us to be no reason why matters that require immediate reform should remain unattended to until a vague and future date. We are glad to learn that it is the intention of the President of the Local Government Board to ask the War Cabinet to allow him to introduce a Bill into the House of Commons immediately, so that it should be passed before Christmas, to deal with the many questions concerned with infant welfare. It is evident from his replyto recent deputations that he sees no need whatever to wait for the introduc- tion of a measure to deal with certain existing evils until the Ministry of Health Bill, and he incidentally corrected a mistake made by Mr. Kingsley Wood in a letter recently published in the Times, who had used the argument for the establishment of a Ministry of Health that it would " save a thousand lives a week." Mr. Wood put that prediction into the mouth of Lord Rhondda. Lord Rhondda. really said that he hoped that a Maternity and Infant Welfare Bill would save a thousand lives a week. Dr. Brend, in the Edinburgh Review, misrepresents Lord Rhondda in exactly the same way. THE HARVEIAN ORATION. Professor R. Saundby, in the Harveian Oration which we print in another column, considers Harvey’s work in relation to the scientific knowledge and the university education of his time, especially university education in medicine. Harvey himselt was a pensioner of Gonville and Caius College, Cambridge, where he entered in May, 1593, being then 16 years of age, and where he took his baccalaureate three years later. He then left Cam. bridge to study medicine at the University of Padua, where there was at the time a famous medical school; and while it is admitted that Harvey was the true discoverer of the circulation of the blood, it is fairly clear that our famous British philosopher did not owe so much to his English as to his Italian university, where many eminent philosophers were congregated at the beginning of the seventeenth century, and where he probably acquired the methods of research which led him to his great discovery. Professor Saundby’s disserta- tion is largely about other people than Harvey, and forms an interesting chapter of medical history. ACUTE NEPHRITIS WITHOUT ALBUMINURIA. I Dr. Carl Muller, of Christiania, has recently ! recorded an interesting case of acute nephritis in which albuminuria was absent during the greater part of the attack. The patient, a factory girl aged 26, was ill with kidney disease" for two months in 1914. In 1916 she had a sore- throat and kept to her bed for a fortnight; the urine was free from albumin and no diphtheria bacilli were found on examination of a swab from the throat. After this she had headache and shortness of breath, with palpitations and a troublesome dry cough; a week later her face and hands swelled and she had pains in the back. Dr. Muller examined the urine and found no trace of albumin in it. The girl was living in miserable surroundings and was taken into hospital. Here she was found to have slight cedema of the legs, with a high blood pressure (185 mm. ]Fig), an irregular pulse of 60, slight hydrothorax and ascites, and a small trace of albumin in the urine when Heller’s test was applied. No formed elements could be found in the centrifugalised urinary deposit. A few days later the per. centage of urea in the blood was observed to be raised, standing at 0’025 per cent. The patient had severe headache, dyspnoea, and vomiting for the first 24 hours, with anorexia. On the fourth day she was put on to a salt-free diet of vegetables, bread, milk, tea, and water, and improved con- siderably. The cedema and fluid exudations were absorbed, the urine increased from nearly two to over four pints a day, and the blood pressure fell to the normal. The trace of albuminuria vanished after a week; at no time could cells or casts be discovered in its centrifugalised sediment. A Strauss test applied to the kidneys later showed that the renal excretion of both salt and water was normal. Discussing this case, Dr. Muller comments on the extreme rarity of the instances of acute nephritis without albuminuria recorded in thepre-war medical literature. In trench nephritis, on the other hand, or in war nephritis as he prefers to call it, absence of albuminuria has often been recorded even in instances in which uraamic convulsions have occurred, and he points out that his recorded case in many ways resembles one of war nephritis. The 1 Tidsskrift f. d. Norske Laegeforening, Christiania, 1917, xxxvii., 481

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Page 1: ACUTE NEPHRITIS WITHOUT ALBUMINURIA

652

engaged in the work of national health. We do notfeel certain that those steps will have that result;the whole medical profession is included" amongthose who are actively engaged in the work ofnational health," and considerable divergenceof opinion seems to mark their views as yet.For example, a large number of those most criticalin days gone by of the working of the NationalInsurance Act are now prepared to regard that Actmore favourably; they would give to the NationalInsurance Commission a predominant part in thefuture Ministry of Health. Dr. W. A. Brend, on theother hand, will have much support for the viewswhich he puts forward in the current number ofthe Edinburgh Review. He premises in a short

essay on the future of the Public Health Servicesthat experience of the working of the InsuranceAct has shown that measure to be seriouslydefective, and considers that it is an open secretthat the National Insurance Act has not fulfilledin many directions what was hoped of it. Thecreation of a Ministry of Public Health is certainto take place, though the difficulties in the wayof so important a piece of Parliamentary workare immense at the present moment. We trustthat there will be no long delay, but we realisethat to undertake so critical a piece of work,when due opportunity is wanting for fullconsideration of the accompanying difficulties,would not be promptitude on the part of anyGovernment, but only mischievous yielding to theview of the muddler that something had better bedone, whether for good or for evil. As we havepointed out several times in these columns, theposition of National Insurance presents consider-able difficulties to the designers of a Ministry ofPublic Health., The general view, and one whichwe have endorsed, is that the Local GovernmentBoard should become the over-authority for NationalInsurance, but Dr. Brend believes that the officeof the Registrar-General should be enlarged andshould take over the work of the InsuranceCommissioners as well as the whole scien-tific and statistical work in public healthat present performed not only by the LocalGovernment Board but by the Home Office and theBoard of Education. We admit that the Depart-ment of the Registrar-General could make a goodclaim if its scope were widened and its staff re-inforced by experts, but we remain of opinion thatif the National Insurance Commission does notremain a separate bureau, its right place is in aMinistry of Public Health, forming a department ofthe Local Government Board, and working in thatdepartment alongside of the machinery now

employed to discharge the medical work of theHome Office and the Board of Education. Thereseems no doubt that we must not expect any con-crete proposals from the Government for thecreation of a Ministry of Public Health just yet,but this appears to us to be no reason why mattersthat require immediate reform should remainunattended to until a vague and future date.We are glad to learn that it is the intention of thePresident of the Local Government Board to askthe War Cabinet to allow him to introduce a Billinto the House of Commons immediately, so that itshould be passed before Christmas, to deal with themany questions concerned with infant welfare. Itis evident from his replyto recent deputations thathe sees no need whatever to wait for the introduc-tion of a measure to deal with certain existing evilsuntil the Ministry of Health Bill, and he incidentallycorrected a mistake made by Mr. Kingsley Wood in a

letter recently published in the Times, who hadused the argument for the establishment of a

Ministry of Health that it would " save a thousandlives a week." Mr. Wood put that prediction intothe mouth of Lord Rhondda. Lord Rhondda. reallysaid that he hoped that a Maternity and InfantWelfare Bill would save a thousand lives a week.Dr. Brend, in the Edinburgh Review, misrepresentsLord Rhondda in exactly the same way.

THE HARVEIAN ORATION.

Professor R. Saundby, in the Harveian Orationwhich we print in another column, considersHarvey’s work in relation to the scientific knowledgeand the university education of his time, especiallyuniversity education in medicine. Harvey himseltwas a pensioner of Gonville and Caius College,Cambridge, where he entered in May, 1593, beingthen 16 years of age, and where he took hisbaccalaureate three years later. He then left Cam.bridge to study medicine at the University of Padua,where there was at the time a famous medicalschool; and while it is admitted that Harveywas the true discoverer of the circulation of theblood, it is fairly clear that our famous Britishphilosopher did not owe so much to his Englishas to his Italian university, where many eminentphilosophers were congregated at the beginning ofthe seventeenth century, and where he probablyacquired the methods of research which led him tohis great discovery. Professor Saundby’s disserta-tion is largely about other people than Harvey, andforms an interesting chapter of medical history.

ACUTE NEPHRITIS WITHOUT ALBUMINURIA.

I Dr. Carl Muller, of Christiania, has recently! recorded an interesting case of acute nephritis inwhich albuminuria was absent during the greaterpart of the attack.The patient, a factory girl aged 26, was ill with kidney

disease" for two months in 1914. In 1916 she had a sore-throat and kept to her bed for a fortnight; the urine wasfree from albumin and no diphtheria bacilli were found onexamination of a swab from the throat. After this shehad headache and shortness of breath, with palpitations anda troublesome dry cough; a week later her face and handsswelled and she had pains in the back. Dr. Mullerexamined the urine and found no trace of albumin init. The girl was living in miserable surroundings and wastaken into hospital. Here she was found to have slightcedema of the legs, with a high blood pressure (185 mm. ]Fig),an irregular pulse of 60, slight hydrothorax and ascites,and a small trace of albumin in the urine when Heller’s testwas applied. No formed elements could be found in thecentrifugalised urinary deposit. A few days later the per.centage of urea in the blood was observed to be raised,standing at 0’025 per cent. The patient had severe headache,dyspnoea, and vomiting for the first 24 hours, with anorexia.On the fourth day she was put on to a salt-free diet ofvegetables, bread, milk, tea, and water, and improved con-siderably. The cedema and fluid exudations were absorbed,the urine increased from nearly two to over four pints a day,and the blood pressure fell to the normal. The trace ofalbuminuria vanished after a week; at no time could cellsor casts be discovered in its centrifugalised sediment. AStrauss test applied to the kidneys later showed that therenal excretion of both salt and water was normal.

Discussing this case, Dr. Muller comments on theextreme rarity of the instances of acute nephritiswithout albuminuria recorded in thepre-war medicalliterature. In trench nephritis, on the other hand,or in war nephritis as he prefers to call it, absenceof albuminuria has often been recorded even

in instances in which uraamic convulsions haveoccurred, and he points out that his recorded casein many ways resembles one of war nephritis. The

1 Tidsskrift f. d. Norske Laegeforening, Christiania, 1917, xxxvii., 481

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attempt has been made to explain some of thesecases of oedema without other evidence of renaldisease as due really to lack of vitamines in thefood; the absence of nervous symptoms makes thisexplanation improbable. Again, it has been sug-gested that the lack of albuminuria in acute

nephritis may be due to patchy involvement of therenal tissue with failure of the inflamed portionsto secrete any urine; Dr. Muller thinks this

explanation untenable, in view of the high bloodpressure met with in such patients. He comes tothe conclusion that acute nephritis without albu-minuria is commoner in civil practice than isgenerally suspected. ____

THE VINDICATION OF A MEDICAL REPUTATION.Dr. S. D. Clippingdale points out that Nov. 6th

is the anniversary of what he describes as a

"tragedy in the annals of English obstetrics," thedelivery and death of H.R.H. the Princess Charlotteof Wales. The untoward event is thus announcedin a London Gazette Extraordinary issued at thetimes" Her Royal Highness the Princess Charlotte of Wales was

delivered of a stillborn male child at nine o’clock last night,and about half-past twelve Her Royal Highness was seizedwith great difficulty of breathing, restlessness, and exhaus-tion, which alarming symptoms increased till half past twoo’clock this morning,..when Her Royal Highness expired."The Princess was in her twenty-first year. Her

grandmother, Queen Charlotte, had been attended inher 13 confinements by a midwife, a Mrs. Draper,with the happiest results. When, however, thePrincess Charlotte was known to be pregnant and anheir to the Throne anxiously desired, it was decidedto take every possible precaution. Hers was the firstRoyal accouchement to be attended by male practi-tioners. Three were employed-Dr. Mathew Baillie,Dr. John Sims, and Sir Richard Croft. Of these,Sir Richard Croft was regarded as a specialist andcontrolled the case. Croft, although he appearedas a maternity specialist, apparently possessed nomedical qualification. He was at Oxford for a short

time, where Foster, in his " Alumni Oxoniensis,"describes him as " chirurgus privilegiatus," butmentions no degree. He was not a Member ofthe Royal College of Physicians, was not uponthe staff of any hospital, nor had he contri-buted anything to medical literature. He was, how-ever, a man of high social position, and possiblyhis social position had something to do with hisCourt appointment. He inherited a baronetcyconferred upon his ancestor by Charles II. Hemarried a twin daughter of Dr. Denman, thefamous obstetrician (to whose practice he succeeded).Dr. Baillie, his colleague, married the other twin,so that there was a personal as well as a profes-sional relationship between these gentlemen. TheCourt wished the Princess’s confinement to takeplace at Kensington. The Princess, however, pre-ferred Claremont, 15 miles away, and, at that time,not easily accessible. The labour was protractedand abnormal. There was hour-glass contractionof the uterus. The infant was known to be deadsome hours before it was born, yet no steps weretaken either to remove it or to terminate labour.The Princess was in an enfeebled condition fromlow diet, repeated bleedings, and unrelievedbowels. Finally there was post-partum hsemor-rhage. A Mr. Jesse Foot demanded a public Iinquiry, stating; upon the report of the nurse,that when the infant was born, all three ’ I

doctors were fast asleep. This, however, was

denied by Dr. Sims, who, in a letter whichwill be found in Playfair’s "Midwifery," says :" It has been said we had all gone to bed,but this is not a fact. Baillie retired about 11 andI lay down in my clothes at 12, but Croft never lefther room." A path is still shown at Claremontwhere Sir Richard Croft had walked up and downin agony not knowing what to do for the best, andFoot’s statement that he went to bed is a libel. Bycommand of the king a post-mortem examinationwas made by Sir Everard Home and Sir DavidDundas, who reported to the king that there was noevidence of neglect, but that everything had beendone which " human science could devise or humanskill effect." The event so preyed upon the mind ofSir Richard Croft that three months later he shothimself.

____

COLD AND COLDS.

THE bleaker days of early autumn have beenaccompanied with an abundant crop of colds, andthe sequence is such a usual one that many people,perhaps the large majority, regard their catarrh as.being directly caused by the reduction of tempera--ture by what they call a chill. The belief lacks.

proof, inasmuch as precaution is generally taken to*avoid the reduced temperature by means of arti-ficial heat in houses and offices and the closing of-windows in railway carriages. But this precautionintroduces complicating factors. The indoor air-becomes more stationary and humid; air-pocketsare present in which little interchange occurs;.-there is a sharp dividing line between indoor airand outdoor air; and with these altered telluricconditions there is a tendency to crowd together andan increased nearness of contact in family life.In one respect, however, the conditions aheadshould be changed in the coming winter. Fuel is.dear and scarce, and it is both economical and.patriotic to be sparing in its use. This will meana reduction in indoor temperature, and less differ-ence between indoors and outdoors. It will beworth noting whether the result is an increaseor decrease of colds.

____

THE King has nominated Dr. J. C. McVail for afurther period of five years a Member of the GeneralMedical Council for Scotland.

NEWS has been received of the death, at the ageof 60 years, of Sir C. Pardey Lukis, honorary surgeonto the King, who has held the position of DirectorGeneral of the Indian Medical Service for a period ofnearly eight years. ____

THE Bradshaw Lecture of the Royal College ofPhysicians of London will be delivered at theCollege by Professor Ernest S. Reynolds on Thurs-day, Nov. 8th, at 5 o’clock, the subject chosenbeing " The Causes of Disease."

THE Bradshaw Lecture of the Royal College ofSurgeons of England will be delivered in thetheatre of the College by Sir John Bland-Sutton onThursday, Nov. 8th, at 5 P.M., the subject of thelecture being " Misplaced and Missing Organs."

THE opening meeting of the Rontgen Societywill be held on Tuesday, Nov. 6th, at 8.15 P.M., atthe Royal Society of Arts. The presidentialaddress, on "The Part Played by X Rays in theWar," will be delivered by Captain G. W. C. Kaye,M.A., D.Se.