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and sometimes a few rales, but no gross signs werefound in the chest. Tubercle bacilli were occasionallydemonstrated in the sputum, but recourse to gastriclavage and guinea-pig inoculation was commonlynecessary. The Mantoux reaction was usually positiveon using 0.1 c.cm. of 1 in 10,000 old tuberculin andalways in 1 in 1000 dilution. Radiography showedthe characteristically diffuse and mottled appearanceof the lung. In the four non-fatal cases, and someof the fatal ones, extrapulmonary lesions were

coexistent.In treatment, rest is of paramount importance,

and it must be continued until the stippling hasdisappeared, which happens when the tubercle isreplaced by fibrous tissue. - All these patients weretreated on open-air balconies, and Dr. Fish gavethem gold in the form of Solganal B, which he thoughtbeneficial. The prognosis proved as difficult in thistype of tuberculosis as in others, and cases apparentlyof the worst type recovered.

RATIONAL SALINE THERAPY

THE intravenous injection of common-salt solutionhas been recommended for a variety of conditions.Some of the recommendations appear contradictory-for example, the use of

" normal " or hypertonicsaline for cure of the anhydrsemia of shock and

haemorrhage and as a treatment for anuria in whichfluid-retention may be taking place. The occasional

efficacy of intravenous therapy can be explained byblood analyses. Root i describes two cases in whichintravenous hypertonic saline restored the urinaryflow in patients with only one kidney. Both patientshad anuria with increasing nitrogen-retention andlow blood chlorides, one as a result of vomiting andthe other from excessive sweating. After intravenoustherapy and restoration of the urinary flow theblood chemistry became normal and recovery followed.An example is given of the calculation of the chloridedeficit and the exact amount of salt solution to remedythis. No doubt if these methodical analyses could beconducted on all patients before the administrationof intravenous solutions, such brilliant results mightbe achieved more often. There seems to be no verygood reason why a vein should be preferred to thealimentary canal for salt or fluid replacement,especially if reasonably early blood analyses are doneto reveal the condition before it becomes acute.If clinician and laboratory were always able to workmore closely together in these circumstances manylives would be saved.

THE BLOOD PICTURE AFTER INDUCED FEVER

THE account on p. 1007 of the congress on artificiallyinduced fever shows to how many different uses thistreatment is now being put in America. Its effecton the haemopoietic equilibrium is thus of considerablemoment. F. H. Krusen has recently summarised 2 hisobservations on a large group of patients. Thepatient’s body was exposed from 3-7 hours in hotcirculating humid air varying from 14°-150° F., thehumidity being kept constant. Samples of bloodwere taken from each patient immediately before andimmediately after each fever treatment. The diseasefor which fever therapy was given appeared to bewithout effect on the character of the response.Similar changes were noted in both venous and

capillary blood, so it may be concluded that such

changes represent a fundamental alteration in hsemo-

1 Root, H. F., J. Amer. med. Ass. March 20th, 1937, p. 947.2 Amer. J. med. Sci. 1937, 193, 470.

poietic equilibrium and are not dependent uponsuperficial hypersemia. Average venous counts on100 patients before treatment gave a leucocyte count,of 7100 per c.mm., while after fever the count was11,300 per c.mm. This increase was dependent uponan increase in polymorph cells. No change that wassignificant was found in the Arneth count. The redcell count was unaltered. The author believes,therefore, that there is a true increase in circulatingwhite cells, since there is no evidence of concentrationof the blood and the white cell increase appears toaffect one cell type only. Rather more elaborate,studies of the same problem have been made byDr. M. M. Hargraves, who adds a note to Dr.Krusen’s paper. Dr. Hargraves followed his patientsfor 20 hours after the onset of fever with half-hourlyblood counts. He found a response so constant that,he characterises it as a " febrile hsemogram." Thereis a post-febrile leucocytosis, the duration and extentof which is an individual affair related to the durationand height of the fever. The peak of leucocytosis isdependent on a polymorphonuclear increase and oftengoes as high as or higher than 40,000 leucocytesper c.mm. At this stage the younger cells as shownby an Arneth count are increased, evidence it isbelieved of bone-marrow delivery rather than ofredistribution. As the polymorph peak declines, thetotal count is sustained, at least to some extent, byan influx of monocytes. The lymphocytes reappearin normal numbers only towards the end of the period.These figures, Hargraves suggests, confirm Krusen’sobservation which was correct for the time ofsampling but usually missed the peak of the response.Apart from their own interest these figures emphasiseagain how rapidly changes in the white cell count.occur, rendering single of far less value than serialobservations.

OBSTETRICAL EMERGENCIES

Prof. Farquhar Murray’s idea of a local emergencyservice for difficult childbirth is now bearing fruit.It is some twelve years since he began to work out a.way of providing the accoucheur with the neededassistance whenever the unexpected difficulty pre-sented itself. In 1929 he advocated the organisingof emergency services, especially in industrial areas,and in 1935, with the cooperation of the medicalofficer of health, he initiated such a service in

Newcastle-upon-Tyne, which was nearly the first of its.kind, something similar having been tried in Lanark-shire two years previously. In that year a localNewcastle journal gave a graphic account of how theefficiency of the service was tested. Prof. Murraywith an accoucheur and the M.O.H. sent an

emergency call from a house in a Newcastle suburb,and within 15 minutes of the call being made a-

nurse was on the doorstep, followed in another minuteby the gynaecologist, who had travelled three milesand was only summoned after the first man onthe rota was found not to be at home. The procedureis simply this : the doctor or someone acting for himtelephones to the maternity hospital where the outfitis kept, asking for the service to be put in motion,and giving name and address of patient and name ofconsultant desired. The hospital rings up the con-sultant named and if he is not at once available oneof the others on the panel of four takes his place.He goes direct to the patient’s house unless this isoutside the five-mile radius, in which case he calls topick up the nurse and outfit. For local cases the

hospital telephones to a taxi rank and sends the

1 Brit. med. J. 1929, 1, 691.

999

nurse and outfit direct to the patient’s house. The

agreed charges for Newcastle-upon-Tyne are: con-

sulting fee two guineas, operation fee four guineas,nurse and outfit one guinea, taxi charges extra.Outside Newcastle the service is now available in

Gosforth, Newburn, Tynemouth, West Hartlepool,and generally throughout the counties of North-umber-land and Durham. During the eighteen months ithas been in operation some 20 emergency cases

have been attended, in a number of which Prof. Murrayis assured that lives have been saved.

Just over a year ago a similar flying squad wasinaugurated at the Birmingham Maternity Hospitalby cooperation between its honorary staff and themedical officer of health, the underlying principle ofthe scheme being to bring the resources of the hospitalto the patient’s bedside in case of serious obstetricalcomplications where transport would be likely to

impair the chance of recovery. The equipment is

supplied by the public health authority and thescheme in general is planned on the northern model.The working has been found quite simple. The

practitioner in charge of the case sends two messages-one to the consultant, the other to the maternityhospital which is in close touch with the St. JohnAmbulance Service. Within a few minutes a seniornurse arrives with equipment which includes blankets,hot bottles, bags containing surgical requirements,and drugs appropriate for any emergency. Theambulance stays at the door in case the patientshould be in a fit condition to be moved, but inpractice it generally does no more than take theapparatus and nurse back to hospital. During the shortperiod in which it has been in use the flying squadhas admittedly been instrumental in providing helpwithout which the parturient mother could not havecome through safely.

THE JOURNAL OF THE UNIVERSITY OF

MANCHESTER

THE first issue of the Journal of the Universityof Manchester represents a venture which must besuccessful. The journal will be recognised by all themembers of the university as forming a common bondbetween the graduates, providing them with topicalnews and interesting personalia as well as informationon developments in university policy. If futureissues maintain the standard of No. 1, Vol. I, thejournal will be welcomed not only by those whomit is specially designed to please, but by all interestedin university education. The recent growth of theUniversity of Manchester and the part to be playedin the future by university education are set out intwo opening essays by Sir Ernest Simon, treasurerof the university, and Prof. Godfrey Thomson, whoseLudwig Mond lecture, delivered last autumn atManchester, is now reproduced. Prof. Thomsoncloses with these words which all who take heedto the meaning and needs of education will endorse :-

" The only hope for unity, permanent unity, amongmankind is through the rule of intelligence, through thecultivation, by an education proper to each, of the

intelligence of all. The schoolmaster is right who considersthat his sole business is to lead his pupils to see truthclearly, and who holds that that is in itself character-training, and the only character-training the school maylend itself to, if it is to refrain from serving party or class,colour or race, or prejudice of whatever kind, but is toserve civilisation and all mankind."

The university is the next stage to the school,and this broad social view is even more obvious inuniversity training. The new journal exhibits the

University of Manchester as a centre of liberalprogress and its graduates will welcome it. Andit is a present to them for it will be supplied withoutcharge to them and the friends of the universityon application to the Manchester University Press,Wright-street, Manchester.

" LYMPHATOLOGY "

A SYSTEMATIC study has been pursued for manyyears at the anatomical institute of the Universityof Kyoto into properties of lymph and the lymphaticsystem for which subject they use the convenientterm " lymphatology." Recent results are recorded 1

in a series of papers numbered 76-101 by a group ofworkers under the general direction of Prof. S.Funaoka. The rabbit has been the experimentalanimal throughout, and lymph was obtained fromafferent and efferent trunks of the popliteal gland,from the gland capsule itself, and from lymphaticsof liver and intestine by simple collection or perfusion.In order to collect lymph at these sources specialtechniques have been developed. Many of the

workers have exploited the method devised byProf. M. Watanabe under the guidance ofFunaoka by means of which all lymphoid tissue isremoved from popliteal glands and lymph is collectedin the shell of the capsule that remains behind.Lymph obtained by this means is referred to as" Brunnenlymphe" to distinguish it from thatobtained from afferent and efferent trunks. An

improved method for gaining access to the efferentpopliteal lymphatic has been devised by Y.Yoshida. It consists in constricting the efferentvessel together with the nutrient artery by meansof a ligature, till it is distended with stagnant lymph.Then, when it is easily visible, a large-sized hypodermicneedle is passed into its lumen, a second ligature ispassed round the needle and the first is removed.This manoeuvre diminishes damage to blood-supplyin the gland and the danger of contamination of

lymph by cells and serum. A method for obtainingliver lymph is described by Funaoka and S.Sumiya. Various quantities of the lymph which wasobtained are given in a Table, but unfortunatelyno mention is made of the time taken to collectthese amounts. In this respect the contribution byK. Okamoto is especially interesting for he

gives the following details : the difficulty in obtainingperipheral lymph depends upon the time of year ;it is more difficult in April and at the end of October(in Japan) ; by the " Brunnenlymphe " method thequantity collected in the first half hour varies from0-3-1-5 c.cm., and the mean is 1.42 c.cm. per hour;the limb from which this flow was obtained wasnormal, was not massaged, and the animal wasloosely held round the abdomen. Details such asthese are conspicuously lacking in the form in whichmost of this Japanese work is available to Europeanand American readers, and they are of far greaterinterest than tabulated results of scantily describedexperiments.Most of the contributions to these two sections

deal with chemical constituents of lymph undernormal conditions ; more than one author has soughtfor ferments passing out of lymphatic glands and inlymphocytes; a few have examined lymph forimmune bodies in various experiments; severalpapers describe the morphology and charactersof cells in lymph ; the vexed question of regenerativecapacity of lymph nodes is tackled by one author, andX ray records of injected lymph vessels have been

1 Acta Sch. med. Univ. Kioto, 1936, 19, Fasc. I and II.