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ANNOTATIONS

OFF-DUTY WORK.

AN interesting recommendation was made lastweek by the central public health committee of theLondon County Council for the council’s acceptance.It has long been the practice in the mental hospitalsunder the council’s control to allow the medicalsuperintendent to hold an appointment unconnectedwith his office, on such conditions as the councilmay decide proper. He may, for instance, be

physician to an out-patient clinic at a general hospital,and in fact has often been such. Application hasnow been made for this permission to be extended tomedical officers of other types of hospital whichhave more recently come under the council’s control.The deputy medical superintendent of Fulham

Hospital has the opportunity of becoming assistantradiologist at the National Hospital, Queen-square;the assistant medical officer at St. Mary (Islington)Hospital would like to apply for the appointmentof honorary medical registrar at the Maida ValeHospital for Nervous Diseases. On his behalf it wasstated that the appointment, which would involveattendance on two or three afternoons a week, wouldbe carried out during normal off-duty hours. Thecommittee’s recommendation was made in no grudgingway. "We are of opinion," they say, "that thestaff generally should be encouraged to hold suchappointments, as association with outside medicalwork provides valuable experience which will be ofbenefit in carrying out their duties under the council";and the grant of similar facilities is to be customaryprovided that (1) the appointment is an honorary one,(2) the holding of it shall not interfere with the efficientdischarge of the officer’s ordinary duties, and (3) thework is done in off-duty hours. The position is

interesting, for the question of the employmentof off-duty hours in a full-time appointment hasprovided many conundrums, some of them so difficultof solution as to require the aid of medical defencesocieties. Broadly speaking, the employer of a

medical person cannot prescribe or prohibit any formof unpaid off-duty employment which does notcontravene his or her terms of service, and, unlessit is expressly stipulated in these terms that no othermoneys whatever shall be received by the officer invirtue of his medical qualification, it is difficult to seehow the prohibition of payment can be enforced.Where the whole-time salary is on a generous basis,the question of supplementing it will hardly arise,but this is not always the case. The arrangementsuggested in London, if it should become general, willresult in a liaison between the voluntary and municipalhospitals which must have its effect on the future ofboth. A possible risk of widespread response tothis permission might be to endanger the practice ofoffering modest honorariums for hospital posts,such as registrarships, to enable young men or womento keep themselves by doing useful routine workwhile waiting for a vacancy on the staff.

DIATHERMY AS PYREXIAL AGENT IN G.P.I.

SiNCE first Wagner-Jauregg brought hope to theblack prognosis of general paralysis of the insane,experimentation has been mainly concerned withvarious ways of producing fever. The essentialelement in the cures that have been attained hasseemed to be the pyrexia induced by the remedialagent, and on the whole the opinion of psychiatrists

still agrees with that of the pioneer workers in regarding the plasmodium of malaria as the best agent.But to give a man malaria is a serious responsibility,and could only be justified by the appalling futurebefore these patients in the absence of treatment andthe very considerable measure of control of thepyrexia afforded by quinine. It seems strange thatthe relatively much less harmful type of pyrexia thatcan be induced by diathermy has not been morewidely tried. Drs. C. A. Neymann and M. T. Koenig3have found that it is not only far safer than infectivemethods but also more successful, especially withdepressed patients who are apt to prove more resistantto treatment than the expansive ones. Neymann andKoenig have treated 50 cases selected at random,over half having a duration of from one to five years,and have compared the results of malarial, rat-bitefever, and diathermy treatment. About 20 per centof the patients had previously been treated withmalaria and tryparsamide without appreciable results.The method of administering diathermy was thatdescribed by C. A. Neymann and S. L. Osborne,2 butno patient was given more than 12 treatments. This,the authors say, is not enough, but the work wasexperimental and they were limited by circumstances.Most patients had between one and two hours’pyrexia of over 103-5° F. after each treatment. Thedeath-rate was 18 per cent. for malaria, 10 per cent.for rat-bite fever, and nil for diathermy. The resultswith malaria were as good as is usual nowadays ; theremissions in rat-bite fever were brief and occurredonly in 8 per cent. Diathermy gave 24 per cent.remissions as compared with 22 per cent. aftermalaria. The criterion of remission is that the

patient should regain insight and be able to leave theinstitution and earn money. Most of the cases onlybegan to show improvement after the eighth or

tenth treatment. The improvement rate-short offull remission-was 26 per cent. for diathermy and22 per cent. for malaria and rat-bite fever. Of seven

depressed patients treated with one or other of thefevers, only one showed improvement, while of fourdepressed patients treated with diathermy two wentinto remission and the other two were sufficientlyimproved to be put on parole. The serological changesdid not correspond with the clinical changes ; somedemented cases improved serologically but not

clinically, and vice versa. There are no complicationsin or centra-indications to diathermy treatment, pro-vided the proper electrodes are used and the propertechnique is applied, and as many as 50 treatmentscan be given without ill-effects. The dosage can bemeasured with scientific exactness, and the methodcan be applied by any practitioner acquainted withthe elements of electrotherapy. The advantages ofthis method are so obvious and the disadvantages ofother forms of induced pyrexia are so well known thatif the results obtained by these American workers aresubstantiated a very great advance has been madein clinical psychiatry ____

RESEARCH FACILITIES AT LINCOLN’S-INNFIELDS.

THE provision in 1930 of laboratories for researchworkers in rooms adjoining the Museum at the RoyalCollege of Surgeons is described by Sir ArthurKeith in his annual report as an important develop-

1 Jour. Amer. Med. Assoc., 1931, xcvi., 1858.2 Ibid., xcvi., 7.

31

ment of the services which the Museum of the Collegerenders to surgery. Hitherto research work hasbeen carried out by the officers of the Museum andby men who found in the Museum material whichelucidated the subject of their inquiry. Thelaboratories now provided are intended to meet theneeds of another class of men altogether-young menwho aspire to become members of the surgical staffsof our great hospitals.Four new research scholarships, offering 500 a

year for varying terms of years, are being founded,of which the Melchett, the Bernhard Baron, and theBeaverbrook are already in working order, beingheld respectively by Mr. J. H. Thompson, Mr. E. G.Muir, F.R.C.S., and Mr. H. J. Burrows, F.R.C.S.A fourth scholarship is to be provided from the fundsof the College. Mr. Thompson is seeking to isolatethe growth-inhibiting factor from parathyroidmaterial. Mr. Burrows is engaged on tissue culture,and Mr. Muir is studying the comparative anatomy,physiology, and pathology of the prostate gland.One of the laboratories has been assigned to Dr. G.Scott Williamson, who holds a Mackenzie MackinnonFellowship, and to Dr. Innes Pearce, who is workingwith him on the nature of the substances secretedby the thyroid gland in health and disease. Voluntaryworkers who are investigating problems relating tothe practice of surgery are also accommodated in thelaboratories, as far as space permits, and six of theseare at present receiving hospitality. For theconvenience of workers an animal hut has beenerected on the roof of one of the laboratories, theCollege having gained recognition as a centre whereanimal experiments may be performed. Thesefacilities, together with the research farm in the

country, of which the plans are set out on p. 39,should give a fresh stimulus to surgery.

STANDARDS FOR SPAS.

HYDROTHERAPY has long been recognised as animportant branch of medical treatment and a concisebut comprehensive survey of the various watersavailable is long overdue. When the scheme by whichspa treatment will be available to members of approvedsocieties comes into operation, it will be essentialfor every panel practitioner to possess some know-ledge of. the spas and their treatments. They willhave good cause to welcome the first instalmentof an International Register of Spas and MineralWaters, just issued by the International Society ofMedical Hydrology. The desirability of uniformmethods for the expression of data led to the appoint-ment four years ago of a standard measurementscommittee, under the chairmanship of Mr. S. JuddLewis, D.Sc., which will promote the compilation ofnational registers of waters to form the basis of aninternational register. When this is done, accurateand comparable information regarding the spas andtheir waters will be available for every one interested.In the past analysts have expressed their results invarious ways, most of them unintelligible to medicalmen. In the register a common form of expressiondesignated by the letters " I.S.M." (InternationalSociety of Medical Hydrology) is given, but provision ismade for the inclusion of the same results expressedin the manner customary in the country concernedand designated as

" National." In the British

register, the figures will at the outset be given inmilligrammes per litre (I.S.M.) and grains per gallon(National). It is hoped that the National form of

1 London : Headley Brothers. Pp. 20. 1s.

expression will ultimately become redundant. Forthe benefit of those who are accustomed to think interms of salines, instructions are given for the calcula-tion of the most probable combinations of the ionspresent in such waters and their mode of expression,but it must be borne in mind that all such combinationsare hypothetical and arbitrary. Physical data are

to be recorded in a standard manner, eliminating forexample the confusion that arises when radio-

activity results are expressed sometimes as milli-micro-curies, sometimes as Mache units. Standardforms are given for recording geographical, climato-logical, geological, and topographical data, andthe register provides for the classification of the watersaccording to their chemical, physical, and medicalcharacteristics. Local information will includemethods of treatment available, facilities for the

investigation of disease, and a list of the diseases anddisorders suitable for treatment. There must remainfor long enough a great gulf between the precisionof the analytical data and of the deductions fortreatment based upon these data. Chemical analysisis a science and medicine an art ; but without accuratedata, treatment will remain purely empirical. Dr.Lewis and his colleagues have provided a sound basisfor the superstructure that is to come.

THE AUSTRALIAN MEDICAL SERVICES

IN THE WAR.

A HISTORY of Australian medical cooperation inthree very different campaigns during the late wargives a good picture of the gallant fight made againstunexpected obstacles on all fronts. Many and gravewere the problems of the Australian Medical Corps.On Gallipoli, for example, on April 25th, 1915, it wasdifficult to land, as is seen in the picture on p. 132 ofthis history. The narrow beaches and steep ruggedhills were hard to climb even for men without equip-ment while G.H.Q. was so absorbed in the problem ofreinforcing an uncertain attack as to have little timefor thought for the wounded. Casualties, who hadto be brought down the narrow ways impeded thereinforcements, congested the beaches, and awaitedhospital ships while it was still doubtful whether shipswould not rather be needed to remove an unsuccessfularmy. But the Navy, less closely involved, lentNeil-Robertson stretchers for lowering woundeddown the cliffs and the indefatigable senior medical

officer of London got many wounded off to the five shipshis admiral had detailed. Thus of over 4275 casualties,3380 were embarked for Egypt on April 26th and 27th.Later, the plague of flies which raised the numberof sick all through the summer was followed by thegreat attack in August, to prepare for which theAustralian A.D.M.S had to plead for help in clearingthe beaches. Sinai and Palestine provided differentproblems, in some ways easier. Twice in 1916, atMagdhaba and Rafa, ambulances were recalled becauseattacks were said to have failed, but the fighting lines,who had not been told they were beaten, went on andwon their battles, which was satisfactory enough, butit was hard to pick up their wounded promptly. Thestrenuous antimalarial campaign along the front inthe summer of 1918, especially in the valley of theJordan, 1280 feet below the sea, tired the troops ;but had they known that Liman v. Sanders wouldlater 2 charge his failure to the epidemics ofmalaria and dysentery, how they would have been

1 The Australian Army Medical Services in the War of 1914-18.Vol. I., War Memorial, Melbourne, 1930. London: AustraliaHouse. Pp. 873. 21s. 6d.

2 Journal of the Royal United Service Institution, 1921, p. 327.