1302

selected groups of young qualified men. No

attempt is made in this inaugural lecture toenumerate the possible interests and functions ofsuch a department, but it is indicated that thestudy of symptoms, their nature and their purpose,by more precise methods should be a main con-sideration ; that intensive and continuous studyof common diseases should generally be preferredto isolated research on rare ones ; and that thera-

peutic trials might constitute a practical service.The more accurate portraiture of diseases, improve-ments in diagnostic and prognostic methods, andstudies of innate predisposition would provideappropriate tasks, with a follow-up system as anessential element of the scheme. Incidentallythe services of the department to the hospital couldonly be stimulating and salutary ; there shouldbe no artificial separation between its functionsand those of the visiting and resident staff, whosemembers would in fact complete the unit.

Prof. RYLE’S fine conception of clinical science,which he recapitulates, is already known to ourreaders.2 It differs from that of Sir THOMASLEWIS mainly in the relative importance attachedto observational as opposed to experimentalmethods. We are reminded (as LEWIS indeedfreely admits) that there are necessary and ratherstrict limits to the possibilities of experiment insick persons ; it is pertinent to refer back to thewords " by every legitimate means " in thedefinition quoted above of the aims of medicalscience, for it is our pride in this country tointerpret them in a most rigid sense. Moreover,as Prof. RYLE points out, the types of diseasewhich at present lend themselves to clinical

experiment are few in number ; it is rarely possibleto reproduce, to vary, or to measure symptoms atwill. But apart from these limitations of the

experimental method in the human subject, it is

clearly Prof. RYLE’s conviction that precise andintensive methods of observational study are notyet and will not soon be exhausted. This messagecommands attention. We cannot doubt that itwill receive it ; that he will be offered scope to

develop his ideas at Cambridge as facilities becomeavailable, and that his school will do its share inmaking " the ward, with its associate out-patientclinic and laboratories, once more both the startingand the rallying point of many researches."

STREPTOCOCCI AND PUERPERALINFECTION

H,2EmOLYTIC streptococci are found much moreoften in carriers than in cases of acute infection;indeed, no other organism shows so high a dis-

proportion between carriers and disease. Thisfact, and the immense variety of infections forwhich they are responsible, have been the chiefreasons for suspecting that all cocci rightly tobe described as StreptocoCCU8 pyogenes are not thesame. Hence the evolution of an increasinglycomplex series of tests whereby it was hoped toclassify pathogenic types, and to differentiate

2 THE LANCET, 1934, ii., 1307.3 Brit. Med. Jour., 1930, i., 479. " Clinical Science, illustrated

by Personal Experiences." London. 1934.

from them others of less or no importance inhuman disease. Having qualified for serious con-sideration on morphological and ordinary culturalgrounds, a streptococcus passes into a more selectthough still extremely wide category by beingshown to form a soluble heemolysin, and is thenexamined as to its capacity to lyse fibrin, toferment a series of carbohydrates, to hydrolysesodium hippurate, and to grow in the presenceof bile. The wider a range of tests of this kind,the more impracticable does their routine per-formance become and the more confusing theirresults. Carried out in toto on a large series ofstrains, these tests have afforded useful indica.tions ; but individually their value is limited.

Serological study has met with even greaterdifficulties, and years of effort have gone to thedefinition by GRIFFITH 1 of no less than 27 typesdistinguishable by agglutination tests. Of theultimate individuality of a streptococcus thismethod is and will probably remain the onlycriterion; by no other means is it possible cer-tainly to identify the source of an infection andto trace the spread of an epidemic strain. Butfew workers are in a position to apply this method,and its large-scale application involves immenselabour. What is needed for many purposes issome cruder test, easy of application which willclearly distinguish strains highly pathogenic forman from those which are not. This requirementis met by the precipitin test of LANCEFIELD,2 2which relegates haemolytic streptococci into a

small number of groups (now unfortunately show-ing signs of considerable extension) among whichstrains causing serious infections in man fall

always into Group A. Results obtained by thismethod correspond with those of the elaborateseries of biochemical tests formerly in use, andseem competent to replace those tests altogether.An opportunity is thus afforded to restudy thedistribution of haemolytic streptococci in carriersites with much more significant results. Someuseful spadework in this direction is reported ina series of papers from Queen Charlotte’s Hospital,where the exclusive significance of Group A inrelation to serious puerperal infections has pre-viously been verified. A large number of strainsfrom throat carriers has been classified by Dr.HARE,3 who finds that of streptococci from thissource about a third belong to Group A ; or if

only those strains are included which have beenshown to form soluble heamolysin, two-thirds.Dr. HARE and Dr. MAXTED 4 have also investi-gated the possibility that dangerous streptococcimay be present in the faeces, a doubtful questionof the utmost practical importance in seeking toexplain the origin of puerperal sepsis. Theyfound no Group A strains in the faeces of 100normal parturient women, but recovered themfrom the faeces of 20 per cent. of cases of scarletfever. It is therefore apparently possible for

streptococci in the throat to reach the anus alive,although uncertain in what numbers or under what

1 Griffith, F.: Jour. of Hyg., 1935, xxxiv., 542.2 Lancefield, R. C.: Jour. Exper. Med., 1933, lvii., 571.

3 Hare, R.: Jour. Path. and Bact., November, 1935, p. 499.4 Hare, R., and Maxted, W. R.: Ibid., p. 513.

1303

conditions. It seems desirable that the faeces ofa series of throat carriers should be repeatedlyexamined in order to get further light on thispossibility. According to COLEBROOK, MAXTED,and JOHNS,5 no Group A strains were found onthe perineal or peri-anal skin of 160 women-another piece of evidence suggesting that thebowel is an unlikely source of infection, althoughhere again the bacteriological state of the throatwas not actually known. In these studies, ofcourse, the delicacy of the cultural technique is

all-important; improved technique, if such is

possible, might reveal the presence of small numbersof streptococci more frequently. In this paper itis reported, on the other hand, that Group Astrains were found on the skin of the hands in7 out of 181 normal persons (3’8 per cent.) ; their

presence in this situation is attributed (reasonably,but without actual’ evidence) to contaminationfrom the upper air-passages, and since the genitaltract may thus hypothetically be infected fromthe throat by a route other than the alimentarycanal, it is suggested that measures should betaken to disinfect the mother’s hands duringlabour. This is perhaps an example of thosemore extreme precautions which do not findfavour generally, and indeed may defeat their

object by arousing ridicule, if only among lessserious students of this difficult problem.While bacteriologists pile up large volumes of

data bearing on the aetiology of puerperal sepsis,obstetricians are still by no means of one mindon this matter, and there are many who still

disregard aerial infection and deny the throatthe all-important place given it in these papersas a reservoir of infection. We publish on p. 1287an article by Dr. PHYLLIS CONGDON which offersfurther evidence that the source of puerperalinfections is sometimes the throat of someone

attendant on the patient. Her results differ fromthose of previous workers in the frequency withwhich a strain of streptococcus identical with thatin the uterus was found in the throat of the patientherself ; it should be pointed out that this doesnot necessarily mean auto-infection, since boththroat and uterus may have been infected fromelsewhere. Do findings such as these constitutea sufficient case for a bacteriological overhaul ofall attendants, and prospective attendants, on

women in labour, and the exclusion of thosefound to be carrying Group A streptococci ? 1This proceeding would certainly have some veryinconvenient results.

THE EXAMINER AT BAYDURING the last century examinations of

innumerable species, created by private andpublic bodies, have sprung up here, there, andeverywhere, and have grown so luxuriantly thatthey overshadow not only our education but thesocial system of our country. Examinations forma barrier between elementary and secondaryeducation, between secondary education and theuniversities; ; they confront the aspirant to pro-

5 Colebrook, L., Masted, W. R., and Johns, A. M.: Ibid.,p. 521.

fessional and many business careers. How fardo they let through the right people ? 1 This is a

question that troubles both teacher and parent,examiner as well as examinee. The latter is aptto feel that the system is one which does not dojustice to his abilities ; that Mr. Smith, for instance,can win approval by means of his retentive memory,whereas he, Mr. Jones, lacking that faculty, isunable to demonstrate his innate superiority inmental power. But another question, of at leastequal importance, to which less attention hasbeen paid, is this : does the fate of Smith or

Jones depend to any appreciable extent upon theinevitable variability between the opinions ofdifferent examiners, or upon the variability of thesame examiner at one time and another ? 1 If anexaminer considers Jones worthy of first-classhonours in 1935, would he place him in preciselythe same category if presented with exactly thesame answers in 1936 ? 1 If one examiner is of

opinion that Smith must be ploughed, will thatopinion be endorsed by others equally competent ? 1In fact, how far does the element of chance enterinto the results of our public examinations ? 1 Intothis question exhaustive inquiries are now beingmade. As the outcome of an International Con-ference on Examinations held at Eastbourne in1931, committees were set up in England, France,Germany, Scotland, and Switzerland, their inves.tigations being financed by grants from the CarnegieCorporation through the International Institute,Teachers College, Columbia University, New York.The English committee, which comprised distin-guished professors of education and psychology,was presided over by Sir MICHAEL SADLER, andDr. E. C. RHODES, reader in statistics at theLondon School of Economics, was engaged toact as their statistician. Their main work is beingrecorded in a volume entitled " The Marks ofExaminers," now in course of printing, but theprincipal results of the investigations are shownin summary form in a pamphlet issued this week.lThe position revealed, as shown by what follows,is, to say the least of it, very disquieting.The methods of inquiry adopted appear emi-

nently satisfactory. The scripts investigated wereall actual scripts which had been written bycandidates in the course of an ordinary examina-tion-e.g., for School Certificate, a college scholarship at one of the older universities (Englishessay), and an honours degree (mathematics andhistory). The examiners by whom these paperswere marked were all persons with experience ofthe kind of examination investigated, and theywere able to mark the papers under less pressurein respect of time than ordinarily prevails at anexamination, so that the marks may be regardedas expressing their deliberate opinion. Further-more they were all paid, so that the conditionswere as near reality as possible. As examplesof the results reached the following may be quoted.When fourteen experienced examiners re-markedindependently fifteen School Certificate history

1 International Institute Examinations Enquiry. An Exa-mination of Examinations by Sir Philip Hartog, K.B.E.,C.I.E., and E. C. Rhodes, D.Sc. London: Macmillan and Co.,Ltd. 1935. 1s.