337

pattern. Dr. Waddington, in discussing the problem oforganisation, offers little hope of solution, but gives a.

good idea of the way in which biologists are trying tosolve it.

SULPHAPYRIDINE AND LUNG ABSCESS

IT is now generally accepted that the presence of pus,whether in the pleural space or within the lung, greatlyinhibits the action of M. & B. 693. In a report fromLahore on another page, Prof. Taylor and others showthat in 3 out of 7 cases of lung abscess dramatic improve-ment followed sulphapyridine therapy, 2 of them losingfever of several weeks duration within twenty-four hours.Should further investigation support the evidence of thissmall group of cases it will be difficult to account for thediscrepancy between Indian results and those obtainedin temperate regions. Fisher and Finney reporting on88 cases of lung abscess treated in Baltimore between1931 and 1938 mention one due to P-hasmolytie strepto-cocci which seemed to be benefited by sulphanilamide;they recommend that sulphapyridine should be used earlywhen an abscess directly follows a pneumococcuspneumonia, but doubt whether the drug will have anyeffect on an abscess once it is fully developed. Pneumo-coccal pneumonia is prevalent in the Punjab, and therelatively susceptible pneumococcus may be more com-monly responsible for lung abscess there than theanaerobes and other organisms associated with dentalsepsis which are so often incriminated in England.

DOES THE CURRICULUM STIFLE RESEARCH?

IN a thoughtful address Dr. A. E. Cohn of the Rocke-feller institute for medical research in New York 2 hasapproached the debatable subject of the faults of thepresent curriculum. He inquires whether it would notbe possible to adjust the approach to scientific researchwithout adhering rigidly to the standards of knowledgeof disease now exacted of medical graduates. His ownview of the solution of the problem is not wholly clearfor he is more concerned to state the difficulties than toprescribe the remedies. The main difficulty as he sees itis that the present curriculum is so long that the would-beresearcher only begins to undertake responsible researchwork at an age when he is already losing something ofthe freshness and ardour of the explorer; and he sug-gests somewhat tentatively that it might be possible so toarrange things that the student who knows early in hiscareer that he wishes to devote himself to scientificresearch would be able to specialise, and so enter on hislife’s work at an earlier age. It is a plea which at firstsight seems to demand unqualined assent, but if we pauseto consider the history of successful research work inmedicine there are grounds for hesitation. Compara-tively few men are gifted with the imagination, the per-sistence and the technical ingenuity which are so requisiteto the explorer; and where these are present themechanical bar of the standard curriculum is rather animagined than a real handicap. The work of Ross or ofBanting, or in earlier generations of Darwin or Jenneror John Hunter, is testimony to the fact that "thedivinely gifted man " can " breast the blows of circum-stance and grapple with his evil star." That is not a fullanswer to Dr. Cohn’s contention however. He seems tomaintain that for one gifted man who can overcome the" invidious bar" of the standard curriculum there areothers who, capable of effective work, find their roadblocked by the difficulty, or their course prolongedbeyond due time by the length of the journey. To thatview it is possible to give a qualified assent, bearing inmind that in other countries the medical curriculum islonger than it is here. Medical students in the UnitedStates are required to do eight years of college work

1. Fisher, A. M. and Finney, G. G. Bull. Johns Hopk. Hosp. 1940, 66,263.

2. Remarks on Professions in Medicine, Science, July 26, 1940.

followed by two years in hospital, so that they are

twenty-nine or thirty before they can earn their livingprofessionally. We can also join with Dr. Cohn in con-demning the time-lag in the reform of the curriculum.There is nothing to be gained, as he points out, by wait-ing until a more or less violent upheaval of our stan-dards becomes necessary; we should be constantly adjust-ing them to meet the needs of the coming generation.

POSTOPERATIVE VENOUS THROMBOSIS

IN genito-urinary surgery there is a high incidence ofvenous thrombosis and pulmonary embolism; and in apaper dealing with these complications in the BradyUrological Institute of the Johns Hopkins Hospital,Culp/ has made suggestions for their prevention, earlydiagnosis and treatment. By way of prevention heforbids the use of intravenous infusions unless absolutelynecessary and emphasises the importance of avoidingvenous stasis after operation. Regarding sepsis as an

important factor, he advises the use of bacteriostaticagents during operation. He suggests routine leg mea-surements on admission and before and after operation,on the grounds that a slight swelling of the limb, notappreciable by the naked eye, is an early sign givingwarning of the danger of pulmonary embolism. Hedescribes cases that were submitted to operation whenthrombosis was already present-an accident that mayeasily happen in this type of case. If routine leg mea-surements are to be employed they might usefully becombined with examination for deep tenderness anddelayed cooling on exposure, which Pilcher has describedas early signs of thrombosis. Culp’s suggestions fortreatment of thrombosis may well be disputed; he advo-cates absolute rest in bed although he agrees with otherobservers that venous stasis is an important cause ofthe condition. Surely rest in bed is one of the best waysof producing venous stasis and may well encouragethrombosis to spread or even to start elsewhere. But,as Homans 3 says, why worry about casual exercise whenthe patient must practise daily the athletic feat of usingthe bedpan? ° Homans, who also attaches great import-ance to venous stasis, is more logical in his treatment.When thrombosis is diagnosed he advises postural treat-ment in bed, to promote venous drainage and absorptionof cedema; he allows exercise of the limbs, and gets thepatient up as soon as the swelling has subsided. In.certain cases he advises division of the femoral vein, butalthough there have been several reports of this treatmentthe results are not numerous enough for its value to beassessed.

SPECIFIC CONTROL OF MEASLES

UNTIL such time as active immunisation against measlesbecomes possible the only efficient method of control isby partial or complete passive immunisation of sus-

ceptible contacts. The use of human immune sera forthis purpose has already proved an inestimable boon tohospital administrators but no great effect on the grossmortality of the disease may be anticipated until pre-ventive inoculation is widely and consistently practisedamong familial contacts in the home. An example ofan organised attempt on these lines is reported by thePublic Health Department of Chicago.4 On receiving anotification of measles the home was visited by a health-department investigator who quarantined the primarycase and prepared a list of contacts. Some of these wereinoculated with convalescent measles serum in age-adjusted amounts of 3-5 c.cm. and some with a placentalextract in doses of 2-3’5 c.cm.; the remainder acted ascontrols. Generally speaking the control group consisted

1. Gulp, O. S. Bull. Johns Hopk. Hosp. July, 1940, p. 1.2. Pilcher, R. Lancet, 1939, 2, 629.3. Homans, J. Amer. J. Surg. 1939, 44, 3.4. Bundesen, H. N., Fishbein, W. I., Abrams, I. R. and Miller,

R. D. J. Amer. med. Ass. July 13, 1940, p. 104.