1207

Manchester Royal Eye Hospital.-Sen. and Jim. H.S.’s. £150and P120 respectively.

Jlanclzester, Salford Royal Hospital.—H.P. and H.S.’s. All atrate of me 125.

Margate, Royal Sea Bathing Hospital.—Two H.S.’s. Each atrate of £100.

Jliller General Hospital for South East London, Greenzcich-roud, S.E.-H.P. At rate of £125. Also H.S. At rate of Y125Oldham Royal Infirmary.-3 H.S.’s. Each at rate of £175.Poplar Hospital for Accidents, East India Dock-road, Poplar, E.-

Sen. Res. O. £200.

-Royal Chest Hospital, City-road, E.C.—Med. Reg. £50.Royal College of Physicians of Lcndon and Royal College nf

Surgeons of England.—Streatfeild Research Scholarship inMed. and Surg. f.:250.

Royal Naval Medical Service.—Surg. Lieutenants. £453.Royal Northern Hospital, Holloway, V.-H.S. At rate of £70.Royal T-1’aterloo Hospital for Children and ll’onzen, Waterloo-road,

S.E.—H.P. At rate of £100.St. illary’s Hospital, W.-Asst. Director to Surgical Unit..&bgr;750.

Also Asst. Pathological Chemist. £300.St. Peter’s Hospital for Stone, &:c., Henrietta-street, Covent Garden,

W.C.—Clin. Assts.St. Peter’s (Whitechapel) Hospital, 74, Vallance-road, E.-Deputy

Res. Med. Supt. £600.Shrewsbury, Berrington Hospital.—Res. M.O. £250.Southampton, Royal South Hants and Southampton Hospital.-

H.P. £130.Southport General Infirmary.—Jun. H.S. £150.South Shields, Ingham Infirmary.—Sen. and Jun. H.S.’s £200

and £150 respectively.University of London.-External Examinerships.University of London, South Kensington, S.W.-Graham Scholar-

ship in Pathology. £300.Victoria Hospital for Children, Tite-street, Chelsea, S.W.-Sen.

Res. M.O. £250.Willesden General Hospital, Gynacological Out-Patient Dept.-

Clin. Asst. Surgical Out-patient Dept. 2 Clin. Assts.-Windsor, King Edward VII. Ilospital.-Sen. H.S. At rate of

£120.Wrexham and East Denbighshire War Memorial Hospital.-2 Res.

H.S.’s. Each at rate of £100.

The Chief Inspector of Factories announces vacant appointmentsfor Certifying Factory Surgeons at Wishaw (Lanarkshire),Scalloway (Zetland) and Beauly (Inverness-shire).

The Secretary of State for the Home Department gives noticeof a vacancy for an Ophthalmic Specialist Medical Refereeunder the Workmen’s Compensation Act for the LanarkDistrict (Sheriffdom of Lanark). Applications should reachthe Private Secretary, Scottish Office, Whitehall, London,not later than June 23rd.

Births, Marriages, and Deaths.BIRTHS.

BILLING.—On May 29th, at Denholm, Chingford, the wife ofDr. E. Billing, of a daughter.

MARRIAGES.BRAYFIELD—Beasley.—On May 26th, at St. Andrew’s,

Xeasden-cum-Kingsbury, Felix Francis Brayfield, D.S.C.,L.D.S., R.C.S. Eng., to Winnifred Mary Beasley, L.R.A.M.,second daughter of the late H. R. Beasley, of Hornsey, andMrs. Beasley, of Neasden. ’,

DEATHS.SHUTTLEWORTH.—On May 28th, at 36, Lambolle-road, Hamp-

stead, George Edward Shuttleworth, M.D., M.R.C.S.,Fellow of King’s College, London, in his 87th year.

YOUNGER.—On June 2nd, at 2, Mecklenburgh-square, W.C.,George Cuthbert Nelson Younger, M.R.C.S., L.R.C.P., sonof the late E. G. Younger, M.D., and beloved husband ofLilian E. Younger (Nee Abdy).

N.B.— A fee of 7s. 6d. is charged for the insertion of Notices ofBirths, ylarriages, and Deaths.

Notes, Comments, and Abstracts.THE SURGERY OF YESTERDAY AND

TO-MORROW.

Being an Address delivered at the Opening of the New OperatingTheatres at Addenbrooke’s Hospital, Cambridge.

BY SIR BERKELEY MOYNIHAN, BART.,PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND.

with light travelling at the rate of 187,000 miles a second,their inhabitants, if any, and if capable of far-distant vision,would now be watching the events upon this earth at thetime of the Crucifixion. I wish that it were possible fora few minutes for us to be in a star so distant that we mightbe able to peep into a Leeds operating theatre and thereto follow the day’s work, 40 years ago. I choose the periodof 40 years, for in 1888 I was house surgeon to Mayo Robson,who in activity of thought, variety of practice, and technicalaccomplishments was far advanced in the incubation periodfrom which he soon emerged as one of the foremost surgeonsof his dav.Let me try to describe what we did in those davs. I fear

you will be shocked.

An Operating Theatre Forty Yeays Ago.The surgeon arrived, doffed his coat, lest he should soil

it with blood or pus, rolled up his shirt-sleeves, and tookdown from a cupboard in the passage leading to the theatrean old coat, as a rule a frock-coat of antique design, whichbore many marks of -usage, and was stiff here, there, andeverywhere with blood, of which layer after layer had driedinto its very fabric. One, at least, of the coats was wornwith a special pride, indeed with a certain jauntiness, forit had been inherited from a retiring member of the staff.The cuffs of the coat were rolled back a little, just above thewrists; and the hands were washed in a " tip-up " basin,which was never cleansed except in the ordinary domesticway. The hands, when clean in a social sense, were soakedin a solution of carbolic acid, whose strength varied withthe resistance of the surgeon’s skin to its irritating effects.We used a 1 per cent. solution; and even with this our handswere often numb by the end of the afternoon ; and the soddenskin became afterwards very rough and harsh, and des-quamated for several days.The patient meanwhile had been wheeled into the theatre,

placed on a flat wooden operation-table (I keep in myconsulting-room that which McGill used for his prostat-ectomies, in memory of the fact that I helped him with hisfirst case), and the anaesthetic was given. In Leeds wepreferred ether, following the teaching of Mr. Pridgin Teale.The skin of the operation area had as a rule been preparedsome hours before ; it was washed with ordinary soap,shaved, and a " compress " soaked in a weak solutionof carbolic acid was applied. When this dressing wasremoved on the operation-table, a further applicationof 1 in 10 carbolic acid was made, and towels wrung outof this solution were laid around the site of the wound nowto be made. The instruments had been taken from thecupboard, whose shelves were lined with green baize,and placed in a tray of 1 in 20 carbolic acid, about half anhour before operation. Turkey sponges, cleansed and soakedin carbolic acid for days or weeks, were used, and whensoiled were wrung out of boiled water and weak carbolicacid ; about six sponges sufficed for an operation. For anabdominal operation we had flat Turkey sponges in addition.When all was ready the spray was turned on, and a finemist of steam, odorous with carbolic acid, soon bathed allengaged in the operation. If the spray failed, as it some-times would, a shudder ran round the theatre, and we gazedat each other in horror and deep apprehension as to the direconsequences of this unpardonable lapse on the part of theresponsible drcsser. In our mind’s eye we could see thebaflled germs, kept back so long by the antiseptic barrage,swooping down to the wound. Rubens, not even when hepainted Saint Ignatius in the rite of exorcism. ever saw evildemons more clearly. In the case of a senior member ofour staff. consternation was turned to respectful admirationat the extent and most decorative varietv of his vocabularyof denunciation and colourful invective. I have alwayssuspected one of our students, a great friend of mine, astalwart colonial, of having now and again engineered thecatastrophe, in order to learn something which mightenrich his own vocabulary, in which, however, few of uswere ever to discover any serious deficiency.The house surgeon, who assisted generally, wore an old

coat or a " blazer," whose long service had earned a rest :the dresser, who handed instruments and ligatures, was

1208

content with the turned-back cuff. The ligatures were ofcatgut, rolled on to spools kept in boxes filled with carbolicoil and fixed to the kidney-shaped instrument tables. Itwas the duty of the operation porter to roll the catgut,delivered by the maker in small bottles, on to the spools.As soon as the operation was complete, the whole area

involved in it was washed, over and over again, with anantiseptic solution, that most commonly used being carbolicacid of strength between 1. in 40 and 1 in 100. Clean casesand infected cases were treated alike. Often the edges ofthe wound were held together, and the lotion forced intothe wound with a Higginson’s syringe, in the hope that the" cellular spaces

" would be distended with the antiseptic.All wounds except the smallest were drained. A " radicalcure " of hernia, for example, was treated by Mitchell Banks’smethod ; the sac up to the external abdominal ring wasremoved. The hernia, that is to say, was converted froma complete rupture to a bubonocele. The wound beforeclosure was wiped over with a 1 in 8 solution of carbolicacid in glycerine, and a drainage-tube was introduced. Thisexact method I saw practised nearly 20 years later byLucas-Championniere (who explained that he had nevervaried the method since he had learned it from his master,Lister, in Edinburgh.) Bassini had not, in 1888, publishedhis paper in which he first made it clear that the inguinalcanal must be laid open and repair begun, not at theexternal, but at the internal ring. Over the closed woundiodoform was dusted and a dressing of carbolised gauzeand salicylic silk padding was held in position by carbolisedbandages.There was one operation day in the week, Thursday.

The senior of our four surgeons began at one o’clock ; hislist completed, the surgeons followed in order of seniority,Jessop, Atkinson (a Hey on his mother’s side), McGill, andMayo Robson. The time at which our firm could beginwas regulated by the length of the lists of the seniors andby their punctuality, not always or often impeccable. Ican still see Mayo Robson, arriving in the hope of an earlystart, but frustrated and delayed, becoming more and moreimpatient. He was even then the busiest member of thestaff outside the hospital and had no time to waste. Soin desperation, another day was demanded for his list, andone of the most startling innovations, bitterly opposed, ofcourse, was inaugurated.

Abominal Siirgery.Abdominal operations were things apart. No deliberate

abdominal section was ever made in the ordinary theatres.Private wards were available, and special nurses ; and thehour of 8 A.M. was consecrated to the performance of suchvery critical operations. It was the prerogative of theresident surgical officer to help with every one.The year 1888 was an eventful one. No case of appendi-

citis was operated upon, though our records show one caseof " perforation of the vermiform appendix " treated byoperation in 1887. In 1888 one case of " perforating ulcerof the stomach " was operated upon with a fatal result -,and one case of gastro-jejunostony for carcinoma of thepylorus also failed to recover. In all, 15 abdominaloperations, including " explorations," were performed,with 12 deaths. Of the 45 cases, 14 were examples ofovarian cyst. The first nine cases of cholecystotomy wereperformed, with two deaths.The cases of acute intestinal obstruction, transferred,

after due delay naturally, from the medical wards to whichin the first instance they were invariably admitted, exhibiteda veritable martyrology. Any escape from the dread ofthe cases was worth consideration, and I am sure we sawlittle humour in the suggestion made by JonathanHutchinson that the victim of strangulated intestines mightfortunately experience a disentanglement of his ensnaredbowel if, while held by the arms and legs by stalwart police-men. his body, face downwards or inverted, was heartilyshaken from side to side, or submitted to vigorous abdominaltaxis combined with copious enemata. Hutchinson in 1890admitted that this was a

" troublesome and somewhatundignified procedure," but was confident that if it couldbe shown to be effectual " no conscientious surgeon willallow himself to neglect it because it, is disagreeable." Asa solace to those who might regret the loss of a case nottreated by operation, he asserted that during 20 years ofsurgeoncy at the London Hospital lie had never, so far asmemory served, encountered a case in which the post- mortem upon a case of intestinal obstruction made himregret that he had not opened the abdomen. If one of Ithe most distinguished members of our profession, whowas then President of the Royal College of Surgeons, couldsay this, what criticisms as to ill-conceived and recklessadventure might not the pioneer in surgery expect from thephysician or pathologist ? What courage and what indiffer-ence to criticism must the surgeon then have shown.Mikulicz told me, in 1903, that he had operated upon 35cases of perforated gastric ulcer with 34 deaths. (I havenever found the published record of this.) But, as I used

to tell my students, there was another way of looking at thisstory. Mikulicz had operated upon 35 cases, with one-

recovery. One life was saved, not a large number sacrificed.

Coats and Gloves.I well remember the first coat ever made for special

wear in the operating theatre. Mayo Robson designed it.The material was a, soft tweed, of rough surface, and alight blue-grey in colour ; it reached the knees, and itsstand-up collar came near to the chin. It was worn foryears, and I clearly remember that on one occasion, certainly,it was cleaned. When I became resident surgical officer,in 1890, I introduced white washable coats ; and I can recall,my shyness at entering the theatre with Mr. W. H. Brown.both of us in spotless white, and the titter which developedinto a guffaw at our ridiculous appearance. Rubbergloves did not come until later, and I believe that I was thefirst surgeon in Europe to wear them. They were introducedinto surgery by Halsted, of Baltimore. I had been struckby Halsted’s writings, and in my youthful enthusiasm andgratitude I had written to him inquiring about some pointin connexion with hernia. He was a good and most con-siderate and helpful correspondent ; and soon after hisintroduction of the rubber glove he sent me six pairs, and Iwore them for months, puncture or no puncture, and enjoyedthe mocking hilarity of my colleagues and the students.The complete change of clothes, white shoes, trousers,

coats, sleeves, cap, and mask, did not begin with us untilMay, 1903. The students called me then the " pyloricpierrot." It is astonishing to learn that even to-day thechange of clothes for work in the theatre is not universal.For, in the first place, it is quite a simple experiment to,demonstrate, by soiling clothes with easily recognisableorganisms (the bacillus prodigiosus, for example) that germsare cast from them to all parts of the theatre. Some ofthese may be harmful to the wound ; and it is better to keepthem away. And, in the second place, the comfort of thesurgeon is something; and the comfort of a change is.undeniable. The reek of ether in the garments of the theatreis sometimes very unpleasant to patients or friends seenlater in the day.

Equipment and Technique.The theatre itself has changed beyond recognition.

Forty years ago the benches in our theatre were of wood ;the windows had heavy sills, the roof had beams across it ;the instrument cupboard was of oak, with lined woodenshelves, the floor was covered with oilcloth, there was an openfireplace, the chairs were of the ordinary kitchen type;one door opened into a corridor, another on to the landingat the top of the staircase along which everyone passed tothe wards, -B. spray in the theatre was very necessary.Leonard Hill has lately shown the surprising effects producedon the germ content of the atmosphere by spraying it withan antiseptic.The work done in the theatre was of course quite different

from that seen there to-day. A comparison of our operationlists 40 years ago. with those of the present time, are fullof interest. Tumours were removed, deformities repaired,defects made good, sinuses leading down to tuberculous,glands or necrosed bone were dilated and scraped." Bigelow’s dilator " was an instrument required for everyoperation list and lay beside Volkmann’s spoon. -11r.

Jessop used to say that the change wrought by Lister in

surgery was that surgeons learnt to wash their hands-before operating rather than afterwards ; that, in short,an operation was a clean thing, not a dirty thing. Surgery,when made safe by Lister, ceased to be merely remedial,and became the most powerful instrument for research into-the diseases of man ever placed in our hands. It is almostimpossible to convey to a young surgeon of to-day the-bewilderment in the minds of older surgeons when firstthey were confronted by conditions within the abdomenwhich no text-book of medicine or pathology could explain.When McGill began his work on prostatectomy the patientwas placed in the Trendelenburg position (a position intro-duced into surgery for operations upon the bladder) and theprostrate nibbled away or enucleated under the eye of thesurgeon. This old method has been rediscovered at theMayo Clinic and by Thomson-Walker ; but such lapses ofprofessional memories, followed by renewal of forgottenmethods, are not unusual. The text-books of the time toldus little or nothing of variations in the form of the prostateand the different mechanical effects thereby produced.In the abdomen the confusion was far worse. I recall anoccasion at the meeting of the Leeds and West RidingMedico-Chirurgical Society when Mayo Robson spoke ofhaving introduced his finger into the common bile duct.A pathologist made this an opportunity for derision at theabsurd statements by surgeons, which he said were becomingalarmingly frequent. He pointed out that the commonduct could comfortably contain a knitting-needle, that thepresence of a human finger within the duct implied eitheran attenuation of the digit, or an expansion of the duct,

1209

with neither of which had his observations made himfamiliar.

The Debt of Medicine to Surgery.During the year of my house surgeoncy the hybrid word

appendicitis was not mentioned. That the appendix wasattacked by inflammation and gangrene, that it might sufferperforation, and be the cause of a generalised peritonitis,had been recognised by Wilks and Moxon, and made clearby R. Fitz, of Boston, in 1888. Fitz it was who first recog-nised and described acute pancreatitis. For our modernknowledge of abdominal diseases, their symptoms, their

alliances, and the modes of operative treatment best suitedto them, we are indebted almost wholly to the surgeons.I have before suggested a comparison between the knowledgedisplayed in the first edition of Fagge’s Medicine, and ourknowledge of to-day, to show the debt which medicine owesto surgery. Surgery then, as created by Lister, is not onlya remedial measure, safer beyond all calculation than itwas before his time, but it is a method, the best indeed ofall methods, of inquiry into the symptoms, the origin,relation, and progress, and the treatment of intra-abdominaldisorders. Surgery has had, however, to fight too muchalone. The physician in many cases, happily not in all,had seemed to lose interest as soon as the surgeon takescharge of a case, with the unfortunate result that a spiritof antagonism as between medical and surgical treatmenthas been allowed to creep in, and to embitter relationshipsbetween the practitioners of each method. This is not onlyfoolish, but wrong. Our business is to understand, tocontrol, and where possible to alleviate or remove diseasesfrom patients who suffer. We are all, therefore, workingto the same end, and we shall work better if we work together.The physiologist, too, has seemed to stand aloof. As Dr.C. G. Douglas and I pointed out last autumn, almostsimultaneously, human physiology has been too muchneglected. Research upon animals, for some quite inex-plicable reason, has been put in the foreground. For thismisdirection of effort, responsibility, or perhaps I shouldsay, blame, in my judgment attaches both to the MedicalResearch Council, which in some degree inspires and finances" research work," unaware, or indifferent to the value ofresearch in the wards or operating theatres, and to the RoyalSociety which now gives its Fellowship as a reward almostexclusively to those who spend their sheltered lives in thelaboratory and are ignorant of clinical research ; neither bodyis well-advised. To-day every surgeon realises how muchhe depends for an insight into the maladies afflicting hispatients, and for his power of control of them, upon thepathologist and his co-workers. They are able to tellhim what things have happened, what changes have alreadytaken place in tissues, secretions, excretions, &c. ; and fromthis much is learnt to guide the principles or the details oftreatment. I think physiologists, by a study of the normal,and the almost normal. would surely give us help in dis-covering far earlier changes, and would enable us to preventsome, at least, of those late and terminal conditions withwhich to-day we are far too much involved. If preventive emedicine is to-day in the forefront of our minds, is therenot preventive surgery also ? And if there is, will a studyof fully developed diseases, such as the surgeon meets inhospital, be the best means of advancing our intimacywith it :’ Can we expect to learn embryology by the studyof fossils ’

The Pathology of the Living.The next step to be taken in hospital administration

will, I hope, involve the appointment of general practitionersalso upon the staff, and the provision of beds where earlycases can be admitted for observation and inquiry. Hereis an almost virgin field for investigation by experts, and inthis matter the general practitioner, and not the consultant.is the expert.

’

When I was a house surgeon our knowledge of thesymptoms and results of disease were based upon descriptionschiefly written by physicians attached to our teaching hos-pitals, and by pathologists who examined the bodies ofthose dead, very often at long last, of their diseases. Patientsare not, and were not then, admitted to hospital unless theirdiseases were in full course, and gravely threatening lifeor health. What could the physician to a teaching hospitalknow of inaugural symptoms, and what opportunitiespresented themselves to a pathologist for recognising earlystructural changes : When the adventures of the surgeonplaced at his disposal earlier material for a study of morbidchanges than those which had caused death, his observationswere often derided and denied by post-mortem pathologists.In support of our claim to a knowledge of far greater valuethan that derived from autopsies, I spoke of the ,. pathologyof the living." And when discussions arose as to theoccurrence or frequency of malignant degeneration in a

chronic gastric ulcer, I suggested that a " histology of the

living" " was needed to settle the question. I have knowndeath occur from " recurrence " of carcinoma in the liver of a patient whose stomach had been removed for what J

the pathologist refused to accept as "cancer." Happilythe process of tissue culture may help us here ; and we mayperhaps recognise a different behaviour in many respects

1 when a simple is compared with a malignant cell, as each is; minutely observed undergoing growth and multiplication.

Alliance of Surgery with the Sciences.The plea I make to-day is for all sciences to be brought

into an even closer alliance with surgery. The craft of. surgery has reached something near the goal. If operationshave to be practised in the future, it is not possible to

imagine any considerable improvement upon the methodsand results of to-day, as exemplified in the hands of the greatmasters. Other methods of treatment may come to the

’ fore, and much may be expected from prevention ; butexpert craftsmanship with a perfect technique can do littlemore to improve our work. The art of surgery has outrunits science. The corollary is obvious. It is that theancillary sciences must help surgery more than they arenow doing. Chemists, physicists, but especially andimmediately physiologists, must come closer to us, and beencouraged to find in routine work upon human beingswho show a minor departure from standards of health, someexplanation of this deviation and some methods of avertingor arresting the morbid process. There are hosts of questionsthat the surgeon asks, and until the physiologist learns, bydaily work in the wards and in the theatres, what thosequestions are, it is not to be expected that he will make theeffort needed to answer them, or even perhaps realise thatan answer is urgently demanded. Physiology needs a neworientation ; its interests are now too largely centred onproblems of secondary interest to mankind. I should liketo see a physiologist also added to the staff of every teachinghospital.Now let us suppose that a surgeon who had ceased to

practise 40 years ago, who had seen and heard nothing ofsurgery in the meantime, could be brought back to anoperating theatre to-day, and could stay with us for a

day’s work. What would be his impressions ? I fearthat he, too, would be shocked. He would discover atonce that the architecture and equipment of theatreshad been radically altered. He would find the appareland behaviour of surgeons, nurses, and spectators changedto a degree that would at first seem ludicrous. He wouldsee the old operations, upon which he embarked withanxiety and alarm, performed with a degree of confidentease and their issues regarded with a degree of certaintythat would astound him. He would watch operations, thevery names of which might be meaningless to him, and thevery thought of which would strike him with acute misgivingand dismay. He would remember that in his day a manwho practised ovariotomy was held, by responsible andsober-minded people of his own profession, to have earnedan indictment for manslaughter. He would realise that thesurgeon was on terms of almost indecent intimacy with thebrain, the heart, lungs, and abdominal viscera : and thisknowledge of the diseases of these organs, which everyword and action revealed, would leave our honoured visitorutterly bewildered and incredulous. You will complete thepicture for yourselves. r ask you only to remember thatit was the labour of one who was physiologist as well assurgeon who made all this possible ; and that if we are tocarry his work still further and perhaps complete it, it canonly be by conjunction in effort of physiologist and surgeonin the wards and operating theatres to-day.

WORLD LEAGUE FOR SEXUAL REFORM.

Dr. Norman Haire asks us to announce the foundationof a World League for Sexual Reform (W.L.S.R.), designedto make the results of scientific sexual research of practicalservice to mankind. Its chief object is to encourage thedevelopment of sexual sociology and sexual ethic based onbiology and psychology rather than, as in the past, ontheology. The first World Congress of this league is to beheld in Copenhagen from July 1st to 4th, the place ofmeeting being the Studentenforeningen, Vestre Boulevard 6.At the inaugural session, 10 A.M. on Sunday, Dr. Hirschfeld(Berlin) will lecture on Sexual Reform, to be followed by adebate in the afternoon. On Monday Mrs. Dora Russell(London) will lecture on Sexual Education. On TuesdayDr. Leunbach (Copenhagen) will lecture on Birth Control,and on Wednesday Prof. Pasche-Oserski (Kieff) willlecture on Sex and Criminal Law. Anyone wishing to

join the League, or to participate in the Congress, shouldapply to Dr. Leunbach, Stockholmsgade 39, Copenhagen,Denmaz k.

_____

THE Health Service Bureau of the Wesleyan and GeneralAssurance Society writes to point out that all distributionsof the pamphlets described in our last issue are made entirelyfree of charge.

1210

PRACTICAL AND VIVA VOCE EXAMINATIONS.DURING this part of a summer session medical students

at all stages are facing examiners with feelings of anxietywhich might have been less acute if they had devoted moreattention to the pattern of the practical and viva voceexaminations before them. In the course of a leaflet onthe duties of examiners issued by one of our largest uni-versities, the general scope of such examinations is welldefined. A practical examination is designed to be a testof practical experience, skill, and accuracy ; a viva voceshould be a guide to the range and precision of the candi-dates’ knowledge. If this distinction were borne in mindby students and their teachers, rehearsals appropriate foreach ordeal might be planned. Before a practical exam- ’,ination, set tasks could be deliberately and carefully ’,performed in a given time, whether in a laboratory or at ithe bed-side. This task should not be hurried. The workset always takes up less time than is allotted if things gowell; even when accidents occur, there is usually amplemargin. Moreover, to quote from the ’recommendationsreferred to above, such exercises are set " in the carrying-outof which one mistake will not lead to the total loss of definiteresults." Before viva voce examinations, preparationshould be sought in the form of " rags " during which arapid fire of quite unconnected questions is directed to onestudent. Systematic interrogation of each member of aclass in turn does not develop the quick reaction timewhich is essential for success. Candidates who complainthat the questions asked them at viva voce examinationsbecome progressively more difficult can take comfort fromthe knowledge that this is not exasperation, but deliberateinstructed policy, for " examiners are reminded that inorder to make it more easy for candidates to overcomethe nervousness from which they are likely to suffer, it isadvisable that the first questions put to them should beof a comparatively simple character." The nervousness isnot likely to be all on one side, since the examiner whoreads his instructions will find that his powers are limitedand his duties arduous. Graduates who are appointed tothis high office before the memory of their ordeals on theother side of the table has had time to fade are nearlyalways surprised by the low level of the answers at ordinarypass examinations. They also learn that a sympatheticattitude towards candidates is required if the pass-list isto be issued with a reasonable proportion of names abovethe line, and that their first and most important duty is to !,Icultivate and maintain this attitude. ,

IMPROVEMENT OF TRANSPORT BY AMBULANCE. ’,THE keen discomfort, sometimes amounting to acute pain,

caused to victims of accident or acute illness by the joltingof a badly sprung ambulance is seldom the subject ofdefinite complaint. The sufferer has to undergo still morestrange and perhaps more distressing experiences in thehospital or nursing home, and his gratitude for the promptattention and sivift removal is stronger than his memoryof the uncomfortable journey. Special inquiry on the partof the practitioner, however, will occasionally elicit the factthat in spite of most careful handling by the attendantsthe journey was a nightmare. This was the experience ofa patient known to us who after a perforation of the intestinaltract found a short drive through a well-paved town in anambulance much less tolerable than a much longer periodin a smooth-running private car on country roads. Squeaksand rattles are disturbing, but not serious inconveniences ;more important are defective springing and shock-absorption,but it was the vibration of an old engine and the jerkingdue to a fierce clutch which caused most distress in theparticular case brought before our notice. The ambulancesunder the control of the Order of St. John and the BritishRed Cross Society are for the most part kept in good repair.According to the report for the last quarter of the HomeService and Ambulance Committee complaints are rare,

and the committee note with satisfaction the increasedattention given by stations to the care of their ambulances.They point out, however, that many of the ambulances are’housed at commercial garages and driven by hired drivers.Arrangements are made for cleaning and ordinary attention,but the average garage proprietor is not likely to be on thewatch for the minor defects that develop in motor vehiclesand may distress or even harm the patient. That theattendants whose duty it is to travel with the patients,do not always observe the development of jolts and rattlesand discover their origin is evident from the condition ofmany of the ambulances when they are returned to head-quarters at the end of their service. The first and mostfrequent neglect is that of oiling and greasing the chassis,especially in the less accessible parts. Especial attentionis drawn to the neglect of the oilers on the spring perches,particularly those at the rear. The springs themselves aresometimes left too long without being re-greased. Backsprings are allowed to settle, bringing the tail of the body

down ; these should be properly set up. Improvement inthis respect can sometimes be achieved bv 1itting longerperches, which are effective in reducing the body sway andalso, when the load is heavy, in preventing the bumping ofthe wings against the tyres. In a number of ambulancesreturned to headquarters the commutator is in a dirty state,the coil system has been exposed to leakage of water throughdefective joints in the dash, and the bodywork has been

neglected in that screws of latches and fittings of windows,doors, and seats have been allowed to get slack. It wouldbe Imfair if this statement were taken to imply that themajority of ambulances are in an unsatisfactory condition.Tributes to the punctuality and care shown by the voluntaryworkers are constantly being received and are well deserved.At the end of March, 1928, there were 302 of the committee’sambulances in the country, as well as 62 affiliated stations : during the last quarter these 364 ambulances carried648,142 cases. It is in view of the increasing activity ofthis branch of first-aid work that attention has been calledto the need of improving the standard of comfort in someof the older vehicles and to maintaining it in the newer ones.The committee offer many hints directed to this end, of whichthe most useful is the information that air mattresses canbe obtained to fit standard road stretchers. The additionof such a mattress to the equipment will make long journeystolerable even in an ambulance which has seen its best days.Local detachments will be well advised to provide themselveswith such a useful and inexpensive means of neutralisingthe shocks of the road.

A MEDICAL SOLDIER.THE death of Major-General Leonard Wood last year

removed a man of great achievement, who will be rememberedas one of the most remarkable Americans of our time.An address by Major-General C. P. Summerall, of theUnited States Army,! gives a good idea of his career.

The son of a village doctor in New Hampshire, he was aman of outdoor sports, but also an omnivorous reader.He took up the study of medicine, graduated in 1884, andpassed, second of 59, into the U.S. Army medical service.Reporting in Arizona on July 2nd, 1885, he persuadedCaptain Lawton to take him next day on an expedition.It lasted 21 months, and when the last company commanderleft through exposure and fatigue, Wood volunteered forthe duty, and at the end, received the Medal of Honor for-distinguished conduct. On 1898 he became colonel of theRough Riders in Cuba ; six weeks later his regiment droveout the Spaniards, and he spent the night dressing the-wounds of 30 of his men. A fortnight afterwards he waspromoted brigadier-general, and was made governor ofSantiago, and such was his success as administrator thatin due course he was appointed military governor of Cuba.He thought yellow fever might be due to a mosquito, andcordially supported Read and his colleagues in their work.His initiative, says General Summerall, made the PanamaCanal possible, and Lord Cromer described his adminis-tration as governor-general of the Philippine Islands as thegreatest colonial work of the century. For four yearshe served as Chief of the General Staff of the United StatesArmy-a prophet of preparedness-and in 1913 he started theofficers’ training camps, which furnished 100,000 officersin the World War. His advice to others, as to himself, was," Always volunteer, no matter how dangerous or unpromis-ing the task ; you are likely to discover opportunity. Dothings, don’t talk about them." No soldier could outwalkhim, none had more ceaseless energy, he was never toobusy to be courteous and kind to juniors, and secured thedevotion of those who served with him. That his namemay be kept continuously in the minds of United StatesArmy officers, it has been decided that the military stationnear Washington shall, in future, be called Fort LeonardWood.

CARBON MONOXIDE GAS POISONING.WE regret that Prof. Hamilton Hartridge’s paper on this

subject, appearing on p. 1137 of THE LANCET of last week,was published without the corrections made by the author.In Table II. the words " in actual haemoglobin " shouldread " found in haemoglobin " ; in section 8 the symptomsof poisoning by exhaust gas ought to be given as " dullness,dizziness, sickness, and weakness of the limbs " (not bowels);whilst in section 10 the remedies mentioned should b&"

oxygen in cylinders, or, better, oxygen with 5 per cent.(not 50 per cent.) carbon dioxide." The publication whosename is given in reference 1 is issued by the United StatesBureau of Mines.

_

1 Military Surgeon, April, p. 526.

BROMLEY (KENT) COTTAGE HOSPITAL.-A DiamondJubilee Fund of £12,000 is being raised for extensions andimprovements. At present the operating theatre can be-

approached only through the surgery and accident ward.