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The M orphia Habit.In one of the Parliamentary Committees a question

has been put to the Government as to whether themorphia habit is increasing in Germany. A represen-tative of the Health Office states iii reply that for every100,000 of the population three men and one womanare known to indulge in the habit. The numberof patients treated in hospitals and sanatoriumsfor this condition was 1497 in the period 1911-13,3084 in 1920-22, 1283 in 1923, and 1623 in 1925.The number of deaths attributed to this form ofintoxication was 32 in 1923, 18 in 1924, and 39 in1925. A total of 2400 kg. of alkaloid imported intoGermany is compared with an export of 9520 kg.during the same period, and the question has beenraised whether its production should not be limitedto the amount consumed. To this suggestion theGovernment spokesman replied that there is a greatneed of alkaloids throughout the world, and thatonly a few countries produced them-namely, GreatBritain, Switzerland, France, Germany, and Japan.The matter is regulated by international conventionswhich make it illegal to use them for purposes otherthan the strictly medical. The committee eventuallyadopted a motion that the Government should con-sider measures to limit the production of alkaloids tothe quantity necessary for medical purposes inGermany.

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The Services.ROYAL NAVAL MEDICAL SERVICE.

Surg. Lts. (D.) to be Surg. Lt.-Comdrs. (D.) : J. M. Park,J. L. Edwards, and S. E. Brown.

ROYAL NAVAL VOLUNTEER RESERVE.

Surg. Lt. S. B. Borthwick to be Surg. Lt.-Comdr.

ROYAL ARMY MEDICAL CORPS.

Maj. P. S. Tomlinson, R.A.M.C., to be Divl. Adjt. 56th(1st Lond.) Div. T.A., vice Maj. A. R. Ross, R.A.M.C., whovacates the appt.Maj. H. H. Leeson retires on retd. pay and is granted the

rank of Lt.-Col. ’

Capt. A. P. Draper, R.A.M.C., to be Divl. Adjt. 52nd I(Lowland) Div. T.A., vice Maj. G. D. Yates, R.A.M.C.,who vacates the appt.

Capt. D. J. Batterham retires, receiving a gratuity.Lts. (on prob.) confirmed in their rank : P. V. MacGarry,

J. E. Swyer. and A. McMillan.Lts. T. S. Torrance and N. R. Rawson to be Capts.A. D. Briscoe and N. H. Watson (late 2nd Lt. Durham

L.I.) to be Lts. _

ARMY DENTAL CORPS.

Lt. A. Hughes to be Capt.TERRITORIAL RESERVE ARMY OF OFFICERS.

Capt. A. S. L. Malcolm, from Active List, to be Capt.

ROYAL AIR FORCE.

Flying Officer R. A. W. Kerr is promoted to the rank ofFlight Lt.

Flight Lt. T. J. X. Canton is promoted to the rank ofSquadron Leader.

Flight Lt. A. H. Mills (Temp. Capt., General List, Army,Dental Surgeon) relinquishes his temporary commission oncompletion of service.

RESERVE OF AIR FORCE OFFICERS.

Flying Officer R. G. J. McCullagh relinquishes his com-mission on completion of service.

DONATIONS AND BEQUFSTS.-The late Mr. C. J.Schoonhoven, of Finchley, left some 230,000 to be dividedamong ten London hospitals at the discretion of hisexecutors.-The late Mr. James Bebby, of New Brighton,left 21000 each to the Liverpool Royal Infirmary, theLiverpool Royal Southern Hospital, the Liverpool DavidLewis Northern Hospital, and the Bootle Borough Hospital,

Iin each case for the endowment of a " James and Margaret IBebby Bed."

Correspondence." Audi alteram partem."

SHOT IN THE VERMIFORM APPENDIX.To the Editor of THE LANCET.

SiB,—I have read with much interest the case

reported in your last issue by Prof. John Fraser,together with his valuable comments thereon. Ithas for many years been my practice to remove theappendix in practically every abdominal sectionI perform for non-urgent conditions, and afterwardsto slit it up for examination. On only four occasionshave I met with shot in the appendix, and in onlyone of these had the condition been suspected priorto operation. This was in a youth of 20, who afterspending five weeks shooting on his father’s estate inScotland and living largely on game, developed somevague abdominal discomfort for, which his medicaladviser ordered him to be radiographed. The radio-grapher reported that there were 15 pellets in theappendix ; a second radiogram ten days later showedonly nine. Although it was considered quite likelythat the pellets might be passed naturally, yet as theyouth was about to take up residence abroad appendi-cectomy was decided upon, and two days laterI removed the appendix. It contained nine pellets atits distal end, the mucosa at this region being verydefinitely reddened ; otherwise the appendix wasnormal, and was free from adhesion.A consideration of the enormous amount of shot

game that is annually consumed suggests that theentry of pellets in the appendix is not a very rareoccurrence, and that most of them ultimately escapetherefrom and are passed naturally.

I am, Sir, yours faithfully,ARTHUR H. BURGESS.

To the Editor of THE LANCET.SiR,-The clinical notes of Prof. Fraser recall a case

I saw, I think it was in 1913, of a locally well-knownsportsman whose shoot was near Edenbridge in Kent,from whose appendix some 24 shot were removed atan operation by Mr. J. B. Footner, of TunbridgeWells.-I am, Sir, yours faithfully,

F. THOMPSON, M.R.C.S., L.R.C.P.

A TUDOR ACT OF INDEMNITY FOR

UNQUALIFIED PRACTICE.To the Editor of THE LANCET.

SiR,-The principal interest attaching to the docu-ment found at New Romney is the question of itsauthenticity. It does not ring true. At no time,so far as is known, has it been possible to inhibitthe medical practice of " divers honest persons...whom God hath endued with the knowledge."Medical faculties possessed of extreme repressivepowers, even ecclesiastical authorities, have tried invain to do so. If, then, Henry VIII. found it neces-sary to protect the self-constituted practitioners ofmedicine, his Statute must be unique.The knowledge of the existence of such a document

is, however, an old story. Sir D’Arcy Power musthave had it before him, in whole or part, 40 yearsago, for he quotes some sentences verbatim from itin his " Memorials of the Craft of Surgery " (Casselland Co., 1886). It is right to add that though hegives no reference to an authority, he appears toaccept the document as genuine. The " customablediseases " are, also, well known. " A pin and thewebbe in the eye " very commonly go together.Thus Leontes in " A Winter Tale " speaks of " alleyes Blind with the pin and web but theirs." Pin orpane or panne (from pannu8, a cloth or web) refers

1209

to some opacity in the eye, generally of the cornea ;sometimes to cataract, where that was visible fromwithout. Webbe was of similar character and sur-vives in web-eye (pterygium). Morfew, or more

properly morphea, was applied to various skin affec-tions, the white variety being identified with leprosy.Saucelim is a variant of saucefleme-i.e., salsum

phlegma, or salt rheum. Chaucer’s Sompnour wasafflicted with it, and the poet’s description of the diseaseand its treatment is probably as definite as can befound anywhere.

That hadde a fyr-reed cherubynes face,For sawceflem he was, with eyghen narwe.

Ther nas quyksilver, litarge, ne brimstone,Boras, ceruce, ne oille of tartre noon,Ne oynement that wolde clense and byte,That him might helpen of his whelkes white,Ne of the knobbes sittyng on his cheekes.

As to the power vested in the bishops to issuelicences to practise and even degrees in medicine,this was common in the Middle Ages, and Henry VIII.in the Act of 1511 was merely following precedent.It may be recalled that a few years ago the suggestionwas made that a certain well-known bloodless surgeonshould have the custom revived in his favour, andreceive the diploma of M.D. from the Archbishop ofCanterbury.

I am, Sir, yours faithfully,G. MATHESON CULLEN.

To the Editor of THE LANCET.SIR,—The word " saucelim " should apparently be

read as sause-fleme, or sawceflem, a word which wasused to signify an eruption of red spots or scabs onthe face. There is a reference in Chaucer as follows :" For sawceflem he was, with eyes narwe," and manyyears ago there was a discussion on this word in Notesand Queries, and in the editorial footnotes to Chaucer.It is the same as the French sauce, Latin salsum, andthe Greek phlegma (cf. phlegmon). In English Isuppose it would mean " salty inflammation." Thefl may be a compound letter in the ancient script,such as we still use in our small printing type, or elsethe 1 has been put erroneously for the compound fl.In the " Index to the Statutes in Force " the Actsare stated as follows :-

Surgeon.-Prohibition from practising as, in England,unless licensed by bishop ; saving of privileges of univer-sities, 3H8.c.l1. Saving as to persons treating outwardsores by external remedies, 34-5H8.c.8.

It is the latter Act which is described in the articlein THE LANCET of Nov. 24th.

I am, Sir, yours faithfully,BLANCUS.

TONSILLECTOMY OR GALVANO-PUNCTURE ?

To the Editor of THE LANCET.SiR,-Dr. Paterson and Dr. Bray tell us (THE

LANCET, Nov. 24th, p. 1074) that 3909 tonsillectomieswere performed at Great Ormond-street Hospitallast year, and they suggest that no other operationin children’s medicine shows such dramatic result.But is there no alternative to the complete removal

of the tonsils, an operation performed nowadays inalmost every case in which there is enlargement,sepsis, follicular disease, or any condition of thethroat, ear, nose, or cervical glands, in which thetonsil is suspected (frequently wrongly) of causing themalady ? Inspectors of schools report that children ofdelicate physique, perhaps backward in intelligence,or undergrown, showing the slightest throat or nosetrouble with any difficulty in breathing, or slightdeafness, should have their tonsils removed. Theparents are informed that this must be done imme-diately, and instructed to take their child to thehospital. If they refuse they run the risk of beingprosecuted for cruelty. The consequence of thiscraze (for I can call it nothing else) is that the hospitalshave great difficulty in dealing with the cases which

they are called upon to treat. A medical correspondentrecently gave an account of the almost appallingfact that, by means of what was called " team-work,"the throat surgeons were able to deal with 20 cases in.an hour. The children, as far as I am able to learn,are mostly sent home the next day. How is it possibleto ensure freedom from septic infection when a rawoozing surface, some 4 sq. in. in extent, is left after thetonsils have been removed, and the adenoid tissuescraped away ? There is also the risk of hoemorrhage.

All is not well when throat surgeons regard thedangers lightly and laugh at those who, after manyyears of clinical experience, consider tonsillectomyunwise. We, who object, consider that all thelymphatic tissue of the body is nature’s first line ofdefence against systemic infection. Why is extractof lymphatic gland recommended for adenoids andhypertrophied tonsils ? Can anyone quote a case inwhich phthisis or general tuberculosis was definitelyproved to originate from a local nidus in the tonsil orelsewhere ? I can give instances which point in theopposite direction. When I was in general practicemany years ago a man of 50 had a small sinus leadingto a tuberculous great toe-joint which had beendiseased for many years. It gave him very littleinconvenience in his daily work. A few drops of puscame away every morning when he washed it, and hecovered it with a small piece of lint. A young F.R.C.S.who was acting as locum tenens for me advised himto have the joint excised, and a month later the poorfellow was dying of acute miliary tuberculosis. Ihave never forgotten that lesson, " Let sleeping dogslie." Daily auto-immunisation from the toe-joint hadbeen sufficient to keep the body healthy for 26 yearsand, but for the surgical interference, the man wouldnot, in my opinion, have lost his life from that cause.I believe that lymphatic tissue has an importantfunction, similar to that of the lymphocytes of theblood. The tonsil is a mass of lymphoid nests, renderedsponge-like by a number of lacunee, crypts, or follicles,call them what you will, which penetrate deeply intothe interstices between the lymphoid tissue. Thesechannels are open on the surface and end in cul-de-sacs in the substance of the tonsil. The tonsil isseparated from the other structures of the pharynxby a fibrous capsule, the function of which seems tobe to prevent the passage of infective material intothe tissue behind it. As, however, the tonsil is freelysupplied with blood-vessels, the serum-soluble toxins,produced in the lymphoid nests which absorb patho-genic germs from the crypts, find their way into theblood stream and stimulate the formation of anti-bodies which immunise the general system. I submitthat the rise of temperature which occurs in thoseinfections which in the old days were called " diph-theritic throats " (streptococcal infection) is due tothe absorption and circulation in the blood of thetoxin generated in the lymph tissue. These throatsyielded readily to conservative treatment : sprayingwith an efficient antiseptic solution and the admini-stration of that powerful antistreptococcic drug,acetanilide.What is the alternative treatment ? Surely the

galvano-cautery. For 35 years I have used no othermethod. After a local anaesthetic the cautery point isinserted deeply into any caseating follicle which canbe seen, and quickly moved round and round in acircle, so that it disinfects the surrounding lining ofthe lacuna. It also opens wide the mouth of the cryptwhich never closes again, thus ensuring free drainage.I estimate that in quite 75 per cent. of septic throatspre-existing nasal infection is the cause ; in such casesI deal with the nasal mucosa first, using a spray ofchloramine T. 1-2000 in camphor water, flavoured withpeppermint and eau-de-Cologne. Any septic or hyper-trophied patches are treated first with the galvano-cautery. The red vascular appearance of the interior ofthe nose and of the pharynx subside, the mucosaregains its normal condition, and excessive secretionvanishes.

Throat specialists may argue : How can we findtime so to deal with all the children we are called