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or not, as students of the University. In this connexionI may perhaps point out that the medical schoolscan materially help the Court in maintaining thisattitude by impressing upon the non-London studentsat the London medical schools the importance of

registering in the new class created by the presentStatutes (No. 23), that of " Associate Students."The University has been disappointed to find howinfrequently students who are eligible to becomeassociate students avail themselves of the privilegeby the payment of the very small fee (10s. 6d.)demanded for registration.The correspondence which my first letter has

evoked suggests that the present character of thefinal examination is largely responsible for thediminished number of students who actually graduatein medicine. Some figures furnished to me by theacademic registrar’s department bear out this con-tention in the low percentage of passes recorded

during the past seven years.

Candidates who Candidates whosat for any part passed both or

of the examina- either parts of the Percentagetion for the final examination for of passes.

-A,I.B., B.S. the finaIM.B., B.S.1927.... 420 .... 288 .... 68-61928.... 412.... 216 52-41929.... 444 .... 270 .... 60.8 81930.... 452 .... 246 .... 54-41931.... 445 .... 246 .... 55-31932.... 443 .... 224 .... 50-61933.... 475.... 25 ... 53-5

Failures amounting to nearly 50 per cent. are in

my submission unduly high for a first qualifyingexamination, and although this position in no wayinvalidates my plea for the new degree in the placeof the second M.B., it suggests that the final examina-tion is in urgent need of overhauling. There can,I think, be no doubt that the present curriculum isgrossly overloaded, and the actual strain of theexamination itself, lasting as it does for 25 days, isa serious fault, as pointed out by your contributor" A successful candidate." But I fear that unlessthe schools themselves take action little will be doneto alter the curriculum. The Medical CurriculumCommittee appointed by the University two yearsago shows no signs of life, and its composition,comprising as it does a large variety of clashing inter-ests, does not give much hope of any practicaloutcome of its labours.

I may say that I have been a member of the Courtinspection of the medical schools of London uponnearly every occasion when an inspection was made,and I assert without hesitation that the presentcorrespondence has been far more useful in suggestingreasons for the paucity of students taking the finalmedical examination in medicine than the information

given at the inspections in answer to the questioninvariably put by the chairman at each visit : " Howdo you explain the small numbers of medical studentswho take London degrees ? " If the medical schoolscan only be persuaded to think out these problemsfor themselves, to come to some agreed opinion andto impart that opinion to the Senate, much good wouldI am convinced result.As chairman of the External Council for the past

12 years, I am extremely sympathetic with the letterfrom an external student in your issue of the 15thinstant. His point that at the final examination theexaminers should have some consideration of thefact that external students taught out of London

may present views other than those of London teachers,illustrates the importance of the provision which was

a part of the old statutes and has been unfortunatelyremoved from the new-viz., that one examiner atleast should be an external teacher. The ExternalCouncil in its recommendation of examiners hasendeavoured, with some success, to maintain thisrule in practice notwithstanding that it is no longerstatutory.-I am, Sir, yours faithfully,

E. GRAHAM-LITTLE.Wimpole-street, W., Dec. 28th, 1934.

SEVERE GASTRIC AND DUODENALHÆMORRHAGE

To the Editor of THE LANCETSiR,—I am surprised to note the complacency with

which blood transfusion is accepted as the routinemethod of treatment in severe gastric or duodenal

haemorrhage, and would suggest the use of liverextract as an alternative. At autopsy on cases treatedby transfusion extreme oedema of the lungs is fre-

quently noted. The patient has literally drownedhimself. As soon as a patient is admitted in anexsanguinated condition, the medical attendant onlytoo often orders an immediate blood transfusion

regardless of the unnecessary movement which sucha procedure entails, especially when veins are nonetoo easy to find. I am quite certain that blood trans-fusion has by itself a certain mortality, and alsothat unless the vessel in the stomach is tightly sealedit will cause the bleeding to recommence.

I have made blood counts on patients, who onadmission have had only about 1,000,000 red cells

per c.mm. and 20 per cent. of haemoglobin and havereceived a transfusion of a pint or more, and threeor four days later I have found their counts raisedby 3-400,000 red cells, provided there has been norecurrence of bleeding. I have also found that ifone has the courage to wait, although a patient is

obviously getting more and more anaemic, a stageis reached at which the bleeding ceases and this isusually not much lower than 1,000,000 red cells perc.mm. Those patients who bleed to death will do soin spite of all medical treatment, as it means that alarge vessel has been eroded, and the only measureto adopt would be to open the abdomen and tie thebleeding point-a procedure usually out of the

question, as by the time such a decision would bemade, the patient is moribund.We know that as soon as bleeding ceases, provided

there is no sepsis, the bone-marrow starts turningimmature red cells into the circulation, as a bloodfilm the next day shows marked poikilocytosis,anisocytosis, polychromasia, and nucleated red cells.For some time I used blood transfusion for thesecases, but was not impressed with the results, andwhen potent liver extract preparations came on themarket it appeared to me that we had a weaponwhich could be used to stimulate the marrow andaccelerate blood regeneration. In a few cases where

daily injections of liver extract were used I foundthat not only did the blood count rise in three or fourdays by the same amount as with blood transfusion,but on examining a film the red cells were far moreregular in size and shape, suggesting that maturercells were being turned into the circulation. There isalso some evidence that liver increases the coagu-lability of the blood. Iron may be given with

advantage after a few days in order that the

haemoglobin may keep pace with the increase ofred cells.

My suggestion is that patients with severe gastricor duodenal haemorrhage should be treated by givingon admission an injection of a potent liver extract

53

and then left undisturbed or, if restless, given morphia.To lessen the thirst the patient should be allowed"*to take sips of cold water as he desires. The injectionsof liver extract, supplemented with iron after a fewdays. should be continued until the blood count is

satisfactory. I am, Sir, yours faithfully,Woodford Green, Essex, Dec. 28th, 1934. L. HEWLETT.

DOCTORS AND OSTEOPATHS

A PARALLEL CASE ?

To the Editor of THE LANCET

SIR,—By a curious coincidence the recent debatein the House of Lords on the Registration and

Regulation of Osteopaths Bill immediately precededthat on the Supreme Court of Judicature (Amend-ment) Bill, one of the objects of which is to increasethe numerical strength of the bench. Were bothmeasures to become law there would be an increasein the number of those qualified to sign deathcertificates and a smaller, but even more significant,increase in the number of those qualified to pronouncesentence of death. It was unfortunately taken forgranted that these additional judges should bemembers of the legal profession, and a slur in conse-quence was cast on another body of men accustomedto dealing with questions of crime and punishment.

The principles of the Church and of the legal pro-fession are fundamentally different. The theory ofconscience and the punishments which an enlightenedconscience may inflict is contrary to the admini-stration of pain and penalties awarded in a court oflaw. But is it not desirable that every avenue shouldbe explored to its utmost limit and the potentialitiesof the Church in the treatment of sin be more fullydeveloped ? It would be a simple matter to pass aBill to enable bishops to sit on the judicial bench.A Board could be established armed with the neces-sary power to compile a Register of Bishops and toregulate their practice. The second main objectof the Bill would be to impose upon the bishops astandard of professional training and competence,comparable to that of the legal profession, whichwould debar the Free Churches and the SalvationArmy from the practice of spiritual discipline.The Church (and by Church is meant the Church of

England) differs from the law in that it usuallyprefers to dispense with the gaol and the gallowsand lays emphasis on a standardised spiritual tech-nique in dealing with the offender. It believesthat so-called crimes are due to a maladjustmentor misplacement of the spiritual framework of manand that the soul itself when it functions properlywill know its own remedy for disease, under theskilled touch of the clergy. Obviously the differencebetween the legal and ecclesiastical schools is funda-mental, but the country is entitled to know that inany addition to the judicature that is made the

existing laws regulating the treatment of delinquencyshall not allow any unnecessary or unreasonableobstacles to lie in the way of each school of thoughtdeveloping its system for what it is worth. Bishopsare at present labouring under a real disability.Their standard of education is high. They do not askfor admission to the legal profession, but they feel,and rightly feel, that they should have equal powerto pronounce sentence of death and in general to sitin judgment on their fellows. It is surely unnecessarythat a person should have a lot @f legal trainingbefore he is able to convict others of error. If anyonewere to go down to Whitechapel and summon a

meeting of hard-living hard-swearing men and womenand put before them the proposition that justice and

mercy can only properly be dealt out by those whohave had a legal training, he would be overwhelminglydefeated on the vote.We must remember that at the present moment any

judge who based his rulings on the instructions ofa bishop would be under a ban. He would do soat his peril and might forfeit his pension. The Innsof Court therefore stamp the bishop as a quack orcharlatan almost indiscriminately, and they have nomeans of helping themselves. The legal professionis notoriously conservative. It is not very long sincethe thumbscrew, the rack, and the stake had their

recognised place in the administration of justice.It has always been opposed to any idea of justicewhich has been in the slightest bit in advance of theordinary. Lawyers are indeed frightened that owingto the influence of the clergy their living may betaken away from them. But whatever the Law

Society may do the Church is here and has come tostay, and the time is not far distant when everysensible family solicitor will send his clients to the

parish priest as a matter of routine. A young fellowwho has furnished the Inland Revenue authoritieswith an inaccurate return of his income-and it

happens again and again-never thinks of going to thepolice. If he did he would be told to lie up for threemonths and get a stiff sentence. He goes to the parishpriest and in a week is his usual self. It is indeed

impossible to understand how anyone could refuse toa profession which now exists for good and is verywidely extending in this country the necessaryprotection and privileges which a Bill such as theone we have been advocating would afford.

I am, Sir, yours faithfully,Dec. 31st, 1934. W. F. H.

PS.-After reading the official report of the earlierdebate I am left with the conviction that there ismore joy in the House of Lords over one sprainedankle that an osteopath has manipulated than overninety-and-nine tuberculous elbows which needed nomanipulation.

UTERINE CONTRACTION

To the Editor of THE LANCET

SIR,—In your issue of Dec. 22nd, 1934, Dr. SamuelR. M. Reynolds offers an explanation of the discre-pancy between the results obtained from my studyof the contractility of the human non-pregnantuterus (Edin. Med. Jour., August, 1934), and thosepreviously obtained by Knaus and by himself on thehuman species and on the rabbit. It is not clearwhat is meant when he says that the uterus wasdistended by "chemical means," but I assume thathis criticism is similar to the one used by Knaus todispose of Schultze’s experiments which also went

contrary to the previous work, and is, in short, thatthe comparatively high initial pressure used in theuterine cavity produced an unphysiological disten-tion, and consequent abnormal irritability of theuterine musculature.

This criticism is reasonable, and pending furtherdirect experimental evidence I am inclined to believethat it may account for some of the findings. I do

not, however, believe that it offers a complete explana-tion of the discrepancy of the results. The intra-uterine bag with which most of the work was donecontains when fully distended only 3.2 c.cm. of fluid.Now, to quote from Knaus’s recently published book(" Periodic Fertility and Sterility in Woman,"p. 73) :-

‘’ On the sixteenth day of the cycle, however, a strikingchange begins to take place in the function of the uterine