85

Medical Research in 1921.

THE LANCET.

LONDON : SATURDAY, JANUARY 14, 1922.

MEDICAL RESEARCH IN 1921.

A COMMITTEE of expert agriculturists entrustedwith the duty of improving the crop of different

species. all difficult to rear, would probably spenda certain proportion of the funds at their disposal ona private experimental farm staffed by experts andthe rest on subsidising farmers working under differentconditions throughout the country. This is the policyadopted by the Medical Research Council in estab-lishing a central research institute at Hampstead,and instigating or supporting by grants specialresearches to be carried on at suitable places. Thoughfew of the results have yet reached maturity and thegrowth of others has been stunted, the main cropappears to be coming on steadily and satisfactorily.The grant of 130,000 provided for the total expendi-ture is E5000 in excess of that allotted last year, butthe increase was only nominal, since the provisionhitherto made for the work of the Industrial FatigueResearch Board and for research into mental disorderswas discontinued, and the Council had to assume

responsibility for both these important activities or tosee them perish. The care with which the resourcesof the Council have been husbanded may be estimatedby the low cost of administration, which has neverexceeded 6 per cent. of the annual expenditure. Inthe introduction to the seventh annual report,which appears to-day,’ the Council draw specialattention to the extensive scheme for the study ofproblems of child life undertaken by them, the

practical object of which is to secure knowledge, atpresent greatly lacking, which may be a sound guideto the conservation of healthy life in the born orunborn child; also to the large group of researchesdealing with vitamins. Although we have stillalmost no understanding of the nature of theseelusive substances or of their mode of action, empiricalknowledge of the broadest practical value has alreadybeen acquired, and great if unforeseen advances inmedicine will come as the clue to the real nature ofthese substances is gained. Other branches of workto which attention is specially called are the investiga-tion of the laws of epidemics-now being studied ina population of mice under controlled conditions-and research on radium. The Council point out thatit is imperative that knowledge should be gained asrapidly as possible to guide the present almostindiscriminate use of radium; because, while it isknown that in some varieties of disease in certainorgans radium may save life, it is also establishedthat in some conditions and in some doses, both stillunknown, the rays may, instead of saving life, actuallyaccelerate disease so that even operation is useless.

Activities in progress at the National Institute forMedical Research were dealt with fully by Dr. H. H.DALE, its director, in a lecture to the ResearchDefence Society published in our issue of July 9th, 1921, and we need only say that the work describedby him is being developed and extended. In the

appreciation of the research work done at thisInstitute what may be regarded as its routine workmust not be ignored. The Institute is alreadybeginning to fulfil in the biological sphere of medicine

1 Report of the Medical Research Council for the Year1920-21. H.M. Stationery Office. 3s. 6d.

functions analogous to those of the National PhysicalLaboratory, by special studies of methods of measure-ment and assay, and by the determination of standards.in the absence of which the scientific progress ofmedicine has been greatly hampered. The thirdsection of the report records the help given to theyounger workers in the clinical units attached toteaching hospitals, and the connexion, direct andindirect, between work done in these hospitals andat the National Institute is a valuable asset to bothsides. Certain research work of medical men engagedin professional practice is also being subsidised, andwe may perhaps anticipate that such grants will beextended in the future. Section 4 deals with thedetermination of biological standards and the methodsof biological assay and measurement carried out atthe National Institute and at the Standards Labora-tory at Oxford, and includes some account of theNational Collection of Type Cultures housed at theLister Institute, and of the scheme of anthropometricmethods and standards of medical measurementdrawn up by a special committee under the chairman-ship of Sir ARTHUR KEITH. The history of thecollection, disposal, and study of the army medical.statistics is described in Section 5.

Research schemes in specific subjects form thesubstance of Section 6, and this is perhaps themost interesting part of the report. Between shortaccounts of work published in the course of the year,with references, are interspersed suggestive, if tantalis-ingly brief, notes on things now in progress. Themountain of rickets unhappily appears to enlargeas we approach it, but some of the many wiseinvestigators must eventually find a pass to conquerit. Problems of bacteriology and immunology claimmany workers, and biochemistry is plainly a subjectfrom the further study of which valuable results

may be expected shortly. The attacks on tuberculosis.are increasing in number and intensity. The scientificinvestigation of mental disorders, hitherto somewhatstarved, will probably receive increased attentionwhen more funds are available. Industrial medicineand industrial fatigue research are slowly developing,and advances in these subjects are chronicled in theseventh section of the report. It is distressing thatunder present conditions the Council must continueto omit the further prosecution of certain researcheswhich might be of great value in the advancement ofpreventive and curative medicine, for, in the words ofthe Committee for Medical Research of the PrivyCouncil, " the financial position of the countryundoubtedly calls for the fullest possible developmentof the sciences by which the health, and so the

productivity, of the people may be protected andincreased." We trust that these pregnant words maybe duly pondered by those responsible for thenational finances. We are only too well aware of the-urgent need which exists for cutting down allunproductive expenditure, but we should regard as apublic calamity any curtailment of such work as is-carried out by the Medical Research Council. It is workwhich has already paid for itself many times over, andlpromises a still richer harvest in the future to makegood its cost.

Surgery and the Jaundiced Patient.LAST week we dealt with the estimation of hepatic-

function mainly from the medical standpoint. It is-

notably strange that, considering the size and

physiological importance of the liver, hepatic insuffi-ciency has only recently been recognised as the

greatest factor militating against success in operations,

86 SURGERY AND THE JAUNDICED PATIENT.-HYGIENE OF SEX-LOVE.

performed upon the biliary tract. To the urologist;obstruction to the outflow of urine from the kidneysspells damage to these organs and indicates the

greatest circumspection in carrying out any measuresdirected to the relief of the urinary retention.Experience has taught him that the kidneys are

working with a reduced but unknown margin of

safety; so he attempts to measure what power theyhave in reserve, and thereby the likelihood of successwhich will attend his premeditated operation, byapplying tests of renal efficiency. Yet, although’itmay be said that the proper functioning of the liveris more essential for the maintenance of life than thatof the kidneys, as evidenced by the relative timesof survival of animals deprived of these organs, butvery little effort has been directed to the discoveryof practical methods of estimating hepatic suffi-

ciency. After gall-stones have been removed from thecommon bile-duct the anxiously awaited appearanceof stercobilin in the stools may be delayed for one ortwo weeks or even longer. During this period thepatient may gradually sink and die, a fate (when theautopsy has revealed that no stones have beenoverlooked) comparable with that of the patient whosuccumbs to uraemia after a prostatectomy. CRILE 1

has recently applied the lessons of urinary surgeryto operations upon the biliary tract in the presenceof jaundice. He recommends that in such cases a

decompression operation only should be done at

first, the bile being gradually and intermittently drawn off by a tube inserted into the gall-bladder, or, when this receptacle is shrunken, by- a tube in th(common duct. After an interval, during whict

recovery of hepatic function takes place, the operationfor removal of stones can be proceeded with. If th(

by no means negligible mortality of operations uponjaundiced patients can be reduced in this way, thetwo-stage operation for stone in the common ductwill be accepted by surgeons as the method of choicein most cases, until we possess methods of estimatingaccurately hepatic insufficiency despite the increasedtechnical difficulties likely to be encountered at thesecond laparotomy, and other obvious objections.WILLIAM J. MAY02 also agrees that in the presenceof jaundice extensive operations should not be

performed and asserts that the procedure should belimited to the simple removal of stones from thecommon duct, cholecystectomy, if necessary, beingleft to some subsequent occasion.

It has long been recognised that operations uponpatients suffering from obstructive jaundice are

attended by a serious risk of secondary haemorrhage,to which they may succumb. When the operationis done on the biliary tract the haemorrhage is

usually within the abdomen and is very difficult tocontrol. Several observers have shown that thisunusual liability to haemorrhage is associated with adecreased power of coagulation in the blood of a

jaundiced patient. The effect is probably due to analteration in the calcium content of the blood, forwhich the bile salts in the circulation may be respon-sible. Operations upon jaundiced patients should beavoided if possible, but occasionally a non-malignantobstructive jaundice cannot be relieved in any otherway. It is therefore necessary to find some means of

removing this risk before operation, or, in other words,to attempt to reduce to normal the coagulation timeof the patient’s blood. LEE and VINCENT 3 have

I1 Crile: The Technique of Gall-bladder Surgery in the

Presence of Jaundice, Surg., Gynec., and Obstet., 1921, xxxiii., 469.William J. Mayo: The Surgical Significance of Hepatic

Incompetency, ibid. p. 463.3 Lee and Vincent: The Relation of Calcium to the Delayed

Coagulation of Blood in Obstructive Jaundice, Arch. Int. Med.,1915, xvi., 59-66.

, shown that, although the administration of calciums salts by mouth will not diminish the abnormally low

clotting time of the blood of jaundiced patients, because so little is absorbed from the alimentary canal,. intravenous injections of calcium chloride are harm-

less, and will often reduce the coagulation time tor normal. Dr. WALTMAN WALTERS, in an article onr

" Pre-operative Preparation in Obstructive Jaundice,"recommends three daily injections of 5 c.cm. of a

. 10 per cent. solution of CaCI2, and in 15 cases at; the Mayo Clinic results have been satisfactory. The. effect of the treatment is estimated by takingthe coagulation time of the blood before and after theinjections, and in most cases the time was found to, be greatly reduced. The injections do not seem tohave any deleterious effect upon the heart ; in fact,it is believed that the patient’s toxaemia is actuallyreduced by combination of the calcium with the bilepigments. Dr. WALTERS remarks that if the treatmentis not effective, then a blood transfusion is indicated24 to 48 hours before operation. Such a prophylactictransfusion of blood has been found to have a favour.able, though transient, effect, and transfusion is theobvious treatment when the haemorrhage has actuallyoccurred. Apparently, therefore, transfusion remainsthe treatment upon which most reliance is to be placedand has not been entirely superseded, but the claimsmade for calcium chloride injections demand that thistreatment shall be given an extended trial.

Hygiene of Sex-Love.IN a famous preface to his sermons Bishop BUTLER

said that confusion and perplexity in writing werewithout excuse, for anyone may if he pleases knowwhether he understands or sees through what he isabout, and it is unpardonable in a man to lay histhoughts before others when he is conscious that hehimself does not know whereabouts he is or how thematter before him stands. Lord DAWSON fallsunder no such reproach ; in dealing with a difficultand contentious subject he has thought out theissues. He was invited by the Church Congress,held at Birmingham last October, to speak on

sexual relationships, and in response to wide request,he has now published 5 the address, which he thengave, with a foreword in which he replies to someof the discussion occasioned by his speech. Clearly,Lord DAWSON understands and sees through what heis about-namely, a study of the significance andpurpose of sex-love in a well-ordered and Christian

community. The early part of his speech dealingfrankly with healthy sex-life has brought him noreasoned disagreement, a fact which gives cause forthought in comparison with the furious disagreementresulting from the discussion of the morbid aspects ofsex-life when such discussion became frank a few yearsago. The controversy aroused by the second part of hisBirmingham speech, dealing with the control of con-ception, will, Lord DAWSON thinks, disappear whenhis critics read and study the full text of his address.His most doughty opponents have wished to see

restored the large families prevalent 50 years ago,which seem now to be seldom attainable or even

desirable. But the present generation may well becontent with smaller families of children born atpredetermined intervals, while appreciating LordDAWSON’S hint to the State to provide educationalfacilities and progressive rebate of taxation for each

4 Surgery, Gynecology and Obstetrics, December, 1921.5 Love-Marriage-Birth Control. By Lord Dawson of Penn.

Nisbet and Co., Ltd. Pp. 27. 1s.