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contemplated at the present juncture. At the sametime there are signs that the civilian popula-tion is feeling the shortage of medical men, thoughto what extent it is difficult to say. From some

localities one story comes, from other localities

another. It is certain, however, that for a longtime institutions of all sorts have been unable to

obtain resident officers, and that public authoritieshave been obliged to put up with depleted staffsand to restrict their energies accordingly. Now

everyone can see that there is here a pointat which danger to the country, as real almost

as danger from the presence of an armed

foe, might come from the absence of propermedical and sanitary precautions at home.It is imperative that the public health of the

country should be kept in a good state, if onlythat munition workers and those directly con-cerned in supporting the effectiveness of our armyand navy should enjoy good health, and that

recruits should be drawn from wholesome sources.Let us place this demand on medical service, if

only for the sake of argument, as in no respectsecond to the direct demand of the War Office, andthe position is at once clear-there is only alimited supply of doctors, urgent claims are madeupon them in two directions, and economical useof them is the only way out of the difficulty.But no one can say, If you take preciselythis number of doctors away from the civilian

population you approach or pass the danger-point. And, similarly, no one can state that thearmy requires an exact number of medical menby an exact date-the War Office attempts no suchexcursion into prophecy when demanding increasedmedical assistance. All that can be done is to

husband resources, and to apply to the situationthe rule that must be observed in every other setof circumstances while we are under the tyrannyof this war: namely, that during the adjustment ofsupplies the civilian population must go short-quite short, if need be, so that the army may bewell supplied-quite well supplied. For in civiliansituations there is time to cope with emergencies,while military needs are invariably urgent andhave to be met in excess of probable requirementsas the only way to guard against surprise. The

phrase "too late’’ has occurred rather frequentlyin explanatory speeches dealing with our militaryundertakings, and it should be the ambition of

every medical man to see that in no circumstancescan these words be applied to medical recruiting.We may fairly urge upon the War Office the

need for making every reform that is possible,so as to use with the nearest approach to par-

simony that is safe the quota of medical menwho can be spared from civilian needs. But we

must not assume that, because somebody knowsof some place or other where the medical officersare for the moment but lightly tasked, thedemands of the War Office are disingenuous, andcould be met by a little reshuffling of the suppliesin their hands. The army must be made safe ; it ;

should be sheltered from the dangers that can beestimated, and should possess reserves with whichto meet the unexpected. Therefore the civilian

population must be prepared to endure sacrifices.This is a side of the matter which is not suf-

ficiently recognised, and the sooner it is understoodby the public the better. That same public whichcan no longer walk with ease and safety aboutthe streets because the supply of lights is

curtailed, which can no longer call for its pipe,its bowl, and its fiddlers without much closerrestrictions than in times of peace, will haveto learn that medical attention can be givenin a perfectly adequate manner by a smallernumber of medical men than is usually available, ifthe people will help in every way to spare the

depleted ranks of medicine unnecessary trouble.It is inconvenient to have to wait a long time for adoctor, it is disappointing not to obtain the servicesof the preferred man, it may be a tragedy for anoperation to be postponed. These things may haveto be endured. The work of public authoritiescannot be so comprehensive when the staffs are

inadequate, but some of the medical energies ofthese authorities are spent in correcting the errorsof the public, who must take greater heed on theirown initiative to the rules of sanitary life. We

know that the National Health Commissioners areunder a contract with regard to panel patients: it

may be that the panel patients will not obtain allthat they consider they have been promised, but weare certain that the medical profession is doing andwill do all that is possible in the existing situation.

Annotations."Ne quid nimis."

THE INFLUENCE OF ALTITUDE ON THENERVOUS SYSTEM.

IT appears from an interesting communication inthe Aeroplane, under date Dec. 15th, that certainofficers of our flying service have suffered fromsome intangible disease which for lack of moredefinite diagnosis is put down as

"

neurasthenia " ;the functioning of the patient’s nerves is so affectedas to make him incapable of flying safely orusefully; he crashes his machine every time helands, or his eye is spoiled for observing or

shooting. Such symptoms are usually summedup by saying that the man is off his form," butthe writer specifies other symptoms of a more

precise nature. These have been referred to alsoin a recent number of the Deutsche MedizinischePresse under the name "flying sickness," and theyare said to be caused mostly by " rapid changes ofaltitude whereby the differences in air pressure andtemperature make themselves seriously felt, caus-ing headaches, ear-drumming, and difficult breath-ing. An aviator overcome by such symptomslands in a state of complete mental and physicalcollapse. His head is splitting’ with almostintolerable pains, but relief usually ensues on

account of the deep sleep into which the victimautomatically falls." The English writer also

37

mentions the occurrence of severe pains in the

eyes, and declares that the sleep above referredto is like a drugged sleep, so profound is it.It appears, further, that when service flying usuallytook place at heights of 3000 to 4000 feet thesecases did not present themselves, whereas since"improvement in anti-aircraft guns and gunneryhas made 10,000 feet an ordinary reconnaissance height, and 12,000 to 15,000 a common height in I,crossing enemy lines " the question of variations in ’,pressure and its possible relation to this curious

pathological state obviously become matters worthyof serious attention. The writer in the Aero_plane ’

makes the interesting suggestion that possibly thedisease is an exact inversion of caisson disease, notoccasioned, however, by excessive or insufficientpressure, but by sudden differences of pressure. Anaviator will come down with a speed frequently exceeding a hundred miles an hour, at an angle of " one in one," so that " it is possible that thechange from the low pressure at 10,000 or 12,000 Ifeet to ground level in a few minutes may produceprecisely similar effects to that produced by excessivepressure when diving."

After years of controversy and conflict of theoryit has been established by exact experiment thatthe cause of caisson disease is that nitrogen dis-solved in the body under pressure forms bubbleson sudden decompression and obstructs the circula-tion. From the most trifling disturbance to suddendeath all symptoms alike are thus produced. Itmust be noted that it is the partial pressure ofnitrogen in the atmosphere and not the generalatmospheric pressure that is the important factor.P. Bert, for instance, exposed an animal to highpressure in an atmosphere poor in nitrogen andrich in oxygen without any untoward result,though decompression was rapid. Dr. Leonard Hillhas shown that other factors are of great signifi-cance. Thus, it is not compression but decom-pression that gives rise to symptoms. Compressionup to 4¼ atmospheres is not in itself to be feared ;the return to the normal pressure is alone to bedreaded. " The risk is proportional to the periodand degree of compression and to the rapidity ofdecompression (Hill). Where the activity of thecirculation is great enough the nitrogen surpluswill be carried away and escape by the lungs,whereas where it is slower and where the tissuesare fatty-since fat absorbs five times as muchnitrogen as water-the risk of bubble formation isvery great. It is for this reason that the familiar" bends " occur in relation to joints and fasciaa, andthat the white matter of the spinal cord iscommonly involved. From the rapidity of thecirculation through it brain symptoms are scarcelyever met with in caisson disease. Hill has alsodemonstrated conclusively that the pulse-rate, theblood pressure, and respiration are but little alteredby air compression per se.

" Flying sickness" in its more essential par-ticulars is rather removed from caisson disease,and is deserving of careful clinical and scientificinvestigation. It raises matters of interest in con-nexion with so-called mountain sickness. EdwardWhymper stated from his own experience of thiscondition that the abiding symptoms are profoundlassitude, intense headache, feverishness, accele-rated respiration and occasional spasmodic gulpingof air,

"

just like fishes when taken out of water,"palpitation, and tinnitus. The latter two symptoms,no doubt, occur also with great frequency at rela-tively low levels. It is clear, we think, that flying

sickness is not comparable in the strict sense withmountain sickness, in spite of the fact that some ofthe symptoms are more or less identical. Hithertowe have had little direct evidence of what occurs asthe result of rapid transference from high to lowaltitudes, for the laborious ascent of the moun-taineer into rarefied air is very different from aspeedy return to normal pressures, while theclimb of a flying machine is hardly so rapid as tocause any ill-effect. The pilot who is lifted fromhis machine, after a fast vol-plane, in a semi-conscious condition, falling thereafter into a deepsleep, shows a phenomenon not met with eitherin mountain sickness or in caisson disease. Never-theless we believe that some light may be thrownon this by another consideration. In his " Scramblesamong the Alps" Whymper states that on one

occasion he slipped and fell some 200 feet in sevenor eight bounds. Curious as it may appear, thoughconscious at first, he " was like a patient underchloroform and experienced no pain," albeit badlycut about the head. The bounding through space didnot feel disagreeable. He says that in his opinionin no very great distance more consciousness aswell as sensation would have been lost, and on thishe bases his view that "death by a fall from a greatheight is as painless an end as can be experienced."In a recent number of a weekly contemporary aninteresting note was given on the facts connectedwith parachute descents of other days, and it wasstated that on one occasion, after reaching analtitude of over 12,000 feet in a balloon, theparachutist launched out, but fell at once manyhundreds of feet before his parachute opened. It

appears that as a result of his rush downwardsthrough space he practically lost consciousness,holding on automatically and regaining his sensesan appreciable time after the parachute had attainedits normal rate of descent. Evidently there areeffects on the functions of the nervous systemwhich are attributable to very rapid descentthrough space, from low to higher air pressures,no doubt, but in which the alteration of pressureis probably only one factor, and that, perhaps, notthe most important. These phenomena are likelyto be less rare now than formerly, and they openup a fascinating subject for study, one in which, asin caisson disease, we may hope that exact methodsof scientific investigation and control will eventu-ally lead to work becoming safe that was oncedangerous, and to the extension of the limitshitherto set to its scope.

THE HEALTH OF THE JAPANESE NAVY.

TpE total strength of the personnel of theImperial Japanese Navy (officers excepted) in1913, the latest year for which statistics have beenissued, was 46,890, being a decrease of 635, as com-pared with the strength in 1912. The ratio of casesof sickness, that is, of admissions to hospital, was682’2 per 1000; this being an improvement on thefigure for 1912, which was 716’6; and a still greaterimprovement on the average of 16 years, which was804’2 per 1000. In our own navy the ratio ofadmissions averaged 656’6 for the five-year period.1908-1912. The average number of men daily inhospital has been 22’34 per 1000, compared withthe similar figure of 26’ 97 for the quinquennium inthe British Navy. The mortality ratio of the

Japanese sailor has been 3’33 per 1000, and the .

invaliding ratio 18’ 64 per 1000; the former figureis a most satisfactory reduction on the ratio