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The authors suggest that some immunity, decliningwith age, may be inherited from the mother and thatbreast milk may prolong this immunity beyond thesixth month ; but this hypothesis cannot accountfor the lower rates amongst the artificially fed inthe first 4 months of life. The comparison of thegroups on the basis of their feeding presumes, of course,that they are broadly equivalent in other respects-e.g., their general environmental conditions. Theauthors do not provide any direct evidence on thispoint, though they show that their population is drawnfrom many different nationalities; only 10 per cent.are American.

It certainly seems impossible that the sickness

experience can be representative of all infants, forthe mortality is incredibly low. Amongst the 20,000infants observed for nine months (or till death if earlier)there were but 227 deaths which gives a rate of

only 11 per 1000. Sixty per cent. of these deathswere recorded in the small group of artificially fedinfants, but in view of the extraordinarily low totalrate it is difficult to accept this excess mortality asa characteristic of the feeding. Each group may be

unrepresentative of the total experience from whichit is drawn and perhaps not equally unrepresentative.

THE ACCURACY OF THE MEDICAL DIRECTORY

THAT admirable book of reference, Churchill’sMedical Directory, should be accurate as a matter ofservice to the medical profession, and accuracy canonly be ensured by regular communication to theEditor of the Directory, of changes of address. On

page (272) of the current issue of THE LANCET willbe found an alphabetical list of members of the medicalprofession concerning whose present address inform-ation is sought. We join with the Editor in hopingthat the information will be promptly forthcoming.Not only those individuals to whom application is

made, but to the whole medical profession one wordof warning is necessary. The maintaining of theaccuracy of the Medical Directory in no way acquitsa member of the medical profession from keeping theRegistrar of the General Medical Council informed ofany change in his residence. From time to time anofficial inquiry is sent to his registered address, andif this is unanswered his name appears in an officiallist of uncommunicated addresses published at definiteintervals in our own columns. Failing reply to eitherof these his name is erased from the Medical Registerunder Section 14 of the Medical Act, 1858, and heloses all the privileges of registration under that Act.No reply to the Editor of the Medical Directoryrelieves a member of the medical profession from theresponsibility of immediate response to any inquiryfrom the General Medical Council. The Medical

Directory is an unofficial list of first value for referenceto the medical profession, but the Medical Registeris the official list, and it must be made plain that amember who finds his name in the list issued byChurchill is not absolved from replying to the GeneralMedical Council.

POST-OPERATIVE CIRCULATORY LESIONS

AN attempt to throw light on post-operativecirculatory lesions by radiography has been madeby J. Frimann-Dahl.l First of all diaphragmaticmovements were studied radiologically after abdominaloperations in 20 cases. This investigation showed

1 Post-operative Röntgenuntersuchungen. I. Diaphragma-bewegungen und der post-operative venenstrom. II. Post-operative Lungenembolien. By J. Frimann-Dahl. Actachirurgica, Scandinavica. National trykkeriet. Oslo, 1935.Vol. lxxvi. Sup. xxxvi. Pp. 168.

that the excursion of the diaphragm is generallymuch diminished, especially when the incision hasbeen made in the upper part of the abdominal wall ;but that normal movement returns in from one totwelve days. The next step was to study the rateof the venous circulation, which was estimated bymeans of intravenous pyelography, following theinjection of Per-abrodil into the saphenous vein.Bed rest, except in thyreotoxic cases, was found tocause a definite retardation in the flow of blood.After operations, especially those frequently followedby thrombosis, the venous blood stream was mostlyfound to be very slow. Sometimes the blood comingfrom the saphenous vein flowed in a retrogradedirection down the femoral vein, indicating almostcomplete stasis. In one such case the femoral veinwas so dilated that it appeared to be under considerabletension and thrombosis was evidently imminent.

Considering the causation of post-operative venousstasis Frimann-Dahl suggests that the chief factorsare post-operative meteorism and muscular inactivity.The retardation of the venous circulation tends tolast throughout the period of bed rest and cannottherefore be due primarily to diaphragmatic paralysis,since this is much more transitory and is often seento be diminishing while the venous stasis is increasing.The flow of blood in the lower extremities may beaccelerated by raising the foot of the bed, by massage,by active movements of the leg muscles, and by theinhalation of carbon dioxide ; any of these methodsmay therefore be useful in the prophylaxis of venousthrombosis. The minute study of 14 patients withpost-operative pulmonary embolism was also under-taken. Small emboli studied in serial radiogramswere found only to produce transitory changes ; thoseof larger size produced definite infarcts of triangularor circular outline usually situated at the base of thelung. Pleural effusion was frequently seen andadhesions obliterating the costo-phrenic angle provedto be a common sequel.

ALCOHOL AND ROAD ACCIDENTS

Mr. Hore-Belisha, Minister of Transport, askedthe British Medical Association at the beginningof the year to give him its observations on the placeof alcohol in the causes of road accidents. TheAssociation appointed a special committee underDr. W. G. Willoughby, and its report has justappeared.l The committee concentrated on smallor

" subintoxicant " doses of alcohol, less than wouldbe likely to bring a motorist into the dock and farless than would cause social drunkenness. It has

perforce relied on indirect evidence : statistics ofaccidents in which the question has been raised ofwhether the driver was under the influence of drink,and experiments on the effect of alcohol upon thefaculties-judgment, memory, reaction, and muscularcoordination-which are the foundation of safe

driving. It quotes the Alcohol Committee of theMedical Research Council for the statement thatalcohol is a narcotic and impairs judgment, con-

centration, self-criticism, and the power of estimatingrisk. It therefore leads persons to take risks andmake rapid decisions less judiciously than theyotherwise would. Impairment of concentration andreasoning power has, the committee point out, beenestablished by physiological experiment. The drivingof a motor car involves a succession of highly skilledmuscular movements which depend on rapid andaccurate coordination between the hands, eyes andfeet. According to the M.R.C., the speed with which

1 Brit. Med. Jour., July 27th, 1935, Supplement, p. 57.

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the gaze is directed to fresh objects is diminished byalcohol. Speed and accuracy of hand movementhave been shown by typewriting tests to suffer,and the coordination required in rifle-shooting andmountaineering is impaired. Alcohol disappearsslowly from the blood, and substantial amountsremain in the blood even several hours after a

moderate quantity of drink has been taken. Thecommittee conclude that three ounces of whiskywill affect the driving capacity of many personssome hours afterwards, and will make themthink they are driving better than usual whilereally they are less efficient. These findingsare no surprise to persons with any training in physio-logy, but may be news to laymen and lawyers.Besides indicating a possibly fertile cause of acci-dents, they suggest that the present law is not beingadministered as the facts demand. Under the RoadTraffic Act a motorist is culpable who is incapablethrough drink or drugs of having proper control ofhis vehicle. This provision will cover the motoristwho is not nearly drunk in the social or police-courtsense, but its application is a matter of opinion. The

subject was threshed out fairly fully at the Medico-Legal Society last month when discussion indicatedthat before a motorist is likely to be convicted hemust show some fairly obvious symptoms. Manyphysiological authorities regard him as a dangerousmotorist even when he is apparently sober, simplybecause a minimal quantity of alcohol will impairhis judgment of speed and distance, his visual acumenand his reaction-time, the factors which the NationalInstitute of Industrial Psychology regard as essentialin a driver’s safety or danger. It is not likely thatpolice surgeons and courts will give the Act thedrastic interpretation which the facts suggest,because incapacity must be proved as a fact, andindividuals differ so much in their initial skill andtheir reaction to alcohol. Better results should beobtained by energetic publication to motorists andpedestrians of the danger of little drinks.

A POISONED KIDNEY

A QUANTITATIVE study of renal injury due to acutepoisoning by bichloride of mercury is recorded byFreyberg and Lashmet.3 The patient, a woman

aged 20, took 1-5 g. of the poison, and though much ofit was vomited, enough was retained to cause severegastro-enteritis for several days. Within a few hoursof ingestion there was much albumin, with large

. numbers of renal epithelial cells and renal tubule castsin the urine, and in 7! hours the urea clearance wasdown to 34 per cent. of the normal. The clearancediminished to 10 per cent. between the second andninth days, and thereafter improved slowly but

steadily, reaching the normal again 3 months afterthe mercuric chloride was consumed. Impairment ofthe capacity of the kidney to form urine of highspecific gravity and of the capacity to excrete phenol-sulphonephthalein was demonstrated, and it is

interesting to note that the quantity of albumin, casts,and renal epithelial cells passed in the urine diminishedconsiderably before there was any great improvementeither clinically or in the capacity of the kidneys toexcrete, or to form high concentrations of, the naturalconstituents of the urine. The treatment of the renallesion consisted in the daily administration of5000 c.cm. of fluid intravenously either as physiologicalsaline or as 5 per cent. glucose. Thus stimulated, the

2 THE LANCET, July 6th, 1935, p. 31.3 Freyberg, R. H., and Lashmet, F. H.: Amer. Jour. Med.

Sci., March, 1935, p. 392.

kidneys excreted the water and evidently the non.protein nitrogen with it, for the non-protein nitrogenof the blood was but slightly increased. Moreover,no ill-effects were observed which could be ascribedto the intravenous administration of fluid, there beingfor example no oedema. It should be rememberedhowever that in acute nephritis not due to metallicpoisons, large volumes of fluid usually fail to increasethe urine flow and are retained in the tissues. Thusthe treatment which has met with success in a case ofmercurial poisoning may prove dangerous if appliedto other renal lesions.

Porter and Simons 4 have described the therapeuticeffects of gastric lavage, alkalis and intravenousadministration of 1000 c.cm. of saline 12-hourly solong as vomiting persists. Of 46 cases of mercurialpoisoning so treated 43 recovered. The plasma non-protein nitrogen was over 50 mg. per 100 c.cm. inthe three fatal ’cases and under 50 mg. in all thosethat recovered.

CSMMG

THE new Register (1935) of the Chartered Societyof Massage and Medical Gymnastics contains thenames of over 9,500 members, of whom more than600 are masseurs. When this societv came intoexistence as a chartered body in 1920, as the resultof the fusion of the Society of Trained Masseuses andthe Institute of Massage and Remedial Gymnastics,its total membership was 3,640. The great and

continuing growth of the society in the last fifteenyears has been due to the increasing recognition ofthe value of physical therapy as an ancillary tomedical and surgical treatment, when under propercontrol, and it sufficiently refutes the occasionallyheard assertion that this branch of therapeutics hasbeen losing its usefulness since the war years. Theseregistered members have passed through a compre-hensive and practical two years’ course of educationin massage and medical gymnastics, including trainingin hospitals, and have been accredited by searchingexaminations. Most of them hold additional quali-fications in medical diathermy and light therapy,which entitle them automatically to admission to theSociety of Apothecaries’ Register of BiophysicalAssistants. Certificates are granted also after trainingand examination in medical electricity, light and

electrotherapy, medical hydrology, and for teachersof massage and medical gymnastics, medical elec-

tricity, and medical hydrology. The Register ofthe Chartered Society indicates these various dis-tinctions in each case. It is supplied free of chargeto medical practitioners anywhere on application,thus providing them with the names and addressesof members practising in all districts. All thesemembers have pledged themselves not to undertakeany case except under the direction of a registeredmedical practitioner, not to advertise except in

recognised medical and nursing papers, and not tosell goods to patients in a professional capacity norto accept secret commissions on the sale of goods. Ahigh standard of professional honour has thus beenattained, and the sweeping away of the evil practicesof last century has gained for the Chartered Societythe confidence of the medical profession and thegeneral public. There has thus been made availablefor medical practitioners a service of highly trainedand trustworthy assistants in physical therapy, andit is a reasonable hope that they will be employed inpreference to other exponents of this therapy whohave not accepted such a course of training, nor

4 Porter, W. B., and Simons, C. E. : Ibid., 1934, clxxxviii, 375.