THE China Medical Journal

P u b l i s h e d b y

The China Medical Missionary Association

VOLUME XXXVII

1923

SHANGHAI:

P r i n t e d b y T h e S h a n g h a i M e r c u r y , L i m i t e d 1923

INDEXES TO ‘Ihe €hina JHtbical Journal.

Volume XXXV II, 1923

General Index

a

Abdomen, teratoma of ...... ••• • •• M ole. 143 Abdominal disease, Mussy’s point in ...... 189 wound, knife inside abdomen ...... Hoijjng and V ickers. 560 Abortion, treatment of...... 525 Accountancy, hospital ...... 885 Accounting, hospital ...... 10b Addicts, morphine ...... 764 Administration of Mission Hospitals in China ... Snoke. S60 Adrenalin, injection of in apparent death ...... 610 Agalactia, treatment of ...... 834 Agricultural Review, Chinese ...... 445 Alastrim and smallpox ...... 753 Alimentary tract, congenital occlusions ...... Smith. 18 Alveolar air gases ...... Cruickshank. Suppl.

Amputations, plaster pylons ...... V an Gokdek. i Anaesthesia, British Journal of ...... S81 regional, Labat (review) ...... 530 spinal ...... 426 Anaesthetics, practical— Hadfield(review)...... 333 Analysis of blood ...... H sien W u. 1019 Anatomy and Physiology, Bundy (review)...... 444 practical, Walmsley (review) ...... 89 Aneurysm, notes of cases ...... V ickers. 747 Animal epidemiology in Cochin China ...... 1060 Ankylosis of elbowT joint ...... C heal 883 Ankylosis of elbow joint ...... T ootell 656 Ankylostoma duodenale ...... H elm. .Suppl. 29 larvae in animals ...... 696 Ankylostomiasis, carbon tetrachloride in ...... 55 Annam, trachoma in ...... 885 Anthrax in Manila ...... 1061 Anthropological Association of China ...... 202 Anti-opium Association, International ...... 415,533 Antiphlogistine, substitute for ...... 201 Antung, Manchuria, medical report...... L arsen. 505 11 GENERAL INDEX.

Anus, imperforate Brunemeier. 74S Appendicitis and oxyuris vermicularis ...... 524 Appendicitis among Chinese ... 448, 875 Arsenical poisoning ...... S e l m o n . 342 in Chinese school...... ‘ ... 344 Arsenicals, penetrative powers of ...... 959 Artificial limbs made by Chinese brass-smiths N e u f f e r . 4S0

Ascaris lumbricoides. ... H elm . Suppl. 28 Ascites, in chronic pancreatitis ... M o le. 141 Assam, kala-azar in ...... 707

A ssociations : — China Medical Missionary Association, see “ China.” Korean Medical Missionary Association, see “ Korean.” National Medical Association of China, see “ National.” Nurses’ Association of China, see “ Nurses.”

Autoclave efficiency, convenient test of ...... A t w a t e r . 234 Autopsies in China ...... 428

B

Babies, identification of by footprints ...... M iles. 734 Bacillary dysentery, treatment of 188 Bacillus tuberculosis, buccal infection 74 Bacteriology, determinative, Bergey (review) 970 general, Jordan (review)...... 195 in relation to human welfare, Conn (review) ... 789 principles of, Eisenberg (review) 973 of trachoma... S m it h . 887 Bacteriophage, the, d’Herelle (review) 616 Bedbugs, to destroy 689 in bedding ... 535 Beri-beri and epidemic dropsy ...... 960

Biochemic race index of Japanese ...... • * % 957 of Koreans ...... 957 of Manchus...... 957 Biological interpretation, limitations in C k u ic k s h a n k . 493 Biology, Lectures in, Bayne (review) 1052 Births ...... 100, -02, 794, 884, 976, 1058 Blindness, causes and prevention of... 325 in China ...... 325 Blood analysis ...... H sien W u . 1019 Blood in malaria ...... 960 Blood pressure, high, treatment o f ...... 697 racial variations ... 823 of Cantonese students ...... C a d b u r y . 715,. 823 of Chinese ...... C r u ic k s h a n k . Suppl.

Blood, regulation of H-ion concentration of C k u ic k s h a n k . n 6 g e n e r a l i n d e x . Ill

Blood transfusion ...... 1047 Blood transfusion, surgical aspects of Maddren and L i Chi-Fan 987 Bone marrow, cancer of ...... • ... 1045 Bones, operative treatment of fractures ...... ••• &75

Book Reviews : — Anaesthesia, British Journal o f ...... S81 Baltne, China and Modern Medicine ...... 33- Banerjee, Cholera and its Modern Treatment...... ••• 5 3 s Barnes, Tonsils, Faucial, Lingual and Pharyngeal ...... 7°- Bandler, the Endocrines ...... ••• 197 Bayne, Lectures in Biology ...... • i>>53 Barker, Clinical Medicine ...... 195 Bergey, Determinative Bacteriology...... 97° Bram, Exophthalmic Goitre ...... 196 Brubaker, Physiology ...... 443 Bundy, Tracy, Watson on Anatomy and Physiology ... 444 Burrows, Surgery, mistakes and accidents of ...... 335 Caduceus, The ...... 619, 1051 Calmette, Tuberculosis in Man and Animals ...... 971 Cancer, Quarterly Journal of ...... 1053 Chandler, Animal Parasites and Human Disease ...... 334 China Inland Mission Health Manuals ...... 703,973 Chinese Agricultural Review ...... 445 Choyce, System of Surgery ...... 87S Colyer, Dental Surgery and Pathology ...... O18 Conn, Bacteriology in relation to Human Welfare ...... 789 Crossen, Women, Diseases of ...... 337 Davis, Impotency, Sterility and Artificial Impregnation ...... 445 Dorland, Dictionary, American, illustrated ...... 86 Dunlap, Psychology, Elements of ...... 334 Eisenberg, Principles of Bacteriology ...... 9^3 Falta, Endocrine Diseases ...... 878 Fitzgerald, Practice of Preventive Medicine ...... 194 Friel, Electric Ionization ...... 336 Gant, Diseases of the Rectum, Anus and Colon ...... 703 Hawk, Physiological Chemistry 443 Haden, Laboratory Methods, Clinical ...... 444 Hadfield, Anaesthetics ...... 333 Hainan News Letter ...... 974 Herelle, the Bacteriophage ...... 616 Herbert, Operative Treatment of Glaucoma ...... 616 Hill, Practical Infant Feeding ...... 197 Jackson, Bronchoscopy and Esophagoscopy ...... 332 Jordan, General Bacteriology ...... 195 Kingscote, Movement in Organic Disease ...... '1050 Krause, Environment and Resistance in Tuberculosis ...... 790 i v GENERAL INDEX.

Book Reviews : — (continued.) Krause, Rest and Other Things in Tuberculosis ...... 530 Labat, Regional Anaesthesia ...... 530 Levinson, Cerebrospinal Fluid in Health and in Disease ...... 702 Lockhart-Mmnmery, Diseases of Rectum and Colon 880 Macleod, Physiology and Biochemistry ...... 87 MacKenna, Diseases of the Skin ... 617 McKenzie, Exercise in Education and Medicine ...... ••• 531 McMurrich, Development of the Human Body ...... 972 Medical Missions in India, Journal of ... 618, 704 Medicine, analytical reviews 445 Meek, Zoology, essentials of ...... 89 Meller, Ophthalmic Surgery ... 969 Meuser, Lleebner’s Organic Pharmacy... ••• 532 Mulierji, Infantile Cirrhosis ... 88 Neuhof, The Heart, its Physiology, Pathology, etc...... 1049 Ochsner, Physical Exercises for Invalids 196 Peters, Chemistry for Nurses ... 1051 Peterson, Legal Medicine and Toxicology ... 700 Phillips, Spectacles and Eyeglasses ... 444 Pirquet, Outline of Pirquet System of Nutrition ... 194 Pottenger, Clinical Tuberculosis 90 Porter, Management of Sick Infants ...... 91 Reed, Obstetrics for Nurses ... 1051 Rose, Phj^sical Diagnosis... 88 Rost, Pathological Physiology of Surgical Diseases...... 531 Sauer, Nursery Guide for Mothers ... 617 Sampson, Physiotherapy Technic ... 791 Scudder, Fractures...... 442 vSluder, Tonsillectomy ... 702 Stitt, Diagnostics of Tropical Diseases...... S6 Stockley, Military Medical Service ... S9 Stevens, Practice of Medicine ... 196 Stevens, Therapeutics ... 789 Taylor, Surgery of the Spine and Extremities ...... 1050 Taylor, With P’u and his Brigands 336 Thomas, Phj^sician, the Successful ••• 335 Tilney and Riley, Central Nervous System ...... 61S Tottenham, Aids to Gynaecology ... 790 Tsinan Medical Review ... 91, 973 United Fruit Company Medical Department, Report of, 1922 ... 790 Vaughan, Epidemiology and Public Health ...... 700 Walmsley, Manual of Anatomy ... 89 Webster, Diagnostic Methods ... S79 Wells, the Chemistry of Tuberculosis...... ••• 533 Whitla, Dictionary of Treatment ... 789

Whitla, Pharmacy, Materia Medica and Therapeutics - 333 ÖEtfERAL i n DEX. V

Book- Reviews :— {■co n tin u ed .) • - Williams', Minor Maladies and their Treatment 1049 Winslow, Healthy L m n g 198 Winslow, Land of Health ...... 92 Wu Lien-teh, Manchurian Plague Prevention Service 89 Boone, H. W., m.d ., Conference Greetings to 448 Bovine tuberculosis 426

Boxer indemnity and Mission hospitals 345 Breast, cancer of... 874

Breast-milk in nursing mothers, deficiency of Smyly. S34 British Medical Association and C.M.M.A.... S84 Bronchial sp’irochaetosis Huizenga. 153 Bronchoscopy and Esophagoscopy, Jackson (review) 332 Buccal infection with, bacillus tuberculosis... 74 Buchanan Memorial Hospital, Ichang 421 Burial, Japan, after death from infectious disease... 186 Burial, premature ...... 348 Burial reform in China ...... 103, 1060

C

Caduceus, t h e ...... 353, 6 t9, 1051 Calculus, large vesical...... 975 Cancer among Chinese in Dutch East Indies ... 524 Cancer : in Formosa...... 424 inoperable, pituitrin in ...... 762 mortality from, in II. S. A...... 192 of the breast ...... 874 of bone marrow, diagnosis ...... , .... •*- 1045 Quarterly Journal of (review) ...... 1053 Cancrum oris ... 424 Canton Hospital, Report o f ...... 954 Canton, irregular practitioners in ...... 876 Purity Cam paign...... Ol.DT. 775 Sanitation of ...... 622 Cantonese students, blood pressure of ...... Cadbury. 715 823 Carbon tetrachloride as an anthelmintic ...... 55 in hookworm disease ...... 191 in helminthiasis...... 872 Carbuncle, serum treatment of ...... 698 Carrel-Dakin electrolytic cell...... Stephenson. 850 solution, preparation o f ...... Cameron. 44 403 Cataract extraction, conjunctival bridge in H oward. 709 Caul, superstitions concerning ...... iox Cautery in skin diseases ...... H eimburger. 223 Central Epidemic Prevention Bureau...... T sen. 515 vi GENERAI, INDEX.

Cerebrospinal fluid, Levinson (review) ...... 702 Cerebrospinal fluid, cholesterol in ...... 238 Cerebrospinal meningitis in Formosa ...... 885 Cervical lyniplio-sareomas T h o m s o n 1010

Cestodes ... I elm. vSupp]., 10 Changchow, General Hospital report ...... 5 °9 Changsha, health campaign in ...... 622

Chaulmoogra oil, in treatment of leprosy...... H ag m an . 568 Chemistry for nurses— Peters (review) ...... 1051 Chemistry, physiological— Hawk (review) ...... 443 Chenopodium, oil of, in helminthiasis ... S72

Child hygiene campaign in Shansi ... W ampi.e r . 83 Childbirth, rectal injection of ether ...... 613 Children, effects of tonsillectomy ...... 73 C hina :

Adminstration of Mission hospitals Snoke. 860 Anthropological Association of ... 202 A field for study of human teeth ...... 34 Autopsies in ...... 428 Blindness in ...... 325 Brigandage and hospitals ...... 102, 103 Burial reform ...... 103, 1061 Curriculum of missionary medical schools M c A ix . 6S5 Drug cultivation in ... R ead . 147 Eyesight of school children 297 Fasciolopsis buski...... B a r l o w . 453 Funeral expenses in ...... 327 Hookworm disease in ...... 94<5 Hookworm problem ...... B e r c o v it z . 576 Hospitals in ...... 246 Hospital notes ...... 424 Insane in ...... 450 Isospora hominis in ...... W asseli,. 661

Kala-Azar in ...... Y o u n g . 797 Medical education...... •• 302, 315, 317, 853 Medical ethics ...... ■ ...... 298 Medical etiquette ...... 202 Medical schools for women ...... 451 Medical survey ...... 246. Medical work i n ...... 588 Missionary help to, during next decade ..W o n g M an. Inset Mission hospitals and Public Health work ...... 1027 Modern industrialism ...... 103 Modern medicine and China— Balme (review) ...... 332 Modern warfare in...... 104, Morphia, laws concerning ...... 184 Narcotic drugs, medical requirements of ...... 415 GENERAL INDEX. Vil

C h in a :— (continued.) Nurses Association, history of ...... S im p s o n . 1S1 Orientation of hospitals in ...... H adden. 70S Orthopaedics in B r a c k e tt . 64

Osteomalacia in J. P r eston M ax w e l l . 625

Physiological standards ... C r u ic k s h a x k . Suppl. Plague in ...... 451 Poisonous plants of ... Read. 481 Prehistoric man in... 1061 President of, on medical work ... 5 88 President of,'message to C. M. M. A. 257 Prostitution in 105 Public Health work ...... G r a n t . 677 Public Health work 239, 1061

Schistosoma japonicum in M ei.exey and F aust. 541, 545

School children, examination of eyesight ...... S t u c k e y . 651 Scientific medicine in 621 Smallpox in ...... 346 Suicide in ...... 420

Taenia saginata in...... M il ls. 932

Toxicology in ...... R ead. 481

Tuberculosis of the knee joint in ...... Stearns. 891

Yangtze valley, Japanese river fever in ...... F aust. 979 China Inland Mission, medical booklets ...... 703, 973 China Medical Board, Rockefeller Foundation ...... 87,30S China Medical Journal...... •■•50, 55, 9S,io i, 269, 446

C h in a M edical M is s io n a r y A ssociatio n : British MedicarAssociation and C. M. M. A...... 884 Committee on Medical Research 503, 952 Committee 011 Translation and Publication ...... 267 Constitution, discussion of ... 967 Constitution and By-laws 297, 446 Council on Health Education 3 1 4 , 499 Council on Hospital Administration, report of ... 2S2 Council 011 Medical Education ... ••• 599 Council on Public Health ... 758 Executive Committee !70, 3 14 . 947 Executive Secretary 674, 882, 1055 Hospital Technicians ...... 294 Kuling Branch ...... S81 Medical Mission policy ... F o w l e r . 2S9 Membership in ...... 300 Membership of ...... 1025 Publication Committee ...... 1036 South China Branch : summer meeting 965 Treasurer's report...... T u c k e r . 500 Tsinan Branch ...... 32S v iii GENERAL INDEX.

C. M. M. A., C o xfer en ce (1923) : — Boone, Henry W., M.D., message to 296 China Medical Journal, report of editor 269 Conference (1925), Hongkong invitation 307 Conference impressions ...... 312, 3 T3 Conference proceedings, report of 285 Conference programme 172 Conference, social aspects of 16 7 Constitution and Bye-laws 297 Council on Hospital administration, report of, discussion ... 2S6 Council on Medical Educations, report of, discussion 302 Council on Public Health Education, report of, discussion... 301 Delegates and visitors, list of ... 310 Epidemic Prevention Bureau ...... T s e x . 293 Ethics, medical, in China... 29S Evangelism, medical 307 Executive Secretaiy, report of ...... ••• B eebe. 264 Hospital internes ... 3°4 Medical evangelism 3°7 Medical school, curriculum of 304 Pasteur, life of, address on ...... Noel D avjs. 296 President of China, message from 257 President of C.M.M.A., C. F. Johnson, M.D., address of 259 Public Health Work in China ... 292 Publicatiou & Translation Committee, report of ... COUSLAXD. 276 Research Committee, report of ...... C o c h r a n . 279

C. M. M. A. C o xfer en ce RESOLUTION'S : China Medical Board 30S China Medical Journal ... 298 Conference (1925), Hongkong invitation 307 Constitution and By-laws, C. M. M. A. 297 Council on Public Health 301 Ethics, medical, code of ... 299 Eye-sight of school children 297 Hackett Medical College for Women ... 305 Health teaching in Christian institutions 302 Hospital internes ... 304 Hospital technicians 294 Hunan-Yale Medical School 306 Institute of Hospital technology 295 Medical advisors to Mission Boards 302 Medical education in China 303 Medical education (resolutions tabled)... 304 Medical ethics 299 Medical schools, union of ...... 303 Medical schools, curriculum of ... 304 GENERAL INDEX. IX

C. M. M. A. Conference Resolutions :— (continued.) Membership in C. M. M. A ...... 300 Mission policy of Association ...... 29 ~ Monkdeu Medical School... 3° 4 ) 3°5 North China Union Medical College for Women ...... 3°3 Phonetic script in teaching patients ...... 307 Premature incapacitation and death among Christians in China... 302 Preventive Medicine in C h i n a ...... 301, 302 Public Health Work in China ...... 301 Public Health, medical committees to supervise health of Mission 0 workers ÍO Public Health, summer schools for instruction in ...... 302 vSt. John's University Medical School, Shanghai ...... 304 Shantung Christian University Medical School ...... 303 South China, medical education in ...... 306. West China Union University ...... 303

d. M. A. C onference—Sectional Meetings :

Obstetrics and (^necology ...... 431 Pharmacologj- ...... 429 Physiology ...... 430

LNESE :

Agricultural Review ...... 445 Appendicitis among 448, 875 Blood pressure of ... Cadbury. 823 Chinese, blood pressure studies ...... C ruickshank. Suppl. Cancer among, in Dutch East Indies ...... 524 Doctors, foreign trained ...... IOI Doctors in Mission hospitals, salaries of 100 Doctors, registration of ...... 794 Doctors, ransom price of ... 102, 103 Drugs of therapeutic interest to Western physicians ... Read. 589

Drugs of therapeutic value ...K ia n g . 742 Footbinding 100 Foot-prints of babies ...... 345 Hospitals in ancient times ...Wong. 77 Medical ambition, lack of ... 204 Medical ethics of ...... 34S Medical institutions, necessity of ...... 104 Medical students in Japan ...... 450 Medical terms ...... 707 Metabolism in ...... 43S Neurosyphilis among L ennox. 663

Nurses ...... 424 Prisons ...... 34S Pelvis, measurements of ...... 433 X GENERAL INDEX.

Chinese :— (continued.)

Physicians and su rgeo n s...... 424

Students, physical examination of ...... F o s t e r . 643

Women nurses in hospitals for men ...... S n ell. 341

C h in e s e C u sto m s S e r v ic e : Antung, Manchuria, medical report— Larsen...... 505

Chinese R ed Cross in Japan ...... 976 Cholera, etiology of, Mendelson ...... 507 Kaolin in treatment of ...... 190

Chloroform and ether, new m ask for...... W itt . S i Cholera, modern treatment— Banerjee (review) ...... 532 Cholesterol in cerebrospinal fluid ...... , ...... 238

Chorea, Sydenham 's ...... L es lie . 752 Chowtsun, Shantung, medical work in ...... 536

Cimex lectularius in bedding...... P a tte r so n . 535 C'.-iristie, D.ignld, C.M.G., F.R.C.P., F.R.C.S. (Edm.) ...... 441, 683 Cirrhosis, infantile— Muherji (review) ...... 88 Cirrhosis of the liver with splenomegal3’ ...... 426 Clinical medicine—Barker (review) ...... 195

Clinical notes ...... L eslie. 750

Clinical physiolo gy ...... E a r le, io io

Clonorchis sinensis ...... H e lm . Suppl. iS Cochin China, animal epidemiology7 in ...... 1060

Cockroaches, to destroy ...... C a m e r o n . 690 Conference (C.M.M.A.) proceedings, report of ...... 285

Congenital occlusions of alimentary tract ...... S m it h . 18

Congenital papillom a ...... L u d l o w . 146 Congenital syphilis and premature births ...... 763 Congress of Far Eastern Association ...... 1037

Conjunctival bridge in cataract extraction...... H o w a r d . 709 Constitution and By-laws, Council 011 Health Education ...... 606

Contused and lacerated wounds of soft parts ...... M a d d r e n . 554

C orrespondence :

Ankjdosis of the elbow joint ... C heat,. 883

Arsenical poisoning ...... S e l m o n . 342 Boone, W. H., M.D ...... 448

Brigandage in Flupeh ...... P a t e r s o n . 793

Cataplasma kaolini, substitute for ... P a tter so n , 201; R e a d . 340

C. M. J., copies needed ...... F aust. 98 C. M. J., notice of ...... 342

Chinese and appendicitis...... A n d r e w s . 448

Chinese women nurses in hospitals for m e n ...... S nell. 424

Cimex lectularius in bedding ...... P atter so n . 535 Crazy Sheep Sickness ...... 705

Gifts, acknowledgement of, ...... F o s t e r . 98 GENERAL INDEX, XI

Correspondence :— (continued.)

Hospital Technicians, training of ...... Jam es. 341 International Anti-Opium Association, Peking : Appeal for

Information ...... A sp la n d . 96 Jaw, necrosis of ...... M e all. 447 Kala-axar, treatment of ...... Struthers 975 Kaolin in dysentery ...... P atte r so n . 448

Leprosy, alleged cure of ...... ••• ■ A ui.d . 1057

L. M. S. Hospital, Tsaoshili, appeal ...... P a tt e r so n . 793

Male nurses and Hospital assistants ...... K i r k . 96

Medals com m em orating opening of P. U. M. C ...... C h ie n . 199

Medical missionaries, qualifications of ...... W h it e . 105(1

Medical Mission Exhibit, San Francisco, 1923 D o d d . 99 Medical pioneer in Wu-han ...... 3 4 1 Ocular therapeutics : a correction ...... P e t t e r s o n . 975 Public Health Work, appreciation of, by Chinese Official ...HsiEN. 9$

Sprue, personal experience with ...... B r o w n . 792

Sprue, treatment of ...... C o u sla n d , W h y t e . 622

Vesical calculus, large ...... Ju d s o n . 975

Cough, morphine in ...... ••• ••• 9^4 Council, Hospital Administration, report of ...... FowLER. 282

Council on H ealth E du cation ...... G r a n t . 603 Council on Health Education, Constitution and By-laws ... ••• 606 Council on Medical Education, C. M. M. A. 599 Curriculum, medical schools in China ...... ••• 599 Cysts, thyroid, cholesterol in ...... R ead and M e le n e y . 236

D

Death, apparent, adrenalin injections in ...... ••• ••• 610 Death-rate in Japan ...... ••• 7°7 Death, time when it occurs ...... ■■■ ... ••• ••• Jo3 D eaths ...... 343, 528, 621, 706, 976 ,1058 Deformation of Chinese feet ...... ••• 100

Delousing Chinese clothes and bedding ...... Jo f f ic k . 25 Demi-monde of Shanghai ...... ••• 782 Dengue in M anila ...... ••• 794 Dental surgery and pathology— Colyer (review) ...... ••• 618 Dentists, Chinese ...... 794

Dermatology,,recent advances in treatment ... H e im b u r g e r . 220

Dermatitis caused by Liparid m oth ...... M ills. 351 Dermatitis, moth, in, Japan ...... 7° 6 Dermatitis, napkin, infants ...... ••• 7^6 Development of human body— McMurrich (review) ...... ••• 9 72 Diabetes, insulin, therapy i n ...... M cL ean. 205 Diagnostic methods—Webster (review) ...... 879 Diagnosis of L e p r o s y ...... 5^2 XU GENERAL INDEX.

Diagnosis, physical— Rose (review) ...... ••• 88 Dicroeoelium deudritieum ...... H ei.m. Suppl. 20 Dictionary, American— Illustrated (review) ...... D orland. 86 Dietics, course in, P. U. M. C...... ••• 9 2 Diet in sprue ...... ••• 1047 Diet studies in Shantung...... A dolph. 1013 Diphyllobothrium mansoni ...... H elm. Suppl. 17 Diphtheria in Shansi ...... 202, 976 Dipylidium eaninum ...... H elm. Suppl. 14 Disease in the tropics, prevention of ...... H oops. 940 Disease, organic, movement in, Kingscote (review) ...... 1050 Disease, vermin as cause of ...... 144 Distomiasis, pulmonary ...... ••• 42t> Doctors, Chinese registration of ...... 794 Drainage in surgery ...... ••• ... ••• 7 1 Drug cultivation in China ...... ■■■ ...... R ead. 147 Drugs, adulteration of ...... ••• ••• --- ••• 152 perlingual administration ...... ••• 523 Duodenum, ulcers of, diagnosis ...... 528 Dysentery", bacillary, treatment of ... 188 Dysentery, diagnosis of ...... ••• ••• 321 kaolin in ...... ••• 448 in Shanghai...... Davis. 107 Dysmeuorrhoea and helminthiasis ...... ••• 71

E

Earthquake lunatics, Japan ...... 1059 Earthquake victims in Japan ...... 1058 East Indies, Dutch, cancer among Chinese...... 525 Eclampsia, Dublin methods of treatment ...... 614

E ditorials : Carbon Tetrachloride as an Anthelmintic ...... 50 C. M. M. A. Conference, 1923 ... 50, 55, 167, 172 China Medical Journal ...... 50 Executive Secretary, C. M. M. A...... 672 Fellowship of the Mark of Pain...... 754 Kirk, John, M.B., ChB., F.R.C.S., President, C. M. M. A...... 256 Limitations in biological interpretation ... Cruickshank. 493 Medical education in China ...... 853 Medical research in the Orient ...... 412 Membership of C. M. M. A. Association ...... 1025 Prevention of Disease in the Tropics ...... Hoops 940 Red Cross Ideals .., ...... 585 Editorial notes ...... 337 Education, medical, Council 011 ...... 599 Education, medical, in China...... 853 GENERAL INDEX. Xlll

Education, Health, Report of Council ...... G r a n t . 603 Education, medical, preventive medicine in 10 r

Elbow joint, ankylosis of ...C h eal. SS3

Elbow joint, ankylosis of T ootei.l. 656 Electric ionization— Friel (review) ... 336 Electrocardiographic laboratory, P. U. INI. C. 42S

Electrolytic cell, Carrel-Dakin . S t e p h e n s o n . 850 Embadomonas sinensis ...FAUST. 231

Endocarditis, malignant ... M ole. 142 Endocrines, the— Handler (review) ... 197 Endoenne diseases— Falta (review) ... 878 Entropion, treatment of 695 Epidemic dropsy and beri-beri 960 Epidemic Prevention Bureau ... • 293, 356, 34s 515 Epidemics, Russia’s mortalitj’ from...... ,349 Epidemiology and.Public Health— Vaughan (review) . 700

Epidermophytosis H e im b u r q e r . 226 Erythema nodosum and tuberculosis 76 Erythema nodosum, chronic ... C a d b u r y . 4 r Esopliagoscopy and bronchoscopy— Jackson (review) 3 3 2 Ether and chloroform, new mask for ... W itt . 81 Ether, rectal injection of, in childbirth b i3 Ethics, medical, Chinese 298, 348 Evangelism, medical, Auld ...... 307 Examination, physical, of Chinese students 643 Executive Committee, see “ C. M. M. A.” ...

Executive Secretary-, C. M. M. A. Report of ...B eebe. 264 Executive Secretary, C. M. M. A...... M a x w e l l . 674, 794, 1055 Exophthalmic goitre, its non-surgical treatment— Bram (review) 196 Exudates, removal of ... 439 Eye diseases in Indo-China ... 885

Eyeglass and spectacles— Phillips (review) 444 Eyesight of school children ... 297

F

Far Eastern Association of Tropical Medicine 343, 621, 1037 Fasciola hepatica H elm . Suppl. 24 Fasciolopsis buski H e lm . Suppl. 25 Fasciolopsis buski in China ... B a r l o w . 453 Feuchow Journal 974 Fenchow, medical mission work in ... 34S Fever, glandular... 866 Fevers of short duration 434 Fevers, treatment of 434 Fever, typhoid ... H u izen g a . 320 Filaria bancrofti...... H elm . Suppl. ' 39 x i v GENERAL INDEX.

Financing of mission hospitals B eth ell. 33r Foochow, Union Medical School 539 Foot, abnormal enlargement of M ole. 143 Footbinding in C h in a ...... 100 Footbinding in Kiangsu ...... 345 Chinese 345 Foot-patterns, European 345 Mongolian 345 Foreigners in the tropics 767 Formosa, cancer in 424 cerebrospinal meningitis in ...... 885 medical education in 45» Tainan Hospital, report ... 418 Formularies, pharmacological R ea d . 925 Fractures of long bones, operative treatment 875 Fractures, plating in treatment of ... 1045 Fractures, treatment of— Scudder (review) 442 Frontal sinusitis 1044 Fuchs’, Professor, visit to Peking 84 Funeral expenses in China ...... 327

G

Gall-bladder disease, medical treatment of...... 695 Gall-stones, differential diagnosis of ...... 962 Gases, alveolar air ...... Cruickshank, SuppL Gastro-intestinal disease, differential diagnosis of ...... 962 Gastric ulcer from hot food ...... 69 Geographical distribution of schistosomiasis ...... 72 Germicides and insecticides ...... Cameron. 689 Gifts, acknowledgment of ...... Foster. 98 Glandular fever...... 866 Glaucoma, operative treatment of— Herbert (review) ...... 616 Gnathostoma spinigerum ...... Helm., suppl. 38 Goitre, simple, prevention o f...... 492 Golden pills, China ...... 347 Granuloma pudendi ...... 425 Granuloma, syphilitic ...... Mole. 139 Guinea-pig tuberculosis ...... Mole. 144 Gynecology, aids to— Tottenham (review)...... 790 Gynecology, conference sectional meetings ...... 430

H Hainan Mission Hospital ...... _ ...... 706 Hainan News Letter ...... 974 Halsted, of Johns Hopkins, as an operator..., ...... 103 Hangchow Hospital and Medical Training College ...... 706,859 GENERAL INDEX. XV

Hanyang, Hupeli, St. Columban’s Medical Mission 538 Hankow, London Mission Hospital...... 421 Harbin, pneumonic plague in ...... C h u n . 7 Hawaiian islands, leprosy in ... 976 Health campaign in Changsha 622 Health Centres...... A ppleto n . 955 Health Committee, League of Nations 856

Health education, report of Council 011 G r a n t . 603 Health, Land of— Winslow (review)...... 92 Health Manual, China Inland Mission (review) ... 703 Health statistics, Japanese 1059 Heart, the, its physiology, pathology, etc., Neuhof (review) 1049 Hearts, human, as medicine ... 707 Helminthiasis and dysmenorrhoea ... 71 Helminthiasis, treatment o f ...... S72 Hemoptysis, treatment of 957 Hemorrhage after extraction of teeth 766 Hemorrhage, post-partum 1046 Hemorrhoids, internal ... 425 Heredity of mental disease 761

H-ion concentration of blood, regulation of C ruicksliank . 116 Histological technique ... S h ie l d s . 329 Hongkong foot ... H e im p u r g e r . 226 Hongkong, tuberculosis ill ...... 105 877 Hookworm disease and public health education ... 622 Hookworm disease, carbon tetrachlorid in ...... 55 191 Hookworm disease in China ... 94b Hookworm problem in China...... B er co y itz . 576 Hospital administration S n o k e . 294

Hospital Administration Council, Repoit of F o w l e r . 282

H ospital and Medical R eports :

Canton Hospital ... 592. 954 Changcliow General Hospital ...... 509 Hangchow Hospital and Medical Training College ...... S59 Hankow, L.M.S. Hospital ... 421 Ichang, Rankine Memorial and Buchanan Memorial ... 421 Kaifeng, Honan, C. I. M. Hospital ... 1032 Kuala Lumpur, Federal Malay States ...... 321 Moukden Medical College ... 681 Ningpo, Wha Mai Hospital ...... 1033 Peking Union Medical College ...... 422 Pingting, Shansi, new hospital...... 1058 Shanghai, Margaret Williamson Hospital ...... ••• 953 Municipal Council ... 679 Shantung Road Hospital ... 419 St. Luke's Hospital ...... 420 XVI GENERAL INDEX.

Hospital and Medical Reports :— (continued.) Shaoshing, Che., Christian Hospital ...... 1033 Tainan Hospital, Formosa ...... 418 Tai Yuan Fu, Shansi, English Baptist Mission ...... 510, 1059 Tsangehow, Roberts Memorial ...... 679 Tsinan, Shantung Christian University Hospital ...... 508 Weihwei, Honan, Canadian Presbyterian Mission ...... 1034 Wuchang, A. C. M. General H ospital...... 859 Yenping, Alden Speare Memorial ...... 592

H ospitals : accounting ...... 10b accountancy ...... 885 administration ...... Snoke. 60 American, in China ...... 251 assistants and male nurses ...... E. W. K ir k. 96 British, in China ...... 251 Chinese, in ancient times ...... W ong. 77 employees, diseases among ...... Tso. 226 European, in China ...... 251 internes ...... 304 mission, and Public Health work in China ...... 1027 mission, financing of ...... BETHELL. 331 mission, salaries of Chinese doctors ...... 100 notes, China ...... 424 orientation of, in China ...... H adden. 768 reports, value of ...... 522 stock mixtures in ...... C hapman. 915 technicians...... 294, 341, 423 verandahs of, in China ...... H adden. 510

Hygiene, child, campaign in Shansi...... W ampler 83 Hygienic reforms among Mohammedans ...... 621 Hymenolepis diminuta ...... H ei.m. Suppl. 16 Hymenolepis nana ...... H elm. Suppl. 15 Hysteropexy ...... Branch. 387 Hysteropexy, Conference discussion ...... 432 Hysteropexy ...... James L. Maxwell. 393

I Ichang, hospital reports ...... 421 Identification of babies by foot-prints ... .Miles. 734 Ileus, diagnosis of ...... 70 Infections, renal...... ;...... W right. 902 Immunity of Orientals to infection ...... 767 Impotency and sterility— Davis (review) ... ■ ... 445 India, Journal of Medical Missions (review) ...... • ... 704 GENERAL INDEX. XVII

India; kala-azar in 822 maternal mortality in 538 medical missionaries in ...... 450 medical missions in 61S plague in ...... 537 Indc-China, eye diseases in 885 Industrialism, modern, in China 103 Infant Feeding— Hill (review) 197 Infant mortality in Manchuria 557 Infant mortality, significance of 557 Infants, napkin dermatitis 766 Infants, sick, management of— Porter (review) 91 Infantile cirrhosis— Muherji (îeview) 88 Infection, Oriental immunity to 7b7 Infectious diseases in schools ... 430 Infectious diseases and League of Nations ... 102 Infectious diseases, burial regulations in Japan ... 186 Influenza in Korea 1059 Influenza, vaccines in ... 73 In Memoriam, A. G. Parrott, M.R.C.S., L.R.C.P., 1856-: 52jS Insane in China ... 450 Insecticides and germicides ... C a m e r o n . 689 Ionization, electric— Friel (review) ... 536 Instruments left in peritoneal cavity 457 Insulin, preparation of, at P. U. M. C. 214 Insulin therapy in diabetes ... M cL ean. 205 International Anti-Opium Association ...96, 415 555 International Congress of Ophthalmology ... 884 International welfare and public health 609 Intestinal infections, oral administration of vaccines in S73 Intestinal obstruction, acute ... 70 Intraperitoneal saline infusions C h a n g . 215 Intussusception, chronic 427 Isospora honiinis in China W assei.l. 661

J J apan : Burial, deaths from infectious disease 186 Chinese medical students in 45° Chinese Red Cross in 97b Death-rate in ...... 707 Medical Association ...... 102 Moth dermatitis in 70Ì- Patent medicines in 45° Syphilis m ...... 180 Yokohama mortality statistics ... 347 X V l l l GENERAL INDEX.

Japanese Medical College in China 795 Medical Commission to U. S. A 347 duration of life of ... S55 earthquake lunatics 1058 earthquake victims 1058 feet, beauty of 100 health statistics 1059 River fever in Yangtze valley F aust 979 tuberculosis of skin among 538 school children, health of 707 Jaw, necrosis of ... Me A li. 39

K Kaifeng, Honan, C. I. M. Hospital report 1032 Kala-azar in Assam ...... 707 in China Y o u x g . 797 in India 822 tieatment of . S t r u t h e r s . 9 75 Kaolini cataplasma, substitute for 201 , 340 Kaolin in dysentery 448 in treatment of cholera ... 190 Kiangsu, foot-binding in 345 registration of physicians 345 Kidney, diagnosis of stone in 1045 Kidney disease, anatomic nature of 612

Kirin, relief work in 794 Kirk, John, M.B., Ch.B., F.R.C.S., Presic nt C.M.M.A.... 250

Knee joint, tuberculosis of, in China S te a r n s . 891 Korea, health of missionaries in 44b Korea, influenza in 1059 Koreans, biochemic race, index of ... 957 Korean Medical Missionary Association 440 Kuala Lumpur, Federal Malay States 321 Kueiteh medical mission work 346 Kuling Branch of C.M.M.A., report of 881 Kuling Hospital... 316

L Laboratory, electrocardiographic, P U. M. C. 42S Laboratory methods, clinical— Haden (review) 444 La-li-tou in China 698 Laryngeal tuberculosis, early diagnosis.of... Liu. 738 Laryngeal tuberculosis, treatment of 741 Lead proisoning, unusual case of James L. M a x w e l l . 584 League of Nations Health Committee S56 League, of Nations, Opium Advisory Committee 857 GENERAL INDEX. x i x

Leg amputations, plaster pylons in ...... Van G order. i Legal medicine and toxicology— Peterson (review) ...... 700 Lepers, number of ...... 348 Leprosy, diagnosis of ...... 562 infiltration method of treatment...... 572 in Hawaiian Islands ...... 976 in Philippine Islands ...... 104 in Siam ...... 539 relief of ...... 795 treatment of ...... 438 treatment of ...... H eimburger. 225 treatment t>f ...... Huizenga. 567 treatment of, infiltration method ...... 572 treatment of, with Chaulmoogra Oil ...... H agman. 568 Leucocytes in health and in disease ...... 962 Lice, method for delousing Chinese clothes and bedding... Joffick. 25 Limbs, artificial, by Chinese brass-smiths ...... Neuffer. 4S0 Liparid moth dermatitis ...... Mills. 351 Liver abscess, treatment by aspiration ...... 761 Liver, cirrhosis of, with splenomegah* ...... 426 Livingstone, David ...... 102 London Missionary Society Hospital, Hankow ...... 421 London Missionary Society protest against poppy cultivation...... 1060 Loxotrema ovatum ...... H elm. Suppl. 21 Lumbar punctuie, sequelae of ...... 1S7 Lungs, alveolar air gases ...... C ruicicshank. Suppl. Lympho-sareomas, cervical ...... T homson. 1010

M M alaria : blood in ...... 960 chronic, treatment of ...... 871 experimental reproduction of ...... 1042 infection ...... 321 notes 011 L eslie. 750 Ochsner treatment of ...... W ilson. 322 prevention of ...... 1042 treatment of pregnant patients with ...... 1043 vomiting in...... 435 Malarial parasites, examination b\r thick film method ...... 74 Malarial splenoniegaty ...... 527 Male nurses and hospital assistants ...... E- W. K ir k . 96 Malignant endocarditis ...... M ole. 142 Manchuria, infant mortality in ...... 537 Manchuria, pneumonic plague in ...... Chun. 7 Manchus, biochemie race, index of ...... 957 XX GENERAL INDEX.

Manila, anthrax in ...... 1061 Manila, dengue in ...... 794 Mask, new, for chloroform and ether ...... WITT. 81 Maternal mortality in India ...... 538 Maxillary and frontal sinusitis ...... 1044 McPhun, J. F., M.B., C.M., retirement of ...... ••• 1053 Medical missionaries, qualifications of ...... 1056 Medical ambition, Chinese lack of ...... ••• 204 Medical education, cost of, in England ...... ••• ••• 101 C. M. M. A. Council 011 ...... ••• 599 in China ...... 302, 315, 317, §53 in the Far East ...... 344 in Formosa ...... ••• 45° in Siam...... ••• ••• 344 Medical ethics, Chinese ...... 29S, 348 etiquette in China...... ••• 202 evangelism ...... A ui.d. 307 missionary work as a vocation ...... 58 Mission Exhibit ...... ••• ...Dodd. 99 Missions, Governor Yen’s appreciation of ...... 344 in India ...... 618 in India— Journal of (review) ...... 704 policy ...... F owler. 246 policy, conference debate— H oughton, Balme and others ... 286 Medical missionaries ...... ••• ...... 344 Medical missionaries in India ...... 450 Medical mission work, difficulties of ...... 348 relation to Christian missions ...... B arnes. Inset Medical papers, writing of-— Mellish (review) ...... 334 Medical pioneer in China ...... 341 Medical research in the Orient ...... 412, 413

Medical schools, missionary, curriculum of ...... Me A ll. 685 curriculum of ...... 304 union of ...... 343 School for Women, Shanghai ...... 621 Medical students, Chinese, in Japan...... 450 terms in Chinese ...... 707 work in China ...... Brackett. 64 Medicine, Analytical Reviews ...... 445 Practice of— Stevens (review) ...... 196 preventive ...... 852 Menorrhagia of puberty ...... 958 Mental disease, heredity of ...... 760 Merchants and missionaries ...... 346 Metabolism of the Chinese ...... 438 GENERAL INDEX. x x i

Metastrongylus apri ...... H elm. Suppl. 32 Microseopists, training of ...... H aughwout. 594 -Military medical service— Stockley (review) ...... S9 Elinor maladies and their treatment— Williams (review) ...... 1049 Mission hospitals, aid to ...... 101 Mission hospitals and Public Health work in China ...... 1027 Mission hospitals, financing of ...... Bethei.L. 331 Mission hospitals in China, administration of ...... Snoice. Sdo Mission hospitals, salaries of Chinese doctors ...... 100 Missions, Medical, policy of ...... F owler. 246 Missionaries and merchants ...... 346 'Missionaries in China, work of, during next decade ... W ong M an. Inset Missionary medical schools, curriculum ...... McA i.l. 6S5 Missionary work, cost of ...... 621 Mohammedans, hygiene among ...... 621 Mongolians, foot-prints of ...... 345 Morphia, Chinese laws concerning ...... 1S4 Morphine, value of, for coughs ...... 964 Morphine addiction, treatment ...... 704 Mortality statistics, Yokohama ...... 347 Mortality from cancer in U. S. A...... 192 Moth dermatitis in Japan ...... 706 Moths, Liparid, dermatitis caused by ...... Mills. 351 Moths, to destroy ...... Cameron. 690 Moukden Medical College Report ...... 68i Muscle necrosis from quinine...... 193 Mussy’s point in abdominal disease...... 189 Myelitis, dorsal...... M ole. 146

N

Napkin dermatitis in infants ...... 766

Narcotic drugs, medical requirements in China ...... 515 sale of ...... 203 smuggling o f ...... 347

Nasal polypus, with extension to frontal sinus ...... LESLIE. 752 Neal, James B., M.D., retirement o f ...... 441 Necator americanus ...... H elm. Suppl. 31 Necrosis, muscle, from injections of quinine ...... 193 Necrosis of the Jaw ...... M cA ll. 39, 447 Nephritis, chronic ...... 963 Nematodes ...... H elm. Suppl. 28 Nervous system, Tilney and Riley (review) ...... 618 Neurasthenia ...... 522 Neurosyphilis among the Chinese ...... L ennox. 663 Niugpo, Hospital for Women...... 344 xxii GENERAL INDEX.

Ningpo, report of Wha Mai Hospital ...... 1033

Nodosum, erythema, chronic ...... C a d b u r y . 41 Nursery guide for mothers— Saver (review) ...... 617

Nurses Association of China, history of ...... S im p s o n . 181

Nurses, male, and hospital assistants ...... E. W . K i r k . 96 needed in mission f i e l d ...... 449 Quarterly Journal of ...... 974 training of ...... 795

N u rsin g in China ......

Nursing mothers, deficiency of breast-millc, treatment ... S m y l y . 834 Nutrition, Pirquet system of ...... 194 Nursing and nursing education in U. S ...... 534

0

Obituaries : Carr, John Cecil, M.D., Ch.B., M.R.C.P.E...... 93 Eckfelt, Odd ...... 1058 Merwin, Caroline Stowe, M.D...... 621 Nilssen, E dvin, M .A., M.D...... 95 Peck, A. P., M .D ...... 621 Whyte, George D u n can ...... 1058

Obstetrics, Conference sectional meetings ...... 431 edampsia, treatment of ...... 614 rectal injection of ether in child-birth ...... 613

for nurses— Reed (review) 1051

Obstruction, acute intestinal...... 70

Ochsner treatment of malaria...... W il s o n . 322

Ocular therapeutics ...... P e t e r so n . 842, 975 Ophthalmic surgery— Meller (review) ...... 969 Ophthalmology, International Congress o f ...... 884

Ophthalmology, vision of school children ...... S t u c k e y . 650 Opium advisory committee of League of Nations ...... 857

O pium for the dead ...... ioòo Opium smuggling in Shanghai ...... 536 Opium, war against ...... 533 Optical methods in control and research laboratories ...... 533 Orient, medical research in ...... 413 Oriental immunity to infection ...... 767

Orientation of hospitals in China ...... H a d d e n . 768

Orthopaedics in China ...... B r a c k e t t . 64 Osier, Sir W illiam ...... 707 Osteopaths, licensing of, in U. S ...... 536

Osteomalacia in C hina ...... J. P r e st o n M a x w e l l . 625 Osteomalacia in Shansi 1058 Outpatient clinics, standards for ...... 203 GENERAL INDEX. Xxiii

Oxyuris vermicularis ...... H elm. suppl., 37 Oxj'uris vermicularis and appendicitis ...... 524

P Pain of ulcer of stomach ...... 762 Pancreatitis chronic, ascites in ...... Mole. 141 Papilloma, congenital ...... L,ui>lo\v. 146 Paragouimus westennani ...... H elm. suppl., 22 Parasites, and human disease— Chandler (review) ...... 334 Parasites, malarial, examination by thick-film method ...... 74 Pasteur centenaiy ...... 202 Pasteur laboratory in Tientsin ...... 203 Patent medicines in Japan ...... 450 Peking, Central Epidemic Prevention Bureau, report of...... T sen. 515 Peking, orthopaedics in ...... Brackett. 66 Peking, searle.t fever in ...... 449

Peking Uniox M edical College : Addresses and papers (review) ...... 972 Aid to Japanese scientists ...... 976 Aid to mission hospitals ...... iui College, aim of ...... 105 Commemoration medals ...... 199 Dietetics, courses in ...... 92 Electrocardiographic laboraton*...... 42S Graduate medical courses ...... 102 Hookworm disease, investigation of ...... 946 Hospital report ...... 422 Hospital technicians ...... 417 Insulin, preparation of ...... 214 Ophthalmology, Department of...... *877 Pre-medical education in China...... 621 Special Courses ...... 318 Students desiring employment...... 537 Students, registration o f ...... 343 Wen ham Hall ...... 53S

Pelvis, measurements of Chinese ...... 433 Peritoneal cavity, instruments left in ...... 437 Peritoneum, exploratory puncture of 521 Perlingual administration of d r u g s ...... 523 Pharmacology, Conference sectional meetings ...... 429 Pharmacy, Materia Medica and Therapeutics— Whitla (review) ... 333 Pharmacological formularies ...... R ead. 925 Philippine Islands, leprosy in 104 Philippines, smallpox in ...... 245 Phonetic script in teaching patients...... 307 GÉNÉRAL ÍNDEX.

Phosphorus matches, manufacture of prohibited ...... -•* ••• io ó ì Physical examination of Chinese students ...... F o s t e r . 643 Physical exercises for invalids— Ochsner (review) ...... ••• 196 Physiological chemistry— Hawk (review) ...... 443

Physiological standards in North China ...... C r u ic k s h a n k . S u m ,.

Physiology, clinical ...... E arle, io io Physiology, human,— Brubaker (review) ...... 443 Physiology and Biochemistiy— Maeleod (review) ...... 87 Physician, the successful— Thomas (review) ...... 335 Physiology, Conference sectional meetings...... 430 Pingting, Shansi, new mission hospital ...... 1058 Pirquet system of nutrition ...... 194 Pituitrin in inoperable cancer...... 762 Placenta, a talisman against sickness ...... 1060 Plague bacilli isolated from healthy human carriers ...... 761

Plague, destruction of rats ...... 015 endemic, origin o f ...... 957 in China ...... 451 pneumonic ...... 602

pneumonic in Harbin ...... C h u n . 7 pneumonic, Manchuria, report— WuLien-teh (review) ...... 89

Plants, poisonous, of China ...... R ead. 481

Plaster pylons in leg amputations ...... V an (Io e d e ii. 1 Plating in treatment of fractures ...... 1045

Poisoning, arsenical ...... S elm o n . 342 Practitioners in Canton, irregular ...... 876

Precipitation test for syphilis...... C o ch r an and Yu. 3S2 Prehistoric man in China ...... 1061 Pre-medical education in China ...... 621 Premature births and congenital syp h ilis ...... 703 Preventive medicine ... ••• ...... 852 Preventive medicine— Fitzgerald (review) ......

Preventive medicine in curriculum of medicai education ...... i 0 i Prisons, Chinese... •• ...... 348 Prolapse of uterus, conference discussion ......

Prolapse of uterus, operation for ...... James L. M a x w e l l . 393 Prostitution in C h in a ...... l0 5 Psychology, scientific— Dunlap (review) ...... 334 Puberty, menorrhagia of ...... 95g

P ublic H ealth W o r k : and international welfare...... 609 C.M .M .A. conference ...... 392 C.M.M.A. Council 011 7^g

in China ...... 98, 239, 301, 1061

Public Health work ...... C h o w K w o H s ie n . 98

Public Health work ...... G r a n t . 677 GENERAL INDEX. XXV

Public Health and epidemiology—Vaughan (review) ... 700

Publication and Translation Committee, Report of ... C oi si.a n d . 276 Puerperal morbidity, C.M.M.A., standard of ...... 432 Pulmonary distomiasis...... 42b Puncture, lumbar, sequelae of...... 1S7

Purity campaign, Canton ...... O i.d t . 776 Plague in India ...... 537 Pyelonephritis ...... WiUGUT. 902

O

Quarterly Journal for Chinese Nurses 974 Quinine, muscle necrosis from injections ... 193 Quinine treatment of pregnant malarial patients 1U45 Quisqualis indica 743

R

Radium in skin diseases H e j m u u r g e k . 222 Radium, price of... 202 Rankiue Memorial Hospital, Iclring... 421 Rats, destruction of 615 Rectum, anus and colon, diseases of— Gant (Review ) ...... 7«3 Rectum and colon, surgical treatment of (Lockhait-Mummery) 880 Reel urn, stricture of 427 Red Cross, Chinese 971 Red Cross ideals 585 Red pills, China, prohibition of sale 3-47 Registration of Chinese doctors 794 Registration of physicians, Kiangsu 348 Renal infections : their guises and disguises W k i g h t . 902 Research Committee, C.M..M.A 5s 9. 952 Research Committee, C M.M. A., report of ... CoCH KAN. 279 Rheumatism, acute ...Lksi.ik 75- Rickets, summary of knowledge of ... 704 Ringworm, treatment of 9 5 - Rockefeller Foundation : Aid to Medical Schools ... 700 China Medical Board b2i Financial aid to medical work ...... 5 , 539 League of Nations Health organization 587 Public Health Work in Siam ...... 344 Report, seventh annual ... 87 Roentgenotherapy in skin diseases...... H kiMEL'RGIvR. 223

s

Sachs-Georgi test for syphilis...... JOFl'ICK. 57- Saline infusion, intraperitoneal ...... C h a x g . 215 XXVI g e n e r a l i n d e x .

Salkowski’s test for cholesterol ...... ••• 23^ Sarcoma, etiology of ...... ••• 104 2 Sarcoma, spindle-eell, of neck ...... Lum.ow. 145 Scarlet fever in Peking 449

Schistosoma japonicum ...... H ei.m, suppl. 26 Geographical distribution of ...... ••• ••• 72 Intermediate host of ...... M ei.KNEY and F aust. 541, 545 Life history of ...... Mei.ENEy and F aust. 726 Tartar emetic in ...... L ikby. 158

Schistosomiasis japonica, treatment of ...... ■■■ ...Faust. S47 SehmaUried, Dr., captured by bandits ...... ••• 1058 School children, eye-sight of, Conference resolutions ...... 297 Examination of vision o f...... Stuckey. 651 Japanese, health of ...... ••• 7°7 Schools, infectious diseases in ...... ••• ••• 436 Serum treatment of carbuncle ...... ••• 6yS

Shanghai : 13.W.A. Hospital Aid Department ...... 34^ Demi-monde of ...... 782 Dysentery in ...... Davis. 107 Infectious Diseases Hospital ... • •• 977 Japanese Medical School, proposed ...... 4 5 1 Margaret Williamson Hospital, report, 1922 ...... --- ■ 953 'Medical Work in ...... Brackett. 65 Opium smuggling in ...... 536 Medical School for Women ...... ••• 621 Public Health Department, report of ...... ••• Ó79 St. Luke's Hospital, report ...... 420 Shantung Road Hospital, report ...... 419 Smallpox in ...... 449 Street accidents in ...... 419 Summer Diseases Hospitals ...... 706 Venereal clinic, free ...... 794 Venereal disease in ...... 343

Shansi, child hygiene campaign in ...... W ampi.er. S3 Diphtheria in ...... 202, 976 Osteomalacia in ...... 1058 Shantung Christian University ...... 50S, 977 Shantung, diet studies in ...... A dou’H. 1013 Shaoshing, Che., Report of Christian Hospital ...... 1033 Shaowu Fu Hospital for Women ...... 349 Shelton Memorial Fund ... ••• ■■■ ... ••• 203 Shelton, Dr., murder of ...... ' ...... 449 Siam, leprosy in ••• 539 Siam, medical education in ...... 344 GENERAL INDEX. XXV11

Sianfu, Shensi, medical work in ...... ■ 537

Sm all-pox : Alastrim and ...... 753 among hospital employees, Peking ...... ••• Tso. 229 Chinese charms against ...... ••• 346 in China ...... • 346 iu the Philippines ...... ■ 245 in Shanghai ...... 449 in Wuliu ...... Brow n. 239 Skin, diseases of— MacKenna (review) ...... ••• ■■■ 617 Skin, tuberculosis of, among Japanese ...... ••• 638 Solution, “ Carrel-Dakiu,” preparation of ... ••• ••• C ameron. 403 Soochow Hospital, opening of ...... ••• 59 Soochow, Schistosoma japouicum in...... M eleney and F aust. 541 Spectacles and eyeglasses— Phillips (review) ...... 444 Spinal anesthesia ...... ■ ...... 426 Spindle-cell sarcoma of neck ...... Ludlow. 145 Spirochaeta pallida in human sperm ...... ••• 190 Spirochaetosis, bronchial ...... Huizenga. 153 Splenomegaly, with cirrhosis of liver ...... • •• 426 Splenomegaly, malarial ...... ••• ••• 527

Sprue and its treatment ...... ScoTT. 5S1 Clinical investigation of ...... 524 Dietetic treatment of ...... 1046 Ktiology o f ...... 68 House incidence of ...... ••• 6S Infective nature of...... t>S Personal experience with ...... L ambert. 792 Treatment of, with calcium and parathyroid ...... W hyte. 622 Treatment of ...... Cousland. 622

Standard pharmacological formularies ...... Read. 925 Standard of puerperal morbidity, C. M. M. A. ... 433 Standards for Outpatient Clinic ...... 203 Stock mixtures, hospital ...... Chapman. 915 Stomach, ulcer of, pain in ...... 762 Stomach, ulcars of, diagnosis...... 528 Stricture of rectum ...... 427 Strongyloides stereoralis...... H elm, Suppl. 33 Students, Cantonese, blood pressure of ...... C adbury. 823 Suicide in China ...... 420

Surgery, drainage in ...... 7 1 mistakes and accidents— Burrows (review) ...... 335 of the spine and extremities— Taylor (review) ...... 1050 pre-and post-operative treatment ...... 760 sys-tem of— Choyce (review) ...... S79 XX Vili GENERAL INDEX.

Surgical aspects of blood transfusion ... M a d d r e n & L i C h i -P a n . 9S7

Surgical case reports ...... L u d l o w . 145

Suspansiou of the uterus ...... B r a n c h . 3S7

S yd en h am ’s chorea ...... L eslie 752

Syphilitic granulom a ...... M o le . 139 .Syphilitic headache ...... 1060

Syphilis, am ong Chinese ...... L e n n o x . 663 among hospital employees, Peking ...... Tso. 227 congenital, and premature births ...... 763 in Japan ...... 1S0

precipitation test for ...... C o ch r an and F uii-H sin Yu. 382

Sachs-Georgi test for ...... Jo f f ic k . 372

treatment of...... H eim imito ER.224

System ic diseases, tonsillectom y in ...... 526

T

Taenia echinococcus ...... Helm. Suppl. 13 Taenia sagiuata ...... Helm. .Suppl. 10

Taenia saginata in North China ...... M il ls . 932 Taenia solium ...... Helm. Suppl. 12 Tainan Hospital, Formosa, report ...... 41S Tai Yuan Fu, Shansi, E nglish Baptist Mission Hospital...... 510, 1059 Tape-worm infestation, treatment of...... 098

Tar, crude, in skin diseases ...... *IIe im h u k g e r . 220 Tartar emetic in schistosomiasis japoniea ...... Liiniv. 15S Technicians, hospital ...... 294, 423 Teeth, hemorrhage after extraction ...... 766

Teeth, study of, in China ...... M cC l e n d o n . 34

Teratoma of abdomen ...... M o le . 143 Thelazia callipaeda ...... Helm. Suppl. 40

Therapeutics, Chinese drugs of value ...... K ian g . 742

Therapeutics, ocular ...... P eter so n . 842 Therapeutics, text book of— Stevens (review) ...... 7S9 Thibet, chasing aw ay disease ...... 104 Thibet, disposal of dead in ...... 103

Thyroid cysts, cholesterol in ...... R ead and M elen ey . 236 Tientsin, Pasteur laboratory in ...... 203 Tinea ill China ...... 698 Tokyo, new hospital in...... 103

Tonsillectomy : Effect of, 011 general health of Children ...... 73 Indications for— D ig b y ...' ...... 475 Indications for— .Slack ...... 473 In system ic diseases ...... 526 Operation of— Sluder (review) ...... 702 GENERAT, IN D EX. x x i x

Tonsils as portals of infection... 697 Tonsils, the— Barnes (review)... 702 Towels and tuberculous infection 765 Toxicology and leg'al medicine— Peterson (review) 700 Toxicology in China ... R ead. 481 Toxins in skin diseases H eimburcîer. 220 Trachoma among hospital employees Tso, 22'S

Trachoma : Bacteriologj’ of .VMIT1I, s s 7 In Annam SS5 Treatment of 187

Transfusion, blood, surgical aspects of M addrkx & Li Chi-Pan. 9S7 Transfusion of blood 1047

Treasurer’s report, C. M. M. A. T ucker 500 Trematodes Helm. vSuppl. 18 Trichinella spiralis Helm. Suppl. 35 Trichuris triehura Helm. Suppl. 34 Trichostrongylus orientalis Helm. Suppl. 3- Trichiasis, surgical operation for 695 Tropical diseases, diagnostics of— Stitt (review 86 Tropical medicine, P'ar Eastern Association of 621, 1037 Tropical sprue, clinical investigation of 5^4 Tropical ulcers, treatment of ... 436 Tropics, prevention of disease in Hoors. 940 Tropics, foreigners in ... 7<>7 Tsangchow, Roberts Memorial Hospital, report 679 Tsaoshih, Hupeh, L. M. S. Hospital...... 793

Tsinan : C.M.M.A., Branch Meeting of 328 Home for Chinese Nurses in 53^ Medical Review 9 i, 973 Medical work in B rackett. 65 Medical School 344 University Hospital medical report 50S

Tsingchowfu, Shantung, medical mission work in 538 Tsutsugamushi disease in Central China .Faust. 979

Tubercle bacillus infecLion— Calmette (review) 971

T uberculosis : Among hospital employees Tso. 229 Bovine 425 Buccal infection ...... 74 Chemistry of— Wells (review) 533 Clinical— Pottenger (review) 90 CÌENERAL INDEX.

T u b ercu lo sis :— (con timi ed.)

Environment and resistance— Krause (review 790 Erythema nodosum and ... 76 In the newborn, phophylaxis 874 In guinea-pig Mol 144

In man and animals— Calmètte (review 9 7 r In Hongkong 105, S77 Infection, towels use of ...... 765 Laryngeal, early diagnosis of L iu. 738 Laryngeal, treatment of ... 741 Of knee joint, treatment of vS t e a r n s . 891 Of skin, among Japanese... 538 Restin— Ivrause (review)... 530 Retrospect, a S elmon. 77 1 Vaccine treatment of 867

T3’phoid fever H uizencîa. 320

Typhoid fever, oral administration of vaccines in §73 Typhus, preservation against... 962

U

Ulcer, gastric, from hot food ... 69 Ulcer, gastric, perforated Moi 140 Ulcers of stomach and duodenum, diagnosis of 528 Ulcer of stomach, pain ... 762 Ulcers, tropical, treatment of ... 436 Union Medical School, Foochow 539 Union Medical School, Moukden 539 United States, mortality from cancer in 192 Uterus prolapse of, Conference discussion .. 432 Uterus, prolapse, operation for James L M axwei 393 Uterus, suspension of ... Braxc ïS7

Vaccination and the Chinese ... 536 Vaccines in influenza ... 73 Vaccines, oral administration of 873 Vaccine treatment of tuberculosis 867 Venereal clinic, Free, in Shanghai 794 Venereal disease in Shanghai... 343 Verandahs in hospitals in China H adden. 510 Vermin as cause of disease 144 Vesical calculus, large Judson. 975 Vision of school children, examination of Stuckey. 650 Vomiting in malaria 435 ifeÊNÉRXt INDEX. x x x i

w

War against Opium ...... vV'O Wassermann reaction, variations in... 1046 Wassermanri test, variability of' 75 Weihvvei, Honan, Report of C. P. M. Hospital 1034 West China University 303 Women, diseases of— Crossen (review) 337 Women, medical schools in China for 451 Wound, abdominal, knife inside abdomen ... H o l l in g s nul V i c k e r s . 560 Wounds, contused and lacerated M a d d r e n . 554 Wuchang, A.C.M. General Hospital, report 859 Wuhu, smallpox in B r o w n . 239

X

X-Rays, dangers of ••• '526 X-Rays in skin diseases H e im b u r g e r . 223

Y

Yangtze Valley, Japanese river fever ill .F a u s t . 979 Yenping, Alden Speare Memorial Hospital report ... 592 Yokohama mortality statistics ...... ••• 347

1

Zoology, essentials-of— Meek (review) 89 L i s t o f illustrations .

Apparatus for preparation of “ Carrel-Dakin ” solution (Cameron), 404, 407, 410, 411 Amputation pylons (Van Gorder) ...... i, 3, 6 Artificial limbs (Neuffer) ...... 480 Ascites : chronic pancreatitis (Mole) 140 Babies’ footprints as means of identification (Miles) 734 Bacteriology of Trachoma (D. V. Smith) ... S87, 888, 889 Canadian Presb. Miss. Hospital, Weihwei, Honan ...... 1035 Carr, John Cecil, M.D., Ch.B., M.R.C.P.E...... 93 Congenital papilloma (Ludlow) 144 Cirrhosis, atrophic, hepatic (M o le )...... 141 Chloroform and ether, new mask for (Witt) ...... 82 Congenital occlusions of the alimentary tract (Smith) ... 18, 19, 2Ci, 22 Conjunctival bridge as safeguard against vitreous losf; in cataract extraction (Howard) ...... 709 Deficiency of Breast-Milk : Chart. (Smyly) ...... 836, 841 Dermoid cyst of ovary (Mole)... 140 David Gregg Hospital, Canton ...... 107 Delousing apparatus (Joffick)...... 28 29 Embadomonas sinensis (Faust) 231 Fasciola hepatieaand Fasciolopsis buski, ova of (Barlow),453, 458,466,468, 472 Fasciolopsis buski, area of infestation, Shaoshing (Barlow) 454 Fasciolopsiasis, Chinese children (Barlow) ... 472 Foot, abnormal enlargement of (Mole) 140 Goat with Osteomalacia (Maxwell) ... 642 Isospora hominis, oöcyst of (Wassell) 661 Instruments used by Shansi midwives (Maxwell) 642 Jaw, necrosis of (McAll) 38 , 39 Kirk, John M.B., Ch.B., F.R.C.S., Pres. C.M.M.A...... 256 Kala-Azar in China, Maps (Young) ...... 797, S05, 813, 817, 821 Leprosy, subcutaneous infiltration of lesions 573 Lympho-sarcomas, cervical (J. O. Thomson) ...... IOOI Moukden Medical College Staff and Students ...... 681 Maxwell, James L., M.D., Executive Secretary C.M.M.A. 674 Moth dermatitis (Mills) ...... 351. 370 Myelitis of dorsal cord (Mole) 140 Osteomalacia, map showing distribution of in China (J. P. Maxwell)... 625 pelvis and other bones in (J. P. Maxwell) ...... 642 cases of (J. P. Maxwell) ... 642 Parrott, A. G., M.R.C.S., L.R.C.P., Shanghai, 1S56-1923 ... 528 Sarcoma, spindle cell, of neck (Ludlow) ...... 144 Soochow Hospital ...... 205 Syphilitic granuloma (Mole) ... 140 Schistosoma japonicum in China (Meleney and Faust) ... 541., 726 Theileria akamushi, Tsutsugamushi disease (Faust) ... 979 Tuberculosis of guinea-pig; cells of bile ducts (Mole) ...... 141 Uterus, suspension of (Coffey) ...... 387 INDEX TO AUTHORS.

A dolph, W. H., Ph.D., Tsinan Diet Studies in Shantung ...... 1013

A ppleton, V. B., M.D., Shanghai What is a Health Centre ? 955

A twater, R. M., M.D., Dr. P.H., Changsha Autoclave efficiency, convenient test of ...... 234

Barlow, Claude H., M.D., Sliaoshing Life Cycl£ of Fasciolopsis buski in China ...... 453

Barnes, W illiam J., M.D., Hwaiyuan, An. Relation of Medical Department of Mission Work to the Christian missionary enterprise as a whole ...... Inset

Beebe, Robert C., M.D., Shanghai Report as Executive Secretary, Conference C.M.M.A...... 264

Bercovitz, X., M.D., Kachek, Hainan The Hodkwonn Problem in China ...... 570

Brackett, E. G., M.D., Boston, U.S.A. Medical work in China ...... 64

Branch, J. R. B., M.D., F.A.C.S., Changsha Suspension of the Uterus...... 387

Brown, R. E., A.B., M.D., M.S.P.H., Wuhu Campaign against smallpox in Wuhu ...... 239

Brunemeier, E. H., S.M., M.D., Tungjen Imperforate Anus : Report of case ...... 748

C adbury, W. W., M.D., Canton Blood pressure of normal Cantonese Students ...... 715,823 Chronic Erythema Nodosum ...... 41

C ameron, John, M. P. S. (Lond.), Peking Insecticides and Germicides in China ...... 689 Preparation of “ Carrel Dakin ” solution ...... 44,403

C iiang, H. C., M.D., Changsha lntraperitoneal Saline Infusion ...... 215

Chapman, H. O., M.B., Cli.M. (Syd.), D.T.M. (L’pool), Hankow Hospital Stock Mixtures ...... 9x5

Cheal, P., M.R.C.S., L.R.C.P., Taiwan, Formosa Ankylosis of Elbow Joint ...... 883

Chun, J. W. H., M.B., B.C. (Cantab.), M.R.C.S., L.R.C.P., Harbin Pneumonic plague in Harbin ...... 7

C ochran, Samuel, M.D., Tsinan Research Committee Conference Report ...... 279 x x x i v INDEX TO AUTHORS.

Cochran, S., M.D., and Fuii-Hsin Y u, Tsinan A simplified precipitation test for Diagnosis of Syphilis ...... 3§2

Cousland, Philip E., M.B., C.M., Shanghai Publication and Translation Committee, Secretar3T,s Report ... 276

C ruicksiiank, E. W. H., D.Sc., M.D., Peking Mechanisn of the Regulation of the H-ion concentration of the Blood. 116 Physiological Standards in North China ...... Suppl. D avis, C. Noel, M.D., B.S., D.P.H., D.T.M. and H., Shanghai Dysentery in Shanghai ...... ••• 107 D igby, K. H., F.R.C.S., Hongkong Tonsillectomy indications for ...... ••• 475 E arle, H. G., Professor, Hongkong University Clinical Physiology ...... 1010

F aust, E.‘ C., Ph.D., Peking- Notes on Embadoiuonas sinensis, F aust and W ass ell, 1921 ... 231 Possible incidence of River Fever (Tsutsugamushi Disease) in Central Yangtze Valley ...... ••• 979 Helminths of China ...... Suppl. Treatment of »Schistosomiasis Japonica ...... ••• §47 Faust, E. C., Ph.D., and M eleney, H. E., M.D., Peking Life history of Schistosoma japonicmn , Katsurada...... 729 Intermediate Host of Schistosoma japonicum in China ... 5 4 1» 545

F oster, H., M.D., Changsha Physical Examination of Chinese Students ...... ••• 643

Fowler, H enry, L.R.C.P., & S. (Edin.), L.F.P.S.G., Shanghai Medical Mission Policy ... ,...... ••• ••• 246 Report of C.M.M.A., Council on Hospital Administration...... 282

F uii-Hsin Y u, and S., Cochran, M.D., Tsinan Simplified Precipitation Test for Diagnosis of Syphilis ... 382

Grant, J. B., M.D., Peking- Public Health Work in China ... 677 Report of Council 011 Health Education ...... 603

H adden, G., M.B., Ch.B., Changsha Orientation of Hospitals in China ... , ...... 768 Verandahs, the Place and Use of, in Hospitals in China ...... 510

H agman, G. L., M.D., Nantungchow On the Treatment of Leprosy with Cliaulmoogra Oil ...... 568

H aughwout, G., M.D., Manila Plea for More Thorough Training of Microscopists...... 594

H eimburger, L- F., M.D., Tsinan Dermatology : Recent Advances in Treatment ...... 220

H ollings, G. W., M.B., Ch.B. and B. R. V ickers, M.B., B.Sc., Shiuchow Ccrse of Wounded Chinese with Knife Inside Abdomen...... 560

H oward, H. J., M.D., Peking J , Cemjunetival Bridge in Cataract Extraction ...... -... 709 INDEX TO AUTHORS. XXXV

H s ie n Wu, PhD., Peking Blood Analysis, with especial reference to seme new methods ... 1019 H u ize n g a , S., M.D., Taicbow Bronchial Spiradraetasis ...... *53 Leprosy, Note on Treatment o f ...... 567 Typhoid Fever, Forty Cases o f ...... 320 J o f f ic k , S. D., M.D., Peking Practical Method for Delousing Chinese Clothes and Bedding 25 Practical Suggestions for performing the Saclis-Georgi Test for

S y p h ilis ...... 10 J o h n so n , C h a r l es F., M.D., Tsinan Conference Address as President of C.M.M.A...... 259 K iang , P. C., M.D., Tsinan Chinese drugs of therapeutic value to Western physicians 742 L a r se n , L. K., M.D., Antung, Manchuria Public Health of Antung : Chinese Customs Service report 505 L en n o x , W. G., M.D., Peking Neurosyphilis among the Chinese 663 L e s l ie , P. C., M.D., Changteho Clinical Notes 750 L ib b y , W. E., M.D., Wuhu Tartar Emetic in Schistosomiasis japónica 158 L i C h i P an, M.D. and R. F. M a d d r en , M.D., Changsha 00 Some »Surgical Aspects of Blood Transfusion... & Liu, J. H., M.D., Peking Laryngeal Tuberculosis, earty diagnosis of ... 73S Ludlow, A. I., M.D., F.A.C.S., Seoul, Korea Surgical Case Reports 145 M ad dren , R. F., M.D., Changsha Contused and Lacerated Wounds of the Soft P a rts ...... 554 M a d d er n , M.D. and Li C h i -P an, M .D. Some Surgical Aspects of Blood Transfusion... 987 M a x w e l l , J a m es, L., M.D., Tainan, Formosa Lead Poisoning, Unusual Case of 5S4 H ysteropexy: A simple, safe and effective operation for prolapse of u teru s ...... 593 Letter and Notes as Executive Secretary, C. M. M. A. 672, 882, 1055 M a x w e l l , J. Preston, M.D., B.S., F.R.C.S., Peking Osteomalacia in China 625 M cA l l , P. L., M.B., Ch.B., Tsinan Necrosis of the Jaw ...... 39 The Curriculum for Missionary Medical Schools in China... 685 M cC len d o n , J. F., Ph.D., Minneapolis, U.S.A. China as a field for the study of Human Teeth ...... 34

M cC r a c k en , J. C., M.D., F.A.C.S. Council on Medical Education, Conference report ... 302 X X X v i INDEX TO AUTHORS.

M cL ean, F. C., M.D., Peking Diabetes : Present Status of Insulin Therapy in ...... 205

M eleney, H. E., M.D., and E. C. F aust, Ph.D. Life History of Schistosoma japonicum Katsurada... The Intermediate Host of Schistosoma japonicum in China. 541, 545 Meleney, F. L., M.D., and Read, B. E.; Ph.C., M.S., Peking- Cholesterol : Its Occurrence in Two Thyroid Cysts : a modification of Salkowski’s Test ...... 236

M errins, E dward M., M.D., Shanghai Report as editor of China Medical Journal ...... 269 E d ito r ia ls ...... 50, 167, 412, 585, 672, 754, 853, 1025

M iles, L ee. M., M.D., Peking Identification of babies by means of foot-prints ...... 734

Mills, R. G., M.D., Peking Dermatitis caused by a Liparid Moth ...... 351 Taenia saginata in North China. Notes 011 the occurrence of ... 932

Mole, R. H oward, B.A., M.D., Ch.B., Moukden Some Recent Cases of Pathological Interest ...... 139

N euffer, H ans, I)r. Med., Hinghwa Artificial Limbs made by Chinese Brass-Smiths ...... 480 O ldt, F., M.D., Dr. P. H., Canton Purity Campaign in Canton ...... 776 Peterson, R. A., M.D., Nanking Some Valuable Aids in Ocular Therapeutics ...... 842

R ead, B. E., Ph.C., M.S., Peking Chinese Drugs of Therapeutic Interest to Western Physicians ... 589 Drug Cultivation in China ...... 147 Standard Pharmacological Formularies in China ...... 925 Toxicology in China ...... 481 Read, B. E. & M eleney, F. L., Peking Cholesterol : Its Occurrence in Two Thyroid Cysts : A Modifica­ tion of Salkowski’s Test ...... 236 Scott, H., M.D., M.R.C.P., F.R.S., England Sprue, New Theory as to Causation of and its Treatment based thereon...... 581 S elmon, A. C., M.D., Shanghai Tuberculosis : A R etro sp ect...... 771

Shields, R. T., M.D., Tsinan Recent Development in Histological Technique ...... 329

Simpson, Miss Cora E., R.N., Shanghai Nurses Association of China : history ...... 1S1

Slack, H enry R., M.D.. Peking Tonsillectomy, indications for ...... 473

Smith, D. V., M.D., Peking Trachoma, Bacteriology of ...... 887 INDEX TO AUTHORS. x x x v i i

Smith, E. D argan, M.D., Kweilin Congenital Occlusions of the Alimentary Tract ...... iS Smyly, E ileen, M.D., Peking Deficiency of Breast-Milk in Nursing Mothers : Treatment ... 834 Snoke, J.H., M.D., Shanghai Administration of Mission Hospitals in China ...... 60, 860

Stearns, T., M.D., Tsinan Tuberculosis of the Knee Joint ...... 891 Stephenson, B. R., M.A., Peking Simple form of Carrel-Dakin electrolytic Cell ...... 850 Stuckey, E. J., M.B., B.S., B.Sc., Tientsin A Plea for the Routine Examination of the Vision of School Children in China ...... 650 Thomson, J. 0 ., M.D., C.M., F.A.C.S. Cervical Lympho-sarcomas ...... 1010 T ootell, T., M.D., Changteh Ankylosis of Elbow Joint 656

T sen, E. H., M.D., Peking Central Epidemic Prevention Bureau, report of ...... 515 Tso, E-, M.D., Peking Statistics of Communicable Diseases among Hospital Employees. 226

V an G order, G., M.D., Peking Plaster Pylons in Leg Amputations ...... 1

V ickers, B. R., M.B., Shiuchow Aneurysm, Notes on two cases of ...... 747 V ickers, B. R., M.B., B.Sc., and G. W. H ollings, M. B., Ch.B., Shiuchow Case of Wounded Chinese with knife inside abdomen ...... 560

W ampler, J-, M.D., Ping Ting Chow Observations 011 Child Hygiene Campaign in Shansi ...... 83

W assell, C. M., M.D., Wuchang Isospora hominis in China ...... 661

W ilson, A. S., M.D., Madura, India Ochsner Treatment of Malaria ...... 322

W itt, E., M.D., Hungkiang New Mask for Chloroform and Ether ...... 81

W ong Man, M.R.C.S., Canton How can Missionaries be of most use to China during the next decade? ...... Inset

W ong, K. C., L.M.S.H., Hangchow Chinese Hospitals in AncientTi m e s ...... 77

W right, H. W. S., M.S., F.R.C.S., Tsimn Renal Infections ; their guises and disguises 902

Y oung, C. W., M.D., Peking Kala-Azar in China ...... 797 Subscription : Voi, XÌXXVIl* Ho. 1. JANUARY, 1923 $5.00 Shanghai Currency

Published Monthly by the MEDICAL MISSIONARY ASSOCIATION OF CHINA.

■ Editor. E. M. Merriue, M.D., St.John’s University. Shanghai. Business Manager, Dr. R. C. Beebe, 5 Quiasan Gardena, Shanghai. Sec'y and Treas., H. H. Morrit. M.D.. 4B Minghong Road. Shanghai.

TABLE OF CONTENTS.

ORIGINAL: ■ The Use of the Plaster Pylon ta Leg Amputations. Opening of Soochow Hospital m By Dr. öeotge Vaa öorder, M.U. Hospital Administration from the Vlew-Poiat of Pneumonic Plague Ja Harbin (Manchnrian Epidemic, the Patient, By J.H . Snoke, M.D. .. 60 1921). By J.W.H. Chun, M.B., B.C. (Cantab.), M.R.C.S., L.R.C.P...... Medical Work in China .. 64 - Con*eattW, Occlusions of the Alimentary Tract: Current Medical Literature .. GS reports. By E . Dargan bmith, M.D. 18 for Med.Variability of Wassermann Test, '* i for Med.Variability fi» A Practical Method for Debasing Chinese Clothes Research 75 and Bedding. By S.D. Jotfick, M.D. 25 Erythema Nodosum and Tuberculosis TO China as a Held for the study of the Nstrltioa of Chinese Hospitals in Ancient Times ,. 77 Human Teeth. By J .F . McClendon, Eh. D. ^ 34 A NewMisktor Chloroform aad Ether 81 Notes on Necrosis of the Jaw. By P. L . Me All, M.B., Ch. B...... Observations on the Child Hygiene Campaign la Shansi. By Fred J. Wampler, M.D. Chronic Erythema Nodosum: Report of Case. By Wm. W . Cadbury, M.D...... 41 Professor Fuchs’ Visit to Peking Book Reviews ...... k Note on the Preparation of “Carrel-Dakin” Solution. By John Cameron, M.P.S...... 44 Peking Union Medical College:—Course in Diet­ Editorial: The China Medical Journal, C.M.M-A. etics ...... m Conference, 1923; An Outlook, Conference in Memoriam J , C. Oarr; E . Nilssen. '• ... 93 Notice, Oarbon Tetrachloride as an Anthel­ mintic...... Correspondence...... Medical Missionary Work as a Vocation .. News and Comment 100

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VOL. XXXVII. JANUARY, 1923. No. I.

THE USE OF THE PLASTER PYLON IN LEG AMPUTATIONS.

G eokge V an G order, m .d ., Peking Union Medical College. Peking.

The problem of the cripple in China is so commonplace and so tremendous, that vve, as physicians and surgeons, are often inclined to disregard it for the more inviting and more inspiring tasks that every day confront us. Jf the problem were a medical one onl}-, we wouid attack it more whole-heartedh- and would feel more directly responsible for its solution ; but being a social and economic problem as well, we feel that we can contribute only to a certain extent towards alleviating the unhappy situation. In this paper the writer wishes to refer to just one phase of the subject, namely, that which concerns a common type of cripple, the “ amputee,” if we may so call the patient, and in doing so, to offer a suggestion or two that 11m7 be of help in dealing with his condition from a surgical point of view. In China, where joint tuberculosis is so prevalent, where frost­ bitten feet with attending gangrene are so common, where infections are often neglected until life-saving measures are imperative, and where the incidence of serious accidents, owing to the increased introduction of automobiles, railroads, factories and machinery, is becoming very heavy, one need scarcely point out that an enormous number of surgical amputations is inevitable. And this fact gives rise to a real problem from the standpoint of proper and adequate surgical treatment of these cripples. The after treatment and disposition of these cases have always been matters of no little concern to many surgeons Mho frankly realize that their responsibility to their patients does not end with a good closure of the stump wound, but that the\' should see to it that everx’thing possible is dons to restore the lost function and help the patient to return to hi? former routine occupation and manner of life. :: 2 The China Medical Journal.

In America and Europe, this is a fairty simple matter, for the lim bless man or „wo'hian can^ tje¿ p£sséd£o.n to a n ^arúlníi^J lim b maker, and-with the departúfé of the fmtieht. the ‘surgeon’s further responsibility7 may cease.; but jn China,.where there are ro such artificial limb factories, what aré.we to do? . ' For the great majority of Chinese people, the artificial appliances from Japan and-America are too. expensive; and the difficulties of accurate and satisfactory measurements are great and known to us all, so that we as surgeons are reduced to one of two procedures: either (i) turn, our “ amputees” out .of our. hospitals without any prosthesis, and add to the number of disabled human •beings many of whom become beggars— a reflection, perhaps, on our past treatment of these ca-ses; or (2) supply each patient in the hospital with some form of prosthesis that will enable him or :her to walk about and earn a living. When the wounded British soldiers, including very many without feet or legs, were pouring into England in the winter of 1917, the artificial limb factories were naturally* overwhelmed with business and a waiting list of thousands was written in th.eir books, for it was' insisted upon at that time that each soldier who had lost an-arm or a leg should have; an artificial limb supplied. The situation was serious and appeared hopelesss : for the number of artificial limb factories was small, the number of artificial limbs required was enormous, and it was evident that some years would elapse before all the patients could obtain their prostheses. Consequently, something had to be done in the interim to answer the great need. In the case of leg amputations this was met by the invention and employment of a good, simple substitute limb, made of plaster-of-Paris, the so-called “ plaster pylon.”

This apparatus proved to be most satisfactory, and in all the large orthopedic centers of England was usually employed as a means of preparing amputated leg stumps for future prosthesis. From ten days to two weeks after complete healing of the stump these pylons were applied, and the patients were encouraged to walk at once, thus preventing the crutch habit and enabling the stump muscles to regain their functions more quickly. Now it seems to the writer that this form of apparatus can also be used to great advantage in all hospitals in China, for the following reasons : Amputation Pylons 6

(i) The plaster pylon is quickly and easily made; (2) the necessary materials are readily available in all parts of China; (3) the apparatus is inexpensive; (4) by covering1 the plaster surface with shellac it will serve from six months to a year without renewal.

.The suggestion offered, then, as a,means of helping our leg amputation patients to “ get back 011 their feet ” is the employment of the “ plaster pylon,” either as a temporary or as a permanent artificial appliance. Instructions for making the pylon follow.

F ig . 1 .—Materials used in making- a plaster pylon.

The following articles are necessary :

( 1 ) Side Bars. (F ig .— 1 a .) T w o bamboo strips, 1^2 inches wide, yl inch thick, and of length as required. By heating over a flame these are bent to fit the sides of the stump. In this way the two bamboo bars are adapted to each individual pylon.

(2) Base Block. (F ig .— ib.) A wooden base block, 4 to 5 inches long, round, with a diameter of 2 inches at the bottom and slightly larger at the top. A groove 2 inches long is cut vertically on each side of the block, into which the bars fit snugly. These are secured by two steel wires riveted at both ends. Screws or nails are unsatisfactory for this purpose, as they invariably cause the bamboo bars to split. 4 The China Medical Journal.

(3) Lining.— (Fig. I c.) The lining of the pylon should preferably be of some form of stockinette, which can be slipped smoothly up over the leg stump; however, felt lining, *4 inch i11 thickness, can be used instead by cutting it to the exact size required and sewing the cut surfaces carefully together to avoid creasing. In many cases the pylon has been made and used unlined. (4) Pad.— (Fig. Id.) A pad of felt, the diameter of which is that of the stump end, is placed over the end of the bone and secured in place by sewing it to the stockinette lining. If felt is used for lining no extra pad is necessary. (5) Plaster Bandages.— (F ig. 1 E.)' Crinoline bandages well powdered with plaster-of-Paris and made into rolls 4 or 5 inches wide. (6) Webbing Straps.— (F ig. I f.) (a) For amputations below the knee :— three webbing straps, each one inch wide and of required length, and one webbing strap three inches wide, to encircle the leg above the knee.

(b) For thigh amputations :— (F ig. I G.) T wo webbing straps three inches wide and long enough to reach over the opposite shoulder and buckle in front.

(7) Buckles.— (Fig. I h .) (a) For lower leg amputations :— five buckles, each one inch wide. (b) For thigh amputations :— one buckle, two inches wide.

CONSTRUCTION. The Wooden Frame.— The two bamboo sice bars, being cut to the proper length, are bent into their required shape by heating over the flame, and are then secured to the base block b}7 long steel rivets. As a general rule, the outer bar of the frame should be two inches longer than the inner, and 111 thigh stumps the upper end of the inner bar should never reach higher than 2 inches below the perineum. The space between the two side bars should be one-lialf inch wider than the width of the limb to be fitted, in order to allow for the thickness of the plaster bandages which are to form the inner layers of the bucket. At varying distances one or two tacks should be driven through the side bars so that their sharp ends project 1/8 to % inch on the outer surface. Later on, these will engage in the plaster and thus prevent slipping. After preparing the wooden frame and making sure of its proper lengtli it is temporarily laid aside (see Fig. X.) Amputation Pylons 5 The Plaster Bucket.— With tlie patient lying flat on the table, the stump is covered weli with talcum powder, after which the stockinette is drawn up snugly over it, as far as tlie patella in lower leg amputations (see Fig. II), and 2 inches above the tuberosity of the ischium in amputations above the knee joint. The excessive length of lining at the top is used later as a turnover. At the lower end of the lining, 3 inches excess is allowed to fold o/er and sew to the circular pad of felt in the case of end-bearing stumps (see Fig. Ill); or to turn back as a cuff in the open-ended variety of pylon. If a felt lining is used it must be cut to the exact size of the stump, then stitched and held in place by a bandage. In case no lining is used, which is not recommended, the stump should be smeared with vaseline instead of talcum powder, and the plaster-of-Paris bandages applied direct. After the lining and end-bearing felt pad have been applied to the stump, the plaster-of-Paris bandages are carefully applied to the stockinette covering, avoiding any creasing or wrinkling. A word of precaution may be added here. At first it is well to apply the bandages up and down the front and back of the leg over the end of the stump before making the circular turns (see Fig. IV). In applying the circular bandages special care must be taken not to pull them tight around the stump, but simply to allow them to conform to its contour; otherwise the bucket will be found to be too small, especially at the top. After the first four or five turns of plaster bandage over the entire stump, a delay of a few minutes is wise, in order to allow the plaster to harden a little before incorporating the wooden frame (see Fig. V). In the case of lower leg stumps it has been found that four or five plaster bandage rolls are sufficient to form this inner layer : in thigh stumps, more are necessary, depending upon the point of amputation, and the plaster should be carried up to the tuber ischii and reinforced there (see Fig. XI). Application.— The frame is now applied to the plaster covering (pylon socket, Fig. V), the side bars touching each side and being maintained in position parallel to the bone shaft while they are caught by succeeding plaster bandages. The tacks previously inserted into the side bars now aid in preventing slipping, since their points penetrate the successive turns of plaster. Also at the top of the side bars, double turns of bandage may be used in order to render additional stability. After incorporating the frame by 4 or 5 plaster rolls, the free end of the lining at the top is pulled 6 The China Medical Journal. down ever the plaster edge to form a cuff (Fig. VI) and is held by subsequent turns of the bandage. Likewise in the open-ended variety of p37lon a cuff is formed of the lower lining in the same way at the bottom. Following this, the webbing straps are applied (Fig. VII). A turn or two' of the bandage fixes the straps, leaving two inches of the lower end uncovered. These lower ends are then iolded upward upon themselves and held by subsequent turns of the bandage, thus preventing them from being pulled out. In the case of thigh amputations, two webbing straps of unequal length, each 3 inches wide, are used, the shorter in front and the longer at the back, both directed to the opposite shoulder. A buckle is placed at the end of the longer strap. In the case of lower leg amputations three webbing straps one inch wide are used, one at each side of the bucket and one at the back (see Fig. VII). The free ends of these straps are fastened into corresponding buckles on the strap above the knee. After incorporating the straps, (Fig VIII). the pylon is allowed to remain on the leg stump from fifteen minutes to a half-hour. In lower leg stumps, the circum­ ference of the leg just above the knee joint can be measured, and a three-inches wide webbing strap cut accordingl}- and marked for the placement of buckles (Fig I). The pylon is then removed (Fig. IX) and placed in a warm room to dry. After wearing the pylon, should the patient’s stump rapidly decrease in size, as often occurs, a stump sock can readily be worn. The making of the pylon takes but little time and with a little practice becomes a very simple matter.

SUMMARY. 1. Because of the high incidence, of joint tuberculosis, gangrene, and severe infections among Chinese patients many amputations are a necessity. 2. The absence of artificial limb factories in China, and the great expense associated with importing appliances from Europe and America, have made the surgical after-treatment of patients with amputated limbs a difficult problem. 3.. In order to improve the condition of leg “ amputee” cases, some form of prosthesis should be given to every such patient before he or she is discharged from the hospital. Big. II.— Representing the amputated stump, covered by stockinette, after the skin has been well powdered.

Fig. III.— Method of inserting a felt pad over the end of the stump and securing it to the stockinette by means of a purse string suture.

Fig. IV .— Method of applying the first layer of plaster-of- Taris. The bandages are carried up and down the front .and back of the leg over the stump end, before making • any circular turns.

A m p u t a t io n P y ix jn s ( V ax G o r d f .R) Pneumonie Plague, Harbin, iqii.

4. The form .of prosthesis recommended by the writer for routine use in the hospital is the so-called “ plaster pylon.” 5. This form of apparatus is quickly and easily made; the necessary materials are readily available in all parts of China;-it is inexpensive, and at the same time effective. 6. Such a form of apparatus, so easily made, so cheap and so effective, might justly find a definite aud valuable place in the subsequent treatment of all leg amputation cases in China, and with this idea in mind, the writer offers as a suggestion, its routine use in our hospitals.

REFERENCES. 1. No. 24. Appliances. 402 Army Medical Department. British War Office. 2. Journal of Bone and Joint Surgery, April, 1922.

PNEUMONIC PLAGUE IN HARBIN (MANCHURIAN EPIDEMIC, 1921) *

J. \Y. H. CB'JN, M.B., li.C., (CANTAK.), M.R.C.S., T.R.C.I'. As a very full report of the Manchurian epidemic of pneumonic plague will be issued by the North Manchurian Plague Prevention Service, it is the purpose of this paper simply to consider some of the salient points of interest which came under our - observation when the plague appeared in Harbin. The first epidemic of pneumonic plague in Harbin, within recent times, occurred in the winter of 1910-11. It lasted from November to February, and a mortality of 9000 was recorded. The population of Harbin was then about 80,000, so the death-rate from plague, approximately, may be said to have been 90 per thousand. The second epidemic occurred in 1921. The first case of pneumonic plague was discovered on the 22nd of January of that year and the last case appeared ^ few months later on the 23rd of May. The total number of deaths was 3,125. The present population of Harbin may be put down as 300,000. The plague

*Report of Nortli Manchurian Plague Prevention Service, 1922. Edited by Dr. Wu ¿Lien Teli. 8 - The China Medical Journal. death-rate was therefore about id per thousand, a very much lower rate than in the previous epidemic'' Moreover, ten years ago, the plague mortality in the whole of Manchuria amounted to 50,000, while in 1921 the total number of deaths in the same area came to 8,500 only. What has caused this surprising fall in the death- rate ? The virulence of the disease was just as great in 1921 as in the former epidemic, for no patient with true pneumonic plague recovered. The sanitation and popular ideas with regard to hygiene have not appreciably advanced during the intervening decade, and the means favoring the spread of this highly infectious disease, such as rapid railway communication, still exist as before. Further, the military control, formerly furnished by Russian soldiers in part, in the later epidemic devolved entirely on Chinese soldiers who, so far as the rank and file were concerned, were hostile to strict anti-plague measures. Taking all this into consideration the large reduction in plague deaths is the more remarkable when the increase of population in Manchuria during this period of ten years’is reckoned as a factor. Briefly, the wonderful change may be assigned to three causes : (1) the existence of a permanent anti-plague service; (2) the willing and enthusiastic support of the Chinese authorities; (3) the active cooperation of the officials -of the Chinese Eastern Railway and of the Russian doctors with our own staff. At the beginning of the epidemic, when cases were first reported in Hailar, October, 1920, the Chinese officials at once took a serious view of the matter and invited the Plague Prevention Service to cooperate with the local Russian doctors. This was done with such good effect that only 54 deaths were recorded in Hailar. Unfortunately, some men carried the disease to the Dalainor coal mines some hundreds of versts west, and from there Manchouli .itself became infected. Passengers travelling eastwards to Tsitsihar caused an epidemic there also, while others brought it to Harbin where the first case was observed on January 22, 1921. From the beginning it was fully realized that. Harbin might be infected at any time., so measures wer.e taken early against the danger. The train service between Manchouli and Harbin was restricted to first-class and second-class passengers who were first examined by doctors before tickets, could be purchased. The number of tickets was also limited and 110 third-class passenger Pneumonic Plague, Harbin, 1Q21. 9 tickets were issued. In spite of these restrictions, however, ccolies managed to steal rides 0:1 gODds trains and in various ways to travel from one place to another.

PLAGUE HOSPITAL SERVICE. One doctor was in charge of the plague hospital. Under him were three dressers: one tcok care of the clerical part of the work : the second had charge of the personal effects of the patients, the procuring of the sputum and urine, etc., as well as the performance of other odd jobs ; the third had charge of the patients. There was one cook. Also a washerman whose duties included the disinfection of gowns, hoods, etc., by formalin gas. There were also two attendants who looked alter the welfare of the patients; these had the dangerous work of feeding the patients, providing them with water, bringing earthen pots for sputum and evacuations, and cleaning the wards generally. A sanitary- squad consisting of ten men also formed part of the service, to convey patients by stretchers when transference was necessary, to remove the corpses to the cremation pit inside the compound, and to cremate the corpses. At the beginning of the epidemic these men had to go into the town to cart away plague corpses to the public burial ground. As the number of corpses increased towards the height of the epidemic, other sanitary squads were formed in the town itself for this purpose. As has already been mentioned, ten policemen were on duty day and night in the compound. It may be realized that work of this nature was highly dangerous. So much so that a very7 keen and able worker, Dr. Yuan Teh Meo, died of this dreadful disease. Two attendants, three members of the sanitary squad, and one policeman also succumbed.

PROTECTION OE STAFF AGAINST INFECTION. Some members of the service were inoculated witli vaccine iagainsl plague. The greater proportion, however, were not thus inoculated, reliance being placed on the protection given by the mask, overall, hood, high boots and rubber gloves. After the mask w-as tied in place, the hood was put 011, and goggles were worn outside the hood. Then came the overall, and lastly the rubber gloves. The hood may be briefly described. It was shaped somewhat like a bag, with, two holes for the ey*es. It was made of ordinary white cloth, and a piece of Chinese silk was sewn to the IO The China Medical Journal. parts covering the nose and mouth for additional protection. On coming out. of the wards the overalls-, etc., were removed and exposed to the sunlight in the open air. In the evening the garments were disinfected b\' formalin gas and were then read}- for use the next mornirg. The boots were sprayed with.lzal lotion. A thymol gargle was provided and the hands were washed in Iza.1 lotion. A special suit of clothes was worn when on duty, so that when the da\’’s work was over, one could change back to a second suit. Daily baths were recommended.

OPPOSITION OF PEOPLE. In commenting on epidemics of plague, Professor W. J. Simpson relates how laymen of all ranks, particularly in Oriental countries, tend to oppose anti-plague measures strenuous!}'. This is not to be wondered at when it is realized how much people are inconvenienced and hampered by the measures taken to check epidemics. In India, people have been so worked up that they have attacked doctors and sanitary attendants while on dut}-. Dr. \Yu Lien Teh, who had charge of the whole campaign in Manchuria, received man\^ threatening and abusive letters. Our doctors, dressers, and attendants also encountered unruly soldiers. Local merchants looked at our work with fear and suspicion. Evil rumours were spread that we shot the patients on our compound, and that we poisoned the wells of the town. Y\ ith all this opposition, hindrance from all quarters, disappointments and difficulties always inseparable from work of this nature, the morale of the whole staff was consistently good.

CONTROL OF THE EPIDEMIC. The first case o! pneumonic plague was discovered near the Hospital. The patient, formerly a miner at Dalainor, had came from Manchouli to Harbin to join his aged mother, his sister and sister-in-law. After positive diagnosis was established, the three contacts were housed in our compound. Of these three contacts, one woman, the sister-in-law, developed plague on the-fifth day of sojourn. The other two remained well, and .were set free subse­ quently. After this, day after day, plague deaths were reported in the town. As the number of plague cases increased, ten trained dressers were stationed in the five districts to take charge of the inspection Pneumonic PlagueHarbin, 1Q21.

squads, to superintend the sending of plague cases to .the hospital, to send for the disinfecting squad, and to arrange for the quarantine of the contacts. The police were a great help and on the whole did their duty nobly. The town of Fuchiatien was divided into five districts and inspectors went round daily. All sickness and deaths were reported to them, and they in turn notified the hospital. A doctor would then go and obtain pathologic material from corpses by spleen punctures or secure sputum for diagnosis from suspected cases. Contacts at first were also kept in the hospital, but later they were isolated in box-cars kindly lent by the Chinese Eastern Railway.

Fig. t.— Plan of Plague Hospital.

Referring to the plan (Fig. I), it will be seen the arrangements were such that when a sick man was admitted, he was placed on a bed near the gate where the doctor and dresser could examine him. If the disease was plague he was taken on a stretcher to the plague ward or building where he remained in a rcom by himself. If it was a case which merely gave rise to suspicion, it was isolated in the suspect ward or building. If, on the other hand, it was a case of ordinary sickness, it was sent home. Each man on admission was questioned as to Ids name, occupation, age, address, how long he had been sick, and if there were any contacts. Money and other valuables were taken care of by the dresser in charge. The China Medical Journal*

These particulars, written co.vn on a temperature chart, were pinned to the door of his room and the result of his stay was also put down later. The drawing sho ws that the cubicles communicat­ ed with one long corridor. Each cubicle w7as provided with an observation window so that the inmates could be seen fro.n the corridor with oat opening the dcors. Near the gate were station­ ed ten policemen who look turns on duty, to guard against the escape of the inmates of the hospital. Next door w-as the disin­ fection rcom where the staff put on their antiplague garments, where antiseptics w:ere stored, and wyhere hot water was obtained. The.hospital was open at all hours of the day and night.

AGE OF PATIENTS. The fol’o ving figures give the age of 1252 patients grouped according to decades. It shorld be noticed that over 78 per cent, were between twenty-one and forty years of age. Years 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-S0 Patients 21 S3 593 385 130 33 6 1 T o ta l= j2 5 2

SEX. Of 1310 patients, 1243 were male and 67 female.

OCCUPATION OF PATIENTS. The fact that out of the 1312 plague patients who came to the Harbin hospital no less than 1139 belonged to the very poor class is noteworthy. The other patients mostly belonged to the small merchant class. Pneumonic plague is a disease which is most dangerous among poor people who live from hand to mouth and who sleep in small crowded rooms. Large numbers of coolies migrate from Shantung and Chihli to Manchuria, leaving their w’omen-folk behind. These poor people come to make money to support their families at home and many live in crowded inns, or small rooms where the “ kang” system exists. Sometimes, in order to economise space, tiers of shelf-like bunks are erected for sleeping purposes. In these ver\7 adverse conditions it is not to be wondered at that such an infectious disease as pneumonic plague can work great havoc among the dwellers, especially when the lack of ventilation, owing to the rigorous climate, is taken into Pneumonie Plague, Harbin, 1Q21. consideration. These factors will explain why so many young and healthy males were killed off, as 593 patients died between the ages of 21-30 years, and 1243 males died as against 67 femajes. It may also be noted that the proportion of plague cases sent from the railway area (284) and from the Chinese town (795) was about 3 to 8. The railway area is cleaner, better planned, and there is not nearly so much crowding.

PLAGUE STATISTICS OF HARBIN HOSPITAL- The total number of patients admitted to the Harbin Plague Hospital during the epidemic was 1,461. Not all of these, however, were victims*of pneumonic plague. The total number of deaths from plague was 1312. Among the Russians, eight onl\- died of pneumonic plague. There was one case of bubonic plague, a young Russian woman, who made a good recovery.

TABLE I. — ADMISSIONS INTO HARBIN PLAGUE HOSPITAL.

From Railway From From From Total Area Fuchiatien Wagons Elsewhere January 0 2 0 O 2

F ebruary 22 57 47 O I 26 M arch 120 367 1 18 37 642 A pril I 33 356 57 1 1 7 663 M a}7 9 *3 5 1 28

284 795 227 *55 1,4 6 1

THE DIAGNOSIS OF PLAGUE. As soon as the patient entered the gate of the compound and after his history had been taken in the open air, he was asked to spit into an earthenware basin. If there was blood in the sputum, if he had fever, if liis facies resembled that of patients with plague, and especially ii he staggered in his gait, he was presumed to have plague and was sent to the plague ward. In case of doubt, the sputum was collected in a Petri dish, which was put inside a round tin case and carried in a rectangular tin box having the capacity for 4 Petri dishes, and taken to the laboratorj- for microscopic diagnosis. If the patient did not spit blood but had fever, he was sent to the suspect ward. As the diagnosis of the different cases became clear, the patients wrere either sent to the suspect w’ard, or plague The China Medical Journal.

ward, or set free, or sent to tlie isolation wagons, in this work, Dr. Pollitzer, our bacteriologist, took great pains to give us every needed assistance at all times to ensure the right diagnosis. Man}- patients with other diseases were sent in by mistake; these were diagnosed correctly and kept temporarily in wards separate from the plague wards. Among these diseases were m orphinomania, sim ple catarrhal fevers, pneumonia, emp3^ema, drunkenness, influenza, Bright’s disease, tuberculosis of the lung, rheumatism, heart disease, starvation, typhoid fever, paratyphoid fever, erysipelas, diarrhoea, dysentery, tuberculosis, of bones, etc. Whenever possible such patients were sent home to make room for real plague cases. As a rift in the cioud, one may relate an amusing instance of mistaken diagnosis on the part of the inspection squad. One man had eaten crab apples, and spat out some red pulp. He was thought tc have spat up blood and was sent to the hospital, happily to be discharged soon after.

BACTERIOLOGY. In the official report a full account will be found of the bacter­ iological work done in the hospital during the epidemic, covering the diagnosis of the disease, mimerous experiments on the ways in which it is or may be conveyed, and on the means to prevent infection. Hence in this place allusion will be made only to a few details. Some research work was done among the contacts, and it was found that two men were plague carriers. From their throats B. pestis was cultivated and Koch’s postulates were all fulfilled. Experiments on the action of different antiseptics on plague sputum showed some interesting facts. It was fouud that methylated spirit or absolute alcohol killed B. pestis in three minutes. When the sputum was mixed with lime and left alone for thirty minutes, no growth could be obtained, while perchloride of mercury i : 500 did not kill:B. pestis in sputum under ten minutes. Mention may be made here of a woman who was pregnant and at full term was stricken by the plague. A few* hours before death, she aborted. The foetus was still-born. On bacteriologic and microscopic examination, B. pestis was found in various organs of the foetus. The germs of the disease were also found in the placenta. Pneumonie Plague, Harbin, iQ2i. 1S

TYPES OK DISEASE. When the epidemic of plague was first reported in Hailar, it was noticed that the first few cases beloiiged purely to the bubonic type. Afterwards purely septicacmic or mixed septicaemic and pneumonic cases were discovered. Even, as late as the third month of the epidemic m Hailar, one purely s.epticaemic case was found. This may account for the comparatively small number (54) of deaths in Hailar owing to the ^conceivably low infectivit}- of the -septicaemic ty p e . , Towards the end of the epidemic in Hailar, it was ..noticed in post-mortem‘examinations that the septicaemic t}Tpe prevailed, io that in the last few cases there was very little tracheitis, and ver\' little or no pneumonia at all. This is important because some light is thrown on the cause of the decline of the epidemic. In Manchouli also, the last case reported was of the bubonic type.

SYMPTOMS. h The plague patient is somewhat cyanosed and short of breath. The conjunctiva is injected. He coughs and often spits up bright blood. He sometimes complains of pain in the chest, and as he walks he staggers from side to side like a drunken man. On auscultation there are often no abnormal physical signs. When a patient has fever of 102° F. or 103° F. and a running feeble pulse of 120, together with the signs and symptoms mentioned, one has strong prima facie evidence of plague. After a little time, one was able to recognise plague cases at sight. The typical patient is apathetic, never actively delirious or maniacal. Depending on the stage of the disease, he cannot respond to questions nor do what he is told. Many of the patients are stolid almost to the point of extreme stoicism. At this point, one would like to emphasize the remarkable fortitude of the Chinese labourer. He is the best patient in the world and is a staunch fatalist. He will suffer and say nothing. He sees his comrades die and utters not a murmur, fully knowing that he himself will soon share the same fate. Moreover, he is very grateful and appreciates the little that can be done for him. He is polite and obliging under all circumstances. In all these respects, he is entitled to our admiration and deep respect. 16 The China Medical Journal.

Urinary Examination,— Thirty specimens of urine were examined. Twenty-three specimens were voided by patients who had'been ill for one or two days; the remaining seven specimens were obtained by caiifteterizing corpses.

In most of the cases the color of the urine was dark,, the specific gravity was high, and out of the thirty specimens, twenty-eight showed a moderate amount or merely a trace of albumin. The test was by boiling and the addition of dilute acetic acid. In the majority of specimens examined, hyaline granular casts were present.

With regard to the bacteriology, in one case only was B. pestis cultivated from the urine, the specimen being obtained by catheterization after death.

It was thought it would be interesting to estimate the amount of chlorides present in the urine, as it is well known that these are diminished in pneumonia as well as in some other fevers, so a rough clinical method with silver nitrate solution was employed Jn three specimens only the chlorides appeared to be normal; all the rest showed a diminution.

TABLE II.— DURATION OF STAY IN HOSPITAL.—

No. of Average Longest Average patients stay stay duration recorded in da}rs F ebru ary ...... 85 2.8 M arch ...... 47^ 1 -7 9 days 1.8 days A p ril...... 561 1-7 M a y ...... 6 2.1

Some patients were so ill that the}" died almost immediatelj’ after admission, while others lived for a few da\-s. It is to be remarked that the average stay was 1.8 da}\s. Though 1,312 plague eases were admitted during the four months, the largest number in the hospital on any one day w:as never above fifty because the patients died so soon after admission. In passing, one may state that most of the plague patients died at night or very early in the morning. Pneumonie Plague, Harbin, IQ21. 17

TABLE III.— NUMBER OF DEATHS FROM PLAGUE IN HARBIN PLAGUE HOSPITAL DURING EACH MONTH OF EPIDEMIC. From .U a il wav From From From Area Fuchiatien Wagons Elsewhere Total. January... 0 0 0 0 2

F ebruary 20 44 34 O 98 M arch ... l i ó 357 92 32 597 A p ril 129 330 47 103 609 M ay I 0 5 0 6

266 733 178 135 1,312

TABLE5 IV. — PLAGUE MORTALITY IN HARBIN DISTRICT.

1921 Hospital City Railwa}’ Total. (first case, January... 2 0 0 2 Jan. 22, 1921) February 9

I,3 Ì2 1,071 742 3,125

TREATMENT With regard to treatment, nothing was of avail. Two early cases were treated with anti-plague serum in large doses both intra- venousty and hj-podermicallv. Four earhT cases were injected with novarsenobillon in 0.9 doses. Intravenous injections of eusol, electrargol, formalin, sodium gj-nocardate, and acid carbolic per os, were all tried and failed. Many other interesting experiments and data together with notes on the whole plague situation will soon be published b}- the Director and Chief Medical Officer of the North Manchurian Plague Prevention Service; to him thanks are due for permission to make public the meagre and sketchy points here presented. i8 The China Medical Journal.

CONGENITAL OCCLUSIONS OF THE ALIMENTARY TRACT: WITH CASE REPORTS.

E. D a r g a n S m i t h , m .d ., Kweilin, A number of indications leads us to believe that congenital occlusions of the alimentary tract occur with much greater frequency than is general^ conceded. While anal atresia, and similar cloacal defects, may be obvious even to the infant’s mother, other occlusions concealed within the thorax or abdomen at times challenge the keenest diagnostic ability. Doubtless the most frequent site of occlusion formation is in the esophagus at the level of the anlage of the respiratory tract. One observer, Joseph Brenuenman1, reported seven such occlusions in his own practice in the total of only one hundred and sixteen collected cases to that date (1918). Since it is unreasonable to contend that one man could have seen such a disproportionate number of cases, we assume that thousands of esophageal occlusions have either not been recognized or remain unreported. In the first case we have to discuss, the upper portion of the esophagus terminated as a blind pouch, while the lower formed a fistula between the trachea and stomach (Fig 1 ). This type constitutes seventy per cent, of the esophageal cases reported to 1921, while the remainder were simple occlusions without the tracheal fistula.

C a se R e p o r t .

R.R.B., male; white; weight, 7 lbs. Born at Susan Speed Davis Maternity, Louisville, K y., April 14, 1921. Mother a priinipara with a trans­ versely contracted pelvis. Wasserman test, negative. Following forceps delivery the parietal bones were: overlapped two centimeters. Respiration was established with difficulty. Inability to nurse on the second day was ascribed to cerebral compression. Milk given by dropper was regurgitated, The continuous accumulation of a frothy mucus in the mouth and the stoppage of a catheter twelve centimeters from the upper gum margin established the diagnosis. No other associated anomalies were demon­ strated. Solution of sodium bicarbonate per rectum and intra-peritoneal injections of physiological saline were given to establish an alkaline reserve, and to maintain body fluids. The child was transferred to the Louisville Children’s Free Hospital, April iSth. Operation was performed immediately, with Dr. Karl David Winter assisting. Through a short, left para-mcdian incision, a small, blunt lig'atuie carrier, loaded with coarse silk, w'as passed about the Fig. i.— Dissection showing esophageal occlusion and tracheo­ esophageal fistula.

C o n g e n it a l o c c l u s io n s o f t h e a l im e n t a r y tr a c t (E. Dargan vSmith) Fig. 2.— Roentgenegram showing esophageal occlusion and tracheo esophageal fistula.

C o n g é n it a l O c c l u s io n s ok t h e a l im e n t a r y t r a c t (E . Dargan Smith) Congenital Occlusions of the Alimentary Tract.

esophagus at its emergence from the diaphragm. The ligature was tied snugly, and the stomach was replaced. Gastrostomy completed the procedure. Death in twenty hours. A t autopsy the esophagus above the occlusion was found slightly thickened and dilated, probably due to peristaltic efforts to swallow amniotic f uid. No connection, as of muscular ■ issue or fibrous band, with the lower segment was demonstrated. The photograph shows the dissected specimen after shrinkage in formalin solution. Dr. Turner, resident roentgenologist to the Louisville City Hospital, made a rather unusual post mortem roentgenogram (Fig. 2). Specimen placed in the Pathological Museum of the University of Louisville.

EMBRYOLOGY. Occlusion of the esophagus is the persistence of an early em­ bryonic state during which the esophagus is normally occluded by- rapid cell proliferation. This period has been clearh’ demonstrated by H. E. Jordan2, in a series of loggerhead turtle embryos. The fistula seems to be best explained by the embryonic difference of origin of the proximal and distal portions of the esophagus. Losse3 reminds us that the buccal cavity, pharynx, and upper extremity of the esophagus develop from the ectoderm, while the endoderm forms the respiratory apparatus, the distal portion of the esophagus and the intestinal tract. This malformation must occur at a very early period, for in embryos of 4 mm. there is a distinct separatiou between the trachea and esophagus. The Harvard Embryological Collection contains a specimen of iS. 1 mm., showing this abnor­ mality fully developed. Incidentally, the observation that a high percentage of aborted ova show malformations, doubtless accounts for more such cases not being observed at term. If no operation is performed the average duration of life of a child with this malformation is seven days. Death is usually due to inanition, though pneumonia from constant regurgitation of gastric mucus may occur. Since it is obvious that all patients who are not operated on inevitably die, any conceivable benefit to be derived from operative intervention fully justifies the attempt. Simple gastrostomy has been tried repeatedly, but all the patients died from operative shock, or from drowning in the milk which passed from the stomach through the fistula into the lungs. Jejunostomy has proven equally futile. H. M. Richter, of Chicago, has in two cases, through a posterior thoracotomy incision, attempted to occlude the lower segment of the esophagus at its 20 The China Medical Journal. emergence from the trachea. This bold method has a limited application, for relative^ few hospitals are equipped with cabinets for chest surgeiy, and Dr. Richter is not over sanguine as to its possibilities. Yet a closure of the fistula, even at a lower level less ideal, seems to us essential, if gastric feeding is to be attempted. We tried to do this before the gastrostonty (Fig. 3). While our

Fig. 3.— Schematic representa- Fi;^. 4 — Schematic sketch of pathologic tion of operative procedure. findings in Baby B.S IV. Rectum was Closure of fistula and gastros- imperforate, there was an atiesia of tomy. the duodenum above the ampulla, and the left kidney was found in the pelvis.

C o n g e n it a l O c c l u s io n s o f t h e A l i m e n t a r y T r a c t (E. Dargan Smith).

effort did not change the existing mortality of • one hundred per cent, we think the procedure is logical and deserving of additional trial. Since the abdominal portion of the esophagus is not entirely surrounded b}' peritoneum, the occluding ligature should be tied with only sufficient snugness to close the lumen. In our case the posterior portion was covered, through chance, b}’ the ligature carrier having picked up Lhe lesser peritoneal sac. Obvioush- the occlusion should not shut off part of the cardia with the lower esophageal segment, for accumulating gastric secretion would be periodically expelled into the trachea. Fig. 5.— Case of Baby, B.S.W. Stomach and duodenal bulb, remainder of duodenum with portion of jejunum, and mal­ formed left kidney.

C o n g e n it a l O c c l u s io n s o f t h e a l im e n t a r y t r a c t (E. Dargan Smith) Congenital Occlusions of the Alimentary Tract. 2 T

Should one of these little patients live, we believe that several years later he might be rendered quite normal in function. Through a left posterior thoracotomy incision, proceeding with substantially the same technique employed in the two stage operation for esophageal diverticula, the fistula could be closed and the two portions of the esophagus united. The subsequent re-establishment of the esophageal opening into the stomach would be a relatively simple matter. The carrying through to a successful conclusion of one of these cases would require the solving of a series of problems in technique *and the exercise of fine judgment, but the satisfaction of success would be immeasurable. If the condition of the patient, or judgment of the surgeon, decides against this rather formidable series of operations, a continued gastrostomy life is concei vable.

In another infant there was an occlusion of the duodenum, above the ampulla, an absence of the rectum, and the left kidney was situated in its early embryonic position, the pelvis (Fig 4).

C ase R e p o r t .

B.S.W., male; white; aged; 3 days; weight, 4 lbs. Born, March 20th, 1921- Mother, a feeble-minded inmate of an institution in Greenville, Ky. Has had three mentally defective children previously. Referred by Dr. Ben Wilson Smock. Infant has occasionally vomited a clear fluid since birth. Examina­ tion showed obvious prematurity, and a shallow dimple at the normal site of .the anal opening. The rectal pouch was judged to be rather high, since vigorous crying produced no transmitted impulse to the perineum, and the attending obstetrician had reported his failure to procure meconium through an aspirating needle. Immediately on admission to the Louisville Children’s Free Hospital, the infant was carried to the operating room. The rectal pouch was fouud to be about four centimeters above the perineum. Its increased size enabled us to suture it in the normal position without tension. Intra- peritoneal injection of physiological saline and a thorough flushing out of the rectr.ir. with bicarbonate solution completed the procedure.

The third d a y following the operation his condition seemed satis­ factory-. The day’s gavage feedings of breast milk, following gastrie lavage, had all been retained,' and there had been two or three voluntary bowel movements in addition to irrigations. However, on the following morning projectile vomiting commenced, and he weakened steadily, dying ninet3T:two hours after operation. Peritonitis was suspected. Necropsy, however, demonstrated a complete occlusion of the duodenum above the ampulla of Vater, with a marked dilatation and thickening of the duodenal bulb above the obstruction. 22 The China Medical Journal.

The lower portion of the duodenum was quite small. No connection between the two portions was observed. The relative size of the two portions i.s shown in Fig. 5. Blood aspirated from the heart showed a negative Wasserman. Dr. Stuart Graves cut sections from each side «~,f the pyloric constriction. Unfortunately, the tissue was so embryonic in type that a differentiation between gastric and duodenal cells cannot l e shown clearh' by photomicrograph. This specimen was also donated to the Pathological Museum cf the University of Louisville. EMBRYOLOGY. These two occlusions, as was noticed in considering the similar condition in Lhe esophagus, occurred in regions of very active embryonic activity (Fig. 6. a. b. c.). Tandler has demonstrated

Fig. 6. —Points of very active erabryological cell proliferation : A.— Origin of the respiratory anlage. B.— Development of liver and pancreas. C.— Separation of cloacal part of hindgut into genito-urinary tract and rectum. that these cell growths obliterate the duodenal lumen between the thirtieth and sixtieth days4. After this time the surrounding mesenchyme grows with relatively greater rapidity, normally per­ mitting the lumen to be re-established when the embryo is between 15 mm. to 20 mm. in length. Congenital Occlusions of the Alimentary Tract. 23

There are about eighty recorded cases of the various more or less extensive duodenal strictures and obliterations. As to symptoms, one author states: “ The oniy* constant symptom of the condition (duodenal obstruction) is persistent vomiting of everything ingested, beginning at birth.” The infant whose case is here recorded vomited scarcely at all until a few hours before death, and the vomiting was never of the projectile type. Doubtless this was due to the enormous dilatation of the duodenal pouch and to lavage removing the residue of preceding feeding. W e cannot think of any reasonable procedure which would have enabled us to determine, or even suspect, the condition. Even had a diagnosis been made the outlook would have been practically hopeless, on account of the infant's prematurity, the depression of the rectal operation, and the technical difficulties of locating and suturing the small lower segment of intestine. As early as 1902, Braun5 collected reports of twenty-five operations for congenital stenosis of various parts of the small intestine, without a single recovery. The abnormal position of the left kidney is explained by an arrest of the relative change of position the kidney- normally undergoes during development. While it does not come within the consideration of occlusions, it affords an example of the association of anomalies which must have occurred at approximately the same period of embryonic life. Occlusions, in general, may be classified as anomalies of persistence of embryonic structures, since the\7 are found at points where active embryonic cell proliferation has been shown to occlude the intestinal lumen. Two defects were noticed in one of these cases, while in the other infant, born prematurel}-, there were three. Such association of defects suggests some common cause. It is also to be observed that the associated malformations originated at the same period of development. For example, normall} at the second month of embry-onic life the duodenum begins to establish a lumen, the rectum having separated from the bladder starts to descend, and the kidney is in close apposition to the pelvic structures. This stage, in the case of the baby, B.S.W ., through some untoward influence was found to have been retained through fetal life. 24 The China Medical Journal.

In the consideration of developmental defects relatively slight attention appears to have been devoted to the physiological influences over growth and development which cause them. Emphasis is usually placed on their anatomical or structural classification. Inherent defects of the sperm have been demonstrated to have much to do with the causation of monsters in lower forms of life. Yet it is probable that in many cases these germinal factors are absent or subordinate. De Lee6 has expressed the opinion that chemical poisons circulating in the maternal blood may affect the young embryo and cause monsters. With our present knowledge of the relation to disease of the blood concentration of urea, creatinin and other substances, of acidosis, and the various toxic by-products of metabolism it is not difficult to believe with De Lee that these substances affect the embn^o. The endocrine secretions of the mother exert another influence on the development of the embryo which is doubtless powerful, though as yet quite imperfectly understood. It seems logical to suppose that an abnormal state of these secretions might result in fault}^ development. Factors capable of profound^ altering the production of these substances certainly existed in each of these cases. The mother of the first child mentioned here, a girl of rather sensitive nature and of some social standing, was unmarried. W7orry, fear, and various other psj-chic influences doubtless altered her endocrine functions during the first few weeks of gestation. The mental state of the other mother made it necessary for her to receive institutional care. The degree to which endocrinolog}' may be expected to explain these and other malformations can only be determined after exten­ sive experimentation, observation and analysis of cases. In this connection Lewelh-n F. Barker7 recently stated: “ How far during intra-uterine life incretions derived from the mother (so called ‘ harmozones ’ of Gley) may reach the fetus and participate in morphogenesis (normal or pathological) is a further task in which students of constitution and condition must sooner or later become interested ” Certainly, if this hypothesis can be sustained, precautions- should be taken against those factors which contribute to irregulari­ A Practical Method for Delousing. 25

ties of endocrine function during gestation. The hygiene of pregnancy, during the first three months, should strictly guard against all emotional stress, undue exposure, and the accumulation m the maternal blood of toxic biproducts of metabolism.

SUMMARY Congenital occlusions are probabhv not very rare. Occlusions are due to the persistence of normal emb^-onic structures. In esophageal occlusions treatment should be directed towards closing the fistula between the trachea and stomach. The lumen, above occlusions, dilates and hypertrophies. Occlusions may be associated with other developmental defects originating at the same embryonic period. Various intoxications and endocrine disturbances of the mother should be guarded against, as they may contribute to the formation of congenital defects.

B ibliography . 1. Bronnemnan, Joseph; American Journal Diseases of Children, Vol. 16, p. 143, August 1918. 2. Jordan, H. E .; Proceedings National Acadcmy of Science, Vol. 3, p. 264, 1917. 3. Losse; Bulletin L3'ing-ln Hospital, New York, January 1914. 4. Tandier, Keibel and Mall, Human Embryology, 1912. 5. Braun; Beitr. z, Chir Vol. 34, p. 993, 1902. 6. De Lee; Principles and Practice of Obstetrics, p. 537. 7. Barker, Ivewellys F. ; jour. A.M.A., Vol. 79, p. S9, July S, 1922.

A PRACTICAL METHOD FOR DELOUSING CHINESE CLOTHES AND BEDDING.

S. D. J o f f i c k , m .d ., Peking.

The role of lice in the spread of disease is now a recognised fact. Nicolle1 and his associates in 1909 demonstrated'that tj^phus fever, and in 19132 that the Algerian type of relapsing fever, are both transmitted by lice. Later on, at the time of the Great War, it was found that trench fever is also transmitted by the same agent. Therefore in combating all these diseases we must first of all destroy the transmitting-agent, i.e., the louse. 20 The China Medical Journal.

Though lousiness is incompatible with cleanliness, yet it may happen in these days that persons, scrupulously clean, when travelling on trains, ships, or staying in camps may become infested by being in contact or in close association with those who are badly infested with lice. Here in China almost everything reminds us of the dark ages when it was thought that filthiness is near to godliness. To us who have had a chance to work in the interior of China, the sight of beggars as well as of merchants eugaged on every corner in a city or village in destroying the lice which abundantly infest them is well known. Before beginning to explain the method described in this paper for the disinfection of Chinese clothes and bedding, it should be stated that the species of lice and nits dealt with, was the body louse or Pediculus vestimenti, the real, conve^nng agent of the above mentioned diseases, as described by Nuttal3, Nicolle4, Ivolle and Hetsch5, and by Zlatogorofi6 who also reports that naked negroes on slave ships escaped typhus although they suffered much from other diseases. According to G. H. F. Nuttal7, typhus fever infection occurs through the bite of infected lice or by rubbing the crushed body of the louse, or its feces, into the excoriated skin. In relapsing fever, however, infection takes place not through the bite but by either, or both, of the other wa3’s just mentioned. So that in prevent­ ing these diseases the disinfecting agent has to destroy not only the lice and their nits, but also their infective virus. This being the case our method of disinfection must be very efficacious; and to meet requirements in China it must be simple and cheap. Most of those who have written upon the subject agree that heat is a very effective means of disinfection (Nicolle8, Nuttal9, Rideal10). So it remains only to decide the kind of heat which will prove the more effective in the conditions mentioned, i.e., dry or moist heat. The question as to the best method of destroying lice and nits in clothes and bedding is the only one considered in this paper. In their recently published book on Chemical Disinfection and Sterilisation, S. Rideal and E. Rideal10 inform us that “ dry hot air is now only used in special cases (books, leather and some other materials). Apparatus solely for this purpose is not often made. Clothes, bedding, woolen and other articles are most reliably A Practical Method for Delousivg. disinfected by steam at a temperature not exceeding 2250 F .” In order to determine the rate of penetration of dry heat these authors placed a roll of blankets in a hot-air oven kept at a temperature between 2450 F. and 2550 F. for eight hours. After this period the temperature at various depths of the roll was recorded as follow's : Under 2 layers ... 230° F . >> 4 > > ... 221° F. 6 ... 21 F . * » 12 When, however, the same blankets are exposed to saturated steam, “ some of the steam condenses in the process of warming up the objects ; the laminae or spaces left b}T the steam on condensation provide a means for fresh steam to penetrate and condense in the deeper la3^ers. Penetration Lakes place in this way through the 1 2 layers in from 10 to 15 minutes.” In comparing the relative advantages of dry and moist heat (steam), Nuttal11 finds dry heat more practical because “ (1) it can be applied to a greater variety of objects without injuring them; (2) a more moderate degree of heat can be applied at a smaller cost of fuel and apparatus; (3) it causes no shrinkage of fabrics and does not cause colors to run; (4) it does not remove the natural grease from woolens and render them hard to the touch; (5) it can be applied without injury to fur and leather (at 60o C .); (0) it does not tarnish metal (buttons) ; (7) the clothing is always warm and dry when removed from the chamber and is ready for immediate use.”

In dealing with Chinese c.o'.hes, most of them made of cotton onh' without anj" metal buttons, and their shoes very seldom made of leather, the first, fourth, fifth and sixth points mentioned do not apply. The possibilit}’ of shrinkage need not be considered seriously as it is well recognised that most Chinese clothes shrink when brought into contact with any form of moisture. With regard to furs, if they are used for bedding, I advise methods in accordance with the saying of Virgil : Infectum eluitur scelus aut exuritur igni (the crime w-ith which they are stained is removed or burned by fire). My experience of thirteen months sanitary work in the interior of Shantung (nine months with the American Red Cross, China Famine Relief, and four months with the Shantung Relief Committee) convinced me that little pieces 28 The China Medical Journal. of fur bedding are the best breeding piaces for lice I have ever seen. Fur coats are seldom found in the interior of the country, but where they are worn I advise special attention in delousing. D. Fulton and K. J. Stamford12 found that “ no damage to woolen goods resulted when subjected to steam at atmospheric pressure for one hour at ioo° C., when dry heat even at 8o° C. does spoil them.” The method described in this paper does not cause the colors of Chinese clothes to run, though very often the clothes are so dirty that we should be glad to see them run. The seventh of the foregoing points mentioned b3’ Xuttal will be explained in the record of the experiments to follow. That steam is much better than dry heat is confirmed also by H. Plotz13 : “ Since the virus as well as the lice and eggs has to be destroyed, steam has been found the best delousing agent.”

He\^man (14) found that “ saturated steam at ioo° C. destroys within half an hour not only all the lice but also the nits.” I believe that steam, in virtue of its greater penetration, probably has a more marked destructive effect on the virus than dry heat. Friedmann15, using the Ohlmueller apparatus for the examination of the resistance of spores, found lhat steam on being applied to lice for thirty, ten, or even five minutes, causes large ruptures in the skin, which makes the penetration of the heat much easier. Only five minutes were required to kill the nits in the Ohlmueller apparatus.

There are two types of steam disinfectors, one with low and the other with high pressure. Although steam at high pressure penetrates the articles more quickly and the time of contact to ensure proper disinfection is shorter, yet the greater simplicity and the easier construction of the steam disinfectors with a low pressure make this type more practicable. The most efficient kind of disinfector generally would be one of such simple construction that every Chinese would know how to use it. It would be better stiil if something used in their daily life could be found to serve this purpose as it would have the added advantage of saving the cost of- special manufacture. Such a thought brought me to the use of the steam-oven (called lung-ti, ff , in Peking, and lungtzu in Shantung) used in China for baking bread (min-teo gU in Peking, and mo-mo fj| in Shantung). Fiir. i.— Chinese breacl-steamer ( ) ccmplete.

Fig. 2.— Iron pot of bread-stcamer.

D ei.o u s in t , A p p a r a t u s (Joffiek). D e i.o ij s ïn o A p p a r a t u s (Joffick). A Practical Method for Delousing. 29

The Chinese steam-oven has one iron pot, three sieves and one cover (Figs. i and 2). The bottom of every sieve is fitted with small bamboo sticks at a certain distance each from the other (Figs 3 and 4). The first sieve is placed on the iron pot, which is filled with water brought to the boiling point, kaoliang stalks being used as fuel. The sieves are put one on top of the other with the bottom up, and so closely that the steam cannot go through the walls. The cover is placed upon the last sieve. The bread is put 011 the sieve bottoms and is coinpletelv baked in one hour. There are small and large sieves corresponding with the size of the iron pot. The sieves of the steam-oven used in these experiments were 2^ feet in diameter and 7 y2 inches high. In the first place, I had to determine that clothes put into the steam-oven were not spoiled by the heating. This was ascertained b3' the following experiment.

EXPERIMENT NO. I On each of the first two sieves from the bottom upward, two Chinese white summer cotton shirts were placed. On the third sieve were placed two white cotton trousers. After the water in the iron pot was boiling well the clothes were left in contact with the steam for one hour. RESULTS Xo harm was done to the clothes; the\^ were of the same strength as before the beginning of the experiment. These clothes were given back to my sanitary men, who had been promised that full compensation would be given if the clothes were in anyway injured or ii they were spoiled. After a good search for weak points nothing could be found and the men had to be satisfied with a small commission only. In order to find out whether steam causes colors to run the next experiment was performed.

EXPERIMENT NO. 2 . Dark and light blue cotton clothes were placed in the sieves in the same way and for the same time as in Experiment Xo. i .

RESULTS. No change was found in either color (blue is the most common color of Chinese clothes and it was therefore chosen for experiment). 3 0 The China Medical Journal.

When these two questions of chief importance were decided, I began next the experiments in delousing which were all performed during April, 1922, in Ku-yeh, Tsiningchow county, Shantung. Lice were bought from beggars for fifty cash a hundred. At first, in order to be sure that the nits were in good condition, they were bought just before the experiment with the pieces of cloth to -which they were attached. Later on, nits were obtained from the lice controls. To ascertain the delousing power of the steam-oven, lice and nits were put in small sacs and placed between the clothes in the steam-oven. To ensure that all the lice were killed, they were kept after the experiments for 2 -3 days, and every twelve hours were examined carefully for signs of life. The nits were kept for two weeks near the body. To be sure that the nits were killed and were not sterile to begin with, each piece of cloth containing nits was divided into two halvesone-half A vas-used in the experiment, the other half was used as a control. In controls some of the nits hatched after three daj^s, but none after more than seven days. The lice from these nits were fed and later on laid nits daily which were used for the subsequent experiments. Not having special apparatus the method devised for feeding was as follows. The lice before feeding were put in a small wooden box, 1 % inches in diameter, containing pieces of cloth. The open end of the box was applied to the arm on a hairless area and held securely in place by means of adhesive tape. Vaseline was smeared around the edge in order to prevent any possible escape of the lice. Feeding was done twice daily. Occasionally the box was kept on the arm for a whole night and no morning feeding w-as done. After feeding, the lice were placed in small sacs, of which mention has been made; these sacs contained small pieces of cloth to which the lice had clung and attached their nits.

E x p e r im e n t N o. 3 . 1. On the bottom of the three sieves clothes were placed as in Experiment No. 1. 2. Between both shirts in the first and second sieves, and between both trousers in the third sieve, were placed small sacs each containing 50 lice, as w-ell as sacs with nits. 3. The clothes were laid across each other. 4. Steam was applied for one hour. A Practical Method for Delousing. 3i

R e s u l t s . In all the sacs the lice were dead (shrivelled hard and brittle); the nits were collapsed and dead.

E x p e r im e n t N o . 4 . The same procedure as in Experiment No. 3, but steam was applied for a shorter time, % hour. The results were the same : lice and nits were all killed.

e x p e r im e n t n o . 5. The same procedure as in previous experiment, but the steam was applied for a still shorter time, half an hour. Result : lice and nits killed. After all these experiments, as stated above, in order to ascertain that the lice were killed they were kept for 2-3 days; the nits, for the same reason, were kept two weeks, during which time they did not hatch, though at the temperature of the human body nits usuallj- hatch in 7-8 days (Nuttal16, Peacock-17, Bacot18, Sicora19). EXPERIMENT NO. 6. 1.— On every sieve three shirts were placed. 2.— Steam was applied for half an hour. 3.— Between every shirt were placed sacs with 30 lice in each, also sacs containing nits. r e s u l t s . All the lice and nits killed, the test of death of the lice and nits being the same as in the previous experiments. Experiment No. 7 (Delousing cotton blankets). 1.— From each of the two upper sieves the bottom was removed. 2 .— Three blankets were placed in the steam-oven. 3.— The blankets were folded back and forth like a folding Chinese fan. 4.— Sacs containing nits onh' were placed in the middle layer of every blanket. (It had been shown previously that when nits are destroyed in the experiment lice also are destroyed). 5.— Steam was applied for one hour.

RESULTS. All the nits were killed. Two further experiments were done with blankets, heat being applied for %. and x/2 an hour respectively with equalfy good results. 32 The China Medical Journal.

As the writer was unable to stay longer in the locality further experiments could not be carried outj so it was not possible to determine, among other matters, whether the time of delousing could be shortened by increasing the steam pressure in the oven, or by adding chemicals, such as formalin, to the boiling water.

DISCUSSION.

Adequate sterilisers for delousing are very seldom found in China; especially is this true in the interior. In many epidemics in China there is an imperative need for sterilisation or delousing of clothes. At the beginning of the epidemic it is extremely important to begin delousing as soon as possible. If one waits for the usual elaborate delousing plant to be put into operation much valuable time is lost. The especial usefulness of the method described in this paper is, that it provides a means, effective and inexpensive, of beginning the delousing process immediately. Furthermore, even though an expensive foreign-made steriliser is available, there is always the difficult}' of transporting it to the area of the epidemic and of operating it.

In liis article on Destroying Lice in Clothes, Hutchison20 emphasizes the importance of the way in which the clothes are laid in the steriliser : “ the difference in the location of the bags on the load had its effect on the results.” In one of the above experiments I made a special point of laying the clothes each across the other, which gives the steam a better opportunity- for penetration. Better penetration of the steam can also be obtained by placing between the clothes and folds small kaoliang stalks.

It is also very important that a good fire be kept under the iron pot during the whole time of disinfection. If a part of the boiling water in the iron pot has evaporated, it is of great importance to add boiling water, in order to keep the same degree of heat all through the time of disinfection. If this is not done some of the lice or nits may not be killed.

As a means of determining from time to time whether the process is being carried out proper 1\', small sacs containing living lice and nits can be placed in the oven with the clothes and examined at the end of the period of sterilisation. This method is more practical than the use of maximum thermometers, and chemicals with suitable melting points, since the former are fragile A Practical Method for Delousing. 33 and expensive and the later are difficult to obtain. It is advisable also at the end of sterilisation to shake the clothes well in order to remove mechanically the dead lice and nits.

SUMMARY AXI) CONCLUSIONS. In order to suppl}- the urgent need for an effective means of carrying on the delousing of clothes in the field, experiments were made with the Chinese steam-oven with this end in view. It was found that the temperature to which clothes (carrying lice and nits) were subjected in this oven was sufficient to destroy- all lice and nits in half an hour. The advantages of the Chinese steam-oven method are as follows : 1. The oven can be obtained in almost even- small village. 2. Kaoliang stalks, which are found everywhere, can be used as fuel. 3. The apparatus is very portable and cheap; the bigger ones are seventy- cents a sieve. 4. Every Chinese knows how to operate it. 5. The fuel (kaoliang stalks) is very cheap and brings the water quickly- to the boiling point.

R e f e r e n c e s . 1. Nicolle, C. C. R. Acad. Science, Paris, C X L IX , p. 157, 1909. 2. Nicolle, C Blariot. I,, and Conseil, E. Arch. Inst. Pasteur, . Tunis, VIII, Part I, p. 1, 1913. 3. Nuttai, G .F .K . Parasitology. Vol. io, p. 74, 1917-18. 4. Nicolle, C. Comte, C. Conseil, E. Ann. Inst. Pasteur, XXIV, p. 261, 1910. 5. Kolle und Hetsch, Kxperim. Bieter, und Infectkr., p. 1232,1919. 6. Zlatogoroff, Spez. Pathol, und Therapie innerl. Krankh. voa Kraus und Brugsch, Part II, p. 6S2, 1915. 7. Nuttal, G .F.H . loc. cit., pp. 51, 59. 8. Nicolle, C. et Ccnseil, E . Revus d’hygiene, XXXVII, p. 18, 1915. 9. Nuttai, G.F.H. loc. cit., p. 429. 10. Rideal, S. and Rideal, E. p. 98, 1921. London. 11. Nuttiü, G.F.H . loc. cit., p. 479. 12. Fulton, D. and Stamford, K. Journ. Am. Med. As., vol. 71, p. 823, 1918. 13. Plotz, H . Journ. Am Med. As., yrol. 72, p. 324, 1919. 14. Heymann, 13. Zeitschrift fur Hygiene, Bd. So, 1915. 15. Friedmann. A. Centralbl. f Eacteriologie and cet. Bd. 77, II. 4, iqt5. . 16. Nuttai, G.F.H . loc. cit., p. 144. 17. Peacock, . A.Tj . Journal Roy. Arm y Med. Corps, London, X X V il, p. 39, 1936. t 8 . Bacoit, A. Parasitology-, vol. IX , p. 248, 1917. 19. Sikora, H. Centrbl f. Bacteriologie, p. 529, 1915. _____ 20. Hutchison, R H. Journal of Parasitology-, vol, 6-7, p. 72rzZfy&- ~

|YALE DIVINITY SCHOOL Ar. ...

CHINA AS A TIELD FOR THE STUDY OF THE NUTRITION OF HUMAN TEETH*

J. F. M cC le n d o n , P h .D., M inn eapolis. According to Pickerill,1 bad teeth are the curse of civilization. He gives figures to show that dental caries increased in the Britons from the stone age to the bronze age, and from the bronze age to the Roman occupation, and m the Angles and Saxons after they came to England and among the English, so that in modern times about 95 per cent, of their descendants have carious teeth. Pie states that the same process took place but far more rapidly among the Maori of New Zealand, and that 95 per cent, of the Maori schoolchildren in the English schools have carious teeth. He places the Chinese among those races with little dental caries. We should remember, however, that while our ancestors led a barbaric life in the forests and swamps of northern Europe and had no agriculture, the Chinese had developed a thickly populated and comparatively civilized community. The central plateau of Asia is considered the “ cradle of the human race,” and the beginnings of Chinese civilization are lost in antiquity. WTe cannot take up the various factors of civilization and their effect on the teeth, but animal experimentation has shown that the chief factor in the well-being of the bones and teeth is diet. I will consider the Chinese civilization from a dietetic standpoint. The origin of domesticated plants is somewhat doubtful, but the emperor Chin-nung, 2800 B. C., ordered a ceremonial in which certain seeds were sown; and by this time and in a few' succeeding centuries, but long before our ancestors took up agriculture, the Chinese had domesticated, or obtained from their neighbors chief! 3^ to the south, quite a number of plants. Among these were the radish, Chinese yam, Chinese cabbage, tea, sugar-cane, orange, mandarin orange, jujube, Chinese plums, apricot, peach, kaki (persimmon), date plum (persimmon), Chinese pear, banana, litchi (nut), buckwheat, soy bean, wheat, Italian millet and rice. The Chinese diet is classed by McCollum as a complete vegetarian diet, suppling in sufficient quantity everything needed in nutrition.

*From the Laboratory of Physiological Chemistry, University of Minnesota Medical School. Published in Journ. Amer. Med. Assoc. Sep. 30, 1922. The Study of Human Teeth in China. 35

As to the special nutrition of the teeth, it has been found that the teeth require all those food elements needed by the body as a whole besides the elements which give teeth their hardness, chiefly calcium, fluorin and the phosphate iron. In other words, as Gautier has shown, the enamel of the teeth has nearly the same composition as crystalline phosphate ro:k or apatite, CaFCa4(P0 4) 3. Magne­ sium is present to a small extent, and it mayT be considered to replace calcium as an impurity, as in the case of the formation of dolomite from limestone. The same elements, with the addition of calcium carbonate and white fibrous connective tissue (collagen), constitute the dentin. When we consider all the articles ol diet of a people, the complexity is so great as to prevent any headway- with the problem. Elsewhere I have shown that the North American Indians used at least 660 species of plants for food, drink and medicine2. But animal experiments have cleared the way for the study of the effects of diet on human teeth. It seemed necessary first to know7 the calcium and phosphate content of the mixed diet.

CHANGES IN BONES FROM DEFICIENT DIET The metabolism of bones and teeth is similar, and the changes in the bones due to deficient diet are of two main types : first, rickets due to deficiency’ of phosphate. The growing areas of bone fail to calcify, but there is an overgrowth of soft bone matrix or osteoid tissue. The teeth are late in developing, and the enamel is thin and soft. I have shown that any substances that increase growth increase the severity of rickets. In fact, the growth multiplied by a constant equals the phosphorus retention in a normal animal; and if the growth multiplied by a-constant minus the phosphorus retention is a positive quantity, rickets is present. In this case Ijrefer chiefly to growth of the skeleton, and some errors may arise, owing to the fact that the skeleton may grow while the body as a whole fails to grow. But even with this inaccuracy I am able by means of this formula to classify the experimental rats into rachitic and nonrachitic as accurately as by any other known method. When young rats fail to grow, 0.13 per cent, of phosphorus in the diet is sufficient to prevent rickets ; but yvhen they grow at the normal rate, 0.45 per cent, is required. In fact, 0.6 per cent, is the usual amount in the normal diet. Thyroxin, exercise, burning with ultra-violet light, and perhaps exposure to cold and some other 36 The China Medical Journal. agencies, increase the metabolism and phosphorus intake at a given growth-rate and in this way tend to prevent rickets. Cod liver oil •in some way increases the phosphorus retention.

In contradistinction to phosphate starvation, calcium starvation produces osteoporosis or light weight bones without any gross rachitic lesions at the epiphysis. Osteoporosis can hardly be considered a specific result of calcium starvation, however, as it occurs in scurvy and beriberi in cases in which there was no intention, at any rate, of producing calcium starvation. The teeth tend to follow- the bones in their development, but osteoporosis in the older animals does not necessarily mean just lighter weight teeth. In sctirvy, for instance, we have an osteoporosis of the bones, but in the teeth an increase in the activity- of odontoblast cells occurs with the formation of irregular osteodentin.8

With the diets of human beings it is difficult to say whether caicium or phosphate is most often deficient. A diet of meat and graham bread contains sufficient phosphate, but is deficient in calcium. Phosphate occurs in the leaves of plants which also contain much calcium. Both the calcium and phosphate occur in cow’s milk in sufficient amount for nutrition, but milled cereals are deficient both in calcium and in phosphate. In fact, the excessive use of milled cereals, including polished rice, patent flour, corn meal, cream of wheat, and Lo a less degree, rolled oats, is perhaps responsible for the greatest shortage of calcium phosphate in our diet. I have shown that rats fed with graham flour are normal, whereas control rats on the same diet otherwise, but with the substitution of patent flour for graham flour are rachitic. The milling of cereals has been the custom for centuries among the white races, but has been partialljr introduced into China only during the last ten years, although patent flour has been imported for a longer period. In fact, the process of introduction is still in progress. It would seem, therefore, that the effect of the milling of cereals upon the nutrition of the teeth could be studied in China during the succeeding years very effectively.

To sum up : calcium phosphate and the vitamins A, B and C (including the antirachitic vitamin) seem all concerned with the well-being of the bones and the teeth, and it would be desirable to stud}-- the concentration of these substances in the primitive Chinese The Study of Human Teeth in China. 37 diet and in^diets as changed by the introduction of modern milling machinery and other causes. The estimation of calcium in the diet is an easy matter, but the estimation of vitamins is more difficult in quantitative work; and although we maj^ suppose that there are enough vitamins in ordinary foodstuffs to prevent there ever being a shortage, some vitamins are of a perishable nature and they may be destroyed before they reach the consumer. It is rather notable that we get from the Chinese two fruits which contain the most perishable vitamin C in large amount, and in which it will with­ stand high temperatures and drying. These are the orange arid the peach ; and though there may be some dispute as to their origin, de Candolle4 has brought strong evidence that they originated in China. ThejChinese dry peaches by ordinal'}- methods, and oranges with the addition of sugar. Perhaps dried peaches are found in ali countries where the peach is grown.

INFLUENCE OF FOOD ON HISTORY

The history of mankind is largely influenced by food. That is to say, lack of food has been about the most serious catastrophe. If we compare the activities toward colonization as carried out by two peoples and try to correlate this with their food, we may arrive at some interesting speculations. The Vikings were among the boldest sailors of history. Norse sailors visited Iceland and Green­ land. Lief Erickson discovered America about 100 A. D. Some years later Thorfin Karlsefmi brought three ships with 160 persons to America. Norse visits to America were occasionally repeated until 1746, and yet these bold seamen were unable to establish sufficient communication with the mother country to keep a colony alive in America. An illuminating commentary on this state of affairs is contained in the fact that it was not until 1910 that Holst and Frolich discovered that the chief sickness among Norwegian seamen was due to the lack of vitamin C in their diet. We do not know of any food in possession of these Norwegian seamen that could be kept for long periods except in fresh or frozen condition without losing its vitamin C.

On the contrary, people of southern Europe had obtained the orange and the peach, and were in possession of two foods in which vitamin C could be stored for long periods. Compare the dismal failure of Norwegian colonization of. America with the brilliant 38 The China Medical Journal. success of the Spaniards. Norwegian mariners, by stopping at Iceland and Greenland, divided the voyage into three relatively short trips. Columbus had to strike out across the Atlantic, and yet he was more successful. It is true that Magellan’s ships in sailing around the world did not carry enough of this vitamin C. In fact, only one of them was able to make the voyage; but the success of Magellan was certainly far greater than that of the Norwegians. These Spaniards brought the peach and orange to America, and these fmits have probably had a good deal to do with the rapidity of extension of colonies where the storage of food was made neces­ sary by long ocean or desert trips.

VALUE OF INORGANIC ELEMENT IN THE DIET

Animal experiments tend to show that the effect of diet on bones and teeth can be worked out with comparative ease, and there is no reason why the same cannot be applied to human bones and teeth. Liebig over-accentuated the value of protein in the diet, and dietary studies have been mainly confined to protein, fat and carbohydrate. W e do not absolutely need fat or carbohydrate in the diet at all times, because we can synthesize them from protein; but we cannot synthe­ size calcium, phosphorus, iodin or any of the inorganic elements— at least, not in our .bodies during life. If we take the relative abund­ ance in the body as an index of importance of elements, we find, of course, that oxygen, hydrogen and nitrogen are common to both organic and inorganic compounds ; excluding these, we find that the ratio of carbon to the inorganic elements is 4 : i. In other words, even on this basis we should not devote more than four times the amount of time to the organic compounds that we should spend on the inorganic in nutrition; and we include among the organic the vitam ins.

REFERENCES.

1. Pickerill : The Prevention of Dental Caries and Oral Sepsis, Philadelphia, 1914. 2. McClendon, J. F. : Some American Plants Considered as Sources of Vitamins and as Parts of a Diet Favorable to the Preservation of die Teeth, J. Dental Res. 3 :2jg, 1921. 3. Robb, Medes, CcClendon, Graham and Murphy : Study of Scurvy and its Bearing on the Preservation of Teeth, J. Dental Res. 3 :39, 1921. 4. De Candolle, Alphonse:" Origin of Cultivated Plants, London, 1884. Fig. 3—Total liecrcsis of lower jaw. The bone w:is divided in the middle line and removed in two halves. Il rests on patient’s arms. X kckosis or Tin-: J aw (McAll). Fiji. i.—Necrosis of lightside of lower jaw. Tlnee day®. aftci photo was taken :i big pati'h of the chcck sloughed.

Fig. 2— Necrosis of alveolar process of upper jaw from phosphorus poisoning.

Xi-cnosis o f t h e J a w (McAll). Notes on Necrosis of the Jaw 39

NOTES ON NECROSIS OF THE JAW.

P. P. M cAij., m .b ., Ch. B., Tsinan (formerly of Hankow). It is a well-known truism that surgical experience in a land like China brings to light conditions and complications of diseases and injuries which are not mentioned in ordinary text-books. The writer has come across the following conditions in connection with necrosis of the jaws, and would be glad to hear what the experience of others has been.

Etiology,— In most cases there was the ordinary history of pain and trouble m the neighbourhood of the teeth and gums. A few patients came from a local match factory. One gave the history that, suffering from a gum-boil, as it seemed to him, he went to a Chinese doctor who told him there was a piece of dead bone in the jaw which would take a long time to come away. According to the patient the doctor applied a paste made from the scales of fish “ to make the bone come away sooner.” Sure enough, before long there came away a big piece of bone with several teeth attached ! A case of “ post hoc” and “ propter hoc ’ !

Extent of bone involved.— The extent of the necrosis may range from a small, superficial area to complete necrosis of the whole bone. The process usuallj- begins opposite the molar teeth ; it may spread forward and cross the middle line; or it may pass backward and in the lower jaw involve the ascending ramus and the condyle, usually forming external sinuses. The site and size of the swelling give a good indication of the extent of the mischief and the size of the sequestrum. The extent of the process seems to depend on whether the pus that forms between the bone and its periosteum gets prompt egress or not. For if not, the pus will continue to strip the periosteum off the affected bone until it is entirely denuded. Indeed, the mischief may spread in spite of free incisions and apparently good drainage. In one case of complete necrosis of the lower jaw— duration about 6 months— the bone was found lying in a pus-filled trough and quite movable. The width of the rami alone prevented it from being extracted in one piece from the mouth. After division of the bone in the middle line each half was easily removed without an anesthetic (see photo). Another patient from the match factory came with complete 40 The China Medical Journal. necrosis of the upper jaw with separation of the entire alveolar pro­ cess and teeth. (The writer regrets he has no note of the resulting condition of the palate, floor of nose, antrum of Highmore, etc.) (See photo). Only one case was seen in which suppuration was confined to the medullary canal of the bone. An abscess had apparently formed around the root of a tooth, and, as drainage was imperfect, it had slowly expanded the bone until after some years there remained a localised abscess of the bone the size ot a walnut, lined with a pyogenic membrane containing a teaspoonful of verjr foul pus, all surrounded by a hard bony wall about an eighth-of-an-inch thick. A small sinus led from the centre up the side of the tooth and from this sinus the pus slowly overflowed. Of course this was not strictl}- a case of necrosis at all, as there was no sequestrum.

COMPLICATIONS AND SEQUELAE

Sloughing oj the cheek.— Case report : Patient, a young man, with acute necrosis and great swelling of the right lower jawand cheek. Openings were made internally and externally to drain off the pus. Three days later the cheek shewed a gangrenous patch and a slough formed leading to the mouth. Query : Were the facial vessels involved in the inflammatory process ?

Spread of the suppuration to the neck and below.— A woman was brought in moribund with the following history : When S months pregnant, she had toothache with local swelling of the jaw and much pain, and the neck became swollen. Two weeks later she was confined, but was too ill to nurse the baby. After another two weeks, during which time an abscess had opened in the neck, her friends brought her to the hospital. On arrival she was pulseless and unconscious. On the left side of the neck sloughing shreds of the sterno-mastoid were hanging from an irregular opening; the skin over the upper part of the chest (front and back) was purplish, covering a huge abscess cavity as was evident by the fluctuation. An incision let out about a pint of foul pus. Patient evidently died of septic intoxication.

Where the necrosis has involved the ascending ramus, the movements of the jaw- are usually interfered with, either from ankylosis of the joint or from sclerotic changes in the masseter or temporal muscle. In some of these cases a fair result was obtained by Hsmarch’s operation of removing a V-shaped piece of bone from Chronic Erythema Nodosum. 4i in front of the cicatrised area. In other cases, my colleague, Dr. Gillison, succeeded in getting movement by excising the coronoid process and thus freeing the bone from the control of the temporal muscle. An acute case of necrosis of the jaw usually shews less constitutional disturbance than one with necrosis of other bones, as the jaw being more superficial the pus, as a rule, finds a more ready exit. On the other hand, owing to the great oral discomfort the patient has much difficulty in feeding, and consequent^ weakens rapidly. Early and free incision in an acute case may prevent the spread of the mischief and limit the necrosis so that the sequestrum is superficial instead of involving the whole thickness of the bone. Attempts on our part to excise the necrosing bone before it had loosened gave no good results; apparently- nature resented any attempt to define for her where the line of demarkation should come.

CHRONIC ERYTHEMA NODOSUM: REPORT OF CASE.

W11. W . C a d b u k y , m .p ., Canton College, Canton.

Erythema nodosum is one of those clinical entities of which the etiology is still very obscure. Most authorities believe that it is rheumatic in nature; others claim that it is generally associated with tuberculosis ; others that it is due not to tuberculosis, but to some other specific bacterial infection (Rosenow, Journ. Infect. Dis., May, 1915-) The disease is comparatively rare, constituting only about one case out of each thousand in dermatologic practice. It is said to be much more common in females than in males, and as to age appears usually between the tenth and thirtieth years. There may be constitutional symptoms, such as fever, sore throat, arthritic and abdominal pains, and sometimes a mild nephritis. The nodules, most common upon the tibial aspect of the legs and upon the arms, begin as small hard swellings of the Sid n which gradually enlarge and become dark red; the surface is hot. If several swellings mature about the same time the patient has 42 The China Medical Journal. chills and fever. With improvement, the swellings gradually decrease in size. The entire cycle of development and recession of any one lesion is about a month. When the swellings are greatest, there is generally fluctuation, but the inflamed tissues seldom break down. If this does occur, a small amount of fluid escapes. The sites of the old lesions remain pigmented after the small scab has disappeared. Sometimes the skin is pitted at the site. Lesions are generally round, but may be elongated. New ones tend to appear at the margins of the old. There is no itching and no numbness, only tenderness and pain. The patient general^ makes a good recovery in a month or so. Sodium salicylate and quinine are the medicines usually- prescribed. The following case is interesting because of its unusual severity^, prolonged course, and quick response to our treatment. T.T.S. Chinese, male, aged 18 ; a farmer by trade. Admitted to the wards of the Canton Hospital, January 28, 1920. (Hist. No. 20-209). The patient complained of painful swellings 011 the face and four extremities. He is unmarried, neither smokes nor drinks alcohol, and has had no serious previous illness. Family- history, negative. The present illness began five years ago. Tumors first appeared on the face, and then on the forearms and legs. Occasionally- the thighs and upper arms were the seat of the lesions and rarely- the trunk. Physical Examination.— The boy appears to be no more than fourteen years of age, though he says he is four years older. There are numerous swellings on the face and four extremities. The anterior surface of both legs is smooth and shinj-, the result of many- tumors, yvliich have always been more numerous on the legs. The appetite u’as fair. The heart, lungs and liver appeared to be normal. The spleen was enlarged and palpable. Laboratory diagnosis : Hem oglobin, 60 per cent. Leucocytes, 23,600 Red cells, 4,750,000 Urine : Dark yellow, acid. Sp. Gr. 1020. No albumin; no glucose. Chronic Erythema Nodosum. 43

Feces : ■ Ova of Ascaris lumbricoides present.

The temperature on admission was 3S.70°C. Pulse, 10S. Respiration, 18.

The treatment consisted in giving calomel and saline pur­ gatives as required, and a course of santonin for the ascaris mfest- ment. Yeast was given for the first week and solution of chloride of iron with Fowler’s solution. Antiplilogistine was applied to the most painful lesions. Quinine was also given for a few days.

The temperature fluctuated from 36.9°C to ^S.y°C for the first three days. Stock typhoid vaccine was then injected intravenously as follows-

January 30th, 20,000,000. February- nth, 10,000,000. February- 23rd, 20,000,000.

The first injection was followed by a severe chill and a temperature of 4o.6°C. The temperature fell to 3S-7°C the next day-, and after fluctuating between 3

A second injection was given on February nth. This was followed by a milder reaction, the temperature varying from 37°C. to 3S°C. until February 20th, after which it remained normal. The injection on the 23rd was followed by a more severe reaction and a return to normal the next day.

As to the course of the lesions there was a slight decrease of pain b y F ebruary 4U1. On the 13th, the patient’s condition w?as much better. He yvas discharged twelve days later. The temperature was then normal. No new lesions were developing, and the old ones had healed and were painless.

Considering the protracted course of the disease, the great improvement during one month of treatment was considered quite remarkable. 44 The China Medical. Journal.

A NOTE ON THE PREPARATION OF “ CARREL-DAKIN ” SOLUTION.

J o h n C a m e r o n , m .p .s ., Pharmacy Department of the Peking Union Medical College, Peking. During the short number of years that the Carrel-Dakin solution-has been in use the technique of its preparation has been altered several times, always with the object of obtaining a product of the greatest possible stability. It is a very slightly alkaline solution of sodium hypochlorite containing 0.45-0.5 per cent, of the salt and is general^ prepared by the double decomposition of calcium hypochlorite and sodium carbonate. According to Dakin himself, the solution of sodium 113-pochlorite (NaOCl) should contain not less than 0.4 per cent, nor more than 0.5 per cent, of sodium hypochlorite. If the percentage of sodium hypochlorite is less than 0.4 per cent, the antiseptic power of the solution will be too low; if greater than 0.5 per cent, the solution will be very irritating. Dakin’s solution differs from all previously used solutions of this character in these particulars : that its chlorine content must be exact within given limits, and that its caustic alkalinity must be completely neutralized. Past failures in the use of previously devised solutions of chorine, were found by Dr. Alexis Carrel, the surgeon, and Dr. Dakin, the chemist, working in their hospital laboratory in Compiegne, France, to be due to the wide and constantly changing variation in the chlorine strength of calcium hypochlorite and to the caustic soda contained in solutions made of it in combination with sodium carbonate. Man}' of tlie-so called Dakin solutions have not been prepared according to the formula of the name they bear, and as a result of this, the solution has been condemned by some surgeons as being useless for disinfecting wounds, or so highly irritating as to render its use dangerous.

PREPARATION Dakin’s solution may be satisfactorily prepared in any one of several ways. (1) The method first used by Dakm himself, namely, the double decomposition of calcium hypochlorite and sodium carbonate. (2) By the action of chlorine on sodium carbonate. This simple method has hitherto been practically unavailable because of C.C. Te.7ith,~/YoT'ma,/ *Sodium //typo

Preparation of Carrel-Dakin Solution. 45

the difficulty of accurately measuring small quantities of liquid chlorine. This disadvantage has lately been overcome and the method has proved entirely satisfactory- 2. (3) By the electrolysis of a solution of sodium chloride. This method gives a satisfactory product wherever apparatus and electric current are available, and is easily the quickest method of preparation. Eight months ago,we had anew electrolytic cell installed in the Peking Union Medical College Pharmacy by the Electro-Chemical Company of Dayton, Ohio, U. S. A. for the manufacture of Dakin’s solution by the third process just mentioned. This apparatus cost us roughly Mex. $450.00 and has been of great interest to surgeons from all over China who have been visiting Peking. I should think it is the first apparatus of its kind to be used in China for this purpose. In another paper I intend to deal with methods number two and three, but as electric current is only available in the larger hospitals and as liquid chlorine in steel cylinders is extremely difficult to import owing to shipping regulations, the first method is the one of most interest to surgeons in our Chinese mission hospitals and the one about which I have been requested to write. I have found that the chief difficulty with Chinese dispensers in the manufacture of Dakin’s solution lies in the fact that they do not understand the principle of titrating the bleaching powder and the finished solution of sodium hypochlorite (NaOCl) for available chlorine, and they are not over-carefui when testing the solution for its alkalinity. Once the principle of titration is understood, the making of proper Dakin’s solution is as easy- as the compounding of a simple mixture. To assist Chinese dispensers in titrating the finished Dakin’s solution, there is printed herewith a graph (Fig 1.) which should enable the dispenser to estimate the percentage strength of the sodium hypochlorite solution immediately- he reads from his burette the number of c.c. of tenth-normal sodium hjqjosulphite that has been required to discharge the brownish iodine coloration of the solution.

TITRATION OF DAKIx’s SOLUTION. The percentage of sodium hypochlorite present in the solution is determined by titrating yvith a tenth-normal sodium thiosulphate (hypo) solution, the amount of iodine liberated by a measured amount of Dakin’s solution. 4 6 The China Medical Journal.

The Technique.— Using a bulb pipette measure 10 c.c. of Dakin’s solution into a beaker or Erlenmeyer flask containing about 50 c.c. of tap water. Add 5 c.c. of a 10 per cent, potassium iodide solution and 3 c.c. of- glacial acetic acid when a brownish iodine colour will appear. Then run decinormal thiosulphate solution into the flask from a burette until the decolorization of the solution is just complete, and read from Fig. I the percentage strength of sodium hypochlorite present in the Dakin’s solution. If greater accuracy, however, is required, it is advisable to add several drops of starch solution when the iodine colour is near’13* gone, and continue the titration until the blue color just disappears, as some ej*es more accurately detect the end point showing the disappearance of blue rather than yellow. Starch solution is prepared by boiling about 0.5 grm. of starch with 100 c.c. wrater, cooling and dccanting or filtering the supernatant liquid. The flask with the contents should be vigorous!3’ agitated during the titration. If dispensers do not wish to use the chart to estimate the percentage strength of the Dakin’s solution, then the number of c.c. of decinormal thiosulphate solution required to decolorize the iodine solution, multiplied by the factor 0.0372, gives the percentage of sodium hypochlorite in the Dakin’s solution. In Peking we use solutions of 0.5 per cent strength and it has been found that, after standing in the wards for 48 hours, these solutions had only lost from 0.02 to 0.03 per cent, of their strength. Tests for alkalinity.— It is important to remember that the tests of Dakin’s solution for alkalinity and for strength of sodium hypochlorite are entirety independent, but equally essential. Test with powdered phenolphthalein.— A few crystals of powdered phenolphthalein are dropped on the surface of about 5 c.c. of the solution to be tested and the solution is vigorously shaken. Dakin’s solution should remain entirely colorless. If there is any red color the solution is too alkaline and this excess alkalinity should be neutralized. It may safety be neutralized with boric acid solution, the amount necessary being determined by titrating 10 c.c. of Dakin’s solution with a 4 per cent, solution of boric acid. From the amount of boric acid solution necessary to neutralize this aliquot Preparation of Carrel-Dakin Solution. 47

portion, a simple calculation is all that is necessary in order to determine the amount necessary to neutralize the entire quantity. The amount required is usually very small and not sufficient to produce irritation. If it requires a large amount of acid to neutralize the alkalinity it is advisable to discard the solution and make up a fresh one.

Test with alcoholic solution of phenolphthalem.— Use a o .i per cent alcoholic solution of phenolphthalein. About 0.5 c.c. of this alcoholic solution is squirted from a dropper into about 5 c.c. of Dakin’s solution in a test tube.

The solution should show a red color which will' soon disappear. If there is not at least a momentary flash of red color the solution has so low an alkalinit}* that its hypochlorite content will rapidly diminish.

BLEACHING POWDER, OR CHLORINATED LIME.

Bleaching powders vary considerably in their “ available chlorine” content, in fact, the amount of available chlorine is never the same in two different samples. Exceptional samples may contain as high as 35 per cent, while samples which have been exposed to the atmosphere ma\7 contain only- 20 per cent. Samples with less then 20 per cent, should not be used in the manufacture of Dakin’s solution. In China a very good grade of bleaching powder may be bought from Messrs. Brunner, Mond & Co. who have branch establishments in all large Chinese cities. They supply the bleaching powder in special sealed containers of seventy pounds capacity for Mex. $7.00. The available chlorine content of this bleaching powder we have found to be about 30 per cent.

To determine the available chlorine content :— Ten grams of bleaching powder made up of small samples from different parts of the container are well shaken with a litre of water. After standing about six hours the solution is filtered and 10 c.c. of the filtrate is titrated in exactly the same manner as in the titration of Dakin’s solution. In this case the number of c.c. of decmormal thiosulphate solution required to decolorize the liberated iodine, multiplied b}^ the factor 3.55 gives the percentage of active chlorine in the sample of bleaching powder.' 48 The China Medical Journal.

TABLE SHOWING THE QUANTITIES OF INGREDIENTS REQUIRED TO

MAKE ONE LITRE OF CARREL-DAKIN SOLUTION ACCORDING

TO . STRENGTH OF BLEACHING POWER EMPLOYED.

Bleaching Bleaching Sod. carb. Sod. bicarb, powd. powd. anhydrous, gram s. available Cl. gram s. gram s.*

20% 22.6 11 -3 9.2 21% 21.6 10.S 8.8 22% 20.8 10.4 8-4 23% 20.0 10.0 S.o 24% 19-3 9-7 7-8 25% 18.4 9.2 7.6 26% 18.0 9.0 7-3 27% i /-5 8.8 7.0 280/0 17.0 8-5 6.8 29% 16.5 8-3 6-5 3°% 16.0 8.0 6.0 31-35% 15.0 7*5 6.0

*40 grams of washing soda crystals equal 14 grams of anhydrous sodium carbonate.

The bleaching power is added to the required amount of water, (in this case 500 c.c.) and allowed to stand over night. A solution of 500 c.c. (containing the correct amounts of sodium carbonate and sodium bicarbonate) should now be made up. In the morning pour the sodium solution into the lime solution and shake; this forms a heavy gelatinous precipitate; filter off the clear solution and titrate according to Fig. 1. If up to proper strength, add a few drops of a 1 per cent solution of potassium permanganate and the solution is read}* for use. It is advisable to keep Dakin’s solution in amber colored bottles and, if possible, use rubber corks. In hot weather keep in the ice box and always away from the direct rays of the sun. We think it is advisable to make up a fresh solution every second day and thus prevent the solution falling below the 0.45 per cent. mark. However, if the surgeon wishes to make up a stock preparation of concentrated hypochlorite solution, the following formula by Hilton 3 yields a preparation of value, five times the strength of Preparation of Carrel-Dakin Solution. 49

Carrel-Dakin solution, which can be readily used for making this solution simph- bj^ diluting i part with 4 parts of distilled water. Chlorinated lime ...... 100 grams Sodium carbonate (anhydrous) ... 50 grams Sodium bicarbonate ...... 100 grams Water...... to 1000 c.c. Add chlorinated lime to 500 c.c. of water contained in a closed container of at least 1500 c.c. capacity; shake well repeatedly, and allow to stand for at least twelve hours. Shake the lime suspension and gradually add the solution of the sodium salts; shake well. If the mixture becomes gelatinous, warm gently- until it begins to liquefy, and allow the solution to stand until the precipitate completely- settles. Decant and filter through paper, transfer the precipitate to the filter and when it has completely drained wash the precipitate with enough water to make about 1000 c.c. solution. Titrate the liquid obtained by- filtration and dilute with the yvashings so that the finished product will contain 2.5 per cent of sodium hypochlorite. The solution is neutral, non-irritating, and has keeping qualities far in excess of the present official (U. S. P.) solution.

SUMMARY 1.— The technique we use in the Peking Union Medical College has been briefly stated in as simple language as possible for the assistance of Chinese dispensers in our misson hospitals. 2.— The table on quantities required for one litre of <(C-D ” solution is based on our own experience in this Pharmacy. 3.— The solution made yvith these quantities has better keeping qualities, yve have found, than previously used solutions.

REFERENCE. 1. Dakin, H. D. Blit. Med. Jl. Aug. 28th, p. 318, 1915. 2. Cullen, C. E .; Austin, A. H. Jl. Biol. Chem. Vol. XXXIV. p. 553. 1918- 3. Hilton, S. L. Jl. Atner. Pharm. Assoc. January, 1922, p. 32. Chinn JtkMral Journal.

V o l . X X X V II. JA N U A R Y 1923. No, 1

All medical papers and other literary communications intended for the Journal, and all books for review and magazines in exchange, should be addressed to the Editor, 4 Quinsan Gardens, Shanghai. Changes of address of members of the Association, departures and arrivals, and all business communications should be sent to Dr. R. C Beebe, 4 Quinsan Gardens, Shanghai. Every member of the China Medical Missionary Association, who has paid his dues for the turrent year, is entitled to a copy of the China Medical Journal for the year, postage free. To chose not members the subscription to the . ourn; 1 is $5 00 Mex , per annum. In remitting by cheque, please specify Shanghai Currency. Payment should be made to the Treasurer of the Association, Dr. H. H. Morris, 4B Minghong Road, Shanghai, or to Dr. Beebe, 4 Quinsan Gardens, Shanghai.

JÊMtorial.

THE CHINA MEDICAL JOURNAL At a recent meeting of the Executive Committee of the C. M. M. A., it was decided to make the China Medical Journal a monthly publication, commencing with this number, instead of issuing it bi-monthly as heretofore. The change is largely a venture of faith — at least it seems so to the editor— for the journal relies almost wholly upon members of the Association for original medical articles, and at times, particularly during the past j'ear, the supply has run very low, and of course with a m ontlity issue the risk will be all the greater. Perhaps the prospect of more speedy publication of all good articles sent in will lead to more of them being written. At all events, as everyone feels very hopeful at the beginning of the 3’ear, we shall not “ bate a jot of heart or hope, but still bear up and steer right onward” . We take the occasion to wish all our readers a happy and prosperous New Year— prosperous in the fullest and highest sense of the term— and hope that the Journal will share in the general prosperity.

C. M. M. A. CONFERENCE, 1923; AN OUTLOOK Very satisfactory progress is being made in the arrangements for our Conference in February next and a full programme of the proceedings will soon be sent to all members of the Association. Whatever the^predilections and needs of the individual may be, there will be much to interest and help him in the papers demonstrations, and discussions so it is hoped the attendance will be large. We can give the assurance there will be comfortable accommodation for all. C. M. M. A. Conference: _4n Outlook. 51

Concerning-previous conferences it-kas been observed that each has been dominated by one particular subject, suck as medical education, hospital efficiency, and so on. What will, be the dominating subject at the- next -Conference? It is hard to say. Some unforeseen question may arise of importance sufficient to influence all our proceedings, or a seemingly innocent, peaceful paper may start a very animated controversy--, or the whole programme may be of fairly’ even interest. However, judging by recent changes and developments in departments of missionary work other than medical, there is one consideration, which may not find public expression, but which should be constantly borne in mind and all other subjects brought into relation with it; that is, the necessity of stead}’ whole-hearted work 011 our part to hasten the day when the Chinese medical profession will be willing and able to undertake the medical salvation of their own people without much foreign control or assistance. As the Edinburgh Medical Missionary Society Quarterly puts it, the main function now of medical missions is to act as beacon lights pointing the way to -a future of health and well-being, of unselfish service and active brotherhood, such as peoples of the lands in which they are established have never known. To some extent this has been the end in view ever since medical missionaries entered the field ; but the time seems to have come to prepare for it with the energy and careful foresight a practical issue demands. Let it at once be said that it will be a considerable time yet be­ fore the work of the foreign medical missionary wili be no longer needed. There are vast districts in China where the people are still in complete ignorance of scientific medicine, and we may be sure there will always be room in the country for missionary hospitals supported by funds from abroad and staffed by foreign physicians. Even where devolution is possible as far as we are concerned, it would be neither wise nor kind to lay heavy professional and financial responsibilities on our Chinese physicians before they are ready to bear them. A vast amount of preparation is necessary. A great many more Chinese physicians are required for hospitals and private practice; hospital traditions must be created; hospital administrators must be trained, for not every physician is a heaven-born hospital administrator; there must be loyalty to the ethics of the medical profession generally accepted in Western lands; difficult questions of financial ways and means must 52 The China Medical Journal. be considered and, most important of all, there must be a better understanding of foreign medicine on the part of the people generally, before we can expect hospitals in which scientific medicine alone is practised, to run smoothly and successfully. All this will take a great deal of time. A few of these requirements will now be considered more in detail, and in connection with papers to be read at the Conference.

GROWTH OF CHINESE MEDICAL PROFESSION First, the training of men and women to be physicians. This should be done on a far larger scale than has been even dreamed of hitherto. If the population of China is 400,000,000, and if we consider a fair proportion of medical men to the population is 1 : 2,000— in the United States it is about one 1 : 700— then China should have a medical profession of 200,000 members and there should be thousands of students in medical schools. But medical students at present are few. Three or four good schools can care for them all very easihT. What can the Association do, what can everyone of us do individuallj’, to increase the number? Dr. McCracken is sure to discuss this matter in his paper on medical education, though it will be mainly concerned with the necessity’ of organizing a medical centre where students may* be given a thorough training and then after graduation returned to the province whence they came.

HOSPITAL ADMINISTRATION In the next place, while the success of a hospital depends to a very great extent on the professional skill of the visiting physicians and surgeons; it depends also on competent management of its business affairs and on the spirit which pervades the institution. Hence the need of training a number of Chinese to become competent, tactful hospital administrators. Dr. Snoke, who has an article in this number in which hospital management is discussed from the point of view of the patient, will cover the ground further in the paper he will present to the Conference.

HOSPITAL TECHNICIANS. Properly trained assistants must also be provided for the doctors, among them hospital technicians, a development of our u'ork ably advocated at the last Conference by Dr. George Hadden. Dr. Snell, in whose hospital courses of this kind ma^^ be taken, has C. M. M. A. Conference: An Outlook 53 promised to deal with this subject in the light of his practical experience. If the whole work of a hospital proceeds smoothly, almost automatically, the easier it will be for Chinese physicians to take hold.

MEDICAL ETHICS If the medical profession in China is to attain to the high position the profession holds in Western lands, so that the missionary physician may be d :spensed with, it must be animated by the same high ideals. It will be appalling if a medical profession is.foimed here consisting of Chinese trained in Western medicine and surgery, with all the power for evil as well as good which such knowledge and training gives, who refuse to be governed, by the ethical principles of their own sages, and are ignorant of, or flatly disregard, the moral principles embodied in Western codes of medical ethics. Frankly, missionary physicians in China are confronted by a very grave situation. Already- there are found Chinese physicians, seme of whom have even studied abroad, of the stamp just described. Further, there are men to be found in almost every large city who stj-le themselves practitioners of foreign medicine ard surgery on the strength of the little knowledge and experience gained while employ-ed as nurses or coolies in our hospitals. What can be done to check the evils and irregularities which are bringing foreign medicine into discredit ? Some of our Chinese medical frier d 5 sincerely desire to uplift and safeguard their profession, but they’ have to pull very hard against the stresm, ard at times it is not surprising if they become wearied. What can we do to help them ? There are other questions also to be considered in this connection. A paper on Medical Ethics will be presented at one of the morning sessions. It is hoped that many will ponder over this vital question and take part in the discussion.

PUBLIC HEALTH EDUCATION To increase the number of Chines2 physicians able to assume hospital responsibilities and to engage in private practice is only a part of our task. It is extremely important that the people shall be instructed to appreciate the work of the scientifically^ trained Chinese doctors at its proper value. As long as the ignorant millions believe that nearly all forms of disease are due to the caprice or malice of ghosts and demons, hoyv can rapid, permanent progress be made in public health ? How can physicians secure the 54 The China Medical Journal. cooperation of their patients- in the rational treatment of disease ? How can we expect young men and women to study medicine with the purpose of becoming private practitioners when, as everyone knows, they will be classed with the ignorant native doctors and be held in no higher estimation and receive no better remuneration. The gap between the practitioners of scientific medicine and the great mass of the people must be lessened. At least an elementar}’ knowledge of hygiene and sanitation ar.-d of the causation of diseases should be widely diffused in one way or another, for example, by popular lectures, and the distribution of leaflets and pamphlets on public health questions. The article by Dr. Wampler in this issue shows that much work of this kind can be done quietly and effectively if the co-operation of the Chinese officials is secured. Dr. Peter, Dr. Yen, and others connected with the National Council of Public Health who are engaged m this work, will speak on the subject at the Conference and should receive ver}' hearty support. It must be admitted that it is pretty difficult to change the personal habits of adult Chinese, and perhaps just as difficult to change their ideas concerning human diseases. A more hopeful field lies in the education of the young. In all our schools elementary lessons in physiology and on the etiology of disease should be given, with more advanced instruction in high schools and colleges. Whenever possible, practical demonstrations should be given by physicians to clinch this teaching. If students are to be drawn into medicine, the subject must be kept constantly before them. Finalh', it is surely “ up to ” us who live and work among the people continually, to educate public opinion concerning the public health, especially in relation to the evils of modern industrialism whenever and wherever we encounter them. All praise to Mr. Sherwood Eddy for denouncing the long hours and hard labor of little children in factories, and the conditions which cause numerous workers to suffer from “ phossy jaw,” and other easily preventable diseases. As missionary physicians, however, we ought not to be altogether silent. AVe hope to refer to this point again. CONCLUSION The more we ponder on the task before us, thus briefly outlined, the more we are impressed by its magnitude. One cannot be blamed for thinking our mission will never end. But who knows? Conference Notice 55

The formation of the Manchurian Plague Prevention Service by the Chinese Government in the closing days of the Manchu dynasty was a surprising leap forward, and it may so happen that in the not distant future, either spontaneously or because of outside pres­ sure, China may establish, as rapidly as did the Japanese, a compre­ hensive national system of education, including medical education, that will greatly hasten the consummation we have been con­ sidering. At all events, not until our own special work has been accomplished, all our visions realized, can we sing our Nunc Dimittis.

CONFERENCE NOTICE. According to the Constitution and By-laws of the Associ­ ation, “ the order of business at each biennial meeting shall be determined by the Executive Committee. All principal motions which members intend to propose at the meeting should be forwarded in writing to the Executive Committee signed b}T the mover and seconder, in time sufficient to allow the order of business with these motions to be published in advance.” At its meeting on December 9 th, 1922, the Executive Committee appointed the Business Committee for the Conference, its Chairman being Dr. John A. Snell of Soochow, to whom all communications relating to the business of the Conference should be sent, including notices of motions, etc. This business committee will arrange that all business matters shall be presented in order and receive due consideration. The more thoroughly everything is prepared in advance, the more the time of the Conference will be saved.

CARBON TETRACHLORIDE AS AN ANTHELMINTIC In China, where parasitic diseases are so very common, it would be a great boon if the ideal anthelmintic could be found or made— a drug deadh’ to the parasites but harmless to the host. Recently carbon tetrachloride has been given as an anthelmintic in ankylostomiasis, and the reports as to its safety and effectiveness are so very favorable as to give the impression, perhaps, that no great caution need be exercised in purchasing and prescribing it. Of course caution in the use of powerful drugs is always necessarjr. The China Medical Journal.

Carbon tetrachloride (C CI4) is a transparent liquid, as colorless as water and with an agreeable aromatic flavor. According to Stitt (Tropical Diseases, 4th ed,, 1922), it may be given, preferably in hard capsules, in doses ranging from three to ten mils (10 c.c.) or even twelve mils (12 c.c.). “ It is cheaper, more effective, and, when chemically pure, safer than thymol or chenopodium. It does not depress unstriated musculature or lessen peristalsis, thus eliminating the use of purgatives which is an item of considerable expense in campaigns against hookworm disease.” Last year Nicholls and Hampton (Brit. Med. J o u r n July 1, 1922) gave six mils of the drug one hour after the midday meal to a murderer under sentence of death, and the same dajT he passed four worms (Ascaris lumbricoides). Thirteen days later, six mils were given at 7 a.m. before any food had been taken. At 11.45 a.m. he felt a little giddy and sleepy, but this soon passed. A week later he was executed. Post-mortem examination was made one hour after death. No hookworms or ascarids were found in the intestinal tract. Sections of various organs were examined microscopically and no signs of degeneration were found. Hence it is held that in single doses of six c.c. to an adult, carbon tetrachloride is a safe remed}^. T h e drug was next given to the students of an agricultural college who were infested with hookworms. A dose of three c.c. was given to each at 6.30 a.m. before any food had been taken; no purgative was administered. The students went on with their wrork and play as usual, there were 110 dietary restrictions and not one of them was inconvenienced by the drug. On searching the stools a total of 719 hookworms, an average of 36 from each student, were recovered. The indications were that 90 per cent, of the patients were cured. Other observations made show that the drug may be safely given in doses of ten to twenty minims to children three and four years of age, even when they are seriously ill from various causes. Further, the drug does not seriously deteriorate on keeping. Many children were given carbon tetrachloride which had been stored in the laboratory for three years. Its advantages, as an anthelmintic in hookworm disease, are summed up as follows : it is more valuable than chenopodium because (a) patients do not object to its taste; (b) it is net necessary to precede or follow7 its administration by a purge; (c) it is more efficient than chenopodium and has not the depressing effects of that drug; (d) it is much cheaper, than any other drug Carbon Tetrachloride as an Anthelmintic. 57 that has been used ; (e) it can be prepared in a high degree of purity, and a chemically pure preparation should always be used; ^f) the person who is being treated can do his usual day’s work. In the Indian Medical Gazette, August, 1922, McVail relates his experiences with the drug. He has given children, aged 12 3rears, one dram each on two successive days without ill effects. A similar dose (3.75 c.c.) given to a very old man was followed by irregularity of the pulse and slurring speech. At a certain leper asylum fifty-one patients were given a 60 minim dose (3.75 c.c.) one evening and all slept so soundly that a burglar was able to remove the contents of the rice godown during the night. Seventy minims (4.32 c.c.) on two successive days is the largest dose McVail has given to an adult. But the drug has its dangers. In 1865, when Simpson of Edinburgh suggested that carbon tetrachloride should be tried as an anesthetic, it was found to be even more depressing to the heart than chloroform, and in some cases it caused convulsions. It is obvious that it should be given carefully to patients with hookworm disease who are in a state of profound anemia and suffering from cardiac palpitation and d3'?pnoea, or who are debilitated b}- other diseases. The vapor has given rise to serious poisoning (Journ. Amer. Med. Assoc., Vol. 53, p. 726), aiid poisoning by it in rubber factories is described by Hamilton {U.S. Bur. Lab. Bull., 179, 1915). One case of poisoning from its use in shampooing has been recorded. Further, it has now been proved that the drug even in comparativehT small doses, may produce a definite fatty degeneration of the liver, and “ on this account it seems inadvisable to prescribe a dose of 5 c.c. with purgation, let alone without. It is apparent also that this dose as a maximum borders on the danger line. A safe m axim um seems to be 3 c .c .” i^Smillie and Pessoa, Intern. Health Board Bull., July, 1922; Docherty and Burgess, Brit. Med. Journ., Nov. 11, 1922). Then 111 its administration care must be taken to see that the hard capsules are swallowed quickfy. Should one open in the mouth or throat and some of the drug enter the trachea, serious results might follow. Evidently it is not a drug that can be given without due consideration of the general state of the patient, mode of administration, dose, and of. a possible idiosyncrasy’. In purchasing this anthelmintic it is most important to specify that it is for medicinal use and should therefore be chemically pure. 5 « The China Medical Journal.

For years, in addition to its employment in various industries, it has been much used by the laity for the dry cleaning of clothes and by barbers and others for shampooing; for such purposes a chemi­ cally pure drug is hardly necessary, yet it is mainly to meet this demand of the public that chemists and druggists have hitherto kept the drug in stock. To inform them when the drug is to be used medicinally is both just and necessary, as then it will be furnished to physicians in a state of chemical purity. And it may be laid down as a general principle that in China when a new drug is being tried physicians should acquaint themselves full}’ with its physical properties and therapeutic effects before ordering it, especially when dealing with a Chinese firm. In what has been written the intent is not to discourage the use of carbon tetrachloride as an anthelmintic in hookworm disease, but simply to urge the need of reasonable care in its purchase and administration.

MEDICAL MISSIONARY WORK AS A VOCATION. “ To medical men suitably endowed the mission field offers opportunities for interesting work. There are now 415 medical practitioners holding British degrees or diplomas employed in different parts of the world by missionary societies, and the latter seem to stand in constant need of men and women to fill vacancies as the}7 occur, and also to enable them to take advantage of fresh openings. Since the conclusion of the war there has been a large number of such vacancies, as most of the mission hospitals are working with depleted staffs. Further, the development of native medical schools as training institutions in connexion with some of the larger mission hospitals affords excellent scope for most useful work to medical men who are qualified to teach. It is not usually ■expected or desired that a medical m issionary should take a position such as would otherwise be occupied by an ordained clergyman or minister. But it is essential that he should be prepared to take his - share of definite missionary work in any hospital in which he may be placed. As for scientfic and other qualifications for the work, a medical missionary, in addition to being physically capable of sustaining what may prove to be a trying life should be a thoroughly well trained physician and surgeon. It is very Opening of Soochow Hospital. 59

desirable, that he should have held a resident appointment at a general hospital and have a good knowledge more particularly of practical surgery, tropical medicine, and the treatment of eve diseases.” — British Medical Journal.

OPENING OF SOOCHOW HOSPITAL. The new hospital in Soochow of the Methodist Episcopal Mission, South, was formally opened on November 6th, 1922- Numerous officials and other friends were present, both Chinese and foreign, some of whom took part in the proceedings. An inter­ esting address was given by Dr. J. H- Snoke on “ Hospital Administration from the Patient’s point of Mew.” Mr. L. C. Goodrich spoke on “ Sportmansliip in Medicine” and Dr. Peter discoursed on the subject of “ Scales” . The dedicatory service was conducted by Bishop S. R. Hay, of the Methodist Church- The following description of the hospital is taken from an interesting and much fuller article in the North China Daily News. The Southern Methodist Mission and the city of Soochow are both to be congratulated on having a complete, modern, and beautiful hospital. The two main buildings are fireproof, and are complete in every7 respect. The lighting and ventilation 01 both the private acd general wards leave nothing to be desired. The operating rooms call for special mention. The operating tables and thé' equipment are of the latesL and most approved designs. The electric lighting is so arranged that practically no shadow is cast on the patient on the operating table, and the position of the lights may be shifted to the most convenient angle by the shifting of one rod, which controls the lighting system. The sterilizing rocm, with its systems of tanks giving perfectly sterilized water to the two operating rooms, one on either side, is most interesting; so also is the laundry* rocm, the ice plant, the X-ray room, and the large kitchen where the rice is cooked by steam. The system of lights arranged for calling the nurses and attendants is most convenient, these call-lights.being controlled by the eall-button at the patients’s bed-side. The roof-garden on the roof-of the third floor of the main building, should attract man}7 summer-time patients, and from this roof-garden one may get a very fine view of the city and the surrounding country. The China Medical Journal.

The medical work of the Soochow Hospital was began by Rev. R. Lambuth, forty-two years ago. Later, Mr. Lambuth was made a bishop and it will be recalled that he died in Japan a little more than a year ago, when on his way to China from America. His brother-in-law, Dr. W. H. Park, took up the work two years after it was founded and has been connected w?ith it ever since. Dr. John A. Snell joined Dr. Park in the work of the Soochow Hospital fourteen years ago. The hospital buildings were now7 old and inadequate; a new- hospital was absolutely necessarj7 if the work was to expand as it should. Towards this goal Dr. Snell has worked with infinite faith and patience. His many friends congratulate him on having such a splendid hospital and such complete equipment, as well as such a capable staff, to assist him in his work. Associated with Drs. Park and Snell in the Soochow Hospital, are Dr. C. H. Hendry, an American dentist, Dr. A. F. Jacobus, and six efficient Chinese doctors; also four American- trained nurses, and a large staff of Chinese nurses.

HOSPITAL ADMINISTRATION FROM THE VIEW-POINT OF THE PATIENT*

J . H . Sxoke, m.d., St. Luke’s Hospital, vShanghai. In China, as in the West, the success and influence of a hospital depend upon the administrative side of its work to an extent which is not alwa\-s realised even by medical men. During the past 3^ear I had the great privilege of being able to visit a number of the best conducted hospitals in the United States for the purpose of studying their organization and administrative methods. I wras very much impressed by the infinite amount of detail neces­ sary to the proper conduct of the administrative side of hospital work; and 1 often wondered whether the patients, even when they had been in hospital for some time, were usually aw?are of the enormous amount of effort constantly put forth to provide for their comfort and general welfare.

*An address delivered at the opening- of the new Soochow Hospital, Scocliow . Patient's View of Hospital Administration. 61

There is no question whatever as to the general knowledge of the public concerning the clinical or professional aspect of hospital work. To the average patient a hospital means doctors, nurses, operations and various kinds of internal and external medical applications. But even this knowledge is so superficial that he is in no wav capable of judging the quality’ or thoroughness of the work done on and for him. He does not know whether a thorough phy­ sical examination has been made; whether the latest laboratory methods for the proper diagnosis of his case have been employed ; whether the X rray Department has been able to interpret rightly the pictures which have cost him so much; nor whether, if his case is surgical, the latest and most accepted operating room technique has been followed. These instances of his limited knowledge might be multiplied man}- times to show that he does not know whether he is being properly treated clinically7 or not; in fact, he is 110 judge of such things. It follows that a patient's estimate of the service the particular hospital he is in is giving the community, must be based upon things he does know about, such as the reception given him by the first person he meets in the hospital service. Was this person kind? Was he accommodating? Did he ask a lot of seemingly unnecessary questions and was he irritated because answers were not given to his satisfaction ? Did the. adm itting officer tn~ to put him, the patient, into a more expensive room than he wanted ? Did the orderly* who took him to his bed handle him as so much freight to be moved to some other place as quickly and with as little trouble as possible? Did he have to wait for an hour in an uncomfortable wheel-chair or stretcher, until the nurse could put him to bed or until his room was ready ? Was he then treated as if he was an added burden, as giving extra and unwelcome work in an already over-c.rowTded day? Was the bedding fresh and inviting, or was it smelly and stained ? Was his food served hot and in an appetizing manner? Were there unnecessary and distressing noises and smells ? These and man}7 other more or less serious trials and difficulties which might be mentioned, are the things which most impress him; and his estimate of the hospital will be based upon them a*nd not so much upon the medical and surgical procedures of which he is no competent judge. The reputation a hospital enjoys in the community, especialh7 in China, depends.largely' upon these administrative details. I certainly7 do 6 2' The China Medical Journal.

not want to convey the impression that 1 think the professional side is not important, for it is very important; but I do want to point out the importance of some details in the care of patients which are often not even thought of. Unless the patient is comfortable in mind as well as in body the most skilful treatment will.not be fully7 appreciated by him and maj’ be of little use. Let us tryT to analyse the state of mind in which the average patient conies to the hospital.

In the first place he is not perfectly normal. Whatever of poise and self-control, peace of mind and reasonableness he may normally have, in all probability he does not have now or not to the same extent. He is about to pass through a ver}^ try-ing and entirely new experience, one about which he has heard others talk with evident horror. He knows he is quite ill and lie wonders what the outcome will be. What will be done to him? What pain and uncertainty will he be called upon to endure? What about the operation ? Will the surgeons wait until he is asleep before they begin ? W'ill he ever come through it ? Then the financial obligations which he must meet after his illness worn* him. Here are doubts and fears and uncertainties which would severely try* a well man. But our patient is not well; he is sick and anxious, and in this state he comes to the hospital.

In the institution the patient is at once subjected to a list of questions, first b}-7 the one at the information desk. Then he is sent to the admitting officer, who asks him further questions about himself, his finances and his family. Many of these questions seem unnecessary to him. He is often at a loss to know just what is meant, or how he should answer. Often he is very slow about answering questions which to the questioner are perfectly simple. The latter has probably asked the same questions perhaps fifteen or twenty- times that very dajr, and is inclined to forget that to a patient who has just entered the questions may be entirely new. Consequently^, although the patient is using his impaired strength of mind and bodyr to the utmost, he is made to feel that he is stupid. Every contact he makes is strange and tn'ing. I was very much impressed with the frequent reminder given by a very successful Hospital Superintendent in America to those who were compelled.to ask the same questions over and over again every day; he said, i( Remember this person was never asked these questions before.’ y Patient’s View of Hospital Administration. 63

in many places very kindly, quiet-mannered -ladies make this routine as little of an ordeal as possible. It is a pity the same thoughtfulness is not shown in even- institution. In China, the manner of dealing with ordinary7 patients is even more important than in the West. There the general public has been used to hospitals and to hospital methods and usages for many generations. There the patients know they will be subjected to verbal examinations and to certain rules as to visits, etc. In China all is different. A hospital is a strange institution to the people; its workings, rules and usages are entirely unfamiliar. Further, in going to a strange institution, the Chinese patient is putting him­ self under the care of a pl^.sician of another nation, one of the foreigners upon whom he usually looks with suspicion if not with actual distrust and fear. It is at once evident how carefully we ought to proceed. For instance, in making inquiries into the family history nothing should be said that will be misinterpreted and lead a suspicious patient to think there is some sinister plot abroad against him and his family. It cannot be ur,ged too often that in dealing with the ignorant, suspicious, and prejudiced, we must win their confidence and co-operation by receiving and treating them in a most considerate and friendly manner. T h e reputation a hospital enjo3rs and the good it does in the community will depend very largely upon how the patient is dealt with by the administration. If his suspicions are increased, his confidences betrayed, the institution not only loses an enthusiastic supporter but makes a real enemy7 and Chinese enmity can be very- serious. At the least, such a patient will most likely tell his friends that, if they are ever so unfortunate as to be obliged to go to a hospital, under no circumstances to go to the one of which he has been an inmate. In conclusion, let us recognize the wonderful service the administration gives to a hospital and through it to individuals and to the community; and let us who are hospital admin istrators and all others connected with the hospital make all possible effort to see that every patient is cared for promptly, kindly., and quietly. 64 The China Medical Journal.

MEDICAL WORK IN CHINA Warm in his praise of the work of American and other foreign m edical men in China, and of the missionary?- spirit that constantly7 spurs them on to new heights of altruistic endeavor, Dr. Elliott G. Brackett, the orthopaedic surgeon, has returned to his home in Boston after three months of lecturing, teaching, and working in the hospitals and medical schools of China. His visit in Peking was under the auspices of the Rockefeller Foundation, and as a result of this, and of his association with his former students in some of the other hospitals, Dr. Brackett was enabled to get a far more thorough understanding of medical conditions in present-day- China, and of her medical problems and needs, than would a casual visitor to the country who merely follows the tourist’s routine. Unlike most other physicians and surgeons, moreover, Dr. Brackett worked side by side with the men already on the field. He lectured, gave demonstrations and operated as though he were a member of the staff of the various hospitals which he visited during the course of his three months’ tour through China. Orthopaedic surgery, his own specialty'-, he found to be undeveloped when com­ pared with its advanced stage in American medicine. He has helped to strengthen an initial impulse in orthopaedic work, and has given aid to those younger men who are placing the opportunities afforded by this branch of surgery within the reach of the Chinese people, and it should not be long before it is a department of the work and teaching in the various hospitals and medical schools.

S T U D Y IN G c h i n a ’ s MEDICAL NEEDS “ I have sesn work in three principal places, Shanghai, Tsinan and Peking,” said Dr. Brackett. “ In addition to this I have visited several of the small places, for the most part in the interior, where the work is carried on under less favorable and less convenient surroundings. Only in such places can one study effectively the real medical needs of China today7. After one has seen the condi­ tions under which this pioneer work has been begun, and has been carried on for a long time, one necessarily is inspired with a feeling of deep gratitude and of admiration for the men who were, and who still are, in a sense, pioneers. “ Medical activity- in the three places, Shanghai, Tsinan and Peking is by no means identical. Each one has its special problem and its individual methods. Shanghai is a cosmopolitan city-, where Medical Work in China. 6 5

men of all lands rub shoulders. The Mission Hospital, which is still a mission post, is working with quite limited equipment. It occupies the site of one of the old medical schools, some of which have survived the introduction of Western medicine into China, and are teaching native doctors to practise in their own country. In­ dustry in Shanghai has shown so marked a development, and so rapid has been the growth of the mechanical appliances of industry, that industrial accidents have recently increased in number. One result of this is that the surgical wards of the hospital are largely' devoted to fracture service. Of the hundred beds on this surgical side of the hospital, as I recollect it, about eighty per cent, were fracture cases and they were being treated with the best methods known to surgical science. As in most other hospitals in China, the surgeon’s ingenuity is severely strained to provide even simple methods to meet the demand made upon him. As elsewhere, the amount of work is greater than should be expected with the limited physical equipment, and the personnel available; nevertheless, the results achieved are little short of remarkable.

TYPICAL WORK AT TSINAN “ My next stopping place was 1'sman, twelve hours south­ east of Peking. The hospital here is distinctly a mission station. It is in the interior, and is therefore much more isolated than the hospital at Shanghai. There is a medical school attached to the hospital, and the doctors on duty here both teach in the school and work in the hospital. The conditions here are much more repre­ sentative of the conditions that prevail throughout China generally, and a visit to Tsinan will give one an accurate idea of the type of work that our doctors are doing in China. 1 have never had the privilege of meeting a group of men w7ho had such a magnificent devotion to their work, and who displayed so fine a spirit of com­ radeship. All my time here was spent in working and teaching in the hospital. The students are taught in Chinese, and it was there­ fore necessary for me to give my* instruction through an interpreter. Not even in the United States have I come in contact with a group of students to work with whom was a greater source of personal satisfaction. They are eager and earnest. ‘ ‘ Chinese students display a wonderful power of application and concentration, and our American students must persist in their conscientious efforts if they wish to maintain their laurels. They 66 The China Medical Journal.

are ready and willing to use their brains and, what is perhaps most important for a student of any science, they are not afraid to think for themselves. One can tell by the questions that a class asks after a lecture or a demonstration whether or not they have grasped the more important principles that the lecturer had in mind. It was often a wonder to me how quickly^ these students would brush aside the unessential details and get down to fundamentals. “ From Tsinan I went to Peking, and most of myr work at the capital was done in the Peking Union Medical College, a splendid institution, established and financed by the Rockefeller Foundation. It might almost be called a research hospital, rather than a treat­ ment hospital, and it contains elaborate and thoroughly^ equipped laboratories. The practical demands of the community in which it is situated, however, are so great that research sometimes now has to give way in a measure to clinical work. At times the clinical demands are very pressing, and some of the doctors in the hospital find it difficult to find time to do the research work in which they are interested. I shall always hold my visit to the Union Medical College in Peking, the intimate contact with students as individuals and as a class, the work in the wards, and in particular the close association writh the members of the medical staff, as one of the most valuable and instructive experiences of my life. “ There can be no question that China offers a great opportunity for work in orthopaedic surgery*, in part due to the great prevalence of tuberculosis, and these orthopaedic cases constitute a large proportion of the cases that now need surgical attention. This group of tubercular cases is especially appealing, for they are capable of relief or of cure, but only under a particularly- favorable environment which does not exist, or after long treatment which is not available because of the lack of physical equipment, a deficiency in personnel and because of the economic condition in China, none of which can be remedied immediately. But in spite of the lack of ideal conditions patients are daily applying for treatment to the various institutions in China, and the surgeons must receive them and then take some measures, however inadequate, for the relief of those who are constantly clamoring at their doors. ‘ ‘ A more difficult matter with which we had to deal in orthopaedic cases was the attitude of the patients themselves. Super­ stition and the traditions of prejudice have prevented many patients from presenting themselves for treatment. But this M edical IITork in China. 67

problem need not discourage us too much. The same prejudice has been encountered in the more remote areas of the United States, and in many instances the prejudice has been just as deeply rooted. In China, as in America, a practical demonstration showing an actual relief of suffering is the most powerful agent in the combating of prejudice and superstition. “ Orthopaedic cases which have to be dealt with by the surgeon in China are the various types of deformity, acquired and con­ genital, and the various stages of bone and joint tuberculosis, particularly those in an advanced stage, with abscesses, etc. This is in part due to the fact that these cases are difficult in themselves, and in part to the fact that it is virtually impossible to apply the usual methods of treatment under the conditions which at present prevail in China, and with the environment which our doctors have to combat. It must always be borne in mind that economic conditions in China are a law unto themselves, and orthopaedic surgeons must bear this fact in mind when they plan their attack upon their orthopaedic cases in China.

HIGH STANDARDS AND TECHNIQUE “ Throughout my stay7 in China the loyalty and devotion of the medical missionaries compelled my constant admiration. They are not only imbued with a spirit of scientific earnestness, but they also possess in a marked degree that spirit of missionary helpfulness through which alone so great an undertaking is possible. One of the most valuable assets of the American medical workers in that country’ is the missionary spirit— the quality7 that makes a man give his life to relieve the suffering and the distress of his fellows. Without this quality the medical pioneer in China would not have achieved the success which his labors have deservedly won for him, and the same quality is largely responsible for the success of a scientific institution such as the Peking Union Medical College. A coldly scientific organization or a group of such organizations cannot alone solve China’s medical problem. All medical institutions must be inspired by the same missionary spirit, if the work of science is to win a full m easure of success. L u c k ily , in China today*, science goes hand in hand with this impelling spirit and Americans may well feel proud of the achievements of American doctors in introduc­ ing among the three hundred millions of China the standards of Western medicine. They are worthy torch-bearers of a worthy cause.” Boston Evening Transcript Sept. 2, 1922. 68 The China Medical Journal.

Current flDetncal ^Literature

THE ETIOLOGY OF SPRUE

T r e v o r H e a t o n , Ind. Jour. Med. Res., A p r i l , 1920. The conclusion is reached that sprue is a definite entity, and not a mere association of symptoms; its predisposing and complicating factors depending on a single pathological condition. There is no evidence to suggest a specific bacterial or protozoal infection, for though these organisms may be present sprue symptoms can exist without them. These symptoms of sprue are due mainly to mycotic fermentation and digestive incompetence. The peculiarities of the incidence and geographical distribution of this disease point to a physiological rather than an infective cause. The immediate relief from all infective symptoms in response to non-specific treatment is contrasted with the veryr slow and uncertain recovery of the digestive function. This is also taken to indicate that the digestive failure is the essential disability, and the infection secondary. The physiological disability of sprue is brought about by the effects of climate.

HOUSE INCIDENCE OF SPRUE SUGGESTING INFECTIVE NATURE

P o w e l l , Trans. Trop. Med. & Hyg., June, 1922. A t a m eeting in London of the Roybal Society of Tropical Medicine, Dr. Powell commenced an address by stating that the peculiar distribution of sprue has led many to suspect its infective nature, though no definite protozoon or protophyte has been proved the cause. He is not aware that any case has arisen in England from contact with the numerous patients returned from the tropics. If there be a causative microbe, it perhaps cannot thrive in the English climate outside the body of its immediate host. He then briefly related the history7 of nine groups, totalling 36 cases of sprue, which originated in certain houses or families. Group A. Husband, wife and two daughters. Husband and wife died of sprue, and one daughter was affected. Tenant who occupied flat in same house died of diarrhoea with sore tongue. Group B. Sixteen cases among members of a certain residential club who occupied bedrooms for short periods in the club in much the same way as in an hotel. The remaining cases occurred among partners, brothers, or other close associates. Current Medical Literature. 69

In the discussion which followed, Dr. Manson-Bahr said that in examining his old records he found a number of instances of sprue occurring in husband, and wife, mother and son, mother and daughter, and other closely associated members of the same house, and that in Ceylon the association of sprue wiLh “ dry-rot” in bungalows is a popular and prevalent idea. After thorough investi­ gation, however, he came to the conclusion that the immediate surroundings of the patients, so far as he could ascertain, could not be held responsible for the spread of the disease, but that the occurrence of one or more cases in those closely associated, pointed to an exposure to the same conditions, or possibly to an infectious cause emanating from one source and spreading from one person to another. What that cause and these conditions are, still remain to be discovered. This appeared to be the general opinion of the meeting.

GASTRIC ULCER FROM HOT AND UNCHEWED FOOD

H e i s e r , Med. Khnik, U e k i.i n , Aug. 6, 1922. The author states that in 10S gastric ulcer patients in the last two years he found only 4 that were not notorious for insisting on their food and beverages being served very hot, or they were very rapid eaters, or both. He tested the temperature of the soups and beverages served on his family table for several winter months, and was surprised to find the tea in the cup and the soup in the plate from 75°C.-8 i °C. in the summer. W'hen the soup in the plate is at 85, we can assume the temperature is 70 or 80 when it reaches the stomach. Personally', he found temperatures above 70 distasteful, but others relished the higher temperatures. Fluids at a temperature of 70°C.-S0°C. may irritate or even blister the skin, especially in prolonged contact. Decker found typical gastric ulcer in two dogs fed with hot gruel at 62°C. But experiments on animals are not needed to corroborate the injurious influence of the scorching, especially when supplemented by the scraping of unchewed food. The hot food is responsible further for hyper­ secretion of gastric juice; the hyperacidity is due to the stimulation from the heat. This, long continued, may exhaust the secretion, and achylia result. Hot coffee on an empty stomach, year after year, may explain a number of puzzling features of gastric ulcers. ¡Scorching, plus the peptic action of the gastric juice— this is enough to explain many ulcers. [A few years ago, W. J. Mayo, of Rochester, Minn., expressed the opinion that perhaps gastric cancer is caused, either directly or indirectly, by the custom of taking food and drink while very' hot. In reply to the question why cancer of the stomach is more frequent yo The China Medical Journal. in males (38 per cent.) than in females (22 per cent.) he thought that “ a possible answer to this question is furnished in the frequency of cancer of the posterior wall of the pharynx and upper gullet in Chinese men, who are served first while the rice is hot; the women eat at the second table, when the rice is cold, and rarel}^ have cancer in this region. It is the social custom of modern civilization for the lady of the house to serve the beverages— herself last/’ The subject is referred to editorial^ m the Ch. Med. Journ., 1919, p. 46. Ed.]

DIAGNOSIS OF ILEUS

Zentiablati jur Chir., I/ e i p s i g , M a y 2 7, 1922. Hofer recounts a method that he uses to discover the cause and seat of intestinal obstruction— the auscultatory7 phenomenon of the aortic pulse audible over the abdomen. Since first establishing the finding, he has examined all his ileus cases with this object in view and was able in every case to evoke the same results. He noted further that, after elimination of the ileus through operative or internal measures, the symptom could no longer be elicited. Three recent cases were especially significant. In one case there was acute intestinal occlusion associated with tuberculosis of the peritoneum. The aortic pulse was audible over the whole abdomen. After an enema had opened up the intestinal passage, the symptom could no longer be demonstrated. In a second case of acute ileus, the history awakened the suspicion of a tumor of the upper large intestine as the cause. The aortic pulse could be heard onl}- over the right lower abdominal region. Operation revealed an isolated accumulation of flatus in the cecum and an occluding carcinoma of the transverse colon. Hofer thinks that the intestinal loops filled with gas and fluid constitute especially good sound conductors which transmit to the ear the pulsation of the abdominal aorta.

ACUTE INTESTINAL OBSTRUCTION

O ’C o n o r , Brit. Med. Journ., S e p t . 30, 1922.

Assuming previous examination fails to give the indication, of the site of the lesion, a very perplexing question arises at the start— where to make the incision in acute intestinal obstruction so as to get directly at the seat of mischief. “ I advocate an incision in the right semilunar line for both acute colic and acute ‘ intestinal ’ (unplaced) obstruction, the reason for doing so being that 70 per cent, of acute abdominal lesions are credited to appendicitis. If to this be added the incidence of pyloric, duodenal, and biliary affections, the ratio of Current Medicai Literature. 71

involvement of tlie right as compared with the left abdomen must certainly- stand not less than 6 to 1 ; and knowing that the most frequent cause of obstruction is the legacy peritoneal agglutination following infective processes and operations for their relief, the deduction is, to say the least, logical that given no direct guide, the chances are greatly in favour of finding the lesion in the right abdomen. And as to the sj-stematic search for obstruction by passing the gut through one’s fingers, my experience dictates that this can be (when serous coat permits) as effectively done through a right semilunar as through a 113- other incision. As to making a separate suitable opening in the right iliac fossa for caecal drainage, I am all in favour of it, for it appreciably diminishes the risk of subsequent virulent infection and its consequences in the large primary wound.”

METHODS OF DRAINAGE IN SURGERY. Rif. Med., June 26th, 1922. After a brief reference to old methods of treating collections of pus, Balsamo divides modern methods of drainage into two main groups: (1) using substances supposed to possess absorptive power — for example, cotton-wooi, threads, charcoal, catgut, sand, iodoform, sugar, etc. ; (2) tubes which keep the channel open and allow the pus to escape within or along Lhe line of the tube— of the various materials used rubber and gauze are the commonest. Cigarette drainage, introduced by Ruggi in 1897, is also used. Paraffin drainage, proposed by Soresi in 1915 (either en bloc or by strips of gauze soaked in paraffin), has given good results. Filiform drainage by means of horsehair or silk is especialh* useful in fistulous tracks. None of these methods give perfect satisfaction, and for some time the author has abandoned drainage in open surgical wounds and trusted to the use of thin rubber sheets. Fragments of old rubber gloves well boiled are introduced to the bottom of the wound, packing loosely like a plug and using no ■strips of gauze. The author has treated in this way empyemata, appendix abscesses, and man37 other conditions, and is very pleased with the result. The pus flows out between the folds of rubber, and the change of dressing is simple and painless. The slight inconvenience of saturation or maceration of the skin by the pus ma3^ be partly avoided by smearing vaseline.

HELMINTHIASIS AND DYSMENORRHOEA

L e o , Bull, de I/A cad, dc Med., M a r c h , 19 2 1. The author is of the opinion that the presence of worms, especially oxyuris and ascaris, is capable of causing pelvic pain during the menstrual periods. A reliable sign of helminthiasis is 72 The China Medical Journal. the “ tongue sign” described by Couillard, characterized by enlargement of the fungiform papillae of the tongue, which become visible to the naked eye as red spots at the tip or margins of the tongue. When a patient shows the tongue sign and painful dysmenorrhoea at the same time, treatment for worms not only causes reduction or disappearance of the tongue sign but also re­ moves dysmenorrhoea. Should the tongue sign return afterward, recurrence of the parasites and of pain during menstruation is correctly foreshadowed. In some cases the treatment consisted of small enemas of tepid salt water, and santonin and calomel by mouth for three or four days, followed by bismuth subcarbonate given internally. Eight women treated in this way for a few months were relieved of their menstrual distress. In one case, a patient who had had dysmenorrhoea from the age of 14 to 36 years had her first painless menstruation the same month that the anthelminthfe treatment was started. Many specimens of ascaris and oxyuris were expelled by this treatment. The treatment for worms was constantly effective in cases exhibiting a combination of the tongue sign and dysmenorrhoea.

GEOGRAPHICAL DISTRIBUTION OF HUMAN SCHISTOSOMIASIS

M i l t o n , Journ. Trop. Med. & Hyg., Sep. 15, 1922.

Human schistosomiasis has a world-wide distribution between 38° N. and 350 S. latitude. Each species of schistosome has certain geographical areas in which it only is found or in which it is greatly predominant.

S. haematobium appears to be the sole species found in South W'estern Asia, and it is greatly predominant in South Africa, Egypt and the Soudan, and in the whole of Coastal Africa. S. mansoni alone is found in Central Africa and in the New W orld. S. japonicum is the only- species met with in China (provinces of Chekiang, Hunan, Hupeh, Anhwei and Kiangsi) Japan and the Philippine Islands. Within the schistosome zone there are large areas in which no species of the parasite has, so far, been found, the principal of these being India, Burma, Siam, the Malay Peninsula and the Sunda Islands in the Old World, the United States of America, Mexico, the States of Central America, Haiti and the West Indian Islands north of 190 N. latitude in the New, together with the Islands of the Pacific. Current Medical Literature . 73

EFFECTS OF TONSILLECTOMY ON GENERAL HEALTH OF CHILDREN

K a i s e r , Jour. Amer. Med. Assoc., June 17, 1922. Of 10,000 children 011 whom tonsillectomy has been performed under uniform conditions, 5,000 have been re-examined one v^ear after operation, and in this paper a detailed history* of the child’ s complaints are tabulated before and after operation. Analysis of the causes for operation shows that obstructive symptoms or evidences of tonsillar infection existed in 99 per cent, of the cases. In 5,000 children re-examined, the greatest improvement came to the group that showed evidence before operation of obstruction and infection. Obviously, a child suffering from obstructive tonsils and adenoids with symptoms of infection should have the beneiit of tonsillectomy. Considerable improvement in the child’s general health was noted in the group that presented evidences of infection from the tonsil but when the tonsil presented no marked hypertrophy. Undoubtedly this group showed beneiit from this operation. No marked change was found in the child’s general condition in the group operated on for hypertrophy only. There was less malnu­ trition in this group. One year is too short a period in which to determine the benefits of the operation to this group. Taken as a group, there was a very decided improvement in the general condition of the children operated on. The nutritional status was improved in many instances. The high percentage of undernourished children one year after operation— 29 per cent. — suggests that diseased tonsils are only7 a small factor in the production of malnutrition. The operative risk is not great, for 10,000 children were operated on without a surgical fatality7, and post-operative complications occurred in only7 a small percentage of the children, assuring reasonable safety' if proper care is taken. The ultimate effect of the operation 011 a child cannot be determined at the end of a year; but at that time 84 per cent, of the children have been considered in better general health, as indicated by their physical examination and analysis of their complaints.

VACCINES IN INFLUENZA

Hygeia, June 15, 1922.

F . B l o c k and others, constituting a committee of inquiry, report on the therapeutic experiences gained in Sweden and elsewhere during the recent epidemics of influenza. They have little good to say of the numerous drugs, including alcohol, experimented with in influenza, but they have come to the conclusion that inoculation with the products of streptococci, pneumococci, and Pfeiffer’s bacillus is of considerable value in 74 The China Medical Journal. preventing the complications of influenza. In Sweden the vaccine distributed was streptococcal and pneumococcal, and of the sixty- five physicians who sent reports on their experiences with vaccines to the Board of Health, forty-one claimed to have obtained strikingly good results, the course of the disease being rendered more mild, and the frequency’ of complications being reduced. The results obtained in the Swedish army by inoculations in November, 1918, pointed in the same direction. This procedure has proved to be perfectly^ harmless, but it is probable that the immunity conferred is of comparatively short duration, and may’ not last for more than about three months.

BUCCAL INFECTION WITH BACILLUS TUBERCULOSIS G i.ovxe, Tubercle, A u g u st, 1922.

An attempt is here made to answer the following questions : (1) Are virulent tubercle bacilli commonly present in the mouths of patients suffering from pulmonary tuberculosis? (2) If so, can these organisms be transferred to table utensils? And (3) does the washing of these utensils destroy’ the bacilli? Of 20 sputum- positive patients 10 had only’ a little and 10 had much sputum. Their mouths were washed out with 40 to 50 c.cm. of sterila water containing 0 .5 per cent, autiformin to destroys secondary’ organisms. The centrifugalized deposit was injected into guinea-pigs, and of the 10 cases with scanty sputum 2 gave a positive result, and of the 10 with much sputum 8 gave a positive result. Similar experiments made with spoons used by 20 patients y-ielded 60 per cent, positive results in cases with profuse expectoration, whereas none of the 10 patients with scanty expectoration gave positive results. Other table utensils were not found to be infected, and samples of ward crockery also gave negative results. The author concludes that patients with profuse expectoration are more infective than those with scanty^ expectoration, and that plain water, used in sufficient quantities, is a satisfactory’ sterilizing agent in consump­ tion hospitals.

FALLACY IN “THICK-FILM” METHOD OF EXAMINATION FOR MALARIAL PARASITES

S i n t o n , Ind. Journ. Med. Res., October, 1922.

For many years it has been pointed out that numerous fallacies may7 occur in microscopical diagnosis due to the accidental entrance of extraneous substances into the material being examined, either during its collection or during the process of preparation for examination. In this note another possible occasion of such error is pointed out. Current Medical Literature. 75

In examining a large number of blood smears from cases of treated malaria for evidence of parasitic relapse, the author was astonished to find one day' that although all the ‘ thin films ’ were negative, yet most of the ‘thick-films’ showed forms which seemed ‘positive’. These results were surprising because a number of the ‘ positive ’ cases were receiving 30 grains of quinine daily and because the results were not in keeping with the previous findings. The forms most commonly seen in these smears consisted of blue masses of protoplasm with a distinct, well-stained, red chromatin mass, obviously a protozoon of some kind, but showing no signs of pigm ent. These forms usually looked like half-grown benign tertian or quartan parasites, but did not show the amoeboid form seen in the former parasite when of the same size; the chromatin mass also seemed much more rounded and compact than that of the malarial parasite of apparently’ the same age. In addition, forms were found which very closely resembled the gametocytes of either of these two malarial parasites and some forms showed two nuclei rather resembling Leishman-Donovan bodies. These forms were not ver\r numerous and 110 ‘ small ring ’ forms were found, but sometimes large bacteria and fungi with a superficial resemblance to crescents were seen. The cause, of the sudden appearance of these protozoa was traced to the fact that during the morning of the dav in question all the fresh distilled water had been useddip, asd while a fresh supplv was being prepared an old bottle of distilled water was used which had apparently become infested with these protozoa. It is necessary that in examining blood by the ‘ thick-film ’ method that freshly distilled water should be used and that all drop-bottles, etc., used to contain it, should be cleaned every few day^s and rinsed out with abslute alcohol before refilling.

VARIABILITY OF WASSERMANN TEST A n n . R ep., 1922, of S. A fr ic . I n s i . fo r M e d . R esearch. The number of specimens (syphilis) examined shows a large increase on the figure for the previous year— 4,222 as against 2,862. The comments made in last year’s Report may be taken as applying equally to this year. Only one feature seems to call for special remark, viz., the fact that on four occasions two speci­ mens taken from the same patient at a few day^s’ interval gave flatly contradictory- results in the Wassermann test, negative with one specimen, strongly positive with the other. In three of the four instances the examinations of the duplicate specimens were made on the same day and with the same re-agents, and the tests were 76 The China Medical Journal. repeated, but always with the same contradictory results. Such experiences are, of course, commonplaces in most laboratories. (See, for instances, Correspondence in the B.M.J., 1921, i., pp. 658, 686, and 719.) They are annoying from the point of view of both the individual patient and the practitioner concerned, but they are oi such comparatively rare occurrence that they do not seriously detract from the value of the reaction as a diagnostic measure; they merely emphasise the fact that the reaction should only be employed as an aid in diagnosis and not as a final court of appeal. It is note­ worthy that in three of the four cases referred to the test was asked for, not for diagnostic purposes, but as a guide to the necessity or otherwise for further treatment in patients known to have syphilis. In the fourth case the test was for diagnostic purposes, but, on clinical grounds, syphilis was unlikely. These anomalous results are known also in individuals not undergoing any anti-sy’philitic treatment. No general explanation can be given for their occurence.

ERYTHEMA NODOSUM AND TUBERCULOSIS Tubercle, July, 1922.

V etlesen has scrutinized the records of more than 1,800 cases admitted to the Communal Hospital in Christiania in the 21-year period 1S95-1915, during which he was medical super­ intendent. He followed two lines of research : (1) to collect the records of cases of erythema nodosum, to search for mani­ festations of tuberculosis in these patients or their relatives, and to ascertain the subsequent fate of the former; and (2) to collect the records of patients admitted with manifestations of tuberculosis, and to ascertain the frequency with which they- had suffered from erythema nodosum. (1) There were 45 cases of erythema nodosum, as manyr as 42 being females. In 24 cases there was no family history of tuberculosis. Three cases were tuberculous at the time of the eruption, another three developed tuberculosis subsequently, and six were tuberculous suspects. Thus altogether 12, or 26.6 per cent, could be regarded as tuber­ culous. (2) O f 350 patients with pleurisy, 18 had previously suffered from erythema nodosum, and of 1,317 patients suffering from other forms of tuberculosis 12 had previously suffered from, erythema nodosum. Thus 5.1 per cent, of the patients with pleurisv, and 0.9 per cent, of the patients with other manifestations of tuber­ culosis, had suffered from erythema nodosum. In no fewer than 12 of the 18 cases of pleurisy the interval between the outbreak of this condition and of the erythema nodosum was only three and a half months or less. The author concludes that there can be little doubt as to the relationship of the two conditions, and he has learnt to regard erythema nodosum as a danger signal and as an incentive to vigilant supervision. Chinese Hospitals in Ancient Times. 77

CHINESE HOSPITALS IN ANCIENT TIMES.

B y K. C . W o n g ( £ § ! £ ) l .m .s .h ., H a n g c h o w In view of the great interest recently taken in the subject of hospitals in China the following references to hospitals in Chinese literature as bearing on their historical development may be of interest.. “ Physicians attend to the sicknesses of the people. There are particular diseases in the four seasons of the year. Headaches and neuralgic affections are prevalent in spring, skin diseases in summer, fevers and agues in autumn, and bronchial and pulmonary complaints in winter. The patients are sent to the different departments to be treated.” Chow Rituals. ( $ m

It may be inferred from the above that government free clinics were known as earhT as the tenth century B.C. A more specific account of hospitals, however, is found in the works of a great philosopher of the same period where they are described as follows : “ In the Capital there are institutions where the deaf, the blind, the dumb, the lame, the paralytic, the defoimed, and the insane are received. When ill they are cared for until they have reeovered.” Kwan Tzu.

“ All infected persons should be sent to empty outhouses where treatment will be provided. Burial expenses will be given at the following rates : two deaths in one family, iooo cash; four deaths in one family, 3000 cash; six deaths in one family, 5000 cash.” Decree of Han Pin, 1st year. (i.A.D.)

“ When Sun Kung-yee was prefect of Min Chow it was the custom of the place to abandon the sick. If one member in a family was infected the rest would flee. Even father and son, husband and wife, would not take care of each other and, 7§ The China Medical Journal.

as a result, most of the sick died. Sun Kung-yee ordered his subordinates to gather in the sick in the district and transport them with beds and carriages to the great hall in his own house. In the summer months, when an epidemic was raging, sometimes hundreds filled the courtyard. He personally attended them, spending his entire income to buy medicines and to engage physicians to treat the sufferers ” History of the Sui Dynasty. (|5g ¿ )

The two epidemics referred to must have been rather severe. To confine all infected persons in empty outhouses specially provided for the purpose corresponds to the modern idea of isolation. “ T h e crown prince H ui "Wen and prince C h ing L in g were both great admirers of Buddhism. They’ organized the ‘six disease kwan ^ fg) to take care of the poor.” Life of Hui Wen, Nan Chi Annals.

“ Prince Ching Ling founded a ‘hai’ to the north of his palace for the sick poor. He clothed them and gave them m edicine.” Life of Ching Ling, Nan Tsi Annals

T h ese kwan and hai were charity hospitals. The six groups of diseases were agues, fevers, headaches, bowel com­ plaints, hysteria and heart troubles. A “ Royal Proclamation dated” October, the 3rd year of Yung Pin, reads as follows : “ There are orphans, widows and sick poor in the country and we do not take care of them. Is this our true intention is thus being the father and mother of the people? Therefore be it ordered that the Master of the Grand Banner shall establish a hospital in some suitable place and send all the suffering people there. Be it further ordered, that the Medical Bureau shall assign doctors to treat them. Examinations will be held on the work of these physicians and promotion made according to the results shown.” The Wei Annals. ( ^ ) Chinese Hospitals in Ancient Times. 79

These hospitals also served the purpose of training students and post-graduates, thus resembling the hospital school of the present time.

A decree of Hui Chang, 15 th year, November, (845 A. D .) reads: “ Convalescent Homes were founded during the Tang dynasty. But on account of the great number of priests throwing up their ecclesiastical orders, too few being left to look after the needs of the patients, the government found it necessary to assign a portion of the rice fields belonging to the temples to keep up these institutions. From seven to ten acres were taken from each province and an elderly person of that district was selected to take charge.”

Old Tang Annals. ( f g # )

Buddhism was introduced into China about 85 A. D. ard was very flourishing in the Han and Tang dynasties. It is estimated that up to the time of Wen Tsung (827 A. D.) there were more than 40,000 temples and several hundred thousands of monks and nuns. These Homes for the Sick were at first entirely managed by priests. In S45 A.D., however, Emperor Wu Tsung ordered all the temples in the country to be demolished. About 27,000 monks and nuns were thus compelled to return to ordinary life. As a result these Homes were deserted until re-organized by the above mandate.

“ In August the first y^ear of Ning Yuan (1102 A. D.) Safety Refuges were organized in every province for the sick poor.”

Sung History. (5^

“ WThen Foo Peh-sing was prefect at Chang Chow he founded the Benevolent Institute for sick people to counteract the prevailing custom of expelling devils in treating patients.”

Life of Foo Peh-sin (4® fg jg; {§)

“ Huang Yung, the prefect of Ying Chow, established the Safety Retreat to house the poor patients. The interest of an endowment fund was used for its maintenence.”

Life of Huang Yung. (' 8o The China Medical Journal.

“ Su Shih, when prefect at Hangchow, said that this city being the terminal of land and sea routes, deaths from plague must be more than in other places. He collected two thousand dollars from others and subscribed fifty ounces of gold himself to organize hospitals, appointing doctors and servants to dispense food and medicine to the people.” Life of Su Shih.

It may be noted that in the Sung dynasty public officials were very energetic in establishing free clinics and the co-operation of the people was sought in this work.

“ In August the 2nd year of Tai Shing the Benevolent Bureau was created. Several court physicians were appointed to direct the work and two old doctors of literature were selected to look after its management. Patients were treated free;” History of the Kins. ^

“ The Benevolent Dispensary was founded during the Yuan djmasty. The government appropriated a fixed revenue for its support, the interest of which was used to buy medi­ cines. Skilful doctors were appointed to take charge of the dispensary and treat the patients.” Political Economy. (7c -ft jjij)

“ Hospitals were first started in the Capital and in the ten provinces in 985 A. D. They were maintained by funds derived from rice fields granted by the government and were under the charge of court physicians. But in 1292 A. D. the work was discontinued because of loss of revenue until 1299 A. D., when it was re-established by the emperor, Tah Teh. Two doctors were appointed to each of the larger hospitals and one doctor to every smaller hospital. The amount of revenue appropriated was according to the population of the district.”

Political Economy. (% )£, “ft

According to Garrison’s History of Medicine hospitals and sick nursing in Europe owe their origin to the teachings of Christ : “ For while the germ of the hospital idea may have existed in the A New Mask for Chloroform and Ether. 81 ancient Babylonian custom of bringing the sick into the market place for consultation, as it were, and while the Iatreia and Asclepeia of the Greeks and the Romans may have served this purpose to some extent, the spirit of antiquity toward sickness and misfortune was not one of compassion, and the credit of ministering to human suffering on an extended scale belongs to Christianity-.” This indifference cannot be said to have existed in China. From the earliest times there hospitals were opened which were centres of benevolence, where the destitute went for food and shelter and the sick for medicine and care. Indeed the hospital was a symbol for charity*, and so deep-rooted is this idea that even now no respectable person with means, unless absolutely- obliged to, will go to a hospital.

From the meagre records available we have no means of ascertaining how these ancient institutions were equipped and managed. It may be presumed that the standard was very low and perhaps they7 scarcely merit the name of hospital if judged according to the modern sense of the word. During the Tang dynasty hospitals were chiefly- in the hands of the ecclesiastical authorities but in other periods they7 were conducted by- the government or by the municipality.

A NEW MASK FOR CHLOROFORM AND ETHER

E . W itt, m.d., Hungkiaug, Hunan. Last y'ear, I saw a paper by Wederhake (Düsseldorf) about a new method of administering chloroform and ether, which he claims to be much safer and cheaper than any- method heretofore used. At the time of writing, he had used it in more than 12,500 cases with­ out one death. The mask has a double frame. The inner one has the form of an ordinary- chloroform mask and has to lit exactly to the face, leaving the eyes visible. The outer frame is connected with the former by a joint of the same shape, but wider, leaving a space of about 2 cm. between them. Both frames are covered with fine wire net; the outer one has a hole for receiving the anesthetic. The space between the masks is filled by a layer of absorbent cotton-wool; the hole in the outer mask is loosely' filled by some gauze. The China Medical Journal.

While the patient breathes quietly, not too deeply, and counts slowly from i. to 8 or i to 10, two or three grams of chloroform are ;dropped or slowly poured on to the gauze. Then three grams of ether are added, and every five seconds a further gram is added until the patient suspends breathing. Short operations may be done at this stage. By giving small quantities of ether from time to time,

the narcosis can be maintained for hours. For a narcosis of half an hour’s duration only three grams of chloroform and about thirty grams of ether are needed. If the narcosis is not sufficently deep, one or two grams of chloroform may be given in between. W'eder- hake states that patients of his who formerly had been anesthetised according to the old methods, much preferred this new one as they did not suffer from the sense of suffocation. Cases of asphyxia were not seen. He saw only one instance of pneumonia in his 12,500 cases. No hypersecretion of mucus occurs, therefore the mask seldom needs to be removed, wrhich is a great advantage. For under this mask the anesthetic is w^armed and concentrated and the accumulation of carbon dioxide enhances the effect of the anesthetic. No contraindication exists; any patient about to undergo an operation is given this form of narcosis if he desires it. So far the description of the method is by W7ederhake. After I had read his paper I improvised a mask for my own use and have since operated far more frequently on patients than ever before, using this method of producing anesthesia with very- gratifying results and much less anxiety than formerly. For a single-handed doctor in the interior this methcd certainly is a great help, because even with an inexperienced assistant the danger is not very great. I may add that I do not always insist on making the patient count as it really does not seem to make much difference. Observations on Child Hygiene Campaign, Shansi. 83

OBSERVATIONS ON THE CHILD HYGIENE CAMPAIGN IN SHANSI.

F r e d . J. W a m p l e r ,, m .d ., Council on Health Education, Ping Ting Chow, Shansi. Owing to unsettled political conditions and to a lack of unity of interest in so vast a country7, it has not been possible so far to obtain an efficient Department of Health under the Central Govern­ ment of China, nor a successful Public Health organization supported by public-spirited men. It is also impracticable at present to establish an efficient Department of Health in any of the provinces. But much can be done, not only to disseminate a knowledge of sanitation and hygiene among the people, but actually to put this knowledge into effective use. That China is not united so that she can whole-heartedly support a Central Government does not mean that smaller commun­ ities are not ready to support measures for the public good. The time is likely past when China needs the big popular health edu­ cational campaign that does not lead to permanent organization for carrying on the work discussed. On the other hand, a quieter campaign that leads to the organization of city or county Public Health organizations, promoted by officials and gentry co-operating and undertaking definite pieces of work, is a very effective way of getting better sanitary- hygienic standards adopted. As an illustration of this latter method, the Child Hygiene Campaign in Shansi conducted by7 Dr. V. B. Appleton, of the Council on Health Education, during the fall months of 1922, should be studied. W ith one exception, in the nine centers where the work was carried 011, it was done under the auspices and support of the local Chinese officials with the missionaries co-operating. In the center excepted, the Mission bore the expenses and directed the campaign. In Taiyuanfu, the provincial capital, there was already7 an active Public Health Association. This association is a civilian organization, but has the sanction and support of the provincial government. Since its organization about ten months ago, it has done very effective wrork in the way7 of vaccination against smallpox and also anti-diphtheria work. The association arranged for Dr. Appleton to conduct a Children’s Health Conference and to lecture in the provincial Normal Schools 011 the teaching of hy7giene in the Primary and Middle Schools and on School Health Supervision. 8 4 The China Medical Journal.

Outside of Taiyuanfu, eight country districts were visited. Five of these eight counties organized Public Health Associations either preliminary to, or during, the campaign. One that had been organized earlier enlarged its plans and program as a result of Dr. Appleton's visit. All of these associations have undertaken two or three definite pieces of work and expect to add other tasks as these are completed. One undertaking in several of the centers is assisting in teach­ ing Public Health in the government schools, first by7 supplying literature and, secondly, by providing well trained persons who will give special courses in hygiene and sanitation. Another work that has been taken up is health surveys. In the parts of Shansi covered by the campaign, osteomalacia is very prevalent, especially in the larger towns and cities. Under the direction of the writer, two of these Health Associations are making thorough surveys of their cities that the incidence of the disease may be known and preventive measures instituted. Several organizations are undertaking to put iu model sanitary toilets in the place of the present fly-breeding pest holes. Most of these organizations are also undertaking to have all the vege­ table and fruit stands screened. Fly swatters made out of local material will be made in large quantities and sold at cost or below. One organization is holding an anti-smallpox campaign and is furnishing free vaccine to all those who will come for vaccination. There were meetings for the gentry, business men, students and women. A Children’s Health Conference was also conducted in several places. Only the future will reveal the real and permanent results of the campaign but, judging from the enthusiasm and celerity with which Public Health Associations were organized and undertook definite tasks, we can reasonably expect some effective results.

PROFESSOR FUCHS’ VISIT TO PEKING. The trustees of the Peking Union Medical College upon learning that Professor Fuchs, of Vienna, intended to visit China following his tour of the United States, offered him a Visiting Professorship in Ophthalmology during his sojourn in Peking. To the delight of the faculty of the Peking Union Medical College he accepted the invitation, in spite of the fact that by so doing he would be unable to take the wonderful trip up the Yangtsze gorges. Professor Fuchs' Visit to Peking. S5

An all-day post-graduate course in ophthalmology for a period of one month was arranged to coincide with Professor Fuchs’ visit. He arrived in Peking on October 21, 1922, and during his stay was the guest of Dr. Howard. Thirty* phy sicians coming from all over China, about half of them Chinese and the other half foreign, were enrolled in the course. Two American physicians came from Canton, a distance of over two thousand miles, and several others from the region of the Yangtsze river valley’. The feature of the course was the series of highly interesting lectures and demonstrations by Professor Fuchs on the pathology of the eye, which had previously been so enthusiastically7 received in America. In addition he gave clinical demonstrations three times a week on selected cases which proved to be exceedingly instructive to the class and to the eye staff. The responsibility for providing instruction to the class during that part of each day- not taken by Professor Fuchs was assumed by the members of the Ophthalmo- logical Department of the Peking Union Medical College. Professor Fuchs received many7 invitations to speak before schools and medical societies. Before the Faculty7 Medical Society1 he spoke on “ The Ocular Symptoms of Tabes” and at another time on “ Postgraduate Medical Teaching” . He spoke before the faculty- and students of the National Medical College 011 “ Arteriosclerosis in Relation to the Eye” . On November 16 the Director and the Faculty of the Peking Union Medical College gave a banquet at the Grand Hotel de Pekin in honor of Professor Fuchs. The faculty of the National Medical College and the officers*of the National Medical and Pharmaceutical Association of China acted as hosts on other social occasions. Professor Fuchs’ brief visit to Peking will certainly result in increasing the efforts to provide in China good medical teaching, especially in the field of ophthalmology where the amount of clinical^ material is so large and the need for men trained in eye diseases so great. The ophthalmologists in China owe him a debt of gratitude for the inspiring service he rendered to them during his brief visit to Peking. The importance of Professor Fuchs’ visit as an historical event will be proportionate to the determination and ability7 of the little group of ophthalmologists in China to maintain and to perpetuate the high ideals that have been set. 86 The China Médical Journal.

üßooft IReviews.

T h e D i a g n o s t i c s a n d T r e a t m e n t o f T r o p ic a l D is e a s e s , by E. R. Stitt, A.B., Ph., M.D., Sc.D., L L . D . Fourth Edition, Revised, with 159 illustrations. Price $4. Publishers : P. Blakiston’s Son & Co., Philadelphia. This very useful manual has now passed into the fourth edition, which ma}- be taken as convincing evidence that it has won an assured position, certainly among American practitioners. Several new chapters have been added, nameh% on epidemic jaundice, ratbite fever, tularaemia, trench fever, tropical diseases of the joints, muscles and bones. Tables of helminthic and arthropodan parasites are also added. Tularaemia in man is a disease affecting the rural population, especially those who work in the fields. It is characterised the: onset of pain and fever within forty-eight hours of receiving the infecting fly- bite. The pain occurs in the region of the lymph-glands draining the bitten area. There is marked prostration, fever of a septic type lasting three to six weeks, inflammation, swelling and usualfy suppuration of lymph-glands. Convalescence is slow and protracted. The disease is worthy of note owing to its resemblance in certain respects to bubonic plague, and the fact that it is the first specific insect-borne fever, since the pathology of plague was worked out, proved to be due to a bacterium, if Rickettsia infections are excluded. Stitt recommends the use of carbon tetrachloride as an anthelmintie in hookworm disease, but investigations since this revision of his book show that the doses he mentions, although on good authority, are much too large. The safe maximum dose seems to be 3 c.c. It is not advisable to prescribe even 5 c.c. with purgation, let alone without. (Docherty and Burgess, Brit. Med. Journal, November 11, 1922.) ■We consider the second part, on the diagnostics of tropical diseases, not the least valuable feature of the book, especially for newcomers. With a large work, such as that of Castellani and Chalmers, or of Byam and Archibald, kept up-to-date by the successive editions of Stitt, physicians in China will be well equipped for dealing with tropical diseases.

T h e A m e r ic a n I l l u s t r a t e d D i c t i o n a r y , by W . A . Newman Dorland, A.M., M.D., F.A.C.S.. Member of the Committee on Nomenclature and Classification of Diseases of the American Medical Association. Eleventh edition, revised and enlarged. Flexible leather 35s. net. With Thumb Index, "57s. 6d. It requires an editor of a medical journal properly to appreciate the merits of a medical dictionary. Of course it gives the correct meaning of words, but there are other important questions for the settlement of which we turn to a dictionary. Shall we transcribe the original Greek b y ankylostoma, ancylostoma, agclndostoma, or one of .five other different ways? Shall we write Fasciolopsis buskii or Fasciopsis buski? Then with the rapid growth of the various branches of medicine an enormous number of new words are being constantly introduced. Moreover, there are medical writers who without the slightest compunction coin words for their own use, and sometimes these fabrications seem so necessary and proper as almost to deceive the elect. A good dictionary kept well up- to-date is our only guide and safeguard. Book Reviews. 8 7

.AVe have only one little complaint to make. The word “case” is not defined, perhaps because of its seeming simplicity. Yet there is probably no other word which gives so much trouble to editors of medical journals. Generally speaking, in medicine a “case” means a person in a state of disease, and disease, as Florence Nightingale remarked, is not a separate entity like a cat or a dog. Yet the author of a well-known book on tropical medicine writes : '‘There were several cases...... but they were mostly in foreigners.” An interne writes, “the case was accustomed to drink wine daily.” A physician tells us, “after recovery, the case went to the hills to recuperate.” A pathologist gives the gruesome direction : “ In cases of Addison’s disease the suprarenal capsules should be removed united to the semilunar ganglia and solar plexus” (Quain’s Medical Dictionary^). Of course the pathologist is writing of necropsies, but is the word case properly applicable to a corpse ? Is it even correct to say, “A case of sudden death from poisoning” ? We think the dictionary might well insert the word “case” with a copious definition in the next edition. We do not find any other important omission. As a practical com­ mendation it may be stated that two or three months ago, we bought a copy for our owiti use, after comparing it with other dictionaries. It is comfortable to hold, and of handsome appearance.

PHYSIOLOGY AND BIOCHEMISTRY IN MODERN MEDICINE, By J. J< Macleod, M. B. Assisted by Roy I. Pearce, A. C. Mcdfield and N. B. Ta3’lor and b y others. Fourth edition. W ith 243 Illustrations, including 9 Plates in colours. Price, Gold $11.00. Publishers : C. Y. Mosbv Company, St. Louis, 1922.

There can be praise only for this book. It is necessary to the medical student who should early learn to- bring his knowledge o£ physiology into relation with clinical medicine; it is equally necessary to the practising physician who desires to base his treatment of disease on the most recent advances in physiological science. To> thoroughly master the contents is 110 light task. It is much easier for the busy physician to make a snapshot diagnosis and then by way of treatment to rely 011 “ specifics,” drugs that “ work like, a charm,” and “favorite prescriptions,” than to study patiently and deeply the functions of the human bod}’, separately and in relation with each other, so far as these has been revealed to us. Yet those who take the narrow and difficult way find the reward is very great. In its issue of November 4th, 1922, the Brit. Med. Journal, referring to recent work ol the author of this volume and of collaborators under his directions, states that a scientific advance of immense importance has been accomplished by them; they have placed beyond all doubt the existence of the pancreatic hormone, its origin from the Langerhans islets, the possibility of extracting and separating it in active and relatively stable condition even from the normal adult mammalian pancreas, and its efficacy in correcting the metabolic defect which causes diabetes mellitus. It is wlork of this kind which will eventually lead to the conquest of many functional and organic diseases, at least until the human machine breaks down completely. Again we cordially commend the volume.

T h e R o c k e f e l l e r F o u n d a t i o n , C h in a M e d ic a l B o a r d . Seventh Annual Report. January 1, xgai-December 31, 1921. 61 Broadwav, New York, N.Y., U.S.A. 1922. Business and institutional reporte are usually dry reading, but this report by Mr. Roger S. Greene of Peking, should be of peculiar interest as it describes the various activities and benevolences of the China Medical 88 The China Medical Journal.

Board of the Rockefeller Foundation, of which Mr. Greene is the Director. The first part deals with medical education and a description of the building’s of the Peking Union Medical College ; the second part with premedical education; the third and fourth describe generally the aid given to many medical men, hospitals, schools and other institutions, for the purpose of strengthening and raising the whole standard of medical work in China. No one who has not looked into the matter by reading this and previous reports can know how extensive this aid lias been, especially to missionary institutions and physicians. As an Association we have not been very effusive in our thanks, but there are fewi of us who do not gratefully appreciate all that has been done.

P h y s i c a l D i a g n o s i s , by W\ D. Rose, M. D. Third edition. Three hundred and nineteen illustrations. Gold $8.50. St. Louis. C. V. Mosby Company, 1922. It has been the purpose of the author to incorporate in this volume the principles of physical diagnosis, together with the physical findings in the commoner diseases of the respiratory and circulatory systems. In this connection anatomy and pathology have been considered from the clinical standpoint, emphasis being laid upon these subjects as they influence the plrysical manifestations of disease of the thorax and abdomen. The matter is well arranged and the style is clear. In this edition, the third, the section dealing with physical examination of the circulatory system has been entirely rewritten and additional material incorporated to cover recent advances in the subject. Similarly, the chapter dealing with blood pressure has been rewritten in its entirety. Polygraphy has been treated with greater detail; and a chapter dealing with electrocardiography and the diagnosis of the cardiac arrhythmias has been contrbuted by Dr. Drew Luten. As in these days, in all medical schools of good standing, students receive very thorough instruction in the principles of physical diagnosis, it seems to the reviewer that some of the illustrations are rather elementary and might well be omitted However, perhaps there are readers who think the more illustrations there are the better. The book can be commended as a, sound guide in the diagnosis of diseases of the circulatory and pulmonary systems.

I n f a n t il f C i r r h o s i s o f L i v e r , by Santosh Kumar Muherji M. B., M. R. A. S. With a foreward by Major General B. H. Deare, C. I. E., M. R. C. P., D. P. H., I. M. S., etc. Cloth cover : Price, Rupees* 2/8; paper cover, Rupees 2. 1922.

The subject of this interesting little monograph is an infantile disease the symptoms of which may be indicated by saying that it is likely to he confounded with malaria, kala-zar, cirrhosis, typhoid fever, amyloid liver, familial acholuric jaundice. The author believes it is due to excess < f starchy food. “Loving parents are always tempted to give to their babies- mcrseis of everything they eat, if the baby sits near by at the time 'i taking food. In vegetarian families, the parents in this \va3- give starchy food to their babies very early, which is the cause of the disease.” Strange, unpleasant remedies are still used in India. For instance, in this disease fresh cow’s urine is given by some physicians to the ailing children. “ It contains urea, which acts as a cholagogue and diuretic in cirrhosis of liver. It is used fresh, and if kept for some time it becomes, injurious.” Book Reviews. 89

The disease is said to be peculiar to India. We wonder if this is so, as in China the native mothers are just as ignorant and ioolish in feeding their children as mothers in India, though perhaps vegetarianism is not quite so common in this country.

A n O u t l in e o f t h e M e d ic a l S e k v i c e o p t h e T h e a t r e o f O p e r a t io n s , b y M . A . W. Shockley, Lieutenant Colonel Medical Carps, U. S. A r m y Price Gold $2.50. Philadelphia P. Blakiston’s Son & Co., 1012 Walnut vStreet, Philadelphia. Perhaps the title is not as clear as it might be, as in a medical or surgical work when “operations” are mentioned, it is almost certain that at first sight .we shall jump to the conclusion that surgical operations are referred to, not militan- operations. The book has been written from lectures and conferences at the General Service Schools of the U. S. Army, and deals with the general organization and functions of the medical department of the army in time of war. W e sincerely hope that warfare is passing away and that such books as these will soon be 110 longer written. In the meantime, it meets a particular need. It contains some very interesting statistics of battle casualties and sickness in the great wars of the world. N o r t h M a n c h u r ia n P l a g u e P r e v e n t i o n S e r v i c e R e p o r t s (1918-1922). Edited by Wu Lien-teh, M.A., M.D., B.D., (Cantab), Hon. Litt D. (Peking) : LL-D. (H’kong) : Sc.I). Tientsin Press, Limited. IQ22. This is a very interesting and instructive report. Of the efficiency i f the Plague Prevention Service there can be no doubt. In 1910-1911 the mortality 111 Manchuria from the epidemic of pneumonic plague was 50,000; in 1920-1921, during an epidemic of equal virulence, it was only 8,500. The best comment on this report, is the paper by Dr. J. W H. Chun, printed elsewhere in this number of the Journal. As Dr. Wu Lien- teh, the editor of the report observes, “ at a time when the world is pointing at China as a country of self-seeking politicians and grasping militarists, it is well to know that, in the domain of medical science at least, there m ay be found a score or more of men and women ready at great personal risk to obey the call of duty to save life at a moment’s notice and for a small enum eration. ’ '

A M a n u a l o f P r a c t ic a l A n a t o m y . A Guide to the Dissection of the Human Body. By Thomas Walmslev, Professor of Anatomy, Queen’s University of Belfast. In three"parts. Part III.— The Head and Neck. Price : 10/6 net. Longmans, Green, and Co., 39 Paternoster Row, Loudon, E.C.4. New York, Toronto, Bombay, Calcutta, and Madras. 1922. There are not a few very good manuals of Practical Anatomy which serve as guides to the dissection of the human body. This book, the third part of which is now issued, can hold its own with the best. The instructions are clear and systematic, and the illustra­ tions are very helpful and not so numerous as to distract attention from actual dissection. Perhaps the book in English is a little too difficult for the average Chinese medical student, but it may be well worth translation.

E s s e n t ia l s o f Z o o l o g y . For students of Medicine and first year students of Science.' By Alexander Meek, D.Sc. With 145 illustrations. Price : 10/6. Publishers : Longmans, Green and Co., London. A thorough, practical knowledge of zoology is necessary for the student who intends to study medicine. He should be taught to find go The China Medical Journal. out for himself the more important facts of comparative anatomy, physiology and embryology, gaining practice in methods of study and forming an acquaintance with the literature of the subject. This work is arranged as a guide in acauiring this essential fundamental knowledge. The types chosen are those used in the majority of the universities and schools, but allied forms may be readily procured everywhere, so that the book may be used in any country. It is well arranged and clearly written and deserves the attention of teachers of zoology in our pre- medical and other schools in China. It is to be noted that, beginning with the metazoa, the development cf the endocrine organs is now traced. In describing the protozoa and the first very rudimentary signs of a nervous system, the author does not hesitate to use the word “psychology.” He cites the vorticella which is able to develop a special band of cilia and to snap itself free from the peduncle when conditions become difficult or impossible.. “This is a postponed reflex, like the other, and is provoked in response to external stimulus; but it points also to volition, and its history to a gradual modification of the cytoplasm in association with protection.” “It is difficult for us to appreciate the meaning of all this. Experi­ ment has shown that such free cells are attracted or repelled by various stimuli. From the results of experiments they are described as being positively or negatively photo tactic, chemiotactic— that is, attracted cr repelled by light or chemical stimuli— and so on. The impression conveyed is that the cell is like a boat without men, directed and controlled by wireless waves. Many Protozoa alternate between periods of desiccation and a free and usually an aquatic life. In the latter state the Protozoon is subject to rhythms of growth, encystment and reproduction. Apart frotn the encystment and the desiccation, it is constantly working for a living, and under normal conditions it is found in so many diverse situations, with reference to depth, light, and other factors, that we are led to conclude that it is not merely the victim of circumstance but is volitional. It is attracted or rebelled b y heat, cold, and other influences. It moves, however, not only in response to external stimuli, but of its c.wn accord, and even if the feeling, be only a dim, incipient one, chemical and physical cliansres communicated by the cell sap, we might be inclined to say that Vorticella is aware when it is hungry, and when it is contracted or expanded, and that all are conscious of their periods of movement and rest.” The chains of pure, hard and fast materialism seem to be loosening. At the same time it would be well if some of those who, in the interest of religion, are opposed to certain branches of science, could be induced to work their way patiently and practically through a volume of this kind; it would lead to a better understanding of the questions at issue. C x in i c a i . T uberculosis , by Francis M. Pottenger M. D. Second Edition. Two Volumes. C. V. Mosby Co., St. Louis, 1922. These two volumes form an encyclopedic monograph presenting a record of observations made during twenty-five years of clinical stud5'. While some parts deal in too much detail with certain phases of the tuberculous problem to interest any but the specialist, yet the book as a whole is an intensely practical one for the general practitioner. In a disease where so much depends upon an early diagnosis anl where so many clinicians fail in recognizing the early signs and symptoms, the chapters which deal with the A arious phases of diagnosis will be found most helpful. The author places much stress upon the value of inspection and palpation as aids in determining intrathoracic pathology. Spasm and Book Reviews.

wasting of certain muscles or groups of muscles, atrophy of the subcutaneous tissues in certain areas, increased deep resistance from intrapulmonary infiltrations, can ali be determined by inspection and palpation. In the discussion of symptomatolog}' a very helpful classification is made. Although the symptoms of tuberculosis are varied and appear as expressions of distuibailee iti many different structures and organs, yet when analyzed they may all be classified according to their etiology in three groups as follows : Group I, Symptoms due to toxemia, the toxic material comprising bacillary products and proteins absorbed from the inflamed or caseous areas. Group II, Symtoms due to reflex causes, the result of peripheral stimulation of the pulmonary ends of both the sympathetic and vagus nerves The pathological process in the pulmonary tissues through stimulation of the sympathetics is manifested in reflex action in certain muscles of respiration and in the tissues of the neck and shoulders. The stimulation of the pulmonary branches of the vagus results in reflex functional disturbances in other organs. Group III, comprises symptoms due to the tuberculosis process per se. Volume II is concerned for the most part with the treatment of tuberculosis; it has an addendum in which there is a full discussion of twelve cases of various types of pulmonary tuberculosis, giving symptoms, diagnosis, -physical and laboratory findings, temperature charts, full outlines of treatment, progress and end results in each case. This is a unique and valuable feature. W ith reference to the use of tuberculin, Dr. Pottenger uses it and believes that, other things taken into consideration, it adds something like 20 per cent, to the patient’s chances of recovery. It cannot be used in any routine way and the best results come only after wide experience in its use. He says : “If one takes the same attitude toward tuberculin th.-t he does toward surgery or other therapeutic measure, he will be forced to agree that tuberculin is of value. All men do not obtain satisfactory results with tuberculin, neither do all men with any other therapeutic measure. If we base our conclusions upon the best results that can be produced, then we must admit that tuberculin is a valuable measure in tuberculosis theraphy.” A.C.S.

M a n a g e m e n t o f S ick I n f a n t s , by Langley Porter, B.S, M .D ., & M.R.C.S. (Lug.), L R.C.P. (Lond.) and William E. Carter, M.D. Price: Gold $7.50. Publishers : C. V. Mosby Company, St. Louis, U. S. A. 1922. The first part of this work deals exculsivelv with the symptoms of the diseases of children. The second with the peculiarities of the diseases which occur in infancy. The third and concluding part deals with methods required for the management of special cases. Books on the diseases of childhood are very numerous and many cf them are excellent. The work we are reviewing has special merits of its own, which should make it very helpful to the general practitioner in the treatment of sick children : it is also a reliable guide to the student of medicine, n . k . k .

T h e T s i n a n M e d i c a l R e v i e w . Vol. II. No. 4. October, 1922- Published by the Medical Department of the Shantung Christian University, Tsinaufu. Price Mex. $1.50 per annum. The body of this magazine is published wholly in the Chinese language and we cannot commend it more strongly than by saying it should be taken regularly by all Chinese practitioners. Its excellence ma3T be judged by the contents, which are as follows : Gynecological Post- 92 The China Medical Journal.

operative Hemmorhage; Biological Therapy (cont’d.); Post-operative Procedures at the Mayo's Hospital; The Chinese General Hospital in France; Wassennanu Test (Cont’d.): Anaphylaxis; Cardio-vascular rating; as an Index of Physical Fitness; Eclampsia, according to Practice in Dublin Maternity Hospital; The Urea-concentration Test in Determining the Renal Reserve; Abstract of Conference on Tetanus, Peking, Union Medical College : New Treatment, of Fractures; Tuberculosis Colony near Cambridge; Scientific Terminology Conference in Shanghai.

T h e L a n d o f H e a l t h , by Dr. C. E. A . Winslow, Prof. of Public Health. Yale University School of Medicine. Price $2.10. Publishers : Charles E. Merrill Company, 432 Fourth Avenue. New York City. The Land of Health is the elementary book of the Winslow Health Series. It is intended as a medium for teaching good health, habits to young children, and is preliminary to Winslow’s Healthy» Living. There are 208 pages with many illustrations. The plan of the book is to teach health by means of a story, which in itself has a fascination for children and adds an invaluable interest to the facts to be taught. The Land of Health is a real story that children will love, told in a simple and delightful style. Simple health facts which every child should know and the laws of health which each must practise are interwoven with the story. The fundamental facts of hygiene and sanitation founded on the latest scientific investigations are simply and effectively stated. The noted authority, Walter Camp, has prepared a chapter on plwsical exercise, which will appeal to the child’s interest and help keep him stronq-. Mr. Camp’s exercises will be found as much sport as any game. They are not in the same category with calisthenics. Simple and interesting study questions are provided in the text. They present to the boy or girl concrete health problems of evervdaj* life which may be solved by the practical application of the knowledge acquired from the text. W. W. P.

PEKING UNION MEDICAL COLLEGECOURSE IN DIETETICS. A short course in practical dietetics especially suitable for women witli nurses’ training is offered at the Peking Union Medical College under its dietitian, Miss E. Grace McCullough, former!}- of the Massachusetts General Hospital and the Peter Bent Brigham Hospital, Boston. Work in ^Chinese diets is offered. The duration of the course will be four months; in special cases, arrangements may be made for a longer period. The course is open to Americans, and to Chinese and Europeans having a good command of the English language. As the facilities are limited, applicants engaged in institutional work and those having a fair working knowledge of the Chinese language will be given the preference. J o h n C e c il C a r r , m .d . ch.B ., m . r .c .p .e ., o f th e Wilson

Memorial Hospital, C.I.M., Pingyang, Shansi. In Memoriam. 93

A limited number of scholarships has been made available by the China Medical Board of the Rockefeller Foundation, providing board, lodging, and travelling expenses. Persons interested may app]y to Mr. L . C. Goodrich, China Medical Board, Peking.

IN MEMORIAM.

JOHN CECIL CARR, M.B., Ch.B. Edin., M.R.C.P.E. Born at Carlisle, England, November 4th, 1S76. Died at Shanghai, China, May Stli, 1922. No one who was present at the great meetings of the National Christian Conference in May, 1922, will easily forget the sense of awe which descended upon the gathering when it learned that one of their delegates, Dr. John Carr, of Pingyangfu, was suffering from a dangerous attack of angina pectoris; and the message which came to the Conference from his dying bed two da3rs later, appealing for a spirit of unity and mutual confidence, left an impression which time can never efface. It was a message which came from the very gates of Heaven, as one who had laboured and pleaded and died for the Chinese whom he loved passed into the presence of his Lord ; and to those who knew John Carr, no passing could well have been fitter. Born of earnest Christian parents, and brought up in an atmosphere of evangelistic fervour and missionary enthusiasm, it was natural for John Carr early to turn his thoughts to the possibility of medical missionary service in China. His education at a Friends’ School and at Edinburgh University; his experience of Christian work at the Cowgate and in other centres : and an interesting visit to India, where he worked for some time with his old college friend, Dr. Rutter Williamson,— all alike prepared him for his lifework, and at the end of 1905 he started off for China, whither his elder brother Sidney and his younger sister had already preceded him. After a few months spent at the China Inland Mission Language School, Dr. Carr was appointed to the station of Pingyangfu, Shansi, there to take charge of the mission hospital erected in memory of one of the Boxer martyrs, Dr. Millar W'ilson. From that time, until the day of his death sixteen 3-ears later, the building up of the work of the hospital on an efficient and spiritual basis, and the nurture of Christian Chinese leadership, formed the daily burden of Dr. Carr’s thoughts and prayers, even during his enforced absences from the field on grounds of health. Alwa}Ts scrupulous 9 4 The China Medical Journal.

in matters of detail, he planned to make the hospital a model of neatness and order, whilst at the same time keeping its missionary purpose ever to the forefront, and in both these aims his success was complete. Under his wise and patient leadership the influence of the hospital extended in all directions. The success of his surgical work, and that of his colleagues, Dr. King and Dr. Hoyte, attracted patients from far and wide; whilst the strong spiritual influence of the institution, and the wonderful capacitj^ for friend­ ship and S3^mpatliy possessed by Dr. Carr and his wife, made visits to the Pingyangfu Hospital memorable events in the lives of many. It was not, however, in medical mission work alone that Dr. Carr made his great contribution to the Church of China. From earliest days he was deeply impressed with the clamant need for a wall-trained, responsible, Chinese Christian leadership, and with characteristic persistence and complete self-effacement he threw himself into every effort calculated to help forward the development of such leadership. He assisted students to obtain a full course of medical stud}1- at the Hankow Union Medical College and the Shantung Christian University School of Medicine, and did every­ thing in his power to establish these young doctors in their new position after their graduation. He helped to establish and organise a schooi; started a City Institute and Y.M .C.A., and arranged for the training of a Chinese secrctar}1-; assisted in the development of a nursing training school; and associated himself with every type of community service in which the Chinese took an interest. But it was perhaps in his relationship to the Chinese Church that his burning passion to see. Chinese leaders “ increase” was most manifest. Although for some time regarded by his mission as being in pastoral charge of the Church, he himself would never regard his position as being anything else than that of a friend and counsellor to the Chinese elders and deacons, whom he sought in every possible way to push forward. His influence in the Church, and particularly his deep love for reverence and order, will never be forgotten by the loyal band of men and women for whom he laboured so strenuoush’. A little group of them were with him in Shanghai, as delegates to the Conference, at the time of his Home-call, and those of us who were privileged to be present at the beautiful Service, when his body was committed to the grave, will alwaj^s remember the touching affection and emotion which they showed, as they helped to bear the casket containing the mortal remains of their beloved leader. The Christians at Pingyangfu, on their own initiative, are placing a brass tablet in the Church, commemorating Dr. Carr’s life of service, and stating that he “ lives again in the Church for which he laboured and suffered and died.” All who knew him and loved him are sure that this prophecy will be fulfilled. H.B. In Memoriam. 95

E dVIN N iLSSEN, M.A., M.D., A cablegram lias brought the sad news that the Reverend Doctor Jörgen Edvin Nilssen, M.A., M.D., General Secretary of the Norwegian Missionar Seciety, died suddenly on October 28th, 1922, presumably at his home in Stavanger, Norway. Dr. Nilssen was born in Storbakken, Sörreisen, Norway, June 17, 1871. He graduated from Cathedral College in Christiania 1890, and received his Medical degree 111 1900. He went through his Military Service in the Norwegian Navy as a Medical Officer. He took post graduate courses m London and Christiania, and practiced as a Physician in Norway until he left for China in the Spring of 1902. In China, he started medical work at Changsha in the Autumn of 1902. In 1904 he was transferred to Yiyang, Hunan, and from 1905-1906 he planned and looked after the building of Yiyang Hospital, of which he was the first Physician in Charge. During his furlough in Norway 1909-1911 he was asked by his fellow-aorkers in China and b}7 the Home-Board to be ordained. To this he consented and was ordained b}- the Bishop of Christiania in January 1911. From 1911-1912 he was in charge of N. M. S. Hospital and Station at Changsha. He was then transferred to Taoliwalun, Yiyang, where he was in charge of several branches of the work until in 1914 he became Superintendent of the Norwegian Missionar}- Society’s work in China. In August 1918 he left China for his second furlough, and in the spring of 1919 he was appointed general secretar}' of the Norwegian Mission­ ary Societjr. Dr. Nilssen w'as widely known in Scandinavia. As a medical student he was one of the leaders in the Christian Student Move­ ment. On his first and second furloughs he did much to arouse new interest in Foreign Mission work, and as General Secretary he was in close touch with the Christian movements not onhT in Norwa}- but also in the other Scandinavian countries. While here in China he was one of the leaders in the Union Movement among the Lutherans, and was greatly loved and respected by all who had the pleasure to meet him and work with him. In our own Mission, both among foreigners and Chinese, we feel the loss keenly. We have lost a good friend, a fine man, a warm Christian, a splendid Christian worker, a good administrator, a man who gave his all for the work, and a true friend of China. WTe mourn his loss, but we also thank God for the fine example he has given us.

J. A. O. GOTTEBERG. 9 6 The China Medical Journal.

£oiTespont>ence. Correspondents are requested to u'rite on one side of the fiflper only, and always to send their real names and addresses. The J o u r n a l does not hold itself responsible for the opinions or assertions of correspondents.

The International Anti-Opium cause we cannot gauge the average Assosiation, Peking: Appeal 3Tearl\- requirement. Some hospitals for Information. use 500 grains per 1,000 patients, and others onh- use 30 grains, and To the Editor, C.M.J. unless replies are received from a D e a r S i r May I through your large number of hospitals the columns appeal to the doctors of average will be incorrect. May I China to assist in a very important ask all readers of this journal to movement, the inauguration of send i-ie a post card stating amount which depends largely on their used yearly of opiumt morphia and early co-operation ? The Interna­ its salts, cocaine, and the total tional Anti-Opium Association, Pe­ annual number of patients (both king, is endeavouring on behalf of inpatients and outpatients). the League of Nations to find out W ith main- thanks for the the amount of narcotic drugs courtesy' of insertion. (opium, 11101 phia and its salts, and Yours sincerely, cocaine) required for strictly medi­ cal use in China. All nations W . H . G r a h a m A s p l a n d . signatoiy to the Hague Convention General Secretary. are committed to a system of im­ Peking, Nov. 27, 1922. portation of narcotics by certificate, which system it was intended by the Lewgue of Nations Opium Council Male Nuses and Hospital should come into operation on Assistants. January 1st, 1923. This is im­ To the Editor, “ C.M.J.” possible owing to so many countries not having estimated their medical D e a r S i r ,—All friends of the requirements. China is one of them. Nurses Association of China are During the past month., I have grateful for your good word in the •written to over seventy Hospitals November editorial re Scientific asking for the amount of n a r c o t ic ^ Nursing. You sa}" that the “work used yearly ar.d the number of of hospital nursing as a desirable patients treated, in order to estimate vocation must be constant^ pre­ the requirements per 1,000 patients. sented to the boys and girls in I regret to sny that bare!3’ one in Chinese Schools in order to secure ten has taken the trouble to repl\ . candidates; there is the long May I point out the importance of period of didactic and practical sincere co-operation ? This is a big training in hospital nursing with world movement by the League to its many disappointments; after restrict narcotic production to medi­ graduation it is necessaiy to main­ cal requirements, but how is this to tain the interest of nurses in their be estimated if hospitals will not work so that it shall not become state their use ? As soon as the drudges ; and to do whatever is Chinese Government has completed possible to increase their knowledge their regulations, morphia, etc., and efficienc3' and to promote their must be under Government control. social and spiritual welfare.” Individual importation will be In the most valuable “Hospital abandoned and the Government, I Supplement” to our Journal in hope, will become the importer; November, 1920, there was an but the whole scheme is hung up be­ article by Dr. George Hadden on Correspondence. 97 the “Hospital Assistant in China.” and distinctions in out hospital That article should not be for­ economy and society. To introduce gotten. The proposals it con­ a new one in the rather finely tains, if carried a little farther, differentiated classes from senior will mitigate the “disappoint­ student nurses, graduate nurses, ments,” maintain the interest and junior and senior internes, foreign transform the “ drudgery” of our nursing sisters and resident Chinese male nurses. The}7" w ill provide an pl^sicians or visiting chiefs, would incentive, and hold before their seem unnecessary. The hospital eyes the “mark of their high assistant in whichever department calling.” They will present to our is realh' the qualified male nurse male nurse graduates such a pro­ who is specialising upon his sound fession that there will be no need general training. for us to “ constantly place before the boys and girls in Chinese The girl nurses are in their Schools the work of hospital nurs­ natural element and in their nurs­ ing of the ward, operating theatre ing so as to secure candidates.” There will be no difficulty in ob­ or maternity block, they arei likely taining male assistants for our to find all the satisfaction which country hospitals. their Western sisters find in one of the most honourable of all pro­ This month we were privileged fessions. The boy nurses are dif­ at Kong Chuen ( ^), South ferent. They must have something China, with a visit from Miss Cora beyond; some sphere in which they Simpson, Executive Secretary of may find their permanent position the Nurses’ Association. I was and wherein they may find scope surprised to find, in conversation and outlet for their peculiar ability with her, that there was in certain and inclination. Those who are quarters, some uncertainty about not led into this sphere, will soon the probable future relationship hive off and in some other sphere between the hospital assistants of will practice as charlatans—the Hadden and the male nurses of epistles of us Western physicians the N. A. C. written to the people of China and There should be no uncertainty; from which they, if they meet us all the hospital assistants should not directly, will judge our art. start off with the N. A . C. diploma. Dr. Hadden’s proposals for hos­ On the general basis of training pital assistants are eminently provided in the curriculum of the sound. There is but little more association they should specialize needed in the machinery already es­ as ‘Subordinate medical aids,’ tablished for their training. Let ‘hospital administrators’ or as each district Branch of the N. A. C. ‘technicians’ for laboratory, operat­ and C. M. M. A. confer as to which ing theatre, records, X-rays, hydro­ hospital may receive N. A. C. therapeutics or massage. The N. A. graduates for their special post­ C. already provides additional graduate training. It may be that advanced diplomas and, I feel one hospital with better laboratory sure, that an arrangement as to equipment will undertake the train­ C.M.M.A, cooperation in special ing of the laboratory technicians; courses according to individual another, with better administration desire and need, and as to the or operative work, the training of granting of the special “Hospital assistants in these special lines. Assistant” diplomas, could readily But let us not deny to .the male be arrived at. graduate nurse his rightful sphere. Dr. Hadden would not, I take He will be a citizen of no mean it, desire to create a new species or city. We of the C.M.M.A., must caste. We have enough of grades see to it that his passport bears the 9 8 The China Medical Journal. initial inscription of the N. A. C. Journals Needed. before other visés or endorsements To the Editor, C.M.J. are later written upon it. D e a r S i r : — M ay I use the Faithfully yours, columns of the Journal to inquire if there are readers of the Journal E. W. K i r k . who know of back numbers, eiher bound or unbound, that may be Kong Chuen, via Canton, purchased? A friend of mine is November 27, 1922. anxious to procure a complete set from vol. I to date, or as much as is available and is willing to pay Acknowledgment of Gifts. whatever is reasonable. If any person is interested will To the Editor, C.M.J. he kindty communicate with me. D e a r S i r : — Through your Faithfully yours, columns I would like to E r n e s t C a r r o l l F a u s t . acknowledge the cordial and Union Medical College, Peking, generous response of the doc­ Dec. iSth, 1922. tors in China to the request sent out last spring by Dr. E. H. Substantial Appreciation of Hume for back numbers of the Public Health Work by “China Medical Journal,” which Chinese Official. were needed to complete our file. C h in e s e C o n s u l a t e G e n e r a l Thanks to the large number cf M a n il a , P. I. givers, our files are now complete from the beginning— 1887 to the October 23, 1922. To Dr. W. W. Peter, present. The following doctors sent copies Secretary, Council on Health from their own files;: Education. Dr. J. L. Maxwell, E- P. M. D e a r S i r :— I understand that Hospital, Formosa. you had taken a trip to Siam and Dr. E. V. Osgood, Tisdale that is the reason why I delayed Hospital, Chuchow. writing to you until now. Dr. Young, Baptist Mission, San I have received your “Health Yuan. H abits” posters for children and Dr. F. Marion Watson, Baptist some other literature. You may rest Mission, San Yuan. assured that I am thoroughly Dr. Volrath Vogt, Norwegian convinced of the good work done Hospital, Yi Yang. by the Council on Health Educa­ Dr. Edgar Robertson, Presby­ tion. terian Mission, Hengchow. I wish more of our rich Chinese Dr. E. D. Vanderburg, Siangtan. here would take more interest in Dr. J. W. Pell, Wesleyan such a movement and give their Mission, Hankow. financial support to it. Special mention should be made 1 enclose a cheque for $250 as of Dr. James L. Maxwell, who let my subscription. I have not us have from his library the first obtained a single cent from the seventeen volumes from 1887 to rich merchants yet. I advise you 1903, and to Dr. Pell for a number to communicate' direct with the of early copies. These files will be president of the Chinese Chamber available to anyone who m ay care of Commerce who m ay be Inclined to to use them. give something himself and to influence others in doing the Sincerely yours, same. With kindest personal regards. J o h n H. F o s t e r , m .d . Yours Truly, Changsha, Hunan, Oct. 15, 1922. (Signed) C h o w K w o H s i e n . Correspondence. 99

Medical Mission Exhibit, books, of native instruments and San Francisco, 1923. similar curiosities. The Exhibit attracted much interest and favor­ To the China Medical Missionary able comment. Twenty-eight medic d Association. missionaries were in attendance at Gentlemen The Committee of the Convention, and made the Ex­ Reference and Council of the Con­ hibit booth their head-quarters. So ference of North American Mission there was always someone 011 hand Boards has commissioned me to to talk with inquiring visitors. write to the leading medical associa­ This year we would like to pre­ tions, hospitals, and medical schools pare a more comprehensive exhibit. on the field with a view to collect­ The Medical Sub-Committee of the ing material for a Medical Missions Committee of Reference and Counsel Exhibit to be presented at the canvassed the matter and felt that next Annual Convention of the we should begin early and vigorous­ American Medical Association to ly to collect material. Wc are there­ l)o held next June in San Francisco. fore writing to some fifteen or Such an exhibit could also be used twenty of the better known institu­ for other medical gatherings. I am tions and associations in various accordingly writing 3Tou for what­ parts of the world to invite them lo ever material 3~ou can arrange to co-operate. What we would like is send us relating to }'Our China prepared posters, or data for posters Medical Missionary Association. if the posters cannot be prepared, The idea is to visualize for the literature, pictures, specimens, or profession at home the character and anything else that would fill in scope of medical missionary work the picture we1 are trying to pre­ around the world in as representa­ sent. tive a way as possible and with as Exhibit space at these conventions great a range as possible. It is a is limited; so we cannot tell in chance to present the needs, pro­ advance how much we can place, blems, achievements and spirit if but we wall try to make the Exhibit the work to the five or six thousand as representative as possible. Even physicians who will attend this if nothing else can be sent to us 1'f Convention as well as to many you could give us some general others at subsequent gatherings else­ figures 011 the work done by your where. Association we could probably work This idea of a Medical Missions this up into a single poster which Exhibit has already been carried out would be worth presenting. successfully at the 1922 Convention Will you please take this under of the A.M.A. at St. Louis last May. consideration and let me know This exhibit was set up on rather whether there is a possibility of short notice and with rather meager your being able to contribute in any material. We were given a cordial w;u' to this Exhibit ? Prepared reception by the officers of the material should be in our hands not A.M.A. and allotted a booth in Lhc later than May 1st. Unformulated Large hall where the scientific ex­ facts, or statistics which we may be hibits were housed. Our Exhibit able to work up into posters for consisted of specialty prepared you, we should have by March 1st. topical posters (giving statistics, striking facts, appealing needs, and E. M . D o d d , m .d . other phases of medical work over­ Acting Medical Secretary. seas) of colored slides of hospitals, patients, etc., of photo­ 156 Fifth Avenue, graphs, a. few calculi and other New York City, U. S. A., pathological specimens, of Chinese translations of modern medical October 26, 1922. IOO The China Medical Journal.

NEWS AND COMMENT

BlR TH S. department of obstetrics for Chinese women medical students. A u l l >.— A t Weihwei, Honan, on November 4th, 1922, to Dr. F. Dr. A. Young, who died on April M. and Mrs. Auld, a sou (Bertram Alexander). 29, 1922, was of Sianfu, Shensi, not Tsinan as stated in the Journal c[ C a d b u r y .— On December 6th, last September. Dr. R. C. Broom- 1922, at Canton, to Dr. and Mrs. hall kindly makes this correction. Wm. W. Cadbury, of the Canton Christian College, a daughter D e f o r m a t io n o f C h in e s e f e e t . — (Catharine J). I11 the case of women, the absurd W h e e l e r .— O n September 26th, 1922, practice of foot-binding, which, in at Caine, Wiltshire, England, to spite of modern ideas of reform, i:; Dr. & Mrs. E. R. Wheeler, of still shockingly prevalent among Tsinan, a daughter. the higher classes, renders all in­ vestigation of the sole impossible where it occurs; girls of college in­ S a l a r ie s o f C h i n e s e D o c t o r s in terests, however, have in the main M is s i o n H o s p i t a l s .— It seems cle-ir natural feet, and they can always that it will be necessary to pay find plenty of women of the ser­ Chinese doctors in mission hospitals vant class, as well as their own larger salaries than in the. past, yet emancipated associates, who have even with the more liberal com­ not been subjected to such artificial pensation there need be no fear that deformation. It is, however, true men will be induced to go into that among the Chinese of both mission medical work from purely sexes the native Chinese shoe, with mercenary motives. Already, some its pointed toe, and the ignoring wcll-oualified Chinese doctors en­ of the fact that feet are normally gaged in private practice have in­ rights and lefts, causes an un­ comes much larger than the salary j intentional deformation affecting the of any foreign medical missionary. toes, so that everywhere one meets Rockefeller Foundation Report, with u gly misshapings fully as bad 1922. as those found in our ultra-fashion­ able set, with their high heels Mr. N. Gist Gee, for twenty and pointed toes. Wilder, Am . J. years professor of biology at Soo- Physic. Anthrop., June, 1922. chow University, has been appointed adviser 011 pre-medical education lo B e a u t v o f J a p a n e s e f e e t .— In the China Medical Board of the Japan are found the most perfect "Rockefeller Foundation. H e will feet in the world. The clog (geta), make a study of tlie teaching of the well-nigh universal form of foot chemistry, plivsics and biology st gear, leaves the foot wholly uncou- colleges in China with special re­ fined, while it saves it from the ference to the institutions with constant knocks and bruises to which the China Medical Board is which habitually barefooted peoples co-operating. are subject. Aside from this the very essential of the clog is the con­ Dr. Florence T. Kraker, who was stant grasping of the thong between given a year’s leave of absence the first and second toes, preserving from the Pennsylvania Women’s unmodified the natural space be­ Medical College, Philadelphia, where tween these toes, and encouraging she is lecturer in Obstetrics, has , their semi-prehensile action. These arrived in Shanghai to establish a { influences, together with the popular News and Comment. 101

regard for feet as about the same students whom the Board lias aided. thing as hands, and the consequent Rockefeller Foundation Report, lack of all false modesty regarding 1922. them, render Japan a paradise for

the student of human feet. The C o m p l e t e S e t o f C h in a M e d ic a l result of this perfectly natural J o u r n a l W a n t e d .—The General treatment here, as contrasted with Library of the University >1' intentional and unintentional de­ Michigan, Ann Arbor, Mich., formation in China, sufficiently wishes to obta in b3r pm chase a accounts for the great difference in complete set of the Journal from sentiment concerning these im­ Vol. I, 1887 to the Volume for 1921. portant members in the two Address, A. M. Belser, Librarian countries. Wilder, Am . J. Physic. in Charge of Accessions. Anthrop., June, 1922.

A M i s s i o n a r y “ C a u l .” — It is .1 A i d t o M i s s i o n H o s p it a l s . remarkable and ancient suspersti- —The experience of the past tiou, general throughout Europe, few 3'ears seems to indicate that it is luck3' to be bom with or that the most effective way to possess a caul. A writer in to aid the mission hospitals is Notes and Oueric;. of October to improve and extend the facilities 12th, 18S9, quotes from the Leeds in China for the training of doctors, Mercury an instructive account of nurses, and technical workers of what may well be the birth of a various kinds who cannot now be legend about a caul. At the time found in adequate numbers, in of the birth of a certain child the China or abroad, even when the precious membrane was laid aside funds for their support are avail­ by the nurse for safe-keeping upon able. It is therefore likely that in a Bibki where it remained un­ aiding individual hospitals in noticed until it was dry. It was future, chief consideration will be then found to have the words given to those strategically located “ British and Foreign Bible Society” institutions which can be made to impressed upon it. There was play an important part in the tremendous excitement among the educational program by providing gossips, and despite the obvious for the post-graduate training of but prosaic explanation given by doctors and by maintaining schools the doctor in attendance, the neigh­ foi nurses. Rockefeller Foundation bours persisted in regarding this Report, 1922. asi a miraculous occurrence and declared that the child was born to be a missionary.— Brit. Med. C h in e s e M e d ic a l G r a d u a t e s fonrn., Sept., 23, 1922. j u s t i f y i n g h e l p g i v e n .— The results of the fellowships granted to Chi­ nese doctors, nurses, pharmacists, C o s t o f M e d ic a l E d u c a t io n i n and medical students for study in E n g l a n d .— It is estimated that in the United States have been England the cost of a student’s particularly gratifying, in view of medical education— first and last— the general feeling' in China that is at least ^1,500. students sent abroad for study have not on their return justified the P r e v e n t i v e M e d i c i n e i n M e d ic a l hopes that have been placed in E l>u c a t io n . Among the resolutions them and have failed to find satis­ and recommendations of the General factory employment. If the Medical Council of Great Britain criticism is .just in the case of men which apply as from the beginning in other branches of learning— which of 1923, is the following : “ That is not 37et clear— it is certainly throughout the whole period of not so in the case of most of the stud3' the attention of the student 1 0 2 The China Medical Journal.

should be directed by his teacher League of Nations to the Far East to the importance of the preventive to make an investigation into in­ aspects of medicine.” The British fectious and contagious diseases, and Medical Journal characterises the to accompany him while he is change which this resolution will in China. involve as an epoch-making advance in medical education. Its reflex and T h e W i s d o m o f t h e E a s t .— An reward will surely be found as time Arab proverb runs as follows : — passes in the diminution of sickness and prolongation of life, in the “ The world is supported by four raising of the present standards of columns : physical health and national welfare. The just of the great, The prayer of the righteous,

G r a d u a t e M e d ic a l C o u r s e s f o r The bravery of the valiant, P h y s i c i a n s in C h i n a .— Foreign and physicians also will be welcomed as The science of the physician.” graduate students at the Peking Union Medical College, Peking, and A G r e a t M e d ic a l M i s s i o n a r y . - it is hoped that they will make In a very interesting paper on still­ constantly larger use of the facili­ births and neo-natal deaths by Dr. ties there; but, since they have W\ J. Ballantyne (Brit. Med. more leisure for study during their Journ., vSep. 30, 1922) we come un­ periodical furloughs in Europe and expectedly upon the following America, it is probable that pro­ eloquent tribute to the work of a vision w ill continue to be made for great medical missionary : “If a limited number of fellowships and David Livingstone had dis­ other grants in aid of their study appeared into Central Africa abroad. Rockefeller Foundation Re­ taking his life in his hands port, 1922. merely to bring back news of peoples, animals, mountains, rivers, At the sixth National Congress of strange, novel, or curious, his the Japan Medical Association held journey would indeed have been a a few months ago in Kyoto, Japan, wonderful achievement and well there was an attendance of 3,000 worthy of record in the annals of delegates and the programme con­ mankind. But it was to carry Hfe sisted of more than sixteen hundred that he put himself in jeopardy; it papers. was to take remedies and cure of disease to the millions who had P r o f it a b l e P i l l s .—In Shanghai them not; it was to proclaim liberty recently the police found ; 5 to captives and death to slavery, and men engaged in the manufacture of to open to the inward sight visions pills, a quantity of which were laid of a life with a marvellous content, out on stoves to dry. One of the with great and generous spaces, a n l men concerned said that white pills with undreamed of possibilities ; and were sold at $2 per thousand and so he has passed into the front rank pink pills at $3, and that a profit of the world’s benefactors, and being of $3,000 a month had been made. dead he yet speaketh.” Apparently, a mixture consisting of strychnine, heroine, cinchona, and R a n s o m o f D o c t o r ' s M o t h e r , sugar was used. M e x . $50.00.— A few days ago, our Chinese doctor, a recent graduate of League of Nations and Infec­ the Chengtu Union Medical College, tious Diseases of A s i a .— According received a letter telling him that his to the Chinese press the Ministry of old neighbourhood had again been Interior has instructed Dr. IVu visited by robbers, that many Lien-teh to welcome to China the people, young and old, had been special commissioner sent by the carried off, and among them his News and Comment.

aged mother. It was reported that you must hurry away from break­ the robbers had heard there was a fast to see him and take 3>our luncii son getting a large salary in a with you. But he lost few eases, foreign hospital, and imagined they and the proportion of “ cures” from could easily get $1,000 from him to his very extensive and minutely ransom his mother. A later letter accurate operation was taken as the from the father warned the son not standard of the best that surgery to return home, lest he too be taken. could do. Brit. Med. Jovrn. The ransom prices came down from $1,000 to $200, and a daj- or two j E v i l s o p M o d e r n I ndustrialism ago news came that probably not i i n C h i n a .— Mr. Sherwood Eddv re­ more than $5o‘.oo would have to be ports that since coming to China he paid. N. C. Daily News, Nov. 1922. has visited mail}’’ factories and mentions instances of a working da5T I n S zech uivN D o c t o r 's R a n s o m of 15 hours, and a seven days’ week, Mex. $75.00.— A few wieeks ago one and this for children and under con­ of the Chinese preachers came to the ditions which would not be tolerated writer in great distress :— “ W ord in the West. From one match has come that m y father has been factory visited, as many as 70 em­ taken off by the robbers. He had ployees were being sent to hospital gone to the home of a wealth}’ man daily suffering from “ phossy jaw ” to attend one who was sick. During and other injuries. the night a band of robbers operat­ ing in the district also made a visit D is p o s a l o f t h e d e a d in G y a n t s e , to the said home, carrying off m y T ibet :— Every part of the dead father as well as some of the in­ body is beaten with hatchets into mates of the house for ransom. Can pulp 011 a rock, and then thrown to you do anything to help us secure the vultures. The birds consume his release?” A couple of weeks every particle of the flesh and the later the doctor was released on the crushed bone. The dead are naught payment of $75.00, the patient in to the survivors, since the spirit has whose home he had been taken beat­ left the body and become reborn 111 ing half the expense. N. C. Dai'.y another being, following its. Wheel News, Nov., 1922. of Life and its eternal weary path to far off Karma. The relatives of the H a l s t e d , o f J o h n s H o p k i n s , as dead man consume chung after­ a n O p e r a t o r .— It was he who first wards, until they become drunk. used rubber gloves and who then set N. C. Daily News, Sep., 1922. the fashion for all the world. As an operator he was exceedingly patient B u r ia l r e f o r m i n C h i n a .— To re­ and careful. H is method of dis­ move the superstitious, insanitary section, of frequent light, swift, and expensive methods of under­ sparing movements with the taking, funeral, and burial 'n sharpest of knives, instead of the Canton, says the “ Canton Times,” a free, heavy-handed deep cutting, af company is in course of formation 110 haemorrhage or the minimum of to introduce the modern science of haemorrhage instead of the sever­ embalming, simplicity in ceremony, ance of many vessels, each bleeding and cheaper cost in disposing cf freely until clipped, has become a the dead. part of the ritual of the great surgical artists of the day. H is N e w H o s p it a l i n t h e F a r E a s t . method required time, but it was — The contract has been awarded for results and not the time taken to St. Lu ke’s Hospital, to be erected win them that he counted. It was in Tokyo at a cost of $400,000. said in jest that if you wanted to The Department of Missions watch Halsted perform a radical of the Protestant Episcopal operation for cancer of the breast, Church, U .S.A ., has made the The China Medical journal.

erection of this institution difficulty of obtaining materials. possible, to take the place of the Pledges to the work by the City temporary buildings erected during Temple amounted to $16,650. Tlio the last twenty years. It is proposed station ministers to 750,000 people, to double the present capacity. and Dr. Bercovitz is the only It is expected that the new build­ physician in that district, it is ing's will be erected within the next stated. The organization which has two years and that when completed been foimed to promote the work the new hospital will be the largest of the hospital will be known as the and best equipped hospital under Parish Abroad Association. foreign patronage in the Orient.

T h e O p iu m T r a d e .— In Shanghai, O n e M il l i o n D o l l a r s f o r recently, a Chinese shopkeeper who L e p e r s i n P h i l i p p i n e I s l a n d s .— The sold opium was charged with Supreme Lodge, Knights of Pythia.;, attempting to bribe a foreign officer has donated $1,000,000 for the lepers in the execution of his duty. The on Culion Islands, it is announced British magistrate, in fining the from Manila. This money is to be accused $1,000 for b r ib e r and used for the following purposes : $500 for selling opium, said that 1. Permanent living quarters to lie medicine shops had 110 right to sell known as “Stevens Memorial Hall” medical pills containing more than for all white lepers at the colony. ten per cent, of opium. 2. Erection of an experimental laboratory with full equipment to carry on experiments in search of an absolute cure. 3. Establishment C h a s i n g A w a v D is e a s e a n d III- of an endowment fund amounting ; l u c k .— In Gyantse, Tibet, at the to approximately $900,000, to pro­ New Year is enacted at the Temple vide money for carrying 011 the | the annual ceremony of purifying experimental Work and to further I the city of the evils of the outgoing the benefit work at the colony year. The Lamas produce a beggar among all lepers. These plans man who is willing, through fana­ were included in the resolutions sub­ ticism and promise of eternal merit, mitted to the grand lodge which to risk his life in the strangest cf held its sessions in San Francisco in ceremonies. Naked, he clothes him­ August. The amount represents an self in the putrid entrails of animais assessment of $1 on every member which he coils round his head, neck, of the Lodge, which has a member, arms, and body. He represents the ship of nearly 1,000,coo men. j evil, the disease, the ill-luck, and the bad things of last year. He runs out of the Temple door, and the mad populace beat drums and T e x a s t o F in a n c e M e d ic a l blow trumpets, hurl stones at S t a t io n i n C h i n a .— Following the him and beat him with sticks to visit of Dr. Nathaniel Bercovit/., frighten away the devil in him. head of the medical station at They chase him through the streets Kachek on the island of Hainan, out into the open country, if he China, the City Temple, Dallas, has does not get killed before. After assumed the financial responsibility' they have disposed thus of the of that station. The station will troubles of last year the people seek have a staff of ten missionaries omens for good fortune in the carrying on work through the coming year. schools, the churches and the hospitals. The hospital which it is planned to erect there will cost M o d e r n w a r f a r e a m o n g C h i n e s e . $60,000 and will take about six — In the recent fighting between years to complete, owing to the the armies of General Chang Tso- News and Comment.

]in and of General Wu Pei-fu, the city and persuaded the merchants total number of casualties has been to put up signs on their doorwaj^ variously estimated. Probably which stated : “ This house approves 10,000 is the figure nearest lo of the abolition of prostitution.” actuality. The wounds were pro­ Can you imagine a. group of duced chiefly by rifle and machine- American students going through gun bullets. Consequently, there one of our American towns 011 the wtere many clean cut, through and same errand ? Yet the Chinese in through wounds which needed little their naive way will do these things or no surgery. The bullets were in great simplicity and earnestness. frequently of low velocity because Missionary Journal. of the poor quality of the atnmuni- tion and were frequently lodged in the soft parts. In these cases, surgery was greatly handicapped in N e c e s s i t y o f n a t i v e M e d ic a l I nstitutions .— It is obvious that those hospitals which had no foreigners can play only a very roentgen-ray facilities. Great num­ limited part so far as giving actual bers of wounded were cared for by medical service is concerned; while the mission hospitals at. Paotingfu, foreign-trained Chinese doctors and General W u’s head-quarters in nurses, though they can be very Southern Chihli, and at K ’aifengfu useful in the initial stages, will in Honan. When the drives were always be few in number and at at their height, and the wounded some disadvantage because the were pouring- into these centers, the schools they have attended have not Peking Union Medical College sent sought to equip them for meeting operating and roentgen-ray units \o the special conditions, whether of aid the local hospitals. Operating climate or of social and economic units also went from the Union organization, which prevail in Medical College at Tsinanfu in China. Therefore the establishment Shantung and from other medical of an institution, the Peking Union centers. The roentgen-ray demon­ Medical C o lle g e , to provide the strated its value so strikingly at requisite training on local soil was those times that General W u offered logically the first step in the pro­ to purchase a complete roentgen- gram of the China Medical Board. ray outfit for the mission hospital Rockefeller Fotmdation Report, in Paotingfu, and the Christian 1922. General Feng followed his example in K ’aifengfu, in gratitude for the service which these hospitals render­ ed. Journ. Amer. Med. Assoc. Oct., T uberculosis i n H o n g k o n g .— In 28, 1922. Hongkong the housing of the poorer Chinese is very bad indeed, the area being limited, and the Chinese population being large and constant­ P u b l ic A g i t a t i o n a g a in s t ly increasing, building sites have l ic e n s e d P rostitution i n C h i n a .— become expensive, so the streets Recently the Chinese churches in inhabited are narrow, and the houses Canton united their strength in a high, the height sometimes being public movement to abolish licensed five rimes the width of the street. prostitution. A great parade was A Chinese family usually occupies held of students, merchants, guilds, a single storey of a house, with the and so on— some 5,000 persons— result that there are many families carrying banners, signs, floats, etc., living one 011 top of the other. The showing the effects on society, houses themselves are poorly built, family, and country of the evil. On the windows being darkened by the day preceding the parade, gratings and shutters. The result is Christian students went through the that 110 sunlight ever reaches the io 6 The China Medical Journal.

rooms, and very little fresh air can Ube Cbina fll>e£>ical journal be obtained. This tends to cause Published by low resistance to disease. In Hong­ kong tuberculosis is a frequent tEbe Cbina Yftjfcical /BMssioitar$ associatio n . cause of death, and it is put down Editor .... Edward M. Merrins, M.D. to the poor conditions of living. The Business Manager . . . R. C. Beebe, M .D. reasons for this conclusion are as Departmental Editors: Dr. Earle, Hongkong, follows: the hereditary trans­ ------; Dr. Elliott, Chengtu, Clinical mission of the bacillus is so rare Su rgery; D r. Faust, Peking-, Parasitology; Dr. Howard, Peking, Ophthalmology; D r. that for practical purposes it may Neville, Moukden, Ear, Nose and Throat ; be declared n egligib le; on the other Dr. Mauwell, Peking, Obstetrics and Gyn­ hand, the incidence of tuberculosis ecology; D r. Wm. M cClure, Tsinan, Internal Medicine. depends on two main factors, the degree of exposure to infection and MANUSCRIPTS. —It is desired that the resistance which the inoculated manuscripts should be typewritten, with wide margins, and double spaced, on one subject is able to put forward, this side of paper 8J by if inches in size. in turn being dependent largely on Number the leaves consecutively, begin­ his environment. Annals Trop. ning with the title page. Put name and Med. and Parasitology. address on the manuscript. When roman, ised Chinese terms or phrases are used the Chinese characters should also be given. To ensure appearance in a parti­ cular number of the J o u r n a l , MS. should H o s p it a l A c c o u n t i n g .— A c c o u n t reach the editor at least six weeks before books based on the system of date of publication. Medical contributions hospital accounting devised ty are solicited from all physicians and sur­ Dr. Houghton and approved by geons in the Far East. the Council on Hospital Adminis­ IL L U ST R A T IO N S.—Illustrations tration, are now on sale at cost should be clear. Of photographs send a price by the Mission Book Com­ good print rather than a negative. Write pany of Shanghai., Full parti­ title or short explanation on back of each picture or table. See that text references culars concerning these books may and “ figures ” correspond. be found in th e China Med. Journal, 1922, p. 188. BIBLIOGRAPHIC REFERENCES.— References to authors in the text should be made in the following way:—“ Ac­ cording to Smith1 (1900) the spleen is enlarged, but Robinson2 (1914) says the reverse ” Authors quoted should be Z b c Quarterly journal for Chinese numbered in the order of citation and the IRurôeô. In English and Easv Wenli. bibliographic reference should be given Published by the Nurses’ Ass ciation of the same number. Arrange references in C h in a. a list at the end of the article in the order of the numbers. Object : To aid the cause of scientific nursing in China by bringing before stud­ REPRIN TS —Contributors of original ents in Chinese schools the value of articles are supplied with sixteen reprints, nursing as a vocation, and by sustaining free of charge. Additional reprints may the interest and efficiency of nurses in be obtained on written request which their duties after graduation. The co­ should be attached to the MS. sent in. operation of medical missionaries in this The price of additional reprints is as work is desired. Annual subscription to fo llo w s :— $ c. Journal $1.00. 50 copies of our p a g e s ...... 1 00 100 „ „ ..... 1.50 Editor : Miss Margaret Dieter, R.N., 200 ,, 2.00 Luchowfu, via Wuhu, Anhwei. 50 copies beyond four up to eight pages 2.00 100 ,1 » ,, 2.50 Subscriptions and other business com­ 200 II •> n 3 00 munications should be sent to Miss Cora Postage extra according to weight. E Simpson, R.N., General Secretary, If a printed cover is desired the extra cost Nurses’ Association of China, 10 Quinsan will be, for 50 copies, $ 1.25 ; 100 copies, §1.75; Gardens, Shanghai. 200 copies, §2 50.