THE

China Medical Journal

P u b l i s h e d b y

The China Medical Association

VOLUME XXXIX

1925

SHANGHAI :

P r i n t e d b y t h e P resbyterian M i s s io n P r e s s

1 9 2 5

TISTDICES

TO ‘She diritta: Jftebical Journal

Volume XXXIX, 1925.

G e n e r a l I n d e x . Page. Abscess o f the l i v e r ...... 76 Acetonaemia simulating appendicitis . . 73 Acidosis, post-operative 753

Acidosis, post-operative treatment with insulin and glucose. L a w n e y , V a x and M cD aniel. 924 Adenoid operations, aspirating apparatus for, CURRAX. 49

Albumen in urine, centrifugal method for determination of S. Y. W o x g . 348 Alcohol and salvarsan treatment 466 Aldehyde test, value o f in the diagnosis of kala azar 1168 Alkaloids, cinchona, other than quinine 369 America, tropical health problems of, (review) .. 565 American Mission Hospital, Petchaburi, Siam, report of 1161

Amoebiasis: K e s s e l . 99,115 laboratory diagnosis of 383 yatren treatment in 383 Amoy, Fukien, Chinchew General Hospital 346 Anatomy, manual of, Buchanan’s, B arclay-S m ith (review) 848 Anemia, pernicious, and sprue 74, 652 Anesthesia: administration by nurses, 279 local, dangers of, .. 838 local in ophthalmic work 559 local, Posner, (review) .. 278 local, textbook of, H e r t z l e r (r e v ie w ) 849 Angina pectoris, treatment of, during an attack 367 Anthelmintic properties of ascaridole 276 Anthrax in Kansuh K in g . 21 Anthropological significance of blood groups 72 Anthropometric data on the Chinese .. Stevenson. 855 Antiseptic dyes in surgery ...... 754 Appendicitis, acute, etiology of, 958 and intestinal parasites 170 helpful sign in the diagnosis of .. 271 simulated by acetonaemia .. 73 Appendix, pulse a guide to diagnosis 1171 Arneth index in clinical diagnosis 275 Arsenical preparation: death from injection of 568 stomatitis sodium thiosulphate, in H all. 785 treatment o f puerperal in fection ...... 1061 ^Arsenic, preparation o f 562 Arterio-venous aneurism ...... 476 ii INDICES. i.,V Arthritis syphilitic ...... •• •• •• 271 Arthropods o f medical and veterinary importance in China, an appeal for,

P a x t o n . 970 Ascaridae, nematode parasitic ...... ’j .. .. . 171 Ascaridole. anthelmintic properties of ...... • • .. .. 276 Asphyxia, resuscitation in ...... • ■ • • .. 561 Aspirating apparatus for tonsillar operations ...... C u r r a n . 49 Atriplicism : cases of , ...... M a r t i n . 808 in Peking ...... ■ . .. 809 Auricular fibrillation ...... B u r n . 128 Autopsies, finding o f miliary tubercles in choroid ...... L e e . 501 review of one hundred in Shanghai Chinese .. .. Oppenheim. 1011,1067

Backache chronic in gynecology ...... 272 Bacteriology, general systematic. B u c h a n a n (review) ...... 472 Bacteriological methods, manual of ...... - 377 Bamboo hairs, poisoning by, ...... 83 Bangkok, treatment of leprosy in .. .. O ’B r ie n and Runchaivon. 600 Bengal, leprosy in ...... 663 Beriberi ...... 75 lack of exercise as predisposing cause ...... 69 Birth control and sexual health ...... R o u t . 378 Birth rate: Chinese ...... H e a t h . 702 in Great Britain ...... 853 Births ...... 182, 283, 380, 852, 971,1064 Blackwater fever ...... 74 Blood coagulometer, simple ...... P e t e r s o n . 1026 films, a useful stain for ...... 1057 groups, anthropological significance of ...... 72 intraperitoneal transfusion of, ...... 275 phosphorus in cancer ...... 172 pressure and pulmonary hemorrhages ...... 846 pressure, high, cause of persistent ...... 68 Boils, insulin treatment of, ...... 842 Bolshevistic, Chinese Medical School ...... 973 Bones and Joints, radiographs of ...... 376

B o o k R e v ie w s : Ashby and Atherton. The Coming of Baby...... 968 Ballantvne, A Pocket Book of OpKthalmology ...... 79 Barclay-Smith, Buchanan's Manual of Anatomy including Embryology. 848 Beattie, Text Book of Pathology ...... 849 Berkeley. A Handbook for Midwifery ...... 2801 Bertwistle. Descriptive Atlas of Radiographs of the Bones and Joints. 376 Bilroth, Medical Sciences in the German University ...... 278 Buchanan, General Systematic Bacteriology ...... 472 Cameron, A Glasgow Manual of Obstetrics ...... 177 Manual of Gynecology ...... 471 Cammidge. Insulin Treatment of Diabetes Mellitus ...... 79 Chesser, Health and Psychology o f the Child ...... 968 Collins. Pathology and Bacteriology of the Eye ...... 660 Copher, Methods in Surgery ...... 1169 .Cousland, English-Chinese Medical Lexicon ...... 37% INDICES. Ill

Cowdry and Nicholson. Experimental Herpetic Infection of Rabbi s . . 37S General Cytology ...... // Cumberbatch, Treatment of Gonococcal Infection by Diathermy . .. 967 Cu^hny, Action and Uses in Medicine o f Digitalis 565 Cushing, Life of Sir William Osier 756 D’Herelle, Immunity in Natural Infectious Diseases .. 178 Disease Prevention by Committee on Social and Moral Welfare .. .. 281 Findlay, Physical Chemistry for Students .. 177 Flexner, Medical Education 472 Ghosh. Hygiene and Public Health .. 80 Materia Medica and Therapeutics .. 471 Pharmacology and Materia Medica 79. 473 Gordon. Haematology in General Practice .. 967 Gurd. Infection, Immunity, and Inflammation 566 Head, Concealed Tuberculosis .. 179 Hertzler, Technique of Local Anaesthesia 849 Hill. Health and Environment .. 850 Hirsch, Compend of Genito-Urinarv Diseases and Syphilis .. 376 Horsely, Operative Surgery . 689 Illinois Biological Monographs .. 179 Inge, Personal Religion and the Life o f Devotion 80 International Problems o f Health and Tropical America .. .. 565 Jamieson. Aids to Dentistry 850 Journal of Medical Missions in India 289 Journal of the North China Branch of the Royal Asiatic Society .. 1170 Kahn. Serum Diagnosis of Syphilis by Precipitation 660 Leslie and Alexander. Pneumonia . . 277 Lister, Lord, Biograph by Sir Rickman John Godlee . . 278 Mackie. Practical Bacteriology .. 375 Manson, Tropical Diseases 756 Manual of Bacteriological Methods .. 377 Matthes, Differential Diagnosis of Internal Medicine .. 849 Methods and Problems of Medical Education 566 Mosquito Control, use of Fish .. 473 Muirhead, Materia Medica for Nurses .. 80 Nall. Aids tc Obstetrics .. 850 Parkinson. Eye. Ear, Nose and Throat Manual for Nurses .. 1063 Pearce, Fundamentals of Human Physiology 79 Philippine Journal of Science ...... 179 Posner, Local Anesthesia Simplified .. 278 Quarterly Journal for Chinese Nurses .. 180 Rogers and Muir. Leprosy 658 Rose, Physical Diagnosis .. 178 Rout. 'Sexual Health and Birth Control 378 Spaeth, Newer Methods of Ophthalmic Plastic Surgery .. .. 966 Stark. An Index to General Practice 967 Strecker and Ebaugh. Practical Clinical Psychiatry for Students and 'Practitioners .. 966 Taylor, Surgery of the Spine and Extremities 758 The Caduceus .. 179 Thorek, The Human Testis .. 78 Transaction of . Far Eastern Association of Tropical Medicine .. 76 IV INDICES.

Tsinan Medical Review ...... j. ' .. ..280 Venereal Diseases: Report by AmericanSocial Hygiene Association. 279 Watkins-Pitchford. Diagnosis of Silicosis .. .. «. : .. -. 378 Publications of the South African Institute for Medical Research. 378 African Institute for Medical Research ...... 378 Webster. Anesthesia for Nurses ...... 279 Wells, A Compend of Gynecology ...... 758 Wong. Handbook of Pathology ...... 1062 Breast, male, carcinoma of ...... L udlow. 1076 Britain. Great, birth rate in 853 British Empire Cancer Cam paign ...... 432 British Pharmacopoeia in Chinese .. .. ■ ...... 381

E konchial A ffections: bronchial spirochetosis ...... 847 bronchial spirochetosis, discussion on .. C adbury, H arvey and Jeu. 412 bronchial spirochetosis in Canton .. .. Cadbury, Jeu, H arvey. 408 bronchitis, ulcerative, caused by Vincents organisms .. . .. 847 bronchitis, peanut, in China .. D u n lap. 903 Eronchoscopy and e s o p h a g o s c o p y ...... Jui H ua L iu . 414 Bubonic plague, diagnosis of, by glandular puncture in Shanghai .. .. 954

Caesarean delivery ...... E. D. S m it h . 788

section unusual indication for .. .. J a m e s . 4 9 8 Calcium in treatment ox tuberculosis ...... 71

C a n c e r : blood, phosphorus in ...... 172 campaign in British Empire ...... 432 etiology of ...... 433 mouth, alcoholic injections to relieve pain ...... 838 prevalence of in China ...... 432 produced by tar ...... 475 surgical treatment of ...... 556

C anton : Bronchial spirochetosis i n ...... C adbury, Jeu, and H arvey. 408 Christian College ...... 765 health of missionaries in ...... C adbury. 723 Hospital: gynecological n o t e s ...... C h a u and W right. 684 plague in ...... • • •• •• • • • • 665 Carcinoma of the male breast ...... L udlow. 1076 Cardiac failure, etiology of .. .. 71 Carnivorous diet and protozoal infestation ...... 67 Carr, J. € ., M e m o r ia l...... 765 Cataract extraction o f ...... • • • ■ • • • • H arston. 199 Central Epidemic Prevention Bureau .. .. • • • • • • 759 Central nervous system, unidentified disease of, in Japan ...... 1 Chaulmoogra oil: Bibliography ...... • • • • R ead. 623 Chinese, experiments on ...... • • • • - • • • • ■ 350 ethyl esters o f ...... R ead and F eng. 605 leucocytosis induced by ...... • • • - - • R ead. 605 oral administration of in leprosy ...... R ead. 619 INDICES. V

Chefoo, Temple Hill Hospital, report of .. 815 Chemistry, physical for students o f medicine, (review ) 177 Chengtu, West China Union University ...... 343,450 Chiengmai, Siam, A .P.M . Hospital, report o f 814 Childbearing and mental diseases 371 Child, health and psychology of, C h e s s e r (review ) 968 Childhood, appendicitis simulated by acetonaemia .. 73 Child labour in China ...... 527 Child marriage in India 285

Children :

decapsulation for nephritis in children C h e a l . 42 healthy, tubercle bacilli in the lymphatic glands of 462 incontinence in urine • • . • 173 rectal prolapse in, ...... 750

C h i n a : A century of medical missions in J a m e s L . M a x w e l l . 636 child labour in 527 deaf children in 83 health and industrial conditions in 1089 health in modern industries 255 hookworm control in B e r c o v it z . 673 hospital internes i n ...... 53 hydrophobia in 51 hygienic latrines in .. B e s t . T/ incidence of tuberculous infection in .. K o r n s . 10 medical experiences during forty years in M cC andliss. 934 Medical Journal 973 medical research in .. 952 modern pharmacy in . . L e e . 5? morphia and narcotic drugs in .. 377 objectives of medical mission work in . . S u t t o n . 826 operations on foreigners in W ILFORI). 922 opium traffic in 758 peanut bronchitis in D u n l a p . 903 progress in ...... 972 purchasing drugs in C a m e r o n . 283 Red Cross Societies of 284 relationships in medicine with the Western world H u m e . 185 survey of leprosy in F o w l e r . 584 syphilis, importance of 776 West, medical progress in 82 X -ray work in 284

C h i n a M e d ic a l J o u r n a l : 661 clinical notes 569 index to 570 editorship 665

C.M .A. and American Medical Association 852 Conference, 1926 ...... 255 membership in 76C v i INDICES.

C h i n a M e d ic a l M is s i o n a r y A s s o c i a t i o n : Conference, Hongkong, (see C.M.M.A. Conference) 227 evangelistic work as related to medical schools M o s s e . 544 Executive Committee 340 Executive Committee, meeting of 53 H ongkong Conference: financial statement .. 744 Medical Missionary Association of India, greetings from 255 report of Central China Branch 563 Research Committee, report of .. 452 South China Branch 461 South China Branch meetings of 181

M. M. A. Conference, 1925 : China Medical Journal. Editor’s report 249 Chinese Government, messages to Joint Conference .. 247 C. M . A. Conference. 1926 255 Medical Missionary Association of India, greetings from 255 Committee on Publication and Translation, report of 160 Committee on Research, report of 166 Conference impressions . . J a m f.s L. M a x w e l l . 262 Conference impressions ...... Henry Fowler. 264 Conference Trade Exhibition 267 Constitution and By-Laws revision 259 Constitution of C.M.A. 1148 Co-operation in School Health Programme . . 254 Council on Hospital Administration, report of 164 Council on Medical Education report 250 Council on Public Health, report of 159 Delegates to Conference 265 Election of Officers, Committees and Councils 260 evangelistic work in mission hospitals M o n t g o m e r y . 534 Executive Secretary's report 151 Health in mission schools 254 health of workers in modern industries in China 255 hospital technicians 254 Institute of Hospital Technology 249 Joint Conference, messages from Chinese Government 247 leper administration conference on 250 medical education 254 medical education, B. Grade medical schools 256 medical ethics, code of 249 midwives, diplomas for 249 mission hospitals : a comparison 230 evangelistic work 231 finance of 234 location of 231 and medical missionary programme J o h n K ir k . 227 and nursing 235 registration of .. 249 and research 238 and salaries of Chinese d o c t o r s ...... 251 and the Chinese profession 236 President’s address ...... J o h n K i r k . 227 INDICES. vii

preventive medicine and child hygiene • • 257 proceedings of 246 Publication Committee report 250 Public Health Council report . . 250 Public Health education and mission hospitals • • * « • . 228 Research Committee report ...... 250 Secretary's report 248 Student Volunteer Movement * • • • . • • . 260 Treasurer's report .. 249

' ferexce R esolutions : Conference. 1926-1927 260 Constitution and By-Laws 259 Co-operation in School Health Programme .. 255 Health oi mission schools 255 Health o f modern industries in China . ^ 255 hospital administration and x-ray work 251 Institute of Hospital Technology 254 medical education, standard of .. 257 medical Association of India 255 medical schools, B. grade ...... 254-257 preventive medicine and child hygiene 257 salaries o f hospital doctors 253 Student Volunteer Movement 260 Votes o f thanks 258 inesk : birth rate H eath. 702 British pharmacopoeia in .. 381 children, mortality of C h a u and W right. 687 collected anthropometric data on . . S t e v e n s o n . 855 diet, influence o f on disease C h u n . 1046 foods in every-day units, fuel values o f .. A d o l p h . 1041 Government, messages to Joint Conference 247 graduate nurses, training of as midwives Ja m e s . 835 herb doctors in U. S. A. 83 hospital in San Francisco .. 665 malaria epidemic 1155 males and females of Chekiang, physical growth of S hirokogoroff . 1029 materia medica inorganic R e a d and L e e. 23 materia medica : Ma Huang C h e n and S c h m i d t . 982 medical sayings and proverbs K. C h i m i x W o x g . 1099 medicines 191 nervous disease of syphilitic origin P f is t e r . 688 physicians, remuneration o f .. 569 plasters ...... 969 primary tuberculosis of tonsils and adenoids among .. K o r n s . 899 Red Cross ...... 853 Shanghai, review of one hundred autopsies .. O p p e n h e i m . 1011,1067 syphilitics, eflfect of antisyphilitic treatment .. P f is t e r . 688 treatment of hydrophobia 81 women, age at menstruation H e a t h . 702 a g e o f at menopause .. C h a u and W r ig h t . 686 Vli.i t n d i c î ;s .

•. women, ectopic gestation in ...... -- •• 753

gynecological diseases of ...... •• H e a t h . 701 onset of menstruation in .. .. C hau and W r i g h t . 684 Cholelithiasis, treatment o f ...... 464 Choroid miliary tubercles i n ...... L ee. 501 Christie, Dugald, ¿.M.G., F.R.C.P ...... , ...... 82 Ciaronic amoebiasis, microscopic picture in .. .. ,. K essel. 99 Cinchona alkaloids other than quinine ...... - . - - 369 Cinchona bark in treatment of malaria ...... • 276 Cinnamon, Chinese, histological stud}r o f ...... K. K. C h e n . 350 Climates, hot: ophthalmology in ...... • • 657 Clinical psychiatry, practical, Strecker and E baugh (review) .. .. 966 Clonorchis infection, epidemiology of ...... F aUst. 287 Cochran, Samuel, M.D., President df the C.M.A...... 147 Cockroach, eradication of ...... -. C ameron. 458 Collyria ., ...... 504 Composition of hens’ eggs in relation to size ...... Tso. 136

Congenital: absence of pectoralis major muscle ...... H all. 224 malaria ...... 746 syphilis, prognosis in ...... 747 Congress of F.E.A.T.M...... - 973 Constitution and By-Laws Revision .. .. . 259.1148 Co-operation in School Health Programme ...... •. 254

C orrespondence : An appeal for arthropods of medical and veterinary importance in China ...... P a t t o n . 970 ^ British Empire cancer campaign ...... Thos. Cochran. 475 China Medical Journal, cover of ...... 661 Chinese plasters ...... D e r m a . 969 Clinical notes in the Journal E.D.S...... 570 Death from injection of arsenical preparation .. B r o w n . 568 Far Eastern Association of Tropical Medicine, circular letter to. Deggeller. 379 Hydrophobia, Chinese treatment of R ead. 180 Leprosy : on the treatment of Lee S. H u i z e n g a . 661 Leucocytosis or leucopenia in typhus fever G. A. M. H a l l . 759 'Medical missionaries in India ..662 Modern treatment of leprosy .. H. Fowler. 970 Pellagra in Korea !,. R. M. W i l s o n . 661 Purchasing drugs in China C a m e r o n . 283 Remuneration o f Chinese physicians C h e n . 569 Standardization of membership in C. M. A. .. Chapman. 760 ... Trachoma, treatment o f ...... W . H. Birks. 851 Cpyncilmania lafleuri J. F. Kessel. 119 Cousland, P.B., M.B., C.M., LL.D. .. ..1 1 2 7 Cytology, Cow dry ( review ) ...... 77

Dangerous drugs: International control ...... 365___ Deaf children in China ...... : ...... 83 I%iths •• •• ~ •• •• 182,570,852 INDICES. IX

Death rate in U .S .A ...... „ .. 1172 Death, valuable sign of ...... 470 Decapsulation of kidneys in chronic nephritis ...... C heal. 40 Delegates to Conference ...... * ...... 265 Dengue, transmission and etiology of ...... 1164 Dentistry, aids to operative, Jamieson (review) ...... 850 D i a b e t e s ...... 48 Diabetes mellitus insulin treatment of, C ammidge (review) ...... 79 surgical infections and in su lin ...... 959 Diagnosis: and treatment of maxillary sinusitis .. W. S. T. N rvillk. 3 7 differential, internal medicine, M atthes (review) .. ., .. 849 of Sillicosis, W a t k in s-P itchford ( r e v ie w ) ...... 378 physical, R ose ( r e v i e w ) ...... , 178 Digitalis, actions of, C u s h k y (review) ...... - .. .. 565 in tropics, potency of ...... 963 Diong-loh A.B.C.F.M., Hospital report of ...... 815 Diphtheria, .subcutaneous lesions in the intracutaneous test for virulence oi L im . 996 Disease, influence of Chinese diet on ., ...... C h u n . 1046 malignant, in Great Britain .. .. • • ...... 971 prevention ...... 281 Disinfection of fruits and vegetables ...... 1164 Dislocation and sprains, treatment o f ...... , . . 467 Double-headed monster ...... D ecker. 44 Dr. Dugald Christie, return to China .. . - 1065 Dr. Nina Beath, death of .. 1065 Dr. Sun Yat-Sen ...... 338 Drugs dangerous: International control signed Geneva .. .. 365 Drugs: intramuscular injections of, local effccts of .. 845 Duodenal hemorrhage treatment of ...... * .. 174 Dyes, antiseptic in surgery ...... 754 Dysentery, fasting and purgative treatment .. • • 843 Dysmenorrhea, treatment of .. .. . - -. .. .. • • - - 170

Ear infections, bacteriology of ...... , D u n lap. 331 Eclampsia, treatment o f ...... • ». .. .. 964 Ectopic gestation, early diagnostic sign of ...... - 752 in Chinese women ...... - • - - • .. 753

E ditorials : The New Year ...... ,...... -. 50 Newly elected President of C.M.A. .. 147 The China Medical Association ...... 149 Dr. Sun Y a t - s e n ...... 338 The, British Empire Cancer Campaign ...... 432 Child labour in China ...... 527 Leprosy ...... N oel C. D avis. 632 Health of missionaries ...... , 714 Nationalism and Medical missionaries ...... 810 The cancer problem ...... 927 Dr., Merrins ,, ...... , .7..- 1056 X in d i c e s ;

E d it o r ia l N o t e s : Dr. E. M. Merrins ...... 112?

Dr. P. B. Cousland ...... • • . . 1127 Institute of Hospital Technology ...... 1127 Institute of Hospital Technology: Pharmacy classes 1128 An I.H.T. Section in the Journal ...... 1129* Typhoid in infants ...... 1129 Leprosy ii3 a Cancer ...... ii3 a Education, medical, F l e x n e r (review ) 472 methods and problems of, (review) 280 Egyptian splenomegaly and hepatic cirrhosis, etiology of 370 Ella Sachs Plotz Foundation ...... 284 Elephantiasis, treatment o f ...... 468 Encephalitis lethargica 7 English-Chinese Medical Lexicon ...... Cousland. 375 Enteric Fever in Chinese infants, (reprint) M in e t t . 1153 Ephedrine in experimental shock and hemorrhage K. K . C h e n . 350s Epidemiology of clonorchis infection in China F a u s t . 287 Erysipelas, quinine in cases of 368 Esophagoscopv and bronchoscopy Jui H au L i u . 414 Ether, rectal injection of in whooping cough 957 Ether treatment of whooping cough ■275 Ethmoidectomy, or exenteration of the ethmoid labyrinth D illey. 989 Ethmoid labyrinth, exenteration of D i l l e y . 989 Ethyl esters from hydnocarpus, use o f in leprosy O’B r ie n and

R u n c h a i y o n . 600 Ethyl esters of chaulmoogra o i l s ...... R ea d an d F e n g . 605 Ethyl morrhuate in treatment of tuberculosis 654 Etiology and treatment of svmblepharon P e t e r s o n . 309 of auricular fibrillation ...... B u r n . 132 o f Egyptian splenomegaly and hepatic cirrhosis 370 Evangelistic work in mission hospitals M o n t g o m e r y .' 534 Executive Committee, minutes of m eeting ...... 1144 Eye, ear, nose and throat manual for Nurses, P a r k i n s o n (review) 1063

Eye. pathology and bacteriology of, C o l l in s (review) .. 660 Eyelids, swelling of, as early sign of Graves’ disease 840 Eyelids, tumours of E v a n s . 145

Face, furuncles of ...... 176 Far Eastern AsBociation of Tropical Medicine 269 Febrile reactions after intravenous injections 844 occurring after intravenous injections, cause of 962

Feeding, in fa n t ...... 368 Truby-King methods ...... 656 Female nurses in a Chinese general hospital S n e l l . 832 Fibrillation, auricular 128 Fish, use of for mosquito c o n tr o l ...... 473 Fistula-in-ano ...... ; 916 Flagellate intestinal ...... J. F. K e s s e l . 121 Flocculation test for syphilis ...... P. V. E a r l y . 140 Focal infection, review of literature on 1079 INDICES. XI

Foreigners in China, operations 0 11 ...... W i l f o r d . 922 Formosa, unqualified, practitioners in ...... 764 F ox spirit and d is e a s e ...... 665 Fractious, Chinese treatment ...... 0 7 1 Fracture, treatment of with plaster of Paris ...... 373 Fruits and vegetables, disinfection o.f ...... 1164 Fuh-ling, chemical analysis o f ...... R e a d and W o n g . 316 Fuh-ling, chemical and physiological properties of .. R e a d and W o n g . 348

Fundus oculi, the, in kala-azar ...... L i n g . 681 Furuncles of face, treatment of ...... 176 Fusiform bacilli in pulmonary infections ...... 464

Gall stones, after history of operations ...... %0 Gangrene following injection of saline solution ...... 465 G astric: hemorrhage, treatment of ...... 174 secretion ...... L im . 505 Gastro-enterostomy, cases of ...... W i l f o r d . 807 Genito-urinary diseases and syphilis, H i r s c h (review) .. . . 376 Gentian violet in treatment of infection ...... R o g e r s . 123 Gonococcal infection, treatment of, by diathermy, Cumbf.rbatch (review). 967 Graduate courses, P.U.M.C...... 380 male nurses ...... 1065 Gratitude of Chinese lepers ...... 635 Graves’ disease, swelling o f eyelids as earlj" sign ...... 840 Great Britain, voluntary hospitals in...... 1172 Grosvenor, Dr. W . C ., resignation of ...... 853 Gynecology: chronic backache in ...... 272 compend of. W e l l s (review) ...... 758 manual of. C a m e r o n (review) ...... 471 Gynecological notes: Canton Hospital .. .. C h a u and W r i g h t . 684 Chinese out-patient clinic ...... H e a t h . 701

Haematology in general practice, G o rd o n (review) ...... 967 Hamsters experimentally infected, kala-azar in ...... 1167 Hangchow C.M.S.. Hospital and Medical Training College report of .. 813 Hangchow Medical C o lle g e ...... 380 Hankow L.M.S. Hospital .. -...... 722 Hankow, report of Margaret Hospital ...... 530 Harbin, plague in ...... 665

Headaches of psychogenic origin...... M c C a r t n e y . 32 H ealth: and environment, H i l l (review) ...... 850 and industrial conditions in China ...... M a i t l a n d . 1089 of missionaries ...... • 714 of missionaries in Canton ...... C a d b u r y . 723 o f workers in modern industries in China ...... 255 programme for schools ...... W a l l a c e . 437 report, Shanghai Municipal Council ...... 1065 Xll INDICES.

H eart: disease and pregnane}' ...... 654 quinidine in ...... ,. 273 failing, etiology of ...... 71

Hemoptysis: in pulmonary tuberculosis ...... C h a o H s i - a x g . 397

Hemorrhage: duodenal treatment of .. . 174 gastric, treatment of ...... 174 retinal, significance of ...... • • • 683 Hemorrhoids, treatment of by pitch taken internally ...... - - 373 Hepatic cirrhosis and Egyptian splenomegaly, etiology of ...... 370

Hernia : following McBurney’s incision ...... 839 inguinal among Koreans ...... L udlow. 204 Herpes Zoster and tuberculosis ...... ■ • - - 1061 Herpetic infection o f rabbits ...... CowrmY and N icholson. 378 Heterophyid flukes, two new. preliminary report on the life cycles of F a u s t and N is h ig o r t . 914 Heung Shan. Kwongtung, Kei Kwong Hospital ...... 435 Honan, Kaifeng, Hospitals, report of ...... -. .. 933 Honan, Weihwei Hospital ...... 381 Hongkong Conference: financial statement ...... 744

Hongkong foot ...... F r a z ie r . 705 Hongkong health report ...... 720 Hookworm control in China ...... Bercovitz. 673 infestation, diagnosis of ...... 1062 infestation, influence of shoe wearing ...... 841 larvae, development of ...... 667 Hospital esprit ...... 553 expenses in U.S.A...... 285 general, Chinese female nurses in ...... S nell. 832 internes in C h i n a ...... 53 mission, evangelistic work in ...... M o n t g o m e r y . 534 Shantung Road, Shanghai ...... 380 technicians ...... 254

t e c h n o l o g y ...... H a d d e n . 817 technology, institute of ...... 745

Huang Chi, reputed diuretic action of .. S c h m i d t . 348 Hunan, Changteh, Presbyterian Hospital ...... 345 Hunan-Yale College of Medicine ...... 852 Hungchiang, Hunan, C.I.M., Hospital .. 83

Hydnocarpus anthelmintica: uses of in leprosy. O’B r i e n and R u n c h a i y o n . 600

Hydrogen peroxide, some observation on ...... C a m e r o n . 352 Hydrophobia: Chinese treatment of ...... 81

Chinese treatment o f ...... R e a d . 180 in China ...... 51 Hygiene and Public Health, G h o s h (r e v ie w ...... 80 for Chinese beggars ...... 82

school .. W a l l a c e . 437 INDICES. xxii

Ichang. Customs medical report ...... 1162 Ichang Hospitals, Church of Scotland, report of ...... 1157 I.H.T. Section. On the keeping of records Ï142 Immunisation against scarlet fever 1166 Immunity in infectious diseases, D ’H e r e l l e (review) .. 178 Incontinence of urine in children 173 India: child marriage in 285 * female seclusion in ...... 83 medical missionaries in 662 medical mission in .. 473 splenomegaly in 273 Infant feeding, some problems of in the Orient L kaçh* 1049 Truby-King methods 656 Infantile scurvy, potato-cream in 749 Infant mortality in Great Britain 971 feeding 368 new-born, pneumonia in .. 749 new-born, prevention of loss of heat and weight 748 of tuberculous mothers 70 typhoid in 1129

Infection, immunity and inflammation, G u r d (review) 566 Infectivity of saliva of tuberculous patients 556 Influenza 9 and pulmonary plague 172 Inguinal hernia among Koreans L u d l o w . 204 Injections to relieve pain of mouth cancer 838 Institute of Hospital technology 249, 817 Insufflation for patency o f uterine . . H o f f m a n . 486 Insulin and glucose in treatment of post-operative acidosis L a w n e y , V a n and M c D a n i e l . 924 and surgical infections in diabetes 959 in surgical and other conditions 926 treatment of boils 842 treatment of diabetes mellitus. C a m midge (review ) 79 Intestinal obstruction 273 obstruction acute T a y l o r . 767 parasites and appendicitis 170 protozoa J. F. Kessel. 85,115 protozoan infections, incidence of J. F. K e s s e l . 975 protozoa, syllabus of 853 spirochetosis .. 847 Intracutaneous test for the virulence o f diphtheria 9v6 Intramuscular injections of drugs, local effect of .. 845 Intraperitoneal transfusion of blood 275 Intravenous injections of febrile reactions after .. 9 6 2 febrile reactions after 8 4 4 Irritable uterus, case o f ...... M orris. 43 Iron, preparations of 562

Japan, epidemic outbreak of unidentified disease of central nervous system. 1 number of medical practitioners in 477 rabies in .. .: ...... 665 xiv INDICES.

Japan, vital statistics o f ...... 663 Jaochow, Kiangsi, Hospital...... 434 Joint Medical Conference, Hongkong, 1925. Report of Section on Pharmacology and Therapeutics ...... 347

Joint Medical Conference in Hongkong ...... C a d b u r y . 241 Joint Conference, messages from Chinese Government ...... 247 Journal of Medical Missions in India ...... 280 Jukao, Ku, Christian Reformed Church Mission Hospital, report of .. .. 1159

Kala-azar, diagnosis of, value of aldehyde test in 1168 fundus oculi in L ixg. 681 in experimentally infected hamsters 1167 in Kansuh K ixg. 20 vector of 270 vector o f in China 285 Kansuh and its diseases K ixg. 19 Kiangsu, Jukao, C.R.C. Hospital, report of 931 Kiangsi, Nanchang, Susan Toy Ensign Memorial Hospital. report of 930 Kidneys, decapsulation of C heal. 40

Korean patients, sugar in urine of . . . V ax B u s k i r k . 47 Korea, Pellagra in W lLSOX. 661 Koreans Inguinal hernia among L u d l o w . 204 Kung Yi Hospital and Medical School 853 Kutien, Fukien, report of Wiley General Hospital . 532 Kwangju Mission Hospital. Korea report of 1160

Labour, China, child in ...... 527 Lactation and rickets ...... 173 Larynx, tuberculosis, treatment of ...... 469

Latrines, hygienic in China ...... B e st. 57 League of Nations grading of Far Eastern Ports ...... L im . 422 Lepers in Siam ...... 663 treatment of in Louisiana, U.S.A. .. . . 663

Leprosy as public health problem ...... D a v is . 632 contagiousness of .. .. . 634 Croonian lectures on, R ogers and M u ir (review ) ...... 658 dread o f by Chinese ...... 634 in Bengal ...... 663

in K a n s u h ...... K in g . 21 ‘ in the Philippines ...... 663

modern treatment of ...... F o w l e r . 5 9 4 .9 7 0 .1 1 3 3 points of importance in dealing w i t h ...... M u ir . 575 spread of ...... ■...... 590 treatment of ...... • ■ H eiser. 591

treatment o f ...... H u iz e x g a . 661 treatment of with ethyl esters and hydnocarpus .. 600 Leucocyte count, differential, in a sub-tropical clim ate ...... 963 normal differential count in South Africans, Chinese and others .. 964 Leucocytosis induced by chaulmoogra o i l ...... - R e a d . 605 physiological in. man ...... • • - • • • 845

Ligature silk, reels for . , . W ebster. 804 INDICES. XV

Liling, Hunan, Evangelical Mission Hospitals report of ...... 1158 Literature, review of on focal infection .. .. D u n l a p . 1079 Liver, abscess of ...... 76

Lord Lister Biography of ...... G odlee. 278 Louisiana, U.S.A., treatment of lepers in ...... 663 Lungchingtsun, Kirin, St. Andrew’s Hospital, report o f ...... 814 Lymphatic glands of healthy children, tubercle bacilli in ...... 462

Magnesium sulphate in puerperal eclampsia 965 Ma Huang: Chinese materia medica C h e n and S c h m i d t . 982 M a Huang, pharmacology of .. K. K. C h e n . 348 Malaria, chronic, mercurochrome in A v i s o n and Koo. 419 cinchona Ijark in treatment of .. 276 congenital .. 746 epidemic, Chinese .. 1155 in Kansuh K i n g . 20 infection, transplacental B u c k i n g h a m . 1140 pseudo attacks in typhoid fever . 558 treatment o f general paralysis . 174 urinary examination in the diagnosis of . 371 Mammalian infestation with protozoa relations to carnivorous diet 67 Manchuria Medical University 82 Manual of Bacteriological methods . 377 Marriage Certificate of health . 381 Marriages 82.182 Mastitis puerperal . 169 Materia medica and therapeutics treatment of, G h o s h (review) . 471 Chinese inorganic R e a d and L ee . 23 for nurses, M u ir h e a d (review) 80

handbook of, G h o s h (review) 79 Maxillary sinusitis, objective examination of W. T. N e v il l e . 300 operative treatment W. T. N e v il l e . 304 McBurney’s incision, hernia following 839 Medical College, Hangchow 380 Medical education 254 a comparative study, F l e x n e r (review) 472 B. Grade medical schools 256 methods and problems of. (review) 280 Medical ethics, code o f .. • 249 ' experiences during forty years in China M c C a n d l i s s . 934 missionaries and school health programme W a l l a c e . 437 in India .. 662 mistakes of 571 on the field from the U.S.A. and the British Empire 1056 Medical Missionary Association of India 285 missions and nationalism 810 in China, a century of 636 in India 473 statistics of 971 strength of 380 women in mediaeval times . .. 1173 work in China, objectives of S u t t o n . 826 XVI INDICES.

reports, (see reports)

research in C hina ...... C a d b u r y . 95 2 research, publications of the South African Institute for ...... 378 schools and evangelistic work ...... M o s s e . 544 schools of the world ...... 377 sciences in German Universities ...... - 278 Medicine in China and the Western w o r ld ...... H u m e . 185 Meningitis, new sign of ...... 844 Menopause, age of Chinese women at .. .. C h a u and W r i g h t . 686 Menstruation, Chinese women H e a t h . 702

onset of in Chinese women ...... C h a u and W r i g h t . 684 sweat during ...... 76 Mental diseases associated with childbearing ...... 371

Mercurial stomatitis thiosulphate sodium treatment of .. H a l l . 785 in chronic malaria ...... Avisox and B y r o n K oo. 419 ... in plague ...... 557 220 soluble and gentian violet in the treatment of infections .. .. 123 Mcrrins, E.M., M.D. . 1056,1125

Mesenteric lymph gland experiments with ...... M o l e . 349,1113 Midwifery, Handbook of, B e r k e l e y (review) ...... 280 Midwives diplomas for ...... 249 training o f Chinese graduate nurses as ...... J a m e s . 835 Missionaries, .health o f ...... 714 health of in Canton .. .. C a d b u r y . 723 health of, resolutions of Executive ...... 53 Lay, medical training for ...... 285 Society, English Baptist...... 381 Missionary work and science ...... 853 Mission hospitals and medical missionary programme .. .. K i r k . 227 and salaries of Chinese doctors ...... 251 registration of ...... 249 taxation ...... 380 Mitochondria in cellular pathology. C o w d r v ...... 377 Mitral stenosis among northern Chinese ...... 841 Mollgaard treatment of tuberculosis ...... 462 Monster, double-headed, with two complete spinal columns .. D ecker. 44 Morphia and narcotic drugs in China ...... 377 Morphine smuggling from England, allegations of ...... 973 Mosquito control, use of iish for ...... 473 Mosse Memorial Hospital, Tatungfu, Shensi, S.P.G. report of .. ;. 1160 Moukden Medical College and H o s p i t a l ...... 283 report of medical college and Hospital ...... 531 Mouth cancer alcoholic injections to relieve pain ...... 838

Naso-pharvngeal growths ...... 755 National essay contest ...... 83 Nationalism and medical missions ...... 810 Nephritis, decapsulation for in children ...... C heai.. 42 -Nephritis, scarlatinal, prognosis in .. ., ......

Nervous disease, syphilitic, effect of antisyphilitic treatment. P f is t e r . 688 INDICES. XVÜ

Neuralgia, trigeminal, treated by injection method .. .. G a s t o n . 1122 New-born infants, pneumonia i n ...... 749 prevention o f loss o f heat and weight in ...... 748 Nicotine and salvarsan treatment ...... 466 Non-pathogenic protozoa ...... J. F. K e s s e l . 90 Novarsenobenzol, in the treatment o f puerperal s e p s is ...... 70

Nurses, female, in a Chinese General H o sp ita l ...... S n e l l . 832

.materia medica for, M u i r h e a d (review) .. . . 80

O b i t u a r ie s : Beath, Dr. Nina H...... 1173 Boone. Dr. Henry ...... 971 King, Howard ...... 764 Cox, Stafford M...... 763 Merrit. Charles Phelps Williams ...... 570 Neal, James Boyd. M.D...... 281 Russell, W .B ...... 182

Obstetrics, aids to. N a l l (review) ...... 850

Glasgow Manual cf, C a m e r o n (review) ...... 177 rectal analgesia in ...... 655 X-ray examinations ...... 799

X-ray examinations ...... S m i t h . 789 Obstruction, intestinal, acute ...... T a y l o r . 767 Oesophageal cancer in Chinese . . . . . 1064 Officers, Committee and Councils election of ...... 260 Operating room team work ...... T a y l o r . 944

Ophthalmic plastic surgery, newer methods of, S p a e t h (review) . . 966 Ophthalmology, the eyes in hot climates ...... 657 Ophthalmic work, local anaesthesia in ...... 559 Opium, addicts, treatment of, outside hospitals ...... 53 Conference in Geneva ...... 183 smokers cure of ...... 183 traffic in China ...... 758 Oriental sores treated with phosphorus ...... 72

Orient, some problems of infant feeding in . . . . L e a c h . 1049

Osier, Sir William, C u s h i n g ( r e v i e w ) ...... 756 Otology, neglected corners of ...... 560

Out of the frying pan into the fire ...... A s p l a n d . 1136

Paraffin bath and warming table ...... I l l i c k . 224 Paralysis general, malaria treatment of ...... • • 174

Parasitology taenia solium triradiate in north China .. .. F a u s t . 800 Pasteurized milk and tuberculosis ...... 274 Pathology, Handbook of, W o n g (review) .. 1062

textbook of. B e a t t ie (review) ...... 849

Peanut bronchitis in China ...... D u n l a p . 903 Pectoralis major muscle, congenital absence of ...... H a l l . 224 Pectoris angina treatment of .. . .. • • • • • • • • 367 Peking, system o f receiving and issuing prescriptions in .. .. C a m e r o n . 949

Pellagra in Korea ...... W i l s o n . 661 Peritoneal adhesions, post-operative, prevention of ...... 1058 Pernicious anemia and s p r u e ...... • ...... 74 and tropical s p r u e ...... ■ - 652 XV111 INDICES.

Peroxide hydrogen, some observations on CaMeron. 352 Personal religion and the life of devotion, I nge (review) ...... 80

Pharmacology and materia medica, G h o s h ( r e v i e w ) ...... 79,473 and therapeutics report on ...... 547 handbook of, B a l l a n t y n f . (review) ...... 79 Pharmacy classes : Institute of Hospital Technology ...... 1128

Pharmacy, modern, in China ...... L e e . 55 Philippines, leprosy in ...... 663 Phosphorus in blood in cancer ...... 172 Physical growth among the Chinese females and males of Chekiang.

S hirokogoroff . 1029 Physicians, legal responsibilities of ...... 477 number of, in Japan ...... 971 Physiological experiments in Fuh-ling ...... R ead and W ong. 318 Ieucocytosis in man 845

Physiology human, ( r e v i e w ) ...... P e a r c e . 79 Pitch taken internally in treatment of haemorrhoids ...... 373 Placenta praevia, treatment of ...... 751 Placenta, tumours of ...... J. P r e s t o n M a x w e l l . 1086 Plague in Canton ...... 665

in Kansuh ...... K i n g . 21 mercurochrome in ...... 557 near Harbin ...... 665 pneumonic, in L’.S.A...... 83 pulmonary and influenza ...... , . 172 Piaster of Paris in treatment of fracture ...... 373 Pneumonia, lobar, quinine in ...... 463

pathology, diagnosis, prognosis and treatment . .. L e s l ie 277 Pneumonic plague in U.S.A...... 83 Poliomyelitis acute ...... 8 Post-operative acidosis ...... 753 gas pains treatment of ...... 176 peritoneal adhesions, prevention of ...... 1058 retention of urine, treatment of ...... 842 Potassium permanganate in treatment o f disease . . .. 843 Potato-cream in infantile scurvy ...... 749 Pottenger, Symptoms of Visceral Disease ...... 1159

Practice, general, an index to, (review) S t a r k . 967

Practical bacteriology, (review) ...... M a c k i e . 375 Practitioners, unlicensed, control of, in J a p a n ...... 973 Pregnancy and heart disease 654 and rickets . . .. • • • • • • - • • • • • ■ 173 and uterine prolapse .. J. P r e s t o n M a x w e l l . 479

compound .. .. • . . • • - • • - - • • E w e r s . 493 early, diagnosis of .. .. • • ■ • • • •. .. 561 in pulmonary tuberculosis ...... 66 Preputial calculus .. •• . - •• -• •• •• W ilfo rd 712 Prescriptions, system o f receiving and issuing in Peking .. .. C a m e r o n 949 Preventive medicine and child hygiene ...... 257

Production o f vaccines and serums in China .. T s e f a n g F. H u a n g . 360

Prolapse and pregnancy .. J^ P r e s t o n M a x w e l l . 479 Prolapse, rectal in c h i l d r e n ...... 750 INDICES. x i x

Protozoa commensal .. .. J. F. K essel. 975 Protozoal infestation relation to carnivorous diet .. 67 Protozoan-like parasites and meningo encephalitis in mice. Cowdrv and F. M. N icholson. 377 Public Health Education and Mission Hospitals . : 228 Puerperal eclampsia, magnesium sulphate in 965 Puerperal infection arsenical treatment of .. 1061 by spirochetes 846 mastitis 169 sepsis treated by novarsenobenzol 70 state, mortality o f, in Great Britain 972 Pulmonary hemorrhages and blood pressure 846 infections, fusiform bacilli and spirochaetes in 464 plague and influenza 172 tuberculosis and pregnancy 66 tuberculosis, diagnosis of .. 954 tuberculosis hemoptysis in C h a o H s i - a n g . 397 tuberculosis, sudden onset in 1059 Puke a guide to appendix diagnosis . . P a t t e r s o n . 1171

Pulse rates, comparison American and Chinese patients L e n n o x . 218 P.U.M.C. a new Association .. 764 Anthropology Department 284 census of graduates 380 Graduate courses 380 Graduate instruction in medicine 664 medical course ...... 664 students in, for 1925-1926 .. 1173

Quinine and quinidine ...... -• •• •• •• 1166 in cases o f erysipelas ...... • • • • • • 368 in heart disease .. .. -. . • ■ • • • ■ • ■ • • 273 in lobar pneumonia ...... • - • • • • • • • 463

Rabies in Japan ...... •• •• 665 Radium bottled . . .. • • • • • • - ■ • • ■ ■ • 476 Rat-bite fever : report of case . . .. ■ ■ •. ■ • • • • ■ G alt. 1029 Records, keeping of .. .. •• •• •• •• •• •• •• H42 Rectal analgesia in obstetrics . . .. • ■ ■ • • • • • • • 65? prolapse in children .. •• •• 750 Red Cross Societies of China .. . • • • • • • • • ■ • • 284 Red stomach .. .. . • ■ ■ • • 961 Reels for ligature silk ...... W e b s t e r . 804 Report of C.M.M.A. Central China Branch ...... 563 Report of Secretary-Treasurer of the Yu Wang Fu Association .. .. 1053 Reports medical and educational: Chefoo, Temple Hill Hospital ...... ■ - • • • • • • 815 Chengtu, West China University ...... •< 450 Chiengmai, Siam, A.P.M. Hospital ...... « «• 814 Chinchew General Hospital (E.P.M.) Amoy, Fukien...... 346 Diong-Loh A.B.C.F.M. Hospital ...... * .. 815 XX INDICES.

Hangchow C.M.S. Hospital and Medical Training College .. .. 813 Hankow L.M.S. Hospital ...... 722 Hankow, Margaret Hospital, L.M.S...... 530 Health of Shanghai ...... 346 Heung Shan, Kwongtung, Kei Kwong Hospital ...... 435 Honan, Kaifeng, C.I.M. Hospitals ...... 933 Hongkong Health report ...... 720 Hunan, Liling, Evangelical Mission Hospitals .. .. . 1158 Hupeh, Siangyang, Bethesda Union Hospital ...... 1159 Ichang, Customs Medical report ...... 1162 Ichang Hospitals. Church of Scotland ...... 1157 Jaochow, Kiangsi, C.I.M. Hospital ...... 434 Kiangsi, Nanchang, Susan Toy Ensign Memorial Hospital (M.E.C.). 930 Kiangsu, Jukao. C.R.C. Hospital ...... 931. 1159 Korea, Kwangju Mission Hospital .. .. 1160 Kutien, Fukien, Wiley General Hospital ...... 532 Lungchingtsun, Kirin, St. Andrew's Hospital ...... 814 Mosse Memorial Hospital, Tatungfu. Shensi, S.P.G. . .. 1160 Moukden Medical College and Hospital ...... 531 Presbyterian Hospital, Changteh. Hunan ...... 345 Seoul, Korea, Severance Union Medical College . . .. 533 Shanghai Municipal Council Health report ...... 718 Shanghai, St. Luke’s Hospital ...... 812 Shansi, Ping Ting Chow. Brethren Hospital ...... 932 Shantung Road Hospital, Shanghai ...... 380. 721 Siam, Petchaburi. American Mission Hospital ...... 1161 Soochow Hospital, Soochow ...... 931 Tehchow, Williams-Porter Hospital, American Board ...... 1158 Weihsien, A.P.M. Hospital ...... 816 West China Union University, Chengtu...... 343 Wuchang, Church General Hospital. A.C.M...... 1159 Resuscitation in asphyxia neonatorum ...... 561 Retinal hemorrhages, significance of ...... 683 Rickets and diet of mother during pregnancy ...... 173 Rickettsia-like micro-organisms in adult locusts occurrence o f ...... 377 Rockefeller Foundation ...... 972

Saline solution injection and gangrene following ...... 465 Saliva o f tuberculous patients : infectivity of ...... 556 Salvarsan treatment, effect of alcohol and nicotine ...... 466 San Francisco, Chinese Hospital in .. .. 665 Sanitary grading of Far Eastern Ports .. Lin. 422 Scalp, removal of tumours of ...... Gibsox. 1041 Scarlet fever, immunisation against ...... 1166 serum treatment in ...... 1059 Schistosomiasis japónica treatment of ...... L ee. 321 School child, health of .. .. M iller. 1101 Schools, health of, and medical missionaries ...... W allace. 437 School hygiene ...... W allace. 437 medical and evangelistic work ...... M osse. 544 medical, of the world ...... 377 INDICES. xxi

Sciatica pain, causes o f ...... 650 relief of pain in ...... 651 Science and missionar}' work .. .. . ^ ...... g53 Scurvy, infantile, potato-cream i n ...... 749 Secretarv-Treasurer, C.M.A ...... 973 Secretion, gastric ...... L im . 505 Seoul, Korea, incidence of human intestinal protozoan infection in. R essel. 975 Seoul, Korea, report of Severance Union Medical College ...... 533 Sepsis puerperal, treated by norarsenobenzol ...... 70 Septicemia, intravenous use o f gentian violet in ...... 960 Serum, a new anti-scarlatinal...... S. P. C hen. 911 Shanghai, health of ...... 346 health report .. .. 718 Medical’ S o cie ty ...... 477 sanitary grading of. as a p o r t ...... L im . 422 sanitation of ...... 431 Shantung Road Hospital report ...... 721 St. Luke’s Hospital, report o f ...... 812 Shansi. Ping Ting Chow, Brethren Hospital report of ...... 932 Siangyang, Hupeh, Bethesda Union Hospital report of ...... 1159 Silicosis, diagnosis o f ...... W atk in s-P itchford. 378 Singapore. Far Eastern Health Bureau ...... 476 Sinusitis maxillary: discussion of symptoms .. W. S. T. N eville. 296 treatment o f ...... W . S. T. N eville. 302 Soochow Hospital, Soochow, reportof ...... 931 Spirochetosis bronchial in Canton .. .. Cadbury, Jf.u, and H arvey 408 in pulmonary infections ...... 464 Spirochetes in tuberculous sputum ...... 1057 on the mucosa of trachea and bronchi ...... 1168 puerperal infections b y ...... 846 SpleiK)megaly in India ...... 273 Sprains and dislocations, treatment o f ...... 467 Sprue and pernicious anemia ...... 74 etiology of ...... • • - - • • • • • • 74 treatment o f ...... 170 treatment of ...... • • • • • • • • • • • • • • 653 tropical and pernicious a n e m ia ...... 652 Stenosis, mitral, among northern Chinese ...... 841 Sterilization, laboratory, with burning spirit ...... 965 Stomatitis metallic, sodium thiosulphate treatment of .. .. H all. 785 Streptococcus haemolyticus in ear infection ...... D unlap. 331 Student Volunteer M ov em en t...... 260 Sugar in urine o f Korean patients ...... V an B u sk irk. 47 Styptic, Chinese ...... 972 'Surgery, antiseptic d}res in ...... 754 methods in, Copher (review) ...... -• •• 1169 of the spine and extremities, T aylor (review ) ...... 758 operative, H orsely ( r e v i e w ) ...... 659 Symblepharon, etiology and treatment o f .. P eterson. 309 Symposium on leprosy ...... R ead. 350 Syphilis and tuberculosis ...... • • • • 840 congenital pr©gnosis i n ...... 747 X X l l INDIÇES.

effect of antisyphilitic treatment on central nervous system. P f is t e r , 688 flocculation test for » . P, V. E a r l y . 140 in K a n s ü h ...... K i n g . 20 in United States ...... 477 its importance in China L e a y e l l . 776

precipitation test, K a h n (review) 660 tryparsamide ...... 169 Syphilitic arthritis ...... 271 Sweat during menstruation 76

Taenia solium triradiate from north China . F a u s t * 800 T-aiyuanfu Hospital 285 Tapeworms, treatment for 367 Tar cancer ...... 27? Taxation of Mission Hospital 380 Technology, Institute of H osp ita l ...... H a d d e n . 817 Tehchow, Williams-Porter Hospital, report of 1158 Temperature: comparison of Chinese and American Patients. L e n n o x . 218 Terminology, medical, Chinese ...... 191

Testis, the human, T h o r e k (review) .. 78 The cancer problem 92-7

The coming of baby, A s h b y and A t h e r t o n (review) 968 The New Year ...... 50 The China Medical Association 149 The health of the school child M il l e r . 1101 Thyroid extract in treatment o f disease 843 Tokyo, St. Luke’s Hospital 285 Tonsillar operations, aspirating apparatus for . . . C u r r a n . 49 Tonsillitis as disease entity 272

Tonsils and adenoids, primaiy tuberculosis of, among Chin K o r n s . 899 Trachoma, treatment of ,851 Transplacental malarial infection ...... B u c k i n g h a m . 1140 Trans-uterine insufflation test .. H o f f m a n . 486 Tieatment of angina pectoris during an attack .. 367 hemorrhoids by pitch taken internally 373 schistomiasis japonica . . L e e . 321 t a p e w o r m s ...... 367 whooping cough 374 Trigeminal neuralgia treated by injection method G a s t o n . 1122 Triradiate taenia solium in north China F a u s t . .800 Tropical diseases, M a n s o n (review) 756 medicine, Far Eastern Association of .. D e g g el ler, 379 medicine, Transactions of F.E.T.M ...... 78 sprue and pernicious anaemia 652 ulcer, treatment of ...... 1060 Tropics, potency of digitalis in 963 Tryparsamide in syphilis ...... 169 Tsinan Medical Review ...... 280 Tsinan Medical School ...... 82 Tuberculosis and herpes zoster 1061 Tuberculosis and pasteurized milk .274 and syphilis ...... 840 INDICES. x xiii

bone and joint, modern treatment of ...... 467 calcium in treatment of ...... 71 concealed, H ead (review) ...... 179 deaths from in England and W a le s ...... ,. 972 extensive, in an eye of an infant .. Li. 1002 human and bovine independence of .. 67 in Kansuh ...... K ing. 20 Mollgaard treatment o f ...... 462 of larynx, treatment of ...... 469 primary, of tonsils and adenoids among Chinese .. .. K orns. 899 pulmonary and pregn an cy...... 66 pulmonary, sudden onset in ...... 1059 sanitorium treatment ...... 972 spu.tum, spirochetes in ...... 1057 treatment by ethyl morrhuate ...... 654 abscess and fistu lae...... 469 infection, incidence of in China ...... K orns. 10 Tuberculous mothers, fate of infants ...... 70 patients, infectivity o f saliva ...... 556 Tubercle bacilli in the lymphatic glands of healthy children ...... 462 Tumours, incidence of in Bengal and England ...... 1163 o f the eyelids ...... E vans. 145 Tung Teh Medical College, Shanghai ...... 665 Turtle heart, autonomic rhythm of. H ung P ih C h u and T orald Sollm ann . 348 Typhoid fever, blood count in .. .. 759 incidence of in U.S.A...... 1172 pseudo-malarial attacks i n ...... 558 treatment o f ...... 841 in infants ...... •• 1129

Ulcerative bronchitis due to Vincents organisms ...... 847 Ulcers treated by phosphorus ...... 72 Ulcer, tropical, treatment of ...... 1060 varicose, treatment of ...... 557 United States, syphilis in ...... - 477 Urinarj’’ examination in the diagnosis o f m a la ria ...... 371 incontinence in children ...... -. 173 Urine, post-operative treatment of .. .. 842 U.S.A. death rate i n ...... 1172 U.S.A. incidence of typhoid fever in .. .. 1172 Uterine insufflation t e s t ...... H offman 487

Vaccines and serums and their production in China. T sefang F. H uang. 360 Vaccination in Shanghai ...... 477 Value of urinary examination in the diagnosis of malaria ...... 371 Varicella, prophylaxis of ...... - - • • 1060 Varicose ulcers, treatment o f ...... 557 Veins, varicose, operation f o r ...... P rice. 712 Venereal diseases report o n ...... 279 Vincents organisms as a cause of ulcerative bronchitis ...... 847 Visceral disease, syptoms of, P ottenger (review ) ...... 1159 Vital statistics, J a p a n ...... 663 x x iv INDICES.

Weihsien, A.P.M. Hospital, report of .. 816 Whooping cough ether treatment o f ...... 275 rectal injection o f ether i n ...... 957 treatment of ...... • • • • 374 Women, Chinese, gynecological diseases o f ...... H e a t h . 701 Wuchang, A.C.M. Church General Hospital report o f ...... 1159

X-ray examinations in obstetric ...... • • • • 799 ' work in China ...... 284

Yatren treatment in amoebiasis...... 393 Y u W ang Fu A s s o c i a t i o n ...... 1053 INDICES. XXV

L i s t o f I llustrations .

Adeno-carcinoma of right breast before operation (Ludlow) .. .. 106/ A simple blood coagulometer (Peterson) ...... 1028

Caesarean section: unusual indication for (James) .. 498 Case of scoliokyphosis requiring caesarean delivery (E. D. Smith) .. .. 789 Chinese, collected anthropometric data on (Stevenson) ...... 872-898 Cochran, Samuel, President of China Medical Association ...... 382 Composite picture of a chain of tubercle bacilli within a giant-cell (Li.) .. 1003 Compound pregnancy (Ewers) ...... 496 Congenital absence of pectoralis major muscle (Hall) ...... 224 Cousland. P. B...... 1067

Delegates of Joint Medical Conference, B.M.A., and C.M.M.A., Hongkong. January, 1925 185

Geographical distribution o f unidentified nervous disease in Japan .. 1

Hernia, double inguinal (Ludlow) ...... 204 Heung Shan, Kwongtung. Kei Kwong Hospital ...... 436 Hygienic latrines in China (Best) ...... 59,61.63,65

Injection of lymphatic gland extract from rabbits (Mole) ...... 1113 Instruments for exenteration of the ethmoid labyrinth (D illey) .. .. 990 Intestinal protozoa (Kessel) ...... 975 Intracutaneous tests of diphtheria (Lim) ...... 996.997

Leprosy, nodular (Rogers and Muir) ...... 574

Neal, James Boyd, M.D...... 281

Faraffine bath and warming table (Illick) ...... 224 Photograph of a section from tumour (J. Preston Maxwell) ...... 1087 Placenta showing tumour (J. P. Maxwell) ...... 1086 Posterior segment of globe of tuberculous eye (Li) ...... 1003 Preputial calculus (W ilford ) ...... 713

Recurrence in left axilla (Ludlow) ...... 1076 Recurrence in right axilla (Ludlow) ...... 1076

Shanghai, St. Luke’s Hospital ...... 666 Sino-Japanese areas s'howing known distribution o f Bythinia striata (Faust). 287 Specimen o f Fuh-ling weighing 12.1 kilos (Read and W ong) .. .. 315 Susan Toy Ensign Memorial Hospital ...... 767

Tuberculosis o f eye. Horizontal sections ( L i ) ...... 1002

Uterine tubes: apparatus for insufflation test (H offm an) .. .. 487 Uterus prolapse .and pregnancy (J. P Maxwell) .. .. 479 XXVI INDICES;

I n d e x t o A u t h o r s .

Adolph, W illiam H., Ph.D., and Wei-Hsin Hsu, Tsinan. Fuel values o f every-day Chinese foods in every-day units .. .. 1041

A s f l a n d , W . W . G r a h a m , M.D.. F.R.C.S.E., Gen. Sec. Anti-Opium Assoc. Out of the frying pan into the f i r e ...... 1136

A v i s o n . D. B ., M.D., and Byron Koo, M.D., K o re a . Mercurochrome in treatment of chronic m alaria ...... 419

Bercovitz, N athaniel. M.D., Kachek, Tung. Practical aspects of hookworm control in China ...... 673

Best, A. B., B.A.. M.B., Chengtu, Sze. Hygiene latrines in China: A s u g g e s tio n ...... 57

Bliss, Theodore. M.D.. Wuchang. Fistula-in-ano ...... 916

Buckingham, E. W .. M.D., Kashing, Che. Transplacental malarial infection ...... 1140

Burn, M atthew, L.R.C.P., London. Auricular fibrillation ...... 128

C a d b u r y , W . W ., M.D., Canton. An analysis of the health of a missionary community in South China during a period of thirteen years ...... 723 Bronchial spirochetosis in Canton ...... 408 Medical research , in China ...... 952

C a m e r o n , J.. M.P.S., Peking. Eradication o f the cockroach ...... 458 Some observation on hydrogen peroxide ...... 352 The system of receiving and issuing prescriptions in Peking .. .. 949

C h a o H s i - a n g , M.D., Changsha, Hunan. Hemoptysis in pulmonary tuberculosis ...... 397

Chau, K. Y., M.D.. and J. AI. W r i g h t , M.D., Canton. Gynecological Notes: Canton Hospital .. .. 684

Cheal, Percy, M.R.C.S., L.R.C.P., Tainan, Formosa. Treatment o f chronic nephritis by decapsulation o f the kidneys .. .. 40

C h e n , K. K., Ai.D., Peking. Pharmacology of Ma Huang .. .. 348 Cinnamon Chinese, histological study ...... *350 Effect of ephedrine on experimental shock and hemorrhage .. .. 350

C h e n , K. K., Al.D., and Schmidt, Carl F., AI.D., Peking. Chinese Materia Medica: Ma H uang ...... 982 INDICES. x x v ii

C h e n , S. P.. M.B.. B.Ch., Peking. A new anti-scarlatinal se ru m ...... 911

C h u n , J. W . W .. M.B., B.C.. Harbin. The influence o f Chinese diet on disease ...... 1046

C u r r a n , J. A., M.D., Peking. Aspirating apparatus for tonsillar and adenoid operations...... 49

D a v is , C. N oel, M.D., B.S., (Lond.), D.P.H., D.T.M.. and H„ (Camb.) Leprosy ...... 632

D e c k e r , H .. W .. M .D ., Shanghai. Double-headed monster with two complete spinal columns ...... 44

D i l l e y , F. E.. M .D ., F.A.C.S., Chefoo. Ethmoidectomy, or exenteration of the ethmoid labyrinth ...... 989

D u n l a p , A. M., M.D., Peking. Bacteriology of ear infections ...... 331 Peanut bronchitis in China ...... 903 Review of literature on focal infection ...... 1079

E a r l y , P. V., M.B., (Lond.), Fatshan, Kwangtung. Flocculation test in relation to syphilis ...... 140

E v a n s , W. J., M.D., S ia n fu , Shensi. Tumours of the eyelids ...... 145

E w e r s , E. M., M.D., Weihsien, Sung. Compound pregnane}-: with report of case ...... 493

Faust, Ernest Carroll, Ph.D., Peking. Case of triradiate taenia solium from north China ...... 800 • Recent aspects of the epidemiology of clonorchis infection in China .. 287

Faust, Ernest C., M.D.. Peking, and Masao Nishigori, Peking. Preliminary report on the life cycles of two new heterophyid flukes occurring in the Si no- Japanese areas .. .. 914

Fowler, Henry, L.R.C.P. and S., L.F.P. and S.G., etc. Survey of leprosy in China ...... 584 Review of and some observations in the modern treatment of leprosy in China .. .. •• 594 Direction for the treatment of leprosy .. .. 1133

Frazier, Chester N., M.D., Peking. Hongkong foot ...... • • ■ ■ • • ■ • • • • • 705

G alt, Curtis, M., M.D., Yunnan. Rat-bite fever: report of case ...... 1029

G a s t o n , J. M., M.D., Laichow, Shantung. A case of trigeminal neuralgia treated by injection method 1122 x x v iii INDICES.

G ib s o n , R. M., M.D., Hongkong. Removal of tumours of the scalp ...... 1041

Hadden, George, M.B.. Ch.M., Anking. Institute of Hospital Technology ...... 817

H a l l , G. A. M., M.B., B.S.. M.R.C.S.. L.R.C.P, Tat^ungfu. Shansi. Congenital absence of pectoralis major muscle ...... 224 Sodium thiosulphate in the treatment o f mercurial stomatitis .. .. 785

Harston, Montagu G.. M.D., M .O ., (Oxon.), Hongkong. Choice of operation in extraction of cataract ...... 199

Harvey, J. L., M.D., C a d b u r y , W . W.. M.D., 'J eu . L. N .. M.D.. Canton. Bronchial spirochetosis in Canton .. 408

Heath, Frances J.. M.D., Peking. Review o f eight years’ work in China in a gynecologic out-patient clinic. 701

Heiser, Victor G.. M.D. Present status o f treatment for leprosy ...... 591

H o f f m a n , P. Doris, M.D.. Peking. The trans-uterine insufflation test for patency of the uterine tubes . . 486

H u a n g . T. F., Peking. Vaccines and serums and their production in China 349

H u m e , E. H .. M.D., LL.D., Changsha. Hunan. Relationship in medicine between China and the Western world .. .. 185

H u n g P i h C h u , and T o r a l d S o l l m a n n , Cleveland, Ohio. Autonomic rhythm of the turtle heart, as influenced by various conditions. 348

I l l i c k , J. T., Nanking. Paraffine bath and warming table ...... 225

James, Mary Latimer, M.D., Wuchang, Hup. The training of Chinese graduate nurses as midwives .. .. 835 Unusual indication for caesarean section ...... 489

J e u , L. N., M.D., C a d b u r y , W. W., M.D.. and J. L. H a r v e y , M.D.. Canton. Bronchial spirochetosis in Canton ...... 408

Jui Hua Liu, M.D., Peking. Present status o f bronchoscopy and esophagoscopy ...... 414

K e s s e l , J. F,. Ph.D., Peking. Distinguishing characteristics of the intestinal protozoa of man .. .. 85 A preliminary report on the incidence of human intestinal protozoan infections in Seoul, Korea ...... 975 INDICES. x x ix

K e s s e l , J. F. Ph.D., and W i l l n e r , O., M.D., Peking. Some clinical and laboratory aspects o f amoebiasis ...... 383

K ing, G. E.. M.B., Ch.B., Lanchow, Kan. Kansuh and its diseases ...... „ ...... 19

K o r n s . J. H., M.D., Peking. Incidence of tuberculous infection in China .. 10 Primary tuberculosis of tonsils and adenoids among Chinese .. .. 899

L a w n e y , J. C., M.D.. L. Van. M.D., and M cD aniel, M. E.. M.D., Shanghai. : Treatment of post-operative acidosis with insulin and glucose .. 924

L e a c h , C. D., M.D., Huchow, Chekiang. Some problems of infant feeding in the Orient ...... 1049

Leavell, George W , M.D., Wuchow, Si. Syphilis : its importance to physicians in China ...... 776

Lee, Charles O., Pharmacist, N a n k in g . Modem pharmacjr in China ...... 55

L e e , C. 0 .„ and R e a d , B. E.. M.P.S., Peking. Chinese inorganic materia medica ...... 23

Lee. C. U., M.B.. Ch.B., D.T.M. and H., Peking. Treatment of schistosomiasis japonica ...... 321

Lee. T. P.. M.D., Peking. The finding of miliary tubercles in the choroid of autopsy specimens .. 501

L e n n o x , W . G., M.D., Boston, Mass., U.S.A. Temperature and pulse rates of patients in Peking and Boston .. .. 218 Li. T. M., M.D., Peking. Extensive tuberculosis of an eye in an infant ...... 1002

L im , C. E ., D.T.M., Dr.P.H., Peking. League of Nations Grading of Far Eastern P o r t s ...... 422 Subcutaneous lesions in the intracutaneous test for the virulence of diphtheria ...... 996 L im , R o b e r t K. S., M.B., Ch.B., Ph.D., Peking. Gastric secretion ...... 505

L in g , W . P., M.D., Peking. Further observations on the fundus oculi of kala-azar patients .. .. 681

L u d l o w , A. I., M.D., F.A.C.S., Seoul, Korea. Inguinal hernia: report o f 100 operations on Korean patients .. 204 Carcinoma of the male breast ...... 1076

Mahk Runchaiyon, M.D., and H enry R. O ’Brien, M.D. Treatment of leprosy in Bangkok with ethyl esters froiri hydnocarpus anthelmintica ...... 60C XXX INDICES.

M a i t l a n d , C. T., M.D., B.Sc., M.R.C.P., England. Health and industrial conditions in China ...... •. 1089

M a r t i n , S. H, M.D., Tungchow, Si. Five cases of atriplicism .. .. 808

Masao Nishigori and F a u s t , E. C., M.D., Peking. Preliminary report on the life cycles of two new heterophyid flukes occurring in the Sino-Japanese areas ...... 914

M a x w e l l , J a m e s L., M.D., Shanghai. Century of medical missions in China ...... 636

M a x w e l l , J. P r e s t o n , M.D., F.R.C.S., Peking. Prolapse and p r e g n a n cy ...... 479 Tumours of the placenta ...... 1086

M cCandliss, H. M., M.D., Hainan, Medical experiences during forty years in China ...... 934

M cCartney, J. L i n c o l n , M.D., Hankow. Headaches: with special reference to those of psychogenic origin .. 32

M cDaniel, M. E., M.D., L a w n e y , J. C., M .D ., and Van, L., M.D. Shanghai. Treatment o f post-operative acidosis with insulin and glucose .. 924

M iller, Iva M., M.D., C.P.H., Shanghai. The health of the school ch ild ...... 1101

M o l e , R. H., B.A., M.D., Ch.B., Moukden. Experiments with mesenteric lymph gland extracts from rabbits .. .. 349

Montgomery, J. H. M.B., Ch.B., Chinchew, Fukien. Evangelistic w ork in mission hospitals .. .. 534

M o r r i s , H. H., M.D., Shanghai. Case of irritable uterus .. 43

M o s s e , F. H., M.R.C.P., Shantung, Tsinan. Evangelistic work as related tomedical schools ...... 544

M u i r , E., M.D., F.R.C.S., Calcutta. Some points of importance in dealing with the leprosy problem .. .. 575

O’Brien, Henry, R., M.D., and Mahk Runchaiyon, M.D. Treatment o f leprosy in Bangkok with ethyl esters from hydnocarpus anthelmintica ...... 600

Oppenheim, F., M.D., Shanghai. Review of one hundred autopsies of Shanghai Chinese .. .. 1011,1026

P e t e r s o n , R. A „ M.D., Chengtu, Sze. Etiology and treatment of sym blepharon ...... 309 A simple blood coagulom eter ...... 1026 INDICES. x x x i

P f i s t e r , M. O., M.D., M.R.C.S.. L.R.C.P., P e k in g . Syphilis: central nervous system and antisyphilitic treatment .. .. 688

P r i c e , R. B., M.D., Taichow, Ku. A simple operation for superficial varicosc veins o f the leg .. 712

R e a d , B. E., and W o n g , S. Y.. Peking. Chemical analysis and phsyiological properties of Fuh-ling .. .. 348

R e a d , B. E.. M.P.S., and L e e , C. O., Peking. Chinese inorganic materia medica ...... 23

R e a d , B. E.* M.P.S., Peking. Experiments upon preparations from Chinese chaulmoogra seeds .. .. 350 The nature of the leucocytosis caused by the administration o f chaulmoogra oil and its derivatives ...... 351 Nature of leucocytosis induced in the rabbit by the administration of chaulmoogra oil and its derivatives ...... 605 Notes on the preparation and use o f the ethyl esters from the chaulmoogra oils ...... 612 Oral administration of chaulmoogra oil in the treatment of leprosy .. 619

R o g e r s , J. M., M.D., Soonchun, Korea. Mercurochromc-220 soluble in the treatment of infections .. .. 123

S c h m i d t , C. F., M.D., Peking. Huang Chi, reputed diuretic action of ...... 348

Shirokogoroff, S. M., Shanghai. Notes on the physical growth among the Chinese males and females of Chekiang ...... 1029

S m i t h , E. D a r g a n , M.D., Chengchow, Honan. Cesarean delivery: indications and safety factors ...... 788

Snell, John A., M.D., Soochow, -Ku. Female nurses in a general hospital ...... 832

S o l l m a n n , T o r l a n d and H u n g P i h C h u , Cleveland, Ohio. Autonomic rhythm o f the turtle heart as influenced by various conditions. 348

Stevenson, Paul, H., M.D., Peking. Collected anthropometric data on the Chinese ...... 855

S u t t o n , L. E., M.D,, Chungking, Sze. Objectives'of medical'mission work'in China .. .. - .. 826

Svensson, Ruth, M.L., Peking. Observations on the development and longevity of hookworm larvae in different temperature conditions...... 667

Taylor, Adrian, S., M.D., Peking. Acute intestinal obstruction ...... 767 T a y l o r , R. V ., M.D., Yangchow. Operating room team work ...... 944

Thacker-N eville, W . S., M.D., (T.C.D.), F.R.C.S., (Edin.), Chang­ sha. Maxillary sinusitis: report of two anatomical anomalies .. ■ • - • 296

T s e f a n g F. H u a n g ,. S. M., M.D., Peking. Vaccines and serums and their production in China .. -- .. 360

Tso. E r n e s t , M.D., Peking. Composition of Hen’s eggs in relation to size ...... ♦ 136

Van Buskirk, J. D., M.D., Seoul, Korea. Occurrence of sugar1 in the urine o f Korean Hospital patients .. . . 47

V a n , L., M.D., L a w n e y , J. C., M.D., and M cD a n i e l , M. E., M.D., S h angh ai. Treatment o f post-operative acidosis with insulin and glucose .. .. 924

W a l l a c e , E. W ., B.A., B.D., Shanghai. Co-operation in a school health programme...... 437

W ebster, Jerome P., M.D., Peking. Reels for ligature silk .. .. 804

W i l f o r d , E. C.. M.D., Chengtu, Sze. Cases of gastro-enterostomy ...... 807 Remarkable preputial calculus ...... 712 Operations on foreigners in China ...... 922

W tllner, O., M.D., and J. F. K e s s e l , Ph.D., Peking. Clinical and laboratory aspects o f amoebiasis and Yatren treatment .. 383

W o n g , S. Y., Hongkong. Centrifugal method for the quantitative determination of albumen in urine ...... 348

W o n g , S . Y., Peking, and Prof. B. E. Read, Peking. Chemical analysis and physiological properties of Fuh-ling .. .. 314

W o n g , K. C h i m i n , L.M.S.H., Hangchow. Chinese medical sayings and proverbs ...... 1099

W r i g h t , J. M., M.D., a n d K. Y. C h a u , M.D., C anton. Gynecological notes: Canton Hospital ...... 684 1 . H okkaido, 17. Sisoka. 32. Tokushim a. 2. Tokyo. 18. Yamanashi. 33. Kagawa. 3. K yoto. 19. Shiga. 34. Ehime. 4. Osaka. 20. Gifu. 35. Kochi. 5. Kanagavva. 21. Nagano. 36. Fukuoka. 6. Hiogo. 22. Miyagi. 37. Yam agata. 7. Nagasaki. 23. Fukushima. 38. Fukui. 8. Nigata. 24. Aom ori. 39. Ishikawa. 9. Saitama. 25. Akita. 40. W akavam a. 10. Guma. 26. Toyam a. 41. Oita. 11. Tshiba. . 27. Tottori. 42. Saga. 12. Ibaraki. 28. Shimane. 43. Kum am oto. 13. Tochiki. 29. Okayama. 44. Kagoshima, 14. Nara. 30. Hiroshima. 45. Iwate. 15. Miye. 31. Y am aguchi. 46. Miyazaki. 10. Ahichi.

Geographical Distribution of the Epidemic of an unidentiiied Disease involving the Central Nervous System, which occurred in Japan, August and .September, 1924. H e (¡puna UM ial Jw iw l

VOL. XXXIX. JANUARY, 1925. No. 1

EPIDEMIC OUTBREAK IN JAPAN OF AN UNIDENTIFIED DISEASE INVOLVING THE CENTRAL NERVOUS SYSTEM *

A severe epidemic of a disease, first reported unofficial^ as 'Cerebro-spinal meningitis, later as encephalitis lethargica, but finally qualified as a hitherto unidentified epidemic disease involving the central nervous system, has developed in Japan. The first cases occurred in July, 1924, in the Department of Toyama •on the vvest coast of the main island, and the disease assumed with great rapidity the character of a very serious epidemic, •culminating as early as August. The provinces bordering on the inland sea, especially Kagawa on the island of Shikoku, and •Okayama on the mainland and Tottori north of Okayama, became the principal centre of the epidemic, which during September .spread over nearly the whole of Japan, without, however, attaining Ihe same prevalence in the later-affected provinces as in the first centres. The Central Sanitary Service of Japan had received reports •of 4,274 cases up to September 5th; in the following ten days 1,609 new cases were notified, and during the two next weeks •ending September 29th there were 66S new cases. The explo­ sive character of the outbreak and its intensity differ funda­ mentally from any of the hitherto observed outbreaks of en­ cephalitis lethargica and recall only a few of the worst outbreaks •of acute poliomyelitis. The incidence has been nearly 3 per 1,000 inhabitants in the most seriously affected province, Xagawa. The geographical distribution of the reported cases is shown in the following table.

*From the League of Nations, Monthly Epidemiological Report of the Health Section of the Secretariat, November 15th, 1924. 2 The China Medical Journal.

Table i . Cases of an Epidemic Disease of the Central Nervous System notified in Japan, August and September, 1924. Cases per Provinces Cases reported Total cases 100,000 to Sept. 5 Sept. 6-15 Sept. 15-29 io Sept. 29 inhab. Hokkaido i 0 3 4 0.2 Tokio 0 18 41 59 1.6 Kioto 0 34 22 56 4.4 Osaka 0 37 20 57 2.2 Kanagawa 9 i 6 16 1.2 Hiogo 445 202 78 725 31-5 Nagasaki... 3 14 4 21 1.8 Nigata *5 45 12 72 4.1 Saitama ... 0 3 0 3 0.2 Guma 4 5 2 11 1.0 Tshiba i 0 3 4 0.3 Ibaraki ... 24 0 3 27 2.0 Tochiki ... 2 i i 4 0.4 Nara 0 5 2 7 1.2 Miye 0 0 0 0 0. Aichi i 0 0 i O.I Shisoka ... 0 0 i 3 0.2 Yamanashi 2 i 0 3 °-5 Shiga i 5 i 7 1.1 Gifu...... 0 6 i 7 0.7 Nagano ... 75 93 25 193 12.4 Miyagi ^ ... 0 21 7 28 2.9 Fukushima 0 7 4 11 0.8 Awomori... 0 3 75 78 10.3 Akita i 36 68 105 11.7 Toyama ... 521 181 10 712 98.3 Tottori ... 291 116 1 3 420 92.4 Shimane ... 0 72 33 10 5 14-7 Okayama... 581 53 20 604 53-7 Hiroshima. 67 67 47 181 11.7 Yamaguchi 72 36 21 129 12.4 Tokushima 2 77 35 4 316 47.1 Kagawa ... i j797 1 3 9 27 *>963 289.6 Ehime 34 200 20 254 24-3 Kochi 0 84 15 99 14.8 Fukuoka... 48 46 18 112 5-1 Yamagata.. 0 5 12 17 1.8 Fukui 0 19 0 19 3-2

4,272 1,592 619 6,483 Epidemie of unidentified Disease of Central Nervous System. 3

Forward : 4,272 I >592 619 6,483 Ishikawa ... 0 8 4 12 1.6 iWakayama 0 3 4 1 - 44 5-9 Oita...... 2 —— 2 0.2 Saga...... 0 0 2 2 0.3 Kumanoto.. 0 3 I 4 0.2 Kagoshima 0 3 I 4 0-3

Totals: 4,274 1,609 &68 6,551 11.7

It is seen that very few new cases were notified in the province of Kagawa, which had been the worst affected during the last two weeks of September, and only 10 new cases occurred in Toyama during the same period as against 181 during the preceding ten days- The decline of the epidemic in its main centres appears, therefore, to have been far more rapid than is usually the case of epidemics of encephalitis lethargica. The provinces of Tokyo, Kyoto and Osaka, which had been quite free from the disease in August, reported each about 60 cases in September, and other departments in Northern Japan were infected at the same time. The case fatality rate is very high, and for all the cases reported up to September 29th is stated as 54.85 per cent. This is a higher case fatality than has usually been found in extensive outbreaks of encephalitis lethargica, in the case of which disease the fatality is very variable and usually much higher than ever met with for acute poliomyelitis; it approaches in this epidemic the ordinary case fatality rate for epidemic cerebro-spinal meningitis. The central sanitary service immediately sent experts to the affected provinces, who have investigated the disease in conjunction with the medical schools and bacteriological institutions throughout the country. The measures of control adopted were those usually- applied in the case of epidemic cerebro-spinal meningitis. Although the progress of the epidemic was extremely rapid, more than one case occurred rarely in the same household, a condition which has frequently been observed in epidemics of acute poliomye­ litis. A careful canvass in the department of Toyama, where more than 700 cases were found, did not reveal more than one case in any one family. It may be added that the summer had been unusually dry and that the decline of the epidemic coincided with the coming of the rains. 4 . The China Medical Journal.

Having applied to the Japanese Health Service in Tokyo, the Health Section of the League of Nations received on October 18th, 1924, the following short description of the recent epidemic disease in Japan :

The symptoms of the disease resembled those of encephalitis lethargica, although the usual eye symptoms were absent.- Persons affected were mostly over 50 years of age. Onset sudden, with high temperature; after one or two days, loss of consciousness and slightly maniac condition.

Death in 5 to t o days, or recovery with the falling of the temperature which is accompanied by a regaining of con­ sciousness.

Cerebro-spinal fluid in all cases clear; pressure not uniform. N o pathogenic micro-organism was found. Incubation period in man not definite; in animal experi­ ments, about three days. Rarely more than two cases occurred in the same family- Fatality about 60 per cent.

First case occurred in July; during the month of August the disease assumed an epidemic character and by the end of the month the number of fresh cases decreased considerably.

T a b l e 2 . Age of Patients attacked by the Epidemic D i s e a s e . Case Case per Recov­ Still fatality 10,000 Age Cases Deaths eries sick per cent popul. Under 10 years .. 21 10 7 4 59 I.— From 11-20 •• 25 10 5 10 66 x*55 ,, 21-30 .. 20 9 6 5 60 1.77 » 3i - 4° • ■ 23 12 5 6 76 2-34 „ 4 3>5° • • 25 17 3 5 S5 2.99 „ 51-60 •• 55 35 6 14 35 8.63 „ 61-70 .. 67 42 12 13 77 13.06 „ 71-80 .. 49 4 i 3 5 93 19*59 ♦Over 80... .. 14 13 0 1 93 20.70

Totals... 299 189 47 63 63 Epidemic of unidentified Disase of Central Nervous System. 5

It appears that the incidence of the disease increases very rapidly with age as seen from the following analysis which has been made of the cases which were notified in the Department of Tokushima. This age distribution is quite different from that commonly observed for the epidemic diseases of the central nervous system. The male sex seems to be the most affected— in Tokushima there were 185 cases among men and 114 among women. The following observations of the clinical characteristics of the disease have been furnished us by Dr. Yoshio Kusama, of the Medical College of the Keio University, Tokyo :

The diseqse begins with a sudden rise of temperature, without or with a few prodromal symptoms, such as slight headache, insomnia and general discomfort. Within one or two days the temperature rises to 39°C . 4o °C . or even 41 °C. Nausea, vomiting, anorexia and insomnia may set in. . In one type of cases the temperature, after lasting at its highest level (betw een 39 °C. and 41 °C.) for several days, comes down by fysis and becomes n orm a l in 10 or 15 days from the onset. However, many patients succumb to the disease before the fall of the temperature sets in. In the other type of cases (usually they are very mild or very severe cases) the temperature comes down at about the end of the first week by crisis. The pulse is usually slow in proportion to the high temperature, but not as slow as in cases of enteric fever. Respiration is not very much accelerated. No Cheyne-Stokes respiration. Nervous system.—There is a distinct spastic condition of both lower and upper extremities. Kernig’s sign strongly marked; Babinski reflex and Oppenlieim absent. Skin reflexes without change. Pupil normal in shape and size. Reaction to light normal. No nystagmus. No paralysis of external eye-ball muscles. Consciousness.—Unconsciousness is a predominant symptom of the diisease. In severe cases with high temperature patients may fall into a comatose condition, sometimes accompanied by delirium, from the begin­ ning ; in others, loss of consciousness does npt set in until 2 or 3 days afier the onset. Loss of consciousness is not absolute; it is rather a state of deep somnolence during which patients may react to simple questions or swallow food. In severe cases patients die without regaining consciousness, in others they regain it with the fall of temperature. In the majority of cases, delirium supervenes 2 or 3 days after, the onset. Skin.— In some, cases petechial hemorrhages on patient’s back have been noticed. Tongue.—Tongue is coated and dry. No congestion of pharynx or ton sils. 6 The China Medical Journal.

Lungs.—Examination' of the chest shows dullness and slight pneu­ monia symptoms in the back. Abdomen.—Sometimes distended, but in general normal : no tenderness. In the majority of cases, constipation. Liver and spleen.— Not palpable. There is retention of urine in many cases.

Recovery.—If there is no fatal issue, recovery is complete after defervescence (10 to 15 d a ys).

L a b o r a t o r y F in d in g s .

Cerebrospinal fluid: Fluid is clear. Cell-count : 10 to 40, occasionally more lymphocytes. Nonne-Apelt reaction: Sometimes doubtful positive in the beginning. Wassermann test : Negative. Pressure : Usually between n o and 150 mm. water, rarely higher, up to 250. Culture : Negative. Blood : Hemoglobin, 70 to 92%. Leucocytosis : (10 to 20,000). There is marked increase of polymorpho­ nuclear neutrophile leucocytes (to some 93% or more), and marked decrease of lymphocytes to about 4%. Wassermann test : Negative. Widal : Negative. Culture : Negative. Urine : Slight albuminuria seems to be the rule.

A u t o p sy . Nervous sysiem: Macroscopic examination.— There is marked congestion and oedem a of meninges. There may be found patchy clouding at the base of the brain. Dura, normal, no adhesions. No increase of cerebro-spinal fluid. Cortex : with the exception of general hypersemia, there is no abnormality. In a few cases one or two petechial hemorrhages at the floor of the fourth ventricle have been noticed. Microscopic examination.— Changes in meninges corresponding to the naked eye appearance. Cortex congested; there are round-cell infiltrations round the blood vessels. There may be found occasionally a few areas in cortex, pons and medulla oblongata with round cell-infiltra- tions. In one case there was found a small area of softening, infiltrated with lymphocytes. There may be found slight degenerative changes in the ganglions, pons and medulla. No changes are found in dura or choroid p le x u s . Lungs : CEdema and congestipn. Leucocytic infiltrations in the basis of the entire lower lobes. trai Nervous System. 7

Kidneys : Marked diffuse parenchjTnatous degenerative changes and distension of the pelvis.

Liver : Marked diffuse parenchymatous degeneration.

Spleen : Somewhat enlarged, of normal consistence.

B acteriological E x a m in a t io n .

Cultures were made from brain tissue, cerebro-spinal fluid, spleen, kidney and blood. No suspicious organisms could be detected. Experimental disease was produced in rabbits by injecting infective materials subdurally, either filtered with Chamberland No. L 3 filter, or non-filtered. After a 2 or 3 days’ incubation period the animals showed fever, lost appetite and remained quiet, while after 3 to 5 days the hind legs appeared to be paralysed. The mortality among animals was v ery h igh.

A short survey of the present situation of the epidemic diseases of the central nervous system and of influenza in the countries from which regular reports are received is of interest in connection with the Japanese outbreak, and the summaries for these diseases follow, therefore, below.

E ncephalitis L e t h a r g i c a .

Encephalitis lethargica has been unusually prevalent in 1924 only in Great Britain and Ireland ; smaller outbreaks have occurred in Italy and Sweden, but the disease has been less prevalent than during the previous years elsewhere on the European continent and in North America.

The outbreak in the United Kingdom came later than usual, the maximum occurring in the middle of May in England and early in June in Scotland, while in 1923 the greatest number of cases were notified in March and in 1921 in February. The epidemics •did not coincide with the influenza outbreaks but preceded these in some cities, as, for example, in Manchester, while in most localities they came later, in London even three months later, than the in­ fluenza outbreaks.

The decline of the epidemic has been very slow once the period of intense outbreak was passed, and the number of notifications have stabilised themselves in September and October at a very much higher level than during the former years. s The China Medical Journal.

It will be recalled that the prevailing type differed from that of the earlier outbreaks ; the case fatality rarely exceeded 20 per cent, while in former outbreaks it had been nearly 50 per cent. The onset often resembled influenza and abortive attacks were frequent. The original oculo-lelhargic tj’pe was less common than, during the earlier epidemics and many cases were characterised by myoclonic symptoms.

It is singular that this epidemic of encephalitis lethargica in Great Britain and Ireland, the most severe on record, has been, so far, an entirely isolated phenomenon, at least as far as true enceph­ alitis is concerned. No report of any unusual prevalence of the, disease had been received up to the middle of November from any country in Europe.

A c u t e P oliomyelitis .

Important outbreaks of acute poliomyelitis occurred this year only in the area where it has usually been most prevalent, namely,, in Scandinavia, Great Britain and in the United States. Although more cases have been notified than during the two previous years, the outbreaks have been far milder than the epidemics of 1911,. 1912 and 1916.

In England and Wales the total number of cases reported during the first ten months of the year was 632, as against. 521 for the corresponding period last year. The. number o£; cases notified in September in Sweden was 192, as against 80 and 13 respectively during the same month of the two previous years. 45 cases were recorded in Denmark during the same month, as“ against 10 in September, 1923. The very intense outbreak in- Iceland, the incidence of which has been about 2 cases per 1,000 inhabitants, culminated two months earlier than in the former' countries/ in July. The case fatality of this epidemic has beeir very high, namely, 37 per cent, counting only the cases showing definite paralysis.

The outbreaks in thè United States culminated also in Sep­ tember; 1,465 cases were reported in 27 States during the 8 weeks ending October 6th, as against 760 for the same period of the previous year. Epidemic of unidentified Disease of Central Nervous System, 9

... Epidemic Cerebro-Spinal .M eningitis. Cerebro-spinal meningitis has, in general, been less prevalent in 1924 than during the preceding years. Major outbreaks have been reported onl3' from certain localities in Africa (Nigeria) and from Japan, where the above-mentioned epidemic appears to have been accompanied by a considerable number of cases of true meningococcal meningitis. During the six weeks ending September 20th there were notified 1,189 cases of cerebro-spinal meningitis in Japan, but it is not shown how many of these were bacteriologically verified, and it is possible that some of them were not the true meningococcal meningitis but appertained rightly to the other epidemic. The decline of cerebro-spinal meningitis is especially marked in Germany, where only about half as many cases as in 1923 Have been notified. A similar decline of this disease is shown by the returns for the United States.

I n f l u e n z a . It will be recalled that the influenza epidemics of last winter occurred at very different periods, culminating as early as Novem­ ber in Russia, in Januarj7 in Paris and Dublin, and as late as the end of March in several cities of Northern England and Scotland. The cases and deaths attributed to this disease have slowly declined since then up to August. A slight increase in October is remarked in the returns from several countries, but the trend of the figures indicate, so far, nothing unusual; thus, in 105 large English towns 138 deaths are recorded as due directly to influenza during the four weeks ending November 1st, as against 85 deaths during the preceding four weeks. The notification of influenza cases in Denmark increased from 1,177 August to 1,692 in September,, and similar increases occurred in Norway and Sweden. Outbreaks of influenza in the southern hemisphere are reported especially from M auritius, where 196 deaths were attributed to this cause in July and 141 in August. An outbreak of influenza is reported also from the Union of South Africa, but no data are $s yet available. 267 cases were reported in July in Uruguay, as against 73 for the same month of the previous year. It is evidently too early to draw any definite inference from the reports thus far received. IO The China Medicai Journal.

INCIDENCE OF TUBERCULOUS INFECTION IN CHINA*

Jo h n H . K o r n s , m .d ., P ek in g. Any one who lias a knowledge of tilings Chinese will support the statement that tuberculosis is prevalent in China. But one can only guess at the incidence of the disease. Those hospitals which make careful diagnoses, as a rule admit few if any cases of pulmonary tuberculosis; consequently, their statistics do not serve as a criterion for judging the incidence of this form of the disease. A large proportion of cases of the other types of tuberculosis also are not admitted for treatment. Such hospitals usually do not re­ port diagnoses on out-patients. Consequently, hospital reports, even if they did deal with a cross-section of the population, which they do not, are of limited value in determining the incidence of tuberculosis. Vital statistics are not and cannot now be kept scientifically in China. In Hongkong, where an attempt is honestly made to record mortality statistics, we learn that in 1922, with a Chinese population of 662,000, there were 2,063 deaths from tuberculosis or 311 per 100,000. This is excessive as compared with the figures given for 1921 in Munich, London and New York, where the rate was 154, 128 and 103 respectively. While it is not possible as society is organized at present to state the incidence either of mortality or, what is more important, the morbidity from tuberculosis in China, it is feasible, through the tuberculin test, to determine with some accuracy the incidence of tuberculous infection. And as a preliminary to intelligent preventive efforts it is important to have such information at hand. An ideal survey would include all children, healthy and sick, up to the age of young adult life. When, however, only tuberculin is used as a test of the presence or absence of infection, it is a fact that ill health may interfere with the reaction and vitiate the result.

P r e s e n t S e r i e s . In the present series Tables I to III have to do with apparently healthy children attending school and working. These tables do

♦From the Department of Medicine, Peking Union Medical College, Peking, China. Incidence of Tuberculous Infection in China. n not include any children below the age of eight j’ears (Chinese reckoning),* as permission to do tests on small children in orphanages was repeatedly refused. For the sake of completeness, therefore, a series of tests on hospital patients under the' age of 8 is added in Table IV . These latter tests were done routinely on the Children’s Ward service of the Peking Union Medical College Hospital. As is implied above, Chinese reckoning of age is •employed in Tables I, II and III. In Table IV the age is recorded in months of extra-uterine life as nearly as possible up to five years, above which the ordinary Chinese reckoning is used. The .series of 2,049 apparently healthy Chinese children here reported include 1,070 boys and 979 girls and range in age from 8 to 20 years inclusive (Chinese reckoning). They are from 12 different institutions either in or near Peking, or in Paotingfu, 120 miles from Peking. The large majority of the children were born in North China. In general, no attempt was made to classify accord­ ing to geographical origin. Table III. however, illustrates such a classification of the Chiao Yang So students. A rough division into urban and rural is shown in Table I, information for this having been obtained by asking each student whether he or she was born in a city (3$ 3g) or in the country ($$ ”]r). An intellig­ ent Chinese told the writer that “ $$ "I»” might mean a rural district, a village, or even a city containing as many as 10,000 people, so this classification is not especially scientific. The institutions known as Hsiang Shan T z’u Yu Yuan, Chiao Yang So, P’in Er Yuan and Kan Hua Hsiieh Hsiao, contain only poor children. Many of them are from famine areas, the remainder being chiefly children of destitute Manchus. They are children, therefore, who have had inferior advantages from a health standpoint and who should show, one would suppose, a high incidence of infection. Of the other groups the P’ei Yuan School, Ma P’i Ch’ ang School, and Gamewell Girls’ School in Peking, the two Presbyterian Schools and the two American Board Schools in Paotingfu, are operated under missionary auspices. The Paotingfu Second Normal is the only Government school in the list. These

*A Chinese child is considered one year old at birth and one year of age is then added at each succeeding Chinese New Year. If a child is born the last day of the old year he is thus considered 2 years of age on the second day of extra-uterine life. 12 The China Medical Journal.

Mission and Government school students come from homes that are not destitute, but chiefly of moderate means. Theoretically they should show a lower incidence of infection than the first group.

Of the hospital group, listed in Table IV , nearly all come from Peking city. A number of them are from orphanages, where health conditions are very bad.

T e c h n i c o f T e s t . The von Pirquet test was done on all children listed in. Tables I-III. After cleansing the flexor surface of a forearm wüth. 70 per cent alcohol, and allowing this to dry, two linear scratches- about two centimeters in length and three centimeters apart were- made with a flamed half-pen point. The oval-pointed Esterbrook. No. 668 was used, and sufficient pressure was exerted to excoriate the epidermis without drawing blood. Mulford’s o . T. pure was then gently rubbed into the lower scratch with a sterile toothpick having a flat end, as much tuberculin being used as adhered to the toothpick on its being inserted into the small tuberculin viaL To- the upper scratch nothing was applied. The reading was made after|48 hours, and all degrees of redness spreading out from the scratch, were considered positive, providing the control scratch was- entirely free from reaction.

The von Pirquet test was used also on some of those in Table* IV , a needle instead of a pen-point being used for scarification. On others the intracutaneous test was done, using 0.1 c.c. of a i »:io O' dilution of o . T. The control .for the intracutaneous test was a like amount of normal salt solution similarly injected. Readings with, both tests were made after 24 hours, and a definite redness persisting at this time, regardless of the size of the areola, was. considered positive providing the control was negative.

R e s u l t s i n A p p a r e n t l y h e a l t h y c h i l d r e n .

, Table I gives the results for the whole group of apparently healthy children according to institution, age, sex and place of birth- Section A includes students in charitable institutions, that is, those who come^from destitute families. Section B includes students of Mission and Government Schools who come from middle-class, and* in some instances, well-to-do homes. Positive Reactions Tests ue siao H eh su H a u H n a K T ota l m ales ales m l ota T i hn u Yu Yuan . n a u Y u Y zu T Shan g n sia H a Yang So... M .. ... o S g n a Y iao h C ... rural or rban U i Yuan a u Y r E ’in P t bt sexes both l ota T ... ales fem l ota T C h iao Y a n g S o ...... o S g n a Y iao h C i hn u Yu Yuan ..M ... n a u Y u Y zu T Shan g n sia H t mae, tve ... e itiv s o p ales, m l ota T n a u Y r E in ’ P t , e ls posii e itiv s o p ales, fem l, ota T ue i M o sia H eh su H a u H n a K re ae mae, stve ... e ositiv p ales, m tage, ercen P P ercen tage o f tota l, p ositiv e, per yr. yr. per e, ositiv p l, tota f o tage ercen P ... e itiv s o p total, f o tage ercen P retg, e ls positive.. ales, fem ercentage, P adttl¿posi ve ... e iv it s o p ¿ total rand G n o s t s e t n i l u c r e b u T — . r e l b a T »» » M ,, „ t f ff ff ft ft f ft ff >) as age f o ears Y t ft ft ...... M .. . F .. M .. . F .. . F .. M .. Sex S . F F F I M M R U 8 2,049 2,049 ... I 118 11 2 2 I 0 0 27 50 22 U R U 2 9 2 9 I 2 sex and birthplace. e c a l p h t r i b d n a x e s , e g a , n o i t u t i t s n i o t g n i d r o c c a d e i f i s s a l c , s t n e d u t s e s e n i h C y h t l a e h y l t n e r a p p a 2 4 3 I 24 9

12 22 33 3 5 3 3 3 7 10 6 4 I 0 10 18 22 25 20 5 2 2 8 4 2 I 2 2 2 26 10

32 44 27 33 29 25 ... 17 R 8 9 5 8 I 2 5 3 5 I I I I 33 13 11 24 19 14 21 U eto A. hrtbe Institutions. Charitable .— A Section 3 4 2 8 3 3 3 3 3 26 11

28 36 13 20 16 17 10 ...... 15 R 3 2 1 7 2 I 7 21 42 38 29 12 33 327 23 ... 13 14 R U 111 11 9 4 4 I 9 2 3 33 12

34 18 19 50 22 39 28 17 ... 6 2 4 I 2 6 I 5 2.3 33 ÓI 36 25 U 32 28 25 17 2 8 3 9 8 I I I 7 30 33 \ ) j... 34 3 I

37 27 25 93 68

25 32 U R 25 3 25 ... 30 12 10 1 6 5 5 2 I 39 49 22 323 23 72 39 29 24 21 12 5 9 I I 8 9 3 I I 14 30 115

47 33 018 20 92 R 30 232 32 31 26 36 66 16 08 10 9 3 4 3 5 2 2 2 2 6 30 773 37 56 U 941 19 12 37 20 14 4 3 I 8 8 15 25 114

48 36 .22 15 R 13 724 17 22 19 5 8 6 8 I I 3 9 5 I I 39 20 53 22 75 U 21 13 14 16 6 2 9 3 5 3 22 16

52 365 93 62 21 31 24 21 26 23 13 R U R 3 4 3 3 9 3 3 7 7 8 I 44 29 21 822 28 14 20 618 16 J3 6 9 4 2 3 2 2 6 7 2 17 19

50 36 73 23 20 19 14 9 4 4 9 5 5 3 I 27 11 29 39 18 26 10 R U 9 S 4 8 8 7 7 2 3 I I 22 18

45 30 15 20 18 10 17 5 5 3 4 I I 2 I 3 44 18 13 54 20 R U 5 8 4 5 7 2 7 2 4 I I I 24 19

20 27 06 20 517 15 11 7 7 0 3 3 3 ... U 750 17 6 6 3 3 I I I I 33 20 50 ... R 6 5 3 1 133 3 2 321 238 144 484 163 44 24 15 19 8126 88 42 13 45 58 13 27 U 27 725 27 t l ota T 3 4 468 i t 3 689 102 221 186 173 30 25 25 10 65 35 10 44 47 727 27 21 R 11 Ó 2 t l ota T ,73 i,i7 G. 549 330 3 789 117 ... 123 214 306 S 54 69 44 IO 48 77 19 24 3- I 92 24 26 4 2 . . . Positive Reactions Tests o ebtra hol M ool ch S resbyterian P u F ao P tl e ls ... ales fem otal T ool ch S l a orm N d econ S u F Pao t mae i ales m l ota T ool ch S oard B . m A u F Pao P ercen tage o f total, p ositiv e, p er yr. yr. er p e, ositiv p total, f o tage ercen P wel hol . .. F ...... ool ch S ell ew m a G P’ Cha Sc o .. . M F ...... ool ... ch S g an h C ’i P a M ool ch S uan Y ’ei P ad total rand G re ae and ttl postve sitiv o p total, d n ra g tage ercen P e ositiv p ales, fem l, ota T e v i t i s M o p ool aies, ch m S l ota l T a orm N d econ S u F M Pao ... ool ch S oard B . m A u F Pao retg, e ls postve... sitiv o p ales, fem ercentage, P ool ch S resbyterian P u F Pao ad oal posii ... e itiv s o p l, tota rand G F ool ch S n a u Y ’ei P retg, ls poii ... e ositiv p ales, m ercentage, P ... ool ch S g an h C i ’ P Ma me l Sc ool ch S ell ew am G ra o l a r u r or Urban > t 9 tt ti 99 9t tt t> ff a ft ft I) JJ , ,F ,, „ ,, f tt if l •*• )l » 9i as f age of ears Y ) » 9) ...... * •* A •** **• ...... A ...

xU ex S F M 1 F F F i M m F M F ' 21 25 24 20 21 4 0 i 5 5 3 13 8

U R 0 2 0 i i i i 100 250 32 30 31 30 10 20 10 3 6 9 i i i 1 33 9

032 50 R 1 2 i i 2 2 38 25 11 75 9 2 22 ... U 7 8 3 4 i 3 3 2 i i i 32 10

eto B. iso ad oenet Schools. Government and Mission .— B Section ... R 0 0 4 6 2 4 i i 25 23 50 28 26 ... 20 U 6 6 7 i i i O 5 i i 24 11 100

20 R 0 1 4 5 i i 2 i i i al i.— i Table 37 29 75 10 13 31 35 7 2 R U 9 3 3 i 4 3 i i 2 i i i 33 12

20 29 10 2 0 2 2 4 3 2 7 i i i i 13 42 40 67 M 61 16 16 16 35 3S 5 2 R U I l ï 2 4 3 2 3 I i l (Continued). 41 314 13

40 42 29 40 11 15 28 12 I 2 7 I 2 5 4 3 9 7 2 1 1 1 38 33 H 49 37 17 25 12 U 2 8 3 2 2 2 i 3 S 3 2 7 40

40 42 29 21 10 11 27 52 25 15 17 R U R 4 2 2 7 5 i ï i 5 7 3 2 i i i i 39 59 33 24 12 31 4 8 4 ï 3 ï 8 9 ï ï ï 5 2 i 7 i 36 5 1 36

36 41 26 20 6 13 13 36 32 16 13 12 4 8 6 7 3 3 S 4 ï ï 3 3 i 42 37 55 10 15 36 27 5 1 U 6 8 2 3 5 6 9 3 5 5 i i 38 16

37 32 24 21 51 ... 47 20 86 39 13 14 11 M u R 4 9 2 8 2 2 1 42 39 50 10 24 18 224 12 U 4 7 3 3 7 2 ï 3 6 2 2 6 i 38 7 1 3 3 53 34 3^ ° 4 40 58 26 33 21 12 82 11 46 36 11 10 15 R U R 4 8 6 5 3 9 40 37 25 24 20 5 1 9 8 2 ï 6 ï 4 2 3 2 i i 18 39 23 23 52 15 421 64 35 29 15 12 413 14 8 8 4 2 5 4 8 7 7 1 100 29 525 25 20 16 6 5 R U R U 2 ï 3 ï 7 i i 19 37 375 53 ... 10 43 24 9 1 01 6 18 10 14 4 4 6 6 2 4 2 6 7 45 45 11 11 ï 4 5 4 5 2 9 20 *5 56 28 15 34 19 20 14 2 ï 6 ï 2 i 7 328 109 135 5 7 1 54 28 i 48 10 6114 26 33 599 35 54 35 86 23 U 14 7 2 11 otal T R U 6 29 9 35 3 752 47 5 9 ï 00 5 u 494 267 227 190 40 14 76 77 50 68 75 18 76 837 38 28 71 10 12 3 2 2 6 otal T 876 5 9 5 G. 2 134 140 7 5 1 325 185 185 42 82 91 50 S 80 3& 38 56 19 50 91 12 31 12 39 n 1 - - ’ Incidence of Tuberculous Infection in China. 13

T a b l e i . —(Continued) Total for both Section A a n d

S e c t i o n B .

A g e 8 10 11 12 13 14 15 16 17 20 T otal 1 9 18 i 1 9

T ests 29 62 70 102 137 232 28S 269 290 244 160 109 57 2049

P o s itiv e rea ction s 5 18 20 26 46 79 94 80 84 70 48 33 28 631

Percentage of positive reaction s 17 29 28 25 33 34 32 29 29 28 30 30 49 30

The following points brought out in Table I may be noted.

1. The percentage of positives for all the years covered is considerably lower in both tables than one would expect in similar groups in Western countries.

2. The percentage of positives in Section A is 26, and in Section B it is 37, although one would expect a priori that Section A would show the higher percentage. The average age for the 876 in Section A is 14.5 years and that for the 1173 in Section B is 15 years.

3. The percentage of positives in Section B is higher for •the upper 13 years than for the lower 5 years, but there is no definite steplike increase with age. In Section A , however, the older years do not show an increase of positives over the younger years.

4. The percentage of positives is practically the same in both sections; for those classed as urban, viz., 30.9 and those classed as rural, viz., 30.6.

5. Males show a higher percentage of positives than females. This is quite marked in Section B, viz., males 50, females 31, while in Section A the difference is slight, viz., males 27, females 24. The average age of the boys and girls in Section A is the same, viz., 14.7 years while in Section B. that for the boys is 15.9 years and for the girls 14.5 years. This slight difference in age can hardly account for the marked difference in percentage of positives. 14 The China Medical Journal.

T a b l e 2 .— Tuberculin tests showing percentage of positives in 848 children according to length of residence in Hsiang Shan Tz’u Yu Yuan.

P ercen tage Length of residence Number of tests Number positive p ositiv e

L ess th an 1 3re a r ...... h i 24 22 1-2 y ea rs...... 76 18 24 2-3 yea rs...... 195 42 22 3-4 y e a rs ...... 466 105 22

Table II shows the percentage of positives in 848 Hsiang Shan T z’ u Yu Yuan children according to duration of stay in the Home since its opening in 1920. x\ccording to this the incidence of tuberculous infection has not increased in children while they have continued to live in the Institution. This speaks well for the management in charge of Mr. Hsiung Hsi Ling, former Minister of Finance. The children who have been admitted from year to year have not varied materially so far as previous health conditions are concerned.

T a b l e 3 .— Tuberculin tests on Chiao Yang So children, showing percentage of positives according to birthplace.

A vera ge N u m ber of N u m ber P ercen tage B irth p la ce age tests p ositiv e p o s itiv e

South China mostly Hunan 13-3 86 40 46 North China ...... 11.4 38 7 23

Table III compares the percentage of positives among a small group of children brought up from the south, mostly from Hunan, with that of some children from North China who are in the same Institution. A sharp contrast is here seen, those from the south showing exactly twice as high a percentage as those from the north. The latter had had no advantage over the former in health conditions as far as is known. The difference in age should account for only a small part of this discrepancy in percentage. Incidence of Tuberculous Infection in China. 15

R e s u l t s o f t e s t s i n h o s p i t a l p a t i e n t s . Table IV presents the results according to age of tests on 97 Chinese children under eight jrears on the Children’ Ward service in the Peking Union Medical College Hospital. For the sake of brevity reference is made here to diagnosis only in the case of those showing a positive reaction and those with a negative reac­ tion who showed other evidence of tuberculosis. Of the negatives some were tested two or three times; but, as a rule, only one test was made Qn each person.

T a b l e 4 .— Tuberculin tests o x 97 hospital patients under a g e of eight years.

P ercen tage A g e Number of tests Number positive p o sitiv e

U nder 1 y e a r...... 27 1 4 1-2 yea rs...... 27 5 20 2-3 yea rs ...... 10 5 50 3-4 y ea rs...... 8 1 12 4-5 y e a rs ...... 6 3 50 5-6 y ea rs...... 4 1 25 b-y y ea rs...... 7 4 57 7-8 y ea rs...... 8 5 62

T ota l 97 25 26

Of the 25 children reacting positively, 15 or 60% gave evidence of clinical tuberculosis. And among the 97 tested were three who responded negatively to a single tuberculin test, but who had tuberculosis as judged from the clinical or laboratory standpoint. These are all listed, following the summary.

D i s c u s s i o n . Just why the percentage of positives is so low in the apparently healthy children tested the writer is unable to say. It is altogether likely that repeated Pirquet tests or intradermal tests would bring out a larger number. It should be noted, however, that all arms showing distinct redness spreading from the scratch, regardless of the degree, were considered positive providing the control scratch was negative. Moreover, to this control scratch nothing was applied, so it is possible that a few false positives were included, although waiting 48 hours to read the tests usually prevents this error. i 6 The China Medical Journal.

The logical conclusion to be drawn is that the infection inci- 'dence of tubercle is lower in Chinese children, than in Western children. But if this be true it is difficult to harmonize it with the apparently high morbidity and mortality from tuberculosis among adults in China, and with the unsanitary, crowded way in which the masses live, their uncleanly habits, and their very low •economic level. The distinctly higher percentage of positives among the children in the series who have had better health conditions in the home, as illustrated in Section B of Table I, is also somewhat disconcerting.

It might be claimed that infant mortality from tuberculosis is unusually high in China and that, because of this, relatively fewer than in Western countries survive among those infected as infants or ver}7, young children. While the first of these assump­ tions probably agrees with fact, it does not follow7, necessarily, that the second does. On the contrary, those factors promoting massive infection and high m ortalitjr in infancy and early childhood should increase the incidence of infection as well.

Or, on the other hand, it might be held that those children who do run successfully the gauntlet of infant diseases do so by ■virtue of their relatively greater resistance and that they would present, natural^, a greater resistance than the average to the implantation of tubercle. Experience, however, has shown the human species to be practically universally susceptible to infection with the tubercle bacillus.

It is possible that in North China, where there is brilliant .sunshine nearly every day in the year and where children’s play is almost wholly out-of-doors, the danger of infection from sources outside the immediate home is considerably lessened. The fact that there appears to be no steady increase in incidence with increasing age indicates to the writer’s mind that there may be factors operating to prevent infection after children ‘ ‘ take to the .street” . Another factor, however, must be considered, namely, that if with increasing age opportunities for infection or reinfection become less frequent a certain percentage of persons who previously have shown a positive tuberculin test will do so no longer; for .hypersensitiveness seems to fade if not entirely disappear with the healing of tubercle. Incidence of Tuberculous Infection in China. 17

It would seem from Table III that a different set of conditions has obtained among children from the North from that among those from the South * although the number tested is entirely too small to draw conclusions. . Certainly reports of tests from various centers would be valuable in helping to determine more accurately the infection incidence and in ascertaining causes for unusual variations in the incidence. S u m m a r y . Tuberculin tests on 2,049 apparently healthy Chinese between the ages of 8 and 20, and on 97 .Chinese hospital patients under the age of 8 years (Chinese reckoning) are reported. In the series of apparently healthy students the percentage of positive reactions is distinctly less than one would expect in similar age groups in Western countries. The percentage of positives for the older years is only very slightly higher than for the younger 3'ears, there being no gradual increase with increase in years. The percentage of positives is practically the same for those classed as urban and those classed as rural. Males show a higher percentage •of positives than females. In the series of hospital patients under 8 years, 26 showed a positive reaction, 15 (60%) of whom gave evidence of clinical tuber­ culosis. In this small series the tuberculin test proved of value, even up to 8 years (Chinese reckoning) not only in diagnosing infec­ tion, but also in confirming the diagnosis of active disease.

The writer is indebted to and wishes to thank Mr. Hsiung Hsi Ling for permission to do the tests in the above charitable institutions. He thanks also the principals of the schools and Dr. W ylie for helpful coopera­ tion, and Dr. Hammond for permission to use the results of tests done on the hospital patients referred to in Table IV.

A p p e n d i x . The 25 cases referred to under Table IV which reacted positively and gave evidence of clinical tuberculosis are as follows : N o. 6024. A g e d 8 months. Diagnosis, enterocolitis; showed on X-ray no evidence of pulmonary disease. The mother had pulmonary tuberculosis. N o. 5757. A g e d 15 months. Diagnosis, Shiga dysentery. X-ray showed increased hilus infiltration both sides. -No. 4437. A g e d 12 months. Diagnosis, lobar pneumonis and measles. X-ray showed thick pleura; hilus heavily infiltrated; extension into right upper lobe. 18 The China Medical Journal.

N o. 7971. A g e d 17 months. Diagnosis, acute miliary tuberculosis, tubercu­ losis of meninges. N o. 5311. A g e d 18 mouths. Diagnosis, acute respiratory infection. No X-ray evidence of tuberculosis; no history of tuberculosis in fa m ily . N o. 6483. A g e d 18 months. Diagnosis, acute miliary tuberculosis, tu­ berculosis of meninges. N o 5778. A g e d 30 months. Diagnosis, bacillary dysentery. X-ray showed a small amount of hilus inGltration. N o. 5730. A g e d 24 months. Diagnosis, tuberculosis of bronchial lymph nodes. X-ray showed heavy shadow at hilus. N o . 5732. A g e d 24 months. Diagnosis, tuberculosis of cervical, bronchial and mesenteric lymph nodes. X-ray showed infiltration of both lung fields. N o. 2696. A g e d 24 months. Diagnosis, tuberculosis of hilus nodes. X-ray showed hilus tuberculosis with extension to apices. N o. 4178. A g e d 24 months. Diagnosis, incipient pulmonary tuberculosis* X-ray was strongly suggestive. N o. 4892. A g e 36 months. Diagnosis, acute encephalitis. X-ray showed hilus heavily infiltrated. N o. 5813. A g e 48 months. Diagnosis, hilus tuberculosis. X-ray showed infiltration of hilus with early extension to apex. N o. 6027. A g e 48 months. Diagnosis, hilus tuberculosis. X-ray showed hilus shadow slightly increased with slight mottling at right apex. N o. 3366. A g e 48 months. Diagnosis, tuberculosis of intestines. N o. 7296. A g e 5 years. Diagnosis, chronic pulmonary tnberculosis, tuberculosis of cervical lymph nodes, and phlyctenular conjunctivitis. N o. 6849. A g e 6 years. Diagnosis, amebiasis and ascariasis. No. X-ray film made. No history of tuberculosis in family. N o. 8079. A g e 6 y2 years. Diagnosis, fever of unknown cause. X-ray showed no evidence of tuberculosis. N o. 2903. A g e 6 years. Diagnosis, incipient pulmonary tuberculosis, chronic cervical lymphadenitis. X-ray showed increased hilus shadow. N o. 3767. A g e 6 years. Diagnosis, carcinoma of pleura, mediastinum and liver. Diagnosis of carcinoma was not proved. Patient had a high remittent temperature. Guinea-pig inoculated with ascitic fluid became tuberculous. N o. 1320. A g e 7 years. Diagnosis, acute bronchitis. X-ray showed a diffuse bronchitis. N o. 3745. A g e 7 y2 years. Diagnosis, chronic pulmonary tuberculosis, serofibrinous pleurisy, tuberculosis of peritoneum. N o. 6492. A g e d 7 years. Diagnosis, chronic tonsillitis, cervical lymphad­ enitis. X-ray showed thickened pleura. N o. 6321. A g e d 7 years. Diagnosis, chronic pulmonary tuberculosis (arrested), chronic fibrous pleurisy. X-ray showed thickened pleura but no evidence of clinical activity. N o 4481. A g e d 7 years. Diagnosis, acute bronchitis, chronic pulmonary tuberculosis. X-ray showed massive hilus infiltration. Kansuh and its Diseases. *9

The three additional cases responding negatively to tuber­ culin but giving evidence of tuberculosis were as follows : No. 734S. A g e d 6 years. Diagnosis, kala-azar, noma, secondary anemia with hemoglobin 32 per cent. X-ray showed hilus infiltration extending to apices. No. 6064 A g e d 20 months. Diagnosis, typhoid fever. X-ray showed large hilus shadow extending into right lung. No. 3089. A g e d 7 years. Diagnosis, incipient pulmonary tuberculosis X-ray showed heavy hilus infiltration but no extension. In the first two of these cases the extremely lowered vitality might account for the negative reactions. In still others of the 97 cases it is possible that a negative response occurred, not because infection had never taken place but because of the child’s extreme illness at the time of the test.

KANSUH AND ITS DISEASES.

G. E. K in g , m .b., ch.B., Lanchow, Kansuh. As far as I know, Kansuh is the only province of China proper where medical missiona^ work is confined to a single hospital centre. Though the remoteness of Kansuh and the bad communications still prevailing militate against much hope of immediate advance of medical work it cannot but be deplored that so small a use is made of the opportunities presented in the numerous large cities of the province. It is perhaps still not generally realised that Kansuh is by no means a desert. It contains ten million people, and at least seven centres where hospitals should be established, and each of these centres would have the care of a million people. It is obvious that the ten years spent by the waiter in the province, and for most of the time in a single district, does not enable him to speak with much authority on*the disease incidence in the whole area. At the same time as it has been suggested that others may be even more ignorant of the conditions and diseases in Kansuh, it behoves the present writer to describe what has been observed by him during this period. C l i m a t i c C o n d i t i o n s . For the most part Kansuh enjoys the bright, sunny winters of north China. The cold rarely goes below thirty degrees of frost, except on the Tibetan plateaus; even in midwinter snow does not cover the ground, and in December and January the sunshine is so 2 O' The China Medical Journal.

warm that it is pleasant to sit out-of-doors. The spring is the time of most dust, fine white “ loess in the making” blown from the desiccated Mongolian plains. The summers are warm, but the temperature rarely exceeds 950 F. in the shade, and of course it is much less, on the plateaus. The nights are almost invariably cool. The autumn weather is almost perfect. For the two months before the coldest weather sets in, it can scarcely be surpassed anywhere: dewy mornings, clear bright days and lucid starlight.

G e o g r a p h y . The province consists of three zones : a northern belt, border­ ing on the desens, which is for the most part well-watered by the streams coming down from the “ Nan Shan ” range of mountains, the true Great W all of China. In this belt malaria is known, but the cases are comparatively few. Then there is a central zone, between the “ Nan Shan” to the north and the watershed between the Yellow River and Yangtse River to the south. This area is loess covered, though alluvial plains skirt the rivers. Towards the west and south, fine verdure clad mountains rear themselves above the loess hills around. Further south a belt may be distinguished which resembles Szechuan in its characters and vegetation. It is in this belt that malaria is prevalent, while in most of the central area it is scarcely known at all.

D is e a s e s o f K a n s u h . Malaria.— On the whole, Kansuh may be considered one of the most malaria-free provinces in China, notwithstanding that in most places the malaria mosquito is found. Further work on the various species of mosquito found there needs to be done. Kala-Azar.— Cases clinically diagnosed as kala-azar are brought to us from most p^rts of the province. The disease is not recognised by the Chinese. Many cases of what they call pi kuai turn out to be kala-azar. In its treatment tartar emetic has given good results in our hands. S yp h ilis.— This disease is widespread. Some of the worst cases come from among the Tibetans. Nearly all its usual forms can be met with. W e have noted a very large number of cases of optic atrophy, in many of which no luetic history can be elicited. Probably some other cause of this condition is at work, at present unknown. Tuberculosis.— In spite of so favourable a climate, tuberculosis is one of the great scourges of the province. The fact that during Kansuh and its Diseases. 21 the cold winter nights many people are. in close proximity on a single kang, or brick bed, with no adequate ventilation, leads to constant infeclion. Tubercular peritonitis is common, and can scarcely be related to the use. of milk, which is rarely used save on tlie Tibetan borders, The habit, common in Kansuh, of swallowing sputum is perhaps accountable for much of it. Surgical tuberculosis is prevalent also. Anthrax.— W e liave seen several cases of this disease with fatalit3T ensuing. Its importance lies in the large export of skins and hides.fiom Kansuh each year, and the carriage of infected skins to other parts. Rinderpest was the cause of death of many cattle on the Tibetan borders a couple of years ago. Plague.— During the past ten years two authenticated out­ breaks of pneumonic plague occurred in Kansuh. Both were probably due to marmots, and both occurred on the slopes of the higher plateaus. In one epidemic energetic measures were taken to combat the disease, but no measures were used in the other. The results in both cases were similar, The outbreak was limited practically to the focus at which it started, and the spring saw the end of the trouble. No recent epidemic has occurred, nor does bubonic plague seem to be’ known in the province. Leprosy.— Among the Tibetans, Salar, and Chinese, who neighbour the Tibetans, leprosy occurs. The cases are often of the mixeid form. Nodular cases are often allowed to live in contact for some time with healthy people. In certain districts, rigid isolation is enforced, and even cases not leprous, but' suspected of the disease, are condemned to ostracism and cast out from the village into hillside caves, etc. Other infectious diseases.— Smallpox, diphtheria, scarlet fever, measles, whooping cough, are all met with, especially in the large centres of population.- Typhus fever and typhoid are ever with us. Relapsing fever seems rare. Dysentery is baciliary in type. Cholera is unknown. Parasitic diseases.— Kxternally, ringworm, favus and scabies are common. Internally, the round worm and thread worm. Tapeworm infestation seems mainly confined to the Moslems, among whom it is prevalent. W e have never found hookworm in our' patients, ,in spite of repeated search. Hookworm disease may exist in the southern or Szechuan border zone. 22 The China Medical Journal.

Diseases proper to Kansuh .— Probably none such, property so termed, exist at all. Yet one or two features due to the climate or habits of the people call for mention. The intense cold of the winter nights causes the majority of Kansuh people to sleep on heated ovens (kang) and many of these are superheated. Most commonly, horse manure is used as the heating agent. Many Kansuh inhabitants have a pigmented brownish patch over each trochanter as a result of this intermittent scorching. A slowly growing epithelioma, with secondary involvement of inguinal glands, not infrequently develops; it can usually be completely removed and with no recurrence even after several years growth. Osteomalacia is prevalent, usually in girls and women with bound feet and suffering from poor nutrition.

Opium is very largely taken in most parts of the province. The methods generally used are inhaling the fumes, eating the ash, or taking opium pills. Morphia is not in use to any extent. The effects of addiction vary greatly. Many who take opium w^ho are well to do seem to suffer little from the symptoms usually associated with the habit. Probably the abundance of good food they take neutralises the opium. In other cases the damage done to the lungs and kidneys is most evident and distressing.

Perhaps I may close with a few lines on the prevalence of hysterias of various kinds. I was formerly under the impression that the Chinese were a phlegmatic race, not likely to show neurotic manifestations. I find, on the contrary, that their training is often of the repressive type, and that marked cases of neurosis, par­ ticularly of anxiety hysteria, abound. Modern analytic methods are often highly successful in the treatment of such patients, partly no doubt from the faith they so often show in the dicta of the foreign doctor. I have been amused, and sometimes a trifle embar­ rassed, to find myself in a country place classed with a strolling Mongol priest, who with his exorcisms had made some reputation for himself. But the patient consideration of the case of each individual neurotic has given most satisfactory results that even my Mongol “ fellow practitioner” cannot beat. The same instincts, the same fears, the same obstacles and weaknesses, confront those reared in Chinese civilisation as confront our own compatriots, and often similar neuroses will yield to the same treatment whether the skin of the patient is yellow or white. Chinese Inorganic Materia Medica. 23

CHINESE INORGANIC MATERIA MEDICA*

B. E. R ead and C. O. L ee, P ek in g . The unusual situation created in the wholesale drug market during 1914-1918, the period of the Great W ar, and its continuance in the subsequent years, has revived interest in the subject of Chinese natural resources, and in the question whether the missionary doctor cannot avail himself of the native supplies of many of our common mineral and vegetable drugs. There is no standard reference work obtainable‘upon the market telling the nature and extent of native supplies. The Chinese Customs Service has a number of lists giving in the form of abstracts much useful information, and considerable work was undertaken many years ago, as reported in the “ China Medical Journal ” , by various workers. However, of late years very little interest has been shown in this subject. In 1889 there was brought to the public attention the excellent reports on native drugs by Dr. J. B- Neal1. The first report dealt with the results of the qualitative chemical analyses of sixteen inorganic medicines purchased in the shops of Nan Tungchow. H e gives the approximate degree of purity and the local price of the following substances : Carbonate of lead. Native carbonate of iron. Calomel. Alum. Native gypsum. Carbonate of copper. Vermilion. Ferrous sulphate. Native carbonate of zinc. Carbonate of sodium. Native sulphide of arsenic. Sulphate of sodium. N itre. This report was followed later by a still more comprehensive one based upon samples purchased in Tsinanfu'. In this was included, other than the drugs above mentioned, the following list, which embraces all the chief substances of mineral origin mentioned in the Pen T ’sao :— Burnt alum. Kaolinite. Ammonium chloride. Mercury. Chalcedony. Cinnabar. Arsenious acid. Mica. Arsenic sulphide. Pumice stone.

*From the Laboratory of Pharmacology, Peking Union Medical College, P e k in g . 24 The China Medical Journal.

Carbonate of-lime. Quartz. Calcium sulphate. Salt. Coral. Sulphur. , Feldspar. Tabasheer. Iron sesquioxide. Silicate of aluminium and „ ore. ' magnesium „ „magnetic. Soapstone „ pyrites. , Shells of clams „ sulphate. „ „ (oysters) Lead monoxide, litharge. „ ,, other bivalves. „ tetroxide, red lead. Petrified teeth Mercuric oxide. bones Mica schist. Pearls. From Dr. Neal’s findings there was particularly recommended for our use : *|f ^ Carbonate of lead.' ;£ W Plaster of Paris IS Calomel. pf IP Commercial iron sulphate M S Calamine. 7JC IB Mercu ry. & Alum. Mercuric oxide 5BS Borax. ^ Pumice stone JH: If Arsenic. Commercial soda S & Sulphur. The foregoing list is quite extensive. However, with the large number of drugs that were used both by Chinese and Westerners at that time Dr. Neal expresses disappointment that the list is so limited and that so manj^ of the other preparations in China are unsatis­ factory. He also points out that native materials are often grossly contaminated and .that the prices ruling in the native markets often make their purchase prohibitory. Both of these observations were made concerning the retail article, not that which might be obtained from the original manufacturers.

P r i c e s o f C h i n e s e I n o r g a n i c D r u g s . In this paper we want particularly to deal with the price and purity of Chinese inorganic drugs. At the outset one should say it appears grossly unfair to compare the retail prices of China with those of our Western wholesale druggists. The only fair comparison to make is that between the Chinese drug markets and the Western drug markets.. Such might be made by comparing lists sent out from the wholesale drug houses and the prices quoted in the list of medicines compiled by R. Braun of the Chinese Customs Service. Of course he recorded the prices of drugs in large quantities only, as they passed through Hankow to other Yangtze ports. Chinese Inorganic Materia Medica. 2 5

A recent trip, by the writer to the Chichow Drug Fair of Northern China gave him opportunity for finding out some of the wholesale prices for material bought in small quantities. The following is a comparison of some of the prices as taken from lists of well-known drug houses.

Shanghai, L on don A m erican H ankow I Chichow L o ca l W uhu foreign price, price, Customs price price retail firm , 1923 F . O. B. F . 0 . B. prices Peking price

Copper sulphate, M ex. commerical ... $ 0.30 per lb. $ 0.24 S o .28 _. $ o.o6i $ 1.00 $ 0.06 00 Alum ...... 0.15 0.09 O •q- — 0.07 O.16 0,04

Mercury ... 2.50 2.70 2.00 — 1.46 3-20

S u lph u r ...... 0.30 0.09 —— 0.16 — —

Calamine ... 0.30 0.87 O.98 0.09 0.24 I .60 —

M en th ol ...... 12.50. 21.10 12.50 19.20 ——

Talcum powder... — O.14 — 0 .01* 0.06 ——

C alom el ...... 3-30 ’ 3-77 2.50 0-75 1.23 4.80 —

B o r a x ...... 0.35 0.24 0-44 2.03 — I .60 o-33

P u r i t y o f C h i n e s e I n o r g a n i c D r u g s To secure a fair estimate of the relative purity of a substance it is practically essential to conduct a quantitative analysis of its contents. It is surprising how few facts and figures are available for material use in China. In i860, Dr. Hanbury4 published his most interesting series of papers on Chinese medicines in which are a number of such valuable analyses. These, and possibly some private informatidn, form the basis of the descriptive information found in such publications as “ Articles of Commerce in China” (Watson,- Customs Service). It.was with this side-of the question in mind 'that careful detailed chemical analyses were undertaken of a number of substances in our-laboratories, the result of which we now publish. r. The following'Tables give an interesting summary an$ confirm, the recommendations of' Dr. Neal as to. the . suitabilit-y for use of some Chinese drugs, and of the relative purity¡: of a num­ ber of samples of alum, copper sulphate 3rnd. sodium sulphate. 26 The China Medical Journal.

1 . Copper sulphate. 3 5 Shih tan. Synonyms : fit §§§ tan fan, H ^ hei shih, 3jp§ hua shih^ ^ ^3 chun shih, IJsj 1$j t’ung lo, #tj li chih shih, (Pen T ’sao.) iJ* §|£ tan fan, !£j §§: shih fan, (Peking colloqial.) The following facts are gleaned from the Pen T ’sao. Locality where obtained.— Ch’in chow, Ch’ing tao shan, Honan. Also from Yii hsiang hsien in Shansi, Tsin chan in Kansuh, and Ynen-shan hsien in Kiangsi, (Porter Smith). Characteristics.— Acid, bitter-tasting salt, of dark green colour, poisonous. Able to dissolve iron and deposit copper. Porter Smith states that no genuine sample of blue copperas has been met with, highly purified sulphate of iron being always furnished. The above description points definitely to a preparation of copper sulphate, and is confirmed by our analyses of a number of speci­ mens examined. One sample from Korea .contained no copper, which shows that this substance has no consistent name or content which could be adopted as a national standard. The Customs List gives JjB IP as purified sulphate, synonymous with |p. The use of these terms is certainly incorrect for Peking, where in agreement with the Pen T ’sao, as our analyses show, the former substance is either pure copper sulphate or a mixture of the two substances. Nomenclature is largely a matter of usage. Tan fan, as originally used, indicated copper sulphate, iron being termed Ch’ing fan. W e should like to emphasize the necessity for specific use of these terms for the two substances indicated. Therapeutic uses.— For dim eyesight, styptic, as a dressing for vaginal and uterine sores, aphrodisiac. Together with alum and the juice expressed from fresh ginger root it is applied to sweaty armpits. Used with honey water for piles. Used with alum and mercury for syphilitic sores. Analyses.— Accurate determinations of the water of crystalliza­ tion and of the sulphate radical were undertaken to show the relative purity of these compounds. Further quantitative analysis of the metals would be useful, but the descriptions and analytical figures obtained show the samples to be either pure copper sulphate or a mixture of the pure sulphates of copper and iron. This is in accord with circumstances prevailing on the Western market where beside our pure pharmacopoeia! salt there is in commerce, a crude Chinese Inorganic Materia Medica. 27

Analyses of Tan Fan » m

0> bp n © 'X . W h ere «■M Cl Description Aqueous soln. D ia gn osis ob ta in ed Sffi 'o p* u0 * § a>

Deep blue crys­ Acid to litmus Sam ple is .Szechuan talline lumps solu tion , has 40. 28.6 C u copper sul­ w ith odor every appearance fate o f C u S 0 4

Characteristic Acid to litmus, Sam ple is Te An T ’ang. lumps of good blue as good 39-i 29-3 Cu good copper P ek in g . copper sulfate CuSO* solution sulfate

Damp green­ Acid to litmus, Sample is a P a o Y uan ish blue lump greenish blue in 34-5 39-2 Cu mixture of T ’ang, with distinct color, and clouds iron and P e k in g od or upon standing F e copper sul­ fates

Dirty grayish- Acid to litmus, Mixture of T ’ ai H o blue lumps, greenish cloudy 30.7 3&-4 Fe iron and T ’ang, odor resembles solution, with in­ copper sul­ P ek in g. Fe S 0 4 soluble residue Cu fates

Grayish green Acid to litmus Sample is a T ’ung ihsing granular pow­ solution, clear 39-3 32.3 Fe mixture of P e k in g der, effloresced, with tendency ferrous and odor of iron to oxidize. Cu copper sul­ sulfate fates, mostly F e S 0 4

Dark greenish- Acid to litmus, C h i S h en g gray powder, clo u d y w ith m u ch 34-3 35-6 Fe Mixture of T ’ang, odor of ferrous insoluble residue. F e S 0 4 and P e k in g su lfa te C u C u SO i m ost­ ly F e SO*

Dry,dirty green Acid to litmus F e Sa m ple is K orea lumps, odor of solution, cloudy 33-2 33-9 K a ferrous sul­ ferrous sulphate and tends to trace fate o x id iz e

U. S. P. or Blue triclinic Acid to litmus Pure stand­ B . P. C rystals Cu ard .

* Average of 6 determinations. ** Average of 3 determinations. 28 The China Medical Journal,

copper sulphate, known as “ blue vitriol/’ sold for the purpose o f wheat dressing6. This is made by roasting pyrites, which contains copper sulphide and sulphides of other metals, chiefly iron. By roasting and exposure to air, the sulphides are converted into sulphates and removed by lixiviation. Such “ blue vitriols” always contain mpre or less iron sulphate, which cannot easily be separated, from copper sulphate by recrystallization since it is isomorphous with it. Note that this isomorphism occurs, although the two sulphates contain different quantities of water of crystallization. The blue and green colours are a plain index of the material in question; hence no difficulty should be experienced in getting the pure article; or the impure, if desired for use!' Distinct from Shih tan there is listed under a subheading of the Pen T ’sao the name :

2 . Ferrous sulphate.

Ferrous sulphate or m Lii fan, refers to purified ferrous sulphate. Synonyms: |£- hei fan, tsao fan, |p ch’ing fan. Uses,— It is used largely as a mordant; with' aconite and peppermint as a hair dye, and it is recommended, like “ Shih tan” ,, copper sulphate, for styptic and astringent purposes. One detailed analysis was made of this salt which showed that apart from slight oxidation it was practically pure.

A n a l y s i s ■ o f ' H e i ; f a n J |

P ercent­ P ercent­ W h ere : 'D escrip ­ A q u eou s age age M etals D ia g n o sis obtained* tion soln. S 0 4 h 2o

F e n g G rayish Acid to litnius • Sample is F e S h en g green to solution, pale f-errous 35-4 N a K u n g , brow n ish brown show­ 38.3 su lfate a trace P e k in g • crysta l ing oxidation

It is exceedingly ¡cheap, selling retail in' Wuhu at 2 ^ c . a lb.

This salt is recommended ^y ^eal as efficient in destroying foul smells. A catty dissolved in,, a ,,bucket-o£ water should be poured down a cesspool once a day. Ckiftesê Inorganic Materia Medica. 29

3 . Crude Sodium Sulphate. P ’u Hsiao i t P’i hsiao, Peking colloquial. Syno- nyms : *£ # S tâ- Description.— Found in deposits in earth. White strong crystals, soluble in water. Used to make ^ ^ Used to tan or preserve ox and horse skins.

A n a l y s e s o f P ' u h s i a o #

P er­ Per­ W her£ cen t­ cen t­ M e­ D ia ­ Description Aqueous soln. O btain ed age age tals gn osis s o 4 H 20

Fine,white, some­ Solution is 62. 8.1 Na S am ple what dirty neutral with is effloresced salt, saline sodiu m p ow d er taste. sulfate

S ooeh ow Fine, white, eff­ S olu tion 65.2 loresced powder neutral and saline.

P ao Y u an Damp, fine, dirty S olu tion 58.8 12.15 Na sodiu m t’ang, Peking white powder. neutral, dirty, sulfate Rapidly efflores­ taste is salt ces in the air. and saline.

C h i S h en g Powdery, gran­ Solution is 38.9 44-5 Na sodiu m T ’ang, Peking ular, much neutral, taste Cl a sulfate effloresced and is Salt and trace white, fairly saline. M g „ clean.

Te An T ’ang, Large crystals Solution is 40.4 46 -3 Na sodiu m P e k in g together with neutral, dirty, Cl a sulfate much effloresced saline and salt trace white powder. to the taste.

Ta Jen T ’ang, Dirty unefflores­ Solution is 36.5 51- Na sodiu m P ek in g . ced crystals. neutral, taste sulfate Rapidly effloreces is salt and in the air. saline.

Tai Ho T’ang, Dirty, crystalline, Solution is 33- 5o- N a sodiu m P ek in g. partially efflor­ neutral, taste sulfate esced crystals. is saline and salt. Sold retail in Wuhu at 5. cts. a lb. P’u hsiao forms the big crystals at the bottom of the crystal­ lizing vats. Mang hsiao is the surface crystals. There is confusion -of identity with “ Hsiao shih ” ; “ Huo hsiao ” = nitre (Adolph). 3 0 The China Medical Journal.

Description.— Obtained from Szechuan salt springs. I he crude yellowish and pink crystals have toxic impurities. Used to test the purity of gold and silver. Cool and bitter in taste, non-toxic. Prescribed with rhubarb or ginger. Incompatible with wheat and “ cyperus” . Able to dissolve all kinds (72) of stones in the body.

Therapeutics.— Used to clean out intestinal tract, to thin the blood, it gets rid of phlegm, improves growth of the hair, is used for amenorrhcea, and improves the action of both bowels and kidneys. The recrystallized salt is quoted by Porter Smith as pure and containing only a trace of chlorides.

4 . Potash Alum. Jp Ming fan. Synonym : 0 || Pai fan.

Porter Smith gives an excellent account of native alum shale and the preparation of the commercial article from it at P'ing-yang. He states that 6,000 tons were exported in one year of a purified article equal to the best Roman alum, free from all traces of iron. Neal reports traces of iron in the alum of Nan Tungchow. Nine samples examined by us (see “ Analyses” , p. 31) were all free from iron and were exceptionally pure except for traces of chlorides in two of them.

5. Kaolin.

It is appropriate here to mention Kaolin or China clay, ChJih Shih Chih. Hanbury gives the following analysis : Silica, 42.93 ; Alumina, 36.53 ; Fe, Mn. & FI, 4.85 ; Mg & Ca, 0.94 ; Water, 14.75.

Therapeutics.— This aluminous earth is recommended with oxide of iron in the treatment of cholera. Of the remaining compounds recommended by Neal, our experience is that mercury, arsenic, and calamine will respond to all the pharmacopceial standards. Other salts useful for specific purposes may also be easily obtained, such as native soda, used in making up absorbent cotton wool and for many cleaning purposes. Also calomel, but this has been found by us to be grossly •adulterated with gypsum. However, no soluble mercury salts are present, and the material is easily purified by resubJimation as recommended by Douth waite3 for treating such Chinese drugs as camphor, sulphur, calomel, etc. Chinese Inorganic Materia Medica.

A n a l y s e s o f P o t a s h A l u m , M i n g f a n fpj

W h ere A q u eou s P ercen t­ P ercen t­ D ia ­ Description M etals ob ta in ed soln. age S 0 4 age H 20 gn osis

Ta Jen Characteristic A c id to litm u s, 41.4 39-9 Al; K Sample, T ’ ang, lumps, fairly and show s potash P ek in g. uniform and dirt. alum clear, colorless.

S ooch ow . Sample small Acid to litmus, 40.6 in q u a n tity : a quite clean white granular and clear. p ow er.

K orea. Characteristic A cid to litm u s, 41. 3S.5 A l ; K Sam ple, lumps, uni­ cloudy and potash form, slightly d irty. d irty. * K orea. Very good, Acid to litmus, 40.4 3S.S A l ; K Sam ple, clean lumps clean and potash of alum . clear. alum

P ao Y u an U n iform A c id to litm u s, 41. 38.1 A l ; K Sam ple, T ’ ang, lumps, but not solution is potash P ek in g . clean andclear. clou d y . alum

T ’ u n g Y i L a rge and Acid to litmus, 40.8 39-3 A l ; K Sam ple, H sin g , small crystal­ solution is potash P ek in g . line lumps, clou d y. alum s lig h tly y ellow ish .

Chi S h en g Lumps char­ A cid to litm u s, 41.4 39-3 A l ; K Sam ple, T ’ ang, acteristic and solution is potash P ek in g. uniform, but clou d y. alum m a n y sh ow dirt.

T a A n Colorless, cry­ Acid to litmus, 41.2 39-2 A l ; K Sam ple, T ’ ang, stalline lumps, solution fairly potash P ek in g. fairly clean clear. alum and uniform.

T ai H o Characteristic Acid to litmus 41.4 39-9 A l ; K Sam ple, T ’ang, lumps, some solution fairly potash P ek in g. coloration. clear. alum 3 2 The Chind Medical Journal.

R e f e r e n c e s c i t e d , i. tfeal, J. B., 1889. Ch. Med. Jour., ii : 1 x6. 2; Neal, J:-B.j 1891: Ch; Med: Jour.* v s 193» 3 . Douthwaite, A. W., 1890. Ch. Med. Jour., iii : 53. 4. Hanbury-j D., i 860. Pharmaceutical Journal, ii : 109. 5. Braun, R., 1909. Imperial Maritime Custom Lists, Vol. ii. Special series, No. 8. 6. White and Humphrey, 1904. Pharmacographia, London, p. 156. 7 . Read, B. E., 1923. Ch. Med. Jour., xxxvii ; 340.

HEADACHES: WITH SPECIAL REFERENCE TO THOSE OF PSYCHOGENIC ORIGIN.

J. L i n c o l n M c C a r t n e y , M . D., Hankow. There is a great tendency in the practice of medicine to treat symptoms, and not directly the diseases of which the symptoms are merely an index. Thus the pain of so-called rheumatism was former!}^ alleviated by the use of salicylates and other sedatives ; it is now known that at least some of these cases are due to focal infections arising from teeth, tonsils, and the nasal accessory ..sinuses. Again, asthmatic d3^spnea is often treated empirically with certain drugs, when we know that renal, cardiac or nasal conditions may lie at the source of asthma, or that it is an -expression of an anaphylaxis due to entrance into the system of •certain foreign proteins. But no affection is perhaps more variable in its etiologj', more annoying to the patient, and more often treated symptomatically, that is, with sedatives, than headache or cephalalgia. In some form or other, and in varying degree, a great majority of people seem to suffer occasionally from headache. A t least, it is quite unusual to find a patient who has not at some time or another had some pains in his head. The etiology of a symptom first engages our attention. Headache, as well as pains in other parts of the body, may be •caused by abnormal conditions of mind and body. Affections of the blood, such as anemia, pelvic disturbances, intestinal derange­ ment, autointoxication, renal or cardiac disease, high blood pressure, or syphilis, may produce severe cephalalgia. In the head itself the patient may have trifacial neuralgia, dental root infections, or pains in the muscles attached to the region of Headaches, especially of Psychogenic Origin.

the occiput and those in the upper portion of the neck posteriorly and laterally (sterno-mastoid and trapezius). Important to remember are the pains due to diseases of the ear and to abscesses or tumors of the brain, as well as headaches arising from the nose, such as pressure and vacuum effects, and accessory sinus infections. Last but not least are headaches of psychogenic origin, such as those complained of by patients with neurasthenia, hysteria and migraine.

It is not intended to enter upon a detailed discussion of all these forms of headache. The important characteristics of some will be mentioned, with most emphasis upon the pains of psychic origin. One of the pitfalls into which many specialists stumble, is to assign to the group of organs they are accustomed to treat any symptoms which the patient presents. How many patients with gastric crises have not had the stomach tube passed and lavage carried out, when tabes was the actual condition present and not a gastritis? Likewise, it behooves the rhinologist to remember that all headaches do not arise from intranasal condi­ tions, but may be due to lues, high arterial tension or other causes. In a word, a knowledge of the correlation of the various parts of .the body is essential.

The conscious sensation known as headache must, it seems, "be the result of some affection or irritation of the great sensory fifth cranial nerve, or trigeminus. The irritation may be direct by pressure or inflammation; by reflection from other cranial nerves via anastomoses, or by the direct action of toxic substances brought to the nerve from other parts of the body by way of the blood stream. Thus w^e may have, as before mentioned, headaches from ■cardiac, renal, intestinal and pelvic lesions, or from high blood pressure, or from anemia. In these conditions there is no specific

localization and distinct prediodicity. The pains in syphilis are, as a rale, more marked at night, but it is said that the headache of brain tumor and uremia is also often worse at that time. W ith reference to luetic headaches a case came to record in which the pains were of the nocturnal type; no nasal or other lesion could be detected to account for them. Suspecting syphilis, Wassermann tests both of the blood and spinal fluid were made, found negative, and yet the pains were entirely relieved by the use probably this was an instance of the late tertiary form. 34 The China Medical Journal.

Headache, due to aural infection, is usually referred either to the ear itself, to the mastoid process or to the temporal region. In these cases of course, we have the various signs and symptoms attending an acute inflammatory process in the middle or external ear. In pain due to brain abscess we may have the history of a preceding ear infection; but in both abscess and brain tumor the pains, as well as the focal signs, depend on the localization of the lesion. If the silent areas are involved, such as the frontal lobes, often no direct symptoms such as pain may be present. Many headaches are due to dental trouble, either caries, or impaction especially of the last molars. There are cases in which pains radiating to the eye, vertex or occiput, have been entirely relieved by extraction of an impacted third molar, after patients have been suspected of accessory sinus disease, and have been treated for this condition without avail. Indurative or rheumatic headache is characterized by pains usually occipital or suboccipital, but at times in one or both temporal regions. It is apt to change w?ith the weather, is subacute or chronic in its duration, is accompanied by tenderness on pressure over the part affected, such as the insertion of the occipito-frontalis and trapezius muscles, or the transverse process of the fourth cervical vertebra. Movements of the head and neck are usually painful. To relieve this condition, the elimination of infective foci, if present, is indicated, together with massage and the application of heat. A very distressing form of headache is that due to irritation of Meckel’s or the spheno-palatine ganglion. This produces a very severe pain radiating from the root of the nose, in or about the eyes, over the frontal region, back to the parietal bone and then posteriorly to the ears, mastoid process, down into the phar3’nx, tonsils, neck, arms and sometimes the fingers. Not all areas are involved in every patient but usually one or several of these may be affected. As a rule, the point of greatest pain is about six mm. behind the mastoid. Headaches are often due to eyestrain, errors of refraction, or muscle unbalance. Here the pains are often present in or about the eyes or in the temporal region, are increased by the use of the eyes, and are relieved by proper glasses and muscular exercises. Headaches, especially of Psychogenic Origin. 35

The suppurative nasal conditions causing headaches constitute probably by far the majority of the cases, and consist of acute and chronic accessory sinusitis. In making a diagnosis of sinusitis, transillumination of the maxillary and frontal sinuses is often of considerable aid, but has little value with reference to the other accessory cavities. Better than this measure is the use of the X-ray picture. But most important is the history of the case, and the finding of pus on examination with or without the use of suction after shrinking the mucosa. Pus issuing from the middle meatus comes from one or more cells of the anterior group of sinuses, namely, the frontal, anterior ethmoidal cells, or maxillary sinus; pus in the superior meatus or in the spheno-ethmoidal recess, arises from one or other of the posterior set of sinuses, posterior ethmoidal cells, or the sphenoid sinus.

There is no characteristic localization of the pain or tenderness in involvement of any particular sinus, but generally speaking it is fairly true that with maxillary antrum disease the pain is mainly in the upper teeth, the cheek and floor of the orbit; with frontal sinusitis usually in the forehead; with anterior ethmoiditis between the eyes and in the temporal and parietal regions; and writh posterior ethmoiditis or sphenoiditis in the occipital region. But all manner of variations from this statement may occur, such as occipital pains with frontal sinusitis, vice versa, and so forth. The sinus pain occurs with considerable periodicity at certain times' of the day, and after some hours may entirely disappear, to recur again the next day, or after several days, weeks, or even months. Particularly with frontal sinusitis (and sometimes also with maxillary antrum and other involvements), do we find that a patient awakes feeling well, later in the morning notices pain which increases in severity toward noon or early afternoon, then again subsides, so that by evening there is complete freedom from pain. The individual sleeps well and awakes, as above mentioned, feeling fine, only to repeat the cycle. The cause for this peculiar periodicity has never been explained. It is important to remember that a slight leukocytosis and a moderate rise in temperature often accompany acute or chronic sinusitis. There is usually tenderness on pressure or percussion, but this is not definitely localized in all cases for the particular sinus involved. 3 6 The China Medical Journal.

The non-suppurative nasal conditions producing headaches comprise two groups. The first is the so-called hyperplastic form, especially ethmoiditis and sphenoiditis. Here there is a thickening -of the mucosal lining of the sinuses involved, or even a potypoidal ''degeneration thereof. The headaches are those described under the suppurative form, but there is, of course, absence of pus, leukoc5rtosis, or fever. A goodly number of headache cases have come to notice in which either pressure of the middle turbinates against the septum, or a blocking of the middle meatus by the middle turbinate has caused severe pain arising from no other source. When the entrance to the infundibulum, namely, the narrow hiatus semi­ lunaris, which is bounded anteriorly by the uncinate process and posteriorly by the bulla ethmoidalis, is obstructed either by a swelling of the mucosa covering these structures, or by contact of a large or edematous middle turbinate, rarefaction of the air in the frontal sinus occurs, and the so-called “ vacuum” headache often follows. The pain is usually felt in the region of the malar bone, ■eye, and forehead of the affected side, and is made worse by the use of the eyes, although the latter may show no abnormality. Years ago Kwing called attention to the exquisite tenderness caused by even moderate pressure against the upper inner wall of the orbit, namely, the orbital plate of the frontal bone, in the region of the attachment of the pulley of the superior oblique muscle. This localized tenderness is considered practically pathognomonic of vacuum headache. Directly opposite in its genesis is the “ pressure” headache caused by undue contact of a middle turbinate against the tuberculum septi, the thick portion of the nasal septum at the junction of its upper and middle third. The pains are usually very distressing and are referred to the root of the nose, the eye, or the supraorbital region. Suppurative or other inflammatory conditions in the accessory sinuses are absent in the typical pressure cases. After carefully going over the above factors in each case of headache, the physician may ■ yet be at a loss as to the etiology of the condition. He should then without hesitancy consider the case one of psychoneurosis, and may feel assured that this most frequent of clinical problems owes its origin to this ■cause. The etiology may be placed in one or other of the following Headaches, especially of Psychogenic Origin. 37 classes of neuroses : (1) neurasthenia, or the exhaustive type; (2) the hypochondriac or complaining type; (3) the anxiety or apprehensive type; (4) the hysteroid, neuralgic or suggestive type; (5) the migraine or hereditary type; and (6) the epileptic or irritable type. In the neurasthenic form of headache there is not really so much an actual pain, as a feeling of pressure or of constriction about the head. As a rule, there is in these cases some contributory mental or emotional factor, but this is often difficult to elicit. The patient may state that the pain has been present daily for many months or even years, yet it does not disturb his sleep. If insomnia is present, it is usuall}' due to some other cause. Neurasthenia is an actual neurosis of somatic origin; the Freudian view is that it is usually due to over-indulgence in the sexual act. According to the psychology taught by Freud, White, Kempf, Firenczi and Stekel there is described certain behaviour which is regarded as motivated by the flight from reality urge. This behaviour shows itself under well-recognized conditions. For example, when the actual demands of life face an individual he can react in two divergent ways. One way, the reality method, is to attack the problem at hand, bring to bear upon it all the conscious efforts of training and education, and to dispose of the matter to the very best of one’ s capacity. This type of behaviour regularly results in virility, efficiency and happiness, the standards held up to us by Kempf. The other type of behaviour is that of the flight from reality. In this group is found the entire gamut of human frailties and neurotic symptoms; these range from quaint mannerisms at the one extreme to terminal psychotic dilapidation and suicide at the other. The principle of the flight from reality is a simple one, but the protean charactcr of its innumerable manifestations makes its recognition extremely difficult at times. It shows itself in such symptoms as sleepiness, “ feeling dopey,” disinterestedness, “ lack of pep,” boredom, irritability, constant criticism, disparagement of others, the desire to maintain a perfect score in bridge-party attendance, incessant novel reading, excessive smoking, going nightly to the moving-picture shows, chronic cabaret attendance, and desire for daily dancing. More marked peculiarities are 38 The China Medical Journal. downright meanness, malicious gossip compensating for an intense feeling of inferiority- by endeavouring to bring about trouble for others, and solitary tippling. More serious symptoms are given by the flight into illness, the true psychoneuroses, such as the obsessions, compulsions, hyteria and the phobias, or by becoming a drug addict. The culminating catastrophe is complete escape from reality by committing suicide. The development of different symptoms, such as headaches, which are etiologicallv a flight from reality, are regularly brought about by the same mechanism. They are compensations on the part of the organism for a repressed wish. It is not germane to the issue that this repressed wish relates invariably and inexorably to unsated desires and mismanagement of the procreative instinct of the individual, in that no neurosis, according to the Freudians, ever takes place in a person whose sexual life is normal. Trifacial neuralgia is characterized by the occurrence of intense, sharp, stabbing pains which are short in duration (usually for ten to thirty seconds), and which are usually excited or aggravated by washing the face, brushing the teeth, eating, talking, etc. This condition is most often found in the suggestive type of person. Migraine is one of the most distressing forms of headache. It is probably a neurosis, the etiology of which is not definitely known, but heredity is an important factor in this condition. The pain is a severe one; it may be unilateral or bilateral (despite the name of hemicrania so often assigned to it); it is not definitely localized, but is most frequently frontal or temporal, though it may be parietal or occipital. Ocular symptoms (scintillating or obscuring scotoma), sometimes precede the attack, and gastric signs (nausea or vomiting) may accompany it. Some women regularly have attacks before or during the first day of each menstrual period, and in these cases some endocrine activity may render the brain particularly sensitive. The real exciting reflex cause is eye-strain, and if the course never comes into operation the attacks do not occur. The ocular defects commonly associated with migraine are hyperopic astigmatism, especially when associated with latent hyperopia, astigmatism, and muscle balance defects of which hyperphoria is the most important. Very small errors are quite sufficient to give rise to migraine, especially in high-strung people with a very irritable migraine storm center. Even the smallest errors should be corrected. Headaches, especiaUy of Psychogenic Origin. 39

Diagnosis of the typical attack is simple. Whenever attacks of nausea occur, with or without vomiting or diarrhea, but without definite abdominal pain, the possibilit}. of migraine should be con­ sidered, as well as in every case of paroxysmal headache, even if it is not strictly unilateral. The smallest errors of refraction and everjr disturbance of muscle balance require correction with absolute accuracy; at least three examinations on different da}~s are required, the second being with the aid of a cycloplegic, and the third 72 hours later. Muscle balance defects are particularly difficult to correct. Improvement after this correction at times is prompt and dramatic, at other times more gradual. Drugs are of little value in such circumstances. In most cases attacks of migraine become less frequent and less severe with advancing age, and spontaneous cure is not uncommon after the age of fifty. Headaches of psychogenic origin have no organic basis and yield surprising^ to psychotherapjr. To assure a patient that there is no organic disease is in itself valuable and lays the foundation for psychotherapy. Personal contact with this type of patient is essential; continued questioning Teally serves the purpose of a systematic psychoanalysis. The physical health of the psychoneurotic must be put at its best. Regular outdoor exercise and fresh air are important.

The doctrine and practice of substitution are necessary. The mind of the neurotic does steady guard duty, as it were, pacing back and forth day after day over certain fixed ideas, phobias, abnormal suggestions, abnormal reactions, and irritations arising in the environment; these influences must be replaced in the mind by an absorbing interest or hobby. Golf has cured many a neurosis. Certain individuals develop neuroses from selfishness, and in them ■a spiritual regeneration is necessary. There is no therapeutic substitute for the overwhelming personality of the physician. Psychotherapy is simply the agent of personality.

S u m m a r y a n d C o n c l u s i o n s . To summarize this survey of some of the numerous forms of lieadaches, we must bear in mind their great variation in etiology, pathology and symptomatology. Psychic, functional, organic or mechanical factors must be considered, for the treatment and relief depend upon an exact determination of the underlying 40 The China Medical Journal.

causes. The pain is only a symptom and for its temporary relief sedatives sometimes may be used. Some cases are practically- incurable with the means now at our command, but a very large percentage of unfortunates may be greatly benefited if we carefully study, not simpty the patient’s head, but the case from every point of viewr in co-operation with internists, psychiatrists, neurologists, surgeons and radiographers, and search for signs and symptoms of disturbed functions in the various parts of the body. At a later date a report will be given of psycho-analysis of psychogenic headache cases.

B ibliography .

1. Freud, S. Nervous and Mental Disease. Monograph Series, Nos. 4 and 7. 2. W h ite, WT. A . 1923. Outlines of Psychiahy, Nervous and Mental Disease Monograph Series, No. 1. 3. K em p f, E. J. 1921. Psychopathology. C. V. Mosby Co., St. Louis.. 4. Ferenczi, S. Contributions to Psycho-analysis. Badger. 5. Stekel, W. 1911. Die Sprache des Traumes., Wiesbaden. 6. Thompson, J. C. The Military Surgeon, March 1924. 7 . Roberts, S. R. 1924. Ann. Clin. Med., ii : 416. 8. Hurst, A. F. The Lancet (London), July 5, 1924. 9. Ewing, J. Orbital Pain. 111. Med. Jour., October, 1900. 10. H ill, F. T. 1924. Otologic Cases. Jour. Maine Med. Assoc., xiv : 165. 11. Dougherty, D. S. 1924. Nose, Throat and Ear Symptoms. N. Y. State Jour., Med., xxiv : 533-

TREATMENT OF CHRONIC NEPHRITIS BY DECAPSULATION OF THE KIDNEYS.

P e r c y C h e a l, m .r . c .s ., l .r . c .p ., Tainan, Formosa. The operation of decapsulating either one or both kidneys for chronic nephritis was brought before the members of the C .M .M .A ., a year or so ago by Dr. James b. Maxwell, and I should like to urge the usefulness of this procedure again, referring to some of the.cases we have treated here in this way and the results.

C a se 1.—A woman, aged 45, was brought to the hospital in March 1924, presenting a lamentable picture, only too common, of gross oedema with ascites. She was passing very little urine and it was “ solid” with Decapsulation of the Kidneys in Chronic Nephritis. 41 albumin. Her heart sounds were almost completely covered by loud murmurs, and she suffered a good deal from cyanosis and dyspnoea. Medical treatment having been tried as long as we dared and her condition becoming worse, she consented to operation. The right kidney was stripped of about half its capsule with the result that the patient improved rapidly from the first. She passed rather more than normal quantity of urine with diminishing quantit}' of albumin. Her general condition was so much improved that she did not then consent to the further operation on the left kidney. She left the hospital quite comfortable and able to get about freely. In November she came again as there was some slight return of the symptoms, with a little oedema of the feet and marked dyspnoea. She demanded immediate operation having experienced so much relief from the first one. We waited for some days before operating, however, as her cardiac condition was giving considerable anxiety; she could not lie down at all with any comfort. Under treatment with digitalis the quantity of urine again increased from 370 c.c. in the 24 h ou rs to 1,600 c.c. and the quantity of albumin which was about half on. admission the second time, increased in proportion. Finally, we yielded to her earnest request for further operation, and she stood the anaesthetic well. The next day there was a slight decrease in the amount of albumin and the following morning there was none at all in the urine. The quantity of urine passed remained about the same. After this the amount of albumin passed varied from a trace to about a quarter. Her cardiac condition improved instantly and she was able to remain, lying flat in bed, until the stitches were removed on the eighth day, with no sign of the former dyspnoea or cyanosis.

Of course we cannot predict what the condition will be six months hence, but the. results in other cases make us confident that there will be continued steady improvement in her general condition.

C a s e 2 .—A girl, aged 20, had been treated several years for albumi­ nuria and anasarca without improvement, at least without lasting improve­ ment. She consented to operation three years ago. Following decapsulation of both kidneys she passed less urine, at first with no albumin. The albumin re-appeared for a short time as the urine increased in quantity,, and she finally left the hospital passing normal urine in normal quantity. W e still see her occasionally, and there is no trace of the old trouble.

C a s e 3.— A boy, aged 7 years, was brought to us in a pitiable condi­ tion with gross oedema. He was passing very scanty urine, solid with albumin. The father consented to operation as a very feeble chance of saving the child’s life. Only one kidney was stripped, as his general condition did not warrant further manipulation. Recovery was practically uninterrupted. The operation was performed two years ago. We have un­ fortunately lost sight of him but be would almost certainly have been brought back had there been any return of the symptoms. 42 The China Medical Journal.

Case 4 .—A girl, aged 12 years, with gross oedema and having fre­ quent uraemic convulsions was brought in unconscious, the fits being almost continuous. Urine was exceedingly scanty and solid with albumin. One kidney was decapsulated. The operation was followed by immediate and complete cessation of the convulsions and return to complete conscious­ ness. There was increase in the amount of; urine passed and steady decrease in the amount of albumin. Unhappily she died very suddenly 011 the tenth day. As a post mortem examination was not allowed I do not know the cause of the sudden death. Case 5.—A man, aged 25, came to us so grossly oedematous that his e}7es were scarcely visible. His mother refused to have him operated upon until life was despaired of. One kidney was stripped with immediate and great improvement. The second kidney was operated on three weeks later and the patient was able to get up and’walk about as soon as the stitches were removed. His oedema had all gone and the urine was normal in quantity, though there was still a slight amount of albumin passed. There has been no recrudescence of the disease in nine moiitlis. The operation is usually extremely easy though there are cases in which the oedema is so great that exposure of the kidney is rather difficult. W e do not find it necessarj? to make complete exposure of the organ, it being sufficient to make an incision along about half of the convex border when the capsule can be easily stripped back as far as necessary. In several cases in which we have performed this operation for ascites with scanty urine with but little or no trace of albumin in the urine, the results have not been veiy strikingly good; though even in these cases there has been improvement usually. I believe that this class of cases maj^ be greatly benefited by the decapsulation operation combined with some form of drainage of the peritoneum into the loin. For chronic nephritis we have every confidence in recommending the operation. It is easy to perform, even w^hen the disease is extremely advanced, and strikingly efficacious in the majority of cases; at the least it preserves the patient's life for a time, and renders that life much more comfortable and useful-

D ecapsulation f o r N e p h r i t i s i n CHiLDREN.-^Fowler, Simpson and F raser, (Edin. Med. Jour., February, 1921,) report seven cases of decapsula­ tion for nephritis in children. They consider that the indication for the operation is chronic parenchynatous nephritis with oedema as the main symptom ; that children stand it w ell; that the benefit is so great as to justify the operation in all cases that do not improve under medical treatment; and that it is best to decapsuJate both kidnej^s on separate occasions. Case of “ Irritable Uterus 4 3

CASE OF “ IRRITABLE U TE R U S” .

H . H . M o r r i s , m . d ., St. Luke’s Hospital, Shanghai. In 1918, J. C. Hirst, ( Amer. Jour. Obstetr., Vol. 77, p. 662) described a condition sometimes found in pregnane}- which, for want of a better term, he called “ irritable uterus ” . His patients liad had several miscarriages, occurring usually at about the same period of their pregnancies; in one case, for example, it occurred about the four month. Examination had failed to reveal any anatomical condition to account for this condition, nor was there any general disease present, such as syphilis. Hirst put forward the idea that there might be a premature “ blasting ” of the corpus luteum in these cases, and treated them accordingly with extract of corpora lutea. Excellent results were obtained and the patients in their next pregnancies went on to full term. Shortly after this article appeared, an xA.merican lady came under my care with the following historjr. She had been married at the age of 31. The menses, which started about the age of thirteen, had always been normal and regular; she never had dysmenorrhea. Past health good. Patient became pregnant soon after marriage, and had a miscarriage about the third month. Examination of the uterus showed no malposition or other reason for the miscarriage. A second pregnancy also resulted in miscarriage at about 3^2 months, and a third miscarriage took place at the third month of pregnancy. At this time a Wassermann test of the blood serum ■of both husband and wife was done, with a negative result. There was no history in either case of syphilitic infection. Later she became pregnant for the fourth time. In the second month she was put on hypodermic injections of extract of corpora lutea (P. D. & Co.), one mil every other day, in all 32 doses being given for a period of a little over two months. The pregnancy progressed normally, with no untoward signs, and went to full term, when she was delivered of a normal baby (a girl). Since then she has had another pregnancy, was put on the same treatment, and was again delivered of a normal baby at full term. Of interest in this connection are a few details of the patient's physical features which seem to indicate that she may be the •subject of glandular dysfunction. She is of moderately short build, rather thickset, and has a slight amount of light-colored hair on 44 The China Medical Journal.

her face. Temperament rather placid, not easily disturbed. The pubic hair extends up to the umbilicus, similar to that seen in the male, and she has quite a little hair on her thighs, even on the inner surfaces. The similarity.of this case to those reported by Hirst is very obvious, and the response to treatment, supposedly specific, was very positive just as in his cases. As to the pathology, a prema­ ture “ blasting” of the corpus luteum, as suggested by him, seems a fairly plausible explanation; but that the condition in my patient was possibly due to something further back seems to be suggested by the findings noted above in regard to the distribution of the hair on the face, abdomen and thighs. I have felt that this case may be well worth reporting, as undoubtedly other similar cases may be observed here in China,, in which the same treatment may do some good.

A DOUBLE-HEADED MONSTER WITH TWO COMPLETE SPINAL COLUMNS.

H . W . D e c k e r , M .D ., S h a n g h a i. The monster was delivered at Hainon, China, on September 13, 1923, the patient being attended by Dr. T . M. Chen, a Chinese physician trained in Western methods of medicine. Dr. Chen brought the specimen to Shanghai and showed it to me. I suggested that a report of the case would doubtless be of interest to the readers of the “ China Medical Journal” , whereupon he requested me to study the case and make the report. I am also indebted to him for the history of the pregnancy and labor. He preferred the specimen not to be dissected, therefore our studies have been confined to photographs and external examination. The monster was born of normal, healthy Chinese parents of the laboring class. The mother was 29 years of age, and had previously given birth to one normal child after an easy labor. This child died from tetanus when about two weeks old. She said that her menstruation had always been regular. After the death of her first child she menstruated several times, then there was a complete cessation of menstruation twenty-four months before the Double-headed Monster. (Decker.) Double-headed Monster, two complete spinal columns. (Decker.) A Double-Headed Monster. 45 birth of the monster. The woman believed herself to be pregnant soon after the above cessation, and thought that she began to enlarge several months after her menstrual flow had stopped. She had no nausea during pregnancy, and had been entirely well. Before the confinement the physician had not been consulted by the patient. In fact he was not called in until she had been in labor for more than ten hours. A physical examination revealed no abnormality. She was not measured. Because of her intense suffering the abdominal examination was unsatisfactory. No ietal heart sounds were heard. In the vaginal examination the physician noted that the cervix was completely dilated and felt the larger head, the left, engaged in the pelvic outlet. He considered the position normal and could see no reason why birth should be unduly delayed. However, as the fetal position did not change after several hard pains, and the woman appeared to be suffering severe­ ly, he applied low forceps and delivered the head with great difficulty. In so doing he felt a peculiar resistance of what he supposed to be the shoulders, so he removed the forceps. Immediately the smaller head, the right, appeared and was delivered and the body followed without difficulty. There was a .single placenta. It was not weighed but appeared normal in both .size and appearance. There was never any sign of the monster breathing. W ith the X-ray plates and the photographs to examine, an •exhaustive description of the monster seems unnecessary. However, attention to the following points may be of some interest. The weight of the monster was 2.7 kilos. Its length was .41.5 cm. Both heads were symmetrical; the fontanelles and sutures appeared to be normal. The eyes, ears, nose, and mouth w^ere perfectly formed. In fact, either head might have belonged to a normal infant, though they varied perceptibly in size, and the .two upper central incisors in both jaws were erupted.

Head Measurements Right Left cm. cm. Fronto-occipital ...... S .1 ... Biparietal ...... 7.8 ... Bitemporal...... 7.4 ... 4 6 The China Medical Journal.

Mento-occipital...... 9 . 5 ...... 11.4. Suboccipito-bregmatic ...... 6 . 9 ...... 8.5. Largest circumference ...... 2 8 . 0 ...... 31.6.

Just midway between the two heads a small, hard swelling could be felt. Upon examination of the X-ray plate this proved to be the point at which the rudimentary arm bones fused. The necks seemed slightly shorter than normal and the chest seemed particularly broad. The distance from shoulder to shoulder measured 14.8 cm. There was an extra nipple in the midline just above the two regular nipples, the three being of equal size. The circumference at the navel was 28.5 cm. The anus was imperforate. The genitals appeared to be normal and were those of a male infant. The distance between the trochanters measured with a pelvimeter was 9.5 cm. The upper and lower extremities were perfect^ formed in every detail, likewise the nails. The skin throughout was normal.

It is stated that in double monsters one of the two fused individuals always has the position of its various organs reversed, it being, as it were, the looking-glass image of its fellow. In the body or bodies here described the X-ray photograph does not show this clearly, if at all, and it was impossible to make a thorough postmortem examination.

The photograph of the posterior view of the monster shows an incision in the middle of the back, which may be mistaken for lack of fusion of the tissues. The fact is, the parents being very ignorant and superstitious, refused to give the body to the physician; instead, they threw it into an old pagoda. The physician being informed as to its whereabouts bj7, a servant went and secured it. He found decomposition had set in, and, anxious to preserve it as much as possible, made an incision into the part of the back which had rested on the ground, which seemed somewhat soft, so that the preserving fluid could soak in. Thus he succeeded in securing the specimen in perfect condition, except for a slight discoloration around the lower extremities and this incision in the back. On the Occurrence of Sugar in Urine of Koreans. 47

ON THE OCCURRENCE OF SUGAR IN THE URINE OF KOREAN HOSPITAL PATIENTS. *

J. D . V an B u s k i r k , m.d., Seoul, Korea. The discovery of insulin has stimulated interest in the study of diabetes mellitus in all parts ¿)f the world. Diabetes has not been commonly found among the Korean people. In a series of 3,045 urinalyses reported by Van Buskirk and M illsf, sugar or some reducing substance was found in 35 cases, but there were onfy two cases of diabetes in the series. It has been felt that the records should be brought up to date in order to see if there is an increase in the number of cases of glycosuria and of diabetes. In the Severance Hospital it is not required that in all cases there must be an examination of the urine; but generally the doctor desires it. Out of 4,825 Koreans admitted to hospital in the 29 months preceding August 31, 1924, urinalysis was performed in 3,705 cases. Sugar or other reducing substance was found in 48 cases (1.3 per cent.) In the former series the percentage was 1.1 per cent. In 12 cases only was the specific gravity of the urine over 1.025, and in only 5 cases was it above 1.030. In most cases the routine examination was of a single specimen passed in the early morning, so that data as to the 24-hour quantity are not available in a sufficient number of the cases. It is clear, however, that most of the 48 patients did not have true diabetes mellitus. Checking up with the hospital records, we find 5 cases diagnosed as diabetes mellitus. This is 0.1 per cent, or one case in 965. This series shows a slight increase in the percentage of cases of glycosuria and of diabetes. The figures are too small to warrant definite conclusions, but they coincide with' the impression that diabetes is more frequently reported than formerly. This may be due in part to the new interest in the disease and greater care in diagnosis. Or it may be a real increase in the frequency of the disease. If the latter, what conditions in the life of the Korean people are responsible for the increase ?

* Article N o. 35 . From the Research Department, Severance Union Medical College, Korea. -)*Van Buskirk and Mills. Routine Examinations of Urine in Korean Hospital Cases. Ch. Med. Jour., M arch , 1924. 48 The China Medical Journal.

'The occurrence of a “ reducing substance ” in the non-diabetic cases may have various explanations. In some cases the reducing substance may have been due to drugs taken by the patients, such as chloral, camphor, morphine, cocaine, acetanilid, etc., which may cause the excretion of glycuronic acid (CH0 -(CH 0 H )4-C0 0 H ) ; this substance will reduce Fehling’s solution and Benedict’s solution. W e use the latter in our laboratories. An excess of intestinal putrefaction may produce an excess of indol, which may combine with the glycuronic acid to form “ indoxyl glycuronate,” and this may reduce Benedict’s solution. Anesthetics may cause a temporary glycosuria. An “ emotional glycosuria,” as a result of fear or pain in new hospital patients, maj^ account for some cases. The author considers this a likely factor in causing a transient glycosuria. Finally, in women patients lactose may be present in the urine, for lactating mothers were frequently admitted to the hospital. The percentage of cases of glycosuria is slightly higher in women patients than in men.

While carbuncles on the neck and back are common in Korea, no case of glycosuria was found in the sufferers from carbuncle in the former series of 3,045 cases. In the present series, one of the five diabetics came to the hospital to be treated for carbuncle.

S u m m a r y .

t . In a series of 3,705 urinalyses in hospital cases, a reduc­ ing substance was found 48 times (1.3 per cent.) But the number of cases of diabetes was onty 5 (0.1 per cent.)

2. This shows a slightly higher frequencj^ of finding sugar or some reducing substance in the urine than was found in a pre­ vious series, and also a higher frequency of diabetes. Does this indicate a real increase in the occurrence of diabetes among the Koreans ? If so, what conditions are responsible for the increase ?

D i a b e t e s .—The epidemiology of diabetes, investigated by Hofimann (Boston Med. and Surg. Jour. 1922, p. 135) for the Prudential Insurance Company, shows wide variations in different parts of the world, from 3S.4 deaths per 100,000 of population of the Island of Malta to 16.4 in the United States and 11.8 in England and Wales. Hoogslag (Nederl. Tijds. v. Gencesk. 1922, p. 173) analysing 250 cases of diabetes in Holland, found con­ sanguineous marriages in 215, and in 43 per cent there was a previous history of diabetes in the family. Aspirating Apparatus. 49

ASPIRATING APPARATUS FOR TONSILAR AND ADENOID OPERATIONS.

J. A . C u r r a n , m .d ., Fenehow, Shansi. When Dr. Hemingway', of Taiku, and I were doing some tonsillectomies and adenoidectomies together recently, we devised an aspirating apparatus which has nothing new about it in principle but is extremely easy to make and as efficient as one run by electricity or yvater power. Since a great many of our mission hospitals are without dajdight electric service, or not well supplied yvith running water, this apparatus is very useful since it can be operated by the hand power of a nurse or attendant. All the materials needed are usually on hand in the hospital or can be very •cheaply purchased. They are as follows : an ordinary large size tire pump, a large glass bottle with a two-hole stopper, two pieces ■of glass tubing, two lengths of rubber tubing, and a suction nozzle .(we used a spray nozzle). Removing the piston from the pump, we turned the discs around and so converted the pump from a force .to a suction pump. A very satisfactory vacuum was kept in the bottle. During •an operation any blood or mucus can be very rapidly aspirated. The accompanying sketch explains the apparatus.

— A&PIB-VrrD - - ~ - -S -l KATEftlAL

ASPIRATING APPARATUS FOR TONSIL AND

ADENOID WORK. China Jfttbical Journal.

V o l . XXXIX. JANUARY, 1925. No. 1

THE NEW YEAR.

The New Year does not open very brightly for China. After much strife, civil war, and political intrigue a provisional Government has been formed in Peking, but no one can tell what good it will accomplish, nor how long it will last. The political and military leaders seem to be struggling for power and wealth with little or no concern for the happiness and prosperity of the people. Throughout the country there is lawlessness and disorder. Looting by disbanded soldiers and brigands is common. Two or three of our own hospitals have suffered from their depredations. The unfriendly feeling towards foreigners seems to be increasing, and, sad to say, there is an anti-Christian propaganda which is influencing even some of the students in our Christian educational institutions. W e hope this anti-Christian movement is not so serious as some people suppose; dark clouds do not always mean a storm. In any event, whatever the clouds portend, it is our plain duty to continue our work with hope and courage, and with the faith that conquers the world. So far as the purely medical work of missions in China is concerned there is no reason for discouragement. During the past year our. work in all its departments has been strengthened and plans for further development have been formed. The membership of our Association has increased considerably. The President and Secretary of our Association have visited several stations where their services were needed and have given great help. In medical education the number of students in the Peking Union Medical College is increasing steadily; the Tsinan Medical School is flourishing ; the Hangchow Medical School has fine new buildings ; there is hope for union medical educational work in Canton; and when the country becomes, peaceful and orderly other educational institutions, now quietly holding their own, will probably develop to their full strength. The various Committees and Councils of the Association have done very good work, particularly the Council on Hospital Administration, which is trying, very hard and Hydrophobia in China. 5 1 successfully to solve the many hospital problems which are still before us in China. A start has been made in the work of training hospital technicians to lighten the routine duties of hospital physicians. The coming Conference, to be held jointly with the China ’Branch of the British Medical Association in Hongkong, should add fresh vigour to our Association, as it will be the first time we have held a Conference outside of our chosen field and with a good number of foreign physicians who are not members of our Association. In the light, therefore, of all that is happening, and with a firm belief in an over-ruling Providence, surely we can with confidence wish for each other a happy and prosperous New Year.

HYDROPHOBIA IN CHINA. During the year 1923, according to an official report recently issued, eighty-seven persons were treated in the Pasteur Institute, Shanghai, who had been bitten by dogs. Twenty-six of these patients were bitten by dogs proved rabid, seven by dogs certified rabid, and the rest by dogs about which less was known. No deaths occurred. The total number of cases sent to the Institute since the beginning is 1,067. Death-rate, three per cent; failure rate, one per cent. In Hongkong, during 1923, twenty-six patients were treated for dog bites. Sixteen of the dogs were examined and five proved to be infected with rabies. In 1922, there were also 26 patients under treatment. Out of 28 dogs examined, 17 were found to be infected. In November, 1924 there occurred in Hongkong what the newspapers reported as an “ Outbreak of Rabies” . One man died from the disease, if not more. Shanghai and Hongkong are under foreign control. Elsewhere in China cases of rabies are probably far more numerous. A definite statement cannot be made as no records are kept by Chinese officials of cases of this disease. In the transmission of rabies the biting animal is usually the dog, but the fact that over twenty persons in Shanghai during the last two decades were recorded as having been bitten by cats proves that this animal also should be carefully watched. In 1923 twenty-eight animals were examined in Shanghai for rabies, of which twenty- five were proved rabid. Two of these animals were cats and one was a horse. In December, 1924* a missionary physician and his wife were bitten by a cat which died on the day following the infliction of the injuries, and postmortem examination proved it to have been 52 The China Medical Journal. rabid. Treatment of the patients at the Pasteur Institute,, Shanghai, was very prompt and it may be confidently asserted quite effective. A remarkable case has been recorded recently (Kocevaloff, Comptes Rondus Soc. de Biol., 1923, p. 1205) of the transmission of the virus by the intermediary of another animal which remained healthy. In Juse, 1923, a mad dog flung itself upon a cat, covering it with saliva, fout apparently without biting it. The cat escaped and climbed a tree, and in its excitement clawed the hand of its mistress when she tried to catch it. A few minutes later the scratch was painted with iodine, and the incident was forgotten, the cat remaining perfectly well. Two months later the woman was taken suddenly ill with the usual signs of hydrophobia the convulsions coming on at intervals of from two to six minutes, and she died on the third day after the onset of s3ymptoms. In China the menace of rabies is always present. Outside of the few places under foreign control “ wonks ” are verj' numerous everywhere. The “ wonks ” are disreputable dogs of disreputable ancestry, half wild and generally ownerless. There is little or no protection against them provided by the Chinese authorities in the way of muzzling and other regulations, and if a dog goes mad from rabies nothing is done to prevent the spread of the infection. Rabies is so terrible a disease that the means of effective treatment should be always at hand, especially in places in China where it may take weeks before the patient can reach a Pasteur Institute. Delay in treatment seriously prejudices the chances of recovery. Cases treated during the first week appear from statistical evidence to have fifty per cent less mortality than those treated later. This delay can now be avoided. A new form of treatment has been adopted in Shanghai after prolonged experiment and study of the methods of treat­ ment used in the various Pasteur Institutes of the world. It is known as the “ Semple Modification” or “ Semple’s Vaccine.” It possesses the following advantages: (1) standard dosage; (2) keeping properties which enable the vaccine to be sent to distant places; (3) a certainty of asepsis. This method is exclusively used in Burma, Palestine, Egypt and Mesopotamia, and has been successfully used in Shanghai and in the interior of China. The Public Health Department* of the Shanghai Municipal Council is ready to supply this vaccine at a very moderate cost to physicians in China who apply for it. Meeting of C.M.M.A. Executive Committee. 53 JÊyecutive Committee

Excerpts from Minutes of Meeting held on December 19, 1924. The following members of the Committee were present : Dr. Kirk (in the chair), Drs. Maxwell, Fowler, Davenport, New, Cousland, McCracken and Morris. Apologies for absence were received from Drs. Houghton, Merrins and Balme. Dr. McCracken was nominated as alternate for the latter.

Health of Missionaries.— The following resolution was passed : Whereas there are vast areas in China where it is impossible to obtain the services of full}' qualified physicians, the Executive Committee of the C.M.M.A. respectfully suggests to the various mission boards, that lay missionaries appointed to such districts should be enabled before their departure to obtain a short practical course of medical instruction, similar in range and standard to the course given to missionaries in Livingstone College, near London, England. It was decided to send copies of this resolution to the Secretary of the Committee on Reference and Counsel in America, and to the Secretary of the British Advisory Board of Medical Missions.

Interneship for medical missions in China.— The following minute was adopted : The Executive Committee would reaffirm the conviction of the last conference that interne appointments should be taken at home and would urge that all medical missionaries should obtain such experience for at least one year before coming out to China. Where such is unobtainable in the home countries, arrangements should, if possible, be made for the securing of such experience at a hospital in China, approved by the Executive Committee of the C.M.M.A. for the purpose, and which can give experience in the type of work required to fit the new doctor for his, or her, particular appointment. Such hospital should be located in a district where the spoken language is similar to that which the new doctor will eventually use. The interneship should precede, and not in any way interfere with, the one year devoted wholly to the study of the language. ;

Committee on honouring distinguished members of the C.M.M.A.— The following minute was adopted : The Executive Committee has considered the question of some appro­ priate recognition of those members of the Association who have rendered faithful and distinguished service to the cause of medical missions in China, and, recommends that the Association with this end-jn.view should 5 4 The China Medical Journal. approve of the conferring of a medal, suitably inscribed, upon such individuals as are from time to time nominated by the Executive Committee of the Association for this honour. The design of the medal and other details to be left to the incoming Executive Committee to decide on and execute. Seal for the C.M.M.A.— It was moved that this Committee recommend to the Conference that the C .M .M .A . adopt a seal, the design of which should be worked out by the incoming Executive Committee. The motion was carried. Training of hospital technicians.— Dr. Maxwell made a general report with regard to what has been accomplished so far, showing that a beginning had been actually made. The following resolutions were adopted : 1. To leave over for the present all questions of standards of admission to the Institute for Hospital Technicians. 2. To leave over for the present all questions of a senior course. 3 . To approve certain definite tentative courses in laboratory, pharmacy technique, etc., suggested details of which were to be reported to the next Executive Committee meeting. 4. To avoid fixing for the moment the length of the courses but to advise a preliminary trial of how far these courses can be covered in six m on th s. 5. To leave, at am* rate till the Hongkong Conference, the settlement of questions concerning examinations and diplomas. 6. To approve of the work done at Hankow, relative to fixing the headquarters there. 7 . To approve making a tentative beginning at once at Anking and in any other centres where the work can be adequate!}* carried on. Treatment of Opium Addicts outside Hospitals.—A letter was read from the Secretary of the National Christian Council asking if the Committee could recommend any drug or preparation that would help opium addicts, unable or unwilling to obtain professional treatment, to free themselves from the habit. The Secretary was instructed to reply to the N .C .C . that owing to obvious difficulties and dangers connected therewith the Executive Committee could not recommend any particular drug or drugs or other form of treatment for the cure of the opium habit in the absence of adequate medical supervision of the patients. Postmortem Examinations and Dissections.— A resolution on the importance of obtaining from the Chinese Government greater facilities for the performance of postmortem examinations in Modem Pharmacy in China. 5 5 hospitals and for human dissection in medical schools, and, in this connection, pointing out the desirability of revising the Chinese terms in -the existing regulations in order to define more clearly the distinction between dissection and postmortem examinations, was submitted to the Committee. The matter was referred to the Section on Anatomy, of the Hongkong Conference.

MODERN PHARMACY IN CHINA.*

B y C h a r le s O. L ee, Nanking Universit3~, Nanking. Not so long ago the writer went into a modern dispensar}' in a large inland city of China. The store was found to be well stocked with all sorts of imported proprietary and patent pharmaceuticals. There was also a good stock- of surgical instruments and supplies and a complete line of toilet articles. Most of these goods were in original sealed packages, so that the purchaser could feel reason­ ably sure of the quality of the goods purchased here. There is also a prescription department in this store where modern prescriptions are received and filled in all confidence. Upon enquiry it was found that the pharmacist. in charge had learned pharmacy in a store in Shanghai, having served a little more than a year as an apprentice. This is the story of Western pharmacy in China as it rapidly spreads from the larger centres inland. Those of us trained in the profession, with respect for it as such, receive a shock when brought face to face with such conditions. W e are told that there are no laws in China regulating Western medical and phar­ maceutical practice. However, both foreign and Chinese Western- trained practitioners are quite well organized, so that there is at least a strong moral influence as regards modern medical practice in China. There is no such good thing for Western pharmacy. Nearly all of the branches of science, including medicine, are offered in the curricula of various Chinese and foreign modern educational institutions in China. So far we have heard of only one place where Western pharmacy has been made a part of the

*Re-printed from the Journal of the American Pharmaceutical Associa­ tio n . 5 6 The China Medical Journal. regular educational work. Even in this place only a start has been made, and just a few have completed the pharmacy course. The mission hospitals in China have found it quite necessary to train some responsible young men to do their routine pharmacy work. Nothing like a sound course in pharmacy can be offered in hospital dispensaries, where equipment and teaching staff are scarcely adequate to carry on the most urgent part of the wTork. Occasionally a hospital has been able to train a few more men than it needed for its own use, thereby allowing them to be released for other places. Quite often men with the meagre training of a few years in a hospital pharmacy, go out and establish a small dispensary for themselves. To know some of these men is to wonder what happens to the tolerant and suffering public. Of the many educational surveys of mission work in China,, none, not even the most recent, has seen fit to recommend any educational work in pharmacy. Rather, a very recent survey recommended that our mission institutions do not offer courses in pharmacy. It is quite clear that those making such a recom­ mendation were not pharmacists in any sense. The writer, however, is quite convinced that the opportunity has come and the need for educational courses in Western pharmacy is at hand. He is also assured that at least one reputable mission university would be interested in adding such a course to its curriculum if funds were provided for its maintenance. The funds needed to offer a course in pharmacy in a school that already has courses in chemistry, biology, physics and other allied subjects, should not be large. It would be necessary to offer, in addition to the present courses, only the necessary courses in pharmacy and materia medica. Students taking such a pharmacy course could graduate with a degree equivalent to the degrees offered in science, agriculture and forestry. Men so trained would be prepared to do the phar­ macy work of modern hospitals, or if they should choose to open dispensaries,, they would be educationally if not fundamentally better qualified than most apprentices are to do so. In China, as in America, we find doctors promoting the best interests in medicine, agriculturists working for better conditions and larger returns in agriculture, foresters not onty planning ways for best conserving the forests at hand, but also working on the problem of afforestation. The engineers are busy at developing the Hygienic Latrines in China: .4 Suggestion. ¿7

industries of the county. Men who are promoting the best inter­ ests of their science or profession are largely men of schooling and experience. Pharmacy in this respect in China has hardly made a beginning. The door is wide open to make a worth-while place for pharmacy in science and education. Pharmacists will have to claim for pharmacy whatever place she is to have in China. There is no other hope. W e have shown that Western pharmacy is already in China, and is here to stay. W e have suggested the route by which it has come. The drug manufacturing interests of nearly every leading country have found China a buyer. Drugs are a great matter of interest to these people. They have a complete and extensive system of pharmacy of their own, which will gradually give way to the newer and we hope better system of the West. The students of China know virtually nothing of pharmacy as a subject of science and research, and are interested to hear about it, as the writer has occasion to know. Not only is there an un­ usual opportunity for good schools of pharmacy in China but there is a rich field for research in native drugs and chemicals. The writer was told recently by a native drug dealer that China has one hundred thousand different important drugs used in medicines. Perhaps so. At least it would be interesting, and no doubt valuable as a contribution to modern medicine, to study the possibilities of Chinese native drugs and drug products.

HYGIENIC LATRINES IN CHINA: A SUGGESTION.

A . E- B e s t , b .a ., m . b ., Union Medical College, Chengtu, Sze. Perhaps no problem has given health workers in China more brain fag than that of devising satisfactory latrines. For any scheme of excrement disposal to ever become extensively used in this country, certain conditions peculiar to the country must be met. One of these is that, until other cheap fertilizers are available, the use of human excrement by farmers is unavoidable! For this same reason the farmer is, for years to come, going to look askance ‘at the septic tank; the value of the sewage as fertilizer after it passes through any tank system varies inversely as the efficiency of the tank. Further, for the great mass of the people, economy in apparatus must play a large part in any sewage disposal plan. A : pail in a box with a lid to it would be the 58 The China Medical Journal. simplest and cheapest plan, but the seat is apt to spread such diseases as itch, and all too often the lid would be left up by the thoughtless. W hat happens to hookworm larvae in the ordinary Chinese sewage pits remains to be worked out, but it was felt that perhaps our largest menace is flies and it was to meet this that we started our experiments. The result is outlined below and it may be of interest to those who are working on the same problem. It is an attempt to solve the question of a lavatory for Chinese nurses and coolies as well as for ambulatory patients. A number of these conveniences are set side by side in a row over an inclined trough, into which the droppings fall and which empties at one end into the septic tank. Under each aperture is a slight depression so as always to hold a little water and thus make sluicing easier. At the upper end of the trough is a self-dumping can,holding ten gallons, into which flows all the water from the three upper stories of our hospital. (We considered that the regular water and sewage system as used at home would be too expensive for a mission hospital.) Further, it was desired to work out something that would be adaptable to Chinese homes and institutions. Some things about this automatic toilet should appeal to the Chinese. First, it permits use of the excrement as fertilizer but keeps the flies away until its removal. Secondly, it is fairly cheap, costing us here in Chengtu about $10. Thirdly, it can be made anywhere locally where there is a carpenter and a blacksmith. Again, there is little to get out of order. It is complete in itself, requiring no doors or wire screening. It can be placed over a pail, crock, or pit, and if the material can be removed from behind through a trap door so much the better. The parts apt to get soiled can be easily removed for cleansing. The squatting posture for defecation, so much discussed now, can be retained, and if there is anything in appearances, it is in outline not unlike the ordinary Chinese privy. Last, but not least, there is no possibility of a person going away and leaving the lid up, as it closes automatically.

It may be admitted there are some objections to it. It takes up more room than many Chinese would care to spare. W e are at present working on another model that takes up slightly less room but the principle of the two is the same. A description of it we hope will appear in a later number of the “ China Medical Journal” . Again the stringers may sag in time and require turning over, Hygienic Latrines in China : A Suggestion. 5 9 though this is not a very serious matter. There will be a little wear where the surface of the lid comes in contact with the trip, and also at the ends of W i (Fig. III). W e have offset this by introducing thin strips of strap iron between the opposing surfaces, and lubrication, which, though it is not essential to efficient working, stili further reduces the friction. The local soft wood of which it is made is subject to rot, but if the parts which are wetted from time to time are treated with some such preservative as solignum, it should last for many years. 6o The China Medical Journal.

E xpla n a tio n o f t h e M e c h a n ism . The^platform on to which the person steps and where he squats is hung- anteriorly (Figs. 6, 7 , & 8) u p on the irons R 6, and posteriorly from the irons R 4 a n d R 3 through to. Ri which is attached to the lid. The weight of the lid, when its centre of gravity is not directly over hinge R 2, is sufficient by means of the leverage it gets through R i to overcome the weight of the much heavier platform and thus keep itself closed. However, it is not sufficient- to overcome the weight of the platform plus the weight of the person. As soon therefore as the person steps on the platform, and as long as he remains on the platform, the lid is up out of the way. The lighter the person the nearer he will have to approach the lid before this rise takes place. The handle, so^prominent in the foreground, is principally for the use of little children and we found that even in their case the gentlest of lifts was quite sufficient to start the lid rising. To adults, and especially to the uninitiated,, the handle obviously suggests that the lid is to be lifted, and for most people the lid has begun to rise before they get near enough to lift on the handle. For those who can read, the Chinese character inscribed tells its. ow n story .

As the person moves off the platform, the “trip” , which has been forced back out of the perpendicular by the rising of the lid to a vertical position, presses the lid forward until it is sufficiently past the vertical for its own weight, through its leverage in R i, to be able of itself to bring the platform back into apposition.

D im e n s io n s of t h e V a r io u s P arts (F ig. 4).

F r a m e . —F 2, F 4, F 6, F 7 are all 3 inches square. F i, F 3, F 5, F 9 are all 2^ in. by in. F 2 is 33 inches over all, measuring from upper surface of F 7. F 3 is 30 inches long, that is, the front and rear posts are 30 inches, apart. F 4, the rear posts, are 3 feet 7 inches high, measuring as for F 2. F 6 is a cross piece at the rear holding the two sides together. F 7 is 7 feet 6 inches long over all. F 8 is a board 1 inch thick running all the way around and nailed firmly to F 6 and F 7. F 9, the cross bar, is 28 inches long, that is, the rear posts are 28 inches apart. F io is a .cleat, 10 inches long, 2 inches thick, and 4 inches high at the back, to support the front of the back post which has been weakened b}r the slot to hold the crossbar, C. B. If preferred» the end of the crossbar may be held between the rear post and this cleat. The cleat must of course be nailed to F 7 . F n is a partition of thin boards filling in between the posts. F 12 is a small box for toilet paper. Hygienic Latrines in China: A Suggestion. 61

. T h e “ T r i p ” (Figs. i, 2, 3, and 4.}

W i is a crossbar from which the trip hangs and is rounded at the ends so as to be freely movable in cleats C. It is 2% inches at its widest, and its ■ends come to a square so that when rounded the}' are perfectly round. It is inches thick. Its lower edge is just 10 inches from the lower edge o f F 9 above.

The cleats, C, are made about S inches long, and the bottom of the lollow for holding the ends of W i should be 4 inches from the top to prevent the cross bar from being jolted out. 62 The China Medical Journal.

Except for the cleats W 2 nailed on the front, the back and the front of the trip are the same. A perpendicular dropped at right angles to the bottom is just 18 inches from the lower surface of W i. The back surface m easures 19 inches down from W i, and the front surface would be the same were it not rounded along the lower edge. Similarly, the bottom surface w o u ld be 14 inches from front to back were it not for this rounded edge. This round commences on the bottom 3 inches back from the front lower edge, and on^the front surface 2 inches up from the front lower edge. Inside, the lower portion is divided into back and front portions by the board W 5. Earth or gravel may be introduced from the back sufficient to carry the lid well forward with its weight, and the amount in the two compartments may be varied so as to have the trip hang at the proper angle. This can be accomplished by anyone with a few minutes experimentation. W 2. two strips, preferably 1 inches thick, 1% inches wide at the widest; the widest portion is just 3 inches from its lower end, the round being continuous with that on the trip. They are nailed at either side to the front surface of the trip. From the widest part it goes straight to the top edge of W i. W 3, two pieces 2 by inches are firmly set into W i and carry the whole weight of the trip. Along the inner surface, lower half, runs a groove toehold W 5. W 4, a cross piece holding W 3 togeth er. W 5, a h alf in ch board. W 6, W 7, front and back surfaces of inch material. The upper half of the back is left open for the insertion of gravel. W 8, cleat on either side to help carry bottom. W 9, bottom of Yj. inch material. Wio,*ends of 1 inch material to which the front and back boards are n ailed. T h e C r o s sb a r (F igs. 2, 3, 4, 7, 8, and 9.) CB, the crossbar, 2 b y 4 inches. The drawings show the ends set into the rear post with a slot above so that it and the whole platform with attachments may be taken out (forwards) should occasion require. However, there is no reason why it should not rest on F 7 and be held against the front of the rear posts by cleat Fio, there being a notch at either end to prevent side play.

T h e L id (F ig s. 1, 2, 3, 5, 6, 7, and 8.) The outside measurements are 2 feet 6 inches long, 13 inches wide, a n d 6 inches high. H, the handle, serves the double purpose of giving the lid a start if a lift be necessary,^and as a point of attachment, by means of string or a bent wire hook, holding the lid up out of the way when cleaning or dipping out the receptacle below is being done. Hygienic Latrines in China: A Suggestion. 63

Li, cover of % inch material.

L 2, ends and sides 5 % inches high by f thick. The ends and sides should be well dovetailed at the corners. A strip of rubber tubing attached along the lower edge does well as a silencer, should that be desired. (N o te.— Should it be found that on account of using light wood in this lid, the weight is insufficient to overcome the weight of the platform, this may be easily remedied by fastening a little sheet of lead to the inside surface of the forward end of the lid.

1

TO TRIP A N D LID

. PLATFORM. THUS UNCOVEBINO DEFECATION APERTURE. '64 The China Medical Journal.

T h e P latform (F igs. 2, 4* 5, 6, 7, 8, and 9.)

Pi. This is the squatting platform, V/2 inches thick, corners well mortised. This platform is removable for access to the space beneath, as for washing or dipping out. Should a small pail be used as the receptacle underneath, it would be preferable to have a few spikes sticking up above the surface in proper position, so as to prevent the squatter from squatting anywhere but exactly over the pail below. P 2, 4 inches by 14 inches apart, carrying platform and extending from R 3 to R 6. P 3, made of f inch material, enclosing aperture 8 inches by 24 in ch es. Fitting inside is a similar aperture (Pi) over which the squatter squats. At front and back this is 5 inches high and scoops down to 3 inches in the middle. The front slopes back a little so as not to interfere with the lid falling, and also projects down below the lower surface of Pi so as to carry urine away from its lower surface. This P 3 is nailed to Pi all around. P4 a n arrow fram e i]4 inches wide running all the way around the squatting platform Pi, and is nailed to the stringers P 2. P 5 is a strip of quarter round running the full length on both sides and is nailed lightly to the inside upper edge of F 8. It covers in the small crack left between the edge of the platform and F 8 on either side. This narrow crack is left purposely so that the platform may have free play moving up and down, and the strip is nailed but lightly so that it can be easily removed and the whole platform taken out. P 6 simply covers in the space at the back and is immovable. P 7, the platform is made of £ inch boards nailed to the stringers below. P 8 is the platform continued at the back. P 9, a cross piece joining the two rear ends of the stringers, to which it must be firmly secured as to it are fastened the irons R 4. Pio, another cross piece, just far enough back to catch the front edge of the lid should it come down accidently when the squatting platform is removed for cleaning. All wood for the above frame can be made of Chinese “ Sung Muh” (;&7fc)

T h e I ro n W o r k (Fig. 10).

“A ” , a side view of the rear irons. Ri may be spoken of as a straight portion and a bent portion. The straight portion is 18 inches long measuring from the centre of the bolt h ole at R 2. The bent portion is at an angle of 1450 to the straight part, and the centre of the bolt hole at the end is 5 inches, from the centre of th at at R 2. Up to the point of the arrow it is all 1% inches wide by inch thick, but from there on, to save iron, it may be a little narrower a n d £ inch thick. R 2 is in two parts for convenience in making (C is the back view), and is bolted to crossbar by % inch bolts ; each is 1 inch wide by inch thick. Hygienic Latrines in China: .-1 Suggestion. 65

R-3, are thin strips (B back view) 1 inch wide by £ inch thick, and in len gth 7 f inches between hole centres. R 4 is 1 yi inches wide by % inch thick. The horizontal portion is 4 inches long and is screwed firmly or bolted to P 9. The bolts represented by the square heads are half inch iron pins Rivets would do fully as well as the bolts, though not so convenient. D represents the irons R 5 and R 6, and for their position see Figs 7 and S. If the platform is not intended to be removable, strong hinges would do equally well. These are 5 x 1 x 3/16 in ches.

C onstruction o f L a t r in e s .— The following points should be observed in the construction of latrines : — 1. The design should be such that all excreta and washings automatically find their way into some receptacle, so that no brushing will be necessary. 2. The materials used should be non-absorbent to prevent pollution of the soil through soakage. 3. Satisfactory arrangements for the reception of night-soil, and -separation of liquid excreta, and for the cleansing of the same, should be m ade. 4. The trap-door (for the sweeper) should be easily accessible, and the passage leading to it should be decent. 5. Ventilation should be thorough and efficient, even when the doors are closed.— G h o s h , Hygiene and Public Health, p. 224. 66 The China Medical Journal.

Current fIDeMcal Xiterature.

PREGNANCY AND PULMONARY TUBERCULOSIS

F o r s s n e r , The Lancet, September 13, 1924- At a recent meeting of the International Union against Tuberculosis held at Lausanne, a paper was read by Professor Forssner on the alleged influence of pregnancy on tuberculosis which drew comments, mostly favourable, from many of his audience, and this was the more remarkable as his conclusions would have been generally regarded as hopelessly unorthodox only a few years ago. His thesis that “ a pregnancy continuing till term is no more dangerous for first stage tuberculous women than for healthy women, and by not interrupting this pregnancy we obtain for the race healtliy children, just as viable as other children,” was supported by much carefully sifted evidence. Forssner’s paper was based on the records of women treated in the tuberculosis dispensaries of Stockholm and, in a certain proportion of cases, recently confined in maternity hospitals. The Swedish National League against Tuberculosis financed for six years a systematic examination of all women confined in two maternity hospitals in Stockholm. Of more than 30,000 women thus examined, 1,500 were kept under observation on account of the diagnosis or suspicion of tuberculosis, and 341 women who suffered from pulmonary tuberculosis, and who were kept under medical supervision for more than a year after confinement (usually for two years or more), were compared withi 396 women whose pulmonary tuberculosis was not complicated by pregnancy. After a two years’ observation period, the non-pregnant women in Turban’s first stage were compared with the women who had been pregnant and had also been in the first stage of the disease. It was found that the disease was stationary or the patients had improved in 59 per cent of the first class, and in 60 per cent of the second class. Only a slight difference in favour of the non-pregnant patients could be found in those whose disease was in the second and third stages. As for the influence of the mother’s tuberculosis on the health of her child at birth, it was found that the average weight of the infants of sputum-positive mothers was equal to that of the infants of healthy mothers. There can be little doubt that Prof. Forssner’s paper and the confirmation which his views received in Lausanne will do much to check the practice, fairly common in some countries, of inducing abortion in the subjects of pulmonary tuberculosis on the assumption that (1) the prospective mother’s health will benefit, and (2) the value of progeny will prove negligible. Current Medical Literature. 67

INDEPENDENCE OF HUMAN AND BOVINE TUBERCULOSIS.

L ichtenstein , Acta Pacdiatrica, June 16, 1924. The author has conducted a statistical survey of the incidence of tuberculosis in cattle in different counties in Sweden, comparing it with the death rate from tuberculosis among human beings during the first 3^ear and first five years of life. It was found that the mortality from tuberculosis during the first year of life varied greatly in different parts of the country, and, as a rule, the infant mortality from tuberculosis was higher in the towns than in the county districts. As for the incidence of bovine tuberculosis there were great differences in the various counties; in the large northern county of Norrbotten only five cattle were found to be tuberculous, but the infant mortality from tuberculosis was exceptionally high. On the other hand, in the count3^ °f Kristianstad there was a low infantile death rate from tuberculosis, although the incidence of bovine tuberculosis was high. The twenty-four counties were divided into two equally large groups, the twelve counties with much bovine tuberculosis being grouped in the one, and the twelve counties with little bovine tuberculosis being grouped in the other. The average incidence of bovine tuberculosis in the first group was 2.7 per 10,000, whereas in the second group it was 13.8. In the first group the tuberculosis mortalit}' among infants under the age of one year was 16.6 per 10,000, in the second group it was 17.8. In other words, though the incidence of bovine tuberculosis was about five times greater in one group of counties than in the other, the infant mortality rate from tuberculosis was practically the same for both groups. Following a second line of research the author has compared the death rate from tuberculosis among children in the first years of life with the tuberculosis death rate at all ages in the different Swedish counties. It was found that counties with a high mortality from infantile tuberculosis also had a high tuberculosis rate for all ages, and vice versa.

RELATION BETWEEN A CARNIVOROUS DIET AND MAMMALIAN INFESTATION W ITH INTESTINAL PROTOZOA.

H e g n e r , Amer. Jour. Hyg., July, 1924. Three rats fed throughout their lives (174 days) on a carnivorous diet were found to be free from Giardia muris and Trichomonas muris. Two of these rats contained a few specimens of Hexamitus muris. Experiments have shown that when rats heavily infested with G. muris, H. muris, and T . muris are subjected to a carnivorous diet for one week the incidence of infestation falls off only slightly; the average numbers of H. muris increase, of G. muris decrease nine-tenths, and of T. muris decrease to one fifty-fourth of those in 6 8 The China Medical Journal. the controls. A t the same time the bacterial content of the intestine changes from a predominantly acidophilus type to a predominantly putrefactive type. It seems probable that the products of decomposition of the putrefactive bacteria bring about an environment unfavourable for T. muris. This does not, however, account for the decrease in the numbers of G. muris, since this species lives in the duodenum. A review of the literature of protozoology reveals the fact that intestinal protozoa (amoebae, ciliates and flagellates) have not been reported from carnivorous mammals in nature except very rarely. Omnivorous mammals seem to be less frequently infested and with fewer species than herbivorous animals, and ungulates are more abundantly infested with intestinal protozoa than rodents. Domestic carnivores (cats and dogs) may be infested experimentally with Entamoeba histolytica and nm* exhibit spontaneous infesta­ tions, probably brought about by contamination of food with C}7sts from man. Giardias have been reported from cats and dogs, chilomastix from the dog and trichomonads from the fox. Examinations were made of faecal specimens, at intervals during a period of seventeen days, from twelve carnivorous animals belonging to ten species (lion, tiger, polar bear, grizzly bear, black bear, Syrian bear, grey wolf, grey fox, red fox, wild cat). No protozoa of any kind were discovered except giardia cysts in the wild cat. Feeding experiments with cats indicate that these animals are difficult to infest with giardia cysts from man and rat and with trichomonads from the rat. One cat became infested with trich­ omonads, probably temporarily. Data from the various sources described above seem to prove that a carnivorous diet is unfavourable for the intestinal protozoa of mammals. Work is now in progress designed to Lest the value of a carnivorous diet in cases of human amoebiasis, giardiasis and trichomoniasis.

CAUSES OF PERSISTENT HIGH BLOOD PRESSURE F a b er, Ugcskri'ft for Laeger, F ebru ary 21st, 1924. The author records an account of blood pressure investigations carried out at Silkeborg Hydro in Denmark. A comparison of the pressures with the ages of the patients showed that in the case of the men a marked rise was not to be observed till the forties had been reached, whereas women showed an appreciable rise of pressure in the thirties. The author sees in this rise one of the earliest signs of the impending climacterium. Among 100 women between the ages of 45 and 55, without gross organic disease, he found 47 with a blood pressure above the normal (exceeding 170 Sahli). Disease of the kidnej's and heart, and more or less localised Current Medical Literature. 69 arteriosclerosis, seemed to play a more important part in men than in women; these lesions were demonstrable in about 60 per cent of the men and only 17 per cent of the women whose weight was below, and whose blood pressure was above, normal. He is very sceptical about the part which arterio-sclerosis per se is supposed to play in producing a high blood pressure. In the March number of the same journal (p. 219) the author defines two main groups of high arterial pressure : in the first group it is associated with renal disease and is possibly due to i t ; in the second group the high blood pressure is ‘ 'essential’ ’— that is, it is independent of renal disease. Of t o o cases in which the blood pressure exceeded 165 mm. of mercury there were signs of renal disease in 34, and in 51 there were no such signs; there were also 11 cases in which the hypertension was associated with valvular disease of the heart, and 4 in which it was associated with polycythaemia. With regard to the influence of excessive weight on the blood pressure, it was found that among the nine women found to be suffering from hypertension in 1923 the excess of the bodj^ weight above normal averaged 16 kilos. As regards prognosis, the author expresses considerable optimism m the case of those patients whose hypertension is “ essential ” and who are willing to submit to appropriate treatment. Even with a pressure exceeding 200 mm. the}T may live happity for decades, provided they cease to poison themselves with tobacco, give up work entailing much or violent psychic strain, reduce their alcohol consumption, and adopt a mainly lacto-vegetarian diet. Coffee and tea need not, however, be interdicted, as is usually the case, and their diuretic action may even be beneficial. Venesection is of little value for the relief of chronic hypertension, but it may have a life-saving value in the acute stages of l^pertension, with sudden attacks of cardiac asthma and pulmonary cedema.

LACK OF EXERCISE AS A FACTOR IN CAUSING BERIBERI. B la ck xo ck , Brit. Med. Jour., June 14th, 1924. In the medical literature on beriberi lack of exercise is frequently mentioned in a general way as a contributory cause, especially when coupled with overcrowding and insanitary sur­ roundings ; but it does not seem to have been recognised hitherto that lack of exercise has such a definite effect as has been brought into evidence by the observations and experiments of Blacklock here recorded. He concludes his paper as follows. 1. Observations of an epidemic in Freetown Prison suggested that lack of exercise plaj-ed an important part in determining an attack of beriberi where the necessary predisposing conditions of diet existed. As beriberi is notoriously a disease which occurs in institutions and in places where a fixed diet and some degree of 70 The China Medical Journal. confinement are almost constantly present— for example, prisons, asylums, ships, etc. it is important for those in charge of institutions to realize that such useful occupations as tailoring, mat-weaving, and basket-making are not such as to provide sufficient exercise. 2- Experiments on fowls showed clearly the decisive influence of lack of exercise in accelerating death in animals fed on a diet deficient in vitamin B. 8. In previous beriberi epidemics this factor has been almost entirely overlooked. 4. The fact that lack of exercise accelerates and accentuates the ill effects of a diet deficient in vitamin B. opens up an interesting problem in metabolism.

PUERPERAL SEPSIS TREATED BY NOYARSENOBENZOL Saint-Blaise and Joanny, La Gyndcol, February, 1924. From January, 1922, Saint-Blaise and Joanny have treated bjr intravenous injections of novarsenobenzol, 268 cases of puerperal pyrexia in which there was no evidence of localised sepsis such as adnexal inflammation or peritonitis. A considerable reduction of mortality has followed the institution of this treatment— namely, from 0.45 to 0.27 per cent (1922) and 0.04 per cent (1924) of labours; and from 5.7 to 2.8 per cent (1923) and 0.5 per cent (1924) of infected cases. The beneficial effect of the treatment was first noted when treating a series of streptococcal cases of puer­ peral infection which were erroneously thought to be associated with congenital or acquired syphilis. At present the authors are inclined to ascribe their results to an action of the arsenical deri­ vative on the micro-organism causing the puerperal infection rather than on the maternal tissues. The arsenobenzol treatment is in­ stituted as a rule at the third to fifth day post partum, but earlier in the cases in which there is evidence of infection at or shortly after labour. Contraindications consist in evidence of impaired hepatic and renal function such as eclampsia, uraemia, or icterus. The usual dose given was small— 1Y grains every two days while fever persisted. Of the 268 cases of infection 55 are classified as slight, 17 as grave and prolonged, and 158 as of moderate inten­ sity ; in 32 infection was evident at the end of labour.

FATE OF INFANTS OF TUBERCULOUS MOTHERS. Couvelaire, La Gynêcol., January, 1924. In a communication to the Société d’Obstétrique et de Gynecologie de Paris, Couvelaire surveys the fate of 63 infants born (since 1921) of mothers suffering from pulmonar3'tuberculosis and with tubercle bacilli in the sputum. All the children, of whom 61 were living and apparently healthy, were strict!y Current Medical Literature. separated from their mothers from the time of birth onwards. In half their number the individual weight was six and a half pounds or more. No fewer than 23 (38 per cent) were dead within the first month after birth, and the percentage mortality was not greater among those of inferior weight, nor those whose mothers were at the time of labour in relatively more advanced stages of pulmonary tuberculosis. Turning to the cause of death in these infants Couvelaire was unable to find precise anatomical explana­ tions, and compares their decease to the extinction of a lamp which has burned up its oil ; these children are born, he concludes, with a diminished “ coefficient of vitality.” The after history of the remaining infants, who survived the first month, appeared to show that in conditions of complete isolation from the tuberculous parent or parents— and conditions which in other respects were hygienically satisfactory— their health and viability were not inferior to those of infants born of healthy mothers.

CALCIUM IN TREATMENT OF TUBERCULOSIS

C h een isse, Presse Medicale, vSeptember, 1924. The author cites Rosen (Moscow) who used intravenous injections of calcium chlorid in 200 cases of active tuberculosis, not to cure any special morbid manifestations but as a systematic treatment of the disease. The course of treatment is divided into two series 01 fifteen injections each, with a ten-day interval; the injections are given usually every second day. The average dose for one injection is 300 c.c. of a 1.5 per cent solution. An increase in weight occurred m the second week, associated with improve­ ment in the heart action. Fever, sweats and cough disappeared, by the end of the third month. The auscultation and percussion signs persisted longer. Calcium in food and by the mouth is given during the whole treatment. Recurrences were noted only in thirty patients in the first three years after apparent recovery.

ETIOLOGY OF FAILING HEART.

A llan , Glasgow Med. Jour., August, 1924. Three hundred and twenty cases of failing heart were analyzed by Allan. The symptoms complained of were as follows: breathless­ ness, 279 cases; pain, 130; palpitation, 107; exhaustion, 78; cough, 68; hemoptysis, 37; giddiness 23; faintness, 14; embolism, 14; dropsy, 125 cases. Of the total of 320 cases of failing heart, 242 were valvular cases, and 78 myocardial cases. Of the 320 cases, 148 were definitely rheumatic. Of the 242 valvular cases rheumatism was the cause m 145. Definite syphilitic infection was noted in 63 of all the cases, and in 63 of the valvular cases. It reached its highest percentage in pure aortic incompetence, in which 72 The China Medical Journal. evidence of syphilis was obtained in 70.75 per cent of the male cases, and in 66.66 per cent of the female cases. The Wassermann test was positive in 51 of the 63 cases ; in the other 12 cases the test was not applied, but there wras definite clinical evidence of the infection. Evidence of syphilis was not obtained in any case of pure mitral stenosis, or of combined mitral stenosis and aortic incompetence in either sex. Renal disease, or arteriosclerosis, occupies the third place in etiologic factors. It was present in 2S cases, or 8.75 per cent of the total; but when the 78 n^ocardial cases are considered alone, it was found to account for 27, or 34.6 per cent of these, and in this group it is the commonest etiologic factor. Other etiologic factors occurred too seldom for the figures to be of any special value. Auricular fibrillation was present in 27 per cent of the cases in this series, and in 28 per cent of those patients who died. While syphilis was present in 20 per cent of ail cases, it was noted in 29 per cent of those patients who died ; rheumatism was noted in 46 per cent of all cases, but only in 43, per cent of those who died.

ANTHROPOLOGIC SIGNIFICANCE OF BLOOD [GROUPS.

B ais and V e r h o e f , Neder. Tijds. v. Geneesk., September 6, 1924. The authors found a blood group index of 0.9 in 1,346 Japanese; of 0.82 in 546 natives of Sumatra, and of 0.92 in 592 Chinese employed in the Dutch East Indies. This confirms the downward trend of the index along a line from northwestern Europe toward the southeast and the Orient. The blood grouping index is evidently an important aid in the study of anthropology. The uniquely high index found b}^ Coca in North American Indians might be interpreted, they sa;v, as evidence in favor of a polygenetic origin of the human race. Further research in this line is particularly needed in regard to the peoples of the extreme north in Europe and America (Scandinavians, Greenlanders and Laplanders) and in the New-Guinea region and the Netherlands- The index found by Cabrera and Wade in the Philippines conflicts with what might be expected in that district, but they regard the number tested (204) as too small for final conclusions.

TREATMENT OF ORIENTAL SORES AND OTHER ULCERS BY PHOSPHORUS. C astellan i, Jour. Trop. Med. and Hyg., O ctober 1, 1924. The preparation of phosphorus used in the treatment of Oriental sore is the Oleum phosphoratum, B.P. It is applied externally to the sore, and given by injections (3 to 5 minims) into the nodule and under the skin around it. When the ulcera­ tive process is fairly developed the simple external application of Current Medical Literature. 75 the oil (after removing the scab), without arn- injection, seems to be sufficient to induce a cure. It would appear also that in certain cases of the nodular type, it is not essential to inject the oil into the nodule; the subcutaneous inoculation in close vicinity to it would seem to be sufficient. The subcutaneous injection of phosphorated oil in small amounts (3 to 5 minims) is painless and also harmless. This was observed several years ago by the author when he used it in cases of rickets and osteomalacia, and in certain cases of very chronic malarial cachexia, as an adjuvant to quinine and arsenic. The intranodular injection of the oil may occasionally give rise to a severe local reaction; in this event the injections are discontinued for a time and hot boric fomentations applied. It is suggested that the treatment might be tried in other Leishmanial conditions, and also in certain cases of ulcers of non-Leishmanial origin such as granuloma inguinale, ulcus tropicum, and certain persistent tropical ulcerations of obscure origin.

ACETONAEMIA IN CHILDHOOD ASSIMULATING APPENDICITIS. B r y a n , The Lancei, October ntli, 1924. Ever}7' 3rear in the early spring the author warns his house surgeons to be on the look-out for children with acetonaemia sent to hospital with a diagnosis of acute appendicitis. There is a histo^ of the child having been suddenly seized with severe vomit­ ing and abdominal pain. On examination of the abdomen general tenderness is found, due, perhaps, to the effort of repeated vomiting. The distended caecum and the liver may be specially tender. It is this right-sided localisation of maximum tenderness that causes the simulation of appendicitis. There is fever, and the child seems seriously ill and exhausted. The facial appearance is characteristic, dark and shrunken under the eyes with general pallor contrasting with the bright-red lips. The tongue is coated. The odor of the breath has the characteristic sweet smell of acetone which is so marked in some cases that it can be noticed on entering the room. The child is lethargic but sleepless; usually there is a history of loss of energy, anorexia, thirst, and constipation going back for some days previous to the onset of the acute illness. In very severe cases there is restlessness progressing to delirium and semi­ coma. Diagnosis is to be confirmed by the finding of much acetone in the urine. Among these cases the most anxious are those in which local signs indicate that the appendix is involved in the distension of the caecum, a result, of course, of the constipation; in several such cases one has been able to palpate the appendix, and very great may be the temptation to operate under the impression that the 7 4 The China Medical Journal. primary condition is appendicitis and the acetonaemia is secondary. There can be no question, however, that the safe policy is to wait, for an anaesthetic is, of course, definitely contraindicated, involving the greatest risk of the disaster of delayed anaesthetic poisoning.

ETIOLOGY OF SPRUE. S m i t h , Journ. Amer. Med. Assoc. N ovem ber 15, 1924. As a result of animal experiments the author supports Ash­ ford’s theory of the specific etiology of sprue as being due to Monilia psilosis, but he emphasises that the organism is one of very low pathogenic properties, and that for infection to occur in man, he feels quite certain that one or more predisposing factors tending toward lower resistance must exist. Chief among these should be mentioned : (1) long continued residence in the tropics; (2) previous acute or subacute gastro-intestinal infections, especially amebic dysentery ; (3) impaired metabolism as a result of unbalanced, excessive or deficient diet, including the prolonged use of alcohol, or (4) a combination of any or all of these.

SPRUE AND PERNICIOUS ANEMIA. V an d e r S c h e e r , Neder. Tijdschr. v. Geneesk., September, 1924. The author has always found tropical sprue confined to the bstter situated classes. Too much fat in the intestines seems to be the primary factor, he states, deranging blood formation and de­ struction and calcium metabolism. The fat may be in normal amounts, or below, but beyond the capacity of the individual to assimilate. The resulting digestive disturbances entail fermenta­ tion and secondary diarrhea, with undernutrition and production of toxins, the whole forming a vicious circle leading to a condition resembling pernicious anemia. In man}7 cases the only differential sign is the presence of hydrochloric acid in the stomach, as achylia seems to be a primary factor in pernicious anemia. In sprue if achylia is found, it subsides as improvement progresses. The author holds that regulation of the diet is all that is needed in sprue. Health returns rapidh’ from the extreme emaciation and weakness, when the proper dietetic measures are instituted, but this may require long tentative dietetic treatment before the opti­ mum is reached. The hemoglobin metabolism is a good guide, estimated by the bilirubin content of the blood serum and the urobilin in the excreta. In one of the typical cases described, 0.322 gm. of bilirubin was the dailj7 average.

BLACKWATER FEYER. Ja c k so n , South African Med. Record, June, 1924. The author asserts that hemoglobinuria is a symptom of pernicious malaria, and should be classified as such. Blackwater Current Medical Literature. 7 5 fever is not coextensive with malaria, but it is coextensive with malignant malaria wherever it is especially intense. And it is m the countries where the parasite found is the quartan or tertian •causing severe malaria that it is not coextensive. The disease is contracted in non-malarial places. It has occurred months and even years after the patient has left the tropics. The patient has left the tropics with malaria latent in his system, development of the parasite has proceeded until, gradually, after a varying period, a high degree of latency is brought about, while the necessary acidemic condition has gradually grown with the increasing depths of latency, until suddenly one of the exciting factors produces the explosion. In Jackson’s opinion a recognition of repeated attacks of malaria with resulting acidosis, and this acidemic condition further increased by occasional dosing with quinin which fails to cure, implanted in a patient who lives a life of habitual acidemia, will explain all that is necessary toward the production of the hemoglobinuria, occurring in what otherwise might be an ordinary attack of malaria. It explains also the failure in treatment.

BERIBERI.

V an d e r W alle, Nedcr. Tijdschri v. Gcnecsk., September, 1924. The author quotes Eijkman’s remark in 1921 to the effect that Hollanders gave the world the remedy for beriberi but have kept beriberi. The number of cases of beriberi in the Netherlands East India has been gradually declining since 1S97, but in 1919 there was a sudden increase. In the garrison at Batavia, for instance, the bsriberi patients increased from 16 to 890. There is some .still unknown factor involved besides the anti-neuritic vitamin, as is evident when beriberi develops in prisons using hand-ground instead of polished rice; from the fact that beriberi becomes more common during the rainy season and drops off during the dry seasons; and the facts which speak for contagion from beriberi cases, as when acute beriberi developed in the occupant of the bed on each side of a pneumonia patient who had been sent from Batavia to a mountain resort, free from beriberi, to cure him of his beriberi, and had acquired pneumonia en route. The European attendant also developed symptoms suggesting beriberi. Van der W alle regards some microbian invasion as the last straw that upsets the precarious balance of the organism undermined by the aliment­ ary deficiency.

TREATMENT OF PLACENTA PRAEYIA,

C ald e ro n and Y illaram a, Phil. I si. Med. A ssoc. Jour., July, 1924. The authors analj’ze 314 cases of placenta praevia out of 10,462 deliveries, or one case of placenta praevia for every thirty- 7 6 The China Medical Journal. four deliveries. The maternal death-rate was 16.56 per cent; the- infantile, 67.18 per cent. Fourteen infants (4.45 per cent) died undelivered. Thirty-eight babies died after deliver}’. The greater number of mothers (59-61 per cent) died from acute anemia. Fourteen were admitted in a dying condition, who were not given any treatment at all. Most of the postpartum complications belong to mild puerperal infection, the patients having recovered after routine treatment. The t\Tpes of placenta praevia were : lateralis, 174 cases; marginalis, 83 cases; centralis, 50 cases; not recorded, 7 cases. Most of the fetal and maternal deaths occurred in the lateralis group. Fetal mortality for Cesarean section was lowest in this series, podalic version was highest. Maternal mortality for spontaneous delivery is second to breech extraction, that is, 5.33 per cent and 4.54 per cent respectively. The highest maternal mortalit}’ is found in manual dilatation followed by podalic version, and second comes Cesarean section, namely, 30 and 28 per cent respectively. Maternal death after Cesarean section is due to profound anemia before the operation. In no case was peritonitis- found to be a cause of death after the operation.

THE SWEAT DURING MENSTRUATION

P o l a n o a n d D i e t l , Miinch. mcdizin. Wochcn., O ctober, 1924. The authors tested the influence of the kneading of a small batch of yeast dough on the fermentative activity of the }Teast. They found always an increased or decreased speed of fermentation, if the women tested were menstruating at the time. No action w-as apparent during the intervals, not even with sweating hands. The}- believe that the action may be due to the higher cholin and creatinin content of the sweat during menstruation.

ABSCESS OF THE LIYER.

B r a d f i e l d , Indian Med. Gaz., O ctobcr, 1924. For some time it has been the routine practice in the Madras Government General Hospital to treat all cases of abscess of the liver by aspiration, followed by a course of emetine treatment. The result of these methods has been entirely satisfactory and a comparison cf the results obtained during the ten years 1912 to 1921 with those obtained during the past year is very instructive. During the former period of ten years, 171 patients were operated upon in the General Hospital for abscess of the liver, of whom 31 died, a mortality of 18.1 per cent. During the past year 33. patients were operated upon for abscess of the liver, of whom 2 died, a mortality of 6.3 per cent. Book Reviews. 77 Book IReviem

O-eceral Cytology—A Textbook of Cellular Structure and Function for Students of Biology and Medicine. By various authors. Edited by Edmund V. Cowdry. Price G. $7.50. Postage extra. Publishers : The University of Chicago Press, Chicago, Illinois. In the words of a great phj^siologist the thought that the enormous number of phenomena constituting life are associated in all their essentials ■with the microscopic bit of living substance that constitutes the living cell is an irresistible stimulus to research. As evidence of this, during recent years a host of investigators have busied themselves with a detailed study -of the cell and its constituents. The present very handsome volume, edited by E. V. Cowdry, formerly on the staff of the Peking Union Medical College, Peking, is a fine presentation of researches of this kind. During the summer of 1922 it happened that a number of cytologists were working together at the Marine Biological Laboratory at Woods Hole, Massachusetts. As a result of their deliberations it was decided to make a co-operative •■attempt to set out in general terms what is known or conjectured regarding the principles which govern cellular structure and function ; in other words, to present briefly for the first time within the scope of a single volume data •concerning the cells which are fundamental alike to the sciences of botany, zoology, physiology and pathology. The short but very interesting introduction to the whole subject is by Edmund B. Wilson. In order, the chapters are : “Some general Aspects of the Chemistry of Cells,” by Albert P. Matthews ; “ The Permeability of the Cell to diffusing Substances,” by Merle H. Jacobs; “ Reactivity of the Cell” by R. S. Lillie, the term '“ reactivity ” being preferred to “ irritability ” because of its broader mean­ i n g ; “ The Physical Structure of Protoplasm as determined by Micro­ dissection and Injection,” b}T Robert Chambers; “ On the Cytological Constituents of the Cell Mitochondria, Golgi Apparatus, and Cliromidial Substance,” by Edmund V. Cowdr}-, the editor of the work; on the '“ Behaviour of Cells in Tissue Cultures ” by Warren H. Lewis and Margaret R. Lewis; “ Fertilisation” by Frank R. Lillie and E. E. Just; “ Cellular Differentiation ” by Edwin G. Conkiin; “ The Chromosome Theory of Heredity” by Clarence E. McClung; “ Mendelian Heredity in Relation to Cytology ” by Thomas H. Morgan. Each chapter, did space pei'init, would receive extended notice, as it sums up very ably our knowledge of its particular subject. The whole volume is most interesting because it hovers round the fundamental problems of life, growth, decay and death. Yet in comparison with the marvellous discoveries of physicists concerning the nature of the atom— its nucleus or nucleons of positive electricity, its negative electrons with their satellites, the separation between the orbital electrons being greater, in proportion to their size, than the separation between the planets -and our sun— the cytologists seem hardly to have made a corresponding progress. With the humility of the true scientist, the editor, in the chapter written by himself, acknowledges that cytologists are still working very ■much in the dark. This is to be expected as the ultimate structure of the living cell must be infinitely more complicated and baffling than that of the inorganic atom. It must long remain a mystery how the physical and mental peculiarities and the temperamental disposition of parents are transmitted to their offspring. But the original studies described in the volume under review, and the researches of numerous other workers, are •expanding our knowledge, and the advance in the future may be more rapid than we anticipate. The volume is beautifully printed and illustrated. 78 The China Medical Journal.

Transactions of the Fifth Biennial Congress of the Far Eastern Association of Tropical M edicine. Held at Singapore, 1923. Edited by the Hon. Dr. A. L. Hoops M.D., D.P.H., B.A. President of the Congress, Principal Civil Medical Officer and Member of the Legislative Council, Straits Settlements ; and Dr. J. W. Scharff, M.B., D.P.H. Hon. Sec. of the Congress, Health Officer. Singapore Lecturer in Biology, King Edward VII College of Medicine. Illustrated with 86 plates (two coloured) and numerous charts in text. Publishers : John Bale, Sons & Danielsson, Ltd. Oxford House, 83-91 G reat Titehfield Street, Oxford St. London. All physicians in the Far East will find this volume very interesting and helpful, as it deals with practical subjects of the greatest importance. Comment has already been made in this Journal (November 1923), on th e Presidential address by Dr. A. L. Hoops 011 the “ Prevention of Disease in the Tropics.” There are numerous papers on malaria, beriberi, ankyl­ ostomiasis, several on plague and leprosy, and the large number of miscellaneous papers cover other tropical diseases, and include such subjects as hospital construction, opium smoking and the Materia Medica of China. The paper on “ Cancer in the Tropics” by Dr. E. P. Snijders and Dr. M. Straub is particularly valuable; it has been noticed before in this Journal (April, 1924). In an interesting article by Sir David J. Galloway on opium smoking the reasons given by Chinese addicts for beginning the habit are : (1) among the better classes simply because opium smoking is the custom; (2) among the poorer and occasionally among the better classes, to aileviate suffering. The particular diseases mentioned in which opium gives relief are phthisis, especially if accom­ panied by haemoptysis ; the glycosurias of the Chinese; malaria ; abdominal pain (especially pelvic), and the nocturnal pains of syphilis. Although no inquiry was made on the point, gross obvious signs of syphilitic infection were noted as being present in 223 opium addicts, a percentage of 1S.54 o f the total. The whole paper is well worth reading by those interested in this much discussed subject. The volume is well bound, printed and illustrated.

The Hum an Testis. — By Max Thorek, M.D. Its gross Anatomy, His­ tology, Physiology, Pathology, with particular reference to its Endocrinology, Aberrations of Function and Correlation to other Endocrines, as well as the Treatment of Diseases of the Testes and Studies in Testicular Transplantation and the effects of the Testicular Secretions on the Organism. 308 Illustrations. Publishers : J. B. Lippincott Co., Philadelphia and London. The subject matter of this volume is fairly well indicated by its comprehensive title. The author has thoroughly examined the literature on the subject in English and other languages and claims that there does not exist at present a work in any other language which embraces the information contained in this volume. At the same time, the author, who for a number of years past has been operating and experimenting in this branch of surgery, gives the results of his own practical experience. The chapters on the dystrophias and on the inter-relation of the glands of internal secretion are very good and are well illustrated. Of course Steinach’s vasoligation and other experiments to accomplish what is popularly known as rejuvenation receive much attention. The author carefully describes his own animal experiments of this kind and on sex gland transplantation and presents a number of clinical case records. He emphatically objects to the use of the term “ rejuvenation 11 on the ground that it is misleading to the laity, who gain from such terminology the impression that by certain procedures the old can be made young. This is erroneous. Yet he holds that the field of usefulness for gland implantation Book Reviews. 79 is varied, and includes 1113113- conditions. Improvement in certain well- defined pathologic states can be anticipated in properly selected cases following the use of proper material and the employment of proper technique. Much controversy has surrounded this whole subject. Physicians and surgeons from a study of the material here presented will be able to draw their own conclusions. To surgeons particularly interested in all diseases of the testes and in the necessary operations will find this volume v ery useful.

Fundam entals of Hum an Physiology.— By R. G. Pearce, B.A., M.D., and J. J. R. Macleod, M.B., D.Sc., F.R.S. Assisted in the third edition by Dr. Norman B. Taylor. Price S3 .50. Publishers : C. V. Mosby Co. St. Louis, U. S. A. 1924. The object kept in view in the preparation of the present volume has been to give'an elementary, yet comprehensive review of the various facts and theories which go to form the science of human physiology. It is mainly intended for college students who for the sake of the knowledge itself wish to learn something of the workings of the human body, and also for those who must know some physiology before they can properly proceed to study other sciences such as pharmacology and hygiene. In this edition, the third, the subject matter has been thoroughly brought up-to-date. The work is very well and clearly written and the illustrations, some of them coloured, are very good. It is an admirable Physiology for those not desir­ ing to study the subject as deeply as medical students.

A Pocket Book of Ophthalm ology.— By Arthur J. Ballantyne, m.d., F.R.F.P.S. (Glasgow). Second edition. Price 6 / -net. Publishers : E- and S. Liviflgstone, t6 and 17 Teviot Place, Edinburgh. 1924. Written for the use of medical students while studying ophthalmology this note book is interleaved and students are recommended to take it with them to the lecture room and clinic and to utilise the blank pages for the insertion of diagrams and supplementary notes. The whole subject of ophthalmology is covered in a clear, concise and systematic manner. There are no illustrations. Perhaps the omission is intended to encourage students to draw illustrations of their own on the blank pages, of the cases seen by them at the clinics. Medical students will find the volume excellent for its purpose.

Handbook of Pharm acology, including M ateria M edica.— By Birendra Nath Ghosh, F. R. F.P.S. (Glas.) Price 6 /6 net. Publishers : Hilton and Co. 1923. The author has written this book to meet the requirements of medical students in India. He has utilised his wide experience as a teacher and an examiner to make the work concise and reliable, so that it can be used not only by students but also by practitioners. The references to various Indian drugs add to its interest. A short appendix gives the alternative preparations sanctioned for use in tropical, subtropical and other parts of the British empire. The book is compact, attractive, and in handy form.

The Insulin Treatm ent of Diabetes M ellitus.— By P.J.Cammidge M..D, (Lond.) D.P.H. (Camb.) Second edition. Price 6 /— Publishers: E.& S. Livingstone, 16 and 17 Teviot Place, Edinburgh. The first edition of this work we reviewed a few months ago (Ch. Med.. Jour., March, 1924.) The demand for the book has been so great that its reprinting became necessary and the opportunity has been taken to bring it completely up-to-date. The author is an authority on the subject as he has had a clinical experience of diabetes mellitus extending over twenty years, and has been continually engaged in experiments upon the normal and abnormal carbohydrate metabolism of the human body, and 8o The China Medical Journal.

was one of the first to use insulin. In the addendum there is a careful re­ view of all recent advances in our knowledge of diabetes and the preparation, nature, and administration of insulin, also a number of clinical notes. The volume is indispensable to all physicians who are treating cases of diabetes.

A Textbook of M ateria M edica for Nurses. —By A. L. Muirhead, m .d . Second edition. Price $ 2.00. Publishers : C. V. Mosby Co. St. L ou is. 1924. According to the preface, this little book has been written for the undergraduate nurse while studying materia medica, and with her needs and limitations constantly in mind. Its aim is to provide her with a book of twenty-four short chapters in which she can obtain easily and in a language she can readily understand, the information concerning drugs and remedies which she needs in her calling. The purpose of the book is accomplished very well as any nurse who thoroughl}' masters its contents will have a sound knowledge of the subject, quite sufficient for all ordinary requirements.

A Treatise on Hygiene and Public Health.— With special Reference to the Tropics. By Birendra Nath Ghosh, F.R.F.P.& S. (Glas.) Fifth edi­ tion. Price Rs .6 or 9 /6 net. Publishers : Hilton & Co., Calcutta. 1924. Written for physicians and medical students in India this volume on “Hygiene and Public Health” should be interesting and instructive to physicians in China, as it deals with the problems of hygiene in tropical countries and with the customs of Oriental peoples. In the preparation of this edition— the fifth— the author has derived great help from the “Medical History of the War” , especially from the volumes dealing with the hygiene of the war. Of particular value to practitioners in China are the chapters on the disposal of refuse, the incineration of night-soil, a description of the different types of latrines used with so much success during the war, the chapter on village sanitation and on the sanitation at fairs and religious festivals. The Indian Factory Act, 1911, (Act XII. 1911), a considerable part of which is quoted by the author, furnishes a good guide to those who wish to see introduced into the factories of China the regula­ tions, based on experience, which have proved efficacious in the West in safe-guarding the health and safety of factory operatives, especially women and children. The volume is in convenient form and contains a very large amount of information.

Personal Religion and the Life of Devotion.— By W. R. Inge, D.D., Dean of St. Paul’s Cathedral, London. With an Introduction by the Lord Bishop of London. With frontispiece. Price 2 / 6. Publishers: Longmans, Green & Co. Paternoster Row, London. This is a very helpful book on the devotional life and therefore it can be recommended to all missionaries; but it is referred to here mainly be­ cause of its testimony to the spiritual value of suffering in little children, a matter upon which medical missionaries are often questioned, and of the possibility that with the suffering there may be great happiness. With reserve and yet with moving tenderness the Dean in the concluding chapter tells of the death of his little girl, eleven years old, after an illness lasting about eighteen months. A few months before the end her little brother said to her when they were alone that he wished she would" get better. He was so impressed by her answer that he repeated it to his mother. “No, Richard, you must not say that; God has spaired me for a whole year to be with you all, and it has been the best year of my life.” A little later, when she was no longer able to use her pencil and paintbox, she was still able to say, “ I am the happiest little girl in all the world.” The Dean writes : “It seems to us that this happiness came from a vivid realisation that the Correspondence. 8 r

Everlasting Anns were about her, and from a consciousness that the deep love which she felt for us all, including her kind doctor and nurse, was fully returned.” Several times during the last few days she said to her nurse ; “I am so happy.” The suffering of little children is a moral problem to many, but such lives show us there may be great spiritual compensation. Am erican Journal of H ygiene— Vol. IV. No. 5. September, 1924. B al­ timore, M.D. P h3'sicians in China interested in the investigation of hookworm dis­ ease are referred to an article in this number by Norman R. Stoll. It con­ tains a description of his work to ascertain what constancy there is in the day-to-daj- output of hookworm eggs from a given human host.

Correspondence. Correspondents are requested to write on one side of the paper onlyt and always to send their real names and addresses. The J o u r n a l does not hold ttself responsible for the opinions or assertions of correspondents. Chinese Treatment of wound as sufficient reason to treat Hydrophobia. the matter ligh ts, is very dangerous. The following letter was sent This prescription has been the means some time ago to the “ North China of saving many lives. People crazed Daily News,” by its Liucliowfu and almost dead have been restored correspondent. to life again, and it is sincerely Sir.—A learned native practi­ hoped that all seeing this notice will tioner having taken special pains to publish it afar. study the effects of bites b\- dogs The Prescription. affected with rabies, and "having Chai Ho ...... dram s discovered a “ Sure Cure” for this Root of Peucedanum malignant disease, now gives it Skin of Citrus freely to the general public, in the Peppermint... hope that others afflicted by this Raw Ginger p ieces dread disease 11133- prove the efficien- Angelica Root dram s cy of his prescription, and be num­ Plat3’codon Grandiflorum . bered among the thousands who Levisticum ... have been cured b3^ his skill. Kiang-lio This notice was pasted 011 the Liquorice ...... walls of the T’angpo rest house at Elm Bark ...... the K u n g 37uan Gardens in the city China R o o t...... of Liucliowfu. To the above add one ounce of raw “ Often those who are bitten b 3* a bamboo rootlets, and steam the mad dog regard the healing of the above in clean water before drinking. wound as complete recovety. This This medicine should be taken is very dangerous, for the bite of a four or five times. Then within ten mad dog is very poisonous. AYheu days the patient should b y and eat a person is bitten the poison goes raw yellow beans. If, when eating, into the system and although the the patient is not conscious of a rank w ou n d m a3^ be healed the poison flavour, poison still lurks in the m a3T still be in the system, and system, and the medicine should be w ith in 100 da\-s m a y break ou t and taken again once or twice. Again prove fatal. Even if the skin is not raw yellow beans should be eaten, broken, when bitten, the mere tear­ and if now the patient is conscious ing of the clothing maj7 be sufficient of a rank flavour, making it almost to infect one with the disease. impossible to swallow the beans, he If, fortunate^, the skin is not has completely recovered, and need bitten, to regard the absence of a not repeat the dose.” 82 The China Medical Journal.

NEWS AND COMMENT.

M a r r i a g e . will cost a million and a half 3’ en Dr. R. M. Ross, physician at the is to be completed next spring. Kerr Hospital for the Insane at Co-education was initiated this Canton, and Dr. Margaret Taylor, a academic year,' and six Chinese teacher at the Haclcett Medical girls are enrolled in the entering College, were married at Canton class. There are also a number of recently, the ceremony being per­ Chinese girls in the school of formed by the bride’s uncle, the nursing. The staff of the medical Rev. Dr. Charles Taylor of Xew school now numbers 87.— P. U. M. C. Y o rk . Bull din .

Tsinan Medical School.—Gra­ H o n o u r t o D r . C h r i s t i e o k duates and friends of the Shantung M o u k d e n .— A singularly fine honour Christian University will be in­ has been paid to Dr. Christie who terested to hear that the Trustees of recently retired from his position at the China Medical Board, at their Moukden after forty years of faithful meeting of November 5, 1924, m ade and strenuous service and is now further appropriations on behalf of living in Edinburgh where he is the maintenance and building funds still woiking .for the cause he loves. of the school of medicine. Due The Chinese officials and business partly to the natural increase of men of Moukden spontaneously came demands made upon the college and together and decided to subscribe hospital, and partly to the recent for a bronze bust of him to be placed union of the North China Union in front of the Medical College Medical College for Women with buildings in recognition of his life­ the men’s institution, the University long work for the Chinese. The now urgently requires additional money was sent to Scotland, and teaching staff, residences, dormi­ the commission has been executed tories, a new hospital of 200 tea ch ­ by Mr. Percy Portsmouth, r . s . a ., ing beds, a private ward building, r . b .s . It is an excellent likeness various units of the mechanical and a beautiful work of art. plant, together with the requisite equipment and furniture. To pro­ M e d i c a l P r o g r e s s i n W e s t vide for the proposed expansion, C h i n a .— The quarterly paper of the more land has already been pur­ Edinburgh Medical Missionary chased. The grant towards the Society, November, 1924, contains annual support of the school for the an interesting article by Dr. J. H. next three and a half years amounts Lechler, Miencliuhsien, Sze. describ­ to a total of Mex. $ 113,000. T ow ards ing the opening of the new hospital buildings and equipment the Board there of the Church Missionary has appropriated a conditional grant vSociety. It is the only hospital in o f M ex . $ 100,000. It will be recalled a district of about 10,000 square that in the summer of 1923 the miles with a population of some 8 Board contributed U. S. $ 50,000 for m illio n s . the same purpose, and since 1916

has been providing funds in varying H y g i e n e f o r C h i n e s e B e g g a r s .— amounts for the maintenance and The Y. W. C. A. in Changsha is at upbuilding of the medical school. work in cooperation with the Hunan Health Association and M anchuria M edical University, W elfare vSociety to look after health M o u i c d e n .—The large medical and hygiene in the poorhouses, school science hall has been found beggar homes, and other such inadequate and an extension which refu ges. News and Comment.

D e s t r u c t o n o f M i s s i o n H o s p i t a l . State. So far as our information —At Hungchiang, Hunan, near the goes, none of these Chinese herb Kueichow border, bandits have doctors has any particular train­ looted and burned the town. The ing. . . It would seem apparent C. I. M. Hospital and residences in some localities that underground have all been burned down there. influence makes it impossible t>> Such was the panic reigning that convict Chinese herbalists of viola­ two of the patients in the hospital tion of the laws of this State.” were burned to death, none being able to get in and save them. F e m a l e S e c l u s i o n i n I n d i a .— The tuberculosis returns in India show a D e a f C h i l d r e n i n C h i n a .— It is very high mortality rate among said there are 400,000 deaf children young females between the ages of in China waiting to be educated. 15 and 20 years. For every boy that dies, six girls die. This appalling

P n e u m o n i c P l a g u e i n U .S .A .— mortality is mainlj- due to the pur­ Up to November 12, 1924, there had dah system, that is, the strict seclu­ occurred in the Mexican quarter in sion of females in the houses, their Los Angeles, California, U.S.A., rooms being usuallj' in the inner thirty-six cases of plague, all trace­ portion of the house, ill-lighted and able to the same origin and to the ventilated. Also early marriage same district. The evidence is, subjects immature girls to the strain according to the health authorities of repeated pregnancies and pro­ investigating the epidemic, that the longed lactation. first case was of the bubonic type, and that all subsequent cases have P o i s o n i n g b y B a m b o o H a i r s .— been pneumonic, except two. In the Cases of poisoning by the use of thirty-six cases thus far noted, there bamboo hairs are not uncommon in have been thirty-three deaths. The the Dutch East Indies. The hairs immediate, drastic and well war­ are general!}- mixed with black sand ranted action taken by the health or with powdered glass and art- authorities seems to have been given with coffee or curry. It. is sufficient to confine the infection said that this form of poisoning definitely to the quarter in which it produces a chronic dj'senterv, originated. Further and extensive causing ulceration of the stomach studies will now be made to deter­ and intestines, and is fatal in mine to just what extent rat infection some weeks, if not treated b\- a prevails, and its bearing 011 the doctor; but if so treated the fatal cases that have already developed. ending in severe cases is postponed for some months.— Jour. Trop. Med. and H yg., O ctober , . C h i n e s e H e r b D o c t o r s i n 15 1924 U. S. A.— Reports have come to the # State Board of Medical Examiners The National Essay Contest in California, that various herbalists on “Medicine as a Life Work ” are in some instances engaged in which was announced last spring the “ abortion business,” and that by the Council on Health Education in other instances the stores of aroused so much interest among the Chinese herbalists are apparently students of the colleges in China conducted as a blind for the sale that the task of awarding the prizes and distribution of narcotics. In seemed at first colossal. It later reply to an inquiry, the secretary of proved, however, that some of the the Board said : “ We do not know contestants were disqualified for of a single instance in which one of one reason or another, and only the so-called Chinese herb doctors, eighteen English essays and forty who advertise extensively in various C h in ese rem ained for final con sid era ­ sections of California, has a license tion. The judges’ report is expected entitling him to practice in this in the near future. 8 4 The China Medical Journal.

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