THE

China Medical Journal

P u b l i s h e d b y

The China Medical Missionary Association

VOLUME XXXIV

1920

S H A N G H A I :

Printed by the Presbyterian Mission Press 1920

INDICES

TO

W xt China JEcbiral Journal

Volume XXXIV, 1920.

G e n e r a l I n d e x . Page. Abscess of liver ...... Dr. B r o w n . 387 Dr. L u d l o w . 258 Abdomen, pain not dependent on surgical conditions ... 563 Abdominal contusion and intestinal rupture, (588) 304 ; (633) 548 ; (635) ... 650 Abdominal surgery ...... Dr. W i l k i n s o n . 26 Acanthosis nigricans, (613) ...... 415 Accidental hem orrhage...... Dr. W h i t m o r e . 587 Accounts, hospital...... Dr. H o u g h t o n , h. s. 99 Adenofibroma, transplantation of, (590) ...... 304 Adenomyoma, rarer forms of D r. J. P. M a x w e l l . 602 Adrenalin, arteriosclerosis produced by, (656) ... 657 Alcoholism and cancer of oesophagus, (553)...... 80 American Red Cross ...... 216,, 340 Gifts to mission h o s p ita ls ...... 682 Amibiasine ...... 462 Amoebae in man ... _ ...... 197 Amoebiasis, hepatic complications ...... 353 Amcebiasis, pulmonary ...... 388 Amoebic dysentery, diagnosis of ...... 198 Benzyl benzoate in ...... 198 Ammonium rhodanatum ...... 461 Amoy, proposed medical school in ...... 216 Amputations, disposal of remains ...... 465 Amputations in a war hospital ... 362 Osteoplastic, 137 ; secondary ...... 136 Anatomical terms, in Chinese ...... D r. I n g r a m , a. s. 9 Anatomy, review of Chinese writings on ...... a. s. 8 Anesthesia, gas and oxygen ...... 135 Local, 147; B ier’s regional ... D r. T a y l o r . 385 Anesthetics, local, action of on peripheral nerves, (627) ...... 543 Aneurysm of aorta, (577)...... 175 Anking, cerebro-spinal meningitis in ...... 431 Medical progress in ...... 703 Ankle, dislocation of, with fracture of fibula...... Dr. L u d l o w . 509 Anthelmintics, therapeutic value of ...... 568 Anthrax bacillus, (614) ...... 4 X5 Anthropological Association of China : Constitution and By-laws, 3 ; members of, a. s. i ; meeting of ...... 689

a. s.=Anatomical Supplement, h. s.=Hospital Supplement i i INDICES.

Anthropology of Asiatic peoples ...... Dr. H r d l i Ck a . a. s. 30 Relation to medicine...... a. s. 4 Anthropometry, methods of ...... D r. H r d l i Ck a . a. s. 8 D r. B l a c k , a. s. 64 Antepartum hemorrhage...... D r. W h i t m o r e . 587 Anhwei, meningitis in ...... 217 Antung, Customs Service Medical Report ...... 676 Aorta, aneurysm of (577)...... 175 Appendicitis, oxyuris and 564 Arachidic bronchitis ...... 559 Arteriosclerosis produced by adrenalin, (656) 657 Arthritis deformans of knee as a senile change, (651) 655 Ascariasis simulating pneumonia 322 Ascaris, in common duct, (648)...... 654 Development of, (645) 654; (646)... 654 Ascaris infection in Japanese prison, (549) 79 Ascaris, somatic cells o f ...... Dr. O no a. s. 263 Ascaris larvæ, migration through lungs 337 Ascaris infection, jaundice in, (648) ... 654 Ascaris, infection in guinea-pig, (616)... 539 In mouse, (617) ...... 539 Asiatic cholera, study of ioo cases ... Dr. B r a a F l a d T. 243 Asiatic peoples, anthropology of Dr. H r d l i Ck a . a. s. 30 Atypical male sexe-ensemble ...... 608 Autopsies in China...... 54 Autumnal fever, etiology of (610) 413 ; (611) 414

Bacillis coli, types of, (563) ...... 171 Bacteria in old graves, (607) ...... 412 Benzyl benzoate in protozoal dysenteries ...... 344, 346 In whooping cough ...... 660 Beri-beri, infantile...... 94 Pathogenesis of ...... ••• 93 Related diseases, nature of, (600)...... 407 Treatment o f ...... 102 Bier’s regional anaesthesia D r. T a y l o r . 385 Bile powder, for demonstration of typhoid bacilli, (631) ... 546 Action of, on uterus, (625)...... 542 Biology in pre-medical education ...... 292 Birds of North China ...... Dr. W i l d e r , a. s . 20 Births...... 105, 214, 340, 700 Blindness in China...... 329, 468 In Japan ...... 108 Blood, apparatus for obtaining specimens of...... 566 Cells, differentiation of ...... D r. C o w d r y . a. 22 Red cells preserved in vitro, changes in, (634) 548 Citrated, phagocytosis in, (630) ...... 545 Coagulation of, (550) ...... 79 Filaria embryos in, ( 5 5 8 ) ...... 82 Hemolysis o f ...... 316 In lymphatic leukemia, (652) ...... 656 Pressure and prognosis ...... 90 Pressure in healthy Japanese, (626) ...... 542

a. s.=Anatomical Supplement, h. s.=Hospital Supplement INDICES. iii

Transfusion ...... 134 Transfusion in obstetrics - 592 Blood-vessels, operations on ... 367 Boils, treatment of...... 33 6 , 699 Bone, necrosed, removal of ... 366

Book R eview s : Balfour, War Against Tropical Disease ... - 459 Bartlett, after-treatment of Surgical Patients ... - 332 Barton, Teaching the S ic k ...... 210 Bayne, Index of Biological Terms in Chinese ...... 334 Berkeley, Handbook of Midwifery ...... 694 Berkeley, Gynaecological Surgery ... 330 Bram, Exophthalmic Goitre and its Non-surgical treatment ... 692 Brown, Principles of Nursing ...... 578 Brown, Physiological Principles in Treatment...... 207 Burnet, Diseases of Children ...... 208 Burke, The Venereal Problem ...... 100 Burton-Opitz, Text-book of Physiology ... 575 Brubaker, Text-book of Physiology ...... 207 Caleb, Practical Physiological Chemistry ...... 99 Castellani and Chalmers, Tropical M e d ic in e ...... 206 Chatterji, Syphilis in General Practice ...... 546 China Mission Year Book ...... - 335 Chinese Nurses, Quarterly Journal f o r ...... 460 Cobb, Neurasthenia...... - 457 Collie, Aids to Materia Medica ...... 100 Darier, Dermatology ...... - 577 Davis, Plastic Surgery ...... 99 Dorland, Pocket Medical Dictionary ...... 211 Douthwaite, Nurses’ Complete Medical Dictionary ...... 578 Dunton, Reconstruction Therapy...... 210 Educational Directory and Year Book of China ...... 461 Egbert, Hygiene and Sanitation ...... 576 Ewing, Neoplastic Diseases ...... 207 Feldman, Principles of Ante-Natal and Post-Natal Child Physiology ... 455 Freyer, Clinical lectures on Enlargement of Prostate ... 690 Gardiner, Skin Diseases ...... 209 Griffith, Diseases of Infants and Children - 577 Grimsdale, Ophthalmic Operations ...... 334 Hainan, the Isle of Palms ...... 580 Hare, Symptoms in Diagnosis of Disease ... 574 Harris, Electrical Treatment ...... 209 Hazen, on S y p h ilis ...... - 3 3i Herman, Difficult L a b o u r ...... 33° Hirst, Manual of Obstetrics...... 459 Johnson, Painless Childbirth and Twilight Sleep ... 210 Jones, Treatment of the Neuroses...... 457 Kiang, Practical Dietetics for Nurses ...... 212 King, Vaccination in the Tropics...... 693 Mackenzie, from China to Bagdad...... 580 McMurrich, Development of the Human Body...... 692 Malaria Bureau Reports, Malay States ...... 212 Mann, Foot Care and Shoe Fitting ...... 334

a. s.=Anatomical Supplement, h. s.=Hospital Supplement IV INDICES.

Book R e v ie w s , (continued :) Mayo Clinic, collected papers o f ...... 208 Metcalf, Bacteria in Nature...... 460 Modi, Elements of Hygiene and Public Health. 693 Nicolle, Toxines et A n tito x in e s ...... IOI Nomenclature of Diseases and Pathological Conditions (U. S. Gov.) 455 Norton, Duties of Sisters in small H o s p ita ls ...... 693 Nurses’ Association of China, Conference Report ...... 461 O ’Meara, Medical Guide for India ...... 332 Overton, The Health Officer ...... 331 Park and Williams, Pathogenic Microorganisms ...... 576 Pasteur, The History of a Mind, by Duclaux ...... 575 Pedersen, Urology, A Text-Book of ...... 576 Pitzman, Fundamentals of Human A n a to m y ...... 692 Quarterly Journal for Chinese Nurses ...... 211 Ross, Anesthetics ...... 210 Saberton, Diathermy in Medical and Surgical Practice 457 Sarney, Personal H y gien e...... 333 Schafer, Essentials of H isto lo g y ...... 578 Schmieden, Course of Operative Surgery ...... 691 Schneider, Micro-Biology of Foods 579 Schneider, Pharmaceutical Bacteriology...... 579 Smith, Genito-urinary Surgery ...... 211 Student Volunteer Movement B u lle tin ...... 580 Syme, Diseases of Nose, Throat, and Ear ...... 457 Transactions of College of Philadelphia, 19 18 -19 19 ...... 693 Tredgold, Mental Deficiency ...... 458 Warbasse, Surgical Treatment ...... 454 Warfield, Arteriosclerosis and Hypertension ... 459 Webster, Diagnostic Methods, Chemical, Bacteriological and Microscopical 691 Wendell, X-ray Plates and Films...... 332 Wheeler, Handbook of Medicine...... 333 Whitla, Dictionary of Treatment...... 208 Whittaker, Surgical Anatomy ...... 45^. 694 Wickwar, the Ghost World...... 335 Wingfield, Study of H y p n o tism ...... 694 British Chambers of Commerce and mission hospitals ...... 687 British medical missions in China ...... 166 Bronchial casts in influenza ...... 103 Bronchitis, arachidic ...... 559 Bronchus, foreign body in ...... Dr. Dü n la p. 510 Bruck’s reaction in syphilis, (570) ...... 172 Burying places, bacteria of, (607) ...... 412

Caesarean section and Walcher posture 666 Caesarean section, post-mortem ... 86 Calmotin, a new hypnotic, (581) 301 Camel, secretion of urine in ...... a. s. 18 Cancer in Hainan ... Dr. BSRCOVITZ. 119 Cancer, prognosis in ...... 663 Cancer of uterus in pregnancy ... 320 Canton Hospital, founding of, 537 ; work of ... Dr. C a d b u r y . 534 Canton, influenza in, 1; lethargic encephalitis in Dr. CADBURY. 371

a. s.=Anatomical Supplement, h. s.=Hospital Supplement INDICES. V

Canton, medical education in ...... 534 Canton, Women’s Medical College 585 Carbuncles, treatment o f ...... 3 3 6 , 699 Carcinoma, gastric, spirochsetes in, (569) 172 Carcinoma of oesophagus, (553)...... 80 Catgut, sterilization of ...... 146 Cathartics, action of, on uterus, (625) ... 542 Catheterization, danger in ...... 462 Causalgia ...... 370 Cervical ribs, 1560)...... 83 Cerebro-spinal meningitis... D rs. S t e v e n s o n and T a n g . 492 Changchow, cholera in ...... 313 Changchow, report of General Hospital 311 Chaulmoogra oil, sources of ...... 479 Chefoo, report of Temple Hill Hospital 311 Chemistry in pre-medical education ... 295 Chengtu, Medical College of ...... 646 Vaccine service of ...... 41 Chest measurements of Chinese students ...... a. s. 13 Chicken sarcoma, ( 5 9 1 ) ...... 305 Chiengmai, Siam, Report of Leper Asylum 674 Childbirth, excessive loss of blood after 95 China, President of, address to Conference 284 China, Anthropological Association of ...... a. s. C h ina : Autopsies in 54 Blindness in ...... 329- 468 Blind Sorrow of Dr. H a r s t o n . 467 British medical missions in ... 166 Digitalis preparations in ... Dr. R e a d . 512 Dissection in ...... 397 Health education in schools of 201 Hermaphroditism in ... 608 Infant mortality in ... 314, 315 Insanity in ...... 50, X04, 514 Lethargic encephalitis in ... D r. C a d b u r y . 371 Medical education in...... 637 Medical education of women in 437 Medical progress i n ...... D r. V i n c e n t . 162 Medicine in ...... 538 Missionary doctors in Dr. V i n c e n t . 325 Neolithic implements in Dr. A n d e r s s e n . a. s. 7, 40 Opium traffic in 68 Paresis, general, in ...... D r. H a r v e y . 123 Quack medicines i n ...... 702 Red Cross Society o f ... 702 Regional Medical Conferences in Dr. H o u g h t o n . 399 Rickets in ...... 280 Social evil i n ...... Dr. W a n g . 630 Thrombo-angiitis obliterans in ...Dr. W h y t e . 219 Typhus fever in ...... Dr. Woo. 572 Witchcraft i n ...... 560 China Medical Board, Rockefeller Foundation ... 65, 162, 451 China Medical Journal, see C. M. M. A,

a. s.=Anatomical Supplement, h. s.=Hospital Supplement VI INDICES.

C h i n a M e d i c a l M i s s i o n a r y A s s o c i a t i o n : China Medical Journal, 642; report of editor ...... 156 Committee on Publication and Translation, report o f...... 182 Conferences, medical, regional ...... 399 Constitution and B y -la w s ...... 586 Council on Hospital Administration : Report of X-ray sub-committee ...... 53° Council on Medical Education, report of ...... 176 Executive Committee, 53, 398 ; meetings of ...... 62, 298, 401, 644 Kuling Branch, report o f ...... 205 Membership dues ...... 644 Peking branch, meeting o f ...... 688 Peking Conference : 48, 56, 416, 451 ; report of proceedings of ...... 162 Recording Secretary, report of ...... 160 Treasurer, report o f ...... 161 C h i n a N u r s e s A s s o c i a t i o n of, Quarterly Journal ...... 460 Chinese writings on anatomy ...... D r. H s i e h . a. s. 8 ‘Children, trade in 695 Customs Service, see “ Customs.” Foods, a study of ...... D r. W i l s o n . 503 General Hospital, in France ...... D r. G r a y . h. s. 145 D r. S t r a n g e . h. s. 158 Government and dissection...... 289 Government and medical education ...... 287

Intestinal parasites in, (622) ...... 5 4 0 Language, medical text books i n ...... 7° ° Medical students in England ...... 217

Origins of ...... 9 6 Physicians and opium prescriptions ...... 338 Physicians, registration o f ...... 216 Red Cross Society ...... 464, 586 Servants, medical examination of...... D r. K o r n s . 624 Skull measurements of ...... a. s. 12 Students, height, weight, and chest measurements of Dr. C h u a n . 13 Students and study of medicine ...... 640 Superstitions as cause of street accidents 108 Vital statistics of ...... D r. S n e l l . 76 Women, medical education of ...... 4 37 Women and the nursing profession ...... '.. 216 Chinkiang, Public Health of ...... 85 Chloroma, report of case, (579)...... 301 Chlorotic form of trichocephaliasis ...... 322 Cholera, Asiatic ...... D r B r a a FL a d T. 243 Campaign against, in Foochow ...... 667 Colloid solutions i n ...... 250 Immunology, ( 6 0 4 ) ...... 409 Paotingfu epidemic ...... 252 Soochow epidemic ...... D r. S n e l l . 253 Thrombosis of mesenteric veins in ...... 118 Vaccine, action of, (582), 301 ; (583) ...... 302 Vibrios, examination of ...... 323 Chorio-retinitis centralis, (573) ...... 173

a. s.=Anatomical Supplement, h. s.=Hospital Supplement INDICES. v i i

Chromaffine cells in gastric and intestinal mucous membrane, (655) 657 Coagulation of blood, (550) 79 College, Medical, of Chengtu University ...... 646 Committee on Publication and Translation, see C. M. M. A. Complement, hemolytic, (608)...... 412 Conferences medical ...... Dr. Hodghton. 399 Congenital syphilis, fever in, (556) ...... 81 Conjunctiva, diseases o f ...... Dr. N e a l . 475 Conjunctivitis, Parinaud’s, (572) ...... 173 Constitution and By-Laws ...... 586 Council on Medical Education, see C. M. M . A . Council on Public Health Education, see ‘Public Health Education/’

C orrespondence : Amibiasine, What is? ...... W . C r a w f o r d . 462 Ammonium Rhodonatum ...... W . C r a w f o r d . 461 Audi alteram partem (on Evolution) ... Ja m e s L . M a x w e l l . 696 Ascaris larvæ, migration through the Lungs ... C . H . B a r l o w . 337 Beri-beri, treatment of ...... G . D . W h y t e . 102 Boils, Carbuncles, etc., treatment of ...... 336 Bronchial Casts in a Case of Influenza ... C. H . B a r l o w . 103 Catheterization, danger i n ...... S. H. M a r t i n . 462 China Medical Board Fellowships ... R . S. G r e e n e . 213 Chinese children, the trade in ... ' ...... 695 Chinese doctors and the prescribing of opium 8nd morphine ...... 339 Chinese language, medical text-books in ... 700 Conference Medical Papers...... 212 D em oniacal Possession ...... 696 Dissection and Post-mortem Examinations, Chinese Government Regula- tions for ...... J. H . K o r n s . 101 Good Samaritan Story ...... W . C r a w f o r d . 213 Hospitals, Architectural Designs for ...... Geo. H a d d e n . 104 Infant Mortality in China ...... J. A. S n e l l . 213 Insane in China ...... J. L. Harvey. 104 R . M , R o s s . 580 Medical Advisory Board ...... R. L. D ic k in s o n . 582 Medical and other Degrees...... F. P. M a n g k t . 698 Medical missionaries, the earliest...... R . F o r d . 699 Medical Missionary Exhibit in London ...... H . H . W e i r . 337 Mission Scholarships, contracts and ...... 462 Nurses, training of ...... N . D. G a g e . 696 Rogers’ Hypertonic Solution ...L. H. Braaitladt. 582 Schistosomiasis in South China ...... B. R. Vickers. 581 Sulphuric acid in Carbuncles, etc...... W. C r a w f o r d . 699 Words of the Wise are as Goads ...... 583 Wounds, treatment of ...... E . F. W i l l s . 336 Cretinism, case of ...... - ...D rs L e n n o x and R e a d . 140

C u s t o m s S e r v i c e M e d i c a i , R e p o r t s : Public Health of Antung ...... D r. L a r s e n . 676 Chinkiang...... Dr. B r a d s h a w . 85 Ichang ...... ••• ... Dr. G r a h a m . 85, 678 T e n g yu e h ...... D r. C h o s e . 87

a. s.=Anatomical Supplement, h. s.=Hospital Supplement viii INDICES.

Deficiency diseases and leprosy...... 316 Deficiency diseases, pathogenesis of ...... 93 Demoniacal possession ...... 521, 529, 696 Dengue and Sand-flÿ fever ...... 321 Diabetes insipidus in baby, (580) ... 301 Diarrhoea in tuberculosis...... ••• ••• ••• ... ••• 194 Diet, protein, in t r o p ic s ...... 275 Digitalis, preparations of, in China ...... Dr. R e a d . 512 Dislocation of ulna alone...... ••• ••• ••• ••• 605 Distomiasis, pulmonary, emetine in, ( 5 5 5 ) ...... 81 Dissection in China ...... 397 Dissection, progress in ...... 291 Dissection, Chinese Government a n d ...... 101, 289, a. s. 4 Duodenal ulcer, syphilitic origin o f ...... 195 Dysentery, amoebic, chronicity of ...... 355 amoebic, diagnosis of ...... 198 Benzyl benzoate i n ...... 198 obstruction of rectum i n ...... 115 Protozoal ...... Dr. Haughw out. 343 Dysentery, see also “ amœbæ,” “ atncebiasis.” Dyshidrosis, (6 12 )...... 415 Dystrophia adiposo-genitalis ... * ...... Dr. Wh y TE. 139

Ear, tetanus, due to infection of ...... 381 Eclampsia, treatment o f ...... 199 Ectopic gestation, diagnosis of early ... *• ...... 318

E d i t o r i a l s : Appeal for medical missionaries ...... 50 Autopsies in China ...... 54 China Medical Journal ...... 642 C. M. M. A., President, Dr. Charles Johnson ...... 276 Cbop-sticks and tuberculosis ...... 395 Demoniacal possession ...... 521-529 Dissection in C h i n a ...... 397 Executive Committee ...... 5 3 . 398 Heat hyperpyrexia...... 3 94 Insane of China ...... 50 ¿u lin g as a health resort ...... 283 Medical education in China ...... 637 Medical missionaries, insufficient number of ...... 392 Medical research, programme of 1920-1922 • •• ...... 278 Mission medical schools ...... • •• ...... 638 Osteomalacia in China ...... 279 Peking Conference ...... 48 , 52 , 54, 277 Public Health Education ...... 281 Rickets in China ...... 280 Social Evil in C h in a...... 635 Education, medical and Chinese government ...... 287 Education, medical, of Chinese women ...... 437 Education, Pre-medical, St. John’s University, Shanghai ...... 452 Pre-medical training of students ...... 292, 453 Eel, chemical study of extra ct of, (618) ...... 539 Elephantiasis with leprosy ...... D r. M a c k e n z i e . 511

a. s. = Anatomical Supplement, h. s.=Hospital Supplement INDICES.

Embryos, study of human ...... Dr. Cow dry. a. s 27 Emetine in pulmonary distomiasis, (555) ...... 81 Emetine kerato-conjunctivitis, (6 0 9 ) ...... 413 Empyema, Dakin’s solution i n ...... Dr. B r a n c h . 486 Empyema, diagnosis o f ...... 49 1 Encephalitis, lethargic, in Canton ...... Dr. C a d b u r y . 371 In H w aiyu an ...... Dr. Jü d s o n . 373 In Peking 376 England and the opium traffic ... 405 Entamoeba, species of ...... 197 Entamoeba, different strains of ...... ' ... 354 Entamcebiasis in Filipino children ...... 353 Enteric fevers, immunity to ...... 658 Epidemic constitutions, theory of ...... 17 Epidermophytot^, viability of ...... D D o l d . 34 Evil habits, conquest o f ...... 205 Evil, social, in China ...... 635. 702 Evangelism, hospital ...D r. G ib s o n h. s. 129 educational evangelism ...... Dr. P h il h. s. 132 follow-up work ...... Dr. L e w i h. s. Ï4 I Evolution, spontaneous, in transverse presentation... 24 Exophthalmos in fishes, (548) ... 78 Exstrophy of bladder, operation for ...... D r. L DLOW. 262 Eyes, effects of quinine on 90 Eye tests, uniform system of D r. H o w a r d . 226

Factory system, to prevent evils of ...... 703 Fellowship, the Mary Putman Jacobi ...... 169 Femur, fractures of ...... Dr. McC r a c k e n . 230 Ferments, activity influenced by H-ion concentration, (650) 655 Ferments, heat during action of, (649) ...... 655 Fetus, human, growth o f ...... Dr. Roys. a. s. 22 Fever, autumnal, etiology of, (610) 413 ; (611) 414 Fibroma of mesentery with development of sarcoma, (592) ...... 305 Fibula, cystic disease of ...... Dr. D a l e . 382 Fibula, fracture of, with dislocation of ankle ...... Dr. L u d l o w . 509 Filaria embryos in blood, influence of O and CO2 on (558) ... 82 Fever, Japanese Flood or River f., (629) ...... 543 Fevers, unclassified, tropical ...... 391 Filial piety, heroic act o f ...... 342 Filipino children, entamcebiasis in ...... 353 Filipino women, pelvimetry o f ...... 97 Fish, stomach in different species of, ( 6 2 4 ) ...... 542 Fish, toxins of, (605) 410 Fistula, vesico-vaginal ...... 567 Flagellates, intestinal ...... 349 Fluke, new species of, (547) 78 ; (567) 171 Foochow, anti-cholera campaign ...... 667 Foot-binding, society to oppose...... 342 Formosa, cholera in ...... 431 Digestive ferments in fruits of, (552) 80 Hookworm infection among soldiers, (551) 80 Fractures of femur...... Dr. M c Cr a c k e n . 230 Fractures, plating in ...... 235

a. s.=Anatomical Supplement, h. s.=Hospital Supplement X INDICES.

France, Chinese General Hospital i n ...... Dr. G r a y . h. s. 145 Dr. St r a n g e , h. s. 158 Fruits of Formosa, digestive ferments in, (552) — 80

Ganglion inter-caroticum, perithelioma o f ...... 3 2 Gangosa in south China...... Dr. Ber co v itz . 263 Gangrene, acute symmetrical ...... ••• Dr. E w rr s. 23 Gastric carcinoma, spirochætes in, (569) ... I 7 2 Gastric mucous membrane, chromaffine cells in, (655) 657 Gastric ulcer, spirochætes in, (569) *72 Gastric ulcer, syphilitic origin of ...... J95 Genital organs, female, helminths in ...... — 3 23 Giardia infections...... 347 Ginseng, Korean and Canton, ( 5 6 1 ) ...... 83 Gloves, rubber, care of ...... *45 Glycogen, conversion of starch into, ( 5 9 9 ) ...... 407 Goat, hermaphroditism in ...... ‘ ••• 608 Goitre, simple, prevention of ...... 688 Graves, bacteria in old, (607) ...... — ••• ••• 4*2 Great Britain and opium traffic in China ...... ••• 68 Gynocardates in treatment of leprosy...... ••• 4&5 Gynecology, diagnosis ...... ••• — ••• 567

Hainan, cancer i n ...... Dr. Be r c o v it z . 119 Hair, human, a study of, ( 5 7 5 )...... *74 Hangchow, Report of C. M. S. Hospital ...... 55^ Suicides in ...... 560 Hankow, I,. M. S. Hospital Report ...... 553 mortality in ...... 466 new hospital in ...... ••• ... 7 0 * Health Education in Chinese Schools...... 201 Public Health and Red Cross ...... 57° Health, seven stages in search of, by Chinese ...... ••• ••• 7 ° 2 Heart disease, modern conceptions o f ...... 5^1 Heart disease and pregnancy ...... 666 Heat hyperpyrexia...... 394 Height of Chinese students ...... a. s. 13 Helminths in female genital organs ...... 323 Hemolysin, antigen of, (594) 3 °5 Hemolysis, viper poison and (554) 80 Hemolysis, is hemolysed blood toxic ?. 316 Hemolytic complement, (6 0 8 )...... 4x2 Hemorrhage, in placenta praevia ...... 587 Accidental hemorrhage (placenta abruptio) ...... 587 following operation for internal hemorrhoids...... 660 Hemorrhoids, internal, hemorrhage after operation f o r ...... 660 Hens, starving, ornithuric acid formation in, (657) ... 657 Hermaphrodites in China ...... 608 Hermaphroditism in goat ... 611 Hernia, operations for ...... 148 Radical operation, (653) 656 Umbilical ...... 3° Honan, opium trade i n ...... 217

a. s.=Anatomical Supplement, b. s.=Hospital Supplement INDICES. XI

Hongkong, dengue fever in ...... 702 “ Hongkong foot,” “ toe rot ” ...... 564 Precautions against Yellow Fever...... 108 Public Health of ...... 217 Tung Wah Hospital...... 701 Hookworm, as cause of respiratory disturbances, (643) 653 Disease in Japanese prison, (549) ... 79 Eggs, viability in Japanese latrines, (644) 653 Infection among Japanese soldiers, (551) 80 Ova, demonstration by incubation, (578) 300 Hospital assistants in China ...... Dr. H a d d e n . h. s. 73 Chinese General Hospital in France D r. G r a y . h.s. 145 Dr. S t r a n g e . h. s. 158 Hospital evangelism ...... Dr. G ib s o n . h. s. 129 Dr. P e i l l . h. s, 132 Follow-up work ...... Dr. L e w i s . h. s. 141

H o spital R eports :

Changchow, General Hospital ...... 311 Chefoo, Temple Hill Hospital ...... 311 Chiengmai, Siam, Leper A sy lu m ...... 674 Hangchow, C. M. S. Hospital ...... 556 Hankow, L. M. S. Hospital...... 553 Ichang, Rankine Memorial Hospital 555 Liling, U. V. M. Hospital ...... 673 Ningpo, Hwa Mai Hospital...... 674 Pakhoi, Leper and General Hospital 307 Peking, Union Medical College Hospital 309 Shanghai, St. Luke’s Hospital 557 General Hospital ...... 558 Swatow, Presbyterian Mission Hospitals...... 552 Tientsin, London Mission Hospital ...... 308 Tsinanfu, University Hospital, 1919 ...... 306 Tsingkiangpu, General H ospital...... 672 Weihsien, American Presbyterian Mission Hospital 556 Wuchang, Church General Hospital ...... 554 Wukingfu and Shanghang Hospitals ...... 311 Yenping, Alden Spear Memorial Hospital 555 Hospitals, mission, in China: Accounting in ...... D r. H o u g h t o n , h. s. 99 American Red Cross and ...... 685 Architectural designs for ...... 104 British Chambers of Commerce and 687 Central hospitals ...... 315 City hospitals...... Dr. S n e l h. s. I Devolution of control of ...... Dr. D a v e n p o r h. s. 67 Efficiency of ...... Dr. Balm h . s. i Methodist Episcopal Church a n d ...... 682 Policy of, future ...... Dr. S t e v e n s o h. s. 60 Presbyterian Church and ...... 680 Problems of ...... Dr. F o w l e h . s. 119 Purchasing agency for ...... D r. BEEB h. s. 1 ,3 Reports, interest o f ...... 552

a. s.—Anatomical Supplement, h. s.=Hospital Supplement X ll INDICES.

Social service in ...... 5 5 i Statistics of ...... * Dr. C r a w f o r d , h. s. 100 Up-country hospitals...... Dr. H o t c h e s o n . h. s. 48 Human embryos, study of ... Dr. C o w d r y . a. s. 27 Hwaiyuan, encephalitis lethargica in ...... Dr. J u d s o n . 373 Hyperpyrexia, heat ...... 394

Ichang, Customs Service Medical Reports ...... 84, 678 Rankine Memorial Hospital Report ...... 558 Imamicol, in Rat-bite fever, (639) ...... 651 Incinerator, an inexpensive Dr. H a d d e n . 190 Infant mortality in China ...... Dr. S n e l l . 76, 314 Infants, death of, ascribed to evil spirits ...... 560 Infantile Beri-beri...... 94 Influenza, in Canton, Pandemic of 1918 i Influenza and pregnancy ... 95 Influenza and puerperal f e v e r ...... 96 Influenza, bronchial casts in 103 Influenza in Japan...... 108 Influenza bacillus in paranasal sinus infections Drs. C r o w e and N e v i l l e . 264 Influenza in pregnancy 319 Inguinal hernia, new operation for 318 Insane, treatment of ...... Dr. Ross. 580 Insanity in C hina ...... 50, 104, 514 Interstitial cells and sex characters ...... A. M. Bo r i n g , a. s. Intestinal flagellates 349 Intestinal obstruction, medical treatment o f...... 659 Intestinal protozoa, bionomics of 350 Intestinal obstruction, unusual case of...... Dr. P o t t . 500 Intestinal mucous membrane, chromaffine cells in, (655).. 657 Intestines, unusual pathological conditions...... Dr. M o l e . 115 Intestines, ulceration of, in pulmonary tuberculosis 117 Intestines, rupture of, in abdominal injuries, (588) 304; (633) 548 ; (635) 650 Iodine, in septic wounds...... 313

Japan, blindness in...... 108 Influenza in ...... 108, 217 Mineral springs of, (576) ...... 175 Japanese, blood pressure in, (626) - 542 Flood or River Fever among, (629) • •• 543 Intestinal parasites in, (622) ... 640 Malignant tumors in, (654)...... 656 Tuberculosis a m o n g ...... 466 Jaundice in ascaris infection, (648) « 654 Jaundice, surgical significance of •• 563 Jews in K a ifen g fu ...... Dr. T e n n e y , a. s. 6 Joint Council on Public H ealth...... 71 See “ Public Health Education.”

Kaifengfu, Jewish colony in ... a. s. 6 Kala-azar in North China...... Dr. WYLIB. 593 Colloid antimony sulphide in 601 Tartar emetic in ...... 593 Kansu, public health education in 669

a. s.=Anatomical Supplement, b. s.=Hospital Supplement INDICES. x iii

Kashing, cerebro-spinal meningitis in ...... 341 Keratoconjunctivitis due to emetine, (60 9 )...... 4 X3 Kiangsu, strange epidemic in ...... 217 Kidney disease and p regn an cy...... 666 Knee, arthritis deformans of, (651) ...... 655 Koji ferments, influenced by H-ion concentration, (650) • •• 655 Korea, health of missionaries in...... 70 Kuling, as a health resort...... 283 Medical work in ...... 341 Kweichow, cholera in ... 701 Kweiyang, new hospital in ...... 107

Labor, third stage, management of ...... 568 Leper hospital in Seoul ...... 464 Leper sanitarium, new, in Taikam ...... 702 Leprosy and deficiency diseases ... 316 Leprosy bacilli, viability of, (563) ...... 170 In prevention of tuberculosis, (564) ...... 170 New methods in treatment of Dr. C a d b u r y . 479 Treatment o f ...... 485 Leprosy with elephantiasis Dr. Mackenzie. 511 Lethargic encephalitis in Canton Dr. Cadbury. 371 In Hwaiyuan ...... Dr. JUDSON. 373 In Peking ...... 376 Leucocytes in rats with sarcoma, (597) ...... 407 Leukemia, lymphatic, acute ... Dr. T y a u . 37 Blood findings in, (589) 304 ; (652) ...... 656 Noma in, (652) ...... 656 Liling, U. V. M. Hospital Report ...... 673 Limbs, artificial ...... 137 Liver, abscess of ...... 195 Dr. L u d lo w . 25S ... Dr. B r o w n . 387 Treatment of ...... 318 Livingston College, England ...... 216 Logan, Dr., influence of life of ...... 340 Lung disease and pregnancy ...... 666 Lymphatic leukemia, see “ Leukemia.” Lymphoma malignum, (6x5) ...... 415

Macula lutea, hereditary degeneration of, (574) ...... 174 Malaria, causes of death f r o m ...... 5 6 5 From surgeon’s standpoint...... 9 1 Man, racial types of ...... 97 Marriages ...... 340,463 Mastoid region, comparative anatomy of ...... a. s. 19 Measles, (571) ...... 172 Medical College of Chengtu University ...... 646 Medical Conferences, r e g io n a l...... Dr. Houghton. 399 Medical education and Chinese government...... 287 Medical education of Chinese w om en ...... 437 Medical etiquette, question o f ...... 698

a. s.=Anatomical Supplement, h. s.=Hospital .Supplement xiv INDICES.

Medical missionaries, appeal for ...... 5° Honored by Government ...... 40° Number of ...... 392 The earliest ...... 699 Medical missions, centenary of ...... — 4^4 Medical profession in China ...... Dr. Yoi. 5x8 Medical schools, mission...... 638

M e d ic a l a n d S u r g ica l N otes : Internal Medicine: Benzyl-benzoate in whoopiug cough...... 660 Blood pressure and prognosis 90 Blood, toxic when hemolysed? ...... 3*6 Deficiency diseases and leprosy ...... 3 1** Enteric fever, new conceptions regarding immunity to ...... 658 Heart disease, modern conceptions of ...... 561 Intestinal obstruction, medical treatment of ...... 659 Nephritis, chronic parenchymatous, treatment of ...... 89 Quinine, effects of, on visual apparatus ... 90 Scurvy, etiology of ...... 3 J7 Tuberculosis, diarrhoea in ...... 194 Tuberculosis, signs of early a c t i v e ...... 193 Tuberculin test, intracutaneous ...... 316 Typhus, prophylaxis of...... 659 Typhus fever, treatment of ...... 194

Gynecology and Obstetrics : Eclampsia, treatment of ...... 199 Cancer of uterus complicating pregnancy...... 320 Ectopic gestation, diagnosis of early ...... 319 Gynecological conditions, diagnosis of ...... 567 Influenza and pregnancy ...... 95, 319 Influenza or puerperal fever ? ...... 96 Labor, excessive loss of blood after...... 95 Labor, management of third stage of ...... 568 Pregnancy and diseases of the Heart, Lungs and Kidneys ...... 666 Treatment of umbilical c o r d ...... 199 Umbilical cord, twisting of, as sign of separation of placenta...... 666 Ureteral ligation...... 567 Vesico-vaginal fistu la ...... 567 Uterus, prolapse of, simple operation f o r ...... 200 Walcber posture versus Caesarean s e c t io n ...... 666

Tropical Diseases: Amoebae living in man...... 197 Amoebic dysentery, microscopic diagnosis of ., 198 Benzyl benzoate in amoebic dysentery ...... 198 Blood samples, simple apparatus for taking ...... 566 Beri-beri and other deficiency diseases ...... 93 Dengue and Sand-fly Fever ...... 321 Malaria, causes of death from ...... 565 Szechwan, relapsing fever in ...... 321

s. == Anatomical Supplement, h. s.=Hospital Supplement INDICES. XV

Parasitology: Anthelmintics, therapeutic value o f ...... 56S Cholera vibrios, how to keep alive for examination ...... 323 Filipino children, parasites in ...... 569 Helminths in female genital organs...... 323 Round-worm infection simulating pneumonia ...... 3*2 Sarcosporidiosis...... 568 Schistosoma japonicum, intermediate host...... 322, 568 Spargamum mansoni, life history of ...... 569 Trichocephaliasis, chlorotic form of...... 322 Tumors, and poisonous secretions of parasites ...... Yellow Fever, elimination from endemic centres ...... 569 gery: ' Abdominal pain, not dependent on surgical conditions...... 563 Appendicitis, o x y u r is ...... 564 Cancer, prognosis in ...... 663 Cholecystectomy, results o f ...... 664 Hemorrhage following operative treatment of internal hemorrhoids... 661 Hernia, inguinal...... 318 Jaundice, its surgical significance ...... 563 .Liver abscess, symptoms of ...... 195 Liver, abscess of, tre a tm e n t...... 318 Malaria, from surgeon’s standpoint ...... 91 Plaster, adhesive, to make adhere ...... 196 Plaster, adhesive, removal of ...... 663 Piles, internal ...... 195 Syphilitic origin of gastric and duodenal ulcer ...... 195 Toe rot (Hongkong foot) 564 Ulcus tropicum, surgical treatment of ...... 665 Mesenteric glands, saccharomycetes in, (637) ...... 650 Mesenteric veins., thrombosis of, iu cholera ...... 118 Mesentery, fibroma of, with development of sarcoma, (592) ...... 305 Methodist Episcopal Church (U. S. A.) and its hospitals...... 682 Milk in race development ... 98 Mission hospitals, efficiency o f ...... Dr. B a l m e . h. S. I Mission scholarships, students’ contracts ...... 462 Missionaries, medical, number of ...... 392 Mite, red, (akamushi), (603) ...... 408 Mitochondria, effect of starvation ...... Dr. Ono. a. s. 25 ' Morphine, prescribing by Chinese physicians ...... 338 Mortality, infant, in China ...... Dr. S n e l l . 76 Moukden Medical School ...... 340 Moukden, Medical College report ...... 670 Myopia, treatment of ...... Dr. R d s h . 605 Operation f o r ...... 607

Nanking,fPublic Health propaganda...... 454 Nasal polyp, unusual size, (562) ...... 83 Nephritis, chronic parenchymatous, treatment o f ...... 89 Neolithic implements iu C h in a...... Dr. A n dersskn. a. s. 7 Nerves, operations on ...... 3^9 Nerves,¡¡peripheral, actionjof local anesthetics on, ( 6 2 7 ) ...... 543

a. s.==Anatomical Supplement, h. s.=Hospital Supplement xvi INDICES.

Neuromata, multiple false ...... 3 J3 Neve, Arthur, public funeral of, in India ...... ••• 2I^ Newchwang, new hospital in ...... 4^5 Ningpo, Hwa Mai Hospital Report ...... 674 Noma in lymphatic leukemia, ( 6 5 2 ) ...... 656 Nurses’ Association of China, Report of Conference ...... 460 Nurses, training o f...... Miss G aGE, 696. h. s. 89

•Obitu a r y : Borthwick, Nancy ...... 7° ° Cousland, Mrs. Philip B...... ••• ••• ••• 5^4 Chalmers, Robert John ...... 4^3 Logan, O. T., M .D...... J° 5 Menzies, J. R., M .D ...... 214, 463 Roys, C. K., M.D ...... 7° ° Swan, J. M., M.D...... l°6 •Obstetrics, blood transfusion in ...... 59 2 Obstetrics, transverse presentation, spontaneous evolution Dr. P h illips. 24 ■(Esophagus, carcinoma of ...... ••• , 80 Operation, bleeding after...... • ••• 147 Operations, transplantation of tendons ...... 3^5 Opium and morphine, smuggling of ...... ••• ••• 2J8 Opium Convention, International ...... 586 Opium, prescribing by Chinese p h y sic ia n s...... 33$ Opium traffic in China ...... 68 Policy of Great Britain ...... ••• 405 Oreodon, endocranial anatomy of ...... Dr. Bl a c k , a. s. 19 Omithuric acid, formation of, in starving hens, (657) 657 Osteomalacia ...... 274 Ovarian cysts ...... 27 Oxyuris and appendicitis...... -...... 5^9

Pakhoi, Report of Leper and General Hospital 307 Palate, innervation of soft ...... Dr. I n o u y e . a. s. 20 ; a. s. 58 Paneth cells, distribution of ...... Dr. T a n g . a. s. 8 Paotingfu, cholera in ...... D r. W y l i e . 252 Paragonimus westermanii, study of ... 539 Infection, treatment by emetine, ( 5 5 5 ) ...... 81 Para-nasal sinus infections, influenza bacillus in ... 264 Parasites, poisonous secretions of, and tumors 5 69 Paratyphoid fever, cases of, a s t u d y ...... Dr. S m y ly . 109 Paresis, general, in China ...... Dr. H a r v e y . 123 Parotid, measurements of, (623) ...... 541 Pasteur, advice to students ...... 520 Peitaiho, hospital in ...... 584 Peking, Branch of C. M. M. A...... 688 Lethargic encephalitis in ...... Dr. L e n n o x . 376 Union Medical College ...... 108, 309 Union Medical College for Women ...... 466, 676 Pelvimetry of Filipino wom en ...... 97 Pepsin, estimation of, in urine, (620)...... 540 Perithelioma of ganglion inter-caroticum ...... Dr. T h o m s o n . 32 Phagocytosis, in citrated blood, (630) ...... 545

a. s.=Anatomical Supplement, h. B.=Hospital Supplement INDICES. XVÜ

Phagocytosis, stimulated by plasma, ( 5 6 5 ) ...... 171 Physics, in pre-medical education ...... 296 Picric acid sterilization of s k i n ...... 138 Piedra, etiology and treatment of, (557) 81 Placenta prævia, hemorrhage in ...... Dr. Wh it m o r e . 587 Placentation in uterus of rabbit, (632) ... • ...... 546 Plague vaccine, practical application, (585) ...... 303 Plaster, adhesive, to make adhere ...... 196 Plaster, adhesive, removal of ...... 663 Placenta, twisting of cord sign of separation 666 Plating in fractures ...... 235 Platycodon, as substitute for senega, (638) ... 650 Pneumonia in in flu e n za ...... 13 Pneumonia, simulated by ascariasis ...... ' ...... 322 Polyp, nasal, unusual size, C562) ...... 83 Post-mortem examinations, Chinese Government and ...... 101 Pregnancy and diseases of heart ...... 666 diseases of lungs ...... 666 diseases of k i d n e y s ...... 666 Pre-medical education, report on ...... 292 Presbyterian Church (U. S. A.) and its h o s p ita ls ...... 680 Prostitution in China ...... 630, 635 Protein diet in tropics ...... 275 Protein requirements of human body ... 50S Protozoa, intestinal, bionomics of ...... 350 Protozoal dysentery ...... Dr. Haoghwout. 343 Pseudo-appendicitis ...... 91 Pseudotyphus exanthematicus, (6 4 2 )...... 652 Pregnancy and influenza...... 95 Pregnancy, cancer of uterus i n ...... 320 Pregnancy', influenza i n ...... 319 Prolapse of uterus, operation for ...... 200 Publication and Translation Committee, see “ C. M. M. A .”

P ublic H e a lth E d u cation in C h in a : Aims of Joint Council on ...... Dr. Woo. 71 Anti-cholera campaign in Foochow ...... 667 Health education in schools of Kansu ...... Dr. K in g . 669 In schools of higher learning ...... 281 In the Orient...... 324 Joint Council on ...... 71 Report o f ...... 186 Propaganda in Nanking ...... 454 Red Cross and...... 570 Pulmonary amcebiasis ...... 388 Pulmonary distomiasis, emetine in, (555) 81 Puerperal fever and in flu e n z a ...... 96 Pyocyanase, its nature and action, (606) ...... 412 Pyocyaneus infection ...... Dr. Ts e n . 389

Rabbit, placentation in, ( 6 3 2 ) ...... 546 Race development, milk in ...... 98 Racial types of Man ...... 97 Radium, curative action on tumors ......

a. s.=Anatomical Supplement, h. s.=Hospital Supplement x v iii INDICES.

Rat-bite fever, imamicol in (639) ...... 651 Records, systematizing of Dr. CRAWKORD. h. s. 100 Rectum, obstruction of, due to dysentery ...... US Red Cross Society of China ...... 57° Regional anaesthesia, Bier’s ...... Dr. T a y l o r . 385 Regional medical conferences...... 399 Registration of Chinese physicians ...... 216 Red Cross, American ...... 216 Red Cross crusade against epidem ics...... 464 Red Cross and Public Health ...... 5 7 0 Red Cross, Chinese ...... 464, 586 Relapsing fever in Szechwan ...... 321 Reports, hospital, see “ Hospital.” Respiratory organs, senile changes in, (628)...... 5 4 3 Rheumatic fever in China ...... 314 Ribs, cervical, (560) ...... 83 Rice, ferment activity in hulls of (621) ...... 540 Rinderpest vaccine, (566) 171; (58 4)...... 303 Rockefeller Foundation, gift of, to London hospital ...... 585

Saccharomycetes in mesenteric glands, (637) ... 650 Sandfly^ fever and dengue ...... 321 Sarcoma, chicken, métastasés of (591) 305 Sarcoma, leucocytes in, ( 5 9 7 ) ...... 407 Sarcoma of mesentery, (592) 305 Sarcoma of white rat, (595) 406 Sarcosporidiosis ...... 568 Savior sodium, (647) ...... 654 Schistosoma japon., intermediate host of ...... 568 Schistosomiasis in south China...... 580 Schistosome problem a.s. 26 Scorpions as medicine ...... 586 Scurvy, t-tiology of ...... 317 Scurvy, experimental infantile, (636)...... 650 Senile changes in respiratory organs. (628)...... 543 Senega root, platycodon as a substitute (638) ...... 650 Seoul, Leper Hospital in ...... 464 Sepsis, recrudescent ...... 136 Servants, Chinese, medical examination o f ...... Dr. K o r n s. 624 Sexe-ensemble, atypical (male) in goat ...... !. Dr. St o n e . 611 Shanghai, new hospital in ...... 465 Shanghai, Red Cross Hospital ...... ,.. ... 218 Shanghai, Report of General Hospital ...... 558 Shanghai, Report of St. Luke’s Hospital ...... 557 Shanghai, St. John’s University, Science Laboratory Buildings...... 452 Sbanghang, medical report ...... 311 Shansi, Governor’s message to C. M. M. A. Con ference...... 287 Shantung, epidemics i n ...... 108 Shantung University, Medical School...... 701 Skin, sterilization of ...... 138 Skull measurements of Chinese...... Dr. C hu an. a. s. 12 Slides, methods for labeling ...... 298 Social Evil in China ...... Dr. Wo n g . 630

a. s.=Anatomical Supplement, h. s.= Hospital Supplement INDICES. x i x

Sodium savior (647) ...... 654 Soochow, cholera in ...... Dr. Sn e l l. 253 Soochow, new hospital ...... 312, 549 Soy bean products, nutritive value of Drs. A d o l p h and K i a n g . 268 Sparganum mansoni, life history 569 Spiral organisms in tissues of human stomach, (598) 407 Spirochaetes in gastric carcinoma and ulcer, (569) ... 172 Splenectomy, hemolysis, viper poison (554)...... 80 Splint, the Thomas 132 Statistics, hospital, uniform system of...... Dr. C r a w f o r d , li. s. 100 Starch, conversion into glycogen (599) 407 Stomach, in different species of Fish, (624)...... 542 Stomach, spiral organisms in tissues of (598) 407 Students, Chinese, and study of medicine ...... 518 Subdural cavity in immunization (583 a) ...... 302 Superstition and infant mortality in C h in a ...... 315 Surgery, abdominal ...... Dr. W i l k i n s o n . 26 Surgery, and its failures ... 261 Surgery, hints to young medical missionaries Dr. E l l io t t . 144 Surgery, war, experiences of ...... Dr. K i r k . 131 Surgery, war hospital in England ...... Dr. J. P. ,Ma x w e l l. 358 Surgical lessons of the war ...... 149 Syphilis, as cause of gastric and duodenal ulcers ... 195 Syphilis, congenital, fever in C556) ' 81 Syphilis, of internal organs (559) ...... 82 Syphilis, reactions in (570) ...... 172 Swatow, Reports of Mission Hospitals ...... 552 Swatow, thro 111 bo-angitis obliterans in 559 Szechwan, relapsing fever in ...... 321

Tengyueh, Public Health of ...... Dr. C h o s e . 87 Tetanus due to ear infection Dr. N e v i l l e . 381 Tetanus neonatorum ...... Dr. J. K i r k . 378 Tetrodon poison characteristics of, (602) 408 Thrombo-angiitis obliterans in C h in a ...... Dr. L u d l o w . 18 ...Dr. W h y t e . 219 Thrombosis of mesenteric veins in cholera ... 118 Tibet, open to medical missionaries ...... 704 Tientsin, drinking water of ...... 586 Report of London Mission Hospital 308 Toe rot ...... 564 Toxeemia, fatal, from sting of insect ...... 315 Transfusion of blood ...... 134 Transfusion of blood in obstetrics ...... 592 Transplantation of adenofibroma, (590) 304 Transverse presentation, spontaneous evolution D r. P h i l l i p s . 24 Trichocephaliasis, chlorotic form of ...... 322 Trichomonad infections ...... 348 Trichomonas intestinal infection ...... 315 Trichuris infection in Japanese prison, (549)-" 79 Tropics, protein diet in ...... 275 Tseliutsing, hospital extension in ...... 341

a. s.=Anatomical Supplement, h. s.=Hospital Supplement XX INDICES.

Tsinan, diseases of conjunctiva in ...... Dr. N e a l . 475 Report of University Hospital ...... 306 School of M e d ic in e ...... 215 Tsingkiangpu, Hospital Report...... 672 Tsutsugamushi disease, Japan, (629) 543; (640) 651 Tuberculosis, and pregnancy ...... 666 Bacillis of, viability, (5 6 3 )...... 170 Chopsticks and infection ...... 395 Early signs o f ...... 193 Diarrhoea in ...... 194 Leprosy bacilli as preventive of, (564) 170 Pulmonary, ulceration of intestine in ...... 117 Treatment by tuberculin ...... Dr. V e n a b l e . 236 Tuberculin, intracutaneous te st...... 316 Tuberculin in tuberculosis ...... Dr. V e n a b l e . 236 Tumors, and poisonous secretions of parasites ...... 568 Immunity, experimental, (586) 303 Malignant in Japanese, (654) 656 Transplantation of, (590) 304; (595) 406 Action of radium on, (59 6 )...... 406 Tungan, Fukien, new h o sp ita l...... 107 Typhoid bacilli, bile powder for demonstration of, (631)...... 545 Typhoid fever, cases of, a study...... Dr. Sm y l y . 109 Immunity t o ...... 658 Typhus fever, delousing clothes in epidemics of ...... 572 Prophylaxis o f ...... 659 Treatment o f ...... 194

Ulcer, duodenal, syphilitic origin ...... 195 Gastric, spirochætes in, (569) '...... 172 Gastric, syphilitic origin ...... 195 of leg ...... 145 Ulcus tropicum, surgical treatment o f ...... 665 Ulna, dislocation of ...... Dr.W a m p l e r . 604 Umbilical cord, treatment of ...... 198 Umbilical cord, twisting of, sign of separationof placenta ...... 666 Umbilical hernia ...... 30 Ureteral ligation ...... 567 Urethra, stricture of ...... 148 Urethral dilatation, danger i n ...... 559 Urine, estimation of pepsin in, ( 6 2 0 ) ...... 540 Urine, secretion of, in camel ...... a. s. 18 Uterus, action of cathartics on, (6 2 5)...... 542 Action of bile on, (625) 542 Cancer of, in pregnancy ...... 320 Perforation o f ...... 31 Prolapse of, operation f o r ...... 200

Vaccine, cholera (582) 301 ; (583) 302 Plague (585) ...... 303 Rinderpest, (566) 171 ; (584) 3 °3 Small-pox, vaccine, service of C h en g tu ...... Dr. Jouvjïau-D ü b r u e il. 41

a. s.=Anatomical Supplement, b. s.=Hospital Supplement INDICES. XXI

Vaccination, new method of ...... 47 Veins of head of chicken, embryology of (587) ...... 304 Veins, mesenteric, thrombosis of, in cholera...... 118 Vesico-vaginal fistula ...... 567 Viper poison and hemolysis, (554) ...... 80 Viscera, measurements of, (601)...... 408 Visual apparatus, effects of quinine on ...... 90 V ita l Statistics o f C h i n a ...... Dr. S n e l l . 76, 314 Vitreous, origin o f ...... D r. H o w a r d , a. s. 17, a. s. 47

W alcher posture instead of Caesarean section ...... 666 Water sterilization ...... 138 War, surgical experiences ...... D r. K i r k . 131 War, surgical lessons o f ...... 149 Wassermann reaction in syphilis, (570) ...... 172 W eight of Chinese students ...... a. s. 13 Weihsien, Report of American Presbyterian Mission Hospital ...... 556 Whooping cough, benzyl benzoate in ...... 660 Wistar Institute ...... a. s. 18 Witchcraft in China ...... 560 Women, Chinese, medical education of ...... 437 Wound infections ...... 133 Wounds, infected, new method of treatment, (641)...... 652 Wounds, secondary suture of ...... 137, 361 Wounds, septic, iodine in ...... 313 Treatment o f ...... 360, D r. WrLLS. 336 W riters, m ed ical, h in ts to ...... 64 Wuchang, mortality in ...... 465 Wuchang, report of Church General Hospital ...... 554 Wukingfu, hospital report ...... 311

X-ray apparatus, sub-committee report o n ...... 530

Y e llo w fever, precautions against in Hongkong ...... 10S Yenping, Report of Alden Spear Memorial Hospital ...... 555 Yellow fever, elimination from endemic centres ...... 569

a. s.=Anatomical Supplement, h. s.=Hospital Supplement x x i i INDICES.

I*i s t o f I llustrations .

Anthropological Association of China, members of...... a.s. I Apparatus for disinfesting Clothes (Woo) ...... 573 Bladder, exstrophy of (Ludlow) ...... 262 Bronchial casts (Barlow)...... 103 Chengtu, Administration Building, West China University ...... 587 China, President of ...... 219

Chowtsun, Foster Hospital Out-patient Department ...... 109 Cretinism, Case of (Lennox and Read) ...... 140, 141 Dystrophia Adiposo-genitalis, Case of (Whyte) ...... 140 Gangrene, Acute Symmetrical (Ewers) ‘ ...... • ... 23

Hermaphroditism in Goat (Stone) ...... 608, 613, 614 Hermaphroditism, Case of (Bercovitz) ...... 608 Ileum, Obstruction of (Mole) ...... 114

Incinerator, an inexpensive (Hadden) ...... 190 Johnson, Charles F., M.D., President C. M. M. A ...... 276 Leprosy with Elephantiasis (MacKenzie) ... 511 Leukemia, acute lymphatic (Tyau) ...... 38

Logan, Dr. O. T ...... 105 Mesenteric Veins, Thrombosis of, in Cholera (Mole) ...... 115 Neolithic Stone Implements in China (Anderssen) ...... as. 41, 43, 44, 45

Parotid gland, sections of ...... 541 Rectum, pathological obstruction due to Dysentery (Mole) ...... 114 Sexe-ensemble, atypical male, in Goat (Stone) ...... 613, 614, 615 Shanghai Science Laboratory Building, St. John’s U n iv e r s ity ...... 343

Soochow Hospital ...... 468 Thrombo-angiitis Obliterans (Ludlow) ...... 1 Thrombo-angiitis Obliterans, Geographical distribution of ( W h y t e ) ...... 224 Tuberculosis, pulmonary, Ulceration of Bowel in (Mole)...... 115 Vitreous, origin of (Howard) ...... a.s. 47, 51

a . s . — Anatomical Supplement, h. s.=Hospital Supplement INDICES. x x i i i

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

Adolph, W. H., Ph.D ., and Dr. K i a n g , Tsinanfu. Value of Soy Bean Products ...... 268

ANDERSSEN, Dr. J. G -, Stone Implements of Neolithic Type in C h in a...... a .s. 7, 40

B a lm e , H., F.R.C.S., D.P.H., Tsinan. Enquiry into the Efficiency of Mission Hospitals h.s. I

B e e b e , R. C., M.D., Shanghai. Purchasing Agency for Hospitals in China ...... h.s. IJ3 Report as Treastrer...... 161

Bercovitz, N., M.D., Kachek, Hainan. Cancer in Hainan ...... 119 Gangosa in Soutt China ...... 263

B l a c k , D., B.A., M.B., Peking. Endocranial Anatcmy of Oreodon... a.s. 19 Anthropometry ani Observations on health}- Subjects a.s. 64

Boring, Alice, M., Ph.D., Peking. Interstitial Cells an3 Secondary Sex Characters ... a.s. 20

Braafladt, L* H., M.D., Tsinanfu. Asiatic Cholera, a Sludv of one hundred Cases 243

B r a d s h a w , G., M.D, Chinkiang. Public Health of Chiakiang, 1918-1919...... 85

B r a n c h , J. R. B., M.D., F.A.C.S., Changsha. Treatment of Empyeaa with Dakin’s Solution 486

B r o w n , R. E ., M.D., Wuhu. Rupture of Abscess ofLiver 3 S7

C a d b u r y , W . W ., M.D., Canton. Lethargic Encephalit* in C h in a ...... 371 Mission Hospital and Medical Educational Work in Canton ...... 534 New Methods in the Treatment of Leprosy ...... 479 Pandemic Influenza inCanton ...... I

C h e n , S. P., Board of Interior. Attitude of Chinese Government towards Dissection...... a.s. 4

C h o s e , C . W., Dr., Tangyueh. Public Health of Tengrueh...... - 87

C h u a n , S. H ., Directcr, Army Medical College. Skull Measurements o 300 Chinese ...... a-s- 12 Height, Weight, and Chest measurements of 860 Chinese Students a.s. 13

a. s.=Anatomidl Supplement, h. s.=Hospital Supplement x x i v INDICES.

C o w d r y , E. V., Ph.D., Peking. Differentiation of Blood Cells by Supravital Dyes ...... a.s. 22 Human Embryos, Study of...... a.s. 27

C r a w f o r d , A. S., M.D., Changsha. Plea for uniformity in Case Records and Hospital Statistics ... h.s, 100

C r o w e , S. J., M.D., and Dr. N e v i l l e . Influenza Bacillus in Paranasal sinus infections ...... 264

D a l e , W. C., M.B., B.Sc., Wukingfu. Cystic Disease of the Fibula ...... 382

D a v e n p o r t , C. J., F.R.C.S., L.R.C.P., Shanghai. Devolution of Control of Mission Hospitals ...... h.s. 67 Conference Address as President of C. M. M. A...... 150 Response as President of C. M. M. A., to address of President of China ... 283

Do ld , H., M.D., Shanghai. On the Viability of Epidermophyton ...... 34

D u n l a p , A. M., M.D., Peking. A Foreign Body in the Left Bronchus...... 510

E l l i o t t , C. C., M.D., F.R.C.S.E., Chengtu. Surgical Hints to Young Medical Missionaries ...... 144 Medical College of West China University, Chengtu...... 646

E w ers, E. M., M.D., Yeungkong. Gangrene, Case of acute symmetrical ...... 23

F a u s t , E. C„ Peking. Present State of Schistosome P r o b le m ...... a*s- 26

F o w l e r , H., L.R.C.P.S., Siaokan. The Problems of our Mission Hospitals...... h.s. 119

G a g e , N. D., R.N., Peking. The Preparation of Nurses for China ...... h.s. 89

G ib s o n , D. M., M.B., Ch.B., Kaifeng. Hospital Evangelism ...... h.s. 129

G o s s a r d , J. E., M.D., Foochow. Anti-cholera campaign in Foochow ...... 667

G r a h a m , A., F.R.C.S., Ichang. Public Health of Ichang 1918-1919 ...... 84

G r a y , G. D., M.D., Peking. The Chinese General Hospital in France ... h.s. 145

H a d d e n , G., M.B., Ch.B., Changsha. The Hospital Assistant in C h in a ...... h.s. 73 An inexpensive Incinerator ...... 190

a. s.=Anatomical Supplement, h. s.—Hosjital Supplement INDICES. XXV

H a r v e y , L. J., M.D., Canton. Cases of General Paresis in China ...... 123

H a u g h w o u t , F r a n k G., M.D., Manila. Some current Problems in Protozoal Dysentery 343

H o u g h t o n , H e n r y S., M.D., Peking. Regional Medical Conferences in China 339 Methods of Hospital Accounting ... h.s. 99

H o w a r d , H . J., M.A., M.D., Peking Uniform System of Eye Tests ... 226 Origin of Vitreous ...... a.s. 17, 47

H o w a r d , H. J., M.D., and Drs. L,e n n o x and H s ie h . Health Education in Schools of Higher Learning in China ... 201

H r d l i c k a , Dr. A l e s . Anthropology of Asiatic Peoples...... a.s. 30 Methods of Anthropometry ...... a.s. Relations of Anthropology to Medicine...... a.s.

H s i e h , E. T., M.D., Peking. Review of Chinese Anatomy ......

H s ie h , E. T., M.D., and Drs. L e n n o x and H o w a r d . Health Education in Schools of Higher Learning in China......

H u t c h e s o n , A . C ., M.D., N anking. The Up-Country Hospital...... h.s. Height, Weight and Chest Measurements of Healthy Chinese a.s.

I n g r a m , J. H ., M.D., Peking. Seal Characters with Reference to Anatomical Terms ......

I n o u y e , M., Dr., Tokyo, Japan. Innervation of the Soft Palate ...... a.s. 20, 58

J o u v e a u -D u b r u e il , H., M.D., Chengtu. Vaccine Service of Chengtu ...... 41

J u d s o n , A ., M.D., Hwaiyuan. Encephalitis Lethargica in Hwaiyuan ... 373

K i a n g , P. C., M .D., and Dr. A d o l p h , Tsinanfu. Value of Soy Bean Products ...... 268

K i n g , G. E., M.B., Ch.B., Lanchowfu. Public Health Education in Kansu ...... 669

K i r k , E. W., M.B., Canton. Surgical Gleanings from W ar Experience ...... 131

a. s. =Anatomical Supplement, h. s.=Hospital Supplement x x v i INDICES.

K i r k , J., M.B., F.R.C.S., Canton. Tetanus neonatorum, A Study in Prophylaxis...... 378

K o r n s , J. H., M.D., Peking. Examination of Chinese servants for communicable diseases ...... 624

LENNOX, W- G., M.D. lethargic Encephalitis in Peking.

L e n n o x , W. G., M.D., and Drs. H o w a r d and H s i e h . Health Education in Schools of Higher Learning in China...... 201

L e n n o x , W. G., M.D., and B- E. R e a d , Ph.C., M.S., Peking. A Case of Cretinism ...... 140

L e w i s , C., M.D., Paotingfu. Hospital follow-up Work ...... h.s 141

L u d l o w , A. I., M.D., Seoul, Korea. Abscess of the L iv e r ...... 258 Cases of Thrombo-Angiitis Obliterans ... 18 Dislocation of Ankle with Fracture of F ib u la ...... 509 Exstrophy of Bladder : implantation of Ureters into Rectum ... 262

M a c k e n z i e , M., M.B., C.M., Foochow. Leprosy with Elephantiasis ...... 511

M a x w e l l , J. L., M.D., Taiwan, Formosa. Surgery of a War Hospital in E n g la n d ...... 358

M a x w e l l , J. P., M.B., B.Sc., F.R.C.S., L.R.C.P., Peking. On the rarer Forms of Adenomyoma ...... 602

M c C r a c k e n , J. C., M.D., F.A.CS., Shanghai. Fractures of the Femur: their Diagnosis and Treatment ...... 230

M e r r i n s , E. M ., M.D., Shanghai. Report as Editor of C h in a M edtcai, Jou r n al ...... 156 Editorials ...... 48, 276, 392, 521, 635

M o l e , R. H., M.D., Ch.B., Moukden. Unusual Pathological Conditions of Intestines...... 115

M o n t a g u , H. G., M.D., (Lond.), D. O. (Oxon.), Hongkong. The Blind Sorrow of China...... 467

M o r r i s , H. H., M.D., Shanghai. Report as Recording Secretary of Association...... 160

N e v i l l e , S. T., M.D., F.R.C.S., Moukden. Tetanus Due to Ear Infection ...... 381 a. s.=Auatomical Supplement, h. s.=Hospital Supplement INDICES. XXVÜ

N e v i l l e , W. S. T., M.D., F.R.C.S., Moukden, and Dr. C r o w e . Influenza Bacillus in Fara-nasal sinus Infections ...... 264

N e a l , J. B., M.D., Tsinan.

Diseases of the Conjunctiva as met with in Tsinan ...... 475

Ono, Shun Ichi, Dr., Tokyo, Japan.

Somatic Cells of Ascaris with Reference to Mitochondria a.s. 23 Effect of Starvation and Refeeding on Mitochondria ... a.s. 25

P a c k a r d , C., Peking.

Effect of Radium on Cell Division ...... a.s. 26

Pe il l , S. G., M.D., Ch.B., Tsangchow. The Irreducible Minimum in Educational Evangelism h.s. 132

P h i l l i p s , W., M.B., F.R.C.S., Newchwang. Transverse Presentation : Spontaneous Evolution ... 24

P o t t , W. H., M.D., Wusih. An Unusual Case of Intestinal Obstruction ...... 500

R e a d , B. E., Ph.C., M.S., Peking. Secretion of Urine in the C a m e l...... a.s. 18 Standard Digitalis in China ...... 512 R e a d , B. E., Ph.C., M.S., and L e n n o x , W. G ., M.D., Peking. A Case of Cretinism ...... 140 Ross, R. M , M.D., Canton.

The Insatae in China...... 514

R o y s , C. K., M.D., Tsinanfu. Growth changes in Walls of Thorax of human Fetus

R u s h , C. C., M.D., Canton. Treatment of Myopia ...... 605

S m y ly , H. J., M.D., B.Ch., F.R.C.S., Peking.

A Siudy of 35 cases of Typhoid and Paratyphoid Fever 109

S n e l l , J. A., M.D., Soochow. Chinese Vital Statistics: Infant Mortality ...... 76 Cholera in Soochow in 1919 ...... 253 The City Hospital ...... h.s. 41

Stevenson, Paul H., M.D., Luchowfu, Anhwei.

Observations on Epidemic Cerebro-spinal Meningitis 492 The Mission Hospital and its Policy for the Future ... h.s. 60

S t o n e , R. S ., B.A., Peking. Atypical Male Sexe-ensemble in G o a t ...... 611

a. s.=Auatomical Supplement, h. s.=Hospital Supplement x x v i ii INDICES.

S t r a n g e , C. F., M.R.C.S., F.R.G.S., Peking. The Chinese General Hospital in France ...... h.s. 15»

T a n g , P. R., M.D., and Dr. Ste v e n so n , Luchowfu. Observations on Epidemic Cerebro-spinal Meningitis ...... 49*

T a y l o r , H. B., M.D., Anking. Note on Bier’s Regional Anaesthesia ...... 385

T e n n y , C. D. The Jewish Colony at Kaifengfu...... a.s. 6

T homson, O. J., M.D., C.M., F.R.C.S., Foochow. A Case of Perithelioma of the Ganglion Inter-caroticum ...... 32

T s e n , e . t . h ., m .d . Bacillus Pyocyaneus Infection ...... 3 8 9 '

T y a u , E. S., M.D., D.P.H., Shanghai. A Case of Lymphatic L e u k e m ia ...... 37

V e n a b l e , W. H., M.D., Kuling. Tuberculosis; Present Status of the Tuberculin Treatment...... 236

V in c e n t , G. E., Ph.D., LL.D., of Rockefeller Foundation. Medical Progress in C h in a...... 162 The Missionary Doctor in C h in a ...... 325

W a m p l e r , F. J., M.D., Pingtingchow. Dislocation of Ulna a l o n e ...... 604

W h itm o r e, C. B., M.D., Shanghai. Cases of Antepartum Hemorrhage ...... 5 87

W h y t e , G. D., M.D., D.T.M. and H. (Camb.), Swatow. Dystrophia Adiposo-Genitalis, Report of Case...... 139 Thrombo-angiitis Obliterans in C h i n a ...... 219

W il d e r , G. W- D., Peking. Birds of North China...... a.s. 20

W ilk in so n , W., M.B., Foochow. Cases of Abdominal Surgery ...... 26

W i l s o n , S. D., Ph.D., Peking. A Study of Chinese Foods...... 503

W o n g, K. C., L.M.S. (Hongkong Univ.), Hangchow. The Social Evil in C h i n a ...... 630

a. s.=Anatomical Supplement, h. s.=Hospital Supplement INDICES. x x i x

Woo, S. M., M.D., C.P.H., Shanghai. Famine and Typhus Fever in China ...... 572 Aims of Joint Council on Public Health Education in China ... 71

W y w b , J. H ., M .D., Paotingfu. Cholera in Paotingfu, 1919...... 252 Kala-azar in North C h i n a ...... - 593

Y u i, C. V o o n p in g , M.D., Shanghai. Chinese Students and the Medical Profession...... 518

a. s.=Anatomical Supplement, h. s.=Hospital Supplement m * China Jtldical JmtrnaL

V ol. XXXIV. JANUARY, 1920. No. 1.

I All copy must be in the hands of the editor at least, six weeks before date of publication to ensure appearance in the following number. The editor assumes no responsibility for the views expressed by the writers of articles published in the Journal. When Romanised terms or phrases in Chinese are used in an article, it is requested that the translation and the equivalent Chinese characters be also given. A dozen complimentary reprints of his article will be furnished to each contributor, but any number of reprints may be had at reasonable rates if a written order for the same accompany the paper.]

THE I9I8 PANDEMIC OF INFLUENZA IN CAFTTON.

Wm. W. CADBURY, M.D., C an to n . The purpose of this paper is to give an account of the appearance of influenza in Canton and vicinity during the year 1918, and to com­ pare the disease as met with there with its manifestations in other parts of the world.

ORIGIN OF THE PANDEMIC OF 1918.

Minkine 1 declares tbat epidemic influenza exists in sporadic form in the unpeopled regions of Turkestan and perhaps in the heart of Africa. The great pandemics of history usually originated in the Far East and gradually extended westward2. Del Pont3 relates that “ in 1781, influenza developed on a ship in mid-ocean— no cases having been known in the port from which it sailed. Every person on the ship was stricken, and when it arrived at Canton the disease was?found epidemic there, the first cases having developed at about the same date in Canton and on the ship in mid-ocean.” In the spring of 1915 an epidemic appeared in the south of England. Bronchitic infections were prevalent during December, 1916, and January, 1917, in the military hospitals in France. Reports are pub­ lished of influenzal attacks having occurred in different parts of Europe in 1917. 'A ll these gradually led up to the outbreak of the so-called Spanish influenza in the spring of 1918. The disease undoubtedly occurred in Germany and France before it appeared in Spain4. Some claim that the disease was carried to America directly from China, and one writer? even makes the absurd suggestion that influenza is a modified form of pneumonic plague and that it was carried from northern China by Chinese coolies. The fallacy of this theory is C a s e N o . S. THROMBO ANGIITIS OBLITERANS. (L u d lo w .) lia , v .

- - i a nC0 USRAT.<^5== _ M E R lt ) £Hf, ¡2-2K1 3H;0 A n Improved Germicidal Catgut to Supersede Iodized Sutures. The first (light colored) specimen is a cross section of a strand of plain Kalmerid catgut, highly magnified. The second (dark colored) specimen is a cross section of the 3ame strand, reacted upon by ammonium sulphid to precipitate the mercuric element. The uniform color throughout the section ahows the thorough permeation by the Kalmerid (potassium mercuric iodid.) Such an equable distribution of the Kalmerid therefore assures a supply of this germicidal substance in the tissues until the suture is entirely absorbed Literature jn English, Spanish, ircnch, German, or Italian Z kA v is

American Trading Company, Agents. 2 The China Medical Journal. abundantly proved by the numerous bacteriological studies which have been made during the present pandemic. In no single instance, so far as we have been able to discover, has Bacillus pestis been isolated from a case of the disease. However it started, we know that early in 1918 a mysterious disease appeared in Spain with symptoms of sudden onset, severe headache, pain in the back, fatigue and perhaps nausea. Recovery occurred in three or four days. Such a disease was also reported from Fort Oglethorpe, Georgia, U. S. A ., March 18, 1918, and in the latter part of March the disease appeared in the American Expeditionary Force anji in the French and British armies. The symptoms were very mild and very little was written about it.6

THE EPIDEMIC OF JUNE, 1918. In the month of June the disease became pandemic. By June I, 1918, it was already reported as prevalent in Spain, 30% of the population having been attacked in May. Madrid was invaded by June 8. The disease was mild in nature, lasting but three or four days7. Coutaut8 claims that the disease broke out in Manila in June, before it was reported in Spain and elsewhere, with one exception. He then records that “ between thirty and forty cases of influenza, with at least one death, occurred on a United States Army transport which left San Francisco shortly before the epidemic appeared in Manila, and arrived here after it was practically over.” This incident bears a striking similarity to the one mentioned above of a vessel infected on its way to Canton. Coutaut says that the disease was of the mild form and lasted through the month of June. From Spain the disease tended to move northward and was soon reported from France, Switzerland, Germany, Great Britain, and Ireland. It was carried into these countries by the various troops. It prevailed in a very mild form among the men in the American Expeditionary Force from April 15 to June 15 9. It had practically disappeared from the Allied troops by the end of September10. Monte- fusco,11 in Italy, claims that the disease is the so-called three-day fever and not influenza. “ The pains of the limbs are more of the ‘ break- bone’ type of three-day fever and dengue than of influenza.” I11 Cuba the disease appeared during June and July. It entered Eugland about June 15, and was widespread there by July 8, lasting until August 3. The disease also spread to Switzerland and was reported from Ivima, Peru, in A ugust12. The June epidemic was apparently very mild everywhere. Few if any deaths were reported and in many The 1918 Pandemic of Influenza in Canton. 3 places no reference at all has been made to its occurrence. This applies to the United States and Canada, from which the most meagre reports •of anything of the nature of Spanish influenza are to be gathered.

THE AUTUMN EPIDEMIC. During October-November, 1918, the entire civilized world appears to have been visited by a veritable plague. The June epidemic had almost disappeared by the middle of August. In July and- August, however, reports appeared in the papers of vessels arriving at Atlantic ports with passengers and crew sick with influenza. However, the disease evidently was not implanted in the country at this time. On Thursday, August 28, a number of cases were taken ashore from a receiving, ship at Commonwealth Pier, Boston, Massachusetts. The following Saturday one of the laboratory doctors, who had examined these cases, was smitten and within two weeks 2,000 cases were reported from the First Naval District. Almost simultaneously other Atlantic ports reported the appearance of the disease. Camp Devens, Ayer, Mass. was the first Army Camp in the United States to be affected, the first case having been noted September 7. From September 12 to November 1 the epidemic spread like wildfire from east to west and north to south throughout the country6. By October 12 the disease was prevalent in every state in the Union and by November 22 it was on the wane again. The maximum for the entire country was reached during the week ending October 26. The highest death rate of any part of the country was iu Philadelphia where there were 7.4 deaths per 1,000 population during a period of ten weeks. Reports from Canada13 show that by the middle of October the cities of Montreal, Ottawa, and Toronto were severely in the grip of the epidemic. In Spain the disease was prevalent again in September and October. In Cuba there were reported to be about 12,000 cases on November 20, the disease taking a very mild form M. In Buenos Aires cases appeared early in October15, and in Iyima," Peru, on November 7. In both places the disease was mild in form. In Mexico the entire country was affected during October and Novem­ ber16. In Paris the disease was on the wane by November 2, and in London by November 19. Even a casual reference to the foregoing account will indicate that the disease spread as fast as railway and steamship lines could carry it, so that both in the June and autumn epidemics various parts of the world were affected within a few days of one another. 4 The Chihd Medical journal. ¿ater despatches indicate ihat a third outbreak of (he disease occurred, beginning in the latter part of December and appearing in- different places as late as March 1919. We have not sufficiently accurate data to give exact dates, but according to newspaper reports the disease was extremely virulent during the winter months in the United States, Great Britain, Australia, South Africa, and other parts of the world.

INFLUENZA IN THE PHILIPPINE ISLANDS. The following information was kindly sent to me by Vincente De Jesus, Acting Director of Health for the Philippine Islands, in anticipa­ tion of the Annual Report of the Philippine Health Service : “ There were two outbreaks of the disease; one in May which was benign, and another in October which was malignant and acute. There were no special symptoms with regard to the disease. T he epidemic lasted not more than six weeks in each case per locality. The persons who were attacked were mostly from ten to twenty-nine years of age. The first epidemic began in the second half of May and lasted until the month of July, 1918, and the second began in September and lasted until February, 1919. The mortality amounted to 70,513 ; average of morbidity was 40 per cent and the mortality was 2.3%. In the first attack there was a mortality of about 2%, and in the second about 60% from broncho-pneumonia. It would appear that the first outbreak rendered many immune to a second attack.”

INFLUENZA IN CHINA.

Unfortunately, no health reports are available for the greater part of the Chinese Republic. We have consulted, however, the Health Reports of the Shanghai Municipal Council from 1898 to 1917 and among the total foreign deaths we find that only the following were attributed to influenza: 1899, one death; 1900, one death; 1907, four deaths; 1910, one death. After this no deaths are recorded from this cause up to and including the year 1917. In the Hongkong Medical and Sanitary Reports, which give the total deaths registered in the Colony, we have examined the record» from 1909 to 1917. During these nine years only two deaths were attributed to influenza and both occurred in 1909. From a personal letter from Dr. Arthur Stanley, Health Officer in Shanghai, dated February nth, 1919,1 quote the following:— “ As to influenza we had an attack beginning at the end of May and lasting through June, and again in the latter part of October and 7 he igi8 Pandemic of Influenza in Canton. 5

lastiug through November. The latter was somewhat more severe. The note-worthy features were general absence of catarrhal symptoms, congestive pharynx frequent, as also was a slight erythematous blush on the neck and chest, which made one thiuk at first of scarlet fever. Fatal pneumonia common among the Chinese and Japanese, but among Europeans very little pneumonia.” In his report for May, 1918,17 Dr. Stanley says that the disease was reported to have reached Peking before it came to Shanghai, but subsequent reports showed that most of the river ports were almost simultaneously infected, the rate of spread conforming to the rate of conveyance by railways and boats of infected persons. The mortality was very low. Newspaper reports indicate that a third appearance of the disease in Shanghai occurred from the middle of February, 1919, which was still prevalent in April. The symptoms were much more severe. For Hongkong I quote from a personal letter from Dr. Hickling, the Principal Medical Officer of Health, dated January 29th, 1919 : “ The epidemic of influenza in the spring was a very mild one, so far as we can judge. The disease did not last more than a few days la most cases. The recent epidemic (October, November, December, and January) has been much more severe, often lasting two or three weeks.” Only one death, which occurred 011 May 14, was reported from Hongkong in the spring. In the later epidemic the deaths reported were as follows: October, 70; November, 95 ; December, 67. The first of these deaths occurred on October 5. The figures for Jauuary had not been compiled but the disease was diminishing. Dr. C. W. McKeuny of Hongkong has kindly furnished me with the following additional facts:— “ During the first five months of 1918 there were 22 admissions for influenza to the Civil and Tung Wa Hospitals (3 in May). In June, there were 269 cases with 3 deaths. In July, August, and September, 43 cases ; and during October-Novem- ber, 130 cases with 4 deaths.”

INFLUENZA IN CANTON. For other parts of China we have been unable to secure thus far any accurate statistics. For the data collected in Canton we desire to express our thanks to the following for the valuable information which they have contributed ;—Miss Elizabeth Faries, of the True Light Seminary for G irls; Dr. J. I,. Harvey, of the J. G. Kerr Hospital for the Insane ; Dr. J. A. Hofmann, of the Kuug Yee Hospital; Dr. E. C. Machle, of the Pui Ying School for Boys; Dr. Mary W. Niles, of the T a blb I. Showing the Incidence of Influenza in Canton.

June Epidemic. October-Novewber Kpidemic. December-January Epidemic.

fi u a aj,

OS ' N a m e o f Characteristic Cliaracteristic Characteristic Zö Journal Medical China The Institution. S ym p to m s. o *1 S ym p to m s. S ym p tom s. °H «J.t +*

S im ila r to F a ll ep id e m ic except milder. 3 spor­ Canton Christian VI: Fever 2-3 days, Renerai XII: VI:27 X I :5 Definite bronchial type, adic cases occurred C o lle g e ...... 25 0 0 pains, Absence of X : i5 67 1:9 13 bronchial symptoms. 25 XI:2i ; XI:29; and XII-'18. VI: Bronchial type. All VII: X I: 25 C a n to n H o sp ita l ... I4 12 0 0 Same as at C. C. C. X:i5 cases but one from 17 X:i5 to XI :n. Canton Post Office, VI: VII: I,asted about 4 days. Generally, bronchial ? 0 X :iS XI:26 C h in e s e S ta ff ... l i 3 0 Pains in back. ty p e.

Congregational 0 Mission School... 1st. 15 ca s e s seen in la tte r lin d part of May and first w k . Marked bronchial

H o sp ita l for Iu s a n e 0 of . of June with severe S ep t. sym p to m s. general pains. Nov.

VI: VII: General aches, head­ Kung Yee Hospital 12 I 0 X :9 X I : 23 Bronchial symptoms. I:i4 15 29 ache, fever, vomiting. General aches over VI: V I : Many cases of sore S im ila r to F a ll ep id em ic. 0 body resembling den­ X u 6 XI.-13 X I I :3 1:28 P u i Y in g S ch o o l ... 47 0 th ro a t. Less severe. 4 24 g u e fev er. I High fever. Bronchial Schools for Blind 0 X : i 4 i X I :i symptoms. Hemor­ Boys and Girls... rh a g e s. Most cases occurred True tight Semi­ 0 X:20 X I I :i XI:n to XI:25. Bron­ n a r y fo r G ir ls ... chial symptoms. The ipi8 Pandemic of Influenza in Canton. 7

Blind Schools for Boys and G irls; Dr. W . G. Reynolds, Physician to the Chinese Post Office, and Miss Helen Tow, of the Congregational Mission School for Girls. The incidence of the disease in Canton may be readily observed by reference to Table I. The city extends about five miles along the north and south banks of the Pearl River and the institutions are situated on or near its banks. On the south bank of the river we find the Canton Christian College at the extreme east, and the Pui Ying School and True Light Seminary at the extreme west. The Hospital for the Insane and the Blind Schools are near together on the middle south bank. On the north side of the river the Kung Yee Hospital is located at the extreme east, the Congregational School for girls at the extreme west, and the Canton Hospital and Post Office are near together about midway between these two. The June epidemic appeared- first at the Pui Ying School, then among the employees of the Post Office, the staff of the Canton Hos­ pital, -the Canton Christian College, and the Kung Yee Hospital. The other schools entirely escaped. Eleven days were taken by the disease to spread from one part of the city to the various other parts. In October the disease was first noted in patients at the Hospital for the Insane, next at the Schools for the Blind, close by, then at the Canton Hospital, the Canton Christian College,, the Pui Ying School, next at the Post Office and finally at the True Light Seminary. About three weeks were required for the disease to spread from its outbreak at the Hospital for the Insane to its appearance at the True Light Seminary, but the other institutions were all attacked within six days of each other. It will be noted that the spread of the disease in Canton was relatively very slow as compared with its spread throughout the camps and large cities of America over far vaster areas of land. This may be explained by the lesser virulence of the epidemic and by the fact that patients in hospitals and children in boarding schools do not travel about very much. It is remarkable to notie that the period of the epidemic in Canton coincided almost exactly with its appearance in the United States and many other parts of the world. A definite epidemic in December-January seems to have occurred only at the Canton Christian College and the Pui Ying School. Almost no cases occurred at other institutions. From the latter part of January to the present writing, May 31, 1919, there has been no return of the disease to Canton except for an Occasional sporadic case. 8 The China Medical Journal.

In considering the disease itself one is almost bewildered by the huge volume of literature that has been produced in Europe and America during the last six months. The briefest references to this will be made and the author will confine himself chiefly to the disease as he observed it in Canton.

ETIOLOGY.

Nationality. In Canton the disease rarely attacked Europeans or Americans; when it did so the form of the disease was mild. One •American family consisting of husband, wife, and five little children, were all slightly affected early in January. A few days later their Chinese cook, boy, and wash-wonian came down with a very much more serious form of the disease. No deaths among foreigners in Canton have come to my knowledge. Reports of the disease in Shanghai during the last few weeks indicate that a number of Europeans have been affected by the disease there, with several deaths.

T a b l e II. Number of Cases in two Institutions.

S e x . June. O ct.-N ov. Dec.-Jan^ Total. Canton Males... 28 15 0 43 Hospital Females 13 12 0 2 5 Christian Males... 25 67 38 130 College Females 0 2 29 3 t A t the Christian College the inmates are predominantly male. There seems, however, to be a greater tendency for males to succumb to the disease than females. Dr. Niles reports that in her schools for blind boys and girls all of the 13 boys were taken sick, and their illness was more severe than that of the girls of whom only 87 out of 116 were affected.

AGE OF PATrENTS. The age of those who died in America was generally from 20 to 40 years.18 In Europe the greatest incidence is said to have been between ‘the ages of 5 and 45, while it was much less common among those over 45 years. In the 1889-90 epidemic, on the other hand, the incidence over 45 was relatively much greater. 19 The ages of those affected in Canton may be seen by a reference to the following table.

T a b le III. Age Incidence in Canton. Years Years Years Years Institution. Date. Years Years Years Total 1-5 • 6-10. 11-20. 2X-30. 31-40 . 41-50. 51-60. Cases, Canton June 5 5 3 1 14 Hospital Oct.-Nov. 2 6 7 4 3 3 25 Canton June ... 4 7 2 I 14 Christian Oct.-Nov. 7 44 14 65 College Dec.-Jan. 10 5 40 6 4 I 66

Totals 12 18 100 36 12 5 1 i§4 The i ç i 8 Pandemic o f Influenza in Canton. 9 The above table shows a very marked preponderance of cases among those of n to 20 years of age. In the epidemic of October- November the great majority of patients were children between 10 and 15 years old, there being 40 patients of these ages out of a total sick list of'65. The older boys were relatively slightly affected.

OCCUPATION.

Persons of every class and every occupation were affected by the disease. Of course at the Christian College the great majority of patients were male students. The classes are graded much as in the United States, beginning with boys of eight to ten in the primary 2nd grade. In the June epidemic the school was closed and the students returned to their homes on June 20th, so that only five students were taken sick, together with seven teachers and 13 workmen. The stu­ dents were enrolled about as follows: Primary School, 150; Middle or High School, 261 ; College, 120. Total number of scholars, 531, of whom less than 30 were girls. Teachers and families, 180 ; household servants, 62 ; coolies and other workmen, enough to make a total population of almost 1,000 persons. The Primary School children are housed in four brick cottages in one part of the campus, and the other students in four brick dormitories in another part of the campus. The girls are located in a building at some distance from the other two groups of buildings. The staff and workmen are pretty well scattered over the campus. Table IV shows how heavily certain sections of this community were affected.

T a b l e IV. Incidence of Disease at the Canton Christian College according to Occupation.

Scholars Scholars College Staff and Primary Middle Servants, etc. students families School School Total No. of persons eurolled ... I5'J 261 120 180 289 October epidemic 40 12 ir 4 2 December epidemic 16 26 0 T7 8 Thus in the October epidemic the disease affected chiefly the little boys in the primary school, and during the winter the middle school was more involved. In October none of the older girls was taken sick, but in December 15 out of 29 in the girls’ dormitory were affected. The relatively small number of workmen, members of the faculty: and college students who were taken sick is quite striking. 1 0 The China Medical Journal.

BACTERIOLOGY OF THE DISEASE. No reference ueed be made to the extensive literature ou the organisms said to be the cause of influenza. Suffice it to say that the rôle of the Pfeiffer bacillus is generally considered to be a minor one. No bacteriological data are available for Canton. The late Dr. Harold MacFarlane, Bacteriologist for Hongkong, informed me that he had isolated the influenza bacillus from a number of cases dying of pneu­ monia in Hongkong during June. Dr. Arthur M, Stanley, Health Officer for Shanghai, writes as follows under date of February n : “ Pfeiffer’s influenza bacillus was usually absent; micrococcus catar- rhalis usually found.”

SYMPTOMATOLOGY. Soper6 in his valuable article describes the appearance of the dis­ ease as an explosion. He says : “ The maximum effect of the epidemic has been felt within about ten days after the onset. The duration has been less than three weeks ; within about a week after the outbreak of the influenza there occurs an ominous prevalence of pneumonia. The pneumonia does not exist as a separate epidemic but always as a follower of influenza. How the two diseases are related is not positively known. It is clear that the influenza paves the way for the pneumonia if it does not actually produce it. The time of greatest incidence is usually about a week after the greatest incidence of iufluenza.” The disease appeared in two forms in Canton, one in June and the other in the fall and winter. These two forms correspond in general with two distinct types reported from Europe and other parts of the world. The following observations were made in Canton during the June epidemic. The disease was ushered in with or without a chill, usually without. The temperature rapidly rose to 390 or 40° C. with no marked prodromal symptoms. The maximum temperature recorded at the Canton Hospital was 40.20 C. Headache with pains in the back and limbs was severe in all cases. Vomiting and anorexa were often present. Bronchial symptoms were generally entirely absent or very slight. The severer cases had fever from five to seven days. In 14 cases at the Canton Hospital nine had fever from five to seven days. Two had fever for three to four days, and three from eight to twelve days. The cases as seen at the Christian College were milder, the temperature lasting but two to three days. There was nothing very characteristic about the temperature curve. Except for the absence of any eruption the disease greatly resembled dengue fever. The ipiS Pandemic of Influenza in Canton. n

The autumn and winter epidemic showed quite a different symp­ tomatology, with bronchial symptoms verging on pneumonia or actually developing into a true broncho-pneumonia. The symptoms cor­ responded quite closely with those reported from abroad where the disease appeared in a mild form. It has been suggested that the marked absence of bronchial symp­ toms in the June epidemic add their general appearance in the fall and winter might be explained by different meteorologic conditions. In order to test this condition we record the comparative figures for the months of June and July, when the first epidemic occurred, and for September, October, November, December, and January, when the second and third epidemics appeared with their attendant bronchial complications. By reference to Table I the exact dates of these dif­ ferent outbreaks may be seen. For the meteorological data herewith presented I desire to express my obligation to A. Hotson, Esq., Harbor Master for the Chinese Maritime Customs in Canton.

T a b l e V. Average daily Temperature, Humidity, and Rainfall during the two Epidemics in Canton.

Jun e J u ly Sep. Oct. N ov. D ec. Jan. Maximum ... 86.5 89.9 88.2 86.3 60.6 Tem p era­ 74.3 68.7 Minimum 78.x 76.2 68.7 61.6 52.6 ture ... 75-3 57.5 Mean...... 80.3 82.8 81.3 76.9 66.5 61.9 57-4 6 a.m. 88.2 86. H u m id ity | ... 94 92.9 77-9 89-5 88.5 3 P-m- ... 78.x 73-2 66.5 44-7 66.9 70.7 69.6 Rainfall •55 • 33 .21 0 .16 .02 .016

By comparing the data in this table several facts are evident. (1) The maximum, minimum, and mean temperatures in October were but slightly lower than these temperatures were during June. (2) The relative humidity during June and July was very much higher than that recorded for September, October, November, Decem­ ber, and Januar}’-. (3) The daily rainfall averaged highest in June and July ; no rain fell in October, and the fall was slight in September, November, December, and January. Bearing in mind,, then, that the epidemic in June was conspicuous because of the absence of pneumonia and bronchial symptoms while these same conditions were the rule in the fall and winter epidemic, it is safe to say that they cannot be attributed to marked lowering of the atmospheric temperature, nor to excessive relative humidity, nor to excessive rainfall during the fall and winter mouths. In fact it seems to us that these meteorological phenomena can be excluded as bearing upon the nature apd course of the disease. 12 The China Medical Journal.

A t the Canton Christian College in the October-November epidemic every person in the institution affected by the disease was seen by the author. More than 90 persons out of a total number of about 1,000 were affected, about 9%. In 69 of these cases a careful history and temperature record was made. The patients were seen on the first day ■of fever and kept in bed until thoroughly convalescent. The first case was taken sick on October 15, and the last one on November 5,— altogether 21 days. As in June, there were practically no prodromes. There was a chill in 14 cases, or 20%. In six cases the chill was very slight and there was no chill at all in 55 cases, or 80%. Cough and other signs of bronchial catarrh were present in 65 cases (95%) an(3 absent in 5%. The highest temperatures were as follows : 40.70 C. in one case; 40.50 C. in one case; 40.40 C. in three cases; 40.0° C. and over in 21 of the 69 cases. At the Blind School one boy who •died was reported to have had a temperature of 41.70 C. within 24 hours of the onset. Headache and general pains were not pronounced, and delirium was scarcely noticeable. The cough was persistent, lasting often for a week or more after the temperature had returned to normal. There was no case of pneumonia at the College. The patients were sick from ■one to 12 days with fever. Of 66 cases in which a record of the fever was kept throughout its course we note the .following :—

T a b l e VI. No. o f days o f Fever. No. o f Cases. Percent. 1 -3 16 24% 4 - 5 27 41% 6-8 18 27% 9-12 5 3% At the Canton Hospital the first case admitted was likewise taken sick on October 15, and with one exception all the patients were ill before November 11. One patient with pneumonia showed a tempera­ ture of 41.20 C. Cough was severe in all but three of the 27 cases. Eleven or 41% of the cases developed pneumonia. Of those without this complication, in two cases the fever lasted 4-5 days ; in seven, 6-7 days; in six, 10-13 days. One child who had convulsions died after 30 days. The patients with pneumonia who recovered had fever 10-24 days. Those who died were sick 7-14 days. In one case a peripheral neuritis developed. My colleague, Dr. J. W. Wright, reported several patients admitted to the Surgical Service of the Canton Hospital at the time, with retention of urine, who regained their function after catheterization once or twice. The ipiS Pandenttc of Influenza in Canton. 13,

Gastric symptoms were marked in two cases; delirium and convulsions also were noted in a few. Dr. Niles has called attention to the fact that hemorrhages were a striking feature at the Schools for the Blind. In five cases the blood came from the nose or bronchi, in one from the vagina, and in two from the lungs. Following the subsidence of the October epidemic there were occasional sporadic cases noted at the College. Some of these were diagnosed as benign tertian malaria ; others were doubtless cases of influenza. On Christmas Day, however, the family of a member of the Chinese staff was affected, and from December 25 to January 9, sixteen days, 64 persons became ill. The symptoms were identical with those seen in the October epidemic. The highest temperature reached was 40.6° C. Out of 52 cases the temperature rose to 40° C. or over in 15 cases.

T a ble VII. Duration of Fever, December-January Epidemic. No. of Days. No. of Cases. Percentage. i-3 18 36% 4-5 19 38% 6-8 11 22% 11-16 2 4% As in October, the disease usually lasted 4-5 days. There was one patient with pneumonia, a servant, who had been in poor health for some weeks. She died with typical signs of septic broncho-pneumonia after she was moved to the Canton Hospital.

PNEUMONIA AS A COMPLICATION.

Dr. McKenny, of Hongkong, in a personal note states that “ for practical purposes there was no pneumonia in the early epidemic and about 20% showed pneumonic symptoms in the second outbreak. In the Tung Wa Hospital there were probably 25-30% of pneumonic cases.” In Canton, pneumonia did not appear in any case during June. In October-November there was no case of pneumonia at the College. A t the Canton Hospital, eleven cases were seen, and one case in January which was transferred from the College. Pneumonia was especially prevalent among the children in the Blind Schools. The patients generally had shown symptoms of influenza earlier and the pneumonia occurred as a relapse, sometimes after the patient had been up and about for a day or two. This complication was often ushered in by a chill and a rise in temperature. One striking characteristic was expectoration of pure blood suggesting the hemoptysis of pulmonary 14 The China Medical Journal.

tuberculosis. The temperature fell by lysis rather than crisis. The physical signs were those of a diffuse broncho-pneumonia.

LEUCOCYTE COUNTS. According to reports from abroad 20 there is a leucopenia in influenza with a slight leucocytosis toward the end of the fever. Lennox 21, Peking, records counts of 2,000 to 18,000, averaging 6,600. Prior to the 10th day, counts averaged normal or below. On the 12th and 13th days a slight leucocytosis was observed. The leucocytes were counted by us in two cases which occurred in June. In one, the leucocytes numbered 6,000 ; and in the other, 5,400. A differential count showed 80% of polymorphonuclears, 14% of small mononuclears, 4% of large mononuclears, and 2% of transitiouals. In October two counts were made in cases without pneumonia and these were 7,600 and 1,280. In six patients with piieumonia the average count was 7,300, the maximum count being 11,800 and the minimum, 4,200.

FEVER CURVE. Betchov 1 in Switzerland speaks of a characteristic fever curve with two high peaks at a two or three day interval, and an exacerbation of symptoms which is parallel with these double peaks. He explains this by assuming a multiple virus, twofold at least, the first being a filtrable ultra-microscopic substance which traverses countries with remarkable rapidity. The second peak is due to the work of ordinary germs, especially the pneumococcus. Tucker 22, writing from Boston, says that in 72 hours many cases have a normal temperature but there is a recrudescence of fever 24 hours later. At the Canton Christian College many of the students had had attacks of malaria previously and these exacerbations of fever were at first considered to be malarial. How­ ever, in some of these cases no quinine was given and no further rises in temperature were noted. The two peaks of highest temperature varied from 24 hours to four days apart.

RECURRENCES. Foley 23 speaks of two patients who were attatked in October and were again attacked in December, one of them dying of broncho­ pneumonia. In general, one attack seems to convey immunity to further attacks. It is because of this apparent immunization given by the June epidemic that we have felt justified in calling it true influenza. Thus at the Canton Hospital, seventeen of the Chinese male internes and nursing staff were affected in June and three escaped; two of these The 1918 Pandemic 0/ Influenza in Canton. 15 three were attacked in October, but none of the 17. In June, ten of the female staff were sick and two. escaped. None of this staff was affected in October or December. A similar condition was noted at the Kung Yee Hospital. At the Christian College one of the Chinese staff was sick in June. His wife and three children fell ill in December, but he escaped. One student who had a typical attack from October 29 to November 4 had a slight attack of fever November 29-30, which may have been a recurrence. We have seen no instance in Canton, however, of one person having two typical attacks of the disease between June, 1918 and April, 1919.

FAMILY INFECTION. A striking feature of the epidemic was the way in which one family would be completely prostrated by the disease while other families escaped. In October the following members of the Chinese college staff with their entire families were affected : Mr. and Mrs. C., infant child, and three servants; Mr. and Mrs. H. and five children; Mr. and Mrs. T. and infant ; Mr. and Mrs. W. and family. In December Mr. and Mrs. H., three children, and three servants were all sick at one time ; also Mrs. B. and her two children. These were members of the foreign staff. Mrs. Ho, of the Chinese staff, and her seven children were all prostrated at one time. Other families on the place were only slightly if at all affected.

MORTALITY FROM INFLUENZA. It is estimated that in September, October, and November, there were more than 400,000 dearths from the disease in Am erica19. Among the troops, from September 20 to November 1 there were reported 725 deaths from influenza, and 18,704 from pneumonia6. In the cities of America the death rate ranged from 1.8 per thousand in Milwaukee, to 7.4 per thousand in Philadelphia for a period of ten weeks. At the Christian College only one death occurred between June and January, or a rate of one per thousand for the three epidemics. Elsewhere in Canton the disease seems to have been very much less malignant than in the United States, although there were rumors of entire families being wiped out, and of 500 deaths having occurred in one block of a city street. At the Canton Hospital there were no deaths in June, and only four among 27 cases in October. Rumors indicate that the disease was much more fatal in certain outlying districts of Canton, but the reports from Hongkong and Shanghai agree with our own observations that the death rate was i6 The China Medical Journal.

extremely low in China. That tropical countrtes did suffer severely from the disease is shown by the above report from the Philippines and by recent despatches from India stating that the deaths there ran up into the millions. As Christian 24 emphasizes, it is a misnomer to speak of some deaths as being due to influenza and others as due to pneumonia, since death is practically always caused by pneumonia.

TREATMENT. A careful review of recent literature indicates that vaccination is of very doubtful, if any value. The only really effective therapeutic measure in the more serious cases of pneumonia seems to be the intravenous injection of the blood serum of convalescent influenza patients. This seems to have had really curative value25. It is our belief that putting the patient to bed at once, with careful nursing until he is thoroughly convalescent, is the surest means of warding off pneumonia and death. Although quinine was given in a number of cases we do not venture to ascribe any specific value to its use. SUMMARY. 1. Three definite epidemics of influenza appeared in Canton, dur­ ing the spring, fall, and winter of 3918 respectively. 2. The epidemics in Canton coincided in time with the appearance of the disease in Europe and America. 3. In Canton foreigners were but slightly affected. 4. The male sex seemed to suffer more severely. 5. At the Christian College, Canton, the majority of the patients were boys between 11 and 20 years of age; the older students, faculty, and servants were affected in relatively much smaller numbers. 6. The disease appeared in Canton under two distinct forms : one in the spring, and the other in the fall and winter. The spring epidemic was mild, the fever lasting but two to four days. The second and third epidemics were more severe; cases of pneumonia developed and the fever usually lasted from four to five days. 7. Iyeucopenia was generally present. 8. The fever curve often presented two high peaks from 24 hours to four days apart. 9. One attack of the disease tended to immunize against further attacks. The igi8 Pandemic of Influenza in Canton. iy

20 . The disease tended to run through a household, affecting every member. i i . The mortality in Canton was relatively very low.

REFERENCES.

( I ) Revue Medicale de la Suisse Romande, Geneva 1918. Vol. 38. No. 11. N. Betchov, p. 625; J. Miukine, p. 634. Abstracted in Journal American Medical Association, 1919. 72. p. 230. ( 2 ) Journal American Medical Association, 1918. 71. p. 1136. ( 3 ) Semana Medica, Buenos Ayres 1918. Vol. 25. No. 27. p. 1. Abstract Journal American Medical Association, 1918. 71. p. 1948. (.4 ) Abstracts of Foreign Literature compiled by British Medical Research Committee, Journal American Medical Association, 1918. 71. p. 1573. ( 5 ) Medical Record, New York, 1918. 94. No. 15. p. 632. (6 ) Soper, G. A. The Pandemic in the Army Camps. Journal American Medical Association, 1918. 71. p. 1899. (7) Ibid., p. 296. ( 8 ) Coutant, A. F. An epidemic of Influenza at Manila. Journal American Medical Association, 1918. 71. p. 1566. ( 9 ) Journ. Amer. Med. Assoc., 1918. 71. p. 1142. (10) Ibid., p. 1063. (11) Montefusco, A. The Prevailing Febrile Epidemic, Riforma Medica, Naples, 1918, 34. No 28 p. 549. Abstract, Journal American Medical Association, 1918. 71. p. 934. ( 12) Journal American Medical Association, 1918. 71. p. 990. (13) Journal American Medical Association, 1918, 71. p. 1331. (14) Ibid., p. 1928. (15) Ibid., p. 2009. (16) Ibid., p. 1675. (17) China Medical Journal, 1918. 32. p. 399. (18) Report of a Special Committee of the American Public Health Associa­ tion. Journal American Medical Association, 1918. 71. p. 2073. (19) Journ. Amer. Med. Assoc., 1918. 71. p. 1677. (20) Ibid., p. 660. (21) Lennox, W. G. China Medical Journal, 1919. 33. p. 93. ( 25} Tucker, F. E. China Medical Journal, 1919. 33. p. 95. (23) Foley, E. A. Journal American Medical Association, 1919. 72. p. 186. (24) Christian, H. A. Journ. Amer. Med. Assoc., 191ft. 71. p. 1565. (25) Kahn, M. H. Serum Treatment of Post-Influenzal Broncho-Pneumonia.: Journal American Medical Association, 1919. p. 102.

T h e T h e o r y ok E p id e m ic C onstitutions .— T he truth of this doctrine [as expounded by Sydenham] is certainly not universally admitted, but the im­ portance of determining whether it is true or fal?e is great. Translated into modern terminology, it means that in estimating the total effects produced upon morbidity and mortality by diseases, the non-specific secondary invaders are as important as the specific causes. The camp followers of an army may do more damage than the regular soldiers, and the same camp followers nif_v ravage in the wake of different armies ; shall we get rid of desolation merely by interning or killing particular armies? To Sydenham belongs the credit of suggesting this difficult and rather disheartening question, which still remains unanswered...... The science and art of medicine cannot be developed harmoniously if the epidemiological point of view is neglected; there is still much to be learned which only the epidemiological method can teach.— Greenwood, Brit. Med. Journ., Sep. 27, 1919- tc'8 The China Medical Journal.

FOUR CASES OF THROMBO-ANGIITIS OBLITERANS.*

A. I. L udlow, M.D., Seoul, Chosen (Korea). An excellent article on thrombo-angiitis obliterans appeared in the China M edical Journal, 1917, written by Dr. G. Duncan Whyte, of Swatow, and in the same number of the J o u r n a l there was an editorial appealing to surgeons in the East to aid in the elucidation of the problems connected with this disease. In response we desire to state that prior to 1917, working in Korea, we had five cases of gangrene, the patients being men from 25-35 years of age. We sought in vain for the cause. In none of the cases was there a history of frost­ bite, of traumatic injury, or the use of carbolic acid dressiugs. There was no arterio-sclerosis and we were able to exclude such diseases as diabetes, Raynaud’s disease, aud leprosy. It is possible that the five were all cases of thrombo-angiitis obliterans, but lacking positive evidence we do not wish to report them as such. In the following four cases, however, the evidence is clearer as to the nature of the disease, attention being directed particularly to the following points :— 1. Sex. A ll four patients were males. 2. Occupations. Farmer, coolie, merchant, and cook. 3. Ages. Patients at time of onset of disease were 31, 30, 32, and 40 years of age respectively. 4. Season. The disease occurred during colder months of the year. 5. A ll the patients used tobacco, but so do nearly all Koreans of the lower classes to which the patients belong. 6. One patient did not drink alcohol; the other three drank Korean wine. 7. Diet of all was chiefly vegetarian. 8. No evidences of syphilis or arterio-sclerosis. I am unable to suggest anything new as to the etiology of this condition, except to call attention to a recent article by Willy Meyer on “ The Etiology of Thrombo-angiitis (Buerger),” Journ. Amer. Med. Assoc., October 19, 1918, in which the author expresses the conviction, based on chemical analysis of the blood of patients, that in this affliction there is a disturbance of the carbo-hydrate metabolism with a con­ sequent tendency to hyperglycaemia, and he suggests that the disease should be called “ glycophilia.” But we are at least now well aware of its presence iu Koreans. Dr. Whyte in his article above mentioned

* Article X V I : Surgical Case Reports. Issued by the Severance Union Medical College, Seoul, Chosen (Korea). Four Cases of Thrombo-angiitis Obliterans. 19

quotes a remark of Parkes Weber that “ the more one sees of this class of cases, the less one favors any drastic operative interference.” My own experience thus far leads me to the same conclusion.

C a s e N o . 7. Thrombo-angiitis Obliterans. (See photo.) Clinical history of patient: Korean, male, farmer, aged 32, admitted to Severance Hospital, July 7, 1919. Family history: Negative. Previous history: General health good until present trouble. No history of gonorrhea or syphilis. Patient uses tobacco but does not drink alcohol. No history of frost-bite. Present illness: In October, 1918, the patient noticed slight anesthesia of the distal phalanx of the second finger of the right hand. During the next ten days the finger varied in color from a dark red to a dark blue. It was also cold. This condition continued and there was some pain radiating from the right shoulder to the finger. In March, 1919, the great toe of the left foot began to swell and a small ulcer appeared on the distal phalanx which gradually became larger until the bone was exposed. The foot and leg became swollen in consequence of infection from a local application of human and dog feces. In April, 1919, the distal phalanx of the first finger of the right hand became affected similarly to the second finger. In addition to the local applications above mentioned the patient had been treated with fumes of mercury (this is a common treatment for syphilis among the Koreans, so a neighbor of the patient suggested that he should take this treatment). Condition on admission: Patient was suffering severe pain in the right hand and the left leg and foot. The pain was so great that he would not remain in bed but sat on the floor groaning. This severe pain was partly due to the secondary infection of the leg, for it was nearly twice the normal size. After considerable argument we persuaded him to keep the leg elevated and, with the local applica­ tion of hot hypertonic saline, this relieved the swelling. When most of the swelling disappeared the foot was still cj^anosed and cold to the touch. No pulsation could be made out in the dorsalis pedis artery. The fingers of the right hand and the hand itself were colder than the left hand. The pulsation in the right radial was perceptible but not strong. The pain was so great at night that sedatives had to be given for relief. Even after the infection was relieved there was still pain in the calf and instep. 2 0 The China Medical Journal*

Blood pressure: max. 115; min. 80. Blood, sputum, and feces examinations : negative. Wassermann reaction : negative. Urine: 24 hr. specimen, 2,000 mils; sp. gr., 1015 ; reaction, alkaline ; no sugar or albumin. No evidence of arterio-sclerosis. Treatment: Rest in bed (for the first few days the patient was out of bed most of the time). Elevation of foot. Hot hypertonic saline bathing of the parts twice a day with moist dressings of same. At the end of a week the inflammatory condition of the leg and foot subsided. Under primary anesthesia we cut off the exposed bone of the distal phalanx of the toe. Local applications of balsam of Peru were then applied, followed later by scarlet red ointment. Although there was no history of syphilis and the Wassermann test was negative we gave a dose of neo-arsaminol for experimental purposes. At the time it was given, on August 21, the patient was making satisfactory progress so I am unable to state whether the neo- arsaminol did much good. At any rate, the patient continued to improve. A t the present time the toe is entirely healed. The fingers are also almost normal in appearance. There is no marked pain. This patient cannot be said to be cured but his condition is certainly greatly improved. Discharged from hospital, October 22, 1919.

C a s e N o . 8. T h r o m b o - a n g i i t i s O b l i t e r a n s . (See photo.)

Clinical history of patient: Korean, coolie, aged 33, admitted to Severance Hospital, August 19, 1919. Family history : negative. Previous history: Patient had small-pox in childhood, and gonorrhea ten years ago. No history of syphilis. Uses tobacco and alcohol (native wine). In May, 1916, the patient came to our hospital and we amputated the third toe of the right foot for gangrene, “ cause undetermined.” The stump healed and patient was discharged apparently cured. In March, 1918, the second toe of the right foot began to show cyanosis accompanied by pain in the foot and calf. In April, a small area of gangrene appeared on the distal portion. Condition remained quiescent until June, then the gangrene extended so as to involve the whole of the distal phalanx. The first finger of the right hand became affected about the same time but showed no evidence of gangrene. Upon patient’s admission to the hospital the distal part of the toe presented a gangrenous mass which was amputated under primary anesthesia. There was no perceptible pulsa­ Four Cases of Thrombo-angiitis Obliterans. 21

tion of the dorsalis pedis artery but the radial pulsation could be felt. Pain in both right arm and leg. Examination of blood; urine, feces, and sputum was negative, also the Wassermann test. Treatment same as outlined in Case No. 7. Patient discharged, September 13, 1919, apparently cured.

C a s e N o . 9. T h r o m b o - a n g i i t i s O b l i t e r a n s . Clinical history of patient. Korean, merchant, aged 37, admitted to Severance Hospital, April 22, 1918. Family history: negative. Previous history: General health good, except for present trouble. Patient uses tobacco and up to the spring of 1917 drank much wine. Five years ago he began to have pain in the great toe of the left foot and the sensation of being pricked with a needle. There was pain in the right foot also.' The pain gradually disappeared, but in November, 1917, it returned, this time in the great toe of the right foot. It was followed in a month by the appearance of gangrene. There was no pulsation in the dorsalis, pedis artery. Examination of urine and blood was negative. No arterio-sclerosis. The toe was amputated on April 26, 1919. Patient was discharged two weeks later, cured. In this case no Wassermann test was made but there was no evidence suggestive of syphilis. A letter received recently from this patient stated that he was still all right. No photograph was taken. We have tried to get the man to come back for further observation but he lives in the country and is unable to come to Seoul at present.

C a s e N o . 10. T h r o m b o -a n g i i t i s O b l i t e r a n s .

Clinical history of patient: Korean, cook, male, aged 40 years, admitted to Severance Hospital, November 4, 1919, complaining of an ulcer of the great toe.

Family history : negative. Parents dead, cause unknown. Previous history: Measles and small-pox in childhood. General liealth good. No history of gonorrhea or syphilis, of frost bite or use of caustic applications. Patient uses tobacco and for the past twenty years has indulged freely in the use of Korean wine. Seven years ago (November, 1912) he had pain in the distal phalanx of the second toe of the left foot with redness of its dorsal surface. The toe then 2 2 The China Medical Journal. became bluish and cold. Ulceration appeared about the nail and later the nail dropped off. The ulcer then became quiescent and healed without special treatment at the end of six months. Present disease: In March, 1918, the left foot became painful, especially in the region of the great toe. The toe was bluish in color and slightly swollen. Within a few weeks the end of the toe showed a spot of gangrene which gradually extended to involve half of the distal phalanx and nail. Condition on admission: General physical examination of heart, lungs, and abdomen: negative. Temperature, pulse, and respiration : normal. No evidence of arterio-sclerosis. The left foot is bluish-red in color, cool to the touch. There is a scar on the dorsal surface of the second toe. The end of the great toe is gangreuous. Pulsation of the dorsalis pedis artery in the right foot is easily felt, but in the left is scarcely perceptible. When the ankle of the left foot is moved rapidly there is pallor of the foot. There is constant pain in the region of the foot about the great toe. This is more marked at night. Much walking causes paiu in the calf of the leg. Blood pressure: max. no; ruin. 80. Pulse pressure, 30. Blood examination: haemoglobin, 85%; red cells, 5,880,000; white cells, 8,000. Differential count : polymorphs, 60 ; large mononuclears, 10 ; small mononuclears, 18; eosinophils, 12. Wassermann reaction : negative. Urine : acid ; sp. gr. 1026 ; albu­ men, trace; sugar, negative; no casts. Sputum : negative. Feces : Ascaris and Trichiuris ova present.

T r e a t m e n t . Rest in bed. Alternating hot and cold baths (hy­ pertonic saline). Dressings, at first saline, followed by balsam of Peru. Although the Wassermann reaction was negative we gave a dose of neo-arsaminol on November 6th, as we did in two former cases. We have been unable to notice any particularly favorable effect so far in any case. If there is any syphilitic basis for this disease process we should expect the neo-arsaminol to be of some benefit. Under local treatment as above mentioned the toe has nearly healed. According to Meyer (op. cit.) this condition is glycophilia, in which there is considerable dehydration of the tissues. His treatment is therefore to supply an abundance of water to the system by the simultaneous use of duodenal flushings combined with hypodermoclyses. Among other effects this reduces the viscosity of the blood so that it is enabled to pass again through the narrowed arterial channels. Good results have been reported in a few cases. Case oj Acute Symmetrical Gangrene. 23

CASE OF ACUTE SYMMETRICAL GANGRENE.

E. M. E w e r s , M.D., Yeungkong, Kwangtung. The patient, a Chinese boy aged nine years, entered the hospital, April 7, 1919, having lost both feet and complaining that the stumps would not heal. Family history: The father, a petty official, is an opium smoker and heavy drinker; he denied con­ traction of venereal disease and stated that his own father died of stomach trouble and that his mother was still living. The mother of the patient has never had any constitutional disease but has suffered from severe toothache for ten years. At time of examination there was a tumor, the size of goose egg, on the right side of her face, which had been there for three or four years, and had never shown any sign of im­ provement; it prevents her from opening her mouth ; the teeth were in fair condition; the pain of the tumor and its size were considerably decreased and greater move­ ment of the jaw was obtained during her stay in the hospital by treatment with a mixture of potassium iodide and bichloride of mercury, given three times daily. Unfortunately, the confirmation by the Wassermann test of a presumptive diagnosis of syphilis was not practicable. She has had five children ; three are living, one died of measles and the other of small-pox.

Present disease ; On November 25, 1917, the boy’s disease began with slight fever for two days and the feet and legs became very painful. Two days later the ankles and feet turned black and blue, and on the 29th were of a greenish color. On December 10, 1917, the skin of the affected parts commenced to “ roll back as one takes off a sock” and the gangrenous tissues sloughed away. By December 20th, the left leg, and by the 25th the right leg, were as shown in photograph. 'T'Vipr#» nn Tiemnrrhnorp. hiit nftpr thp thp nflrts had a vprv fntil *4 The China, Medical Journal. smell. By July, 1918, the skin had healed over the stumps and remained so until October, 1918, when it again broke down. It was treated with native remedies which seemed to act satisfactorily for a time. In March, 1919, there was recrudesceuse of the trouble so the parents brought the boy to the hospital to try foreign medicine. Examination showed complete amputation of left leg at the lower epiphysis ; the surface over the ends of the bones was discolored and gangrenous. The right leg showed complete amputation at the upper border of cuboid and scaphoid bones. The stumps were covered with white granulations and crusts which, 011 removal, left bleeding surfaces. The distal phalanx of the third finger of the right hand showed evidence of previous gangrene. The mother said this happened at same time as the gangrenous process in the feet, but the finger did not drop off, and was comparatively well in a very short time. The physical examination in other directions was negative. The urine was normal, except for a very high acidity. L,eucocytosis was present, 10,000-12,000. No further examination of the blood was made. The boy was well nourished, very bright, and could tell his own history. The temperature was normal during his stay in the hospital. He complained of very little pain w'hen the dressings were changed.

TRANSVERSE PRESENTATION: CASE OF SPONTANEOUS EVOLUTION.

W. P h te xips, M.B., F.R.C.S., Newchwang. Those of us who have much obstetric practice among the Chinese are unhappily familiar with neglected shoulder presentations and their attendant difficulties and dangers. Apart from the exceptional termina­ tions described in text-books, experience has proved that the usual termination in such cases, when untreated, is the death both of mother and child. Figures indicating the frequency of these unaided deliveries are not available, even assuming it were possible to compile them. The spontaneous termination of shoulder presentations comes about with considerable frequency in cases of unusually small childreu, second twins, and premature births. Nevertheless, its occurrence in the case of a full term child of normal size must be of sufficient rarity to make it worth while to place on record a case of spontaneous evolution which I had the good fortune to observe recently. According to Transverse Presentation Case of Spontaneous Evolution. 25

Jellett {Manual of Midwifery, p. 128) transverse presentations occur iu only 0.56% of all births. The patient was a northern Chinese, aged 39, the wife of a railway employee. This was her seventh labour, and had come on at full term. The other confinements had been easy. Subsequent examination showed the pelvis to be roomy and large. She was carried to hospital at 9 p.m. on the sixth day after rupture of the membranes. A hand of the fœtus had come down two days previously, and her friends had made the usual vigourous attempts at delivery both by compression of the abdomen and traction on the arm. On admission the patient’s general condition was good. Pulse, 90 ; temperature, 102° F. Examination showed considerable swelling of the parts and there was a putrid discharge. The fœtus was lyiug transversely, head to the left and its back to the front, and the uterus was tightly moulded down on its body. The right arm was prolapsed, the skin macerated, and the fingers turning black. The patient was anaesthetized, the vulva carefully cleaned and a douche administered. My hospital assistant, Dr. Tien, then began cautiously to ascertain the possibility of versiou. On introducing his hand into the vagina the patient strained considerably. He withdrew his hand, and I immediately noticed that the presenting shoulder was descending and passing under the pubic arch ; soon the arm-pit became visible, and the perineum began to bulge from pressure of the vertex. We did not^interfere and the straining continued. A moment later the side of the child’ s body, first of the chest and then of the abdomen, ap­ peared at the vulva, the long axis of the body lying in the transverse pelvic diameter. Next, the breech rolled out from under the perineum and right labium, the back of the child now being directed downward and strongly flexed. When the breech emerged the body rotated so that the shoulders lay in the transverse diameter with the back of the body to the front. In this position the legs descended and the arms and shoulders came down unassisted. With the aid of slight traction iu the mouth the head was readily delivered. The placenta gave no trouble. Thereafter a copious intra-uterine douche of eight quarts of hot dilute izal was given. During the puerperium the lochia were very foul and there was some fever; otherwise, recovery was uneventful. The fœtus was fulty developed, but had been dead some days and was macerated and very soft. Apparently, the shoulder had been driven very far down by the strong uterine contractions, and then the straining induced by the examination brought extra force to bear on 2 6 The China Medical Journal.

the child’s spine, the ligaments of which had been softened by decom­ position at the point where it was already acutely flexed by the jamming of the shoulder under the pubis. As soon as sufficient flexure was produced to approximate the breech to the'non-presenting shoulder, the doubled-up body, rotating round the fixed shoulder, passed down into the pelvis, with the breech still above the brim. It is difficult to see how this could occur with a living foetus unless the child were very small or the pelvis unusually large, since the flexure of the dorsal spine is at first lateral. As the thorax descended the body rotated, the back coming to be directed downwards, and the point of flexure seeming to travel down the spine until the breech emerged. It is possible that if enough time be given in such cases for the child’s tissues to become soft, and if the mother survive, the universal Chinese method of treating these cases by continued tugging on the arm may tend to promote the process I have described— always suppos­ ing the arm is not torn off, as frequently happens. On this theory, spontaneous evolution of transverse presentations should' be more common among the Chinese than among other less persevering races !

CASES OF ABDOMINAL SURGERY.*

G. W il k in s o n , M.B. (Cantab.), B.Cli., D. T. M. & H., Foochow. While abdominal surgery is one of the most interesting branches,of surgical work it is possibly also one that we are inclined to shrink from, since the consequences of mistakes may be very serious. In the district of Foochow, the Chinese, as a rule, do not yield them­ selves readily to abdominal operations. Generally, a blunt refusal is given to advice of this kind, as in cases of early appendicitis, and oper­ ation is also usually refused by women in the early stages of disease. It is only when numerous native doctors have been tried and the patient’s condition seems hopeless that the turn of the foreign doctor comes. Even then a considerable amount of confidence in the foreign doctor has to be gained ; the patients may demand to see an array of those who have been successfully treated for similar complaints. A series of unsuccessful surgical cases, even though they were almost hopeless and the operations were properly performed, may hinder the surgeon in acquiring the confidence of the people, and thus it requires a nice discrimination to determine what should and what should not be attempted.

* A paper read before the Fukien Medical Association, Kuliang, July 1919. Cases of Abdominal Surgery. 2 7

Altogether, I shall present the reports of twelve cases, seen be­ tween August 6, 1918, and June 21, 1919. Two of the patients were men treated in our Men's H ospital; ten were women, nine of whom were in the Women’s Hospital, the other being treated outside. I shall deal with the male cases first.

TUMOUR OF MESENTERY : EXPLORATORY OPERATION. Case No. 1 (Men’s Hospital). This was an exploratory laparotomy for a solid tumour of the mesentery in a middle-aged man. The tumour had been growing for several years and resembled in size and position a foetus in a fifth to sixth month pregnancy, but was considerably firmer in consistency. The remark about operation in my diary is as follows : “ Laparotomy, for what proves to be a solid tumour of mesentery. Cannot raise it, or shell it out, without provoking an undesirable amount of haemorrhage. Sutured various layers of the tumour carefully and closed up abdominal wound. Wound healed well except that there was a stitch abscess at one point.” I was careful with this patient because a few years ago I had a similar case, though the tumour was higher up and not so large. In my zeal I separated the layers of mesentery considerably from the tumour. Great hsemorrhage resulted and I could not complete the operation by bringing away the tumour; the patient died, after a short interval of about twelve hours if I remember rightly.

SUPRAPUBIC LITHOTOMY. Case No. 2 (Men’s Hospital). In this case a calculus was re­ moved, about the size of a filbert, probably consisting of oxalate of lime. The wound healed well without any leaking of urine. We have a lithotrite, but I always prefer to do the abdominal operation as our cases of this kind are few, seldom more than one a year.

GYNECOLOGICAL CASES. Of the nine hospital cases, Dr. Shire assisted in two of the operations, Dr. Churchill in three, and Dr. Hook in four. Dr. Ding, a graduate of Foochow Union Medical College, gave the chloroform in all these" cases ; Miss Baldwin and the native nurses were responsible for the preparations and the nursing afterwards. We usually gave a subcutaneous injection of morphia, g r.^ , half an hour before operation.

OVARIAN CYSTS. Six of these nine cases (Nos. 1, 21, 31, 5, 6, 9) were patients with ovarian cysts, nearly all of huge size. A not uncommon 2 3 The China Medical Journal.

measurement was five feet round the greatest circumference of the abdomen, and the length of time during which the tumours had been growing varied from two to twelve years. All of these cases, with the exception of one (No. 9) in which the tumour was not of unduly large size, were tapped once or twice before operation. I used to think this tapping process was a great mistake. I remember some years ago our old friend Dr. Woodhull inviting me to operate on a patient with an ovarian cyst which had been tapped twice at least. I declined, whereupon our worthy chairman (Dr. Betow) performed the operation with no untoward results, and I felt “ small.” For tap­ ping we generally use a long small-bore trocar with a phalange and tap. The part of the cannula beyond the tap screws off, so that it is easy to fix the rubber tube on this and screw on before opening the tap to let the fluid drain. As a rule, we found that the release of several hundred ounces of fluid gave relief to lungs and stomach, after some preliminary discomfort due probably to the clearing of the congested organs. On one occasion •our head native nurse let the fluid run longer than we had intended, and drew off 700 ounces. There was a rise of temperature for some weeks afterwards. If my memory is not at fault, in another case 1,020 ounces were drawn off in two tappings. It was in this case that we had some difficulty during the operation in getting the fluid to flow through a large Spencer Wells cannula, owing to clotting of fibrin in the fluid. In another case 980 ounces of fluid were drawn off in two tappings and there was still a considerable quantity fouud at the operation. There was no «special difficulty in the performance of these operations. The usual incision was up to the umbilicus; this was enlarged in some instances almost up to the eusiform cartilage. On one occasion the cyst-wall was thin and burst, and some of the contents leaked into the abdominal cavity. On another occasion I separated for some time between layers of cyst before discovering my •error. Adhesions were double-sutured with fine silk and divided between. The pedicle was sutured in sections with thick twisted silk, and peritoneum was sutured over the end of stump. The abdominal cavity was flushed out with hot normal saline and some of the solution was left in. After operation the temperature usually ranged between 100.70 F. and 102° F- Ordinarily it subsided in a 4 ay or two. I11 some cases there was a rise about the tenth day which gradually subsided (stump?). These six patients all got quite well. The reports of the remaining -three cases of this series will be more detailed. Cases of Abdominal Surgery. 29

DERMOID CYST OF OVARY. Case No. 4 proved to be one of unusual interest. A mistaken diagnosis was made, but we are not inclined to blame ourselves too severely for the error. The patient was a girl of 17, who came to the hospital on December 12, 1918, complaining of abdominal swelling. She first noticed it about six months before admission. She had never menstruated. The swelling of the abdomen was of firm consistency, not painful, about the size of a five to six months pregnancy, and situated slightly more to the left than to the right of the lower abdomen. On examination the patient was found to have no external genital opening; there was merely a slight depression, and on further examination, with sound in bladder and finger in rectum, it was evident from the thinness of tissue between sound and examining finger that there was also no vagina. The tumour of abdomen was certainly firm, and there had been no history of increase of fulness and pain at the time that would correspond to a menstrual period. How­ ever, no other diagnosis than haematometra was thought of, and the patient eventually consenting, preparation was made to perform abdominal hysterectomy. On opening the abdomen a dermoid of left ovary was found, combined with a very rudimentary uterus. The dermoid was removed and abdominal hysterectomy performed. The other ovary was not removed. The tumour weighed 10 lbs. and on section was found of typical dermoid type. The patient made a good and quick recovery.

TUMOUR, «FIBROID (?) OF I.EFT BROAD UGAMENT.

Case No. 8. Mrs. Wong, aged 39, admitted April 20, 1919. Has never borne children. A t the age of 31 menstruation began to be ir­ regular, coming on only three-or four times a year and then lasting only two or three days. A t the age of 34 she noticed an increase in the size of the abdomen, but there were no other symptoms ; she continued to increase in size until she came to the hospital. Two years ago, at the age of 37, she began occasionally to lose the power of speech for two or three days at a time. She said that something seemed to rise out of her stomach to her throat and until it subsided again she could not speak. Otherwise she was normal and kept working as a servant until admitted to hospital. Operation was performed on April 26, 1919. The tumour proved to be a solid one, probably fibroid, of left broad ligament. It was of 12 lbs. weight and required an incision considerably above the go The China Medical Journal.

umbilicus to deliver it. The pedicle was large, and fleshy in the middle. It was tied in about five sections. Vessels spurting after excision were tied in addition, and the peritoneum was stitched over the end of the stump. The left ovary was removed as it was cystic; the right ovary was not removed. On the day following the operation the patient’s condition seemed satisfactory. The temperature was slightly above 101" F. and inclined to come down rather than go up higher. Next day the patient was not so well and there was difficulty in getting the bowels open. After pituitrin had been given the bowels were relieved, and there was a little hope that she would recover from her serious condition ; but she did not really rally. Temperature, 104° F. The patient died on April 29. The abdomen in this case was not at all distended and it would seem as if paralysis of the bowels was the chief factor in the fatal result. UMBILICAL HERNIA. The next case (No. 7) was that of a very stout woman with an umbilical hernia, about the size of a large orange. The operation attempted was radical cure by Mayo’s method. A vertical oval incision was made on each side of the hernia down to the aponeurosis. The skin and subcutaneous tissue were freed from the aponeurosis for some distance on each side. The hernial sac was carefully incised on one side at the junction of the sac with the aponeurosis. The contents were found to be omentum, although bowel was seen. An omental adhesion was tied at one point and contents reduced into the abdominal cavity. The sac was now removed all round the hernial opening, flush with the aponeurosis. The opening in aponeurosis and peritoneum was enlarged vertically above and below, and a flat sponge inserted to keep contents back. The peritoneum was separated from under surface of aponeurosis; a little tearing occurred in the process, and the two sides and rent were sutured. The sides of aponeurosis were now overlapped about an inch by mattress sutures and also the free edge was sutured to the surface of the aponeurosis, chromicised catgut being used. The skin with subcutaneous tissue was sutured in the usual way with silk-worm gut sutures. No drain was used. Apparently this was a mistake. There was considerable effusion from separated surface of subcutaneous fat, which collected between it and aponeurosis and gradually changed to pus. Fortunately, the overlapped aponeurosis held throughout and shut off the abdominal cavity. The chromicised catgut came away at intervals. The sutures of the skin held well. After three months the end result was excellent. Cases of Abdominal Surgery. 31

PERFORATION OF UTERUS.

The last case of the series is so interesting and, I am bound to say, so rare, that I cannot refrain from presenting the report. I became professionally connected with the case through being asked to perform the abdominal section. The patient was a sick-lookiug woman, aged thirty, wife of a rickshaw man. On admittance her temperature was 102.6° F. and pulse, 120. She had missed one or two menstrual periods, but on admission had been losing for five days. On examination, what was thought to be an incomplete abortion was felt and it was somewhat offensive. With aseptic precautious the uterus was curetted with a blunt curette as the abortion could not be brought away with the finger. The uterus was found to be large enough for a three mouths’ preguaucy, but what puzzled the operator was that the curette went much farther in on the right. A little of the result of the scraping came away and then Bozemann’s catheter was used to wash out. The patient complained of great pain, and when the catheter was being taken out, it seemed as if it were caught in something, believed to be omentum, which came down with it. The operator only learnt later that a native woman doctor had examined the patient and thinking there was a retroversion had tried with a sound to restore the uterus to its normal position. There is not much doubt that it was punctured in this process. A s it was considered that the patient’ s condition was very serious, her husband was asked to take her home and she was afterwards visited there. The report was as follows : “ Pain is the chief symptom and it is very severe. Temperature 98.4° F. Pulse 96, and fairly good. There must be torsion of great omentum and perforation of uterine wall. Is it any use urging them to have a laparotomy?” On April 28, 1919, at 2 p.m. laparotomy was performed. The only difficulty was that of knowing when the abdominal cavity had been entered; after that all was plain. A portion of omentum, about the thickness of the index finger and three or four inches long, was found blocking the puncture in the fundus of the uterus. This was spread out and sutured in sections with chromicised catgut and the whole was then tied lower down and divided between. It was thought best, careful precautious being taken to block off the abdominal cavity, to draw the piece of omentum up through the wound, rather than extract it from below, which would have involved dilating the cervix. The wound in the fundus was carefully cleaned and sutured deeply 32 The China Medical Journal. with thin silk. Some yellowish lymph on coils of bowel was noticed. The abdominal cavity was flushed out with salt solution and some fresh solution was left in. The next day the patient seemed as well as could be expected, but she died soon afterwards, probably from peritonitis.

A CASE OF PERITHELIOMA OF THE GANGLION INTER- CAROTICUM.

J. O scar T h o m s o n , M.D., F.A.C.S., Canton.

Private patient, No. 19-1683, of Shun Tak, near Canton, a charcoal merchant, male, widower, aged 56, entered the Canton Hospital, surgical service, on September 6th, 1919. Patient denied having had syphilis, and presented no symptoms of either syphilis or tuberculosis. As to his complaint he said that twenty years ago he first noticed a small tumor, the size of a bean, on the right side of his neck. The tumor was movable, painless, not tender. Two years ago it commenced to increase in size more rapidly and there was now slight pain. The present condition of the patient is that of a generally well nourished man. Temperature 36.8* C. Pulse, 80. Heart, normal. Lungs, normal. The right cervical region presents a tumor, about the size of an egg, the upper part of which is hard and nodular, lower portion firm and smooth. The tumor is movable laterally, slightly tender, pulsates laterally, is not attached to the skin, and shows no signs of inflamma­ tion. No bruit is audible. The centre of the tumor is situated at the upper border of the thyroid cartilage. Urine, acid; specific gravity, 1010; sediment. Feces, no ova found. Hemoglobin, 68%. Pre-operative diagnosis : tumor of the carotid body or aneurysm at the carotid bifurcation. Pre-operative treatment: Sodium bicarbonate, 6 gm. t.i.d,, for three days. Enema. The patient was operated upon on September 13th by Dr. J. Oscar Thomson, assisted by Dr. K. M. Chau. Chloroform administered by Dr. P. C. Ch’ an. The operative field was iodined. An incision three inches in length was made over the tumor, through skin, platysma, and deep fascia. The sterno-mastoid muscle was retracted laterally,. A Case o f Perithelioma of the Ganglion Inter-caroticum. 33

and the thyroid gland, internal jugular vein, and vagus nerve separated from the tumor, which was found to be situated in the carqtid fork, inseparately connected with the arteries. The common carotid, internal and external carotid arteries were ligated with chromic gut, the vessels severed, and the tumor dissected out and removed. The wound was closed in layers, the deep fascia and platysma sutured with gut, and the skin with silkworm gut. Pre-operative temperature, 36.8° C. Pulse 80. Post-operative ,, 37-2° C. ,, 84. The tumor which was by 1 inch in diameter was a chronic, circumscribed, primary; perithelial neoplasm. Final diagnosis: perithelioma of ganglion intercaroticum. The wound healed by first intention. Patient complained of slight pain in the right side of the head after operation. Discharged well, on September 23rd, 1919.

COMMENT. “ The carotid gland is a small body attached to the wall of the carotid artery, usually at its bifurcation. In size it varies froru that of a grain of rice to that of a grain of corn. Funke found its location to vary several inches up or down the vessel, and noted its frequent absence. The body was first described by Haller in 1743, and the microscopic anatomy by Dushka in 1862. The liability of this gland to become the seat of malignant growths was noted in 1880 by Rieguer, who removed such a tumor by operation. Maydl, Dittel, Gersuny, Malmosky, Reclus and others later reported cases in Europe, as have Scudder, Hearn, Keen, and DaCosta in America. It would seem that very early removal should be advised in every case of carotid tumor. A ll cases are not seen in this favorable stage, however, and very formidable difficulties are met with when the extirpation is attempted in advanced cases, from the fact that the three carotids usually require ligation. This step alone causes a mortality of over 25%. Many who do not die have serious brain complications or nerve disturbances. Of seventeen cases collected, seven are reported cured without permanent complication, and several as cured, but left with aphonia or some paretic condition.” (Ifeen’s Surgery, Vol. 3, page 307.) 3 4 The China Medical Journal.

ON THE VIABILITY OF EPIDERMOPHYTON.

H e r m a n n D o l d , M.D., Shanghai. Cases of (fyshidrosis and eczema of a vesiculo-pustular, intertrig- iuous type, and of mycotic origin, have been repeatedly recorded. To these conditions various names have been given, such as “ foot-tetter,” “ Hongkong foot,” “ dermatitis rimosa of the toes,” “ dermatitis plantaris bullosa,” “ ringworm of the hands and feet,” “ eczematoid favus,” “ epidermophyton infection,” and others. The fungus, which is rather regularly found associated with this disease, is neither the Achorion schonleinii (the causative agent of favus) nor Trichophyton tonsurans (the causative agent of ringworm) but a micro-organism which corresponds to Epidermophyton ingiiindle Saboeraud, or is closely related to it. These affections should therefore properly be termed epidermophyton infections (Epidermophytia). In Europe and America these infectious are comparatively rare, but they are of very common occurrence in China, as was shown by me in the China M edical Journal, March, 1919. Out of ninety- eight cases of “ Hongkong foot,” which were examined microscopically, in ninety-five cases a fungus was found either on or within the layers of the epidermis. In fourteen cases where the attempt at cultivation of the fungus was successful, a growth appeared more or less characteristic of Epidermophyton inguinale. Further, I was able to give a contribu­ tion to the elucidation of the etiology of these skin affections, as I succeeded in two instances in producing the characteristic symptoms of the disease by placing pure culture material of Epidermophyton in close and prolonged contact with the skin of the interspaces of the toes. The lesions are usually found on the feet, especially between the toes. The infection once acquired may persist for a long period, even through the whole of the year, showing as a rule exacerbations during warm weather. These clinical peculiarities lead to the assumption that the fungus is possessed of a great viability. To ascertain the exact degree of this viability, I undertook two series of experiments under varying condi­ tions : in one, using pure culture material; in the other, scales of diseased skin wliich contained large numbers of the organism.

EXPERIMENTS WITH PURE CULTURE MATERIAL. Pure culture material of the fungus, grown on Sabouraud’s maltose agar, was ground carefully in a sterile mortar, a few drops of broth On the Viability of Epidermophyton. 35

being added to make a rather thick emulsion. Small pieces of sterile gauze were then soaked in the emulsion and afterwards placed in a sterile glass jar to dry. When dry, half of them were transferred to a sterile paper envelope and placed in a drawer of the laboratory, whilst the other half, in a sterile paper envelope, was placed in the incubator at 370 C. From time to time from each of these two groups of infected pieces of gauze, four pieces were taken out and, under sterile conditions, were placed separately in the depth of four culture media. The inoculated cultures were theu incubated at 370 C. and watched for at least fourteen days. The results of these experiments will be seen from the following table.

T able; i . Showing results of cultivation in darkness of fungus on gauze. Temperature, 180 C.— 23.50 C. Humidity, from 68%-8o%. Experiment* Results after number of days specified. 3 6 9 12 15 20 30 No. 1 + 4- — ' — — _ — No. 2 + No. 3 + — — — — — — No. 4 +

T a b l e 2. Infected pieces of gauze, kept in the dark at 370 Humidity : 68%-8o%. Experiment. Results after number of days specified. 3 6 9 12 15 20 30 No. 1 + — _____ No. 2 + — — — — — — No. 3 + — — — — — No. 4 +

EXPERIMENTS WITH SCALES OP DISEASED SKIN. Scales of the diseased skin, containing the organisms in large numbers, were removed, placed in sterile paper envelopes and kept partly at room temperature and partly at 370 C. Further, as in the foregoing experiments, from time to time from each of the two groups of scales, four specimens were taken out, and under sterile conditions separately placed in the depth of four culture media. The inoculated cultures were incubated at 370 C. and watched for at least fourteen days. The results of these experiments are shown in following tables.

• Each experiment comprised four cultures. The result was recorded as positive if at lea*t one of the four cultures yielded growth of the Epidermophyton fungus. 36 The China Medical Journal.

T a b l e 3. Infected scales, kept in the dark at room temperature varying from i 80-23.5° C. Humidity : 68%-8o%. Experiment Results of cultivation after number of days specified. 3 6 9 12 15 20 30 40 No. i + + + + + — — — No. 2 + + + ——— — — No. 3 + + + + + + — — No. 4 + + — —— — — —

T a b l e 4. Infected scales, kept in the dark at 370 C . Humidity: from 68%-8o%. Experiment Results of cultivation after number of days specified. 3 6 9 12 15 20 30 40 No. 1 + + — — — — — — No. 2 + + + — — — _ — No. 3 + + No. 4 + +

EXPERIMENTS ON THE EFFECT OF SUNLIGHT ON THE FUNGUS.

Pieces of gauze impregnated with pure culture material of the fungus, and also scales of the diseased skin containing large numbers of the fungus, were for different periods of time exposed to direct sunlight. Afterwards, the scales and the pieces of gauze were respec­ tively inoculated into culture media as described before, and incubated at 370 C. The results, after fourteen days observation, will be seen from the following tables.

T a b l e 5. Infected pieces of gauze, exposed to sunlight. Experiment Results of cultivation after number of days specified. 1 2 3 4 5 10 15 No. 1 + — — — No. 2 + + — — _ _ — No. 3

T a b l e 6. Infected scales, exposed to sunlight. Experiment Results of cultivation after number of days specified. I 2 3 4 5 10 15 No. 1 + + + + — — — No. 2 + + — — — — — N o. 3 + +

CONCLUSIONS. It is evident from the results of these experiments that the causa­ tive agent of the above mentioned skin diseases is capable of surviving for a remarkable length of time. Acute Lymphatic Leukemia with Report oj a Case.

In pure culture material, attached to pieces of gauze aud kept in the dark at room temperature varying from i8° C.-23.50 C. the fungus was found alive at the end of nine days; if kept at 370 C. it survived to the sixth day. On the other haud, scales of diseased skin which were kept in the dark at room temperature (180 C.-23.50 C.) contained living fungus elements up to twenty days, aud if kept at 370 C. up to nine days. The fact that the fungus keeps alive longer at room temperature than at 370 C. is in all probability due to its drying more quickly at the higher temperature. A longer vitality was found to exist in the organisms of the scales than in those of the pieces of gauze impregnated with pure culture material. This may be explained by the assumption that the fungus in its natural environment possesses a higher degree of virulence and viability, besides being probably better protected against the detrimental effects of drying. If we particularly consider the results of our experiments with the scales kept at room temperature, which correspond most closely to the natural conditions, it is evident that this fungus may survive for a considerable length of time on the skiu, especially in places where there are moist and warm pockets, as, for instance, in the interspaces of the toes. As to the mode of transmission of the disease, it seems most likely that articles of clothing sent to outside laundries, especially socks, stockings, aud other foot-wear, become infected with the fungus, which may survive for a remarkable length of time, as indicated by our experiments. Such infected articles of clothing coming into contact with other articles sent to the laundry may in this way transmit the infecting agent from one person to another. This makes it under­ standable why the disorder often affects the white foreign population, in spite of the greatest personal care aud cleanliness.

ACUTE LYMPHATIC LEUKEMIA WITH REPORT OF A CASE.

E. S. T y a u , M. D., D. P. H., Shanghai. In the West lymphatic leukemia is a disease of rare occurrence. Apparently it is even rarer in China as I find no record of a single case in the history of St. Luke’s Hospital, one of the oldest medical institu­ tions in Shanghai, and I can only find the report of one case in the many pages of the C h i n a M e d i c a l Jo u r n a l . And from the experiences of older physicians in different parts of the country, I learn 38 The China Medical Journal.

that leukemia, even the myelogenous form, is but occasionally seeu. In view of this rarity I send the report of the following case. The patient, shown at a branch meeting of the C. M. M. A. in Shanghai, was a boy aged fifteen years, who came to the Skin Clinic of St. Luke’s Hospital primarily for a course of tuberculin treatment for his enlarged cervical glands, as he had repeatedly heard of our signal success in this line of therapy for tuberculosis. He was at once admitted into the hospital as a case of tubercular adenitis, but the diagnosis was soon changed after examination of the blood had been made. Family history: His parents died when he was very young. Father died of hemoptysis ; cause of death of mother, unknown. Has one brother living and well. Personal history : Patient’ s habits are good. He has never been very strong. Had the common diseases of childhood, and a chronic cough. Present illness : A t the time of admission to the hospital, the illness had lasted about six weeks. It began with the enlargement of the lymph glands on the right side of the neck, without pain or fever.

ACUTE LYMPHATIC LEUKEMIA. PATIENT’S CONDITION ON ENTERING HOSPITAL.

In the course of a week the glands on the left side also began to swell. Then followed the involvement of the axillary glands, the inguinal glands, etc. He coughed more than usual and the expectoration in the Actite Lymphatic Leukemia with Report of a Case. 39 morning was at times tinged with blood. No night sweats. Owing to the presence of adenoids he suffered much from difficult breathing. His appetite was very good, but he did not assimilate his food very well, as his strength and weight steadily decreased. Physical examination: There was general pallor with flushed cheeks. The abdomen was large and there were a few purpuric patches. There was hypertrophic rhinitis of the right nostril with adenoids in the rear. The palate showed hemorrhagic patches; the pharynx was congested. The tonsils were much enlarged with dilated veins cours­ ing over the surface. The cervical glands on both sides of the neck were extensively enlarged from the back of the ears down to the supra­ clavicular fossae ; they varied in size from a bean to a cherry. These enlarged glands were firm but painless, and loosely joined in groups which were freely movable, under the skin. In the axillae a few glands were much enlarged. The .chest was flat and expansion poor. Poster­ iorly, there was dullness at the apex of the right lung, with prolonged expiration and increased vocal fremitus but no iales. The heart action was rapid, with a soft systolic murmur, not transmissible at the apex. The abdomen was soft but distended. The liver was enlarged down­ wards only, about three finger breadths below the costal margin. The spleen was likewise enlarged and palpable about three finger breadths below the costal border. The enlarged part was not tender or nodular. The inguinal and epitrochlear glands were enlarged. The glands in the popliteal spaces were found enlarged about five days after admission. The patellar reflex was not impaired. Petechial eruptions of pinhead size and purpuric hue were visible along the tibial surfaces, the forearm, and over the abdomen. The patient’s weight was 75 lb. Pulse, 105. Temperature, normal. Blood pressure: systolic, 115 ; diastolic, 75. " Laboratory examinaiiojis : No tubercle bacilli in sputum. Urine and feces, negative. Blood showed hemoglobin, 64% ; red count, 4,500,000 ; white count, 45,500. Differential count was as follows :

Polymorphonuclear neutrophils ...... 5 -5% Large mononuclears ...... 2.5% Lymphocytes ...... 90. % Eosinophils ...... 1. % Myelocytes ...... -5% Nucleated reds ...... 5% Clinical course : The glands increased not only in size but also in number, the disease taking a downward course very rapidly. On February 14, three days after admission, clusters of enlarged glands 40 The China Medical Journal. appeared below the nipples. One of these glands was removed and sent to the laboratory for section. Much subcutaneous hemorrhage appeared around the incision and the stitch wound. The coagulation time of the blood was delayed. According to the laboratory report, the gland on section was found to consist of uniform masses of small lymphoid cells with extravasation of erythrocytes towards the capsule. The stroma w^as very scanty and in their general appearance the cells resembled sarcomatous round cells, having hardly any cytoplasm but with nuclei which stained deeply^. No giant cells were found. On February 18, three hemorrhagic patches, the size of a cherry and of bluish color, suddenly appeared on the right leg; these wrere soon followed by similar subcutaneous hemorrhages on the right arm. On February 20, the patient became slightly deaf in both ears. The old hemorrhagic patches on the skin turned purplish in color. Fresh crops of bluish patches also appeared on the left foot. The pro­ gressive enlargement of the glands had reached down to the popliteal space. As the patient’s condition w'as rapidly becoming worse under treatment with arsenic and calcium lactate, it was decided to try the Roentgen rays; these were applied over the spleen once every three days. No improvement was evident after four exposures. In fact, by March 1, patient’s general condition was worse, as evidenced by the blood picture, and he complained of pain in the spleen. More purpuric patches 'appeared— a very extensive one over the chest. Roentgen rays were next applied to the enlarged glands of the neck instead of to the spleen. On March 6, while the anemia was more pronounced, the glands after two exposures had become much reduced in size. The white count dropped to 19,500. The spleen showed no change. On March 14, the anemia was more marked and there was oedema of the legs. The heart’s action was more rapid. The white count suddenly rose to 115,000. Evidently a rapid and very grave change for the worse had occurred. The Roentgen ray treatment uo longer showed any efféct. On March 18, the anemia had perceptibly increased and there was the further symptom of dyspnoea. There now occurred a severe attack of epistaxis which weakened him so much that he succumbed at midnight. Autopsy wras not obtainable, but the clinical picture, the blood examina­ tions, and the rapid course of the disease suffice to warrant the diagnosis of acute lymphatic leukemia. Chengtu Vaccine Service.

NOTES ON THE VACCINE SERVICE AT THE "INSTITUT BACTERIOLOGIQUE " OF CHENGTU.

H. J o u v e a u -Du b r e u il , M.D., Chengtu, Sze. Vaccination against small-pox, as practised abroad, was introduced in Szechwan only a few years ago. British, American, and French doctors and missionaries performed the first vaccinations about thirty years ago and tried to get the method adopted in this country. The task was a difficult one, as the number of medical practitioners was infinitesimal compared with that of the population. Moreover, foreign science, far from having the prestige it is beginning to have now, was looked upon with suspicion and even with contempt by the Chi­ nese people. Yet the greatest of all hindrances was due to the gly- cerinated pulp itself, owing to the fact that, as it came from the Hongkong Institute, it had to stand a very long journey (thirty to fort}^ days) and also frequent chauges of temperature, so that on arrival its action was considerably diminished and at times it had lost all its strength, It was therefore very difficult to induce the natives to recognize the advantages of a product which proved to be so variable and of such poor quality. The result was that vaccinations were few and were confined to those in the near vicinity of foreigners. On the completion of the Hanoi-Yuuuanfu railroad in 1909, some progress was made as the railway line allowed of faster communica­ tions with Tonkin and it crossed high plateaus where the temperature is always below 150 C. Certain doctors availed themselves of the new facility. Dr. Esserteau obtained some vaccine from the Institute in Hanoi and in one of his reports he says concerning it: “ Of all the vaccines (European and Japanese) tried, it is the one that gave the best results. But even when taking advantage of the most favorable season for procuring vaccine, one should not expect to be successful in more than 20% of the cases with adults, and in 50% of the cases with newly born babies.” This was still far from sufficient to fight with success the custom of] variolization, implanted in this country cen­ turies ago. To remedy this state of affairs and to cope with the requests for, microscopic analysis from the various Chinese, French, and other foreign hospitals in the town, and to gather more accurate data on the diseases of China, the French Foreign Office decided to establish in Chengtu a laboratory of bacteriology which would also be a vaccine producing centre. For this purpose, buildings were erected in 1909- 42 The China Medical Journal.

I9I°. and, at the beginning of ign , I was able to start manufacturing vaccine from stock brought from Tonkin. The product thus obtained proved to be of excellent quality from the very beginning, and in the case of children gave 98% of successful vaccinations. A fast postal service allowed its being transported in a short time to all parts of the province ; there only remained to make it known to the natives and, more particularly, accepted by them. This was a work of patience. All the difficulties we have had to contend with in Indo-China, such as mistrust of the inhabitants, ill will on the part of the officials, atid the open hostility of the native doctors, are well known. W e have had to struggle there for more than forty years, yet we had control over the country and in case of necessity could have taken strong steps. Results which were truly satisfactory commenced to be obtained only fifteen years ago. In Szechwan, the first vaccinations, made by Dr. Mouillac, showed that the same difficulties would be met with here. All possible means of persuasion had to be used to decide a few families to bring their children. Free clinics, held in the centre of the city by Dr. Esserteau and advertised to the public by the magistrate, most of the time attracted no one. Our own efforts met with no better success. The Chinese patients in the French Hospital only reluctantly allowed themselves to be vaccinated ; they did not understand why they should undergo, as it seemed to them, an operation similar to inoculation, which it is customary in the country to submit to only once in a lifetime, and that during childhood. The help that missionaries gave us from all parts of the province was indeed most welcome ; but it was unfortunately limited to their immediate sphere of action, aud each one could barely perform more than one or two hundred vaccinations per annum. It could not be hoped to reach in this way the greater portion of a population of over forty millions. The best course, therefore, was not only to refrain from competing with the native doctors, but to try to win them over aud have recourse to their help to obtain the desired results. The variolic virus they use is difficult to preserve, it gives uncertain results, and during the summer heat often becomes inert. Theu each doctor keeps his own virus jealously, asserts that it is of much better quality than that of his colleagues, and when out of stock finds it very difficult sometimes to obtain a new supply. They were therefore certain to appreciate the advantages of having a virus very active, of constant strength, not dangerous, aud easily procured. Cheng tu Vaccine Service. 43

As early as the beginning of 1913, about ten native doctors applied to us regularly for their supply of vaccine, and in 1914 about forty of them were among the Institute’s customers. Moreover, important demands for lymph were coming in, not only from far away places in Szechwan, but also from the provinces of Kweichow and Yunnan. From that time, down to the beginning of 1919, the quantity of pulp thus delivered has been constantly 011 the increase. The number of doses forwarded yearly now exceeds one hundred thousand. At present the Cheugtu Institute supplies the foreign establish­ ments of the province with vaccine, and the possibility these have of obtaining very rapidly, aud all the year round, fresh and active lymph, enables them to increase considerably the number of their vaccinations. Demands received from different places in the province state how much this service is appreciated. Vaccinifers. Ever since Calmette* proved that in Indo-Chiua the water-buffalo.is far superior to the heifer as a producer of vaccine, the former animal has been used by all the vaccine producing institutes in the Far East. Heifers in Indo-Chiua are usually of a small breed and of poor appearance. The Szechwan breed is stronger, but both give poor erup­ tions ; the pustules are small and soon dry up. In 1911, we inoculated fourteen heifers in order to ascertain whether the Szechwan breed was better than the Tonkin breed. The mean yield was thirty-two grammes, the highest being sixty-seven grammes, aud the lowest teu grammes. In 1918, having no buffalo at our disposal, we inoculated a heifer which gave only twenty-nine grammes. The buffalo, on the contrary, is a very sturdy animal and strongly resistant to infection. It thrives quite satisfactorily in the Far East, which is probably its country of origin. It is extremely'’ receptive to vaccine, and, at equality of weight, gives three times more pulp thau a heifer. The pustules are large, of good appearance, bulky, and perfectly umbilicated. The successive inoculations of the virus do not attenuate its action, which remains constant; and eruptions, even extending over both flanks, do not affect the animal sèriously as it stands them without getting sick. Buffalos may be vaccinated between their tenth and twenty-fourth months, but the best time is when they are eighteen months. A t this

* A . Calmette et G. Lepinay.— Mémoire sur l’organisation et le fonctionne­ ment du service de la vaccine en Cochinchine de 1867 à 1890. (Rapport général présenté par l ’Académie de Médecine sur les vaccinations et revaccinations pendant l ’anuée 1892.) 44 The China Medical Journal.

period the animals have reached almost two-thirds of their full size, and yield a very abundant eruption. Some of the animals have a kind of mycosis of the skin which spreads rapidly all over the body; it causes them to continually scratch themselves and induces a deplorable state of thinness and decay. Rubbings with kerosene oil may cure them, but it is best to refuse the animals on arrival. In order to obtain long and regular scarifications so as to lose as little space as possible, we now use a kind of flexible ruler made of thick leather. The assistant holds the ruler against the flank of the animal and perpendicularly to its axis, while the vaccinator, using a lancet, scarifies the first time all along the ruler; then slightly inclining the instrument he scarifies again so as to leave a space of about one millimetre between the first and the second incisions. This way of operating allows a more uniform and more certain inoculation. The ruler is then drawn one centimeter backward and the operation started anew. Meanwhile, the second assistant spreads the virus with a spatula, causing it to penetrate in the furrows. The buffalos generally stand the operation very well; they keep their usual appearance and continue to feed. Some of them, however, become depressed, the muzzles become hot aud there is diarrhea. But they get over these symptoms very soon and we have never had any animal die. On an average, the product yielded per animal varies from 150 to 200 grammes. The maximum obtained reached 270 grammes. But the quality depends principally on the size, stoutness, and state of the skin of the vaccinifer. A fine buffalo with a smooth skin, 18 months old, is the one that yields the most. Animals with a black and thick skin are suitable to a less degree. Yet we have never found any to be refractory to the inoculation. I11 order to preserve the vaccine during the summer heat, it is packed in ice and placed in capacious receptacles of the “ Thermos” type ; these have a large aperture and the temperature in them always keeps a few degrees below freezing point.

Origin of ihe virus used. The first stock used was brought from Hanoi in March 1911, and proved to be of even virulence during two years. But in 1913, having to stand the temperature of the laboratory during all the summer, it became inert for want of ice. New stock was then procured from Tonkin, which served till last year without its virulence becoming altered in the least. Chengtu Vaccine Service. 45

Utilisation of desiccated vacci?ie. In September, 1917, we received from the “ Institut de Vaccine Animale ” of Paris a supply of 500 doses of desiccated vaccine. During the mouth of October, 1918, sixty vaccinations were effected with this product on young children who had never been vaccinated, aud, out of the twenty-nine who came again for control purposes, we recorded the same number of successes. During November, 1917, what remained of the above provision, prepared and diluted in accordance with the instructions accompanying the vaccine, was tried on part of the flank of a buffalo, while at the same time the other flank was inoculated with the laboratory’s ordinary virus gathered forty days previously. The result was excellent; there was no difference between the eruptions resulting from the two stocks, either as regards dimension: of the pustules or confluence. Yet the desiccated vaccine had remained duriug the summer out of the ice-chest, exposed to the temperature of the laboratory. This temperature, however, is not excessive, as it averages only 26°C. and seldom reaches 3 O ° 0 . Still, it is sufficient to sterilize glycerinated vaccine in the space of four months, as was the case in 1913. A second supply of dry vaccine was sent to us this year. We tried it on a certain number of children, each time with success. The rest is kept as reserve iu case our present stock should become inert. We believe it is for this reason that dry vaccine may be of most use in Szechwan. This province has a mild climate and presents no serious difficulty as regards the preservation of the lymph ; but it is so far from other vaccine producing centres that if through any cause the Chengtu laboratory came to be without effective virus it would be nearly a month before a new supply could be procured. A reserve supply of desiccated vaccine is an insurance against such an eventuality and does awayr with all apprehension of stoppage in the production. We therefore propose to procure a supply each year during spring. The vaccinations begin in September and continue in moderate number till the end of December. The natives consider this period as sufficiently favorable owing to the mildness of the climate, but not as the best period. Many parents, more particularly of the well-to-do classes, prefer to wait. January is considered to be too cold, and as towards the end of this month or the beginning of the next, the Chinese New Year Festival occurs, which lasts fifteeu days, very few or no vaccinations are performed. The end of February and the whole of the month of March constitute the most favorable time. The vaccinations are then more 46 The China Medical Journal.

than twice as numerous as during autumn. In a large number of families this favorable time has been waited for. The reason given by the native doctors for preferring this .period' is that at the beginning of spring the weather is mild, that everything in nature is growing, and that the virus also develops better. In reality the custom is due to tradition and, as in a good many other things here, it rules tyrannically. ~ The following diagram shows the quantity of vaccine des­ patched per month from July i, 1918, to June 30, 1919.

During the summer, the Chinese do not vaccinate. The few hundred^doses leaving the laboratory during the summer are always destined for foreign doctors. In .Szechwan the climate is temperate enough to permit a sufficient preservation ofj the virus and, thanks to the central position occupied by the Cliengtu laboratory, it can reach in a few days the remotest places in the province. As variola is endemic everywhere, and Chengtu Vaccine Service. 47 frequently prevails here to such an extent that barely a month passes without the doctors findibg cases, it is necessary to advise the people that the vaccination of children should take place as early as possible, 110 matter what the season may be. This is a principle the native doctors must be taught and which they will admit in time. Of the 97,000 doses that were supplied this year by the laboratory, 18,000 have been used in the town of Chengtu. The population of this city is about 500,000, aud as the Chinese never vaccinate anew, it may be deduced that nearly the totality of the children have been vaccinated with the Institute’s vaccine. The result is extremely encouraging as it proves that as soon as the "native doctors become acquainted with the new method, they perceive its advantages and superiority and completely drop their own methods. In fact, they abandon their antiquated prejudices and customs more easily than one years ago would have dared to hope.

N ew M ethod of V accin a tio n .— A method of vaccination, which appears both to be efficacious and to have considerable advan­ tages over ordinary methods, is described by W. H. Hill in the Brit. Med. Journ., 1917, I, 189. The sleeve of the person who is to be vaccinated is rolled up, and the skin of the selected site is successively washed with soap and water, rectified spirits, and ether. The vaccine lymph is then expelled from the capillary tube on to the arm at three or foiir points, making a triangle or square, leaving not less than two inches between the points. With an ordinary sewing needle, sterilized, six liny punctures, drawing no blood, are made through each drop of lymph, each set of six occupying a space not more than one-eighth of an inch square. The needle is held almost parallel with the surface. Not over one-thousandth of an inch occupies the epithelial layer. The lymph is then wiped off the skin and the sleeve is pulled down. Typical lesions usually result in peisons who have not been previously vaccinated. No after-treatment (shields, bandages, etc.,) is required, for if left alone the pustules dry up, to form scabs which separate without leaving an ulcer. Amongst the advantages claimed for this method are that there is no waiting for the vaccination sites to d ry ; there are no bad arms, because there is no removal of the epidermis ; and that, where a large number of persons are to be vaccinated, the process can be carried out very rapidly with the aid of nurses or orderlies. m e dlhirta Jfltbical Journal

V o l . XXXIV. JANUARY, 1920. No. 1

All communications on Editorial Matters, Articles, Letters, Exchanges, and Books for Review s h o u ld b e addressed to the Editor o f t h e J o u r n a l . Changes of address, departures and arrivals of members of the Association should be notified to the Business Manager, Dr. R. C. Beebe, 5 Quinsan Gardens, Shanghai. Members are requested to invite all missionary physicians who come to China and other parts of the East to join the Association. Every member of the China Medical Association, who has paid his dues for the current year, is entitled to a copy of the China M edical Journal for the year, postage free. To those not mem­ bers, the subscription to the J o u r n a l is $5 Mex., per annum. In remitting by cheque please s p e c ify " S h a n g h a i cu rrency ^

j£Ditonal.

The preparations for the Conference to be held The Conference, next month in Peking are now almost complete and it is hoped that the programme, which appears elsewhere in this number of the Jo u r n a l , will meet with general approval. The mornings will be devoted mainly to the consideration of the standards and needs of mission hospitals. The large number of replies received by Dr. Balme to his questionnaire is proof of the wide interest taken in this subject so that we may expect a very instructive and helpful discussion of it in all its bearings. If we state the requirements of our hospitals clearly and convincingly, it will be of service to the mission boards in framing a progressive policy for the churches and will thus lead to the strengthening of the work of medical missions not only in China but also in other parts of the world. The sectional meetings in the afternoons will give ampler opportunity than has been afforded at previous conferences for the reading and discussion of scientific papers, and for practical demonstrations of clinical and laboratory methods within the scope of small hospitals. In the evenings lectures will be delivered or papers read on subjects of general interest more or less connected with our work as medical missionaries.

The social programme is also attractive, for it is not intended that the Conference shall be so strenuous as to send the delegates Editorial. 49

home utterly wearied by hard work without intermission. Besides, Peking is a very interesting city. Every afternoon two or three hours will be spent in sight-seeing and social functions. There is a further object in this than mere relaxation. It is now three years since the last meeting of the C. M. M. A., and during this period there has been considerable change in our membership. Our stations may lie far apart but we ought not to be strangers personally to each other. Let us take this opportunity to get together and become more closely acquainted. In social unity is strength.

The whole of the last morning of the Conference, with a little of the time of each preceding morning, has been set aside for the consideration of business. To promote the welfare of the Associa­ tion and to strengthen it as an organization it is necessary that as many as possible should attend the business meetings. No doubt there are doctors who dislike business and have little aptitude for it. Nevertheless, the affairs of the Association must be dealt with, and if this is not done at the Conference it means that additional work and responsibility devolves upon the Executive Committee. Ours is a very democratic organization, a government of the members, by the members, and for the members, without cliques or parties ; it is therefore the duty of all to take part in its business meetings.

The closing session of the Conference will be set apart for the religious side of our work and each day will begin with a short devotional meeting. This should really be the most uplift­ ing part of all. Owing to the great pressure and absorbing interest of our professional work, the constant and close contact with much that reveals to us the evils of unregenerate humanity, the lack of that spiritual support which is derived from living in large Christian communities of our own people, and other unfavorable circumstances, there is always the danger of losing missionary love and enthusiasm. Yet it is essential to the highest success of our work that the spiritual glow should be maintained. During the week of the conference it will be well for us to meet frequently for mutual edification, and as fellow-workers in the same great Cause to realize more fully our corporate life and aims. We shall then go forward with renewed power. .50 . The China Medical Journal.

S oo n after the signing of the armistice the The Appeal for Executive Committee received word from Dr. More Medical George C. Worth, of Kiangyin, that he desired Missionaries. to bring before the Conference aresolution pro­ posing that an appeal should be issued by the Association to those doctors and nurses interested in Christian missions, or likely to become so, who had been released from military service. The Committee decided that it would be in accordance with the wishes of the Association to issue the appeal at once, while possible candidates were still undecided as to their future course. Accordingly, an “ Appeal for Medical Missionaries

to China” appeared in the May number of the C h in a M e d ic a l

J o u r n a l , and copies of the appeal were sent to all missionary societies and to many religious papers. By mutual arrangement the Nurses’ Association of China undertook to issue the appeal for nurses. The response to our own appeal has not been very impressive. It may be said, however, that the first step only has been taken. The resolution will come before the Conference in due order, but more will be necessary than to simply endorse what has been done ; we should indicate the further practical steps that can be taken. It was suggested some time ago that each missionary society should have a “ candidate secretary,” whose duty would be to get into personal touch with all mission candidates and smooth their way to the field. Are there any other suggestions ? Can use be made of the Inter-Church World Movement to obtain more medical mis­ sionaries for China ?

W h a t immediate and practical measures can be The Insane taken1 to alleviate the miserable condition of the in China, insane in China ? This is another question which it is desired to bring before the Conference and certainly it is one that deserves our careful and sympathetic consideration. In Japan, with an estimated population of 56,000,000 there are 140,000 people who are insane, or 1:400 of the general population. If the same proportion exists in China, with its population of 400,000,000 it means there are about 1,000,000 people here who are insane or weak-minded. Editorial. 51

In describing the present condition of the insane in Japan, where the system prevails of keeping the mentally afflicted at home or sending them to monasteries, two Japanese physicians investi­ gated the conditions in which 361 of these patients were kept. They state that “ the whole aspect is one of misery and desolation, and the circumstances are such as to preclude absolutely the recovery of the persons so confined. Food, clothing, bedding, and the necessities of life are most sparingly supplied, and baths are very infrequent. A mentally defective person is considered by his family as lost to them and as long as he lives he is a burden to all concerned. The treatment is probably not intentionally cruel but is rather that of neglect. Many of these cases might improve under better treatment. What is needed is more enlightenment of the people as to the nature of these maladies.” It is also said, “ Without exception these persons had committed some act of violence or other violation of the criminal code and were confined for that reason.” (Tokyo Igakukai Zasshi, July 5, 1918 : abstr.,

Ch. M e d . Jo u r n ., 1919, p. 269.) In China the head of the family is usually held responsible for the injurious acts of any of its members ; consequently, many of the insane who are dangerous are rigidly confined either in the home or in a monastery, as in Japan, and the disposition to treat them cruelly is enhanced by the fear and dislike inspired by the belief that madness is due to possession by evil spirits. Compared with Japan there can be little doubt that the treatment of the insane in China is very much worse (see Dr. Ingram’s article on “ The

Pitiable Condition of the Insane in North China,” Ch. M e d . Journ., 1918, p. 153). At the present time there are no government institutions for the insane in this country. In Peking there is a place which is sometimes called a hospital for the insane, but it is nothing more than a prison where the insane are confined and sometimes put in chains. Christian missions are doing a little for these unfortunates. There is a small Roman Catholic hospital in Shanghai for twenty patients, and two or three hospitals of Protestant missions set aside a ward for mental cases. The only large institution devoted wholly to the care of the insane and conducted on scientific principles is the John G. Kerr Hospital in Canton. 52 The China Medical Journal.

At a meeting last summer of the Kuling Branch of the C. M. M. A., it was determined to send an appeal to the organizers of the Inter-Church World Movement, suggesting that in aiding mission work steps should be taken to establish in central China a hospital for the insane and feeble-minded. This appeal has been recently endorsed by the Executive Committee and it has given its approval to the proposal to bring it before the Conference. The tragic death a few weeks ago of Dr. Logan, whose place will not be easily filled and for whom we shall long mourn, s'hould convince everyone of the necessity of steps being taken as soon as possible to provide for the proper care of persons of unsound mind, especially of those liable at any time to commit terrible acts of violence.

T h e reading of long, dull papers at a conference Conference usually bores if it does not exasperate, though we Papers. may be too polite to say so. It has therefore been suggested that at the sectional meetings all papers should be short and snappy. Yet care should be exercised not to go too far in this direction. The papers read at our conferences furnish the main supply of material for the J o u r n a l , and if these are fairly numerous and of good quality and length, the editor is able to perform his duties with a quiet mind as it is almost certain that during the intervening period other articles will come in to eke out the number required. So far, there is a list of about one hundred papers to be read at the conference next month which seems very encouraging. But if they aré all short and snappy they may not carry us very far. Then the qualities specified, while desirable for oral discussions, are not always quite so admirable when the articles are seen in cold print. There are medical subjects which cannot be treated briefly, and others are almost beyond the wit of man to make very entertaining, and yet they may be of great value. A compromise is suggested. Let the articles intended for publication in the J o u r n a l be as long as proper consideration requires, and for the conference let short copies be made which the authors can make as bright as they please. As to the reports of the subsequent discussions, previous arrangements have not been satisfactory. In a public meeting few men are able to speak extempore on scientific subjeqts and give Editorial. 53

expression to their thoughts as fully, clearly, and interestingly as they desire. When there has been time for reflection nearly every speaker feels how much more clever and convincing his remarks would be if he had the chance to speak again on the same subject. It is suggested that after each Conference meeting is over, every extempore speaker should carefully revise the secretary’s report of what he has said. The revision should then be submitted to the author of the leading paper, particularly if anything new has been added, so that he may reply to it if necessary, and everything will then be before him so that he can adequately sum up the discussion.

The whole can then be printed in the J o u r n a l . T his is the usual procedure. It is much better than our present plan, which encumbers the minutes of the meetings with fragmentary reports of discussions without the papers, while the principal papers are printed elsewhere without the notes of the discussion. The China Medical Missionary Association con- The Executive sists of medical missionaries in China and other Committee. parts of the Far East, and of Christiau physicians working in sympathy with them. Its affairs are all dealt with at its conferences, at which every active member is entitled to vote, so that not a single medical missionary interest is without its representative. An Executive Committee is elected to carry out the directions of the Association and to act for it in the intervals between conferences in matters requiring immediate attention. It has little or no independent, initiative power. Until the last conference the committee generally consisted of ten members. As Shanghai is the great business centre of China, nearly all missionary societies having their business head-quarters there, and as much of the business of the Association must necessarily be transacted in this centre, it was customary to elect the majority of the committee from among members of the Associa­ tion stationed in Shanghai or within easy distance of it. Perhaps this was not an ideal arrangement but 011 the whole it worked very well. The members of the committee were able to meet together frequently and without much expense ; questions were threshed out in oral discussion, a far more effective method than by long and wearisome correspondence, and it was possible for the committee to act promptly and uuitedly in emergencies. At the Conference 54 The China Medical Journal.

held in Canton, 1917, owing to regrettable misunderstandings the section of the Constitution of the Association relating to the formation of the Executive Committee was aftered. The number of members was increased to thirteen, with eight as a quorum, and they were to be chosen from all parts of China, a small sub-committee being appointed to attend to “ routine business,” and the whole committee was directed to meet at least twice annually. This scheme is full of difficulties. There are very few matters of business coming before the committee which do not deserve the careful attention of all its members ; but it can rarely meet as a whole as members cannot leave their stations whenever required just for this purpose only ; there is the inconvenience of travelling long distances, and the expense to the Association is considerable. During the three years since the last conference only two or three such meetings have been called and at one of these there was no quorum. In emergencies nothing can be done promptly and the transaction of ordinary business entails a mass of correspondence with limitless possibilities of misunderstandings and delays. Every­ where during the last few years experience has proven that much more and better work is done by conversations between a compact body of men, than by correspondence between members of a large and scattered organization. There is no good precedent for the organization of a large C. M. M. A. Executive Committee, the members of which are separated by vast distances, and certainly the scheme does not work well.

In the “ Correspondence” on another page there is an Autopsies important letter from Dr. Korns, of Peking, relating to in China, the post-mortem examination or dissection of the bodies of Chinese patients. According to the original regulation, if any Chinese were willing for the benefit of science to offer their bodies for dissection and left word to that effect before death, autopsies could be performed without further permission. It is now necessary to obtain the consent of the family as well, and of the local authorities. A translation of the regulation as it now stands is as follows : “ If any are willing for the benefit of science to offer their bodies for dissection and leave word to that effect before death, they may do so, but the family must inform the local Editorial. 55 authorities and obtain their permission before the body is sent to the doctor' or doctors. After dissection the whole body must be sewed up and returned to his or her family.” It should be clearly understood that the regulation applies to post-mortem examination and to dissection. The matter will be discussed at the forthcoming Conference and it is hoped that the Government may be persuaded to modify the regulation so that it shall not be a serious obstacle to pathological investigation and the training of medical students.

T h e following resolutions, proposed by Dr. Lennox Conference and seconded by Dr. Korns, have been sent to Resolutions. the Executive Committee for presentation to the Conference.

W h î r b a s , The health of the individual missionary and his family is essential to the success of the missionary enterprise ; and

W h e r e a s , The war has demonstrated the possibility of greatly reducing disease among the forces in the field through the use of modern methods of prevention and cure ; and

W h e r e a s, Preventable sickness and death constitute a continuing drain on the Christian forces in China ; therefore Resolved, That the China Medical Missionary Association should, and hereby does, call the attention of the missionary boards doing work in China to the need of an energetic, comprehensive, cooperative program, looking toward the physical well-being of the workers in the field. Among other items, such a program should include : First, the tabulation by the boards of their health statistics for the past, and where the records are inadequate, the installation of a system of vital book-keeping by means of which they and the doctors on the field may be in possession of the basic facts necessary for intelligent action. Second, a thorough physical examination of candidates, with a greater degree of cooperation between examining physicians at home and physicians on the field. Third, the more complete instruction of missionaries in the best means of guarding against disease in the section of the country in which they are to work. Fourth, the securing for the missionaries of all the up-to-date means for the prevention of disease, such as regular vaccination against typhoid, paratyphoid, and small-pox, proper housing, screening, etc. Resolved, That the China Medical Missionary Association offers its support in the planning and in the execution of any such forward-looking program.

The following resolution, proposed by Dr. Houghton, of Peking, and duly seconded, has also been sent in :

Resolved, That the Executive Committee of the China Medical Missionary Association be authorized to adopt and recommend for use in mission hospitals a uniform system of accounting and recording. 56 The China Medical Journal.

A c o r d i a l invitation is given to the delegates Invitation to attending the Conference to visit Tsinanfu, either Conference on their way to or from the Conference, for the Delegates. purpose of seeing the Medical School, Hospital, and other institutions of the Shantung Christian University in that city. Word should be sent to Dr. Balme by those intending to accept the invitation of the day of their probable arrival and departure, so that the necessary arrangements may be made for their accommodation.

PRELIMINARY PROGRAMME

CHINA MEDICAL MISSIONARY ASSOCIATION CONFERENCE

Peking, February 2 X-28f 1920.

Summary.

Devotional meetings ...... 9.00 to 9.15 a.m., daily Business sessions ...... 11.30a.m. to 12.00 m., daily

M o r n in g S e s s io n s : 9.15.11.30 a.m. The Problems o f the Mission Hospital, a Symposium. Monday, February 23 A general survey The city hospital The up-country hospital Hospital accounting Cooperative supply organization T uesd ay February 24 Discussion of papers oj previous morning. Records and statistics Training of assistants Training of nurses Follow-up work Wednesday, February 25 Discussion of papers of previous morning. The irreducible minimum The Health of Missionaries. Thursday, February 26 The surgical treatment of empyema Surgical experie7ices in a base hospital Studies in the diet of the Koreans Studies in the diet of the Chinese F r id a y , February 27 Business session. Preliminary Programme. 5 7

A f t e r n o o n S e c t io n a l C o n f e r e n c e s : 5 to 6.30 p.m. Surgical-. Including orthopedics, gynecology and obstetrics, pathology. M e d ic a l: Including laboratory and X-ray, pathology; venereal; parasitology. Eye, Ear, Nose, Throat'. Anatomy and Anthropology : On Friday, from 5 to 6.30, Hospital evangelism, a survey.

E v e n i n g Jo in t S ession s w it h N a t io n a l M e d ic a l A ssociation :

Saturday, February 21. Reception Monday, February 23. Anthropology . Dr. Ales Hrdlicka, Washington, D. C. Tuesday, February 24. Public Health Education, illus. Wednesday, February 25. Medical Education : Pre-medical standards Thursday, February 26. Narcotics. A campaign against the hookworm. Each day, Monday to Friday , Sight-seeing from 1.30 to 4.30 p.m. Tea 4.30 to 5.00 p.m. Conference Sermon February 22, at 5.30 p.m. in Union Church. Rev. E. C. Lobenstine Daily Devotional meetings, led by Rev. J. Leighton Stuart .. 9.00 to 9.15 a.m. Daily Business sessions...... 11.30 a.m. to 12 m.

Full Programme.

G e n e r a l S essions : Mornings 9.15 to 11.30 daily The Problems o f the Mission Hospital, a Symposium. Monday, February 23 A general survey Harold Balme The city hospital ...... John A. Snell The up-country hospital ...... Allen C. Hutcheson .Hospital accounting ... Henry S. Houghton Cooperative supply organization ...... Robert C. Beebe Tuesday, February 24 Discussion of papers of previous morning. Records and statistics...... A. S. Crawford Training of assistants ... George Hadden Training of nurses ...... Miss Niua D. Gage Follow-up work Charles Lewis Wednesday, February 25 Discussion of papers of previous morning. The irreducible miuimum The Health of Missionaries ...... W. G. Lennox Thursday, February 26 The surgical treatment o f empyema ...... A. I. Ludlow Surgical experiences in a base hospital ...... James L. Maxwell Studies in the diet o f the Koreans ...... J. D. Van Buskirk Studies in the diet of the Chinese ...... B. E. Read, S. D. Wil­ son, Peter Kiaug Friday, February 27 Business Session. Friday afternoon 5-6.30: Hospital Evangelism, a survey. Devotional evangelism ...... D. M. Gibson Educational evangelism ...... Sidney Peill 5 8 The China Medical Journal.

Jo in t S essions w it h N a t io n a l M e d ic a l association : 8.45 p.m. S atu rd ay, February 21 Reception to delegates by Peking Branch of C, M. M. A. in Administration Building, Peking Union Medical College, 5 San Tiao Hutung. 9.00 p.m. Monday, February 23 Anthropology of Asiatic Peoples Address by ...... Ales Hrdlicka, Curator of Division of Physical Anthropology of the United States National Museum, Washington, D. C. Tuesday, February 24 Public Health Education. Illustrated by motion p ic tu r e s ...... W. W. Peter Report of Council on Public Health and programme for the future ...... S. M. Woo Wednesday, February 25 Medical Education Report of Council on Medical Education...... H. Balme Report of Committee on Pre-medical Standards... W. Adolph Thursday, February 26 Narcotics...... Wu Lien Teh A campaign against the hookworm ...... F. C. Yen

S e c t io n a l S e s s i o n s : 5-6.30 p.tn,

Section on Surgery.

M onday, February 23. G e n e r a l Su r g e r y : Vesical calculus ...... J. Oscar Thomson Discussion, including The choice of operation D. M. Gibson The value of functional tests of renal efficiency in operations for vesical calculus. Harold Balme Treatment of empyema with Dakin’s solution J. B. B. Branch- Secondary suture of wounds E. W. Kirk Discussion of last two papers. Demonstration of blood grouping for transfusion J. Heng Liu Tuesday, February 24 Incidence of abdominal disease in Chinese ...... J. Heng Liu Discussion. Fistula-in-ano ...... W. E. Libby Discussion by Charles Lewis and others. Some practical points in the surgical treatment of cervical tumors...... Paul J. Todd The use of tuberculin in surgical tuberculosis,.. Thornton Stearns Discussion oj last two papers.

Wednesday, February 25. O r t h o p e d ic s : Fractures ...... J. C. McCracken The use of boiled beef bones as transplants in tuber­ culosis of the spine, and as internal splints in -reduction of fractures...... Way Sung New Discussion of last two papers. An X-ray plant for a small hospital ...... Paul C. Hodges Demonstration. Technique in the application of plaster of Paris bandage ...... Way Sung New Demonstration of surgical instruments and other hospital appliances. Preliminary Programme.

Thursday, February 26. Gyn eco lo g y : (Subject to be announced)...... J. Preston Maxwell Discussion. (Subject to be announced)...... Way lying New Discussion. Demonstration of surgical pathological specimens.

Sectio n a l Sessions : 5-6.30 p.m. Section on General Medicine. Monday, February 23 Syphilis of the central nervous system among the Chinese: incidence, report of cases, and treatment W. G. Lennox Discussion. Notes on cases illustrating the diagnosis, prognosis, and treatment of insanity in everyday Chinese p r a c tic e ...... R. M. Ross Discussion. Tuesday, February 24 Chemical constituents of Chinese urines ...... B. E. Read Wassermann statistics among Chinese ...... J. A. Snell Discussion. Parasites— demonstration...... E. S. Tyau A new parasite— demonstration...... E. C. Peake Discussion. Venous pressure apparatus— demonstration ...... P. S. Evans g Discussion. Wednesday, February 25 Present status of the tuberculin treatment of tuber­ culosis ...... W. H. Venable Out-patient treatment of tuberculosis...... J. A. Snell Discussion. Blastomycosis...... L. H. Braafladt Discussion. Tetanus neonatorum—-a study in prophylaxis...... John Kirk The problem of feeding the foreign baby in China ... H. B. Taylor Treatment of leprosy (by t i t l e ) ...... W. W. Cadbury Thursday, February 26 The management of the recent cholera epidemic in China, with special reference to H a r b in ...... Wu Lien Teh J. W. H. Chun Bubonic plague in Shan si...... P. T. Watson Discussion. The internist in the autopsy room ...... L. H. Braafladt Discussion. The dangers from unhealthy servan ts...... J. C. McCracken E. S. Tyau The etiology of poliomyelitis (by title)...... E. T. H. Tse*

Se c t io n a l Sessions : 5-6.30 p.m. Section on Eye, Ear, Nose, Throat.

Monday, February 23. E a r , N o se, T h r o a t : Mimeographic demonstrations; common operations on nose, throat, and ear ...... A. M. Dunlap Tuesday, February 24 Operative clinic, ear, nose and t h r o a t ...... A. M. Dunlap 6 o The Chifia Medical Journal.

W ednesday, February 25. Eye: Some uotes on ophthalmic practice J.*B. Neal' Practical considerations in refractions...... T." M. Li ‘ Observations on retinal detachment ...... D. V. Smith The Blind Sorrow of China ...... G. Montagu Harston Two cases of paresis of the superior rectus with tenotomy of the inferior oblique ...... H. J. Howard T hu rsda y, February 26 Comparative anatomy of the e y e ...... Davidson Black (To be announced) ...... F. W. Goddard Intracapsular operations for cataracts (two papers) ... H. J. Howard

S e c t io n a l S ession s : 5-6.30 p.m.

Section on Anatomy and Anthropology. Monday, February 23 The attitude of the Chinese Government toward dissection ...... S. P. Chen, official re­ presentative of the Board of the Interior Paneth c e l l s ...... E. H. Tang, Director, Government Medical School, Peking Problems of anthropology in the Far East ...... A. HrdliEka, United States National Museum, Washington, D. C. {Title to be announced) ...... Michio Inouye, Tokyo Imperial University, Tokyo Programme of the Wistar Institute for the advance­ ment of anatomical and biological sciences in the Orient ...... Representative of the Wistar Institute Business meeting. Tuesday, February 24. Demonstrations, 2 p.m. (а) Preparations of mitochondria in the somatic cells of Ascaris...... Shun Ichi Ono, Tokyo (б) Preparations illustrating the effect of starvation and nutrition upon cytoplasmic constituents S. I. Ono ( c ) A demonstration of preparations suggesting a possible origin of mitochondria in plant cells ... N. H. Cowdry, Peking (d) Microscopical preparations of the interstitial cells of Sebright testes ...... Alice Boring, Peking Union Medical College, Peking (e) A demonstration of the behaviour of mitochondria in bone marrow cells by supra-vital staining with Janus green ...... E. V. Cowdry (/) Methods of anthropom etry...... Davidson Black,Peking Union Medical College Tuesday, February 24. 5 p.m. A review of Chinese anatomy from the period of Huang Ti (Yellow Emperor, 2697 BC) to the Tang Dynasty. Illustrated...... E. T. Hsieh, Peking Union Medical College The comparative anatomy of the mastoid process ... A. M. Dunlap Cytological reinvestigations on the somatic cells of Ascaris, with special reference to mitochondria (with a demonstration) ...... S. I. Ono Preliminary Programme. 6r

The efiect of starvation and nutrition upon cytoplas­ mic constituents (with demonstration) ...... S. I. Ono Stone implements of neolithic type in China. (Illus­ trated) ...... j. G. Anderssen, Geo­ logical Survey of China, Peking Development of the vitreous humor in the lmman eye. (Illustrated) ...... Harvey J. Howard Wednesday, February 25 The secretion of bile and of urine in the camel ... B. E. Read, Peking Union Medical College Remarks on the anatomy of the biliary system of the camel ...... Davidson Black Head flattening ...... E. T. C. Werner, H. B. M. Consul, Foochow, (retired) The endocranial anatomy of O r e o d o n ...... Davidson Black A study of the differentiation of blood cells in the bone marrow with the aid of Janus green and other supravital d y e s ...... E. V. Cowdry The effect of radium on cell division ...... Charles Packard, Pe­ king Union Medical College Thursday, February 26 Cytological studies on the interstitial cells in Sebright testes (with demonstration)...... Alice M. Boring Anthropological studies on the lower extremities of C h in e s e ...... KotaroShiino.Mukden,. South Manchuria Railway Medical School Some growth changes in the walls of the thorax in the human fetus ...... C. K. Roys Business meeting.

Entertainment. Saturday, February 21. Reception to delegates, 5 San Tiao Hutung, 9 p.m. Sight-seeing Excursions. Monday, February 23 Escort Museum ...... Dr. George T. Candlin- Market and cloisonné shops ...... Medical students Government Isolation H o s p ita l...... Dr. S. P. Chen Tuesday, February 24 Temple of Heaven ...... Rev. Liu Fang Embroidery and lantern s h o p s ...... Mrs. J. H. Ingram Mrs. George Davis Government Medical College ...... Dr. C. C. Yen Wednesday, February 25 Lama and Confucian temples ...... Mr. C. L. Ogilvie Presbyterian Industrial work ...... Mr. W. H. Gleysteen Chinese Orphanage industrial school ...... Mr. J. S. Burgess Central Hospital ...... Dr. S. P. Chen

Thursday, February 26 Pei Hai and Coal Hill ...... Dr. S. D. Wilson City wall and Observatory...... Mr. Samuel M. Dean Model Prison...... ••• ••• Rev. Liu Fang 62 The China Medical Journal.

F rid a y , February 27 President Hsu’s reception (tentative) Afternoon Tea served at the Administration Building , 5 San Tiao Hutung, February 23 to 27, from 4.30 to 5.00 p.m. Hostesses Monday ...... Methodist Mission Tuesday Congregational Mission Wednesday Presbyterian Mission Thursday Anglican and London Missions Friday ... Union Medical College

Special a ll Day Excursions, Saturday, February 28, 1920. 1. Great Wall ...... Dr. J. Hua Liu, guide 2. Summer Palace (in the morning) ...... Mr. C. B. Malone,guide Tsinghua College (in the afternoon) ... President Y . C. Chang (Delegates invited to luncheon by the President) Zoological gardens on return trip. 3. Lung Fu Sze bazaar ...... Medical students, guides

MEETING OF EXECUTIVE COMMITTEE.

A meeting of the Executive Committee was held on November 14, 1919, the following members being present : Drs. Davenport, Beebe, Garner, Main, Merrins, and Morris. A letter was read which had been received from the Federation of Women’s Boards of Foreign Missions of North America, concerning the scheme to establish in Shanghai a Medical School for Women, the medium of instruction to be the English language. It asked, that three lady physicians should serve as special members of the Council on Medical Education to consider the questions involved. The committee decided to suggest to the Council the names of Dr. Ruth Massey, of Wuchang ; Dr. Agnes G. Murdoch of Hwaiyuan ; Dr. E. C. Fullerton, of Shanghai, to be the co-opted members and to act as delegates to the Women’s Conference to be held early next year. In view of the approaching Conference of the C. M. M. A., and the necessity of the Council on Medical Education being at its full strength, Dr. H. S. Houghton was appointed to fill the vacancy caused by Dr. Samuel Cochran having left for the U. S. on prolonged furlough, and in the absence of Dr. E. H. Hume, the chairman, Dr. Harold Balme, was appointed to report to the Conference on the work of the Council. A motion was carried that the National Medical Association of China be cordially invited to join the C. M. M. A., in its professional Meeting of Executive Committee. 6 3 meetings at the time of the Conference, and a similar invitation was extended to the executive officers of the various missionary societies in China. The following resolution was proposed and carried:

R esolved , That a letter be sent by the Executive Committee, as representatives of the China Medical Missionary Association, informing the China Medical Board of the Rockefeller Foundation that the abstracts of Japanese medical literature compiled by Dr. Ralph G. Mills and published in the China M edical Journal' have been of great value to medical men in all parts of the world and have formed a. prominent feature of the J o u r n a l ; that the discontinuance of the publication of these abstracts, owing to the appointment of Dr. Mills as Professor of Pathology 'in the Union Medical School, Peking, will therefore be a very great loss; and that as the medical enterprises of the Rockefeller Foundation in different countries have been, and are, of a varied kind, the Executive Committee of the C. M. M. A. appeals to the China Medical Board to make arrangements whereby this most useful'work may be resumed and continued on even a broader foundation than has hitherto been possible, as part of the good -work it is doing for medicine in China, and for the spread of medical knowledge due to Japanese research beyond the limited field to which at present it is confined. ' An appeal for the establishment in central China of a hospital for the insane and feeble-minded, which will help to meet a very urgent need and set an example both of humanitarian effort and of scientific excellence to the Chinese people, sent by the Kuling Branch of the C. M. M. A ., to those in charge of the Inter-Church World Movement, was presented to the Executive Committee for such action as it deemed necessary. The appeal is as follows : To the Inter-Church World Movement. Greetings : We, the members of the Kuling Medical Association assembled in Kuling, August 12, 1919, beg to bring before you some facts which are of vital importance to the best interests of missionary work in China. 1. There are enormous numbers of insane and feeble-minded in the country. We believe they are in far greater proportion to the population than in any Western country, as every city and village in China has some of these unfortunates wandering about the streets, and in countless homes there are individuals under lock and key. 2. The uneducated Chinese believe that insanity is produced by the powers o f evil spirits and demons, and for that reason many of the insane are treated most inhumanely. 3. In the whole of China there is only one asylum for the insane, and one ward iu another hospital. In all the vast stretches of the Yangtsze there is not one single institution for the insane. Therefore we beg that in your enumeration of the needs of the world you put institutions for the insane and feeble-minded in China among the first to be considered. We ask that one of these institutions shall be built in central China, and conducted in accordance with the best methods of modern psychiatry. Such an institution will not only take care of the insane but will be a center from which education of the Chinese in the humane treatment of the insane and feeble-minded can be promulgated. We believe this is one of the most important appeals which can come before you, and bespeak your most earnest and careful attention. 64 The China Medical Journal.

We have asked Mr. Bleecker Van Wagenen to be our representative in presenting this matter to you. We recognize his interest in the people of China,, and in this branch of service especially, and therefore are very glad to present this appeal through him. Respectfully yours,

(Signed) A il ie S. G a l e , M.D. For the Kuling Medical Association.

The Executive Committee heartily endorsed this appeal, and also approved the proposal to bring it before the Conference. Until such time as a Public Health Service shall be established in China it was decided to ask members of the C. M. M . A. to forward to

the Executive Secretary, for publication in the C h i n a M e d i c a l

Jo u r n a l , reports of epidemics occurring in their districts and other local matters of general medical interest; and the Executive Secretary was authorized to send specjal post-cards for this purpose to all mission hospitals. Correspondence with "the Programme Committee in Peking con­ cerning preparations for the Conference was considered and further arrangements made. Rev. E. C. Lobenstine, of the China Continuation Committee, Shanghai, was introduced and addressed the Committee in regard to plans that are under consideration looking to a united forward move­ ment of the Christian forces in China and of the desirability of all missionary societies and agencies cordially co-operating with it; and he further suggested that perhapsthe C. M. M. A., at its next Conference would not only approve the movement but also give to those in charge as much practical advice and assistance as it could. In reply the Committee assured Mr. Eobenstine that it would endeavor to have the subject laid before the Conference in accordance with his suggestions, and Dr. Davenport was asked to serve as the representative of the C. M. M. A. at the meeting to be held in December, to consider plans for co-operating with the Inter-Church World Movement.

Hints to W riters of Medical Papers. — “ Before you attempt to write on any subject be quite certain that you can say something fresh about it.” “ The subject chosen, facts must be collected, inferences formulated, and the whole presented with due proportion in its several parts, and in language as nervous and lucid as the author can command.” “ In scientific prose words should be used as carefully as symbols in mathematics.” “ Be patient and accurate.” “ Padding is mischievous as well as superfluous.” “ Slatternly writing may well be compared with careless and superficial laboratory methods.” “ The order of thought may be either the order of research or the order of exposition ; and under ordinary circumstances the latter is to be preferred.” ‘ ‘ First state your general conclusions, then give your cases, and your reader will be able to carry along with him the- clne.” “ How telling a place is the end of a paper for a weighty reflexion, or a summary view of the field.” The China Medical Board of the Rockefeller Foundation, 65

THE CHINA MEDICAL BOARD OF THE ROCKEFELLER FOUNDATION*

I11 December, 1918, Dr. Wallace Buttrick, who had been in charge of the home office of the China Medical Board sinee its organization in the fall of 1915, felt it necessary to resign this position, 011 account of the demands made upon his time by the General Education Board, of which he had lately become president. His place as General Director of the China Medical Board has been taken by Mr. George E* Vincent, president of the Rockefeller Foundation, who is assisted by Mr. E. R. Etnbree, formerly secretary of Yale University and now secretary both of the Rockefeller Foundation and of the China Medical Board. Doctor Buttrick continues, however, to take a deep interest in the China work, and as he is a member of the board of trustees, the organization still has the advantage of his counsel on all important matters. Mr. Roger S. Greene, the Resident Director in China, was in the United States for four months early in 1919, and upon his return to China in July, Mr. Vincent accompanied him, in order to familiarize himself to some extent with the actual conditions in the field. Mr. Vincent visited Seoul and Mukden on his way to Peking, and he was able to see something of the medical work in those places. He remained at Peking for about four weeks, giving especial attention during that time to the Peking Union Medical College, but visiting also most of the other important medical institutions in the vicinity. Special trips were made to Tientsin, Tsinaniu, and Paotingfu. Mr. Vincent and Mr. Greene then went south, visiting Changsha, Hankow, Kiukiang, Kuling, Anking, Wuhu, Nanking, and Shanghai. During their two weeks' stay at Shanghai, trips were made to Soochow, Hangchow, Kashing, Shaohsing, and Ningpo. From Shanghai Mr. Vincent went on alone to Manila, Hongkong, and Canton. After a fortnight in Japan he sailed for the United States 011 September 19, 1919- The experience gained duri.ng the first three years of the Board’s work, and the increased cost of all enterprises in China due to the exchange and the high prices of foreign materials and supplies, have made it seem necessary to restudy some of the policies which had been adopted at the outset. Particularly in the matter of aid to mission hospitals, it may not be possible to cooperate with such a large number of institutions as had at first been hoped. Whereas the need for additional doctors had seemed at first the most urgent, in cases in which a more nearly adequate staff has been provided, it has been found that other equally urgent needs develop, that is, in the matter 66 The China Medical Journal. of equipment and funds for current expenses, if the staff is to be utilized to the best advantage, and the attempt has been made to help meet some of these needs in the institutions to which the "Board was already in a sense committed, thus reducing the funds available for extension of the work. The future policy of the Board in this respect received special consideration at a meeting held in December, a full report of which has not yet reached China. The policy in regard to fellowships and scholarships will also probably be modified with the opening of graduate courses at the Peking Union Medical College. From now on Chinese graduate students will be sent abroad only in exceptional cases, and after demonstrating special ability in some particular department, during actual service in one of the institutions in China in which the Board is interested. A few scholarships for graduate students, sufficient to cover actual living expenses in China, are being offered this year by the Peking Union Medical College for periods of three months or more, and five appointments have been already made. It is thought that it will be possible in Peking to give such students more individual attention than they would be able to get in the United States ; and in the fundamental sciences, which most of them need to review in any case even if they are primarily interested in clinical work, good-facilities will be available in Peking this year. It is hoped also to emphasize hereafter the opportunities for graduate study at Peking for mission doctors, and an appropriation is being asked to cover the living expenses of those who wish to come to Peking for study, with some allowances for travel to those coming from a distance.

SHANGHAI MEDICAL SCHOOL.

War conditions prevented further progress with the Shanghai project during the past year. A t the December meeting a decision was to be reached in regard to the method of starting this enterprise. A grant was made for the support of one teacher on the staff of the Pennsylvania Medical School of St.. John’s University, and a payment of $1,200 was authorized as a scholarship for one science teacher who was to go to the United States for graduate study in preparation for teaching in the premedical department of that institution, this being part of a grant of $80,000 for building and maintenance, the remainder of which has since been formally voted. Appropriations have also beeu made to Ginling College of $2,400 Mex. per annum for five years for the support of a physics teacher and $5,000 gold for equipment. The China Medical Board of the Rockefeller Foundation. 67

SCHOLARSHIPS AND FELLOWSHIPS. Since June, 1918, grants amounting to $11,852.33 were made to ten Chinese doctors for postgraduate work in the United States, six of these grants being renewals. New grants for four undergraduate medical students, already in the United States, amounted to $5,005. Scholarships to six Chinese nurses came to $4,066. While the original appropriations included travel allowances, the increased cost of transportation made necessary an additional appropriation of $4,000 for this purpose, making the total amount authorized for the foreign study of Chinese doctors, medical students, and nurses $24,923.33 to June 30, 1919. Fellowships and grants-in-aid of various kinds were given during the same period to sixteen foreign doctors, all but one of whom were missionaries, to a total amount of $15,875.

AIDS TO HOSPITALS. The demands upon the Rockefeller Foundation for war work, the unfavorable exchange— affecting both the missionary societies and the China Medical Board— and the absence from the field of many mission doctors, contributed to lessen the work done towards the improving of mission hospitals during the past year. Appropriations for this purpose were made from June, 1918, to June, 1919, as follows : Southern Baptist Hospital, at Yangchow, $45,000 Mex. for build­ ings and equipment. American Presbyterian Hospital, at Changteh, Hunan, ati annual grant of $2,250 gold for maintenance. Northern Baptist Hospital, at Shaohsing, $1,050 gold towards the additional cost of an X-ray outfit. London Mission Hospital, at Tsangchow, Chihli, towards the support of a nurse. American Board Hospital, at Tehchow, $3,583.56 Mex. towards the cost of repairs and improvements made necessary by the floods of 1917 and an additional grant for the support of a business manager. Foreign Christian Missionary Society for improvements in buildings and equipment for the Luchowfu Hospital, $25,500 Mex.; an annual grant of $4,500 Mex. for maintenance; and contributions to the support of a nurse and a secretary. American Episcopal Mission, at Auking, $6,000 Mex. towards a doctor’s residence. American Methodist Mission, at Kiukiang, for the support of a Chinese nurse returned from the United States, and to the same mission 68 The China Medical Journal.

for the Wuhu Hospital, $40,000 gold towards a new building and $7,250 per-anuum for increased maintenance expenses, including salaries of additional personnel. This appropriation was made condi­ tional upon the contribution of an equal amount by the mission over and above its previous budget. It is likely that in the future the China Medical Board will make most of its grants on this basis, that is, upon condition that the missionary society concerned assumes at least one half of the total cost of the proposed additions or improve­ ments. -Southern Methodist Mission, at Soocliow, $50,000 Mex. towards a total of $192,000 M ex., the balance to be raised by the mission, for a new hospital building and equipment, and also the support of one doctor and two nurses, upon condition that the mission provide in addition two doctors and two nurses. An appropriation of $144,115 was made to cover loss by exchange on those grants to mission hospitals on which a rate of two for one had been guaranteed, and $50,000 additional was voted to cover similar losses 011 grants to the Shantung Christian Universit)*-.

GREAT BRITAIN AND THE OPIUM TRAFFIC IN CHINA,

At the Conference of the British Chambers of Commerce held in Shanghai during November, 1919, the following resolution was passed unanimously : “ That this Conference of British Chambers of Commerce assem­ bled at Shanghai is convinced of the necessity for immediate action by the British Government with regard to the opium and drug traffic, and that in the best interests of Great Britain’s prestige and of her commerce in the Far East the Government should give immediate effect to the various measures which the International Opium Convention agreed to in 1912 at The Hague Conference in respect to ‘ raw opium,’ ‘ prepared opium,’ medicinal opium, morphine, cocaine, etc., without waiting for ratification by other countries, and would especially urge the British Government to control the production of such habit-forming drugs and to limit their production to the amount required for legitimate medical use, and to limit their export to such countries as have established laws- and regulations which .effectively control the traffic in these drugs and restrict their use to legitimate purposes only.” . . . . . Great Britain and the Opium Jraffic in China. 69

A t the closing session of the Conference, Sir John Jordan, British Minister to Peking, referred as follows to the trade in opium and morphine in China :— “ There was one point which I did not know was going to come before the Conference, but I am very glad that it did. I mean the resolution moved by Mr. Mayers with regard to opium. I feel very deeply on that question. Mr. Mayers also spoke of the trade in morphine. The facts are not, I believe, fully known at the present moment, and I would ask this Conference and the public to suspend judgment until we have fuller details from home. My impression is that the export of morphine from the United Kingdom has beeu stopped from 1917 and I suggest that you should leave it an open question. The facts as to whether or not morphine is now coming to China as it formerly was will soon be known. I have written home asking for full particulars. “ The resolution also deals with opium. Now I think I may say without hesitation that the British Government has done its part, and done it well, as regards opium. For twelve years we worked in close co-operation with the Chinese Government. Under the Manchu Dynasty the officials worked well and whole provinces which had beeu ablaze with poppy were cleared in a few years. The Indian Govern­ ment made a sacrifice of millions of pounds, and did everything in its power to put an end to the opium traffic. We on our part did all that could be done and the traffic stoppedjentirely. “ What is the result? I say it publicly, the Chinese at the present moment are cultivating opium in a great number of provinces and are doing so with the connivance of the officials. Opium is coming down the Yangtze ; every steamer which comes down brings opium. Customs officials do try to seize it, but such efforts must be useless so long as the whole population connives in the traffic. The same applies to the West River at Canton, where a great many of the officials are engaged in smuggling operations. I am very glad that Mr. Mayers moved this resolution. “ The British Government has clean hands. Whatever our past record may or may not have been, China cannot now say that we have not done our duty fully with regard to opium. China is not, however, doing her duty, and I think that you can hardly imagine the Chinese people will be content to have it said that they instituted this great reform ten years ago merely in order to stop the Indian traffic that they might substitute for it the traffic in Chinese-grown opium. That is really what it amounts to now; at the present moment native opiutp 70 The China Medical Journal,

has taken the place of Indian. I agree with Mr. Mayers that the more publicity given to this matter the better. There are provinces in China which are simply cultivating opium for revenue. For example, Shensi. The Chinese Government informed me that the Governor of Shensi had reported that province as free from opium. It is not free. Opium is being cultivated there in every part of the province and the Governor of Shansi, the adjoining province, told me the other day that he spent a considerable portion of his revenue in trying to keep Shensi opium out of his territory. I say the more publicity the better.”

THE HEALTH OF MISSIONARIES IN KOREA.

In a long and instructive article by J. D. Van Buskirk, M.D., on “ The Climate of Korea and its Probable Effect on Human Efficiency,” which appeared in the Trans. of Korea Branch of Royal Asiatic Society, Vol. x, 1919, and has been reprinted as a separate pamphlet, he refers as follows to the health of missionaries in Korea. “ It is undoubtedly true that there are many breakdowns in health among the foreigners in Korea. I can not verify the accuracy of the statement, but a world-famed student of missions is quoted as saying that there are more breakdowns and more ill-health among the mission­ aries in Korea than in any mission field outside Central Africa and such places. Even if this is exaggerated it signifies a serious condition. W hy should it be so ? ‘ ‘ The weather in Korea is unquestionably fine ; most of us boast of the fine climate, usually with a reservation in regard to the rainy season. But I am inclined to think the rainy season a blessing in disguise for us westerners, the clouds protecting us from the intense heat and light. We boast of the climate, and yet send many invalids home. Is it not because we consider the climatic conditions so fine that we try to keep up the same rate of work we maintained in the homeland ? The climate lacks the stimulus of storms and weather and electricity and ozone, and is depressing in its constant temperature and high humidity in summer with too much sunshine for blond races. Maintaining the homeland rate of energy consumption depletes the reserve forces, and either there must be slacking of work or exhaustion. Ambition to do good work in a land of great things in missionary lines, the pressure of duties that results from the successful work with too few workers,— these lead the worker to overtax his reserve. Even when a period of rest is taken, the lack of stimulus causes slower and lesi Public Health Education in China. 71 complete recuperation. The result is that, as a whole, the Occidentals in Korea look worn ; newcomers and those returning from furlough notice this, but they also soon join the ranks of the ‘ weary-looking.’ “ The obvious conclusion from this is that we need to realize we are not in so fine a climate, not so good for energy stimulation, and to be content to lead less of the ‘ strenuous life ’ ; to put down the conscience that tries to drive us on when the flesh is rebelling; to realize that it is not necessarily a sign of laziness that we are less inclined to exertion ; and to lead a wholesome life of good hard work with rest and recreation, too. Work as we may, there will be things undone, and if we do not use our powers wisely there may be still more than there ought to be undone when we are worn out or broken down. We need to heed the voice of the weary body, when it tries to warn us to conserve what is given us, and to let well-filled years of work be our portion instead of a short period and then be worn out. Not many of us are in danger of 4 rusting out,’ and don’t let us hasten the ' burn­ ing out.’ This means less strenuosity in the day’s work, taking time for ‘ sleep that knits up the ravel’d sleave of care,’ and taking real vacations and having recreations throughout the year. There may be time when a set of tennis or a mountain climb is as religious and as much to the glory of God as attending a prayer meeting. But don’t let us neglect the latter in its time. And Mission Boards should not send workers to Korea thinking this a good place for a person short on reserve energy. Korea is not a health resort for workers.”

AIMS OF THE JOINT COUNCIL ON PUBLIC HEALTH EDUCATION IN CHINA.

Dr. S. M. Woo, M.D., D.P.H., Shanghai. Undoubtedly there exists a general desire among the Chinese for education in all matters pertaining to the public health. Students are eager to go out and lecture on health topics to the neighbouring peasants. Recently the Christian Educational Association reported our activities at their annual meeting and passed a resolution express­ ing- a desire to work with the Joint Council. The Commercial Press is eager for literature on the subject for which it pays handsome royalties, showing that there is a good demand for it. The Sunday School Union and almost all benevolent associations are keenly interested. Even the British-American Tobacco Company is buying a 72 The China Medical Journal,

complete health outfit from us to be put at the disposal of Canton missionaries. In a word, the demand for health education is great. Not all the people interested, however, want large health cam­ paigns to be conducted by us. What most of them do want is the meaus for enabling them to carry on small campaigns themselves. The reasons are two: ( i ) most of them really cannot afford to finance a big health campaign; (2) they like to be doing something themselves. How to help these well-meaning enthusiasts to do this work in the most efficient manner is our first problem. If we do this well we can multiply our work a thousand fold. To answer this great demaud efficiently, we must aim at the following points : —

1. S tandardization : Iti previous campaigns there was no proper standardization of our exhibits, lectures, and other procedures, and much time had to be sacrificed in order to prevent confusion. When I arrived at Amoy for conducting a health campaign I found the city unprepared and the exhibits in poor order. It took 11s ten days to help the local people to organize and conduct some sort of publicity work, and two days were required to arrange the exhibits in good topical order. W hat we ought to do is to standardize our exhibits in units, each properly numbered, labelled, and packed, in one separate box. A collection of such units will form the large exhibits, while the single units may be sold or rented to those conducting small campaigns. Explanations of the exhibits should be properly worked out in printed form. A few essential data regarding the Joint Council, its history, its personnel, and our terms for holding a campaign should be worked up as far as possible and printed, ready to be sent to interested inquirers.

2. F o l lo w -up W o r k : Enthusiasm for a health campaign cools down as rapidly as it is roused, so that without further guidance and follow-up.work a health campaign is but a passing show. If, however, we train up a few workers, and sell or rent to them our well standard­ ized lecture materials, we may expect more genuine and permanent results.

3. P u b l ic it y : That publicity work is important there can be no doubt. We must therefore have systematic publicity work if we are to get the support of the people; for, when people hear nothing about any work, they think that nothing has been done. My first five hundred copies of “ Sanitation of a Chinese City” remained on the shelf for months, because I did not advertise. Some publicity work was done and 140,000 copies were disposed of. What further proof is necessary Public Health Education in China. 73

to show the importance of publicity? What must we do? Well, we must flood the newspapers with health material from our Joint Council. We must put many important people 011 our mailing list and send them all our bulletins. We must keep in sympathetic touch with the friends of the Joint Council, so that their hearts may not be chilled by silence, •which they often take for coldness, indifference, laziness and what not, and they are sometimes right. This will cost money but, I dare say, the fruit will be thirty fold, sixty fold, one hundred fold.

4. R e n d e r in g P r a c t ic a l S e r v i c e : To render ingratiating service to important institutions and individuals is the most effective way of getting their support. A prominent merchant in Shanghai was helped in some practical manner and his sympathy was won. So with a certain university and a number of other cases. What does this mean? It means that in order to get the support of the Y. M. C. A., also schools and merchants, we must study how to be of definite service to them. We must demonstrate to the merchants that health does pay dividends, and teach them how to do it in a practical way. We must help the schools to solve their problem of school hygiene and mental hygiene. We must make it worth while for the Y. M.C.A. to help us.

5. Working for Quality: A word must be said regarding the importance of working for quality rather than speed and quantity. In fact, quality is bound to be followed by quantity, because of the subsequent large demand. Thus if we standardize a good lecture it will be used throughout the whole country for years. Moving picture companies must have understood this point very well through ex­ perience.

6. C oncentrating t h e E f f o r t on Schools : Now where shall we concentrate our efforts, on popular campaigns, work among students, or the training of those whom we may call health officers to do this work? Personally, I feel that the student population is by far the most hopeful material to work with. “ You can’t teach old dogs new tricks,” is a proverb quite applicable to the situation. My reasons for this belief were more than confirmed by the Amoy campaign. Iti the schools we are dealing with youths during their formative period. No educator^ thinks of concentrating his educational efforts on old people, because with them he cannot expect much success. No more can one succeed in educating society concerning public health principles if he does not concentrate his efforts on the plastic brains of the youths. Again, how much knowledge can educators expect a student to have on any subject, if the professor lectures to him once a year, skips 74 The China Medical Journal.

three 3>ears, and then gives him a second lesson ? And yet this is exactly what popular educators are doing. I do not mean to criticize popular education ; it has values of its own ; I am simply pointing out a better way. It takes systematic efforts to produce results. Further knowledge of health principles, to be of any value, must be acted upon. Students because of their youth, adaptability, and favorable school environment, may be successfully directed to form hygienic habits. Older people, who have already formed unhygienic habits, can change them only with difficulty, if at all ; besides, they usually resent interference ; and, as a rule, there is no adequate author­ ity to control their conduct towards themselves. What should be the program for our work among the students? Well, we may help the schools to prepare appropriate text-books on hygiene and standardize lectures and exhibits for them ; train volunteer lecturers and organize them for circuit lectures in the neighbourhood of the schools ; standardize forms for physical examinations; work out plans for school privies, water supplies, and give instruction regarding mental hygiene, etc.

7. L a r g e C a m p a ig n s n o t to b e N e g l e c t e d : But in doing all this we need not give up work among those who are not students. It is true that you cannot teach old people successfully, but as they hold the power and purse something must be done to rouse them up and get their money and moral support before they cool down. While a campaign does not finish efforts of this kind it is a good starter. As to the training of workers we can give a teacher’s course after each campaign. Besides, in a campaign we practically reach all the students.

8. I n c r e a s e P u blic H e a l t h L i t e r a t u r e : This is not to be neglected. It is really a powerful way of getting publicity for the work of our Joint Council. Imagine a million pamphlets going out through the length and breadth of China, with the Joint Council’s name conspicuously written on the covers ! Properly conducted, it will make considerable money for us also. Again, people can constantly refer to our publications and get help from them. Careful translations of good books, e.g., “ How' to L ive,” will help to uplift the popular conception of public health. Unfortunately, most people, who think at all, imagine that they know all about public health, that it is confined to such measures as street cleaning, removal of dead animals, and building comfort stations. W e must i.ry to make them feel that they know very little, and need to sit at the feet of specialists and learn marvellously interesting as well as valuable lessons. Only first class Public Health Education in China. 75 scientific knowledge presented in good language will do this. The Chinese have great respect for modern science. Let us show them that public hygiene and sanitation is a science, and that it should permeate all efforts to promote the welfare of the State.

SUMMARY. There is an increasing demand for health education, which is a challenge to be accepted and an opportunity not to be missed. From the standpoint of efficiency it is wise for us to teach and equip local educators in nation-wide health education. To do this we must train the local men and women, and standardize for them good sets of lectures, illustrated by charts, slides, and apparatus, and other necessary articles, all well explained by pamphlets. We may ourselves undertake campaigns to set the ball rolling, but we must make the local folks follow it up and keep it rolling. Schools form the most hopeful centres of our work. Merchants and other important classes must be actively helped and their assistance enlisted afterwards. Popular conceptions of public health must be uplifted by means of health literature which commands respect. To do this work at all adequately we need the following staff:— 1. The secretary, who will supervise the general work, formulate plans, make connections with the outside, and see to the financial needs. His is the work of organization and administration. 2. The associate secretary, guided by the secretary and assisted by a technical expert and full-time artist, will standardize lectures, charts, exhibits, slides and other equipment. 3. A well-trained Chinese physician with a fair command of the English language and good Chinese style should be employed to attend to health bulletins, systematic publicity and the less important cor­ respondence. 4. A lecturer to respond to minor invitations and thus utilize what has been standardized. 5. In order to do systematic work on publicity much clerical work is indispensable. For this reason a full-time stenographer and a Chinese writer must be secured. 6. A man for copying work, wrapping bulletins, etc. As to whether the aims of the Joint Council on Public Health Education can be realized, much depends on whether the public, particularly the medical profession, are interested sufficiently to keep up their support. 7 6 The China Medical Journal.

CHINESE VITAL STATISTICS: INFANT MORTALITY.

John A. S n e l l , A.B., M.D., Soocbow. A few years ago my attention was called to a statement made by a prominent authority that the infant mortality in China was 85%. I immediately challenged its accuracy, but as there were no reliable figures to prove or disprove any statement on the subject, I determined to make an effort to secure statistics of several thousand Chinese families with special reference to infant mortality. The method was not elaborate: 1 simply asked the parents how many living children there were in the family of one year and under, of two years, and of three aud over three years of age, and then the number of the children who had died and their age at time of death. After thus secur­ ing the records of 500 families I made a study of the records and con­ cluded that the information regarding the dead was so incomplete and unreliable it was better to discontinue this part of the inquiry. Most of this information was obtained by a pupil nurse. A certain number of the records were made by myself, and to me the ease with which the Chinese seemed to forget their dead children was very striking. Their memories had to be stirred up pretty sharply to secure the information desired. The page in the record book recorded by myself shows a much larger number of dead children than any other page in the entire record. According to my statistics, 55 children out of 125 died under three years of age. This gives a mortality of 44%. The following results of this study were secured. Total number of families ...... 500 Total number of children ...... 1,901 Average number of children to the family ...... 3.8 Of course many of these families had other children later.

NUMBER OF CHILDREN TO FAMILY.

No. of Children :...... 12345 6789 10 II 13 No. of Families:...... 84 80102 89 44 33 25 14 II II 5 2 Total number of living children :...... i >2 33 6 4 -8% 1 year old 53— 2.8% 2 „ „ 76— 4% 3 .. ,, 60— 3.1% ...... 9 -9 % Over 3 years old...... 1,044 5 4 .9% Total number of children who had died : 668 3 5 -1% Died 1st day or still-born ...... 63-3.3% ,, during the 1st month ...... 107— 5-7% „ » year of age ... 169— 8.9% 4, n 11 2nd ,, ,, ,, ... 83-4.4% 11 11 ji 3 rd ,, ,, ,t ... 60-3.1% 2 5 -3% after 3 years of age 186 9 -8 %

/ Chinese Vital Statistics; Infant Mortality. 77

Concerning the children still living of one, two, and three years of age respectively, the probability of death occurring before they reach the age of three years is as follows : 53 children, one year old, from 8.69% to 16.4%; 76 children, two years old, from 5-7%Jo 7.5%; 60 children three years old, from]i.86% to 3.1%. Thus sixteen (.8%) more of the living children will die before they pass the three-year mark. Add this to the 25.3% and we have a mortality of children under three years of age of 26.1%. But there is an error here. I should have taken the record for the fourth year because of the Chinese method of reckoning age. This would add approximately another 3%, or a total mortality of 29%. Another and the greatest error, in my opinion, is in the still-births and the deaths which occur on the first day. Contrast the figures here recorded with the similar statistics which Edgar gives of the State of New York, U. S. A., where the percentage of still-births is 8%, and 6% die during the first four weeks. Gross reports that 10% die within the first month. The Chinese rarely count the deaths at or near birth and must be asked particularly on that point. There can be little doubt that the reports of the number of deaths which occur oil the first day, giving a percentage of only 3.3%, are very erroneous, and the errors are due solely to the failure of the Chinese to report such deaths. Of these 500 families 179 (35.8%) had lost no children, and 15 (3%) had lost all their children. Of the 179 families which lost no children, 16 had 4 children each, 6 had 5 each, 3 had 6 each, and I had 7. Thus 26 families (5.2%) have more than the average number of children and all survive. Had this information been secured without error I am persuaded that it would show a mortality of over 40% of children under three full years of age. I believe it would not show over 50%, which varies considerably from the statement of a recent writer who asserts it is 85%. 40% is an exceeding^ high rate of mortality and a people cannot increase very rapidly with such an infant death rate. There are certain easily perventable factors which contribute to this high infant mortality and, if these were eliminated, the mortality rate would probably be very low. The lack of proper attention at birth accounts for a large percentage of deaths. Sheer neglect in the care of the baby by its mother, or by the relative who is given charge of it while the mother nurses another baby, is responsible for no small number of deaths. As to disease, syphilis accounts for a large percentage of infant deaths, and malaria and other common diseases all' take their toll. 7 8 The China Medical Journal.

3apanese HDefcical ^literature.

Review of Current Periodicals by the Staff of the Research Depart­ ment, Severance Union Medical College, Seoul, Korea.

R a l p h G. M i l l s , M.D., Director.

Taiwan Igakukai Zasshi (Journal of the Formosa Medical Society) No. 182. January 25, 1918.

( 547) Fluke, A nbw Species found in Crabs. Pp. 105-106. K. Nakagawa. The author, in association with Dr. Yohogawa, investigated the crabs of the mountains of Formosa iu connection with their researches on Paragotiimus tv ester manii. In these crabs they found small cysts chiefly in the liver. At first they thought that these cysts might be those of Paragotiimus westertnanii, but later these same cysts were found in crabs from the Ako district where pulmonary distomiasis is unknown. The author fed these crabs to four young cats and obtained a few adult flukes in one instance. This fact the author has referred to in the Tokyo Iji Shinji, No. 2035, August, 1917. Recently he repeated these experiments with bjjby cats fed only on their mother’s milk, ip order to eliminate the possibility tbpt the flukes found had come from other food. In these cats he found that at first the flukes were small and were situated deeply in the substance of the liver. This is probably the explanation of the failure to demonstrate these parasites in three out of the four cats used at first. He also fed a dog with these infected crabs and obtained large numbers of adult flukes in the liver and gall bladder. These adult flukes were oval in shape with the anterior end sharper than the posterior end. They measured about 2 mm. iu length and 1.3 mm. in width. "They were easily destroyed by slight pressure. The oral sucker was on the ventral side and measured about 1.4 mm. in diameter. The pharynx was well developed and the esophagus slightly longer than the pharynx. The intestine was long and straight, and divided at the ventral sucker into two branches which traversed each side of the body and ended blindly at the posterior end. The ventral sucker was slightly larger (0.16 mm. in diameter) than the oral sucker, and was located well anteriorly. The ovary was elliptical in shape, and placed slightly to the left and posterior to the ventral sucker. The uterus was long and convoluted. The genital pore was situated on the ventral surface posterior and to the right of the oral sucker. Near this was the seminal vesicle. The testes were large, oval in shape and located in the middle and slightly posterior to the center of the fluke. The vitellaria were well developed. The vitelline ducts ran along the dorsal part of the body on either side and ended iu a large ootype. The excretory pore was at the extreme posterior end. Over the entire surface of the body were long, slender dermal spines. The eggs were brownish-yellow in color, elliptical, and slightly pointed at the ends. They measured 0.045 mm. in length by 0.02 mm. in width. The author considers this is a new species of fluke, and suggests for it the name, Karopai distoma, from the locality where it is found.

(5 4 8 ) Exophthalmos in Fishes kept in Spring Watkr. - Pp. 263-275. C. Saito and R. Tanaka. The authors found that the water from certain springs in the Daichu district caused a peculiar disease in fishes, characterized chiefly by a marked exoph* Japanese Medical Literature. 79 thalmos, usually bilateral, but sometimes unilateral. The exophthalmos was caused by a gradual formation of air vesicles in the orbit. This disease occurred after the fish had lived in the running water for from 5-20 days. By placing the fish in river water, or in spring water which had been allowed to stand for several ■days, the disease could be made to disappear. Owing to the fact that it occurred only when the fish were placed in running water and not in stagnant spring water, the authors assumed that the cause of the disease might be a deficiency of oxygen or an excess of carbon dioxide in the water. They found by adding known quantities of oxygen to the water that the disease would not develop if sufficient oxygen was present, and furthermore that the degree of exophthalmos varied inversely with the amount of oxygen added, The addition of carbon dioxide to the oxygenated water did not produce the disease. They conclude, therefore, that the cause of the disease is a deficiency of oxygen in the water, and an autointoxication with carbon dioxide. The authors do not consider the water unfit for drinking purposes, since it is only toxic for fishes while it is running, and its toxic action apparently depends solely on a diminished content of oxygen. Moreover, the inhabitants of this region have been drinking this water for a long time with 110 apparent harm resulting.

( 549 ) Hookworm, Ascaris and Trichuris Infection Among the Inmates o f Taikoku Prison. Pp. 109-112. R. Ohns. In the Taikoku prison there were 300 political prisoners from the mountain villages of Oho and Dainau taken during the rebellion of 1913. More than half o f them had scabies, eczema, and oedema of the face and legs. All of them were undernourished. A large number of these prisoners had died with severe anaemia, cederna of the face and legs, and stomatitis with loosening of the leeth. At autopsy nothing was found to account for these symptoms except hookworm infection. On account of this finding the author made stool examinations of all these political prisoners, aud 90.3% of them were found to be infected with hookworm. An investigation was then made of the stools of the otlier prisoners numbering about i.ooo, of whom 97 were Japanese, and the rest Formosans. A small piece of stool was emulsified thoroughly in 100 mils of water end filtered through a piece of gauze. After the sediment had settled it was spread on a slide and examined microscopically for ova. Of the patients examined, 59% of the Formosans and 36.1% of the Japanese were found to harbor hookworms. Ascaris ova were found in 66.4% of the Formosans, and in 45.4% of the Japanese. The percentage of ascaris infection was relatively higher in women and children than in men. Trichuris ova were found in 66.1% of the Formosans, and in 67% of Japanese, with a relatively higher percentage in women aud children. In all, 92.6% of the Formosan prisoners and 88.6% of the Japanese were infected with at least one of these parasites, and 30.9% of the Formosans and 12% of the Japanese with all three. These figures show the great prevalence of hookworm, ascaris and trichuris infection among both Formosan aud Japanese prisoners.

(550) Coagulation of Blood. Action of Tissue Extracts upon. Pp. 119- 130. K. Uchihara. The author isolated a globulin from extracts of different organs, and found that it accelerated the clotting of blood. He also isolated a non-dialyzable albumin-like substance which hindered blood coagulation. This substance was always present in the same amount, while the amount of the globulin was variable. So The China Medical Journal.

(5 5 1 ) Hookworm Infection among'The Japanese Soldiers of Formosa* Pp. 107-10S. Z. Ikeda. The author examined the stools of 321 Japanese soldiers stationed at Taiiiatt for hookworm and other ova. He found hookworm ova present in 15.8%; oxyuris -vermicularis in 12.5%, and ascaris in 65.7%. Filaria (?) were found in 21% of the soldiers examined, The stool examinations were made with the microscope without any attempt at concentration of the ova, so that these percentages are probabh" too low. Other statistical studies of hookworm infection among the troops have yielded about, the same results,— 12.7% among the soldiers dispatched to North China in September 1912 ; 23% in the 9th division of the army in October, 1912; 18,4% in the 3rd division of the army. Among these soldiers the author has not found the constitutional .symptoms often associated with hookworm infection, such as anaemia, headaches tinnitus aurium, nausea, tach}7cardia, and fatigability.

(5 5 2 ) D i g e s t i v e F e r m e n t s i n F o r m o s a n F r u i t s . Pp. 159-164. K. Uchihara. The author has made a study of the ferments (especially diastase, trypsin, and pepsin) contained in the ordinary fruits grown in Formosa, with the idea of determining whether or not fruit juices aided digestion by means of their "ferments. For the tests he obtained the fruit juice by mashing the pulp (after removing the skin and seeds) through a cloth. He then neutralized the juice with sodium hydroxide and filtered it through dry filter paper. The diastase was determined by Wohlgemuth’s method ; the trypsin by the Gross-Field method ; and the pepsin by the Gross method. For the latter test the juice was not neutralized. Of thirteen fruits examined only three contained any appreciable quantity of diastase, namely the banana, the persimmon and the Pyrus cathayensis. Two other native fruits contained traces of diastase. Three fruits, the persimmon, the pineapple, and the Pyrus cathayensis contained trypsin. No pepsin could be demonstrated by the Gross method, although the juice of the pineapple, the persimmon, the banana, and the Pyrus cathayensis digested slightly small bits of hard-boiled white of egg. The juices of pineapple and of sour peaches were the most acid, while that of watermelons was the least acid. The author concludes that digestion may be aided by -eating these fruits for dessert, especially the Pyrus cathayensis and the persimmon.

Chu Gai Ifi Shimpo (Home and Foreign Medical News) No. 907. January 5, 1918.

(5 5 3 ) Carcinoma of the (Esophagus, its Relation to Chronic Alco­ h o li s m . Pp. 20-28. S. Yamagivo. The author has made a statistical study of cases of carcinoma of the oesophagus from which he concludes that chronic alcoholism and heredity are important factors in its causation.

Chu Gai Iji Shimpo (Home and Foreign Medical News) No. 908. January 20, 1918.

(5 5 4 ) Resistance of reh Corpuscles to the Hemolysin of Trimeresus AND AGISTRODEN AFTER EXCISION OF THE SPLEEN AND AFTER LIGATURE OF t h e s p l e n i c V E IN . Pp. 63-74. A. Fukushima. Trimeresus is a poisonous viper found in the Luchu Islands, Japan, and agisfroden is a viper found in Hokkaido, Japan, and in Korea. Hemolytic solutions were prepared from the toxines of these animals. The hemolysin of Japanese Medical Literature. 81

trimeresus was activated by lecithin. The author first determined the resistance o f red blood cells of healthy dogs to different dilutions of these hemolysins. He then removed the spleens of some of these dogs and ligated the splenic vein of others. At intervals after the operation he obtained blood from the animals, and again tested the resistance of the red blood cells to different dilutions of these hemolysins. He found that the resistance of the red blood cells of the splenectomized dogs to these hemolysins was increased on the third day following the splenectomy, and that this increase persisted for from 4-8 weeks. After this time their resistance t>ecame normal again, or slightly subnormal. On the other hand, the resistance of the red blood cells of the dogs whose «plenic veins were ligated became less than normal immediately following the operation ; it then rose gradually until after four weeks the resistance to these lemolysins was slightly greater than normal.

(5 5 5 ) Paragonimus westermanii, Infection, Treatment by Emetine Hydrochloride. Pp. 75-86. M. Kikuiko and H, Imamura. The.authors report favorable results in the treatment of pulmonary distomiasis by the subcutaneous or intravenous injection of emetine hydrochloride. The injections should be given daily and continued for five or six days after the disappearance of ova and blood in the sputum. Patients with long-standing disease are more prone to develop untoward symptoms due to the drug than are the e a r l y cases. These symptoms can be relieved by discontinuing the injections.

(5 5 6 ) Congenital SypHiLis, Fever in. Pp. 87-88. K. F u jii. This is a case report of a boy, aged eleven years, with a past history suggestive of congenital syphilis, and with a positive Wassermann reaction. For three weeks the patient had had fever ranging from 99.6® F. in the daytime up to 102.2* F. at night. After salvarsan treatment the fever subsided. According to the author, such fever in congenital syphilis has not hitherto been reported, although fever is not an uncommon accompaniment of acquired syphilis in the secondary stage. Ch« Gai Iji Shimpo (Home and Foreign Medical News) No. 910. February 20, ip/8.

(5 5 7 ) Piedra, Etiology and Treatm ent of. Pp. 190-196. K. T a k a k i. The author has isolated from three cases of piedra an organism which he considers to be the etiological agent of this disease. The patients were women from Aifu. On the hair were small, white, spherical or oval bodies about 1-3 mm. long and mm. wide. In cultivating the organisms the author obtained some of the infected hair, washed it with 7% alcohol, then with sterile water, and then soaked it for one minute in 1-1000 bichloride solution, washing it again with sterile water. It was then planted on agar slants and allowed to grow at body temperature and at room temperature. From both cultures an organism was obtained. This organism was subcultured on different media, and grew rapidly. On meat infusion peptone agar there appeared after 24 hours small, white, powdery colonies which after a few -days became yellowish-brown. In plain broth the colonies adhered to the wall of the tube, and there was no diffuse clouding of the medium. The addition of glucose or litmus to the agar favored the growth. No acid or gas was produced from glucose, and 110 indol was formed in peptone water. Microscopically, the mycelial threads measured from 2-5 microns in length, and were divided by septa from 6-25 microns apart. The ends of the mycelia were branched. The sporangia 82 The China Medical Journal* were spherical or oval, and on the second day reached a diameter of from 8-12 microns. The spores were small, refractile bodies staining readily with methylene blue. When uninfected hair was placed in a broth culture of this mould for seven days, and then transferred to a Petri dish and allowed to remain at room tempera­ ture, yellowish-white bodies developed on the hair similar to those found in the disease. This mould was killed by 5% carbolic acid in one minute, and 0.5% mercuric chloride solution in three minutes. For treatment of the disease the author suggests an ointment containing carbolic acid and salicylic acid, 10%.

(5 5 8 ) Filaria Embryos in the Blood, Influence of Oxygen and Carbon Dioxide ON. Pp. 196-202. S. Wayakawa. The peculiar fact that filaria embryos appear in the blood only at night and live in the lung during the daytime, has suggested to some the possibility that this phenomenon may be due to differences in the oxygen and carbon dioxide tension in the blood and lung. In order to determine the effect of oxygen and carbon dioxide upon the dura­ tion of life of the embryos, the author carried out the following experiments. Into each of six flasks containing filaria embryos he put 16 mils of blood to which had been added enough 2% sodium citrate solution to prevent clotting. He then passed oxygen through the blood in two of the flasks, and carbon dioxide through the blood of two flasks. The other two flasks served as controls. After the gases had been passed through the flasks one set was kept at body temperature and the other set was placed in the ice box. In both sets the duration of life of the embryos was shorter in the blood through which oxygen had been passed than in the blood containing carbon dioxide or than in the control blood. In all the specimens kept at ice-box temperature, the duration of life was very much longer than in the corresponding specimen kept at thermostat temperature. The embryos in the control blood flask and those in the flask containing carbon dioxide lived about three weeks in the ice box. To explain this prolongation of life at ice-box temperature the author assumes that the embryos hibernate at this temperature and do not use up the nutritive substance in the blood ; while at higher temperature their metabolism is more rapid and the food is quickly consumed. He has noticed that the embryos in the blood kept at body temperature are more active than those kept at ice-box temperature. The author explains the fact that the embryos live longer in the carbon dioxide blood than in the oxygen blood in the same way. He believes that they hibernate in the carbon dioxide blood, while in the oxygen blood they are more active and consume the nutritive substances more quickly. Kyoto Iji Eisei Shi (Kyoto Journal of Medicine and Sanitation) No. 286. January 25, 1918.

( 5 5 9 ) Syphilis of the internal Organs, Unusual Case o-p. Pp. 9-13. H . Natori. The patient, aged 29, suffered from disease which during life had been diagnosed as valvular disease of the heart with chronic nephritis. An enlarged liver, found ante mortem, was supposed to be due to chronic passive congestion and certain changes in the eye were ascribed to albuminuric retinitis. Death occurred during an apoplectiform attack. At autopsy the heart valves were found to be normal, but the myocardium was hypertrophied, and there was a fibrous myocarditis with plaques of connective Japanese Medical Literature. 8 3

tissue on the pericardium and endocardium. The thoracic and abdominal aorta was the seat of an extensive syphilitic mesaortitis, which, however, did not involve the coronary arteries. Both lobes of the liver contained large gummata. There was an extensive chronic nephritis. The caecum and the first part of the ileum contained syphilitic lesions. The fundus of the eyes showed the changes of a syphilitic retinitis. The terminal apoplexy could not be accounted for at autopsy. No hemorrhage or softening was demonstrable in the brain. It was thought that the symptoms may have been uremic, or may have been due to an undiscovered syphilitic focus in one of the cerebral arteries. Iji Shimbtin (Medical News) No. 990. January 25, 1918.

(5 60 ) Cervical Ribs. Pp. 86-90. K. Seki. The author reports a case of pleurisj* with effusion first on the left and then on the right side, due to bilateral cervical ribs. In the left supraclavicular fossa a bony tumor could be felt. On X-ray examination the transverse processes of the 7th cervical vertebra were seen to be well developed, and a small rib was articulated to each. The right rib was only about 1/3 the size of the left rib. The author also refers briefly to a second case.

(561) Korean and Canton Ginseng. Pp. 112. W . Sakai. Canton ginseng is the best quality of Chinese ginseng, and is about the same in quality as Korean ginseng. The so-called Canton ginseng sold in Japan comes mostly from Korea. The chief ingredients of ginseng are saponin, paraquillain, phytosterin ester, terpene, panacean, and fatty acids. The relative amounts of these substances depend upon the length of cultivation, the method of preparation, and the age of the drug. The Korean product is generally cultivated for six years until the roots are large and have a strong odor. The Chinese and Japanese products are picked after three or four years’ cultivation and, as a rule, are inferior in quality to the Korean drug. The efficacy of the drug is tested by selecting two men of equal physical strength and giving the drug to one of them. The men then run a race, and, if the one who took the drug wins, the ginseng is considered to be potent. Ginseng is said to stimulate respiration and circulation, and to have a sedative action on the nervous system. It is also supposed to have a diuretic action. It is used for insomnia, headache, seasickness, neurasthenia and hysteria. The dose is from four to eight grams a day. In sensitive individuals there may be hypersemia of the conjunctive, epistaxis, and slight dizziness.

Sei-i-kwai Keppo (Journal of the Sei Medical Association)

N o . 439. September 10, 1918.

(562) N asal Poly^p of unusual size. Pp. 382-383. K. Tominaga. The patient, a young man aged eighteen years, complained chiefly of an excessive secretion of mucus from the nose, gradual loss of smell, nasal obstruction on the left, and headache with impairment of memor}-. On examination the left nostril was filled with a pink, shiny, semi-translucent mass which was surrounded by gray mucus. After extirpation this polyp measured 10.2 cm. long and 2.8 cm. wide and weighed 27 gm. 84 The China Medical Journal.

flDefcical IReports of Chinese Customs Service*

Public Health of Ichang, I9t8-f9i9.

Andrew Graham, F. R. C. S., Customs Medical Officer.

METEOROLOGICAL REPORT. Compiled by Mr. G. E. Sberman, Customs Harbour Master. 1918 Thermometer B arom eter R a in fa ll H . L.H. L. Ins. H rs. October 87 56 30.250 29-750 -95 16# November 72 41 30.478 29.710 3-86 3 1 # December 58 27 30-540 29.800 2.04 70 1919 - January 60 28 30.684 29.660 •23 9 February 68 *9 30.520 29.670 •51 24 March 78 36 30.350 29-540 3*74 61 April 82 50 30.010 29.500 2.43 55 May 95 56 30.300 29.370 6.46 45 June 92 68 29.950 29.260 14.43 120=^ July 9 4 70 29.784 29.440 12.55 136^ August 102 69 29-844 29.438 6.23 32 x September 93 60 30.080 29-430 3-00 63K

MEDICAL REPORT.

E u r o p e a n C o m m u n i t y . There has been no serious sickness among the Europeans during the past year. The precautions taken to prevent disease, such as house screening from flies and mosquitoes, efficient sterilization of water and food supplies, have successfully prevented epidemic diseases which were common amongst the natives. Freedom from such diseases is doubtlessly partly due to the large airy compounds in which most of the foreign houses stand, and to the adequate dealing with sanitation and drainage of these compounds. Such cannot be said for many of the foreign houses recently built and occupied by Chinese, who seem to have no regard for such measures. The result is that stagnant pools of water lie all around what are otherwise good properties. As such houses are constantly being built in the foreign quarter of Ichang, some means of dealing with the question of drainage will soon become imperative. The formation of a joint Chinese and foreign Municipal Council would probably be sufficient to carry out such a scheme.

N a t i v e C o m m u n i t y . The diseases seen amongst the natives have not varied from those of former years, and are not in any way Medical Reports of Chinese Customs Service. 85

peculiar to this city or district. Tuberculosis in all its forms; syphilis in all its stages; diseases of the lungs, stomach, and skin are all very common. The ordinary varieties of anaemia are very common, and for this many causes are easily found. Malaria, syphilis, and hookworm disease are perhaps the commonest of these, but a good proportion of the patients seen from the country are simply suffering from inadequate diet. With regard to epidemic diseases, influenza, malaria, smallpox, and dysentery have been more or less prevalent during the year.

I n f l u e n z a . This was not so virulent here as in some parts of China, but there were numerous cases.

M a l a r i a . This disease has again been present in its malignant form, and the mortality has been very great, especially amongst country people and soldiers who were away from the means of appropriate treatment. Very commonly the disease was of the abdominal type, causing very severe dysenteric symptoms. Patients who came undef treatment in time usually responded to large doses of quinine, rather than to emetine. Nevertheless, there are cases of mixed infection where the amoeba is at work, and then only emetine clears up the case.

D y s e n t e r y . The usual epidemic of amoebic dysentery, so com­ monly seen here in the autumn, has not been so severe this year as formerly ; but it may be that the disease, in many cases, has been confused in the Chinese mind with malarial dysentery above noted. The bacillary type of dysentery is seldom seen here.

C h o l e r a . In the early part of the summer one case of cholera was seen, and at the time of writing this report several others have been attended to, and the disease is reported to be common in the city. The cases seen were of a very virulent type.

Public Health of Chinkiang» i 9 i8-19t9t

Gerald Bradshaw, M. D., Customs Medical Officer.

The public health of the port of Chinkiang, as far as foreign residents are concerned, has on the whole been very satisfactory during the period covered by this report. There have been no deaths during this time among foreign residents in Chinkiang. The summer was exceptionally mild with cool nights. Whilst the great bulk of my practice here is the usual Chinese hospital practice, the report refers, unless otherwise stated, to foreigners. 86 The China Medical Journal.

INFECTIVE DISEASES.

DIPHTHERIA. One case, which recovered. Many Chinese cases.

V a r i c e l l a . Three cases in the same family. Patients recovered after a somewhat delayed course.

P a r a t y p h o i d . Two cases, recovery. Several cases of the typhoid group seen and treated amongst Chinese.

D y s e n t e r y . T wo cases; one very severe. Both patients recovered.

C h o l e r a i c D i a r r h e a . One severe case with ricewater stools; the patient, a sailor, recovered. No cases amongst residents, and noue seen in my fairly extensive Chinese work.

S p r u e . One patient has developed this condition, and is leaving for home advisedly.

M a l a r i a . The cases seen presented nothing for special comment.

V e n e r e a l D is e a s e s . A fair amount of venereal disease was seen amongst patients (mostly non-resident) and Chinese. They were treated in the usual manner.

'D isea ses of t h e E a r , N o s e , a n d T h r o a t . Cases of chronic otitis media treated by inflation and air massage with corresponding improvement formed the bulk of my cases. Beyond a few cases of nasal polypi and laryngitis I have had nothing of special interest to record in this department of work.

D isea se s of t h e E y e . Patients with eye disease constituted the bulk of my Chinese clientele. All the ordinary conditions were seen repeatedly, and the necessary operations performed.

Su r g e r y . The usual general surgery was performed by me in my hospital during this period. Very little surgical work was required by foreigners during this time.

Post-mortem Cesarian 'Section. — Pfaff (A m e r . Journ. Obset., 1916, ii, 967) finds that out of 331 cases previous to 1900, only 6 or 7 living children were secured; but out of 52 ruore recent cases, the child was saved alive in 22, or 42 per cent. This writer sympathizes with the suggestion that in certain pregnant women at or near term who are known to be dying, the child should be delivered by Caesarian section without waiting for death. It is not legal to do a post­ mortem section without the consent of the relatives ; thus a medico-legal question arises. The l e x regia of Numa Pompilius, the second king of Rome, provided that all women dying at the end of pregnancy should be opened. A legal opinion recently given in New York was to the effect that the law would protect the medical man in cases of this kind. An old Austrian law makes post-mortem delivery compulsory in order that the child may be baptized. Medical Reports of Chinese Customs Service.

Pttblic Health of Tengyueh, Í9Í8-Í9Í9.

D r. C. W . Chose, Customs Medical Officer.

METEOROLOGICAL REPORT.

Month Maximum j Minimum Rainfall in inches 1918-1919. Temp. Mean. Temp. Mean. 1918-19 1917-18

September 80 75-00 57 61.50 IO.37 6.60 October 78 7 r-8 3 44 54-54 6.99 2.72 November 71 67.56 35 40.02 0.02 0-57 December 69 64.84 26 34-16 0.01 0.00 January, 1919 67 63-74 26 34-35 0.05 0.64 February 69 6 3.93 29 36.18 0.95 0.24 March 77 71.71 33 43-45 0.16 3-68 April 79 73.06 44 77-45 1.96 2.89 May 84 77-45 48 54-45 1.24 9-99 June 85 76.01 59 62.66 8.7 3 10.38 July 82 72.87 58 62.16 13.24 8.40 August 83 72.22 60 63.26 8.41 16.96 Total Rainfall 1 52.13 j 63.01

From the above table it will be seen that compared to the year 1917-18 the rainfall is less by eleven inches up to the end of August aud that the raias started rather later than usual.

P o p u l a t i o n . Estimated Chiuese population, 25,000.

m e d i c a l r e p o r t . The duties of Medical Officer to His Britannic Majesty’s Consulate and to the Chinese Customs at Tengyueh were taken over by me temporarily on June 16th, 1919, from Mr. Nihal Chand, of the Burma Medical Service, 011 his transfer to Burma where he has applied for six months’ leave. The general health of the people of this district was fair during the year. The most common causes of death among the population were malarial fever and its complications, diarrhoea, dysentery, tuberculosis of lungs, diseases of respiratory system, pneumonia, Bright’s disease. The prevailing diseases are malarial fever, diseases of the eye, skin, and of the digestive system, diarrhoea, dysentery, tuberculosis of lungs, venereal diseases, and ulcers.

M a l a r i a l F e v e r . This disease was prevalent all over the district during the rainy season. The few cases treated by me were of the benign aud malignant tertiau types. Most of the hamlets in the district are situated facing the paddy fields, where the anopheles 88 The China Medical Journal.

mosquitoes breed profusely iu the rainy season. This is the most common and natural source from which the inhabitants get infection. In the case of those who are weak and debilitated before infection the disease generally assumes the malignant tertian form and usually ends fatally.

D is e a s e s o f t h e E y e . Conjunctivitis and eczema of lids, are conditions due to the natural filthiness of the habits of the people, to- over-crowding, and to flies. Generally, the poorer classes are the worst sufferers. Unless the people can be taught to observe the ordinary rules of sanitation aud personal cleanliness it is hopeless to expect any diminution of these diseases.

D isea se s o f t h e S k i n . Scabies and ringworm were the most common skin diseases.

D isea se s of D ig e s t iv e S y s t e m . These include dyspepsia, diarrhoea, dysentery, and helminthiasis, usually contracted by eating unwholesome food aud fruits of different kinds which have been exposed to infection from flies.

T uberculosis o f L u n g s . In the absence of any attention to the rudiments.of hygiene no diminution in the incidence of this disease is to be hoped for.

D isea se s o f R e s p ir a t o r y Sy s t e m . The ravages of pneumonia are worst among the poor population owing to their insufficient clothing and low vitality.

V e n e r e a l D is e a s e s . A large number of cases of primary, secondary, and tertiary syphilis came for treatment. During my short tenure of office here I have treated nine persons with intravenous injections of “ Novarseuo Billon.”

L e p r o s y . Six patients with leprosy came to me for relief. They were all homeless beggars. I could not treat them with intravenous injections of sodium gynocardate on account of their uncertain stay.

E p id e m ic s . There was an outbreak of influenza in the middle of last October, which lasted for about six months. As no registration of deaths is kept in this province, I am unable to furnish the total number of deaths from this disease.

miscellaneous n o t e s . Since 1915 a hospital for the poor has been maintained by sub­ scriptions from a few Chinese officials and gentry. There are about fifteen beds provided for patients in one small building. During the rainy season these beds were not sufficient to accommodate the patients Medical and Surgical Progress— Internal Medicine. 89

who were at times placed two in a bed. They are mostly coolies aud others of the very pooresPclass of people. The medicines arefprepared by the medical officer who also attends the hospital gratuitously. On the whole, the working of this hospital for the poor was fair. In conclusion I am pleased to note that the foreigners resident in Tengyueh kept in fairly good health during the year under report.

flDefcical anfc Surgical progress.

internal flfteMcine.

T r e a t m e n t o f C h r o n ic P a r ­ and there are practically no signs enchymatous N e p h r i t i s .— In the of oedema. The urine has also con­ Indian Medical Gazette, August, tinued to improve, the albuminuria . 1919, McCay reports an interesting at the present time— 15/7/19— hav­ case of chronic parenchymatous ing become reduced to a mere trace. nephritis, in which a change of In a clinical lecture published in diet caused the patient’s recovery The Lancet, October 4, 1919, Sir when his condition seemed hopeless. James Galloway reports at length He presented a typical picture of a very similar case of a Chinese, renal disease : the face puffy and which improved in the same re­ pallid, and there w?as water-logging markable manner after a change to of the tissues and serous cavities. a more highly protein diet.' Despite a diet conMSting mainly of The treatment is based on sound carbohydrates, the restriction of the physiological principles. In health intake of salts and fluids, the use the fluid of the blood is replaced of diaphoretics, diuretics, hot-air by the fluid in the tissue spaces baths, dry cupping of the kidneys, according to two views, viz., saline purgatives, etc., the functions the backward filtration theory of of the kidneys steadily failed until Lauduer and the osmotic theory of there was almost complete suppres­ Starling. When the pressure in sion of urine and the patient was the capillaries falls below that in in extremis. the tissue spaces, the fluid passes A very high protein dietary, from the tissue spaces into the mostly composed of animal protein, capillaries by the backward filtra­ was now tried. The kidneys which tion process; 011 the other hand, heretofore were seemingly disor­ when the osmotic pressure exerted ganized and absolutely unable to by the colloids of the blood falls perform their ordinary functions, below its normal, the fluid from the then began to excrete water, nitro­ capillaries passes into the tissue genous bodies and salts, as if prac­ spaces. In normal conditions an tically no structural changes or equilibrium is maintained between pathological condition existed. these two processes. In chronic The patient continued to improve parenchymatous nephritis, as has in his general health ; he rapidly been pointed out by Kpsteiu, the gained strength and colour. The protein of the blood is very anaemia has now almost disappeared much reduced, hence the osmotic 9 0 The China Medical Journal.

tension falls and fluid passes out 118 men to 39 women), aud group­ into the tissue spaces, and will be ing the patients according to their retained there unless and until the ages brought out no difference in blood recovers its protein element. the prognosis for the various ages. The rational treatment, therefore, Of the remaining 16 % who sur­ is to increase the protein of the vived the two-year period, most blood, which is safely doue by were leading the restricted life of increasing the protein of the diet. the chronic invalid. In two-thirds The carbohydrate portion of the of all the cases there was evidence diet should be reduced, because one of renal sclerosis, but the mortality of the main products of its me­ was practically the same for the tabolism is water. In McCay's patients with or without renal case the carbohydrate could not be disease. The author criticizes the reduced to less than 132 grammes observations 011 this subject pub­ per day because the man was lished by Janeway in 1913, and brought up mainly on carbohydrate suggests that some fallacy must food and was very much upset when underlie his comparatively favour­ this element was reduced. The able prognosis for high blood protein wras increased up to 165 pressure. grammes per day and this raised the total nitrogen of his blood to 2.03 T h e E f f e c t s on t h e V isu a l per cent, which was quite enough A p p a r a t u s of L ong C o n t in u e d to turn the scale in his favour and D o s a g e w it h Q u i n i n e .— D rs. maintain the equilibrium between Jamieson and Lindsay, the authors the blood fluid and the fluid in the of a paper on this subject in the J l. tissue spaces. The patient could Roy. Army Med. Corps, 1919. xxxii, then take from 40 to 50 ounces pp. 295-301, were respectively of water a day, and pass the whole Medical Officer Malaria Section quantity out with his urine ; where­ and Ophthalmologist of the 4th as, before, almost every drop of London General Hospital. They fluid he took used to pass out into examined by methods which are the tissue spaces and collect there ; described 170 cases of chronic aud no measures— medicinal or malaria, under quinine treatment otherwise— could make that water for varying periods; of these 145 pass out of his body. had more quinine after admission to hospital and 25 had no more. B l o o d P r e s s u r e a n d P r o g ­ Details of the fields of these cases n o s i s .— V . Topp (Hospitalstidende, are given. Ophthalmoscopic exam­ June 4th, 1919) has investigated ination of the fundus of 106 of the subsequent fate of patients the cases showed perfectly normal admitted to hospital with heart fundi in 95. The colour vision disease aud a high blood pressure was normal in all and none of them in the period 1913-16 inclusive. showed any central scotoma or Of the 164 cases with a permanently central scotoma for colour ; two raised blood pressure— that is, over showed typical malarial retinitis. 180 mm.— there were 157 whose The authors write :— subsequent fate could be ascer­ “ Long continued treatment with tained. Within two years 84 per quinine apparently has some effect cent were dead. The mortality in contracting the fields of vision, for rate was directly proportional to twenty-two per cent of our cases the height of the blood pressure. showed medium fields, and thirteen The expectation of life was the per cent small fields. [Small fields same for the two sexes (there were are where the field is concentrically Medical and Surgical Progress— Surgery. g i

contracted to 200.] An improve­ normal as did those of the men who ment in the fields of vision of those were treated with single doses of who had no further quinine treat­ 60 grains.” ment was to be expected, but it is “ Our investigations lead us to surprising to find that under further believe that no one need be deterred quinine treatment forty-five per cent from giving moderate doses— 10 to should show an increase in the 15 grains three times a day— of any field of vision, and only eight per of the preparations of quinine we cent a decrease.” have used, by the fear of causing “ Our experimental cases are few permanent damage to the eyes. in number, but tend to show that Also that when the visual field is in normal healthy men, large doses found to be contracted, either imme­ up to 90 grains of quinine hydro­ diately 011 completion of a course of chloride daily for three days have quinine or during its progress, the not even a temporary effect 011 the prognosis is good, aud ultimate fields of vision. Their fundi aud expansion of the fields of vision fields of vision remained perfectly may be expected.”

Surgery.

M a l a r i a fr om t h e S u r g e o n ’s splenitis, on the pancreas an acute S t a n d p o i n t .— In an article on this hsemorrhagic pancreatitis, 011 the subject in The Lancet, July 26, liver a hepatitis, etc. 1919, Dr. M. White states that the The number of cases in which only type of malaria to be con­ malaria has proved to be the direct sidered from the surgeon’s stand­ cause of surgical ailments referable point is the subtertian or malignant to oue organ is comparatively small tertian. In the quartan type the aud with a very small mortality. Plasmodhim malarice goes through Malaria as a complication in sur­ the entire process of reproduction gical cases and malaria simulating in the circulating blood, and does certain diseases are far more com­ not especially accumulate in any­ mon, especially the first, where all one orgau or produce special effects. the symptoms may indicate some The tertian type, produced by the other illness, for instance, after a Plasmodium vivax, also goes gunshot wound of the head (aud through its life-cycle in the blood, this is frequent) the symptoms and although the tertian sporulat- may all point to a cerebral abscess, ing forms are found in the internal but under quinine therapy the organs, such as the spleen, they do urgent symptoms disappear and not tend to accumulate in these recovery is uninterrupted. organs or produce special effects. The third type, the subtertian or Pseudo-appendicitis. — The writer malignant tertian, caused by the has seen many cases of pseudo- sestivo-autumnal parasite, sporulates appendicitis due to malaria, which almost entirely in the internal cleared up rapidly under intramus­ organs, attacking any organ and cular quinine. If the diagnosis is producing symptoms peculiar to made, surgical interference is not the disease of that organ : on the necessary. “ The cause of the pain heart causing endocarditis or myo­ on the right side is, I believe, carditis, on the lung a pneumonia, a referred pain due to an acute on the spleen a splenitis aud peri­ spleuitis, which, in my own obser- 92 The China Medical Journal. vatious, has always been present, without a rigor. If I happen to although in some cases it may be see the patient at this stage, I give due to the localization of the para­ immediately quinine gr. 15, in­ site in the intestinal mucosa. tramuscularly.” “ I have had many cases of appen­ dicitis, both catarrhal and suppura­ conclusions . tive, iu malarial patients and the “ It is to be doubted whether any only point in the differential diag­ of us realize sufficiently what a nosis, as far as I have been able to protean disease malaria is, and the observe, is the white cell count. points to be emphasised are :— In both classes of cases all Mur­ phy’s symptom-complex are present 1. That an operation often brings except leucocytosis— i.e., pain, on an attack of malaria of a very vomiting, a little temperature, and severe nature, and an acute dilata­ rigidity of the right rectus. Iu tion of the heart during or follow­ pseudo-appendicitis or pseudo­ ing an operation is very frequent, cholecystitis due to malaria one often proving fatal, and the utmost finds a marked leucopenia, with a precautions should be used in regard decrease in the polymorphs and a to anaesthetics for these malarial high mononuclear count. In true patients. Ether given by the Ver­ cases of appendicitis complicated non Harcourt method is the safest; with malaria one finds a relative chloroform, in my opinion, is abso­ leucocytosis, with au increase in the lutely contraindicated. polymorphs. The non-discovery of 2. That the malarial parasites of the malarial parasites in the peri­ subtertiau malaria may attack any pheral blood is of no account in the organ, giving all the clinical symp­ diagnosis.” toms of disease of that organ, as the surgeon who has no experience Malarial attack following opera­ of malaria will find to his cost. tion.— “ It is practically always the 3. That the negative history of condition of latent malaria in pa- malaria and the absence of parasites tieuts which is the most annoying, in the blood is of no account in the though rarely fatal, complication diagnosis of a positive malaria. iu surgical cases. These patients give no history of having had 4. That in a malaria patient malaria, and usually a history of convulsions and coma occur iu an perfect health up to the time apparently healthy man without they were wounded. The surgeon any warning, and that it is not operates quite confidently that uncommon for a man with acute everything will be all right, then cerebral malaria to be arrested for 24 to 48 hours after operation an drunkenness ; and that in every impending attack of malaria is case of brain or spinal disease, or often foreshadowed by these symp­ other obscure complaints occurring toms, and I have> noticed this in men who have been East, malaria especially in bone and joint cases. is one of the first things that should The patient complains of severe be considered by the surgeon. pain in the wound ; the latter looks 5. That the subtertian malaria unhealth)7; joints often become may simulate almost any disease, very swollen and exquisitely pain­ surgical, mental, or medical. It ful, the least movement causing may produce such insidious symp­ much pain. The temperature at toms that when the patient feels ill this time is subnormal, but in a. enough to see a doctor treatment is few hours rises to io5°F. or io6°F., of little avail. Medical and Surgical Progress— Tropical Diseases.

6. In the acute attacks therein danger of his life. As Profes­ tnay or there may not be a chill, sor Osier wrote some years ago : and parasites may or may not be ‘ There is no other disease which found in the blood in this type. compares with it, except perhaps The patient may have no idea tuberculosis, in the extent of its himself that he has malaria, aud distribution and its importance as a herein lies the danger. A man killing and disabling disease.’ ” with a subtertian infection is always

tropical SMseases.

T h e P athoqenesis o f B e r i­ the ovary, the pancreas, the heart, b e r i AND OTHER DEFICIENCY the liver, the kidneys, the stomach, D isea sks :— In the Indian Journ. the thyroid, and the brain. Med. Research, January, 1919, “ The pituitary gland showed a McCarrison states the results of a slight teudency to enlargement in careful series of experiments which adult male pigeons only. he has been conducting for a num­ “ 4. The enlargement of the ber of years, and draws attention to adrenals is a true hypertrophy ; it the effects caused by a deficiency of is associated with a proportionate vitamines upon the glandular or­ increase of the glauds’ adrenalin- gans, particularly the endocrine content. The amount of adrenalin structures. His general conclusions in the hypertrophied organ is, area are as follows : for area, approximately the same as that found in the adrenals in GENERAL CONCLUSIONS. health. The hypertrophy is equal­ “ i. The absence of certain acces­ ly well-marked in both sexes. sory food factors from the dietary— “ 5. CEjdema has invariably (roo improperly termed * anti-neuritic ’ per cent) been associated with great — leads uot only to functional and hypertrophy of the adrenal glands : degenerative changes in the central 86 per cent of all cases having great nervous system but to similar hypertrophy of these organs had changes in every organ and tissue oedema iu some form. The amount of the body. The morbid state to of adrenalin, as determined by which their absence gives rise is physiological methods, in such cases not a neuritis. has been considerably in excess of “ 2. The symptom-complex re­ that found in cases not presenting sulting from the absence of these this symptom, and greatly in excess substances is due (a) to chronic of that found in normal adrenals. inanition, (b) to derangement of “ 6. Inanition gives rise to a function of the organs of digestion similar state of adrenal hypertro­ and assimilation, (c) to disordered phy ; and to a similar state of at­ endocrine function especially of the rophy of other organs— the brain adrenal glands aud (d) to malnutri­ excepted. tion of the nervous system. “ 7. The cedema of inanition “ 3. Certain organs undergo hy­ and of beriberi is believed to be pertrophy ; others atrophy. Those initiated by the increased intracap­ which hypertrophy are the adrenals. illary pressure which results from Those which atrophy, aud in the the increased production of ad­ order of severity uamed, are the renalin, acting iu association with thymus, the testicles, the spleen, malnutrition of the tissues. Failure 9 4 The China Medical Journal.

of the circulation and venous stasis of atrophy would result in sterility may subsequently contribute to it. in males and in amenorrhcea and Age is an important factor deter­ sterility in females. This finding mining its occurrence. is held to account in great measure “ 8. Wet beriberi and dry beri­ for the occurrence of ‘ War Amen­ beri are essentially the same disease; orrhcea.’ the former differs from the latter “ 13. The central nervous sys­ in the greater derangement of the tem atrophies little ; the paralytic adrenal glands. symptoms are due mainly to im­ “ 9. Gastric, intestinal, biliary, paired functional activity of nerve and pancreatic disorders are im­ cells; much more rarely to their portant consequences of a dietary degeneration. too rich in starch and too poor in “ 14. It is thought that because ‘ vitamines ’ and other essential of their atrophy out of all propor­ constituents of the food. It is sug­ tion to other tissues the thymus, gested that some of the obscure the testicles, the ovary, and the metabolic disorders of childhood spleen provide a reserve of accessory might be examined from this view­ food factors for use 011 occasions of point as well as from that of endo­ j metabolic stress. This reserve, crine gland starvation. j however, is rapidly exhausted.

“ 10. A state of acidosis results j “ 15. The bones are thinned and from the absence of so-called ‘ anti- there is a loss of bone-marrow. neuritic vitamines’ ; this state is “ 16. The red cells of the blood due to the imperfect metabolism of are diminished by about 25 percent. carbohydrates and to acid-fermenta- i “ 17. The whole morbid process tion of starches in the intestinal is believed to be the result of nu­ tract. Clinically^, it is evideuced j clear starvation of all tissue cells. in pigeons by progressive slowing j Even the adrenals, which alone of and deepening of the respirations. all organs undergo hypertrophy, “ 11. Great atrophy of muscular show 011 section changes in some tissue results from deficiency of of their cells indicative of nuclear ‘ anti-neuritic vitamines ’ ; it is due starvation. in part to the disturbance of carbo­ “ 18. Finally, although deficien­ hydrate metabolism itr consequence cy of certain accessory food factors of disorded endocrine function, in is the essential etiological factor in part to the action pf the adrenals the genesis of beriberi, it is held in supplying blood to the vegetative that infectious and parasitic agen­ organs of the body at the expense cies may often be important causes of the muscles. determining the onset of symptoms. “ 12. Profound atrophy of the “ ‘ Vitaminic’ deficiency renders reproductive organs is an important the body very liable to be overrun consequence of ‘ vitaminic ’ de­ by the rank growth of bacteria. It ficiency. It leads to the cessation is probable that varying metabolic of the function of spermatogenesis. disturbances may determine the In the human subject such degrees character of these growths.”

The Treatm ent of In fan tile BERr-BERi.— Prior to 1914 no less than 95% of the babies in Manila attacked by beri-beri died ; but now, and corresponding to the increased employment of the rice-polishings extract (tiki-tiki), this percentage has been reduced to practically nil, the only deaths from infantile beri-beri now recorded being instances in which the illness had not been notified to the health authorities until it was too far advanced for treatment.— The Lancet, Nov. 22,1919. Obstetrics and Gynecology. 95

©bstetrics an£> ©pnecologv.

E xcessive L oss of Blood after beats per minute as compared with Labour. — Whitridge Williams those w'ithout excessive blood loss. (Avier. Journ. of Obstet., July, Williams is unable to explain the 1919) discusses the remarkable tol­ tolerance of freshly delivered women erance of freshly delivered women to the loss of a proportion of the to excessive loss of blood. The total blood volume which would normal blood loss at a confinement in ordinary circumstances produce has been estimated by different ob­ marked symptoms. He is disposed servers with results varying from 80 to correlate it with the fact that the or 100 mils (Fabre) to 800 mils nitrogenous metabolism is reduced (Ahlield). Williams observed to a minimum during labour. He 1,000 cases at the Johns Hopkins suggests that this fact may explain Hospital. A sterile douche pan the absence of shock, and that in was placed beneath the patient’s this way the patient may be tided buttocks immediately after the birth along until, by the time the normal of the child and left until the birth metabolism is restored, the repar­ of the placenta. The total blood ative processes are sufficiently ad­ was then measured. After the birth vanced to obviate danger. The of the child the uterus was gently observations are, of course, not palpated and the level of the fundus intended to indicate that freshly noted. After five to thirty minutes delivered women are wholly immune the level w7a&. noticed to rise four to to the ill effects of excessive bleed­ six cm., indicating the separation of ing. the placenta and its extrusion into the lower uterine segment or the Influenza and P regn an cy.— vagina. It was then expressed by K. Bley (Münch. A fed. Wo ch., p. gentle pressure. Williams believes 294).— The writer, who is attached that routine massage only prolongs to a maternitj^ hospital, analyzes the process of separation, and that the effects of influenza on pregnancy premature attempts to expel by and the puerperium according as Crede’s method frequently lead to the disease occurred (1) in the early retention of placental fragments mouths of pregnancy, (2) in the and so increase the blood loss. In later months and during labour, the 1,000 cases Crede’s method and (3) in the puerperium. (1) was only required 18 times. The There was no definite evidence that average loss of blood was found 1 influenza induces abortion early in to be 343 7 mils, while 527 cases pregnancy, but the writer suspected lost less than 300 mils. The that in many cases influenza was observation of the pulse showed blamed for criminal abortion. (2) that the traditional slow pulse In mild attacks of influenza the after labour is not a usual pheno­ disease did not appear to affect, or menon. In only 121 cases was the be affected by, advanced pregnancy pulse rate below 79, and in 662 it and labour. But in the more severe was between 79 and 99. Further­ forms of the disease, pregnancy more, it was found that loss of blood and labour proved dangerous and did not accelerate the pulse to the sometimes fatal complications. Of extent expected. In spontaneous four patients admitted to hospital labours, cases with haemorrhage immediately after the termination above 600 mils showed on an of labour, all died of pneumonia average an iucrease of only five in three to thirty-six hours; and 9 6 The China Medical JotirnaL

only one baby of the four survived. Kalliwoda ( Munch. Med. Wock., Three other patients died in hospi­ p. 294).— In the spring of 1918 tal before the termination of labour. considerable difficulty was experi­ In seven cases of severe influenza, enced in distinguishing between labour was completed in hospital influenza and puerperal fever : the and three of the mothers and only onset of both was insidious, and two of the babies survived. The the early symptoms were indefinite. five other babies were born before Bacteriological examinations proved term and died half an hour to six futile, but blood examinations hours after birth. (3) The disease showed that in influenza the number ran a comparatively light course of red cells is almost invariably in­ when it did not develop till the creased ; in some cases they reached puerperium ; the infant was unaf­ 6,500,000. In puerperal fever, on fected by slight influenzal symptoms the other hand, the number of in the mother. The writer attrib­ the red cells is reduced. In the utes the ill effects of pregnancy on early stages of influenza, the number the disease to the encroachment of of leucocytes is somewhat reduced ; the enlarged uterus on the thoracic there is neutrophile leucopenia organs, and he has found neither with slight lymphocytosis. In the medicinal nor operative treatment slight forms of puerperal fever, on of benefit. the other hand, there is almost invariably more or less neutrophile’ Influenza or P u e r p e r a l leucocytosis. F e v e r ?— E. Nürnberger and G.

anthropological IRotes on peoples of Jfar j£ast.

ORIGINS OF THE CHINESE. Dr. L. Wieger (Am. Journ. Physic. Anthrop., Vol. I, No. 2, April- June, 1919), advocates origin in Indo-Chinese peninsula, because, (a) ideograms point to tropical origin ; (¿) Chinese language tonal like languages of Indo-China; (c) oldest form of Chinese in south, and, (d) language purer than in north. Author rejects this theory, because, (a) ideograms point rather to Temperate Zone as origin ; (b) tonal character of Indo-Chinese languages due to incoming from China, and, (c) and (d) also explained by successive waves of migration from north to south. Doctors Hirth, Ross, and Giles believe Chinese to be autochthonous. They declare Chinese tradition knows nothing of immigration from elsewhere. The author submits evidence to the contrary. Author’s theory is that Chinese originated in central Asia. 1. The tribute of Yu in the Shu King shows ancient China to have included regions far to the west of the boundaries under the Chous. 2. Traditions as to birthplace of Huang Ti indicate same. 3. The Shan Hai King supports theory of western origin. 4. Pumpelly’s explorations in central Asia, in 1903-04, report progressive desiccation of that region with emigra­ tion of peoples. 5. The Sumerians probably driven by this change to Euphrates Valley from central Asia. 6. Ball shows Sumerian ideo­ grams similar to ancient Chinese. 7. King shows Sumerians had oblique eyes, indicating possible relationship with Chinese, and strengthening argument for central Asian origin. Anthropological Notes on Peoples of Far East. 97

PELVIMETRY OF FILIPINO WOMEN. As the result of measurements of the pelvis in 1,237 obstetrical cases among Filipino women, Acosta-Sison and Calderon (Philip. Jonrn. Science, March, 1919, reach the conclusion that there are five pelvic types among the Filipinos, but that in the present state of our knowledge these types cannot be associated with any particular racial variety. “ Though unable to draw conclusions from our pelvic measurements, it may be proper to state here that anthropologists have demonstrated from other sources that the predominant Philippine racial types are two : first, a type known as the Indonesian, which came into the Islands from the south and is related to the races of India; and, second, a Mongol-Chinese type, which came into the Islands chiefly from the north. The so-called Malayan Filipinos of to-day are essenti­ ally a mixture of these two Lypes, with the addition of certain minor elements. The most important of the latter is a type represented by immigrants from Melanesia. Other minor types are of course due to the historical immigrations of Chinese and of Spanish Europeans. It is possible, then, that our five pelvic types correspond to these racial elements ; though for the present such a conclusion must be regarded as mere speculation.” As to pelvic measurements the general conclusions of the writers are as follows : 1. The Filipino pelvis is of a type different from either the white American or the Negro pelvis, and its average normal measurements are similar to those of the generally contracted pelvis of the white American. 2. The index of the posterior pelvic plane in cases of contracted intertuberal diameter is important in the determination of the probable outcome of labor. 3. Contracted pelvis, except in cases of osteomalacia, is rarely an indication to Cesarean section among Filipino women. 4. There is practically no difference in the measurements of the pelvic diameters of multiparse and primiparse. 5. The newborn babies of multiparse are longer and heavier than those of primiparse. 6. The babies of mothers who stayed in the hospital for one or more weeks before delivery are heavier than those whose mothers entered the hospital at the time of labor. 7. The male babies are in greater number and are longer and heavier than the female babies. 8. Labor is longer in primiparse than in multiparse.

RACIAL TYPES OF MAN. A t the Annual Meeting in 1919 of the British Association for the Advancement of Science, Professor Arthur Keith president of the Anthropological Section, delivered a most interesting address on the “ Differentiation of mankind into racial types.” Starting with a description of the racial characteristics of the Mongol, Negro, and 98 The China Medical Journal. Caucasian or European, he unfolded the thesis that these differentia­ tions depended on the functional development of the endocrine glands. Abnormality, tumour, or disordered action of the pituitary gland was associated with acromegaly, gigantism, eunuchoid condition of the body, or dwarfism. Physiologically the conclusion seemed justified that the pituitary was one of the main parts in the machinery of regulation of growth, and that it was directly concerned in determining stature, cast of features, texture of skin, and character of hair-—all of which were marks of race. The Caucasian type showed the greatest predom­ inance of the pituitary ; the sharp face, strong superciliary ridges, prominent chin, bulk of body, and height of stature could best be explained in terms of hypophyseal function. The interstitial cells oi the testicles evidently played a part in bringing about the robust manifestations of the male characters, and this sexual differentiation was more emphatic in the Caucasian than in the Mongol or negro types. The evidence of loss of suprarenal gland function, as shown in Addison’s disease, led to the inference that at least part of the function of these glands was concerned with the clearing away of pigment, and to their action we might attribute the fairness of skin in the European. Again, malignant growth of the adrenals in children produced a premature sexual maturity with all its bodily characteristics, and a similar result followed disease of the pineal gland. The thyroid gland was perhaps the most important of all the organs of internal secretion from the anthropological point of view. Apart from its immediate function in manufacturing a substance which regulated the rate of combustion of the tissues, and which could be correlated with the selection and survival of human races, it had remoter morphogenetic effects on growth and the shaping of racial characters. Cretinism, myxoedema, achondroplasia, and mongolianism, were evidences of characters induced by the thyroid glaud changes of disease, and the racial characteristics normally corresponding were dependent on the physiological action of thyroid secretion. The endocrine glands thus possessed a growth-controlling mechan­ ism, and the respective parts played by each in their relation to the rest of the economy were dominated by hormones, which, according to the nature of the recipients on which they acted, brought about the endless variety in the relative development of racial and individual features.

MILK AS A FACTOR IN RACE DEVELOPMENT. In a recent work, The Newer Knowledge of Nutrition: Ike Use o f Food for the Preservation of Vitality and Health, by K. V. McCollum, it is stated that milk is our most important foodstuff, for in addition to the extraordinary value of its protein, when used in combination with the foodstuffs of either animal or vegetable origin, it corrects their dietary deficiencies. Milk and leafy vegetables and eggs are regarded as protective foods. The author is loud in his praises of milk ; indeed, according to him mankind can be classified into two groups. Both groups have derived the greater part of their food-supply from seeds, tubers, roots, and meats, but differ in the character of the remainder of their diet. Those peoples— Europeans and North Americans— who Book Reviews. 99 have made liberal use of milk as a food, in contrast with those peoples— Chinese, Japanese, and people of the tropics generally— who have made use of the leaf as their sole protective food, in the words of the author, “ have attained greater size, greater longevity, and have been much more successful in rearing their young. They have been more aggres­ sive than the non-milk-using peoples, and have achieved greater advancement in literature, science, and art. They have developed in a higher degree educational and political systems which offer the greatest opportunity for the individual to develop his powers. Such develop­ ment has a physiological basis, and there seems every reason to believe that it is fundamentally related to^nutritiou.”

Book IReviews.

Plastic Surgery. Its Principles and Practice. By John Staige Davis, P h .B ., M.D., F.A.C.S. With 864 illustrations containing 1637 figures. Price, G. $10 net. Publishers: P. Blakiston’s Son & Co., Walnut Street, Philadelphia. 1919. About ten years ago the author was induced to specialize in plastic surgery by the remark of a friend who said that every general surgeon was doing this kind of work but that few were doing it properly, and that plastic surgery was practically an undeveloped field. This book has now been written to record his personal experience and to collect from scattered sources, and place in an accessible form, the principles and methods which he has found most useful. During the war plastic surgery was arbitrarily limited to maxillo-facial reconstruction and wonder­ ful results were achieved ; but the author rightly contends that this branch of surgery should include within its range every part of the body, as the results are of the utmost importance to patients, though perhaps less spectacular than the reconstruction of the human face. The earliest part of the book gives the technique of the transplantation of skin and other tissues. Next follows an instructive chapter on the treatment of wounds generally. The various methods of treating intractable ulcers and varicose veins follow, a section which should be very useful to surgeons in China where ulcers of this kind are v e ^ common. The chapters on malformations— harelip, cleft-palate, ectopia vesicse, epispadias, hypospadias, etc.,— should also be very serviceable. The remaining chapters, comprising about one half of the book, deal with plastic surger}- as applied to the various regions of the body, the different parts of the head and face being dealt wTitli very fully. In the chapter on the lower extremities there is an adequate description of the Kondoleon operation for elephantiasis. Judging by the illustrations, which are numerous and very good, the author has himself obtained extremely good results. The book will certainly reveal to the general practitioner the possibilities of plastic surgery, and will start the surgeon inexperienced in this specialty on right lines. And, as the author says, the more experienced surgeon may also find methods with which he is unfamiliar and which may be of use to him in dealing with plastic cases. At the end of each chapter the bibliography relating to the subject is given. It is a book which surgeons in China will find very useful.

Practical Physiological Chemistry. For Indian Medical Students and Clinical Assistantg. By C. C. Caleb, M.B., M.S., Professor of Physiology, King Edward Medical College, Lahore ; Examiner in Physiology to the Punjab and Allahabad Universities. Price Rupees 6 net. Publishers : Butterworth & Co., Calcutta. 1919. This work consists mainly of notes amplified and revised, which the author, as Professor of Physiology, has given from year to year to the students working in the chemical laboratories of the King Edward Medical College, Lahore. Uuder every important qualitative test, and in connection with the chemical reactions involved 100 The China Medical Journal.

in most of the quantitative estimations, explanatory notes are given which form one of the most valuable features of the book. It is the author’s object to minimize, as far as possible, the strong tendency of the Indian student to be mechanical in his experiments, to be satisfied with noting results without wishing or attempting to understand why those results are produced. As Chinese students have the same tendency the volume should be very useful to them as a handbook in the laboratory, and the very moderate price is an additional recommendation. Not quite so much ground is covered as in the larger text-books on the subject, but we cordially commend the work to the careful consideration of teachers of physiology in our Chinese medical schools, when choosing for their students a work intended for practical use in the chemical laboratory.

A id s TO M a t e r i a M e d i c a . B y Arnold E. Collie. Price 3 / - net. Publishers: Bailliere, Tindall & Cox, Covent Garden, London. 1919. Introducing his work with the Shakespearian quotation, “ Experience is by industry achieved, and perfected by the swift course of time,” the author states his object is to aid students in their industrious acquirement of the knowledge required to write prescriptions readily without frequent reference to a pharmaco­ poeia. His little book is an amplification of the notes and mnemonics which he made for his own use when a medical student. For instance, the following rhyme gives the doses of all the tinctures in the Schedule : Opium, Hemp from an Indian Sky, The substance placed in an Actor’s eye, [i.e. Belladonna] Tincture of Squills and Stramonii, Digitalis and Nux Vom. Fruit, Add Colchicum Seeds the rhyme to suit, Tr. Chloroformi et Morphinse Co , 5-15 is the dose we must know. 2-5 minims of Cantharides, Aconite Root and Strophanthus Seeds, Add Iodine too ; now I don’t care a damn, For the dose of the rest is a half to one drachm. '

We fear that most students will only be able to remember part of the last two lines of this elegant and stirring composition, with the probable result that at the final examination the examiner will say emphatically that he doesn’t care either. For the difficulty is that rhymes and tips are apt to vanish just w'hen they are most needed. It is not encouraging to those inclined to depend upon them to see by the title page that the author apparently forsook medicine for law, before taking his final medical examinations. - However, the book generally, quite apart from the mnemonics, will be very helpful to those learning the preparations and doses of the pharmacopoeia.

T h e V b n e r e a i , P r o b l e m . A Description of the Venereal Diseases ; their'history ; their prevalence in Great Britain ; their effect upon the national life ; the factors causing their propagation and spread ; and a discussion of methods for their control and eradication. By E. T. Burke, D.S.O., M.B., Ch.B. With six illustrations. Price 7/6 net. Publisher : Henry Kimpton, 263 High Holborn, Don don. 19x9. The social and moral problems connected with prostitution and venereal disease are now receiving the serious attention of all interested in national welfare. In Shanghai a special Vice Committee has been appointed to inquire into the social evil as it exists in that city and to suggest such measures of reform as it shall judge necessary and practicable. The China Continuation Committee has also organized a Moral Welfare Committee to consider the subject from the point of view of the Christian missionary working among the Chinese. The time has passed for the great social evil to be publicly ignored, or discussed only in secrecy and with bated breath. The evil can only be conquered by the union of all classes in open and vigorous conflict with it. For the battle to be intelligently and successfully waged it is necessary that the laity as well as medical men, should know the origin and strength of the evil. Hence many publications have been issued, especially since the war, with the object of giving the requisite medical information to all who desire it. The Correspondence. IOI

present work is one of the best we have seen. It is written in a clear and interesting manner and the medical details are accurate. The first part describes the different venereal diseases, their mode of infection, symptoms, and effects, and the consequence of these effects upon the national life. In the second part there is a discussion of the mental and moral attitude of societj' regarding venereal diseases, a subject it is necessary to consider when investigating the forces which are at work in causing the propagation and spread of these disorders. Finally, there is a discussion of the measures which the author advocates for the control and eventual eradication of venereal disease. We heartily commend the book to all who are interested in social reform. As medical men cannot well stand aside from the struggle, they should be familiar with the arguments of reformers as contained in books of this kind, so as to support or oppose, as their judgment may dictate, the different measures advocated.

T o x i n e s e t A n t i t o x i n e s par M. Nicolle, E. Césari, C. Jouan, de l’Institut Pasteur. Un vol. de 123 pages. Massonet Cie Edit. 5 fr. net. Cet ouvrage est avant tout un livre “ personnel” et cependant peut être considéré comme une monographie complète et une mise au point de la question des T o x in e s, telle que la Science expérimentale peut actuellement la concevoir. Personnel, cet ouvrage l’est, d’abord, parce que les auteurs sont parmi ceux qui ont le plus contribué à définir d’une façon explicite les problèmes soulevés par les conceptions modernes de l’immunité et des réactions de défense de l’organisme. Aussi, étudier de ce point de vue les “ T o x in es et les Antitoxines ,” c’est pour une très grande part citer et commenter leurs travaux C’est encore une œuvre personnelle, en ce sens qu’aucune donnée expéri­ mentale, même classique, n’est avancée par les auteurs, sans qu’ils aient procédé à une vérification de laboratoire, sans qu’ils aient repris le problème ab ovo de façon à éliminer les interprétations parasites. Une pareille méthode supposait de nombreuses années de patient travail et des ressources techniques de laboratoire qu’on aurait trouvé difficilement ailleurs qu’à l’Institut Pasteur. Si ce livre, qui est sorti de cet ensemble considérable de recherches, est réduit et tient seulement en 1 23 pages, il suffit de le feuilleter pour voir par le soin matériel même apporté à présenter les divisions et les articulations des sujets traités, quelle est l’étendue et la portée des conceptions et des faits qu’il embrasse. Fidèles à une méthode classique dont les maîtres de la science française se sont bien rarement départis, le tableau que nous présentent M. Nicolle et ses collaborateurs est dépouillé de toutes considérations étrangères ; une vaste question est abordée pour elle-même et de front sans chercher dans des considérations annexes des appuis et des secours hypothétiques. C’est ce qui permet à cette monographie d’être, quoique volontairement courte, un exposé systématique, complet, objectif et même d idactique de problème des T oxin es.

Corrcspcmfceitce.

Correspondents are requested to write on one side of the paper onlyK and always to send iheir real names and att'dresses. The Journal, does not hold itself responsible fo r the opinions or assertions of correspondents.

Chinese Government Regulations for other doctors ; I have seen no correction Post-mortem Examinations and made in later numbers of the Journal. The way the matter came to my atten­ Dissection. tion was as follows: we had a patient die in our hospital who had prior to To the Editor, C. M. J. death consented to autopsy. Immediately D e a r S i r :— Until a few days ago I after death his fellow soldiers came did not know that paragraph four of the and demanded the body, saying that a Board of the Interior regulations cover­ relative objected to autopsy. I wrote ing dissection, as printed in the C h i n a to the district police commissioner, M I' DIC A T* JOTTRNAI,, 1914, p. 237, is ill- asking whether or not, in spite of our correct. The fact may not be known to legal right to proceed with the post- 102 The China Medical Journal.

mortem, it would be in accord with the tion and leave word to that effect before wishes of the police for us to do so. I death, they may do so, but the whole had a prompt reply, enclosing a copy body must be sewed up and returned to of the official regulations, in which par­ his or her family after dissection.” agraph four is quite different in content / l m from paragraph four as printed in the mm mm J o u r n a l . I euclose herewith a copj7 of it mm ± m m & m each. It might be well to let other doctors know of this discrepancy and In the China Medicai, Journal, 1916, thus prevent embarrassment in the p. 126, we reprinted from tht N a tio n a l future. Medical Journal of China, November, Sincerely yours, 1915, these same regulations with “ Order

J o h n H . K o r n s . No. 85 of the Board of Interior,” which consists of “ Supplementary regulations promulgated for the performance of post­ In a second letter, dated December 3, mortem examinations.” The section 1919, Dr. Korns writes :— “ You will note quoted is given unchanged but it is in the second article of the regulations qualified and extended by Art. 2. of the for dissection as published in the C h i n a Supplementary Regulations which reads: M edical Journal, that while only the “ According to Articles I and IV of the word dissection is used, the reference is General Laws this may be enforced and distinctly to post-mortem. I am told by the medical men allowed to perform the Chinese doctors that the Government postmortems as soon as the consent of has not made any distinction in terms, the fam ily is obtained.” and we have been accustomed here to As Art. IX expressly states that “ these use chieh p 'o u [$£ $]] for both ideas. It by-laws may be revised at any time with might be possible at the coming Con­ a view to improvement, a complete revi­ ference for us to recommend to the sion of this most important section has Government that such a distinction be evidently been made recently and it now made and that the post-mortem ex­ stands as follows : amination be given an official Chinese “ If any are willing for the benefit of name. Also might it not be possible for science to offer their bodies for dissection us to get the Government to change the and leave word to that effect before fourth article, so as to delete the para­ death, they may do so, but the family graph requiring consent of relatives once must inform the local authorities and the patient himself has given consent and obtain their permission before the body the matter has been attested bj' proper is sent to the doctor or doctors. After witnesses? For our work in Peking dissection the whole body must be sewed where so many patients are from distant up and returned to his or her family.” provinces with 110 relatives here in the The consent of the family to the ex­ city, such a provision would maik a amination is implied. distinct advance in the matter of secur­ ing more autopsies.” +**Medical men in China are indebted to our correspondent for calling attention to this important regulation as any in­ m m m & mm m m- fringement of it may lead to very trouble­ - In accordance with the suggestion of some consequences. We do not think Dr. Korns, the whole matter should be there has been any inaccuracy. The very carefully considered at our Con­ regulations are here given in chronologi­ ference uext month with the object of cal sequence, so that their purport and obtaining a modification of the Regula­ development may be seen more clearly. tions.— E d . In the China M edical Johrnxl, 1914, p. 237, Dr. Cormack published a copy of the Regulations relating to post­ The Treatment of Beri-berl. mortem examinations and dissections, To the Editor , C. M .J . issued a few months before by the Board of Interior (Gov. Gaz., 563; Order No. D e a r S i r : — May I venture to write a 51; dated November 22, 1913)- The few words upon the treatment of beri­ fourth section of these regulations was beri ? particularly mentioned, and the follow­ Probably we have all accepted the ing, as given at the time, is the correct vitamine theory, that there are at least English translation: two accessory food substances or vita- “ If any are willing for the benefit of mines necessary to nutrition, one associ­ science to offer their bodies for dissec­ ated with certain fats, the antirachitic or Correspondence.

growth factor known as the “ Fat-soluble went to normal in the morning but rose A . ” ; and the other the antineuritic to 99.40 F. in the afternoon. factor, soluble in water, and known On October 24, the patient found it as the “ Water-soluble B.” There is necessary to go to Shaohsing, an all­ also an antiscorbutic factor. All must day’s trip by chair, boat, and native be present in sufficient amount in any launch. A relapse followed the next day dietary providing proper nutrition. The as a result of the unusual exertion, and water-soluble vitamine is the substance for the following two weeks the patient which is necessary for the prevention of was confined to his bed with all the beri-beri, hence this vitamine must be symptoms of a severe influenza aud with given for the successful treatment of the concomitant symptoms of bronchitis. disease. There are three main sources, pulses, bran, and yeast, from which it may be obtained. In the ordinary way the pulses require prolonged cooking to render them di­ gestible and this must destroy much of the vitamine; it is better to use germin­ ated pulses (e.g., Tfji 3?) as these require very little cooking and they contain an abundant supply of the Water-soluble B. factor. The brau is usually obtained from the pounding of unhusked rice ($¡51 and should be sieved. It contains almost all the pericarp in a finely powdered state and from it a watery acid extract can be made, preferably fresh every day, which will contain all the B. factor required. It can be given in large doses. It is best to prepare the extract with a weakly acid solution (e.g., 0.3% solution of hydrochloric acid) in order to extract all the B. factor available. The most convenient medicament for beri-beri, however, is 3 east. It is rich BRONCHIAI, CASTS. in the antineuritic factor, requires no On November 2, on getting up to cooking, and presumably it can be shave, a severe coughing fit resulted in obtained in any Chinese town in the the dislodgement of two casts from the form of little cakes (jffi f$ ), of which two bronchioles. As the writer is the patient or three may be taken three times a da}'. he will describe the sensation of cough­ Surely it is unnecessary to send to ing them up. The cough was particularly Burope for supplies of “ mermite ” when paroxysmal, unlike the usual cough an ample supply of active yeast is at our which attended the influenza; finally, hand. The benefit obtained from this with an unusual effort, the cast from the yeast in the treatment of beri-beri is left side loosened and shot up into the sometimes marvellous. mouth leaving behind a distinct pain at Yours sincerely, the site of its dislodgement in the bron­ chioles. When the cast entered the G . D u n c a n W h y t e . mouth it felt entirety different from an Swatow, December, 1919. ordinary mass of sputum. It had a sensation of coldness and firmness, giv­ ing one the feeling of having vomited a Bronchial Casts in a Case of roundworm. Influenza. In about fifteen minutes another par­ oxysm of coughing dislodged another lo the Editor , C. M . J . cast. This one was smaller and from the D k a r S i r : — At Hangchow, October 20, right side. It also was accompanied by 1919, the patient had a prolonged chill a sensation of pain. lasting from half past seven in -the On November 6th and following day morning till four o’clock in the after­ other casts were expectorated with much noon. His temperature reached 102.8° F. the same symptoms. Most of these casts at one o’clock in the afternoon. B}> were saved in weak alcohol solution. nine o’clock in the evening it had The illustration shows the largest of the reached 103.20 F. and it did not touch casts expectorated with most of the normal again till October 23, when it smaller ones. 104 7 he China Medical Journal.

Recoverj' aiid return to routine work: I dozen grades, together with more or less was slow and at the date of writing,, standard specifications for details,— December 23, the patient is troubled in1 windows, doors, stairs, floor-beams, roof- the morning with a severe cough and1 trusses, and the like ? Surely something copious expectoration, but without rise■ of the sort has been done ere now by the of temperature. C. M. M. A. Yet I cannot find any re­ Bacteriological examination of one of cord of it. the fresh casts «howed strepto-bacilli, These two matters I submit for thought­ diplo-bacilli, encapsulated diplococci, ful consideration. staphylococci and many very large I should greatly like to bring some­ square-ended bacilli, but no tubercle thing of this matter before the Peking bacilli. Conference if it in any way commends The writer would be pleased to know itself as being practical. And I should whether others have seen like cases. appreciate criticism and suggestions, and Yours sincerely, hope that something will be done at the C. H. B a r l o w . forthcoming Conference to carry these suggestions into effect. Shaohsing, December 23, 1919. Yours sincerely, George Hadden. Hospital Architectural Designs. Hunan-Yale Hospital, Changsha, To the Editor , C. M .J . November 26, 1919. D e a r Sra:— We are talking a lot about efficiency, and we still go on building The Insane in China. inefficient hospitals. Nor do the archi­ tects help us much ; they are apt to be To the Editor, C. M .J , either too ingenious, or too comprehen­ D e a r S i r :— Your letter concerning sive, often too pretentious, usually too or­ the necessity of establishing more hos­ nate, and always too expensive. Besides, pitals for the insane in China has been most of them seem to know little about received. designing hospitals, and none of them I may say that all I know about the has worked in the interior of China. origin of the John G. Kerr Hospital for Wherefore up-country doctors are apt to the Insane, in Canton, has been from be still their own architects, and we still hearsay. But from that I gather that the 'see hospitals going up without side-rooms, idea of establishing a hospital for the wards for special cases, rooms for storing insane came to Dr. Kerr during his work bedding and patients* clothes, or even in the Canton Hospital. Of course he provision for a laboratory. knew of the lack of proper treatment by Surely the China Medical Missionary the Chinese of these patients in their own Association or the China Continuation homes, how they were heavily chained, Committee can help us out. For instance, etc., but it did not seem possible to take I have lately seen hospital plans that are charge of these patients in a general utterly without inspiration. Why could hospital. As the story goes, one day not they be mailed to a secretary in Shang­ when he had turned an insane woman hai, with copies of the outline, who could away, a concubine, the husband took submit them individually .to an honorary took her to the river just in front of the group of several experts or semi-experts, hospital and threw her in. I am told who need not formally meet together but that Dr. Kerr’s resolution to establish a who would be willing individually to place for the insane dales from the above comment on such plans, or possibly to occasion. suggest something ’ altogether different As for the need of such institutions, but of the same type and cost, which com­ anyone who knows China and the Chinese ments could be sent back to the builder is aware that very little, comparatively for his instruction. There is an immense ;speaking, is being done for this class of amount of experience locked up in the patients ; and that nothing is being done ranks amongst u s; surely it would be of to check them from reproducing their the very genius of the China Continuation kind, except as the law of the survival of Committee to co-ordinate it, and make it the1 fittest comes in. Estimating that fruitful. there is at least one insane person to In the same direction, would there every < 1,000 inhabitants (in other coun­ not fee place for a Committee 011 Hospital tries I the proportion is about 1 to 500 or Design, who should produce a small 600) < and taking the population of China pamphlet, summarizing the essentials of 1as 250,000,000 then there are at least good designing, together with gener- 250,000 : insane, of which the 600 patients alized suggestions for grouping ; also the in i the hospital here are about all that are dimensions for hospitals of, say, half a receiving 1 any scientific treatment. / (iHNKRAL FENG. DK. LOGAN.

RECENT PHOTOGRAPH OF DR. O. T. LOGAN, News and Comment.

A s to the good this institution has financial support of these hospitals, there done, we have had over 4,600 admissions may be: (1) philanthropic institutions and about 25% of the patients have re­ which are entirely supported from outside covered. No doubt some of these would sources; (2) those conducted in the style have recovered anyway, but many would of sanatoriums which could easily be not have done so. And, from the mis­ made more than self-supporting; (3) sionary point of view, the institution institutions which would be a combina­ has been an object lesson to the Chinese. tion of the other two kinds, in which the The relatives that come and go as visitors poor would only pay a part of the amount give a splendid opportunity for the dis­ required for the support of their relatives, tribution of tracts. Out of curiosity while the wealthy could be charged rent many investigate what kind of a doctrine for fancy quarters and thus help meet the it is that will make a person want to take expenses of the others. The patients of care of the insane relatives of others. the John G. Kerr Hospital are mostly The institution gives an excellent oppor­ poor people, but even so the institution tunity for evangelistic work. has been practically self-supporting ex­ To my mind it will be impossible to cept for the salaries of the foreign staff. take care of all the Chinese insane unless Yours sincerely, the work is taken up by the Government. But model hospitals can be established Joseph L. Harvevt. immediately that will teach the Chinese Fongtsuen, Canton, how to treat their insane. As to the December 27, 1919.

NEWS AND COMMENT.

BIRTHS. him to the patient. The necessary examination was made and treatment DALE.— At Wukingfn, Tung., on Decem­ prescribed. As Dr. Logan was about to ber 3, 1919, to Dr. and Mrs. W. Chal­ depart General Feng asked him to re­ mers Dale, of English Presbyterian main for a chat, the patient having Mission, a son (Robert John). gone to his bedroom. A little later they talked with the patient again. Dr. R u s s e l l .— On September 23, 1919, to Dr. and Mrs. W. B. Russell, of Chang- Logan made a further examination, and chow, Ku., a daughter (Katheryne once more indicated the course of treat­ Grace). ment including certain physical exercises which he demonstrated. He was about to sit down when the patient, in his in­ sanity, suddenly and without the least DEATHS. warning drew a revolver and shot him; L o g a n .—At Changteh, Hunan, on De­ the bullet entered the cheek and passed cember 18, 1919, Oliver Tracy Logan, through the neck to the back where it M.D., of the American Presbyterian lodged. Bloodvessels were severed and Mission, died in the performance of he had to remaiu in the yatneii without duty from a bullet wound inflicted by professional help for half an hour, and a demented Chinese soldier. was then carried to the hospital bleeding all the time. Although the appliances The death of Dr. Logan was sudden for immediate assistance were not ready, and tragic. According to the reports of everything that could be done to save General Feng, a Christian Chinese and him was done. All was unavailing, and very friendly to all missionaries, and of he died within an hour after receiving the Dr. Locke who presumably reached the wound, thus ending a missionary career city shortly after the occurrence, Dr. of over twenty years of skilful, patient, Logan was asked by General Feng Yu- and loving service to the Chinese. hsiang to se<" professionally a brother General Feng grappled with the in­ officer who had come to his yamen three sane patient as soon as the shot was fired or four days before from the north, and and was himself wounded in the hand who was said to be greatly depressed and shoulder. On making inquiries as over his ill health. As a matter of fact, to how the patient came to be in posses­ he had previously suffered from perio­ sion of a revolver, it was learned that dical outbreaks of insanity. Upon Dr. his wife, the daughter of a military Logan’s arrival General Feng introduced official and accustomed to the use of fire­ io6 The China Medical Journal.

arms, had brought it with her on the From that date until 1898, he was journey as a protection against brigands. associated with, the distinguished sur­ By the courtesy of Dr. Henry Fowler geon, Dr. J. C- Kerr. In 1899 Dr. of Siaokan, we are enabled to present Swan succeeded him as the Medical what is probably the last photograph Superintendent of the hospital. Build­ taken of the deceased. The tall Chinese ing upon the excellent work of Dr. officer in the centre is General Feng. Kerr and his associates and predeces­ On his left stands Dr. Logan. The sors, Dr. Swan carried the institution party was about to start on a holiday steadily forward. During the more shooting expedition for a day or two. than fifteen years of his superinten­ Dr. Logan, who came to China in dency, from 1899 to May, 1914, he 1898, was a most active and untiring enlarged the facilities and equipment member of the American Presbyterian ; of the hospital in numerous ways. Mission. His work c o v e r e d a wide field j Many improvements in, and additions and was highly appreciated by foreigners j to, the old buildings were made. and all classes of the Chinese. He was ! Much additional land was secured, a skilful physician and surgeon, in- i and new buildings were erected. genious in constructing practical devices j On January 15, 1902, under Dr. for use in hospitals, and won distinction Swan’s leadership, the Canton Medical for his research work in parasitology. 1 Missionary Society voted to establish He was a valued contributor to the j the South China Medical College, and C h in a Me d ic a l Jo u rn al and other ! the next year an imposing building medical papers, his articles always being j was erected on newly acquired ground. instructive and covering a variety of sub­ The first year fifty students were jects. At the Conference in Hankow in j enrolled. The course adopted ex­ 1910, he was elected Vice-president of ! tended over three years. After much the C. M. M. Association, an honor fruitful work resulting in several tens which he deserved to the full, and in the of fall graduates, the College was absence of Dr. Cousland acted as Presi­ closed in 1912 owing to inadequate dent at the following Conference in staff. In May, 1914, Dr. Swan retired Peking. i from the service of the Medical Mis­ When America entered the great war, , sionary Society, and thereafter engaged Dr. Logan responded to the appeal for in private practice and with marked medical men to proceed to Siberia to success conducted a hospital at Tung attend to the sick and wounded there. Shan, Canton. He was accompanied by his wife and It is doubtful whether any name is they were placed in charge of the more generally known to the Chinese American Red Cross Hospital in Vladi­ of Kwong Tung than “ Kwan I Shang” vostok. After doing excellent work they (Dr. Swan). It is uttered with affec­ returned home with a detachment of tion in almost every section of this troops to the United States at the close province. It is an open sesame to of the war, and they had but recently hundreds of villages and towns. returned to China when the tragedy Reports of his skill as a surgeon occurred. spread far and wide. What vast num­ Dr. Logan was an earnest Christian bers he ministered to through his missionary, unselfish and lovable. His more than thirty years of residence loss will be greatly felt in China and in here ! The humblest readily obtained the United States by all who knew him, his help : the highest often anxiously and he will be deeply mourned by the sought it. He was never too weary to members of the C. M. M. Association. respond to the call to serve. His To Mrs. Logan, the children, Dr. Man- record is one hard indeed to equal, get and other relatives we offer our most and one seldom surpassed. The sum heartfelt sympathy. total of the influence of such a life is beyond estimation. Everywhere and always, Dr. Swan S w a n .— A cablegram was received from was the servant of his master, Jesus the United States on November 22, Christ. Never did he forget that he 1919, which announced the accidental was a missionary, “ one sent” to the death of J. M. Swan, M.D., of Canton, Chinese. His piety was of the solid, aged sixty years. Presbyterian type. He hated sham Dr. Swan came to China in 1885 as a and indirection. No one ever doubted missionary of the American Presby­ what his convictions were. He did terian Foreign Mission Board. After not court favor. His friends were true a period of language study he joined to him, and he to them. The last call the staff of the Canton Medical Mis­ came to him suddenly. H e was jeady. sionary Society’s hospital in 1887. To his children and his grand-children News and Comment. 107

lie leaves a priceless heritage. He Surgeons, at its seventh annual conven­ lives, and will live on in the deathless tion, October 24, 1919. work he did. Dr. Swan is survived by his widow, three sons, and two grandchildren. Dr. Wu Lien Teh has been elected by Two of the sons, James and Robert, the ratepayers of the Railway area of are in school in America. The other Harbin to serve as a Councillor of the son, Dr. C. A. Swan, with his wife and Harbin Municipal Council, as it is be­ two children, resides at Tung Shan, lieved that his expert advice on sanitary Canton. affairs will be found useful to the com­ R. E. C. munity.

Dr. J. Stanley Ellis, a graduate from On December 17th, 1919, the Medical Trinity College, Cambridge, has come out College of Shantung Christian University to join the faculty of the Medical School gave a public demonstration of the work of Shantung Christian University, as of the various departments. Private Professor of Roentgenology and Electro- invitations had been sent to one hundred Therapeutics. and fifty of the prominent provincial officials and to the leading local business Dr. Andrews, daughter of the Secre­ men, nearlj" all of whom attended. The tary of the Wesleyan Missionary Society, exhibition consisted of various experi­ has arrived in China as a medical mis­ ments, and was a great success. sionary and will be stationed at Wu­ chang. Dr. E. M. Crooks, of Kirin, sailed last C. M. B., F e l l o w s h i p s a n d S c h o l a r ­ month for Ireland on furlough. s h i p s .— Medical study has been carried on during the year, under fellowships Dr. N. Prescott has returned to his and scholarships of the China Medical work at Siachang, Chihli, after a year’s Board, by thirty-five medical missionaries furlough in England. and nurses on furlough, eleven Chinese doctors, ten undergraduate students Dr. Judson, son of Rev. J. H Judson (from the Harvard Medical School of of Hangchow, recently came to the field China), six Chinese nurses, and three under the Presbyterian Board and is supplying at Hope Hospital, Hwaiyuan, Chinese pharmacists. for one year. Dr. Cochran expects to teach in the Medical School at Tsinanfu on his return from the United States. M. J. Patell, a business man of Canton Dr. Barnes, now attending the Language and Hongkong, has made a gift of $5,000 School at Nanking, will eventuallj’ be to the John G. Kerr Hospital for the stationed at Hwaiyuan. Insane, and $2,000 for the Ming Sam School for the Blind, both established in Having served their country in the Canton. late war as military surgeons the follow­ ing members of the London Missionary Society have now returned to China: N e w H o s p i t a l in T u n g a n , F u k i e n . Captain A. C. Price, of Shanghai; Cap­ — Great interest is being shown in the tain E. F . Wills, of Tsaoshih, H upeh; building of The Elizabeth H . Blauvelt Captain J. Lee H. Patterson, of Hsiaokan, Memorial Hospital, a gift from her family H upeh; Captain E. J. Peill, of Siao- in America to commemorate the mission­ chang, Chihli. ary service of the late Miss Blauvelt. It will be the largest building in the Dr. I. E- Mitchell, of the London Mis­ city and as it brings the first resident sionary Society, Hankow, has been re­ foreign physician the city has had it is transferred to Hongkong. most sincerely welcomed. Dr. and Mrs. Dr. O. G. Nelson has returned from M. Vandeweg have already arrived and furlough and has taken up his work at are studjdng the language preparatory to the Union Hospital, Huchow. taking charge. On February 5, 1919, Dr. Ada B. Speers of the C. M. M. Hospital, Chengtu, will Public Hospital in Kweiyang, sail for Canada on furlough. K w bi.— Under official auspices a public hospital was opened in November, I9J9 , Dr. W. B. Russell, of Changchow, in the city of Kweiyang. The physician Ku., was formally admitted to the in charge, Dr. Teng, received his medical Fellowship of the American College of training in Japan. io8 The China Medical Journal.

P e k i n g U n i o n M e d i c a l C o l l e g e .— of the Hongkong Sanitary Board, Dr. During the year 1919, construction work Pearse, the Medical Officer of Health, on the buildings of the Peking Union moved that yellow fever be made a Medical College -went forward. The notifiable disease. He stated that he total number of members of the faculty asked for this measure because he wished proper was increased to thirty-four, and to make the schedule of diseases com­ a large number of other persons were plete. Although yellow few'er did not appointed to less important positions in occur in the Colony there might be a connection with the school. Contri­ possibility of it, and it was advisable butions were paid to nineteen hospitals, that »it should be notified early. It three medical schools, and sixty-five was only a preventative measure and fellows and scholars. therefore should not create any alarm. | Although he did not anticipate an out­ break, it was well to bear in mind that Chinese Superstition and Motor 1 the mosquito which carried the disease A c c i d e n t s . — According to a Shanghai i from infected persons to others was in daily newspaper some of the Chinese ! the Colony. take delight in crossing the road directly in front of a swiftly moving motor car

for the sake of their spiritual welfare. j T h e Blind in Japan.— There are The explanation offered is this : when a I about 800 blind people in Kobe, and Chinese is in bad luck he believes that a i they are mostly shampooers and teachers demon is literally dogging his footsteps. I of Japanese music. They have just Now if the victim can just manage to ! established a society of their own. The escape a car travelling at the rate of '• opening ceremony was held recently and sixteen or twenty miles an hour the ! more than 200 blind people were present, demon “ gets it in the neck.” The besides a number of guests. It wTas narrower the margin of safety for the ; decided to send a petition to the Minister human being the worse it is for the j of Education urging him to make com- demon. If Chinese motorists believe in I pulsory education applicable to the blind the same superstition these deliverances I as well as to others. should make them rather fearful of the wrath to come.

E p i d e m res i n S h a n t u n g .— The part of The W eaker Sex in China. — The the province of Shantung in and around new woman in Canton is not the tender Taikuhsien is at present being scourged and slim, timid and frail, pale-faced and ! by the most serious epidemics known tiny-footed Chinese woman of yesterday. ; for many years. Influenza, scarlet fever, Mrs. Wu, wife of a Colonel of the Army, i and diphtheria are all raging in various is organizing in Honam a club to teach ; places, and the victims in the aggregate the members of the gentle sex the must number thousands. In this city national game of Chinese boxing. In ! and suburbs the demands on the coffin- one of the government schools for : shops are far beyond the available supply. women, Chinese boxing is taught to the ! Coffins have doubled in price, and the girl students. j carpenters have been reduced to using ! thin boards instead of the heavy planks I n f l u e n z a , i n J a p a n , 1919-1920.— j usually employed. While the greatest Considerable fears are expressed in mortality has been among young children Japan with regard to this season’s in­ and old people, not a few7 young men fluenza owing to the fact that it has first and women have been carried away also, attacked the army and navy where it is -so marin fact that in the case of the claiming victims by the dozen every day. men the supply of labourers has been In Tokio, the Imperial Guards are most very seriously affected. badly affected by ’flu, while on board In the face of a crisis such as this several warships at Kure fifty or more are it is interesting to observe some of the laid up on each vessel. As there are methods the people employ in their growing indications of the spread of the ignorance. In one village where there epidemic in Tokio, the health authorities had been sixty or seventy deaths from are advising the public to avoid, when­ contagious disease, the people said the ever possible, going to crowded places. deities must be propitiated by theatricals, so these were arranged and people came flocking from all the surrounding coun­ H o n g k o n g : P r e c a u t i o n s a g a i n s t try. The result in the dissemination of Y e l l o w F e v e r .— At a recent meeting the diseases may well be imagined.