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TROPICAL MEDICINE IN THE FAR EAST.

IF a bulky volume be any index of a successfulmeeting, then the Sixth Congress of the Far EasternAssociation of Tropical Medicine must have trans-cended all its predecessors. In the 1197 pages ofits transactionsl is contained a variety of pabulumto suit the most catholic of tastes. There are no

less than 149 original contributions, and the subjectsrange from tatooing and dentistry to elaboratebiochemical and metabolic studies. The Congresswas inaugurated with an eloquent address bythe Prime Minister of Japan, Viscount TakaakiKato, followed by Prof. Shibasaburo Kitasato,whose name is familiar throughout the medicalworld. Appropriately enough, the subject of beri-beri and nutritional diseases occupy quite one

quarter of the volume. and it is a matter of veryconsiderable ecological interest that undoubtedpellagra has been recorded in Japan by Dr. MinoruItoh. There are many papers of helminthologicalinterest, such as studies on clonorchis infection. on thelung-fluke (paragonimus), by H. Kobayashi; hookworminfestation among Japanese immigrants and residents.the pathology of Schistosomum spindale, by Dr. N. H.Fairley and Lieut-Col. F. P. Mackie; and a differentialtable of 17 species of schistosomes, by B. Tanabe.which affords, for the first, time, an accurate synopsisof the subject. Anthropology has not been neglected.for there are studies of the racial indices andcilaracteri sties of the aboriginal Ainu and other folkfrom Saghalien and China. The great majorityof the contributions are written in English or Germanlanguages, though there are a few from Indochinain French. The secretaries of this meeting, Dr. S.Hata and Dr. Y. Miyagawa, are to be congratulatedon the efficient manner in which they have com-pleted their unenviable task in collecting thisheterogeneous matter into one volume, the printingand binding of which leave nothing to be desired.

THE GENESIS OF GASTRIC PAIN.

THE common association between gastric and.duodenal ulcer and high concentrations of hydro-chloric acid in the stomach is too well-known to

require comment, but the actual part played bythe acid in the genesis of gastric pain is not yet fullyunderstood. On the one hand. the word hyper-chlorhydria reminds us that to a great manyphysicians some excess of acid in the stomach mayby itself be the explanation of unusual symptoms;on the other hand, the work of A. F. Hurst andothers, and of Izod Bennett and others, teaches usthat not only does the introduction of strong acid- into the normal stomach not induce pain, but thatwhen a large number of normal stomachs are

examined cases are not infrequently encounteredin which the normal acidity is fully as high as thatmet with in disease. The subject of the mechanismof pain in gastric and in duodenal ulcer has recentlybeen further investigated by Dr. W. L. Palmer whohas introduced acids and other chemical irritantsinto the stomachs of patients suffering from pepticulceration. With normal men he found that theintroduction of 0-5 per cent. hydrochloric acid-solution caused either no sensation at all, or at mostone of slight epigastric burning. In patients sufferingfrom gastric or duodenal ulcer, on the other hand.such injections led to the immediate occurrence ofpain which the subjects described as indistinguishablefrom their normal pains. The fluids used for suchinjections were of interesting variety. Sometimesthe patient’s own acid stomach contents were

removed, their reinjection subsequently producingtypical pain : in other cases solutions of hydrochloricor sulphuric acid were employed with similar effects.Sodium hydroxide in tenth-normal solution produced

1 Far Eastern Association of Tropical Medicine, Transactionsof the Sixth Congress, Tokyo. Kyorinsha Medical PublishingCo. 1925. Vol. I. Pp.1197.

2 Arch. Int. Med., 1926, xxxviii., 694.

similar pain. the symptoms in both acid and alkaliexperiments disappearing when the stomach hadby secretion or regurgitation reduced the strength ofthe exciting chemical to something approachingnormality. Some of the patients were seen at periodswhen they were without symptoms, and it was foundthat in these circumstances the introduction of acidprovided no sensory response. In general, Dr. Palmerconcludes that the gastric acid acts as a true chemicalirritant to the pain-producing mechanism, thevariable factors on which the production of paindepends being (1) the sensitiveness of the pain-producing mechanism, (2) the concentration of theacid, (3) the amount of acid used. (4) time. (5) therate of emptying of the stomach, and (6) the rateand amount of duodenal regurgitation. Theseexperiments seem to produce confirmatory evidencein favour of the view that, whilst the gastrichydrochloric acid is norrnally responsible for theexcitation of pain in gastric ulcer, it is necessary foran ulcer or other pain-producing factor to be presentbefore this symptom can be aroused. The termhyperchlorhydria is, in short, misleading, and shoulddisappear from diagnostic nomenclature. In thisconnexion it is interesting to note Prof. M. T. Finney’sstatement in the discussion reported on page 228that the action of gastric juice does not prevent therapid healing of artificially produced defects so longas there is no interference with the blood-supply.

ANTI-VIPER SERUM.’1’HE serum treatment of snakebite is now well

, established in India, South America, and othercountries where deadly snakes are common, butalthough there are a fair number of casualties everyyear from the bites of vipers in Europe, little has beendone to provide an efficient seral antidote. The

; demand for it may be small, inasmuch as only a smallproportion of viper bites are fatal, but the greathindrance to its production lies in the fact that. vipersbeing much smaller than cobras and rattlesnakes,it is difficult to obtain sufficient venom for practicalpurposes. Colonel M. L. Crimmins states that it takesas many as 200 rattlers to give 60 c.cm. of venom. Theonly European source of anti-viper serum at presentis Prof. Calmette’s laboratory at the Pasteur Institute,where the poison used is that of Vipera aspis; butProf. R. Kraus, of Vienna, has recently demonstratedthat the antidote need not be rigidly specific.2 Hehas experimented with two other sera besides that ofCalmette ; one prepared from the blood of animalsinoculated with the poison of Lachesis jararaca, andanother taken from blood rendered immune to themixed poison of several South American vipers. Hefound that the first of these would not only neutralisethe poison of Vipera aspis when mixed with it,but was as effective as Calmette’s serum when injectedseparately into an inoculated animal. He points out,however, that this serum contains two separateantitoxins, which have similar properties in vitro butnot in vivo-a discrepancy which has been alreadyremarked on by workers on antidiphtheric andantidysenteric sera. The antilachesis preparationwould neutralise a dose (0’03 mg.) of aspis poisonsufficient to kill a normal guinea-pig in 1-3 hours,and should therefore, Prof. Kraus considers, beeffective on human subjects suffering from the bitesof European vipers. The second preparation, whichhas the formidable name of " Vital Brazil polyvalentanti-Bothrops," proved as efficient as Calmette’sserum, 1 c.cm. saving guinea-pigs after a dose of0’025 mg. of aspis poison, and 3 c.crn. after a dose of0’05 mg.-a control animal dying in one hour from theeffects of 0’025 mg. While Prof. Kraus’s experimentsthus indicate a second existing source of efficient anti-viper serum, it would be inconvenient for cliniciansto rely on a South American remedy, and it is to behoped that further experiments will be made nearerhome. It might, for instance, be possible to manu-

1 Jour. Amer. Med. Assoc., Nov. 13th, 1926.2 Wiener Klin. Woch., 1926, lii., 1514.

245

facture a serum in Europe from the poison of Africanvipers, which are probably easier to obtain in largequantities than the European reptile.

STRANGEWAYS MEMORIAL.A MEETING will be held at the Royal Society of

Medicine on Wednesday, Feb. 2nd, at 5 P.M., insupport of an appeal arising out of the prematuredeath of Dr. T. S. P. Strangeways, which was recentlyrecorded in THE LANCET. Dr. Strangeways left;, widow and seven children, the five youngest ofwhom are still being educated, and all the circunx-stances will elicit the deep sympathy not only of hiscolleagues and workers along his special lines, butthrough the whole medical profession. It is knownto many that any part of his income which was notrequired for household expenses was habitually usedby him to assist the Research Hospital at Cambridge ;he could never divorce personal needs from those ofthe work he was passionately engaged upon. Theimmediate position of the family has been met bysubscriptions from friends in Cambridge, but a largesum will be required to complete the education ofhis sons, the eldest of whom is in his second year atTrinity Hall. During the last 30 years a very largenumber of medical men graduating at CambridgeImye been taught by Strangeways the essentials ofpathology, and these men in particular may feel thatthis is an opportunity of expressing their appreciationof his work ; but the additions to medical knowledgemade by him, as well as his self-effacing enthusiasm,give the family a. claim upon all medical men. The

appeal is now open and cheques should be drawnto Lloyd’s Bank, Cambridge, and crossed " c/aStrangeways Memorial Fund." They may be sentto Mr. G. F. C. Gill, manager of the bank, who haskindly consented to take charge of the account, orto Sir Humphry Rolleston. Southfield, Cambridge,to Prof. H. R. Dean, Dr. M. Donaldson, Dr. G. P.Bidder, Dr. L. E. Shore, or Dr. Cobbett. We hopethat the meeting at the Royal Society of Medicineon Wednesday next will be fully attended by thosewho sympathise with an appeal that is alike urgentand well justified. _____

Sir Ernest Hodder-Williams’s condition indicatesthat during the past week he has made satisfactory progress. ’,.

The Services.ROYAL NAVAL MEDICAL SERVICE.

Surg. Comdrs. J. C. Bringan and G. B. Scott are placedon the Retd. List with the rank of Surg. Capt.

Surg. Lt.-Comdr. H. C. A. Tandy-Cannon is placed on theEmergency List.Surg. Lt. (D) E. G. Adams to be Surg. Lt.-C’omdr. (D).T. Prentice, P. II. Deeny, C. R. Boland, and G. Rorison

to be Surg. Lts.

ROYAL ARMY MEDICAL CORPS.Capts. W. C. Hartgill, J. II. Baird (Prov.), and F. Harris

(Prov:) to be Majs.ARMY DENTAL CORPS.

Maj. J. G. Worsley (Temp. Sqdn. Leader, R.A.F.) retires.Temp. Capt. W. A. Cowden, Dental Surg., Gen. List,

to be Capt.TERRITORJAL ARMY.

Lt.-Col. J. W. Kemp to be Bt. Col.2nd Lt. W. L. Kinnear. late 4th/5th Bn. Black Watch,

to be Lt.Capts. R. D. Cran and R. A. Lennie to be Majs.Lt. J. F. Fraser. from the Gen. List, T.A., to be Lt.

with precedence and to be supern. for serv. with the Med.Lnit, Aberdeen rniv. Contgt. Sen. Div., O.T.C’.R. A. M. Scott to be Lt.

ROYAL AIR FORCE.The undermentioned are granted short service commissions

as Flying Oiticers. for three years on the active list : J. E.Foran and M. O’Regan.

Modern Technique in Treatment.A Series of Special Articles, contributed by invitation,on the Treatment of Medical and Surgical Conditions.

CCVIII.—TREATMENT OF UNUNITEDFRACTURES.

1. GENERAL PRINCIPLES.*

Ix recent years much light has been thrown on theprocesses of bone repair both by animal experiment and also by practical experience with the mass ofbone injuries and ununited fractures left in the wakeof the Great War. Now, too, the increasing-frequencyof street accidents makes the subject of the treatmentof ununited fractures one of growing importance.As in many other branches of surgery, the most

effective and desirable form of treatment is preventive.Moreover, the treatment of each individual case isso much guided by the factors causing the non-unionthat it is necessary to survey briefly the commoncauses of the condition before discussing the relative values of different methods of treatment.

Before proceeding to the operative treatment of acase of ununited fracture, it is important to diagnosethe cause of the non-union, since, if this is not merelya mechanical one which can be eliminated at theoperation, the same factors will continue to act andwill almost certainly mar the final result.

Causes o,f Failure to Unite. -

General causes of non-union include conditions whichlower the bodily vitality in any way-e.g., acuteillness ; chronic diseases like nephritis and tabes ;other conditions which directly upset the calciummetabolism of the body, such as the various typesof fragilitas ossium, scurvy, and rickets ; variousobscure diseases of the ductless glands ; and old age,in which the processes of decalcification normallyoutrun those of ossification.

Local abnormalities of the bone, such as the presenceof a tumour or a cyst, which may itself have beenthe original cause of the fracture, can usually bediagnosed by X rays, and should always be suspectedwhen a fracture occurs after very slight violence.

Other local causes are usually mechanical, such as theinterposition of muscle or periosteum between thebone-ends, and if such are known to exist, or are

strongly suggested by the X rays, operation shouldnot be delayed. Another local complication is injuryto the nutrient artery, and recent experiments on animalssuggest that this plays an important part in theproduction of the non-union.

In the treatment of fractures it must always beremembered that bone is a living, varying structure, notconstant in shape and density like the leg of a table. Everybone in the body is the constant subject of a doubleprocess-i.e., simultaneous destruction and reconstruction.The balance of these two processes is influenced by age,disease, and accident. In children the constructive processpredominates, giving increase in length, width, and densityto the bones. In old age the destructive phase is theprominent one, so that the bones become more porous andbrittle. It is evident, therefore, that fractures in childrenare likely to be followed by rapid union, but there is a dangerof excessive callus formation, which may interferemechanically with neighbouring joints : in the fractures ofold age, on the contrary, union is likely to be delayed, butthe vigorous manipulations that stimulate it can be resortedto without fear of inducing excess of callus.With regard to the function of the periosteum, it seems

to be generally agreed now, after much swinging of thependulum, that the fibrous layer acts as a limiting membrane,to keep the bone-forming elements within due limits ; while.on the other hand. some of the most active of these cellsare to be found just under the membrane, on the surface ofthe bone. Accordingly, when the periosteum is torn thereis a risk of the formation of exuberant spurs of bone ; butif it gets between the bone-ends at seat of fracture it may socheck new-bone formation as to cause non-union. This is avery frequent finding with transverse fracture of the patella* The Treatment of Ununited Fractures—II. Special Fractures

—by Miss Forrester-Brown, will appear next week.