1188 IRELAND.-BRITISH ORTHOPEDIC ASSOCIATION.-THE SERVICES.

and also thanked the President for occupying thechair. Lastly, in the name of the subscribers, hethanked the artist, Mr. David Alison, who had sosatisfactorily carried out the commission entrusted tohim.The proceedings closed with cheers for Dr.

Bramwell. ______________

IRELAND.

(FROM OUR OWN CORRESPONDENT.)

The Dail and the Dublin Hospitals.A DEBATE took place last week in the Dail out of the

vote of 216,738 for hospitals and charities. This sumis made up of grants voted at various times by theold Irish Parliament or the British Parliament in aidof various Dublin hospitals, and they are withoutsystem and proportion. The amounts bear no

relation to the absolute or relative needs of theseveral hospitals. Mr. T. Johnson asked that theMinisters for Home Affairs and for Finance shouldconsult in order to devise a method of financing thehospitals to a much greater extent. Mr. D. Figgisurged the appointment of a commission to reconsiderthe grants and treat the hospitals as primarily apublic responsibility. Sir James Craig supportedMr. Figgis’s demand and argued against any Statecontrol of the hospitals. He thought that Statecontrol would increase the expense and diminish theefficiency of the hospitals. He thought a commissionought to report on the financial position of thehospitals. Mr. Blythe promised that the wholematter would be considered very shortly, and not, asin the past, with one department looking after onesection and another looking after another. A publichealth Bill was being drafted.

The Sweepstakes Bill.The Public Charitable Hospitals Bill, generally

known as the Sweepstakes Bill, came up in thecommittee stage before the Dail last week. Aftersome debate it was referred to a select committee,with power to examine witnesses and call for papersand records. Enthusiasm for the Bill seems to haveevaporated, and the reference to a select committeewas spoken of-though not without protest-as adecent interment. It is worth noting that the pro-moter of one of the recent sweepstakes-while keepinghis contract with the hospital concerned-admittedthat the venture had not been over-successful.

A .Forthcoming Census.In the Dail last week the Minister for Local Govern-

ment announced that it would be desirable to have acensus soon. The census in Ireland has been duesince 1921. Preparations were being made in thatyear to have the census taken at the same time as itwas to be taken in Great Britain. The condition of thecountry was then so disturbed, however, that theauthorities of the time wisely abandoned the idea ofa census, which, if it were taken at all, would onlyhave given misleading results. Since 1921 no

favourable opportunity has occurred, but there seemsto be no longer any reason for postponement.

BRITISH ORTHOPÆDIC ASSOCIATION:AN INTERNATIONAL MEETING.

THE meeting of the Association held at Leidenon May 24th was attended by 24 members ’fromEngland and Ireland, and several Dutch visitors andone Austrian were present. The programme ofscientific work was provided entirely by Dutchorthopaedic surgeons and included the following shortpapers and discussions :-

Mr. Alvares Correa : On Avulsion of the Axillary Nervein Dislocation of the Shoulder.-On Multiple Enchondromata.

J. van Asscn : Excision of the Obturator Nerve in SpasticConditions.—Demonstration of an Orthopaedic OperatingTable.-Demonst,ration of an artificial leg.

W. F. Wassink: Demonstration of an instrument fordirecting Albee’s peg in fracture of the femoral neck.-Reconstruction of the Socket-roof in the Hip-joint.

J. W. P. Fransen : On the Treatment of NeglectedCongenital Dislocation of the Hip.Murk Jansen : Demonstration of cases.-Clawfoot and its

treatment.-Clubfoot in the Adult and its treatment.-Abdominal Pressure in the treatment of Deformities of theSpine.-Flattened Hip-socket and its Sequoias.—Demonstra-tion on how the plaster bed in side position is made.

Dr. Murk Jansen, of Leiden, met the members ofthe Association and arranged for their entertainmentthroughout the day. Most of them proceeded on theevening of May 24th to Amsterdam, where theyattended the twenty-fifth anniversary meeting of theDutch Orthopaedic Association. This meeting was heldunder the presidency of Dr. Jansen and was of aninternational character. On May 25th the papersincluded one by Dr. Lorenz on an Operation forUntreated Congenital Dislocation of the Hip, by SirRobert Jones on Orthopaedic Experience During theWar, by Dr. Calot on the Nature of Arthritis Deformansof the Hip, Dr. F. H. Albee on Bone Transplantation,Dr. Biesalski on the Physiological Treatment ofInfantile Paralysis, Dr. Spitzy on the Surgery of theJoints, and Dr. Putti on Arthroplasty, in addition toeight papers by Dutch surgeons. On the morning ofMay 26th the meeting discussed the social care ofcripples when the methods of organisation in theBritish Isles, Germany, Austria, America, and theNetherlands were described by representatives of thesecountries.The British visitors were liberally entertained by

their hosts in Holland. A largely attended dinner ofthe combined British and Dutch Associations was heldat Amsterdam on May 25th, and on the following daythe party was taken for a trip on the Zuyder Zee,visiting Marken and Vollendam. As the dam, whichis to enclose a large section of the Zuyder Zee, willshortly be finished, this trip, which is very well knownto visitors to Holland, will probably be impossibleafter the present year.

The Services.ROYAL NAVAL MEDICAL SERVICE.

R. R. Baker is entered as Surg. Lieut. for short service.Surg. Lieut.-Conidrs. to be Surg. Comdrs. : L. A.

Moncrierf, A. C. Paterson, H. E. Scargill, and T. Cock.

Lt.-Col. P. H. Henderson, R.A.M.C., to be Asst. Directorof Hygiene, vice Maj. and Bt. Lt.-Col. W. C. Smales.

ROYAL ARMY MEDICAL CORPS.

Maj. M. J. Cromie, half pay list, late R.A.M.C., retires onret. pay on account of ill-health contracted on active service,and is granted the rank of Lt.-Col.

Maj. J. H. R. Winder to be Lt.-Col., to complete estabt.Maj. and Bt. Lt.-Col. W. C. Smales relinquishes the temp.

rank of Lt.-Col.Maj. A. C. Osburn retires on ret. pay and is granted the

rank of Lt.-Col.The undermentioned Capts. retire, receiving a gratuity :

H. H. Mulholland (granted the rank of Maj.) and M. McGeeRussell.Temp. Capt. C. K. O’Malley relinquishes his commn. and

retains the rank of Capt.TERRITORIAL ARMY.

General List : Capt. G. B. Tait, from 7th Bn., MiddlesexRegt., to be Lt., and relinquishes the rank of Capt.

Capt. F. J. Lidderdale (late R.A.M.C.) to be Lt., andrelinquishes the rank of Capt.

Capts. F. F. T. Hare and W. P. Moffet relinquish theircommns. and retain the rank of Capt.

Capt. A. Wilson relinquishes his commn. and is grantedthe rank of Maj.

Capt. R. W. Aitken, having attained the age limit, isretired, and retains the rank of Capt.

INDIAN MEDICAL SERVICE.Samuel Mufty to be temp. Lt.The King has approved the retirement of Lt.-Cols.

W. J. W. Brackenbury and W. Hesketh. Also of Cart.B. G. S. Clarke on account of ill-health.

1189DELAY IN GIVING DIPHTHERIA ANTITOXIN.

Correspondence."Audi alteram partem." " I

DELAY IN GIVING DIPHTHERIA ANTITOXIN.To the E’ditor of THE LANCET. I :

SiR,-Although the paramount importance of

giving antitoxin in the early stage of the disease iswell recognised by those who have seen much of

diphtheria, there is evidence, unfortunately, thatthis fact is not so widely appreciated as it should be.A striking illustration is afforded by the experienceobtained in one of the large metropolitan feverhospitals during the past year. Of 150 cases ofdiphtheria which proved fatal at this hospital during1922, according to the report of the medical superin-tendent, no less than 46, or 30 per cent., died within24 hours of admission, and 17 more, or 42 per cent.,within 48 hours.In view of the almost invariable success of anti-

toxin, if administered in the early stage of diphtheria,and the comparative harmlessness of the remedy,even should its use subsequently prove to have beenunnecessary, this record must be regarded as nothingshort of deplorable. In some instances the delay insecuring a proper treatment is due to the failure ofthe patient’s parents to call in a doctor, perhaps onaccount of expense, or, possibly, by reason of theirnot realising that he is ill. The general appearanceof a diphtheria patient, especially in severe attacks,is occasionally very deceptive in the early stage, andeven the medical attendant is apt to be misled,unless the throat be examined.

I am convinced, however, as the result of observa-tions extending over many years of cases of diph-theria received into hospital, and a knowledge of thecircumstances attending their removal, that the mostfrequent source of delay in treatment is the fatalpractice of awaiting the result of bacteriologicalexamination before deciding to give antitoxin, or

sending the case into hospital. Hesitancy on thepart of the practitioner to certify for removal beforehis diagnosis is confirmed is not unnatural, but thesame objection does not apply to giving antitoxin.Until outside practitioners can be persuaded toadminister serum on the mere suspicion of a casebeing one of diphtheria, the sad experience of patientsbeing so frequently sent into hospital in a hopelesscondition will continue to be a reproach to theprofession.

It has been stated that a belief exists in the mindsof a good many outside practitioners that the medicalsuperintendents of the fever hospitals are averse toantitoxin being given to patients before they aresent into hospital. I do not know on what founda-tion this belief exists, if, indeed, it does exist, but Ido know that the fact is quite to the contrary. Speak-ing on behalf of all my colleagues in the fever service,I am able to assert that if serum were to be given toevery case of suspected diphtheria at the earliestpossible moment before being sent into hospital,such action on the part of the certifying practitionerwould be warmly welcomed- It is with the objectof removing any misconception on this point whichmay exist that I venture to trouble you with thiscommunication.-I am, Sir, yours faithfully,

F. FOORD CAIGER,Chief Medical Officer, Infectious Hospitals Service,

Metropolitan Asylums Board.London, S.W., June 1st, 1923.

IS DIABETES MELLITUS A PROGRESSIVEDISEASE ?

To the Editor of THE LANCET.. SIR,-Prof. H. Maclean in the address publishedin your issue of May 26th states that " in humandiabetes two factors are present : (1) An essentiallyprogressive lesion absent in experimental .animals ; , I

and (2) the detrimental effect of improper diet." Idoubt whether anyone who has studied diabetesmellitus will disagree with the second factor. Thereare some, amongst them the writer, who do notagree that diabetes is essentially progressive whenthe detrimental effect of an improper diet is removed.In some lectures delivered at the London HospitalI spoke of the conditions other than improper dietthat lead to progress, several of which might awakenalmost any obsolescent disease.1At the moment there are two camps : the belief

in one is that correct diet will prevent progress ofthe disease ; in the other, that however the diet beregulated the disease will progress. The first ques-tion which must be settled is this : Are the methodsof regulating the diet adopted by the two campsidentical ? I do not know, and Prof. Maclean doesnot give me an opportunity of deciding. But I doknow that it is not possible to find the correct dietby regulating it to prevent either glycosuria, or

hyperglycaemia before meals. In my experience thediet which prevents the blood-sugar rising at anytime above 0-15 per cent. arrests the disease, exceptin the conditions referred to above.

These two views were of considerable importancebefore the advent of insulin ; now it is essential thatcrucial experiments be carried out to decide whichis correct. If diabetes mellitus be essentially a

progressive disease, comparatively little will be gainedby correlating dose of insulin and diet to preventhyperglycsemia, for in any case the pancreas willgradually deteriorate. On the other hand, if sugarin the blood be the stimulus to activity for thepancreas and overwork is the cause of the deteriora-tion, then the diet and dose should be fixed to preventhyperglycaemia at any time.

I am, Sir, yours faithfully,Portland-place, W., May 29th, 1923. O. LEYTON.

IS INFANTILE DEATH-RATE SELECTIVE?To the Editor of THE LANCET.

SIR,-I have just read your leading article ofMarch 17th with the above title, and I have alsore-read Chapter XVI. of Prof. Raymond Pearl’s mono-graph from which you quote, and I am still of theopinion that he j Listifies what you call his " dogmatic "statement. Your criticism is based on two argu-ments : (1) That partial correlation coefficients are notreliable, and (2) that there are wide differences ofinfantile mortality in differing districts which must beascribed to differences of environment. I am sur-prised that no statistician has written in defence ofpartial correlation coefficients (having due regard toprobable error and the possibility of spurious correla-tion), and I will not pretend to the necessary mathe-matical knowledge to do so myself. But the secondargument appears to me to miss the mark.Take a hypothetical case. Suppose two batches of

ten boys of exactly similar hereditary constitution.One batch is sent to a school where no epidemicoccurs, the other to a school where there is a severeepidemic of diphtheria. The first batch all survive,but six of the second get diphtheria, and two die.Now, the facts that there is a markedly differentdeath-rate between the batches and that properprecautions might have prevented that epidemic ofdiphtheria, have surely nothing to do with the

question whether or no the diphtheria acted selectivelyupon the six who were taken ill !However, though Prof. Pearl is happy that truthshould be vindicated, there is no reason why welfareworkers need be unhappy about it. They maycertainly be preserving lives which are destined tobe below the average in duration, but not necessarilyin value. As a race we have no ground for fearingthat their efforts will do us harm ; our expectation oflife is all the time forming a more and more satis-factory curve from the sociologist’s point of view.

1 Brit. Med. Jour., April 28th, 1923.