fitina UMial Jmmwl. - Yale University Library Digital Collections

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fitina UM ial Jmmwl.
VOL. X X X V III.
A U G U S T , 1924.
N o. 8
MORBID HISTOLOGY OF PNEUMONIC PLAGUE.
A k ir a F i ji n a m i , m .d ., Professor of Path o lo gy,
Im perial U n iv ersity , K y o to
and
W u L ik n -Te h , m . d ., D irector of M anchurian P lagu e
Prevention Service, M oukden.
The following descriptions of pathologic changes in pneumonic
plague are based upon the examination of small specimens, supplied
by Dr. Wu Licn-teh, from twenty-three cases of this disease which
occurred during the epidemic of 19 2 1 in North Manchuria.
Tonsils.— Eight cases.— Marked hypenemia in all cases.
The tonsils were more or less rich in parenclmnatous cells.
In some cases the so-called “ germinating centres” appeared greatly
enlarged. These “ germinating centres” were composed of large
mononuclear light cells, including histiocytes which act as
phagocytes. These histioc3’tes, containing plague bacilli, were also
frequently observed in other parts of the glands. It is noteworthy
that in some cases these enlarged “ germinating centres” were not
to be found. A slight inter-cellular deposition of hyaline substance
was occasionally observed.
The epithelial layer covering the surface of the tonsil appeared
in most parts to be generally intact, or at least not destroyed.
Here and there, however, destruction of epithelium took place,
accompanied by destruction or necrosis of tonsillar cells of the
superficial laêr, and an emigration of leucocytes. More or less of
inflammatory exudation might have occurred, but no considerable
destruction of tissue was noted.
Plague bacilli, more or less isolated or in masses, existed in
the cavities of the surface and also within the tissue. The
penetration of the bacilli into the tissue at the points of epithelial
'•'Reprinted from the R eport of M anchurian P lagu e P reven tion .Service,
19 23-19 2 4. A bridged .
U n io n H o s p it a l , H u c h o w , C h k k ia n g .
6 i8
T h e China Medical Journal.
i
destruction was dense and the bacilli were found to be massed
about the lymph follicles. Besides the plague tiacilli numerous
Gram-positive bacteria were also observed, especially in the
cavities of the surface, and occasionally in small numbers within
the tissue.
While these tonsils showed considerable liypersemia and some
necrosis of the cells with inflammatory exudation, the pathological
changes were not particularly marked. In comparison with the
changes that occur in the lungs and neighbouring lymph glands
they were very slight. This condition agrees with that observed
in the epidemic of 1 9 1 1 , with one exception. In that case the
lymph glands of the neck showed such remarkable enlargement
with haemorrhages as to indicate that the priraar}^ infection had
occurred in these glands rather than in the lungs. Also the tonsils
and surrounding tissues of the pharynx and larynx suffered great
pathological changes. None of the present specimens exhibited any
such changes as occurred in this particular case.
Kidneys.— In addition to the pathologic tissue changes described,
plague bacilli in the blood vessels of the kidney and also in the
capillaries of the glomeruli were always seen. This was not the case,
however, in the lumen of the tubules. In one of these cases a very few
isolated Gram-negative bacteria were noted, the morphology of which
appeared similar to those of plague bacilli, but it was not possible to
identify them as such. In the epidemic of 1 9 1 1 bacilli were found
within the rectus tubules in only one case. While the passage of
plague bacilli into the urinary tubules may not be impossible, this
is not in any sense a usual or necessary feature. The relatively
small number of plague bacilli in the blood vessels of the kidney, as
compared with those in the liver, corresponds to our observations in
the epidemic of 1 9 1 1 .
Spleen.— Besides the tissue changes described, plague ba
cilli were found to be abundant in the blood space of the pulp. Be
tween the pulp cells they appeared either singly or in colonies.
They were mostly free between the cells, but a few were phagocyted.
Regarding the phagocytosis of plague bacilli in the spleen the speci
mens were not suitable for minute examination, and this report
must accordingly remain incomplete.
But the histological
examination of cases during the epidemic of 1 9 1 1 showed phagocytes
Morbid Histology of Pneumonic Plague.
619
originating from endothelial or reticulo-endotlieliai cells or
histioc3^tes in the pulp. The same condition must have happened
in these specimens also.
The h-mph follicles were found to contain plague bacilli, but
they were less numerous than in the pulp. The bacilli were mainly
limited to the surrounding or peripheral zones of the follicles, as
very few were noted in the central parts. Gram-positive bacteria
in the pulp were found only in small numbers in some cases.
Lu n gs.— Fifteen cases. Pneumonic plague causes most im
portant and very complicated tissue changes in this organ. Several
stages of histological change, from simple hyperaemia, or
hyperaemia with slight serous exudation, to severe cellular
exudation, were observed. More or less haemorrhage occurred in
various parts of the lungs.
Haemorrhage within the alveoli in
these cases was not especially severe, but erythrocytes in larger or
smaller numbers within the alveoli were always apparent. In most
cases, in and under the pleura, haemorrhage was histologically very
marked.
Some haemorrhage was also noted in the interstitium,
especially in the interlobular septum and within the connective
tissue surrounding the bronchi and blood vessels. At the root of
the lung in the connective tissue surrounding the bronchi and blood
vessels severe haemorrhage was sometimes observed.
Fulness and dilatation of the capillaries of the alveolar walls
was noted even in portions of the lung where no plague bacilli were
found in the alveoli, or no inflammatory exudation had taken place.
This hyperaemia was accompanied by serous exudate which filled
the alveoli and contained a few exudative cells, especially leucocytes.
In the early stages of inflammation, plague bacilli occurred within
the serous exudate 111 fairly large numbers. Where the inflam
mation was more advanced the alveoli became filled with cells,
polyuuclear cells being most numerous, but which were accompanied
by mononuclear cells, the latter being mostly histiocytes and
desquamated epithelial cells.
These cells in the exudate were
more or less mixed with erythrocytes and serous exudate which
contained a comparative^ very small quantity of fibrin.
The degree of density of cells in the exudate within the alveoli
varied greatty; in some cases the cells were loosely arranged, while
in others they were closely packed together. In every case the
620
alveoli contained dense masses of plague bacilli. In no other form
of pneumonia are the pathogenic bacilli to be found in such
abundance. It is also characteristic of plague, pneumonia, as
compared with ordinary^ pneumonia, that fibrin exists within the
exudate only in small quantities. The other important histological
characteristic of plague pneumonia is the frequent appearance of
hyaline substance in the alveolar walls.
The presence of this
hyaline material is accompanied by various changes in the walls of
the alveoli. Where these changes occur the latter are irregularly
thickened. This enlargement of the alveolar walls in one case was
due to a hyaline thickening of the capillary walls; in another it was
due apparently’ to hyaline thrombi within the capillaries; and in
still other cases to a hyaline deposition 011 the outside of the
capillary walls or within and inside of the alveoli walls themselves.
T his hyaline deposition was also observed in the epidemic of 1 9 1 1 .
At that time, in addition to a deposition on the alveolar walls, a
similar hyaline substance was observed to radiate out from the
walls of blood vessels. In the present specimens a somewhat
similar deposition seemed to have occurred, but the radiations were
not especially marked.
T h e character of this hyaline substance is difficult to deter
mine, and in chemical composition it may- not be identical; a part
of it without doubt is composed of fibrin. In one case this hyaline
substance yvithin the lumen as well as on the walls of the blood
capillaries of a number of alveoli was very clearly stained by
W eigert’ s fibrin-staining method, while the staining of the fibrin
itself in the same specimen was not good. It is probable that this
hyraline deposition is caused by the severe exudative inflammation
of the lung and, excepting the fibrin thrombi, is a coagulated
substance resulting from the exudation from the blood vessels.
T h is is not necessarily a specific characteristic of plague pneumonia.
T he deposition of hyaline in and on the walls of the ahreoli also
occurs, for instance, in influenza pneumonia. G iant cells of bone
marrow are often to be found in the blood capillaries of the lung
tissue.
“ G itterfaser” and elastic fibre showed no distinct changes in
those portions of the lung which were not affected by inflammatory
exudation. W here marked exudation did occur, however, some
diminution and even destruction of these fibres were to be noted.
Investigation of the distribution of bacilli in the lung tissue
is most important in studying the pathology of pneumonic plague.
They are abundant in the alveoli within areas of hepatization and
also where the alveoli have discharged only serous exudate. In
the former case, where the alveoli are filled with cellular exudate,
the bacilli are densely massed in the spaces between the cells. Of
this great multitude of bacilli only a few seem to be phagocyted by
the cells within the exudate. In some cases the phagocytes for
plague bacilli could only with difficulty be observed in the
pneumonic area. This condition was also noted in the lumen of the
bronchi. Those cells which do act as phagocytes for the plague
bacilli are mainly large mononuclear cells, most of which seem, to
be histiocytes. To what extent polynuclear leucocytes may act as
phagocytes to the plague bacilli is difficult to determine.
While plague bacilli are to be found in abundance throughout
pneumonic lung tissue, including the blood vessels and capillaries,
the greatest accumulations occur in the lymph vessels and lymph
spaces of the tissue. The lymph vessels at the root of the lung
and those accompanying the branches of the bronchi and neighbouring
blood vessels are very often most densely packed with piague
bacilli. The pathological change in the walls of the bronchioli, as
noted above, where the destructive process was working through
from the outside of the wall towards the mucous membrane within,
was due to the virus being brought by the tymph vessels along the
bronchioli.
It was peculiar of many of the blood vessels within the plague
pneumonic area that their walls were surrounded by marked
accumulations of bacilli. This may be due to some perivascular
space which may provide passage for lymph and thus becomes
densely filled with bacilli. Very often the wall of the blood vessel
itself is invaded by the bacilli, and if this is not too thick, as in the
case of the veins, an accumulation of bacilli may penetrate to the
interior, where the endothelial cells are destroyed. In this way
great numbers of plague bacilli enter the blood stream. These
changes in the walls of the blood vessels were also noted in
the epidemic of 1 9 1 1. The lymph vessels, greatly dilated and
fi lied with bacilli, contain also polynuclear leucocytes and some
blood.
622
While the bacilli found in greatest abundance in the pneumonic
areas were almost entireh* plague bacilli, mixed infection in varying
degrees was not uncommon. In most of these specimens, Grampositive bacteria, such as diplococci, staphylococci and other bacilli,
were noted in the blood vessels and alveoli. The number of these
bacteria, however, was much smaller than the plague bacilli. In a
few cases the number of these other bacteria was fairly large in the
pneumonic area, aud they might have aggravated the pneumonic
condition of the lung, but the chief source of pneumonic infiltration,
whose manifestations were almost identical in all cases, is due to
plague bacilli.
Pleura.— In addition to the pathological changes described,
plague bacilli were densety massed in the sub-pleural and pleural
tissue. Occasionally at points on the pleura rather isolated colonies
of plague bacilli, accompanied by some leucocytes, were noted. These
patches did not appear to result from the general process of pneu
monic hepatisation.
Lymph Grlands.— Mesenteric, two cases; cervical, two cases;
bronchial, five cases. In the two cases of mesenteric lymph glands
hyperplasia of cells, accompanied by more or less hyperaemia, was
noted. In one of these a diffused hy'perplasia of lymphoid cells
had occurred, while the other case was marked by a proliferation of
endothelial cells which had filled up the dilated lymph sinus. Socalled “ germinating centres” in the follicles were not well
developed. No necrosis, haemorrhage, or inflammatory areas were
observed, and polynuclear leucocytes appeared only in small
numbers.
Bacilli were not numerous in the blood vessels.
Examination of numerous slides revealed no plague bacilli in the
tissue of the mesenteric lymph glands. In an occasional slide,
among the cells of the tissue, a few bacilli were noted which
resembled plague bacilli, but the exact character of the former
could not be determined.
One of the two cervical lymph glands showed marked
hyperaemia and proliferation of the endothelial cells of the dilated
lymph sinus. In some of the follicles “ germinating centres”
appeared. A s to the existence of plague bacilli, because of poor
staining, no definite results could be obtained. It is at least
-certain that no large accumulations of bacilli existed, and no tissue
changes characteristic of plague were observed.
623
The other cervical lymph gland proved to be severely affected
by chronic tuberculosis. A fibro-caseous substance occupied almost
the whole gland, lymph tissue remaining only iii one corner. T h is
lymph tissue, especially within the lymph sinus, contained small
accumulations of bacilli which resembled plague bacilli. Whether
plague bacilli can penetrate into a tubercular area is an interesting
question. So far as this specimen is concerned, no plague bacilli
were found in the fibro-caseous substance.
The bronchial lymph glands, being most intimately7 connected
with the lung, are the ones which undergo the severest histological
changes in pneumonic plague. The entire tissue of the gland
becomes heavily infected with plague bacilli. Where these were
abundant, the cells of the gland were diminished in number. Cells
undergoing necrosis were seen. No marked blood extravasation
within the gland was observed. On the other hand, the normal
tissue structure of the lymph gland was severely- affected. Elastic
fibres and “ Gitterfaser” were less stained and became attenuated or
even more or less destroyed. Augmentation of bacilli occurred
more markedly in the peripheral zone than in the central
portions, and more 111 the lymph sinus than in the lymph follicles
and medullarv fasciculus. The presence of bacilli could be noted
within the follicles, where they were found scattered among the
lymph cells, particularly if the gland yvas severely- infected, but
the lymph follicles were alwa3’s less affected by’ the bacilli than
other parts of the gland. Often follicles were observed to be
surrounded bv a lajêr of varying thickness consisting of a mass of
bacilli. These seem to offer more resistance to the effects of
plague virus than other parts of the gland tissue, but eventuallythey undergo a gradual atrophy’ and destruction.
Infiltration of polynuclear leucocytes into the tissue of the
lymph gland occurred to some extent. Sometimes these appeared
in fairly large numbers, but no suppurative areas were noted. A
limited amount of serous infiltration was occasionally observed, and
staining revealed the presence oi fibrin, but only in small
quantities. A deposition of hyaline substance on the walls of the
blood vessels and the reticulum , present in cases during the
epidemic of 1 9 1 1 , may also have occurred, but it yvas not promin
ent. In spite of the presence of great numbers of bacilli and some
augmentation of leucocytes and mononuclear m igratory cells,
624
phagocytosis in the lymph glands could not be clearly ascertained.
In some cases no cells carrying plague bacilli could be found. But
investigations during the epidemic of 1 9 1 1 indicated that phagocy
tosis in the plague bubo did occur to some extent, especially in the
early stages of the infection. This was noted particular^’ in the
lymph sinus. In those cases the swollen and desquamated sinus
cells or endothelial cells, which partook of the nature of histiocytes,
acted to a large extent as phagocytes. Other mononuclear cells
may* also have become phagocytes.
It was occasionally noted,
furthermore, that blistered phagocytes which were carrying
lymphocytes and blood pigment had also absorbed some plague
bacilli. Where the augmentation of plague bacilli in the lymph
sinus became ver}’ marked the swollen and desquamated cells and
phagocytes disappeared. This is perhaps the reason why in the
present specimens, which show advanced stages of plague bubo,
phagocytosis is difficult to determine.
In those areas where carbon dust had been heavily deposited
in the bronchial iympli glands the accumulation of plague bacilli
yvas less marked.
The relation of the penetration of plague bacilli into tubercular
areas of the bronchial lymph glands is the same as in the cervical
gland mentioned above.
The tissue surrounding the bronchial lymph glands in the
root of the lung was alway’s infected with dense accumulations of
plague bacilli, and severe haemorrhage was often noted.
Lymph
vessels near the bronchial glands appeared dilated and filled with
bacilli. Numerous leucocytes, lymphocytes, and some red blood
cells were also found in these lymph vessels.
D
is c u s s io n
and
C
o n c l u s io n s .
The most important tissue changes caused by pneumonic
plague occur in the lungs and neighbouring bronchial lymph glands.
In these organs the plague bacilli are most abundant, and the tissue
changes which take place are mainly due to the presence of these
bacilli. The lungs are affected by hypememia, serous and cellular
exudation and more or less haemorrhage. The specimens examined
in connection with this report did not, however, reveal specially
marked haemorrhage into the alveoli. Fibrin within the alveolar
625
exudate was inconsiderable.
Hyaline substance, the origin of
which is more or less intimately related to that of fibrin, was in
most cases found deposited on the alveolar walls.
These tissue changes, together with the enormous increase of
plague bacilli in the pneumonic areas, are characteristic of plague
pneumonia.
The plague bacilli are abundant not only in the alveoli, but
also in the interstitial tissue, especially in the lymph vessels and
spaces in the immediate neighbourhood of the bronchi and blood
vessels and under the pleura. In these lymph passages the plague
bacilli are usually found to be most densety massed. The tymph
vessels at the root of the lung in the neighbourhood of the infected
bronchial lymph glands are likewise always greatty dilated and
filled with bacilli. The lymph vessels seem to provide an especial
ly favourable medium ior the augmentation of the plague bacilli,
and at the same time the}- serve as convenient canals along which
the latter can proceed to other parts of the tissue.
Examination of the lung shows small areas of plague pneumonia
developing in the peribronchial alveoli. The multiplication of
bacilli in the peribronchial and perivascular lymph vessels and
spaces is a most important cause of this lobular pneumonic infec
tion. On the other hand, the spreading of pneumonic areas majalso be due to the inhalation of plague bacilli from the upper and
wider parts of the bronchi and bronchioli into the deeper recesses
of the lung. In this case the mucous membrane of the bronchioli
is affected from within the lumsn and the plague bacilli penetrate
from the mucous membrane, whose epithelium is more or less
destroyed, into the tissue of the walls. This inhalation of bacilli
may also carry them directly into the alveoli.
The peribronchial and broncho-pneumonic areas, whilst expand
ing, join with each other, thus diffusing the pneumonic infiltration
through a large portion of the lung. When, however, the process
of pneumonic infiltration occurs over a wide area in a very short
space of time its relation to the condition of the bronchioli is not
clear.
As to the condition of the cervical, mesenteric and bronchial
lymph glands in pneumonic plague, it is the latter which are by
far the most severely affected both as to pathological tissue change
626
T he China Medical Journal.
and the presence of bacilli which are especially augmented in the
lymph sinus. The tissue of the mesenteric lymph glands showed
only slight evidence of the presence of plague bacilli, and in the
cervical glands no large accumulations of bacilli were found.
Plague infection in an individual may result in some cellular
hyperplasia in these lymph glands. The tonsils are only slightly
affected, comparatively small accumulations of bacilli being found,
and these mainly in the superficial layer.
A STUDY OP THE FAT, LACTOSE, AND PROTEIN
CONTENT OF CHINESE WOMEN’S M ILK*
E
r n est
T so ,
m . d .,
Peking.
The average composition of human milk as given in most of
the older text-books is : fat, 4 per cent; lactose, 7 percent; protein,
1.5 per cent; and salts, 0.2 per cent. The present tendency,
however, is to set the average figures for these constituents at 3.5
percent, 7.5 percent, T.25 percent, and 0.2 percent, respectively1.
The composition of individual samples may vary within wide limits,
particularly as regards the fat content. It is not unusual, for
instance, that the fat content at the beginning of a nursing period
may be as low as 1 per cent, whereas toward the end the fat
may have increased to 7 or S per cent. Of the different constituents
of milk the lactose is the least variable. The protein content varies
to a wider extent than does lactose and less so than the fat.
Denis and T alb o t2 have recently studied the variations of the
composition of human m ilk under certain specific conditions. T h ey
found, among other things, that the lactose content showed a
tendenc}’’ to increase as lactation progressed and to decrease from
the beginning to the end of a single nursing. T he protein is known
to be high in the colostrum m ilk. It rapidly falls to about its
average figure in the transition period when colostrum changes into
mature m iik. According to Denis and T albot, the protein content
tends to diminish further as lactation goes on.
*From the Departm ent of Medicine, P eking Union Medical College,
Peking,
Study of Chinese Women's M ilk.
6 27
The investigation here recorded of the fat, lactose, and protein
content of Chinese women’ s milk was divided into similar lines of
inquiry. These consisted of, first, a study of the composition of
milk at different periods of lactation; second, a study of the
composition of milk at the beginning and at the end of a single
nursing; third, a comparison of the milk of those women who
nurse their own babies with the milk of wet-nurses; and fourth, a
comparison of the composition of milk taken almost simultaneously
from the right and left breasts.
The samples of milk were obtained from the Children’s Wards
and Out-patient Department of the Peking Union Medical College
Hospital. A few samples were taken from the wet-nursery
of the Peking Foundling Home. The fat was determined by the
Babcock method, or, when samples were small, by the Adams-Soxhlet
process, or the Babcock method as modified by the author'1. The
determination of lactose was made according to Folin and Peck’s
titration method4. The protein was calculated from the nitrogen
values obtained by means of the usual Kjeldahl-Gunning method,
the factor 6.25 being employed. It was planned to obtain one
ounce of milk before nursing and one ounce immediate!}- after
nursing from the same breast. In a considerable number of cases
the attempt was not successful owing to the irregularities in nursing
intervals. Typical samples were, however, secured from those
women who came to nurse the sick children in the hospital at
regular hours. It should be mentioned that onty those samples
were included where the nursing babies were either supposedly
healthy or had no disease directlj7 due to the milk.
Table I contains the results of analyses of 87 samples of milk
arranged in the order of age of the nursing child. The average
figures are : fat, 3.72 per cent, lactose, 7 .17 per cent; and protein,
1.36 per cent. Attention is called to one instance (last two anaWses
in Table I) in which the fat was found to be 8.45 per cent; lactose,
4.1 per cent; and protein, 0.32 per cent. I11 this case the child
had been nursed continuously from birth until it was 47 months’
old.* Excluding this case, the range of variations in this series of
analyses is ; fat, o.S to 10.5 per cent; lactose, 6.7 to 8.6 per cent;
and protein, 0.9 to 2.39 per cent.
*There are instances among the Chinese in which the mother nurses
an older child when the younger nursling has died.
Table II illustrates more clearly the variations of the composi
tion of milk according to the periods of lactation. The results seem
to agree with those reported by Holt and his associates5 and other
investigators, in that the fat content is higher in mature and late
milk than in the colostrum; that the reverse is true of the proteins;
and that beyond the colostrum period the lactose does not tend to
vary as lactation progresses. However, Denis and Talbot* noted
rather an increase of the sugar content during the course of
lactation.
Table III shows the variations in the composition of milk from
the beginning to the end of a single nursing. As reported by other
investigators, there is considerably more fat toward the end of
nursing than at the beginning. Variations o f the other constituents
are not so striking or constant.
In Table IV is shown the difference in the fat content between
the milk of those women who nurse their own babies and the milk
of wet-nurses. The higher fat content of “ mothers’ ” milk is
maintained in the fore-milk as well as in the strippings.
A comparison of the composition of milk taken practically
simultaneously from the right and left breasts is presented in Table
V . The figures seem to indicate that although the milk tends to
have the same composition from both breasts, it may vary con
siderably as regards the fat content.
S
um m ary
A study of 87 sampies of Chinese women’ s milk shows that
its percentage composition differs in no essential respects from the
composition of human milk in other countries.
Like the milk of Occidental women, the fat content varies
considerabl}- in individual samples. It is generally high in the
strippings and low in the fore milk. It tends to be higher in
mature and late milk than in colostrum milk. Samples obtained
practically simultaneously from the right and left breasts may
at times be quite unlike in their fat percentage. An investigation
of the milk of those women who nurse their own babies and the milk
of wet-nurses shows that the former is usually richer in fat content
than the latter.
Study of Chinese Women’s M ilk.
T
able
I .— A
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B
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if f e r e n t
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3
4
4
4
4
4
5
5
5
5
5
5
5
„
>1
>>
»i
».
„
(
A g e of
m other
29
29
29
24
24
26
27
21
27
23
23
26
23
22
22
M
2Q
26
31
38
20
29
28
22
28
...
36
36
29
33
„
o th er s at
Sam ple
A g e of
taken before
wet1 or after
nurse
n u rsin g
28
28
32
26
>1
»
»
ii
n
n
j*
5-5 »
5-5 »
6
„
6
„
6
„
6
,,
0
6
„
6
h in e s e
a c t a t io n
M
3
1.27
1.3S
1.47
i -35
1.20
1.17
i -95
i.oS
1.24
1.28
J - i5
1.S3
1.24
1.46»
2.20
1.02
1.2 0
1 .1 8
1.20
C
629
24
24
21
21
27
29
29
2S
25
3 3
3 3
28
2 3
2 3
25
3 8
Before
Before
A fter
Before
Before
A fter
A fter
Before
A fter
Before
Before
A fte r
A fte r
Before
A fte r
A fte r
Before
A fte r
A fte r
A fte r
Before
Before
A fte r
A fte r
Before
Before
Before
A fte r
A fte r
A fte r
A fte r
Before
Before
A fte r
Before
A fte r
B efore
B efore
A fte r
A fte r
A fte r
A fte r
A fte r
B efore
B efore
B efo re
A fte r
A fte r
The China Medical Journal.
630
A m ount
Fat
L acto se P ro tein
of
p ercen t p ercen t percent
sam ple
a ge
age
age
20
25
c.c.
35
„
20
30
30
10
30
~5
30
*5
„
„
„
„
„
»
>»
„
20
»
„
15
„
25
t)
30
30
20
30
„
«
25
»
„
„
6.30
8.64
6-75
4-55
3-30
1.80
2.30
2.90
0.80
315
3-55
I -55
7.61
7.16
8.60
8.40
7 .12
„
*5
»
4.20
1.80
3.00
*5
30
»
3-75
„
„
20
15
15
15
15
s
10
„
„
„
»
„
„
„
f)
„
A v e ra g e
7-56
1.70
2.40
4 -r5
7.28
7-56
7 34
7.10
7-34
4-05
7 .10
3-65
7.21
7 .10
b.92
8.76
2.70
3 -7»
4.40
3.00
3-55
3-6 o
8-45
3.72
T.4M.E II.— A
»
27
»
32
7
u
„
24
24
21
27
S
„
s
s
8
8
8
„
„
10
10
10
10
11
11
20
21
„
».
»
„
„
25
25
27
27
35
„
„
20
„
20
30
30
II
12
12
12
13
13
14
14
14
15
15
»
IÓ
„
24
»
»
„
..
¿73
1 . 17
1.05
1.42
i -34
1 .1 7
1.6 1
17 2
30
4 .10
0.32
47
47
7 .17
1.36
verage
30
30
U
1-34
6.92
7.09
18
„
„
A fte r
A fte r
A fte r
A fte r
A fte r
B efore
B efore
Before
Before
B efore
Before
A fte r
B efore
A fte r
B efore
A fte r
B efore
B efore
A fte r
A fte r
Before
A fte r
Aftfer
A fte r
A fte r
Before
A fte r
A fte r
A fte r
A fte r
Before
Before
A fte r
A fte r
A fte r
A fte r
A fte r
31
3i
19
7
7
9
9
i . 21
7-23
Sam p le
A g e of tak en before
wetor after
n u rse
n u rsin g
7
8
0.90
2.01
i -59
1.26
i . 21
1 . 10
1.58
1-15
1.03
1 . 19
1 . 14
1 . 14
1.17
1.20
1.30
1.83
i -33
1.19
1.12
7.80
6.92
7-34
7-34
7-3°
7-34
7-52
*5
J5
35
35
6.70
3-20
4 .10
8.40
2.52
2.80
1.60
„
„
6 73
6.92
»
»
„
6.90
4-§5
3-25
30
15
20
7 .10
7-03
6.5 m os.
6.5 ,,
/
>J
I -3 i
1.46
1 . 12
1.12
2 .10
1.22
13 1
7-34
2.00
25
20
7.20
7-34
A g e of
m other
A g e of
ch ild
32
34
34
„
„
»
»
20
20
25
...
24
24
20
2\
27
24
4i
33
33
C o m p o s it io n o r M i l k o f C h i n e s e M o t h e r s
P e r io d s o r L a c t a t io n
a c c o r d in g to
Periods
F irst 10 days
One to 9 m onths
A fter 9 m onths
N o. of
an alyses
6
58
23
Fat
percentage
Lactose
percentage
Protein per
centage
2.24
7 .1 1
1.89
3.86
372
7-17
• 7 .18
1-35
1.2 3
__ _
Study of Chinese Women's M ilk.
T a b le I I I .— A
n alyses
B eg in n in g
•Sample obtained
before or
a fter
n u rsin g
and
of
C h in e s e M o t h e r s ’ M il k
E nd
of a
Before
A fte r
15
Before
A fte r
30
25
„
„
3-94
7.46
6.84
Before
A fte r
20
,,
»>
3.60
7.18
3°
5-40
7-34
Before
A fte r
,,
„
1.20
7.40
7.10
20
Before
A fter
3°
15
»
>,
2.30
5 .10
6-73
Before
A fter
20
„
4-55
7-°5
15
»
B efoie
A fter
30
15
„
2.00
„
4-§5
6.92
1.26 j
Before
A fter
30
„
20
„
1.70
2.40
7.10
7-34
1.19 )
1.12 )
of the
A
15 c.e.
„
2-34
2.70
2.70
10.50
T ahle IV .— A C o m p a r is o n
of
at t h e
S in g l e N u r s i n g
Fat
Lac
Protein
A ge
per
tose
percent
of
cent- percent
age
child
age
age
A m ount
of
sam ple
25
631
C h in e s e M o t h e r s
and
2.08 ■)
2 .3 9 )
7-34
7-32
1 mo.
7.5(1
34
23
years.
2 mos.
22
years.
1.08 7
1.24 >
5 mos.
24
years.
1.28 )
i- i5 J
5 mos.
21
years.
1.2 4 ^
1.4 6 3
5 mos.
1-59 7
8 mos.
6.92
7-03
verage
29
y e rrs ,
30
years.
34
12 „
C o m p o s it io n
A ge
of
wetn u rse
years.
i -35 1
i . 83 5
7-03
of
4
d ays
A ge
of
m o
ther
years.
of
M il k
C h in e s e W e t -N u r s e s .
Protein
Fat
| L actose
No. of
A n a ly ses percentage! percentage percentage
W et-nurse before n u rsin g
W et-nurse after n u rsin g
A verage
“ M others ” before n u rsin g
“ M o th e rs ” after n u rsin g
24
22
A v e ra g e
3-h7
,
j
7.20
7.19
i -39
1.42
3-41
j
7.19
1.4 1
3-03
5-°4
.
7.19
7.06
1.40
1.2 3
2.87
13
27
;
3-99
j
7-13
j
i -32
T h e China M edical Journal.
632
T able V .— A n a l y s e s
of
fro m
Lactose Protein
Fat
p ercen t percent percent
age
age
age
A m ount
of
sam p le
S am ple from
rig h t or left
breast
M i l k o f C h i n e s e M o t h e r s s im u l t a n e o u s l y
R i g h t a n d L ef t B r e a s t s .
the
A ge
of
ch ild
Sam p le
tak en befor
or after
n u rsin g
2 m onths
A fte r
4 m onths
A fte r
!
R ig h t
L e ft
35 c .c.
25 >>
3--5
4-25
7.20
(1.02
1.04
1.40
R ig h t
L e ft
30
20
„
„
2.So
0.90
6-73
7-34
1.47
R ig h t
L e ft
10
15
„
3-25
3-70
7.02
7'34
1.18
1.12
6 m onths
A fte r
R ig h t
L e ft
20
25
„
»1
6.30
S.64
7.20
i- 3 i
1.4(1
n.5 m onths
A fte r
R ig h t
L e ft
30
„
„
1 .So
2.30
6-73
30
1.22
1-3 1
7 m onths
Before
R ig h t
L e ft
30
20
„
„
2.52
2.80
7 3°
7-34
!
1.03
1.19
10 m onths
Before
R ig h t
" L e ft
15
,,
»
1.80
3.00
8. bo
j
| 8.40
|
'
i .30
1-83
11 m onths
A fte r
*5
I
j
j
1
1-55
7-43
6.70
i
The lactose is, relatively speaking, the most constant. The
protein content varies to a wider extent than does lactose, and less
so than the fat.
B i b l io g r a p h y
1. H o lt, L . E -, and H ow land , J . T h e D iseases of In fa n c y and C h ild
hood, 1922, p. 140. D. A pp leton & Co.
2. D en is, and T alb ot, 19 19 . A m . Jo u r. D is. C h ild ., x v iii : 93.
3. In P ress.
4. F o lin , O., and P eck , E . C., 19 19 Jo u r. Bio. Chem . x x x v i i i : 2S7.
5. H o lt, L . E ., C o u rtn ey, A . M., and F a le s, H . L . 19 15 A m . Jo u r. D is.
C h ild ., 229.
D r i e d M i l k .— A s the re su lt of a stu d y in Boston un d ertaken b y the
U. S. P u b lic H ealth S e rv ic e , a rep ort h as been issu ed w hich confirm s earlier
observations th a t th ere are now a v a ila b le d ried -m ilk pow ders from which
products m a y be recon stitu ted w h ich are sa fe for in fa n t feed in g-.
The g a in s in w e ig h t and p h y sic a l d evelopm ent of in fa n ts no u rish ed on
such food w ere s a tisfa c to ry . A s to b acterial d an gers, pow dered m ilk , and
e sp e cia lly w h o le-m ilk pow d er, can be s a fe ly used w hen a good g rad e of
fresh cow ’s m ilk is not o b tain ab le. C o n cern in g the e ssen tial vita m in s, the
pow ders are s till s u b ju d ic e ; it a p p e ars th ere is not n e c e ssa rily a destruction
o f the whole of the v ita m in C. S a fe p ractice, h ow ever, s till d ictates th e use
of fru it or vegetab le ju ic e s. N o p le a is m ade, and th is is of m om ent, to
su p p la n t fresh ra w m ilk in it s p osition as the m ost d esira b le su b stitu te for
breast m ilk .— M edical A n n u a l, 1924.
Chemical Purity of Carbon Tetrachloride.
633
“ THE CHEMICAL PURITY OF CARBON
TETRACHLORIDE.
J ohn C a m er o n ,
m .p . s .
(Lond,), P e k in ".
The interesting compound of carbon known as carbon tetra
chloride was discovered by Regnault in 1839, but did not come into
general notice until December 1865, when Simpson of Edinburgh sug
gested its use as an aniesthetic. The medical profession, however,
disapproved of its use as an anaesthetic. During the past few years
the use of this drug as an efficient anthelmintic or vermifuge has
been suggested to the medical profession, and in 19 2 1 1 M. A. Hall
found carbon tetrachloride an effective remedy for hookworm in
dogs; the dose was 0.3 c.c. per kilo of bod}- weight, He tried
3 c.c. on himself and experienced no bad effects, and concluded
that it should prove effective in human beings and safer than
thymol or chenopodium. C. X . Leach' reports that 10 c.c. given
to a human patient produced no ill effects whatever and completely
removed all hookworms and ascarides. The drug had little effect
on trichurides and oxyurides. Since these statements were written
much valuable work has been done by various investigators in
different parts of the world on the use of this compound, carbon
tetrachloride, as an anthelmintic. Perhaps the most valuable
contribution to the literature on the subject is an article by Leach,
Haughwout and A sh:‘ . They state in their conclusions that “ the
same care should be exercised in prescribing carbon tetrachloride
as is observed in the administration of any potent drug that may
work harm in the presence of contra-indications or in excessive
quantities ; in other words, it always should be given under competent
medical supervision. Doses of ‘ pure ’ carbon tetrachloride, com
puted on the basis of 1 cubic centimeter of the drug to each 5.5
kilograms of body weight, are safe in the absence of contra-indi
cations. ” “ On this basis we have administered doses ranging up
to 12.5 c.c. and even 15 c.c., without observing untoward effects of
a serious nature. ” In all their experiments these authors used
only chemically pure carbon tetrachloride, and to this end they
submitted every shipment of the drug they purchased to a chemist
for analysis. In one instance4 a shipment of 1,000 liters was found
to contain an excessive amount ol carbon disulphide. During the
634
past two years we have been using carbon tetrachloride in this
hospital of the Peking Union Medical College as a vermifuge.
Carbon tetrachloride5 may be obtained by passing the vapors
of carbon bisulphide together with chlorine through a red-hot
porcelain tube, the resulting mixture of sulphur chloride being
freed from the former by distilling with potassium hydroxide or
milk of lime. It occurs as a heavy colorless liquid, having an
agreeable, pungent, chloroform-like odor. Its specific gravity is
about 1.600 and it boils at 77°c. In this laboratory during the
past year we have submitted samples of carbon tetrachloride
supplied by leading pharmaceutical houses in different parts of the
world to careful analysis and have had, with only one exception,
positive reactions for the presence of carbon disulphide. In June,
19 2 3, a routine analysis on three different lots of carbon tetra
chloride was carried out, and in one case the content of carbon
disulphide was found to be as high as one per cent. During the
past month five further samples of recent shipments of carbon
tetrachloride C. P. have been analysed, and in only one sample was
a negative reaction shown for impurities. In one of the samples
the percentage content of carbon disulphide was approximately one
per cent. In three of the samples only traces of this impurity
were found, less than 0 .1 per cent. The following extract from
the monograph on carbon tetrachloride in the newly, published
British Pharmaceutical Codex, 19 2 3, is of interest 111 this connection :
“ Carbonjjtetrachloride for medicinal use should not contain more
than”o .i per cent of carbon disulphide. ”
A s carbon'tetrachloride is likely to become an item which will
be carried in stock by most of our Chinese mission hospitals in
future, it occurred to the writer that a few notes 011 the methods of
ridding this compound of all traces of impurities and of testing the
compound for likely impurities might be of general interest at the
present time in China. When carbon tetrachloride is intended for
internal administration it would seem a wise proceeding, in view of
our experiences here, to carry out a test on the sample for the pre
sence of carbon disulphide, and if more than the merest trace is
found we would suggest that the drug be purified by the method
suggested later in*this note.
On the other hand, if it is for any reason found impossible
to p u rify the drug at the hospital, one of the brands of carbon
Chemical Purity of Carbon Tetrachloride.
635
tetrachloride (medicinal) listed in the latest supplement to New and
Non-official Remedies, 19 2 3 6, should be purchased. These are :
Carbon T etrach lorid e
M ed icin al,
M allin ck ro d t Chem ical W o rks, S t. L ou is.
M. C.
W.
Carbon T etrach lo rid e C. P. (P. W . R .) (M edicinal).
Pow ers, W eigh tm an , R o se n ga rte n Co., P h ila.
M anufactured
by
M anufactured b y
In consulting various standard references it was rather
surprising to find that the boiling point of carbon tetrachloride
was variously quoted as :
770 C. U nited S tates D isp en satory.
77°— 7S0 C. S q u ires Com panion, 19 16 .
770 C. B ritish Ph arm aceutical C odex, 1923.
76°— 770 C. P erk in and K ip p in g , 19 2 1 (page, 183).
7b0— 770 C. N ew and N on-official R em edies, 1923.
770 C. M e rc k ’s In d ex, 19 10 .
We have found the boiling point of carbon tetrachloride C. P.
to be 76.3° C. to 76.7° C. Most of the commercial samples have a
boiling-point of 7S0 C.
The details of the method we use in the Peking Union
Medical College for the purification of commercial carbon tetra
chloride are as follows : 250 c.c. of the impure carbon tetrachloride
are refluxed for approximately one hour with an oxidizing mixture.
(Potassium dichromate, 60 grammes, and concentrated sulphuric
acid to 150 c.c.) The carbon tetrachloride assumes a dark-red
color (like bromine), it fumes in the presence of moisture, has a
chlorine odor and irritates the ey&s. Decant the dark-red upper
layer. Add 50 c.c. of a 15 per cent, potassium hydroxide solution.
Transfer to a separator, shake during fifteen minutes. Separate
the lower layer, which is now almost colorless. Wash this lower
layer four times with 10 c.c. of 15 per cent potassium hydroxide
solution and separate the lower layer each time. Wash the lower
layer with 50 c.c. .of distilled water divided in two portions or until
the aqueous washings are neutral to litmus. Then add 30 grammes
of calcium chloride to the separated and well-washed liquid
contained in a distilling flask. Shake. Stopper the flask and
allow to stand overnight.
Distil from a water bath.
The
distillate consists of chemically pure carbon tetrachloride suited for
internal administration. The process of purification is not nearly
63 6
so complicated as it seems and can be mastered by the average
Chinese dispenser after one trial in the presence of a foreign-trained
medical man or chemist.
The following are a lew quick tests which may be applied to a
sample of carbon tetrachloride to ascertain its purity or otherwise :
j.
Shake 10 c.c. of carbon tetrachloride with 10 c.c. of
distilled water. The aqueous layer should be neutral to litmus
paper and should not give an opalescence with silver nitrate
solution. (Absence of chloride.)
2.
Shake io c.c. of carbon tetrachloride with 10 c.c. of
distilled water containing a few drops of potassium iodide solution.
On standing for five minutes the lower layer should not be colored
violet- (Absence of free chlorine.)
3. Warm 10 c.c. of carbon tetrachloride with 10 c.c. of 25
per cent potassium hydroxide solution. No yellow or brown
color should develop. (Absence of aldehydes. )
4. M ix 10 c.c. of carbon tetrachloride with 10 c.c. of pure
sulphuric acid and shake occasionally for five minutes. Not
more than a barely perceptible color should be present in either
layer. (Organic impurities).
¿. Mix 10 c.c. of carbon tetrachloride with 10 c.c. of 10 per
cent alcohol potash ; allow to stand one hour, acidify with glacial
acetic acid, add 1 c.c. of a 10 per cent, copper sulphate solution.
If a yellow precipitate appears writhin two hours, the presence of
carbon disulphide is indicated.
6. Take 3 c.c. of carbon tetrachloride in a dry tube, add a
few drops of a mixture of potassium dichromate and sulphuric
acid (1 to 3). Apply heat gently. If the yellowish mixture
becomes green while the sample remains colorless carbon disulphide
is indicated.
7. The quantitative estimation of carbon disulphide in a
sample of carbon tetrachloride may be carried out in the following
manner :
Weigh about 5 gm. of the sample accurately, place in a reflux
apparatus with 20 c.c. of half normal alcoholic potassium hydroxide
and the mixture gently boil for half an hour. Dilute the solution
with 50 c.c. of distilled water and 5 c.c. of 20 per cent, alcoholic
potassium hydroxide solution, warm the mixture on the steam bath
Chinese Matena Medica.
637
until the carbon tetrachloride and alcohol have been removed, and
add gradually 50 c.c. of bromine water to the alkaline solution.
(An excess of bromine water must be used.) After warming for 15
minutes an excess of hydrochloric acid is added and the solution
filtered. Then add an excess of barium chloride solution. The
barium sulphate is collected, heated and weighed in the usual way.
The weight of barium sulphate obtained should correspond to not
more than 0 .15 per cent, of carbon disulphide.
N o t e .— Since w ritin g the above article the author has received a
com m unication concerning carbon tetrachloride from D r. R u sse ll, of the
Internationa] H ealth B oard, in w h ich he su g g e sts that in C h ina it w ould
perhaps be w ell for in stitu tio n s re q u irin g a v e ry pure brand of carbon
tetrach lo rid e to p urch ase it from the E astm an C om pany, R ochester. T h is
brand is e x ce p tio n a lly pure and w ell fitted for internal adm in istration.
R eferen ces.
1.
H a ll, M. A .
Leach , C. N.
19 2 1.
1922.
Jo u r. A m er. Med. A ssoc., lx x v ii : 16 4 1.
Jo u r. A m er. Med. A ssoc, lx x v ii i : 1789.
3. Leach , C. N ., H au gho w o u t, F . <j., and A sh , J. E .
Jour. Sci. x x i i i : 455.
19^3-
4.
W ells. 1923.
5.
B ritish P h arm aceu tical C odex, 19 23, p. 278.
6.
Su pp lem en t to N ew and N on-O fficial R em edies, T923, p. 5.
P h ilip .
P h ilip . Jo u r. Sci. x x i i i : 457.
CHINESE MATERIA MEDICA (VEGETABLE KINGDOM).
B. F . R e a d , Ph. C., M .S., P e k in g Union M edical C ollege, P ek in g.
A study of the drugs of the Chinese materia medica
belonging to the vegetable kingdom is different from the study of
the mineral drugs. The latter consist of ores or chemical salts of
definite identity, the medicinal values of which are well known.
The drugs of the vegetable kingdom, as pointed out in a previous
paper1, may be regarded as made up of :
1.
Well-known standard Western drugs.
2.
Drugs of near botanical origin which may be substituted
for our standard drugs.
3.
The remainder, including drugs of potential worth to
modern scientific medicine.
638
It is impossible in a short paper to speak of each drug
separately*. A general classification along the above lines, with
specific information concerning drugs of interest and of immediate
use to physicians in China, will constitute the aim of this paper. In
a separate Supplement there is a comprehensive Reference L ist' of
Chemical, Botanical and Pharmacological literature concerning
each drug, compiled by the writer and published in Peking.
1.
S
tandard
D
rugs
There are quite a number of standard Western drugs in China.
Some of these are shipped to Europe and America to be shipped
back again to China for use in our mission hospitals. On the
face of things this appears absurd, yet it would not be right to
condemn such a practice without finding out why.
Prim arily,
without any doubt, this is lack of reliable information. Secondarily,
the price, purity and preparation of native drugs are alwaj's ques
tionable. A s to the price and purity, what has been said regarding
the price of mineral drugs applies still more to vegetable drugs,
particularly- those which are exported from the E ast to countries in
the West. No fair estimate can be obtained of the market value
in China by simply purchasing through retail shops, though even
so the retail Chinese price is as often as not below the wholesale
price of the drug from home. The writer recently paid a visit to
the national drug fair held semi-annually at Chichow in North
China. Here assemble regularly many- members of thirteen
caravans from as many drug-producing centres in China. From
distant Tibet they bring saffron and sal ammoniac; orange peel and
litchis from Canton; mushrooms and huang ch’ i from Mongolia;
rhubarb from Szechuan, etc. Myrrh and frankincense are brought
to the famous God of Medicine there, as wise men of old brought
their treasure to the infant Christ. With the blessings of the gods
the Chinese merchants sell their goods, stay several weeks
and hold nightly festivals, where each caravan takes the stage in a
large amphitheatre and with much acting and music have a royal
time. It is possible then, or at any time during the year, to go
directly to the warehouses and buy wholesale any quantity of any
drug. There is open for inspection bale after bale of crude
material. The first remark passed by my colleague, a well-trained
pharmacist, was, “ How exceptionally good all the samples appear
Chinese Materia Medica.
639
to be.” When it is realized that such drugs as senna leaves appear
on the London drug market adulterated ro to 20 per cent, or even
50 per cent, with foreign material, and that digitalis, henbane, and
our common leaf drugs are seldom free from a certain percentage
of foreign material, the fact that crude Chinese drugs bought on
the Chinese wholesale market are exceptionally pure, should induce
those interested in the purchase of drugs to give greater attention
to China’s products than they have done heretofore.
We purchased about $50 worth of material, and if bulk be worth
noting I may say it took an extra cart to get it to the station. The
prices were most reasonable. Some material for which I had paid
$ 1.5 0 in the city shops, I purchased for 23 tael cents per catty in
Chichow. First-class Szechuan rhubarb was 26 tael cents a lb. ;
splendid orange peel, 46 cents a lb. ; fennel, 9 cents a lb .; gentian,
41 cents a lb. ; catechu, 19 cents a lb. ; leprosy seeds, less than 7
cents per lb. and so on.
As pointed out by Drs. Thompson’, Douthwaite4 and others,
many years ago there existed upon the China market supplies of
pharmacopoeial material in the following lines :
Camphor <$$/}[§ chang nao).
Asafetida
ah u'ei).
Cinnamon
kuei
p ’i ). Ginger root (]!£ chiang)
Cloves (
ting hsiang).
Rhubarb ("frM ta huang).
Orange peel (Mjfe kuang p ’i).
My-rrh m m mo yao).
Benzoin
an hsi hsi- Croton oil seeds ( E d t-p Pa
ang).
tou (zu)
Gamboge
t'eng huang). Pomegranate bark
shih
Star anise and its oil (
liu ).
pa chiao hui hsiang).
Peanut oil
lo hua
Menthol(7JC.H* ping p’ ien.)
sh en gyu ).
Cardamoms
pai tou Castor oil
p im a y u ) .
k'ou)
Catechu
erh chJa).
Fennel (
hsiao hui Linseed (¡yjjjll hu ma).
hsiang).
Galls
(«’» shih tzu).
Mustard
chieh tzu ).
All of these and other valuable drugs are used to-daj' in
Chinese medicine as they have been for centuries. The Pen T s ’ ao
Kang M u5, by L i Shih-chen, 1597, has pictures and good
descriptions of each one of them, and of a number o f other drugs
native to China some of which in North China we see less of, such
as coriander,, aniseed, taraxacum, storax, mastic, dragon’s blood,
stramonium, figs, lycopodium, long peppers, nux vomica, ignatius
bean,, sappan wood, sandal woods, red and white, rosemary, broom,
malt, &c.
Som eO bsoleleDrugs.— The aconites of China contain aconitine.
Were aconite a drug in daily use, one might say much in support
of adopting native material. This is true for a number of other
medicines which are becoming almost obsolete in our Western
practice. It may be well to mention some, for they are still
mentioned in Western books, being used as condiments, sweetmeats
or foods.
Sesame oil
Marshmallow (W St) < * £ )
Rose petals (%
Logwood ( fM c j
Flag root ( 0 H )
Cassia pods
&)
Calendula
Turmeric (H iff)
Xutmeg
Abrus
Verbena
Dulcamara ( © 355)
Honey f £ £ ;
Mulberry
Tamarinds
Agar
Prices and detailed information concerning them are given in
the Customs List of Medicines of the Hankow ports, prepared by
Mr. Braun6.
Preparation.— From practical experience it has been found that
the condition or form of the drug is of importance. Large lumps
of ginger root are almost useless to a young dispenser who has not
learned how to grind up fibrous material to a condition sufficiently
fine to suit the requirements of the pharmacopoeia; naturally he
prefers the nice-looking homogeneous material which comes from
Europe in a nice bottle with a nice label. The drugs above
mentioned, secured in the wholesale market, were all in a condition
suitable to easy manipulation. The Chinese have a way of cutting
these drugs into very thin slices, which, when dry, are quite friable
and easily powdered if one has a small grinder like a coffee-grinder
or a small powder mill. We have found those made in Philadelphia,
U .S .A ., and sold by Arthur H. Thomas, very useful. There is no
apparent good reason why all our hospitals should not buy the
crude material and make up their own tinctures, infusions and
641
other galenicals. For many hospitals in China it would be a great
service and of mutual financial benefit if one of our well-trained
hospital pharmacists at a port suitable for distribution would take
up this work of the manufacture of galenicals from native material.
It would be possible to sell the same at quite a cheap rate whilst
securing quite a good profit to cover all overhead expenses.
II.
S
u b s t it u t e s
The second class of drugs to engage our attention are those of
botanical origin similar to our Western products and which have
proved to be satisfactory substitutes.
The drugs of this group require strict individual attention,
detailed chemical analysis and careful testing, so that no mistakes
occur by making an unsatisfactory, or a seriously inferior, or an
altogether mistaken, substitution of material.
A good tincture 01" cardamoms can be made from the cheap
Chinese “ So S h a ” or “ Sha Je n ,” Amomum xanihoides. The
slight difference iu flavour does not warrant buying the very
expensive official cardamoms.
In 19 13 there was an interesting article in the “ China
Medical Journal ” by Dr. Bowman7, who drew attention to the
great use that can be made of Chinese chilies, “ La-chiao,” in
making a tincture suitable for many types of internal and external
complaints. Externally- it is a strong rubefacient; as an ointment,
made by boiling with vaseline and straining out the solid marc
through muslin, it forms the basis of electric pain-killers and patent
remedies for rheumatism and sciatica.
As previously pointed out, the Daturas are common in China ;
D. alba and D. stramonium are found throughout the country.
Whilst it has not been possible to secure these on the drug market,
the}- are easily collected in the countryside, or sufficient ior the
regular need of a hospital can be grown without much trouble.
Mentha arvensis
$f) is the official Chinese “ m int” and may
well be adopted for regular use.
Other good substitutes may be found in gentian, cinnamon,
hydnocarpus, polygala, coptis, and Japanese belladonna. A ll of
these have been inserted in the Japanese pharmacopoeia, their
adoption being based upon full chemical analyses, usage, and
known physiological effect.
642
Details follow of several quite reliable drugs which
substituted for foreign material.
1. Glycyrrhiza:
M ei t ’s a o ;
Kan
L u i'sao.
t ’sao-,
M i-k a u \
may
Ml
be
t ’sa o ;
Description.— Long, dry, wrinkled pieces of the roots of
“ Glycyrrhiza glabra ” , and G . echin ata. The surface is reddishbrown with a yellow fibrous stellate interior. Often sold in slices
which are thick transverse sections of the root. It is sweet and
mucilaginous; the flavour is. practically identical with European
liquorice.
Composition*.— The two roots are of similar chemical composi
tion, each containing about 7 to 12 per cent of the sweet principle,
glyc\’rrhizin, much simple sugar, a little malic acid and 2-5 per
cent of ash. Glycyrrhizin is the ammonium salt of the glucoside,
glycyrrhizic acid.
L s c .— To disguise the bitter taste of such drugs as quinine,
and to impart an attractive brown colour to mixtures. The
ammonia it contains renders it a useful adjunct to cough medicines.
In Chinese medicine9 it stands next in importance to ginseng.
Tonic, alexipharmic, alterative, and expectorant properties are
ascribed to it.
2 . G e n t i a n : IB
“ G en tian a se a b ra ” .
Lun£
ian
i 's a o ; also called
L in g
Yu.
Description.— Long, brown, twisted rhizomes with numerous
rootlets. Many oxalate crystals, but no starch grains. The taste
is agreeably bitter.
Composition.— Its close botanical relationship, with its
similarity of taste and other physical characteristics, make it an
excellent substitute for the European root.
Action and Use.— It is the best of the simple bitters, exciting
the flow of gastric juice, promoting the appetite and aiding digestionThe Chinese* prescribe it in fevers, rheumatism, and general
debility. It is recommended in nocturnal sweating, hematuria,
ophthalmia, and as an anthelmintic.
3.
C o p t i s :— Gold thread : J£ jgi, H u a n g L ien .
Description9.— The dried rhizomes of “ coptis teeta,” in short
branching pieces, one or two inches long, of a yellowisli-brown
643
colour. The interior is a rich yellow colour pierced by a pith of
deeper shade. The taste is bitter and aromatic. It has a sharp,
rough fracture. It has no odour.
Composition''.— Contains 8-9 per cent of Berberine, a yellow
alkaloid, and a small amount of a toxic alkaloid., “ coptine.” V ery
similar to American coptis.
Action and Uses.— Bitter, astringent tonic.
and India as a bitter.
Used in China
Chinese doctors9 regard it as a remedy for a great many ills.
It is used in all forms of dysentery; in diabetes to relieve thirst
and reduce the amount oi u rin e; to clear inflamed eves, and as an
alterative.
4 . S e n e g a : — j§L ife,
Jap a n e se : senega.
Y uan
Description.— The dried
In brown cylindrical pieces,
scars of the lateral roots. It
wood. No odour. An acrid
chili.
C la ssical
nam e
|gfg&,
Yao-jao.
root of “ Polygala tenuifolia,” wild.
branched at the apex and bearing the
occurs in quills deprived of the centre
taste.
Compositions.— Consists of 0.66 per cent senegin; 8.8 per
cent resin.
Action and Use.— The same as European senega. It is
prescribed by the Chinese for coughs, jaundice, mammary abscess,
and gonorrhoea.
5 . H yd n o caryu s: j c l f
T a fen g tzu.
Description.— The irregular, greyish-brown seeds of Hydnocarpus anthelmintics are imported from Siam and are found all over
China and Japan. The expressed oil is official in the Japanese
Pharmacopoeia, which gives numerous physical constants. M .P .
22-230 C. Iodine value, 80 to 90; opticalh' active. A clear
solution is obtained on warming the oil with live times its volume
of absolute alcohol, etc.
Composition*'.—Consists of 17-20 per cent oi a fatty oil
composed of chaulmoogric, hydnocarpic, linolic, oleic and palmitic
acids. Very similar to chaulmoogra oil.
Ó44
Action and Uses.— Has been used in the Orient for many
centuries in the treatment of leprosy. Its ethyl esters have been
found beneficial. It is also recommended in China for scabies,
syphilis, psoriasis, etc.
6. C innam on: S
gc Kuei
p’i.
Description.■—There is official in Japan the dried bark of the
trunk and roots of Cinnamomum Loureirii N e e s . It occurs in
China in half-quills of a J ’oot in length, diameter
inch, thickness
i 12th inch. Exceedingly pungent and spicyComposition.— Consists of 1 .1 7 per cent Nikkei oil, and 0.2
per cent of an oil containing 27 per cent of citral and cineol, and
40 per cent linalool.
Action and Use.— The same as cinnamom. Fabulous stories
are recorded in Chinese literature of its virtue and ability to enable
people to do impossible things.
III.
O
th er
C
h in e s e
D
ru g s
u sed
in
W
ester n
M
e d ic in e
The remainder of the drugs described in the Chinese Materia
Medica lend themselves to a critical study in various groups.
(a) Those whose chemical composition and potential worth are
well known, which have never received serious attention. As will
be seen from the references in literature, this group is quite large,
much larger than most people suppose. The majority of Chinese
drugs belong to it.
(b) Drugs well known in the West which, on account of weak
phj'siologicai action, have never gained a place in modern scientific
medicine, such as shepherd’s purse, ivy, plantago, violet, bistort,
coltsfoot, etc. They are still sometimes used by certain classes of
doctors. These drugs are best discussed here, in that they merit
investigation in order to test the claims made for them in old works
on Chinese medicine.
(c) Other drugs which may or may not have been examined
by scientific methods. In any case, the normal sequence would be :
(1)
Satisfactory identification by a trained pharmacognocist.
(2)
Thorough extraction and chemical analysis of essential
principles.
Chinese Mat eri a Medica.
645
(3)
Physiological testing of same upon all the body systems,
tissues, etc.
(4)
The trial, elinicali}', of those known to be of potential
value.
The chapter on poisonous Chinese plants naturally suggests
itself as being the most likely to mention potent active principles.
T his group demands early attention, not only for its promise of
therapeutic value, but for the knowledge which is needed of Chinese
toxicology and the contribution which modern science may make to
render it of service to medical men.
The purpose of such research may be defined as :
(a) To find a means of helping to meet the great economic
need of our hospitals.
(b) To discover specifics, or drugs with potent action, useful
in the treatment of disease.
(c) To add to the sum total of our scientific knowledge
which indirectly benefits everything and everybody.
So far this work has been very* limited in extent. A begin
ning has been made, and some of the findiugs are reported in another
paper. Their adoption requires wise judgment and caution.
In our enthusiasm for this most interesting subject, care is
needed that there be not given too much credit to something which
later becomes discredited in value. Overrated claims will seriously
set back scientific interest and will delay the acceptance later of
worth}7 remedies which may help to meet the world-wide needs of
the sick.
R efer en ces.
1.
R ead . B. E . 19 2 1.
2.
Ib id ., 1923
N at. Med. Jo u r, of C h ina, v ii : 12 1 .
3.
Thom pson, J. C. 1890.
4.
D outlnvaite, A . \Y. 1S90.
R eference L is t of Chinese M ateria M edica, P e k in g .
Ch. Med. Jou r., iv : 11 7 .
Ch. Med. Jou r., iv : 10 0 .
B y L i S h ili Chen, 1597 A.n.
6.
B rau n , R . 1909.
7.
B ow m an, N. H . 19 13 .
L is t of M edicines exported from H an k o w .
8.
W ehm er, C. D ie Pflanzenstoffe, Jena, 19 1 x.
9.
S tu a rt, ('». A. i u t i .
Ch. Med. Jou r., x x v i i : 31
C h in ese M ateria M edica, S h a n g h a i.
646
THE THYMUS GLAND IN THE CHINESE.*
J. L . S h k ix sh e a k ,
d .s o ., m . b ., c h . m .,
H o n g k o n g University-.
The interest of the thymus gland is twofold. In the first
place the stimulus given to preventive medicine in China by the
Rockefeller Foundation has awakened the necessity for the study
of medicine in China by the Chinese themselves. The teaching of
anatomy and medicine makes use of textbooks which have been
worked out by the stud}- of the European. The standards of
morphological structure are European.
It seems more than
probable to me that we shall find that those standards are not
strictly applicable to the Chinese race. It ma}^ turn out that the
age standards are different; that the dates of ossification of the
bones are later; that the general blood pressure is lower. If on
the accumulation of knowledge such conditions are found to prevail
it is clear that modifications will have to be made, not only in the
teaching of medicine, but also in its practical application.
In the second place the study of the thymus is interesting
from the anthropological point of view. Races are distinguished
b}' their more obvious characteristics, by the colour of the hair and
its form, by the general appearance ; the anthropologist distinguishes
differences m the skeleton, particularly the skull. Elliot Smith in
his work on evolution has clearly demonstrated that more important
than the skeleton is the brain. He has given clear indications that
the brain of the Egj'ptian is of a different type from the European.
I have strong evidence of a similar character that the brain of the
Chinese differs also from that of the European.
The work of Keith, Bolk, Stockard and others has drawn our
attention to another group of organs— the endocrine or internal
secretory organs. T hey suppose that racial differentiation is in some
way brought about by the influence of the secretions of these
organs. Sir Arthur Keith states that “ the theory which best
explains all the facts is to suppose that Mongolian features arise
under a peculiar or altered action of the growth mechanisms
*A paper read before the H o n g k o n g and C h in a Branch of the B ritish
M edical A sso ciation on A p r il 2nd, 1924. R ep rin ted from T he Caduçeus,
M a y , 1924.
The Thym us Gland in the Chinese.
647
centred in the thyroid gland.”
The evidence can not be regarded
as altogether satisfactory, for the arguments are based in great part
on analogy.
The features of certain diseases are so like the distinguishing
features of certain races that Sir Arthur Keith has been led to
believe that the causes of the features in those cases must be
identical. In acromegal}- we get an increase of bone and muscle
growth in certain places ; the hands become la rg e ; there may be a
similar enlargement of the feet. But more important are the bony
changes in the cranium and face. The cranium becomes increased
in size, and in particular in relation to the function of mastication—■
an increase in the prominence of the temporal ridges, marked
prominence of the supraorbital ridges, etc. In the face we find
marked enlargement of the lower jaw and the masticatory apparatus
in general. If we now look at the features of a gorilla we find that
many of the characters of the acromegalic are normal to the gorilla.
It certainly- appears that the possibility- of any individual becoming
gorilla-iike is always present, but that some influence prevents
it happening. Now an increased pituitary secretion over a pro
longed period is the cause of acromegaly-, and without doubt the
pituitary has an important influence on growth. It would appear
that man has some mechanism which restrains this gland, and
therefore Keith suggests that the influence of endocrine glands is
important in racial differentiation. The race most closely- allied to
the acromegalic is the Neanderthal race. The similarity between
certain diseases of the thyroid and the features peculiar to the
Mongolian has further caused Sir Arthur Keith to postulate that
the Chinese race is differentiated under a thyroid influence.
It would be more correct to say that the general appearance of
any individual has been brought about by the combined influence
of a great number of different factors, that his growth is capable of
being influenced in particular by any or all of the ductless glands,
and that the final result is possibly due to alteration in either the
combining values of these glands or on the time at which they
begin to act. It can be postulated that the onset of maturity is
brought about mainly under the influence of the internal secretion
of the sex organs, and that man’ s supremacy is due to a later
onset of maturity than in other mammals, his yvhole life being
retarded, as Bolk in particular has shown.
648
Now, have we any evidence that the influence of the sex
glands can be delayed in its action ? We have ; for, if the thymus
gland is removed, the onset of sexual maturity is hastened; and
vice versa, if the sex glands are removed the thymus gland fails to
involute as early as normally. We also know that there is a close
association between the sex glands and the thyroid. So that not
only on the evidence of experimental physiolog}-, but also on the
evidence of pathology, we have no doubt that the endocrine organs
pla\- a very important part in the growth processes of the body.
The action of these internal secretions is so much a combined
process that it becomes a great difficulty to determine whether any
particular phenomenon is the direct result of a particular gland, or
whether the stimulation or suppression of that gland may not
remove some factors which permit the uncontrolled action of the
others. A s an example, there is no doubt whatever that the
physical signs of acromegaly are the direct result of a change in
the pituitary gland. But are the signs produced by the actual
pituitary hormone, or are they produced by the combined action
of other glands modified in their proportions by the deranged
pituitary? Again, certain growth processes are intimateW associ
ated with the thyroid gland. Are these due to the thyroid directly
or are the oxidation processes of the bod3' so disturbed that once
again the combined factors of all the growth processes become
deranged ?
We have made use of experiment and pathological conditions
to help us in the answer, but to my knowledge there is no work
which can tell us whether there are actual morphological differences
between different races of men in the endocrine system.
Bolk tells us that the sutures in the skull of man are later in
joining up than they are in the anthropoid apes. He says that
this must be due to the thymus. Such may be the case, but have
we any evidence that the thymus gland is in any way different
whether in function or structure ?
During my investigations on other matters at the mortuary
I was impressed by the fact that the thymus gland of the Chinese,
as examined at the mortuary of Hongkong, was considerably larger
than any I had previously seen, in spite of late age. The close
association which has been shown to exist between the thymus
and the thyroid led me to think that perhaps by an investigation
The Thymus Gland in the Chinese.
649
of the thymus I might be able to throw light on the hypothesis
put forward b}TKeith that the Mongolian characters arise under a
peculiar or altered action of the growth mechanisms centred in the
thyroid gland.
The thymus gland is an organ which has a definite function
to fulfil, and whatever that function may be it ceases to act with
the same fulness after the onset of puberty, unless that function is
taken over by some other organ.
From an anthropological point of view its investigation in
China is very important, as it may act as a basis for work on time
relationships in the body. These time relationships are different
in different species of animals. The length of intrauterine life in
man is about nine months; in other mammals closely related it is
shorter. Sim ilarly we have a lengthened period of childhood,
adolescence, adult life and senility. These time relations are
definite anthropological characters and quite conceivably have a
marked influence on the ultimate structure of the race. This is a
preliminary communication to a fuller investigation of the whole
time relations in the Chinese. If these time relations arc different
in the Chinese, then we must modify our medical teaching.
T his paper can only be regarded as preliminary for another
reason, and that is that it may have to be modified on the advent of
further information regarding the age of Chinese. Unfortunately
conditions are such that one cannot ascertain the age with certainty.
The official form gives the name, age and address, which are
obtained from the relatives. Apart from the fact that many- of the
coolie class do not know their own age, complications arise in not
knowing whether the age given is according to Chinese or British
reckoning. Kvery effort has been made, however, to arrive at as
close an approximation to the correct age as possible. Furthermore,
even if the ages given are not strictly accurate, the findings are
very significant. I have included with the description of the
thymus the state of the hair development. At the present time an
investigation is being made for the C .M .M .A . Conference of the
state of the sexual development and hair development at known
ages in the living, which should act as a useful check.
The examination of the thymus was both microscopic and
macroscopic. The microscopic condition has been classified into
five types by Hammar.
650
Type t . Infantile, with abundant parenchyma and moderate
connective tissue. (Birth to 10 years-)
Type 2- Juvenile, with parenchyma and connective tissue
both abundant. ( 11 to 15 years.)
Type 3.
Young adult, parenchyma somewhat reduced,
connective tissue abundant and the formation of fatty tissue going
on. (16 to 20 years.)
Ty*pe 4. Adult, with parenchyma more reduced, connective
tissue more abundant and fatty tissue increasing in amount.
(21 to 45.)
Type 5. Adult. Mostly connective and fatty tissue, with
strands of parenchyma.
The macroscopic classification of the gland is more difficult.
Hammar and others have taken the weight at different ages and
found a gradual diminution in weight after the young adult stage.
The weight is, however, difficult to use as a basis for comparison as
to the amount of thymic tissue present. I have adopted an
arbitrary classification, depending on the general size and bulkiness
of the organ, into five groups, and have compared the microscopical
appearance as far as possible.
Group 1 . Gland abnormally large. Length from 6 to 8
inches, breadth from 2 to 3 inches. Full and lobulated. (Fig. 1.)
Group 2. Gland large. Length from 5 to 6 inches, breadth
from 2 to 3 inches; relatively bulky and lobulated.
Group 3. Gland medium size.
relatively bulky7.
Length 4 to 5 inches and
Group 4. Gland small, obviously lobulated, and thymic tissue
of a reddish colour.
Group 5.
Gland insignificant in appearance.
Obvious pathological conditions have been excluded.
In the European the thymus gland in the adult is mostly a
thoracic structure. It is cervico-thoracic'up to the third embryonic
month, after which a fusion takes place with the pericardium; this
fusion is said to cause an atrophic process to set in, in the cervical
portion, the relation with the thy'roid being maintained by strands
of connective tissue. In the Chinese the condition in d ifferen t; the
The Thym us Gland in the Chinese,
cervical portion of the gland is always well marked and is re
presented by two well-marked lobulated upper extremities which
reach, and in some cases pass under, the thyroid gland. The
Fig. i —The thymus gl nd of a Chinese
male, aged 2?, No. ?4 of the series.
The protractor on the right i* the
ordinary military protractor t " in
length.
The two superior lobes
dissected out from uni'.r the thyroid
gland are well shown.
Fig. 2.— A drawing of the same
case as Fig. i sketched at the
time of post-moitem.
microscopic examination shows that the regressive changes arc
later here than elsewhere. The gland should therefore be classified
in the Chinese as cervico-thoracic.
I have drawn up a table to summarise the information so far
gathered. It will be seen from this table that up to the age of
twenty practically every gland is of large size. Figures 1 and 2
give a very good indication of the size of the glands placed in group
1 and regarded as abnormally large. The gland figured weighed
46 grammes after formalin fixation. It had a length of eight
inches and a breadth of two and a half inches. There are in all
eleven cases in the series classified in Group i , nine of which occur
652
before the age of thirty, and two over that age at thirty-three
and forty-three.
Nine of them were subjected to microscopical
examination and found to belong to either t\rpe 1 or 2 of H am m ar;
thus it is clear that the large size is clearly associated with
an abundance of thy*mic parenchyma.
Glands which are
included in Group 2 are slightly smaller than the above, and weigh
from 35 to 40 grammes. It will be seen that glands of this size
predominate up to the age of thirty, although many are found after
this age, and in the particular group of cases which I have
examined six are found between forty and fifty-. The glands in
Group 3 would be regarded as large in the European, and it will be
seen that they begin to appear at the age of twenty-five, and that
after thirty-five the gland begins to get smaller in size.
If we compare the size of the glands with their microscopic
structure it will be seen that the large size is due to thymic
tissue, for the abundance of parenchyma is held until a later
age than in the European.
Hammar's ages corresponding to
his types are not in agreement with the findings in the Chinese.
The young adult condition, instead of changing at 20, runs on
till about 25 yrears of age. After thirty, regardless of the actual
size of the gland, all the specimens are of the adult type. From
these tables we can therefore assert that the thymus gland is later
in undergoing its involution changes than it is in the European.
We are now faced with the problem of determining whether
the delay in thy mus involution is a normal physiological, and there
fore anthropological, condition in the Chinese. The problem is
not yet capable of a satisfactory answer; nevertheless, we can
hypothesise, remembering that the function of an hypothesis is to
build up further knowledge. It may fulfil its function and yet be
found to be wrong; in yvhich case it is replaced by a further hypo
thesis as a scaffolding for further advance. Taking firstly our
known facts, the thymus is an organ which normally begins to
undergo involution at puberty; it is in some way under the
influence of both the sexual glands and the thyroid. Does the
thymus give out a secretion which restrains the action of the sex
glands, and therefore allows the sex glands to act by its involution ?
T his would necessitate acceptance of the thymus within the group
of endocrine organs, but it can by no means be considered as proved
that the thymus gland gives off any internal secretion. Whatever
653
its function, however,, it may be regarded as an organ belonging to
the period of growth and development, and may therefore be taken
as an index of maturity. One other question : Does its persistence
so influence the thyroid as to cause this gland to exercise those
influences of which Keith speaks? We do not know. The whole
question is enlightened by the work of Bolk of Amsterdam. He
says : “ I have advanced a ground to prove that the developmental
rate of man has been retarded, a retardation which, by the way, is
stronger in the male than in the female sex. To this retardation
process he owes it, I would observe, that he is born nudus ei
inerm is; that, in contradistinction to the other mammals, it is
only rather a long time after his birth that his consciousness of self
awakes, followed by the longer infantile, puerile, and juvenile
phases.” The evidence of the thymus seems clearly to indicate
that this retardation rate may be affected, not only as between man
and the mammals, but between the. different races of man himself;
and I would suggest that such differences in developmental rate are
just as much anthropological characters for investigation as the
size of the nose, etc. What evidence have we, besides the thymus
gland, for making this hypothesis as far as the Chinese are con
cerned? I have included the state of the hair development in the
table, and it will be seen that the development of pubic hair can be
considered to be retarded, an.l this may be regarded as the retarda
tion of a secondary sexual character. From my present observa
tions I am also of the opinion that the growth and development of
the external organs of generation are later in reaching maturity.
We are thus faced with the question as to whether our method
of making racial comparisons has been correct. We have not
sufficiently examined into the question of the time relationship.
The stud}' of the skull is a study of an object in one unit of tim e;
whereas the study of a race must include the whole period of its
development. The problem of the anthropologist is very closely
paralelled by that of the psychologist who attempts to analyse
behaviour. Rivers tells us that “ the most important distinction
which has been made between instinct and intelligence is that the
former is innate and the latter acquired.” “ But when we endea
vour to use the theoretical difference as a guide in practice and
research, we are met by several difficulties.” The examination of
behaviour from this standpoint is an examination of behaviour as a
sequence of events rather than the examination of a single event in
¿54
a unit of time. The advances in anthropology must be made along
the same lines; for the race we must determine what are the
characters which are innate in the race, and what are those qualities
which have been acquired in the individual.
The distinction
between the acromegalic and Neanderthal man is that the characters
of the one are acquired ; of the other, innate. Whilst it may be
that the pituitary gland is the causative agent in both cases, the
problem which has to be answered in the case of the Neanderthal is
how the germ plasm becomes modified so that a pituitary influence
becomes inherited. The condition in which the thymus gland is
found in the Chinese must be regarded as innate unless we can
show that each individual is subjected to environmental conditions
causing its persistence to be acquired. The persistent thymus is
an expression of reLarded development and is only a part of the
general retardation. K eith’s hypothesis might possibly be modified
b\T stating that, whereas the cause of the racial differentiation of
the Chinese is not known, its results are expressed in a general
retardation process which permits the hormones of the thyroid
to exercise a fuller influence on the race. This of course assumes
that the thymus retardation is an index of some altered condition
of the thyroid; and of this there is some evidence. We may say
of structure what John Hunter says of function : “ A s every naturai
action of the body depends, for its perfection, on a number of
circumstances, we are led to conclude that all the various combin
ing actions are established while the body is in health and well
disposed; but this does not take place in diseased conditions, for
disease, on the contrary, consists in the want of this very com
bination.”
If we are to assume, therefore, an endocrine influence in racial
differentiation, we must regard the thymus persistence as a part of
the difference in the time relationship of the combining factors, not
necessarily the cause.
This difference of combining factors
expresses itself in those slight differences of features which go to
distinguish races.
The differences, not apparent at first on
account of the great variety of minor cjifferences in the race itself,
become more apparent when viewed as a whole.
Is it possible for us to give any indication of why it is that
the thymus gland is retained ? I will try to give an indication of
the possibility of an answer; the proof of which it should be
655
possible to work out by a careful study of Chinese customs. It is
more than possible that selection has played a part in the racial
differentiation of the Chinese. If selection is of such importance
in determining the types of domesticated animals, it should play
some part in the differentiation of man. The marriage customs of
the Chinese are, I think, ancient and conservative.
These
customs have for their basis that the selection of the contracting
parties is parental. In the very nature of things the parental
choice will be such that, other things being equal, the contracting
parties are as near to the ideals laid down by social convention as
possible. The Chinese admire the placid type— the type which is
expressionless, and not given to the outward display of fear, anger,
and the emotions in general. The anthropological type might
almost be regarded from European standards as a child-like type;
the Chinese countenance with its hairlessness, smooth forehead,
wide interocular distance, etc., is child-like.
Taking the
European as a standard they seem to have been retarded. And if
so, according to the observations of Bolk, should be looked upon as
very high in evolutionary advance. It is conceivable, then, that
the choice would fall on those who gave the appearance of being
late in arriving at m aturity; and who might, therefore, have a
persistence of the thymus as one of the expressions of that
immaturity, perhaps even the cause thereof. If such is the case
the presence of the persistent thymus is due to some change in the
germ plasm transmitting influences which cause a retardation of
that orderly sequence 01 events going to make up the adult
characteristics of the race.
The possibility of the persistent thymus being of an acquired
nature must not be overlooked. It has been suggested that the
thymus has some function concerned with the production of
immunity from disease. Hammar has avoided any cases which
show evidence of disease in his work on the thymus of the
European, knowing that it is subject to change in infectious
conditions. Diseases of all kinds, and in particular infectious and
parasitical diseases, are so common in China that it is next to
impossible to obtain data from normal people; and it is possible
that malaria and other conditions may have, to be seriously
considered. If we had data from other infected countries as to the
state of the thymus a definite answer might be given to this aspect
of the problem; at present it is not possible.
Th e China Medical Journal.
656
No.
S ex.
age
94
i
2
3
F
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
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M
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12
15
15
i6
16
16
17
17
18
4
99
5
6
7
S
9
10
il
97
12
89
13
!4
15
16
*7
18
19
20
21
22
23
24
IOI
25
26
96
90
27
28
29
30
31
88
32
33
35
36
JOOX
37
3S
39
40
41
iS
18
19
19
19
19
19
20
20
20
21
22
22
23
25
23
23
23
23
23
24
24
24
24
25
25
25
25
25
25
20
27
27
27
27
28
30
3°
3°
3°
THYM US
!
G roup
T ype
2
2
H A IR
Punic
B ody
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Mod.
Scanty
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do.
Scanty
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Scanty
Full
do.
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Scanty
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F u ll
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N.B.—100 x. Thymus tissue on Diaphragm.
Pneum onia
Frac, skull
Pneum onia
Beri-beri
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do.
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Post-part, sepsi-.
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Spleen 3 lbs. io z .
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a rod.' ■
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F rac, sk u ll
L e p ro sy
6¿8
CASES OF PATHOLOGICAL INTEREST.
R. H o w a r d M o le , b.a., m.d., Medical C ollege, Moukden.
Case 1. —
P
e r io s t e a l
S
S
h o w in g
arcom a
C
y st ic
U
of
C
pper
E
nd
of
T if e iA
h an g es.
Figure i is a low power view of the tumour in the less changed
part. Even here, in the upper part of the micro-photograph, there
is a mare or less circular patch of hyaline degeneration. The cells
of the Lumour are spindle cells for the most p art; multinuclear cells
are present. There is hyaline change in the protoplasm of the
cells, with loss of nuclei.
Figure 2 shows multiple areas of degeneration. These are
roughly circular or oval in shape. The rim and the central part of
these areas of degeneration show different staining reactions, the
rim staining intensely with haemotoxylin and the central area with
acid fuchsin. Sometimes the central part is streaky in appearance
or actually absent, leaving an empty- space.
Figures 3 and 4 show a still further stage. The tissue here
is acellular and numbers of empty spaces are present, occupying
the places of the areas of degeneration (Fig. 2). These areas have
evidently become liquified and absorbed. With Van Gieson’s stain
the lining wall of the spaces takes the acid picric stain while the
inter-cystic areas take either the acid fuchsin or the picric stain.
Anything more unlike a sarcoma than Figures 3 and 4 delineate, it
is difficult to imagine.
Case 2 . —
L
arge
S
arco m a
of
th e
S
capu lar
R
e g io n
.
This tumour occupied the whole of the upper part of the left
side of the back, being of very considerable size. It occurred in a
man of fifty years of age. A t operation it was apparently encapsuled. Before the tumour was removed some difficulty was
experienced in diagnosis, because in several places the tumour was
so soft that fluctuation was elicited.
The tumour seems to belong to the variety of sarcoma that
grows from tendons and aponeuroses, and is usually found in the
hand or foot, although some of the features said to belong to this
type of tumour are not evident. At any rate, it is a form of
giant-celled tumour.
Fig. I.— Periosteal sarcoma: circular
patch of hyaline degeneration.
Fig. 2 — Periosteal sarcoma : multiple
areas of degeneration.
Fig. 3.— Periosteal sarcoma: absorption
of areas of degeneration.
F ig - 4-— Periosteal sarcoma : absorption
areas of degeneration.
P e R io s t e a j . S a r c o u a
of
U pi*f.r E n d
of
T jm
a
; C v s t i c C h a n g e s . (M oi .e .)
Cases of Pathological Interest.
Figure 5 shows a low power view of this tumour, and Figures
6 and 7 a higher power view. The tumour is seen to be composed
of cells both iarge and small, many of which have undergone hyaline
changes in.their protoplasm; the nucleus also is eccentric. Figure
7 shows the very great d isparity in the size of the cells composing
the tumour. Above and to the right is sean a huge cell, quite 12 5
microns in diameter, while in the middle part of the picture are
seen some very small cells.
Case 3. —
L
arge
F
o l l ic u l a r
S
u p e r io r
M
O
d o nto m e
a x il l a
of
the
L
eft
.
This specimen of a follicular odontome came to the writer through
a mistaken diagnosis on his part. During the previous twelve
years half a dozen follicular odontomes of the superior maxilla had
passed through his hands. These all had one common charac
teristic; onh' the anterior wall of the bone' c}\st bulged (i.e.,
forwards); there was no bulging of the other walls; this wall was
thin and could easily be pushed backwards by pressure within the
lip above the line of the teeth.
The picture presented by this tumour, taken from an eighteenyear-old girl, was typically that of a sarcoma of the superior
maxilla growing from within the bone. The left cheek bulged
greatly forwards, the nose was pushed toward the right, the eye
was pushed upwards and the palate downwards. The anterior wall
could not be pushed back b\* the finger. The superior maxilla was
removed
The photograph ( F ig .8) shows through a window afterwards
made in the wall of the bone cyst,, the unerupted tooth, T ; also
a considerable amount of bony degeneration in the floor of the c y st;
M points to a molar tooth.
Case 4. —
B
il a t e r a l
S
y p h il it ic
E
p id id y m it is .
The patient had bilateral syphilitic epididy-mitis with almost
complete obliteration of vessels of the spermatic cord (Fig. 9), and
complicated on one side by a large inguinal hernia.
B ilateral syp h ilitic epididym itis must be a very rare condition';
as is well known, syphilitic orchitis is the common scrotal lesion.
66o
Case 5. — 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 .
Patient on admission to hospital was thirty-six years of age.
No history of syphilis or other illness. His diet was the usual
one in North China, consisting mainly of millet. At the age of
sixteen years patient had pain in his right leg, due, he said, to a
chill; tor eight days it felt numb and was a useless member. -He
could-not put it down... At the age of 25-26 both his legs felt cold,
and this in spite of warm clothes. This condition was progressive
and was felt whether standing or walking. After lialf-an-hour’s
walking he was obliged to rest on the k ’ang (warm brick bed) for
four or five hours before the circulation was restored. Each night on
going to bed he was conscious of cold lim bs; after the lapse of time
they warmed up. He stated that in summer time things seemed
all right. He also stated that there was 110 sweating below his
knees.
During the past year, 011 going to his shop door to open it he
had to stand before returning, because of his inability to use his
legs; this was due to cramps in the calves of his legs, and in the
soles of his feet. Sitting down and rubbing his limbs restored
their function.
Patient came to hospital with commencing gangrene in the
tues of the right foot. Even in the femoral artery of the right leg
110 pulsation could be detected. T he Sachs-Georgi test was negative.
Amputation of the right limb half-way between the knee and ankle
was perform ed; healing was protracted.
Figures 10 and 1 1 show the condition of the posterior and an
terior tibial a r t e r i e s below the level through which amputation was
carried out. The anterior tibial artery not only showed marked
endarteritis but also a thrombus within the vessel, and the vein
showed endophlebitis.
The posterior tibial arten also showed
marked endarteritis-
Case 6. —
T
erato m a
fro m
Palate
of
F
o etu s.
1 am indebted to D r. M acN eili of Ch-ang-ch’ un for the
tumour, a photograph of which is shown in F ig u re 12 .
The
tumour is a teratomatous growth from the palate of a foetus.
M icroscopically the tumour contains glandular tissue, cartilage, etc.
The tumour caused considerable difficulty at childbirth. The
picture shows the inner surface of the em pty skull, and the inner
surface of the sectioned tumour.
Fig. 5.— Giant cell sarcoma.
Low power.
Fig. 6.— Giant cell sarcoma
High power.
Fig. 7.— Giant cell sarcoma.
High power.
Fig. 8.— Follicular Odontome of superior
maxilla : T,\ unerupteil tooth :
J /, a molar tooth.
I'. ia n t -C e u
S ar co m a : F 0 u .1cn .A R O d o n t o m e .
(M o l e ).
Fig. 9.—Obliterated vessels of spermatic
cord: bilateral syphilitic
epididymitis.
Fig. 11.—Thrombo-angiitis obliterans
anterior tibial artery and vein;
thrombus in artery, also
endophlebitis.
M
is c e l l a n e o u s
Fig. 1 0 —Thrombo-angiitis obliterans:
posterior tibial artery and veins,
marked endarteritis.
Fig. 12.— Teratoma from palate
of foetus.
P a t h o l o g ic a l C a s e s .
(M o l e ).
Urinary Retention in Pregnancy.
661
URINARY RETENTION IN PREGNANCY:
RETROFLEXION OF UTERUS.
G. T. T
o o te i -U, m . d .,
C h a n g te h , H u n an .
The' following case is reported because of the unusual
distension of the bladder following retroflexion of a gravid uterus.
This .is the second case of this condition seen by the writer during
ten years in China. Probably- there are many similar cases here
which do not come to the practitioners of foreign medicine.
According to De Lee, “ it is usual that in retroflexion the
uterus is displaced before the pregnancy'. Unless the displacement
is complicated by adhesions, no symptoms are complained of until
the uterus begins to draw on the neck of the bladder. Sometimes
there is a sensation of fulness in the pelvis, with bearing down
pains, or pains radiating from the sacral or lumbar plexuses. At
the end of the third month bladder symptoms appear— frequent
desire to urinate, great pain, and the necessity to strain to pass
water, the feeling that the viscus has not been emptied, and then
coming on 'more suddenly^, retention of urine.” Two cases are
mentioned by^ the same author in which the bladder contained
2,880 c.c. and 8,000 c.c. of urine respectively.
: R e p o r t of C ase.
C ase
1S 8 0 .
P .H .C .— M rs
D zu n g ,
m u ltipart!,
second
p re g n a n c y .
T h irty -o n e y e a rs of age.
F a m i l y h is t o r y . — N e g a t iv e .
Present history .— L a s t re g u la r m en stru atio n four m onths a g o ; had a
slig h t blood y d isch arge for two w eek s.
regu la r.
P revio u s to four m onths ago w as
A b o u t a m onth ago she w as co n stip ated for a fe w days, and also
had abd om in al p ain s and d v su ria .
T h e latter sy m p to m h as in creased in
se v e rity and for the la st eleven d a y s she has h a rd ly been able to u rin ate.
E x a m i n a t i o n .— P atien t w alk ed into hosp ital w ith som e assistan ce, blit
each step cau sed her to cry- out in p ain .
T h e face w a s d r a w n ; bo d y bent
forw ard w h en t r y in g to w a l k ; she w as unable to stan d , lie, or sit w ith
com fort.
A b d o m en g r e a t ly s w o lle n ; no m ass p alp ab le, alth o u g h sw e llin g
extend ed to eu siform .
and perin eum sw o llen .
No fetal heart tones heard.
W ith d ifficu lty cath eterizatio n w a s perform ed.
w ith d ra w n .
V u lv a v e r y edem atous
Both th ig h s and le g s m u ch sw ollen .
A t 7 p.m . 4,10 0 c.c. w ere
A t 6.30 n e x t m o rn in g , 1,500 c.c. w ere w ith d r a w n : at 1 2 m . 3,000
c.c. a n d at 6 p.m . 2,2 50 c.c.
w a s 10 ,8 50 c.c.
T h e to ta l-a m o u n t w ith d ra w n in the 24 hours
662
F o r tw e lv e
d a y s t h e p atien t had
to be cath eterized
tw ic e a
day.
U rotropin, in five g r a in doses, w ^ s g iv e n for the c y s t it is w h ic h had developed,
and m a gn esiu m su lp h ate w a s g iv e n d a ily in 30 g ra in doses to help reduce
the bo d y fluids, as w ell as a d iu retic m ix tu re . A ft e r the tw e lfth d a y she w a s
able to vo id b y ly in g on her b a c k an d u sin g a bed-pan, an d tw o d a y s later
she w a s sen t hom e, b e in g told to return if she h ad fu rth er d ifficu lty.
The
s w e llin g of the leg s, th ig h s, p erin eu m and v u lv a h ad e n tire ly d isap p e are d b y
the fifth
day.
E x a m in a tio n
revealed
a p re g n an t u teru s of about fou r
m onths, w ith fu n d u s tip p ed b a c k w a rd and c e r v ix p re ssin g a g a in st the n eck
o f the bladder.
N o r t h C h in a :— H u m a n I n t e s t i n a l P r o t o z o a . — A t a m eet
in g of th e F a c u lty M ed ical S o c ie ty of th e P e k in g U n io n M edical
C o lle g e on M a y 28, 1924, D r . K e sse l and D r . S v en sso n p resen ted
“ A S u r v ey of th e H u m a n In te stin a l P rotozoa of P e k in g — A R ep ort
o f 1 , 0 3 7 C a ses E x a m in e d .”
T h e fo llo w in g -is a b rie f sum m ary'.
T h e fu ll report w ill be p u b lish ed in th e near fu tu r e.
Of the 1,037 cases examined, 221 were foreigners and 816 were
Chinese. Of this number 340 received 6 examinations each.
39
j >
5
>>
>)
5®
>>
4
>>
»>
62
,, 3
So
,, 2
,,
,,
466
,, 1
,,
,,
The general conclusions of the survey are :
(1) Of the Chinese in Peking sixty per cent harbor intestinal
protozoa of one species or another.
(2) Of all positive cases seventy-two per cent harbor mixed
infections of protozoa.
(3) The percentage of Chinese positive for pathogenic protozoa
is four to five times as great as it is among civilians in
Great Britain and America.
(4) The foreign adults residing in Peking show a percentage
of pathogenic protozoa about equal to that of the British
and American troops returned from the war fronts or
about three times that of the civilian population of these
countries.
(5) The foreign children in Peking show a very low percent
age of infection with the intestinal protozoa, indicating
that care is exercised in their diet.
'Shi China Jfltbic¡íl Journal.
V o l . X X X V III.
A U G U ST , 1924.
N o .'8
NEW VIEWS OF BUBONIC AND PNEUMONIC PLAGUE.
The Heaith Committee of the League of Nations appointed
one of its members, Dr. F . Norman White, to go to the F'ar East
and collect information regarding the incidence of epidemic diseases,
especially those of international importance, in important ports,
and the measures taken to prevent the transmission of these diseases
to other ports. During a tour that lasted over nine months,
Dr. White visited most of the principal cities of the Orient and
made careful investigations. As the result he was able to present
a voluminous and very valuabie report to his Committee. Of special
interest to practitioners in China, wherever plague is endemic or
epidemic, is the part of the report dealing with this disease in its
different forms.
B
u b o n ic
P
lague
and
D
P
n e u m o n ic
is e a s e s
P
lague
S
eparate
?
The epidemiology, etiology, symptoms and so forth of bubonic
plague and pneumonic plague are compared and contrasted, and
the conclusion is reached that there is justification for considering
them as two separate and distinct diseases; that certainly from an
epidemiological view they are as different as any two diseases well
can be. Dr. White admits that no real difference has ever been
demonstrated between plague bacilli isolated from patients suffering
from primary pneumonic plague and the bacilli isolated from
patients suffering from bubonic plague. Nevertheless, a prolonged
and careful study of all the available epidemiological data, only a
fraction of which is referred to in the report, has driven Dr. White
to the conclusion that the plague bacillus alone does not, and
cannot, cause widespread epidemics of pneumonic plague.
It
seems more than probable that there is an additional organism at
work; in other words, the plague bacillus is in symbiosis with
another pernicious organism when pneumonic plague is caused,
664
The China. Medical Journal. "
.
which is thus a disease sui generis. The continuation, or refuta
tion, of this theory must pend further laboratory investigation,
opportunities for which may be afforded by the next outbreak of
primary- pneumonic plague. If the existence of this hypothetical
organism be postulated— an organism nonpathogenic for rodents—
all', or nearly^ all, that has been written regarding the history- and
epidemiology- of plague that is obscure 111 the light of present
knowledge becomes clear.
In
k e c t iv it y
of
H
um an
B
u b o n ic
P
la g u e
?
In support of his argument Dr White urges that bubonic
plague is essentially a disease of rats, and that all available evidence
goes to show that human bubonic plague patients are not infective
except in very exceptional circumstances. Plague hospitals in British
India, and in other parts of the Hast in which epidemics of bubonic
plague occur, are almost completely* free from danger to doctor and
nurse in spite of the fact that the precautions taken to avoid infec
tion are nil compared with the elaborate precautions that are
absolutely essential during pneumonic plague epidemics of the
north. Further evidence of the lack of infectivity- of human bubonic
plague patients is afforded by the fact that approximately 75 per
cent of cases of bubonic plague are single cases, that is to sayT,
one case per house. When multiple cases occur, it is the rule for
them to fall ill more or less simultaneously. Exceptional cases
of personal infection do occur, which is not surprising when one
remembers that in fatal cases of bubonic piague there mayr be term
inal pneumonias in which the patients may- expectorate sputa
containing vast numbers of virulent plague bacilli, but the exceptions
are relatively unimportant and do not upset the main argument.
Xone of the outbreaks of bubonic plague gives rise to an epidemic
of pneumonic plague.
Furthermore, the term “ septicaemic,” which has given rise to
much confusion, should be discarded. The difference between
bubonic and septicaemic cases is one of degree, not of kind, for the
vast majority' of plague cases have plague bacilli in their blood at
some period of the disea.se. The term “ septicaemic” should
therefore be rigidly confined to the description of a clinical
condition, and its use excluded from writings on the epidemiology
of the' disease.
Bubonic and Pneumonic Plague .
T
he
Im po rtan ce
of
S
C
h a in
pread
and
of
P
the
G
lagu e
r a in
T
665
rade
in
the
.
Whether the distinction advocated between bubonic plague
and pneumonic plague be accepted or net, it is claimed that at any
rate from the point of view of sanitary conventions and prophylactic
procedure, bubonic plague and pneumonic plague should be
regarded as different diseases. If this is done, plague prevention
cari be rendered less irksome and more effective than it is at
present, and it will be possible to concentrate on probabilities and
essentials and to neglect mere possibilities.
As Dr. White has often done before, he insists on the
importance of grain and the grain trade in the spread of plague.
He gives some examples of the association of plague with rice
importation, and affirms that if it were possible to break the
association of rats and grain the control of plague in the Far East
would be readily assured.
“ In the East, as elsewhere, rats are much more numerous in
grain stores and markets than they are in oilier places. It is for
this reason that grain stores and markets afford special facilities
for plague infection surviving the adverse climatic and other
conditions of the non-epidemic season. During the height of the
epizootic, which incidently synchronises in many parts of the East
with the harvest, a time of the year when the movements of grain
are especially active, the dangers attendant upon the transference
of such merchandise from an infected to a plague-free locality’ are
obvious. Consignments of grain afford opportunities for the
transport of rats and rat-fleas unsurpassed by those afforded by the
movements of any other form of merchandise, and they are placed
in the most rat-infested parts of the town of arrival.” The sanitary
and other measures that should be taken from this point of view to
prevent the spread of plague are described.
S
um m ary
of
C
o n c l u s io n s.
The report is summarised by Dr. White in thirty-one con
clusions, some of which are as follows :
1. Bubonic piague is, all things considered, the most im
portant ship-borne' disease in the Orient.
2. Bubonic plague is essentially a disease of rats, arid the
human case is, for all practical purposes, not infectious.
666
3 . T h er e is a b u n d an t ep id em io lo g ica l in fo r m a tio n , based on
a quarter of a c e n tu r y ’s e x p er ie n c e, to j u s tify th e co n sid era tio n o f
bubonic p la g u e and p n eu m on ic p la g u e as tw o e n tir e ly sep a ra te and
d istin c t ep id em ic d isea ses.
4. It is extremely doubtful whether the plague bacillis alone
can give rise to pneumonic plague epidemics.
5. Epidemiological facts indicate the probability that pneu
monic plague epidemics are caused by the plague bacillus in symbiosis
w7ith another organism.
6. It is probable that this “ hypothetical'’ organism will be
found to be non-pathogenic for rodents.
11.
The control of the grain trade and the proper storage of
grain are almost synonymous w7ith efficient plague preventive
measures.
13 . If due consideration be given to the attributes of the rat,
it is possible to erect storehouses that can be kept automatically
rat-free. Many “ rat-proof” stores now in existence harbour a
large rat population.
17. Further work is required to devise more satisfactory
methods of fumigation than those at present in use.
18. The disinfestation before shipment of rat-favoured mer
chandise from plague-infected localities demands much, more
consideration than it. receives. Such measures should, wherever
possible, be taken at the port of departure.
20. The history of the spread of plague in the East indicates
that attention paid to the usual channels of infection could secure
almost absolute immunity from plague, and that without vexatious
restrictions to the free flow of commerce.
21. The tendency of the disease to die .out in large areas of
the East, unless reinforced by repeated introduction of infection,
accentuates the importance of preventing such re-infection.
25. British India is by far the most important reservoir of
plague infection in the East. Java comes second. The prevalence
of the disease in British India is decreasing, noticeably in those
provinces that have suffered most.
29.
In most Oriental towns, anti-plague measures are unsuc
cessful, largely on account of the antagonism of the population to
such measures.
Bubonic and Pneumonic Plague.
667
30. 'The disinfection of houses and their contents is the most
commonly practised of all anti-plague measures; it excites great
antagonism and, as carried out, is of extremely doubtful utility.
3 1. Suggestions are made regarding a new orientation of
plague policy in many Oriental towns.
When the report was presented by Dr. W'hite to the League
of Nations Health Committee, his hypothesis that pneumonic
plague and bubonic plague are two distinct kinds of plague and
that in the former there is a symbiosis of causal germs, was
considered very* cautiously, one expert saydng that “ symbiosis had
never yet been observed, and was a mere hypothesis not based on
any concrete facts.” After much discussion a Sub-Committee was
appointed to consider the whole question. Its report, of which the
following is a part, was adopted as an Annex to the main report.
“ As the author [Dr. White] candidly admits, it is impossible
to discuss here the very ingenious theory regarding pneumonic
plague, [that it is] a disease totally distinct from bubonic plague.
Only experiments and laboratory research will make it possible to
solve this question and to determine the part played by symbiosis
between the various organisms.
“ Although it would not be wise at the present stage of
scientific research to draw prophylactic conclusions from this
theory- regarding pneumonic plague, certain facts are recorded in
Dr. Norman White’s report which the Sub-Committee unanimously
accepts.
“ There is no doubt that too great an importance has been
assigned to man in the propagation of plague. Not that man is
incapable of directly transmitting this disease. We know cases—
rare, but conclusive—of bubonic plague being transmitted from man
to man, but only-' in eminently ecto-parasitic surroundings.
“ The pandemic form of pneumonic plague appears to be
localised in the North-east of China and Siberia, and, up to the
present, conditions in the southern regions of the Far East and of
Europe do not appear to have been favourable to its extension;
subject to due reservations, therefore, pneumonic plague may be
c o n s i d e r e d as relatively unimportant, in so far as the framing of
regulations for maritime traffic is concerned.
66S
“ Pneumonic plague, as met with in Europe, in North Africa
and in America, has never formed anything but small foci centres
which were easily* stamped out.
“ Despite these considerations, we must not, however, exclude
the possibility* óf danger from this disease ; the variations in what
the ancients called the epidemic spirit are well enough known, as
also its manifestations, which differ so greatly according to place,
times and conditions, which as yet are unknown.
“ From the practical point of view, we may consider it as
established that human plague is in all cases a concomitant of
epi zootia plague. It is, therefore, the rat and not man which
represents the danger against which measures must primarily be
taken.
“ If it is the case that certain ports, as, for instance, Manila,
Shanghai, and the Formosan ports, have succeeded in totallyeradicating plague, the Sub-Committee is anxious that the attention
of the Governments interested in this question should be drawn to
these facts and that they should be informed of the measures which
made it possible to achieve this remarkable result.
“ All observations made by epidemiologists in the East, as
well as in Europe, show that epizootic plague is in any^ case
tending to disappear; only reinfection keeps it alive, and il is of
the greatest importance that such reinfection should be prevented.
“ It is essential that all vessels and goods coming from infected
ports should be protected from rats before embarkation ; that such
vessels should be cleared of rats before their departure, and that
goods liable to carry* infection should be isolated under conditions
such as those laid down by* Dr. Norman W hite.”
The following resolution was also adopted :
“ The Health Committee recommends the creation, in a Far
Eastern port to be chosen by* agreement between the Governments
concerned, of a Bureau which would represent, for that portion of
the globe, an extension of the Epidemiological Intelligence Service
of the Health Section of the League of Nations. The Rockefeller
Foundation might be asked to lend its assistance in the organisation
of this bureau. The Committee points out that the Far Eastern
Association of Tropical Medicine has unanimously recognised the
utility* of such a bureau.”
Hongkong Medical Conference., 1925-
669
HONGKONG MEDICAL CONFERENCE, 1925.
S
e c t io n a l
M
e e t in g s
The China Medical Missionary Association will hold its
Biennial Conference at Hongkong from January 21-28, 1925, at the
invitation of the Hongkong and China Branch of the British Medical
Association. A s this is the first time that the Association has
met in Hongkong, both bodies are very- anxious that this joint
conference shall advance medical science in China as much as
possible and have therefore invited delegates from other bodies and
associations of kindred aims.
The sectional meetings of the Conference have been placed
under the control of a joint chairmanship, each chairman acting as
secretary on behalf of the. association lie represents. The honorary
secretaries of the conference are Dr. Joseph Shellshear, of
Kongkong, and Dr. James L . Maxwell, of Shanghai.
The sections and their representatives are as follows, the name
of the Medical Missionary Association representative preceding
that of the British Medical Association representative.
General Medicine.— Dr. W. W- Cadbury, Canton Christian
College; Prof. J. Anderson, Hongkong University.
Therapeutics.— Prof. B. E. Read, Peking Union Medical
College; Dr. C. W. MacKenny, Govt. Civil Hospital, Hongkong.
Pathology.—Prof. L . H. Braafladt, Tsinan; Dr. J. Morrison,
Union Buildings, Hongkong.
General Surgery.— Dr. Oscar Thomson, Canton Hospital;
Prof. K . H. Digby, Hongkong University.
Ophthalmology.—Dr. PI. Howard, Peking Union Medical
College; Dr. G. M. Harston, Union Buildings, Hongkong.
Ear, Nose and Throat.— Dr. Thacker Neville, Changsha;
Dr. S. S. Strahan, Alexandra Buildings, Hongkong.
Radiology.— Dr. j. L . Harvey, Canton Hospital; Dr. J.
Macgoury, Alexandra Buildings, Hongkong.
Obstetrics.—Dr. J. Wright, Canton H ospital; Dr. C. Forsyth,
Alexandra Buildings, Hongkong.
Anthropology.—Prof. D. Black, Peking Union Medical College;
Prof. J. U. Shellshear, Hongkong University.
670
Physiology.— Dr: P. S. Evans, (jr.)1 Shantung Christian
U niversity; Prof. H. G. Earle, .Hongkong University.
1H ygiene and Public Health.—Dr. F . Oldt, Canton Hospital;
Dr. J. B. Addison, P. C. M. O., Hongkong.
Parasitology.—Dr. E- C, Faust, Peking Union Medical Col
lege; Dr. E . P. Minett, Govt. Bacteriologist, Hongkong.
Naval and Military Hygiene. — Surg. Capt. Burniston, R . N .,
Lt.-Col. Fitzgerald, R. A. M. C.
flDefcical IRcports.
N O R TH M A N C H U R IA N P L A G U E P R E V E N T IO N S E R V IC E
R EPO R T, 1923 1924
Edited b\- Wu Lien Teh, M .A ., M .D., B.C. (Cantab.), Hon.
Litt.D ., (Peking), L L .D ., (H’kong), Sc.D. Publishers : Tientsin
Press, Limited, Tientsin. 1924
Fortunately there has been no epidemic recently of pneumonic
plague in the north of China, so the report consists mainly of a
review of work done in the past. It contains an interesting history
of plague epidemics in all countries from the earliest times, so far
as these have been recorded. This is followed by a chapter on
“ Plague in Wild Rodents, including latest investigations into the
role played bjT the Tarabagan,” in which it is proved that the
tarabagan can be the source of plague in man, but the exact mode
of transmission is still undetermined. The next paper on “ A
Study of the Morbid Histology^ of the 1921 Manchurian Plague
Epidemic,” appears elsewhere in abridged form in this number of
the “ China Medical Journal.” Two other papers on plague are
entitled “ Notes on the Histological Lesions found in Organs of
Naturally Plague-infected Tarabagans” and “ The Original Home
of Plague.” Then follow “ Remarks on the Incidence of Certain
Diseases in Chinese and Europeans,” and other papers on miscel
laneous subjects. The report is well illustrated, some of the
pictures being colored.
HAN G C H O W , C H EK IA N G .
L o v e i n A c t i o n '. Report of the Universal Benevolent Healing
Office in Heaven Below. Being the Annual Report of 1923 of the
Medical Reports.
671
Hangchow Hospital and Medical Training College in connection
with the Church Missionary Society.
Staff : Foreign physicians 6, and 2 Lecturers in Chem istry;
Chinese physicians and lecturers, 14 ; Foreign nurses, 5 ; Chinese
nurses, servants, and artisans, 70. Departments of work in the
city, 13 ; departments of work outside the city, 14.
This is the report of' a large Institution with many
Departments. The work and the report are alike unique, and
difficult to summarise. The first article is a general review, which
passes from the particular activities of the Hangchow Hospital to
the aims and methods of medical missions in general; then follow
comments on the value of medical education ; on opium smoking;
spiritual healing; work among out-patients; venereal disease and
the social e v il; the work of the Leper Hospital; the treatment of
leprosy with the ethyl esters of chaulmoogra o il; reports by Dr
Sturton and Dr. Chen on the medical and surgical work; by Miss
Curtis, as head of the Nursing Department in the Men’s Hospital
and of the Maternity Section; by Miss Weathereil, of the Women's
Hospital; by Mrs Main, on the needs of the various departments,
and acknowledging help received. There is also a report of the
evangelistic work, the reprint of a circular letter sent out by?- Mrs.
Main, and a graphic account of the experiences of Dr. and Mrs.
Main, who were staying at Miyanoshita at the time of the terrible
earthquake in Japan last year.
Total number of in-patients during the year, 3 ,14 5 ; out
patients, 35,25 3; lepers, 74; patients with tuberculosis, 204;
opium-smokers, 47 ; cases of attempted suicide, 138 ; accident cases,
3 2 3 ; operations, 843; pathological specimens examined, 2,784;
maternity cases, 334 in hospital and 31 outside. A number of
students are studying medicine, and sixteen girl students are
studying midwifery-. Financial statement : income, $85,749,20 :
expenditure, $83,045.93.
The object of all these manifold activities is well stated in the
report : “ If crowds of out-patients, full wards, brilliant operations,
diseases cured, precious lives saved, lepers cleansed, consumptives
relieved, students taught, chemists graduated, old buildings
Renewed, new hospitals and homes built, the new college building
going on well, lame ducks helped, the gospel preached, tracts and
672
scripture portions distributed, happy fellowship, loyal workers,
many friends, just debts paid, together with many other blessings
received, were our end and aim, then might we cry ‘ Eureka’ arid
rest on oyir oîrs. But these things do not constitute the chief end
of our work. We are out through every department of ours to win
souls for Christ, to work through men's bodies to their hearts,’to restore men from sickness to health, and to lead them from
darkness into light.”
CANTON: KUNG Y E E M E D IC A L COLLEGE A N D
H O SP IT A L A N D T R A IN IN G SCHOOL FOR N U R S E S .
R E P O R T FOR 1922-1923.
Faculty of Medical School : 7 foreign and 23 Chinese medical
instructors. Hospital Staff : 3 foreign physicians and 13 Chinese
physicians. Nursing Staff: Mrs. M. S. Todd, R .N ., Superintendent;
S .Y .A u , R .N ., Assistant Superintendent; nine graduate nurses.
The object of the Kung Yee Medical College is to give a
thorough medical education to promising young men and women
who desireljto enter the medical profession. Connected with the;
school is a modern hospital, where real scientific work is done and
where the students receive their practical training.
The Society was first organised in 1909. At the present time
it has 140 mow of land (25 acres), two hospitals, one out-patient or
free clinic building, the main College building with six laboratories,
two lecture rooms, a library, an Assembly hall, three office rooms,
a faculty room, a book room, a waiting room and a large lobby; an
anatomy building with a large dissecting room, a lecture room, a
laboratory and an office; one dormitory^ accommodating 120 medical
students; four modern^ bungalows for staff residences; and a
temporary Nurses Home, which will accommodate 24. These build-r
ings are all well furnished and the laboratories are fairly well
equipped. The policy of the staff is to meet tlie standard set by
the American College of Surgeons for the recognition of hospitals.
In 1923 the Medical College was organised as a university, as
the Government of China permits one department, such as medicine,
agriculture, or law, to take the name of a university if it is able to
meet the standard required by the Government.
Therefore the
name of the institution has now been changed to the Kwong Tung
Kung Yee University Medical School and Hospital. Total number
Medical Reports.
673.
of students enrolled during tlie year, 16 4 ; students graduated
during the year, 13 . Total number of graduates since the school
was opened, 234.
The work of the hospital staff during 1923 was the hardest it
has so far experienced, which was partly owing to the arrival of
numerous wounded soldiers following the fighting which took place
near Canton between the Kwangsi and Yunnan forces. From the
beginning of April to the end of the year there was a daily average
of about 400 in-patients. The Government was unable to pay in
hard cash for the cost of taking care of the soldiers, so it settled
part of its bill byr giving the institution seven acres of land. The
total number of m-patients during the year 1923 was 4,788, with
121,0 56 hospital days, as against 3,440 in-patients with 47,560
hospital days in 1922.
Total receipts, $18 0 ,0 9 1.0 5 ;
total
expenditure, $178 ,552.6 5.
R O C K E F E L L E R F O U N D A T IO N . R E P O R T FOR 1923.
During the year 1923, the International Health Board, the
China Medical Board, and the Division of Medical Education of the
Rockefeller Foundation supplied fellowship funds for 636 individuals
in 29 different countries; supported through the League of Nations
interchange institutes for 54 public health officers from 27 nations;
arranged international visits of one commission and of 24 visiting
professors; furnished emergency relief in the form of medical
literature or laboratory equipment and supplies to' institutions in
15 European countries; sent scientific material to Japan after the
earthquake and invited a group of Japanese medical scientists to
use the laboratories of the Peking Union Medical College as guests
of the institution; continued to contribute to schools or institutes of
hygiene at Harvard, London, Prague, Warsaw, and Sao Paulo,
Brazil; co-operated in nurse-training at Yale University and in
France, Belgium, Brazil, China and the Philippines.
It accepted an invitation from Brazil to participate in a com
prehensive attack upon yellow fever; had a share in demonstrations
of malaria control in 12 American States, and conducted malaria
surveys or studies in the Unjted States, Brazil, Australia, Nicaragua,
Porto Rico, Salvador, the Philippine Islands and Palestine; either
continued or began anti-hookworm work in conjunction with 20
governments in various parts of the world; contributed to 183
674
county health organizations in the United States, New Brunswick
(Canada), and Brazil; continued a study of the medical schools of
the world by visits to Belgium, Austria, Czechoslovakia, Germany,
Hungary, Poland, Turkey, Hongkong, the Straits Settlements,
Siam, Canada, England, Scotland, Wales, the Netherlands, Mexico
and Colombia.
It offered to contribute £280,750 to the development of medical
education in certain universities in the British Isle s; gave $500,000
to the University’ of Alberta, and pledged $250,000 to the
University of Pennsylvania toward buildings for anatomy' and
physiological chemistry ; continued to support a modern medical
school and teaching hospital in Peking; aided two other medical
schools and 25 hospitals in China; assisted premedical education in
several institutions in China and agreed^to do this also in Bangkok,
Siam ; lent representatives to governments and institutions for
various types of counsel and service; continued to support a disease
reporting service of the Health Section of the League of Nations;
contributed to mental hygiene projects, demonstrations in dispensary
administration, organization of dispensary work in France, and to
other undertakings in the fields of public health and medical
education.
STATUS OF THE MEDICAL PROFESSION IN CHINA
K . Chim in W ang
L .M .S .H ., S h a n g h a i-H a n g c h o w
R a ilw a y ,
H angchow .
The well-known author, R . L . Stevenson, for years under the
constant care of physicians, expressed the conviction that “ the
doctor is the flower of our civilization—such as it is—and partakes
more of its virtues and less of its defects than any other class of
m en.” Can the same be said of Chinese medical practitioners?
In other words, what is the status of the medical profession in
China?
Some Chinese writers speak well of doctors. Chia Y i, of the
Han dynasty, remarked that the “ superior m an” , if disinclined
for official life, will practice medicine for the reason that a doctor
also can serve the people. Cheng Ym-chuan thought that the
The Medical Profession in China.
675
scholar who serves his parents should not be ignorant of medicine.
L u Chi, a prime minister of the Tang dynasty, compared the
merits of a good doctor with that of a good premier, which made
Fan YVen-ching of the Sung dy’nast}’, utter the famous saying that
if he could not become a good statesman he would be a good doctor.
Medicine itself is spoken of as a benevolent art, and physicians are
styled “ kou sh ou ” ( ® ^ ) or “ healers of nations,” who have
the great responsibility of “ controlling life and death.”
In spite of these high tributes, however, members of the
profession have never been accorded any position in society. Con
fucius said ironically that without perseverance one cannot even
become a priest-doctor. The Sea and H ill Classic (Oj m m ) states
that east of Kai Min there lived certain sorcerers named Pan, Ti,
Yang, L i, Fan and Shang, who were all skillful physicians.
According to the Shou Wen (fgj .3 0 , the sorcerer Pan was the first
doctor. Thus religion and astrology merged into healing, and, as
in all early civilizations, the first physician was a priest and the
first priest a physician.
It was not until the Chow dynasty that the functions of these
two professions were separated. The book entitled Chow Rituals
(M i i > records that the chief sorcerer shall direct the junior
sorcerers to make offerings m times oi. drought, and that the doctor
shall superintend all matters relating to medicine and shall collect
drugs for medical purposes.
An interesting sidelight on the art of medicine is found in the
formation and development of the ancient Chinese character for
doctor (H). It is composed of three parts. At the top on the left
corner is a quiver (£§} ; oh the right corner a spear ( £ ) ; below is
the symbol for sorcerer or priest (3$), the whole character meaning
that the priest employs strong weapons to kill or expel the demons
of disease. Later, the third part of the s\7mbol was changed to
wine ( I f ) , signifying that the practice of medicine was no longer
confined to the priests but had been taken up by doctors who
administered elixirs or wines to their patients.
In later tunes, though doctors were a distinct class from priests,
their social standing was still not much raised, for we learn from L u ’ s
Spring and Autumn (& J£ ^ $ C) that medical practitioners were
held in low esteem by the people, as “ they employed poisonous
drugs to treat and expel disease, hence the ancients despised them
and assigned jthem a low position in society.” Because of this
social inferiority, Hua To, the celebrated surgeon, felt ashamed of
bis profession and wanted to retire from it.
During the Han dynasty and the two following dynasties,
superstition reached the highest point. A new form of treatment
was invented by Chang Tao-ling, a Taoist priest, who made use
of charms and incantations for the curing of diseases. His followers
were called “ robbers-of-five-piculs-of-rice,” as they usually exacted
this quantity of rice for their services. Seeing the lucrative income
brought in by these devices, Buddhist monks soon invented their
own system of charms. The result was that the market was flooded
with the wares and remedies of both schools, and it was claimed
they had the power of conferring every benefit under the sun.
The search for the philosopher’ s stone and the elixir of life
was also most popular at this time. Magicians, doctors, and
alchemists were found everywhere experimenting with herbs and
minerals in an attempt to discover an elixir which would confer on
the person drinking it everlasting life and beauty. Of the twentytwo rulers of the Tang dynasty- seven experimented with these
elixirs and died from their effects.
Such were the prevailing conditions. It is no wonder that the
Tang Annals
said that “ mathematicians, surveyors, fortune
tellers, physiognomists, physicians and magicians were charlatans.
The sages did not regard them as educated.” The culminating
blow to the old Chinese medical profession was when Szu Ma-chien,
the Herodotus of China, classified doctors on the same footing with
fortune-tellers, astrologers and palmists.
Since then educated
people have disdained the practice of medicine as a regular
profession.
Hence Chu Hsi, the famous commentator on the
Confucian classics, indicated the social position of physicians in the
following words : “ Sun Szu-mo was a noted doctor of literature of
the Tang dynasty, but as he practised healing as a profession he
was relegated to the class of artisans. What a pity- ! ”
The general distrust of the doctor’s ability and character mayr
be further shown by the following quotations and proverbs.
“ Doctors cannot cure their own complaints4’ (Huai Nan-tzu,
•=p). “ The son of the good sorcerer is generally killed by
demons.” “ The son of the great doctor usually dies of disease”
The Medical Profession m China.
677
(Ancient Essay ^ $C). “ It is a middling course to leave a disease
untreated” (Annals of Art and Literature,
‘ " t o take
lio medicine is the best cure” (Proverb).
“ Medicine does not
kill, the physician k ills ”
(Proverb). “ Do not take medicine
compounded by a doctor who is not backed by the experience of
three generations” (Record of Rites, jjjf[ fS). “ Quack doctors kill
people ” (Proverb). “ What the doctor says is all right, but what
he sells is false” (Proverb). “ Doctors puncture and plaster and
use spurious drugs” (Proverb).
On account of the low estimate of the value of their services
doctors often play a very secondary role in the treatment of a case.
Their prescriptions are viewed with suspicion, carefully examined,
discussed and analysed as to whether the medicine is “ cooling” or
“ heating” , suitable or unsuitable to the patient. If, in the
opinion of the patient’s relatives or friends, the medicine prescribed
is not perfect, they will add, alter, remove some of the drugs
mentioned, or entirely reject it. Physicians are called or dismissed
at w ill; two or three or even a dozen may^ be engaged at the same
time. Only rarely is this for the purpose of consultation. The
physicians come one after the other, each writes a prescription,
explains the supposed cause of the illness, and his duty is done.
The richer the family, the more numerous the doctors engaged ; the
larger the household, the greater the fuss. It is not an uncommon
sight to find half a dozen doctors all waiting in the house for their
turn to examine the sick person. When each has written his
prescription the relatives and friends will hold a consultation and
“ pass sentence” on the relative merits or defects of all the
prescriptions, and then one will be sent to the druggist for
dispensing.
The unfavourable attitude adopted by the people, especially
by the educated class, towards medicint in general has been
brought about by many causes. Instead of being regarded as a
learned science and art, the practice of medicine has been, and
still is, considered as an avocation, a side occupation, or else it is
regarded as pure business. There are no proper schools to prepare
a medical student for his work. Any one can set up as a doctor.
A coolie who inherits a few prescriptions from his ancestors, or an
old woman who has had some experience from rearing her children,
will put up his or her sign-board and start practice. Going a little
higher we find a class of men who are too lazy or too weak for
manual labour, or not educated sufficiently for literary work, who
study for a few months some old medical books and then take to
medicine to earn the means of livelihood. In the higher grades of
practice an apprenticeship is served either under an old doctor, or
in a druggist shop, to enable the beginner to pick up some
knowledge of medicine before he commences practice.
The following poem, entitled “ Lamenting the Practitioner'*
(IT •§! HP» by Hsu Ling-tai, a famous and versatile doctor of the
Kien-lung period, describes the standing of Chinese physicians in a
most thorough manner. We give a prose translation.
“ Having nothing to do they took to healing. W hat do such
people know about the value of human life ? Or that saving people
is not a business proposition? They onty read half a medical book
and learn the uses of a few drugs. Before starting practice they
just inquire what medicine the popular quacks are using and then
try it on their patients. If some good results happen they are
themselves surprised ; if death occurs they will say that the medicine
is good but the disease is fatal. How many innocent boys and
girls, young husbands and wives, aged fathers and mothers, have
you killed? And people do not blame you, but on the contrary
compensate you for the attendance and medicine! Oh, how could
you have the heart to do it ? Though the law cannot reach you,
yet heaven will not be deceived. Should you really want to serve
suffering humanity you must first read more. If unable to do so,
better change your profession so as to escape the fires of hell ! ”
T he
C h in e s e
S i c k - r o o m . —Nothing in the habits of the
Chinese presents a greater contrast to those of Westerners, than
the behaviour of the Chinese to one another in cases of sickness.
The notification of the event is a signal for all varieties of raids
upon the patient, from every quarter, in numbers proportioned to
the gravity of the disease. Quiet is not for a moment to be thought
of and strange to say no one appears to desire it. The bustl
attendant upon the arrival and departure of so many guests, th
work of entertaining them, the wailings of those who fear that
death is soon to take place, and especially’ the pandemonium mad
by priests, priestesses, and others, to drive away the malignant
spirits, constitute an environment from which death would be
to most Europeans a happy escape.— Arthur Smith, Chinese
Characteris tics.
Medical Ethics in China
679
MEDICAL ETHICS IN CHINA.*
E d w a r d M. M e r r in s , m.d., S t. J o h n ’s U n iv e r s ity , S h a n g h a i.
The purpose of this paper is not to discuss abstract moral
questions concerning human motives and conduct remote from the
practical affairs of the medical profession, nor to discuss questions
of casuistry interesting onljr to logicians and theologians. Its
object is to consider the ways and means by which we can help our
Chinese friends to give to the medical profession now being formed
in China the same high dignity and honor that the profession has
in the West.
This is a task of peculiar difficulty. China is a country of
advanced and ancient civilization, but the state of medicine has
always been very7 backward. Laws and regulations governing the
practice of medicine are unknown. Anyone is at liberty to proclaim
himself a doctor, even an ignorant coolie on the street. Generally,
the native doctor possesses a lew prescriptions, perhaps heir-looms,
some of which are of considerable value if reports be true, and
these constitute his whole armamentarium. Among the people at
large there is no conception of medicine as a science. All diseases
are ascribed to the agency7 of supernatural beings or to unknown
supernatural causes, hence the temple priest with his charms and
incantations is visited equally with the doctor. In such an environ
ment our young scientifically-trained Chinese doctors, not very
numerous, are obliged to follow their calling. They are between
the horns of a dilemma. If they do not fall into the ways of their
counti'ymen, it will be very slow and difficult to build up a lucrative
practice ; if they d^> fall into such ways it is hard to see how a- high
ethical standard can be established and maintained. Further,
when a doctor is called in and prescribes, if there is no immediate
improvement, even though the case is one of typhoid fever or
small-pox, a change of physicians is made and this goes on until
the patient gets well or dies. In these circumstances it is impossible
to expect unity of the medical profession, for there is no common
knowledge or scientific purpose to hold it together, and medical
ethics are not even dreamed of.
* R e a d at the C .M .M .A . C onference, held in S h a n g h a i, F e b r u a r y , 19 2 3.
The China Médical Journal.
68o
In the West,1-ifledicine’ has beeiumuch -more fortunate from the
very earliest times. It has been recognized that the delicacy and
complexity of the professional relations of a doctor with the patient
and with the patient’s family necessitate a code of ethics more
particular and specific than the general moral rules which govern
ordinary human conduct, although based upon it. One of the
earliest, if not the earliest of these codes, is the Hippocratic Oath
(circ. B.C . 460— B.C. 380), of which the British Medical Journal
k s recently reprinted the following full translation.
The
H ip p o c r a tic
O a th
“ I sw e a r b y A p o llo the p h y sic ia n and A e s c u la p iu s , and H e a lth , and
A ll-h e a l, an d a ll
the go d s and go d d esses,
th at, a c c o rd in g to m y a b ilit y
alid ju d g em e n t, I w ill keep th is O ath an d th is stip u la tio n — to recko n him
w h o ta u g h t m e th is A r t e q u a lly dear to m e as m y p are n ts, to sh are m y
su b sta n ce w ith him , an d r e lie v e his n ecessities if r e q u ir e d ; to look upon
h is o ffsp rin g on the sam e fo o tin g as m y ow n brothers, an d to teach them
th is A r t , if th e y s h a ll w ish to learn it, w ith o u t fee or stip u la tio n ; an d th at
b y p recept, lectu re, and e v e r y oth er m ode of in stru ctio n , I w ill im p a rt a
k n o w le d g e of th e A r t to m y ow n so n s’, an d those of m y teach ers, and to
d iscip les bound b y a stip u la tio n and oath a cco rd in g to th e la w of m ed icin e,
bu t to none others.
I w ill fo llo w th a t sy stem of re g im e n w h ich , a cco rd in g
to m y ability- and ju d g e m e n t, I co n sider for the benefit of m y p atien ts, and
a b sta in from w h a te v e r is d eleterio u s an d m isch ie v o u s.
I w ill g iv e
no
d e a d ly m ed icin e to a n y one if ask ed , nor su g g e s t a n y su ch c o u n s e l; and in
lik e m an n er I w ill n ot g iv e to a w o m an a p e ssa ry to prod u ce abortion.
W ith p u r ity an d w ith holin ess I w ill p a ss m 3' life and p ra ctise m y A r t .
1
w ill not cu t persons la b o u rin g u nd er th e stone, but w ill leav e th is to be
done b y m en w ho are p ractitio n e rs of th is w o rk ,
in to w h a te v e r hous.es I
enter, I w ill g o in to them for the benefit of the sic k , and w ill a b stain from
e v e r y v o lu n ta r y act of m isch ie f an d c o rr u p tio n ; and, fu rth er, from the
seduction of fem ales, of freem en and slav es.
W h a te v e r, in co n n exio n w ith
thy p rofession al p ra ctice or not in co n n exio n w ith it, I see or hear in the
life of m en w h ich o u g h t not to be sp ok en of abroad, 1 w ill not d iv u lg e , as
re c k o n in g th at all such sho u ld be k e p t secret.
W h ile I co n tin u e to keep
th is O ath u n v io la ted , m a y it be g ra n te d to m e to e n jo y life an d the p ractice
of the A r t , resp ected b y all m en in all tim es !
B u t sh o u ld I tre sp a ss an d
v io la te th is O ath, m a y the reverse be m y lo t.”
All through the centuries medical students in Western lands
at graduation have promised to conform to the requirements of
this oath, and adherence to its main principles is still required
by some of the medical schools in Great Britain and America.
But more and more it is falling upon medical associations, general
arid local, to take the necessary measures to protect themselves
Medical Ethics in China.
681
and the honor of the medical profession against those of their
number to whom gain, or reputation is .the first and. only
consideration. In Great Britain the General Medical Council keeps
vigilant watch over the conduct of doctors, and for any breach of
ethical rules the penalty is swift and severe. In America there
is no Council with punitive powers; it is left to the medical
associations to protect the profession. To such an extent is this
carried that our friends the parasitologists have recently compiled
an ethical code entirely for their own use. This does not imply
that the parasitologists find it harder to be virtuous than the rest
of us, but the nature of their work in identifying and naming
multitudes of newly-discovered organisms with all the conflicting
claims which such work engenders makes a special code necessary.
The difficulties in forming a code with which all will agree and
in enforcing its observance are very great. In the first place, rules
of medical ethics upon which even religious, honorable men hold
different opinions are very numerous. We need not be disturbed
by this as if it were evidence of moral perversity or backward moral
development. It is much the same as when soldiers are fighting
for a noble cause but do' not agree as to the motives and reasons
why they fight for it, and it is well knowm that among theologians,
all of them good men, there is much dissension when it comes to
the formulation of ecclesiastical and doctrinal statements.
In the second place, observation of the spirit of the code is far
more, important than apparent conformity to the letter. A physi
cian may say and do things of which his brethren may not wholly
approve, but if he is a man of honor there may be no serious con
sequences. On the other hand, a physician who is not thoroughly
honorable may evade or violate every provision of the code and yet
be so clever as to furnish no evidence to warrant his professional
ostracism. In China there is a further difficulty : when a physician
does violate medical ethics, there is no power, State or medical,
which can punish him in any way.
With regard to honest differences of opinion on ethical questions,
some instances will now be given, for discussion of them is most
necessary if we intend to compile a code for the guidance of the
medical profession in China. We think it will become evident that
we should confine ourselves to a few fundamental moral principles
6S2
and that we should deal with the whole matter in a kindly,
sympathetic spirit, being fully aware that the lack of unanimity is
a disadvantage to those who assume moral leadership.
P
r o f e s s io n a l
C
o n f id e n c e s .
Upon the question whether professional confidences shall be
held inviolate or not, there is much diversity of opinion, not only
between the medical profession and the State, but in the profession
itself. The large majority of physicians contend that the knowledge
and confidences obtained by medical men in the course of their pro
fessional duties should be held as sacred and inviolate as the con
fidences reposed by penitents in the priests of the Roman Catholic
Church, or in other ministers of religion. But in some countries,
as in England, it is held that in the interests of public justice a
medical man can be compelled to disclose professional confidences.
In a recent volume of essays (1922), Lord Birkenhead, a former
Lord Chancellor of England, declares that no case can be made out
for privilege when privilege may come in contact with law. The
physician must tell all he knows about his patient, no matter what
pain the telling may cause innocent people.
On the other hand, when public interest does not demand such
disclosures, the State will punish heavily any medical man who
discloses the information he has obtained in his professional capacity,
even though it is given to members of his own family^ and to no one
else. For instance, a famous English obstetrician and gynecologist,
called to attend his sister-in-law during the absence of her husband
in a distant land, considered he had found indubitable evidence of
misconduct. He told his wife so, and said that he wished she and
other members of his family7 would have no further social intercourse
with her and stopped an annual allowance (£500) which he had been
giving her. The lady felt very much aggrieved and retaliated by
bringing an action against her brother-in-law. She obtained the
handsome sum of £12,0 0 0 by way of compensation and consolation.
In China, we imagine, the elderly ladies of the clan, energetic and
eloquent, would have taken a very active part in the dispute, and it
would have gone very hard indeed with the sister-in-law. Instead of
winning a large sum of money, her career would have been short
and bitter, and probably she would soon have sought peace at the
bottom of the nearest well.
683
But is the State always justified in requiring the disclosure of
medical confidences ? A few years ago, one of the eastern States
in America passed a law requiring that in every case where it came
to a physician’s knowledge that abortion had been attempted he was
to notify the State authorities. What may be the consequences ?
A girl in a moment of weakness is led astray and becomes pregnant.
To hide her shame, for she would rather die than have her condition
made public, she goes to an irregular practitioner; an operation is
performed and septic infection follows. A regular practitioner is
then called in. Is he to notify at once the public authorities? If
the patient believes that he is going to publicly expose her misdeeds
she will not call him in ; she will prefer a thousand times to keep
her shame hidden, whatever the physical consequences to herself
may be. To obey this law rigidly may therefore indirectly' cause
her death. Members of the medical profession are divided on the
point, whether their duty to the State or their duty to the patient
should take precedence.
The difficult subject furnishes another problem : Suppose a
family physician knows that a patient of his, who is suffering from
a virulent venereal disease, is about to marry an innocent girl whom
he has known and cared for from infancy. Is he bound to keep his
knowledge of the prospective bridegroom’s condition a profound
secret ? Ought he not to inform the parents of the girl that at all
costs the marriage should not take place? In answer to the solemn
injunction of the Church : “ If any man can show any just cause
why they may not lawfully' be joined together, let him now speak,
or else hereafter for ever hold his peace,” is he bound to remain
silent? Interpreting the code of medical ethics strictly', perhaps
he ought to keep his knowledge secret. But there are not a few
medical men who openly declare that whatever the code may state,
their duty is to do all in their power to prevent the marriage.
Even the little Code of Medical Ethics adopted by* the American
Medical Association, in regard to this difficulty, practically makes
a strategic retreat from the main position in the words : “ There
are occasions, however, when a physician must determine whether
or not his duty to society requires him to take definite action
to protect a healthy individual from becoming infected because
the physician has knowledge, obtained through the con
fidences entrusted to him as a physician, 01 a communicable
6 8 4
disease to which tlie healthy individual is about to be exposed.
In such a case, the physiciau should act as he would desire
another to act toward one of his own family under like circum
stances.”
In China, such questions are hardly likely' to arise for some
time to come, for in this country there can be no secrecy. As
Arthur Smith says in “ Chinese Characteristics” : “ Every
Chinese individual is a mere cog in a vast system of machinery.
He has relatives beyond all count or remembrance. His wife has
as many more. His married children add to the ever-widening
circle. By the time he is sixty years of age, a man is related to
hundreds upon hundreds of individuals, each of whom is entirely
conscious of the relationship and does not forget or ignore it. Not
only does all this army of relatives feel themselves entitled to know
all the details of one’ s affairs, but the relatives of the relatives—a
swarm branching into infinity^— will perhaps do the same. . . .
There are no. secrets in China. Everybody crowds in everywhere
— if not in sight, then ‘ behind the arras.’ Everyone who can get
access to them, reads every dispatch he can see. He reads
‘ private’ letters in the same way. ‘ W h at!’ one exclaims, ‘ not
let one see? There must be treason, stratagems and spoils in
anything which is not accessiblc to everyone.’ The wise Chinese
adage applies to all : ‘ If you would not have it known that you
do it, do it not.5 ”
P
r e s e r v a t io n
of
H
um an
L
if e
.
Perils of Child-birth.— In a way it is strange that religion
itself should cause differences of opinion on ethical questions. For
example, in those desperate cases of child-birth where it is
necessary that either the life of the mother or child must be
sacrificed in order that both shall not perish, the Roman Catholic
physicians, in obedience to the directions of their church, sacrifice
the mother to save the child, because it is believed that the child’ s
eternal welfare depends on its being baptised. On the other hand,
Protestant physicians, who have not the same terrible anxiety
concerning the future destiny of the child, hold that the mother’ s
life is of much more value to the community and therefore sacrifice
685
the child.* According to ancient custom, we- think that in such an
emergency in China the father has the right to decide the
question. The patria potestas gives him great power over the wife
and absolute power over the children. He may' not only- chastise, but
even sell, abuse or kill them. (Von Mollendorf, Fam ily L ife of
the Chinese.) If the infant in peril is a boy, we believe that to
secure the rites of ancestral worship the father would unhesitatingly
declare in its favor; whereas iu the case of a female infant, who is
relatively oi little value because when a girl grows up she passes
on her marriage wholly into another clan and can perform no
ancestral rites for her ancestors, probably the verdict would be
adverse to-her existence.
Infanticide.— This brings us to another problem which mayr
involve Chinese doctors in ethical difficulties if they* become aware
of the circumstances. To what extent is infanticide practised
^ C u r io u s ly , after th is p ap er had been w ritten , the D ecem ber (19 2 2)
n u m b er of
the
Amer i c an
Journal
oj
Obsictrics
and
w as
Gy nec ol ogy
received , iu w h ich is a rep ort of a d iscu ssio n of th is v e r y point at a m edical
m ee tin g.
A p h y sic ia n in co m m en tin g on a p aper 011 *• P r e g n a n c y in the
T u b e r c u lo u s ,” m en tio ned th at he had re c e n tly attended a v e r y d ifficu lt case
o f c h ild -b irth .
sacrifice
the
T o p re serve tlie tu b ercu lo u s m o th e r's life
ch ild
by
p e rfo rm in g
cran io to m y.
lie w ish ed
E v id e n t ly
the
to
fa m ily
belonged to the R o m an C a th o lic ch u rch ; at a il} 7 rate, m em bers of th at ch u rch
p resen t refused to consen t to th is operatio n , but in sisted on Caesarean section
b ein g perform ed instead.
co u ld
be b ap tised .
A
In his opinion th is w as done so th at the ch ild
C a th o lic p h y sic ia n ,
after
th eo lo gian s do not k n o w th eo lo g y a n y m ore than
h isto ry, sa id b ap tism w a s not the co n sid eratio n .
re m a rk in g
th a t
som e
som e h isto rian s know'
J11 m atters of th is k in d ,
the position of the C a th o lic C h u rch is founded sim p h ’ on the co m m an d m en t
“ T h o u sh a lt n ot k i l l . ”
E v e n if the positio n of th is p h y sic ia n
is
eth ica l difference, th o u g h the g ro u n d is ch an ged .
correct, there is still an
T h e com m and m en t cited
forbid s m u rder, the m ore com m on tra n sla tio n b e in g , “ Th o u sh a lt do no
m u r d e r.”
T h e sin lie s w h o lh r in the in ten tio n .
ta k e life, but th e }' are not g u i l t y of m u rder.
S o ld iers and ex ecu tio n ers
N o su rg eo n , w h eth er C a th o lic
or P ro testan t, o p erates w ith m u rdero u s in ten tio n and it seem s to the w r ite r
a w o efu l m ista k e to quote the co m m and m en t in th is connection.
A n d w ln r
it is “ k i l l i n g “ or “ m u r d e r ” w h en the ch ild is sacrificed , and not " k i l l i n g ”
or “ m u r d e r ”
w h en the m other is sacrificed , needs e x p la n a tio n .
S o the
statem en t in th e t e x t has been left u n altered , as w e are not su re th e R o m an
C ath o lic p h y sic ia n is correct, and because there is a conflict of eth ical opinion
w h ich e ve r gro u n d is tak en .
686
among infant girls, especially those, who are illegitimate ? f It was
certainly not prohibited in former days, though whenever it spread
too far the officials issued proclamations against it. In any event,
this is usually an affair which is managed by the native midwives.
Perhaps it is seldom that an infant’s life is terminated by active
means. Exposure and neglect may do all that is required.
“ Thou shalt not kill, but need’ st not strive,
Officiously to keep alive.”
On inquiry, we have not heard of any Chinese physicians
being involved in these affairs.
Artificial Abortion.— Passing further back towards the genesis
of human life, there is the practice of abortion. By' the laws of
all civilized and Christian countries this is generally' regarded as a
crime. Yet circumstances arise which sometimes seem to make it
justifiable to relax the stricter dictates of law and morality in
certain cases. Questions of this kind arose during the recent great
war. If in the conquest of a city7 a weak innocent girl is outraged by
a drunken enemy soldier, ought she to be burdened with the shame
and suffering of undesired offspring ? Of course the correct reply
is, that she must allow nature to take its course; and some will add
that it is only by and through the sufferings of innocent women and
children that war will ever be abolished.
Artificial abortion is not unknown among the Chinese, for in
former times it was punished with great severity. “ Abortion is
not capitally punishable and a person administering the noxious
thing is only liable to transportation for life, even though the
woman dies. If the share taken by the offender was merely to
procure the noxious thing, and although fatal results ensue, the
sentence of one hundred blows and three years’ transportation will
be imposed, comniutable in the case of a female offender by a fine.”
(Alabaster, Chinese Criminal Law.) On inquiry we have not heard
of Chinese foreign-trained doctors giving medicines or using other
measures to cause abortion. However, in any code of medical
f It w o u ld a p p ear from the case of th e G io ro T 'a n g W u - t ’ u th a t it is
no offence to k ill an ille g itim a te c h ild
if
the k i llin g be done
at
or before
birth ( H . A . H . L ., vol. x x v i , p. 24) and it is but a triv ia l offence— s i x t y
b lo w s and a y e a r ’ s tran sp o rtatio n if the k illin g be done a fte r the b irth and
after the c h ild
C r i mi n al
has been m ain tain ed for som e tim e
L a w , p. 170 ).
(A la b a ste r, Chinese
687
ethics this is a procedure, when unlawful, which should be
mentioned and condemned. It is even prohibited by the ancient
Hippocratic Oath.
Voluntary Restriction of Conception.—Concerning the con
ception of life there is the question as to the morality of restriction.
Upon this point there is a very sharp difference of opinion in Western
lands. The Roman Catholic church condemns restriction and I
believe the Church of England with its affiliated Churches officially
does the same. On the other hand, there are physicians and good
people among the laity who contend that children should not be
brought into the world’unless they can be reasonably provided for,
and certainly that the physically and morally unfit should not be
allowed to perpetuate their kind. A missionary lady in a letter to
the North China Daily News recently wrote in favor of this Mal
thusian doctrine, and her words almost implied that it should form
part of the Christian missionary propaganda. With regard to the
Chinese, the great mass of the people are still quite ignorant of this
restriction, but before long they may hear of it.* Some time ago we
received circular letters from Chinese in America urging the
abolition of early marriage among the Chinese and the restriction
of childbirth. On inquiry I find that, at present, Chinese doctors
are not practically interested in the subject.
A
d v e r t is in g
.
Advertising by physicians is generally condemned because it is
held that a physician should make headway solely by sterling un
obtrusive methods, not by having trumpets blown before him. Yet
there are many and subtle ways of evading this restriction. It is
* T h e in e v ita b le ch an ge has a lre a d y com e. “ S tr a n g e a s it m a y seem , the
t a lk on b irth co n tro l, u n w elco m e even in m a n y W e stern co u n tries, is h a v in g
a la r g e au d ien ce in C h in a , w h ere th e C h in e se so c ia listic conception of th e
f a m ily m ig h t be e x p ected to fu rn ish the stro n g e st o pposition to it.
S ta rt
in g w ith a h an d fu l of ra d ica ls, the m o ve m en t is n o w e n listin g th e lead ers
of so ciety.
It is in th e p re se n t m onth th a t th e W o m a n ’s Journal (a m ag a z in e
in C h in ese), issu ed a sp ecial n u m b er on b irth control.
four a rticles d is c u s s in g birth
It co n tain ed t w e n ty -
control from th e stan d p o in ts of eth ics, re li
gio n , b io lo g y , p h y s io lo g y , m ed icine, ed u catio n , so cio lo gy , so cialism , etc., s u g
g e s tin g a ctu a l so lu tio n of the p ro blem , and v o ic in g a u niform u n co n d itio n al
a p p ro va l of b irth
control in C h in a.
It w o u ld be tedious to m en tio n the
sp ecial n u m b ers on th e sam e top ic of sm a lle r m agazin es.
b irth control is r a p id ly g a in in g gro u n d in C h in a .”
litical Science Revi ew, A p r il, 19 2 4 ., p. 14 5 .
Su ffice it to s a y ,
Chinese Social and Po
6 8 8
easy to announce in the social column of the newspaper that Dr.
John Blank, the distinguished surgeon, has returned from a wellearned furlough and has resumed his busy practice, and reporters
are always willing to give accounts of difficult and unusual operations.
Many medical books and papers have been written which are of no
earthly use except to make known the knowledge and abilities of
the writer, whose qualifications and honors occupy half the space
of the title page. Then we are all familiar with the expedients of
Bob Sawyêr, the famous character in one of Dickens’ novels. After
an extremely riotous career as a medical student, when he began
practice he suddenly became a model of decorum. He attended
church on Sunday morning, but he so arranged matters that in the
middle of the service his office boy would come rushing into the
church with horror and dismay depicted 011 his countenance, to
summon his employer to an imaginary* patient. Thereupon Dr.
Sawyer would leave the church with becoming gravity , giving
the impression that he was bowed down with the cares and
responsibilities of a very large practice. The members of the
congregation, perhaps not displeased with the momentary- diversion,
especially7 if it happened during the delivery of a dull sermon,
would look at each other significantly as if to say?, “ Bless me !
someone taken suddenly- i l l ; what a very busy- man Dr. Sawyer
must b e !” We cannot help smiling, yet advertising in every
shape and form must be closely scrutinised.
Among the Chinese, advertising a physician is in accordance
with well-established custom and tradition. On recovery- from an
illness, a grateful patient often sends a very- laudatory notice of his
physician to the newspapers; if he is somewhat dilatory, it is easy
for the phy-sician to stimulate him to the performance of the custom.
If the patient is extremely grateful, he will present his benefactor
with a huge tablet, gorgeous with gilt and lacquer, proclaiming in
large characters his marvellous virtues and abilities. This is carried
through the streets publicly, so that all may see, to the house of the
doctor, to whom it is presented with much ceremony?. Afterwards
the tablet is hung in a conspicuous place in his reception room. It
is doubtful if this custom would be tolerated in the West, but among
physicians in China, both foreign and Chinese, although ethics ought
not to vary with latitude and longitude, disapproval is not likely to
be hearty and unanimous. There are few foreign missionary physi-
689
■cians who have not accepted these tablets*; not in the least because
we desired advertisement, but. because the tablets were evidence to
us that we were winning the friendliness and confidence of the people^
and therefore that the .-help we.could give to the sick and suffering
among them would, be all the greater. To refuse the tablet would
be regarded as unfriendly and. perhaps give rise to sinister suspicions.
We know' of one-missionary lad}', not a physician, who with hex
husband began missionary work in a far inland station where the
people were hostile and prejudiced. She opened a dispensary for
the treatment of simple ailments, but the attendance was small. The
chief mandarin of the city watched the mission. After some time
he called the lady in to attend-his little daughter who had been ill for
a long time. The child eventually recovered her health completely.
The father was very much pleased and, to show his appreciation, lie
went to the house of the missionary in full official state, in his sedan
-chair with umbrella, and a retinue before and behindhand presented
her with a very handsome tablet; he also issued a friendly proclama
tion. The attitude of the people in the city toward the Christian
missionaries completely changed. The dispensary patients rapidly
increased in number and the lady and her husband were most success
ful in their Christian work. If ever the end justifies the means, did
not the giving of a tablet in this case merit approval? Where is
.the line to be drawn? At any rate the incident may help us to
understand the perplexities and difficulties of Chinese doctors when
ithere is an apparent conflict between Chinese and Western customs.
A ll we can sa}- is, certain forms of advertising should be proscribed.
It is reported that some oi the Chinese physicians have very
large sign-boards outside the front door and much electric illumina
tion. We have heard somewhere of an ideal commonwealth, where
it was the law that on the death of a patient the doctor who attended
ihad to place an additional lamp on the front ot his house.
Accordingl}7 some doctors' houses were brilliantly illuminated every
»evening.
This may have served for an advertisement, but
prospective patients were likety to be chilled when they discovered
±0 what the illumination was really due. Perhaps in the long run
advertising always defeats itself. We hope so. Unfortunately,
many foreign physicians, of all nationalities, advertise themselves
in the daily newspapers, which makes it the more difficult fpr some
of the Chinese to see wherein advertising is wrong.
ÓQO
The China Medicai Journal.
T h e Ph y s ic ia n a n d H is R e m e d ie s .
Secret Preparations.-—According to the medical ethics of the
West, a physician is forbidden to derive any financial benefit from
the sale of surgical instruments or appliances which he may invent*
and he should have no pecuniary interest in secret or proprietary
medicines. The reason is plain. Whatever can be done to relieve
human pain, misery, and disability should freely become the
common property of all.
Hence the sale of instruments and
proprietary medicines is nearly always undertaken by commercial
firms. In China, public opinion on this point is different. A s
already said, the whole armamentarium of a native physician often
consists of a few secret prescriptions. Some are undoubtedly of
value, but judging by my own experience it is almost impossible to
obtain a copy of them. It seems quite natural, therefore, that
young Chinese doctors, even those who have been foreign-trained,
should prepare and sell their own medicines of which they alone
know the composition. Sometimes, we are sorry to say, the bottles
are labelled with a statement that the medicine will cure the disease
for which it is given. This custom is cruel and deceiving when
the patient is in the advanced stage of a disease such as pulmonary
tuberculosis. A recent lawsuit in Shanghai (K iang v. Koseal)
shows the necessity of dealing with this subject.
Ambiguous Guarantees.— Another reprehensible practice which,
is said not to be uncommon, is that physicians give a guarantee in
the form of a pao ih ( ^ HI ) to their patients. This Chinese
term seems to be ambiguous. It may mean that the physician,
gives a guarantee that he will cure the disease, which is the
interpretation usually given to it by the patient; or it may simply
mean that the physician will attend the patient until he gets well,
if ever he does get well, which is the interpretation usually given toit b}? the physician. This is a custom which ought to be abandoned.
Protection against Venereal Disease.— Some physicians
prescribe certain precautions and applications with a guarantee that:
a man by using them will obtain immunity from the physical
consequences of immorality. In Europe and America opinion is
hopelessly divided as to the propriety of these preventive measures,
good honorable men being found on either side. Those who regard
venereal disease apart from all moral considerations, solely as a
dreadful disease which infects not only erring men but also-
691
innumerable innocent women and children, advocate preventive
measures. Those to whom the disease is indissolubly linked with
moral sanctions, cannot and will not approve preventive measures.
In England, where there are two large societies both fighting
venereal disease, but in bitter antagonism over this question, a
strong committee has been recently appointed to investigate the
whole subject and make whatever recommendations it deems
necessary, ignoring absolutely all moral considerations. These
recommendations will probably be adopted by the medical
profession and it will be left to the people to decide whether they
are ethical or not.
Without leaning to one side or the other, it may be proper to
point out that the way in which we deal with this matter may have
a very important bearing upon our work as missionaries in this
non-Christian land where the moral standard is high. In India
the Mahatma Gandhi, who is regarded as a saint by hundreds of
millions of the people who are powerfully influenced by him, has
recently inveighed against the scope of Western medicine. He
bluntly states that “ hospitals are institutions for propagating sin,”
because when people know that ailments and diseases caused by
wrong-doing can be removed they are encouraged to sin. It is true
that much of our work does lie in relieving or curing the miserable
consequences of ignorance, folly and sin, but most certainly
nothing is done by medical missionaries to justify Gandhi’s
contention ; on the contrary, every possible effort is made to lead
the erring to repentance and goodness. Perhaps more ought to be
done to show our opposition to the social evil and to the wrong social
conditions upon which much of it depends.
S
um m ary
of
C
r it ic is m s .
On the whole, judging by the answers to inquiries which we
have made, and remembering that China is passing from one form
of civilization to another with consequent weakening of the old
standards and imperfect realization of the new, and that the Chinese
medical profession is being slowly formed during this period of
unsettlement, we think it is a matter for thankfulness that among
the foreign-trained Chinese practitioners, the ethical state of affairs
is not very much worse. The most serious of the charges are the
following : advertising ; the luring away of patients from one
another; merciless criticism of the knowledge, judgment and
6gi
The China Medical journal.
methods of the physicians called to attend a case, before them; th^
preparation and sale of their own medicines: the composition of
which is kept secret; giving ambiguous guarantees to patients.
This is not a very dreadful indictment. Still, we. should do all we
can to help our Chinese colleagues, or else matters may become
very much worse later on. “ if they do these things when the
wood is green, what will they do when the wood is dry? ”
To bring the discussion to a practical issue the following
suggestions are respectfully offered :
First, that a small committee be appointed to draft an ethical
code composed of a few simple, comprehensive rules. These we
can discuss and decide upon at our next Conference.
In this
paper no attempt has been made to define medical ethics fulty and
precise^ because so much depends on current opinion. But there
are three principles, regarded as the foundation of medical ethics,
which we may take as a guide : (a) in the relation of a medical
man to his patients, their welfare and interests should be his
highest consideration; (b) toward his colleagues, he should obey
the Golden Rule, “ whatsoever ye would that men should do to
\7ou, this do ve even so to them ” (St. Matthew vii, 12 ); (c) in his
relation to the State he should obey all lawful authority, in
accordance with the precept, “ Render therefore unto Csesar the
things that are Caesar’s ” (St. Luke xx, 25). The suggestion
has been made tljat the code should be incorporated in the Consitution to serve as a guide to the membership and as a requirement
to which candidates for membership shouid, either tacitly or
avowedly, promise to conform.
2.
Having compiled an ethical code, the next step is to secure
its observance. Here we come across a serious difficulty. The
Chinese doctors who are determined to go their own way regardless
of what others ma}' think, will care nothing for our code or anj?
other,code, or for merely moral opinion of any kind, and reputable
practitioners cannot restrain them. All we can do is to help those
who wish to conform to our standards. How can this help be
given? This is the main point.
;
One way is to broaden the basis of our Association so as to
include within its membership all phj^sicians of good standing in
China, whatever their nationality,mav be, who are willing to con-
6 9 3
form to our rules and requirements. This may mean the sacrifice
to some extent df our religious exclusiveness. But to help others
and for the sake of the moral issues involved, is not the sacrifice
Worth making? <<;Except a grain of wheat die, it abideth alone.”
After all, the surrender need not be very great. Our Association
could still remain a distinct religious unit, even in a larger
organization. Of course such a change ought not to be made with
out the most careful and leisurely weighing of all that can be said
for and agaiiist it. Hence we suggest that when a committee is
appointed to revise the Constitution and By-laws of our Association
—the revision is certainly needed—it shall be requested to consider
this question as part of its work and report to the next Conference.*
3. With the adoption of an ethical code it should be under
stood that the Executive Committee has full power to investigate
all alleged' cases of professional misconduct and to expel from the
Association those who refuse to observe its rules.
4. The Council on Medical Education might be asked to con
sider the question whether sufficient importance is given to the
teaching of medical ethics in all medical schools in China.
F
o r e ig n
P
h y s ic ia n s
and
F
o r e ig n
N
u r ses
.
This paper is already very long, but there is one other matter
to which it has been requested reference should be made. It is said
that in not a few hospitals throughout the country there is a certain
amount of friction between the foreign physicians and the foreign
nurses concerning the extent to which the nurse in her work is
independent of the doctor. The root of the trouble seems to be that
both are engaged in the larger work of Christian evangelization in
which both stand on an equal footing, and on their appointment as
* D u r in g
the C o n feren ce
the
fo llo w in g
R eso lu tio n s
w ere
p asse d
u n a n im o u sly .
R e s o lv e d :
T h a t th e A s so c ia tio n in stru c t the E x e c u tiv e C o m m ittee to
a rra n g e for the p re p aratio n of a code of M ed ical E t h ic s an d E tiq u e tte h a v in g
esp ecial r e g a rd to co n d itio n s e x is t in g in C h in a, and th at w h en co m p le te it
be p u b lish ed in th e Jo u rn a l of the C .M .M .A ., and p resen ted for actio n at the
n e x t r e g u la r m e e tin g of th e A sso c ia tio n .
R e s o lv e d :
T h a t the E x e c u t iv e C ctn m ittee be in stru cte d to s tu d y the-
C o n stitu tio n w ith a v ie w to th e p o s s ib ility of e n la r g in g t h e basis of m em b er
s h ip , and to c irc u la te proposed re v isio n s at an e a r ly date.
The China Medical Journal .
694
missionaries by the home board equality in all respects seems to
be implied. In kindness and justice to all concerned there must be
no haziness or ambiguity on this point. In all matters relating to
the care and treatment of the sick and injured the physician stands
first, and it is the duty of the nurse to follow kis instructions fully
and loyally. Even when a somewhat inexperienced Chinese
physician is in charge of a hospital we do not see that any other
■coarse can be suggested.
On the other hand, the physician should remember that the
nurse is very highly trained ; that probably she has been in a position
•of authority at home, and that in the mission field she is also in a
position of authority with Chinese nurses under her. Th eve fore if
he is wise he will not be harshly authoritative, but will endeavor to
obtain her full and friendh7co-operation and give her his confidence.
In the training of native nurses, she should be given full authority
and freedom. All that is required is tact and sympath}-. If it is
necessary, however, we suggest that the standing committee of
physicians ana nurses appointed several years ago be requested to
compile a few simple rules to govern the relations between doctors
and nurses in mission hospitals in China.
C
o n c l u s io n
.
This brings our paper to a conclusion. The whole subject of
medical ethics is very difficult and controversial, but as we all have
the wel fare of our profession at heart and are extremely anxious
that the Chinese medical profession shall in all respects be equal with
the profession in the West, our discussion this morning will be sure
to fasten upon the points of central importance and we shall reach
conclusions that will be helpful to all.
A
d v e r t is e m e n t s
of
P
a t en t
M
e d ic in e s
in
C
h urch
— A leaflet drawn up by the British Medical Association,
and based on the lines of the Association’ s evidence before the
Departmental Committee on Patent Medicines, drawing attention to
the harmful effects of patent medicines, has, through the instru
mentality of the Rev. S. D. Bhablia, M . D. (the Representative of
the Greenich and Deptford Division), been issued to clergymen of the
Church of England by the St. Luke’s Guild, accompanied by a
warning by the Guild against publication of certain classes of
advertisements of patent medicines in church magazines. Enquiries
axe being made with a view to getting the Nonconformist Church
unions to take similar action.— British Medical Journal, May 3,
1924.
M
a g a z in e s.
Opening of New Union Hospital, Huchow.
695
OPENING OF NEW UNION HOSPITAL, HUCHOW.
On June 4th, 1924, the new buildings of the Union Hospital,
Huchow, in the province of Chekiang, were formally opened.
The main address was given by Dr. J. V. Latimer, who traced the
early history of the medical work, particularly mentioning the
coming of Dr. Eubank, of the Baptist Mission, and later the
representatives of the SouthernMethodist Mission, including
Dr. J. B. Fearn of Shanghai, and the present members of the
hospital staff—Dr. F . P. Manget, Dr. C. D. Leach and Dr. Oscar
Nelson. Other speakers spoke of the splendid co-operation that
has existed between the various bodies that have made possible
this achievement. The buildings
have been put up by the
Rockefeller Board, the Southern
Methodist Mission, and the
American Baptist Foreign Mission Society. The land was in
great part the gift of the local gentry, who are represented equally
with the two Missions on the Board of the Hospital.
The plant includes hospital, out-patient buildings and power
house. A building for the Chinese staff is already started. This
plant, which was constructed and equipped with every modern
convenience throughout at a cost of nearly $200,000, is considered
by competent men to be the finest hospital building in Chekiang
and Kiangsu provinces, aside from Shanghai. (See frontispiece.)
In fact, it would be hard to find one better in all China, with the
exception of Peking.
The main building is a magnificent structure, of fireproof
construction, having wards and rooms for 100 patients. It contains
a well-equipped operating pavilion, laundry and kitchen. The
latter attracts particular attention with its white tiled sinks and
stoves. Modern bathrooms are generously supplied for wards and
private rooms. Water, hot and cold, is in use in all the buildings.
The main building is connected by a covered passage-way to
the dispensary building, which is classical looking in its style
of architecture. It resembles a small Carnegie Library, with
its pillars and rounded balcony over the entrance.
Appropriate remarks were made by the military and civil
heads of the city, a message was read from the Governor of the
province, and a ringing speech was made by the head of the
Chamber of Commerce.
6g6
\The China Medical Journal.
ne."j e a iitren t ilßeöicai Híterltuire.
S E R U M T R E A T M E N T OF A N T H R A X
B o d i n , Biti/. Soc. Française d e -Derm, et de Syph. , ¡December, 19 3 3 .
The treatment of a severe case of anthrax by serum is described,
the patient being completely cured in a few days.. He was a work
man in a tannery, aged 22, and had been handling Chinese hides.
When seen he had had a swelling on the right side, of the lower jaw
for three days; it extended from the lobe of the ear to the chin,
and from the lower ej-elid to the middle of the neck. Over the
centre of the horizontal ramus there' Was a typical oval black scar
surrounded by the usual vesicles. The patient’ s general condition
was good, his temperature was 10 0 .20 F ., and pulse 100. He
received 40 c. cm. of serum between November 17th and 20th,
given in daily doses of 10. c. cm. In addition, compresses saturated
in I in 1,000 mercuric chloride solution were applied locally, and
each day 4 or 5 c. cm. of 2 per cent, phenol solution were
injected at four “ cardinal” points of the periphery. Eight days
after the commencement of treatment the oedema had almost
completely disappeared, and one week later he was completely
cured ; the slough had separated, leaving a pink depression 1 cm. in
diameter. Bodin quotes statistics which show that the mortality of
anthrax is low in those cases treated prior to the fourth day of the
disease.
A C A U S E OP P A IN IN T H E K N E E .
S a d o u n , Uges knf t for Laeger, March 20th, 19 2 4 .
Sadolin describes a condition which, he says, is often
mistaken for arthritis of the knee, although there are no signs
indicative of a lesion of the joint. On walking the patient
complains of pain referred to the back of the patella, and there is
frequently a history of excessive walking up and down stairs or
walking upstairs with a heavy burden. In several of the author’s
cases the pain had gradually become so troublesome that work had
to be given up, but rest, even rest in bed had not helped much.
This condition, w'hich may be unilateral or bilateral, forms a
remarkably definite clinical picture which the author associates
with a lesion of the median head of the gastrocnemius. He has
found that if this median head is massaged for five minutes at a
time every other day for about three wêeks the symptoms
disappear without any other treatment, even in cases . which
have been refractory to rest, baths, and massage of the joint and
thigh.
Current Medical Literature.
697
LYM PH ATICOSTOM Y IN P E R IT O N IT IS .
C o o k e, B rit. M ed. Jo u r., Ju n e 14 th , 19 2 4 .
To Costain (C a n a d . M e d . Assoc. Jour., November, 1922.) we
are indebted for the suggestion that opening and draining the
thoracic duct may assist surgical measures in serious cases of
general peritonitis. He assumed that the chief cause of toxaemia
in peritonitis was the flow of toxic Ijnnpli into the left subclavian
vein, and went far to prove this in dogs suffering from gangrenous
appendicitis by diverting this stream to the surface of the neck.
He published a successlul case of lymphaticostomy in a girl with
pneumococcal peritonitis.
Cooke records a case of his own in which recovery ensued
after lymphaticostomy in an attack of peritonitis apparently
hopeless. He makes the following comments : (1) The thoracic
duct is not very easy to find, because it is delicate in texture and
thinner than one expects. After the exposure by dissection one is
glad to have confirmation in the living subject by the presence of
beads of lymph. In this case the beads were honey 3-ellow at the
time of operation; two days later the discharge had the usual
appearance of thin dirty milk. (2) The paucity of lymph in the
first twenty-four hours in this case is explained by the fact that
the patient was depleted of fluid b}' starvation and by a large faecal
vomit; it was only after continuous rectal saline for twenty-four
hours that lymph began to flow freely. No measures were taken
to stop the flow of lymph, and this subsided in a week. Costain
states that the lymphatics on the right side restore the circulation.
D R A IN A G E IN A C U T E A P P E N D IC IT IS
B r o c k m a n , B ril. Jo u r. S u r g ., A p r i l, 19 2 4 .
In discussing the advantages and disadvantages of drainage in
acute appendicitis, Brockman points out that in many cases success
or failure depends upon the general resistance of the patient and
not upon drainage.
The advantages of dispensing with the
drainage tube are the less frequent occurrence of faecal fistulre and
delayed convalescence. Secondary haemorrhage, he says, is rarely
encountered and no residual 'abscess developed in his undrained
cases. Intestinal obstruction occurred six times in his series, all
following drainage. Convalescence is both shorter and more plea
sant when drainage has been avoided. The problem of drainage
depends largely on the state of the peritoneum; if there is to be
closure without drainage it is necessarjr to leave behind an intact
peritoneum. The chief indication for drainage is the age of the
patient : children of twelve years and under, with a gangrenous
appendix and purulent fluid in the pelvis, will not stand closure so
well as adults with similar conditions. The degree of toxaemia is
a valuable piece of evidence and can be estimated from the general
6g8
[The China Medical Journal.
appearance of tlie patient; cyanosis is a bad sign and often foretells
a fatal ending. Where drainage is necessary three methods are
available : local drainage when invagination of the appendix stump
is insecure; pelvic drainage with the use of the Fowler position;
and safety-valve drainage when a potential abscess is present and a
tube passes to the parietal peritoneum as an outlet for pus. Though
the peritoneum may be closed in many cases, the abdominal wall
often requires drainage; each layer of the incision should be drained
by a series of rubber tubes. It is found in actual practice that the
peritoneal cavity can be closed in most adults without drainage, but
in children it should be drained by the safety valve tube.
A C U T E A P P E N D IC IT IS A N D IN T E ST IN A L . OBSTRU C TIO N
R a y n e r , Brii. Med. Jour., M a y 1 7 t h , 19 2 4 .
The management of a case of post-operative obstruction after
an attack of acute appendicitis presents one of the most anxious
and difficult tasks with which the surgeon has to deal The follow
ing plan of treatment, which Rayner believes should in all cases be
adopted in th? first instance, is based on the fact that the obstruc
tion is rarely a complete one and that the intestine will frequently
recover its funcliou if relieved of some of its load.
1. All nourishment and drinks by mouth are stopped, but
chewing of fresh fruit (orange, grape pulp), etc., is encouraged.
2. Subcutaneous infusion of saline solution.
3. Evacuation and lavage of stomach by stomach tube.
Morphine, too, in many instances will be found beneficial,
despite the apparent contraindication to its use, in producing rest
and sleep.
For the subcutaneous infusion, of saline solution Souttar’s
apparatus answers admirably; the rather stout needles fitted to
this can be painlessly introduced by previously injecting novocain
through a hypodermic needle at the selected site. About three
pints should be introduced in the first twelve hours. The passage
of the stomach tube is an unpleasant task with a very poorly
patient, especially with a child, but its use is of the greatest value.
B y retaining the tube in a position for a few minutes after the
stomach has been emptied it is often possible to withdraw several
ounces more of intestinal contents. The drainage of the stomach
may need repeating in twelve or twentjz-four hours.
COLON A D H E S IO N S S IM U L A T IN G
C . D a v is o n , M . D a v is o n
and
A P P E N D IC IT IS
D .G . R
o ver,
Sur^. Gynccol. and Obsiet., F e b r u a iy , 19 24 .
T h e au th o rs draw a tte n tio n to a grou p of ca ses w h ich seem to
th em to p resen t a d efin ite su rg ic a l e n tity .
A tte n tio n w as draw n to
th e n u m b er of p a tie n ts w ho w ere not relieved b y o p era tio n s for a cu te
699
or chronic appendicitis. The symptoms were vague abdominal
pains. X-ray examination revealed a definite alteration ill the con
tour of the ascending and transverse colon, which seemed to be
caused by bands of adhesions producing partial or complete ob
struction of the large bowel. The findings are definite, and
laparotomy reveals the mechanical condition exactly as shown by
the radiograms; operative correction of the pathological condition
quickly relieves the subjective symptoms. The etiology of the
condition is still somewhat doubtful, but the condition is evidently
inflammatory and due to colonic stasis; chronic appendicitis often
accompanies the condition, but it is not a cause. In most cases ptosis
of the transverse colon is found and is probably an important factor.
Stasis in the colon leads to band formation at the point of least
resistance in the bowel wall. Relief is obtained by careful dissection
of the adhesive bands; raw surfaces are covered by peritoneum.
The patients are made to lie on the left side and the bowels are kept
active to prevent new adhesions from forming.
A C U T E IN T U S S U S C E P T IO N IN C H IL D R E N .
T h o m p s o n , Brit. Med. Jour., M a y 1 7 , 19 2 4 .
The following observations are based on fifty consecutive cases
of acute intussusception in children operated on by the author.
Thirty-eight of the patients recovered.
1.
Eighty-eight per cent, of cases occurred in the first twelve
months of life.
,2. Sixty-two per cent, occurred between the fourth and the
eighth month.
3. The ileo-csecal type only includes those cases where the
intussusception apparently started at the ileo-ciecal valve and
where this remained as the apex (28 per cent).
4. The majority of cases started as ileo-ileal (60 per cent),
in which the last portion to be reduced was ileum. The commence
ment of the intussusception in the ileum was recognised as a well
defined dimple. Of these, eight cases, or r6 per cent, progressed
only to the ileum; they have been called “ ileo-ileal ” ("that is, ileal
or enteric). The remaining 22 cases (44 per cent) were made up
of two intussusceptions— the original an ileo-ileal which, when it
reached the ileo-caecal valve, was superseded by a second which
had the ileo-cascal valve for its apex (that is, an ileo-ileo-caecal
intussusception.)
5. The jejunal type of intussusception described in so many
textbooks was not met with in this series. It is found post m o r t e m
in children dying from other diseases.
It is probably of no
pathological importance.
6. The ileo-colic type was the most fatal (two deaths out of
four cases).
700
7. Perhaps the ileo-colic type may occur in those cases where
the coscum is less mobile; at any rate, in two of these cases great
difficulty was experienced in delivering the caecum to the abdominal
wound.
8. Ten cases required resection, because of irreducibilily or
strangulation. Of these, three recovered and are still well. One
other patient lived nineteen days and then died of broncho
pneumonia. The remaining six cases died without recovering from
the initial and operative shock.
CHRONIC IN T U S S U S C E P T IO N IN C H IL D R E N
O w e n , Brit. Med. Jour. M a y 24, 19 2 4 .
Chronic intussusception in children is a somewhat rare
complaint. A typical case is described as follows :
“ O n a p a rtic u la r d a y the ch ild seem ed to h a v e p ain in the abdom en
an d vom ited once or tw ice. D u r in g the n e x t fe w d a y s he o c ca sio n a lly
vom ited, g e n e r a lly in asso ciatio n w ith a c o lic k y p ain . T h e v o m itin g has
becom e less frequ en t, o n ly once in tw o or three d a y s, and the pain is o n ly
occasio n al. T h e bo w els, w h ich before w ere open d a ily , h a v e sin ce the onset
been less r e g u l a r ; ap erien ts h a v e been n ece ssa ry , bu t w h en g iv e n h a v e
w o rk ed w ell and the stools h a v e been n o r m a l; there has been 110 blood in
th e stool, or at m ost there has been o n ly a stre ak once or tw ice , su ch as
m ig h t be seen on the stool of a n y co n stip ated ch ild . T h e s3rm ptom w h ic h
lias troubled the p aren ts m ost is the w a s t i n g ; the ch ild after three or fou r
w e e k s of these v a g u e tro u b les is o b v io u sly g e ttin g thin . T h e tem p eratu re
th ro u gh o u t has been n o rm a l.”
The diagnosis is made by feeling the sausage-shaped tumour,
which varies in consistence under the fingers at different times, and
by the sense of unnatural emptiness in the right iliac fossa. The
condition may be mistaken for chronic appendicitis, tuberculous
peritonitis, “ bilious attacks” and other complaints.
The treatment is reduction by operation. In the event of the
intussusception being irreducible or gangrenous, or both, the
various operations for these conditions—namely, short-circuiting,
removal of intussusception through the ensheathing layer, or
resection with end-to-end union, wiil have to be considered, always
on the assumption, of course, that the patient’ s condition is good
and that the relations inside the abdomen can be made out.
P O ST U R E IN T R E A T M E N T
W h i T E lo c k e , Brit. Med.
Jour., M a y 3 1 , 19 2 4 .
At a meeting of the Section for the Stud}T of Disease in
Children, of the Royal Societj* of Medicine, on May 23rd, Mr.
R.H .A nglin Whitelocke gave his presidential address on “ posture”
in relation to therapeutics and prophylaxis generally. He cited
instances of postures due to occupations of various kinds, those neces
sitated by certain diseases of the pulmonary and cardiac systems,
and by disorders of the abdominal viscera, and referred to the three
701
postures so much used in medicine and surgery—namely, the
Trendelenburg, Sims and Fowler positions. All these positions
had proved valuable in treatment, but Mr. Whitelocke had found
that patients, especially children, suffered no harm if allowed to lie
in the position most comfortable to them, and made a more rapid
and easy recovery. Nurses should be instructed to allow patients
to assume the posture of greatest ease. He knew of at least three
cases in adults in which death had immediately supervened upon
the patient being raised up into the Fowler position from which he
had slipped. It was well recognised how almost impossible it was
to maintain this position with children. The fact that drainage of
the abdominal cavity did not seem to depend upon gravity, but
upon intra-abdominal pressure and vital processes, had interested
Mr. Whitelocke, and from his personal observations he had been
led to the conclusion that a forced posture was unnecessarj? and
frequently harmful.
H Y P E R T R O P H Y OF T H E PR O ST A T E .
The Statistical Department of the Johns Hopkins Hospital,
Baltimore, has issued a preliminary report on the etiology of benign
hypertrophy of the prostate gland. The purpose of the study is to
show that with the aid of modern statistical methods the minutest
detail which it might be desirable to know in the course of a
thorough investigation of a special problem can be collected and
made available for tabulation in every conceivable manner, with the
minimum amount of effort. For this purpose data from 997 cases
of prostatic hypertroph}’ have been transferred to punch cards for a
monographic study. This research has been carried out with great
thoroughness by Dr. Mary Gover, and certainly constitutes a
valuable contribution to our knowledge of a condition that has so
far proved a pathological mystery. The mean age of operation in
cases of benign enlargement is 66.72 3rears, the period during
which the main part of the abnormal growth in the prostate takes
place being between 45 and 75 years of age. Single men do not
appear to be as liable to the trouble as married, but, on the other
hand, when hypertrophy occurs the prostate becomes as large as in
married men. Previous affections of the genito-urinarv tract are
comparatively rare, and childhood diseases and certain infections of
later life do not appear to have anj? relation to the condition.
Those who pursue sedentary occupations are no more likely to
suffer from enlargement than those engaged in active work, whilst
alcohol bears no relation to the disease. These results, although
all of a negative kind, are nevertheless of considerable interest,
since thejr show that some of the factors that have been supposed
to influence the development of enlargement of the prostate actually
play no part in its production.—Brit. Med. Jour., June 7, 1924.
702
T he China Medical Journal.
3Book IRevnem
An Outline of Endocrinology.—B y
W . M. C ro fto n, u .a ., m .d ., L e c tu re r
of S p e cia l P a th o lo g y , U n iv e r s ity C o lle ge, D u b lin . P a th o lo g ist, D r.
S te e v e n s H o sp ita l, D u b lin . Illu stra te d . P rice 6 / - net. P u b lish e rs: E .
and S . L iv in g s to n e , 16 an d 1 7 T e v io t P lace, E d in b u r g h , 19 24.
In v ie w of the enorm ous am ou nt of literatu re r e c e n tly p u b lish ed
co n cern in g the en d ocrin e g la n d s and th eir relation to disease, there is room
for a book of th is k in d w h ic h d eals w ith the su b ject c le a r ly , c o n siste n tly ,
an d y e t is su ffic ie n tly co m preh en sive. T h e m icro scop ic ap p earan ce of each
g la n d is g iv e n , its h isto lo g y , d evelo pm en t, p h y sio lo g y an d the diseases for
w h ich its e x tra c t m a y be prescribed . T h e horm ones of the g a stro -in te stin a l
tra c t are in clu ded and there is a good d escription of the secretions of the
p an creas, an d th e v a lu e of in su lin in th e tre atm en t of diabetes. T h e
a c c o m p a n y in g ch arts, and th e p h o to grap h s of p a tie n ts are v e r y good. T h e
au th or does not join the e n th u siastic en d ocrin o lo gists w ho believe th a t th e
fu tu re of th e ra p y depends on the fu rth er d evelo pm en t of treatm en t b y
horm ones so th a t all d isease w ill be e v e n tu a lly overcom e b y p re scrib in g
th ese s u b s ta n c e s ; he is cau tio u s in h is statem e n ts co n cern in g the
th era p e u tic va lu e of som e of the g la n d u la r e x tra c ts an d p re fers to g iv e
th e ex p erien ces of others rath er th an h is ow n. B u t he closes w ith a hope
th a t in the fu tu re endocrine th e r a p y w ill be more p recise and th at w e sh a ll
be able b y tests to k n o w w h en a p a rtic u la r glan d is not a c tin g su fficie n tly.
A s our k n o w led g e of th is su b je ct is c o n sta n tly a d v a n c in g there are b lan k
p ages at the end of the volu m e for reco rd in g notes on n ew w o rk . It is a
volu m e th a t can be com m ended to b u s y p h y sic ia n s.
Aids to Medical Diagnosis.— B y
A . W h itin g , M . D.
T h ird E d itio n .
P rice, 3 / 6 d .
P u b lish e rs : B a illie re , T in d a ll and C o x , 8, H e n rie tta
S tree t, C o v e n t G ard en , L o n d o n , W . C . 2, 19 2 4 .
In th is little book, b e lo n g in g to a series s p e c ia lly d esig n e d to a ssist
stu d en ts in g r o u p in g an d co m m ittin g to m em o ry the su b je c ts on w h ich
th e y are to be ex am in ed , the su b je ct of m ed ical d ia g n o sis is treated v e r y
c o n cise ly, c le a r ly and sy ste m a tic a lly . O f p a rtic u la r v a lu e is the ch ap ter on
d iseases of the h eart w ith the n um erou s ch arts and tra c in g s. In the r e v is
ion, all has been b ro u gh t up to date. N o t o n ly stu d en ts bu t p h y sic ia n s also
w ill find th is sm a ll v o lu m e v e r y u seful for r a p id ly r e v ie w in g the p o in ts of
m ed ical d ia g n o sis.
Studies on Various Intestinal Parasites (Especially Amoebae)
of M an. — B y W illia m C. B o eck and C h . W . S tile s. P u b lish e rs :
G o vern m en t P r in tin g Office, W a sh in g to n , 19 2 3 .
T h e au th ors h a v e com piled a m ost va lu a b le w o rk w h ich sh o u ld be in
th e possession of all w h o are d o in g clin ic a l la b o ra to ry w o rk in C h in a ,
e s p e c ia lly in d istricts w h ere d jrsen te ry and other diseases cau sed b y
in testin al p a ra site s are com m on. T h e first two p apers deal w ith a “ S u r v e y
of 8,029 person s, in the U n ited S ta te s, for in testin al p arasites, w ith sp ecial
reference to amoebic d y se n te r y am o n g return ed so ld ie rs.” T h e n e x t p ap er
is on the “ T e ch n iq u e of F e c a l E x a m in a tio n s for Protozoan In fe c tio n s,” and
th is is follow ed b y an e x c e lle n t p ap er en titled, “ D escrip tio n s of the more
com m on In te stin a l Protozoa of M a n .” L a s t ly , there is an elaborate and
sc h o la rly a rticle on “ T h e N o m en clato rial sta tu s of certain protozoa
p a ra s itic in M a n ” w h ich w e are afraid o n ly th e h arassed editors of m ed ical
jo u rn a ls w ill ap p reciate at its fu ll v a l u e ; it shou ld be ca re fu lty stu d ied b y
a ll m edical w riters.
T h e illu stra tio n s are n um erou s and v e r y good.
C o p ies of th e p u b licatio n m a y be procu red fro m the S u p erin ten d e n t of
Book Reviews.
703
D ocu m en ts, G o vern m en t P r in tin g Office, W a sh in g to n , D . C ., for the ab su rd
l y sm all su m of 25 cents (U. S . cu rren cy) per cop}7, b u t p u rch asers m u st
agree not to sell or re d istrib u te the p u b licatio n for profit.
A Manual of Histology.—B y
H e n r y E rd m an n R a d a sch , m. sc., m.d., Seco n d
E d itio n . W ith 3 3 3 illu stra tio n s. P rice : G $ 5 .o o net. P u b lish e rs :
P. B la k is t o n ’s So n & Co., 1 0 1 2 W a ln u t Street, P h ila d e lp h ia , U . S . A .
T h e au th or h as w ritte n a th o ro u g h ly p ra ctica l h is to lo g y for th e in
stru ctio n of m ed ical stu d en ts. In th is revisio n he has added n e w m aterial
and rew ritten som e sectio ns so as to m eet the te a c h in g of the p resen t tim e.
A m o n g th e a d d itio n s are tw e n ty -tw o n ew m icro p h o to grap h s and the
d escription of sev eral n ew sta in in g m ethods. T h e sections on Bone, the Blood,
the Sto m ach , th e E y e b a ll, the tracts of the S p in a l Cord , the P in eal B o d y,
and the A c c e s s o r y N a sa l S in u se s h av e all been revised . T h e fu n ctio n s of
m a n y of the o rgan s are g iv e n , as fu n ctio n is dependent 011 stru ctu re. T h e
v olu m e is w7ell illu strated .
General Cytology.—A
te x tb o o k of C e llu la r S tru c tu re and F u n ctio n for
S tu d en ts of B io lo g y an d M ed icine. E d ite d b y E . V . C o w d r}'. P rice :
G . $ 7 .7 5 . P u b lish e rs : T h e 'U n iv e r s it y of C h ica g o , P ress C h icag o , Illin o is.
T h is w o rk 011 G en e ral C y t o lo g y is th e first co -o p erative and com pre
h en sive a ttem p t b y sp e c ia lists in research fields to state in g e n eral term s
w h a t is k n o w n or co n jectu re d r e g a r d in g the p rin cip le s w h ich go v ern
c e llu la r stru ctu re an d fun ction . It is the first vo lu m e to p resent the data
co n cern in g the cell th at are fu n d am en tal not 011I37 to the scien ces of b o tan y
and zoolog}7, b u t also to p h y s io lo g y and p ath o lo g y .
T h e conten ts are o rig in al. E a c h sectio n 01 ch ap ter rep resen ts the co n
tribu tio n of a sp e c ia list w h o h as w ritten on that p art of the su b ject w h ich
has occupied h is own research, and the resu lt is a m ore co m preh en sive and
a u th o rita tiv e p resen tatio n of c y to lo g y th an has p re v io u s ly been attain ed .
T h e w o rk is p ro fu se ly illu stra te d an d p ro vid ed w ith a b ib lio g ra p h y for
each section. T h e se references to cu rren t lite ra tu re on the su b ject m ak e
the book a p a rtic u la r ly v a lu a b le one for stu d en ts an d in v e stig a to rs. T h e
fo reg o in g is the p u b lish e r ’ s annou ncem ent. W h e n the book is received a
m ore exten d ed r e v ie w w ill be g iv e n .
Journals and Reprints.
The Effect of Kaolin on the Intestinal Flora in Normal and
Pathological Conditions.— B y L o u is H e n r y B raaflad t, m .d . R e
p rin ted from the Jo u rn a l
N o v e m b e r , 19 2 3 .
of In fectio u s
D iseases,
V o l.
33.
N o. 5.
League of Nations Health Organization.—
T
S t a n d a r d i z a t i o n o ? D y s e n t e r y S e r u m . F ir s t rep ort b y K iy o s h i
S h ig a , H . K a w a m u r a and K . T s u c h iy a . T h e K i t a s a t o I n s t i t u t e
F o r I n f e c t i o u s D i s e a s e s . T o k y o , Ja p a n . G e n e v a , 19 24.
M o n t h ly E p id e m io lo g ic a l R e p o r t o f th e H e a lt h S e c tio n o f th e
S e c r e ta r ia t.
N o. 66. G e n e va , M a y 15 th , 19 2 4 .
T h e P r e v a l e n c e o f E p id e m i c D i s e a s e a n d P o r t H e a l t h O r g a n i z a t i o n a n d
P r o c e d u r e i n t h e F a r E a s t . R e p o rt p resented to the H e a lth C o m
m ittee of the L e a g u e o f N atio n s. G . F . N orm an W h ite . G e n e va , 19 2 3 .
he
Schistosomiasis in China: Biological and Practical Aspects.— By
The
P rofesso r E r n e s t C arro l F a u s t , m .a., ph.D. F ro m the P a ra sito lo g y
L a b o ra to ry , D ep artm en t of P a th o lo g y , P e k in g U n ion M ed ical C o lle ge.
P resen ted from the P ro cee d in gs of the R o y a l S o ciety, of M ed icin e.
V o l. x v i i : 3 1 - 4 3 .
Composition of Typical Korean Diets.—J . D . V a n B u s k ir k , m .d .
A r t. N o. 26, R esearch D ep artm en t, S ev eran ce U n io n M ed ical C o lle g e ,
S eo u l, K o rea. R e p rin te d from the Ja p a n M ed ical W o rld , Ju n e 1 5 ,
19 2 4 . V o l. iv . N o . 6.
704
iThe China Medical Journal.
WITH THE EXECUTIVE SECRETARY.
The problems of opium poisoning, chronic and acute, are
always before the medical missionaries of China and it has been a
great grief to us all to watch the steady recrudescence of the
growth and use of the drug in recent years.
In view of this and especially in connection with the meeting
of the League of Nations’ Narcotic Committee in November of this
year, a great effort is being made by the Anti-opinm forces, both
Christian and non-Christian, to rouse opinion both in China and
outside this country to the supreme importance of this question.
As known to most of us, the only true solution of the question
is the world-wide reduction of poppy cultivation to the amount that
will guarantee sufficient of the drug and its alkaloids to meet the
world’ s needs for medicinal and scientific purposes, and that this
solution should be adopted at the coming meetings of the League of
Nations is our earnest prayer and aim. To commend it convincingly
it is essential that evidence should be before the League that the
recrudescence of the growth of the poppy in China is entirely
against the will of the people and that the best elements in this
country are entirely opposed to the traffic.
The medical missionaries of China have always been among
the leaders iu the opposition to the habitual, unnecessan? use of
opium and it becomes us to use every effort in the coming months
to help the good cause. All that can be done at headquarters we
are doing already. A Memorial to the League of Nations represent
ing the medical opinion of China on the use of opium is being
drawn up and signed on behalf of tbe National Medical Association,
as representing the Chinese physicians, and on behalf of the
China Medical Missionary Association, as representing the foreign
physicians in China, by their respective Executive Committees.
However, this is not sufficient. Each one of us in our
respective places can do our little to help the good work along. The
ways suggested for this are as follows : —
r. To help in the districts in which we are placed to rouse
public opinion and to make an effort by petitions or otherwise to
influence the Government on the subject of poppy planting.
2. To obtain accurate information on the subject of the
amount of poppy growth being carried on in our district and to
transmit such information to the Honorary Secretary of the
International Anti-Opium Association, Dr. W. G. ¿Aspland, Peking.
3. To. obtain photographs illustrative of the present opium
situation both as to growth and transportation of the drug.
4. To obtain accurate documentary evidence of illegalities in
connection with the traffic with a view to steps being taken to put a
stop to them.
Correspondence.
7'o5
.. Gorresponfccnce.
C orrespondents are requ ested to w rite on one side of the paper o n ly ,
and. alw ays' to send their rea l nam es and addresses. T h e J o u r n a l does
not hold itself respon sible for the opinions or assertions of correspondents.
P e lla g r a in K orea.
To the Edi tor, C . ' M . J.
D kar S ir ,
A m o n g the p a tie n ts w h o h av e
v is ite d the L e p e r H o m e in this
station (K w a n g ju , K o rea) 1 h ave
com e across several w h o are not
lep ers b u t w h o are su ffe rin g from a
disease w ith w h ich I am not fa m iliar.
It is v e r y m uch lik e the tex t-b o o k
d escrip tion of p e lla g ra . I sh all be
g la d if y o u w ill in sert th is letter in
the Jo u rn a l so th at I m a y obtain
su g g e stio n s as to d iag n o sis and
treatm en t.
T h e s y m p to m s arc as fo llo w s :
d a rk brow n sk in lesion s a p p ear on
the b a ck of the fo re-an n , about the
an k les, and in a fe w cases on the
n eck. T h e se lesion s at first are
eryth em a to u s ; later th e }' ta k e on a
brow nish colour, m u ch lik e the
colour of th e sk in after several
a p p lica tio n s of iodine. O ccasio n al
ly , at certain p eriods the lesion s
d isap p ear. T h e p a tie n ts co m plain
of sore m outh and g a stric d istu rb ances. T h e ten p atien ts at p resent
in this in stitu tio n w ho seem to be
p e lla g r in s do not look v e r y bad,
nor are th e y confined to bed, though
the lep ers assert th e y h a v e k n o w n
several w h o h av e died
from it.
T h ese p atien ts also co m plain of
w e a k n e s s ; fo u r of the ten cases
h a v e had d iarrh ea. M o st of those
w ho h a v e re c e n tly entered th e
in stitu tio n had p re v io u sly suffered
from la c k of food, but som e h av e
been w ith us for som e years.
T h e ir d iet at p resen t co n sists
m a in ly
of rice and v e g e t a b le s ;
p erh ap s there is a d eficien cy of
protein. D o y o u th in k th e y w o uld
g e t su fficient protein if th e y w ere
g iv e n so y beans d a ily ?
Of course
in an in stitu tio n of this k in d our
fu n d s are lim ited and to g iv e the
p atien ts a lib eral d iet w o u ld m ean
th a t w e should be forced to ad m it
a sm aller n um b er, and those not
ad m itted w o uld p ro b a b ly su ffer m ore
ou tsid e than if th e y cam e in an d
took the
chan ce w h eth er th e y
co ntracted th is p e lla g r a -lik e d isease
\ or not.
|
I
have been in . th is c o u n try
j
seven teen y e a rs, and, as fa r as m y
j
k n o w led g e goes, h ave not seen a
! case of p e lla g ra . O11 co n su ltatio n
• w ith several co lleagu es th e y also
j
s a y th e y h av e n o l seen cases.
!
I sh all g r e a t ly ap p reciate the
j
su g g e stio n s th at a n y of the readers
of the Jo u rn a l 11133- m ak e as to these
i
c ases, and the best w a y to tak e care
of them .
j
Y o u rs tru ly ,
‘
R. \Y. W ilso n .
i
,
K w a n g ju L e p e r H om e, K o rea.
* * * P ro b a b ly the d isease d escribed
is p e lla g ra . D r. E . S . T v a u and D r. S .
C. \Y u ( Xat. Med. Jour.' of Chma.
D ecem ber, 19 2 3.) report se p a ra te ly
011 seven cases of p e lla g ra in C h in a
>
. w here the d isease has not h itherto
been reco gn ized . “ T h e cases p resen t
; ed the u su al clin ical fe a tu r e s : sto m a
titis, u lceration of the ton gu e, d iar
rhea, d y se n te ric stools, abd om in al
j
p ain , loss of ap p etite, p igm e n tatio n
and ro u g h n ess of the sk in on the
b a ck of the h an d s, 011 the cheeks,
, and more r a r e ly on the neck, u p p er
p a rt of chest, feet, an d leg s ; v esicles
j
| an d bulla? in these regio n s, sen sat
j ions of heat in h an d s and feet,
| and dim in u tio n or e x a g g e ra tio n of
T h e n e cro p sy in one
| k n ee-je rk s.
case bro u gh t to lig h t c lo u d y s w e ll
in g and fa t t y d egeneration w ith
brow n p igm e n tatio n of the k id n e y s,
liv e r, sp leen , and heart, and m a rk e d
a tro p h y of the en tire w all of th e
ileu m . T h e p atien ts w ere m ale
ad u lts from 36 to 60 }’ ears of age, of
the w o rk in g class, liv in g u nder
in sa n ita n * cond ition s on a d iet of
w h ich rice w as the sta p le a r tic le .”
I
A s to the e tio lo g y of the d isease
j it does n ot seem th a t a definite
j an sw er can be g iv e n . vSir L eo n ard
7 o6
R o g e rs, M . D ., F . R . C . P., F . R . S .,
in his r e v ie w of recen t w ritin g's on
p e lla g r a (M edical A n n u a l, 19 2 4 )
refers to G o ld b e rg e r an d T u rn e r
(Jour. A m er. Med. A ssoc., D ecem b er
2 3 , 19 2 2 ) w h o co n ten d th a t the
d isease is cau sed so le ly b y a d iet
deficient in p rotein . On the other
han d , Jo b lin g an d A rn o ld (four.
A m er. M ed. A ssoc., M a y 10 , 19 2 3)
d e n y th is, an d m a in ta in th a t the
d isease is au in fectio n d ue to an
e x c e s s of ca rb o h y d ra te food w h ich
affords su ita b le c u ltu ra l co nd itio n s
fo r the d evelo p m e n t of a sp ecific in
te s tin a l o rga n ism . O th ers su g g e s t
th a t p e lla g r a m a y be a p h o to d y
n a m ic
in to x ic a tio n .
H in d eh ed e
(Jour. A m er. M ed. A ssoc., Ju n e 9,
19 2 3 )
also d isp u tes G o ld b e rg e r’ s
co n clu sio n s, on th e basis of h is e x
te n s iv e stu d ie s of m etabo lism , in
w h ic h he tested diets 011 h im se lf
a n d other h u m an su b je cts, an d p ro v
ed th a t good h e a lth can be m a in
ta in ed for lo n g on v e g e ta b le p ro teid s
.to tallin g o n h ' 20 g rm . p er d a y w it h
o u t fat (wh-icli v e g e ta b le s can also
re p la ce ), w h o le rye -b read , potatoes,
m a rg a rin e , and b arle y -m e a l p o rrid g e
all s u p p l\d n g
su fficien t p ro tein ,
w h ile bran can be d ig e ste d b y m an
an d rep lace both m eat an d m ilk ,
v ita m in s also b e in g am p le on su ch
d iets. G . C . S h a ttu c k (Boston M ed.
and Stirg. Jo u r., Ju n e 7, 19 2 3 ) g iv e s
ev id en ce to sh o w th a t ch ro n ic a lc o
h o lism and e c c e n tric ity of diet h av e
m o st effect in p re d isp o s in g to the
disease. J . G . H u c k (Johns H op.
H osp. B u ll., M a y , 19 2 3 ) g iv e s a fu ll
su m m a ry of the lite ra tu re 011 the
blood ch a n g e s in p e lla g ra , and re
cords n um ero u s carefu l o b serv atio n s
of his o w n , fro m w h ich he conclu d es
th a t the d isease sh o w s a seco n d ary
t y p e of an iem ia w ith n orm al total
leu co cyte count, but an in crease of
the ly m p h o id elem en ts d u rin g a c tiv e
s}rm p tom s, fo llo w ed b y e x c e s s of
eosin o ph ils d u rin g co n valescen ce,
the latter ch a n g e a u g u r in g a fa v o u r
able p ro g n o sis. R . H u tch in so n and
D.
P aterso n
( h it. M ed. Jo u r.,
O ctober, 19 2 3 ) record tw o cases of
p e lla g r a in ch ild ren w h o h a v e n ever
been out of E n g la n d , and w h o se
d iet w a s not d eficient in p ro tein s,
an d the}* th in k m a n y such cases
rem ain u n d iagn o sed .
1
NEWS AND COMMENT.
B ir t h
T h a c k e r -X e v ille . — On J u l y 1st,
19 2 4 , to
D r.
an d M rs. W . S .
T h a c k e r -N e v ille .o ft h e Y a le M ission ,
C h a n g s h a , a d a u gh ter.
T h e B r i t i s h P r im e M in is t e r an d
F o r e i g n M is s io n s
“ I h a v e p erused w ith m uch p le a
su re the rep ort of th e good w o rk
done b y y o u r m issio n a rie s in the
field. T h e irs is a g re a t a d v e n t u r e ;
th eir ta s k is n ot an e a sy o n e ; an d
th e re su lts a c c ru in g from th eir
lab o u rs cann o t be c a lcu la te d b y the
com m ercial m ethod of profit and loss
account. S o lo n g as th e y m a y cau se
one hom e to be b rig h ter, one hu m an
h eart to be unburd en ed and one
c h ild to be ed u cated in a h ig h e r
fa ith , th a t is a profit to the hu m an
race w h ich cann o t figu re in a n }'
balan ce sheet. T h e ir s is a sp iritu a l
c r u s a d e ; w o rk , for the s p ir it of
th in g s th a t are noble, is m ore essen
tial n ow th an ever.
T h e w o rld
req u ires the cru sad er once a g a in .
1 hope th e y w ill be en co u rage d in
th is g ra n d cru sad e b y tho se at hom e
w ho cann ot in the v e r y n atu re of
th e case see e x a c t ly h o w m u ch is
b e in g done b y our m issio n a rie s. I
w ish them w e ll in th eir m agn ificen t
la b o u rs.” — Y o u rs fa ith fu lly ,
(S g d .) J . R a m s a y M a c D o n a ld .
M is s io n a r y O f f i c ia l l y H o n o u r e d
b y J a p a n e s e - — In connection w ith
th e Ja p a n e se im p e ria l w e d d in g , th e
P rin ce R e g e n t of Ja p a n co n ferred
News and Comment.
m a rk e d honour upon a n u m b er of
p eo p le w ho h ad ren dered sp e cia l
so cial services d u rin g the p a st 15
y e a rs . A m o n g them is D r. L a n d s borough, one of th e m issio n a rie s in
Fo rm o sa , w h o w a s a w a rd e d a s ilv e r
c u p and Y 2 0 0 .
from those th e y loved, w ith o u t the
co m fo rts an d m ate ria l a d v a n ta g e s of
th eir hom e, th e y fo llo w ed
the
e x a m p le of th e B elo ved P h y s ic ia n ,
S t. L u k e , sc o rn in g am b itio n and all
selfish aim s. M iss D o ra T ic k e ll, a
m em b er of the d eleg atio n sen t to
In d ia b y th e so c ie ty, sp o k e of the
p re se n t-d a y c h a n g in g co nd itio n s in
th a t co u n try. M issio n h o sp ita ls had
g a in e d the confidence of th e people
to an e x tra o rd in a ry ex ten t. F u rth e r,
t h e y had a g r e a t w o rk to do in th e
tr a in in g of In d ian n u rses
an d
w om en doctors. S h e su g g e ste d th at
in e v e ry m issio n area there sh o u ld
be a n u m b er of sm all d isp en saries
w ith
In d ia n
m en
and
w om en
doctors in c h a rg e , lin k e d up w ith a
h o sp ital u nd er the care of a h ig h ly
q ualified doctor, E u ro p ean or In d ian .
S u ch a p o lic y w o u ld dem an d la rg e
rein forcem en ts
of personnel an d
m o n ey. M iss (Trace C ro sb y p aid a
trib u te to the m ed ical m issio n arie s
and to the C h in e se doctors and
j n u rses w h o m th e y are tra in in g and
i
se n d in g out to help their ow n
co u n try-p eo p le . D r. H . H . W e ir
pointed out th at even if all the
e x is t in g posts w ere filled at once
th at w o u ld h a r d ly touch the frin g e
o f the need for m ore doctors.— British
|
\ Medical J ou r n al , M a v 3 1 , 3924.
W e s le y a n M e d ic a l M is s io n s .—
T h e re w a s a go o d atten d an ce a t
th e a n n u a l m e e tin g on b e h alf of
m ed ical m issio n s.
D r. E . C ro n in
L o w e , of S o u th p o rt, p resid ed , an d
th e se c re ta ry , D r. P erc}’ W ig fie k l,
rep orted an incom e of £ 17,0 0 0 , of
w h ich ¿ 9 ,0 0 0 w a s g iv e n on the m is
sion field. A d eficit of ¿ 6 ,0 0 0 w as
m et by th e g e n e ra l fu n d s of the
M is s io n a r y S o cie ty .
E i g h t n ew
m ed ical m issio n a rie s saile d d u rin g
th e y ea r.
D r. M abel Iverr had been
a w ard e d the K a is ir -i-H in d m ed al
an d S is te r G . S te p h e n so n h ad been
ap p o in ted p re sid en t of the C h in a
N u r s in g A sso c ia tio n .
D r. W e b b
A n d erso n told sto ries of w o n d erfu l
w o rk in the F a ts h a n H o s p ita l. D r.
G . O rissa T a y lo r , of the B a p tis t
M is s io n a r j7 S o c ie ty , d w e lt on the
ig n o ra n ce in
In d ia
co n cern in g
m ed ical w o rk and the m ean s of
c o u n te ra ctin g p la g u e s and feve rs.
D r. C . G ro sv e n o r u rg e d the tra in in g
o f C h in ese th em selv es as m ed ical j
|
m issio n a rie s.
|
S. P. G . M e d i c a l M e e t i n g . — A
m ed ical m issio n s m e e tin g w a s held
d u rin g th e S . 1’. G . a n n iv e r s a r y
w e e k in the C h u rch H o u se , L o nd o n,
on M a y 14 th , 19 2 4 . T h e ch air w as
ta k e n b y S ir H u m p h n ^ R o llesto n ,
K . C . B ., P re sid e u t of the R o y a l
C o lle g e of P h y s ic ia n s, w h o said th at
the care of the soul and the care of
p h y s ic a l ills had been clo se ly allied
sin ce the tim e of H ip p o c ra te s. W ith
the a d ve n t o f tru e re lig io n an d the
d evelo p m en t of
m ed icin e
th e y
becam e sep arated , b u t in m ed ical
m issio n s th e y w ere com bin ed and
w o rk ed to g eth er to th eir m u tu a l ad
v a n ta g e . H e w ish e d w h o le -h e a rte d ly
to
ex p re ss
a d m iratio n
for the
noble m em b ers of our p ro fessio n
d e v o tin g th em selv es soul an d bo d y
to
m ed ical m issio n s.
B an ish ed
707
-
C o n fe re n c e on T r o p ic a l D is
e a s e s . — On Ju h * 23rd ., 19 2 4 , at
K in g s to n , Ja m a ic a , th e In tern atio n al
C o n ference on T ro p ica l d iseases w a s
opened.
S ir L e o n a rd R o g e rs and
oth er B ritish e x p e rts w ere p re sen t.
I m m u n it y F o l l o w i n g S m a l l p o x
V a c c i n a t i o n . L e a k e ( Milit. S ur
O ctober, 19 2 3 )
p oints out a fa ct
w e ll k n o w n to m ed ical officers in
th e tro p ics th at the im m u n ity
w h ic h w o u ld be q u ite su fficien t
to p ro tect an in d iv id u a l a g a in s t
ch an ce e x p o su re in a w ell-vaccinateid
c o m m u n ity is in ad eq u ate in a p o o rly
va ccin a te d p lace w h ere the e x p o su re
m a y be in ten se an d co n tin u al.
T h u s va ccin a te d person s h a v e been
kn o w ii to co n tract s m a llp o x an d die
from the hpem orrhagic form .
70S
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