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The coroner, perhaps, on his side, has a right toprotest that his least considered remarks in court are,-sometimes torn from their context and reported withunnecessary elaboration. He tries to deal with all theaspects of the case but the reporter may be interestedonly in the case against a particular suspect. Doubtlessthere are coroners, as there are judges and stipendiarymagistrates, who<!e running comments are no greathelp to the administration of justice, and whoseindividual views on certain favourite topics of theirown (whether medical or legal) are apt to find a-tediously constant expression. But the critics of theprocedure at inquests make a profound mistake if theyignore the historical and popular associations of the.coroner’s office, or if they commit themselves to thetheory that the only good coroners are lawyers and theonly bad coroners are medical practitioners.

THE RED CELLS IN PERNICIOUS AN&AElig;MIA.

THE work of Price-Jones has established that in

pernicious anaemia there is an abnormally widevariation in the size of the red cells, and the presenceor absence of this phenomenon may now be regarded.as the absolute criterion for diagnosing the condition.’The plotting of the Price-Jones curve, however, isL,so laborious as to be hardly feasible in a busy labora-tory, whilst the " halo " method of Adrianus Pijper,2though affording means of demonstrating optically-the same variation and the approximate averageincrease in size of the red cells, demands special.apparatus and somewhat formidable calculations.Some time ago Haden2 pointed out that a relatively’J3mall increase in the average diameter of the redcells causes a relatively great increase in the total i"red cell volume, and various workers have brought Iforward evidence to show that much of the valuableinformation to be gained from the Price-Jones curvecan be got by calculations based on the total volume,and total number of red cells. Wintrobe, whose work,on blood standards has already been referred to in ourcolumns, has recently dealt with the subject in acomprehensive way.3 He points out (what has beenrecognised for some time) that the average corpuscular"volume in cubic millimicrons may be obtained bydividing the total volume of red cells per litre, asdetermined by the haematocrit, by the total numberof red cells per c.mm. The figure thus obtained heTefers to as the corpuscular volume. This cor-

puscular volume he finds in healthy young adults tolie between the figures of 70 and 98 cubic millimicrons,with the average round about 83. In strong con-tradistinction to this, Haden found the corpuscularvolume in pernicious anaemia to lie between 108 and163 cubic millimicrons with an average of 128. The.difference between the normal red cells and those fromcases of pernicious anaemia is conspicuous, and inas-much as determination of the corpuscular volumeonly demands the use of a haematocytometer and aIiaematocrit, this particular determination bids fairto be of considerable use in establishing the diagnosisof pernicious anaemia. Wintrobe further draws,attention to the interesting fact that, although thesize’of the red cell is increased in pernicious anaemiaand though it carries a greater load of haemoglobinthan the normal red cell, the actual proportion of thevolume of the red cell occupied by the haemoglobinis no greater than in normal blood. Haden foundthe percentage of haemoglobin in the red cell inpernicious anaemia to range between 16 and 35per cent. ; Wintrobe in normal blood finds verysimilar figures, the actual average being about 33 percent. The proportion of haemoglobin in the red cells isdetermined by dividing the haemoglobin, expressedas grammes per cent., by the volume of red cells per100 c.cm. of blood. Both for this calculation and forthat of the corpuscular volume a h&aelig;matocrit isrequired ; the importance of centrifugation until the

1 THE LANCET. 1924, ii., 367.2 Haden, R. L. : Arch. Int. Med., 1923, xxxi., 164.

3 Wintrobe, H. M. : Amer. Jour. Med. Sci., April, 1929, p. 513.

column of red cells has reached a final level ispresumably apparent. Wintrobe, however, drawsattention to a source of error which has possibly notbeen sufficiently considered. He finds that the additionof potassium oxalate to the extent of 20 mg. to 10 c.cm.of the blood under estimation caused a decrease incell volume of 3-7 per cent., while addition to theextent of 40 mg. to 10 c.cm. of blood brought abouta diminution of 6-7 per cent.

OBSERVATIONS ON UNILATERAL DIURESIS.

To the April number of Guy’s Hospital Reports,Mr. H. 1. Maister, Mr. W. H. Ogilvie, and Prof. M. S,Pembrey contribute a paper on a case of total cystec-tomy in which certain investigations were made ofurinary secretion. The patient had a carcinoma of thebladder and at operation the ureters were brought tothe surface. The urine excreted by the two kidneys wascollected separately by an apparatus which kept thepatient dry and allowed her to get about. Variationsin the activity of the two kidneys were shown byestimating the volume and specific gravity of samplescollected in consecutive periods of half an hour. Themost interesting observation was that the applicationof warmth to the loin did not, as is usually supposed,produce diuresis but rather the reverse. When a hotpoultice was placed over the right kidney the amountof urine excreted on that side was diminished and adiuresis was noted on the opposite side. On anotheroccasion as a control the poultice was applied to theleft side and a diuresis from the right kidney wasobtained. It appears, therefore, that warmth over theloin produced a vaso-constriction of the underlyingkidney and since the skin, apart from the poulticedarea, was cold, a compensatory dilatation occurredwith increased excretion on the opposite side. Theseobservations are of a special interest in view of thecommon practice of applying warmth and cuppingover the lumbar region for the purpose of stimulatingurinary secretion-a method which seems likely todiminish rather than stimulate the activity of thekidneys. It may, indeed, be deduced that the applica-tion of warmth over a kidney might be of use in thosecases of renal heematuria in which diminution ofactivity is thought desirable.

BOOTS AND SHOES.

ONE of the disadvantages of civilisation is to befound in the degradation of the human foot which iscaused by the use of footgear. Many writers havepointed out the evils wrought by boots and shoes,and by stockings, too, for that matter, and many anessay has been written on the proper form andmaterial of foot covering. The last contribution to theliterature of this subject comes from Dr. J. D. Adams,!of Boston, who holds views on the footgear of thechild which are sound as far as they go, but hardlyseem to go far enough. A study of the history ofboots and shoes and of the current practice in shoeingof many peoples all over the world, such as was inpart attempted in our columns by Mr. MuirheadLittle2 in 1914, shows that, with the exception ofsandals, all footgear tends to cause abduction of thegreat toe and gradual loss of the power of voluntaryadduction of its phalanges. The Greek or Romansandal with a thong between the great and secondtoes did not have this pernicious effect, and the sameis true of certain sandals worn in India and elsewhereat the present time. The most primitive form ofprotection was probably a strip of the skin of ananimal or some flexible leafs and the result of windingthis or any other bandage round the foot and toeswould be abduction of the great toe, involving intime loss of the support afforded by its phalanges.This tendency is evident in Red Indian mocassins,

1 Jour. Amer. Med. Assoc., May 25th, p. 1753.2 Boots and Shoes from Historical and Surgical Points ofView, THE LANCET, 1914, i., 1738.

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some of which are quite sharply pointed. The earlyHighland brogue, which was made out of a singlethickness of deer’s or other hide, had the same defect.The loss of the power of voluntary abduction of thehallux is incurred quickly because of the comparativefeebleness of the so-called abductor hallucis and themechanical disadvantage under which it acts, losing,as it does, all power of adduction after the firstphalanx is abducted so that its long axis is a con-tinuation of that of the metatarsal bone. But it is notonly the great toe that has suffered from footgear.As soon as man added a stiff sole to the moreor less sock-like mocassin or brogue, or made thesandal stiff, the muscles began to atrophy and thecomplicated musculature of the foot to lose its raisond’etre. Every normal child appears to be born withactive foot muscles and joints, but in every shoe-wearing adolescent the process of degradation andatrophy is gone through, until the foot becomes nomore than a lever hinged at the ankle and jointed at thetoes. Dr. Adams figures the radiogram of a " footin a properly fitted shoe," but even in this a degreeof hallux valgus is apparent. Such deformity is,we fear, unavoidable in all boots and shoes, anddespite the provision of shoes of which the soles havestraight or incurved inner edges, the halluxnecessarily pressed upon at the metatarsophalangealjoint declines to avail itself of the space provided.We regretfully conclude that unless digitated stockingsand sandals with toe-thongs become our only wear,we must have a more or less abducted great toe.Even the athlete’s running shoe is badly shaped.Those that we have seen do not allow for adductionof the hallux and in so much sacrifice the supportand propulsive leverage of the great toe.

Men’s boots and shoes may be bad, but if so, whatepithet of depreciation is strong enough for theshoes of women ? Now that all females are ladies,the workers among them have aped the fashionswhich were popular with the wealthy idlers of pastgenerations who rode in carriages and did but littlewalking on their high heels and pointed toes. It isastounding that so few complain out of the millionswho now for several years have been defying naturein this way.

SCLEROSIS OF THE RETINAL VESSELS.

SINCE the signs of retinal arterio-sclerosis werefirst pointed out by the late Marcus Gunn, thiscondition has been dealt with by many writers,notably by Foster Moore in 1917.1 The subjecthas been reopened in a series of papers, reprintedfrom the British Journal of Ophthalmology forMarch, April, and May, 1929, by Dr. Noe Pines,a Russian ophthalmologist, now living in London.He distinguishes between general arterio-sclerosisin which the general blood pressure is not necessarilyhigh and essential hyperpiesis in which it is. Thetwo conditions, of course, are often present together,but it is the second and not the first, he argues,to which the retinal changes are due. As to whatthese changes are, he attaches little or no importanceto the loss of transparency in the retinal vesselswhich is extremely common’in elderly people. Thealteration in the reflex which gives rise to the appear-ance known as "silver wire" arteries is more

important but not always easy to determine. Themost important signs of sclerosis he considers to be,first, white lines bordering the vessels-not on thedisc or even in its near neighbourhood, as these may bepurely physiological, but in the retina and especiallyat and near the points where artery and vein cross.These white lines he attributes to perivasculitis inthe sheaths of the vessels. Secondly, signs ofcrushing of the veins at the arterial crossings evidencedby white lines, banking, and deflection of the veins.A number of reproductions of drawings fromHamblin’s collection are given as illustrations, andthis appears to be an excellent way of studying the

1 Quarterly Journal of Medicine, January, 1917.

subject. There is originality in the author’s viewsas to the interpretation of some of the appearances.It is of interest, too, that he finds no connexionbetween this form of retinal disease and nephritis,.and consequently does not consider the changesthat he describes are premonitory of albuminuricretinitis. On the other hand, the connexion between-sclerosis of the retinal vessels and those of the brainis notorious. Both depend on persistently highgeneral blood pressure, and this again on some form oftoxaemia. Once again we see that the ophthalmoscopeis one of the most essential instruments of diagnosison which the general physician has to rely.

TRANSPLANTATION OF AN EPIPHYSIS.

WE do not expect to hear of surgical noveltiesfrom the Sandwich Islands and therefore the reportof a new procedure coming from Honolulu is the morewelcome. Dr. G. F. Straub, of The Clinic, Honolulu,reports1 the successful implantation of a section ofdiaphysis and epiphysis in 1912, as suggested byMurphy. The case was one of osteomyelitis of thetibia with consequent necrosis of the bone includingthe lower epiphysis, and the graft was obtained fromthe sound leg. As the operation was performed as longago as 1912, a definite opinion can be formed on thevalue of the result. The leg, which at the age of 14was 4’5 cm. shorter than its fellow, is now 5-0 cm.shorter, showing that growth has taken place paripassu with the sound limb. The deformity of thefoot, due to unbalanced growth of the fibula beforethe operation, has much diminished, but there isstill some calcaneo-cavus deformity. This paper isillustrated well by photographs and radiograms.

HOSPITAL MATERNITY WORK IN GLASGOW,

THE Glasgow Royal Maternity and Women’s Hos-pital contains 114 beds, 25 of which are reserved forthe antenatal department. The report of the hospitalfor the year 1927, which has reached us, covers thetreatment of nearly 4000 in-patients and 3500 districtcases, its general arrangement being based on thatrecommended by the Committee of the Royal Societyof Medicine, in which cases which have attended theantenatal clinic and emergency cases are recordedseparately. In Glasgow, however, a large numberof patients apply for admission without havingattended a clinic, or having been seen by a doctoror midwife, and for these it has been necessary toform a third section, numbering 700 in all. For thewhole hospital a 2 per cent. decrease is recorded onthe morbidity of the previous year. Comparisonof the results obtained in the antenatal and emergencysections goes far to prove the value of antenatalwork, particularly in centres where pelvic contractionis common. This is the case in Glasgow, for 288cases of contracted pelvis were treated by triallabour, Csesarean section, or forceps. Labour seemsto have been induced only in six cases, in three ofwhich no measurements are recorded, one of themresulting in the delivery of a 10 lb. baby at term inless than three hours. In two of the other threecases the pelvis is described as generally contractedalthough the diagonal conjugate measured 4 inches.Csesarean section was performed in 112 cases, mostlyfor contracted pelvis, eight of the operations beingof the "lower segment" type. The mortality-rateswere: maternal 11-6, foetal 16-0 per cent. Thereport has been compiled for the second year insuccession with great care by the registrar, Dr. J. N.Cruickshank, who remarks that the method ofrecording the cases has involved the omission ofcertain details. The reader would have liked moreinformation, for instance, as to whether or not foetalheart sounds were heard when the patient was

1 Surg., Gyn., and Obst., May, 1929, p. 687.