957

BROADBENT also maintained that while mitral regurgitant Icases " almost always " benefited from the use of

cardiac tonics, this was by no means equally so in mitralstenosis.

It seems, however, to have been generally agreed in the

past that digitalis has found its most striking successes in un-

complicated mitral regurgitation associated with the generalevidence of cardiac failure, on whatever lines it has been

sought to explain this fact. In these circumstances of still

existent uncertainty on many important points, every care-

fully considered record of experience in the use of the drugis worthy of note, and such a contribution appears in the

last issue of Heart, which is wholly occupied by an articleon digitalis from the pen of Dr. JAMES MACKENZIE.

After an introductory generalisation as to the efficacy,or want of efficacy, of the drug in certain circum-

stances, he gives a detailed account of 40 cases in

which the dosage and effects of the drug were carefullynoted, and certain conclusions or impressions are finallyexpressed. Of his 40 cases no less than 20 had mitral

stenosis or were diagnosed as such, one is described as

"mitral," ten as "mitral and aortic disease," two as

"aortic," and the remaining seven constituted a miscel-

laneous group containing cases of paroxysmal tachycardia,bradycardia, and emphysema. Of the mitral stenotic cases

ten responded well to digitalis and eight apparently did

not; of the mitral and aortic, only one seems to have

answered definitely to the remedy. One of the stenotic

cases could scarcely have been expected to show definite

results, as it was evidently one of infective endocarditis,

although the fact is not mentioned in the record, and

had, of course, a fatal issue. Of the two aortic cases

neither was notably affected by the drug, while in the

miscellaneous group four improved under digitalis andthree did not. It is not the amount of material here

set forth, but the Care with which the investigation wascarried out which renders it worthy of consideration.

The language employed by Dr. MACKENZIE is largely thatof the new cardiology in which the auriculo-ventricular

bundle and the various possible starting places for cardiaccontraction and fibrillation of the auricle play a part,although he does not fail to ascribe a considerable i6le

to the action of digitalis upon the vagus in modifying theaction of the heart.

The general conclusions arrived at are, that " Cases of

auricular fibrillation are more readily and markedly affectedthan cases with the normal rhythm." In other words, thatthe irregular heart, and particularly that explosively andoften temporarily irregular heart which is usually associatedwith mitral disease, especially in younger subjects whohave suffered from rheumatic fever and in whom the

cardiac muscle is fairly sound, respond most easily to

the drug. It is admitted that in persistent irregularitiesand in older people it is less successful. Dr. MACKENZIE

suggests that the fibrillating auricle may render the

auriculo-ventricular bundle more susceptible to the actionof digitalis, which, by impeding the shower of auricular

impulses regarded as falling upon the ventricle, mayinduce calm. Digitalis, however, it is contended, at

times tends to produce auricular fibrillation. Some

evidence is adduced that the diuretic effects of digitalismay be observed without any perceptible change in the

heart, and two cases of tachycardia "arising from ars

abnormal source are mentioned in which a more normal

rate was established after the occurrence of fibrillation 06

the auricle.

The preparation of digitalis chiefly used was the tincture,.and it was given in doses of 15 or 20 minims three or fourtimes a day "until some definite reaction was obtained " ofthe kind indicated by WITHERING. The principle of push-ing the drug, as experience has taught many, is frequentlynecessary to attaining success, but, while not averse from a

guarded boldness in the use of digitalis, we own to &.

conviction that slow increase in dosage is usually quiteeffectual when remedy is possible by this means, and thatthe comparatively rapid induction of nausea or vomiting-is rarely necessary and not always safe. Incidentally.,Dr. MACKENZIE mentions some interesting observations.

on the inefficacy of some and the efficacy of other agents.which have been employed in the treatment of heart diseasesThus he found aconite, long regarded as a retardant

of cardiac action, to be quite inert in medicinal doses

Although he found strophanthus acted well in regulatingirregular hearts, he never observed it to succeed where -

digitalis had failed. Atropine, he convinced himself, was

potent in accelerating some hearts retarded by the action of

digitalis. It will thus be noted that Dr. MACKENZIE’S

experience of the use of digitalis in heart disease differs

little from that of many others who have recorded their:

observations. Yet we fully recognise his painstakingendeavour to secure trustworthy data for the formation ofmore precise and scientific opinion on the use of a drugwhich is still used by many empirically, and which, likemost agents capable of effecting good, requires to be

employed with all the circumspection possible.

Annotations." Ne quid nimis."

CERTIFICATE OF PROFICIENCY IN VACCINATION.

THE Local Government Board has issued a circular dated

Sept. 21st, 1911, with reference to the certificate of pro-ficiency in vaccination which is required to be produced’bya medical practitioner to a board of guardians before he canenter into a contract with them for public vaccination. A.

certificate of proficiency in vaccination can in general onlybe obtained from a teacher authorised by the Board afterdue instruction and examination. The Order of 1905, how-ever, permitted certificates of proficiency to be given tocertain classes of medical men after examination only andwithout a previous course of instruction. The present Orderextends the exemption from the course of instruction priorto examination to any person already holding a medicaldiploma or degree granted in a British, possession or foreign’country who is a candidate for examination by an examining-.b)dy in the United Kingdom for a diploma, licence, ordegree conferring the right of registration under the MedicalActs. The new Order supersedes the Order of 1905 and

incorporates its provisions. The following teachers and

examiners are entitled to give such certificates of proficiency

958 T

in vaccination (to the special classes of medical men definedin the Order) after examination only, and without a pre-liminary course of instruction :-

STATION. NAME OF VACCINATOR WITHSTATION. ADDRESS.

A practitioner who has obtained a certificate of proficiency invaccination granted by a teacher authorised for the purpose bythe Board as a condition of obtaining a diploma, licence, ordegree is not required to produce it before entering into acontract with a board of guardians for public vaccination.The Order will be placed on sale, so that further copiesmay be obtained from Messrs. Wyman and Sons, Limited,Fetter-lane, E.C., either directly or through any bookseller.

COW-DUNG FLOORS AND PLAGUE PREVENTION.

FROM a medical correspondent possessing an intimate

knowledge of the social and religious life of the nativesof India, and a close acquaintance with their habitsand customs, we have received an interesting communicationin which he endeavours to prove that the comparativeimmunity from plague experienced by Madras and EasternBengal is due to their methods of practising domestic

hygiene, and particularly to their carrying out the veryancient custom of frequent spreading or washing of floors

with cow-dung. He points out that, on the other hand, inthe Punjab and other northern and north-western provinceswhich have been, and still are, suffering severely from theravages of plague, and which are, as he expresses it, I I too

.highly Mahomedanised," this spreading of cow-dung on thefloors has been neglected, the people having abandonedlargely this old Hindu practice handed down to them bytheir forefathers. There is no doubt a religious side to thisquestion, and for that reason we hesitate to expressourselves as freely as we otherwise might have done. But

our remarks are made strictly from the sanitary point ofview. We understand our correspondent’s view to be thatthis dung treatment of floors acts in two ways :-firstly, thereis a slight chemical action upon organisms which may be’present on the floor ; secondly and mainly, the mechanicaleffect i3 to entangle in the semi-liquid dung and thus destroyaay fleas or flea-eggs. We think, however, that sprinklingthe floor with a weak solution of some disinfectant, accom-

panied with frequent vigorous sweeping, would effect morebenefit, especially if the floor were made smooth and im-

pervioas by cement or in other ways. There is also anotherconsideration to be kept in mind-namely, that tuberclebacilli may be present in the cow-dung, and that these

might in one or another way infect the inmates of the

dwelling, Our correspondent argues that the ancientmethod of " cleansing" floors is well known to all classes ofthe inhabitants of India, and that its adoption could be moreeasily enforced than could any other procedures suggested bysanitarians. We are, however, of opinion that as a plague-preventive measure this use of cow-dung has nothing to

commend it. The first Indian Commission showed by experi-ments that B. pestis can live in sterilised cow-dung forseveral weeks, or even months, though in unsterilised dungthe microbe did not survive longer than six days. That cow-

dung has little effect in preventing the multiplication of

fleas has been proved by the Advisory Committee for theInvestigation of Plague in India, one of whose promi-nent members, Dr. C. J. Martin, director of the Lister

Institute, has made the following statement in one of hisreports: "The Indian hut, with its floors of cow-dung andits indescribable litter, in addition to providing cover forrats to nest, affords good breeding ground for fleas of allsorts. The amount of vermin infestation of these houses

may be gathered from the fact that in one room in

which dead rats had been found and plague cases

had occurred the Commission for the Investigation of

Plague in India secured 263 fleas." Cleanliness of personsand of house interiors, with admission of sunlight and freshair, will do more to prevent plague in Hindu huts than thespreading of cow-dung on the floors. It is well known thatthe vitality of B. pestis is quickly acted upon by exposureto the rays of the sun or to the effects of drying, as, forexample, by a current of air.

INJURY OF THE SPINE DUE TO MUSCULAREFFORT.

IT does not appear to be generally known that serious, andeven fatal, injury of the spine may be a result of musculareffort. In the Glasgow Medical Journal for July Dr. George S.Middleton and Dr. John H. Teacher have reported a remark-able case of rupture of an intervertebral disc. An engineer’slabourer, aged 38 years, was admitted into the GlasgowRoyal Infirmary on Feb. 12th, 1910. At 6.30 A.M. on the

8th, while lifting with another man a heavy plate fromthe floor to a bench 3 ft. high he ’’ felt something crack inhis back." He could not stand up straight, but had to

remain bent on account of pain and a feeling of weaknessin the back. For a quarter of an hour he tried two straightenhimself " and then walked home-a distance of two or threeminutes-in a bent position. He said that he had oftenlifted heavier weights before without injury, and the manwho assisted him did not suffer in any way. When hereached home he sat in a chair fairly comfortable, but move-ment caused intense pain, radiating from the back roundboth sides. He was seen about 1 P.M. by his medical

attendant, who ordered him to bed. He was able to

walk to the bed, but could not stand, his legs givingway. He attributed the difficulty to excruciating pain inthe back. In bed he was most uncomfortable, turningand twisting to find a comfortable position and suffering muchpain in the attempts. He felt sick, but did not vomit. Onthat night he micturated for the last time. Between 2 and3 A. M. he felt an agonising pain shoot down from his chestto his feet with peculiar sensations as if his limbs were"sleeping." This soon passed away, and he found that hecould not move either leg. The bladder and bowels became

paralysed and on Feb. 12th he was sent to hospital as acase of intestinal obstruction. In the ambulance van his

bowels acted without his knowledge. On admission therewas great distension of the intestines and bladder and com-plete flaccid paralysis of both legs with anaesthesia as highas Poupart’s ligaments. The cremasteric and all the reflexesof the lower limbs were absent. Both legs became atrophiedin their whole length, including the glutei. At the upperpart of the buttocks two acute decubital sores formed. He

grew steadily weaker, the urinary sepsis increased, the

temperature rose, rigors occurred, and he died on Feb. 24th.At the necropsy no irregularity of the spine could bemade out either externally or after opening the canal.There was no clot outside the dura mater. Therewas marked softening of the lumbar enlargement of thecord with brown staining indicative of haemorrhage, butthere were no clots. There were also early hypostaticpneumonia at the left base, septic cystitis, pyelitis, and