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Correspondence.

EXPERIMENTAL EPIDEMIOLOGY.

"Audi alteram partem."

To the Editor of THE LANCET.

SIR,—In your leading article under the aboveheading in THE LANCET of Oct. 3rd there is one

point on which I should wish to offer a comment.and an explanation. When I first had the goodfortune to engage the interest of Dr. Greenwood inthese experiments, some five years ago, it soon

became evident that the satisfactory progress of the

).investigation demanded close cooperation, not onlyin interpreting the results, but in planning the Iexperiments. Since that time those experimentswhich were likely to yield data requiring statisticalanalysis have been devised by Dr. Greenwood andmyself, after consideration of the results alreadyobtained, and of the experimental or statisticaldifficulties likely to be encountered ; and the experi-mental method has, from time to time, been modifiedas new problems or unforeseen difficulties havepresented themselves.

Dr. Greenwood’s part of the investigation has,therefore, not consisted merely in applying statisticalmethods of analysis to results which I have indepen-dently obtained ; but throughout this part of thework the investigation has been a joint one in thefull sense of the word, and the statistical side hasbeen carefully considered in devising the experimentsas well as in interpreting the results. It is our firmconviction that full and equal cooperation of thiskind is essential if progress is to be made in theinvestigation of an intrinsically difficult problem.

T .— __.,___....

W. W. C. TOPLEY.Public Health Laboratory, Manchester, Oct. 2nd, 1925.

TECHNICAL INSTRUCTION IN OPERATIVESURGERY.

To the Editor of THE LANCET.

SIR,—From what I constantly see I am forced toconclude that in the plethora of subjects whichstudents have nowadays to tackle surgical handicraftis apt to be forgotten, and that operative training isdistinctly inferior to that of midwifery in which anumber of personal attendances must accompany theapplication for admission to the final examination.I should like to know what percentage of the candi-dates for the higher surgical diplomas know how to mopa wound-that is, will apply the sponge with a steadyvertical dab instead of a fierce wipe which sweeps awayligatures and causes small unclamped vessels to bleed.

I beg to invite the attention of clinical operators alsoto avoid teaching their pupils to retain their hands infull pronation when assisting at operation. There isnot anything which tempts me more to open mymouth than when the assistant is retracting theedges of wound or applying a ligature to have thewhole field obfuscated with his pronated fists, withthe result that he barely sees what he is doing and Icannot see anything. It seems somewhat of a farceto set papers for examination containing questions-for example, the dissection and difficulties attendingexposure of the pituitary gland, carotid body, or semi-lunar ganglion-to candidates who do not know howto hold a knife or handle a needle, and if entrusted withthe application of a ligature to a pedicle, even money,will make such a violent tug on the second knot as tosmash up the whole procedure.

I am quite aware that this burlesque is not, in themajority of instances, due to any personal fault of theunfortunate youth camouflaged with a licence topractise surgery, but to the miserable dog-in-the-manger stunt which gives nothing, and in wanton

stupidity, admits of a yearly turn-out of men asqualified surgeons who are absolutely incapable forwant of personal technical instruction to perform anyoperation on any living thing.

I wonder what kind of door or window an embryocarpenter would turn out if he had not served his time, -

with tools in fist, under the direction of his boss.I am, Sir, yours faithfully,

Buenos Aires, Sept. 9th, 1925. JOHN O’CONOR.

** * Sir John O’Conor adds in a postscript that hisletter was not inspired by anything which Mr. BernardShaw has written - or may write. Coming nearerhome it cannot have been inspired either by theannotation on " The Surgeon as a Technician " inour issue of Sept. 26th (p. 657) to which it is so highlyapposite.-ED. L.

JOHN O’CONOR.

PERSISTENT DIARRHŒA IN PHTHISIS.

To the Editor of THE LANCET.

SIR,—I have found two drugs not mentioned byDr. de Carle u’oodcock useful in the treatment ofthis very distressing complication. For some timenow I have used intramuscular injections (or intra-venous, in much weaker dilutions) of calcium chloridein doses of -1 gr. at intervals of two or three days.It has certainly some beneficial effect, especially ifgiven in conjunction with large doses of bismuth bythe mouth, say 1-2 dr. thrice daily. The action ofcalcium chloride is very slow, and injections shouldbe continued for two or three weeks before definiteresults are expected. Persistent diarrhoea in tuber-culosis is not always due to specific infection of thebowels ; and when there is clinical evidence offermentative changes in the large gut, dimol in dosesof 1 gr. thrice daily is also a very useful adjunct todietetics and other methods of treatment. Thistreatment is more effective if a preliminary periodof semi-starvation has been prescribed and the tractprepared with a dose of calomel.

Dr. Woodcock raises an interesting point whichwill have to be settled soon unless pneumothoraxtherapy is to suffer a set-back. I refer to the connexionbetween artificial pneumothorax and a superveningdiarrhoea. It appears to me that pneumothorax hasa tendency to cause (sooner or later) the appearanceof another active focus somewhere else in the body,and this tendency is more marked if comparativelyhigh pressures have been used in producing collapse.The intestinal tract, or some other organ, may be the;eat of one or two small and comparatively quiescent’oci, and by collapsing the lung too effectively or tooIuickly the patient’s system gets an overdose of auto-luberculin, resulting in reactivation of these indolentoci.This is, in my opinion, a real danger in pneumo-

horax treatment. One is apt to overlook the facthat pulmonary tuberculosis is one manifestation (offiany) of a general disease.

I am, Sir, yours faithfully,FELIX SAVY.

Grampian Sanatorium, Kingussie, Sept. 29th, 1925.FELIX SAVY.

ALTRUISM AND THE "COMMON COLD."To the Editor of THE LANCET.

SIR,—Your correspondent, Dr. J. A. Drake, writesof the thoughtless distribution of the " cold " fromperson to person. The late Sir William RobertsonNicoll is said to have maintained that " colds,neuralgia, and most other ills arise from the greatmodern curse of fresh air." The sound of such avoice crying in the wilderness must find an involuntaryecho in many conservative hearts beating beneathheavy overcoats to-day ; for the curse of fresh airis upon us, and the curse has come to stay. It istrue, of course, that although there are few who dareto protest there are many who only accept the