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delivering the judgment of the court, Lord Hewartsaid that the Acts and the regulation chiefly in question(Regulation 3 made May 20th, 1921. under the Act of1920), if compared, did not support the appellant’scontention that the physical bringing of the goods tothis country, or the intention to bring them, must beproved before a charge of procuring or attempting toprocure could be sustained. The sentence was nodoubt severe, but it was impossible to believe that theaccused acted innocently.

The Case of Ball v. Howard.An action against a medical man was heard before

Mr. Justice Bailhache in the King’s Bench Division ofthe High Court on Jan. 23rd and 24th, damages beingclaimed on the ground of negligence in the performanceof an operation for appendicitis. It was stated thatthe plaintiff patient requested that a specialist shouldbe called in, but the defendant said that this was notnecessary. The plaintiff went on well at first, butcomplications arose, for which a consulting surgeon,who was called in. performed a second operation,followed by a good recovery. Mr. Bailhache, in givingjudgment, found the practitioner’s conduct in generalto be worthy of the profession of which he was anhonourable member, but that contrary to his usualpractice and habit, he had committed two seriouserrors of judgment : (1) In not attending at once tothe patient’s call ; and (2) by going away withoutleaving proper instructions what to do. The plaintiffhaving suffered no permanent harm, Mr. Bailhachegave judgment for him with £70 damages and the costsof the action, and judgment for the defendant on hiscounter-claim of 30 guineas - fee with costs of thecounter-claim.

The Kind of Persorz that Kills.It is regrettable that the matter of legal responsi-

bility enters so largely into the investigation of suchterrible acts as the recent murder of two children bytheir nurse, to the exclusion of the scientific study ofthe kind of person that kills. Jealousy and anger arecommon human failings ; murder is rare, but we arewithout detailed life-histories that might give us anunderstanding of the dispositions which underlie crimesof this nature, though even such histories wouldconstitute only the approach to a subject whichinvolvesthe fullest investigation of the mind of the criminal.The horror aroused by this deed should not shut outconsideration of the mental stress and conflict thatled to it, for the murderer’s previous behaviour andundoubted love for her victims suggest an exaggerationand distortion of the noblest of instincts. The weaponsof modern psychology have enabled us to understandsomething of the unconscious urgings of the minordelinquent; their application to such cases as thismight add to knowledge whilst leaving to society theright to decide whethel or how that knowledge shouldbe applied.

TUBERCULOSIS.

Coördination of the Work of Tuberculosis Officersand Insurance Practitioners.

THE Ministry of Health has issued a Memorandum,dated December, 1923, on this subject (Memo. 286).It is a timely exhortation to cooperation, and it givesnotice of certain alterations in the terms of service ofinsurance practitioners who, in the future, must sendtheir initial and periodical reports on cases oftuberculosis direct to the tuberculosis officers insteadof, as formerly, to the regional medical officer of theMinistry of Health. The Memorandum pays specialattention to the cases in which tuberculosis is suspected Ibut cannot be definitely diagnosed. These cases arealmost incredibly numerous and, from the adminis- ’,trative point of view, are very difficult to deal with. ’,Yet their successful handling would probably do more ito stamp out tuberculosis than any other single Imeasure. The Memorandum suggests that " it willusually be to the interest of the patient that the case

should be referred to the tuberculosis officer, both inorder that a second opinion may be obtained on thediagnosis, and in order that there may be no avoidabledelay in giving the patient the benefit of any facilitiesavailable under the scheme of the local authority fordiagnosis, treatment, or general care and supervision."This advice is, on the whole, sound, and it will be stillmore helpful when the tuberculosis service is staffedonly by specialists in tuberculosis and not by medicalofficers of health who act as part-time tuberculosisofficers and who have little or no special knowledgeof tuberculosis. The Memorandum also lays downcertain rules in order that there may be no doubt as towho is responsible for the treatment of a patient at anyparticular time. In the past the patient has beenapt to fall between two stools, represented by thetuberculosis officer and the insurance practitionerrespectively.The Costs of Residential Tuberculosis Institutions.A document, which promises to become an annual

institution, has been published by the Ministry ofHealth under date December, 1923. It shows intabulated form the cost of running the various publicinstitutions for tuberculosis in this country. Thesetables are guaranteed to provide much disciplinaryheart-burning and heart-searching, and they show ata glance that the administration of certain institutionsis conducted on much more economical lines than thatof others. Indeed, in some cases economy would seemto have been raised to such a high, or reduced to sucha low, level (it all depends on the point of view) thatit is natural to ask whether efficiency has gone handin hand with economy. In one column the averagenumber of the staff to each 10 beds is published, andit is noteworthy that at one institution this numberis as high as 6.5, whereas in another institution it is aslow as 2-3. As for the cost of living, the fluctuationsare also great ; at one institution the average costper head for provisions is over 28s. per week, whereasat another institution this average is under 10s. It ispointed out that the information in these tables maybe of substantial assistance in enabling the authoritiesconcerned " to decide whether in a given case thevarious items of expenditure are on the lowest possiblelevel compatible with efficiency." The publication ofthese tables should have a salutary effect not only on.those institutions where expenditure is excessive, butalso on those, if such there be, where expenditure hasbeen reduced to a level incompatible with efficiency.

GYNÆCOLOGY AND OBSTETRICS INSCANDINAVIA.

THE twenty-fifth anniversary of the Gynaecologicaland Obstetrical Society of Copenhagen has recentlybeen celebrated by a special number of ActaGynœcologica Scandinavica,1 to which Danish andSwedish specialists in gynaecology and obstetrics havecontributed 17 original articles. Some are of strictlylimited interest ; a paper on the occurrence ofeosinophil cells in the appendix of the feetus andnew-born infant is not calculated to be of interest tomany. But several of the papers are of both generaland scientific interest, and they show, among otherthings, how closely Scandinavian gynaecologists are intouch with the outer world.

The Place of Cœsarean Section in Obstet1’ics.There are two papers with this heading, and the

authors represent opposite schools of thought. Prof.Elis Essen-Möller, of Lund, Sweden, discusses the risksof rupture of the scar of the classic Caesarean sectionwhen the patient is again confined, and he holds thatthe importance of this risk has been exaggerated. If

asepsis is maintained, and linen or silk sutures areused instead of catgut, there should be little chanceof a weak scar being left. As for the choice betweenthe classic and cervical sections, he finds that in

1 Vol. ii., fasc. 3, 1923.

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aseptic cases the two operations are about equallysafe for the mother and infant; it is not yet possibleto decide whether the scar in the uterus is more firmafter one operation than the other. In defence ofthe classic operation he stresses its special advantagesin cases of placenta prsevia, in certain other emer-gencies rendering it absolutely necessary to removethe foetus at once, and in the case of elderly primi-parae. But in cases suspected of sepsis he is not infavour of the classic operation, and of the twoalternatives-the transperitoneal and the extra-peritoneal cervical sections-he much prefers theformer. Even when a case has been definitely septic,he notes that, according to the literature, better results,as far as the mothers were concerned, have beenobtained with the transperitoneal than with the extra-peritoneal operation. This has surprised him, for hehad expected that germs would be more dangerous inthe peritoneum than in the connective tissue, and thata phlegmon must be less serious than a peritonitis.At his hospital Csesarean section has been performedin 132 cases since 1900, the chief indication beingdisproportion between head and pelvis (95 cases).Of the nine foetal deaths, seven had occurred beforethe operation. Another foetal death was due tocongenital malformation of the foetus, and theremaining foetal death was due to defective ligature ofthe umbilical cord, the infant bleeding to death.Thus none of the foetal deaths could be laid at the doorof the operation itself. Among the maternal deathsthere was one from peritonitis, one from intestinalobstruction caused by strangulation of a loop of theintestine between a myoma of the uterus and thepelvis, three were due to eclampsia, and one wasprobably due to air embolism.The other paper on this subject is by Dr. Viggo

Esmann, who seems to find certain objections to thegrowing popularity of Cæsarean section. In cases ofhabitual death of the foetus a few weeks before term,he is in favour rather of inducing premature labourthan of performing Caesarean section. He takes thesame line when difficult labour at term is anticipatedon account of slight disproportion between the headand the pelvis. In 1916 he gave an account of 23 casesin which premature labour had been induced, andamong these cases there were only four foetal deaths,to two of which prolapse of the cord contributed.Since 1916 he has induced premature labour in 24 casesbecause he anticipated mechanical difficulties, and ofthe two infants who died, one was malformed and notviable. All the mothers left hospital in good health.Hence his conclusion that this procedure was moresuccessful as well as more natural than the moreradical undertaking of a Caesarean section would havebeen.

Treatment of Dystocia Due to Bandl’s Ring.Dystocia due to Bandl’s ring has recently been

characterised as a figment of the imagination, butProf. B. Hauch refuses to subscribe to this agnosticteaching and states that since the obstetricalservice B of the Rigshospital in Copenhagen was started some dozen years ago, 25 cases of dystocia fromthis cause have been observed among about 20,000confinements. In 12 of these cases the diagnosis of ’,Bandl’s ring was confirmed by abdominal palpation.This revealed a distinct furrow in the uterus which, ’,in one case, was so marked as to give the uterus anhour-glass shape. In the rare cases in which this Icondition is diagnosed early, he is in favour of givingmorphine and waiting for at least an hour in the hopethat the contraction may pass off. He adds thewarning that the morphine may render the infantoligopnoeic at birth, artificial respiration beingnecessary for some time. In most cases, however,matters have proceeded so far that it is necessary toterminate labour as soon as possible, and the courseto be followed must depend on whether the infant isalready dead or not. In the former case, forceps maybe applied or perforation and basiotripsy performed.Another procedure is decapitation with version andextraction. If-, however, the infant is- still alive, andthe case is not already septic, the best procedure is

transperitoneal cervical Cæsarean section. If thisoperation is contra-indicated, an attempt should bemade to bring down an arm and apply forceps.

Kielland’s Forceps.The arguments for and against the use of Kielland’s

forceps are discussed by Dr. Oscar Horn, who has usedthem in 70 cases. He also summarises the bulkyliterature on the subject. He naturally finds that theauthorities who have used these forceps extensivelyare greatly impressed by their superiority over otherforceps, whereas the opponents of the Kielland forcepshave either not used them at all or only seldom. Dr.Horn concludes that Kielland’s forceps undoubtedlyrequire a more accurate topographical diagnosis aswell as more practice than the older and simplerforceps, but when these two conditions are fulfilled,Kielland’s forceps may be most helpful in cases ofdifficult labour. He had only one maternal death(pulmonary embolism on the fourteenth day) amonghis 70 cases, and only six fœtal deaths. When he firstbegan to use these forceps, he fairly often found aclear-cut mark close to the external canthus of oneeye, but during the last few years he has not seen thismark. In three or four cases there was slight transitoryfacial paresis, but only in one case did it last as longas eight days.

Diagnosis of Pregnancy by the Induction ofGlycosuria.

Dr. F. Jensen traces the development of these testsfor pregnancy since 1920, when Frank pointed outthat the administration of 100 g. of grape sugar bythe mouth on an empty stomach provokes glycosuriain pregnant women but-not in others. Subsequentlytwo other tests have been devised, both of which alsodepend on the fact that the capacity for assimilatingcarbohydrates is reduced in pregnancy. One of thesetests, associated with the names of Joseph andKamnitzer, consists of injecting 2 mg. of phloridzin,which provokes glycosuria in the pregnant but notin others. The other test, that of Brinitzer andRoubitschek, consists of inducing glycosuria by aninjection of adrenalin after 10 g. of grape sugar havebeen given by the mouth. Dr. Jensen has worked withFrank’s test, which he has modified, and instead ofgiving 100 g. of grape sugar in every case, he gives1 g. for every kilo of body-weight. He comes to theconclusion that though the blood-sugar examinationsrender this test tedious, and at present suitable onlyfor hospital practice, it is remarkably trustworthy,giving useful information in cases of threatenedabortion as to whether the foetus is dead or alive.The phloridzin test may be easier, as it is notnecessary to carry out blood-sugar examinations,but only when it is negative is its evidence of value.

The Ultimate Results of Menge’s Hysterorrhaphia.Dr. W. Ottesen, of the Diakonissestiftelsens

Hospital in Copenhagen, has investigated the subse-quent fate of the patients on whom Menge’s hysteror-rhaphia was performed in the period 1909-20. Hesucceeded in tracing 55, 40 of whom were re-examinedin his own hospital, 10 were re-examined elsewhere,and 5 sent a written report of their health after theoperation. Among the 50 who were medicallyre-examined, there were only two showing a definiterelapse, and in neither of these cases was the uterusso much retroflexed that its fundus lay at the bottomof the pouch of Douglas. It was also found thatsubsequent pregnancies and labours had not beendisturbed by this operation, the technique of whichwas described in 1904.2

Spurious Perforation of the Uterus.Dr. H. Wulff records a remarkable case which may

bring some consolatory reflections to obstetricians whohave pleaded guilty to perforating the uterus whilecuretting it for an abortion. Dr. Wulff’s patient was amarried II-para, aged 39, who suffered from incompleteabortion in the eighth to the tenth week of pregnancy.Examination under ether anaesthesia showed the

2 Centralblatt f. Gynäkologie, No. 21, 1904.

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cervix to be soft, the external os admitting the tip ofone finger. The body of the uterus was anteflexed,anteverted, freely movable, and very soft. Dilatationwas started with Hegar’s No. 12. Some difficulty wasexperienced with Nos. 16, 17, and 18. Dilatationproceeded somewhat more easily with the largernumbers, and was continued up to No. 26. A curettewas now introduced to a distance of 14 or 15 cm., andsome placental tissue was removed. It was suddenlyfound that the curette could pass a distance of 23 cm.without encountering the slightest resistance in variousdirections. On bimanual examination the uterus wasso soft as to be hardly palpable. Perforation of theposterior wall of the uterus was diagnosed, and

hysterotomia anterior vaginalis was undertaken. Itwas found that the cervix had not been injured, andwhen a finger was introduced into the uterus, its relaxedwalls could be felt definitely contracting. The foetusand some placental tissue were removed, and theinterior of the uterus was carefully explored bypalpation. At no point could any perforation befound. Though the patient’s recovery was delayedby protracted fever, a malodorous vaginal discharge,and pneumonia, there were no signs of peritonitis,and she was ultimately discharged as cured, withsatisfactory involution of the uterus and mobility ofits appendages. Dr. Wulff assumes that this was acase of relaxation of the uterus and not of perforation,but he admits that, not having removed the uterusfor examination, he cannot swear to its freedom froma perforation.

This special number of Acta Gynœcologica Scandi-navica also contains an account, by Dr. J. Fog, of acase of considerable medico-legal interest. It wasthat of a female infant, found alive on a railway line,10 minutes after an express train had passed. Thoughboth parietal bones were fractured, death did notoccur till six hours after the infant was found. Themother had evidently been overtaken by precipitatelabour while in the lavatory of the train. This andmany other papers make the anniversary number ofthis journal interesting reading.

SWITZERLAND AND THE OPIUMCONVENTION.

(FROM OUR OWN CORRESPONDENT.)

AT the last assembly of the League of Nations ISwitzerland was severely criticised by Dame Edith ILittelton, the British delegate, for not having yetjoined the Opium Convention. As a matter of fact,the Convention was signed in 1913 by the SwissMinister at The Hague, but it was never ratified bythe Federal Parliament. The reasons for this failureare several. One is constitutional. Legislation ongeneral hygienic matters belongs to the cantons.The Federal Government cannot on its own powerregulate the production and traffic of certain drugs.This belongs to the sphere of the different cantons.This constitutional difficulty was the cause that thequestion was allowed to sleep. As the drug-habit ispractically unknown in Switzerland public opiniondid not take much interest in the Opium Convention. ’,On the other side there was the opposition of certainchemical industries which feared a considerabledamage through the regulations of the Convention.Naturally in a small country like Switzerland thecontrol would be much more effective than in a countrywith vast colonial possessions. It was feared thatwhile inflicting an enormous damage on one of ourflourishing industries the ultimate scope of theConvention would be frustrated by the Great Powerstolerating drug-production on a large scale in theircolonies. This lack of confidence found recentexpression by Dr. A. Jaquet. professor of pharmacologyat the University of Basle. Prof. Jaquet writes :-" Whoever studies the question since the opium wars

cannot deny that this is a great enterprise of internationalhypocrisy ; the States interested in opium production and

opium traffic are hiding their fiscal interests under a humani- ’

tarian cover. The Opium Conference of Shanghai and theConference at The Hague of 1911 were summoned with thedefinite object to suppress with all means the production ofand traffic with opium. With time this object vanishedin the background as the States interested in the opiumcommerce formulated so many conditions for their coopera-tion that the war against the opium pest become more orless illusory. Instead, the Conference concentrated its effortsmore and more on the regulation of production and trafficof the alkaloids of opium and of cocaine with the object ofcurtailing both.... I am of opinion that it would be bestif each country would deal separately in combating the misuseof morphia and cocaine without taking refuge in an Inter-national Convention of which the great would take butsmall notice and which would crush the small."

I have quoted these words of an impartial observer.His views are shared by many Swiss not in the leastinterested in the chemical trade. In the last years,however, opinion is coming round in favour of aspeedy ratification of the Convention. This change isprobably due to the influence of the League of Nationson the Opium Commission. The Federal Councilhas lately been strongly attacked both in the pressand in Parliament for moving so slowly in thismatter. Under this pressure the Federal Council hasprepared a Bill on narcotic drugs which will shortly

’

be submitted to Parliament. When this Bill hasbecome law the Convention can be signed. Waivingsome constitutional scruples the Government basesthe Bill on a paragraph in the constitution empoweringthe Federal Council to take legislative action forcombating epidemic diseases. The Bill, which isdated Dec. 12th, 1923, provides for the supervision ofimport, export, production, manufacture, storage,purchase, sale, and distribution of the following drugs :opium in all its forms, morphia and its salts and allpreparations containing more than 0-2 per cent. ofmorphia ; heroin, its salts and preparations contain-ing more than 0-1 per cent. of heroin ; coca-leaves ;cocaine, its salts and preparations containing morethan 0-1 per cent. of cocaine. Production of and tradein these drugs are only allowed with a Governmentlicence. Export to other countries which have signedthe Convention is only granted if the addressee hasa licence for his respective country. This Bill maybe taken as a clear indication that the Swiss Govern-ment intends to carry out loyally and scrupulouslythe provisions of the Opium Convention.

NOTES FROM INDIA.

(FROM OUR OWN CORRESPONDENT.)

Delhi: National Baby Week.IMMENSE activity is being shown throughout India

in connexion with a National Baby Week which isbeing held in all parts of the country during the thirdweek in January. The " Week " is celebrated atDelhi so as to coincide with the meeting of the Legis-lative Assembly, and an effort is being made to directthe attention of India’s new legislators to the appallingloss of human life which is going on throughout thePeninsula. As is well known, on an average 400babies out of every 1000 born alive die before theycomplete their first year in the great Indian cities.and the rate is often much higher.With a view to preventing the outbreak of plague

in Delhi, the Public Health Commissioner with theGovernment of India has worked out a scheme forintensive rat destruction and the closing down ofexisting grain stores and their replacement by rat-proof buildings, but although the municipality iswilling to provide half the cost of the proposedmeasures their execution is held up for want of helpfrom the Government.The recently founded University of Delhi, at which

the Inchcape axe is levelled, issued its first report atChristmas. The report forms an excellent apologiafor the University’s existence, but there is alreadya flourishing university at Lahore, less than 300 milesaway.