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bound themselves not to compete with the medicalprofession. The evils of uninstructed and uncon-trolled physical therapy can only be overcome ifmembers of the Chartered Society receive the full

support of medical practitioners ; they depend fortheir livelihood on such cooperation which they haveset themselves to merit. The annual congress this

year of the Chartered Society is to be held in

Harrogate from Sept. 18th to 21st, and its scientificmeetings are open freely to medical practitioners onpresentation of their visiting cards. Among thesubjects to be discussed are : the treatment of hipsand spines at American orthopaedic clinics ; functionaldisorders and malingering ; fibrositis ; short-wavetherapy ; bone regeneration ; and the spa treatmentof rheumatism. All these topics will be introducedby medical experts.

CATARACT FOLLOWING THE USE OF

DINITROPHENOL

ANYONE who has followed recent medical writingon the subject must be aware that opinion on theplace of dinitrophenol and allied compounds in thetreatment of obesity is sharply divided. Some ofthe arguments were stated briefly in these columnsabout a year ago. It was admitted that certain ofthe nitrophenols are powerful stimulants of kata-bolism and are therefore bound to be effective in

reducing flesh. At the same time, it was pointedout that unpleasant symptoms and even death hadfollowed the indiscriminate use of these drugs, andreaders were reminded that the physician commandsno means of lowering a basal metabolic-rate whichhas been raised too far. There is still no generalagreement whether the undesirable symptoms en-

countered are specific toxic effects of the drug, orsimply expressions of excessively high metabolism,although it is not easy to attribute some of therecorded symptoms to the latter. Meanwhile two

papers from San Francisco 2 provide a strong argu-ment in favour of giving up the use of these drugsfor the present. They record six instances of cataractoccurring during the treatment of obesity withdinitrophenol; the patients were women in a periodof life when spontaneous cataracts are rare, the agesin five being 50, 36, 39, 40, and 30 ; the cataractswere bilateral and rapidly progressive, becomingmeasurably worse in periods measured by days andleading in more than one instance to almost completeblindness within a month. Two of the patients hadreceived the drug under strict medical supervision,a third had treated herself, and in the remainderno particulars are given. The authors of the papersurge that " further use of dinitrophenol should bediscontinued, pending further study on its secondarysystemic effects." It is possible, though very unlikely,that the cataract in these cases was due to somefactor other than the treatment. A less improbableexplanation is that the particular preparation of

dinitrophenol was contaminated with some unknowntoxic substance. But with the eyesight of a patientat stake, however slight the risk, the duty of thephysician is clear.

Our previous article concluded with the followingquestion : " Is it justifiable, in dealing with a condi-tion which almost always responds readily to a littlewholesome discipline (i.e., dietetic restriction), to

employ instead a drug of unquestioned potency but

1 THE LANCET, 1934, i., 746.2 Boardman, W. W.: Jour. Amer. Med. Assoc., July 13th,

1935, p. 108 ; Horner, W. D., Jones, R. B., and Boardman,W. W.: Ibid.

uncertain toxicity " The tragic accidents nowdescribed should resolve any lingering doubts aboutthe answer.

AIR RAID PRECAUTIONS

THE first of a series of handbooks on Air RaidPrecautions has just been issued by the HomeOffice. It is entitled No. 2-" Anti-gas Precautionsand First Aid for Air Raid Casualties." (H.M.Stationery Office, 6d.) The general preface to theseries of handbooks emphasises that their productionis a measure of precaution only, and does not arisefrom any belief that war is imminent. This particularhandbook has been written for those who would beengaged on first-aid services for the civil population,and especially members of the St. John AmbulanceBrigade, the St. Andrew’s Ambulance Associationand the British Red Cross Society. It deals with the

gases and other chemical agents which might beemployed in war, and indicates the probable methodsof their use. No suggestion is made that there arenew gases of exceptional potency. Two types of

respirator are described : the general service respiratoras issued to the Navy, Army and Air Force, and asimplified pattern designed mainly for personsemployed in civil air raid services. The last chaptersets out the organisation of a combined first-aid anddecontamination centre for members of the public.In addition to these handbooks the Home Office

promises a series of memoranda dealing with the

organisation of public air raid precautions by localauthorities.

MALIGNANT DISEASE OF THE GALL-BLADDER

Is the possibility of future malignant change agood reason for persuading a patient with gall-stonesto consent to operation ’? Dr. John F. Erdman/reviewing his experience of 525 gall-bladder operations.concludes that it is not. His argument is that,considered statistically, the patient’s chance of dyingas a direct result of his operation is higher than hischance of subsequently developing cancer in thegall-bladder. Among his 525 cases there were 15deaths-a mortality of 2-8 per cent.-but only 6

(1-1 per cent.) with malignant change. Erdmanwould have us, therefore, lay stress rather on thelikelihood of chronic ill-health or of repeated colicthan on the possibility of cancer. C. F. W. Illing-worth,2 on the other hand, maintains that the dangerof cancer developing is quite appreciable, and that,for the prevention of future malignancy, the benefitsof excision of the gall-bladder in all cases of calculuscholecystitis far outweigh the risk. The figures hequotes for the incidence of carcinoma following gall-stones-viz., 7-8 per cent. in 500-600 cases (Riedel),and 81 carcinomas in 592 autopsies on patientswith gall-stones (Fawcett and Rippelman)-are veryconsiderably higher. In all 5 of Erdman’s cases

in which operation revealed carcinoma of the gall-bladder, a stone or stones or biliary sand was alsopresent ; and in the single case of sarcoma therewere five stones. (Sarcoma is, of course, a veryremote possibility ; he found only 30 cases on record.)Of Illingworth’s 50 cases of malignant disease 31

definitely had gall-stones ; in 7 they were undoubtedlyabsent; in 12 there was no record of presence orabsence.

Illingworth is convinced that carcinoma of thegall-bladder is preceded in every case by cholecystitis.The patient will therefore tend to give a typical

1 Ann. of Surg., May, 1935, p. 1139.2 Brit. Jour. Surg., July, 1935, p. 4.

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gall-bladder history, with " flatulent indigestion,pain below the costal margin, and occasional attacksof biliary colic." Nausea he found to be a constantsymptom. The diagnosis of malignancy is very un-likely to be made until the abdomen is opened, sinceonly the presence of metastases can give definite pre-operative evidence. Erdman says that jaundice doesnot develop unless the liver is already invaded. Allhis cancer patients had the typical pain, in the usualsite and with typical radiation, and they laterdeveloped digestive disturbances. In one case, operatedon for a perforation of the gall-bladder, a suspicionof malignancy at the time of operation was notconfirmed by the pathologist’s report, but in 7tmonths secondary deposits had caused a recurrenceof pain and jaundice, and nothing could be done.In the solitary case of sarcoma a definite lump waspalpable in the right hypochondrium. Cholecystec-tomy was performed with ease ; the wall of the gall-bladder was 1-1 in. thick, and there were present init several large nodulated masses of a livid to purplishhue. While Erdman thinks that papillomata maybe a precursor of cancer, Illingworth holds that theybear no important relationship to one another.In the cholecystogram papillomata show up as

patches of decreased density ; one such case is illus-trated in Erdman’s paper. He is strongly in favourof cholecystectomy as the operation of choice indiseases of the gall-bladder. The danger of missinga carcinoma or papilloma in the simple drainageoperation is one of his main reasons for this opinion.In his own series, cholecystectomy was performed.522 times, and cholecystostomy 3 times.

Illingworth recognises four pathological types ofcarcinoma of the gall-bladder-the scirrhous carci-noma, which is the common type, the papillary, themucoid, and epithelioma (very rare). This last

type-an example of a squamous-cell growth occur-

ring in a columnar-cell epithelium derived fromectoderm-is to be regarded as arising by a processof metaplasia, the columnar-cells reverting to primi-tive form and, subsequently assuming squamouscharacters.

The Duke of Kent has appointed Dr. A. E.Gow, physician to St. Bartholomew’s Hospital, to bephysician in ordinary to his household.

Sir George Chrystal, secretary to the Ministry ofPensions, has been appointed permanent secretaryto the Ministry of Health, in succession to Sir ArthurRobinson. After fifteen years at the Health MinistrySir Arthur has accepted the chairmanship of theSupply Board, newly reconstituted with a view tothe needs of the Defence Services.

INDEX TO " THE LANCET," VOL. I., 1935.

THE Index and Title-page of Vol. 1., 1935, whichwas completed with the issue of June 29th, is now inpreparation. A copy will be sent gratis to sub-scribers on receipt of a post-card addressed to theManager of THE LANCET, 7, Adam-street, Aldephi,W.C.2. Subscribers who have not already indicatedtheir desire to receive Indexes regularly as publishedshould do so now.

CENTRAL LONDON THROAT, NOSE, AND EAR HOSPITAL.-Princess Louise, Duchess of Argyll, recently laid thefoundation stone of the nurses’ home at this hospital ofwhich she is president. The estimated cost of the newbuilding is 30,000, and E12,000 has already been sub-scribed. The site has been provided by an anonymousfriend who contributed E2000 for the purpose.

THE SERVICES

ROYAL NAVAL MEDICAL SERVICE

Surg. Comdr: M. Brown and A. H. Harkins to Victoryfor R.N.B.; and G. D. Macintosh to Vernon.

Surg. Lt.-Comdrs. F. B. Quinn to Victory for R.N.B. ;and M. Barton to Drake for R.N.B.; C. R. Boland toPembroke for R.N.B., temp., and to Woolwich (on commg.);J. J. Cusack, M.B., to Victory for R.N.B., temp., and toFaulknor ; and T. F. Crean, to Drake for R.N.B.; F. C. M.Bamford and W. A. Hopkins to President for course ;C. Keating to Drake for R.N. Hospl., Plymouth; G.Rorison to Victory for R.N.B. ; and W. G. C. Fitzpatrickto Pembroke for R.N.B., and to President for course.

Surg. Lt.-Comdr. (D) D. Barker to Woolwich.Surg. Lts. S. K. Foster to Pembroke for R.N. Hospl.,

Chatham ; and J. A. Page to Drake for R.N.B.Surg. Lts. (D) A. W. Y. Price and F. A. Pearse to rank

of Surg. Lt.-Comdr. (D).Act. Surg.-Lts. R. S. Jenkins, L.D.S., and W. J. Wolton,

L.D.S., to be Surg.-Lts. (D).

ROYAL NAVAL VOLUNTEER RESERVE

Surg. Lt.-Comdrs. R. L. Stubbs to Victory for R.N.Hospl., Haslar; and E. E. Henderson to Furious.

Surg. Lt. T. H. Pierce to Renown.

ARMY MEDICAL SERVICES

Col. T. S. Dudding, O.B.E., late R.A.M.C., havingattained the age for retirement, is placed on ret. pay.

Lt.-Col. G. F. Rudkin, D.S.O., from R.A.M.C., to beCol.

ROYAL ARMY MEDICAL CORPS.

Majs. to be Lt.-Cols. : W. P. Croker and E. W. Wade,D.S.O.

Capt. R. A. Bennett to be Maj. Jan. 29th, 1935. (Sub-stituted for notification in the Gazette of Feb. 8th, 1935,vide THE LANCET, Feb. 16th, 1935, p. 398.)

REGULAR ARMY RESERVE OF OFFICERS

Maj. Sir Robert G. Archibald, C.M.G., D.S.O., M.D.,having attained the age limit of liability to recall, ceasesto belong to the Res. of Off.

ARMY DENTAL CORPS

Lt.-Col. W. M. Ferguson, having attained the age forretirement, is placed on ret. pay.

Maj. G. F. Charles to be Lt.-Col.Maj. (prov.) A. H. Kay reverts to the rank of Capt.

TERRITORIAL ARMY

J. J. M. Brown (late Cadet, Edinburgh AcademyContgt., Jun. Div.), O.T.C., to be Lt.

Lt. A. C. Armstrong to be Capt.G. Carruth (late Offr. Cadet, Queen’s Univ., Belfast,

Contgt. (Med. Unit), Sen. Div., O.T.C.), to be Lt.

ROYAL AIR FORCE

MEDICAL OFFICERS AS PILOTS

An amendment to the King’s Regulations and AirCouncil Instructions provides that a medical officer whohas qualified as a pilot may, when facilities exist at theunit to which he is posted and provided he is medicallyfit, keep himself in flying practice. Unless, however, hehas flown solo during the preceding three months andhas had solo flying experience in the type of aircraftwhich it is proposed to fly, the C.O. will ensure that hereceives adequate dual instruction in that type before heflies solo.Wing. Comdr. R. W. Ryan to Central Medical Estab-

lishment for duty as President of the Central MedicalBoard.

Dental Branch.-H. M. G. Williams, L.D.S., is granteda non-permanent commission as a Flying Officer.

RESERVE OF AIR FORCE OFFICERS

Flight Lt. P. J. Nyhan relinquishes his commission oncompletion of service.