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secretion, and to symptoms not unlike those ofcarcinoma of the stomach. But in all these cases

ordinary X rays will show little or nothing.The treatment of physiological dyspepsia is to see

that the patient avoids articles of diet found to

upset him, to eradicate bad habits in eating, andto supply teeth if these are lacking. The treatmentof a dyspepsia born of an anxiety neurosis is in thefirst place to avoid such diagnoses as ulcer, chronicappendicitis, and visceroptosis. Gastric ulcer is

diagnosed too readily. The appendix is still removedmuch too frequently in people whose dyspepsia is

entirely nervous. Visceroptosis, a doubtful cause

of symptoms at any time, is a diagnosis from whichfew patients have ever recovered. Wholesale dentalextraction is advised much too lightly. The next

thing is to reassure the patient by careful examination,persuasion, and an X ray, if necessary, that no

structural lesion is present. It must be explained thatflatulence is due to air-swallowing and not to gasformed internally. Self-treatment, particularly overdieting and the taking of patent medicines, must bestopped. These patients have poor gastric tone,deficient secretion of acid, and over-secretion ofmucus. A dry diet is therefore indicated. Sodiumbicarbonate before meals will dissolve mucus andeliminates gastric secretion. Lastly, as these patientsare highly introspective, extroversion should be

encouraged, and for that there is nothing like somehobby or manual occupation. These patients requirediscipline rather than psycho-analysis. On the otherhand patients with early organic disease, incipientgastric or duodenal ulcers, or generalised gastritiswant frightening. The former will swallow medicinefor a week or two but when their pain disappears theytake no further precautions and no more medicineuntil the next attack. I am sure that such patientsshould be frightened into realising that they are

heading straight for ulcer, and that they shouldexercise reasonable dietetic restriction and takealkalis between meals for at least six months or a

year after all symptoms have disappeared. In this

way chronic ulcers may be prevented. But youmust not frighten the patient with nervous dyspepsiain this way-hence the importance of accurate

diagnosis. Hurst regards chronic gastritis as a

precancerous condition, and the treatment of chronicgastritis with achlorhydria as unsatisfactory. Onlya few do well on acid ; the majority do better onsodium bicarbonate before meals.

In conclusion let me remind you again that anydisorder of function may be due to poor physiology,an anxiety state of the mind, hysteria, organic disease,or have no real existence and only be a delusion in thepatient’s mind. Success in treatment depends onaccuracy in diagnosis.

SPECIAL ARTICLES

PARIS

(FROM OUR OWN CORRESPONDENT)

MEDICAL ASPECTS OF THE MARSEILLES ASSASSINATIONS

THE gunshot wounds from which King Alexanderdied were evidently such as to prove rapidly fatal.But it seems that Louis Barthou’s life might havebeen saved had he received skilled treatment in a

reasonably short time. Excelsior bluntly says thatif Barthou’s injured arm had been ligatured at oncehe need not have died. Though the assassin’sbullet had fractured a bone in the arm and woundedits main artery, Barthou was able himself to openthe door of the motor-car in which he had been shotand to walk to the Bourse where he found a taxi,which took him to hospital. Here the interne atonce put a ligature on the arm above the elbow, and,when surgeons arrived, Barthou was taken to theoperating theatre and anaesthetised. The woundwas cleaned and the fracture set. On beginning torecover consciousness, he was so weak that bloodtransfusion was undertaken, but death occurredat 5.45 P.M. Excelsior expresses amazement over thefact that it took 20 minutes to transport Barthoufrom the scene of the shooting (at 4.10 P.M.) to thehospital, and that, owing to the absence of anyemergency ambulance service, yet another 20 minuteshad to pass before he was given first aid. Thisabsence of medical preparedness at Marseilles iscommented on with much disgust in Paris where amunicipal councillor, Mr. Armand Massard, hasasked the Prefect of the Seine and the Prefect ofPolice if it would not be possible to assure the presenceof a medical service at all official meetings at whichpersons of distinction are present.

WELL-TO-DO PATIENTS IN PUBLIC HOSPITALS

The well-to-do patient (whether out-patient or

in-patient) in a public hospital raises one or other oftwo questions. If he pays nothing, he acceptsservices destined exclusively for the poor from whom

he is in a sense stealing. And if he pays, little ormuch, he is impaling the public hospital on the hornsof a forensic dilemma, for it is illegal for such aninstitution to develop any commercial activity.Pressure has been put on the hospital authorities toinduce them to discourage the well-do-do in their

patronage of the public hospitals in this sense ;and the director-general of the Assistance Publiquede Paris has recently addressed to the Parisian publichospitals a memorandum in which he points out that,thanks to the constant improvement in the publichospital services, well-to-do persons have taken

advantage of them in spite of being able to employprivate practitioners and clinics. Accordingly certainemployees of the public hospitals must henceforthinvestigate the financial status of patients who mayconceivably be well-to-do. Such persons will beasked to sign a statement and to produce documentaryevidence of their eligibility to receive free treatment.There are, however, five groups of cases to remainexempt from the effects of these instructions. Theyare (1) urgent cases, duly certified as such by adoctor ; (2) cases raising public health problems(venereal disease or tuberculosis); (3) street andoccupational casualties ; (4) the subjects of nationalhealth insurance ; and (5) war pensioners. The

public hospital which finds itself the embarrassedhost of a patient who has secured admission to it byan elliptical approach is to notify the head of theAssistance Publique who will dispense the sanctionscon venables.

INTRAVENOUS METHYLENE-BLTJE IN LEPROSY

On Oct. 2nd a report was presented by Dr. Marchouxto the French Academy of Medicine on the treatmentof leprosy on behalf of Dr. Montel, of Saigon. SinceNovember, 1933, he has given intravenous injectionsof methylene-blue to 172 patients suffering fromleprosy. Every form of leprosy was included in thisgroup. In early cases continuous improvement wasobserved, sleep and appetite returning and the ulcershealing. In cases of old standing, the rapid improve-

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ment observed at the outset was followed by a stageof relative stagnation from which most of the patientshad not yet emerged, although some degree of progresswas still being made. Dr. Montel is of the opinionthat no other treatment has hitherto been able toeffect such rapid improvement ; he finds the actionof methylene-blue at least three times as rapid asthat of chaulmoogra oil and its derivatives, over whichit has the advantage of being effective in all formsof disease. But the best results would seem to beobtained by a combination of methylene-blue withchaulmoogra oil treatment. From the public healthpoint of view it is interesting to note that opencontagious forms of the disease can be rapidlychanged into closed non-contagious forms by thistreatment. Though its mode of action is still

imperfectly understood, it seems that methylene-bluehas an elective affinity for leprous tissues-a conditionnot without its inconveniences, for the blue colourof the leprous lesions is distressing to patients anxiousto hide their condition. The selective discoloration,however, vanishes some six weeks after the lastinjection.

CANCER OF THE CERVIX

The anti-cancer centre of Marseilles, established in1927, has functioned regularly since the beginningof 1928. Prof. Leon Imbert has recently 1 analysedthe results of radiological treatment, according toRegaud’s technique, given to 252 cases of cancer

of the cervix during the years 1928-31. Of the 102cases dating at least five years back, only 12 could beclaimed as cures. It should however be noted that

every patient coming to the centre was treated, andthat 50 belonged to the fourth stage of the disease.There were indeed no patients in the first stage.Seven of the 17 patients in the second stage (41 percent.) and five of the 35 patients in the third stage(14 per cent.) could be considered cured, as judgedby the five-year test. There were no survivors amongthe 50 fourth-stage patients. Between 1928 and 1933inclusive, the proportion of early cases, in the first andsecond stages of the disease, had risen from 11 to 48 percent.-one of the most encouraging features of Prof.Imbert’s report.

AUSTRALASIA

(FROM OUR OWN CORRESPONDENT)

CATGUT AND TETANUS

IN Australia it has been the practice for most

hospitals and many private surgeons to buy rawcatgut and prepare it themselves, by the biniodidemethod. This method was used almost exclusivelyfor many years ; post-operative infection was

uncommon and post-operative tetanus was rarelyreported. The first suspicion that all was not wellwith this means of sterilisation, which for yearsappeared to have given satisfactory results, was thepublication of the Medical Research Council’sinvestigation by Bulloch, Lampitt, and Bushill.Even after this many surgeons maintained thatthe clinical results had been so uniformly good thatthey scarcely felt disposed to make a change. Aseries of deaths from post-operative tetanus has,however, necessitated further review of the situation,and the biniodide method has been almost generallyreplaced in New South Wales by the iodine method.Still there are a number of surgeons who stronglyoppose this change claiming that there are manygrave disadvantages in the use of iodine and that the

’ Presse méd., Oct. 10th, 1934, p. 1580.

case against catgut as a cause of tetanus, or againstthe biniodide method, is not proven.The main disadvantages of the iodine method are

said to be that it makes the gut slippery; that it

seriously interferes with its physical properties,including its tensile strength ; that it tends to preventits absorption ; and that the iodine in the tissuesacts as an irritant, causing the formation of serumand infection in wounds. One of the main pointsemphasised in the method of preparation, as outlinedin the Medical Research Council report, is that the

glycerin makes the catgut so slippery that knotscannot be tied with safety and that ligatures andsutures are liable to come undone, thus causingreactionary haemorrhage and post-operative hemiae.There can be no doubt that as regards gut preparedin Australia by this method there is some substancein these objections.The New South Wales Branch of the British Medical

Association in a letter to the Medical Journal ofAustralia (August 4th, 1934, p. 172) gives a reportby its section of surgery in which it is held to beproved, from the work of Bulloch, Cooper, Williams,and others, that spirituous biniodide is ineffectiveas a sterilising agent ; the section believes that themethod advocated by Bulloch, Lampitt, and Bushilland the modifications of it employed at the RoyalPrince Alfred and the Sydney Hospitals and at theRoyal Infirmary, Edinburgh (published in the

Edinburgh Medical Journal, April, 1934, by T. J.Mackie), is safe. The modifications of the iodinemethod by the Sydney and Royal Prince AlfredHospitals have been made with a view to the elimina-tion of the disadvantages mentioned above. Inboth the modifications the iodine solution is thesame as that recommended in the Medical ResearchCouncil report, except that at the Prince AlfredHospital no glycerin is used in the solution, or atany stage of the sterilisation ; further, after ten daysin the iodine solution, the gut is placed in repeatedchanges of 1 in 250 biniodide in rectified spirit andthen stored in this solution. In the Sydney Hospitalmethod, 5 per cent. glycerin is used in the iodinesolution instead of 10 per cent. as recommended in theMedical Research Council report ; the gut is then

placed in a decolorising solution of 85 per cent. alcoholand 5 per cent. glycerin, and after repeated changesof this solution it is stored in rectified spirit. Theletter from the British Medical Association concludeswith a full quotation of the Therapeutic SubstancesAct of Great Britain.The editor of the Medical Journal of Australia

devotes several pages to an instructive leading articleon the subject, in which it is revealed that ninecases of post-operative tetanus have been investigatedin New South Wales since 1930. These occurredat seven different hospitals ; the same brand of

catgut had been used in the first five cases, but in thewhole series five different brands had been used. Ashas previously been noted, in every case the operationhad been undertaken for the relief of an abdominalcondition, and in seven of the nine the biniodidemethod of preparation had been used. In only onecase was the tetanus bacillus recovered from thetissues. In this article reference is made to a papershortly to be published in the October issued of theAustralian and Netv Zealand Journal of Surgeryby Dr. C. H. Kellaway and Miss F. Eleanor Williams,who isolated tetanus bacilli from catgut which hadbeen used in operations followed by tetanus andfound that on injection some of these organismsgave rise to tetanus in animals. They state that