878

cons as set out in the official journal of the IncorporatedSociety of Hospital Officers.The least of the junior officers in a hospital is the

office boy, who is in some cases recruited from thestaff of messenger boys, and of whom one, at least,has risen to the position of secretary at a provincialhospital. Many junior hospital officers will neveradvance far on account of lack of initiative, education,or ambition ; some may be influenced unduly by thesuggestion of overtime and the alleged benefit oftrade-union membership. Although the junior officeris not the 30s. a week clerk which he was before thewar, he still tends to remain junior officer. In regardto the higher posts, undoubtedly the successfuladministrative officers of hospitals are those who havepassed the acid test of public school and universitytraining. The Rockefeller scheme of training, however,hardly seems to meet the need in this country. Thesuggested nine months’ course followed by four monthsof practical work in hospital and two months spent invisiting other hospitals would certainly be usefulpreparation, but the’aspirant for executive distinctionwould still have to be prepared to start at the bottomof the ladder. Administration of a large hospitalmay involve keeping the peace between conflictingfactions, disciplining the unruly, exercising tact anddiscretion, and generally bringing a mature mind tobear upon decisions. Nevertheless there will bepractical agreement that the general hospital doesprovide facilities for educating additional personnelof which more use might be made at the present time.

THE FAILURE OF VACCINATION WITH LIVETUBERCLE BACILLI.

WHEN a physician, who for years has advocated aremedy, recants his praise of it, it is fairly safe to drawtwo conclusions. The first is that he must be an almostincredibly honest man. The second is that hisrecantation is justified by events ; we do not repudiateour offspring unless and until they have proved quiteunworthy of us. More than two years ago Prof. H.Selter,l of Konigsberg, was so hopefal of the benefitsaccruing to the subcutaneous injection of live, butattenuated, cultures of tubercle bacilli, and so con-vinced of their harmlessness, that he injected 2 mg. ofsuch a culture into his own thigh. Hyperpyrexiafollowed, and a swelling of the size of a fist turned intoa cold abscess which was evacuated three weeks later.No tubercle bacilli could be found in the fluid pus, andthere was no swelling of the neighbouring lymphaticglands. Since then he has prepared for subcutaneousinjection a solution which he called " vital tuberculin,"and which contained attenuated living tubercle bacillias well as the protoplasm of crushed tubercle bacilli.The question he asked himself was : Will this prepara-tion have other or better effects than those of oldtuberculin ? If not, there is no reason for preferringit to the old tuberculin of guaranteed sterility. Hedistributed his " vital tuberculin " among 52 physi-cians, 25 of whom tested it on 352 patients, to whomaltogether 3686 injections were given. Inquiries wereaddressed to them concerning any ill-effects the livecultures might have had on the patients, and a requestwas made for a comparison between the effects of" vital tuberculin " and old tuberculin. It transpiredthat abscess formation had followed 44 injections, butin no case had tubercle bacilli been microscopicallydemonstrable in the pus. The subcutaneous inocula-tion of a guinea-pig with the pus of one of these casesdid not generate tuberculosis in it. These abscessesdid not, apparently, exercise any ill-effects on thetuberculosis from which the patients were alreadysuffering, and one physician, who had given morethan 900 injections, had found them to be welltolerated. But-and this is the point Prof. Selteremphasises with all the force that italics can convey-the conclusion to be drawn from his colleagues’ testsis that the action of live tubercle bacilli depends

1 Deut. med. Woch., Sept. 8th, 1922.

solely on their tuberculin content; live tuberclebacilli injected subcutaneously in small quantities intoan organism already infected with tuberculosisexercise no other function. They cannot, he arguec,increase the immunity already present in the body,and they act simply as specific stimulants in the sameway as the various tuberculins. So, though thisprocedure is practically harmless to the alreadyinfected organism, it is no advance on treatment bythe injection of sterile tuberculin. Though it canhardly be expected that this paper will discourageFriedmann and his followers, it will be read withinterest by the many who have tried to keep an openmind on this subject.

VACCINIA OF THE EYELIDS.

ACCORDING to Dr. J. M. Ball and Dr. N. Toomey,1of St. Louis, who report a case in a girl aged 5 years,about 80 cases of vaccinia of the eyelids have beenrecorded in the literature. Only 25 per cent., however,of these cases were due to vaccinated persons inoculat-ing their own eyes, as in the writers’ case, the remainderbeing due to vaccinators, mothers, nurses, and othersinfecting their eyes from the vaccination vesicles ofsomeone under their care. In addition to these casesthere have been eight in which the cornea was

accidentally the primary seat of inoculation. In the80 cases of palpebral vaccinia the cornea was involvedby extension in about 10 per cent. The class of casescaused by hetero-inoculation-i.e., inoculation ofvaccine matter from the arm or leg of one person on theeye of another-occurs 20 times oftener in adults thanin children, 90 per cent. being in women on accountof vaccinated children being mostly under their care.On the other hand, cases of homo-inoculation occuralmost without exception in young children. Theclinical appearances of palpebral vaccinia are notquite the same as those of vaccinia on a dry skinsurface. Owing to the macerating effect of continuouslacrymation the vaccine lesion soon loses its vesiculatedepidermis and acquires a more yellowish or creamytinge even before the epidermis is detached than whenthe lesion is on other skin surfaces. After detachmentof the epidermis the base does not become coveredwith thick tenacious crusts, but has something of adiphtheritic appearance. As lacrymation subsides theulcerated base becomes covered with a thin, glazed,reddish-brown crust. In view of the degree of scarringcaused by primary vaccinia of the skin, the prognosis ofsecondary vaccinia of the eyelids is usually surprisinglygood. Severe complications, however, may arise whenthe conjunctiva or cornea is involved by secondaryextension. The loss of the eye has then been observed,and corneal opacities that interfered markedly withvision have been described. The palpebral deformitymay consist only of a small pale area of thin softscar with a loss of some cilia, as in the writers’ case,or it may amount to marked adhesions binding oneor both lids down to the globe.

THE MECHANISM OF EMPTYING THE

STOMACH.

THE accepted explanation of the mechanism bywhich the food is passed periodically out of thestomach into the duodenum is based on the relativecondition of acidity of the food, first on the gastricand then on the duodenal side of the pyloric sphincter.The acidity of the food on the gastric side is believedto cause a reflex opening of the pylorus, and theacidity of the food on the duodenal side causes itsclosure. Hence, until the acid food which arrives inthe duodenum becomes neutralised by the duodenaljuices, no further opening of the sphincter can takeplace. Dr. E. Egan, 2 of Szesed, states that as a resultof numerous examinations by means of the bariummeal on persons with all degrees of acidity of thegastric contents, he is led to the conclusion that the

1 Journal of the American Medical Association, Sept. 16th.2 Medizinische Klinik, Sept. 3rd, 1922.