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first.attack among student nurses. It is thus possiblethat Dr. Myers is right in his contention that when.disaster occurs it does so for the most part in thebodies of persons who have already developed the

first infection type of tuberculosis, and that it isusually remote in time.

PAINLESS DENTISTRY

MEASURES devised to lessen the pain which occurswhen a tooth is filled must be easy of application,devoid of risk to the health of the tooth, and speedyin their use and effect. The busy dentist has to workto a time-table and methods which are so onerous asto demand a lengthy special appointment cannot beused as a routine. Long ago it was laid down thatthe discomfort of preparing a tooth for filling is

proportionately lessened if sharp tools are used, if themovements of the hand are deliberate and purposeful,- and the engine bur is not allowed to run until itbecomes hot. These very simple precautions willoften suffice to render the filling of a tooth free fromactual pain, although a stimulus which one personwill find trivial may be unpleasant or even unendurableto another. Various drugs have their uses on occasion :- eugenol or pure phenol placed in the cavity and- evaporated with warm air will sometimes lessen thepain for a few moments and can be renewed frequently.At best they mitigate pain rather than abolish it.A paste recommended by Lewin Payne, containingparaform, is undoubtedly useful, but cannot be usedin deep cavities for fear of irritation. The applicationof cold lessens the pain of excavating a cavity. Manyyears ago a spray of ethyl chloride on the tooth wasadvocated, but the pain produced by its evaporationproved almost greater than that of the drill. A finejet of oxygen under pressure was also tried, but themachine was cumbersome and the freezing was aptto cause after-pain and even permanent damage tothe pulp. More recently a spray of cold water onthe tooth has been found surprisingly effective ; thewater must be continuously applied and needs anassistant. The method is most suitable for accessible- cavities in anterior teeth, such as the sensitive holes.at the necks of teeth. A jet of compressed air,-available in most surgeries, is often equally usefulwithin the same limitations. Local anaesthetics whichplay so large a part in painless extraction have adistinct field in conservative dentistry, but a limitedone. The upper front teeth can usually be renderedinsensitive in a few minutes by a submucous iniection,but the analgesia is less complete in the case of theupper molars. In the lower jaw the density of theibone makes the effect of submucous injection uncer-tain. Regional injection of the inferior dental nerve-where it enters the jaw will usually result in complete.analgesia after 10 to 20 minutes, but the time is solong that the dentist who finds a lower tooth extremelypainful must either trench on the time allotted tothe next patient or make a special appointment ofsumcient length. Difficulties of this kind place adefinite limitation on the use of local anaesthesia inconservative dentistry. Another drawback is thatthe analgesia deprives the dentist of the warningconveyed by a sensitive pulp. The fact that thetooth is inert may tempt him to run the bur so quicklyas to become hot and damage the pulp. An exposureof the pulp may be made, and since the anaesthetietends to constrict the blood-vessels of the pulp, sothat there may be no bleeding point, the exposuremay pass unnoticed; and if the filling be thencompleted there may be severe pain when sensationreturns. If such errors are avoided, there is still a-xisk that the tooth may remain tender for a time

after a local ariaesthetic. Again, many patientsdislike intensely the prick of the needle, the woodenfeeling of the tissues when anaesthetised, and thesensation when they return to life. It may indeedhappen that, when a local anaesthetic is suggestedas a means of making the preparation of a sensitivetooth painless, the patient says frankly that he

prefers the pain to the injection. Yet with all itsdrawbacks this method has a greater field of usefulnessin lessening the pain of conservative dentistry thanany other device. In cases of extreme sensitivenessor with very nervous patients a light nitrous-oxideanaestbesia may be used to abolish pain, but this

handicaps the dentist in his work, and should onlybe used exceptionally. The wise dentist will employevery device to lessen pain in its appropriate place,but no physical or chemical method can supplant thepersonal factor. The sympathetic operator whoworks with a light touch and keeps his instrumentssharp, who knows the anatomy of the teeth so

thoroughly that his every stroke is purposeful, whowatches the unconscious reactions to painful stimuliand does not allow them to become unendurable,who above all can inspire his patients withconfidence and make them realise that he is the masterof the tools he uses-such an operator will make thedental chair, if not painless, at least tolerable to thevast majority of his patients.

THE VOLUNTARY BOARDER

THE tendency of all those engaged in reform of thelunacy laws is to encourage the system of voluntaryboarding in mental hospitals and to keep certificationas a last resort. Dr. H. L. Wilson, in a careful studyof the voluntary boarders admitted to The Retreat,York, points out that there are certain drawbacks tothe voluntary system which have not been given muchattention. He has- therefore set himself to classifyand elucidate these drawbacks by a study of theexperiences of The Retreat, where 837 persons wereadmitted on a voluntary basis between Jan. 1st, 1891,and Dec. 1st, 1930. As 134 of the patients wereadmitted on two or more occasions he had 1095admissions to consider-a number which wouldprobably have been greater had the fees of the

hospital been lower. The great majority were casesof melancholia (38 per cent.) or manic-depressivepsychosis (13 per cent.), followed by schizophrenia(7 per cent.), mania (7 per cent.), anxiety states andhysteria (6 per cent.), confusional states and alcoholism(5 per cent. each), and senile dementia (4 per cent.).Other conditions reached only 1 or 2 per cent. It is clear,Dr. Wilson remarks, that the types of psychosis fromwhich these patients were suffering would not ordin-arily be associated with clear volition. He pointsout that even paranoid and senile cases may sometimesbe suitable for voluntary admission, as the hospital andits routine may remain outside the delusional systemof the paranoid, and improvement is not infrequentlyseen in the senile-for instance in the acute confusionaccompanying a small thrombosis. A study of theresults of treatment shows that these are very similarin the certified and in the voluntary, but comparison iscomplicated by the relatively frequent departure of thevoluntary patient before full recovery has beenattained : 44 per cent of the boarders, but only 4 percent. of the certified, leave against the advice of those incharge. An unsatisfactorily high number of boardersleave while their prognosis is still good if they will stayin hospital but is doubtful if they leave. The number

1 Jour. Med. Sci., January, 1933, p. 102.

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of recovered and relieved voluntary cases cannot,therefore, be properly compared with the number ofthe certified, whose’departure is usually the-result’ofquiet decision and less associated with hurry andimpulse.

Dr. Wilson discusses the reason for this ratheruncertain state of the voluntary boarder in relation tothe different types of psychosis. The melancholic isanxious for admission, but his very dependence onothers increases his apprehension as soon as the

support of his family is removed, and until he hastransferred his affects to doctor or nurse he is all toolikely to feel that he has done wrong and to want toreverse his decision. The hypomanic, on the otherhand, confers a favour on the hospital by entering it ;he will march off if things are not as he would likethem to be and resent any suggestion that he is unfit todo so. Psychoneurotics give in their notice constantlyin order to attract attention to themselves. Dr.Wilson emphasises the importance of making both thepatient and his relatives feel that hospital is the bestplace for him. He analyses the motives, consciousand unconcious, which make the relatives doubt thewisdom of their decision and unsettle the patient inhis, and points out the value of spending time andtrouble in securing the cooperation of all parties fromthe start. The doctor, he thinks, is apt to under-ratethe strain imposed on the relatives even if he isprepared to take the necessary trouble to relieve theanxiety of the patient. The latter needs a sense ofsecurity, routine, and friendliness. The sense ofpowerlessness of the melancholic must be recognisedand relieved, and the hypomanic must be met on hisown plane, accepting his assertions and avoiding hisarguments.A very serious aspect of this departure against

advice is the possibility of subsequent suicide. Almosthalf the boarders who left in this way were melancholic,and 58 of them were deemed to be potential suicides ;14 of these actually ended their lives within ninemonths, and 2 nearly succeeded in doing so. Dr. Wilsoncannot escape the conclusion that the voluntarysystem allows a number of suicidal cases to leavehospital care where certification would retain them.The possibility of suicide is not easily recognised byrelatives and even the general practitioner plays apart in discouraging hospital treatment of cases of thiskind. One of the great advantages in the voluntarysystem recognised by Dr. Wilson is the possibility oftreating alcoholics and psychoneurotics who wouldnot be certifiable. Fifty-two of the cases admitted toThe Retreat were alcoholics, and 99 suffered fromsome form of psychoneurosis. The neurotic is willingto come for treatment and finds in hospital a routineand discipline which are unobtainable at home andwhich are of the greatest benefit to him.

THE LIVER IN "CATARRHAL" JAUNDICETHE mechanism of catarrhal jaundice has long

been in dispute, for opportunities of examining theliver have been few and far between. Particularinterest therefore attaches to a case described byDr. J. F. Gaskell.1 A child of 5, in apparent goodhealth, was operated on for tonsils and adenoids.There was a good deal of haemorrhage, and next dayshe was jaundiced and febrile. The jaundice increased,though the temperature fell to normal, and the childdied on the third day from uncontrollable haemorrhagefrom the throat. Subsequent inquiries showed thata mild epidemic of jaundice had been going on in thevillage where the child lived ; no evidence of spiro-chsetal infection was obtained. Post mortem the liver

1 Jour. Path. and Bact., 1933, xxxvi., 257.

was swollen, pale, and yellow. Microscopically therewas a general infiltration of the portal canals withpolymorphonuclear leucocytes and lymphocytes, mostmarked towards the final interlobular ramifications.The bile-ducts were everywhere patent, empty ofbile, and the epithelial lining healthy. The liver cells.were swollen and degenerated, with irregular nuclearstaining, and numbers had been detached in thesinusoids and were found in the hepatic and portalveins. The condition, therefore, is one of toxic

injury to the liver cells, and that this should cause:jaundice is easy to understand now that we knowthat the function of the liver parenchyma is not to.make bile-pigment but to pass it from the blood into.the bile-ducts. The case evidently- belongs to the.form of epidemic jaundice which is not due to spiro-.chaetes, and Gaskell points out that the more severeexamples may constitute what are generally knownas

" subacute " and " acute atrophy "-indifferent

names for varying degrees of liver necrosis; inSweden and elsewhere the association has actuallybeen observed.

UNIVERSITIES YEAR BOOK, 1933UNDER the guiding hand of Sir H. Frank Heath,,

the Year Book of the Universities of the Empiregains in completeness and usefulness from year to,

year. From its first appearance in 1914 it has aimedat presenting in handy form such information aboutBritish universities, of which there are now 70 or more,as is likely to interest members of other universities.and colleges, government departments, clubs, school-.masters, and the public generally. This year perhaps.the public has been served to especially good effect,,as the qualifications for admission to a universityin the first instance have been set out with great,fullness and clearness in an appendix of nearly 3Qpages. This information had previously been con-tained in two separate appendices and in paragraphsin the main part of the book under the severaluniversities ; but the conditions of admission, forbetter or for worse, are still so complicated that theycannot be set out other than as rather an inchoatewhole. Another substantial addition is the inclusionin this volume of the Memorandum and new Articles.of Association of the Universities Bureau, togetherwith the names of the representatives of the memberuniversities. Some of the other newly added appen-dices tend to grow, as, for instance, the list of,international federations and the useful short biblio-

graphy at the end. The register of names continues.to be a bright spot in every reference library, and th&indexing throughout is adequate. The Year Bookis published by Messrs. G. Bell and Sons at 15s.

ST. GEORGE’S HOSPITAL

St. George’s Hospital was founded in 1733, and the=Bi-Centenary will be made the subject of a specialcelebration. A thanksgiving service will be held onthe afternoon of Tuesday, June 27th, at St. Paul’s.Church, Knightsbridge, at which the Bishop of Londonwill be the special preacher. In the evening of thesame day a conversazione will be held at the hospitalat which it is hoped a large gathering of old St. George’smen, and of nurses who were trained or who haveserved in the hospital, will be present. On the

Wednesday of the following week a festival dinner will-.be held at the Mansion House, by permission of theLord Mayor of London, when an appeal for funds willbe made, and it is trusted that a strong appeal willmeet with a favourable response, for the institution is.sadly in need of money. We understand that there i&no need to wait for the festival dinner before sending a