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considerably more so that these American methodsare really impracticable here. Notwithstanding thisfundamental difference these drastic eradicationmethods are not without their supporters in thiscountry. Quite recently the West of ScotlandDivision of the National Veterinary Medical Associa-tion has issued a pamphlet entitled " Scheme for theEradication of Bovine Tuberculosis," which whilediffering in details from the American model is, never-theless, based on the same principles.

It is of interest to note that Dr. Hilton’s articleappears in the first number of a new periodical,the Journal of Dairy Research, which is financiallysupported by the Empire Marketing Board. LordPassfield, in a foreword, states that the journal isdesigned to assist dairy research workers in every partof the Empire, and is planned to include in each issuethree classes of material-namely, a monographby a leading authority on some broad question ofdairy research work, detailed papers of scientificinterest, and reviews and records of current scientificcontributions to dairy research. There is ampleroom for such a publication, and if later numbers areup to the standard of the first issue it should finda large and appreciative circle of readers. Theeditor is Dr. R. Stenhouse Williams, of Reading, whosename will be familiar to many of our readers in

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connexion with his work as Director of the NationalInstitute for Research in Dairying.

TREPANS AND TREPHINES.

FEW instruments employed in surgery at the presenttime have a more interesting and ancient history thanthe trepan. Its use dates back at least 2300 years,when Hippocrates first described the various instru-ments employed in his time in the operation oftrepanning. Even long before this period there isevidence that prehistoric man practised the operationby scraping away the bone with a piece of sharp flintor obsidian as the bushmen of Australia and thenatives of New Britain and New Ireland do at thepresent time. In the New World the Incas of Peru,from a period of antiquity, employed a flint with aserrated edge to remove the fractured bone, as shownin many skulls that have been excavated. Theancient Greeks used three kinds of instruments fortrepanning-viz., the terebra or borer, the terebraserrata or circular saw, and the perforator, which wasoperated with a bow drill. The first, which had aspear-shaped point, was employed when the piece ofbone to be removed was larger than could be coveredby the circular terebra serrata, and was operated bymeans of a thong twisted round the centre or attachedto a cross-beam. It was used for boring holes aroundthe piece to be removed, and when this was done thelenticular was introduced to break through the inter-spaces between each perforation, and the roundel ofbone then removed. The terebra serrata was a

conical piece of metal with a serrated edge, shapedsomewhat like a thimble, with a straight shaft risingfrom the top, and was operated by rapidly rolling theshaft between the palms of the hands. In thisinstrument we have the origin of the crown saw whichthe Romans adopted for their modiolus. They alsoemployed the terebra, which they operated with abow-drill, using a terminal with a sharp point whichsuddenly became broader, as described by Celsus.In the twelfth century Albucasis described an

instrument terminating in a spear-shaped headcalled " incisoria," and a borer with a sharp point,both of which were employed in his time for trepan- Ining ; while in the fourteenth century Lanfrancalludes to a borer with a spear-shaped point called a"

trepanon " for making a ring of perforations.In an interesting manuscript of the same periodby John Wryghtson, an English surgeon, there is adrawing of an instrument similar in shapl to theRoman modiolus with a circular saw and centre-pin,fixed to a straight handle, which was evidentlyoperated by rolling between the palms of the hands.

In the fifteenth century Bruynswyke described andlgured " trepanes

" terminating with a long gimlet-cike screw,

" to make small holes in the skull."Andrea della Croce, the Italian surgeon, in his work" Chirurgie " printed in 1573 devotes considerablespace to the operation of trepanning, and describesseveral instruments with a brace and drill-stock, towhich a circular saw or perforator could be fixed witha screw as occasion required, and the same type ofinstrument was used and described by Ambroise Pare.The first mechanical trepan was described by

Matthia Narvatio of Antwerp in 1575 ; this consistedof a horizontal beam with a cog-wheel in the centre,turned with a handle, that actuated the saws or

borers, which were fixed on a straight bar with a

screw. To Fabricius Aquapendente (1537-1619) isattributed the invention of the trephine, thoughWoodall in 1639 alludes to the trephine as " an

implement of my owne composing," it was figured byFabricius before his time. According to Savigny," The name trephine is so-called from the triangularform it acquires by the horizontal position of itshandle, in contradistinction to the trepan, in whichthe head or crown is affixed to a frame ()Ii[’ brace,similar to and used in the manner of the carpenter’swimble." To Fabricius is also attributed the intro-duction of the trepan saw with shoulders, whichprevented the instrument sinking down into themembranes of the brain ; although Ambroise Parefigures a brace or drill-stock with a binding screw tofix the saw, the drum of which was straight andsmooth, with a shoulder ’of a similar kind. Paredescribed " trepanes " as " round saws for cutting outa circular piece of bone with a sharp-pointed nail in thecentre projecting beyond the teeth." He also figuresa trephine which he says, " is most in use and thefittest, set forth by Dr. Crooke." In the seventeenthcentury Scultetus describes a trepan operated witha drill-stock which he calls " the handle," and alsomentions a trephine with a transverse handle to whichcircular, conical saws could be fixed.The eighteenth century marks a new era in the

history of the instrument, during which the trephinegradually replaced the trepan worked by means of abrace or wimble. In 1739 Sharp introduced histrephine with a wide transverse handle of steel, theextremities of which were roughened so that theycould be used as elevators. He claimed to be thefirst to use a trephine with a cylindrical in place of aconical, crown saw, with a key to remove the centrepin. Heister in 1743 says, " the moderns have amethod of fastening the crown on the trepan otherwisethan by screwing, but this is my way." He upheldthe use of the screw and the saw with a conical crown.He also describes an exfoliative trepan, the handleand saw of which were fashioned from one piece of steel.In 1779 Petit introduced his perforator with a steeldrill head, smooth and bevelled for drill edges, butthe head was shorter than Sharp’s. The type ofinstrument used at the close of the century is thusdescribed by Savigny in 1798. " It had a cylindricalsaw with a smooth drum, the barrel being insertedinto the handle direct. It had fine teeth withoutgaps, and the pin ran into a slot in the barrel regulatedby a binding screw and plate." The peculiar forma-tion of the teeth (exactly perpendicular) was claimedto be an important advantage to the operator. " Atthis time," remarks Savigny,

" the trepan used with abrace or wimble is now wholly laid aside in thiscountry." In 1801 Benjamin Bell introduced histrephine with a wooden cross-bar, into the middle ofwhich was screwed a steel key-barrel with a springgrip made to grasp a slot in the key-end of the trephinesaw. The chief improvement was in the saw, whichhad a cylindrical smooth drum, with long straightteeth arranged in three series of nine, three gaps beingthus left to let out bone dust, the forerunners of thewindows in modern instruments. The prismaticwas controlled by a thumb or binding screw andplate, which worked in a slot on the side of the barrel.Rudtorffer introduced a further improvement in 1817,by adding a screw button in the shaft by means of

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which the pin could either be raised or lowered. Fromthat period the shape of the trephine has practicallyremained unaltered, although the saw has passedthrough many modifications. Examples of theinstruments mentioned, illustrating the origin anddevelopment of the trepan and trephine from ancienttimes, may be seen in the Historical Section of theMuseum at the Royal College of Surgeons of England,to which an excellent guide1 has just been issued.

SPLENO-MEDULLARY LEUKÆMIA.

THE occasional association of spleno-medullaryleukaemia with trauma has been noticed ’from timeto time, and the injury has been regarded as animportant aetiological feature by more than one writer.Dr. S. C. Lewsen records a new case on p. 288 of thisissue and quotes a large number of other cases fromliterature. To these may be added one just reportedby Dr. Annelise Wittgenstein.2The patient, a railwayman of 42, had never been ill until

one day he fell on the ground and one of his mates trippedover him; The only apparent result was a slight effusion ofblood from the leg. He remained at home for a month.Soon after the injury he started to complain of pain in thefoot and loss of appetite, with heavy day sweats. Hesuffered from general debility and lost weight. Neverthe-less, he continued to work ’under regular medical super-vision for the next four mouths, during which time the causeof his poor condition remained undiagnosed. He died eightmonths after his injury, and the blood counts made inhospital admitted no doubt of the diagnosis of myelogenousleukaemia, the only unusual feature of the case being thenormal size of the spleen. The number of red cells and the Ihaemoglobin index were greatly reduced, the figures being1,600,000 and 35 per cent. respectively. The leucocyteincrease, as is usual in the acute condition, was moderate, thecolmt giving only 20,000.

It proved impossible to ascertain whether thepatient had substained a blow in the region of thespleen, but Wittgenstein thinks that a severe shaking,especially if combined with contusion of the abdomenand the long bones, may be enough to lead to leuksemiain predisposed persons. He thinks that the cause is tobe sought in exogenous influences of toxic, mechanical,or infectious origin. The reference to " predisposedpersons " seems to bring this author nearly into linewith those who believe that trauma does no more thanreveal a pre-existent disease. This opinion is verywidely held. Prof. Salvatore Diez,3 for instance,who lately collected 30 cases of a supposed association,

Icame to the conclusion that they afforded no proofthat leukaemia could originate from a blow.

FIRST-AID IN ELECTRICAL ACCIDENTS.

IT cannot be too widely known that electric shockhardly ever causes death outright. Dr. D. Pometta,principal medical officer of the Swiss AccidentInsurance Institute, has recently given a usefulresume 4 of the various methods of treatment whichwill probably save the victim’s life if applied promptlyand patiently. Such measures should be as familiaras the first-aid treatment of the common forms ofpoisoning, and the practitioner living in a districtwhere accidents of this kind are particularly likely tohappen will do well to have his apparatus packed ina special case ready to take up at a moment’s notice.He should put aside all other work to answer the callto an electrical accident immediatelv, and should beprepared to stay by the patient for several hours.As soon as the victim has been removed from thedanger zone, his mouth should be freed from dirt andany other obstacle to respiration, such as artificial

1 Guide to the Surgical Instruments and Objects in the HistoricalSeries, with their History and Development. By C. J. S. Thompson,M.B.E., hon. Curator of the Historical Section of the Museum.With a foreword by the Conservator, Sir Arthur Keith, M.D.,F.R.C.S., F.R.S. London : Printed for the College and sold by Taylor and Francis, Red Lion Court, Fleet-street. 1929. Pp. 92.2s. 6d.

2 Med. Klin., 1930, i., 22.3 See THE LANCET, 1927, ii., 562.

4 Schweiz med. Woch., 1930, iv., 82.

teeth, and clothing should be removed from the upper-part of the body, preferably cut off to save time. Heshould be kept warm with blankets and hot-water-bottles or heated bricks, but zealous assistants mustbe warned of the danger of causing burns. The face-and chest may be splashed with water, the limbs andcardiac region may be massaged, and cardiac andrespiratory stimulants such as lobeline may be givensubcutaneously ; but none of these secondaryrequirements must delay or interrupt artificialrespiration-the essential treatment-for more thana few seconds. While pointing out that prompt andcorrect application is more important than the choiceof any special form of artificial respiration, Pometta.prefers the Sylvester method. Here he is in a

minority, for most authorities agree with Prof.S. Jellinek5 in recommending Schafer’s. He regards.

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manual methods as better than mechanical, but saysthat apparatus may be useful to replace assistantswhen everyone is tired out. Carbon dioxide is avaluable respiratory stimulant, and can be given froma soda-water syphon when no cylinder is available.The syphon is half emptied and a rubber tube isattached to its nozzle ; it is then inverted and thefluid is blown out of the glass tube. Gas is admittedto the patient’s air passages through one nostril,while artificial respiration is maintained continuously.Unless the patient’s other injuries are so severe thathe cannot possibly be alive, respiration must becontinued for at least five hours, and the absence of-the sounds of heart or respiration or of the cornealreflex are no indication that he is dead.

Sir Thomas Legge, who retired from the position ofSenior Medical Inspector of Factories in 1926, has.joined the staff of the Trades Union Congress as.

adviser to the Social Insurance Department on thehealth of workers as affected by conditions arising outof their employment. His work will lie primarilyin the prevention of industrial disease and disability,.and he will continue by pen and word of mouth tokeep the trade-union movement informed on theproblems of health in industry. There is undoubtedlya still untapped source of study and research in thesickness records of the big trade-unions in thiscountry.

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INDEX TO " THE LANCET," VOL. II., 1929.

THE Index and Title-page to Vol. II., 1929, whichwas completed with the issue of Dec. 28th, isnow ready. A copy will be sent gratis to sub-scribers on receipt of a postcard addressed to theManager of THE LANCET, 7, Adam-street, Adelphi.W.C. 2. Subscribers who have not already indicatedtheir desire to receive Indexes regularly as publishedshould do so now. _______

5 See THE LANCET, 1927, ii., 1001 ; 1928, ii., 314.

DONCASTER ROYAL INFIRMARY.-The report for theyear ending Sept.. 30th, 1929, shows that 1805 patients wereadmitted, who stayed for an average of 25-13 days, as com-pared with 23-4 days in the preceding year. New out-patients numbered 7143, an increase of 745 : there were3786 casualty cases and the attendances and treatments inthe massage department were 27,416. A supply of radiumto the value of 3000 has been given by Mr. William Nuttall.During the year Dr. H. J. Clarke, who has since died, cele-brated his fifthieth year of general practice in Doncaster andwas presented by his colleagues with a piece of plate. Dr.Clarke handed over to the hospital the balance of the Presen-tation Fund, amounting to .875, with the proviso that theincome should be used for the purchase of a medal to beawarded annually to the best nurse of the year. The well-arranged and informative report sets out that the cost perbed was 2129 8s. 9d., a reduction of 12s. 5d. The cost perin-patient was 98 16s. 10d., and per day 7s. 0. ; out-patients cost 9s. 6d. The first block of the new Infirmary,containing 150 beds, with accommodation for 85 nurses andmaids and the usual accessories, is approaching completion.The Doncaster Collieries Association has contributed£ 10.000 towards the cost.