860

chance of danger he likes to keep down the number of nurses

immediately concerned in the operation to a minimum.

There are, too, more well-trained nurses now than formerly,and one of these can rapidly render any bedroom of fair sizeas favourable an operating theatre for all ordinary proceed-ings as that of any surgical home. For these reasons, unless

the operation has to be done at very short notice, a surgeonwho can send his nurse into the house 24 hours before the

operation may usually count on success in a patient’sresidence just as surely as in a nursing home. Moreover,in a private house his nurses are under his own control,whereas in a home it is not unknown for the authority ofan ill-trained matron, who is constantly on the spot, to bear

adversely upon the directions of the surgeon.From the patient’s point of view to go into a nursing

home offers this great advantage, that his own house

is spared the inevitable disturbance that an operationdemands, as well as the continual inconvenience of

harbouring one nurse, if not two or three. The nurses,

however, presuming that they are of a kind now

happily becoming common, will soon be found to add

to the convenience of the household, and the upsettingof the house for the operation will not be of much momentunless it is a very small abode. Unhappily, it is justin these instances that a nursing home is likely to be outof the question for pecuniary reasons, which brings us

to a second criticism of the institutions. In spite of the

large number of homes there is no doubt need of one, in

London at any rate, where patients could be received belong-ing to that large class who are not suitable for hospitaltreatment and yet cannot afford the expense of a surgeon’sfee, in addition to the hotel charges during the long periodnecessarily passed in a surgical home if the operation is one of

any severity. Except the saving of inconvenience in his ownhouse there is no advantage offered by a nursing home thata patient in well-to-do circumstances cannot get if he is in

the hands of a careful medical attendant who has providedgood nursing. There are, however, several disadvantagesfrom which he will be free. First of all he will be amonghis own people, and this is not simply a sentimental con-sideration. but often one of therapeutic influence. We are,of course, excluding all cases in which removal from familiar

surroundings anu mu sympaLiienc rrienus is an essennai

part of treatment. Again, choice of food will be freer,subject to professional advice, and the manner in which itis served will be more to the patient’s taste than is possibleat any rate in most nursing institutions. Quiet, too, is farmore easily obtained in a private house than in a nursinghome, where there is an inevitable amount of constant move-ment due to the passing to and fro of nurses, the arrivaland departure of surgeons and physicians and anaesthetists,and the visits of friends. With regard to the visitors there isin some homes an amount of tyranny exercised that is

unknown to the medical man in charge of the case but is

very annoying to his patient. The matron may decide that

a patient is to see nobody on a certain day, and the veryvisitor may be refused admittance whose presence would

have favourably influenced the progress of the case.We have mentioned the surgeon’s point of view, in I

which must be included the great advantage to him of i

being able to see several patients in one visit to a home, i

that home being probably quite close to his residence.

We have considered the point of view of the patient. Now

there is a third aspect of the case requiring attention-

that, namely, of the general practitioner. When the-

patient is placed in a surgical home it often means

that visits entailing no exercise of particular skill

are paid by the operating surgeon, often a compara-tive stranger, rather than by the general practitionerto whom the patient is accustomed and by whom he

would be welcomed. The surgeon no doubt has said,"Come and see your patient whenever you like," but

perhaps the home is not within the practitioner’s usualround, and perhaps he knows that the patient will not

relish paying for two professional visits when only one isiiuuubzjztly. HHtH Ztluul-uluuulllullu EtLIUIJU6 Paitluuiuf M1UW-

ledge and skill the case is, of course, different; but in theledge and skill the case is, of course, different ; but in thevast majority of instances the general practitioner, fortifiedby the definite instructions which he will be careful to

receive from the operator, is perfectly capable of takingcharge of the case. He will naturally arrange for additionalvisits from the surgeon as may be necessary. The surgeonshould not overlook the point of view of his colleague thegeneral practitioner nor forget that the patient, whose

welfare and comfort are of course the main objects of both,may desire to see and consult his regular adviser. Such

are the pros and cons of the surgical home question. From

them, in our opinion, it becomes apparent that the main

objects desired-namely, the patient’s safety and comfortand the surgeon’s and practitioner’s convenience, will be

as well, and often better, met if the sufferer is nursed in

his own house than if he is bundled willy-nilly into thestrange surroundings of a nursing home.

On Coming Back.THE proper conduct of a holiday is a subject upon which

many writers have expatiated from different aspects. We

have pointed out in these columns the futility of making a

holiday only a change of work, and have urged upon

persons no longer in their first youth to refrain from rushingto Switzerland, immediately to climb mountains regardlessof the facts that their arteries are no longer so elastic

as formerly and that their heart muscle is somewhat

more easily tired than of yore. But if the changefrom work to play has its dangers so also has the

return from holiday-making to the daily grind of profes-sional or office work. The change in methods of life is not

properly appreciated, and in the desire to extend the holidayto its utmost limit the return journey is apt to be made at,the greatest possible speed, so much so that we know of

certain instances where the repatriated travellers have been

compelled to rest for a week to recover from fatigue.But allowing that the holiday has been a real holiday, a

time of rational enjoyment and of healthful exercise dulyadjusted to the physical condition of the holiday-maker,the return to work is often accompanied by attacks of ill-health. It is not at all uncommon in our experience forthose who return to London (or to any large city) from acountry holiday to complain of suffering from a form of

sore-throat. The explanation of this is probably to be foundin the presence of dust in the air ; and this dust, in London

861

at any rate, is mainly composed of horse-dung, particlesof wood, and the various débris to which four or five

millions of human beings constantly moving about

naturally give rise. All this foreign matter sets up

an irritation in the air-passages and pharynx. After

a residence of some weeks in the midst of a more or

less polluted atmosphere the tissues get acclimatised to

the irritation and the cough and sore-throat subside, but

they are one source of malaise which has to be looked forafter a holiday. We do not suggest that, because continuedresidence in a large town begets a certain amount of

tolerance, therefore it is of no avail to go away ; for

.although a holiday may make the tissues more responsiveto external irritation yet the same holiday increases theresisting powers of the body, so that it repels with greaterease the attacks of other poisons. Therefore too much

importance must not be laid upon the fact that many personswho felt in robust health while away on their holidays,upon returning have the sensation of being worse in healththan they were before they went away. Their natural dis-

appointment at these sensations can as a rule be justlyremoved by a few optimistic words. Yet again, too little is

made of the change from active exercise to sedentary life.

From passing most of his time in the open air engaged insome form of exercise a man turns suddenly to working inan office or study-in the case of members of our own pro-fession to going from one sick-bed to another. There is no

section of the community so notoriously careless of its

own health as is the medical profession, and while

its members would impress upon the returned worker to

.avoid errors in diet we doubt whether it is their habit to

be careful themselves in this respect. It cannot be too

much insisted on that, although on a holiday a large break-fast, a large luncheon, and a large dinner may be par-taken of with impunity, under the altered conditions of

the working life no such heavy feeding can be right. To a

man employed in fishing or shooting most of the day, or

to one who spends his time in walking or bicycling, a dose,of alcohol may give a feeling of contentment as well as

wholesome slumber at night, which it will completelyfail to do when the daily round of work is taken

up again. Properly enjoyed and used a holiday is of

illimitable use and if care be taken the return to work will

be felt to be all the more easy for the rest enjoyed duringthe vacation. But it is impossible to combine, as so manythink they can do, the brain expenditure of work-time withthe physical digestiveness of play-time. -

Annotations.

MR. BRODRICK’S COMMITTEE ON THE ROYALARMY MEDICAL CORPS.

" Ne quid nimis."

ALTHOUGH the report of Mr. Brodrick’s Commission on thereconstitution of the Royal Army Medical Corps is not yetpublished there can be no indiscretion, we think, in sayingthat the document, when it appears, will give considerable

pleasure to those interested in the branch of the service

concerned. The report will recommend that the Royal Army

Medical Corps should be in the hands of an advisory com-mittee, not an unwieldy one, to be made up of the Director-General, certain officers of the Royal Army Medical Corps,certain civilian medical men, and certain War Office officials.

The dignity of the position of the Director-General will, wehope, be preserved, while his responsibility will be lightened.Three changes will be suggested as making for the betterscientific education of the officers of the corps. A candidate

for the Royal Army Medical Corps, if on the verge of

holding an appointment as house surgeon or phy-sician, is to be allowed after passing his examina-

tion for the Royal Army Medical Corps to hold his

appointment and to count the term of office as partof his military service. By this wise recommendation theCommissioners attempt to secure for the service what may betermed the flower of the medical students. Study leave,which has always been somewhat of a farce, is to be done

away with, but in its place surgeons are to be gazetted tolarge provincial or metropolitan medical centres where theycan attend hospital practice and perform their duties as mili-

tary surgeons as well. Lastly, but not lastly in importance,the pay will be increased. The Commissioners have not

taken into question the Indian Medical Service at all. This

service is in no way touched by these recommendations, andno amalgamation of the Royal Army Medical Corps with theIndian Medical Service appears to have.been contemplated.

THE NEW CRANIOMETRY.

IN his Presidential Address delivered to the Anthropo-logical Section of the British Association Professor D. J.

Cunningham, while reviewing the features which distinguishthe brain of man from that of the higher apes, entered a

powerful but, many will think, a premature plea for thecareful consideration and, where possible, the revision, of

the present system of craniometry. Broadly speaking, thecranium under normal circumstances was considered to exertbut little influence ir. determining the head form, so that, hesaid, "in speaking of brachycephalic or short heads and

dolichocephalic or long heads we are merely using terms toindicate conditions which result from individual or racial pecu-liarities of cerebral growth." " Probably few anthropologistswould deny this, yet if followed to its logical conclusionthe cephalic or length-breadth index, for instance, shouldbe derived from measurements taken from the interior ofthe skull. This is Professor Cunningham’s view, which hesupported by the argument that "the measurement of thelong diameter of the cranium does not give the true lengthof the cranial cavity. It includes, in addition, the diameterof an air-chamber of very variable dimensions which is

placed in front." " A case in point was given. " Measured

in the usual way the Neanderthal skull is placed in the

dolichocephalic class, whereas Schwalbe had shown that ifthe brain-case alone be considered it is found to be on the

verge of brachycephaly," while Huxley was quoted to theeffect that no "safe basis for that ethnological cranio-

logy which aspires to give the anatomical characters of thecrania of the different races of mankind" will be found"until it shall become an opprobrium to an ethnologicalcollection to possess a single skull which is not bisected

longitudinally." While regretting that our present know-

ledge of cerebral growth and the value to be attachedto its various manifestations was still so far from com-

plete, Professor Cunningham held that since "the areas

of cerebral cortex to which man owes his intellectual

superiority are now roughly mapped out, the time has

come when the effect produced upon the cranial form by themarked extension of these areas in the human brain should