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of gentian violet. Chen’s experience has been mostlywith the less extensive type of burn ; only five of hispatients were bad enough to be admitted to hospital.He does not use tannic acid but first cleans the burnwith boric-acid solution or normal saline, removingoily dressings, if they have been applied, with soap ;blisters are opened and loose epidermis cleared away.He then applies a 1 per cent. aqueous solution of

gentian violet (crystal form) to the affected area, andafter an interval of five to ten minutes applies thesilver-nitrate solution. The gentian violet is reappliedtwo or three times at fifteen-minute intervals, andwhen the surface has been exposed to the air for twohours the patient is allowed to go home. No directdressings are applied after the first treatment, theburns being either left uncovered or guarded byiron-wire screens covered with dry gauze. The dyeis reapplied once or twice on the second day, and thewounds are then covered with a dry dressing which isremoved for inspection daily for the first two to threedays, and after that only every four days. In casesknown to be infected with B. coli Chen replaces thegentian violet by a mixture of gentian violet, acri-flavine and brilliant green. He says that only thefirst dressing is painful, and healing is very prompt.The eschar formed with gentian violet is pliant anddoes not crack in the body folds or at the edges, butits removal is not always easy. Chen recommendssaline compresses to loosen the parts of the escharthat have not peeled off at the end of three or fourweeks, but Blackfield and Goldman have not beensatisfied with this method. They hold that any escharremaining after this period covers third- or deepsecond-degree burns, and that if it is merely soakedoff epithelisation will not take place. They favoursurgical removal of the eschar under light generalanesthesia, and preparation of the resulting raw areafor skin-grafting.

PITFALLS IN INJECTING FOR HERNIA

REPORTS on the injection of sclerosing solutionsfor the cure of herniae usually make little mention ofthe unpleasant results that may follow possibleaccidents. Perhaps most of these reports are writtenby the specially skilled, at whose hands accidentsdo not happen. Wernickel however feels it necessaryto emphasise the fact that injecting a hernia is not asimple matter like giving a hypodermic injection.The two most serious calamities which can occurare injection into the peritoneal cavity and injectioninto the deep epigastric vessels. Wernicke quotestwo deaths, reported by another writer, in which thesolution was injected into the bowel wall with result-ing gangrene, perforation and peritonitis ; he addsthat it is quite wrong to think that intraperitonealinjection is not of serious consequence. Injectioninto the deep epigastric artery may be followed bysloughing of the deep tissues. The obvious safe- *

guard is to withdraw the plunger a little way beforestarting the injection. All patients who experiencesevere abdominal pain after injection should betreated as potential cases of peritonitis and kept undercareful observation.(Edema of the cord, hydrocele of the cord, epididy-

mitis and dermatitis under the truss worn duringtreatment all seem to be of minor significance, but itis as well to recognise that they may occur. Abscessformation may be troublesome and does occasionallyarise even in skilled hands. Harris and White 2

report a series of 236 cases treated by injection with-

1. Wernicke, H. O., Surg. Gynec. Obstet. June, 1939, p. 1093.2. Harris, F. I., and White, A. S., J. Amer. med. Ass. 1938,

111, 2009.

out a single serious complication. No abscessesoccurred and no impotence resulted. They considerthat there is little difference in the fibrosis producedby the two types of solution in popular use-thosecontaining tannic acid in alcohol and those containinga fatty acid basis. It is perhaps as well to mentionthat the solutions in use for the injection treatment ofvaricose veins are not suitable. Wernicke believes,as a result of experimental work, that phenol-alcohol-thuja solution gives the most enduring scar tissue.

It is rather disappointing that these authorsall restrict the injection treatment to the smallindirect inguinal hernia in healthy patients, in factto the cases which most certainly give good resultsfrom operation. Harris and White have taken greatpains to analyse their results and compare them withresults of operation. The analysis is in favour of

operation. It has at times been urged that treat-ment by injection saves the patient time and money.This Harris and White are inclined to doubt; the

prolongation of the treatment and the number ofvisits entailed cause great inconvenience. Wernickethinks that 10 injections should suffice for most

cases, and that when 20 or 40 are required the casehas been badly chosen. He gives a good practicaltip to prevent the formation of subcutaneous nodules.The syringe should contain a little air above thesolution, and, after the injection, this air is forced

through to clean the needle before its withdrawal.

TETANUS ANTITOXIN

SOME contusion may still exist owing to the twounits employed for expressing dosage of tetanus anti-toxin. The international unit (LU.), adopted by thePermanent Commission on Biological Standardisation,is now used in this and many other countries, whereasthe American unit (A.U.) is still employed in theUnited States and elsewhere. The relation betweenA.U. and LU. is 1 : 2. The routine prophylactic doseat the beginning of the last war was 500 A.U., andthere was a tendency later to increase this to 1000 oreven 1500 A.U. The memorandum issued by theDirector-General of Emergency Medical Services lastweek (see Lancet, Sept. 2, 1939, p. 578) recommendsa prophylactic dose of about 2600 I.U., equivalent toabout 1300 A.U., or some two and a half times theold routine dose.

OXYGEN AND THE BRAIN

ALTERATIONS in brain metabolism-mainly andessentially a matter of the burning of dextrose-occurin the new " shock " treatments of schizophrenia, andmany attempts have been made to find in them theeffectual happening common to all these therapies.Some have assumed that cerebral anoxia is theanswer. 1 Russell Fraser and Reitmann 2 in thiscountry, and Himwich and his associates in theUnited States, have turned this interpretation to

practical account by causing in schizophrenic patientstemporary acute anoxia by the inhalation of nitrogen.The therapeutic value of the method is doubtful, butthe significance of cerebral anoxia remains an urgentquestion. Gerard,4 who has lately reviewed the wholetopic, would attribute the effect of thyroid treatmentin schizophrenia to its power of increasing the rateof respiration and the use of sugar in the brain; heregards the low basal metabolic rate and the relativeinsensitiveness to thyroid of one group of schizo-

phrenics as prima-facie evidence of lowered brain

1. See Lancet, 1938, 1, 37, 210.2. Fraser, R., J. Neurol. Psychiat. 1939.3. Himwich, H. E., Alexander, F. A. D., and Lipetz, B., Proc.

exp. Biol. Med., N.Y. 1939, 39, 367.4. Gerard, R. W., Arch. Neurol. Psychiat., Chicago, 1938, 40, 985.

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metabolism. He suggests that as the cortical brainpotentials are increased in rate and amplitude afteracute anoxia, there is neuronic stimulation eitherduring the early stages of decreased oxidation or

" on

the rebound " after it ; hypoglycsemia acts much likehypoxia on the function of the brain, leading to thissecondary " overshooting " with increased activitywhich may be the basis of the therapeutic action.Gerard would attribute the improvement in the

schizophrenic to the increase in the respiration of hisbrain which may be so caused, and points to thefindings of Kerr and of Ghantus 5 that the neurologicalcomplications of hypoglycsemia correspond less tothe hypoglycaemia in the blood than to the glycogencontent in the brain.That there are difficulties in the way of accepting

cerebral anoxia as the common feature in Cardiazol,insulin and other physical methods of treatingschizophrenia may be seen from the study by Stone 6of the effect of various drugs upon the lactic-acidcontent of the brain in mice. These small animalswere chosen because they could be plunged into liquidair and frozen instantaneously without the anaes-

thetics and surgical procedures, or the post-mortemchanges, which would interfere with accurate estima-tion. Stone found that during insulin convulsionsthe amount of lactic acid in the brain is significantlydecreased, and that a similar decrease sometimes takesplace during severe insulin hypoglycsemia without con-vulsions ; a decrease also occurs during anaesthesia. Ifconvulsions are induced with cardiazol, however, thelactic-acid value in the brain remains normal or is

significantly increased ; picrotoxin produces an

increase, too, above the level that can be attained innormal mice after strenuous exercise, and in cyanideconvulsions the increase is large. But during nicotineconvulsions there is no significant alteration in theamount of lactic acid in the brain.

These striking differences between the effects ofcommon convulsants and those of anaesthetics or

hypoglycaemia deserve attention. Although themechanism of glucose katabolism in the brain is stillobscure, certainly an alteration in lactic-acid contentin one direction is not easily made compatible with theview that much the same disturbance of oxidative

activity in the brain is taking place then as when thelactic-acid change is in the opposite direction. Stone’s

findings also run counter to Quastel’s 7 hypothesis thatthe anaesthetic action of drugs-as employed in thecontinuous narcosis method of treatment of psychoses-is due to specific inhibition of some part of anenzyme system concerned in the oxidation of carbo-hydrate products, such as lactate ; if that were so,one would expect an increased lactate content duringanaesthesia, whereas Stone found it to be lowered.

Stone discusses various hypotheses to account forhis observations, such as that the lactic-acid contentis dependent on the activity of the tissue, being highestduring convulsions; or that analeptics inhibit somepart of an enzyme system, as in Quastel’s explanationof the action of anaesthetics, but the readings obtainedfor nicotine convulsions are not consonant with eitherof these hypotheses. Since, moreover, normal or lowreadings for lactic acid in the brain were obtained inconditions, such as ether anaesthesia and insulin con-vulsions, in which there is a high proportion of lacticacid in the blood, it is presumably not from the bloodthat the extra lactic acid in the brain during picrotoxinor cardiazol convulsions is derived. Stone mentionsthe possibility that in the latter two conditions the

5. Kerr, S. E., and Ghantus, M., J. biol. Chem. 1936, 9, 116.6. Stone, W. E., Biochem J. 1938, 32, 1908.7. Quastel, J. H., and Wheatley, A. H. M., Ibid, 1934, 28, 1521.

high values may be due to circulatory disturbancesresulting in cerebral anoxaemia : this would leaveunexplained the readings in hypoglycaemia. It isevident that cerebral metabolism is a field for activeresearch in psychiatry as well as in physiology.

SURGERY OF GALL-BLADDER AND BILE-DUCTS

THE history of the surgery of an organ is not onlyof interest in itself, but in addition it frequentlyconveys valuable lessons which, by analogy, can beapplied in other directions. With this in mind,Prof. Grey Turner opened his Lettsomian lectures 1on the surgery of the gall-bladder and bile-ducts witha survey of the history of the subject. The later phasesin the development of the surgery of the bile-passagesare made particularly interesting by the author’s

personal knowledge of many of the pioneers. Withan experience of 1040 operations on the gall-bladderand bile-ducts to his credit, Grey Turner’s opinionsnecessarily carry much weight. Having lived andoperated throughout the period of the great " chole-cystectomy versus cholecystostomy " controversy,such an experienced operator still has occasion some-times to employ the latter operation. His warningquotation from a friend that " a living problem isbetter than a dead certainty " might well be takento heart by the type of surgeon who sets out to removethe gall-bladder at all costs, and whose skill is some-times no better than his judgment.

It is a surprise to find Professor Turner statingthat in his experience cholecystitis apart from gall-stones is an uncommon disease in this country. Itis not clear with what diagnosis he would label thelarge number of patients with flatulent dyspepsia,tender gall-bladder, positive cholecystographic evi-dence, and possibly infection of bile taken from theduodenum. There is still considerable controversy asto whether the acutely inflamed gall-bladder shouldbe operated on as a matter of urgency or should be

allowed, if it will, to subside before operation isundertaken. Professor Turner is on the side of earlyoperation, but advocates simple drainage in preferenceto removal. His reasons are the added risks of

bleeding, the increased danger of injury to the ductsand the possibility of later sclerosis of the commonduct, if cholecystectomy is carried out in the presenceof acute inflammatory changes. It is a complimentto the sound judgment and careful presentation offacts in these lectures, that one regrets what is notthere. In particular we should have welcomed theauthor’s views on the many pathological and clinicalproblems associated with cholesterosis, but on thismatter he has contented himself with a brief referenceto the uncertainty of the results of cholecystectomyfor " strawberry gall-bladder."

1. Turner, C. Grey, Proc. Med. Soc. Lond. 1939.

A " France " pension of f:30 per annum will be filledshortly by the council of Epsom College. Candidates mustbe fully qualified medical men of not less than 55 years ofage, whose income, independently of any allowance fromthe Royal Medical Benevolent Fund, does not exceed f 100a year, if single, and JE150 if married. Two or more St.Anne’s scholars will also be elected by the council. Candi-dates must be fully 9 years of age, and must be orphandaughters of medical men who have been in independentpractice in England or Wales for not less than 5 years.The value of each scholarship is dependent upon the meansof the applicant and the locality and fees of the schoolselected. Forms of application for the pension and

scholarships may be had from the secretary of the college,49. Bedford Square, London, W.C.i, and must be com-pleted and returned by Oct. 15.