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ANNOTATIONS

SHOULD FIRE INQUESTS BE REVIVED?LAST month a protracted trial ended in the con-

viction of a gang of fire insurance swindlers. Theystocked premises with over-insured goods, lit theirfires, and made their fortunes at the insurance com-panies’ expense. So large were the sums involvedthat the danger to human life was almost overlookeduntil Mr. Justice Travers Humphreys sternly remindedthe prisoners of this aspect of their criminal activities.The ease with which these audacious conspiracieswere engineered must have been a painful shock tothe public. We were told how a solicitor’s suspicionswere aroused, how he and his allies devoted monthsto the sole task of shadowing the suspects, analysingtheir bank accounts and business transactions, howthousands of one pound notes (" the currency offraud ") were traced through many hands, and howby almost superhuman patience and industry thewidespread crimes were revealed to the satisfactionof a jury. Would the criminals have enjoyed so longan immunity if coroners held inquests upon out-breaks of fire ? ‘? It is common knowledge that thewisdom of our ancestors originally entrusted thisduty to coroners, and that in many cities the coronercontinued to exercise this jurisdiction until litigationover a Manchester fire in 1860 gave the High Courtthe opportunity to declare that non-fatal fires wereno business of the modern coroner. We know alsothat the City of London Fire Inquests Act of 1888sanctioned a local survival of the old jurisdictionand that the late coroner for the City, Dr. F. J. Waldo,carried out this duty with exemplary care and witha firm belief in its service to the public, investigatingsometimes as many as 150 fires in the year even

though inquests were held in only a small proportionof these cases. In 1910 the Home Office Committeerecommended that what was good enough for theCity of London might well be made available foradoption elsewhere. After the war the LondonCounty Council asked that its coroners should be

given powers of fire investigation, but disagreementon details caused Parliament to postpone attentionto the proposal pending general legislation whereofnothing has since been heard.With an admirable public spirit the principal

insurance companies undertook the heavy respon-sibility and cost of the recent prosecutions. It isnot a question of commercial interests only. Arsonin crowded centres means the jeopardy of humanlives. Would this risk be diminished if coroners

were given back their ancient powers of fire inquiry ?To this question Dr. Waldo’s experience answers

with a confident affirmative even if the comparativestatistics of fires in London and elsewhere does notsupport the conclusion that the special legislationfor the City has conferred any noticeable immunityfrom fire outbreaks. It was Dr. Waldo’s practice tocall accountants and fire experts to give evidence.The proceedings in his court usefully drew attentionto dangerous structures, and the lack of properfire escapes and appliances. He has lately statedthat his records show 25 fire inquests held in the

City in the year 1921 in no fewer than 11 of thesea verdict of arson was returned. One such inquestrevealed the work of an alien who was afterwardsconvicted and deported. In another case the coronerhimself, on a prompt personal visit to the scene,discovered an empty petrol can. On this occasionHarris, one of the gang recently convicted, wasclosely examined, and the coroner decided to watch

his future association with such matters. Later thesame man’s name was mentioned in connexion withanother fire ; but the outbreak had occurred, perhapssignificantly, just outside the City boundary, andtherefore was beyond its coroner’s jurisdiction. Theobvious difficulties of accumulating evidence for thepurposes of the recent trial enable us to appreciatethat ordinarily the police can take no action uponmere suspicion. A magistrate will not act until adefinite case is established. On the other hand, thecoroner, both by preliminary inquiry and by formalinquest, has authority to act judicially in siftingmatters of suspicion. As no individuals are neces-sarily accused before a coroner, the scope of an

inquest is untrammelled by the restrictive rules ofevidence which apply elsewhere. The publicity ofthe coroner’s court must in itself be in some measurea deterrent. Our eyes have been opened to theperils of arson ; we can hardly afford to neglect anyweapon which may serve to defeat the fire-raiser.

SODIUM NITRITE IN HIGH BLOOD PRESSURE

INASMUCH as the kidney function is impaired insome patients with raised blood pressure, either as aprimary or secondary event, it is important to knowwhat effect, if any, drugs used with the object ofreducing pressure will have on this function. S. Weissand L. B. Ellis have noted the effect of sodiumnitrite on cardiovascular and renal function innormal people, in essential hypertension with andwithout renal involvement, in glomerulonephritis,and in patients from whom one kidney had beenremoved. They first studied the symptoms pro-duced by large doses (3 to 5 grains), and found thecommonest to be headache, weakness, giddiness, andfaintness, the latter verging on unconsciousness inextreme cases. However, severe symptoms were

seen in only about one-sixth of the patients. Theheart-rate was usually increased by a few beats perminute, but the minute volume output of bloodremained practically unaffected. The reduction ofblood pressure with sodium nitrite was found to begreater in the hypertensive than in the normalindividuals, although when expressed as a percentageof the initial pressure the drop was about the samein both. The reduced pressure was maintainedrather longer in the hypertensive patients, thougheven in them it did not exceed two hours. The fallinvolved the systolic to a much greater degree thanthe diastolic pressure ; it averaged 35 mm. Hg inthe hypertensive cases, but occasionally the reductionwas very great, for example, from 240 to 80 mm.,such a fall being usually though not invariablyassociated with pronounced symptoms. The effectsof the nitrite on renal function were the same in allgroups of patients. Studied with the urea-clearancetest-i.e., output of urine per minute multiplied bythe ratio urine-urea concentration/blood-urea con-

centration-this function was never found to be

improved after exhibition of the drug ; it was eitherdecreased or more commonly unaffected.The conclusion reached from the investigations

that sodium nitrite lowers blood pressure by a directaction on the smooth muscle of the larger arterieswas based on the unchanged cardiac output, therelative stability of the diastolic pressure, and theabsence of flushing of the skin ; the last two observa-tions are arguments against a dilatation of the smallerarteries, arterioles, and capillaries. Severe symptoms

1 Arch. Intern. Med., July, 1933, p. 105.

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are explained by supposed selective action of the

drug on different vascular areas, e.g., fainting in a

patient in whom splanchnic arteriolar dilatation isrelatively pronounced, while the cerebral blood flowis impaired from a lack of corresponding arteriolarrelaxation. This selective action is attributed to

physiological differences in the tissues concerned,but in diseased conditions another factor may operateto cause variable responses-namely, local vasculardegeneration. In view of the inconstancy and shortduration of its action, its failure to dilate arterioles,and a tendency to produce unpleasant symptoms,the authors consider sodium nitrite to be unsuitablefor the treatment of high pressure cases. Moreover,since it may diminish renal function, its use in anycase with damaged kidneys is held to be irrational.

REAL AND IMAGINARY CONSTIPATION

THE well-worn subject of the vagaries of thehuman bowel is reviewed with humour and sanityby Dr. Robert Cooped Although he refusesto be frightened by the bogy of intestinalintoxication, he nevertheless recognises that, whenthe condition does exist, it requires treatment onmedical lines, surgery being contra-indicated unlessthere is chronic mechanical obstruction. The taskof the physician, he holds, is to prevent undigestedor partially digested protein from reaching the largebowel and putrefying there. This can be done byrestricting the meat intake, and by giving pancreaticjuice. Growth of putrefactive bacteria is said to bediscouraged by a lacto-vegetarian diet, while carbo-hydrate fermentation can be delayed by the givingof large amounts of lactose, and certain tough fruitssuch as dates may help. Drugs are less important,though calomel, an alkaline powder containinglactose, and Burney Yeo’s chlorine water mixture

(without quinine) are recommended. Bowel lavageis condemned as harmful. Dr. Coope’s suggestionsare simple and practical, and should be of serviceto the practitioner daily confronted with the problemof constipation, whether real or imaginary. " If Idon’t get my bowels open at least once a day I feelmiserable," is a statement with which he is only toofamiliar, and he may be tempted to wonder, with Dr.Groddeck, whether this feeling of misery is not some-times purely psychogenic. Few of us, from our nurserydays, have escaped warnings of the dire results of a" blank day." It may well be that this constant

propaganda causes an obsession about constipationwhich is a greater danger than constipation itself.

CONTROL OF TRAFFIC IN NARCOTIC DRUGS

A NEW supervisory body has been set up, under theConvention of 1931, for limiting the manufacture andregulating the distribution of narcotic drugs inaddition to the League of Nations Advisory Com-mittee on Opium and Dangerous Drugs and thePermanent -Central Opium Board. The personnelconsists of Sir Malcolm Delevingne (British), Mr.Herbert L. May (American), Prof. Tiffeneau (French),and Dr. H. Carriere (Swiss). It will be their dutyto see that the quantity of the drugs manufacturedis limited to the estimates of medical requirementssupplied in advance by the several governmentsnot later than August 1st in each year. No countrywill be permitted to manufacture drugs in excess ofsuch estimates ; imports and exports will be inter-nationally controlled, and checked ex post factoby the annual statistical returns.At the recent session of the Permanent Central

Opium Board at Geneva the present situation in

1 Liverp. Medico-Chirurg. Jour., 1933, xli., 51.

China was regarded as disquieting. Not only hasthe disturbed state of the country led to recultivationof the opium poppy, but it is notorious that for yearsChina has been flooded with large quantities of

morphine and heroin smuggled from abroad. A newand most disturbing feature, however, is the establish-ment of clandestine factories of the alkaloids invarious parts of the country. Discoveries of illicitfactories of morphine have been made in the westerndistrict of Shanghai, in Tientsin and at or near

Dairen. The advisory committee in reporting tothe Council of the League of Nations justly observedthat " nothing but the effective control of the produc-tion and supply of raw opium will render impossiblethe establishment of works of this kind in districtswhere opium is grown or is easily available." In

response to the appeal of the Chinese delegate a

subcommittee has been appointed consisting of

representatives of the interested powers to cooperatewith China in suppressing illicit traffic and factoriesof narcotic drugs as well as to assist in the campaignagainst the use of prepared opium as contemplatedin chapter iv of the Hague Opium Convention of 1912.

ARE CHILDREN’S HEART HOSPITALS JUSTIFIED?

THE doubts held by a substantial body of peoplewhether the huge expenditure on sanatorium treat-ment is justified by results are now being reflectedin discussions on the value of special convalescentheart hospitals for children. At the recent annualsession of the American Medical Association, Dr.W. D. Stroud and his co-workers in Philadelphiabrought forward observations on 458 children withrheumatic heart disease cared for at the Children’sHeart Hospital in Philadelphia over a period of tenyears. Of these 98 are known to be dead (21-4 percent.), while 138 are back at school and 22 are work-ing ; 20 are unable to work because of heart trouble,22 for other reasons, and 7 are in hospital.Unfortunately, it appears from the tables that151 of the children have not been followed up,so that the total mortality and morbidity may verywell be more than is stated. It is interesting to note,however, that a comparative study in this countryby Carey Coombs over a similar period also gave amortality-rate of 21-4 per cent. In the Philadelphiagroup a large number of children (124) stayed inhospital less than two months ; this group includedmany children, overwhelmed by infection, whonever should have been sent from the wards of a

general hospital to this special institution, and suchpatients were usually returned to the city hospitalswithin a few weeks. In the course of the discussionon these figures Dr. A. G. Young expressed disappoint-ment that despite the care and money expended and" the best treatment we have to offer " nearly 50 percent. of the children were either dead or helplesslydisabled. It is therefore important to examineDr. Stroud’s results in detail to see what advantagesthese " heart hospitals " provide and what methodsmight be adopted to improve the results obtained.An alternative discussed by Dr. Stroud that in viewof the rarity of the disease in tropical climates themoney used for institutions should be devotedinstead to transferring the affected children to thetropics until they are past the age of puberty maybe dismissed as impracticable. The educative valueof the heart hospital system on parents has beenstressed, but it is surely possible to teach parentshow to handle children with defective hearts throughrheumatic supervisory centres, as is being done on

1 Jour. Amer. Med. Assoc., August 12th, p. 502.