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manufacturers of insulin to avoid the chaos whichwould ensue if the firms concerned were to issue

protamine insulin possessing different degrees ofretarded action.-I am, Sir, yours faithfully,

FRANCIS H. CARR.The British Drug Houses Ltd., Graham-street,

London, N.1, Jan. 25th.

THE LEGAL POSITION OF HERBALISTS

To the Editor of THE LANCETSIR,-The summing up by Mr. Justice Atkinson

in the case of Sones v. Foster, tried in the Court ofKing’s Bench on Jan. 21st, calls, I think, for medicalcomment. The learned judge is reported in theTimes to have said that " Herbalists have been

recognised legally since the passing of a statute inthe reign of Henry VIII which has never been

repealed " ; and as the defendant in the case seemsto have claimed to be a herbalist as well as a

naturopath the inference to be drawn was that hewas exonerated by that Act as far as its applicationwent.

I recall a previous occasion when the learned

judge, Mr. Atkinson as he then was, evinced an

interest in unqualified practice, for he moved anamendment in the House of Commons on Feb. 9th,1926, to a motion which I had introduced: "That,in the opinion of this House, an authoritativeenquiry, with the object of making recommendationsto Parliament for dealing with the whole position ofirregular practice in medicine and surgery, is urgentlynecessary." Mr. Atkinson’s amendment was " Thatin the opinion of this House an authoritative enquirywith the object of securing the recognition andregistration of manipulative practitioners havingapproved qualifications is urgently necessary."With all respect I submit that the learned judge’s

exposition of the present position of herbalists isinaccurate and his description of the effect of thestatute incomplete. The history of this statute is

interesting. The first attempt to regulate medicalpractice in England was made by Act 3 Henry VIII,by which no person was allowed to practise as a

physician or a surgeon within the City of London ora radius of seven miles from it without examinationor approval by the Bishop of London, or, outsidethat area, by the Bishop of the diocese concerned.A curious survival of this prerogative of the bishopsis the privilege, still existing but never put intooperation, of the Archbishop of Canterbury to conferdegrees in medicine. The Act 34 and 35 Henry VIII,which is the Act referred to by the learned judge, wasapparently passed to allow certain persons toadminister medicines without having the licencefrom the bishops provided for by the earlier statute.The permission given by it for herbalists to practise

was limited to the use of external applications or,in the event of internal medication, to the treatmentof three specified diseases, " stone, strangury, or

agues." Judicial interpretations subsequent to thepassage of the Act declared limitations furtherrestricting its scope. Thus it was early laid downthat its effect is that " it does not extend either inwords or intent or meaning to give liberty to anyperson to practise or exercise for gain or profit."The parties licensed by that statute are " suchpersons as shall be good honest people, as old womenand such as are inclined to give their neighboursphysic from charity and piety " ; and indeed theoriginal Act contained the stipulation that the privi-lege should be restricted to those who " minister tothe sick without fee." As the original Act made noprovision for testing the knowledge of the herbalist

or for any responsible body to administer the Act,it remained practically inoperative and this circum-stance, as well as its implied supersession by laterMedical Acts, no doubt explains the omission to

repeal it formally.Surely any claim that the statute of Henry VIII

legalises the general practice of medicine and surgeryby herbalists and that their position is unaffected

by the Medical Acts which have since been placedupon the Statute Book could not be sustained.

I am, Sir, yours faithfully, -

E. GRAHAM-LITTLE.

PERFORATED GASTRIC ULCER

To the Editor of THE LANCETSIR,-The annotation on p. 216 of your last issue

on the use of "a hollow sound" by Dr. Robert

Leclercq, in treating a perforated gastric ulcer whichcould not be sutured, reminds me that it is someseven or eight years since I first employed a similarmanoeuvre. I do not suppose that the procedurewas " original " on my part, though it is not men-tioned in most books on operative surgery. Beingfaced, like Dr. Leclercq, with a large perforationwhich could not be closed, I introduced into thestomach a large soft rubber catheter which fittedthe hole. This was not employed afterwards, however,for emptying the stomach, for I pushed it on intothe duodenum, and used it for giving the patientlarge amounts of fluids directly into his alimentarycanal. The catheter was brought out through a layerof omentum and then through a stab wound in theabdominal wall. No leakage took place and after afew days, when adhesions had formed, the catheterwas removed and the opening quickly healed. I haveused the method on two or three occasions since thattime with the same success. Small perforations canoften be successfully " plastered" with a tag ofomental fat, but this method may fail when the

perforation is large. The catheter may then beemployed with confidence.There can be few surgeons in this country who

would contemplate the alternative of performing apartial gastrectomy in the presence of any perforatedulcer. To save the patient’s life is the first con-

sideration, without prejudice to whatever furthertreatment may be necessary afterwards when thecrisis has been passed.

I am. Sir. vours faithfully.GEOFFREY KEYNES.

OVERBREATHING TETANY

To the Editor of THE LANCETSIR,-We were much interested in the two papers

by Drs. McCance and Watchorn, and Drs. Cumingsand Carmichael in your issue of Jan. 23rd. Theseworkers record their failure to confirm some experi-mental findings published by us last year, and theirpapers call for some comments.

In the second case recorded by Drs. Cumings andCarmichael, the level of the calcium in the cerebro-spinal fluid (C.S.F.) rose from 4-2 mg. per 100 c.cm.to 4’4 mg. in eighteen minutes and to 4’8 in thecourse of twenty-eight minutes. Whilst these workersstate that the first alteration is within their limitsof experimental error, they do not say whether thisapplies to the total rise. If it does so their resultsin no way vitiate our own, for we recorded alterationsof only 0’5 mg. per 100 c.cm. and this would fallwithin their limits of experimental error.

There is no record in their paper of the volumesof C.S.F. used in their estimations of calcium. We

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ourselves calculated our experimental error in a

preliminary series of determinations on knownsolutions, and reduced it by using 60 c.cm. of fluidin each estimation. This necessitated the removal of15 c.cm. of C.S.F. from the patient for each deter-mination of calcium and phosphate. One of thereasons why we did not take our resting specimensimmediately before the period of tetany, but on theprevious day, was our fear that we might producesevere post-lumbar puncture headaches in our patientsif we removed as much as 30 or 45 c.cm. of C.S.F.within half an hour. The other reason was thatour first patient seemed to develop symptoms of

tetany gradually, and had premonitory symptomsand signs such as paraesthesise and Chvostek’s sign forfour or five hours before overbreathing brought oncarpopedal spasm and laryngismus stridulus. Itseemed reasonable to assume that during this periodchanges in the diffusible calcium might already havebeen occurring.

If this alteration recorded by Drs. Cumings andCarmichael in the C.S.F. calcium is outside theirlimit of experimental error it becomes of importance,for it shows that changes were occurring in the levelof the C.S.F. calcium during that period of twenty-eight minutes-although in a direction opposite tothat recorded by ourselves.

Clearly determinations of the ultrafiltrate calciumof the serum were desirable in our patients, but wehad not the facilities for overcoming the great practicaldifficulties involved in such estimations-as, for

example, keeping the serum in gaseous equilibriumthroughout the ultrafiltration. We were thereforeinterested to read that Drs. McCance and Watchornhad performed this determination (presumably onserum, although this is not made clear by them)but regret that experimental details were not given.

If one sets aside theoretical considerations as tothe mechanism by which the C.S.F. is formed, onwhich we do not find ourselves in agreement withthese workers, the experiments of Drs. McCance andWatchorn suggest that the drop which we found inthe C.S.F. calcium was not related to the tetanyitself. Were this the case the changes found by usand by Drs. Cumings and Carmichael would indicatethat the calcium content of this fluid does not remainconstant for any individual, but varies by as muchas 10 or 12 per cent. from day to day and from hourto hour. This would be of great importance in theinterpretation of the work which has been done, andis being done, on the calcium content of the C.S.F.in other conditions.We are not aware that such variations have

been reported.We are, Sir, yours faithfully,

C. G. BARNES,R. I. N. GREAVES.

WAS SHERLOCK HOLMES A DRUG ADDICT ?

To the Editor of THE LANCET

SIR,-I am writing to comment upon a recentreference in your columns concerning the characterof Sherlock Holmes, the fictional creation of myfather, the late Sir Arthur Conan Doyle, M.D.Your contributor’s interesting notes on cocaine

poisoning give the erroneous impression that Holmeswas a " drug addict." As a matter of actual fact,my father neither conceived nor depicted Sherlock

Holmes as a drug addict. He was represented as oneof those rare individuals who use drugs sparingly

and occasionally, and who are the masters ratherthan the slaves of the drug concerned.

It would be superfluous for me to emphasise theiifferentiation between the two categories.

I am, Sir, yours faithfully,DENIS P. S. CONAN DOYLE.

HOSPITAL AMALGAMATION IN LIVERPOOL

To the Editor of THE LANCET

SiR,-The alterations in the Liverpool UnitedHospital Bill, of which the secretary of the AssociatedVoluntary Hospitals Board gives particulars (p. 232),are interesting, especially the exclusion of the pur-chase of surgical instruments and appliances fromthe purview of the medical board. As regards therepresentation of sections of the medical staff on theboard my letter, in spite of the secretary’s assertionto the contrary, stated clearly that " there is a

power to coopt within limits of particular offices setforth in a schedule." The point, of course, is whetherthe old phraseology of legal documents referring to" medical and surgical staffs " is adequate in view ofthe development of special departments, especiallysince the establishment of the British College ofObstetricians and Gynaecologists.

I am, Sir, yours faithfully,C. E. A. BEDWELL,

King’s College Hospital, Denmark- House Governor.hill, S.E., Jan. 25th.

OMENTOPEXY

To the Editor of THE LANCET

SIR,-In Mr. O’Shaughnessy’s admirable accountof the surgical treatment of cardiac ischsemia, thereis one point that deserves correction. The authorrefers to the omentopexy of Rutherford Morisonas an operation for cirrhosis of the liver and -hecomments on this matter as though that operationmight be expected to influence favourably thisobscure disease. May I say that Drummond andMorison devised their operation not with the ideathat it might cure cirrhosis, but as a method of dealingwith the ascites, which may be such a distressingsequel of the changes in the liver When used forthis purpose alone, and in the circumstances whichthe authors of the operation indicated as beingnecessary to hold out a prospect of success, it hasbeen most valuable.

In showing its usefulness, may I be permitted tosay that the patient to whom Mr. O’Shaughnessyreferred and on whom I operated-and who is nowwell thirty years after the operation-was rapidlygoing downhill at the time of the intervention. Hewas accustomed to be tapped every fortnight andas a rule 22 pints of fluid were removed. A yearafter the operation he underwent a further inter-vention for the radical cure of hernia and for manyyears afterwards he was to all intents and purposesperfectly well and able to follow the laborious occupa-tion of a stoker in a gas works. For some yearsnow he has lived in retirement, but when I heardfrom him in November last he was still enjoyinggood health.

Experience of this operation extending over manyyears has emphasised, what Rutherford Morisonoriginally pointed out, that if these patients are toremain well they must give up the use of alcohol.The successful cases with which I am familiar havealways faithfully observed that rule.

I am, Sir, yours faithfully,G. GREY TURNER.