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CORRESPONDENCE

THE HEALTH OF MERCHANT SEAMEN

To the Editor of THE LANCET

SiR,—The discussion on help for shipping in theHouse of Commons reported in the Times of Dec. 15thand THE LANCET of Dec. 22nd became of interestto the medical profession when the Labour Partyraised the question of health conditions of merchantseamen. It involved a dispute between Dr. Addisonand Mr. Runciman, apparently old antagonists in

1917, and still at cross purposes. Dr. Addison for

his statements, so far as I can see, was relying onthe Board of Trade’s octavo Blue Book of 1932:" Statistics relating to mortality in the Mercantile

Marine," which revealed for the first time the sur-

prisingly increased mortality of seamen just whenthey leave the service ; and Mr. Runciman counteredby quotations from the provisional conclusions of

the committee in Paragraph (7) (quoted in THE

LANCET, Dec. 22nd, page 1422) as if definitive.Dr. Addison quoted from the very exceptional,indeed unique, report which discussed the deaths

of merchant seamen, employed and unemployedand retired, between Oct. lst, 1929, and Sept. 30th,1930. Here of men employed at sea, 127,518 of

them, 642 died in the year, most of them from

accidents, while of the others 622 died within a yearof leaving the service, comparatively few from

accidents.The deaths of the 642 were reported to the Board of

Trade, but not those of the 622, where the reportswent only to the local registrars. But with a viewto this Blue Book the Board of Trade had got fromthe registrars the forms on which each death indi-vidually had been entered. These Mr. Runciman

kindly let me examine, and my results were printedin THE LANCET, August 19th, 1933, p. 440. I foundthat from disease 288 employed died in the year,but, within a year of becoming unemployed, 556 ofthe men unemployed or retired died. Thus in threemonths, a quarter, 72, of the employed died, butwithin three months of leaving the service 267 of theseothers died. Of pneumonia in an ordinary quarter8 employed would die, but 44 of the others in theirfirst three months after leaving. Of 127,518 men,6 per quarter died of tubercle in the active service,but of the clearly much smaller number who retired,’29 died of tubercle within three months of leaving.Now who will condemn me if I say that all 29 musthave been infected before leaving the service andwhile yet in the service ? ‘t

In the service 24 men died of tubercle in a year,out of the service in that same year 110 men died oftubercle within a year of leaving. These are factsfor one year, of other years we have no information ;yet something of the sort no doubt happens. Is itthen right for the Government department responsibleto try to persuade us that 24 tubercle deaths among127,518 seamen measures with some accuracy the:annual liability of seamen in the merchant serviceto death from tubercle, when the only relevantstatistics they have suggest that the liability in theone year of which they have information is of anorder five times as great-24 and 110 is 134 ? 1 Theonly possible excuse I can see is that the Board of

Trade does not understand what it is doing. Andthis is no fantastic suggestion.The Board of Trade annual return of deaths of

merchant seamen is a very exceptional production.It-a medical return-is not issued over the signatureof any doctor but over that of a layman, generally(in my time, 1921-1931) an assistant secretary of theBoard of Trade, there being no specially experienceddoctor on the staff to take responsibility for thesepublished statistics. Is it wonderful then that ten

years ago the Royal Sanitary Institute petitionedthat the preparation of these statistics should beturned over to the Ministry of Health, " the Board ofTrade not being specially organised for this duty " Itis not the reasoned judgment of a committee; as theythemselves say (Art. 154) not definitive or final " (infact provisional), and we know, contrary to all experi-ence, that seafaring is rather a healthy occupation.Of course there are difficulties in preparing death-rates,but as was seen in the Dardanelles during the war,war is rarely made successfully by committees. Whatthe Board of Trade wants is a doctor of experienceand education to keep on examining ships and reportsof deaths, and tell the Board what they signify. Inthe merchant service afloat in the year 1929-30, 24 mendied of tubercle, in the same year 110 men died oftubercle within a year of leaving the service ; togetherthese make 134. There were 127,518 men in theservice afloat, that makes rather more than 1 per 1000dead of tubercle. The total mortality from tuberclein England and Wales in 1930 was, I believe, 0-89per 1000, yet one gathers the Board of Trade thinksit has no more worlds to conquer in making seafaringhealthy for merchant seamen.

Mr. Runciman said the replacement of Britishseamen by foreign seamen was largely a matter ofclimate. He omitted to mention space. Lascars need

only have 72 cubic feet, British seamen must have120 cubic feet ; each absorbs an extra ton of cargospace. Why do the Transport Regulations require200 cubic feet for each soldier on passage but theBoard of Trade only 120 for seamen (72 for lascars)to live in permanently ? Is the army extravagant orthe Board of Trade niggardly ?We hear nothing in the discussion of any decision

of the shipowners to make use of the report on

suitable standard accommodation for seamen sug-gested by the Shipping Federations committee,reviewed appreciatively by THE LANCET in 1932

(1932, i., 1367) : perhaps it will govern the plans ofnew ships ? Who will tell us of an English ship givingmen 240 cubic feet in their cabins and 120 cubic feetin their mess place besides, and free coffee all thetime ? I have seen all that and more in a UnitedStates’ ship.

I am, Sir, yours faithfully,W. E. HOME, M.D., B.Sc., D.P.H., &c.,

Fleet-SurgeonDec 21st.

PLEURISY AS A PRECURSOR OF PHTHISIS

To the Editor of THE LANCET

SIR,-I read with great interest the annotation withthis title in your issue of Dec. 8th. In my experiencethere is a great difference between dry pleurisy andpleural effusion. In cases of artificial pneumothoraxan effusion is common in tuberculous cases but

extremelv rare in non-tuberculous conditions. In casesof spontaneous pneumothorax the development of

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an effusion is rightly regarded as suggesting tuber-culosis. Many years ago Osler pointed out that

spontaneous pneumothorax occurred in young adults,chiefly men, and that, if no effusion followed, a goodrecovery could be expected without danger of

pulmonary tuberculosis developing later. Wheneffusion does develop in a case of so-called idiopathicpleurisy it is almost invariably found that a sampleof the fluid is of a tuberculous nature, and it seems tome most unwise to suggest to students and medicalpractitioners that such effusions are not of tuberculousorigin. The effusion is the result of a tuberculouslesion, and sanatorium or similar treatment is essentialto prevent the development of activity in the lung.I suggest that the good results described in yourannotation are the direct outcome of sanatoriumtreatment, and that one should appreciate the factthat active tuberculosis can be prevented by thoroughtreatment and that neglect often leads to disastrousresults. I am, Sir, yours faithfully,

L. S. T. BURRELL.New Cavendish-street, W., Dec. 18th.

SEVERE GASTRIC AND DUODENALHÆMORRHAGE

To the Editor of THE LANCET

SiR,-Dr. Tidy tells us that under modern methodsmany cases of severe gastric and duodenal haemorrhagedie and die quickly. The question is, he remarks,whether or not the methods can be improved. MayI submit that it would be interesting and perhaps veryuseful to invoke the aid of Dr. Macfarlane’s snakevenom as a haemostatic in these desperate cases. Iwould suggest that the stomach should be washed outto remove the clots and the gastric secretion, and thata small quantity of snake venom-say, 1 in 10,000 inice-cold water-should be introduced through thetube. In this way little gastric juice would be leftin the stomach to interfere with the protein elementof the venom, although the risk that the venomshould lose its potency is probably small, since its

rapid action is a distinctive characteristic.I am, Sir, yours faithfully,

GORDON RANSOME.Mecklenberg-street, W.C., Dec. 19th.

SERUM PROPHYLAXIS AND PUERPERALSEPSIS

To the Editor of THE LANCET

SIR,-Dr. Pulvertaft writes : "If I am wrong in

thinking that early septicaemia deaths’ are toxic,there is no valid basis whatever for my suggestedprophylaxis." If, as I suppose, he regards these" early septicaemia deaths " as

" toxic " because at

post mortem there are no signs of extensive pyogenicinvasion, he is profoundly wrong, and may wellabandon his proposal for a prophylactic method whichdoes not seek to prevent infection. A perusal of ourmany post-mortem records would show him at oncethat about 80 per cent. of the deaths are associatedwith generalised peritonitis (a fact which was broughtout by Lea in 1910), or with septic thrombophlebitisof large veins-both very gross evidences of progres-sive pyogenic infection. The " early septicaemicdeath " which Dr. Pulvertaft seems to have in mindis a very rare event in puerperal fever.

It may well be that a toxic product of some kind(perhaps produced by the streptococcus, perhaps bydamaged tissues ) is ultimately responsible for theactual death in all these cases, but I know of noevidence whatever that this hypothetical toxic

product is identical with the Dick toxin or the com-bination of toxins in Dr. Pulvertaft’s broth cultureswhich kills rabbits within a few hours. Let us franklyadmit our ignorance on this important matter. Theone fact we do know-Dr. Pulvertaft as well as I-is that the most characteristic effect of Dick toxinin the human body-viz., the scarlatiniform rash, isnotoriously absent in the great majority of cases ofpuerperal fever.

Finally, will Dr. Pulvertaft explain one point ?Mrs. A dies in three or four days of infection by ahaemolytic streptococcus. According to him she hasreally died of poisoning by Dick toxin elaborated bythe streptococcus in her body. An " irrelevant "mouse injected with the same streptococcus dies in24 hours. It is not susceptible to Dick toxin. Whatkilled its z? I am. Sir. vours faithfullv,

LEONARD COLEBROOK.

Queen Charlotte’s Maternity Hospital, Hammersmith, W.,Dec. 24th.

TRICHLORETHYLENE

To the Editor of THE LANCET

SiR,—My attention has been directed to the

following paragraph on page 2 of " IndustrialMaladies," by Sir Thomas Legge (Oxford MedicalPublications) :

" Again the rapidity of absorption is important, forwith some poisonous gases in sufficient amount, it is so

quick as to cause instantaneous unconsciousness (carbonmonoxide, sulphuretted hydrogen gas, trichlorethylene)."I have had very considerable experience of the effectsof chemicals and the measures of protection. It iswell recognised that the effect of carbon monoxideand sulphuretted hydrogen of sufficient quantity is

dangerous because of the rapidity of the onset of thesymptoms of poisoning and in some cases suddenunconsciousness. In the case of trichlorethylene,however, my experience of the effects of this substanceare at variance with the above paragraph. Tri-

chlorethylene is similar to other chlorinated hydro-carbons such as dichlorethylene, perchlorethylene,and chloroform in that it is a narcotic and it issimilar to chloroform in that it does not producesudden unconsciousness. In these circumstances, theclassification of trichlorethylene with carbon monoxideand sulphuretted hydrogen appears to me not inaccordance with fact.

T a,m. Sir. vmirs faithfully.THOMAS E. A. STOWELL, M.D., F.R.C.S.,

Chief Medical Officer.

Imperial Chemical House, Millbank, Westminster, Dec. 17th.

MATERNAL MORTALITY

To the Editor of THE LANCETSIR,-In reply to a deputation from the Maternal

Mortality Committee, as you noted in your lastissue (p. 1419), Sir Hilton Young indicated fivedirections in which he considered an improve-ment most desired. That is to say, fivedirections improvement in which would lead to areduction in maternal mortality. The first of theMinister’s recommendations is for an improvedantenatal service. The last four which cover the

provision of more trained midwives, more beds, andthe service of consultants, may be summed up asmeaning a maternity service scheme for the country.Such a service, however, could do little towards

reducing mortality unless one vital factor is giventhe most complete recognition. That one factor isskilled treatment at the time of the actual confinement.The provision of nurses, beds, and consultants can be