1036 BOOKS AS FOMITES.-GLUCOSE IN NORMAL URINE.

Annotations."Ne quid nimis."

BOOKS AS FOMITES.

A REPORT 1 of the Consultative Committee to theBoard of Education briefly reopens a subject dealtwith in our columns three years ago,2 the conveyanceof infection through books. Dr. J. E. McCartneythen concluded that-with the exception of small-pox-books from public libraries were not to beregarded as dangerous sources of infectious disease.His reasoning was based on the well-known delicacyof most of the organisms conveyed by dropletinfection and on the absence of any record of casesinfected through the agency of books. The strepto-coccus is known to survive drying for a short timeonly, and the unknown viruses of chicken-pox,rubella, and measles are also known to have littleviability outside the body. The diphtheria bacillushas greater powers of survival ; the membrane keptin the dark was found to contain living organismsseveral months later, but even this did not convinceDr. McCartney that it would live under the usualconditions in which books are kept. Small-pox, hefelt, was in rather a different category. The diseasein its severe form is so virulent and serious that norisks can safely be run, and it would be wiser toregard all books and papers as potential dangersif they have been handled by a small-pox patient.The conclusions reached by the advisers of theBoard of Education do not differ from those ofDr. McCartney..The pathological laboratory of theMinistry of Health, several county and urban schoolmedical officers, and three medical officers of largepublic schools contributed evidence, and advised thatthe risk of conveyance of infection was negligible.A book, they said, could only become infected ifactually used by an infected child, and then wouldbe dangerous only for a very short time. Attentionhad far better be concentrated on articles liable to,gross infection, such as towels, handkerchiefs, suckedbrushes, and chewed pencils. In the schools of theLondon County Council books are not disinfected as.a routine, although library books from infected homesare usually disinfected by the medical officer ofhealth before return to the school library. Therehas been much recent evidence and argument to showthat room-disinfection, as usually carried out, isentirely futile and, indeed, the report mentions thatsterilisation of books by formalin vapour has novalue unless every page is closely exposed. Mostof the witnesses preferred dry heat, which is liableto warp bindings a little but otherwise does not:seriously injure the volumes. The general question’is important because if books are, or can be, carriersof virulent organisms they must be responsible foran enormous amount of disease. Often the first thinga sick person demands is an extra supply of booksfrom the library, and few households dream of feelingany responsibility for the infectiveness of the books,on return. They may be back in the library lessthan an hour before they are handed out to someother subscriber who is highly susceptible to theorganism in question. It would, however, be difficultto get direct evidence of actual cases of infection arisingin this way. So far the evidence is more theoreticalthan practical, although there is no doubt that mostauthorities would agree with Dr. J. A. Brincker,principal assistant medical officer in the Public HealthDepartment of the L.C.C., that " dosage, virulence,and susceptibility of the individual are of such greatimportance in the process of infecting the individualand spreading disease that the importance of spreadfrom school-books recedes almost into insignificanceas compared with the more common and importantsources of spread."

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1 Books in Public Schools. H.M. Stationery Office. 1928. 1s. 3d.2 THE LANCET, 1925, ii., 212.

GLUCOSE IN NORMAL URINE.

THE belief that glucose is a constituent of normalurine, although usually considered heretical, has been.expressed from time to time by serious observers,including Pavy. For over thirty years it has been adebatable point. Recently an Egyptian worker, AliHassan,1 has examined in the Faculty of Medicine atCairo the urine of some 700 Egyptians, mostlystudents, from 17 to 27 years of age, and has foundglucose, in small amounts, in conditions which donot point to abnormal carbohydrate metabolism.He discusses the various tests employed and pointsout the unsatisfactory character of the yeast fermenta-tion test as usually carried out, especially when thequantity of glucose is very small. The phenyl-hydrazine test, in which the characteristic osazoneis formed, needs care when applied to urine as thecrystals are frequently entangled with oily substanceswhich render characterisation difficult. The techniquefollowed by Hassan is as follows :-25 c.cm. of urine were well mixed with 2 g. of charcoal

(Merck’s decolorising charcoal was used as a rule) andfiltered after standing for 5 minutes. About 15-17 c.cm.of clear colourless filtrate was usually obtained, and to thiswas added 1 g. of a freshly made mixture of pure phenyl-hydrazine hydrochloride and sodium acetate (1 phenyl-hydrazine, 2 acetate, well mixed). The filtrate was placedin a boiling water-bath for 5 minutes, or just until the

reagents were dissolved, and then filtered into another tube.The final filtrate was put back into the water-bath for2 hours ; it was then allowed to cool gradually in the bath,and the deposit was examined for crystals after 12-15 hours.

The reaction carried out as above is, the author says,not only sensitive but seldom fails to yield clear andwell crystallised osazones, although sometimes yellowoily drops, which can be removed by washing withether, may separate with the crystals. Normal urinegives mixed crystals of osazones, which Hassanstates can be resolved into one identical with glucosa-zone and another which appears to be the same asBaisch’s iso-maltosazone. As we have said, theurine of 700 people was examined, and 20-30 percent. of the specimens voided 1-2 hours after anordinary meal yielded typical glucosazone, the per-centages being reduced to 12-15 and 7 with specimensvoided respectively 4-5 hours and 12 hours aftera meal. Experiments on the tolerance to 50 g. of

glucose by 28 students showed that this was notnecessarily due to abnormal carbohydrate meta-bolism. The old view that glucose in small quantitiesis a constituent of normal urine is thus in thisinvestigator’s opinion confirmed.

NATIONAL ASSOCIATION FOR COMBATING

RHEUMATISM.

WHEN there are already many bodies engaged in thefight with some great national scourge, it is essentialthat any new organisation should have sufficientprestige and authority to be able to link up the workof the older foundations and to advise them in theiractivities. It is this need of a central body that led theformer British Committee on Rheumatism of theInternational Society of Medical Hydrology, havingdissociated itself from the Society, to propose theformation of a national association to deal with theproblem of rheumatism in this country. Similarcommittees have already been formed in France,Germany, and other countries. A meeting to discussthis proposal was held at the Royal Society of Medicineon Nov. 7th. Sir Thomas Horder, having been electedto the chair, explained the position and emphasised theabsolute necessity of constituting a .really nationalbody, representing all interests and of high status. Heconsidered that the rheumatic problem in this countryhad great need of a central body to link up and

1 Biochem. Jour., 1928, xxii., 1332.

1037ACCOMMODATION FOR THE SICK IN PUBLIC SCHOOLS.

strengthen existing efforts such as the Red CrossClinic, the British Medical Association committee andthe work carried on at the spas, as well as the activitiesof the Ministry of Health, which were described to themeeting by Dr. J. A. Glover. Already we have inLondon 230 beds allocated by the public authorityfor rheumatism and chorea, and 350 more are to beprovided. The three rheumatism centres of theLondon County Council and the rheumatism clinicsof Paddington and Kensington boroughs are doingexcellent work, and indeed for acute rheumatism thepublic authorities are doing far more than they are forthat bugbear of all concerned, chronic rheumatism.Nevertheless, the valuable reports of the Ministry ofHealth Office Committee and of the Medical ResearchCouncil have served to draw attention to the seriousmedical and economic problem. As Dr. FortescueFox observed, no group of diseases, save perhaps thetropical, is so disastrous to the public health andprosperity.The meeting unanimously approved of the

motion of Mr. W. A. Appleton (General Federationof Trades Unions) and Dr. C. W. Buckley, that aNational Association should be constituted. After alittle discussion of detail it was decided that theAssociation should have a Council representing allthe various interests concerned and an executivecommittee of 12. The nucleus of this committee waselected at the meeting, the Chairman, Dr. FortescueFox, Dr. Kerr Pringle, Dr. Buckley, and Mr. Appletonbeing appointed, with power to coopt. Dr. M. B.Ray will act as secretary pro tem. There are to bea number of standing committees, including thefollowing: General purposes, Medical, Finance, In-dustrial, Approved societies, Administrative, Research.Dr. Morley Fletcher proposed, and Mr. H. Lesserseconded, that membership of the Association be opento all on payment of an annual subscription, and thatmembers be entitled to attend and take part in anannual conference as well as other general or extra-ordinary meetings and to receive any publicationsissued by or on behalf of the Association. On themotion of Mr. P. Rockliff and Dr. W. Edgecombe, itwas agreed to hold an annual conference for papers anddiscussions, the proceedings to be printed and circu-lated to all members.

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" ENDOGENOUS " CYANOSIS.

ONE by one the abnormal conditions of urineformerly classed as " endogenous " or " essential " arebeing removed from that group as their aetiology isdiscovered. An interesting example is reported inGuy’s Hospital Reports, July, 1928 (p. 275), byDr. M. 0. Raven, whose patient, a middle-aged ladywho had suffered from many diseases and undergonemany operations, was found suffering from pyrexia,haematuria, and marked cyanosis. On spectroscopicexamination the blood showed the bands of methaemo-globin. This discovery was followed by a very fullexamination of the patient by Dr. A. F. Hurst; theconclusion was reached that the patient was sufferingfrom a colonic infection. A caecostomy was per-formed and the patient thereafter irrigated the lowerbowel through the opening with 20 pints of waterdaily for some weeks, during which she improved notat all and continued to live in a pitiable state of ill-health. Not long after, when the patient hadreturned home, she was accidentally found to betaking very large quantities of antikamnia, a prepara-tion that contains 70 per cent. of acetanilide. Assoon as this habit of drug-taking was stopped thecyanosis disappeared not to return, though thekidneys had evidently been permanently damagedby the passage of abnormal blood-pigments over along period of time. Dr. Raven remarks that duringthe war individuals anxious to escape military servicewere sometimes found by examining boards to betaking overdoses of phenacetin. Dr. J. A. Ryle addsa note to Dr. Raven’s communication, stating thatfor some time he has been becoming increasingly jsuspicious that cases of so-called enterogenous cyanosis Iare in reality due to drug-addiction, most of the-

patients with this rare complaint known to himhaving had peculiar psychological characteristics.Dr. Raven’s case confirms this view and he pointsout that before declaring any case of methsemo-globinsemia with cyanosis to be of endogenous origin,it is necessary to exclude the taking of drugs of theacetanilide group. Indeed, he goes further and isinclined to doubt the existence of enterogenouscyanosis altogether. Cases of methaemoglobinaemiaare so rare that it is unlikely that any single observercould decide the question; cases of microbiccyanosis have been described in some detail, but inthe absence of any suspicion of the connexion norigid exclusion of drug-addiction has been made.A well-organised collection of cases of endogenouscyanosis throughout the country and an impartialinquiry into their history and clinical conditionwould be required before a decision could be arrivedat. In the meantime it must be remembered that-other drugs besides those of the acetanilide group,especially potassium chlorate, carbon monoxide,sulphuretted hydrogen, sulphonal, and trional are

capable of causing a chronic cyanosis. On the otherhand, such rare diseases as Winckle’s disease (epidemichaemoglobinuria in the new-born), in which methsemo-globinaemia undoubtedly occurs, render it quitepossible that corresponding changes in blood-pigmentmay occur in the adult as a result of infection.

ACCOMMODATION FOR THE SICK IN

PUBLIC SCHOOLS.

A MEMORANDUM’ on the accommodation for the sickin public schools has been published by the Ministryof Health, based upon an inquiry conducted at aconsiderable number of well-known public schools inEngland. The memorandum puts forward variousrecommendations which Sir George Newman hopesmay be of some practical use to the governing bodies ofthe schools, to the masters and parents, and to schoolmedical officers. The provision for the sick wasfound adequate as a rule to deal with ordinarytrivial illness and mild infectious diseases in someschools, and with almost any sickness except largeepidemics of infectious disease in others. The differenttypes of accommodation provided included (a) housesick-rooms, (b) a sick-house, (c) an infirmary, (d) asanatorium. The house sick-rooms were usually-utilised for minor illnesses, but in some schools thisaccommodation had to deal with all cases of sicknessother than infectious or major surgical cases. Thehouse sick-rooms were usually near the quarters of thehouse matrons, and were of greatest use in thoseschools where the medical officer gave only part timeto this work ; in those schools where the medical

I officer was on a whole-time basis, the boys wereusually transferred, when sick, to the sick-house,infirmary, or sanatorium. Great differences were

found between the sick accommodation of variouskinds provided at different schools ; many schoolshaving ample, others negligible, accommodation. Thesick-house was, as a rule, a building intended for thereception of all non-infectious cases and often replacedhouse sick-rooms. An out-patient department andsometimes an operating theatre and an X ray roomwere occasionally included in the sick-house, whichhouse was usually centrally situated. The infirmary-was found to be a building intended for the accommo-dation of all kinds of sickness, whether medical,surgical, infectious, or non-infectious, including anout-patient department, all under the care of a medicalofficer. It was usually situated away from the schooLbuildings. As regards emergency accommodation forepidemics of infectious disease, it was found that insome schools no prearranged plan existed for dealingwith such an emergency, while in others, dormitoriesand large class-rooms could be quickly converted into

1 A Memorandum on the Accommodation for the Sick providedat certain Public Schools for Boys in England. By Capt. W.Dalrymple-Champneys, M.R.C.P., Ministry of Health. London :H.M. Stationery Office. Pp. 35. 1s.