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in palatal paresis can usually be overcome by carefulfeeding with semi-solids. In pharyngeal paresisthe patient requires to be fed by the nasal tubeand the foot of the bed raised so that saliva maydrain from the mouth. The recovering patientshould be carefully fed at first with thickened fluids.

Laryngeal Diphtheria.Laryngeal diphtheria should be treated by an

immediate dose of antitoxin of 12,000 to 20,000units ; if severe faucial or nasopharyngeal lesionsare present in addition 30,000 to 40,000 units shouldbe given. A croup kettle and a half-tent should bearranged so that the air in the neighbourhood of thehead is kept moist and warm by a current of steam.Hot fomentations should be applied to the neckfrequently. In hospital it is usual to postpone inter-ference as long as possible, but in general practice thismay be dangerous. Rapidly recurring spasms ofdyspnoea, great restlessness, cyanosis, and a fastflickering pulse are obvious indications, but there aremany lesser gradations of the obstructive syndromewhose gravity has to be estimated. It is better tooperate early than too late, and when the doctor cannotbe within easy call it is sound practice to operate.

Tracheotomy.-Intubation is essentially a hospitalprocedure, and the operation to be recommendedfor the practitioner is high tracheotomy. A detailedaccount of this is not possible here, but some of theimportant points may be stressed.An ansesthetic is not necessary, but the patient must

be firmly held, especially the head, which must not be allowedto move from the vertical. The anatomical landmarksmust be carefully selected, the midpoint of the lower borderof the cricoid never being lost sight of. The incision shouldbe absolutely in the midline. Bleeding need not cause alarm,and steady swabbing must be carried on to prevent the fieldof operation from being obscured. When the trachea isopened there is no urgency about inserting the tube untilthe first spasm of coughing has cleared away mucus, blood,and fragments of membrane. In the after-treatment themain consideration is to get the tube out, and attempts tothis end should be made about the third day after operation.As a rule the patient can be fed quite well by means of afeeder or a spoon and very rarely is the nasal tube required.

Diphtheria in other Situations.Nasal diphtheria with membrane formation re-

quires from 6000 to 8000 units of antitoxin, andcases in which there is a watery or blood-stainednasal discharge containing B. diphtherice will usuallyyield to a small dose of 2000 units. Conjunctivaldiphtheria should be treated with 6000 or 8000units, and in diphtheria complicating operationwounds or occurring as a secondary infection ofskin eruptions it may be necessary to give largeinitial doses up to 20,000 or 30,000 units.

Prophylaxis.Passive immunisation can be conferred bv the

subcutaneous injection of 500 units of antitoxin. Theprotection lasts about three weeks and is immediate.

Active immunisation can generally be secured bythree doses each of 1 c.cm. of toxin-antitoxin mixturesubcutaneously. The procedure should be delayedtill after the ninth month of life; in children underschool age no preliminary Schick test is necessary.Up to puberty a preliminary Schick test without acontrol should be performed, but after that age, andin retesting after immunisation, all tests should becontrolled by the heated inactivated toxin. Pro-tection takes some months to develop ; the lapseof six or twelve months will be found a convenientinterval before retesting. Those still susceptible arevealed by the Schick test should receive a furthercourse of toxin-antitoxin injections.

Carriers.Local applications have little effect, and the best

prospect of terminating the carrier state is held outby investigating the nasopharynx and correctingany deformity or pathological condition. Tonsillec-tomy and removal of adenoids are often useful.

ALEX. JOE, D.S.C., M.D. Edin.,Medical Superintendent, North-Western Hospital (M.A.B.).

Special Articles.A FURTHER VISIT TO GERMAN SPAS.

A VISIT to some of the West German spas waseported in THE LANCET of June 12th, 1926. This,pring an opportunity was given to our representative.0 visit nine other spas, and so to complete his account)f German inland watering places.

AACHEN.

Aix-la-Chapelle, to use the more familiar name,s situated on the main line from Brussels to Cologne,ust on the German side of the frontier betweenBelgium and German. It is an industrial town ofL50,000 inhabitants, chiefly engaged in makingneedles and in the woollen industry. At its westernmd is the spa, at the foot of well-wooded hills, and1S the prevailing winds are from the west the smokerom the town and its factories rarely approacheshe area occupied by the Kurhaus with its baths andwells. Indeed, unless one climbs the wooded slopeswhich overlook the town, the neighbourhood of theLndustrial area is forgotten. The hot sulphur3prings issue at temperatures varying from 162° F.ilownwards; the hottest, of course, being cooledbefore use. In addition to sulphuretted hydrogen,the waters contain sodium chloride, sodium bicar-bonate, and sodium sulphate, being thus well suitedfor the treatment of rheumatism and gout. Hereis found an excellent form of douche massage peculiarto the place. The patient enters a deep immersionbath, with steps on either side, in company with thebath attendant. The latter, seated facing the patient,applies massage and under-current douching for some15 minutes, during which the bath is graduallyemptied. The manipulations over, the attendantleaves the bath, which is gradually refilled, and thepatient lies quietly in the warm water for the pre-scribed period. He is then dried with warm towelsand sent to rest, or, if he be physically fit, is allowedto swim or wallow in a commodious bath of runningwarm sulphur water.

Until the introduction of intravenous methods,Aix-la-Chapelle was justly famed for the treatment ofsyphilis and parasyphilitic ailments by the combineduse of mercury inunction and sulphur waters. Acertain number of these patients are still treated here,but most of those coming for the cure are sufferersfrom rheumatism, gout, skin diseases, torpid liver,or intestinal catarrh. The principal hotel adjoiningthe baths and Kurhaus is well warmed and mostcomfortable in every way. Mention should bemade of the Landesbad, a hospital of 365 beds, forthe treatment of the insured classes, with well-staffedlaboratories for all pathological and biochemicalinvestigations.

KREUZNACH.This spa lies in the valley of the River Nahe, a

quarter of an hour’s journey from Bingen, where theNahe flows into the Rhine. Here are large saltworks,and radio-active brine baths containing lithiumand iodine are the most important features of thetreatment. The strength of the baths is varied bythe addition of mother-lye from the saltworks or ofconcentrated radium emanation water. Diseases ofwomen, rheumatism, and " scrofula" are said to derivespecial benefit. Scrofula would appear to be a pre-tuberculous condition in children characterised byglandular enlargement. There are several largechildren’s homes, both for treatment and convales-cence, but although several homes were visited, atypical case of scrofula could not be demonstrated.The children appeared well-fed and happy, and thebracing climate and good feeding should do muchto reinforce the action of the local radium emanationin overcoming the after-effects of malnutrition in

early childhood from which many German childrensuffered during the war and the subsequent inflation

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period. The Kurhaus and Palast Hotel was the

headquarters of the German General Staff in 1917and 1918. The baths contain inhalation rooms filledwith vapourised saline water for the treatment ofcatarrh of the lungs, nose, and throat, and it was ofpassing interest to be told that in this foggy atmospherethe ex-Kaiser sought relief. The Palast Hotel hasonce more assumed its normal function, and is a mostcomfortable place. The hotel adjoining is still theheadquarters of the French occupying this area.

Kreuznach has some 27,000 inhabitants, and is thecentre of the Nahe wine industry.

BAD MIiNSTER AM STEIN.This lies in the Nahe valley, a few miles above

Kreuznach, in the concavity formed by a wide bendin the river, on the opposite bank of which theRheingrafenstein rises sheer to a height of 300 metres.The waters are radio-active salines, and the bath-houses, when rebuilt in 1911, were so constructedas to retain as much as possible of the natural radiumemanation. The lawns in front of the Kurhaus arebounded on two sides by high Gradier-Werke, beingstacks of brushwood used for concentrating thesalines by evaporation. Consequently, the patientsspend a large part of their time in an atmosphereimpregnated with moisture and salt, and even inthe height of the summer the gardens are cool andpleasant. Bad Miinster is little more than a largevillage, but it has modern sanitation and lighting,and is a real beauty spot. Shaded walks in the valleysor stiff climbs in the hills afford choice in plenty.The diseases mainly treated are gout, rheumatism,scrofula, and female ailments.

BAD MERGENTHEIM.

Mergentheim, on the River Tauber, is the oldFrankish town whose castle was for centuries the homeof the powerful " Deutsch-ritter," a religious order ofGerman knights. The old castle and town are sepa-rated by a park and the river from the Kurhaus andmodern buildings surrounding the springs. Unlikemost German spas, Bad Mergentheim is privatelyowned. It is to be hoped it will weather the leanyears, for in many respects Mergentheim is an idealcure place. Although patients may live in thelodgings or hostelries in the old town, the principalhotels belong to the spa, and each hotel has a residentdoctor. In all these hotels different kinds of dietare prepared daily, and each kind of diet is sub-divided according to the needs of the individualpatient, the quantity as well as the quality beingordered by the medical resident. A shady promenadeand colonnade adjoins the springs, and by the timethe orchestra arrives to play the opening morninghymn, most of the patients are on parade sipping theirmineral waters. More importance is attached todrinking the waters than in most spas. They arebitter salines containing different quantities of sodiumand magnesium sulphates as well as sodium chloride.The ailments principally treated are cholecystitis andgall-stones, cirrhosis of the liver, obesity, diabetes,and catarrhal diseases of the stomach and intestines.In Bad Mergentheim the cure is of primary importance,but full provision is made for amusement, and withWirzburg and Rothenburg within easy reach, it is avery pleasant spot to visit.

BADEN-BADEN.In a pamphlet issued by the municipal inquiry

office it is stated, " Only a small percentage of thosewho visit Baden come for the cure." More’sthe pity, but the reason is not far to seek. Badenhas been made so attractive by nature and art thatit can rely on drawing a sufficient number of visitorswhose spending power renders the authorities moreor less independent of the invalids on whose supportother spas must rely. Gardens, reminding one ofthe ordered beauty of the Cambridge " Backs,"border the banks of the rippling Oos in the bottomof the valley, surrounded by the mountains of theBlack Forest. In the spring, with magnolia, syringa,azalea, chestnut, and lilac in bloom, with a soft, warm

air sufficiently stirred by the cool breezes followingthe course of the river, the outdoor conditions areideal for the invalid or the weary.The spa waters issue at a temperature of 154° F.,

and contain lithium and iodine. The bathing establish-ments have evolved an elaborate form of treatmentwhereby the patient enters in turn a hot air room,very hot air room, douche massage, steam room,hot swimming bath, cooler immersion bath with sandat the bottom, still cooler swimming bath, colddouche room, and finally a cold plunge bath. Thistakes about 1 to 1 i hours. It is all quite pleasant,and the patient is ready for his couch and towelswhen it is over. Subsequently a feeling of buoyancyand hunger follows. This must be the moment oftemptation for the obese gentlemen who appear toform the majority of those undergoing the cure. Thegouty and rheumatic take this treatment, and thereare well-equipped inhalation rooms for those sufferingfrom bronchial catarrh. There are luxurious hotelswhere wealthy people can enjoy rich food and dancetill the small hours. It is evident that the practice ofearly water drinking is not as prevalent as it once was.

BuIiLEFCIioI3E SANATORIUM, some 800 metres abovesea-level, is reached by a 40-minutes irregular ascentfrom Baden-Baden through the Black Forest.Originally built to accommodate 12 German generalsin need of rest or convalescence, it is now underprivate control, and offers rest and open-air treatmentin most attractive surroundings. Diet receivescareful attention, and there is a small hydropathicdepartment. The resident physicians have a labora-tory where necessary pathological and biochemicalinvestigations can be carried out. Buhlerhohe isspecially recommended for the after-cure of patientswith heart disease who have been treated at Nauheimand Kissingen, or after sulphur treatment at Schinznach.Anaemia and non-infectious diseases of the respiratorysystem are also treated.

WILDBAD.111G ILLIUIU UUVV II 1W 1U‘AGUUGI,L u ct) 1GW111GtL1.1 1GJ J..J..1..l.l.II;:;i::)

up a valley from the main line from Paris to Vienna.That is has historic associations, readers of " JewSuss " will remember well-they would also under-stand the presence of several royal baths in thecomparatively small bathing establishment. Thespa waters issue at a temperature of 91° to 104° F.,and are consequently applied without previous heatingor cooling. They contain little mineral matter, butare radio-active. Drinking the waters is not pressed,though there is the usual Trinkhalle. Rheumatismand gout are treated by immersion baths, and thewaters frequently cause a " bath reaction " after thefirst five or six baths, after which more rapid progressmay be expected. Dr. Schober has made someexperiments indicating that the local radio-activewaters stimulate a more rapid growth of protoplasmthan plain water. Through the valley of Wildbadruns a trout stream, and visitors for the cure canobtain permission to fish a long stretch of likely-looking water.

BAD REICHENHALL.Reichenhall is a country town, 1500 feet above

North Sea level, surrounded by the snow-cappedpeaks of the Bavarian Alps. The frontier betweenAustria and Germany runs between Reichenhalland Salzburg, which is only a few miles away, butthe passport visa is obtained without difficulty toenable visitors to see the historic palaces and castles ofSalzburg. There is a daily air service to Reichenhallfrom Munich, and as the aeroplane reaches Reichenhallearly in the morning and does not leave till evening,it is available for short or long flights over theBavarian Alps and Austrian Tyrol. Reichenhall hassome of the richest salt springs in Germany, containing24 per cent. salt (as compared with the 2-4 per cent.of sea water) and whilst winning salt is the mainindustry of the 7000 inhabitants, these salines,containing bromine and iodine salts, are carefullygraded for bathing purposes. The mountain air,mild and clear from impurities, is specially suitable

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for the sufferers from non-tuberculous pharyngitis,laryngitis, bronchitis, asthma, and hay fever, whoflock here from all parts of Germany and Austria.The climate is also beneficial in rickets and scrofula.Inhalatoria and compression chambers abound, whilstthe notice that smoking is forbidden meets the eyeeverywhere. Spitting on the ground would probablybe followed by banishment. There is a peasanttheatre where the players wear the picturesquenational costume. The artists are of peasant origin,but are true professionals. Each performance endswith the folk dances of the Bavarian Highlands,which are invigorating to watch, and recall the smallhours of a St. Andrew’s night. Bavarian hospitalitymust be experienced to be appreciated ; both placeand people make the visitor feel at home.

BAD ELSTER.This Saxon spa is only a few miles from the neigh-

bouring Czecho-Slovakian spas, Franzensbad andMarienbad, and has very similar waters. These allcontain iron and varying quantities of Glauber’s saltand sodium bicarbonate, with free carbonic acidgas. Peat baths and packs are used on a large scale.The chief indications for the cure are anaemia anddisorders of the respiratory system-tuberculosisexcluded-cholecystitis and gastric catarrh, diseasesof women, particularly inflammatory conditions ofthe pelvis and menstrual disorders. The last wingof the new bath-houses has just been opened, and isspacious and well-equipped. Outdoor treatment insunlight and swimming baths has been well-developed,the climate and surroundings being particularly suit-able. Bad Elster is only a small place, but has anattractive casino and theatre and pleasant country-side.

Dr. Kohler’s sanatorium is a well-equipped privateinstitution for diagnosis and treatment, where dietis properly controlled. Attached to it is a home forthe open-air treatment of poor children sufferingfrom surgical tuberculosis and malnutrition. Excellentwork is being done here. Dr. Kohler said that atone time he was only enabled to keep the place goingby the aid of money received from the British " Savethe Children " Fund. The money sent to him waswell spent.

BAD BRAMBACH.Brambach lies on the frontier between Saxony

and Czecho-Slovakia, being about half-way betweenBad Elster and Franzensbad. It was only in 1910that building operations revealed what proved to bethe strongest known radio-active springs. There isa large mineral water factory and bottling depart-ment, which exports a palatable table-water and gingerale, the only other buildings being the four smallhotels owned by the same company. The bathing-rooms are in these hotels. The climate is bracing,and the atmosphere has been shown to be radio-active up to a good height and over a considerablearea around the springs. Bad Brambach is still a

Ispa in embryo, but has waters which may some daymake it famous.

SOUTH AFRICA.

(FROM OUR OWN CORRESPONDENT.)

Report of the Hospital Survey Committee.A REPORT by this Committee on the hospital

facilities and kindred services in the LTnion waspresented to both the Houses of Parliament on

June 25th. Sir Edward Thornton was chairman ofthe Committee, of which there were four othermembers, and in addition a member for each of thefour provinces was nominated to take part in theinvestigation in so far as the particular province wasconcerned. The needs of each of the four provinces aredealt with separately in detail. The report lays stresson the extreme shortage of beds at most of the publichospitals, particularly in regard to provision for thecoloured and native races. The overcrowded state of

many of the hospitals has already been pointed out bythe Hospital Committee of Inquiry in 1925, and thepresent Committee is satisfied that the strain on thehospital beds of the Union to-day is appreciably worsethan it was in 1925 ; at hardly any large centre, withthe exception perhaps of Johannesburg, can it recordany amelioration of conditions. Greater hospitalaccommodation is required in the Union than inEuropean countries, as separate provision has to bemade for European, coloured and native patients.The Committee concludes that in other countries aratio of one bed for every 200 persons is the ideal tobe aimed at, and that in practice a community is notill-served if it has one hospital bed for every 250 ofits population. In most countries it is generally foundthat proportionately greater hospital facilities are

required by the inhabitants of a densely settled areathan by those living in the more sparsely populated.This is true to a certain extent for South Africa, buthere there are other factors to be taken into con-sideration, such as the proportions of the constituentelements of the population and the character, habits,and development of each section thereof. Thus it willbe many years before the raw native living in theheart of Natal or the Transkei will require the sameproportion of hospital bed accommodation as theEuropean. Even among Europeans the demand variesenormously. The older generation of Boers, particu-larly amongst the farming community, has not lostits fear of hospitals, and in an area such as the OrangeFree State the demand for accommodation ofEuropeans is relatively small.Among the constructive proposals made in the

report is the suggestion that each province shall bedivided for hospital purposes into a number of centralareas. Under this scheme the Province of the Cape ofGood Hope would be divided into six of these areas,and the Transvaal, Natal, and Orange Free State wouldeach be divided into two. The Committee estimatesthat if its proposals are accepted a capital expenditureof over z2,000,000 on hospitals will have to beprovided for the provinces over a period of four or fiveyears. The approximate figures for each provinceare : Cape of Good Hope (including 290,000 for chronicsick), .6950,000 ; Transvaal, .6574,000 ; Orange FreeState, z400,000 ; and Natal, .6235,000. Theseestimates include the cost of building a new generalhospital at Cape Town, the new hospital at Pretoria,and the new hospital at Bloemfontein ; to the con-struction of which, it is understood, the Governmentis already committed in principle. Their erection willcost not less than 21,000,000. The Committee regardsits proposals as minimal. Their adoption would notentirely solve the very unsatisfactory problem of thehospital service in the Union, which in three provincesparticularly has been sadly neglected, but it would,at any rate, simplify the position of the Government ifit ultimately takes over the control of the hospitals.The Committee believes that Government control isbound to come in view of the increasing body of publicopinion which is in favour of it.

Native Medical Practitioners.In order to bring European medicine within reach

of the native population it has been suggested thatfacilities for the training of natives as medical prac-titioners are required. A committee appointed somemonths ago to consider this question has expressed theconviction that the needs of the native reserves andlocations will not be met by providing for an influx ofnatives into the medical profession. Experience inother parts of Africa shows that it is exceptional fora native medical practitioner to be content to practisein his home surroundings. He nearly always drifts intoa large town, and money spent on his education withthe object of providing medical attention for hispeople in the bush is to a large extent wasted. It hasbeen found impossible in practice to draft agreements.that will bind such practitioners. Apart, however,from this consideration the committee thinks that itwill not be practicable for many years to give nativestudents facilities for full medical training in the