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radium tubes, without lead filters, into this greyishmass in various directions, the total dose of radiumbeing 11 cgm. A week later the signs and symptomsof severe abdominal disease had vanished, and thechild lived to die several months later of acute middle-ear disease. The necropsy showed extensive healingof tuberculosis in the peritoneal cavity and elsewhere.Among the reviews of original papers on tuberculosisin childhood there is one in which the value of asingle Pirquet test is shown to be very untrustworthy.Of 800 children thus tested only 537 gave a positivereaction to the first Pirquet test with old tuberculin.Of the remaining 263 cases as many as 170, or 64-6 percent., gave a positive tuberculin reaction either to asecond Pirquet test or to the intracutaneous injectionof old tuberculin in varying strengths.

FAITH AND PRACTICE.

IT is always rather difficult for a nonconformist ofany complexion to understand the principles of thetrue faith, and when the Homceopathic World (No. 690,June, 1923) says that THE LANCET has " acknowledgedthe truth of the homoeopathic principle," it is interest-ing to wonder to which or what principle assent hasbeen given. Is it the original doctrine that similiasimilibus curantur ? Or is it the more moderndevelopment which claims that drugs are effectivein dilutions which would not contain a single moleculeof the original active agent ? Or is it the attribution ofnatures and qualities and emotions to plants which canbe apprehended and used only by those in spiritualcommunion with the sources of drugs ? It wouldbe as difficult for the orthodox medical practitioner todraw up his creed of allopathy. Upon some of theclauses in both cases there would, we imagine, beinsoluble differences of belief. But does this greatlymatter when there is so much that is plain and funda-mental from which no one will dissent ? In certisunitas, in dubiis libertas, in omnibus charitas. No cultof medical men could have a better motto. And if it isfollowed in practice-and the more unconsciously thebetter-there is not much need to embark on thedangerous sea of putting down on paper what eachgroup believes. They can all meet on the commonground of sincere humane and skilful work.

THE REGISTRATION OF DISEASE.

HOSPITAL statistics run largely to waste. Thisis, we think, the main lesson of a very interest-ing discussion on the Registration of Disease, openedby Dr. Reginald Dudfield at a meeting of theRoyal Statistical Society last March,1 and now re-

printed. In his opening remarks at this discussionDr. Dudfield pleaded for a utilisation of the recordsof sickness which accumulate in our general hospitalsand other institutions for the treatment of disease." It is a common experience," he said, " to read reportsby different workers, dealing apparently with similarmaterial, diametrically contradictory to each other."What is needed is the bringing together of the dataderivable from all institutions, the collation andanalysis of such data by a central body of statisticianswho are not only statisticians but medical men of ripejudgment, well versed in the problems of publichealth. Other medical statisticians, Dr. T. H. C.Stevenson and Dr. Major Greenwood, and sucheminent experts in public health matters as Sir WilliamHamer and Dr. John Mc Vail, were in sympathy withDr. Dudfield’s general contentions. Dr. Stevensonpointed out that, even without drastic reform of thepresent system, some improvements might be effected.He instanced the emendation of the law required tosecure knowledge of the sex and age distribution ofcases of infectious disease, and suggested that a verygood indication of the social class of each decedentwould be afforded by a mere record of the number ofrooms in the tenement occupied by the family. Dr.Greenwood dwelt upon the importance of a proper

1 Jour. Roy. Stat. Soc., 1923, lxxxvi., 129.

exploitation of hospital statistics, supplemented bya system of following up cases, in the study of theprognosis after operative or other treatment ofmalignant disease. Dr. Hamer advised Dr. Dudfield" in addition to trying to get more out of his Poor-lawand health statistics " to try " to persuade the hospitalauthorities to introduce the study of disease as a massphenomenon to their medical students." The medicalprofession as a whole will, we think, be in sympathywith Dr. Dudfield’s ideas. Without doubt theeconomic and administrative difficulties of anycentralisation of records are great, but the fact remains-and it is worth repeating and italicising-that, toa large extent, hospital experience as a statisticaldatum runs to waste. Of course, its value as such is,only secondary, the highest use for hospital experienceis its incorporation in the minds and practice of eachgeneration of physicians and surgeons. But there isno opposition between these purposes. Sir WilliamOsler could not be accused of having underrated thepractical element in medical education, but, in histext-book, he employed the statistical method morefully and frequently than any other physician of histime. Dr. Dudfield’s proposals would have had thefull approval of that great physician.

A MILK-BORNE EPIDEMIC OF GASTRO-ENTERITIS.

A RECENT epidemic of milk-borne gastro-enteritisin Denmark has been the subject of instructiveinvestigations by Dr. A. Christensen and VeterinarySurgeon P. Grinsted,l who claim that for the firsttime (with the possible exception of Dr. K. F. Meyer’scase reported in the Journal of Infectious Diseasesfor 1916) proof positive has been found of a typicalbovine paracoli infection being conveyed by cow’s.milk to man. The epidemic in question broke outon Oct. llth, 1922, in a large hospital. Thirty-nineof the staff and 56 of the patients were seized withgeneral malaise, fever, abdominal pain, nausea,headache, vomiting, and diarrhoea. In two cases

there was an outbreak of herpes on the upper lip,and in one case there was partial loss of consciousnessfor 24 hours. None of the patients died, and no-

new cases occurred after the first outbreak. Theincubation period was evidently very short, as wasalso the period during which the disease was con-tracted ; for among the patients there was one whohad been admitted to hospital for some other diseaseonly the day before the outbreak occurred, and noneof the persons admitted to hospital on the morningof the outbreak developed gastro-enteritis. All thepatients had taken unboiled milk. and an inspectionof the sources of the milk-supply led to the discoverythat at a small farm one of the 13 cows in milk hadfallen ill on Oct. 9th. Next day it had been very ill,with offensive diarrhoea and a temperature of 40° CThe cow died in the night of the llth and 12th, butthe milk yielded on the 9th had not been thrownaway, although the cow’s udder was oedematous.The necropsy on the cow showed definite signs ofsepticaemia, the spleen being gigantic and the liverand mucous lining of the small intestine showingacute inflammatory changes. Sections of the uddershowed early mastitis which was evidently secondaryto the enteritis and septicaemia. Numerous Gram-negative short bacilli, identified as bovine paracolibacilli, were found in the spleen and secretion fromthe udder. A pure culture of the same bacilli wasobtained from the fasces of two of the patients, andagglutination tests of the sera of 31 patients on theninth to the twelfth day of the disease left littledoubt as to the relation of the germs found in thecow to the epidemic in man. There is a disease incattle known in Denmark as " paracoli bacillosis,"from which calves often suffer, but to which full-grown cattle are usually immune. It may be thatthis comparative immunity of full-grown cattle toparacoli bacilli explains the rarity with which human

1 Hospitalstidende, April 11th and 18th, 1923.

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beings seem to contract this form of gastro-enteritis.But it is conceivable that this rarity is more apparentthan real, and that were agglutination tests to becarried out more frequently in epidemics of this"kind, bovine paracoli bacilli would often be convicted.The moral of this episode is not far to seek. Werefarmers to be systematically taught the risks ofkeeping the milk of sick cattle, they would not betempted to follow the penny-wise-pound-foolish policyof mixing infected with pure milk.

A POST-GRADUATE COURSE ON ALPINE

THERAPEUTICS.

WE have received the announcement of a course ofvacation lectures on Tuberculosis in the AlpineClimate to be held at the Research Institute in Davosfrom the 19th to 26th of the coming August. ThisInstitute, in regard to which we were able to give somepreliminary details last autumn, has now materialisedas far as its physiological section is concerned, underthe management of Prof. A. Loewy, who was for longone of a group of collaborators with Prof. Zuntz inrespiratory problems. The bacteriological section ofthe Institute is also ready for occupation, and it ishoped to place this in the charge of an expert, when theexpected help from the Swiss Confederation comes inafter the Tuberculosis Bill has become law. Atpresent the joint sponsors of the Institute are themedical associations in Davos, Arosa, and the Grisons,the Swiss Association of Naturalists, the Swiss RedCross, and the Swiss Association for Balneology andClimatology. The meteorological observatory, underthe direction of Prof. C. Dorno, is in close associationwith the Institute, and it is therefore possible to

study clinical problems from the varied standpoint ofmeteorology, physiology, and pathology. Voluntarystudentships at the Institute will be open to a certainnumber of workers. The principal items of studyduring the vacation course will be the pathology oftuberculosis, modern views on immune biology,general and special diagnosis with exhibition of cases,X ray and laboratory demonstrations, pneumothoraxand other surgical treatment of pulmonary disease,and the application of altitude treatment to diseasesother than tuberculosis, such as asthma, diabetes, andmalaiia. Forenoons will be devoted to lectures anddemonstrations, while afternoons will remain free forvisits and excursions. The course is free, the lecturesbeing delivered in French or German. Board andlodging is offered at an inclusive charge of 10 francsa day to those attending the course. Furtherinformation will be given on application to theScientific Research Institute, Davos, Switzerland.

THE AGENT PRODUCING SYMPTOMS IN

EXOPHTHALMIC GOITRE.

THE symptoms of exophthalmic goitre are usuallyattributed to the presence in the blood of an abnormalamount of the active principle of the thyroid secretion-a supposition supported by the known fact thatadministration of an excessive amount of thyroidsubstance to normal individuals is followed bysymptoms which are similar to those characterisingthis disease. In order to ascertain whether thyroidsecretion circulating in the blood is the agent producingthe characteristic symptoms, certain tests have beenapplied by Sir E. Sharpey-Schaferl to the blood ofpersons suffering from exophthalmic goitre and to thatof normal individuals as controls. The "intestinaltest " depends on the fact that the addition of asmall amount of extract of thyroid to Ringer’s fluidin which a strip of cat intestine is suspended causesan increase both in the rhythmic movements of thestrip and in its tone. The test is not very delicate,nor indeed specific, since many other substances mayproduce a similar action. The serum of normalblood contains a substance which produces marked

1 Quarterly Journal of Experimental Physiology, xiii., 2.

augmentation and acceleration of the contractions ofan isolated strip of cat’s ileum ; the effect of serumfrom cases of exophthalmic goitre is, however, fargreater than that of the serum of normal blood.Thyroid extract also produces augmentation andacceleration of the contractions of the intestinal strip,but the action of thyroid extract is relatively slightcompared with that even of normal serum, and thespecific autacoid of the thyroid (thyroxin) has noeffect in the intestinal strip. Moreover, neithernormal blood nor exophthalmic blood, when fed totadpoles, have any influence upon their metamor-phoses, though thyroxin markedly accelerates the

metamorphosis of frog tadpoles (tadpole test). Theseexperiments, therefore, lend no support to the viewthat normal thyroid secretion containing thyroxin ispoured into the blood in appreciably increasedamount in exophthalmic goitre. Nor do they supportthe view that the symptoms of the disease are due tothe presence of an abnormal amount of free adrenalinin the blood, since if this were the case, the con-tractions of the intestinal strip would tend to beinhibited instead of being augmented.

TWIN TUBAL PREGNANCY.

ACCORDING to Mr. Leslie B. Arey, of the AnatomicalLaboratory, Northwestern University Medical School,Chicago, the commonest plural pregnancy whichinvolves the uterine tubes is the combined tubo-uterine type. One hundred and nineteen cases werecollected by Weibelin 1905, although probably someof them were merely presumptive and not all weretwins. Plural gestation in the same tube, of which37 genuine cases were collected by Hardouin in 1919,is next most frequent, while bilateral tubal preg-nancies are rarest of all, there being less than a dozenon record. A study of the literature shows that tubalpregnancy, whether single or twin, tends to occur inwomen who are older by 4t years (31-0 years) thanthe average age for motherhood (26-5 years). Twogroups of cases may be distinguished. The firstwhich forms three-quarters of the total consists ofwomen who have borne children, but without recentpregnancies, and nearly one-half are multiparee,many having had abortions. The remaining fourthconsists of women who have been married a relativelylong time, on an average six years, but withoutbecoming pregnant. The explanation of this sterileinterval is to be found in tubal inflammation, which isthe chief factor in tubal gestation. An inflammatoryprocess may prevent pregnancy for a variable periodeither by mechanically blocking fertilisation or bycausing young ova to disintegrate, and on subsidenceof the inflammation the tube becomes a possiblenidus for the growing ovum. Rupture occurs in

58 per cent. of all cases of single tubal pregnancy.It is most frequent in tubes containing normalembryos, less common in tubes in which the embryosare pathological, and rarest in those without embryosbut containing degenerated ova, so that a growingnormal embryo is a special menace to the mother.Eighty per cent. of the recorded specimens of mono-chorionic tubal twins have ruptured, but the writerregards this figure as too high, because unrupturedspecimens with degenerated embryos necessarilyescape recognition. The average time of rupture insingle tubal pregnancy in 25 cases was at 7-7 weeks,as compared with 10-3 weeks in a series of 28 cases oftwin tubal pregnancy, but it is probable that theunusual feature of twinning leads to a more representa-tive collection of the older specimens than in singlegestations, so that the later date in the twin group isnot really significant. The symptoms of twin tubalpregnancy are identical with the classical picture ofordinary tubal gestation. In 9 out of 36 caseswith adequate menstrual histories the embryos wereof such size as to indicate that there had been oneand in a few cases more than one menstrual periodbefore pregnancy had begun. The condition has

1 Surgery, Gynecology, and Obstetrics, June, 1923.