1041

quantities as small as 15 cubic centimetres of alcohol pro-longed the time of learning considerably, as the second tableshows.

TABLE I.

TABLE II.

The alcohol taken after breakfast increased the requiredtime by 5 to 7 per cent. ; when it was taken before break-fast the time was increased by 69 per cent. The influence,too, of 50 cubic centimetres of alcohol taken after break-fast was less than that of 25 cubic centimetres takenbefore breakfast. After some months’ practice the time

required to learn 25 lines by heart was reduced by aboutone-third, whether alcohol was taken or not. Not onlydid the alcohol lengthen the time taken to learn 25 lines byheart, but it also lengthened the time taken to repeat byheart the same lines a given number of times, and from thisthe writer concludes that the lines could not have been so

thoroughly learnt under the influence of alcohol. Each lot oflines which had been learnt by heart from Jan. 20th to

April 16th were again learnt by heart 107 to 108 days later,when no alcohol was taken. The shorter the time taken torelearn these lines the better must have been the mind’s

power of assimilation on the first occasion. It was foundthat those lines which had been learnt under the in-fluence of alcohol took an appreciably longer timeto relearn than the others. The table illustrating this

point also shows the interesting fact that, after ex-

cluding the alcohol days, those lines which after practicein learning by heart took a short time to learn on the firstoccasion took longer to relearn than those which had costmore time at the first-in other words, "quickly come,quickly go." Since A. Smith’s well-known experiments onthe influence of alcohol on the memory little work has beendone in this particular field, and though Dr. Vogt’s resultsare merely confirmatory of Smith’s, the former deserves ourheartiest praise for the indefatigable energy which led him toinflict so many thousand lines upon himself in the cause of

Sent. 26th. 1910. C. L.

POOR-LAW REFORM: THE COMMISSION’STWO REPORTS.

To the Editor of THE LANCET.

SIR,—The issue of two conflicting reports by the late Com-mission has, no doubt, been useful in increasing the interestin the important subjects dealt with. But are not the medicalprofession, like many other people, taking the details of theseconflicting schemes too seriously ? When we consider care-fully the personnel of the Commission we can only regard onereport as a judicious compromise by men and women

possessed of strong and very diverse views, and the other asthe work of a very small body of people whose strong viewsare not generally acceptable to the community. This beingso, it seems extremely improbable that any proposals put beforethe country by Parliament will coincide with those containedin either report, whether in the form in which they are printedor in the various modifications which we are from time totime informed by their supporters have since been accepted bythe authors. But the waste of time entailed in blessing orotherwise one or other of these reports is not so seriousas the tendency caused by these essays in partisan-ship to divide the profession into different camps. It willtake us all our time to think out, and agree upon, the bestway of arranging the medical treatment of the poor so thatthe poor shall be properly treated and the doctors be properlypaid, which are after all the two main ends upon which weas a profession are called to express an opinion. We cannotafford to follow the example of some laymen engaged inthis controversy and seek out the private and politicalopinions of our colleagues in order to discredit their

proposals. Even a free trade doctor may be expected to

protect the interests of the poor, and the most Fabian Socialistmay generally be trusted to look after his individual fee.Time presses, and all unnecessary points of personal contro-versy must be neglected if the profession is to have its properinfluence in shaping Poor-law medical reform.

I am, Sir, yours faithfully,Sept. 23rd, 1910. PROFESSIONAL UNION.

A VISIT TO THE MUSKOKA SANATORIUMSFOR TUBERCULOSIS.

(FROM A SPECIAL CORRESPONDENT.)

BY the invitation of Mr. W. J. Gage of Toronto, chair-man of the executive committee of the National SanatoriumAssociation of Canada, I visited the sanatoriums for thetreatment of tuberculosis at Muskoka.

The Muskoka Lake Distriet.-TToor the Sanatoriums are-Reached. -The2.r Origin.

The Muskoka Lake district is situated at a distance of112 miles or so from Toronto. I got on a mid-day expressof the Grand Trunk Railway at Toronto, and although astrike was in progress among the workers of the railway, thetrain travelled smoothly and at a moderately rapid rate.The scenery of the first 50 miles of the route is placid andsomewhat uninteresting, but after Lake Simcoe hasbeen sighted the country begins to take on a wilder

aspect. On Kempensfeldt Bay, an inlet of Lake Simcoe,ten miles wide, are the towns of Allandale on one side andBarrie on the other. The train makes a detour of the bay,passing within a few feet of the lake, so that one has the oppor-tunity for judging of the remarkable clearness of the water, acharacteristic of Lake Simcoe, for which it is widely famed.When the train leaves Barrie a really lovely country is passedthrough. Glimpses are caught here and there of lakes andstreams shimmering in the sun, and forests and rocks borderthe line on both sides. At length the train pulls up at

Muskoka Wharf, at the foot of Lake Muskoka, the mostsouthern of the three large lakes of the district, and whatmay be termed the entrance to the Muskoka region properis reached. The region comprises an area of about 10,000square miles, and is perhaps the most picturesque part of theProvince of Ontario. Within this district, which has a meanaltitude above the sea of 800 feet, there are nearly 1000lakes and ponds, connected by innumerable streams. The’chief lakes are Muskoka, Rosseau, and Joseph. The regionabounds in pine forests, and the soil is of a rocky porousnature.On leaving the train at Muskoka Wharf I made it my

business to discover a launch, which I had been informed

plied between the sanatorium and the wharf for the purposeof conveying patients and visitors to and fro. I did not find

the launch, but I came across Dr. W. B. Kendall, the

physician-in-chief of the sanatoriums, who had come withhis speedy gasoline boat to fetch some friends. I gave himthe letter of introduction I carried and was quickly in hisboat, which can travel at the rate of about 20 miles an hour.The Cottage Sanatorium to which we were bound is some

1042

two miles from the wharf, and it took us but a short time toreach our destination.

The Mitskoka Cottage Sanatorium.There is, and has been for a long period, much pulmonary

tuberculosis in Canada, and in 1896 the National SanatoriumAssociation was founded, the pioneer association of its kindin Canada. Its object is to provide institutions for the isola-tion, treatment, and cure of persons affected with pulmonarytuberculosis. The Muskoka Cottage Sanatorium was thefirst institution to be established under its auspices, and isfor the treatment of those suffering from incipient tuber-culosis.The main building of the Cottage Sanatorium, the one of

which I first caught sight when our boat slackened speedand drew up at the landing, is a striking landmark ofMuskoka Lake. It is a large roomy wooden building, itsfront faced by wide verandahs and surmounted by a toweroverlooking Muskoka Bay. It stands on a height, and

together with its cottages is placed in a park of 75 acres,chiefly consisting of pine forest. It is sheltered from thenorth and north-west winds by rocky ridges and pine trees.From the standpoints of scenery, air, and soil the situationseems almost ideal for its purpose. The air is very clear, themean relative humidity is 70 to 75, and the mean averagetemperature is 42° F. ; the district is very rocky and thesoil porous and dry.The administration building (Fig. 1.) was erected at the

joint expense of Mr. W. J. Gage and of the late Mr. Hart A.Massey, both of Toronto, and was opened in 1897 by Dr.H. Barnes, then president of the British Medical Association,which had just met in Montreal. Dr. Kendall shortly aftermy arrival showed me through the building. It willaccommodate 20 patients and contains the sleeping apart-ments of the management and service of the institution, thehousehold and medical staff offices, the laboratories, thedispensary, reception-room, music-room, and dining-room.There are sun chambers for patients who cannot sit outsideon stormy days. I was favourably impressed by the roominessand comfortable appearance of the whole building, andespecially by the laboratories, which form a very prominentfeature of the institution. Dr. Caulfield is in charge of thelaboratories, assisted by Dr. Beattie, and some valuableinvestigations have been, and are being, undertaken chieflyin studies of complement deviation with a view to the

discovery of immunising methods. A collection of animalsis kept for the purpose of experimentation and Dr. Caulfieldinformed me that he intended to make use of young pigswith this object in view. I am happy to be able to state thatall the animals looked well and contented and did not seemto have suffered in any way as a result of the use which hadbeen made of them.The Muskoka Cottage Sanatorium is really a colony for

consumptives, and reminded me both with respect to situa-tion and management of another colony for consumptives atLake Saranac in the Adirondack region of New York State.As at Saranac, the majority of the patients are housed inpretty cottages, built at the expense of private individuals,which are dotted about within easy reach of the administra-tion building. These cottages contain from two to eightsleeping rooms each, and are, of course, one and all fittedwith spacious verandahs. The cottage system was establishedfor the sake of ensuring privacy, and also because the patientswho live in cottages are not embarrassed by the feeling ofrestraint and confinement which is apt to oppress those whoare massed together in considerable numbers in one building,however large that building may be.Many patients live in tent cottages, small roofed wooden

buildings, which can be occupied by one or two persons.Other patients occupy what are known as "shacks." A

building of this kind, designed by Dr. Kendall, is a longone-storey building with entrance in the centre, which opensinto a fair-sized room provided with lavatory accommoda-tion, and which is so furnished that it can also be usedas a sitting-room. On either side of the sitting-room areplaced the sleeping cots. The front of these shacks fromthe top to within a short distance from the ground has

glass shutters which can be opened or closed as the medicalattendant may think fit. The accompanying illustrationswill convey a good idea of the appearance inside and outof the shacks. (Fig. 2 and Fig. 3.)

It should be mentioned that all the patients of the

Cottage Sanatorium have their meals in the large dining-roomof the administration building at numerous tables which willeach seat from four to six individuals. The food is plentifuland wholesome, but the over-feeding plan is not followed atMuskoka. I partook of meals with the patients and cantherefore vouch for the good quality of the food. I likewise

slept in a cottage reserved for patients, and can also givetestimony as to the comfort and healthfulness of the sleepingquarters. Each patient has a separate room, but there areseveral large bedrooms, so that if desired two patients mayshare a room.

Indoor and outdoor amusements at the sanatorium are

many. Muskoka Bay is well suited to boating of everydescription, and fair partridge and rabbit shooting is to behad. In the winter snow-shoeing, tobogganing, skating,and driving are the favourite forms of exercise. There isalso a shooting club amongst the patients, and the sana-

torium possesses an excellent billiard room.The medical staff of the Cottage Sanatorium consists of a

physician in chief and two medical men who devote theirattention largely to laboratory work. The resident nursingstaff is fully adequate to the ordinary needs of the institu-tion, but, if required, special nurses can be secured. Inoticed that several of the permanent nursing staff wereBritish, and was pleased to learn that nurses of British birthare in request at Muskoka.

The Muskoka Free Hospital for Consumptives.At a distance of about one mile from the Cottage Sana-

torium (Fig. 4), nearer to the railway and to the town ofGravenhurst, is situated the Muskoka Free Hospital for Con-sumptives. The main buildings are of wood and are locatedon a rocky ledge above the lower part of Lake Muskoka.The buildings are large and rambling and have been addedto as necessity and convenience dictated, and from the veryincoherence of their architecture they present an extremelypicturesque outward appearance. The sanatorium faceswest and south and is protected from the north and eastwinds by thick pine woods. The matron of the institutionaccompanied me to every part and was most courteous inexplaining matters. The main building contains four eight-bed wards, one of five beds, and one of four, and the patientswere mostly women. The wards are lofty, well-lighted, andin the nature of things airy and well ventilated; they arealso provided with wide verandahs. The bathroom and

lavatory accommodation is adequate. The heating is bysteam and the lighting by electricity. There are, in addi-tion, in the main building a reception-hall and sitting-roomfor patients, physicians’ office, throat-room, dispensary,laboratory, and staff quarters ; and in a detached annexthere are dining-room, pantries and kitchen, and servants’

quarters. Another building contains the ice house and coldstorage chambers. Most of the male patients reside in

shacks, which in all essential details resemble the one alreadydescribed. The basis of the treatment is open air, and it hasbeen demonstrated that these shacks best fulfil the requiredconditions.As at the Cottage Sanatorium the food is wholesome and

provided without stint. I saw the patients at dinner at theFree Sanatorium, and remarked that with very few excep-tions they seemed to enjoy the meal heartily. The patients areencouraged to take exercise and to do light work. Gardeningis a favourite diversion with them, and I was greatlyinterested in the poultry-raising experiments which areconducted under the direction of a patient. I was shownover the "hennery, as it is termed, and was astonished atthe success achieved in rearing chickens under somewhatadverse circumstances. Hawks are plentiful, and of courseare a source of danger to the young fowls, but rats which arevery numerous are a far greater peril. However, the guardianof the fowls is provided with a gun and with traps of greatvariety with which to fight the enemy, and his results maybe gauged by the fact that he has nearly 1000 fowls in hisenclosure, and that the institution is supplied with poultryand eggs from the hennery. "

General Remarks.

The Cottage Sanatorium is for paying patients and theprices are moderate. The Free Sanatorium, as its nameimplies, is more or less free. However, as is the case in all

public institutions on this continent, if a person can afford topay for treatment or care he does pay. Consequently, at the

1043

Fia. 1.

Administration Building, Muskoka CottageSanatorium.

FiG. 2.

Interior view of a ’’shack."

FIG. 3.

Exterior view of a " shack.’

FlG.4.

Muskoka Free Hospital for Consumptives, Cirav enhurst.

1044

Free Hospital for Consumption at Muskoka a large number ofthe inmates pay whatever sum may be within their powertowards the upkeep of the institution. The Free Hospitalwill accommodate more than 100 patients and is always fullto overflowing. The Cottage Sanatorium will hold about 75patients, and it is rather curious to note that the favouritesanatorium season at Muskoka is in the winter, when thetemperature is frequently 200 F. below zero. The physician-in-chief visits the Free Hospital every day, and there isbesides a resident medical man. It may be stated that theFree Hospital was opened in 1901 and that the results oftreatment therein and at the Cottage Sanatorium have beenvery encouraging. After an instructive and interesting visitI travelled to the railway depot by the omnibus in whichpatients are conveyed to and from the train. I am convincedthat few situations can be better for the treatment of

incipient pulmonary tuberculosis than Muskoka, and so far asI was able to judge the management of the two sanatoriumsI visited leaves little to be desired.

THE CHOLERA MENACE AND THE

RESPONSIBILITY OF HULL.

(FROM OUR SPECIAL SANITARY COMMISSIONER.)

Hull,Sept. 23rd.IT will be remembered that when, in 1892-3, the last great

cholera epidemic spread throughout Europe, reaching fromHamburg to Marseilles and from Calais to Constantinople,the only towns affected in England were Grimsby and Hull.Some isolated cases of cholera occurred even in inlanddistricts, but there were 35 cases at Grimsby, resulting in 21deaths, and 17 at Hull, causing 12 deaths. These cases wereall the more menacing as it was easy to show that most of thepatients had been living in very insanitary surroundings, butthere was no such clear evidence of contamination importedfrom abroad. It seemed as if the diarrhoea and the choleraicdiarrhoea which then prevailed in an epidemic form might bethe forerunners of an epidemic of genuine Asiatic cholera.Thus at Hull, from Sept. 6th to Oct. 20th, 1893, out of apopulation of 208,639, the 17 cases of cholera resulting in 12deaths were notified, together with 137 cases of choleraicdiarrhoea, giving rise to only 4 deaths, and 396 casesof diarrhoea causing 112 deaths-altogether 550 cases and128 deaths. The death-rate from diarrhoea in 1893 was2-27 per 1000 of the population, and the deaths from theseven principal zymotic diseases were equal to 4-01 per1000. Last year, that is in 1909, the deaths from diarrhoeawere only equal to 0 - 59 and from the seven zymotics to 1 - 35per 1000. These figures do not, however, imply that we aresafer now than in 1893, for in 1891, before the cholera

epidemic began, the zymotic death-rate at Hull was only1 - 61 per 1000 and the deaths from diarrhoea 0 - 60 per 1000.There was a slight rise in 1892 and then the high figures of1893 were reached, and they constituted the maximum of thelast 20 years.The exceptional heat of the summer in 1893 was doubtless

the chief cause of the extensive prevalence of diarrhoea, but italso gave rise to the fear that it would favour the importationof cholera and that Hull and Grimsby would be the doors ofentry. To-day the cholera is once more travelling westwardsin Europe. As yet the chief mischief is in Russia, but it is

precisely at Hull that the largest number of Russian

emigrants land, and there is much traffic and tradebetween Hull and the Baltic ports. Will the conditionsof 1893 repeat themselves and shall we escape as easily ? It is true that we have had an exceptionally coldsummer, and this lessens the danger ; but by next year thecholera may have travelled much nearer to our coasts and theclimatic conditions are likely to be less propitious. Are webetter armed to resist an invasion than we were 17 yearsago ? It would be very unsafe to rely on the fact that weescaped from serious injury on the previous occasion. Somuch depends on hazard. An accident may defeat the best

precautions, though the better the precautions the less

likely the occurrence of such an accident. The question,therefore, that the virulence of the Russian cholera epidemicforces upon us to-day is whether our defensive position is

stronger now than in 1893. In answer it may be con-

fidently asserted that, so far as the first precaution to be

taken is concerned, we are distinctly in a stronger position.In 1893 the Aliens Act was not in force. This law was notmeant as part of our sanitary legislation, but incidentally itsapplication greatly facilitates the medical examination of

precisely that class of incomers who are the most likely tobring with them the seeds of cholera.Under the Aliens Act the shipping companies are held

responsible for all the emigrants they bring over. To letone escape is to incur the penalty of a heavy fine.Therefore, on the arrival of a ship all the emigrantsare gathered together and the medical inspection does notbegin until the officials are assured that no one is missing.Of course, if there is an infectious case it is at once removedto the hospital, the family of the patient isolated, and anypersons who have been in contact with the patient are notifiedto the sanitary authorities of their place of destination.

Special care, of course, is now taken in watching for symptomsof cholera. Of the numerous and international crowd of

patients treated at the Hull Hospital for Infectious Diseasesit appears that the Lascars make the best patients. They arealso very grateful. When, on a following voyage, theyreturn to Hull they make a point of going to thehospital and by signs and bows endeavour to expresstheir thanks. Chinamen also make very good patientsif nothing is done to offend them. Unfortunately itoften happens that some ignorant person indulges in careless,silly remarks, especially about the pig-tails, and if a Chinesepatient thinks he is not treated with proper respect then it isdifficult to manage him. But the real trouble, and at thepresent moment the special danger, is in respect to the poorimmigrants from Russia. It is true that they are for themost part transmigrants and are merely landing at Hullon their way to Liverpool or Glasgow, where they are

to sail for America. Formerly some of these poorpeople did not have a through ticket, or had beenrobbed at Hamburg and landed penniless at Hull underthe impression that in England the streets were pavedwith gold. They might be seen wandering about thestreets in the hope of obtaining some help. To-day,with the Aliens Act in force, this is no longer possible.Shipowners are very careful not to allow anybody to embarkfor an English port unless he is in possession of money or atranshipment ticket. Thus it would be difficult nowadaysto meet with a stranded emigrant; and though efforts aremade occasionally to sell false tickets to ignorant people, allthe shipping companies are interested in preventing suchfraudulent practices and securing the severe punishment ofthe culprits. The immigrant who lands in England mustprove that he has money and give a satisfactory explanationabout himself. Though this was intended to exclude un-desirables and to prevent foreigners becoming paupers assoon as they landed, it will easily be understood that it also,if only incidentally, serves to keep better watch over thepersons and health of these new arrivals and thus see that

they do not introduce such diseases as cholera into thiscountry.The emigrants who are going on farther are placed in vans

or wagonettes and taken to the large sheds and waiting-rooms built purposely for them by the side of the mainrailway station at Hull. If they are numerous enough aspecial train is made up for them ; if not, they have specialcarriages attached to an ordinary train. As a rule, andwhile waiting, a meal is served, and if many Jews are

present a rabbi from Hull generally attends to see that

they get nothing but Kosher food. In regard to theaccommodation for emigrants provided at the Hull railwaystation, it must be noted that the closets are not satisfactory.They are on the trough system and there is no privacy.Better might be managed. There should be stand-up closetsas on the continent, and perhaps a few lock-up closets withseats, the keys to be supplied to the cleaner passengers at acharge of perhaps a halfpenny. On reaching their destina-tion, which in the majority of cases is Liverpool, representa-tives of the shipping companies meet the train and conveythe passengers on board or to lodging-houses specially pre-pared for them, where they remain till their ship starts.Thus, it will be seen that both the emigrant and the trans-migrant are much more carefully looked after and watchedthan was the case 17 years ago. This, however, is only ourfirst line of defence, and by far the weakest line. Nofrontier, however keen the watch ; no quarantine regula-tions, even, as in olden days, when prolonged to the