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Annotations.

THE DIRECTOR OF THE NEW SCHOOL OFHYGIENE.

" Ne quid nimis."

THE selection of Dr. Andrew Balfour for the postof first director of the School of Hygiene endowed bythe Rockefeller Foundation will cause no surprise,since his unique qualifications for the post are

sufficiently obvious. We expressed a belief lastmonth when recording his resignation from theWellcome Bureau of Scientific Research, which hehas directed for ten years, that his period of unemploy-ment would be short, and indeed it- has proved so.Dr. Balfour has had a brilliant academic career atEdinburgh and Cambridge, where he was a prominentmember and afterwards captain of the football team,He also gained his Scottish international colours. Heserved in the South African War as civil surgeon andwas director of the Wellcome Tropical’ ResearchLaboratories in Khartoum from 1902-1913. Duringthe Great War Dr. Balfour acted as sanitary adviserto Headquarters in Egypt, Salonika, Mesopotamia.India, and Africa. His reports on the health condi-tions of that period are of first-rate importance.In 1918 he undertook the investigation of the organisa-tion of the public health services for the EgyptianGovernment and his report on the health problemsof Mauritius followed on a visit to the island in 1921.At the Wellcome Bureau and elsewhere Dr. Balfourhas himself undertaken much valuable research,notably on the spirochaetosis of relapsing fever,blood conditions, and bacteriological problems con-nected with sanitation. He is joint editor of Lewisand Balfour’s " Public Health and PreventiveMedicine " and has published a number of mono-graphs in connexion with sanitation in the tropics.The choice of a director of an institute establishedfor teaching and research is analogous in some

respects to that of a Prime Minister, for on the wisdomshown in this initial appointment depends the forma-tion and later the cohesion of the team of associateworkers. Honesty of purpose, skill in administration,knowledge of men-all these are indispensable in thehead of a State or of a research intitute, but the lattermust also possess considerable scientific standing ifhe is to attract fine colleagues. We congratulate thecommittee on having chosen a man under whosegeneral direction distinguished specialists will beproud to work. ____

THE STRUCTURE OF THE THYROID GLAND.

THE appearance of diagrammatic simplicity which I"ordinary sections of the thyroid present has encourageda belief that its essential structure is obvious andwell understood. In the current number of theJournal of Pathology and Bacteriology (vol. xxvi.,p. 459), however, Dr. G. Scott Williamson andDr. I. H. Pearse bring forward a novel interpretationof its morphology. The familiar vesicle lined withcubical or columnar epithelium and filled with colloidis not, according to these authors, the unit of structure,but a mobile and transitory phase of functionalactivity. The fundamental unit is a lymphatic spaceor sinusoid in which long convoluted columns ofsyncytial epithelium float, richly covered with a

plexus of capillaries and not continuous with oneanother. In their resting stage these epithelialcolumns are familiar as the interalveolar masses ofundifferentiated epithelium lying between the colloid-filled vesicles. Activity takes place along twodistinct lines. In the first, droplets of colloid appearat various places in a column and increase in size untilits continuity is broken up by a series of tense vesiclesof varying sizes round which the epithelium isrearranged ; this process of " vesiculation " givesrise to the conventional typical appearance of thethyroid, but, in the view of the authors, it does not

represent the real secretory activity of the gland.This is exhibited in the second process described as" lacunation " in which the epithelium swells, becomesgranular and vacuolated, and then partly dissolves,the resultant fluid mass accumulating in relativelylax irregular spaces in the centre of the epithelialcolumns. At the same time the lymphatic spacebecomes more or less distended with liquid, andlymphocytes appear in the intralobular lymphchannels. This secretory activitv is present in verysmall amount in the average normal thyroid. Judgingfrom the authors’ description and figures it isrepresented more largely in Graves’s disease, and weshall await with interest the extension of these newideas to the interpretation of pathological changes.

FIFTH CONGRESS OF THE FAR EASTERN

ASSOCIATION OF TROPICAL MEDICINE.

FROM Sept. 3rd to 8th the Fifth Congress of theFar Eastern Association of Tropical Medicine met atSingapore, under the presidency of the Hon. Dr. A. L.Hoops, principal civil medical officer of the StraitsSettlements, and member of the Legislative Council.In his presidential address Dr. Hoops referred to theformless growth of cities, with the consequent over-crowding and dissemination of preventable diseasessuch as tuberculosis. Town planning, zoning, thebuilding of houses, the provision of cheap transport,and of modern sanitary arrangements, must precedethe destruction of insanitary tenements. Dr. Hoopscontinued :-

Starvation is not common in the tropics. More malnutri-tion results from the use of improper food, and badlyprepared food, than from lack of food. The three greatdeficiency diseases, beri-beri, scurvy, and rickets, are allpreventable by proper diet, plus sunlight in the case of rickets.... The prevention of dental decay will avert the majority ofdigestive troubles to which flesh is heir.... In Malaya therural population, amongst whom under-milled rice is thestaple food, and breast feeding is almost universal, have goodteeth. Amongst city dwellers, many of whom eat overmilledrice, or overmilled wheaten bread, and whose babies are oftenbottle fed, a sound head of teeth is the exception. Medicalinspection of schools here during the past two years disclosesthat nearly two-thirds of school-children in Singapore cityare suffering from serious dental decay, while the proportionin our rural schools in Province Wellesley is under 5 per cent.Our large Eastern cities need pre-natal clinics, maternityhospitals, training centres for midwives, post-natal clinics,child welfare activities-dispensaries and sanatoria for thetuberculous-venereal clinics, school and dental clinics.But what will these avail, unless we remove the sources ofevil-overcrowding and bad feeding ? Good housing is apowerful agency in the suppression of that scourge ofmankind-plague. In Assam the moving of inhabitants frominfected houses to new quarters has greatly aided the diminu-tion of kala-azar.

Dr. Hoops went on to deal specifically with malaria,ankylostomiasis, beri-beri, and other diseases, all ofwhich were the subjects of many papers and discussionsduring the Congress. Three hundred medical men,representing 15 countries, were present, the Congressbeing the largest and most representative yet held.A painful interest attached to the acceptance by theAssociation of the invitation to hold its sixth congressat the Tokio Imperial University, for many of themembers of the strong Japanese delegation whichdelivered the invitation had left their families inTokio and could hear no news of how they had faredduring the earthquake. Among the social functions ofthe Congress was the laying of the foundation-stone ofthe Singapore Medical School, by Sir LaurenceGuillemard, Governor of the Straits Settlements. Atthe final meeting of the Congress the following resolu-tions were adopted concerning uniform port quarantineprocedure in the Far East :-

1. The regulations of the International Convention ofParis, 1912, are not suitable for the ’proper carrying out ofquarantine measures in the Far East.

2. The division so far proposed by 1’Office Internationaled’Hygiène and the Office of Hygiene of the League of Nationsdo not alter this unsuitability.

3. That circumstances ir the Far East demand a quitedifferent quarantine procedure from that in Europe. It is

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therefore desirable that a separate agreement should be.drawn up to govern quarantine regulations in the Far Eastto allow of the necessary cooperation between the differentFar Eastern countries. It is also agreed that a copy of thisresolution be sent to all Governments of the Far East andthe Office of the Health Committee of the League of Nationsat Geneva, and l’Office Internationale d’Hygiene at Paris.

In regard to these proposals the Hon. Mr. E. A.’Crilmore, head of the Health Service in the Philippines, Ihad previously expressed the hope that the handlingof the matter by the League of Nations Committee- would not make it difficult for America to participate,and had suggested that a conference of the countriesinterested would be helpful. The Congress was feltto have been a great success, and the following weekwas spent by a number of the overseas members intouring the Federated Malay States and Penang.

PAINLESS MAXILLARY SINUSITIS SIMULATING

PULMONARY TUBERCLE.

THE early diagnosis of pulmonary tuberculosis is’of such fundamental importance that any febrilecondition associated with cough and wasting mustof necessity excite suspicion. It is a familiar fact tomost physicians and laryngologists that pulmonarytuberculosis is often simulated both as to symptomsand physical signs by inflammatory conditions ofthe upper air passages, but it is open to questionwhether this fact is sufficiently generally recognised.An interesting paper by Dr. A. Lowndes Yates, whichwe publish in this issue of THE LANCET, should serveto draw attention to a special form of this problem-viz., maxillary sinusitis--especially in cases withoutempyema of the antrum and not associated with pain.Dr. Yates gives a brief resume of the literature onthe subject, and shows that since 1916 considerableattention has been paid to this question. He suggeststhat when the nasal protective mechanism fails andinfective organisms reach the nose, in some patientsthe infection may stop short of producing empyemaof the antrum and yet lead to reactive changes owingto the flow of pus into the pharynx and laryngo-pharynx. The delay in the removal of the infectedmucus allows of toxic absorption, resulting in somecases in wasting and evening rise of temperature andnight sweats. He describes in some detail the signsproduced by such a condition. Apparently anteriorrhinoscopy shows little or nothing, whereas posteriorThinoscopy may show very definite changes and moreor less characteristic appearances may be seen in thepharynx and larynx. Dr. Yates finds that thiscondition may coexist with pulmonary tuberculosis,and in this combination the appearances are different.A point of interest and importance is that a patientwith the painless form of maxillary sinusitis may bequite unaware of its existence, and may refer all hissymptoms to his chest. Dr. Yates’s observationswould suggest that in any case in which cough existswith obscure signs in the chest, and in which repeatedinvestigation of the sputum is negative, a carefulexamination of the nose and throat for maxillarysinusitis should be made. He gives such a cleardescription of the appearances found in this con-

dition that his observations should be capable ofeasy confirmation or criticism. The subject is ofspecial importance, as it may afford a means of exclud-ing pulmonary tuberculosis without loss of time insome obscure cases, and lead to a more rapid restora-tion to health and comfort.

THE INCOME AND EXPENDITURE OF THE

LONDON HOSPITALS.

THE annual statistical report for the year 1922 onthe income and expenditure of 113 London hospitals,issued under the auspices of King Edward’s HospitalFund for London, has just been published. 1 Thereport is divided into five sections, each of which

1 Spottiswoode, Ballantyne and Co., Ltd., 1, New-streetSquare, London, E.C. 4. Price 2s. 6d., post free, 2s. 9d.

respectively gives in tabular form : (a) General parti-culars of the work done and the accommodationprovided ; an analysis of (b) the income, and (c) theexpenditure ; (d) the cost of working ; and (e) groupcomparisons of the different hospitals. In this lastsection the hospitals are classified as (1) larger generalhospitals, with and without medical schools; (2)smaller general hospitals ; (3) consumption hospitals;(4) hospitals for women and children ; (5) ophthalmichospitals ; (6) hospitals for epilepsy and paralysis ;(7) cottage hospitals, and (8) lying-in hospitals. Itis encouraging to note that in 1922 the total averagenumber of available beds (12,421) in the 113 hospitalsunder review shows a net increase of 995 over thefigures for 1913, although there has been a slightdecrease since 1920. In-patients in 1922 numbered162,149, a net increase of 17,511 over 1913. Whilethe new out-patients in 1922 show a decrease of48,000 as compared with 1913, the out-patientattendances have increased by 1,225,000. Theaverage attendances of each out-patient were, in1913, 3-5 ; in 1920, 4-3 ; in 1921, 4-2 ; and in 1922,4-5. The income of these 113 hospitals (apart fromspecial distributions) increased from 21,470,000 in1913 to z2,401,000 in 1920 and z2,566,000 in 1921.In 1922 it decreased slightly to joe2,398,000. It mustbe remembered, however, that the special distribu-tions which are omitted from these figures includedin 1922 z243,000 from voluntary sources-viz., fromthe first and second instalments of the proceeds ofthe combined appeal. It was part of the scheme ofthis appeal that for an agreed period the cooperatinghospitals should suspend all independent appeals.It was anticipated therefore that, other things beingequal, the income from voluntary sources would bebelow the normal if the proceeds of the combinedappeal were excluded, and above the normal if theywere included. The difficulties of the hospitals, ascompared with conditions before the war, were pro-duced by increase of expenditure and not by decreaseof income. That expenditure now shows a substantialdecrease : after having risen from 21,192,000 in 1913to z2,784,000 in 1920, it fell to 22,776,000 in 1921 andto 22,572,000 in 1922. It is reassuring to observethat the greater part of this fall in expenditure since1920 is not due to decrease in work but to reduction

, in cost. The report is a valuable document for all, concerned in hospital management.

THE OTOLITH APPARATUS AND FŒTAL

ORIENTATION.

As is well known, the internal ear is divisible intothree parts, which subserve three separate anddistinct functions : the cochlea serves for the percep-tion of sound ; the semicircular canals serve for theperception of movements of the head in space, or,more exactly, for the perception of acceleration ofsuch movements ; and the otolith apparatus forapprehension of the relative position of the head tothe perpendicular, and also for the regulation of themuscle-tonus of the limbs, trunk, neck, and eyes.Our knowledge of the function of the otolith apparatushas recently been considerably advanced by theexperiments of Magnus and de Kleijn, and it has beenshown that, through reflex action from the otoliths,the various positions of the head in space influence thetonus of different groups of muscles of the trunkand limbs, and therefore the position of the body ;the so-called " neck-reflexes," whereby alterations ofposition of the neck affect the tonus of the body-muscles, complicate these reactions, and it is probablethat a whole series of similar reflexes exists whichassist the animal in maintaining or in rapidly alteringits posture. Dr. Ant. Precechtel, dozent in theCzechoslovak Aural Clinic of Prague, in a paperrecently read before the Society of CzechoslovakPhysicians, makes the suggestion, interesting alike toobstetricians and otologists, that these otolith reflexesplay the principal part in regulating the position of thefoetus in utero, whereby some 97 per cent. of births