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ending 1936 there have been about 10,000 deaths inDenmark from croupous pneumonia alone, irrespectiveof bronchopneumonia.The pneumococcal rabbit serum issued by the state

serum institute and now in general use in Denmarkhas been found to be quite as effective as horse serum,and a dose of 200,000 units now costs only aboutKr.40, whereas the price for the same quantity usedto be about Kr.350. The concentration of the serumhas been increased so that now there are 4000 to 6000units in every c.cm. The serum is in most cases givenintravenously rather than intramuscularly. Theresults, as shown by a recent study of Dr. N. I.Nissen, have been quite encouraging. His materialhas consisted of 932 cases of pneumonia in whichserum was given. The mortality of 13.5 per cent.might well have been reduced for window-dressingpurposes had he allowed himself the luxury of weedingout several fatal cases in which the serum treatmentwas not given a fair trial.

FATE OF LUPUS PATIENTS

Dr. C. N. S. Gundtoft has inquired into the causesof death of patients who had attended the skindepartment of the Finsen Institute in Copenhagenduring the past 25 years. He collected information

about 211 such cases. His findings suggest that thepatient who suffers from lupus vulgaris runs littlechance of dying of this disease, but he has a fifty-fifty chance of dying of some form of tuberculosis.The deaths ascribed to lupus itself numbered only10. But there were as many as 61 patients who haddied of pulmonary tuberculosis, and 33 who had diedof some other form of tuberculosis, such as tuberculousmeningitis. As for the non-tuberculous causes ofdeath, malignant disease was the most important,being responsible for 24 deaths. This is in itself a

testimony to the benign character of the lupus whichallowed its victims to attain a high enough age tobecome subject to malignant disease. Pointing in thesame direction were the 8 cases in which the cause ofdeath was said to be senile decay. Dr. Gundtoftdraws attention to the great frequency with whichpulmonary tuberculosis broke out shortly after treat-ment of lupus was started ; he suggests that in thesecases the lupus had been the cutaneous manifestationof an already serious though still latent pulmonarytuberculosis. The late Dr. Reyn, formerly chief ofthe Finsen Institute, was among the first to emphasisethe importance of a tuberculosis background in thelungs and elsewhere of patients who at first sightseemed to be suffering from lupus and nothing else.

GRAINS AND SCRUPLESUnder this heading appear week by week the unfettered thoughts of doctors in

. various occupations. Each contributor is responsible for the section for a month ;

his 7came’can be seen later in the half-yearly index

FROM DOCTOR DON

III

EVERY time I revisit London I rejoice that Ino longer live there. Somewhere about 100,000appears to be the maximum size to which a town can

grow and remain a coordinated social organism.Beyond that level its membership becomes as

irrational and irresponsible as a swarm of locustsor lemmings. When people are condemned to livein Hoxton or Clerkenwell or one of those amorphousareas around Wembley or Penge, it is almost impos-sible for them to feel local patriotism or to take anactive part in the life of the community. The women’sinstitutes have developed so vigorously in the villagesthat they have become a power in the land, but thehealth centres and community centres in the townslanguish and seem unable to stand by themselves.The picture-palace, the billiard-room and the by-passroad are poor substitutes for the parish pump andthe village hall, and largely in consequence Hog’sNorton is months ahead of London or Birminghamin A.R.P. Dwellers in the Harley-Wimpole Streetarea develop a sentimental attachment to St.Marylebone, but I lived there for five years withoutknowing the names of the mayor, the town clerk orany of the borough council, and I am sure thisexperience is not unique.

In medicine London has become the great Wasser-leapf with hundreds of consultants and thousands ofconsultoids. I have always deplored and foughtagainst this over-centralisation, though it is probablethat the specialist must follow the crowd as thesalmon follows the herring shoal. It is a bad thingthat the Wasserkopf should dominate clinical educationas it does by historical prestige, weight of numbersand proximity to the Royal Colleges. Few teachingphysicians in London have many friends outside theirown profession and fewer still work actively alongside

scientists, humanists or industrialists. The state ofaffairs is quite different in places like Aberdeen,Edinburgh or Oxford. In Aberdeen, for example,with the Rowett Institute and the fishing industrylooming so large, it is natural that clinical teachingshould be permeated with the importance of nutritionand industrial hygiene. London clinical teachers arepreoccupied with technical matters of interest to theguild, such as the differentiation of subarachnoidbleeding from cerebral haemorrhage or the separationof coronary thrombosis from angina of effort, andthey are less likely to stress really significant thingswhich are new but not easily incorporated in theircraft, such as the facts that a high-carbohydrate dietrequires more vitamin B, or that compensation tendsto increase the incidence of the disability compensated.The cynic cannot but observe that the deification ofLondon applies not at all to the fundamental sciences.

In surgery also famous schools have recentlyflourished outside London-in Edinburgh, Leeds andNewcastle, for example. It is internal medicine andrelated subjects such as paediatrics and psychologywhich have received excessive representation inLondon and this suggests to me that as at presentpractised they are luxury trades. The state of affairsin America and Germany, where there are manyuniversity schools of equal prestige, is much healthier,and the whole-time or semi-whole-time clinical unitsin the Scottish universities, in Manchester, Cambridgeand Oxford, may restore British medicine to a bettercondition. For highly trained physicians to do muchof the pettifogging work that is done in the HarleyStreet area is as if the president of the Royal Societywas employed at mending old ladies’ wireless sets.It is perhaps no worse than the tradition in musicwhere artists of the calibre of Hindemith may givelessons for fees and cannot very well pick and choosetheir pupils, but it links medicine with the seamierside of the arts. I was going to say that medicine

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should be more of a priesthood ; but the churchhas been commercialised for centuries and bishopsmore commonly celebrate marriages in Westminsterthan in Wigan.

* * *

The sixty-mile journey to London takes little overan hour and the time passes pleasantly enough. Forthe two-mile journey from Paddington to the RoyalSociety of Medicine the bus requires twenty minutesand a succession of stops, but this allows me to studythe most important section of Oxford Street and thecrowd which throngs it. The concourse of women

busy about nothing impresses me with one of the lessfavourable aspects of the rise in the standard of living.Seen from the top of a bus one must perforce regardthem as a herd or group and criticise them on thebasis of the opportunities they have had and thesesthetic pleasure they provide. The poets havestated that they are less beautiful than the animalsand with this one cannot but agree. Nor can theycompare with the crowds in clogs and shawl againstwhom I jostled on the streets of South Lancashirethirty years ago. Those women were rude and coarsebut they expressed vitality and they wore a localcostume or industrial uniform which enhanced thelooks of the pretty and made the whole group attrac-tive. The outburst of sympathy for Gracie Fieldsexpresses a nostalgia for a day which has gone sinceMrs. Deeds came to town. To see an attractive crowdtoday one has to travel to Ireland or to the Medi-terranean-somewhere in fact where poverty still

reigns.It is curious that women who pass so much of

their time gazing in shop windows and spend a bigproportion of their income on clothes should makesuch a bad job of it. The colours are drab, there isno sense of form, and the lines of hat, neck-line,waist and skirt clash in a way that the most amateurstudent of composition would avoid. Skirts are

either too long or too short, and high heels throwthe silk stockings in wrinkles or make the calf muscleunpleasantly prominent. Hair has improved in thelast two years as bobbed hair has grown a little

longer but is still too often either frivolous or frowsy.Finally, modern outdoor dress for women is exceed-ingly unkind to those-and they are the majority-in whom the contours have begun to sag. An Indianwoman in her sari, however old her face or form,appears in this crowd like a songbird amidst thesparrows.

I will not deny that the area between Marshalland Snelgrove and Dorville reveals some betterlookers, but these are largely young saleswomen andbuyers whose face is their fortune. Moreover thelast thing I grumble at is that women are attractedby pretty things in shops. I read 17 ague regularlyand I appreciate the thrill women get out of colours,surfaces, textures, furs and jewels. It is not theexpense which is lamentable but the result. Aboutthe only dress in which a crowd of women looks

really attractive today (and remember I am thinkingof them as groups and not as individuals) is thesemi-nude of the bathing beach, the tennis-court andevening dress. Allow them more liberty and theybecome fussy or dowdy. Access to the materials andmarkets of the world has been as bad for the modernwoman as for the modern builder, and women’s dresstoday is as depressing to look at as the new estatesthey live in. I do not believe the average crowd ofwomen will ever look attractive unless their dressfreedom is confined within narrow limits ; but untilwe can provide the right amounts of Norman Hartnelland compulsion, the promenaders in Oxford Street

will continue to be unprepossessing and I on topof my bus will sigh for the attractive crowds of Kosand Rhodes.When I look into the faces of these women, I feel

that very few of them have " laid hold on life " inthe words of the hymn tune or are keeping themselvesin intellectual or spiritual training. Behind them Isee the English middle-class home. No account oftrench warfare makes the reader feel its boredom, andno play, film or novel sufficiently stresses the insipidquality of English bourgeois life. With the decline ofchild-bearing and of religious interests the field ofconsciousness has narrowed at the same time as theamount of leisure has increased. The day passes withaimless chatter as to why Mrs. X has changed herwindow curtains, what year Princess Y had her

operation, whether the latest child-murderer has akind face, and the like. Much of the discussion leadsto bickering and rouses emotion out of all proportionto the context, for the atmosphere is charged withunutilised energy and any little lightning conductorattracts the storm. All those trivialia and tempersare stamped on the faces of the Oxford Street women.And so let us leave them to get back to their jerry-built homes.

* * *

I really do not know why I pay fifteen guineas ayear to a club when I usually lunch at the RoyalSociety of Medicine, close to my books and journals.The creation of the Royal Society of Medicine out ofa group of pre-existent societies impresses me as oneof the greatest feats of our time ; and if any surviveof those that worked that miracle, I should like themto know that we of a younger generation bow downand call them blessed. For the Royal Society ofMedicine is undoubtedly as efficient, obliging, usefuland comfortable an institution as any man could hopeto belong to.

* * *

But I must hurry off to my committee ; which,after all, is the nucleus round which the rest of thisday’s activities cluster. It is customary and of courseeasy to regard committees as the bane of professionallife. This is partly because they are not called boardmeetings, attendance at which is handsomelyrewarded, but it is even more because they are sooften inefficient at their work. Hospitals cannotfunction or laboratories be built without some

mechanism for pooling the knowledge and advice fortheir direction, but the method of representativegovernment commonly followed in colleges and

hospitals, where every fellow, or everyone who is incharge of beds or head of a department, is on thecommittee, is fundamentally wrong. A college doeshave the advantage of a permanent president, butthe chairman of a hospital committee is commonlyappointed on grounds of seniority rather than effi-ciency. When I have seen a hospital committeesolemnly discuss whether the charlady should retireon pension at 55 or 60, or a college meeting withan attendance of nearly forty fellows, whose timemust be worth at least 15s. an hour per head, wastehalf an hour deciding whether the catalogue of collegeplate should be duplicated or printed with pictures,I have realised only too clearly why democracy hasfailed in so many countries.The Medical Research Council, with a highly skilled

permanent secretariat, an independent chairman, alimited membership of experts with regular retirementsand replacements, and a large number of specialisedsubcommittees of a purely advisory nature, seemsto me a model which might be more widely copied.

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There is no medical or paramedical organisation inthe country which spends 250,000 a year with greaterwisdom or profit. With the development of jointhospital boards and hospital amalgamations importantcommittees have swollen to gigantic size, and theyshould now regard themselves merely as a folk-mootwhich will create a new instrument of government andthen disband. I have said elsewhere that most medicalschools would do well to have their organisationsoverhauled at intervals by a business psychologistor efficiency expert, and I am sure that the trend istowards smaller executive committees with greaterauthority, more employment of junior staff on

advisory committees, more whole-time administrativepersonnel, and the disappearance of the idea of acommittee as a soviet or a place to blow off steam.

* * *

Blackham’s amusing article sets me wonderingwhy the applied physiologists, who are so happy foran excuse for a trip abroad, have never taken up thestudy of sea-sickness. They have dwelt on Pikes Peakand with sulphur-miners on the high slopes of theAndes, they have raced their mules in the torriddeserts of Mexico, they have heard the avalanchesroaring down Everest and the ice cracking at thePoles, but I do not remember ever to have read ofan expedition to study sea-sickness. Of course itwould be difficult to do laboratory experimentsbeforehand, for everyone seems to agree that behaviourin the Barany chair has little to do with a life on therolling main. Nor does there seem to be much tomeasure, for though a series of papers on the Electro-lytes of the plasma, the sweat and the vomit in sea-sickness or Audiometric tracings in the prevertiginousstage of morbus maris might look well in my depart-mental report, they would merely add to the literature

and not lessen the burden of sea-sickness. And thenthere is the horrid psychological factor.

So it is clear that it is no use applying to theapplied physiologists, and our ship must be mannedby men of robuster breed, the clinical experimentaltherapeutists. We believe that it can be quite aprofitable occupation to put drugs of which we knowlittle into bodies about which we know still less,provided we follow certain general rules, which arenow pretty clearly established. It often requires agreat deal of moral courage on the part of bothpatient and investigator, as is clearly shown inMurpby’s account of the discovery of the liver treat-ment of pernicious anaemia. Mainly by these methodswe have found that nitroglycerin relieves angina,theophyllin-ethylendiamine relieves periodic breath-ing, adrenaline asthma, ergometrine migraine, andphenobarbitone and diphenylhydantoin relieve epi-lepsy, and we believe that by the same methods we shallfind a symptomatic cure for sea-sickness, nocturnalenuresis, colon-spasm, chorea, and most othermanifestations of this type, perhaps before we knowwhat is happening to the cholinesterase or thecatalase gradient in them. We finally believe that weshall creep back into the fold under the label of

chemotherapeutists now that empiricism is once

more in fashion. So if anyone will supply me with aboat of 15,000 to 20,000 tons, and about 300 passengerswho have been bribed by cheap cruising rates toagree to accept when necessary special diets, drugsand routine ward procedures, I shall be very happyto organise an expedition to study sea-sickness.On our first trip we shall probably go north, as itsounds rough north of Cape Wrath (though I believethe name really means the turning-point), and in anyevent I have always wanted to see Greenland’s icymountains.

PUBLIC HEALTH

ADVANTAGES OF CENTRALISATION IN

THE HOSPITAL TREATMENT OF FEVERS

BY DUNCAN FORBES, M.B.E., M.D. Edin., D.P.H.LATE MEDICAL OFFICER OF HEALTH FOR BRIGHTON

PRIMARILY fever hospitals were built to providefor the isolation of patients, for it was hoped in thisway to control the spread of such diseases as scarletfever and diphtheria. Just as the exclusion of home.contacts with measles fails to prevent the spread ofthe disease throughout infected schools, because thechief sources of infections are the large numbers ofschool contacts who develop and spread the disease,so the isolation in hospital of scarlet fever and

diphtheria patients has failed materially to affectthe incidence of these diseases, because the chiefcauses of spread are the overlooked case and thecarrier who freely mix with their fellows. Further,patients nursed with others not only run a risk ofcontracting diseases such as measles and chickenpox,but often have their period of infectivity prolonged:for instance a large proportion of cases of scarletfever acquire other strains of hsemolytic streptococciwhich render them more highly infectious on dischargethan home-nursed patients. The chief function ofthe fever hospital, therefore, is no longer the isolationbut the efficient treatment of the patient, includingthe prevention of cross-infection during his stay inhospital.

The public, influenced by the fear of the spread ofinfection, did not grudge the capital cost of feverhospitals because they regarded, and still regard, theisolation of these dangerous patients in hospital asof primary importance to the common weal. Unfor-tunately they have not the same interest in the careof the individual patient in hospital, and although ithas been proved that to prevent cross-infections thepresent large undivided wards should be supplementedor replaced by smaller ward units and cubicle wards,local authorities are loth to expend money for theprovision of these. They are equally backward inthe provision of efficient medical treatment for thepatients.

EFFICIENCY IN TREATMENT IN LARGE AND

SMALL HOSPITALS

It is not surprising therefore to find great variationsin the standards of treatment possible of attainmentin fever hospitals. There is no doubt that higherstandards are maintained in the large fever hospitalsprovided, for instance, by the London County Counciland the large county boroughs. There we havemedical superintendents in charge who give theirwhole time to fevers and who are assisted in theirwork not only by a resident medical staff and a

highly trained nursing staff but also by visitingconsultants. Patients are seen by a doctor in theambulance or receiving-rooms before admission,doubtful cases are properly isolated and all patientsare at once given appropriate treatment including