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educating the public in the plain truths of healthy living.He emphasises the urgent need of more houses in Birming-ham to reduce overcrowding and replace the unwholesomeback-to-back courtyard houses with healthy homes.The report contains an interesting account of the incidence

of measles and of the mortality resulting from that diseasein different areas of the city and in houses of differentsize. During the year under review there were 15,516cases of measles, which resulted in 333 deaths, and 472 casesof German measles, 4 of which had a fatal termination.There was an extensive epidemic of measles in Birmingham,which commenced in the fourth quarter of 1916 and ended

_ in the third quarter of 1917. The following are a few of thedeductions drawn from study of the statistics of the epidemicin which more than 17,000 cases occurred. For purposes of

comparison the city was divided into three areas-namely,"central wards," "middle ring," and "outer ring." It wasfound that there was no striking disparity in the prevalenceof measles in these three groups of wards, the averagenumber of cases per 1000 of the population in the "centralwards " being 18-6; in the" middle ring," 18-9; and in the"outer ring," 20-9. The difference in the fatality rates was,however, very marked. This rate per 100 cases in the"central wards" was 3’8; in the "middle ring," "2-1; andin the "outer ring," 0-7. In order to carry the inquiryfurther the measles rates in houses of different sizes wereworked out. The rate of incidence per 1000 houses and thenumber of deaths per 1000 cases respectively in three-roomed houses were 100’5 and 36; in four-roomed houses,111’0 and 25; in five-roomed houses, 86’1 and 15; insix-roomed houses, 96’9 and 9; in seven-roomed houses,40-0 and 7; and in houses with eight rooms or over

63-2 and 3. These figures show that the prevalenceof measles in the larger houses was not nearly so great as iqthe smaller houses. This is what might be expected, becausethe residents in larger houses are more widely separated andtherefore less exposed to infection than in the smaller

dwellings, and the proportion of adults per house is prob-ably larger, thus lessening the incidence of the disease. Butthe fatality rates in houses of different sizes are much morestriking than the figures relating to incidence. Of the 1012cases of measles in houses of eight rooms and upwards only3 proved fatal, equal to a case mortality of 3 per 1000,whereas in three-roomed houses there were 4021 cases

of the disease with 145 deaths, giving a case mortality of36 per 1000, or 12 times as high.

In considering this question, however, it is important notto lose sight of the fact that the children of the well-to-doclasses generally receive much greater care and attentionthan those in working-class families. They are usually putto bed as soon as the rash appears and are carefully nursedunder medical supervision. An attempt is also often madeto isolate the patient from the other children in thehousehold. The working-classes, on the other hand,generally regard measles as a disease of no importanceand take little trouble to isolate the patient, even where thisis possible, or to take sufficient care of the sick child to avoidunnecessary exposure which may give rise to subsequentcomplications. It is for this reason that the Local Govern-ment Board made measles a notifiable disease and empoweredlocal authorities to provide home nursing.

URBAN VITAL STATISTICS.(Week ended March 29th, 1919.) !

English and Welsh Towns.-In the 96 English and Welsh towns, with an aggregate civil population estimated at 16,500,000 persons, the annual rate of mortality, which had steadily declined from35’7 to 20’9 inthe four preceding weeks, further fell to 19-3 per 1000. In London,with a population slightly exceeding 4,000,000 persons, the annualdeath-rate was 17’6, or 0’4 per 1000 below that recorded in the previous jweek; among the remaining towns the rates ranged from 7’0 inEastbourne, 7’8 8 in Wimbledon, and 9’0 in Coventry, to 29.6 in Oldham, 33’2 in Bury, 33’6 in Merthyr Tydfil, and 36’7 in Great Yarmouth tand in Middlesbrough. The principal epidemic diseases caused j201 deaths, which corresponded to an annual rate of 0’6 per 1000, and included 67 from measles, 50 from diphtheria, 49from infantile diarrhoea. 24 from whooping-cough, 7 from scarlet fever, and 4 from enteric fever. Measles caused a death-rate of 1-2 in East Ham, 2-3 in Sheffield, 6-4 in Rotherham, and 7-0 inMiddlesbrough; and whooping-cough of 1’5 in Stoke-on-Trent. The (

deaths attributed to influenza, which had declined from 3889 to 1361 in : the four preceding weeks, further fell to 888, and included 125 in London, 94 in Birmingham, 54 in Manchester, 27 in Sheffield, and 23 each inBradford and Leeds. There were 6 cases of small-pox, 1027 of scarletfever, and 1163 of diphtheria under treatment in the MetropolitanAsylums Hospitals and the London Fever Hospital, against 5, 1010, (and 1191 respectively at the end of the previous week. The causesof 43 deaths in the 96 towns were uncertified, of which 12 were registered in Birmingham, 5 in Liverpool, and 4 in Preston.

Scotch Towns (week ended March 22nd).-In the 16 largest Scotchtowns, with an aggregate population estimated at nearly 2,500 000persons, the annual rate of mortality, which had declined from 40’0 to28’1 in the three preceding weeks, further fell to 22’9 per 1000. Thedeaths from influenza numbered 33, while in 184 deaths classified as due

two other conditions influenza was a contributory cause; in the previousweek these numbers were 39 and 257 respectively. The 546 deaths inGlasgow corresponded to an annual rate of 25’5 per 1000, and included27 from whooping-cough, 7 from measles, 3 each from diphtheria andinfantile diarrhoea, and 2 from scarlet fever. The 118 deaths in Edin.burgh were equal to a rate of 18’3 per 1000, and included 5 fromwhooping-cough, 4 from diphtheria, and 1 each from measles and scarletfever.March 29th.-In the 16 largest Scotch towns, with an aggregate popu-

lation estimated at nearly 2,500,000 persons, the annual rate of mortalitywhich had declined from 40’0 to 22’9 in the four preceding weeks,further fell to 20’5 per 1000. The deaths from influenza numbered 14,while in 88 deaths classified as due to other conditions influenza was acontributory cause; in the previous week these numbers were 33 and184 respectively. The 489 deaths in Glasgow corresponded to anannual rate of 22’8 per 1000, and included 31 from whooping-cough,8 from measles, 7 from infantile diarrhoea, 4 from diphtheria, and 2from scarlet fever. The 99 deaths in Edinburgh were equal to arate of 15’3 per 1000, and included 4 from whooping-cough and 3 frommeasles.

Irish Towns.-The 245 deaths in Dublin corresponded to an annualrate of 31’5, or 5’6 per 1000 below that recorded in the previousweek, and included 34 from influenza, 3 each from measles andinfantile diarrhoea, and 1 each from whooping-cough and diphtheria.The 207 deaths in Belfast were equal to a rate of 26’9 per 1000, andincluded 3 from infantile diarrhoea and 1 from diphtheria.

Correspondence." Audi alteram partem."

IRELAND AND THE MINISTRY OF HEALTHBILL.

To the Editor of THE LANCET.

SIR,-The new clause setting up an Irish Public HealthCouncil, inserted on March 27th by the Standing Committeeof the House of Commons in the Ministry of Health Bill, onthe proposal of the Attorney-General for Ireland, may bedeemed familiar to your readers, as the text of the proposalshas appeared in the daily press. But I should like to pointout that the approval given to this clause in the House ofCommons has not been general in Ireland, where a deputation,fully representative of the medical profession in Ireland

(headed by the Presidents of the Royal College ofSurgeons and the Royal College of Physicians), presentedto the Chief Secretary, on March 25th, a scheme forthe establishment of a Ministry of Health in Ireland.They urged that the Public Health Council should beconstituted as follows: (a) Four members elected by thecounty councils, one for each of the four provinces-Ulster,Munster, Leinster, and Connaught ; (b) four members of themedical profession to be elected by the practitioners ofIreland ; and (e) four members to be nominated by theCrown. The deputation, through their spokesmen, pro-tested very strongly against the Local Government Boardbeing a part of the Council. They pointed out that allparts of Ireland, and not Dublin alone, should be repre-sented on the Council, and they urged the right of demo.cratic election instead of bureaucratic or Governmentnomination. The Chief Secretary, as was natural, tried tomake some defence of the Irish Local Government Board, ofwhich he is officially chairman, and of which, naturally, fromhis short residence in Ireland he knows little. He promisedto give more medical representation on the Public HealthCouncil, which he said would be only a temporary body, andadded, as reported in the press : "If the deputation couldassure the unanimous support of the public and the pro-fession for any scheme of health reform, he might then beprepared, in consultation with his Council, to consider such ascheme, and, if approved, to introduce legislation to carryit into effect." In a letter to the press Mr. Maurice J.Hayes, F. R. C. S. L, honorary secretary, Dublin Division ofthe British Medical Association, criticises very severelythis statement, which he calls the "latest sample ofofficial nonchalance." " How can hard-worked doctorsstart a health campaign," he asks, and "secure theunanimous support of the public for a scheme of healthreforms " ? And especially how can there be any delay inacting, when the figures published in the "quarterly return" of the Registrar-General for July-August-September, 1918,show the appalling fact that in Ireland there existed anannual birth-rate of only 18-5 per 1000 and a death-rate of

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24 6 per 1000, and an infantile mortality of 101-3 ofchildren under one year ? The Chief Secretary should actas soon as possible, but the constitution of his "Irish PublicHealth Council" has lost him the confidence of the Irish

medical profession, upon whom will depend the working ofany scheme he may in the future carry in Parliament.

I am, Sir, yours faithfully,April 1st. 1919. F. R. C. S. I.

COLLOIDAL SILVER IN TRENCH FEVER.To the Fditor of THE LANCET.

SIR,-I was interested to see in your issue of Feb. 15th anote by Major J. E. Sweet and Lieutenant H. B. Wilmer,U.S.M.O., on the effect of collargol in trench fever. In thewinter of 1916-17 I tried a similar drug on cases of trenchfever. The preparation I used was electrargol (argentcolloidal électrique à petits grains) prepared by theLaboratoires Clin, Paris. I endeavoured to vary the mannerand the time of administration in relation to the phases ofthe disease. Thus, I gave it intravenously to some of thecases, subcutaneously to others, and by both routes to yetothers. I gave it intravenously every third day for threedoses ; to others intravenously or subcutaneously the day of,or the day before, the expected relapsing pyrexial spike" " orbout. Sometimes I followed this by small daily subcutaneousdoses. The dose varied from 5 to 10 c.cm. and the cases (about 30 in all) included examples of the acute and of thesubacute (myalgic type) fever. In no single case could Isatisfy myself that the drug had any effect at all on thecourse of the disease ; the acute cases continued to havetheir relapsing bouts of fever and the subacute (myalgictype) their pains.

I remember seeing in the Daily Review of the ForeignPress" for February, 1918, the note regarding Richter’sfindings, and I thought that his cases of trench fever andthe ones I had dosed must have varied from each other tohave given such different results to similar treatment.

Perhaps this is the explanation that also underlies MajorSweet’s and Lieutenant Wilmer’s apparently more successfulattempts than mine.-I am, Sir, yours faithfully,

J. H. LLOYD, M.D. Lond.,Major, R.A.M.C. T.F., 58th C.C. Station.

I am,Sir,yours faithfully,

J. H. LLOYD, M.D. Lond.,Major, R.A.M.C. T.F., 58th C.C. Station.

WOMEN CHIEFS ?To the Editor of THE LANCET.

SIR,-I see that a body called the Women’s WatchingCouncil has been pressing for one of the consultative councilsto the Ministry of Health to consist solely of women, and forsome important appointments on the administrative staff tobe similarly reserved.The position of all present municipal medical employees

is that they were appointed under a system where medicalmen never had to work under medical women ; as I think

rightly, because the former are vastly more numerous, andthe latter, two generations of them, have never made a note-worthy discovery or even written a standard text-book ; whilethere is no living woman with first-rate knowledge of sanitaryscience. However that may be, I think there will be troubleif the unwritten condition I have alluded to is altered.

I am, Sir, yours faithfully,March 20th, 1919. W. C. RIVERS.W. C. RIVERS.

ACQUIRED IMMUNITY IN INFLUENZA.To the Editor of THE LANCET.

SIR,-Referring to the interesting question of acquiredimmunity against influenza raised in your leading article ofMai ch 8th, 1 am of the opinion that undoubtedly an attackof influenza carries with it immunity for a certain time, thatthe immunity lasts for six months at least, and that theduration of the immunity possibly depends on the severity ofthe attack. Daring the last three waves of the epidemic Ihave had to deal with the sick of 2000 (two thousand)troops, and during this time we treated in hospital over400 cases. No cases admitted in June, July, or Augustwere readmitted in October, November, or December,and no cases admitted in either of these two periodswere readmitted in February this year. Unfortunately,I am unable to trace the cases into March as thetroops were changed. Again, in private practice I have had

no recurrence. In several instances where some of thehousehold were attacked during the period, October andDecember, and the other inmates escaped, the position hasbeen reversed in February and March.My own personal experience also points to there being a

distinct immunity. I had a bad attack of influenza in 1890.I ran free through the epidemics of 1891 and 1892, and atthat time congratulated myself on being immune. How-ever, I again contracted it the end of 1893, and from thattill last May I developed slight attacks each time influenzaoccurred. Last May I had a very severe attack with a hightemperature lasting a week, insomnia, delirium, and patchesof broncho-pneumonia. I resumed work in July, so far withcomplete immunity. My experience makes me, therefore,argue that the duration of immunity depends on the severityof the attack.

I have had very little experience of the immunity con-ferred by vaccine treatment, but I have had several caseswho developed influenza after vaccine treatment, someshortly after the vaccine and some two months afterwards.This rather suggests that a bigger dose of vaccine would givea longer immunity, and that the doses recommended at theconference held at the War Office in October last were fartoo small. I am, Sir, yours faithfully,Mullingar, March 31st, 1919. JOHN GEO. GIBBON, M.D.JOHN GEO. GIBBON, M.D.

CORNS ON BABIES’ NOSES.

To the Editor of THE LANCET.

SIR,-Babies, like bull-dogs, have snub-noses to enablethem to breathe while holding on to the soft, yielding skinwith their mouths. In most babies the shape of the nose-the button-ended, turned-up nose-varies little ; but in racesin which the parents have a hooked nose the end of thebaby’s nose is often turned down into a partial hook."

I once observed this shape in a baby of ancient Britishlineage. Careful inspection showed a smooth, yellow, flat,horny surface at the tip of the nose which seemed to compressthe end into a "hook." After a few days a horny scaleseparated and the nose assumed the usual shape, " tip-tilted, like the petal of a flower." I have seen two similarcases in hospital patients. The corn reminds one of the

bill-scale or "hammer" " on the chicken’s beak whichenables it to break the egg-shell, and is perhaps producedby friction of the baby’s hands against the end of thenose in utero. This friction would be favoured by scanti-ness of liquor amnii or vernix caseosa, as to which I have nonotes in the cases mentioned. Perhaps some colleague willsupply the deficiency.-I am, Sir, yours faithfully,

HERBERT R. SPENCER, M.D.Harley-street, W., March 25th,1919.

HOT LIQUIDS AND CANCER.To the Editor of THE LANCET.

SIR,--In Mr. D’Arcy Power’s interesting Bradshaw lectureon Cancer of the Tongue, of which you gave a report inTHE LANCET of Jan llth (p. 75) no mention is made of theconstant thermal irritation to which some tongues are sub-jected from tea and coffee drinking. Mr. D’Arcy Power’sremarks about the increased consumption of tobacco applyalso to that of tea and coffee, beverages which are constantlytaken hot, and very frequently too hot, and thereby areproduced frequent slight irritative thermal injuries on thedelicate mucous membrane of the tongue. This thermalinjury corresponds closely to that of kangri cancer, and thatof the adult male Chinaman who, sitting at the head of histable, is always served first with the hot rice, and beingabout the only person in China to suffer from carcinoma ofthe stomach. There can be no doubt but this factor cannotbe neglected, more especially as it is notorious that the maletongue is capable of comfortably supporting more irritationfrom tobacco, hot liquids, curries, &c., than the femaletongue. Therefore, summing up, we must state that syphilis,tobacco, thermal irritation, and unhealthy teeth conditionsare responsible factors if we wish to adopt prophylaxis intreatment of lingual carcinoma.

I am, Sir, yours faithfully.M. J. PETTY, jun., M.B. Camb., F.R.C.S. Eng.,

Assistant Surgeon to the Kawson Hospital,Feb. 20th 1919. Buenos Aires.