1343

initial dose should not exceed 0-3 g. per kg. body-weight, but may be gradually raised to 0-7 g. Theamount given must be considerably reduced duringthe late second, and in the terminal, stage of sleepingsickness. Administration is subcutaneous.

Antityphoid Inoculation.A Bill is being presented to the Senate for rendering

antityphoid inoculation obligatory for all Frenchcitizens. No penalties for failing to comply withthe law have so far been provided.Cabanes has been examining the hereditary

characters of the Hapsburg dynasty, which includeprognathism, hypertrophy of the nose and lower lip,and acrocephalia. These stigmata, he finds, have beentransmitted notably in the direct line, and are moredistinct in the males.

Since dealers are not always above suspicion offavouring rises in the price of food-stuffs, legislation isbeing introduced providing penalties for those whowaste food or wilfully allow it to spoil. The penaltiesprovide for fines ranging from 100 to 30,000 francs,and for imprisonment for periods of eight days tothree years.

In order to encourage the growing of medicinalplants in France and in the French colonies a cine-matograph film has been prepared at the instanceof the Minister of Agriculture.

Public Health Services.REPORTS OF MEDICAL OFFICERS OF

HEALTH.THE following are the 1925 statistics of the City ofLiverpool and six counties :-

* Excluding Cambridge borough.

Liverpool.Dr. A. A. Mussen describes how the Schick test and

subsequent immunisation were successfully used to.end outbreaks of diphtheria in four residential institu-tions. The notifications of encephalitis lethargicanumbered 108 as compared with 189 in 1924. Thedeaths, however, were more. Eight of the deathswere those of persons notified in earlier years, butexcluding these the case fatality in 1925 was 33-4 percent. During 1922 and 1923 the choreiform typewas prominent, but during 1925 the lethargic typepredominated again. Half the cases occurred under30 years of age, and there were few cases over 60.The fatality increased with advancing age, but thesmaller fatality in youth is offset by the liability todevelop sequelae. Cases are cited to indicate theinfectious nature of the disease. Thus 17 per cent.of the acute cases in Liverpool during 1925 had apossible connexion with a preceding case. In 1924

and 1923 a similar possible connexion was traced in17-7 per cent. and 9 per cent. respectively. From theconsideration of such groups the incubation periodis thought to be from a week to a fortnight. Theoccurrence of cases in contacts, after five months intwo cases and after 20 months and two years in twoother cases, indicates the possible duration of infectivityfor prolonged periods. Of the 22 cases which occurredamong school-children during 1925 two proved fatal,and of the survivors 14 are known to have developedsequelæ. In seven of these the prominent symptomwas inversion of the sleep rhythm, in four Parkin-sonism, and in three mental deterioration. Dr.Mussen suggests that such survivors should at firstbe taught in special classes in the schools for physicallydefective children, but kept quite’ apart from theother physically defectives. If experience showssuch treatment to be unsatisfactory, residentialtreatment in conjunction with other local authoritiesmay have to be considered. Home contacts are nowexcluded from school for three weeks.

Five cases of anthrax occurred, with two deaths.Two handled wool in a warehouse, two worked amongwool and hides at the docks, and one in a tannery.Fur dermatitis from rabbit skins dyed to resemblebeaver is reported to be increasingly common. Inthe dyeing process an oxidising agent is used, and ifoxidation is complete the dyed article is innocuous.The skin irritation caused may be very severe andmay become eczematous. At the Fazakerley Hospitalsuccess has been obtained in the immunisation ofthe staff against scarlet fever. The Schultz-Charltonreaction has been in general use since December, 1924,for diagnostic purposes, and the use of specific anti-streptococcus serum in the treatment of scarlet feverappears to give good results. Also passive immunisa-tion by scarlatinal antistreptococcus serum is foundto be of value in preventing cross-infection.A table shows that an increase in the routine

veterinary inspections of the city herds reveals morecases of tubercle of the udder. There are 286 citycowsheds, with accommodation for 3870 cows. In1920, 56 routine inspections discovered six cases oftubercle of the udder, while in 1924 and 1925 therewere 697 and 717 inspections, and 26 and 21 tuberculousudders discovered respectively. The city bacterio-logist reports that of 172 samples of milk examinedfor the city hospitals 14 contained the tuberclebacillus, and that seven out of 84 samples from infantwelfare centres and 63 out of 586 samples frommilkshops, railway stations, &c., were tuberculous.An advance has been made in housing matters by thescheduling of Pitt-street area. A confirming orderwas made by the Ministry, and the buildings are nowbeing demolished, and plans have been approved forthe erection of 57 tenements on the site. Despitethe operations of the housing committee and theactivity of private builders, who during tlie lastfive years have erected 8122 dwellings, there wereover 11,000 applications for corporation dwellingson the waiting list at the end of 1925.

Kent.Dr. Alfred Greenwood describes the growth of the

county pathological laboratory, which was establishedin 1911 with the intention primarily of carrying outsimple bacteriological examinations for districtmedical officers of health. The work has beengradually extended, until at the present time almostevery kind of pathological work is done at Maidstonefor the medical practitioners of the county. Inaddition to the ordinary examinations for infectiousdiseases, the work now includes examinations ofurine and pus, histological examination of tissues,tumours, &c., with supply of sections if required,blood examinations, blood counts, bloodsugar tests.A whole-time pathologist is employed. During theyear ending 1926, 21,784 specimens were reportedupon. The charge on the county rate for the labora-tory for the year was £1663, and the average cost perexamination Is. 6d. Dr. Greenwood emphasises thefact that the laboratory has been well worth while

1344

especially in a county like Kent, where there is nouniversity or commercial laboratory available.

The clean milk competition was continued success-fully during 1925, and the reports from the districtsshow the need for it. Little, if any, veterinaryinspection of cows appears to be in operation, andonly 25 samples of milk were sent to the countylaboratory to be tested for tubercle, including onesent on account of a complaint of tuberculous milkfrom the medical officer of health of the London Countycouncil. The arrangements for the reception of theKentish hop-pickers are being greatly improvedyear by year, but there still remains a minority ofgrowers who are not amenable to reason in this matter.The reports from the districts show that manyimprovements have been made during the last fiveyears in drainage, sewerage, and the prevention ofthe pollution of rivers. As regards scavenging,however, Dr. Greenwood mentions that among his42 urban and 23 rural districts it is the exception tohave a thoroughly well-organised and up-to-datemethod of disposal, and that in the majority of theurban districts there is no justification for this. Thenuisance from the tipping of London refuse has beenlessened in recent years, but several of the ruraldistricts suffer from the deposit of refuse by theKentish towns. A duel is reported between South-borough and Tunbridge Wells. Southborough,deposits its refuse and creates a fly and rat nuisance in Tunbridge Wells. Tunbridge Wells returns the Icompliment. An amicable arrangement for a jointdestructor for these two urban districts may be theresult.Taken as a whole, the housing situation does not

improve. Thus the shortage estimated in 1922 at5554 is estimated in 1925 as 9742.

Staffordshire.Dr. W. D. Carruthers gives a survey of the position

as regards the pollution of rivers. Three-quartersof the county is within the watershed of the Trent.The narrow strip along its north-western border is-within the watershed of the Mersey, and further souththere is an area draining into the Severn. The Trentand its main tributary, the Tame, are heavily pollutedin the industrial areas of the county. The sameremark applies to the Stour, which drains intothe Severn. The standards recommended bythe Royal Commission assume that an effluent willbe diluted eight times by river water on its discharge,but this does not occur in the industrial areas ofStaffordshire, and Dr. Carruthers urges that a higherstandard of purification is, therefore, necessary. Healso emphasises the bad effects when the river wateris completely held up by a weir, making the basinabove the weir practically a septic tank, and inter-fering with the natural power of recovery. Tables aregiven showing the percentage of oxygen saturationof the rivers Trent and Stour at various points, whichmake it clear that these rivers are usually too muchpolluted to support fish life. Many of the authoritiesin Staffordshire are quite alive to the situation, anda considerable amount of work has been done, butobviously much more is required.

Building during the last five years has only beensufficient to meet the natural increase of the popula-tion. Dr. Carruthers hopes that the new Act, whichallows assistance from the public funds for theimprovement of existing cottages, will help to findhouses for the agricultural workers at something likean economic rent. The county council has notappointed whole-time veterinary surgeons to dealwith tuberculous milk, but has allocated this workto the officers appointed under the Diseases of AnimalsActs. During 1925 six complaints of tuberculousmilk were received from the London County Council,and in each case animals were slaughtered under theTuberculosis Order. One complaint from Stokehad a negative result. At the end of 1925 there werefour licences for the production of Grade A milk.One of these four producers could not comply with- the standard, and it was found that his bottles would

not stand being put in the steriliser without cracking.Dr. Carruthers points out that two small-pox hospitalswould serve the whole county, and that seven othersmight be abolished. There were 45 cases ofencephalitis lethargica and 26 deaths during 1925.About 35 per cent. of the county population are

without satisfactory isolation hospital provision.The bacteriological work of the county was transferredfrom Birmingham University in July, 1922, and acounty laboratory has been established at theWolverhampton General Hospital.

Cheshire.Dr. Meredith Young states that the greater portion

of the county comes within the maternity and childwelfare scheme. There are seven county midwives,who are granted an allowance of £60 per annum inaddition to the fees which they earn until they havea practice sufficient to support them. Through theenterprise of the county nursing superintendent aCheshire Midwives Association has been formed, withseven branches, each of which has a series of monthlylectures. The shortage of houses interferes with thecharacter training of children. The mothers wholive in rooms say they have to give a child anythingit wants to keep it quiet. The shortage of houses isgeneral, but the local authorities are said to be facingthe problem in a satisfactory manner. Constantsupervision has been maintained over the Dee,Weaver, and Dane, and all these rivers are fit for

fish to live in. The greatest difficulty is found withthe Dee because of the pollutions which emanatefrom Wales. In the neighbouring counties of Flintand Denbigh river pollution is regarded with indiffer-ence, and the Dee was not long ago associated withan outbreak of typhoid fever. Dr. Young advocatesthe formation of a joint committee armed with powerssimilar to those possessed by the Mersey and IrwellCommittee. The only industrial waste which givestrouble is ammonium sulphate spent-liquor fromcollieries. The Cheshire College of Agriculture havedone much to encourage clean milk. Dr. Youngthinks, however, that the time is ripe for a whole-time veterinary service, and that the recent Milkand Dairies Order will make this step almostobligatory.

Norfolk.Dr. J. T. C. Nash points out that school medical

inspection work is still in a watertight compartment andhas not been coordinated with the other public healthwork. He also advocates the appointment of a

deputy medical officer of health and school medicalofficer. There are practically no factories in the countyarea, and in the rich fruit-growing land on the westthe inhabitants are comparatively well above thepoverty line, but the benefit of this is somewhat dis-counted by mothers leaving their children to go out asland-workers. Women’s institutes, largely due to theexertions of Lady Suffield, are a great feature in thevillage life. Cinemas and wireless have alsodeeply invaded districts which at the beginning ofthe century were either " deadly dull " or " unspoilt,"according to the particular viewpoint. An outbreakof catarrhal jaundice, affecting many persons, bothadults and children, but without a death, appearedto be associated with influenza. Influenza itself wasresponsible for 181 deaths during the year. Asregards isolation hospitals, Dr. Nash has for manyyears held that in these days of motor transport onecentral hospital for the whole county would be muchthe best solution. The county health committeesupports this view and had secured a suitable site,but the districts could not agree among themselves.The housing work of the last five years has not metthe needs of the agricultural labourers-the class mostin need of cottages. A move has been made in thedirection of an orthopaedic scheme by the appoint-ment of a joint committee.

Leicestershire.Dr. T. Robinson points out that the present

arrangements for treating surgical tuberculosis

1345

are of a temporary nature and insufficient. A

joint scheme under the county council and theLeicester City Council is now under consideration.The county council make a grant of £50 to theLeicester and Leicestershire Maternity Hospital,and in return for this sent in six cases during 1925. *There are now 37 maternity and child welfare centresoperating in the county. During 1925 an exhibitionwith lectures and demonstrations was held at sevencentres. Lectures were given to practising midwivesat five centres by Dr. E. L. Lilley, obstetric surgeonto the maternity hospital. The subjects dealt withwere chart-keeping, danger signals in pregnancy, andantenatal work.The county bacteriological laboratory, which was

opened in 1919, did more work than ever before in1925. An extension has been made for the purposeof dealing with bacteriological examinations of milk.The districts are encouraged to send samples, andduring 1925 8 of the 12 urban districts and 5of the 13 rural districts fell in with the scheme;589 samples were sent in. Of these 320 were classifiedas good and 143 as bad, 112 being fair and 14 moderate.Of the 320 good samples, 265 came within Grade Astandard. During 1926 six more rural districts aretaking part in the scheme, which is said to be pro-ducing an improvement as regards the production ofclean milk. There are 2290 milk producers in the countyand 35,000 cows. The Ministry have issued licencesfor Certified Milk to four producers and for Grade A(tuberculin-tested) to one. The county council have eissued Grade A licences to eight producers, one ofwhom, however, gave up his licence in Septemberowing to adverse reports on his samples. One Grade A

producer was unable to comply with the B. colistandard, and it was found that his water-supply was unsatisfactory. A fresh water-supply enabled himto comply with the standard.

Cambridgeshire.Dr. Frank Robinson reports that the county council

pay maintenance charges for tuberculous patientsat Papworth Colony, and depend upon Addenbrooke’sHospital for the treatment of surgical tuber-culosis, for V.D. work, and for maternity beds. Ascheme for the provision of a maternity home for theuse of the town and county within the curtilage of thelast-named hospital was also under considerationduring the year. In January, 1906, there were

24 trained and 42 untrained midwives in the county ;in January, 1926, there were 50 trained midwivesand two untrained. The county council grantnursing scholarships and also subsidise associationsemploying nurse-midwives. Of the 129 rural parishesthere are still 27 with a total population of 9198, forwhich a midwifery service has not been provided.The provision of light treatment was consideredduring the year, and it was decided to send lupuscases to the London Hospital for treatment and boneand joint tuberculosis cases to Alton, but it is hopedto have a local out-patient light centre. The countycouncil have taken no action in the matter of tuber-culous milk, nor have they received any applicationfrom the district councils with regard to this matter.Housing accommodation in the county is still inadequate and closing orders for unfit houses areseldom made.

--

INFECTIOUS DISEASE IN ENGLAND AND WALESDURING THE WEEK ENDED DEC. 11TH, 1926.

Notifications.—The following cases of infectious diseasewere notified during the week :-Small-pox, 328 (last week316) ; scarlet fever, 1716 ; diphtheria, 1185 ; enteric fever,49 ; pneumonia, 1309 ; puerperal fever, 47 ; puerperalpyrexia. 121 ; cerebro-spinal fever 8 ; acute policmyelitis.37 ; acute polio-encephalitis, 6 ; encephalitis lethargica, 42 ;continued fever, 1 ; dysentery, 4 ; ophthalmia neonatorum, 124. There was no case of cholera, plague, or typhus feB-er (

notified during the week.Deaths.—In the aggregate of great towns, including 1London, there was no death from small-pox, 2 (0) from enteric r

fever, 15 (1) from measles, 8 (3) from scarlet fever, 37 (10)from whooping-cough, 47 (9) from diphtheria, 72 (15) from diarrhœa and enteritis under 2 years, and 52 (18) from influ- (enza. The figures in parentheses are those for London itself.

SCHOOL MEDICAL SERVICE.

* Excluding uncleanliness and dental defects. t Not given.

Cumberland.Dr. F. H. Morrison, in his report for 1925, describes

the method of coordinating the health servicesthroughout the county, by which in no case is thefull time of any doctor or nurse given to school workalone. The county is divided into six areas, withone medical officer in charge of the whole of the work(except venereal diseases) in each area. This systemhas obvious advantages, although no one man canbe an expert in all branches, with the .result thatcertain conditions may attract less attention thanthey deserve ; it may be for this reason that inCumberland comparatively few exceptional childrenhave been discovered-e.g., only four blind and sevenmental defectives in the whole county. The facilitiesfor dealing with such children are few, but the difficultyin making adequate arrangements in rural areas isvery real. This difficulty exists, also, in providingclinics, and the proposed travelling motor-van clinicwill be a useful expedient. The dental caravan hasbeen highly successful, as has also the work of thetravelling orthopaedic nurse. Surgical clogs have beenused in the correction of deformities of the feet andlegs, and present many advantages in mining districts,where clogs are worn daily by the children. Dr.Kenneth Fraser has carried out a special inquiry intothe association of deficiency of iodine with manycommon conditions met with in school-children.He gives a full account of iodine deficiency and of theprevention and cure of its effects, stating his beliefthat goitre is only one of these effects. Finally thereis a record of 100 children suffering from differentdiseases such as septic infection, bronchitis, andgeneral debility, whom he treated with iodine withdefinite improvement in almost every case.

Wigan.

Dr. Henry Whitehead presents his report in aconcise and interesting manner. There is directcoordination in Wigan between the child welfarescheme and the school medical service, so that theschool medical inspector has the previous history ofthe child when it first attends school. Dr. Whiteheadgives a depressing account of the sanitary conditionsof the schools, the majority of which were built priorto 1880, and many were not originally intended as.

school premises. Heating, lighting, and ventilationare generally bad, while some of the sanitary con-veniences constitute definite nuisances. He sums up :" The conditions which exist must have some

deleterious effect on the general health of thechildren." An outline is given of the system employedin the control of infectious diseases, and much extrawork has been laid on the staff since every case ofchicken-pox (made compulsorily notifiable in 1925owing to the prevalence of small-pox) is at oncevisited bv a medical officer. Measles was alsonotifiable during the epidemic at the beginning of1925, and extra nurses had to be employed to keeppace with the home visiting. Dr. Whitehead has anJphill fight in combating the verminous condition)f the Wigan children : " it is deplorable," he writes,’ to find a great number of children with verminousleads, again about 17 per cent. of the total inspecred."There are at present no open-air schools in the town,ior school baths, nor any provision for the blind orleaf, nor for physically or mentally defective children.t would appear that the Education Committee Oi

1346

this county borough is scarcely shouldering itsstatutory duties for the welfare of children.

MENTAL HOSPITAL REPORTS.The Derby Borough Mental Hospital had 484

patients in residence on Dec. 31st, 1925, 70 morethan at the beginning of the year, so that the numberof vacancies was reduced to 12. The recovery ratewas 22-3 per cent. and the death-rate 5-96 per cent.,verified by autopsy in 86 per cent. of cases. Thegeneral health was good, apart from an epidemic ofinfluenza in the spring and six patients under treat-ment for tuberculosis. The unused isolation hospitalhas been refitted for the reception of 16 convalescentsor parole patients. Wireless has been installed in allthe wards. Only three patients have as yet beenallowed out on trial. A dentist visits twice monthly.Six nurses and one attendant obtained their M.P.A.certificate during the year, bringing the total up to33 per cent. and 59 per cent. respectively.The Inverness District Asylum h,)used 717 patients

at the end of May, 1926, an increase of 27 during theyear. The recovery rate was 62-3 per cent., and 15patients were sent out on trial. Two of them had toreturn. The death-rate was 8-2 per cent. ; 25 deathswere due to senile decay, which, with phthisis,accounted for over half. The farm, gardens, and-constructive work, including a new reservoir, provideoccupation for a large number of male patients.Eleven beasts were shown at the Farmers’ SocietyShow in August, 1926, and gained 11 prizes andrecommendations. A hall of suitable size is beingbuilt. For the second year in succession all theentrants for the final M.P.A. examiration were

.successful. Fourteen obtained their certificate.

Institutions for Mental Defectives.The -Royal Albert Institution for the Feebleminded,

Lancaster, had 805 names on its books on March 31st,1926, and its financial position remains satisfactory.There were 17 deaths during the year, four fromphthisis, 2 from influenza, and one from diphtheria,the source of which could not be found. Among newoccupations introduced are art sealing-wax, leatherand pewter work, paper-hat and lampshade con-

.struction, elementary woodwork, and leather stitching.’Twelve school garden plots have been prepared forthe inmates to work in. More facilities have beenprovided for clock golf, and this has been found verysteadying for patients with such affections as

athetosis and spasmodic tic. It has been decided thatrecent cases of encephalitis lethargica shall not beadmitted, as the superintendent feels that there mightbe an infectivity risk. The report is illustrated byphotographs of the patients at work and play.The Derby Borough Committee for the care of the

mentally defective reports continued difficulty infinding accommodation for the urgent cases reportedto them. They have e 28 patients in the MentalHospital, costing about £1300 a year. Could thesehave been placed under the Mental Deficiency Actthe cost would have been halved. There were 40defectives under certificate in institutions on Dec. 31st.

The Lancashire and Cheshire Society for the Per-manent Care of the Feebleminded maintains a

colony with 90 women, 45 girls, 127 men, and 55 boys.Their health during the year has been good , there’were two deaths and no infectious disease. The farmand gardens successfully provide occupation fornumbers of patients, even including imbeciles. Therewas a marked improvement in the liveliness andhappiness of the school-children last year. The staff-have formed themselves into a committee to teach theboys cricket and football, a great improvement onthe haphazard games that were previously the rule.Twenty-three acres of land have been added to the.society’s estate, and it is proposed to alter the farm-house so as to provide 50 additional places for boys.Every vacancy is filled as it arises, and many applica-tions have to be refused. The report is illustratedwith photographs of the buildings and land, and anurgent appeal is made for contributions.

Correspondence.ULTRA-VIOLET RADIATION.

"Audi alteram partem."

To the Editor of THE LANCET.

SIR,—The excellent results recorded by Dr. Punchand Dr. Wilkinson in your issue of Dec. llth call forgreater detail of the technique they adopted. Forgeneral exposures they appear to have used on thesame patient both the air-cooled mercury-vapourand the carbon arc. One notes, for instance, that inCase 1, after the first nine exposures with the mercury-vapour lamp, succeeding exposures alternated betweenthe mercury vapour and the carbon arc. What werethe indications for changing the apparatus ? If themore continuous spectrum of a carbon arc was

indicated for one occasion, why was it contra-indicated at the next ? It does not appear to havebeen merely a matter of convenience, for a definitesystem of changing the lamps was adopted. Do theauthors claim any particular advantage for thismethod ? Again, for local treatment to the scar inthis case the tungsten arc was used. Was there anyparticular indication for changing from the mercury-vapour lamps, either of which could have been usedfor treating the scar ? What was the relation of acarbon arc dose to the mercury vapour dose in

erythema-producing terms ? °

Case 3 shows up the dangers of ultra-violet therapy.Conclusions are based on a single case and that not ofa very progressive type, nor one in which the anaemia,was very striking. There are so many practitionersusing ultra-violet radiation that some may also betempted to rely on ultra-violet rays for the treatmentof Hodgkin’s disease, to the exclusion of methods suchas X rays, which are far more likely to be of benefit.It is not suggested that ultra-violet radiation may notbe of benefit for the secondary anæmia, but surelythere is no justification as yet for making it the onlyor even the most important method of treatingHodgkin’s disease.My own experience of ultra-violet radiation in

Hodgkin’s disease is limited to two cases. One case,owing to the erroneous diagnosis of tuberculousglands (tubercle bacilli had been found in his sputaat a sanatorium) was treated for four months withboth local and general ultra-violet radiation. He didnot improve, the main mass of glands becomingsomewhat larger. A gland was then excised, whichshowed the case to be one of Hodgkin’s disease. Thesecond case was put on ultra-violet treatment, pendingX ray treatment. After a month’s treatment thepatient stated he felt better, but beyond a slightdecrease in the size of the spleen there was no clinicalevidence of improvement. The patient dischargedhimself from the hospital then, only to return severalmonths later in a hopeless condition. I feel, therefore,that the value of ultra-violet radiation in Hodgkin’sdisease still remains to be proved.

I am, Sir, yours faithfully,M. WEINBREN.

THE DISSOLUTION OF INSULIN.To the Editor of THE LANCET.

SiR,-The hyperglycaemic action of insulin isdescribed on pages 122 and 123 of the first volume of" The Nature of Disease," published in 1924. Itwould appear from further experimentation that theaction of insulin is influenced by the state in whichthe protein particles in the plasma happen to bewhen the injection is made. The previous adminis-tration of certain conductors, such as sup 468, tartra-zine, &c., and of certain condensers, such as oxygen,the carbon disulphide product of dimethylamine,&c., prevents insulin from causing hypoglyca-mia.The subsequent administration of certain conductors,such as sup 36, and of certain condensers, such asglucose, dihydroxyacetone, &c., prevents fits occur-