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jaundice. The Wassermann reaction was still stronglypositive, and the question was whether the condition of thetongue was due to syphilis or was a later arsenical manifesta-tion. This was the first case in 3000 given stabilarsan byhim which had developed jaundice after it.The second patient was a Chinaman, who came from his

ship with the diagnosis of acute syphilitic myelitis. Hewas unable to stand or work. He also had a Hunterianchancre on each eyelid, hard and firm. The knee-jerks wereentirely absent ; the pupils reacted to both light and accom-modation. He had an acute attack of beri-beri. Nospirochsetes had been found, and antisyphilitic injectionshad not produced any effect.

Dr. SEMON thought that in the first case the tonguewas syphilitic.

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JOINT TUBERCULOSIS COUNCIL.

AT a meeting of the Council held on Nov. 16th,Sir HENRY GAUVAIN presiding, the hon. secretary,Dr. ERNEST WARD, gave an account ’of the presentposition of the scholarships in Canada and Americanext year offered by the Sun Life Company. Aselection and management committee was appointedas follows : Sir Henry Gauvain (for the Ministry ofHealth), Prof. Lyle Cummins (to represent theNational Association), Dr. Lissant Cox, Dr. G.Jessel, and Dr. Ward. The following memorandumwas adopted :-

Improvement of the Tuberculosis Service.The efficiency of the tuberculosis service varies widely

in different districts, but backward areas are being improvedby wise stimulation from headquarters. Supervisionshould not be used so as to hamper individual initiative orimpede experimental methods. The chief factor in successis the personality and ability of tuberculosis officers andsuperintendents of sanatoriums, and to secure this remunera-tion sufficient to attract good officers is all-important.An indifferent officer fails to obtain the confidence andesteem of the general practitioners on whom so muchdepends.

It is better to have fewer and better-paid officers withlarger areas that a large number of poorly-paid men andwomen of mediocre capacity. Rural areas of 250,000population and urban areas of 350,000 can be managed byone whole-time officer, with adequate medical and clericalassistance, and would provide sufficient remuneration.The service should be graded so that those who had actedas assistants might become higher-salaried, whole-time,consultant tuberculosis officers or senior sanatorium super-intendents. Superannuation schemes should be generallyadopted, or so arranged that an officer does not lose bytransference to another district.The tuberculosis officer and sanatorium superintendent

should have at their disposal facilities for diagnosis, such asan X ray outfit, and for special forms of treatment, suchas light and artificial pneumothorax. Each tuberculosisofficer should have hospital beds. Dispensary and sana-torium officers should be first and foremost clinicians, butshould have a public health outlook. Facilities to attendpost-graduate courses are of the highest importance. Incertain circumstances, where the sanatorium belongs to theauthority responsible for the district in which it is situate,it may be advantageous for the medical superintendent of asanatorium to be responsible for the tuberculosis work inthe vicinity of the institution as part of his whole-time duties. ’,It is not intended that this should apply to sanatoriums ’,other than those under direct control of local authorities.The practitioners’ sense of responsibility in the diagnosis,

prevention, and treatment of tuberculosis must in no waybe impaired, and it is the first duty of dispensary and sana-torium officers to ensure this. One of the most helpfulqualifications for these officers is to have been themselvesin private practice. Any improvement in the tuberculosisservice is closely bound up with the preliminary trainingof men entering this service, and with the education ofmedical students and general practitioners in tuberculosis.A memorandum on the notification of tuberculosis

Was also adopted. Dr. Lissant Cox undertook toprepare an investigation on the fate of delicatechildren in tuberculous households. The Research Com-mittee suggested as a further inquiry, the Occurrenceof Acute Tuberculosis in Infants and Children under5 Years of Age. Dr. W. Brand reported that thecourse in X ray work at the Brompton Hospital wasalready fully booked; a second course was beingarranged after Christmas.

Reviews and Notices of Books.PRACTICAL LOCAL ANESTHESIA.

Its Surgical Technique. Second edition. ByROBERT EMMETT FARR, M.D., F.A.C.S. London :Henry Kimpton. 1930. With 268 engravingsand 16 plates. Pp. 611. 42s.THE first edition of this book appeared nearly

seven years ago. Since that time the use of localanalgesia has extended considerably and fresh drugshave been brought into play, tutocain, for example,and novocainborate. The value of the book, however,does not depend so much on its being up to date indetail, but on the excellent way in which the broadprinciples involved in the practice of local anaesthesiaare enunciated and explained by the author. Hisforecast is that " unlike the past, the future willfind available individuals who are equipped to offerto patients the greatest merits that local anaesthesiapossesses. These surgeons will not only be able toanaesthetise thoroughly the various regions of the

body with minimum discomfort to the patient-butwill, in addition, realise the full significance of sur-rounding and protecting the patient with everyavailable artifice essential to its successful use. Thisconcept embodies a large variety of factors. Itdemands the cooperation of every individual who-inany manner, comes into contact with the patient, theoffice force, hospital managers, nurses, interns, equip-ment and, indeed, every factor entering into thepatient’s environment from the time of his first visittill he is discharged." This statement may appearoverloaded, but there is no doubt that attempts atlocal anaesthesia often meet with only partial successbecause of the lack of importance attributed toapparently irrelevant accessories. The stage in factmust be perfectly set, and all, not only the chief,actors thoroughly trained in their parts when aconscious patient is being handled. It is from thispoint of view that the combination of powerfulsedatives with local anaesthetics is so important andone may well believe that the success of the latter willbe enhanced and their use made more popular byfamiliarity with such agents as avertin and paralde-hyde. The author, however, rightly lays stress on thenecessity for the surgeon who wishes to succeed withlocal anaesthetics being proficient in operating withthem on perfectly conscious patients. The methodis, in fact, often brought into disrepute by its occa-sional practice by men not versed in its niceties. Asthe author writes : " Surgeons of repute would,without doubt, freely admit that none but the mostperfectly trained experts should be allowed toadminister general anaesthesia, yet without any specialtraining or experience in the use of local anaestheticsthey appear to be quite willing to proceed to usethem upon their patients." Referring to the earlyoccurrence of pain after operations under localanaesthetics, the author recommends the giving ofmorphia hypodermically before the patient leavesthe table. In wounds which are to heal by granula-tion, quinine-urea hydrochloride 1 in 600 should beliberally injected as a prophylactic against after pain.Opium is to be used freely during the first 48 hours.All details of technique are fully discussed and illus-trated by the numerous diagrams. The author is, ofcourse, an enthusiast for the method of local analgesia,but his support of it is logical, and he does not failto point out the care and patience which it demandsfor success.

PRACTICAL SURGERY.

Be-itrage Zllr Praciischen Chiruxgie. By Dr.ALBERT s<f -Pacsce CMrMrM. By J. F.. Lehmann. 1929. Pp. 1094. M.12.

I THESE two volumes are composed of short essayson subjects suggested by the work the author hascarried out in his private clinic during the period1923-26. There is much sound common sense in

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his reflections, and it is of interest to read how a Ipractical general surgeon solves the problems coming Ihis way and how his conclusions have been arrived Iat. Failures are impartially reported with successes. IThe sections are short and serve to pass an odd hour Iwith profit and entertainment.

I

ELEMENTS OF HYGIENE AND PUBLIC HEALTH.Third edition. By J. P. Mom, L.R.C.P. & S.,L.F.P.S., Reader of Medical Jurisprudence inthe Faculty of Medicine, Lucknow University.London: Butterworth and Co. (India), Ltd.Pp. 645. 10s.

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’.t’HIS is a manual designed tor Indian students otpublic health. It is ambitious in scope and coversthe whole field of public health activity, specialattention being given to the sanitary problem bpeculiar to India. In the chapter on ventilatormuch space is accorded to relatively unimport L

details (for example, enumeration of types of h ),while there is only a brief reference to the wo 11Leonard Hill (page 93) and no mention of the a-

thermometer. A useful section on the construe, of

hospitals and schools (page 145) is included, alt ghthe size of wards suggested (viz., 40, 32, and 24 Is)does not conform to modern ideals of hospital adr is-tration. The chapter on meteorology and clim; : gycontains no reference to ultra-violet rays. F ceof faulty proof-reading is furnished on page 228,where hydrogen peroxide is described as destroyingthe water-soluble B-vitamin, thus depriving milk ofits <xMMsco)’6MMc properties. In the description ofthe modes of infection the important method ofdroplet spread is omitted, and the discredited viewthat foul air plays a part in the transmission ofdysentery and diarrhoea is included. Damp soil isheld to predispose to tuberculosis, diphtheria, measles,and other diseases. Noguchi’s leptospira is stilldescribed as the causative organism in yellow fever,though its association with the disease is not nowaccepted. The arm-to-arm method of vaccinationstill appears to enjoy pride of place in Tndia. Thehypothesis that putrid meat causes ptomaine poisoningshould no longer find a place in a text-book. Noreference is made to bacterial agents of food poisoning.The book is marred by a certain crudeness in style andoccasional misuse of words.

DISEASES OF THE SCALP.Pelades et alopdcies en aires. By Dr. R.SABOURAUD, Director of the Paris Municipal andSt. Louis Hospital Laboratories. Paris: Massonet Cie. 1929. Pp. 378. Fr.80.THE appearance of this the fifth and last of his

series on diseases of the scalp almost coincides withSabouraud’s retirement from hospital routine. Thefive volumes have occupied his spare time for thirtyyears, and is not the least of many monumentsto his indefatigable diligence and devotion to thescientific progress of dermatology. The subject isarranged in sections which deal consecutively withthe microscopic appearances, the bacteriology, thedifferentiation of analogous conditions of hair loss,heredity and congenital syphilis, causes suspected bypatients, associated disorders of the menopause,thyroid dyscrasia, which the author favours as afactor in some cases ; and finally, a masterly con-sideration of the sympathetic and reflex nervous

theories first propounded by the author’s fellow-countryman, N. Jacquet. The last section is a

general summary, and reviews the best of the manytreatments that have been advocated. As in theother volumes there are many excellent reproductionsof original drawings from microscopic sections andclinical photographs.

There is no cutaneous abnormality so mysteriousand dramatic in its manifestations and so frequentlydiscussed as alopecia areata. It has evolved or,rather revolved, in the course of decades throughnervous, infective, toxic, reflex, and endocrine- I

sympathetic phases of conjecture and hypothesis.There is no general agreement to date. A certain" quid ignotum

" remains to be discovered-a commonfactor which will explain the mechanism of productionin every case. The subject teems with difficulties,for we are but floundering at the periphery of theendocrine-sympathetic physiology, and are stillseeking the instruments of precision which are nowavailable for estimating the functions of most of theother systems and organs of the human body.The author’s modest claim will, we think, be con-

ceded by every reader. " If our conclusions remaindubious, we have at least illuminated the subject tothe best of our ability, and we may thereby havefacilitated the work of those that shall follow after."

PHARMACOLOGY.Pharmaceutical Therapeutics, with Pharmacology,Posology, and Toxicology. By ELDIN V. LYNN,Ph.D., Professor of Pharmacology and Chemistry,University of Washington, College of Pharmacy,Seattle. London : McGraw-Hill Publishing Co.,Ltd. 1929. Pp. 431. 20s.

Prof. Lynn, while not in favour of prescribing bydruggists, holds the opinion that the capable pharma-cist, in addition to his knowledge of the chemical andphysical properties and doses of drugs, must beacquainted with their physiological action andtherapeutical uses. This view may be correct, butsince it would involve the pharmacist of the future inthe strenuous duty of studying anatomy, physiology,pathology, and clinical medicine, he might well preferto take a medical qualification. The followingdescription of the physiological action of digitalismight well bewilder the reader. " The most prominentresult is a powerful persistent stimulation of selectedmedullary areas, including the vagus, the vomitingcenter, the heat regulation, the respiration, and thereflexes." The author says in the preface that he hasfreely consulted numerous treatises on pharmacology,therapeutics, and toxicology. On the whole, hehas given a good account of the action and uses ofdrugs, but it is difficult to see what advantage thebook presents to the student of pharmacy over

similar works intended primarily for physicians.

Theoretische und Klinische Pharmakologie. Third’, edition. By H. V. HoESSLiN, Prof. Dr. med.,

und FRANZ MuLLER, a.o. Prof. Dr. nat. et med.Leipzig : Georg Thieme. 1929. Pp. 231.ivr a RO

THIS book was published originally in 1921 byProf. Muller as a companion volume to his text-bookfor dental students, and while based on the well-known work of Meyer and Gottlieb, was intended togive a succinct account rather than an elaboratediscussion of experimental and clinical pharmacology.That it appealed to the German student is indicatedby the fact that in 1924 a second edition appearedunder the joint authorship of Profs. Hoesslin andMiiller, the collaboration of a clinician resulting in abroader discussion of clinical subjects. The generalplan is that followed by most modern text-booksof pharmacology and therapeutics, though theintroductory chapter deals in somewhat greater detailthan is usual with the subjects of prescribing, dosage,and the preparations of drugs. There is a shortaccount of general pharmacology, but the bulk of thebook deals with special pharmacology, the drugsbeing classified according to the system on which theyexert their main action. By adopting the didacticmanner and avoiding discussion, the authors havesucceeded in packing more information regardingthe action and uses of drugs into its pages thanappears in most other works of a similar size. Thethird edition has brought the book into line with theadvances in pharmacology during the past four years,and deals with many of the drugs recently introducedinto medical practice. It can be recommended tothe busy practitioner as a handy manual of reference,and to the student as a companion to his lectures.

1201AMENDMENT OF THE LUNACY ACTS.

AMENDMENT OF THE LUNACY ACTS.

THE LANCET.

LONDON: SATURDAY, DECEMBER 7, 1927.

THE new Mental Treatment Bill which was read a’second time in the House of Lords last week was, as may be seen from our Parliamentary correspon-;dent’s report, well received. Lord RussELL in his

opening remarks stated that the Bill had the approvalof the chairman of the recent Royal Commission,and we believe that in so far as it provides increasedfacilities for the treatment of mental disorders the

Bill will commend itself to the medical profession.There are certain details to which exception may betaken, but when these are amended the result of itsenactment will be to bring the treatment of mentalillness much more in line with the general practice ofmedicine than it has been in the past. Persons

suffering from milder forms of mental disorder will,regardless of their social position, be able to obtaintreatment without certification and without sufferingfrom any civil disability. The Bill is a short one of22 clauses. Clauses 1-5 make provision for the treat-ment of voluntary boarders. Clause 5 provides fortreatment without certification of persons temporarilyincapable of volition. Clauses 6-10 deal with theduties of local authorities in these matters. Clauses11-14 provide for a reorganisation of the Board ofControl. Clause 16, in amending Section 330 of theprincipal Act, raises the important question of theprotection of medical men signing certificates.Everyone is agreed that our public mental hospitals

should be able to receive voluntary patients. The

scandal will at last be ended that persons applying fortreatment in these well-equipped hospitals built atpublic expense should be refused treatment and

virtually told to go away and wait until they are badenough to get certified as insane. Few will quarrelwith the proviso that the name of every voluntarypatient admitted to a recognised mental hospital orlicensed home must be notified to the central authority.The position is, however, very different when voluntarypatients are admitted to general hospitals, nursinghomes, or under the care of medical men privately.If a person with mental disturbance voluntarily askfor treatment in a hospital or home why should hemore than any other invalid have to be notified to theBoard of Control &deg; Who, it may be asked, is going tomake a distinction between hysteria and mentaldisorder or to say that this or that person is sufficientlyover the border-line to be notified ? ‘ It is obvious thatthose in charge of such patients, let alone the patientsthemselves and their relatives, will object to

compulsory notification, with the result that therewill be considerable evasion of the law. It should beremembered that Section 315 of the principal Act isnot repealed and that anyone who receives persons of

unsound mind for profit will be liable to prosecution ;indeed if this Bill passes the section may well bemuch more strictly enforced. Doubtful cases therewill always be, and those in charge of them, perplexedand worried at the possibility of prosecution, willprefer to inform the Board of the presence of suchpatients. If, instead of requiring that all persons withmental disorder who present themselves voluntarilyfor treatment should be notified, the Bill left this to thediscretion of those in charge, the possibility is that alldoubtful cases would be reported. This should initself be a sufficient safeguard. If there were noconcealment the evil of illegal detention would be to avery large extent prevented. Whilst it must not beconcluded that mere notification would necessarilybe a bar to prosecution under Section 315,it is not likelyj that the Board would initiate proceedings when they’d had opportunity of ascertaining all the facts.

:}1if trust that obligation to notify all voluntary mental.1,,;,ents will be withdrawn and discretion left to the44ical man responsible for the treatment of the

t. We also concur with Lord DAwsorr in

Wtf-nhg to drop the word " boarder" altogether.?3 most undesirable to draw a distinction between1j,}j""-er and patient ; all are patients and the term

Vintary patient’’ is sufficiently explicit..TTie clauses of the Bill providing temporary treat-ment for persons unable to exercise volition withoutcertification will prove a great boon to many. Theacute puerperal case, many post-febrile confusionalcases, a large proportion of alcoholic and toxic insanitywill be treated to recovery without formal certification.The procedure recognises recommendations by twomedical practitioners, one of whom must either bethe usual medical attendant of the patient or a

practitioner appointed for the purpose, either by theBoard or by the local authority. This creation of a

specialist class,, although in some respects open toexception, may prove desirable on the balance ; itwill make the position of practitioners generally mucheasier if in difficult cases they can call to theirassistance someone whose knowledge and experiencehave official recognition. It is most satisfactory thatthe Minister of Health has had the courage to departfrom the recommendations of the Royal Commission indispensing with the application to a judicial authorityin respect of these cases. How patent it is to everyonewith clinical experience that the recommendations-reluctantly proposed by the Commission-requiringan application to a justice of the peace before securingtemporary treatment, would defeat the end in view.These patients are not being detained against their will,they are confused and indifferent, and their relativeswould certainly not apply to a magistrate unlesscompelled to do so ; serious delay would result andthe procedure would resemble so closely that

adopted for the certification as of unsound mind thatthe provision would be hardly worth while. In theHouse of Lords debate Lord BRENTFORD seemedto suggest that a judicial inquiry was desirable,and the Lunacy Reform Association will press for it.We are of the opinion that the intervention of amagistrate is neither a protection to the patientnor to the medical man who signs recommendationsor certificates ; it generally means delay, and theprotection afforded is illusory. Neither the RoyalCommission (nor, we believe, the DepartmentalCommittee which preceded it) was able to find asingle case of any person improperly detained; itis surely clear that the public has no cause fordisquietude.The proposed reorganisation of the Board of Control

does not greatly affect medical men generally, but