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Special Articles.ROYAL INSTITUTE OF PUBLIC HEALTH.

WHITSUNTIDE VISIT TO PARIS, AIX, AND VICHY.

THE successful study tour organised last autumn IIby the Royal Institute of Public Health 1 to theSwiss tuberculosis institutions has been followed upby a visit to the Paris hospitals and to two of themore famous French inland watering places in whichupward of 150 Fellows of the Institute and theirfriends took part. The programme was arranged byDr. Gustave Monod of Vichy, with the assistance ofa reception committee, of which Prof. Leon Bernardwas president, and the travelling arrangements werein the able hands of Sir Henry Lunn, who accompanied ithe party to Paris. i

PARIS. ’

The visit of the Institute to Paris was inauguratedby a dinner to the leaders of the medical profession inParis, given by Sir Henry Lunn on Sunday, May 20th,at the Palais d’Orsay, which was attended by morethan 200 persons. Sir Henry Lunn, who presided, fgave expression to the pleasure that he felt at bringingtogether so many French and English medical menand women who were anxious to know each otherand to learn from each other. Prof. Henri Roger,Dean of the Medical Faculty, proposed the health ofthe King, and Sir Thomas Oliver followed with atribute to the pioneers of medicine in France, to whichProf. Bernard replied. Dr. Monod, in proposing thehealth of the chairman, explained, in a neat little Ispeech delivered in perfect English, that thedevelopment of the Paris hospitals was hindered by ithe lack of pecuniary support, due to their associationwith the State; the hospitals of London, on the otherhand, based as they were on voluntary assistance,lacked for nothing-a view for which he wassubsequently taken genially to task by some of hiscolleagues. Amongst the French guests presentwere Prof. Henri Hartmann, Prof. Jean Sicard, Prof. IGeorges Guillain. Dr. Paul Garsaux, Dr. Etienne :Braissaud, Dr. Desfosses, Dr. M. Robineau, Dr. PierreQuiserne (of Bagnoles de l’Orne), Dr. Raoul Bensaude,Dr. Paul Ferreyrolles (representing the InternationalSociety of Medical Hydrology), and Dr. Louis Blanc(of Aix-les-Bains).Monday opened with a visit to La Pitie, a hospital

with 1000 beds on the pavilion system, modernised Ijust before the war. Here Prof. Henri Vaquez received

A leafy thoroughfare in the grounds of the Hopital de la Pitie.* *

the party and conducted them to a lecture theatre, Iwhere the veteran Prof. Jules Babinski demonstrated Ian admirable film dealing with cerebellar tumours

1 THE LANCET. 1927, ii., 824 ; Jan. 14th, pp. 94, 99.* The five illustrations of Paris hospitals are adapted from

photographs in an official volume of the Assistance Publique.

and illustrating many of the characteristic features indiagnosis. In the same theatre a demonstration wasgiven of heart sounds transmitted, after electricalmagnification by means of two loud speakers, to large

A group taken under the statue of the anatomist Bichat in theforecourt of the Paris Faculty of Medicine.

Photo by E. C. 2empiier.

audiences. Dr. Lutembacher, who was present,introduced the film, but left the loud speaker to deliverthe lecture in his own voice.At the Salpetriere, which was next visited, Prof.

Guillain, the director, conducted the party to Charcot’slecture theatre, where films were shown of myopathy

1 -.0 T’--1?.CM1’H til JiUUICO a

disease. A visitwas afterwardspaid to theCharcot library,containing,besides the price-less collection ofneurologicalbooks and manu-scripts, manyinteresting reIic=of the master,including some

little humoroussketches made onscraps of paperas people some-times draw on

their dinnermenus.

In the after-noon Dr. Louis Martin and. his colleagues took theparty round the Hopital Pasteur, which is not,as are the other hospitals, a unit of the AssistancePublique, but was founded in 1888 by internationalsubscription as a memorial to the discoverer of theprevention of rabies. Here there is no isolation in

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separate wards, but all manner of infectious diseases Iare treated on the cubicle system, a central corridor Iallowing the friends and relatives of patients to see Iand greet them without actual contact. The road I

The 17th-century chapel of the Hospice de la Salpetriere.

was then crossed to the Pasteur Institute, where awreath was laid on Louis Pasteur’s tomb, and inProf. A. Calmette’s absence one of his co-workersdelivered a short address on the B.C.G. antituberculousvaccine, his remarks being translated by Dr. L. Field iRobinson. This vaccine, administered by the mouth Ito new-born infants, is regarded as free from risk iand able to confer immunity at least up to the ageof 5 years. It is now being placed free of charge atthe disposal of all maternity hospitals, dispensaries iand social organisations in Paris. Work is now Ibeing done on subcutaneous administrations.On Tuesday morning at the Hopital Laënnec a

demonstration was given by Prof. Bernard andDr. Ed. Rist, of the tuberculosis unit, initiated there inthe year 1910 on the suggestion of Sir Robert Philip.Dr. Rist frankly admitted that their work at firsthad no great success, owing to an attempt to do too imuch, but opportunity came with the war when a !private association of visiting nurses offered their i

services to the hospital dispensary, and otherdispensaries were started throughout the department.The French, he remarked, were the most conservativenation in the world, and nothing but a war could haveled to such a development. Wards and dispensary,being under the same direction, continuity was Iensured and patients were never lost to sight. They Ihad inherited from Grancher the system of ensuring ithe survival of the offspring of tuberculous mothersby separating them at an early age. The childwelfare problem had not then been tackled, andGrancher’s work began with children over 3 yearsof age. But Bernard, with the cooperation of i

Prof. Alex. Couvelaire, undertook the double problem.The consumptive pregnant woman, admitted tothe Laennec, was sent to the Clinique Baudelocque Ifor her confinement, the infant being separated Ifrom her immediately after birth, artificially fed for ia few weeks in a special department, and then brought i back to the Laënnec. If then the cuti-reaction wasnegative, the infant was sent to one or other of the iwelfare centres in the villages of central France .under medical and nursing supervision. Each centre ]of 50 children includes a milk station, and is visitedperiodically by Bernard or his assistants. Contacts s

are also taken in the hospital but kept apart on a <

separate floor, the mothers sometimes being allowed < :to continue nursing the child, wearing a special 1mask during the act of suckling. The hospital, I 1said Dr. Rist, now has a teaching centre for visiting Inurses and post-graduates; the clinical material E z

was ample, for the number of patients treated at thedispensary had risen to 34,000 in the year. Along

with Edinburgh and Cardiff, the University of Parishas now recognised a special chair of tuberculosis., With regard to

.A..1’<;ty w

every patient,he said, was

examinedseveral timesduring thecourse of treat-ment, coordina-tion beingensured by theclinicians beingtheir own radio-logists.The next hos-

pital visited wasthe Necker, with480 beds, madefamous by thefact that it wasin its wards thatLaennec dis-covered auscul-tation. Prof.Sicard gave alantern demon-

stration of lipoidol : first in its harmlessness toexperimental animals when injected into the venoussystem ; secondly, in its application to the diagnosisof spinal tumours and affections of the bronchialtree ; and finally, as a treatment for fibrositis in itsvarious manifestations. He was followed by Dr.Robineau, who showed on the screen the treatmentof fractures by means of bony screws and metal

One of the old wards for incurables in the IMpita.1 Laennee.

sleeves, illustrating his thesis that union should beperfect if only complete immobility can be secured.

In the afternoon a tour of the military medicalschool of the Val-de-Gr&acirc;ce was made under thecombined tutelage of the Abbe and of the repre-sentative of Med. Inspect. H. Rouvillois. Foundedby Anne of Austria, mother of Louis XIV., the hospitalhas a church full of antiquarian interest, cloisters ofrare beauty, and a fascinating museum of war materialembracing many campaigns down to the Great War.

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The military training is not superposed on the medical,but the student at the end of his first year of medicalstudy enters the school and becomes a soldier.A visit was then paid to the Institut Prophylactique,

founded in 1916 in cooperation with the State forthe extinction of syphilitic infection. At this InstituteDr. Arthur Vernes, the director, has perfected a methodfor the measurement of leutic infection by opticalmethods. After saying a few introductory words,Dr. Vernes left the exposition of his work to Dr. E.Ofenheim, director of bacteriology at the LewishamMemorial Institute, who had travelled to Paris byaeroplane for the purpose. The method, he said, wasone which left nothing to human judgment or error, andwas superior in this way to the Wassermann test.More than 100,000 patients had passed through theInstitute ; there were now 100 centres in France,and 41 countries which had adopted the syphilimetricmethod. Uncontrolled treatment of syphilis hadresulted too often in increasing the incidence ofcomplications, and the syphilimetric method ofVernes afforded the opportunity of an exact controlof treatment, so that it was now possible to conductthe course of treatment and dosage on exact lines.The Institute, he said, had no use for the termssecondary and tertiary in connexion with syphilis ;cerebro-spinal lesions might begin as soon as 6 to 8weeks after infection, and it was essential for thedisease to be treated continuously on a well-definedplan. After the lecture the ingenious instrumentwas demonstrated and questions were put as to theevidence for the assumption that the opacity of

Cloistered entrance to the Hospital Necker.

the serum is an exact criterion of progress in thetreatment of the disease.

Wednesday morning was fully occupied by a visitto the Hopital Cochin, which, founded in 1780,has been almost entirelv rebuilt, and now ranksamong the newest of the Paris hospitals. The visitgave a welcome opportunity of witnessing the methodsof teaching clinical medicine in the Paris faculty,and especially those of Prof. Fernand Widal, at whose

instance the visit was paid but who was preventedby illness from being present. In Paris students whohave completed their preliminarv study of chemistryand biology are at once brought into contact with

Street frontage of the H&ocirc;pital Cochin.

patients, for " medicine," said the lecturer. " is apractical trade." The morning begins at 9 o’clockwith a short theoretical lecture on each of the greatclinical syndromes in turn ; next comes an hour in thewards with an assistant to superintend, although eachstudent has to work with his own hands, eyes andbrain. During the third hour Prof. Widal performsthe complete examination of a single patient." Superficial examination is," he says, " the chieforigin of faulty diagnosis," and he prefers to paintone complete clinical picture each day. As an

example was shown a patient who had pure asthmawithout nervous or endocrine symptoms, susceptibleto cat’s hair, and subject to frequent haemoclasiccrises. Later the party was conducted round a

remarkably well-equipped genito-urinary department.In the afternoon Prof. Roger received the Institute

at the Facult6 de Medecine, when parties were

conducted,in groups round the lecture theatres andlaboratories. Prof. Hartmann took the opportunityof setting out the aims of the A.D.R.M., of which heis president. This is an association, founded sixyears ago, for the development of medical relationsbetween France and allied or friendly countries. Theassociation works under the presidency of Prof. Roger,with a patronage committee comprising the heads ofthe medical profession in Paris. The office, knownas the Salle Beclard, is convenient of access on thefirst floor of the faculty buildings, and here visitingmedical men and women are sure of finding exactand precise information as to where they can satisfytheir needs. During the last twelvemonth 127visitors have come to Paris to study surgery orgynaecology, 80 general medicine, 52 obstetrics, andother subjects in smaller proportion. Fourteen cameto gratify their curiosity as to laboratory work, and50 desired to know how thev could enter for thefull medical curriculum and become qualified to

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practise medicine in France. They included representa-tives of at least 30 different countries or nations.The Paris faculty decided last year to organise aseries of post-graduate congresses in English with aview of diverting the flow of English-speaking studentsfrom Vienna and Germany to Paris and the provincialFrench universities. The endeavour is making slowprogress, but as Prof. Hartmann put it, " petitpoisson deviendra grand si Dieu lui prete vie," andit was evident to Fellows of the Institute that manyof the Paris teachers are well equipped to take classesin the English language.A number of the party went out to the aeroport at

Le Bourget to witness a demonstration of the caissonpneumatique of Dr. Garsaux, which is used to reproduceunder experimental conditions the effects of cold andaltitude on airmen.

V ICHY. -

’

On Thursday the party left Paris by special train forVichy, a run of five hours, the latter half of which isup the fertile valley of the Loire and then of itstributary the Allier, punctuated with old chateauxand the creamy-white milch cattle seen there alone.In May the journey is throughout a riot of colourwith the yellow broom in full flower. They werereceived on arrival by Mr. Baugnies, chairman ofthe Compagnie Fermiere of Vichy, to which the bathsare leased, and by representatives of the local medicalsociety, and taken to the Carlton Hotel. At 8 P.M.a gala dinner was given in the Salle des Fetes of theGrand Casino, at which Mr. Baugnies, who presided, iwas supported by Dr. P. Jardet, past president ofthe medical society, Dr. R. Durand-Fardel, Dr. Guinard,Dr. E. Willemin, Dr. L. Chabrol, and Dr. Monod.Speeches were brief and witty, and the evening ended

. pleasantly with an entertainment by Parisian artistes.On Friday morning after a visit to the Vichy-Etat

Pastillerie, at which the natural salt is obtained by

A group taken at the entrance to the Etablissement Thermal, Vichy.

evaporation in vacuo and put up plain in packets and ias elegant barley-sugar lozenges, a film was shownat the Vichy-Cin&eacute; room illustrating the principalfactors of the Vichy cure and the surroundings inwhich it is taken. In the afternoon the party wasdivided into sections, each of which was conducted Iround the new Thermal Establishment by one or ! I

other of the local medical fraternity. Vichy, it seems,although well enough known as the vicus calidusfrom Roman times, remained a small thermal townuntil its glorification in the years 1861-66, whenNapoleon III. chose it for his place of residence.It was he who redeemed from the swift-flowing buterrant Allier the semicircular strip of land which isnow a magnificent wooded park. Napoleon’s chalet-dwelling which overlooks the park has for the last40 years been occupied by Dr. Willemin. It was inNapoleon’s time that the baths were first leased tothe company at present holding them, to whosecourageous foresight the remarkable development ofthe place as a health resort is largely due. Thecompany’s lease was extended last year to run until1970, and it is proposed to begin at once with the con-struction of a second thermal establishment, with allthe essential equipment, but on lines less lavish thanthose of the existing house. A large swimming pool andgymnasiums are also in the contemplated programme.

The Vichy waters are plutonian rather thanneptunian, and originate, it is believed, from a seriesof faults in the volcanic strata which are characteristicof the Auvergne. There are five natural springs ofwhich the temperature varies from 16&deg; to 42&deg; C.,rising to the surface of the ground within a fewhundred yards of one another. There is much sub-terranean pressure behind them, and one or other ofthese springs would still, if undaunted, rise above thesurface and provide a geyser of no mean appearance,as indeed must have been the case in pre-Romantimes. Hotter springs up to nearly boiling-point existin the near neighbourhood. All these waters haveessentially the same composition, the temperaturedepending solely upon the length of sojourn in the

=

1000-feet thick layer of marl which overlies thevolcanic stratum through which the water -rises.Alongside the Celestins spring lies an enormous rock,

I some 350 by 30 by 20 metres, out of which the waterappears to rise, the fact on the contrary being, asDr. Willemin points out, that the rock has arisenfrom. the water rather than the water from the rock.The composition of this great rock is quite unrelated

I to the marl in which it lies, and it owes its origin to a! gradual accretion of deposit from the cooling water

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through the ages. All the waters, too, are practicallyisotonic with the blood serum, the total mineralisationbeing roughly 0’7 per cent., a point of some therapeuticimportance ; the presence of helium and argon alongwith certain colloid metals is further evidence of theirdeep origin.The essential Vichy cure is, of course, the treatment

of gastric and hepatic disorders by the systematic Idrinking of warmcarbonated water,and the typicalsight is the never-ceasing throngaround the springsin the glass-roofedpavilions, eachpatient bringinghis or her own

mug or glass totake the pre-scribed dose ofwater. The usualcourse is of3-4 weeks, andalthough the resi-dentsonlynumbersome 20,000 thereis an annual in-flux of more than150,000 visitors. Apart, however, from the water-drinking, Vichy has considered it prudent to provideall manner of baths and treatments available at otherspas; the balneo-therapeutic, gymnastic, and electro-medical equipment compare favourably with those at

any continental spa.AIX-IJES-BAINS.

The journey to Aix-les-Bains was continued onSaturday in the special train which brought the partyto Vichy. The cross-country journey proved ofunusual interest with the climb out of the LoireValley into that of the Sa6ne, the transit of Lyon,and the remarkable route up the Rhone Valley tothe beautiful lake of Le Bourget, on the north shoreof which the Romans discovered hot sulphur springsand built around them the very elaborate system ofbaths which has only been laid bare during the lastfew years and is still being excavated. The receptionat the station was by the Mayor of Aix, Mr. HenriClerc, who, when free from official duties, is a dis-tinguished author and dramatist, and after the guestshad been allotted to their hotels, they were receivedby representatives of the local medical society atthe thermal establishment and conducted round thebaths. It is hardly necessary to dwell on the douche-massage, or Aix douche, which is now a familiaritem in the thermal bathing of any well-equipped spa,but the Berthollet cabins were new to many of theparty. In them the hot sulphur water, falling froma height, becomes pulverised to produce a warmvapour bath at a temperature of about 42&deg; C., inwhich the patient stays for 5-10 mins. before or afterthe massage douche. This bath is also used locally,the spray being directed for 20 mins. on the affectedparts by cornets surrounding them, the applicationoften being followed by dry massage.

Later in the afternoon, in the Town Hall, Dr. L.Bertier, this year’s president of the medical society,gave a short but very comprehensive address on thecurative waters* and the local arrangements forhydrotherapy. The baths, he said, were known andvisited by the Romans. There were two springs,known as the sulphur and alum sources, both highlyradio-active, the former containing a kind of algaknown as baregin, which facilitated the douche-massage characteristic of Aix treatment. The bathingestablishment was owned by the French Government,which put in their own director in charge, and thanksto his initiative there was an early prospect ofbuilding an entirely new bathing establishment onthe site of the old Roman baths, for which the planshad been put out to competition among architectsthroughout France. In Aix they were employing

200 masseurs and masseuses, who were taught theelements of anatomy, and who were themselves ofnecessity of robust constitution, as they workedin the baths from 5 A.M. till noon every week-day.The supply of water to the baths was practicallyinexhaustible, which was just as well since eachdouche-massage used up 400 gallons of water, and an

I enormous volume was required to produce the

A characteristic view of the foothills of Mont Revard at Aix-les-Bains.

Berthollet spray, which was a characteristic featureof Aix treatment. The cases coming under medicalcare of Aix included all forms of chronic rheumatismand arthritis, whether infective or not, neuritis,lumbago, fibrositis, and gout. Dr. Bertier remarkedthat his colleagues and himself attended at the, bathsevery morning in order personally to supervise the treat- .

ment which they prescribed, and to modify it in detailas need arose. This was, he thought, unique at Aix.

In the evening a banquet was given at the GrandCercle under the presidency of the Mayor, followedby a display of fireworks in the semi-tropical gardens.In an eloquent speech Mr. Clerc sketched the develop-ment of Aix, the modern history of which began withthe building of the first thermal establishment in1776 by King Victor-Amedee III. and the popularisingof its beauties by the historian and poet, Alphonsede Lamartine. On Sunday the whole party was theguest of the P.L.M. Railway, which conducted itby cog-wheel railway (the earliest of its kind inEurope), or by automobile, to the summit of MontRevard (5070 ft.) where weather conditions werefavourable for a perfect view of Mont Blanc and themountains of Savoy. Some of the party made thedescent on foot in the company of Dr. Forestier,junr., learning from him much of local history andcustoms. In the afternoon the Zander Institutewas visited, and the evening closed with a performanceof Charles Dickens’s " Cricket on the Hearth,"presented by the Societe des Casinos.On Monday morning a visit was paid by steamboat

on the Lac du Bourget to the royal abbey of HauteCombe. Here there is a little enclave of Savoyardterritory within present-day France, at the foot ofthe Dent du Chat, in which lie buried the Princes ofthe House of Savoy. On the way to the lake a haltwas made at the laboratory, founded by LordRevelstoke, which serves a double purpose as publichealth institute for the control of water and milk,and of a place for clinical investigation of the casesunder the care of practising doctors. A glance atthe Marlioz establishment, where the hot alum-springis vapourised for inhalation, and a brief visit to thegolf course concluded the official programme, afterwhich members were free to return home or tocontinue their journey on one or other of severalitineraries suggested by the Institute.

This account cannot conclude without a word ofappreciation addressed to Dr. T. N. Kelynack, hon.secretary of the Institute, without whose continuoushelp and cooperation the visit could hardly have beenthe success which it was.