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1918). Figs. 2 and 3 have been drawn by using as ordinatesthe percentage of the total subsequent cases occurringon each day, so that the area corresponding to the casesis the same for each disease. The smaller numbers ofcases of poliomyelitis and infective hepatitis mean thatthe percentages estimated for these diseases are not soreliable as those for measles and scarlet fever. However,the numbers are sufficiently great to establish that thereare striking differences in the time of appearance ofsubsequent cases in the four diseases.

DAY OF APPEARANCE OF 240 SECONDARY FAMILIAL CASESOF INFECTIVE HEPATITIS

The graph for infective hepatitis (fig. 2C) shows thesame three waves as the Wensleydale graph (fig. lA).The first wave of parallel infections is followed by awell-defined second wave, including 49-6% of the cases,between the 20th and 40th days. There are a smallnumber of cases from the 41st to the 70th day infected byan intermediate case.

The graph for poliomyelitis shows only a single initialpeak. The incubation period is reckoned to be 10-14days and the absence of a second peak is due to the rarityof case-to-case infection in poliomyelitis.The measles graph shows a definite second wave from

the 8th to the 18th day, corresponding roughly to theincubation period of 11 days with limits of 6 and 16 days,and including 61-2% of the cases. The third wave is avery small one, probably owing to the greater infectivityof measles as compared with infective hepatitis.The scarlet fever graph shows a single peak, because the

first wave of parallel primary infections is fused with thewaves of true secondary and later cases on account of theshort incubation period. Chapin collected figures fordiphtheria in Providence which are very similar to thosefor scarlet fever (quoted by Lavinder et al. 1918). It is,clear that the time distribution of secondary familial casesof a respiratory infection with a short incubation perioddiffers completely from that of infective hepatitis.The duration of the wave of secondary cases will be

greater if there is much variation in the incubation periodor if the duration of infectivity in the infecting case islengthy. The second waves in the graphs in ,this papertaken in conjuriction with the usually accepted incubationperiods suggest that the period of infectivity is short inmeasles and infective hepatitis.

DR. MCFARLAN: REFERENCESChapin, C. V. (1925) Amer. J. Hyg. 5, 635.Frost, W. H. (1938) Amer. J. publ. Hlth, 28, 7.Lavinder, C. H., Freeman, A. W., Frost, W. H. (1918) Publ. Hlth

Bull., Wash. No. 91.McFarlan, A. M. (1941) Publ. Hlth, 55, 56.Pickles, W. N. (1939) Epidemiology in Country Practice, Bristol.

SUMMARY

- In families with more than one case of infective hepa-titis the cases after the first occur in three waves. Thefirst wave consists of parallel primary cases. The secondwave occurs from the 20th to the 40th days, includesabout half of all subsequent cases, and consists of casesinfected bv the first case. The small third wave consistsof cases infected by an intermediate case.

This time-distribution of secondary familial cases ofinfective hepatitis differs considerably from that foundin mumps, measles, poliomyelitis, scarlet fever, anddiphtheria. The peculiarities of the time distribution ofinfective hepatitis cases are compatible with : (1) anincubation period of 20-40 days ; (2) a short duration ofinfectivity : (3) a degree of infectivity in the family greaterthan that of poliomyelitis and less than that of measles.

I wish to thank the Regional’Medical Officers of the EasternRegion and many medical officers of health and medicalpractitioners for cooperation and assistance in the collectionof data.

References at foot of next column

Medical Societies

ROYAL SOCIETY OF MEDICINEAT a meeting of the section of urology on April 27,

with Mr. F. McG. LOUGHNANE, the president, in the chair,a discussion on the use of

Penicillin and the Sulphonamides in Urinary Diseasewas opened by Wing-Commander J. C. AINSWORTH-DAVIS, who reviewed the present position of sul-phoiiamide therapy in urinary infections under (1)indications, (2) basic principles in their use, (3) dosageand mode of administration, and (4) complications andtheir treatment. He preferred sulphathiazole in acuteand chronic coliform infections, but it was not effectivein infections with Bacillus proteus and Streptococcusfcecalis, and its value in staphylococcal infections wasdoubtful. After a large initial dose the drug should begiven four-hourly day and night for at least 2 days, afterwhich dosage was gradually reduced. A white-cellcount should be done before treatment was begun, andrepeated on alternate days. Fluid intake should be5 pints daily to ensure a urinary output of at least 2 pints.Alkalis were given because the sulphonamides weremost effective and more soluble in an alkaline medium.There need be no restriction in the diet. He favoureddoses of 1 -0 g. four-hourly, the tablets being crushed andgiven in an alkaline mixture. Dosage, intake, and outputof fluid should be charted daily. Complications whichmight occur were drug sensitivity (e.g., drug-rash anddrug-fever), granulocytopenia, and oliguria or anuria.from blockage of urinary outflow in the kidney itselfor in the ureters. The symptoms and treatment of thislast complication were fully discussed. Large dosesof alkaline fluid should be given at the oliguric stage ;massage in the knee-elbow position, ureteric catheterisa-’tion, use of the speaker’s ureteral corkscrew, or nephros-tomy were the methods recommended for anuria.

Dr. ROBERT CRUICKSHANK emphasised the value oflaboratory control in the use of, penicillin. In adminis-tratioi4 there was a tendency to return to intermittentintramuscular injections : doses of 15,000-20,000units 4 or 5 times a day were effective in the morelocalised infections. The staphylococcal kidney abscess,which might be multiple or coalesce to a renal carbuncleor lead to perinephric abscess, was very suitable forpenicillin therapy. It was usually secondary to a focuselsewhere and had been common at the end of theHH4-18 war when chronic osteomyelitis was prevalent.Staphylococcal cystitis, often a low-grade infection dueto the white staphylococcus and very resistant to other-forms of therapy, might also respond to penicillin.Treatment of staphylococcal infections should continuefor some time after clinical cure, because of the tendencyto relapse. Although the organisms responsible forthe commoner urinary infections-coliform bacilli,proteus, pyocyaneus and Str. fœcalis—were classifiedamong the penicillin-resistant bacteria, penicillin wasgreatly concentrated in the urine, so that, with a dailydosage of 100,000 units, concentrations of 30 to 40units per c.cm. were obtainable. Helmholtz and Sungin America had lately shown that Str. fmcalis wasinhibited in vitro by a concentration of 3 units ofpeni-cillin per c.cm. of urine at pH 7-6, B. proteus by 8 units,and coliform bacilli by 15-30 units: B. aerogenes andpyocyaneus resisted concentrations over 30 units perc.cm. Thus penicillin might prove beneficial in urinaryinfections due to proteus and Str. fœcalis which resistedsulphonamide therapy. Non-specific urethritis andabacterial pyuria might also respond to penicillin. Fromexperience in the treatment of gonorrhoea, systemicrather than local penicillin therapy was indicated inthese infections. ’

In the discussion that followed, a number ofspeakers referred to the failure of sulphonamides inchronic urinary infections, and the need to deal

594

with local infective foci; and emphasis was laid onobstructive factors or atony which led to urinary stasis.Prophylactic sulphonamides had proved very usefulin preventing fever and infection following instrumenta-tion. Sulphamezathine was recommended as less toxicand more soluble than sulphathiazole. Anuria neednot be due to mechanical obstruction. The tendencyto secondary infection with pyocyaneus and coliformbacilli after penicillin therapy was a common experience.It was doubted if a high urinary concentration of peni-cillin would reach the infecting organisms in the mucousmembranes, but penicillin would not be inactivated byassociated acid or alkali treatment since it was effectiveover a range of pH 5 to 8.

MANCHESTER MEDICAL SOCIETYPHARYNGEAL DIVERTICULA

AT a meeting of the society on April 4 Prof. JOHNMORLEY read a paper based on his series of 21 patientswith posterior pharyngeal pouches, and 2 further casescomplicated by squamous epithelioma arising in thepouch. He showed that what was described by the lateSir Arthur Hurst as an anterior pharyngo-cesophagealpouch was merely barium lodged in the vallecula betweenthe tongue and the epiglottis. The average age inProfessor Morley’s series was 60 years at the time ofoperation, males outnumbering females by more than2 to 1. He discussed the differential diagnosis fromcarcinoma of the oesophagus, fibrous stricture, and cardio-spasm, and stressed the importance of radiologicalexamination, quoting one case where a pouch filled withfood’was mistaken on X-ray examination for an intra-thoracic goitre. In discussing operative treatment headvocated primary excision of the pouch and suture ofits neck in one stage rather than the two-stage procedure,which is followed by a fistula in 50% of cases. In his21 pouches, all treated by one-stage resection, there wereno deaths ; 16 healed by first intention, 3 developedsevere iistulae, 1 a transient fistula, and 2 residualabscesses. Preliminary gastrostomy was only employedwith large pouches in patients who appeared to be badsurgical risks.

. THE GASTRO-INTESTINAL MUCOSA

Dr. F. DURAN-JORDA, in a paper on some new histo-logical facts concerning the gastro-intestinal mucosa,described what appeared to be a flat epithelial layeroverlying the mucosae of the stomach,..small intestine,appendix, colon, and gall-bladder, and-he supported theexistence of this layer by finding capillaries in it. Thislayer, was also found in foetal stomachs and in severalother mammalian stomachs. In studying the layerDr. Duran-Jorda had used his own method of formalinvapour fixation. He touched briefly on the relationbetween this new layer and the histology of some lesionsfound in the stomach,. intestines, and ulcerative colitis,illustrating each stage with coloured photomicrographs.

Reviews of Books

Health Instruction Yearbook, 1944Compiled by 0. E. BYRD, ED D, associate professorof hygiene and director division of health education,Stanford University. Foreword by C. MORLEY SELLERS MD.(Oxford University Press. Pp. 354. 188. 6d.)

ONE of the perennial problems of the health educatoris the content of his teaching. It is easy to utter banalgeneralities, yet these make little impression. Onerecalls a senior physician who once, to his horror, foundhimself addressing an audience of nurses thus : "’ Thetongue is a wiggley organ. It woggles in and out ofthe mouth." Dr. Byrd has placed all health educators,medical and lay, in his debt by producing a really usefulguide to current medical advance, and work in the fieldof social medicine. Though in theory a series of 305abstracts, these are so arranged as to produce a con-tinuous narrative, under such headings -as nutrition,.exercise and body mechanics, heredity and eugenics,habit-forming substances, family health, and occupationalhealth. Every abstract is really informative and theyinclude a large number of vital and other statistics.Though most of them relate to the United States, their

interest is none the less considerable for British healthteachers. The information supplied is catholic ; thusthe book records that : The country with the lowestcrude death-rate in the world is the Dominican Republic,with New Zealand next; about 68% of all births in theUnited States take place in hospitals ; the maternalmortality-rate in the United States is lowest in the age-group 20—24: years ; the death-rates of married people,particularly married men, are substantially lower thanof single people ; less than 5% of American divorces aregranted on the grounds of adultery ; the Kenny methodof treating infantile paralysis has now been very widely ‘adopted in the United States ; there is a Mormon familyin Utah in which 41 achondroplasiacs have been bornsince 1833, and only 3 have so far died, at the ages of 61,78, and 79 ; a statistical study of people over 50 showedthat the factors mentioned as making for happiness in old age were (in order of frequency) good health, trust inGod, a cheerful state of mind, money, friends, gainfuloccupation, pleasant relation with family, children, andgrandchildren. With such a quarry to dig in, there cannow be no excuse for dullness among health educators.

Principles and Practice of Ophthalmic Surgery(3rd ed.) EDMUND B. SPAETH, MD. (Kimpton. Pp. 934.50s.)

ROUTINE operations of ophthalmic surgery for squint,glaucoma, and cataract have not- changed much in thelast decade ; they are set down here in detail, and withall possible variations. Fair to all parties ProfessorSpaeth often gives his own experience and opinion onlyat the end, in brackets. All varieties of skin graftingand plastic surgery applicable to the eyelids are welldescribed-corneal grafting by Castroviejo, and gonio-scopy by Barkman. Every known technique for dealingwith detached retina is recorded, but many of thesedescribed have no more than a historic interest in thiscountry, and a few coloured plates in this section wouldhave saved a mort of words.The thoughts of most European eye surgeons today

are directed towards the treatment-of battle casualties.This book, by a civil surgeon for civil surgeons, is writtenfar from the scenes of war. This does not detract fromits great merits, but the surgeon seeking advice on acuteinjuries of the lids and globe will find the standard ofthe sections dealing with them below that of the restof the book. Transscleral removal of foreign bodies istoo lightly dismissed, and the immense possibilities ofprimary and delayed primary suture of the lids deserveda place in this useful text.Your Doctor of the Future

H. H. LEESON, MO, MRCS. (Freer and Hayter. Pp. 32.1s.)

Dr. Leeson continues in this pamphlet his series ofcomments upon the future of the medical services.He would be content, it seems, to accept the generalstructure of service suggested in the white-paper providedthat the administrative machinery allowed full profes-sional participation in the planning of the service, andthat the terms and conditions of service were sufficientlyattractive. He has given much thought to the details ofadministration, has prepared a comprehensive list ofmedical subdepartments which he considers would benecessary, and has shown how they could function bothin central and local administration. Throughout thepamphlet he shows a greater readiness than most of usto enter into the discussion of detail. Sometimes thisleads him into positions unacceptable even to thosedoctors who would agree with him in principle. Forinstance, many who would agree as to the need forhealth centres might not agree that there isa universalneed for a type of centre as elaborate as is here described.Dr. Leeson is a little confusing in his section on re-muneration, both for consultants and GP’s. It is clearthat he would personally prefer a salaried service forboth, but he is willing to accept as an alternative(particularly for part-time service) a system of paymentby what he calls capitation, but which is really not acapitation method, but a system of payment by item ofservice. Yet on the whole this is a useful pamphlet,which will stimulate readers to formulate more clearly,and in more detail, their own views on many contro-versial subjects.