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family during disinfection of dwellings, means of disinfec-tion, and ample power in relation to the disinfection ofpremises. The Board may erect and maintain mortuaries,and when necessary order the removal of bodies thereto,may enforce speedy burial, and generally take steps to

prevent infection from corpses. Penalties are sought to beenforced on persons who let, without disinfection, houses inwhich infected persons have lodged, or make false statementsas to the previous existence within six weeks of infectiousdisease. These clauses refer also to hotels. Parents orteachers knowingly admitting children suffering from in-fectious disease, or from a house where such has existed, aremade liable to fine unless, in the latter case, a certificate ofsafety from a medical man be produced. Stringent pro-visions against the use of infected milk are proposed. The

supply of milk from a contaminated source may be prohibitedby the sheriff or a magistrate’s order, and a list ofcustomers must be supplied by any cowkeeper or milkvendor whenever, in the opinion of any medical man, in-fectious disease is attributable to such sale. Finally, allexpenses regarding the prevention and mitigation of diseaseshall be defrayed by assessment under the Public HealthActs; and two or more boroughs may combine for the

purpose of carrying out the whole or any part of the pro-visions of the proposed Bill.

SANITARY CONDITION OF CALCUTTA.

THE sanitary condition of Calcutta has lately been thecause of considerable anxiety and of a large amount of news-paper correspondence. Towards the end of December the

Englishman, in a very strong leader, called public attentionto what it characterised as the " calamity" which had over-taken that city. It described it as "literally reeking with fetidgases of a character which no one can mistake ...... We are

living over one vast cesspool, which is pouring forth its pesti-lential vapours at every crevice, and through the soil itself."The writer of the article gave an account of a walk-and a pleasant walk it must have been !-which he tookthrough the city on the preceding night, and of the lethalsmells with which the air was charged. He stated that the

sanitary condition of Calcutta has for some years been steadilydeteriorating, that typhoid fever has been on the increase,!In.1 th!l.t tha rt!r!-w3t’Tir fmrtTm nf frjra a npw

feature in the sanitary history of the town," is now of annualoccurrence. These serious evils he attributed to the cumula-tive contamination of the soil through which the sewers run,"not to the mere fact of the drains being covered, but to theabsence of proper means of flushing them, combined with amethod of ventilating them which allows the noxious gasesto escape at a level with the ground," and called upon theGovernment to take immediate and effective measures toremedy these serious defects. It was hardly to be expected thata statement involving such serious considerations as affectingthe public health. and implying, at least, neglect on the partof the municipal authorities, should be permitted to passunchallenged. Accordingly, Deputy Surgeon-General K.McLeod, the sanitary officer, in a long and temperate letter,called in question some of the facts adduced, and stated asthe result of a personal investigation that the foul smellscomplained of were not given out from the sewers throughthe grating in the roadway, but by the "wet putrefyinghorse and cow dung in the streets," for the removal of whichno special provision seems to exist. He also denied theexistence of typhoid fever to any extent, and attributed theepidemic of cholera not to the state of the sewers or theexhalations from them, but to "stagnant open drains, foultanks, filthy byres, and ill-drained privies, defiled waste lands,and so forth."

It may be necessary to mention that there are in Cal.cutta thirty-four miles of main sewers, which’ have beenconstructed of dimensions sufficient to carry off not onlythe sewage but the storm waters ; and besides these, aboui150 miles of pipe sewers ranging from six to twelve inches irdiameter. From the level nature of the ground the aewerihave been laid with so slight a fall that a copious supply owater is necessary to carry the sewage through them, andwhen. constructed, the engineer intended that they should bi

thoroughly and regularly flushed, which does not appear tohave been done.The existence of these fetid odours being admitted on all

hands, though their actual source was a matter of dispute,the subj ect was taken up by the Municipal Commissioners,who decided to take immediate steps to ascertain, so far aspossible, to what cause they were attributable, and whatmeasures were necessary for their abatement or removal.Some energetic members of the Commission resolved to assistpersonally at an examination into the state of the sewers bycompetent professional advisers. Prior to doing so theyinspected all the books kept in connexion with the service,and discovered that for a period of ten months no record hadbeen made of the sewers having been flushed, but that "anumber of entries, purporting to be records of the nushingsof the sewers made at various dates during the past year,had really been written within the last few days." Theexamination of the main sewer, which was made in the pre-sence of several of the Commissioners. is stated to have givenmost satisfactory results ; it was perfectly inodorous, andthe silt deposit was less than anticipated. But there is asuspicion, and certainly not an unjustifiable one, that thepersons who had falsified the records had also flushed thesewers subsequently to the discussion being raised as totheir condition, and strong corroborative evidence in sup-port of this charge was subsequently brought before thespecial Sanitary Committee. Whether it be correct or not,however, there seems no reason to doubt that the smallersewers and house connexions are in a very unsatisfactorystate, and play an important part in the production of theinsanitary emanations. There is not a sufficient supplyof water to flush them, and they have consequentlybecome foul and in some instances choked, while manyof them are inefficiently trapped or not trapped at all.This being the case, there can be no doubt as to one

source at least, and that a very important and general one,of the sewer gases. Subsequentlv to the examination intothe state of the main sewers, Mr. Harrison, the Chairman ofthe Commission, in a letter addressed to the Editor of theEnglishman, denied the statements which had been made asto tne insanitary condition ot Calcutta, and, in support othis opinion, adduced the fact that the death-rate was lowerin 1882 than in any of the five preceding years, except 1879.The returns on which this conclusion is founded have notreached us ; but the Englishman, by an analysis of thecauses of death occurring in seven weeks in the end ofthe three years 1877-79 compared with the same period in1880-82, shows that the annual average from bowel diseasesand cholera in the first period was 488, and in the second695. As these are diseases most likely to be affected byinsanitary conditions arising from defective sewerage, theresults afford a strong presumption that the death-rate hasbeen abnormally affected by these conditions.In this state of affairs it is a most important question,

what are the measures necessary to restore and maintain thesanitary condition of Calcutta ? The first and most essentialis an increased and adequate supply of water to the housesto ensure efficient flushing of the house connexions with thesmaller drains. Of this measure Mr. Harrison says :

,. Theincrease of the filtered water-supply is the one sovereignremedy. We have in no degree overlooked the gravity ofthis matter, and have in season and out of season urged itsimportance."

" To this should be added the compulsoryintroduction of automatic flushing tanks to secure that thedrain pipes are cleaned out at least once in the twenty-four hours. It is stated that steps are now being takenby which the water-supply to the houses will be morethan doubled. If this be so, the work should be pushedon rapidly without regard to expense. Measures also shouldbe taken for the efficient flushing of the smaller sewers,in addition to that which they will receive from the in-creased now of water through the house connexions, and a

check should be put on the responsible parties by whichsuch gross neglect as has been shown in flushing the maindrains may be impossible without detection. In additionto these measures, the abolition of gratings on the road levelin connexion with the sewers is urgently required, theadoption of some system of ventilation which will not exposethe inhabitants, like that now in use, to the risks attendingthe emanation of gases from the sewers, and the organisationof a service for the removal of "the wet putrefying hopeand cow dung" from the streets, to which Dr. McLeod attii-butes much of the insanitary odours.

, We have endeavoured to give an impartial account of this

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important question from the information we have received,and to avoid entering into any personal questions connectedwith it. We must, however, congratulate Calcutta upon pos-sessing a paper which takes up so warmly, and brings out soclearly, the defects in sanitary matters which are exercising aninjurious influence upon the health of its inhabitants, and a I’Municipal Council which so promptly recognises its duty to Iinvestigate such questions, instead of ignoring the statementsadvanced or threatening the authors of them with legalpenalties. We trust they will follow up the subject in thesame spirit they have already shown, and that in thepractical application of remedies they may be as prompt, asjudicious, and as successful as they have shown themselvesin the preliminary investigations.

Correspondence.RHEUMATIC ENDOCARDITIS.

"Audi alteram partem,"

To the Editor of THE LANCET.SiR,—To one or two points in connexion with the abovE

subject, touched on in Dr. Sansom’s Lettsomian Lectures,published in recent numbers of your journal, I would, wit!your leave, direct attention.In speaking of rheumatic endocarditis, Dr. Sansom quotes

and endorses the two practical reasons which I give for thefailure of the salicyl compounds to control the cardiac, asthey do the arthritic, inflammation : first, that the cardiacmischief has generally commenced before the patient comesunder observation; and, second, that rest, which is so

essential to the recovery of an inflamed organ, and which is

easily got in a joint, is unattainable in the heart. Thefirst reason makes prevention impossible, the second is abar to successful treatment. But though this is true, itdoes not express the whole truth. That a joint generallyrecovers from rheumatic inflammation, and that the heartdoes not, is a statement which expresses the broad resultsof clinical experience, but expresses them in a mannerwhich, from a pathological point of view, is bald and mis-leading. The truth is (and striking as the statementmay appear, it is absolutely correct), that everything whichrecovers in a ,joint recovers also in the heart. The onestructure in the heart which does not recover, the endocardium,is also the one which has no analogue in any of the structuresof a ioint. In studying the natholosv and treatment ofrheumatic endocarditis it is essential that this fact shouldbe kept before us, for unless we do keep it in view we are sureto ;fall into error. The parts which suffer in a joint inacute rheumatism are the fibrous ligaments and tendons andthe synovial membrane. The parts which suffer in theheart are the fibrous rings and valves, the endo- and peri-cardial linings, and occasionally the muscular substance.Thefibrous rings and valves are similar in nature and functionto the fibrous structures of a joint. Each is apt to be theseat of rheumatic inflammation, and in both this inflam-mation is generally recovered from. The pericardium findsits analogue in the synovial membrane; each is a very vas-cular membrane ; each secretes a lubricating fluid ; andeach has for its function the facilitating the movements of asolid body; each, too, is apt to be the seat of rheumaticinflammation ; in each the inflammatory process tends tospread, and in both the tendency is to recovery. Theendocardium has no analogue in a joint. There isnothing in a joint which bears the least resemblance to

it, either anatomical or physiological. It is a non-

vascular membrane, in which inflammation cannot, and,as ,a matter of fact, does not, spread. In nature andfunction it is identical with the lining membrane ofthe bloodvessels, with which it is structurally continuous.When it is affected in acute rheumatism there is no generalinflammation of its surface such as is found in the pericar-dium and synovial membranes; the mischief is limited to asmall portion of one surface of the affected valve. I haveelsewhere 1 shown that the occurrence of the lymphy deposit

1 On Rheumatism; its Nature, its Pathology, and its Successful Treat-ment, by T. J. Maclagan, M.D. London: Pickering and Co. 1881.

which constitutes the endocardial lesion in acute rheumatism,and its limitation to one particular portion and surface of thevalve, are to be explained, not by the direct action of therheumatic poison on the endocardial lining, but by themechanical rubbing against each other of valvular ligamentswhose deeper fibrous structures are the seat of rheumatic in.flammation and thickening. This thickening of their fibrousstructure it is which makes the valves rub, and the rubbingit is which irritates and roughens the membrane whichcovers them externally. The inflammation and thickeningof the fibrous structure of the valve may be recovered from.What is not recovered from is the roughening of, and lymphydeposit on, its non-vascular endocardial covering. This isnot recovered from because the continued action of the valvekeeps up the rubbing and mechanical irritation, and becausethe want of bloodvessels in the endocardium preventsabsorption. This is a condition over which no drug couldpossibly exercise any control. It is directly of mechanicaland only indirectly of rheumatic origin. But it is by nomeans certain that we may not in some cases, by the earlyand free administration of the salicyl compounds, prevent theinflammation and consequent thickening of the fibroustexture of the valve, which are the origin of all the mischief.If we see a case early, and give these compounds freely, wemay prevent the heart from suffering as we undoubtedly doprevent joints from suffering. In no given case can we besure of having got this result, for the absence of heart mis.chief can never be demonstrated to be due to the treatment.The possibility of such a result, however, is worth strivingfor, especially as the means of attaining it are also thosecalled for in the interests of the joints. What is wanted isthe speedy arrest of the rheumatic process. This object canbe attained onlv bv sivina’ salicin or salicvlate of soda inlarge and frequently repeated doses.

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This leads me to remark that my recommendations in thisrespect have not been acted up to. Why I cannot say, forI have pressed the point over and over again. What Irecommend is that from twenty to forty grains should begiven every hour for six hours, or until pain is relieved(which it generally is within that time); that the same doseshould then be given every two hours till the pain is goneand the temperature at or near the normal, which is gene-rally the case within twenty-four hours. After that thesame dose is given at widening intervals of three, four, andsix hours for ten or twelve days. But instead of giving itthus freely and largely, most observers are content to givefrom fifteen to twenty grains every three or four hours.That is quite an inadequate dose, and not nearly enough toget the full curative effects of the drug. I would again,through your pages, urge the giving of the dose which Irecommend. I do not exceed my right in asking that mytreatment should be carried out in all its details before itsresults are subjected to criticism. Salicin is the preparationto which I give preference, not because I regard it as superiorto salicylate of soda as an anti-rheumatic, but because itmay be given in large and frequent doses without causingsuch disturbance of the system as not unfrequently followsthe use of the salicylate, ’and necessitates its suspension.My experience, too, is that those treated by salicin (whichis a bitter tonic) convalesce more rapidly than those treatedby the salicylate. There is an impression abroad that it isvery expensive. It is not so. Two of the chief English manu-facturers of it have told me that they are prepared to supplyit to hospitals and dispensaries at 10s. 6d. a pound. Con-

valescence is so much more rapid under its use that I amnot sure that it would not, in the long run, prove cheaper thansalicylate of soda. But whichever is employed, let it begiven in large and frequent doses. I make this appeal inthe interest of the heart as well as of the joints. Let everycase of acute rheumatism be regarded and treated as one inwhich heart complications may possibly be prevented, andit is probable that in some cases they will be prevented.But every hour is of importance ; for it needs no argument.to show that the danger to the heart is less in a case inwhich the course of the disease is arrested within twenty-four hours than it is in one in which three or four days areexpended in the process. The fact has never been acceptedby the profession that the course of acute rheumatism mayin many cases be arrested within twenty-four hours of thetime that treatment commences. The recognition of thatfact is the keystone to all possible success in the preventionof cardiac complications.

I am, Sir, your obedient servant,February, 1883. T. J. MACLAGAN, M.D