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727 conditions which orthodox medicine says will lead to infection. If he declines this issue, the chiropractor will then stand ashamed in the presence of Reid and Lazear. The discussion is a fair and useful one and does credit to the pages of a technical journal. ENDOGENOUS INFLUENCES IN RICKETS. OF late the teaching that vitamins are an important factor in the setiology of rickets has been given such prominence that other factors have been, to a certain extent, thrust into the background. In a recent paper Prof. I. Jundell,l of the Children’s Department of the Karolinska Institute in Stockholm, has adduced numerous arguments against the vitamin theory in rickets, and has developed the theory that this disease is due to " a disturbance of the endogenous production of ferments (hormones), caused by an overloading of the general nutritive functions within certain endocrine organs." The excellent results he has obtained by systematically treating rickets by " relative inanition " have convinced him that the disease is brought on by an absolute or relative over- straining of the general alimentary functions of the cells, and a consecutive checking of the development of certain " osteoplastic " and other ferments. As he points out, rickets never develops in children suffering from persistent vomiting, pyloric stenosis, or an inadequate supply of human or cows’ milk, and, on the other hand, underfed children often show abnormal hardness of bone--the antithesis of rickets. In several cases of early rickets he has succeeded in rapidly curing the disease simply by a reduction of the dietary, and in more advanced cases the combination of a reduced dietary with cod-liver oil and phosphorus proved curative in one or two months. But the combination of cod-liver oil with overfeeding did not even prevent the outbreak of rickets. If rickets develops for want of vitamins introduced from with- out, why, he asks, does it break out only in some of the children fed in an institution on one and the same dietary ? The vitamin theory does not explain the fact that it is possible to cure rickets in a child simply by reducing the quantity of the same food that has earlier produced rickets in the same child. Why do feeble and prematurely born children almost invariably develop rickets even when they are breast- fed ? Surely, Prof. Jundell writes, endogenous influences must play an important part in these cases. He has seen severe rickets develop during over- feeding with a mixture containing 300 c.cm. of un- boiled 18 per cent. cream, 100 c.cm. of unboiled skimmed milk mixed with 600 e.cm. of an aqueous decoction of 42 g. of flour and 30 g. of sugar-a mixture which ought to contain much fat-soluble A-vitamin. With regard to the anti-rachitic proper- ties of cod-liver oil, he doubts whether they are due to a vitamin, and he inclines to the view that the anti- rachitic action of cod-liver oil is due to a product formed within by the animal organism, to be classed among the ferment-like metabolic products of the animal kingdom. As he points out, vitamins are supposed to be the product of vegetable cells, but the cod is a carnivore, depending for its food on the animal kingdom. Prof. Jundell has also tested the vitamin theory by feeding some children on pre- sumably vitamin-rich milk obtained from cows fed on green pastures, and other children on presumably vitamin-poor milk obtained from cows fed on linseed cake, wheat, bran, crushed oats, and peas, and only enough hay of last year’s crop to keep the cows in health. The results of this experiment gave no sup- port to the vitamin theory. Prof. Jundell concludes that it is possible to eradicate rickets as an endemic disease simply by the exhibition of cod-liver oil and his system of " relative inanition," and he argues that if every child were examined by a physician about four times before the middle of the second year of life, being guided by the system he advocates, much ill-health would be avoided. Right or wrong, Prof. 1 Acta Pædiatrica, 1922, i., 355. Jundell has made out a case against the vitamin theory as to the causation of rickets which deserves more than casual consideration. THE TRAINING OF HEALTH VISITORS. most wno nave at heart the emciency of the public health service will view with grave misgiving an Order of the Ministry of Health, dated Sept. 16th, which rescinds, as from the first day of 1923, the Health Visitors (London) Order of 1909. Under the 1909 Order the Local Government Board set forth the qualifications at that time approved by the central public health authority, and, by enacting that the selection of a health visitor must be approved by the board before appointment, ensured a certain standard of efficiency. Later, in 1916, this standard was further raised by the memorandum on training issued by the Board of Education. Last May, as we have already noted, the Ministry of Health relaxed its scheme for an extension of the two-years’ special training. course (Memo. 65), and now under the present Rescission Order local authorities will be able to appoint women as health visitors with the barest of qualifications. No doubt authorities with a sense of values in social economics will continue to maintain a high standard for their appointments, but the new Order provides the opportunity for false economy on the part of those which aim at lowering the rates at any cost. There will be a renewal of the old vicious circle : a low standard of training commands a low salary, a low salary keeps out those women who are most needed as health visitors-and few indeed are able to afford a long and specialised training without the guarantee of an adequate salary at the end. The duties of health visitors, terms of office, suspension of office, and payment of salaries, as set forth in the 1909 Order will presumably be annulled by the Rescission Order, but these matters have become well established in practice. It is in the matter of training and consequent working efficiency that the Rescission Order gives cause for anxiety. SKIN DISEASES IN GERMANY DURING THE WAR. Prof. -Eugen Galewsky,l the well-known Dresden dermatologist, remarks that the treatment of skin diseases in Germany during the war was rendered exceedingly difficult by the lack of the necessary ingredients for salves and ointments, and the scarcity of soap and materials for bandages. Substitutes which were irritating to the skin had to be employed for inunction, and clay was used for soap. In spite of the extensive delousing arrangements and the universal establishment of disinfecting stations, pyodermia and scabies were among the first conse- quences of the war. In 1915 and 1916 the military hospitals were filled with cases of suppurative folli- culitis and all forms of impetigo and furunculosis. Shortly after the epidemic of pyodermia had subsided an epidemic of eczema marginatum broke out among the troops and in the military hospitals. Owing to its localisation in the genito-crural and anal folds and on the inside of the thighs, it was readily spread by water-closet seats, bandages, baths, blankets, and thermometers. In 1917 there occurred an extra- ordinarily severe outbreak of trichophytosis which has not disappeared altogether at the present time, though it reached its high water mark in 1918 and1919. In Dresden alone Prof. Galewsky treated over 3000 cases in his skin department in the course of 18 months, more than 50 per cent. of all skin diseases being due to trichophytosis. In addition to these skin diseases a number of dermatoses were caused by the use of lubricating oils in the munition factories. These oils were mostly heavy, dark-brown fluids smelling strongly of tar, or they were yellowish-green and fluorescent in character and not purified owing to the lack of sulphuric acid. Much substitutes, in which 1 The Urologic and Cutaneous Review, August, 1922.
