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ravages of undulant fever in Lorraine have been

brought to light, and measures have been taken tolimit its further spread among human beings andcattle. A little more than three years ago thedisease was non-existent, or at any rate unknown inthis area, and in 1929 only two cases came to light.This figure rose to 20 in 1931, to 31 in 1932, and to43 in 1933. All these 96 cases have been confirmed

by bacteriological examinations. It is, of course, notclear how many other cases have escaped detection ;the approximate ratio of slight and abortive to

clinically well-defined cases is as yet unknown.Among the 96 cases were three deaths. Encouragingresults have already followed the chlorination of thewater-supply in certain districts, and it is on theselines that the authorities hope to combat successfullynot only undulant fever but also typhoid fever andother water-borne diseases in this area.

EVACUATION OF THE WOUNDED BY AEROPLANE IN

MAROCCO

An account given in la Presse Médicale for May 9thof the campaign in Marocco in 1933, Dr. R. Charletdraws a vivid picture of first aid by the air, contrastingit with the older method of terrestrial transport, withits inevitable delays and sufferings. It would seemthat the new arm has replaced the old one to such anextent that, during these operations, the air ambulanceservice found almost as much employment as themotor ambulances. Smoothly as the former worked,reforms were found necessary in two directions. Theambulance aeroplanes were fitted with one type ofstretcher, the motor ambulances with others. Thismeant the painful shifting of patients from one

stretcher to another. The other important lessonwas that a rough country demands a type of aeroplanecapable of negotiating the most primitive landinggrounds.

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SPECIALIST OR GENERAL PRACTITIONER ?

We used here as elsewhere to be either specialists orgeneral practitioners. Now many of us are specialistswith general practice as a distracting avocation. Orwe are general practitioners whose interest in, andalmost profound knowledge of, certain subjects renderus specialists de facto if not de jure. But how is the

money value of the services we render (a) as generalpractitioners, and (b) as specialists to be assessed IWhen there is no third party, and we have none butthe patient to consider, it is comparatively easy totreat him with discriminating benevolence. Whenthe State becomes a third party to the transaction, asin the case of the insured and pensioners, war orotherwise, elastic compromise must yield to rigidrulings. They have been applied not long ago to theby no means rare case of the general practitioner withan X ray outfit. As a general practitioner he mayfind the opinion of a radiologist desirable in a givencase. Accordingly, the radiologist examines and

reports. Dr. Jekyll needs information, and Mr. Hydesupplies it. There is nothing sinister about thisdual personality, but it has been found to cost theState too much. The State now honours the billsof only those radiologists whose patients have beenreferred to them by another doctor. It is laid downthat one must be either a specialist or a generalpractitioner; it is not possible, under the conditionsdescribed, to be a facultative specialist or an optionalgeneral practitioner.

PAYMENT FOR BLOOD TRANSFUSION F

As from April 1st, 1934, blood donors in military hos-pitals in France are to be paid according to a certainscale, 50 francs being the price of the first 150 c.cm.,and 50 francs for every supplementary 100 c.cm.These charges are doubled when the donor -has beenartificially prepared for an immuno-transfusion.

PUBLIC HEALTH

SWIMMING BATHS AND HEALTH

THE healthy urge to bathe in the fresh air receivedlittle official encouragement until recent times. Wellinto this century those who wished to swim at anyother time than the summer holiday, and who livedfar from natural ponds or rivers, were obliged toindulge their craving in small rectangular poolssurrounded by a narrow gangway giving access toa row of small clammy cells. The dust or mud depositon the gangways from the bathers’ shoes was for themost part carried into the bath on their feet afterundressing. The water was changed perhaps two orthree times a week-on days well known to the moreexperienced bathers. Fresh air and direct sunshinewere excluded by a skylight, and by the time thebath came to be emptied the water was of a greycolour and so opaque that bathers could drown, andnot infrequently did, without being noticed.

All this is changed. Swimming has become a popularpastime, and every up-to-date municipality providesopen-air baths where persons of both sexes can swim,bathe, and bask in the air and sunshine. The extensiveuse of swimming baths has led to a much betterlay-out, and continuous purification of the water isfast replacing intermittent emptying ; in fact manybaths are so large that the time needed for emptyingwould put them out of use for an inconveniently longperiod, and the cost of repeatedly heating such avolume of water would be prohibitive. The assemblyof large numbers of bodies in a limited mass of water

which is not renewed, but only made up to constantvolume, and in which they may spend hours at atime and take active exercise, may lead people to asktheir doctors whether they or their children shouldgo to public swimming baths, and the answer needssome consideration.

Every bather, however clean his habits, bringsinto the bath not only the dirt from his shoes, butdried sweat, grease, bacteria, probably moulds, andmiscellaneous dirt accumulated on his skin. Aftera day at school or at work this accumulation may beconsiderable, especially if his opportunities of washingand bathing are small. The individual contributionto the bath water may seem insignificant, but if everybather enters the water without preliminary ablutionit will soon become obviously dirty as well as

bacterially contaminated. Infection of the mucousmembranes and of the middle ear have frequentlybeen associated with bathing, and in any case fewpeople would care to bathe in dirty water if theywere offered clean. It is therefore desirable thatbathers should not reach the undressing rooms bywalking along the edge of the bath, and that theyshould have some means of cleansing the skin, andespecially the feet, before entering the water. Thiscan be done by making them pass on their way to thebath under a shower of sterilising water and througha trough filled with similar water. As some do notlike cold showers, it may be advisable to have thiswater warmed. The best way of cleansing the feetis by means of a spray which impinges on a raised

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platform on which the foot can be placed ; this is

likely to clean the spaces between the toes which arespecially subject to cracks and sores. All this appliesto relatively clean people. Others should have furtheropportunities of cleansing or be sent away.

Having regard to the effect of cold water on

urinary excretion it is desirable that urinals shouldbe situated on the way to the bath, and that childrenshould be required to use them before going into thewater.A bath may be used by none but the cleanest

bathers and yet the originally clean water will becomecontaminated with both dirt and bacteria. Only inthose rare cases where water is derived direct from

springs, like the hot baths at Bath and Matlock, isit practicable to let water run to waste through thebath. Some means of continually purifying the wateris needed. This is achieved by pumping water fromthe deep end of the bath, coagulating the suspendedimpurities to form a thin turbid emulsion, filtrationthrough sand, and final sterilisation of the now clearand relatively organic matter-free water. Alum orits equivalent followed by lime is commonly used ascoagulant. Sterilisation may be brought about in avariety of ways ; the most usual is chlorination, butozone, catadyn silver, and ultra-violet radiation areall effective if properly used. The process of continualpurification if successful will give water which is

bright and attractive. As the bottom of the bath isalways visible the responsible attendant will be ableto see anyone who is in difficulties under water, whilesuch things as cigarette or chocolate cartons and usedcostumes are less likely to be thrown into water inwhich they can be seen. The platform surroundingthe bath should slope away from the water, and achannel a little above the water level serves both ashandrail and spittoon.

Doctors who are consulted by their patients aboutswimming baths should certainly advise them toavoid public baths not fitted with filtration andsterilisation plants.

Treatment of Bath Water

Small baths can be kept in tolerable condition bysimple chlorination, either with chloride of lime ormore conveniently with a solution of sodium hypo-chlorite such as Chloros, if care is taken to add somuch as will maintain a suitable excess of freechlorine. One ounce per 6000 gallons is equal to onepart per million, and this amount of chlorine iscontained in three ounces of good bleaching powderor ten fluid ounces of chloros. To a bath full of cleanwater rather less than one part per million of freechlorine should be added, care being taken to distributeevenly, and the free chlorine content should be keptup by additions to 0-2-0-5 part per million. This

requires daily tests of the water with ortho-tolidene,comparison being made with coloured solutions

representing the permissible limits. If the upperlimit is not exceeded the water is unlikely to irritatethe eyes, and if the lower limit is not reached sterilisa-tion is likely to be unsatisfactory.

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FILTRATION

The water will not remain clear for prolongedperiods and must be changed before it becomes soturbid that the bottom of the bath at the deepestpart is invisible. The use of ammonium salts willhelp matters, but larger doses of chlorine must thenbe used and control becomes difficult. Withoutfiltration chlorination is but a makeshift, at best onlysecuring sterility of the water and effecting someeconomy in its use. The only satisfactory treatment

is filtration after coagulation, followed by sterilisationof the clear water, already freed of grosser impurities.This preliminary clarification enables a choice of

sterilising agents to be made, and their amount to becut down to a minimum. The bath is worked as acirculating system and, once filled, very little make-upwater is needed to replace losses by evaporation,splash, or overflow at scum channel.

Although some of the impurities introduced intobath water during use can be removed by simplefiltration-some indeed, e.g., dead leaves, bathingcostumes, by mere straining through a coarse-meshedgrid-it is in every way better to introduce into thestrained water as it is pumped from the bath a smallpredetermined dose of a soluble aluminium salt (alumor "alumino-ferric "), followed, if necessary, bysufficient of an alkaline solution (soda ash is the mostconvenient) to make the liquid alkaline as testedwith phenolphthalein. The precipitated aluminiumhydroxide will separate with it, either mechanicallyor by coagulation of colloids, the fine matters insuspension which cause turbidity, as well as those inquasi-solution, in a state removable by filtrationthrough sand. The clear water which passes from thefilter contains only matters in solution and bacteria,which have not been removed by the previousprocesses. Whatever sterilising agent is now usedwill not be spent in effecting changes on any otherimpurities than micro-organisms.

STERILISATION

The most common sterilising agent is chlorine,which is best used as gas from steel cylinders. Severalfirms make plant for coagulation, filtration, andchlorination which is practically fool-proof and

requires little attention. If for any reason the

handling of a gas cylinder is undesirable the hypo-chlorite solutions already mentioned can be used ; anelectrolytic cell is obtainable, specially suitable forsmall baths. As chlorine is an irritant both to the

eyes and nasal passages the amount must be regulated.A simple colour test, with standard limiting tints

representing the minimum useful content of freechlorine and the maximum proportion which mostpersons can tolerate with comfort, is usually suppliedwith the plant for treatment. The water leaving thebath should contain the minimum and that enteringapproximately the maximum.Where an electric supply is available the use of

ozone or of ultra-violet rays is worthy of consideration.Ozone has been used largely on the continent forsterilising drinking water, and a plant erected at BarnElms by the Metropolitan Water Board not onlysterilised the water but greatly improved its colour.The residual dose can easily be adjusted so that thereis only the merest smell of the gas, which is notunpleasant. Ultra-violet light can be used success-fully to sterilise clear well-filtered water and iseffective when none of the water flowing past thelamp is more than 12 inches from it and the exposurelasts at least 4 seconds. It should be easy to use amuch smaller working distance than this. Advantagemay well be taken of the formation of ozone in the

region of the lamp, by letting the ozonised air flowthrough the water, thus giving it some residualsterilising power in its passage through the bath. Theshorter waves appear to be the most effective.A method of sterilisation unlike all the others is the

Catadyn process in which the filtered water on its

passage back to the bath either flows over sandcoated with silver, or a portion of this returning waterflows past two silver electrodes between which a smallcurrent passes. An extremely small amount of silver

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ions goes into the water from the anode. The silverintroduced in this way or from sand possesses remark-ably high sterilising power, provided the water is

relatively free from organic matter other thanbacteria. No smell is imparted to the water, whichretains a sterilising power for some time, exerting aninhibitive effect on green growths. This oligodynamicaction of silver and other relatively noble metals,although not well understood, is simple to apply andmerits further study.The economic use of filtration and sterilisation is

now made easy by the many makes of plant for thispurpose. ____

A Hop-picking Dispute SettledAs our readers will recall, difficulties have arisen

for some years past about the responsibility for thetreatment of infectious disease occurring amongLondoners who had gone to pick hops during theseason in Kent. Last year the London CountyCouncil were unwilling parties to the transference oftwo cases of diphtheria from Kent to their homes inSt. Marylebone, and the L.C.C. asked the Minister ifit would not be possible to make it obligatory on alocal authority to treat persons suffering from infectiousdisease temporarily resident within its district. As aresult of this request the following new regulation isto come into force on July 1st next :

The London County Council, the council of everyborough or urban or rural district and every joint hospitalboard constituted under the Public Health Act, 1875, andhaving the powers of Section 131 of that Act, shall have thesame powers and duties in relation to the provision ofhospitals or temporary places for the use of persons whoare for the time being within their county, borough ordistrict, as the case may be, and are suffering frominfectious disease, as they have for the use of the inhabitantsof that county, borough or district.The L.C.C. has informed the Minister of its willing-

ness to enforce a regulation of this kind.

At its meeting on Tuesday the London CountyCouncil agreed to the proposal of its hospitals and

medical services committee to remove to St. James’Hospital the plastic surgery unit at present atHammersmith Hospital. The transfer will takeeffect on August lst next. The arrangement includesthe provision of one position of plastic surgeon andone of assistant plastic surgeon for one session aweek each at a salary of E125 a year.

INFECTIOUS DISEASEIN ENGLAND AND WALES DURING THE WEEK ENDED

JUNE 9TH, 1934:

Notifications.-The following cases of infectiousdisease were notified during the week : Small-pox, 2(last week 2); scarlet fever, 2368; diphtheria, 1101 ;enteric fever, 16 ; acute pneumonia (primary or

influenzal), 939 ; puerperal fever, 60; puerperal pyrexia,110 ; cerebro-spinal fever, 24 ; acute poliomyelitis, 3 ;acute polio-encephalitis, 2 ; encephalitis lethargica, 5 ;dysentery, 7 ; ophthalmia neonatorum, 89. No caseof cholera, plague, or typhus fever was notified duringthe week.

The number of cases in the Infectious Hospitals of the LondonCounty Council on June 18th-19th was as follows : Small-pox,3 under treatment, 0 under observation (last week 3 and 0respectively); scarlet fever, 1624 ; diphtheria, 1686 ; measles,1750 (last week 1890); whooping-cough, 281 ; puerperalfever, 22 mothers (plus 6 babies); encephalitis lethargica,269 ; poliomyelitis, 2 ; "other diseases," 178. At St. Margaret’sHospital there were 20 babies (plus 7 mothers) with ophthalmianeonatorum.

Deaths.-In 121 great towns, including London,there was no death from small-pox, 3 (0) from entericfever, 60 (22) from measles, 5 (2) from scarlet fever,27 (6) from whooping-cough, 30 (4) from diphtheria,45 (21) from diarrhoea and enteritis under two years,and 36 (6) from influenza. The figures in parenthesesare those for London itself.

Brentford and Chiswick, Southampton, and Worcester eachreported a death from enteric fever. Swke-on-Trent reported5 fatal cases of measles, Salford 4, Newcastle-on-Tyne 3, noother great town more than 2. Liverpool reported 5 deathsfrom whooping-cough, Birmingham 3.

The number of stillbirths notified during the weekwas 271 (corresponding to a rate of 39 per 1000total births), including 52 in London.

PANEL AND CONTRACT PRACTICEAn Election without Enthusiasm

THE Ministry of Health has decided to keep thepresent personnel of insurance committees in office foranother three years and the Insurance Acts Committeehas, with a show of reluctance, agreed to this course.On the other hand the panel committee for the Countyof London goes out of office at the end of this monthand a new committee is now in the course of election.The machinery for this is elaborate. Every practitioneron the medical list is furnished with a list of namesand addresses of those eligible for election, who includeany doctor in practice on his own account or inpartnership. Assistants are not eligible. Each

borough has so many seats on the committee accordingto the number of insurance practitioners in its area.A returning officer is appointed and approved by theMinister ; nomination forms are sent out and signedby the candidate as willing to serve after beingproposed and seconded by two members of theprofession in that area. The date of election is thenfixed and a voting paper sent to every insurancepractitioner, giving the names of candidates nominatedin his borough. The completed voting paper may beposted to the returning officer to reach him not laterthan the morning of the appointed date or it may behanded to the returning officer at the agreed meetingplace ; but it may not be sent by proxy to the meeting.

After the election it is usual for an address to be

given by someone conversant with the past work ofthe committee. A speaker is selected who does hisbest to reply to any questions raised of difficultyunder the Act.How well these elections are conducted, what ample

precautions are taken to ensure a proper election-maybe the thought in the mind of the uninitiated. Thefacts are different. In London insurance practitionersdo not take the slightest interest in these expensiveand elaborate proceedings. A recent meeting heldin the Battersea Town Hall for the adjacent boroughsof Battersea and Wandsworth was attended byexactly four doctors. Three of these were old membersof the panel committee up for re-election and one wasa new candidate to be elected. There were fivecandidates for eight seats for the borough of Wands-worth ; three of those seats remain to be filled. Suchelections scarcely justify so expensive a procedure.But it may be time for insurance practitioners generallyto be roused from the lethargy in which they appear tobe living. Medical men who serve on the Londonpanel committee give their services gratuitously ;many of them devote hours each week to the workof committees and subcommittee meetings besidesrepresenting the panel on insurance committee,medical service subcommittee or after-care com-