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hospitals, but were not considered suitable for use atdispensaries and in the field owing to their toxiceffects. Comparing atebrin and quinine an appendixto Dr. Briercliffe’s report states :-

" Z)e<x<AN.&mdash;Among 681 patients treated with atebrinmussonate 17 or 2’5 per cent. died and among 424 treatedwith quinine 6 or 1’4 per cent. died. Four of the 17 deathsfollowing atebrin mussonate were attributed to the toxiceffect of the drug. If these four cases are excluded, thenatural death-rate among the atebrin treated cases wouldhave been 1*9 per cent., which is not significantly greaterthan the death-rate for the quinine treated series."

Discussing the toxic effects and the sudden deathsafter atebrin injections, the appendix states that-" among adults, pregnant women have been found

particularly liable to collapse after injections. Convulsionsdue to malaria were of frequent occurrence among childrenin the early stages of the epidemic. Convulsions occurringa few minutes or hours after an atebrin injection andattributed by the medical officer concerned to the atebrininjection have occurred in both children and adults.They were always fatal."

PROPOSALS FOR THE FUTURE

In Part II. of his report, on the Control of Malariain Ceylon, Colonel Gill discusses the scientific problemunder the headings, the mosquito factor, the parasitefactor, and the human factor, and summarises thisby saying endemic malaria in Ceylon presents nonovel or remarkable features. Although these epi-demics have hitherto been regarded as uncontrollable,there is now reason to believe that their emergencecan be prevented if measures are taken that willreduce the spleen-rate and the anopheline-rate(A. c7.dcitacies) to the level of these factors in thesouth-west healthy area. This will take time, butcan be accomplished if medical science provides thetechnical knowledge, Government the machinery,and public opinion the motive power. Government

having decided that the population is sufficientlyadvanced politically to control its own internaladministration, the success of the scheme will dependon the actual cooperation of the people. Colonel Gillreminds them that so far only a few antimalarialschemes had been begun in Ceylon, and had achievedonly a certain measure of success-not from any faultin the schemes, but from lack of popular interestresulting in a lack of funds to complete or maintainthem. The recent epidemic, however, has produceda profound change in public opinion.No attempt is made to frame an antimalarial scheme

for adoption in each individual area. Colonel Gillrecommends generous provision of hospital facilitiesand that apothecaries and dispensers in the Govern-ment and estate hospitals and dispensaries be replacedby registered medical practitioners provided withmicroscopes, so that diagnosis and treatment may bemore accurate ; this is to control the parasite factorin man. Malaria control schemes should be under-

J taken in urban, rural, and estate areas ; by landdrainage, irrigation and development schemes, andriver training operations. He deprecates colonisationschemes which involve the introduction of non-

immune settlers into hyperendemic areas ; and heconsiders antimalarial measures in such areas will notbe effective unless accompanied by measures designedto promote rural betterment by increasing the food-supply and relieving economic distress.The recommendations include establishment of a

Sanitary Works Board, with the Minister of LocalGovernment as president, and an equal number ofofficial and unofficial members. It is also advisedthat an Anti-Mosquito Ordinance be passed. A

proposal had been made to erect a Malaria Research

Institute in commemoration of the Jubilee ; ColonelGill recommends that a malaria department beaccommodated in a wing of a main institute. Hestates his proposals will cost money; "good health,including freedom from malaria, is a purchasablecommodity, but it is doubtful whether it is worth

having as a free gift." Financially stricken as theisland has been by the world depression and the greatepidemic of malaria, the Government and people ofCeylon have now the anxious task of deciding howthe maximum benefit is to be obtained from theminimum expenditure; which of Colonel Gill’srecommendations are to be carried out now and whichpostponed ; for Colonel Gill says of this " balancedscheme " that " many parts indeed can be postponedor omitted without destroying its general structure."

THE CONGRESS OF DERMATOLOGY

(FROM OUR BUDAPEST CORRESPONDENT)

THE Ninth International Congress of Dermatologyand Syphilology has been memorable both for itsunprecedented size and for its scope. Dermatology,it was apparent, ranges widely through the wholefield of medicine ; and without attempting to sum-marise the hundreds of addresses delivered I willendeavour to convey something of the catholicoutlook they revealed.

VENEREAL DISEASES

During the first few days venereal disease wasconsidered from the international standpoint. Itwas accepted as a fact that syphilis and gonorrhceacould be made extinct throughout -the world withina single year if all who suffer from them would havethemselves fully treated. Starting from this prin-ciple the Congress proposed the application of legalpenalties and the State control of treatment, togetherwith the regulation of prostitution. From this it

passed on to discuss some of the social questionsarising in the practice of dermatology and venereo-logy, including out-patient dispensaries, sick clubs,beauty specialists, barbers, masseurs, and quacks.Prof. KERL (Vienna), in an address lasting severalhours, pointed out that while specialists in derma-tology and venereal diseases keep strictly to theirown territory, practitioners in adjacent fields pressever harder on their confines ; indeed, it is often

suggested that the treatment of syphilis is ratherthe business of the internist and the neurologistthan of the venereologist ! Kerl’s idea is that thelatter must gain exact knowledge of the borderlandof his subject-even if it means adding a couple of

years to his training-and that when he has suchknowledge even neurosyphilitic affections shouldcome within his province.

&Acirc;LMQUlST (Stockholm) early created a sensation

by proposing that the present division of syphilis intothree stages should be abandoned; by means ofmany histological preparations he demonstratedthat this infection, at all stages and in all places,will always produce what is essentially the samelesion. This view was accepted by many otherpathologists present but on the whole was consideredunproven. GRUNBERG, who has been studying thenature of the Wassermann reaction, reported thathe has obtained positive tests from healthy animalstreated with " spirochaete lipoids," whereas previoustreatment with non-specific

"

organ lipoids " didnot yield the same results. SCHERESCHEVSKY (Paris)made known his successes in the treatment of syphilis

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in animals by means of a quinine preparation ofhis own, but it was felt that further evidence of itsefficacy was required. Also in the discussions on

syphilis an interesting dispute arose between ARZTand KERL, both leading clinicians of Vienna, aboutthe importance to be attached to early changes inthe cerebro-spinal fluid. Arzt looks on these changesas an indication for treatment with malaria, whereasKerl upholds the conventional view that they aremostly transitory. PINARD (Paris) took the viewthat fever therapy is desirable in syphilis (1) if theblood-serum is obstinately positive, or (2) if thereis a positive Wassermann reaction of the cerebro-

spinal fluid or other evidence of neurosyphilis. Ifthe blood Wassermann cannot be made negativehe prefers sulphur ; in neurosyphilis and G.P.I. heuses malaria, or sulphur if it fails. LUDwIG WINKLER(Oradea, Rumania) drew attention to his priorityas advocate of sulphur therapy in neurosyphilis,and spoke of its value, in cardiovascular and arthriticsyphilis as well. He also referred to the importanceof estimating the erythrocyte sedimentation-rate asa control of cure of syphilitic infection. HILGERMAN

(Landsberg) and SpiTZER (Vienna) gave an accountof their method of inoculation with a spirochsetevaccine, which they believe makes the organisms ofsyphilis accessible to chemotherapy,The five largest American clinics reported their

experience of cardiovascular syphilis ; it appearedthat in 6253 cases of syphilis-treated early, late,satisfactorily, unsatisfactorily, or not at all-the

percentage of cardiovascular complications was 9-9 ;while in the smaller group, comprising only thosewhich had not been treated early enough, it was23 per cent. The Americans are the champions ofuninterrupted treatment at all stages of syphilis.Gonorrhoea did not receive as much attention as

sometimes. Austrian and German members of the

Congress expressed doubt about the value of the

serological reaction, which they considered veryproblematical; VERESS (Cluj) thought it undulyoptimistic to use this reaction as a criterion fortreatment. As regards actual remedies no advanceworth mentioning seems to have been made duringthe past few years. The horse serum injections pro-posed by Szilvassy have proved useless in GuszMANN’shands, and all the speakers seemed to agree thatvaccines are valueless in the acute stage, while theiraction on complications is probably not specific.Of’ new preparations methylene-blue and acridine

dyes seem to be the only ones which represent animprovement. Goldberger’s abortive cure with

Trypaflavine was received very dubiously, and somerejected it altogether.

SKIN DISEASE AND THE BODY AS A WHOLE

With the object of increasing the internationalsolidarity of dermatologists a number of committeeswere appointed to go into such problems as cutaneoustuberculosis, industrial and other environmentalaffections of the skin, and the classification andnomenclature of skin disease. This last committee,under the leadership of Howard Fox of New York,is faced with a difficult task of reconciling manydifferent attitudes ; it has to bear in mind the dif-ferent effects of identical causes and the identicaleffects of different causes, the individuality of thepatient, the transitory nature of symptoms, thevarying virulence of maladies, and the accumulationof diverse processes. In the present state of know-ledge no system of eternal validity can be laid down,but one can imagine a working classification whichwould adapt itself to the advance of knowledge.

DARIER (Paris), MAYR (Munster), and STEIN

(Vienna) spoke of the importance of the skin as anorgan, especially in relation to diuresis and dys-hidrosis. Too much attention, they feel, has beengiven to the heat-regulating function of the skinand not enough to the excretory. It is significantthat in pemphigus, for example, the quantity ofurine passed decreases to a minimum, simply becauseof the excessive external loss of fluid. With the fluidgoes sodium chloride, and the chloride excretion inthe urine is. reduced-an effect which may easilygive rise to a mistaken impression that renal functionis impaired. Means of testing the normality or

abnormality of the skin as an organ are providedby the injection of such drugs as atropine and pilo-carpine, which respectively promote and decreasesweating but have no influence on a sick skin. Caffeinedoubles perspiration under normal circumstancesbut again may have no action when cutaneous func-tion is already damaged. Such tests can be performedwith delicate and complicated but reliable instru-ments. Stein also spoke of the elimination of toxinsthrough the skin : the old exponents of humoral

pathology used to maintain that all skin diseaseswere due to poisonous substances inside the body,and though this is an exaggeration many such diseasesare really connected with puberty, pregnancy, andthe menopause, and presumably with poisonoussubstances produced in these states. Juvenile acne,for instance, begins in puberty and is seldom seenafter 40 years of age, and Stein has made the interest-

ing observation that it occurs (almost without excep-tion) in children who are precociously mature, andnever, on the other hand, in eunuchs. Is it anywonder that another lecturer should urge the neces-sity for exact endocrinological tests in cases ofobstinate skin disease Much was said about the action of vitamins on

the skin, and several speakers assumed that theyhave a preventive or curative action ; a Hague pro-fessor, for example, reported good results from theuse of vitamin-rich raw foods in conditions such aspsoriasis and eczema. The importance of dietetictreatment in skin diseases where the patient suffersalso from digestive disorders was fully recognised.Due consideration again was given to the role offocal infections.LEVADITI (Paris), NICOLAU (Bucharest), and others

introduced the important subject of the filtrableviruses, and spoke of the proof that lymphogranu-loma inguinale is due to a virus and can be recognisedwith the Frey antigen. URBACH and WoLFRAM reportedthat pemphigus vulgaris and dermatitis herpeti-formis are likewise due to a virus, while NEUBER(Debrecen) stated that rhinoscleroma is caused bya capsulated bacillus-findings which will be of

great interest provided that they can be corrob-orated. MANNSHEIMER (Essen) brought forwardstatistics supporting the Russian view that lupusin its aetiology has nothing to do with pulmonarytuberculosis. He denies that phthisical patientsare particularly liable to contract lupus ; indeed,he finds that their illness tends more towards recoverywhen they do so. Also speaking on lupus, AITKEN(Edinburgh) said that among 270-280 cases he hadfound that about half followed tuberculous infectionof glands of the neck. It was very important, he said,that practitioners should recognise the great value ofultra-violet irradiation for tuberculous adenitis.

Elsewhere the Congress provided evidence of a

reaction against methods of irradiation in derma-tology ; it was evidently felt that these have been

1080

carried to excess. FRANCIS POLLER has not found shortand ultra-short wave therapy particularly valuable ;physicians from the United States quoted cases

which suggest that diathermy is just as efficacious.To sum up, although this Ninth Congress brought

no great new discovery it has cleared up many prob-lems of diagnosis and treatment and brought outnew principles and objectives. Apart from skindiseases caused by external infections, it seems thatthe time is not far distant when the use of ointmentsin dermatology will be almost extinct. What hasbecome chiefly important, for efficient diagnosisand for efficient treatment, is a knowledge not ofthe changes discovered but of their underlyingcauses.

LONDON WATER

SOME PRESENT-DAY PROBLEMS

Colonel Harold’s first report 1 as Director of WaterExamination to the Metropolitan Water Board isfull of interest, for, as he says, he came from thecomparative quiet of a peace-time army into the heartof the Board operations at a time of national

emergency arising from two years’ drought when itbecame necessary to consider ma,tters of high policy.London was, however, saved from anything more thananxiety and inconvenience owing to the huge storagesystems built up in accordance with the wise policyof his predecessor ; and the danger being ovar

Colonel Harold feels free to poke a little fun at theLondoner who talks about a condition of droughtwhen he has sufficient water for all purposes, includinga daily long bath. He compares it with the water

shortage of an Eastern war-time cantonment, wherethe daily issue resolved itself into a petrol drum ofwater, derived from brackish underground sources,receiving the unpurified road washings of an unpavedEastern town. But the shortage ot water in London,such as it was, led to the relaxation of a provisionin the Thames Conservancy Act of 1932 that everyday 170 million gallons of water must pass over

Teddington Weir. This eased the situation, butthe reduced flow of the river must have reacted onthe condition of the tJ’dal reaches if only to a smallextent. At Barking sewage carried upstream by thetide gave rise to many complaints from those usingpiers and boats. The total volume of water in theThames between Barking Creek and TeddingtonWeir amounts at low tide only to some 8000 milliongallons and the average content is 15,700 gallons,while the incoming water each tide is about doublethe low tide figure. The minimum statutory flowof fresh water over Teddington Weir of 170 milliongallons per day obviously bears to the average volumementioned the ratio of 170 to 15,700 or 1 to 93.A reduction of 30 million gallons per day in thestatutory flow would change this ratio of fresh totidal water to 1 to 113, a change which could havelittle adverse effect on the Pool of London. Alsoit should not be overlooked that some of the extrawater abstracted from the river must ultimately reachthe sewers and dilute the effluent which is passed into+1i< Tns

TASTE TROUBLES

Apart from this special source of complaint Londonconsumers found little. to grumble about last year.The complaints reaching the offices of the Board

1 Metropolitan Water Board. 29th Annual Report by Lt.-Col.C. H. H. Harold, O.B.E., M.D., D.P.H. London : P. S. King andSon. 10s. 6d.

numbered no more than one three-thousandth of aper cent. of population served. Only half of thesewere complaints about taste, and again only halfwere accepted as valid after investigation. Strictlyspeaking the responsibility at law of the Water Boardterminates at its mains-no small liability in itselffor there are 7760 miles of them. But in practiceall complaints are investigated on account of the

light which they may throw on adventitious pollution.During the year definite pollution was twice tracedto cross connexions of piping in important buildings.Generally speaking, Colonel Harold says, most of thecomplaints arise from local causes beyond the mains.The tank room offers great attractions as a play-ground on wet days and the household storage systemis a fertile source of pollution. In one case, wherea complaint was made that tap water was unfit fordispensing, inquiry revealed an aggregation of lead,shavings, and oakum left in the pipe by the

plumber. Evidently every consumer should demandof his landlord a tap direct off the main for drinkingpurposes. In periods of high atmospheric temperaturecomplaints of a disinfectant taste were sometimesreceived and later of an earthy taste at the time whena profuse growth of algae dies on the filter beds.But, all in all, London water is no mean beverage, andits palatability . may be largely attributed to itsmoderate hardness. During the year a committeeof residents in West Wickham, after wide investiga-tion, concluded that whilst it would be possible fortheir water to be softened, that would on balancebe no advantage to the community.

OZONE OR CHLORINE

But the scientific interest of the present report isgreatest in the big issue which will soon have to bedecided as to the choice of the final disinfecting agentin water purification. The drought brought to lightdefects in the filtration system as a result of whichchlorine and ammonia points have been installedin many places as an additional safeguard. Thecontinuous flow of water through storage systemsresults in an enormous reduction of the bacterialand organic content of the water. Next comes anefficient filter barrier, and finally a chemical processwhich needs time for effective action either in contacttanks or in the mains before the draw off. The aimof successful water practice is to supply a worked-out weathered water with a composition like the

unpolluted natural water, and in contradistinctionto campaigning measures chemicals are used onlyas a finishing process and as a corrective to counteran emergency. The importance of such an invulner-able barrier is illustrated by an incident at Milwaukeein 1916, when the chlorine was accidentally shut offfor several hours and the water was badly pollutedfor one day. The result of this was 25,000 to 100,000cases of diarrhoea followed by about 500 cases of

typhoid fever with 60 deaths. The choice of finalprocess for London water rests between ozone andchlorine-or rather combinations of chlorine andammonia, for free chlorine is no longer used. Ozone

imparts an excellent finish to water and removes themajority of disagreeable tastes. When it has doneits work it leaves nothing behind but oxygen. Awater cannot be overdosed with ozone, since the gasis ultimately dissipated. Ozone is increasinglypopular in France and has been tried out at one ofthe Board’s works at Barn Elms. But whereaschloramine continues to function as an efficient

germicide under the worst possible conditions,ozone requires a filtrate of fairly uniform quality.On the other hand, with ozone the contact period