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the moment an attack begins. Pure oxygen is a lessvaluable stimulant than oxygen to which 5 per cent.carbon dioxide has been added for its effect on thecentres. Lobeline is said to be useful, and an intra-muscular injection of 0-003 g. as a single dose isadvocated. Adrenalin may be injected direct intothe heart as a last resort if the child seems to be onthe verge of death.Such studies as these may help to elucidate some

of the physiological and pathological aspects ofrespiration. Besides throwing light on arrestedrespiration in infants they have a bearing on theso-called asphyxia neonatorum.

CLOSED PNEUMOLYSIS.

IN many cases of pulmonary tuberculosis, including Imost of those occurring in early adult life, artificialpneumothorax is the only method of treatment thatoffers any prospect of cure. The success of suchtreatment depends chiefly upon obtaining effectivecollapse of the diseased lung. If the collapse isincomplete ultimate spread of infection to the oppositelung is almost inevitable. In a recent article Dr.R. C. Matson says that the success of artificialpneumothorax treatment is

" almost in direct propor-tion to the number and character of adhesionspresent " and attributes 40 per cent. of its failures tothis cause. The attempt to stretch adhesions byincreasing the intrathoracic pressure is seldom satis-factory, and is not without danger. Grave risks arealso incurred when open operation is performed. Lessdanger and a greater measure of success haveattended the cauterisation of adhesions by the methodof closed pneumolysis devised by Jacobaeus, whosethoracoscope permits a clear view of the offendingbands and thus enables their severence to be effectedwith the galvano-cautery. Risk of haemorrhage andof the liberation of tuberculous infection is stated tobe lessened if an endotherm is used instead of thecautery. Before deciding to operate Matson rightlyinsists that there should be reasonable assurance thatthe patient will recover if a satisfactory collapse isestablished. The rules which guide the physician indeciding to induce a pneumothorax will obviouslydetermine his decision whether to persist in hisefforts to establish a complete collapse. Matson givesthree chief indications for cauterisation : (1) incom-plete collapse due to adhesions ; (2) satisfactorycollapse maintained only by high intrapleuralpressures which involve discomfort to the patient andrisk of rupture of the lung ; (3) when in a previouslysatisfactory pneumothorax the organisation of bands,or adhesions. is causing expansion of the collapsed lung.The benefit that may be expected from intrapleuralpneumolysis in the hands of an expert is shown byMatson’s own records, for he was able to convert apartial into a complete pulmonary collapse with theabolishment of cough and expectoration in 63 casesout of a series of 100. It is perhaps needless to addthat this method of treatment should only be employedby those whose experience of collapse therapy isextensive, and who by constant practice have masteredthe necessary technique. The correct use of thethoracoscope and the manipulation of the endothermor cautery demand the highest degree of skill.

ANTITOXIC SERUM IN SCARLET FEVER.

THERE is no longer any doubt that certain strainsof streptococci produce a true toxin, in addition toa destructive substance, " haemolysin," which doesnot seem to fall into that category. Such streptococciare chiefly associated with scarlet fever ; and twostrains, known to bacteriologists as " Dick " and"

Dochez," are recognised as being true toxin-forming strains. The toxin produced by streptococciis not comparable with that of diphtheria, save inthat an antitoxin is procurable, for it is not the

1 Amer. Rev. Tuberc., March, 1929, p. 233.

chief weapon of the organism. It is of slight virulenceto laboratory animals, though when concentrated,as by the methods of Percival Hartley and R. J. V.Pulvertaft, it is lethal to rabbits. Where, as

apparently in scarlet fever, the toxic action of theorganism predominates in the clinical picture, theuse of antitoxin is followed by excellent results. Butthe invasive action of the organism is not dependenton the toxin-production.Many problems remain. In the first place, are all

streptococcal toxins, even in scarlet fever, the same ?The famous Park strain of diphtheria bacillus is knownto be the best toxin-producer, and to yield a highantitoxin of general utility. There is doubt whether asimilar strain can be found among streptococci. Wads-worth, Kirkbride, and Hendryl bring forward evidenceto show that, in fact, the best antitoxins are providedby the Dochez strain-which is fortunate for dwellersin England, where this strain is used to make anti-toxin. They further throw doubts on the keepingqualities of the antiserum, which needs carefulcontrol. The most urgent necessity, however, is foran adequate method of standardising antitoxin. Theaccepted one, in America, is the neutralisation of skintest doses in susceptible men. M. B. Kirkbride andM. W. Wheeler have substituted a similar test ongoats. In this country the protection of rabbits againstdeath, within a specified time, from intravenousinjection of living organisms has been used, withexcellent results, by C. C. Okell and H. J. Parish.More recently Hartley and Pulvertaft have suggestedthe use of concentrated toxin on rabbits ; Hartley’smethod is highly commended in the latest annualreport of the Medical Research Council. Wadsworthfinds by the skin test method a great variation in thevalue of antitoxin. Some have as many as 600 unitsper c.cm. ; others are utterly useless, having nodemonstrable antitoxin. So long as human beingsare necessary for the purpose of standardisation, theantitoxin is of necessity limited in amount, expensive,and, it must be said, unreliable.

There is sufficient proof of the efficacy of thisantitoxin, when really standardised, to make it urgentthat the problem should be further examined. Theintroduction of animal tests may put this work on anew footing.

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THE GASTRIC DIGESTION OF MEAT.

SOME important observations on digestion have latelybeen made by M. E. Rehfuss and G. H. Marcil,2 whohave compared the results obtained by a fractionaltest-meal of the usual carbohydrate type and one com-posed of 60 g. of scraped meat, the two meals beinggiven within 48 hours of each other. After the meatmeal they found that the acid response in the normalwas 30 per cent. higher and two types of responsewere noticed, one prompt and decided and the otherslow and indifferent. Meat is a true intragastricstimulant and in health is capable of producing themaximal response from the gastric mucosa. Theresponse in disease is no less interesting. Though,as they point out, only a limited number of caseshave been investigated, too few to allow of completegeneralisation, three groups may be separated. Whilein purely functional cases and in those with pepticulcer the meat produces the extra acid response,there was no response to either carbohydrate or meatmeal in pernicious anaemia, gastric carcinoma,delayed resolution in lobar pneumonia, and chroniccholecystitis. The intermediate stage, in which themeat response is present but is less than normal, isfurnished by such cases as cardiac or renal disease,blood dyscrasias, and " other conditions commonlyencountered in medical ward service." In thesecases the power of the stomach to deal with meat ismerely lowered and not lost. It is suggested thatthese variations in the response to a meat and carbo-hydrate meal may be regarded as a measure of

1 Amer. Jóur. Hyg., March, 1929, p. 371.2 Jour. Amer. Med. Assoc., March 9th, 1929, p. 763.

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mucosal efficiency and that persons who give a (

similar response to bread and meat, as shown by the 1fractional test-meal, cannot be regarded as normal. <

This work is illuminating and suggests several 1

possibilities. It throws light on those puzzling caseswhere acidity and acid regurgitation are complainedof by patients who on investigation, with a carbo-hydrate meal, show a subacidity amounting even toachylia. The interpretation of the fractional test-meal is beset with pitfalls. It is usually carried outunder conditions anything but pleasant or normalto the patient, who is as a rule nervous ; the mealitself is unappetising and often distasteful; it isdigested in the prone position or partially reclining,with a foreign body in the stomach causing a certainamount of discomfort and usually producing excessivesecretion of mucus. There is often a tendency toplace too great faith in results obtained under theseabnormal conditions, for while it is true that mostof these drawbacks may disappear with severalexaminations, very few patients will consent tobecome proficient in this method of investigationin the interests of scientific accuracy. The sameobjection-namely, examination under abnormalconditions-may be urged against other methodsdaily employed, but this does not answer the objec-tion ; it merely sounds a note of caution againstaccepting results too literally. To this inherentlimitation of the fractional test-meal Rehfuss andMarcil have added another in showing how great isthe variation of response to different food stimuli.Their work must make the medical man look againat some of the diets he orders. Are we not often toonervous of ordering good red meat for our patients,and giving in its place some patent or partiallydigested sloppy pabulum which we cheerfully call a" light diet " ? Often it is anything but light to thepatient. Would it not sometimes be better to cleanthe gastric lining membrane, make sure the teethare adequate and efficient, and then try the effectof, say, a nicely cooked chop, carefully masticated,with a couple of slices of dry bread ? P In tropicalclimates raw meat juice is of great value where milkis badly borne by an infant with summer diarrhoeaand vomiting. The complete change seems to putthe child’s stomach on its mettle and it usuallyresponds to the challenge.

Apart from its valuable suggestion of a new tesifor the efficiency of the gastric mucosa, this papeseems to show that we have not sufficient faith in thEadaptability of our stomachs.

ANTIVENEREAL MEASURES IN THE STRAITSSETTLEMENTS AND MALAYA.

MORE than forty years have passed since, after anagitation conducted with relentless fervour byJosephine Butler and her friends, the ContagiousDiseases Acts, 1864-69, in this country were repealed.An echo of the controversy surrounding this reversalof policy is to be heard in the arguments set out by acommittee! appointed by the Secretary of State for theColonies to examine a Straits Settlements Ordinance(No. 15 of 1927) and a Federated Malay States Enact-ment (No. 18 of 1927). These provisions are substantiallysimilar, their object being to diminish the spread ofvenereal disease. The sections to which the attentionof the committee has been drawn are those permittingthe compulsory medical examination of any individualprostitute when there is reason to suspect her ofsuffering from venereal disease. After careful con-sideration of the local situation, as well as the generalproblem, they advise that these sections of theordinance and enactment shall be held strictly inreserve, and eventually, when alternative legislationcan be passed rendering illegal the keeping of brothels,shall be repealed. This does not imply that the

1 The committee consisted of Lord Balfour of Burleigh(chairman), the Hon. Mrs. Alfred Lyttelton, Dr. F. BarrieLambert, Mrs. Neville Rolfe, Sir O. E. Warburg, and theRev. W. C. Roberts, with Mr. G. L. M. Clauson as secretary.

ommittee do not view with sympathy the dilemmavhich has led to the attempt to strengthen the hands)f the local authorities in enforcing the existing law,but that they hold, in agreement with expert opinionn most countries, that the use of compulsion in anyform is likely to destroy the atmosphere of encourage-ment to make the fullest use of the provisions madefor free treatment.

The local position is difficult to understand withoutsome reference to the history of the legislation nowin force. When, in 1886, Mrs. Butler and her co-workers had convinced Parliament that the subjectionof prostitutes to periodical medical examination wasa gross interference with the liberty of the subject,besides being useless as an antivenereal measure, thewave of feeling rose so high as to overflow to theColonies, as far as legislation was concerned, beforepublic opinion there was educated to the need fora change. In the Straits Settlements the system ofcompulsory medical examination of prostitutes wasthus abruptly brought to an end in 1888, and in 1894the registration of brothels was discontinued there,

and also in the Federated Malay States. Unfor-tunately the local authorities, though they had toobey directions from the Home Government, werenot convinced that the innovation would not lead toan increased incidence in venereal disease. as wellas to further exploitation of prostitutes, who are,for the most part, non-Europeans of a low type.Fruitless efforts have more than once been made toinduce the Home Government to consent to a re-introduction of registration and periodical medical

examination, on the grounds that the incidence ofvenereal disease was increasing. In 1898 the repre-sentations were effective to the extent of securing anamendment to the law in both colonies wherebybrothel-keepers were made subject to fine or imprison-ment if a prostitute in their houses carries on hertrade while suffering from any contagious disease.Unfortunately for the success of this scheme, whichhas now remained in force for some thirty years,some of the brothel-keepers fined for the offenceare known to have recovered the money from theprostitutes concerned. The obvious countermove ofimposing terms of imprisonment without the optionof a fine proved ineffective, since the keepers realisedthat proceedings could only be based on medical

, evidence, which in turn could not be obtained withoutthe consent of the woman ; if they could persuade

her to refuse examination they were safe fromprosecution.

This, briefly, was the situation which, in 1927, ledto the framing of new provisions which would preventsuch evasion of the law. The committee haveevidently given the complex situation the mostcareful thought, have examined many witnesses, andhave come to the considered conclusion that, what-ever its purpose, the punishment of a prostitute fornot complying with a requirement which is not appliedto the community generally is not justifiable, andthat even the provision penalising brothel-keepers,which was framed at a time when the present systemof treatment of venereal disease had not beendeveloped, is now obsolete. They advocate in its placethe extension of the powers of closing brothels alreadypossessed by the authorities, in order to prevent akeeper of a closed brothel from starting another.When the policy of suppressing known brothels,which should be actively pursued, has resulted intheir decline, legislation rendering illegal the keepingof a brothel should replace the existing provisions.Meanwhile free facilities for the treatment of venerealdisease in men and women should be extended, andto this end financial provision should be made for theemployment of highly qualified medical men andwomen at all clinics and dispensaries, and for a

development of the health visitor service. The reportdeserves study by all concerned with the controlof venereal disease. It epitomises knowledge painfullygained in the struggle to combat venereal diseasethroughout the world.