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epidemic of pneumonic plague then raging in thenorthern provinces. The bureau has attractednumbers of Chinese medical men interested in publichealth work, and has furnished doctors for field workduring various epidemics of cholera, pneumonicplague, and typhus occurring since its foundation.In 1921 a reorganisation of the bureau took place ; anannual maintenance grant was obtained from MaritimeCustoms revenue, and a Medical International Boardof Managers-having at its head Dr. S. H. Chiian,formerly Medical Director-General of the Chinese

Army-was created and took over the direction of thebureau. The latter now possesses two departments,one devoted to laboratory work, the other to fieldservice. The first bulletin of the bureau, written byDr. Edgar T. H. Tsen, head of the laboratory depart-ment, printed in English and bearing the title " Noteson Biologic Therapeusis," appeared in January of thisyear. Dr. Chuan contributes a general foreword,and three other members of the International Boardwrite introductory notes in English, Chinese, andFrench respectively. The various sections of thebulletin deal with methods of injection, serum reaction,general and particular considerations of vaccines andsera, and diphtheria toxin and toxin-antitoxin.Appendices contain information relating to the fieldservice department, charges for various laboratoryexaminations, and the prices of biological products.No better evidence of the progress of medicine in theOrient could be desired than these two publications.The difficulties which faced the pioneers of Westernmedicine during the earliest days of the now well-advanced transitional period are clearly described in achapter on Medical Education in China, contributedby Dr. George Hadden, of Changsha, to a recent

publication of the Student Christian Movement, 1which is described as a series of open letters onprofessional subjects from missionary doctors prac-tising abroad addressed to their colleagues at home.Another of these chapters, by Dr. G. Duncan Whyte, ofSwatow, contains a useful reminder that " while...there is much that is ludicrous and a great deal that isdangerous in (indigenous) Chinese medicine, yet manyof the fundamental ideas that actuate the nativedoctor are very sound, and some of his drugs are mostuseful."

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ÆTIOLOGY AND PROGNOSIS OF CIRRHOSIS

OF THE LIVER.

AN important monograph has recently been pub-lished by Prof. S. Laache 2 of the University ofChristiania, on cirrhosis of the liver. His materialconsists of 44 cases, 34 of which came to necropsy.During the 32 years in which these cases occurred,16,000 patients were treated in Prof. Laache’s medicalwards, and he accordingly estimates the incidence ofcirrhosis of the liver among in-patients in medicalwards at 0-28 per cent. This ratio is surprisinglylow. With regard to the aetiology, there was a

history of alcoholism only in 39 per cent., and allthe patients giving a history of alcoholism were

males. Not one of the 14 women suffering fromcirrhosis of the liver confessed to alcoholism, and thequestions therefore arise : (1) Are men more truthfulthan women when questioned on this rather tendersubject ? (2) Do men drink much more alcohol thanwomen ? (3) Is the male liver more susceptible toalcohol than the female liver ? These are questionsto which Prof. Laache has found no final answer, andit is significant that in as many as 12 of the 14 casesof cirrhosis of the liver in women its cause remainedobscure. It was also obscure in many of the malecases, and as Prof. Laache points out, only a minutefraction of bibulous males suffer from cirrhosis of theliver, and the development of this disease musttherefore probably depend on a certain predisposi-

1 Medical Practice in Africa and the East. Edited byHugh Martin. M.A., and H. H. Weir, M.A., M.B., with anintroduction by Stephen Paget, F.R.C.S. London : StudentChristian Movement. 1923. 4s.

2 Norsk Magazin for Laegevidenskaben, April, 1923.

tion, without which alcohol cannot provoke cirrhosis.This point is well worth bearing in mind when thepresent decline in the incidence of cirrhosis of theliver is correlated with a real or supposed decline inthe consumption of alcoholic liquors. With regardto prognosis, Prof. Laache confirms the old observa-tion that ascites is an ominous sign. It was presentin 81 per cent. of the 26 cases of atrophic cirrhosiscoming to necropsy, and the duration of life after thedevelopment of ascites was, on the average, only10 to 12 months for men and only five to six monthsfor women. The longest span of life after the develop-ment of ascites was only 30 months. Statistics suchas these are not encouraging, and they suggest thatcirrhosis of the liver with ascites is a hopelesslyterminal stage, or that the treatment hitherto advo-cated is hopelessly inadequate. Paracentesis abdo-minis is but a symptomatic remedy, and in Prof.Laache’s experience it may sometimes do more harmthan good ; in one of his cases haematemesis followedthis operation. A drug which he has found remark-ably effective in some cases is calomel, and he is alsoin favour of a salt-free, lacto-vegetarian diet. But inview of the ultimate results in the majority of hiscases there would seem to be ample scope for thera-peutic reforms in this field.

THE PSYCHOLOGY OF EPILEPSY.

ON May 24th, under the auspices of the Universityof London, Dr. E. T. Wiersma, Professor at thePsychiatric and Neurologic Clinic at Groningen,delivered at the Royal Society of Medicine an Anglo-Batavian lecture on the Psychology of Epilepsy. Hegave an admirable summary of his researches into theperceptual processes, the fluctuations of attention,and the reaction times in epileptics. Experimentswere made with respect to the " just noticeable "’perceptions of sound and light in a number of epileptics, yand he found that the results were most marked whenfits were imminent, and were reduced when thepatient was under the influence of bromide. He alsoexhibited diagrams of statistics relating to the mentaland moral characteristics of epileptics as comparedwith normal people, and gave reasoned arguments for-the conclusions to which he had arrived. It is note-worthy that exact psychological methods are beingpursued by psvchiatrists in the difficult problems ofepilepsy and the psychoses, and no doubt much maybe achieved in this direction towards a furtherelucidation of their origin. Dr. Wiersma traced therelationship of epilepsy to normal sleep ; in the last-named condition some persons had a tendency tomuscular startings before slumber. This habit, indeed,was frequently to be observed in children and animals.Hypnagogic hallucinations and nocturnal fears borea close resemblance to epileptic equivalents, andsimilar phenomena were to be seen in disturbances ofconsciousness from other causes such as chloroformanaesthesia and alcoholism, which Dr. Wiersmaregarded as links in the chain of the stage fromepilepsy to the normal. He placed insistence on twophenomena which occurred in preoccupied or fatiguedindividuals and which appeared in aggravated form inepileptics-viz.," fausse reconnaissance " or the con-sciousness of having experienced present perceptions inthe past, and

"

depersonalisation " or the failure torecognise actual perceptions with consequent disorien-tating effects. These might. no doubt, be assumedto arise through transient dissociation. Discussingepileptic characteristics, Dr. Wiersma endeavoured toestablish a connexion with normal traits, and gave anaccount of an interesting series of percentage figurescompiled from an investigation of 2523 normalpersons. This was conducted by means of a list of90 questions forwarded to Dutch practitioners, whowere asked to send replies with respect to the mental" make up " of normal individuals well known to them.The questions included inquiries into capacity forcomprehension, practical applications of common

sense, breadth of mental vision, originality of idea,

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verbosity, inclination to repetition, perceptive acuity,memory, mental reserve, wit, stubbornness, irritability,moodiness, self-satisfaction, conflict between thoughtand action, and so on. From this compilation Dr.Wiersma had divided the individuals into two main

groups-viz., normally active persons and the absent-minded-the latter being prone to be inactive, losinggrip on the outer world and its restraining influenceon temptation, ill-at-ease with their fellow-men, andwandering in their thoughts. Dr. Wiersma’s con-

clusion is that the absent-minded class representstransition between the normal and epileptic sectionsof the community. The fundamental nature ofepilepsy he regards as due to an inherent failureadequately to assimilate impressions from the externalworld and holds that the convulsions, equivalents, andmental and moral characteristics associated withepilepsy are secondary and dependent phenomena.

THE MAUDSLEY LECTURE.

WHEN the Maudsley Lectureship was instituted in1919 it was laid down that while the lecturer musthave made contributions of well-recognised import-ance and value bearing on the knowledge of mind andits disorders, he might be of any nationality or ofeither sex. Sir James Crichton-Browne, who deliveredthe first lecture, dealt with the modern combinationof laboratory and clinical work and the necessity offounding mental hospitals, and his lecture includeda critical conspectus of psycho-analysis and psycho-therapy. Last year Sir Maurice Craig took as hissubject Some Aspects of Education in Relation toMental Disorder, his key-note being Maudsley’sremark that " there are not many natures predisposedto insanity but might be saved from it were theyplaced in their earliest days in exactly those circum-stances and subject to exactly that training mostfitted to counteract that innate infirmity." Thisyear a distinguished visitor from the Dominions,Prof. C. K. Clarke of Toronto, was invited to deliverthe lecture, of which we give an abstract on a laterpage of this issue. Prof Clarke dealt as was naturalwith the special needs and conditions of a developingcountry, starting from the unfortunate fact that thehost of immigrants drifting from the Old Worldcontain an undue proportion of defectives and mentallydiseased persons. He described the work of theCanadian National Committee for Mental Trainingwhich he directs, frankly admitting that its firstfunction is to educate people to a knowledge of theimportance of having well educated psychiatristsabroad in the community-with the idea of keepingprevention of mental disorder before the public mind,and its second to scan school populations with skilledeye in the hope of forestalling the thousand-and-onetragedies seen to-day. Dr. J. G. Soutar, in pro-posing the vote of thanks to Prof. Clarke, welcomedhis address for its helpfulness and hopefulness. Thelecturer’s enthusiasm had driven without stampedinghim, and it might well be true that Canada could facepsychological problems with greater freedom, beingless hampered by tradition and entrenched in pre-conceptions than the mother country.

PRESERVATIVES IN FOOD.FRESH point has been given to the need for further I

control of preservatives added to our daily food bythe appearance of Dr. W. J. Howarth’s report for theyear 1922 on the health of the City of London. Duringthat year nearly 1000 samples of food or drugs weresubmitted to the public analyst for examination, andof these more than 11 per cent. were found to beadulterated, the substances being very various, as thefollowing list shows : Coffee essence, milk, borax,butter, British wines, margarine, tinned spinach,honey, gelatin, lemon curd, cider, Gregory powder,whisky, preserved cream, sauce, mustard, rum, cream,table jelly. The list shows a wide field of sophistication,although Dr. Howarth believes it to be not greater inthe City area than elsewhere, his method of group-sampling tending to give higher figures than

random sampling would. However, he regardedthe situation as disquieting enough, as we haverecently pointed out, and the position fully justifiesthe plea of a proposed deputation to the Ministerof Health, asking for the speedy introductionof legislation to notify and limit the presence ofpreservatives in food. This deputation, which in-cluded representatives of nine societies and a numberof medical officers of health and others who have takenspecial interest in the matter of pure food, receivedthe gratifying assurance that a Committee on the Useof Preservatives was in course of appointment. It isunfortunate that the only official action to be takenon the recommendations of the Departmental Com-mittee of 1890 has been the issue of the Milk and CreamRegulations (1912 and 1917), prohibiting entirely theaddition of preservatives to milk and limiting theamount of boric acid or hydrogen peroxide which maybe added to cream, making obligatory an announce-ment of their presence on the label, and a furtherprohibition under the Foreign Meat Regulations of theimportation of certain meat foods containing preserva-tives. But outside these there is a wide field foraction. Laxity on the part of local authorities cannot,however, be entirely due to lack of powers, for the5 administrative counties and 13 county boroughs, inwhich during recent years no sampling whatever hasbeen done for the discovery of preservatives, have, asa matter of fact, possessed during that period full

powers under the Milk and Cream Regulations. Itis good fortune that just at this moment should appeara new edition (the seventh) of Bell’s " 8ale of Foodand Drugs Acts" which Mr. C. F. Lloyd hasendeavoured to bring completely up to date, although,as he says, the law relating thereto has fallen intoconsiderable confusion. The chemical notes of Mr.R. A. Robinson in the same volume have also beenrevised and enlarged. —————

A DIPLOMA IN BACTERIOLOGY.BACTERIOLOGY is coming to occupy a large place

not only in medicine and in public health but inmany of the other arts and sciences. This themeformed the text of Sir Frederick Andrewes’s addresswhen opening last week the new bacteriologicallaboratories at Newcastle-upon-Tyne. It is significantthat during the same week, at the annual meetingof the Court of the University of Manchester,approval was given to the institution of a specialdiploma in bacteriology. This is the first diplomain the subject instituted in this country, andthe courses of instruction, which candidates willbe required to attend before presenting them-selves for examination, are designed to supply a

thorough training in the general principles of thesubject, together with advanced courses in one ormore special branches. Graduates in medicine and inscience of any approved university may enter for thecourse, and the syllabus has been designed to meetthe requirements of medical graduates who wish toqualify for bacteriological posts, or to obtain a specialknowledge of medical bacteriology, and also ofgraduates in science who desire to take up some branchof bacteriological work. The diploma will be awardedto candidates who have, after graduation in science orin medicine, attended the prescribed courses in thedepartment of bacteriology and preventive medicine,under the general direction of Prof. W. W. C. Topley,over at least one academic year. The course of studycomprises (a) courses of instruction in general bacterio-logy, including the morphology and physiology ofbacteria and bacterial classification, the history ofbacteriology, quantitative methods of bacteriologicalinvestigations, and elementary bacteriologicalchemistry; (b) special courses of instruction in two ormore of the following subjects must also be taken :(1) bacteriological analysis of water. milk, food, &c. ;(2) advanced bacteriological chemistry ; (3) biometry(4) parasitism, infection, and resistance ; (a) epidemio-logy ; (6) comparative pathology. The examinationwill consist of written papers on the general subjects1 THE LANCET, April 21st. 2 Butterworth and Co. 1923. 15s.