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Annotations.

HOPE FOR THE LEPER.

"Ne quid tunis." "

A FORMAL campaign against leprosy is beinginaugurated this week in London. The precise extent Iof the disease throughout the world is not known withaccuracy, although there are probably about 500,000lepers in India and twice as many in China. Thenorthern section of the New World is comparativelyfree--Mexico being an unknown quantity-but in thesouthern republics, colonised from the IberianPeninsula, only Chili appears to be free, and Colombia,a former centre of slave import, is credited with a highproportion of lepers. Missionaries state that SaoPaulo in Brazil has a higher comparative rate of non-segregated leprosy than any other city in the world.Oceania has some high rates, but Australia is free withthe exception of the coastland of tropical and sub-tropical Queensland. Sir Leonard Rogers recentlyestimated the total leprous population in all countriesat 2 million, or 3 million if the early cases are includedin the calculation. Fortunately, the effectiveness ofthe chaulmoogra treatment is opening up great possi-bilities both for the individual and for the infectedneighbourhood. Clinical improvement is by no meansrendered vo:d by the fact that pharmacologists havenot yet been able to agree as to which of the con-stituents of chaulmoogra oil it is that possessestherapeutic value. Much still ramains to be done inisolating the active ingredients. But the latestadvances towards the solution of the problems ofleprosy have been chronicled in our columns, andtheir story warrants the hopeful attitude adopted bythe leaders of the new campaign.Under the British rule, apart from India, leprosy has

to be dealt with in the tropical African colonies, inCeylon, the Malay States, Malta, and Cyprus, and theImperial responsibility implied has led to the founda-tion of the British Empire Leprosy Relief Association,with the Prince of Wales as patron, and the Viceroyof India and the Governors-General of Canada, NewZealand, and South Africa as Vice-Presidents. LordChelmsford is chairman of the General Committeeand Sir Leonard Rogers chairman of the MedicalCommittee. The aims of the Association are :

(1) To help all lepers in the Empire by providing the latesttreatment for all, and houses for those who are homeless anddestitute.

(2) To supply the latest medical information and the mostimproved drugs to leper institutions, settlements, and hos-pital clinics ; and to train those in charge of lepers in applyingthe treatment efficiently.

(3) To support sound schemes of segregation, with the besttreatment, in countries where large numbers of lepers oughtthus to be dealt with.

(4) To collect information and statistics and to issuebulletfins of information and advice to all working amongstlepers.

(5) To support further researches on both the aetiology andtreatment of leprosy, with a view to discovering moreefficient methods of prevention, and to further simplify,shorten, and cheapen the curative measures.

The movement is being formally launched at aMansion House meeting as we go to press, where thespeakers include Lord Chelmsford, Sir HumphryRolleston, and Sir Leonard Rogers. The appeal shouldmeet with a ready response in the light of the assurancegiven by Dr. E. Muir, working at the School of TropicalMedicine in Calcutta, who is able to state his beliefthat in all early cases the arrest and retrocession of thedisease, up to a relative cure, may be expected if diet,exercise, and general sanitary conditions are favour-able, and if the chaulmoogra treatment is continuedfor a sufficiently long period of time. In one of thelarge Indian asylums the mortality has already beenreduced to one-fifth of its former rate. Reports in thequarterly magazine of the Mission to Lepers repeatedlymention the special treatment and the new atmospherewhich its application is bringing into leper colonies.

THE TREATMENT OF INCOMPLETE FEBRILEABORTION.

SOME recent papers, contributing statistical evidenceon behalf of the conservative, expectant treatment ofincomplete febrile abortion, would suggest that thesuperiority of this course over the routine immediateevacuation of the uterus was established. But asrecently as 1922 the well-known German gynaecologist,Prof. A. Dbderlein, of Munich, expressed himself asfollows : " I regard it as a fatal heresy to recommendexpectant treatment in febrile abortions." Prof.Doderlein’s views, it may be remembered, were thoseof unchallenged orthodoxy less than a generation ago,and when Prof. G. Winter, of Königsberg, ventured toplead for expectant rather than active treatment somescore of years ago the opposition he encountered wasformidable. He has, however, repeatedly returned tothe charge, and in his most recent publication 2 he issupported by an impressive show of statistics. Hefinds that this controversy has yielded 267 originalarticles, dealing with about 24,000 febrile abortions.Among 276 cases treated on expectant lines there were178, or 64-5 per cent., in which abortion was terminatedspontaneously. It was also found that among6512 cases of abortion treated by digital evacuationthe mortality was 2-9 per cent., whereas among1048 cases in which abortion was completed spontane-ously the mortality was only 1 per cent. Prof. Winterthinks bacteriologically in this matter, and he hascome to the conclusion that the fate of the patientlargely depends on the nature of the infecting organism.He has collected the 2080 cases reported by 21observers publishing their bacteriological findings, andhe has found that the mortality ranges from 7,3 per cent.to 20.8 per cent., according to the nature of theinfecting organism, haemolytic streptococci being themost toxic. He suggests that, whenever it is possible,a bacteriological examination should be made of thevagina, and that when haemolytic streptococci are

found no attempt should be made to evacuate theuterus till they have disappeared. In the absence ofa bacteriological examination he urges that evacuationof the uterus in the febrile stage of an abortion shouldnot be attempted forthwith, and when expectanttreatment is not followed by the spontaneous expulsionof the ovum evacuation of the uterus should be witha blunt curette rather than with a finger.

Prof. Winter has had many followers, one of theearliest being Dr. Emil Bovin, of Stockholm. His lastpaper 3 on this subject contains a statistical analysisof the 1141 cases of incomplete febrile abortiontreated at his hospital up to Dec. 31st, 1922. Thoughthe period under review included the pandemics ofinfluenza and the deprivations of the late war, hehad to record only 24 deaths (2-1 per cent.). In623 cases the abortion was completed spontaneously,the mortality being only 1-3 per cent. Among the518 cases in which expectant treatment had to begiven up and evacuation of the uterus performedthere were 15 deaths, or a mortality of 2-9 per cent.There were considerable differences in the results,according as evacuation was performed during, orsome time after, the febrile stage ; the mortality was1-9 per cent. in the latter class, and as great as

8 per cent. in the former. Like Prof. Winter, Dr.Bovin has found that giving quinine frequently bythe mouth for a few days favours the spontaneouscompletion of an abortion. During the three years1920-22 expectant treatment alone was successfulin 241 out of 366 cases of febrile abortion (65-8 percent.), partly, at any rate, owing to the use of quinine.However conflicting opinions may be as to the bestcourse to pursue in the treatment of incomplete febrileabortions, there seems to be little doubt that most ofthem represent criminal acts. It is, of course, oftendifficult to obtain reliable information on this point;much depends on the desire and ability of practitionersto elicit information from their patients. In thisconnexion Dr. Bovin refers to investigations published

1 Deut. med. Woch., Jan. 5th, 1922.2 Ibid., Dec. 21st, 1923. 3 Hygica, Dec. 31st, 1923.

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in 1922 by Dr. Richter, of the Swedish Allm.Sarnbordhuset. Among the 107 women admitted tohospital between September, 1920, and April, 1921,suffering from febrile abortion and a temperatureexceeding 38° C. there was not one who failed to admitthat criminal abortion had been attempted.

THE PREVENTION OF STREET ACCIDENTS.

STATE medicine is a wider subject than publichealth, for it has its forensic as well as its preventiveside ; but neither of these titles in their ordinaryacceptation in this country comprises the preventionof accidents from machinery or from traffic or other-wise. Thus outside the sphere of activities of localsanitary authorities and county councils-and neverhitherto proposed to come within the control of thecentral Ministry of Health-there lies preventivework of great public importance, by the execution ofwhich much loss of life and many minor injuriesmight be obviated. Of such work the prevention ofaccidents forms a most important part. Its import-ance is brought home to us by a valuable report of theAmerican National Safety Council on " The Warningof Public Accident Statistics." The work of thisCouncil illustrates to how great an extent in theStates important public health functions are beingcarried out by voluntary associations. It is notsurprising to find that large accident and life insurancesocieties and traffic engineers of railways and large

Iindustries form the Accident Statistics Committee ofthe Public Health Section of this National SafetyCouncil.The statistics displayed by them are startling. In

1922 there occurred 75,300 fatal accidents in theUnited States ; the number would have been 35,000to 40,000 fewer if they had occurred on a scaleaccording with the experience of England. Of thisnumber the automobile was the chief cause of fatalaccidental injury, and accounted for 18 per cent. ofthe total accident budget. This increase is the more

noteworthy in view of the fact that the automobiledeath-rate was 24-0 in 1915 and 11-6 in 1922 per 10,000automobiles registered. The regulation of auto-mobile traffic has improved, but the mass cf destructionof life has nevertheless augmented. It is noteworthy,further, that the automobile death-rate per 10,000automobiles registered varied from 2-98 in Chicago,2-90 in New York, and 1-05 in Los Angeles to 0-47 inSalt Lake City. The question remains as to whetherthe blame for these great variations in death-rate isdue to carelessness of pedestrians or of chauffeurs, orto variations in the permeability of streets and theregulation of traffic. The report in hand does notprofess to answer these important questions in detail,but it gives most valuable information throwing lighton them ; and it serves, further, as a remarkablyexcellent example of the fact that statistics carefullycollected and intelligently analysed may give a

valuable lead on problems of life-saving. In the citiesfor which statistics are given children under 15 yearsof age formed on an average 37 per cent. of the personskilled. In the city of New York they formed 50 percent. These figures clearly indicate that it is notmerely additional precautions on the part of thepedestrian that are needed, but that additional safe-guards are called for to protect him. The Committeelays stress on the importance of traffic movementstudies in showing how to diminish automobilefatalities. The first essential is the preparation foreach town of a " traffic-artery " map, which usuallywould show possibilities of diversion of traffic on aconsiderable scale. The Committee’s definite con-

clusion is that in most cities traffic congestion is dueto the ineffective use of street areas rather than tothe lack of them. We wonder whether even inLondon the police authorities could show that thepresent deplorable amount of traffic congestion is notcapable of being materially reduced by application ofthis axiomatic statement. The next point which isstressed is the importance of each city maintaining

spot-maps of traffic accident occurrence, by means ofwhich an approach might be made to a determinationwhether the troublesome nature of the road itselfor the lack of traffic discipline is more to blame.Such spot-maps form the first line of guidance incontrol and diversion of congested traffic.We have merely indicated a few of the many

important points comprised in this valuable report,which should be studied by all interested in thisproblem. The prevention of accidents, especially nowthat automobile accidents are becoming increasingly aserious cause of death, is of interest to all medicalmen ; the proper control of traffic and the reductionof congestion at certain points concerns them as busymessengers of health intent on carrying out theirmission in life.

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A NEW TEST FOR TYPHOID FEVER.

Dr. E. Moretti,! of the Ospedale Maggiore, Milan,has devised the following modification of Petzetakis’siodine reaction for the diagnosis of typhoid fever.25 c.cm. of urine are saturated with 20 g. of crystallisedammonium sulphate. After about a quarter of an hourthe urine is filtered and diluted to about a third if it istoo thick. To 10 c.cm. of the filtrate one-fifth of itsvolume of a 10 per cent. solution of sodium hydrate isadded, and then a drop of a 5 per cent. tincture ofiodine. The solution is then shaken, and if the reactionis positive a persistent golden-yellow colour is produced.Out of 100 cases of typhoid fever in which this testwas tried, it was positive in 95 and negative in only 5,which were remarkably mild cases in which thetemperature became normal at the beginning of thethird week. In two cases of paratyphoid A thereaction was negative, while it was positive in two outof three cases of paratyphoid B. In the great majorityof all the typhoid cases the reaction was positive in thefirst week, and very frequently during the first fewdays of the disease. The intensity of the reactionincreased until the disease reached its height and thengradually decreased as the symptoms subsided, thereaction becoming negative before the temperaturereached normal. The reaction was also invariablypositive in pulmonary tuberculosis with cavity forma-tion, very frequently (80 per cent.) positive in casesin the second stage, and occasionally (20 per cent.)positive in the first stage. It was often positive duringthe height of pneumonia and measles, and alwaysnegative in malaria and acute rheumatism. Theiodine reaction is thus positive in the same diseases asthe diazo-reaction, and like it is an expression of anincreased elimination of urochromogen. It is of greaterdiagnostic value than the diazo-reaction owing to itsearlier appearance, greater constancy, and longerduration. In Dr. Moretti’s cases the diazo-reactionwas positive in only 78 per cent., and, as a rule, didnot become so until the first half of the second week.

THE HISTORY OF PERCUSSION AND

AUSCULTATION.

IN another column we publish an abstract of anaddress delivered by Sir William Hale-White beforethe Midland Medical Society upon the History ofAuscultation and Percussion. Broadly speaking, wemay say that these methods of diagnosis did not comeinto use until the beginning of the nineteenth century,and, though Hippocrates knew the succussion splash,until the discovery of the X rays in 1895 auscultationand percussion remained the sole means by which thephysician could form any opinion as to the conditionsexisting within the chest, other than the nature of thesputum. It is easy to be wise after the event, andwhen we read the treatises of Auenbrugger andLaennec to say " Why did no one think of thisbefore?" Auenbrugger was born in 1722 and

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Laennec died in 1826. For nearly the whole of thesehundred years Europe was convulsed by wars, andthere was no soldier who beat the ground with a

1 Riforma Medica, Nov. 19th, 1923.