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marrow had taken place. The operation does notseem to be very dangerous, but of the durability of itsachievements there must still be doubts.

THE PRESENT EPIDEMIC OF LETHARGICENCEPHALITIS.

THE anticipations of the Ministry of Health ir1919 that epidemic encephalitis was likely in th(future to manifest its activities in wider epidemi(form appear to be only too truly realised. ThEseasonal incidence of encephalitis in England andWales has been unduly high, the number of cases oithe disease notified since the beginning of the yearbeing 1612, compared with 1025 during the whole oi1923, 454 in 1922, 1470 in 1921, 890 in 1920, and541 in 1919. In all other European countries, aE

well as in the United States of America, the firstquarter of 1924 has shown improvement on thecorresponding quarter of 1923. The returns for theweek ending April 26th now show a decline in thenumber of notifications for England and Wales from253 to 210. The fall has been marked in the chiefcentres of infection : Sheffield returns 26 cases as

against 41 in the preceding week, Birmingham 17 asagainst 29, Newcastle 3 as against 7, and Bristol8 as against 13. There have also been an appreciablenumber of sporadic cases in rural and outlyingdistricts. In Liverpool and Sheffield several examplesof multiple cases in households have occurred and therecognition of mild or abortive cases, characterisedby transient palsies, stiffness of the neck muscles,febrile attacks, sore throats, or mild catarrhs is seento be of importance in tracing the paths of case-to-caseinfection. On the whole, the clinical type of caseseen in the present outbreak appears to be of a

relatively mild degree of severity. In Sheffield outof 163 cases notified since March 10th, 20 deaths haveoccurred. In many instances the prodromal periodof infection appears to be over the usual seven days.Many patients have a febrile onset often ascribed to"influenza," and a fortnight or more elapses beforethe definite signs of encephalitis are manifest. Whilsta proportion of cases can be classed as the originaloculo-lethargic type or present the Parkinsonianphenomena seen in 1918, it is noteworthy that manyof the cases show myoclonic movements and thatfibrillary twitchings of the abdominal muscles are

also common. Cortical affections are more frequentlyseen than in previous outbreaks ; these are character-ised by epileptiform convulsions sometimes associatedwith maniacal outbursts or insomnia. Catalepsy israre in the present outbreak. Some patients make anunusually rapid recovery.

THE ATTEMPT TO ASSESS PHYSICALFITNESS.

THE results of certain investigations conductedduring the war gave rise to the hope that by anappropriate treatment of measurements long familiarto physical anthropologists and physicians (measure-ment of body dimensions and of vital capacity) itmight be possible to obtain simple and widely applic-able methods of assessing physical condition. TheMedical Research Council have collected then andsince much data with the object of throwing light onthis point, and though the whole of this material hasnot yet been analysed, a sufficiently large samplehas given negative results. Inquiry as to whetherany other less familiar system of measurements ortests might serve to found a rational and accuratemode of judging goodness or badness of physiquehas led to equally disappointing results. It seemsnow to be established on grounds of an analysis ofmeasurements of young adult males, in adult women,2 2

1 Greenwood, Newbold, and Cripps: Biometrika, 1923,xiv., 316.

2 Medical Research Council Special Report Series No. 84.The Application of the Air Force Physical Efficiency Tests toMen and Women. By Lucy D. Cripps, M.B., D.P.H. 1924.H.M. Stationery Office. 1s. 6d.

; and schoolboys,8 of various ages and social class; (Mumford and Young) that the inherent variability

of vital capacity within homogeneous groups ofapparently healthy persons is so great that inferencefrom deviations above or below the normal of a

particular combination of measurements will rarelybe of service in the assessment of individual cases.In the most recent of the special report series issuedby the Medical Research Council Dr. Lucy Crippshas applied to young women engaged in widelydifferent occupations Group Captain Martin Flack’stests for physical efficiency in airmen. Her studyhas not resulted in the discovery of any simple orgenerally valid relationships. She is careful to pointout that these negative findings do not detract fromthe value of these tests for the particular purpose forwhich they were devised and are used-that is, toascertain fitness for flying. Certain side-issues ofthe inquiry are of interest. For example, the women

subjected to the tests included 115 students at BedfordCollege, 241 students at a physical-training school,and 125 civil servants. Of the third-named group all,of the first many, and of the second none habituallywore corsets. The conclusion reached confirmedthat of other modern observers, that the costal typeof breathing at one time thought to be characteristicof women is due only to constriction of dress andthat there is no essential difference in the mechanismof respiration in men and women. Another interestingfact is that among students at the physical-trainingcollege in three of the tests-vital capacity, breath-holding, and the fatigue tests-those students whohave had a longer training show on the whole worseresults than those in the earlier stages of training.The suggestion is that these girls may be overtrainedin their third year. In connexion with this reportthe results recorded by Burgess Gordon, S. A. Levine,and A. Wilmaers in the current Archives of InternalMedicine on the vital capacity of a group of Marathonrunners is of interest; their vital capacities varieda great deal from below to above normal and boreno important relation to the order in which theyfinished.

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TUTOCAIN.

I THE German firm of Bayer, who introduced thesubstance " 205 " as a means of treating trypano-somiasis, have now produced a new local anaestheticknown as tutocain. It is a substance of the novocainetype, and a derivative of a--y-amino-alcohol ; itcontains two asymmetric carbon atoms, but isnevertheless a racemic combination. It is very solubleand can be sterilised by boiling for a short periodwithout undergoing decomposition. Its pharmaco-logical properties have been described by Schulemann, 4who states that tests on the eye of the rabbit showthat a solution of per cent. strength is potent enoughto produce anaesthesia, while the lowest concentrationsof novocaine and cocaine able to do so are 2 per cent.and 1/20 per cent. respectively. Thus tutocain wouldappear 16 times as powerful as novocaine and onlytwo and a half times weaker than cocaine. Its effectis prolonged. Its toxicity, as tested on rabbits byintravenous injection, and on mice by subcutaneousinjection, is twice as great as that of novocaine, and,so far as intravenous injection into the rabbit isconcerned, about half that of cocaine. When appliedto the human eye it produces no irritation, but has thedrawback of causing some hyperaemia ; this may beprevented by the addition of adrenalin. Variousclinical reports of its use have now appeared 5; allthese are entirely favourable, both as regards its usefor superficial as well as for infiltration anaesthesia. Ithas been used in operations for hernia, hydrocele,gastrostomy, colostomy, osteotomy (hallux valgus) ;also in major abdominal operations by Braun’s method

3 Mumford and Young : Biometrika, 1923, xv., 109.4 Klin. Wochens., 1924, iii., 676.

5 Lotheissen : Wien. Mediz. Wochens., 1924, lxxiv., 891 ;Finsterer: Ibid., lxxiv., 895 ; Seiffert and Anthon : Deutsch.Mediz. Wochens., 1924, April 25th, 538 ; Marcuse: Ibid., 539 ;Suchanek: Wien. klin. Woch., 1924, No. 17, 415.

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of splanchnic anaesthesia and also injected into thespinal canal. For nose and throat work, when usedin conjunction with adrenalin, it is stated to be justas effective as cocaine. The price of tutocain is thesame as that of novocaine ; since, however, consider-ably less is required, it is cheaper than novocaine to use.Up to the present no clinical trials have been made inthis country, so that it will be necessary to wait toknow to what extent such favourable reports requirequalification. Certain preliminary laboratory testswhich have been carried out confirm the statementthat it is considerably more active than novo-

caine. It is interesting that the Bayer firm are

reported to have expressed the opinion that tutocainwill prove the most valuable discovery they havemade within the last ten years.

DISPOSAL OF THE DEAD.

FOR 50 years the Cremation Society has advocatedthe disposal of the dead by cremation, and the reportwhich was read at the annual meeting on April 30thshowed how much this practice has gained groundduring the last half century. The total number ofcremations in Great Britain during the last year was1986, a decrease of 23 on the figures of 1922, but thereport points out that there are many indications ofgrowing interest not only in all parts of the Empirebut throughout the world. When full statistics areavailable it is probable that the ratio which cremationbears to the death-rate will show a marked improve-ment, and the slight decrease is probably due to theabnormally low death-rate of the past year. TheSociety has given during the past year considerableattention to the question of death certification, whichis intimately bound up with the future of cremation,as was pointed out in our columns recently.1 Owingmainly to the efforts of the late Sir Malcolm Morrisa fully representative committee was formed under theaegis of the Federation of Medical and Allied Servicesfor the purpose of drafting a Bill amending the lawof death certification. There is urgent need for a Billwhich will leave no room for the certification of deathon insufficient information, as can at present takeplace under the existing laws. The scope of theproposed Bill was outlined in THE LANCET ofJan. 12th last. It is hoped that this Bill will beintroduced into Parliament during the present sessionand, should it become law, it will do much to removethe existing anomalies which prevent cremation frombeing more widely adopted among the poorer membersof the community who at present have no alternativeto the common grave. The first crematorium inWales has been established at Pontypridd, and thequestion of providing a crematorium for the West ofEngland has again been brought into prominence. Itis hoped that a crematorium may be established atPlymouth or some other convenient centre. The pro-vision of a crematorium is also be to considered by thelocal authorities at Cardiff, Chiswick, Canterbury, andRichmond in Surrey. The disposal of the dead vitallyconcerns the health and welfare of the living in allclasses of the population and is also of the greatesteconomical importance to the country at large.

THE principal firms engaged in the production ofinsulin in Great Britain are reducing the retail priceof insulin to 5s. per 100 units as from May 12th.The present retail price is 6s. 8d., and is the result ofa series of reductions which have taken place sinceinsulin first came on the market here at 25s. per100 units early in 1923.

1 THE LANCET, Feb. 16th, p. 344.

THE Manager of THE LANCET would like to purchasecopies of the issue of Feb. 2nd, 1924, for whichsubscribers may have no further use. He will be

pleased to pay ls. each for them. Such copies should beaddressed to him at 423, Strand, London, W.C. 2.

Modern Technique in Treatment.A Series of b’pecial Articles, contributed by .

invitation, on the Treatment of Medicaland Surgical Conditions.

LXX.-INFECTIONS OF THE HAND.THE great prevalence of hand injuries and the

need of obtaining complete restoration of functionfor wage-earners makes their treatment of greateconomic importance. The following processes willbe dealt with here: (1) Acute lymphangitis; (2) infec-tions of the terminal segment of the fingers; (3) acutetenosynovitis; and (4) the infections of the fascialspaces in the palm. The degree of disability andthe time lost from work depend largely upon theearly and exact recognition of the type and the siteof the infection. Most really bad septic hands aredue to faulty diagnosis.

Prophylactic Treatment.-In all industrial worksfacilities for immediate treatment of minor injuriesshould be provided. In small works the foremanshould be given instruction in elementary first-aidand be put in charge of a small surgical box, whilein large concerns a special first-aid dispensaryshould be established. In the treatment of smallcuts, pricks, and skin abrasions no attempt is madeto cleanse the wound, which should be liberally paintedwith tincture of iodine and a dressing applied.

Acute LLilrrzpharzgitis.In this condition diagnosis is of the utmost

importance, for if it is unrecognised and the fingerincised, the general condition of the patient may beseriously imperilled. The finger, following a slightprick some hours previously, becomes slightly swollenwith a dull ache, this condition being ushered in bya feeling of malaise or, in bad cases, by severe chill.Within a few hours the tell-tale red line has appearedin the forearm and there may be quite obviousswelling of the dorsum of the hand, though theprimary site of infection remains but slightly swollen.The degree of systemic involvement varies veryconsiderably in different cases. Treatment will bedirected to the local lesion and to the general con-dition of the patient. Locally, oft-repeated, largehot dressings will be applied to the whole hand andforearm, while Bier’s passive hypereemia obtainedby a Martin’s bandage placed round the arm willbe found of great service. Generally, the patientmust be treated in bed, eliminative measures, suchas saline purges and diuretics, must be instituted,and the patient’s general condition supported bystimulants. An incision will be required only if a,

localised abscess develops at the site of infection orin the lymph glands at elbow or axilla. Completerecovery is often rapid, though in a few fulminatingcases death cannot be avoided.

Infection of the Terminal Segment of the Fingers.In these cases, usually, but not always, preceded

by a slight prick, a stabbing pain is felt which soongives place to a severe throbbing pain, sufficient tokeep the patient awake. The end of the fingerbecomes swollen, red, tense, and very tender overthe site of infection. The pain, swelling, andtenderness increase, and the swelling will spreaddown the finger and on to the dorsum of the hand,but the pain and tenderness remain localised to theterminal segment. Treatment consists of an incisionon the lateral surface of the finger-never in the middleline-from the distal flexion crease to within half aninch of the tip. This will suffice in early cases, butin severe ones a second lateral incision should be madeon the other side and these two joined up over theend of the finger, keeping within a quarter of an inchof the edge of the nail. The flap thus formed shouldbe dissected up so as to open completely the fibro-fatty pocket and a slip of rubber tissue insertedbetween the flap and the periosteum. This promotesexcellent drainage, rapid subsidence of the infection,and complete restoration of function.