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sponding rise. The standardised mortality-rate fromcancer, for both sexes combined, has shown very littlechange over the last decade. In 1928 there were 1001such deaths per million living, in 1933 997, in 19381005. Infant mortality continues to show itspronounced contrasts between one locality and another.For instance, in 1937 and 1938 the deaths per 1000livebirths were 37 and 43 in Stoke Newington and83 and 78 in Kensington, 46 and 42 in the countyborough of Bristol and 92 and 99 in Wigan. Takingwider areas, stillbirths in 1938 varied between 31 per1000 total births in Greater London, 46 in Cheshireand Lancashire and 51 in Wales.

SUBDURAL HÆMATOMA

ATTENTION has been drawn to the importance ofreaching an early diagnosis in subdural hasmatoma byTempleton in our issue of March 16 and again byEckhoff in this issue. In this they echo Trotter, whopointed out in 1914 that the only chance of savingthese patients lies in early operation. This howeveris difficult to achieve unless all concerned bear thediagnosis in mind in problematical cases. Trivialinjury to the skull is the accepted cause of the condi-tion but many cases give no history of trauma. Aftera known injury there is a latent period which accord-ing to Trotter is usually about six weeks. Duringthis time headache and a certain amount of mentalimpairment are present without definite physical signs.The mental disturbance may be such that the patientis liable to be transferred to a mental hospital. The

prodromal period is followed by a sudden lapse intounconsciousness, usually preceded by violent headacheand vomiting. Trotter says that the most characteristicfeature of the coma is its spontaneous variability:" there is no other condition in which this is so clearand striking a feature." This variability is welldemonstrated by Templeton’s case. The assistance indiagnosis that may be given by radiography has

recently been described by Bull in an analysis of 26cases studied in Olivecrona’s clinic at Stockholm. Ofthe different techniques available in this spherepneumo-encephalography seems of most value. By thismeans it is possible to recognise the type of ventricu-lar displacement that will be produced by a structurehaving the characteristic shape and position of a sub-dural haematoma.

DRUG STANDARDS IN INDIA

MAINLY as a result of the persistent efforts of agroup of Indian medical men under the leadership ofDr. Chopra, the standardisation of drugs in India isin sight. All the provincial legislatures have passedresolutions empowering the central legislature to passa measure for the control of drugs and a bill has nowbeen introduced to regulate their importation, manu-facture, distribution and sale. The word drug hereapplies to all substances intended to be used for " thetreatment, mitigation or prevention of disease inhuman beings or animals, other than medicines or

substances exclusively used or prepared for use inaccordance with the Ayurvedic or Unani systems ofmedicine." The standards proposed for both importedand home-manufactured drugs are the same. Patentand proprietary medicines must conform to theformula or list of ingredients displayed on the labelor the formula disclosed to the central drugs labora-tory, as the case may be. For vaccines, sera, toxins,toxoids, antitoxins, antigens and the like, as well asvitamins and hormones the standards are those main-tained at the Medical Research Institute, Hampstead,

1. Trotter, W. Brit. J. Surg. 1914, 2, 271.2. Bull, J. W. D. Proc. R. Soc. Med. February, 1940, p. 203.

and such others as may be prescribed by the central(or provincial) government. Other drugs must be upto the standards specified in the latest edition of eitherthe British Pharmacopoeia, the British PharmaceuticalCodex or any other prescribed pharmacopoeia, or thoseadopted by the permanent commission on biologicalstandardisation of the League of Nations. Thus it is

proposed to adopt for the last two groups standardswhich are followed in this country. In the case of

proprietary medicines the bill appears at first sightto go much further than English laws and to be basedrather on recent American legislation. For instance,the sale of any proprietary medicine will be unlawfulunless its label displays either its formula or a list ofits ingredients in a manner readily intelligible tomembers of the medical profession, or else the numberof the certificate of registration granted by the CentralDrugs Laboratory after being informed of its formula.This provision loses some of its force by an explana-tion in a later clause to the effect that the formula orlist of ingredients shall be deemed to comply with theprovision if " without disclosing a full and detailedrecipe of the ingredients, it indicates correctly all thepotent or poisonous substances contained thereintogether with an approximate statement of the com-position of the medicine." This explanation seems tobring the labelling of proprietary medicines more orless into line with the practice which has grown up inthis country under the pressure of the medicine stampduty acts.

INVESTIGATION OF CANCER CURES

FROM New York comes a very definite claim byGlover and ’Phite that cancer is being cured by aspecific antiserum. They claim that in 1920 it wasdemonstrated before members of the staff of St.Michael’s Hospital, Toronto, that the inoculation of abacterial suspension containing a micro-organismobtained from human cancer produced metastasisingtumours in animals, and that this work was repeatedin the hygienic laboratory of the United States PublicHealth Service in 1929. Their antiserum is preparedby repeated injection of horses with Berkefeld filtratesand fluid cultures of various strains of this micro-organism and the serum is used to treat patientssuffering from cancer. Such claims are familiar to allwho treat cancer patients because patients and theirfriends hear or read of them and at once beg to betreated by a method which seems to them simple andlogical. The cures set out in this booklet are strikingand however doubtful the doctor may feel aboutclaims that appear in private publications and do notconform to the usual medical criteria for the presenta-tion of statistics, it is not helpful if he tells thepatient that he does not believe the facts. It can besaid that many of the cases quoted have no histologicalproof, have really been cured by operation, or presentthe signs of radiation reaction with a cured cancer.

Even then a residue of cases remain in which noexplanation is possible and the question becomes oneof truth or falsehood. There is, for instance, a

record of a case of adenocarcinoma with a positivepathological report alive for 14 years with no othertreatment than antiserum. Had this case been quotedin a statistical report for any of the accepted methodsof treatment it would have been accepted withoutquestion. The work of the American Medical Asso-ciation in investigating the claims made for secretremedies is well known, and it is probable fromreferences to the hostile reception of their work madeby the authors of this report that some such investiga-1. Treatment of Cancer in Man. By T. J. Glover, M.B. and

J. E. White, M.D. New York : Murdoch Foundation. 1940.

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tion has already been made. It would be of realvalue to the medical profession if all claims to curethe diseases which at present are regarded as inevit-ably fatal without special treatment and which yieldonly low percentages of cures could be investigatedby a specially appointed body. The authority of aninternational committee sponsored by the League ofNations would lend great weight to such investigation,but even without this the national bodies such as theBritish Empire Cancer Campaign, who have alreadydone good work on these lines, could give a usefullead.

THE IRREPRESSIBLE BACTERIUM TULARENSE

TULARAEMIA, a plague-like disease of animals andman, is an infection which America is proud to callits own, for although it has been reported from coun-tries as far away as Norway, Russia and Japan thewhole history of the disease has been worked outby American observers, particularly McCoy andFrancis. For our part we are content that the diseaseshould remain American, for the ways in whichBacterium tularense attacks its victims are wide andvaried. A natural disease of ground squirrels andwild rabbits in the western states of America, theinfection may be conveyed to man from the skin orcarcases of these animals, or from hares (Norway) orwater-rats (Russia), or from the bites of ticks or ofhorse flies. Even when it is apparently safely cagedin the bacteriologist’s test-tube it may still escape, andthere is no other organism which is so dangerous tothe laboratory worker. It will pass through the intactskin of the guineapig and probably, too, of homo

sapiens, and infection takes place most often throughthe skin of the fingers and the conjunctival mucousmembrane. Polluted water had not until lately beenincriminated as a possible source of infection, althoughthe "lemming fever" of Norway, which follows thedrinking of water polluted by the bodies and excretaof the small rodents called lemmings, is thought to bea form of tularaemia. Now, however, comes a report 1from America that the water in three Montana streamshas been found contaminated with Bact. tularense.Two of the streams are flowing creeks, while thethird consists at certain times of the year of a

succession of pools, and the organism was present alsoin the mud of one of these pools. These findings weremade while studying epizootic tularaemia in beavers,and in the neighbouring state of Wyoming theseanimals have provided a striking illustration of theinfectiousness of tularaemia.2 A year ago the gamewarden sent a dead beaver to the University ofWyoming for a post-mortem examination, and the manwho unwrapped the body developed tularaemia fivedays later and took three months to recover from therecurring attacks of fever. At Pass Creek, fromwhich this beaver came, a large number of beavers haddied mysteriously and the trapper developed what waslater proved bacteriologically to be tularasmia. Itseemed likely that the beavers had died of the samedisease, and there was some evidence that the infectionwas water-borne.

GENTIAN VIOLET FOR THREADWORMS

NEw remedies for the cure of threadworm infectionsare liable to enjoy but a brief popularity since relapsesare frequent, and, what is less recognised than it shouldbe, familial infestation leads to early reinfection.Unfortunately the most efficient remedies so far sug-gested have involved long courses of enemas whichare in many ways undesirable for children, difficult to

1. Publ. Hlth Rep., Wash. Feb. 9, 1940, p. 227.2. Science, March 15, 1940, p. 263.

carry out on a large scale in the family circle or ininstitutions, and if hexyl-resorcinol is used (certainlythe most reliable rectal medicament to date) definitelyexpensive. For some time past the United StatesPublic Health Service has been issuing a series ofvaluable studies on oxyuriasis, and the National Insti-tute of Health anal swab for diagnosis and for check-ing cure has featured in many of these. Armed withthis weapon Wright and Brady now bring forwardevidence that in gentian violet there has at last beenfound a relatively cheap, safe and practical methodof getting rid of threadworms without the use ofenemas. Four methods have been tested. In the first4-grain " enterie-coated " tablets of gentian violet weregiven to adults three times a day before meals for tenconsecutive days. Children received smaller doses,based on a general rule of gr. 1/6 per day for eachyear of apparent age, divided into three doses. In aseries of 107 patients 91 per cent. gave negative swabresults ten to twenty-one days after the completionof treatment. Since the life cycle of the threadwormmay be as long as twenty-one days a second groupof patients were given the tablets for eight days, thenrested for a week and given the tablets again foreight days. Of 30 patients treated in this way 27were negative in swab examinations made between thefourteenth and twenty-first day after the end of treat-ment. A third method involved similar dosage butexamination was deferred until between the forty-second and the forty-eighth day after the end oftreatment; here only 58 per cent. were negative. Itwas felt that the efficiency of gentian violet might beimproved by varying the coating of the tablets so as toensure complete disintegration. A fourth group ofpatients were therefore given tablets with a water-soluble coating an hour before meals for the sixteen-day course with a week’s rest in the middle. Here79 per cent. of patients were negative for threadwormova on seven consecutive dailv swabs taken from theforty-second to the forty-eighth day after the end oftreatment-a rigorous test it will be agreed. Some ofthe positive results may have been due to reinfectionin the environment from which the patients came, sothat if all infested individuals in the patients’ familieswere treated at the same time better control might beobtained. A small proportion of the patients treatedsuffered from nausea, vomiting, diarrhoea andabdominal pain but these complications quickly dis-appeared when the dosage of gentian violet was

reduced or omitted for a day or two. The drug shouldnot be used where there is concomitant infection withthe round worm (which must be got rid of first),moderate to severe cardiac, hepatic or renal disease,alcoholism, or diseases of the gastro-intestinal tract.Wright and Brady conclude that gentian violet is" eminently superior to some and superior to all theother methods of therapy tested under similar condi-tions." Previous publications have shown that suchconditions, including the use of the anal swab, arestrict, so that "because of its relative cheapness, itsease of administration and its relatively high degreeof efficacy" gentian violet appears to hold the fieldfor the treatment of threadworms, especially whenfamilial infestation is present. The sixteen-day coursewith a week’s rest in the middle is the method of choiceand tablets with a water-soluble coating should be used.

Dr. JOHN GRAY, senior medical officer in St. Helena,has been made a member of the executive council ofthe island.

1. Wright, W. H. and Brady, F. J. J. Amer. med. Ass. March 9,1940, p. 861.