508 LUNATICS AS A PUBLIC DANGER.

investigations, believe it to be because autopsy isdelayed too long, for the parasites are altered by postmortem changes more quickly in the tissues than inthe vessels. The flagella disappear first, then theprotoplasm assumes a rounded shape and loses itsspecial staining affinities ; the blepharoplast andnucleus persist longer, but are apt to be mistaken forbacteria unless examined under a high power, whentheir irregular edge and lighter central staining dis-tinguishes them. Subjects of trypanosomiasis areapt to suffer from peri- and myo-carditis with dilata-tion ; is the infection brought by the blood stream ?The Hamburg investigators think not, but duerather to an extension from the pericardium withinwhich the trypanosomes are growing ; morbid changesare more advanced in the epicardium than in theheart, and in the superficial layers of the myocardiumthan in the deeper. The first histological evidenceof trypanosome infection is an oedema which may bedue to toxins, though such toxins have not yet beenisolated. Into this cedematous area the trypano-somes having penetrated, they increase, setting up asmall-cell infiltration similar to but less in degreethan that of bacterial inflammation ; the musclecells degenerate later. Trypanosomes, living andmoving, may be found in plenty in the fluids of serouscavities and in that of the conjunctival sac, evenwhen they are but scantily present in the blood.Conjunctivitis is not unusual in trypanosome-infectedanimals; iritis and keratitis also occur, and livingtrypanosomes have been found in the anteriorchamber. Thence they make their way along thelymph stream into the subconjunctival connectivetissue, causing oedema and inflammation, and so

reach the conjunctival sac, where they are mostnumerous about the fornix. This sequence of eventswas first observed with T. equiperdum, althoughmost of the work was done with T. gambiense andT. rhodiense, of which the latter gives rise to themore acute infection in apes. Whether the growthof trypanosomes in serous cavities accounts forrelapses will be discussed in a subsequent paper.

MINIMAL DOSES OF HEAVY METALS.

DR. Guisepp6 Sabatini, professor of special patho-logy in the University of Rome, has been investigatinglthe effect of injecting into the circulation extremelysmall quantities of salts of the oligo-dynamic metals,such as copper, zinc, and mercury. The vogue of the

infinitely small, he remarks, is continually extendingits influence in biology, and even in clinical medicine.He has been impressed by the demonstrations of16 ultravirus," of aphanozoa, of fatal anaphylaxisproduced by minute doses of serum, of the powerfuleffects of imponderable amounts of hormones, and ofthe posology in fractions of a decimilligramme of purealkaloids. In Italy there has been a tendency toreconsider the doses of commonly used drugs, andclaims have arisen for remarkable effects from dosesconspicuously smaller than those generally employed intherapeutics. It may easily be predicted that theedifice of necessary and sufficient therapeutic dosesfixed by scientific medicine is not really on the vergeof collapse, but according to Prof. Sabatini we shouldbe guilty of stupidity to ignore such investigationsaltogether. His own experiments were inspired bythe observations of A. van Egmond on the action ofcertain drugs on the bundle of His, and on the pro-duction of heart-block by the action of oligo-dynamicmetals. This author showed that simple contact ofthe bundle of His with a copper wire 2 mm. in diametercaused heart-block. Having excluded the possibilityof thermic effect, pressure, and galvanic current, heconcluded that it was due to an infinitesimal chemicalaction on the cells in the bundle. In the same field ofobservation, Stock, in 1926, maintained the possibilityof mercurial intoxication in man caused by theamalgam used in stopping carious teeth, and Seifert,examining several hundreds of syphilitic patients

1 Policlinico, Medical Section, June 1st, 1929, p. 281.

belonging to every social grade, noticed that about80 per cent. of them had no teeth filled with metallicstopping, while in a series of patients with many filledteeth syphilis was much less prevalent than in others,and he suggests that the minute doses of mercuryabsorbed by the organism in these subjects may actas a prophylactic. The researches carried out byProf. Sabatini fall into five groups : (1) chloride of

copper, one milligramme dissolved in 2 c.cm. ofdistilled water ; (2) chloride of zinc, in the same pro-portion ; (3) bichloride of mercury, in the same

proportion; (4) bichloride of mercury, half thatstrength ; and (5) controls consisting of injections of2 c.cm. distilled water only. These quantities wereinjected into a vein and samples of blood taken after1 hour, 8 hours, and 24 hours. These sampleswere examined as to the number of red cells, thenumber of leucocytes, the leucocytic formula, and forglycaemia. The specimens showed very definitechanges, the number of red cells and leucocytes beingdistinctly, and sometimes conspicuously, increased,while the glycaemic content was raised to aboutdouble the normal. The changes were transitoryand a return to the previous condition took place after24 hours. Dr. Sabatini is continuing his investigationsespecially with other salts.

RESEARCH IN TUBERCULOSIS.

Two years ago the Prudential Assurance Companyprovided a new pathological department for the Cityof London Hospital at Victoria Park, and the report for1928, recently issued, testifies very clearly to the valueof this benefaction. The laboratory has examinednearly 10,000 specimens from the wards and out-

patients during the year, and the report includes alsoreprints of four papers published by Dr. S. RoodhouseGloyne and his assistants. The chief one is a usefulreview by Dr. Gloyne of the clinical pathology andbacteriology of fluids obtained by tapping the pleura.With Dr. J. R. Simpson he has also attempted, andfailed, to produce tuberculous meningitis in rabbits.It is curious that generalised infections produced byintravenous injections in these animals hardly everinvolve the meninges, and it is suggested that this isso because the bacilli do not lodge in the cerebralvessels; tuberculous meningitis is perhaps alwayspreceded by lesions in the choroid plexuses. Lesserpapers deal with the viability of tubercle bacillusat freezing temperature and with the relationshipbetween syphilis and tuberculosis which seems to bevery small. The whole report indicates a livelyresponse to the help given by the Prudential Companyand augurs well for the extension and expansion ofactivity which future years will doubtless show.

LUNATICS AS A PUBLIC DANGER.

Lord Alness, the Lord Justice-Clerk, has beencommenting in the Glasgow High Court upon thedanger to the community from the freedom allowedto persons of unstable mind. In the case towhich our Scottish correspondent draws attentionon p. 525 a man had been proved to be ofunsound mind and unfit to plead. He was alsodescribed in the evidence as being in the same mentalcondition when released some time earlier from amental institution. While thus at large he hadshot a young woman dead and had attempted toshoot a man. The Lord Justice-Clerk, while refrain-ing from attributing blame to individuals, suggestedthat the general position was disquieting and thatthe authorities should inquire whether some machinerycould not be devised to prevent the recurrence ofsuch deplorable incidents. Similar comments mightat any time be made in England where full investiga-tion has been officially made without any attempt togive effect to the resultant conclusions. RoyalCommissions may make recommendations but, untilsome prominent personage is killed by a lunatic, itmay be difficult to translate those recommendations

509PREVENTING DIPHTHERIA IN NEW YORK.

into law. More than one judge has warned the publicin England’of the consequence of exposing membersof the medical profession to the risk of huge andcapricious awards of damages for alleged negligence.When a jury gives a verdict of this nature, medicalpractitioners are scarcely encouraged to sign thecertificates which are the statutory preliminary to amagisterial order for the detention of a lunatic in asuitable institution for treatment.There is an allied question whether issues involving

an exact estimate of medical skill are best deter-mined by juries consisting entirely of laymen. Inthis connexion a correspondent in the daily press haslately been giving an interesting illustration. Hedescribes his experiences as foreman of a jury at atrial at the Old Bailey in a case involving charges offraudulent income-tax returns. The nature of theissues involved frequent references to columns ofstatistics and complicated figures and calculations.A woman member of the jury said to him at onepoint, "I do not know what they are all talkingabout : this is not a case that women should beasked to try, do you think ? " So frank a con-

fession by a layman faced with technical issues issignificant. The correspondent remarks upon theincongruity of expecting persons who have had nofinancial training to adjudicate upon facts in whichcomplicated figures form the material. How is itany more reasonable to expect 12 laymen to adjudi-cate upon complicated issues of medical diagnosisand treatment ?

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THE TASTE OF CHLORINATED WATER.

IT is well known that although one part of freehalogen in a million of water will render drinkingwater sterile, yet the taste produced is offensive tomost people. As this taste resembles that of iodoformand is not like that which would be produced by freechlorine itself, its investigation is a matter of con-siderable interest, both on theoretical and practicalgrounds. In the Medical Officer of August 17th Mr.B. A. Adams describes some work done by him whichseems to show conclusively that the taste is to beattributed to the action of chlorine on salicylic acidor some of its derivatives extracted from the leaves ortwigs of certain willows and waterside plants, such asthe meadow-sweet (Spirea ulmaria). Mr. Adamspoints out that although it is usual to attribute thedevelopment of taste to phenolic bodies, it appearsthat only those which are associated with coal-tarproducts will produce the taste, and in some casesthese have been shown not to be present. The phenolsfound in vegetable and animal substances do notappear to yield the taste, but natural salicylic acid(which cannot be suspected of containing even tracesof phenol) will give a faint taste when present to theextent of only one part in a hundred millions of waterif treated with 0’25 part of chlorine, as will sodiumsalicylate, phenyl salicylate, salicylaldehyde, andsalicyl alcohol. On the other hand, salicin, methylsalicylate, acetyl salicylic acid and coumarin do notgive the taste in any concentration examined. Assalicin, which is an easily hydrolysed glucoside, occursin large quantities, together with its appropriatehydrolytic enzyme, in many willows and poplars aswell as in meadow-sweet, all of which are, along withother salicyl compounds, typical waterside plants,Adams experimented with this and with other naturalsalicyl compounds. He found that infusions ofwillows (Salix fragilis and alba), poplars (Populustremula, candescens. alba, nigra, deltoida, ital1ca), andmeadow-sweet are all capable of producing an iodoformtaste on chlorination, whilst the sallows do notinvariably give the taste, and a large variety of othertrees do not do so. The taste tends to be prevalent inautumn when there is a great fall of leaves and smalltwigs into the water, by which willows and meadow-sweet grow. It is easy, therefore, to see that an appre-ciable amount of salicyl compounds may thus passinto solution, and when the water, which is likely atthis time to need chlorination more than at any other

time, is so treated the taste is developed. A remark-able point brought to light in this research is the non-formation of taste when ammonium salicylate ischlorinated, a fact which throws some light on the useof ammonia in removing the taste from chlorinatedwater. Direct proof of the presence of salicylic acidor its derivatives in the water of any river or othernatural water would be very difficult. The Americanworkers who investigated the organic matter of lakesfound it necessary to evaporate hundreds or thousandsof litres of water in order to obtain enough to examine.Besides this it by no means follows that evaporationwill leave all the organic matter behind. We feel,however, that Mr. Adams has sufficiently maintainedhis thesis, more especially as his experiments weremade with well water, which may be considered asoriginally free from either salicyl compounds or theirchloro-derivatives.

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INSTITUTES OF RADIOLOGY.

THE twelfth volume of the series called " Methodsand Problems of Medical Education," issued by theRockefeller Foundation, is concerned with rontgeno-logy and radiation work in general. Beautifullyprinted and lavishly illustrated it describes 39installations in different parts of the world, five ofthem in Britain-Edinburgh, Liverpool, Manchester,Cancer Hospital, and Guy’s. Despite the general titlethis volume will be of less interest to teachers than tothose engaged in the therapeutic and diagnosticapplications of radiations. For these it will be par-ticularly useful, because the technical details of thearrangements are really important, and not, as is oftenthe case, matters of preference or prejudice. Especiallyinformative is Dr. A. E. Barclay’s description of theX ray department which he organised at the RoyalInfirmary in Manchester, for he gives careful anddetailed lists of the equipment and personnel, withtheir cost, which are needed for hospitals of differentsizes and varying characters, and discusses many ofthe problems of construction and arrangement withmuch informative detail. The account of the FinsenInstitute in Copenhagen is also conspicuous and givesus a pleasing photograph of Finsen’s statue in thegrounds. Careful study of books such as this should dosomething to correct the parochial experience whichour in-bred hospitals too often show.I

PREVENTING DIPHTHERIA IN NEW YORK.

IT is now on record that in certain districts inAmerica diphtheria has been almost entirely eliminatedas a result of immunising all children with toxin-antitoxin. In Auburn, for example, the death-ratefrom diphtheria has been reduced from 38-4 to zero,while New York State, which began a campaignthree years ago, has a mortality and morbidity rateconsiderably lower than New York City. On anotherpage we comment on a collection of studies from thelaboratories of the health department of New YorkCity which show the overwhelming evidence nowavailable of the value of therapeutic immunisation.These considerations, coupled with the fact that in NewYork City there were last year over 10,000 cases ofdiphtheria with 642 deaths, led to the formation of a" Diphtheria Prevention Commission," under thepresidency of Mr. Thomas W. Lamont, whichlaunched a campaign early this year. The methodsemployed in this campaign and some of the earlyresults are recorded in a handbook, entitled " How toProtect your Children from Diphtheria," which hasbeen prepared under the supervision of Dr. ShirleyW. Wynne, commissioner of health for the City ofNew York, and edited by Mr. E. Fisher Brown. Mr.Lamont gave an address to the editors of the variouscity newspapers at the Harvard Club in January,and leading articles appeared in the more importantjournals during the following week indicating thescope of the campaign. Some of these are reproducedin the handbook. The Health Department wroteto 11,345 practising physicians asking them to