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impossible to pass a bougie without internalcosophagotomy. A temporary recovery was madeand olives passed, but the patient was unable tocontinue to swallow on account of the pain caused.It was shown by radiography that a false passagehad been made by the cesophagotomy.

"GRADE ’A’ CERTIFIED MILK."

MILK bearing this description is now beingretailed in Manchester, put up in sealed one-pintbottles at a cost of 7d. per pint-that is, 3d. a pint,dearer than the milk usually supplied for domestic

purposes. The milk comes from the farms directin the natural raw condition, accompanied by aGovernment guarantee of purity, and is neither

pasteurised nor sterilised. The cattle must have

passed the tuberculin test, and the buildings andutensils have to be certified by the Ministry ofFood as conforming to their required exactingstandards of cleanliness. To safeguard the publicagainst the substitution of old milk the date onwhich the milk was bottled and sealed at the farmis stamped on the outer label. The milk appears tobe bought chiefly by those who have charge of

young children, and it would be an interestingexperiment, in view of the approaching hot weather,to subsidise some of the poorer families attendingwelfare centres to enable them to use this milk, inthe attempt to estimate the extent to which cleanmilk would prevent summer diarrhoea in infants.

NORMAL HORSE SERUM IN SEPSIS.

IN the Journal of the Royal Army Medical Corpsfor April Dr. E. Emrys-Roberts gives an account ofthe use of normal horse serum inoculation in thetreatment of sepsis in war wounds. Two classes ofcase are recorded by Dr. Emrys-Roberts: one a

group of three cases of acutely spreading gasgangrene at a casualty clearing station, the other agroup of 14 cases of serious wounds, with swingingtemperatures, undergoing treatment at the QueenMary’s Military Hospital, Whalley, Lancashire.Neither septicaemia nor secondary haemorrhage washeld to be a contra-indication, but cases with

"pocketing" or sequestrum formation were

excluded as ar as possible. In all the cases

recorded encouraging results were obtained, withreduction of temperature, disappearance of sloughfrom wounds, and ultimate recovery. Normalhorse serum has, of course, been used in the treat-ment of various acute and chronic infective diseasesfor a number of years. It has also been used for

hæmoptysis, haemophilia and secondary heamor-rhage. In most cases the doses employed have beensmall-e.g., 5-10 c.cm. Dr. Emrys-Roberts, how-ever, used massive doses, beginning with 50 c.cm.and increasing up to 150 c.cm. The questionof dosage, therefore, may be a matter of

importance, and may partially explain why Dr.Emrys-Roberts’s cases did so much better thancases previously reported in civilian practice. Weare inclined to think, also, that some allowancemust be made for the character of the cases-theyoung healthy adult in excellent physical conditionis probably a better subject from the point of viewof resistance to sepsis than the weakly town-dwelling civilian of ordinary hospital practice.But in any case the results are so exceptionallygood that we hope extended trial of the methodwill be made ; and that, furthermore, care will betaken in the choice of suitable cases. New methods

of treatment are often unjustifiably condemnedbecause they will not cure everything from migraineto carcinoma. With regard to the interpretation ofthe good results which he obtained, Dr. Emrys-Roberts is inclined to seek an explanation in thecomplement-content of the normal horse serum.

Possibly this question might be cleared up by theuse of decomplementised serum. If increased com-

plement-content is in some way at the bottom ofthis treatment, then, as Dr. Emrys-Roberts pointsout, questions of leucocytic activity, cellularreaction, and antibody formation will have to beexplored to this end. It is interesting to note thatinoculations of peptone, bacterial protein (i.e.,vaccines), and numerous other non-specific proteinsubstances, appear to possess the power of reducingpyrexia in certain cases of chronic infectivediseases, such as tuberculosis and chronic sepsis.Here is a difficult though fascinating field of research.Numerous cognate questions in serological andbacterial therapeutics seem to suggest that we arepossibly on the verge of interesting new light onthe old question of the relation of metabolism totemperature and antibody production.

THE SPAS OF SPAIN.

WE have received from a correspondent somenotes about the spas of Spain, which are regret-ably little known in the British Isles. The mineralwaters of Spain are of great number and variety,rich in medicinal properties, and are much favouredby Spaniards themselves. Some of the more

accessible of these health resorts are likely in thenear future to be visited by those tourists who usedto frequent German and Austrian spas.To many accustomed to the extraneous luxuries and

amusements of spa life in other countries, Spanishhealth resorts may appear somewhat dull. The hotelsoften supply but little beyond the essential services ofboard and lodging. A band is by no means a matter ofcourse, even in a fairly large establishment. The spasare private properties, licensed by the State only aftera thorough investigation and analysis of the medicinalproperties of the water in the springs. Many of themare run by a limited liability company and are

advertised extensively. The advertisements do not erron the side of moderation; some spas appear to be6 1 cure-alls," and among the "indications" given forthe waters, no organ of the body or vague symptom ofdisease is left out. There are no municipal spas.Unlike the watering-places in other countries, no onecan take the waters without consulting the officialdoctor of the establishment, who is a member of theAssociation of Mineral Water Doctors and holds hisappointment as a specialist.

There are over 200 spas in Spain, scattered broadcastthroughout the peninsula. Some of these resorts are ofthe most primitive character. In general, however,the arrangements are sufficiently convenient for

ordinary people who desire to take their cure

seriously and are content to lead a simple life andenjoy a delightful climate among a friendly and politepeople. The difficulties for travellers in Spain are

mainly those of the railways, but in certain parts thesehave greatly improved in recent times. In Spain " acure " is a very popular holiday. A few weeks at aninland watering-place compares with an Englishman’strip to the sea. Some of the best known resorts aresituated amid beautiful surroundings, and are withineasy reach of interesting places. As a rule the seasonlasts from the beginning or middle of June to the end ofSeptember. For convenient travelling it would be

necessary to confine the list of places to those withineasy range of San Sebastian and Santander, and auseful variety of waters can be obtained in these .

districts. The following are among the best known,

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and in general the arrangements are on more or lessup-to-date lines.Alzola.-Saline and gaseous, with an appreciable amount

of lithia; suitable in dyspepsia, gout, and rheumatism,situated in beautiful surroundings. Several hotels besidethe establishment with 80 bedrooms. In the Balnearioevery kind of apparatus for hydropathic treatment.

Caldas de Besaya.-Thermal saline, not far from Santander.Approached from San Sebastian. Useful in rheumatism.Cestona.-Thermal saline, sulphated alkaline with a trace

of lithia, used in diseases of liver and digestion, in goutand rheumatism. Fine bath installation, Zander, &c. StationArrona on San Sebastian-Bilbao line.

.FMMcetHti..—Mild ferruginous alkaline waters, useful indebility. On San Sebastian-Madrid line, near Miranda.Lierganes.-" Gypsum waters in chronic catarrh and in

skin diseases. Near Santander from San Sebastian.Molinar de Carranzas.-Saline and gaseous, radio-active,

indicated in rheumatic affections. Not far from Bilbao, onthe line to Santander.Ontaneda.-Thermal sulphur waters, similar to those of

Harrogate; near Santander, on Bilbao-Santander line.Sobron Y Sorportilla.-Alkaline waters, indicated in

rheumatism and dyspeptic troubles. Situated on the Ebro,near Miranda.Solares.-Alkaline water, situated in beautiful scenery

and within easy distance of interesting ’places. NearSantander.Zaldiva.-Strong sulphur waters. A quiet little spa,

situated in a small park near Bilbao. Good bath installation;on San Sebastian-Bilbao line.

The above resorts are all easily approached fromSan Sebastian and form samples of Spanish spas ;pamphlets, with fuller details of their attractions,can be had from their respective directors. It isto be hoped that continental travel will soonbecome less complicated by passport formalities,as the interchange of visits between the people ofneighbouring countries is more likely to cementnational friendship than formal visits by theirrulers. The insular attitude of the British waspassing peacefully away, under the influence of

cheap tours abroad, when in 1914 the whole ofcontinental society was turned upside down andinside out by the war. That attitude should notreturn, but it will remain alive until habitualcontinental travel can be re-established among themiddle classes. The present generation will hardlycare to fraternise with the German-speaking people,but Spain is such an old enemy as to have beenfor many years a valued friend.

TUBERCULOSIS IN A REMOTE COMMUNITY.

IN the current number of Titberele Dr. E. Björn-Hansen records a series of observations on theincidence of tuberculosis in a Norwegian mountainvillage in which no death from tubercle has beenknown. There is no road to the village, and themother-parish is 14 miles distant. The folk arefarmers, and number 53; the children go to thevillage school and are thus isolated from the outerworld till they are prepared for confirmation in themother-parish, apparently at the age of 15. It isthus not surprising to find that all the 17 childrenunder that age were tubercle-free, as indicated by anegative von Pirquet reaction. Among personsfrom 16 to 25, 40 per cent. showed a positivereaction and, as might be expected, advancing agesrevealed an increasing percentage of positiveresults, but there is again a fall at ages above 45,doubtless due to the fact that even in the mother-parish there was hardly a case of tuberculosisbefore the late "seventies" and that the wholedistrict was then still more isolated than now. Ofactual clinical tuberculosis 3 cases are noted. First,a consumptive labourer lived on one of the farms18 or 20 years ago for 3 years, and in this anda neighbouring farm which he frequently visited

all the adults, but none of the children, gavepositive reactions. The second case is that of a

young man who suffers from benign tubercle ofthe lungs contracted while at work elsewhere andonly recently returned, while the third case is oneof non-suppurating disease of the glands. Dr.Bjorn-Hansen considers that all cases giving apositive reaction are derived from contact with thefirst of these three cases, or are newcomers, or arethose who work much elsewhere, and he attributesthe fact that tuberculosis has not been morevirulent in this virgin soil to " the small quantityof infectious matter, the rare opportunity of re-

infection, or the healthy life on these mountainfarms." It should be added that the veterinarysurgeon knows of no tuberculosis among the cattle,but no tuberculin tests have been applied.

THE SYSTEMATIC CONSERVATION OF MUTILATEDFINGERS.

IN the Gazette des Hôpitaux of April 27th M. PaulBonnet has called attention to the importance ofsystematic conservation of mutilated fingers thefunction of which is definitely lost, with a view totheir use in plastic operations. During the war thepremature or unexpected explosion of hand grenadesrendered us familiar with such lesions. The treat-ment found necessary for conserving as muchfunction as possible furnishes details of techniquewhich may be useful in industrial accidents.M. Bonnet insists on the need of being as

parsimonious as possible with regard to removalof skin and of delaying amputations which mayappear necessary at first because the use of fingersseems to be irremediably lost. The skin of fingerswhich it is decided to sacrifice may afterwardsprove useful in plastic operations necessary for lossof substance of the palm. M. Bonnet reports thefollowing example.A shoemaker, aged 43 years, was wounded by frag-

ments of a grenade on August 27th, 1916, and broughtto a field hospital four hours later. In addition to otherwounds, there was a large irregular wound of the leftpalm extending slightly on the dorsum of the hand. Thesuperficial palmar vessels were torn, and the tendonsof the middle and ring fingers were divided. The ringfinger was torn off from the middle of the first phalanx.The third phalanx of the middle finger°with its integu-ment was blown away, and the base of the finger wasinvolved in the palmar wound. The first phalanx wasfractured, and the flexor tendons were divided, but thefinger was still attached to the hand by the skinof its dorsum. The superficial palmar arch and twocollateral vessels were wounded and were ligatured.Dead tissue was removed from the margins of thewound. The function of the middle finger was irreme-diably lost because the- first phalanx was the seat ofcomminuted fracture and the flexor tendons were

divided, but sufficient integument remained for thenutrition of the finger. The wound was cleansed withDakin’s fluid, and then carbolic solution was appliedand a dressing impregnated with iodised alcohol. OnSept. 14th the aspect of the wound seemed to befavourable for a plastic operation. The wound waspainted with tincture of iodine and freshened overits whole surface by curetting exuberant granulations.The margins, which showed a few points of sloughing,were freshened with a bistoury and in places under-mined so as to allow the skin to be drawn over thewound, which was too large to be covered by the digitalflap alone. The middle finger was divided longitudinallyon its palmar surface, and then boned and freed from its tendons, the skin only being preserved. This con-stituted a large flap, connected to the dorsum of the

’

hand by a pedicle 3 em. broad. It was decided to :

preserve the stumps of the first phalanges of the middle ;