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152 patients suffering from pulmonary tuberculosis. The disease in the lungs seems to progress rapidly if arsenobenzol is administered, but bismuth seems to have no deleterious effects and is not contra-indicated in these cases. Poor Results.—Cases occur in which bismuth seems to have little or no therapeutic action. Seven cases of recurrence after bismuth are reported by Simon and Bralez,47 who consider that at least 2 g. of bismuth should be given to prevent relapse, although in one of their cases the disease recurred within a month of receiving 9.5 g. of bismuth. Lortat-Jacob reported a case of secondary syphilis which developed a mucous plaque full of S. pallida after receiving seven injections of bismuth, totalling 1’12 g. of metallic bismuth, but recovered with mercury inunctions. Burke’s 28 opinion is that mercury has become obsolete in the treatment of syphilis, and that bismuth falls little short of arsenobenzol in its effect upon superficial and visceral manifestations, and upon the serological reactions of the blood and cerebro-spinal fluid. - ’I.ilian 48 expresses the relative therapeutic values of the antisyphilitic drugs as follows : arsenobenzol 10, bismuth 7, and mercury 4. Personally I have no evidence for such a high curative figure for bismuth and consider bismuth and mercury more nearly equal, mercury possibly being as effective as bismuth—if not more effective when skilfully administered. Bismuth. however, though possibly not so powerful as mercury, is more convenient to use. (In the concluding portion of this article, which will appear later, Dr. Anwyl-Davies deals with intolerance to bismuth, itidic-tt,ioiis for its prefer- ence to mercury, and concludes with references to current literature.) SCOTLAND. (EROM OUR OWN CORRESPONDENT.) Unrest amonyg Poor-law Authorities. THERE are many signs of unrest among the parish councils as the result of Lord (’onstable’s decision that emergency relief paid to miners’ dependents during the strike was illegal. In one area the parish council has received a number of refusals to pay the rate involved. and resolutions have been passed suggesting that the Government should refund to the parish councils the amounts illegally incurred on the central initiati ve- all this notwithstanding the announcement that the position will be dealt with by legislation. In some areas the parish rates have risen to a point where recovery may be difficult or impossible, and the stop- page has undoubtedly raised some very difficult questions of local government finance. The parallel conditions in England are equally difficult, although the law is different in some essential points. The early part of the Parliamentary session promises some interesting discussions. Scottish Hospitals and the Coal Stoppage. It is now possible to see to what extent the coal stoppage affected two large hospitals-namely, the Edinburgh and Glasgow Royal Infirmaries. In Edinburgh the miners’ contributions showed a falling away to the extent of £4655. In Glasgow the loss amounted to about £6000 and the bill for coal showed a rise of some £5000 ; thus the stoppage directly cost Glasgow Royal Infirmary £11,000, and doubtless other hospitals suffered in proportion. In both cities, however, the general financial position of the Royal Infirmaries is satisfactory. In Edinburgh the League of Subscribers, instituted in 1919, has been very successful in maintaining or even in increasing the contributions. The patients treated in 1926 num- bered 17,024, as against 15,755 in 1925. The daily average remained as before, 905 ; for the average stay in hospital fell from 20-6 days to 19-03. The cost per occupied bed was £143 10s. 9d.. an increase of 22 7s. tjd. own the figure for 1925. Edinburgh Royal Infirmary and the Simpson Memorial. It is announced that the Royal 3Iaternity and Simpson Memorial Hospital is to be amalgamated with the Royal Infirmary. For many years the need for a larger maternity hospital has been dis- cussed, and at first it was proposed that an appeal should be made for a new or extended maternity hospital to work as an independent body. It was all along felt that the great name of Simpson deserved to be perpetuated in this way, and I have no doubt that in the arrangements now in prospect that name will not be forgotten. But the advantages of functional unity were admitted on every hand from the beginning. and when it was clear that the maternity and gynaam logical services of the infirmary must be improved. some working arrangement had to be made if the medical school was not to suffer and if the functions of two rival organisations were not to overlap. Under the able and generous chairmanship of Dr. Goodall Nasmyth, the Simpson Memmial has undergone many improvements ; the new Ballantyne Memorial Ante- natal Department is acknowledged to be a model of its kind and worthy of the life-time of propaganda which its name commemorates. But circumstances have arisen to make the amalgamation of the Royal Infirmary and the Simpson Memorial both desirable and practical. It is likely that a portion of the Watson’s College site will be used for the erection of a modern gynaecological and maternity hospital: this whole department will then be an integral part of the Edinburgh Medical School, and the arrangement is certain to give general satisfaction. IRELAND. (FROM OUR OWN CORRESPO-ND-F,-NT.) ,S’t(ttist,ies of the Irish Free State. THE most notable fact in the 192.5 report of the Registrar-Creneral is the high figure for emigration- :30,302, compared with 19,077 for 1924. As usual the great majority—26,546—of the emigrants went to the United States of America. Marriages numbered 13,820, which is equivalent to a rate of 4-63 per 1000 of the estimated population and is 1002 below the figure for 1924. Births numbered 62,069 (31,818 boys, 30,251 girls), which is equivalent to 20-8 per 1000; the rate in Northern Ireland was 22, in England and Wales 18-3, and in Scotland 21-3. The total number of deaths was 43,650, and the death-rate (14-2 per 1000) was 0-41 below that of 1924 and 1-30 below the average for ten years. The death-rates in other countries were : Northern Ireland, 15.74 ; England and Wales, 12 16 ; and Scotland, 13-39. The death- rate from all forms of tuberculous disease was 1.57 per 1000, as compared with Northern Ireland, 1,67; England and Wales, 1-04 ; and Scotland, 1.10. During the past two years the mortality in the Free State from this cause has been rising. In 1925 the death-rate was highest in Dublin Borough (2’31), Cork City (2-22), and Tipperary S.R. (2-02). The lowest rates were in Roscommon (0-78), Longford (1-13), Mayo and Sligo (1-16). Deaths from cancer numbered 2801, a decrease of 12 as compared with 1924. There was a distinctly upward tendency in the mortality from cancer in the years 1923 and 1924. The number for 1923 gave an increase of 8 per cent. on 1922, and 1924 gave a further increase of 6 per cent. on 1923. The mortality from cancer in An Saorstal during the five years 1921-25 is given as 0-9 per 10CO’ A total of 1171 deaths were registered as due to influenza, compared with 2073 in 1924. Of deattt from all causes, 14-6 per cent. occurred among children under 5 years, 45-7 per cent. amongst persons aged 65 or over, and 37-3 per cent. in persons of 70 or over, The mortality amongst infants under one year was 68 per 1000 births, compared with an average 77 for the ten years 1915-24. In Northern Ireland

IRELAND

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patients suffering from pulmonary tuberculosis. Thedisease in the lungs seems to progress rapidly ifarsenobenzol is administered, but bismuth seems tohave no deleterious effects and is not contra-indicatedin these cases.

Poor Results.—Cases occur in which bismuth seemsto have little or no therapeutic action. Seven casesof recurrence after bismuth are reported by Simon andBralez,47 who consider that at least 2 g. of bismuthshould be given to prevent relapse, although in oneof their cases the disease recurred within a month ofreceiving 9.5 g. of bismuth. Lortat-Jacob reported acase of secondary syphilis which developed a mucousplaque full of S. pallida after receiving seven injectionsof bismuth, totalling 1’12 g. of metallic bismuth, butrecovered with mercury inunctions. Burke’s 28

opinion is that mercury has become obsolete in thetreatment of syphilis, and that bismuth falls littleshort of arsenobenzol in its effect upon superficial andvisceral manifestations, and upon the serologicalreactions of the blood and cerebro-spinal fluid.- ’I.ilian 48 expresses the relative therapeutic values ofthe antisyphilitic drugs as follows : arsenobenzol 10,bismuth 7, and mercury 4. Personally I have noevidence for such a high curative figure for bismuthand consider bismuth and mercury more nearly equal,mercury possibly being as effective as bismuth—ifnot more effective when skilfully administered.Bismuth. however, though possibly not so powerful asmercury, is more convenient to use.

(In the concluding portion of this article, whichwill appear later, Dr. Anwyl-Davies deals withintolerance to bismuth, itidic-tt,ioiis for its prefer-ence to mercury, and concludes with references tocurrent literature.)

SCOTLAND.

(EROM OUR OWN CORRESPONDENT.)

Unrest amonyg Poor-law Authorities.THERE are many signs of unrest among the parish

councils as the result of Lord (’onstable’s decision thatemergency relief paid to miners’ dependents during thestrike was illegal. In one area the parish council hasreceived a number of refusals to pay the rate involved.and resolutions have been passed suggesting that theGovernment should refund to the parish councils theamounts illegally incurred on the central initiati ve-all this notwithstanding the announcement that theposition will be dealt with by legislation. In someareas the parish rates have risen to a point whererecovery may be difficult or impossible, and the stop-page has undoubtedly raised some very difficultquestions of local government finance. The parallelconditions in England are equally difficult, althoughthe law is different in some essential points. The earlypart of the Parliamentary session promises someinteresting discussions.

Scottish Hospitals and the Coal Stoppage.It is now possible to see to what extent the coal

stoppage affected two large hospitals-namely, theEdinburgh and Glasgow Royal Infirmaries. InEdinburgh the miners’ contributions showed a fallingaway to the extent of £4655. In Glasgow the lossamounted to about £6000 and the bill for coal showeda rise of some £5000 ; thus the stoppage directly costGlasgow Royal Infirmary £11,000, and doubtlessother hospitals suffered in proportion. In bothcities, however, the general financial position of theRoyal Infirmaries is satisfactory. In Edinburgh theLeague of Subscribers, instituted in 1919, has beenvery successful in maintaining or even in increasingthe contributions. The patients treated in 1926 num-bered 17,024, as against 15,755 in 1925. The dailyaverage remained as before, 905 ; for the average stayin hospital fell from 20-6 days to 19-03. The cost peroccupied bed was £143 10s. 9d.. an increase of 22 7s. tjd.own the figure for 1925.

Edinburgh Royal Infirmary and the SimpsonMemorial.

It is announced that the Royal 3Iaternity andSimpson Memorial Hospital is to be amalgamatedwith the Royal Infirmary. For many years theneed for a larger maternity hospital has been dis-cussed, and at first it was proposed that an appealshould be made for a new or extended maternityhospital to work as an independent body. It wasall along felt that the great name of Simpson deservedto be perpetuated in this way, and I have no doubt thatin the arrangements now in prospect that name willnot be forgotten. But the advantages of functionalunity were admitted on every hand from the beginning.and when it was clear that the maternity and gynaamlogical services of the infirmary must be improved.some working arrangement had to be made if themedical school was not to suffer and if the functionsof two rival organisations were not to overlap. Underthe able and generous chairmanship of Dr. GoodallNasmyth, the Simpson Memmial has undergone manyimprovements ; the new Ballantyne Memorial Ante-natal Department is acknowledged to be a model ofits kind and worthy of the life-time of propagandawhich its name commemorates. But circumstanceshave arisen to make the amalgamation of the RoyalInfirmary and the Simpson Memorial both desirableand practical. It is likely that a portion of theWatson’s College site will be used for the erectionof a modern gynaecological and maternity hospital:this whole department will then be an integral partof the Edinburgh Medical School, and the arrangementis certain to give general satisfaction.

IRELAND.

(FROM OUR OWN CORRESPO-ND-F,-NT.)

,S’t(ttist,ies of the Irish Free State.THE most notable fact in the 192.5 report of the

Registrar-Creneral is the high figure for emigration-:30,302, compared with 19,077 for 1924. As usual thegreat majority—26,546—of the emigrants went to theUnited States of America. Marriages numbered13,820, which is equivalent to a rate of 4-63 per 1000of the estimated population and is 1002 below thefigure for 1924. Births numbered 62,069 (31,818 boys,30,251 girls), which is equivalent to 20-8 per 1000;the rate in Northern Ireland was 22, in England andWales 18-3, and in Scotland 21-3. The total numberof deaths was 43,650, and the death-rate (14-2 per1000) was 0-41 below that of 1924 and 1-30 below theaverage for ten years. The death-rates in othercountries were : Northern Ireland, 15.74 ; Englandand Wales, 12 16 ; and Scotland, 13-39. The death-rate from all forms of tuberculous disease was 1.57per 1000, as compared with Northern Ireland, 1,67;England and Wales, 1-04 ; and Scotland, 1.10.During the past two years the mortality in the FreeState from this cause has been rising. In 1925 thedeath-rate was highest in Dublin Borough (2’31),Cork City (2-22), and Tipperary S.R. (2-02). Thelowest rates were in Roscommon (0-78), Longford(1-13), Mayo and Sligo (1-16). Deaths from cancernumbered 2801, a decrease of 12 as compared with1924. There was a distinctly upward tendency in themortality from cancer in the years 1923 and 1924.The number for 1923 gave an increase of 8 per cent.on 1922, and 1924 gave a further increase of 6 per cent.on 1923. The mortality from cancer in An Saorstalduring the five years 1921-25 is given as 0-9 per 10CO’A total of 1171 deaths were registered as due toinfluenza, compared with 2073 in 1924. Of deatttfrom all causes, 14-6 per cent. occurred among childrenunder 5 years, 45-7 per cent. amongst persons aged65 or over, and 37-3 per cent. in persons of 70 or over,The mortality amongst infants under one year was68 per 1000 births, compared with an average 77 for the ten years 1915-24. In Northern Ireland

153

the infant mortality was 86 per 1000 births ; in

England and Wales, 75 ; and in Scotland, 91.

Enforcement of Vaccination.The Department of Local Government and Public

Health has been for some time impressing on the healthauthorities of the county and town of Wexford thenecessity for enforcing the Vaccination Acts, but littlelias so far been done. According to recent reportsthere are 2653 vaccination defaulters in the town,or nearly one-quarter of the total population. Inthe county there are some six or seven thousanddefaulters. Despairing of obtaining any result bypersuasion, the Department has at length taken stepsto compel the Wexford Corporation to discharge itsresponsibilities. A conditional order, directed to themayor and the other members of the corporation,has been granted by the High Court. The order directsthe mayor and the other members to enforce theVaccination Acts in this district, and warns themthat unless they do so within ten days of the serviceof the order, application will be made to charge themwith the costs of the court proceedings. As regardsthe county health authority the Minister has notas yet taken any drastic steps. He has, however,directed a letter to be sent to the effect that neglectof vaccination shows a very lamentable want of

public spirit and poor citizenship on the part of theBoard of Health and Public Assistance. He is not

prepared to acquiesce in the disregard of the provisionof the Vaccination Acts. A serious outbreak of

:<mall-pox at present exists in a neighbouring country,which renders suitable precautions all the more

essential. ___ ____

BERLIN.

(FROM OITR. OWN CORRESPONDENT.)

The Campaign against Practice by the Unqualified.BEFOItE a combined meeting of the Berlin Arzte-

Bund and the Society of Berlin Lawyers Dr. Ebermayer, retired director of public prosecutions in ]the Supreme Court of Leipzig, recently read a paper .on the duty of the Government to protect the publicagainst the consequences of unqualified practice and on the legislation at present in force. He stated thatsince the Trades Act of 18(i9 unqualified practice hasspread in a way never anticipated by the authors of ]the Act, amongst whom was the late Prof. Virchow,then a member of the Reichstag. Since the passageof the Act anyone has been allowed to attend patients’provided he does not use the title of Art (doctor) ora similar one. Dr. Ebermayer described as quacksboth the man who attends patients without being dulyqualified, and the man who advertises secret remedies. iThe number of unqualified practitioners rose in ]

Berlin from 28 in 1879 to 1349 in 190:;’, and by 1925there were 5648 unqualified doctors in Prussia alone. :The causes of the increase are (1) the bad tinancial ’condition of the population, which induces patientsto consult unqualified persons because they believetheir advice to be cheaper ; and (2) the prevalence ofmysticism and the systematic campaign againstso-called official medicine carried on by the associa-tions of quacks. Several German Acts. however,contain provisions against unqualified practice ; underthe Workmen’s Insurance Act and the VaccinationAct, for instance, medical practitioners are onlyrecognised as such if they have a qualification.Unqualified persons are also liable to prosecutionunder the Trades Act, the Unfair Competition Act,and the Criminal Code. The provision of the TradesAct that only a qualified medical man may callhimself Arzt is often violated by unqualitied personswho use titles with a similar sound. The UnfairCompetition Act may be brought into force againstanybody who in advertising a secret medicine allegesthat it cures ailments in a quicker and surer mannerthan other remedies. The Criminal Act may applyto an unqualified person who has caused death or

bodily injury by neglect, but prosecution on thischarge seldom leads to punishment as the prosecutormust prove that the defendant has failed to use thecare which could be expected of him in view of histraining. Dr. Ebermayer concluded that as thepresent legislation is unsuitable, unqualified practiceought to be made a criminal offence by a new Act,which should prohibit the attendance of unqualifiedpersons on any patients, except those requiring first-aid. Such a prohibition, he considers, would beneither ineffective nor superfluous, as was alleged inthe debates on the Bill of 1869. If complete prohibi-tion has no chance of being enacted by the presentParliament, the absolute freedom to practise whichis now enjoyed by quacks must at least be restricted.

The Arrangement of Medical Study.The regulations of 1924 concerning the State

medical examination have proved satisfactory neitherto medical students nor to examining boards. At thetime when the new regulations came into force, thetinancial condition of Germany was such that themedical curriculum could not be extended on accountof expense, although the regulations included morebranches of medicine than were formerly recognised.The Home Office has been considering revision ofmedical education and the State examination, andthe medical faculties have been invited to makeproposals. In order to allow students and theprofession in general to give their opinions thepublishers of the Deutsche Medizinische Wochen-schrift have opened a competition for an article onthe best arrangement of medical studies. Thoseentitled to take part in the contest are the sub-scribers to the journal (other than members ofmedical faculties and of examining boards), andmedical students who have already completed theninth or tenth term of their curriculum. The pub-lishers reserve the right to publish the prize essayand to send others to the Home Office for consideration.

Deafness in School-children.Prof. Gustav Briihl, aurist to the Berlin School

Board, recently stated that 72,000 children in Berlinschools suffer from affections of the ear, and that7250 of them are hard of hearing, 10 per cent. of thesebeing almost deaf. The city has only six specialschools where 410 deaf children are educated-anaccommodation obviously far too small. It seems

practically impossible to have all the hundreds ofthousands of Berlin school-children examined byaurists, for not even the regulation that every childwho is hard of hearing shall be shown to the municipalaurist has so far been complied with, many of themunicipal schools not having sent a single child forexamination. It is true that children often concealtheir disability by following with their eyes the lip-movements of their teachers. Prof. Briihl is of opinionthat every child who makes no progress in his workshould be examined by an aurist, since deafness is sooften the cause of inefficiency. Half the deaf childrensuffer from double chronic otorrh&oelig;a. Twenty percent. of them might be cured by adequate treatment,but this is often hindered by the indolence of theparents.

Hospital Accommodation in Berlin.The Berlin municipal hospitals have a total of

13,875 beds, 400 of which have been added duringthe past year. By far the biggest is the VirchowHospital with 2517 beds ; then come the Neukollnwith 1086, the Friedrichshain with 1065, and theWest End with 1030 beds. Of social hospitals thereis the Children’s Hospital with 440 beds, an infants’hospital in Weissensee with 80 beds, a maternityhospital with 270 beds and sanatoria for tuberculouspat.ients in Charlottenburg, Sommerfeld, and Hasen-haise with 350 beds each. With the construction ofnew wards and the purchase of private hospitals thenumber of beds in the municipal hospitals will nextyear be about 15,000. Besides the municipal hospitalsthere is the Charitc Hospital, belonging to the State,and some university clinics having together 2000 beds.