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unless it may be that the sausage was infected before the

smoking process had been started.

STANDARD BEER.

THERE can be no doubt that the only effectual way of

dealing with modern subtleties in regard to tampering withfood and drink is to set up standards. Evidence in favour of

this method accrues day by day. For a long time the

adoption of a legal standard for milk was resisted, but inAugust last limits in regard to fat and non-fatty solids werefixed by law and the result has been a very material improve-ment in the quality of the milk-supply. In the same way astandard is required for butter that we may recognise oncefor all what is genuine butter as distinct from wateredbutter. Mr. Hanbury has promised to deal with this matter.Again, the new Beer Bill provides a definite beer standard :(1) it must contain not less than 85 per cent. of malted

barley ; (2) hop substitutes are to be totally prohibited ; and(3) foreign-brewed beer is only to be sold with a declarationto the purchaser that it is "imported" beer. The Excisewill control the sale of such standard beer, so that it may behoped that in future nothing but what is practically pure beerwill reach the consumer. The fact that the Excise autho-rities will examine the beer at the breweries should securethis result, while the same step will render the subsequentwatering of the beer by the retailer easy of detection. The

Bill seems to us to be a healthy compromise between thepure beer party on the one hand and the" substi-tute " party on the other, the latter urging that the absoluteprohibition of substitutes would expose them to severe

competition. Another point is that a small proportion ofsubstitute renders the beer rapidly brilliant. From the

point of view of the public the Bill, we think, is, on the

whole, sound, for should it become law those whose tastesare in favour of beer will have the satisfaction of

knowing that what in future is supplied as beer will bea standard article, in the production of which the Statewill insist upon the use of a satisfactory proportion of itsessential constituent-malt.

REPEATED ECTOPIC PREGNANCY.

REPEATED ectopic pregnancy does not appear to be such arare event as might be supposed. The Scottish Medical and

Surgical Journal for February contains an interesting paperon the subject by Dr. J. A. C. Kynoch. He points out thataccording to Varnier in 177 cases of ectopic pregnancywhich were treated by operation 17 subsequent pregnanciesoccurred, of which four were extra-uterine. Dr. J. HaigFerguson had stated that out of 100 cases of extra-uterinepregnancy both tubes were involved simultaneously or suc-cessively in five. Recurrence may occur in the same tube, asin a case reported by Coe of a three-months foetus and a litho-pasdion representing a pregnancy which had occurred twoyears previously in the same tube. Duhrssen in one case foundincomplete tubal abortion on both sides within an interval of20 months. Dr. Haig Ferguson reported a case in which atubal pregnancy of four months terminated in the formationof a lithopsedion. Four years later this and a three months

ectopic pregnancy in the opposite tube were removed byoperation. Mackenrodt reported the case of a woman, aged32 years, with all the symptoms of ectopic pregnancy on theright side who refused operation. 18 months later there were

symptoms of left tubal pregnancy and the gravid tube wasremoved by operation. In the right tube foetal boneswere found. Edgar published a case in which both tubeswere gravid and ruptured at the seventh and eightweeks respectively. They were successfully removed at

one operation. Dr. Kynoch relates the following case inwhich the diagnosis of the first pregnancy was made only

on clinical grounds. A woman, aged 30 years, was admittedto hospital on Jan. 19th, 1900, with pain in the left iliacregion of one month’s duration. She had been married for 1

years and had had six children. Menstruation, which wasalways regular, had last occurred 10 weeks before admission.Six weeks later there were sudden severe pain and irregularmetrorrhagia. The pain was aggravated on defecation.The left lower quadrant of the abdomen was very tender andin it an ill-defined resistance was felt. The uterus was some-

what fixed and displaced to the right and there was a swell-ing in the left fornix, which under chloroform was found tobe of the size of an orange and appeared to be in the broadligament and close to the uterus. A smaller swelling wasfelt behind the uterus which was regarded as a pro-lapsed ovary and probably the cause of the pain on

defecation. Hsematoma, in the broad ligament from ruptureof a six weeks tubal pregnancy was diagnosed and it wasdecided to allow absorption to take place. After seven

weeks only a slight thickening could be felt in the left

fornix. In the next 18 months menstruation was regular. OnSept. 5th, 1901, the patient was readmitted with pain in theright iliac region of five weeks’ duration. It began a weekafter she had passed her expected period and was followedby continuous hasmorrhagic discharge. Two large pieces ofmembrane were passed a few days after it began. Under

chloroform a fixed, tender swelling was found to the right ofthe uterus. On rectal examination it felt like an inflam-

matory thickening of the utero-sacral ligament, therefore

operation was postponed. Intermittent pain and irregularhaemorrhage occurred, and as the swelling did not diminishit was regarded as tubal gestation. On Oct. 3rd laparotomywas performed. The right tube, which was adherent anddistended to the thickness of the thumb, was removed. It

contained blood-stained fluid and numerous villi. The left

appendages (which were not removed) were adherent andthe upper part of the broad ligament was slightly thickenedo.Dr. Kynoch thinks that a six-weeks ectopic pregnancy

ruptured into the left broad ligament and was absorbed.s -

LIVERPOOL SCHOOL OF TROPICAL MEDICINE.

As already indicated in THE LANCET of March 22nd, p. 858,the annual report of the Liverpool School of Tropical Medi-cine shows that much good work was accomplished during1901. At a public meeting held in Liverpool Town Hall onFeb. 12th in that year, on which occasion Sir William S.

Church, President of the Royal College of Physicians of

London, was the principal speaker, the staff of the schoolsubmitted a scheme for the sanitary improvement ofthe West African settlements and after various negotia-tions the case was submitted to Mr. Chamberlain, the

Colonial Secretary, who proposed that a special commissionconsisting of merchants should proceed to West Africa in

the company of a scientific expert for the purpose of investi-

gating the subject. The sending-out of expeditions to carryon practical research in West Africa has been from the first aleading feature in the work undertaken by the committeeof the school. Two such expeditions were sent in 1899.In 1900 a third expedition was sent to Nigeria and a

fourth, composed of Dr. H. E. Durham and Dr. Walter

Myers, proceeded to Para, in Brazil, for the purpose of

studying yellow fever. Both of these gentlemen contractedthe disease and Dr. Myers unfortunately died, but Dr. Durhamsurvived to continue the work and presented his reportwhich is in course of publication. From June, 1901, to thsend of the year three expeditions, making the fifth, sixth, andseventh, were despatched ; Major Ronald Ross, late I. M. S., andDr. M. Logan Taylor being sent to Freetown, Sierra Leone ;.Dr. J. E. Dutton being sent to Gambia, where he discovereda new parasite which causes a special type of fever ; and.

Dr. C. Balfour Stewart being sent to the Gold Coast. The

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’course of instruction giveri at the school includes lectures.and training in research work at the Thompson YatesLaboratories, University College, Liverpool, and clinical

teaching in the special tropical ward of the Royal SouthernHospital. About 20 students attended the school during theyear, including medical men from Canada, India, East

Africa, Penang, Sierra Leone, Germany, Belgium, and

Sweden. The chairman of the committee of the school isSir Alfred Jones; K: C. M. G.

-

REPORT OF THE MEDICAL OFFICER OF HEALTHOF LIVERPOOL ON THE OUTBREAK OF

SMALL-POX IN LIVERPOOL.

THE report of the medical officer of health of Liverpool(Dr. E. W. Hope), dated March 13th, 1902, with referenceto the outbreak of small-pox in that city, which has

been furnished at the request of the Local Government

Board, contains matter of much interest. Embodied in the

report are tables and diagrams showing the sequenceand history of the importations by sea ; one of the

- diagrams shows how from a single case of small-pox im-

ported on shipboard on Jan. 10th, 1902, the disease was.communicated to 11 other individuals. The total number

-of cases of small-pox (including imported ones) occurringin the city since Dec. 6th, 1901, has been 112. Of these, twopatients died, unvaccinated, and 69 remained under treat-ment on March 13th, 1902. During the first 10 months ofthe year 1901 25 cases of small-pox occurred in Liverpool,.eight of which were imported by sea, and one developedsmall-pox a few days after arrival from a neighbouring town.The city was entirely free from small-pox during the month.of November, 1901, and it may, therefore, be assumed thatthe present outbreak originated subsequently to that month.On Dec. 6th the s.s. Volta arrived, having 11 convalescent.cases on board, five of which were temporarily detained.This was followed on Dec. 12th by the discovery that afireman from the s. s. -Devonian had landed on Nov. 28th and

subsequently had developed small-pox at his home. This

- case was followed bv a second one at the same address onDec. 22nd. On Dec. 19th the s. s. Norseman arrived ; one case-of small-pox was removed from her and three persons who- had been in contact developed small-pox shortly afterwards.- It does not appear that there were any further developments-from these cases. During January, 1902, importations of

small-pox by sea occurred repeatedly and besides these therewas also the case of an emigrant intending to travel to

America who had arrived from Austria via Grimsby on theprevious night; he was rejected by the s.s. Garth Castle.One other case during January calls for special comment and-that is a case of a saloon passenger who arrived on board anAtlantic liner on Jan. 10th. This passenger had been sus-

pected to be suffering from chicken-pox and had been

.carefully isolated by the surgeon. The disease, however,was ultimately regarded as a highly modified case of small-pox. On Feb. 18th a man arrived from London. He had

been one of the crew of the s. s. Ulunda and he was removed

to hospital from a lodging-house suffering from small-pox.He had been in attendance on a case of small-pox whilst onboard the Ulunda but he had not been revaccinated. The

importations of small-pox since Dec. 6th, 1901, either by.sea or by land, number no less than 30 cases. The diagramsshow the consequences of some of these imported cases andthe extension of disease from person to person. The intense

dnfectiousness of small-pox makes it difficult or impossibleto trace the source of infection in the majority of instances.Under the routine practice, whenever a case of small-pox is

notified (often by telephone) the patient is removed at once,to hospital, the house is disinfected throughout, and the<bedding and clothing are removed to the disinfecting stationon the same day ; other necessary precautions are also taken.

A special effort is made to induce other inmates of the housewho may be employed in large works or offices to be

revaccinated. If they refuse an intimation is sent to the

employer that it is advisable for them to remain at home for14 days. The infected house is visited and all contacts arevisited every day for 24 days and every few days after foranother period of 14 days to ascertain if any further sicknesshas occurred. When a case occurs in a house in a court orsimilar insanitary premises the other inmates are removed tothe city hospital for isolation and revaccination. They canusually be persuaded to go. A staff of 20 men is at presentengaged exclusively in the prevention of small-pox. The

difficulties in dealing with small-pox are owing largely todefects in legal powers to insure efficient protection by vac-cination. It is no doubt true that in cases of limited

importation or in cases in which the infected person has

by chance only been in contact with those who havebeen vaccinated it has been possible effectually to isolateinfected persons and by increasing watchfulness to trace

those who have been exposed to infection and to inducethem to submit to revaccination ; and so the outbreak hasterminated, but it is by no means always possible. Everyday reveals the lamentable deficiency of the law in

regard to vaccination. The President of the LocalGovernment Board himself very properly laid down the

importance of revaccinating inmates of an infected house orthose who had been in contact with an infected person.Unfortunately, the law has never contemplated the neces-

sity and consequently people are deprived of the pro-tection which the law should give them. Glaring cases ofthe mischief resulting from the want of this protectivepower are frequent not only from negligence but also fromwilfulness, as when a thoughtless drunken person. a

vagabond, or a tramp departs from an infected lodging-house and the next that is heard of him is that he has

developed small-pox in some other equally low and crowdeddistrict of the city. The report emphasises the necessity forsome official control over the supply of vaccine lymph so asto ensure efficiency of quality. No doubt commercial enter-

prise has to a great extent met the demand for lymph, butwhat is wanted is some efficient guarantee of its quality-aguarantee which nothing short of Government supervisioncan give. No less than 35,000 persons (other than infantsbelow six months of age) have been vaccinated or revacci-nated in Liverpool during the last three months, a resultlargely owing to the highly creditable manner in which thepress, ministers of religion, medical men, and others havestimulated the interest of thinking people on the subject.

PERIL AND PLAY.

A CERTAIN number of the street accidents that take placedaily in a vast and busy city like London may fairly beregarded as unavoidable. By the mere working of the law ofaverages, human beings remaining liable to sudden affectionsand drivers and pedestrians being human beings and horsesalso being subject to fright under certain conditions, suddenaffections and frights may be expected in a certain numberof instances daily among the thousands of horses, drivers,and pedestrians of the London stieets, and when occurringwill often inevitably lead to damage. For the inevitable

nobody is to blame. Unfortunately, the larger proportion ofaccidents resulting in danger to life or limb are not inevit-able. They are generally the result of carelessness whichcarries only one consolation-viz., that it is often the carelessparty who gets the most damage. Even this righteousretribution, however, is only partial and very often the

penalty and the fault are unfairly divided between two

individuals. In one class of accident, when damage befallsa child too young to be responsible for his actions, this

is always the case. These accidents to children are