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The following names will be recognised withpleasure in the list, as their owners in differentcapacities have worked in relation to medicine inone aspect or another.

Sir Gregory Foster, late Provost of UniversityCollege, London, has been created a baronet.Mr. L. L. Cohen, hon. sec. to King Edward’s HospitalFund for London, receives the K.C.V.O. MissGertrude Tuckwell, a member of the Women’s CentralCommittee on Women’s Training and Employment,receives the C.H. Major-General William SamuelAnthony, C.M.G., Director-General, Army VeterinaryServices, is created C.B. Prof. J. S. S. Brain, professor ofchemistry at the R.N. College, Greenwich, receivesthe C.B.E., and Mr. E. S. Russell, D.Sc., of theMinistry of Agriculture and Fisheries, receives theO.B.E. The M.B.E. has been conferred uponMiss Elsie Hughes, secretary to Lord Dawson ofPenn, for services rendered during His Majesty’srecent illness, and the same distinction has beenconferred upon Mr. D. H. J. Nicholas, in charge of theGovernment House Dispensary, Madras.The O.B.E. (Civil Division) has been conferred upon,

Miss Helen Grace Palin, principal matron, Ministryof Pensions Nursing Service, and Miss Lily Richards,matron, Royal Westminster Ophthalmic Hospital,while Miss Ethel Harrison, superintendent of theNorthrup McMillan Nurses’ Institute, Kenya Colonyreceives the M.B.E.The following names among the nursing profession

are included :-

Royal Red Cross lst Class.-Superintending Sister NitaCourtice.

Superintending Sister Marguerite M. Abraham.Royal Red Cross 2nd Class.- Nursing Sister Leonora C.

Hooper.Nursing Sister Alice M. Shrewsbury.

THE CHANGES IN THE HOSPITAL SYSTEM.

JANUARY will be an important month in relationto the arrangements, often difficult and complicated,for the taking over, under the new Local GovernmentAct, by county councils and the town councils ofcounty boroughs, of institutions hitherto belongingto poor-law authorities. In self-contained areas theoperation will be simple enough ; the complicationscome in when the areas of these institutions are notwholly comprised within one county or countyborough. When this happens the councils affected,which may be more than two, will have to come toan agreement. A fair number of such agreementshave been reached, but many are still outstanding,and the sands are running out. If these adjustmentsare not made by the end of the present month theywill be made by the Minister of Health, whose Ordermight conceivably take a form not altogether pleasingto one or other of the authorities concerned. TheMinistry of Health has laid stress upon the obviousdesirability and convenience of the ownership oftransferred institutions being vested in one council,and it is here that friction seems most likely to arise.Happily, goodwill appears to be in the ascendant, andwe may therefore hope that troublesome details willget themselves settled without an aftermath of localjealousy.Good progress appears to have been made in the

constitution of the Public Assistance Committee uponwhich so much hard work will fall. In a number ofinstances, however, councils have taken the view,which they are perfectly entitled to take, and actupon, that only elected representatives of the rate-payers ought to serve on these bodies. Neverthelessthis view will probably be found, by experience, tobe short-sighted. By no means every elected coun-cillor has been a guardian, and intimate knowledgeof poor-law work on the part of those who will infuture have to administer it is surely essential.Education committees are almost invariably" stiffened " by the coöperation of experts, and thepower to coopt is one of the most useful of the liberties I’accorded by the Act. Some complaints are also made I

of the insufficient representation of women on thecommittees. Women long ago became expertguardians, and there would seem to be wide scope fortheir help, also on the hospital side of public assistance.Upon certain subcommittees they are bound to beplaced, but it is desirable that they should have avoice in that shaping of general policy which will bethe work of the main body. It is hardly to beexpected that a great new system, some of the impli-cations of which are as yet obscure, should " shakedown " at once. Experience, especially in thevitally important matter of cooperation between thepublic assistance hospitals and the voluntaryhospitals, will be gained gradually, but meanwhile,so far as a general survey of the field is possible atthis juncture, there appears to be an entire absence onthe part of the county and town councils of any desireto interfere with the control of the voluntaryhospitals.The latter are, indeed, in so strong a position that

there seems to be little ground for the fears that havesometimes been expressed, that they might beswallowed up. The simple fact that they are entitledto be consulted upon developments proposed by thecouncils, but are not called upon to consult thecouncils upon their own development, should bean almost complete safeguard. It is to be hoped,however, that there will be no mere standing upondignity, no insistence upon the letter of the law inthis highly important matter. The whole future ofthe new hospital system will depend upon constantgood understanding and systematic well lubricatedcooperation between the voluntary hospitals and thoseadministered by public authorities. Not otherwisewill it be possible to derive the fullest advantagefrom a change which aims at coordination and inter-change, although not at technical fusion. Anygeneral lack of understanding would have deplorableresults, not the least deplorable of which wouldinevitably be a large degree of that bureaucraticinterference which would be the worst of menacesto the voluntary system.

POSTURE IN HEALTH AND DISEASE.SOME of the principles which govern the actions

of the joints and muscular systems of the body wereexpounded by Miss M. Forrester-Brown in an addressdelivered to the London Association of the MedicalWomen’s Federation on Dec. 16th. She held thatthese were not well understood either by generalpractitioners or by medical gymnasts. It was notgenerally realised that the normal spinal column isnot equally mobile in all its joints. X rays show thatextensor movements occur chiefly in the lumbar andcervical regions, and that there is a fixed kyphos inthe thoracic region with its maximum at the seventhvertebra. Back-bending exercises, she said, increaserather than reduce this kyphos, and only underpathological conditions or in acrobats can it bereduced to lordosis. Other useful observations made bythe lecturer are the following: The number and shapeof the vertebrae exhibit considerable variation withinnormal limits. In the lumbar region four vertebrae maybe present in an individual of stocky build, and five deepvertebrae are commonly found in slender, long-backed subjects, who tend to become visceroptoticand are always unsuited to heavy physical work.Ill-health may often be prevented by the choice ofwork to which the individual’s physical type is bestadapted. Muscles are more important than ligamentsin affording support to joints. The tone of musclesdepends on an intact reflex arc, and is diminishedby fatigue in the central nervous system, and not byfatigue in individual or groups of muscles.The effects of emotion on posture are illustrated by

the typical attitudes assigned to fear, deceit, courage,and triumph, and, according to Miss Forrester-Brown,the effects on a child’s temperament of treating faultsin posture are often striking. The slouching childis often a sulky child. When judicious use of a longmirror makes the child realise the unsightliness of

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her posture, he or she can often be stimulated totake an interest in the treatment ; it is when thepatient cooperates with enthusiasm that the bestresults can be obtained. The attitude of the spinedepends on the tone of the vertebral and abdominalmuscles and on the tilt of the pelvis. The positionof the head is relatively unimportant in connexionwith good posture, for the reflex motor system is atpeace provided the eyes are horizontal. That thiseffect can easily be achieved with a faultily held spineis evident in many tuberculous lesions of the spinewhere gross deformities are present. Good posturedepends chiefly on good balance, and in maintainingthis the spinal and abdominal muscles are of equalimportance ; factors such as warm air, tonsillarinfection, and chronic constipation, which lower theirtone, are responsible for bad posture in many children.The child living in a civilised community certainlysuffers in several ways by being deprived of thestimulus of cold air and sunshine on the body, andthe provision of these stimuli is an important factorin treatment.The treatment of faulty postures, said Miss Forrester-

Brown, are rest, fresh air, massage, and exercises,with correct breathing as an important adjunct.Mobility rather than depth of chest should be aimedat; the well-developed puffed out chest is not theideal inspiratory position. When inspiration is carriedout with both arms raised the muscles attaching thearms to the chest wall are shortened, the play of theribs inhibited, and movements of the diaphragmdiminished. Since diaphragmatic respiration repre-sents a larger volume of air than thoracic respiration,so-called " abdominal breathing " should be taughtto children in the recumbent position, and theshoulder-shrugging and leg-bending exercises shouldalso be done in this attitude. The value of recumbencyto the growing child is not nowadays generally appre-ciated. The Victorian principle of resting on a back-board was,in Miss Forrester-Brown’s view, a sound one,and the teaching of deportment should be advocated.The country dancing now popular makes for a senseof rhythm, but does not inculcate balance, controlof movements, and grace, as did training in the oldcourt dances. Faulty sitting postures are commonin school-children, and result in crowding of the ribsand sagging of the abdomen. Sitting in a straight-backed chair causes less fatigue if a small pillow is

placed in the small of the back to support the naturallumbar lordosis. Such a pillow should be used alsoduring operations in the Trendelenburg position. Its

support of the sacro-iliac joint should prevent thepost-operative pain in the leg which is caused bypressure on the nerves as they pass through theforamina.

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CAUSES OF BALDNESS.

THE problem of common baldness is still more Ior less unsolved, and in its treatment we havemade scarcely any progress of importance since ’Cnnaattributed the condition to infection by the organismsof seborrhcea. This explanation is evidently not thewhole story ; protracted and conscientious applicationof sulphur, which remains our most potent remedy forseborrhoea, is rarely successful in promoting a cure,although it is of undoubted value if begun early inlife when excess of scurf is first noticed. In a recentpost-graduate lecturel in Vienna, R. 0. Stein pointedout that seborrhoea is common in African natives,and yet the bald man is seldom seen among them.Clearly there are other factors at work besidesinfection, and no one can fail to be struck by the closeassociation of the state of the hair and the state ofendocrine metabolism. In his first Lettsomian lecturelast year Dr. H. W. Barber 2 said that " virility tendsto loss of hair on the scalp with its increased luxurianceon the beard and body; feminism to a converse

distribution." Sabouraud states that eunuchs are

seldom if ever affected by the male type of baldness,1 Wien. klin. Woch., Nov. 21st, 1929, p. 1510.

2 THE LANCET, 1929, ii., 369.

and women, of course, show a similar immunity,which can be disturbed by endocrine disease. Dr.Barber mentioned a case in which a woman with asuprarenal tumour grew a beard and moustache, andwent bald like a man. When the tumour was removedthe hair on the face fell off, and the scalp regained itscovering, but the signs of virility again returned withrecurrence of the tumour. It is, perhaps, somethingof an anti-climax to recall that popular belief attributesbaldness to the wearing of a tight hat-a view whichis shared to some extent by dermatologists. W. A.Pusey3 has lately remarked that " in the commonoccurrence of baldness we have a manifestation of atransitional stage in man’s evolution..... Man nowuses a hat instead of relying upon a shock of hair ashis ancestors did..... This does not mean that we cansave our hair by discarding our hat,s. We are aresult of our ancestors. and to save our hair we shouldhave to discard the hats of all our ancestors for scoresof generations back." There is a certain amount to besaid for this " vestigial " aetiology of baldness, but ithas to reckon with a persistence of the axillary andpubic hair, which has survived in spite of all ourclothing. Every theory yet devised has its weakspots, and at present it looks as though alopeciapresenilis would long continue to embarrass theprofession and enrich the advertising quack.

RUMINATION IN MAN.

Three hundred years ago Jerome Fabricius ofAquapendenta recorded the case of a young man whobegan to ruminate through worry because his father’sforehead had’ suddenly sprouted horns-a state ofaffairs calculated to disturb even the least filial. Dr.Charles-Francis Long, who quoted this story beforethe College of Physicians of Philadelphia, has collected 4six cases exhibiting th e phenomenon of rumination, andhas investigated some of them radiographically, witha view to determining the mechanism of the act.Three out of the six subjects were Russian Jews, andall were of the fidgetty and neurasthenic type. Onlyone appears to have appreciated the commercial valueof his condition, and he was an Egyptian who publiclyperformed prodigies of swallowing and regurgitation,finishing regularly with half a pint of kerosine, whichwas expelled in jets over a lighted candle, and produceda series of spurts of flame. Most ruminants, Dr. Longdiscovered, were hasty and large eaters, and were atgreat pains to conceal their ruminating faculty fromtheir friends and relations. The food usually returnedto the mouth without effort, 15 to 30 minutesafter the meal, in the state in which it was swallowed,and could be re-masticated ; the process stoppedautomatically as soon as the food began to taste sour.Most of the patients derived considerable pleasurefrom the second mastication, one of them insistingthat it doubled the enjoyment of a good dessert. Inmost cases there was no selective power over the typeof food returned, though the Egyptian actor claimedto have this faculty. The hereditary aspect has beenstressed by other writers, but Dr. Long found evidenceof this only in the family history of the actor. Rumina-tion in the cow, as investigated by Toussaint 50years ago, is, he says, associated with reduction in theintrathoracic pressure, and aspiration of the food outof the passive rumen. In the two cases which Dr.Long examined radiographically no evidence wasfound of an analogous mechanism in human ruminants,except that, as with herbivora, the act was precededimmediately by one of swallowing, which inducedrelaxation of the cardia. In the first case examinedradiographically the stomach showed a functionalhour-glass constriction, and when rumination occurredthe food was squeezed out of the upper pole by ageneral contraction of the muscle wall. In the secondcase, which was that of the actor, the stomach wasenormously distended, and some of the barium passedthrough into the small intestine. The stomach wasapparently emptied both by contraction of the

3 Care of the Skin and Hair, New York, 1929, p. 164.4 Amer. Jour. Med. Sci., December, 1929, p. 814.