400 THE ETIOLOGY OF RICKETS.-REFUSE TIPS.

Preliminary scrutiny at the recruiting stage may failaltogether to aid the military authorities in the selec-tion of human material likely to withstand strain andstress; but, putting all suspicious cases aside, andmaking every a,llowance for the scepticism of somewho had to deal with poor specimens of humanity in-strenuous times, we must still hold to the genuinenessof the neuroses of war and the realitv of their dis-tinction from simple cowardice ; they made theirappearance in soldiers whose every action till thenhad been above reproach ; they developed in Ithe most unlikely subjects ; in actual numbers theyformed but a very small proportion of the totalcasualties of all the combatant nations.

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Annotations.THE ÆTIOLOGY OF RICKETS.

"No quid nimic3."

DESPITE the considerable number of able investi-gators of all nations who have applied themselvesto the work, few current problems can display suchincomplete and conflicting results as those presentedby the aetiology of rickets. The report which weprint of a discussion on this subject at the BritishMedical Association provides ample evidence of this :there is little common ground to be found amongthe opinions there expressed. Results, definiteenough in themselves, appear to be swamped in asea of hypotheses, from which two facts stand outhigh and dry : first that the absence of an anti-rachitic vitamin is a potent factor ; second, that it isnot the only factor. The most important secondaryfactor appears to be the influence of lack of light.These two factors, vitamin and light together, will,we feel confident, go far towards filling up the blankpages of the aetiology of rickets. Prof. A. Hardeneven suggests that light actually causes the forma-tion of vitamin-A. By a happy coincidence weare able to print in this issue a lecture by Prof.Alfred F. Hess, of New York, the chief protagonistof the light theory, which we commend to our readers’careful attention. An explanation is provided forthe well-known fact that rickets is commoner inthe poorer classes of the gloomy industrial cities,especially in the north, than in the equally underfedchildren of villages not robbed of light by a pall ofsmoke or mist. Dr. Hess and his co-workers are to be-most sincerely congratulated on having carried outa remarkably valuable piece of work in a thoroughway ; and the work will, we think, stand the test offurther- advances. Though we believe that the anti-rachitic vitamin and the effect of light are the chiefpractical essentials to be borne in mind in the com-bating of rickets, it cannot be denied that, underlaboratory conditions, some other factors must beincluded for further consideration and experiment.But here we are met with two difficulties not easilycircumvented. In the first place, it is essentialstrictly to define exactly what rickets is : if we raisean animal with bent legs in consequence of removingcalcium from its diet, clearly we cannot call thatrickets, but a less glaring example might be includedin the rachitic category. This may be the explana-tion of the diet-balance hypothesis ingeniouslyadvanced by Prof. E. Mellanby-we think thatfurther investigation will show a good deal to be saidfor this ; but there remains the question of whatconstitutes an adequate amount of vitamin-A undervarious conditions.

In the second place, judgment needs to be exercisedin applying to the human subject the results of experi-ments on animals. Sheep, pigs, rats, and puppieshave been used and the type of lesion produced andthe factors requisite for their production might differmaterially. Such experiments serve to frame andtest hypotheses which can later be applied to human

infants : the fact that rickets is associated with activegrowth is too often forgotten in animal experiments.With regard to the theory that a specific virus isresponsible for the causation of rickets, we cannotbelieve that such a hypothesis, opposed as it isboth to clinical and to laboratory facts, was mentionedwith any seriousness by the speaker. An importantpoint was raised by Prof. Noel Paton in the discussion,when he challenged the statement that butter wasclassed as of equal value with cod-liver oil. It wouldseem that the vitamin-A is not wholly and solelyan anti-rachitic vitamin-it may be a mixture, thatof cod-liver oil being richer in the anti-rachitic factor,while that of butter is potent in preventing kerato-malacia. The same speaker’s view that the energycontent of the diet is important, is hard to reconcilewith many known facts ; we think that we cannotbe dealing with the same pathological condition asrickets, when mere increase in the caloric value ofthe diet will set things right.

It would seem, therefore, that there is a disharmonyof opinions on the subject because the protagonistsof each opinion tend to regard the problem as capableof one simple explanation, which varies in each case.From a discussion which has developed some heat wemay also expect light to arise. The most reasonableposition is surely that taken up by Dr. Hess, that thereare two chief factors at work in producing rickets, lackof anti-rachitic vitamins and lack of ultra-violet light.The issue is further obscured by the obtrusion of otherfactors which modify the operation of the two mainones, and also, and to a very considerable extent, bylack of unanimity regarding the pathological anatomyof rickets.

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REFUSE TIPS.

THE elementary method of disposal of refuse bydepositing it upon tips is apt to give rise to offence inmany ways. In Manchester a recent report credits itstips with the local prevalence of septic conditions suchas erysipelas. A tip becomes the breeding ground offlies, rats, and other vermin ; the decomposition oforganic matter may cause unpleasant smells. Perhapsthe most serious drawback to this system of refusedisposal arises from the liability of the tips tosmoulder and emit foul-smelling smoke and vapours.Efforts to extinguish tip fires are rarely successful,even when they include attempts to cut off theburning portions by digging trenches which are

subsequentlv filled with earth ; the labour involvedis costly, and is not without danger to those engagedupon the task. Moreover, those responsible forburning tips not infrequently find themselves facedwith the prospect of expensive litigation set up byaggrieved parties. Local authorities should thereforewelcome a series of suggestions submitted to them bythe Ministry of Health in a recent circular. Thecircular does not suggest that the method of refusedisposal by tipping can ever be regarded as a

satisfactory one, but, in the opinion of the Minister,the nuisances associated with tips may be, to someextent, prevented by careful management. Theprecautions recommended are that the refuse shouldbe deposited in shallow layers, each layer beingpromptly covered with earth or other suitable material.The depth of any stratum of refuse should be notgreater than 6 feet, and the covering layer shouldat least be 9 inches in thickness. No refuse shouldbe left uncovered for more than 72 hours from thetime of deposit ; if the material deposited at any onetime consists entirely or mainly of fish, animal, orother refuse, there should be no time allowance, thematerial being covered forthwith by earth or othersuitable substance to a depth of 2 feet. Coveredlayers should be given time to settle before furtherlayers are superimposed. Tipping refuse into wateris likely to give rise to nuisance, and should be avoided.Persons making deposits should take all reasonableprecautions to prevent the breaking out of fires andthe breeding of flies or vermin. To these precautionswe would add an instruction that tins and other

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hollow receptacles should be crushed flat beforebeing deposited, for it has been found that otherwise,there is a tendency for a layer of such containers to.act as air shafts conveying oxygen to the fires ; whileburied tins also function a.s dwellings for rats. The.circular suggests that screens or other apparatusshould be provided to prevent paper or other debrisfrom being blown away by the wind ; this is anecessary precaution, for cases are known in whichthe country for miles around a tip has been litteredwith dirty papers. With a view to avoiding theunsightly mound tip the Minister suggests thatdepositors should avoid raising the surface of the tipabove the level of the adjoining ground. Theprecautions suggested in the circular are eminentlypractical, and it is to be hoped that local authoritieswho practise tipping will carry them out, whether thework is done by their own workmen or by contractors.The extra expense involved will have been wiselyincurred if it results in the prevention of costly firesand other nuisances which at present are all toocommon in connexion with this system of refusedisposal. ---

THE LABORATORIES AND HEPATIC DISEASE.

IN our review columns this week we notice a volumedealing with the work of the late Frantz Glenard.Known throughout the medical world for his descrip-tions of visceroptosis, this physician, during the last20 years of his life, devoted himself to the clinical studyof hepatic disorders. Although relying solely on theordinary methods of clinical observation, Glénard wasable, by tracing the histories of the numerous invalidsvisiting Vichy each year, to acquire an experience inthis group of diseases which few have excelled. It isimpossi,ble definitely to accept or reject opinions formedin such a manner, but all clinicians will read his viewswith respectful interest, and it is a matter for regretthat such an observer was deprived of the aid which-the chemical laboratory now affords to workers inthis field. Some time ago we reported briefly an.address by Sir Humphry Rolleston on the bearing ofrecent physiology on diseases of the liver, in which he,dwelt on the differentiation of jaundice due to dis-ordered function of the liver cells from true obstructivejaundice. Several tests are now being employed bybiochemists in making this distinction, probably themost important being that associated with the name-of Hijmans van den Bergh, of Groningen. In thistest some 5 c.cm. of blood is withdrawn from thepatient and centrifuged, 1 c.cm. of the serum so

obtained being tested by the addition of 1 c.cm. ofEhrlich’s diazo-reagent, which is prepared by mixingequal quantities of (a) sulphanilic acid, 1 c.cm. ; HCl-cone., 15 c.cm. ; distilled water to 1000 c.cm. ; and,(b) sodium nitrite, 0-5 g. ; distilled water, 100 c.cm.A positive response to this test is shown by theimmediate appearance of a bluish-violet reactionwhich reaches its maximum in about 30 seconds, suchan immediate direct reaction indicating a true obstruc-tive jaundice. If, on the other hand, this reaction doesnot appear for some minutes, the delay indicates ahsemo-hepatogenous jaundice probably associated withdisturbed hepatic function. Sometimes, and especiallyin cases of "cardiac liver," there is a biphasic reactionin which a slight reddish colour appears immediatelyand slowly deepens to the violet tint. Cases givingonly the delayed reaction can be better tested by theindirect method ; in this the serum is treated withtwice its bulk of 96 per cent. of alcohol, and centri-fuged ; to 1 c.cm. of the clear liquid are then added0-5 c.cm. of alcohol and 0-25 c.cm. of the reagent ;a violet-red colour appearing immediately indicatesa heemo-hepatogenous jaundice. The mechanism ofthese reactions is still obscure, depending, in theopinion of such workers as van den Bergh and C. M.Jones,3 on alterations in bile-pigment metabolism,

1 THE LANCET, 1922, i., 908.2 H. van den Bergh: Die Gallenfarbstoff im Blute, Leiden,

van Doesburgh, 1918.3 Jones, C. M. : Arch. Int. Med., xxix., 643, 1922.

bilirubin being either free in the serum or looselycombined with albuminoid substances. The tests arebeing employed by Dr. J. W. NcNee and other workersin this country, with results of distinct practical value.Many other tests of hepatic function are coming

into use, the old tests for bile in the urine have beensupplemented by reactions such as Ehrlich’s diazoand aldehyde tests, and other methods chiefly designedfor the detection of urobilin. Again, there are testssuch as the " hsemoconia" test, used by Frenchobservers for demonstrating the presence of fatparticles in the blood serum after a meal ; and inFrance increasing interest is being shown in thehsemoclastic crises5 described by Widal. Apart fromthese, tests are being elaborated for demonstratingthe glycogenic function of the liver, one of these, inwhich the effect of the ingestion of Isevulose on theblood-sugar was considered, was described by Dr.J. C. Spence and Dr. P. C. Brett" in THE LANCET lastyear. There is, in fact, an enormous amount ofinvestigation now in progress which should have theeffect of elucidating much that is at present obscure,and- it is to the chemical laboratories that we mustlook for light on those difficult problems to whichprophets like the late Frantz Glenard were continuallypointing. ____

EXAMINATIONS IN DENTISTRY.

WE have received from Mr. Norman King, theRegistrar of the Dental Board of the United Kingdom,the following revised table of the results of the first seriesTabulated Results of the Prescribed Examinations inDentistry held during July, 1922. --

of examinations which took place last month, witha request that it should be substituted for the tablewhich appeared last week. Part I. of the examinationincludes the written paper and the oral and Part II.the Practical Examinations in Operative Dentistry andDental Mechanics.

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ADMINISTRATION OF THE SALE OF FOODAND DRUGS ACT IN SCOTLAND.

THE Scottish Board of Health state, in their recentlyissued report on the administration of the Sale ofFood and Drugs Act for the year ending Sept. 30th,1921, that most of the local authorities in Scotlanddevote a good deal of attention to sampling andanalysis. It is noted, however, that in some localitiesonly a few articles are sampled ; in a few instancesmilk alone is subiected to examination, whilst in

4 McNee, J. W.: Brit. Med. Jour., 1922, i., 716.5 THE LANCET, July 22nd, 1922, p. 191.

6 Spence, J. C., and Brett, P. C.: THE LANCET, 1921, ii., 1362.