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.at the Bristol Royal Infirmary the two-bottle method," thetwo anaesthetics (chloroform and ether) being in separatebottles and added to the mask as required, as I think it is animprovement on the use of one definite mixture. :

By this method the amount of either anaesthetic can be.altered at will, an enormous advantage in combating shock.For example, take a case where this I two-bottle " method isused. The anaesthetist sees that the next step of the opera-tion is calculated to produce shock. He is able by addingmore ether to his mask to anticipate the surgeon, stimulatehis patient, raise his blood pressure, and place him in aposition to better resist the effects of the coming manipula-tion. In this way more ether than required is never used;the type of anassthesia is excellent ; respiration, pulse, andcolour remain good ; and the amount of anæsthetic used

very small, in my experience less than with the mixture.I should have been glad if Dr. Hewitt and Dr. Blumfeld

had given more particulars with regard to the use they makeof oxygen, the only reference being in connexion with a casesuffering from pneumonia. My own experience leads me tothink that, when a patient is very ill and feeble at the timeof operation, oxygen used in conjunction with the abovemethod is a very valuable factor in the prevention of shock.

I am, Sir, yours faithfully,Clifton, Bristol, July 19th, 1909. STUART V. STOCK.STUART V. STOCK.

THE ASSOCIATION OF MEDICAL DIPLO-MATES OF SCOTLAND AND AMEMBERSHIP QUALIFICATION.

To the Editor of THE LANCET.

SIR,-The holders of the Licentiateship of the EdinburghRoyal College of Surgeons, either alone or conjoined withthe Glasgow or other Scottish qualifications, have for a longtime laboured under a disadvantage in practice through nothaving a Membership open to them. The matter has forsome years engaged the attention of the Association ofMedical Diplomates of Scotland, on whose behalf I venture

. to ask the publication of the following communicationaddressed to the Edinburgh College.

I am, Sir, yours faithfully,DAVID WALSH,

Welbeck-street, W., July 21st, 1909. President, A.M.D.S.TO THE PRESIDENT AND COUNCIL OF THE ROYAL COLLEGE OF

SURGEONS OF EDINBURGH.

GENTLEMEN,—The Association of Medical Diplomates of Scotland begrespectfully to remind you of a petition formally presented to yourPresident and Council in 1905, praying that steps be taken, by extensionof Charter if necessary, to secure an additional diploma of Membershipfor your ancient College. It was shown in that petition that thelack of an intermediate qualification between the Licentiate-ship and the Fellowship imposes a serious social and pro-fessional handicap upon your Licentiates in various parts of theUnited Kingdom and elsewhere, inasmuch as the majority oftheir competitors hold the Membership of other Colleges. The Councilof the Association of Medical Diplomates of Scotland, therefore, as

representing the interests of Edinburgh Diplomates in all parts of theworld, would be glad to learn whether the Council of the Royal Collegeof Surgeons of Edinburgh have taken any further steps in the matter.tf nothing has yet been done they would venture to ask if there be anylikelihood of this most important, and, in their opinion, most salutarychange being considered seriously by the Council of the College.

It need hardly be said that the Council of the Association would mstwillingly cooperate with the College in any way that might lead to thedesired end. They presume the College will hardly require any furtherproof of the popularity of the proposed change than that afforded bythe petition already formally lodged with the College-a document thatwas signed by many hundreds of Fellows and Licentiates.

In conclusion, we venture to urge that the institution of the diplomaof Membership must infallibly lead to a great increase of the popularity.and the usefulness of our ancient College; nor could it fail to establisha fresh bond of union between the College and its diplomates in allparts of the world, at the same time re-awakening old memories,interests, and associations ; while it would add to the material.prosperity of the College for many years to come.Awaiting the honour of your further reply to the considerations set

forth in our former petition,We have the honour to remain, on behalf of the Association of

Medical Diplomates of Scotland,(Signed) Yours faithfully,

DAVID WALSH, M.D., President.SKENE KEITH, M.D., Hon. Treasurer.P. H. PARSONS, L.R.C.S. & P. Edin., &c., Hon. Secretary.

DAVID WALSH,President, A.M.D.S.

DAVID WALSH, M.D., President.SKENE KEITH, M.D., Hon. Treasurer.P. H. PARSONS, L.R.C.S. & P. Edin., &c., Hon. Secretary.

FACTORY GIRLS’ COUNTRY HOLIDAYFUND.

To the Editor of THE LANCET.

SIR,—May we bring before your readers the claims of theFactory Girls’ Country Holiday Fund ?

The Fund last year sent away over 5000 of the poorestwomen and girls of London, some of whom, even some of theyoungest, work from nine to 11 hours a day, and are in

many cases the chief bread-winners in their families. Manyof these girls have been saving up for months for their

holiday ; the total contribution from them reached, last year,the sum of 1558. But it is obvious that, from wages some-times as low as 2s. 6d. a week, the whole cost cannot possiblybe paid by them. A fortnight at the country or seaside,including fare, costs on an average 25s., yet many factorygirls cannot afford even a week, and if they could theywould not know where to go. Many have never been out ofLondon at all to stay.To all, then, who value their annual holiday, we appeal,

confident that they will not allow those who are workingamid many hardships, to go on working without any changeor refreshment. It has been already necessary to refuse allfurther applications since the end of June, and it is doubtfulwhether many applicants, numbering some thousands, maynot after all be disappointed of their longed-for holiday unlessfurther help be at once forthcoming.

Subscriptions and donations will be thankfully received bythe chairman, the Rev. Edward Canney, St. Peter’s Rectory,Saffron-hill, London, E.C., and by the honorary treasurer,Herbert Rendel, Esq., 51, Gordon-square, London, W.C.

Yours obediently,-MARY ST. HELIER,BEATRICE B. TEMPLE,LOUISE CREIGHTON,H. L. STEPNEY,EDW. SOUTHWARK,

July 21st, 1909.

NORFOLK,HENRY SCOTT HOLLAND,H. ADLER (Chief Rabbi),ROBERT F. HORTON,FRANK LLOYD.

SANITATION AT SEA.(FROM OUR SPECIAL SANITARY COMMISSIONER.)

FROM EGYPT TO MARSEILLES BY THE MESSAGERIESMARITIMES.-THE BEAUTIES AND ADVANTAGES OF THEROUTE.-OLD SHIPS WITH GOOD COMPANY AND GOODCUISINE. -BETTER QUARTERS FOR THE CREWS. -SANITARY PROGRESS IN TONQUIN.-THE MESSAGERIESMARITIMES’ MODEL LAUNDRY AT MARSEILLES.HAVING travelled to Egypt by the Austrian-Lloyd I

returned by the French Messageries Maritimes. The twocompanies work together and give circular tickets, so thatpassengers may go by the one route and return by the other.For persons who are wintering in Egypt and can afford tostop on the road I would recommend Trieste for the out-ward journey and Marseilles for the return. Near Marseillesthere are numerous half season places where the traveller maygradually prepare for the change of climate. An economicand pleasant way home for those who like the sea would beby the General Steam Navigation Company’s ships whichsail twice a week from Bordeaux to Tower Bridge, London.From Marseilles to Bordeaux, Arles, Nimes, Aigues-Mortes,Montpellier, Narbonne, Carcassonne, and Toulouse can bevisited. They’are all on the road and but a few hours’journey from each other. Though not winter stations, still,being in the South of France, they are much warmer thanParis or London. Then by taking a route that is not so directall the health stations of the Pyrenees can be reached, togetherwith Pau and Biarritz. In regard to the ships from Alexandriato Marseilles, it must he confessed that these are not up todate. They are old boats, and as the agreement betweenthe company and the French Government has now run itscourse and must be renewed, the building of better shipswas deferred until the new arrangement should be concluded.This was all the more necessary, as there was not only thequestion of the contract between the Government and the

company, but a new law pending on the construction of

ships and the conditions of navigation. This law has nowbeen enacted and its stipulations are such that it-will placethe French passenger lines in the very fore rank of progressso far as health considerations are concerned.To secure a better ship instead of taking the ordinary boat

running from Alexandria to Marseilles, I was able, with thecourteous assistance of the company, to embark at Port Saidon the Tourane, a ship of 6000 tons which was on her home-ward journey from Japan, China, and India. To my mindthe principal advantages of this line are the sociability, the

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cheerfulness, the ready wit, and the savoir vivre which so

specially distinguish the French people. In Cairo I heardsome English visitors complain that the discipline on theFrench ships was not severe enough, and that second-class passengers gained too easily and too frequentlyaccess to parts of the ship reserved for first - class

passengers. But on pushing the inquiry further Ifound that the second-class passengers who had renderedthemselves obnoxious by their loud and vulgar behaviourwere Englishmen, and I can quite understand that theFrench officers would overlook conduct on the part of

foreigners which they would never tolerate on the part offellow-countrymen. The second great advantage of a Frenchship is the cuisine, while it is not necessary to pay 2s. or 3s.for a bottle of ordinary wine which only cost 2d. or 3d. Forthe sake of promoting temperance by encouraging the con-sumption of cheap natural wines instead of spirits all taxeshave been abolished on ordinary wine. In France, therefore,the retail price varies from 2d. to 4d. the litre. In France ’,or on French ships there is consequently no more reason tomake a special charge for wine at meals than there is forbread, or pepper and salt.

So far as sanitation is concerned, the Tourane has none ofthe appliances found on modern ships. There is no

mechanical ventilation, so that when the weather is bad theconditions below deck, especially among the third-class

passengers, must be anvthing but pleasant. On the otherhand, there is no general steerage, but cabins holding sixberths with mattresses-in fact, complete beds. The sailors’

quarters looked clean and airy, particularly as it was

fine enough weather to keep the port-holes open. Butheat came from the kitchens, which were too near,and the cooks complained of insufficient ventilation. Someof the firemen had cabins like the third-class passengers, andthis is better than what I have seen on English ships.Indeed, in regard to space, bedding, and lockers, the poorestquarters seemed better than what obtains on inferior linesof passenger ships in England. Even the best British shipsare only superior because they have mechanical ventilation,and not because there is more space or greater cleanliness.The Chinese and Arabs cook for themselves. The former eatno bread and only half cook their vegetables, but the Frenchchef entertained a high opinion of the skill of hisChinese colleague. The crew’s closets, and especially thoseused by the Arabs, were very clean and free frombad odour. The closets consisted of iron troughs withsalt water flowing in them all the time. There was no

hospital on board, but a first-class cabin with four berthswas kept empty to be used as an emergency hospital, thoughit was not properly situated or furnished for such a purpose.There was a disinfecting stove on deck. It is used once onevery journey even when there is nothing to disinfect, butsimply to see that it is in good working order. Butfor this it might happen that when urgently wanted a screw,an indiarubber flange, or other small thing would be missing.The stove is also usually brought into operation on

arriving at Suez from the East. The passengers are

then asked for all their dirty body linen as a routine,so as to accustom them to the idea and to demonstrate thattheir linen is not injured by the process. Then when a realdanger is present there is not the same resistance nor as

many objections offered as there used to be when it was

proposed to apply an altogether unprecedented and unknownproceeding.During the passage I was able to obtain some interesting

information from medical officers who had terminated theirterm of service in Tonquin. The natives, they said, werepeaceful agriculturists who only desired not to be molestedand to pay as few taxes as possible. They were still

oppressed by the mandarins, but they knew that, at leastin extreme cases, they could obtain redress by complaining tothe French authorities. Consequently, there was a partyamong the natives that favoured the French occupation.All attempts at scientific farming, I was told, had beendismal failures. The only paying thing a European coulddo was to buy land and let the natives cultivate it,reserving a share of the profits; this would bring infrom 10 to 20 per cent. The French have introducedthe usual evils of civilisation, and the resources of the

country are strained to pay pensions to those who,having served their time, will spend their money at

home. On the other hand, the French have abolished

plague and cholera. The natives aiding, the first cases

are promptly reported, the patients and contacts are

isolated, and then if there are 20 to 30 cases remaining tobe dealt with they can soon be stamped out. As sanitaryreformers the French have evidently done very goodwork in Tonquin; but I gathered that it was considereddoubtful whether this colonial enterprise is, on the whole,of benefit to the natives. Further, it should be noted, and Iwas much impressed by the fact, that the latter observationinferred the belief that such enterprise was only justified if itdid improve the condition of the natives.The journey from Egypt to Marseilles affords opportunities

of enjoying some magnificent scenery. On approaching theStraits of Messina a commanding view of Mount Etna canbe obtained. Then the Straits are so narrow that Reggioand the Calabrian ranges on one side, and the thicklypopulated verdant mountains of Sicily on the other side,are both quite near enough for the full appreciation oftheir beauty. On the other hand, it needed good glassesto see the ruins caused by the recent earthquakes. Afew hours later, after passing through the Straits, the

ship approaches the cone-shaped volcanic mountain islandof Stromboli. On the other side of the ship, alsowell in sight, was the rock-formed Lipari and other

wild-looking, picturesque islands, celebrated for the deliciouswines obtained from the grapes grown on their volcanicsoil. Then on the morrow the ship sails through theStraits of Bonafacio, and here again beautiful viewsof the coasts of Corsica and Sardinia can be enjoyed;while, finally, the islands of Hyeres, the coasts of theFrench Riviera, and Marseilles itself form a magnificentframework of purple mountains and white glistening townsthat wall in the deep waters of the blue Mediterranean.A very important part of the problem affecting sanitation

at sea is the laundry question. An abundant supply of

absolutely pure linen is an essential to health and comfort,and this the Messageries Maritimes have taken into con-sideration from the very beginning. So long as 47 or 48years ago they purchased a country house surrounded

by extensive grounds some three miles outside ofMarseilles. It was not a question of being near the

ships so as to quickly transport the linen, but of gettingaway from the dirty atmosphere of the town and of

securing plenty of pure air and sunshine to dry the linen.Now, however, Marseilles has so grown that the estate is notso free from the soot and smoke of factories as it used to be.Nevertheless, I have not seen elsewhere and in connexion withshipping companies such extensive open-air drying groundsas those of the Messageries Maritimes laundry near thePont du Jaret in the rue Saint Pierre. Here all the woollenblankets are dried in the open air, and this not only makesthem delightfully fresh and sweet but prevents their becominglike felt, which is a very general consequence of being driedartificially. There is room for several miles of rope to beextended backwards and forwards across the grounds,and here all sorts of linen as well as the blankets can be

exposed to the wind, the country air, and the sunlight. Itis hardly necessary to insist on the great advantage of thissimple natural method of drying. The only disadvantage isthat the laundry is a long way from the docks, but a tramline passes close by and a branch line into the laundry willsoon be built. Then special cars for carrying linen will beconstructed, and these will run straight from the ships to thelaundry and back from the laundry to the ships.When this laundry was first installed there was no

machinery and everything was done by hand, but inthose days the company had only a few very smallships. In 1852 there were not more than 17 ships,with a total tonnage of 13,600 ; now there are 68 ships,with a total gross tonnage of 294,973. When one of thelarger ships arrives from the Far East it brings some 25,000pieces of dirty linen. At the laundry something like3,000,000 different articles are washed during the course ofthe year. There are a series of large rooms to receive thislinen. On one side there is the yard where the carts driveup to the doors of these rooms, and the chief stewardaccompanies the linen, for which he is responsible till it hasbeen counted out. An opening in the wall of the counting-room serves to receive the linen and convey it to the

laundry and a receipt is given to the chief steward; the

laundry then becomes responsible. For this it is importantto have separate receiving- and counting-rooms, so that

259

no two ships’ linen shall be unloaded in the one room. Myship, the Tourane, brought no less than 30,000 pieces to wash,and it required a good-sized room to sort and count all this.After counting, and when once in the hands of the laundryadministration, the linen has to be divided into three classes-the very dirty, the.dirty, and the comparatively clean. Eachcategory is washed differently so as to avoid wearing out thecleaner pieces. There are great vats or tubs some five to sixfeet deep and nearly as wide, and these will hold about700 kilos weight of linen. With the linen there is some900 litres of washing water, and this is made to circulate

slowly round and through the linen for some six hours.After that the linen can be cleaned much more easily andtherefore with less wear. Otherwise the linen could at oncebe put into the revolving and beating drum or mechanicalwashers, but it would be necessary to knock the linen aboutfor a much longer time before it would be cleaned.Wine stains on the table linen are very frequent, and for

this the eau de Javel so popular with the French laundressis used. It consists of a solution of chloride of lime ofstable strength and easy application. After remaining halfan hour in the washer where the linen is beaten amid soap-suds the hot soapy water is drained off and replacedby fresh cold water, so delivered as to allow the linento cool gradually and thus avoid fixing the stains. Tenminutes of fresh-water rinsing follows on this gradualchange. To dry the linen it is first placed in a centrifugalhydro extractor, which whirls round so rapidly as to throwthe water out, and the linen is then damp but no longerwringing wet. Certain sorts of linen may then be ironed,and there are huge revolving cylindrical rollers no less thar3’50 metres long. Under these two sheets can be passecand ironed side by side. Like those employed at Liverpoo:in the laundry works of the Cunard Steamship Companythey are much larger than the standard size. I fountthat at Marseilles they had not introduced any automaticfinger-guards. There was nothing to prevent the finger:of the attendants being carried under the roller and crushedAt the Cunard laundry works, as I have described, theris a sort of rod in front of the ironer, and if the fingerpress too far forward they will lift this rod before the:reach the roller. The raising of the rod at once stops thmachine and no accident can happen.The place where the greater part of the washing is don

is like a large and lofty hall with lantern openings on botsides of the roof and windows facing each other along thlongitudinal walls. There is therefore plenty of air spacand light. The mending rooms are also large and light, bcthe room for ironing by hand is not important. Machinerhas almost entirely taken the place of this sort of worlThere is only a little hand ironing to be done and th

principally for hotels, for which establishment the companis now beginning to cater, and it will be an advantage fctravellers who have to stop at Marseilles to have a sanitalaundry at their disposal.One of the greatest difficulties in washing ships’ lin(

is to remove rust stains. These are naturally moplentiful at sea than on land. The problem has now besolved, perhaps in a somewhat empirical manner. Tlrust-stained linen is soaked in a bath placed in the opair and containing a very weak solution of oxalic aciThe secret of success is to never change the water;may be replenished, but the bath is never emptied, and itonly after it has been in use for about two months that tmaximum of effectiveness is attained. Another peculiaridemonstrated by experience is that the result also depends ccsiderably upon the weather. The rust stains disappear mumore quickly when the sun shines. The mistral wind, whiis not only very violent and cold but ensures the maximumsunshine and a very dry atmosphere, is also favourable.the other hand, dull, heavy, cloudy weather is absolut,unfavourable for the process. The rust-stained linen irthen have to remain in the solution of oxalic acid allnight. This is likewise the case when the stains are v,

bad. Generally speaking, it suffices to lay out the linen :in the tank and let it soak for about four hours. By ttime the rust stains will have disappeared. Then the limust soak in a soda bath for two hours so as to remthe oxalic acid and check its burning action. It will t’

-

be found that the linen has not lost any of its streng

1 See THE LANCET, Sept. 26th, 1908, p. 973.

Put to the test of a dynamometer it will not break sooner bypulling than if it had not been washed in this manner.Apart from these ingenious devices it was a pleasure to

observe the freshness, ample space, and abundance of lightthat prevailed throughout the premises. There was an

abundance of trees, while flowers, some wild and some

cultivated, disputed with the linen for a share of sunlight.The steam, the sloppy wet floor, the hot muggy atmosphere,the sour effluvia of the old-fashioned and small laundries__the characteristics that render laundry work unhealthy—are quite unknown here. The women workers are rarelyill and have no complaint to make on the score of

unhealthy conditions.

CHOLERA AND PLAGUE IN RUSSIA ANDTHE NEAR EAST.

(FROM THE BRITISH DELEGATE ON THE CONSTANTINOPLEBOARD OF HEALTH.)

1’resA Outbreak of Cholera in St. Petersburg.As stated in my last letter (THE LANCET, June 26th, p. 1864)

the epidemic of cholera in St. Petersburg, which began inAugust last, appeared to have come to an end on May 14th(27th). The respite was, however, a very short one. On

May 25th (June 7th) the city was once again declaredI infected." In the week ending May 30th (June 12th)there were 58 cases of the disease there with 19 deaths.Since then the returns have been as follows :-

Between May 31st and June 6th ... 202 cases, 46 deaths.

" June 7th " 13th... 548 " 155 "

" " 14th " 20th ... 664 " 234 "

(All the dates mentioned are according to the Old Style.)

The epidemic so far has been confined to St. Petersburgitself, with the exception of a few cases imported elsewhereby persons coming from the capital. Thus in the week

ending June 13th the figures include three such cases,,

imported respectively to Mariengam (government of St.

Petersburg), and to places in the governments of Olonetzand Riazan ; and in the last week of the table they includetwo similar cases, imported respectively to the governmentof Novgorod and to the town of Riga. All these importedcases have, it is said, been isolated. But the situation is

s unquestionably a disquieting one. Already the epidemic int the capital may be regarded as of serious proportions (though7 it is still far from the maximum height of last year’s out-- break), and a further extension of the infection to other partss of Russia is almost inevitable. It will be fortunate, indeed,y if other countries escape the disease.r In former letters I have referred more than once to the

y question of the St. Petersburg water-supply. It will berecalled that a Government Commission was recently

n appointed to study the whole question of the water-supplye and drainage of the city. According to the daily papersn the expense is estimated at 100,000,000 roubles (about

10,000,000), and this sum it is proposed to raise by a publicn loan. The works will, it is thought, take about 15 years to1. complete. It is obvious, therefore, that this great schemeit can have no immediate effect on the present epidemic, whichis will have to be fought with the same inadequate weapons asie in the past. But it is very satisfactory that the Russianty authorities are taking a large view of their responsibilities,n- and are contemplating works intended to attack the evil ath its root. The problem set before the Commission is, ash already pointed out, a difficult one, in view of the topo-of graphical conditions at the mouths of the Neva, and the)n method by which the problem is attacked and the solutionly arrived at will be watched with interest by all who are

ay called on to deal elsewhere with such large public healthhe questions.:ry Plag1lC in Adalia.lat On July 2nd a case of suspected bubonic plague was observediat in the port of Adalia, on the southern shores of Asia Minor.,en The patient was a girl, aged 10 years, daughter of a workerwe in a mill. She had already been ill for seven days, with all

the clinical symptoms of an attack of plague, the bubo beingin the left groin. The case is recovering. It will be recalled

- that similar isolated cases of plague occurred in this town in1905, 1906, and 1908. In last year’s outbreak two cases were