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attention has, they think, been devoted to the possi-bilities of efficient home treatment. There are

districts and towns where home treatment is now beingadopted at comparatively little cost and, as far as isknown, without harm to the patients or the com-munities to which they belong. The further provi-sion of nursing facilities would do much to ensurethe successful development of these local experiments.In connexion with such home treatment the com-mittee regard it as more rational to practise currentrather than terminal disinfection-that is to say, tosterilise as quickly and as thoroughly as possible allarticles exposed to contamination by the patient’sdischarges, and to observe a careful sick-room regimenduring the whole time that the room is occupied bythe patient. The destruction of remnants of foodand fluids which have been handled by the patientdemands more attention. than it has hitherto received.These and other conclusions are stated in provisional,tentative, and guarded form, for the object of thereport is to open the subject to wide discussion, notto close it. If the time is not ripe for universal action,the materials provided by Dr. PARSONS’s very ableand comprehensive report will bring it nearer.

Annotations.

THE TREATMENT OF RABIES.

THIS country is fortunate in its freedom from rabies.Energetic muzzling stamped out the pest completelyat the beginning of the century, and again when itwas reintroduced in a dog smuggled by aeroplaneduring the war, and there has now been no case

reported for six years. Switzerland and theScandinavian countries are also fairly free, but every-where else in the world it remains the same scourgethat it was in the Middle Ages. The active immunitygiven by the Pasteur treatment has mitigated itsterrors, but it is still a source of great loss and anxiety,and will remain so until facilities for treatment are sowidespread that everyone exposed has immediateaccess to them. Statistics of the numbers treated arevery difficult to correlate and far from being complete,but they show on the whole that the applications forprotection grow considerably every year. The dangersof rabies and the existence of its antidote are nowfairly well realised in all countries. The authors of arecent Austrian text-book,’. in dealing with theresults of protective inoculation, mention the chiefdifficulties of estimating the degree of protection itgives-namely, that it is very often unknown whetherthe bite was really infectious, and that individualimmunity is so variable that it is impossible to deter-mine whether any given patient would have developedthe disease or not. What does stand out from thefigures, however, is the importance of early treatment.With a week’s delay the mortality-rate is 0.56 per cent. ;with three weeks’ delay it is 3.19 per cent. Thepercentage of fatalities among patients treated on thesecond day after the bite is only 0.088. The authorsconclude that the Pasteur treatment reduces theprobability of death in all cases from 10 per cent. to0.6 per cent.The method of protection has been little altered since

its introduction in 1885, and consists of a series ofinjections of emulsion of an infected spinal cord whichhas been dried for varying periods. A dog is infectedwith rabies and killed at the height of the disease bybleeding; its spinal column is then removed anddried in caustic potash. After 12 or 14 days it losesall its virulence ; after eight days an emulsion willstill produce rabies now and again on injection intothe dura; after five days it will evoke a normal attack,

1 Lyssa bei Mensch und Tier. Prof. Dr. R. Kraus, Dr. med.vet. F. Gerlach, and Dr. F. Schweinburg. Vienna : Urban andSchwarzenberg. 1926. Pp. 461. M.30.

though with a slightly lengthened incubation period,and after four days or less its virulence is unimpaired.The weakening of its effect is purely quantitative.In Pasteur’s original schemes the patient was given14-day emulsion to begin with, the age being reducedby a day at each injection, until on the fifth dayof the course he was getting six-day emulsion.Three-day virus was given on about the ninth day(earlier for severe and head-bites), and the wholecourse lasted 18-21 days. The virus was, of course,of the " fixed " type. After some years of use,however, it was realised that this series was not drasticenough ; it let slip too high a proportion of cases,usually those with a more or less massive infection.Once it was realised that the fixed virus was practicallynon-pathogenic to man, the method was intensified,and the custom of nearly every institute is now to startstraight away with five-day emulsion and decrease by aday on each of the first three days. A typical patternin terms of emulsion-age is 5 4 3 2 4 3 2 3 2 3 2 3 2 2 ;the dose is 3 or 5 c.cm. daily. Although there has beenlittle coordination between the many Pasteur institutes,the series in use differ but slightly one from another.Hogye’s method is similar, but dilution is employedinstead of drying, and more use is made of variationin the dose. One of the most recent improvements ininoculation technique is that of Philipps. The brainis ground down with glycerine, and can be kept forsome months in the dark at a low temperature ; whenrequired it is mixed with a 0-5 per cent. phenol andsaline solution in the proportion of 1 part to 20. Thismixture is heated at blood temperature for 24 hoursto sterilise it. Out of 1540 patients Philipps had onedeath only. The chief technical advantage of thismethod is that a single substance is used throughoutthe whole series; the vaccine, moreover, can be

transported any distance without losing any of itsefficacy.

All these schemes have the drawback of requiringa period of from 13 to 25 days to complete them,and much work has been done to find a way ofspeeding up the immunising process. This is desirablenot only for the convenience of everyone concerned,but for the greater safety of the patient, for thetreatment is a race between the antibodies andthe invading virus. The authors consider that thequickest and safest method is now that of Hempt,the director of the Pasteur Institute in Novisad,Jugo-Slavia. Brain substance is kept in 50 per cent.glycerine for a period varying from a few days to24 hours, inversely with the severity of the wound.An emulsion of 1 part in 60 is made up for injection,and the doses fixed likewise according to the natureof the lesion ; the total amount given is 4 g. for ahead-bite, 3 g. for deep wounds, and 2 g. for slighttears. The treatment takes five days only, and thepatient gets two injections a day ; the first is of5 c.cm., the next two of 10 c.cm., then one of 15 c.cm.,and the remainder of 20 c.cm. On the last day threeinjections are given. A very severe case, where therehas been a long delay, may have a sixth day of threeinjections. The results in a series of 2011 patients havebeen uniformly excellent. One only died, and hehad undergone a delay of 16 days. In the latestmodification of all, Remlinger proposes to employundried cord kept in glycerine for varying periods ;the virulence of the emulsion will be much greater thanthat of the preparation of dried substance. The firstinjection is to be of 25-day emulsion, which is sterile(the virulence disappears suddenly after about24 days), and succeeding injections will be of rapidlyincreasing potency. The course is a five-day one.This method has not yet been sufficiently tested tobe put into practice. The developments in packinginjection-material for transit are perhaps the mostimportant feature of the book from the standpoint ofthe administrator, for only when every generalpractitioner in the world can give the protectivetreatment will the problem of human infection beadequately dealt with. Even then there will remainthe infinitely greater one of eradicating the diseasefrom domestic and wild animals.