PERIL AND PLAY.

908 of instruction giveri at the school includes lectures in research work at the Thompson Yates Laboratories, University College, Liverpool, and clinical teaching in the special tropical ward of the Royal Southern Hospital. About 20 students attended the school during the year, including medical men from Canada, India, East Africa, Penang, Sierra Leone, Germany, Belgium, and Sweden. The chairman of the committee of the school is Sir Alfred Jones; K: C. M. G.

’course

.and

training

-

REPORT OF THE MEDICAL OFFICER OF HEALTH OF LIVERPOOL ON THE OUTBREAK OF SMALL-POX IN LIVERPOOL. THE report of the medical officer of health of Liverpool E. W. Hope), dated March 13th, 1902, with reference to 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 sequence and history of the importations by sea ; one of the - diagrams shows how from a single case of small-pox imported 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) occurring in the city since Dec. 6th, 1901, has been 112. Of these, two patients died, unvaccinated, and 69 remained under treatment on March 13th, 1902. During the first 10 months of the year 1901 25 cases of small-pox occurred in Liverpool, .eight of which were imported by sea, and one developed small-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 that the 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 a fireman 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 on Dec. 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 there was also the case of an emigrant intending to travel to America who had arrived from Austria via Grimsby on the previous 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 an Atlantic liner on Jan. 10th. This passenger had been suspected 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 smallpox. 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 on board 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 diagrams show the consequences of some of these imported cases and the extension of disease from person to person. The intense dnfectiousness of small-pox makes it difficult or impossible to 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
(Dr.

special effort is made to induce other inmates of the house who may be employed in large works or offices to be If they refuse an intimation is sent to the revaccinated. employer that it is advisable for them to remain at home for 14 days. The infected house is visited and all contacts are visited every day for 24 days and every few days after for another period of 14 days to ascertain if any further sickness has occurred. When a case occurs in a house in a court or similar insanitary premises the other inmates are removed to the city hospital for isolation and revaccination. They can usually bepersuaded to go. A staff of 20 men is at present engaged exclusively in the prevention of small-pox. The difficulties in dealing with small-pox are owing largely to defects in legal powers to insure efficient protection by vaccination. 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 have been vaccinated it has been possible effectually to isolate infected persons and by increasing watchfulness to trace those who have been exposed to infection and to induce them to submit to revaccination ; and so the outbreak has terminated, but it is by no means always possible. Every day reveals the lamentable deficiency of the law in The President of the Local regard to vaccination. Government Board himself very properly laid down the importance of revaccinating inmates of an infected house or those who had been in contact with an infected person. Unfortunately, the law has never contemplated the necessity and consequently people are deprived of the protection which the law should give them. Glaring cases of the mischief resulting from the want of this protective power are frequent not only from negligence but also from wilfulness, as when a thoughtless drunken person. a vagabond, or a tramp departs from an infected lodginghouse and the next that is heard of him is that he has developed small-pox in some other equally low and crowded district of the city. The report emphasises the necessity for some official control over the supply of vaccine lymph so as to ensure efficiency of quality. No doubt commercial enterprise has to a great extent met the demand for lymph, but what is wanted is some efficient guarantee of its quality-a guarantee which nothing short of Government supervision No less than 35,000 persons (other than infants can give. below six months of age) have been vaccinated or revaccinated in Liverpool during the last three months, a result largely owing to the highly creditable manner in which the press, ministers of religion, medical men, and others have stimulated the interest of thinking people on the subject. A

PERIL AND

PLAY.

A CERTAIN number of the street accidents that take place daily in a vast and busy city like London may fairly be regarded as unavoidable. By the mere working of the law of averages, human beings remaining liable to sudden affections and drivers and pedestrians being human beings and horses also being subject to fright under certain conditions, sudden affections and frights may be expected in a certain number of instances daily among the thousands of horses, drivers, and pedestrians of the London stieets, and when occurring will often inevitably lead to damage. For the inevitable nobody is to blame. Unfortunately, the larger proportion of accidents resulting in danger to life or limb are not inevitable. They are generally the result of carelessness which carries only one consolation-viz., that it is often the careless party who gets the most damage. Even this righteous retribution, 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 befalls a child too young to be responsible for his actions, this These accidents to children are is always the case.

909 to the widely prevalent practice of allowing children from the earliest ages to make a playground of the streets of London. No district of London is free from these irresponsible little danger-seekers, although in the crowded small streets of Whitechapel they do not run so much risk as among the more rapidly-moving carriage The child, of course, is not to traffic of the West-end. He has been sent blame for incurring unnecessary peril. to play in the street and it is the mothers who should If there be brought to see the danger of their advice. could only admire a were no open spaces available we determination to let the children have fresh air at all As it is we ought to insist that such a practice, costs. in itself admirable, should be carried out under the safe and most suitable conditions that are so freely available to the London poor in the public parks and open spaces. District visitors, among whom we believe a suitable topic of conversation at once edifying -and capable of sensational treatment is often welcome and sought in vain, may do good service by a crusade against the use of the streets as a playground. We recommend the subject their and are certain that medical to consideration cordially men in London, some of whom perhaps have had the unpleasant experience of treating a child whom their coachman has run over, will thankfully endorse the efforts of the district visitor.

surgeon, stated that a patient under his observation withtabetic symptoms which appeared seven or eight years after syphilitic infection had been put under the mixed treatment " with mercury and iodides with the result that all tabetic symptoms had disappeared and recovery could be: now regarded as complete. On the other hand, he had. seen similar treatment fail entirelv in a number of cases of tabes. Professor A. Fournier stated that his personal experience of syphilitic and parasyphilitic diseases included 1300 cases of tabes collected from his case-books and that 1000 of these patients had had undoubted syphilis, 200 weredoubtful, and 100 were quite free from syphilis. There were undoubtedly cases of tabes which improved with anti-syphilitic treatment but were not cured and he had only seen one case which could be regarded as completely cured by thetreatment mentioned. Tabes in women had a tendency to: remain benign for a very long time, the clinical symptoms consisting of slight darting pains in the limbs, myosis and inequality of the pupils, Argyll-Robertson reflex, and slight bladder troubles. Some of these cases might easily be mistaken as instances of recoveries when the pains in the limbs and the bladder troubles improved under treatment, whereas the disease nevertheless progressed slowly. Parasyphilitic nervous affections were, in the vast majority of cases, incurable, whereas true syphilitic affections (commencing gummatous lesions and connective tissue hyperplasias in the nervous system, as well as mucous plaques) AFFEC- were in most cases amenable to anti-syphilitic treatment.

largely due

THE

SYPHILITIC AND PARASYPHILITIC TIONS OF THE NERVOUS SYSTEM.

AN important discussion syphilitic affections of the

on

the

nervous

Leredde, Professor Fournier, and

syphilitic and parasystem by Professor

others is recorded in Médical of Feb. 12th and March 12th last. Professor Leredde stated that under the designation of parasyphiliticnervous affections there were included two groups of ailments-viz., first, hysteria, neurasthenia, and other rare nervous troubles which might occur in syphilitic subjects, as in patients suffering from other infections or toxæmias ; and secondly, tabes dorsalis, general paralysis of the insane, and leukoplakia lingualis, which constituted parasyphilitic diseases in the proper sense. It was his experience that a certain proportion of patients in the latter group were beneficially affected by anti-syphilitic treatment carried out with perseverance and regularity. A case in support of this statement was quoted of a man, aged 43 years, who had contracted syphilis, and who had after an interval of five years rapidly developed grave nervous symptoms like those of tabes dorsalisdiplopia, visual troubles of accommodation, tachycardia, For this he muscular atrophy, and bladder troubles. was treated with mercurial injections for 12 months and with calomel for 18 months, the latter drug being alternately given for six weeks and stopped for an equal interval. Under the above treatment the symptoms were improved and the progress of the disease was arrested. M. Hallopeau, in his contribution to the discussion, stated that the degenerative lesions of tabes dorsalis were initiated by syphilitic hyperplasias and neoplasms affecting the posterior root ganglia of the spinal cord and hence followed the want of success in the anti-syphilitic treatment of tabes dorsalis of long standing when the degenerations of nerve-tissue were advanced, whereas treatment was often successful at the onset of the disease when the nerve cells and fibres had not as yet been degenerated or destroyed. M. Jaquet pointed out that tabes sometimes underwent sudden arrest in its development and even improved or retrogressed without anti-syphilitic treatment and that when optic neuritis developed in the course of tabes the other symptoms of the disease were often arrested, as was pointed out long ago by Professor Benedikt of Vienna. Dr. Moty, an army

Progres

ATAXY AND TETANY AFTER

DIPHTHERIA.

IN the twenty-eighth volume of St. Thomas’s Hospital Reports Dr. Charles R. Box has called attention to the: occurrence of two rare sequels of diphtheria-transient,, ataxy and tetany-and has recorded a remarkable case in which both were present. A house physician contracted nasal and pharyngeal diphtheria. On the third day thebacilli were found and 7000 units of antitoxin were injected. On the fourth day the dose was repeated. The temperature became normal and the throat rapidly assumed a healthy appearance. On the fourteenth day there were a feeling of oppression in the chest and prceoordial pain. The latter increased and radiated into the arms. Tingling of the fingers and dyspnoea followed and the pain extended to the legs. The hands were clenched, the wrists wereflexed, and the forearms were strongly pronated. The legs were extended and the feet were in a position of extreme plantar flexion with flexion of the toes. The back was slightly arched, but the jaws were not affected. The patient spoke with difficulty and complained of pain in, the wrists, the ankles, and the chest. The spasm gradually disappeared but next night it recurred in less degree. During convalescence slight spasms occurred in the armsfor many weeks. About the end of the third week nasal regurgitation and intonation and tingling of the tongue The regurgitation lasted; and finger-tips were present. for a month. The patient was allowed to sit in a chair but he betook himself to bed again on the sixty-first day. The legs were weak and hyperassthetic. Tenderness was sogreat that he could not sit with the legs crossed. The external popliteal nerves were tender. The knee-jerks were easily obtained. The fingers were hypothetic and the arms were paretic. Ataxic symptoms were definitely noticed on the seventy-third day. The patient could not stand and in attempting to walk he reeled in all directions ; the movements of the arms were incoordinate and almost choreic. In trying to feed himself he nearly injured his eyeball with the fork. He never knew where his arms and legs were. The fingers and hands were hypæsthetic, the arms and feet were parsesthetic, and the soles were hyper2estlietic. The kneejerks were obtained with difficulty. Muscular weakness was