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(38 per cent. of 887 cases), and many of them weremembers of large families. As regards childhood,tuberculosis is commoner at the beginning andend of this period of life ; in the case of girls, I

going out into service and hard work increase theliability to tuberculosis. So far as men are

concerned, occupations like those of printers andworkers in wood, cork, straw, and metal, in-crease the liability to tuberculosis; agriculturallabourers, both men and women, are comparativelyrarely infected. Domestic service seems to be

particularly unfavourable in the case of women.

Importance is attached to the home circum-stances ; tuberculosis is commoner in houses that

get no sunlight, and in persons who have slept twoor more in one room or one bed. The actual sourceof infection was undiscovered in 488 of the 1510cases investigated ; in 823 (or 54’5 per cent.) the in-fection was acquired beneath the parental roof,and in the remaining 199 patients the source wassaid to be the husband or wife, fellow workers,friends, servants, boarders, persons nursed, or, in30 cases, residence in an infected house. In 604married tuberculous persons the spouse was

certainly tuberculous in 65 instances and possiblytuberculous in 12 more. The commission statesthat no conclusion as to the importance of heredityin the acquisition of tuberculosis can be drawnfrom their figures; but they are of the opinion thatit is a factor of some significance.

THE PATHOGENESIS OF ACROMEGALY.

SINCE Pierre Marie in 1886 called attention tothe peculiar and interesting dystrophy which henamed acromegaly, numerous cases of this strikingmorbid entity have been described, but although intheir general aspect and evolution such cases moreor less resemble each other, clinical investigationof each particular case reveals some peculiarity ordetail worthy of special examination. ProfessorMassalongo and Dr. Piazza, in the medical sectionof Il Policlinico, February and March, 1916, publisha case which lends support to the view thatacromegaly, which has its primary origin in hyper-function of the pituitary gland, is often compli-cated by contemporary or successive phenomenadependent on functional or organic change inother glands with internal secretion ; such com-plications are deserving of discussion and inter-

pretation as to whether they should be consideredinvariable or exceptional, independent or acci-dental occurrences, or subordinate and necessary.In the case published by these observers, oculardisturbances, modification of the field of vision withmarked changes shown by radiography, left no doubtas to the existence of a pituitary lesion. Otherfacts, however, made it impossible to exclude thepresence of symptoms dependent on simultaneouschanges in other endocrinous glands, especially ofthe thyroid and genital glands. In fact, the casemight be taken as an example of a thyro-genito-pituitary syndrome to which various authors,chiefly French, have drawn attention in recent i

years. The implication of the other glands exceptthe pituitary, whether it represents an independentand accidental occurrence or one subordinate andnecessary, is not, however, equivalent to sayingthat acromegaly is a pluri-glandular syndrome.Changes in these glands do not signify theirparticipation in the pathological process of acro-

megaly, but, according to these observers, are

capable of an entirely different explanation, which

is that the ondocrinic system constitutes an organo.functional whole, whoso constituent elements arephysiologically in such intimate connexion that oneof them cannot undergo any change without areaction taking place in the others.

THE SUPPLY OF PETROL TO MEDICALPRACTITIONERS.

THE President of the Board of Trade has appointeda committee, consisting of Mr. Oliver Bury (chair-man), Mr. A. E. Bowen, Sir John Prescott Hewett,G.C.S.I., and Mr. P. G. L. Webb, to control the supplyand distribution of petrol, and to consider whatmeasures are necessary in the national interest--(1) To ensure that adequate supplies of petrol shallbe available for the purposes of the war and forother essential needs ; and (2) with the aboveobject, to regulate the use of petrol for otherpurposes in the United Kingdom during the periodof the war ; and, subject to the direction of theBoard of Trade, to give executive effect to themeasures decided upon. Mr. H. W. Cole, of theBoard of Trade, will act as secretary to theCommittee, whose offices will be at 29, Abingdon-street, Westminster, S.W. The Committee willnot consider individual applications for suppliesof petrol, or deal with correspondence relatingthereto ; but if the medical man is to receivethat adequate supply which is absolutely neces.

sary to enable him to carry out his professionalduties, it should be somebody’s business togive attention to his requirements. A fewdays ago, in one of the daily papers, a medicalpractitioner complained of inability to get petrolfor over a fortnight, stating that he was reosponsible for medical attendance on over 2000

people engaged directly or indirectly on munitionwork." If such instances as these are allowed tomultiply, the health of the community will speedilysuffer. A form has been issued to medical men

by the National Health Insurance Commission, onwhich they are requested to state their estimatedneed of petrol, but we learn that some 7000 practi-tioners have not yet made a return as to theirrequirements. We think this is regrettable. The

question of the supply of petrol to the medicalprofession is one which will be best dealt with byan organised body, and the National Health Insur.ance Commission should be able to influence theGovernment to ensure that medical men generallyshall have the first consideration, so far as privateusers are concerned.

STREPTOCOCCAL PUERPERAL FEVER IN THEANGLO-EGYPTIAN SUDAN.

IN an interesting paper in a recent issue of theJouroat of Tropical Meclicine and Hygiene Dr.Albert Chalmers, director of the Wellcome TropicalResearch Laboratories, Khartoum, and Dr. SalimAtiyab, medical officer in charge of the OmdurmanCivil Hospital, discuss the incidence of streptococcalpuerperal fever in the tropics, with special referenceto the Anglo-Egyptian Sudan. The attention of theseobservers was called to the subject by the occurrenceof several cases in Khartoum and Omdurman asso.ciated with the presence of a streptococcus in theuterine discharges. The question of childbirthamong non-civilised races is considered, and itappears that there is some agreement of opinionthat labour is easier among them than amongthose that are more civilised. The reason advanced

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for this is that pregnancy in the former generallytakes place at an earlier age than in the latter,and that the hard life and spare diet commonin the non-civilised races keep the youngwomen thinner, a condition which is favourableto a quick and easy labour. Some expertsalso assert that the head of the child in theuncivilised races is smaller than in the civilised,and that on an average the child of the uncivilisedwoman weighs at birth about a pound less thanthat of a civilised mother. Childbirth in thesecircumstances is often a simple physiologicalprocess among savage races, and therefore less

likely to be complicated by puerperal infection.According to Dr. Chalmers and Dr. Atiyah, amongthe semi-civilised Arabs and Sudanese of Kordofanand other parts of the Sudan every young girl onattaining the age of 5 or 6 years undergoes one orother of the two forms of so-called circumcision,the milder operation consisting of the removal ofthe clitoris and labia minora, while the more

severe, or " Old Egyptian circumcision," entailssome additional cruelty in the removal of theupper two-thirds of the labia majora. The resultof these operations is the formation of scar

tissue and contraction of the orifice of thevagina, necessitating enlargement by means of arazor at the time of marriage, and again at thebirth of a child, otherwise it would be difficult forthe head to emerge from the outlet at the momentof delivery. The enlarged orifice is again closed

’’

partially after the child is born, and consequentlyincision with the razor is required at each succeed-ing labour. These wounds naturally offer oppor-tunities for septic infection, and streptococci andother organisms have been found in the vaginaldischarges. After reviewing the literature of thesubject, the writers refer to the various forms ofthe genus streptococcus, and call attention to twoclosely allied streptococci-S. salivarius and S. bovis-both of which are known to occur in humansaliva and in cow-dung, S. bovis being also foundin human faeces. Cow-dung, it appears, is used asa remedy for various ailments in the Sudan, some-times in the form of a poultice applied to thepainful part of the body, including the externalgenitals of pregnant women. Moreover, a cow-dungwash is used on the floor and walls of rooms tokeep away biting insects, and in Khartoum andOmdurman cow-dung is employed as a washfor the top of ovens and also for the wallsof outhouses where grain is stored. When thiswash dries it forms dust, which may be waftedabout, the streptococci contained in it being knownto be resistant to the effects of desiccation. It is

possible therefore for this streptococcal dust tocontaminate the hands of attendants upon par-turient women and thus lead to their infection.Dr. Chalmers and Dr. Atiyah state that theysuspect that the vagina and later the uterusbecome infected by bovine faecal streptococci, con-veyed either through the agency of the patient’sown faaces to her genitals, or by dust on the handsof the attendants or on the instruments whichmay be employed. In their opinion the realprotection against this form of infection is the useof antiseptic vaginal douches before and afterdelivery, associated with antiseptic intra-uterineirrigation in cases in which it has been necessaryto introduce the hand or an instrument into theuterine cavity. Every antiseptic precaution must,they say, be more forcibly insisted upon in thetropics than in more temperate climates.

THE FRENCH TREATMENT OF THEDISCHARGED SOLDIER.

(FROM A SPECIAL CORRESPONDENT.)

THE Government and the people of France are now

grappling with a problem which they recognise is onlysecond in its effect on the destinies of the nation to thesuccess of their military operations. After 18 months ofwar they have to make arrangements for the return tocivil life of several tens of thousands of soldiers no

longer capable of bearing arms nor, in most cases, of con-tinuing their pre-war occupations. Before peace is declaredthis number will be augmented and they will then have tocope in addition with the competition of the able men whohave also lost their means of livelihood for some causeconnected with the war. The same problem in differentdimensions will have to be faced in all the allied countries,but the others will have the advantage of being able to noteby the success or failure of the different steps taken inFrance what to imitate and what to avoid.

Development and Organisation of the Movement.As it has so often happened in her industrial history

France was the originator of the idea of educating theinfirm in which she afterwards saw herself surpassed byother countries. I am indebted to the excellent reportmade by Dr. Borne on ’’ La Reeducation et la Readapta-tion au Travail des Blesses et des Mutiles de la Guerre "

for the information that the famous Paris hospital of

Salpetriere was originally an asylum where the disabledwere taught to work, founded in 1657 by M. Pomponnede Believre, the then President au Parlement. In the -

last century several schools for educating the infirmwere founded, the most noteworthy being the Marsoulan

asylum workshops for both sexes, of which there are

four branches in Paris, and the establishment of theFreres de St. Jean de Dieu, which discharges 40 young meneach year perfectly able to earn their own living in spite oftheir infirmity. With such meagre resources it was, ofcourse, impossible to meet the needs of a sudden influx ofthousands of disabled soldiers. The danger to the State ofa large percentage of unoccupied men was quickly realised,but at first the means taken to remedy matters were more orless chaotic. The presence in the streets of the convalescentsoldiers who had lost their limbs aroused the compassion ofthe public and a great many enterprises were started byprivate subscription to provide these men with a means ofgaining their living. At the present time there are over 50such organisations in Paris alone, and this only represents atithe of what is being done, as similar ones are scattered allover France. The absence of any central bureau, wherethe aims of the different ceuvres could be tabulated andany overlapping checked, resulted in a certain lack ofcohesion and a proportionate waste of energy. The same

difficulty was found in the Government where thecontrol of the destinies of disabled soldiers was brokenup between the Ministries of War, the Interior, and Labour,with a resulting indescribable confusion. On March 3rd a

paragraph appeared in the French press stating that an"OfRoe National des Muti]6s et Reformes de la Guerre" "

would be formed by a combination of these three ministriesto deal with every possible provision to be made for the dis-charged soldier. The Government idea is to gather up allthe threads of public and private concerns into its own handsand so achieve more widespread efficiency through centralisedeffort. The philanthropic idea is that while private endeavourmay lack cohesion it undoubtedly possesses more elasticityand variety of form than the state-moulded machine, and ismore likely to meet individual requirements than any rigidinstitution. At the moment both methods are supplementingeach other fairly successfully, but the private benevolencethat may actually be preferable when dealing individuallywith restricted numbers is bound to be superseded by thecentralised methods which must be adopted by the Statewhen it has to deal with large numbers. The ideal organisa-tion is a central administrative body which will coordinatemd control the actions of the executive and provincialjodies to which the actual carrying out of measures designed:or securing the proper return of disabled men to civilian lifewill be entrusted.