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is somewhat Barmecidal, for the evidence on whichto build any hypothesis regarding the many problemsof tuberculosis is almost overwhelming in quantityand perfectly distracting in lack of accuracy. Afew years ago it was said of a prominent politicianthat it could be conclusively proved by his speechesthat he was in favour of Free Trade, Protection, bothand neither. The supporters of various hypothesesprofessing to explain the erratic ways of tuberculosisare in much the same position: there is plenty ofevidence, of a kind, wherewith to make out a

plausible case for almost any hypothesis. ProfessorCummins’s facts are more helpful, and with regard tothe ravages of tuberculosis among our native levies hediscloses information which it was inadvisable to

publish during the war. It appears that in 1917-18the average strength of the British troops in Francewas over a million and a half, but there were only 2881cases of tuberculosis, with 165 deaths. In the sameperiod the average strength of Cape Boys and Kaffirswas only about 11,000, but the deaths from tuberculosisnumbered 182. The Fijian Labour Unit had to berepatriated on account of tuberculosis, and in 1916 theincidence of tuberculosis among the Indian divisions inFrance was 27’4 per 1000 as compared with 1.1 per 1000British troops. Professor Cummins also refers toa recent paper by A. Borrel on tuberculosis inthe French African troops. Among recently recruitedSenegalese at the Camp of Frejus, Borrel foundv. Pirquet’s reaction positive only in 4 or 5 per cent.In 1916 there were only 48 deaths from tuberculosis inthis camp. In 1917 the deaths rose to 312 and in 1918 to557—an increase from 6’24 to 11’14 per cent. This sus-

ceptibility to tuberculosis cannot, however, be regardedsolely as a racial phenomenon, for, as Dr. Klotz, of theAmerican Army Medical Service has shown, there wasno excessive susceptibility to, or mortality from, tuber-culosis among the negro battalions in the AmericanExpeditionary Force. -

DIPHTHERITIC PARALYSIS OF THE RESPIRATORYMUSCLES TREATED BY PROLONGED

ARTIFICIAL RESPIRATION.

Dr. W. M. Marriott has recently reported a remark-able case of diphtheritic paralysis of the respiratorymuscles, in which life apparently was saved byprolonged artificial respiration.A girl, aged 10 years, was admitted into the St. Louis Child-

ren’s Hospital six weeks after A severe attack of pharyngealdiphtheria. She had received intramuscularly 10,000 unitsof antitoxin. About a week after the attack signs of palatalparalysis appeared. Subsequently the muscles of the eyes,extremities, back, and neck became paralysed. On admissionshe could not move the legs or body or hold up the head.Swallowing was very difficult. There was almost completeaphonia and much difficulty in expectorating mucus. Theheart was enlarged, the left border being 3 cm. outside thenipple line. Electrocardiographic tracings showed evidenceof myocardial affection. There was dyspnoea with slightcyanosis. During inspiration the abdomen was retracted.The temperature was normal, and a culture taken from thethroat was negative for the diphtheria bacillus. The urinecontained a small amount of albumin and a few hyalinecasts. The dyspnoea increased. No movement of thediaphragm could be detected, and ultimately the intercostaland accessory muscles of respiration became involved. Thecyanosis deepened and the child became semi-comatose.There were no signs of pneumonia or obstruction to therespiratory passages. It was evident that death fromsuffocation would ensue unless artificial respiration wasemployed. An apparatus designed by Gesell and Erlanger toconvert a continuous air-current into an intermittent one ofany desired rate and volume, and used extensively in physio-logical laboratories for artificial respiration in animals,was employed. A nitrous oxide mask was connected to theapparatus and applied to the child’s face. There wasat first no cooperation, partly on account of the semicoma. But within a few minutes the slight responsenecessary was obtained and air was forced into thelungs. The cyanosis disappeared and the patient becamesufficiently conscious to cooperate well. The rate of respira-tion of the machine was adjusted to correspond withvoluntary respiration. After ten minutes the child fell asleepand the mask was removed. Cyanosis slowly developed again

1 Journal of the Americal Medical Association, Sept. 4th, 1920.

and was again relieved by artificial respiration. This waskept up during most of the time the child was awake. Itwas possible to discontinue artificial respiration for shortperiods when she fell asleep. Artificial respiration was keptup at intervals for five days. Then the respiratory muscleshad so far regained their function that it was necessary onlyat relatively infrequent intervals. When the child wasperfectly quiet it was not necessary at all. But after exertion,such as coughing or after feeding with the nasal tube, it wasnecessary to apply the apparatus for a short period. Thepower of the respiratory muscles steadily improved and aftera week artificial respiration could be altogether dispensedwith.

As the majority of cases of diphtheritic paralysis.of the respiratory muscles are fatal, some form of.artificial respiration would seem advisable in everysevere case. Other means than the one here described

might be adopted. The possible risk of aspirationpneumonia should not influence the practitioner againstartificial respiration when the greater danger of suffoca-tion is threatened.

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LEPROSY IN NEW SOUTH WALES.

THE Public Health Department’s Report on Leprosyin New South Wales gives a good deal of information intabular form, but with very little comment. The CoastHospital Lazaret was opened in 1883, although deten-tion of lepers was only made compulsory late in 1890,after which the number of admissions increased greatly,the total to date having been 149. Of these 67 havedied, 18 have been discharged or absconded, 4&repatriated, mainly coloured races, especially Chinese,and 24 remained at the end of 1919. During the lastfour quinquennial periods the admissions appear to havebeen 28, 20, 16, and 14 respectively, showing a steadydiminution, although this has been mainly among thecoloured races, so may have been due to closerinspection of immigrants; no information on theeffect of the compulsory segregation of lepers on

the prevalence of the disease in the colony is givenin the report. Notes of each of the remaining casesare to be found among the appendices, from which itappears the majority of the patients have been treatedmore or less regularly with gynocardate of soda orally,but its more efficient intravenous use is not mentioned.A few were given only chaulmoogra oil. The notes giveno information regarding the effects of the treatmentexcept as regards the weight of the patients, but nearlytwo-thirds of the gynocardate of soda cases appear tohave gained weight, as did two out of four cases onchaulmoogra oil. Owing to the policy of repatriation of.most of the coloured cases the majority of the remaininginmates are of white descent. The cost of upkeepamounted to £138 5s. per head of the patients.

"P.U.O." IN CIVIL PRACTICE.

THE war brought to the notice of medical officers inthe field the frequency of pyrexia whose origin wasnot only "uncertain’’ at the time of observation, but alsodifficult to discover after employing all the availablemeans of diagnosis. In India, as Lieutenant-ColonelA. White Robertson last week reminded the HunterianSociety (see p. 1046), short acute fevers used to behastily labelled malaria; not so long ago they were heredubbed influenza. All the criteria which ColonelRobertson suggests for differentiating chronic feversmay not command general assent, but we cordiallyendorse his plea to the practitioner to take a many-sided look at "P.U.O.," whether martial or civil.

THE Bradshaw lecture on the Surgery of the Diseasesof the Spleen will be delivered at the Royal College ofSurgeons of England by Sir Berkeley Moynihan onMonday, Dec. 6th, at 5 P.M.

THE next Congress of the Royal Institute of PublicHealth, which will be of an international character, willtake place in the University of Geneva from May 10thto May 16th, 1921. ’