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tinnitus, and blurring of vision. The general symptoms weremuch less marked than before, but there was some weaknessfor a day or so. According to the literature of lithium

poisoning the common symptoms are marked prostration andgastro-intestinal irritation. The latter was absent in this

case. The striking symptoms, resembling those of cinchonism,do not appear to have been described by any previous writer.They may have been due to the large doses taken, whichwere twice or thrice those which seem to have been taken in

any recorded case. --- I

THE HOUSE AS A FACTOR IN THE

DEATH-RATE.

AN interesting paper on this subject was read at a recentmeeting of the Epidemiological Section of the Royal Societyof Medicine by Dr. A. K. Chalmers, medical officer of healthof Glasgow. It had previously been ascertained that in thatcity the number of occupants per room almost invariablyincreases as the number of rooms occupied by a familydecreases. In recent years the average number of inmatesin one-apartment houses (i.e., tenements) has been 32. In

two-apartment houses the inmates average 2’4 per room, inthree-apartment houses 1-7, and in houses of four apart-ments :L-3. Shortly after the Census of 1901 Dr. Chalmersset himself to examine the statistics of mortality in Glasgowamong the inmates of houses of different sizes, and foundthat an inordinate interval separated the death-rates of

occupants of one-roomed tenements from those of

occupants of tenements of more than a single room.

In the one-roomed tenements the inmates died at the rate of33 in each 1000 living, in the two-roomed tenements at therate of 21 per 1000, in the three-roomed tenements at therate of 14 per 1000, whilst in tenements of four rooms ormore it was only 11 per 1000. The extremes differed so

widely as to suggest a discrepancy in the units compared.Lack of information regarding the age constitution of theseveral classes of occupants made it impracticable to carrycomparison beyond a simple statement of the relative

prevalence of certain groups of diseases. It was, howeverapparent that the death-rate from all causes uniformlyincreased as the size of the house diminished, and it furtherappeared that the death-rate from common zymotics, as wellas from tuberculous phthisis and from other respiratory affec-tions, followed for the most part a similar course. Scrutinyof the 1911 Census figures supplied the data as to ageconstitutions lacking at the previous enumeration, and

suggested that much of the difference of mortality may beaccounted for by the larger proportion of children in the

smaller houses. For whilst in the aggregate city popula-tion 11 per cent. consists of children under 5 years of age,in the one-apartment class they formed 19 per cent. and inthe two-apartment class 14 per cent., while in the three- andfour-roomed classes the proportions were 7 per cent. and

4 per cent. respectively. Dr. Chalmers has selected for

special inquiry the causes of death at the early agesbecause of the importance attaching thereto as indices ofinsanitary conditions, and gives a table showing strikingcontrasts between the rates associated with the several typesof house. For example, the mortality in the first yearafter birth in the one-apartment tenements is double

that in those of four apartments; but during the next

four years of life the resistance of the child in three andfour-roomed houses improves so rapidly that the death-rateamong children in three-apartment houses is less than half,and in four-apartment houses only one-quarter of that

among one-apartment children. With respect to mortalitywithin the first year after birth Dr. Chalmers observes that

1 Proceedings of the Royal Society of Medicine, 1913, vol. vi.,pp. 155-181.

if the rate in one-apartment houses be taken as 100, therate in two-, three-, and four-apartment houses may be statedas 78, 61, and 49 respectively. Recent statistics furnish

evidence that Glasgow children do not enter on life withan equal chance of surviving, and that the chances are

worst in houses of the smaller sizes. Respecting the

relation of housing to mortality from tuberculous phthisis,we learn that a reduction of about 25 per cent. has occurredin that mortality in the course of the last decade, and that,with few exceptions, this reduction has been fairly constantin the several types of house. In dwellings of one and twoapartments the female phthisis rate is higher than the male,and speaking generally it is below the male rate in one-

apartment houses, only at ages 20-25 and 45-75.- Anexcessive drift of male consumptives at these ages to

parochial hospitals might tend to explain the excessive

incidence on females in their own homes, but there is noevidence of this in the institutional death-rate, whichshows an almost continuously excessive female rate at agesfrom 5 to 55 years. In summarising the results of

his inquiry Dr. Chalmers inclines to the belief thatthe death-rates indicated in his tables are too low.

They are not the rates of a stationary population,bat suggest an ebb and flow of families caught in

successive waves of good or of evil fortune. Whatever maybe the effect of selective forces in other directions, Dr.

Chalmers thinks that with respect to infectious disease

prevalence the element house" predominates, for thedeath-rates per 1000 from the principal infectious diseases ofchildhood and from pneumonia are 16 and 6 respectively inone-apartment houses, 12 and 6 in two-apartment houses, butonly 7 and 2 in houses of three apartments.

TUBERCULOUS ANEURYSM OF THE COMMONILIAC ARTERY.

THOUGH tuberculosis is a familiar cause of aneurysm as it

is seen in the pulmonary arterioles in phthisical subjects, itso seldom appears as a blood-borne infection of the walls of

the large systemic arteries that its capacities in this direc-tion are often forgotten. The case of aneurysm of the rightcommon iliac artery, due to tuberculosis of its wall, which is

reported by Professor Samuel R. Haythorn, of Pittsburg, inthe Joqtrnal of the American Medical Association of May 10th,is therefore of educational value, since it affords a

notable example of the potentialities of the tubercle bacillusin this direction. Four general types of tuberculosis of

the aorta and its chief branches have been described:

miliary tuberculosis of the intima, tuberculous polypiadherent to the intima, tuberculosis of all the layersof the arterial wall, and aneurysms .-with walls com-

posed of tuberculous tissue. The first is by far the com-monest type, while the fourth category, that of tuberculousaneurysm, is represented by only three or four examplesin addition to that now recorded by Professor Haythorn.The patient, a man aged 33, had suffered at 18 from pleurisywith effusion, and at 31 a tuberculous testis was removed.He was now admitted to hospital with symptoms indicativeof spreading tuberculosis of the lungs with a generalisedmiliary infection of the other viscera and ulceration of theintestines. There was a pulsatile swelling below and to theright of the umbilicus, with a systolic bruit over it. He died

shortly after admission, and only a limited necropsy wasallowed. Through the incision a smooth spindle-shapedswelling was felt in front of the right common iliac artery.It was torn in the process of removal owing to its denseadhesion to the tissues lying behind it, but it was not

adherent to the peritoneum, which covered it. It was 7 cm.in length, 4 em. broad, and 3 cm. deep ; its wall was con-tinuous above with that of the common iliac artery and

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below with that of the internal iliac artery, and its cavitywas connected with the lumen of the common iliac artery,the external iliac artery springing from its lower end. Thiscavity was nearly full of reddish-grey clot which appeared tobe caseous. The channel by which it communicated with thearterial lumen was small and appeared to have been formed bya limited rupture of the intima and media, the outer wall ofthe aneurysmal sac consisting of adventitia only. This com.

munication was partially occluded by a polypoid mass ofclot springing from the intima of the common iliac artery ;this clot, as well as that lying within the sac, containedlarge numbers of acid-fast bacilli. Tuberculous lesions were

also found in the lungs, kidneys, spleen, liver, intestines,bladder, prostate, and right seminal vesicle. In Professor

Haythorn’s judgment, the appearance of lesions indicatedan infection of the arterial wall from without inwards ; butwhether from a focus in the vertebral column or the neigh-bouring lymph nodes he was unable to determine. This

interpretation of the case brings it into line with the otherexamples of tuberculous aneurysm of systemic arteries whichhe was able to collect from the literature.

Dr. W. P. Herringham has been re-elected Vice-Chancellorof the University of London.

A PLEA FOR THE APPOINTMENT OF AROYAL COMMISSION ON VENEREAL

DISEASE.BY SIR MALCOLM MORRIS, K.C.V.O.

To insist in a medical journal that venereal diseases cannotbe successfully combated so long as the State holds alooffrom the conflict, and that the time has come for an investi-gation by a Royal Commission of the whole question of theirprevalence and incidence and the best means of controllingthem, is almost a work of superfluity. At first sight it seemsstrange enough that while the State compels local authoritiesto build asylums for the insane, encourages them to makeprovision for the segregation of cases of infectious fevers,enforces the notification of many infectious diseases, andlaboriously builds up a vast system of public health legisla-tion, it chooses to stand aside and permit a disease so highlycontagious and so dire in its effects as syphilis to pursue itsbaleful course unchecked by the least attempt at legislativecontrol. The anomaly can only be explained by referenceto the reticence on sexual subjects which since the Puritanera has been a characteristic of the British mind. I haveno intention of denouncing that mental habit. At its bestit is no offspring of the hypocrisy to which many criticshave pleasantly attributed it. But none the less it isa disastrously mistaken counsel, the effect of which isto allow a free course in - the body politic to grossevils which might be substantially checked were they butfrankly recognised and boldly grappled with. Fortunatelythere are indications that the policy of silence is breakingdown. The blast of public indignation which assisted thepassage of the .Bill to suppress what is popularly known asthe white slave traffic, and the recognition of syphilis as aracial poison in works on social reform intended for generalreading, are evidences that the more enlightened of the laityare coming to see that it is better to bring the force ofpublic opinion to bear upon evil things than to ignore theirexistence. Surely it is not too much to hope that theGovernment will strengthen this essentially wholesometendency by ordering a thorough exploration of the wholesubject of venereal disease.

In these paragraphs I shall deal chiefly with syphilispartly because it is the venereal disease "1ith which mywork as a dermatologist has given me intimate familiarity,but also because, widespread as is gonorrhoea, and serious asare its consequences, especially in women, if left untreated.syphilis none the less forms much the more importantbranch of the subject. If the effects of this disease wereconfined to those who acquire it and those whom they

directly infect with it, the State would still lie under animperative obligation to do what it can to hinder its spreadand mitigate its effects. But the case for legislative actionbecomes incomparably stronger in view of the fact thatsyphilis is one of the rare conditions that can be transmittedfrom parent to child, so that the offspring of a syphilitic maybe born not with a mere predisposition to the disease, as intuberculosis, but with the virus actually in its tissues, tocause, it may be, hideous deformity, or blindness, or deaf-ness, or epilepsy, or idiocy, ending often in premature thoughnot untimely death. Even that is an understatement of thecase, for syphilis is a prolific cause of death before birth. Inthese days of a falling birth-rate and of an internationalrivalry in which the weight of numbers is one of the factorsof national success or failure, a disease which is so frequenta cause of abortion, which at the best diminishes efficiencyand at the worst consigns its victims to our asylums andinfirmaries and workhouses and prisons, or to an early grave,cannot continue to be a matter of indifference to the State.

Syphilis of the 1-innocent.The old view that syphilis is a divinely ordained penalty

for illicit sexual indulgence, and that it is wrong, therefore,to seek to avert it, now seldom finds formal expression.Unconsciously, no doubt, it still colours the thought andfeeling of many. But as a dogma it has gone the way ofthe argument which Simpson had to meet when he began touse chloroform to allay the pangs of difficult labour-that it wassinful to mitigate the penalty attached to childbearing as theresult of woman’s transgression in the Garden of Eden. Evennow, however, the general public are ignorant of the extentto which venereal diseases are innocently acquired. Did theybut know how large a proportion of those who contract thesediseases are the innocent victims of cruel misfortune theirattitude towards this subject would be sensibly affected. Thebabes who are infected before birth with syphilis or at birthwith gonorrhoea which may cause irremediable blindness,the wives to whom these diseases are conveyed by theirhusbands, the children to whom the father’s kiss communi-cates syphilis, the industrial workers who acquire it from theuse of infected implements, the wet nurses who are con-

taminated by the children whom they nourish, the medicalmen and nurses and midwives who are inoculated with it inhandling patients who may not be known to be syphilitic-these make up an immense multitude of those who areentirely innocent of moral wrong. A striking example ofsyphilis insontium was recently recorded by Dr. J. F.Schamberg, of Philadelphia’. Following a benefit per-formance, a company of youths and girls, whose agesranged from 16 to 22, engaged in kissing games. One of theyouths had a sore on the lip, and in due course six girlswhom he kissed developed labial chancres, as also did aseventh girl whom he kissed at another party, while a youngman was apparently infected by kissing one of the girlswhile the contagion was fresh upon her lip. Besides itsimmediate moral, the dangers of promiscuous kissing, theincident suggests more generally the perils of an ignorance ofwhich the last thing that could be predicated is that it is41 wise." " It is more than time such ignorance were ended,and the State should no longer be a party to the conspiracyof silence which yields fruits such as these.

-Zs Syphilis Increasing? /*

If this question be asked, the failure of the State to do itsduty is at once brought into relief. The result of its policyof non-interference is that no statistics are available whichenable an authoritative answer to be given. I do not pro-pose on this occasion to discuss such facts as bear upon the

question, for they are admittedly inconclusive ; but when oneremembers the ease with which syphilis is communicated,and the absence of any systematised effort to treat it andcheck its spread, the antecedent probabilities are against anysuch diminution in this disease as has been effected, mainlyas the result of public health legislation, in many others.That syphilis has an extremely wide distribution everymedical man knows. In the illuminating discussion onSyphilis by the Royal Society of Medicine last year it wascalculated by Dr. Douglas White that in London there are40,000 fresh cases of syphilis every year, and in the UnitedKingdom as a whole 130.000 cases. This i" but an estimate,but my own observation during a long professional careerinclines me to believe that it is at least as likelv to be anunder- as an over-calculation.

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