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1000. The state of vaccination in Egypt is shown in the Isubjoined table :- I

According to the census of 1897 the number of Bedouins dis-tributed throughout Egypt was 602,139, the largest con-tingents being located at that time in the provinces ofBehera (103,626), Sharkia (91,633), and the Fayoum (60,555).It is impossible at present to give further vital statistics

regarding these nomads but it is believed that vaccination isfairly well established among them.

HYOSCINE-MORPHINE-CACTIN ANÆSTHESIA.

IN a recent number of the International Journal of 81/;’1’-gery Dr. Emory Lanphear of St. Louis, Missouri, recom-mends the use of a combination of hyoscine, morphine, andcactin for the production of narcosis in country practiceand in labour. He has used it with satisfactory results in300 major surgical or severe obstetrical operations. The

narcotic is prepared in the form of tablets, each contain-ing th of a grain of hyoscine hydrobromide, a quarter ofa grain of morphine hydrobromide, and 11-the of a grain ofcactin, the last being a product derived from cereus

grandiflorus, the night-blooming cereus. Dr. Lanphearstates that under the influence of two, or at most three,tablets the most severe and prolonged operations may beperformed in country practice with apparent safety. The

hyoscine so completely antagonises the poisonous propertiesof the morphine that there need be no hesitation in usingthree tablets in three hours if two doses do not produce thedesired effect. The narcosis is too profound and the sub-sequent sleep is too long to warrant the use of this combina-tion in minor surgery. It is injected into the arm, the first

dose three hours and the second one and a half hoursbefore operating, a third dose being administered ifneeded when the patient is put upon the table. In cases

of accident requiring an operation the cactin soon decreasesthe shock and the patient soon becomes tranquil andpartially narcotised under the influence of the morphine andhyoscine. In employing this narcotic mixture the respira-tion frequently falls as low as eight per minute, while thepulse remains normal or becomes slightly accelerated, butthe respiration usually becomes normal during, or soon after,the operation. This statement appears to conflict with the

assertion that hyoscine antagonises morphine in this com-bination. If the patient breathes less than six times perminute he should be awakened from time to time by shaking,but so long as the pulse is good and the face is red (i.e., notpurple) there is no serious danger. Dr. Lanphear hasneither experienced nor heard of any serious results or

unpleasant experiences from the use of this anae3thetic. It

does not materially interfere with uterine contractions, andso far as is known it does not affect the foetus in any way.It should usually be given only after the os uteri is dilatedso far as to admit two fingers. In one and a half hours asecond dose may be injected if required, and after half anhour, unless the patient is unusually nervous, forcepsdelivery may be made. Occasionally a third dose may be

necessary in contracted pelvis or for Csesarean section.

Hyoscine and scopolamine have been largely used, bothalone and in combination with morphine, and it is only rightto point out that other workers have been less fortunate intheir cases than Dr. Lanphear appears to have been.

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Whether cactin is an active and efficient addition to our

armamentarium we think has yet to be proved.THE CARE OF THE TEETH.

THE whiteness and beauty of the teeth of the African

negroes are generally ascribed to the food which they eat andto favourable climatic conditions, but, according to a recentissue of the Midrc;hener lediNnisele WochenscMift, theseignorant natives take special care of the teeth and arefamiliar with many remedies for the treatment of dentaldiseases. From the observations of officials in Germancolonies it appears that the natives exercise more care in

preserving the teeth than do most Europeans. They may owethe possession of sound teeth of ivory whiteness partly tothe influence of environment and habits, but in addition

they employ many herbs, barks, and juices as prophylacticand curative agents. Thus, in Ngumba it is customarywhen a child has finished teething to rinse the mouth with aninfusion of the leaves of the sson tree with the objectof tightening the teeth. The action of the infusion is.

probably due to the presence of a styptic constituent in theleaves which causes the gums to shrink. The natives livingnear the source of the Nile employ the roots of a leguminousplant, Dalbergia rnelanoaeylon, to relieve toothache, while the-natives to the west of the source of the same river use aninfusion of the seeds of kasso, a climbing vine, for the same-purpose. It is interesting to notice that the use of thetooth-brush is not restricted to the so-called civilised peoples.The African negroes fashion tooth-brushes out of the woodof a species of adansonia and other trees. In this respectthe natives probably have an advantage over those who nsean ordinary bristle tooth-brush which is frequently used forsix months or even longer-indeed, until it becomes too

offensive to be tolerated longer. The sticks of wood suchas the natives employ are, on the other hand, easy tomake and cost nothing, and they are probably usedfor only a short time. They would possess the addi.tional advantage of offering less opportunity for particlesof food and other debris to be retained mechanically than is.the case with a bristle brush.

ACUTE TENO-SYNOVITIS AFTER TONSILLITIS.

IT is now recognised that tonsillitis frequently precedesrheumatic fever. Indeed, some authorities, such as Pro-fessor William Oler, go so far as to say that there is alwaysa primary infection in the lacunas of the tonsils to which therheumatic fever is secondary. Recent writers have reportedother diseases as sequential to tonsillitis-acute nephritis,acute endocarditis (without the intervention of rheumatism),meningitis, and septicmmia. It appears that the tonsils

may be the portal of entry of the microbes in these andother diseases. In the Boston Medical and SU’I’,qical Journalof July 25th Dr. E. A. Tracy has reported two cases ofacute teno-synovitis following acute tonsillitis-a sequencethat does not previously seem to have attracted atten-

tion. In the first case the patient was a man, aged 2Byears, who sought advice for an affection of the foot.A week previously he had tonsillitis from which he re-

covered without medical treatment. He was in bed, hadmoderate fever, and complained of pain in the left ankle.On attempting to move the joint great pain was felt.There were marked swelling and tenderness over the commonsheath of the peroneal tendons, which evidently containedfluid. Under salicylates and local elastic pressure recoverytook place in a week. In the second case, a man, aged 35years, had acute tonsillitis for a week and was treated withdomestic remedies. A few days after this subsided he hadan acute attack of pain in the feet and in the region of thelower part of the tendo Achillis. He came under observation

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towards the close of this attack when tenderness was con-fined to the lower third of each tendo Achillis and painoccurred when the tendons were put in motion. Absolute

rest and painting with tincture of iodine were ordered andrecovery took place in three days. That tonsillitis is liableto be attended with serious complications is not sufficiently’appreciated. People, as these cases show, often fall intothe error of regarding it as a trivial affection which they arecompetent to treat. -

DIRECT INFECTION IN ENTERIC FEVER.

SOME attention has recently been directed to the possi-bility of direct infection in enteric fever, of the same natureas occurs in measles or scarlet fever, as opposed to the well-recognised mode of conveyance by drinking water and milk.An outbreak which occurred at the State Hospital, Trenton,New Jersey, affords a good illustration of the possibilityof direct conveyance from patient to patient under favour-able conditions, though it does not throw much lighton the possibility of contagion when ordinary measuresof cleanliness are carried out. In this instance a case

was admitted to the west wing of the asylum, and

ultimately 80 cases occurred in the main building,of which this was a part, whereas none occurred in theannex which was dependent upon the same supplies ofwater and milk. Clearly direct conveyance was at

work, and this was easily explicable by the dirtyhabits of the inmates, owing to which contamination of

bathrooms, door-knobs, and furniture was unavoidable,while spoons and forks were washed by the patients withoutboiling water and could scarcely escape infection. Casesfrom time to time occur in our hospitals in which a patientoccupying the next bed to a sufferer from enteric fevercontracts the disease. These are usually ascribable to somedefect in the precautions taken by the nursing staff. The

question which it is of importance to settle is whether with-out any direct conveyance of germs on eating utensils orother such vehicles an air-borne infection exists. This is

not yet satisfactorily decided, but it must at any rate be

regarded as a rare occurrence in view of the infrequency ofsuch cases in general hospitals to which cases of entericfever are admitted in company with sufferers from otherdiseases.

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BUTTERMILK IN THE FEEDING OF INFANTS.

Dr. H. C. Carpenter of Philadelphia has recently advocatedthe feeding of infants with buttermilk in cases of gastro-intestinal disorders and infantile atrophy and in view

of a recent correspondence in our columns we think

his observations of interest.l Buttermilk contains on

an average from 0’5 5 to 1’5 5 per cent. of fat, thoughsometimes there is as little as 0’25 per cent. From2 to 3 per cent. of proteid is found in average samples ofbuttermilk. The calcium casein of ordinary milk undergoesa change to casein lactate during the preparation of butter-milk. It is noteworthy also that buttermilk contains a higherproportion of albumin than does ordinary milk. Infantstake it readily and it causes no unpleasant effects. A fewvomit slightly during the first one or two days. Dr.

Carpenter considers that the advantage of buttermilk is duenot so much to the low proportion of fat as to the greaterease with which the proteids are digested. Severalinfants who were unable to digest milk containing0-75 per cent. of calcium casein were able to digest the2 to 3 per cent. of casein lactate in buttermilk. At the

Philadelphia Hospital the following method is employed inpreparing it. A pint of fresh milk is allowed to stand for24 hours in a jug covered with a cloth at a temperature ofTom 65° to 700 F. The cream is then skimmed off and thesour milk is churned for 15 minutes in a glass churn of the

1 THE LANCET, Sept. 7th (p. 733) and 14th (p. 794), 1907.

capacity of one quart. It is then placed on ice and is fit foradministration during the next 24 hours. At this hospital itis given in the form of a food, which is prepared as follows.A quart of buttermilk is added gradually at first with

constant stirring to one teaspoonful of wheaten flour and fourtablespoonfuls of granulated sugar. The food is then heated

just to the boiling point in a double saucepan with constantstirring, care being taken not to curdle it by excessiveboiling. It is cooled rapidly and kept in bottles readyfor use.

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THE ORIGIN AND PREVALENCE OF ENTERICFEVER IN THE DISTRICT OF COLUMBIA.

. THE ’enteric fever problem in any one city or country isnot radically different from that in many other communities.Enteric fever forms a world-wide problem. The disease isendemic in almost every civilised community. The pre-valence of the disease in Washington has long been a

matter of concern to the inhabitants of the District ofColumbia. The visitor to Washington observing the broadboulevards and the stately buildings and the general air ofbeauty and cleanliness of the city is surprised to learn thatthe death-rate is comparatively high, especially from entericfever. As the water of the Potomac, the source of the water-

supply, was considered impure a large expense was incurredin constructing sand filters, under the supervision of theEngineering Corps, United States Army. The filtered waterhas been supplied to the city since November, 1905, and yetthe disease assumed an epidemic form in July, 1906.

Arrangements were then made for almost the wholeforce of the hygienic laboratory, under Surgeon-GeneralWalter Wyman, to cooperate with Dr. William C. Wood-ward, the health officer of the district, in orderto solve the problem. The results of several months’work have recently been published. I The investigations in-clude a sanitary survey of the Potomac watershed; an

epidemiological study of 866 cases of the disease ; dailychemical and bacteriological examinations of the water-

supply ; an examination of pumps, wells, springs, ice and icefactories, bottled waters, shellfish, salads, fruits, and otherfoods ; and an inspection of dairies and laboratory examina-tions of the milk-supply. Special attention has been paid tothe communicability of the disease from person to person bydirect or indirect contact. The relation of privies and sewersto wells has been studied and the question of flies and otherinsects as carriers of infection has received attention. The

bathing beaches and public markets have been inspected.Finally, many specimens of fseces have been subjectedto examination in order to determine the possiblerelation of animal parasites to the disease. The reportcontains numerous maps, charts, diagrams, and curves andforms a most comprehensive monograph on the subject. It

, affords valuable information to medical officers of health in: any part of the world because the situation in Washington, has been studied, not only with regard to local requirements. and conditions, but also in relation to studies made of theI disease in other countries.

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r

TiiE next International Congress on Tuberculosis, held

. under the auspices of the National Association for the Study: and Prevention of Tuberculosis, will meet in Washington on

l Sept. 21st to Oct. 12th, 1908. Dr. Theodore Williams, who,

has been elected a Vice-President of the Association in the

: room of the late Sir William Broadbent, has accepted an

: invitation from the committee to deliver one of the speciali addresses at Washington.

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r THE Department of Public Health of Queensland, in aE bulletin dated August 24th, states that no case of plague has’ occurred in Brisbane since July 26th. As regards the

1 Bulletin No. 35, Hygienic Laboratory, United States Public Healthand Marine Hospital Service, p. 361, 1907.