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rarity of rheumatism in warm damp climate. Thisobservation also applies to countries where hot

vapour baths are part of the ordinary routine of life.He makes an interesting suggestion about physiologyand rheumatism. Deficient oxidation in the tissues asa cause of local acidosis appears to me to be a conditionwhich needs much study. In this connexion GowlandHopkins’s observations on Glutathione are particularlyinteresting. Further, the work of Marsh in Persiaon blood lactic acid and chlorides in heat strokedeserves consideration.

I agree that one should not always think ofbacteria, but I think that the study of antidotes tobodily toxins is even more important than that ofthe bacterial soil.

I am, Sir, yours faithfully,HENRY W. HALES.

Portland-place, W., July 28th, 1933.HENRY W. HALES.

CARDIOVASCULAR SYPHILIS

To the Editor of THE LANCET

SIR,-I was much interested in Dr. Noble Chamber-lain’s article on this subject in THE LANCET of

July 1st, since a lengthened experience with circu-latory diseases has convinced me that the syphiliticelement in cardiovascular diseases is not sufficientlyrecognised, especially in patients over 50 years ofage. I desire to call attention to a sign which Ihave frequently noted in these cases-viz., hyper-algesia over the neighbourhood of the sternum.

This is especially found in a,ortitis, a condition generallyof syphilitic origin. The method of applying thetest is this. A large needle with a blunted endor similar instrument is held at an acute angle withthe chest wall well to the right of the dull area,gentle pressure is made, and the line carried across

the sternum beyond the left margin of the dullness.No pain is experienced at first, but soon the patientflinches and complains of sharp pain, which ceaseswhen the needle arrives beyond the left line of dullness.It is to be noted that this super-sensitiveness to

pressure diminishes along with an improvementin other symptoms under treatment. A minorcondition of puffiness (not very soft) is generallyfound over the sternum.

Failure to recognise the syphilitic element in thesecases is partly due to the fairly healthy appearanceof the patient and, when suspicion of its presence isaroused, a too implicit reliance on the Wassermanntest, especially a single one. Even in spite of a

negative test the patient should not be denied thebenefit of specific treatment when clinical evidencewarrants it. In treating these cases I have foundiodides the most reliable drug, aided by a two tothree weeks’ addition of half drachm doses of liq.hyd. perchlor. The dose of iodide may be increasedfrom grs. 5 to 20 three times a day.

I am, Sir, yours faithfully,CHARLES W. CHAPMAN.

Wimpole-street, W., July 28th, 1933.CHARLES W. CHAPMAN.

PUBLIC HEALTH SERVICES

Maternal MortalityON July 15th the National Federation of Profes-

sional Workers wrote to the Minister of Health

expressing its anxiety " at the evidence to bediscerned in some quarters of a dangerous desire toeconomise " in maternity and child welfare services.Sir Hilton Young has replied, saying that "themaintenance and development of these vital servicesis, by common agreement, a matter of first necessity,"and promising that full advantage will be taken of thespecial opportunity afforded by the general surveyof the health services of local authorities by medicalofficers of the Ministry now in progress to press fornecessary developments. He adds : " Publicity hasbeen given to a statement that there has been arecent deplorable increase ’ in the maternal death-Tate. The deaths per 1000 live births during 1932were indeed 4-21 as compared with 4-11 in 1931, anincrease of 0-01 per cent. of live births. The rate for1932 was, however, lower than that for the threepreceding years, 1928-30, which were : 1928, 4-42;1929, 4-33 ; 1930, 4.40... It is indeed a matter ofconcern, with which we cannot be satisfied, that thematernal mortality-rate, although it has shown noincrease of any statistical significance, has not shownthe same marked and satisfactory fall that has beenshown of late years both by the general death-rateand notably by the infant mortality-rate. It is thisthat makes it necessary to press ahead wherevernecessary with raising the standard of the relevantservices. But it can serve only to weaken our attackupon the evil to attach an exaggerated significanceto minor variations in the rate, and to attributethem to causes with which they are wholly uncon-nected." The number of antenatal clinics increased

by 84 during 1932, and there was an addition of274 maternity beds during the year. "These facts,"the Minister claims, "show that local authorities are

continuing to improve and increase the maternityservices."

INFECTIOUS DISEASEIN ENGLAND AND WALES DURING THE WEEK ENDED

JULY 22ND, 1933Notifications.-The following cases of infectious

disease were notified during the week :-Small-pox,4 (last week 15); scarlet fever, 2384 ; diphtheria,827 ; enteric fever, 62 ; acute pneumonia (primaryor influenzal), 466 ; puerperal fever, 46 ; puerperalpyrexia, 103 ; cerebro-spinal fever, 22 ; acutepoliomyelitis, 14 ; acute polio-encephalitis, 1 ;encephalitis lethargica, 8 ; dysentery, 2 ; ophthalmianeonatorum, 89. No case of cholera, plague or typhusfever was notified during the week.The number of cases in the Infectious Hospitals of the

London County Council on July 25th-26th was as follows :Small-pox, 27 under treatment, 0 under observation (lastweek 33 and 0 respectively) ; scarlet fever, 2120; diph-theria, 1627 ; enteric fever, 18 ; measles, 573 ; whooping-cough, 390 ; puerperal fever, 29 (plus 12 babies) ; encepha-litis lethargica, 256 ; poliomyelitis, 1 ; " other diseases,"209. At St. Margaret’s Hospital there were 21 babies(plus 8 mothers) with ophthalmia neonatorum.Deaths.-In 118 great towns, including London,

there was no death from small-pox, 3 (2) from entericfever, 17 (2) from measles, 9 (2) from scarlet fever,21 (12) from whooping-cough, 32 (10) from diphtheria,50 (6) from diarrhoea and enteritis under 2 years,and 12 (1) from influenza. The figures in parenthesesare those for London itself.

Ashton-under-Lyne reported the only death from entericfever outside London. Measles was fatal in 4 cases atLiverpool, 2 each at South Shields and Birmingham.Four deaths from diphtheria occurred at Liverpool, 2each at Croydon, West Ham, and Huddersfield. Of thedeaths from diarrhoea outside London 14 were reportedfrom Liverpool and 3 from West Bromwich.The number of stillbirths notified during the weekwas 260 (corresponding to a rate of 39 per 1000 totalbirths), including 46 in London.