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t.ically never came across a normal thyroid, and whenit was normal it belonged nearly always to a foreigner.It is easy to understand that under such circumstancessurgery of the thyroid gland has gained an importantposition in this country. Kocher, of Berne, laid thefoundations for the operative technique which wasafterwards further developed by Roux and DeQuervain. The operation for goitre is a routine

operation in our hospitals which is undergone everyyear by several thousands of patients. The aetiologyof goitre has been studied by a large number ofmedical scientists but no clear result has been broughtforward. For some time the geological theoryadvocated by H. Bircher was generally accepted, butin recent years several investigators have been able toprove its fallacy. Our ignorance regarding theaetiology was probably the reason why the prophylaxisof goitre was long neglected. Steps are now beingtaken to remove this reproach. The Federal HealthOffice has appointed a Goitre Commission which willsuggest the best methods for an extensive prophy-lactic campaign against goitre. Following an Americanexample, Dr. Klinger, of Zurich, has shown what asystematic prophylaxis can do. Under his supervision761 school children in six villages of the canton ofZurich received during 15 months every week onetabloid containing 10 mg. iodine plus cacao and sugar

(chocolate-iodostarin of the Hoffmann-La Rocheworks). At the beginning of the treatment 90 per cent.of the children had goitre, after 15 months’ treatmentonly 28 per cent.

Puplic Health Services.WILLESDEN MUNICIPAL HEALTH SERVICE :

A BASIS FOR COOPERATION.WE recently summarised 1 the interchange of view

between Willesden Urban District Council and themedical practitioners in the Willesden area regardinglocal public health administration. On March 1stthe Council approached the Willesden division of theB.M.A. (to which for brevity we allude hereinafter asthe " Association ") with the request for a scheme ofcooperation. The Association has now replied, byresolution of the division, dated March 21st, submittingthe following basis for consideration of the Council :-

1. Advisory Medical Council.-Recognitioi-i by the Councilof an advisory medical body to be elected by the medicalpractitioners of Willesden and consulted by the HealthCommittee on all matters affecting the municipal medicalservices. The modification of the existing service to standreferred to this body in the first instance, the Council tohave the final decision.2.Municipal Hospital.-To be restored to its original use

as an isolation hospital, other cases to be provided for byarrangement with other institutions.

3. School Children.-Routine inspection of all age-groups,as prescribed by. the Board of Education, to be carried outin addition to such special inspections as may be determined.All defects other than those in cleanliness, clothing, andfootgear, and such special conditions as may be determined, tobe referred for treatment to the family doctor, who shall havethe right if he thinks that the best course in the interests of hispatient to refer the case to be dealt with through the schoolservice. The cost of treatment through the school serviceto be recovered from the parent in all but necessitous cases.

4. lYlccternity and Child V’elfnre.-The activities of thecentres to be confined, in the first instance, to preventivework, in accordance with the instructions of the Ministry ofHealth, such work to be gratuitous. Cases requiring treat-ment to be dealt with on the method indicated above inconnexion with the treatment of school children.

5. Staff.-Specialist services to be carried on as at presentby the Council’s part-time specialists. Medical inspectionof school children to be carried on for the present by theCouncil’s whole-time medical staff. Vacancies in the clinicsto be filled by advertisement and local practitioners (part-time) to h,.ve the preference-We understand that, with the approval of the

Association, Dr. W. Lock, Dr. D. V. Muller, andDr. G. W. R. Skene are standing as medical candi-dates at the municinal election to be held on ADril 1st.

1 THE LANCET, Jan. 21st, p. 150.

THE ISOLATION OF WIlOOYING-CUUGH.In this country most of the local sanitary authorities

require that persons suffering from whooping-coughshall be isolated for six weeks from the beginning ofthe illness. Opinions, however, are frequentlyexpressed that, when the catarrhal stage has passed,the patient no longer gives rise to infection. In theforty-third annual report of the Local GovernmentBoard 1913-1 for England and Wales, it is statedthat :-

" If the bacillus pertussis described by Bordet and Gengoube accepted as the cause of whooping-cough, it is significantthat the expectoration contains very few of these bacilliafter the first 14 days of illness. The complications, such aspneumonia, which subsequently supervene are due to invasionby other bacilli and streptococci. The observation as to therarity of the specific bacillus in the expectoration after thefirst fortnight of the attack gives some support to the opinion,held by some as the result of clinical experience, that thedisease is not infectious in its later stages. In New York,where arrangements have recently been made for hospitalprovision for whooping-cough, it is proposed to dischargeuncomplicated cases from hospital when this period ofmaximum infectivity is over. In practical experience inthis country, whooping-cough frequently remains unrecog-nised during the first 10 or 14 days of the attack."*

In view of this statement a communication wasaddressed to the Commissioner of the Department ofHealth of the city of New York, Dr. Royal S. Copeland,who has kindly consented to the publication of hisreply which reads :-

’’ The assumption that the Bordet and Gengou bacillusis the cause of whooping-cough is probably correct. Whileit appears to be undoubtedly true that the period of greatestinfectivity exists before the beginning of the whoop andcontinues for about two weeks thereafter, it has neverthelessnot been proved that infection at the expiration of two weeksafter the onset of the whoop is unlikely to occur. It, there-fore, seems to me that the purely arbitrary quarantine periodof two weeks from the definite onset of the disease with orwithout whoop is probably insufficient for the preventionof the spread of this disease.

" Although the regulations of the health department ofthe city of New York still conform to this purely arbitraryrule of two weeks quarantine for pertussis, we are consideringa modification of this rule in order that we may err on theside of caution and safety in a disease which has come to berecognised as one of the grave communicable diseases.I do not feel satisfied with our present regulations. In theabsence of conclusive proof that the Bordet and Gengoubacillus is the cause of whooping-cough, and in the absenceof knowledge of the average duration of the period ofinfectivity in these cases, it is most difficult to commitoneself to the formulation of a quarantine period, which willat one and the same time be based on scientific knowledge,and practical from an administrative viewpoint.

*’SupposiDg that the maximum infectivity in typhoidfever is ended about 10 or 12 days after the temperaturehas fallen to the normal level, would we be justified, therefore,in making a flat rule for the termination of quarantine inall cases, losing sight of the fact that the continued dischargeof typhoid bacilli by even a small number of persons may besufficient to cause a, great epidemic, if overlooked ?

" To sum it up, I do not believe that when a child beginsto whoop, the infectious stage is over, and I am stronglyof the opinion, though I cannot prove it, that even two weeksafter the onset of the whoop, many of the cases may stillbe discharging large numbers of the infectious organismresponsible for the disease."

Dr. Copeland concludes with an expression of hisbelief that most public health bodies have been toolax in the enforcement of compulsory notificationand in efforts to effect at least a moderate measure ofcontrol in the isolation and quarantine of whooping-cough cases. ____

CYPRESS OIL IN WHOOPING-COUGH.In a special report presented to the Poplar Public

Health and Housing Committee, the medical ofticer.Dr. F. W. Alexander, calls attention to the 44 deathsfrom whooping-cough which occurred in Poplarduring the six weeks ended Feb. llth, and to thedoubt as to how many deaths included under thevarious respiratory diseases were not also due to

whooping-cough in its primary catarrhal stage. Hethen goes on to quote the experience of the late Prof.Otto Soltmann, director of the Leipzig Children’s

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Hospital, who found that in all cases of whooping-cough, both in older and younger children, cypress oilreduced the number of paroxysms promptly andrapidly, and generally prevented the occurrence ofcomplications. Cypress oil, Dr. Alexander adds, canbe taken internally on sugar, in doses of 1 or 2 minims ;pastilles, also, are made containing one minim of theoil, or the bedding of the patient may be sprinkledwith an alcoholic solution of the oil, one part tofour or five parts of alcohol. Cypress oil being scarceand costly, Dr. Alexander suggests its issue to thepatient in the form of a liniment mixed with camphor-,ated oil; 2 oz. of this liniment in a poison bottlecould be supplied at a cost of Is. Expenditure wouldbe nearly all recovered through persons purchasingthe liniment, as other medical sundries are sold at thematernity clinics. Cypress trees not being scarce,Dr. Alexander concludes that if the oil could bedistilled in quantities at low cost, it would be advisableto use it for spraying the air of maternity clinics,schools, and kinemas as a possible preventive duringepidemics. ____

CONTINUITY OF TREATMENT IN VENEREAL DISEASE.In his report to the sanitary committee of the City

of London for the seven weeks ended Feb. 18th, Dr.W. J. Howarth submits a table showing the number ofpatients suffering from syphilis and gonorrhoea whoceased attending the City treatment centre beforecompleting the course of treatment, and the number ofthose who completed the course and were proved to becured. In the case of syphilis the figures were 181 and95 ; in the case of gonorrhoea 640 and 312. In otherwords, not more than one-third of the cases completed their treatment. Dr. Howarth describes this as a mostunsatisfactory state of affairs and one which affectspractically every treatment centre in the country. Hesubmits that the time is now ripe for joint discussionof a difficult problem and suggests an invitation to theN.C.C.V.D. to call a conference at the Guildhall ofrepresentatives of sanitary authorities, Poor-lawauthorities, and the medical profession, with the objectof considering how continuity of treatment up to thepoint of freedom from infection can be best secured.Such an opportunity would, he thinks, be generallywelcomed.

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SCHOOL DENTISTRY.

School dental work is steadily growing in popu-larity with the parents of the children whose teethare cared for. Mr. C. Doswell Wallis makes thisclear in his review of a school dental scheme for WestSussex in the third issue of a little journal entitledOral Topics (January, 1922). This growing popu-larity has its drawbacks when the call for economy.dogs the footsteps of the hygienist. In Hampshirevoluntary effort has provided the Eastleigh centrewith a dental chair at a cost of £52, but the EducationCommittee has failed to provide a dentist to use it.The -3-,Iedical Officer in a recent number refers to avery practical suggestion made by Dr. S. Barwisethat women should be specially trained to act asdressers to dental school clinics. Dr. Barwise’s

suggestion is based on the experiences gained in con-nexion with a school clinic at Chesterfield. Thedental dressers there examine the teeth of the childrenwith probe and mirror, chart the intervention required,and select the children to attend the clinic, wherethey are examined by the dentist, who then marksthe work he considers necessary. A certain amountof this work is then carried out by the dresser, suchas cleaning, the removal of tartar, polishing, applyingdressings, the extraction of temporary teeth wherethis involves no difficulty, the preparation and fillingof simple cavities in the temporary and permanentteeth. This solution of the dental personnel questionis admittedly practical, but grave doubt ariseswhether such work can safely be entrusted to dressers.Some of the objections were stated in our review1 ofthe annual report for 1917 of the chief medical officer

1 THE LANCET, 1918, ii., 891.

of the Board of Education. It is most necessary forevery school child to pass an inspection by the schooldentist, and it seems to be overlooked by the advocateof the scheme outlined above that the proper prepara-tion of cavities in the teeth of a child requires con-siderable judgment. The methods of dealing withdental disease in children have undergone consider-able changes during recent years. Dirty teeth anddeposits of calculus are in large measure due to mouth-breathing and the presence of septic roots, and therestoration of nasal breathing, along with removal ofseptic teeth, is the first stage in well-considered dental

treatment. When these are remedied little remainsto be done in the way of polishing, cleaning, andscaling. Dressings are only needed for exposedpulps, and the dental surgeon must decide when itis desirable to retain such teeth. Improvement ofthe teeth of the nation will make slow progress unlessit is recognised that the primary function of theschool officer is to teach prevention. It should bethe duty of the dental nurse to instil this into theminds of children and parents. The causes of toothdecay should be explained, attention drawn to theharmful effects of sweets and soft starchy food, andclear instructions given about the artificial cleansingof the teeth.

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THE PROVISION OF DRUGS FOR INSURED’

PERSONS.’ The question of the provision of medicine forinsured persons has been arousing considerable con-. troversy in South Wales, and in a recent issue of theWestern Alail appears a statement that the advent

of the chemist has added very materially to the cost, of administration. In support of this statement the

following reasons are given : the cost of the com-mittee work, in time and money, taken up in con-sidering cases of over-prescribing ; the cost of thebureaux which price each individual ingredient ofeach prescription, make out and check the chemist’saccounts ; the cost of the prescription forms, whichnumber millions in the larger areas, and the amountpaid in dispensing fees. The average fee for dis-pensing a prescription is at present 4-72 pence, andthe sum paid out annually in dispensing fees amountsto nearly as much in the aggregate as the cost ofdrugs and appliances supplied. The answer to thequestion, Why was the chemist brought into the Act ?is, if we remember aright, that the originators of theinsurance scheme consulted high medical authoritiesin the persons of two regius professors of medicinewho strongly advised the separation of prescribing,the province of the physician, from the dispensing ofdrugs, the province of the pharmacist. But whileit is for the good of the insured person that these twoarts should be kept distinct, the present systemdemonstrably leads to extravagance and incon-venience. Insurance practitioners as a whole couldnot and would not do the dispensing for their insuredpatients, but the present system leaves much to bedesired in its organisation. Just as suggestions havealready been made for central combined surgeries,so it would afford one solution of drug difficulties ifcentral dispensaries were established with qualifiedpharmacists always in attendance. The drug fundis at present financed by the Treasury, and somemeans of controlling expenditure will always berequired, but the method of payment for the chemist’sservices and for the drugs he dispenses may requirereconsideration in view of the urgent need for economy.We doubt, however, whether a salaried service inpharmacy can logically be demanded by those whoobject to a salaried service in medicine.

NORTH OF ENGLAND OPHTHALMOLOGICAL SOCIETY.At a meeting of this society held on March 10th the followingwere elected to the committee: President, Mr. G. H.Pooley, Sheffield ; Vice-President, Mr. Thomson Henderson,Nottingham ; Treasurer, Mr. Harry Lee, Leeds ; Secretary,Mr. Percival J. Hay, Sheffield ; Members of Council, Mr.J. Gray Clegg, Manchester, and Mr. A. L. Whitehead,Leeds.