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of thymol in commercial alcohol proved a reliable anti-mycotic agent, and it is interesting to note that anincrease in the concentration of the drug did not haveany marked influence in reducing the times-minutesfor the mycelial group, and hours for the yeasts-in which the results were achieved. Kadisch statesthat silk stockings, for instance, can be disinfectedof all mycotic organisms, both fungi and yeasts,by six hours’ immersion in this fluid.

GYNÆCOLOGY IN VIENNA,

THE large volume before us 1 describes the techniqueof operative gynaecology employed at the First

University Women’s Clinic, Vienna, and the resultsobtained there. The opening section is devoted to adescription of the precautions against infection,anaesthesia. (including a very detailed descriptionof local and sacral anaesthesia), post-operativecomplications, general operative technique, and

preparatory and after-treatment. The second sectionis given to anatomy, and the third and last sectionto descriptions of the various gynaecological operations,starting with cancer of the cervix, to which 160 pagesare devoted, mostly occupied by a detailed description,with plates, of the extended vaginal operation whichis chiefly used by the authors, though a very full andbeautifully illustrated description of radical abdominalhysterectomy is also given. The numbers of casesdealt with are impressive. Thus between the years1901 and 1920 were seen 1787 cases of cancer of thecervix, and from 1921 to 1925 a further 461 cases, ofwhich 258 were operable-an operability-rate of 56 percent., the primary mortality-rate being 6.6 per cent.In most cases the extended vaginal operation wasdone. From Jan. lst, 1921, to May 31st, 1922,161 cases were seen, and of these, 92 came to operation,82 of which were done by the vaginal route, and 10by the abdominal. In this group the primarymortality was 9-8 per cent., the five-year cure-

rate being 26-7 per cent. of all cases seen (161).The results which are given in detail will repay carefulstudy. Few cases seem to have been treated by radium,and the results obtained are, on the whole, poor,though of 249 inoperable cases treated by radiumbetween 1913 and 1919, 26 (10.5 per cent.) were wellin 1924. From 1921 to 1925 (five years), 921 myomaswere seen in the clinic, 620 of which came to operation.In 349 vaginal hysterectomy was done with onlyone death, while supravaginal hysterectomy was

carried out in 176 cases with six deaths, and totalabdominal hysterectomy in 69 cases with six deaths ;the total death-rate in the series being 1-6 per cent.Cancer of the cervical stumps the authors found to berare, only eight cases in 1253 supravaginal hysterec-tomies. As the frequency of cancer of the cervixin the general population is 0-025 per cent., theconclusion is reached that subtotal hysterectomypredisposes to cancer in the stump. Since howeverthe patients know that menstruation has finished,and therefore do not expect bleeding, they comeearly, and so most cases are operable. The absenceof menstruation and accompanying hyperaemia tendto limit infiltration of the parametrium, so that of 13cases in the authors’ experience only two were inoper-able. Of metropathia hsemorrhagica 580 cases wereseen in the five years from 1921 to 1925 ; of these,

1 Gynäkologische Operationslehre. By Dr. Heinrich Peham,Professor of Obstetrics and Gynæcology at the I UniversityFrauenklinik in Vienna, and Dr. J. Amreich, Privat dozentin the University, and sometime Assistant at the Frauenklinik.With 448, mostly coloured, original illustrations. Berlin:S. Karger. Pp. 766. RM.140.

239 were treated by vaginal hysterectomy, of whichfour died, and 332 were treated with X rays-success-fully in all but seven cases. In treatment of cancerof the body, operation by the vaginal route is againfavoured. The results from radium have been poor; xit was used in nine cases, of which seven were operable,and only one of them was completely cured. For retro-version the Baldy operation is preferred. Eighteenpages and 15 colour plates are occupied with inter-positio uteri. A feature of the book is the beauty ofthe illustrations, all but two of which are original.The book, which is a notable addition to gynaeco-logical literature, constitutes the last work from thepen of the late Prof. Peham, and really amounts to arecord of his unique and lifelong experience.

SERUM IN ACUTE POLIOMYELITIS.

THE value of immune serum in the treatment ofthe acute stages of anterior poliomyelitis is nowfirmly established,1 but it is difficult to get a readyand sufficient supply. In America some workershave adopted the practice of collecting and poolingsmall quantities from patients recovered from thedisease. This, however, is not altogether devoid offallacies, as Shaughnessy, Harmon, and Gordon a

have shown, since they found that of seven personswho had been attacked by poliomyelitis from 6 to 24months previously in only four was the serum potentto neutralise the virus. But in addition theseworkers confirmed the previously recognised fact thatthe serum of many people who have never sufferedfrom the disease contains immune bodies in highconcentration. For these reasons H. K. Faber 3,

urges firstly, that all convalescent serum intended tobe used therapeutically should be tested, and,secondlv, that bv testina the serum of transfusiondonors a large and readily accessible supply ofimmune serum could be obtained. It was foundthat 77 per cent. of the donors tested were immuneand use was made of this fact in the recent epidemicin California with satisfactory results. M. Neustaedter 4has attacked the problem from a different aspect.Despite Flexner’s original failure, he has attemptedto immunise horses to the virus of poliomyelitis,and he succeeded in producing a serum which is

capable of protecting monkeys from large intra-cerebral injections of potent virus. Pettit and otherFrench workers have confirmed his findings and reportthe successful use of this serum clinically. In thiscountry R. W. Fairbrother and W. T. J. Morganhave done a good deal of work on the immunisationof horses, and a limited supply of their serum isavailable for tria1,1 but so far they have not drawnconclusions about its clinical efficacy.5 5 Meanwhilethese results are of great interest, and prompt oneto hope that eventually we shall have a supplyof efficient serum for use whenever necessary.

VITAMIN STANDARDS.

I THE vitamins enjoyed an important rise of statuswhen they became the subject of a conference calledin London last June by the League of Nations HealthOrganisation, in connexion with the meeting of thePermanent Commission on Biological Standardisation.Here was a case of wise foresight ; before the ahaoa

1 See THE LANCET, Oct. 31st, p. 977.2 Proc. Soc. Exper. Biol. and Med., 1930, xxvii., 742.

3 Jour. Amer. Med. Assoc., 1931, xcvi., 935.4 Ibid., p. 933.

5 THE LANCET, Sept. 12th, p. 584.

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-of varying standards, whether of substances or of.animal units, had time to develop in different countries,international cooperation came into play to secure.-such unity as might already be possible. Clearlyall the vitamins could not yet be dealt with, butwhat one might call the senior group-vitamins A,- B1 (antineuritic), C, and D-seemed ready for con-sideration. Those attending the conference were

.a small group of the biggest figures in the purelyscientific field, and they came well prepared withdata, abundant and to the point. Though it had.looked beforehand as if some of the problems mightprove to be knotty ones-the relative claims, forinstance, of cod-liver oil or irradiated ergosterol tobe standard substance for vitamin D, and the suita-bility or otherwise of carotene to be the standard forvitamin A-yet, in fact, nothing could have beenaettled more smoothly, and the fruits of the confer-ence’s deliberations are now embodied in a terseimanimous reports For vitamin A, carotene, prepared.and preserved in a special way, is provisionally adopteds a standard substance, with cod-liver oil as a

- provisional second string. For vitamin D, a certain.solution of irradiated ergosterol is recognised. For-vitamin B , an adsorption product from a specially-prepared extract of rice polishings ; and for vitamin C,lemon juice. The methods of preparation are

carefully specified, and also the amount of the sub-stances whose vitamin value is to be reckoned as-the unit. Scientific institutes are designated which;shall be responsible for preparation and distribution.of the standards, and lines of further research, against-a future meeting of the conference in about two

years’ time, are indicated. International cooperationhas seldom found a happier expression, while at the:same time affording us the opportunity to behold in- the flesh such legendary figures as Harry Steenbock.and Elmer V. McCollum.

MEDICAL CERTIFICATION IN IRELAND.

WE gave last week (p. 1105) extracts from a circularissued by the National Health Insurance Commission.of the Irish Free State to medical certifiers, dealing- with the increase in the number of certificates ofincapacity issued. The circular qualifies this increase- with the word " undue," without stating whatreason, if any, it has for assuming laxity on the part.of the certifiers. The rules as given in the circularinclude a provision for the issue of a special form of:notification to the Commission in cases in which a.certificate has been refused, and a warning note is.added informing medical certifiers that if they issuea large number of certificates without indicating.a number of cases in which certificates have beenrefused, a special investigation will be made. Forthose accustomed to insurance practice in this countryit is difficult to visualise the situation which will beraised by the proposed regulations, which apparentlyTiave the same force as similar regulations wouldTiave here in view of the notice given in the circularthat the monetary penalty for breaches of agree-ment has been raised. Panel practitioners wouldTegard as drastic, if not arbitrary, the requirement toissue a special form in every case in which a certificateis considered unnecessary, for this would increase his- clerical work without compensating advantage eitherto the insured person or to the service. From the

1 Report of the Permanent Commission on BiologicalStandardisation. Annex IV. League of Nations Publications.Geneva. 1931. Obtainable from Messrs. Allen and Unwin,38, Great Ormond-street, London, W.C.1 1s. 6d.

administrative point of view it may certainly be acunning way of discovering how much pressure isexercised by persons who are not incapable of workon the easy-going and kind-hearted practitioner.But the rule would appear to place the practitionerin a cleft stick ; he must avoid giving certificates,and he must seek to get refusal forms filled up, sothat he may avoid the special investigation. Thoughit is conceivable that such a method would reducesickness claims, it would, one fears, result in hardship onthe insured population, for it is difficult to see how apractitioner can exercise an unfettered judgmentin dealing with patients under such a scheme. Practi.tioners are recommended to refer cases of difficultyto the district referees, but it is pertinent to askwhether there is any obligation on the part of insuredpersons to submit themselves to examination. Theposition is quite different with references from

approved societies. ____

LEISHMANIASIS IN THE ARGENTINE.

AMERICAN or Brazilian leishmaniasis is a scourgeto the workers in the uplands of the Argentine. Ithas been treated since 1916 with intravenous injectionsof tartar emetic, tartrate of potassium, and pentava-lent antimony. But it is difficult to find suitableveins; intramuscular injections cause great pain,anaemia sometimes results, and ulcers of the mucousmembrane are but little improved. Recently Prof.S. Mazza and Dr. C. A. Aranda were fortunate

enough to be sent a supply of Fuadin, a trivalentantimony derivative of pyrocatechin,l which theyhave found much more useful. In a 6-3 per cent.solution it causes no pain when injected intra-muscularly, no sickness or other trouble, and it hasproved a cure in numerous cases, of which three arereported in detail, with pictures. The second case,supported by five pictures in series, may be brieflymentioned. The patient, aged 9, was put by somecompassionate person on the train to Salta in thenorth of Argentina, where a policeman found himand took him to hospital on June 3rd. He couldonly say he had been ill four years. He had a .leishmania ulcer on the left temple, another involvedboth left eyelids, the orbit, part of the nose, the leftupper and lower lips, and the gum beneath. Theulcers were covered with granulations and blackenedstinking crusts ; there was much loss of tissue,including the left ala nasi. Many leishmania para-sites and bacteria were found in the discharge. This

boy was given seven stibosan injections, beginningthat day, the first five intravenous, the sixth andseventh intramuscular, causing great pain. Therewas slight improvement everywhere. Fuadin wasthen employed ; intramuscularly it caused no pain,and striking improvement began at once. The ulcerover the temporal healed forthwith, then the ulcersof the eyelids, and in great part those of the lips andnose. Treatment was suspended on account of anattack of measles, but there was no relapse as wouldbe expected under pentavalent antimony treatment.The course of fuadin was then resumed, 0-5, 1-5,3-5 c.cm. on successive days, then on alternate days,3-5 c.cm. seven times-a course of ten injections.On August 30th, after seven stibosan and 20 fuadininjections, all the ulcers were soundly healed withoutcontraction, and the gum had also healed. Picturesof the conditions before and after treatmentcorroborate the clinical account.

1 Arch. für Schiffs- u. Tropen-Hygiene, October, 1931,p. 583.