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any written opinion on the subject, but was unable Ito discover any.-I am, Sir, yours faithfully, THOMAS DUTTON.

New Cavendish-street, W., Jan. 10th, 1914.

To t7te Editor of THE LANCET.

SIR,-The evidence of the appalling effects ofcooked milk upon the infant and child is so over-whelming to those who are in a position to appre-ciate the facts that it is terrible to think of themasses of children condemned to suffer such a diet.Owing to " the concurrent use of lemon or

orange juice " to which you refer, the infantmanages to survive only that he may be furtherplied with a profoundly unwholesome food. Everyday I see children as ill as they can well be, with allsorts of mysterious diseases that have baffled theirdoctors-doctors who are good men at their workbut who have not yet managed to grasp the factthat the elemental requirement of the offspring ofall mammals is raw milk. It is too great a thing toattempt to cite the evidence in a letter, but I maycite certain documents. 1. Acute IntestinalToxaemia in Infants, London, 1911. 2. The

chapter on "The Bacteriology of Milk" in "TheNutrition of the Infant," London, 1913. 3. TheBacteriology of Alimentary Toxaemia in the Infantand Child 1

I may further cite the paper read by me before theNew York Academy of Medicine on Nov. 13th, 1913,which is to be published on Feb. lst, I am informed,in the American Journal of Diseases of Children,the title being " The Bacteriological Diagnosis andTreatment of Alimentary Disease in the Infant andChild." In these writings I describe diseased con-ditions which are of extremely frequent occurrence,and which cannot occur in a child fed on raw milk.To prevent tuberculosis ! Where is the surgeon

who will advise a man to have his legs amputatedin order that he may escape the danger of slippingupon orange peel ? There is a violent contrastbetween the actual investigations of the RoyalCommission on Tuberculosis and the Final Report.The investigations are overwhelmingly in favour ofKoch’s contentions. For the details I must referthose interested to my article in Science Progress,April, 1912, " Fallacies in the Report of the RoyalCommission on Tuberculosis."

"

Fallacies " is asufficiently mild word in the circumstances, for theCommissioners took the words of their scientificinvestigator, " bovine tubercle bacilli of human

origin,"2 and changed them into " bacilli of bovinesource."3

I take this opportunity to express my highappreciation of the valuable contribution to the

progress of scientific medicine which Mr. RobertMond has made in his recent communication to theTimes. May I be allowed to add a quotation fromRobert Koch’s address (1901) ? " It is well knownthat-the milk and butter consumed in great citiesvery often contain large quantities of the bacilliof bovine tuberculosis in a living condition, as thEnumerous infection experiments with such dairproducts on animals have proved. Most of thEinhabitants of such cities daily consume such livingand perfectly virulent bacilli of bovine tuberculosifand unintentionally carry out the experiment whiclwe are not at liberty to make. If the bacilli obovine tuberculosis were able to infect humaibeings many cases of tuberculosis caused by the

1 Proceedings of the Royal Society of Medicine, May, 1913.2 Final Report, Part 2, Appendix, Vol. I., p. 532.

3 Second Interim Report, p. 28.

consumption of alimenta containing tubercle bacillicould not but occur among the inhabitants of greatcities, especially children. And most medical menbelieve that this is actually the case.In reality, however, it is not so. That a case of

tuberculosis has been caused by alimenta can beassumed with certainty only when the intestinesuffers first-that is, when a so-called primarytuberculosis of the intestines is found. But suchcases are extremely rare. Among many cases oftuberculosis examined after death I myselfremember having seen primary tuberculosis ofthe intestine only twice. Among the great post-mortem material of the Charite Hospital in Berlinten cases of primary tuberculosis of the intestineoccurred in five years. Among 933 cases of tuber-culosis in children at the Emperor and EmpressFrederick’s Hospital for Children Baginsky neverfound tuberculosis of the intestine without simul-taneous disease of the lungs and the bronchialglands. Among 3104 necropsies of tuberculouschildren Biedert observed only 16 cases of primarytuberculosis of the intestine. I could cite from theliterature of the subject many more statistics ofthe same kind, all indubitably showing that primarytuberculosis of the intestine, especially among

. children, is a comparatively rare disease, and ofthese few cases that have been enumerated it is by

. no means certain that they were due to infection by

,

bovine tuberculosis."’

I am, Sir, yours faithfully,RALPH VINCENT,

Senior Physician and Director of the Research Laboratory,the Infants’ Hospital, London.

Harley-street. W., Jan. 10th, 1914.

TREATMENT OF GASTRIC AND DUODENALPERFORATION.

To the Editor of THE LANCET.

SIR,-In THE LANCET of Jan. 10th there appeareda paper by Mr. Edred M. Corner on this subject, inwhich the writer recommended a form of opera-tion which, to my mind, is only justified on therarest occasions.Whilst in the title of the paper both gastric

and duodenal perforations were included, in thetext no direct reference was made to the latter typeof case. Any form of operation which involves theestablishment or even the risk of a duodenal fistulais essentially a bad operation, for there is no morerapid form of what may be called physiologicaldeath than that resulting from duodenal fistula.

It is reckoned that not less than five or six pintsof fluid secretions are poured into the duodenumand reabsorbed lower down in the intestine in the24 hours, and the rapid emaciation which followsthe loss of even part of this secretion is verystriking. In the Edinburgh statistics on 200 casesof perforated duodenal ulcer1 there were three casesin which the perforation was not closed at theoperation, but merely drained to the exterior. "All

’ three cases died --within a few days with rapid.

emaciation and asthenia, illustrating how impera-’ tive it is that the perforation be closed in one way

or another at the operation." Whilst this danger’ does not exist in the case of gastric fistulæ, there

are as rapid, and certainly cleaner, ways of dealingE with the perforation than by tamponade.In cases where the gastric wall around the per-

f oration is so indurated and oedematous that invagi-nation is impossible, the opening may be closed by a

1 Edinburgh Medical Journal, November, 1913.

212

Iplug of omentum, as first recommended by Bennett.2 In the rare cases of perforated duodenal ulcer inwhich invagination is impossible the same methodmay be employed or the gall-bladder may bestitched over the perforation. If the patient besubmitted to operation within a few hours of theperforation all elaborate methods for draining the- abdomen with gauze packs, &c., are unnecessary andmay be harmful.The dramatic onset of the illness in these cases

rarely leaves any doubt as to the diagnosis; there-fore an incision should first be made in the upper,part of the abdomen to gain access to the perfora-tion. This should be closed by invagination if

possible, and where this is not feasible by an-mental plug or ,stitching to a neighbouring viscus.If there has been much escape of gastric or

duodenal content a tube may be inserted into the

pelvis through a suprapubic stab-wound and theupper wound closed. If little escape has occurredthe peritoneum may be left to look after itself andthe abdomen may be completely closed. Such anoperation takes no longer than that advocated byMr. Corner, and the after-treatment of the case ismuch simpler-an important point where the

patient is in a private house or at some distance,from the medical man.

I am, Sir, yours faithfully,Edinburgh, Jan. 12th, 1914. D. P. D. WILKIE.

ANTS AS TRANSMITTERS OF TROPICALDISEASE.

To the -Editor of THE LANCET.

SIR,-The annotation entitled "Ants as Trans-mitters of Tropical Disease," which appeared inTHE LANCET of Jan. 10th, serves a useful purposein directing attention to a matter which is possiblyof very considerable importance, and which untilrecently had not received the attention it appearsto merit. You kindly mention the suggestion Imade in 1908 )and refer to the interesting work ofDr. Bates on the mechanical transmission ofB. typhosus and B. dysenteriæe by a species of large.ant in the Canal Zone. I would like to mentionthat it was Dr. S. T. Darling who re-directed atten-tion to this question, and that Messrs. Bates, Jacob,.and Jennings carried out the necessary tests underhis direction.

Dr. Darling’s paper, which appeared in the’Transactions of the Fifteenth International Con-.gress on Hygiene and Demography, is entitled " ThePart Played by Flies and other Insects in the Spreadof Infectious Diseases in the Tropics, with SpecialReference to Ants and to the Transmission ofTr. Hippicum by Musca Domestica."

I had hoped to carry out at Khartoum experimentson the lines of those conducted by Dr. Bates and his.colleagues, but was unable to do so. At the sametime I made one observation which is of some

interest, and to which I think I once referred at a

meeting of the now defunct Society for theDestruction of Vermin. A species of large ant in-the Sudan has a great liking for urine. It haunts

chamber-pots. This idiosyncrasy is not to be

,explained by a mere love of fluid, for if urine beallowed to dry in a vessel the ants are almostcertainly to be found crawling over the dry uratic.’deposit which in the tropics so often results. I aminclined to think that urea has a special attraction

2 THE LANCET, August 1st, 1896.

for them, though no doubt liquid and moisture alsoentice them.This being so, it is possible that in certain cases

ants might transmit the Micrococcus melitensis in.food such as milk or cheese. In the same wayB. typhosus might be carried from the urine bythese insects. It is not very likely that either ofthese accidents happens in nature, but it is worthwhile keeping the possibility in mind, for some.times isolated sporadic cases of undulant fever andenteric fever crop up and are very difficult toexplain. In any case, it is to be noted that urineand urinary deposits serve to attract a species oflarge ant which is very common in Khartoum, butthe scientific name of which I have unfortunatelyforgotten. I am, Sir, yours faithfully,

ANDREW BALFOUR.Wellcome Bureau of Scientific Research

Wigmore-street, W., Jan. 13th, 1914.

THYROID SECRETION AND ANTITOXIN.To the Editor of THE LANCET.

SIR,—In reference to my article entitled " TheRelation of the Thyroid to Antitoxin," whichappeared in THE LANCET of Dec. 27th, 1913, 1 alu in.formed by Dr. A. T. MacConkey that he does not usepotassium mercuric iodide as an antiseptic, and thatas regards the sera supplied by the Lister Institute,any iodine present cannot be accounted for in thisway. In the annotation upon the same subject,which appeared in the same issue, "the toxic effectsinduced in rabbits by injection of antitoxic serum,"should read, "the toxic effects induced in rabbitsby feeding with antitoxic serum. "

I am, Sir, yours faithfully,RUPERT FARRANT.

Queen Anne-street, Cavendish-square, W., Jan. 7th, 1914.

THE PATHOLOGY OF RHEUMATOIDARTHRITIS.

TO the Editor of THE LANCET.

SIR,-I have read with much interest the letteron this subject contributed by Dr. P. W. Latham toTHE LANCET of Jan. 10th. In the second columnon p. 145 and on p. 146 he expresses his opinionthat the presence in the blood and tissues of the" products of imperfect metabolism of muscular andother tissues" " imperfectly excreted" enable micro-organisms otherwise avirulent to become patho-genic, and so cause arthritis. My experience offibrositis-and periarthritis and many conditions atpresent described as rheumatoid arthritis are

forms of fibrositis-has led me to the beliefthat not only does imperfect elimination ofwaste matter enable pathogenic organisms to

develop and become virulent, but that thesematerials are sufficiently toxic to be themselves acause of fibrosis and fibrositis. I have dealt withthis in some detail in a paper published in theTransactions of the Royal Society of Medicine(Balneological Section, April, 1913), entitled "DailyHabits in Civilised Life as Factors in the Causationof Fibrositis," and hope with your permission topresent certain aspects of it to your readers at anearly date. If the view thus expressed is correct,in all conditions of chronic arthritis and fibrositis,and possibly in most diseases of middle and laterlife, the vitiation of the blood and tissues caused byimperfect elimination of waste products-a con-

dition I have ventured to name "

dyscatharsia "-isa very important, if not the most important, factor.In recent years in the study of the seeds of