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and can quite reasonably be supposed to lower thephysique, and make the infant more liable to pileslater on in life. The ideal should be a normal actionof the bowels without any medicine whatever, whenif an aperient should be necessary for illness at anytime its efficiency is so much greater. As an extremeinstance, a mother informed me last winter that shewas unable to afford any woollen garments for herchildren, but stated, with evident pride, that she wasable to afford a 3s. 6d. bottle a week of some lungtonic to prevent them catching colds.

It is suggested that some competent body shouldissue a small cheap book stating exactly what is theideal life time-table of a healthy infant, breast-fedand bottle-fed, with practical and economical advicere clothing, &c., from birth up to 2 years. I believe

Ithis would fill a much desired want on the part of Imothers and welfare staffs and might obviate someof the defects of infant life which still permit a mortality iof 69 per 1000 births.-I am, Sir, yours faithfully, ISouthampton, July 6th, 1924. A. G. G. THOMPSON.

THE PROBABLE DUAL CONSTITUTION OFINSULIN.

To the Editor of THE LANCET. ISiR,-It has been assumed that since insulin

administered by the mouth does not induce a fallin the sugar-content of the blood similar to thatwhich results when it is given intravenously or

hypodermically, it has no influence upon metabolism,and is either not absorbed by the mucous membraneof the alimentary tract or is destroyed by the digestivesecretions. The metabolic experiments on animalsupon which I have been engaged for some time inassociation with Mr. H. A. H. Howard, B.Sc., suggestthat this conclusion is not entirely correct, for fromobservations on the respiratory quotient in a seriesof guinea-pigs and rats to which insulin had beengiven by the mouth it was found that, althoughthere was no diminution in the blood-sugar, the effects Iof a subsequent injection of adrenalin were counter-acted in much the same way as in animals to whichinsulin had been administered hypodermically. Itwould therefore seem that insulin may be absorbedthrough the walls of the alimentary tract, but thatits properties are modified in the process, or, whatis more probable, a fraction which promotes theutilisation of sugar by the tissues is destroyed, whileanother fraction which is able to neutralise theglycogenolytic effect of adrenalin passes into thecirculation unchanged.

Six guinea-pigs, with an average fasting respiratoryquotient of 0-73, gave an average respiratory quotientof 081, with the usual drop in the blood-sugar, aftertwo units of insulin had been injected subcutaneously,and 081, with increases in the blood-sugar rangingbetween 0-14 and 0-18 per cent., after a hypodermicinjection of 0’25 c.cm. of adrenalin. When insulinand adrenalin were injected in succession therewas little or no change in the sugar-content of theblood or in the respiratory quotient if the doseswere correctly adjusted, showing that the hypo-glycaemic effect of the adrenalin had been neutralisedby the insulin and that less carbohydrate was beingutilised than when either was given separately.In the same series of animals the administration oftwo units of insulin by the mouth at hourly intervalsfor three hours was found to have no influenceupon the sugar-content of the blood or upon therespiratory quotient, but when a hypodermic injectionof 0’25 c.cm. of adrenalin was given 15 minutessubsequently the increase in the respiratory quotient,which should have developed if the adrenalin wereacting unchecked, failed to appear, the average forthe six animals working out at 0-735, or practicallythe normal fasting value. It was therefore evidentthat, although insulin given by the mouth had noeffect upon the sugar-content of the blood, it wascapable of preventing the glycogenolysis consequentupon the introduction of a potent dose of adrenalininto the circulation.

Similar results were obtained with white rats.The average respiratory quotient of three of theseanimals worked out at 0-77 in the fasting state.A hypodermic injection of two units of insulin produceda characteristic fall in the blood-sugar and a rise inthe respiratory quotient to 0-82, while a hypodermicinjection of 0-25 c.cm. of adrenalin was followed byan increase in the sugar-content of the blood and anaverage respiratory quotient of 0-82. Two units ofinsulin given by the mouth for three hours producedno alteration in either the percentage of sugar inthe blood or in the respiratory quotient, and when0-25 c.cm. of adrenalin was injected a quarter of anhour later there was still no change, an averagerespiratory quotient of 0’77 being obtained, demon-strating that in these animals, as in guinea-pigs,insulin administered by the mouth was capable ofinfluencing carbohydrate metabolism, although onlyso far as its anti-glycogenolytic properties were

concerned.If, as these experiments indicate, the anti-

glycogenolytic fraction of insulin taken by the mouthenters the circulation, while the sugar-utilisingfraction is destroyed, or at any rate is not absorbed,it is possible to account for the beneficial effectsclaimed to have resulted in some cases of diabetesfrom the oral use of crude extracts of insulin, suchas that of Mackenzie Wallis, and from the administra-tion of raw pancreas, or preparations of the gland,by the mouth, for the anti-glycogenolytic portionbeing effective such treatment would be likely tobe helpful where the hyperglycaemia was dependentupon defective storage of glycogen and there was nointerference with sugar utilisation. It would, however,be of little or no value in cases in which there wasdefective utilisation as well as over-production ofsugar, thus explaining the failure of oral treatmentwith pancreatic preparations where actual diseaseof the pancreas existed.

I am, Sir, yours faithfully,July 4th, 1924. P. J. CAMMIDGE.

DEAFNESS IN SCHOOL-CHILDREN

To the Editor of THE LANCET.SIR,-May I, as one who has had some experience

of the needs of the deaf child in elementary schools,be permitted to comment upon the report of MissE. Lowry’s paper in THE LANCET of July 5th (p. 20) ?What I have to say may be best summed up underfive heads.

1. There should be more adequate provision forremoval of tonsils and adenoids, both at hospitalsand in school treatment centres throughout thecountry, and the cases operated upon should befollowed up.j 2. These operations should be done by experts.In my experience many such operations are inade-quately performed, and it is quite common for mothersto state that their children’s deafness was " madeworse " by the treatment. Moreover, it is by nomeans uncommon to find children who have beenoperated upon not twice, but three times. In manycases, also, the operation appears to have been thebe-all and end-all, the deafness being left to get wellby itself.

, 3. In school treatment centres, ear conditions shouldbe treated by specialists. Harm has been done byclassing ear troubles as " minor ailments," which theymost distinctly are not. There is no dearth of com-petent young specialists to take charge of thesecentres.

4. Efforts should be made to deal with the childof pre-school age, with the definite view to preventingthe conditions which lead to deafness.

5. More effort should be made to discover cases ofearly deafness in the schools. This, as I have pointedout repeatedly, -could be done by introducing a

whisper test during the vision-card test ; or, as inFrance and Chicago, by means of games. I pointedthis out in my

" Plea for the Deaf Child " two and ahalf years ago (THE LANCET, 1922, i., 1027). These

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tests are best done by the teacher, whom the childrenknow and trust, rather than by the doctor, with whomthey are apt to be Hhy. Children found wanting canbe handed to the medical authority for more detailedexamination. Deaf children could thus be discoveredwhen treatment is of use and a large number of casesof deafness could thus be prevented. At present, Ithese children go unrecognised, often until too late.

I may add that it is a matter of great gratificationto me to find that the attention of otologists is becomingaroused to the necessity of prevention. I have beenpreaching it for the past 15 years, as has my friendDr. Kerr Love in Scotland.

I am, Sir, yours faithfully,MACLEOD YEARSLEY, F.R.C.S.

Wimpole-street, W., July 7th, 1924. ’

RESEARCHES ON LEPROSY AND THEIR

BEARING ON THE TREATMENTOF TUBERCULOSIS.

To the Editor of THE LANCET.Sin,—May I draw attention to a statement in

Sir Leonard Rogers’s lectures (THE LANCET, June 28th,p. 1297) in which he credits me with the statementthat " the addition of 3 per cent. solutions of sodiumgynocardate, morrhuate, or oleate to a pancreaticextract doubled the fat-splitting effect of the pan-creatic lipase on an emulsion of olive oil." Theaccelerating action of sodium oleate on lipase variesconsiderably according to the percentage strength ofthe solutions used, and so far from using 3 per cent.strength solutions, 0-9 per cent. strength solutionswere used in my experiments. My statement in thepaper 1 referred to by Sir Leonard Rogers is " Syste-matic investigation of sodium oleate had previouslyshown that the accelerating action on extract ofpancreas varies considerably according to the per-centage strength of the solutions used ; graduatedamounts added to the extract show also a gradualrise in values up to a maximum, falling ultimatelyto nothing. I chose, therefore, a 0-9 per cent. solutionof sodium oleate which had given good resultsformerly, and the same percentage solutions ofsodium morrhuate and sodium gynocardate, using1 and 2 c.cm. amounts of these solutions." Obviouslythe matter is of importance also in therapeuticdosage. He says further that these experimentsin vitro led me to suggest a stimulating action oftissue lipolysis in part explanation of the therapeuticeffect of sodium morrhuate and sodium gynocardateon acicl-fast- bacilli, and led him to investigate -thepossibility of these substances also stimulating theproduction of fat-splitting lipase in the blood ofleprosy and tubercle cases, whereas, as a matter offact, in my paper, after giving the actual results in myexperiments in vitro, I went on to say that in view ofthe ascertained action of sodium oleate in vivo, 2" it would seem reasonable to infer a direct stimulatingaction of tissue lipolysis in, at any rate, partialexplanation of the therapeutic effect of sodium inor-rhuate and of sodium gynocardate, in addition to adirect destructive action claimed for both (Rogers)or for the chaulmoogrates alone (Walker and Sweeney)on acid-fast bacilli."

I am glad to see the confirmation of the lipasetheory by Sir Leonard Rogers in the particular caseof leprosy, which I have so long pointed out andmaintained in cancer, tuberculosis, and other infec-tious diseases. I may, perhaps, be permitted toadd that in 1912 I showed that in recoveredtuberculosis the lipolytic activity of the serum isincreased. Somewhat later it was found to bedecreased in the acute stages, as well as (1914) inT.B. infected guinea-pigs and rabbits examined inthe bacteriological laboratory, King’s College. In myculture experiments also lipase killed tubercle bacilli.

I am, Sir, yours faithfully, .

J. A. SHAW-MACKENZIE, M.D. Lond.London, July 4th, 1924. - -- I

1 Med. Press and Circ., August 18th, 1920.2 Proc. Physiol. Soc., Jour. Physiol., xlii., p. 11.

Obituary.CHARLES HUNTER STEWART, D.Sc.,

M.B., C.M. EDIN.BY the death of Dr. Charles Hunter Stewart,

professor of public health and sanitary science anddirector of the John Usher Institute of Public Health,the University of Edinburgh has suffered anotherloss. Although he had been in poor health for sometime, his death on June 30th at his residence inMelville-street, Edinburgh, came quite unexpectedly.

Prof. Stewart was born in Edinburgh in 1854, andI educated at the University of his native city, whilelater he studied extensively on the continent. Hefirst underwent training as a pharmaceutist, but,forsaking materia medica and chemical pharmacy, heapplied himself with marked success to the studyof experimental science and medicine, graduatingBachelor of Science in 1882, Bachelor of Medicine in1884, and Doctor of Science in 1894. In 1880 he wonthe Hope Prize Scholarship in organic chemistry, andfour years later the Mackay-Smith scholarship inchemistry. His early scientific training made him akeen observer and a most painstaking investigator.When in 1894 the University of Edinburgh decided toinstitute a public health laboratory in connexion withthe chair of forensic medicine he was chosen bySir Douglas Maclagan, then professor of medicaljurisprudence, to organise and conduct the instructionin it. In 1898 he was appointed to the newly foundedBruce and John Usher Chair of Public Health, and heoccupied that chair till his death. In 1902 he becamealso director of the Usher Institute of Public Health,to the planning and arranging of which he devoteda large amount of time and thought, the result beingthe provision of laboratories, which at that time wereregarded as perhaps the finest in the country.

His colleague, Dr. J. Buchanan Young, writes:" In experiment Prof. Stewart was resourceful, andabove all accurate, and he demanded the same

accuracy in working from those whom he trained.As a young man he had worked hard, and he neverfailed to impress on his students the necessity for hardwork if success was to be attained, and he took a keeninterest in following the careers of those whom hehad taught. His prolonged study in continentallaboratories and his vast experience in laboratorywork made him quick to appreciate improvements inprocesses and methods, but before any new methodswere introduced into his courses of instruction theyhad to be thoroughly tested by himself as to accuracyof the results given. For many years he was wellknown and much sought after as an expert witnessbefore the Scottish courts in river pollution cases, andin reference cases involving special knowledge ofwater-supply, &c. To the investigations connectedwith these he devoted a large amount of time andenergy. The number of experiments he conducted,and the amount of labour and time he expended insatisfying himself as to the soundness of the views heexpressed in evidence, were only known of by thosewho were associated with him in such work. Hisfavourite reply when asked if it was absolutelynecessary to make a certain experiment, which to theinquirer seemed somewhat troublesome, was Proveall things’ ! In later years he devoted himself largelyto the epidemiological and statistical departments ofpublic health. His grasp of figures was marvellous,and his memory for figures rather uncanny.’ As alecturer he was emphatic in style, interesting, andinsistent on salient points. He had a quiet, somewhat9pawky ’ humour, and those who met him in privatelife found in him a most interesting conversationalist,willing to discuss practically any subject. During40 years as a teacher in the University (26 of these asprofessor of public health) he had seen many changesin the Edinburgh Medical School, and had taught avery large number of students. We who remain areall the poorer by his passing."