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    "source_key": "britannica_1926",
    "source_title": "Encyclopaedia Britannica (1926)",
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    "chunk_id": "1926:influenza:a129ffe2187c",
    "title": "INFLUENZA",
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    "verified_text": "the term influenza will be used to imply ‘a pandemic outburst of disease characterised, clinically, by a rapid course, catarrh of the respiratory tract, pyrexia and some degree of prostration; and epidemiologically, by a tendency to occur in several successive waves at short intervals of time.” this provisional definition is applicable to the visitation of 1918-9, and to other outbreaks of febrile respiratory catarrh more re- mote in time and about the distribution of which less is known, but is not applicable to the sporadic cases or even the localised epidemics of respiratory catarrh to which the name influenza has been so often applied, especially in the years following fairly | closely upon pandemic outbursts. the influenza pandemic of 1918-9.— this pandemic swept over the world in three successive waves, the first appearing quite suddenly in may and june 1918, the second starting at the end of september or early in october and waning in december, and the third wave, less uniform in character, appeared early in march r919. this outbreak, attributed by france to spain, by spain to france and by america to eastern europe, seems to have appeared almost simultaneously amongst the nations of the “ entente ” on the western front, and amongst all those communities in intimate touch with them and in the closely linked theatres of war. it showed the explosive character that is possible only for a highly invasive infection assisted by con- ditions of swift communication such as obtain in modern war. this first wave made its appearance a little later amongst the central powers and their neighbours. early in july it attained its full proportions in germany, austria, norway, sweden and denmark, holland and switzerland. in several large areas of the world’s surface, in the south american republics, in ber- muda, the british west indies, the azores and in the islands of the pacific and australia, the summer of 1918 seems to have passed without an influenzal‘outbreak. in new zealand, cases are said to have appeared in aug., the harbingers, perhaps, of the autumn, rather than the first manifestations of the summer, wave. this first wave passed rapidly, so thata“ frequency curve ” by wecks, in which the incidence in the worst week is taken as 100°%, shows a steep ascent to a maximum, followed by an equally steep and almost symmetrical fall, the whole episode passing within about five or six weeks. so benign was the type that many cases among soldiers at the battle-front escaped record, as the men never “ reported sick ” but mercly rested for a day or so in their units, and this was fortunate, as the army hospitals were soon overcrowded. the death-rate was incon- siderable, but there was an ominous tendency to a higher mor- tality amongst the later cases, just before the wave came to an end, seeming to suggest an increase in virulence. the first batch of cases looked ‘like a mild attack of measles without a rash.” respiratory catarrh, congested conjunctivae, headache, lassitude, pyrexia of short duration, a feeling of prostration with the return of temperature to normal, and then a rapid recovery of health; such was the course in the vast majority of the cases during the first wave. complications were almost unknown during this out- break. a few cases which developed broncho-pneumonia or haemorrhagic oedema of the lungs towards the end of the wave sent up the case mortality. in all these characters, the first wave closely resembled the outbreak of 1890, except that in 1890 the death-rate was greatest amongst the middle-aged and elderly, while in 1918 the chief sufferers were amongst the “‘ young adult ” groups. 473 the second wave.—towards the end of september or early in october, the second wave suddenly gathered force and swept over the world. st. helena is said to have escaped. mauritius, too, had a reprieve; and the quarantine measures applied by australia were successful for the moment but this fatal pandemic spread throughout europe, america, asia and africa. the upward curve of morbidity was almost precisely similar to that of the summer and the maximum was reached as quickly as in the previous wave, but the fall was much slower and less regular. the outstanding difference between the two waves was the marked tendency to pulmonary complications and the high death-rate of the second. the singularly uniform syndrome of the summer epidemic gave place, in the autumn, to several vari- eties of clinical picture depending on varying combinations of several factors, amongst which might be reckoned the virulence of the microbic invader, the resistance of the patient, the nature of the bacterial flora of his respiratory tract, and environmental conditions such as occupation, wages and housing. as a rule, the attack was ushered in by the catarrhal and pyrexial symp- toms noted in may and june. in many cases, especially where circumstances permitted of immediate rest and treatment, the disease took a favourable course towards recovery, although prostration was clearly always a more marked feature than in the summer. in others, the early pyrexial catarrh was sometimes followed by intense toxaemia leading so rapidly to a fatal issue that there was no time for pulmonary complications to develop. but frequently the lungs became severcly affected and the pa- tient passed into a state of anoxaemia recalling that due to exposure to the “ pulmonary irritants ” of gas warfare. but there was a formidable difference between the two condi- tions. while the “ phosgene ”’ patient had to deal with a sterile exudate, evoked by a chemical irritant and capable of rapid ab- sorption if vitality was maintained, the lungs of the influenza patient were charged with an exudate evoked by a living virus whi¢h had already overcome tissue resistance and could offer to “‘ secondary invaders ” conditions of symbiosis favourable to their growth. here lay the danger. the virus of influenza could open, as it were, the door to the streptococci, preamococci, sia phy- lococci and other organisms normally held within safe numerical limits upon the respiratory mucous membrane. the post-mortem appearances, while tending to have certain basal characters in common, varied considerably with the nature of the “ secondary invaders ” and other factors. in nearly all cases, there was a haemorrhagic tendency not often seen in other acute jung af- fections; and this sometimes amounted to a haemorrhagic oedema involving the greater part of both lungs. ‘ wet lungs,” “ drip- ping lungs,” were expressions frequently heard in the post-mortem room. areas suggesting haemorrhagic infarcts with their bases extending under the pleura were often noticed. the cut suriace of the lungs showed, as a rule, peribronchiolitis and patches of broncho-pneumonia with a general state of oedema throughout the parenchyma of the lung; or a whole lobe might give the ap- pearance of red, or in older cases, grey hepatisation.!. the third wave had no distinctive characters. it resembled the first wave rather than the second, though pulmonary complications and fatal cases were fairly numerous. etiology —aas to the causative organism of influenza we re- main, even now, still in doubt. the view that the bucillus influensae (pfeiffer) was the cause of the disease, received little support from the new investigations carried out from 1918 on- wards. this work was directed, for the most part, to the search for a “ filter-passing virus.’ during the second wave of 1918, the researches of c. nicholle and lebailly in the french war zone, of h. g. gibson, f. b. bowman and j. i. connor at abbe- ville, and of j. a. wilson at etaples, in the zone of the brit- ish armies in france, afforded highly significant evidence in favour of a filterable virus, although the restrictions imposed upon bacteriological work by war conditions and the transitory nature of the epidemic rendered conclusive findings impossible. 1 for a detailed account of the post-mortem appearances, together with their morbid histology, see the article by maj. tytler, r.a.m.c.. in special report series no. 36, medical research council (1919). 474 in 1919, an investigation was undertaken by zamanouchi, sakakami and iwashrima, in which the filtered and unfiltered emulsions of sputum from 43 cases of intluenza were injected into the throats and noses of 24 healthy volunteers, six of whom had recently suffered from influenza. of the 18 previously un- infected persons, all developed influenza after an interval of two or three days, but the six who had had the disease remained in good health. similar results were obtained with the filtered blood of patients. at the same time, the spraying of cultures of pfeif- fer’s bacillus, sometimes “ pure,” sometimes mixed with other respiratory bacteria, into the throats of 14 healthy persons failed to lead to illness of any kind. p. kk. olitsky and f. l. gates in the laboratories of the rocke- feller institute for medical research were able to approach the subject with much more deliberation and with a much better equipment than was available in france; and their results are proportionally more convincing. like gibson and his co- workers, they produced in rabbits a condition closely resembling human influenza by means of filtered or unfiltered nasal secre- tions taken from human patients during the earliest stages of the attack. they provided independent confirmation of the discovery of gibson and bowman that “ cultures ” in noegouchi medium were capable of transmitting the disease to animals, and showed that the anaerobic and filterable organism thus cul- tivated retained its activity after long exposure to glycerine and possessed antigenic propertics. to the minute organism isolated by them in the course of this inquiry, they gave the name of bacterium pneumosintes (rvebpov lung: and otyrys injurer), “* since a striking feature of its effect in rabbits ts to diminish the resistance of the lungs to the action of ordinary pathogenic bac- teria.” their work received speedy confirmation at the hands of dr. m. h. gordon, c.m.g., f.r.s., in the course of an intluenzal outbreak among the nursing staff of st. bartholomew’s hospital, london, in 1922. still further support for a “ filter-passere’”’ as the virus of influenza was later provided by sir spenser lister in south africa. these independent inquiries, leading to similar findings in america, england and south africa, go far to establish the “ case ”’ for a filterable virus as the causative agent of influenza; but caution 1s still needed in drawing final conclu- sions until a more precise knowledge is available as to “ filter- passers ”’ in general (see filter-passing microbes). epidemiology.—in the absence of final knowledge as to the causative agent, many points of fundamental importance still remain obscure. was the pandemic of 1918-9 a sudden awak- ening to virulence of some germ already widely distributed in western europe or was it a “ new arrival ’’ operating in “‘ virgin soil’? then the question arises: ‘‘ where could such a germ come from?” if previous pandemics were due to the same agent, no doubt, somewhere, from one pandemic to another, some human individual or chain of individuals carried on the virus until the time was ripe for a fresh outbreak. the first wave coincided with the arrival of the first drafts of american troops in europe, who must have brought into common circulation pathogenic strains that had long remained dormant in isolated and relatively immunised communities. the crowded troopships afforded just the incubation places that would permit of the maturation of such an infection; and europe, with its crowded concentration areas and billets, offered an unequalled opportunity for its spread. the last influenzal pandemic had occurred just 28 years before. there might be a few scattered “ carriers’ and perhaps some residual immunity among the middle-aged and the elderly; but the adolescents and the young adults would in 1918 be ‘ virgin soil.” it was just these lower age-groups that suffered most. how, then, explain the second wave with its greater severity? —and the third? surely, if immunity played a part, these waves should have been much less extensive, much more benign, and confined to those persons who had previously escaped. ‘these are good, but not final, arguments. the passage of the first wave may have left behind it a virus of exalted virulence, many “ carriers’? and many ‘‘ allergic”? subjects whose behaviour to influenza reinfection might betray the phenomena of hypersensitiveness of the respiratory surfaces and a tendency to inflammatory exu- dates on contact with the air-borne virus. under such condi- tions a fresh outbreak would be specially likely to arise in the fall of the year, a period of rapid fluctuations of temperature when the chill evenings drive men into the warmth and close con- tact of crowded dug-outs, shelters and billets. it is impossible to believe that the so-called “ influenza’ to which deaths were attributed every year between 1892 and 1918 was the same disease as the fulminating pandemic that followed. apart from the extreme contrast in invasive power, the distri- bution of “ intluenza ” mortality by age-groups! emphasises the essential difference between, let us say, the death-rates for 1917 and r918, the one having a preponderating death-rate amongst the old, the other, amongst the young. such differences can hard- ly leap into existence within a few months. the known facts of increase and diminution of bacterial virulence do not support the idea that such a vast alteration is probable or even possible in so short a time. acquired immunity — evidence that morbidity and mortality were less marked, in the second wave, amongst those who had been attacked in the first, when thoroughly analysed? was found to indicate that ‘ these data show a considerable immunising power in the summer attacks and we conclude, although with natural hesitation, that it is probable, on the average, that an appreciable degree of active immunity was attained by those who passed through an attack in its first and mildest manifestations.” the evidences for immunity are of varying efficiency in dif- ferent places, and the populations of many areas show no tend- ency at all to acquire resistance to infection as judged by a comparison between the behaviour of those attacked and those missed by the first wave when confronted by the second. we believe these data to be unsound as a basis for comparison. it is highly probable that many persons were infected during the summer and yet failed to show appreciable illness. the vast difference that may exist between the numbers infected and the numbers affected by a bacterial invasion can be judged from what we know of the meningococcus and the diphtheria bacillus. and yet these latent infections may confer active immunity, as we know from the ‘ schick reaction ” in the case of diphtheria and from many other examples as well. the mere fact of a previ- ous “‘ attack ” is not a safe guide in classifying populations for inquiry as to their relative immunities. the best evidence of the acquisition of immunity is to be found in the phenomena of natural recovery of the individual and of the disappearance of pandemic waves from the community. ‘the fact that these groups of pandemics are separated by long and fairly regular intervals, as a rule about 20 years, is not without significance in this connection, since at least this period might be necessary to reduce the residual ‘ immune population ” from the last pan- demic to an ineffective number. artificial immunity—no vaccine can be entirely satisfactory unless it is known to contain the virus or germ of the disease in question. the vaccine issued by the war office and afterwards by the ministry of health was confessedly of a provisional nature since the causative agent was still uncertain. its formula was as follows:— per cu. cm. of vaccine bacilli influenzae (pfeiffer) : . 400,000,000 pneumococcli : : : : : : . 200,000,000 streptococci . : : , ; ; ; ; . 60,000,000 unless pfeiffer’s bacillus be accepted as the causative agent, this vaccine must be described as consisting entirely of the * secondary invaders.’ as such, its issue was entirely justifiable and its effects were such as might be expected: satisfactory in diminishing complications and mortality but practically 7/ in preventing the disease. vaccine, then, cannot, as a prophylactic, help us much at present; nor can we, in the light of recent ex- perience, hope for great results from general measures of hygiene. ' proceedings of the royal society of medicine (jan. 1919). 2 the report of the ministry of health, chap. 6 (1918-9). inge—inland water transport bibliography.—ministry of itealth, repori of public health and medicine subjects no, 4, reportonthe pandemic of influensa,1918—-1919, h.m.s.o. (1920); d. b. king, studies in influenza and its pulmo- nary complications (1921); f. g. crookshank, ed. influenza essays by several authors (1922); medical research council, special report, no. 63. studies in the aetiology of epidemic influenza, h.m.s.o. (1922). (sita) inge, william ralph (:860- ), english divine, was born june 6 1860 at crayke, yorks., the son of william inge, sometime provost of worcester college, oxford, and was edu- cated at eton, and at king’s college, cambridge. from 1884 to 1888 he was a master at eton, and during the last two years of that time was fellow of king’s college, cambridge. from 1885 to 1904 he was fellow of hertford college, oxford. bampton lecturer in 1899, and paddock lecturer in new york in 10906, from 1905 to 1907 he was vicar of all saints’, ennismore gar- dens, london, and in 1907 was made lady margaret professor of divinity at cambridge. in torr he became dean of st. paul’s, where his sermons attracted great attention owing to their originality, their caustic criticism of the tendencies of modern life and a somewhat pessimistic tone which earned for him the sobriquet of ‘‘ the gloomy dean.” among inge’s numerous historical and theological works may be mentioned society in rome under the caesars (1888); christian mysticism (1899); types of christian sainiliness (1915); pht- losophy of plotinus (1918); outspoken essays (1919, second series 1922); personal religion and the life of devotion (1924). inglis, elsie maud (1864-1917), british physician and surgeon, was born at naini tal, india, aug. 16 1864. after a childhood spent in india and australia, in 1878 she settled with her family in edinburgh. she studied at the school of medicine for women in edinburgh and at st. margaret’s college, glasgow, graduating m.b. and c.m. in 1895 she took up private practice in edinburgh and was instrumental in establishing a second school of medicine for women in that city. dr. inglis became one of the most prominent suffrage workers in scotland. in aug. 1914, inspired by her, a special committee of the scottish federa- tion of women’s suffrage societies, aided by the national union of women’s suffrage societies, undertook the organisation of the scottish women’s hospitals for foreign service, and raised £449,000. she first went to serbia in april r915 to relieve dr. soltau at kragujevac. in nov., during the enemy invasion of serbia, dr. inglis and a few others remained behind until feb. ro16 as prisoners of the enemy to care for the serbian wounded. in aug. 1916 she took a unit to the dobruja for service with the newly formed serbian division attached to the russian army. she died at newcastle-on-tyne nov. 27 1917. see lady frances balfour: dr. elsie inglis (1918). initiative (sce 23.1).—the initiative is one of the two forms of direct popular legislation, the other being the referendum. switzerland is the classic land of both initiative and referendum. as late as 1910 its experience with these devices of popular rule was much more extensive than that of the rest of the world combined. the swiss example was copied first in the united states where the initiative was introduced by south dakota as early as 1898. subsequently nearly half the states in the american union have adopted one or both forms of direct legislation. most of these commonwealths are west of the mississippi, but of more recent years five eastern states, among them ohio and massachusetts, have accepted the initiative. twelve states provide for official bulletins of information, commonly known as “ publicity pam- phlets,’”’ containing texts of laws to be voted upon with argu- ments pro and con, which are distributed before the vote to all electors in the state. as a common feature of the commission and commission-manager forms of government now in effect in some 400 cities throughout the united states, direct legislative methods have also been made widely applicable to local charters and ordinances. following american developments in this field the next great step in the extension of the initiative was taken after the world war by the constitution makers of several revolutionised or new o 479 lished by the constitutions both of the german reich (10919) and of the prussian state; also by the constitutions of austria, estonia and the free city of danzig—all the latter dating from the year 1920. the constitution of the irish free state (1922) provides specifically for the referendum; it authorises also the irish parliament to establish the initiative by law, expressly stipulating that a petition signed by 50,c00 voters shall be sufh- cient to start action either upon a constitutional amendment or upon an ordinary law. swiss expertence.—up to 1908 the federal initiative in switzer- jand was employed, generally without success, to promote radical measures. since that year it has scored a number of constructive achievements, among them the amendments providing for federal regulation of water-power (1908) for election of the national council by proportional representation (1918) and for the submission of treaties concluded for periods of 15 years or more to popular vote upon the same terms as ordinary fegislation, 7.e., petition signed by 30,000 voters or demand of eight cantons (1921). in 1922 a drastic capital levy initiative proposal brought forward by the socialists was defeated by a popular vote of 736,652 to 109,702 and by all cantons against none. experience with clircct legislation under the new constitutions of europe has been too brief to warrant con- clusions. in germany where a petition requires 3,000,000 signa- tures, the initative has been used but once (june 20, 1926) but with- out success. (see germany.) american experrence,—in the united states the initiative has been freely employed, so freely indeed that in connection with referendum measures the ballots of certain states have been at times greatly overcrowded. the initiative has been repeatedly used by small rcform groups to advertise their projects. in oregon it was ejn- ployed successfully to pass a so-called compulsory school attendance law (1922), obviously inspired by hostility to parochial schools, which was held by the supreme court of the united states (1925) to be unconstitutional. coincident with the extension of direct legislation there has developed a tendency to exclude from its operation certain classes of measures, particularly finance bills and acts of an urgent character. thus in the united states the massachusetts initiative and referendum amendment (1917) bristles with restrictions exclud- ing from popular vote religious issues, judicial tenure and powers, local legislation, specific appropriations, anti-prohibition measures and various personal and property rights. in spite of much criticism, however, direct legislation is gencrally sustained by popular opinion in those american states which have provided for its establishment. bribpliography.—e,. ni, bacon and m. wyman, direct elections and lawmaking by popular vote (1912); c. a. beard and b. e. schultz, documents on the state-wide initiative, referendum and recall (1912); amer. acad. of political and social science, the initiative, referendum and recall (1912); w. b. munro, ed., the initiative, referendum and recall (1912); w. h. taft, popular government (1913); randolph leigh, the citadel of ee oe (rc... inland water transport.—transport by navigable water- ways in the last years before the war reached very high figures indeed. in 1875, 10,400,000 tons were carried by water in ger- many; in 1910, 64,750,000 tons. the bulk of the increase was on the large rivers and canals; the less important waterways showed no advance, and in some cases actually a falling-off. inthe neth- erlands and belgium the ports of rotterdam, amsterdam and antwerp benefited by the great development of rhenish industry in germany, the rhine being admirably suited for carrying both ores and coal. in the riparian states of the danube the move- ment of industrial products downstream and of cereals and oil upstream has produced a similar increase in water-borne traffic. this general development of traffic by navigable waterways everywhere led to the undertaking of important hydraulic work in the construction of new waterways and the improvement of existing ones. steps were taken to regulate and canalise rivers; canals were cut to link up important rivers; existing canals were enlarged so as to be navigable by vessels of larger tonnage; and gradually a whole network of navigable waterways has spread over central and western europe. the total length of the navi- gable waterways in france before the war was more than 11,000 kilometres. in germany it exceeded 10,000. the capacity of the german waterways was on the whole greater than that of the french, since many of the canals in france were navigable only for vessels of 300 tons or less. effects of the war.—the world war interrupted the develop- ment of inland navigation, and its termination was followed by a transport crisis due mainly to the disorganisation of the rail- states of europe. in varying forms this device has been estab- | ways through the wear and tear of rolling stock and rails, and the 476 destruction of considerable portions of tracks and railway in- stallations. normal currents of traffic had to be re-established, and demobilisation raised a difficult transport problem. even the full use of navigable waterways was insuflicient to meet immediate requirements. the destruction of many waterways with their works (bridges, locks, etc.) and of many vessels used in inland navigation, helped to make matters more difficult. but repairs were fairly quickly effected and in 1920-1, indeed, when the railway crisis was still acute in consequence of a shortage of rolling stock, there was a surplus of inland navigation tonnage owing to the considerable increase in freights due to the rise in the cost of living. governments avoided or took measures to prevent any great increase in railway rates until the existence of large deficits showed that it was necessary to adapt rates to the increased expenditure. navigation, on the other hand, being entirely in the hands of private individuals, had to adapt itself immediately to the increased working expenses. furthermore, governments in some cases used the railways to establish new currents of transport, which had become desirable in consequence of altered frontiers, or to help national seaports to compete with forcign seaports. sometimes, too, by instituting competitive rates on the railways, governments tried to obtain larger receipts which would enable them to meet the deficit of the railway budget. another factor which unfavourably affected the financial results of inland navigation concerns was the absence of, proper upkeep of the waterways during the years 1914-8. rivers which require constant attention suffered to a large extent in this respect, and it proved impossible to employ the river- craft to their full capacity. but the main cause of the bad conditions of inland navigation after the war was that financial and economic criscs, the insta- bility of the exchanges, and general impoverishment did not allow the resumption of transport which had been expected. in france the total amount of goods carried on rivers and canals, which was 41,896,754 tons in 1913, was only 21,500,000 in 1920. in 1924 the figure had risen to 36,758,000 tons, traffic assuming large dimensions in the north of france, as well as in respect of goods and vessels coming from and proceeding to the port of strasbourg. the following figures for the port of paris may be noted: in 1913, 4,786,649 tons were loaded and 11,709,824 tons unloaded; the figures for 1924 were respectively 2,769,166 tons and 10,221,228 tons. the total traffic for the rhine, which in 1913 was 54,562,574 tons, had fallen in 1918 to 25,608,609 tons and by 1923 as low as 16,608,609 tons. in that year—a quite abnormal one certainly, owing to the ruhr occupation —trafiic through the port of duisburg-ruhrort, which in 1913 was about 26,000,000 tons, and which was still 14,000,000 tons in 1922, fell to 3,980,412 tons. the situation is exactly the same as regards traffic across the german-dutch frontier near lobith. from over 37,000,000 tons in 1913 the figures fell in 1918 to scarcely 5,000,000 tons, but by 1924 had risen again to 23,000,000. on the danube in ig911 the total movement of goods was 6,802,639 tons and in 1924, 3,757,010 tons. the year 1925, however, showed a considerable increase in traffic. the same effects are observable in russia, although, in this case, it is necessary to take account of the great disturbance caused by the civil war, the bolshevist regime and the famine which ravaged the volga basin in 1921. in 1913 the total weight of goods carried by water amounted to 2,281,900,000 pouds (approx. 38,000,000 tons), of which corn accounted for 229,000,000 pouds. in 1920 the total figure had fallen to 665,500,000 pouds. the corresponding figure for corn is negligible. for 1925 the total figure was, according to official statements, 1,405,200,000 pouds. nevertheless, general improvement took place. take as an example the port of rotterdam. the total amount of goods transported on barges 1n 1924 was 19,000,000 tons, whereas in 1923 the figure was only 8,000,000 tons. even allowing for the effects of the ruhr occupation, this denotes a very considerable increase. extension of waterways—the improvement of navigable waterways was resumed after the war and, although many big schemes can hardly be expected to materialise, it 1s none the less true that a large number of far-reaching plans are already in course of being realised, or are ripe for execution. rhene-rhine navigation.—the navigable waterway which the canalisation of the rhdne would establish from marseilles through lyons and geneva (if the french and swiss governments agreed inland water transport about the regime for the lake of geneva), might be of first-class importance for traffic to switzerland, and the eventual continuation of this waterway through switzerland by the canal known as entre- roches (a scheme warmly supported by the swiss assn. for rhene- rhine navigation), would increase its importance. this scheme for a navigable waterway between the rhene and the rhine through switzerland seems still immature. : rhine navigation.—the second large scheme prepared by the french govt. is for the great alsace canal between hluningue and strasbourg. this canal, which will serve both for navigation and the supply of water-power, is to follow a course nearly parallel to the khine over a distance of about 114 kilometres. the plan involves the erection of a weir across the rhine bed. further, eight power stations will be constructed on the canal and two locks placed at each station. the dimensions of this waterway would allow barges of 1,200 tons, normal type on the upper rhine above mannheim. the scheme for this canal required the approval of the central com- nission for rhine navigation. after giving its consent to the con- struction of the first reach of the canal in 1922, the commission in april 1925 approved the scheme for the seven other reaches subject to certain conditions. switzerland has prepared a scheme for the regulation of the rhine between strasbourg and basel. this scheme has also been condition- ally approved by the central rhine commission, and the work may therefore shortly be put in hand (see rminr), communication wiih antwerp.—aa clause in the treaty of versailles provides for the possible construction of a deep-draught canal from antwerp to the meuse and the rhine, ending in the neighbourhood of ruhrort. the early execution of this scheme is unlikely, especially as the plan for the antwerp-moerdijk canal, which is provided for in the new dutch-belgian treaty, will secure for antwerp advan- tages at least equal to those offered by the antwerp-ruhrort canal and at an infinitely smaller cost. no technical details are yet known of the antwerp-moerdijk canal scheme, but the waterway thus created will be made navigable for the large khine barges, that is to say, for vessels up to 3,000 tons. afeuse canalisation.—in the netherlands the most important scheme now being carried out is the canalisation of the meuse on dutch territory, which further involves a junction canal between the meuse and the waal and the juliana canal from maasbracht southwards, the latter intended to link up the mining centre with the navigable waterways of the country. ‘the canalised meuse will be navigable for boats of 2,000 tons. locks 260 metres long will be able to take a tug and two barges of 2,000 tons each. the meuse-waal canal will be navigable for boats of the same tonnage. completion ef rhine-visinla system.—in germany two large schemes are being carried out. vhe mittelland canal, which wall connect hanover with the elbe near magdeburg, will establish an uninterrupted navigable waterway between the rhine and the vistula. this canal will form the last section of the waterway begun with the construction of the dortmund-ems canal between 1889 and 1899, followed by the rkhine-]herne canal, opened in 1914, and the bevergern-misburg canal constructed during the war. the last-mentioned canal, which is 172 km. long, 1s without locks. the total length without locks, including certain parts of adjacent canals, is no less than 213 kilometres. vhe mittelland canal will be naviga- ble for boats of 1,000 tons. it will cross the elbe by a bridge, the plans for which have been submitted for the approval of the inter- national elbe commission. rhine- main-danube connection.—the second important scheme in process of execution is the junction between the rhine, the main and the danube. the idea of linking up the rhine and the danube isa very old one. charlemagne conceived the idea of constructing a canal, traces of which can still be seen. the ludwig canal, opened in 1846, was only navigable by small boats up to 120 tons and has never been much used. it is anticipated that the area tapped by the rhine-main-danube navigable waterway will exceed that of any other european river and canal system, the scheme involves the canalisation of the main, the construction of lateral canals and of a junction canal between the main and the danuhe, joining up with the jatter near kelhcim. it also necessitates the regulation of the danube between regensburg and hofkirchen, and between passau and the frontier and in addition its canalisation over the stretch between hofkirchen and passau, that is to say, in the ba- varian kachlet. the waterway will be navigable for canal barges of 1,200 tons and for rhine barges up to 1,500 tons, the scheme also provides for the utilisation of hydraulic power; in fact, it is the pro- duction of electric power that has made the scheme practicable. other german schemes,—among the other plans for the construc- tion of canals in germany, such as the hansa canal, the canal from the weser to the main, the kuesten-kanal and the junction canal between neckar and danube, only the last deserves serious con- sideration at present. the canalisation of the neckar might be of considerable value for the development of navigation and for the port of mannheim. at one time it seemed that, mainly for political reasons, opinion in germany was in favour of constructing the weser-main canal (the weser being the only important river which has escaped internationalisation) in order to direct part of the traffic from the danube to bremen, after the construction of the main-danube canal. the weser could also carry some of the traffic inland water transport normally carried by the rhine and the elbe. but the changed polit- ical situation makes it improbable that this scheme will be put into effect at any early date. italian vwaterways.—in italy a canal has been constructed from the po to brondolo on the lagoon of venice. a canal is also in course of construction from milan to the confluence of the adda and the po, whereby milan will be linked by waterway to venice. czechoslovakian waterways.— in czechoslovakia, besides canalisa- tion work on the elbe and the moldau and the regulation of the danube, the govt. has carefully considered two canal schemes, an elbe-danube canal and an flbe-oder canal navigable for vessels of 1,200 tons. the length of the [:ibe-danube canal would be about 300 kilometres. its course would follow as far as possible the line of the most important towns. financial considerations are retarding the execution of these schemes. polish waterways.—polish plans include schemes for several canals which, navigable by boats of 1,000 tons, would constitute, together with the regulated parts of the vistula, a complete system of naviga- ble waterways across poland. this plan would involve the construc- tion of a canal which would start from kattowitz in upper silesia, extend northwards and join the vistula either at the mouth of the brda or near thorn, making use in several of its sectors of existing navigable waterways as, for example, lake goplo. another canal would extend from posen via konin and warsaw to pinsk, taking in a part of the warte and of the canalised bug, together with the reconstructed king’s canal between brzesc and pinsk. the latter waterway would have to be continued from pinsk to the russian frontier in order to link up with the great navigable system of russia. the russian system.—the russian rivers which are naturally navigable have suffered but little from the lack of upkeep in the course of the last 10 years. the proposal to construct the rostov canal to unite the volga and the don may be carried into effect, though there are great technical difficulties in the way of this scheme. its completion would reduce the cost of transport of oi! from baku, fish from astrakhan, corn from the valleys of the volga and the kama, coal from the donetz and merchandise from persia. the importance of the proposed cana! is obvious, as the immense system of the volga, which is navigable for more than 16,000 km., will thus be linked up with the black sea, and the baltic, black and caspian seas will be connected by navigable waterways. there is already a service between leningrad via the mariinsky system and the volga to astrakhan and thence to the persian port of enzeli. the immense territory of russia may become of capital importance in the future from the point of view of inland waterway communications. the system of waterways is more than 200,000 km. in length, of which at present some 40,000 are navigable. the asiatic russian system from the ob-yenesei mouths to central asia and lake baikal lics outside the scope of this article. economic considerations.—economic considerations will natu- rally play an extremely important part in any decisions taken in regard to the improvement of existing waterways or the con- struction of new ones. the question will inevitably arise whether a railway would not prove more serviceable than a waterway. the preference will clearly go to whichever mode of transport is cheaper. in comparing the advantages of waterways and rail- ways, we must distinguish between rivers and canals; and we must further discriminate between canals built across flat country and those constructed across land where there are marked differences in level. rivers not naturally navigable may generally be rendered nav- igable by regulation works, such as spur dikes or longitudinal dikes, or by canalisation works such as the construction of dams across the bed of the river and locks to enable boats to pass. the forming of large reservoirs in the upper courses of water- ways belonging to the basin of a large river may also constitute an excellent means of improving navigability by regulating the flow of water. in this way a greater minimum depth is obtained and the period of navigability during the year is lengthened. as a rule the cost of building a railway having the same carrying capacity as a river is appreciably higher than the cost of making the river sufficiently navigable. moreover, the cost of river-craft having a given loading capacity is less than that of railway rolling stock having the same capacity. further, the haulage power of a locomotive is only a small fraction of that ofa tug. this argument remains true even if a proper use of a water- way involves the execution of improvement works. moreover, the economic development of the area served by the river leads to a considerable increase in passenger and parcels traffic, for which the railway is necessarily more suitable than the water- way, so that we always find railway lines alongside the river, : — 477 connecting up the various important centres situated thercon. the argument that a river can compete with a railway holds good even if the traffic does not, strictly speaking, consist of heavy goods, such as ores or coal. the danube is a case in point; before the war the volume of traffic on that river amounted to nearly 7,000,000 tons. : the case is different, however, if it is an artificial navigable waterway, @.e., a canal, which has to be built. asa rule sucha work is not justified from the economic point of view unless the prospective traffic in heavy goods (ores, coal, building material, cereals, and certain other agricultural products) js to amount to several million tons per annum. in order to determine the cost price of transport by canal we have to allow for possible profits and advantages derived from the exploitation of hydraulic power, and accordingly we have to make a distinction between a canal crossing flat country and a canal built in mountainous districts. many projects for artificial waterways have been ren- dered feasible by the utilisation of water power. wherever the configuration of the ground has permitted, recent schemes have combined the construction of a navigable waterway with the exploitation of hydro-electric power. the question therefore whether, in any given case, it is preferable from the econornic point of view to construct a canal rather than a railway cannot be answered so readily as when the alternatives are a railway and a river; the answer depends upon a very large number of factors. international rivers.—a special category of waterways js con- stituted by those which come under the scope of the convention on the regime of navigable waterways of international con- cern' concluded at barcelona on april 20 1921. the criteria adopted at barcelona were the fact of crossing or separating a number of countries, and natural navigability to and from the sea. in addition to the obligations which devolve upon riparian states, particularly in connection with works of upkeep, the rar- celona convention lays down the principle of freedom of naviga- tion and equality of treatment for all flags. the objection has sometimes been raised that two different ideas have been confused, namely, the territorial idea and the idea of international traffic. it is clear that if it is in the interest of international traffic that there should be no flag discrimination, this principle applies wherever international navigation is carried on, independently of the fact whether the navigable. waterway crosses or separates several states or not. on the other hand it is only natural that, as regards inter- national rivers, there was a desire to impose certain strict ob- | ligations on riparian states in connection with the hydraulic works to be carried out; these obligations, however, should rather be regarded as reciprocal obligations between riparian states. it would seem not impossible by drawing a clear distinc- in the application of the statute, the following are declared to be navigable waterways of international concern: 1. all parts which are naturally navigable to and from the sea of a waterway which in its course, naturally navigable to and from the sea, separates or traverses different states, and also any part of any other waterway naturally navigable to and from the sea, which con- nects with the sea a waterway naturally navigable which separates or traverses different states. it is understood that: (2) trans-shipment from one vessel to another is not excluded by the words “ navigable to and from the sea \"; (6) any natural waterway or part of a natural waterway, is termed “naturally navigable ” if now used for ordinary commercial naviga- tion, or capable by reason of its natural conditions of bcing so used; by ‘‘ ordinary commercial navigation ’’ is to be understood naviga- tion which, in view of the economic condition of the riparian coun- tries, is commercial and normally practicable; (c) tributaries are to be considered as separate waterways; (d) lateral canals constructed in order to remedy the defects of a waterway included in the above definition are assinulated thereto. (e) the different states separated or traversed by a navigable waterway of international concern, including its tributaries of inter- national concern, are deemed to he “ riparian states.” 2. waterways, or parts of waterways, whether natural or artifi- cial, expressly declared! to be placed under the regime of the general convention regarding navigable waterways of international concern either in unilateral acts of the states under whose sovereignty or authority these waterways or parts of waterways are situated, or in agrecments made with the consent, in particular, of such states, — 47 tion between the territorial idea and the idea of international traflic, to lay down, for all navigable waterways on which inter- national traffic can be carried on, contractual provisions similar to those which have been drawn up for maritime ports. inquiry into lxisting conditions.—in accordance with a resolution of the economic conference of genoa, which was approved by the council and assembly of the league, the organ- isation for communications and transit decided in 1924 to make inquirics of the various european governments concerned regarding the present situation of inland navigation in their re- spective territories. it also decided that the study of the com- plex problems which might be raised in connection with the great international rivers with many riparian states, should be en- trusted to mr. walker d. hines, united states director of transport during the war, who was appointed after the war as arbitrator in the allocation of river tonnage on.certain inter- national rivers. accordingly mr. hines carried out an exhaus- tive study of the position of inland navigation on the danube and also carefully examined the existing ditliculties on the rhine. it is hoped that mr. hines’s reports on danube and rhine navigation as well as the results of the general inquiry will help to promote co-operation among the riparian states and to solve existing difficulties, in order that inland navigation may develop unhindered, and may occupy among the various means of com- munication a position which will enable it to play a great part in restoring economic stability and promoting the prosperity of the european nations. for the development of inland water trans- port in america see the articles great lakes and st. lawrence and mississippr river. bislrograpny.—a. l. sympher, wasserwirtschaftliche vorarbei- ten (leipzig, 1901); report of the royal commission 1 ppointed to en- guire into and to report on the canals and inland navigations of the lintied kingdom. cd. 3183 (1906); e. r. johnson, ocean and inland water transportation (1906); cauer and w. rathenau, afassengiiter- bahnen (berlin, 1909); h. g. moulton, weterways versus ratlways (cambridge, mass., 1912); o. teubert, dre binnenschiffahrt (leip- zig, 1912); g. v. hlauffstengel, die ferderung von \\fassengiitern (1921); a. l. sympher, die wasserwirtschaft deutschlands und thre suktinftige aufgaben (berlin, 1921); b. schultz, die volkswirtnenen bedeutung der fisenbahnen (jena, 1922); n. e. whitford, htstory of the barge canal (new york, 1922); zettschrift fiir binnenschiffahrt 1go0-26 (duisburg). (ro rn) inouye, kaoru, marguess (1835-1915), japanese states- man (see 14.587), died sept. 1 1915. insanity (see 14.507, and dpsycmtatry; psyclioanalysis; psycuosis; psyctiotherapy).—a change in the conception and in the handling of the facts characterises the present century. instead of “ lunacy ” and “ insanity ”’ we speak to-day of men- tal disorders, of psychoses and psychoncuroses, viewed as prob- lems of the adaptation of the individual to his environment. during the world war a wide range of mental disorders had to be met by medical and military officers many of whom had never before concerned themselves with such problems. a new type of sympathy and sense of duty towards the victims of “ war shock ” laid the foundation for a more understanding interest in mental disorders in general, and aroused the demand for their effective management, not by mere relegation to oflicial asylums, but by active therapeutic measures. definition‘ insanity ’’—implying as a rule an incapacity to grasp the fact and nature of the existing sickness or disorder and a lack of responsibility for personal care and conduct, with possible neglect of or actual danger to self or others—is a con- tingency rather than the essence of many disorders, and cannot properly be studied and understood by limiting oneself to the “insane ’’’ as we find them in the centres of segregation which we call asylums, refuges, retreats or mental hospitals. the wider field of psychiatry (g.v.) now includes mental and behaviour problems outside as well as inside hospital walls, and experienced help, medicinal at times but also to a large extent taking the form of guidance in the problems of adaptation, has supple- mented or replaced mere custody in institutions. mental hy- giene, administered through mental health boards and com- mittees in the united states and in several european countries, offers constructive and preventive measures which are carricd inouyie—insanity out largely in centres where physicians, psychologists aad social workers collaborate in the work. advances in etiology nationality and race——itnteresting statistics on mental dis- orders in different nationalities making up the admissions to the massachusetts hospital at worcester, and to the new york state hospital at blackwell island suggest that national and racial habits play an important part, the greatest differences lying in the relative rele of alcohol and syphilis and in the frequency of temperamental and psychoneurotic maladjustments.! the irish admitted had 27-69% alcoholic psychoses and 37° % largely psy- chogenic (temperament- and behaviour-determined) disorders, while the jews presented 0-32% alcoholic but 65%% largely psy- chogenic disorders. of the irish only 7-59°%% showed paresis (i.e., a form of brain syphilis); of the jews 14°94; of the germans 20°%; and of the negroes 29-41 %. occupation. the incidence of mental disorders in certain occupations is dependent largely on the degree of exposure to harmful influences, and also on the temperamental factors whjch may determine the choice of a profession.? herediiv—the question of heredity is not as simple as it appeared in 1911. while the dispositions are inherited, it seems highly probable that additional factors, in the form of life-expe- riences, play a considerable rdle. the attempts to use mendelian principles led to the conviction that affective disorders (manic- depressive psychoses) follow a dominant, and schizophrenic dis- orders a recessive type. the work of mott and others appears to show that these two conditions may follow a law of anticipa- tion according to which the mental symptoms develop at an earlicr age in succeeding generations of psychopathic stock. lately, we meet with the assumption that at least two or more factors are needed to determine schizophrenic or manic-depres- sive attacks, and geneticists like jennings even tell us that we had best forget the theory of unit characters, in man, because of the complexity of the facts to be considered. eugenics (q.v.) has shown itself applicable in two ways, negatively in the sterilisa- tion of the most obviously degenerate offspring of psychopathic families, and positively in the training of the young towards healthy mating and sound sexual hygiene. infections —the claims made with regard to the importance of infection (14.598) and in the publications of a few surgically inclined psychiatrists have not been borne out under recent scrutiny. both the “ agglutinines pointing to streptococcus infections present in every case ”’ of manic-depressive disorders, and the claims of 80 to 90% recoveries after removal of focal infections and of the colon, are largely discredited, partly on the very material of those making the claims. in the face of all the propaganda, the theory of autointoxication and much of the more recent theory of endocrine disorders as etiological factors in mental disturbances are having an equally difficult time before the rigorous tribunal of strict hospital and field werk and statis- tical tests. this does not mean that the ‘ physical causes ”’ are being neglected or belittled. much research has been and is still being carried out on the morbid anatomy and biochemistry of the psychoses and psychoncuroses. mott has demonstrated changes in the endocrine and particularly the generative glands of dementia praecox which in his view point to an “‘ inborn lack of vitality ’’ in these patients. however, the old controversy between the physiogenic and the psychogenic theories as to the causation of mental disorders is dying down before the newer and more comprehensive conception of psychobiology, according to which the physical and mental make-up, the personality tendencies and the determining factors and situations are taken into account in the study and treatment of the patient. most cases constituting or akin to the dementia praecox or schizo- phrenia or parergasia group (described as katatonia and hebe- phrenia in 14.606) have been shown to be much more readily understood and formulated for purposes of treatment on a genetic-psychodynamic basis, with special attention to the cir- 1g. h. kirby, new york state hospital bulletin, 1, p. 666. 2 james v. may, afental diseases, a public health problem, p. 32. insanity cumstances of the development of symptoms, than on the basis of a sweeping claim of inevitable deterioration due to ‘ un- known ”’ toxins or other causes, or on the theory of insufficiency of endocrine glands. special types of disorder feeble-mindedness.—the study of feeble-mindedness has been enriched in various ways. the binet-simon tests and their modifications furnish a dependable and comparative measure of the actual intelligence in terms of the “ mental age” and the “intelligence quotient ” or i.q., i.¢., the mental age attained divided by the chronological age. one speaks of idiots where the attainable age does not exceed three vears, of imbeciles up to a seven-year level and of the higher grades of feeble-minded or morons between the eight and 1s-year level. a retardation of less than three years may lie within the range of error. the british roval commission of 1904 found that in groups of urban indus- trial and agricultural areas there was an average of -32°% of fecble-minded children and adults in the general population, and of -83°% of feeble-minded among the children of school age, with a higher percentage in towns than in country districts. a house-to-house survey of the children of school age of a well-cir- cumscribed industrial district of baltimore, md., was undertaken by the henry phipps psychiatric clinic and published by dr. c. macfie campbell. since then numerous surveys in the united states have corroborated the baltimore results, which make it clear that about 2° of the children of a community should have special institutional training and some of these protection for life, an additional 6° should be in special classes for the re- tarded, and another 5° should have at jeast individual adapta- tions of the curriculum. greater attention to the psychology of education has revealed the fact that children may fail to keep up to the standard of their age for causes other than feeble-mindedness, and may pre- sent problems of maladjustment which had best be handled by the psychiatrist. in england and scotland the mental defi- ciency act of 1913 has widened the range of defectives who may legally be committed to institutions and makes provision for moral imbeciles. early diagnosis and anti-syphilitic treatment of defect due to congenital syphilis is followed by improvement. acquired mental diseases —a distinct advance is shown by the fact that the disease entity concept is giving way to the less dogmatic concept of reaction-types. the specifications of the types of mental disease given in 14.597 are to-day largely replaced by a more genetic and constructive formulation and interpre- tation of patients or individualitics. dementia praecox.—an intermediate phase of rather opti- mistic simplification had introduced the concepts of maniac- depressive (or alfective) psychoses as essentially non-deteriorating. as opposed to the schizophrenic psychoses (also called dementia praecox), which are apt to pass into deterioration, emotional indifference and apathy. the manias and the melancholias would constitute the manic-depressive psychoses, while hebe- phrenia and katatonia are now included in schizophrenia. but even these diagnoses, which aim largely at prognosis, have had to yield to the recognition that one had best admit a number of practically important reaction-types of special working and tendency of evolution, requiring further a specification of the causal factors and the assets of the patient both for the deter- mination of the intrinsic nature and the formulation of a prog- nosis in each case. the simple notion of “ one patient one disease,” and a classi- fication under a one-name diagnosis indicating either a good or a bad outcome, cannot do justice to the multiplicity of points which demand consideration. a totally new conception of the constitution of personality and its hereditary and individual components has supplemented the formerly dominant and almost exclusive conception of brain destruction by poisons and other agencies. there is to-day less interest in special disease entities than in the working of definite processes or develogments vari- ously open to modification and adjustment. 1 mental hygiene, 1917, t., pp. 96-147. 479 the psychoanalytic contributions towards our knowledge of personality and towards the interpretation of mental symptoms, and the methods of treatment based on these theories, are vari- ously evaluated, but have been stimulating in the study and utilisation of life-experiences (see psychoanalysis and psycno- therapy). general paralysis ——one of the most remarkable changes has occurred in our experience with the most fatal and disastrous form of mental disorder, general paralysis or paresis. there is no longer any doubt about its being due to an invasion of the brain by the spirochaete of syphilis. the disease may occur in children or adolescents through hereditary transmission of this orginism, as well as in adults in whose cases symptoms may appear 10 or even more vears after acquired syphilitic infection. but, far from being a uniformly fatal disease, it has now been found to yield to treatment. early diagnosis, assisted by the application of the wassermann test to the cerebrospinal fluid and not only the blood serum, and therapeutic infection with malaria (q.z.) or other recurrent fevers which appear to be incom- patible with syphilis of the nervous system, enable as many as 40°, of patients to enjov a prolonged remission from their symp- toms or to obtain a complete cure. commitment or certification : it is unfortunate that there will probably always be a group of patients or phases of illness that lie between the two extremes of (1) voluntary co-operation and (2) forcible treatment. while there is a growing desire to extend facilities for treatment on a voluntary basis, it frequently happens that delay in dealing with an unwilling patient involves risks when suicidal or homicidal impulses are present. following the lead of the continental clinics, hospitals have been opened in the united states and elsewhere for the study and treatment of early cases of mental disorders. most of the american institutions have an increasing number of “‘ voluntary commitments” requiring in writing a “ three days’ notice of intention to leave,” so that the physician may have the right to detain the patient pending the consideration of the best course to take in the further care. the commitments themselves in many states are left toa statement of two impartial physicians; in others they require court procedure or even jury trial, a method that is, however, more and more limited to habeas corpus actions, i.c., a demand to show cause for the detention of a patient as a “ committed ” person. the medico-legal problems of responsibility in mental disorders are still in an archaic state on account of the unfortunate fact that the rules of evidence which were invented for the normal are not favourable for the presentation of facts which have a psychiatric bearing. another point of joose practice occurs in the united states in the proper disposal of patients who are de- clared “ not guilty on account of insanity.” a patient who gets into conflict with the laws should remain under safeguard until he shows evidence of insight and capacity for self-management. the principles of equity procedure in use in juvenile courts promise benelicial reform and valuable experience based on a study of the individual delinquent according to psychiatric principles. the moral changes which are liable to follow an attack of epidemic encephalitis constitute a new and difficult problem (sec encephalitis lethargica). statistics —statistics are notoriously inadequate where no continuous census and control of the population and its where- abouts is maintained. the number of ‘‘ certified ” insane patients under care in england and wales was 131,557 on jan. 1 1925, an increase of 1,217 over the number on jan. 1 1924, but evi- dently less than the number before the war; 48-9% are males, s1-t% females. the recovery rate calculated on the direct admissions is given as 34°86°%. the death-rate calculated on the daily average number of interned patients is 7-62%. the absence of any greater increase of numbers during and since the war is probably only apparent. the fifth report of the british lunacy and mental deficiency board of control (1919) brought out a ratio of 208 (instead of the usual 76) cases of death to each 480 1,000 of the interned insane and defective population, owing to a temporary increase of tuberculosis, diarrhoea and dysentery, typhoid fever, etc. the lack of fresh milk and fats and the disorganising of the nursing through the war must have been largely responsible. effects of prohibition considerable interest adheres to the question of the effect of prohibition in the alcoholic mental dis- orders. wherever the alcohol traffic has been brought under control the reduction of ‘‘ alcoholic insanity ” has been striking. where propaganda against prohibition has been most active, a moderate return of the old conditions has been noticeable. the experiment is too short and too imperfectly carried out to furnish an answer to the many questions arising. bibliography.—w. a. white and s. e. jelliffe, nervous and mental diseases, 2 vol., 2nd ed. (1917); w. healy, the individual delinquent (191 5): w. h. b. stoddart, mind and its disorders ae j. v. may, mental diseases, a public health problem (t0922). f tredgold, mental deficiency (1922); eugen bleuler, lehrbuch ne psychiatrie (1923); authorised eng. transl. (1924); 11. s. theobald, law relating to lunacy (1924); w. c. sullivan, crime and insanity (1924); a. myerson, the inheritance of mental diseases (1925). (a. mey.) insect bites and stings.—linsects may be the cause of disease or of morbid conditions in man in several different ways: (1) by living ox his skin or hair, as in the case of three varieties of pediculi or lice (the head-louse, the body-louse, the crab-louse) ; or 7# his skin, as with the itch-insect (though this is strictly not an insect at all but a spider-like parasite), or with the tropical chigger, jigger or sand flea; (2) by depositing their eggs on the skin or mucous membrane, or on wounds, whence the larvae find their way below the surface, usually by boring or burrowing, as is the case with several tropical flies; (3) by being the instru- ment of transferring a bacterial infection to man from some other animal, as is the case with the rat-ilea in plague, or by taking part as host in the life-cycle of a spirochaete or a protozoon and passing the parasite on to man, as is done by certain mosquitoes in yellow fever or in malaria; (4) by the direct and immediate effects of their bite or sting. it is with this last method only that the present article is concerned. in great britain, ds in most other countries, such bites and stings are exceedingly common, the most frequent biting insects being the common flea, the bed-bug, gnats and mosquitoes, and the most frequent stinging insects being the wasp, the bee, the hornet and the ant. it should be realised, too, that the effects of the louse are due not merely to its presence, as mentioned above, but to its actual bite. the consequences of these bites and stings are well known, very few persons escaping some personal experience thereof, though susceptibility varies widely in different persons. local irritation may be extreme, and the skin jesion produced may vary from a small reddened or erythematous patch or a tiny papule, to large urticarial or nettle-rash wheals, or even to a spreading cellulitis or inflammation of the tissues under the skin. these effects, though giving rise to intense discomfort, are rarely serious and usually pass off completely in a few hours or at most a day or two. occasionally, however, dangerous developments occur. the conditions most likely to lead to such developments are: (1) a very large number of stings, as when a swarm of angry bees settles on the body; (2) the lesion being on a mucous surface such as the tongue, the palate or the pharynx; (3) the supervention of some local complication such as erysipelatous or other strepto- coccal infection, or the direct transmission of some form of septic poisoning as by the bite of a fly which has been feeding on putrid material. in all such cases skilled surgical aid should at once be sought, as in extreme instances death has occasionally resulted and urgent measures may be necessary to deal with the situation. treatment.—the poison injected with an insect sting is, at least in many species, formed by a mixture of the secretions of two glands, one of which is acid (formic acid) and the other of which is alkaline. in most cases the acid predominates; hence weak alkaline solutions (soda or ammonia) are commonly effec- tive in allaying the irritation. in some cases, however, especially, it is said, with the sting of some wasps, the alkaline element is insect bites and stings—instalment selling predominant and in such instances a weak acid lotion (such as diluted vinegar) gives most relief. other local applications of an effective character are alcohol, spirits of camphor, a solution of menthol or of permanganate of potash, a dilute solution of car- bolic acid, or even slices of the homely onion. in every case the sting itself, 1f1t remains in the skin, should be carefully removed. as preventive measures when tnsects are prevalent, camphor, menthol, lavender and oil of eucalyptus appear to have some virtue; and skilful and assiduous campaigns against flies, mos- quitoes and wasps have of late added greatly to the amenities of a number of localities. see bacteriology; kala-azar; para- sitology. (ii. b. br.) instalment selling is in essence an extension of credit to retail purchasers, under some form of contract by which the purchaser agrees to make partial payments at stated intervals over a period of weeks, months or even years. it enables thou- sands of persons of limited means to acquire goods which they could not otherwise possess. the goods purchased are usually delivered after the payment of an initial deposit. this deposit is sometimes merely a nominal sum; but frequently it amounts to one-fourth or one-third of the price of the goods. the seller re- tains title, or its legal equivalent, in the property until the last instalment is paid. this is accomplished by means of a chattel mortgage, a conditional sales contract or a lease. the latter is the method employed in great britain. in this article a resume of american developments will be given first. i. in the united states the customary practice in the united states, where the greatest development of instalment selling has occurred, is described as follows: ‘‘ when goods are bought on lease or con- ditional sales contract, the title remains in the sellers, and passes to the buver only upon completion of the stipulated payment. under the lease plan, instalment payments are designated as ‘rent.’ (this form of instalment selling was devised to conform to the laws of certain states.) but when the chattel mortgage form is used, the title passes immediately to the buyer, and he gives the mortgage as security for payment of the balance due. under any of these forms, the sellers may re- possess the property if the conditions of the sales contract are not met by the buyer.” (see fustaliment merchandising, com- pilation no. 2, issued by the national association of credit men.) a tremendous expansion of instalment selling took place in the years following the world war. the aggregate amount of instalment credit in force in the united states in 1926 was estimated to be close to $3,000,0c00,000; and this estimate, though based on insufficient data, is believed to be conservative in view of figures from the automobile industry showing that the total of automobile instalment paper then outstanding amounted to about $1,500,000,000. the grand total of all instalment sales in the united states in 1925 was said to be $5 000,000,000. this extraordinary development was naturally viewed “ with alarm’? by many conservative economists, merchants and bankers. aside from what might be called moral objections, the chicf criticism was that large-scale instalment buying must lead to unhealthy inflation and consequent disorganisation of business and finance. it is probable that severe business depres- sion, with its accompanying uncmployment and the conse- quent failure of workers to pay their instalments, would prove disastrous to commercial firms that had failed to scrutinise carefully all credit applications. on the other hand, it was pointed out with much force that a high element of safety at- taches to eredit risks, each relatively small, which are widely scattered throughout the community. the continued success of many firms whose experience in instalment selling long ante- dates the latest boom, is proof that such a business may be as soundly and as profitably conducted as any other. credit merchandising, in fact, had made a rapid growth before the beginning of the present century. it was first applied extensively to the sale of subscription books ard was later adepted by the piano and musical instrument business. it was instalment selling then applied to the sale of furniture, sewing-machines, jewellery, gas-stoves; and thousands of these products have been paid for by the month by people with moderate, steady incomes. a very large proportion of instalment purchasers in the days before the automobile were housewives who found it possible to make small weckly or monthly payments out of their household allawances. women have continued to exercise a jarge influence on this type of buying; and most articles thus obtained are decided upon by the whole family. yor a long period a certain social disapproval hung over instalment buying, particularly if the articles purchased were luxuries. the purchase of homes by this methed was, however, always regarded as praiseworthy, and most homes have been bought on this plan. the boom of recent years, which has almost entirely removed the social stigma, began with the adontion of this method of selling on a jarge scale by the auto- mobile industry. when the united states entered the world war the time payment plan was utilised in the sale of huge quantities of liberty bonds; and in the years that followed many investment houses did a considerable volume of business selling securities on deferred payments. the volume of instalment sales of automobiles prior to 1916 was almost insignificant. mass production of motor-cars closely followed the development of finance companies to cate for in- stalment business. some of: these finance companies were organised outside of the automobile industry; others were organised by large manufacturers. one of the most important of these was the general motors acceptance corp., the volume of whose transactions grew from $10,000,000 in 1919 to nearly $150,00c,000 in 1925. alfred p. sloan, jr., president of the general motors corp., stated that the losses, 7.¢., retail charge- off, during this whole period were only .199 of 1° of the volume of retail business handled. (see nafion’s business, april 1926.) c. c. hanch, general manager of the national assn. of finance companies reported the results of an extensive survey completed during ra24 as showing a loss ratio of less than 4 of 1% on aggregate new and used car business, amounting to $195,500,000. (see -tmerican bankers’ journal, april 1926.) it is seen there- fore that losses in collection have been very small. | in 1926 there were more than 1,000 finance companies in the united states created for the purpose of handling automobile purchases. more than 75% of all motor vehicles sold during the previous year were purchased on the instalment plan, the deposit usually being about 4 of the price of the car, the balance being divided into 12 equal monthly payments. finance corporations did two kinds of business, wholesale and retail; that is, they financed the purchase of cars by dealers from manufacturers and the purchase by retail buyers from dealers. in the case of one low-priced car it was possible in 1925 to get possession by making an initial payment of $12.40, and furnish- ing two endorsements to the note. this was followed by weekly payments of $5 for a year, and at the end of the year a so-called balloon-payment completed the transaction. the fee of the finance company added to the purchase price was known as the time-price. after deducting the initial pay- ment from this time-price the remainder was generally divided into 12 or more equal parts which constituted the monthly pay- ments. finance corporations usually calculated 15° per annum interest on money actually outstanding, or from 6 to 8% on the purchase price. however, 11 some cases, where initial payments were very low, the subsequent payments extending over more than a year, and with no responsibility by the dealer for col- lections, the final cost to the purchaser was as much as 30% above the cash price. tinance corporations secured their funds from the banks, and the particular function thev served was to provide the necessary machinery for investigation, supervision and collection which the banks lacked. the different contract forms emploved have already been described. [t was customary for the purchaser to make out a note to the dealer for the amount remaining alter the initial payment. the dealer passed on this note to the finance corporation, which paid him its face value minus its asi own fee. the dealer would either indorse the note, and thus assume responsibility for the payment of the monthly instal- ments, or he would agree to re-purchase the car in case of de- fault by the purchaser. in some instances, however, the dealer assumed no responsibility: under this, the “‘ no-recourse ”’ plan, the charges of the finance company were higher. under any plan the purchaser was usually required to insure the car against fire, theft and accident. the prosperity of the automobile industry and the cnormous sale of motor-cars in the united states was the direct outcome of instalment selling. vhis fact could not escape notice by manu- facturers and dealers in other products. corsequently many articles never hitherto distributed by this means were offered on the time-payment plan; and many retail merchants who had once frowned on instalment selling either adopted the method gladly as a proved means of increasing business, or did so re- luctantly to meet competition. in 1926, in the united states, it had become possible to purchase practically every article of consumption costing upwards of $25 (with the possible exception of food) on time payments. this trend was well illustrated by the announcement in 31925 by a leading men’s clothing store of chicago of a so-called budget system”? under which garments might be purchased on a cash payment of / to } of the purchase price, the remainder be- ing payable in 10 weekly instalments. this shop had always con- ducted its business very conservatively, and had refrained from everything remotely related to instalment methods. other retailers were inclined to be censorious, and clothing manufac- turers were divided as to the merits of this innovation. but the minagement reported, after a short test, that it was successful, and some interesting facts were brought out. this store, like many others of the same class, maintained charge accounts for a large number of customers; and it is stated that payment on these accounts was often delayed as much as 60 or oo days. but the customer who pavs | down and then 10°, of the balance each week pays for his goods more quickly than he would under the ordinary charge-account. one of the most conservative stores in new york has in- stituted an elaborate budget system for the sale of furniture. this budget system is essentially a plan for selling on time pay- ments, but it has the advantage that the store first consults with the purchaser as to his income and furniture requirements, seeking by this means to minimise their risk and at the same time more accurately to satisfy the customer's needs. the con- sultation is of genuine benefit to the purchaser and often enables him to make a larger purchase with greater economy than if he bought haphazardly or piece by piece. it is apparent that under these conditions credit can be ex- tended to thousands of persons to whom a merchant would hesitate to grant an open charge account. morcover, the pur- chascr doubtless feels it safer and more convenient to budget his payments by the week or month rather than to have the entire amount fall due within 30 days and then allow the account to remain unpaid for a longer period, through the acquiescence of the store-keeper, but with a consequent impairment of the purchaser’s credit standing. although it has been customary to add a time-price or in- terest charge in making instalment sales, some merchants have endcavoured to maintain the same price for the cash customer as for the instalment customer. this practice probably cannot long continue. certain stores have already taken advantage of the situation to advertise “no credit ’? and “ cut prices” for cash, with the idea of showing the public the cost of time purchases. the possibility of selling more cheaply on a strictly cash basis will doubtless prove sufficient incentive for the expansion of this class of business; and by the operation of ordinary economic law will serve as a salutary check on instalment buying. the cost of instalment selling, considered by itself, is high. tt has been estimated te be as much as $800,000,000 yearly in the united states. this might be regarded as sheer economic waste were it not for the fact that tremendously increased pro- duction, made possible by the time payment privilege, has 482 served to lower prices; so that the purchaser buys enough cheaper to pay the cost. increased demand likewise keeps factories busy and gives employment to more workers. ‘the protagonists of instalment selling insist that much of the prosperity of the united states since the war, in the face of strong european competition with its cheap labour, can be traced to the development of the home market by means of time-payment financing. it is even suggested that certain backward countries could benefit by the cautious introduction of this method of marketing. it is typical of the diversity of opinion which still envelops the subject that some authorities regard instalment buying as tend- ing to demoralise the purchaser, while others, probably more numerous, believe that it benefits the individual and society. “we are sorry,” said the babson statistical organisation in july 1925, ‘‘ to see this stampeding to an instalment business. we don’t believe that it is wise for anyone unnecessarily to get into debt, whether manufacturer, merchant or the public. getting into debt has been the cause of most failures, and we are sorry to see another stratum of the public adopt it. on the other hand, is there any ethical reason why your employees are not justified in giving serial notes for their purchases of goods, as you are justified in giving notes for your purchases?” the story is told by a writer opposed to instalment selling of a man on an income of $60 a week who had contracted for purchase amounting to $72 a week. he explained that he could not re- sist the persuasive suggestions of salesmen. but most observers agree that the american houschold had not lost its sense of pro- portion; and the occasional emergence of cases like this 1s a re- flection on the credit departments of the sellers rather than on the principle of instalment selling. it is probably true, also, that further experience with deferred payments not only tends to make credit departments more cautious, but likewise trains the purchaser to be on his guard against undertaking obligations which he cannot meet. this training must have considerable social value. the workingman who seeks to buy a piano or an automobile on credit soon learns the importance of having a good reputation for meeting his obligations promptly. the instalment merchant would prefer, as a matter of fact, to sell an expensive article to a man of moderate income with a proved reputation than to a more prosperous individual who was dilatory in meeting his ob- ligations. having bought his automobile or piano, having dis- covered the value of established credit, and having learned some of the mechanism of business, the buyer becomes a more stable unit in the community. he sees it will not be at all impossible for him to buy his own home, and, if his interests lie in that direction, to establish his own business. the question is at once raised: why does not the instalment purchaser save the money in the first place? the psychologists could doubtless provide a complete answer; it is perhaps sufficient to say here that it is easier to pay for an article already acquired, especially if the sense of obligation is reinforced by a properly managed collection department, than it is voluntarily to lay aside each week or month a certain sum for the satisfaction of a desire that cannot immediately be realised. the wage-earner, attempting to save, necessarily finds it difficult to resist the demands made on his money, even though he manages to avoid petty temptations to squander; and instalment selling serves its best purpose when it provides the purchaser with products of enduring value. the fact is business could hardly go back to the pre-instalment days even if it wanted to. an analysis of the population in the area between boston and chicago, the great lakes and the ohio river, proved that for the purchase of an article costing $75 or more, after house-rent, groceries and clothing are taken care of, only 10% can pay cash; 30% are entitled to standard credit terms on a 30 to oo day basis, and 60°, must have four months to one year to pay. (see advertising and selling fortnightly, april 22 1925.) it is only necessary to glance through the magazines and note the advertisements of hundreds of articles selling for more than $75 to realise that these businesses could not prosper if they were instalment selling forced to reduce their output to the level of the cash demand. where, then, does the money come from to pay for these products? it is difficult to escape the conclusion that people work harder and deny themselves casual expenditures in order to pay for some- thing of real worth which they greatly desire. in many instances, too, it is certain that the article so acquired promotes greater pro- ductivity on the part of the purchaser. the opposition to instalment selling has come from many sources. partly, no doubt, it is inspired by manufacturers and merchants who have failed to change with the times; partly from other manufacturers and merchants whose goods: will not fend themselves to this method of merchandising and who suspect, rightly or wrongly, that money is being diverted from the purchase of their goods. open opposition has come from jabour leaders, who probably feel that the working-man who is paying for goods on the instalment plan will be less disposed to go on strike, and perhaps prove more docile in his attitude toward his emplover. a few banks have expressed themselves as opposed to the instalment business, but the majority have been willing to underwrite it in one form or another, otherwise the vast expansion already noted could not have occurred. if instalment selling is to continue on a sound and profitable basis, there is no doubt that certain precautions must be ob- served. (1) it seems undesirable to extend this method of sale to expensive products of great fragility or little intrinsic worth. (2) an article combining high cost of operation, upkeep and depreciation, with little or no earning power, is for the most part unsuited for sale on jong-term credit. (3) special safeguards must be devised if the goods sold on time have little or no value when repossessed, or if the period of payment is likely to outrun their usefulness. (4) no company should engage in credit business without a well-equipped collection department under the «lirection of an experienced credit man. (5) credit should be granted only after sufficient investigation to give a reasonable assurance of the applicant’s ability and willingness to pay. the last point is by all odds the most important; there could hardly be any “‘ problem ” as to instalment selling if all credit departments were properly managed. the seller is never forced to sell against his better judgment, and if abuses have crept in, the seller must take the major share of the responsibility. fortunately, such abuses tend to rectify themselves. there is no surer road to business disaster than the extension of credit on terms that are too easy, or to irresponsible persons, or on goods that are utterly unsuited to anything but cash sale. these principles of sound instalment selling are not new; they were discovered by the first banking institutions that began to lend money for the promotion of business. they are principles, however, that may have to be learned all over again by certain finance corporations and business houses who have taken up instalment selling as a quick and easy means to ar profit. ih. bra.) il. in great britain the development of the system of purchase on the instalment plan in great britain and her colonies has proceeded on similar lines to those outlined above in the united states, though not in so accentuated a form. the idea was by no means new in england, since pianos were being sold.on the hire-purchase system in london so far back as 1838. the present century, however, has seen an enormous expansion in instalment selling, which has been accelerated since the end of the world war. one instance of this will suffice. in 1919 few motor-cars were sold on the instalment plan m great britain. four years later one of those best able fo judge computed that of the £15,000,000 retail turnover on motor vehicles, over {4,000,000 was done on the hire-purchase system, the greater proportion of this latter amount being spent on commercial cars, including motor-vans, motor-lorries and motor chars-a-bancs. in 1925 the total turn- over had risen roughly to £52,000,000, of which not less than one-half was done on the instalment payment system. the estimate of the hire-purchase traders is that between 50°4 and 60° of the furniture turnover and over 50° % of insulin the piano, metor-cycle, sewing-machine and farm implement business in the same year was done on the same basis. even the british govt. in 1926 was selling by instalments surplus army stores including aeroplanes and horses. the percentage of instalment selling of factory machinery in great britain is, however, very low on account of the fact that british limited liability concerns prefer either to take a discount for cash or to take credit for the full amount of the purchase, since many of them are public companics. particularly remarkable, however, are the successes reached through the sale of what may be called ‘‘implements of business.” tor instance, the remington type- writer co. offered their portable typewriters on the instalment system in april 1925, the terms being an initial payment of £2.28.0d., followed by eleven monthly payments of {7.1s.0d. taking the sales for the six months preceding this offer at the rate of roo per month (a purely fictitious figure) it was found that the sales had increased in oct. 1925 to 210, in nov. to 269 and in dec. to 325. thus in eight months instalment selling had increased the sale of portable typewriters by over 200%, while the news- paper advertising for the cight months was only about 5% above that for the preceding six months. ‘lo-day there is practically no great londen or provincial department store that is not selling furniture, gramophones, wireless sects, pianos and sewing-machines on the instalment system. the financing of instalment selling in great britain has pro- ceeded more slowly than in the united states. there is one important reason for this. the city docs not like motor flotations at any time; and it likes motor finance corporations even less. accordingly, these companies have usually had to go to the insurance companies or their own directorate for their money. further, the british public has never become enamoured of motor shares, and this dislike has extended to the shares of the finance companies. yet there are several corporations in great britain doing a turnover of {2,000,000 to {5,000,000 per annum, and it is probable that the present prejudice of both the city and the small investor against the shares of such concerns will be over- come eventually. the system of financing motor hire-purchase in great britain is identical with that in use in america. in the case of a new car, however, it is usual to ask 25% in cash as a first payment, the remaining payments being spread over a period of 6 to 18 months. it is common for the financing com- pany to charge 7°% to 8°64 on each transaction for 12 months’ accommodation. obviously the actual rate of interest paid is 154% to 16% since the average amount on loan for each month is only half of the total. it must be remembered, too, that the retailer is normally charging his customer from 5% to 8% for the credit given, so that the net cost to the retailer is quite small. it will be clear, thercfore, that the use of the instalment method of selling eniails a greater capital in relation to turnover than cash selling. in other words, it tends to turn a former cash business back to the basis of the old-fashioned credit business, when the customer took from 3 to 12 months’ credit. the question which exercises british business men is whether | an expansion of instalment selling similar to that which has taken place in the united states during the past six years would be salutary or dangerous. goods sold on the instalment system are, in a sense, put into stock. one of the main causes of any business slump is the excess of goods in stock. in a time of depression it is clear that the number of failures to meet payment would increase. how seriously would it increase? further, as the bank rate rose, the financing companies without large re- serves would find their profits heavily cut, and possibly turned into losses. at the same time it would be difficult for them to secure new business on account of shortage of money and higher rates of interest. british fmance and british business are compelled to study this problem for themselves, since the con- <litions of american business are so different and no serious slump has occurred in the united states since instalment selling became so prevalent. the conclusion, however, would appear to be that the sale by instalment of articles with a re-sale value, i.e., of articles which do not depreciate with enormous rapidity, is safe within almost any achievable limits. but very large sales 483 in articles unsuitable for re-sale owing to the heavy depreciation, e.g., clothes, might be extremely dangerous if acute business depression became rapidly felt. the legal aspects of instalment sclling in great britain are somewhat different from those prevailing in the united states. the property in an article purchased on ‘ deferred payments ” passes to the purchaser, 7.e., he becomes owner from the moment of the first payment, whereas under the hire-purchase system the purchaser merely acquires the right of possession, no right or property passing to him until the final payment has been made. it is vital therefore for the business which desires to sell its goods on the instalment plan to see that the actual contract signed by the buyer is one for hire-purchase, in which the suc- cessive payments are considered mercly as rent, until the final payment is made, prior to which latter event the ownership remains in the vendor. otherwise the purchaser alter obtaining possession will be able to sell or encumber the goods, and an intiocent purchaser or mortgagee will obtain priority of title. another contingency which has to be considered in great britain is that of distraint for rent. in the united states generally the landlord does net possess this remedy. all he can do is to put the tenant who is in arrears out on the street together with his goods. in great britain the landlord can enter upon the premises, seize the tenant’s goods found therein, and sell them to realise the amount of rent due, and this liability extends to goods purchased by the tenant under the hire-purchase system, other than pianos, sewing-machines, safes, gas-engines and printing- machines. on a par with this is the danger of the purchaser becoming bankrupt, in which case the trustee in bankruptcy may, and prebably will, sell the goods in question for the benefit of the debtor’s creditors, unless the agreement has been drawn up in consonance with the best british practice. the legal situation, generally speaking, is so full of pitfalls and the law on many points so uncertain that any firm considering entering into the instalment business should take care to obtain the best legal advice on all phases of the subject. it should be added that, from a credit standpoint, the instal- ment business has proved quite as safe so far in great britain as in the united states. the average losses through bad debts by the members of the hire traders protection assn. is under 2% per annum. one of the leading london firms reported re- cently that their loss from bad debts was less than 1% per annum. even in one of the most risky fields, that of the sale of motor-cars by instalment, the average percentage of losses from this cause has never been placed above 23% by competent authorities. (chc) insulin.—in 1889 von mering and minkowski proved that the complete removal of the pancreas from animals produced signs and symptoms which are practically identical with those found in human beings suffering from diabetes mellitus. previous to that year the pancreas, the gland which secretes powerful digestive enzymes into the first part of the small intestine, was not definitely associated with the utilisation of sugar by the animal body. it was soon shown that a small amount of pan- creas grafted under the skin prevented the development of diabetes in an animal from which the rest of the pancreas had been removed. it was also discovered that blockage of the pancreatic duct did not produce diabetes, although degeneration of the pancreatic tissue, with the exception of numcrous small structures called the islets of langerhans, resulted. historical notes —these minute structures apparently un- related to the acinous tissue which forms the digestive enzymes, were first noted by paul langerhans in 1869. schafer was one of the first to suggest that pathological changes in the islet tissue might be responsible for the production of diabetes in man. ile also suggested that “ insuline ” would be an appropriate name for the hypothetical internal secretion by means of which some authorities believed the islet tissue to exert its control over sugar metabolism. experiments and discovery.—in the year 1921 banting and best, at the university of toronto, began a series of experiments the results of which proved that a substance could be obtained 484 from the pancreas which would enable diabetic animals to utilise sugar. this substance was originally secured from the degenerated pancreas of the dog. the degeneration was pro- duced by tying the pancreatic ducts, which causes an atrophy of the cells of the gland which produce the digestive ferments, but leaves intact the islet tissue. the available supply of de- generated pancreas was, of course, very small and efforts were soon made to secure the material from other sources. after a series of experiments in which small amounts of material were obtained from the normal pancreas of the dog and from the fetal calf pancreas, the active substance was obtained from the adult beef pancreas by alcoholic extraction of the fresh tissue. this discovery provided ample material with which to study in detail its action on experimental animals and to apply it to the treatment of patients suffering from diabetes mellitus. animals from which the pancreas has been removed suffer from the same symptoms that the human diabetic experiences (see diabetes). the sugar which cannot be used accumulates in the blood and is excreted in the urine. the normal animal-stores sugar in ils liver in the form of glycogen, but the ciabetic liver does not form this substance. the administration of insulin to the diabetic animal corrects all these abnormal conditions and cnables the animal to utilise carbohydrate in a normal manner. ‘the average life of a completely depancreatised dog before the discovery of insulia was less than three weeks. these animals have now been kept alive, by the administration of insulin, for over two years and will undoubtedly live much longer. use and value.—insulin was first applied to the treatment of diabetic patients in jan. 1922. the results have been uni- formly successful, and thousands of patients are now being kept alive by the hypodermic injection of this material. insulin does not cure the disease but replaces the internal secretion which the diabetic has lost the power to produce. the substance is ad- ministered subcutaneously and is not effective when given by mouth, standardisation.—insulin is standardised by observing the extent of lowering of the normal rabbit’s blood sugar produced by small amounts of the active material. the administration of too much insulin to diabetic patients is dangerous but the situa- tion can be recognised by the occurrence of definite symptoms. the condition can be quickly corrected by the ingestion of sugar in any convenient form. employment in cases of coma.—previous to the discovery of insulin a large proportion of diabetics died of coma. the intel- ligent use of insulin combined with proper dietetic treatment prevents the devclopment of coma: patients in coma can in most cases be rescued by the administration of large doses of insulin. , specific in diabetes afellitus—insulin has proved to be a specific in the treatment of diabetic coma. it 1s invaluable in the treatment of severe diabetes mellitus. the use of the active substance in the investigation of the physiology and the bio- chemistry of the carbohydrates tn the animal body has already brought to light numerous important new facts. it is quite possible that it is in this last field that insulin will contribute most to the welfare of the human race and the progress of medical science. 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