Considering the necessity for increasing the educational qualifications of our citizens, it is shocking to record that eighteen states have no definite educational requirements for children leaving school to enter industry, and only twelve states require the completion of the eighth grade before the acquisition of employment certificates. It is noteworthy that the southern states have a larger percentage of child labor than any other section of the country. The New England states possess a larger proportion in non-agricultural work, while Pennsylvania has a larger percentage of children employed in manufacture than any other state. During 1920, six per cent, of our population of ten years of age and over were adjudged to be illiterate. In the cities the percentage of illiteracy was 4.4 per cent., as compared with 7.7 per cent. in rural districts. The foreign born white children and the negro children between the ages of ten and fifteen do not have a high proportion of illiteracy in our cities, but in the rural sections their rates range from 11.9 to 14.2 per cent. There is a definite parallelism between the number of children employed as laborers and the percentages of illiteracy.

If the advance in public health carries with it the necessity for increasing educational power, child labor is contrary to the best interests of the public health movement. Laying aside education, there must be considered the liability of child laborers to accidents and diseases in a proportion. that is far above the ordinary hazards of child life. The maiming of children as part of an industrial process is more than the exploitation. It represents a criminal laxity on the part of the State, that regards itself as the protector of childhood, in the fulfilment of its obligations to youth.

The child deprived of an eye or an arm is indeed limited in his economic resourcefulness, but his shortcomings as an adult will have to be met by social institutions. Industry does not bear the brunt of the damage that it causes to the youthful bodies and minds that it bruises and blights. Child labor is unnecessary and its continuance is merely a useless toll to Greed.

Every resource of communities should be utilized to safeguard the period of dependence of children, so as to provide an adequate opportunity for normal growth and development. The potentials of adult life are bound up in the richness of youthful experiences. There is a vast difference, however, betweeen acquiring the rudiments. of vocational training, with the consequent power for industrial adaptation, and the direct utilization of juvenile muscles and nerves, for the economic advance of special groups in communities.

It is to be hoped that Congress may find some constitutional method for abolishing this national scandal of child labor, even if, as a last resort, another amendment may be required to our Constitution. Certainly, child labor frequently results in the destruction of life and liberty and interposes insuperable obstacles to the pursuit of happiness.

The Radium Hazard. The place of radium in therapeutics is still undetermined. Its practical use and the experimentation with it is increasing the number of persons manipulating it and therefore subject to its radiations. It is important, therefore, to recognize that continued exposure to radiation may produce a number of unpleasant results. Pain and sensitiveness of the skin of exposed fingers, burns, or destruction of the skin and underlying tissues are possible results. More marked, however, is the effect of radiation upon the blood and bloodmaking organs. Obviously, the extent of the influence of radium emanation varies with the length of time, the frequency, the nearness, and the amount of radium tó which the subject is exposed.

In The Public Health Report, December 21. 1923, R. C. Williams makes some definite recommendations for those who are employed in the daily handling of radium. He advises complete physical examinations. at regular intervals, after the initial complete physical examination, including that of the blood at the time of entering upon active work with radium. He urges the use of all practicable protective devices, such as screens, lead-lined carrier boxes, handling forceps, in rooms that are thoroly ventilated. As a special protection he advocates that blood examinations and bloodpressure readings be made at regular intervals, because definite blood changes, with lowered blood-pressure, are common among workers with radium. As a further prophylactic measure, he urges that all persons regularly employed in handling radium be allowed to work only five days a week, and that there be thirty days annual leave, occurring in two-week periods.

When the Roentgen-ray was first intro

duced and our knowledge concerning the effects of radiation were limited, many research workers and physicians sustained irreparable damage. Considerable time was required to appreciate the necessity for protective devices, but today the radiographer is achieving his remarkable results, free from most of the hazards of the powerful instrumentality he utilizes. For this reason it is important to recognize that radium, too, possesses hazards, the exact nature and extent of which are not fully known. Hence, the determination of some protective principles represents a step in advance and serves as a foundation of intelligent protection against damage by radium and its emanations. The values to be secured from prophylactic measures of the kind indicated depend upon their adaptation. Certainly, hospitals, laboratories, and specialists in radium therapy should be familiar with the means for safeguarding workers in radium and make use of them.

Occasionally one notes a laxity on the part of hospitals to employ the technic which physicians are wont to urge upon the laity. This is well exemplified, for instance, in the outbreak of an epidemic of typhoid among nurses in a hospital, when anti-typhoid vaccination might have prevented it. Similarly, the occurrence of diphtheria among internes and nurses is discreditable in the light of our present-day knowledge concerning Schick testing and active immunization. There is reason, therefore, to believe that the method of preventing injury by radium should be given special attention, particularly in institutions devoted to the treatment of malignant diseases and in the institutions where radium · is utilized daily for purposes of treatment or experimentation.

A Doctor's Service to His Community. -In a recent issue we called attention to the candidacy of Dr. F. W. Bock for the mayorship of Rochester, N. Y., pointing out the advantages that would surely accrue to his community if he was elected.

Unfortunately Dr. Bock was not elected, but there is no question but that his campaign accomplished great good. The following editorial from the Rochester Herald (Nov. 7, 1923) tells in no uncertain way of the fine service Dr. Bock rendered to his city and the people at large by running for the office of mayor, and tho he was defeated, the educational features of his campaign brought home to the intelligent people of Rochester the paramount importance of the things he stood for. Thus says the Rochester writer:

"The vote cast for Dr. Bock was entirely an expression of idealism and represents one of those fine, patriotic, unselfish gestures of which we as a free, intelligent and righteous people are traditionally supposed to be capable. It is not a flattering commentary on our civic vision and aspiration that we often are heedless of the voices that cry in our wilderness, and the man who sets his path straight toward an idealistic goal is more likely to receive jeers for his pains than cheers.

"Dr. Bock has done an unselfish and tremendously important service to his city. He has clarified and renewed a vision of proper civic righteousness and has given to us to see for a moment the true purpose of political faith. Such crusaders as he, their armor unsullied by fanaticism and armed with a sword Excalibur of wisdom and courage, are the pathfinders of the world, making straight in the desert the highways of God. But for such brave and undaunted souls our vision of what may be would soon be lost in the muck of what is. 'Our reach should exceed our grasp or what's a Heaven for ?'

"It is quite certain that those who cast their votes for Dr. Bock, knowing almost to a certainty that they were espousing a hopeless cause, did so with a clear conscience and a stalwart faith in the right. They are of the sort of rare spirits who persist in the face of obstacles and who valiantly refuse to compromise with evil.

"Dr. Bock is more honored by their allegiance in his foreordained defeat than the victor in his victory. There should be for him in their unafraid loyalty an encouragement to continue with strong heart his course of idealism, for of such visions as his are men made better."

Those of us who know Dr. Bock will read this tribute with gratitude and say with all sincerity Amen!

Striking the Balance in Insulin Therapy.-Brief references in endocrine literature indicate that insulin therapy, despite the immense interest taken in the subject, is beginning to pall a little, both upon the physicians who have to administer it and upon the unfortunate diabetics who have to receive it two or three times a day by hypodermic injection. As the editor of the Journal of the American Medical Association has well said recently:

"The present methods of administering insulin parenterally, and particularly by the device of frequent subcutaneous injections, are far from satisfactory, even when the technic is carefully carried out so that there is a minimum of irritation at the site of the introduction of the drug. The difficulties are aggravated by the fact that the effects of insulin are transitory, so that the supply to the organism must be renewed at fre

quent intervals. Depending upon the severity of the patient's diabetic symptoms, injections must be repeated twice or thrice daily for periods of as yet undetermined

lengths. Consequently, even the earliest investigators of insulin and other pancreatic preparations attempted to secure physiologic effects by oral administration of the products."

The workers in Toronto are quite insistent in their belief that because insulin is destroyed by trypsin it cannot be given by mouth and because insulin reduces blood sugar and cannot be given by mouth that pancreas therapy by mouth is useless and that those who believe that it is thus useful and so use it, are misled

We have had occasion to refer to this previously in our editorial columns and not only cannot agree with, but also feel sincere regret at the Toronto attitude. Our position recently has been strengthened by the reports of some work done by Winter and Smith (Journal of Physiology, p. 108, Vol. LVIII), who seem to have shown that the Toronto workers evidently are mistaken, for they have given insulin by the mouth in an experimental way, with very definite influence upon the blood sugar. But they had to devise a means of protecting the insulin, which it happens they have done by the use of alcohol.

Apropos of the above comments regarding the oral administration of pancreas therapy, another very interesting development is reported in a recent issue of the British Medical Journal (November 17, 1923, No. 3281, p. 916). A physician in Newcastle-on-Tyne, Dr. W. Devereux Forrest, referring to the work of Winter and Smith, who found that when insulin and parathyroid were injected simultaneously into rabbits, hypoglycemia was caused by almost one-fourth the usual dose of insulin necessary to bring about the expected hypoglycemia reaction, reports five cases with numerous blood sugar figures indicating that parathyroid extract, when given by mouth in conjunction with injections of insulin brings about a more marked reaction than is obtained following the use of insulin. alone, which, in addition to being a means of broadening the treatment of diabetes, is an interesting vindication of the position so long held by Harrower and others in respect to pluriglandular therapy that it is in many instances superior to the use of a single extract alone. We regret that this phase of the problem of the treatment of diabetes has been ignored by the Toronto

School, as well as by a number of other workers who have seen fit to criticize what they call "the pluriglandular theory." really seems as tho a new era is being opened up for the diabetic, which may render present methods obsolete and broaden the field of insulin and pancreas therapy in general.

Deaths from Diphtheria.-Many practicing physicians feel that we have conquered death-dealing diphtheria, especially since the far-heralded antitoxin came into use. But, while there is much reason for congratulation, diphtheria still claims a large number of victims and the mortality is still much higher than it really ought to be. There has been no decrease in deaths from diphtheria during the past few years, and, since nothing really stands still, there is always the possibility of an increased death

rate.

Dr. Bertrand E. Roberts, who is epidemiologist to the New York State Department of Health, has recently published an article in the New York State Journal of Medicine analyzing 500 deaths from diphtheria occurring in New York State, excluding New York City, during 1922. The article is well worth careful study, but it suffices here to draw certain valuable conclusions therefrom. In the first place, diagnosis is not made as promptly as it should be in many cases. Allowing for the fact that a physician is not called promptly, there is still further delay on his part in making the diagnosis. Most of the cases are seen later than the second day of the disease, a considerable number are seen when the disease is well advanced, and there remains a considerable percentage of late and nearly moribund cases which go to a fatal issue. One of the deductions to be drawn from Dr. Robert's paper is that any child seen at any stage having sore throat with what looks like a patch, membrane, high fever and prostration, should receive antitoxin at once, regardless of laboratory diagnosis. Of course, it may be tonsillitis, but even so a dose of antitoxin can do no harm. The time lost in waiting for the report on a culture is often valuable time that can never be made up, for some of these little patients grow progressively worse by the hour.

If there is time it is advisable to "de-sensitize" in cases giving a history of asthma or in those that have had serum before. Waiting for a report on the culture, and failure to give antitoxin at once was a definite factor in the death of at least 85 per cent. of the patients in the 500 reported. There is, in these days, a preference for the intravenous administration of antitoxin wherever possible; that is, wherever the vein can be found and the patient can be kept quiet long enough to administer the dose. In the 500 deaths analyzed, this method is said not to have been used on the first day of the disease in a single instance. Usually antitoxin was given intramuscularly, but the intravenous technic is easy to learn and ought to be employed more often.

Dr. W. H. Park has given us a table of dosage which is helpful but like all other tables, is capable of misinterpretation. For instance, he classifies cases as mild, early moderate, late moderate, and severe and maligant. To the first two groups, he advises giving antitoxin into the muscles. To the latter two groups, into a vein, the intravenous dosage, being, of course, smaller than would be given into the muscles in the same case. It is possible that a more extended use of the intravenous method might result in saving still more lives. There is a question of interpretation of groups-how to distinguish between mild, early moderate, late, severe, malignant, etc. Here, the personal equation enters so largely into the matter that judgment is rendered exceedingly difficult thereby, but in general, one may say that where the diphtheritic process has extended from the throat into the nose or thru the nose into the throat, the case is severe, and in any case one should always take cultures from both the nose and throat regardless of clinical appearances. Dr. Roberts says that the full amount of antitoxin should be given at one sitting; for it is poor economy to save antitoxin on the theory that a little may be enough and that more can be given later, if necessary. One should give all that he thinks the patient can tolerate promptly and efficiently.

In the laryngeal cases, it is probably better to do either intubation or tracheotomy promptly, for, of 110 deaths from laryngeal obstruction 58 did not receive this kind of treatment. Recently, suction has proved helpful in loosening the membrane from the

larynx and thus freeing the lower airways. This, of course, is more easily carried out in a hospital with plenty of nurses and doctors in attendance, and, as a matter of fact. it is doubtful whether diphtheria should ever be treated in the home, if hospital care can be provided. In the past, too little attention has been paid to the patients during convalescence. Therefore, heart involvement has played a rôle in nearly half of all deaths, and, in a goodly number, failure to keep the patient quiet, which means at rest in bed, was definitely mentioned as the immediate cause of a fatal issue.

Advertising Versus Medical Publicity. -This is an age of "advertising pests." The countryside is bespoiled by glaring signboards and fences calling the attention of the automobilist to the virtues of soap and corsets and tobacco. But, following a wellknown common-sense rule, the thing that is advertised most may be the least desirable of all, since the worthy article will somehow find its way to public attention in the majority of instances.

There are those who firmly believe that in the near future the medical profession will advertise its abilities. In a limited sense, it is attempting to do so now thru. its propaganda in various bulletins and periodical literature which it is aiming to circulate among the laity. A few years ago, banking, which is regarded as a profession by some, was on such a high ethical level that banks never solicited business. Now every bank solicits either thru the mails or by personal interview. They "need the business" and seem to be getting it. It would sound very banal and worldly to apply such a phrase to the high-minded medical profession which is, after all, very different from banking from every standpoint.

There is certainly a difference between advertising and respectable publicity, but neither the one nor the other can be done ethically by individual physicians because the practice of medicine would thereby soon be reduced to a commercial basis wherein truth would be sacrificed to personal exploitation for the purpose of making money. Publicity is a function of organized medicine which is just beginning to