177BACTERIOLOGY OF ’THE °‘ SPANISH INFLUENZA."

tion on massive scale demands; such a man Iis of prime value to this country to-day, and it Iis well that our politicians should have begun toperceive this truth. For much work lies aheadthat ought to be done now, while the raw nativematerials at the disposal of the enemy give himmany advantages, presenting to him a simplerproblem in regard to the extraction and prepara-tion of ultimate products. Commercial men familiarwith questions of this kind, it is to be devoutlyhoped, will give science that hearing which thepresent position claims and which hitherto hasbeen refused. Such are the reasons why the forth-coming exhibition is of the greatest national

importance, and we are glad to learn that a

gratifying demonstration of what British scienceis able to do in regard to industrial develop-ments is promised. Our statesmen have con-

sistently disregarded the warnings of science in thepast; - they must do so no longer.

Annotations.

BACTERIOLOGY OF THE "SPANISH INFLUENZA."1

"Ne quid nimis."

THE pandemic of influenza has not spared anysingle part of Germany. The clinical course doesnot seem to’ differ from that run by the disease inthis country. Relapses and fatal pneumonias areparticularly noted. The clinical picture is declaredto be identical with that of the last pandemic of1889. A very striking observation has been broughtforward and generally confirmed at a specialmeeting of the Munich Medical Union on July 9th-namely, that persons under 30 years of agemainly fall victims to the disease; this was

explained by a survival immunity in the elder

generation. The meeting considered all the aspectsof the epidemic on the basis of the hospital andUniversity material of Munich. Pfeiffer’s bacillushas been found but exceptionally; streptococci,and occasionally pneumococci, were recoveredfrom the sputum, organs, and also blood ofthe patients. Similar findings were recordedin 1889, and thus the present results were in"

keeping with precedent." Pfeiffer’s bacillus hadnot been found until 1892, although it shouldhave been impossible to overlook it in 1889,thus it may be that it will yet turn up in duecourse. The editors of the Deutsche niedizini8cheWochenschrift have addressed a circular inquiry toall the leading bacteriologists in Germany request-ing enlightenment as to the results of their labora-tory investigations. Pfeiffer himself had reservedhis final opinion as to the relationship of thepandemic with those of 1889 and 1891-92. He hadnot examined a sufficient number of cases atBreslau, but found his bacillus in some whilefailing to recover it from others, and was stillinvestigating the causes of this discrepancy.Gruber answered from Munich very simply:"Influenza bacilli not found hitherto-investiga-tions proceeding." Ulrich Friedemann, who is incharge of the infections- wards of the VirchowHospital of Berlin, expressed his belief that thesymptomatology and complications of the epidemiccorrespond exactly with those described in 1889-90.He had not found the Pfeiffer’s bacillus, streptococciand pneumococci being the most common agents1 Der bakteriologische Charakter der "Spanischen Krankheit."

Deutsche med. Wchnschr., Berl. u. Leipz., 1918, xliv., 775 and 808.Editorial Notes, München. med. Wchnschr., 1918, lxv., 804.

of the complicating pneumonias. The influenzabacillus may be evading capture on account of

faulty method of inquiry, yet on the other handthe possibility must not be overlooked that theremay be epidemic diseases clinically resemblinginfluenza of which the Pfeiffer’s bacillus is notthe agent. Uhlenhuth has so far reported fromStrassburg the same contradictory results as thoseof Pfeiffer. Kolle reported under the date of July 18thfrom Frankfort his failure to detect Pfeiffer’sbacilli in any of the few cases which he hadthoroughly examined. In practically all cases

there were found, however, large numbers of a

Gram-positive coccus-often in a pure culture or insymbiosis with pneumococci. The diplococcustended to develop involution forms and to grow invery long chains in the condensation water. Heregards them as agents of a secondary infection inthe " Spanish disease" which to his mind maynot be identical with the pandemic influenza of1889-1893. The finding of this pleomorph Gram-positive diplococcus is very interesting in view ofthe observations of Rosenow and his pupils in theUnited States.

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A YEAR’S WORK AT A MENTAL SECTION.

Dr. R. Eager, Major, R.A.M.C., the officer in chargeof the mental division of the Lord Derby WarHospital at Warrington and formerly seniorassistant medical officer of the Devon CountyAsylum, has submitted to us a valuable analysis,appearing in full in the current number of theJournal of Mental Science, of the admissions anddischarges in the division from June 17th, 1916, toJune 16th, 1917, amounting to some 2429 of theformer and 1466 of the latter. The main facts ofthe analysis may be summarised thus :-The average number of admissions per month was 202 and

discharges 122. It may be stated that these figures refer bothto men who have served with one or other of the Expedi- .

tionary Forces and to cases occurring with the home troops,although the latter are now dealt with in other ways. Thegeneral method adopted was to admit the patient for thepurpose of examination, observation, and diagnosis, and ifhis case was considered mental and he did not make definiteimprovement he was certified and sent to the county asylumto which he was chargeable. If, on the other hand, he showedsigns of improvement he was retained in hospital till he wasable to be discharged to the care of his friends. To take theadmissions from among the home troops first. Theseamounted in the year selected to 258. Of these, 168 wereeventually discharged to their civil occupation, 66 werecertified and sent to asylums, 6 died, and 8 were sentback to home duty with the army. The main clinicalgroupings in the 258 were: mental deficiency, 53 ; delusionalinsanity, 43 ; melancholia, 37 ; neurasthenia, 26 ; dementiapraecox, 24 ; G.P.I., 16; mania, 13 ; confusional insanity, 11;secondary dementia, 10; and alcoholic insanity, 9. Thecorresponding figures for the cases from the ExpeditionaryForce in France may also be quoted. These amounted inthe same year to 1652, of which 536 were eventually dis-charged to some civil occupation, while 75 were sent toasylums, 11 died, and no less than 175 were sent to homeduty with the army. Among the 1652 were 309 cases ofmelancholia, 242 of delusional insanity, 233 of mentaldeficiency, 179 of confusional insanity, 135 of mania, 127 ofdementia praecox. 99 of neurasthenia, 78 of G.P.I., 63 of shellshock, 33 of mental stupor, and 19 of alcoholic insanity.We wish to emphasise only one point out of

much that is instructive-viz., that of 258 homemental cases 176 recovered and went back towork, while of 1652 expeditionary cases 711recovered and also returned to work. These figuressupply one more confirmation, if such were needed,of the contention that the opening of receptionhospitals, as distinct from asylums, for the earlytreatment of the psychoses and psychoneuroseswill materially advance matters in this field ofmedicine. THE LANCET has many times dealt withthis subject, and has urged strenuously that the

178

unfortunate civilian patient should not be handi-capped as compared with the military patient.The success of the military mental hospitals isproof conclusive of the immediate necessity of

tackling the problem seriously for the civilian.As things stand at present, it is scarcely an

exaggeration to say that if a medical officerconnected with an asylum is consulted by someone who fears he has incipient mental trouble theonly thing to be done is to tell him to " go away andget much worse," when a general practitioner will beable to certify that he is fit for admission to anasylum. Surely, one of the ironies of the situationis that certification is mainly in the hands of menwho are not familiar with the subtleties of patho-logical mental states. The goal to be aimed at isthat all cases should pass through a reception hos-pital prior to certification, and that the latter, ifnecessary, should be carried out in the special hos-pital by properly qualified men. The advantage ofbeing able to treat mental cases in early non-certifiable stages is too obvious for the point to belaboured. It is satisfactory to record that a selectcommittee of the Medico-Psychological Associationis sitting to deal with such proposed reforms of theLunacy Laws as will incorporate all the valuableexperiences gained by the successful methods oftreating military mental cases, the elaboration ofwhich is one of the outcomes of the war that havebrought good in their train.

HEMIPLEGIA DUE TO TUBERCULOUS MENINGITIS.

TUBERCULOUS meningitis in adults differs inmany ways from the disease in children. Fre-

quently it shows a tendency to be circumscribed toa point in the cortex and the symptoms suggest afocal lesion. At a meeting of the Académie deMedecine of Paris M. T. Legry reported a case inwhich the symptoms were so typically hemiplegicthat a different disease was suggested. >A woman, aged 31 years, was admitted into the Charite

Hospital on Sept. 6th, 1915. She had felt fatigued for twomonths and for a week had noticed at irregular intervalstingling beginning at the extremities of the left foot and handand spreading over the whole of the left half of the body. Shecoughed a little, but examination of the chest was negative,and there had never been haemoptysis On the left side theknee-jerk was exaggerated, Babinski’s sign was present, andsensibility and muscular power were diminished. In walkingthe left leg was dragged. Lying down the patient could notraise the left leg more than 20 cm. above the bed. Move-ments of the left arm were also limited. The temperaturewas 98-6° F. Because of the age of the patient, the clearlyorganic character of the hemiplegia, and the absence ofother cause which might be invoked, specific hemiplegia,probably the result of arteritia, was diagnosed. Iodideinjections were given and blood was taken for a Wassermanntest. On the following days the symptoms persisted; therewas no vomiting, stiffness of the neck, or sign of Kernig.On Sept. 16th the temperature rose to 1022° and paresisappeared in the right lower limb. Lumbar puncture yieldedfluid under very high pressure which presented abundantlymphocytosis and contained tubercle bacilli. Deathoccurred on Sept. 24th.The necropsy showed a few isolated tubercles atthe apices of the lungs. At the superior border ofthe right cerebral hemisphere was a thick granulartuberculous patch of the size of a 2-franc piece.In the longitudinal fissure it encroached on theparacentral lobule and on the external surfaceof the hemisphere on the ascending frontal andparietal convolutions. It was very adherent to thesubjacent nervous tissue. In the rest of the piamater were found some whitish-grey spots repre-senting early tubercles. In this case all the

symptoms, as well as the age and the absence ofpulmonary signs, pointed to specific disease. Onlythe results of lumbar puncture enabled the diagnosisto be rectified.

PARIS.

(FROM OUR OWN CORRESPONDENT.)

Yooational Re-educq,tion of H’ar Invalids.

1--KTF,RESTINC,l experiments in the vocational re-educationof war cripples have been carried out at Bordeaux andrecently reported to the Academy of Medicine. Dr. Gourdon’sobservations extend over 5014 cases with loss of limb orgrave and incurable injuries, of whom 73 per cent. have beenable to resume their trade (with or without prosthesis)without special training ; 27 per cent. required some neweducation or a modification of their old work. 30 percent. only of the patients examined were disabled inthe upper extremity. In each case a careful examina-tion of physical and psychical aptitude was made,for the war cripple varies greatly in both these respects,and it is essential to place him under the sur-

veillance of instructors and foremen who can adapt thetechnical methods of a craft to the degree of intelli-gence, energy, and skill, as well as to the age of the cripple.62 per cent. of the patients at the Bordeaux centre wereagricultural labourers, and of all cripples the worker on theland most readily resumes his former work. He is fond of

it, he knows his work thoroughly, and it is work which doesnot demand precise movement. Thus 85 per cent. of thesmallholders or farmers, and 48 per cent. of the gardeners,were able with suitable appliances to resume work at once.Cases with loss of hand or forearm have shown practicallynormal output of labour ; with loss of arm 75-85 per cent.of the normal ; with disarticulation of the shoulder 40-50 percent. Among lower limb cripples only those with amputationthrough the thigh showed any considerable handicap ; in thiscase an output of 50 per cent. of the normal. Nearly all thecripples are apt at manual work, whether sitting or standing,the diminution of output not exceeding 10 per cent. Pro-fessor Bergonieis, from his own experience, strongly in favourof re-education by agricultural work, considering it greatlysuperior to, and more rapid in results than, all the methodsof artificial physiotherapy practised in urban hospitals, thefield-work being continued all day and every day under thesupervision and direction of doctors. In the Bordeaux areaduring one year cripples undergoing the agricultural curehave furnished 107,000 days’ work on the fields.

..4 Preventive and Ourative Ser1tm for Gas Gangrene.M6decin-inspecteur Vincent, professor at the Military

School of Medicine of Val-de-Grr.ce, has announced to theAcademy of Science the discovery of a serum, prepared incollaboration with M. Stodel, with which he has successfullytreated gas gangrene. The action of the serum is both

preventive and curative. Guinea-pigs injected with theserum after previous inoculation showed a mortality of only4 per cent., against a rate of 80 per cent. in the non-injected.On the strength of these results M. Vincent determined totry the curative effect upon man. Thirteen patients sufferingfrom gas gangrene, all in a serious, four in a desperate,condition, were thus treated by him, with the result that11 recovered. These results augur well for the new method,details of which will be furnished later, as observationsare being continued.

- Shook and Musoular Autolysis.In order to decide the question of the toxicity of

muscular autolysis occurring at the seat of the wound,which has been regarded by some as the principal causeof the grave symptoms of traumatic shock, M. PierreDelbet and M. Karajonopoulos have made a series ofobservations which seem to establish the part played byauto-intoxication. After operating upon dogs and guinea-pigs damaged tissue from the region of the wound was.taken immediately after death, finely triturated withnormal saline, and incubated at 370 C. The filteredextract was then injected into the peritoneum after carefulsterilisation. In dogs it was found impossible to obtain asterile extract for this purpose. With guinea-pigs and rats,

"

especially with the latter, which live on a flesh diet resem-bling that of the soldiers, the authors obtained highly autolyticextracts producing in animals all the symptoms of shock afew moments after injection-acceleration of respiration,absolute inertia, and abolition of reflexes, then gradualcessation of respiration and death in coma. They conclude