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Annotations.

WAR NEPHRITIS.

.. Ne quid nimis."

THE growth of a child is notoriously discon- enti:

tinuous, and it often happens that knowledge of a Ca1new disease advances sometimes rapidly, sometimes routwith tiresome slowness, while apparently the same faile

amount of work is being put into it by competent 11investigators. A striking example of this is given ma4iby war nephritis. The recent report of the Medical at iResearch Committee is largely of a negative char- poiacter, throwing little or no further light on the thecausation of the disease. Interesting additional rea

information is, however, incidentally given. neThe first part of the report is drawn up by the Committee rei:

on War Nephritis working in France. This shows that whalthough the first rise in the incidence of nephritis occurred thein the spring and early summer of 1915, after that timemost cases occurred in the winter, the temperature curve hasvarying inversely with the rate of incidence so closely that preit can hardly be without significance. It is gratifying to reflearn, however, that the total numbers have never reached 1a figure that could be considered of importance to thestrength of the Army. As each group of the new army Cawent to France there was a rapid and uninterrupted rise ofin the incidence of cases in that group, reaching its highest epoint in about six months, after which a fall occurred,

"

reaching its lowest point the following summer. After wa

that the incidence curve of the group followed closely that daof the whole Army. The suggestion is that the individuals th,naturally prone to nephritis were first attacked, leaving a thmore or less homogeneous residue. We might add that these Iresults also suggest that though climatic conditions were th,not responsible for producing the outbreak, since it did thnot start till after the severe winter of 1914-15 was

mepast, they have played a considerable part in modi

befying the incidence of the disease once it had started. be

Fortunately, the death-rate has remained low. The co

average annual mortality for all cases was 0’93 per cent. reDuring 1916 only two officers died from nephritis, and none urduring 1917. The Committee could not find that diet, uchlorinated water, metallic poisons, intestinal intoxication, elprevious renal disease, or illness immediately prior to the ofnephritis had any influence. They comment on the occur- e::8rence of cases in hospital orderlies who had never left their albase hospitals, and note that the disease was not limited in aits incidence to the older men. They also conclude that the yisevere exertion and fatigue undergone during training at the tbbase played little or no part in its etiology. ccThe second part of the report is a clinical study by Captain

0. L. V. de Wesselow and Captain H. MacLean, who found pthat in a large proportion of the cases the onset was com- J!paratively insidious. The first indication in those doing J.heavy manual work was increasing shortness of breath ; in d.those leading a sedentary life headache was the firstsymptom. The oedema tended to clear up rapidly, its dis- P’appearance being usually accompanied by a well-marked ndiuresis, and often by heavy sweats, so that there might be a ploss of weight amounting to as much as 5 or 61b. in the24 hours. With the subsidence of the dropsy the albu- "_minuria usually improved considerably. Hyaline casts were t]the most abundant, granular next, and epithelial next in oorder of frequency. A moderate rise of systolic blood pressure nwas almost invariably present during the period of oedema,falling to a normal level or below it as the oedema subsided. S

The diastolic pressure was less affected. During the pperiod of raised tension there was frequently a marked 0difference in the height of the morning and evening

opressures, the latter being the higher. In the great majority boof cases a very definite hydraemia could be demonstrated. bAlthough cardiac symptoms were frequent, the only fphysical sign was a temporary enlargement of the heart

eto the left in 23 per cent. On discharge from hospital, IIhowever, the heart appeared to be normal, as judged bythe ordinary methods of clinical examination. Chemicalinvestigations showed no differences in kind between thisand ordinary nephritis, but merely that it was of a mildertype. Usually the chemical results ran parallel with theclinical course. In a few instances, however, the results ofchemical investigation were much less grave than the imme- ...diate clinical manifestations appeared to indicate. Such cases (did well. They found the urea in the blood was usually Eincreased, while the chlorides were variable. in the twocases of fits-which recovered-the urea in the blood was (

not appreciably raised, whereas in a fatal case of ursemia (

it was exceedingly high. This is interesting as supporting 1

the conclusion to which this outbreak has gradually beenleading various observers, that the various clinical manifes-tations usually regarded as uraemic are not due to the sametoxins, and that the most dramatic of the symptoms, theconvulsions, are really the least serious.The third part of the report is a laborious investigation by

Captain MacLean into a possible relationship of previouslyexisting albuminuria to war nephritis. The results are

entirely negative, no such relationship being found.The fourth part is -a bacteriological investigation’ by

’ Captain J. A. Wilson, also negative in its findings, since: routine examination of the urine, blood, throat, and fseoes,i failed to demonstrate a causal organism.j It will be seen that these reports confirm in thei main the earlier observations, such as those madeL at St. Bartholomew’s Hospital in 1915. The chief. point of difference is that whereas 30 per cent. of the earlier cases had a positive Wassermann1 reaction, all of 90 cases here investigated showed a

negative result. The chief new point is the:I relationship of the incidence of the cases to climate,t which was entirely lacking in the earlier phases ofI the outbreak. But the question as to why nephritisg has been so frequent in this war and so rare in allt previous wars, except the American Civil War, stillo remains unanswered.

e In our last week’s issue we published a paper byy Captain S. C. Dyke mainly relating to the prognosise of this disease. He found that in 40 per cent. ofst his series the re-establishment of renal function

I was incomplete and some degree of permanenttt damage resulted to the general health. He heldls the early disappearance of cedema to be one of

I: the best prognostic signs; its persistence aftere e the second week made the outlook worse ; whileLd the presence of oedema after the end of the first month indicated that restoration to health woulda_ be incomplete. In the same way albuminuriaie continuing after the end of the third monthIt. rendered the prognosis as to complete recoveryie unfavourable. His suggestion is that the disease isn, either a primary acute nephritis or an exacerbationM of a pre-existing disease induced by fatigue or

r- exposure, and he thinks that an inquiry into thein alterations of metabolism produced by fatigue wouldhe yield fruitful results. Such an inquiry has beenhe thoroughly undertaken by Captain Macleod, and his. conclusions do not support this suggestion. A

nd paper in the Qlta1’te1’Zy JOlwnaZ of Medicine form- January, 1918, by-Captain W. H. Tytler and Captainng J. A. Ryle gives as their impression an increasingin doubt as to whether the kidney lesion is theis- primary event-whether, in fact, the nephritis is:ed not a complication of some other disease, possiblye a pulmonary. That this is probable is indicated not only by the pulmonary lesions in fatal cases but byare the enlargement of the spleen, which this lastin observer found to occur frequently. That the

lie nephritis once thus established should be closelyed. similar to ordinary nephritis would then be com-bhe prehensible, since nephritis is so usually the resultied of an infection or an intoxication. But the .effect

its of such a cause might persist long after the causeed. had disappeared; hence the negative bacteriblogicalnly findings. A pulmonary infection might also be

art expected to show the seasonal variation which theby Medical Research Committee have noted.

LONELY DWELLERS AND THEIR NEIGHBOURS.

IT was stated in the newspapers recently that awoman, 73 years of age, living alone in a house inGray’s Inn-road, fell downstairs one Wednesdayevening, and, being unable to move, was not dis-covered until the following Saturday. On the next

day she died in the hospital to which she hadbeen taken. Stories of this kind, or of solitary

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persons who die and whose bodies are only discoveredafter some time, are not infrequent, and such casesoccur in the country as well as in great cities.Probably, however, they are rarer in rural districtsand small towns, where eccentric characters andthe poor and lonely are of greater interest to theirneighbours than they are in the metropolis. Itis difficult, indeed, to suggest any means whichwould prevent such an occurrence in the crowdedarea round Holborn, nor can we say that anyduty of neighbourliness was neglected by those inher vicinity who went their daily way while an oldwoman lay at the foot of a staircase in a housewhich they had no reason for entering. Nordoes society, the State, or the local authorityappear to be called upon to interfere if persons of

- mature age, whether poor or not, prefer to livealone rather than in surroundings which wouldexpose them to observation. In the absence oforganised intervention it is usually the baker, or themilkman, or the postman, particularly the last incountry districts, who reports that he cannot get theaccustomed answer at a certain door, when furtherinquiry shows that a lonely dweller is ill or dead. Itmight conceivably be made an instruction to postmento be observant in such matters, and to report thenon-delivery of a letter through failure to get areply to a knock at the door. But lonely dwellersreceive few letters. There remain the baker and themilkman, whose services might also be requisitionedin normal times, but even then there are manycases where the customer fetches his own bread ormilk from a shop where his abode is not known.It is, indeed, likely that any such system as wehave suggested, even if reinforced by the aid of thepolice, would not only lead to many false alarms,but would break down and be inoperative in asubstantial proportion of genuine instances. Cases,therefore, such as that upon which we have com-mented will continue to fill us with pity, but willnot be averted unless and until the State under-takes even greater surveillance over the details ofour daily lives than it does at present. Do wewant that ?

THE SIMULATION OF MUMPS.

AT a recent meeting of the Societe Medicale desH6pitaux of Paris MM. Tremolieres and L. Caussadereported a curious form of simulated disease whichappears not to have been previously described. AMoroccan soldier was sent back from the front andpassed in succession through seven " formationssanitaires " with the double diagnosis of mumpsand hysterical crises. Probably in every hospitalthe first diagnosis was abandoned, but the realnature of the affection was not ascertained. Fromthe moment he first came under the observation ofMM. Tremolieres and Caussade they were struck bythe unusual character and evolution of the parotidswellings. They involved the retro-maxillaryhollow, the neck and the pre-auricular, zygomatic,and temporal regions, giving the head a pyriformappearance. On some days the eyelids were affected,so that the features were unrecognisable. Theparotid tumours were resistant, difficult to delimit,and little painful. There was no fever. The orificesof Stenson’s ducts were projecting and red, and onpressure emitted a remarkably aerated saliva. One

day it was noticed that the tumours were resonanton percussion and were accompanied by sub-cutaneous emphysema. The patient was thensubmitted to radioscopic examination and thepurely aerial nature of the swellings was confirmed.Two days later he was surprised while forcibly

blowing out his cheeks, pinching his nostrils, andapplying his hand to his mouth. By inflating hisparotid glands he had simulated mumps. He hadeven in his efforts ruptured an acinus, and the airhad penetrated into the periglandular cellulartissue. The repetition of the manoeuvre hadled to a secondary inflammation of the gland,as was shown by the abundance of poly-nuclear cells in the saliva removed from Stenson’sduct by catheterism. It was then ascertained thatthis method of simulating mumps was well-knownamong -the Moroccan soldiers. They pricked themucous membrane of the cheek and then blew hardinto a bottle or simply closed the mouth with theback of the hand. Being ignorant of the existenceof Stenson’s duct, they did not know that the prickwas useless. This simulation is therefore of thesame nature as the parotid swellings which occur inglass-blowers -and performers on wind instruments.In the discussion which followed M. E. de Massarypointed out,that the simulation of mumps, whetherin the parotid or the testicle, can be detected bylumbar puncture. He has found that lympho-cytdsis of the cerebro-spinal fluid is constant in

mumps. The knowledge that such a test might beapplied should stop the simulation.

TRAUMA AND IMPOTENCE.

OUR conception of the remoter results of trau-matism is constantly being widened by the expe-riences of the war, but its effects on sexual activityhave received little notice in this country.Bloch divides trauma as a cause of impotenceinto psychical and physical. As to the former, hisresearches show mental depression by itself canlower sexual potency, which is always impaired innervous diseases marked by depressive states. It

has been observed that men rarely become fathersin the year of their bankruptcy. Anger, too, isantagonistic to sexual activity. The more suddenand acute the mental shock, as from scenes ofbloodshed, so much the more obstinate is theimpotence. In ancient and mediaeval superstitionmagicians were credited with being able to cast aspell of impotence upon a man through the agencyof fright. John Hunter related a case of impotencecoming on very rapidly from fright, and the samehas followed sudden bereavement of a startlingkind. In the front line of a battle it is obviousthat all these emotional factors have abundant play.With regard to the pathogeny of impotence thuscaused, Bloch doubts whether it is purely psychical;if of long continuance, some unknown disturbanceof the internal secretions, of the endocrinic system,is probably responsible. Thus a Dutch clinicianrecorded amenorrhaea and acromegaly in a woman 25years old, with no abnormal family history, attributedto severe fright; and an increase of the secretion ofthe adrenals has been found in the blood after greatmental excitement. Physical trauma may be dividedinto trauma to the genitals or other part of thebody generally and trauma to the central nervoussystem. In war experience sexual paresis is oftenmet with from the pain of an injury. If the

genitals themselves have not been greatly injuredthe prognosis is good, potency usually returningwith healing of the wound and cessation of thepain. The outlook is much worse when the causeis concussion of the brain or spinal cord, thesecases being similar to the impotence and testicularatrophy long observed in civil practice as an

occasional sequela to falls on the back of the head1 Iwan Bloch: Zeitschrift für Sexualwissenschaft, July, 1918.