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Annotations

BENEVOLENCE AT CHRISTMASSOME people can wish others well, and act upon it, all

the year round ; but many of us find this Cheeryblestandard of benevolence out of our class. We all haveour benevolent moments, however, and it is a good thingfor us if one of these happens to coincide with the annualChristmas appeal of the Royal Medical BenevolentFund ; for then we have the satisfaction of knowing thatour kindly impulses will be directed to good purpose.The appeal published in another column this week fromthe new president of the Fund, Sir Arnold Lawson, is onethat must impress us all.

In an annual review of the Fund’s work, Sir Arnoldnotes the rise in investments from 109,428 in 1927 to1:307,248 in 1944, with a comparable rise in income.Distribution has gone up from jet 1,916 in 1927 to 25,284in 1944. Nowadays the administrators of the Fundset themselves a higher standard of relief than used to bepossible : they plan to give every case a minimum allow-ance of 30s. a week after the rent has been paid. Thosewho need special care and attention have been helped tomeet the expenses of nursing-homes, and there is a projectunder consideration to provide a home or homes for oldpeople who need residential care. Medical students haveresponded well to an appeal for support, and old sub-scribers have remained loyal. Letters from recipients ofChristmas grants show as usual how imaginative it wasto establish a custom which brings so much pleasure andease to doctors and their kin who have fallen on evil days.

THE REGISTERED DISABLED

SzrrcE the end of September the Ministry of Labour hasbeen compiling the voluntary national register of dis-abled persons. The final numbers on the register areexpected to be in the neighbourhood of 2 million, with awage-bill amounting to 300 million a year. These

figures were quoted by Lord Rushcliffe, presiding at aconference on health and work arranged by the BritishCouncil for Rehabilitation on Oct. 10.

It is believed that most of the disabled on the registerwill be able to take jobs on equal terms with the fit ;and, to make this possible, services are being providedunder the Act to give these disabled men and womenwhatever physical or mental treatment or vocationaltraining they need to fit them for work. Employers of20 or more workers will be under a statutory obligationto fill vacancies with people on the register until theyhave reached the quota prescribed for their industry. Toreable these people thoroughly, doctors in charge of theirtreatment may need to keep an eye on them until theyare settled in industry ; and, the industry should keep intouch with those who get injured until they are fit toreturn to work. To help the Ministry of Labour, andto foster this joint interest, employers, workers, anddoctors have been brought together on the NationalAdvisory Council, under the chairmanship of Lord Ridley.Local advisory committees on disablement, with panelsof experts to advise them, have also been set up in some270 places; and these will keep in touch with localindustries, employment exchanges; hospitals, welfareorganisations, and voluntary bodies.’ The local advisorycommittees are in touch with the Ministry through thedisablement rehabilitation officer (DRO), whose task itis to shepherd the disabled man from the hospital backto the workshops. PEP has criticised the present D ROs,lbut it is likely that, when there are more candidates,the type of man chosen will be better suited to the job.

It will be a skilled task to place each disabled worker inthe right work ; but, as a correspondent of the Timespoints out,2 the difficulties will be lightened by the, useof a iaew form drawn up by the Ministry of Labour with1. See Lancet, Sept. 15, p. 343. 2. Times, Oct. 10, p. 5.

the help of experts from the Ministry of Health andPensions. This provides a means of analysing physicalfunction in such a way that it can be interpreted in termsof working capacity. The questions can be answeredwith a " yes " or a

" no

" by the examining doctor : forexample, can the man lift a weight of 20-56 lb., can heclimb a ladder, can he work in extremes of hot and cold Industry, the Times writer says, must now produce acounterpart form, showing what demands different jobsmake on the worker.

NUTRITION IN ITALY

A RELATIVELY rapid method of assessing the nutritionof the inhabitants of a region must prove valuable inthe coming months. An TJBEA team, working in Italyunder Dr. A. J. McQueeney and Dr. J. Metcoff, hasshown that a fair estimate can be based on the exam-ination of children and of pregnant and nursing women,since these are the people who suffer first and worst fromfood shortage. Speaking at UNRRA’s London headquarterson Oct. 9, Dr. Metcoff said that the team carried out 34nutritional surveys, samples being drawn from amongthe poorest members of the population ; the resultstherefore reflect not the average Italian nutrition, butnutrition at the lowest level. Some 2500 children, and600 pregnant or nursing mothers were examined indistricts in and near Rome, eastward to Ravenna andMilan and southward as far as Pontecorvo. The datafrom all-these ,places showed that the nutrition of thechildren, judged by height and weight, fell roughlywithin the lower limits of the normal range for Americanchildren. Some form of nutritional deficiency was evi ’-dent in 31 % of them, and in 90 % of these the deficiencydisease was rickets. The remaining 10% mostly had’riboflavine and vitamin-A deficiencies. Anaemia andgross malnutrition accounted for only 1-2% ; indeedthere were only 17 grossly malnourished infants in thewhole survey, and these were all in institutions-eitherhospitals or orphanages. No evidence was found ofeither vitamin-B1 deficiency or pellagra. Of the preg-nant and nursing women 3-5% had classical nutritionaldeficiencies, mainly of riboflavine and vitamin A. Therewere only 4 cases of anaemia among them. ’

The team, besides assessing the degree and extentof malnutrition as evidenced by clinical examination,and providing information for the use of UNRRA, wasable to encourage Italian interest in the organisation ofsurveys and the treatment of malnutrition. A technicalsubcommittee which included the leading medicalspecialists was formed by the Italian government, andthis body drafted a pamphlet on malnutrition which wassent to 20,000 doctors. The pamphlet. set out basiccriteria for the diagnosis of malnutrition, and was accom-panied by record cards on which detailed findings couldbe recorded. A notifying system,based on these records,has also been established, so that malnutrition is nowin effect notifiable in Italy. The criteria were proposedby the Italian subcommittee, and Metcoff thought it

possible that in some respects they would not the fullyacceptable to American or British physicians. Theyincluded, for children, famine oedema, signs of pellagra,purpura, signs of rickets or scurvy, craniotabes, night-blindness, keratomalacia, cheilosis, rhagades, spongy orbleeding gums, a red shiny tongue, or an atrophictongue indented by the teeth, and any evidences ofneuritis or beriberi. In the pregnant or nursing womenthe examiner is required to note the presence of famineoedema, hypertrophied or bleeding gums, night-blindness,neuritis, and signs of endocrine imbalance and of tuber-culosis, malaria, or syphilis. Tuberculosis is on theincrease, but this can be ascribed in part to factors otherthan malnutrition-to overcrowding, the breakdownof sanitation, the closing of sanartoriums, and the dis-semination of infectious patients. Rickets has alwaysbeen common in Italy and there seems to be no evidence

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that it has suddenly increased. The Italian subcom-mittee has arranged;at five. universities, refresher coursesin paediatrics for Italian doctors ; and the Rome courseshave already begun. They last a fortnight and include38 hours spent at lectures, and about an equal periodspent in watching practical demonstrations and in visits.Many Italian doctors have been out of touch withmedical advances for some years ; they have provedextremely keen and gave much support and help to theAmerican team.

ANILINE POISONING FROM MARKING-INK. NEARLY 60 years ago a curious outbreak of cyanosisamong babies in London was traced to absorption ofaniline from the marking-ink used to mark their

napkins. The danger of using such napkins beforethey have been boiled or otherwise laundered seems tohave been forgotten, because Graubarth and his col-

leagues of New Orleans now report 17 cases of poisoningfrom this cause with 4 deaths, and they have collectednearly 40 reported instances of similar trouble. Of32 babies in the nursery at Touro Infirmary, 17 un-expectedly and gradually became cyanotic, with rapidand in some cases difficult breathing. All of thoseaffected were wearing unwashed napkins stamped withan aniline dye, whereas the remaining 15 were wearingold napkins. War-time shortage, both of napkins andof staff, is blamed for the mishap, although it might,out of ignorance, happen anywhere. Other clinicalmanifestations included irritability, jaundice, loosestools, vomiting, hsematuria, and in one instance anenlarged spleen. Of those who survived none showedany evidence of cerebral damage and there was noreport of any refractory anaemia. Of the 4 deaths, 3were in premature babies. Differential diagnosis isconcerned with other possible causes of cyanosis-congenital heart disease, enlarged thymus gland, pneu-monia (especially that associated with the aspiration offoreign material), intracranial haemorrhage, inhalationof coal-gas, various drugs, and disinfectants; all thesewere eliminated, and Graubarth made the diagnosis onthe basis of a similar experience in Cincinnati in 1929.Treatment included the administration of methyleneblue, gr. t with each feed for 2 days, and the use ofoxygen with 5% of carbon dioxide. Blood-transfusionswere given to 9 infants. Neither oxygen nor methyleneblue had any obvious effect. Apart from the removalof the source of poisoning, transfusion of blood or redcells suspended in saline seems the most logical treat-ment. The conclusion to be drawn from this accidentis that all newly marked clothes must be launderedbefore being worn by babies, or indeed by anybody.

EVOLUTION OF ANTIBIOTICS

IN ms Jbisier lecture to tne .1toyal uonege or surgeonson Oct. 11, Sir Howard Florey, FRS, reviewed the historyof the use of micro-organisms for therapeutic purposesfrom Pasteur to penicillin. He recalled that the term" antibiotic " was introduced by Vuillemin in 1889 toindicate an organism which was not a parasite but wasstrictly antagonistic towards the life of another organism,as a lion or a snake is antibiotic towards its prey.Pasteur and Joubert in 1877 were the first to describeantibiosis affecting a pathogenic micro-organism, whenthey showed that the rapid growth of the anthraxbacillus in urine can be stopped by addition of somecommon aerobic bacteria. By adding such bacteria to asuspension of anthrax bacilli they made it harmless wheninjected into animals, and " these facts," they said," perhaps justify the highest hopes for therapeutics."In 1885 Babes studied the mutual antagonism Of differentkinds of bacteria, which he recognised might be due todefinite chemical inhibitors, and he suggested that one1. Graubarth, J., Bloom, C. J., Coleman, F. C., Soloman, H. N.J. Amer. med. Ass. 1945, 128, 1155.

kind might be used to cure an infection caused byanother kind. Cantani, in the same year, in the treat-ment of tuberculosis, explored the idea of replacing oneorganism by another less harmful. In 1887 Grarredemonstrated on agar plates antagonism such as thatbetween Pseudomonas fluorcsccns and Staph. aureus andproved that it was not due merely to rapid growth of oneorganism at the expense of the other, but to a substanceelaborated by one of the organisms and killing the other.His technique and that of Doehle, said Sir Howard,"differ little, if at all, from those employed by someworkers at the present day." After discussing the

attempted use of certain infections (such as erysipelas)to produce immunity against others more chronic (suchas lupus) he described how in 1898 two Russians, Honland Bukovsky, treated infected ulcers with "proteins "from cultures of Ps. pyocyanea. In the following year,Emmerich and Low introduced the first antibac-terial extract into medicine namely

"

pyocyanase,"prepared from cultures of the same organism. This was

undoubtedly bactericidal and was given for manydifferent diseases and by many routes, even intrathecally." It can be said with some truth that there is littlethat has been done with penicillin which was notattempted with the earlier antibiotic, so far as the meansthen available allowed." In 1898 Gosio produced acrystalline antibiotic, mycophenolic acid, from a mould.

After recalling further work on related lines by Lode,Frost, and Nicolle; Vandremer’s use of aspergillus extractsagainst the tubercle bacillus both experimentally andclinically; and various forms of "replacement therapy,"including Metchnikoff’s advocacy of colonising the bowelwith B. acidophiZus, the lecturer reached the 1920’s, whensome new ideas and procedures were introduced. Experi-menters turned their attention to yeasts, actinomycetes,streptothrices, and spore-forming organisms, and Dubosproduced his tyrothricin. Various antagonistic con-

taminants were noticed in cultures before 1929 whenFleming found that a contaminated mould had lysed aculture of staphylococcus, and obtained from the mouldthe active substance he called " penicillin." Yet anotherdecade was to pass before penicillin was put on a practicalbasis in 1940 by the observations of the Oxford team, andonly after 70 years of experiment on antibiotics didmedicine find itself possessed of

" an antiseptic beyond

the dreams of Lister."

Sir JOHN ORR, MD, FRS, MP, is accompanying the Britishdelegation to the United Nations Congress on Food andAgriculture in an advisory capacity.

"... Every successive war has narrowed the margin ofsafety by which the species itself survives in the midst of thepowers of destruction it has devised. It is the aim of everybelligerent during the war to break down not merely thematerial supports of the enemy’s fighting power but the verycohesion of the society they sustain. Experience all over

Europe today shows that when hostilities end the forces ofanarchy set in motion by war do not automatically cease tooperate. The engines of victorious power, which have been

’

hitherto used to destroy, have to be reversed and used con-structively to re-establish society, and government among thedefeated. But with every war there is more leeway to makeup, more effort required to overcome the disruptive tendencies,before reconstruction proper can begin. In their striving forvictory the allies created in Germany such devastation anddestruction of the foundations of society as industrial Europehas never known. The proportion of their available strengththat they must now devote to the mere cancelling out of whatthey themselves have done is perilously high. The danger isthat there may ultimately be a war after which the continuingmomentum of decay is too great to be balanced even by theentire strength of the victors-that is, that the progresstowards a final collapse of eivilisation will go on even afterformal war has ceased. The menace of the atomic bomb isthat this point would almost certainly be reached if war shouldever again break out between the great Powers."-From aleading article in THB TiMES, Oct. 9, p. 5.