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ANNOTATIONS

SERUM TREATMENT OF PNEUMONIA

THE preparation of an efficient antipneumococcalserum has been difficult for several reasons. Thecausal organism of lobar pneumonia comprises severaldistinct serological types, and the serum will agglu-tinate only the particular strain from which it is

prepared. Further, the pneumococcus does notproduce either ei6tb-xiii or endotoxin, and its antiseramust be antibacterial instead of antitoxic-a factthat makes it hard to prepare a serum of highenough titre. In 1926 L. D. Felton, of Harvard,succeeded in preparing a concentrated polyvalentantiserum against pneumococci of types I. and II.Several clinical reports on the use of this serumin lobar pneumonia due to these two types havebeen published, notably by N. Plummer andR. L. Cecil in America, and later in our own

columns 2 by physicians of the Royal Infirmariesof Glasgow and Edinburgh. These observers, withcommendable discretion, agreed that although no

. definite conclusions could yet be drawn, the evidence,so far as it went, indicated that Felton’s serum mightprove to be of value. The further report from

Glasgow, appearing on p. 8 of this issue, shows that itsauthors are fully aware of the great difficulty of

assessing results in a disease like lobar pneumonia,whose mortality depends on many factors which itis impossible to control. They have clearly takenpains to make the comparison between treated anduntreated cases a fair one, but although the remedywas given to 137 patients, they think this series againtoo small for any accurate conclusion about its value.Their mortality for type I. is only 4 per cent. in casestreated with serum, compared with 10 per cent. inuntreated cases, but the latter group is numericallymore than four times as large. They are unable toconfirm previous observations that the use of serumlessens toxemia and prevents complications, but

they agree that it may shorten the febrile period.It is noteworthy, moreover, that they conclude theirreview of the evidence with the observation thatserum and oxygen for the treatment of pneumoniashould be available in every hospital. This is a

definite and practical conclusion, and should receiveattention. While it is disappointing that more

obvious success has not been obtained with thetreatment, the Glasgow investigation has alreadybeen fully justified. The Scottish Branch of theBritish Red Cross Society, which provided the

necessary funds, is to be congratulated on the supportit has given to a useful piece of work.

OBSERVATIONS ON BARBITURATE NARCOSIS

Prof. J. F. Fulton and Dr. A. D. Teller, of YaleUniversity, record some ,experiments in which a

chimpanzee was submitted to three major neurologicaloperations at intervals of one or two months in orderto demonstrate the respective virtues of dial, amytal,and nembutal as anaesthetics. In its neurologicalbehaviour and in its response to drugs this apeapproaches the human being more closely than thebaboon or the monkey. It had previously beenfound that the barbiturates afforded " almost ideal "anaesthesia for neurological work on primates, since

1 New Eng. Jour. Med., 1928, cxcix., 415 ; Jour. Amer. Med.Assoc., 1930, xcv., 1547.

2 THE LANCET, 1930, ii., 1387 and 1390.3 Surg., Gyn., and Obst., May, 1932, p. 764.

in a series of nearly 200 operations on baboons,.monkeys, and chimpanzees there were only threedeaths attributable to the narcotic. In the course ofthis investigation the interesting observation was.

made that in very dry atmospheres, such as a

centrally heated laboratory in New Haven, the,recovery period was considerably longer than inmoist ones, such as the Thames valley. The delayis attributed to the relatively greater loss of fluidthrough lungs and skin, and it was observed in cat&as well as monkeys. In the experiment underreview the chimpanzee seems to have behavedtowards dial much as an average child would. It.was considerably disturbed and cried at the prospectof injection, but once this was over it soon grewquiet and subsequently fell into an excellent narcosis.Renex coughing persisted throughout, and the opera-tion, which consisted of raising a bone-flap and thenperiodically stimulating and excising certain motorareas, lasted about seven hours. The chimpanzeetook nearly three days to throw off entirely the effectsof the dial, but with sodium amytal recovery was.quicker and with nembutal much quicker still.The last-named drug was found to differ from thetwo others in depressing the excitability of the motorcortex.

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SCHOOL MYOPIA

FORMERLY it was agreed that the development ofmyopia during school life, which is well known totake place in a certain proportion of children, is dueto the long hours during which school-children con-centrate their eyes on near work. Notably, sinceProf. H. L. Cohn, of Breslau, published his statistics.more than 50 years ago, showing the rapid increasein the proportion of myopia in the various schools.examined by him, varying directly with the length oftime spent in the schools, has this proposition beenfurther illustrated and in more modern times takenfor granted. In recent years, however, it has beenquestioned. In 1913 Dr. A. Steiger published a.

lengthy volume to prove that to attribute myopiato school life was to argue from post-hoc to propter-hoc, and there was much in what he said. Mr.Arnold Sorsby now sums up recent views on thesubject.l There is, he says, no difference in kindbut only in degree between the hypermetropic orshort eye and the myopic or long one, any more thanthere is difference in kind between individuals who-vary in stature. Apart from cases in which there aremyopic crescents or other fundus changes, or again,apart from all cases of myopia of over six dioptres, acurve can be constructed for adults showing emme-

tropia as an average condition, with deviations on thehypermetropic side corresponding roughly both infrequency and in degree to deviations on the myopiaside. For children such a curve would have its

peak somewhere on the hypermetropic side, sincemyopia in infants is a rarity. It is an unwarrantedassumption that all myopes are afflicted with a disease.due to pressure on the eyeball. It is generally assumedthat myopia depends on axial length alone, but thisis far from being necessarily the case. The limits ofvariation of refraction, both of the cornea and of thelens, are very wide. Myopia of 20 dioptres withtypical fundus changes has been reported in an eye of22-4 mm.-i.e., about average-axial length. It isalso contended that the fundus changes associated

1 Brit. Jour. Ophth., April, 1932.

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with many cases of myopia are not necessarily dueto stretching of the globe, but may be regarded as asort of abiotrophic manifestation analogous to themacular degeneration which is termed senile.

These are the arguments of the modern school,ibut we agree with Mr. Sorsby in regardingthe problem of myopia as not yet solved. The.different behaviour of the hypermetropic and the

myopic eye during school life is a fact that cannotbe ignored, and although no theory of muscular

pressure during convergence, causing lengthening ofthe globe, can be considered as more than a hypo-thesis, the presumption that either from this cause orfrom the vascular engorgement due to long-continuedstooping overwork of the eyes is harmful, at any rate,to those eyes that have already shown a tendency tolengthen, is sufficiently strong to justify the hygienicmeasures usually recommended, and more particularlythe special treatment adopted for children with highmyopia in the L.C.C. schools. But in the past the’theory that myopia is a disease due to overwork ofthe eyes has certainly been pressed too far. Theincidence of high myopia among the labouring classes.and the phenomenon of monocular myopia tell againstit. Heredity is probably the main factor in the,causation of myopia as it is of hypermetropia andof astigmatism ; but to admit this is not to justifyz fatalistic attitude which would deprecate thehygienic precautions which have an influence inchecking it. ____

PROGNOSIS OF HEART-BLOCK

IT is generally held that if complete heart-block isdiscovered the outlook is necessarily bad ; but acase described by K. E. Harris shows that this isnot always so, for the patient was alive and free from.symptoms 28 years after the heart-block was recog-nised. L. B. Ellis,2 in a study of 43 cases of transient’and complete heart-block, has confirmed this view,since four of the twenty-nine patients in whom theblock was permanent lived 24, 15, 14, and 7 yearsrespectively, and it is probable that a further twohad lived for at least nine years with complete heart-block. Two important factors in assessing theprognosis in any given case are the 2etiology and the;age. This is shown by the fact that of the patientsfollowed up under 40 years of age all were living,whereas of those over 40 only 20 per cent. were aliveat the time of the inquiry. As regards setiology there- were nine cases in which the cause was either unknownor congenital, and of -these all were alive. Only onecase was found to have a definite diphtheritic setiologyand in only four others was a history of diphtheriaobtained. This is in marked contrast with the

findings of Butler and Levine,3 who obtained.a history of diphtheria in 10 out of 20 adultpatients with otherwise unexplained heart-block.In the diphtheritic case described by Ellis the blockhad persisted for 24 years without producing anydisability or symptoms. In 52 per cent. of the whole,series arterio-sclerotic changes were the probablecause of the heart-block, and of the 12 patientsfollowed, only three were still alive. Althoughsyphilis is usually regarded as an important cause ofheart-block only two cases in this series had a positiveWassermann reaction and in both of these there was.associated arterio-sclerosis. While it is unusual forpatients with heart-block to have a heart of normal

1 Heart, 1929, xiv., 289.2 Amer. Jour. Med. Sci., February, 1932, p. 225.

2 Butler, S., and Levine S. A. : Amer. Heart Jour., 1930, v.,

size, six of those followed showed no cardiac enlarge-ment and of these, five were still alive. Anotherfactor influencing prognosis is the occurrence ofStokes-Adams attacks, only one of the living patientshaving suffered from these attacks, which were,

however, common in-the -.patients who failed tosurvive. These studies show that heart-block shouldnot be considered as a disease entity but rather asa sign of cardiac damage. The severity of this damagedepends largely on the cause, since when the blockis due to arterio-sclerotic changes it is usually onlypart of a generalised myocardial lesion; whereasif the block is the result of some congenital defector of an acute infection the lesion is more likely to belocalised to the conducting tissue while the rest ofthe myocardium is spared any serious and permanentdamage. ____

A VERY YOUNG HUMAN OVUM

AT a meeting of the Anatomical Society of GreatBritain and Ireland, held at St. Mary’s Hospital onMay 6th, Prof. J. E. Frazer showed and describeda very young human ovum in situ. The specimenwas obtained post mortem, and for material of suchsort was in good condition ; the ovum itself, however,had apparently suffered in some ways from the markedtoxemia which existed for a time before the mother’’8

Ovum in situ. U.C., uterine cavity. E.V., embryonic vesicles;amnion and yolk-sac, against basal chorion.

death. We give a tracing of a section, through themiddle of this ovum, in the accompanying figure,at a magnification of approximately 16. The section.passes through the minute embryonic vesicles, whichare embedded in mesoderm on the basal chorion.The cavity in which the ovum lies is in the moresuperficial part of the stratum compactum, andcontains much blood (represented blank in the figure),and rather stumpy and short villi, with a considerableamount of cyto- and plasmodi-trophoblast. Thedecidua is very vascular, and blood is also containedin some of the glandular tubes, which have beencut through in the extension of the cavity. Nodefinite aperture of entry was apparent, nor wasthere any " closing coagulum," and the epitheliallining of the uterus was only partially destroyed overthe convexity of the capsular decidua. Implantationwas in the extreme upper part of the posterior wall.No history was obtainable, nor does there seem tohave been any menstrual irregularity or interruption,but the specimen appears to be perhaps a few hoursolder than the classical one of Peters, and is estimated