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Annotations.

THE PREVAILING PANDEMIC.

" Ne quid nimis."

THE clinical features of the infectious febrile

complaint which has invaded this country are

sufficiently well known, and the following briefaccounts by our Paris and Belfast correspondentssuggest that they are dealing with the same

malady.Paris.—A widespread epidemic of grippe in a mild form is

at present invading Paris and a large part of France. It isprobably an extension of the epidemic which has recentlyattacked the whole population of Spain, from the highest tothe lowest. The cases are very numerous, but none so farof a grave nature. Complaint is made of headache, pain inthe back, naso-pharyngeal catarrh which is persistent butrarely invades the lower respiratory tract. The temperatureis moderately raised, dropping at the end of two days. Theresulting indisposition, which seems to be spreading to thetroops at the front, fortunately lasts at most a few days.

Belfast.—An extremely widespread epidemic of what iscalled "influenza" is prevalent in Belfast and surroundingdistricts. The number of deaths in Belfast for the weekending June 29th was 341, and of these 92 were from" pneumonia and 75 from other diseases of the respiratorysystem." It began apparently in the military barracks atfirst, but soon spread to munition works, mills, &c., andthence all over the city and surrounding areas. The sym-ptoms are mainly high temperature with a sudden onset,congesterl eyes, sore-throat, and headache, with muscularpains, and in uncomplicated cases the duration of the feveris about three days. Occasionally there are sickness andbronchial catarrh, but pneumonia is not common. Itresembles influenza in its sudden onset and its widespreadepidemic character, but differs from former visitations ofthat disease in comparative absence of chest complicationsand post-febrile depression. The locus of the disease seemsto lie in the throat, at the junction of pharynx and larynx.Bacteriological examination so far has shown the presenceof diplococci, streptococci, and pneumococci, but no specificorganism. It is being recommended to close the primaryschools-a measure as little likely to be effective as shuttingdown the banks, mills, munition works, and cinemas. Theepidemic seems very like the Spanish one recently reported.The paper by Captain T. R. Little, Captain C. J.Garofalo, and Captain P. A. Williams, of theCanadian Army Medical Corps, which appears inanother part of our present issue, is the firstserious contribution which we have seen to thebacteriological study of the pandemic. Theseauthors- deal with about 1000 cases occurring inseveral camps served by their mobile laboratory.After setting out three points in which the clinicalsymptoms differed from those generally ascribed toPfeiffer’s bacillus, the statement is made that in allthe cases studied one organism predominated inturecc smears TiaKen trom naso-pnarynx, tnroac, and sputum. This was a small Gram-positive diplo-coccus, flattened on its opposing surfaces. It wasfound to grow freely on legumin serum-agar plates,forming small transparent granular colonies closelyresembling those of streptococcus. No colonies ofB. influenzœ were discovered. The authors are

now working to establish Koch’s third postulate inrelation to the organism. It is noteworthy that Dr.A. MacLean, who contributes to this present issuea memorandum on an outbreak of an acute febriledisease in certain Glasgow factories, has also founda diplococcus, in this case Gram-negative, in asso-ciation with it. The disease, of which he dealt with436 cases, was of a very mild type, characterised bysudden onset with severe headache and prostration,followed by rapid recovery in 2-4 days. No deathwas recorded, but a similar outbreak was broughtto his notice in the county of Lanark, in which8 deaths occurred in 280 cases. Acting under Dr.A. K. Chalmers, medical officer of health forGlasgow, Dr. MacLean is studying further the bac-

teriology of the outbreak. We commend both theseseries of investigations to the attention of bacterio-logists in general. The loose application of the term"

influenza " to a febrile infection in which Pfeiffer’sbacillus cannot be demonstrated is, to say the least,unfortunate and we have always deprecated its use,suggesting as an alternative the term " catarrhalfever.". Mild though the present form of the

malady is in a vast majority of cases, its death-ratehas not been insignificant, and its epidemiology isa matter of very pressing importance.

ECGONINE AND ITS DERIVATIVES.

, THE Home Secretary has given notice that the

definition of "

cocaine " in Defence of the Realm

Regulation 40 B (which regulates dealings in cocaineand opium) and in the Proclamation prohibiting theimportation of cocaine has been further amended soas to include ecgonine, its salts and derivatives. Thedefinition now reads as follows:-" Cocaine includes ecgonine and any substance, whether

preparation, admixture, extract or otherwise, containing0’1 per cent. (one part in a thousand) or more of cocaine orecgonine or of any salt or derivative thereof."

Ecgonine is the parent of cocaine, which isbenzoyl-ecgonine methyl ester. There are manyother derivatives of ecgonine in the leaves of

Erythroxylon coca, from all of which ecgonine canbe separated. Cocaine is obtained economicallyfrom ecgonine by a synthetic process, using methylalcohol and benzoyl chloride. Ecgonine is theessential pharmacological group of the alkaloid.

THE DEVELOPMENT OF THE MEDICAL PRO-FESSION: THE CAVENDISH LECTURE.

Major-General Sir Bertrand Dawson, in deliveringthe Cavendish lecture this year before the WestLondon Medico-Chirurgical Society, found that thesubject which he had selected could not be intelli-gibly expounded within the compass of one lecture,with the result that on Thursday evening he con-tinued at the Royal Society of Medicine his Utopianpicture of the future of the medical profession in thiscountry. At the West London Hospital, where hehad a large audience, he made the following pointin an incontrovertible manner-that the growthof knowledge had rendered medical effort,. whetherfor treatment or prevention, a combination ofenergies. No man any longer can pretend to haveparticular equipment or special knowledge by whichhe can do the best possible for all patients in allcircumstances. There must in every case be some

point where the special knowledge not possessed byany particular doctor might have been useful, andwe shall all endorse Sir Bertrand Dawson’s pleafor the development of team-work " in medicalpractice. The need for adequate medical servicehas outstepped its provision not only for themasses but for the well-to-do, added Sir BertrandDawson, who prophesied that the unsuitability ofthe home for the treatment of the sick would soonbecome generally recognised when larger institu-tional organisation would follow as a sequel. Recon-struction of medical practice on these principles,with the general practitioner the central pillar oferection, implies that the general practitioner musthave opportunities for observation, advancededucation, and prosecution of research whichhe is now totally without, but, as the Cavendishlecturer acutely pointed out, he requires, if he is toget any advantage out of such improvement in his

, professional life, adequate repose and adequate1 THE LANCET, 1910, ii., 1289.

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remuneration. The medical service which SirBertrand Dawson outlined would have the localhospitals and clinics as their centre, and the staffof the central hospital would provide the con-

sultants and specialists for the local hospitals, andwould be a whole-time or part-time service accord-ing to the nature of the work. He dwelt upon thecomplications of working such an organisationalongside of the National Insurance Act, whoseadministration of medical benefits is directedtowards the treatment of disease rather than its

prevention. In the sequel, a second part of theCavendish lecture delivered on Thursday night, thelecturer supplied the arguments to show that theofficiate of the Ministry of Health should be in itsessential characters medical, and the profession ata critical time in its career will be grateful to himfor an outspoken pronouncement.

°

ANTINEURITIC AND ANTISCORBUTIC FACTORSIN FOOD.

Two interesting papers on the obscure but Iimportant constituents of foods known respec-tively as antineuritic and antiscorbutic substancesappear in the June number of the Bio-ChemicalJournal. The first is by Mr. J. C. Drummond,which embodies a study of the water-soluble acces-sory growth-promoting substance and its influenceupon the nutrition and nitrogen metabolism of therat. In this research, carried out in the CancerHospital Research Institute, London, the authorfound that the only apparent deviation from normalhealth in rats fed upon an artificial diet deficientin the water-soluble accessory substance was theappearance of creatinuria accompanied by a slowwasting of the skeletal muscles. The food con-

sumption of rats fed upon the deficient diet is low,being probably reduced to that amount sufficient tosupply the calorific requirements of maintenance.An increased food consumption is brought aboutby the addition of flavouring agents such as meatextract to the diet, but it is interesting to add thatunless this agent contains the water-soluble sub-stance no growth results. This observation seemsto supply a criterion as to the value of meatextracts in the dietary, and those deficient in theaccessory substance might have to be ruled outas possessing any dietetic value. The addition tothe inadequate diet of water-soluble substance,causes a greatly increased food intake, imme-diately followed by growth, the amount ofgrowth being, within certain limits, proportional tothe amount of accessory substance added providedthat the diet is adequate in other respects. Theexperiments bear evidence that the length of timean animal is able to maintain itself upon a dietdeficient in the water-soluble substance withoutsuffering a serious loss of body-weight is directlyproportional to the age at which the restriction isimposed. During the research it was found thatactively growing animal tissues (embryos, tumours)do not contain appreciable amounts of the " water-soluble B " and pituitary gland, thyroid, thymus,testicle, and ovarian tissues showed a deficiency inthis substance. The results are of interest, althoughthe cause of the fatal decline which inevitablyfollows a deficiency of the water-soluble substancehas not been determined. It may be noted, however,that symptoms of nerve disorder preceded death inthree cases. In the second paper Arthur Hardenand Sylvester S. Zilva deal with the differentialbehaviour of the antineuritic and antiscorbuticfactors towards adsorbents. This research was

undertaken in the Biochemical Department of theLister Institute. The authors have confirmed thefact that fuller’s earth absorbs almost quanti-tatively the antineuritic factor out of autolysedyeast. Dialysed iron does the same thing, butneither fuller’s earth nor dialysed iron affectsappreciably the antiscorbutic potency of orangejuice, so that in a fluid containing autolysed yeastand orange juice the antineuritic factor is removed,while the antiscorbutic activity remains unim-paired. These observations are of interest inshowing that there is nothing in common, apparently,between these antineuritic and antiscorbutic sub-stances respectively so far as regards their behaviourwith adsorbents. It is early yet to lay down whatphysiological significance these observations possess.

INCIDENCE OF INFECTIOUS DISEASE IN 1917.

Sir Arthur Newsholme’s report to the LocalGovernment Board on the local incidence ofnotifiable infectious disease has recently beenpublished, the present being the seventh of theseries.

’

Notifications in England and TVales ditring 1917.--Only 7,cases of small-pox were reported in the year, the averagenumber in the preceding six years being 139. Typhus feverwas reported in 4 cases only, against an average of 30. Ofscarlet fever 48,817 cases were notified, or fewer by 26,905than in the preceding year. Of diphtheria 43,315 cases, or8392 fewer; of enteric fever 4601 cases, or 963 fewer; and ofpuerperal fever 1345 cases, or 651 fewer. The only diseasesknown to have shown increased prevalence in 1917 werecerebro-spinal fever and pulmonary tuberculosis, thereported cases of the former having increased to 1465, againstan average of 1123 in the previous four years, and the casesof the latter having numbered 73,654, or more by 1175 thanthose notified in 1916. But this number includes duplicatenotifications. The cases of measles notified under the Orderof 1915, by medical men or by persons in charge of patients,exceeded half a million, but in this total German measles isincluded. In addition to the foregoing there were notifiedin England and Wales 13,325 cases of erysipelas, 357 of polio-myelitis, 8 of plague, and 6716 of ophthalmia neonatorum.Seasonal incidence.-With respect to the seasonal.incidence

of scarlet fever, diphtheria, enteric fever, cerebro-spinalfever, poliomyelitis, and measles particulars are given in atable-the actual average weekly attacks being shown at thefoot of each column. The proportion of the notifications tothis average is given for each week, any special seasonalexcess of 30 per cent. being indicated by heavy type.Cases of sickness among sailors and soldiers.—Under a recent

Act local medical officers of health now receive notificationof all cases of infectious disease arising in barracks, camps,&c., in the occupation of H.M. Forces. The number thusreported in 1917 include 1244 of scarlet fever, 1296 ofdiphtheria, 177 of enteric fever, 442 of erysipelas, 2 of small-pox, 1023 of cerebro-spinal fever, 2210 of pulmonary tuber-culosis, and 122 of other forms of tuberculosis.In proportion as it becomes possible to comparethe behaviour of infection in a longer series of yearsthe value of these reports will obviously increase.

THE TREATMENT OF SCIATICA BY LUMBARANÆSTHESIA.

THE strenuous life of troops in the trenches andthe exceptional climatic conditions of damp andcold have been productive of a large number ofsevere and refractory cases of sciatica and alliedconditions in the military hospitals in Italy. Inaddition to these rheumatic cases there have beenmany others due to the direct action-contusion orwound of the nerve, or indirect action-neuritisfollowing septic wounds, of projectiles. A largenumber of such cases have come under the noticeof Dr. Claudio Mancini at the military hospital atSpezia, who has obtained very encouraging resultsfrom treatment by lumbar anaesthesia, which maybe summarised as follows.

1 La Biforma Medica, June 1st, 1918.