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with pyridoxine is confirmed in a controlled trial. Mean-while Waldman and Pelner cannot explain the adjuvanteffect.

1. Bensted, H. J., Atkinson, J. D. Lancet, Feb. 7, 1953, p. 265.2 Barrett, N. R., Thomas, D. M. E. Brit. J. Surg. 1952, 40, 222.

PULMONARY HYDATID DISEASE

PuLMONAUT hydatid disease is unusual in this country,but it does crop up from time to time among those wholive in close contact with dogs. Infection with Tcg)MC6echinococcus is commonest in country districts but it isalso found in towns where stray dogs can gain access tothe offal of infected sheep in slaughterhouses. When anovum excreted by a dog enters a human stomach, thesmall embryo develops and finds its way in the portalblood-stream to the liver. A few embryos may getthrough the liver and will not then be held up until theyreach the lungs. Wherever it lodges the embryo maygive rise to a hydatid cyst.

In the lung, the cyst usually grows silently,- and themajority are found unexpectedly on X-ray examinationof the chest. Sometimes, however, the enlarging cystcauses cough, haemoptysis, and pain ; and it mayrupture, producing sudden expectoration of a largeamount of sputum containing blood, hydatid fluid, andfragments of membrane. After a cyst has ruptured theforeign protein of the fluid may cause severe anaphylacticshock, which is occasionally fatal. There are several

possible consequences of rupture : the entire cyst andall its membranes may be coughed up, leading to spon-taneous cure ; but more often the rupture is partial, andafter the loss of some fluid the cyst seals itself and theparasite continues to grow. A partial rupture may openup the potential space between the outer laminatedmembrane of the cyst and the surrounding adventitiaof compressed lung. If this happens air may leak infrom the surrounding lung and the cyst develops a

small crescentic cap of air, which gives it a charac-teristic radiological appearance, the so-called " perivesi-cular pneumocyst." Sometimes after rupture the

parasite dies ; if it is not expectorated it remains as a

foreign body in the lung, and sooner or later infectiongives rise to a hydatid abscess. Hydatid fluid is alwayspotentially dangerous because of the risk of anaphylacticreactions and of dissemination. There is a distinct chanceof fresh daughter cysts developing if hydatid fluid entersthe pleural cavity, but surprisingly the spilling of fluidwithin the lung itself does not lead to fresh lesions, sothat multiple cysts in the lungs show that more than oneembryo has reached the lung from the liver. The Casoniintradermal test may help in diagnosis; and, thoughreliable fluid for the test has been hard to get, the use ofstandardised reagents both for the intradermal and thecomplement-fixation tests has lately given very goodresults.!

The treatment is surgical, for there is no drug whichwill kill the parasite in the tissues, and, even if there was,it would still leave a dangerous foreign body in the lung.Hitherto, all the operations designed to deal with hydatidcysts in the lung have involved a risk of contaminatingthe pleura with hydatid fluid and they have often beenfollowed by severe postoperative complications. Lobee-

tomy or pneumonectomy certainly enable the cyst to beremoved entire, but they mean the sacrifice of healthylung tissue, and this operation is now reserved for infectedcysts. To get round these difficulties, Barrett andThomas,2 whose experience of 71 cases in fourteen yearsmust be unique in this country, have devised an ingeniousoperation whereby the whole cyst can be removedwithout lung tissue. The operation takes advantage ofthe potential space between the adventitia and the cystproper. After dissecting down to the laminated mem-brane, the cyst, protected by a sort of rubber sponge-bag,is allowed gradually to herniate out of the lung with each

breath until finally it is free. " The moment when a

hydatid rolls out of the lung intact is one of the mostsatisfying in surgery." Since this operation was devised,it has been performed successfully on 17 occasions. It issuitable for smaller cysts, provided that they are uncom-plicated, but not for the large ones, which are betterremoved through the plane of cleavage which separatesthe adventitia of old cysts from surrounding lung. Aftera cyst has been removed the empty space within the lungmay persist for many months, but Barrett and Thomassay that this seldom gives rise to any trouble. Compli.cated and infected cysts must still be dealt with bylobectomy, pneumonectomy, or even pleuropneumo-nectomy.

1. de la Pradelle, P. Le Droit Medical International. Paris. 1952.

AN INTERNATIONAL MEDICAL CHARTER?

THE movement towards closer study and more rapiddevelopment of international medical law is of such recentorigin that many doctors and lawyers in this country arestill unaware of its purpose and practical importance.We therefore welcome the publication of a series oflectures 1 delivered last year by Prof. Paul de la Pradelleto fifth-year medical students of the University of Aix-en-Provence and to student members of the FrenchOverseas Army Medical Corps ; for they should bringbefore a wider audience a survey of the beginnings, aims,and methods of this movement. M. de la Pradelle,professor of international law at Aix, is closely associatedwith the group of lawyers and doctors in France andBelgium who have recognised the need for clear definitionand international protection of the status of the medicalprofession in war and peace, and who are trying topersuade their colleagues all over the world of the urgencyof this task. International medical law has already beengiven a place in the medical syllabus at the Universitiesof Marseilles and Bordeaux in accordance with the wishof the Académie de Medecine.The humanitarian work of the doctor has always been

a subject for truly international cooperation. The inter-national medical law movement seeks definite legalrecognition of the special, status of the medical professionat the international, as well as the national, level, andit wants international guarantees and safeguards whichwill protect and, as far as possible, facilitate medicalwork in times of international tension no less than inwar itself. To this end, the movement hopes eventuallyto obtain acceptance by all governments of what, forwant of a better term, is provisionally called an " inter-national medical charter," which will define, regulate,and above all protect the rights of medical men vis-a-vistheir own and foreign States in peace as well as war.

Before it can find such general recognition, inter-national medical law has a long way to go, but alreadyseveral important bodies, such as the World Health

Organisation, the World Medical Association, and theMixed Medico-Legal Commission of Monaco, have made abeginning, albeit embryonic, of an international organisa-tion for medicine. Moreover, there is already a hard coreof positive international law, affecting the status ofdoctors in war, in the Hague and Geneva Conventions,discussed in one of Professor de la Pradelle’s lectures.Though the Geneva conventions were generally respectedduring the late war, and have proved of great benefit asfar as they go, many people consider that they do notgive nearly enough protection to civilian doctors whofind themselves either in captivity as temporary membersof the army medical services or under an occupationregime. Moreover, it is now clear that there are two verydifferent points of view : there are those who insist on a

belligerent’s right to detain enemy medical personneland to treat them as prisoners-of-war in order to preventthem from aiding, once again, in the recuperation of

535

enemy " effectives " ; and there are those who consider

it a serious retrograde step to prevent trained medicalmen from carrying on their calling where it is most

needed. Certainly the distinction now made between

enemy and neutral members of the same medical services,who may be captured at the same moment doing. thesame job, suggests that heed is paid only to the nation-ality, and not to the work, of the prisoner.We are still very far from achieving neutrality for

medical personnel in war-perhaps the only solutionworthy of civilised nations. But even in peace vital

questions arise which may be insoluble except on aninternational level, but which have hardly been tackledat all so far. For example, what of the independence ofthe doctor who is torn between the interests of his

patients and his loyalty to an increasingly powerfulbureaucratic State ? The trials of German and Japanesedoctors for their terrible experiments on human beingsestablished, after the late war, some rudiments of aninternational criminal law on the subject of microberesearch ; but the preparatory phases of atomic, bacterio-logical, and chemical warfare open to doctors all overthe world many distasteful prospects which involve thegravest moral and indeed legal issues. Among thosewhich have lately come to the fore, and are discussed inProfessor de la Pradelle’s lectures, are the questions ofwhich line of conduct should be adopted by a doctor who,in the course of research into defences against bacterio-logical warfare, discovers a new aggressive weapon, andhow far the defence of superior orders can be pleadedby a member of an army medical service engaging inprohibited research.These are some of the open issues which await eventual

solution by a properly developed and acknowledgedbody of international medical law. In his last lectureProfessor de la Pradelle discusses whether the task of

preparing for this far-reaching work and of marshallingpublic opinion can be carried out with the best prospectof real progress by national or international professionalbodies, such as the World Medical Association, by inter-national agencies, such as W.H.O., or by a special supra-national council, comprising both doctors and lawyers.He leans to the view that W.H.O., though primarilyconcerned with epidemiology and public health on thewidest scale, may have the best chance of eventual successbecause, as an institution attached to the United Nations,it is sponsored by the very governments on whom accep-tance of the necessary international conventions will

depend. But this is perhaps looking too far ahead. In themeantime something will have been achieved if the move-ment towards international medical law succeeds in

stimulating discussion and thorough examination of thepractical possibilities of gaining wider protection for thestatus of doctors. The difficulties are great, but oncethe urgency of some kind of action, however gradual andtentative, is recognised, the first and perhaps the mostawkward step will have been taken.TUBERCULOSIS AND SOCIAL CONDITIONS IN

LONDON

Benjamin 1 has lately examined in detail the relationof tuberculosis mortality and notification rates to variousindices of social and economic conditions in the Londonboroughs. He points out that in this type of study afundamental difficulty is that " these indices representbroad averages and the conditions described are by nomeans uniform over an individual borough." Benjaminfinds that between 1931 and 1948 the mortality andmorbidity rates declined in each borough ; but the innerindustrial boroughs had rates above the general average,dnd they tended to lag behind in the general improve-cif-iit. In the other boroughs the changes were complex,artd were as likely to be related to movements of popu-I<inoB, and to changes in the distribution of industry dur-

1. Benjamin, B. Brit. J. Tuberc. 1953, 47, 4.

ing and after the war, as to anything else. Calculating fromthe figures for 1931, Benjamin found statistically’*signifi-cant associations between mortality and all the indicesof social and economic factors, but no significantassociation between mortality and attendances at

dispensaries or expenditure on clinic services. He alsocalculated partial correlation coefficients between tubercu-losis mortality and the various economic indices. Thispart of the study showed a very high correlation betweenthe various indices of social and economic circumstances ;so it seems that little is to be gained from investigatingmore than one such index.

1. Stevens, F. A. J. Amer. med. Ass. 1927, 88, 1937.2. Simpson, J. Med. Offr, 1953, 89, 85.3. Reme, G. Z. ImmunForsch. 1930, 69, 25.4. Satake, T. J. orient. Med. 1927, 6, 17.5. von Bormann, F. Klin. Wschr. 1938, 17, 120.

STAPHYLOCOCCAL SCARLET FEVER

ALTHOUGH it is certainly uncommon for staphylococcalinfection to simulate scarlet fever, there is a wealth ofevidence that it occasionally does so. Most clinicianswith a long experience of scarlet fever have seen a few

‘

examples. In one London infectious-disease hospitalthere are records of 3 cases, all with abscesses anda generalised bright, - somewhat coarse, scarlatiniformrash, but no significant throat infection. 2 of these

patients died. Staphylococcus aureus was cultured fromthe abscesses. As early as 1927, Stevens reported 3cases in which the haemolytic Staph. aureus was the onlypathogen isolated. Simpson 2 has lately described 3more cases ; 1 followed an intramuscular injection of

streptomycin, the site of which had become infected ;the 2nd resulted from a septic sore on the knee, andthe 3rd from a large boil. All 3 infections were dueto a coagulase-positive Staph. aureus, and in none ofthese cases was Streptococcus pyogenes isolated. A solubletoxin was prepared from each of the three strains ofstaphylococcus isolated. This toxin produced in theconvalescent patients, and in a known positive and aknown negative Dick reactor, virtually the same reactions &middot;

as a standard Dick toxin. These results strongly suggestthat the antigenic structure of both toxins was similar,and that the erythrogenic toxin produced by the staphylo-coccus was responsible for the negative Dick reaction inthe 3 convalescents.

Others have obtained supporting bacteriological data.Reme 3 tested 15 strains of hsemolytic Staph. aureU8

and found that 12 of them produced an erythrogenictoxin. Satake 4 cultured from the throat of a scarlet-fever patient a Staph. aureus whose toxin producedin Dick-positive volunteers a systemic reaction with

generalised punctate erythema, characteristic tonguechanges, and subsequent desquamation. von Bormann 5

studied 28 cultures of haemolytic Staph. aureus, a fewfrom cases of scarlet fever, but the majority with noknown relation to the disease. Of these cultures 17

produced an erythrogenic toxin which could be specificallyneutralised by scarlet-fever antitoxin prepared with

Strep. pyogenes.There can be little doubt that staphylococci can produce

a soluble erythrogenic toxin antigenically similar to thatof the haemolytic streptococcus, and that they can, bythis means, reproduce in man the scarlatinal syndrome.That they very rarely do so may merely mean that thequantity of the toxin is usually insufficient to produce thiseffect. Clinicians should, however, be prepared to

recognise the occasional case of staphylococcal scarletfever, for adequate treatment will usually depend uponearly recognition.

Dr. W. J. HoRNE, consulting surgeon to the 3letro-politan Ear, lose, and Throat Hospital, London, anda former president of the section of laryngology of theRoyal Society of Medicine, died on March 7 at the ageof 87.