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November enact that no one may have any dealingsof any kind in benzoyl-morphine and its salts or
preparations without the Home Secretary’s licence ;the general authorisation which doctors and dentistsenjoy in respect of the other dangerous drugs does notapply here. Unquestionably the law as to the useand supply of dangerous drugs is complicated andincreases the cares of the busy practitioner. At thesame time it must be admitted that the Home Officereasonably met the interests of the medical professionin the matter of the Reference Tribunal and themachinery for withdrawing a practitioner’s authorityunder the Acts; and the recent re-issue of thememorandum is to be commended as an aid to thecomprehension of the profession’s responsibilities.
EPIDEMIC ENCEPHALITIS AND WAR SERVICE.
IN this country from time to time considerabledifficulty has been experienced in deciding how faran ex-Service man’s disability, when it takes the formof chronic disease, can be held attributable to his warservice. The administrator adjudicating on thequestion of war pension is naturally guided largely, ifnot entirely, by medical advice. The medical expert Ihas to consider on the one side that a too ready alacrity i
to accept all post-war manifestations as due to warservice is not only scientifically incorrect, but ismaking unfair demands on public funds, even
although the individual case may excite justifiablecompassion ; on the other hand, he must rememberthat too rigid definitions of war diseases may beunjust to the victims of the chronic maladies whichhad their aetiology during the period of the war andwere fostered by military conditions.That difficulties of this nature have equally arisen
in Germany is shown by a paper 1 in which Rombergand Bremer deal with the problem of epidemicencephalitis as a disease attributable to war. At theoutset they found that the possible association ofepidemic encephalitis and influenza demanded con-sideration, and were led to the same conclusion asF. Stern-namely, that the time-relations of the twodiseases indicate an epidemiological association. In1918, they point out, influenza was almost universallyepidemic on the German front, whole battalions havingto be invalided home, and epidemic influenza was bothpreceded and followed by epidemic encephalitis. Theyhave formed the opinion that true influenza contractedon military service has been followed by epidemicencephalitis, although such a contention is admittedlydifficult to prove and no valid statistical evidence isprocurable in its favour. They urge that the connexionif not direct may be indirect and the influenza viruswhich is unknown may activate or endow with patho-genic properties the equally unknown virus ofepidemic encephalitis. In 1925, at the request of theGerman National Welfare Board, Romberg gave aruling on the war attributability of cases of epidemicencephalitis. Premising that the question is a complexone, he stated :-
(1) The connexion of epidemic encephalitis with warservice must be assumed in all cases where epidemic ence-phalitis occurred in the field and even in cases where thisevent is only a probability.
(2) The same connexion must be assumed if an attackof influenza occurred in the field and after the war wasimmediately followed by the so-called pre-neurasthenicstate which merged into the clinical picture of chronicencephalitis.
(3) A similar connexion is assumed if epidemic ence-
phalitis did not immediately follow on the attack of" influenza " in the field, but developed after a certain intervalof time during which the individual had been apparentlyfree from disease.
Romberg considers this interval of time should notexceed six months. His third ruling has been thesubject of most criticism, but in defence it is arguedthat it is only applicable to a few special cases. The
1 Romberg, E. von, and Bremer, F.W.: Encephalitis epidemicaund Kriegsdienstbeschädigung, Münch, med. Woch., April 5th,p. 570.
possible influence of war-strain and war conditionson the aetiology of epidemic encephalitis is not dis-discussed in Romberg and Bremer’s paper. It must beobserved that the evidence they adduce for theassociation of influenza and epidemic encephalitis isnot very substantial, as they themselves acknowledge,.whilst their experience of the occurrence of true" encephalitic
" cases in the influenza epidemics of
1890-94 is at variance with the British experience.Again, in the outbreak of epidemic encephalitis in thiscountry in April to June, 1918, when the first wave ofthe influenza epidemic had appeared, the cases werealmost, if not entirely, sporadic and no connexion withcases of influenza was established. A. S. MacNaltyconsiders that the prodromal stage of epidemicencephalitis is often mistaken for mnuenza, whilstA. J. Hall has pointed out in his Lumleian lecturesthat if there is any connexion between epidemicencephalitis and influenza it is unusually well concealedfrom the clinician. The occurrence of an encephalitisdue to influenza, although rare, must not be forgotten.
It is probable that by using the term " influenza"Romberg and Bremer have made the attributabilityof epidemic encephalitis to war conditions moreextensive than many neurologists would allow. The-difficulties of the position have to be recognised, andit must be agreed that if any error has been made ithas been on the side of generosity to the ex-Service-man.
THE MACKENZIE MACKINNON RESEARCH
THE late Sir George Sutherland Mackenzie directedin his will that z30,000 should be paid to the RoyalCollege of Physicians of London and the RoyalCollege of Surgeons of England to form a fund for-the promotion of scientific medical investigationThe immediate object of the bequest was to assiststudents of high intellectual promise by renderingthem independent of ordinary professional incomewhilst carrying out research. The fund he desired" to be named after and in grateful remembrance ofmy best friend, the late Sir William Mackinnon,Baronet of Balinakill and Loup, to whose unvaryingkindness and influence upon me in my youth is duethe means and inclination that prompts me to providethis endowment." It was further his hope thatothers might from time to time add to the fund" feeling like myself that should the conditions befulfilled the steady cooperation of trained workersmay ensure the settlement of questions admitting ofdoubt and thus prepare the way for the great dis-coverer who may be destined to throw the light ofgenius upon problems which their predecessors failedto solve." The annual income from the bequest isat present 21278 and a joint committee of the twoColleges has recommended that it shall be used forthe foundation of Mackenzie Mackinnon Fellowships,of which not more than two will be granted annually.Candidates must be nominated for election by amedical school; they will be eligible for re-election,but their tenure of Fellowships will not extend formore than three years except by special resolutionof the Colleges. ____
SPINAL ANALGESIA IN OBSTETRICS.
SPINAL injection is but little employed in thiscountry for the facilitation of labour. It wouldprobably not be incorrect to say that its use inobstetrics is restricted to cases of Caesarean sectionwhere there is definite reason to prefer spinal to anygeneral anaesthetic. Dr. Max Cheval, of Brussels,who has had a wide experience of spinal injectionboth in gynaecology and in obstetrics, considers 1that for the latter branch of work it is only exception-ally the method of choice. He does not find thatspinal injection facilitates the dilatation of the cervixalthough he’ does consider that it abolishes uterinecontraction. The indications for the use of spinal
Bruxelles Médical, March 31st, p. 619.
injection in obstetrics he holds to be conditionsof the patient which forbid general anaesthetics, forexample, pulmonary tuberculosis and heart disease,and tetanically contracted uterus threatening rupture.The author gives details of a case refuting the con-tention of Delmas that with spinal injection dilatationof the cervix is always an easy matter. Other writers 2
on the same ground are more enthusiastic supportersof Delmas, maintaining that the cervix is alwayswell relaxed under spinal analgesia if it is normal tostart with. A failure in dilatation of the cervix isdue in their view to fibrosis or other pathologicalchange prior to the labour. They also lay stress onthe complete relaxation of all the external genitalcanal and perineum as an additional advantagegained by the spinal injection. On the other hand,they describe difficulty in the method advocateddue to hypertonus of the uterine muscle which mayrender version well-nigh impossible.
SEROTHERAPY IN INTESTINAL OBSTRUCTIONAND IN APPENDICITIS.
ONE of the few legacies of the late war which arelikely to prove of permanent benefit to humanity hasbeen the elucidation of many problems in anaerobicbacteriology. The work of Weinberg in France hasbeen of great value, and in this country MurielRobertson and W. E. Gye have made contributionsof importance. The fact that Bacillus welchii, oneof the causal organisms of gas-gangrene, is a normalinhabitant of the intestinal tract leads logically to asearch for possible pathogenic effects in its normalhabitat. Pernicious anaemia has been related to itwith some plausibility, whilst its relation to septicconditions has been investigated in this country byB. W. Williams and in France by Weinberg and hiscolleagues. A recent publication 3 by the lattersummarises his elaborate work on the nature of theinfection in acute appendicitis. His technique deservesattentive notice ; he has slit open the affected organ,removed faeces, and then made cultures of the inflamedmucosa. In this way he has hoped to get rid of allsave the pathogenic organisms, but analysis of thefindings suggests that in this respect he is undulyoptimistic. Of 160 cases there are no fewer than23 in which four different organisms, and 16 in whichfive organisms, are inculpated. Such a multipleinfection is certainly not impossible, but it is highlyimprobable if we may draw deduction from acuteinfections elsewhere ; moreover, the commonestorganism is B. coli, the normal saprophyte of thefaeces. Of anaerobic forms 14 different types oforganisms have been found, and apparently theirpresence is taken as proof of pathogenicity ; it oftenseems to come as a surprise to bacteriologists thatthe faeces are seldom sterile. Having determined tohis satisfaction the nature of the infection Weinberghas proceeded to serotherapy. His view of themultiplicity of the infection has led to the use of apolyvalent antitoxic serum. In particular he includesan anti-coli serum, and his work (which is entirelynovel) on the production of both toxin and antitoxinto B. coli will be awaited with interest. He alsoincludes among other sera the antitoxins of anaerobicforms. The use of these and analogous sera is perhapsmore widespread than he realises. He qpecincallystates that no work has been done in this country onthe subject, whereas in fact the papers of Williams 4have attracted a great deal of attention. But Williams’sconception is fundamentally different. He arguesthat in acute obstruction and in the stasis incident onacute appendicitis, there is a proliferation of B. welchiiin the small intestine, and absorption of toxin withoutinfection. Therefore he treats such cases with anti-welchii serum and claims excellent results, largelysubstantiated by others.
2 Ibid., April 14th, p. 679.3 Ann. de l’Inst. Pasteur, 1928, xlii., 1167.
4 Brit. Jour. Surg., 1926, xiv., 295 ; THE LANCET, 1927, i.,907.
The nature of the toxaemia of obstruction andstasis has long been a mystery. It seems reasonable tosuppose that infection is due to one cause and toxemiato another. The vastly larger number of B. welchiiin the small intestine (and in almost pure culture)than in the appendix certainly supports Williams’sview. Perhaps too much stress may be laid on thesedistinctions ; perhaps, if the view of Weinberg is tooextensive, that of Williams is too narrow. At leastserum therapy in appendicitis is firmly established,and further work on both sides of the channel maysoon determine the best proportion between availablesera.
A SET-BACK IN MID-LIFE MORTALITY.
UNDER this heading the Metropolitan Life InsuranceCompany surveys in a recent bulletin 1 the course ofmortality since the issue of the last official Americanlife-table for 1919-20. The previous table (1910)compared with that for 1901 had shown an actualincrease in mortality at the higher ages of life, but themisgivings engendered by this finding were to someextent allayed by the experience of the succeedingdecade when improvement at nearly every age was inevidence. The outstanding features of the experienceof the current decade in the United States of Americaare a decline in mortality at ages under 37 years anda definite tendency for adult mortality to increase.Most instructive in this connexion is the comparisonof the extreme years of the series-1927 and 1921.The expectation of life at birth (mean after-life time)for these two years was 59-10 and 58-01 respectively,a gain of just over one year. At the end of the firstyear of life, however, the expectations were almostequal-namely, 61-48 and 61-49 respectively. Theimprovement within the period 1921-27 has thus beensecured chiefly by the decline in mortality of infants;higher ages show an actual loss. Similar facts emergewhen instantaneous death-rates are subject to com-parison. From age 37 till the end of the life-span,mortality in 1927 exceeded that of 1921. The promisegiven by the experience of the previous decade hastherefore not been fulfilled. Possibly in 1921 condi-tions, so far as concerned adult mortality, were undulyfavourable, and the result of such a comparison inconsequence too pessimistic. Subsequent to thepandemic of influenza, which played havoc particu-larly with persons in impaired health, a great declinein mortality at older ages took place, and the deteriora-tion observed at these ages between 1921 and 1927may simply represent a return from abnormallyfavourable to normal conditions. Such an explana-tion, even if true, does not make the figures much lessdiscouraging. The state of affairs is not very dis-similar in this country where the improved expectationof life at birth is in the main due to a declining infantmortality. Some diminution of the deaths at adultages is surely within the scope of preventive medicine,and there is no reason to believe that mid-lifemortality has been reduced to its lowest possible level.
THE UTILISATION OF MILK RESIDUES.
THE Scottish National Milk and Health Associationand the Empire Marketing Board have done a usefulpiece of work by carrying out an investigation of theutilisation of surplus milk and milk residues in Scot-land. The investigator appointed was Mr. ArchibaldMacHeilage, jun., and the result is to hand in theinformative Bulletin I. of the Hannah Dairy ResearchInstitute. Prof. E. P. Cathcart, the Interim President ofthe Institute, in a preface lays emphasis on the factthat the full utilisation of the milk produced is amatter of national importance and that all milkresidues, whether skimmed milk, buttermilk, or whey,have a high biological value. The report shows thatmilk residues produced on the farms are utilisedlocally by feeding to stock and by sale to bakers andthe local population. That this method of disposal
1 Statistical Bulletin, 1929, vol. x., No. 2.