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Annotations.

LIFE-TABLES.

"Ne quid nimis."

IN the fifth annual report of the Registrar-General,published 83 years ago, there is a remarkable pane-gyric on life-tables. The report is, indeed, signed" George Graham," but a belief that-" By thesecomparisons (i.e., of National Life-Tables) a noblenational emulation might be excited : and rivalnations would read of sickness diminished, deformitybanished, life saved-of victories over death and thegrave-with as much enthusiasm as of victories overeach other’s armies in the field ; " argues a robusterfaith in the saving virtues of vital statistics than any-body but William Farr has ever possessed. Farr,indeed, was the pioneer in using the life-table as a

biometer, holding it to be as " indispensable in

sanitary inquiries as the barometer or thermometerand other instruments in physical research." Nodoubt there was exaggeration in this, but the experi-ence of three generations has proved that, for someimportant purposes, the life-table is a statisticalinstrument of medical value. A practical difficultywas that, to the ordinary medical man, the methods ofconstruction, even those of Farr, who knew how littlealgebra most medical men knew, were more than atrifle perplexing. To Sir Arthur Newsholme belongsthe credit of having pointed out to medical men thatthe (to them) most perplexing stage of the process ofconstruction could be carried out without any resortto algebra. Newsholme and Stevenson proved thata graphical method was quite satisfactory, but thereis reason to suppose that students still believe thatgraduation by formula is, in some mysterious way,more scientific than graduation by the graphic method.On that account we are glad to publish a furtherillustration, from the pen of Miss H. M. Woods, of theLondon School of Hygiene and Tropical Medicine, ofthe simplicity and success of the process. It is truethat the use of this method does not dispense theworker from some hours of arithmetical calculation ;but the virtue of it is that a medical man, after a verylittle practice, can confidently perform all the opera-tions intelligently and easily without having to carryin his head, or in a notebook, formulae the derivationof which he does not understand. There are enoughinherent difficulties in statistical work for it to bevery desirable that unessential oostacles should beremoved. We hope that by recalling the attentionof readers to Sir Arthur Newshoime’s work, MissWoods may induce others besides professed studentsof public health to use Farr’s beloved instrument.

DANGEROUS DRUGS ACTS REQUIREMENTS.THE Home Office has issued a third edition of its

memorandum on the duties of doctors and dentistsin respect of the Dangerous Drugs Acts and theRegulations made thereunder. It is probably commonknowledge by this time that any duly qualifiedmedical practitioner and any registered dentist isauthorised " so far as is necessary for the practiceof his profession " to be in possession of dangerousdrugs and to supply them to his patients by personaladministration or by administration under his directpersonal supervision and in his presence. The doctor-but not the dentist-may also dispense dangerousdrugs for his patient’s use and may be in possessionof the raw materials for use in the compounding ofmedicines though he may not supply the raw materialsto a patient. Probably the two most important aspectsof the law are those which concern prescriptions andthe keeping of records. There are some 17 specifieddrugs which, though they come within the DangerousDrugs Acts, are specially exempted by the regulationsand are purchaseable in Great Britain in the same

way as ordinary " poisons " under the PharmacyActs. Apart from these specified drugs (which arelisted in the Third Schedule of the ConsolidatedRegulations issued last December) any other dangerousdrug (if prescribed in sufficient strength to bring itwithin the Dangerous Drugs Acts) involves the followingduties on the part of the prescriber. The prescribingdoctor or dentist must write his prescription, date it,sign it with his usual signature and-except in thecase of health insurance prescriptions issued on theofficial form-must add his address ; he must alsogive the patient’s name and address and must specifythe total amount of morphine, cocaine, or other druerto be supplied. The only exception to this lastrequirement is that, where a preparation is prescribedwhich is contained in the British Pharmacopoeia, theBritish Pharmaceutical Codex, or the Minister ofHealth’s health insurance drug tariff, only the totalamount of that preparation need be specified. TheHome Office, perhaps not unreasonably, explains thatchemists are not allowed to dispense a prescriptionwhich does not comply with the foregoing requirements, and the memorandum hints that irregularitiesdo occur, and that doctors must not take offence ifchemists ask them to correct an irregularity.A chemist cannot dispense a prescription containinga dangerous drug unless (a) he knows the prescriber’ssignature and has no doubt of the genuineness of theprescription, or (b) he has taken reasonably sufficientsteps to satisfy himself that the prescription is genuine.As the Home Office points out, this situation can beuncomfortable for the chemist, who may find himselfobliged either to delay the prescription (with theprospect of offending the prescribing practitioner)or to break the law. As to the requirement of record-keeping, the memorandum draws attention to theobligation upon a medical practitioner to keep arecord of all supplies of dangerous drugs to patientsexcept only in cases where the drug is administeredby the practitioner himself or under his direct super*vision and in his presence. The memorandum alsoreprints in an appendix paragraphs 50 to 60 of thereport of the Departmental Committee (presided overby Sir Humphry Rolleston) on Morphine and HeroinAddiction. The passages are those which deal withthe precautions necessary in administering these twodrugs on the one hand in treating addicts and on theother hand in ordinary medical practice ; but,indeed, the whole of the Departmental Committee’sreport (published in 1926 by H.M. Stationery Officeat the price of Is.) is worth study.The special occasion of re-issuing the Home Office

memorandum is the embodiment therein of certainchanges in the law due to the operation of the GenevaConvention of 1925-changes which the DangerousDrugs Act of 1925 was designed to implement. Oneresult is an alteration of the list of drugs within theDangerous Drugs Acts. The Geneva Conventionamplifies the International Opium Convention signedat The Hague in 1912. Among other provisions itcreates machinery (through the agency of the Leagueof Nations) for varying the list of narcotics inChapter III. of the Convention, a list which corre-sponds with that of the drugs to which Part III. ofour Dangerous Drugs Act of 1920 applies. The newmachinery will enable the exclusion of any narcoticwhich is found not to give rise to the drug habit.Part III. of our 1920 Act named morphine, cocaine,ecgonine, diamorphine (or heroin) and their respective

salts, and also medicinal opium. Our 1925 Act hasa fresh definition of ecgonine and medicinal opium;it explains that cocaine includes synthetic cocaine; ;.and it adds to the list of narcotics in Part III. " anyextract or tincture of Indian hemp." Subsequentregulations, however, show that medicinal prepara-tions containing extract or tincture of Indian hempas one of their ingredients do not come within theDangerous Drugs Regulations. It remains to addthat an Order in Council last August applied Part III.of our 1920 Act to benzoyl-morphine, dihydro-oxycodeinone, dihydrocodeinone, and their respec-tive salts. Subsequent regulations issued last

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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

FUND.

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.