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ANNOTATIONS

DRUGS LIMITATION

THE Supervisory Body set up under the DrugsLimitation Convention of 1931, at its recent meetingin Geneva, reviewed the progress made during thefive years of its existence. Its operations haveestablished an entirely new system of internationallaw and its experience may serve as a precedent inother directions of international activity. Thenumber of states that have ratified the LimitationConvention now stands at 62-a number higherthan that hitherto recorded of any conventionsconcluded under the auspices of the League ofNations. This system of international control of themanufacture and distribution of dangerous narcoticdrugs is based upon estimates furnished in advanceby Governments of their respective requirements forthe ensuing year. Failing the supply of suchestimates it devolves upon the Supervisory Bodyto frame them. It also revises excessive estimatesand requires explanations from Governments wherenecessary. A comparison between the estimatesmade in advance and the statistics of the actualmanufacture and consumption of drugs no longershows the considerable discrepancies that were

apparent in 1933 and 1934. The number of countriesfor which the Supervisory Body has been obligeditself to frame estimates has fallen from 23 in 1933to 9 in 1936. The number of countries and territoriesthat sent in estimates this year was 140 comparedwith 97 furnished to the first session of the SupervisoryBody in 1933.

DENTISTRY AND DYSPEPSIA

HITHERTO the association of diseases of the mouthwith those of the stomach has mostly been a matterof clinical observation and deduction in individualcases. Statistical studies in this field are nearly allof recent date, and a useful addition to them has nowbeen made by Dr. S. Lossius 1 of Oslo. In charge ofthe dental department of the Ullevaal Hospital, hehas since 1933 cooperated with the other departmentsto which patients suffering from gastric disordershave been admitted. Up to the beginning of 1936the team-work done by the various hospital depart-ments has concerned 328 patients, the diagnosesbeing gastric or duodenal ulcer in 161, gastritis in 50,and dyspepsia (indeterminate) in 117. All theseunderwent a thorough dental overhaul, and only some10 per cent. could be considered as orally and dentallysound. The 328 patients included 171 whose oraland dental condition was found to be quite deplorablein various respects, and 157 who passed muster.A control group of 328 patients in hospital fordiseases other than those of the stomach alsowent through the dental department, and only 80of these were held to be in an orally deplorable state.Here then was statistical evidence suggesting a

relationship between diseases of the mouth andstomach. A classification of the 328 dyspepticsaccording to the frequency with which the membersof the three groups suffered from disease of themouth and teeth showed that the ulcer and gastritisgroups contained the highest percentage of oraloffenders, while in the indeterminate group only 47of 117 patients showed serious disease of the mouthand teeth. Yet another comparison was made byaddressing inquiries to the patients after their dis-charge from hospital, and ascertaining how they had

3 Nord. med. Tidskr. July 31st, 1937, p. 1214.

fared according as they had or had not acceptedtreatment of the mouth and teeth in hospital. Itwas found that 21 per cent. of the orally untreatedhad required renewed treatment in hospital for theirgastric disease, whereas this was the case with only10 per cent. of the patients submitting to measuresof dental and oral hygiene. While only 17 per cent.of the patients refusing oral treatment were found tobe symptom-free, 30 per cent. of those who hadsubmitted to skilled dental hygiene had no furthercomplaints. Though Dr. Lossius is conscious of thesmallness of his figures, he thinks he has made out acase for systematic cooperation in hospital practicebetween dentists and physicians in charge of casesof disease of the stomach.

DIAGNOSIS OF TRICHINOSIS IN THE LIVING

THE prevalence of trichinosis in the United States,to which we recently called attention,’ has beenemphasised by D. L. Augustine,2 who points out thatthe examination of diaphragms at necropsies inBoston has shown an incidence of 27-6 per cent.

Commenting on the diagnosis of this infection in theliving Augustine notes that in the local typhoidepidemic of 1924-25, twenty of the suspects turnedout to have active trichinosis ; and he reports hisfindings in 75 patients thus infected. Larvae werenever obtained from the peripheral blood in manbut were isolated occasionally from that of animalsexperimentally infected, though they have rarelybeen seen in the cerebro-spinal fluid by anyone;and in the course of many examinations of the stoolsof trichinous man, pig, and guinea-pig, adult wormswere never found by Augustine. He therefore lookson all these laboratory aids to diagnosis as in

general a waste of time. Similarly he has beenled to regard biopsy with microscopic examinationof the bit of excised muscle as quite unreliable;for though he examined over 80 pieces of musclefrom an infected guinea-pig, without finding a measle,larvae were displayed after gastric digestion of its

ground-up muscles. Antigen from larvae, freed frommuscle in this way, dried, ground and infused inCoca’s .fluid, was made the basis of precipitation andskin tests which gave much better results in his hands.With this antigen, used in a strength of 1 in 100,precipitins were sometimes found to be present asearly as the second week, always from the fourthweek onwards ; they persisted for the year duringwhich the patients were followed up. Augustinestates that they may be simulated in the blood ofthose to whom certain drugs have been given-notably, quinine and arsenic. Positive precipitintests are of special value in the diagnosis of anyacute illness if they appear only during its course.

In the skin tests the antigen must be as weak as1 in 10,000 if reactions in the uninfected are to beavoided. The character of the reaction alters as theillness runs on ; during the first week it is a delayedone, pronounced after 24 hours and positive whilethere are still no precipitins, but after this date it isimmediate. Apart from the persons who have a

general sensitivity to foreign protein (and they haveno precipitin reaction to trichinella antigen) it is

apparently specific, for it was present in 59 of 60

persons examined, the exception being moribund,and it has not been found in those infected with thezoologically related trichuris ; but in view of its

1 Lancet, Sept. 4th, 1937, p. 685.2 New Eng. J. Med. 1937, 216, 463.

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persistence, and the number of persons, in the UnitedStates at least, who have become infected, its presencedoes not necessarily brand an acute illness as trichin-osis. In determining this point Augustine laysparticular stress on an eosinophilia, shown by a

series of examinations to have set in during the secondweek of illness, though even eosinophilia, as in hook-worm infection, may be absent if the illness is grave,and particularly if there is a secondary infection.He insists that diagnosis is a tedious affair and maybe made only after the medical attendant has weigheda careful history and the results of a complete physicalexamination against those aids which the laboratorycan give him.

LATE RESULTS OF TUBERCULOUS

LYMPHADENITIS IN CHILDHOOD

RADIOSCOPY and bronchoscopy are continuallythrowing new light on chest conditions that formerlyleft the clinician doubtful-largely because physicalsigns were variable and recovery happily preventedpost-mortem examination. One of these is theso-called epituberculosis, which some attribute to

collapse of the lung while others regard it as a localisedconsolidation of unusual type.1 That recovery fromsuch a condition is possible, even if there is a miliaryspread, has lately been shown by Fish.2 Now Brock,Cann, and Dickinson 3 bring forward studies of

enlargement of mediastinal glands in childhoodwhich lead them to conclude that collapse is the morecommon cause of epituberculosis. On bronchoscopythe carina shows a characteristic widening by theenlarged glands. This widening of the carina neces-sitates approximation of the bronchial walls andsometimes obliteration of the opening. Collapse ofdifferent lobes may follow. A case is described inwhich a primary focus of tuberculosis in the rightlung narrowed the left main bronchus by glands of theinferior tracheobronchial group sufficiently to bringabout complete atelectasis of the left lung. This wasconfirmed at autopsy. In another child with clinicaland radiological signs of lung collapse on the left

side, a bronchogram with iodised oil showed a strictureof the left main bronchus with dilatation behindit. Bronchoscopy confirmed the narrowing of thebronchus. In yet another case where there was acollapsed lower right base material aspirated at

bronchoscopy was found to contain tubercle bacilli,and a solid piece of granulation tissue large enoughfor biopsy, which was coughed up through the

bronchoscope, proved to be a fragment of lymphaticgland occupied by a follicular caseating tuberculosis.After the bronchoscopy the air entry in the lowerlobe began to improve, six days later it was normal,and with subsequent clinical improvement the arearepresenting the caseous gland was replaced in theradiogram by a calcified shadow. Brock and hiscolleagues conclude that epituberculosis may often bedue to simple atelectasis from pressure of enlargedcaseous bronchial glands and that a fibrous stricturemay give rise to secondary bronchiectasis. The childwith tuberculous mediastinal lymphadenitis must bekept under observation till he grows up.

This study resembles one by Rossle,4 who thoughtatelectasis the probable cause of the radiographicappearance and observed that if air re-entered the

collapsed lung the shadows disappeared. Some of

1 Cameron, H. C., and De Navasquez, S., Guy’s Hosp. Rep.1936, 86, 366.

2 Fish, R. H., Arch. Dis. Childh. 1937, 12, 1.3 Brock, R. C., Cann, R. J., and Dickinson, J. R., Guy’s Hosp.

Red. 1937, 87, 295.4 Rossle, R., Virchows Arch. 1935, 296, 1.

his cases, which developed tuberculous bronchitisthrough invasion of the bronchus by caseating glands,were progressive ; but some others, in which theobstruction was caused by a catarrhal pneumonia,ended in recovery.

PREVENTION OF NEUROSYPHILIS

SiNCE the establishment of a special centre atHorton (L.C.C.) Hospital some 800 cases of generalparalysis of the insane have been treated there, anda valuable analysis of the results has now beenmade by Dr. W. D. Nicol, the medical superintendent,and Dr. E. L. Hutton.1 It appears that compara-tively few of the patients had had antisyphilitictreatment in the primary or secondary stages of thedisease. A history of primary infection is less oftengiven by women than by men, and a relatively largerproportion of women seek advice for the first timewhen they already have advanced neurosyphilis.The reasons for which patients then seek advice aretabes, tabes with optic atrophy, somatic lesions

occasionally, paralysis or other meningovascularsigns, and mental symptoms which can only beregarded as the precursors of G.P.I. itself. Of 81cases coming under notice in the late stages only13 could be regarded as truly latent and asymptomatic,and these were discovered in the course of routineexamination or because some other member of the

family was found to have syphilis. In manyof these cases treatment was pursued until thepatient developed G.P.I., but in only two men andtwo women was pentavalent arsenic given in the

shape of Tryparsamide and all four were tabeticsin the preparetic stage.

Nicol and Hutton emphasise the importance ofexamining the cerebro-spinal fluid (C.S.F.) whereverthe serum gives a positive reaction. In the casesunder review very few spinal fluids had been

examined, and there was no record of a lumbarpuncture having been done unless the patient showedmental or neurological signs and symptoms. Theconversion of a positive serum Wassermann to a

negative one is no guarantee against the invasionof the central nervous system by spirochaetes, andthe present series includes some 30 cases in whichthe serum was negative, but the C.S.F. strongly posi-tive-indicating that the nervous system was alreadyinvolved. Among malaria-treated cases that hadrelapsed mentally after a good remission, it was foundthat the C.S.F. remained positive, and it appears thatthe persistence of positive reactions in the spinal fluidof a patient who is mentally well is a strong reasonfor a second course of malaria therapy.

Investigations into family histories gave some

unexpected but illuminating results. Among 320men about whom inquiries were made 51 were singleand in a further 99 cases it was impossible to obtainadequate information. Of the remaining 170 patients89 had families whose members gave negative serumreactions, while in a further 18 there was reason toassume that the wives and children were free from

syphilis. On the other hand, in the remaining63 cases there was evidence of the disease in oneor more members of the family. Nicol andHutton find that syphilis is usually acquired by menwhen they are still young-as a rule probably beforethe age of 25-and that the patient remains infectiousfor a period of two or three years after the primaryinfection. Accordingly men who married before25 or within two years of acquiring the disease

1 Brit. J. ven. Dis. July, 1937, p. 141.