34

that in countries where social control is more

vigorous and the question may be asked how farthe arguments against compulsory notificationand penalisation of the delinquent are still valid.There are nowadays so many incursions intothe personal liberty of the subject that it is

by no means certain that the provision of limitedpowers to coerce the infectious defaulter or theneglectful parent would cause resentment. Aclue to the popular feeling on this point wasprovided a short time ago. In 1934 a question-naire 2 was submitted to patients attending theSalford municipal clinic for the treatment ofvenereal diseases, inviting expressions of opinionon two points: (1) Should a person sufferingfrom a venereal disease be compelled to receivetreatment, provided it is given confidentiallyand free ? 1 (2) Should the parents or guardians ofchildren suffering from venereal disease be com-pelled to have such children treated under thesame conditions ? 1 In reply to both questionsthere were 429 ayes and 5 noes. The opinionamong this group of infected people was thusoverwhelmingly in favour of some form of

compulsion.Nevertheless, in considering the coercion of non-

cooperative or defaulting patients we must notrisk losing all that has been gained by the per-suasive approach. The risk is that minatoryregulations will drive the disease underground, and

2 City of Salford V.D. Scheme. Annual Report, 1934, p. 14.

this risk is far greater in England than, for

example, in the Soviet Union where venerealdiseases are regarded as diseases like other diseasesand nobody thinks the worse of a man becausehe contracts them. The conditions are really notcomparable. But in England and Russia alikethe object must be to make the patient realisehow much he stands to gain by cure, and a usefulillustration of this comes from the social service

department of the University of Pennsylvania,3where there has been complete freedom to experi-ment in what Louise Ingraham calls " technics ofpersuasion." Here as in many other places theaim has been to obtain from the syphilis patienthis voluntary disclosure of recent sexual intimatesand his services in personally recruiting them formedical examination. On this basis persuasionwas 92 per cent. effective when the individualcontact could be personally reached, and thissuccess was independent of the type of com-

munity, whether black or white, well-to-do or

indigent. - Of 201 patients with syphilis it appearsthat 114 of them identified 174 exposures, beingan identification-rate of 1’5 contacts per productivecase. Possibly, the author admits, a more aggres-sive technique would give greater immediatereward, but at the same time it would almost

certainly sacrifice future gains. Father O’Flynn,who had a way with him, did however sometimescoax the lazy ones on with a stick.

3 J. Amer. med. Ass. Dec. 12th, 1936, p. 1990.

ANNOTATIONS

GREAT ALTITUDE

AT a time when the sport of mountain-climbing isattracting every summer a larger crowd of devotees,especially in England and Germany, any soundresearch into the medical aspects of great altitudemust have a practical interest. A more serious import-ance comes from the growing conviction that aero-planes are likely to fly at increasingly greater heights,and the recognition of anoxoemia as a factor in

pulmonary and circulatory disturbances.On the firm foundations built at Oxford by Haldane,

Douglas, Priestley, ’and their co-workers, there is

arising a superstructure, much of the work on whichhas been done in America. It is possible that thereis lacking in the United States the coordinatinginfluence of Barcroft over the Cambridge school.But the Americans are fortunate in having highmountains near at hand, a circumstance which hasgiven to much of their work a very practical bent.Somervell, Raymond Greene, and others in thiscountry have written of the digestive disturbancesand failure of appetite accompanying the manyefforts which have been made to climb Everest.Recently, working in a steel chamber, Van Liere 1has shown that at only 14,000 feet there is an averageprolongation of the emptying-time of the stomachof 35 per cent., the least susceptible subject showinga prolongation of 13-2 per cent. The delay is causedby a loss of motility, which may be due to theincreased output of adrenaline during anoxaemia. Itwill be recalled that medical officers of variousEverest expeditions have laid stress upon loss of

1 Van Liere, E. J. (1936) Arch. intern. Med. 58, 130.

appetite as a possible factor in the degenerationnoted after prolonged residence above 20,000 feet,but it has generally been held that its influence wasnot the paramount cause. From this point of view,the new work of Talbott and Dill,2 of Harvard, is ofimportance. They describe a disease, first reportedby Monge, and named after him, which developsafter residence over many years at such alti-tudes as 15,000 feet. It seems probable that thoughMonge did not observe it in anybody who had livedin the highlands for less than two years, it mightappear much sooner at a greater altitude. Talbottand Dill give as its symptoms headache, hoarseness,loss of appetite, weakness, paraesthesise, and transientspells of stupor; and, as its signs, cyanosis, pig-mentation, generalised vasodilatation, and hypo-tension. Some, though not all, of these signs and

symptoms have been observed in climbers sufferingfrom altitude deterioration. The exact aetiology ofthe disease is unknown, and in discussing it Talbottand Dill pay, perhaps, too little attention to the workof Argyll Campbell.The time seems ripe for trying to elucidate this

and many kindred problems of growing importance.Everest was almost climbed in 1933. In 1936,through no fault of the climbers, the expedition wasa fiasco. A repetition of this fiasco, due to weatherconditions, can never be excluded. Yet if the lastexpedition had included a scientific programme itwould have produced some solid return for the manythousands of pounds expended. It is not enoughthat the medical officer should pursue a line of

2 Talbott, J. H., and Dill, D. B. (1936) Amer. J. med. Sci.192, 626.

35

research of his own : he is usually one of the climbers ;he has a gigantic responsibility for the health of theparty which must absorb most of his mental energy ;and he may even himself be suffering from the clinicalabnormalities which he is attempting to describe.If the necessary separate fund can be raised, thenext Everest expedition should take in its train anindependently financed scientific group. This shouldinclude not only physiologists but clinicians, as

capable as the medical officers of past expeditionsof observing the reactions of their companions tothe abnormal environment, but, like Lord Nuffield’sprofessors, freed from the responsibilities of practice.

VARIATION IN ANIMAL VIRUSES

VARIATION in filtrable viruses has been known

nearly as long as the viruses themselves. Almostbefore the conception of filter-passing viruses hadtaken shape, and certainly before it was generallyrecognised, Pasteur demonstrated that a variant ofthe virus of rabies could be produced, and, as every-one knows, employed it in the prophylaxis of humaninfection. The adaptation of the virus of small-

pox to growth in the tissues of the calf, resulting inthe fixed variant vaccinia, also belongs to the earlyhistory of viruses. And since that time, especiallyin the last decade, many more examples of virusvariants have been brought to light. Some of thesehave been discovered more or less by accident-for example, the necrotic variant of Shope’s rabbit-fibroma virus-but most have been sought inten-

tionally, often with specific prophylaxis in view.In a long and well-documented paper the whole

question of variation in animal viruses has latelybeen reviewed at length by Findlay.l Much of

Findlay’s work on viruses has been concerned withthe production of variants and a study of their

properties, so that he is peculiarly fitted to writesuch an article, and he has done it extremely well.Starting with an enumeration of all the availablefacts concerning virus variants, he briefly reviewsour knowledge of variation in multicellular andunicellular organisms and finally considers the

application of this to viruses. Naturally it is harderto study variation in viruses than in multicellularorganisms or even unicellular organisms like protozoa,for viruses cannot be cultivated apart from livingcells. As yet it has not been found possible to raisestrains of virus from a single virus particle and thereappears little likelihood of viruses possessing a

demonstrable nuclear apparatus, thus making itimpossible to distinguish between Lamarckian and

genetic variation. Nevertheless, as Findlay pointsout, the available evidence suggests that there is nofundamental difference between variation in viruseson the one hand and in unicellular and multicellular

organisms on the other. It is true that the absenceof any demonstrable mechanism whereby hereditarycharacters are transmitted, such as exists in higherplants and animals, makes the application of the termmutation to some virus variants incorrect, and inorder to overcome the difficulty it has been suggestedfrom time to time that viruses are themselves genes ;that they have arisen from higher forms and thatas the result of highly specialised parasitism allstructure and function, other than that associatedwith the hereditary characters, has been lost. This,however, is pure hypothesis with little to commend it,and it seems more reasonable to assume that in suchprimitive forms of life as viruses any such specialisedmedium for the transmission of heritable characters

1 Findlay, G. M. (1936) J. R. micr. Soc. 56, 213.

has not been developed. That viruses are livingthings is strongly supported by the fact that theyexhibit this phenomenon of variation. Indeed,as Findlay says in his conclusions, it is hard to

explain the facts except by regarding viruses as

organised living entities. But interesting andimportant though this aspect of variation in virusesmay be there is an eminently practical side to it.Virus variants have proved their value in the activeimmunisation against virus infections : in recent

years we have seen them used with success in the

prophylaxis of yellow fever and horse-sickness, andno doubt the near future will provide further examples.It is this side of the problem, quite apart from theacademic one, which will ensure adequate attentionbeing paid to this interesting question of variationin viruses.

THE SAFETY OF PREMEDICATION

THE use of formidable accessory agents givenbefore the anaesthetic proper is so frequent at thepresent time that it is important to know what,if any, disadvantages may accompany the manyundoubted benefits which the practice confers on

most patients. Dr. Dawkins in order to determinethe answer to this question contrasts 1 two series ofpatients, the first operated on between 1921 and1925 and the second between 1931 and 1935. Eachseries comprised more than three thousand opera-tions, and altogether he has for his study analysedthe histories of over 16,000 anaesthetics given atseveral London hospitals and in private practice.Conclusions drawn from a study of this dimensionare worthy of serious notice, and perusal of this littlework gives information with regard to almost everycomplication that has been associated with an2es-

thesia. The matter is well arranged and tabulatedso that the author’s findings are easily perceived.His final conclusion is that during the last five yearsdefinite progress has been made towards the reductionof anaesthetic complications. Injudicious use ofbasal narcosis however increases the risk of pulmonarytroubles. Some of the figures in the many tablesprovide an interesting study. Generally speakingthey agree with commonly held opinion both as

regards mortality and morbidity. For example,the hope that spinal anaesthesia might save patientsfrom lung trouble, not infrequent after inhalation,a hope long since dissipated, is here again shown to bewithout foundation. Pulmonary morbidity is shownby the author at 11-5 per cent. after spinal anaesthesia,and at 5’ 9 per cent. after ether. Chloroform shows thesame pulmonary morbidity as ether, but the numberof patients is so small that much value cannot beplaced on this conclusion.

CATGUT SENSITIVITY

THERE are still many problems that await solutionin the use of catgut as material for ligatures.Examination of a wound that has broken downoccasionally reveals absorption of the catgut in afraction of the time stated by the manufacturers.Local reaction to the presence of the catgut alsooccurs most unexpectedly in some presumably cleanwounds, followed either by delayed healing or bydisruption. Dr. C. J. Kraissl of New York hasthrown light 2 on these problems by his investiga-tions into defects in the structure of catgut andby his demonstration of the possibility of catgut

1 On the Incidence of Anæsthetic Complications and theirRelation to Basal Narcosis. By C. J. M. Dawkins, M.A., M.D.,D.A. London: John Murray. 1936. Pp. 56. 3s. 6d.

2 Surg. Gynec. Obstet. November, 1936, p. 561.