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one must infer’that most cases are toxipathic in originand unlikely to benefit to the same remarkable extentfrom the dietetic and supplementary treatmentsoutlined above. But before the value of supplementsto the dietetic treatment of cirrhosis can be assessedtruly, larger series of cases observed over long periodsand with suitable group-controls will be necessary forstatistical analysis.

Annotations

COMPULSORY SEGREGATION OF CARRIERS ?

NINE patients, who were presumably in the con-

valescent stage of paratyphoid fever, one of them beingambiguously styled a "milk producer," lately walkedout of a Bedfordshire isolation hospital before theywere known to be free from infection. They werethus potential dangers to the community. The reason

given for this premature departure was the remotenessof the hospital. Another, and more accessible, hospitalin which these patients would normally have beentreated was closed for lack of nurses.The members of the hospital board were naturally

perturbed by the incident ; but, as the medical officerof health pointed out, there were no legal powers ofdetention. In England and Wales a M.o.H., under thePublic Health (Infectious Diseases) Regulations, 1927,may require a suspected carrier of enteric or dysenteryorganisms to undergo medical examination ; and if thecarrier state is confirmed, the local authority mayprohibit him or her, under heavy penalty and for aspecified time, from handling food or drink for humanconsumption. The M.o.H. also has powers under theFood and Drugs Act, 1938, to deal with dairy workerswho may be in an infectious condition ; and here hisauthority is not limited to enteric or dysentery infections.North of the Border, the Public Health (InfectiousDiseases) Regulations (Scotland), 1932, give localauthorities wider powers ; a carrier of any diseasecertified as such by a practitioner and the M.o.H.

may be isolated compulsorily, or otherwise controlled,for renewable periods of three months. The carrierhas the right of re-examination at any time, andof appeal to the Department of Health. It seemsdesirable to confer similar powers in England andWales.

Usually a sense of responsibility to his family and thepublic leads the patient or his parents -to accept isolationuntil release is believed to be safe-belief can neveramount to certainty because the carrier-state tends tobe intermittent. The long detention of patients afterphysical recovery is, at best, tedious. Adults sometimes

worry about family or finance to a degree borderingon an anxiety state, whereas children, similarly cabinedand confined, tend to become " hospitalised." Browning,lin his classical report on chronic enteric carriers, quotedDittmar’s observation that most enteric carriers arewomen, whO’ may be unable to earn a living as cooksor dairy workers and therefore should be recompensedby the community (as was the late Typhoid Mary inthe U.S.A.). Adult chronic carriers of any disease whoconsent to isolation should at least not suffer financial’loss through no fault of their own. But the cure for the

psychological and financial ills attendant on a protractedcarrier-state is to shorten the period of infectivity andhence the duration of detention or restrictlon. So far,the enteric carrier-state has proved resistant, or but

uncertainly responsive, to chemotherapy, but there canbe little doubt that this too will yield to some futuresulphonamide or antibiotic, alone or in combination,

1. Browning, C. H. Spec. Rep. Ser. med. Res. Coun., Lond. 1933,no. 179, p. 26.

and thus be added to the list which already includescarriers of the causal organisms of bacillary dysentery,diphtheria, scarlet fever, and cerebrospinal fever.

HOPES AND FEARS IN INTERNATIONAL HEALTH

THREE small clouds overhung the fourth session of theInterim Commission of the World Health Organisation,held at Geneva from Aug. 30 to Sept. 13. The first wasthe delay in ratification of the constitution of the

Organisation, now signed by 64 countries but onlyratified by 22, of whom 17 are members of the UnitedNations. The World Health Conference in New York in

July, 1946, anticipated that the 26 ratifications of UnitedNations’ members necessary to establish the permanentorganisation would be forthcoming by the summer of1947. The delay is not due to opposition by any countryor group to ratification-promises of ratification are

two a penny-but to the inevitable lack of priority whicha non-controversial matter like health receives in a

politically troubled world. The result is that the life ofthe Interim Commission is prolonged by at least a year,until the summer of 1948, with all the consequentialdifficulties of programme, finance, and staff involved inthe continuation of an interim body beyond its expectedperiod of existence. The Interim Commission has askedthe chairman of the U.N. General Assembly to impresson delegates the importance of early ratification, since" essential progress in international health work is beingseriously hindered by the long delay in establishing theWorld Health Organisation."The second cloud was a financial one. A Republican

congress and the British financial crisis made it inevitablethat the 1948 budget would not substantially exceedthat for 1947. Instead of the expanded programme, itis doubtful if sufficient funds and staff have been providedfor the tasks already laid on the secretariat by thecommission. Indeed, the commission only just rescueditself from denying to its staff the allowances for maternityand hospital treatment to which they were alreadyentitled-a curious situation for a world health organisa-tion. More important, many recommendations for fieldwork and research made by the expert committees onmalaria and tuberculosis were turned down, thoughprovision for a team or two for B.c.G. vaccination wasmade, a meeting of experts on streptomycin will be held,and an expert committee on venereal diseases is to beset up.

Thirdly, the general deterioration in the politicalsituation had some inevitable, though slight, reper-cussions. These were principally shown in the longdebate on the place where the first World Health Assem-bly should be held. Most European States, including theU.S.S.R., wanted Geneva on the grounds of workingfacilities and economy ; the Latin Americans, U.S.A.,Great Britain, and China favoured the western hemi-sphere, since all meetings of the Interim Commission,except the first, had been in Geneva. The western

hemisphere won by a considerable majority and the firstWorld Health Assembly will probably be held aboutnext May in New York, or in Canada if the United Stateshas not ratified by then. The next meeting of theInterim Commission will be in Geneva in mid-January.More than 200 documents had to be considered, but,

with the help of three night sessions, this was accom-plished in the 13 days available, thanks to improvedefficiency of the secretariat and the commission itself.Though it would be unfair to suggest that the contribu-tions of members were in inverse ratio to the size of their

delegations, the work done by some of the " singleton "

delegates was outstanding-notably Dr. K. Evang(Norway), Dr. C. Mani (India), and, considering his

linguistic difficulties, Dr. N. Vinogradov (U.S.S.R.).Besides administrative and financial matters, whichwere discussed in great-perhaps too great-detail by

475

the 15 members attending, interesting discussions wereheld, in continuation of the Paris Office tradition, on theimmunity reaction of smallpox vaccination, postvaccinalencephalitis, alcoholism, and rat-infestation of ships ;and two protests by the government of India on quaran-tine restrictions imposed by other countries were dealtwith. The reports of the expert committees on malaria,tuberculosis, and biological standardisation were alsodiscussed and some limited action taken to implementthem.The report of the Field Services Division showed

that WHOIC now has a mission of 25 teaching andepidemic control experts in China, much smaller missionsin Ethiopia, Greece, and Italy, and single medical liaisonofficers in Budapest, Vienna, and Warsaw. The elemen-tary training courses for dressers and sanitary officersin Ethiopia have been particularly effective, and theresults of the antimalaria campaign in Greece promiseto be as good as in 1946. The fellowship programme isnow in full swing, some 100 awards having been madeout of about 200 expected in 1947. Medical publicationshave been provided for four countries, and a very success-ful lecture tour in Austria by a group of American andSwiss professors was sponsored and financed jointly byWHoic and the Unitarian Service Committee ofAmerica. Proposals from the Ukraine and Byelorussiafor spending their considerable allocations for fellowshipsand literature are still awaited.Just after the session it was learned that UNRRA

had given a further 11/2 million dollars for the first ninemonths of 1948 or proportionately until a field servicesprogramme can be financed by the World Health

Assembly. This recalls the magnificent gift of theRockefeller Foundation to the Health Organisation ofthe League in its early days and will ensure that war-devastated countries can continue in 1948 to obtain

practical help from Wi-ioic, in expert missions, lectures,fellowships, or literature, or indeed in any form--exceptsupplies-which their governments choose.

PARTIAL ELECTROCARDIOGRAPHY

EvER since the introduction of electrocardiographythe aim has been to record the potentials of the right andleft sides of the heart separately. The original limbleads do not give records representing actual potentialdifferences existing in the heart ; the records merelyrepresent the summation of the many potentials presentat a given time in different parts of the heart. Chestleads were introduced as a refinement, but their onlyadvantage (admittedly an important one) is that theyrecord a higher potential and therefore give a curve oflarger amplitude but of the same pattern. Using aunipolar technique, Groedel and Koch 2 showed that thepotential was lowest in the right arm, and by placingthe indifferent electrode here and the other on the chestwall they recorded the potentials of the right and left sidesof the heart separately. Even though separation wasnot quite complete it was much more so than with chestor limb leads. Landecker 3 has now published a prelimi-nary evaluation of the clinical use of this " partialelectrocardiography." As the maxima of the fields ofpotential of both ventricles partly depend on the positionof the ventricle, preliminary fluoroscopic examination ofthe heart is necessary. Landecker used the right arm forthe indifferent electrode. For the placing of the otherelectrode he mapped out twelve areas on the front ofthe chest and the same number on the back of thechest, and took electrocardiograms in each of thesesituations. From this selection he could pick out theone recording predominantly right ventricular activity(dextrocardiogram) and that recording left ventricular

1. Liberia, Mexico, and the Ukraine did not send representativesto the fourth session.

2. Groedel, F. M., Koch, E. Z. KreislForsch. 1933, 25, 794.3. Landecker, H. M. Med. J. Aust. 1947, ii, 29.

activity (laevocardiogram). Conventional limb and chestleads were also recorded, and by comparing these withthe dextrocardiogram and levocardiogram he claims tohave demonstrated significant differences which will

help to localise myocardial lesions, extrasystoles, and- arrhythmias. Thus he produces evidence in favour ofthe old terminology of bundle-branch block, which shouldclarify our knowledge of this confusing condition.

This method of recording unipolar electrocardiogramsdoes not detract from the proved value of the conven-tional limb and chest leads, but it may throw fresh lighton some of the outstanding puzzles of cardiology.

HORMONE TREATMENT BY IMPLANTINGPELLETS

TEN years ago Deanesly and Parkes 1 described inanimals a method of implanting under the skin tabletsof tightly compressed hormone crystals which con-

siderably prolonged the therapeutic effect as comparedwith previous modes of administration. In 1938 themethod was for the first time applied to the humansubject.2 Since then hormone implantation has becomea well-established procedure. It is applicable only tosubstances which are comparatively insoluble in water,such as the steroid hormones and the synthetic oestrogensof the stilbene group, and is useless in the case of water-soluble hormones such as insulin since the durationof effect is only slightly greater than with subcutaneousinjection.3 Even with the steroid and stilbene groupsthe rate of absorption varies considerably with thedifferent hormones. A 100-mg. pellet of stilboestrol, forinstance, remains effective for about three or fourmonths, whereas a pellet of oestradiol of similar weightmay be active for over a year, and ethisterone is onlypartially and very slowly absorbed. -l Desoxycortone,testosterone, and progesterone show absorption-ratesbetween these two extremes.

Apart from this specific variability in the absorption-rates of the different hormones, the main factor deter-mining the amount of hormone reaching the blood-stream daily is the surface area of the pellet. As the

pellet becomes smaller the daily dose absorbed becomesless. With compressed pellets the surface area is difficultto calculate because of the irregularity of the’surface,but pellets prepared by melting the crystals and thenfusing them into a block exhibit a smooth surface andtheir absorption curve can be very accurately calculated.5 5Another factor which may interfere with absorptionfrom compressed pellets is

"

ghost " formation,6 due to thedeposition of highly insoluble protein in the intersticesof the pellet. With fused pellets "

ghost " formation

does not occur 5 ; theoretically their rate of absorptiondepends only on their surface area and the solubilityof the hormone in the environment into which they areimplanted, but there are indications that other factorsplay a part. It is sometimes possible to remove a

substantial remnant of the pellet long after it has ceasedto produce a functional effect. This may be due to

encapsulation by fibrous tissue, though the capsule is

undoubtedly formed long before the activity wears off.The absorption-rate may also vary with the site of

implantation. It is a clinical impression that pelletsdeeply implanted into muscle are more rapidly absorbedthan when they are placed just beneath the skin. Thatthis may be an important point is suggested by Zondek’sclaim in last week’s issue (p. 423) that oestrogensimplanted beneath the vaginal mucosa are 5-6 timesmore effective than when placed subcutaneously.The actual technique of implantation has by no means

been standardised. Some choose simply to make an1. Deanesly, R., Parkes, A. S. Proc. roy. Soc. B, 1937, 124, 279.2. Bishop, P. M. F. Brit. med. J. 1938, i, 939.3. Parkes, A. S., Young, F. G. J. Endocrinol. 1939, 1, 108.4. Forbes, T. R. Endocrinology, 1943, 32, 282.5. Bishop, P. M. F., Folley, S. J. Lancet, 1944, i, 434.6. Folley, S. J. Nature, Lond. 1942, 150, 403.