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Annotations.

PANEL INQUIRY: TERMS OF REFERENCE.

" Ne quid nimis."

THE Minister of Health has approved the followingterms of reference for the Court of Inquiry set up inconnexion with the terms of remuneration for theinsurance medical service after.Jan. lst, 1924 :-

" To inquire and report to His Majesty’s Governmentwhat should be the amount of the capitation fee (perinsured person per annum) on the basis of which theCentral Practitioners Fund under Article 19 of theNational Health Insurance (Medical Benefit) Regula-tions, 1924, should be calculated as from Jan. 1st,1924, so as to afford adequate remuneration for thetime and service to be given by general practitionersunder the conditions set out in those Regulations, inconnexion with the medical attendance and treatmentof insured persons, due regard being had to the servicein fact rendered under the Regulations hitherto inforce. This capitation fee is not to include any paymentin respect of the supply of drugs and appliances (suchpayments being made out of the Drug Fund underArticle 24 of the Regulations), or any payments tomeet the special conditions of practice in rural andsemi-rural areas."

It will be remembered that the personnel of theCourt of Inquiry consists of Mr. T. R. Hughes, K.C.,Mr. F. S. Goodenough, and Sir Josiah Stamp. !

TRANSMISSION OF LEPROSY FROM RATTO MAN.

IN a paper in Paris Medical for Oct. 27th Prof.E. Marchoux, of the Pasteur Institute, discusses thepossibility of the transmission of leprosy from therat to man in connexion with a most instructive case.It was that of a man who, since 1910, had beentreated in France and England for leprosy, and whofinally drifted into the Pasteur Hospital under thecare of Dr. Veillon. Superficially, the disease waslimited to the limbs and face, where there werenumerous brown patches. No cutaneous sensorydisturbances were noted, but periodic pemphigoideruptions had given rise to small round ulcers whichhad been slow to heal. There were numerous scarsresulting from the slow healing of these ulcers, andwhen their surface or the nasal mucous membranewas lightly scraped and the substance thus obtainedwas examined under the microscope numerous fine,short, cocciform bacilli were seen, to which Prof.Marchoux has provisionally given the name Myco-bacterium pulviforme. After the patient’s death theseorganisms were found in great quantities in the skin,lymphatic glands, liver, and spleen; in the last-named organ they were particularly numerous.

Rabbits, guinea-pigs, and rats were inoculated fromthis spleen, and whereas the rabbits and guinea-pigswere unaffected five of the six rats contracteda disease closely similar to, if not actually identicalwith, rat leprosy-a disease discovered in 1905 byStefansky in sewer rats. Prof. Marchoux has workedwith his virus since 1921 ; it is now in its fourth passagethrough rats, and the morbid changes evoked haveshown no macroscopic or microscopic deviation fromthe changes associated with spontaneous rat leprosy.It would seem that the relation of rat leprosy tohuman leprosy may be somewhat similar to that ofbovine to human tuberculosis ; the micro-organism ofrat leprosy may not find the human body congenialsoil except under most rare conditions. Rat leprosy,by the way, would seem to be a comparatively commondisease in the sewers of Paris, and it has been calcu-lated that 0-6 per cent. of the Parisian sewer rats aredefinitely leprous, and that about 5 per cent. are

infected to such a limited extent that the diseasecan only be detected post mortem. This is a pointwhich Prof. Marchoux includes among the manyparallels he draws between the leprosy of rats and

man. For in man, too, the disease may be limitedto the lymphatic glands, and in the French coloniesthe bacillus of leprosy has sometimes been found inthe lymphatic glands of apparently healthy personsliving in contact with definite cases of leprosy.Hitherto experimental cultivation of Hansen’sbacillus has seldom, if ever, been successful, but therecent researches of Prof. Marchoux suggest that theanaerobic properties of the lepra bacillus are largelyresponsible for cultural failures in the past, and thatfuture progress in this direction will depend on

appreciation of this fact.

THE LEUCOCYTES IN MEASLES ANDSCARLET FEVER.

Dr. H. K. Von Winterfeld and Dr. E. Hahne, ofthe Rostock University Medical Clinic, examined theblood in 28 cases of measles and seven of scarlet fever,with the following results. In only two cases ofmeasles was there absolute leucopenia (below 4000leucocytes) ; normal leucocyte values (4000-8000)were found in 18 cases, and leucocytosis (8000-20,000)in four cases. In other words, the great majority ofthe cases showed normal leucocyte values, leucopeniawas rare, and leucocytosis occurred only in complicatedcases. As regards the differential count, of 25 cases ofmeasles investigated 20 per cent. showed lymphopenia(below 20 per cent.), 28 per cent. normal lymphocytevalues (21 to 29 per cent.), and 52 per cent. lympho-cytosis (over 30 per cent.). Complete absence ofeosinophils was found in 24 per cent., normal eosinophilvalues (1 to 3 per cent.) in 56 per cent., and eosinophilia(4 to 9 per cent.) in 20 per cent. The writers concludethat while the leucocyte values are not characteristic inmeasles, the presence of leucocytosis in uncomplicatedcases contra-indicates measles, and lymphocytosis, asa general rule, is in favour of the diagnosis of measles.While the behaviour of the eosinophils is notcharacteristic in measles, high values are rare, and thepossibility of their being due to intestinal parasitesshould be borne in mind, especially in children. Inalmost all the cases of scarlet fever there were leuco-cytosis associated with lymphopenia and a distincteosinophilia during the eruptive stage. The eosino-philia persisted well into convalescence, so that indoubtful cases with indefinite desquamation withouta history of a rash the combination of desquamationand eosinophilia justified a diagnosis of scarlatinasine eruptione. The writers’ conclusions as regardsthe blood picture in scarlet fever are as follows : c(1) Leucocytosis points to scarlet fever and againstmeasles. (2) Lymphocytosis points to measles andagainst scarlet fever. (3) High eosinophilia pointsto scarlet fever, especially in convalescence, whilenormal eosinophil values do not exclude measles.(4) The leucocyte picture is of considerable value inthe differential diagnosis between scarlet fever andmeasles, especially as the other- signs supposed to bepathognomonic of measles, such as Koplik’s spotsand the diazo-reaction were frequently absent in thewriters’ cases.

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MODERN MEDICINE IN ICELAND.

THE conception of Iceland as a centre of medicalscience may seem a little startling, for we have beentaught to associate this country with volcanoes, fogs,and ice rather than with the modern laboratory andhospital. But a jubilee number of Laeknabladid,which celebrates the sixtieth birthday of Prof. G.Magnusson, and which contains 12 original articles,shows that Iceland is not only in close touch with theoutside world of medicine, but is also in the van ofresearch. A paper by Dr. A. Arnason deals with thenotifications of tuberculosis in a country district inthe period 1890-1922, and the earlier date shows that,in the matter of notification, Iceland has been nolaggard in the administrative control of tuberculosis.Approximately a quarter of the 102 tuberculouspatients had tuberculous parents, and the majority

1 Klinische Wochenschrift, Oct. 22nd, 1923.