183

comment on the diffioulty of distinguishing betweenpernicious anaemia., sprue, and nutritional macro-

cytic anaemia. Their rule was to label as perniciousanæmia those patients with histamine-fast achlor-

hydria ; as sprue those with acid steatorrho3a ; andas nutritional macrocytic anaemia those with neither.But the borderlines were not clear, and one patientcould present different pictures on different occasions.In this climate the problem is not quite the

same. Here the presenting conditions are perniciousanaemia, non-tropical sprue or idiopathic steatorrhoea,and coeliac disease ; pernicious anaemia is clinicallydistinct from the other two. The value of folic acidin the treatment of pernicious anaemia can be regardedas established, but at the present price (Is. 2d. for10 mg.) it is so much more expensive than parenteralliver treatment that it is likely to be reserved fordifficult cases. In non-tropical sprue results have beenirregular : some patients have responded well, othersonly partially or slowly; some have improved so farwith folic acid and then further progress has beenobtained with proteolysed or ordinary oral livertreatment, while others have shown the reverse.

The preliminary results in coeliac disease, which are,all we yet have to go on, suggest that the response isslow and that perseverance in treatment is necessarybefore failure is conceded. That some patients withnon-tropical sprue or coeliac disease and a normo-blastic marrow would not respond was to be expected,because it is reasonably clear that folic acid is effectiveonly where megaloblastic erythropoiesis is present.

In this issue SPIES and STONE report an observationwhich, if confirmed, will establish a serious limitationin the value of folic acid in pernicious anaemia ; for

they find that folic acid has no effect on the degenera-tion of the posterolateral tracts of the spinal cordcommonly associated with the disease. Not onlyhas folic acid failed to relieve this syndrome but theneurological signs have worsened while the patientwas receiving it ; and similar results are reported withthymine. All the patients recovered when given anordinary concentrated parenteral liver extract. Itwill be recalled that DoAN 3 noted a remission of minorneurological signs-presumably due to peripheralneuritis-in his cases of pernicious anaemia givenfolic acid, and none of his patients had developedneurological changes while on treatment ; so far.this has also been the experience in this country,but there has probably not been sufficient time forany such complications to appear. The findings ofSPIES and STONE have practical and theoreticalimplication. The practical ones are that cases ofpernicious anaemia on regular folic acid must becarefully watched for the onset of posterolateral cordsigns and promptly put on liver extract if theseappear; and when such signs are already presentthe patients are best treated with liver. On thetheoretical side this report would have delightedARTHUR HuRST, who contended that the haemo-poietic factor was distinct from the neurotrophicfactor. It fits in too with other evidence suggestingthat folic acid cannot in every case of perniciousanaemia completely meet the deficiency that is filledby a liver extract-that some cases are also sufferingfrom the lack of an unidentified factor.

3. Doan, C. A. Amer. J. med. Sci. 1946, 212, 257,

Annotations

WORLD FOOD PLAN

LAST September the Food and Agriculture Organisa-tion received from Sir John Boyd Orr, F.R.S., its director-general, a -plan for a World Food Board 1 which was todispose of the funds necessary to stabilise prices and toestablish a world reserve for emergencies. That planwas rejected, the United States voicing a preferencefor multilateral agreements covering specific com-

modities2; and it has since become evident that

many countries would have been unable, or unwilling,to subscribe the large capital needed to keep the boardin business.

For the last three months the preparatory commissionof the F.A.O. has been trying to work out an acceptablealternative. Its proposals, published last week, thoughless ambitious in design than those of Sir John Orr, havethe same end. The idea of a World Food Board hasbeen abandoned ; instead, a World Food Council willbe established. The council will, however, not be amarketing concern, nor will it have mandatory powers :for the attainment of stabilisation it will rely entirelyon good will and international consultation. Producercountries will be expected to establish buffer stocks tokeep prices within agreed limits ; to sell to needy coun-tries at prices they can afford ; and, under certainconditions, to establish national reserves for world usein the event of famine. The report-looking some wayahead-emphasises that stabilisation must ultimatelydepend on greater consumption rather than on reducedproduction ; and to increase their purchasing-powerundeveloped regions are urged to set about the task ofindustrial development, seeking credits, if necessary,from the World Bank.The virtue of these proposals is the chance that they

may be generally accepted ; indeed for success they mustbe universally accepted, since one country standing apartcould wreck the accord between those loyal to the plan-for example, by undercutting for quick returns in a yearof plenty. The nations may yet have to return to the Orrplan, if experience shows that nothing less will servethe world’s purpose.

CONTROL OF MUMPS

No writer on mumps can refrain from quoting itsdescription in the Hippocratic corpus ; indeed, untilrecently it was not easy to say that there had beenany advances in our knowledge of an ailment which,however painful or embarrassing, gave no reason foranxiety except in its involvement of the genitals and itsrarer neurological manifestations. In the years beforethe war the most noteworthy innovation was the surgicaltreatment of orchitis which gave promise of the imme-diate relief of pain and the prevention of testicularatrophy at the cost of simple incision of the tunica

albuginea. Soldiers and schoolboys have provided muchdata in the past, and it is not surprising that the oppor-tunities provided by mobilisation turned the attentionof the epidemiological board of the U.S. Army to someof the problems presented by mumps. Johnson andGoodpasture,l in 1934, had shown that the " cause "was a filtrable virus which would produce a transmissibleparotitis in the rhesus monkey. The team headed byJ. Stokes jun. and J. F. Enders 2 have been investigatingthe possibilities of inducing an active or passive immunityin man which would either prevent an infection or

modify one already established. It cannot be said thatthe attempt has as yet been entirely successful. From

1. See Lancet, 1946, ii, 463.2. Ibid, p. 683.1. Johnson, C. D., Goodpasture, E. W. J. exp. Med. 1934, 59, 1.2. Ibid, 1945, 81, 93, 119, 137 ; 1946, 84, 323, 341, 407.