305

It is not quite clear whether the S and R forms,which Commanders Dudley and Parker found to becontrasted in toxigenicity, were from different sourcesor were both derived in each instance from a singlestrain. In the former case the reasons for believingthat they were all C. diphtherice are required to

complete the evidence. Definition of a species inbacteria is difficult as Commander Dudley admits,and the assignment to C. diphthel’iae of a culture whichis neither toxigenic nor descended from a toxigenicstrain is a difficult and often unconvincing task.The study of variation in bacteria is not yet very

far advanced, but definite variation in antigenicconstituents has already been described in severalinstances and found related to more obvious changesin character. There is also good evidence that anti-genic composition may be closely connected withsome factor in the composite character known asvirulence. This is notably the case in the factorswhich have been studied both chemically andbiologically by Avery, Heidelberger, and others-e.g.,in the pneumococcus. It therefore seems probablethat even in so variable a group as the bacteriatangible evidence of orderly variation will furtheraccumulate and prove to be of wide theoretical andpractical value.

I am, Sir, yours faithfully,JOSEPH A. ARKWRIGHT.

Lister Institute, S.W., August 7th, 1928.

THE HEREDITARY AND CONSTITUTIONALFACTOR IN ADDISON’S (PERNICIOUS)

ANÆMIA.

To the Ed’Îtor of THE LANCET.

SIR,-In your annotation last week on theIntestinal Bacteria in Pernicious Anaemia you statethat the evidence for an hereditary or constiutionalelement in the disease is " rather nebulous." In alecture published in THE LANCET five years ago Ibrought forward what I regarded as conclusive eevidence in favour of such an hereditary or consti-tutional element. I believe this conception is offundamental importance in the pathogenesis, prophy-laxis, and treatment not only of Addison’s anemia(A.A.), but also of the associated nervous disease-subacute combined degeneration of the spinal cord(S.C.D.). I should like once again to summarisethe evidence on the subject, as many further observa-tions bearing on it have been made since the publica-tion of my lecture.The absence of hydrochloric acid from the gastric

secretion appears to be the one essential predisposingcause of the two allied diseases. It is most frequentlydue to constitutional achylia gastrica, an inbornerror of secretion, which is strictly comparable withGarrod’s inborn errors of metabolism, such as cystin-uria, alkaptonuria, and pentosuria. The error isone of function and not of structure, as the mucousmembrane is normal and has a normal number ofoxyntic cells. Achylia was present in 4 out of100 healthy students examined by Bennett andRyle at Guy’s Hopsital ; it occurs in early childhood,and is often present in several members of a family.Martinez has observed more than 20 such families,in one of which a great-grandmother, her daughter,four grandchildren, and five out of 13 great-grand-children had achylia. I have had under my owncare a brother and sister and two sisters with digestivesymptoms caused by achylia gastrica.The familial occurrence of achylia gastrica must

be the explanation of the familial occurrence of A.A.which has been recorded by many observers. I havecollected no less than 62 family histories from theliterature, and 7 out of a series of 25 cases at NewLodge Clinic (27 per cent.) had one or more relationswho had died of the disease.

Liepelt records the case of a mother and daughterboth of whom suffered from S.C.D., and of a father

and son with the disease, the grandfather havingdied of A.A. Willson, in 19] 2, described the caseof a woman with S.C.D., two of whose maternalaunts had died of A.A. I have set with a similarfamily history in 4 out of 16 private patients withthe disease : the mother of one and the paternalgrandfather of another died of A.A. The mostremarkable case was that of a doctor who died ofS.C.D. associated with achylia gastrica and A.A. ;his brother, father, paternal uncle, and paternalgrandfather had all died of A.A. The brother ofanother doctor with severe A.A. and slight S.C.D.was found to have S.C.D. and achylia, but perfectlynormal blood.

Five patients, who have consulted me for variousconditions associated with achlorhydria, had one ormore relatives who had died of A.A. I have collectedrecords of 28 other cases in which A.A. in one ormore members of a family was associated withachylia in others. The brother of a doctor of 42,who consulted me for digestive symptoms due toachlorhydria, had died at the age of 41 after beingill for 18 months with S.C.D. and terminal severeanaemia, and Evans has described the case of a manwith S.C.D. and achlorhydria but no anaemia whohad a sister with achlorhydria. Dorst has describeda family, different members of which had either A.A.or S.C.D., or achlorhydria without nervous symptomsor anaemia.A woman of 50, who was feeling quite well except for

occasional diarrhoea and eczema, sought my advice mainlybecause she had become worried about herself owing tothe number of relations on both sides of her family whohad died of Addison’s anaemia. Her sister, paternal grand-mother, and a cousin of her father’s had died of it, a paternalcousin of her own had it now, and her mother died of it.Her tongue, which had been sore from time to time forthree years, had the characteristic appearance of Hunterianglossitis. Her haemoglobin percentage was 76 with 4,100,000red corpuscles per c.mm., and the average size of thered corpuscles was increased from the normal of 7’23 .to 8.35µ, but the red cells were otherwise perfectly normalin appearance. She had complete achlorhydria.

In connexion with the bacteriology of Addison’sanaemia I regret that you make no reference to theimportant observations of Knott on the subject,most of which have been published in the Guy’sHospital Reports, as the more recent investigationsof Dr. Stanley Davidson, which form the basis ofyour annotation, do little more than confirm hispioneer work.-I am, Sir, vours faithfully.

ARTHUR F. HURST.New Lodge Clinic, Windsor Forest, August 6th, 1928.

INSTRUCTION IN PSYCHIATRY.

To the Editor of THE LANCET.

SIR,-Your review of Dr. H. J. Norman’s book onMental Disorders (July 21st, p. 125) will be approvedby many of the older school of psychiatry. Yet it isdisconcerting to find approval of a book, intended for-students, on the ground that it does not deal withmodern psychopathology. The most elementaryknowledge of mental processes is withheld from ourstudents. The metaphysical nature of the effort to.correlate disordered conduct with disordered neurones,and its entire failure and practical futility in thepsychoneuroses, are concealed from them. The mentalattitude thus induced often persists throughoutprofessional life in people of a certain temperament.Others make the discovery that something is wrong-with their education or philosophy and feel helpless.when faced with the many psychoneuroses of generalpractice, with only their traditional training in" neurones " to fall back upon. I am often asked by-practitioners where they can learn about these matters,and where they can meet others of similar inclinationto discuss their clinical difficulties and find out what.is to be learnt from modern psychopathology. Forthis reason I ask the indulgence of your columns tonotify that an effort is being made to form a small

306

society with these aims and I shall be pleased to hearfrom any would-be supporters.

I am, Sir, yours faithfully,ESTELLE COLE.Harley-street, W., July 24th, 1928.

z * Dr. Cole raises a very important point, but ourreviewer has not exactly approved the absence ofteaching in psychopathology so much as conveyed theopinion that so important and difficult a subjectshould be properly taught or left alone. We have seeninstructions in manuals of psychiatry which could havebut little relation to the counsels which would begiven by lectures to students out of first-hand experi-ence.-ED. L.

CANCER AND THE BLOOD-GROUPS.

To the Editor of THE LANCET.

SiB,—In general practice there are occasions inwhich cancer appears to be a family disease, and onthe other hand, some family strains appear to beimmune. If not already dealt with and known, aninvestigation of the relative incidence of cancer

in the different blood-groups might prove interesting.I am, Sir, yours faithfully,

PENROSE WILLIAMS, F.R.C.S. Edin.Cornwall, August 6th, 1928.

HOME PRODUCTION OF COCAINE.To the Editor of THE LANCET.

SIR,—In an annotation entitled The Traffic inNarcotic Drugs, which appeared in your last issue(p. 236), you refer to the manufacture of cocainein this country and state that hitherto there hasbeen no production of cocaine from the leaves, or

by refining crude cocaine, in Great Britain, addingthat in 1927 a licence was granted to a firm of manu-facturing chemists to carry on experiments in suchmanufacture. You will be interested to learn thatcocaine was manufactured by us in 1903 at theWellcome Chemical Works, Dartford. We were

granted a Home Office licence in March, 1917, andhave manufactured many thousands of ounces ofcocaine at Dartford.

We are, Sir, yours faithfully,BURROUGHS WELLCOME AND CO.

Snow-hill-buildings, London, E.C.,August 8th, 1928.

SMOKE ABATEMENT INQUIRY AT BRADFORD.-Mr.F. 0. Sandford, of the Ministry of Health, recently conductedan inquiry at Bradford into the application by various WestRiding authorities for new by-laws on the smoke nuisance.The proposed by-laws provide that the emission of blacksmoke for two minutes in the aggregate within any con-tinuous period of 30 minutes should constitute a nuisance.The authorities applying for the by-laws were Bradford,Huddersfield, Leeds, Halifax, Dewsbury, Batley, Spen-borough, and Guiseley. In support of the applicationit was stated that the decision to apply for new by-lawsarose out of a recommendation by a regional smoke abate-ment committee for the West Riding of Yorkshire, whichrepresented something like 100 local authorities and a millionpeople, and that committee approved of the terms of thesuggested by-laws. In Bradford alone there were 438industrial chimneys and 1330 furnaces. During the lastseven years there had been 73 proved cases of smokeoffences, and one firm had been prosecuted 70 times. Thestandard adopted in regard to smoke nuisance variedwidely in the districts concerned. Amongst others evidencein support of the application was given by the medicalofficers of Bradford and Leeds. In opposition to theproposed by-laws by various trade associations andchambers of commerce it was stated that it had beenproved by experience by firms with the most modern plantthat it was impossible to comply with the terms of theby-laws. It could not be worked in practice, except byimposing a tremendous burden on industry. It was con-tended that the existing local Acts in Bradford were quitesufficient to deal with the problem.

Parliamentary Intelligence.NOTES ON CURRENT TOPICS.

PROROGATION OF PARLIAMENT.

PARLIAMENT was prorogued on Friday, August 3rd. untilTuesday, Nov. 6th. The Hoyal Assent was given by RoyalCommission to a large number of Acts passed during thepast session.

HEALTH ADMINISTRATION IN SCOTLAND.

On Tuesday, July 31st, the House of Commons went intoCommittee of Supply on a vote of £2,037,515 for the salariesand expenses of the Scottish Board of Health. Mr. JAMESHOPE was in the chair.

Mr. W. ADAMSON said the subject he wished to raise wasthe deterioration of the physical condition of the Scottishpeople due to the inadequate provision that was being madefor them by the Scottish Board of Health. There were anumber of causes that were leading to the poverty-strickenconditions in which a large number of Scottish people foundthemselves to-day, but the main cause was unemployment.That problem was even more severe in Scotland than it wasin England. Nearly one-third fewer miners were beingemployed to-day than were at work in 1924. In many casesthe unemployed persons had been out of work for a con-siderable time. In Glasgow the period of unemploymentranged from six months to six years. This problem wasbearing very heavily upon the local authorities in Scotland,and particularly upon the parish councils. He wished toimpress upon the Secretary for Scotland that the provisionsmade in these estimates to deal with the problem of povertyand distress in Scotland were quite inadequate. In last year’sestimates they had £260,000 in grants made to parishcouncils in respect of poor relief, but this year there was nota single penny. He appealed to the Secretary for Scotlandto examine this problem closely with a view to more beingdone by the Scottish Board of Health to enable Scotland toshoulder this grievous burden.

Dr. DRUMMOND SHIELS said that that was the last timethey would discuss the report as the report of the ScottishBoard of Health. In the valedictory foreword which themembers of the Board had inserted in the report theyexpressed the belief that the efficiency of the work of thedepartment in future would not be inferior in any way tothat of the Board. Although Labour Members had stronglyopposed the change that was to be made they sincerelywished that the high standard of efficiency associated withthe Board of Health would be maintained under the newregime. He wished to know what was the position withregard to the vacancy in the medical membership of theBoard. It was known for a long while in advance that SirLeslie Mackenzie was going to resign. Could the Secretaryfor Scotland now intimate who his successor would be ?He sincerely hoped that when the appointment was madeit would be found that a member of the present staff hadbeen promoted to the position.

Milk-supply and Tuberculosis.The question of the milk-supply and tuberculosis was, he

said, dealt with in the report. Undoubtedly under theeffective administration of Dr. Leighton a very great improve-ment had taken place in the milk-supply of Scotland. Itwas much cleaner and better than it had ever been. Therehad been a gratifying increase in the quantity of licensedgraded milk, but it still amounted to little more than 1per cent. of the whole milk used in Scotland. The nomen-clature of the grades was very misleading. There was nodoubt that Grade A in bulk, which was only the third of thequalities, was considered by many people to be the firstquality, while the tuberculin-tested milk had not got itsproper position in the public mind because of confusion ofGrade A milk with that of the highest quality. Somerevision of that nomenclature ought to be made, so that thepublic could understand properly what the position was.He would like to know if the Secretary for Scotland wassatisfied with regard to pasteurised milk ? If pasteurisationwas carried out effectively this milk was safe, but there was agreat liability for pasteurisation to be done ineffectively,and to be a danger rather than a help by misleading peopleas to its safety. The report did not deal with the point.Was any definite standard laid down; if so, was it beingenforced ; and had there been any cases where pasteurisation.which was becoming almost the most popular form ofprotecting milk, was regarded by the Department as beingwholly safe and to be trusted ?The report stated that last year 2240 animals, mostly

cows, were condemned as tuberculous, compared with 1852