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itself before very long in an era of renewed peace,and that in the not too distant future reawakenedcommercial enterprise may find no place left forthe misapplied ingenuity and pernicious activity ofthe quack medicine vendor.

Annotations.

THE QUESTION OF ANTITYPHOID VACCINATION :

RECENT ITALIAN EXPERIENCE.

"Ne quid nimis."

Professor Lustig, of Florence, has submitted acommunication on this subject to the ItalianMinister of Marine. In it he draws attention to the

praiseworthy initiative of the Chief Inspector ofHygiene, by which optional antityphoid vaccinationwas introduced into the navy, and to the goodresults already obtained in the sense of a markedreduction of this disease among those vaccinated.’The efficacy of this prophylactic measure, however,is, according to Professor Lustig, frustrated, or atleast considerably restricted, by the fact that it isnot obligatory. Some, owing to their natural lazi-ness as much as to general repugnance, will notsubmit to medical interference of a compulsorycharacter, even if it is of a slight nature and freefrom inconvenience; owing also to lack of educationon matters of hygiene, it is a fact that many willnot undergo this vaccination, which has its mainadvantage when done on a massive scale and overa wide area. To secure its result it is neces-

sary, in Professor Lustig’s opinion, that such vacci-nation should be compulsory in the army and navy,3,S it is in Japan, the United States, and some other.countries. Its absolute harmlessness is a morethan sufficient guarantee to the State againstpossible judicial and moral responsibility. The

.efficacy of the results, however, is only obtainablewhen the vaccination is practised under the mostfavourable conditions in every respect. Professor

Lustig does not place complete faith in highlyoptimistic statistics, whether civil or military.In his exhaustive report on antityphoid vaccinationat the Twenty-third Congress of Medicine, Dr.Moreschi observed that the diversity of resultsobtained in France were illustrated by an enormousreduction of mortality from 168’44 per 1000 amongunvaccinated to 0’18 per 1000 among vaccinated;in Germany and England, on the other hand, themortality fell respectively only from 99 to.55 per 1000 and from 30 to 5 per 1000. Accord-

ing to both Moreschi- and Lustig the Englishstatistics reflect more exactly the value of this

prophylactic measure. In Italy it has not beenhitherto possible to carry out this vaccinationwith the precision employed in England and

Germany. The Pfeiffer-Kolle and the Vincentvaccine have, for example, been used promiscu-ously on the same individual and vaccine of morethan a year old has been utilised. Again, statisticstake no note of persons who have already passedthrough an attack of typhoid fever, nor do theystate whether individuals vaccinated in 1912 andrevaccinated in 1913 were attacked. Neither doesit appear what practical and scientific considera-tions induced those in authority to prescribe verysmall vaccinal doses, since the intensity of the

reaction observed in those vaccinated is not a

satisfactory scientific criterion. In order that theseand similar mistakes may be avoided, Professor

Lustig is of opinion that there should be specialisa-tion, or at least special technical instruction, inregard to those who are entrusted with the carryingout of these vaccinal methods.

A PHYSICIAN OF ANCIENT SARDIS.

WE have on many occasions written of themedical personalities of ancient Greece and Rome,concerning whom archaeological research has comeupon some details. We may particularly refer tothe case of Menophantos, the public or municipalphysician of Amphissa, near to Delphic and to thatof Aurelius Heron and Aurelius Didymus, publicphysicians of Oxyrrhynchus. Another name hasnow to be added to these prosopographia ofmedical men in classical times. It is that of a

practitioner at Sardis, in Asia Minor, whosememorial has been found by United States explorerswhen excavating upon the site of that ancientLydian and Roman city. The inscription reads asfollows: "Artemas a physician (iaTpos) built thistomb for himself, and for Melitene his wife, andfor his heirs; he is living." The title of iatros "

may suggest that Artemas also was a public phy-sician. Such medical officers were very frequentlyemployed by the Greek cities of Asia Minor, and ininscriptions their official epithet, such as bomoror &7,uo-te6wv, was commonly omitted. The usualnumber in office in a town varied from 5 to 10.8 3The nearest date assignable to this new text is thefirst century B.C.

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THE SEAT OF FUNCTIONAL HEART-BLOCK.

THERE elapsed a considerable interval of timebetween the discovery that under certain con-

ditions the auricles could beat independently of theventricles, and the further evidence that lesser

degrees of heart-block could be caused by suchinfluences as vagal stimulation or drugs such asdigitalis. Whilst the former gross forms of heart-bloek are recognisable in many cases by the extra-ordinarily slow pulse and frequent syncopal or

epileptiform seizures, the lesser degrees of block,causing, perhaps, only a lengthening of the intervalbetween auricular and ventricular systoles, causeno disturbance of either pulse rhythm or rate. Thelatter forms of block may arise from slightlesions of the bundle of His; they may alsoarise from the causes above noted. It is nowknown, further, that the conducting system is madeup of several parts; there is the auriculo-ventricularnode at the " top " or auricular end of the bundle;then the bundle proper-a short, tiny structure;then its two branches to the right and left ventriclerespectively; and, finally, its terminal brancheswithin the main ventricular mass. It has now

become important to discover at what particularsite or sites in this system functional blockoccurs. If block occurs at any one of theconstituent structures, the end result, namely,disturbance of auriculo-ventricular sequence, isthe same. The degree or type of block willtherefore not assist in this matter. Somevaluable observations relating to this subjecthave been made by Dr. T. Lewis and theseare published in Hea7t (1914, vol. v., p. 247). His

1 THE LANCET, March 7th, 1903, p. 676.2 THE LANCET, Feb. 27th, 1909, p.636.

3 See Pohl De Graecorum Medicis Publicis, 1905.

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observations were made upon dogs, and electriccurves demonstrated the effects induced. By slowingthe heart rhythm at the sinus-the normal site oforigin of the heart’s contraction-he produced whatis known as the a.-v. rhythm (nodal rhythm).In such a rhythm the heart’s contraction isinitiated at the a.-v. node, not the sinus, and as aresult auricles and ventricles contract practicallysimultaneously. When such a rhythm was inducedvagal stimulation was applied. The result of this

procedure is important. Instead of producing a"forward " or typical heart-block, a block in whichthe ventricle follows the auricle, but at a longertime interval, the reverse occurred ; the auriculo-ventricular interval, which in a.-v. rhythm may be0’04 second, instead of the normal 0’12 to 0’16second, is still further reduced. The interval maybe nil, or even a minus quantity. Such a resultshows that the block is situate between node andauricle, since the pause between node and auricledelays the latter and so pushes it later and

approximates its time-incidence to the ventricle.Functional block, then, has its seat at or inthe immediate auricular vicinity of the a.-v.

node. The observations showed also an additionalfact. It was demonstrated that vagal action is

- more powerful upon the a.-v. node than upon thesinus. The value of this effect is obvious. If itwere not so, it is possible that with high heart rates,such as those following exercise, an a.-v. rhythmwould be readily induced, but the associated con-trolling effect of the vagus sustained during exerciseupon the a.-v. node to a greater relative degreeensures little opportunity for its rhythmicity tcexceed that of the sinus and thus initiate the rhythm.In this way the normal a.-v. sequence is preservedover wide variations of rate. The observations arEof much value and reveal, incidentally, in a ratheiunexpected manner still another protectiv(mechanism for preserving intact, under wid(possible variations of conditions, the heart’s vitaaction.

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THE ETIOLOGY AND CURE OF PELLAGRA.

Professor Alessandrini and Professor Scala haverecently published in the form of a largepamphlet containing excellent coloured reproduc-tions of histological and other specimens a Icommunication made by them last year to the

I

Royal Academy of Medicine at Rome under the

auspices of the Commission on Pellagra.1 Theirresearches have led them to two fundamentalconclusions : (1) that pellagra is not dependenton a maize diet; and (2) that it is a disease

strictly localised and limited to areas wherewater is drunk which has been almost exclusivelyin contact with a clay soil. Hitherto it had notbeen suspected that common mineral substances, inthe quantities present in drinking water, couldprovoke immediate or delayed disturbances of

health, anl it was only investigations as to thequality of the soil which was the source of thewater drunk in pellagrous districts that ledProfessor Scala to formulate the suspicion thatsilicic acid in a colloidal state could produce achronic intoxication such as is observed in pellagra.Ninety-four experiments were undertaken on

monkeys, rabbits, guinea-pigs, and puppies, andconsisted in the administration of silica in colloidalsolution and in a gelatinous state by subcutaneous

1 Contribuito Nuovo alla Etiologia e Patogenesi della Pellagra. ByGiulio Alessandrini and Alberto Scala. Tip. naz. G. Bertero, ViaUmbria, Rome, 1914.

and intraperitoneal injection and also by mouthsThe effect was an intoxication with symptoms andpathological changes similar to those observed inpellagra. These experimenters also found that a.

similar intoxication was produced by the adminis.tration by mouth, mixed with bran, of waterobtained from the pellagrous district of GualdoTadino ; and, moreover, that the feeding of animalsexposed to the action of silica with maize had no.effect in aggravating these symptoms, provingthereby that maize has in no sense a contributoryaction. The effect of silica on the organism is tocause a retention of salts, whence there eiasues,

first, excessive fixation in the tissues, and

subsequently liberation of mineral acids, also>-

excessive, which produce the pathological lesions-noticed by the authors. Silica, therefore, acts,in an indirect rather than in a -direct manner,and it was found that its effects could be-neutralised by intramuscular or subcutaneous.

injections of neutral citrate of sodium. Theauthors were thus led to make use of this fact inan attempt to cure pellagrous patients. Detailsare given of ten cases treated with daily injectionsof a 10 per cent. solution of trisodic citrate. Thatconsiderable improvement, if not cure, was obtainedis evident from the photographs given in the

I pamphlet, and it may suggest the advisability ofadopting this method of treatment in those cases

i of pellagra which are from time to time met with-- in this country.

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DEMENTIA PRÆCOX AND MALINGERING.

THAT the early symptoms of dementia prsecoxare such as to lead the practitioner to suppose thathis patient is only pretending to be sick is thethesis supported by Dr. Hesnard, surgeon in theFrench Navy, in the Archives de ]}Iédecine et dePharmacie Navales, in a recent article on the

Importance of Absurd Answers in the Diagnosisof Insanity. Patients suffering from dementiapraecox, just after the first onset, are, he says,as yet so little changed, and their mental powers.are so slightly impaired, that it is difficult forthe alienist to convince the friends of the patient,and even his medical advisers, that he isnot wantonly perverse, but, on the contrary,stricken with a truly serious disease. Dr. Hesnardrecounts his observations on a case, that of a manwho, much run down owing to early phthisis,became excited one day in his barrack-room, andhad to be sent to hospital. In hospital he soonbecame calm, and thereafter was generally vagueand irrelevant in his answers to questions, and at,times incoherent, though occasionally his answerswere shrewd and amusing. He could be made to.speak more rationally if he was sharply questionedand his slumbering self-control awakened. His.friends thought he was shamming, and asked himwhat he was doing it for, and they pointed out to,him that he need not sham to get out of the service,as he was going to be invalided for phthisis any-way. Dr. Hesnard, after considering the case-

closely, concluded that the patient was not a.

malingerer, and believed that he recognised in himthe onset of dementia prsecox. The man looked-strange and haggard and always wore a weaksmile. Quiet generally when alone, he becameuneasy and agitated when observed. He mimickedhis medical attendant cleverly and could talk

brilliantly. This was not like a malingerer. The

malingerer has a narrow range of ideas, bring&back the conversation to the points about which,