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stringent precautions that the infection could notbe carried by individuals who came in contact withthe patients. The exact details are described intheir communication, and prove that a patient andpainstaking investigation was carried out. Thediseases under treatment consisted of scarlet fever,diphtheria, rothein, mumps, whooping-cough,measles, and chicken-pox. The arrangementof the ward was an interesting one, and as

the result of their experience Dr. Thomsonand Mr. Price assert that they could treatthese infectious diseases in one ward, almostcertainly, with perfect safety if the day of thedisease on which the patients were to be admittedcould be selected. The conclusions which werearrived at are stated with due caution. With regardto scarlet fever they consider that the infection isnot air-borne. The evidence as to whooping-coughwas uncertain, but in regard to measles they believethat the infection is probably carried by the airearly in the disease only. The infection of chicken-pox also appears to be air-borne until the third day.The number of cases of other diseases which weretreated were too few to be of any definite value.’These observations are certainly interesting, and ifcorroborated by a larger number of cases wouldprove of considerable value.

PELLAGRA IN NYASALAND.

THE awakened interest in the problem of

pellagra justifies reference to a recent paper byDr. Hugh S. Stannus, medical officer at Zomba,Nyasaland, read before the Society of TropicalMedicine and Hygiene, and published in theirTransactions. To Dr. Stannus belongs the honourof discovering the existence and describing thesymptomatology of pellagra as it occurs in that

part of the world, and in this second communica-tion 2 be amplifies his previous statements and

supplies important data for a study of the etiologyof the disease. During the last two years thespread of pellagra in and around the CentralPrison at Zomba has been such that it amountsto an actual epidemic, in the course of which131 cases have been directly under Dr. Stannus’sobservation. As far as the symptoms are con-

cerned, stress is laid on the remarkable symmetryof the rash, which begins in these African casesusually on the antero-lateral surfaces of the upperthird of the forearm, the anticubital fossa, and thelower third of the upper arm, appearing thereafteron the back of the hand, the triangles of the neck,the "butternv" " area of face, forehead, and uppersurface of pinna. It is very common to find acondition like syphilitic rhagades at the cornersof the mouth, where the epithelium becomessodden and thickened, and cracks appear in it,passing across the mucocutaneous junction a littleway into the mouth. A not infrequent affectionof the free margin of the prepuce is exactlysimilar. There is often a glossitis with subse-quent irregular epithelial denudation, giving anappearance described as "geographical" tongue.The whole mucous membrane of the mouthmay be involved, and the process may spreadto the fauces and pharynx. Dr. Stannus believesin the possibility of pellagra sine exanthemata,and quotes illustrative instances. The nervoussystem symptoms, the alimentary symptoms,1 Transactions of the Society of Tropical Medicine and Hygiene,

vol. vii., No. 1., p. 32.2 See, for reference to the first, THE LANCET, Feb. 3rd, 1912, p. 314.

and the numerous complications of the diseaseare described and tabulated, and then thewriter proceeds to discuss the difficult matter ofetiology. Six cases occurred among 27 warders

employed in the prison, and 16 in some 150 menof the King’s African Rifles, whose lines are closeto the prison. On the other hand, none occurredin some 72 Sikhs, also stationed in the neighbour-hood. The rations to prisoners, Sikhs, troops, andwarders consisted mainly of rice, all drawn fromthe same supply. It is certain that in the case ofmany of the pellagrous prisoners maize has notentered into their diet at all for years. Dr.Stannus thinks that the data he adduces abso-

lutely put all maize theories, as such, out of thequestion. On the other hand, if

"

grain " be sub-stituted for " maize," then the theory is not to beso easily dismissed. At Zomba the prison rationconsists of rice and salt, and in the majority of £cases little or nothing else. It is therefore quitepossible that so restricted a diet may lead to theappearance of pellagra as the expression of a

deficiency, after the analogy of beri-beri. As therice is eaten in Nyasaland, part at least of thepericarp is left on the grain. Dr. Stannus, how-ever, shows that the risk of partaking of damagedrice is considerable. Turning to the theory ofprotozoal infection, Dr. Stannus has made a

laborious investigation of the simulium distribu-tion in Nyasaland in its bearing on Dr. Sambo n’stheory of the association of pellagra with thesimulium fly. He has found the fly in abundance onall of the streams in the neighbourhood of Zomba,and frankly states that he can bring forward nofacts to militate against Dr. Sambon’s theory. Atthe same time, he points out that it must be care-

fully noted that the data brought forward equallysupport the theory which lays the cause of thedisease at the door of malnutrition-i.e., nutritionwanting in some essential principle. Further, Dr.Stannus declares that in no disease caused by aliving virus is a regular -complete cessation of

symptoms seen, with relapse at a definite seasonmany months later, such as occurs or may occurin pellagra, and this leads him to believe that if thecondition is associated with a protozoal infectionthere must be seasonal reinfection or intoxication,and not a relapse. Dr. Stannus’s very carefulclinical observations and investigations form avaluable contribution to the study of the disease.

INDEX CORRELATIONS.

IN connexion with the Lister Institute of Pre-

, ventive Medicine a statistical study of index

, correlations has been undertaken by J. W. Brown,M. Greenwood, jun., and Frances Wood, particularsof which appeared in a paper in the Jozinrnab

of the Royal Statistical Society for February last.The problem, which is of some importance inmedical statistics, is of the following nature. Ina series of districts with populations represented

L by zo, zi, Z2, &c., the deaths from a certain diseaseare xo, xi, X2, &c., and from some other disease

L yo, Y], Y2, &c. The question arises whether there isany association between the x’s and y’s which isindependent of the common relation of each with z.In order to obtain the requisite materials for thisstudy the Report of the English Registrar-Generalfor 1901 has been laid under contribution,the investigators having faced the very con-

siderable labour of taking out from that source

the first thousand registration subdistricts with

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populations between 1000 and 10,000, togetherwith the corresponding numbers of births anddeaths. The birth- and death-rates were thencomputed and the necessary correlation tables drawnup. These data were then completely analysedand the resulting constants appear in Table 10.The provisional conclusions derivable from thisstudy are fully set forth in the paper, which willbe found instructive and suggestive for furtherstudy of the problem. ____

ANAPHYLAXIS AND IDIOSYNCRASY.

SINCE the introduction of serum therapy thephenomena of hypersensibility and the " serumdisease" have been closely followed and studiedwith absorbing interest. One of the latest originalcontributions to the subject is from the pen ofProfessor T. Silvestri, of the University of Modena,published in a recent number of It Policlinico.1Whether there exist anaphylactic properties incertain drugs, or whether such properties are

limited to albuminoid substances or are possessedby colloids in general and by certain crystalloids, arequestions which have previously attracted the atten-tion of other observers, such as Gubler, Bruck, andKlausner, while E. Friedberger and Ito attemptedto produce hypersensibility to iodine in guinea-pigs z,

by preparing them by injections of iodised albumin. ’,Nicola Barbaro in a recent note on the deter-

mining action of certain crystalloid substancesrelates the case of a patient with acute poly-articular rheumatism in whom a small quantity ofsalicylate of sodium (30 grains daily) and minimumdoses of iodide of potassium (4 to 8 grains) werefollowed by gastro-intestinal disturbance, diffuse

erythema, pyrexia, and blood changes, and anothercase of a man, in whom the ingestion of fish gaverise to urticaria, who exhibited alarming symptomsafter the injection of Hh grain of morphia. These

phenomena may be of an anaphylactic nature, butas the anaphylaxis is not specific in each case itmust be admitted that the anaphylactic state mayhave been prepared or merely brought into actionby the morbid process and determined by themedicinal crystalloids. While waiting for morelight to be thrown on such cases, it might be statedprovisionally that the crystalloids do not give riseto antibodies, but that where the latter alreadyexist they may determine anaphylaxis. In the

present state of our knowledge concerning theanaphylaxis of crystalloids it may be affirmedthat it does not yet rest on a solid basis of experi-ment, and that although we are not in a positionto deny in an absolute manner the affinity, if notthe identity, between the manifestations of idio-

syncrasy for certain drugs and those of anaphylaxis,there is a tendency among scientists to recognisethat at least some crystalloid bodies have a

determinant action, direct or indirect. In allcases of idiosyncrasy the symptoms are those ofpoisoning by the respective drugs; the peculiarityof the case consists in the rapidity, and especially inthe disproportion between cause and effect. Hencewe do not speak of anaphylaxis in such cases,but of intolerance or idiosyncrasy towards the drugsused. When, however, we come to investigate thesignificance of true anaphylactic shock we arestruck by the fact that whatever be the antigenused the symptoms are more or less identical. To

explain this phenomenon it has been supposed

1 Il Policlinico, anno xxi., fasc. 10, March 8th, 1914. Via del Tritone46, Roma.

that anaphylactic shock is the effect of thereaction between albuminoid antigen and anti-bodies in the presence of blood serum, the antigenundergoing a fermentative action with the forma-tion of highly toxic products. But, on the otherhand, Doerr has pointed out that fermentativeactions are slow processes, while anaphylactic shockoften takes place with lightning rapidity, and thatthe quantity of antigen sufficient to cause fatalshock is so small that it is difficult to imagine how,from the release of so minute a quantity ofalbumin, sufficient toxic bodies can be produced.Professor Silvestri, in criticising these views,advances the opinion that just as in true

anaphylaxis, i.e., a poisoning of proteic nature,so in drug idiosyncrasy we have a group of

symptoms whose peculiarity consists in the rapidity,violence, and disproportion between cause andeffect, which reproduces exactly the symptoms ofpoisoning corresponding to the substance in ques-tion. Hence anaphylaxis and drug idiosyncrasyhave essentially something in common, nor is ita valid objection that in the latter we cannot

explain the mechanism of the accident causedby substances not biologically active, since weare in the same state of ignorance concern-

ing those instances where the system becomestolerant of and accustomed to large doses of

poisonous drugs. It seems to Professor Silvestristill uncertain whether the field of anaphylaxisshould be so far extended as to cover true drugidiosyncrasy, or whether experimental or spon-taneous anaphylaxis should be considered simply aparticular instance of idiosyncrasy in general.Anaphylaxis he considers a defensive reaction ofancestral origin against anything that threatens theintegrity of the economy, either wholly or in part.It is for him a tumultuous reaction, disproportionateowing to a lack of adaptation to a given virusor given substance, a reaction which precedesimmunity. It may be that the exceptional gravityof the diseases which rage for the first time in agiven locality is in some cases an instance of

anaphylactic reaction. In evolution, says ProfessorSilvestri, anaphylaxis must have preceded im-

munity, as it precedes it, as a rule, in experi-mental and clinical anaphylaxis. If at timesit accompanies or follows immunity-at least inthe laboratory, in animals which furnish a

highly antitoxic serum, and which therefore haveacquired a marked immunity with respect to a

given infection-this fact is not in absolute contra-diction to what has been just stated, for it may beassumed that by repeating the stimulus (injectionof toxin) for too long a time the organism wouldrespond with a paradoxical reaction. This wouldconstitute another argument in favour of the theoryof the identity of anaphylaxis and idiosyncrasy ingeneral.

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JAUNDICE OF PREGNANCY WITH JAUNDICE INTHE OFFSPRING.

A REMARKABLE case is recorded by Dr. F. E.

Tylecote in the Medical Chronicle (1914, p. 465) ofa woman who married at the age of 18 in 1894, andwho has since then had eight children. Each childwas born prematurely, the first at six months, thesecond at seven months, and the remainder at

eight months. With each pregnancy the womanhad jaundice which came on at the third month,increased in intensity, persisting till three monthsafter confinement, and was unassociated with anypain. Its onset was always insidious. She had