AGRANULOCYTOSIS AND ITS TREATMENT

93 with carbon dioxide from the soil air dissolves some of the chalk in its passage to form calcium bicarbonate, the water thereby acquiring its characteristic hardness and the chalk itself becoming less compact. Under natural conditions or when a well has been sunk and the demand for water is not excessive this effect may be insignificant, but with increased pumping and deepening of the well to tap a larger area the conoid of supply becomes greater and much of the water reaches the well by relatively rapid routes through swallow holes and fissures, new channels being formed as a result of solution and erosion. Colonel Harold puts it this way. With the widely diffused systems which abound in the chalk it is obvious, he says, that healthy conduits or fissures may have access to or communication with those bearing impure water and, by the erosion resulting from pumping, intercommunication may be enormously facilitated. For such reasons the passage of swallow-hole water may be traced to wells some miles distant within 72 hours. It is therefore essential, he remarks, particularly with chalk wells going straight into supply, that changes or alteration in bacteriological quality should be detected at the first possible moment. During the thirty-one years of water examination under Colonel Harold and his predecessor, the late Sir Alexander Houston, continuous records have accumulated of the bacterial and chemical characters of London waters under every meteorological condition. These findings have led to the crystallisation of ideas regarding the controversial coli-aerogenes pollution. The first evidence of deterioration of the quality of water in a well, even before an increased colony count, may be the appearance of atypical coliform organisms, which may increase to a concentration of one or more per mil before the typical colony appears. In other words the danger sign, or red light, of pollution is the atypical coliform organism. As the degradation of the well progresses, typical dominance is established and this becomes more apparent with the use of preferential methods of isolation. When the general level of water is high and especially where, as in the northern district under the Board’s control, the chalk is covered by clay the movement of water underground is less rapid and less direct than in times of drought, and the water pumped from a deep well is mainly that which has been underground for a long time with better opportunities of filtration and of removal by death of organisms of all kinds. The worst combination of circumstances is for drought, which has served to emphasise the existence of channels, to be succeeded by periods of heavy rainfall, as occurred in 1935-36. If the drought and the break thereof did nothing else, Colonel Harold concludes, it permitted of a critical and controlled study of the advance of pollutions from the minor to the more serious stages, when in every instance the application of chloramine treatment closed the

chapter. AGRANULOCYTOSIS AND ITS TREATMENT Dr. Preben Plum publishes his own experimental and clinical observations on 88 cases of agranulocytosis in the form of a monograph 1 which includes a review of the literature of the subject, with over 400 references. The result is a concise and valuable summary of present knowledge, well illustrated by diagrams, tables, and pictures of the marrow obtained at autopsy and by sternal puncture. He concludes

1 Plum, P.,

that, in Denmark at least, amidopyrine is by far the commonest cause of the disease, and advises that of this drug for any purpose should be forThe curves for the consumption of amidofor the incidence of agranulocytosis in and pyrine Denmark run parallel, and continuing work described in our columns three years ago2 Plum was able to demonstrate that in persons sensitive to amidopyrine small doses of the drug produce a decrease in the immature granulocytes of the bone-marrow preceding a fall in the number of circulating granular cells. He found that other drugs had no such effect in these people, while amidopyrine was without influence on the marrow of non-sensitive persons. His case reports show further that clinical symptoms are preceded by these changes in marrow and peripheral blood. From hisown experience he attributes little value to any therapeutic measure, and in this connexion a recent report from France is of considerable interest. Dr. Ravina3 discusses 3 cases of agranulocytosis treated in different German clinics with transfusions of blood from patients with myeloid leukaemia: in one of them fourteen transfusions were given, in another recovery followed two transfusions of 500 c.cm. It is suggested that the high white cell content of the leukaemic blood sufficed to tide the patients over the period during which their own marrow was out of action, and also acted as a stimulant to leucopoiesis. Admittedly in one case radiotherapy and pentose nucleotide were also given so that the value of the leukaemio transfusion is by no means certain. On the other hand the prognosis in this condition is so bad that if the leukaemic blood is available its effect ought to be tried more the

use

bidden.

carefully. WORKMEN’S COMPENSATION FOR SILICOSIS

diversity of methods adopted in applying the principle of compensation for silicosis in different countries is shown by the report summarised on THE

another page. The methods in use fall into two main groups: (1) silicosis classed with other industrial diseases and, like them, assimilated to the compensation law relating to accidents ; and (2) special legislation introduced to deal expressly with silicosis. The question arises which method has greater advantages. The first, adopted in Germany and more recently in a number of other countries, involves the inscription of the disease on the schedule of industrial diseases covered by the Workmen’s Compensation Act, and followed by the usual procedure of examination of a claimant by the appointed practitioner and payment of compensation by the last employer. It seems on the face of it a convenient method ; but silicosis presents some peculiar characteristics. First, it is insidious in onset and slow in development, making difficult the apportioning of liability among different employers. Secondly, its diagnosis is difficult in the early stages ; the International Labour Conference (1934) resolved that only medical men specially qualified and suitably equipped, especially with radiological facilities, should be entrusted with the diagnosis and certification of silicosis. Thirdly, the

gradual development of the disease might lead some employers to discharge workmen with suspicious symptoms, in order to evade a possible liability. For such

than its inclusion in

Clinical and

Experimental Investigations in London : Agranulocytosis. Copenhagen : Arnold Busck ; H. K. Lewis and Co. 1937. Pp. 410. 18s.

reasons

the British Committee

on

Com-

pensation for Industrial Diseases (1906) favoured special trade insurance schemes for silicosis, rather 3

a

schedule with other industrial

2 Plum, P., Lancet, 1935, 1, 14. Ravina, A., Pr. méd. Dec. 8th, 1937, p. 1760.